e d medi iamr f &r journal of physiotherapy se...

INSTITUTE OF APPLIED MEDICINES & RESEARCH

An experimental study to see the effect of core strengthening on antero-posterior postural sway in young college male recreational athletes.

Chitra Kapoor, Dr. Maneesh Arora

To compare effects of general trunk stabilization exercises and proprioceptive neuromuscular facilitation technique in chronic low back pain patients on muscle endurance, pain and functional activity.

Harneet Kaur, Dr. Shagun Agarwal

To evaluate the effect of muscle length and resisted exercise on EMG activity of contralateral upper extremity muscle.

Divya Sharma, Dr. Pravin Kumar

Comparison of lung volumes & capacities in smokers and non-smokers.

Ruchika Gupta, Dr. Himanshu Sekhar

INSIDE

Volume 1 • Number 2 • March 2013

ME DD IE CI IL NP EP SA &F RO EE ST EU ATI RT CS HNI

IAMR

ISSN 2277-8101

IAMRIAMRJOURNAL OF PHYSIOTHERAPY

IAMR Journal of Physiotherapy (ISSN No. 2277-

8101) is related to physiotherapy evaluation and

rehabilitation. IAMR Journal of Physiotherapy

focuses on publishing scholarly articles from the

areas of physiotherapy assessment, management,

rehabilitation protocols, medicine, orthopedic and

neurological illnesses and other illnesses in the

management of which a physiotherapist plays an

important role, & recent advances in

physiotherapy assessment and management.

IAMR Journal of physiotherapy seeks original

manuscripts that identify, extend, unify, test or

apply scientific and multi-disciplinary knowledge

concerned to the field of physiotherapy. The

content of the journal consists of Original research

works in the above-mentioned fields. Surveys,

opinions, abstracts and essays related to

Operations research. Few review papers will be

published if the author had done considerable work

in that area. Case studies related to medical

conditions which require physiotherapy. The

prime objective of the advisory board is to publish

latest research work which has significant clinical

relevance and implications for physiotherapy

evaluation and rehabilitation. Our objective is to

make the journal a leading one around the nation,

and to provide a format to researchers where they

can share their work with others physiotherapists

around the nation.

Subscription information

Yearly: 1000/-5 year: 3000/-

Printed at:

Sugandha EnterprisesGhaziabad

The views and opinions expressed are of the authors and not of the IAMR Journal of Physiotherapy. IAMR Journal of physiotherapy does not guarantee directly or indirectly the quality or efficacy of any product or service feratures in the advertisement in the journal, which are purely commercial.

Corresponding address:Department of physiotherapy

Institute of applied medicine and research (IAMR)TH9 KM Milestone, Delhi meerut road

Duhai, Ghaziabad, UP

CHIEF PATRON

Prof. R.K. Gupta Chairman, Educationist & Philanthropist

PatronMr. Sanjay Bansal, Mrs. Anshu bansal

Editor-in- Chief Executive EditorsDr. Shagun Agarwal Dr. Huma Siddiqui

Editorial Board

Dr. Poonam Singh, Dr. Nidhi Singh

Dr. Vaishali Chaudhary

ADVISORY BOARD

Dr. Ali Irani (PT) HOD, Physiotherapy and Sports MedicineDr. Balabhai Nanavati Hospital, Mumbai

Dr. Dharampani PandeyHOD, B L Kapur Hospital,New Delhi

Dr. Harpreet SinghSenior Physiotherapist, AIIMS

Dr. Jasmine HOD, Sir Ganga Ram Hospital, Delhi

Dr. K GanesanDirector, Movement SolutionsChennai

Dr. Maneesh Arora Principal, SBSPGI Dehradun

Dr. Neelima PatelSr. Lecturer, College of Physiotherapy, S S G Hospital, Baroda


Dr. Nikita JoshiPrincipal, Dept of Physiotherapysikkim manipal university, gangtok.

Dr. Ram Babu ChandanaPrincipal, Dept of Physiotherapy,DAV College of physiotherapy,Yamuna Nagar

Dr. Shabnam AggarwalDirector, Department of Physiotherapy,Nopany Group of Institutions, Kolkata

Dr. S.K.S MaryaVice Chairman, Max Health Care, Saket, New Delhi Chairman, Max Institute of Orthopaedics & Joint Replacement Surgery.

Dr. Tejbir singhDirector, Kamal Hospital

An experimental study to see the effect of core strengthening on antero-posterior postural 1-12sway in young college male recreational athletes.

Chitra Kapoor, Dr. Maneesh Arora

To compare effects of general trunk stabilization exercises and proprioceptive 13-29neuromuscular facilitation technique in chronic low back pain patients on muscle endurance, pain and functional activity.

Harneet Kaur, Dr. Shagun Agarwal

To evaluate the effect of muscle length and resisted exercise on EMG activity 30-35of contralateral upper extremity muscle.

Divya Sharma, Dr. Pravin Kumar

Comparison of lung volumes & capacities in smokers and non-smokers. 36-42

Ruchika Gupta, Dr. Himanshu Sekhar

Contents


Volume 1 • Number 2 • March 2013

1

An experimental study to see the effect to core strengthening on antero-posterior postural sway in young college male ...

An experimental study to see the effect to corestrengthening on antero-posterior postural sway in

young college male recreational athletesChitra Kapoor* and Dr. Maneesh Arora**

* Research Student, M.P.T Sports Medicine, SBSPGI, Balawala, Dehradun.** Research Guide, Principal, M.P.T Sports Medicine, SBSPGI, Balawala, Dehradun.

INTRODUCTIONThe “core” is much more than just the abdominalmuscles; it is a complex of 29 muscles that act togetherto stabilize the lower back, pelvis and hip (called thelumbo-pelvic-hip complex or LPHC).15

Muscles of the trunk may be divided into “mobilizers”and “stabilizers”. Mobilizers of the spine are themore superficial muscles that cross over multiplejoints so that when they contract they move manyjoints at once. They are the rectus abdominis, external

Background & Purpose: The purpose of this experimental randomized outcome study was to evaluate the effect of corestrengthening exercises on postural sway in young college male athletes and to find out the correlation between post –exercise regime core strength and postural sway.

Method: 35 recreational athletes were selected by random sampling out of which 30 completed the study, during theinitial session a brief history and examination was carried out. Assessment of core strength was done using the side planktest and the duration of side plank hold time was noted in seconds.The assessment of postural sway was done by the swaymeter which was designed for the study. The Swaymeter recordeddisplacements of the body in the horizontal plane at waist level.To record the postural sway, the subjects were asked to stand still with their feet about 12 cm apart and eyes open. Eachsubject was given three trials with a gap of 30 seconds in between each trial for relaxation. Each trial was held for aperiod of 30 seconds. Average of the three readings was taken out and recorded on the data collection form. A set of five core strengthening exercises were used for a period of four weeks to improve the core strength. The exerciseregime was carried out on alternate days. At the end of 4 weeks the readings for side plank and postural sway were takenagain and recorded

Result: Data analysis revealed that there was significant improvement in the core strength from 0th day to end of 4weeks i.e. 30th day. (S <= 0.05).Data analysis also revealed that there was no significant reduction in postural sway from 0th day to end of 4 weeks i.e.30th day. (S>= 0.05). Correlation between core strength and antero-posterior postural sway at the end of core strengtheningregime revealed a moderate correlation between the two. (S<= 0.05).

Conclusion: Segmental analysis reveals that there exists some relationship between core strength and postural sway.Further study is required to recognize the mechanism which correlates the two so that a specific core programme can bedevised to reduce postural sway and hence accuracy of sport can be improved and the chance of injury can be reduced.

Keywords: Postural Sway, Sway meter, and Core Strengthening Exercises.

and internal obliques, lateral portions of errectorspinae, latissimus dorsi and the quadratuslumborum. The primary deep stabilizers are the coremuscles that go from spinal segment to spinalsegment. They are the multifidus, the rotators andthe transversus abdominis.

By their fibre type the core muscles are designed forlong term, prolonged use with a high capacity forendurance. They contract for long periods to supportthe body in activities such as sitting or standing. They

2

IAMR JOURNAL OF PHYSIOTHERAPY • Volume 1 • Number 2 • March 2013 • Page1-12

control the fine movements that occur betweenvertebrae. 38

Injury causes a decrease in the level of activity ofthese muscles as well as a loss of muscular endurancein these muscles. These changes can occur within asshort a period as 24 hours post-injury. It is importantto realize that these muscles will not reactivate ontheir own. They have to be retrained to preventrecurrence of injury.

In essence the passive human spine is an unstablestructure and therefore further stabilisation isprovided by co-contraction of trunk muscles.

Hodges and Richardson popularized the term corestability in the late 1900s. They described the spineinherently unstable and requiring active supportfrom the intra-abdominal pressure and tensioningof the thoracolumbar fascia and deep lumbarstabilizers. Thus, core strength was considered to bemuscular support about the lumbar spine necessaryto achieve and maintain functional stability. Goodcore strength contributing to adequate core stabilityhas been suggested to be necessary in maintainingthe correct lumbar and pelvic posture and alignmentduring movement and sport. Similarly, inadequatecore strength leading to poor core stability maydecrease biomechanical efficiency and increase riskfor injury. It should be noted, however, that neitherof these assertions appear to be supported by prereviewed science. The lack of consensus regardingwhat constitutes a core-strengthening program hasbeen cited as a major contributing factor for thisabsence of research.5

Postural sway during quiet standing reflects theinterplay between destabilizing forces acting on thebody and actions by the postural control systemto prevent a loss of balance.18.. The influence ofdifferent factors on postural sway during quietstanding has thus been the focus of much clinicaland basic scientific study. Important considerationsin such studies are which measures best characterizepostural sway, which measures are best for detectingdifferences in postural sway, and how do differencesin these measures relate to the postural controlsystem.18

Postural sway is an indicator of body alignment dueto posture and how well the body’s center gravity ofthe body is balanced. Postural sway demonstrates adeviation of the center of gravity from normal.15

Vierordt (1862) is thought to have been the first tomeasure this postural sway.3The need for a simplemeasure of postural sway exists due to the issue ofbalance problems A low tech Swaymeter (lord’sswaymeter) was designed to address the needs ofclinicians and researchers with limited resources (e.g.no access to forceplates or motion laboratories).11 It isa useful field test, as it is compact, lightweight, hasshort administration and data processing time.Unlike other lightweight and easily applied systems,such as accelerometers and gyroscopes, theSwaymeter involves no electronics or computerprocessing. Thus, assessment can be conducted in avariety of community settings and health carefacilities. Several research groups have found theSwaymeter to be feasible for use in differentpopulations of young and older people.

Though stabilization exercises have become a majorfocus in spinal rehabilitation as well as inprophylactic care such as sports injury prevention ,the therapeutic evidences in terms of postural controlvariables are limited so this study has beenpostulated to measure postural sway and analysethe effect of core strengthening on postural sway.

Statement of studyTo see if there is any effect of core strengthening onpostural sway in young male athletes.

Aim and purpose of the studyThe purpose of this experimental randomizedoutcome study is to evaluate the effect of corestrengthening exercises on postural sway in youngcollege male athletes and to find out the correlationbetween post – exercise regime core strength andpostural sway.

HYPOTHESISAlternate Hypothesis1) Core strengthening exercises shall be effective in

reducing postural sway in young college athletes.2) There will be a positive correlation between post-

exercise regime core strength and postural sway.

3


Null Hypothesis1) Core strengthening exercise shall not be effective

in reducing postural sway in young collegeathletes

2) There shall be no correlation between post-exercise regime core strength and postural sway.

RESEARCH DESIGN AND METHODOLOGYNature of studyThe study has experimental and correlationaldesigns, which observes the effect of corestrengthening exercises on the swiss ball on antero-posterior postural sway and correlates the corestrength to the postural sway after a period of 4 weeksof core strengthening regime in young collegeathletes.

Sample size 35 subjects were selected by random sampling outof which 30 completed the study, 3 dropped out andcould not complete the study and two of them weremade to discontinue due to their inability to adhereto the regime.

Inclusion criteriaYoung college male athletes between 18 -25 yearsof age.

Exclusion criteriaAny history of low back pain for the past threemonths.Any history of ankle or knee injury for the pastthree monthsThose undergoing any form of balance trainingor any fitness regime that may influence theoutcome measuresPresence of any disease causing neuromusculardeficit.Any balance abnormalities.

VariablesDependent variables1. Duration of side plank position maintained2. Antero-posterior postural sway

Independent variables1. Swiss ball exercises

Materials used1. Swaymeter

2. Graph sheets3. Stopwatch4. Swiss ball5. Exercise mats

PROCEDUREDuring the initial session a brief history andexamination was carried out and noted in the pre-screening form.

Assessment of core strength was done using the sideplank test and the duration of side plank hold timewas noted in seconds. In this the subject was askedto assume the side lying position and then lift hisbody upwards so that the body then remainedsupported on the forearm and ankles only. Theathlete was asked to hold this position till the timehe could comfortably hold it without any waveringof the body. The duration of hold time was noted inthe data collection form.

The assessment of postural sway was done by theswaymeter which was designed for the study. TheSwaymeter recorded displacements of the body inthe horizontal plane at waist level. The deviceconsisted of an inflexible 40-cm-long rod with avertically mounted pen at its end. The rod wasmounted on a 20 cm wide metal plate which wasfitted over the participant’s lower back (level of theposterior superior iliac spine) by a firm belt so thatthe rod extended posteriorly. Fitted firmly, theSwaymeter offers 1 degree of freedom between thebelt and pen as it is free to move in the pitch plane.

The pen recorded participant’s postural sway on asheet of millimetre graph paper, fastened to the topof an adjustable-height table.

The sway path length was manually determined asthe number of millimetre squares traversed by thepen [14]. The anteroposterior (AP) peak to-peak swaydisplacements were also calculated from theextremes of sway length.

The subjects were asked to stand still with their feetabout 12 cm apart and eyes open. Each subject wasgiven three trials with a gap of 30 seconds in betweeneach trial for relaxation. Each trial was held for a periodof 30 seconds. Average of the three readings was takenout and recorded on the data collection form.

4


Measurement of Side Plank Test Hold Time

The Swaymeter

Measurement of Postural Sway

Core strengthening exercises and parameters used:A set of five core strengthening exercises were usedfor a period of four weeks to improve the corestrength. The exercise regime was carried out onalternate days. Each exercise was demonstrated toeach subject on the first day. On subsequent days ofthe protocol, the subject carried out the exercise inthe presence and supervision of the researcher.

The exercises used were:Abdominal bracing. This is a part of all exercisesand is to be maintained during each exercise.Theabdominal bracing technique involves a submaximalisometric contraction of the three layers of theabdominal wall (rectus, obliques, and transverse)which produces a true muscular girdle around thespine to buttress against buckling and shearinstability.

Seated marching on a physio-ball. The athlete beginsby sitting upright on a physio-ball, with the lumbarspine in a neutral position (mid-range). He placeshis feet hip-width apart. While bracing theabdominal muscles, she lifts one leg and foot off theground. (The limb does not need to be lifted high,just enough to be off the ground with2 inches to start.)The athlete should focus on controlling the weightshifting to the weight-bearing limb whilemaintaining lumbo-pelvic stability.

Spinal flexion on ball (abdominal crunch). Theathlete pre-activates his abdominal brace in thestarting position and maintains this as she rolls backinto spinal extension. He slowly raises the body,focusing the rotation in the thoracic spine. Picturethe head and neck as a rigid block on the thoracic

5


spine to prevent flexing the cervical spine. The athleteconcentrates on attempting to touch the bottom ofhis ribs to her pelvis anterior superior iliac spine.The hands can be placed over the ears to eliminatepulling on the neck. 10 repetitions performed.

Alternate leg bridge with shoulders on ball. Theathlete starts this exercise by sitting on the physio-ball and walking forward with his feet on the ground,slowly leaning back until her back rests on the ball.This is called the bridge position. The head, neck,and shoulder blades should be supported on the ball.Knees should be bent at a 90_ angle, with feet on theground. While bracing the abdominal muscles, theathlete raises the foot and extends the leg off theground. The weight is be shifted to one side, and theathlete should focus on maintaining of the lumbo-pelvic region. The athlete should strive for stabilityand balance, while holding this position for 10seconds and alternating lower limbs. 10 repetitionsperformed.

Abdominal roll-out. This is an excellent exercise totrain the abdominals eccentrically.

The athlete kneels behind the ball, with both handson the ball. Keeping the abdominals braced and lower

Seated Marching on The Ball

back in a neutral position, he rolls the ball away fromhis body a short distance until there is a straight linefrom the shoulder to hips. While maintainingalignment, he pulls the ball back towards them ashort distance, then pushes it away a short distance.The movement should occur only at the shoulders,not the back. 10 repetitions performed.

Prone leg extensions on the ball: with abdominalbrace maintained, the athlete lies prone on the ball.He then rolled the ball forward so that the bodyremained supported on the hands and toes. Then legraise is performed with a hold time of 10 seconds foreach leg.10 repetitions performed.

Spinal Flexion on The Ball

Alternate Leg Bridge on The Ball

6


Abdominal Roll-out

Prone Leg Extension on The Ball

Protocol: On receiving the athlete on the first day, theentire procedure was explained to him. His readingsfor side plank and postural sway were taken andrecorded on data collection form. The athlete wasrequested to co-operate at all stages. He was ensuredthat his discomfort and complaints will be respectedat all times and he should immediately report aboutthem. After this the athlete was placed on the physio– ball. He was asked to maintain the abdominal braceand the first exercise was started. One by one allexercises were performed and then repeated onalternate days till four weeks. On the last day thereadings for side plank and postural sway were takenagain and recorded on data collection form.

RELIABILITY AND VALIDITYInstrument reliabilityICC and SEMs for Swaymeter data recorded during3 repeated trials are presented in Table A. Swaymetermeasures showed good-to-excellent reliability. r =0.928. (s = .023)Lord et al in 1991 proposed that body sway during a

bipedal stance could be measured using a swaymeter.Lord et al in 1996 used the swaymeter to find themaximum balance range in a randomised controltrial and concluded that it has good test retestreliability and can be used to analyze posture.

Outcome variable reliabilitySide plank test – the interclass correlation coefficientfor side plank on right side is highly reliable r=0.91-0.98

Validity of side plank o right side (moderate to highcorrelation with other endurance tests) r= 0.568-0.972T G Palmer et al in their study “Interday reliability ofpeak muscular power outputs on an isotonicdynamometer and assessment of active trunk controlusing the chop and lift test” concluded thatIntraclass correlation coefficients for peak muscularpower were highly reliable for the chop (range, 0.87-0.98), lift (range, 0.83-0.96), and endurance (range,0.80-0.98) tests between test sessions.

Measurement of postural sway–reliability-thecorrelation coefficient are good for antero-posteriordisplacement ICC >=0.654.

Validity- The Swaymeter measures are moderatelyto strongly associated with COP measures, with ICC= 0.560 to 0.865.

In particular, the Swaymeter has excellent correlationwith COP for the AP displacement measure, withICC > 0.74 across all conditions.

Sturnieks et al in their study “Validity and reliabilityof the Swaymeter device for measuring posturalsway” concluded that the Swaymeter was reliableacross trials, with intraclass correlation coefficients

Table ACorrelations intra

T1M T1ET1M Pearson Correlation 1 .928*

Sig. (2-tailed) . .023N 5 5

T1E Pearson Correlation .928* 1Sig. (2-tailed) .023 .N 5 5

* Correlation is significant at the 0.05 level (2-tailed).S= SIGNIFICANT s <= 0.05

7


ranging from 0.654 to 0.944 and the Swaymeter is areliable tool for assessing postural sway.

Tester’s reliabilityThe same therapist had taken all the readings of thesubjects. The standard deviation of the valuesrecorded show minimum deviation in the values thusshowing high intra-rater reliability.

Procedural reliabilitySide plank test hold timeThe athlete is positioned on his dominant sidesupporting the upper body on the elbow in 0 degreesof trunk flexion with legs fully extended and feetplaced one on top of the other. He is asked to lift hisor her hips off the table, using only his or her feet andelbow for support. The examiner records how longhe or she can hold this position. Usually this positionshould be held without alterations in form for 45 to60 seconds to demonstrate competency. (John Hill etal ,American College of Sports Medicine 2011 ,Review and Role of Plyometrics and CoreRehabilitation in Competitive sports)

Measurement of Postural SwayFitted firmly at the level of posterior superior iliacspine, the Swaymeter offers 1 degree of freedombetween the belt and pen as it is free to move in thepitch plane. The pen records participant’s posturalsway on a sheet of millimeter graph paper, fastened tothe top of an adjustable-height table. The sway pathlength was manually determined as the number ofmillimetre squares traversed by the pen. (D L Sturniekset al, BMC Geriatrics 2011, Validity and reliability ofthe Swaymeter device for measuring postural sway)

Core Strengthening Exercise RegimeA set of five core strengthening exercises were usedfor a period of four weeks to improve the corestrength. The exercise regime was carried out onalternate days.

The exercises used were seated marching on thephysioball, abdominal crunches, alternate leg bridgewith shoulders on the ball, abdominal rollout andprone leg extensions on the ball. (Michele Fredericsonet al, Physical Medicine and Rehabilitation Clinicsof North America 16 (2005) 669–689, MuscularBalance, Core Stability, and Injury Prevention forMiddle- and Long-Distance Runners.)

DATA ANALYSISThe data was analysed using SPSS 11.5 versionsoftware. Paired t-test was used to compare themeans of side plank and antero-posterior posturalsway before and after the core strengthening regime.Karl pearson’s correlation coefficient was used tocorrelate the core strength and antero-posterioirpostural sway post core strengthening regime.(0.05level of significance was used)

RESULTSData analysis revealed that there was significantimprovement in the core strength from 0th day to end of4 weeks i.e. 30th day. (S <= 0.05). Refer Table No. 1 Dataanalysis also revealed that there was no significantreduction in postural sway from 0th day to end of 4weeks i.e. 30th day. (S>= 0.05). Refer Table No. 2.

Table 2Comparison of mean antero-posterior postural sway

at 0th day and 30th day

0th day 30th day SignificanceAntero-posterior 1.28 + 0 .36 1.08 + 0.42 N Spostural sway inmillimetres

S= Significant p<=0.05NS = non-significant p>=0.05

Table 1Comparison of mean core strength at 0th day and 30th day

0th day 30th day SignificanceCore strength 69.63+ 32.03 84.73+33.43 S(side plank hold timein secs)

S = significant p<= 0.05NS = on-significant p>= 0.05

Table 3Correlation between core strength and antero-posterior

postural sway at 30th dayCorrelations

PSPOST SPPOSTPSPOST Pearson Correlation 1 .451*

Sig. (2-tailed) . .012N 30 30

SPPOST Pearson Correlation .451* 1Sig. (2-tailed) .012 .N 30 30

* Correlation is significant at the 0.05 level (2-tailed).S= SIGNIFICANT s <= 0.05

8


Correlation between core strength and antero-posterior postural sway at the end of corestrengthening regime revealed a moderate correlationbetween the two. (s<= 0.05). Refer Table No. 3

Graph 1: Mean Comparison of Side Plank Hold Time

Graph 2: Mean Comparison of Changes in Postural Sway

Graph 3: Correlation of Post Exercise Core Strengthand Postural Sway

DISCUSSION The hypothesis that Core strengthening exercisesshall be effective in reducing postural sway in youngcollege athletes cannot be fully accepted on the basisof findings of this study. This is said on the basis of

primary finding that though the exercise regimehelped in significant improvement of core strength,but there was no marked reduction in antero-posterior postural sway(s> 0.05).

From the results of the study it is evident that therewas significant improvement in core strength andbut no significant reduction in antero-posteriorpostural sway at the end of core strengthening regime.This is shown by an increase in the duration of sideplank (in seconds) but no marked decrease in theamplitude of antero-posterior postural sway (inmillimetres). Also improvement on core strength hasbeen moderately correlated with antero-posteriorpostural sway present in the athletes.

In our study the lateral deviations were not recordedand analysed. This could account for the moderatecorrelation between improvement in core strength andpostural sway. Previous literature supports thepresence of sway in all direction during normal quietstanding in all directions. Further investigation whichtakes into account sway in all four directions (anterior,posterior, right lateral and left lateral) could depict abetter correlation between the two and better effect ofcore strengthening on reduction in postural sway.

Sivakumar Ramachandran et al in their study“Measurement of postural sway with a swaymeter:an analysis” found that in both eyes open and eyesclosed condition there were subjects who did notshow sway in any direction. 23.3% patients did notshow any sway in the right lateral direction ascompared to other directions. All subjects taken inthe study had right side dominance. Maximum swayhas been observed in anterior and posteriordirections but sway in lateral diections in differentconditions of eyes open and eyes closed are alsoremarkable.34

The coreAs stated by Kibler et al.34, 2, the larger muscles of thecore create a rigid cylinder and a greater moment ofinertia against body perturbation while allowing astable base for mobility. The abdominal musclesconsisting of the transverse abdominus, internal andexternal obliques and rectus abdominus all contractto provide stabilization for the spine and therefore astronger base of support for lower extremity movement.When the transverse abdominus contracts, the intra-

9


abdominal pressure increases and tenses thethoracolumbar fascia. These contractions occur beforeinitiation of limb movement allowing the limbs to havea stable base for motion and muscle activation. Therectus abdominus and oblique abdominals areactivated in specific patterns with respect to limbmovement that also provide postural support.34

It appears from the limited number of studies thatcore stability training regiments can improve themuscle activation patterns of trunk musculature.Others have noted the importance of proper activationand stability of the trunk during maintenance ofstatic postural control. Their results demonstrate thatimplementing a core stability training regiment toyoung, physically active individuals can improvedynamic postural stability. However; our results doallow us to speculate that the introduced core stabilityexercises improved the strength and recruitment oftrunk musculature, which may help to explain theobserved improvements in dynamic postural control.As Kibler et al34 describe, the activation of coremusculature in patterns with extremity movementshelp to improve postural control; a phenomenon thatmay have been improved in the athletes thatcompleted Core Stability exercises.

According to Kibler et al.34, the body uses core muscleactivation to generate the necessary rotationaltorques around the body and produce extremitymotion. Also, the multifidi and transverse abdominismuscles would help to maintain dynamic balanceduring lower extremity movement by providingsupport to the lumbar spine.

Similarly, in a study conducted by Marshall andMurphy35, it was found that exercising on a Swissball lead to greater activation levels of the muscles ofthe lumbopelvic region during performance tasks.Exercising on the Swiss ball increased activity forthe rectus abdominus, transverse abdominus andobliques during a press-up exercise when comparedwith exercise on a stable surface. In our study, thesubjects performed exercises on a Swiss ball, whichmay have created similar improvements reported byMarshall and Murphy35.

Postural controlDuring quiet stance1, healthy subjects control theirupright posture with small movements made in

different segments of the body (Nashner 1985, Carr& Shepherd 1990). The optimal position duringbalanced stance requires that the centre of the bodymass is maintained within the support frames of thesoles. In the lateral direction of body sway, keepingthe feet apart gives the best base of support, i.e.introduces a diagonal force against the ground. Theshoulders should be directly above the hips and thehead and trunk erect (Carr & Shepherd 1982). Balancedstance also requires an ability to move one’s positionwhile standing and to move out of the standingposition, all without using the arms for support. Thisincludes an ability to shift weight in the lateral andanteriorposterior directions (Carr & Shephard 1987)and to make flexible movements in the verticaldirection (Woollacott & Shumway-Cook 1990).

Body swayControl of the whole body COM(centre of mass) isthe primary goal of the balance system26. TheSwaymeter provides an indirect measure of COMmovement as it is fixed at approximately the level ofthe COM (pelvis) and records motion of the body in2D while standing. In order to stabilise the COM, anindividual produces forces on the support surface/s(predominantly under the feet while standing). Dueto the relative ease of forceplate recordings, the COPhas commonly been used in previous studies ofstanding balance control as an indicator of balancestability. However, while COM and COP measuresare related, they are not synonymous . The COP-COMposition separation varies across individuals andconditions.

The Swaymeter enables measurement of posturalsway that is simple and less expensive than methodsemploying forceplate or motion capture systems. Thisstudy has found the Swaymeter to be a reliablemeasure of postural sway.

Competitive and recreational sports26 are dependenton multiple components of training and thedevelopment of strength, power, and endurance 36.Balance training is a relatively recent phenomenonin the fitness industry that has developed into aprimary point of interest for consumers and fitnessprofessionals. Balance is comprised of the dynamicreactions of involuntary sensations and impulsesthat maintain an upright stance and is necessary formost functional movements. Success in athletic and

10


recreational activities depends on both balance andfunctional movements. The proper function of al!active muscles and the velocities at which thesemuscular forces are applied are crucial 37. Manyrecreational activities require lateral, forward, andbackward movements during which the center ofgravity (COG) is often at the edge of the base ofsupport (BOS) 37. To maintain balance, it is necessaryto have a functional awareness of the BOS to betteraccommodate the changing COG . The goal of balancetraining is to improve balance through perturbationof the musculoskeletal system that will facilitateneuromuscular capability, readiness, and reaction.Muscle imbalances inevitably result in injury16.

Muscle imbalances disrupt the natural biomechanicsof the joint or joints they surround. Stabilizing muscles(called stabilizers) maintain ideal posture and optimalbiomechanics by ensuring congruence of the jointsurfaces; but when the stabilizers weaken from injury,poor posture or long periods of sitting, other musclesattempt to substitute or compensate for this weakness.These compensatory muscles are called mobilizerssince they are responsible for causing movement andoffer little in the way of stabilizing the body. Mobilizingmuscles cannot perform the role of both stabilizingand mobilizing, and as a result change the normalmovement of the joint or body part.

These compensations and substitutions result in awasting of muscle energy and power and abnormaljoint wear, eventually leading to injury.

Strengthening the core muscles is the key to restoringmuscle balance The “core” is much more than justthe abdominal muscles; it is a complex of 29 musclesthat act together to stabilize the lower back, pelvisand hip (called the lumbo-pelvic-hip complex orLPHC). The muscles of prime importance are thetransversus abdominis and the multifidus (deepestabdominal and back muscle respectively).

Strengthening the core muscles helps “reset” musclebalance far from the core itself however it is importantto combine a core strengthening routine with aneffective stretching program for chronically tightmobilizing muscles too.

Performing core stability exercises as part of warm-up programs may be useful for temporarily

improving postural control during standing in mainexercise programs.

Decreased core stability has been suggested to beassociated with a higher occurrence of lower extremityinjuries and low back pain15.

There is a large body of research investigating theeffects of trunk stabilisation or core strengtheningon patients with low back pain, particularly withregard to muscle timing, activation, and response.Patients with low back pain have been observed todisplay altered trunk muscle activation patterns andlarger postural sway when compared with healthycontrols during perturbation testing. The inclusionof stabilisation targeted to the deep abdominal andlumbar multifidi muscles has been shown to reducelow back pain significantly among patients withspondylosis or spondylolisthesis. Stabilisationexercises have also been found to be more effective inreducing low back pain and improving functionwhen compared to manual therapy alone. Incomparison to no exercises or non – specific homeexercises, stabilisation exercises elicited greaterfunctional outcomes in patients who had undergonemicrodiscectomy5.

These data provide strong support for the use of corestrengthening exercises, however the direct effects ofthe intervention on muscle strength orneuromuscular stability have not been determined.

Clinical experience and these studies provide amotivation for further investigations involving corestrength and stabilization as it pertains to thetreatment and prevention of musculoskeletal injuries.

To provide the most effective and efficient programfor athletes and patients, it is necessary to investigatethe mechanisms and actions by which strengthcontributes to stability and how stability is achievedand maintained during static and dynamic tasks.

Therefore on the basis of the results of study, we cansay that core strength definitely has a role to play inthe body’s postural control system. But furtherstudies are required to rule out the mechanism whichinterlink the two and hence improve performanceand prevent injuries.

11


LIMITATION OF THE STUDYLumbar lordsis degree varied and made it difficultto place the swaymeter. The marker did not fallperpendicular to the graph.Only unidirectional sway (antero-posterior) couldbe measured.The motivational level of the athlete could not bemonitored or altered and could have affected theoutcome variables.The activity level of the athlete prior to therecordings could not be monitored or altered andseems to have affected the outcome variables.

FUTURE SCOPE OF STUDYAnthropometric variations can be includedGender differencesMore variables to measure postural sway such asvelocity of sway, frequency of swayEMG recording of muscles activated during thesway

CLINICAL IMPLICATION OF STUDYThe study proves that there exist a correlationbetween core strength and postural sway.

There is a strong relationship between a strong coreand a healthy body and reduced chance of injury.

A reduction in postural sway will help increase theprecision and accuracy of sport. Increased precisionand accuracy are very useful in sports such as diving,baseball pitchers, tennis players (at time of service),shooters, golfers, runners and football players.

By recognising the exact mechanisms and parmeterswhich correlate the two, a core strengtheningprogramme can be devised to reduce the posturalsway and the performance of athletes can beimproved and chances of injury can be reduced.

CONCLUSIONSegmental analysis reveals that there exists somerelationship between core strength and posturalsway. Further study is required to recognize themechanism which correlates the two so that a specificcore programme can be devised to reduce posturalsway and hence accuracy of sport can be improvedand the chance of injury can be reduced.

REFRENCES[1] Pirjo Kejonen. Body movements during

Postural Stabilization, measurement withmotion analysis system. Department of PhysicalMedicine and Rehabilitation, University ofOulu, 2002.

[2] Nicole Kahle. The effects of Core StabilityTraining on Balance Testing in Young, HealthyAdults. The University of Toledo, April 2009.

[3] David L Stevens and G E Tomlinson.Measurement of human Postural Sway.Department of Neurology, the University ofLeeds.

[4] Michael Fredericson, Tammara Moore.Muscular balance, Core Stability and InjuryPrevention for middle and Long DistanceRunners. Physical Medicine and RehabilitaionClinics of North America, 16(2005), 669-689.

[5] Marc Sherry, Thomas Best and BryanHeiderscheit. The Core: Where We Are andWhere Are We Going? Clinical Journal of SportsMEDICINE, Volume 15, Number 1, January2005.

[6] Kaji Ayuko, Sasagawa Shun, Kubo Takahiro,Kanehisa Hiroaki. Transient Effect of CoreStability Exercises on Postural Sway DuringQuiet Standing. Journal of Strength andConditioning Research, February 2010, Vol 24,Issue 2, pp 382-388.

[7] Robert Stanton, Peter R Reaburn, BrendanHumphries . the Effect of Short Term Swiss BallTraining on Core Stability and RunningEconomy. Journal of Strength and ConditioningResearch, 2004, 18(3), 522-528.

[8] John D Willson, Christopher P Dougherty, MaryLloyd Ireland, Irene McClay Davis. CoreStability And its Relationship to LowerExtremity Function and Injury. 2005, AmericanAcademy of Orthopaedic Surgeons.

[9] Christopher McLean. Core Stability:Anatomical, Biomechanical And PhysiologicalEvidnce.2006

[10] Daina L Sturneiks, Ria Arnold, Stephen R Lord.Validity and Reliability of the Swaymeter Devicefor Measuring Postural Sway. BMC Geriatrics2011, 11:63, doi 10.1186/1487-2318-11-63.

[11] Ramprasad Muthukrishnan, Shweta D Shenoy,Sandhu S Jaspal. The Differential Effects of CoreStabilization Exercise Regime andConventional Physiotherapy Regime on

12


postural control Parameters duringPertubations in Patients With movement andcontrol impairment chronic low back pain.

[12] Brian Fullem. How Core Muscles Can Affectthe Lower Extremity. Podiatry Today, vol 21,Issue 4, April 2008.

[13] F Owen Black, Howard E Rockette. NormalSubject Postural Sway during Romberg Test.American Journal of Otolaryngology, Vol 3,Issue 5, September-October 1982, pages 309-318.

[14] Arend Borghuis, Koen Lemmink. Core MuscleResponse Time and Postural Reactions inSoccer Players and Non-players. Medicine AndScience in Sports and Exercise, January 2011,Vol43, Issue 1, pp 108-114.

[15] David Peterson. Balance Training for ReducingPostural Sway and Improving Golf Fitness.

[16] D J Lanska. The Romberg Sign and EarlyInstruments for Measuring Postural Sway.Semin. Neurol.2002 Dec, 22(4):409-418.

[17] A M Sabatini. Analysis of Postural Sway usingEntropy Measures of Signal Complexity. Medboil. Eng Comput.2000 Nov, 38(6): 617-624.

[18] V Cornilleau, N Shabana, J Droulez, J C H Goh,G S M Lee. Measurement of Visual Contributionto Postural Steadiness from the COP Movement:Methodology and Reliability. Gait and Posture,Vol 22, Issue 2, October 2005, pages 96-106.

[19] Darin T Leetun, Mary Lloyd. Core StabilityMeasures as Risk Factors for Lower ExtremityInjury in Athletes. Medicine science. SportsExercise, Vol 36, no. 6.pp 926-934, 2004.

[20] Does a sprinter need aerobic capacity.[21] Abdullah M Alqarani, Anthony G Schneiders,

Paul A Henderick. Clinical tests to DiagnoseLumbar Segmental Instability: a SystemicReview. Journal of Orhtopaedic and SportsPhysical Therapy, March 2011, Vol 41, number3.

[22] P B Sullivan. Lumbar Segmental Instability :clinical Presentation and Specific StabilizingExercise Management. Manual Therapy 2000,5(1), 2-12.

[23] Luigi Baratto, Pietro G Morasso, Cristina Re,Gino Spada. A New Look at PosturographicAnalysis in the Clinical Context: sway densityvs. Other parameterization techniques.. motorControl 6, 2002, pp 246-270.

[24] Robert J Peterka. Postural control modelinterpretation of Stabilogram DiffusionAnalysis. Boil Cybern. 82, 335-343, 2000.

[25] Lysholm M, Ledin T, Odkvist LM, Good L.Postural Control- A Comparison BetweenPatients With Chronic Anterior CruciateLigament Insufficiency and HealthyIndividuals. Department of Orthopaedics,University Hospital, Sweden.

[26] James A Yaggie, Brian M Campbella. Effects ofBalance Training on Selected Skills. JOURNALOF Strength and Conditioning Research, 2006,20(2), 422-428.

[27] Ian D Loram, Sue M Kelly and Martin Lakie.Human Balancing of an Inverted Pendulum: IsSway Size Controlled by Ankle Impedence.Journal of Physiology 2001, 532.3, pp 879-891.

[28] Nadler Scott, Wu Karen D, Galski Thomas. LowBack Pain in College Atjletes: A prospectiveStudy Correlating Lower Extremity Overuse orAcquired Ligamentous Laxity with Low BackPain. Spine, 1 April 1998, Vol 23, Issue 7, pp828-833.

[29] Warren B Young. Transfer of Strength andPower Training. International Journal of SportsPhysiology and Performance, 2006, 1:74-83.

[30] Sivakumar Ramachandran, RoopaYegnaswamy. Measurement of Postural Swaywith a Swaymeter: an Analysis. J Phys Ther.2011, 2: 46-53..

[31] Functional Anatomy- Myofacsial Core Slings.2008 ARC Performance Traing Systems.

[32] W B Kibler, J Press, A Sciascia. The Role of Corein Athletic Function. Sports Medicine 2006,36(3), pp 189-198.

[33] P Marshall, B Murphy. Core Stability exerciseson and off a Swiss Ball. Archives of PhysicalMedicine and Rehabilitation. 2005, 86(2), pp242-249.

[34] Hickson R. Interference of Strength Developmentby simultaneously training for Strength andEndurance. Eur. J. appl. Physiol. 45:255-263.1980.

[35] Lephart SM, DM Pincivero, JL Giraldo and FHFu. The role of proprioception in themanagement and rehabilitation of athleticinjuries. American Journal of Sports Medicine.25(1), 130-137. 1997.

13

To Compare The Effects of General Trunk Stabilization Exercises and Proprioceptive Neuromuscular Facilitation Technique...

To Compare The Effects of General TrunkStabilization Exercises and Proprioceptive

Neuromuscular Facilitation Technique in ChronicLow Back Pain Patients on Muscle Endurance,

Pain and Functional ActivityHarneet Kaur* and Dr. Shagun Agarwal**

* Research student, M.P.T orthopedics, institute of applied medicine and research, Ghaziabad.** Research Guide, Dr.Shagun Agarwal, M.P.T sports medicine, HOD physiotherapy department IAMR Ghaziabad.

INTRODUCTIONLow back pain (LBP) is one of the most common andmusculoskeletal pain syndromes of modern societywith upto 80% of people having LBP at some time intheir life 10, 42, 53. Empirical research has shown thatphysiological changes (e.g. muscle dysfunction) occurin the lumbar spine in tandem with initial episodes ofpain 22. Chronic low back pain (CLBP) is a commonclinical syndrome affecting about 2 billion people sinceit responds poorly to treatment, it is, as suggested by

Background and purpose: To evaluate the short term effect of general trunk stabilization exercises and proprioceptiveneuromuscular facilitation technique which is more effective in chronic low back pain and to analyze the effect of generaltrunk stabilization exercises and PNF technique in chronic low back patients individually.

Method: 30 patients with chronic low back pain were selected after evaluation to get fit into inclusion and exclusioncriteria, and were further divided into two groups- group 1 had performed general trunk stabilization exercises with onecontrol modality and those in group 2 had performed proprioceptive neuromuscular stimulation exercises with the samecontrol modality and all the outcomes measures were assessed pre and post intervention for decrease in pain,improvement in functional ability and develop muscular strength.

Result: Our study indicated that general trunk stabilization exercises and proprioceptive neuromuscular facilitationtechniques reduced pain and disability, and enhances muscular endurance in the short term (i.e., up to 4 weeks) insubjects with chronic low back pain. In this study, paired t-test showed that both groups, individually showed significantpositive changes in Pain, functional activity and trunk muscle endurance level at the end of week 4 of the treatment inpatients with chronic low back pain (CLBP). On comparison between the groups at week 0, 2 and 4, were not showingsignificant improvement. It appears therefore that both the groups group 1 and group 2 are effective in reducing pain,acheiving functional activity level and muscular endurance level of patients with chronic low back pain. Regardless ofintervention, however, both groups experienced minimal pain after 4 weeks.

Conclusion: We found that there is no significant difference between the conventional trunk stabilization exercises andproprioceptive neuromuscular facilitation along with continuous mode TENS and stretching in comparison to each other,but both the groups showed significant improvement individually in functional activity, reduction in pain and enhancingmuscle endurance in patients with chronic low back pain after the treatment duration of 4 week.

Keywords: Chronic low back pain (CLBP), Proprioceptive neuromuscular facilitation (PNF), Isometric contraction,isotonic contraction, Static muscle work, concentric muscle work, Agonists or prime movers.

Strenback and Associates, among the most frustratingof medical problems 73. Excessive movement beyondthe normal physiologic limits, referred to as spinalinstability, may result in CLBP 72.

CLBP is one of the most disabling and therapeuticallychallenging pain conditions affecting older adults,yet there is a limited body of research dedicated todefining its impact on function (Hartvigsen et al,2003) 21.

14

IAMR JOURNAL OF PHYSIOTHERAPY • Volume 1 • Number 2 • March-2013 • Page 13-29

Epidemiological studies suggest that paraspinalmuscles dysfunction/lumbar instability may beimportant in the aetiology of low back pain, andparaspinal muscle weakness has been documentedin severe CLBP (Long et al, 1996) 46, 53, 62.

The concept of spinal stability was influenced byBergmark (1989). Spinal stability is highlydependent on spinal load and posture (Shirazi-Adi,El-Rich, Pop, and Parnianpour et al, 2005) as well astask requirements (Kavric, Grenier, and McGill, 2004).Sufficient spinal stability is usually achieved by lowintensity coordinated co-contraction of the anteriorand posterior trunk muscles (McGill, Grenier, Kavricand Cholewicki, 2003), spinal stability is considereddetrimental to the spine, and it has been suggested tobe both a cause and a consequence of low back pain(LBP) (McGill, 2002). The core stability or lumbarstability exercises appear to be especially importantin cases of spinal stability. Care is comprised of solelythe abdominals in front, paraspinal and gluteal inthe back, diaphragm as the roof, and the pelvic floorand hip girdle musculature as the bottom 38, 18.

Stretch exercises commonly are prescribed as part ofthese programs. It is believed that stretch increasesmuscle extensibility and therefore, improves jointrange of motion (ROM), movement, and function. Thelasting effects of stretch are more controversial butarguably of more importance, particularly forindividuals with chronic pain 14.

There are three commonly used stretching techniques:static, dynamic, PNF 8, 41, and 60. PNF was developed byHERMAN KABAT between 1946 and 1951.Proprioceptive means having to do with any of thesensory receptors that give information concerningmovement and positioning of the body. Neuromuscularmeans that it involves nerves and muscles. Facilitationis to make it easier. They focused the patient can doboth psychological and physiological levels with theprimary goal of helping the patients to achieve theirhighest level of function 15, 70.

The treatment goals for LBP are to relieve pain, reducemuscle spasm, improve range of motion (ROM) andstrength, endurance, correct postural problems andultimately improve functional status 51. Andmanagement of patients with low back pain includesphysiotherapy interventions are exercises, advice,

manual techniques, and electrotherapeutic or thermalmodalities 27. The dynamic and static endurance ofabdominal muscles were measured by curl up test.The dynamic and static endurance for extensormuscles was determined by Sorensen test 23.

Musculoskeletal physiotherapy is the most commonform of conservative treatment for CLBP 2, 12. Exerciseis a widely prescribed treatment for chronic low backpain (CLBP), with demonstrated effectiveness forimproving function and work 6, 23. Some exercisesprograms often called “general exercise programs” aredesigned to enhance trunk performance through thetraining of long trunk muscles (erector spinae, rectusabdominis), whose primary function is to generatemovement. 23, 26

“Core stabilization exercises (also commonly knownas “lumbar stabilization” or “motor control exercises),which comprise of abdominals and trunk musclesstrengthening exercises, are recommended on theaccumulated evidence demonstrating that theseexercises selectively activate the key abdominal andtrunk musculature, involved in controlling forcesacross the lumbar spine 7, 11, 12,56.

Eriksson and Sjolund showed that with conventionalTENS (continuous 100 Hz stimulus) patientstolerated upto 3 times the perception threshold, andwith acupuncture- like (pulsed TENS) 2 Hz trainswith internal frequency of 100 Hz patients tolerated5-8 times the perception threshold, which gave amarked muscle stimulation16,28, 71,74.

However the body of professional literature does notcontain research regarding the efficacy of TENS alongwith trunk stabilization exercises and TENS withPNF program in the management of chronic low backpain patients. The study was designed to determinethat if, PNF program and trunk stabilization exercises,affects the amount of pain, disability and muscularendurance in chronic low back pain after four weekof treatment. Specifically, the present research wasdesigned to study the efficacy of TENS with PNFprogram and trunk stabilization exercise respectively.Therefore the purpose of this study was to comparethe effects of proprioceptive neuromuscular programand general trunk exercises in chronic low back painon muscle endurance, pain and functionalperformance after 4 weeks of the treatment.

15


METHODSThe subjects were selected on the basis of inclusionand exclusion criteria and were allocated to one ofthe two groups as per his/ her sequence ofparticipation in the study (by lottery method). Eachgroup had 15 subjects.

Inclusion criteria20-45 yearsPain longer than 24 weeks(6 months)Patients complain of low back pain during, orafter activity, during or after sitting, and duringwalking on stairs.Both male and femalePatient must be medically fit (no heart problems,pregnancy, or inflammatory arthritis).

Exclusion criteriaPatient with previous spinal surgery,Red flags (serious spinal pathology or nerve rootpain signs)Signs and symptoms of instability.Radiological diagnosis of Spondylosis orspondylolisthesis corresponding to asymptomatic spinal level; “catching,” “locking,”“giving way”, or “a feeling of instability” in onedirection or multiple directions of spinalmovements.Gynecological problems

Instruments and tools usedTENS (Trans cutaneous electrical nervestimulation): Three in one combination (interferential therapy, TENS and ultrasonic)therapy machine made in 2009 had been usedwith the frequency of 100 Hz, conventional(continuous) mode used three times in a week for30 minutes to promote a reduction in swelling,pain, spasm and improvement in activity levelslike walking, running, standing, climbing stairs.71

Short form Mc Gill pain questionnaire: Painperception measured using the short form McGillpain questionnaire, a responsive pain scale thatyields reliable and valid data, derived fromoriginal McGill pain questionnaire. 26

Roland Morris disability questionnaire:Disability was measured using the Roland Morrisdisability questionnaire, a 24 item scale (0=”nodisability”, 24=”highest disability”) 26

Trunk curl up test/ flexion test (FT): Done to testthe endurance test of trunk flexors (abdominals).Sorensen test/ extension test (ET): Done to testthe endurance of trunk extensors (para spinalmuscles).

METHODOLOGYOnce all the patient’s met with the inclusion andexclusion criteria. A thorough clinical assessmentwith relevant test was performed for each subject.The sample of the study was confined to a groupof 30 patients who suffered from chronic low backpain (more than 3 weeks) 23 were randomly dividedinto two comparative groups by lottery method.Total population was divided into two groups(group 1 and group 2) each consisting of 15subjects.Group 1- general trunk stabilization exercisesalong with stretching exercises and conventionalTENS was givenGroup 2- proprioceptive neuromuscularstimulation exercises along with stretchingexercises and conventional TENS was given.

TREATMENT PROTOCOLThe subjects were randomly assigned into the twogroups: Group 1: general trunk stabilization exercisesalong with stretching exercises and conventionalTENS. Group 2:-proprioceptive neuromuscularstimulation exercises along with stretching exercisesand conventional TENS.

Before going to start the treatment session all thereading were recorded at week 0 for pain levels byshort form Mc gill pain questionnaire (SFMPQ),disability levels were recorded by Roland Morrisdisability questionnaire (RMDQ), trunk flexion test(FT) used to check the endurance for abdominals andtrunk extension test (ET) to check the endurance forpara spinals muscles.

After half of the treatment session, at the middle ofthe session at week 2 all the outcomes measures wereagain measured by all the scales.

And at the end of the treatment session that is atweek 4 all the outcomes were again measured tocompare them from the initial readings.

Training programs: - the two experimental groups(proprioceptive neuromuscular facilitation and trunk

16


stabilization exercises) participated in 4 weekprogram that aimed to develop muscular endurance,decrease in pain and improvement in functionalactivity in patients with chronic low back pain.

The training frequency for both groups was 5 times/week 23. A typical weekly schedule included trainingsessions on Monday, Tuesday, Wednesday,Thursday, and Friday with no training on Saturdayand Sunday.

Common componentsTENS: it had been applied in both the groups priorto the training session for a time duration of 30mins16,28,77, three times in a week for 4 weeks28 andonce in a day77. It included the days i.e. Monday,Wednesday and Friday.

Conventional TENS, parameters between 80-100 HZis considered to be very effective in treatment ofchronic pain16 .TENS is most often applied as shortpulses of around 50 microsec at 40-150 HZ; this iscalled conventional TENS, and is high frequency,low intensity stimulation. The intensity is turned ongradually until a prickling or tingling sensation isfelt. It should be neither painful nor should it cause amuscle contraction, that was approximately 2-3 timesthe sensory threshold16, 77.

Frequency of 100 Hz was used in a conventionalmode 71. Two surface electrodes were placed in oradjacent to the painful area at a distance of 5cm-20cm apart16. Often one electrode is sited over theplace where the most intense pain is felt or the greatesttenderness elicited. Electrodes are fixed to the skinwith adhesive tape. A conducting gel is appliedbetween electrode and skin.77

Stretching exercises-26 each stretch is given five timesand holding each stretch for five seconds.

Back stretch- side twisting in supine position bothright and left side, single and double knee to chestfrom supine position and side bending in standingposition with or without contra lateral arm elevation.

Leg/pelvic stretches- hip flexors stretch from Thomastest position, hamstrings stretching for each legindividually, calf stretches with knee straight.

Training program for Group 1Subjects in these groups performed general exercisesonly, exercises activating the extensor (paraspinal)and flexors (abdominals) muscle groups wereadministered, because muscle contraction occurringwith exercise imposes extra loading on the spinaltissues, the general exercises were selected on thebasis of maximizing the contraction benefit/ spinalloading ratio, according to recommendationsprovided from recent experimental studies26.

Each exercise in this group are performed initiallywith the holding time of five seconds and with therepetition of each exercises five times i.e. 5contractions X 5 seconds for week 1 and 2,progressively increasing holding time to 10contractions X 10 seconds for week 3 and 4 for eachexercise.

Fig 1: Knees Bent Rising Shoulders off the Couch

Fig. 2: Lifting trunk to Neutral Position

17


Week 0-1;- Upper and oblique abdominals from lyingposition- with knees straight and knees bent risingshoulders off the couch. Back extensors-lifting trunkto neutral from prone position with pillow under theabdomen and arms by the side.

Week 1-2: Abdominals from lying- lower abdominalscrunches, heel slides, Back extensors- bridging andlifting trunk to neutral from prone position withpillow under the abdomen and arms by the side or inelevation.

Fig. 3: Heel Slides

Fig. 4: Bridging

Week 2-3: Abdominals from lying- lower abdominalscrunches, heel slides, leg slides, straight leg raisingtowards ceiling, For obliques- hip lift from side lyingposition, Back extensors- bridging, lifting trunk toneutral from prone position with pillow under theabdomen and arms by the side or in elevation, single

leg extension from prone and four point kneelingposition. (Fig 5, 6, 7, 8)

Fig. 5: Leg Slides

Week 3-4: Abdominals from lying- lower abdominalscrunches, heel slides, leg slides, straight leg raisingtowards ceiling, full abdominals crunches, cyclingexercises, or obliques- hip lift from side lying position.

Fig. 6: Straight Leg Rising

Fig. 7: Hip Lift from Side lying

18


Back extensors- bridging, lifting trunk to neutral fromprone position with pillow under the abdomen andarms by the side or in elevation, single leg extensionfrom prone and four point kneeling position, alternatearm/ leg extension from 4 point kneeling and lyingpositions, single leg bridging (Fig9,10, 11)

Fig. 8: Single Leg Extension from Prone

Fig. 9: Full Abdominals Crunches

Fig. 10: Alternate Leg/Arm Extension from 4 Point Kneeling

Fig. 11: Single Leg Bridging

Fig. 12: Resisted Active Concentric Contraction

Training program for Group 2Before going to start the treatment for group 2, all theoutcome measures were assessed. The preintervention recording of the outcome measures wasdone at week 0, using short form McGill painQuestionnaire for pain, Roland Morris disabilityQuestionnaire for functional disability, and flexionand extension test for muscular endurance. Theoutcome measures were re-assessed again at week2(middle of the treatment) and at week 4(postintervention). And Application TENS and givingstretching exercises before the intervention were sameas group 1. (Fig 12, 13, 14)

Week 0-1:- the COI (combination of isotonic) programconsisted of alternating concentric and eccentriccontractions of agonists without relaxation. Resistedactive concentric contraction for 5 sec (trunk flexion),resisted eccentric contraction for 5 sec (trunk flexion),and resisted maintained contraction for 5 sec (trunkflexion -extension). Three sets of 5 repetitions initiallyat maximal resistance were performed.

19


In week 2, 3 and 4 the exercises are same but usgradually increasing the number of repetitions as perpatients’ tolerance (upto 3 sets of 10 repetitions).Theexercise performed with the subject in sitting positionfacing the physical therapist. Resistance was providedby physical therapist by placement of hands on theupper part of chest (trunk flexion) or the scapulashoulder region (for extension) Subjects from both thegroups were also instructed to perform all ADLs thatdid not increase symptom and to avoid activities thataggravated symptoms. They were encouraged not tochange their activity level and instructions related tocare of back was given. Subjects were re assessed byusing all the outcome measures.

Fig. 13: Resisted Eccentric Contraction

Fig. 14: Maintain Static Position (Trunk Extension)

RESULTSVarious statistical measures such as mean, standarddeviation and test of significance such as paired t-

test and independent t- test was utilized for thispurpose. Paired t-test was utilized to measure thedifference within the two groups and independent t-test between two separate groups in terms of decreasein pain by short form McGill pain questionnaire(SFMPQ), improvement in functional activity byRoland Morris disability questionnaire (RMDQ) andenhancement in muscle endurance levels by trunkflexion and extension test (FT & ET). Age of subjectsin this study was between 18-40 years. There were15 subjects in each group. Group 1 had 9 femalesand 5 males; in group 2 had 7 females and 8 males.

Changes in SFMPQ in group 1 and group 2 at week0, 2 and 4 (relief in pain) the average pain score ingroup 1 at week 0 (pre treatment) was 9.93 (+/- 1.90)and average pain score in group 2 at week 0 was10.13 (+/-3.20). The difference was found to be notstatistically significant (t= -0.208, p>0.05).Theaverage pain score in group 1 at week 2 (middle oftreatment) was 2.80 (+/- 1.14) and average pain scorein group 2 at week 2 was also 2.80 (+/- 2.04). Thedifference was found to be not statistically significant(t=0.00, p>0.05).The average pain score in group 1 atweek 4 (post treatment) was 0.40 (+/- 0.50) andaverage pain score in group 2 at week 4 was 0.73 (+/- 0.33). The difference was found to be not statisticallysignificant (t=0.37, p>0.05).( Table 1, Graph 1)

Changes in RMDQ in group 1 and group 2 at week 0,2 and 4 (increase in functional activity) the averageRMDQ score in group1 at week 0 (pre treatment) was6.33 (+/- 1.54) and average RMDQ score in group 2at week 0 was 6.60 (+/-1.80). The difference wasfound to be not statistically significant (t= -0.435,p>0.05).The average RMDQ score in group 1 at week2 (middle of treatment) was 2.53 (+/- 0.91) andaverage RMDQ score in group 2 at week 2 was 2.60(+/- 1.29). The difference was found to be notstatistically significant (t=-0.163, p>0.05).Theaverage RMDQ score in group 1 at week 4 (posttreatment) was 0.13 (+/- 0.35) and average RMDQscore in group 2 at week 4 was 0.46 (+/- 1.06). Thedifference was found to be not statistically significant(t=-1.156, p>0.05). (table2, graph 2)

Changes in FT in group 1 and group 2 at week 0, 2and 4 (increase in muscle endurance) the average FTscore in group 1 at week 0 (pre treatment) was 4.13(+/- 1.50) and average FT score in group 2 at week 0

20


was 4.00 (+/-1.51). The difference was found to benot statistically significant (t= 0.242, p>0.05).Theaverage FT score in group 1 at week 2 (middle oftreatment) was 8.66 (+/- 2.22) and average FT scorein group 2 at week 2 was 8.53 (+/- 2.47). Thedifference was found to be not statistically significant(t=0.155, p>0.05).The average FT score in group 1 atweek 4 (post treatment) was 13.33 (+/- 2.94) andaverage FT score in group 2 at week 4 was 14.00 (+/- 3.46). The difference was found to be not statisticallysignificant (t=-0.568, p>0.05). (Table 3, graph 3).

Changes in ET in group 1 and group 2 at week 0, 2and 4 (increase in muscle endurance) the averageET score in group 1 at week 0 (pre treatment) was1.80 (+/- 1.52) and average ET score in group 2 atweek 0 was 2.06 (+/-1.27). The difference was foundto be not statistically significant (t= -0.519,p>0.05).The average ET score in group 1 at week 2(middle of treatment) was 4.40 (+/- 1.68) and averageET score in group 2 at week 2 was 4.86 (+/- 1.40). Thedifference was found to be not statistically significant(t=-0.824, p>0.05).The average ET score in group 1 atweek 4 (post treatment) was 7.13 (+/- 1.80) andaverage ET score in group 2 at week 4 was 7.26 (+/-1.83). The difference was found to be not statisticallysignificant (t=-0.201, p>0.05). (Table 4, graph 4).

Changes in mean differences between the group 1 andgroup 2 in PAIN, RMDQ, FT & ET during the wholetreatment The average means differences of PAIN scorein group 1 was 9.53(+/- 1.88) and in group 2 was 9.40(+/- 2.47) .The difference was found not to bestatistically significant (t=0.166, p>0.05).The averagemeans differences of RMDQ score in group 1was 6.20(+/- 1.47) and in group 2 was 6.13 (+/- 1.68). Thedifference was found not to be statistically significant(t=0.115, p>0.05).The average means differences of FTscore in group 1 was -9.20 (+/-2.14) and in group 2was -10.00 (+/-2.82). The difference was found not tobe statistically significant (t=0.873, p>0.05).Theaverage means differences of ET score in group 1 was-5.33 (+/-0.89) and in group 2 was -5.20 (+/- 1.82).The difference was found not to be statisticallysignificant (t=-0.254, p>0.05). (Table 5, graph5)

Using Paired T- testComparison within grp 1 for all four outcomeMeasures (Table 6, graph 6)

Changes in SFMPQ (relief in PAIN) within group 1The average SFMPQ in group 1 at week 0 (pre

treatment) was 9.93 (+/- 1.90) which was thenreduced at week 4 (post treatment) to an average of0.40 (+/- 0.50). The difference was found to be highlystatistically significant (t=19.590, p<0.01).

Changes in RMDQ (decrease in disability/increasein functional capacity) within group 1 The averageRMDQ in group 1 at week 0 was (pre treatment) was6.33 (+/- 1.54) which were then reduced at week 4(post treatment) to an average of 0.133 (+/- 0.35). Thedifference was found to be highly statisticallysignificant (t=16.295, p<0.01).

Changes in FT (increase in muscle endurance) withingroup 1 The average FT in group 1 at week 0 was (pretreatment) 4.13 (+/- 1.50) which was then increasedat week 4 (post treatment) to an average of 13.33 (+/- 2.94). The difference was found to be highlystatistically significant (t= - 16.613, p<0.01).

Changes in ET (increase in muscle endurance) withingroup 1 The average ET in group 1 at week 0 (pretreatment) was 1.80 (+/- 1.52) which was thenincreased at week 4 (post treatment) to an average of7.13 (+/-1.80). The difference was found to be highlystatistically significant (t=-22.958, p<0.01).

Comparison within group 2 for all 4 outcomemeasures (Table 7, graph 7)

Changes in SFMPQ (relief in pain) within group 2The average SFMPQ in group 2 at week 0 (pretreatment) was 10.13 (+/- 3.20) which was thenreduced at week 4 (post treatment) to an average of0.73 (+/- 1.33). The difference was found to be highlystatistically significant (t=14.723, p<0.01).

Changes in RMDQ (decrease in disability/increasein functional capacity) within group 2 The averageRMDQ in group 2 at week 0 was (pre treatment) was6.60 (+/- 1.80) which were then reduced at week 4(post treatment) to an average of 0.46 (+/- 1.06). Thedifference was found to be highly statisticallysignificant (t=14.100, p<0.01).

Changes in FT (increase in muscle endurance) withingroup 2 The average FT in group 2 at week 0 was (pretreatment) 4.0 (+/- 1.51) which was then increasedat week 4 (post treatment) to an average of 14.00 (+/- 3.46). The difference was found to be highlystatistically significant (t= - 13.693, p<0.01).

21


Changes in ET (increase in muscle endurance) withingroup 2 The average ET in group 2 at week 0 (pretreatment) was 2.06 (+/- 1.27) which was thenincreased at week 4 (post treatment) to an average of7.26 (+/-1.83). The difference was found to be highlystatistically significant (t=-11.063, p<0.01).

TABLES: Comparison between the group 1 and group2 for all four outcome measures:

Table 5Comparison of mean differences in PAIN, RMDQ, FT AND ET

between the group 1 and group 2 at week 0, week 2 and week 4

Total Scales Group 1 Group2 T Value(N=15) (N=15)

Mean Sd Mean SdDIFF PAIN 9.53 1.88 9.40 2.47 0.166 NS*DIFF RMDQ 6.20 1.47 6.13 1.68 0.115 NS*DIFF FT -9.20 2.14 -10.00 2.82 0.873 NS*DIFF ET -5.33 0.89 -5.20 1.82 -0.254 NS*

NS: - Non Significant (*:- P> 0.05)

Using Paired T- testComparison within group 1 for all four outcomemeasures:

Table 1Comparison of short form McGill pain questionnaire between

group 1 and group 2 at week 0, week 2 and week 4

Short Form Mc Group 1 Group2 T ValueGill Pain (N=15) (N=15)Qusetionnaire (45) Mean Sd Mean SdPain0 9.93 1.90 10.13 3.20 -0.208 NS*Pain 2 2.80 1.14 2.80 2.04 .00 NS*Pain 4 0.40 0.50 0.73 1.33 -0.904 NS*


Table 2Comparison of Roland Morris disability questionnaire (RMDQ)

between group1 and group 2 at week0, week 2 and week 4

Roland Morris Group 1 Group2 T ValueDisability Question- (N=15) (N=15)naire (max 24) Mean Sd Mean SdRMDQ 0 6.63 1.54 6.60 1.80 -0.435 NS *RMDQ 2 2.53 0.91 2.60 1.29 -0.163 NS*RMDQ 4 0.133 0.35 0.46 1.06 -1.156 NS*


Table 3Comparison of Trunk curl up test/ flexion test (FT) between

group1 and group 2 at wk 0, week 2 and week 4

Trunk Curl Up Test Group 1 Group2 T Value(Flexion Test) (Max) (N=15) (N=15)Repetition 25/min) Mean Sd Mean SdFT0 4.13 1.50 4.0 1.51 0.242 NS*FT 2 8.66 2.22 8.53 2.47 0.155 NS*FT 4 13.33 2.94 14.0 3.46 -0.568 NS*


Table 4Comparison of trunk Sorenson test/ extension test (ET)

between group1 and group 2 at week 0, week 2 and week 4

Trunk Sorenson Test Group 1 Group2 T Value(Extension Test) (Max (N=15) (N=15)Repetition 25/min) Mean Sd Mean SdET 0 1.8 1.52 2.06 1.27 -0.519 NS*ET 2 4.40 1.68 4.86 1.40 -0.824 NS*ET 4 7.13 1.80 7.26 1.83 -0.201 NS*


Table 6Comparison of PAIN, RMDQ, FT AND ET within group 1 at

week 0 (pre treatment) and week 4 (post treatment)

Total Scales Week 0 Week 4 T Value(N=15) (N=15)

Mean Sd Mean SdPAIN A 9.93 1.90 0.40 0.50 19.59 **RMDQ A 6.33 1.54 0.13 0.35 16.29 **FT A 4.13 1.50 13.33 2.94 -16.61 **ET A 1.80 1.52 7.13 1.80 -22.95 **

**:- p<0.01 significant at 1%

Table 7Comparison of PAIN, RMDQ, FT AND ET within group 2 at

week 0 (pre treatment) and week 4 (post treatment)

Total Scales Week 0 Week 4 T Value(N=15) (N=15)

Mean Sd Mean SdPAIN B 10.13 3.20 0.7 1.33 14.723 **RMDQ B 6.60 1.80 0.46 1.06 14.100**FT B 4.00 1.51 14.0 3.46 -13.693**ET B 2.06 1.27 7.26 1.83 -11.063**

**:- p<0.01 significant at 1%

Graph 1: Comparison of SFMPQ between Grp 1and Grp 2at week 0, 2 and 4

22


Graph 2: Comparison of RMDQ between Grp 1and Grp 2at week 0, 2 and 4

Graph 3: Comparison of FT between Grp 1 and Grp 2at week 0, 2 and 4

Graph 4: Comparison of ET between Grp 1 and Grp 2at week 0, 2 and 4

Graph 5: Comparisons of mean differences between Grp 1 andGrp 2 in PAIN, RMDQ, FT and ET at week 0, 2 and 4

Graph 6: Comparison of PAIN, RMDQ, FT and ET in Grp 1at week 0, 2 and 4

Graph 7: Comparisons of PAIN, RMDQ, FT and ET in Grp 2at week 0, 2 and 4

DISCUSSIONOur study indicated that general trunk stabilizationexercises and proprioceptive neuromuscularfacilitation techniques reduced pain and disability,and enhances muscular endurance in the short term(i.e., upto 4 weeks) in subjects with chronic low backpain. In this study, paired t-test showed that bothgroups, individually showed significant positive

changes in pain, functional activity and trunk muscleendurance level at the end of week 4 of the treatmentin patients with chronic low back pain (CLBP).

On comparison between the groups at week 0, 2 and4, were not showing significant improvement.However, occur significant statistical improvementwithin the groups after 4 week of treatment in group

23


1 with mean scores that is in PAIN levels (t=19.590,p<0.01), RMDQ levels (t=16.29, p<0.01), FT levels (t=-16.61, p<0.01), ET levels (t=-22.958, p<0.01). Whereasin group 2 that is in PAIN levels (t=14.72, p<0.01),RMDQ levels (t=14.100, p<0.01), FT levels (t=-13.693,p<0.01), ET levels (t=-11.06, p<0.01). It appearstherefore that both the groups (group 1=trunkstabilization exercises group with TENS) and (group2= proprioceptive neuromuscular facilitation groupwith TENS) are effective in reducing pain, achievingfunctional activity level and muscular endurancelevel of patients with chronic low back pain.Regardless of intervention, however, both groupsexperienced minimal pain after 4 weeks. Thisobservation concurs with previous reports thatpatients with nonspecific low back pain recoveredwithin 2 months56.

The results of our study differ from those of thestudies in which no improvements were foundfollowing exercise intervention. The exerciseprograms in these studies consisted of general trunkstabilization exercises in group 1 it contains flexionand extension mobility exercises. Lindstrom et al andIndahl et al found some positive effects of theirexercise programs on pain and function 56.

Hides et al found that localised physical trainingrestored the size of the multifidus muscle in patientswith acute low back pain. According to Welsh andRutherford, in exercises incorporating an isometricphase, a greater level of metabolite accumulation canbe expected for two reasons. Firstly, the duration ofthese exercises is much longer than in the dynamicmode, and secondly, the static component causeshigher intramuscular pressure, reducing oxygenationin a significant ways. 48

Large reviews conclude that there is strong evidencefor the effectiveness of exercise as a treatment for LBP.For instances, activity and general exercises therapyimproves pain and disability and reduces the numberof sick days in patients with non specific CLBP.Stabilization exercises are a popular treatmentoption, yet reviews of these conclude that the outcomeof specific stabilization and motor control exercisesare not more effective than general exercise programs.However, previous studies paid attention to theselection of patients to receive specific, individualmovement control exercise or general exercise. This

may explain the inconclusive results. Positive studiesinvolved defined clinical subgroups. Benefits ofspecific exercises were demonstrated in other subgroups of patients with LBP. Brennan et al (2006)showed that the outcomes are better if patients receivetreatment adapted to their clinical presentation.2

The effects of motor control exercises in people withCLBP have been investigated in a few studies. Costaet al compared a comprehensive motor controlexercise with placebo ultrasound and shortwavediathermy therapy. After 12 treatments, motor controlexercises had beneficial effects on global impressionof recovery, activity, and activity limitation.6

Pain is a multidimensional experience that has bothperipheral and central substrates. Peripheralnociceptor sensitization, dorsal receptor fieldexpansion, and altered central neuromodulation ofpain may all play a role in the transition from acuteto chronic CLBP. It is thought that the neuroregulatory peripheral and central effects of the TENSmay be more effective with higher intensityapplications such as acupuncture like TENS.Certainly, both psychological as well as biologicfactors influence the severity of the CLBP. Thepossibility exists that individualized benefits fromTENS cannot be precisely captured with small RCTs.Indeed, individual response to different stimulationsettings (frequency, amplitude, pulse width,waveform) may be quite variable. Marc hand et alfound a cumulative effect with successive treatmentsessions of conventional TENS over a period of 10weeks, suggesting that clinical tolerance does notdevelop upto that point.28

There is no evidence of superiority of one type ofTENS in treatment of patients with chronic pain.Johnson eta l (1991) mentioned that patient’spreference for specific pulse frequencies and patternsis more related to reasons of comfort than to the causeand site of pain. Psychological mechanisms, such asincreasing the feeling of control and enhancingcoping with pain by TENS should be taken intoconsideration for explaining effects of TENS, as thesefactors influence pain severity in general (Jensen andKaroly, 19991) 36

Eriksson et al considered patients continuation ofuse of TENS as an indication of benefit from the

24


treatment. They used conventional TENS as the initialtreatment, and this reduced the VAS score by 50% ormore in 30 % of cases at 3 months. Mannheimer andCarlsson found high frequency TENS to be moreeffective and the effect to persist over a longerduration. There appears to be no overall effect ofpulsed as opposed to continuous stimulation.However, the results do suggest that the speediestresponse was obtained using the pulsed highfrequency “accupunture like “TENS and this effectwere particularly marked for patients with neurogenicpain as claimed by Eriksson and Sjolund. 71

In some previous studies, it clearly shows that TENSsignificantly decreased pain intensity ratings in acumulative manner over repeated treatment sessions,in contrast to animal research, where repeated TENSadministration results in gradual diminution ofanalgesic effect via opioid tolerance, but in line withthe results of Marchand et al. Osiri et al found, as aresult of reviewing TENS studies in osteoarthritis,that a significant difference in pain relief wasachieved in studies with an intervention period ofTENS application of at least 4 weeks.25

In group 2 PNF techniques had been performed. Thereare three different type of stretching: static, PNF andballistic 19. The techniques of proprioceptiveneuromuscular facilitation (PNF) rely mainly onstimulation of the proprioceptors for increasing thedemand made on the neuromuscular mechanism toobtain and facilitate its response. Treatment by thesetechniques is very comprehensive and involves theapplication of the principles of PNF. This method ofrehabilitation was developed by Doctor HermanKabat. He stated that treatment by these techniquesaims to summate the effects of facilitation to increasethe response of the neuromuscular mechanism.Proprioceptive stimulation is the principal meansused to increase the demands made by voluntaryeffort, the initiation of some reflex reactions andphysiological principles concerned with theinteraction of antagonistic muscles are also used insome techniques. Resistance and stretch are appliedmanually to muscles working to perform patterns ofmass movements; dynamic commands give verbalstimulation to the patient’s voluntary effort. Maximalresistance is considered to be the most importantmean of stimulating the proprioceptors. 75

According to D. Becker: PNF is an integratedapproach: each treatment is directed at a total humanbeing, not just at a specific problem or segment. Thetreatment approach is always positive, reinforcing,and using that, which the patients can do, on aphysical and psychological level. The primary goalof all treatment is to help patients achieve theirhighest level of function. The basic facilitationprocedures provide tools for the therapists to helpthe patient’s gains efficient motor function andincreased motor control. For example, resistance isnecessary to make the stretch reflex effective(Gellhorn 1949). The effect of resistance changes withthe alignment of the therapist’s body and directionsof the manual contact. We can use these basicprocedures to treat patients with any diagnosis orcondition. The therapist should avoid causing orincreasing the pain. Pain is an inhibitor of effectiveand coordinated muscular performance and it canbe a sign of potential harm (Hislop 1960; Fisher1967).76

In a previous study, by Nick Kofotolis and EleftheriosKellis (2006): Concluded that the positive effects ofthe training programs could be attributed to thenature of PNF exercises, which are designedprimarily to maximize improvements in flexibility.Such exercises take advantage of the body’sinhibitory reflexes to improve muscle relaxation. Thismuscle relaxation allows greater stretch magnitudeduring stretch training, which should result insuperior gains in flexibility. Trunk muscle endurancehas been identified as a potential risk factor for thedevelopment of back pain. In the study, both staticand dynamic muscle endurance were observed.These findings could be attributed to the fact thatboth exercise techniques involve muscle work atsignificant intensity levels that result in musclestrength and endurance improvements. The exerciseprograms applied in the study were short termintensive programs. 23

As the pain scores decreased, the RMDQ scores alsodecreased. The reduction of pain may have enabledthe subjects to carry on with their activities of dailyliving, and thus they reported reduced disability.Disability was better correlated with pain measuresthan endurance performance in subjects withsubacute low back pain. These findings are inagreement with the findings of ROLAND Morris and

25


Hides et al. in both the studies, the correlationbetween pain and back disability as measured bythe RMDQ was examined for the subjects with acutelow back pain.56

Our study shows that in chronic low back pain,using modality i.e. TENS with general trunkstabilization exercises and TENS with proprioceptiveneuromuscular facilitation can reduce pain, improvefunctional activity level (decrease in disability) andenhancement in muscular endurance. Spinalstabilization exercises is more effective over time thanmanual therapy or a minimal education booklet atreducing pain, disability, dysfunction, medicationintake, and improving the quality of life with CLBdisorder. 22The application of 4 week RST and COIPNF programs increased the muscle endurance ofpeople with CLBP by 23.6% to 81%. Back painintensity and functional disability also decreasedsignificantly.23 General trunk exercises alone may bebetter suited for patients with recurrent episodes ofnonspecific subacute or chronic LBP but without anyovert signs or symptoms of instability.26 Stimulationwas based upon best available evidence from theliterature. For conventional TENS, parametersbetween 80-100 Hz and 100-200 micro sec areconsidered to be effective in the treatment of chronicpain. In studies specifically of CLBP populations,parameters of 80 Hz/140 microsec and 100Hz/125microsec resulted in pain reduction.16The highfrequency TENS of 100 Hz gave a speedier reductionin pain levels than 10 Hz, although the differencewas not statistically significant. There appeared tobe no difference between the continuous as opposedto the pulsed form of the therapy.71

Our result support the null hypothesis that there isno significant difference between the propioceptiveneuromuscular program and general trunk exerciseson pain, endurance and functional capacity after 4weeks in patients with CLBP.

LIMITATIONS OF THE STUDYThe sample size was small in size.The duration of the study was short, thereforelong term effectiveness of TENS with stabilizationexercises and proprioceptive neuromusculartechniques to improve muscle endurance,reduction in pain and enhancing functionalactivity is required.

No specific age and gender is taken.No specific profession was taken.Home exercise program was not given to either ofthe groups

CONCLUSIONIn the present study, we found that there is nosignificant difference between the conventional trunkstabilization exercises and proprioceptiveneuromuscular facilitation along with continuousmode TENS and stretching in comparison to eachother, but both the groups showed significantimprovement individually in functional activity,reduction in pain and enhancing muscle endurancein patients with chronic low back pain after thetreatment duration of 4 week.

REFERENCES[1] Farhad Adelmanesh, Ali Arvantaj, Hassan

Rashki et al; Results from translation andadaptation of the Iranian Short form McGillpain questionnaire: preliminary evidence of itsreliability, construct validity and sensitivity inan Iranian pain population; sports medicine,Arthroscopy, Rehabilitation, therapy andtechnology: 3:27, 2011

[2] Hannu Luomajoki, Jan Kool, Eling D de Bruinand Olavi Airaksinen; improvement in lowback movement control, decreased pain anddisability, resulting from specific exerciseintervention; sports medicine , Arthroscopy,Rehabilitation, therapy and technology: 2:11,2010.

[3] Weppler CH, Magnusson SP. Increasingmuscle extensibility: a matter of increasinglength or modifying sensation? Physicaltherapy; 90:438-44, 2010.

[4] Steven Z. George, Virgil T. wittmer, Roger B.filligim, Michael E. Robinson. Comparison ofgraded exercise and graded exposure clinicaloutcomes for patients with chronic low backpain; journal of orthopedics and sportsphysical therapy 2010; 40(11):69-704.

[5] Macedo LG, smeets RJEM, Maher CG, et al.graded activity and graded exposure forpersistent nonspecific low back pain: a systemicreview. Physical therapy, 2010; 90:860-879.

[6] Unsgaard- Tondel, Fladmark AM, salvesen O,vasseljen O, Motor control exercises, slingexercises and general exercises for patients with

26


chronic low back pain: a randomized controlledtrial with 1 year follow up. Physical therapy,2010; 90: 1426-1440.

[7] John D. Childs, Deydre S. Teyhen, Patrick R.Casey, Kimberly A. McCoy-singh, et al. effectsof traditional sit up training versus carestabilization exercises on short termmusculoskeletal injuries in US Army Soldiers:A Cluster Randomized Trial. Phys ther. 2010;90: 1404-1412.

[8] Coach Rizal, review of stretching: short termand long term effect and its techniques: august11th, 2010.

[9] Freidrich M, Hahne J, Wepner F. a controlledexamination of medical and psychologicalfactors associated with low back pain incombination with widespread musculoskeletalpain: physical therapy, 2009; 89: 786-803.

[10] Wim Dankaerts, peter O Sullivan, AngusBurnett, Leon straker, Paul Davey et al.discriminating healthy controls and twoclinical subgroups of nonspecific chronic lowback pain patients using trunk muscleactivation and lunbosacral kinematics ofpostures and movements. Spine volume 34,number 15; 2009.

[11] Macedo LG, Maher CG, Latimer J, McAuley JH.Motor control exercises for persistentnonspecific low back pain: a systemic review:physical therapy. 2009; 89: 9-25.

[12] Costa LOP, Maher CG, latimer J, et al. motorcontrol exercises for chronic low back pain: arandomized placebo- controlled trial. Physicaltherapy. 2009; 89:1275-1286.

[13] Danik Lafond, Mathilde Dimmock, Annickchampagne, and martin descarreaux.Intrasession reliability and influence ofbreathing during clinical assessment of lumbarspine postural control. Physiotherapy theoryand practice, 25 (3): 218-227, 2009.

[14] Law RYW, Harvey LA, Nicholas MK, et al.stretch exercises increase tolerance to stretch inpatients with chronic musculoskeletal pain: arandomized controlled trial. Physical therapy.2009; 89: 1016-1026.

[15] Vibeke valdal, Lars petter edvardsen, freidrikrustad, Andreas gefle and Snorre KrosbyHansen. A pilot study on the effect ofproprioceptive neuromuscular facilitation ongait. Saxion University of applied sciences,

international physiotherapy program,Enschede, Netherlands, 2009.

[16] Karen L Barker, Christopher J Elliott, CatherineM Sackley and Jeremy CT Fairbank. Treatmentof chronic low back pain by sensorydiscrimination training. A phase I RCT of anovel device (FairMed) vs. TENS. BMCmusculoskeletal disorders. 2008; 9:97.

[17] Eric D. Ryan, Travis W.Beck, Trent J. Herda,holly R. hull et al. do practical durations ofstretching alter muscle strength? A dose-response study. Medicine and science in sportsand exercise, vol 40, no.8. pp, 1529-1537; 2008.

[18] Venu Akuthota, Andrea Ferreiro, Tamara Mooreand Michael Fredericson. Core stability exerciseprinciples. Current sports medicine reports.., vol7, no 1, pp 39-44; 2008.

[19] Bruno R. da Costa and Edgar Ramos Vieira.Stretching to reduce work relatedmusculoskeletal disorders: a systemic review.Journal of rehabilitation medicine: 2008; 40: 21-328.

[20] David A Browder, John D Childs, Joshua ACleland, Julie m Fritz. Effectiveness of anextension oriented treatment approach in asubgroup of subjects with low back pain: arandomized clinical trial. Physical therapy.20007; 87: 1608-1618.

[21] Thomas E. Rudy, Debra K. Weiner, Susan J.Lieber et al. the impact of chronic low back painon older adults: a comparative study of patientsand controls. PAIN 131 (2007) 293-301.

[22] Lucy Jane Goldby, Ann P. Moore, Jo Doust andMarion E. Trew. A randomized controlled trialinvestigating the efficiency of musculoskeletalphysiotherapy on chronic low back paindisorder. SPINE 2006; 31: pp 000-000.

[23] Nick Kofotolis, Eleftherios Kellis. Effects of two4-week proprioceptive neuromuscularfacilitation programs on muscle endurance,flexibility, and functional performance inwomen with chronic low back pain. Physicaltherapy, 2006: 86: 1001-1012.

[24] Wasuwat Kitisomprayoonkul, JakkritKlaphajone and Apichana Kovindha. Thaishort form McGill pain questionnaire. Journalof medical association Thai vol. 89 no. 6. 2006.

[25] Jan Oosterhof, Theo M. De Boo, Rob A.B.oostendorp, Oliver H.G. wilder- Smith.Outcome of transcutaneous electrical nerve

27


stimulation in chronic pain: short- term resultsof a double- blind, randomized, placebo-controlled trial. Journal of headache pain(2006)7:196-205.

[26] George A Koumantakis, Paul J Watson,Jacqueline A Oldham. Trunk musclestabilization training plus general exercisesversus general exercise only: randomizedcontrolled trail of patients with recurrent lowback pain. Physical therapy. 2005; 85: 209-225.

[27] Geertruida E Bekkering, Maurits W van Tulder,Erik JM Hendriks, Marc A Koopmanschap, DrikL Knol, et al. implementation of clinicalguidelines on physical therapy for patients withlow back pain: randomized trail comparingpatient outcomes after a standard and activeimplementation strategy. Phys ther. 2005; 85:544-555.

[28] Amole Khadilkar, Sarah Milne, Lucie Brosseau,George wells, peter Tug well et al.transcutaneous electrical nerve stimulation forthe treatment of chronic low back pain: asystemic review. SPINE. Volume 30, number 23,pp 2657-2666, 2005.

[29] Mark Laslett, Birgitta Oberg, Charles N. Aprill,Barry McDonald. Centralization as a predictorof provocation discography results in chroniclow back pain, and the influence of disabilityand distress on discogenic power. The Spinejournal; 5(2005) 370-380.

[30] Steven Z George, Joel E Bialosky, Julie M Fritz.Physical therapist management of a patientwith acute low back pain and elevated fear-avoidance beliefs. Phys ther. 2004: 84: 538-549.

[31] Julie M Fritz, Julie M Whitman, Timothy WFlynn, Robert S Wainner, John D Childs. Factorsrelated to the inability of individuals with lowback pain to improve with a spinalmanipulation. Phys ther. 2004; 84:173-190.

[32] Sandra Brouwer, Wietske Kuijer, Pieter U.Dijkstra, Ludwig N.H. Goeken et al. reliabilityand stability of the Roland Morris disabilityQuestionnaire. Disability and rehabilitation,2004; 26(3): 162-165.

[33] James Rainville, Carol Hartigan, EugenioMartinez, Janet Limke, Cristin Jouve, MarkFinno. Exercise as a treatment for chronic lowback pain. The Spine journal. 4(2004); 106-115.

[34] Nikolai Bogduk. Clinical update: managementof chronic low back pain. MJA 2004; 180:79-83.

[35] Francisco M. Kovacs, Victor Abraira, JavierZamora, Maria Teresa Gil del Real, Joan Lloberaet al. correlation between Pain, Disability, andquality of Life in patients with common lowback pain. SPINE. Vol 29, number 2, pp206-210:2004.

[36] Albere J.A. Koke, Jan S.A.G. Schouten, MyriamJ.H. Lamerichs-Geelen, Jos S.M. Lipsch et al.pain reducing effect of three types oftranscutaneous electrical nerve stimulation inpatients with chronic pain: a randomizedcrossover trial. PAIN 108(2004) 36-42.

[37] Ruth Sapsford. Rehabilitation of pelvic floormuscles utilizing trunk stabilization. Manualtherapy. 9 (2004) 3-12.

[38] Paul J. Goodman. Connecting the core. NSCA’sperformance training journal. Vol 3, number 6.

[39] Kim D. Christensen. Proprioception andeffective rehab care.

[40] Scott Biely, Susan S. Smith, Sheri P. Silfies.Clinical instability of the lumbar spine:diagnosis and intervention. Orthopedicpractice. Vol.18; 3:06.

[41] Sean Fyfe. Stretching- stretching: what’s thepoint? Sports injury Bulletin.

[42] Manohar M. Punjabi. Clinical spinal instabilityand low back pain. Journal of electro-myography and kinesiology 13 (2003) 371-379.

[43] Carol S. Burckhardt and Kim D. Jones. Adultsmeasures of Pain. Arthritis and Rheumatism(Arthritis care and research). Vol. 49, No. 5S,2003, ppS96-S104.

[44] M. Grotle, J. I. Brox and N. K. Vollestad. Crosscultural adaptation of the Norwegian versionsof the Roland Morris Disability and OswestryDisability Index. Journal of rehabilitation andmedicines 2003; 35: 241-247.

[45] Petros J. Boscainos, George Sapkas, EugeniaStilianessi, Konstantinos Prouskas et al. Greekversions of the Oswestry and Roland Morrisdisability questionnaire. Clinical orthopedicsand related research. No 411, pp 40-53; 2003

[46] L.A. Danneels, P.L. Coorevits, A. M. Cools. G.G.Vanderstraeten, et al. differences inelectromyographic activity in the multifidusmuscle and the iliocostalis lumborum betweenhealthy subjects and patients with sub-acuteand chronic low back pain. European Spinejournal. 2002: vol 11: 13-19.

28


[47] R. Ferber, L.R. Osternig, D.C. Gravelle. Effect ofPNF stretch techniques on knee flexor muscleEMG activity in older adults. Journal ofelectromyography and kinesiology. 12 (2002)391-397.

[48] L. A. Danneels, G.G. Vanderstraeten, D. C.Cambier, E.E. Witvrouw, J Bourgois, et al. effectsof three different training modalities on the crosssectional area of the lumbar multifidus musclein patients with chronic low back pain. Britishjournal of sports medicine: 2001; 35: 186-191.

[49] Anne F. Mannion, Astrid Junge, Simo Taimela,Markus Muntener, Kaser Lorenzo, et al. activetherapy for chronic low back pain. SPINE. Vol26. No 8, pp 920-929; 2001.

[50] K. d. Wright, G J Asmundson, D R McCreary.Factorial validity of the Short Form McGill PainQuestionnaire. European Journal of painLondon England (2001), vol 5; issue 3: pp 279-284.

[51] Philadelphia panel evidence based clinicalpractice guidelines on selected rehabilitationinterventions for low back pain. Phys ther. 2001;81: 1641-1674.

[52] Ian Shrier. Does stretching help preventinjuries? Evidence based sports medicine. 1999-2000.

[53] P. B. O’Sullivan. Lumbar segmental“instability”: clinical presentation and specificstabilizing exercise management. Manualtherapy: 5(1); 2-12: 2000.

[54] Martin Roland and Jeremy Fairbank. TheRoland Morris Disability Questionnaire and theOswestry Disability Questionnaire. SPINE, vol25, no 24, pp 3115-3124; 2000.

[55] Effective health care: the bulletin summarizesthe research evidence on the effectiveness of themost common conservative treatments for acuteand chronic low back pain. The University ofYork. NHS center for reviews anddissemination. Nov 2000. Vol 6: no 5.

[56] Beverley Chok, Raymond Lee, Jane Latimer,Seang Beng Tan. Endurance training of thetrunk extensor in people with subacute low backpain. Phys. Ther. 1999; 79: 1032-1042.

[57] Elaine Thomas, Alan J Silman, Peter R Croft,Ann C Papageorgiou, et al. predicting whodevelops chronic low back pain in primary care:a prospective study. British medical journal,1999; 318: 1662-7

[58] Gunnar B J Andersson. Epidemiologicalfeatures of chronic low back pain. Lancet 1999;354: 581-85.

[59] Jari P.A. Arokoshi, Markku Kankaanpaa, TaruValta, Ilkka Juvonen, Juhani Partanen, et al. backand hip extensors muscle function duringtherapeutic exercises. Arch phys med Rehabil1999; 80: 842-50.

[60] Jan P. K Halbertsma, Ingrid Mulder, LudwigN.H. Goeken, et al. repeated passive stretching:acute effect on the passive muscle moment andextensibility of short hamstrings. Arch physmed Rehabil 1999; 80: 407-14.

[61] Peter B. O Sullivan, Lance Twomey, Garry T.Allison. Altered abdominal muscle recruitmentin patients with chronic back pain following aspecific exercise intervention. Journal oforthopedics and sports physical therapy.vol 27:no 2; 1998.

[62] Peter B. O. Sullivan, Lance T. Twomey, Garry T.Allison. Evaluation of specific stabilizingexercise in the treatment of chronic low backpain with radiologic diagnosis of spondylosisor spondylolisthesis. SPINE. Vol 22, no 24,pp2959-2967; 1997.

[63] J Cholewicki, S M McGill. Mechanical stabilityof the in vivo lumbar spine: implications forinjury and chronic low back pain. Clinicalbiomechanics. Vol 11, no. 1, 1-15; 1996.

[64] S peter Magnusson, Erik B. Simonsen, PerAagaard, Poul Dyshre Poulsen, et al.mechanical and physiological responses tostretching with and without preisometriccontraction in human skeletal muscle. ArchPhys Med Rehabil; 1996: vol 77: 373-8.

[65] Audrey L. Long. The centralizationphenomenon. Its usefulness as a predictor ofoutcome in conservative treatment of chroniclow back pain. SPINE; 1995; 20: 2513-2521.

[66] Johan W. S. Vlaeyen. Ank M.J. Kole- Snijders,Ruben G.B. Boeren, and H. van Eek. Fear ofmovement/ reinjury in chronic low back painand its relation to behavioral performance.PAIN 62; 1995: 363-372.

[67] Jan P.K. Halbertsma, Ludwig N.H. Goeken.Stretching exercise: effect on passiveextensibility and stiffness in short hamstringsof healthy subjects. Arch phys med Rehabil;1994; 75:976-81.

29


[68] Manohar M. Panjabi. The stabilizing system ofthe spine. Part I. function, dysfunction,Adaptation, and Enhancement. Journal ofspinal disorders; 1992: vol5; no 4: pp 383-389.

[69] Ibrahim Magdy Elnaggar, Margareta Nordin,Ali Sheikhzadeh, et al. effects of spinal flexionand extension on low back pain and spinalmobility in chronic mechanical low back painpatients. SPINE; 1991; vol 16: no 8: pp 967-972.

[70] Mel C. Stiff. Modified PNF as a system ofphysical conditioning. National strength andconditioning association journal; 1991; vol 13:no4.

[71] T.P. Nash Ffarcs, J.D. Williams and D. Machin.TENS: does the type of stimulus really matter?The pain Clinic; 1990; vol 3: no 3: pp 161-168.

[72] Manohar Panjabi, Kuniyoshi Abumi, JoanneDuranceau and Thomas Oxland. Spinal

stability and intersegmental muscle forces: abiomechanical model. SPINE; 1989; vol 14: no2: pp 194-200.

[73] Joseph Wosk, Arkady S. Voloshin. Low backpain: conservative treatment with artificialshock absorbers. Arch phys med Rehabil 66:145-148; 1985.

[74] Ronald Melzack, Phyllis Vetere and Lois Finch.Transcutaneous electrical nerve stimulation forlow back pain. Physical therapy; 1983: vol 63:no 4: pp 489-493.

[75] S.s. Adler, D. Beckers, and M. Buck. PNF inpractice: an illustrated guide. Second, revisededition, 1999; pg 3.

[76] M. Dena Gardiner, the principles of exercisetherapy, fourth edition: 2005; pp 78-79.

[77] John Low and Ann Reed. Electrotherapyexplained: principles and practice: 3rd edition;2000: pp 115-116.

30


To evaluate the effect of muscle length and resistedexercise on EMG activity of contra lateral upper

extremity muscleDivya Sharma* and Dr. Pravin Kumar**

* Research Student, M.P.T Neurology, D.A.V. Institute of Physiotherapy & Rehabilitation, Jalandhar.** Associate Professor M.P.T Neurology, D.A.V. Institute of Physiotherapy & Rehabilitation, Jalandhar.

INTRODUCTIONCross training exercises are referred to the contralateral limb, by increasing strength in thehomologous muscle of the untrained limb, withoutdirectly involving the later in the motor activity.7

These exercises are refers to the contralateral effect ofchronic motor activity in one limb.13 Muscle strengthrefers to the ability to generate force at a given speed(velocity) of movement. The process of overloadingthe muscular system is referred to as resistancetraining.3 Resistance exercises are those in whichforces of resistance offered to action of the workingmuscles are artificially and systematically to developthe power and endurance of the muscles.6 Resistancetraining exercises are mostly applied to overload themusculoskeletal system, leading to the accelerationenhancement of the muscle length.8 Re-educationmeans educating something, which is alreadyknown by an individual. So the functional re-education program helps the patient to make himindependent. Making the man independent is themain motto for functional re-education programs.14

Background & Purpose: The purpose of this study is to determine the effect of muscle length and resisted exercises onthe EMG resting activity of contralateral upper extremity muscle.

Method: This study included minimum of 30 subjects of both sexes. Then each subject received isometric exercise at fourdifferent positions 0°, 45°, 90° and 135° of elbow flexion. Each received one minute relaxation period between eachcontraction. EMG activity was noted from contralateral sites of biceps brachii muscle during each isometric contractionResult: A total of 50 subjects, which consist of 38 females and 12 male with the mean age of 20.76 (SD 1.94). Oncomparison between 0°-45°,0°-90°,0°-135°,45°-90°,45°-135° and 90°-135°. The result of this study shows, there wassignificant increase in EMG activity at 135 compare to 0, 45 and 90.

Conclusion: We found that, 135° is the best position for the cross training effect.

Keywords: Cross Training, Muscle length, Resisted exercises, EMG Activity, Biceps.

Several investigators have demonstrated a directrelationship between integrated EMG and muscleforce during isometric contraction within the rangeof the physiological muscle length.15 The purpose ofthis study is to determine the effect of muscle lengthand resisted exercises on the EMG resting activity ofcontralateral upper extremity muscle.

There are so many studies have been done to see theactivity of contralateral extremity by doing differentPNF patterns and exercises in upper limb and lowerlimb. Aria M et al conducted a study effect of the useof cross education to the affected side through variousresistive exercises of the sound side and setting ofthe length of the affected muscle and concluded thatvarious resistive exercises on the sound sideconsisted of PNF movement combined with hipinternal rotation was found to be significantlyeffective for inducing cross education.1 Paula cMeniningroni et al conducted a study contralateralforce irradiation for the activation of tibialis anteriormuscle in carriers of charcots-marrie-tooth disease

31

To Evaluate The Effect of Muscle Length and Resisted Exercise on Emg Activity of Contra Lateral Upper Extremity Muscle

effect of PNF intervention program and concludedthat the phenomenon of cotralateral muscle forceirradiation, through the pattern of PNF diagonalspattern used in this study, is an effective therapeutictool.12 Marilyan Pink MS conducted a studycontralateral effect of upper extremity PNF patternand concluded that the production of electricalactivity in the nonexercised limb.9 Inman VT et alconducted a study on relationship of humanelectromyogram to muscle tension and concludedthat there is increase in EMG activity in the shortenedmuscle.2 Aim of this study was to determine the effectof muscle length and resisted exercise on the EMGactivity of contralateral upper extremity muscle.

MATERIAL AND METHODSStudy design was Observational in nature. Study wasconducted at DAV Institute of Physiotherapy andRehabilitation, Jalandhar. Total duration of studywill be one and half years. A total of 50 subjects weretaken in the study. All the subjects were selectedaccording to the criteria:

Inclusion Criteria:1. Age: 18-30 years.2. Gender: Both male and female.3. Individuals should be mentally and physically

fit.4. Subjects should be co-operative.

Exclusion Criteria:1. Engaged in strenuous physical activity for at least

12-24 hours prior to data collection.2. Ingest any substance containing alcohol or drug

for at least 12 hours prior to data collection.3. No history of neurological and musculoskeletal

disorder.

PROCEDURE:-Procedure for data collectionA written consent was obtained from all the subjects.All subjects who met the inclusion and exclusioncriteria in the study were taken and the requiredassessment of every subject was done.

Positioning of the patientSubjects were placed in supine lying position torecord the EMG activity of biceps muscle of nondominant hand. Shoulder is adducted and externallyrotated. To standardized the body position and

localize the contraction of biceps muscle, measurewere taken to stabilize the body parts to preventshoulder flexion, arm was strapped with couch.7

Preparation of the patientThe skin was cleaned with alcohol on the bicepsbrachii muscle in the distal third of the arm in thecommon portion of muscle.2 Surface electrodes wereplaced over the bulk of biceps muscle positioned witha centre to centre inter-electrode distance of 3cm.Ground electrode was positioned on the styloidprocess of the wrist non dominant hand.3

Procedure of EMG recordingThe subjects were asked to produce three maximalcontractions of dominant hand biceps muscle tobecome familiar with the movement before testing.The testing procedure consist of single brief isometriccontraction of the biceps brachii muscle of dominanthand at four different positions of elbow flexionwhich is at 0°(fig.1), 45°(fig.2), 90°(fig.3) and at135°fig.4) of elbow flexion6. Each subjects receivedone minute relaxation period between eachcontraction. EMG activity was noted from

Fig. 1: Resisted Isometric Contraction at 0° of Elbow Flexion


32


contralateral side of biceps brachii muscle duringeach isometric contraction.

DATA ANALYSISStatistical analysis of the data obtained as perprocedure adopted was performed using SPSSsoftware (SPSS version 13.0). Repeated measureANOVA and post hoc paired t-test were used forstatistical analysis. Repeated measure ANOVA testwas used to find out the significance of the study.Significance level was set at p value < 0.05. post hocpaired t test was uses to find out the changes inEMG activity at different angles of elbow flexion.

RESULT:DemographicsA total of 50 subjects were included in this study ofwhich 38 were females and 12 males. Their meanage was 20.76 years (SD ± 1.94).

Interangular ComparisonsThe mean of the EMG activity of contralateral upperextremity muscle at different angles of the elbowjoint were at 0° (X = 114.23, SD ± 40.73), at 45° (X =152.81, SD ± 53.18), at 90° (X = 209.65, SD ± 89.55), at135° (X = 246.48, SD ± 108.72). On comparisonbetween different angle result of this study showed a



significant (p<0.05) change in EMG activity of bicepsmuscle. (Table no. 1, Graph no. 1)

Comparison between 0° and 45°At 0° mean EMG activity was 114.23 ± 40.73 and at45° the mean EMG activity was 152.81 ± 53.18 oncomparing result showed that there is significant(p<0.05) increase in EMG activity at 45° (Table no.1). This suggests that irradiation is more at 45° whencompared to 0° position.



Comparison between 45° and 90°At 45° the mean EMG activity was 152.8 ± 53.18 andat 90° the mean EMG activity was 209.65 ± 89.55 oncomparing result showed that there is significant(p<0.05) increase in EMG activity at 90° (Table no.1). This suggests that irradiation is more at 90° whencompared to 45° position.

Comparison between 45° and 135°At 45° the mean EMG activity was 152.8 ± 53.18 andat 135° the mean EMG activity was 246.48 ± 108.72on comparing result showed that there is significant(p<0.05) increase in EMG activity at 135° (Table no.1). This suggests that irradiation is more at 135° whencompared to 45° position.

Comparison between 90° and 135°At 90° the mean EMG activity was 209.65 ± 89.55and at 135° the mean EMG activity was 246.48 ±108.72 on comparing result showed that there issignificant (p<0.05) increase in EMG activity at 135°(Table no. 1). This suggests that irradiation is moreat 135° when compared to 90° position.

33


Table 1Comparison between Different Angles

Ranges Mean (±SD) t-Value Significance0° 114.23(±40.72) -7.88445° 152.81(±53.18)0° 114.23(±40.72) -9.45390° 209.65(±89.55)0 ° 114.23(±40.72) -10.13135° 246.48(±108.72)45° 152.81(±53.18) -6.9990° 209.65(±89.55)45° 152.81(±53.18) -9.07135° 246.48(±108.72)90° 209.65(±89.55) -6.16135° 246.48(±108.72) – significant (p<0.05)

Graph 1: EMG Activity at Different Angles

So the result of this study showed that there issignificant (p<0.05) maximum increase in EMGactivity of biceps muscle at 135° when compared to0°, 45° and 90° of elbow flexion.

DISCUSSIONThe result of this study shows that there is significant(p<0.05) increase in EMG activity at 135° as comparedto 0°, 45° and 90°.

According to Jack D et al, the change in EMG activityat different muscle length may be a result of autogenicinhibitory afferent innervations from Golgi tendonorgans. When the tendons at a lengthened position.The inhibitory afferent impulses at a lengthenedposition, the inhibitory afferent impulses in theregion of the tendon decreases autogenic muscleactivity. The neurophysiological effect of decreasing

the EMG activity at greater muscle length, togetherwith the mechanical effect of increased force by thepassive parallel elastic components, may account forthe constant force and decrease in EMG activity ofthe lengthened muscle. As a muscle is lengthened,the parallel elastic components are placed on stretch.These fibers may act like an elastic band thatpassively produces increased force with stretch. Asthe overall muscle force remains Constant, anincrease in the force produced by this passive musclecomponent allows for a decrease in force developedby the contractile elements. Hence, fewer motor unitsare needed, which results in reduced EMG activity.The resetting of the spindle afferents may influencedecreased motor unit firing.4

Kennedy PM et al conducted a study on the effect ofmuscle length on motor unit recruitment duringisometric planter flexion in humans. Single motor unitactivity was recorded from the medial gastrocnemiusmuscle while electromyographic activity was recordedfrom the soleus muscle. With the ankle angle heldconstant at 90 degrees, the knee angle was changedform 180 degrees to 90 degrees, corresponding to along and short gastrocnemius muscle length,respectively. At short length, onset of motor unitactivity occurred at significantly higher levels ofplantar flexor torque and soleus EMG. He explainedthat motor units in the shortened gastrocnemiusmuscle may be influenced by peripheral afferentscapable of reducing the excitability of the motorneuron pool. This may also reflect a specific inhibitionof motor units having shortened, non optimal fasciclelengths, and they are thereby incapable of contributingto plantar flexor torque.5

Nicolas Babault et al studied the effect of quadricepsfemoris muscle length on neural activation duringisometric and concentric concentric contractions.Maximal voluntary and evoked twitch torque,activation level, and EMG activity measurements ofthe right knee extensor muscle were performed.Higher neural activation was recorded for shortmuscle length. According to Nicolas Babault et al, atshort muscle length, reduction in torque could partlybe due to mechanical factors such as the reducednumber of attached cross bridges subsequent tosarcomere shortening beyond the optimal actin-myosin overlap. Higher surface EMG activities andslightly higher activation levels recorded for

34


shortened muscles. The higher neural activationrecorded for short muscle length, joint receptorsrespond to mechanical events that result in loadingthe capsule and, together with ligaments receptors,could inhibit the á-motoneurons activity. Thus ashortened position would lessen joint and ligamentstrain as a consequence of the lower torque, thereforeleading to an improved neural activation of themuscle. A reduced inhibition of the motoneurons poolvia peripheral inputs coming from joint and ligamentreceptors is therefore partly expected. Besides theseeffects, muscle length changes are related tomodulations of the muscle spindle activity. Howevermuscle spindles would enlarge neural activation forlengthened muscles. Thus muscle spindles wouldlikely have a reduced contribution partly due to alower sensitivity. Indeed, the muscle spindlesensitivity could be modified by ã-motoneurons thatalso receive connections from joint and ligamentreceptors. Changes in joint and ligament receptoroutput as a function of muscle tension might thereforereduce the muscle spindle sensitivity to muscle lengthchanges. This indirect effect of joint receptors onneural activation has a more potent role than itsdirect action on á-motoneurons. Joint and ligamentreceptors would likely contribute, directly orindirectly (via ã-motoneurons), to neural activationchanges as a function of the muscle length. The higherlevel of neural activation observed in shortenedmuscles performing isometric MVC would result fromspinal mechanisms.11

Several neural mechanism have been proposed forcross exercises including diffusion of impulsesbetween hemispheres, coactivation via bilateralcorticospinal pathway, postural stabilization and thecerebral corticospinal pathway, posturalstabilization and the cerebral cortex theory thatduring the voluntary contraction of the muscle onthe trained side is produced a facilitation effect onthe same motor point in the opposite side of cerebralcortex. This is also explained anatomically by thefact that 10% of the corticospinal fiber enter in thelateral and anterior corticospinal tract of the trainedside, whereas the remaining fibers cross to theopposite side of it through diffusion of the impulses.Because of the crossing over of the fibers ofcorticospinal tract during voluntary contraction ofthe muscle on the trained side produce a facilitationeffect on the same muscle on the opposite side.10

As per study conducted by Virginia M mills whenexercising the uninvolved extremities in patients withCVA caused significant increase in EMG activity inthe hemiparetic extremity during the exercisecondition.16

There are so many studies which shows thecontralateral effect when giving exercise to the soundside.3, 6, 8, 9, 13-15

CONCLUSIONThe result of this study shows that there is significant(p<0.05) maximum EMG activity at 135° in the nondominant hand, as compared to 0°, 45° and 90°. Sowe conclude that the 135° is the best position for thecross training exercises.

REFERENCES[1] Arai Met et al, (2001) ‘Effect of the use of cross-

education to the affected side through variousresistive exercises of the affected side throughvarious resistive exercises of the sound side andsetting of the length of the affected muscles,’Horoshima Journal of medical sciences, Vol50,No3, pp.65-73

[2] Inman VT, et al, (1952) ‘Relationship of humanelectromyogram to muscle tension.Electroencephlography,’ CilnicalNeurophysiology, Vol4, pp. 187-194

[3] Jeffery L. Roitman. (1998): ACSM‘s Resourcemanual for guidelines for exercise testing andprescription, Third edition, Chpt43, pp. 363

[4] Jack D et al, (1981) ‘Relationship between musclelength, muscle activity and torque of thehamstring muscle,’ Physical therapy, Vol61, No2

[5] Kennidy PM, (2001) ‘The effect of muscle lengthon motor unit recruitment during isometricplanter flexion in humans,’ Experimental brainresearch, Vol137, No1, pp58-64

[6] Liliam F et al. (2009), Sports and medicine, vol8,pp. 24-29

[7] Maria G Papandreou et al. (2009) ‘Effect of crossexercises on quadriceps acceleration reactiontime and subjective scores (Lysholmquestionare) following ACL reconstruction’,Orthopedic surgery and research’, Vol10, pp.1749-1799

[8] Mauro Goncalves et al, (2007) ‘Electromyographic analysis of Biceps Brachii and Erector

35


spinae muscles before and after fatiguingdynamic test,’ Salusvita Bauru, vol26, no1, pp.23-27

[9] Marilyan Pink S, (1981) ‘contralateral effects ofupper extremity propioceptive neuromuscularfacilitation pattern,’ Physical therapy, Vol61

[10] Maria G Papandreou et al, (2009) ‘Effect of crossexercises on quadriceps acceleration reactiontime and subjective score (Lysholm questionare)following ACL reconstruction,’ Orthopedicsurgery and research, Vol10, pp. 1749-1799

[11] Nicolas babault et al, (2002) ‘Effect ofquadriceps femoris muscle length on neuralactivation during isometric and concentriccontractions,’ Journal of Applied Physiology,Vol.94, pp. 983–990

[12] Paula C Meningroni et al, (2009) ‘contralateralforce irradiation for the activation of tibialis

anterior muscle in carrier of charcot- marrie-tooth disease effect of PNF interventionprogram,’ Revista Brasileira de Fisioterapia,Vol13, No.5

[13] Shi Zohu. (2003) ‘Cross education andneuromuscular adaptation during early stageof strength training’, Exercise science andfitness. vol1, no1, pp. 54-56

[14] S Lakshmi Narayanan, (2005) ‘Textbook oftherapeutic exercises,’ First edition, chpt12,pp.12

[15] Timothy J. et al, (2006) ‘Contralateral effects ofunilateral strength training: evidence andpossible mechanisms,’ Applied Physiology, Vol101, pp. 1514–1522

[16] Virginia M Mills et al, (1985) ‘Electromyographyresult of exercise overflow in hemiplegicpatients,’ Physical therapy, Vol65, No7

36


Comparison of lung volumes & capacities insmokers and non-smokers

Ruchika Gupta* and Dr. Himanshu Sekhar**

* Researcher Assistant Professor, DAV Institute of Physiotherapy & Rehabilitation, Jalandhar.** Research Guide Assistant Professor, DAV Institute of Physiotherapy & Rehabilitation, Jalandhar.

INTRODUCTIONAddiction to tobacco kills one person prematurelyevery six seconds. One in two long-term smokerslargely in low and middle income countries will diefrom tobacco addiction.1, 2 This epidemic reflects thehighly addictive nature of tobacco, and specificallyof nicotine, its principal addicting component.Cigarette smoking is a practice of burning dried orcured tobacco leaves and inhaling its smoke.According to the world health organization (WHO)about 1/3rd of the total male population in the worldsmokes tobacco.3 most people smoke tobacco in the

Background & Purpose: To compare the lung volumes & capacities in smokers and non smokers.

Method: 30 subjects were taken for the study. Out of which 15 were chronic smokers & 15 were non smokers on the basisof inclusion and exclusion criterion within the age group of 35 to 70 years. After taking a brief clinical assessment, thesubjects were asked to sign the consent form and then Peak expiratory flow rate (PEFR), Inspiratory breathing holdingcapacities (IHC) and Chest Expansion were performed on the enrolled subjects in sitting position.

Result: Unpaired t-test was used for between group data analysis. The mean difference and standard deviation of PEFRin smokes and non smoker was found to be 170+ 64.961 and 170+62.322 respectively. The average value of PEFR insmokers and non smokers was 205.27 and 375.53 respectively. This clearly shows that PEFR in smokers is less than nonsmokers & it was significant (p<0.05). In case of Inspiratory breath holding capacity mean difference and standarddeviation was 5.93+5.058 in smokers and 5.93+4.004 in non smokers. The average value of IHC in smokers and nonsmokers was 6.65 & 12.58 respectively. This reveals that IHC in smokers is lower in smokers than non smokers & it wassignificant (p<0.05). In case of Chest Expansion: AT AXILLARY LEVEL-mean diff. and standard deviation in smokersand non smokers was 2.50+1.572 and 2.50+2.282 respectively. The average value of chest expansion in smokers was3.66 and in non smokers was 6.16. AT NIPPLE LEVEL- the average chest expansion of smokers and non smokers was3.65 and 6.57 respectively. The mean diff. and standard deviation were 2.91+1.434 in smokers and 2.91+1.941 in nonsmokers. AT XYPHOID LEVEL- the average value of chest expansion in smokers and non smokers was 3.58 and 6.18respectively. The mean diff. and standard deviation was 2.60+1.410 in smokers and 2.60+1.73 in non smokers. All theresults and data analysis proves that chest expansion in smokers is less than non smokers & it was significant (p<0.05).

Conclusion: The study concludes that smokers between the age group of 35 to 70 years who had been a habitual smokerfor last 5 years suffered from decreased lung functional capacity. The PEFR, IHC and CHEST EXPANSION are lower insmokers than in non smokers. It should be concluded that smokers are always at par with non smokers. They live a betterhealthy life compared to smokers and live longer.

Keywords: Peak expiratory flow rate (PEFR), Inspiratory breathing holding capacities (IHC) and Chest Expansion.

form of cigarette. If one starts smoking for any reason,it usually ends in becoming a habit. Knowingly orunknowingly, people get addicted to smoking.

Ingesting a compound by smoking is one of the mostrapid and efficient method of introducing it into theblood stream, second only to injection. On average ittakes about ten seconds for the substance to reachthe brain, as a result of the efficiency of this deliverysystem, many smokers feel as they are unable tocease.4 Nicotine contained in tobacco smoke is ahighly addictive psychoactive chemical when

37

Comparison of Lung Volumes & Capacities in Smokers and Non-Smokers

tobacco is smoked most of the nicotine is pyrolyzed,a dose sufficient to cause mild somatic dependencyand mild to strong psychological dependencyremains. There is also formation of a hormone (a MAOinhibitor) from the acetaldehyde in cigarette smokewhich seems to play an important role in nicotineaddiction.5 Recent evidence has shown that smokingtobacco increases the release of dopamine in brainspecifically in the mesolimbic pathway. Thussubstances present in tobacco smoke stimulate thebrain, increase reaction time, improves mentalperformance and mood and cognitive processing butall these effects are short lived. Then start thesymptoms of nicotine withdrawal, such as irritability,restlessness, fatigue, insomnia, hunger, inability toconcentrate etc. Then to overcome these symptomsthe smoker lights up another cigarette and hence avicious cycle of smoking starts.6

Harmful effects of smokingTobacco contains harmful chemicals such as nicotineand cyanide which at higher doses are lethal.Nicotine is an alkaloid that has been used ininsecticides and in medicine.

Smoking affects mostly all the organs of the body’simmune system. It results in a bad skin (due to lackof oxygen supply), bad breath (halitosis) and alsoleads to yellowing of teeth. Tobacco use leads to mostcommonly to diseases effecting the heart and lungs,with smoking being a major risk factor for heartattacks, stokes, chronic obstructive pulmonarydisease (COPD), emphysema and cancer of differentorgans.7

Let’s see some harmful effects of smoking on thehuman body.

HEART DISEASE AND STROKE- A mixture ofcarbon monoxide and nicotine in tobacco smokeincreases the heart rate of a smoker temporarilyleading to high blood pressure or hypertension,it also causes fat deposition in the blood vesselsand narrows them causing heart attack andstroke.DIGESTIVE SYSTEM- Smoking affects the wholedigestive system of the body leading to heart burnand peptic ulcer. Chances of stomach infectionare also higher in smokers as compared to nonsmokers.

SKELETAL SYSTEM- smoking leads toosteoporosis and degenerative disk diseases.CANCER- smoking can cause different types ofcancer including lung, throat, stomach, bladderand pancreatic cancer.COMPLICATIONS OF PREGNANCY- tobaccouse is significant factor in miscarriages amongpregnant women those who either are smokers orcome in prolonged contact with smokers (passivesmoking). Smoke contains several carcinogenicpyrolytic products that bind DNA and causemany genetic mutations. It contributes to anumber of other threats to the health of fetus suchas premature births and low birth weights.FERTILITY- Incidence of impotence isapproximately 85% higher in male smokerscompared to non smokers and it is a key cause oferectile dysfunction (ED).EFFECT ON LUNGS- every time a cigarette issmoked, the following occurs-The minute hairs in the upper airways (cilia) areparalyzed or damaged by chemicals in cigarettesmoke.The lungs are irritated so the airways narrowwhich encourages phlegm (viscid mucous) andmakes it hard to breath.Carbon monoxide a poison is forced into the bloodand restricts the oxygen carrying capacity of theblood.Hydrogen cyanide and other chemicals in smokeattacks the lining of bronchi, inflaming them andcausing chronic smokers to cough (smoker’scough).8

Thus leads to a number of lung diseases:Chronic obstructive pulmonary disease(COPD),chronic bronchitis, emphysema andasthma.7

Lung cancer and other cancers of airwaysincluding the esophagus and larynx.Smokers are more likely to get bronchial infectionssuch as pulmonary TB and other infections ofupper and lower respiratory tract.Smoking also has an adverse affect on lungvolumes and capacities. Peak expiratory flow rate(PEFR), vital capacity (VC) and tidal volumesdecrease predominantly with chronic smoking.9,10

A person’s increased risk of contracting a disease isdirectly proportional to the length of time that a

38


person continues to smoke as well as the amountsmoked. Thus lung damage is also more prominentin chronic chain smokers and lung function testsperformed on them show more significant results.Chronic smokers face a major loss in their health. Theylive a poor unhealthy life and are always at a risk ofcontracting life threatening diseases and ultimatelylead to a disability and death. Male and femalesmokers lose an average of 13.2 and 14.5 yrs of liferespectively.11 The world health organization (WHO)estimated that tobacco caused 5.4 million deaths inyear 2004 and 100 million deaths over the course of20th century.3Smoking is very cost ineffective in termsof life and money. Smokers are dangerous not only forthemselves but also for their family and other peoplecoming in their contact. Smoke released by themremains in the environment for a sufficiently long timeand enters into the lungs of the people breathing inthat air (passive smoking) and it can cause samedeleterious effect on their body. Thus smoking isequally harmful for an individual as well as to hisfamily, society and environment around them.

In other way, we can say that non smokers are at apar with the smokers they enjoy various benefits intheir health and wealth. Non smokers are a boon tosociety and environment as well. Via are researchstudy we have taken the initiative to make the peopleaware of ill affects of smoking, especially on lungs.11

If some one stops smoking, deleterious affects ofsmoking can be reversed and damage to there bodycan be repaired and they can also live a better healthylife. Thus we convinced them to quit smoking as soonas possible, because it’s never too late.

Aims and objectives of studyTo compare the PEFR using a peak flow meter inchronic smokers (CS) and non smokers (NS).To compare the inspiratory breath holdingcapacity (IHC) using a spirometer and a stopwatch.To compare the chest expansion at three levels –axillary level, nipple level and xiphoid level insitting position using an inch tape in CS and NS.

Significance of studyThis study will be helpful in finding the adverseeffects of smoking on lung volumes and capacities(PEFR, IHC and CHEST EXPANSION).

This study will make the people aware of howtheir lungs get damaged by smoking and willencourage them to quit smoking for the sake oftheir health.

HypothesisAlternative hypothesis

There is significant difference in PEFR, IHC and lungvolumes of chronic smokers and non smokers.

Null hypothesisThere is no difference in PEFR, IHC and lung volumesin chronic smokers and non smokers.

MethodologySTUDY DESIGN – observational studySAMPLE SIZE - 30 subjects divided in 2 groupsof 15 each in chronic smokers and non smokerson the basis of inclusion and exclusion criterionwithin the age group of 35 to 70 years.SAMPLING TECHNIQUE - incidental sampling.

Inclusion criteriaIndividuals who are chronic smokers (who aresmoking for minimum of last 1 years) betweenthe age group of 35 to 70 years (only males).6

Individual who smoked more than 200 bidis/cigarette per year.10

Individual having no present/past history ofsmoking at all are included under non smokersgroup.Subjects should be co-operative.

Exclusion criteriaFemalesIndividuals above or below the age limit were notincluded.Individuals diagnosed with any systemicdiseases, any respiratory deseases or any chestdeformity or spinal deformity such as kyphosis,scoliosis etc. were not included.Individuals who were smoking for a time periodof less than 1 years were not included.

VARIABLESDependent variables1. Peak Expiratory Flow Rate2. Inspiratory breath holding capacity3. Chest expansion

39


Independent variables1. Smokers2. Non smokers

PROCEDURE30 subjects were taken for the study. Out of which 15were chronic smokers & 15 were non smokers on thebasis of inclusion and exclusion criterion within theage group of 35 to 70 years. After taking a briefclinical assessment, the subjects were asked to signthe consent form and then Peak expiratory flow rate(PEFR), Inspiratory breathing holding capacities(IHC) and Chest Expansion were performed on theenrolled subjects in sitting position.

• To measure the Peak Expiratory Flow Rate: Apeak flow meter with tight fitting mouth piece wastaken and subjects were asked to take a deepbreath and exhale as forcefully as possible in asingle blow into the instrument. The procedurewas repeated five times with an interval inbetween and result of each recording wasrecorded in l/min.17

• To measure the inspiratory breath holdingcapacity: The subjects ,in high sitting position,were asked to hold the spirometer parallel to thesurface, and were then asked to inhale maximallythrough the mouth piece of spirometer in order topick all 3 balls up from the base. Then we askedthem to hold the breath as long as possible. Thetiming was then recorded with the use of stopwatch in seconds.18

Table 2Showing average, standard deviation and range of PEFR,

inspiratory breath holding capacity, chest expansion (at axillarylevel, nipple level and xyphoid process level) in smokers

SMOKERSAGE PEFR IHC AL NL XL(years) (l/min) (sec.) (cms) (cms) (cms)

Average 50.4 205.27 6.65 3.66 3.65 3.57Standard Deviation 8.773 64.961 5.058 1.572 1.434 1.410Highest 68 278 21.32 6.04 5.6 5.5Lowest 38 56 1 1.24 1.1 1.14Range 30 222 20.32 4.8 4.5 4.36

DATA ANALYSIS

Table 1Showing the average, standard deviation and range of

PEFR, inspiratory breath holding capacity and chestexpansion (at axillary level, nipple level and xyphoid

process level) in non smokers

NON SMOKERSAGE PEFR IHC AL NL XL(years) (l/min) (sec.) (cms) (cms) (cms)

Average 51.4 375.53 12.58 6.16 6.57 6.18Standard Deviation 6.833 62.322 4.004 2.282 1.941 1.731Highest 68 464 19.38 11.3 10.5 9.7Lowest 40 255 3.48 2.7 3.2 3.3Range 28 209 15.9 8.6 7.3 6.4

Table 3Showing the result of PEFR, IHC & CHEST EXPANSION analysis using unpaired t-test in smokers and non smokers

Unpaired Smokers Non Smokers Non Smokers Non Smokers Non Smokers Non Smokers NonTest Smokers Smokers Smokers Smokers Smokers Smokers

A G E A G E PEFR PEFR I H C I H C AL AL N L N L XL XL(Years) (Years) (l/min) (l/min) (sec) (sec) (cms) (cms) (cms) (cms) (cms) (cms)

Mean 50.4 51.4 205.27 375.53 6.65 12.58 3.66 6.16 3.65 6.57 3.57 6.18MeanDifference 1 170.27 5.93 2.5 2.91 2.6SD 8.773 6.833 64.961 62.322 5.058 4.004 1.572 2.282 1.434 1.941 1.41 1.731Highest 68 68 278 464 21.32 19.38 6.04 11.3 5.6 10.5 5.5 9.7Lowest 38 40 56 255 1 3.48 1.24 2.7 1.1 3.2 1.14 3.3Range 30 28 222 209 20.32 15.9 4.8 8.6 4.5 7.3 4.36 6.4TestStatistics 0.348 7.325 3.563 3.49 4.677 4.515p value 0+++++.7302 0.0000 0.0013 0.0016 0.0001 0.0001Table Value 2.04 2.04 2.04 2.04 2.04 2.04Result Not Significant Significant Significant Significant Significant Significant

• To measure chest expansion: After a short breakof 1 min. the subjects were asked to remove extraclothing and were made to sit erect. Then thesubjects were asked to exhale and readings were

40


Graph 1: Showing the comparison of peak expiratory flow rate (PEFR) in smokers and non smokers

General consideration• Dettol was used as a sanitizer for the purpose of

hygiene. Proper demonstration of procedure wasgiven to the subjects and they were made to takeadequate rest in between.

RESULT AND DISCUSSIONOn lungs, smoking is one of the most importantetiological risk factors in COPD and it significantlyincreases the progressive deterioration of lungfunction.20 Smoke passes through the bronchi,hydrogen cyanide and other chemicals in smokeattack the lining of bronchi inflaming them andbecause the bronchi are weakened, smokers are morelikely to get bronchial infection, mucous secretion insmoker’s lungs is also impaired leading to chroniccough.21 Thus has an adverse affect on lung volumesand capacities – resulting in fall in peak expiratoryflow rate (PEFR), Inspiratory breath holding capacity(IHC) and chest expansion.22,23 Our data supports thisview as it has shown a great diff. in PEFR, IHC andChest expansion of chronic smokers and non smokers.

Graph 2: Showing the comparison of inspiratory breath holding capacity (IHC) in smokers and non smokers.

Graph 3: Showing the comparison of chest expansion ataxillary level (AL), nipple level (NL) & Xiphoid level in smokers

and non smokers in cm.

noted using inch tape at 3 different levels- axillarylevel , nipple level and xyphoid level, then thesubject was asked to inhale the values were againnoted down at the above mentioned 3 levels. Thedifference of readings with expiration andinspiration corresponding to the 3 levels is chestexpansion at that particular level.19

41


• Data analysis of 15 smokers and non smokersrevealed that PEFR in smokers is lower than nonsmokers. The mean difference and standarddeviation of PEFR in smokes and non smoker wasfound to be 170+ 64.961 and 170+62.322respectively. The average value of PEFR insmokers and non smokers was 205.27 and 375.53respectively. This clearly shows that PEFR insmokers is less than non smokers.

• In case of Inspiratory breath holding capacitymean difference and standard deviation was5.93+5.058 in smokers and 5.93+4.004 in nonsmokers. This reveals that IHC in smokers is lowerin smokers than non smokers.

Chest expansion• At Axillary Level mean diff. and standard

deviation in smokers and non smokers was2.50+1.572 and 2.50+2.282 respectively. Theaverage value of chest expansion in smokers was3.66 and in non smokers was 6.16.

• At Nipple Level the average chest expansion ofsmokers and non smokers was 3.65 and 6.57respectively. The mean diff. and standarddeviation were 2.91+1.434 in smokers and2.91+1.941 in non smokers.

• At Xyphoid Level the average value of chestexpansion in smokers and non smokers was 3.58and 6.18 respectively. The mean diff. and standarddeviation was 2.60+1.410 in smokers and2.60+1.73 in non smokers. All the results and dataanalysis proves that chest expansion in smokersis less than non smokers.

Hence the study supports the view of SatipattiChaterjee n et al that PEFR and other spirometriclung functions are significantly lower in smokersthan non smokers. Our study also supports the viewof William Holt that states that the chest expansionin smokers is less than in nonsmokers. So smokingalters the lung volumes and capacities in otherwisenormal individuals. Hence non smokers live a betterlife than smokers.

LIMITATIONS OF STUDY1. Study was very gender specific.2. BMI was not considered in the study.3. Subjects with any diagnosed systemic disease

were not considered.

4. People below and above the age limits were nottaken.

5. People who were smoking for duration of lessthan 10 years were not considered.

FUTURE SCOPE OF THE STUDY1. This study can be carried out on both genders.2. Can be done on larger sample size.3. Impact of smoking on respiratory diseases can

also be studied.4. Long term effects of smoking on lungs can be

studied.5. Effect of smoking on other systems of the body

can also be studied.

CONCLUSIONOur study showed that smokers between the agegroup of 35 to 70 years who had been a habitualsmoker for last 5 years suffered from decreased lungfunctional capacity. The PEFR, IHC and CHESTEXPANSION are lower in non smokers than insmokers. So adverse effects of smoking on the bodyare as follows

1. The peak expiratory flow rate in smokers issignificantly reduced thus decreasing thefunctional capacity of the lungs.

2. Smoking also decreases the inspiratory breathholding capacity (IHC) in smokers to a significantlevel.

3. The chest expansion is also reduced in smokersthat results in decreased air entry in to the chest.

It should be concluded that smokers are always atfar with non smokers. They live a better healthy lifecompared to smokers and live longer. Via thisresearch study we tried to make people aware ofharms of smoking on there lungs and encouragedthem to stop smoking as soon as possible becausethere is nothing more important in live than health.

REFERENCES[1] Jha P et al. Tobacco addiction. In: Jamison DT et

al., eds. Disease control priorities in developingcountries 2nd ed. New York, NY, OxfordUniversity Press, 2006, 869–886.

[2] WHO report on the global tobacco epidemic:implementing smoke-free environments,Geneva, World Health Organization, 2009

42


[3] “Prevalence of current tobacco use amongadults aged e” 15 years (percentage)”. WorldHealth Organization. Retrieved 2009-01-02.

[4] Omur Syden, Adile Berns, Dursum, Behar Kurtand et al. Correlation of functional andradiological findings of lungs in asymptomaticsmokers. Turkish respiratory journal, vol. 9,issue-1, 2008.

[5] Pelin Kovic, Dalif MD, Lorcha, Ulrich MD,Ronald MD. Spirometeric gated quantitative CTof lungs in healthy smokers and non smokers.Investigative radiology. Vol. 32(6) pp335-343,1997.

[6] Michels A, Decoster K, Derdal, et al. Influenceof posture on lung volumes and impedance ofrespiratory system in healthy smokers and nonsmokers Japple physio.71:14771488, 1991.

[7] Lund Back B , Lindberg A, Lindstrom M,Ronmark E and et.al. Not 15 but 50% of smokersdevelop COPD, report from obstructive lungdisease in northern Sweden, Respir Med.97(2):115-22, 2003.

[8] WHO – A global status report Anonymous.Tobacco or health: world health organizationGeneva 115-115, 1997.

[9] Quanjer, P.H., G.J.Tammeling, J.E.Cotis and etal. Lung volumes and forced ventilator flowrate. Standardization of lung function tests.European community for steel and coal. Eur.Respir.J.6 (suppl.16). 5-40. 1993.

[10] Hussain G. Zafar S, Ch A.A and et.al.Comparative study of peak expiratory flow ratein cigarette smokers and non smokers of Lahoredistrict. Annual vol.13.no.4, 2007.

[11] William L.Holt. The statistical study of smokersand non smokers. University of lennessce.1921.

[12] Ali, Vehdette and et.al. Assessment Of chest andpostural alignment in healthy Turkish coalminers. Med Sci, 4(3):240-245. 2004.

[13] GORAN Hedensitierna, Lennart Jorfelt, StellanBygdeman. Flow volumes curves in healthynon smokers and smokers. Annals , vol 13no.4.1980.

[14] Satipati CHATTERIEE, Samir Kumar NAG andSwapan Kumar DEY Spirometric Standards forNon-Smokers and Smokers of India (EasternRegion) Japanese Journal of Physiology, 38,283-298, 1988

[15] Maurel A, Apovo M, Beuzard Y, Boynard M,Lagrue G: [Effect of smoking on bloodrheology]. J Mal Vasc; 1996 Oct;22(4):239-43

[16] K.M.Padmavasthy, comparative study ofpulmonary function variables in relation totype of smoking, Indian J Physiol Pharmacol2008; 52 (2) : 193–196

[17] Geijer RM, Sachs AP, Hoes AW, Salome PL andet. al. Prevalence of undetected persistentairflow obstruction in male smokers. 40-65years old. Fam pract.22 (50)485-9.2005.

[18] Golding John F. Smoking In: respiratorymedicine, Gibson G J Saunders. Elsevier scienceLtd., 3.Ed.2003, 1:665.

[19] Alakija W, Lyawe VI, JarikreLN. Ventilatoryfunction of workers at Okpella cement factoryin Nigeria.w .Af, J med, 1990:187-192.

[20] Peter KJ. Chronic obstructive pulmonarydisease, pathology of COPD, in: respiratorymedicine. Gibson JG Saunders Elsevier scienceLtd. 3, 2003; 2:11.

[21] Suzuki S. Divers lung function. Influence ofsmoking habit. J occupational health 1997; ( 2):95-99.

[22] Gautrin D, D’Aquino LC Gagnonh, Malo JL,Comparison between peak flow rate and FEV1in the monitoring of asthmatic subjects at anout patient clinic. Chest 1994, 106(5):1419-26.

[23] Sri Nivas P, chia YC, poi PJ AND Shah Ebrahim.Peak expiratory flow rate in elderly Malayans.Apollo life your health 2001; 1.

Title of the study:

Name of the first author:

Occupation :

Name of the second author:

Occupation:

Year of the study:

Date of submission:

MANUSCRIPT SUBMISSION FORM


Declaration

I _________________________ have been informed about the rules and regulations of manuscript

submission in “IAMR journal of Physiotherapy. This study is my original work and my co-author has

helped/guided me in this and we have not applied this for another publication.

I am giving my consent to “IAMR Journal of Physiotherapy” to publish my research work.

Name of the first author:

Signature :

Date:

Name of the second author:

Signature :

Date:

(a) The manuscripts should normally not exceed 25(A 4 Size) pages, margin 1 inch in all sides including figures and tables, typed in 1.5space in 12-point – preferably- in Times New Roman font.

(b) Research paper / article should be submitted in the form of MS Word file through e-mail.

(c) The cover page of the article should contain: (i) Title of the article (in bold) (ii) Name(s) of authors (iii) Professional affiliation (iv) Address of correspondence and Email Kindly note the authors name should not be mentioned in any other page.

(d) The second page should contain (i) title of the article (Time New Romans 16, in bold) (ii) an abstract of the paper in about 200-250 words (Times Roman 12-point type, single spacing, in italics) that clearly includes the Purpose, Design/methodology/approach, Findings, Research limitations/implications, Practical implications, Originality/value. (iii) Keywords should be provided which encapsulate the principal topics of the paper. (3-5 key words)

(e) The manuscripts may contain footnotes /end note. References should be placed at the end of the paper and arranged alphabetically.

(f) References must be given in alphabetical order and typed on a separate page, single-spaced, at the end of the paper.

(g) All Figures (charts, diagrams and line drawings) and Plates (photographic images) should be submitted in electronic form. They should be of clear quality, in black and white and numbered consecutively

(h) Tables should be typed and included as part of the manuscript. They should not be submitted as graphic elements.

(i) Mathematical expressions, figures and charts should be presented in a way that will be easily printable. Tables and diagrams should be numbered consecutively and included in the text. Source must be mentioned below the table.

(j) Please check your manuscript for clarity, grammar, spellings, punctuation, and consistency of references to minimize editorial changes.

(j) The editorial team has the right to modify or edit the work in order to match the standard and style requirement of the journal.

(k) The following format should be used for referring books, articles in journals, electronic documents etc:

Journal article:Bekaert, G., Harvey, C.R. and Lundblad, C. (2007) ‘Liquidity and expected returns: lessons fromemerging markets’, Review of Financial Studies, Vol. 20, pp.1783–1831.

Book :BGeddes, K.O., Czapor, S.R., Labahn, G. (1992): Algorithms for Computer Algebra. Kluwer Publishing, Boston

Online DocumentCartwright, J.: Big stars have weather too.IOP Publishing Physics Web. http://physicsweb.org/articles/news/11/6/16/1 (2007). Accessed 26 June 2007

Author's Guidelines

• Author should make a soft copy of his/her research work in the above mentioned format and mail the soft copy to [email protected]

• Authors should also post a hard copy of their research work in the above mentioned format and the duly filled manuscript submission form to the following address:

• C/o Dr. Shagun Agrawal

Department of Physiotherapy

Institute of Applied Medicine and Research (IAMR)

9th Km Milestone, Delhi-Meerut Road

Duhai, Ghaziabad, UP

I want to subscribe to international class journal “IAMR JOURNAL OF PHYSIOTHERAPY”.

Subscription Rates: Yearly Rs 1000/- and for 5 Years Rs 3000/-.

Name and complete address (in capitals) ...............................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Please find enclosed my Demand Draft No ....................................... Dated ................................. for

Rs ................................. in favour of IAMR GZB, payable at Ghaziabad.

1. Advance payment required by Demand Draft payable to IAMR GZB payable at Ghaziabad.2. Cancellation not allowed except for duplicate payment.


SUBSCRIPTION FORM

SEND REMITTANCE TO

Institute of Applied Medicines and Research (IAMR)9th KM, Delhi-Meerut Road, Ghaziabad, UP, India – 201 206

TEL: 0120-2675904/05E-mail: [email protected]

INSTITUTE OF APPLIED MEDICINES & RESEARCH9th K.M. Milestone, Delhi-Meerut Road, Duhai, Ghaziabad, U.P.

Phone: 0120-2675904 / 05, Website: www.iamrgzb.com

ME DD IE CI IL NP EP SA &F RO EE ST EU ATI RT CS HNI

IAMR

e d medi iamr f &r journal of physiotherapy se...

Documents