E D MEDI IAMR F &R JOURNAL OF PHYSIOTHERAPY SE...

INSTITUTE OF APPLIED MEDICINES & RESEARCH

The effectiveness of a work style intervention on the recovery from chronic neck and upper limb symptoms in computer workers

Rahul Sharma, Dr. Shagun Agarwal

Effect of microcurrent facial muscle toning on fine wrinkles & firmness of face

Shilpa Jain, Dr Maneesh Arora

Comparing OKC (open kinetic chain) with CKC ( closed kinetic chain) along with hot pack on quadriceps strength and functional status of women with osteoarthritic knees.

Divya Rashmi Negi, Dr. Poonam Rani

Effect of neural mobilization on H-reflex and Oswestry Disability Questionnaire in sciatica

Dr. Pravin Kumar, Rajinder Kaur

Comparing efficacy of eccentric training, static stretching and awareness through movement in improving hamstring flexibility in females

Shweta Jain, Dr. Vijeta Arora

INSIDE

Volume 1 • Number 1 • March - August 2012

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.

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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 features in the advertisement in the journal, which are purely commercial.

Corresponding address:Department of Physiotherapy

Institute of Applied Medicines and Research (IAMR)th9 Km Stone, Delhi-Meerut Road,Ghaziabad, UP, India - 201 206

CHIEF PATRON

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

PatronMr. Sanjay BansalMrs. Anshu Bansal

Editor-in- Chief Executive EditorsDr. Shagun Agarwal Dr. Baljeet Kaur

Editorial Board

Dr. Poonam Singh, Dr. Meenakshi Bhadana,

Dr. Huma Siddiqui, Dr. Nidhi Singh

ADVISORY BOARD

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

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

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

Dr. Maneesh Arora Principal, SBSPGI Dehradun

Dr. Nikita JoshiPrincipal, Dept of PhysiotherapySikkim Manipal University, Gangtok.

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

Dr. Jasmine HOD, Sir Ganga Ram Hospital, Delhi

Dr. Tejbir singhDirector, Kamal Hospital

Dr. Harpreet SinghSenior Physiotherapist, AIIMS


The effectiveness of a work style intervention on the recovery from chronic 1neck and upper limb symptoms in computer workers.

Rahul Sharma, Dr. Shagun Agarwal

Effect of microcurrent facial muscle toning on fine wrinkles & firmness of face. 13

Shilpa Jain, Dr Maneesh Arora

Comparing OKC (open kinetic chain) with CKC ( closed kinetic chain) along 20with hot pack on quadriceps strength and functional status of women with osteoarthritic knees.

Divya Rashmi Negi, Dr. Poonam Rani

Effect of neural mobilization on H-reflex and Oswestry 34Disability Questionnaire in sciatica.

Dr. Pravin Kumar, Rajinder Kaur

Comparing efficacy of eccentric training, static stretching and 44awareness through movement in improving hamstring flexibility in females.

Shweta Jain, Dr. Vijeta Arora

Contents


Volume 1 • Number 1 • March - August 2012

1

The effectiveness of a workstyle intervention on the recoveryfrom chronic neck and upper limb symptoms in computer

workersRahul Sharma *, Dr.Shagun Agarwal **

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

INTRODUCTIONJobs requiring the use of a computer input deviceoften expose workers to awkward and sustainedposture and repetitive motion of the upper extremitieswhich have been demonstrated as cause of workrelated shoulder and neck pain. The US Departmentof health and human services estimated that in 1996,7% of human men and 9% of US women experiencedsome of work related neck pain.54

The incidence of neck pain combined with theincreased numbers of workers using computerprompted the US occupational safety and healthadministration (OSHA) to institute guidelines andergonomics evolution procedures for working safelywith visual display terminals. The OSHA visual

Background and purpose: Jobs requiring the use of a computer input device often expose workers to awkward andsustained posture and repetitive motion of the upper extremities which have been demonstrated as cause of workrelated shoulder and neck pain. Generally the assessment of computer workers posture is done in clinic and mostly instanding and seating position usually do not involve work style modification or work habit modification. The purposeof this study was to evaluate the effect of an intervention that tends to decrease work load by improving work style andto increase capacity by giving physical therapy intervention in computer workers with chronic neck pain. A work stylemodification has been shown to be effective in reducing musculoskeletal discomfort.

Methods: Thirty patients with chronic neck and upper limb symptoms in computer workers were randomized into twogroups: as follows: group 1 – physical therapy intervention and work style intervention, group 2 – physical therapyintervention only. This is a three weeks intervention. The patients were evaluated with a visual analogue scale, NeckDisability Index, and Northwick park neck pain questionnaire (NWNPQ). Measurement has taken before start ofstudy, after one week, and at the end of study.

Results: Subjects those who received physical therapy intervention with work style intervention their VAS, NDS, andNWNPQ scores improved 1.4, 1.2 and 1.2 times more respectively than those who received only the physical therapyintervention.

Conclusion: This study provides evidence that both the intervention programs are effective in improving neck andupper limb symptoms in computer workers .but work style intervention with physical therapy intervention is moreeffective.

Keywords: Neck and upper limb symptoms; Computer workers; Work style intervention; deep neck flexors trainingendurance strength training.

display terminal guidelines allow companies todetermine the presence of work related musculo-skeleton discomfort risk factors and provide specificrecommendation for safe seating and visual displayterminal setup in order to protect office workers.Altering the position of office equipment such as thevisual display terminal or mouse input device hasbeen shown to modify muscle activity and reducesymptoms.54

Cook and kothiyal demonstrated that positioning ofcomputer mouse closer to the key board andeliminating the numeric key pad results in asignificantly lowered muscle electro myographicactivity in VDT users than when mouse placed in aposition where the user was required to abduct the

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upper extremity and reach for mouse Static low levelloading of the deltoid and upper trapezius muscleshas been correlated with increased incidence ofshoulder and neck pain.54

There was a decrease in upper extremity and necksymptoms in computer workers who follow workstyle intervention. A lower risk of the work relatedmusculo skeleton disorders of the shoulder wasassociated with key board placement than put theelbow at a more neutral, Angel described as key boardlower than elbows without arm abduction and alower risk was shown with a monitor position thatallow a head tilt angel of less than 3 degree 54 Work-related musculoskeletal complaints in the upperextremity are common among computer workers. Inthe Netherlands, about 15% of the workingpopulation report complaints in the neck, shouldersand arms defined as pain, numbness, or tingling,resulting in loss of productivity, sick-leave or evendisability. In 1998, about 8% of all Dutch employeeswere absent from work due to work-relatedmusculoskeletal complaints, and 2% of the employeepopulation was absent from work for more than fourweeks. These complaints impose a substantialeconomic burden in compensation costs, lost wages,and productivity. Apart from the individualsuffering, the financial costs within member states ofthe European Union associated withmusculoskeletal complaints are high.30

Work-related musculoskeletal complaints are multifactorial in origin and involve biomechanical,psychosocial, and individual components. As aconsequence different intervention approaches exist.Most often interventions address alterations of thephysical work environment by adjustments of thework station and/or education about workingposture according to ergonomic principles. There areseveral studies reporting on the effectiveness ofergonomic approaches and it is commonly acceptedthat properly designed work stations areprerequisites for healthy working.30

Neck and upper limb symptoms have a multi-factorialetiology. However, primary and secondaryintervention studies have primarily focused onphysical components of the workplace likeergonomics and workstation adjustment”1

The deep muscles of the neck, which act like dynamicligaments, play an important role in maintaining thestability of the cervical spine.85

Visual display terminal (VDT) work typicallyinvolves remaining for a long time in a fixed positionfound that individuals increase their forward headposture during VDT work, which involves anexcessive anterior position of the head in relation tothe theoretical plumb line perpendicular to thebody’s center of gravity, and can be consideredsimilar to a protracted position of the cervical spinein which the lower cervical vertebrae are flexed in aforward glide and the upper cervical vertebrae areextended. This causes a shortening of the posteriorcervical and sub occipital muscles, lengthening andweakness of the anterior neck muscles, weakness ofthe scapula retractor muscles, and increased stresson the ligaments. The imbalances created by thisposition decrease muscular efficiency, and extramuscular action is needed to hold the head and neckin a stable position.86

The Cinderella-hypothesis is one of the mostinfluential hypotheses explaining the process ofdevelopment and persistence of pain in low intensityjobs like computer work, and states that lack ofsufficient muscle relaxation is a crucial factor in thisprocess. Continuous muscle activity, even at lowintensity levels, may result in homeostaticdisturbances of the activated motor units due toaffected blood flow and removal of metabolites.Several studies have found an association betweenabsence of moments of complete muscle rest andmyalgia, especially for the commonly affecteddescending part of the trapezius muscle. Warningsubjects when their muscle relaxation is insufficientcould thus contribute to recovery.30

In the twenty-first century, computers have becomealmost as ubiquitous as the humble pen and paperin many peoples’ daily life. There are approximatelysix computers per thousand populations with aninstallation of 18 million personal computers (PCs)and their number is increasing all the time. Thecomputer is a vital tool in every dimension. However,the long periods of working at a computer as mostpeople do, can cause musculoskeletal problems,eyestrain, and overuse injuries of the hands andwrists which can be reduced or eliminated with

3

proper workstation design and improved posture.”85

A survey done by the American OptometricAssociation estimates that at least 10 million casesof computer-related eyestrain were reported eachyear. The proliferation of video display terminals(VDT), in the modern office setting has generatedconcern related to potential health hazardsassociated with their use. Using the wrong chair orjust sitting improperly in front of a computer for longtime can lead to chronic debilities such as stiffness,headache, and backache. Muscles and tendons canbecome inflamed due to greater periods of sitting onPC’s. Carpal tunnel syndrome is a common exampleof an overuse injury associated with computer work.This painful disorder of the hand is caused bypressure on the main nerve that runs through thewrist. The fingers are also prone to overuse injury,particularly the finger that clicks the mouse buttons.85

The human eye basically prefers to look at the objectsgreater than 6 m away, thus work done on computerdemands a close-up view which strains eye musclesand thereby leads to eye fatigue. Surveys of computerworkers reveal that vision-related problems are themost frequently reported health- related problems,occurring in over 70% of computer workers.85

Defined by OSHA as a disorder of the muscles,nerves, tendons, ligaments, joints, cartilage, bloodvessels, or spinal disks in the neck, shoulder, elbow,forearm, wrist, hand, abdomen (hernia only), back,knee, ankle, and foot associated with exposure torisk factors. According to OSHA, these disorders mayinclude muscle strains and tears, ligament sprains,joint and tendon inflammation, pinched nerves,spinal disk degeneration, and medical conditionssuch as low back pain, tension neck syndrome, carpaltunnel syndrome, rotator cuff syndrome, DeQuervainsyndrome, trigger finger, tarsal tunnel syndrome,sciatica, Epicondylitis, tendinitis, Reynaudphenomenon, hand-arm vibration syndrome, carpetlayer’s knee, and herniated spinal disk.’74

METHOD

SUBJECTSTotal 30 patients out of 32 patients meeting theinclusion criteria were selected.

NUMBER AND SOURCE-30 subjects were selected on the basis of inclusioncriteria from Modern physiotherapy centre,Ghaziabad and randomly divided into two groups.

INCLUSION CRITERIA• Frequent at least once a week or long term

pain; stiffness or tingles in neck, shouldersarms wrist and hands. We intend to includeworkers with recent symptoms.

• Performing computer work for at least threedays a week during at least three hours aday.

• Not under treatment of a doctor or physicaltherapist for complaints in the neck,shoulders arms, wrist and hands.

• No clear somatic disease example –Rheumatic arthritis, cervical hernia, tenniselbow carpal tunnel syndrome.

• Sickness absence of less than fifty percent.

EXCLUSION CRITERIA• History of cervical spine injury or surgery.• Secondary Neck Pain (including neoplasm,

neurological diseases or vascular diseases)• Infection or inflammatory arthritis in the

cervical spine,• Had received physiotherapy within the 6

months prior to study.• Poor general health status that would

interfere with the exercises during the study.• If they had pain with any cause in or around

the scapula, shoulder, upper extremity andlumbar spine that prevents stabilization ofthese structures.

SAMPLING -Sample of convenience was selected and randomlyallocated into 2 groups Group (A) control and Group(B) experimental.

INSTRUMENTS AND TOOL USED-• Visual analogue scale.• Mirrors• Dumbbells’• Theraband• Towel

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PROCEDURE DESIGN OF STUDY-An experimental study.

METHODOLOGY-30 patients meeting the inclusion criteria wasrandomly divided into two groups (Group A and B)each consisting of 15 subjects. Treatment is given 5times per week for 3 weeks total 15 sessions.

Measurement has taken before start of study, aftertwo weeks, and at the end of study.

Group (A) - Physical therapy intervention (15)Group (B) - Physical therapy intervention with

work style intervention (15).

GROUP (A) -All sets of exercises are performed 10 repetitions in1st week. After 1st week 15 repetitions are done.

• Postural exercise therapy - Verbalreinforcement, Visual reinforcement (donein front of mirror), 2

• Moist heat therapy (10minute)• TENS (10 minute),41• Neck stabilization exercises.96• Endurance strength training, (supine

position).16,26• Strengthening the cervical and upper

thoracic extensor muscles,75• Isometrics neck exercises (sitting position)17• Progressive resistive exercise for

periscapular muscle (done by Theraband,dumbbell),75

CONVENTION STRETCHING -Upper trapezius, suboccipitalis, pectoralis major andminor rhomboids, forearm pronators, supinators fingerand wrist extensors, slowly at normal breathing.17, 79

GROUP (B) physical therapy intervention follows as aboveand given work style intervention. Patient had receivedwork style intervention pump let for office and said strictlyfollow of that.

• The goal is to provide general informationabout neck and upper limb symptoms andits known risk factor e.g.-work placeadjustment and body posture, static workload and insufficient breaks and high workload and work stress.,1,78

• Head and neck to be about upright (not bend

down/back).78

• Head, neck and trunk to face forward (nottwisted)78

• Trunk to be about perpendicular to floor (notleaning forward /backward)78

• Shoulders and upper arms to be aboutperpendicular to floor (not stretched forward) and relaxed (not elevated)78

• Upper arms and elbow to be close to body(not extended outward)78

• Forearms wrists and hand to be straight andparallel to floor (not pointing up/down)78

• Head and neck to be about upright (not benddown/back).78

• Wrists and hands to be straight (not bentup/down or sideways toward little finger)78

• Feet to rest flat on floor or be supported by astable footrest,78

• Take micro breaks.78

• Seating –Backrest provides support foremployer’s lower back(lumber area)78

• Armrests support both forearms whileemployees perform task and do not interferewith movement.78

• Keyboard/input device – platform shouldbe stable enough to hold keyboard and inputdevice.78

• Input device (mouse) is located right next tokeyboard so it can be operated withoutreaching. 78

• Input device is easy to activate and shape/size fits hands of specific employee(not toobig/small );78

• Wrist and hands do not rest on sharp or hardedge.78

• Top line screen is at or below eye level soemployee is able to read it without bendinghead or neck down/back.,78

• Monitor distance allow employee to readscreen without leaning Head, neck or trunkforward/backward.

• Monitor position is directly in front ofemployee so employee does not have to twisthead or neck.,78

• Window light should not be on screen thatmight cause employee to assume anawkward posture to read screen.78

• Work area –Thigh have clearance spacebetween chair and computer table/keyboardplatform.78

5

• Legs and feet have clearance space undercomputer table so employee is able to getenough to keyboard/input device.78

• Wrist rest should be padded and free of sharpand square edges.78

• Wrist rest should be employed to keepforearms, wrist and hands straight andparallel to ground when using keyboard /input device.78

• Telephone can be used with head upright(not bend) and shoulder relaxed (notelevated) if employee use computer at thesame time.78

Work station and equipment have sufficientadjustability so that the employee is able to read tobe in safe working posture.

DATA ANALYSIS:Groups were compared by repeated measuresanalysis of variance (RMANOVA) and thesignificance of mean difference within and betweenthe groups was done by Newman-Keuls post hoctest. A two-tailed (á=2) probability (p) value p<0.05was considered to be statistically significant. Allanalyses were performed on STATISTICA (version6.0).

For each treatment (group) and outcome measure(VAS, NDS and NPNPQ), a relative percent meanchange (from 0 wk to 4 wk) was also evaluated as

% change =

RESULTSVISUAL ANALOGUE SCALEThe visual analogue scale (VAS) scores of two groups(conventional and experimental) at three differentperiods (day 0, day 7 and day 21) were summarizedin Table 1 and also shown graphically in Fig. 1. Table1 and Fig. 1 both showed that the mean VAS scoresin both the treatments (groups) decreases after thetreatment and the decrease was evident higher inExperimental group (82.2%) than Conventionalgroup (58.0%).

Table 8.1 Visual analogue scale summary (Mean ±SE, n=15) of two groups at three different periods

Groups Periods %meanAt After After change (dayday 0 day 7 day 21 21-day 7)

Conventional 5.87 ± 4.00 ± 2.47 ± 58.0% 0.22 0.20 0.26

Experimental 6.00 ± 3.60 ± 1.07 ± 82.2%0.20 0.21 0.23

Graph 8.1 Mean (± SE) visual analogue scale scoresof two groups at three different periods.

On comparing the mean VAS within the groups(Table 2 and Fig. 2), the VAS in both treatmentsdecreases significantly (p<0.001) at day 7 and day21 (post therapy) as compared to day 0 (pre therapy).Further, the VAS in both the treatments also decreasessignificantly (p<0.001) at day 21 as compared to day7.

Table8.2 For each group, significance (p value) ofmean difference in VAS between the periods- withingroups

Comparisons Conventional Experimentalgroup(p value) group(p value)

day 0 vs. day 7 0.0002 0.0002 “ vs. day 21 0.0002 0.0001day 7 vs. day 21 0.0001 0.0001

MEAN day 21 – MEAN day 0oday0 0

MEAN day 0

Visual analogue scale


Groups

6

**p<0.001- in comparison with day 0 Bar graphs 8.2 showing mean (± SE) VAS of twogroups and compares the level within the groups.

Similarly, comparing the mean VAS between thegroups (Table 3 and Fig. 3), the VAS at day 0 andday 7 did not differed significantly (p>0.05) betweenthe two groups (treatments) i.e. found to bestatistically the same while at day 21 it decreasedsignificantly (p<0.001) more in Experimental groupas compared to Conventional group.

Table8.3 For each period, significance (p value) ofmean difference in VAS between the groups

Periods Conventional vs. Experimental (p value)day 0 0.6674day 7 0.1999day 21 0.0001

ns- P>0.05, **- p<0.001Bar graphs 8.3 showing mean (± SE) VAS at threedifferent periods and compares the level between thegroups.

NECK DISABILITY SCALEThe neck disability scale (NDS) scores of two groups(conventional and experimental) at three differentperiods (day 0, day 7 and day 21) were summarizedin Table 4 and also shown graphically in Fig. 4. Table4 and Fig. 4 both showed that the mean NDS scoresin both the treatments (groups) decreases after thetreatment and the decrease was evident higher inExperimental group (87.1%) than Conventionalgroup (72.1%).

Table 8.4 Neck disability scale scores summary(Mean ± SE, n=15) of two groups at three differentperiods


Conventional 16.27 ± 9.87 ± 4.53 ± 72.1%1.02 1.09 0.42

Experimental 16.53 ± 9.20 ± 2.13 ± 87.1%1.06 0.71 0.32

Graph 8.4 Mean (± SE) neck disability scale scores oftwo groups at three different periods.

On comparing the mean NDS scores within thegroups (Table 5 and Fig. 5), the NDS scores in bothtreatments decreases significantly (p<0.001) at day 7and day 21 (post therapy) as compared to day 0 (pretherapy). Further, the NDS scores in both thetreatments also decreases significantly (p<0.001) atday 21 a compared to day 7.

Table 8.5 for each group, significance (p value) ofmean difference in NDS scores between the periods-within groups

Comparisons Conventional Experimentalgroup (p value) group (p value)

day 0 vs. day 7 0.0002 0.0002vs. day 21 0.0002 0.0001day 7 vs. day 21 0.0001 0.0001

*


Periods

Neck disability scale

Periods (days)


Groups

7

*p<0.001- in comparison with day 0 Bar graphs 8.5 showing mean (± SE) NDS scores oftwo groups and compare the level with in the groups.

Similarly, comparing the mean NDS scores betweenthe groups (Table 6 and Fig. 6), the NDS scores at day0 and day 7 did not differed significantly (p>0.05)between the two groups (treatments) i.e. found to bestatistically the same while at day 21 it decreasedsignificantly (p<0.05) more in Experimental groupas compared to Conventional group.

Table 8.6 For each period, significance (p value) ofmean difference in NDS scores between the groups

Periods Conventional vs. Experimental (p value)day 0 0.8213day 7 0.5726day 21 0.0459

ns- P>0.05, *- p<0.05Bar graphs 8.6 showing mean (± SE) NDS scores atthree different periods and compare the level betweenthe groups.

NORTHWICK PARK NECK PAIN QUESTIONNAIRE

The Northwick park neck pain questionnaire(NPNPQ) scores of two groups (conventional andexperimental) at three different periods (day 0, day 7and day 21) were summarized in Table 7 and alsoshown graphically in Fig. 7. Table 7 and Fig. 7 bothshowed that the mean NPNPQ scores in both thetreatments (groups) decreases after the treatment andthe decrease was evident higher in Experimentalgroup (80.2%) than Conventional group (64.6%).

Table 8.7 Northwick park neck pain questionnairescore summary (Mean ± SE, n=15) of two groups atthree different periods


Conventional 45.50 ± 30.72 ± 16.11 ± 64.6% 2.59 2.17 1.37

Experimental 45.06 ± 28.59 ± 8.92 ± 80.2%2.33 2.29 1.42

Graph 8.7 Mean (± SE) Northwick park neck painquestionnaire scores of two groups at three differentperiods.

On comparing the mean NPNPQ within the groups(Table 8 and Fig. 8), the NPNPQ scores in bothtreatments decreases significantly (p<0.001) at day 7and day 21 (post therapy) as compared to day 0 (pretherapy). Further, the NPNPQ scores in both thetreatments also decreases significantly (p<0.001) atday 21 a compared to day 7.

Table 8.8 for each group, significance (p value) ofmean difference in NPNPQ scores between theperiods- within groups

Comparisons Conventional Experimentalgroup (p value) group (p value)

day 0 vs. day 7 0.0002 0.0002“ vs. day 21 0.0002 0.0001day 7 vs. day 21 0.0001 0.0001


Periods

8

**p<0.001- in comparison with day 0

Bar graphs 8.8 showing mean (± SE) NPNPQ scoresof two groups and compare the level within thegroups.

Similarly, comparing the mean NPNPQ scoresbetween the groups (Table 9 and Fig. 9), the NPNPQscores at day 0 and day 7 did not differedsignificantly (p>0.05) between the two groups(treatments) i.e. found to be statistically the samewhile at day 21 it decreased significantly (p<0.05)more in Experimental group as compared toConventional group.

Table 8.9 for each period, significance (p value) ofmean difference in NPNPQ scores between the groups

Periods Conventional vs. Experimental (p value)day 0 0.8213day 0 0.8213day 7 0.5726day 21 0.0459

ns- P>0.05, *- p<0.05

Bar graphs 8.9 showing mean (± SE) NPNPQ scoresat three different periods and compare the levelbetween the groups.

DISCUSSIONThis study consisted of two groups- group A (control)and group B (Experimental). The subjects of group Awere given physical therapy intervention and groupB were given physical therapy intervention and workstyle intervention. The main findings were that boththe group shown significant improvement in VAS,NDI, NWPNPQ.

There is more improvement in pain and functionaldisability in group B. There are also many others

who show the effect of work style intervention.

The purpose of this study was to assess theeffectiveness of single (WSI) work style interventionand a combined intervention targeting work styleand physical therapy intervention on the recoveryfrom chronic neck and upper limb symptoms ofcomputer workers .The WSI was effective in reducingin all pain and disability outcome at 3 weeks follow-up. Study show that WSI is effective in workers withneck /shoulder /arm /wrist and /hand symptoms.After 3 weeks study all the outcome measures werereduced significantly VISUAL ANALOGUE SCALE/NORTHWICK PARK NECKQUESTIONNARIES/NECK DISABILITY SCALE and greater reduction isfound in WSI group.

The workstation modifications mainly includedadjustments of the screen, mouse, keyboard, forearmsupports, and chair. These modifications changedthe head, Neck, and arm postures and movements.Since the positive effects were seen primarily in theshoulder, upper arm, neck, and upper back area, it ispossible that the health effects were brought aboutby these changes. Discomfort and strain arepredecessors of pain.

An ergonomic training program to be an effectivetool in improving the ergonomics of computerworkers’ workstations. The intervention of Menozziet al also showed training to be useful in optimizingergonomics in computer work. Statistical analysisshow similarly, comparing the mean VAS betweenthe groups (Table 3 and Fig. 3), the VAS at day 0 andday 7 did not differed significantly (p>0.05) betweenthe two groups.NDI it decreased significantly(p<0.05) more in Experimental group as comparedto Conventional group. NWPNPQ it decreasedsignificantly (p<0.05) more in Experimental groupas compared to Conventional group.

Amanda manda et al. (2007) Reducing neck andupper limb symptoms of computer workers is a majortask for occupational health care. Low cost solutionsthat are effective on the long term are needed. Ourstudy indicates that an intervention on group levelaiming to change work style behavior is effective inimproving recovery from neck/shoulder symptomsand reducing pain on the long-term in computerworkers with neck and upper limb symptoms.1

Our results showed that both a work styleintervention and physical therapy interventionapproach help reduce discomfort in computer work.

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To improve the level of physical ergonomics incomputer workplaces, the best result will be achievedby cooperative planning in which both workers andpractitioners are actively involved.

CLINICAL IMPLICATIONSThis study shows that computer workers withchronic neck pain and upper limb symptoms showsimprovement in giving work style intervention inaddition with physical therapy intervention on theneck pain and upper limb symptoms as compare tothose who are performing only physical therapyintervention . Thus, physical therapy interventionshould be incorporated along with work styleintervention to improve neck pain and upper limbsymptoms.

FUTURE RESEARCHFuture research could be done by using various workstyle intervention on the recovery of chronic neckand upper limb symptoms in computer workers.Advancement of work style intervention will alsoneed consideration. A advance Physical therapyintervention also need consideration in futurestudies.

LIMITATIONS OF THE STUDY• Only for work related neck and upper limb

musculoskeleton disorders of computerworkers.

• The sample size of the study is small.

CONCLUSIONThis study found both the therapy [physical therapyintervention (Conventional) and physical therapyintervention with work style intervention(Experimental)] effective in the management ofchronic neck and upper limb symptoms in computerworker but physical therapy intervention with workstyle intervention was found to be more effective thanphysical therapy intervention. All outcome measures(VAS, NDS and NPNPQ scores) improvedsignificantly in both the treatments but physicaltherapy intervention with work style interventionshowed significant improvement over physicaltherapy intervention in all outcome measures at finalevaluation (after 21 days post therapy). At finalevaluation, subjects those who received physicaltherapy intervention with work style interventiontheir VAS, NDS, and NWNPQ scores improved 1.4,1.2 and 1.2 times more respectively than those whoreceived the physical therapy intervention.

Thus, for effective management of chronic neck and

upper limb symptoms in computer workers, thisstudy recommends clinician to use physical therapyintervention with work style intervention. But beforethat more trails are needed to validate its clinicalsignificance in other population.

ACKNOWLEDGEMENTI wish to thank my guide Dr. Shagun Aggarwal. AlsoI would like to thank Dr. Baljeet Kaur and all thefaculty members of Institute of applied medicine &research. Lastly my thanks to all the participants ofmy study and my friends without whose supportthis study would not have been successfullycompleted.

REFERENCES1 Amanda Manda, M Bernard. A cost effectiveness

of life style intervention in addition with workstyle intervention in the recovery of chronic neckand upper limb symptoms. BMC-2006

2 A cost effectiveness of postural exercise therapycompare with usual physiotherapy. BMC 2009

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4 Ankrum, D.R., Some New Visual Considerationsat Computer Work stations. Some New VisualConsiderations at Computer Workstations,World Workplace ’95, Conference Proceedings,(1995)

5 Ankrum, D.R. Integrating Neck Posture andVision at VDT Workstations Integrating NeckPosture and Vision at VDT Workstations. 1997

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Effect of microcurrent facial muscle toning on fine wrinkles &firmness of face

Shilpa Jain *, Dr Maneesh Arora **

* Research Student MPT, Sports Rehabilitation, SBSPGI Balawala, Dehradun** Principal MPT, Sports Medicine, SBSPGI Balawala, Dehradun

INTRODUCTIONThe skin is the most superficial part of the body. Thesigns of ageing are most visible in the skin, speciallythe wrinkles. The world’s population is aging, andaesthetic demands from people are increasing.Looking young and feeling fit is considered the normin all industrialized countries. Surgical techniqueswere the first ones, considered in the past forrejuvenation Although, ageing skin is not a threat toa person, but it can have a detrimental effect on thepsychology of a person because everyone wants toremain more competitive in their careers by lookingvibrant and youthful, enhance or maintain their

Background & Purpose: To determine the effect of microcurrents on fine wrinkles & firmness of face. Young skincontains a large amount of hyaluronic acid, which declines with age. Since the body requires it to help bind water,the skin’s ability to retain water is further reduced and as a result the skin becomes drier, thinner, and less able torestore itself. This combined with a lack of collagen formation, and GAGS concentration results in loss of hydration,integrity and reduced skin tone. All this starts to show significantly in the skin from the age of forty to fifty,microcurrent has the ability to continue & speed up all the functions inside the cell by mimicking it with the body’sown current.

Method: Design: Pretest- Posttest Experimental design. Total 30 subjects were taken for the study. Subjects wererandomly divided into two groups. Group A: (n=15) Experimental, Microcurrent interventions. Group B: (n=15)Control, Microcurrent placebo. In Experimental group, i.e. group A, microcurrent was delievered for 10 dayscontinuously for 30 mins. In control group, i.e. group B, placebo microcurrent sessions were given for 10 dayscontinuously for 30 mins. Between every session there was a gap of 24 hours. The subjects were assessed two timesduring research period i.e. at 0 session & 1st session which were, at the start of study to collect the baseline data &at the end of the study to get the progressions, respectively. All the recordings & progressions were documented.Outcome measure: Fine wrinkles & firmness measured by VAS.

Result: There was a non significant difference found between the pre & post scores for fine wrinkles in Group A butfirmness improved significantly in Group A. There was a non significant difference found between group A & groupB in post scores of wrinkles, t = .646 & p > .05. But as comparison was made there was a significant result found forthe variable of firmness, t = 6.42 & p < .05 as compared to pretest value but there was no significant differencebetween the two groups at the end of the intervention.

Conclusion: This study proposes & provides the evidence that concludes that there is no significant differencebetween pre & post intervention of microcurrent in reducing fine wrinkles in experimental group, where as forvariable of firmness, significant difference was found between pre & post interventions.

Keywords: Microcurrent, Fine Wrinkle, Hertz, Microampere.Frequency, lengthening

facial attractiveness, to delay future signs of aging,avoid plastic surgery or injections of substancessuch as Botox and Restylane, are interested inpreventing and slowing visible signs of aging on theface and neck. After the age of 20, a person producesabout 1% less collagen in the skin each year. As aresult, the skin becomes thinner and more fragile withage. 26 There is also diminished functioning of thesweat and oil glands, less elastin production, andless GAG formation. The breakdown of thesecomponents is accelerated by certain reasons suchas exposure to UV rays, gravity, pollution, smoking,lack of exercise, and/or a consistently poor diet, results

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in the more visible signs of old age on our skin, whichis now a days occur 2-3 decades before the usual.Years of facial expressions trigger small temporaryfolds in the skin where our muscles move with age,depleting levels of collagen and loosening elastinfibers develop a memory of each crease & hence giverise to wrinkles.

Escoffier et al. illustrated that many biologicalprocesses start to slow down as we begin to age, soonafter puberty the fibroblasts cease to make elastin28

and by thirty, the rate at which the damaged skincells are replaced can decrease significantly by up to50%. At forty, the dermis and subcutaneous layersof fat begin to lose their ability to retain smoothnessand the quality and amount of collagen the bodyproduces also starts to deteriorate. The formation andrepair of collagen is one of the most important factorswhen it comes to maintaining natural skin care.Collagen has been likened to a biological rope, in asmuch, which it is made up of small molecules calledtropocollagen, which contains three amino acids,glycine, proline and lysine. The collagen, gags andwater form the skins foundation and retain waterwithin the structure of the dermis, which helps tomaintain the skins strength and flexibility. Youngskin contains a large amount of hyaluronic acid,which declines with age. Since the body requires itto help bind water, the skin’s ability to retain wateris further reduced and as a result the skin becomesdrier, thinner, and less able to restore itself. Thiscombined with a lack of collagen formation, andGAGS concentration results in loss of hydration,integrity and reduced skin tone. All this starts toshow significantly in the skin from the age of forty tofifty, which is why advanced skin care products areso important at this age.

The American Academy of Dermatologists say theskin’s elasticity declines dramatically when peopleare in their 50s but due to their wrong dietary habits,frequent alterations in body clock, pollution, UV rays,etc. premature ageing occurs i.e atleast 2-3 decadesbefore. Although this is true for both men and women,it impacts women much more dramatically. Women’sskin has less collagen content than men’s skin. Also,the drop in estrogen following menopause impactsthe fibroblasts in the dermis and the cells that createcollagen and elastin. As a result, women may look

older than the men of same ages Assessment ofwrinkles can be done by several ways like byphotographic scoring & analysis by team of experts& grading or with the help of softwares, by scanningetc. As Johnson’s wrinkling sacle, Weiss’s scale, bothhave given grades for assessing wrinkles forphotodamage. Simultaneusly there are manyequipment available for the measurement of firmnessof skin like cutometer.Lever et al.11 scored the signs of photoageing on 0–10visual-analogue scales with separate scores for theface and each hand.

Curtis A Cole et al. in an open clinical trial evaluatedthe safety & efficacy of the product containingDimethylaminoethanol (DMAE ), female volunteersin a one month study, subjects self evaluated theirfacial skin condition at the beginning & at the end of4th week, in which skin firmness was also a variable.

Microcurrent therapy, commonly referred as MENS(Microcurrent Electrical NeuromuscularStimulation), is extremely small pulsating currentsof electricity. These currents are finely tuned to thelevel of the normal electrical exchanges which takeplace at body’s cellular level. These currents beingmore biologically compatible than any other electricalstimulation device that have the ability to penetratethe cell - as opposed to passing over the cell as otherstimulation devices do. It works on ARNDT -SCHULTZ Law which states that: “Weak stimuliincreases physiological activity and very strongstimuli inhibit or abolish activity.”

This subsensory current normalizes the ordinaryactivity taking place within the cell if it has beeninjured or otherwise compromised. The externaladdition of microcurrent will increase the productionof ATP, protein synthesis, oxygenation, ion exchange,absorption of nutrients, elimination of wasteproducts, and neutralizes the oscillating polarity ofdeficient cells. Homeostasis is restored. Thebiologically sensitive stimulation effect ofmicrocurrent picks up where the body’s ownelectrical current fails, as the human body mustadhere to the natural law of electricity which is:“electricity must take path of least resistance.”Therefore, its electrical current is destined to movearound an injury or defect, rather than through it. By

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normalizing cell activity, inflammation is reducedwhile collagen producing cells are increased. Healthycell metabolism creates a healthy, pain free internalenvironment. Microcurrent causes the following: 35%increase in blood circulation 40% increase inGluconeogenesis (production of new glucose) 45%increase in the number of elastin fibers in the dermis50% increase in the length of the elastin fibers 10%increase in collagen thickness in the connective tissue35% increase in the number of blood vessels 28%increase lymphatic drainage.

Statement of QuestionWhether Microcurrent facial muscle toning is effectivein reducing fine wrinkles & improving firmness offace or not?

Experimental HypothesisMicrocurrent is not effective in reducing fine wrinklesof face.

Null HypothesisMicrocurrent is effective in reducing fine wrinkles &improving the firmness of skin of face

METHODOLOGY

SUBJECTSThe subjects of the study constitutes the femalehostlers of Mata Gujri Hostel C/O Sardar BhagwanSingh Post Graduate Institute of Bio-medical Sciencesand Research, Balawala, Dehradun. Subjects werechecked for all inclusion & exclusion criteria. Subjectswere included in study that fulfilled all the criteria.

SAMPLE & METHOD OF SELECTIONSample:30 healthy female hostlers with mean age 22.9±2,having Skin Type I on Glogau Classificaion Chart45,were selected for the study & were divided to groupA & B by lottery method.

Sampling:Random Sampling.

Method:30 subjects met the inclusive criteria with &assured for full participation & continuity in theentire program & consent form was signed by them

VARIABLES OF STUDYDependent variable:

Microcurrents

Independent variables:Fine wrinkles of faceFirmness of facial skin

MATERIALS / INSTRUMENT USEDIntelect 580 combo (source of microcurrents) &accessories

RESEARCH PROTOCOL30 female subjects with men age 22.9±2, having skintype I on Glogau scale were taken. After gettingapproval from the ethical committee the subjects wereinformed about the study and informed consent wastaken. These 30 subjects were then divided into twogroups randomly by chit system on zero session.Group A was the experimental group and was giventhe microcurrent treatment. Group B was the controlgroup & was the placebo group. Each group consistedof 15 subjects. VAS was taken from them for wrinklesand firmness of the skin prior to treatment then theywere given treatment for 10 days daily for 30 mins.Experimental group was given microcurrenttreatment at frequency 10Hz & and intensity 70W/cm2 . And placebo group was given zero frequencyand intensity. After the 10th session i.e. last day theirVAS was again taken for wrinkles and firmness of

skin.

PROCEDURE30 healthy hosteller females, having skin type I ofGlogau classification, who met all the inclusioncriteria & pre screening test, with mean age 22.9, afterethical committee approval. All the participants weregiven verbal instructions for the procedure andinformed consent form was obtained from each oneof them, prior to the participation in the study. Theywere advised to maintain their normal dietary intake,as per the hostel menu, & plenty of water intake wasadvised to them, for the time period in which studywas run & not to change their face wash, soaps,crèmes & not to go for any other beauty product ortreatment.

At 0 sessions, VAS for wrinkles & firmness for eachgroup was obtained. Total sessions of microcurrenttreatment were 10 without any day gap & on the lastsession again firmness & wrinkle scores data wasobtained by VAS & compiled.

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Areas to be treatedThe Nasolabial fold, peri-oral, peri-occular, forehead,brows, glabella, jowls & chin. (Muscles Covering:Buccinator, Corrugator Supercili, Depressor LabiiInferioris Frontalis, Levator Anguli Oris,LevatorLabii Superioris, Masseter, Mentalis, OrbicularisOculi, Orbicularis Oris, Procerus, Risorius,Sternocleidomastoideus, Triangularis, ZygomaticusMajor, Zygomaticus Minor)

During the sessions, for experimental group, thesubjects were given comfortable supine lying positionon couch. Inactive probe was kept stationary at theend of 1 muscle or group & active was movable fromthe end of the same muscle or group towards theinactive, with intensity 70 W/cm2 & frequency 10 Hzfor 30 min continuously for 10 days.

For control group, the subjects were givencomfortable position & Inactive probe was keptstationary at the end of 1 muscle or group & activewas movable from the end of the same muscle orgroup towards the inactive & the modality was kepton with 0 intensity & 0 frequency, for half an hour,continuously for 10 days. 11

Reliability of Procedure & outcome measuresThe procedure of delivering microcurrents has beendocumented in Microcurrent Research Institute,Advisory Manual; 1997; 3rd Ed. Lever et al. scored thesigns of photo-ageing on 0–10 visual-analogue scaleswith separate scores for the face and each hand.

In an open clinical trial, Curtis A Cole ChristianeBertin evaluated the safety & efficacy of the productcontaining Dimethylaminoethanol (DMAE ), onfemale volunteers in a one month study, subjects selfevaluated their facial skin condition at the beginning& at the end of 4th week, in which skin firmness wasalso a variable.

DATA ANALYSISThe data were analyzed using statistical tests, whichwere performed using SPSS 17.0 software packages.Paired t-test has been performed for comparing finewrinkles & firmness of face between 0 and 10th sessionwithin the groups i.e. A & B.

Unpaired t-test has been performed for checking thelevel of significance between 2 groups i.e. A & B forfine wrinkles & firmness of face. Significance levelhas been selected as 0.05.

RESULTSPost scores on VAS of Group A & B

Group Wrinkles Pos FirmnessA M = 3.66 SD = 1.32 M = 7.43 SD = 1.21B M = 3.94SD = 0.93 M = 4.14SD = 1.57T 0.646 6.42P 0.524 0.000S/ NS NS S

As unpaired t-test was used to compare the postscores of experimental group & control group on 10th

day for fine wrinkles & firmness. There was a nonsignificant difference found between group A &group B in post scores of wrinkles, t = .646 & p > .05.But as comparison was made there was a significantresult found for the variable of firmness, t = 6.42 & p< .05

There was a non significant difference found betweenthe pre & post VAS score of wrinkles in group A i.e.the experimental grou, p = .107 but in the same groupa significant difference was found between in thescores of firmness, p =.000

Comparison of pre post scores of Group AGroup A Wrinkles FirmnessPre M = 4.17SD = 1.35 M = 3.85SD = 1.105Post M = 3.66SD = 1.39 M = 7.43SD = 1.209T 1.723 9.434P .107 .000S/ NS NS S

Comparison of pre post scores of Group BGroup B Wrinkles FirmnessPre M = 3.939SD =1.317 M=3.746SD= 0.8675Post M = 3.940SD = 0.935 M = 4.14SD = 1.575T .210 .824P .836 .424S/ NS NS NS

In the comparison of pre & post scores of group B, thecontrol group, for both variables i.e. fine wrinkles &firmness, there was a non significant differencefound, where in both p > .05.

Comparison between Mean & SD of post scoresof Group A & B

Dependent t- test values in Group A revealed nosignificant difference in reducing fine wrinkleswithin the experimental group from 0 session to 10sessions of Microcurrent electrical stimulation(pÃ0.05) but in the same experimental group, asignificant difference in improving firmness of skinof face was found, with in the same session & same

17

subjects. When comparisons were made between thereadings of control and experimental group,significant improvement was noticed whilecomparison between the mean differences of the twogroups, was also found to be significant.

DISCUSSIONMany secondary outcomes were noticed during thesession n after completing the sessions. As noticedby subjects only severe headaches were gone , theyremained energetic & active throughout the day evenafter their hectic schedule as Cheng (1982) showedin his research that microcurrent stimulationincreased adenosine triphosphate (ATP) generationby almost 500% & also ATP production wasdecreased with milliampere.

A feeling of tightness in skin was there only after 1st

session n kept on increasing as sessions wereincreasing as statistical results calculated by VASshow a highly significant difference between pre &post sessions fo variable of firmness with meandifference of 3.58 at p = 0.000. Vibrant glow on facescould easily be noticed & surprisingly post acne scarsstarted healing.

Emil Y Chi said, using MicroCurrent, resulted in a14% increase in production of natural collagen, 48%increase in natural elastin and a 38% increase inblood circulation & increase in production of GAGs& Hyaluronic acid (HA). This subsensory currentnormalizes the ordinary activity taking place withinthe cell if it has been injured or otherwisecompromised. The external addition of microcurrentwill increase the production of ATP, proteinsynthesis, oxygenation, ion exchange, absorption ofnutrients, elimination of waste products, andneutralizes the oscillating polarity of deficient cells.Homeostasis is restored. The biologically sensitivestimulation effect of microcurrent picks up where thebody’s own electrical current fails, as the humanbody must adhere to the natural law of electricitywhich is: “electricity must take path of leastresistance.” Therefore, its electrical current isdestined to move around an injury or defect, ratherthan through it. By normalizing cell activity,inflammation is reduced while collagen producingcells are increased. Healthy cell metabolism createsa healthy, pain free internal environment. Byapplication of microcurrents, as natural collagen isproduced with hyaluronic acid & many otheressential molecules, which are essential componentsof healthy skin, so youthful skin can be got with fewsessions.

Pierre Andre MD,46 illustrated that, HAs can beinjected by mesotherapy to hydrate skin’s surface,thicker HAs are useful to improve wrinkles,nasolabial folds, hollow under eyes, for lipaugmentation and thickest HAs are used forincreasing volumes. Longevity depends on treatedareas, stabilization and viscosity of injected HAs,and taking also into account the possibility of anindividual response. Longevity of natural human HAin the skin is very short (24–48 h); cross-linkingincreases this longevity. Degradation depends onthermal effect, enzyme (hyaluronidase), and freeradicals interaction.

Since 1996, HA has been used as a filling agent. HAis a glycoaminoglycan polysaccharide present in thehuman body. HAs give opportunity not only to fillwrinkles but also to increase volume.

Wang et al. did not find HA binding with specificCD44 receptors after injections for rejuvenation 48 theyconclude that collagen production could besecondary to stretching by a mechanical effect.Exogenous HA may demonstrate severalphysiological functions, which interfere with healingprocess and rejuvenation.

Escoffier et al. illustrated Collagen has been likenedto a biological rope, in as much, that it is made up ofsmall molecules called tropocollagen, which containsthree amino acids, glycine, proline and lysine. Thecollagen, GAGs and water are the skin’s foundationand retain water within the structure of the dermis,which help to maintain the skin’s strength andflexibility. Young skin contains a large amount ofhyaluronic acid, which declines with age. Since thebody requires it to help bind water, the skin’s abilityto retain water is further reduced and as a result theskin becomes drier, thinner, and less able to restoreitself. This combined with a lack of collagenformation, and GAGS concentration results in lossof hydration, integrity and reduced skin tone. Allthis starts to show significantly in the skin from theage of forty to fifty, which is why advanced skin careproducts are so important at this age.

P. Andre illustrated 46 “HAs are safe and suitable forwrinkles and volume restoration, but besides theirmechanical properties, they have numerousphysiological functions. With the analysis ofliterature about the action mechanism of HA and itsreceptors, it is evident that HA also has a stimulatingaction on different physiological process”, so going

18

in to physiology of this natural HA can be producedby stimulation of receptors, invasive techniques caneasily be avoided, when microcurrent will be used.

Overall the result of our study could be of followingreasons or limitations.

• Sample size was small• Could not be used for coarse wrinkles as age

of samples was younger.• Duration of study was much less & also the

long term results of improvement could notbe recorded.

FUTURE RESEARCH1. The effects can be compared with that of

iontophoresis & vitamin supplements.2. Development of a scale on assessment of

wrinkles & other parameters also3. Effect on males.4. Effect on Acne, scars & much other skin

condition.5. Effect on obesity & toning loose skin folds

after weight loss.

IMPLICATION OF THE STUDYIn the course of the present study, it was seen thatclinically relevant intensity of Microcurrent electricalstimulation had an instrumental in giving skin avibrant look. This can be beneficial considering inbeauty clinics & in the field of cosmesis. As there hasbeen an era of premature ageing has been started, sothat will prove very beneficial even in keeping peopleenergetic & relaxed without any side effect. As themethods used were very simple & non invasive sothat would be very safe & people will get rid of thoseproducts giving harmful & deleterious effects & muchcheaper than Botox injections etc. & surgical lifts.

CONCLUSIONStatistically result concludes that there is nosignificant difference between pre & post interventionof microcurrent in reducing fine wrinkles inexperimental group, where as for variable of firmnessa significant difference was found between pre &post interventions.

REFERENCES1 Andre, P. (2008), New trends in face

rejuvenation by hyaluronic acid injections.Journal of Cosmetic Dermatology, 7: 251–258. doi: 10.1111/j.1473-2165.2008

2. Curtis A Cole Christiane Bertin,Dimethylaminoethanol : A new skin care

ingredient for aging skin, Page no. 95-97,Chapter 10, Textbook of Dermatology, ByRobert Baran, 3rd ed.

3. Microcurrent Research Institute, AdvisoryManual; 1997; 3rd Ed.

4. 12 & 12 Electroaccupuncture book oncommon problems.

5. Operational Manual of MicrocurrentResearch Institute Clinics; 1997; vol. 3

6. Pierre Andre MD, New trends in facerejuvenation by hyaluronic acid injections; Journal of Cosmetic Dermatology; Volume7, Issue 4, pages 251–258, December 2008

7. Lever L, Kumar P, Marks R. Topicalretinoic acid for treatment of solardamage.Br J Dermatol 1990;122: 91–8.

8. Becker R. 1988; Mechanism of woundhealing by microcurrent; Southern MedicalJournal, July 1969.

9. Christopher E. M. Griffiths, MD, MRCP;Timothy S. Wang; Ted A. Hamilton, MS; JohnJ. Voorhees, MD; Charles N. Ellis, MD; APhotonumeric Scale for the Assessment ofCutaneous Photodamage ; ArchDermatol. 1992;128(3):347-351 Emil Y Chi,PhD, director of Washington’s Departmentof Pathology

10. U P Kappes; Skin Ageing & wrinkles :Clinical & Photographic scoring; deptt ofdematology, Boston University School ofmedicine, USA

11. Bernstein EF, Uitto J. The effect ofphotodamage on dermal extracellularmatrix. Clin Dermatol. 1996;14:143-151.

12. Escoffier C, de Rigal J, Rochefort A, VasseletR, Leveque JL, Agache PG. Age-relatedmechanical properties of human skin: an invivo study. J Invest Dermatol. 1989;93:353-357.

13. Meyer LJ, Stern R. Age-dependent changesof hyaluronan in human skin. J InvestDermatol. 1994;102:385-389.

14. Bernstein EF, Chen YQ, Kopp JB, et al. Long-term sun exposure alters the collagen of thepapillary dermis. J Am Acad Dermatol.1996;34:209-218.

15. Piérard, G. E., Uhoda, I. and Piérard-Franchimont, C. (2003), From skin

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microrelief to wrinkles. An area ripe forinvestigation. Journal of CosmeticDermatology, 2: 21–28. doi: 10.1111/j.1473-2130.2003.00012.x

16. New Delhi, Apr 12: Teenagers’ expenses oncosmetics exceed Rs 4000/month: Survey;About 75 per cent of teenagers’ expenses oncosmetics has exceeded Rs 3,000-4,000 permonth against their average expenditure ofless than Rs 1,000 in the year 2000 due togrowing awareness with intense publicitycampaign, according to survey conductedby Associated Chambers of Commerce andIndustry of India (ASSOCHAM).

17. Wang F, Garza LA, Kang S, et al . In vivostimulation of de novo collagen productioncaused by cross-linked hyaluronic aciddermal filler injections in photodamagedhuman skin. Arch Dermatol 2007; 143: 155–63.

18. Margaret W. Mann, David R. Berk, DanielL. Popkin, Susan J. Bayliss; GlogauWrinkle Scale; Handbookof Dermatology:A Practical Manual

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Comparing OKC (open kinetic chain) with CKC (closed kineticchain) along with hot pack on quadriceps strength andfunctional status of women with osteoarthritic knees.

Divya Rashmi Negi* and Dr. Poonam Rani**

* research student, MPT (Orthopedics), Institute of Applied Medicines and Research Ghaziabad** research guide, MPT Orthopaedics, Associate Professor, Institute of Applied Medicines and Research Ghaziabad

INTRODUCTIONOsteoarthritis of the knee is an active disease processinvolving cartilage destruction, subchondral boneRadiographic appearance has thickening and newbone formation.

For treatment of various knee disorders , musclesare trained in Open or Closed kinetic chain tasks.Coordination between the heads of quadricepsmuscles important for stability and optimal jointloading for both the tibiofemoral and patellofemoraljoint. There is considerable debate regarding theefficacy of OKC and CKC exercises for increasedstrength and control of knee muscles.9

Most of the previous researches on OA have

Background & Purpose: To analyze the therapeutic effects of CKC and OKC when combined with hot packon quadriceps strength, functional status of women with osteoarthritic knees.

Method: Thirty female subjects with OA aged in between 50-70years are included in study on basis of inclusioncriteria . The subjects were than randomly selected for Group 1 and Group 2.Group 1 received OKC and hot packsand Group 2 received CKC and hot packs. Patients were evaluated before and after the treatment. Demographic dataincluding age, body weight, height and BMI were obtained.BMI was calculated by weight divided by height as kg/square meter. Then hot packs were applied around knee for 15min. in sitting position with knee extended. Aftertreatment with hot packs, patient perform individual warm-up exercises on stationary bicycle for 20 cycles/minutefor 5 minutes before undergoing therapeutic exercises. Then the therapeutic effects were evaluated with respect topain, disability, function and muscle strength by using Strain gauge, WOMAC osteoarthritic scale. The effects weremeasured on 0 day, 18thday and 35th day. Participants were instructed to continue taking any current medicationsand not to start any therapies for knee OA during 5week study.

Result: Results of this study show that the CKC (Closed Kinetic Chain Exercise) along with the hot pack are muchmore effective in improving the Quadriceps Strength and functional Status of women with Osteoarthritic Knees.Improvement in quadriceps Strength was much more marked in Group 2 and contributes to functional statusoutcome.The values of Quadriceps strength between and within the group were significant and the values ofWOMAC between the groups were not significant but within the group the values were significant.

Conclusion: The study therefore concludes that Null hypothesis that CKC exercises along with Hot pack are nomore effective in improving quadriceps Strength and Functional status of women with Osteoarthritic Knees isrejected and the experimental hypothesis that CKC exercises are effective in improving Quadriceps Strength andfunctional status of women with Osteoarthritic knees.

Keywords: lowback pain (LBP), Disability, Nurse, Muscle endurance, Occupational, risk factor, Numeric RatingScale(NRS), Modified Oswestry Low Back Pain Disability Questionnaire(MOLBPBQ).

compared exercises alone or Physical agents alone.In this research the combined effect of exercisesalong with physical agent is considered.

METHODThirty female subjects with OA aged in between 50-70years are included in study. The population ofstudy constitutes the elderly females of OA from theMetro Hospital Noida and various private patientsaround Ghaziabad.

INCLUSION CRITERIAFor nurses with LBP

• Subjects with clinical and radiologicalcriteria for diagnosis of OA.

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• Mean age 50-70years.• Clinical presentation of unilateral OA• Ability to walk at least 100m on an uneven

surface.• Full or near full passive ROM at each knee.

EXCLUSION CRITERIA• Patients not fulfilling Inclusion criteria• Patients with previous history of knee

surgery.• Lower extremity arthoplasty• Intra articular injection of Hyaluronic acid/

steroids in last six months.

SAMPLINGThe subjects were screened first on basis ofdemographic data and fitted according to inclusioncriteria and informed consent was taken from thepatients and explained the procedure in detail. Thesubjects were than randomly selected for Group 1and Group 2.

INSTRUMENTS AND TOOLS USED

Equipment:-Strain Gauge Specification:-Model:-GTH-30/60Capacity:- 30/60KgDivision:- 10/20gCompany:- Gold Tech ScalesHydrocollateral pack Specification:-Model-M2Manufactured by: - ChattanoogaPharmacal Co. Inc.Mini TrampolineStepperRowing machineStationery Bicycle

PROCEDURE

DESIGN OF STUDY: - Comparative study

METHODOLOGY:- 30 female patients with OA kneewere selected on basis of inclusion criteria anddivided into two groups with 15 patients in eachgroup.

Group 1:- OKC and Hot packGroup 2:-CKC and Hot pack

Patients were randomly assigned to two groups of15 patients each. Patients were evaluated before andafter the treatment. Demographic data including age,body weight, height and BMI were obtained.BMI wascalculated by weight divided by height as kg/squaremeter. Then hot packs were applied around knee for15min. in sitting position with knee extended. Aftertreatment with hot packs, patient perform individualwarm-up exercises on stationary bicycle for 20cycles/minute for 5 minutes before undergoingtherapeutic exercises. Then the therapeutic effectswere evaluated with respect to pain, disability,function and muscle strength by using Strain gauge,WOMAC osteoarthritic scale. The effects weremeasured on 0 day, 18thday and 35th day.Participants were instructed to continue taking anycurrent medications and not to start any therapiesfor knee OA during 5week study

Therapeutic OKC exercise programme:-Maximal static quadriceps contractions(quadriceps setting) with the knee in fullextension.SLR with the patient in supine position.Short arc movements from 10 degree of kneeflexion to terminal extension.Leg adduction exercises in lateraldecubitus position.

Therapeutic CKC programme:-Seated Leg pressDouble or single one third knee bend.Stationary bikingRowing machine exerciseStep up and down exerciseProgressive jumping exercise on MiniTrampoline

TREATMENT PROTOCOLIn both training protocols the patients wereinstructed to perform the conventional staticquadriceps hamstring and gastronemius stretchingexercise after each training session. All subjects wereinstructed to perform three repetitions of a 30 secondstatic stretch of these muscle groups.

Intervention:-Patients were trained three times per week for 5weeks. Each exercise session lasted for approximately45 minutes. Each exercise was performed in 3 sets of

22

10 repetitions. Exercises are explained to the patientin detail. If patient feels pain while performing anyone of the exercises it is stopped and started at laterstages.

ASSESEMENTMeasurement of Quadriceps strength with Strain GaugeIt is measured by Strain gauge. It is a reliable tool forclinical measurement testing. All muscle groups weretested in mid range of joint motion. The idea behindthis to get maximum force production. The straingauge will be perpendicular to limb segment. Afterthe subject is positioned and stabilization isachieved the subject is asked to flex and extend theknee and dorsiflex the ankle actively as warm up.One practice trial will be given prior to eachmovement. Best of the three trials will be recorded foreach muscle group and average of these scores willbe recorded and used for Data analysis. Each triallasted 4-5sec so that the subjects could be instructedto increase their force to a maximum over a few sectimes .Rest period of 60 sec. will be given for eachtrial. Knee extensor muscle forces will be tested withthe subject positioned high sitting with hip flexed to90 and the strap is placed distal tibia for extension.6

WOMACThe WOMAC (Western Ontario Mac Master) scalewas designed to measure dysfunction and painassociated with OA of the lower limbs by assessingseventeen functional activities, five pain relatedactivities and two stiffness categories. Thisinstrument has been well studied and many of itspsychometric properties are known. It is among themost sensitive of all instruments used in theassessment of OA of the hip/ knee and has beenwidely used in the clinical trials. Although it isprimarily used in OA there is nothing about theinstrument that makes it unsuitable for use in otherillnesses that affect the lower extremities such, asRheumatoid arthritis,fibromyalgia.Infact theWOMAC might be particularly useful in RA andfibromyalgia where no other functional instrumentsexist to assess the region adequately.85WOMAC indexis used to assess the patients with OA of the hip/knee using 24parameters.It can be used to monitorthe course of the disease or to determine theeffectiveness of anti rheumatic medications.Interpretation can be done as83

Min. total score=0Max. total score=96Min. pain score=0Max.. pain score=20Min. stiffness score=0Max. .stiffness score=8Min. physical function score=0Max. physical function score=68

Figure6.5, Showing attachment of Strain Gauge

DATA ANALYSISData analysis was done using SPSS-7.0 and STATA8.0 software packages. The values collected were thatfor the dependent variables –measurement ofQuadriceps strength and WOMAC score. GeneralDemographic data was also analyzed i.e. Age,Weight, Height and BMI and expressed in Mean andStandard deviation, ‘t’ test was used to compare thedifference in mean and S.D between group 1 andgroup 2.Variables are then compared between andwithin the group.

RESULTSTable8.1:-Comparison of Age, Weight, Height andBMI between two groups:-

Background Group 1N Group 2N tvariables =15 =15 value

Mean S.D Mean S.DAge 60.20 7.24 61.27 5.37 0.46NSWeight 74.40 12.50 76.87 8.59 0.63NSHeight 1.59 0.05 1.57 0.04 1.78NSBMI 29.26 4.79 31.45 4.25 1.33NS

‘S.D’ means Standard deviation.‘NS’ means Not Significant

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Table8.2:-Comparison of WOMAC between twogroups

Group 1N Group 2N tWOMAC =15 =15 value

Mean S.D Mean S.DWOMAC0 0.33 0.11 0.40 0.03 1.87NSWOMAC18 0.27 0.05 0.25 0.05 1.01NSWOMAC35 0.22 0.05 0.20 0.06 0.74NS

WOMAC 0= WOMAC score on 0 dayWOMAC 18= WOMAC score on 18 dayWOMAC 35= WOMAC score on 35 day

S.D = Standard DeviationNS= Not significant

Table 8.3:-Comparison of QS between two groups

Group 1N Group 2N tQS =15 =15 value

Mean S.D Mean S.DQS0 8.70 1.44 9.34 1.44 1.21QS18 11.33 1.75 13.32 2.65 2.43*QS35 14.11 1.89 16.35 2.71 2.63*

QS0= Quadriceps Strength at 0 dayQS18= Quadriceps Strength at 18 dayQS35= Quadriceps Strength at 35 dayN= No. of patients in each group*= significant at .05 level.** = significant at .01 level.

(GROUP-1)

Table8.4:-Comparison of WOMAC 0 withWOMAC 18 of Group 1- paired t test

WOMAC N=15 t valueMean S.D WOMAC0

with WOMAC18WOMAC0 0.33 0.11 2.27*WOMAC18 0.27 0.05

*Significant at .05 level

Table 8.5:-Comparison of WOMAC 0 with 35 ofgroup 1-paired t test


with WOMAC35WOMAC0 0.33 0.11 3.81**WOMAC35 0.23 0.05

**= significant at .01 level.

Table 8.6:-Comparison of WOMAC 18 withWOMAC 35 of group 1- paired t test



** = significant at .01 level.

Table8.7:-Comparison of QS 0 with QS 18 ofGroup 1- paired t test

QS N=15 t valueMean S.D QS0 with QS18

QS0 8.71 1.44 6.01**QS18 11.33 1.75


Table8. 8:- Comparison of QS 0 with QS 35 of group1-paired t test


QS0 8.71 1.44 10.40**QS35 14.11 1.86

**=Significant at .01 level.

Table8.9:- Comparison of QS18 with QS35 ofgroup 1- paired t test


QS18 11.33 1.75 14.46**QS35 14.11 1.89

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(GROUP-2)

Table 8.10:- Comparison of WOMAC 0 withWOMAC 18 of Group 2- paired t test



**Significant at .01 level.

Table8. 11:-Comparison of WOMAC 0 with 35 ofgroup 2-paired t test




Table8.12:-Comparison of WOMAC 18 withWOMAC 35 of group 2- paired t test




Table8.13:-Comparison of QS 0 with QS 18 of Group2- paired t test


QS 0 9.34 1.44 5.36**QS 18 13.32 2.66


Table 8.14:- Comparison of QS 0 with QS 35 of group2-paired t test


QS 0 9.34 1.44 9.92**QS 35 16.35 2.70


Table 8.15:- Comparison of QS18 with QS35 of group2- paired t test


18 13.32 2.65 9.92**

QS 35 16.35 2.70


Graph 8.1:-Comparison of Age, Weight, Height and BMI between two groups

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Graph 8.2 :- Comparison of WOMAC between two groups

Graph 8.3:-Comparison of QS between two groups

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Graph 8.4:- Comparison of WOMAC 0 with WOMAC 18 of Group 1- paired t test

Graph 8.5:-Comparison of QS 0 with QS 18 of Group 1- paired t test

27

Graph 8.6:-Comparison of WOMAC 0 with WOMAC 18 of Group 2- paired t test

Graph 8.7:-Comparison of WOMAC 18 with WOMAC 35 of group 2- paired t test

28

Graph 8.8:-Comparison of QS 0 with QS 18 of Group 2- paired t test

Graph 8.9:-Comparison of QS 0 with QS 35 of group 1-paired ‘t’ test.

29

RESULTSThirty female subjects (N=30) divided into twogroups i.e. Group 1 (N=15) and Group 2 (N=15) wereevaluated at Day 0, Day 18 and Day 35 for dependentvariables i.e quadriceps Strength and WOMAC.General demographic data was obtained with respectto age ,weight, height and BMI.On observation it wasfound that there was no significant differencebetween Group 1 and Group 2 for Demographic dataas shown in table 7.1.

Demographic dataIn Group 1 with N=15 the mean age was 60.20 andS.D was 7.24 and for Group 2 the mean age was 61.27and S.D was 5.37 with a ‘t’ value of 4.6 which is Notsignificant. Similarly the‘t’ value for weight, heightand BMI are 0.63,1.78 and 1.33 respectively and theseare all Not significant.

WOMACComparison of WOMAC between the Groups:- In Group 1 the mean was 0.33 and S.D was 0.11 forWOMAC 0.For WOMAC 18,the mean was 0.27 andS.D was 0.11 and for WOMAC 35 the mean was 0.22and S.D was 0.05.

In group 2, the mean was 0.40 and S.D was 0.03 forWOMAC 0.For WOMAC 18,the mean was 0.25 andS.D was 0.05 and for WOMAC 35 the mean was 0.20and 0.06.

The‘t’ value for both the groups for WOMAC 0 was1.87 i.e. Not Significant. For WOMAC 18 andWOMAC 35‘t’ value was 1.01 and 0.74 that too werenot significant. It shows that there was no significantdifference between the WOMAC scores of the twogroups.

Quadriceps StrengthComparison of quadriceps Strength between theGroups:-In Group 1, the QS 0 value of mean was 8.70 and S.Dwas1.44 and the QS 18 value for mean was 0.27 andS.D was 0.05 and for QS 35 mean was 0.23 and S.Dwas 0.05.QS 18 value for mean was11.33 and S.Dwas 1.75 and the mean value for QS 35 was 14.11and S.D was 1.89.

In Group 2, the QS 0 value of mean was 9.34 and S.Dwas1.44 and for QS18 the mean value was 0.25 andS.D was 0.05 and for QS 35 mean was 0.20 and S.D

Graph 8.10:- Comparison of QS18 with QS35 of group 2- paired ‘t’ test

30

was 0.60.The QS 18 value for mean was 13.32 andS.S was 2.65 and the mean value for QS 35 was16.35and S.D was 2.71.

The’t’ value for both the groups at QS 0 was 1.21,which is not significant. at QS 18 it was 2.43 whichis significant at .05 level and for QS35 it was 2.63which too is significant at .05 level. It shows thatthere is significant difference between the values ofQS0, QS18 and QS35 between the two groups andthere was significant effect of CKC exercises onquadriceps strength as compared to OKC exercises.

Paired ‘t’ test/’With in the Group’ for Group-1Comparison of WOMAC 0 with WOMAC18:- The mean value foWOMAC0 was 0.33and S.D was 0.11 and for WOMAC 18 themean value was 0.27 and S.D was 0.05 witha‘t’ value of 2.27 which is significant at 0.05level. It shows that there is significantdifference between the values of WOMAC 0and WOMAC 18.Comparison of WOMAC 0 with WOMAC35:- the mean value for WOMAC 0 was 0.33and S.D was 0.11 and for WOMAC 35 themean value was 0.23 and S.D was 0.05 witha ‘t’ value of 3.81 and is significant at.01level.Comparison of WOMAC 18 with 35:- themean values for WOMAC 18 was 0.27 andS.D was 0.05 and the mean value forWOMAC 35 was 0.23 and S.D was 0,05 witha ‘t’ value of 6.37 i.e. significant at 0.01 level.

Paired ‘t’ test /with in the group for Group-2Comparison of QS 0 with QS 18:-The meanvalue of QS 0 was 9.34 and S.D was 1.44 andthe mean value for QS 18 was 13.32 and S.Dwas 2.26.The ‘t’ value for both QS 0 and QS18 was 5.36 which was significant at .01level.Comparison of QS 0 with QS 35:-the meanvalue of QS0 was 9.34 and S.D was1.44 andthe mean value for QS 35 was 16.35 and S.Dwas 2.70.the ‘t’ value for both the groupswas 9.92 which was significant at .01 level.Comparison of QS18 with Qs 35:- The meanvalue for QS18 was 13.32 and S.D was 2.65and the mean value for QS 35 was 16.35 andS.D was 2.70 and the‘t’ value was 9.92which was significant at .01 level.

DISCUSSIONThe primary goal of this study was to test thehypothesis that comparative effect of OKC and CKCalong with hot pack on the quadriceps strength andfunctional status of women with osteoarthriticknees.Subjects included in the study had similarbaseline values of mean age, weight, height and BMIand there are no significant differences betweenthem.

Overall results of the study indicate that CKCexercises along with hot pack have more significanteffect than OKC exercises with hot pack on thequadriceps strength and therefore contribute to thefunctional outcome. Group B showed greaterimprovement in muscle strength and hence the resultsfor group B are statistically significant.

These findings suggest that there is clear advantageof the use of Closed Kinetic Chain exercises alongwith hot pack on Quadriceps strength and functionalstatus of women with Osteoarthritic knees.

Kristen et al;2009 demonstrated that quadricepsstrength is an important factor to target because theweakened quadriceps muscle may increase jointstresses from decrease ability to alternate loadsacross the joint while exercises leads to increase inquadriceps strength along with improve pain andfunction.

Thomee et al; 1995 investigated the role of muscleinhibition and isometric and isokinetic musclestrength in 10 patients with unilateral OA knees. Thequadriceps of all OA legs demonstrated muscleinhibition and was significantly weaker than thenondiseased legs.

Osteoarthritis is a common progressive healthproblem among adults. It is estimated that 80% of theadults at or over the age of 65 years exhibitsradiographic evidence of OA.57Osteoarthritisincreases with age and sex specific differences areevident. After about 50 years of age women are moreoften affected with hand, foot and knee OA thanmen.3Osteoarthritis is the most common conditionaffecting the synovial joints. OA of the knee causessubstantial pain and disability among elderly,resulting in a significant burden on healthcareprovision.58Knee OA at the baseline was defined asthe presence of grade 1+ osteophyte or JSN(joint

31

space narrowing) in at least one of the fourcompartments(lateral or medial , right or leftknee.81The development and progression of OA ismultifactorial with quadriceps weakness being oneof the main factors that is modified by resistancetraining according to this review.62RecentlyAndriacihi et al,2004 suggested that the initiation ofKnee OA is associated with the Kinematic change inthe tibiofemoral load bearing areas where cartilageis not accustomed to such loads and breakdown.93Multiple factors play a role in the etiology ofMuscle weakness. In addition to pain and disuseatrophy reduced quadriceps activation has beensuggested to contribute osteoarthritis.91Sharma et alreported that varus or valgus laxity andmalalignment may influence the relationshipbetween quadriceps strength and progression oftibiofemoral arthritis.51 In the unloaded state ,varusvalgus stability is provided by the ligaments, capsule,and other soft course, condylar geometry andtibiofemoral contact forces at the joint interfacegenerated by muscle activity and gravitationalforces.53Quadriceps weakness is clinical importantbecause it is associated with impaired functionalperformance and disability .As in OA in patientswith RA with lower limb involvement we found thatquadriceps weakness is associated with objective andsubjective disability and intervention that increasequadriceps strength would therefore expected todecrease disability.80For instance Steultjens andcolleagues reported that decreased quadricepsfemoris muscle structure accounted for 15-20% of thelower extremity functional disability and for 5% ofthe knee pain associated with OA.Therefore one aimof physical therapy intervention for patients withOA to increase strength of the musculaturesurrounding the Knee joint.4Self reported knee pain,stiffness and difficulty in physical function will bemeasured using the WOMAC osteoarthritic Index avalid, reliable and responsive disease specificinstrument.77Exercises that strengthen thequadriceps leads to decrease in knee pain.8 There ishigh quality evidence that exercise reduces pain andimproves physical function in patients with knee OAType of exercise e.g improving muscle strength, gait,ROM and stability varied widely both within andacross sessions. Muscle strength exercises were mostcommonly used (90%).92Huang and coworkerscompared the Therapeutic effects of different musclestrengthening 9 i.e. Isotonic, Isometric and isokinetic)

exercise on the functional status of patients with KneeOA.8Open Kinetic chain leg extension exercises havebeen the traditional means of strengthening thequadriceps. The clinical use of CKC exercises hassignificantly increased during the past several yearsas they simulate and replicate many functionalmovements.10 The use of unilateral weight bearingexercises in the rehabilitation of the knee dysfunctionis supported by extensive analysis of EMG signalamplitude of thigh muscle. Use of lateral step up,maximal one legged squat and forward step upexercises for improving or targeting quadricepsactivation in rehablitation.94In recent yearsimportance of using closed chainevaluation(Greenberger and Paterno 1995) andrehabilitation (Beynnon et al;1997) has been stresseddue to the belief that closed as opposed to openkinetic chain movement is more closely related tofunction.95Topical heat and cold are commonly usedto treat injuries of musculoskeletalsystem.(bones,ligaments,muscles,tendons) Thesemodalities are useful adjuncts to exercise medicationand education for the comprehensive treatment ofmany musculoskeletal conditions.90 There is apopular opinion that CKC exercises tend to promotefunction more than do OKC exercises because CKCexercises involve primarily weight bearing activities.During the swing phase, the quadriceps femorismuscle may be required to produce a large amount ofOKC hip flexion and extension torque to maximizethe stride length. This functional activity includesboth OKC and CKC knee extension may actually domore to improve function in this circumstance thatsimply using one type of exercise.69

Gro Jamtvedt; 2008, Long term adherence is requiredto maintain the benefits of exercise in Knee OA andbecause long term adherence requires regularmotivation, supervision and monitoring.

Future ResearchStrengthening exercises (OKC and CKC) is an areathat needs to be explored more with special attentiongiven to strength in healthy and diseased individuals.Although there are many studies which havesupported the use of OKC and CKC exercises inimproving muscle strength but unfortunately theprotocols and programmes used in studies aredifferent and there is not set protocol for a particularpathology and age group. Hence there is need to set

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or explore a standardized protocol for healthy anddiseased individuals with different pathologies andage groups.

A comparison of both OKC and CKC with other typeof strengthening exercises can be made as a basis offuture research or long term effects of these exercisesin patients with knee OA should be considered forfuture research.

Relevance to Clinical PracticeMuscle weakness plays an important role inpathogenesis of Knee OA., even in early stages ofdisease; therefore emphasis should be laid onStrengthening (OKC and CKC) exercises. Hot packscan be used as an adjunct to these exercises as it hasproved to be better than exercises alone especiallyfor individuals who find it difficult to do exercisesbecause of pain or psychological reasons. Strengthcan make a marked difference in the functional statusof patients in Osteoarthritic knees as it will also delayprogression of the disease, prevent development ofdeformity and need of joint replacement.

LIMITATIONS OF THE STUDYTime period for the study was only 5 weeksand the frequency was only 3 times per week.Keeping in mind the time considerations,increase in muscle girth would not have beenpossible and hence that was not includedunder dependent variable.The Therapeutic OKC and CKC protocolused for the patient was little hectic for theOsteoarthritic elderly patient and patientmight felt discomfort.Small sample size i.e. No. of subjectsincluded were less, only 30 patients wereincluded.Only female subjects were chosen for thestudy.

CONCLUSIONResults of this study show that the CKC (ClosedKinetic Chain Exercise) along with the hot pack aremuch more effective in improving the QuadricepsStrength and functional Status of women withOsteoarthritic Knees. Improvement in quadricepsStrength was much more marked in Group 2 andcontributes to functional status outcome.The values of Quadriceps strength between and within

the group were significant and the values of WOMACbetween the groups were not significant but withinthe group the values were significant.

The study therefore concludes that Null hypothesisthat CKC exercises along with Hot pack are no moreeffective in improving quadriceps Strength andFunctional status of women with Osteoarthritic Kneesis rejected and the experimental hypothesis that CKCexercises are effective in improving QuadricepsStrength and functional status of women withOsteoarthritic knees.

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66. Guoan Li et al; Three dimensionaltibiofemoral articular contact Kinematics ofacruciate retaining total knee arthoplasty.

67. An implementation study of two evidencebased exercise and health educationprogrammes for older adults with OA of theKnee and Hip.

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70. Luc Noreau et al; 1998, comparision of threemethods of assessing Muscle Strengthinpatients with Spinal cord injury;International Medical society of paraplegia,36,716-723.

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Effect of neural mobilization on H-reflex and OswestryDisability Questionnaire in sciatica

Dr. Pravin Kumar*, Rajinder Kaur **

* Associate professor MPT, D.AV. Institute of Physiotherapy & Rehabilitation Jalandhar** Research student, MPT Neuro, D.A.V. Institute of Physiotherapy & Rehabilitation Jalandhar

INTRODUCTIONThe term sciatica has come to be applied to a benignsyndrome characterized especially by painbeginning in the lumbar region and spreading downthe back of one lower limb to the ankle.1 There is alsonumbness, muscular pain, pins and needles ortingling and difficulty in moving or controlling theleg.2 It is a common condition that is associated withsignificant pain and disability. The lifetimeprevalence is at least 5.3% in men and 3.7% in women,representing 6% of total work disability. Sciatica hastraditionally been regarded as a self-limitingcondition with a good prognosis for completerecovery; however, 30% of patients still havesignificant symptoms at 1 year, with 20% out of workand 5-15% requiring surgery.3,4

There is slowing of nerve conduction velocity inradiculopathy patients. Because of compressionelectrophysiological changes takes place like H-

Background & Purpose: To know the effect of neural mobilization on H-reflex and on ODQ.

Method: 30 subjects were systematically assigned with 15 in each group. After assessment and evaluation ofpatients on 1st day, H-reflex and ODQ were recorded. Treatment was given for 5 days per week for two weeks.Similarly all these data re-evaluated on 5th day and on 10th day. Group A (control) were given SWD and intermittenttraction. Group B (experimental) were given SWD, intermittent traction and neural mobilization for sciatic nerve.

Result: The repeated measure ANOVA test and student t-test was used for in between group data analysis andpaired t-test was used in within group data analysis. Group A, mean of H-reflex on 1st, 5th and 10th day of treatmentwas 27.25(±2.30), 28.25(±2.48) and 28.97(±2.75) and 27.60(±2.25), 28.82(±2.02) and 30.03(±1.41) for group Bshowed significant (p<0.05) improvement. Group A, mean of ODQ on 1st, 5th and 10th day of treatment was62.42(±7.13), 46.44(±9.91) and 23.47(±7.42) and 63.41(±8.89), 45.48(±8.57) and 16.66(±6.95) for group B showedsignificant (p<0.05) improvement. But when compared between groups there was a non-significant improvement inH-reflex but ODQ showed significant improvement in experimental group.

Conclusion: The effect of neural mobilization on H-reflex was non-significant when compared with Control Group,but significant improvement in ODQ scores in experimental group. So functional status of patients was improvedsignificantly in Experimental Group.

Keywords: H-reflex, Traction, Nerve mobilization

reflex, F-wave and change in Sensory nerveconduction velocity (SNCV), these are very sensitivediagnostic test to check the peripheral nerveinvolvement.5 There are many scales which aredesigned to measure the disability from thoseoswestry disability questionnaire (ODQ) is morereliable and valid scale.6,7 Neural mobilizationtechnique is used to regain the movement andelasticity of nervous system.8

Sciatica was initially thought to occur predominantlyas a result of a prolapsed lumbar vertebral disccausing compression of the nerve root, leading toneural ischaemia, odema and eventually to chronicinflammation, scarring and perineural fibrosis.9

Riccardo Mazzocchio et al conducted a study onRecruitment curve of the soleus H-reflex in chronicback pain and lumbosacral radiculopathy. Theyconcluded H-threshold may be the earliestabnormality in the absence of focal neurological

38

signs.10-11 Hesham N Alrowayeh et al conducted astudy; H-reflex amplitude asymmetry is an earliersign of nerve root involvement than latency inpatients with S1 radiculopathy. In this study patientwith radiculopathy showed significant amplitudeasymmetry when compared with healthy controls.However, latency was not always significantlydifferent between patients and healthy controls.These findings suggest nerve root axonal compromisethat reduced reflex amplitude earlier than the latencyparameter (demyelination) during the pathologicprocesses.12 The Oswestry disability questionnairecan be used to monitor the response to treatment andrehabilitation because it is more reliable and validscale.13,14 There was many studies which showed thatSWD and traction helped in radiculopathy cases.Paul wagstaff et al conducted a pilot study tocompare the efficacy of continuous and pulsedmagnetic energy/short wave diathermy on relief oflow back pain, the study showed that all three groupshad a significant relief of pain and that the groupsreceiving pulsed magnetic energy had a reliefsignificantly greater than those patients in the groupreceiving continuous magnetic energy.15

Md. Shaik Ahmed et al conducted study onEvaluation of the effects of shortwave diathermy inpatients with chronic low back pain. They foundsignificant improvement in patients who receivedSWD.16 B.J.Sweetman et al conducted a study on arandomized controlled trial of exercises, short wavediathermy and traction for low back pain withevidence of diagnosis-related response to treatmentand results showed that patients of sciatica moresignificantly improved by traction as compared toshort wave diathermy. But results showed nosignificant difference between control groups andexperimental groups.17 Ibrahim M. Elnaggar et alconducted a study, Influence of Spinal Traction inTreatment of Cervical Radiculopathy. In this studyPatients were evaluated before and after treatmentfor neck pain severity, arm pain severity,amplitude and latency of flexor carpiradialis H-reflex, and neck mobility. They concluded that bothof the intermittent and the continuous cervicaltraction had a significant effect on neck and arm painreduction, a significant improvement in nervefunction, and a significant increase in neck mobility.However, the intermittent traction was more effective

than the continuous type.18 Annette A Harte et alconducted a study on the effectiveness of motorisedlumbar traction in the management of LBP withlumbo sacral nerve root involvement. The aim of thisstudy was to test the feasibility of a pragmaticrandomized controlled trial to compare the differencebetween two treatment protocols (manual therapy,exercise and advice, with or without traction) in themanagement of acute/sub acute LBP with ‘nerveroot’ involvement. 27 patients completed treatmentwith a loss of another four patients at follow up.Intention to treat analysis demonstrated animprovement in all outcomes at follow up points butthere appeared to be little difference between thegroups.19,20

According to new trends neural mobilization wasmore effective in radiculopathy case. Kim D.Christensen and Kirsten Buswell conducted a study,Chiropractic outcomes managing radiculopathy ina hospital setting: a retrospective review of 162patients. The treatment protocol includedchiropractic manipulation, neuromobilization andexercise stabilization. The results of this studysuggest that the combination of manipulation,neuromobilization and stabilization exercise may beuseful for patients with radiculopathy. 21,22

Gladson R. Bertolini et al conducted study on neuralmobilization and static stretching in an experimentalsciatica model and they concluded that neuralmobilization is more effective as compare to staticstretching.23,24

So purpose of my study was to find out the effect ofneural mobilization on H-reflex and on ODQ

MATERIAL AND METHODSThe study design was experimental in nature. Totalduration of study was one and a half year. Total 30patients were conveniently assigned to Group A(Control Group) and Group B (Experimental Group)15 in each group. All subjects were selected accordingto the criteria for subject selection as follows;

INCLUSION CRITERIA• Age – 30-50 yrs.• Gender – Both Males and females.• Patient should be co-operative.

39

• Patients with Sciatic nerve compression.• Patients with Lumbar radiculopathy or

Prolapsed intervertebral disc.• Patients with lumbar spinal stenosis.

EXCLUSION CRITERIA• Fracture of Spine and Lower limb.• Bone tumours.• Metal implants in spine and lower limb.• Post operative sciatica patients.• Tuberculosis of spine and hip.• Any Neurological impairment and

musculoskeletal disorders.• Deformity of lower limb.

PROCEDUREVARIABLESDependent variable: H-reflex and ODQ Independentvariable: Neural mobilization.

Verbal and written consent was taken from patients.After assessment and evaluation of patients on 1st

day, H-reflex and ODQ had recorded. To check H-reflex of soleus muscle patient lie in prone lying andrecording electrode were placed on distal edge of calfmuscle and reference electrode on tendoachilles andstimulation was given on popliteal fossa (Fig-1).25

Treatment was given for 5 days per week for twoweeks. Similarly all these data re-evaluated on 5th

day and at end of treatment sessions or on 10th day.

Group A: Which was Control Group got SWD for 10mins at Lumbo-sacral region by co-planar method(Fig-2).26,27 and intermittent traction keeping hip andknee 90p flexed with a parameter of 40 second holdand 10 second relax with 1/3 rd of body weight for15 mins (Fig-3).17,28

Group B: Which was Experimental Group inaddition to above treatment patients were givenneural mobilization for sciatic nerve .Patient lie insupine lying, therapist on the affected side facingtowards the patient and place one hand on theanterior side of knee and other on the plantar surfaceof foot and take the leg in hip flexion at the firstrestriction point and then adduct the leg and medial

Fig-1: Electrode Placement for H-reflex recording

Fig-2: Positioning of SWD

Fig-3: Positioning of Lumbar Traction

40

rotate it, knee in extension and then oscillatorymovements were given at ankle joint in dorsiflexionand plantar flexion and these were given in 10repetitions in 3 sets (Fig-4).23

DATA ANALYSISStatistics were performed using the SPSS 13.0software. Data was tabulated on a master chat. TheChi-square test was used to compare sex ratio andstudent’s t-test was used to compare mean age ofsubjects in between the group.

The repeated measures ANOVA test and student t-test was used for in between group data analysisand paired t-test was used for within group dataanalysis.

RESULTSThe repeated measures ANOVA test and student t-test was used for in between group data analysisand paired t-test was used in within group dataanalysis. Both groups were similar with respect toage and sex ratio and mean of variables H-reflex andODQ before starting the treatment. Group A (Fig.5)Mean of H-reflex on 1st, 5th and 10th day of treatmentwas 27.25(±2.30), 28.25(±2.48) and 28.97(±2.75) and(Fig.7)27.60(±2.25), 28.82(±2.02) and 30.03(±1.41) forgroup B showed significant (p<0.05) improvementafter treatment. Group A (Fig.6) Mean of ODQ on 1st,5th and 10th day of treatment was 62.42(±7.13),46.44(±9.91) and 23.47(±7.42) and (Fig.8)63.41(±8.89), 45.48(±8.57) and 16.66(±6.95) for groupB showed significant (p<0.05) improvement aftertreatment. In group A and Group B there was

significant improvement in H-reflex and ODQ after10 days of treatment. When we compared betweenthe Control and Experimental Group, (Fig.9) therewas non-significant (p>0.05) difference in H-reflex.But Experimental Group showed significant (p<0.05)improvement in ODQ (Fig.10) over Control Groupafter 10 days of treatment.

DISCUSSIONThe results of this study suggest that H-reflex andODQ improved significantly in both the Control andExperimental Groups after 10 days of treatment. ButExperimental Group was statistically highlysignificant. When we compared both the groups itshowed non-significant difference in H-reflex after5th and 10th day of treatment, but there was significantimprovement in ODQ Experimental Group compareto Control Group, so the functional status of patientshad improved significantly in experimental groupafter the 10 days of treatment.

It has been hypothesized that prolonged irritation ofnerve tissue through mechanical, chemical or thermalstimuli can result in electrical hyper excitability ofthe nerve membrane resulting in a lower thresholdfor stimulation and the development of ectopicimpulses.29 Gibson et al. studied 109 patients andsignificant improvements after treatment wereobserved in 59% patients who received shortwavediathermy.30 Kerem and Yigiter studied 60 patientsand showed significant improvements in measuredparameters in shortwave diathermy group after thetreatment.31 The force exerted by traction tends toseparate vertebrae; therefore, nerve root pressure canbe relieved. Also, in exerting a longitudinal stretchon the annulus fibrosus plus anterior and posteriorlongitudinal ligaments, there is centripetal forcetending to move the nucleus centrally. A respectableworking theory is that blood and lymph flow areincreased by reduction in nerve root compression,bringing nutrition and removing inflammatory wasteproducts. Therefore, the leg pain is diminished atfirst and cleared by three or four treatments. Voltonenet al who concluded that traction relieves musclespasm and significantly decreases electrical activityin the muscles producing relaxation, which leads tosystematic relief of pain. There was a non significantdifference between both groups. The above mentionedfindings are most likely due to the decompression ofthe compromised spinal root or dorsal root

Fig-4: Position of Neural Mobilization

41

ganglia.32,33 Hall and Elvey contraindicate stretchingas therapy for nerve lesions and they indicate gentleoscillatory movements in the anatomical structuresaround the affected nerve tis-sue. They mention thatwhen the nerve fascicle is stretched, its cross-sectionalarea is reduced, intra-fascicular pressure increases,nerve fibers are compressed and microcirculation iscompromised; and the pressure received by the nervewill affect the edema and the demyelination. Giventhat neural mobilization consists of short oscillatorymovements and that in the present study thistechnique was more effective than static stretching,it is suggested that the tension main-tained by staticstretching may be less beneficial to nerve integritythan short, repetitive stress.12

It is of interest to note that the improvement in H-reflex and ODQ in both the groups after treatmentbut Group B that had received Neural mobilizationwith SWD and intermittent lumbar traction showedhighly significant improvement. So improvementsin the value of these variables have been contributedby the combined effect of SWD, intermittent lumbartraction and Neural mobilization.

Saher M Adel was cleared that neurodynamictechniques (neurodynamic) has a great role inmanagement of sciatica resulted from herniated discconcerning pain and restoring mobility of nerveroot.34 This comes agreement with Cleland et al35 andGladson et al36, who mentioned that when the nerveroot was compressed and microcirculation wascompromised; and the pressure received by the nervewill affect the edema and the demyelination,neurodynamics techniques consists of shortoscillatory movements and was sufficient to dispersethe edema, thus alleviating the hypoxia and reducingthe associated symptoms. It could also be directlyassociated with the immobilization reduction in theneurogenic inflammation.37 In addition, there is thehypothesis that nerve movement within pain-freevariations can help to reduce nerve compression,friction and tension, therefore decreasing itsmechanosensitivity. Therefore, a neurodynamictechnique seems to be a better form of treatment whencompared to passive stretching alone. There wasreduction in pain intensity so functional status ofpatients had improved and significant improvementwas noted on ODQ scores.

Moreover, it was believed that patients with chronic

constant symptoms of radiculopathy need a long timeand frequent treatment sessions to improve H-reflex.The results of the present study may support suchbelief. Chronic constant symptoms of radiculopathyno signs of improvement in H-reflex could indicatethat the cause is a large irreducible disc herniationand both bulging annulus displaced disc material isin a state of fixation and unable of moving by fibrousrepair. This discal abnormality causes constantentrapment of the nerve root.17

Age and temperature are the two most influentialfactors that can cause variations in conductionvelocity. Nerve conduction is slowed considerablyin infants, young children and elderly individuals.Motor and sensory conduction velocities have beenshown to decrease slightly after age 35, with larger,significant differences noted after age 70.

There was reduction in pain intensity so functionalstatus of patients had improved and significantimprovement was noted on ODQ scores.

The results of this study showed that theelectrophysiological tests given relevant informationabout the radiculopathy conditions which was usedfor diagnosis purposes. But these are also used toknow the effectiveness of treatment if we done beforeand after the treatment. Future research is needed toconsider the height, weight, room and bodytemperature in this study.

CONCLUSION:It can be concluded from the results of this study thateffect of neural mobilization on H-reflex was non-significant when compared with Control Group. Butthere was significant improvement in ODQ scores inExperimental Group when compare to ControlGroup. So, the functional status of patients wasimproved significantly in experimental group in thisstudy.

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and disability important in low back care?’Phys Tlier, Vol.74, Pages 452-462.

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Comparing efficacy of eccentric training, static stretching andawareness through movement in improving hamstring

flexibility in femalesShweta Jain *, Vijeta Arora **

* MPT (Ortho), Institute of Applied Medicine and Research, Ghaziabad (U.P.)** MPT (Sports) Asst. Prof., Institute of Applied Medicine and Research, Ghaziabad (U.P.)

INTRODUCTIONFlexibility is an essential component of injuryprevention and rehabilitation6. Flexibility has beendefined as the capacity to move a joint through itsavailable range of motion without producingexcessive myotendinous stress7 Flexibility programsare used clinically for many benefits includingmuscle relaxation, posture improvements, bodysymmetry, relief of low back pain, relief of musclecramps and soreness and injury prevention8

Hamstring muscles are important contributors to thecontrol of human movement and are involved in awide range of activities from running and jumpingto forward bending during sitting or standing and arange of postural control actions 1, 2, 3 Reducehamstring flexibility has often associated withinjuries of low back and lower extremities and havebeen implicated in lumber spine dysfunction with

Background & Purpose: To compare efficacy among Eccentric Training, Static Stretching and Awareness throughMovement in improving hamstring flexibility in females. Few studies have evaluated that static stretching andeccentric training have equal effect on hamstring flexibility but awareness through movement a new technique ofinterest in improving flexibility of hamstring.

Method: We used four group repeated measure experimental design. Subjects were assigned randomly to 1 of 4groups: eccentric training, static stretching, awareness through movement or, control. A total of 60 subjects, withmean age group of 28.67 ± 3.65 years with limited hamstring flexibility (defined as 20º loss of knee extensionmeasured with the thigh held at 90º of hip flexion) were recruited for this study. Hamstring flexibility was measuredusing the active knee extension test before, after 2 weeks and at the end of 4-week program.

Result: The experimental groups were shown statistically significant improvement in hamstring flexibility whencompared with control group, whereas there was no significant difference between the groups at 2 weeks and 4weeks. But the net (from 0 wk to 4 wks) improvement (% mean change) in ROM was highest in eccentric training(15.6%) followed by awareness through movement (13.7%), then static stretching (10.9%) and least in controlgroup (0.3%).

Conclusion: The gains achieved in range of motion of knee extension (indicating improvement in hamstringflexibility) with eccentric training were 52, 1.4 and 1.1 times higher than that of control, awareness throughmovement and static stretching.

Keywords: Eccentric Training; Static Stretching; Awareness Through Movement; Hamstring Flexibility.

number of studies showing strong positivecorrelation between decrease hamstring flexibilityand low back pain4, 5.Stretching has been recommended to prevent injuryand to improve performance by regaining joint rangeof motion i.e. increasing flexibility. A number ofresearches have focused on the technique, frequency,and duration of stretching necessary to achieve thegreatest flexibility gains10-15. Among the differentstretching techniques, three types of stretching havebeen traditionally defined in the literature in an effortto increase flexibility: Ballistic Stretching,Proprioceptive Neuromuscular Facilitation andStatic Stretching.

Ballistic stretching is a technique involving arhythmic, bouncing motion17. Momentum is used toplace a muscle on stretch and may involve bouncing

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at the end of range18. Proprioceptive NeuromuscularFacilitation involves the use of brief isometriccontraction of the muscle to be stretched beforestatistically stretching the muscle17. Static stretching,considered the gold standard for measuring theflexibility, is lengthening the muscle to its maximumrange of motion while maintaining the position for agiven amount of time16. Eccentrically training themuscle through a full range of motion theoreticallycould reduce injury rates. But mechanism for thisincreased flexibility with eccentric hamstring activitythrough full range of motion is unclear. Duringeccentric training or contraction, the muscle islengthen under active tension, concentric contractionare frequently used to resist gravity the muscle beingused as a brake17, 22.

“Awareness Through Movement” (ATM) is a processof verbally guiding a person through an activityduring which movements usually are performedslowly and gently. It is thought that this processfacilitates the learning of strategies for improvingorganization and coordination of body movementby developing spatial and kinesthetic awareness ofbody-segment relationships at rest and duringmotion, awareness of ease of movement, reducingeffort in action, and learning the feeling of longermuscles in action1.

To our knowledge, previous groups have comparedstatic stretching and eccentric training for measuringhamstring length on males only and only one studyhas been done on the awareness through movementon increasing hamstring length. But no one hadstudied the comparison of the above three methodson lengthening the hamstring muscles in femalegroup. Therefore, research is needed to compareeffectiveness of eccentric training, static stretchingand awareness through movement in improvinghamstring flexibility in females.

METHODSSelection and description of participants:

We recruited 60 female subjects, ranged in age from25-40 years. Subjects selected from pool of employeesof HCL Technologies Ltd. and housewife’s fromNoida offices and clinics, all of whom signed aninformed consent form.

The volunteers met 5 requirements (InclusionCriteria) First, age group 25-40 years, second, subjectshould be sedentary28 i.e. having sitting work of 6-8hours27, 29 for atleast 6 months before starting thestudies and should not get involved in any newactivities. Third, extremity to be tested had no historyof impairment of knee, thigh, hip or lower back forone year before the study. Fourth, Subjects exhibitedtight hamstrings, tight hamstrings were defined as20o knee extension deficit with the hip at 90o 14. andfinally subjects with low physical activity as obtainfrom international physical activity questionnaire24,

30.Subjects were excluded from the study if Activeknee extension angle was greater than 160o. Subjectexhibiting any neurological, musculoskeletal,cardiopulmonary or metabolic disorder and historyof any surgery in last one year as reported by thesubject which may affect the protocol followed in thestudy. Subject involved in any stretching program inlast 6 months/ during the course of study.

All subjects were then randomly assigned to 1 of 4groups, that received eccentric training (n= 15), staticstretching (n= 15), ATM group (n= 15) and thatreceived no intervention (control group [n= 15]).

Alignment apparatus similar to that described byDePino14 was constructed of 2.5 cm (1" in) diameterwooden stick. Two vertical uprights of 50 cm in heightconnected to a cross bar of 66 cm in length with baselength of 64 cm for all active knee extensionmeasurements. 360o universal goniometer to measurehip and knee angle of 90o. Active knee extensionmeasurement from each subject was used for pre-testand post-test calculations.

Measurement Protocol:The hamstring muscle length of all subjects who metthe inclusion criteria was measured using the activeknee extension test (AKET) 1 day prior to beginningthe intervention. Hamstring muscle was measuredagain at 1-2 days interval after 2 weeks and at theend of intervention period i.e., after 4 weeks.

Subjects were positioned supine on a standard 0.9 x1.8 m (3 x 6 feet) plinth under the alignmentapparatus. A 10.2 cm wide (4" in) Velcro strap wasplace around the subject at the level of anteriorsuperior iliac spine to stabilize the pelvis and lumbarspine. An additional 10.2 cm wide Velcro strap was

46

place over left thigh to stabilize the pelvis and leftlower extremity. The subject right hip was flexed to90o until the anterior thigh was just touching the crossbar of the alignment apparatus. Black felt tip markerwas used to draw circle around the lateral femoralepicondyle, the head of fibula, and the lateralmalleolus of the right leg. Once the subject wasplaced in the supine AKE position, palpation of circledone to verify the identified the desired bonylandmarks Subject were told to maintain the positionof the anterior thigh in light contact with cross bar ofthe alignment apparatus. The starting position forthe test was with anterior thigh touching the crossbar of alignment apparatus and the right knee in 90o

flexed position. One repetition of knee extensionmovement consisted of moving knee into extensionuntil a feeling of resistance from the stiffness ofhamstring muscle stopped the movement and thenreturning to starting position. Examiner measuredthe knee extension angle by placing goniometer onlateral epicondyle of femur as shown in fig 1.

PROCEDUREThe eccentric group (n=15) performed full range ofmotion eccentric training17 for the hamstring muscle3 days a week for 4 weeks. The subject lay supinewith the left leg fully extended. A 3-ft (0.91-m) pieceof black Theraband was wrapped around the heeland the subject held the ends of the Theraband ineach hand.

The subject was instructed to keep the right kneelocked in full extension and the hip in neutralinternal and external rotation throughout the entireactivity (photo 1). The subject was then instructed to

Figure 1.Setup for measuring hamstring muscle lengthusing alignment apparatus.

bring the right hip into full hip flexion by pulling onthe Theraband attached to the foot with both arms,making sure the knee remained locked in fullextension at all times. Full hip flexion was definedas the position of hip flexion at which a gentle stretchwas felt by the subject (photo 2). As the subject pulledthe hip into full flexion with the arms, he wasinstructed to simultaneously resist the hip flexion byeccentrically contracting the hamstring musclesduring the entire range of hip flexion. The subjectwas instructed to provide sufficient resistance withthe arms to overcome the eccentric activity of thehamstring muscles, so that the entire range of hipflexion took approximately 5 seconds to complete.

Once achieved, this flexed hip position was held for5 seconds, and then the extremity was gently loweredto the ground (hip extension) by the subject’s arms.This procedure was repeated 6 times, with no restbetween repetitions, thereby providing a total of 30seconds of stretching at the end range.

The static group (n=15) stretched for 30 secs 3 daysper week for 4 week using methods described by

Photo 1

Photo 2

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Nelson and Bandy17. Subjects performed the ham-string stretch by standing erect with the left footplanted on the floor and the toes pointing forward.The heel of the foot to be stretched was placed on aplinth/chair with the toes directed toward the ceil-ing (photo 3). The subject Then flexed forward at thehip, maintaining The spine in a neutral positionwhile reaching the arms forward. The knee remainedfully extended. The subject continued to flex at thehip until a gentle stretch was felt in the posteriorthigh. Once this position was achieved, the subjectmaintained this position for 30 seconds .

The ATM intervention was given over a four weekperiod and consisted of an initial group traininglesson. All subject in the ATM group participated ininitial class room lesson targeting movements of theright lower extremity. The lesson consisted of theintroduction plus movement segment in side lying(Appendix), with each segment covering variationof movements requiring lengthening of hamstringmuscle.

Each segment of the lesson began and ended with abody scan in supine position. This scan wasdesigned to make subjects aware of their quality ofneuromuscular control, including the rate and depthof breathing, the level of neuromuscular systemtension throughout the body from the jaw to the feet,and the effort involved in simple movements such asrolling the leg left and right. Movements weresuggested in which subjects flexed and extended theright knee, tilted the pelvis forward and back, androtated the right hip as shown in photo 4, 5 and 6.The goal was for subjects to learn to extend the knee,medially (internally) rotate the extending leg, and

Photo 3

anteriorly tilt the pelvis at the same time, anorganization of movements designed to lengthen thehamstring muscle from both ends.

The movements were done slowly and continuouslyfor 30 secs. Movements done within a comfortablerange of movement, noticing when effort in otherareas of the body interfered with these specificmovements intension and trying to reduce thoseefforts and breath easily through the entire process.Subjects were told explicitly not to push into the endrange of knee extension.

Photo 4

Photo 5

Photo 6

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DATA ANALYSIS:The age of four groups of subjects were compared byone way analysis of variance (ANOVA) and thesignificance of mean difference between groups wasdone by Student Newman-Keuls test. The effect oftreatments and periods (within subjects) on ROMwas compared together by general linear modelrepeated measures ANOVA and the significance ofmean between groups (i.e. between treatments) andwithin groups (i.e. between periods) were done byStudent Newman-Keuls test. A two-tailed (á=2)probability value p<0.05 was considered to bestatistically significant.

RESULTS(a) AGEThere were total 60 subjects randomized equally(n=15) to treat either with control or static stretching,or awareness through movement, or eccentrictraining. The age (yrs) of four groups of subjects weresummarized in Table 8.1.a and also showngraphically in Fig. 1. The age of subjects of controlgroup, static stretching group, awareness throughmovement group and eccentric training group rangedfrom 25-37 yrs, 26-35 yrs, 26-37 yrs, and 26-32 yrsrespectively with an average (± SD) of 28.20 ± 3.65yrs, 28.00 ± 3.05 yrs, 29.53 ± 3.567 yrs and 28.67 ±2.35 yrs respectively. The mean age of all four groupsseems to be the same (Table 8.1.a and Graph 8.1.a).

On comparing (Table 8.1.b), ANOVA revealed a notsignificant (p>0.05) difference in the age of all fourgroups of subjects (F=0.68, p=0.5657) i.e. the meanage of all four groups of subjects were statisticallythe same.

Statistic Control Static ATM Eccentricstretching training

N 15 15 15 15Min 25 26 26 26Max 37 35 37 32Mean 28.20 28.00 29.53 28.67SD 3.65 3.05 3.56 2.35

Table 8.1.a: Summary of age of four groups of subjects.p>0.05- not significant

Graph 8.1.a: Bar graph shows mean (± SD) age ofsubjects of four groups and compares the age betweenthe groups.2

(b) ROMThe range of motion (degree) of all four groups ofsubjects were summarized in Table 8.2.a and alsoshown graphically in Graph 8.2.a (bar graphs) and8.2.b (line graph).

Source of Sum of Degrees of Mean F- p-variation squares freedom square ratio value(SV) (SS) (DF) (MS)Between 20.93 3 6.98 0.68 0.5657groupsResidual 571.50 56 10.20Total 592.40 59

Table 8.1. b. Analysis of variance summary of age of fourgroups of subjects.

Table 8.2.a and both Graph. 8.2.a and Graph. 8.2.bshowed that the mean level of ROM in all groups oftreatment increases with the time (wks) except controlgroup. The increase was evident similar and highestin both eccentric training and awareness throughmovement followed by static stretching and least incontrol group (Graph. 8.2.b).

On comparing (Table 8.2.b), ANOVA revealed asignificant (p<0.01) effect of both treatments (F=8.37;p=0.001) and periods (F=1427.92; p<0.0001) on ROM.The interaction effect of both treatments and periodson ROM was also found to be significant (F= 165.67;p<0.0001).

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Comparing (Table 8.2.a) the ROM within the groups(i.e. for each treatment comparison between periods),the mean ROM levels in all groups of treatmentdiffered significantly (p<0.01) between the periodsexcept control group. In other words, the level of ROMin static stretching, awareness through movement,and eccentric training improved (increase)significantly at 2wks and 4 wks as compared to 0 wk(pre treatment) while it also improved significantlyat 4 wks as compared to 2 wks.

Similarly, comparing (Table 8.2.a) the ROM betweenthe groups (i.e. for each period comparison betweentreatments), the mean ROM levels in all four groupsat 0 wk were found to be the same i.e. not differedsignificantly (p>0.05). Similarly, the mean ROMlevels in all four groups at 2 wks and 4 wks were alsofound to be the same but differed significantly(p<0.01)in comparison to control group.

In conclusion, the net (from 0 wk to 4 wks)improvement (% mean change) in ROM was highestin eccentric training (15.6%) followed by awareness

through movement (13.7%), then static stretching(10.9%) and least in control group (0.3%) (Table 8.2.a).In other words, the net improvement in ROM ofeccentric training was 52, 1.4 and 1.1 times higherrespectively than that of control, static stretching, andawareness through movement.

Table 8.2.a: Summary (Mean ± SD, n=15) of ROM of fourgroups of subjects

Treatment At 0 At 2 At 4 % meangroups (Pre wks wks change(0 wk

test) to 4 wks)Control 128.53 ± 128.60 128.93 0.3%

7.62 ± 7.61 ± 7.89Static 130.53 ± 139.60 146.53 10.9%stretching 4.67 ± 4.15a ± 4.12ab

Awareness 129.47 ± 140.07 150.07 13.7%through 7.80 ± 7.73a ± 7.07ab

movementEccentric 127.00 ± 140.00 150.47 15.6%training 9.01 ± 8.96a ± 7.89ab

ap<0.01 in comparison with at 0 wkbp<0.01 in comparison with at 2 wks

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ns- p>0.05, **- p<0.01Graph 8.2.a: Bar graph shows mean (± SD) ROM level offour treatment groups at three different periods and for

each period compares the level of control group with othergroups.

ns- p>0.05, **- p<0.01Graph 8.2.b: Line graph shows mean (± SD) ROM trend offour treatment groups over the periods and for each periodcompares the level of control group with other groups.

Table 8.2.b: Repeated measures analysis of variancesummary of ROM of four groups of subjects over threeperiodsSource of Sum of Degrees of Mean F- p-variation squares freedom square ratio value(SV) (SS) (DF) (MS)Treatme 3825.75 3 1275.25 8.37 0.0001ntsError 8531.20 56 152.34Periods 6871.03 2 3435.52 1427.92 <.0001treatme- 2391.50 6 398.58 165.67 <.0001nts xPeriodsError 269.47 112 2.41

DISCUSSIONThis study rejected the null hypothesis that no differencewould be seen in knee extension range of motion after

four weeks of Static Stretching, Eccentric Training andAwareness Through Movement as compared with controlgroup (no exercise). The group that performed staticstretching, eccentric training and awareness throughmovement in combination with hip flexion and extensionrange of motion for four weeks showed significantlygreater gains in flexibility than control group, althoughthere was no significant difference between the groupsbut the group that performed the eccentric trainingimproved by 1.4 and 1.1 times more as compared to thosewho received static stretching and awareness throughmovement respectively. The result supports the theorythat eccentric training through a full range of motion andawareness through movement increases muscle flexibilitymore than static stretching.

Improvement seen in static stretching group was expectedwith considering previous research studies consistentevidence regarding the effectiveness of static stretchingto improve flexibility. Marques et al21, examined the effectsof statically stretching the hamstring for differentfrequencies including once a week, thrice a week and fivetimes a week for 30 seconds duration found stretchingthrice a week for 30 seconds is sufficient to improveflexibility and range of motion. Bandy et al20, 24, alsoexamined the effect of statically stretching the hamstringfor variety of durations, including 30 seconds. The 12.85

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degrees21, 12.50 degrees20 and 11.50 degrees31

respectively gain in knee extension range of motionafter six weeks of statistically stretching thehamstring muscle for 30 seconds were very similarto the gains by static stretching in present study forfour weeks.

Though eccentric training and awareness throughmovement are new methods of increasing hamstringflexibility but they showed better gains in our studythan static stretching. Nelson and Bandy17 were thefirst to study the eccentric training effect on flexibility.They examined the effect of 30 seconds staticstretching and eccentric stretching for six weeksperiod. Both methods were shown to increasehamstring flexibility, the gain made by staticstretching was 12.05 degrees and eccentric traininggroup was 12.79 degrees but there was no significantdifference between them. Thus the result presentstudy are strongly in coherence with abovementioned study.

The similar study done by Waseem23 on evaluatingflexibility by same techniques as Nelson et al17, buttreatment was given for five consecutive days andfollow up on 8th day yielded better result in staticgroup though both group increased flexibility. Afterfollow up flexibility was decreased as compared topost-test and showed increased after pre-test values.

The mechanism for increased flexibility with eccentrichamstring activity through full range of motion isunclear. One explanation may be found in examiningthe possible neurologic mechanism that occurs withstretching. But according to the study by Nelson andBandy, eccentric contraction through full range ofmotion is a continual movement lasting for 5 seconds;the muscle spindle does not appear to have time toadapt. Skeletal muscle has a large adaptationpotential induced by eccentric contraction andmorphological changes are related to addition ofsarcomere in series23. On repeated contraction(eccentric) leads to disruption and membranedamage, this leads to uncontrolled Ca+ movementsand development of localized contracture26 this couldbe another reason in improvement of hamstringflexibility.

Whereas mechanism behind the effectiveness of Staticstretching may be effective in increasing the length

of muscle due to prolonged stretching, which mayallow the muscle spindle to adapt over time and ceasefiring, the result of this adaptation of muscle spindleis an increased length17. However, Kubo9, 25 suggestedthat static stretching decreased viscosity of tendonstructures but increased the elasticity that is thestiffness of muscle. Static stretching resulted in anincreased flexibility due to changes in viscoelasticproperties.

The result of my study also determined thatAwareness Through Movement (ATM) is better thanstatic stretching. The two previously published publicresearches on the effect of ATM on hamstringslengthening showed two different results. One studyby James et al19 showed that effects of ATM were nodifferent from the effect seen in a waitlist controlgroup or a relaxation training control group over thestudy period. He suggested 3 problems with theirstudy that may explain their observation of no changein hamstring length. Firstly, subjects may not havehad enough opportunity within their interventionprocess to perform ATM lessons directed towardslengthening the hamstring muscles. Secondly,subjects had some negative preconceived ideas aboutusefulness of ATM and therefore did not co-operatedfully. Thirdly, the motor pattern of hamstring musclelesson used during the intervention was not the sameas that measuring the outcome of training.

However, in the study by Stephens et al1 showedthat ATM group gained more significant increase inhamstring muscle length (+ 7.04º) compared tocontrol group (+1.15°). Their study showed betterresults due to the reason that they controlled the 3possible problems in the previous study while presentstudy showed much better results from previous twostudies based on the following points:

We have used same ATM lesson which was directedtowards lengthening hamstring muscle and thisvariable was controlled whereas in previousresearches three or more ATM lessons were used inwhich they did not control this variable and did notknow what exactly their subjects did in this regard(subjects may have selected any one form or somecombination of 3 or more forms over training period).

Side lying ATM lesson which WE thought was betterthan other two lessons because side lying lesson offersbetter pelvic stability.

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There has been an interest in describing ATM as aprocess of motor learning. But our study was notdone using a formal motor learning design so we didnot assist a results in terms of motor learning1,because ATM process is different from stretching soneural mechanism should be considered forlengthening of muscle. It has been shown that stretchreflex can be regulated by operantconditioning, patterned sensory stimulation and skilltraining1. In present study, ATM showed greater gainthan static stretching but 1.1 times lesser gain thaneccentric training, so we hypothesize that probablemechanism for gain in ATM group have beenattributed to neurophysiologic mechanism ofstretching and stretch reflex mechanism.

Although eccentric flexibility and AwarenessThrough Movement of hamstring achieved bettergains as compared to static stretching, so eccentrictraining and ATM training offers a more functionoption for flexibility training.

CONCLUSIONThis study found all three treatments effective in themanagement of hamstrings flexibility in female buteccentric training and awareness through movementwas found to be more effective than static stretching.The range of motion (ROM) in subjects those whoreceived eccentric training improved by 1.4 and 1.1times more as compared to those who received staticstretching and awareness through movementrespectively.

Thus, for improving hamstrings flexibility in females,this study recommends clinician to opt both eccentrictraining and awareness through movement in placeof static stretching. Though, this study did not provethe efficacy of treatments over one another due toshort period (at 4wks only), but evident a much bettertrend of improvement in both eccentric training andawareness through movement as compared to staticstretching. Thus to confirm the efficacy of either ofthe treatments, this study recommends to evaluate itfor higher period of time and also validate its clinicalsignificance in different population eg. Athletes,Children, Elderly group. It opens up broad area forfurther studies.

ACKNOWLEDGEMENTI am thankful to Dr.Shagun Agrawal HOD IAMR,Dr.Poonam Singh MPT(Ortho) IAMR, Dr.Vijeta AroraMPT(Sports) IAMR and Mr.Negi Statistical analystfor their skills and willingness to help me for study.

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