Physio Article

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EFFICACY OF THREE PHYSIOTHERAPY INTERVENTIONS IN

INFLUENCING CLINICAL AND BIOCHEMICAL CHANGES OF

DELAYED ONSET MUSCLE SORENESS(DOMS) IN RECREATIONAL

ATHLETES

Synopsis Submitted to

SAVEETHA UNIVERSITY

For the award of the degree of

DOCTOR OF PHILOSOPHY

in

PHYSIOTHERAPY

by

S. SUDHAKAR

Research Supervisor

Dr. G. Arun Maiya, Ph.D

DEPARTMENT OF PHYSIOTHERAPY

SAVEETHA UNIVERSITY

CHENNAI-602105

October 2010

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CONTENTS

S.No CHAPTERS Page No

1. CHAPTER 1 –INTRODUCTION 4

1.1 Introduction 4

1.2 Problem Statement 5

1.3 Recent trends in the scientific study of the importance of

Physiotherapy Modalities in ameliorating the delayed onset muscle

soreness (DOMS) of recreational athletes.

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1.4 Need for the study 6

1.5 Significance of the proposed study in the context of current status 6

1.6 Operational Definitions 7

2. CHAPTER 2: OBJECTIVES, PLAN AND SCOPE 7

2.1 Aim of the study 7

2.2 Objectives of the study 7

2.3 Relevance and Scope of the study 8

3. CHAPTER 3: MATERIALS AND METHODS 8

3.1 Study Procedure 10

3.2 Induction Of Delayed Onset Muscle Soreness 10

3.3 Treatment Protocols 11

3.4 Post test Measurements 11

4. CHAPTER 4: STATISTICAL ANALYSIS AND RESULTS 13

4.1 Creatine kinase (CK) 13

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4.2 Lactate dehydrogenase (LDH) 15

4.3 Maximum isometric voluntary contraction (MIVC) 18

4.4 Repeated measures ANOVA results for dependent variables CK,

LDH and MIVC 19

4.5 Pain score 19

5. CHAPTER 5: DISCUSSION 20

6. CHAPTER 6: CONCLUSION 21

7. CHAPTER 7: REFERENCES 22

8. List of Publications 23

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INTRODUCTION

1.1 INTRODUCTION

Delayed Onset Muscle Soreness (DOMS) is a common phenomenon experienced by

individuals who perform unaccustomed exercise that typically involves an eccentric

component. The soreness begins to occur at approximately 8 - 24 hours post-exercise and

peaks at approximately 48 hours post exercise. Perception of soreness is generally reduced at

72 hours with residual soreness remaining beyond that time frame. After the exercise, the

symptoms usually appear a couple of hours to a day, peak between 1 and 3 days, and may

subside within 5 to 7 days, (Clarkson and Hubal, 2002).This constellation of symptoms is

often called “Delayed Onset Muscle Soreness (DOMS)”.

DOMS PHYSIOLOGICAL CAUSES:

By mid 80’s the thought of lactic acid build up in the muscles as a cause for DOMS

was put to rest. Likewise from the 80's and early 90's the main theories that seem to be still

active are DOMS is due to muscle cell damage (ruptured cells spilling contents), where the

repair process makes nerve endings sensitive to the pain signal, or it is due to an

inflammatory response ( Tidball 1995). The latter suggests that the 48 hour period when

DOMS hits is the peak time for cell death (Armstrong 1984).From the reviews it is assumed

that the pain is actually the building up of the new muscle fiber material where other fibers

are getting pushed out of the way as new tissue comes in.

PATHOPHYSIOLOGY OF DELAYED ONSET MUSCLE SORENESS (DOMS):

Five hypotheses are used to explain the pathophysiology of DOMS.

1. Structural damage from high tension.

2. Metabolic waste product accumulation.

3. Increased temperature.

4. Spastic contracture.

5. Myofibrillar remodeling.

WHY DOMS NEED TO BE TREATED: DOMS can temporarily reduce muscle

performance. The diminished performance results from reduced voluntary effort due to the

sensation of soreness and from the muscle's lowered capacity to produce force. DOMS hurts

and the consequent effects are decreased range of motion, increased size from swelling, and

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less power to work in the affected muscles. Negative implications of DOMS include minimal

to severe soreness, the inability to continue safe and effective training or performance,

biomechanical alterations predisposing individuals to injury, decrease in strength and power,

interruption of activities of daily living (ADL’S) and a decreased motivation and willingness

to continue training due to negative experiences of the soreness( Weber servedio et al.1994).

In order to minimize negative experiences associated with DOMS and potential detrimental

effects on performance, it is necessary to identify a successful treatment intervention.

HOW DOMS CAN BE TREATED:

DOMS can be treated either by advising complete rest from the participation, by medical

management and various physiotherapy approaches to reduce the soreness symptoms.

VARIOUS PHYSIOTHERAPY APPROACHES: Physiotherapy Interventions play a major

role both in prevention and treatment for the negative effects associated with DOMS. Many

treatments have been investigated which include massage, electrical stimulation, ultrasound,

acupuncture (Barlas, 2000), cryotherapy, repeat bout exercise, stretching (Johansson 1999),

Low intensity Laser therapy (Craig 1999), Iontophoresis (Hasson 1992), Transcutaneous

electrical nerve stimulation (TENS) (Craig 1996), preventative training, and even hyperbaric

oxygen therapy (Mekjavic, 2000).

1.2 PROBLEM STATEMENT:

Strength, range of motion, and a feeling of competence are important factors in

performing sports and exercise. Unaccustomed eccentric exercise causes adverse effects on

these factors (Bourgeois, MacDougall, 1999).Eccentric exercise, therefore may cause

significant reduction in performance during training and competition and/or increase the risk

of further injury. If athletes perform eccentric exercise with several muscles during training,

it is possible that the exercise efficiency on the subsequent day might be impaired. To date, a

sound and consistent treatment for DOMS has not been established. Although multiple

practices exist for the treatment of DOMS, few have scientific support. Suggested treatments

for DOMS are numerous and include pharmaceuticals, herbal remedies, stretching, massage,

nutritional supplements, and many more. As DOMS has been shown to alter biomechanics of

movement (Ebbeling and Clarkson 1989) and predispose participants to injury, it is important

to determine an effective treatment intervention that will reduce the negative impacts of

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DOMS. The present research is done on recreational athletes as they usually begin a

new exercise programme, increase their exercise intensity and commonly change their

sports activity.

1.3 RECENT TRENDS IN THE SCIENTIFIC STUDY OF THE IMPORTANCE

OF PHYSIOTHERAPY MODALITIES IN AMELIORATING THE DELAYED

ONSET MUSCLE SORENESS (DOMS) OF RECREATIONAL ATHLETES:

In the past, gentle stretching was one of the recommended ways to reduce

exercise related muscle soreness, but a study by Australian researchers published in 2007

found that stretching is not effective in avoiding muscle soreness. Recently study was done

on better attenuation effects of compression in DOMS, compression (and compression suits)

have been studied over the past 8 years. In another recent study Rhea, Bunker (2009),

investigated DOMS pain reduction with Vibration, Perceived pain was measured at 12, 24,

48, and 72 hours post workout. Many studies have been done to find out the significance

effects of modalities on DOMS, but none of the studies so far have been shown much

significant results in the markers of DOMS and in relieving the symptoms of muscle

soreness.

1.4 NEED FOR THE STUDY: The extensive reviews of the literature reveal that, there is

paucity of studies on role of various Physiotherapy modalities in ameliorating the DOMS.

Coaches, athletes, and medical practitioners are well aware of the symptoms of muscle

damage after eccentric exercise because it clearly affects subsequent exercise or performance

(i.e., strength, power, range of motion and probably exercise economy). Muscle weakness

requires a longer recovery and might have more impact on performance than soreness

sensation. Therefore the present study is needed to help for the athletes to be safe from the

above problems arising out of muscle damage.

1.5 SIGNIFICANCE OF THE PROPOSED STUDY IN THE CONTEXT OF

CURRENT STATUS:

INTERNATIONAL STATUS: Developed countries with their modern “Know how” are

progressing rapidly in exploring the possibilities of various physiotherapy modalities to

supplement the medical management thereby to facilitate early recovery.

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NATIONAL STATUS: The wealth of knowledge that has been provided by our researchers

regarding the use of various physiotherapy modalities for DOMS has to be collaborated with

detailed well organized study. Such a scientific study will facilitate Indian researchers and

clinicians to use these modalities to treat DOMS effectively.

1.6. OPERATIONAL DEFINITIONS:

Delayed onset muscle soreness (DOMS) Muscle soreness experienced by individuals

Who perform unaccustomed exercise that involves an eccentric component

Eccentric action Lengthening of a muscle under tension (Hall, 1991)

RECREATIONAL ATHLETE: “Recreational athlete" means an individual participating in

fitness training and conditioning, sports or other athletic competition, practices or events

requiring physical strength, agility, flexibility, range of motion, speed or stamina and who is

not affiliated with an amateur, educational or professional athletic organization or any

association that sponsors athletic programs or events in the State.

2. OBJECTIVES PLAN AND SCOPE OF THE STUDY

2.1 AIM OF THE STUDY:

To investigate the effects of three physiotherapy interventions in delayed onset muscle

soreness and its influence on biochemical markers in recreational athletes.

2.2 OBJECTIVES OF THE STUDY:

1. To investigate creatine kinase (CK) and Lactate dehydrogenase (LDH) enzymatic activity

taken at repeated time measures in 3 different physiotherapy interventions and compared

with a control group.

2. To evaluate the effect of 3 physiotherapy modalities on Maximum isometric voluntary

contraction (MIVC) in experimentally induced delayed onset muscle soreness in

recreational athletes

3. To determine the effect of physiotherapy on pain parameters using VAS scale.

4. To compare the effectiveness of physiotherapy modalities on biochemical parameters(CK

& LDH), maximum isometric voluntary contraction and pain scale taken at different

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times after experimentally inducing delayed onset muscle soreness in recreational

athletes.

2.3 RELEVANCE AND SCOPE OF THE STUDY:

Delayed onset muscle soreness (DOMS) is a familiar experience for the elite as well as

the novice athlete. Symptoms can range from muscle tenderness to severe debilitating pain.

The mechanisms, treatment strategies, and impact on athletic performance remain uncertain,

despite the high incidence of DOMS (Cheung, Hume, Maxwell Sports Med. 2003). DOMS is

most prevalent at the beginning of the sporting season when athletes are returning to training

following a period of reduced activity. Several theories have been proposed to explain the

underlying cause of delayed onset muscle soreness, however none is universally accepted.

There are also many anecdotal claims that the effects of DOMS can be reduced with various

treatment modalities. Again no method has any conclusive, empirical support for the

prevention of delayed onset muscle soreness. In India, recently increasing numbers are

participating in athletic activities and are taking a more active approach to achieve health and

wellness. This increase in activity exposes individuals to DOMS and the associated negative

effects. Even though the benefits of regular exercise are well known, many of us don't do it.

One reason may be that pain or discomfort sometimes goes along with fitness activities.

Starting or continuing an exercise program may be easier if you understand what muscle

soreness is and what to do about it. Interventions such as physiotherapy play a major role

both in prevention and treatment for the negative effects associated with DOMS. Most of the

individuals and athletes experience muscle soreness after unaccustomed exercises due to lack

of training, this highly demands some intervention, and not much research have been done in

India to meet those demands. Also, the exact role of a physiotherapist in alleviating the

DOMS and therapeutic interventions is also not successful in India.

3. MATERIALS AND METHODOLOGY

SUBJECTS: 160 normal collegiate recreational athlete subjects in the age group 18-25 years

who were not under any training protocols and with no history of upper arm injury were

recruited after approval from the Institutional Ethics committee. The number of subjects was

determined by a power analysis with 90% power and a 1-tailed level of significance of P

<.0.5 based on data from the pilot study. During the experimental period, subjects were

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requested not to take any medication, change their diet, or perform any strenuous exercise.

All subjects were informed about the meaning of the study.

SAMPLING: Quota sampling technique was used and all the subjects were randomized

equally in to four groups, each group having forty subjects.

STUDY PERIOD: The study was conducted for a total period of two years and eight months.

STUDY CENTER: The whole study was conducted in Saveetha University.

PILOT STUDY: A pilot study was performed prior to data collection for the present study.

The goal of the pilot study was to: (1) to collect data that will provide an opportunity to gain

some practical experience in carrying out the proposed protocol, (2) ensure that instructions

to subjects are clear and concise, and make modifications where necessary, (3) determine

whether or not the soreness inducing exercise session would elicit the expected level of

perceived soreness, (4) collect and analyze preliminary data.

After the approval of ethical clearance from university, the pilot study was

conducted. The main objective of the pilot study was to know the percentage of 1 RM to be

selected for inducing delayed onset muscle soreness (DOMS) and to know their recovery

from DOMS. In the pilot study, 9 college athletes were selected, and they were divided in to

3 groups, each group having 3 participants.70 % of 1 RM for group A, and 80 % of 1 RM for

group B, and 90 % of 1 RM for group C have been taken to induce DOMS experimentally.

Subjects were then given a VAS scale with specific instructions on how to record information

regarding their level of soreness. From the results it was found that group B (80% of 1 RM)

recovered faster when compared to group C. Group A did not developed the symptoms of

DOMS. Group C took much time for pain recovery. Pain by VAS scale is the outcome

measure taken at 24 hours and after 96 hours.

GROUP A (70% of 1RM) GROUP B (80% of 1RM) GROUP C (90 % of 1 RM)

Mean SD Mean SD Mean SD

24 Hours 3 1 7 1 8.3 0.57

96 Hours 0.6 1.15 4.3 0.57 7.3 0.57

From the results of the pilot study it was found that 80 % of 1 RM was enough to induce

DOMS experimentally when compared to 70% and 90% of 1 RM.

STUDY DESIGN: The research design consisted of Pre test- Post test true experimental

study design with two factors (Groups and time) with repeated measures on time.

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3.1 STUDY PROCEDURE

160 collegiate athletes Participated in the study

Study divided in to 4 phases

PHASE-I BASELINE

MEASUREMENT

Serum CK, LDH, MIVC

and Pain measurement

were taken at the baseline

before inducing DOMS.

PROCEDURE

PHASE-2 DOMS

INDUCTION

All participants were

induced DOMS by an

eccentric loading

protocol with barbell

after calculating 1 RM.

PHASE-3

TREATMENT

After inducing DOMS,

Participants were

allocated randomly in

to four groups. Each

group consisting of 40

participants.

PHASE -4 POST

TESTMEASUREMENT

Serum CK,

LDH,MIVC and Pain

measurement were

taken at 24, 48, 72 and

96 hours before the

treatment intervention

Group ICryotherapy

Group IIUltrasound

Group IIIExercises

Group IVControl

Treatment was applied at 24, 48, 72 and 96 hours.

3.2 INDUCTION OF DELAYED ONSET MUSCLE SORENESS:

All the subjects were induced delayed onset muscle soreness (DOMS) by an eccentric

loading protocol with a barbell (Tiidus and Ianuzzo, 1983)

Eccentric Loading Protocol:

1 RM Calculation:

The subject was asked to lift a fixed weight in his hand from a fully extended to a fully flexed

position in standing position. The amount of weight was determined by subject's perception.

Initially 1 Repetitive maximum (RM) was calculated by using the formula

[Number of repetitions + 1] X Weight used.

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80 % of 1 RM was calculated and used for inducing DOMS. Concentric contractions were

followed by eccentric contractions for 7 seconds. Assistance was given for concentric

contractions and no assistance given for eccentric contractions and all the subjects were

verbally encouraged. The subjects were instructed to perform 4 sets, 1 set consisting of 10

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repetitions, with a rest period of 3-5 minutes between each set. After inducing DOMS the

subjects were divided into one of four treatment groups.

3.3 TREATMENT PROTOCOLS

Treatments were administered at 24, 48, 72, and 96 hours post exercise.

The following protocols outline the treatment that subjects received in their respective

groups.

Group I: Cryotherapy-Ice massage was given by a method of direct application with ice bag

technique for duration of ten to fifteen minutes after 24, 48, 72 and 96 hours.

Group II: Phonophoresis- Participants in group II received Phonophoresis ( Phyaction 190i

ultrasound), Intensity of 0.8 watts/cm2 for a duration of 8 minutes given after 24, 48, 72 and

96 hours.

Group III: Participants in group III were instructed to do an exercise protocol. The

individuals in the exercise group performed mild full ROM elbow flexion and extension

exercises, with only the gravitational pull on the hand and arm providing resistance. The

repetitions were performed continuously during a 20-second period and then rested for 40

seconds. This exercise /rest interval was continued for a total treatment time of 15 minutes.

Group IV: Control-No therapy was administered. Rest advised for them.

3.4 POST TEST MEASUREMENTS

DEPENDENT VARIABLES:

Maximum isometric voluntary contraction (MIVC) of elbow flexors by modified hand held

dynamometer, Plasma Creatine kinase (CK) and Lactate dehydrogenase (LDH) activity were

measured from blood samples taken from Cubital veins. Pain assessment was made from

VAS scale. All measurements were taken at the baseline, 24, 48, 72 and 96 hours after

inducing delayed onset muscle soreness (DOMS).

DATA COLLECTION:

SERUM CK AND LDH LEVELS:

The analysis is done in Erba Chem 5 plus v2 instrument, Blood samples of 2 ml were

collected from all the subjects using a disposable syringe and the serum separated. Than 50

micro liters of serum added to1 ml of CK reagent, and incubated at 37 degree Celsius for 100

seconds in an incubator. Similarly 50 micro liters of serum added to 1 ml of LDH reagent,

and incubated at 37 degree Celsius for 1 minute in an incubator.

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Test has been done by using the kits from Agappe diagnosis following the standard protocol

and readings displayed in the instrument were noted. This procedure was done at baseline,

24, 48, 72 and 96 hours and the values were noted.

MAXIMUM ISOMETRIC VOLUNTARY CONTRACTION (MIVC):

INSTRUMENT: The dynamometer is a modified Wika pressure gauge (van der Ploeg, 1984)

the pressure range is 0-300 Newton (N). The meter is equipped with a maximum indicating

pointer with a resetting knob and a curved applicator.

MEASUREMENT TECHNIQUE AND TEST PROCEDURE: At least one practice trial was

given to the participants to familiarize them with the feel of pushing against the

dynamometer. The participants then performed the action actively until they performed it

correctly. Participants were asked to build their force gradually to a maximum voluntary

effort over a self-determined 2-second period. They then maintain maximum effort for 5

additional seconds during which dynamometer was held stationary against the limb segment.

A rest period lasting 1 or 2 minutes was provided before a second (repeat) measure of an

action was taken. Peak force values were recorded for each trial from the digital readout on

the dynamometer. The test was repeated three times and an average measure was taken.

SUBJECT POSITION- Shoulder at neutral, elbow flexed at 900, Forearm supinated.

Dynamometer placement- elbow just proximal to styloid process. Stabilization of subject-

Superior aspect of shoulder or arm.

PAIN MEASUREMENT: The VAS consists of a 10-cm line with the two endpoints labeled

with verbal descriptors. The patient is required to place a mark on the 10 cm line at a point

that corresponds to the level of pain intensity he or she presently feels (Turk and Melzack

1992). VAS consists of a 10 cm line with descriptors at each end. At the left end there was

the number zero with the descriptor "no soreness at all", and at the right end there was the

number ten with the descriptor "soreness as bad as it could be". Each subject placed an x

dong a 10 cm line to describe the amount of muscle soreness he/she was presently

experiencing. Data was collected at baseline and at 96 hours.

The Outcome measurements Creatine Kinase (CK), Lactate Dehydrogenase (LDH), Pain

measurement, and Maximum Isometric voluntary contraction (MIVC) were taken at the

baseline before inducing DOMS, and taken at 24, 48, 72 and 96 hours after inducing delayed

onset muscle soreness (DOMS).

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4. STATISTICAL ANALYSIS AND RESULTS

4.1 CREATINE KINASE (Normal level =60-180 I Units/Liter)

To find out the difference between the groups in each measure ONE WAY ANOVA is done.

CREATINE KINASE VALUES IN CONTROL AND IN 3 EXPERIMENTAL GROUPS

TAKEN AT DIFFERENT TIMES POST EXERCISE

Groups Baseline 24 hours 48 hours 72 hours 96 hours

Mean SD Mean SD Mean SD Mean SD Mean SD

Cryotherapy 86.38 23.33 276.55 66.21 606.50 156.18 921.48 222.80 1134.18 342.42

Phonoporesis 81.50 18.67 252.10 71.58 589.95 146.07 905.98 305.10 1043.70 430.79

Exercise 94.70 28.93 327.78 122.16 558.70 242.53 544.00 368.53 479.60 448.04

Control 86.80 21.05 313.08 80.07 661.00 147.65 1003.05 254.28 1244.65 414.39

Anova f

value

2.19 6.14 2.32 19.44 27.49

p value .091 NS

.001*** .077NS

.000*** .000***

Note: *p<0.05, **p<0.01, ***p<0.001, NS- Not significant (p>0.05)

RESULTS: From the above table values, it is noted that at baseline and at 48 hours, there is

no significant difference seen in creatine kinase elevation between the four groups (p >0.05),

But significant difference were observed at 24 hours, and after 72 hours and 96 hours

(p<0.001)

PAIRED t TEST ANALYSIS: To find out the changes between baseline-24 hours, 24-48

hours, 48-72 hours, 72-96 hours for all the four groups paired t test was used.

CREATINE KINASE VALUES ANALYSIS WITHIN THE GROUPS AT DIFFERENT TIMES

CK measures Cryotherapy Phonoporesis

Mean SD

t value p value Mean SD t value p value

Baseline-24 hrs 190.17 67.20 17.89 .000*** 170.6 71.6 15.06 .000***

24-48 hrs 329.95 146.65 14.22 .000*** 337.85 121.20 17.62 .000***

48-72 hrs 314.97 157.74 12.62 .000*** 316.02 250.905 7.96 .000***

72-96 hrs 212.69 241.00 5.58 .000*** 137.72 259.74 3.35 .002**

14


RESULTS: In the above table it is observed that changes between baseline-24 hours, 24-48

hours, 48-72 hours, 72-96 hours for group 1 (Cryotherapy), group 2 (phonophoresis) and

group 4 (control) were showing significant difference statistically (p<0.001), where as in

group 3 (exercise) alone, the CK measures between baseline-24 hours and 24-48 hours were

having significant difference (p<0.001) but measures between 48-72 hours and 72-96 hours

were not showing significant difference statistically (p>0.05)

ONE WAY ANOVA RESULTS: To find out the significant difference of changes of

Creatine kinase measure from baseline- 24 hours, 24-48 hours, 48-72 hours, 72-96 hours

(within the period) between the groups, One-way ANOVA test was used.


RESULTS: From the above table it is found that changes of creatine kinase measure from

baseline- 24 hours, 24-48 hours, 48-72 hours, 72-96 hours (within the period) between the

groups, were having statistical significant difference (p<0.001).

CK

measures

Exercise Control

Mean SD t value p value Mean SD t value p value

Baseline-

24 hrs

233.0 113.48 12.98 .000*** 226.27 79.48 18.00 .000***

24-48 hrs 230.92 175.24 8.33 .000*** 347.92 119.03 18.48 .000***

48-72 hrs 14.70 225.67 0.411 .683 NS

342.04 185.64 11.65 .000***

72-96 hrs 64.39 175.54 2.320 .026 NS

241.60 293.98 5.19 .000***

CK

measures

Cryotherapy Phonoporesis Exercise Control f

value

p value

Mean SD

Mean SD

Mean SD

Mean SD

0-24 hrs 190.17 67.20 170.6 71.6 233.0 113.48 226.27 79.48 4.88 .003**

24-48 hrs 329.95 146.65 337.85 121.20 230.92 175.24 347.92 119.03 5.82 .001***

48-72 hrs 314.97 157.74 316.02 250.90 14.70 225.67 342.04 185.64 26.68 .000***

72-96 hrs 212.69 241.00 137.72 259.74 64.39 175.54 241.60 293.98 12.54 .000***

15

CREATINE KINASE MEANS VALUES OF THE CONTROL AND 3 EXPERIMENTAL

GROUPS TAKEN AT DIFFERENT TIME MEASURES

4.2 LACTATE DEHYDROGENASE (Normal level = 220-400 I Units/Liter)

I.PAIRED t TEST ANALYSIS: To find out the changes between baseline-24 hours, 24-48

hours, 48-72 hours, 72-96 hours for all the four groups paired t test was used.

LACTATE DEHYDROGENASE VALUES ANALYSIS WITHIN THE GROUPS IN

DIFFERENT TIMES POST EXERCISE

LDH measures

Exercise Control

Mean SD t value p value Mean SD t value p value

Baseline-24 hrs 177.77 85.15 13.20 .000*** 210.67 85.14 15.64 .000***

24-48 hrs 97.89 90.79 6.81 .000*** 189.77 87.12 13.77 .000***

48-72 hrs 85.0 120.55 4.45 .000*** 122.14 94.92 8.13 .000***

72-96 hrs 87.19 77.26 7.13 .000*** 4.85 171.91 0.17 .859 NS

16


RESULTS: In the above table it is observed that changes between baseline-24 hours, 24-48

hours, 48-72 hours for all the four groups the LDH measures were showing significant

difference (p<0.001), but the changes between 72-96 hours also were showing significant

difference statistically only in group 3 (exercises), but in other 3 groups between 72-96 it was

not having significant difference (p>0.05).

II. ONE WAY ANOVA: To find out the difference between the groups in each measure one

way ANOVA is done.

LACTATE DEHYDROGENASE VALUES IN CONTROL AND IN 3 EXPERIMENTAL

GROUPS TAKEN AT DIFFERENT TIMES POST EXERCISE


RESULTS: The above table shows that at baseline, 24hours, 48 hours,72 hours and at 96

hours the LDH values between the four groups were statistically having significant difference

(p<0.001).

LDH measures Cryotherapy Phonoporesis

Mean SD t value p value Mean SD

t value p value

Baseline-24 hrs 174.25 53.04 20.77 .000*** 171.62 74.15 14.63 .000***

24-48 hrs 200.79 100.96 12.57 .000*** 191.799 78.88 15.37 .000***

48-72 hrs 84.72 79.03 6.77 .000*** 87.12 130.03 4.23 .000***

72-96 hrs 14.32 121.28 0.74 .460NS

25.19 137.48 1.15 .253NS

Groups Baseline 24 hours 48 hours 72 hours 96 hours

Mean SD Mean SD Mean SD Mean SD Mean SD

Cryotherapy 256.35 35.77 430.6 56.56 631.4 122.35 716.12 126.09 730.45 171.23

Phonoporesis 288.5 28.53 460.12 75.99 651.92 94.22 739.05 131.17 713.85 207.03

Exercise 275.2 46.88 452.97 102.82 550.87 143.96 465.87 141.39 378.67 119.97

Control 288.6 35.85 499.35 89.05 689.12 118.39 811.27 136.77 806.42 249.70

ANOVA f

value

6.67 4.77 9.31 50.38 38.82

p value .000*** .003** .000***

.000*** .000***

17

III.ONE WAY ANOVA: To find out the significant difference of changes of lactate

dehydrogenase measure from baseline- 24 hours, 24-48 hours, 48-72 hours, 72-96 hours

(within the period) between the groups, One-way Anova test was used.

LDH

measures

Cryotherapy

Phonoporesis Exercise Control f value p value

Mean SD

Mean SD Mean

SD

Mean SD

Baseline-

24 hrs

174.25 53.04 171.62 74.15 177.77 85.15 210.67 85.14 2.33 .076Ns

24-48 hrs 200.79 100.96 191.799 78.88 97.89 90.79 189.77 87.12 11.59 .000***

48-72 hrs 84.72 79.03 87.12 130.03 85.0 120.55 122.14 94.92 29.68 .000***

72-96 hrs 14.32 121.28 25.19 137.48 87.19 77.26 4.85 171.91 4.48 .005**


RESULTS: One way ANOVA results shows that the LDH changes between the four groups

were found to have significant difference statistically at 24-48 hours, 48-72 hours and at 72-

96 hours.

LACTATE DEHYDROGENASE MEAN VALUES OF THE CONTROL AND 3

EXPERIMENTAL GROUPS TAKEN AT DIFFERENT TIME MEASURES

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4.3. Maximum Isometric Voluntary Contraction(MIVC):

MIVC MEAN VALUES OF THE CONTROL AND 3 EXPERIMENTAL GROUPS TAKEN

AT DIFFERENT TIME MEASURES

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4.4 REPEATED MEASURES ANOVA RESULTS:

To find out the overall changes within the group Repeated ANOVA was adopted.

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLES CK, LDH AND MIVC

BY GROUP AND TIME

Groups Creatine Kinase IU/L (CK) Lactate dehydrogenase IU/L

(LDH)

Maximum Isometric

Voluntary contraction

(MIVC) lbs

Repeated

measures

ANOVA f value

P value Repeated

measures

ANOVA f value

P value Repeated

measures

ANOVA f value

P value

Cryotherapy 844.63 0.000*** 1947.39 0.000*** 1531.01 0.000***

Phonophoresis 512.93 0.000*** 2333.43 0.000*** 1790.19 0.000***

Exercise 136.23 0.000*** 840.49 0.000*** 2226.80 0.000***

Control 759.53 0.000*** 1599.87 0.000*** 2600.80 0.000***


RESULTS: Repeated measures ANOVA results shows that the CK, LDH and MIVC

measures overall changes within the groups for all the four groups were found to have

difference statistically significant (p<0.001)

4.5 Pain Score: To find out the difference between the groups in each measure one way

ANOVA is done.

PAIN VAS SCORES FOR FOUR GROUPS TAKEN AT PRE AND POST

TREATMENT LEVELS

Groups 24 hours 96 hours

Mean SD Mean SD

Cryotherapy 5.08 0.512 2.90 0.49

Phonoporesis 5.12 0.51 1.145 0.258

Exercise 5.07 0.52 1.94 0.33

Control 5.13 0.62 2.915 0.459

Anova f value 0.110 183.4

p value . 954NS .000***

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The above table shows that pain scores at 24 hours between the groups were not found to

have significant difference (p>0.05) but at 96 hours the pain scores were showing statistically

significant difference (p<0.001).

To find out the significant difference of changes of Pain measure from 24-96

hours (within the period) between the groups, One-way ANOVA test was used.


The differences of change in pain measure from 24-96 hours between the groups were found

to be statistically significant in between the four groups (p<0.001)

5. DISCUSSION:

The onset of muscle pain in all the four groups occurred within the first 24 hours

following the eccentric exercise protocol, which is consistent with other studies, investigated

the onset of DOMS resulting from exercise-induced muscle damage. (Nosaka, 1995)

In the present study, three different Physiotherapy modalities were compared to

facilitate the recovery of DOMS. In the present study, we found that electrotherapy

modalities Cryotherapy and Phonophoresis do not have direct influence on reducing the

biochemical markers like Creatine kinase (CK) and Lactate Dehydrogenase (LDH). However

the modalities are useful in reducing the pain. When we compared the maximum isometric

voluntary contraction (MIVC), Ultrasound is found to be better in improving the muscle

Pain

measures

Cryotherapy

Phonoporesis Exercise Control

f value

p value

Mean SD

Mean SD

Mean SD

Mean SD

24-96

hours.

2.18 0.41 3.98 0.55 3.13 0.38 2.21 0.50 133.19 .000***

21

contraction at 72 hours as compared to cryotherapy. The probable reason may be pain gate

mechanism and anti-inflammatory action of Ultrasound is better than cryotherapy.

In the present study, we compared exercises and electro modalities; exercise

is effective in all the four parameters-CK, LDH, MIVC and pain. The probable reason may be

breakup of adhesions from the injured, sore muscles takes place during exercise. Increased

blood flow or temperature in the muscle helps to decrease the accumulation of noxious waste

products. Endorphin release by neurons in the central nervous system increases during

exercise. Increased afferent input is noted from large, low-threshold sensory units in the

muscles (muscle group-Ia, Ib, and II fibers [gate control theory]). The training effect appears

to be highly specific, not only for the particular muscles involved in the exercise, but also for

the type of contractions performed. For example, Schwane and Armstrong (1983) found that

in rats, the muscle damage that occurs during downhill running is prevented by downhill or

level training but not by uphill training. The eccentric protocol causes more DOMS and rise

in the plasma CK and LDH activity. Subjective enzymatic values (CK & LDH) remained

elevated for at least 4 days after exercise induced muscle damage in group1 (cryotherapy),

group 2 (phonophoresis) and in group 4 (control), but in group 3 (exercises), the values

remained elevated for 2 days only, than the values start to decrease at 72 hours and the values

were reaching near to the baseline values in day 4. Maximum Isometric voluntary contraction

(MIVC) scores were found to be decreasing until 48 hours in all the groups, But however in

group 3 (Exercises), the scores started to increase after 48 hours and in group 2

(Phonophoresis) the scores started to increase after 72 hours. In group 1 (Cryotherapy) and

Group 4 (Control) the MIVC scores were not much improving even till 96 hours. Therefore

we strongly recommend that exercises can be advised for the early recovery of DOMS in

recreational athletes to facilitate their early participation.

6. CONCLUSION:

In conclusion, the eccentric protocol causes more muscle soreness and rise in the plasma

CK and LDH activity. Subjective enzymatic values remained elevated for at least 4 days after

exercise induced muscle damage in group1 ( cryotherapy), group 2 ( phonophoresis ) and in

group 4 ( control), but in group 3 ( exercises), the values remained elevated for 2 days only,

than the values reached near to the baseline values in day 4. But in the variables MIVC and

VAS scores, both phonophoresis (group 2) and exercises (group 3) were found to be effective

when compared to cryotherapy (group 1) and control groups.

22

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LIST OF PUBLICATIONS:

1. Role of Physiotherapy in Ameliorating the Delayed Onset Muscle Soreness (DOMS)

and Influence on Biochemical Markers of Recreational Athletes. The Journal of

Indian Physiotherapists April 2010 Volume 4, Issue 1: 20-28.

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