cryotherapy and steching in hemiplegia

1

A COMPARITIVE STUDY TO ASSESS THE EFFECT OF CRYOTHERAPY OVER THERMOTHERAPY WITH COMMON

USE OF HOLD RELAX IN IMPROVING GAIT PARAMETERS ON HEMIPLEGIC PATIENTS

A Dissertation submitted to the RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

In partial fulfillment of the award of

M.P.T. Degree (Master of Physiotherapy)

Elective in Neurology and Psychosomatic Disorders

By

SUNIL VARGHESE

September – 2005

Goutham College of Physiotherapy, Bangalore – 560 010

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2

A COMPARITIVE STUDY TO ASSESS THE EFFECT OF CRYOTHERAPY OVER THERMOTHERAPY WITH COMMON

USE OF HOLD RELAX IN IMPROVING GAIT PARAMETERS ON HEMIPLEGIC PATIENTS

A Dissertation submitted to the RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

In partial fulfillment of the award of

M.P.T. Degree (Master of Physiotherapy)

Elective in Neurology and Psychosomatic Disorders

By

SUNIL VARGHESE

September – 2005

Guided By: Dr.J.Ramesh Kumar MPT

Associate Professor Goutham College of Physiotherapy,

Bangalore – 560 010




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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

DECLARATION

I here by declare that this dissertation/thesis entitled “ A COMPARITIVE STUDY TO

ASSESS THE EFFECT OF CRYOTHERAPY OVER THERMOTHERAPY WITH

COMMON USE OF HOLD RELAX IN IMPROVING GAIT PARAMETERS ON

HEMIPLEGIC PATIENTS” is a bonafide and genuine research work carried out by

me under the guidance of Dr.J.RAMESH KUMAR MPT., Associate Professor,

Goutham College of Physiotherapy.

Date : Signature of the candidate

SUNIL VARGHESE Place : Bangalore




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Certificate

This is to certify that this dissertation on “A COMPARITIVE STUDY TO



HEMIPLEGIC PATIENTS” has been carried out by the candidate himself under my

direct supervision and the findings have been checked thoroughly.

I am fully satisfied with the work of SUNIL VARGHESE, which is being

presented by him as a dissertation for Master of Physiotherapy – Elective in Neurology

and Psychosomatic Disorders examination of Rajiv Gandhi University of Health

Sciences, Bangalore.

It is further certified that SUNIL VARGHESE has undergone prescribed course

of studies leading to Master of Physiotherapy Degree Examination (Elective in

Neurology and Psychosomatic Disorders) in accordance with the University

regulations.

Dr.J.Ramesh Kumar MPT Associate Professor & Guide Goutham College of Physiotherapy Bangalore.




5

Endorsement by Principal

This is to certify that this dissertation on “A COMPARITIVE STUDY TO



HEMIPLEGIC PATIENTS ” has been carried out by the candidate himself under my

direct supervision and the findings have been checked thoroughly.

I am fully satisfied with the work of SUNIL VARGHESE, which is being

presented by him as a dissertation for Master of Physiotherapy – Elective in Neurology

and Psychosomatic Disorders examination of Rajiv Gandhi University of Health

Sciences, Bangalore.

It is further certified that SUNIL VARGHESE has undergone prescribed course

of studies leading to Master of Physiotherapy Degree Examination (Elective in

Neurology and Psychosomatic Disorders) in accordance with the University

regulations.

Prof. Jasobanta Sethi MPT Principal Goutham College of Physiotherapy Bangalore.




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COPYRIGHT

Declaration

I here by declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation/thesis in print or

electronic format for academic/research purpose.

Date : Signature of the candidate

SUNIL VARGHESE Place : Bangalore © Rajiv Gandhi University of Health Sciences, Karnataka




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ACKNOWLEDGEMENT

I thank the Almighty God and my beloved parents who has been the foundation

for knowledge, wisdom and a source of strength and inspiration.

It has been my privilege and honour to receive the able guidance of Dr.J.Ramesh

Kumar MPT, Associate Professor, Goutham College of Physiotherapy. I sincerely

acknowledge my indebtedness to him, for his keen interest and guidance throughout the

work.

I am equally grateful to Prof. Jasobanta Sethi MPT, Principal, Goutham College

of physiotherapy, for his able guidance and constant encouragement throughout the

course of the study.

With due respect, I would like to thank Dr.A.T.S.Giri, Chairman, Goutham

College of Physiotherapy for providing me all the facilities for this study.

I wish to express my gratitude to Mr.Sathyajit Dash, Administrator, Goutham

College of Physiotherapy, for his timely suggestions, advice and for giving me all the

encouragement to fulfill this work.




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My special thanks to Dr.P.B.Balamurugan MPT, Assistant Professor,

Dr.Saravanan MPT, Assistant Professor, Dr. D.Prabhavathi MPT, Assistant Professor,

Dr.S.Saratha Devi, Lecturer, Goutham College of Physiotherapy for their support &

invaluable help, without which this project wouldn’t have been a success.

I would like to show my gratitude to Dr.Glady Samuel Raj, Principal,

Padmashree College of Physiotherapy & Dr.S.Balasubramanian, Assistant Professor,

Garden City College of Physiotherapy for their valuable guidance. I am also very

thankful to Dr. Venkatesan Sreethar, Professor of Biostatistics, who gave me a great

helping hand on the statistical methods of Data Analysis & Research Methodology.

My thanks to all other contributors, whose names I have not mentioned, but

though they all deserve my gratitude.

Last but not the least, my heartfelt and sincere thanks to all the subjects on whom

this study was carried out, my beloved juniors, my friends especially Dear Lourdhu Raj

for being there for me in every phase of my work , sanjay and vivek and lovings muthu

for giving me the support and relatives both far and near, for their kind co-operation

rendered to me during the study.

SUNIL VARGHESE




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CONTENTS

1. INTRODUCTION

1

Need of the Study

Significance of the Study

2. AIMS OF THE STUDY

8

3. REVIEW OF LITERATURE

9

4. HYPOTHESIS

16

5. MATERIAL AND METHODS

17

Study Design

Sample Selection

Materials Used

Measurement tools

Procedure

Data Analysis

6. RESULTS & INTERPRETATION 30

7. DISCUSSION

40

8. CONCLUSION

45

9. SUMMARY

46

10. REFERENCES

47

11. ANNEXURE

52




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ABSTRACT

Background and Objectives: Cryotherapy has opened a wide outlook to reduce

spasticity along with proprioceptive neuromuscular stretching. The study intended to

ascertain the effectiveness of Cryotherapy with proprioceptive neuromuscular stretching

to improve the gait parameters of hemiplegic patients.

Methods: Thirty male hemiplegic patients where divided into two groups , Group I

received Cryotherapy (n=15)and Group II with Thermotherapy(n=15) both received

commonly proprioceptive neuromuscular stretching(6seconds) .Both groups received 10

to 15 minutes of Cryotherapy and Thermotherapy respectively along with 6 seconds of

stretching, 6 days a week for 6 weeks.

Results: After a 6-week treatment period, the Cryotherapy along with proprioceptive

neuromuscular stretching was the group that scored significantly higher with the

parameters of gait such as Stride length (0.05), Cadence (0.05) and Walking velocity

(0.05) showing p=0.05 which proves the above statement.

Conclusions—Cryotherapy along with proprioceptive neuromuscular stretching was

found much effective in reducing spasticity which helped in increasing the weight

bearing and functional outcome of the patients.

Key words: Hemiplegia; Gait; Rehabilitation; Cryotherapy; Thermotherapy; Stride

length; Cadence; Walking velocity.




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INTRODUCTION

Mobility and functional independence are two important concepts addressed

during the rehabilitation process of stroke patients; Mobility is defined as the quality of

being able to move about in ones environment which automatically gains the functional

independence.

Upright bipedal ambulation is unique to the human subjects; plantigrade

alignment of lower extremities provides both the mean of support to the proximal heavy

trunk segments and propulsion of entire mass through space, walking is a complex

interaction of the neurologic, musculoskeletal, cardiopulmonary and numerous other

systems that requires minimal conscious thoughts for most people. In the CVA

population involvement of one or more of the integrated physiological system can result

in movement dysfunction that alters or completely impedes walking ability.

In stroke, lesions to one side of the brain results in hemiplegia which is

characterized by uncoordinated movements and lack of control of the contra lateral side

of the body. The severity of the lesion will determine the degree of motor and cognitive

involvement which produces hypertonicity of the muscles of arm and leg which disrupts

the balancing mechanism, proprioceptive feedback, voluntary motor control and

ambulatory abilities.




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Patients with such cerebrovascular accidents presents lower extremity extensor

synergy with equinovarus positioning of the foot and ankle complex, sustained plantar

flexion of the ankle, sustained hip and knee extension, and pelvis retraction on involved

side. Notable gait deviations include weight transfer on the lateral aspect of the foot, knee

hyperextension, limitation to functional hip flexion and sustained pelvic retraction.

As a result of this asymmetric gait pattern the various gait parameters like

walking velocity, stride length on involved limb, cadence, support time on the involved

limb, weight transfer through the limb are decreased thereby increasing the energy cost of

the gait.

Lehmann et al29 reported a reduction in walking speed, cadence and step length

when comparing a small group of able-bodied and hemiparetic subjects. A decrease in

walking speed will tend to increase energy costs associated with the ambulatory pattern.

Presumably this can be attributed to an increase in heart rate of deconditioned individuals

with sedentary lifestyles of those patients recovering from trauma.

In hemiplegic gait, initial loading of the limb occurs with a flat-footed or toe-heel

contact, secondary to motor deficits and an extensor synergy that produces a concentric

contraction of the gastrocnemius-soleus complex. This serves to disrupt the forward

momentum of the body as a whole and a drastic decrease in velocity can often be

observed. Weak quadriceps and/or gastrocnemius-soleus muscles create excessive knee

stability and postural compensations also appear in the form of increased hip external




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rotation and pelvic retraction, these postural adjustments serve to align the knee axis

externally to the line of progression and decrease step length.

Stance phase movement is also characterized by a distribution to forward

momentum as the knee progresses posteriorly into hyperextension. Observational gait

assessment reveals the thigh and distal limb segment proceeding posteriorly while the

trunk segment is attempting to advance anteriorly.

Initiation of the swing phase is difficult because a hyper extended hip alignment

during terminal stance is never obtained. Sustained pelvic retractions and anterior trunk

lean prevents prestretch to the hip flexors; as a result, the hip joint receptors do not

receive the proper signal to decrease extensor muscle activity and initiate flexor muscle

patterning. As a result lateral trunk deviation is often required to unload the limb toward

the contra lateral side, which adds to increased energy costs.

Considerable time is spent by physiotherapist on gait retraining to improve the

patients independence after stroke 50-80% of stroke survivors will walk independently.

This striking success however hides the fact that many of these patients walk slowly and

rarely venture outdoors. Gray CS et al30 (1990) in their study provided evidence for the

fact that the necessity of long-time institutional care for stroke patients is correlated to a

gait velocity below 9m/min.




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Muscle relaxation and pain relief are closely related. Spasticity associated with

upper motor neuron lesions can be reduced by heating, but these effects are only short-

term and therefore the use of cold may be a more effective method of treatment in this

instance8.

It has been demonstrated both in experimental studies and clinical practice that

cooling a muscle reduces spasticity and this has proved to be a useful therapeutic tool in

the rehabilitation of patients with upper motor neuron lesions22; Price et al, 1993 13. In the

study there was statistically significant reduction in spasticity at the ankle that occurred

secondary to head injury following the application of liquid ice in a bag to the

gastrocnemius muscle for 20 minutes.

The underlying physiology behind the reduction of spasticity using ice is not

totally understood, it may be due to slowing of conduction in both the muscle and motor

nerves, a reduction in the sensitivity of the muscle spindle, or impaired conduction in the

gamma efferents which are more susceptible to cooling than the alpha efferents. The

response is rapid occurring in a matter of seconds and it is clinically important that the

muscle is cooled thoroughly for at least 30 minutes in order to achieve a longer lasting

effect. There are also various studies supporting the duration of cryotherapy in reducing

spasticity.

The spasticity encountered in hemiplegics can also be decreased by means of

giving stretching. Though many studies are there supporting passive stretching to reduce




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spasticity, only few studies were done with proprioceptive neuromuscular stretching that

may be either hold-relax or contract-relax type.

Reflex relaxation is the goal of hold relax technique, relaxation may allow an

increase in passive range of motion and may help to decrease pain related to excessive

tension. Sherrington’s concepts of reciprocal innervation and successive induction call

for inhibition of the antagonist during an agonist contraction and inhibition of a muscle

group immediately after its contraction. 24

In hold relax technique after reaching the range of the agonist pattern a hold

(static) contract is performed against gradually building resistance and the goal is a pain

free response. After the entire phase the new agonist range is achieved and the process is

repeated. This sort of stretching is thus helping the therapists to slowly overcome the

pathologically evolved tightness of the muscles due to the excessive firing of the gamma

motor neurons.

The impairment of gait is one of the major handicaps after stroke and a prime aim

to recover for the patient since it is closely related to activities of daily living and

independence. In this study an attempt has been made to analyse the effects of

cryotherapy and thermotherapy with common use of Proprioceptive neuromuscular hold-

relax stretching in reducing the spasticity and improving the gait parameters of the stroke

subjects thereby promoting their lifestyle and independence.




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NEED OF THE STUDY

Normally in hemiplegic patients there is impairment in the dynamic stability,

imbalance and loss of normal gait pattern. These are the main factors which affects the

normal functional movement and ambulation. There are several

ways of treating techniques that aim to minimize these adverse effects.

We have a lot of past evidences of using cold therapy13 as well as

Thermotherapy11 in reducing the increased muscle tone for these hemiplegic patients

there by favoring improvement in pathological gait. Also there are evidences supportive

of proprioceptive neuromuscular facilitation stretching in rehabilitation of hemiplegic

patients15. Mostly spastic impairment is confined to quadriceps and plantar flexors of

lower limbs which contribute in the gait deviation in hemiplegic patients.

The improvement in gait parameters of hemiplegics is stressed in this study with

the use of cryotherapy and thermotherapy with common use of proprioceptive

neuromuscular facilitation stretching.




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SIGNIFICANCE OF THE STUDY

1. The results of the study may help the physiotherapists to effectively use the

Proprioceptive Neuromuscular Facilitation Stretching to reduce spasticity and

improve the gait parameters.

2. This study can help the therapists to understand the relation of excessive tone in

the Quadriceps and Plantar Flexors hampering the weight bearing and locomotion

in the hemiplegic subjects.

3. This study also provides an idea of utilizing cryotherapy and thermotherapy in an

effective manner to reduce the spasticity of the affected muscles in various

neurological disorders.




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AIMS & OBJECTIVES OF THE STUDY

The main objectives of the study were:

1. To assess the effect of cryotherapy with common use of hold relax technique in

improving the gait parameters of hemiplegic patients.

2. To assess the effect of thermotherapy with common use of hold relax technique in

improving the gait parameters of hemiplegic patients.

3. To compare the effectiveness of cryotherapy over the thermotherapy with

common use of hold relax technique in improving gait parameters of hemiplegic

patients.




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REVIEW OF LITERATURE

Several studies by different group of researchers were going on to find out the

effective technique in the reduction of spasticity & improving the independence of the

affected individuals in various neurological conditions. Some of the eminent studies

which were reviewed for this study are discussed below:

Kofotolis N et al , 2005 from the Department of Physical Education and Sports

Science, Thessalonki, Greece. They studied the proprioceptive neuromuscular facilitation

training induced alteration in muscle fiber type and cross-sectional area of the vastus

lateralis muscle, considering 24 male university students and dividing them into two

equal groups receiving proprioceptive neuromuscular facilitation training and isometric

training. Both groups performed 3 sets of 30 repetitions each for a period of eight weeks.

After the training they found that both proprioceptive neuromuscular facilitation and

isometric training alter fiber type distribution and mean cross-sectional area of the muscle

and these changes specifically occur in the type II fiber subgroup. Medicine, 1

Bonnar BP et al, 2004 studied the relationship between isometric contraction

duration during hold relax stretching and improvement of hamstring flexibility on 60

active individuals without history of knee and hip injury. Each subject was randomly

assigned to a 3 second hold relax, 6 second and 10 second hold relax proprioceptive

neuromuscular facilitation stretch. They performed 3 trials. The results showed that all 3




20

hold time conditions produced significant gains in the range of motion compared to

baseline measurements. 2

Feland JB and Marin HN, 2004 analyzed the effect of sub maximal contraction

intensity in contract-relax proprioceptive neuromuscular facilitation stretching of the

hamstrings yield comparable gains in the hamstring flexibility to maximal voluntary

isometric contractions using 60 male subjects in the Brigham Young University, USA.

The results were analyzed using paired t test which showed a significant change in

flexibility proving that the contract- relax proprioceptive neuromuscular facilitation

stretching is just as beneficial at improving hamstring flexibility as maximal

contractions.3

Funk DC et al, 2003 of the University of Texas at Austin, USA compared the

Proprioceptive neuromuscular stretching and static stretching on hamstring flexibility in

40 undergraduate student athletes. The duration of stretching was 5minutes in both the

types. The results demonstrated that Proprioceptive neuromuscular stretching performed

after exercise enhanced hamstring flexibility and no differences were observed with static

stretching across time. 4

Rowlands AV et al, 2003 from the School of Sport Health and Exercise Sciences

assessed the effect of isometric contraction durations during PNF stretching on gains in

flexion at hip using 43 subjects in the University of Water-Bangor, UK. The subjects

were assigned to 5-second isometric contraction, 10-second isometric contraction and




21

control groups. The flexibility was assessed at the baseline and weeks 3 and 6. The

ANOVA was used to find out the significance and the results showed a longer

contraction time led to greater flexibility. 5

Mirek E et al, 2003 of the Academy of Wychowania analyzed the proprioceptive

neuromuscular facilitation method of therapeutic rehabilitation in the treatment of

patients with Parkinson’s disease in Zaklad Rehabilitation Center of Neurology &

Psychiatry, Poland; using a sample of 3 patients with an average age of 64. After 3 weeks

of therapy specific characteristics of gait were examined. The results showed that the

subjects have considerably approached the standards of frequency and speed thereby

showing better rhythm of gait. However stride length and duration of single limb support

has not changed significantly. 6

Yigiter K et al, 2002 did a study on traditional prosthetic training over

Proprioceptive neuromuscular resistive gait training with transfemoral amputees in

Hacettepe University, Ankara, Turkey. They selected 50 subjects and assigned into

groups receiving the traditional training or PNF and evaluated the outcome of both using

time distance parameters of gait from footprints. The results of the study suggested that

the prosthetic training based on proprioceptive feedback was more effective to improve

weight bearing and gait when compared with a traditional program. 7

Harlaar J et al, 2001 from the Department of Rehabilitation Medicine, Free

University Hospital, Amsterdam investigated the effect of cooling on muscle co-




22

ordination in spasticity by giving a repetitive movement (RM) test of the ankle while

measuring the surface electromyography of tibialis anterior and triceps surae in 16

patients. This test was carried on before and after cooling the muscle for duration of

20minutes. The results showed the reduction in spasticity with a slight increase in the

active range of motion. 8

Spernoga SG et al, 2001 of Wake Forest University, Canada did a study to

measure the duration of maintained hamstring flexibility after a one time modified hold

relax stretching protocol in 30 male subjects performed six warm ups active knee

extensions with the experimental group receiving 5 modified hold relax stretches. The

repeated measures analysis of variance revealed a significant outcome produced

significantly increased hamstring flexibility that lasted 6min after the stretching protocol

ended. 9

Suzuki K et al, 1999 died the relationship between stride length and walking rate

in gait training for hemiparetic stroke subjects in Tohoku University graduate School of

Medicine, Japan. They took 63 male hemiparetic patients in the recovering stage and

were trained for period of 4 weeks. They found that the maximum walking speed for 10m

was significantly gained from 32.3 to 53.2m/min on average and the stride length and

walking rate also rose. However the ratio of stride length to walking rate did not change

significantly in 4 week. 10




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Preisinger E and Quittan M, 1994 of University of Physical Medicine &

Rehabilitation, Germany compared the effect of heat as well as cold on spasticity

resulting from upper motor neuron lesions. The results suggested that muscle spasm can

be reduced by heat as well as by therapeutic cold, however in upper motor neuron

lesions; the therapeutic cold is more effective in reducing the spasticity.11

Wang RY, 1994 studied the effect of proprioceptive neuromuscular facilitation

on the gait of patients with hemiplegia of long and short duration in the Department of

Physical Therapy, National Yang-Ming Medical College, Taiwan, China. The subjects

were 20 patients with hemiplegia of short duration or large duration and each received a

total of 12 sessions of proprioceptive neuromuscular facilitation (3 times per week) with

treatment lasting for 30 minutes. The results showed that in subjects with hemiplegia of

short duration gait, speed and cadence improved immediately after the therapy. 12

Price R et al, 1993 from University of Washington, Department of Rehabilitation

Medicine, Seattle, USA did a study on the influence of cryotherapy on spasticity at

human ankle in 25 subjects with clinical signs of spasticity secondary to traumatic brain

injury, spinal cord injury and stroke. They did a baseline cryotherapy and one-hour post

cryotherapy measurements and found that there was a diminished spasticity relative to the

baseline measurements after giving cryotherapy. 13

Nanneman D, 1991 reviewed the physiologic effects of thermal modalities: heat

and cold with clinical applications and described that for topical application, cryotherapy




24

has much greater potential for restorative and therapeutic effect, while topical heat is

almost exclusively limited palliative effects. He also suggested that the knowledge of the

physiology of the modalities and the pathophysiology of the neurological disorders

enables the therapists to use them appropriately. 14

Osternig LR, 1987 did a study on muscle activation during proprioceptive

neuromuscular facilitation stretching technique on hamstring in 10 male and female

subjects aged between 23 to 26 yrs in the Department of Physical Education, University

of Oregon, Eugene. They studied the activity of quadriceps and hamstring muscle using

Electromyography by giving all three PNF techniques: stretch-relax, contract-relax and

agonist contract-relax. The results showed the reduction in hamstring activity due to

proprioceptive neuromuscular facilitation stretching techniques. 15

Bell KR & Lehmann JF, 1987 studied the effect of cooling on H and T reflex in

16 subjects and recorded the reflexes via surface EMG on triceps surae. Skin and

intramuscular temperatures were also recorded and found that the muscle spindle activity

as measured by T reflex decreased by muscle cooling. 16

Deanna Fish M S and Cheryl S Kosta, 1986 has studied the effect on walking

impediments and gait inefficiencies in the cerebrovascular accident patients and revealed

that use of motor activity parameters for patient’s results in arbitrary values of acceptance

for measuring balance, alignment, range of motion, walking and other functional

activities. They also postulated that each patient must be evaluated individually to




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maintain the integrity of the structural components and produce the maximum level of

functional independence. 17

Hefland AE and Bruno J, 1984 also studied about the therapeutic modalities of

heat and cold. They concluded that cryotherapy has got the physiologic effects such as

sedation; refrigeration and tissue destruction based on the mode of application and

duration of exposure, whereas the therapeutic heat has the primary effects such as

hyperemia, sedation and analgesia. 18

DeLisa JA and Little J, 1982 did a study on the management of spasticity

resulting due to upper motor neuron lesions using stretching exercises. They found that

the stretching exercises and the elimination of nociceptive stimuli are the first steps in the

management of spasticity. They also did a detailed study on the other medical

interventions for reducing spasticity. 19

Merritt JL, 1981 did a prospective study on the management of spasticity in

spinal cord injury. He did an analysis of many techniques for modulation of spasticity

and found that the establishment of an effective daily stretching program forms the

foundation on which all other management is based. 20




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HYPOTHESIS

EXPERIMENTAL HYPOTHESIS:

There is significant improvement in gait parameters of hemiplegic patients by

using Cryotherapy over Thermotherapy with common use of Proprioceptive

neuromuscular hold relax technique.

NULL HYPOTHESIS:

There is no significant difference in the gait parameters in the hemiplegic

patients using Cryotherapy over Thermotherapy with common use of Proprioceptive

neuromuscular hold relax technique.




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MATERIAL & METHODS

STUDY DESIGN:

This study is of completely randomized type of experimental design in nature

with the subject being measured on dependable variables such as Stride length, Cadence

and Walking velocity before the study and after the third and sixth weeks respectively.

This study was conducted in GPRC, Bangalore; ESI, Rajajinagar, Bangalore and

Kirloskar Hospital, Bangalore during the first three months of the year 2005.

SAMPLE SELECTION:

Thirty male hemiplegic subjects aged between 40 to 60 years with a mean age of

53 (SD=2.46) and graded as recovery stage IV of Brunnstorm classification were

randomly selected by way of simple random sampling and divided into two groups

mainly Group I and Group II with 15 subjects each. All these subjects participated in this

study voluntarily after signing a consent form. The demographic data was collected from

each subject; the purpose of the study was explained to all the subjects.

The selection criteria are listed below:

Inclusion criteria:

Hemiplegic patients graded as recovery stage IV according to Brunnstorm

classification.

Age group between 40 and 60.




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Only male subjects.

Hemiplegic patients without any deformity in the lower limb.

Ambulatory hemiplegic patients.

Exclusion criteria:

Hemiplegic patients graded as recovery stages I, II, III and V according to

Brunnstorm classification.

Age group below 40 and above 60 years.

Patients with cognitive and perceptual deficits.

Patients with cardiac and musculoskeletal abnormalities, head injuries, fracture of

lower limbs and recent surgeries of lower limbs.

MATERIALS USED:

Treatment couch

Pillows & towels

Moist pack

Cold pack

Mackintosh sheet

Velcro Straps

Chalks

Stop watch

Marker & Inch Tape.




29

Fig-1 Showing materials used such as moist pack, ice pack, stop watch, inch tape, velcro straps, chalk pieces, chalk powder tray & marker pens.

Fig-2 Showing the subject receiving PNF hold-relax stretching for the plantarflexors




30

MEASUREMENT TOOLS:

The parameters of gait21 such as Stride length, Cadence and Walking velocity

were assessed to find out the effect of Cryotherapy over Thermotherapy with common

use of Proprioceptive neuromuscular hold relax technique.

STRIDE LENGTH:

Stride length21 is the distance between two successive foot placements. Footwear

and a person’s height have a direct influence on stride length. This is calculated from the

start of a particular phase of gait cycle in an extremity to the same phase of the cycle of

the same extremity.

The temporal parameters reflect the timing of events in the gait cycle and include

stance time, swing time, single support stance time, double support stance time and the

entire gait cycle time.

The combined temporal and spatial parameters allow the calculation of cadence

and walking velocity.

CADENCE:

Cadence 21is the number of steps in a given time i.e. steps per minute (a speed

dependent variable). In normal walking, each person adopts his own cadence and he will

change only when he changes speed. When his walking speed increases or decreases, his

cadence increases or decreases correspondingly.




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WALKING VELOCITY:

Walking velocity21is step length ×cadence or (stride length/2) ×cadence,

measured in distance travelled per time, usually meters per minute. It is important to

remember that velocity of gait will alter the dynamic joint ranges recorded.

Due to the fact that the analysis of temporal parameters requires a very observant

eye to measure it, there are chances for poor inter-rater reliability. However it can be

reliably used if video taping is available. In this study however the temporal parameters

are recorded only on researcher’s observation. The subjects were made to walk 3 times

and their best values utilized for study to bring the error margin to acceptable levels.

PROCEDURE:

Thirty male hemiplegic subjects were selected on the basis of inclusion and

exclusion criteria and were divided into two groups namely Group I and Group II

randomly. All of these subjects were assessed using a general neurological proforma

(Annexure-II) and the pre test values of the gait parameters such as stride length, cadence

and walking velocity were recorded.

Group I was treated with Cryotherapy (icepacks) for 10 to 15minutes8 followed

by 6 seconds of proprioceptive neuromuscular hold relax stretching24 and the patient had

to be well prepared before application of cryotherapy. Before that it was essential to rule

out any contra indications for the cryotherapy procedure. The patient was positioned

prone36 and with adequate pillow support for maximal comfort.




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Following this, the ice pack wrapped in a towel fastened in position by means of

Velcro strap was applied in close approximation to the skin overlying the muscle belly of

the quadriceps1, 2 for 10 to 15 minutes. Preceding the ice pack application PNF stretching

was given. In this the patient was made to push against the palm of the therapist

maximally for 6 seconds. In this process the quadriceps muscle was made to contract

isometrically till it reached its peak or maximum contraction state, followed by

immediate relaxation during which the muscle was taken to the new lengthened position

(hip and knee flexion) and maintained for 10 seconds.

Simultaneously the plantar flexors 8were treated with ice packs followed by PNF

stretching. Here the patient was positioned in supine with proper pillow support to ensure

relaxation. The foot was held in neutral position by proper support. Following

cryotherapy the PNF was given. Here too the patient was asked to push against the

therapist palm to his maximal capacity for 6 24seconds preceded by acquisition of the new

range (dorsi flexion) which was held for 10 seconds. The hold relax proprioceptive

neuromuscular stretching was given three times with a rest period of 20 seconds between

each stretch daily and the same was continued for a period of six weeks(six days a week).

Group II was treated with Thermotherapy (moist packs) for 10 to 15minutes23

followed by proprioceptive neuromuscular hold relax stretching24 given in the same

manner as mentioned above for group I. They were also treated daily for a period of six

weeks (six days a week).




33

To assess the gait parameters, the patients were asked to relax and walk from a

starting point marked on the floor after immersing the affected foot in a tray containing

chalk powder paste to gain the impressions of the foot. This procedure was repeated

twice for the reliability factor and the time was recorded in the stop watch for the number

of steps walked per minute and the stride length was measured using an inch tape21. The

formula mentioned above in the measurement tools with the values of the stride length

and the cadence.10

The gait parameters such as Cadence, Stride length and Walking Velocity11 were

assessed during the first day before treatment and at the end of third and sixth weeks

respectively for both the groups.




34

Fig-3 Showing the subject measured for gait parameters




35

DATA ANALYSIS:

In this study, independent‘t’ was used as a statistical tool for both the groups of

subjects to find whether cryotherapy with common use of proprioceptive neuromuscular

stretching was effective over thermotherapy with proprioceptive neuromuscular

stretching. Descriptive statistics (mean and standard deviation) were calculated for both

the groups and for all the measurements. Then an independent‘t’ test was done to

interpret the findings. An alpha level of P<0.05 was the level of significance for the test.

ARITHMETIC MEAN:

_ X = x N

__ where, X = Arithmetic Mean, x = Sum of all variables

N = total number of variables.

STANDARD DEVIATION(S.D):

________ S.D = √∑(X-X1) 2 √ N

where, X1 = Arithmetic Mean, X = Sum of all variables

N = Total number of variables.




36

ANOVA

Analysis of variance (abbreviated as ANOVA) is an extremely useful statistical

technique that is used when multiple sample cases are involved. It is a technique that

enables us to examine the significance of the difference amongst more than two sample

means at the same time26. Here it is used to analyse the variance between the three

positions of the foot.

The basic principle of ANOVA is to test for differences among the means of the

populations by examining the amount of variation within each of these samples, relative

to the amount of variation between the samples25. It includes the following steps.

Step I :

To find the SS between.

SS between - Sum of squares for variance between the samples.

SS between = Tc2 / n – [ x] 2 / N

Where, Tc2 = T1

2 + T22 + T3

2

T12, T2

2 & T32 are the square of the sum of the individual item in one sample.

[x]2 = Square of the sum of the total of the individual item in all

the samples.

N = Number of total items in all the samples.

and ‘n’ = Total number of items in one sample




37

Step II :

To find the SS within.

SS within - Sum of squares for variance within samples.

SS within = x2 – Tc2 / n

x2 – Sum of the square value of individual item in all the samples.

Step III :

To find the SS total.

SS total - Sum of squares for total variance.

SS total = x2 – [ x] 2 / N

Correction Factor:

SS total = SS between + SS withi

Step IV :

To find the degrees of freedom.

d.f. for total variance = N – 1

where ‘N’ = No. of items in all samples.

d.f. between = k – 1

where ‘k’ = No. of samples.

d.f. within = N – k




38

Step V :

To calculate F-ratio.

For this, Mean square (MS) between and within samples is calculated.

MS between = SS between

d.f. between MS within = SS within d.f. within

F-ratio = MS between MS within

This ratio is used to judge whether the difference among several sample means is

significant or is just a matter of sampling fluctuations. For this purpose the table values of

F for given degrees of freedom at different levels of significance is compared. If the

worked out value of F, as stated above is less than the table value of F, the difference is

taken as insignificant.

In case the calculated value of F happens to be either equal or more than its table

value, the difference is considered as significant. The higher the calculated value of F is

above the table value, the more definite and sure one can be about his conclusions26.




39

Step VI :

Setting up analysis of variance table.

Source of variation

Sum of Squares (SS)

Degrees of freedom

(d.f.)

Mean Square (MS)

MS = SS/d.f

F-ratio

Between samples

Within

Samples

Tc

2 / n – [ x] 2/ N

x2 – Tc2 / n

(k – 1)

(N – k)

SS between

k-1

SS within N-k

MS between MS within

Total

x2 – [ x] 2 / N

(N – 1)

UN-RELATED ‘t’ TEST

_ _ X1 – X2 t = __________________________________________________________ _________________________________________ __________ √{∑(X1)2 – [∑(X1)] 2 /n1} + {∑(X2)2 – [∑(X2)] 2 /n1} x √ 1/ n1 + 1/ n2 _________ √ n1 + n2 – 2 __ __ where, X1 , X2 = Mean of scores from I & II condition

respectively. ∑(X1)2 = Square of each individual score from condition 1 to total. ∑(X2)2 = Square of each individual score from

condition 2 to total. [∑(X1)] 2 = Square of the sum of individual score from condition 1. [∑(X2)] 2 = Square of the sum of individual score

from condition 2. n1 = Number of samples in I condition. n2 = Number of samples in II condition. __ __ X1 = X1i – X1 X2 = X2i – X2




40

RESULTS & INTERPRETATION

Thirty male hemiplegic subjects with a mean age of 53 (SD=2.46) years were

selected for the study. The number of subjects in each group and the mean values of age

are shown in Table-1. The Group I (Cryotherapy group) had a mean age of 53.06 years

and the Group II (Thermotherapy group) had a mean age of 52.93 years.

TABLE-1.1

MEAN AGE VALUES

Subjects

N

Mean Age Values

Group I

15

53.06

Group II

15

52.93




41

TABLE-1.2

POST-TREATMENT MEAN VALUES OF THE GAIT PARAMETERS

Parameters

Group I

Group II

Stride length

9.73

4.66

Cadence

11

5.6

Walking velocity

4.97

2.28

The above Table-2 shows the mean values of the gait parameters such as Stride

length, Cadence and Walking velocity of the Group I and Group II after the 6th week of

intervention.




42

TABLE-1.3

POST-TREATMENT STANDARD DEVIATION VALUES OF

THE GAIT PARAMETERS

Parameters

Group I

Group II

Stride length

1.43

1.04

Cadence

1.25

0.73

Walking velocity

1.19

0.53

The above table shows the standard deviations for the gains achieved in case of

Group I and Group II after 6 weeks of intervention.




43

COMPARISON OF BOTH GROUPS FOR HOMOGENEITY Test of Homogeneity of variances:

The homogeneity of the data in both the groups was analyzed for all the

parameters using one-way ANOVA.

TABLE-2.1

HOMOGENEITY OF GROUPS USING STRIDE LENGTH

Source of variation

Sum of Squares

Degrees of freedom

Mean Square

F-ratio

Significance

Between Groups

611.900

12

50.992

0.524

0.809

Within Groups

194.500

2

97.250

Total

806.400

14

INTERPRETATION:

The above Table-2.1 gives the details of ANOVA done for the homogeneity of

groups using the stride length, the calculated F-value shows significance for variance and

all the values have significance greater than 0.05 proving that the groups are

homogenous.




44

TABLE-2.2

HOMOGENEITY OF GROUPS USING CADENCE

Source of variation

Sum of Squares

Degrees of freedom

Mean Square

F-ratio

Significance

Between Groups

1500.933

9

166.77

1.130

0.471

Within Groups

738.000

5

147.60

Total

2238.933

14

INTERPRETATION:

The above Table-2.2 gives the details of ANOVA done for the homogeneity of

groups using the Cadence, the calculated F-value shows significance for variance and all

the values have significance greater than 0.05 proving that the groups are homogenous.




45

TABLE-2.3

HOMOGENEITY OF GROUPS USING WALKING VELOCITY

Source of variation

Sum of Squares

Degrees of freedom

Mean Square

F-ratio

Significance

Between Groups

230.299

14

16.450

.

.

Within Groups

0.000

0

0

Total

230.299

14

INTERPRETATION:

There is no significant difference between the groups, therefore it was non-

homogenous between the groups for the gait parameter-Walking velocity.

Following this, to analyze the significance of each parameters between the two

groups, an independent‘t’ test was carried out with the values of pretest and post test.




46

TABLE-3.1

INDEPENDENT ‘t’ TEST PERFORMED WITH STRIDE LENGTH

S.No.

Pre test values of Group I

Post test values of Group I

Difference (X1)



Difference (X2)

1 28 38 10 40 44 4 2 42 50 8 35 39 4 3 35 44 9 37 40 3 4 40 49 9 49 53 4 5 25 34 9 29 33 4 6 38 48 10 40 44 4 7 37 46 9 43 47 4 8 29 36 7 34 40 6 9 46 55 9 25 30 5 10 29 41 12 28 32 4 11 30 42 12 52 58 6 12 47 59 12 38 42 4 13 42 52 10 29 35 6 14 41 51 10 32 38 6 15 49 59 10 44 50 6

Mean 9.733333 4.666667 S.D. 1.437591 1.046536

N1 15 N2 15

Factor 5.477226 Mean Diff 5.066667

S 2.857537 ‘t’ 9.7116

INTERPRETATION:

The above Table-3.1 shows the value of ‘t’ as 9.7116 for Stride Length at p<0.001, hence

the ‘t’ value is significant at p<0.001, which is lesser than p=0.05.




47

TABLE-3.2

INDEPENDENT ‘t’ TEST PERFORMED WITH CADENCE

S.No.



Difference (X1)



Difference (X2)

1 32 45 13 56 62 6 2 64 76 12 52 59 7 3 52 60 8 50 55 5 4 60 72 12 60 65 5 5 30 41 11 38 43 5 6 48 58 10 58 63 5 7 48 59 11 60 66 6 8 34 44 10 36 42 6 9 62 73 11 30 35 5 10 34 45 11 38 45 7 11 36 46 10 68 73 5 12 60 72 12 50 56 6 13 56 66 10 36 42 6 14 56 68 12 38 43 5 15 64 76 12 62 67 5

Mean 11 5.6 S.D. 1.253566 0.736788

N1 15 N2 15


S 2.926101 ‘t’ 10.108

INTERPRETATION: The above Table-3.2 shows the value of ‘t’ as 10.108 for Cadence at p<0.001, hence the

t’ value is significant at p<0.001, which is lesser than p=0.05.




48

TABLE-3.3

INDEPENDENT ‘t’ TEST PERFORMED WITH WALKING VELOCITY

S.No.



Difference (X1)



Difference (X2)

1 4.48 8.55 4.07 11.2 13.64 2.44 2 13.44 19 5.56 9.1 11.51 2.41 3 9.1 13.2 4.1 9.25 11 1.75 4 12 17.64 5.64 14.7 17.23 2.53 5 3.75 6.97 3.22 5.51 7.1 1.59 6 9.12 13.92 4.8 11.6 13.86 2.26 7 8.88 13.57 4.69 12.9 15.51 2.61 8 4.93 7.92 2.99 6.12 8.4 2.28 9 14.26 20.08 5.82 3.75 5.25 1.5 10 4.93 9.23 4.3 5.32 7.2 1.88 11 5.4 9.66 4.26 17.68 21.17 3.49 12 14.1 21.24 7.14 9.5 11.76 2.26 13 11.76 17.16 5.4 5.22 7.35 2.13 14 11.48 17.34 5.86 6.08 8.17 2.09 15 15.68 22.42 6.74 13.64 16.75 3.11

Mean 4.972667 2.288667 S.D. 1.193683 0.53121

N1 15 N2 15


S 1.639257 ‘t’ 8.968

INTERPRETATION: The above Table-3.2 shows the value of ‘t’ as 8.968 for Walking Velocity at p<0.001,

hence the t’ value is significant at p<0.001, which is lesser than p=0.05.




49

GRAPH-1

The following graph (fig-4) and the table shows the representations of the mean

improvements in all the parameters between both the groups.




50

DISCUSSION

In this study, totally 30 subjects were selected and assigned randomly to two

groups of 15 subjects each who received Cryotherapy (Group-I) and Thermotherapy

(Group-II) respectively. Both the groups received proprioceptive neuromuscular hold

relax stretching in common after the heat or cold therapy.

The two groups were analyzed with improved parameters of gait such as Stride

length, Cadence and Walking velocity. The mean was calculated and the statistical

analysis of the values showed considerable increase in mean improvement for the Group-

I than the Group-II which proved that the subjects who received Cryotherapy had a better

outcome than Thermotherapy with common use of proprioceptive neuromuscular

stretching thereby reducing the tone of spastic muscles such as the quadriceps and the

plantarflexors, thus improving their gait pattern.

Thus the null hypothesis of this study can be rejected and the experimental

hypothesis stating that there is significant difference in the gait parameters in the

hemiplegic patients using Cryotherapy over thermotherapy with common use of

Proprioceptive neuromuscular hold relax stretching was accepted.




51

To date, as per available information, this study seems to be the first objective

investigations of the comparison between cryotherapy over thermotherapy with common

use of Proprioceptive neuromuscular hold relax technique. Also the study showed

significant changes in the assessment of tone by coupling both cryotherapy and

thermotherapy for reducing spasticity and found cryotherapy had a superior hand in the

diminishment of the increased tone in the muscles13. Mainly the muscle group employed

for the study was Quadriceps and plantar flexors since it has been proven for increased

gamma motor neuron firing in the anti gravity muscles of the limbs during hemiplegia.

The natural study on patients did provide a proven insight into distinction of

which mode of treatment between both the groups was better and found cryotherapy

much proven for improving muscle output by reducing the abnormal tone. However,

there was a significant result when “t”test was performed to find out the effect of

Cryotherapy over Thermotherapy with common use hold relax technique was analysed in

reducing the reduction in spasticity.

These results strongly support the earlier findings of Harlaar J et al (2001)8 that

the Cryotherapy reduces spasticity and studies done by Preisinger E and Quittan M

(1994) 11 also supports the results of this study that there was a reduction of increased

tone in muscles by Thermotherapy but less effective in comparison with Cryotherapy.




52

The study also showed that the common use of PNF hold relax stretching was

effective when given along with either thermotherapy or cryotherapy and this is

supported by Funk DC et al (2003) 4

This study was done with only male subjects and all the patients found a

considerable decline in the increased tone and had a better outcome for the weight

bearing and increased cadence and stride length which ultimately increased walking

velocity.

The result of the present study indicates that effect of Cryotherapy had a proven

effect over Thermotherapy with common use of Proprioceptive neuromuscular hold relax

technique.




53

LIMITATIONS

1. This study was done in hemiplegic subjects especially for the lower limbs

muscles spasticity and so the study does not validate its role in the Upper limbs

spastic muscles.

2. In this study subjects were tested only on those who presented only with extensor

type of spasticity in the lower limbs, flexor type of spasticity of lower limb were

not discussed.

3. Plantaris and its contribution as a plantar flexor are still under scrutiny.

4. As this study was done only in males, further studies should be done on females

too so that the study can be justified to both the sexes.

5. This study was done only with the age group ranging from 40-60years, other age

groups were not considered.

6. Only three parameters of the gait was included in the study to assess the

improvement in the gait of the hemiplegic subjects; other parameters such as step

length, base of support etc were not included.




54

SUGGESTIONS & RECOMMENDATIONS FOR FUTURE STUDIES

1. It would be interesting to assess how long improvement would be maintained by

adding a delayed post test.

2. Inclusion of a measure to determine whether observed improvements are a result

of learning or solely due to better endurance.

3. This treatment can be applied in other type of neurological impairments like

spinal cord lesion and cerebral palsy.

4. More research should be done on older ages to see how they fare by this

treatment.

5. Long term functional improvements can be measured for evolving a better insight

into rehabilitation of affected individuals.

6. The reduction of muscle tone can be better analysed using Electromyography.

7. This study can be modified in future considering the functional outcome of the

hemiplegic subjects.




55

CONCLUSION

This study had shown that in hemiplegic male subjects (40 to 60years) the group

given Cryotherapy along with proprioceptive neuromuscular hold relax stretching ( 10 to

15minutes,6 seconds stretch, repeated 3 times, once per day, 6 days a week for 6 weeks)

was better than with Thermotherapy along with proprioceptive neuromuscular hold relax

stretching Over the 6-week treatment, Group I showed considerable increase in all the

parameters of gait and in gaining independence and achieving weight bearing on the

affected limb as well as gaining confidence to endure a better rehabilitation outcome.

The study was done on Quadriceps and Triceps surae muscles of the lower limb

and found the need of reducing spasticity in the Anti-gravity muscles to allow a proper

facilitation of a smooth and voluntary locomotion with the functional independence of the

patient.

Cryotherapy and Proprioceptive neuromuscular stretching provided a base for the

treatment strategy to vary and to find an effective maneuver to reach the affected patients

for improving gait parameters.




56

SUMMARY

A prospective study of thirty Hemiplegic subjects was undertaken to determine

the effect of Cryotherapy over Thermotherapy with common use of hold relax technique

to improve the gait parameters of hemiplegic patients.

Cryotherapy was found to be more effective than thermotherapy with common

use of hold relax technique and showed a sizeable decrease in the increased tone and

facilitated greater cadence and weight bearing capacity of the individual. Thereby the

treatment choice for the physiotherapist should be cryotherapy with Proprioceptive

neuromuscular hold relaxes Stretching to effectively reduce spasticity and to rehabilitate

the patient to an optimum level of self independence.




57

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62

ANNEXURE-1

ASSESSMENT FORMAT

Demographic Data

Name: Age: Sex: Occupation: Address:

History

Present medical history

Duration of stroke : Side of involvement : Type of stroke : Territory of involvement :

Past medical history

Prior history of CVA : Hypertension : Diabetes mellitus : Orthopedic disorders : Visual problems : Personal history : Socioeconomic history : Previous therapies taken : On observation General condition : Attitude of limbs-Lower limb : Wasting if any : On palpation Tenderness :




63

On examination Level of consciousness : Cranial Nerve examination : Higher Mental functions :

Appearance - Behavior - Intelligence - Judgment - Memory - Orientation - Speech and language - Perception -

Sensory Examination Superficial : Touch, pressure & pain. Deep : Position sense, Kinesthetic sense & Vibration. Cortical : Stereognosis, Barognosis, Tactile localization Tactile discrimination & Two point discrimination. Motor Examination ROM : Lower limb

Hip Flexion Extension Abduction Adduction Medial Rotation

Lateral Rotation

- Knee Flexion Extension - - Ankle Plantarflexion Dorsiflexion Inversion Eversion - -

- - - Assessment of Tone (Spasticity) : Tightness : Contracture : Deformity :




64

Reflexes Knee jerk : Ankle jerk : MMT

Hip Power Knee Power Ankle Power Flexors Flexors Dorsiflexors

Extensors - - - - Abductors Extensors Plantarflexors Adductors - - - -

Gait Assessment : Coordination: lower limb

Hand function Grip and grasp Release Bladder and bowel disturbances :

ADL :

Eating - Grooming - Toileting - Bathing - Bed mobility - Ambulation - Stage of Hemiplegia : (Based on Brunnstorm stages of Recovery)

DATA COLLECTION TABLE

Group : I or II

Variables Pre test values Third week values Sixth week values

Stride Length in cms.

Cadence in steps/min

Walking Velocity in m/min




65

ANNEXURE-2

CONSENT FORM

I…………………….hereby volunteer myself for the study done by

Mr. Sunil Varghese, MPT Student, Goutham College of Physiotherapy,

Bangalore. He has explained all the procedures that will be done on me, and

I give my full consent to participate in this study.

Place: Signature

Date: (Name)




66

ANNEXURE-3

BRUNNSTORM STAGES

SEQUENTIAL RECOVERY STAGES IN HEMIPLEGIA

STAGE 1: Recovery from Hemiplegia occurs in a stereotyped sequence of events that

begin with a period of flaccidity immediately following the acute episode. No movement

of the limbs can be elicited.

STAGE 2: As recovery begins, the basic limb synergies or some of their components

may appear as associated reactions, or minimal voluntary movement responses may be

present. At this time, spasticity begins to develop.

STAGE 3: Thereafter, the patient gains voluntary control of the movement synergies,

although full range of all synergy components does not necessarily develop. Spasticity

has further increased and may become severe.

STAGE 4: Some movement combinations that do not follow the paths of either synergy

are mastered, first with difficulty, then with ease and spasticity begins to decline.

STAGE 5: If progress continues, more difficult movement combinations are learned as

the basic limb synergies lose their dominance over the motor acts.

STAGE 6: With the disappearance of the spasticity, individual joint movements become

possible and coordination approaches normal. From here on as the last recovery step,

normal motor function is restored, but this last stage is not achieved by all, for the

recovery process can plateau at any stage.




67

ANNEXURE-4 MASTER CHART

MASTER CHART OF GROUP I TREATED BY CRYOTHERAPY WITH PNF HOLD RELAX STRETCHING

Patient Age Stride Length in cms Cadence in steps/minute Walking Velocity in m/min No. Pretest 3rd Wk 6th Wk Pretest 3rd Wk 6th Wk Pretest 3rd Wk 6th Wk 1 58 28 33 38 32 40 45 4.48 6.6 8.55 2 47 42 46 50 64 69 76 13.44 15.87 19 3 45 35 39 44 52 56 60 9.1 10.92 13.2 4 54 40 45 49 60 65 72 12 14.625 17.64 5 56 25 29 34 30 35 41 3.75 5.075 6.97 6 60 38 42 48 48 52 58 9.12 10.92 13.92 7 52 37 40 46 48 53 59 8.88 10.6 13.57 8 49 29 31 36 34 37 44 4.93 5.735 7.92 9 59 46 49 55 62 66 73 14.26 16.17 20.075 10 48 29 35 41 34 39 45 4.93 6.825 9.225 11 51 30 36 42 36 39 46 5.4 7.02 9.66 12 55 47 53 59 60 65 72 14.1 17.225 21.24 13 60 42 46 52 56 60 66 11.76 13.8 17.16 14 56 41 46 51 56 62 68 11.48 14.26 17.34 15 46 49 53 59 64 70 76 15.68 18.55 22.42

MASTER CHART OF GROUP II TREATED BY THERMOTHERAPY WITH

PNF HOLD RELAX STRETCHING Patient Age Stride Length in cms Cadence in steps/minute Walking Velocity in m/min

No. Pretest 3rd Wk 6th Wk Pretest 3rd Wk 6th Wk Pretest 3rd Wk 6th Wk 1 56 40 42 44 56 60 62 11.2 12.6 13.64 2 58 35 36 39 52 54 59 9.1 9.72 11.505 3 48 37 38 40 50 52 55 9.25 9.88 11 4 47 49 51 53 60 63 65 14.7 16.065 17.225 5 60 29 31 33 38 40 43 5.51 6.2 7.095 6 54 40 42 44 58 60 63 11.6 12.6 13.86 7 52 43 45 47 60 63 66 12.9 14.175 15.51 8 45 34 36 40 36 40 42 6.12 7.2 8.4 9 56 25 28 30 30 32 35 3.75 4.48 5.25

10 47 28 30 32 38 42 45 5.32 6.3 7.2 11 50 52 55 58 68 70 73 17.68 19.25 21.17 12 54 38 40 42 50 54 56 9.5 10.8 11.76 13 59 29 32 35 36 40 42 5.22 6.4 7.35 14 48 32 35 38 38 40 43 6.08 7 8.17 15 60 44 46 50 62 65 67 13.64 14.95 16.75




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LIST OF TABLES

S.No. Table No. Contents Page No. 1 1.1 Mean Age Values 30 2 1.2 Mean Values for all the Parameters of Gait 31 3 1.3 Standard Deviations for all the Parameters of Gait 32 4 2.1 Anova for Homogenity of Groups 33

using stride Length 5 2.2 Anova for Homogenity of Groups 34

using Cadence

6 2.3 Anova for Homogenity of Groups 35 using Walking Velocity

7 3.1 Independent t-values for Stride Length 36

8 3.2 Independent t-values for Cadence 37

9 3.3 Independent t-values for Walking Velocity 38




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LIST OF FIGURES

Fig. No. Contents Page No. 1 Materials Used 19

2 A Subject receiving PNF Stretching 19 3 A Subject assessed for gait parameters 24

4 Graphical representation of Mean improvement 39

of all the parameters of both the groups




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LIST OF ABBREVATIONS USED

ADL Activities of Daily Living EMG Electromyography et al and others MMT Manual Muscle Testing PNF Proprioceptive Neuromuscular Stretching ROM Range of Motion SD Standard Deviation




Documents

cryotherapy and steching in hemiplegia