Scientific Research Journal of India SRJI Vol 3, Issue 2, Year 2014 Full Issue

Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, International Journal of science)

ISSN: 2277-1700

Vol: 3, Issue: 2, Year: 2014

Editor in Chief

Mrityunjay Sharma, Varanasi, India

Executive Editor

Krishna N. Sharma, Cameroon

Editors

Ankita Kashyap, Bhopal, India

Florence Ngwanyam, Cameroon

Gayatri Jadav Upadhyay, Bhopal, India

Jyoti Sharma, Jabalpur, India

Kuki Bordoloi, Guwahati, India

Neha Dewan, Canada

Ngeh Etienne Ngeh, Cameroon

Nick Ngwanyam, Cameroon

Piyush Jain, New Delhi, India

Popiha Bordoloi, Guwahati, India

Sudeep Kale, Mumbai, India

Sushil S. Dubey, Mumabi, India

Tufon Emmanuel, Cameroon

Waqar Naqvi, Canada

Office

Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403

Website

http://srji.drkrishna.co.in

URL Forwarded to

http://sites.google.com/site/scientificrji

Email

[email protected]

Contact

+91-9839973156

Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the

editorial board will not be held responsible for the same.

Copyright © 2014 Scientific Research Journal of India

All rights reserved.

CONTENTS

Title Author/s Department Page

Editorial Mrityunjay Sharma I

THE EFFICACY OF

KINESIOTAPING ON

LOCOMOTOR ABILITIES IN

CEREBRAL PALSY: A CASE

STUDY

Deepika P. Metange,

Madhavi V. Lokhande Physiotherapy 1

EFFICACY OF RETROWALKING

IN PATIENTS WITH CHRONIC

KNEE OSTEOARTHRITIS: A

SINGLE GROUP EXPERIMENTAL

PILOT STUDY

Gauri Arun Gondhalekar,

Medha Vasant Deo Physiotherapy 7

AN ANALYSIS OF MEMORY

RETRIEVAL AND

PERFORMANCES OF

PHYSIOTHERAPY EXERCISES IN

NON-SPECIFIC LOW BACK PAIN

PATIENTS

Disha Jacob, Varoon C

Jaiswal Physiotherapy 16

TO ANALYSE THE SHORT TERM

EFFECT OF UPPER TRAPEZIUS

INHIBITION TAPING IN

PATIENTS WITH MECHANICAL

NECK PAIN

Meenakshi Verma, Nidhi

Gautam, Deepak Raghav,

Tanvi Aggarwal

Physiotherapy 23

ITO TEST: DOES HEIGHT OF

THE PAD AFFECT BACK

MUSCLE ENDURANCE?

Juanita E. Soans, Keerthi

Rao, Chandra Iyer, Dnyanda

Newasekar

Physiotherapy 31

TO COMPARE THE

EFFECTIVENESS BETWEEN PRE

EXERCISE TAPING AND POST

EXERCISE TAPING IN

IMPROVING PAIN AND

FUNCTIONAL OUTCOME IN

Parul R, Vishal G, Deepak R,

Monika S Physiotherapy 38

ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

iv

KNEE OSTEOARTHRITIS

ATTITUDE AND AWARENESS

TOWARDS PHYSICAL ACTIVITY

IN PRAVARA RURAL HOSPITAL

AND COLLEGE

Shalu Bhardwaj, Nisha

Shinde Physiotherapy 47

TO FIND OUT THE

EFFECTIVENESS OF MAITLAND

MOBILIZATION IN CONTEXT OF

ADDITIONAL BENEFIT OVER

ADVICE AND EXERCISE ALONE

FOR PATIENTS SUFFERING

FROM FREEZING STAGE OF

FROZEN SHOULDER – A

RANDOMIZED CONTROL TRIAL

Amit Murli Patel Physiotherapy 55

PROFILE OF SEVERE

NUTRITIONAL ANEMIA IN

CHILDREN AT A TERTIARY

CARE HOSPITAL, SOUTH INDIA

Madoori Srinivas, Kapil

Challa, Mangat Bhukya,

Srikanth Darisetty, Radhika

Kodimela

Pediatrics 72

ANTIOXIDANT POTENTIALS OF

PARTHENIUM

HYSTEROPHORUS L LEAF

EXTRACTS

Sankar Narayan Sinha, Dipak

Paul

Environmental

Microbiology 80

COMPARATIVE STUDY ON s-

LPS AND bp26 BASED iELISA

FOR HUMAN BRUCELLOSIS

Narayana Rao.K , R Shome,

Jayapal Gowdu

B,Nagalingam M,

Balamurugan1V, B. R.

Shome, K Prabhudas,

Rahman.H

Microbiology 87

AUTOMATIC FILLING

MANAGEMENT SYSTEM FOR

INDUSTRIES

Saubhagya Tandon, Shreya

Srivastava, Sandeep Pal

Electrical

Engineering 100

Scientific Research Journal of India ● Volume: 3, Issue: 2, Year: 2014

v

i


ii

FROM EDITOR IN CHIEF

Dear Friends,

Greetings! First of all I’ld like to apologize for the delay in publishing this issue due to few unforeseen

problems. Like all our previous issues, this issue also remains a multidisciplinary issue that contains total 8

papers from Physiotherapy, 1 paper from Pediatrics, 1 paper from Microbiology, 1 paper from Environmental

Microbiology, and 1 from Electrical Engineering. I hope you’ll find these papers informative.

Be aware that the journal also has a website, http://srji.drkrishna.co.in where subscribers can access the full

content and also submit papers for future publication.

Please send me informal comments directly, or formal letters we can publish, about the journal. I welcome new

ideas about topics (content) and process. Let me know your thoughts.

Thanks for the opportunity, and stay tuned for future editions.

-Mrityunjay Sharma

1

THE EFFICACY OF KINESIOTAPING ON LOCOMOTOR ABILITIE S IN

CEREBRAL PALSY: A CASE STUDY

Deepika P. Metange*, Madhavi V. Lokhande

ABSTRACT

Abstract- Objective of the study was to investigate the effect of kinesiotaping along with conventional

treatment protocol on locomotor abilities in a patient with spastic diplegic cerebral palsy. Design: A

single case study. Patient: A 5 year 3 months old female patient diagnosed as cerebral palsy shortly

after birth. Intervention:Motor ability of the patient was assessed using clinical measures ankle and

knee tardieu scale, and Gross Motor Function Measure-88, [GMFM]. The goal area score was

71.66% which included standing and locomotion dimension. Intervention included a session of

conventional physical therapy consisting of 1 hour session repeated 3 days a week for a period of 4

weeks based on neurodevelopmental treatment. It included stretching, weak muscle strengthening

exercises, postural, balance and gait training exercises and kinesiotaping Taping was applied to

lateral hamstring muscle bilaterally using facilitatory approach. Changes in locomotor abilities were

observed by means of video recording and observing changes in the gait parameters. There was an

increase of 18.85% in the GMFM goal score. Also the gait pattern demonstrated more stable and

symmetrical locomotor pattern.. Conclusion: The findings show that kinesiotaping when combined

with conventional physical therapy can improve locomotor abilities and thereby can be a useful

adjunct to therapy.

Keywords: Kinesiotaping; cerebral palsy; locomotor abilities; gait

2

INTRODUCTION

Limitations in the motor activity of children

with cerebral palsy (CP) are the consequence of

a failure to acquire appropriate motor schemas,

caused by arrested normal brain maturation.

Nevertheless, some of these children,

exploiting their few available resources1,

manage to walk, thanks to the emergence of

atypical but still functional locomotor patterns2,

3. However, these patterns can lead to long-

term instability, contractures, and deformities4.

Common treatments for children with CP

include botulinum toxin, serial casting,

orthopaedic surgery, and orthoses5. These

interventions are designed to act at the

peripheral level, without particularly aiming at

promoting more normal motor development at

the central level. Kinesiotaping may be a

solution in trying to reach this objective. .

Although it has been used in the orthopaedic

and sports settings, it is gaining acceptance as

an adjunct in the treatment of other

impairments. The use of Kinesiotaping in

conjunction with the child’s regular therapy

program may favourably influence the

cutaneous receptors of the sensorimotor system

resulting in subsequent improvement of

voluntary control and coordination6, 7. This

intervention could favour the integration of

therapy and daily activities and increase

participation in social life. Nevertheless, it has

been only applied infrequently in these

children8, 9. Important intervention objectives

are to strengthen weakened muscles, to

improve the quality and active range of motion,

and to improve the child’s level of

independence with activities of daily living.

Kinesiotaping, when applied properly, can

theoretically improve the following: strengthen

weakened muscles, control joint instability,

assist with postural alignment, and relax an

over-used muscle. When the application

procedure is followed correctly, the taped area

can be used to facilitate a weakened muscle or

to relax an overused muscle. The method for

applying the tape varies depending on the

specific goals: improve active range of motion,

relieve pain, adjust malalignment, or improve

lymphatic circulation (Kase, Wallis, &Kase,

2003)10. The variables in tape application

include the amount of prestretch applied to the

tape, position of the area to be taped, treatment

goals (pain reduction, subcutaneous blood flow,

improved muscle function)11. Therefore the

purpose of the case study was to investigate the

efficacy of kinesiotaping along with

conventional physical therapy on gait in a

patient diagnosed as spastic diplegic cerebral

palsy.

METHODOLOGY

Patient was a 5 year 3 months old female

diagnosed as spastic diplegic cerebral palsy

shortly after birth. She was going to normal

school and parents came with chief complaints

of walking on toes and difficulty in

independent walking. She was on regular

physiotherapy treatment 2 years back which


3

was later stopped and was not using any

orthosis. Informed consent was taken from the

parents and the patient prior to the study. Motor

ability of the subject was assessed using

clinical measures ankle and knee tardieu scale,

and Gross Motor Function Measure-88,

[GMFM] 12. On observational gait analysis the

patient walked on toes, had bilateral in toeing,

mild hip and knee flexion and scissoring gait.

The total score on GMFM was 46.8%. The

grand total score or goal area score was 71.66%

which included standing and locomotion

dimension. Intervention included a session of

conventional physical therapy consisting of 1

hour session repeated 3 days a week for a

period of 4 weeks based on

neurodevelopmental treatment (derived from

the Bobath concept)13. It included stretching,

weak muscle strengthening exercises, postural,

balance and gait training exercises and

kinesiotaping. After thorough assessment it was

found that lateral hamstrings on either side

were weak while medial hamstrings on both the

sides were overactive. Specifically right side

hamstring showed more hypertonia and over

activity while walking which was manifested as

in-toeing gait. Also bilateral plantar flexors

showed hypertonia, which manifested as toe

walking. Ankle plantar flexors showed more of

static component of spasticity, due to which

plantar flexors were not assessed for

kinesiotaping.

Prior to kinesiotaping, basic assessment was

done to decide on the technique of application.

Active knee flexion in prone position was used

as outcome measure. Active knee flexion in

prone showed excessive internal rotation of

tibia right more than left because of hyperactive

medial hamstrings which could be the cause of

bilateral scissoring during gait. Change in

lateral hamstring strength was assessed by

using muscle technique of kinesiotaping.

Assessment revealed that the muscle gliding

towards origin i.e. ischial tuberosity gave better

recruitment of lateral hamstrings and thus better

quality of active knee flexion.

2 Inches wide, pink coloured kinesio tape was

applied by using ‘I’ technique. Pink coloured

tape was preferred as it has facilitatory effect

on a muscle performance. The length of the

tape was measured with the muscle in

maximally stretched position .Because of

balance issues in standing this measurement

was done in supine with hip knee flexion. Base

of the tape was applied in prone position near

ischeal tuberosity with the muscle in resting

position (without any stretch).The base of tape

was activated by rubbing a tape. The rest of the

tape was applied carefully over the lateral

hamstrings without giving any stretch to the

tape. Again tape was activated by rubbing it.

Lateral hamstring function was reassessed by

active knee flexion, which showed significant

improvement in prone as well as in standing &

walking. Changes in gait pattern were observed

by means of video recording.


4

Fig 1. Findings seen on observational gait analysis.

RESULTS AND DISCUSSION

Results showed the acquisition of more

incremented GMFM. The improvement in the

goal GMFM score was 90.4% which was with

the difference of 18.85% post treatment. Also

the gait pattern demonstrated more stable

(reduced step width) and symmetric (more

similar step length and reduced scissoring)

locomotor patterns. However, the equines foot

was not corrected by the taping. Muscles which

are usually tackled are antagonist to spastic

muscles. But as spastic muscles are also weak,

and there is need to work upon these weak

muscles too. Also, kinesiotaping increases

proprioceptive and tactile information and

therefore restores optimal muscle length,

thereby providing a foundation for normal

firing and recruitment patterns.

Observed functional improvements were not

accompanied by evident changes in the ankle

and knee tardieu scale values. This result could

represent a specific difference between

kinesiotaping and serial casting. Serial casting,

in fact, typically leads to short-term

improvements on passive range of motion, but

does not always improve active functioning14, 15

since it may lead to muscle wasting, and

weakening spastic and non-spastic muscles5.

Kinesiotaping, conversely, provides support to

the weak muscles, facilitating their normal

activity. Further randomized controlled

investigations on wider samples are certainly

needed to assess effectively the effects of the

taping treatment. Nevertheless, the fact that

observed gait improvements occurred during

the treatment period, demonstrate the efficacy

of kinesiotaping along with conventional

physical therapy. Also, parents reported

positive feedback about the effects of the

kinesiotaping on child’s participation in social

activities, locomotor ability, and tolerability to

the treatment which could also be an advantage


5

over use of orthosis. In conclusion,

kinesiotaping seems to be a promising

intervention for improving locomotor function

in children with CP and a very useful adjunct to

the conventional therapy.

Fig. 2. Graph demonstrating effect on GMFM

scores pre and post intervention.

Fig 3. Changes seen in the gait pattern pre and

post intervention.

REFERENCES

1. Fonseca ST, Holt KG, Fetters L, Saltzman E. Dynamic resources used in ambulation by children with spastic

hemiplegic cerebral palsy: relationship to kinematics, energetics and asymmetries. PhysTher 2004; 84: 344–54.

2. Kra¨geloh-Mann I, Cans C. Cerebral palsy update. Brain Dev 2009; 31: 537–44.

3. Berger W. Characteristics of locomotor control in children with cerebral palsy. NeurosciBiobehav Rev 1998; 22:

579–82.

4. Ferrari A, Cioni G. Paralisicerebraliinfantili. Storia natural e orientamentiriabilitativi. Tirrenia: Edizionidel

Cerro, 1993.

5. Berker AN, Yalc¸in MS. Cerebral palsy: orthopaedic aspect and rehabilitation. PediatrClin North Am 2008; 55:

1209– 25.

6. Thornton JL,Webster JA. The ‘Tape Cast’ functional taping for the injured athlete. J Athl Train 1996; 31: 179–81.


6

7. Lohrer H, Wilfried A, Gollhofer A. Neuromuscular Properties and functional aspects of taped ankles. Am J Sports

Med 1999; 27: 69–75.

8. Yasukawa A, Patel P, Sisung C. Pilot study: investigating the effects of kinesio taping in an acute pediatric

rehabilitation setting. Am J OccupTher 2006; 60: 104–10.

9. Footer CB. The effects of therapeutic taping on gross motor function in children with cerebral palsy.

PediatrPhysTher 2006; 18: 245–52.

10. Kase, K. (2000). Illustrated Kinesio Taping (3rd ed.). Albuquerque, NM: Universal Printing and Publishing.

11. Kase, K., Wallis, J., &Kase, T. (2003). Clinical therapeutic applications of the Kinesio Taping Method.

Albuquerque, NM:Kinesio Taping Association.

12. Annika L, Gun-Britt J, Christina G, Eva N. Longitudinal Construct Validity of the GMFM-88 Total Score and

Goal Total Score and the GMFM-66 Score in a 5-Year Follow-up Study. PhyTher 2009; 89: 342-350.

13. Butler C, Darrah J. Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence

report. Dev Med Child Neurol 2001; 43: 778–90.

14. Autti-Rami I, Suoranta J, Anttila H, Malmivaara A, Makela M. Effectiveness of upper and lower limb casting and

orthoses in children with cerebral palsy: an overview of review articles. Am J Phys Med Rehabil 2006; 85: 89–

103.

15. McNee AE, Will E, Lin JP, et al. The effect of serial casting on gait in children with cerebral palsy: preliminary

results from a crossover trial. Gait Posture 2007; 25: 463–8.

CORRESPONDENCE

* Assistant professor, Terna Physiotherapy College, Nerul, Navi Mumbai, INDIA. Email:

[email protected]

7

EFFICACY OF RETROWALKING IN PATIENTS WITH CHRONIC K NEE

OSTEOARTHRITIS: A SINGLE GROUP EXPERIMENTAL PILOT S TUDY

Gauri Arun Gondhalekar*, Medha Vasant Deo**

ABSTRACT

Background: Increased external knee adduction moment during ambulation is a strong predictor of

the severity of symptoms in patients with chronic knee osteoarthritis. Objectives: To assess the effects

of Retro-walking along with conventional treatment on pain and disability in patients with acute

exacerbation of chronic knee osteoarthritis. Methods: Twelve patients (6 men, 6 women) with chronic

knee osteoarthritis fulfilling the inclusion criteria received conventional treatment and Retro-walking.

Pain and disability were the primary outcomes and knee range of motion (ROM), hip abductor and

extensor strength were the secondary outcomes; measured pre-intervention, after 1 week and after 3

weeks of intervention. Results: One way analysis of variance was used for all the primary and

secondary outcomes. At the end of 3 weeks; the primary outcomes showed highly significant difference

(P < 0.0001), secondary outcomes showed significant difference ( P < 0.05). Conclusion:

Retrowalking is an effective adjunct to conventional treatment in decreasing pain and disability in

patients with knee osteoarthritis.

Keywords: Retrowalking, Backward-walking, Knee osteoarthritis, external knee adductor moment

INTRODUCTION

Osteoarthritis (OA) is a chronic degenerative disorder of multifactorial etiology characterized


8

by loss of articular cartilage, hypertrophy of

bone at the margins, subchondral sclerosis and

range of biochemical and morphological

alterations of the synovial membrane and joint

capsule.1-5

Osteoarthritis is the most common form of

arthritis.6,7 It is the most frequent joint disease

with a prevalence of 22-39% in India;6,8 and

one of the leading causes of pain and disability

worldwide.9-12

Knee is the most common site for OA13 with

characteristic signs like pain during weight

bearing, limitation of knee range of motion

(ROM), crepitus, joint effusion, and local

inflammation.11,14-16

In knee joint, OA affects the medial

compartment more frequently than the lateral.

This is attributed to higher transfer of loads

through the medial compartment than through

the lateral, resulting in higher external knee

adduction moment.14

The external knee adduction moment (EKAM)

is the product of ground reaction force (GRF)

and the moment arm with respect to knee joint

center. 17-21 It leads to adduction at the

tibiofemoral joint causing compressive load at

the medial compartment of the knee joint. This

increase in joint forces results in a deleterious

effect on knee cartilage and leads to

development and progression of knee OA. 21-29

Various studies have stated that, the first peak

knee adduction moment during walking is a

strong predictor of the severity and rate of

progression of medial compartment of knee

OA.14

Management of knee OA aims to control pain

and reduce disability.30-32 A multidisciplinary

approach Is required with physiotherapy as the

main choice of conservative management;

which includes various strategies such as

exercises, patellar taping, manual therapy and

various electrical and thermal modalities for

pain relief. 6,31,32

Recently, weight bearing exercises have drawn

much attention in the management of knee

OA.33-34 Studies suggest that these exercises are

more effective and functional than the

traditionally employed non weight bearing

exercises.32 Weight bearing exercises for knee

joint can be incorporated in many ways; one of

them is Retro-walking.30 Retro-walking is

walking backwards.6 Since there is backward

propulsion, it leads to reversal of leg movement

in Retro-walking. This requires different

muscle activation patterns than in forward

walking.33 Various studies have stated the

effects of backward walking and backward

running in strength gains and joint stress

reduction and facilitating rehabilitation.6 Along

with a unique muscle activation pattern; Retro-

walking is leads to increased cadence,

decreased stride length and different joint

kinematics as compared to forward walking;

offering some benefits over forward walking

alone.30,32

A growing body of evidence suggests the

importance of exercises in improvement of

symptoms and joint function in knee OA.

Precise guidelines as regards their type and

dosage have not been established. Hence,


9

Retro-walking may offer additional benefits in

this population. The current study aimed at

finding out the efficacy of Retro-walking as an

adjunct to conventional treatments on pain and

disability in patients with chronic knee OA.

MATERIALS AND METHODS:

Written informed consent was obtained from all

participants prior to screening and participation

in the study. The study was conducted at the

Department of Physiotherapy in Terna Hospital

and Research Center, Navi-Mumbai, India.

Out-patients with diagnosis of knee OA

referred by a physician or an orthopedic

surgeon were screened for inclusion criteria.

Participant selection

Patients having knee pain for more than 6

weeks and fulfilling three out of the six clinical

criteria listed by The American College of

Rheumatology were included in the study.34-35

The inclusion criteria are:

• Age >50 years,

• Morning stiffness lasting <30 min,

• Crepitus with active motion,

• Bony tenderness,

• Bony enlargement, and

• No warmth to touch.

Exclusion criteria:

Patients with bilateral involvement, a history of

any lower extremity injury or underlying

pathology and a history of any inflammatory

joint disease and balance problems,

neurological problems and using an assistive

device for ambulation were excluded.

Testing instruments

For primary outcomes:

(1) A 10 cm visual analogue scale (VAS) for

rating the intensity of perceived pain. The scale

had 0 (no pain at all) and 10 (maximum pain

felt at this moment) at either ends. The patient

was asked to mark his/her pain where he felt it

would take its position in the scale.

(2) Western Ontario and McMaster Universities

Arthritis Index (WOMAC) of OA, a patient

reported scale, was used to assess pain,

stiffness and physical function levels in the

subjects. It measures five items for pain, two

for stiffness, and 17 for functional limitation.

Physical functioning questions cover activities

of daily living. Good test-retest reliability in

pain and physical function domain has been

established for WOMAC.36

For secondary outcomes:

Medical Research Council grading was used to

assess concentric strength of hip abductors and

hip extensors and quadriceps muscles.

(2) Universal Goniometer was used to assess

knee joint ROM in prone position.

Methods

Twelve patients (6 men, 6 women) with chronic

knee osteoarthritis fulfilling the inclusion

criteria received conventional treatment and

Retro-walking.

Conventional treatment was in the form of deep

heating modality (Short Wave Diathermy)

(Electro Medical Control, Electrotherm 250 W)


10

for 20 minutes and exercises (static and

dynamic quadriceps, knee bending exercise in

prone lying, hip flexion exercise in supine, hip

abduction in side lying and hip extension in

prone lying position). All exercises were done

in sets of 10 repetitions; twice a day for 3

weeks.

Subjects also underwent two sessions of Retro-

walking per day (10 mins. per session) for 3

weeks on a flat surface at their maximum pace.

Data collection:

Pain and disability were the primary outcomes

and knee range of motion (ROM), hip abductor

and extensor, and quadriceps strength were the

secondary outcomes; measured pre-

intervention, after 1 week and after 3 weeks of

intervention

Statistical-analysis:

The outcomes were analyzed using one way

analysis of variance with level of significance

set at P < 0.05; using SPSS version 17.0 for

Windows.

RESULTS

Fifteen patients fulfilling the inclusion criteria

were screened and included in study after

obtaining their consent.

Three patients were lost to follow-up. The

study population thus had 12 adults (6 men, 6

women) of mean age 64.23 ± 3.01 years [Table

1].

Scores were analyzed pre intervention, at the

end of 1 week and at the end of 3 weeks [Table

2]. VAS and WOMAC showed highly

significant difference over a period of time

[Table 3].

Knee joint ROM, Strength of hip abductor

muscles and hip extensor muscles, and

quadriceps muscles showed significant

improvement [Table 3].

Table 1: Demographic characteristics of participants

Characteristics

N 12

Age 64.23 ± 3.01

Female % 50 %

N: Number of subjects

Table 2: Baseline parameters


11

PARAMETER PRE POST 1 WEEK POST 3 WEEKS

VAS 7.79 + 1.09 6.04 + 1.03 3.75 + 1.32

WOMAC 64.72 + 15.48 52.08 + 11.34 37.16 + 14.14

Knee ROM 72.11 + 11.09 88.78 + 14.99 90.32 + 13.22

Quadriceps Strength 3.55 + 0.32 4.2 + 0.88 4.43 + 0.11

Hip Extensors

Strength

3.22 + 0.78 3.59 + 0.32 4.11 + 0.2

Hip Abductor

Strength

3.8 + 0.43 4.17 + 0.71 4.63 + 0.19

VAS: Visual Analogue Scale, WOMAC: Western Ontario and McMaster Universities Arthritis Index ,

ROM: Range of Motion

Table 3: One way analysis of variance

Parameter F value df P value Significance

VAS 37.022 2 <0.0001 HS

WOMAC 12.059 2 <0.0001 HS

Knee ROM 7.027 2 0.001 Sig

Quadriceps Strength 8.436 2 0.001 Sig

Hip Extensors

Strength

9.585 2 0.001 Sig

Hip Abductor

Strength

8.584 2 0.001 Sig

F value: Observed F value; df: Degrees of freedom; P value: Significance level, HS: Highly significant;

Sig: Significant

12

DISCUSSION

Current pilot study examines the efficacy of

Retro-walking as an adjunct to conventional

treatment in reducing pain and disability in

patients with chronic knee OA.

Pain relief could be attributed to reduced

compressive forces on medial compartment of

knee joint by reduction of excess adductor

moment due to Retro-walking. Along with

thermal effects causing local hypoalgesia29 and

muscle relaxation, improvement in strength of

musculature around knee and hip providing

steadiness in the knee and giving additional

joint protection from shock and stress as a

result of conventional treatment.

Improvement in function may be attributed to

the pain relief, improved ROM, improved

muscle activation pattern and reduction in

abnormal joint kinetics and kinematics during

functional movement. Several studies have

stated that compared to forward walking;

backward walking creates more muscle activity

in proportion to efforts.37-43

It has also shown to reduce external adductor

moment at knee during stance phase of gait.

Due to a specific kinematics Retro-walking

leads to augmented stretch of hamstring muscle

groups during the stride. Other advantage of

Retro-walking includes improvement in muscle

activation pattern; all of these serve in reducing

disability thus leading to improved function.

Since it is a weight bearing exercise, it could

have led to proprioceptive and balance training,

adding to its benefits. Retro-walking also has

effect on preventing abnormal loading at knee

joint by improving strength of hip extensors

leading to reduced hip flexion moment during

stance phase and thus and, in turn, the

disability. As a result of exercises and Retro-

walking there was improvement in the strength

of muscles at knee and hip which may have

helped in improving functional ability.

There were certain limitations in the current

study. Effects of BMI, severity of knee

deformities (for eg. genu valgum/varum), lower

limb mal-alignments (for eg. flat foot),

footwear used, activities of daily living and

recreational activities of patients were not taken

into account. The compliance of patients with

the home exercise program was not monitored.

CONCLUSION

Retrowalking is an effective adjunct to

conventional treatment in decreasing pain and

disability in patients with chronic knee

osteoarthritis.

ACKNOWLEDGMENT

The author would like to acknowledge Dr.

Senthil P Kumar and Dr. Sujata S. Wagle for

their valuable guidance in preparation of this

manuscript.


13

REFERENCES

1. Kugler LM. Amstrong CW. Moleski B. Comparative Analysis Of The Kinematics And Kinetics Of Forward And

Backward Human Locomotion. ISBS 1988:451-464.

2. Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the

Management of Osteoarthritis.Phys Ther. 2005;85:907–71.

3. Silva LE, Valim V, Pessanha APC, Oliveira LM, Myamoto S, Jones A et al. Hydrotherapy versus con-ventional

land-based exercise for the management of patients with osteoarthritis of the knee: a ran-domized clinical

trial.Phys Ther. 2008;88:12–21.

4. Rutjes AWS, Nüesch E, Sterchi R, Jüni P. Therapeutic ultrasound for osteoarthritis of the knee or hip. THE

COCHRANE REVIEW.

5. Rutjes AWS, Nüesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M etal. Transcutaneous electrostimulation for

osteoarthritis of the knee (Review) cochrane

6. NOR AMN. LYN KS. Effects of Passive Joint Mobilization on Patients with Knee Osteoarthritis. Sains Malaysiana

2011;40:1461-1465.

7. McKnight PE, Kasle S,Going S, Villaneuva I, Cornett M, Farr J, Wright J etal. A comparison of strength-training,

self-management and the combination for early osteoarthritis of the knee. Arthritis Care Res (Hoboken). 2010

January 15; 62(1): 45–53.

8. Mahajan A. Verma S. Tandon V. Osteoarthritis. JAPI 2005;53:634-641.

9. French HP, Brennan A, White B, Cusack T. Manual therapy for osteoarthritis of the hip or kneeeA systematic

review. Man Ther 16 (2011) 109-17.

10. Bar-Ziv Y, Beer Y, Ran Y, Benedict S, Halperin N. A treatment applying a biomechanical device to the feet of

patients with knee osteoarthritis results in reduced pain and improved function: a prospective controlled study.

BMC Musculoskeletal Disorders2010,11:179.

11. ALTMAN R, ASCH E, BLOCH D, BOLE G, BORENSTEIN D, BRANDT K etal. Development Of Criteria For The

Classification And Reporting Of Osteoarthritis-Classification of Osteoarthritis of the Knee. Arthritis and

Rheumatism, Vol. 29, No. 8 (August 1986) p 1039-49.

12. Fary RE, Carroll GJ, Briffa TG, Gupta R, Briffa NK. The effectiveness of pulsed electrical stimulation (E-PES) in

the management of osteoarthritis of the knee: a protocol for a randomised controlled trial. Study protocol. BMC

Musculoskeletal Disorders2008, 9:18.

13. Currier LL, Froehlich PJ, Carow SD, McAndrew RK, Cliborne AV, Boyles et al. Development of a clinical

prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a

favorable short-term response to hip mobilization. Phys Ther. 2007;87: 1106–1119.

14. Mundermann A. Dyrby CO. Andriacchi TP. Secondary Gait Changes in Patients with Medial Compartment Knee

Osteoarthritis Increased Load at the Ankle, Knee, and Hip During Walking. Arthritis & Rheumatism

2005;52:2835-2844.

15. JAN MH, TANG PF, LIN JJ, TSENG SC, LIN YF, LIN DH. Efficacy of a Target-Matching Foot-Stepping Exercise

on Proprioception and Function in Patients With Knee Osteoarthritis. J Orthop Sports Phys Ther 2008;38(1):19-

25.

16. Hinman RS, Bowles KA, Bennell KL. Laterally wedged insoles in knee osteoarthritis: do biomechanical effects

decline after one month of wear? BMC Musculoskeletal Disorders2009, 10:146.

17. Zhao D, Banks SA, Mitchell KH, D'Lima DD, Colwell CW Jr, Fregly BJ: Correlation between the knee adduction

torque and medical contact force for a variety of gait patterns. J Orthop Res 2007, 25:789-797.


14

18. Shelburne KB, Torry MR, Steadman JR, Pandy MG: Effects of foot orthoses and valgus bracing on the knee

adduction moment and medial joint load during gait. Clin Biomech 2008, 23:814-821.

19. Schipplein OD, Andriacchi TP: Interaction between active and passive knee stabilizers during level walking. J

Orthop Res 1991, 9:113-119.

20. Hurwitz DE, Sumner DR, Andriacchi TP, Sugar DA: Dynamic knee loads during gait predict proximal tibial bone

distribution. J Biomech 1998, 31:423-430.

21. Teoh et al.: Investigation of the biomechanical effect of variable stiffness shoe on external knee adduction moment

in various dynamic exercises. Journal of Foot and Ankle Research 2013 6:39.

22. Setton LA, Mow VC, Muller FJ, Pita JC, Howell DS:Altered structure-function relationships for articular

cartilage in human osteoarthritis and an experimental canine model.Agents Actions1993,39:27–48.

23. Teohet al. Journal of Foot and Ankle Research2013,6:39 Page 7 of 9 http://www.jfootankleres.com/content/6/1/39

24. Radin EL, Burr DB, Caterson B, Fyhrie D, Brown TD, Boyd RD:Mechanical determinants of osteoarthrosis.Semin

Arthritis Rheum1991,21:12–21.

25. Frost HM, Jee WSS:Perspectives: Applications of a biomechanical model of the endochondral ossification

mechanism.Anat Rec1994,240:447–455.

26. Hovis KK, Stehling C, Souza RB, Haughom BD, Baum T, Nevitt M, McCulloch C, Lynch JA, Link TM:Physical

activity is associated with magnetic resonance imaging-based knee cartilage T2 measurements in asymptomatic

subjects with and those without osteoarthritis risk factors. Arthritis Rheum2011,63:2248–2256.

27. Imeokparia RL, Barrett JP, Arrieta MI, Leaverton PE, Wilson AA, Hall BJ, Marlowe SM:Physical activity as a

risk factor for osteoarthritis of the knee.Ann Epidemiol1994,4:221–230.

28. Yoshimura N, Kinoshita H, Hori N, Nishioka T, Ryujin M, Mantani Y, Miyake M, Takeshita TT, Ichinose M,

Yoshiida M,et al: Risk factors for knee osteoarthritis in Japanese men: A case–control study.Mod Rheumatol

2006,16:24–29.

29. Sharma L, Hurwitz DE, Thonar EJMA, Sum JA, Lenz ME, Dunlop DD, Schnitzer TJ, Kirwan-Mellis G, Andriacchi

TP:Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral

osteoarthritis.Arthritis Rheum1998,41:1233–1240

30. Pollard H, Ward G, Hoskins W, Hardy K. The effect of a manual therapy knee protocol on osteoarthritic knee

pain: a randomised controlled trial. J Can Chiropr Assoc 2008; 52(4). 229-42.

31. Jamtvedt G, Dahm KT, Christie A, Moe RH, Haavardsholm E, Holm I et al. Physical therapy interventions for

patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther. 2008;88:123–136.

32. McCarthy CJ, Callaghan MJ, Oldham JA. Pulsed electromagnetic energy treatment offers no clinical benefit in

reducing the pain of knee osteoarthritis: a systematic review. BMC Musculoskeletal Disorders2006, 7:51.

33. Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-

blind randomized controlled trial. Phys Ther. 2007; 87:32– 43.

34. Ageberg E, LinkA, Roos EM. Feasibility of neuromuscular training in patients with severe hip or knee OA: The

individualized goal-based NEMEX-TJR training program. BMC Musculoskeletal Disorders2010, 11:126.

35. Chen LY. Su FC. Chiang PY. Kinematic and EMG analysis of backward walking on treadmill. Engineering in

Medicine and Biology Society 2000;2:825-827.

36. Tsauo JY, Cheng PF, Yang RS. The effects of sensorimotor training on knee proprioception and function for

patients with knee osteoarthritis: a preliminary report. Clin Rehabil 2008; 22; 448-57.

37. Cipriani DJ. Armstrong CW. Gaul S. Backward Walking at Three Levels of Treadmill Inclination: An

Electromyographic and Kinematic Analysis. JOSPT 1995;22:95-102.


15

38. Kumar TRN. Ashraf M. The Effect Of Backward Walking Treadmill Training On Kinematics Of The Trunk And

Lower Limbs. Serbian Journal of Sports Sciences 2009;3:121-127.

39. Brotzman BS. Manske RC. Clinical Orthopedic Rehabilitataion: An Evidenced Based Approach. 3rd ed. Elsevier

MOSBY; USA 2011:380-381.

40. Jan MH, Lin JJ, Liau JJ, Lin YF, Lin DH. Investigation of clinical effects of high- and low-resistance training for

patients with knee osteo-arthritis: a randomized con-trolled trial. Phys Ther. 2008; 88:427– 436.

41. McConnell S. Kolopack P. Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index

(WOMAC): a review of its utility and measurement properties. Arthritis & Rheumatism 2001;45:453–461.

42. Brosseau L, Yonge KA, Welch V, Marchand S, Judd M, Wells GA etal. Thermotherapy for treatment of

osteoarthritis (Review). Chocrane review. 2010, issue 7

43. Yang YR. Yen JG. Wang RY. Yen LL. Lieu FK. Gait outcomes after additional backward walking training in

patients with stroke: a randomized controlled trial. Clinical Rehabilitation 2005;19:264-73.

CORRESPONDENCE

*Physiotherapist at Breach Candy Hospital Trust, Mumbai, email: [email protected]

**Professor and Principal, TPCT’s Terna Physiotherpy College, Navi Mumbai. Email: [email protected]


16

AN ANALYSIS OF MEMORY RETRIEVAL AND PERFORMANCES OF

PHYSIOTHERAPY EXERCISES IN NON-SPECIFIC LOW BACK PA IN

PATIENTS

Disha Jacob*, Varoon C Jaiswal**

ABSTRACT

Objective-the goal of the current study was to analyze the memory retrieval and performance of exercises that

are prescribed in mechanical low back pain by using RATSALL scale (ten point exercise assessment scale).

Design-cross sectional study. Setting-JC Bamfordexcavators Ltd, talegaon, Pune. Method-60 subjects with the

problems of mechanical low back pain were selected and were divided into 3 groups, each group containing 20

subjects. Groups are: Group A-verbal instructions and self performance. Group B-written instructions and self

performance. GroupC-Human model demonstration and self performance. Exercises were prescribed to the

subjects as per above mentioned techniques and they were told to recall these exercises on 2nd and 5th day for

short term memory and long term memory respectively. Outcome was measured by RATSALL scale and points

were allotted. Result-Subjects in group A scored an average of 7.24 and 5.74(on 2nd and 5th day respectively)

out of 10 according to the rastsall scale. Subjects in group B scored an average on 5.32 and 3.74. Whereas,

Subjects in Group C scored an average of 9.45 and 39.17. Hence "demonstration by Human model and self

performance" has better memory retrieval of short term and long term memory in patients compared to other

two groups i.e. "Verbal Instructions and Self Performance & Pictorial Diagram / Written Material and Self

Performance". Conclusion-The study concluded that the best way of giving a home exercise program is by

demonstration on a Human model and then self performance, as in this way subject remembers most of the

exercises and hence will be effective.


17

Keywords- retrieval, short term memory, long term memory, RATSALL scale.

INTRODUCTION

Therapeutic exercise intervention is considered

the core of physiotherapy practices. Physical

therapy and home exercise are two parts of a

whole. To support a therapy program, patients

are provided with instructions over the

exercises that they should continue to perform

at home known as home exercises. Home

exercise program (HEP) is unique to each

patient that facilitates the desired movements,

reduces pain and/or centralizes the symptoms,

performed exclusively by the patient. HEP is an

integral part of achieving success in physical

therapy. Physiotherapist prescribing HEP

should be aware that unsupervised exercise can

hinder the patient’s goal. So prescribing

exercises for home program is very

challenging. Exercise performance can be

enhanced by multiple ways. Typically, physical

therapy incorporates some re-training and

strengthening of specific muscles to perform

according to individual functions. In order to

activate the muscle and begin responding

appropriately, frequent and consistent practice

is necessary, and hence it is important for the

patients to perform some set of exercises even

at home. For maximum benefit, it is important

for the patients to take a active role in home

exercise program1.

Non-specific low back pain is tension, soreness

and/or stiffness in the lower back region for

which it is not possible to identify a specific

cause of the pain. Several structures in the

back, including the joints, discs and connective

tissues, may contribute to symptoms.The lower

back is commonly defined as the area between

the bottom of the rib cage and the buttock

creases. Some people with non-specific low

back pain may also feel pain in their upper legs,

but the low back pain usually predominates1.

Those patients who are good about

performing their home exercise program are the

same patients who feel better, stronger, and

more functional. Those patients who don’t

perform their home exercise program are often

not able to progress through therapy at the

expected rate2.

Background

When we look into the literature some of the

factors were elaborately used to prescribe a

home exercise program. Those factors are:

verbal cues3, written cues or pictorial

diagrams3, demonstration on a Human model4.

Pictorial diagrams are commonly used in the

clinics to teach exercises. The pictures usually

demonstrate the exercise in the start and finish

position. Arrow showing the direction of

movement with marks clearly indicating the

start and the end positions can be helpful. Often

pictures show positions midway through the

exercise and patient is unclear about the full

excursion of the movement1.

Practical demonstration is another one of

the most commonly used clinics to teach

exercises. In practical demonstration, there will


18

be a Human modeling of an action either by

videotape or by the teacher performing the

action, it will help the learner to develop and

helps to understand the conceptual

representation of the action. By observation the

leaner can know the amplitude of movement,

appreciate the timing and fluency of the action

and relationship between the body parts2.

Lastly, Verbal instructions are most

commonly used for conveying information or

prescribing the exercises. Verbal instructions

mainly focus on kinematics description for

example angular displacement, oaths of the

body parts, which require an understanding by

the therapist of linked segment dynamics and

biomechanical necessities ofthe action to be

learned5.

Friedrich et al, (1996) concluded from the

study that exercises that are based only on

written instructions often are not performed

properly and therefore lead to poorer outcomes

compared with exercises learned under the

supervision of a physical therapist and hence

prescribing home exercises by written material

isn’t the best method of giving a home exercise

program, yet it is found that many hospitals

prescribe home exercises in this way.

Very few studies have compared the methods

of prescribing home exercise program and their

memory retrieval in non-specific low back

pain, since home program plays a vital role in

achieving physiotherapy success, it is an utmost

important for a physiotherapy for proper

prescription of home exercises program.

METHODOLOGY

Patient Selection

Inclusion Criteria

1. Younger adults of age group from 20 to 35.

2. Subjects with mechanical low back pain

3. With no memory deficits (subjects were

screened with mini-mental scale, those who

scored zero only those patients were selected).

Exclusion Criteria

1. Neurological deficits.

2. Visual impairments.

3. Hearing impairments.

4. Cognitive problems.

Material Used

1. Human model – To demonstrate the

exercises. The Human model was initially

trained to perform the given set of exercises for

each of the three conditions. When he was well

versed with all the exercises, he was asked to

demonstrate same for the subjects.

2. Plinth, Exercise instruction sheets.

3. Rastall scale.

Sample selection

Purposive sampling was done in this study.

Sample consists of 60 subjects in the age group

of 20-35 years. Subjects included in the study

were assessed for any impairment and/or

disabilities as per inclusion/exclusion criteria.

The total number of subjects in the study

design was 60. These 60 subjects were divided

into 3 groups with 20 subjects in each group.

Informed consent was obtained from the

subjects.


19

Data collection

A qualified physiotherapist [1] was engaged in

diagnosing and prescribing the exercise to low

back pain subjects. Another physiotherapist [2]

was trained to rate them on Rastall scale on 2nd

& 5th day of exercise prescription.

Physiotherapist [2] was blinded to the

allocation. She jus calculated the mean and

standard deviation and the results were

obtained.

Outcome measure

Ten point exercise assessment scale6. This scale

was developed by Maggie Rastall el at 2000.

This scale measure primarily four components

of an exercise. They are

1) Correct starting position of the exercise.

2) Exercise body components moving in

correct plane

3) No compensation or cheat movements.

4) Movements performed within correct range.

Every exercise performance had a maximum

scoring of 10 points.

Correct starting position for

exercise

2

Exercising body component

moving in the correct plane

3

No compensations or cheat

movements

3

Movement performed within 2

the correct range

On exercise performance a score of 8 points or

more, was seemed to be correctly done they

were considered as number of exercises

correctly performed by the subject.

Procedure

Subjects with mechanical low back pain were

selected. A set of five exercises were given to

each subject. These set of exercises were

explained in all three medium of instructions.

These exercises were performed in three

different ways, they are-

1) Verbal Instructions and Self Performance.

2) Pictorial Diagram, Written Material and Self

Performance.

3) Demonstration by Human model and Self

Performance.

Methods for verbal instructions and self

performance-

In this group, exercises were explained to the

patient verbally and were asked to remember

them and do it. Patients were asked whether he

or she understood all the exercises properly.

The subjects were told to recall the same

exercises on 2nd and 5th day for both short term

and long term memory respectively.

Methods for written material/pictorial

diagram and self performance-

In this group, exercises were told to the patients

by the therapist in the form of pictorial

diagrams/written material. Subjects were asked

whether he or she understood it properly or not.

They were told to recall exercises on

Contains of Maggie Rastall exercise scoring table with points allotted.


20

subsequent 2nd and 5th day for short term and

long term memory respectively.

Methods for demonstration by Human

model and self performance-

In this group, exercises were demonstrated to

the patient by the help Human model who

demonstrated the exercise to the subject, as told

by the therapist. Patients were told to remember

and do it and recall them on 2nd and 5th day for

both short term and long term memory

respectively.

Statistical Analysis- we have used descriptive

statistics to analyze the results. Mean and

standard deviation- measures of descriptive

statistics were used to analyze the result.

RESULTS

The study shows that subjects in group

C(Human model and self performance) scored

the maximum on 2nd and 5th day. Whereas,

subjects given oral instructions and self

performance scored less as compared to

subjects in group C.

Figure 1

Figure 2

DISCUSSION

The aim of the study was to analyze the

memory retrieval of HEP in mechanical low

back pain patients and which is the best method

of prescribing a home program. The result of

the study was, subjects in group C had an

average of 9.45(SD=±1) and 9.17(SD=±), on

2nd and 5th day respectively) out of 10

according to the Rastall scale, which suggest

that subjects in this group were able to

remember most of the exercise components as

well the exercises.When given an exercise

program by performance on a Human model

and then self performance, subject remembers

most of the exercises and has better memory

retrieval of exercise performance.However,

patients in group A i.e. verbal instructions

performed well as compared to group C , they

had an average of 7.24(SD=±1.7) and

5.74(SD=±.5) on 2nd and 5th day respectively as

they couldn't remember exercises components

and even some of the exercises.

When exercises were prescribed by

performance on a Human model and then self

performance, subjects got a visual feedback.

Eye is the main organ of processing memory,

and hence the better memory retrieval7. It has


21

been found that vision also has an effect of

performance of a task8.

Also the subjects were more attentive when the

exercises were performed on the Human model.

It has been found that attention play a major

role in memory retrieval9.

Subjects in group B scored the least with an

average of 5.32(SD=±1.8) and 3.74(SD=±1.3)

on both 2nd and 5th day as they were not able to

recollect much of the exercises as compared to

subjects in the group A and C.

In most of the hospitals patients are given

handouts, and hence our study reveals that it

isn't the best method of giving a home exercise

program. Whereas, giving exercises by

performance on a Human model or oral

instructions are found to be more productive.

CONCLUSION

The study concluded that the best method of

giving a home exercise program is by Human

model and then self performance as in this way

patient remembers most of the exercises and

hence will be effective.

REFERENCES

1. Early management of persistent non-specific low back pain.NICE clinical guideline 88. Issued: May 2009.

2. Henchoz Y, de Goumoëns P, Norberg M, Paillex Role of physical exercise in low back pain rehabilitation: a

randomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary

rehabilitation. May 20, 2010;35(12)

3. Friedrich et al, 1996, The Effect of Brochure Use Verses Therapist Teaching on Patients Performing Therapeutic

Exercises and on Changes in impairment Status, Physical Therapy, 76(10): 1082-1088, Oct 1996.

4. Carr and Shepard 1998, NEUROLOGICAL REHABILITATION: optimizing Motor Performance, Ch-2, 34-35.

5. Park K, 1997, Effect of Age event Based and time Based Prospective Memory, Psychological Aging, 12(2): 314 -

327, June 1997.

6. An Investigation into Younger and Older Adults' Memory for Physiotherapy Exercises-Maggie Rastall MCSP, Ten

point exercise assessment scale (Rastall, et al., 1999)

7. Berryhill, M.(2008, May 09). Visual memory and brain.

8. Bhatt, E., Catteneo, Z., Merabet, L.B., Pece,A.(2008).The influence of reduced visual acuity on age-related decline

in spatial working memory. Neuropsychology and cognition.

9. Exploring the role of attention during memory retrieval: effects of semantic encoding and divided attention. Mem

cognit.2006 jul;34(5):986-89.

10. Indian Journal of Physiotherapy and Occupational Therapy - An International Journal Year : 2012, Volume : 6,

Issue : 3

11. Alexander, N. B., Fry-Welch, D. K., Marshall, L. M., Chung, C. C., & Kowalski.

12. Guidelines for Exercise Testing and Prescription, DN. (1991)..Journal of Gerontology A Biological Science and

Medicine and Science, 46(3), M91-M98.

13. Kristin D Henry et al (1999), Effect of Number ofHome Exercises on Compliance and Performancein Adults Over

65 Years of Age, Physical Therapy,Vol 79 No. 3, March 1999.

14. Peggy MC Guire (2000), A Performance Frame Work for Teaching and Learning with Equipped for Future

Content Standards. Adventures In Assessment, Vol 12, 2000.


22

15. Zimmer (2000), Pop Out Into Memory: A Retrieval Mechanism that is Enhanced with the Recall of Subject

Performed Tasks, Learning, Memory and Cognition, Vol 26(3), 658-670

CORRESPONDING AUTHOR:

*Intern, Maeers Physiotherapy College, Talegaon Dabhade Pune, Maharashtra, INDIA. Email:

[email protected]

**Asst. Professor, Maeers Physiotherapy College, Talegaon Dabhade Pune, Maharashtra, INDIA


23

TO ANALYSE THE SHORT TERM EFFECT OF UPPER TRAPEZIUS

INHIBITION TAPING IN PATIENTS WITH MECHANICAL NECK PAIN

Meenakshi Verma*, Nidhi Gautam**, Deepak Raghav***, Tanvi Aggarwal****

ABSTRACT

Background and Purpose: Improving pain & functional performance in patients with mechanical

neck pain is the priority. The purpose of the study was to visualize the effect of upper trapezius

Inhibition taping on pain score and functional outcome in mechanical neck pain. Method: Thirty

patients who were assessed and diagnosed by mechanical neck Pain were selected. Patients were

given hot pack, stretching strengthening exercises of neck and taping assessed of VAS & NDI score

on 0 sitting,5th sitting & 10th sitting during intervention . Results : The outcome measures (NDI and

VAS) over the periods were compared by one factor repeated measures analysis of variance (ANOVA)

using general linear models (GLM) and significance between groups (periods) was done by Turkey

HSD (honestly significance difference) post hoc test after ascertaining the normality by Shapiro-Wilk

test and the homogeneity of variance by Levene’s test. Conclusion: the result of the study suggests that

upper trapezius inhibition taping shows significant improvement in visual analogue scale and neck

disability index in patients with mechanical neck pain in 2 weeks.

Keywords. Mechanical neck pain,upper trapezius inhibition taping,neck disability index,Visual

Analogue Scale Upper trapezius stretching, scalene(anterior) stretching,sternocleidomastoid

stretching,neck isometrics.

24

INTRODUCTION

Mechanical neck pain defines cervical spine

pain as pain perceived anywhere in the

posterior region of the cervical spine, from the

superior nuchal line to the first thoracic spinous

process1 Mechanical neck pain commonly

arises insidiously and is generally multifactorial

in origin, including one or more of the

following: poor posture, anxiety, depression,

neck strain, and sporting or occupational

activities.2,3

Neck pain affects 30–50% of the general

population annually 15% of the general

population will experience mechanical neck

pain (>3 months) at some point in their

lives.11–14% of the working population will

annually experience activity limitations due to

neck pain. Prevalence peaks at middle age, and

women are more often affected than men. Risk

factors include repetitive work, prolonged

periods of the cervical spine in flexion, high

psychological job strain, smoking, and previous

neck/shoulder injury.4 Despite the prevalence,

less-than optimal prognosis, associated risk of

disability, and economic consequences of

individuals suffering from mechanical neck

pain, there remains a significant gap in the

literature, which fails to provide sufficient,

high-quality evidence to effectively guide the

conservative treatment of this patient

population5

A biomechanical mechanism that may explain

this association involves impairment in

alignment of cervical spine and scapula are

commonly cited as possible source of pain and

dysfunction6 and Range of motion

limitations7.The scapula and cervical spine are

anatomically linked through the upper trapezius

muscle,changes of the alignment of either the

scapula or cervical spine can potentially

influence the biomechanics of the other by

altering the tension at the upper trapezius

muscle8 it has been suggested that an ideal

vertical scapular alignment is when the scapula

is located between the spinous process of

second and seventh thoracic vertebrae9.It has

been proposed that the depressed scapular

alignment affect neck function potentially

through increasing compressive loading in the

neck region . Mechanical pain occurs due to

changes in muscle length when assuming a

poor posture for a prolonged period and

performing repetitive movements10. Faulty

cervical spinal alignment, such as Forward

Head Posture(FHP), is usually associated with

shortening of the neck extensor muscles i.e.

trapezius, levator scapulae, serratus

anterior,rhomboids etc, and lengthning and

weakness of the anterior neck muscles i.e.

scalene,sternocleidomastoid,longus capitis

longus colli and , as well as the shoulder

muscles, affecting scapular position and

kinematics11.Weakness of anterior cervical

muscles is postulated to contribute to persistent

neck pain in patients with mechanical neck

pain, quantitation of weakness has never been

reported12. The trapezius muscle is divided into

3 areas upper fibers,middle fibers & lower

fibers. The significance of this division lies in

the variety of functions performed by this


25

muscle. The trapezius muscle has several

functions to move the shoulder blade in toward

the spine, to rotate the shoulder blade so that

the topmost part of the upper arm faces up,to

move the shoulder blade up and down,to bring

the head and neck in a backward direction, to

rotate and side bend the neck,to assist in

breathing etc. The trapezius muscle works to

move the neck in several directions, its degree

of tightness or looseness affects neck

flexibility. For people who work at desks and

computers, or who spend many hours driving,

the upper trapezius is the muscle on top of your

shoulder that becomes very sore and

painful36,37,38

Postural deviations observed in FHP involve a

downwardly rotated, anteriorly tilted, and

protracted scapula leading to imbalanced

movement of neck.13 Physiotherapists often

give advice about changing lifestyles with an

emphasis on posture, in addition to teaching

specific exercises. Exercises and certain

electrotherapeutic modalities are commonly

used to improve pain & neck muscle function

& thereby decrease pain or other symptoms.

Massage, manual therapy, neck strengthening

& stretching exercises have also improved pain

& neck functions14 Elastic therapeutic taping

offers a unique combination of flexibility and

support, providing practitioners with a tool to

address a variety of conditions. Since 1973,

when Kenzo Kase, DC, began developing the

concepts in his practice, and then introduced its

use in the 1980s, the range of applications has

expanded tremendously15.

To the extent there is no evidence shows the

study about analysis of short term effect of

upper trapezius inhibition taping technique in

patients with mechanical neck pain.

METHODOLOGY

Subjects: 30 patients were taken in the study

with mechanical neck pain with duration of

symptoms for 2 week. The exclusion criteria

included that patient Cervical pathologies

Cervical spine Fracture, Migraine,

Cervicogenic Headache, Trigger points in neck

or scapular muscles, allergy to taping product.

Subjects were selected and received

conventional treatment of neck with upper

trapezius inhibition taping. Protocol : All

patients underwent a descriptive orthopaedic

assessment. A baseline measurement of all the

variables visual analogue scale , neck disability

index was taken.

Visual analogue scale

The VAS is presented as a 10 cm horizontal

line, anchored by verbal descriptors labeled

with “no pain” at point zero (0 cm) and “worst

imaginable pain” at point ten (10 cm). The

patient marks the line at the point

corresponding to the intensity of the pain

currently experienced. Using a 1 cm-per-point

scale to measure the patient’s score, the VAS

provides ten levels of pain intensity. The visual

analog scale (VAS) is a valid and reliable

measure of chronic pain Intensity.19

Neck Disability Index


26

The NDI is the most widely used, translated

and oldest questionnaire for neck pain. It has

been shown to have high “test-retest”

reliability. It consists of 10 questions.

Questions include activities of daily living,

such as: personal care, lifting, reading, work,

driving, sleeping, recreational activities, pain

intensity, concentration and headache. Each

item scored from 0-5 and total score is

expressed as a percentage with high scores

corresponding to greater disabilities.20,28,29

Upper trapezius Inhibition Taping

Elastic therapeutic taping offers a unique

combination of flexibility and support,

providing practitioners with a tool to address a

variety of conditions. Since 1973, when Kenzo

Kase, DC, began developing the concepts in his

practice, and then introduced its use in the

1980s, the range of applications has expanded

tremendously.

DATA ANALYSIS

The data were summarized as Mean ± SD. The

outcome measures (NDI and VAS) over the

periods (sitting 0, sitting 5th and 10th ) were

compared by one factor repeated measures

analysis of variance (ANOVA) using general

linear models (GLM) and significance between

groups (periods) was done by Tukey HSD

(honestly significance difference) post hoc test

after ascertaining the normality by Shapiro-

Wilk test and the homogeneity of variance by

Levene’s test. All analyses were performed on

STATISTICA (window version 6.0).

RESULTS

Table shows the mean age and standard

deviation of patients.

Characteristics Statistics

Age (yrs) 25.30 ± 2.84

Comparisons NDI

0 sitting vs. 5th sitting P<0.001


5th sitting vs. 10th 0.149

Comparisons VAS


0 sitting vs. 10th

sitting

P<0.001

5th sitting vs. 10th

sitting

0.149

NDI (score)

0.002.004.006.008.00

10.0012.0014.0016.00

day 1 day 5 day 10

Treatment periods

Mea

n ±

SD


27

VAS (score)

0.001.002.003.004.005.006.007.008.00

day 1 day 5 day 10

Treatment periods

Mea

n ±

SD

DISCUSSION

The aim of the study was to analyze the short

term effects of upper trapezius inhibition taping

in patients with mechanical neck pain. The

results of the study suggest significant

differences in NDI & VAS score favouring the

upper trapezius inhibition taping. Upper

trapezius inhibition taping may be a viable

option for treating mechanical neck pain.

It has been observed and described how Pain

in the neck region may occur because of a

downward pull on the cervical vertebrae or

facets by the upper trapezius muscle as well as

by the weight of the upper extremity along with

mal-alignment or movement of scapula has the

potential to alter the biomechanics of the

cervical spine and produce neck pain..

Increased upper trapezius stiffness may

contribute increased compressive load and

shear force on the cervical spine during active

neck movement. Repetitive and excessive stress

on the upper trapezius muscle has the potential

to cause cumulative micro trauma in the

cervical region, neck pain, and limited neck

rotation range of motion. Upper trapezius

inhibition taping technique significantly

increased the maximum active neck rotation

range of motion ,neck pain and daily functions.

Taping the skin overlying the trapezius muscle,

as performed in this study, traction on the skin

Or the pressure of the tape provides cutaneous

sensory cues, thus providing additional

proprioceptive input to the central nervous

system. inhibits its reflexes therefore results in

reduction of swelling, Accelerate blood flow

,Contribute to optimizing movement patterns34,

therefore reduce mechanical stress on the

cervical spine, and does Promotion of optimal

inter joint coordination, modification of

scapular alignment is currently performed in

the clinical field and in studies. Effect of

Taping on posture is Inhibition of overactive

movement synergists and antagonists;

Facilitation of underactive movement

synergists; Direct optimization of joint

alignment during static postures or movement;

Offloading irritable neural tissue; Direct or

indirect reduction of pain associated with

movement.31,40,17. These findings are supported

by study done by Host HH et al a case reports

scapular taping can be used as an adjunctive

therapy to attempt to attain a more favorable

scapular alignment and alleviate pain31 The

tape should never restrict a patient’s ROM

,Additionally it should allow the patient to

perform motions that would have been painful

without the tape in place thus providing an

immediate assessment of the tapes

effectiveness. upper trapezius inhibition taping

should be used in conjunction with other

intervention especially selected exercise and


28

patient education about modification of

performing neck movements. Taping along the

length of a muscle inhibits that muscle’s reflex

excitability41.

It is also supported by the study done by peter

miller et al they suggested there may be a

potential role for taping as an adjunct to usual

physiotherapy treatment in management of

people with mechanical neck pain.35

CONCLUSION

The present study evaluates the short term

effect of upper trapezius inhibition taping and

hypothesized that it may be effective in

treatment of mechanical pain, was found to be

true. The neck related disability (NDI) and pain

(VAS) improved significantly by 85.4% and

74.5%, respectively in patients of mechanical

neck pain. The present study thus concluded

that there is a short term effect of upper

trapezius inhibition taping in mechanical neck

pain. The study states that null hypothesis is

rejected.

REFERENCES

1. Merskey H., Bogduk N., editors. Classification of chronic pain. Descriptions of chronic pain syndromes and

definitions of pain terms. 2nd ed. IASP Press; Seattle: 1994. p. 11.

2. Sarig-Bahat H. Evidence for exercise therapy in mechanical neck disorders. Man Ther. 2003;8:10–20

3. Binder AI. Cervical spondylosis and neck pain. BMJ. 2007;334:527–531.

4. Cote P, van der Velde G, Cassidy JD, Carroll LJ, Hogg-Johnson S, Holm LW, Carragee EJ, Haldeman S, Nordin

M, Hurwitz EL, Guzman J, Peloso PM. The burden and determinants of neck pain in workers: results of the Bone

and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33(4

Suppl):S60–74.

5. Hoving JL, de Vet HC, Koes BW, et al. Manual therapy, physical therapy, or continued care by the general

practitioner for patients with neck pain: Long-term results from a pragmatic randomized clinical trial. Clin J

Pain. 2006;22:370–377.

6. Braun BL. Postural differences between asymptomatic men and women and craniofacial pain patients. Arch Phys

Med Rehabil. 1991;72:653-656

7. Swift TR, Nichols FT. The droopy shoulder syndrome. Neurology. 1984;34:212-215.

8. Szeto GP, Straker LM, O’Sullivan PB. A comparison of symptomatic and asymptomatic office workers performing

monotonous keyboard work--2: neck and shoulder kinematics. Man Ther. 2005;10:281- 291.

http://dx.doi.org/10.1016/j.math.2005.01.005

9. Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of changingposture on shoulder

range of movement. J Orthop Sports Phys Ther. 2005;35:72-87. http:// dx.doi.org/10.2519/jospt.2005.1578

10. Johnson G, Bogduk N, Nowitzke A, House D. Anatomy and actions of the trapezius muscle. Clin Biomech (Bristol,

Avon). 1994;9:44-50.

11. Hoppenfeld S. Physical Examination of the Spine and Extremities. East Norwalk, CT: Appleton Century Crofts;

1976.

12. Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function with Posture

and Pain. 5th ed. Baltimore, MD: Williams & Wilkins; 2005. Magee DJ. Orthopedic Physical Assessment. 3rd ed.


29

Philadelphia, PA: W.B. Saunders; 1997.

13. Bergqvist, U., Wolgast, E., Nilsson, B., Voss, M., 1995. Musculoskeletal disorders among visual display terminal

workers: individual, ergonomic, and work organizational factors. Ergonomics 38, 763e776.

14. Kebaetse, M., McClure, P., Pratt, N.A., 1999. Thoracic position effect on shoulder range of motion, strength, and

threedimensional scapular kinematics. Archives of Physical Medicine and Rehabilitation 80, 945-950.

15. Quantitative cervical flexor strength in healthy subjects and in subjects with mechanical neck

pain.(PMID:1859264)79-681]

16. Lewis, J.S., Green, A., Wright, C., 2005. Subacromial impingement syndrome: the role of posture and muscle

imbalance. Journal of Shoulder and Elbow Surgery.

17. Kase, K. W. (2003). Clinical Therapeutic Appliocations of the Kinesio Taping Method

18. Williams S, Whatman C, Hume PA, Sheerin K (2012). "Kinesio taping in treatment and prevention of sports

injuries: a meta-analysis of the evidence for its effectiveness". Sports Med42 (2): 153–64.

19. Brown L 1999 The effect of taping the glenohumeral joint on scapulohumeral resting position and trapezius

activity during abduction. Unpublished MSc Thesis, UCL London

20. Bassett K, Lingman S, Ellis R (2010). "The use and treatment efficacy of kinaesthetic taping for musculoskeletal

conditions: A systematic review". New Zealand Journal of Physiotherapy

21. Gkotsi et al: Pain point system scale (PPSS): a method for postoperative pain estimation in retrospective studies.

Journal of Pain Research 2012:5 503–510

22. Polly E. Bijur, Wendy Silver, E. John Gallagher: Reliability of the Visual Analog Scale for Measurement of Acute

Pain. ACADEMIC EMERGENCY MEDICINE • December 2001, Volume 8, Number 12 1153-1157

23. Vernon H, Mior S. The neck disability index: a study of reliability and validity. JMPT. 1991;14:409–415.

24. Guzman J., Hurwitz E.L., Carroll L.J., Haldeman S., Cote P., Carragee E.J. A new conceptual model of neck pain.

Linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its

Associated Disorders. Spine. 2008;33(4S):S14–S2322. Ylinen J. Physical exercises and functional rehabilitation

for the management of chronic neck pain.Eura Medicophys. 2007;43:119–132]

25. Ylinen J., Takala E.P., Nykanen M., Hakkinen A., Malkia E., Pohjolainen T. Active neck muscle training in the

treatment of chronic neck pain in women: a randomized controlled trial. JAMA.2003;289(19):2509–2516

26. Dziedzic K., Hill J., Lewis M., Sim J., Daniels J., Hay E.M. Effectiveness of manual therapy or pulsed shortwave

diathermy in addition to advice and exercise for neck disorders: a pragmatic randomized controlled trial in

physical therapy clinics. Arthritis Rheum. 2005;53(2):214–25Hoving J.L., Koes B.W., DeVet H. Manual therapy,

physical therapy, or continued care by a general practitioner for patients with neck pain. Ann Intern Med.

2002;136:713–

27. O'Leary S., Falla D., Hodges P. Specific therapeutic exercise of the neck induces immediate local hypoalgesia. J

Pain. 2007;8(11):832–839.

28. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of

Rheumatology 1990 criteria for classification of fibromyalgia: report of the multicenter criteria committee.

Arthritis Rheum 1990;33:160e70.

29. Emily R. Howell: The association between neck pain, the neck disability index and cervical ranges of motion: a

narrative review; J Can Chiropr Assoc.2011 September; 55(3): 211-221.

30. S. Peter Magnusson, Erik B. Simonsen & Per Aagaard : Measurement properties of disease-specific

questionnaires in patients with neck pain: a systematic review ; Qual Life Res (2012) 21:659–670.

31. Miller P, Osmotherly P: Does scapula taping facilitate recovery for shoulder impingement symptoms? A pilot


30

randomized controlled trial J Man Manip Ther 2009

32. Host HH: Scapular taping in the treatment of anterior shoulder impingement. Phys Ther 1995, 75(9):803-812.

33. Shamus JL, Shamus EC: A taping technique for the treatment of acromioclavicular joint sprains: a case study. J

Orthop Sports Phys Ther 1997, 25(6):390-394.

34. Lentell G, Hetherington T, Eagan J, Morgan M. The use of thermal agents to influence the effectiveness of a low-

load prolonged stretch. J Orthop Sports Phys Ther.1992 ;16:200–207.

35. Ernst GP, Kawaguchi J, Saliba E 1999 Effect of patellar taping on knee kinetics of patients with patellofemoral

pain syndrome. Journal of Orthopaedic and Sports Physical Therapy 29(11): 661±667

36. Gerrard DF 1998 External knee supports in rugby union. Effectiveness of bracing and taping. Sports Medicine

25(5):313±317

37. Gilleard W, McConnell J, Parsons D 1998 The effect of patellar taping on the onset of vastus medialis obliquus

and vastus lateralis muscle activity in persons with patellofemoral pain. Physical Therapy 78(1): 25±32

38. Henricson A, Fredriksson K, Persson I, et al. The effect of heat and stretching on the range of hip motion. J

Orthop Sports Phys Ther.1984;6:110–115.

39. Kisner C, Colby L.A. Therapetic exercise foundations and Techniques 5th ed. Philadelphia,PA:F.A. Davis

company ;2007

40. Smith M, Sparkes V, Busse M, Enright S: Upper and lower trapezius muscle activity in subjects with subacromial

impingement symptoms: is there imbalance and can taping change it?Phys Ther Sport 2009, 10:45-

41. Alexander CM, Stynes S, Thomas A, Lewis J, Harrison PJ: Does tape facilitate or inhibit the lower fibres of

trapezius? Man Ther 2003, 8(1):37-41.

42. Kendall, Florence, McCreary, Elizabeth Kendall, Provance, Patricia Geise. Muscles Testing and Function 4th ed.

Williams and Wilkins. Baltimore, Maryland, 1993

43. Amit V Nagrale, Paul Glynn: The efficacy of an integrated neuromuscular inhibition technique on upper trapezius

trigger points in subjects with non-specific neck pain: a randomized controlled trial ; J Man Manip Ther. 2010

March

44. Morrisey D. Proprioceptive shoulder taping. Journal of Bodywork and Movement Therapies 2000;4:189–94.

45. Alexander CM, Stynes S, Thomas A, Lewis J, Harrison PJ. Does tape facilitate or inhibit the lower fibres of

trapezius? Manual therapy 2003;8:37–41


*Assistant Professor, Santosh College of Physiotherapy, Ghaziabad

**Student MPT Musculoskeletal, Santosh College of Physiotherapy, Ghaziabad

***Principal, Associate Professor, Santosh College of Physiotherapy, Ghaziabad

****Assistant Professor, Santosh College of Physiotherapy, Ghaziabad

31

ITO TEST: DOES HEIGHT OF THE PAD AFFECT BACK MUSCLE

ENDURANCE?

Juanita E. Soans*, Keerthi Rao**, Chandra Iyer***, Dnyanda Newasekar****

ABSTRACT

Background: Decreased back muscle endurance is sometimes associated with high rates of low back

pain. Ito test is a safe and reliable test for assessing trunk extensor muscle endurance, however it limits

recognition due to lack of studies and absence of standardized testing procedure. Hence this study

aims to find out whether the height of the pad that is to be used while performing the test has any effect

on back muscle endurance in normal healthy individuals. Methodology: 84 healthy college volunteers

were recruited in the study. A pilot study was conducted to find out the optimal height of pad that can

be used for conducting Ito test. Back extensor endurance was evaluated using a foam pad of height 5,

6.5 and 8 centimeters. Results: There was no significant difference in trunk extensor endurance with

different height of the foam pad. Conclusion: Any height of the pad ranging from 5 to 8 centimeters

can be used for assessing back muscle endurance, however the self reported comfortable height of the

pad was 5 centimeters for most of the healthy participants.

Keywords: Ito test, back endurance, low back pain

INTRODUCTION

Muscular endurance is the ability of an isolated

muscle group to perform repeated contractions

over a period of time (dynamic endurance) or

sustain a contraction over time at a certain level

(static endurance)1,2. Decreased static

endurance in back extensors is sometimes


32

associated with high rates of low back pain,

decreased proprioceptive awareness, poor

balance, decreased productivity at work place,

increased muscular fatigability and overload on

soft tissues and passive structures of the spine.3

Therefore, measurement of trunk muscle

endurance is potentially important for

identifying the risk factors, as prognostic

indicators, for planning treatment goals and

measuring patient’s progress.4 Hansen JW

developed the first test for evaluating isometric

back extensor endurance.5 Troup and Chapman

evaluated muscle fatigability by surface

electromyography in patients during this test.6

After a study of Bieiring- Sorensen in 1984,

which was published in the Spine journal, this

test came to be known as Sorensen test

structures of the spine7.

Although there are no gold standards for

measurement of trunk endurance, Sorensen test

is the most popular method of assessing trunk

extensor endurance. However there are some

disadvantages pertaining to the use of this test

in patients with chronic low back pain.8 It

increases the lumbar lordosis because of

extended hip and knee during the test which

can produce bulging of intervertebral disc and

buckling of ligamentum flavum followed by

reducing the intervertebral foramen. The

hyperextension of lumbar spine may aggravate

pain.9 Also a study by Callaghan et al,

estimated that the compression load imposed on

spine during Sorensen test was 4000N, slightly

above the value recommended by the National

Institute of Occupational Safety and Health in

1981.10 To overcome these disadvantages Ito et

al developed a new method based on Sorensen

test and studied its reliability, safety in

application of this method and established its

validity by evaluating the endurance using this

test in 190 healthy individuals and in

individuals with chronic low back pain. The

reliability of this test in healthy individuals is,

ICC= 0.97 for trunk extensor muscles.8 Also,

maximal neck flexion and gluteal muscle

contraction included in the test procedure are

supposed to be the most optimal position for

decreasing lumbar lordosis and for activating

the lumbar erector spinae muscle to the

maximum.11 Muller et al in his study showed

that Ito test has a good criterion validity and it

can assess back extensor muscle endurance

more specifically as compared to Sorensen

test.12

Although, Ito test had a very high test-retest

reliability and did not seem to induce pain or

increase spinal loads the factors that limit the

recognition of Ito test includes lack of studies,

absence of standardized test procedures like the

type of pad used and extent of raising the upper

body and theoretical risk of exaggerating the

lumbar lordosis.8,10 Hence our study aims at

determining the most appropriate height of pad

to assess back muscle endurance during Ito test

in normal healthy individuals.

METHODOLOGY

Eighty-four healthy college volunteers (53

females and 31 males) between 18 – 25 years

of age who volunteered for the study from


33

College Of Physiotherapy, Pravara Institute of

Medical Sciences, Loni were recruited. The

study was conducted from March 2013 till June

2013. The participants were selected by

convenience sampling and were screened based

on the exclusion criteria by physiotherapist who

later were involved with data collection.

Exclusion criteria were a history of

symptomatic low back pain within one year to

the time of the study, any obvious spinal

deformity, individuals participating in high-

intensity regular exercise or elite sports at

competitive level or individuals involved in any

prior systematic exercise program of lumbar or

hip extensor muscles, a history of

cardiovascular disease representing

contraindications to exercise or any disability

limiting the ability to exercise. The participants

were informed about the study and a written

consent was obtained before any measurements

were taken. Anthropometric data like height,

weight, BMI and abdominal girth of the

participants were calculated. Height was

measured using a stadiometer to the nearest 0.1

cm. Body weight was taken with light clothes

and measured to nearest 0.1 kg using a

weighing scale caliberated from 0-120 kgs with

the participant in standing position and shoes

off. BMI was calculated using the above data.

Abdominal girth was calculated using a

measuring tape at the level of the umbilicus to

the nearest 0.1 cm.

Before taking the readings the participants were

demonstrated the procedure of the test and were

also asked to perform it themselves. They were

encouraged to clarify their queries, if any and

all queries were addressed for complete

familiarization of the test. For evaluating the

back extensor endurance the participants were

asked to lie in prone position with a foam pad

(figure 1) under the lower abdomen.

Figure 1: Foam pad used for the test

This foam is medium rubber, high density and

has a medium to soft feel depending on the

body weight of the sleeper. It offers a high

degree of comfort and will retain its shape and

density. Participants were made to perform the

test in the following manner. The foam pad was

first placed below the lower abdomen of the

participants and they were asked to lift the

sternum off the plinth and hold the position as

long as they could upto a maximum of 300

seconds8. While performing the test participants

were asked to maintain maximum flexion at

cervical spine with pelvic stabilization through

contraction of glutei, the most optimal position

for reducing lumbar lordosis and activating the

lumbar erector spinae (Figure 2).


34

Figure 2: Participant performing ITO test

The pattern of selection of height of the foam

pad with which the participants were to start the

test was done by block randomization method

which was computer generated. The time for

which the participants could hold the test

position with the height of the foam pad was

measured in seconds using a stop watch. After

a rest period of 10 minutes, the test was

repeated with the same height of the pad and

similarly 2 readings were taken. An average of

the two readings was calculated and

documented for that height of the foam pad to

obtain highest accuracy and decrease any

manual error. The criteria for stopping the tests

were trick movements, altered pain sensation

and pain tolerance. The participants were called

the next day and the same procedure was

repeated with the other height of the foam pad

on the consecutive day. The main purpose of

taking two readings was to decrease fatigability

and for obtaining the best value for each height

of the pad. Before starting with the data

collection a pilot study was conducted with ten

participants to find out the optimal height of the

pad that can be used as reference for this study.

For any height below 5 cms in height, the

participants reported an absence of fulcrum

through which they could maintain the upper

body in the desired position, and for any height

above 8 cms the participants felt excessive

pressure on their abdomen and pain in the low

back which averaged 5.3 on VAS. Any height

greater than 8 cms was also flattening the

lumbar lordosis more than that required while

performing the Ito test. The criteria for stopping

the test were trick movements, altered pain

sensations, and pain tolerance.

Based on the results obtained, the participants

performed the test with a foam pad of 5, 6.5

and 8 centimeters in height. All the tests were

performed two hours after the last meal taken

by the participants. After each test the

participants were asked to rate their level of

discomfort on VAS so as to find out the height

of foam pad which was most comfortable.

STATISTICAL ANALYSIS:

The statistical analysis was done using Graph

Pad Instat Trial Version 13.3. ANOVA with

repeated measures was used for data analysis

and p<0.05 was considered to be statistically

significant.

RESULTS:

The baseline data for participants are as follows

and represented in table 1.

Participants Males

(n= 31

Females

(n=53)

Age

(years) 21.20 ± 2.31 21.9 ± 1.97


35

BMI

(kg/m2) 20.26 ± 3.49 20.19 ± 2.84

Abdominal

girth

(cms)

87.12 ± 10.31

76.18 ±

12.83

Table 1: Baseline demographic data of

participants

BMI of all participants were 20.26 ± 3.49

kg/m2 and 20.26 ± 3.49 79 ± 10.3 kg/m2 for

male and female participants respectively and

did not show co-relation to discomfort

experienced by them while performing the test

with different heights of the foam pad. The

abdominal girth for both male and female

participants were 87.12 ± 10.31 and 76.18 ±

12.83 centimeters respectively. The mean

holding time of all participants with pad height

of 5, 6.5 and 8 centimeters were 69.54 ± 36.79,

70.20 ± 44.96 and 68.78 ± 33.79 seconds

respectively.(figure 3)

Figure 3: Mean Holding Time

Statistical analysis was done using ANOVA

with repeated measures with p < 0.05. This

shows that results obtained were not

statistically significant leading us to conclude

that height of foam pad does not actually alter

the endurance. It was found that 72% of

participants self reported that a height of 5

centimeters of pad was most comfortable while

performing the test as compared to 6.5 and 8

cms.

DISCUSSION:

The results of the present study show that there

was n significant alteration in back muscle

endurance with different height of foam pads.

Also, most participants reported that 5

centimeter height of foam pad was most

comfortable. In our opinion the height of the

foam pad did not vary much with respect to

each other in order to change the kinematics or

coupled movements of the muscles. Time, as a

measure of endurance of low back musculature,

varies with intensity of loading and with

posture. The Ito test, as compared to Sorensen

test is safe, reliable and easy to perform and

doesn’t require any other equipment apart from

a foam pad. In the present study, a pilot study

was initially conducted to find out the optimum

height of the pad that can be used. The height

of the pad was kept between 5cms and 8cms

beyond which the participants reported

discomfort while performing the test. On

interrogation participants reported that

increased height of the foam pad placed below

the lower abdomen created excessive

compression which made it difficult for them

to breathe and reduced their performance. In

our opinion this is because a trunk extension

from 45 degrees of trunk flexion needs


36

dynamic pelvic and trunk movement. The leg

muscle will extend the pelvis, and the lumbar

muscles will stabilize and extend the lumbar

region on the pelvis whereas thoracic muscles

will lift the trunk.13 Therefore more the height

of the pillow the glutei muscles have to contract

more in order to stabilize the pelvis and the

thoracic muscles will work in order to clear the

sternum off the plinth during extension. Also

lesser the height of the pillow the compression

on the lower abdomen is less thus reducing the

discomfort in breathing. In another study

conducted by Muller et al, an EMG study to

find out the criterion validity of Ito test, a foam

roll of 0.2 m in diameter, the density of which

was not stated in the study was used to evaluate

the trunk extensor endurance.12 However, in

our study participants felt abdominal

discomfort and pain with any height above 8

centimeters. Another interesting observation

was that participants with greater abdominal

girth reported more comfort with a greater

height of the pad as compared to other

participants however the co-relation of this was

beyond the scope of this study.

The participants in the study were healthy

young adults hence the results cannot be

generalized to population with low back pain.

Evaluating back endurance muscle in patients

with low back pain using different height of

pad would have been difficult for the patients

because of repeated test procedures resulting in

aggravation of pain, hence this study was

conducted on normal individuals to find out the

optimal length of pad that can be used while

performing the test which would be

comfortable to the patients. Future scope of the

study may include finding the co-relation

between the height of the pad and abdominal

girth. Lastly as proposed in the original study

lumbar lordosis during the test should be

evaluated either by radiography or by using a

flexicurve.

CONCLUSION:

It can be concluded that any height of the foam

pad made of medium rubber and high density

having soft feel ranging from 5 to 8 centimeters

can be used for assessing back muscle

endurance however the self reported

comfortable height of the pad was 5

centimeters for most of the healthy participants.

ACKNOWLEDGEMENT:

We would like to thank the participants in the

study for their kind co-operation.

REFRENCES

1. Karen H, Glenn TM. Principles of aerobic exercise. IN: Kisner C, Colby LA, Therapeutic Exercise: Foundations

and Techniques, 5th edition, Jaypee Brothers, New Delhi, 2007.

2. Mayer T, Gatchel R, Betancur J, Bovasso E. Trunk muscle endurance measurement: isometric contrasted to

isotonic testing in normal subjects. Spine, 1995:20:920-926.

3. Chidozie M, Olusola A, Rufus A.Reference values of static back extensor muscle endurance in healthy Nigerian

adults, Med Princ Pract, 2009:18: 345-350.


37

4. Julie M, Elspeth F, Paul S, Brad Br, Caroline G.Interrater Reliability of Six Tests of Trunk Muscle Function and

Endurance, JOSPT , 1997:26 (4): 203-208.

5. Hansen JW. Postoperative management in lumbar disc protrusions. I. Indications, method and results II. Follow-

up on a trained and an untrained group of patients, Acta Orthop Scand, 1964:17(Suppl 71):1-47

6. Troup JD, Chapman AE. Changes in the waveform of the electromyogram during fatiguing activity in the muscles

of the spine and hips: the analysis of postural stress. Electromyogr Clin Neurophysiol, 1972:12:347-365

7. Beiring S. Physical measurements as risk indicators for low back trouble over a one year period, Spine, 1984:9:

106-119.

8. T Ito, Osamu Shirado, Hideki Suzuki, Masaaki Tokahashi, Kiyoshi Kaneda. Lumbar trunk muscle endurance

testing: An inexpensive alternative to machine for evaluation, Arch Phys Med Rehab, 1996:77:75-9

9. White AA, Punjabi MM. Clinical biomechanics of spine, Philadelphia, Lippincott co.1990:379-474

10. Christophe D, Marc V, Christophe D, Jean MC. Spinal muscle evaluation using the Sorenson test: a critical

appraisal of literature. Joint Bone Spine, 2006:73:43-50.

11. Shirado O, Ito T, Kaneda K, Strax TE.Electromyographic analysis of four techniques for isometric trunk muscle

exercises. Arch Phys Med Rehab,1995: 76:225–9.

12. Muller R, Strassle K, Wirth B. Isometric back extensor muscle endurance: An EMG study on the criterion validity

of the Ito test. J Electromyograph and Kinesiology, 2010:20:845-850

13. Eline MD, De Ridder, Jessica OV, Andry V, Guy V, Lieven D. Posterior muscle chain activity during various

extension exercises: an observational study, BMC Musculoskelet disord, 2013:14:204.


*Final year M.P.Th (Orthopaedics) student, College of Physiotherapy, Pravara Institute of Medical

Sciences(DU), Loni, Maharashtra, India. Email Id: [email protected]

**M.P.T, Associate Professor, College of Physiotherapy, Pravara Institute of Medical Sciences(DU),

Loni, Maharashtra, India.

***M.P.T, Assistant Professor, College of Physiotherapy, Pravara Institute of Medical Sciences(DU),

Loni, Maharashtra, India.

****B.P.Th, College of Physiotherapy, Pravara Institute of Medical Sciences(DU), Loni, Maharashtra,

India.


38

TO COMPARE THE EFFECTIVENESS BETWEEN PRE EXERCISE T APING

AND POST EXERCISE TAPING IN IMPROVING PAIN AND FUN CTIONAL

OUTCOME IN KNEE OSTEOARTHRITIS

Parul R*, Vishal G**, Deepak R***, Monika S****

ABSTRACT

Aim: To compare the effectiveness between pre exercise taping and post exercise taping in improving

pain and functional outcome in knee osteoarthritis. Background: A large body of research has been

conducted to analyze the effect patellar taping in patients with knee osteoarthritis. But non e of the

studies have compared whether pre exercise taping or post exercise taping is beneficial in the

treatment of knee osteoarthritis. Thus in this study it is intended to check the efficacy of pre exercise

taping or post exercise taping to improve the pain and functional outcome of the patient. Methods: A

total of 30 subjects were selected with age group 40-60yrs. diagnosed osteoarthritis of knee. They

were randomly divided into three groups. Each groups having 10 subjects, Group A received

conventional treatment. Group B received conventional treatment and pre-exercise taping and group C

received conventional treatment and post- exercise taping. Result: The comparisons concluded that

for improving WOMAC in knee OA patients, both Group B and Group C are more effective than Group

A. The comparisons concluded that all three treatments are effective for improving pain in knee OA

patients. The significance level was set at p≤0.05. Conclusion: The Study concludes by stating that

null hypothesis is rejected as results of the study suggest that post exercise taping is more effective than

pre exercise taping and conventional treatment in reducing pain and improving functional outcome in



39

Key words: Taping, WOMAC scale, Osteoarthritis, knee etc.

INTRODUCTION

Knee osteoarthritis is a major public health

concern worldwide and one of the foremost

causes of chronic disability in older adults.1

Osteoarthritis (OA) is a chronic degenerative

disorder of multifactorial etiology characterized

by loss of articular cartilage, hypertrophy of

bone at the margins, subchondral sclerosis and

range of biochemical and morphological

alterations of the synovial membrane and joint

capsule. Pathological changes in the late stage

of OA include softening, ulceration and focal

disintegration of the articular cartilage;

synovial inflammation also may occur.2

Osteoarthritis is usually regarded as a non-

inflammatory disease.3

Knee osteoarthritis was the most common type

(6% of all adults). The likelihood of developing

osteoarthritis increases with age. Studies have

shown that knee osteoarthritis in men aged 60

to 64 is more commonly found in the right knee

(23%) than in the left knee (16.3%), while its

distribution seems to be more evenly balanced

in women (right knee, 24.2%; left knee,

24.7%). The prevalence of osteoarthritis of the

knee is higher among 70- 74 year-olds, rising

as high as 40%.4 Osteoarthritis (OA) affects

more than 21 million people in the U.S., with

36% of elderly Americans aged 70 or older

having some degree of radiographic knee OA.

The prevalence of OA continues to grow as the

population ages.5Arthritis affects around 3

million people in Australia, representing about

15% of the population.6 There are a number of

possible causes for this increase in disease

prevalence with age. Metabolic changes in

cartilage that occur with aging do not parallel

the biochemical changes of osteoarthritis, but

they may make cartilage more susceptible to

fatigue fracture. Joints become increasingly

incongruent with age, and this may leave

previously protected areas vulnerable to injury

(more likely in the hip than in the knee). Bone

underneath the articular cartilage may be made

increasingly stiff from microfractures, and this

loss of compliance in bone may make overlying

cartilage susceptible. Finally, neuromuscular

decline occurs in the elderly years, leaving

joints unprotected by the muscles and tendons

that otherwise serve as shock absorbers.7

The symptoms of OA, such as pain and

stiffness of the joints and muscle weakness, are

serious risk factors for mobility limitation and

impaired quality of life. Indirect evidence

suggests that muscle strength deficits may be

interrelated and that pain may have a

confounding influence on the measurement of

these factors in knee OA. However, these

relationships have never been clearly

evaluated.8 The quadriceps weakness

commonly associated with osteoarthritis of the

knee is widely believed to result from disuse

atrophy secondary to pain in the involved joint.

However, quadriceps weakness may be an


40

etiologic factor in the development of

osteoarthritis.9

There is no single treatment that is known to

cure OA. Most treatments have aimed at

reducing symptoms or slowing the progression

of the disease and its consequences.10

In knee osteoarthritis acupuncture, capsaicin,

chondroitin, education to aid self-management,

exercise and physiotherapy, glucosamine,

insoles, intra-articular corticosteroids, intra-

articular hyaluronan, joint bracing, knee

replacement, non-steroidal anti-inflammatory

drugs (including topical non-steroidal anti-

inflammatory drugs), opioid analgesics,

osteotomy, simple analgesics, and taping can be

effective.11

METHODS

Sample

Size: On the basis of inclusion & exclusion

criteria, 35 subjects were selected for the study

out of which only 30 completed the study.

Three patients were allergic to the tape and two

could not complete the duration of the study

Source : 70 osteoarthritis patients visiting the

MMJ physiotherapy clinic, Noida.

Inclusion Criteria 1, 20

• Subjects with age group 40-60 years,

diagnosed by orthopedic surgeon with

unilateral osteoarthritis of knee.

• WOMAC score more than 57.

Exclusion Criteria1, 20

• Subject having any deformity of hip and

back

• Any neurological problems

• Patients with back ache with radiating pain

to legs

• Any history of fractures, trauma to knee

joint or muscles

• Any metallic implants

• Wound on/around knee or thigh

• Peripheral vascular disease

• Any local or systemic infection

• Febrile and mentally deficit participants

• Pregnancy

• Auto immune disease (eg. Rheumatoid

arthritis, ankylosing spondylitis)

• Tumors of hip, knee or leg region

• Any spinal deformity

• Contraindication to exercise therapy

(unstable angina, blood pressure,

myocardial infarction in previous 3 months,

cardiomyopathy, uncontrolled metabolic

disease, recent ECG changes, advanced

COPD)

VARIABLES

Dependent Variable: VAS, WOMAC scale.

Independent Variables: Pre exercise taping,

Post exercise taping, Conventional treatment

Research Design: Experimental study design.

Sampling Method: Simple randomized

sampling method was used for the selection of

patients and divided into 3 groups.

Study duration: 3 weeks.

INSTRUMENTS AND TOOLS

• Quadriceps Table

• Sports tape

• Goniometer

• WOMAC scale


41

• Stepper

PROCEDURE:

Subjects who full filled the inclusion criteria

were randomly divided into three groups, 10

subjects in each group. The subjects were

requested to fill the consent form and the

voluntary participation form before taking part

in the research.

Group A received conventional treatment i.e.

Ultrasonic therapy (dosage 0.8 W/cm2), TENS

and Knee Exercises

Group B received conventional treatment i.e.

Ultrasonic therapy, TENS and Knee Exercises

and pre exercise taping ( Mcconnell’s Taping to

correct lateral patellar shift)

Group C received conventional treatment i.e.

Ultrasonic therapy, TENS and Knee Exercises

and post exercise taping

The subjects were asked to fill the WOMAC

scale and VAS scale before the start of the

treatment, on 5 sitting and on 10 sitting. After

giving the treatment the data was subjected to

statistical analysis.

RESULTS

The age of Group A, Group B and Group C

ranged from 49.50 ± 3.87 yrs, 52.70 ± 5.48 yrs

and 51.10 ± 6.10 yrs, respectively. Pre and post

WOMAC score between the groups (Table 1).

Table 1: Pre and post WOMAC scores (Mean ±

SD, n=10) of three groups

Comparing the mean WOMAC scores within

the groups ( Fig. 1), the WOMAC score in all

three group decreased (improved) significantly

(p<0.01 or p<0.001) at both day 9 and day 21

(post treatment) as compared to day 1 (pre

treatment). Further, the mean WOMAC scores

in both groups Group B and Group C also

decreased significantly (p<0.001) at day 21 as

compared to day 9; however, not decreased

significantly (p>0.05) in Group A. The

comparisons concluded that for improving

WOMAC in knee OA patients, both Group B

and Group C are more effective than Group A.

WOMAC (score)

0.00

20.00

40.00

60.00

80.00

100.00

day 0 day 9 day 21

Treatment periods

Mea

n ±

SD

Group A

Group B

Group C

Fig. 1: Comparative mean WOMAC scores

between the groups.

Similarly, comparing the mean WOMAC

scores between the groups ( Fig. 2), the

WOMAC score of three groups did not differed

(p>0.05) at day 0 i.e. found to be statistically

the same. In others words, WOMAC scores of

three groups were comparable. Further, the

mean WOMAC scores of three groups also not

differed (p>0.05) at both day 9 and day 0,


42

indicating that all the three treatments are

equally effective for improving WOMAC in

patients with knee OA.

WOMAC (score)

0.00

20.00

40.00

60.00

80.00

100.00

Group A Group B Group C

Treatment groups

Mea

n ±

SD

day 0

day 9

day 21

Fig. 2: Comparative mean WOMAC scores

within the groups.

VAS (score)

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Group A Group B Group C

Treatment groups

Mea

n ±

SD

day 0

day 9

day 21

Fig. 3: Comparative mean VAS scores within

the groups.

Table 5: Pre and post VAS scores (Mean ± SD,

n=10) of three groups

Comparing the mean VAS scores within the

groups (Table 6 and 7), the VAS score in all

three group decreased (improved) significantly

(p<0.001) at both day 9 and day 21 (post

treatment) as compared to day 1 (pre

treatment). Further, the mean VAS scores in all

three groups also decreased significantly

(p<0.001) at day 21 as compared to day 9. The

comparisons concluded that all three treatments

are effective for improving pain in knee OA

patients.

Table 6: For each group, comparison (p value)

of mean VAS scores within groups (i.e. between

periods) by Tukey HSD test

Table 7: For each period, comparison (p value)

of mean VAS scores between the groups by

Tukey HSD test

DISCUSSION

The aim of the study was to compare the effect

of pre exercise taping with post exercise taping

on pain and functional outcome in patients with

knee osteoarthritis. The results of the study

suggest that all the three protocols were equally

effective in improvement of WOMAC score

within the groups but none proved to be

effective within the group. The VAS score also

showed significant improvements on

comparison within the three groups but Group

C i.e., post exercise taping showed significant

improvements when the results were compared

between the groups.


43

This suggests a decline, or even loss, in tape

effectiveness, possibly due to decreased tape

tensile strength or reduced adhesiveness to the

skin.16 An increase in the stability of the body

or extremities, support or protection of the

joint, the correction of the alignment of the

body or limbs, the modification of the

biomechanics of movements and the promotion

of sensor-motor functions like the

proprioception influence and insignificance

sensory input inhibition might be reasons that

have contributed to the effects of elastic

taping17. The tape has been suggested to

stimulate neuromuscular pathways via afferent

feedback. Increased afferent stimulus to large-

diameter nerve fibers might reduce pain

perception level due to an input decrease from

the small diameter nerve fibers conducting

nociception. Many clinicians believe that

bracing and taping provide increased cutaneous

stimuli as well as external support to the joint

that they surround. The increased stimulation of

the cutaneous proprioceptors, provided through

direct or indirect contact between the skin and

the brace or tape, would enhance kinaesthetic

and joint position sense awareness and possibly

help prevent injuries.18 Patellar taping may

enhance the onset of VMO activity, which may

result in improved patellar tracking. They

suggested that this early activation of the VMO

may be caused by cutaneous stimulation

brought by the patellar tape, although the

precise mechanisms for this phenomenon are

unclear. First, some have suggested that the

mechanical advantage of the quadriceps is

maximized because of increased leverage by

the patella via a medial shift as it returns to the

trochlear groove of the femur. Some

hypothesize that the application of patellar

taping may reduce neural inhibition of the

quadriceps and modulate pain via large afferent

fiber input. This may be attributed to the fact

that large afferent fibre input travels more

rapidly to the brain than pain signals, as

described in the gate control theory and

Castel’s level I pain theory. Herrington

proposed that patellar taping may lead to

altered large fibre afferent input to the dorsal

horn, decreasing the perceived pain that may be

contributing to quadriceps inhibition. With a

reduction in pain, Herrington27 suggested that

there is potential for restoration of quadriceps

function through increased alpha motor neuron

excitation. Many authors reported a significant

reduction in pain via tape application; however,

evidence is scarce to claim that the reduction in

pain is caused by increased alpha motor neuron

excitability.19 The application of a simple

patellar taping technique covering 50% of skin

over the knee had effects on areas of the brain

associated with sensation, coordination,

decision making, and planning of complex

coordination tasks and the coordination of the

unconscious aspects of proprioception. There

was decreased activity in the anterior cingulate

and the cerebellum, which are the regions of

interest concerned with proprioception, the

decision making and planning of complex,

coordinated tasks, and the coordination of the

unconscious aspects of proprioception. This


44

finding indicates a relative decrease in activity

with the tape on, which could be interpreted as

participants perceiving the task to be easier to

perform with the tape and, as a result, the

activity of the cerebellum and anterior cingulate

was less because these areas did not have to

work as hard.

Because of quadriceps weakness in persons

with knee OA, strengthening exercises have

been demonstrated to benefit static and

dynamic muscle strength and also functional

performance during gait and stair climbing. In

general, strengthening exercises improve the

ability to control the forces at the joint during

dynamic movements, thus potentially reducing

the effects of loading and ensuing pain. The

ability to improve the speed of contraction is

also an important consideration to enhance

functional capabilities.16 Resistance training

program can potentially counteract the

functional limitations seen in knee OA; positive

associations were found between increased

muscle strength and walking self-efficacy,

reduced pain, improved function, and total

WOMAC score. Deyle et al demonstrated that

manual therapy techniques and exercises

applied by physical therapists for 8 clinical

visits produced a 52% improvement in self-

reports of function, stiffness, and pain as

measured by the Western Ontario and

McMaster Universities Osteoarthritis Index.13

Future research

• Future studies can be done by extending the

duration of the study.

• Instrumental errors cannot be ruled out.

• More functional variables could be assessed

to measure the effects of taping in patients

with knee osteoarthritis.

• Electromyographic studies can be

conducted further to explain the effect of

taping

Relevance to Clinical Practice

Taping is one of the most commonly used

methods in physiotherapy treatment. The study

helps us to identify that application of tape after

the performance of exercise can help to

improve the pain and functional outcome in


CONCLUSION

The Study concludes by stating that null

hypothesis is rejected as results of the study

suggest that post exercise taping is more

effective than pre exercise taping and

conventional treatment in reducing pain and

improving functional outcome in patients with

knee osteoarthritis.

ACKNOWLEDGEMENT

The author acknowledges support of staff of

Santosh medical college and Hospital.

CONFLICT OF INTEREST

There is no conflict of interest.


45

REFERENCES

1. Neil A Segal, James Torner, David Felson, Jingbo Niu, Leena Sharma, Cora E. Lewis, MSPH, and Michael Nevitt,

The Effect of Thigh Strength on Incident Radiographic and Symptomatic Knee Osteoarthritis in the Multicenter

Osteoarthritis (MOST) Study. Arthritis Rheum. 2009 September 15; 61(9): 1210–1217. doi:10.1002/art.24541.

2. A Mahajan, S Verma, V Tandon. Osteoarthritis JAPI, VOL. 53 , JULY 2005.

3. Paul Dieppe, Inflammation In Osteoarthritis. January 30, 2011.

4. Joern W.-P. Michael, Klaus U. Schlüter-Brust, Peer Eysel, The Epidemiology, Etiology, Diagnosis, and Treatment

of Osteoarthritis of the Knee. Dtsch Arztebl Int, 107(9): 152–62, 2010.

5. Parastu S. Emrani, Jeffrey N. Katz, Courtenay L. Kessler, William M. Reichmann, Elizabeth A. Wright, Timothy E.

McAlindon, and Elena Losina. Joint Space Narrowing and Kellgren-Lawrence Progression in Knee Osteoarthritis.

PMC, 16(8): 873–882, 2009.

6. Lynette M March and Hanish Bagga. Epidemiology of osteoarthritis in Australia. MJA 180: S6–S10, 2004.

7. David T. Felson. Epidemiology Of Hip And Knee Osteoarthritis1. Johns Hopkins University School of Hygiene

and Public Health. Vol. 10, 1988.

8. N. Shakoor, S. Furmanov, D.E. Nelson, Y. Li, J.A. Block. Pain and its relationship with muscle strength and

proprioception in knee OA: Results of an 8-week home exercise pilot study. J Musculoskelet Neuronal Interact

8(1):35-42, 2008.

9. Charles Slemenda, DrPH; Kenneth D. Brandt. Quadriceps Weakness and Osteoarthritis of the Knee Ann Intern

Med. 127:97-104, 1997.

10. Mohammad A. Alkhazim Alghamdi, Sandra Olney, Patrick Costigan. Exercise Treatment for Osteoarthritis

Disability. Ann Saudi Med 24(5) September-October 2004.

11. David Scott and Anna Kowalczyk. Osteoarthritis of the knee. BMJ Publishing Group Clinical Evidence,09, 1121,

2007.

12. K L Bennell, R S Hinman, B R Metcalf, R Buchbinder, J McConnell, G McColl, S Green, K M Crossley Efficacy of

physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann

Rheum,64, 906–912, 2005.

13. José M Quintana, Inmaculada Arostegui. Validation of a screening questionnaire for hip and knee osteoarthritis in

old people. BMC Musculoskeletal Disorders, 8:84, 2007

14. Leslie Ann Nobbs. The effect of electrical stimulation and isokinetic exercise on muscular power of quadriceps

muscle. UNIVERSITY OF BRITIS COLUMBIA, 1979.

15. Electrical Stimulation. American Medical Association, 2004.

16. H. D. Hartsell. Electrical Muscle Stimulation and Isometric Exercise Effects on Selected Quadriceps Parameters.

JOSPT, Vol. 8, No. 4 October 1986.

17. Marcin Krajczy, Katarzyna Bogacz, Jacek Luniewski, and Jan Szczegielniak. The Influence of Kinesio Taping on

the Effects of Physiotherapy in Patients after Laparoscopic Cholecystectomy. The ScientificWorld Journal Volume

2012, Article ID 948282.

18. Todd A. McLoda, PhD, ATC; Jennifer A. Carmack. Optimal Burst Duration During a Facilitated Quadriceps

Femoris Contraction. Journal of Athletic Training, Vol. 35, No 2, June 2000.

19. Shari M. Ling1, Robin A. Conwit. Electromyographic Patterns Suggest Changes in Motor Unit Physiology

Associated with Early Osteoarthritis of the Knee Osteoarthritis Cartilage. October, 15(10): 1134–1140, 2007.


46

20. Erik witvrouw, Lieven Danneels, Damien Van Tiggelen. Open Versus Close kinetic chain exercises in

patellofemoral pain syndrome. The American Journal of sports Medicine, Vol.32, NO.5, 2004.


*MPT (Cardio-Pulmonary), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad,

Uttar Pradesh. Address: Address: D-2, First floor , Adjacent chetak complex, pocket B & E market,

Dilshad garden, Delhi- 95. Email ID: [email protected]

**MPT (Musculoskeletal).Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh

***MPT (Musculoskeletal), Principal, Santosh Medical College and Hospital, Ghaziabad, Uttar

Pradesh.

****MPT (Neurology), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar

Pradesh


47

ATTITUDE AND AWARENESS TOWARDS PHYSICAL ACTIVITY IN

PRAVARA RURAL HOSPITAL AND COLLEGE

Shalu Bhardwaj*, Nisha Shinde**

ABSTRACT

Objective: To find out the attitude and awareness towards physical activity among clinical and non-

clinical staff of Pravara Rural Hospital and College.Design and Setting: It was a Questionnaire based

survey conducted in Pravara Rural Hospital and College, Pravara Deemed University, Loni,

Ahmednagar,Maharashtra. Methodology:170 participants from Pravara Rural Hospital and College,

aged between 23-60 yearswith graduation degree or diploma as their minimum level of education were

randomly selected. Questionnaires in printed format were handed over to all the participants and

werecollected by the principal investigator after four weeks.Results:31% participants does exercise 1

to 2 times a week, there were more participants engage in physical activity outside sports like walking,

cycling, etc., 29% participants like to involve in physical activity on the way to their home, 80% of

participants engage in physical activity to improve their health and 54% for weight reduction. Most the

participants gave lack of time as the main factor which prevents them from doing physical activity.

Conclusion: The survey concluded that the importance of physical activity is widely accepted across

the participants of the present study though there was some diversity among participants which

underserved when it comes to sporting opportunity.

KEYWORDS: Attitude, awareness, physical activity, sedentary life style

INTRODUCTION The key to augmentation of physical activity is


48

to understand the attitude of a population

towards exercise and health, together with any

change in such attitude induced by the

immediate rewards of training.1Physical

activity is defined as “any bodily movement

produced by skeletal muscles that result in

energy expenditure”.2Recommended physical

activity is reported as moderate-intensity

activities in a usualweek (i.e.,brisk walking,

bicycling, vacuuming, gardening, or anything

else that causes small increases in breathing or

heart rate) for greater than or equal to 60

minutes per day, greater than or equal to six

days per week.3Increased physical activity

improves quality of life, and individuals

reaching recommended level physical activity

are more likely to have better overall health

related quality of life.

Physical inactivity is a major public health

challenge in the developed world and is

recognized as a global epidemic.4In the long

run physical inactivity increases the risk of

many chronic diseases in adulthood, including

coronary heart disease, colon cancer, and

diabetes.5The National Center for Health

Statistics 2009 and Healthy People 2010lists

physical activity as one of its focus areas and

also as one of the leading health

indicators.6According to the World Health

Report 2000, physical inactivity was estimated

to cause 1.9 million deaths worldwide every

year.The prevalence of physical inactivity in

selected rural populations in nine Health and

Demographic Surveillance Sites (HDSS) in

Asia showed that 25% of the men and 35% of

the women were physically inactive.The same

study reported that less than 20% of

respondents in the HDSS in India engaged in

vigorous or moderate activities at work.7

Physical activity has both health promoting and

disease prevention properties. If everyone

followed the recommendation of being

physically active on a daily basis, the health of

the population would improve considerably and

healthcare costs would drop dramatically.8To

achieve the health objectives in Healthy People

2010 and 2020, concentration should be on

motivating individuals to continue physical

activity programs throughout their life span.

This survey sought to determine the current

physical activity levels and the factors

influencing these levels in the clinical and non-

clinical staff. It will contribute to the

development of appropriate policy and

interventions that will promote an active and

healthy population.

METHODS

The study received approval from Ethical

Committee of Pravara Institute of Medical

Sciences, Loni. The survey was conducted

among clinical and non- clinical staff aged

between 23 and 60 years and those who have

sedentary lifestyle in Pravara Rural Hospital

and College.In this study, the minimum levels

of education for all the participants were

graduation degree or diploma. 170

participants,who were volunteered, included in

the study. Verbal consent was obtained from all

the participants. A brief explanation about the


49

study was given to all the participants.Well

trained study investigators visited the

participants in a randomized manner and

instructed them face-to-face on how to interpret

and answer the questionnaire. Participants were

given fourweeks’ time to complete the

questionnaire and it was collected from them

by the principal investigator. Confidentiality of

participants was maintained.

PROCEDURE

Questionnaire in a printed format was given to

each participants and one month time was

given to all the participants for completing the

questionnaire. Questionnaire consists of eight

questions with multiple choices answers. For

some questions,participants had to tick mark

only one answer and for questions like three,

four and seven questions participants had to

mark more than one answers.All the questions

were self-explanatory.The questions placesan

emphasis on the context in which people

exercise – for example, whether they play

formal sports or are active in other,

moreinformal ways, as well as highlighting

how many individuals do the most (and the

least)physical activity. It also reveals how

Indian citizens perceive the opportunities to

engage insporting activity in their areas, as well

as how many people volunteer to help run

sporting activities in their communities and

how much time they spend on such activities.

RESULTS

The data analysis was done after calculating the

mean for all the answers of filled questionnaire

of each participant and accordingly pie-chart

and bar graph was plotted using Microsoft-

Excel Sheet. Incomplete questionnaires were

not included for the data analysis.

Questionnaire consists of eight questions with

multiple options.

Q1. How often do you exercise or play sports?

Q2. And how often do you engage in physical

activity outside sports such as cycling or

walking from a place to another, dancing,

gardening?


50

Q3.Where do you engage in physical activity?

Q4. Why do you engage in physical activity?

Q5. From the following reasons, what is currently preventing you the most to do physical activity more

regularly?


51

Q6. To what extent do you agree or disagree with the following statements about physical therapy?

Q7. Are you a member of any of the following

clubs where you participate in recreational

physical activity?

Q8. How much time do you spend on physical

activity?

DISCUSSION

According to the present analysis, 31%

participants actively participate in physical

activity 1 to 2 times a week, 25 % stated that,

they do it 3 to 4 times a week and no response

was given by 3%. WHO estimate that less than

one third of young people are sufficiently

active to benefit their present and future health

and well- being.932% participants engage in

physical activity outside sports such as cycling,

walking from one place to another, dancing,

gardening, etc. for five times a week. 19%

participate for one to two weeks in physical

activity outside sports and 2% were not

involved. Increase in the dependence on

motorized reach jobs and other amenities, and

thus reduce opportunities for walking and

cycling.10Many participants are physically

active as part of their everyday routine and do

not have specific motivation for it. 29% of

participants involve in physical activity on the

way between home and work place, 25%

participants spend their time in school and

university, 21 % like to do it in nature out in the

park and 16% also says that they were involved


52

in somewhere else for the physical activity, it

differs from individual to individual where they

want to and how much time they want to give

for the physical activity. Exercise on the way to

and from home was the main factor

determining the usage of such facilities is

presumably quite simple.

In increasing health conscious world, it is

perhaps unsurprising that an 80% participant

does physical activity to improve their health.

The next most commonly cited reason for

exercising was to improve fitness. 50% does it

for weight reduction and some for relaxation.

As all participants, belong to medical

profession, they mention lack of time as a main

factor for not involving in physical activity.

And this place is in rural area, many

participants approximately 24% gave reason for

lack of infrastructure close to their residential

area. Even some of the participants belong to

50-60 years of age group their illness or

disabilities restrict them from doing physical

activity, 44% strongly agree that college had

provided many opportunities to be physically

active. Some studied in the past showed a

strong link between education and the amount

of sport that people play.11 From the agegroup

25-35 years, 21% participants were the member

of health fitness club and 24% were not aware

of any fitness club near to their place. This

outcome suggests that many participants who

do it regularly prefer to exercise in other

context- perhaps just exercise on their own.

Man and women generally do very similar

amount of physical activity though with some

variation. Some studies suggest that women are

particularly health conscious or perhaps they

tend to have more time for exercise than men of

equivalent age.11

According to this study, 59% participants spend

their time occasionally or at individual event

for sporting activities. Some 15% stated that

they spend 1 to 5 hours per month for voluntary

work or sporting activities. It has been studied

that if you live alone you are more likely to be

physically inactive.11At the start of the 21st

century, however so much physical activity has

been removed from life that people may begin

to ignore how essential it is for health and well-

being.10

CONCLUSION

This survey indicates that physical activity is an

area where big gains can be made by

identifying and spreading good practices

between different individuals with sedentary

lifestyle.The importance of physical activity is

widely accepted across the participants of the

present study though there was some diversity

among participants which underserved when it

comes to sporting opportunity.An increase in

physical activity is one of the measures that

would have the greatest positive impact on the

health of the population.

ACKNOWLEDGMENT

We would like to thank all the participants of

Pravara rural Hospital and College who had

given their time to take part in this survey.

Without their active participation this study


53

would not have been possible.


54

REFERENCES

1. Sidney K. and Shephard R. Attitudes towards health and physical activity in the elderly. Effects of physical

training program. Medicine and Science in Sports.1976; 8(4):246-252.

2. Steven Allender, Gill Cowburn and Charlie Foster.Understanding participation in sport and physical activity

among children and adults: a review of qualitative studies. Health education research.2006;21(6):826-835.

3. United States Department of Health and Human Services. Physical activity and health: A report of the Surgeon

General. Atlanta, GA: Centers for Disease Control and Prevention Printing Office.1996.

4. Allender S, Cowburn G and Foster C. Understanding participation in sport and physical activity among children

and adults: a review of qualitative studies. Health education research.2006; 21(6):826-835.

5. A D Christodoulou, H T Douda, M Polykratis, and S P Tokmakidis. Attitudes towards exercise and physical

activity behaviors in Greek schoolchildren after a year long health education intervention. Br J Sports Med.2006;

40(4): 367–371

6. Center for Disease Control and Prevention (2008), National Center for Health Statistics. About Healthy People

2010 Retrieved, from http://www.cdc.gov/nccdphp/dnpa/obesity

7. Navi Ng, Hakimi M, Van Minh H et al. Prevalence of physical inactivity in nine rural in depth health and

demographic surveillance systems in five Asian countries. Glob Health Action.2009; 2: 44-53.

8. Carl John. Physical activity in the prevention and treatment of disease. Professional association for physical

activity.2010.Sweden.

9. National action plan on physical activity. Republic of Mauritius. 2011

10. Cavil N, Kahlmeir S and Racioppi F. Physical activity and health in Europe. Evidence for action. Denmark:

WHO; 2006.

11. Survey by European commission.Sports and Physical Activity. 2010


*Post graduate student, College of Physiotherapy, Pravara Institute of Medical Sciences, (PIMS),

Pravara Rural Hospital, Pravara Deemed University, Loni.413 736 Ahmednagar, Maharashtra, India.

Email: [email protected]

**Associate Professor, College of Physiotherapy, Pravara Institute of Medical Sciences (PIMS),

Pravara Rural Hospital, Pravara Deemed University, Loni.413736 Ahmednagar, Maharashtra, India.

Email: [email protected]


55

TO FIND OUT THE EFFECTIVENESS OF MAITLAND MOBILIZAT ION IN

CONTEXT OF ADDITIONAL BENEFIT OVER ADVICE AND EXERC ISE

ALONE FOR PATIENTS SUFFERING FROM FREEZING STAGE OF

FROZEN SHOULDER – A RANDOMIZED CONTROL TRIAL

Amit Murli Patel*

ABSTRACT

Background: Maitland mobilization of shoulder region joints, often in conjunction with other

treatment modalities, is used for the treatment of people with shoulder pain and minimal movement

restriction. However, there is only limited evidence supporting the efficacy of this treatment modality.

Objective: The purpose of this study was to determine whether Maitland mobilization of shoulder

region joints adds treatment benefit over exercise and advice alone for people with shoulder pain and

minimal movement restriction. Design: This was a randomized controlled clinical trial with short-,

medium- and longer-term follow-up. Setting: The study was conducted in a Shivam Orthopaedic

hospital. Patients: Ninety-eight patients with shoulder pain of local mechanical origin and minimal

shoulder movement restriction were randomly allocated to either a control group (n = 51) or an

experimental group (n = 47). Intervention: Participants in both groups received advice and exercises

designed to restore neuromuscular control at the shoulder. In addition, participants in the

experimental group received Maitland Mobilization specifically applied to shoulder region joints.

Measurements: Outcome measurements of shoulder pain and functional impairment, self-rated change

in symptoms, and painful shoulder range of motion were obtained at 1, 3, and 6 months after entry into

the trial. All data were analyzed using the intention-to-treat principle by repeated-measures analyses


56

of covariance. Results: No statistically significant differences were detected in any of the outcome

measurements between the control and experimental groups at short-, medium-, or longer-term follow-

up. Limitations: Therapists and participants were not blinded to the treatment allocation. Conclusion:

This randomized controlled clinical trial does not provide evidence that the addition of passive

mobilization, applied to shoulder region joints, to exercise and advice is more effective than exercise

and advice alone in the treatment of people with shoulder pain and minimal movement restriction.

Key Words : Maitland Mobilization, Frozen Shoulder, Shoulder pain and functional impairment

INTRODUCTION

Shoulder pain is a common complaint, with the

prevalence ranging from 20% to 33% in the adult

population.1–4 It has been reported that shoulder

pain is the third most frequent musculoskeletal

complaint, after back and knee pain, in the

general community. 4 In 2007, the Indian

statistical Bureau reported that injuries to the

shoulder in the workforce required the most

number of days off work, with a median of 18

days to recuperate.

With the exception of the knee and wrist, the

shoulder took at least twice the median time to

recover compared with all other body parts.5

Nocturnal disturbance, the inability to sleep on

the affected side, functional disability, and a

reduction in the overall quality of life are

common complaints resulting from shoulder

pain.6 – 8 .Manual therapy in the form of passive

joint mobilization is used by physical therapists

for the management of pain, including shoulder

pain, and often is used in conjunction with other

treatment modalities, including exercise

therapy.9–11 For the management of shoulder

pain, mobilization techniques are commonly

applied to the joints of the shoulder region

(glenohumeral, acromioclavicular, and

sternoclavicular joints), to the scapula, to the

joints of the cervicothoracic vertebral column,

and to the ribs. Passive joint mobilization aims to

manage shoulder pain by physiological

mechanisms (eg, inducing hypoanalgesia)12-13 or

by mechanical mechanisms (eg, restoring normal

biomechanical relationships by addressing

related joint stiffness).14 Clinical trials that have

investigated the effectiveness of passive joint

mobilization therapy, which included

mobilization of the cervicothoracic vertebral

column and ribs, for the management of painful

shoulder dysfunction indicate that this form of

mobilization therapy is more effective than other

therapy modalities. Winters et al 15 demonstrated

greater, more rapid decrease in pain in patients

with acute and chronic shoulder pain who

received manipulation and mobilization of

vertebral column, ribs, or shoulder region joints

than those who received massage, exercises, and

electrotherapy. In addition, patients with chronic

shoulder pain demonstrated added treatment

benefit (greater decrease in pain intensity and

functional limitation) when passive mobilization

of vertebral column or shoulder region joints

were added to exercises.16 In the only clinical

trial that has investigated mobilization and


57

manipulation therapy specifically applied to the

vertebral column and ribs for the management of

shoulder pain, patients who received the manual

therapy in addition to usual care reported

significantly greater overall improvement and

decrease in pain.15

Despite their common use, little evidence is

available to support the contribution of passive

mobilization applied specifically to shoulder

region joints in the management of painful

shoulder conditions. Indeed, the results of a

recent well-powered randomized controlled trial

(RCT) indicate that this form of manual therapy

is not more effective than exercises and advice

from a physical therapist in the management of

the painfully restricted shoulder.18 These results

support the findings of another study of a small

sample of participants in which passive

mobilizations of shoulder region joints were

found to be ineffective in the management of

adhesive capsulitis.19 Only one RCT that

examined the effects of passive mobilization of

shoulder region joints in patients diagnosed with

impingement syndrome showed limited evidence

in support of the benefit of this treatment

modality. 20

Although the evidence indicating no additional

benefit of passive mobilizations of shoulder

region joints above exercise and advice in

painful, restricted shoulder conditions 18-19 is

mounting, little information is available

regarding the effectiveness of this modality for

the treatment of people with shoulder pain and

minimal movement restriction. Therefore, a clear

clinical rationale for the use of mobilization

therapy applied to shoulder region joints for the

management of non restricted painful shoulder

conditions has not been established. As passive

joint mobilization therapy is most commonly

used in conjunction with other treatment

modalities and with increasing evidence to

support the efficacy of exercise therapy in the

management of painful shoulder conditions, 21-26

the specific aim of the study was to determine

whether low-velocity passive joint mobilization

therapy specifically applied to shoulder region

joints (glenohumeral, acromioclavicular, and

sternoclavicular joints) and passive mobilization

of the scapula add benefit over exercise and

advice alone in the treatment of people with

shoulder pain and minimal movement restriction.

METHOD

Design Overview

This RCT compared passive mobilization of

shoulder region joints, exercise, and advice with

exercise and advice alone for the treatment of

people with shoulder pain and minimal

movement restriction. Prior to group allocation,

baseline outcome measurements were obtained.

Following measurements of pain, functional

ability, and painful active range of motion

(AROM), participants were randomly allocated

to an experimental or control group based on a

concealed assignment schedule that had been

generated by an investigator who was not

involved with recruitment, treatment, or outcome

measure assessment in the study.

Primary outcome measurements of pain,

functional impairment, and self-rated


58

improvement were obtained from participants

who were not blinded to treatment group

allocation at 1, 3, and 6 months after

randomization. Secondary outcome

measurements of painful AROM were obtained

by a researcher (R.Y.) blinded to group

allocation at the same time points.

Setting and Participants

All patients referred to the outpatient physical

therapy department at Shivam Orthopaedic

hospital with painful active flexion or abduction

shoulder movements of greater than 1 month’s

duration and minimal shoulder movement

restriction were eligible to participate in this

study. In addition, pain, tenderness, or restriction

during passive accessory movements at the

glenohumeral, acromioclavicular, or

sternoclavicular joint or during passive scapular

movements was required to be present.

Diagnostic classifications systems were not used

to select participants for inclusion in this study

because they lack reliability and uniformity, thus

causing confusion and miscommunication among

health care professionals.27–35 Participants were

excluded if: they were less than 18 years of age;

they were unable to understand spoken Gujarati

or Hindi; their shoulder symptoms were

reproduced during active cervical spine

movements or during palpation of cervical or

thoracic region joints; they reported paresthesia

in the affected upper limb; passive shoulder

region joint mobilization was contraindicated;

shoulder flexion or abduction range of motion

(ROM) was less than 140 degrees, as determined

from digital photographs; shoulder pain was due

to an inflammatory or neoplastic disorder; they

had had surgery or trauma to the shoulder in the

previous 4 weeks; or they reported a feeling of

shoulder instability.

Ninety-eight volunteers (47 men and 51 women)

were recruited for this study after providing

written informed consent. The sample size for

this study was calculated using data from the

Shoulder Pain and Disability Index (SPADI)

questionnaire, one of the primary outcome

measures in this trial. Statistical power

calculations indicated that a sample size of 98

participants would provide an 80% chance of

detecting a minimum change of 15 points in total

SPADI score, assuming a standard deviation of

25 points and a maximum 10% loss to follow-up.

Randomization and Interventions

All patients seen at the participating hospital who

were potentially eligible to participate in this

study were contacted by telephone. The aims of

the study and its procedures were explained, and

an appointment was arranged to conduct an

interview and physical assessment. At this

appointment, the patients were questioned and

examined to confirm that they fulfilled all

inclusion criteria. Suitable participants then

signed a consent form, and baseline outcome

measurements of pain, functional impairment,

and painful AROM were obtained. Additional

demographic information such as participants’

age, sex, affected and dominant upper limb, and

duration of symptoms were recorded during the

interview.


59

Following initial assessment, participants were

randomly allocated to either the control group or

the experimental group. Random allocation of

participants was performed using a previously

determined treatment assignment schedule with

random numbers generated from the data

analysis function in Microsoft Excel.* To ensure

concealment, the randomization procedure was

carried out by a researcher (K.A.G.) not involved

in participant recruitment, treatment, or

assessment, and the treatment assignment

schedule was stored in consecutively numbered,

sealed opaque envelopes.

All participants received treatment in the form of

advice and exercises. Physiotherapists provided

advice on how to avoid or minimize painful

shoulder movements during activities of daily

living. This advice included: limiting movement

to the pain-free ROM; maintaining normal

scapulohumeral rhythm within painfree ROM;

using the affected upper limb in a slow, careful

manner; using techniques to minimize shoulder

pain (eg, during dressing and reaching); and

preferentially using the non affected upper limb.

Exercises were directed toward restoring

neuromuscular control mechanisms at the

shoulder. This exercise approach has been shown

to be effective in previous clinical trials,22,23 and

all participating therapists were given

instructions in the implementation of this

treatment approach. The primary aim of the

exercises was to restore normal muscle function

in order to regain normal dynamic stability and

muscle force couple coordination at the shoulder

region, thus leading to restoration of function.37

Stretching exercises to lengthen shortened

muscles, exercises to strengthen weakened

muscles and to improve muscle coordination, and

exercises aimed at restoring normal scapula

humeral rhythm could be included. Motor

retraining exercises were devised and upgraded

based on motor learning principles designed to

improve motor skills by incrementally

increasing the complexity of the exercise tasks.

Full range of shoulder movement requires the

coordination of a number of muscle force

couples.

Therefore, less-difficult exercises principally

involved muscles within one force couple (eg,

isolated rotation exercises for the rotator cuff

muscles or scapular depression exercises with the

arm by the side). The most difficult exercises

involved all shoulder muscle force couples (eg,

full range flexion and abduction exercises

requiring coordination of axiohumeral, rotator

cuff, and axioscapular muscles).37 The exercises

were performed in a pain-free manner to

optimize normal muscle function and movement

patterns.22

Exercises and advice were tailored by the

treating physical therapist to meet the

requirements of each participant. The exercise

treatment was administered as a daily home-

based program and reviewed by the treating

therapist 1 or 2 times per week. The purposes of

this review were to correct the performance of

the exercises if necessary and to increase the

intensity and complexity of the exercises as

muscle function improved. As motor skill

acquisition is a lengthy process that requires


60

regular practice to establish new habituated

motor patterns, participants were strongly

encouraged to do their exercises on a daily basis

at home and to continue them after formal

treatment had ceased.37 In addition to this advice

and exercise therapy, participants allocated to the

experimental group received low-velocity

passive joint mobilizations applied to any of the

shoulder region joints (ie, glenohumeral,

sternoclavicular, and acromioclavicular joints)

and passive mobilization of the scapula.

Mobilization therapy was aimed at relieving pain

and restoring pain-free functional movements 14

Passive mobilizations could be applied in a

sustained or oscillatory manner. As per routine

clinical practice, the regions mobilized, as well

as the force, direction, and amplitude of the

mobilization techniques, were individually

determined and progressed by the treating

therapist based on each participant’s clinical

signs and symptoms. The study design required

that a minimum of 60% of all treatments

provided to participants in the experimental

group involved passive shoulder region

mobilization in order to ensure an adequate

dosage of the mobilization therapy under

evaluation.

Participants in both groups received 1 or 2

treatment sessions per week for the first month of

the trial, followed by additional treatment over

the next 4 weeks to a maximum of 12 treatment

sessions if deemed necessary by the treating

therapist. The physical therapists involved in the

trial recorded the number of treatment sessions

and the type of mobilization techniques applied

for each participant in a logbook. All participants

were requested to receive physical therapy

treatment only from the involved physical

therapy department and to refrain from seeking

any other form of therapy while participating in

this clinical trial.

Seventeen physical therapists were involved in

providing treatment to participants in this clinical

trial. Five of these Physiotherapists had

postgraduate qualifications in physical therapy:,

and two with Doctorate in Manipulative therapy.

The number of years of clinical experience for

therapists involved in this study ranged from 2 to

28 (X = 8.4, SD = 7.5). All therapists received

instructions regarding all treatment options and

clinical trial adherence, and all therapists were

involved in treating participants in both the

control and experimental treatment groups.

Outcomes and Follow-up

Two primary outcome measures were used in

this study. The first primary outcome measure,

shoulder pain intensity and functional

impairment during the previous week, was

assessed using the SPADI questionnaire.36 This

self-administered questionnaire consists of 2

sections: the first section of 5 questions relates to

pain, and the second section of 8 questions

relates to function.36 This questionnaire was

chosen because it has been shown to be reliable,

valid,38,39 and responsive to change 39–42 and has

no floor or ceiling effects.40 The second primary

outcome measure, self-rated change in

symptoms, was measured with a 6-point Likert

scale. This scale consisted of a horizontal line


61

with 6 points, each with verbal anchors relating

to participants’ perceived change in symptoms

(ie, feeling “much worse,” “slightly worse,” “the

same,” “slightly improved,” “greatly improved,”

and “fully recovered”).43 Participants were asked

to use this scale to indicate their perceived level

of change in symptoms since their last

assessment. A Likert scale was chosen because it

is easy to administer and interpret and it consists

of categories labeled with words, which assists

individuals to specifically relate to how they feel,

thus assisting in defining the change in their

symptoms.44 Secondary outcome measurements

of AROM during shoulder flexion in the sagittal

plane and abduction in the coronal plane were

assessed using a photographic method shown to

be reliable in previous studies of patients with

shoulder pain.18,22,23 Participants were instructed

to perform these movements, and photographs

were taken when pain was initiated and when

pain either resolved or when the maximal

achievable ROM was reached. Using markers

placed on bony landmarks, 22,23 shoulder joint

angles were measured on the photographs. The

painful ROM was recorded as the difference

between the shoulder angles in the 2

photographs. This method of measuring painful

AROM was used because it is quicker to perform

than standard goniometry and thus less likely to

exacerbate symptoms and influence

measurement. 18,22,23 The intrarater reliability of

these AROM measurements was established for

the blinded assessor (R.Y.) in this study prior to

the commencement of the trial. Intraclass

correlation coefficients (2,1) demonstrated

excellent intrarater reliability of .92 and .98 for

flexion and abduction, respectively.45

Participants received between 4 and 8 treatment

sessions over a 1-month period. Primary outcome

measurements of pain and functional impairment

were reassessed, and self-rated change in

symptoms was obtained from participants who

were not blinded to treatment allocation.

Secondary outcome measurements of painful

AROM were reassessed by a researcher (R.Y.)

who was blinded to treatment allocation. To

ensure blinding, participants were instructed to

refrain from discussing their treatment with this

assessor.

Following assessment at 1 month, treatment

could continue for a maximum of 12 treatment

sessions over a maximum of 8 weeks.

Reassessment of all outcome measurements was

repeated at 3 and 6 months after baseline

measurements.

Data Analysis

All analyses were conducted using an intention-

to-treat approach. Missing data (lost to follow-

up) were replaced with values obtained by

imputation using regression models within each

variable and group at all available time points.

For the 2 control group participants who were

lost prior to reassessment at 1 month after

recruitment and, therefore, did not have a self-

rated change in symptoms score, the average of

the group was used for their missing scores. A

repeated-measures analysis of covariance was

used to analyze between group differences in

both primary (SPADI and self-rated


62

improvement) and secondary (painful AROM)

outcome measurements at 1, 3, and 6 months

following randomization. There was a

statistically significant difference in the mean

duration of current shoulder symptoms between

the experimental and control groups at baseline,

and this factor was used as the covariate in the

analysis.

RESULTS

A total of 230 patients referred to the outpatient

physical therapy department for the management

of shoulder dysfunction between May 2011 and

August 2013 were contacted via telephone

regarding potential inclusion in this clinical trial.

The flow of participants through the trial is

illustrated in Figure 1. Of the 230 patients

screened via telephone, 64 were not considered

eligible for inclusion in the clinical trial,

primarily because they indicated that they had

severely restricted shoulder flexion or abduction

ROM or because their pain was exacerbated by

neck movements suggesting referral from the

vertebral column. The remaining 166 patients

were invited to attend a physical assessment. Of

these patients, 68 failed to meet the inclusion

criteria. The reasons for exclusion were shoulder

flexion or abduction of less than 140 degrees of

AROM and shoulder symptoms reproduced

during active cervical spine movements or during

palpation of cervical or thoracic joints. The

remaining 98 patients who met the inclusion

criteria accepted the invitation and were recruited

for the study.

Baseline characteristics for the total cohort at the

commencement of this trial are presented in

Table 1. Groups were well matched at baseline,

with the only significant difference being a

longer duration of symptoms in the control group

(P<.03).


63

The study population consisted of a young

elderly cohort, with approximately equal numbers

of men and women with chronic shoulder pain.

At baseline, both groups reported a moderate

level of shoulder pain and functional impairment

(mean total SPADI score = 50% for both groups)

and approximately 30 degrees and 50 degrees of

painful shoulder flexion and abduction AROM,

respectively.

Four participants were unable to physically attend

the outpatient physical therapy department for

reassessment: 1 at both 1- and 3-month follow-


64

ups, 1 at the 3-month follow-up, and 2 at 3- and

6-month follow-ups. For these participants, data

relating to their shoulder pain and functional

impairment and self rated change in symptoms

were obtained via telephone. The SPADI has

been found to be suitable for administration via

telephone.46 Therefore, primary outcome

measurement data were obtained for 98%

(control group = 96%, experimental group =

100%), 95% (control group = 96%, experimental

group = 94%), and 93% (control group = 92%,

experimental group = 94%) of all participants at

the 1-, 3-, and 6-month follow-ups, respectively.

Reasons for participant withdrawal are detailed in

Figure 1. Participants in both experimental and

control groups received a mean of 9 (SD = 5)

treatment sessions, ranging from 0 to 24 and 1 to

24 sessions, respectively. Participants in the

experimental group received a mean of 7

(Range= 2–16) treatment sessions involving

passive mobilization of shoulder region joints.

On average, 67% of the total number of treatment

sessions for the experimental group included

passive mobilization of shoulder region joints,

thus meeting the minimum dosage requirement

(60%) for this study. All but 1 participant in the

experimental group received some mobilization

therapy. However, 11 experimental group

participants had mobilization therapy in less than

60% of their treatment sessions, even though they

had up to 9 mobilization treatments. Of the

participants who received passive mobilization

therapy, 59% received mobilization solely to the

glenohumeral joint, 2% solely to the

acromioclavicular joint, 2% solely to the scapula,

and 35% to a combination of shoulder region

joints, including the glenohumeral,

acromioclavicular, and sternoclavicular joints.

Group data for all outcome measures at 1, 3, and

6 months following randomization for the

experimental and control groups are presented in

Table 2 and Figures 2, 3, and 4. Improvement

was seen in all outcome measurements in both

groups at 1, 3, and 6 months (P< .001).

Differences in mean total shoulder pain and

functional impairment scores (total SPADI

scores) between the control and experimental

groups at all follow-up periods were small and

statistically non significant. At the 1-month

follow-up, the experimental group had 1% (95%

CI [confidence interval] - 7% to 9%) less

shoulder pain and functional impairment than the

control group. The control group had 5% (95%

CI - 3% to 12%) and 0% (95% CI - 7% to 7%)

less shoulder pain and functional impairment than

the experimental group at 3 and 6 months,

respectively. Similarly, small and statistically non

significant differences in scores for self rated

change in symptoms between the control and

experimental groups were demonstrated at all

follow-up periods. The control group was 0.2 out

of 5 (95% CI = - 0.1 to 0.6) better than the

experimental group at the 1-month follow-up,

and the experimental group was 0.2 out of 5

(95% CI = - 0.3 to 0.6) and 0.1 out of 5 (95% CI=

- 0.2 to 0.5) better than the control group at 3-

and 6-month follow-ups, respectively. No

adverse

effects of any treatment intervention were

reported.


65

Discussion

This is the first adequately powered RCT that has

specifically evaluated the effectiveness of passive

joint mobilization specifically applied to shoulder

region joints for the treatment of people with

shoulder pain and minimal movement restriction.

Our results demonstrate that the addition of

passive mobilization of shoulder region joints to

exercise and advice is not more effective than

exercise and advice alone in decreasing pain and

painful ROM and improving function and self

rated change in symptoms in this cohort, with no

significant differences in any of the outcome

measurements between the 2 groups at short-,

medium-, or longer-term follow-up. The findings

of small, non significant differences in functional

impairment and AROM between the groups

receiving and not receiving passive mobilizations

to shoulder region joints in this study support the

findings of the only other clinical trial that

specifically evaluated the effectiveness of this

modality for the treatment of people with

shoulder impingement syndrome.20 However,

although Conroy and Hayes20 found passive

mobilization of shoulder region joints to be

effective in decreasing

the maximum pain level reported over a 24-hour

period and during an impingement test in this

cohort in the short term, the current study found

no differences in pain levels measured on the

SPADI questionnaire in the short, medium, or

longer term.

Table 2

The current well powered, longer-term study


66

confirms and extends the majority of findings of

this smaller short-term study (i.e. that passive

mobilizations applied to shoulder region joints do

not add clinical benefit in the management of

painful shoulder dysfunction). The results of the

current study also strongly support the findings of

previous RCTs investigating the effectiveness of

passive mobilizations specifically applied to

shoulder region joints for the management of

painful, restricted shoulder dysfunction.18,19

Similar to the current study, these studies found

no significant differences in pain,18,19 functional

impairment, 18 self-rated change in symptoms,18

or AROM18,19 between a group that received

passive mobilizations and a group that did not

receive passive mobilizations at short-term

follow-up18,19 or longer term follow-up.18 The

results of the current and other relevant RCTs,

therefore, indicate that passive joint mobilizations

specifically applied to shoulder region joints for

the management of shoulder pain of local

mechanical origin without instability do not

provide additional clinical benefit above exercise

and advice alone. Systematic reviews of clinical

trials investigating mobilization therapy have

concluded that there is limited evidence to

support the effectiveness of passive joint

mobilization therapy for the management of

shoulder pain.11,47,48 Of the 3 available clinical

trials included in these reviews,15,16,20 the

majority investigated mobilizations directed at

vertebral column or rib joints, as well as shoulder

region joints.15,16 With the addition of more-

recent evidence from clinical trials conducted

since these reviews were performed, this

conclusion can be further refined.

The results of the current study and of the study

by Chen et al18 considering the effectiveness of

passive mobilization specifically applied to

shoulder region joints provide strong evidence

that passive mobilization of shoulder region

joints does not add clinical benefit in the

treatment of people who have shoulder pain with

and without movement restriction. In addition,

Bergman et al17 provided evidence that

mobilization or manipulation therapy specifically

applied to the vertebral column and ribs is more

effective than usual care in the management of

shoulder pain. It would appear, therefore, that the

conclusion that patients with painful shoulder

dysfunction gain clinical benefit from the

application of mobilization therapy only applies

to passive joint mobilization of the vertebral

column or rib joints.

Figure 2

Mean (95% confidence interval) Shoulder Pain

and Disability Index (SPADI) questionnaire

scores (%) for shoulder pain and functional

impairment for the control and experimental

groups at entry into the trial (baseline) and at 1-,

3-, and 6-month

follow-ups.


67

The design of the current study included several

features to minimize bias, thus enhancing the

internal validity of results obtained and

strengthening the conclusions that can be drawn

from this study. Participants were allocated to 1

of 2 treatment groups using a predetermined

random and concealed allocation process. An

exercise approach of proven efficacy was

implemented as the control treatment.22,23 Passive

mobilization therapy was isolated to the shoulder

region joints in order to evaluate the contribution

of this specific component of the common group

of treatment modalities used by physical

therapists to treat people with shoulder pain.

Participants in both groups were provided with

the same mean number of treatments and thus the

same amount of

participant-therapist contact time. Short-,

medium-,and longer-term reassessments were

conducted. The number of participants

unavailable for reassessment was low at all

follow-up periods, thus preserving the successful

randomization achieved at the commencement of

the clinical trial. The sample size was large

enough to provide adequate power to detect

significant differences, and responsive, reliable

outcome measures were used. With the exception

of duration of symptoms,

which was taken into account in the analysis,

baseline demographics were similar at the

commencement of the trial, and baseline outcome

measurements were well matched. Finally, an

intention-to-treat analysis was implemented. In

addition, this RCT included features to enhance

the external validity of the study and thus

enhance the generalizability of the results

obtained. All treatments were specifically tailored

to the individual participant rather than following

a prescribed pattern and, therefore, were more

reflective of a typical clinical setting. Seventeen

physical therapists with varying clinical

experience ranging from 2 to 28 years were

involved in providing treatment in this study, and

all of these physical therapists provided treatment

for participants in both the experimental and

control groups.

Figure 3.

Scores for self-rated change in symptoms for the control (shaded) and experimental (unshaded) groups

at 1-, 3-, and 6-month follow-ups.


68

Figure 4.

Mean (95% confidence interval) painful flexion and abduction active range of motion for the control

and experimental groups at entry into the trial (baseline) and at 1-, 3-, and 6-month follow-ups.

The conclusion from this clinical trial, that the

addition of passive joint mobilizations of

shoulder region joints to exercise and advice is

not more effective than exercise and advice

alone for the treatment of people with shoulder

pain and minimal movement restriction,

however, does need to be viewed in light of

some limitations. The lack of a reliable

diagnostic classification system for shoulder

pain resulted in a heterogeneous study

population in the current study consisting of

patients with a mix of mechanical shoulder

symptoms, only excluding those with restricted

shoulder ROM. It is possible that specific

subgroups within this heterogeneous group, if

they can be reliably identified, may benefit

from mobilization therapy directed at the

shoulder region joints. In addition, the lack of

evidence to guide therapists in the choice of

passive mobilization technique may have

resulted in the choice of less-than-optimal

mobilization therapy for some participants.

Finally, although the loss to follow-up was

smaller than that assumed in the calculation of

the sample size for the current study, there is

the chance that significant differences between

the treatment groups were missed due to type 2

statistical error, and the possibility of bias due

to the lack of blinding of the treating therapists

and participants cannot be discounted.

REFERENCES

1. Luime JT, Koes BW, Hendriksen IJ, et al. Prevalence and incidence of shoulder pain in the general population: a

systematic review. Scand J Rheumatol. 2004;33: 73–81.

2. McBeth J, Jones K. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. 2007;21:403–

425.

3. Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of shoulder pain in the community: the influence of

case definition. Ann Rheum Dis. 1997;56:308–312.


69

4. Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the

comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann

Rheum Dis. 1998;57: 649–655.

5. US Department of Labor. Nonfatal Occupational Injuries and Illnesses Requiring Days Away from Work, 2007.

Washington, DC: Bureau of Labor Statistics. Available at: http://www.bls.gov/iif/oshwc/osh/case/osnr0031.pdf.

Accessed November 5, 2010.

6. Chipchase LS, O’Connor DA, Costi JJ, Krishnan J. Shoulder impingement syndrome: preoperative health status. J

Shoulder Elbow Surg. 2000;9:12–15.

7. Ostor AJ, Richards CA, Prevost AT, et al. Diagnosis and relation to general health of shoulder disorders

presenting to primary care. Rheumatology (Oxford). 2005;44: 800–805.

8. Smith KL, Harryman DT Jr, Antoniou J, et al. A prospective, multipractice study of shoulder function and health

status in patients with documented rotator cuff tears. J Shoulder Elbow Surg. 2000;9:395– 402.

9. Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions

for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ. 1998;316: 354–360.

10. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev.

2003;2: CD004258.

11. Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial

impingement syndrome: a systematic review. J Hand Ther. 2004; 17:152–164.

12. Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with

movement for lateral epicondylagia. Phys Ther. 2003;83:374–383.

13. Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system

activity and motor activity. Man Ther. 2001;6:72– 81.

14. Maitland G. Maitland’s Vertebral Manipulation. 7th ed. Oxford, United Kingdom: Butterworth-Heinemann; 2005.

15. Winters JC, Sobel JS, Groenier KH, et al. Comparison of physiotherapy, manipulation, and corticosteroid

injection for treating shoulder complaints in general practice: randomised, single blind study. BMJ.

1997;314:1320–1325.

16. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients

with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126–137.

17. Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients

with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004; 141:432–439.

18. Chen JF, Ginn KA, Herbert RD. Passive joint mobilisation of shoulder region joints plus advice and exercise does

not reduce pain and disability more than advice and exercise alone: a randomised trial. Aust J Physiother.

2009;55:17–23.

19. Nicholson GG. The effects of passive joint mobilisation on pain and hypomobility associated with adhesive

capsulitis of the shoulder. J Orthop Sports Phys Ther. 1985;6:238 –246.

20. Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary

shoulder impingement syndrome. J Orthop Sports Phys Ther. 1998;28:3–14.

21. Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator

cuff: a systematic review. Br J Sports Med. 2007;41: 200–210.

22. Ginn KA, Cohen ML. Exercise therapy for shoulder pain aimed at restoring neuromuscular control: a randomised

comparative clinical trial. J Rehabil Med. 2005;37: 115–122.

23. Ginn KA, Herbert RD, Khouw W, Lee R. A randomised, controlled clinical trial of a treatment for shoulder pain.


70

Phys Ther. 1997;77:802–811.

24. Grant HJ, Arthur A, Pichora DR. Evaluation of interventions for rotator cuff pathology: a systematic review. J

Hand Ther. 2004; 17:274–299.

25. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesised evidence-

based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18:138–160.

26. Trampas A, Kitsios A. Exercise and manual therapy for the treatment of impingment syndrome of the shoulder: a

systematic review. Phys Ther Rev. 2006;11:125–142.

27. Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoulder: can consultants agree? Br J Rheumatol.

1996;35:1172– 1174.

28. De Winter AF, Jans MP, Scholten RJ, et al. Diagnostic classification of shoulder disorders: interobserver

agreement and determinants of disagreement. Ann Rheum Dis. 1999;58:272–277.

29. Hanchard NC, Howe TE, Gilbert MM. Diagnosis of shoulder pain by history and selective tissue tension:

agreement between assessors. J Orthop Sports Phys Ther. 2005;35:147–153.

30. Hughes PC, Taylor NF, Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a

systematic review. Aust J Physiother. 2008;54:159– 170.

31. Kuhn JE, Dunn WR, Ma B, et al. Interobserver agreement in the classification of rotator cuff tears. Am J Sports

Med. 2007; 35:437–441.

32. Liesdek C, van der Windt D, Koes BW, Bouter LM. Soft-tissue disorders of the shoulder: a study of interobserver

agreement between general practitioners and physiotherapists and an overview of physiotherapeutic treatment.

Physiotherapy. 1997;83:12–17.

33. Norregaard J, Jacobsen S, Kristensen J. A narrative review on classification of pain conditions of the upper

extremities. Scand J Rehabil Med. 1998;31:153–164.

34. Park HB, Yokota A, Gill HS, et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial

impingement syndrome. J Bone Joint Surg Am. 2005; 87:1446–1455.

35. Schellingerhout JM, Verhagen AP, Thomas S, Koes BW. Lack of uniformity in diagnostic labeling of shoulder

pain: time for a different approach. Man Ther. 2008;13: 478–483.

36. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index.

Arthritis Care Res. 1991;4:143–149.

37. Stevans J, Hall KG. Motor skill acquisition strategies for rehabilitation of low back pain. J Orthop Sports Phys

Ther. 1998;28: 165–167.

38. MacDermid JC, Solomon P, Prkachin K. The Shoulder Pain and Disability Index demonstrates factor, construct

and longitudinal validity. BMC Musculoskelet Disord. 2006;10:12.

39. Paul A, Lewis M, Shadforth MF, et al. A comparison of four shoulder-specific questionnaires in primary care. Ann

Rheum Dis. 2004;63:1293–1299.

40. Bot SD, Terwee CB, van der Windt DA, et al. Clinimetric evaluation of shoulder disability questionnaires: a

systematic review of the literature. Ann Rheum Dis. 2004;63:335–341.

41. Heald SL, Riddle DL, Lamb RL. The shoulder pain and disability index: the construct validity and responsiveness

of a region-specific disability measure. Phys Ther. 1997;77:1079–1089.

42. Schmitt JS, Fabio RP. Reliable change and minimum important difference (MID) proportions facilitated group

responsiveness comparisons using individual threshold critieria. J Clin Epidemiol. 2004;57:1008– 1018.

43. Likert R. A technique for the measurement of attitudes. Archives of Psychology. 1932; 83:12–17.

44. Bolognese JA, Schnitzer TJ, Ehrich EW. Response relationship of VAS and Likert scales in osteoarthritis efficacy


71

measurement. Osteoarthritis Cartilage. 2003;11: 499–507.

45. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420–428.

46. Williams JW Jr, Holleman DR Jr, Simel DL. Measuring shoulder function with the shoulder pain and disability

index. J Rheumatol. 1995;22:727–732.

47. Desmeules F, Cote CH, Fremont P. Therapeutic exercise and orthopedic manual therapy for impingement

syndrome: a systematic review. Clin J Sport Med. 2003;13: 176–182.

48. Faber E, Kuiper JI, Burdorf A, et al. Treatment of impingement syndrome: a systematic review of the effects on

functional limitations and return to work. J Occup Rehabil. 2006;16:7–25.


*BPT, MPT-Orthopaedics, Senior Physical therapist, Ahmedabad, Gujarat


72

PROFILE OF SEVERE NUTRITIONAL ANEMIA IN CHILDREN AT A

TERTIARY CARE HOSPITAL, SOUTH INDIA

Madoori Srinivas*, Kapil Challa, Mangat Bhukya, Sri kanth Darisetty, Radhika Kodimela

ABSTRACT

Anemia is the most prevalent problem in the world particularly in the developing countries1 NFH

survey (NFHS-3) data shows that 7 out of every 10 children age 6 to 59 months in India are anemia 2.

Here we report study done to find out the profile of hospitalized children with severe nutritional

anemia, to compare the clinical, and laboratory profile of iron deficiency anemia (IDA) and vitamin

B12 deficiency. Methods: This retrospective study was carried out in a tertiary care hospital at

Karimnagar in children aged 1 year to 14 years, admitted with severe nutritional anemia from January

2012 to August 2013. The Chalmeda Anand Rao Institute of Medical Sciences is located in north

Telangana which caters low and middle class people from Karimnagar, Adilabad and part of

Warangal district. Hemoglobin level less than 7 gm/dl was considered as severe anemia and

categorized into iron deficiency anemia and vitamin B12 deficiency in the light of historical

information, physical examination and relevant laboratory investigations and were compared. Results:

Out of 62 children with severe nutritional anemia, males were 35.5% (n=20), and females were 64.5

%( n=42). Mean age of presentation was 8.7 years. The common presenting symptom was pallor

(90.3%), followed by fever (83.87%). IDA was observed in 85.48% ( n=53) and vitamin B12 deficiency

was observed in 14.5% ( n=9). Mean age of presentation in IDA and VitaminB12 deficiency was 8.7

years and 12.7 years respectively. Children with hemoglobin less than 3 grams/dl, 44% (n=4), more in


73

vitamin B12 deficiency. Blood transfusion was given to children with Hb less than 3gm/dl, Iron,

vitamin B12 supplementation given to children with Iron deficiency and vitamin B12 deficiency

respectively. Nutritional advice was given to parents and during the course of the hospital stay no

advance effects noted. There was statistically significant difference in mean hemoglobin (p=0.05),

weight percentile (p=0.021), RBC count (p=0.01), MCV (p=0.000), MCH (p=0.000), MCHC

(p=0.000) in between two groups. Conclusion: Nutritional anemias are conditions in which Hb

concentration of a given individual is below the normal level due to deficiency of one or more nutrients

needed for haematopoiesis. The main nutrients are Iron, Folate, vitamin B12, Proteins and vitamin E.

In this Iron deficiency anemia is currently the most wide spread micronutrient deficiency and affects

nearly 1.5 billion people globally. Children with severe anemia younger the age mostly due to Iron

deficiency and preadolescence age group vitamin B12 deficiency. Early identification, prompt

nutritional supplementation at the community level will decrease the hospitalization of children with

severe nutritional anemia, also aids in their growth and intellectual development. Early

supplementation of iron in younger children especially with malnutrition, preterm, LBW babies.

Exclusive breast feeding and nutritional advice will improve the anemia status in children. In

preadolescence and pure vegetarians with severe anemia suspect B12 deficiency and supplement with

Vitamin B12.

Keywords: Iron deficiency anemia (IDA), Vitamin B 12 deficiency, cognitive impairment

INTRODUCTION

Anemia continues to be a public health problem

of global proportions. It is the most common

preventable nutritional deficiency in children.

The WHO has estimated that, globally 1.62

billion people are anemic with the highest

prevalence of anemia (47.4%) among preschool

aged children, of these 293 million children, 89

million live in India while prevalence of

anemia among school children is 25.4% 3. The

Term nutritional anemia encompasses all the

pathological conditions in which the blood

hemoglobin concentration drops to an

abnormally low level, due to one or more

several nutrients4. Iron deficiency is one of the

major causes of anemia among Indian

children5. Nutritional anemia develops

secondary to interplay of diverse factors like

poverty, malnutrition, large family size, faulty

dietary habits and repeated infections6 . In our

study children with severe nutritional anemia

were identified and categorized into iron

deficiency anemia and vitamin B12 deficiency

and their clinical and laboratory profile were

compared.

MATERIALS AND METHODS

This study is a hospital based retrospective


74

cross sectional observational study. It is

conducted at Chalmeda Anand Rao Institute of

medical sciences, Karimnagar,AP, South India

between Jan 2012 to Aug 2013. Children with

severe pallor aged 1 year to 14 years admitted

in the paediatric wards were enrolled. Complete

blood picture was carried out in all these

children. Using the WHO cut-off values anemia

was defined as Hb <11.0gm/dl and severe

anemia was defined as Hb < 7gm/dl . Children

with severe nutritional anemia were identified

and categorized in to Iron deficiency

group[IDA] and B12 deficiency group [B12

Def] in the light of history, physical

examination, relevant laboratory investigations

and were compared. We measured serum iron,

total iron binding capacity, folic acid and

vitamin b12 as indicated. Bone marrow

aspiration was performed in children with

pancytopenia to rule out bone marrow failure

syndromes or neoplastic disorders. Children

with severe anemia secondary to non-

nutritional causes like leukemia , MDS,

bleeding disorders were excluded from the

study.

Frequency and 95% confidence interval were

calculated for categorical variables, median and

interquartile ranges (IQR) for continuous

variables were calculated. Man-Whitney U test

was applied to calculate the significant

difference between the medians of two groups.

Epi info versions 7, SPSS 19 were the

statistical software used for the study. P value

of 0.05 was taken as significant.

RESULTS

Out of 62 children admitted with severe

nutritional anemia, median age of presentation

with severe anemia was 8.7 years ± 4.44, males

were 35.5 % (n=20) and females were 64.5%

(n=42) . Among the severe nutritional anemia

cases 17.7% (n=11) belonged to 1 to 3 years of

age group, 17.7% (n=11) were 4 to 6 years

age group,64.5% (n=40) belonged to 7 to 14

years age group, The older children have

increased prevalence of vitamin B12 deficiency

The iron deficiency anemia was observed in

85.48% (n = 53) [95%CI 6.8-25.7] and B12

deficiency was observed in 14.5% (n=9) [95%

CI 74.2-93.14]. Median age of presentation

was 8.1 years with iron deficiency anemia and

12.7 years in vitamin B12 deficiency anemia.

Among 53 Iron deficiency anemia children

found 19(35.8%) were males, 34(64.2%) were

females, out of 9 children with B12 deficiency

3(33.3%) were males, 6(66.7%) were females.

In both groups females are more affected than

males.

TABLE 1 :Hemoglobin categorization in two groups i.e. comparison between IDA

& B12 deficiency

Hemoglobin(gm /dl)

Level

No(%) of children Total

B12Deficiency IDA


3 4 (44.4%) 12 (22.6%) 16 (25.8%)

4 - 6 5 (55.6%) 36 (67.9%) 41 (66.1%)

7 0 (0.0%) 5 (9.4%) 5 (8.1%)

Total 9 (100.0%) 53 (100.0%) 62 (100.0%)

We categorized hemoglobin of severe

nutritional anemia into three groups (group I<3

gm/dl , group II 4 to 6 gm/dl , group III 7

gm/dl) among these 67.9% (n=36) of iron

deficiency anemia and 55.6 % (n=5) of B12

deficiency group had hemoglobin of 4 to 6

gm/dl (group II) as shown in table 3. Children

with hemoglobin less than 3gm/dl were more in

vitamin B12 deficiency anemia as compared to

iron deficiency anemia as shown in table 1

Among the children with severe nutritional

anemia, pallor was present in 90.3% {(n=52)

followed by fever (83.8%), Generalized

weakness 58.06% (n=36, 95% CI, 44.85% to

70.49%) , Icterus 24.19% (n=10, 95% CI,14.22

to 36.74%) cough 19.35% (n=12, 95% CI,

10.42% to 31.37%), and pain abdomen 16.13%

(n=10,95% CI,8.02 to 27.67%), breathlessness

8.2% (n=5,95%CI 2.72 to 18.10%) as in Table

2.

TABLE (2): CLINCAL PROFILE ANALYSIS

S. NO SYMPTOM PRESENT ABSENT

1 Pallor 90.3% (n=56)

CI� 80.12% to 96.37%

9.7% (n=6)

CI � 3.63 to 19.88%

2 Fever

83.87% (n=52)

CI � 8.02% to 27.67%

16.13% (n=10)

CI� 72.33 to91 .98

3 Weakness 58.06% (n=36)

CI� 44.85% to 70.49%

41.94% (n=26)

CI� 44.85%to 70.49%

4 Icterus 24.19% (n=10)

CI� 14.22 to 36.74%

75.81% (n=47)

CI� 63.26 to 85.78%

5 Cough 19.35% (n=12)

CI�10.42% to 31.37%

80.65% (n=50)

CI � 10.42 to 31.37%

6 Pain abdomen 16.13% (n=10)

CI� 8.02 to 27.67%

83.87% (n=52)

CI� 72.33 to 91.98%

7 Hepatomegaly 11.29% (n=7)

CI� 78.11 to95.34%

88.71% (n=55)

CI� 78.11 to 95.34%


76

8 Breathlessness 8.20% (n=5)

CI� 2.72 to 18.10%

91.80% (n=56)

CI� 81.9 to 97.28%

9 Koilonychia 4.84% (n=3)

CI � 1.01 to 13.5%

95.16% (n=59)

CI� 86.5 to 98.99%

10 Previous blood transfusion 3.23% (n=2)

CI� 0.39 to 11.17%

96.77% (n=60)

CI� 88.83 to 99.61%

11 Lymphadenopathy 3.23% (n=2)

CI� 0.39 to 11.17%

96.77% (n=60)

CI� 88.83 to 99.61%

12 Hyperpigmentation 1.61% (n=1)

CI� 0.04 to 8.66%

98.39% (n=61)

CI� 91.34 to 99.96%

There is a significant statistical difference

between mean age at presentation (12.7 years

versus 8.11 years, p=0.008), mean hemoglobin

( 4.5 g/dl versus 3.5 gm/dl, p=0.05) mean

weight percentile ( 19.5 versus 43.33 p=0.021),

mean RBC count (2.70 versus 1.30, p=0.001),

mean WBC count (7433 versus 2711 ,p=

0.007), platelets (2.5 lakhs versus 0.79 lakhs,

p=0.00) and blood indices

(MCV,MCHC,MCH) between iron deficiency

anemia group and B12 deficiency anemia group

as shown in Table 3. Children treated

accordingly with iron, folic acid and Vitamin

B12 given, children with severe anemia were

give lasix, blood transfusion in the form of

packed cells, there is symptomatic

improvement. Vigorous counseling was given

regarding nutritional supplementation; there is

no mortality in our series.

TABLE (3): Comparison of variables in IDA& B12 deficiency anemia with P value

Variable B12 def IDA Pvalue

Mean ±std

(n)

Median[range]

(n)

Mean=±std

(n)

Median[range]

(n)

Age at

presentation

12.7778±1.09

(9)

13

(9)

8.1132+4.449

(n=53)

9

(n=53)

0.08

RBC 1.306+0.8032

(n=9)

1.10

(n=9)

2.7057+1.225

(n=53)

2.7

(n=53)

0.01

Wt percentile 43.33+32.88

(n=9)

50

(n=9)

19.528+26.95

(n=53)

3

(n=53)

0.021

Hb% 3.51+1.03 3.80 4.5132+1.447 4.2 0.05


(n=9) (n=9) (n=53) (n=53)

WBC 2711.1+822.26

(n=9)

2900

(n=8)

7433.9+5010

(n=53)

6100

(n=53)

0.07

PLT 0.7911+0.3452

(n=8)

0.8

(n=8)

2.566+1.9199

(n=53)

2.0

(n=53)

0.000

MCV 104.512+7.150

(n=8)

104.35

(n=8)

65.74+17.922

(n=43)

58

(n=43)

0.000

MCH 35.925+1.923

(n=8)

35.9

(n=8)

18.381+7.585

(n=42)

15

(n=42)

0.000

MCHC 0.7911+0.3452

(n=8)

33.75

(n=8)

26.98+4.132

(n=42)

25.75

(n=42)

0.000

DISCUSSION

Nutritional anemia has major consequences not

only on the morbidity and mortality but also

affects their growth and the intellectual

development in children. The prevalence of

severe anemia among children varies between

1.3 to 11% in different regions of the world6.

Iron deficiency is the most prevalent

micronutrient deficiency which affects nearly

70% of under 5 children a per NFHS 3 survey.

In this study severe nutritional anemia of which

females (64.5%) were more compared to males

(35.5% respectively), our data is contradictory

to previous study which shows association

between low hemoglobin levels and male

gender7. Deeksha Kapoor et al have reported

that prevalence of severe anemia among Indian

children aged between 9 to 36 months was

7.8% but in our study 17.7% of children of

same age group had severe anemia8 . Young

children aged 6 to 24 months are particularly at

high risk for severe anemia and a study done by

Nasera Bhatti et al reported that children aged

1 to 3 years constitute the highest risk group

(72.6%) which in comparison to our study,

children aged 7 to 14 years constituted the

highest risk group (64.5%)6. May be due to

nutritional supplementation anganwadi centers

for below 5years children

Severe nutritional anemia was identified as iron

deficiency in 85.4% and vitamin B12

deficiency in 14.5%, younger the age group (<6

years) iron deficiency anemia is the cause for

severe nutritional anemia as opposed to older

age group (7-12yrs), where B12 is the most

common cause. This is consistent with the

study done by Nasera et al6. A study done on

young Mexican9 children and another study

conducted in Malawi10, iron deficiency is not a

predominant cause of severe nutritional anemia,

this is contradictory to the present study.


78

Majority of children with iron deficiency

anemia presented with symptoms of pallor

(90.6%) which is a similar finding by Rachana

Bhoite et al11 who reported pallor in 78.3% of

the children aged 5 to 12 years. Anemia

significantly causes growth impairment and in

the present study, children with iron deficiency

anemia compare to vitamin B12 deficiency

anemia were more underweight (3rd to 25th

percentile, Agarwal charts).

Pancytopenia is a consistent feature of

megaloblastic anemia as proved in earlier

studies and found in our studies, further

supported by Khunger et al who observed that

megaloblastic anemia accounted for over 72%

of cases presenting with pancytopenia 12.

Limitations of the present study are findings

cannot be extrapolated to the community as it is

a hospital based cross sectional study.

Incidence and prevalence of anemia have not

been characterized because of nature of the

study. Though this study was done in small

sample we need to remember that children with

severe anemia younger age IDA is common

older children with B12 deficiency. To validate

this a population based study with the large

number of sample is required.

CONCLUSION

Severe anemia due to nutritional deficiency

more common in younger age . we need to

strength the anganwadi centre for Early

identification, prompt nutritional

supplementation at the community level which

will decrease the hospitalization of children

with severe nutritional anemia, and also aids in

their growth and intellectual development

Acknowledgement: We would like to thank

Chalmeda Anand Rao Institute of Medical

Sciences for granting permission to conduct our

study.

Conflict of Interest: None

Role of Funding Source: None

REFERENCE

1. DeMaeyer EM, Dallmen P, Gurney JM, Hallberg I, sood SK, Srikantia SH, Prevention of iron deficiency anemia

in: Preventing and controlling iron deficiency anemia through primary Health Care, Geneva, world Health

organization 1989, PP, 33 – 42 Anupamsachdeva, AK duth

2. Satya P Yadav, Ramesh Kumar Goyal, Ajay Arora, Devesh Aggarwal, Advances in Peadiatrics . 2012. PP. 760

3. Worldwide Prevalence of Anemia 1993–2005. Geneva, Switzerland: world Health Organization; 2008.

4. Nutritional Anemia in Young Children with Focus on Asia and India, Prakash V Kotecha, Indian J Community

Med. 2011 Jan-Mar; 36(1): 8–16.

5. World Health Organization. Iron Deficiency Anemia: Assessment, Prevention, and Control—A Guide for

Programme Managers.Geneva, Switzerland: World HealthOrganization; 2001.

6. Nasera Bhatti et.al Severe Nutritional Anemia in Hospitalized Children. Ann. Pak. Inst. Med. Sci. 2008; 4(2): 81-

84

7. Domello¨ f M, Lonnerdal B, Dewey KG, et al. Gender differences in iron status during infancy. Pediatrics.


79

2002;110(3):545–552

8. Deeksha Kapoor, Kailash N, Sushma Sharma, Kusum Kela, Iqbal Kaur. Iron statusof children aged 9-36 months

in an urban slumIntegrated Child Development Services Project in Delhi. Indian Pediatr. 2002; 39: 136-144.

9. Duque X, Flores-Hernandez S, Flores-Huerta S, et al. Prevalence of anemia and deficiency of iron, folic acid, and

zinc in children younger than 2 years of age who use the health services provided by the Mexican Social Security

Institute. BMC Public Health. 2007;7:345

10. Calis JC, Phiri KS, Faragher EB, et al. Severe anemia in Malawian children. N Engl J Med. 2008;358(9):888–899

11. Magnitude of Malnutrition and Iron Deficiency Anemia among Rural School Children: An Appraisal Rachana

Bhoite, Uma Iyer ASIAN J. EXP. BIOL. SCI. VOL 2(2) 2011

12. Khunger JM, Arulselvi S, Sharma U, Ranga S, Talib VH. Pancytopenia- a clinicohematological study of 200 cases.

Indian J Pathol Microbiol 2002; 45: 375-379.


*Dr. Madoori Srinivas, Professor, Department of Pediatrics, Chalmeda Anand Rao Institute of Medical

Sciences, Karimnagar, Andhra Pradesh, Ph No: 9866535700, Email ID: [email protected]

Contribution details:-

Concept and guarantor: Author – Madoori Srinivas

Manuscript preparation: Mangat B, Radhika K, Srikanth D

Data compiled: Kapil C


80

ANTIOXIDANT POTENTIALS OF PARTHENIUM HYSTEROPHORUS L

LEAF EXTRACTS

Sankar Narayan Sinha*, Dipak Paul

ABSTRACT

Aim: Synthetic drugs are potentially toxic and are not free from side effects on the host. Therefore an

attempt has been made to study the antioxidant activity of plants. As plants and plant-based drugs are

less toxic and have acceptable side effects, hence in the present study the crude extracts of leaf of

Parthenium hysterophorus L were selected to study antioxidant activity. Methodology: The plant

extracts were prepared by using methanol and the activity was determined by DPPH and ABTS

scavenging assays. Results And Conclusion: It was found that this extract has considerable

antioxidant activity. Phytochemical analysis indicated the presence of flavonoids, tannins, phenolic

compounds, steroids, terpenoids, alkaloids and proteins along with other chemicals.

Key Words: Antioxidant activity, DPPH radical scavenging assay, Parthenium hysterophorus

INTRODUCTION

An antioxidant is a molecule that inhibits the

oxidation of other chemical substances. During

oxidation process transfers of electrons or

hydrogen from a substance to an oxidizing

agent occurs. Oxidation reactions can generate

free radicals which later on can start chain

reactions. When the chain reaction takes place

in a cell, cells may be damaged or dead.

Antioxidants inhibit and stop these chain

reactions by removing intermediary free

radicals, and terminate other oxidation

reactions. They act by being oxidized


81

themselves, so usually antioxidants are

reducing agents such as ascorbic acid,

polyphenols, thiols etc.

Reactive oxygen species (ROS) are major free

radicals generated in many redox processes,

which may cause oxidative damage to

biomolecules, including proteins, sugars, lipids

and DNA. Reactive oxygen species have an

impact on living cells, which help the

pathogenesis of several chronic diseases 1-7.

The action of ROS is opposed by a balanced

system of antioxidant compounds produced in

vivo 8-10. Endogenous antioxidants are

insufficient, and dietary antioxidants are

required to counter measure excess ROS 11.

Hence there has been an increased interest in

the food industry and in preventive medicine in

the development of “Natural antioxidants” from

plant materials.

Parthenium hysterophorus Linn, also known as

carrot grass, congress grass, chatak chandini.

This plant was accidently introduced in India as

contaminants in PL-480 wheat imported from

the USA in the 1950s 12. Plant used as an

analgesic in neuralgia, antipyretic tonic,

febrifuge and its root decoction was helpful in

amoebic dysentery. The leaf extracts have a

role in the fertility, fecundity and behavioral

response 13. The whole plant possesses the

various pharmacological activities such as

anticancer activity on A549 cell line 14, skeletal

muscle relaxant activity 15 and hypoglycaemic

activity 16.

Though the plant is regarded as the allergy

causing agent and develop asthma, the study on

this herb as an alternative of antimicrobial

agents is still limited. Since Parthenium

hysterophorus are known with the herbs with

wide uses, this study therefore set out to assess

the antioxidant potentials and to determine the

phytochemical constituents of methanol extract

of the leaves of this plant.

Plant Description

Parthenium hysterophorus is a much-branched,

annual, erect herbaceous plant which forms a

basal rosette of leaves during initial phase of

growth. The height of the plant is 0.5-1.5 m,

but can occasionally reach up to 2 m or more.

Mature hirsute stems are greenish and

longitudinally grooved and become much

branched at maturity.

Leaves simple, petiolate of growth, lower

leaves relatively large (3-30 cm long and 2-12

cm wide) and are deeply divided. Leaves on the

top branches decrease in size and are also less

deeply divided than the lower leaves. Short,

stiff hairs are present in the lower surface of the

leaves, and to some extent upper surfaces.

Numerous small, white or creamy pedicellate

flowers are arranged in clusters (capitula).

Seeds are achenes, 1.5-2.5 mm long usually

with two or three small scales (a pappus)

produced in each flower-head (capitulum)

(Figure 1).

Taxonomic position of Parthenium

hysterophorus

Kingdom: Plantae

Order: Asterales


82

Family: Asteraceae

Genus: Parthenium

Species: P. hysterophorus

Figure 1: Parthenium hysterophorus Linn

MATERIAL AND METHODS

Collection of Plant Material

The fresh leaves of Parthenium hysterophorus

Linn was collected from Kalyani, West Bengal

(India) in the month of July, 2012 and the plant

was identified and authenticated.

Preparation of extracts

For the preparation of methanolic extract, the

leaves of Parthenium hysterophorus Linn was

cleaned, air dried and grinded into coarse

powder. 50 gm powder was packed into the

soxhlet extractor with methanol (170ml). The

extract was concentrated and dried by using

rotary evaporator and the extract was stored in

a refrigerator at 40C.

Phytochemical Screening

The methanol extract of Parthenium

hysterophorus was studied for their

phytoconstituents using different

phytochemical tests 17.

Antioxidant activity

1. Free radical-scavenging ability by the use

of a stable DPPH radical

The DPPH radical-scavenging activity was

determined using the method proposed by Yen

and Chen 18.

2. Free radical-scavenging ability by the use

of a stable ABTS radical cation

The free radical-scavenging activity was

determined by ABTS radical cation

decolourization assay 19.

RESULTS AND DISCUSSION

Results of phytochemical screening are shown

in Table 1. The leaves extract tested positive

for flavonoids, tannins and phenolic

compounds in both aqueous and methanolic

extract. The methanolic leaves extract

contained alkaloids and proteins, whereas, the

aqueous extract contained steroids and

terpenoids.

Phenolic compounds are important

phytoconstituents and have potential against

different disease because of their antioxidant

properties 20. They are known to possess anti-

diarrheal, anti-inflammatory, antiulcer, anti-

secretary, anti-spasmodic, antitumor activities

and antiviral activities 21. Radical scavenging

via hydrogen atom donation by phenols is


83

believed to be the predominant mechanism of antioxidant action.

Table 1: Qualitatively phytochemical analysis of Parthenium hysterophorus leaves extract

Test Reagents Observation Aqueous

extract

Methanolic

extract

Alkaloids Mayer’s reagent Creamy

precipitate

Negative Positive

Steroids Conc. H2SO4 Reddish brown

precipitate

Positive Negative

Terpenoids Chloroform +

Conc. H2SO4

Reddish brown

interface

Positive Negative

Flavonoids Alkaline reagent Yellow colour to

colourless

Positive Positive

Saponins Water+shake Foam formation Negative Negative

Phenolic

compounds

Alcohol+Ferric

chloride

Bluish green Positive Positive

Tannins Pb-acetate White

precipitate

Positive Positive

Proteins Conc. HNO3+

40% NaOH

Orange colour Negative Positive

Carbohydrates Barfoed’s

reagent

Reddish brown

precipitate

Positive Positive

Amino acids Ninhydrine

reagent

Violet colour Positive Positive

Reducing sugar Benedict’s

reagent

Red precipitate Positive Positive

84

The scavenging the stable DPPH radical is a

widely used method to evaluate the free radical

scavenging ability of various samples 22 which

can accommodate a large number of samples in

a short period of time and is sensitive enough to

detect natural compounds at low concentrations

so it was used in the present study for screening

of antioxidant activity. The present study

revealed that the radical- scavenging activities

of all the extracts increased with increasing

concentrations (Table 2).

Table 2: In vitro free radical scavenging activity of Parthenium hysterophorus leaves by DPPH method

Compounds % Scavenging IC50

20µg/ml 40µg/ml 60µg/ml 80µg/ml 100µg/ml

Standard

(Ascorbic acid)

6.3±0.52 16.2±0.92 29.9±0.76 33.8±0.84 48.6±0.32 54.4±10.22

Parthenium

hysterophorus

Linn

8.2±0.74 17.4±0.45 33.8±0.98 40.9±0.68 54.5±1.20 60.2±14.09

The ABTS scavenging assay, which employs a

specific absorbance (734 nm) at a wavelength

remote from the visible region and requires a

minimum reaction time and may be used as an

index that reflects the antioxidant activity of the

test samples 23. In the following table (Table 3),

Parthenium hysterophorus extract was found to

be effective in scavenging radicals and the

increase was concentration-dependent. At

100µg/ml, the inhibition of the extract was

93.2% (Table 3).

Table 3: In vitro free radical scavenging activity of Parthenium hysterophorus leaves by ABTS method

Compounds % Scavenging IC50

20µg/ml 40µg/ml 60µg/ml 80µg/ml 100µg/ml

Standard

(Ascorbic acid)

53.4±5.2 68.4±2.1 81.5±4.2 85.4±5.1 91.5±0.85 17.22±5.82


85

Parthenium

hysterophorus

Linn

45.8±3.8 56.2±6.01 68.8±2.4 78.6±3.05 93.2±0.72 33.6±10.6

CONCLUSIONS

Methanolic extracts of P. hysterophorus L.

showed significant antioxidant activity as

compared to the ascorbic acid. This might be

due to the presence of bioactive elements and

phenolic constituents present in the extract.

Based on the significant results obtained in this

study, further work is required for isolation and

purification of bioactive compounds so that

novel antioxidant drugs from this medicinal

plant can be exploited.

ACKNOWLEDGEMENT

The authors are thankful to University of

Kalyani, West Bengal, India for providing

necessary facilities for doing this research.

Authors acknowledge the financial support

received under the grant from DST PURSE,

New Delhi, India for this study.

REFERENCES

1. Halliwell B, Grootveld M. The measurement of free radical reactions in humans: some thoughts for future

experimentation. FEBS Letters. 1987; 213(1): 9–14.

2. Ames BM, Shigenaga MK, Hagen TM. Oxidants, antioxidants and the degenerative diseases of aging. Proceedings

of the National Academy of Sciences of the United States of America. 1993;90(17): 7915-7922.

3. Harman D. Aging: phenomena and theories. Annals of the New York Academy of Sciences. 1998; 854:1-7.

4. Finkel T, Holbrook NJ. Oxidants, oxidative stress and the biology of ageing. Nature. 2000; 408: 239–247.

5. McDermott JH. Antioxidant nutrients: current dietary recommendations and research update. Journal of the

American Pharmacists Association. 2000; 40(6): 785–799.

6. Chahar MK, Sharma N, Dobhal MP, Joshi YC. Flavonoids: a versatile source of anticancer drugs.

Pharmacognosy Reviews. 2011;5(9): 1-12.

7. Wong FC, Chai TT, Hoo YW. Antioxidation and cytotoxic activities of selected medicinal herbs used in Malaysia.

Journal of Medicinal Plants Research. 2012;6(16): 3169-3175.

8. Halliwell B, Gutteridge JMC. Free radicals in biology and medicine (3rd ed). Oxford: Clarendon Press. 1999.

9. Khan RA, Khan MR, Sahreen S, Bokhari J. Prevention of CCl4-induced nephrotoxicity with Sonchus asper in rat.

Food and Chemical Toxicology. 2010;48(8-9): 2469-2476.

10. Khan RA, Khan MR, Sahreen S. Protective effect of Sonchus asper extracts against experimentally induced lung

injuries in rats: a novel study. Experimental and Toxicologic Pathology. 2012;64(7-8): 725-731.

11. Lim YY, Murtijaya J. Antioxidant properties of Phyllanthus amarus extracts as affected by different drying

methods. LWT-Food Science and Technology. 2007;40(9): 1664-1669.

12. Rao RS. Parthenium: A new record for India. Journal of the Bombay Natural History Society. 1956;54: 218-220.


86

13. Kumar S, Singh AP, Nair G, Batra S, Seth A, Wahab N, Warikoo R. Impact of Parthenium hysterophorus leaf

extracts on the fecundity, fertility and behavioural response of Aedes aegypti L. Parasitology Research.

2011;108(4): 853–859.

14. Ramamurthy SK, Pittu VP, Kotturi R, Devi P, Kumar S. In vitro cytotoxic activity of methanol and acetone extracts

of Parthenium hysterophorus Flower on A549 cell lines. International Journal of Pharmaceutical Sciences Review

and Research. 2011;10(2): 95-99.

15. Jha U, Chhajed PJ, Oswal RJ, Shelke TT. Skeletal muscle relaxant activity of methanolic extract of Parthenium

hysterophorus L. leaves in swiss albino mice. International Journal of Pharmacy and Life Sciences. 2011;2(11):

1211-1213.

16. Patel VS, Chitra V, Prasanna PL, Krishnaraju V. Hypoglycemic effect of aqueous extract Parthenium

hysterophorus L. in normal and alloxan induced diabetic rats. Indian Journal of Pharmacology. 2008;40(4): 183-

185.

17. Harborne JB. Phytochemical methods.3rd ed. London. Chapman and Hall. 1984.

18. Yen GC, Chen HY. Antioxidant activity of various tea extracts in relation to their antimutagenicity. Journal of the

Agricultural and Food Chemistry. 1995;43(1): 27–32.

19. Re R, Pellegrini N, Proteggente A, Pannala A, Yang M, Rice-Evans C. Antioxidant activity applying an improved

ABTS radical cation decolorization assay. Free Radical Biology and Medicine. 1999;26(9–10): 1231–1237.

20. Rice-Evans C. Flavonoid antioxidants. Current Medicinal Chemistry. 2001;8(7): 797–807.

21. Carlo GD, Mascolo N, Izzo AA, Capasso F. Flavonoids: old and new aspects of a class of natural therapeutic

drugs. Life Sciences. 1999; 65(4): 337–353.

22. Lee SE, Hwang HJ, Ha JS, Jeong HS, Kim JH. Screening of medicinal plant extracts for antioxidant activity. Life

Sciences. 2003;73(2): 167-179.

23. Wu LC, Hsu HW, Chen YC, Chiu CC, Lin YI, Ho JA. Antioxidant and antiproliferative activities of red pitaya.

Food Chemistry. 2006;95(2): 319–327.

CORRESPONDENCE

* Environmental Microbiology Research Laboratory, Department of Botany, University of Kalyani,

Kalyani-741235, West Bengal, India; Email: [email protected]


87

COMPARATIVE STUDY ON s-LPS AND bp26 BASED iELISA FOR HUMAN

BRUCELLOSIS

Narayana Rao.K *, R Shome, Jayapal Gowdu B**,Nagalingam M, Balamurugan1V, B. R.

Shome, K Prabhudas and Rahman.H

ABSTRACT

Brucellosis is an emerging zoonotic disease caused by members of the genus Brucella and remains a

serious cause of human illness from livestock. Presently used sero-diagnostic tests depend upon the

smooth lipopolysaccharide (sLPS), which cross react with other Gram–negative bacteria resulting in

low specificity. To overcome this, several recombinant outer membrane proteins (OMP) have been

tried as diagnostic antigen (s) in ELISA. In the present study, the ORF (753 bp product) of BP 26

protein was amplified from Brucella suis strain 1330, cloned in pET32a vector and expressed in BL21

E.coli hostcell. The expressed protein was purified by Ni-NTA column and characterized by SDS-

PAGE and Western blot analysis. The purified recombinant protein (rbp26) antigen was tested in

indirect ELISA (iELISA) and specificity was checked with E. coli (O157 H7), 17 salmonella and five

Yersinia entericolitica reference sera. Further, rbp26 based standardized ELISA was evaluated with

serum samples (n=626) collected from risk group individuals (veterinarians) using two conjugates IgM

and IgG for diagnosis of brucellosis. Comparative evaluation of the developed assay with RBPT and

sLPS based ELISA was carried out. In RBPT, 60 (9.5%) and in sLPS antigen based iELISA-IgM 36

(5.75%) and iELISA-IgG 122 (19.48%) were positive, respectively. Whereas in rbp26 based ELISA 18

(2.87%) and 66 (10.54%) were positive in IgM and IgG ELISA, respectively.


88

Keywords: RBPT, STAT, IgM ELISA, IgG ELISA, Human, Brucellosis, Blood donors, Risk group

INTRODUCTION

Brucellosis is a zoonosis caused by facultative

intracellular bacteria of the genus Brucella,

which are capable of surviving and multiplying

inside the cells of mononuclear phagocytic

system and are widely distributed in both

humans and animals 1. Human brucellosis

varies from an acute fabrile illness to chronic,

low grade ill defined disease. It is a systemic

disease characherized by pausity of signs

accompanied with nocturnal sweating, malaise,

fatigue and backache 2. The disease can be a

very debilitating, despite the fact that the

fatality rate is generally low. It often becomes

sub-clinical or chronic, especially if not

diagnosed early and properly treated. The

incidence in humans ranges widely between

different regions, with values of up to 200 cases

per 100,000 populations with high prevalence

in Middle East, Mexico, Central and South

America and the Indian subcontinents 2,3.

High-risk groups include those exposed

through occupation in contexts where animal

infection occurs, such as slaughterhouse

workers, hunters, farmers and veterinarians.

The diagnosis of brucellosis can be

challenging, and its diagnosis demands

epidemimology, clinical and laboratory

information. Its routine biochemical and

hematological laboratory tests also overlap with

those of many other pathogens such as

Salmonella, Yersinia, and Vibrio 4. Many tests

are reported for diagnosis of Brucella, ranging

from microbilogical culture to serodiagnostic

tests such as slide or tube agglutination, indirect

coombs test, enzyme-linked immunosorbent

assay (ELISA) and indirect fluorescent assays,

to the recent molecular techniques such as

polymerase chain reaction (PCR) are

available.5, 6, 7.

Isolation from blood, bone marrow and other

tissues of suspect is classical diagnostic (gold

standard) method for brucellosis. However, this

microbiological technique is having the draw

back of time consumption as the organism is

having incubation period of 6 weeks and

possibility of contamination to personnel

cannot be avoided 8. Rose Bengal Plate test

(RBPT) is commonly used for the screening of

brucellosis however results may at times

inconclusive 9. In standard tube agglutination

test (STAT), interpretation of the result is

difficult due to false positive reaction with

Salmonella, Yersinia and Vibrio species.

Further PCR is the molecular technique which

is employed for the detection of brucellosis,

but the technique is uneconomic and poorly

suited for the laboratory with limited resources.

In view of these limitations, robust, coast

effective and rapid ELISA has been found an

ideal tool for the diagnosis. Current serological

tests based mainly on s-LPS antigen, chances in

possible of false positivity due to cross-

reactivity. In view of all these facts, the present

study have been taken to develop recombinant


89

antigen based ELISA for diagnosis of

brucellosis in swine and humans. The

recombinant outer-membrane protein (rOmp26)

was purified from B.suis 1330 in pET-32a

bacterial expression system and used in an

indirect ELISA for the detection of Brucellosis.

Comparisons of recombinant antigen based

iELISA against RBPT, and s-LPS based

iELISA.

In brucellosis, titre of IgM usually raises from

day 5 to 7 with peak titre and IgG starts to

appear from day 14 to 21, reaching peak during

next 2 to 3 weeks in the infected individuals.

Clinical applications of IgM and IgG ELISA in

human disease have been reported 10, 11. This

manuscript deals with the study on

development and evaluation of recombinant

bp26 antigen based indirect ELISA for the

sero-diagnosis of Brucella infection in human

beings and its comparison with laboratory

standardized IgM and IgG ELISA protocol.

MATERIALS AND METHODS

Collection of sera samples

During the course of the study, 2 ml of blood

samples without anticoagulant was collected

aseptically in vaccutainers. The samples were

sourced from risk group (veterinarians, para

veterinarians, farm workers, animal-handlers

and farmers), blood donors and patients with

pyrexia of unknown origin (PUO). The pyrexia

may be due to systemic cause of rheumatic

fever, jaundice, C reactive protein, hepatitis

etc., The samples were allowed to clot,

transported to laboratory immediately at 4°C.

The serum was separated by centrifuging the

sample at 2500 r.p.m for 5 min and stored at –

20°C for further use.

Rose Bengal Plate Test (RBPT) and

Standard Tube Agglutination Test (STAT)

Sera samples received were initially subjected

to rapid screening RBPT according to standard

procedures 12. Briefly, for the RBPT, undiluted

serum sample (30 µl) was mixed with an equal

volume of colored antigen on a glass slide. The

results were rated negative when agglutination

was absent and 1+ to 4+ ratings as positive,

according to the strength of the agglutination

within 1 to 3 min.

Smooth Lipopolysaccharide (sLPS) antigen

extraction

Standard strain

Standard antigenic strain of B.suis 1330

procured from Indian Veterinary Research

Institute, Izatnagar, U.P., India and confirmed

as B.suis 1330 by biochemical tests, PCR,

cloning and sequencing in our was used for

antigen extraction 15.

Large scale bacterial culturing

Freshly grown pure colonies were suspended in

10 ml of sterile PBS, after vortexing, the

bacterial suspension was overlaid on Tryptose

Agar (TA) in Roux flasks. Thirty flasks were

simultaneously inoculated from the same

master plate to provide the identical bacterial

population originating from a single colony.


90

After one-hour adsorption, Roux flasks were

inverted and incubated for 72 hours at 37oC.

The purity of the culture in every flask was

confirmed by Gram’s staining after 48 hours.

To each flask, 30 ml of 2% phenol saline was

added, gently agitated and incubated for 24

hours at 37oC. The suspensions were collected,

pooled, centrifuged at 14,000 r.p.m at 4oC for

20 min. The centrifugation was repeated and

pellets were carefully collected, weighed and

used for antigen extraction.

Preparation sLPS antigen extraction

Wet cells of Brucella (5 gm) were suspended in

17 ml of distilled water and followed by the

addition of 19 ml of 90% (v/v) phenol at 66°C.

The mixture was stirred continuously at 66°C

for 15 min, cooled and centrifuged at 10,000

rpm for 15 min at 4°C. The brownish phenol in

the bottom layer was aspirated with a long

micro tip and large cell debris was removed by

filtration (using a Whatman No.1 filter).The

sLPS was precipitated by the addition of 50 ml

chilled methanol containing 0.5 ml methanol

saturated with sodium acetate. After 2 hours

incubation at 4°C, the precipitate was removed

by centrifugation at 10,000 r.p.m for 10 min,

stirred with 8 ml of distilled water for 18 hours

and centrifuged at 10,000 r.p.m for 10 min. The

collected supernatant solution was kept at 4°C

and this step was repeated twice for the best

recovery of antigen. Then, 0.8 g of

trifluroacetic acid was added to the 16 ml of

crude sLPS, stirred for 10 min and the

precipitate was removed by centrifugation. The

translucent supernatant solution was

concentrated and dialyzed against distilled

water (two changes of at least 4000 ml each)

and then freeze dried to get the final yield of 10

ml of sLPS containing the antigen

concentration of 3 mg/10ml. 16.

The optimum concentration of antigen for

ELISA was standardized by checkerboard

titration against 1:100 and 1:200 dilution of

strong positive convalescent sera . The OD

values were plotted on a graph and the point

where there was sharp fall on the line graph

was taken as the optimum dilution of antigen.

Standardized ELISA protocol

The polysorp micro titer plates (Nunc,

Germany) were coated with 1:300 dilution of

sLPS antigen at 100 µl per well in carbonate-

bicarbonate buffer (pH 9.6) and incubated 4°C

for overnight. Antigen coated plates were

washed three times with PBST wash buffer

(Phosphate buffered saline containing 0.05 %

Tween 20) pH 7.2. Test and control sera diluted

in PBST blocking buffer (1:100) containing 2%

bovine gelatin was added to respective wells

(100 µl) of the plates in duplicates (test sera)

and quadruplicate (controls) and incubated at

37°C for 1hour. The plates were then washed as

mentioned earlier. The anti-human IgG and IgM

HRP conjugates (Pierce, Germany), diluted

1:8000 and 1:4000 respectively in PBST buffer

were added to all the wells (100 µl) and

incubated for 1 hour at 37°C on orbital shaker

(300 r.p.m./min). After washing, freshly

prepared o-Phenylenediaminedihydrochloride

(OPD) (Sigma, Germany) solution containing 5


91

mg OPD tablet in 12.5 ml of distilled water and

50 µl of 3% H2O2 was added and kept for color

development for 10 min. Enzyme-substrate

reaction was stopped by adding 1M H2SO4 (50

µl) and color development was read at 492 nm

using an ELISA micro plate reader (Biorad).

The optical density (OD) obtained for the

negative and positive samples were interpreted

by cutoff values set at 3 standard deviations

above the arithmetical mean of the OD obtained

for the healthy controls 17.

Production and purification of recombinant

BP26 protein.

Standard antigenic strain, Brucella suis 1330

was procured from IVRI, Izatnagar. The

organism was grown in brucella selective agar

media at 37ºC for 48 hrs at 10% CO2. The

organism was identified as Gram negative,

coccobacillary rods on Gram’s staining. The

genomic DNA was extracted as per the standard

protocol, using the “Bacterial genomic DNA

spin” – QIAamp. The PCR amplification was

carried out in 25µl reaction volume containing

12.5µl of 2X PCR master mix (4 mM MgCl2;

0.4 mM of each deoxynucleotide triphosphates

(dNTPs); 0.5U of Taq DNA polymerase; 150

mM Tris-HCl PCR buffer), primers and 2.5µl of

template DNA. The Thermal cycler conditions

for BCSP31 are 930C for 5min 1 cycle; 35

cycles of 900C for 1min; 60 0C for 30sec and

720C for 1min with a final extension of 720C for

7 min. The PCR amplicons (5µl) were separated

by electrophoresis in 1.5% agarose gel with

TAE as running buffer and purified.

The purified Genomic DNA from B.suis 1330

was used for the amplification of the target

gene rbp26 using published primer sequences.

The cycling conditions followed were:

preheating at 950C for 2min 1 cycle; 35 cycles

of 940C for 45sec; 50 0C - 60 0C for 45sec and

720C for 2min with a final extension of 720C

for 10 min. The products were analysed by

agarose gel electrophoresis as mentioned

before. The amplified product was purified

from the gel using “MinElute gel extraction

kit” from QIAGEN and employed for further

sequencing and cloning 35,36.

Cloning and expression of rbp26 gene :

The purified PCR product digested with EcoR1

and Not1 which was ligated with digested

pGEMT vector, was transferred into E. coli

Top10F competent cells and plated on LB amp

plates, incubated overnight at 37oC. Several

ampicillin resistant colonies appeared and were

streaked on LB amp plates for further

recombinant clones for the presence of rbp26

gene. After an incubation of 16 hours at 370C,

both blue (non recombinant) and white colonies

(recombinant) were observed on LB Agar-amp

supplemented with IPTC and X-gal plate and

white colonies (recombinant clones) were

purified, used as template and confirmed by

Colony PCR. The amplified products were

analyzed by agarose gel electrophoresis and

further subjected to confirmation by restriction

enzyme (RE) digestion 40.

The inserted rbp26 gene sequence is of 753bp

nucleotides. The cloned bp26 gene was


92

released from pGEMT bp26 by EcoR1 and

Not1, digestion. The fragment was sub cloned

into pET-32a vector and analyzed by agarose

gel electrophoresis then it was digested with

EcoR1 and Not1. After transformation of

pETBP26 into E. coli BL21 competent cells

several recombinant clones were formed on the

LB plate supplemented with ampicilin. Plasmid

DNA extracted from recombinant clone

digested with which was ligated with digested

pET-32a vector, was transferred into EcoR1

and Not1 released 753bp insert.

The transformed competent BL21 cells and

pET-32a vector as a control and pETBP26

recombinant clones of interest were induced

with 1mM IPTG and incubated for sixteen

hours at 370C. The induced cell lysates were

collected at one hour interval. The lysates of

proteins were analyzed by 12 percent SDS

PAGE and followed by western blotting. The

size of the rbp26 gene is 753bp which

corresponded to 42kDa protein. Thus along

with fusion tag of 18kDa, the rbp26 protien

showed in the gel as 42kDa band. No reaction

was seen with respect to blots treated with

Yersinia enterocolitica O:9, and Escherichia

coli O:157 referral sera, This showed that the

expressed protein was of Brucella specific

epitope and there was no cross reaction with

positive and negative sera.

Standardized ELISA protocol

The polysorp micro titer plates (Nunc,

Germany) were coated with 200ng/well

antigen at 100 µl per well in carbonate-

bicarbonate buffer (pH 9.6) and incubated 4°C

for overnight. Antigen coated plates were

washed three times with PBST wash buffer

(Phosphate buffered saline containing 0.05 %

Tween 20) pH 7.2. Test and control sera

diluted in PBST blocking buffer (1:100)

containing 5% skim milk power was added to

respective wells (100 µl) of the plates in

duplicates (test sera) and quadruplicate

(controls) and incubated at 37°C for 1hour.

The plates were then washed as mentioned

earlier. The anti-human IgG and IgM HRP

conjugates (Pierce, Germany), diluted 1:5000

and 1:5000 respectively in PBST buffer were

added to all the wells (100 µl) and incubated

for 1 hour at 37°C on orbital shaker (300

r.p.m./min). After washing, freshly prepared o-

Phenylenediaminedihydrochloride (OPD)

(Sigma, Germany) solution containing 5 mg

OPD tablet in 12.5 ml of distilled water and 50

µl of 3% H2O2 was added and kept for color

development for 10 min. Enzyme-substrate

reaction was stopped by adding 1M H2SO4 (50

µl) and color development was read at 492 nm

using an ELISA micro plate reader (Biorad).

RESULTS

In ELISA, the 1 in 200 sLPS antigen

concentration was found optimum at serum

concentration of 1 in 100 (Fig 1). Similarly, the

conjugate dilutions were established by

checkerboard titration and IgM conjugate of 1

in 4000 and IgG conjugate at 1 in 8000 were

found optimum dilutions for the test (Fig. 2).

Similarly for rbp26 based ELISA antigen

concentration was 200ng / well was found


93

optimum at serum concentration of 1:32 and

the conjugate dilutions were established by

checkerboard titration at 1:5000 for both IgG

and IgM.

Among the 626 serum samples collected from

risk group individuals (veterinarians) using two

conjugates IgM and IgG for diagnosis of

brucellosis. Comparative evaluation of the

developed assay with RBPT and sLPS based

ELISA was carried out. In RBPT, 60 (9.5%)

and in sLPS antigen based iELISA-IgM 36

(5.75%) and iELISA-IgG 122 (19.48%) were

positive, respectively (Fig.6). Whereas in rbp26

based ELISA 18 (2.87%) and 66 (10.54%)

were positive in IgM and IgG ELISA

respectively (Fig.5). Similarly comparative

evaluation of the OD values of the both the

assays were documented. (Fig:7,8)

Antigen and antibody optimization

00.20.40.60.8

11.21.41.61.8

0 1000 2000 3000 4000

Antigen dilution

OD

at

492

nm

1 in 200

1 in 100

Figure 1. Optimization of antigen versus serum concentration for ELISA (All the dilution are at the rate

of 1 in 100, 1 in 200, 1 in 400, 1 in 800, 1 in 1600 and 1in 3200 respectively)

Conjugate titration curve

0

0.2

0.4

0.6

0.8

1

1.2

0 10000 20000 30000 40000

Antigen dilution

OD

at

492

nm

IgM Conjugate

IgG Conjugate

Figure 2. Optimization of conjugates for ELISA (All the dilutions are at the rate of 1 in 1000, 1 in


94

2000, 1 in 4000, 1 in 8000, 1 in 16000 and 1in 32000 respectively)

Fig 3: SDS-PAGE analysis of sequential elutes

of recombinant protein bp26 suis1330

Fig 4: Western blot analysis with swine

brucella positive and negative sera

Fig 5: Comparision of OD values with two

conjugates used in rbp26 based Human iELISA

Fig 6: Comparison of OD values with two

conjugates used in sLPS based Human iELISA

Fig 7: Comparison OD of values sLPS and

rbp26 based Human iELISA with anti human

IgG


95

Fig 8: Comparison OD of values sLPS and

rbp26 based Human iELISA with anti human

IgM

Fig 9: Standardization and cut-off PP for s-LPS

and rbp26 based Human iELISA

DISCUSSION

The true incidence of human brucellosis

however, is unknown for most countries and no

data are available for many parts of India. It has

been estimated that the true incidence may be

25 times higher than the reported incidence due

to misdiagnosis and under-reporting. Several

publications indicate that human brucellosis

can be a common disease in India. The ELISA

was first developed by Carlson et al, for the

diagnosis of human brucellosis and since then,

a large number of variations have been

described 18. ELISA have a distinct advantage

over conventional serological tests in that, they

are primary binding assays that do not rely on

secondary properties of antibodies such as their

ability to agglutinate or to fix complement.

Secondly, ELISA can be tailored to be more

specific by using highly purified reagents such

as antigens and monoclonal antibodies.

The sLPS antigen of Brucella is considered the

most important antigen during immune

response and is the target for many serological

and immunological studies. It gives better

sensitivity and specificity with good

reproducibility. It also possesses a convenient

cut off value for diagnostic purposes. Finally, it

is not restricted to bovines alone and can be

adapted to different species of animals as well

as to humans beings 3. The sLPS antigen coated

passively on to a polystyrene matrix is the

method commonly employed in the ELISA19.

The indirect ELISA and AB-ELISA have seen

standardized by several researchers using sLPS

antigen from B. abortus S99 to screen the

livestock and humans for brucellosis 15, 19, 20, 21.

Similar antigenic studies has been taken on the

bp26 by several researchers and previously

identified B.suis 1330 bp26 immunodominant

antigen36 is nearly identical to the B. abortus

BP26 antigen reported by Rossetti et al 35. The

name of BP26 should therefore be retained. The

fact that two independent laboratories have

identified the same immunodominant antigen

either in the field of bovine or ovine 37,38,39

brucellosis emphasizes the importance of BP26


96

as diagnostic antigen40.

The higher prevalence rates reported by various

researchers are in accordance with our present

findings in the high risk groups 21, 25, 30. High

sero prevalence in the risk group is attributed to

constant exposure to infection due to

contamination of hands and arm while handling

animals and also human infection can occur

through aerosol, occupational exposure of

abattoir workers, veterinarians and laboratory

technicians. In addition, consumption of

infected raw milk, raw milk products and raw

meat can result in infection 25.

The transmission of brucellosis to man is

primarily by direct contact with infected

animals or their products. However, the

organisms can also be transmitted by

transfusion of infected blood 31. The blood

donors tested in the study, showed 1.62%

positivity by RBPT and 4.87%, by IgG ELISA.

Two such similar reports from Karnataka,

revealed the prevalence ranging from 1.8%

(out of 26,948 adult donors )25 to 14.7% (out

of 353 donors) by RBPT32. These findings

are relatively identical to our findings. This

infection in the donors might be due to the

exposure of the donors unintentionally to the

animals or due to the consumption of raw milk,

or may be due to the cross reacting antibodies

such as vibrio or yersinia.

The basic knowledge of this study will help us

for the development of indigenous ELISA kit

for sero screening of the disease in humans and

to identify active infection (IgM ELISA). The

use of sLPS and rbp26 as antigen in the I-

ELISA might be one of the reasons for higher

sensitivity as the stronger immune responses

are elicited against sLPS and found that the

very specific immune response against rbp26 in

infected individual. The advantage of using the

indigenously developed kit/tests is that the

large number of samples can be analyzed

economically and it will also help to generate

seroepidemiological data of the disease in the

country. Screening of large number of sera

samples and validation as per OIE guidelines is

underway.

REFERENCES

1. Jarvis BW, Harris TH, Qureshi N, Splitter GA: Rough lipopolysaccharide from Brucella abortus and Escherichia

coli differentially activates the same mitogen-activated protein kinase signaling pathways for tumor necrosis

factor alpha in RAW 264.7 macrophage-like cells. Infect Immun 2002; 70:7165-7168.

2. Vaishnavi C, Kumar S. Investigation for background prevalence of Brucella agglutinins among the blood donors.

Indian J Med Micro 2007; 25:302-304.

3. Salmani AS, Siadat S, Fallahian MR, Ahmadi H, Norouzian D, Yaghmai P, Aghasadeghi MR, Mobarakeh JI, Sadat

SM, Zangeneh M, Kheirandish M. Serological evaluation of Brucella abortus S99 Lipopolysaccharide extracted by

an optimized method. Am J Infe Dis 2009; 5:11-16.

4. Fadeel MA, Wasfy MO, Pimental G, Klenna JD, Mahoney FJ, Hajjeh RA. Rapid enzyme linked immunosorbent

assay for the diagnosis of human brucellosis in surveillance and clinical settings in Egypt. Saudi Med J. 2006;

27:975-981.


97

5. Baily G, Krahn G, Drasar JB, Stoker NG. Detection of Brucella melitensis and Brucella abortus by DNA

amplification. J Trop Med Hyg 1992; 95:271–275.

6. Bricker BJ, Halling SM. Differentiation of Brucella abortus bv. 1, 2, and 4, Brucella melitensis, Brucella ovis, and

Brucella suis bv. 1 by PCR. J Clin Microbiol 1994; 32:2660-2666.

7. Ouahrani-Bettach S, Soubrier MP, Liautard JP. 1S6501- anchored PCR for the detection and identification of

Brucella species and strains. J Appl Biotechnol 1996; 81:154-160.

8. Srikantiah P, Girgis FY, Luby SP, Jennings G, Wasfy MO, Crump JA Population based surveillance of typhopid

fever in Egypt. Am J Trop Med Hyg 2006; 74:114-119.

9. Dahouk SA, Tomaso H, Nockler K, Neubauer H, Frangoulidis D. Laboratory based diagnosis of brucellosis. A

review of literature. Part II : Serological test for brucellosis . Clin Lab 2003; 49:577-589.

10. Queipo-Ortuno MI, Morata P, Ocon P, Manchado P, Colmenero JD. Rapid diagnosis of human brucellosis by

peripheral-blood PCR assay. J Clinic Microbiol 1997; 35: 2927–2930.

11. Morata P, Queipo-Ortuño MI, Reguera JM, García-Ordoñez MA, Cárdenas A, Colmenero JD, Development and

evaluation of a PCR-enzyme-linked immunosorbent assay for diagnosis of human brucellosis. J Clin Microbios

2003;41:144-148.

12. Alton GG, Jones LM, Angus RD, Verger JM, Techniques for the Brucellosis Laboratory. 1st Edn., Institute

Nationale de le Rech, France, Paris, 1988. pp: 174

13. Smits HL, Kadri SM. Brucellosis in India: A deceptive infectious disease. Indian J Med Res 2005; 122:375-384.

14. Moreno S, Ariza J, Espinosa F J. Brucellosis in patients infected with the human immunodeficiency virus. Eur J

Clin Microbiol Infect Dis 1998; 17:319–326.

15. Shome R, Shome BR, Deivanai M, Desai GS. Patil SS, Bhure SK, Prabhudas K. Microbiol, Immun Infect Dis

Seroprevalence of brucellosis in small ruminants. Indian J Comp mirobiol, Immunology-infectious disease 2006;

27:13-15.

16. World Organization for Animal Health (OIE). Manual of diagnostic tests and vaccines 2004 [online]. Paris: OIE;

2004. Bovine brucellosis. Available at: http://www.oie.int/eng/normes/mmanual/A_00052.htm. Accessed 4 Jun

2007

17. Daniel TM, Debanne SM, Sero diagnosis of tuberculosis and other mycobacterial diseases by enzyme linked

immunosorbant assay. Am Rev Respir Dis 1987:137: 1137-1151.

18. Carlson, HE, Hurvell B, Lindberg AA. Enzymelinked immunosorbent assay (ELISA) for titration of antibodies

against Brucella abortus and Yersinia enterocolitica. Acta Pathol. Microbiol Immunol Scand Sect C 1976;

84:168-176

19. Nielsen KH, Kelly L, Gall D, Nicoletti P, Kelly W. Improved competitive enzyme immunoassay for the diagnosis of

bovine brucellosis. Vet Immunol Immunopathol 1995; 46:285–291.

20. Renukaradhya GJ, Isloor S, Rajasekhar M. Epidemiology, zoonotic aspects, vaccination and control/eradication of

brucellosis in India. Vet. Microbiol 2002; 90: 183-195

21. Agasthya AS, S Isloor, K Prabhudas. Brucellosis in high risk group individuals Indian J Med Microbiol 2007; 25:

28-31

22. Guarino A, Serpe L, Fusco G, Scaramuzzo A, Gallo P.. Detection of Brucella species in buffalo whole blood by

gene-specific PCR. Vet Rec. 2001; 147: 634- 636

23. Bricker BJ. PCR as a diagnostic tool for brucellosis. Vet Microbiol 2002; 90: 435–446

24. Mantur BG, Akki AS, Mangalgi SS, Patil SV, Gobbur RH, Peerapur BV. Childhood brucellosis - a

microbiological, epidemiological and clinical study. J Trop Pediatr 2004; 50:153¬7.


98

25. Mantur BG, Biradar MS, Bidri RC, Mulimani MS, Veerappa, Kariholu P, Protean clinical manifestations and

diagnostic challenges of human brucellosis in adults: 16 years' experience in an endemic area. J Med Microbiol

2006; 55:897-903

26. Mathur TN. A study of human brucellosis based on cultutre isplated from man and animals. Indian J Med Res

1968; 56: 250-258

27. Handa R, Singh S, Singh N, Wali JP. Brucellosis in north India: results of a prospective study. J Commun Dis

1998; 30: 85-87.

28. Mrunalini N, Reddy MS, Ramasastry P, Rao MR. Seroepidemiology of human brucellosis in Andhra Pradesh.

Indian Vet J 2004; 81:744-747.

29. Ajay Kumar VJ, Nanu E. Seropositivity of brucellosis in human beings. Indian J Public Healt 2005; 49:22-24.

30. Hussain I, Gokul BN, Paul A. Brucellosis associated with thrombocytopenia. Saudi Med J 2000; 21:877-879.

31. Khorasgani MR, Esmaeili H, Pourkarim MR, Mankhian AR, Zahraei Salehi T. Anti-brucella antibodies in blood

donors in Boushehr, Iran. Comp Clinic Pathol 2007; 17: 267-269.

32. Nagrathna S, Sharmada S, Veena kumari HB, Arvind N, Sunder P, Sangeeth S. Seroprevalence of Brucella

agglutinins: A pilot study. Indian J Pathol Microbiol 2009; 52:457-458.

33. Sen MR, Shukla BN, Goyal RK. Seroprevalence of brucellosis in and around Varanasi; J. Commun. Dis 2002;

34:226–227.

34. Kadri SM, Rukhsana A, Laharwal MA, Tanvir M. Seroprevalence of brucellosis in Kashmir (India) among patients

with pyrexia of unknown origin. J Indian Med Assoc 2000; 98:170-171.

35. OSVALDO L. ROSSETTI,* ALICIA I. ARESE, MARIA L. BOSCHIROLI, AND SILVIO L. CRAVERO Cloning of

Brucella abortus Gene and Characterization of Expressed 26-Kilodalton Periplasmic Protein: Potential Use for

Diagnosis JOURNAL OF CLINICAL MICROBIOLOGY, Jan. 1996, p. 165–169

36. Xuan Z. Ding, Apurba Bhattacharjee, Mikeljon P. Nikolich, Ian T. Paulsen, Gary Myers, Rekha Seshadri and

David L. Hoover Cloning, expression, and purification of Brucella suis outer membrane proteins Division of

CD&I, Department of Bacterial Diseases, Walter Reed Army Institute of Research, Washington, DC, USA The

Institute for Genomic Research, MD, USA 04/2005; 40(1):134-41. DOI:10.1016/j.pep.2004.12.017 Source:

PubMed.

37. Cloeckaert, A.. Salih-Alj Debbarh. H., Zygmunt. M.S. and Dubray. G. (1996) Production and characterization of

monoclonal antibodies to Brucella melitensis cytosoluble proteins which are able to differentiate antibody

responses of infected from Rev.1 vaccinated sheep. J. Med. Microbial.

38. Salih-Alj Debbarh, H.. Cloeckaert, A., Bezard. G.. Dubray. G. and Zygmunt, M.S. (1996) Enzyme-linked

immunosorbent assay with partially purified cytosoluble 28-kilodalton protein for serological differentiation

between Bruce/la melirensis-infected and B. melirensis Rev. I -vaccinated sheep. Clin. Diagn. Lab. lmmunol.

39. Debbarh. H.S.A.. Cloeckaert. A., Zygmunt, M.S. and Dubray. G. (1995) Identification of sero-reactive Bruce/h

nditen.si.s cytosoluble proteins which discriminate between antibodies elicited by infection and Rev.1 vaccination

in sheep. Vet. Microbial. 44, 37-48.

40. Duraipandian Thavaselvam, Ashu Kumar, Sapana Tiwari, Manvi Mishra and Archana Prakash Cloning and

expression of the immunoreactive Brucella melitensis 28 kDa outer-membrane protein (Omp28) encoding gene

and evaluation of the potential of Omp28 for clinical diagnosis of brucellosis. Journal of Medical Microbiology

(2010), 59, 421–428.


99

CORRESPONDENCE

*Project Directorate on Animal Disease Monitoring and Surveillance, (PD_ADMAS), Hebbal, Bangalore-560

024, Karnataka, India

**Dept.of Microbiology, Yogi Vemana University, Kadapa, Andhra Pradesh


100

AUTOMATIC FILLING MANAGEMENT SYSTEM FOR INDUSTRIES

Saubhagya Tandon*, Shreya Srivastava**, Sandeep Pal***

ABSTRACT

In this era of industrialization, technological revolution/automation is fast shrinking the need of

humans to assist machinery. Looking at the current industrial scenario, birth of new products and

private brands is sharply raising the competition among industries. In order to hold out the promise of

timely delivery of product, high tech automated production is essential. The concept of automation is

so versatile that it can bring radical development in almost every field. Keeping view of present

requirements, this paper proposes a filling management system for industries which is a complete

application of automation. The notable thing about this project is its high degree of flexibility and its

remote control. A prototype of commercial bottle filling system, controlled using programmable logic

controller (PLC) is proposed and the whole process is monitored using supervisory control and data

acquisition (SCADA). This system provides the provision of mixing any number of liquids in any

proportion. It’s remote control and monitoring makes the system easily accessible and warns the

operator in the event of any fault.

Keywords: PLC; SCADA; Bottling Plant; Automation

INTRODUCTION

Beverage market offers opportunities that can

be transformed into success only by those

companies that have technology to take it

beyond competition. High degree of flexibility

is its prior need. Also industries face many

other challenges. The pressure to continually


101

increase production volumes has stressed older

systems and has increased maintenance

requirements. For manufacturers, this creates

two problems: higher costs and increased

downtime. Production managers are being

challenged to reduce cost, wastage and

downtime. New technologies are required that

will reduce water usage, increase energy

efficiency and minimize downtime in high-

speed beverage production environments.

Increasing competitive pressures, ever more

stringent legal regulations, rising costs of

commodities and energy and consumers whose

preferences are subject to rapid change –

beverage companies today are forced to

increase their flexibility and operate with

maximum efficiency at the same time. The key

to this problem is an integrated process

approach. After all, if all processes are

perfectly coordinated with each other and

reliable communications have been established

between all parts of the manufacturing plant, it

is much easier to address the big challenges1.

In small industries, the refilling system usually

operates in manual mode and even this is true

for some other industries also. Literature

suggests that microcontrollers are being used in

these industries as it brings a cost effective

solution for controlling the process 2. Although

PLCs are costly, still those are also used in

industries. The implementation of PLC for

commercial bottle filling plants is not discussed

widely in literature, therefore in this work an

endeavor is made to bring out the important

facts about its commercial use. In addition the

use of SCADA is also implemented in this

project work which is a high-tech tool for

providing monitoring through the remote

location. The system developed in this work is

a complete package of filling management

system for industries. It provides flexibility

with reliability. It also provides an extra

advantage of production flexibility and ability

to extend or modify an existing plant. It

provides remote monitoring of the entire plant

that makes it easily accessible.

The paper has been discussed mainly in four

sections: first section gives the introduction

followed by the system description where the

general block diagram and process flow is

discussed. The complete prototype description

is discussed in section III and finally

conclusions are given in section IV.

SYSTEM DESCRIPTION

This project is a complete application of

automation. The various process of this system

is controlled by PLC and is remotely controlled

using SCADA. PLC and SCADA are heart of

the system. The system is controlled according

to the programmed PLC. To monitor the

processing of the entire plant SCADA is used.

Figure 1 shows the block diagram of the whole

process.


102

Fig. 1. Block Diagram of the whole process

There are two inputs to the PLC out of which

one is the output of the proximity sensor. The

proximity sensor senses the presence of the

bottle at the conveyor belt. In this work

metallic bottles are used which are detected by

a proximity sensor. Infra red sensor is another

choice that may be used in place of proximity

sensor. When the bottle is sensed by the

proximity sensor, a signal is sent to the PLC

through signal conditioning circuits. The PLC

then operates the two dc motors to start the

mixing process and deliver the mixture to the

third tank. In real time systems AC drives may

be used for the purpose. Depending upon the

need, proportion and amount of liquid to be

filled in bottle, the closing and opening

operation of valves connected to motors is

controlled through PLC. This section further

broadly discusses the main parts of the system:

A. Programmable Logic Controller, PLC

PLC is a programmable device developed to

replace mechanical relays, timers and counters.

PLCs are used successfully to execute

complicated control operations in a plant. The

PLCs helped reduce the changeover time from

a month to a matter of just few days. PLC

consists of an input/output (I/O) unit, central

processing unit (CPU) and memory. The I/O

unit acts as the interface between PLC and real

time systems. All logic and control operations,

data transfer and manipulation work is done by

CPU.

PLCs provide the advantages of high reliability

in operation, flexibility in control techniques,

small space and computing requirements,

expandability, high power handling, reduced

human efforts and complete programming and

reprogramming in a plant. The PLC is designed

to operate in the industrial environment with

wide ranges of ambient temperature, vibration,

and humidity and is not usually affected by the

electrical noise that is inherent in most

industrial locations. It also provides the cost

effective solution for controlling complex

systems3.

B. Supervisory Control And Data Acquisition,

SCADA

PLC & SCADA combination gives the

advantage of better monitoring and control of

the plant. SCADA enables engineers,

supervisors, managers and operators to view

and interact with workings of entire operations

through graphical representation of their

production process. SCADA runs on a PC and

is generally connected to various PLCs.

SCADA constantly gathers data from plant in

real time, stores and processes it in the

database, evaluates and generates alarms,


103

displays information to plant operators,

supervisors and managers and can issue

instructions to PLCs on the plant floor4.

C. Filling System

The filling system consists of three tanks where

liquids are kept and mixed according to

proportion given in PLC program. For large

industries any number of tanks can be used to

mix any number of liquids. Hence the system

using PLC provides large flexibility. AC drives

for main motors with valves and conveyor belt

arrangement is used in industries for filling

operation. At the appropriate timings motor

connected to valves is made ON and

accordingly the valve opens. The filling system

consists of subsystems that include Conveyor

system and Sensors. A sensor is a device,

which responds to an input quantity by

generating a functionally related output usually

in the form of an electrical or optical signal.

Sensors are designed to have a small effect on

what is measured; making the sensor smaller

often improves this and introduces other

advantages also. Here sensors are used to detect

the bottles so that there is no wastage. Hence

system has also given the advantage that even if

the program is running and there is no bottle on

the conveyor the motor 3 will not start and thus

valve 3 will also not open, so no spill of liquid

takes place. The valve 3 will open only when

there is a bottle and filling will be done.

Conveyors are especially useful in applications

involving the transportation of heavy or bulky

materials. Conveyor systems allow quick and

efficient transportation for a wide variety of

material. The conveyor system is used to

transport bottles from one end to other. At the

initiating end the bottle is empty while at the

destination end filled bottle reaches.

PROTOTYPE DESCRIPTION AND

CONTROL IMPLEMENTATION

In this project, a prototype illustrating the

commercial bottling plant automated using

PLC is developed and the whole process is

monitored using SCADA. The sensing

mechanism used in the system takes care of

unnecessary spill or wastage. The system

provides best accuracy and precision in the

mixing any number of liquid in any proportion.

The system is completely monitored using

SCADA and plant may be stopped or

controlled through SCADA in case of

emergency.

In this system, liquids can not only be filled but

this system can also mix liquids in desired

proportion. In this system, there are two

different liquids in two different tanks which

are mixed in third tank (final tank). The mixing

can be done in any proportion, say 2:3; 5:5; 4:6;

etc. Motor 1 and Motor 2 shown in Figure 1

control the proportion which gets mixed up in

the third tank. Finally, this liquid is filled in the

cans or bottles and the biggest advantage of this

system is with automation, it provides remote

monitoring and controlling. That is, the entire

working of the system or filling plant is

displayed on the SCADA screen from where

the whole plant can be monitored and

controlled.


104

Fig. 2. Process Monitoring through SCADA

Screen

The plant can be started from the SCADA

screen as well as it can be stopped from the

same screen only, in case of any fault. Thus no

waste or harm to the plant if any fault occurs.

Figure 2 shows the process visible on SCADA.

PLC is the main part of the automation plant.

The plant is automated by the programmed

PLC. PLC used is MICROLOGIX 100 and

supply to PLC is provided through SMPS.

Ladder programming is the main programming

method used for PLC. Ladder programming is

done using software RS LOGIX ENGLISH.

The program is then downloaded on PLC. As

per the program written for this work, when the

system is switched on, motor 1 starts and runs

for stipulated time and valve 1 opens and liquid

reaches in tank third. Then when motor 1 stops,

motor 2 starts and in the same way liquid from

tank 2 reaches third tank. The liquids get mixed

up in the third tank. When the bottle is present

in front of third tank motor 3 starts and valve 3

opens to fills the bottle. 24V solenoid valves

are used for the purpose and proximity sensor

in used for sensing the bottle. The bottles are

placed on the conveyor belt which is moved

using dc motor drive in this case. In industrial

systems ac drives are used. When the bottle is

sensed by the sensor, a signal is sent to the PLC

which stops the drive motors and after the

filling process is over, the PLC again starts the

drive motors to move the conveyor. The

conveyor moves till the presence of other bottle

is sensed by the proximity sensor.

This complete working is monitored on

SCADA screen interfaced with the PLC. RS

232 cable is used for the interference of PLC

and SCADA and wonderware Intouch software

is used for SCADA. SCADA screen shows all

the working of the plant i.e. the whole

movement of the conveyor/filling system is

visible on the SCADA screen. Here SCADA

provides the remote control operation of the

system. It is not necessary that the SCADA

screen be placed near to PLC. If there is any

error in the working of the plant, like if any

motor does not start at its set time or runs for

more time, will be displayed on the screen and

the plant can be immediately stopped from the

SCADA screen itself. This feature also helps

the system in avoiding any spill or wastage.

CONCLUSION

This paper has proposed an application of

automation illustrating a PLC based fully

automatic untouched liquid filling system. The

system meets the demand of high-speed

production using the least mechanism

requirements. The system has proved to work


105

effectively avoiding unnecessary spill or

wastage of liquids. The system also provides

high accuracy and precision in proportion of

liquids mixed. Although proposed system

illustrates the mixing process of two liquids,

any number of liquids may be mixed in varying

proportions. It is true that the use of PLC is a

costly affair particularly for small industries but

it offers many advantages that overcome its

cost. One of the additional features of the

proposed system is the use of SCADA that

makes it controlled through a remote location.

Complete monitoring of the system is possible

through SCADA and in fact the process may be

stopped or started by SCADA screen. This

feature is particularly very useful in case if

some fault occurs in the system.

REFERENCES

1. http://www.industry.siemens.com/verticals/global/en/food-beverage/bev erage-industry/Documents/E20001-A100-

T110-V1-7600.pdf

2. Ashwini P. Somavanshi, Supriya B. Asutkar and Sachin A. More, “Automatic Bottle Filling Using Microcontroller

Volume Correction,” International Journal of Engineering Research and Technology IJERT, vol. 2, Issue 3,

March 2013, pp. 1-4.

3. Ahmed Ullah Abu Saeed, Md. Al-Mamun and A. H. M. Zadidul Karim, “Industrial Application of PLCs in

Bangladesh,” International Journal of Scientific & Engineering Research, vol. 3, Issue 6, June 2012.

4. Stuart A. Boyer, Scada – Supervisory Control and Data Acquisition, International Society of Automation USA, 4th

Edison, 2009.

5. Mallaradhya H. M., K. R. Prakash, “Automatic Liquid Filling to Bottles of Different Height Using Programmable

Logic Controller,” in proceedings of AECE-IRAJ International Conference, July 2013, pp. 122-124.

6. T. Kalaiselvi, R. Praveena, Aakanksha R. and Dhanya S., “PLC Based Automatic Bottle Filling and Capping

System with User Defined Volume Selection,” International Journal of Emerging Technology and Advanced

Engineering, vol. 2, Issue 8, August 2012, pp. 134-137

7. Shaukat N., “PLC Based Automatic Liquid Filling Process,” IEEE Multi Topic Conference, 2002.

CORRESPONDENCE

*Department of Electrical Engineering, Ideal Institute of Technology, Ghaziabad, India, Email:

[email protected]

**Department of Electrical Engineering, Ideal Institute of Technology, Ghaziabad, India, Email:

[email protected]

***Department of Electrical Engineering, Ideal Institute of Technology, Ghaziabad, India, Email:

[email protected]

106


107

CALL FOR PAPERS

Scientific Research Journal of India (SRJI) globally welcomes research scholars & scientists from

different fields of science like Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental

Sciences, Natural Sciences, Anthropology etc to contribute their researches in this Open Access

Publication.

::Mail your article/s to::

[email protected]

::For full detail kindly visit::

http://srji.drkrishna.co.in

http://sites.google.com/site/scientificrji


108