Category: Physiotherapy

Ishwarya vardhini. C¹, Nelshiya Anni Ruby Aishwariya. H. P²

Author:

¹Assistant professor, Faculty of physiotherapy, Dr.MGR Educational and research institute University, Velappanchavadi, Chennai, Tamilnadu, India

Corresponding Author:

²BPT Internee, Faculty of physiotherapy, Dr. MGR. Educational and research institute University, Velappanchavadi, Chennai, Tamilnadu, India, Email id: nelshiyaannirubyaishwariya@gmail.com

ABSTRACT

Background of the study: Osteoarthritis (OA) knee is a commonest degenerative disorder, accompanied by pain,   muscle weakness, and decreased ability to carry out activities of daily living. Strengthening of VMO is the exercise choice commonly used. Studies suggest that strengthening of hip abductor; can reduce the KOA-associated symptoms. Objective of this study was to find whether VMO in combination with hip abductor strengthening can improve the function and reduce pain in KOA. Materials and methods: 30 subjects with grade 1- KOA of both the genders belonging to age group from 45-60 years were chosen and subjected to VMO & hip abductor strengthening for a period of 12 weeks.  Pre and Post exercise outcome scores were measured using VAS and WOMAC scale. Results: This study showed a substantial   improvement of pain, stiffness and physical function in subjects who underwent VMO and hip abductor strengthening program. P-value on VAS and WOMAC scale was less than 0.0001 which was found significant.  Conclusion: Hip abductor along with VMO strengthening is a better health interventionin subjects with Grade 1 Osteoarthritis knee .Thus hip muscle strengthening can serve a better intervention in slowing the progression of disease and reduction of symptoms in grade -1 KOA.

Keywords:  Grade-I-KOA; Hip Abductor Strengthening; Vastus Medialis Obliqus (VMO); WOMAC; VAS.

Received on 28th January 2021, Revised on 18th February 2021, Accepted on 27th February 2021; DOI:10.36678/IJMAES.2021.V07I01.007

INTRODUCTION 

Osteoarthritis of knee is the second most common chronic degenerative joint disease occurring among elderly.  It leads to pain, muscle weakness especially quadriceps and disability  which  are the  earliest clinical signs of OA knee¹. OA knee is classified into 2 divisions.  Primary OA knee is without any known reason (idiopathic) and ccurs in the elderly due to ageing process. Secondary OA knee is due to increased body mass index, family history, joint hyper mobility, repetitive strain to the knee, trauma, immobilization, neuropathic disorders ².

The symptoms that halt the function include morning stiffness, reduced joint movement, crepitus and muscle atrophy ³. Diagnosis of knee osteoarthritis can be confirmed based on clinical and radiographical Findings .The American College of Rheumatology criteria , EULAR diagnostic criteria  ,can be further used to diagnose KOA which includes presence of constant knee pain,  morning stiffness reduce function,  joint crepitus, restricted mobility  and hypertrophy of bone. The available treatment options are non-pharmacological, pharmacological or surgery. Physical therapy is a least expensive intervention for OA knee which is recommended by the American college of Rheumatology and the European League against Rheumatism⁴.

 Exercise is recommended as a first-line of conservative management option for osteoarthritis (OA). They can decrease pain status, improve joint mobility & functional ability. Quadriceps weakness is common among OA knee which in turn causes painful lower limb thereby making it a risk factor for development of OA. The function of quadriceps group of muscles, particularly VMO muscle has an important role in the stability of the patella-femoral joint ⁵. Reduction in activity of hip abductor muscle has been suggested as a contributing factor for the disease progression in knee osteoarthritis (OA).

Hip abductor strengthening can serve as an intervention to reduce knee joint loading in subjects with OA knee ⁶. Increased hip abduction moment magnitude is directly proportionate in reducing the progression of medial compartment OA knee^7. Hip abductor weakness results in poor functional performance in subjects with OA. They  are  stabilizer of trunk & hip during walking, maintain the position of  lower extremity and transmit the forces from the lower extremity  to the pelvis⁸. Therefore inclusion of hip abductor exercises along with VMO can prove beneficial when designing a rehabilitation program for persons with knee OA.

METHODOLOGY

This was an Experimental study and the participants those attending the outpatient physiotherapy department in ACS medical college and hospital, Dr. MGR Educational and Research institute, Chennai India. The study duration was around 12 weeks. This study included 30 subjects with grade I Osteoarthritis knee (as per kellgrenn and Lawrence radio graphical grade(9) of both the genders in age-group between 45 and 60 years. The participants were selected by simple random sampling method. Subjects apart from grade 1 OA knee, non-cooperative subjects, those with balance, auditory, visual disorder, lower limb injury were excluded from the study.

The objective of this study was to find the effect of  hip abductor  and vastus medialis oblique muscle (VMO) strengthening exercises on Pain and Physical function were measured using VAS (Visual analog scale) and WOMAC (The Western Ontario and McMaster Universities Osteoarthritis Index).

Procedure: The subject’s pain & functional ability were documented using Visual Analogue Scale (VAS) in which the patient denotes pain level on the line between two endpoints. The distance between point of no pain  and the marking measures  the subject’s pain score(10). Then  WOMAC (The Western Ontario and McMaster Universities Osteoarthritis Index)  which

 includes five questions about pain, two about stiffness and seventeen on degree of disability of activities performed every day¹¹.

Following this, the subjects underwent hip abductor and vastus medialis oblique muscle (VMO) strengthening exercises namely clam shell, lateral leg slides, abduction lifts, terminal knee extension, single leg lifts, leg extension respectively for a total of 3 sets consisting 12 repetitions each .The exercises were given for 4 days in a week for total of 12 weeks. Subjects were advised to continue the medications as prescribed by their physician. After 12 weeks post exercise, they were subjected to Post Vas, WOMAC and findings were documented.

RESULT

This study showed a substantial   improvement of pain, stiffness and physical function in subjects who underwent VMO and hip abductor strengthening program. P-value on VAS and WOMAC scale was less than 0.0001 which was found significant. 

DISCUSSION

This study was aimed to find the impact of hip abductor & VMO muscle strengthening in subjects with grade 1 osteoarthritis knee.  Pain and Physical function was measured using VAS and WOMAC. The outcome of the study was markedly improved, on the WOMAC score after twelve weeks intervention program for the hip abductor and VMO in 30 participants.

In addition to the reduced dynamic loading at the knee, each subject experienced a marked decrease in knee pain during the study. VMO Strengthening served to reduce pain in subjects.  The hip abductor plays an important role as pelvic and trunk stabilizer in locomotion ¹⁰.

The subjects gave a feedback on reduced gait deviations and improved stability during walking which is well evident from findings of Yujiexie, chi zhanget.al, (2018) who reported that the position of body center is depends on the strength of hip abductor weakness which

can alter in the contra lateral movement of the pelvis or lateral leaning of the trunk over the weight bearing lower extremity ¹¹.

Knee adduction moment, associated with hip adduction has proved effect on reduce the disease severity on OA Knee. Hip abductor appears to have certain impact on knee joint load, which may also play a potential role in the symptoms, progression of disease & studies have pointed that hip abductor strengthening exercises  may be helpful to improve the physical function & alleviate pain in OA knee¹².

A study on lower limb muscle strengthening also have reported effect on reduce pain and potential ability at knee joint which is inexpensive treatment for OA. The findings are evident for the effects of hip abductor and VMO strengthening on relieving pain and improving physical function in knee OA subjects. Hip abductor strengthening routine can be included in grade-1 stage of knee OA as it can reduce the progression of the disease and improve quality of life.

Ethical Clearance: Ethical clearance has obtained from Faculty of Physiotherapy, DR.MGR. Educational and Research Institute, Chennai to conduct this study with reference number: A–026(A)/ PHSIO/IRB/2018-19dated 07/01/2019.

Conflict of interest:  The author reported no conflict of interest to do this study

Funding: The researchers had self financial support to conduct this research.

Limitation: A small sample size, less study duration. Effect of medications was not taken into consideration.

Recommendations of the study: More outcome measure can be used. Several types of exercises can be compared for future studies. This study can be compared with other grades of KOA.

CONCLUSION

We can conclude that hip abductor and VMO strengthening is effective in reducing pain and improving physical function in subjects with grade- 1 KOA. Hence it can be included during the initial phase of rehabilitation of KOA.

REFERENCE

1.   Hinman RS, Hunt MA, Creaby MW, Wrigley TV, Mc Manus FJ BK. (2010). Hip muscle weakness in individuals with medial knee osteoarthritis. Arthritis care Res. 62(8): 1190.

2. Michael JW, Schlüter-Brust KU EP. (2010).  The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arzteblatt Int. 107(9): 152.

3. Gorial F I, Sabah S A, Kadhim M B J N. (2018). Functional Status in Knee Osteoarthritis and its Relation to Demographic and Clinical Features. Mediterr J Rheumatol. ; 29 (4): 207.

4. Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, (1962). Herrero-Beaumont G, Kirschner S, Leeb BF, Lohmander LS MB. Eular evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 69(3): 483.

5.  Sled E A, Khoja L, Deluzio K J, Olney S J C E. (2010). Effect of a home program of hip abductor exercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: a clinical trial. Phys Ther. 1 ; 90(6) :895-904.

7.  Rutherford DJ H-KC. (2009). Explaining the hip adduction moment variability during gait: Implications for hip abductor strengthening. Clin Biomech. 1; 24(3): 267-73.

8.   Harikesavan K, Chakravarty R D, Maiya A G, Hegde S P S S. (2017). Hip abductor strengthening improves physical function following total knee replacement: one-year follow-up of a randomized pilot study. Open Rheumatol Journal. 11:30.

9. Kellgren J H L J. (1957). Radiological assessment of osteo-arthrosis. Ann Rheum Dis.; 16(4): 494.

10. Yang KA, Raijmakers N J, Verbout AJ, Dhert WJ SD. (2007). Validation of the short-form WOMAC function scale for the evaluation of osteoarthritis of the knee. J bone Jt surgery Br Vol. 89(1): 50-6.

11. Xie Y, Zhang C, Jiang W, Huang J, Xu L, Pang G, Tang H, Chen R, Yu J, Guo S X F.  (2018). Quadriceps combined with hip abductor strengthening versus quadriceps strengthening in treating knee osteoarthritis: a study protocol for a randomized controlled trial. BMC Musculoskelet Disord. 19(1): 1-7.

12. Lim BW, Hinman RS, Wrigley TV, Sharma L BK. (2008). Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial. Off J Am Coll Rheumatol Care Res. 59(7): 943.

Citation:   Ishwarya vardhini. C, Nelshiya Anni Ruby Aishwariya. H. P (2021).  Efficacy of Vastus Medialis Oblique Muscle and Hip Abductor Strengthening on Pain and Functional Ability in Patients with Knee Osteoarthritis, ijmaes; 7 (1); 969-974.

S. M. Divya Mary¹, S. Bhargavy²

Author:

²BPT Internee, Faculty of physiotherapy, Dr. MGR. Educational and research institute University, Velappanchavadi, Chennai, Tamilnadu, India

Corresponding Author:

¹Assistant professor, Faculty of physiotherapy, Dr.MGR Educational and research institute University, Velappanchavadi, Chennai, Tamilnadu, India, Email id: divyamary.physio@drmgrdu.ac.in

ABSTRACT

Background of the study: Forward head posture is the anterior positioning of the “cervical spine”. This posture is sometimes called “text neck” or “reading neck”. Mostly the targeted group is younger & older adults. The main reason is our sedentary lifestyle-sitting at computers for hours, playing games continuously, driving for long distance time. Objective of the study is to find out the effectiveness of conventional exercise over fencing exercise to correct the forward head posture in individuals with abnormal head posture. Methodology: this study is the experimental design comparative pre & post type.30 subjects will be divided into two groups. Group a will be given conventional exercise & group b will receive fencing exercise. Ruler measurement & Cranio vertebral angle will be used as outcome measures. Result: on comparing pre test & post test within group a% group b on ruler measurement & cranio-vertebral angle shows highly significant difference in mean values p ≤ 0.001. Conclusion: This study shows that there was improvement in forward head posture in both groups. however conventional exercise(Group-A) showed more improvement than fencing exercise (Group-B) & to correct forward head posture & brings them back to normal posture.   Keywords: Fencing exercise; Ruler measurement; Forward head posture; Cranio-vertebral angle.

Received on 29th January 2021, Revised on 14th February 2021, Accepted on 26th February 2021; DOI:10.36678/IJMAES.2021.V07I01.006

INTRODUCTION 

Forward head posture is one of the most commonly recognized types of poor head posture in the       sagittal plane. Forward head posture has been defined as any alignment in which external auditory meatus is positioned anterior to the plumb line through the shoulder joint^{1, 2}.

Mostly, the targeted group is younger and older adults. Totally,100 peoples are affected in the age group between 20-70 years old. The prevalence  of anterior head translation in neck pain patients was found to be 37%, out of which 58% were female and 42% were male number. A review of different observational studies of neck pain around the world showed that its 1-year prevalence ranged from 16.5 to 75.1% for the entire adult population which aged from 17 to 70 years^{3, 4}.

Data show that the people affected by “Forward Head Posture” in their fifties accounting for more than 23% of the total followed by those in their forties, thirties, and seniors over sixty. It has become more prevalent in modern times as the COG shifts in the body posture. For, compensation the upper body drifts backward and shoulder slump forward by placing head anterior to the trunk^5,6.

While sitting, forward head inclination involves a combination of lower cervical flexion, upper cervical extension, which reduces the average lengths of muscle fibers, contributing to extensor torque around the upper cervical joint. In addition to this, abnormal posture causes musculoskeletal abnormalities such as decreased scapular upward rotations well as greater internal rotation and anterior tilting, which may be the difficulties in maintaining upright posture .Conventional exercise aims at improving function of muscle, which counteracts the forces of gravity in order to maintain the head and neck in upright position^7-9.

Fencing response designation arises from stimulating the “asymmetric tonic neck reflex” in infants. like reflex, a positive fencing response resembles the en grade position that initiates fencing with extension of one arm and flexion of other. This study aims at the effectiveness of fencing exercise with conventional exercise in forward head posture in individuals with abnormal head posture¹⁰.

Biomechanics: In forward head posture, the head shifts anteriorly from the line of gravity, the scapulae may rotate medially, a thoracic kyphosis may develop and overall vertebral height may be shortened. The features are as follows: there is an obliteration of the cervical lordosis and a compensatory tilting back of the head at the atlanto-occipital joint. In the posterior cervical muscles there is stretching and weakness of semispinalis cervicis and overaction with ultimate shortening of semispinalis capitis ¹¹.

Pathomechanics: Instabilities lead to more serious pathology eventually, such as desiccation(thinning disc),cervical spine spondylosis, disc pathology facet &central cord stenosis, thoracic spine compression fractures. People with uncorrected FHP posture potentially suffer chronic or unpleasant conditions, such as pinched nerves ¹².

Upper Cross Syndrome– Tightness of the upper trapeziums and elevator scapula on the dorsal side crosses with tightness of pectorals major and minor. Weakness of the deep cervical flexors ventrally crosses with weakness of middle and lower trapeziums’ his pattern of imbalance creates joint dysfunction, particularly at the Atlanta occipital joint,C4-C5 segment, cervico-thoracic joint, gleno-humeral joint&T4-T5 segment ¹³.

METHODOLOGY

This study is the experimental design comparative pre & post type. 30 subjects were recruited from dr.mgr educational & research institute (A.C.S medical college and hospital) – physiotherapy – opd, Chennai. Subjects were selected by simple random sampling method. Study duration was 5 days in a week for 4 weeks. Inclusion criteria were both male and female subjects between age group 18-35 years old, who have 4-12cm in “ruler measurement” & “cranio-vertebral angle” less than 50 degree. Exclusion criteria were age group between below 18 & above 35 years were excluded. Subjects with systemic illness, no recent injuries & neurological complications were excluded. Ruler measurement & cranio-vertebral angle will be used as outcome measures. Mobile application (on protractor), adhesive skin markers, millimeter ruler were the materials used.

Procedure: 30 volunteers fulfilling the inclusion criteria were included in this study. The forward head posture is identified by measuring the spinal column alignment.

Measurement of Forward Head Posture Ruler Measurement: This method is done with ruler (scale),ask the patient to lean on the wall in relaxed position & measure the length between the wall and head.

Cranio-vertebral Angle

This method was measured using smartphone application-“ON PROTRACTOR”. This application allows to take picture and draw angle by touching the screen at the reference points on the markers. Two markers were Used: One placed on the tragus of the ear and second placed on C7 vertebra were measured and photographs taken.

Position of patient: The patient is made to stand against the wall. 30 Volunteers Were Divided Into 2 Groups,

Group A- In this group, 15 volunteers performed forward head posture correction program ,the exercise were done 5 days in a week for 4 weeks, which consists of 2 sets with 15 repetitions.

Chin tucks, Isometric neck exercise,  Shoulder retraction/ Protraction, Shoulder shrugging/ Dropping, Then followed by posture correction techniques. The patient should stand in front of the mirror and correct the abnormal posture, Chin tucked position. Shoulder retracted position. The patient should correct their abnormal posture for every one hour.

Group B- In this group, 15 volunteers performed fencing exercise, the exercise were done 5 days in week for 4 weeks, which consists of 2 sets with 15 repetitions. The patient is given a wand to perform fencing movements. All the fencing movements are done under the instruction and supervision of physiotherapist only.

Lunge pose:                         

Lead Side:

Upper body:

Neck position- Chin tucked. Shoulder- Retraction., Arm- Fully extended at 90 degree. Trunk- Neutral position. Wrist- Mid prone.

Other Side: Upper body:

Neck position- Chin tucked. Shoulder- Retraction. Trunk- Neutral position.

Arm- Fully extended at 90 degree. Wrist- Supination.

Lower body: Lunge position.

Parry pose:

Lead Side

Upper body:

Neck position- Chin tucked.

Shoulder- Shoulder abducted at 160 degree & internally rotated. Trunk- Neutral position.

Wrist- Pronation.

Lower body: Knee semi -flexed

Other Side

Upper body:

Neck position- Chin tucked. Shoulder- Adduction. Elbow- Flexion. Wrist- Supination.

Trunk- Neutral position.

Lower body:

Leg abducted.

Riposte pose:

Lead Side; Upper body:

Neck position- chin tucked. Shoulder- Adduction. Elbow- Slightly flexed. Wrist- Supination.

Trunk- Neutral position

Other Side: Upper body:

Neck position- Chin tucked. Shoulder- Abduction 90 degree. Elbow- Flexed.

Wrist- Flexion.

Lower body: Mid squat position.

Group – B In Pre And Post  Test

Comparison of  Cranio-vertebral Angle Between Group – A And Group – B In Pre And Post Test

Comparison Of Ruler Measurement Score Within Group – A & Group – B Between Pre & Post Test Value

RESULT

On comparing the pre and post test values within the experimental group, Group A & Group B on Ruler Measurement & Cranio-vertebral Angle shows highly significant difference in Mean values where p value is  P ≤ 0.001.Group A – Conventional Exerciseshows statistically significant improvement then Group B – Fencing Exercise.

DISCUSSION

In this world, almost everywhere including schools, colleges, offices and even in homes computers and Smartphone’s are commonly used today. Forward head posture is the misalignment of head on trunk, leads to increased lordotic curve of the cervical spine and accompanied by increased kyphosis of thoracic spine. Forward head posture leads to body mechanical deformation anterior to centerline of gravity, this reduces muscle strength of neck stabilization muscles, reduces

the activity of the stabilizer muscles of the scapulae and changes body mechanics of the scapulae. A sample of 30 subjects were selected and assessed then recorded the values. After, giving treatment the values are analyzed for significant differences. Cranio-vertebral angle is a good indicator for measuring forward head posture. The cranio-vertebral angle was measured using, ”On Protractor App” which is available on goggle play store ^13,14.                          

A study on validity and reliability of “ON PROTRACTOR” smartphone application for measurement of cranio-vertebral and cranio-horizontal angle. In this study, the mean cranio-vertebral angle in non forward head posture is 50 degrees. The result of the study showed a effectiveness between conventional exercise and fencing exercise. This study proved that there was an increased effect in conventional exercise than fencing exercise after correction forward head posture ¹⁵.

The conventional exercise treatment showed improved ability in holding an upright posture of cervical spine and retraining these muscles was shown to reduce the neck symptoms and improved ability in maintaining an upright posture of cervical spine. The result showed that forward head posture significantly, reduced in the treatment groups after 4 weeks exercises, this improvement was also maintained after 1 month follow-up. Moreover, when compared with group A and group B, the forward head posture was reduced in group A (conventional exercise), which is effective ¹⁶.

In this study 15 subjects were included for conventional exercise (Group-A). It supported on effect in forward head posture which reveals significant difference in mean values. In pre-test 7.09 in ruler measurement and 46.69 in cranio-vertebral angle. In post-test 3.89 in ruler measurement and 53.56 in cranio-vertebral angle.  Another 15 subjects included in fencing exercise (Group-B) .The fencing exercise also showed effect in forward head posture correction. The study reported significant differences in mean values. In pretest 7.30 in ruler measurement and 46.33 in cranio-vertebral angle. In post-test 5.95 in ruler measurement and 49.40 in cranio-vertebral angle.

Fencing is a great cardiovascular exercise, using several sets of muscles at a demanding intensity level over an extended period of time. The physical benefits of fencing include increased agility, balance, flexibility, Strength and cardiovascular endurance. While fencing is a whole exercise, it exercises the arms, thighs, buttocks hardest of all .You also benefit from fencing by gaining greater mental agility. Key muscles used for fencing exercise are, Upper body-Back muscles and Trapezius, Lower body-quadriceps, hip flexors, Gluteus, Hamstrings, Calves and core ¹⁷.

The purpose of this present study is to focus the effects of conventional exercise and fencing exercise in correction of forward head posture in younger adults. The conventional exercise is very effective because it demands deep muscles to work and strengthen muscles. Conventional exercise are very easy to learn and 15 subjects were practiced at home without the supervision of physiotherapist.These,15 subjects set remainder in their mobile phones to correct their posture and to do exercise regularly. They, also see mirror to correct their head posture which act as visual feedback. Because, of active participation of subjects in group A showed good and effective results.

In fencing exercise, especially in upper body few sets of muscles are used like trapezius, back muscles, biceps, triceps which is used for holding a wand and to keep shoulders in retracted position. The 15 subjects in group also actively participated for fencing exercise. To prevent unwanted consequences fencing exercise was done under the supervision of physiotherapist. Fencing exercise also showed values nearing to conventional exercise in 4 weeks duration. The pre-test and post-test of ruler measurement and cranio-vertebral angle in experimental groups is statistically significant at p<0.01 i.e. there is improvement in correction of forward head posture after treatment.

Ethical Clearance: Ethical clearance has obtained from Faculty of Physiotherapy, DR.MGR. Educational and Research Institute, Chennai to conduct this study with reference number: A-12/ PHSIO/IRB/2018-19dated 08/01/2019.

Conflict of interest:  The author reported no conflict of interest to do this study

Funding: The researchers had self financial support to conduct this research.

CONCLUSION

By the obtained result from this experimental study , it is concluded that there was improvement in forward head posture in both groups. However, conventional exercise(Group-A) showed more significant improvement than fencing exercise (Group-B) and corrects forward head posture and brings them back to normal posture.

REFERENCES

1. Levangie P,Norkin C. (2012). Joint structure and function, 5th edition. New Delhi:Jaypee Brothers Medical publishers (P) Ltd; .P 502.
2. Jung Won Kwon, Phd, PT, et ai. (2015). Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. J Phys Ther Sci; 27(6): 1739-1742.
3. Gupta BD,Aggarwal S, Gupta B, Gupta M, Gupta N. (2013). Effect of Deep Cervical Flexor Training vs. Conventional Isometric Training on Forward Head Posture, Pain, Neck Disability Index In Dentists Suffering from Chronic Neck Pain. J Clin Diagn Res. 7(10):2261-4.
4. Deborah Falla, Gwendolen Jull, et al.(2007). Effect of neck exercise on sitting posture in patients with chronic neck pain.Physical therapy 87 (4), 408-417.
5. John S.Y. Chanaalan C.N. et al. (2011). Fencing expertise and physical fitness enhance action inhibition. Psychology of Sport and Exercise Volume 12, Issue 5, September Pages 509-514.
6. Johnson, Gillian M., Dip Phty, Msc Spine. (1998). The Correlation between Surface Measurement of Head and Neck Posture and the Anatomic Position of the Upper Cervical Vertebrae. April 15, – Volume 23 – Issue 8 – p 921-927.
7. Bhuvan Deep Gupta, Shagun Aggarwal, and Neha Gupta. (2013). Effect of Deep Cervical Flexor Training vs. Conventional Isometric Training on Forward Head Posture, Pain, Neck Disability Index In Dentists Suffering from Chronic Neck Pain. J Clin Diagn Res.; 7(10): 2261-2264.
8. Alireza Rabieezadeh, et al. (2016). The relationship of height, weight and body mass index with curvature of spine kyphosis and lordosis in 12-15 year old male adolescents of Tehran. Turkish Journal of Sport and Exercise.6Year: -Volume: 18 – Issue: 3 – Pages: 42-46 .
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10. Jae Woong Han (2016). Biomechanical Analysis of Chin Tuck Exercise with a Subject-Specific Neck Model for the Forward Headed International Journal Of Precision Engineering And Manufacturing Vol. 19, No. 4, pp. 587-592.
11. Jeong-Gon Na, et al. (2018). Effects of Exercise Type on Neck Disability, Pain, and Postural Changes in Subjects with Forward Head Posture: Systematic Review and Meta-Analysis. J Korean Soc Phys Med;13(3): 121-132.
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Citation: S. M. Divya Mary, S. Bhargavy(2021). Effect of movement therapy in individuals with abnormal head posture , ijmaes; 7 (1); 960-968.

Vijayalakshmi B¹, Padmanabhan K²

Corresponding Author:

¹MPT Student, Faculty of physiotherapy, Dr. MGR. Educational and research institute University, Velappanchavadi, Chennai, Tamilnadu, India, Email id: vijayalakshmi260497@gmail.com

Author:

²Associate professor, Faculty of physiotherapy, Dr.MGR Educational and research institute University, Velappanchavadi, Chennai, Tamilnadu, India

ABSTRACT

Background of the study: Osteoporosis is reduced density of bone due to vitamin D deficiency, which can be prone for bone fracture. Bone mineral density (BMD) has to be checked routinely to screen out its deficiency. Osteoporotic fractures in India occur commonly in both sexes, and many occur at a younger age. Objectives of the study are to find the status of BMD among women using calcaneal ultrasound bone densitometer (QUS) and the effect of progressive resisted exercises (PRE) on BMD. Methodology: It is an Experimental study, the study was conducted among women, of ‘’Bone Mineral Density Free Camp’’ organized at the ACS Medical College and hospital, Chennai. A total of 270 subjects (women) were screened by using Calcaneal Ultrasound Heel bone densitometer (QUS), out of which 66 subjects were detected with Osteoporosis. They were randomly assigned into Group A (Calcium supplements +Progressive Resistance Exercises) and Group B (Calcium supplements) by Randomized Control Trial (RCT) method. The duration of this study was three months. Results: The study has reported there is a significant difference after post test t-score measurements between group A and group B. The mean of Group A was higher than that of Group B. Conclusion: This study has recommended doing resistance exercises to prevent growing Osteoporosis among women. Calcaneal Ultrasound measurement could be a useful tool to asses BMD.   Keywords: Osteoporosis, Bone mineral density, Progressive resisted exercises, Calcaneal Quantitative Ultrasound Densitometer.

Received on 22nd January 2021, Revised on 7th February 2021, Accepted on 26th February 2021; DOI:10.36678/IJMAES.2021.V07I01.005

INTRODUCTION 

Osteoporosis is a foremost cause of bone related health issues, which can lead to skeletal abnormalities including morbidity and socio economic troubles¹. By 5^th decades of life it is reported as most women are affected with osteoporosis. Early detection and treatment with adequate supplement is important to avoid complication of low bone mineral density ^{2, 3}.

Currently the most widely used tool is Dual energy X-ray absorptiometry, which can measure density of skeleton both appendicular and axial, but portable ultrasound is most cost effective. It can measure the bone density more accurately with more cost effective and radiation free screening test ^{4, 5}.

Quantitative Ultrasound (QUS) is the commonest device used to measure bone density. Bone density measurement sites include vertebra, hip, forearm and calcanium. QUS can rule out osteopenia of bone at any age of population^{6, 7}.

Lack of exercises has been found to significantly associate with lower BMD in Indian women. Hormonal therapy is assumed to be helpful to prevent loss of bone density, which can leads to osteoporosis. Different exercise program has proved effect on bone absorption and prevent osteopenia. Best exercise program to prevent osteoporosis need to be developed. Adequate levels of estrogen, calcium intake, and vitamin D are essential along with exercise program to get best effect on prevention of osteoporosis^{8, 9, 10}.

Objectives of the study were to find out the status of BMD among women using calcaneal ultrasound bone densitometer (QUS) and to find the effect of progressive resisted exercises (PRE) on the level of BMD.

METHODOLOGY

This is a comparative experimental study conducted by a camp based approach to screen out bone mineral deficiency. Free health check-up camps were organized in ACS Medical College and hospital, Velappanchavadi, Chennai. Total 66 patients were participated in this study.  The study was conducted for 3 months. Each week consist of 2 sessions per week.

Inclusion Criteria of the study were female subjects with age of above 35 years, subjects with osteoporosis.Exclusion Criteria were Systemic disease like renal disease and hepatic disorders, Rheumatoid arthritis, Endocrine disorders, Chronic medications of steroid and hormonal drugs, Impaired skin sensation, Any malignancy / infections, Metal implants, Poor hysterectomy and Known osteoporosis under treatment.

Materials used were treatment couch, towel, Chair, Stop watch, Sand bags and Assessment sheet. Outcome measured was bone mineral density by Quantitative Calcaneal Ultrasound (QUS) Bone densitometer.

Method: Based on the selection criteria 66 patients were randomly selected. Group A(n=33) Progressive Resisted Exercises for 30-45mins per session of twice per week for 3 months and Calcium Citrate supplements twice a day (800mg). Group B (n=33) Calcium Citrate supplements twice a day alone (800 mg).

Procedure: The subjects were selected based on inclusion and exclusion criteria. All the patients underwent pre-test assessment for Calcaneal Ultrasound on BMD. They were randomly assigned into two groups (Group A Progressive resisted exercises and calcium supplements) & (Group B calcium supplements only ). Written informed consent was taken.

Menstrual history, systemic illness, height and weight were checked before measure the bone mineral density. BMD was measured in Calcaneus (heel bone) ultrasound bone densitometer. QUS device used to measure BMD values in term of specific T-score criteria.  T-score of −1.0 or higher considered as normal and Osteopenia is defined when the score is between 1.0 and 2.5, Osteoporosis is defined as 2.5 or more.

Group-A

Exercises interventions: Progressive resisted exercises and calcium supplements: Exercise protocol (Lora M, Giangregorio et al): Week-1 (elimination of gravity), Hip Extension 3X8 at 10 %  , Knee Extension 3×8 at 10 %, Back Extension  3×8 at 10%, 1RM, Abdominal Flexion 3×8 at 10%, all exercise at 1RM, for week- 2 to 6 weeks 2 sets of 8-10 Repetitions At 1RM (against gravity).

Sit to stand or Squat, Wall Squat Combine with Lateral Pull, Squats to touch chairs- arms folded, Squat without touching chair, Standing Hip, extension and abduction 10 repetitions, progress to abduction. Perform these exercises and add resistance progress by sand bag.  Lunge 1 walking lunge; alternating legs, week-8 to 12 weeks (resistance against gravity), and the progression will be 15 repetitions at 60 to 80 % of 1RM.

Data analysis: The data were collected and analysed using both descriptive and inferential statistics .

This table shows that there is no significant difference in pre-test values of the BMD between Group A & Group B and statistically significant difference in post-test values of the BMD  between  Group A & Group B

Based on the BMD values, it shows that there is a statistically significant difference between the pre- test and post -test values within Group-A and Group-B.

RESULTS

On comparing the mean values of Group A & Group B on Bone Mass Density (BMD) test values, it shows significant increase in the post test mean values but (Group A- Progressive  Resistance exercises and Calcium supplement) shows (-2.38) which has the higher mean value is effective than (Group B-Calcium Supplement alone) (-2.55) at P ≤ 0.05.Hence Null Hypothesis is rejected.

On comparing Pretest and Posttest within Group A & Group B on Bone Mass Density (BMD) Test Values shows significant difference in Mean values at P ≤ 0.001

DISCUSSION

This present study was based on camp conducted in ACS medical college and hospital, Chennai. The aim of the study was to evaluate

bone mineral density. The study reported the role of progressive resistance exercises in association with BMD. Women of 5^th decade found more vulnerable for osteoporosis and bone fracture, so need to take more measures to prevent disability.

Osteoporotic changes are common among aged women than men. This has been reported as the mineral bone density is decrease with increase of age. Above 50 year are shown more prone for osteoporosis over 36.4% of women population. Fewer symptoms in early stage make the people to be less aware about low bone mineral density. Later stage with bone fracture leads the patients to measure bone density, by the time they would have developed osteoporosis. As BMD screening is not done routinely turns up the patients with fractures ^{11, 12}.

Boneosteoblastic activity suppresses in both elderly male and female, it is common in women with aging.  Estrogen withdrawal in aged people suppresses osteoblastic activity and enhances osteoclastic activity.  Low BMD increases with age in both the sexes, so prevention of deficiency in BMD is essential to avoid complications. Timely intervention with proper nutrition and exercise can improve bone density and can prevent the progression of the condition ^{13, 14, 15}.

In addition Progressive resistance exercises are found to be more effective in recent researches. Hence, for the women to be normal, she must be enrolled in effective exercises, adequate calcium intake along with their routine physical activities, despite the availability of gym with efficient friendly atmosphere for women is rarely found in India. To overcome these difficulties and to enroll women in exercise session and to educate them, home based Progressive resistance exercise protocols are intervened ^{16, 17,  18}.

Ethical Clearance: Ethical clearance has obtained from Faculty of Physiotherapy, DR.MGR. Educational and Research Institute, Chennai to conduct this study with reference number: IV B–051/ PHSIO/IRB/2017-18dated 08/01/2018.

Conflict of interest:  The author reported no conflict of interest to conduct and publish this article.

Funding:The researchers had self financial support to conduct this research.

CONCLUSION

The present study demonstrates that there is positive significant relation between Bone Mineral Density and Progressive Resistance Exercises among women. Hence, Progressive Resistance Exercises is an important determinate factor of Bone Mineral Density among women. Thus, more sensitive methods are recommended at this stage for formulating policy regarding preventive interventions. Through this study, we concluded that risk of Osteoporosis among women should be targeted for Resistance exercises to prevent growing increase of the condition and its complications.

REFERENCES

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5. Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N. (2005). Bone status of Indian women from a lowincome group and its relationship to the nutritional status. Osteoporos Int.; 16(12):1827-35.
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9. Widmaier EP, Raff H, Strang KT. (2011). Vander’s human physiology the mechanisms of body function. 12th edn. New York: McGraw-Hill; p. 345-48.
10. Navarro MC, Sosa M, et al. (2009). Poverty is a risk factor for osteoporotic fractures. Osteoporos Int. Mar; 20(3): 393-8.
11. Paul TV, Thomas N, et al. (2008). Prevalence of osteoporosis in ambulatory postmenopausal women from semi-urban region in south India: relationship to calcium nutrition and vitamin D status. Endocr Pract., 14(6):665-71.
12. Baheirai A, Pocock NA, et al. (2005). Bone mineral density, body mass index and cigarette smoking among Iranian women: implications for prevention. BMC Musculoskelet Disord. 6:34.
13. Salamat MR, Salamat AH, Abedi I, Janghorbani M. (2013). Relationship between weight, body mass index and bone mineral density in men referred for dual-energy X-ray absorptiometry scan in Isfahan, Iran. J Osteoporosis 2013:205963.

Citation: Vijayalakshmi B, Padmanabhan K(2021). Effectiveness of progressive resisted exercises among women on bone mineral density , ijmaes; 7 (1); 954-959.

Syeda Khanam. P1, Manjunatha. H2, Thummala S. Pavani3

Corresponding Author:

¹Professor, East College of Physiotherapy, Bidrahalli, Bangalore, Karnataka, India

Co Authors:

²Principal, East College of Physiotherapy, Bidrahalli, Bangalore, Karnataka, India³Assistant Professor, East College of Physiotherapy, Bidrahalli, Bangalore, Karnataka, India     

 ABSTRACT   

Background and purpose: This study was to find the effect of inspiratory muscle training on dyspnoea and exercise tolerance among chronic obstructive pulmonary disease patients. Methods: It is a randomized control study of 30 COPD participants with 15 in each control and experimental group. Experimental group underwent inspiratory muscle training with threshold IMT device in the physiotherapy department, where subjects have to breathe against various threshold levels, 30sets/sessions where as control group underwent only breathing and general mobility exercises at home. The training lasted for 20-30 minutes, twice daily 6days per week, and was continued over the course of 4 weeks duration. Parameters included were 6minutes walk test, MRC dyspnoea grade, PEFR values. The data collected data of control and experimental group was compared to find the outcome. Results: Before interventions, all patients showed increased dyspnoea levels and reduced exercise tolerance. After interventions they all exhibited reduced dyspnea and increased exercise tolerance based on 6min walk test, MRC dyspnoea grade, PERF Parameters. Control group patients didn’t exhibit any improvement in any of the parameters. Conclusion: The results support that inspiratory muscle training is more effective on reducing dyspnoea and increasing exercise tolerance among COPD patients.   Keywords: Chronic Obstructive Pulmonary; Dyspnoea; Exercise tolerance; Inspiratory muscle training

Received on 20th January 2021, Revised on 4th February 2021, Accepted on 24th February 2021; DOI:10.36678/IJMAES.2021.V07I01.003

INTRODUCTION 

Chronic obstructive pulmonary disease is a condition characterized by narrowing of airway tract with symptoms of chronic cough, expectoration, wheeze and exertion dyspnoea. COPD can develop and progress by 25% risk factors of smoking and to mortality by 15% with addiction of smoking ^1-3.

Diaphragm is the main inspiratory muscle morphologically and functionally responds to the inspiratory muscle training. There are evidence documented in possibility of resultant accumulation of co₂ takes place even after resolution of acute exacerbation of conditions and relative obstruction of airway ^{4, 5}.

The IMT device can help to do inspiratory training exercise which can increase strength of inspiratory muscle; there by it can improve the threshold of inspiratory resistance. Overall health related quality of life (HRQL) can improve by repeated inspiratory muscle training. The exercise training decrease dyspnoea and work of breathing becomes easier in patients with COPD. Regular inspiratory training can facilitate to perform physical activities more easily ^6-10.

Aims and objectives of the study was to find the effect of inspiratory muscle strength and endurance to increase exercise tolerance, decrease work of breathing, and to improve functional exercise capacity and also to increase overall health related quality of life.

METHODOLOGY

The study Design was Randomized control study. Data collected were from the patients recruited from pulmonology OPD and treated in the physiotherapy department, Nizam’s institute of medical sciences, punjagutta Hyderabad. Patients were assessed thoroughly and treated during the trails. Period of study intervention was 4 weeks and materials used were threshold inspiratory muscle trainer.

Peak expiratory flow meter is used to record the peak expiratory air flow rate of a person. The forced expiratory volume of a person is measured using this device. The forced expiratory volume of a person is measured using this device. The forced expiratory volume is given in liters’/minute. In COPD patients the PEFR is altered due to biomechanics of chest.

GAIAMS*Power breathe provides a threshold resistance during inspiratory phase. It helps in increasing strength and endurance of respiratory muscles, reduce severity of dyspnoea and improves exercise capacity patients with COPD, asthma, cystic fibrosis, chronic  heart failure,chronic spinal injury, muscular dystrophy, before cardio thoracic surgery.Materials required for the study was Sphygmomanometer, Stop watch, and Measure tape ^11-14.

It has got 9 levels and load varies from level 1 to level 9, approximately as follows: Load (-cm H₂O).

Intensity: 10% to 52% of maximal inspiratory pressure (PI Max).most commonly used training device in these studies is threshold IMT. Frequency of the study duration was 7days/week and total duration of the study was 4 weeks, 20-30 min session, twice a day.

Procedure: Subject has to sit in a  high sitting position on a couch, hold the apparatus close to the mouth and take deep breathe against the resistance set with in the threshold IMT apparatus and blow air out relax. Patient has to repeat the same for 30 times. This procedure should be done twice a day, 30 minute every session. Patient is instructed properly and to discontinue usage if they have symptoms of breathlessness and cough.

Inclusive criteria for this study was Mild and moderate exacerbation of COPD

Exclusive criteria for  this study was Severe exacerbation of COPD, Pulmonary tuberculosis, Restrictive lung disease, Severe asthma, neuro muscular disorders, musculo skeletal problems of spine, Heart failure/unstable angina and  Peripheral vascular diseases.

The data collected ranged from parameters: 6 min walk test, Peak expiratory flow rate, and MRC dyspnoea grading.

During study period 60 patients were examined who were all COPDS associated with other problems but only 30 met the inclusive criteria.15 patients were assigned for group A and remaining 15 for group B according to randomized control study. Their mean ages (group A 58.13; group B 52.06) were calculated.

Data analysis and results:  All data analysis was computed with statistics, paired T-test .within groups, student T-test between groups and mean values were used for both groups to determine the difference between outcome measures of 6 min walk test, MRC dyspnoea and PEFR. Level of significance was fixed as 5 % for the present study.

Out of large proportion COPD with mild and moderate exacerbation the sample taken for the study is 30,based on convenience sampling method after thorough examination based on inclusive criteria from the department of physiotherapy.30 participants were present for the whole duration of the study 4 (week).

During 4 week of study course the parameters studied were 6 min walk test, MRC dyspnoea scale, Peak expiratory flow rate.

The data was collected on subject on 1^st week and 4^th week, and raw data was arranged in order to maintain the master chart, which was subjected to further statistical analysis.

To find out of the average line score in above mentioned parameters in each subject the means were calculated at 1^st week and these values were considered as base line values for the study simultaneously the same parameters are studied at 4^th week and average variations were recorded in terms of means of each parameters and the variations from the mean were also calculated.

The difference in each parameter from 1-4 weeks was tested with paired T-test, within group and student T-test between groups, finally the observed variations in each parameter was represented in graphical format for easy understanding.

RESULTS

From 1^st week to 4^th week all the parameters collected from the data are arranged in master chart for further statistical analysis .The difference in each parameter from 1^st week(initial )to the end of 4^th week(final),of the subject is shown in the following tables.

6 Min Walk Test:  The performance of 6min walk test was conducted for both the groups (Experimental and control group) that to in particular time schedule (1^st week to 4^th week). 1^st week taken as base period which is compared with other time factors, combination allay. Different variables were studied between: 1^st week-4^th week. For with group paired T-test was performed and among two different groups student T-test was used; same tests are used for other parameters MRC dyspnea, PEFR too.

Within Control Group: Among all the variables within the control group, paired T-test calculated value for 1^st -4^th week is 1.00000 and the table value is 2.145 at 5%level of significance with 14 degrees of freedom.

Within Experimental Group:  Among all the variables within the experimental group, paired T –test calculated value for 1^st week -4^thweeks is 14.58441 and the table value is 2.145 at 5% level of significance improvement in 6minute walk in experimental group to control

Between Control Group and Experimental Group: Between control and experimental group student T-test was performed. Among all the variables the student T- test calculated values for 1^st and 4^th week (2.24).

The tabulated value at 5% level of significance with 28 degree of freedom is 2.049 showing the significant difference.

MRC Grading of Dyspnea within Control Group: Among all the variables with in control group, paired T-test calculated value for 1^st week-4^th week is less than 1.000 and the Table value is 2.145 at 5%level of significance with 14 degrees of freedom.

MRC Grading of Dyspnea within Experimental Group: Among all the variables within the experimental group, paired T –test calculated value for 1^st week -4^th weeks is 5.69 and the

table value is 2.15 at 5% level of significance improvement in dyspnoea levels in experimental group to control

MRC Grading of Dyspnea between Control Group and Experimental Group: Between control and experimental group student T-test was performed. Among all the variables the

student T- test calculated values between1^st and 4^th week (6.25).The tabulated value at 5% level of significance with 28 degree of freedom is 2.05 showing the significant difference.

Peak expiratory flow rate within Control Group:Among all the variables within the control group, paired T-test calculated value for

1^st -4^th week is 1.46759 and the table value is 2.145 at 5%level of significance with 14 degrees of freedom.

Peak expiratory flow rate within Experimental Group: Among all the variables within the experimental group, paired T –test calculated value for 1^st week -4^th weeks is 9.57556 and the

table value is 2.145 at 5% level of significance  with 14 degrees of freedom showing  significant improvement in PEFR values  in experimental group compared  to control

Between Control Group and Experimental Group: Between control and experimental group student T-test was performed. Among all the variables the student T- test calculated values for 1^st and 4^th week (4.09).The tabulated value at 5% level of significance with 28 degree of freedom is 2.05 showing the significant difference.

DISCUSSION

COPD is progressive and irreversible disorder of airway. Therefore even after resolution of acute exacerbation of condition there may be relative obstruction of airway. So complete expiration is not possible after resultant accumulation of Co₂. Therefore, these patients frequently report dyspnoea related to activities of daily living, such patients are considered as stable COPD patients. The symptom induced inactivity leading to deconditioning and muscle weakness & thus resulting into crucial impact of functional and health status^15-17.

The present study has done on patients with mild and moderate COPD for 4 weeks showed significant effects of IMT on dyspnoea &exercise tolerance.  Many studies have reported the effect of inspiratory muscle training on dyspnoea and exercise tolerance among COPD Patients. Parameters included in this study are 6 minute walk distance test, PEFR, and MRC grading of dyspnoea.

In experimental group in present study the mean improvement in 6 minute walk distance at the end of 4 weeks of training is 109.4 m, T _cal values 14.584, T _tab value 2.145, showing significant improvement. In control group the mean difference in 6 min walk is 3.2 m at the end of 4^th week T _cal values 1.000, T _tab value 2.145, showing no significant improvement. The limiting factors for reduced exercise tolerance in patients with COPD are dyspnoea. The increase in 6 min walk distance could be because of reduction in dyspnoea, increased exercise tolerance.

PEFR mean difference within the experimental group is78.66 T _cal values at the end of 4^th week is 9.576 and the, T _tab value 2.145, showing significant improvement compared to control group where the mean difference is 1.33, T _cal values 1.468, T _tab value 2.145. MRC grading of dyspnoea within experimental group at end of 4^th week the mean difference is 1.33, T _cal values 5.69, T _tab value 2.15, showing significant changes in dyspnoea levels in experimental group compared to control where there is no significant changes in mean values, at the end of 4^th week T _cal values is less than 1.000, and T _tab value is 2.145.

A study on specific inspiratory and specific expiratory muscle training has proved both are effective on improving respiratory function, specifically it could reduce dyspnoea and improve exercise performance. There was no difference in effect on the outcomes when the patient performed combined specific inspiratory and expiratory muscle training exercise program among COPD Patients ^18-20.

The effect of specific expiratory muscle training for one year among COPD patients have shown, it improves in respiratory muscle strength and health related quality of life.  The study has also reported maximal inspiratory pressure and improves 6 minute walk distance and a decrease in the mean Borg score during breathing against resistance scores. Some studies have reported inspiratory muscle training has improved functional exercise capacity and strength of respiratory muscles ^{21, 22}.

Present study even showed significant improvement in dyspnoea, exercise tolerance in COPD who underwent IMT for 4 weeks. Most commonly used training device in these studies is threshold IMT where intensity varied from 10% to 52% (high) of maximal inspiratory pressure (PI max) 20-30 min session, twice a day.

The reduction in dyspnoea due to IMT could be due to increased inspiratory muscle strength as determined 20% Larson et al. study (1999), 34% Lisboa et al(1997), 25%weiner et al (2000),50%, Sachez Riera et al (2016).

Inspiratory muscle training for five weeks has proved effect on external intercostals muscles with strong evidence of biopsy report on increase in size of type 2muscle fibers among COPD patients.

A study among COPD patients in Spain, they have analyzed health related quality of life (HRQL) using Questionnaire after inspiratory muscle training and found effect on outcomes of sustained maximal inspiratory pressures, shuttle walk test, in experimental group.

Comparatively the present study even showed significant changes and improvement in dyspnoea and exercise tolerance on mild and moderate COPD patients where the duration of the study was for 4 weeks and the outcome measures used were 6 min walk test, MRC dyspnoea grade and PEFR values. Experimental group showed significant improvement in all these outcome measures than the control group.

In a study conducted at south Korea, the effects of inspiratory muscle training has reported the changes in outcome measures of FEV1, level of dyspnoea based on Borgs score, and 6 min walk distance, they were analyzed in experimental group and showed decreased perception of dyspnoea and improved exercise capacity among moderate to severe obstructive components in the presentation of COPD.

Comparatively in the present study subjects were only mild, moderate COPD patients where control group did not participate in IMT for 4 weeks but practiced general mobility exercises and breathing exercises where as experimental group who underwent inspiratory muscle training showed significant improvement in dyspnoea and exercise tolerance.

The meta-analysis has reported the effect of inspiratory muscle training on inspiratory muscle strength and endurance, improved functional exercise capacity and decreased dyspnoea in patients with COPD. The documented effects of inspiratory muscle training were examined in a meta-analysis. The study is also recommended inspiratory muscle training is a very essential addition to pulmonary rehabilitation programs.

In the present study done on patients with mild and moderate COPD for 4 weeks the experimental group showed significant effects of IMT on dyspnoea &exercise tolerance than control group who underwent only breathing and general mobility exercises.

The studies conducted were performed on a limited number of subjects. Further study is required on a large group to quantitatively analyze the results of IMT on large scale.

Ethical Clearance: Ethical clearance has obtained from Faculty of Physiotherapy, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad on 02/05/2008 to conduct this study.

Conflict of interest: There was no conflict of interest to conduct this study.

Fund for the study: It was aself financed study.

CONCLUSION

The study has concluded from the study that inspiratory muscle training can reduce dyspnoea and improved exercise tolerance in COPD patients with mild and moderate exacerbation. The study has also supported the exercise program can improve overall health related quality of life (HRQL) among COPD patients.

Limitations: Limitations of the study were small sample size, short time training period, IMT apparatus is not accessible and it is cost effective for the patients and study was limited to a specific group of mild and moderate COPD.

Future Direction: The present study can be extended for long term rehabilitation. Future study can imply IMT on severe exacerbation of COPD/chronic asthma, cystic fibrosis, pre op lung conditions such as lobectomy, pneumonectomy. Pre and post training PI Max value of IMT can be taken to further strengthen the study, and also can imply expiratory muscle training.

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Citation:   Syeda Khanam. P, Manjunatha. H, Thummala S. Pavani (2021). Effect of Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease on Dysponea and Exercise Tolerance, ijmaes; 7 (1); 933-942.