Category: Publications

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.
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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 .
9. Kyeong-Jin Lee, et al.(2015).The effect of forward head posture on muscle activity during neck protraction and retraction. J. Phys. Ther. Sci. 27: 977-979.
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.
12. Lindsay M. Bottoms, et al (2011). Physiological responses and energy expenditure to stimulated epee fencing in elite female fencers. Serbian Journal of Sports Sciences, 5(1): 17-20.
13. Jonathan D. Wiles, et al. (2018)  The safety of isometric exercise Rethinking the exercise prescription paradigm for those with Stage 1 hypertension. Wiles et al. Medicine 97:10.
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16. Jerrold S Petrofsky, Richard L Burse, AR Lind. (1975). Comparison of physiological responses of women and men to isometric exercise. Journal of Applied Physiology 38 (5), 863-868.
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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

1. Aggarwal N, etal. (2011). Prevalence and related risk factors of osteoporosis in peri and postmenopausal Indian women. J Midlife Health 2: 81-5.
2. Syed Z, Khan A. (2002). Bone densitometry: Application and limitation. J obstet Gynaecol Can 24:476-84
3. Cumming SR, et al. (1995). Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med.; 332(12):767-73.
4. Sharma S, Tandon VR, Mahajan A, Kour A, Kumar D. (2006). Preliminary screening of osteoporosis and osteopenia in urban women from Jammu using calcaneal QUS. Indian J Med Sci; 60:183-9.
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.
6. Kataria SK, Pareek P, Dadhich A, Kataria KR, Bhati M. (2012). The effect of body mass index on bone mineral density in pre and postmenopausal women of western Rajasthan population. Int J Biol Med Res. 3(3):1899-1901.
7. Anburanjan M, Kumar D A,  Sapthagirivasan V. (2011). Evaluation of osteoporosis in Indian women and men usingp DXA. Academia.ed. International conference on bioscience, biochemistry & bioinformatics (ICBBB- 2011), ISBN: 978-1-4244-9388-3 pp 470-474,.
8. Shukla J, Sarkar PD, Bafna A, Shukla N. (2013). A retrospective study to investigate association among age, BMI and BMD in postmenopausal women. IOSR-Journal of pharmacy and biological sciences, 6(2):93-6.
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.

REFERENCES

1. Nice, L (2000). Mechanism and measures of exercise intolerance in chronic obstructive lung disease.Clin Chest Med 21, 693-704.
2. Van’tHul, HA, Gosselink, R, Kwakkel, G (2003). Constant-load cycle endurance performance; Test-Retest reliability and validity in patients with COPD. J Cardio-pulmo rehabil. 143-150.
3. Polkey, MI, Moxham, J, (2004). Improvement in volitional tests of muscle function alone may not be adequate evidence that inspiratory muscle training is effective Eur Respir. J, 23, 5-6.
4. Holm, P, Sattler, A, Fregosi, RF (2004). Endurance training of respiratory muscle improves cycling performance in fit young cyclists.BMC Physio., 4: 9.
5. Weiner, P, Magadle,R, Beckerman, M, et al (2003). Specific expiratory muscle training in COPD. Chest 124, 468-473.
6. Weiner, P, Magadle, R, Beckerman, M, et al (2003). Comparison of specific expiratory, inspiratory and combined muscle training program in COPD Chest 124, 1357-1367.
7. Bourjeily, G, Rochester, C L, (2000). Exercise training in chronic obstructive pulmonary disease, Clinical chest med, 21,763-781.
8. Caine MP and MC Connell AK (2000). Development and evaluation of a pressure threshold inspiratory muscle trainer for use in the context of sports performance. Sports Engin 3,149-159.
9. Covey MK, Larson JL, Wirtz SE, Berry JK, Pogue NJ, Alex CG and Patel M., (2001). High intensity inspiratory muscle training in patients with chronic, obstructive pulmonary disease and severely reduced function. J. Cardiopul. Rehabil. 21; 231-240.
10. Lotters, F, Kwarkkel, G, Gosselink, R. (2002). Effect on controlled inspiratory muscle training in patients with COPD.A Meta-analysis. European Respiratory Journal, 20,570-577.
11. Oh, Eui-Geum. (2003).The Effect of home-Based pulmonary Rehabilitation in patients with chronic lung disease. International journal of nursing studies, 40, 873-880.
12. Beckerman, Marinella, Magadle, R, (2005, November). The effect of one year of specific inspiratory muscle training in patients with COPD. Chest, 5, 3177-3183.
13. Martin, Daniel, (2002). Use of inspiratory muscle strength training to facilitate ventilator weaning. Chest 122,192-196.
14. Sanchez, RH, Monte mayor, RT, Ortega, RF, et al. (2001). Inspiratory muscle training in patients, with COPD; Effect on dyspnoea, exercise performance, and quality of life chest 120,748-756.
15. De Jong W, Van Aalderen WM, Koeter GH, and van der schans CP.(2001). Inspiratory muscle training in patients with cystic fibrosis. Respir Med., 95: 31-36.
16. Enright, S, Chatman, K, Lonescu, A.(2004). Inspiratory muscle training improves lung function and exercise capacity in adults with cystic fibrosis. Chest, 2, 405-412.
17. Lisobia, C, Munoz, V, Beroza, T, Leiva, A, Cruz, E, (1994). Inspiratory muscle training in chronic airflow limitation: A compensation of two different training loads with a Threshold Device European Respiratory Journal, 7, 1266-1274.

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.

Rosintan Milana Napitupulu¹, Novlinda Susy Anrianawaty Manurung²

Corresponding author:

¹Physiotherapy Program, Faculty of Vocational Studies, Universitas Kristen Indonesia.

Mail id: rosintan.napitupulu@uki.ac.id

Co-Author:

² Physiotherapy Program, Faculty of Vocational Studies, Universitas Kristen Indonesia

ABSTRACT

Introduction: The composition of the elderly population is increasing rapidly in both developed and developing countries, which is caused by a decrease in fertility (birth) and mortality (death) rates as well as an increase in life expectancy, which changes the structure of the population as a whole. Stroke can generally occur in all age groups, but three quarters of strokes occur in people who are already 65 years old or older (the elderly) and result in the onset of disability or invalidity. Stroke is one of non-communicable diseases, which is the leading cause of death worldwide. Methodology: Data was taken from the integrated health service post (for the elderly) to obtain an overview of the risk of stroke in the elderly based on the available secondary health data of the elderly. Results: Two hundred and sixty-eight (268) elderly people with the available health data can be described by the following criteria: 56% of the elderly have low risk, 32% of the elderly have moderate risk, and 12% of the elderly have high risk. Conclusion: The elderly in the integrated health service post for the elderly have various risks of stroke from moderate to high. Keywords: Risk of stroke; Physiotherapy; Health status; Elderly

Received on 18th January 2021, Revised on 24th January 2021, Accepted on 20th February 2021; DOI:10.36678/IJMAES.2021.V07I01.002

INTRODUCTION 

Stroke is one of non-communicable diseases, which is the leading cause of death ^1,2. Stroke is included in cerebrovascular disease, which is a brain function disorder associated with the disease of a blood vessel that supplies blood to the brain³. Stroke is also called a brain attack which always occurs suddenly with various symptoms. However, most of the symptoms that are often found are the condition of the body that is half paralyzed and/or accompanied by decreased consciousness⁴. Stroke can generally occur in all age groups, but three-quarters of strokes occur in people who are already 65 years old or older (the elderly) and result in the onset of disability or disorders ⁵.

 The large number of elderly people in Indonesia will have both positive and negative impacts. It has a positive impact if the elderly population is healthy, active, and productive. On the other hand, the large number of the elderly population becomes a burden if they have a problem of declining health which results in an increase in the cost of health services, a decrease in revenue/income, an increase in disability, the absence of social support, and an environment that is not friendly to the elderly population⁶.

Based on the magnitude of the problem that will arise due to stroke in the elderly, we consider it important to portray or describe the risk of stroke that exists in the elderly in sub-district of Cililitan, Jakarta, Indonesia as an area that is fostered by Universitas Kristen Indonesia. We processed the secondary data on the health of the elderly to describe the risks of stroke that exist in the elderly in this area. The research was conducted at the Integrated Health Service center for the elderly of Cililitan because it is one of the Integrated Health Service center that also fostered by the UniversitasKristen Indonesia, so further research is needed to increase the role of the university to the community in terms of health, disease prevention, and improvement of public health.

RESEARCH METHODOLOGY

The methodology of this research is a descriptive study by taking secondary data from the Integrated Health Service Centre for the elderly in Sub-District of Cililitan, Jakarta, Indonesia. The selection of this integrated health service post was based on its collaboration with the Universitas Kristen Indonesia, so that community service-based research could be carried out. The data taken was then processed using a cross sectional study method.

Secondary data was obtained from the report on the results of examining the general condition of the elderly made by health workers from the integrated health service post for the elderly with the examination period in March 2020. The data used is on routine health checks carried out by health care professionals at the integrated health service center for the elderly. The use of data in this study has received permission from the management of the integrated health service post by not displaying the identity of the elderly.

Data analysis: The data obtained is the health data of the elderly which includes: blood pressure, random blood sugar level, cholesterol, age, and sex. This secondary data was processed using Microsoft Excel software in order to obtain an overview of the risk of stroke in the integrated health service center for the elderly of Sub-District of Cililitan.

RESULTS and DISCUSSION

The following is the data obtained through the secondary data available in the integrated health service post for the elderly taken in March 2020. The data in Table 1 shows the profile of the elderly at the integrated health service center for the elderly.

Thereafter, from the profile of the elderly, the researchers continued to process the health profile data of the elderly consisting of the conditions of blood pressure, blood sugar, and cholesterol.

Based on the results of the profile data processing in the form of sex and age shown in Table 1 above, it is known that there are 268 elderly people consisting of 33% males (90 people) and 66% females (178 people), with 76% (203 people) in the age range of 60-70 years, 20% (55 people) in the age range of 71-80 years, 3% (9 people) in the age range of 81-90 years, and 1% (1 person) in the age range of 91-100 years. In this data, it is found that most of the elderly are female. In the study, stroke is more common in men aged 65-79 years although older women can also be at higher risk, namely those over 80 years ^7,8.

Based on the health profile shown in Table 3, there are three important factors that constitute indicators in the assessment of potential risks of stroke, such as:blood pressure, blood sugar, and cholesterol. A study also explains that those three indicators can be initial risk assessment for stroke conditions ⁵.

In the data processing table of the recorded results of medical examination based on blood pressure, it is concluded that 19% (51 people) of the elderly havea low risk potential, 61% (163 people) have a moderate risk potential, and 20% (54 people) have a high risk potential of stroke. It is also supported by a study conducted by Seshadri et al., which actually states that high blood pressure would result in higher risk of stroke in the elderly below 80 years old⁹. It is also visible from the data that such condition can also affect more than 70 percent of the elderly in the integrated health service center. A study conducted by Rodgers et al. also states that hypertension in the elderly can also result in a higher risk for the occurrence of stroke in the elderly⁵. A study conducted by Arboix et al. also states that high blood pressure conditions play a major role in increasing the risk of ischemic stroke in the elderly who are older than 85 years or more¹⁰.

In the data processing table of the recorded results of medical examination based on random blood sugar level,it was found that 57% (154 people) of the elderly have a low risk potential, 27% (70 people) have a moderate risk potential, and 16% (44 people) have a high risk potential of stroke. In general, the blood sugar condition and other conditions such as food management are also influential to the risk level of strokein the elderly ¹¹.

In the data processing table of the recorded results of medical examination based on cholesterol, it was found that 72% (194 people) of the elderly have a low risk potential, 20% (53 people) have a moderate risk potential, and 8% (21 people) have a high risk potential. It can be said that most of the elderly are still safe in terms of cholesterol contained in the blood as a stroke risk parameter. Nevertheless, high cholesterol levels in the blood can be one of the risks that result in stroke among the elderly⁴. A study conducted by Reddy et al. stated that, besides the risks of diabetes and hypertension, dyslipidemia, obesity, smoking, and drinking alcohol can also increase the risk of stroke in the elderly¹².

In this study, there were still more elderly women who came regularly, so that the data presented has not covered all the elderly. The data displayed is also only the data taken in the month of March. The activities in the integrated health service post for the elderly need to be enhanced with simple exercises that can increase physical activity in the elderly to help improve general health ¹³.

Ethical Clearance: Ethical clearance has obtained from Universitas Kristen Indonesia, Jakarta, Indonesia to conduct this study with reference number: 309/UKI.F8.D/PPM dated 01/06/2020.

Conflicts of Interest: The author declares that there is no competing interest in publishing this article.

Fund for the study: This is self-funded study.

Recommendation: The participation of elderly men in the integrated health service post needs to be increased, so that the elderly men who are at risk can be recorded because, based on data, many men have the risk of stroke. Health examination in the integrated public health service center for the elderly needs to be conducted regularly which needs to be supplemented with exercises or gymnastics for the elderly to improve their health condition. Simple exercises to increase physical activities can improve the health condition of the elderly.

CONCLUSION

As a conclusion, the elderly in the integrated health service center have quite various stroke risk potentials from moderate to high. In such conditions, information about health condition needs to be disseminated about the basic risks that would result in stroke also with initial handling for the prevention of stroke.

REFERENCES

1. Hu, G., Sarti, C., Jousilahti, P., Peltonen, M., Qiao, Q., Antikainen, R., &Tuomilehto, J. (2005). The impact of history of hypertension and type-2 diabetes at baseline on the incidence of stroke and stroke mortality. Stroke, 36(12),2538-2543.
2. Feigin, V. L., Krishnamurthi, R. V., Parmar, P., Norrving, B., Mensah, G. A., Bennett, D. A., & Davis, S. (2015). Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology, 45(3), 161-176.
3. Dávalos, A. (2005). Thrombolysis in acute ischemic stroke: successes, failures, and new hopes. Cerebrovascular Diseases, 20 (Suppl. 2), 135-139.
4. Chen, R. L., Balami, J. S., Esiri, M. M., Chen, L. K., & Buchan, A. M. (2010). Ischemic stroke in the elderly: an overview of evidence. Nature Reviews Neurology, 6(5), 256-265.
5. Rodgers, H., Greenaway, J., Davies, T., Wood, R., Steen, N., & Thomson, R. (2004). Risk factors for first-ever stroke in older people in the north East of England: a population-based study. Stroke, 35(1),7-11.
6. Parr, E., Ferdinand, P., &Roffe, C. (2017). Management of Acute Stroke in the Older Person. Geriatrics, 2(3),27.
7. Appelros, P., Stegmayr, B., &Terént, A. (2009). Sex differences in stroke epidemiology: a systematic review.  Stroke, 40(4), 1082-1090.
8. Arboix, A., Oliveres, M., García-Eroles, L., Maragall, C., Massons, J., & Targa, C. (2001). Acute cerebrovascular disease in women. European neurology, 45(4), 199-205.
9. Seshadri, S., Wolf, P. A., Beiser, A., Vasan, R. S., Wilson, P. W., Kase, C. S., & D’Agostino, R. B. (2001). Elevated midlife blood pressure increases stroke risk in elderly persons: the Framingham Study. Archives of internal medicine, 161(19), 2343-2350.

Citation:  Rosintan Milana Napitupulu, Novlinda Susy Anrianawaty Manurung (2021). Overview of the health profile of the elderly referring to the risks of stroke in the Sub-district of Cililitan, Jakarta, Indonesia , ijmaes; 7 (1); 927-932.

Gummadi Ashish¹

Coresponding Author:

¹Senior Physical therapist, Department of Neurorehabilitation, Institute of Neurosciences, Kolkata, Mail id: ashishgummadi@gmail.com

Aim and background of the study: Pes Anserine Bursitis is an inflammatory condition of pes anserine bursa which affects medial and inferio- medial aspect of the knee with more painful and swelling around the knee joint. Aim of the study is to find the effectiveness of iontophoresis and open kinematic chain exercises on pain, and knee range of motion of sports person with pes anserine bursitis. Methodology: 30 male and female subjects according to inclusion and exclusion criteria were randomly divided into two groups for the study where, Experimental Group was treated with Iontophoresis and open kinematic chain exercise. Control Group was treated with Ultrasound therapy. Result: The study reported  the Group  treated with Iontophoresis and open kinematic chain exercise got significant improvement in VAS and KROM score with p=0.001. Conclusion: the study concluded that the experimental group which received iontophoresis along with open kinematic chain exercises demonstrated good effect in reducing pain and increasing Knee ROM. Key Words: Iontophoresis, open kinematic chain exercises, Pes anserine bursitis, VAS, KROM.

Received on 14th January 2021, Revised on 22th January 2021, Accepted on 18th February 2021; DOI:10.36678/IJMAES.2021.V07I01.001

INTRODUCTION 

Knee is a hinge variety joint, which provides flexion and extension movements and a small degree of medial and lateral rotation. Pes anserine bursa of knee joint get inflamed due to over use and the bursitis affect medial and inferio- medial aspect of the knee with more painful and swelling around the knee joint ^{1, 2}.

Pes Anserine Bursitis Epidemiology: Pes anserine bursitis is a common in running sports person. It is self-limiting condition, it can be cure with surgery or without surgery.¹Pes anserine bursitis risk increases with endurance sports (distance running or triathletes), making changes to or beginning a new training program, sports that place stress on the muscles that insert at the pes anserine, such as those that require pivoting, cutting or, jumping, improper training, poor strength and flexibility, failure to warm-up properly before activity, improper knee alignment (knock knees), arthritis of the knees and trauma or constant friction on the bursa³.

Pes Anserine Bursitis in Sports Person (Marathon Runners): Pes Anserine bursitis risk is higher in endurance training and one of the most frequently affected individuals are Marathon Runners as they performs lots of endurance training. Usually in marathon runners, the tendon may become overused due to change in the training- for example running more uphill or just increasing the intensity of training program. Or any change in footwear can also be a cause ⁴.

 The new runners or those who have not had a professional gait analysis can develop Pes Anserine Bursitis. This Bursitis may develop over the course of long run, or may be a few weeks. Whatever be the duration, the main cause is due to overuse of the tendons that guards the pes anserine bursa.⁶

Pain in the inner aspect of knee, swelling and difficulty to bend the knee are the main symptoms of Pes Anserine Bursitis. Later stage muscle around the knee which produce extension and flexion movements may go for week followed by reduce the range of movement in knee joint ⁵.

Physiotherapy is the most widely used form of treatment adopted for gaining relief from pes anserine bursitis. It is used in both modes as single line of treatment including exercises or in form of combination with electrotherapy modalities like Ultrasound, Iontophoresis etc. The exercises include stretching, strengthening, ROM exercises. In flat feet individuals suggests with wearing arch supports in their shoes. Compression bandages or knee sleeves also helpful for reduce symptoms ^6,7.

Iontophoresis is a therapeutic technique in which ion transfer into the body tissues by using electrical current as a driving force (LeDue, 1903).Iontophoresis is painless, sterile and non-invasive method to introduce specific ions into the body tissues. In case the ions are used in the form of ointment, a layer of its applied at the site to be treated. Iontophoresis treatment with dexamethasone is well tolerated by the majority of the patients⁵.

Open kinematic chain exercises (OKC) are the form of exercises in which the distal segment is mobile or not fixed like isolated joint exercise e.g. Seated leg extension. Open kinematic chain exercises are helpful to correct strength deficits of specific muscles or joints and beginning of rehabilitation when athlete not able to perform CKC exercises^.11Open kinematic chain exercises are helpful to gain strength, flexibility and endurance of.3 hamstrings muscles group in sports person affected with Pes anserine bursitis⁸.

To evaluate the pain intensity VAS has been used whereas Knee ROM was measured using Goniometer. This study aimed to find the effectiveness of both the intervention in sports person with Pes Anserine bursitis.

In this modern age, there is a need of active research on an easy and effective intervention to reduce the pain and gain the near full ROM which enhances the performance in sports person.

Many Pes anserine bursitis patients experience pain, muscle weakness, decreased ROM and functional disability. Most patients regain their ROM muscle strength within a few week, but between 30 to 50 % are no longer able to get full ROM, muscle strength and functional ability after 1-2 month. So there is a strong need to gain full ROM muscle strength and pain reduction in Pes anserine bursitis rehabilitation .The persisting problem of ROM at knee muscles weakness and increased pain needs to be addressed and newer  strategies such as Iontophoresis with open kinematic chain exercises  can bring better insights for sports person with Pes anserine bursitis^7,8.

In this study, iontohoresis with dexamethasone sodium and open kinematic chain exercise has been used to treat the sports person diagnosed with Pes Anserine bursitis.Iontophoresis is a therapeutic technique in which ion transfer into the body tissues by using electrical current as a driving force (LeDue, 1903).

Iontophoresis is painless, sterile and noninvasive method to introduce specific ions into the body tissues. In case the ions are used in the form of ointment, a layer of its applied at the site to be treated^.11Iontophoresis treatment with dexamethasone is well tolerated by the majority of the patients and is effective in reducing symptoms such as pain and tenderness and better enable patients to tolerate therapeutic exercises and, therefore, will accelerate the rehabilitative process⁸.Hence this study is an attempt to find out the effectiveness of Iontophoresis with Open kinematic chain exercises (OKC)

METHODOLOGY

The subjects for the study were taken from the outpatient department of Neuro-rehabilitation Instuite of neurosciences kolkata. The subjects referred to the physiotherapy department with the diagnosis of Pes Anserine bursitis were screened for inclusion and exclusion criteria. The subjects who were qualified for the trial will be explained the aim and objectives of the study.

The subjects were requested to sign the consent form. The subjects were measured for their baseline outcome measures. A total 30 subjects who fulfil the inclusion criteria were included for the study and allotted into 2 groups, Experimental group (EG) and Control group (CG) randomly. The subjects with both groups received intervention for 12 days, the baseline measurements will be compared to the data at the end 12 days.

Procedure of intervention for the experimental group

Iontophoresis: Dexa-methasone sodium phosphate 0.4% with aqueous water was given via Galvanic current. The current used for this process was kept 1mA with subjects comfort considerations. In Iontophoresis current density always depends on quantity of current delivered per unit surface area. For this, two electrodes are used negative electrode (cathode) and positive electrode (anode), Negative electrodes used was double the size of the positive electrode.  Since Dexa-methasone sodium phosphate is negative ion (-), it was placed over the cathode (-). The cathode was placed over the pes anserine bursa where as the anode was placed over the calf muscle. Duration for iontophoresis was 20 minute per session once a day for 5-7 days ³

All the 15 patient of experimental group treated with Iontophoresis for initial 5 days were then treated with Open kinematic chain exercises (OKC) for knee everyday two session each session consisting  of 30 minutes .Each exercises was performed with proper rest period of  about 2 minutes after each exercises. Patient performed these exercises in supine lying position and support was provided by te assistant as necessary.

These exercises included the following exercises-

Hamstring stretch on wall: Subjects was in supine lying with hands by side, subjects involved leg on wall and other leg as free, as instructed by examiner, 10 repetitions were done with feel stretch.

Single leg hip extension: The patient was asked to lie down on his back with his knee bent at 90 degree and his feet hip width apart. From this position patient was asked to raise the leg and hold it suspended. Then the patient was asked to push his hips and lower back as one unit through the stabilizing leg, keeping his weight centered at his heel.10 repetitions with 10 counts hold

Seated knee extension: Subjects was in high sitting position, and the patient was asked to straight the knee.10 repetition with 10 count hold

Straight leg raise (SLR): The non-affected leg was flexed for 90 degree at the knee joint; the affected lower limb is straight on the table. The patient was asked to raise the affected lower limb straight to the level of the other leg.10 repetitions with 10 count hold.

Procedure of intervention for control group

Each participant in this group received ultrasound therapy with the intensity ranging from 0.8 -2 W/cm² for 8 minutes in pulsed mode. The subject was positioned in high sitting position with the knee slightly rotated outward and the other leg of the subject was asked to keep apart from the involved limb.  The ultrasound was given by the therapist over the painful area in small concentric circles.³³

Method for outcome measures

Visual Analogue Scale (VAS): VAS was used to measure subjects perception level of pain due to Pes anserine bursitis .It consists of scale where scoring is from 0-10. With score 0 subjects express no pain and with score 10 expresses maximum pain. The patient was asked to level the highest amount of pain they were getting at the time of assessment.

Knee Range of Motion (ROM)-Goniometry: Knee ROM includes flexion and extension which was measured by goniometer. To measure knee flexion, patient was asked to lie down in supine position and the subject was asked to bend the knee. Three trials of the same procedure were performed and average of the readings was considered for data analysis. To measure Knee extension, the patient was asked to lie down in prone position. The subjects was instructed to lift the knee without pelvic tilt (stabilize femur) and then goniometer was placed and the average reading of the three trials was recorded.

Inclusion criteria: Subjects between ages of 15-30 yrs. Both genders were included. History of improper training, running up hills with trackers, which produce pain and tenderness localized near Pes anserine bursa, Marathon runners, running for > 2 years were selected for the study.

Exclusion Criteria: Subjects with stress fracture, subjects with other lower limb musculoskeletal pathology, subjects with ischemic disorder of lower limb, subjects with muscle spasm of hip extensors, malignancies or tissue damaged by radiation therapy, subjects with visual impairment   or  with  any   other  neurological

disability like any head trauma, dementia, learning disorder and schizophrenia, and Osteoarthritis of knee were excluded from the study.

Materials and Methods: It includedCouch, EMS/Galvanic, Dexamethasone sodium phosphate aqueous solution, Cotton, Microspore tape, Goniometer, Ultrasound machine, and Aquous gel

Outcome Measures: Visual analogue scale (VAS) and Knee range of motion (ROM) goniometry

RESULT

Study design: A Comparative two group interventional clinical study

Table 1 show that there is 46.7% of patient in Experimental group and 40% in Control group of age group 15-20. However, 53.3% were in

experimental group and 60% in control group of age group 21-30. 

In table 2, Experimental group consists of 60% female and 40% male whereas control group consists of 53.3% female and 46.7% male patients. Overall, 56.7% of patient was females and 43.3 % was males.

VAS score of both the group were analysed in table 3 and the mean difference in percentage was obtained. Range of VAS scale score was made as 0, 1-3, 4-6, 7-10 in both the groups. The VAS score has been significantly reduced in Experimental Group as compared to Control Group. In the VAS score the % difference between the pre and post treatment is 46.7%, 53.3%, 0% and -100%.

In table 4, Knee ROM has been ranged as 50-80, 80-100,100-120,120-135 degree. The % difference between pre and post treatment is -73.3%,-26.7%, 66.7%, and 33.3% which shows the high significance of the treatment in Experimental Group. The P value is of <0.001** resulting highly significant. In control Group, the KROM in day 14 is 60%, 33.3%, 6.7%, 0% respectively for the given ROM range which indicates that there is very less improvement in KROM  after treatment. The mean difference is not as high as that of experimental Group which is -13%, 6.6%, 6.7% and 0.0% respectively for the given range.

In table 5, VAS score of the patient in EC was 8.27±0.80 whereas post treatment in day 14 it became 0.67±0.72. The mean difference noted is 7.600 and the p value is highly significant at <0.001**. Similarly for control group, VAS score in day 1 is 7.80±0.94 and for day 14 is 4.40±0.83. There is not much difference between pre and post score for VAS in control group, which is just 3.400.

Knee ROM for EC in day 1 was 69.67±14.82 whereas in day 14 it is 119.67±6.67.The mean difference between pre and post treatment score is of -50.000 and the P value at <0.001**. However, control group doesn’t depict much change after treatment. The mean difference between Pre and Post treatment score is just -13.333, far less than that we achieved in EC.

Table 6 displays the difference in VAS and Knee ROM of patients of. Experimental group and control group. Difference in VAS score is 5.50±2.42 and Knee ROM is 31.67±22.18.

DISCUSSION

The purpose of the study was to find the effectiveness of iontophoresis with open kinematic chain exercises to reduce pain and to increase knee ROM in sports person with pes anserine bursitis. The study consists of 30 sports persons diagnosed with Pes Anserine bursitis.15 subjects were kept in experimental group and other 15 in control group. The subjects in experimental group received iontophoresis with open kinematic chain exercises of knee and the control group was treated with ultrasound only. In this study, experimental group and control group result were analysed using student t test and chi square test.

Result obtained from this present study shows that when the mean reduction values of VAS and ROM were analyzed within the groups, it was statistically significant in both the groups for VAS score whereas there was no any effect in KROM in control group. Iontophoresis along with open kinematic chain exercises was found to be very effective in reducing pain and improving ROM. VAS score assessment for pain showed significant improvement in both the groups after the treatment.

This statement is supported by Robert et al (2003) where they concluded that iontophoresis administration of Dexa-methasone sodium phosphate is well tolerated by the patients and is able to reduce pain.The statement is further supported by Linda C et al (1995) where dexa-methasone sodium phosphate was used to treat rheumatic arthritis and the result obtained showed that iontophoresis treatment was more effective in reducing pain and improving ROM. The dexamethasone sodium phosphate delivered via iontophoresis penetrates deep into the joint and thus reduces the symptoms ⁹.

Iontophoresis is the most commonly used method for pain and inflammation. Iontophoresis for treatment of locomotor system lesions should be considered as an alternative to peri and intra-articular injections because the drugs used diffuse to the tissues along the dermal barrier and penetrate into the body and thereby reduces the symptoms more effectively.Iontophoresis administration of dexa-methasone sodium phosphate was more effective in reducing the pain and other symptoms in short term follow up for patients with lateral Epicondylitis.

Although ultrasound was found to be reducing pain and increase the healing process, the result obtained from this study was not as highly significant as in experimental group. Therefore all the above literature supports the efficacy of iontophoresis in reducing the pain and allowing the better tolerance for exercises.The study was designed to find the effectiveness of iontophresis and open kinematic chain exercises   to reduce pain and to improve KROM in sports person with Pes anserine Bursitis.

This study was a randomised experimental study where 30 sports person with Pes anserine bursitis of age group 15-30 wereselected.The subjects were evaluated and included for the study using inclusion criteria such as VAS score 6-9, both the gender and tenderness over the pes anserine bursa. Subject with recent surgery in and around the knee, stress fracture, and other progressive neurological deficit were excluded. Subjects who were willing to participate in the study were requested to fill the consent form.

On day one, pre- treatment baseline assessment was done using VAS for pain assessment and knee ROM by using goniometer.30 Subjects were assigned to either group of 15 in each group. That is experimental group (EG) which received iontophoresis and OKC exercises and control group (CG) which received ultrasound therapy. Post treatment assessment was done on 12^th day of treatment using VAS and by measuring KROM using goniometer. Data were analysed using Paired –“t” test and Un-paired “t” test. The result shows that there is reduction of pain and improvement in KROM after 12 days of intervention in EG when it is compared to CG.

Therefore the study concludes that the iontophoresis and open kinematic chain exercises are an effective intervention to reduce pain and to increase KROM in sports person with Pes Anserine bursitis after the 12 days of treatment. The analysis found the highly significant differences in between the pre and post test score of KROM for experimental group. This statement is supported by M Seshagirirao et al (2016) which concluded that open kinematic chain exercises are effective in improving the strength and knee function ¹⁰.

Graham et al (1993)found that Open kinematic chain exercises are helpful in improving range of motion and strength of quadriceps and hamstrings muscles. This statement is further supported by the study William E Prentice (2003) who observed that open kinematic chain exercises are helpful to gain strength, flexibility and endurance of hamstrings muscles group in sports person affected with Pes Anserine bursitis.  Open kinematic chain exercises of knee were studied and the result obtained showed significant improvement in the hamstrings strength and ROM. Therefore all the above literature supports the efficacy of iontophoresis and open kinematic chain exercises in reducing pain and improving knee ROM in sports person with Pes anserine bursitis¹¹.

As Pes anserine bursitis is considered as a self- limiting disorder, in some cases it is not possible to determine if this self-limiting factor led to the improvement of pain levels and knee ROM instead of treatment administered. The sample size is small and the treatment duration is for short period of time. In future, further studies can be done on larger sample size and for long duration. Additionally, further studies can be done which involves treatment programs like iontophoresis and close kinematic chain exercises.

Ethical Clearance: Ethical clearance has obtained from Institute of Neuroscience, Kolkata to conduct this study with reference number: 214/ Research/IRB/2018-19dated 24/09/2019.

Conflicts of Interest: The author declares that there is no competing interest in publishing this article.

Fund for the study: This is self-funded study.

CONCLUSION

This study concluded that the experimental group which received iontophoresis along with open kinematic chain exercises demonstrated   good effect in reducing pain and increasing Knee ROM.  But when the experimental groups is compared with the control group which received only ultrasound therapy, EG showed significant improvement in VAS and KROM score whereas there is not much significant improvement in outcome measures post treatment in control group.

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Citation:   Gummadi Ashish (2021). A study to find the effectiveness of iontophoresis with open kinematic chain exercises in Pes Anserine bursitis in sports persons, ijmaes; 7 (1); 916-926.