Scientific Research Journal of India SRJI Vol-3 Issue-3 Year 2014

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

ISSN: 2277-1700
Vol: 3, Issue: 3, Year: 2014
Jyoti Sharma, Jabalpur, India
Editor in Chief
Kuki Bordoloi, Guwahati, India
Mrityunjay Sharma, Varanasi, India
Neha Dewan, Canada
Executive Editor
Ngeh Etienne Ngeh, Cameroon

Nick Ngwanyam, Cameroon
Krishna N. Sharma, Cameroon
Piyush Jain, New Delhi, India

Editors
Popiha Bordoloi, Guwahati, India

Sudeep Kale, Mumbai, India
Ankita Kashyap, Bhopal, India
Sushil S. Dubey, Mumabi, India
Florence Ngwanyam, Cameroon
Tufon Emmanuel, Cameroon
Gayatri Jadav Upadhyay, Bhopal, India
Waqar Naqvi, Saudi Arabia
Office
Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403
Website
http://srji.drkrishna.co.in
URL Forwarded to
http://sites.google.com/site/scientificrji
Email
editor.srji@gmail.com
Contact
+91-9839973156
Scientific Research Journal of India Volume: 3, Issue: 3, Year: 2014
Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the
authors, and the editorial board will not be held responsible for the same/ plagiarism or some aother issues.
Copyright 2014 Scientific Research Journal of India
All rights reserved.
CONTENT
DEPARTMENT
TITLE
AUTHORS
PAGE
FROM THE EDITOR IN CHIEF
Mrityunjay Sharma
A STUDY TO DETERMINE THE RELATIONSHIP

BETWEEN THE MEASUREMENT OF BALANCE
AND MOBILITY TO QUALITY OF LIFE (SF-36) IN
ELDERLY POPULATION
Meenakshi Verma, Amita
Dr.Nisha Shinde,
Dr.Subhash Khatri,
Dr.Sambhaji Gunjal
11
Juanita E. Soans Keerthi

Rao, Subhash Khatri,
Chandra Iyer
22
Dr. Vivek H. Ramanandi
34
Amit Murli Patel
54
Alagappan Thiyagarajan,
Prem Karthik, Sathish
Kumar
70
Nitika Anand, Sunil Bhatt
79
Sunil Bhatt, Jagun Tomar,

Money Rajput, Udaykant
Yadav
88
Shivam Karn, Sunil Bhatt,

Sonali Surbhi, Anup Raj
Thapa
98
Baiju Prasad Jaiswal, Sunil

Bhatt, Shilpa Kumar, Prerna
Bhardwaj
109
Dr. Sumit Asthana
120
Shahanawaz sd
131
EFFECT OF JACOBSONS PROGRESSIVE

MUSCULAR RELAXATION ON QUALITY OF LIFE
IN PATIENTS WITH TYPE II DIABETES MELLITUS
(TDM2) : RCT
EFFECTIVENESS OF PROPRIOCEPTIVE
NEUROMUSCULAR FACILITATION IN CHRONIC
LUMBAR SPONDYLOSIS
PREVALENCE OF SACROILIAC JOINT PAIN AND
DYSFUNCTION IN PATIENTS WITH NON-SPECIFIC
CHRONIC LOW BACK PAIN
CASE STUDY OF ERGONOMIC INTERVENTION IN
TREATMENT OF A COMPUTER PROFESSIONAL
SUFFERING FROM UPPER EXTREMITY & NECK
PAIN
PHYSIOTHERAPY STUDENTS EXPERIENCES OF
Physiotherapy
BULLYING ON CLINICAL INTERNSHIPS: A

QUALITATIVE STUDY
RELATIONSHIP BETWEEN BALANCE AND
QUALITY OF LIFE IN ELDERLY WITH VERTIGO
OF VARIOUS CAUSES
EFFECT OF SMOKING ON ATTENTION AND
MEMORY IN YOUNG ADULTS: A DESCRIPTIVE
STUDY
DEMOGRAPHIC TRENDS AND QUALITY OF LIFE
IN GERIATRIC POPULATION IN AND AROUND
DEHRADUN
RECOVERY OF HAND FUNCTION IN AN ACUTE
STROKE PATIENT USING MIRROR THERAPY AND
EMG BIOFEEDBACK: A CASE STUDY
CORRELATION BETWEEN TRUNK IMPAIRMENT
SCALE AND HISTORY OF FALLS IN STROKE
PATIENTS: A RETROSPECTIVE STUDY
EFFECT OF MUSCLE ENERGY TECHNIQUE AND
SHOE MODIFICATION ON THE RIGHT LATERAL
TIBIAL SHIN PAIN IN JOGGERS
BELLS PALSY AND ITS IMPACT ON VARIOUS

Occupational
Therapy
AREAS OF OCCUPATION
HETEROTROPIC PREGNANCY-AN UNUSUAL

CASE MANAGED SUCCESSFULLY
Obstetrics &
Gynecology
HYPERTENSION IN PREGNANCY STUDY IN A
TEACHING HOSPITAL IN A RURAL AREA IN
ANDHRA PRADESH, INDIA.
Mr. Guruprasad.V, Mrs.

Banumathe.KR
136
Sudha Rani, E.Ramadevi,

N.Mamata, N.C.Rama,
G.B.Madhavi,
Chandramathi, V.Kavitha,
Arjumand Bano, Neeraja,
Loukya
139
Kavitha Kothapally, Ramdas

J, Srinivas S, Srinivas
Pallerla, Madoori Srinivas,
Sandeep G, Sindhu Y
144
Syed Rehan Ahmad, Dr.

Abul Kalam, Dr. Kishan Pal
152
Bashir A. Sheikh, Tanveer

A. Sofi, Fayaz Ahmad
162
Noman Nisar, Muhammad

Junaid Aslam
182
Noman Nisar, Muhammad

Junaid Aslam
190
PHYTOCHEMICAL ANALYSIS AND

Microbiology
ANTIMICROBIAL ACTIVITY OF CHLOROPHYTUM

BORIVILIANUM AGAINST BACTEIAL PATHOGEN
CAUSING DISEASE IN HUMANS
ECOLOGY OF THE ASIAN TAPEWORM,
Zoology
BOTHRIOCEPHALUS ACHEILOGNATHI
YAMAGUTI, 1934 OF FISHES IN THE DAL LAKE
OF SRINAGAR, KASHMIR
ELECTRIC FIELD SWING ADSORPTION METHOD
Electrical
Engineering and
Automation
FOR IMPROVED (CO2) CARBON CAPTURE

THERMOELECTRIC GENERATION USING
COMBINED (CONCENTRATED) SOLAR
TECHNOLOGY
FROM THE EDITOR IN CHIEF

Dear Friends,
Greetings! First of all Ild like to apologize for the delay in publishing this issue due to few
unforeseen problems.
Like all our previous issues, this issue also remains a
multidisciplinary issue that contains total 12 papers from Physiotherapy, 1 paper from
Ocupational Therapy, 2 papers from Obstetrics & Gynecology, 1 paper from Microbiology,
1 paper from Zoology, and 1 from Electrical Engineering & Automation. I hope youll find
these papers informative.
Be aware that the journal also has a website, http://srji.drkrishna.co.in where subscribers
can access the full content and also submit papers for future publication.
Please send me informal comments directly, or formal letters we can publish, about the
journal. I welcome new ideas about topics (content) and process. Let me know your
thoughts.
Thanks for reading, and stay tuned for future editions.
-Mrityunjay Sharma
A STUDY TO DETERMINE THE RELATIONSHIP BETWEEN THE

MEASUREMENT OF BALANCE AND MOBILITY TO QUALITY OF
LIFE (SF-36) IN ELDERLY POPULATION
Meenakshi Verma*, Amita**
ABSTRACT
A number of sensory cognitive and functional declines occur with age, which threatens
independence. In a number of previous studies incidence, there has been correlated with
function in elderly population but there is scarcity of studies to find out differential role of
mobility as well as balance on quality of life in community dwelling elderly population.
Methods-60 subjects of 60+ years were taken. All were assessed on BBS, TUGT, Short
form 36. Pearson correlation between BBS and SF-36 (r = -0.237, p= 0.068), in between
TUG and SF-36 (r = 0.145, p=0.268) and TUG and BBS (r = 0.064, p = 0.629) and paired
t test. The level of significant is 5%. The study suggest that appropriate screening methods
are developed to identify elderly individuals with decrease quality of life who should be
referred for a detailed physical therapy evaluation.
Keywords: Balance, Quality of life, Health, SF-36, BBS, TUGT
individuals (55%) are over the age of 65

years. The likelihood of having difficulty
in carrying out basic life activities
increases as an individual ages. In the 65
to 74 year old age group, one in nine
individuals has difficulty performing
basic activities. This ratio rises to 1 in 4
individuals aged 85 years of age and
over.1
INTRODUCTION
The number of persons over the age 65
years has increased since the turn of the
century, with the most dramatic increase
occurring in the number of elderly
persons has grown, there has been a
corresponding rise in the number of older
persons with disability. Based on data
from the 1987 National Medical
Expenditure Survey, an estimated 9.5
million non institutionalized individuals
experience difficulty in the performance
of basic life activities such as walking,
self-care, and home management
activities. Out of this total of 9.5 million
people, approximately 5.6 million
The risk of falls of individuals with a fear

of falling is most marked when it is
linked to restriction of activity. In both
faller and non-faller groups, poor mental.
Several clinical indicators of balance and
mobility, such as activity level, the
presence of neurological symptoms,
organizing a free camp in the health

centre of south Delhi.
Selection
Criteria-Inclusion
Criteria39,40-Age
greater than 60 years of age, Non
dependent on the assistance of another
person or the assistance of a support
device. (e.g. cane, crutch), Those who can
able to follow the instructions, Scores of
24 or above on Mini Mental Scale
Examination, Those who can able to do
their functional activities. Exclusion
criteria39,40-Any severe conditions of
orthopedic,
neurology
or
cardiopulmonary, Depression, Significant
loss of hearing and vision, Amputees.
muscle strength, and joint flexibility, are

associated with functional performance
(Newton, 1997; Means et al., 2005).63
Balance, or postural stability, is a generic
term used to describe the dynamic
process by which the bodys position is
maintained in equilibrium. Equilibrium
means that the body is either at rest (static
equilibrium) or in steady-state motion
(dynamic equilibrium). Balance is
greatest when the bodys center of mass
(COM) or center of gravity (COG) is
maintained over its base of support
(BOS).4
Procedure- subjects were thoroughly

informed regarding the purpose of study
in the camp. Informed consent was taken
from subjects. Initial heart rate and blood
pressure were measured to establish a
baseline of physiological function prior to
testing. Subjects were asked several
questions
concerning
functional
activities,
depression,
cognitive,
orientation (Mini mental scale). After
matching, inclusion and exclusion
criteria, the based test was performed.
The based test that is Berg Balance Scale
(balance), Timed Up and Go test
(mobility) and Short form-36 (quality of
life). For each movement, subjects were
instructed to move at their normal or
customary pace (self selected speed).
After completion of each movement,
subjects were allowed rest for 1-2
minutes to allow them to recover from
possible fatigue. Heart rate and blood
pressure monitoring was done at various
intervals to ensure safety of subjects. The
mean and standard deviation were
calculated for subjects age, weight, BBS,
TUG and SF-36 scores. Comparisons
between the scores on the three scales
were made using correlation test.
Limits of stability refers to the sway

boundaries in which an individual can
maintain equilibrium without changing
his or her BOS.6
Evidence suggests that therapeutic
exercises are a valuable tool in the
prevention of falls, especially when
employed as a part of comprehensive
stategy targeting multiple risk factors that
contribute to falls (Weeks, 2005)64. There
is a lack of clear cut evidence in the
association of functional performance and
clinical indicators of balance and
mobility, such as activity level, presence
of neurological symptom, muscle
strength, joint flexibility. Whether any
improvement in balance and mobility will
benefit geriatric population by preventing
future falls is unclear.
This study intends to find out the relation
between balance and mobility to physical
physical function in this population.
METHODOLOGY
Subject number and Source:
60
subjects of 60+ years were taken by
DATA ANALYSIS
A computer software package, SPSS.11

was used for statistical analysis. Mean
and standard deviations were calculated
for
subjects
age,
weight,
BBG,TUG,SF36 scores. Comparisons
between the scores on the three scales
were made using Pearson correlation test.
Mean is
TUG and SF-36

36 and BBS and SF-36
SF
respectively.
Variables
Mean
S.D
Age
65.2666
2.9580
Weight
66.0833
8.8774
Where, n= no. of subjects, x= each

subjects value
Standard deviation is
Pearson correalation of two variables (X

and Y) is
BBS
1.5129
47.1
Paired t test were also used
TUG
10.1683
1.4650
SF-36
71.3766
4.1540
RESULT
60 subjects 28 were male and 32 were
female. Table 1.1 shows mean and
standard deviation of subjects age (Mean
= 65.2666, SD = 2.9580), weight (Mean
= 66.083, SD = 8.8774), TUG (Mean =
10.1683, SD = 1.4650), BBS (Mean
=47.1, SD = 1.5129) and SF-36
SF
(Mean =
71.3766, SD = 4.1540). Table 1.2 shows
Pearson correlation between BBS and SFSF
36 (r = -0.237,
0.237, p= 0.068), in between
TUG and SF-36
36 (r = 0.145, p=0.268) and
TUG and BBS (r = 0.064, p = 0.629). The
level of significant is 5%. Graph 1.1 and
1.2 shows the mean and standard
deviation of age, weight, TUG, BBS and
SF-36.
36. Graph 1.3, 1.4 and 1.5 shows the
scatter graph between TUG and BBS,
TABLE 1.1: Mean and Standard

deviation of age, weight, BBS, TUG, SFSF
36 of 60 subjects.
Variables
TUG and SF36
0.145
80
70
60
50
40
30
20
10
0
0.268
MEAN
SD
BBS TUG SF-36
BBS and SF36
-0.237
0.068
GRAPH 1.2; Mean and Standard
deviation of TUG, BBS, SF-36 of 60
subjects.
TUG and
BBS
0.064
0.629
DISCUSSION
From the statistical analysis, the results of
this study show that clinical assessment
tools that detect balance and mobility
impairments are useful for screening
elderly individuals who may be in need of
a detailed physical therapy evaluation and
possible intervention. As BBS was
developed specifically to measure the
balance in geriatric population. TUG was
developed specifically to measure
mobility and SF-36 for quality of life.
TABLE 1.2: Pearson correlation between

TUG and SF-36, BBS and SF-36 and
BBS and TUG
80
60
Postural balance was indicated as risk of

falling in an ambulatory and independent
geriatric population. Control of lateral
stability may be an important area for fall
prevention
intervention
(Lin
and
Woollacott, 2005)61.
MEAN
40
SD
20
0
AGE WEIGHT
In a study of inner-citydwelling older

adults, Newton found a mode score of 53
on the BBS for 251 subjects aged 60 to
95 years (X =74.3, SD=7.9). The majority
of subjects in the study were African
American or Hispanic and women. All
subjects lived independently in the
community, but 12% used an assistive
device for ambulation and 22% reported
GRAPH 1.1: Mean and Standard

deviation of Age and Weight of 60
subjects.
falling in the past 6 months but in this

study the number of subjects were 60 and
the mean scores was 47.1 and SD was
1.5, subjects were lived independently.
for the physical function in the geriatric

population. Identification of balance and
mobility
associated with physical
function in geriatrics can provide crucial
information for the development of the
therapeutic strategies for prevention and
intervention in misbalancing and falling,
thus reducing the loss of independence.
Vahid Nejali, the study was to identify

the determinants of quality of life and
investigate their association with physical
and social functions, physical and
emotional roles and physical and mental
health among the normal elderly
population. The identification of domains
of physical function may be useful to
physical therapists in the development of
specific interventions targeted for
physical impairments and disabilities that
contribute to deficits in performance of
ADL. Targeting interventions for
physical impairments and disabilities
related to physical therapy reduce the loss
of independence among the geriatric
population.
CONCLUSION
As the Indian population over the age of
60 years continues to grow, there will be
rise in the level of functional disability.
Both balance and mobility are strong
predictors for the quality of life in the
geriatric population. Physical therapists
can play an important role in delaying the
onset of functional disability and
prolonging health. It is therefore
imperative that appropriate screening
methods are developed to identify elderly
individuals with decrease quality of life
who should be referred for a detailed
physical
therapy
evaluation.
HS et al, in his study concluded that both

balance and mobility are strong predictors
REFERENCES
1. Disability Statistics Program, University of California. San Francisco. Disability
Statistics abstract, Washington, DC: US department of Education, National institute on
Disability and Rehabilitation Research; April 1992.
2. Hoeing H, Mayer-Oaks SA, Siebens H, et al. Geriatric rehabilitation: What do
physicians know about it and how should they use it? J Am Geriatric Soc 1994;42:341347.
3. Koska MT. Rehabilitation growth fuels PT shortages. Hospitals 1989;63:32.
4. Kisner C. Colby LA: Therapeutic Exercise : Foundations and Techniques : Philadephia.
PA, FA Davis Co, 1985,p251.
5. Shumway-Cook A, Woollacott M. Motor Control: Theory and Practical Applications,
2nd ed. Lippincott Williams & Wilkins,2001.
6. Nashner LM. The anatomic basis of balance in orthopaedics. In Wallman HW, editor.
orthopaedic Physical Therapy Clinics of North America: Balance. Philadelphia, WB
Saunders, 2002.
7. Lin SI, Woollacott MH, Jensen JL. Postural response in older adults with different levels
of functional balance capacity. Aging Clin Exp Res 16:369374, 2004.

8. Chandler JM, Duncan PW. Balance and falls in the elderly: issues in evaluation and
treatment.
In: Guccione AA, editor.Geriatric Physical Therapy. St. Louis, Mosby, 1993,pp. 237251
9. Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age
Ageing 28:121125, 1999.
10. Nevitt MC. Falls in the elderly: risk factors and prevention. In Masdeu JC, Sudarsky
L,Wolfson L, editors. Gait Disorders of Aging: Falls and Therapeutic Strategies.
Philadelphia, Lippincott-Raven, 1997,p 1336.
11. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med
121:442451, 1994.
12. Sattin RW. Falls among older persons: a public health perspective.Annu Rev Public
Health 13:489508, 1992.
13.American Geriatrics Society, British Geriatrics Society, American Academy of
Orthopaedic Surgeons Panel on Fall Prevention. Guidelines for the prevention of falls
in older persons. J Am Geriatr Soc49:664672, 2001.
14.Susan B. OSullivan, Thomas J. Schmitz: Physical Rehabilitation; Philadelphia
F.A.Davis Co Fifth addition 2007, p1334.
15.Susan B. OSullivan, Thomas J. Schmitz: Physical Rehabilitation; Philadelphia
F.A.Davis Co Fifth addition 2007, p389.
16. Roberts H, Knee TS, Philp I. Setting priorities for measures of performance for
geriatric medical services. Age Ageing 1994; 23: 154-7.
17. Roberts H, Philp I. Prioritizing performance-measures for geriatric medicalserviceswhat do the purchasers and providers think? Age Ageing 1996; 25: 326-8.
18. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I
Conceptual framework and item selection. Med Care 1992; 30: 473-83.
19. Jenkinson C, Coulter A, Wright L. Short form 36 (SF-36) health survey questionnaire:
normative data for adults of working age. Br Med J 1993; 306: 1437-40.
20. Lyons RA, Fielder H, Littlepage BN. Measuring health status with the SF-36: the need
for regional norms. J Public Health Med 1995; 17: 46-50.
21. Garrat AM, Ruta DA, Abdalla MI, Buckingham JK, Russell IT. The SF-36 health
survey questionnaire: an outcome measure suitable for routine use within the NHS? Br
Med J1993; 306: 1440-4.
22. Ruta DA, Abdall MI, Garratt AM, Courts A, Russell IT. SF-36 health survey
questionnaire: I. Reliability in two patient based studies. Quality Health Care 1994; 3:
180-5.
23. Brazier JE, Harper R, Jones NM et al Validating the SF-36 health survey
questionnaire:new outcome measure for primary care. Br Med J 1992; 305: 160-4.
24. Garratt AM, Ruta DA, Abdulla MI, Russell IT. SF-36 health survey questionnaire:
II.Responsiveness to changes in health status in four common clinical conditions.
Quality Health Care 1994; 3: 186-92.
25. Lyons RA, Perry HW, Littlepage BNC. Evidence for the validity of the short form 36
questionnaire (SF-36) in an elderly population. Age Ageing 1994; 23: 182-4.
26. Gallicchio L, Hoffman SC, Helzlsouer KJ: The relationship between gender, social
support, and health-related quality of life in a community-based study in Washington
County Maryland.Qual Life Res 2007, 16:777-786.
27. Bowling A: Aging well, quality of life in older age. First edition. Maidenhead: Open
University Press; 2005.
28. Farquhar M: Elderly people's definitions of quality of life. Social Sciences and
Medicine 1995, 41:1439-1446.
29. Victor C, Scambler S, Bond J, Bowling A: Loneliness in later life. In Growing
Older:Quality of Life in Older Age Edited by: Walker A, Hagen Hennessy C.
Maidenhead:Open University Press; 2004.
30. Walker A: Understanding quality of life in old age Maidenhead: Open UniversityPress;
2005.
31. Bowling A, Grundy E, Farquhar M: Living Well into Old Age First edition. Glasgow:
Open University Press; 1997.
32. Vahdaninia M, Goshtasebi A, Montazeri A, Maftoon F: Healthrelated quality of life in
an elderly population in Iran: a population-based study. Payesh 2005, 4:113-120.
33. Mathias S, Nayak USL, Isaacs B. Balance in elderly patients: The Get-up and Go Test.
Arch Phys Med Rehabil. 1996;67:387-389.
34. Bischoff HA, Stahelin HB, Monsch AU, et al. Identifying a cut-off point for normal
mobility: a comparison of the timed up and go test in community-dwelling and
institutionalised elderly women. Age Ageing. 2003;32:315-320.
35. Bohannon RW. The Timed Up and Go: A descriptive meta-analysis. J Geriatr Phys
Ther. 2006;29:64-68.
36. Newton RA. Validity of the multi-directional reach test: A practical measure for limits
of stability in older adults. J Gerontol Med Sci. 2001;56A:M248-M252.
37.Steffe n TM, Hacker TA, Mollinger L. Age- and gender-related test performance in
community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed
Up & Go Test, and gait speeds. Phys Ther. 2002;82:128-137.
38. Lusardi MM, Pellecchia GL, Schulman M. Functional performance in community
living older adults. J Geriatr Phys Ther. 2003;26:14-22.
39. H Singh, AG: Correlation between balance and mobility to physical function in healthy
elderly population: Vol.21,No. 3. Pp257-266, 2007.
40. Teresa M Steffen, Timothy A Hacker and Louise Mollinger: Age and gender related
test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg
Balance Scale, Timed Up and Go Test and Gait Speeds: 2001.
41. Moorer P, Suurmeijer PBM, Foets M, et al: Psychometric properties of the RAND 36
among three chronic diseases (multiple sclerosis, rheumatic diseases, and COPD) in the
Netherlands. Qual of Life Res2001; 10:637645.
42. Ware JE: SF-36 Health Survey Update. Spine 2000; 25:31303139.
43. Ware JE, Sherbourne CD: The MOS 36-Item Short-Form Health Survey (SF-36):
I.Conceptual framework and item selection. Med Care 1992; 30:473481.
44. Benjamin-Coleman R, Alexy B: Use of the SF-36 to identify community dwelling rural
elderly at risk for hospitalization. Public Health Nurs 1999; 16:223227.
45. Sneed NV, Paul S, Michel Y, et al: Evaluation of 3 quality of life measurement tools in
patients with chronic heart failure. Heart Lung 2001; 30:332340.
46. Walters SJ, Munro JF, Brazier JE: Using the SF-36 with older adults:a cross-sectional
community-based survey. Age Aging 2001; 30:337343.
47. Wagner, A.K., K. Wyss, B. Gandek, P.M. Kilima and D. Whiting, 1999. A Kiswahili
version of the SF-36 health survey for use in Tanzania: Translation and test of scaling
assumptions. Qual.Life. Res., 8: 101-110.
48. Taft, C., J. Karlsson and M. Sullivan, 2004.Performance of the Swedish SF-36 version
2. Qual.Life. Res., 13: 251-256.
49. Fukuhara, S.S. Bito, J. Green, A. Hsiao and K.Kurokawa, 1998. Translation, adaptation
and validation of the SF-36 health survey for use in Japan. J. Clin. Epidemiol., 51:10371044.
50. Fuh, J.L., S.J. Wang and S.R. Lu et al., 2000.Psychometric evaluation of a Chinese
version of SF-36 health survey amongst middle age women from a rural community. Qual.
Life. Res., 9: 675-683.
CORRESPONDENCES
*Assistant Professor, Institute of Applied Medicines and Research, Ch. Charan Singh
University, Meerut. Email: verma.meenakshi222@gmail.com
**MPT, Institute of Applied Medicines and Research, Ch. Charan Singh University,
Meerut
10
EFFECT OF JACOBSONS PROGRESSIVE MUSCULAR

RELAXATION ON QUALITY OF LIFE IN PATIENTS WITH TYPE II
DIABETES MELLITUS (TDM2) : RCT
Dr.Nisha Shinde*, Dr.Subhash Khatri**, Dr.Sambhaji Gunjal***
ABSTRACT
Introduction- Diabetes is becoming a serious Global Public Health issue especially in
developed countries. It is a metabolic disorder. WHO says that India ranks highest with 32
million diabetic patients and this number will increase to 79.4 million by the year 2030.
Purpose: To determine the effects of Jacobsons progressive muscle relaxation on quality
of life and to control chronic complications in type II diabetes.. Materials and Methods:
In this study 40 subjects were taken diagnosed with type II Diabetes Mellitus. Out of fourty
subjects were divided into two groups by block random sampling method that is group A
and B. Both groups were re-evaluated for baseline parameters like, QOL and stress level.
Group A was given routine medical management. Group B was given Jacobsons
progressive muscular relaxation and routine medical management for three months.
Results: Statistical analysis was done for comparison of both groups. After applying t
test data shows highly significance difference between values of all parameters in group B
i.e. (p < 0.001) Conclusion: Our study concludes that Jacobsons progressive muscular
relaxation is effective along with medication to reduce stress and improves the quality of
life in patient with type II diabetes mellitus.
Key words: Diabetes Mellitus, JPMR, Quality of life, Stress.
INTRODUCTION
protein metabolism resulting from defects
The term diabetes mellitus describes a
in insulin secretion, insulin action, or
metabolic disorder of multiple aetiology
both. The number of people with diabetes
characterized by chronic hyperglycaemia
mellitus II (TDM2) is increasing where
with disturbances of carbohydrate, fat and
there is no cure, it is important to

establish that therapy really makes people
11
feel better. Constant stress is one of the
diet) may have a negligible, rather than a
defining features of modern life, and the
positive impact on quality of life.( 6).
source of many common health problems.
This
Stress
understand
plays
an
obvious
role
in
suggest that
a need to better
factors
qualities
is also thought to contribute to a vast
symptoms, ( 7,8,9 )..In 1948 the World
number of other illnesses (1). Stress and
Health Organization defined health from
anxiety have become part and parcel of
a new perspective, stating that health was
everyones day to day life. Stress
defined not only by the absence of
experiences often lead to various chronic
disease and infirmity, but also by the
health conditions such as hypertension
presence of physical, mental and social
and
(2,3),
wellbeing (10). In recent years, there has
depression, and has been viewed as a
been a burning interest in quality of life
potential danger in the personal growth of
issues, and especially in health-related
an individual. Diabetics are more prone to
quality of life, fuelled by several factors,
anxiety and often display characteristic
including a growing body of evidence
symptoms of anxiety such as increased
concerning
heart rate, dizziness, nervousness etc.
psychosocial factors on physical health
Studies have been done in past to achieve
outcomes, and dramatic changes in the
relaxation
organization and delivery of health care.
Jacobsons
heart
using
disease
various
techniques.
progressive
Muscle
People
guide
the
with
monitoring
both
nervousness, anxiety, and insomnia, but it
coronary
to
underlying
potent
diabetes
effect
often
of
of
feel
Relaxation (JPMR) is a popular technique
challenged by their disease and its day-
known for its muscle tension relieving
today management demands and these
effects and consists of a series of
demands are substantial. Patients must
exercises involving tensing and relaxing
deal with their diabetes all day, every
muscle groups. This training enables the
day, making countless decisions in an
subject to relax voluntarily by passively
often futile effort to approximate the non-
relaxing muscles after training of 30
diabetic
minutes over a period of three months
therapy, such as taking insulin, can
(4,5)
substantially affect quality of life either
Research indicates that some aspects of
positively, by reducing symptoms of high
diabetes-specific health behaviour (e.g.,
blood sugar, for instance, or negatively,
12
metabolic
state.
Diabetes
by increasing symptoms of low blood
strongly associated with quality of life.
sugar. The psychosocial toll of living
Studies which look more closely at
with diabetes is often a heavy one, and
specific domains of functioning and
this toll can often, in turn, affect self-care
wellbeing in people with each type of
behaviour and, ultimately, long-term
diabetes suggest that Type 1 diabetes may
glycaemia control, the risk of developing
be associated with decrements in role
long-term complications, and poor quality
limitations due to physical health and
of life ( 11,12, 13)
current health perceptions, while Type II
Quality of life has importance for people
diabetes perhaps partly as a function of
with diabetes and their health care
the more advanced age of this group may
providers for several reasons. ( 14,15)
be associated with decrements in physical
Diabetes
functioning, limitations due to emotional
overwhelm
us
leads
to
diminished self-care, which in turn leads
problems, and energy level. (14 15,16)
to worsened glycaemic control, increased
Patients with TDM2 have statistically
risks for complications, and exacerbation
significant impairment of all aspects of
of diabetes overwhelm us in both the
QOL, not simply physical functioning.
short run and the long run. Thus, quality-
DM put a substantial burden on affected
of-life issues are crucially important,
individuals
because they may powerfully predict an
psychological and social aspects of QOL.
individual's capacity to manage his
The progressive nature of type 2 DM and
disease and maintain long-term health
the real risk for developing chronic
and well-being. ( 14,16)
complications certifies that insulin use
Most studies report that quality of life is
will be a reality for most diabetic
worse for people with diabetes than in the
patients, but its use did not seem to have
general population, especially with regard
a negative impact upon QOL. Glycemic
to physical, social or mental aspects of
control
wellbeing.
At the same time, most
measurement for preventing long-terms
studies do not include and generate
complications and provides a better QOL
prevalence estimates for sub-samples of
to diabetic patient. This end-point should
diabetic subjects who vary by disease
be a much more important target for
characteristics
or
healthcare
interventions.
(17,18
characteristics
which
Recently,
in
to
demographic
appear
to
be
13
by
influencing
becomes
an
addition
physical,
important
usual
management of diabetes mellitus such as
treatment with Jacobsons progressive
insulin, diet, and exercise, alternative
muscular relaxation. (20)
medicine are increasingly used world
Participants:
wide
relaxation
participants with clinical diagnosis of
(JPMR) are as special Physiotherapy
type 2 Diabetes Mellitus who were
techniques that recently are used in many
willing to participate in the study and
chronic disorders. JPMR is a technique
who were referred to physiotherapy
that every person is able to learn it and
Department,
applied to relieve stress and anxiety.
Loni, Ahmednagar, Maharashtra.
Surwit et al found that muscle relaxation
Inclusion criteria:
could decrease. Blood glucose, Reduce
progressive
muscle
Male
and
Female
Pravara Rural Hospital,
Both male and female with clinical
Stress and improve Quality of life.
diagnosis of type 2 Diabetes Mellitus
The aim of our study was to reduce one
with 40 to 60 years
of the symptoms of stress and anxiety
Those willing to participate in the

study.
level using well known techniques that is

Jacobsons progressive muscle relaxation.
Exclusion criteria:
And improve the quality of diabetes
Hypotension, Mental retardation .

Blindness, Deafness, Ketoacidosis
patient with this easy and cost effective
intervention.
Newly diagnosed sever
physical
illness
MATERIALS AND METHODS

Study Design: Randomized Controlled
Outcome measurement:
Trial.
1.QOL (Quality of life),
Sample size: Forty participants.
2. Stress level
Sampling Method: The participants

Procedure:
were clinically diagnosed as type 2

Diabetes Mellitus
block
random
and
and in accordance with the PIMS

Declaration. . Participants were randomly
Group A and Group B
allocated to either the experimental
Was given routine medical
(JPMR) or the control condition. The
treatment (20)
Group B:
was
approved by the Local Ethics Committee
were
randomly allocated into two groups. i.e.
Group A:
consent
obtained from all participants, Procedure
were recruited by
sampling
Informed
intervention explained to participants in
Was given routine medical
14
their language that is the technique is
20.650.9 and
muscle tension relieving effects and
depression score was 8.12.1. There was
consists of a series of exercises involving
statistically significant difference in the
tensing
muscle
mean and SD,for anxiety ( t =24.46. P<
groups.Questionnaire were answered 5
0.001) and for depression with t =.23.49,
minutes before the intervention and after
P < 0.001) Group B
the completion of the three months
intervention Anxiety score was 18.851.9
intervention.
and post intervention anxiety score was
The effects of 30 minutes of JPMR were
2.151.170. Pre intervention depression
compared with a control condition.
score was 18.91.8 and post intervention
During
depression score was 1.851.1.
and
three
relaxing
months
participants
was
post
intervention
HADS. Pre
undertook one weekly habituation session
There
statistically
significant
in order to get used to the environment
difference in the mean and
and the protocol. Feedback was elicited
anxiety (16.70 t =32.70. P< 0.001) and
during these sessions to allow participants
for depression (17.05. t = 35.30., P <
to experience and share the changes and
0.001). The score showed statistically
sensations of relaxation
significant difference in pre and post
SD, for
measurement in WHOQOL in all four

DATA ANALYSIS AND RESULTS
domains.
The score showed statistically significant
significant difference in the
difference in pre and post measurement in
8.24, P < 0.05 ) D2 ( t = 3.43, P < 0.05 )
Group A. Preintervention anxiety score
D3 ( t = 14.60,, P < 0.001 ) and D4 ( t =
was
2.396, P < 0.001 )
HADS)
201.2
and
post
depression
score
was
statistically
D1 ( t =
The results shows group B is more

significant than group A in all the
parameters of QOL and stress level.
intervention anxiety score was 8 19. Pre

intervention
There
was
Table no.1. Pre and post Comparison of HADS of both the groups.
Pre Test
MEANSD
Post Test
MEANSD
Mean
Difference
t-value
201.2
819
12.60
24.46
20.650.9
8.12.1
12.55
23.49
HADS
Group
A
15
p-value
p< 0.01, Significant
p< 0.01,Significant
p< 0.0001,
Highly
significant
Group
B
p<
0.0001,Highly
D 18.91.8
1.851.1
17.05
35.30
significant
Table No 2: Mean difference comparison of HADS of both the groups
A
18.851.9
2.151.1
16.70
32.70
Group A
Group B
(Mean difference) ( Mean difference)
t-value
12.60
16.70
5.941
12.55
17.05
5.836
HADS
p-value
P< 0.0001
Highly significant
P< 0.0001
Highly significant
Graph no.1. Mean difference comparison of HADS of both the groups
20
15
Group A
10
Group B
5
0
A
Table no.3: Pre and post Comparison of WHO Quality of life of both the groups.
(WHOQOL)
Pre Test
MEANSD
Post Test
MEANSD
Mean
Differenc
e
tvalue
p-value
D1
783.7
903.4
12.16
10.60
D2
419.3
666.3
25.41
10.04
D3
8.14.5
267.5
18.18
9.26
P < 0.01, Significant
D4
415.8
857.1
44.24
21.45
P < 0.01, Significant
WHOQOL
Group A
16
D1
706.0
887.1
18.11
5.14
D2
478.6
849.3
37.43
15.51
D3
6.81.9
317.7
24.12
13.49
D4
384.7
896.8
50.75
27.51
Group B
P<0.0001,Highly
significant
p<0.0001,Highly
significant
p<0.0001,Highly
significant
p<0.0001,
Highly
significant
Table No. 4: Mean difference comparison WHO Quality of life of both the groups. (
WHOQOL)
WHOQOL
Group A
(Mean difference)
Group B
(Mean difference)
t-value
value
p-value
D1
12.11
18.77
8.24
0.0254, significant
D2
25.41
37.43
3.43
0.0014, significant
D3
18.18
24.12
14.60
P < 0.001,Highly
Significant
D4
44.24
50.75
2.396
0.021, Significant
Graph no.2: Mean difference comparison WHO Quality of life of both the groups.
60
50
40
Group A
30
Group B
20
10
0
D1
D2
D3
D4
DISCUSSION
patients to improve quality of life in a
The purpose of the study was to analyze
group of diabetic patients .Present study
the
pharmacological
has shown JPMR training to result in
intervention that will helpful to all
significant Improvement in quality of life
effect
of
Non
17
and decrease in stress and anxiety level.
improves
subjective
Constant stress is one of the defining
patients with Diabetes mellitus. Our
features of modern life, and the source of
findings replicate in previous findings (
many common health problems. Stress
Surwit et al. 2011). The study findings do
plays an obvious role in nervousness,
provide
anxiety, and insomnia, but it is also
evidence for the utility of JPMR within
thought to contribute to vast number of
the multidisciplinary care in patients with
other illnesses. Patients with Diabetes
Diabetes mellitus.
mellitus
have statistically significant
The ability to deal with state anxiety,
impairment of all aspects of QOL, not
psychological stress and negative affect
simply physical functioning. Diabetes put
during JPMR may of relevance for
further
well-being
rigorous
in
scientific
on
affected
several other mental health benefits. The
influencing
physical,
use of alcohol, nicotine, or illegal drugs is
psychological and social aspects of QOL.
a common practice among individuals
( 15,17)
with
The progressive nature of TDM2 and the
S.Schneideret
real
chronic
numerous motivations exist to use these
complications, certifies that insulin use
substances, it has been suggested that the
along with stress reliving interventions
mentioned unhealthy behaviours may
will be a reality for most diabetic
partly be attempts to alleviate or to cope
patients, but its use did not seem to have
with unpleasant affective states and
a negative impact upon QOL. Glycaemic
feelings of state anxiety (Gregg et al.
control
important
2009, Winterer et al. 2010). This study
measurement for preventing long-terms
demonstrates that relaxation techniques
complications and provides a better QOL
may offer such an easy to learn healthy
to diabetic patient. This should be a much
alternative for subjective stress and state
more important target for healthcare
anxiety regulation.
interventions. (15,17) Our present study
We
with a randomised controlled group
population's lifestyle can be favourably
design clearly demonstrates that after
modified by applying a simple and
three months session, JPMR reduces state
economic system of prevention
anxiety and psychological stress and
primary health care level. This would
substantial
individuals
risk
by
for
burden
developing
becomes
an
18
TDM2
conclude
surwit and
al.2007).
that
Although
the
diabetic
at the
bring about a reasonable reduction in
blood glucose and there
mortality,
costs
stress and improves the quality of life in
resulting from this illness, which we
patient with TDM2. We conclude that
expect would encourage the application
the diabetic population's lifestyle can be
of this pilot program in other health care
favourably modify by applying a simple
centres across the country
and economic intervention for prevention
CONCLUSION
at the primary level .
The current results indicate that a cost-
Acknowledgments: We most appreciate
effective intervention in a real-world
all the participants of this research. And
setting can result in statically significant
ethical committee of Pravara Institute of
benefits for patients with Diabetes. As
Medical sciences, Loni PMT/ PIMS
group B shows more improvement in
/RC/2013/227
QOL and stress reduction. So this study
Funding: No funding was gained for the
concludes that Jacobsons progressive
study
muscular relaxation is effective to reduce
Conflicts of Interest: None declared
complications
and
by
anxiety,
REFERENCES
1. Definition, diagnosis and classification of diabetes mellitus and its complications ( report
of WHO consulation )1999
2. Diagnosis and Classification of Diabetes Mellitus: New Criteria, Jennifer
3. Mayfield, Indianapolis Bowen Research Centre, Indiana University, Indiana.
4. Risk factors for type 2 diabetes, Pubmed health, April 19, 2009
5. Anderson RM: Patient empowerment and the traditional medical model: a case of
irreconcilable diflerences? Diabetes Care 18:412-15, 1995
6. Funnell MM, Anderson RM, Arnold MS,Barr PA, Donnelly M, Johnson PD, TaylorMoon D, White NH: Empowerment: an idea whose time has come in diabetes education.
Dratees- fifoc 17:371, 1991
7. Ruggiero L, Glasgow RE, Dryfoos JM, Rossi JS, Prochaska JO, Orleans CT, Prokhorov
Ay Rossi SR, Greene GW, Reed GR, Kelly K,Chobanian L, Johnson S: Diabetes seltmanagement: self-reported recommendations and patterns in a large population. Diabetes Care;
20:568-576, 1997
19
8. Glasgow RE,Ruggiero L, Eakin EG, Dry foos J,Chobanian L: Quality of life and
associated characteristics in a large national sample of adults with diabetes. Diabetes
Can; 20:562-567, 1997
9. Weinberger M,Kirkman S, Samsa GI? Cowper PA, Short Hfle EA, Simel DL, Feussner
JR:The relationship between glycemic control and health-related quality of life in patients
with non-insulin-dependent diabetes mellitus. Merf Care; 32:1173-1181, 1994
10. Lau RR: Cognitive representations of health and illness. In Handbook of Health
Behavior Research. Gochman DS, Ed. New \brk, Plenum Press, 1997, p. 51-69
11. Nuttall FQ, Chasuk RM: Nutrition and the management of type 2 diabetes. JFam Pract
(Suppl. 5):S45-S53, 1998
12. Diabetes/ metabolism research and reviews Diabetes Metab Res Rev 1999; 15: 15207552/99
13. Rubin RR, Peyrot M: Quality of life and diabetes. Diabetes Metab Res Rev 15:205- 18,
1999.
14. Peyrot M, Rubin RR: Persistence of depression in diabetic adults. Diabetes Care
22:448-52, 1999.
15. Peyrot M, Rubin RR: Levels and risks of depression and anxiety symptomatology
among diabetic adults. Diabetes Care 20:585-90, 1997.
16. Assessing health related quality of life in diabetic patients Porojan M1, Poant L,
Dumitracu DL.
17. Ken W. Watkins, phd Laura Klem, ba Cathleen M. Connell, phd Tom Hickey, dr ph
James T. Effect of Adults' Self-Regulation of Diabetes on Quality-of Life Outcomes
Fitzgerald, phd Berit Ingersoll-Dayton,
18. Jeong I; Effect of progressive muscle relaxation using biofeedback on perceived stress,
stress response, immune response and climacteric symptoms of middle aged
women.Taechan Kanho Hakhoe Chi, 34(2), 113-224.2004
CORRESPONDENCES
*Associate Professor, College of Physiotherapy, Pravara Institute of Medical Sciences,
Loni. Ahmednagar, Maharashtra, India 413736
**Principal, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni.
Ahmednagar, Maharashtra, India 413736
20
***Postgraduate student,, College of Physiotherapy, Pravara Institute of Medical Sciences,

Loni. Ahmednagar, Maharashtra, India 413736
21
EFFECTIVENESS OF PROPRIOCEPTIVE NEUROMUSCULAR

FACILITATION IN CHRONIC LUMBAR SPONDYLOSIS
Juanita E. Soans*, Keerthi Rao** , Subhash Khatri***, Chandra Iyer*****
ABSTRACT
Background: Lumbar spondylosis affects 80% individuals older than 40 years of age
leading to chronic low back pain. Lumbar spondylosis may lead to instability thus exercise
that targets the stabilizing system of the spine including the active, passive and neural
system of the spine can be beneficial. PNF exercises are designed to enhance the response
of neuromuscular system by stimulating the proprioceptors. Hence, this study aims at
finding out the effectiveness of PNF in participants with chronic lumbar spondylosis.
Objectives: The objectives of this study were to find out the effectiveness of PNF in chronic
lumbar spondylosis on pain, lumbar range of motion, abdominal and back muscle
endurance and functional performance. Methodology: Twenty-six participants of lumbar
spondylosis were selected on the basis of purposive sampling method and were requested
to participate in the study. They were given IFT along with PNF in the form of combination
of isotonics for a period of 4 weeks, 5 days/week for duration of 40 45 minutes per
session. Pain, range of motion, static abdominal and trunk extensor endurance and
functional performance was evaluated on the first day and at the end of four weeks of
intervention. Results: There was highly significant difference in pain, lumbar flexion and
extension range of motion, static abdominal and trunk extensor muscle endurance after
four weeks of intervention (p < 0.01). Conclusion: PNF and IFT can be used as an
effective physiotherapy treatment for chronic lumbar spondylosis.
Key words: Low back pain(LBP), lumbar spondylosis, PNF, IFT, combination of isotonics
INTRODUCTION
costal margin and above the inferior
Back pain has been known since the start
gluteal
of written history. The first report of
pain.[2] It is said that human beings
back pain has probably been found in
are paying a price for being erect in
ancient text, the Edwin Smith Surgical
the form of backache.[3] Some theories
Papyrus
around
propose that the transformation in the
1550 B.C.[1] LBP is defined as pain
mechanics of locomotion is an inciting
and discomfort, localised below the
evolutionary event that made lumbar
presumably
written
22
folds
with
or
without
leg
spine
susceptible
changes,
to
although
degenerative
this
is
disc degeneration although osteophytes
not
may infrequently form in the absence of
age
diseased discs.[11,12] There are two types
related alterations in the spine, the
of injuries that are responsible for
degenerative
inducing
accepted.[3-5] Among
universally
spondylosis,
osteoarthritis,
lumbar
hypertrophic
spinal
degenerative
changes:
1)
lumbar
osteophystosis,
recurrent rotational strain which can
osteophyte
deformans,
quite rapidly lead to degeneration of
spondyloarthropathy
are
posterior joints and disc and 2) minor
most often used terms in literature.[5,6]
compression injuries sometimes with
Lumbar spondylosis
as
rupture of a cartilage plate which
progressive, degenerative changes in
leads to slow degenerative changes in
the spine which are manifestation of
the disc and later in the posterior
increasing age or secondary to trauma
joints. Changes starting at one level,
is
termed
and
tear.[5]
affects
80%
40
years
Lumbar
usually the L4 L5, which later in
individuals
life places the level above and the
and
3%
level below at risk to strain and this
individuals between the age of 20-29
way the process continues till the
or
wear
spondylosis
older
years.
than
[7]
initial lesion becomes more severe and
It has also been observed that
27-37% asymptomatic individuals have
degenerative
lumbar spondylosis.[8] Autopsy studied
generalized. Also lesions affecting the
by Schmorl and Junghanns reported
posterior
evidence of spondylosis in 60% of
joints would affect the intervertebral
women and 80% men by the age of
disc
49 years and in 95% of both sexes
degeneration begins when the balance
by the age of 70 years.[9] The term
between synthesis and degradation of
spondylosis was historically an effort
matrix is disrupted.[14] There is net
to
loss of
distinguish
between
degenerative
changes in spine and those involving

synovial
joints.[10]
spondylosis
In
is
other
changes
joints
and
including
disruption
of
the
facet
versa.[13] Disc
vice
water
become
and glycoproteins,
collagen
fibre
words
organization and increased level of
considered
proteolytic enzymes as a result of
mechanistatically, as the hypertrophic
aging
response of adjacent vertebral bone to
loading.[14,15] There is penetration of
23
or continuous
and repetitive
nerves
and
vessels
to
Lumbar spondylosis presents primarily
otherwise
as
avascular nucleus thus making the disc

a source
of
pain.[14]
The
discogenic
pain
syndrome with
normal
or
facet
joint
deep aching pain in
healthy spine bears approximately 20%
the low back, may be present in the
of spinal compressive force, but
if
buttocks and groin radiating to the
there is a loss of disc height due to
posterior thigh. Pain may aggravate in
degeneration, load bearing can be as
flexion
high as 70% resulting in fibrillation of
increased after prolonged sitting or
articular
and
bending with spine in semi flexion or
ulcerative lesion of articular cartilage,
walking downhill. The pain aggravates
gross degeneration and irregularity of
after rest and improves with motion.
articular cartilage, gross degeneration
Patients often feel stiff in the morning
and irregularity of
and have a walk in period. Some
cartilage,
denudation
articular cartilage,
or
extension
inflammatory hypertrophy of synovial
patients
membrane, formation of osteophytes
radiculopathy.[3,5,7,11,18]
and
sclerosis
of
subchondral
It
bone.[14,16,17] The combined changes at
a period
of
years
lead
is
ligament
thickened.[19]
subjected
flavum
Muscle
to fatty
the
that
spinal
co-ordinates the muscle response to
are
stability
and
needs
Therefore
includes
strength and endurance. Kirkaldy-Willis
described
by
(mechanoceptors, proprioceptors) which
reduction of muscle mass reducing its
and Bernard in the year
derangement
(tendons, muscles) and neural system
becomes
degeneration
that
(bone, disc, ligaments), the active system
reduced
fibres
hypothesized
related systems ; the passive system
elasticity and strength of the ligaments

and
with
stability is provided by three inter-
parts and limit the range of motion in

There
been
present
Studies have reported
The ligaments of the spine constrain its
directions.
often
degeneration may produce instability.
to
multilevel spondylosis or stenosis.[18]
all
has
mechanical
one level or both changes at one level

over
may
and rotation,
of
exercise
the
spine.[20]
program
enhancing
that
proprioception
along with muscle endurance could be
1983 first
degenerative
cascade[14,18]
beneficial
in
spondylosis.
Evidence
exercise
24
therapy
treating
lumbar
suggests
is
the
that
best
intervention for patients with chronic
spondylosis
by
low back pain but nothing concrete on
Department,
aged
the effects of the same on lumbar
years with plain radiograph showing
spondylosis has been studied. Also,
degenerative changes in the lumbar
studies conducted in the past have
spine and having a score of 20 60%
compared the effectiveness of rhythmic
on Modified Oswestry Low Back Pain
stabilization
Disability
Questionnaire
isotonics in chronic low back pain
Participants
having
among women and also in patients
history of trauma in the past
with recurrent low back pain and it
months,
has been seen to improve pain, range
spondylolisthesis,
of
and
motion
combination
of
endurance.[21,22]
and
stenosis,
the
Orthopedic
between 40 60
(MODQ).
radiculopathy,
acute
disc
six
prolapse,
lumbar
recent
abdominal
or
back
Therefore this study aims to find out
surgeries,
the
any advanced cardiac disorders with
effectiveness
of
proprioceptive
neuromuscular
facilitation
combination of
isotonic
flexibility,
muscle
functional
on
in
hypotension,
using
pacemaker or respiratory disorders and
pain,
epilepsy
excluded.[23-25]
were
The
and
outcome measures used in the study
patients
were visual analogue scale (VAS) to
endurance
performance
hypertension,
canal
assess pain, partial curl up test and
with lumbar spondylosis.
Ito test to assess abdominal and trunk
MATERIALS AND METHODS:
extensor endurance, Modified Schobers
The research design used in the study
test to evaluate range of motion and
was pre test- post test study design
functional
conducted
at Physiotherapy outpatient
MODQ.
department. The study received ethical
primary
approval
supervision
from
performance
Data
was
by
using
collected
by
under
the
investigator
Institutional
Ethical
(Ref
no.
staff having an experience of over
PIMS/CPT/IEC/2013/1365). The study
five years. Thirty-nine participants who
was conducted between April 2013 -
fulfilled
[3,7]
selected
according
both male and female participants with
sampling
method
participate in the study out of which
Committee
November 2013. The study included
clinical
diagnosis
of
lumbar
25
of
senior
the inclusion
and
Physiotherapy
criteria were
to
purposive
requested
to
twenty seven participants agreed to
standing in front of the participants.
participate in the study.
The participants were asked to resist
written
from
the concentric contraction into trunk
A baseline demographic and
extension. Push back away from me.
clinical data of the participants were
At the end of the participants active
then
range of motion, the participants were
them.
consent
was
An informed
obtained.
obtained
The
intervention
included Interferential Therapy (IFT)
told
[Bio 2002 Computerized IFT Unit IF-
Stop, stay there, dont let me pull
6 manufactured by Bionics, Mumbai]
you forward. After the participants
along with PNF using Combination of
were stable, they were moved back to
Isotonics. The intervention was given
the original position while maintaining
for a period of four weeks, five
control with an eccentric contraction
[21,22]
of the trunk extensor muscles. Now
Interferential Therapy was applied for
let me pull you forward, but slowly.
(figure 1) The similar procedure was
15
repeated in trunk flexion.[26] (figure 2)
minutes, five days/week for 2 weeks.[27]
The concentric contraction, stabilization
The participants were positioned in
and eccentric contraction each was
prone
quadripolar
maintained for 5 seconds. Three sets
arrangement of carbon electrodes using
of 15 repetitions at maximal resistance
electrode gel at the lateral limits of
were
painful area, parallel to the vertebral
participants had less pain on alternate
column. The area was cleaned
with
days for flexors and extensors. Rest
the
interval of 30 seconds and 60 seconds
electrodes were secured by adhesive
was provided after the completion of
tapes.
15
days/week
for
duration
frequency
spirit
40 45 minutes.
of
of
two
80 150 Hz
position
prior to
The
weeks,
with
application
intensity
was
at
for
and
increased
to
stabilize
performed
repetitions
until the participants felt strong but
respectively.
comfortable sensation. After IFT, the
reassessment
participants were treated using PNF
weeks.
with
combination
of
isotonics.
For
trunk extension, the participants were in

sitting position.
The
therapist
was
26
in
that
starting
and
where
between
For all
was
position.
done
the
set,
participants,
after
four
STATISTICS:
Statistical
analysis
was
done
using
Graph Pad Instat Trial Version 13.3.

Descriptive statistics for all outcome
measures
were
expressed
as
mean,
standard deviation and students paired

t-test was used for paired comparison
of
all
values.
The
data
was
considered statistically significant with

p<0.05
and
highly
significant
with
p<0.01.
RESULTS:
Out of twenty-seven participants who
Figure 1: Combination of Isotonics in
agreed to participate in the study, one
trunk extension
participant dropped out of the study

as he stayed away from the hospital
and
found
it
difficult
to
travel
everyday. Hence data analysis of twentysix participants
was
done.
The
demographic data of the participants

are represented in the table below
(table 1).
Table
1.
Table
representing
demographic data of participants.
Figure 2: Combination of Isotonics in

trunk flexion
27
The
post
motion and functional endurance have
interventional values along with the p-
been represented in table below (table
values for pain, static abdominal and
2)
trunk
baseline
values
and
extensor endurance,
range of
Table 2. Table representing mean SD and p value of baseline and post

intervention parameters.
was
functional performance in participants
highly significant difference in pain,
after intervention. The results have
static abdominal and trunk extensor
been graphically represented in the
endurance,
graph
The
results
extension
show
that
lumbar
range
of
there
flexion
motion
and
below.
(figure
and
Figure 3: Graphical representation of the pre and post intervention outcome measures
28
3)
reducing
DISCUSSION:
caused
The present study aimed at finding out

the
effectiveness
of
PNF
in
static
reducing
abdominal
pain,
and
spine
of
motion
and
extensor
neuromuscular
Neurophysiological
studies
with
disturbances
and
in
the
impairment
of
et al demonstrated that PNF helps reduce

pain
functional
and
compared
performance. The findings of the present
repositioning
errors
as
stabilization
exercise
by
to
improving proprioceptive sense.[32]
study were consistent with the studies
There
conducted by Kofotolis N and Kumar et

[21,22]
structures
superior proprioception centres.[31] Byuon
endurance, lumbar flexion and extension

range
other
altered
mechanoceptors
increasing
trunk
on
have linked pain development in lumbar
present studies show that PNF has been

in
by
activation.
chronic
lumbar spondylosis. The results of the
effective
stresses
is
significant
improvement
in
In the present study IFT was
lumbar flexion and extension range of
used to reduce pain. The parameters of
motion. This could be as a result of
IFT
reduction in pain and muscle spasm
al.
used
in
this
study
was
in
accordance with the findings seen in the
associated
meta-analysis conducted by Fuentes et al,
Vicky
who also stated that IFT when used as
combination
an adjunct
to
significantly
better
placebo
for
lumbar
Saliba
et
of
al.
spondylosis.
states
isotonics
offers
that
an
treatment
is
alternative to traditional hold relax and
control
or
contract relax techniques that make use
musculoskeletal
of bodys inhibitory reflexes to cause
other
than
reducing
with
pain.[27] Also, in a study conducted by
muscle
relaxation
thus
Zambito et al and Werners et al show
superior
gains
flexibility.[33]
Also,
reduction in pain among patients with
stress
relaxation
occurs
when
low
with
musculotendinous
gate
muscles and connected tendons are under
mechanism, physiological block, removal
constant stress. Muscles and tendons have
of irritant or pain substance from the
viscoelastic properties which itself allows
site
the
back
pain
IFT.[28,29] This
of
when
occurs
application
treated
by
by
pain
improving
muscles
in
to
unit
be
leading
involving
stretched
to
the
and
[30]
In
elongated as a result of inhibitory signals
as
an
without substantial damage to the tissue.
intervention helps improve proprioceptive
It allows the material to creep and
function thus distributing the forces and
slowly
circulation
addition
or
to
placebo
IFT,
PNF
effect.
used
29
lengthen
over
time.[34,35]
The
flexibility gains as a result of PNF
technique in the form of slow reversal,
stretching
relatively
rhythmic stabilization or combination of
quickly after training ceases.[34] However,
isotonics is effective in increasing lumbar
the repetition of internal shortening and
stability.[37]
seems
lengthening
to
of
reverse
muscle
fibres
against
There was a positive change in MODQ
resistance in COI yields lasting increase

in
ROM
of
subsequently
the
soft
affects
tissues
seen among participants. This could be
and
associated
due to the collective effect of reduction
joint
in pain, increased muscle endurance and
motion.[33]
flexibility
There was significant improvement in

static
abdominal
and
trunk
extensor
concentric,
exercise
is
combination
eccentric
through
and
a
sample size and no long term follow up

of participants. Future study could aim
of
at finding out the effectiveness of PNF
isometric
over
progressively
PNF
training
of
PNF in the form of combination of
percentage of type II B fibres of vastus

and
increase
in
type
isotonics and IFT can be used as an
II A
effective physiotherapeutic intervention in
fibres.[36] Another study, examined the

effects
An
CONCLUSION:
lower
extremity showed significant reduction in
lateralis
physiotherapy.
taken into consideration.
al. in his study demonstrated that eight

of
conventional
EMG analysis of the muscles could be
increased range of motion. Kofotolis et
weeks
functional
The limitations of the study were small
the dynamic nature of combination of

which
enhancing
performance.
endurance. This could be attributed to
isotonics
thus
treatment of chronic lumbar spondylosis.
of lumbar stabilization exercise

ACKNOWLEGEMENT:
and PNF techniques on lumbar deep

muscle thickness and found that muscle
I would like to thank all the participants in
thickness had significantly increased in
the study for their co-operation. I would like
transverse abdominis, external obliques

and
multifidus
PNF
group
among
participants
suggesting
that
to express my gratitude towards my parents
in
and all my staff-members for their support
PNF
and valuable guidance.
REFERENCES
30
1. Breasted JH. Edwin Smith Surgical Papyrus in Facsimili and Heiroglyphic

Transliteration and Commentary, 2 vols, Oriental Publications, University of Chicago,
Chicago, 1930
2. Burton AK, Eriksen HR, Leclerc A, Balague F, Henrotin Y, Muller G et al. European
Guidelines for Prevention in Low Back Pain. Euro Spine J. 2004:15(2):136-168.
3. Mahesh Pandya, Degenerative Lumbar Spine Disorders and Its Conservative Treatment.
Ahmedabad: Jaypee Brothers; 2011
4. Rickenbacher J, Landolt A.M. and Theiler K. Applied Anatomy of the Back. Berlin:
Springer-Verlag; 1955.pg 96, 184-186.
5. Adams J. Outline of Orthopaedics. 13th edition. Edinburgh: Churchill Livingston; 2001.
6. Khatri S. Basics Of Orthopaedic Physiotherapy. New Delhi: Jaypee Brothers Medical
Publishers, 2013.
7. Kimberly Middleton. Lumbar spondylosis: clinical presentation and treatment
approaches. Curr Rev Musculoskelet Med, 2009:(2) 94-104.
8. Rothschild B. Lumbar spondylosis, In: Emedicine publication. 2008. available via
WebMD http://emedicine.medscape.com/ article/249036-overview.
9. Junghanns SA. The human spine in health and disease. Grune and Stratton, New York.
1971
10. Vernon-Roberts B, Pirie CJ. Degenerative changes in intervertebral disc of the lumbar
spine and their sequelae. Rheumatol Rehabil. 1977:16:13-21.
11. Schneck CD. The anatomy of lumbar spondylosis. Clin Orthop Relat Res. 1985:193:2036.
12. Gibson JNA, Wadell G. Surgery for degenerative lumbar spondylosis. Spine.
2005:20:2313-20.
13. Frafan HF, Sullivan JB: The relation of facet orientation to intervertebral disc failure.
Can J Surg. 1967:10:179
14. Michael Papadakis, Georgios Sapkas, Elias C, Pavlos Katonis. Pathophysiology and
Biomechanics of the Aging Spine. The Open Orthop J, 2011:5:335-342.
15. Harry Herkowitz, Jiri Dvorak, Gorden Bell, Margereta Nordin, Dieter Grob. The Lumbar
Spine. 3rd edition. Philadelphia: Lippincott William & Wilkins; 2004.
16. Adams MA, Hutton WC. The effect of posture on the role of apophyseal joints in
resisting intervertebral compressive force. J of Bone Joint Surgery. 1980:62B:358-362.
17. W.H. Kirkaldy-Willis, J.H.Wedge, K Yong Hing, J Reilly. Pathology and Pathogenesis
of Lumbar Spondylosis and Stenosis. Spine. 1978:3:4
18. Nobert Boos, Max Aebi(editors), Spinal Disorders Fundamentals of Diagnosis and
Treatment, Berlin: Springer Verlag, 2008
19. Panjabi MM, Goel VK, Takata K. Physiologic strains in the lumbar spinal ligaments. An
in vitro biomechanical study. Spine 1982:7:192-203.
20. Panjabi M. The stabilizing system of the spine. Part 1. Function, Dysfunction, Adaptation
and Enhancement. J Spinal Disord Tech. 1992:5(4):383-389
21. Kofotolis N, Kellis E. Effect of two 4-week Proprioceptive Neuromuscular Facilitation
Programs on Muscle endurance, flexibility and functional performance in women with
chronic low back pain. Phys Ther. 2006: 86(7) : 1001 1012.
31
22. Kumar A, Zutshi K, Narang A Efficacy of Proprioceptive Neuromuscular Facilitation

training on chronic low back pain. Int J Sport Sci Eng.2011: 5 (3): 174-180
23. Khatri S. Basics of Electrotherapy. 2nd edition. New Delhi: Jaypee Brothers Medical
Publishers Ltd; 2012.
24. Allen Last, Karen Hulbert. Chronic Low Back Pain: Evaluation and Management. Am
Fam Physician, 2009:79(12):1067-1074.
25. Myrto D, Linda S, Julius Sim. Effects of Interferential Therapy Parameter Combinations
Upon Experimentally Induced Pain in Pain-Free Participants: A Randomized Controlled
Trail. Phys Ther. 2012:92(7):911-923.
26. Susan Adler, Dominiek Beckers, Math Buck. PNF in Practise-An Illustrated Guide. 3rd
edition. Springer, Heidelberg.2008
27. Jorge F, Susan O, David M, Douglas G. Effectiveness of interferential current therapy in
the management of musculoskeletal pain: a systematic review and meta-analysis. Phys
ther, 2010:90(9):1219-1238
28. Zambito A, Bianchini D, Gatti D, Viapiana, M Rossini, Adami S. Interferential and
horizontal therapies in chronic low back pain: randomized double blind, clinical study.
Clin Exp Rheum, 2006:24:534-539.
29. Werners R, Pynsent P, Bulstrode C. Randomized Trial Comparing Interferential Therapy
with Motorized Lumbar Traction and Massage in the Management of Low Back Pain in a
Primary Care Setting. Spine. 1999:24(15):1579-1584
30. Giovanni De Domenico, Pain relief with interferential therapy. Aust J Physiother,
1982:28(3):1418
31. Yashmita T, Cavanaugh J, Bohy A. Mechanosensitive afferent units in the lumbar facet
joint. J Bone Joint Surg. 1990:72:865-870.
32. Byuon S, Son H. The effects of PNF and stabilization exercise on trunk repositioning. J
Phys Ther Sci. 2012:24:1017-1020
33. Vicky Saliba, Gregory Johnson, Cheryl Wardlaw. Proprioceptive Neuromuscular
Facilitation. In: John Basmajian and Rich Nyberg, editor. Rational Manual Therapies.
Philadelphia: Williams and Wilkins; 1992. pg. 243 -284.
34. Sharman M, Cresswell A, Riek S. Proprioceptive Neuromuscular Facilitation Stretching:
Mechanisms and Clinical Implications. Sports Med. 2006:36(11): 929-936.
35. Hindle K, Whitcomb T, Briggs W, Hong J. Proprioceptive Neuromuscular Facilitation
(PNF): Its Mechanisms and Effects on Range of Motion and Muscular Function. J
Human Kinetics. 2012:31:102-113.
36. Kofotolis N, Vrabus IS, Vamvakoudis E, Papanikolaou A, Mandroukas K.
Proprioceptive neuromuscular facilitation training induced alterations in muscle fibre
type and cross sectional area. Bri J Sports Med. 2005:39:1-4
37. Kim Gi, Yun-Jung Lee, Wan-Suk Choi, Dong-Woo Lee, Dae-In Jung, Kyung-Yoon
Kim. Effects of Lumbar Stabilization Exercise using PNF techniques on thickness of
Lumbar deep muscle and functional Activity in chronic low back pain patients. Kor J
Phys Ther. 2012:12(13):233-234
32
CORRESPONDENCES
*Final year M.P.Th (Orthopaedics) student, College of Physiotherapy, Pravara Institute of
Medical Sciences(DU), Loni, Maharashtra, India. Email Id: soans_juanita@yahoo.co.in
**M.P.T, Associate Professor, College of Physiotherapy, Pravara Institute of Medical
Sciences(DU), Loni, Maharashtra, India.
***M.P.T, PhD Principal, College of Physiotherapy, Pravara Institute of Medical
****M.P.T, Assistant Professor, College of Physiotherapy, Pravara Institute of Medical
33
PREVALENCE OF SACROILIAC JOINT PAIN AND DYSFUNCTION IN PATIENTS

WITH NON-SPECIFIC CHRONIC LOW BACK PAIN
Dr. Vivek H. Ramanandi (PT)*
ABSTRACT
Among all the chronic pain disorders, pain from various structures of the lumbar spine
constitutes the majority of problems. The lifetime prevalence of low back pain has been reported
as high as 80%. Facet joint pain, discogenic pain, and sacroiliac joint pain have been proven to
be common causes of chronic low back pain (CLBP) by using reliable diagnostic techniques.
Both the SI joint pain itself and the diagnosis of SI joint dysfunction are underappreciated cause
of pain. The diagnosis of undiagnosed and symptomatic SI joint pain and dysfunction will help
the clinician to concentrate on the treatment modalities directed towards the SI joint and pelvic
girdle.
This cross sectional observational study was aimed at finding out the prevalence of undiagnosed
SI joint pain and dysfunction associated with non-specific CLBP in patients between 25-45 years
of age and having no specific diagnosed cause of the back pain. 313 Subjects were recruited
from various physical therapy clinics in Ahmedabad and Vadodara cities of Gujarat during
September 13 to April14. To find out the presence of SI joint dysfunction a test item cluster of 5
diagnostic provocative tests was used.
The results were suggestive of high overall prevalence (i.e. 60.06%) of SI joint pain and
dysfunction in patients with the non-specific CLBP. Higher prevalence of presence of SIJD was
found in age group 37-39 years (12.14%), male gender (33.55%) and occupation involving
mixture of activities (17.57%).
Key Words: Chronic Low Back pain, SI Joint, Pain, Dysfunction, Prevalence.
INTRODUCTION
usually as the duration of an episodes of
1. INTRODUCTION
Low back pain (LBP) is defined as pain and
LBP persisting for <6 weeks, subacute is
discomfort
costal
between 6 to12 weeks and chronic LBP
margin and above the inferior gluteal folds
(CLBP) is>12 weeks [1]. Among all the
with or without leg pain. Acute LBP is
chronic pain disorders, pain from various
localized
below
the
34
structures of the lumbar spine constitutes the
other diarthrodial joint [28-30]. The SI joint
majority
contains fibrocartilage in addition to hyaline
of
problems.
The
lifetime
prevalence of low back pain has been
cartilage,
reported as high as 80%. Modern evidence
discontinuity of the posterior capsule, with
differ persistent CLBP in 25% to 75% of
ridges
patients, 1 to 5 years after the initial episode
movement and enhance stability [31, 32].
[2-8]. The high prevalence of CLBP, the
Consequently,
numerous modalities of treatments for
described as a true synovial joint only in the
management of the problem, and the
anterior portion. In contrast, the posterior
growing social and economic costs continue
connection is a syndesmosis consisting of
to influence medical decision making [9-
the sacro-iliac ligament, gluteus medius and
17].
minimus muscles, and the piriformis muscle
CLBP is a multi-factorial disorder with
[32].
many possible etiologies. The structures
The postulated functions of the SI joint are
responsible for pain originating in the spine
to transmit or dissipate the loading of the
and affecting
the low back and lower
upper trunk to the lower extremities and vice
extremity include SI joints, intervertebral
versa [33-36]. The SI joint is very stable and
discs, nerve roots, facet joints, vertebrae,
capable of only minimal movement due to a
spinal cord, ligaments, and muscles [18].
combination of factors including the strong
Facet joint pain, discogenic pain, and SI
ligamentous
joint pain have been proven to be common
interlocking joint surface, and the large
causes of CLBP by using reliable diagnostic
force required to disrupt the joint [37].
techniques [19-21]. Now, the SI joint is
Motions in the lumbar spine, hip joint, and
accepted as a potential source of low back
the symphysis pubis affect sacroiliac motion
and or buttock pain with or without lower
[33, 38, 39].
extremity pain [22-24]. Studies evaluating
SI pain refers to the pain arising from the SI
prevalence of sacroiliac SI joint pain in
joint structures, whereas SIJ dysfunction
select population showed its presence in the
generally refers to aberrant position or
order of 13-29% i.e.; about 15% [25-27].
movement of SIJ structures that may or may
The SI joint is a true diarthrodial joint;
not result in pain [35]. SI joint dysfunction
matching articular surfaces separated by a
can cause pain to arise from joint itself
joint space containing synovial fluid and
[37].There are two clinical perspectives to
enveloped by a fibrous capsule, but, with
consider the SI joint as a load transferring
unique characteristics not typically found in
mechanical junction between the pelvis and

35
and
and
is
characterized
depression
the
SI
complex,
that
joint
the
by
minimize
has
been
irregular
the spine that may cause either the SI joint
2. AIMS AND OBJECTIVES:
or other structures to produce painful stimuli
2.1. AIM:
and the SI joint as a source of pain [38].
To find out the prevalence of undiagnosed
Possible pain mechanism associated with SI
SI joint pain and dysfunction associated
joint dysfunction come from a number of
with non specific chronic low back pain in
areas:
patients attending physical therapy OPD for
muscle
imbalance,
ligament
sprain/strain, sacral or ilial malalignment
treatment.
[36].SI joint dysfunction is a common
2.2. OBJECTIVES:
source of low back pain: however, it is
To find out the presence of association of
frequently overlooked [40]. According to
age, gender and occupational activity type
Daum both the sacroiliac joint itself and the
with the presence of SI joint pain and
diagnosis of SI joint dysfunction are
dysfunction.
underappreciated cause of pain in the low
3. METHODOLOGY:
back, pelvis, and proximal lower extremities
3.1. SAMPLE SELECTION
[42]. The differential diagnosis of back and
Study
design:
Cross
sectional
leg pain should include SI joint dysfunction
observational study using Test item
[41].
cluster (TIC) including 5 provocative
The confusion and lack of awareness of the
tests for SI joint.
SI joint as a pain generator throughout past
Study
setting:
different
century has contributed to the lack of
Physiotherapy clinics in Vadodara and
diagnostic uncertainty and lent to few
Ahmedabad, Gujarat.
available treatment options to address SI
1. Pioneer Physiotherapy College OPD,
joint. An inaccurate or incorrect diagnosis
Vadodara.
may lead not only to treatment failure, but
2. Divine Multispecialty Physiotherapy
also results in wasted health care funds,

while
diverting
essential
health
Clinic, Ahmedabad.
care
3. Yogini
resources to unnecessary aspects.

The
diagnosis
of
undiagnosed
Vasantidevi
Hospital
Physiotherapy OPD, Vadodara.
and
symptomatic SI joint pain and dysfunction
Study duration: September 2013 to

April 2014.
associated with CLBP will help the clinician
Sample population: Patients having
to concentrate on the treatment directed
chronic
towards the correction of pathomechanics of
physiotherapy clinics for treatment.
SI joint and pelvic girdle while dealing

appropriately with the pain.
36
LBP
and
attending
Sample method: Convenient incidental
6 Physiotherapists with at least 2 years
sampling.
of experience in dealing with patients
Sample size: 313 patients with chronic
of
LBP.
knowledge
Inclusion criteria :
procedures were selected as examiners
Patients complaining of chronic (>12
and were given brief introduction and
weeks) LBP.
training about purpose of the study,
Patients with buttock pain, with or
Mc Kenzie evaluation to rule out disc
without lumbar or lower extremity
lesions
symptoms [38].
provocation to be used for the study.
Age group: 25-45years.
Total 416 patients were approached
Sex: Both male and female.
and screened for inclusion in the study
Exclusion criteria:
out of which 106 subjects were
Patients
who
were
unwilling
LBP
and
having
of
and
spine
tests
thorough
evaluation
of
SI
joint
excluded due to various reasons. (
to
participate.
Unwilling = 13, Having specific
Patients having significant history of
exclusion criteria = 93)
trauma or surgery in lumbar or lumbo-
Remaining 313 subjects were included
sacral region.
for
Patient had only mid line pain or
informed consent for participation
symmetrical pain above the level of L5
after explanation of the purpose and
[38].
procedure.
Patient had clear sign of nerve root
Detailed examination for finding out
compression [38].
presence of specific structure of origin
Patient had complete sensory or motor
for chronic low back pain was done
deficit [38].
through
Age > 45 years.
method.
Patients with diagnosed SI joint
Examination
pathology e.g. Ankylosing spondylitis.
presence of signs of SI joint pain and
the
study after
Mc
Kenzie
of
the
signing
the
evaluation
patients
for
dysfunction using the test item cluster
3.2. STUDY PROCEDURE:

Selection of physiotherapy clinics in
of 5 provocative test items including
various regions of Ahmedabad and
[38]:
1. SIJ Distraction test
Vadodara, Gujarat.
2. SIJ Compression test

3. Thigh thrust test
37
4. Sacral thrust test
to be 15, 17, 16, 23, 30, 25 and 17. Male
5. Gaenslens test
subjects were found to be distributed in these
Patients with at least 3 tests positive
age groups with the frequencies of 27, 31, 17,
out of these 5 were considered to be
21, 28, 24 and 22. Mean age of subjects in
positive for SIJD [38].
these age groups were 26.14 + 0.78 years,
3.3. STATISTICAL ANALYSIS:
29.13 + 0.79 years, 32.06 + 0.83 years, 35.14 +
The aim of the study was to determine point
0.80 years, 38.02 + 0.76 years, 40.94 + 0.85
prevalence for presence of SIJ pain and
years and 44 + 0.89 years.
dysfunction, i.e. to get the percentage of
Out of these subjects about 24.28% (i.e. 76)
subjects with symptoms in the SI joints at
subjects were involved in desk job, 23.32%
the time of evaluation, in patients of non-
(i.e. 73) in standing and walking job, 24.61%
specific CLBP. The predictors of SIJ pain
(i.e. 77) in travelling jobs and 27.80% (i.e. 87)
were identified by means of multivariable
in the jobs involving of the mixture of all kind
analysis and presence of association was
of works. It is observed that male subjects
determined by calculation of odds ratio
were maximally involved in travelling jobs i.e.
(OR) using Graph pad Prism version 6 and
15.34% followed by mixed jobs (14.70%),
Medcalc statistical software. In all analysis
desk
alpha was set at p<0.05 for two-tailed
(11.50%). Involvement of female subjects in
calculations and level of significance was
the mixed jobs was maximum i.e. 13.10%
calculated using Z statistics.
followed by standing jobs (11.82%), desk jobs
jobs
(12.78%)
and
standing
jobs
(11.50%) and travelling jobs (9.27%). Mean
4. RESULTS:
age of the subjects in these groups are
4.1. DESCRIPTION OF THE STUDY
35.71+5.89 years, 35.04+5.73 years, 35.2+5.85
SAMPLE
Among the 313 subjects included in the
years and 35.13+6.03 years (Table 1,Graph 1).
study, total number of female subjects was

143 i.e. 45.69% with mean age 35.83+5.62
years. About 54.31% i.e. 170 subjects were
4.2. SYMPTOM PREVALENCE
male who had mean age 34.74+ 6.10 years.
With the use of a test item cluster including
Age group wise distribution of the all 313
5 provocation tests for SI joint, point
subjects was done in total 7 sub groups. These
prevalence of the SI joint dysfunction was
sub groups were 25-27 years, 28-30 years, 31-
measured in all 313 subjects. Over all
33 years, 34-36 years, 37-39 years, 40-42 years
prevalence of the SIJD in the subjects with
and 43-45 years. Frequency distribution of
non-specific CLBP was found out to be
female subjects in these groups was observed
60.07%, which means total 60.07%( n=188)

38
subjects were positive for presence of SIJD
values in the male subjects i.e. 33.55% as
symptoms, out of 100% (n=313) patients of
compared to female subjects who showed
non-specific CLBP evaluated.
26.52% prevalence. Subjects in the age
As seen in Table 2, highest values i.e.
group 37-39 years showed highest positive
29.41% were described in females between
findings and prevalence was observed to be
of 28-30 years and working with most of
12.14%, whereas lowest value was observed
activities involving standing and walking.
in age group 31-33 years which was 5.75%.
Female engaged in activities of mixed types
4.3. IDENTIFICATION
and with age between 43-45 years also

showed
same
values
i.e.
OF
PREDICTING FACTORS
29.41%.
Symptom-predicting factors were identified
Occupation group in which
with the help of the analyses of variables on
subjects were engaged in all types of mixed
the basis of multivariable analysis using
activities showed highest overall values of
odds ratio (OR) on the basis of point
prevalence for females, which is 19.58%.
prevalence, as described above. Despite
In contrast, for male subjects overall
analysing separately for individual factors
prevalence was highest i.e. 18.82%, in the
(age, gender & occupational activity type),
subjects engaged in occupations involving
the results of these steps were described
frequent travelling. Males subjects between
cohesively as some predictors are the same.
the age of 34-36 years and involved in
Analysing the individual factors revealed
frequent travelling showed higher values i.e.
significant effects of occupational activities
23.81% as compared to other age groups.
on the occurrence of SIJ symptoms with
Highest values of prevalence were found in
desk and sitting activities (OR: 4.34,
the subjects of all age groups who were
p<0.0001), standing and walking activities
involved in jobs including mixture of all
(OR:
activities
activities (OR: 0.32, p<0.0001) and mixed
i.e.
17.57%.
Comparison
of
0.3621,
=0.0002),
travelling
activities (OR: 2.47, p=0.0012).
prevalence in both genders showed higher
TABLE 1: DEMOGRAPHICS OF THE SAMPLE

PERCENTAGEOF
NO. OF
AGE
SUBJECTS
OCCUPATION
GENDER
(n)
MEAN (years)
39
ALL
SD
(%)
FEMALE
36
36.22
5.6977
11.50
MALE
40
35.20
6.0814
12.78
TOTAL
76
35.71
5.8896
24.28
FEMALE
37
35.14
6.1456
11.82
MALE
36
34.94
5.3185
11.50
TOTAL
73
35.04
5.7321
23.32
FEMALE
29
35.48
5.5525
9.27
MALE
48
34.92
6.1396
15.34
TOTAL
77
35.19
5.8460
24.61
FEMALE
41
36.37
5.9066
13.10
MALE
46
33.89
6.1580
14.70
TOTAL
87
35.13
6.0323
27.80
FEMALE
143
35.83
5.6188
45.69
ALL
MALE
170
34.74
6.0997
54.31
SUBJECTS
TOTAL
313
34.85
5.8593
100
DESK JOB
STANDING
TRAVELLING
MIX JOB
GRAPH 1: DEMOGRAPHICS OF THE SAMPLE
DEMOGRAPHICS OF THE SAMPLE

100
NO. OF
SUBJECTS (n)
MEAN AGE
(years)
60
40
20
DESK JOB
STANDING
TRAVELLING
OCCUPATIONAL SUBCLASSES
40
MIX JOB
TOTAL
MALE
FEMALE
TOTAL
MALE
FEMALE
TOTAL
MALE
FEMALE
TOTAL
MALE
0
FEMALE
FREQUENCY
80
positive out of these 5 tests were considered
5. DISCUSSION:
to be having probable SI joint involvement.
5.1. AIM OF THE STUDY AND
Sacroiliac joint region dysfunction is a term
REVIEW OF METHODS
The basic aim of the study was to describe
used to describe pain in or round the region
the point prevalence of undiagnosed SI joint
ofthe joint that is presumed to be due to
pain and dysfunction associated with non
malalignment or abnormal movement of the
specific CLBP patients attending physical
SIJs [43]. Whereas according to Laslett, SI
therapy OPD for treatment. In addition,
joint pain and SIJ dysfunction are clinically
factors predicting the occurrence of SIJ
different entities. SI pain refers to the pain
symptoms were also identified.
arising from the SI joint structures, whereas
With the help of a standardised screening
SIJ dysfunction generally refers to aberrant
format
were
position or movement of SIJ structures that
interviewed regarding their personal, work
may or may not result in pain [35]. The fact
related and symptoms associated details.
that SI joint is a part synovial and part
Standardised physical examinations were
syndesmosis may support the fact that the
carried out to rule out possible exclusion
study of the joint by eliciting pain using
criteria. The high degree of participation
passive
suggested that the subjects were very
determination of SIJ dysfunction [44]. Tests
interested in the topic and ensured full co-
for the SIJ dysfunction have poor inter-
operation during and after the study.
examiner reliability and validity due to lack
Whereas the high proportion of survey
of readily available reference standard for
participants may be related to the lower
SIJ
levels of satisfactory treatment outcomes in
combination
the
for
provocation tests and whose symptoms
treatment, the symptoms were apparently
cannot centralize have a probability of
not specific enough to raise suspicion of SI
having SIJ pain of 77%, and in pregnant
joint
population with LBP, a probability of 89%
checklist,
patients
the
employees
attending
involvement
in
the
the
OPD
treating
physiotherapist.
movements
will
help
in
dysfunction [36,45]. Patients with

of
or
more
positive
[35]. As suggested by Laslett et al. 2 out of

4 positive tests (distraction, compression,
5.2. SELECTION AND DIAGNOSTIC

ACCURACY OF PAIN
thigh thrust or sacral thrust) or 3 or more out
PROVOCATION SI JOINT TEST
of the full set of 6 tests are best predictors of
This study used 5 tests of the standard full
a positive intra-articular blocks [38]. Studies
set suggested by Laslett et al. in their study
reviewing the reliability and validity of
[35, 37, 38]. Subjects who showed 3 tests
different tests evaluating SIJ pain and

41
dysfunction showed insufficient reliability
for further research to establish specificity
and presence of poor methodological quality
and sensitivity of test item cluster for more
[35, 43-45]. Diagnostic utility of the test
easy use at the time of consultation to
item
determine the presence or not of SI pain and
cluster
along
with
Mc
Kenzie
evaluation to rule out discogenic pain is
dysfunction.
established by the studies, but number of
5.3. SYMPTOM PREVALENCE
studies approving the reliability and validity
Prevalence of SIJ pain and dysfunction was
of this combination is less and sample size
found to be 60.07% in the present study
of these studies was also small which makes
with higher prevalence in male subjects
generalisation of the test item cluster
(33.55%) and in those who were involved in
difficult [35, 37, 38, 47, 48].Therefore, the
activities including mixture of sitting,
results of this study can provide a baseline
standing, walking and travelling (17.57%).
42
GRAPH 2: SIJD PREVALENCE CLASSIFIED ACCORDING TO

GENDER AND OCCUPTION SUB CLASSES
43
PREVALENCE OF SIJD CLASSIFIED ACCO. TO GENDER AND OCCUPATION

87
90
76
NO. OF SUBJECTS
80
76
73
77
73
87
77
70
60
POSITIVE
FINDINGS
50
40
30
32
27
24
20
28
27
FEMALE
MALE
TOTAL NO.OF
SUBJECTS
19
20
11
10
0
FEMALE
MALE
DESK JOB
FEMALE
MALE
FEMALE
STANDING
MALE
TRAVELLING
MIX JOB
OCCUPATIONAL SUBCLASSES
TABLE 3: MULTIVARIABLE ANALYSIS OF SYMPTOM PREDICTING

FACTORS (POINT PREVALENCE)
PRESENCE OF POSITIVE FINDING FOR SIJ PROVOCATION
SIGNIFICANT
TESTS
FACTORS
p
p-VALUE
ODDS RATIO
95% -C.I.
C.I.
Z -VALUE
25-27
0.7935
1.0934
0.5604,2.1334
0.262
28-30
0.9567
1.0175
0.5427,1.9078
0.0542
31-33
0.4946
0.7765
0.3757,1.6048
0.683
34-36
0.8494
1.0654
0.5540,2.0490
0.19
37-39
0.3484
1.33
0.7327,2.4141
0.938
40-42
0.4407
0.7851
0.4245,1.4521
0.771
43-45
0.882
0.9496
0.4799,1.8789
0.148
GENDER
0.5031
1.1678
0.7414,1.8385
0.67
DESK JOB
<0.0001
4.3422
2.2658.8.3113
4.433
STANDING
0.0002
0.3621
0.2116,0.6196
3.707
TRAVELLING
<0.0001
0.3151
0.1850,0.5366
4.252
AGE
(years)
44
2.4741
0.0012
MIXED
1.4278,4.2873
3.23
NOTE: UNDERLINED FONTS INDICATE SIGNIFICANT INDICATORS
These values are higher as compared to
concluded that the prevalence of SIJ pain
the previous studies which have shown
was only 10%, but as the reference
the prevalence varying from 10%-62%
criterion was set at higher level with dual
(Mean: 33.63%, SD: 13.90) and were
block and level of relief set at 80%, only
done in the time period from 1994-2012
20 of the 120 subjects were suspected of
by various authors in the variety of
SIJ pain and underwent block thus
setups. Most of the studies conducted to
reducing prevalence [16].
find out the prevalence of SIJ pain and
The difference of outcome in the present
dysfunction included either single or dual
study and previous studies may be due to
intra articular block with the help of
the lack of inter examiner reliability and
anaesthetic agent and finding out number
validity of the manually performed SI
of positive blocks defined in terms of
joint provocative tests as suggested by the
pain relief and or reduction in pain
previous studies [35, 37, 38, 43, 47, 48].
intensity
The
Laslett et al (2003) have concluded that
amount of pain relief used as a criterion
restricting the interpretation of sacroiliac
standard to evaluate pain SI joint pain
joint
using a cut-off threshold varying from
noncentralization cases was shown to
50% to 100% [16, 24, 25, 37, 49-58].
improve the specificity of 3 or more
Lower prevalence rates found in the
positive maneuvers from 78% to 87%,
previous studies were in the range of
without compromising sensitivity, which
10%- 25.6% [16, 25, 37, 51]. One of
remained at 91% [37]. Second important
these studies by De Palma et al (2012)
factor affecting the results of study may
used retrospective design with large
be the experience and expertise of the
population included in the study, but as
evaluating physiotherapist in performing
the study did not identify the subjects
standardised tests. As the previous studies
undergoing SI joint block in particular the
have suggested provocative SIJ tests are
actual prevalence could not be calculated
more frequently positive in back pain
for
[51].
patients than the accepted prevalence of
Manchikanti et al (2001)in their study
SIJ pain indicating higher amount of
SI
on
joint
provocative
patients
tests.
only
45
provocation
tests
to
false-positive test results which depends
involving sudden heavy lifting, prolonged
upon the expertise and experience level
lifting and bending, torsional strain, fall
of the therapist [48, 49, 58].
onto a buttock, or rear-end motor vehicle
Other
studies
suggesting
higher
accident
[60,62,63].
In
addition,
prevalence of SIJ pain dysfunction in
sacroiliac joint pain and dysfunction may
female are supported by the results of the
occur from chronic repetitive shear or
present study where female subjects
torsional forces to the sacroiliac joint
involved in 2 different activity subgroups
associated with constant sitting or lying
showed higher prevalence i.e. 29.41% as
on the affected side [40, 64]. It also has
compared to male subjects [40, 50, 60,
been described that pain in the sacroiliac
61]. In a recent study, Stoev et al (2012)
joint may be aggravated by sitting, lying
found
SI
on the affected side, weight bearing on
malalignment in 77% of their female
the affected side with standing or walking
subjects as compared to male subjects in
and forward flexion in the standing
paediatric population [61]. Vleeming et al
position with knees fully extended [39,
(1997) have mentioned the worldwide
40, 64]. These findings are supported by
prevalence of SIJ pain and pelvic girdle
the present study by showing higher
pain associated with pregnancy to vary
prevalence of SIJ dysfunction in the
from 20-25% [40]. These similarities of
subjects with mixed activity levels.
the results are being supported by the
Higher values for the Odds ratio and
developmental anatomical and hormone
significant
association
associated physiological changes in the
occurrence
of
female pelvis [60, 61].
symptoms with desk and sitting activities,
out
the
presence
of
SIJD
between
and
the
associated
standing and walking activities, travelling

activities and mixed activities strongly
5.4. SYMPTOM PREDICTING
support and enhance the predictive
FACTOR
Association of the various shearing and
association of these factors with SIJ
torsional forces on the pelvis and inter
dysfunction.
linked SI joint has been well established
Age and gender of the subject are not
in the previous studies [40, 50, 62,
found
to
be
statistically significant
63].Sacroiliac joint pain and dysfunction
indicators
of
the
may be either secondary to acute trauma
dysfunction in this study, which is
46
presence
of
SIJ
supported by Irwin et al (2007) in their
calculation of correlation and relative risk
study to find out the association of age,
was not included. Future studies may
body mass index and gender differences
focus on the finding and establishing
in SI joint pathologies and concluded that
predictive- causative factors associated
gender, age and smoking status were not
with SIJ pain and dysfunction.
found to correlate with SIJ pathology
6. CONCLUSION
[50].
As derived from the study, number of
5.5. STUDY LIMITATIONS AND
subjects with probable SI joint pain and
FUTURE RESEARCH
dysfunction in patients of non-specific
SUGGESTIONS
CLBP is higher. Primary health service
As it has been already discussed the
providers then will be able to use the
reliability and validity of SI joint mobility
diagnostic test item cluster for physical
and provocative tests is in question till
examination thus checking for tentative
date, face validity of the test item cluster
diagnoses which may be confirmed by a
is also questionable. So, further study
medical specialist and, if appropriate, via
including fluoroscopically guided intra-
apparative diagnostics so that the specific
articular anaesthetic injections as a
cause of the pain and disability can be
standard reference should be conducted to
differentiated and dealt with accordingly.
establish the acceptable validity of test
The data gathered in this survey can be
items cluster.
used as a reference for further studies
Present study did not consider effects of
with
level of experience and expertise and
occupational safety and health campaigns
inter-rater reliability of the test items
addressing
executed by 6 different examiners in
preventive strategies in patients of SI
different setups. So standardisation of
joint pain and dysfunction.
examination and recording should be

established and documented for reliable
ACKNOWLEDGEMENTS
The author thanks Dr. Dhara Panchal
outcomes.
(MPT), Dr. Jalpa Patel (BPT), Dr.
In this study the association between the
Maharshi Trivedi (MPT), Dr. Himanshi
age, gender and gross occupational
Sharma (MPT) and Dr. Kirti Patel (BPT)
activities
was
multifactorial
comparable
the
outcomes
health
and
needs
in
and
established
but
the
for their support in examination of the
analysis
including
subjects and data collection as well as
47
preparation and proof reading of the
Yogini Vasantidevi Hospital, and Dr.
manuscript.
are
Mihir Mehta (MPT), Director, Divine
extended to Dr. R.A. Patel (MD),
Multispeciality Physiotherapy and fitness
Director, Pioneer Medical Campus; Dr.
centre for support and permission of the
Kailash
research in their institutions.
Special
Shah
(MD),
gratefulness
Superintendent,
REFERENCES
[1] Du Vat HCW, Heymans MW,Dunn KM, Pope DP, Van der Beek AJ, Macfarlane GJ,
Bouter LM, Corft PR (2002). Episodes of low back pain: A proposal for uniform
definitions to be used in research. Spine 27: 2409-2416.
[2] Boswell MV, Terscot AM, Datta S, Schultz DM, Hansen HC,et al (2007). Interventional
techniques: Evidence based practice guidelines in the the management of chronic spinal
pain. Pain physician 10:7-1111.
[3] Bressler HB, Keyes WJ, Rochon PA, Badley E (1999).The prevalence of low back pain
in the elderly. A systematic review of the literature. Spine (Phila pa 1976)24 :18131819.
[4] Lawerence RC, HELMICK cg, ARNEET fc, Deyo RA, Felson DT, et al.(1998).
Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the

United States. Arthritis rheum 41:778-799.
[5] Cassidy JD, LJ Cote P (1998). The Saskatchewan health and back pain survey. The
prevalence of low back pain and related disability in Saskatchewan adults. Spine
23:1860-1867.
[6] Walker BF, Muller R, Grant WD (2004). Low back pain in Australian adults:
Prevelance and associated disability. J manipulative physiol ther 27:238-244.

[7] Guo HR, Tanaka S, Halperin WE, Cameron LL (1999). Back pain prevalence in US
industry and estimates of lost workdays. Am j public health 89:1029-1035.

[8] Elliott AM, smith BH, Hannaford PC, Smith WC, Chambers WA (2002). The course of
chronic pain in the community: Result of a 4 year follow up study. Pain 99:299-307.
[9] Cassidy JD, coteP, carroll LJ, kristman V (2005). Incidence and course of low back
pain episodes in the general population. Spine (Phila pa 1976) 30:2817-2823.
48
[10] Hestbaek L, Leboeuf-yde C, Manniche C (2003). Low back pain: what is the longe
term course? : A review of studies of general patients population. Eur spine j 12:149165.
[11] KuslichSD, Ulstome CL, Michael CJ (1991). The tissue origin of low back pain and
sciatica: A report of pain response to tissue stimulation during operation on the lumbar
spine using local anesthesia. Orthop clin north am 22:181-187.
[12] Pizzo PA, Clark N. Alleviating suffering 101- pain relief in the United States. Nengl j
med 2021:366:197-199.
[13] Manchikanti L, Boswell MV, Singh V, Benjamin RM, Fellows B,
Abdi S,
Buenaventura RM, Conn A,Datta S,Derby R,Falco FJ, Erhart S, Diwan S, Hayek SM,
Helm S, Parr AT, Schultz DM,Smith HS, Wolfer LR, Hirsch JA (2009).
Comprehensive evidence based guideline for interventional techniques in the
management of chronice spinal pain. pain physician ;12:699-802.
[14] Deyo RA, Mirza SK, Turner JA, Martin BI (2009). Overtreating chronic back pain :
time to back off? J Am board fam med; 22: 62-68.

[15] Bogduk N (1997). International spinal injection society guidelines for the performance
of spinal injection procedures. Part 1. Zygapophyseal joint blocks. Clin j pain; 13:385302.
[16] Manchikanti L, Singh V, Pamapati V, Damron K, Barnhill R,Beyer BC,Cash K (2001).
Evaluation of the relative contribution of various structure in chronic low back pain.
Pain physician; 4:308-316.
[17] Bogduk N.( 2005). The sacroiliac joint. In: Clinical anatomy of lumbar spine and
sacrum, 4th edition. Churchill livingstone, New York, pp.173-181.

[18] Foley BS, Buschbarche RM (2006). Sacroiliac joint pain: Anatomy, Biomechanics,
Diagnosis,and treatment. Am j phys med rehabil; 85: 997-1006.

[19] Manchikanti L, Staats P, Singh V et al (2003). Evidence based practice guidelines for
interventional techniques in the management of chronic spinal pain. Pain physician;

6:3-87.
[20] Bos well MV, Singh V, Saats PS, Hiresch JA (2003). Accuracy of diagnositic blocks
in the diagnosis of chronic spinal pain of facet or zygapophyseal joint origin. Pain
physician 6:449-456.
49
[21] Sehgal N, Shah RV, Mckenzie Brown AM, Everett CR (2005). Diagnostic utility of
facet joint injection in chronic spinal pain: A systematic review of evidence. Pain
Physician 8:211-224.
[22] Bogduk N, McGuirk B (Eds.) (2002). Causes and sources of chronic low back pain. In
Medical management of acute and chronic low back pain: An evidence based approach
.Pain research and clinical management Vol .13 Elsevier science BV Amsterdam,
pp.115-126.
[23] Merskey H, Bogduk N (1994). Classification of chronic pain. In Merskey H, Bogduk
N, editors. Description of chronic pain syndromes and definition of pain terms, (2nd
edn.) Seattle: IASP press.
[24] Schwarzer AC, Aprille CN, Bogduk N (1995). The sacroiliac joint in chronic low back
pain. Spine ;20:31-37

[25] Maigne JY, Aivakiklis A, Pfefer F (1995). Results of sacroiliac joint in chronic low
back pain. Spine; 20:31-37.

[26] Pang WW, Mork MS, Lin ML et al (1998). Application of spinal pain mapping in the
diagnosis of low back pain Analysis of 104 cases. Acta anaesthesiol sin; 21:18891892.
[27] Fortin JD (1993). The sacroiliac joint: A new perspective. J back muskulosketal
rehabil; 3:31-43.
[28] Fortin J, Sehgal N (2000). Sacroiliac joint injection and arthrography with imaging
correlation. In: Lennard TA (ed.) Pain procedure in clinical practice. Hanley & belfus,
Philadelphia, pp. 256-273.
[29] Smidt GL, Wei S, Mcquade K (1997). Sacroiliac motion for extreme hip position.
Spine ( Phila pa 1976);22:2073-2082.

[30] Cunningham DJ (1931). Cunninghams text book of Anatomy. Oxford university
press, New York.

[31] Forst SL, Wheeler MT, Fortin JD (2006).The sacroiliac joint: Anatomy, Physiology
and clinical significance. Pain physician; 9: 61-67.

[32] Vanderlen P, Szadek K, Choen SP, De witte J, Lataster A, Pijin J, Mekhail N, Van klee
FM,Van zundert J (2010). Sacroiliac joint pain. Pain pract; 10: 470-478.
50
[33] Cibulka MT, Delitto A and Erhardt RE (1995). Pain patterns in patients with and
without sacroiliac joint dysfunction, low back pain and its relation to the SIJ. San
diego; 110-112.
[34] Florence PK and Elizabeth KM. Muscles testing and function 3
RD
Ed. Williams and
wilkins 8-10.
[35] Laslett M (2008). Evidence-based diagnosis and treatment of the painful sacroiliac
joint. J Man Manip Ther; 16:142-152.

[36] Don Tigny RL. A detailed and critical biomechanical analysis of the SI joint and
relevant kinesiology. The implication for lumbo-pelvic function and dysfunction

(2007). In Vleening A, Mooeny V, and Stoeckart R (eds.) 2nd ed. Movement, stability
and lumbo sacral pain integration of research and therapy Philadelphia, PA: Churchill
livingstone.
[37] Laslett M, Young SB, Aprill CN, McDonald B (2003). Diagnosing painful sacroiliac
joints: A validity study of a McKenzie evaluation and sacroiliac joint provocation tests.
Aust J Physiother; 49:8997.
[38] Laslett M, Aprill CN, McDonald B, Young SB (2005). Diagnosis of sacroiliac joint
pain: Validity of individual provocation tests and composites of tests. Man Ther; 10:
207218.
[39] Bernard TN, Cassidy JD (1997).
The sacroiliac joint syndrome. Pathophysiology,
diagnosis and management. In Frymoyer JW (ed). The Adult Spine: Principles and
Practice, 2nd Ed. Lippincott-Raven Publishers, Philadelphia; pp 2343-2363.
[40] Vleeming A, Mooney V, Snijders CJ, Dormann TA, Stoeckart R, (eds.) (1997).
Movement, Stability and Low Back Pain: The Essential Role of the Pelvis. 1 ed. New
York: Churchill Livingstone.
[41] Cassidy JD, Mireau DR (1992). Pathophysiology of the sacroiliac joint. In : Haldeman
S. Principles and practice of chiropractic. 2nd ed. Connecticut: Appleton and Lange. pp
211-224.
[42] Daum WJ (1995). The SacroIliac joint: an unappreciated pain generator. Am J Orthop
(Belle Med NJ); Jun; 24(6): 475-8.

[43] Riddle DL, Freburger JK (2002). Multicenter Intertester Reliability Study Dysfunction
Using a Combination of Tests: A Evaluation of the Presence of Sacroiliac Joint Region.

PHYS THER; 82:772-781.
51
[44] Broadhurst NA, Bond MJ(1998). Pain provocation test used for assessment of
sacroiliac joint dysfunction. J Spinal Disorder; 11:341-345.

[45] Potter N, Rothstein J (1992). Intertester reliability for selected clinical of the sacroiliac
joint. Phys Ther; 12:903-916.

[46] van der Wurff P, Meyne W, Hagmeijer RHM (2000). Clinical tests of the sacroiliac
joint: a systematic methodological review. Part 2: validity. Manual Therapy;5(2):89

96.
[47] Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RR (2008).
Diagnostic validity of criteria for sacroiliac joint pain: A systematic review. J Pain;
10:354-368.
[48] Simopoulos TT, Manchikanti L,Singh V,Gupta S,Hameed H,Diwan S,and Cohen S P
(2012). A Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac

Joint Interventions. Pain Physician: May/June; 15:E305-E344.
[49] Maigne JY, Planchon CA (2005). Sacroiliac joint pain after fusion. A study with
anesthetic blocks. Eur Spine J; 14:654-658.

[50] Irwin RW, Watson T, Minick RP, Ambrosius WT (2007). Age, body mass index, and
gender differences in sacroiliac joint pathology. Am J Phys Med Rehabil; 86:37-44.

[51] Laplante BL, Ketchum, JM, Saullo TR, DePalma MJ (2012). Multivariable analysis of
the relationship between pain referral patterns and the source of chronic low back pain.
Pain Physician; 15:171- 178.
[52] van der Wurff P, Buijs EJ, Groen GJ (2006). A multitest regimen of pain provocation
tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures.

Arch Phys Med Rehabil; 87:10-14.
[53] Young S, Aprill CN, Laslett M (2003). Correlation of clinical examination
characteristics with three sources of chronic low back pain. Spine J; 3:460-465.
[54] Stanford G, Burnham RS (2010). Is it useful to repeat sacroiliac joint provocative tests
post-block? Pain Med; 11:1774-1776.

[55] De Palma MJ, Ketchum JM, Saullo TR (2011). Etiology of chronic low back pain in
patients having undergone lumbar fusion. Pain Med; 12:732-739.

[56] Liliang PC, Lu K, Liang CL, Tsai YD, Wang KW, Chen HJ (2011). Sacroiliac joint
pain after lumbar and lumbosacral fusion: Findings using dual sacroiliac joint blocks.
Pain Med; 12:565-570.
52
[57] Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N (1996). The value of
medical history and physical examination in diagnosing sacroiliac joint pain. Spine
(Phila Pa 1976); 21:2594-2602.
[58] Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E (1996). The value of
radionuclide imaging in the diagnosis of sacroiliac joint syndrome. Spine (Phila Pa

1976); 21:2251-2254.
[59] Laslett M (1997). Pain provocation sacroiliac joint tests: Reliability and prevalence. In
Vleeming A, Mooney V, Snijders CJ, Dormann TA, Stoeckart R, eds. Movement,

Stability and Low Back Pain: The Essential Role of the Pelvis. 1st ed. New York:
Chuchill livingstone.
[60] Brolinson PG, Kozar AJ, Cibor G(2003). Sacroiliac joint dysfunction in athletes. Curr
Sports Med Rep 2:4756.

[61] Stoev I,Powers AK,Puglisi JA,Munro RA,and Leonard JR (2012). Sacroiliac joint pain
in the pediatric population. J Neurosurg Pediatrics 9:602-607.

[62] Toussaint R, Gawlik CS, Rehder U et al (1999). Sacroiliac joint diagnostics in the
Hamburg Construction Workers Study. J Manipulative Physiol Ther; 22:139-143.

[63] Slipman CW, Whyte WS, Chow DW et al (2001). Sacroiliac joint syndrome. Pain
Physician; 4:143-152.
CORRESPONDENCES
Lecturer, Pioneer Physiotherapy College, Vadodara. e-mail:vivekramanandi@gmail.com
53
CASE STUDY OF ERGONOMIC INTERVENTION IN TREATMENT

OF A COMPUTER PROFESSIONAL SUFFERING FROM UPPER
EXTREMITY & NECK PAIN
Amit Murli Patel
ABSTRACT
Background and Purpose. Work-related musculoskeletal disorders (WRMD) are
widespread among computer users. Workstation setup and worker postures contribute to
upper-extremity and neck symptoms among computer users. Ergonomic interventions such
as work risk analysis and workstation modifications can improve workers symptoms.
However, ergonomic interventions do not appear to be a common component of traditional
Physiotherapy treatment. Case Description. The patient was a 26-year-old woman with
right upper extremity and neck pain referred for Physiotherapy. A course of traditional
Physiotherapy treatment was performed followed by an ergonomic intervention. Outcomes.
Following 4 weeks of traditional Physiotherapy, the patient showed a 1.0-cm improvement
in her resting pain level but no change in her pain level during exacerbations on the visual
analog scale. An ergonomic intervention was performed following traditional
Physiotherapy. At the conclusion of the full course of treatment (traditional Physiotherapy
plus ergonomic intervention), resting pain level decreased by 4.6 cm and exacerbation pain
level decreased by 3.2 cm. Improvements in Rapid Upper Limb Assessment and Workstyle
scores also were realized. Discussion. This case report demonstrates the importance of
examining the work habits and work-related postures of a patient who complains of upperextremity and neck pain that is exacerbated by work. Providing an ergonomic intervention
in concert with traditional Physiotherapy may be the most beneficial course of treatment.
Key Words : Work-related musculoskeletal disorders, Rapid Upper Limb Assessment and
Workstyle scores, Ergonomic intervention
INTRODUCTION
Jobs requiring the use of a computer input
The incidence of upper-extremity work
device and video display terminal (VDT)
related musculoskeletal disorder (MSD)
often expose Professionals to awkward
occurrences for computer-related injuries
and sustained postures and repetitive
increased from 1.6% of all upper-
motions of the upper extremities, which
extremity injury claims in 1986 to 14.6%
have been demonstrated as causes of
of all upper-extremity injury in 1993.2
work-related shoulder and neck pain.1
The relationship between work related
54
MSDs and VDT use was explored by
presence of work-related MSD risk
Marcus and Gerr,6 who reported a 63%
factors
incidence of neck and shoulder symptoms
recommendations for safe seating and
among 416 female office workers using
VDT setup in order to protect office
VDTs daily in their jobs. More recently,
workers.10 Altering the position of office
Korhonen et al7 found that the annual
equipment such as the VDT or mouse
incidence of neck pain among Finnish
input device has been shown to modify
VDT workers was 34%. Sillanpa et al8
muscle activity and reduce symptom
found that the incidence of neck pain and
complaints.1114. Cook and Kothiyal11
shoulder pain among 979 VDT users was
demonstrated
63%
These
computer mouse closer to the keyboard
authors8 indicated a strong association
and eliminating the numeric key pad
between mouse use, including mouse
resulted in a significantly lower deltoid
position, and workers pain symptoms.
muscle electromyographic activity in
Hernandez et al9 reported an increased
VDT users than when the mouse was
incidence of neck, shoulder, and hand
placed in a position where the user was
work-related MSDs in 179 newspaper
required to abduct the upper extremity
workers using VDTs compared with non-
and reach for the mouse. Static, low-level
VDT users in the same company.
loading of the deltoid and upper trapezius
Furthermore, they demonstrated that the
muscles
type and amount of computer use and the
increased incidence of shoulder and neck
posture of the worker were related to the
pain.12 Marcus et al13 showed that there
incidence of work-related MSDs.
was a decrease in upper-extremity and
The incidence of neck pain combined
neck symptoms in office workers who
with the increased numbers of workers
used
using
Indian
postures. Specifically, a lower risk of
and
Health
work-related MSDs of the shoulder was
to
institute
associated with keyboard placement that
guidelines and ergonomic evaluation
put the elbows at a more neutral angle,
procedures for working safely with
described as keyboard lower than elbow
VDTs.10 The IOSHA VDT guidelines
without arm abduction, and a lower risk
allow
of neck symptoms was shown with a
and
23%,
VDTs
respectively.
prompted
Occupational
Safety
Administration
(IOSHA)
companies
to
the
determine
the
55
and
has
more
provide
that
been
specific
positioning
correlated
ergonomically
the
with
sound
monitor position that allowed a head tilt
postures and performing the appropriate
angle of less than 3 degrees.13 Pillastrini
tests and measures to determine the
et al14 and Hignett and McAtamney15
causes and consequences of awkward
have shown that personalized ergonomic
postures. However, in our experience, an
intervention,
assessment
including
postural
of
patients
awkward
assessment and proper adjustments of the
working postures is rarely made by the
seat, desk, VDT, keyboard, and mouse,
physiotherapist
resulted in significant decreases in pain
demonstrates
and Rapid Entire Body Assessment
workstation. Postural assessments usually
(REBA) scores for office workers using
are made while the patient is in the clinic
VDTs for 20 hours per week.
and generally in the standing and seated
while
those
the
postures
patient
at
the
although
positions. Furthermore, interventions for
primarily designed to benefit the worker,
awkward postures assessed only in the
also may benefit the company although
clinic usually do not involve workstation
the concept is not been applicable in India
modifications
as the insurance sector does not cover the
modifications. An ergonomic assessment
MSD claims. The implementation of an
and workstation modifications have been
ergonomic intervention has been shown
shown to reduce the incidence of work-
to decrease work-related MSD claim
related MSDs in a variety of work
costs.4 During the period of 19951998,
settings.4,11,13,14 From the afore mentioned
Lewis et al4 implemented an ergonomic
research, it may be concluded that the
intervention program among VDT users
inclusion of an ergonomic assessment and
in a petrochemical plant. Individual claim
intervention in the treatment of an office
costs were reduced from an average of
worker with complaints of neck and
$15,141 before intervention to and an
shoulder pain can result in improved
average of $1,553 after intervention.
patient outcomes when combined with
Ergonomic interventions are based on
traditional physiotherapy treatment. The
reducing awkward postures that occur
current literature demonstrates ergonomic
while the client is at the workstation
interventions on a company-wide scale
while
tasks.
but does not examine the inclusion of an
Physiotherapists have unique knowledge
ergonomic intervention added after a
and training in identifying awkward
course
Ergonomic
interventions,
performing
work
56
of
or
traditional
work
habit
physiotherapy
treatment as a plan of care. The purpose
assessing
of this case report is to describe the
correlation coefficient = . 99), good
effects
physiotherapy
validity for measurement of chronic pain
treatment of a patient with right-sided
and temperature, and a minimum clinical
neck
the
significant difference of 1.6 cm.16,17 The
subsequent outcomes associated with
patient described her 24-hour pain pattern
ergonomic evaluation and intervention
as decreased pain in the morning (VAS
that were initiated after the traditional
score of 3.2 cm) and increasing pain as
treatment.
the day progressed (VAS score of 6.4
of
and
traditional
shoulder
pain
and
acute
pain
(intraclass
cm), which she noticed daily during her

PATIENT HISTORY AND REVIEW
40-minute drive home from work. She
OF SYSTEMS
also described her pain as limiting her
The patient was a 26-year-old woman
time spent at her computer station and
with a chief complaint of right upper-
making her work uncomfortable. The
extremity pain and right-sided neck pain
physicians report and the patients past
who was referred for physiotherapy with
medical history were unremarkable, with
orders from her primary care physician
no indication of any systemic disorders,
for
neurological or cardiovascular concerns,
physiotherapy
for
neck
strain,
evaluate and treat. The patient initially
or
described her pain as a dull ache of
extremities, neck, or back.
insidious onset approximately 3 months
The
prior and worsening since that time. The
administrative
pain appeared, to her, to radiate from her
requirement of typing and VDT use for
neck into her shoulder and arm, with pain
65% to 75% of her day. The remaining
intensity at the time of her initial
daily tasks were equally divided among
appointment equal to 5.5/10 cm on a
using
visual analog scale (VAS). The VAS was
appointments, and filing paperwork. She
assessed by having the patient mark her
had been at her current position for 6
pain rating on a 10-cm line between no
months and noted that a new partner had
pain (0 cm) or the worst imaginable
joined the law firm in the past 4 months
pain (10 cm).16 The VAS has been
and that her typing and VDT workload
shown to have good reliability for
had increased to 85% as a result.
57
previous
patient
the
injuries
was
to
the
employed
secretary
telephone,
with
upper
as
an
job
scheduling
Examination
impingement and a high specificity value
The patient initially was seen in an
of 96%.18,19 Palpation revealed increased
outpatient
and
bulk with an active myofascial trigger
underwent traditional evaluation and
point (MTrP) in the right upper trapezius
treatment, which are outlined below. The
muscle and right levator scapulae muscle
patient
distal attachment.
physiotherapy
was
clinic
right-hand
dominant.
Observation of her posture in a standing
At the initial visit, the patient completed
position revealed a forward head posture
the Quick DASH outcome tool, scoring
with bilateral forward shoulders. The
50 on the disability symptom score and
thoracic spine curve was unremarkable,
75 on the work and sport/performing arts
and the lumbar curve was slightly
modules (Table).20 The Quick DASH is a
lordotic.
shorter version of the original Disabilities
Upper-extremity posture demonstrated an
of the Arm, Shoulder, and Hand (DASH)
elevated right shoulder and increased
questionnaire that has demonstrated good
bulk of the right periscapular muscles.
agreement with the DASH (intraclass
Significant physical examination findings
correlation coefficient = .96) and good
are summarized below. Active range of
test-retest
motion (AROM) of the cervical spine and
correlation coefficient = .93) related to
upper extremities was within normal
function, where higher values indicate a
limits for all motions. Muscle length
greater level of disability.20 The diagnosis
examination revealed tightness of the
by the treating Physiotherapist was Guide
bilateral pectoralis minor muscles, and
to
manual muscle tests revealed weakness in
musculoskeletal preferred practice pattern
the bilateral middle and lower trapezius
4E (Impaired Joint Mobility, Motor
muscles. Neer and Hawkins- Kennedy
Function,
tests
Range
were
positive
for
shoulder
reliability
Physical
of
(intraclass
Therapist
Muscle
Motion
Practice
Performance,
and
Associated
With
impingement on the right, and upper-limb
Localized
tension tests were positive for median
musculoskeletal preferred practice pattern
nerve entrapment in the arm. The Neer
4F (Impaired Joint Mobility, Motor
and Hawkins-Kennedy tests have shown
Function, Muscle Performance, Range of
sensitivity of 75% to 88.7% and 92.1%,
Motion, and Reflex Integrity Associated
respectively,
With Spinal Disorders).21 The patient
for
subacromial
58
Inflammation)
and
indicated that her goals for physical
and to participate in yoga and aerobics
therapy were to be pain free, to work at
sessions without being interrupted by her
her desk without symptoms for 1 hour,
symptoms.
TRADITIONAL PHYSIOTHERAPY
periscapular muscles. The patient was
INTERVENTION
consistent with her physical therapy
Physiotherapy treatment commenced at a
appointments, attending 12 of 12 sessions
frequency of 3 times per week for 4
over 4 weeks, and reported consistency
weeks.
tissue
with her daily home program. Following
techniques and stretch were used to
4 weeks of traditional physical therapy,
relieve the MTrPs in the right upper
the patients MTrPs were resolved,
quarter.22
an
neurodynamic testing and impingement
education program on treatment day 1
tests were negative, and posture, as
consisting of posture correction, a home
examined
exercise
strengthening
physical therapist, was improved. The
exercises for the middle and lower
patient reported her pain level at that time
trapezius, and self-neurodynamic gliding
as 4.5 cm (VAS), with exacerbations of
exercises.
6.4
Initially,
The
manual
patient
program
The
of
in-clinic
soft
received
treatments,
cm
visually
(VAS)
by
and
the
treating
abatement
of
started on treatment day 2, consisted of
symptoms to 2.2 cm (VAS) (Table).
manual neurodynamic gliding for the
The changes in the patients symptoms
median nerve, soft tissue mobilization
were 1.0 cm for present pain and 1.0 cm
and MTrP release, and a therapeutic
for best level of pain, and the minimum
exercise program consisting of exercising
clinically significant difference has been
on an upper-body ergometer followed by
established as 1.6 cm.17 The Quick
progressive resistive exercises for the
DASH disability symptom score was
59
reduced from 50 to 36, and scores on the
tool for use in all types of industry.24 The
sports/performing arts modules were
IOSHA VDT workstation checklist is
reduced from 75 to 50 for each module
used specifically for identifying risk
(Table).
traditional
factors for work related MSDs associated
and
the
with workstation postures and devices.10
subsequent ergonomic assessment and
The IOSHA assessment tools are a
treatment,
logical primary step in ergonomics
During
physiotherapy
the
treatment
the
patient
continued
to
assessment because they are readily
perform her normal work duties.
available, simple, and easy to use and are

ERGONOMIC ASSESSMENT
supported by current research and NIOSH
Following
traditional
recommendations. The RULA tool is
Physiotherapy, the patient was referred to
used to estimate the risks of work-related
another Physiotherapist for an ergonomic
upper-limb disorders and scores the
work
workers
completion
risk
analysis
of
(WRA).
The
awkward
postures
at
the
Physiotherapist performing the WRA was
workstation into action levels ranging
Assessment
from 1 (sound positioning/safe) to 7
Specialist and had 7 years of experience
(worst posture/ immediate risk for
in performing ergonomic assessments.
injury).25,26 The initial WRA identified
The pain rating and the Quick DASH
risk factors for work-related MSDs using
scores were repeated, and the Workstyle
the IOSHA W-1 Basic Screening Tool in
short-form measure of work demands was
the categories of awkward postures and
assessed.23 The WRA was completed
repetition. The IOSHA VDT workstation
using the Indian Occupational Safety and
checklist revealed specific risks for work-
Health Administration (IOSHA) W-1
related MSDs related to positioning of the
Basic Screening Tool,24 the IOSHA VDT
head, neck, shoulders, and trunk, as well
workstation checklist10 (Appendix), and
as seating issues. The VDT workstation
the Rapid Upper Limb Assessment
checklist also identified risks associated
(RULA).25,26 The IOSHA W-1 Basic
with keyboard and mouse position,
Screening Tool identifies risk factors for
monitor position, and lack of document
work related MSDs related to awkward
holder, wrist rests, and telephone hands-
postures, repetition, force, contact stress,
free headset. The RULA tool identified
and vibration and is a general assessment
risks associated with shoulder abduction
Certified
Ergonomic
60
and elevation, forearm flexion, wrist
response.23 The Work style short-form
flexion and ulnar deviation, neck flexion
survey has been shown to have good
and rotation, trunk flexion and rotation,
internal consistency ( =.89) and good
and leg position. The initial RULA score
test-retest reliability (r =.88) and is
was 7, indicating the need for immediate
correlated with measures of pain (r = .41)
ergonomic intervention.
25,26
The RULA
and upper extremity symptoms (r =
score presented for this case report
.33).23 The Work style score for the
represents only the affected side. The
current patient was 52, with an at risk
RULA
score defined as greater than 28.23 The
was
completed
for
the
noninvolved side, but the data are not
Work
presented here to preserve the clarity of
completed following the observation
the case. The WRA involved the therapist
period.
observing the patient for a 2-hour period
A specific description of the patients
while she performed her normal work
workstation
duties on what was deemed by the patient
monitor was low and offset; the top of the
to be a typical day of work. The awkward
monitor was positioned below eye level;
postures were averages of what had been
and the monitor was set to the left of the
visualized
The
work surface, requiring flexed and rotated
subsequent scores were an average of the
trunk and neck postures. The keyboard
postures and positions as seen over the
was positioned on the desk surface,
examination period.
higher than the elbow position, resulting
In addition to the WRA performed by the
in bilateral wrist extension and shoulder
therapist, the patient completed a Work
elevation. The mouse was positioned 25.4
style short-form survey. The Work style
cm (10 in) away from the keyboard,
short
requiring
form
by
the
survey
therapist.
measures
the
style
short-form
follows.
right
arm
survey
The
was
patients
abduction
and
individuals perception of his or her job
shoulder elevation. The chair height and
and workstation in relation to symptoms
seat pan angle could not be adjusted,
in the following categories: working
contributing to increased trunk and neck
through the pain, social reactivity, limited
flexion and unsupported bilateral foot
workplace
position and contact stress in the popliteal
support,
deadlines
and
pressure, self-imposed workplace and
fossa.
workload, breaks, mood, and autonomic
61
elbows at 80 degrees of flexion, elbows
ERGONOMIC INTERVENTION
The
ergonomic
was
higher than the keyboard, and neutral
undertaken immediately after completing
wrist position of 0 degrees of flexion or
the scoring of the outcome measures and
extension while resting on the keyboard
followed guidelines in IOSHA document
or
3092, Working With Video Display
shoulder/elbow/wrist position is designed
Terminals, which describe head, trunk,
to decrease muscle activation during
upper extremity, and lower-extremity
seated postures that may be caused by
positioning that is in agreement with
constant low-level loading of the upper-
current research regarding safe VDT
extremity muscles. Previous research12,29
working postures.10 An adjustable seat
has shown that constant low-level muscle
from
was
loading at the shoulder, neck, and
substituted for the patients seat. The new
forearms produced by positioning the
seat height was adjusted to accommodate
elbow and wrist in non-neutral postures
the monitor viewing angle combined with
leads to an increase in pain at the
a relaxed leg and foot position, as well as
shoulder, neck, and wrist. The mouse was
the shoulder and elbow positions that are
positioned at the right upper corner of the
described below. An adjustable chair
keyboard to eliminate excessive shoulder
provides a platform from which all other
abduction and decrease muscle activation
adjustments can be manipulated.
and fatigue.30,31 The monitor height was
The addition of an adjustable seat,
adjusted to the proper eye level by using
combined with ergonomic education, has
a 10.16-cm (4-in) riser, and the monitor
been shown to reduce pain complaints in
was positioned directly in front of the
workers whose jobs required sitting for
patients
four hours per day while working at a
appropriate viewing angle and distance
VDT.27 Rempel et al28 demonstrated that
from the patients eyes.32 Previous work
adding a properly fitted, adjustable chair
by Marcus et al13 showed that monitor
significantly reduced shoulder and neck
height adjustment requiring less than a 3-
pain in seated workers. The height and
degree tilt angle produced a significant
seat pan of the patients new chair were
decrease in neck and shoulder symptoms.
adjusted to allow proper positioning of
Subsequent
the trunk and upper extremities with the
ordering a split keyboard to reduce ulnar
an
unused
intervention
workstation
62
mouse.
view
The
to
neutral
approximate
intervention
the
involved
strain.33
deviation
and
assessment combined with the immediate
Simoneau33 demonstrated that using a
workstation changes discussed above. A
split
single 1-hour follow-up visit occurred 1
keyboard,
Marklin
compared
with
conventional keyboard, reduced ulnar
week
deviation by as much as 10 degrees,
intervention
allowing the wrist to be at a more neutral
devices that were ordered and to review
position
patient education regarding the new
and
reducing
RULA wrist
after
the
to
initial
ergonomic
implement
the
new
working postures.
position score. A keyboard tray and

mouse tray were ordered and later
incorporated to better align input devices
OUTCOME
while reducing the shoulder/elbow/wrist
The outcome measures were reassessed at
awkward postures.11,30,31 A document
1 month following implementation of the
holder was later implemented to reduce
ergonomic
head and neck movement and to reduce
period
the chance that the patient would
intervention and to the day of the
encounter a head tilt angle that put her at
reassessment, the patient was no longer
risk for neck pain.13 The patient also was
being treated with formal Physiotherapy
educated on the postural adjustments
and
made to her body and her workstation and
exercise program 4 days per week. The
was instructed to take 20- second
results
microbreaks as a means to break any
summarized in the Table and briefly
sustained
her
presented here. The patients present
myoelectric
level of pain rating on the VAS
posture
symptoms
activity
by
in
and
reducing
the
relieve
shoulder
intervention.
following
reported
of
During
the
continuing
the
the
ergonomic
her
reassessment
home
are
decreased by 1.0 cm following 4 weeks
girdle
musculature.34 Each microbreak consisted
of
of a 20-second period of standing
decreased by an additional 3.6 cm
stretches (AROM for shoulder flexion,
following the ergonomic intervention
wrist flexion and extension, and scapular
period. The patients worst pain rating
adduction) performed every 30 minutes
did
while at her desk.
Physiotherapy, but showed a decrease of
The
duration
of
the
4.4
ergonomic
traditional
not
cm
Physiotherapy
decrease
following
during
the
and
traditional
ergonomic
intervention. The patients best pain
intervention consisted of 2 hours of
63
rating improved by 1.0 cm following
Additionally, it is important to note that
traditional physical therapy and by an
assessments using the RULA and Work
additional
style tools were not performed prior to
2.2
cm
following
the
beginning
ergonomic intervention.
traditional
Physiotherapy.
score
Therefore, a true comparison between
improved by 28% following traditional
treatments cannot be accurately assessed
Physiotherapy and by 100% following the
using the RULA and Work style tools.
ergonomic intervention. The RULA and
The patient had been continuing her
Work style ratings improved by 86% and
home
81%,
the
traditional Physiotherapy stage through
ergonomic intervention. Four weeks after
the ergonomic intervention and had been
the ergonomic intervention, the patients
instructed on proper postural corrections
outcome scores for disability, pain, and
during traditional Physiotherapy. She also
work risk showed greater improvement
had been continuing to work at full
than during traditional Physiotherapy
capacity
alone.
Therefore, it may not be appropriate to
The
Quick
DASH
disability
respectively,
following
exercise
in
program
her
from
current
the
position.
conclude that the ergonomic intervention

DISCUSSION
was the sole mechanism for the patients
The purpose of this case report was to
pain relief. Although it has previously
describe
traditional
been demonstrated that improvements in
ergonomic
neck and upper-extremity pain can be
the
effects
Physiotherapy
of
and
intervention in the treatment of a patient
seen
with neck and shoulder pain. It appears
workstation
that
of
adjustments of the worker, the role of
ergonomic assessment and modifications
exercise provided through the initial
following
traditional
traditional Physiotherapy protocol and the
greater
educational component provided to the
decrease in symptoms than the patient
patient also need to be considered.35 A
experienced
traditional
possible confounding element in the
Physiotherapy alone. However, it is
current case is the home exercise
difficult
either
program. Patients experiencing neck pain
beneficial.
previously demonstrated a decrease in
the
combined
Physiotherapy
to
intervention
interventions
weeks
of
provided
during
say
was
whether
more
64
following
adjustments
combined
with
to
the
postural
pain symptoms and a decreased disability
working environment while performing
score following 6 weeks of exercise
the tasks required of the job. Patients may
therapy alone when compared with
try to demonstrate artificially constructed
controls.36 Perhaps, in the present case, a
work-related tasks in the clinic in the
greater portion of the decrease in
manner that they think the physical
symptoms was realized through the
therapist wants to see.
patients continuing her home exercise
In the workplace, the bias is removed and
program
the patient is more likely to perform tasks
rather
than
through
the
introduction of ergonomic interventions.
and
Previous research also has shown that
representative of his or her daily habits.
initial education regarding ergonomic
It is equally important to note that the
postures
can
patient in this case underwent traditional
influence symptoms. The initial postural
Physiotherapy for an extended period
education during traditional physical
with minimal improvement. The VAS
therapy may have contributed to the end
scores reflect the minimal improvement
result. However, Ketola et al37 showed
in the patients symptoms after traditional
that
treatment, with values remaining below
at
VDT
workstations
37
combination
of
ergonomic
exhibit
more
the
provided a greater positive effect on
difference
patients
ergonomic assessment and intervention
than
ergonomic
for
clinically
closely
education and workstation modifications
symptoms
minimum
postures
the
VAS.
significant
Had
the
may
been undertaken earlier in the treatment
implicate one of the shortcomings of
plan, perhaps the patient would have
traditional Physiotherapy. In many cases,
achieved her results in less time. In the
it seems physical therapists may discuss
current case, the VAS scores exceeded
or show a patient the proper posture for
the
sitting at a VDT, but without actual
difference after the completion of the full
assessment and modification of the
course of treatment, which included the
workstation, significant symptom relief
ergonomic intervention. At a time when
may not be achieved. The evidence from
the health care industry continually
education
alone.
37
This
finding
minimum
clinically
significant
would suggest that there is
strives to provide efficient care, a
greater value in the therapists actually
treatment plan that is not yielding results
observing the patient in his or her natural
should be reevaluated or, in the present
Ketola et al
65
case, where the combined treatment of
intervention should be explored prior to
traditional Physiotherapy and ergonomics
beginning Physiotherapy to assess the
was shown to be beneficial, the office
interaction of ergonomic intervention
assessment should have been performed
with
earlier. In the current case, the patient
amount and type of education regarding
completed
traditional
workstation posture also needs to be
significant
controlled in order to assess the true
12
Physiotherapy
visits
of
without
traditional
Physiotherapy.
The
improvement of her symptoms.
impact of the ergonomic intervention.
Had the ergonomic assessment and
In the current report, it is difficult to
intervention taken place earlier and
assess the extent to which the initial
possibly during the traditional physical
introduction of physical therapy treatment
therapy, perhaps the patient would have
may have been responsible for the
achieved a decrease in symptoms in a
patients progress.
timelier manner, thus removing any
Would reversing the treatments, with an
indication of possible overutilization of
ergonomic intervention as the initial
physical therapy.
treatment
An ergonomic assessment is a cost
intervention implemented 4 weeks later,
effective choice for the initial stages of
show the same results? There is a need
treatment in patients with upper extremity
for continued research into and study of
dysfunction that may appear to be work-
ergonomic
related. Furthermore, the range of costs in
relationship to patient symptoms and its
individual
modifications
role in augmenting traditional physical
allows the ergonomic intervention phase
therapy. One must consider that if
to remain cost-effective.
ergonomic
To more adequately assess the benefits of
implemented
ergonomic intervention alone, the work
seemingly work related upper-extremity
risk assessment (RULA, Work style)
and neck symptoms, there must be a
should be performed prior to beginning a
screening mechanism to predict which
program of Physiotherapy treatment as a
patients would benefit from ergonomic
part of the initial evaluation procedures.
intervention.
workstation
Additionally, a course of ergonomic
66
and
physical
intervention
measures
for
all
were
therapy
and
to
patients
its
be
with
REFERENCES
1 Bernard BP, ed. Musculoskeletal Disorders and Workplace Factors: A Critical Review of
Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper
Extremity, and Low Back. Atlanta, GA: US Dept of Health and Human Services, Public
Health Service, Centers for Disease Control and Prevention, National Institute for
Occupational Safety and Health; 1997.
2 Fogleman M, Brogmus G. Computer mouse use and cumulative trauma disorders of the
upper extremities. Ergonomics. 1995;38:24652475.
3 Webster BS, Snook SH. The cost of compensable upper extremity cumulative trauma
disorders. J Occup Med. 1994;36: 713727.
4 Lewis RJ, Krawiec M, Confer E, et al. Musculoskeletal disorder worker compensation
costs and injuries before and after an office ergonomics program. Int J Indust Ergon.
2002;29:9599.
5 Pilligan G, Herbert R, Hearns M, et al. Evaluation and management of chronic work
related musculoskeletal disorders of the distal upper extremity. Am J Ind Med. 2000;37:75
93.
6 Marcus M, Gerr F. Upper extremity musculoskeletal symptoms among female office
workers: associations with video display terminal use and occupational psychosocial
stressors. Am J Ind Med. 1996;29:161170.
7 Korhonen T, Ketola R, Toivonen, et al. Work-related and individual predictors for
incident neck pain among office employees working with video display units. Occup
Environ Med. 2003;60:475482.
8 Sillanpaa J, Huikko S, Nyberg M, et al. Effect of work with visual display units on
musculo-skeletal disorders in the office environment. Occup Med (Lond). 2003; 53:443
451.
9 Hernandez LO, Gonzalez ST, Alcantara SM, Ramirez IM. Computer use increases the
risk of musculoskeletal disorders among newspaper office workers. Arch Med Res.
2003;34:331342.
10 Computer Workstation eTool. Occupational Safety and Health Administration Web site.
Availableat:http://www.iosha.gov/SLTC/etools/computerworkstations/
index.html.
Accessed December 12, 2013.
11 Cook CJ, Kothiyal K. Influence of mouse position on muscular activity in the neck,
shoulder, and arm in computer users. Appl Ergon. 1998;29:439443.
12 Mork PJ, Westgaard RH. Low-amplitude trapezius activity in work and leisure and the
relation to shoulder and neck pain. J Appl Physiol. 2006;100:11421149.
67
13 Marcus M, Gerr F, Monteilh C, et al. A prospective study of computer users, II: postural
risk factors for musculoskeletal symptoms and disorders. Am J Ind Med. 2002;41:236249.
14 Pallastrini P, Mugnai R, Farneti C, et al. Evaluation of two preventive interventions for
reducing musculoskeletal complaints in operators of video display terminals. Phys Ther.
2007;87:536544.
15 Hignett S, McAtamney L. Rapid entire body assessment (REBA). Appl Ergon.
2000;31:201205.
16 Price DD, McGrath PA, Rafii A, Buckingham B. The validation of the visual analogue
scales as ratio scale measures for chronic and experimental pain. Pain. 1983;17:4556.
17 Gallagher EJ, Bijur PE, Latimer C, Silver W. Reliability and validity of a visual analog
scale for acute abdominal pain in the ED. Am J Emerg Med. 2002;20:287290.
18 Calis M, Akgun K, Birtane M, et al. Diagnostic values of clinical diagnostic tests in
subacromial impingement syndrome. Am Rheum Dis. 2000;59:4447.
19 MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the
Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000; 9:299
301.
20 Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder
and hand questionnaire (QuickDASH): validity and reliability based on responses within
the full-length DASH. BMC Musculoskelet Disord. 2006;7:44.
21 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 746.
22 McPartland JM. Travell trigger pointsmolecular and osteopathic perspectives. J Am
Osteopath Assoc. 2004;104:244249.
23 Feuerstein M, Nicholas RA. Development of a short form of the Workstyle measure.
Occup Med. 2006;56:94 99.
24 OSHA W-1 Basic Screening Tool. Occupational Safety and Health Administration Web
site. Available at: http://www.iosha. gov. Accessed December 1, 2014.
25 McAtamney L, Corlett EN. RULA: a survey method for the investigation of work
related upper limb disorders. Appl Ergon. 1993;24:9199.
26 McAtamney L, Corlett EN. Rapid Upper Limb Assessment (RULA). In: Stanton NA,
Hedge A, Brookhuis K, et al, eds. Handbook of Human Factors and Ergonomics Methods.
Boca Raton, FL: CRC Press; 2004:7.17.11.
27 Amick BC, Robertson MM, DeRango K, et al. Effect of office ergonomics intervention
on reducing musculoskeletal symptoms. Spine. 2003;28:27062711.
28 Rempel DM, Wang PC, Janowitz I, et al. A randomized controlled trial evaluating the
effects of new task chairs on shoulder and neck pain among sewing machine operators.
68
Spine. 2007;32:931938.
29 Keir PJ. The effect of typing posture on wrist extensor muscle loading. Hum Factors.
2002;44:392403.
30 Ahlstrom V, Kudrick B. Human Factors Criteria for the Design and Acquisition of
Non-keyboard Interaction Devices: A Revision to Chapter 9 of the Human Factors Design
Standard (DOT/FAA/CT). Atlantic City International Airport, NJ: Federal Aviation
Administration, William J Hughes Technical Center; 2004.
31 Bernaards CM, Ariens GAM, Hildebrandt VH. The (cost-)effectiveness of a lifestyle
physical activity intervention in addition to a work style intervention on the recovery from
neck and upper limb symptoms in computer workers. BMC Musculoskel Disord. 2006;7:80
91.
32 Ahlstrom V, Kudrick B. Human Factors Criteria for Displays: A Human Factors
Design Standard Update of Chapter 5 (DOT/FAA/TC-07/11). Atlantic City International
Airport, NJ: Federal Aviation Administration, William J Hughes Technical Center; 2007.
33 Marklin RW, Simoneau GG. Effect of setup configurations of split computer keyboards
on wrist angle. Phys Ther. 2001;81: 10381048.
34 McLean L, Tingley M, Scott RN, Richards J. Computer terminal work and the benefit of
microbreaks. Appl Ergon. 2001;32: 225237.
35 Bernaards CM, Ariens GAM, Simons M, et al. Improving work style behavior in
computer workers with neck and upper limb symptoms. J Occup Rehabil. 2008; 18:87
101.
36 Chiu TT, Lam TH, Hedley AJ. A randomized controlled trial on the efficacy of exercise
for patients with chronic neck pain. Spine. 2005;30:E1E7.
37 Ketola R, Toivonen R, Hakkanen M, et al. Effects of ergonomic intervention in work
with video display units. Scand J Work Environ Health. 2002;28:18 24.
CORRESPONDENCES
BPT, MPT (Orthopaedics), Senior Physical therapist, Ahmedabad, Gujarat
69
PHYSIOTHERAPY STUDENTS EXPERIENCES OF BULLYING ON

CLINICAL INTERNSHIPS: A QUALITATIVE STUDY
Alagappan Thiyagarajan*, Prem Karthik**, Sathish Kumar***
ABSTRACT
Objectives To consider the experiences of final-year physiotherapy students who have
experienced workplace bullying on a clinical internship. Design Qualitative methodology
using individual semi-structured interviews. Setting A set of student who pursue intership
on kilpauk medical college (kmc,Chennai) Participants eight undergraduate physiotherapy
students who had experienced one incident of bullying on a clinical internship Main
outcome measures Thematic analysis of semi-structured interviews Results Four main
themes were identified: (1) external and situational influences of bullying; (2) students
reactions to the experience of bullying; (3) inability to reveal the experience; and (4)
overcoming problems. Bullying had a range of adverse effects on the students, with many
expressing self-doubt in their competence and viewing their supervisor as unapproachable
and unsupportive. Five students were not initially able to recognise the experience as
bullying. In addition, students did not feel able to report the experience and use the support
mechanisms in place. This may have been a result of having concerns that the problem
would escalate if they reported the experience and, as a consequence, have a negative
effect on their grade. Students were keen to offer a range of strategies for clinical practice
in order to prevent bullying for future generations of students. Conclusions Students
health, security and confidence in their ability as a physiotherapist can be at great risk
from bullying. Steps are needed to ensure that students are better protected from bullying,
and feel more able to address bullying behaviour during clinical internships.
behaviours such as incivility and

aggression. The literature has categorised
three types of behaviour that relate to
bullying (1) physical intimidation (such
as threats of violent behaviour); (2) workrelated behaviour (such as removing
responsibility or
overworking
an
individual);
and(3)
person-related
behaviour (such as being excluded
socially and causing personal offence to
INTRODUCTION
The Chartered Society of Physiotherapy
defines work-place bullying as any
action taken which makes another feel
intimidated, excluded or unsafe.
Evidence suggests that workplace
bullying is often a repeated, deliberate
and subtle behaviour that accumulates
over time . How-ever, the term bullying
should be distinguished from other
70
another individual). This study has

focused on the latter two types. Bullying
in healthcare settings is an international
problem,with high levels being reported
in Australia, Canada,India and the USA .
In the UK, Quine established that 37% of
community therapists had been bullied in
the previous year. This was comparable
with levels reported by junior doctors,
although higher than reports from the
Healthcare Commission . Importantly,
healthcare pro-fessionals with the least
experience, such as students, may be at
greatest risk . For instance, 25% of
physio-therapy students and around 50%
of medical students have reported being
bullied during their clinical training in
india. Bullying has a significant impact
on the organisation where it occurs,
including an impact on productivity,
financial costs and reputational costs. In
2008, it was estimated that the financial
cost of bullying and harassment to the
National Health Service (NHS) was 325
million per annum. In a work
environment where bullying occurs, it
acts as a strong reason for all individuals
to leave the job,and has a negative impact
on the victims well-being. For example,
it causes psychological distress and
psychosomatic complaints, it decreases
motivation,
job
satisfac-tion
and
performance and it has a negative effect
on the victims family .Very limited
research is available on student
physiotherapists experiences of bullying
in the workplace. Only one other study
with ours study has used a qualitative
approach with in a mixed methods study
design to investigate bullying in the
physiotherapy profession. we conducted
semi-structured interviews with five
senior physiotherapists in india, and

established that victims were often
bullied when they were in a vulnerable
position (new to the job) and did not
realise what was happening. In addition,
the bullying caused the physiotherapists
to lose confidence and blame themselves;
disturbingly, 90% of those individuals
left their job as a result of being bullied.
In summary, very limited research has
investigated bullying in the physiotherapy
profession, and, to the best of ours
knowledge, no qualitative research has
been conducted on physiotherapy
students experiences of bullying. As
such, the purpose of this study was to
investigate
physiotherapy
students
experiences of workplace bullying during
clinical placements with a view to better
protecting the future of the profession.
METHODOLOGY
Design
A single semi-structured interview was
under-taken between the primary author
and eight final-year physiotherapy
students (see Table 1 for demographic
characteristics). The semi-structured
interview questions (Appendix A, see
online supplementary material) were
formed from the literature .
Sample
The sample included eight final-year
undergraduate stu-dents (8/55; 15% of
students) reading for a Bpt degree in
physiotherapy at a tn dr.mgr medical
university. The project used a pur-posive
sampling technique, and the selection
criteria were students who were in their
final year of study and had experienced at
71
Before commencing the interviews, all

participants read the information sheets
provided and gave informed written
consent. In addition, students were given
information about how to access sup-port
from the university or counselling
services following the interview.
least one incident of bullying during a

clinical internship. The incident could
have been on more than one occasion and
at any time over the course of their study.
No exclusion criteria were used.
Procedure
An e-mail invitation was sent to all finalyear undergraduate students explaining
the project and asking for volunteers who
met the inclusion criteria. Recruitment of
participants was undertaken by the
primary author (access was likely
enhanced as the primary author was a
student at the university at the time of
data collection). Access to four
individuals was obtained by e-mail (n =
4), and an additional four students were
identified through informal face-to-face
meetings. It is not known if all students
within the cohort who met the inclusion
criteria came forward. The study was
conducted in a private room at the
primary author clinic using a digital
recorder. The interviews lasted between
10 and 33 minutes (mean 20 minutes).
ANALYSIS
After completion of the interviews, the
responses were typed up individually
using verbatim quotations. All interviews were analysed using thematic
analysis. To achieve thematic saturation,
the sample size needed to be of a
sufficient size that no new themes would
occur. There were five stages of analysis.
The first stage required the primary
author to become immersed in all eight
interviews, after which a senior
investigator critiqued and validated the
initial themes .The primary author created
a thematic map and coded each interview
using data-driven coding . The senior
investigator critiqued and developed the
codes and categories (an audit trial is
available from the primary author). The
primary author subsequently illustrated
the strength and consistency of each subtheme by undertaking a quantitative
content analysis detailing the frequencies
of
each
sub-theme
Ethics
Ethical approval was obtained from the
University ethics committee (Life and
Health
Sciences
Ethical
Review
Committee, Ref No. ERN 10-0037).
Table 1 Demographic Data

Participant
Age
Experience
bulling
of Years
experience
of Bulling location
M1
20
Icu unit
M2
22
Musculoskeletal
72
treatement area
M3
24
Leprosy unit
M4
22
Sports
physiotherapy
unit
M5
21
Paediatric
physiotherapy
unit
F1
22
Oncology lab
F2
21
Obg unit
what Im doing and I dont know what is

going wrong. He kept asking why I was
doing badly and I was like I dont know
why Im doing badly even though I
knew exactly what the reason was, it was
because I had him there constantly
putting me down, all the time. He said
thef word but it wasnt for you, it was
for this andit was wasnt for that .The
negative impact this had on their
willingness to attend placements was
tangible. For example, one student
stated:It made me feel really intimidated
which I dont think you should have to
feel, at work or at placement really. I
used to cry all the time [nervously
laughs]. There were days when I felt like,
God, I really need to look at [learn
about]ventilators for example. Id read,
and I just wouldnt absorb anything, I
was so paranoid about how I was going to
put that knowledge across [to the
educator].The three most prevalent
factors within this theme regarding
bullying were identified as: (1) perceived
pressures of the placement where the
RESULTS
Eight student physiotherapists agreed to
take part and met the inclusion criteria
(see Table 1).The incidents of bullying
experienced by the participant so ccurred
in multiple placement settings. The
majority of bul-lying incidents (75%)
occurred whilst the students were in their
second academic year. Following the
procedure out-lined in the methodology,
four main themes were identified from
the eight interviews: (1) external and
situational influences of bullying; (2)
students reactions to the experience of
bullying; (3) inability to reveal the
experience; and (4)overcoming problems.
Theme 1: external and situational
influences of bullying The students were
frequently able to recall the feeling
sattached to the perpetrator, and reported
feelings of isolation, inferiority and
unworthiness. For example, one student
could remember the experiences clearly:
He wasnt ranting and raving, but I was
frustrated, so I was like, I dont know
73
bullying occurred; (2) lack of perceived

support from the educator; and (3) a
meta-perception that the educator had a
lack of confidence in the students ability
as a physiotherapist. A number of
students articulated negative qualities of
their supervisor, including feeling that the
super-visor was not approachable.
Students were able to identify the
bullying methods used by supervisors
with explicit detail, including devaluating
comments and embarrassing situations
(see Table S1, online supplementary
material). Students were able to offer
insightful and reflective accounts of
possible contributing factors, including
conflicts in personality and their
perceived
inapproachability
and
mannerisms, such a stone of voice and
body language. Table S1 provides a full
breakdown of Theme 1, including its subthemes
residual effects are that I am full of selfdoubt. .

All up until that time Id cruised along
fine, had good marks, had great
experience but this last one seems to have
really knocked my confidence.Im going
to still try [and] get into physio but if it
doesnt workout I wont be heartbroken
now as I have this fear that if Igo in as a
rotational band 5 and I have to come
across that situation again, I am really
scared of it to be honest as I just feel like,
you know, youre there, youre trying to
learn, you dont really know what youre
doing and the person who is supposed to
teach you is a bully, it makes your life a
living hell basically (F5).Students may
have had a lack of insight into what
constitutes bullying behaviour when they
were involved in thesituations on
placement. The sub-themes in Theme 2
are listed in Table S2 (see online
supplementary material).
.Theme 2: students reactions to the

experience
of
bullying
Students
frequently
internalised
negative
cognitions of their bullying experience,
and self-doubt was identified as the main
consequence of bullying by students.
Instead of con-fronting the situation with
the supervising physiotherapist, students
appeared to interpret the bullying
behaviour as being their fault, and
would typically question their own ability
and future in the profession. Participant
F5s response illustrates the profound
impact of bullying (this student achieved
a first class honours degree):It did make
me feel like a bad physio and that I didnt
want to do it anymore and having been
away from that placement a little while, I
feel a bit better, but I would say, the
Theme 3: inability to reveal the

experience The two main reasons that
students gave for not reporting bullying
were that: (1) they did not believe it was
significant enough to be reported (five of
the eight students did not report their
experience to the university); and (2) they
were only on placement for a limited
time. Some students felt that they should
have been prepared to deal with such
situations when they arose but were ill
equipped to do so, whilst others felt that
the university had not prepared them
adequately for dealing with such
situations whilst on placement. For
instance, one student stated:I dont think
that when they [university] prepare you
for clinical placements, they dont tell
74
you if you get bullied or if you feel

someone
has
said
something
inappropriate, there outes to go down to
tell, to report it. I think half the time if
you had a problem on placement you
wouldnt want to report it anyway
because thats going to affect [your
mark]. . . you dont want to annoy the
person even more whos marking you
(F6).The majority of students suggested
that the best solution to dealing with
bullying was to ignore it. This meant that
theperpetrator would not be confronted
by the student, university or hospital.
Students were very clear on why they
would not reveal such incidences;
primarily, a number of students believed
that revealing problems could have a
negative impact on their mark and would
cause further friction between them and
their educator. In a similar way, some
students believed that the problem would
escalate if they contacted the university,
and feared what would happen if formal
proceeding stook place. However, a
perceived lack of action following
disclosure prevented one student from
reporting the incident of bullying.The
sub-themes in Theme 3 are listed in Table
S2 (see online supplementary material).
university] should maybe do a sort of

mediation between you and your educator
so that they can sit down and see and
have an honest grown up conversation
.The full content of Theme 4 is illustrated
in Table S2.
DISCUSSION
This research examined final-year
physiotherapy students experiences of
bullying during clinical placements. All
students identified two work-related types
of bullying, including the perception of a
highly pressurised environment on the
clinical internship and a lack of support
from their supervisor. An air of
inevitability and acceptance of the
bullying behaviour was identified through
the students responses, with some
students feeling that they had to grit their
teeth and get through the placement.
Five students failed to report this
experience to their visiting tutor from the
university, and most students did not feel
adequately prepared to deal with the
situation. In most cases, the bully was the
students clinical supervisor. Lived
experiences of bullying and reactions to
that experience: The experiences of
bullying identified in the present study
mirror the experiences identified in
previous research. The current research
was able to identify the personal nature of
bullying both directly and indirectly .A
number of students reported that they had
a difficult relationship with their
educators and they were often
unapproachable;
this
has
been
acknowledged previously in other
healthcare professionals. Some students
were aware of the pressurised
environment that may contribute to some
Theme 4: overcoming problems Students

believed that implementing a procedure
for dealing with problems was the best
strategy for overcoming difficulties. This
was closely followed by education to
increase awareness of bullying and
promote better communication skills.
Suggestions for dealing with problems
included a support system that feels
accessible to the student. For example,
one student stated:I think they [the
75
forwards: The current research illustrates

several important points that need
consideration:
types of bullying behaviour (e.g. unfair

criticism), meaning that they recognised
the bullys situation or that the bully may
be unaware of their behaviour. This has
been reported previously. In addition, it is
possible that some behaviour may relate
to the organisation and be blamed
inappropriately on the bully Thus, it
appears important for clinical educators
to consider the types of verbal and nonverbal communication that are associated
with or perceived by the student as
bullying. It is important for super-visors
to understand the difference between
supervision that is destructive and
undermines the student, and supervision
that is constructive and supportive to the
student. With in this context, it is
important to note that highly performing
individuals are often the target of a bully
.Thus, the potential to damage highly
talented students is great.
(1) Appropriate pathways are needed

where an open discussion about bullying
can take place. This has been successful
for other health-related professions.
(2) Clinical educators must consider the
effects of being a role model to
impressionable learners .
(3) A three-way partnership involving
clinical training sites, universities and
professional bodies is required to ensure
that students learning and professional
engagement is protected . Research has
highlighted that students who feel that
adequate support or policies are lacking
are at greatest risk. It is important to
acknowledge that victims who are able to
report bullying experiences can be left
dissatisfied with the outcome. This often
acts to prevent further reporting by them
and others .At an organisational level,
NHS trusts and universities should have
policies and procedures that address the
issue
of
workplace
bullying
comprehensively
Reasons why students did not report the

bullying experience and suggestions to
overcome bullying: There is a tendency
for bullying experiences to be
underreported in the, specifically among
student physiotherapists [3]. When faced
with a serial bully, even competent
healthcare professionals do not speak up
because of the fear of reprisal or the fear
that management will be unable to
respond to a grievance procedure [20]. In
the current study, many of the bullies
were responsible for assigning a clinical
mark to the students, and this influenced
willingness to identify the bullies. This is
an aspect that needs further consideration
through policy.
(4) Whilst nursing students are educated

to deal with bullying and harassment, no
current guidelines dictate the same within
physiotherapy education.
Limitations of study This study has
several limitations. The main limitation
was that it was not possible to investigate
and consider why the bullies initiated
their behaviour towards their students
.Thus, there is a need to hear from these
clinicians, identified as bullies, in order to
gain a more detailed understanding of this
Suggestions to overcome bullying and

strategy for the profession going
76
consideration from institutions that train

physiotherapists and their NHS partners.
Importantly, each student must believe
that the university will tackle the problem
in a thorough, professional and
confidential manner, and that the
reporting of such incidents will not affect
their grades.
issue. Secondly, it was difficult to

establish if theoretical saturation had
occurred, although given the focus of the
topic and support from previous studies,
further findings with in the scope of this
research seem unlikely. Third, this
research focused on a sensitive topic and
people with other experiences may be
reluctant to participate. Finally, all
interviews were conducted at one
university, and it is not known whether or
not the results are relevant to a wider
population.
Ethical approval: University ethics

committee,dr.mgr
medical
university,chennai (Ref. No.ERN 100037).
Funding: This project was self funded
CONCLUSION
Conflict of interest: None declared
This study found that bullying can have

profound and adverse effects on the
health of physiotherapy students. Most
respondents felt unprepared when dealing
with bully-ing, and did not communicate
their experiences directly to the
university. This situation requires further
Appendix A. Supplementary data

Supplementary data associated with this
article can befound, in the online version,
at
http://dx.doi.org/10.1016/j.physio.2013.0
6.005.
REFERENCES
[1] Chartered Society of Physiotherapy. Dealing with bullying: a guidefor physiotherapy
students on clinical placement. London: CharteredSociety of Physiotherapy; 2010.
[2] Hutchinson M, Vickers M, Jackson D, Wilkes L. Workplace bullyingin nursing:
towards a more critical organisational perspective. Nurs Inq2005;13:11826.
[3] Stubbs B, Soundy A. Physiotherapy students experiences of bul-lying on clinical
internships: an exploratory study. Physiotherapy2013;99((June) 2):17880.
[4] Bartlett JE, Bartlett ME. Workplace bullying: an integrative literaturereview. Adv
Develop Hum Resour 2011;13:6984.
[5] Trpanier S-G, Fernet C, Austin S. Workplace psychological harass-ment in Canadian
nurses: a descriptive study. J Health Psychol2012;18:38396.
[6] Scott JBC, Child S. Workplace bullying of junior doctors:cross-sectional questionnaire
survey. NZ Med J 2008;22:104.
77
[7] Askew DA, Schluter PJ, Dick ML, Rgo PM, Turner C, WilkinsonD. Bullying in the
Australian medical workforce: cross-sectional datafrom an Australian e-Cohort study. Aust
Health Rev 2012;36:197204.
[8] Crutcher RA, Szafran O, Woloschuk W, Chatur F, Hansen C. Fam-ily medicine
graduates perceptions of intimidation, harassment, anddiscrimination during residency
training. BMC Med Educ 2011;11:88.
[9] Bairy KL, Thirumalaikolundusubramanian P, Sivagnanam G,Saraswathi S,
Sachidananda A, Shalini A. Bullying among traineedoctors in Southern India: a
questionnaire study. J Postgrad Med2007;53:8790.
[10] Daugherty SR, Baldwin Jr DC, Rowley BD. Learning, satisfaction, andmistreatment
during medical internship: a national survey of workingconditions. J Am Med Assoc
1998;15:11949.
[11] Quine L. Workplace bullying in NHS community trust: staff question-naire survey.
BMJ 1999;318:22832.
[12] Quine L. Workplace bullying in junior doctors: questionnaire survey.BMJ
2002;324:8789.
[13] Peacock L. Violence against NHS staff fails to decline, staff surveyreveals [online];
2009
http://www.personneltoday.com/articles/25/03/2009/49996/violence-against-nhsstaff-fails-to-decline-staff-survey-reveals.htm [Last accessed 25/09/13].
[14] Rippon TJ. Aggression and violence in healthcare professionals. J AdvNurs
2000;31:45260.
CORRESPONDENCES
*MPT (Sports), PhD scholar Singhania University; Consultant Sports Physiotherapist- First
Step Physiotherapy Clinic
**MPT (Orthopaedics), Consultant Physiotherapist- Physiofix Physiotherapy Clinic
*** BPT, Pursuing MPT (Ortho), Student- Adhiparasakthi College of Physiotherapy;
Physiotherapist: Get Fit Physiotherapy Clinic
78
RELATIONSHIP BETWEEN BALANCE AND QUALITY OF LIFE IN

ELDERLY WITH VERTIGO OF VARIOUS CAUSES
Nitika Anand*, Sunil Bhatt*
ABSTRACT
Vertigo is an illusion of movement, either of oneself or the environment. The aim of our
study is to assess the relationship between balance and quality of life in vertigo
patients and also to identify the elderly with vertigo who are at risk of falls. 34 elderly
subjects with vertigo were included. Dizziness handicap inventory (DHI), Berg balance
scale (BBS) and SF-36 quality of life (QOL) scales were the outcome measures. A
significant correlation was found between DHI and BBS, BBS and falls and between
falls and QOL of BPPV patients, athough no correlation was there between other
variables. Elderly patients with vertigo have balance impairments, reduced quality
QOL and are at the risk of falls. Patients with BPPV were at higher risk of falls as
compared to others and so these patients present a lower QOL.
Keywords: Vertigo, dizziness, balance, elderly, falls, berg balance scale, BPPV
INTRODUCTION
disequilibrium (tendency to fall), and
Vertigo is defined as an illusion or
presyncope
hallucination
increase is directly proportional to the
of
movement,
usually
presence
rotational or horizontal, either of oneself
(light-headedness).2
of
multiple
Age
neurotological
symptoms associated with body balance,
multisensory syndrome when originating
such as vertigo and other dizziness,
in the vestibular system; it is often sub
hearing loss, tinnitus, changes in body
classified into peripheral or central
balance, gait disorders and occasional
vertigo and termed neurological vertigo.
falls,
The most prevalent diseases classified
experience vertigo have reported that its
under vestibular vertigo are benign
symptoms cause frustration, disrupt their
paroxysmal positional vertigo (BPPV),
normal activities, and profoundly and
Meniere disease, vestibular neuritis, and
negatively impact their health-related
migraine-associated vertigo. Dizziness is
quality of life.4Vestibular deficits, central
described as unsteadiness, imbalance,
neurologic deficits, and gait disturbances
or the
environment.1
Vertigo
is
79
among
others.3
Patients
who
can place a patient at significant risk of
Exclusion criteria- Subjects with history
falling, with potentially life-threatening
of cardiopulmonary complications
sequelae.5
-Subjects
The
falls
are
strongly
with
uncontrolled
seizure
associated with a drop in physical skills,
disorder as diagnosed
which follows the individuals aging pro-
-MMSE<23
cess,
-Any other known neurological disorder
functionally
represented
by
reduction or loss of the skills to execute
Outcome Measures-
daily functions and demands when facing
i. Dizziness Handicap Inventory
environmental challenges and affecting
(DHI)-
the quality of life of an individual.3
Inventory (DHI), a 25-item self-
Although, falls and balance both may
report
influence the quality of life of a vertigo
rationally
individual. But, there are no studies
designed
known to us which assess the relationship
emotional, and physical disability
between balance and quality of life in
associated with vestibular disturbance
elderly vertigo patients with various
ii. Berg Balance Scale (BBS) It is
causes.
a 14- item scale designed to measure
The
Dizziness
questionnaire
derived
to
Handicap
with
three
subscales,
measure
is
functional,
balance of the older adult in a clinical

METHODS AND
setting. The BBS has high inter rater
METHODOLOGY
reliability 0.76
Sample- Total 34 patients were taken
.iii. SF-36- It is one of the most
from various hospitals and clinics in
widely used of the health-related
delhi and Dehradun.
quality of life measures. It contains

36 items based questions used in the
Study Design- A correlational study
RAND health insurance study. It has
Inclusion criteria- Age- 50 years
high
and above
(correlation coefficients ranging from
-Both genders
0.81 to 0.88).
-Subjects diagnosed with vertigo with
Procedure- Subjects were selected on the
any known cause by the general
basis of inclusion and exclusion criteria.
practitioner, ENT specialist or
An informed consent was duly signed and
neurologist
proper explanation was given about the
80
reliability
and
validity
procedure and appropriate instructions
The DHI and BBS showed significant
were given while the performance of the
results as p <0.05. There was a negative
scales. Then, one by one each subject was
correlation between the two variables.
evaluated on DHI, SF-36 and then BBS
This depicts that when there will be high
scoring was done. After the completion of
scores on DHI the patient will have low
both the scales and administration of
scores on BBS i.e. patient will be
BBS, total scores were found. After
severely
evaluating the scores, correlation was
impairments.
done between DHI and BBS, DHI and
The correlation between DHI and SF36
SF-36, DHI and falls and BBS and falls.
and DHI and falls all showed non-
Then, patients with individual vertigo
significant as p>0.05 showing that falls
cause i.e. BPPV (A), cervical spondylitis
does not affects QOL in elderly with
(B) and others (C) were categorized.
vertigo of various causes and the scales
Again correlation was done in between
assessing QOL were not correlated.
DHI and BBS, DHI and SF-36 and DHI
There
and falls in individual cause of vertigo.
between BBS and falls as p<0.01. There
handicapped
was
with
significant
balance
difference
was a negative correlation between both

DATA ANALYSIS
of them i.e when the scores of the BBS
Data was analyzed using SPSS version
would be high the probability of falls
17.0.The statistical significance was set at
would be low and conversely when BBS
0.05 at 95% confidence interval.Pearson
scores would be low the probability of
correlation test was used for the data
falls would be high.
correlation between DHI and SF-36, DHI
Table
and BBS, DHI and falls and BBS and
falls
vertigo.
RESULTS
The mean and standard deviation of age,
DHI, BBS, SF-36 and falls were 58.44
29.7013.20,
Mean
and
Standard
Deviation of age, DHI, BBS, SF36 and
falls in overall and individual causes of
9.26,
No.1-
47.978.411,
67.865.73, 0.610.98, respectively.
81
were also not correlated in BPPV

patients. But, there was a good negative
correlation
between
QOL and
falls
signifying that the falls affects the quality

of life. The increase in number of falls
will reduce the quality of life.
Table No4- Correlation between DHI(A)
and BBS(A), DHI(A) and SF36(A) and
DHI(A) and falls(A)
Table No2- Correlation between BBS and

falls and DHI and falls
There was no significant difference

There was no significant difference
(p>0.05) between DHI and BBS, DHI
(p>0.05) between DHI and BBS and DHI
and SF36 and DHI and falls in patients
and SF-36 in
with vertigo due to cervical spondylitis
BPPV (A) patients,

significant
(B) and other causes(C). This shows that
difference (p<0.05) between DHI and
balance and falls does not affect the
falls in BPPV patients. It shows that the
quality of life of patients with cervical
balance does not affect quality of life in
spondylitis and other known vertigo
patients with BPPV. Both the QOL scales
causes. Both the QOL assessing was not
although
there
was
82
correlated with each other.
know that the specific instruments usually

provide different assessment of health
Discussion
when compared to generic measures. This
The purpose of our study was to find out
difference has generally been assumed to
the correlation between the quality of life
be due to the content of the disease
and balance in the elderly patients with
specific questions and their focus on
vertigo of various causes. The hypothesis
disease specific problems, which are not
of our study was that there may be a
reflected in more global generic measure.
correlation between balance and quality
This can be due to the framing of the
of life in
patients.
question. Specific measures of health
Different variables of quality of life and
related quality of life (HRQOL) focuses
balance were used and were correlated in
on the aspects of the condition that are
the elderly patients with vertigo of
important to patient. For e.g. In DHI
various causes and then the variables
patient is asked Because of your
were correlated in individual cause of the
problem do you restrict your travel for
vertigo.
business or recreation? whereas SF-36
elderly vertigo
states that During past 4 weeks, how
DHI and SF -36-The results of our study
much time your physical health or
showed that there is no correlation
emotional problems interfered with your
between the two scales and both of them
social activities (like visiting friends,
assesses the different aspects of an
relatives etc)? In DHI patient may
individual so; both scales should be
answer accordingly only when he gets the
administered separately in elderly vertigo
attack of vertigo, whereas in SF 36 he
patients of different causes. Duracinsky et
may answer that after he may get
al6 in their study stated that DHI is
improved he does not restrict his social
regarded as a reference questionnaire,
life. So framing and wording makes a
because the questionnaire items seen
patient interpret the things differently.
relevant to the context of symptoms.
This makeup of the questionnaires i.e.
Generic QOL questionnaires such as SF-
framing and wording of DHI and SF 36
36 may not be sensitive enough to detect
would have led to the in significant
changes, as they fail to capture the
results in our study.
specific impact of vertigo/dizziness. The

reason for these results could be, we
DHI and BBS As already stated DHI is a
83
specific questionnaire for QOL in vertigo
performance appears to be closely related
patients.
to disability in individuals with bilateral
The
BBS
is
balance
assessment tool. The results or our study
vestibular
hypofunction
showed that there is a weak negative
compared
to
correlation between DHI and BBS in
vestibular hypofunction (UVH). Jacobson
overall various causes of vertigo patients.
et al8 also showed similar results that
This means that balance can affect QOL
there are significant correlations between
of vertigo patient. If the scores on the
DHI and sensory organization. Birgul and
DHI will be high, then the scores on BBS
Gulden9 saw that vestibular rehabilitation
will be low, depicting that the patient will
can significantly improve scores on BBS
be more handicap and will have balance
and DHI in patients with unilateral
impairment. With converse, low scores
peripheral vestibulopathy.The results of
on DHI and high scores on BBS will
our
depict that patient will be less handicap
differences between DHI and BBS in
and will have less balance impairments.
individual causes of vertigo i.e. BPPV,
Vertigo
of
cervical spondylitis and others. The
vestibular origin are most common
possible reason for this could be the
disorders.
objective
smaller samples in individual causes of
symptoms of damage of the labyrinth are
vertigo in our study. These results go in
reduced in the process of vestibular
accordance with the studies done by other
compensation.
researchers.
and
balance
Subjective
It
disorders
and
results
from
study
those
showed
Robertson
(BVH)
with
no
as
unilateral
significant
and
Ireland10
spontaneous activity of other subsystems,
found no correlation between DHI scores
which
and
balance.
are
engaged
Visual,
in
maintaining
vestibular
Computerized
Dynamic
and
Posturography and suggested that this is
somatosensory signals coming from those
because of the desychrony between signs
subsystems are constantly analyzed in
and symptoms that may be related to
CNS which can affect the balance of
underlying
vestibular dysfunction patient and this
differences in coping strategies.
may affect the quality of life of the
and
and
showed that there is no correlation
results of Gill et al7 who concluded that

impairments
anxiety
DHI and Falls The results of our study
person. Our results were similar to the
balance
patient
between DHI and falls in overall vertigo
functional
patients. The reason for this could be that
84
patient may always not be in a motion
low fall risk and in contrast patient who
while getting an episode of vertigo.
score low BBS scores have a high
Similarly, in case of cervical vertigo in
probability of falls. It has been already
which vertigo only occurs when there is a
proved in several studies that BBS is a
compression on vertebral artery on neck
good predictor for falls. Berg et al12
movements, the patient may not always
showed the use of BBS for predicting
be rotating his neck and may not get a fall
multiple falls in community dwelling
which ultimately do not affect his quality
elderly people. Shumway cook et al13 also
of life. . Gazolla et al11 observed that
concluded that BBS can be used to
recurrent
the elderly with
quantify fall risk in community dwelling
vestibular disorders are those statistically
older adults. Cheryl Hawk et al14 also
more associated with the onset of vertigo,
used BBS as a assessment of balance and
while a single fall is more associated with
risk for falls in community dwelling
slipping. The motor tasks developed by
adults aged 65 and older.The BBS
the elderly with vestibular disorders at the
involves the components which are used
time of fall, followed by walking, going
in daily activities such as sit to stand,
up and down stairs, postural transfer
standing unsupported, bending down etc.
activities and taking a shower frequently
The aging process affects all postural
involves rotations or hyperextension of
control components - sensorial (visual,
the head, which can cause vertigo and
somatosensorial and vestibular), effector
positional nystagmus in patients with
(strength, range of motion, biomechanical
BPPV, which can result in fall. Although
alignment,
flexibility)
in the case like cervical vertigo where the
processing.
The
vertigo only comes when there is a
different body systems under central
pressure on the vertebral artery, the
command is critical for body balance
patient does not always hyperextend his
control. The performance of such systems
neck, so chances of falls reduces.
has a direct impact on the individuals
falls
in
good
negative
of
the
functional capacity and makes him
between BBS and falls was seen, we

a
integration
central
capacity to perform daily tasks, his/her
BBS and Falls When the correlation
found
and
susceptible to falls.
correlation
between them. This suggests that patients
Limitations of the study
who score high on BBS have a relatively
85
The sample size was very small. No
present a lower quality of life. Based on
correlation was found between DHI and
relatively low correlations, the DHI and
SF-36.
the SF-36 appear to provide different but

complementary information about the
Conclusion
health status of patients with vestibular
It can be concluded that, elderly patients
dysfunction. Also the balance impairment
with vertigo of various causes have
results in falls which affects quality of
balance impairments, reduced quality of
life in elderly vertigo patients. So, a
life and are at the risk of falls. It was seen
proper intervention should be planned to
that patients with BPPV was higher at the
decrease
risk of falls as compared to others and
improve balance and to increase the
because of falls these group of patients
independence in daily activities.
the
symptoms
of
vertigo,
REFERENCES
1. Hanley K and Dowd TO. Symptoms of Vertigo In General Practice: A Prospective Study
Of Diagnosis. British Journal Of General Practice.2002 Oct;52:809-812
2. Mundhenke M. Vertigo: A Clinical Problem in Clinical Practice. Journal Of Biomedical
Therapy.2010;4(2):17-21
3. Gananca F.F et al. Elderly Falls Associated With Benign Paroxysmal Positional Vertigo.
Brazilian Journal Of Otorhinolaryngology.2010 Feb;76(1) :113-20
4. Roberts Richards A, Abrams H. Utility Measures Of Health-Related Quality Of Life In
Patients
Treated
For
Benign
Paroxysmal
Positional
Vertigo.Ear
And
Hearing.2009;30(3):369-376
5. Macias JD, Massingale S, Gerkin RD. Efficacy of Vestibular Rehabilitation Therapy In
Reducing Falls. Otolaryngology-Head And Neck Surgery.2005 Sep;133(3):323-325
6. Durancisky M et al. Literature Review of Questionnaires Assessing Vertigo and
Dizziness and Their Impact on Patients Quality Of Life. International Society For
Pharmacoeconomics And Outcome Research.2007;10(4):273-284
7. Gill Body KM, Berninato M, Krebs DT. Relationship among Balance Impairments,
Functional Performance and Disability in People with Peripheral Vestibular Hypofunction.
Physical Therapy. 2000 Aug;80(8):748-758
8. Jacobson GP, Newman CW. Balance Function Tests Correlates Of The Dizziness
Handicap Inventory. J AM Acad Audiol.1991 Oct;2(4):253-260
86
9. Giray M Et Al. Short Term Effects of Vestibular Rehabilitation In Patients With Chronic
Unilateral Vestibular Dysfunction: A Randomized Controlled Study. Arch Phys Med
Rehab.2009 Aug;90:1325-51
10. Robertson DD, Ireland DJ. Dizziness Handicap Inventory Correlates or Computerazed
Dynamic Posturography. Jorrnal Of Otolaryngology.1995 Apr; 24(2): 118-24
11. Gazzola JM, Perracini MR, Gananca MM, Gananca FF. Functional Balance Associated
With Chronic Vestibular Disorder. Rev Bras Otorrinolaringol.2006 Sep-Oct;72(5):83-90
12. Berg KO, Muir SW, Chesworth B, Speechley M. Use Of Berg Balance Scale For
Predicting Multiple Falls In Community Dwelling Elderly People: A Prospective Study.
Physical Therapy. 2008 April;88(4):449-459
13. Shumway Cook A, Baldwin M, Polisar N, Gruber W. Predicting The Probability For
Falls In Community Dwelling Older Adults. Physical Therapy. 1997 Aug; 77(8): 812-819.
14. Cheng Y.Y et al. Anxiety, Depression and Quality Of Life (QOL) In Patients With
Chronic Dizziness. Archives Of Gerontology And Geriatrics.2011 May
CORRESPONDENCES
*Lecturer, Department of Physiotherapy, Dolphin (PG) Institute of Biomedical and Natural
Sciences, Dehradoon. Email: physionitikajain@gmail.com
**Assistant professor, Department of Physiotherapy, Dolphin (PG) Institute of Biomedical
and Natural Sciences, Dehradoon. Email: physiocaresunil@gmail.com
87
EFFECT OF SMOKING ON ATTENTION AND MEMORY IN

YOUNG ADULTS: A DESCRIPTIVE STUDY
Sunil Bhatt*, Jagun Tomar**, Money Rajput***, Udaykant Yadav****
ABSTRACT
Cigarette smoking is a prominent risk factor for a wide range of diseases. Present
literature is inconsistent in explaining how smoking influence the cognitive functions.
Objectives: We aim to evaluate the attention and memory in smokers and compare that
with those of non-smokers. Methods: Descriptive study. 50 subjects aged 18 to 28 years
were enrolled for study based on inclusion and exclusion criteria from educational institute
in Dehradun. Rating scale of attentional behaviour (attention and memory) and stroop task
of all subjects was measured. The assessor was blinded regarding the smoking habit of the
subjects. Results: the results for memory and attention scale did not show significant
difference between smokers and non-smokers. But there was significant difference in stroop
task between these groups. Conclusion: Immediate memory and attention is significantly
affected in smokers compared to non-smokers.
Keywords: Smoking, attention, memory, stroop task
INTRODUCTION
experimentation with tobacco, including
Tobacco use is the leading cause of
advertising and other forms of promotion
preventable death worldwide, killing
of tobacco and tobacco brands, is a
nearly six million people every year. Half
critical public health priority.[1]
of all regular smokers die prematurely as
According to the WHO Global Report on
a consequence of their smoking, and
"Tobacco Attributable Mortality" 2012,
smokers have an average life expectancy
seven percent of all deaths (for ages 30
10 years lower than non-smokers. Since
and over) in India are attributable to
more
first
tobacco. Within communicable diseases,
experiment with and become addicted to
the deaths attributed to tobacco use
smoking in their teenage years, protecting
accounted for 5 percent of all deaths
children
caused by lower respiratory infections
than
and
80%
of
young
smokers
people
from
exposures that increase the likelihood of
and 4 percent of tuberculosis deaths.
88
The Report on Tobacco Control in India
for dementia in the elderly.There is also
(2004) said that nearly 8-9 lakh people
evidence to suggest that its impact on
die every year in India due to diseases
adverse cognitive outcomes, including
related to tobacco use. It says that up to
dementia, may have been underestimated
one in five deaths from tuberculosis (TB)
due to selection effects as a result of
could be avoided if TB patients did not
greater mortality among smokers in
smoke.[2]
midlife.The extent to which smoking

increases the risk of cognitive decline
Cigarette smoking significantly increase
remains unclear.[4]
the risk of heart disease, lung cancer and

microbial infection (such as respiratory
Posner and Boies 1971, suggested that
infection,periodontitis
bacterial
attention
is
also
orienting to sensory events, detecting
associated with delayed recovery from
signals for focussed processing and
injuries and a higher incidence of
maintaining a vigilant or alert state.[5]
atherosclerosis,
Working memory capacity (WMC) acts
meningitis
and
).Tobacco
use
chronic
obstructive
has
three components
i.e.
disease,
as a kind of scratch pad for temporary
rheumatoid arthritis and cancers of lung,
recall of the information which is being
mouth, larynx, esophagus and bladder.
processed at any point in time. [6]
Children
sensitive
Working memory is defined as a system
tobacco
smoke
pulmonary
disease,
crohns
to
environmental
increasing
that assists in the temporary (<10 s)
evidence of respiratory infection bacterial
holding and manipulation of information
meningitis and development of atopy and
(Baddeley
asthma during childhood. A large body of
demonstrating an association between
literature now exist on the consequences
working memory capacity (WMC) and
of cigarette smoke inhalation on the
executive
human immune system.[3]
accumulated. In tasks of visual selective
shows
1999).
attention
Research
findings
capabilities
have
attention, individuals with high WMC are

The
number
of
dementia
cases
typically more effective at selectively
worldwide, estimated at 36 million in
attending to relevant, and overcoming the
2010, is on the rise and projected to

double
every
20
years.Smoking
influence
is
of
irrelevant
information,
compared to individuals with low WMC.
increasingly recognised as a risk factor
Low WMC individuals are more prone to

89
interference from the irrelevant attribute
orienting is concerned with the directing
of the stimulus than those with high
of attention, and executive function is
WMC.Engle,
(2003)
associated with response inhibition and
reported that people with high working
filtering out unnecessary information.
memory capacity show more flexible
Similarly, working memory, a system that
allocation of the focus of visuospatial
assists in the temporary holding and
attention compared to those with low
manipulation of information, can be
working memory capacity. [7]
divided into subsystems: the central
and
Khanna
executive, the verbal loop, and the visual
Memory is the process of maintaining
sketchpad (Baddeley, 1999). Specifically,
information over time. (Matlin, 2005)
the verbal
Memory is the means by which we draw
information
(Sternberg,
in
1999).
the
is
responsible for
maintaining verbal stimuli and the visual
on our past experiences in order to use

this
loop
sketchpad deals with the maintenance of
present
visual stimuli. [10]
[8] Retrospective
memory is where the content to be
It has been suggested that the cholinergic
remembered (people, words, events etc)
activity in the brain is pivotal for certain
is in the past, i.e the recollection of past
aspects of attention and only determines
episodes. Prospective memory is a term
the efficacy of learning and memory
which refers to the memory to perform an
through
intended action at a particular point in the
process.[Prompt
future. Thus, prospective memory can be
Nicotines ability to enhance cognitive
described as the delayed execution of an
processing
intended action. [9]
understanding of the role of cholinergics
subsystems:
be
alerting,
divided
into
orienting,
and
acetylcholine,
to
greater
dopamine,
serotonin,
glutamate and other neurotransmitters

known to be involved in cognitive
Peterson; 1990). Alerting is related to

sustained
led
inefficient]
brain and facilatates the release of
Sommer, Raz, & Posner, 2002; Posner &
and
but
attentional
acetylcholine receptors (nAChRs) in the
executive function (Fan, McCandliss,
vigilance
in
Nicotine binds to pre-synaptic nicotinic
selection of stimuli from the surrounding

can
has
role
mechanism in cognitive functioning.
Attention, a system that modulates the
environment
its
processes.[11]Nicotine has been shown to
attention,
improve both memory and attention when

90
motor
study. The need of the study was
responses but also slows down perceptual
explained to all the participants and a
processing speed when assessed using
verbal consent was taken prior to the
accuracy-based measures of cognitive
study.
performance.[12]
demographic information, information
assessed
through
speeded
Baseline
assessment
like
regarding smoking pattern, frequency of

This study aims to evaluate the memory
headaches (except fever and migraine),
and attention abilities in smokers.
frequency of upper/lower respiratory tract

infection in last 1 year, food habits,
METHODOLOGY
involvement in physical activities, any

The
study
educational
was
conducted
institute
in
at
an
history of insomnia or sleep disturbances
Dehradun.
were recorded. Then the participants were
Descriptive design was adopted for the
asked to fill the assessment form related
study. A total of 65 subjects were
to attention and memory.
investigated for the study and 50 subjects

aged 18 to 28 years met the inclusion
The participants then took the stroop task.
criteria and were enrolled for the study.
The stroop task is the most frequently
Out of 50 subjects, 25 were smokers and
used
25 were non-smokers The inclusion
functioning. It measures the ability to
criteria
cigarette
focus attention on releveant stimuli while
smoking not less than 2 years, smoking
ignoring distractors and to supress a
atleast 5 cigarettes daily, the participant
prepotent response (i.e. word reading) in
must not have consumed alcohol at the
favor of an atypical one (i.e. color
time of data collection, normal to
naming) (Stroop 1935). Performance is
corrected normal vision, no prior history
measured
of neurological and psychiatric diseases
reaction time, RT) and or accuracy; and
and willingness to participate in the
specific deficiencies in attention are
study. Participants with history of chronic
reflected in a Stroop effect which
alcoholism, on anti-depressant or anti-
indicates the degradation in performance
epileptic drugs, participants who quit
caused by interference in the incongruent
smoking since last 6 months, participant
condition (e.g.. the word red displayed in
undergoing
misuse
blue).[13] For the stroop task, the patient
rehabilitation were excluded from the
was seated on a chair comfortably and
for
smokers
were
substance
91
measure
by
of
inhibitory
response
control
latency
(i.e
then a video of stroop task (71 seconds in
an objective to determine the relationship
length, each slide was 2 seconds in
of the effects of smoking on attention and
length) was played on a laptop. The
memory.
laptop was placed at the level of eye of
A total of 50 individuals were enrolled
the participant at a comfortable distance.
for the study (25 smokers and 25 non-
The error was calculated on the basis of
smokers). The mean age of smokers were
late response, identified wrong color and
23 2.14 years while the mean age of
no response. The stroop task was
non-smokers were 21.7 2.28 years.
performed thrice and the best of three

readings were taken for the study.
The
assessment form related to memory had

questionnaires
related
to
Table 1 : Memory and Attention in
both
Smokers and Non-Smokers
retrospective and prospective memory,

while the attention questionnaire included
focussed attention and divided attention.
DATA ANALYSIS
The data obtained after study was
analysed by using SPSS 11.5 software
packages. Statistical measures like mean,
standard deviation and percentages were
used. Only the data of the participants
who completed the stroop task were
Fig 1 : Errors percentage for Stroop task
included. Error rates, calculated as the per
in non-smokers
cent of incorrect responses of the total

trials, were analyzed separately. The data
between the smokers and non-smokers
were then compared.
RESULTS
This descriptive study was conducted in
an educational institute in Dehradun with
92
Fig 1 illustrates error percentage in non-
diffference between both the groups
smokers. 55 per cent of participants
(Smokers and Non-smokers).The Stroop
showed 0 error, 28 per cent showed 1
task percentage was calculated on the
error, 12 per cent showed 2 errors and 6
basis of minimum to maximum error(s)
per cent showed 3 errors.
performed .
The mean value of attention in smokers
DISCUSSION
and non-smokers is 25.9 8.21 and 26.0
The
7.8 respectively. While, the mean value
effect
of
performance
of memory in smokers and non-smokers
difference
were found to be 16.56 5.0 and 19.28
smoking
showed
for
on
task
significant
attention
in
smokers
compared to the non-somkers..This may
6.4 respectively.
be due to the interaction of nicotine with
Fig 2: Errors percentage for Stroop task
its receptor so we suggest that the normal
in Smokers
physiological
response
of
nicotine
influence the function of central nervous

system. Nicotine from the cigratte smoke
enter the brain and interact with nicotinic
receptor in the brain ; activation of
nicotinic receptor could modulate the
immune response by either of two
pathways :(a) Activation of hypothalamus
pituitary
adrenal
axis
whereby
the
corticotropin releasing hormone fron the

hypothalamus stimulates the release of
adrenocorticotropic homones from the
pituitary gland which in turn stimulate the
Fig 2 illustrates error percentage in
production of glucocorticoid by the
Smokers. 4 per cent of participants
adrenal
showed 0 error, 48 per cent showed 1
gland.
glucocorticoid
error, 32 per cent showed 2 errors and 16
system.(b)
per cent showed 3 errors.
Increase
suppress
Activation
the
of
level
of
immune
autonomic
nervous system which connect the brain

directly to the visceral target tissue
The Stroop task result shows significant
93
including
lymphoid
tissue
sympathetic
and
innervation.
Noradrenaline
towards the higher side. This was due to
through
increased
parasympathetic
chances
of
filling
the
from
questionnaire on the lower side by the
might
smokers to show no variations in the
through
result as compare to the non-smokers.
adrenoceptor that are present on T-
However, memory is affected as related
cell.[2]
in
sympathetic
modulate
nerve
T-cell
terminal
function
smoking and declined brain function has
attention
long
increase the person responsiveness to the

to
perform
thus
supports
response
time
denicotinized
exhibited
more
than
cigarettes.
attentional
Impaired
but
not
memory,
fully
for
smoking related diseases, such as cancer,

heart
response time in smokers.[14]

cigarettes
known,
example, is a common symptom of
which show that there is increased
nicotine
been
understood.
the
attentional interpretation of the findings
Smoking
the
non-smokers. The connection between
that there is lack of self-focused attention
task
in
much faster rate of memory loss than
task by the smokers it is due to the fact
self-focused
published
that smokers over the age of 40 have a
numbers of errors on performing stroop
smoker.As
Research
American Journal of Public Health shows
In our study we also found more
in
the
disease,
stroke,
bronchitis,
emphysema and asthma. Other studies

reduced
have shown smokers to have much
smoking
greater difficulty remembering names and
Smokers
faces. But
Richards
and
his
toward
colleagues suspect that its high blood
smoking
pressure, a common side effect of
reduced response time but had no specific
smoking, that may cause brain damage,
effect
The
early signs of dementia and subsequent
performance boost may contribute to a
memory loss. Another possibility is that
smokers impression that resumption of
toxic chemicals in cigarette smoke could
smoking reverses performance deficits
also be the cause of direct damage to the
induced by abstinence.[15]
brain.[16]
In the present study there is not much
There is abundant evidence that smokers
significant result between the groups for
experience
memory, moreover smokers scored less
in cognitive function (Jacobsen et al.,
smoking-related
on
cues
bias
Dr.
and
attentional
bias.
94
abstinence-induced deficits
2005; Mendrek et al., 2006; Myers et al.,
studies that will include large cohorts of
2008) While further research is needed,
women and men, conducted in the
emerging support for the role of cognitive
context of a clinical trial quantifying
function
has
smoking hazards on cognitive function is
implications for treatment development.
required . In comparison to men, women
The development of treatments, both
also show greater left amygdala (Cahill et
behavioral
to
al, 2001) and insular reactivity when
cognitive
processing emotional memories (Piefke et
performance could be a viable strategy to
al, 2005). In addition, women may be
improve cessation outcomes. Potentially
more vulnerable to cue reactivity than
support the use of cognitive performance
men because of this sex difference in
tasks as an early screening tool for
emotional
treatment efficacy and to characterize
possibility exists that men and women
individual differences in relapse risk.[17]
engage different neural networks when
enhance
in
smoking
and
relapse
pharmacologic,
post-abstinence
memory
processing.
The
responding to smoking stimuli.[18]
RECOMMENDATION
CONCLUSION
Tobacco ban is required to safeguard

young people from exposure associated
We conclude that smoking does have an
with
effect on the memory and attention in
smoking
initiation
and
other
young adults, thereby reducing their
smoking related health hazards.
attention
LIMITATIONS
and
immediate
memory
capabilities. It will be helpful to include
This study was limited to men and so it
the
remains unknown whether attention and
smoking cessation program in these
memory also affected in women smokers.
individuals.
cognitive
retraining
along
with
To address these limitations, future
REFERENCES
1. Spanopoulos D, et al., Tobacco display and brand communication at the point of scale :
implications for adolescent smoking behaviour, Tobacco Control.bmj.com;23 :64-69,
28 Feburary 2013
95
2. Mohan Sapori, Effect of cigarette smoke on the immune system www.nature.com

/reviews /immunol may 2 volume 2,2002
3. "The History of Tobacco". World Health Organization(WHO). Retrieved 07 October
2010
4. Severine Sabia,et al., Impact of smoking on cognitive decline in early old age :the white
hall 11 cohort study,Arch Gen Psychiatry,7 June 2013
5. Attention,Chapter 3 page no.103-104 oxford publication. 2010
6. Luke Mustin,The human memory, www.human-memory.net/types.html.
7. Lubna Ahmed, et al.,Focusing on attention :The effects of working memory capacity
and load on selective attention, plosone.org volume 7,issue 8 28 August 2012,
8. Saul
Mc
Leod,Stages
of
memory-encoding,storage
and
retrieval,simply
psychology.org,2007
9. Anselm B.M.Fuermaier et al., Complex prospective memory in adults with attention
deficit hyperactivity disorder, plosone .org, volume 8,issue 3 ;6 March 2013,
10. Bethea A. Kleykamp et al., Effects of transdermal nicotine and concurrent smoking on
cognitive performance in tobacco-abstinent smokers, Exp Clin Psychopharmacol. ;
19(1): 7584; February 2011
11. Signe Vangkilde et al., Prompt but inefficient: nicotine differentially modulates discrete
components of attention Psychopharmacology,218:667680; June 2011
12. Stephen J. Heishman,et al., Meta-analysis of the acute effects of nicotine and smoking
on human performance Psychopharmacology (Berl). 210(4): 453469; July 2010
13. Catherine P. Domier,Effects of cigarette smoking and abstinence on stroop task
Performance, Psychopharmacology (Berl) 195(1): 19; November 2007
14. Scheier, Michael F.; Carver, Charles S Self-focused attention and the experience of
emotion: Attraction, repulsion, elation, and depression. Journal of Personality and
Social Psychology, Vol 35(9),, 625-636 Sep 1977
15. Catherine P. Canamar et al., Acute Cigarette Smoking Reduces Latencies on a
Smoking Stroop Test Addict Behav. 37(5): 627631 ;May 2012
16. Marcus Richards, American Journal Of Public health;93, 2003
17. Freda Patterson et al., Working Memory Deficits Predict Short-term Smoking
Resumption Following Brief Abstinence Drug,Alcohol Depend. 106(1): 61 January1;
2010
96
18. Amy C Janes et al., Neural Substrates of Attentional Bias for Smoking-Related Cues:
An fMRI Study Neuropsychopharmacology; 35, 23392345;2010
CORRESPONDENCES
*Assistant professor, Dolphin (PG) Institute of Biomedical & Natural Sciences,
Manduwala, Dehradun physiocare.sunil@gmail.com
**Student, Dolphin (PG) Institute of Biomedical & Natural Sciences, Manduwala,
Dehradun jagguntomar@gmail.com
***Student, Dolphin (PG) Institute of Biomedical & Natural Sciences, Manduwala,
Dehradun dr.m.rajput@gmail.com
****Student, Dolphin (PG) Institute of Biomedical & Natural Sciences, Manduwala,
Dehradun uday0003@gmail.com
97
DEMOGRAPHIC TRENDS AND QUALITY OF LIFE IN GERIATRIC

POPULATION IN AND AROUND DEHRADUN
Shivam Karn*, Sunil Bhatt**, Sonali Surbhi***, Anup Raj Thapa****
ABSTRACT
AIM: The quality of life of the geriatric population is continuously deteriorating courtesy
to rapid modernisation and urbanisation. The study aims at assessing the health related
quality of life in the geriatric population and to see the demographic trends how they vary
in different population. METHODOLOGY: Seventy five individuals (21 Rural, 35 SemiRural, 19 Urban areas) 60 years in age were enrolled for the study. A community based
cross sectional design using WHO Quality of Life-BREF (WHOQOL-BREF) was adopted
for the study. The demographic trends included physical activity, educational status, habits
etc. RESULTS: Around 33.33 per cent of elderly in rural area had excellent quality of life,
higher than Semi-Urban and urban areas. 23.8 per cent of rural population were very
active physically. Economic status and educational status were better in the urban
population. CONCLUSION: Quality of life is better in rural areas and demographic
trends varies significantly in different population.
KEYWORDS: Geriatric population, Quality of life, Demographic trends
INTRODUCTION
The United Nations have identified
Ageing is an inevitable gradual and
global warming, global terrorism and
continuous
childhood
global ageing as the top three socio-
resulting in maturity.[1] The National
economic issues of the century.[3] The
Policy on Older Persons adopted by the
demographic transition
government of India in January, 1999
about an increase in the average life
defines elderly or senior citizen as a
expectancy of an individual, yielded by
person whose age is 60 years or
declination in both fertility rate and
above.[2] The 21st century has been
mortality rate courtesy to availability of
designated as the century of transitions,
better
process
from
98
health
care
has
services.
brought
Thus,
increasing the number of geriatric
a broad concept which covers an
population in the society.[4]
individuals
physical
is
psychological
state,
expected to rise more than 1.2 billion by
independence,
social
2025 with 840 million of these in the
personal beliefs and their relationship to
developing nations.[5] The demographic
salient features of the environment.[8]
transition have had an impact on India as
Singh et al, 2012; stated, the reduction in
well. Situational Analysis of Elderly in
mortality rates have brought an increase
India, June 2011 reveals a sharp
in the morbidity resulting from varieties
increase
in
of
between
1991
The
global
geriatric
the
population
elderly
(6.7
population
of
total
physiological
health,
level
of
relationships,
and
psychological
problems for the elderly population.
population) and 2011 (8.2 % of total
Moreover
population). The number of elderly in
modernization in the society has brought
population is expected to climb to 10.7
economic insecurity, social isolation and
% by 2021. Above 7 per cent of the
elderly
population of Uttaranchal are elderly.[2]
psychosocial illness.[9] Thus, the rapidly
rapid
urbanization
abuse
increasing
and
the
growing population of elderly prompts
Kanfade et al 2012; stated, the life
for
expectancy of an average Indian would
higher
risks
of
developing
deliberating diseases.[10]
climb up to 70 years by 2025.[6] This

increase in life expectancy is predicted
Previous studies have reported rural-
to transform the current population
urban differences in the prevalence of
pyramid into pillar by 2050 wherein the
disability with greater prevalence of
narrow apex currently refers to number
severe disability of rural population.[]
of elderly in the population.[7]
The life style of the people in different
World
quality
Health
of
Organization
life
as
strata of community (Rural, Semi-
defines
Urban, Urban) varies significantly so
individuals
there is need to assess the differences
perception of their position in life in the
between the life styles. This study aims
context of the culture and value systems
at assessing the health related quality of
in which they live and in relation to their

goals,
expectations,
standards
life
and
in
elderly
and
to
see
the
demographic trends that how they vary
concerns. Thus, quality of life (QOL) is
in different strata of the community.

99
habits), physical activity (in young age
METHODOLOGY:
and now), social status (recreational
The study was conducted in the rural,
activities
semi-urban and urban areas in and
and
social
participation),
history of falls in last 2 years (fall
around Dehradun. A community based
episodes, any fear of fall), history of any
cross-sectional design was adopted for
hospitalization in last 1 year (if yes,
the studying the health problems of the
reason
elderly and their health related quality of
for
hospitalization),
family
support (number of children, living
life. Data collection was done by house
together or not, spouse alive or not), any
to house visit. A total of 71 elderly
specific
people (21 from rural population, 35
designed
geriatric
exercise
program in last 2 years (if yes, what
from semi-urban population and 19 from
exercises),
urban population) with age 60 years
any
problem/cognitive
were included for the study. Individuals
depression/memory
issues,
economic
status, educational status.
who were not willing to participate or

not in position to provide information
ii)Performa to assess the health related
were excluded from the study. All the
quality of life:
individuals enrolled for the study were
The WHOQOL-BREF was used to
informed about the need of the study and
assess quality of life. It took into
verbal
consideration four domains of quality of
consent
was
taken
before
conducting the study. The eligible
life
subjects
an
environmental and social relationship.
investigator and data was collected after
The questionnaire comprises of 26
building rapport with the patient and
questions and mean score of each domain
their family members. The participants
was used to calculate the score. Method
were
for manual calculation of individual
were
asked
interviewed
to
by
show
all
i.e.
physical,
psychological,
medications/medical reports they had.
scores were:
STUDY TOOLS:
Physical domain: [(6-Q3) + (6-Q4) +
i)
Performa
for
Q10 + Q15 + Q16+ Q17 + Q18] 4
assessing
demographic trends:
Psychological Domain: [ Q5 + Q6 + Q7+

Q11 + Q19 + (6-Q26)] 4
A self-designed Performa was used to

assess habits (smoking, drinking, food
100
Social Relationship domain: [Q20 + Q21
was
analyzed
by
using
SPSS-11.5
+ Q22] 4
Software packages.
Environmental domain: [Q8 + Q9 + Q12
RESULTS:
+ Q13 + Q14+ Q23 + Q24 + Q25] 4
This community based cross-sectional
If more than 20% of data were missing
study was conducted with an objective to
from an assessment then the assessment
determine the health related quality of
was discarded. Where up to 2 items
life in the elderly population and to see
missing, the mean of other items in the
that how the demographic trends vary in
domain was substituted. Where more
the different strata of the community. A
than 2 items were missing, the mean of
total of 75 individuals from different
other items in the domain was not
strata (rural, semi-urban and urban) of
calculated. These scores were then
the community. Most of the enrolled
transformed to a scale of 0-100 by
subjects were in age group of 60-84
multiplying each domain scores with
years (67.7 7.09).
100/16.
Table 1 illustrates, a total of 36.8 per cent
The present study did not impose any
of subjects in the urban area were
kind of financial burden on the patient or
smokers, which was higher than the
his/her family.
smokers in the rural (23.8 per cent) and

semi-urban areas (28.6 per cent). Habit
DATA ANALYSIS:
of alcohol drinking was also higher in the

The scoring of WHOQOL was done with
elderly residing in the urban areas (42.1
the help of the template provided by
per cent) in comparison to the elderly in
WHO. Statistical measurements like
the rural (23.8 per cent) and semi-urban
percentages, mean, standard deviations
areas (31.43 per cent).
were used for analyzing the data. Data

Table 1: Demographic trends including habits, social status, history of falls and
hospitalization
Rural
Semi-Urban
Urban
Yes
No
Yes
No
Yes
No
(%)
(%)
(%)
(%)
(%)
(%)
101
Smoking
23.8
76.2
28.6
71.43
36.8
63.2
Alcohol
23.8
76.2
31.43
68.6
42.1
57.9
Social
42.9
57.14
28.6
71.43
42.1
57.9
History of falls
23.8
76.2
54.3
45.7
31.6
68.4
Hospitalization
9.5
90.5
34.3
65.7
26.3
73.7
participation
Social participation in the elderly of rural

areas (42.9 per cent) and urban areas
(42.1 per cent) were almost similar,
while that of the semi-urban population
was very low (28.6 per cent). Almost
54.3 per cent of the elderly in the semiurban areas had a positive history of fall
in last 2 years. The total individuals with
history of falls in rural and urban areas
were 23.8 per cent and 31.6 per cent
respectively. Hospitalization in last 1
year was higher in the semi-urban elderly
23.8 per cent of elderly in the rural areas
(34.3 per cent) in comparison to elderly
were very active physically even at their
in rural (9.5 per cent) and urban (26.3 per
present age, while 19.04 per cent of them
cent) elderly.
were involved in some kind of mild
Table 2: Comparison in Physical activity
activity. 47.6 percent of the elderly in the

rural
level in elderly of different strata in
population
were
involved
in
moderate physical activities while 9.5 per
young age and old age
cent of them had sedentary life style.

None of the elderly in the semi-urban
population were very active physically.
102
But 0.4 per cent and 34.3 per cent of
Some of the elderly in the urban
them
and
population (5.3 per cent) were very
moderate physical activity respectively.
active even at their age. 47.34 per cent of
25.7 per cent in the elderly were living a
them were involved in some kind of
sedentary life style which was higher
moderate physical activity and 5.3 per
than any other population (rural and
cent had sedentary life style [Table 2].
were
involved
in
mild
urban areas).
Table 3: Economic and Educational status in elderly of different strata
and
semi-urban (5.7 per cent) areas. Urban
educational status of elderly in different
elderly were more educated than the
strata of community. 15.8 per cent of the
elderly in other areas. Almost 38.1 per
elderly in the urban areas had excellent
cent of elderly in rural area and 37.1 per
economic status which was higher than
cent of elderly in semi-urban area were
the elderly in rural (9.5 per cent) and
uneducated.
Table
illustrates
economic
Table 4: Demographic trends including family support, exercise program and

depression/cognitive issues
Family Support
Exercise
Depression or
Program
cognitive
problems (%)
103
Spouse
Spouse
Children
Children
alive
deceased
together
not
Yes
No
Yes
No
together
Rural
76.2
23.8
52.38
47.62
23.8
76.2
42.86
57.14
Semi-
62.86
37.14
65.7
34.3
14.3
85.7
71.43
28.6
57.89
42.1
84.21
15.79
15.79
84.2
57.89
42.1
Urban
Urban
Almost 47.62 per cent of elderly in the

rural population had their children living
away from them, this was higher than the
semi-urban
and
urban
population.
Around 71.43 per cent of the elderly in

the semi-urban population had some kind
of depression or cognitive issues. The
main
reasons
for
depression
were
economic problems, loneliness, neglect

by family followed by illness. Not many
An overwhelming 33.33 per cent of
of the elderly in either of the three areas
elderly in the rural population had
followed any exercise regime daily.
excellent quality of life. And 73.68 per

Table 5: Distribution of subjects
cent of elderly in urban area were living
according to quality of life
a good quality of life. 20 per cent of

elderly in semi-urban area had fair
quality of life.
Table 6: Scores of different domains of quality of life

Physical
Psychological
Social
Environmental
Domain
Domain
Relationship
Domain (Mean
(Mean
(Mean SD)
(Mean
SD)
104
SD)
Rural
23.19
SD)
20.67 3.167
4.295
28.619
2.88
5.6875
Semi-
22.457
18.314
9.428
27.628
Urban
3.559
3.453
2.488
6.1504
Urban
27.474
18.421 3.01
10.158
27.474 5.66
5.66
2.291
representative of the entire community.
DISCUSSION:
On the other hand, many of the elderly in
The well-being of elderly has been

mandated
10.904
in
Article
the rural areas may not have health
41(5) of the
seeking behavior or access to the health
constitution of India, which directs that
services.[Mohapatra
the state shall within the limits of its
ending]
Many
individuals refused to participate in the
economic capacity and development,
present study due to lack of time, lack of
make effective provision for securing the
interest and as no monetary benefit was
right to public assistance in old age.[
promised. Thus, the chances of selection
Govt. of India. National Policy on older
bias cannot be ruled out.
persons. 4-6, 1996.] Research on the

ageing process has contributed to the
In the present study, smoking was
realization that ageing need not to be
prevalent in the elderly population (23.8
equated with inevitable decline and
per cent in rural, 28.6 per cent in semi-
disease.[Shalika Sharma] The present
urban and 36.8 per cent in urban).
study was undertaken to assess the health
Prevalence
related quality of life and to see the
population has been reported in many
variation in demographic trends in
studies (Prakash et al [], Bhatt et al[])
different
community.
Social participation (28.6 per cent) was
Community based cross-section design
very low in the elderly of semi-urban
was adopted for the study as the patients
area, which can be attributed to higher
coming to the clinics or hospitals are not
rate of fall in the last 2 years in these
strata
in
the
105
of
smoking
in
elderly
population (54.3 per cent) and fear of
literacy and health consciousness in these
fall. Also, the history of hospitalization
individuals.[Joshi et al]
in last 1 year (34.3 per cent) was higher
Most of the elderly in the rural
in these individuals contributing to
population were very active physically
apprehensiveness in social participation.
(23.8 per cent) as farming is still the
The
increases
major source of income and livelihood in
significantly in elderly. History of falls in
these areas. The individuals in this area
last 2 years have been reported (23.8 per
were dependent on the their physical
cent in rural, 54.3 per cent in semi-urban
labor. Hence, the physical activity in the
and 31.6 per cent in urban) by the
rural population was very high compared
elderly.
been
to population in semi-urban and urban
reported in earlier studies where the rate
population where most elderly were
of fall was higher in the urban population
dependent on their family members for
when
their needs and supplies.
number
of
Similar
falls
results
compared
have
to
rural
population.[Joshi et al] Studies shows
Economic status and educational status
that the number of falls increases with
were very good in elderly residing in
age and injury rate is highest among the
urban areas. Most of the elderly in rural
oldest old (> 80 years old). There is a
population (38.1 per cent) and semi-
vicious cycle where, due to poor
urban population (37.1 per cent) were
perceived health and morbidity there is
uneducated.
increased tendency to fall which itself

leads
to
increasing
disability
Family support was excellent in all the
and
population. But almost 47.62 per cent
distress.[Joshi et al]
rural population were living without their

Hospitalization rates were very low in
children, the most appropriate reason
rural elderly, which can be attributed to
being the children migrated to near urban
poor treatment seeking behavior in these
areas to earn the livelihood. Depression
population as well as lack of availability
was higher in semi-urban population
of proper health services in these
which can be attributed to loneliness, low
areas.[Joshi
of
literacy level, poor health status and
hospitalization in elderly of semi-urban
reduced social participation.[Mannanpur]
area can be attributed to low level of
People should try to cope up loneliness
et
al]
High
rate
106
by adopting a positive way of life and
endow tailor made recreational facilities
behavior
like municipal parks, social clubs and
conducive
to
their
health.[Naresh et al] In an Australian
drop-in-centers
study, the specific behaviors that were
Government needs to generate strong
found to ameliorate loneliness among
will to understand life concerns of
aged 65 years and more, included
elderly which could have significant
utilizing friends and family as an
positive impact on their QOL and health.
emotional resource, engaging in eating
for
the
elderly.
LIMITATIONS:
rituals as a means of maintaining social

There might be increased chances of
contact, and spending time constructively
misreporting by the elderly. We could
by reading and gardening.[Pettigrew S]
not follow up the study due to lack of

33.33 per cent of elderly in rural area had
time and source. One possible source of
excellent quality of life. The reason for
biased reporting of medical conditions
better quality of life in elderly people can
may arise from differential access and
be attributed to the fact that QOL would
utilization of health care services by
be affected by a number of significant
different segments of population.
positive and negative life events and

CONCLUSION:
these life events may be related either to

his family or society or community
The
demographic
trends
varies
where he lives.[10] QOL need not be
significantly in different population. As
poor in poor mans home.
there is rapid increase in the elderly

population there is need to develop
RECOMMENDATIONS:
geriatric health care services and tailor

Government
needs
to
focus
their
made recreational parks to improve
attention on better penetration of various
social
status
of
the
elderly.
social schemes. It is imperative to
REFERENCES
Datta PP, Sengupta B, Gangopadhyay N, Firdoush KA, Chanda S, Dutta A, Bharati S.
Hypertension and Its Related Morbidity Among Geriatric Population of Eastern India. Mat
Soc Med, 2012;24(1):29-33.
Situational Analysis of The Elderly In India, June 2011.
107
Ageing Asia: A Special report. Corporate India Nov 1-15, 2008; 1-17: 76-78.
Kanfade M, Sharma R. Morbidity patterns in elderly males and females of Nagpur city.
International Indexed and Referred Research Journal. 2012 Sept; 4(36):20-21.
Singh Z. Aging: The triumph of humanity- Are we prepared to face the challenge. Indian
Journal of Public Health. July-Sept 2012; 56(3):189-195.
CORRESPONDENCES
*Student, Dolphin (PG) Institute of Biomedical & Natural Sciences, Manduwala,
Dehradun. shivam.karn@gmail.com
**Professor, Department of Physiotherapy, Dolphin (PG) Institute of Biomedical &
Natural Sciences, Manduwala, Dehradun. physiocare.sunil@gmail.com
***Student, Dolphin (PG) Institute of Biomedical & Natural Sciences, Manduwala,
Dehradun. Email: sonaliiii.survi@gmail.com
****Student, Dolphin (PG) Institute of Biomedical & Natural Sciences, Manduwala,
Dehradun. Email: thapa.anup.raj@gmail.com
108
RECOVERY OF HAND FUNCTION IN AN ACUTE STROKE

PATIENT USING MIRROR THERAPY AND EMG BIOFEEDBACK:
A CASE STUDY
Baiju Prasad Jaiswal*, Sunil Bhatt**, Shilpa Kumar***, Prerna Bhardwaj****
ABSTRACT
Introduction and Objectives: Use of mirror therapy along with electromyographic (EMG)
biofeedback for hand function in stroke is limited. This study aims to examine the recovery
of hand function in an acute stroke patient using mirror therapy along with EMG
biofeedback. Methodology: A patient with unilateral acute stroke; Brunnstroms staging 4
with poor strength in upper limb and limited hand function went through thirty minutes of
mirror therapy program along with EMG biofeedback 6 days in a week for 4 week, therapy
consisted of non paretic side wrist extension, watching the image of their non-involved
hand. The outcome measures (Fugl-Meyer scores, Functional Independence Measures
(FIM) scores, EMG scores, Modified Ashworth Scale (MAS) and Manual muscle testing.)
were recorded before and after intervention. Results: Fugl-Meyer, FIM, EMG scores along
with wrist and finger muscles strength showed improvement post intervention. However we
found no improvement in spasticity. Conclusion: Mirror therapy training with EMG
biofeedback is helpful in improving hand function along with conventional therapy.
Key Words: Mirror Therapy, EMG Biofeedback, Hand Function.
INTRODUCTION
A stroke, previously known medically as
than 50% of stroke patients report
cerebrovascular accident (CVA), rapidly
continuous disability of upper extremity
developing loss of brain function(s) due
function, which can cause stroke patients
to disturbance in blood supply to the
to trouble in activities of daily living;
brain. According to WHO stroke is acute
even after conventional treatment and
onset on neurological dysfunction due to
learned nonuse-the avoidance of the use
abnormality in cerebral circulation with
of
resultant
frequently.[2]
signs
and
symptoms
that
corresponds to involvement of focal area
the
injured
arm
is
observed
So, to restore the function of upper
of brain lasting more than 24 hrs.[1] The
extremity,
incidence of the stroke is growing, more

109
new
methods
for
the
rehabilitation
of
upper
rehabilitation,
based
relief. Since the initial report, successful
extremity
motor
use of the mirror therapy has been
learning theory, are being assessed.
reported in the patients with other pain
Representative treatment methods include
syndromes, such as complex regional
the constraint induced movement therapy,
pain syndrome and in sensory re-
robotic-arm
using
education of severe hyperesthesia after
virtual reality, mental practice and mirror
hand injuries.[3,4] In mirror therapy
therapy.
results
(MT), the patient sits in front of a mirror
supporting the effectiveness of these
that is oriented parallel to his midline
methods
of
blocking the view of the affected limb
randomized controlled clinical trials have
positioned behind the mirror. When
been conducted.[2] However, most of the
looking into the mirror, the patient sees
treatment protocols for the paretic upper
the reflection of the unaffected limb
extremity are labor intensive and require
positioned as the affected limb. This
1-to-1 manual interaction with therapists
arrangement is suited to create a visual
for several weeks, which makes the
illusion whereby movement of or touch to
provision of intensive treatment for all
the intact limb may be perceived as
the patients difficult.
It has been
affecting the paretic or painful limb.[5]
suggested that mirror therapy is a simple,
Hence, it is thought that this form of
inexpensive
importantly
therapy can prove useful in stroke
that
patients who have lost movements of an
on
training,
Even
training
though
scarce,
and
patient-directed
the
the
wide
most
treatment
range
may
improve upper extremity function.[3]
arm or leg.[6]
Ramachandran
Rogers-
Previous studies in the stroke suggested
Ramachandran et al, 1996; were first to
that mirror therapy may be beneficial for
introduce the use of these visual illusions
motor function recovery in paretic hand.
created by mirror for treatment of
In a randomized crossover study of 9
phantom limb pain. By superimposing the
chronic stroke patients, Altschuler et al,
intact arm on the phantom limb pain
1999; reported that range of motion
using
patients
(ROM), speed and accuracy of arm
reported the sensation that they could
movement were more improved after
move
often-cramped
mirror therapy.[7] Stevens and Stoykov et
phantom limb pain and experienced pain
al, 2003; also reported that their 2 stroke
and
mirror
relax
and
reflection,
the
110
patients trained with mirror therapy for 3-
finger
4 weeks and had an increase in Fugl-
kinesthetic awareness and recruitment of
Meyer assessment scores, active range
motor units in weak hypoactive muscles
motion, movement speed and hand
(e.g. wrist/forearm extensors muscles).
dexterity
therapy.[8]
Reported benefits include improvements
Similarly, Sathian et al, 2000; found that
in ROM, voluntary control & function.[1]
2 weeks of intense mirror therapy in
EMG biofeedback is useful tool for
chronic stroke patient resulted in a strong
neuromuscular re-education. The basic
recovery of grip strength and hand
EMG device comprises of one ground
movement in paretic arm.[9] Yavuzer G
and two surface electrodes, an amplifier,
et al, 2008; in a randomized control trial
an audio speaker and a video display. A
(RCT) in 40 sub-acute stroke patients
surface EMG for skeletal muscle activity
found that improvement in scores of
can be compared with electromyography
functional
measurement
being done for heart. The EMG signal is
(FIM) and Brunnstrom stages for hand
transmitted from muscle through the skin,
functioning and upper extremity after 4
though the electrodes, through the wires
weeks of intervention and 6-months of
and then to the amplifier.[11] EMG
follow-up.[3] Dohle et al, 2008; in a RCT
biofeedback has been used the 1960s, and
in 36 patients with severe hemiparesis
several studies, the effectiveness of this
had found MT patients regained more
technique
distal function and improved recovery of
Armagan et al, 2003; in a placebo-
surface sensibility after 6 weeks of
controlled study in 27 sub-acute stroke
intervention.[10]
patients found that the improvements in
after
mirror
independent
flexors)
has
or
on
been
increasing
investigated.
AROM and surface EMG potentials were

Electromyographic (EMG) biofeedback
significantly
has been introduced for improving hand
greater
in
the
EMG
biofeedback group after the 4 weeks of
function in the patient following stroke.
treatment.[12] Maheswari et al, 2012; in a
This technique allows the participants to
RCT
alter their motor unit activity based on
in
30
patients
were
found
improvement in Action Research Arm
augmented audio and visual feedback
Test (ARAT) and Voluntary control
information. Training can focus on
grading scale.[1]
voluntary inhibition of spastic muscles

The effect of mirror therapy has been
(e.g. reducing firing frequency of spastic

111
well proved in stroke patients but use of
occupational therapy. During the mirror
mirror
with
therapy, patient seated close to a table on
electromyographic (EMG) biofeedback
which a mirror (40X45 cm) was placed
for hand function in stroke is limited. So
vertically in saggital plane. Both the
in this case study we tried to examine the
hands were placed laterally on either side
recovery of hand function in acute stroke
of mirror. The therapy consisted of non
patient using mirror therapy along with
paretic side wrist extension, holding and
EMG biofeedback.
releasing of glass or block, hand opening
therapy
along
and closing, forearm supination and
METHODOLOGY
pronation while the patient looked into
The study was conducted in a patient
the mirror, watching the image of their
admitted and transferred to physiotherapy
non-involved hand, thus seeing the
department at a tertiary care hospital. The
reflection
case in the present study was a patient
projected over the involved hand. During
with unilateral acute stroke. Patient was a
the session patient was asked to try to do
60 years-old, right handed women who
the same movements with the paretic
survived
hand while she was moving the non-
left
Brunnstroms
capsular
staging
4,
infract,
with
poor
of
the
hand
movement
paretic hand.[3,13]
strength in affected upper limb, and

limited hand function. Unaffected upper
extremity had complete ROM and good
strength, without any proprioceptive or
kinesthetic impairment. The patient did
not
have
any
visual
or
auditory
impairment. Verbal informed consent was

taken
prior
to
study.
Patient
was
explained about the procedure.

Intervention included thirty minutes of
mirror therapy program along with EMG
biofeedback 6 days in a week for 4
weeks.
consisted
The
of
conventional
program
Physiotherapy
and
Fig.1: Mirror therapy along with EMG
112
biofeedback watching the image of their
table 1. Fugl-Meyer scores increased after
non-involved hand.
(55/66) the intervention as compared with

before (36/ 66) intervention, FIM scores
For EMG biofeedback, MYOMED 932
increases after intervention from 107/154
model was used where two surface
to 129/154, muscle strength of finger,
electrodes were placed on the dorsal
wrist and forearm showed improvement
aspect of paretic forearm on the belly of
post intervention from MMT grade 2 to
wrist extensor (extensor digitorum) and a
3+ EMG scores as average found
reference electrode on lateral angle of
increased amplitude and power after
unaffected arm at common origin of wrist
intervention shown in graph. However we
extensor. In stroke patients extension
found no improvement in spasticity.
wrist and fingers are usually deteriorated

and this lead to limitations of hand
Table 1: Comparison of clinical
functions that is why these muscles
assessments scores before and after
preferred
interventions.
for
EMG
biofeedback
training.[12] During movement asked the

patient to achieve the goal or asked to
Duration
take point which was heard maximum.[1]

Duration
of
EMG
Before
After
(0 days)
(at 4
weeks)
biofeedback
intervention was for thirty minutes and
Scales
before and after session analysis of EMG

36/66
55/66
FIM scores
107/154
129/154
EMG scores
Min-3
Min-2
Max-100
Max-91
Average-
Average-
scores (surface EMG potentials) were
Fugl-Meyer
done. Sensitivity of EMG biofeedback
scores
was 100V. The outcome measures were

recorded before and after intervention.
The outcome measures were Fugl-Meyer
scores,
Functional
Independence
Measures (FIM) scores, EMG scores,

Modified Ashworth Scale (MAS) and
Manual muscle testing.
Results
Clinical assessment scores are listed in
113
21
Power--
Power-
14223
25247
This case study showed improvements in

wrist and hand power and hand related
functioning when mirror therapy was
applied
in
combination
with
EMG
biofeedback and conventional therapy in
MMT
early phase after the stroke.

Finger flexor:
3-
3+
Clinical assessment
essment scores are listed in
Finger extensor: 2
3+
Wrist flexor:
3+
Wrist extensor:
3+
Forearm
2-
3+
supinator:
table 1. Fugl-Meyer
Meyer scores increased after
(55/66) the intervention as compared with
before
intervention
and
wrist areas of Fugl-Meyer

Meyer sub-scores.
sub
Stevens and Stoykov et al, 2003; also
reported similar results in their study
where two stroke patients were trained
Pronator:
with mirror therapy for 3-4

3 weeks and
had
MAS
1+
Wrist flexor:
Wrist extensor:
Forearm
1+
1+
an
increase
in
Fugl
Fugl-Meyer
assessment scores.[8]
1+
Finger extensor: 0
supinator:
66)
improvement was more towards hand and
Forearm
Finger flexor:
(36/
Forearm
Fig.2: Graph of EMG scored after 4
Pronator:
weeks of session
FIM scores increases after intervention
from
DISCUSSION
107/154
to
129/154
but
improvement was more in self-care

self
and
sphincter control subscale of FIM scale.
114
However we found no improvement in
cortices associated with observation of
spasticity, it might be due to finger
touch
flexors and forearm pronators were
Rizzolatti et al, 1996; Keysers et al,
stronger
2004).[5,19]
than
finger
extensors
and
(DI
Pellegrino
et
According
al,
to
1992;
V.
supinators respectively, even after 4
Ramachandran et al, the beneficial effect
weeks of intervention. Similarly, Yavuzer
of mirror therapy is possibly mediated by
G et al, 2008; in a RCT in 40 sub-acute
visual illusion that actions carried out by
stroke patients found that improvement in
one self are performed normally. It is
FIM scores.[3] Muscle strength of finger,
quite probable that this illusion can
wrist and forearm showed improvement
prevent, or at least reduce learned non-
post intervention from MMT grade 2 to
use of a paretic limb. The effects of
3+. Similarly, Sathian et al, 2000; found
mirror therapy are attributed to mirror
that 2 weeks of intense mirror therapy in
neurons i.e. neurons in the pre-motor
chronic stroke patient resulted in a strong
area of both monkeys and humans that
recovery of grip strength and hand
are
movement in paretic arm.[9] EMG scores
meaningful movements.[14]
as average found increased amplitude and
may
patients found that the improvements in
substitute
proprioceptive
AROM and surface EMG potentials were

the
of
looks like affected arm moving correctly,
controlled study in 27 sub-acute stroke
in
observation
reflection of good moving arm, which
Armagan et al, 2003; in a placebo-
greater
during
Altschuler et al proposed that the mirror
power after intervention shown in graph.
significantly
active
for
decreased
information,
thereby
helping to recruit the pre-motor cortex
EMG
and
biofeedback group after the 4 weeks of
assisting
rehabilitation
though
intimate connection between visual input
treatment.[12]
and pre-motor areas.[7] Stoykov et al,
Several underlying mechanisms for the
2003; suggested that mirror therapy
effect of mirror therapy on motor
related to motor imagery that creates
recovery after stroke have been proposed.
visual
Mirror neurons were found in areas of the
performance of the imagined actions with
ventral and inferior pre-motor corex
the impaired limb.[8] Yavuzer G et al,
associated with observation and imitation
2008; the possible mechanism for the
of movements and in somato-sensory
effectiveness of mirror therapy might be
115
feedback
of
successful
bilateral arm training. Summers et al
active inhibitory influences, unmasking
investigated the effectiveness of bilateral
of existing pathways to subserve new
arm training was more effective in
movement strategies, transfer of function
facilitating upper-limb motor function in
to
chronic stroke patients.[3]
alternative pathways, or sprouting of
intact
neural
structures,
use
of
collateral axons to form new synapses.
Garry et al, 2005; performed TMS during
Wolf and Binder et al applied EMG
mirror illusions in healthy subject and
biofeedback plus physical therapy in
showed increased excitability of primary
chronic
motor cortex (M1) of hand behind
stroke
patients
and
found
improvement in upper limb ROM and
mirror.[15] Matthys et al. proposed that
muscle strength.[12,17] Crown JL et al,
there is supplementary activation in 2
1989; in a single blinded RCT in 40 the
visual area: the superior temporal gyrus
acute stroke patients found that the
(STG) and superior occipital gyrus with
improvement in ARA test and Fugl-
mirror-induced visual illusion of hand
Meyer scores for arm after 6 weeks of
movements in mirror group as compare to
intervention and 12 weeks of follow up
non-mirror group a fMRI study.[16]
but beneficial effect did not persist once
Kang YJ et al, 2012; suggested that
treatment ended.[18] Yun GJ et al, 2010;
corticospinal excitability was facilitated
conducted a comparative study Synergic
to a greater extent in the virtual mirror
effects
paradigm than in the real mirror and
of
Neuromuscular
intermittent visual feedback than in the
mirror
therapy
electrical
and
stimulation
(NMES) for hand function in stroke
continuous visual feedback because it
patients in 60 sub-acute stoke patients
could be that the virtual mirror paradigm
were allocated in three groups with each
is task oriented, more interactive and
group had 20 patients (combined MT plus
interesting, thus increasing attention and
NMES, only mirror and only NMES) and
evoking the visual illusion that might
had resulted that the mirror therapy and
putative mirror neuron system and the
NMES
ipsilateral motor cortex.[2]
group
showed
significant
improvements in the Fugl-Meyer scores
Many research investigated the complex
of hand wrist, coordination and power of
neurophysiologic mechanisms are still
hand, wrist, coordination and power of
unclear and might include elimination of
hand extension. The possible mechanism
116
given that combined therapies improve
speculative whether this result would be
motor
valid for chronic stroke patients.
functions
by
affecting
the
activation the primary motor cortex.[20]
CONCLUSION
Maheswari SH et al, 2012; in a RCT in

30 patients showed greater improvement
This case study suggests encouraging
in hand function and voluntary control of
effects of mirror therapy for improving
hand in hemiplegic stroke participants.
hand function. Mirror therapy training
Improvement showed because of EMG
with EMG biofeedback for 4 weeks is
biofeedback
conventional
helpful in improving hand function when
physiotherapy which alter motor unit
given along with conventional therapy in
activity based on augmented audio and
the acute stroke patient. The skill required
visual feedback information.[1,12]
to perform mirror therapy is not very
and
high. Hence, mirror therapy can be

promoted as an adjunct to home program
LIMITATIONS
for
The limitation of this study is that the
these
patients.
Therefore,
the
application of the mirror therapy can be
result cannot be generalized. Another
considered as one of the rehabilitation
limitation was in the form of total number
programs to improve hand functions in
of patients as only one patient was
acute and sub-acute stroke patients.
enrolled for the study. Mirror therapy was
Studies including a large sample and
not only treatment and other therapy
control group are required to generalize
might be even more beneficial to
the results. Hence, more extensive studies
improving hand functions. It remains
should be performed
in this area.
REFERENCES
[1] Maheshwari SH, Singaravelan RM. Effectiveness of EMG biofeedback on improving
hand function in hemiplegic stroke patients. Revisa Romana De Kinetoterapie, 2012; VOL
18 (30): 56-64.
[2] Kang YJ, Park HK, Kim HJ, Lim t, Ku J, Cho SK. et al Upper Extremity
Rehabilitation of Stroke: Facilitation of Cortical Excitability Using Virtual Mirror
Paradigm. Journal of Engineering and Rehabilitation, 2012; 9: 71.
[3] Yavuzer et al Mirror Therapy Improves Hand Function in Sub-acute Stroke: A RCT
Arch Phy Med Rehabil, March 2008; 89: 393-398.
117
[4] Ramachandran VS, Hirstein W. The perception of phantom limbs. The D.O. Hebb
lecture. Brain, 1998; 121: 1603-1630.
[5] Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. The clinical aspects of
mirror therapy in rehabilitation. Lippincott Williams and Wikins.2011; 34: 1-13
[6]. Goel D, Goel S. Mirror Therapy in Stroke Rehabilitation. Physiotherapy and
Occupational Therapy Journal, July-2008; VOL 1 (1): 57-61.
[7] Alschuler EL, Wisdom BW, Stone L, Foster C, Galasko D Liewellyn DME.
Ramachandran VS. Rehabilitation of Hemiparesis after stroke with a mirror. THE
LANCET, June 12 1999; 353: 2035-2036.
[8] Steven JA, Stoykov MEP. Using motor imagery training in the rehabilitation of
Hemiparesis. Arch Phys Med Rehabil, July 2003; 84: 1090-1092.
[9] Sathian K, Greenspan AI, Wolf SL. Doing it with mirror: a case study of a novel
approach to neuro-rehabilitation. Neurorehabil Neural Repair. 2000; 14: 73-6.
[10] Dohle C, Pullen J, Nakaten A, Kust J, Rietz C and Karbe H. Mirror Therapy
Promotes Recovery from Severe Hemiparesis: A RCT. Neurorehabil Neural Repair;
December 2008; 10: 1-8.
[11] Jagmohan S et al. Textbook Of Electrotherapy. Jaypee Brothers, New Delhi.2005
[12] Armagan O, Tascioglu F, Oner C. Electromyographic Boifeedback in the Treatment
of the Hemiplegic Hand. Arch Phys Med Rehabil, 2003; 82: 856-861.
[13] Sciusco A, Ditrenta G, Rahino A, Damini S, Megna M, Ranieri M, Megna S. Mirror
therapy in motor recovery of upper extremities. EUR MED PHYS 2008; 44: 1-3
[14] Ramachandran V.S, Alschuler EL. The use of visual feedback, in particular mirror
visual feedback in restoring brain function. Brain 2009; 132; 1693-1710.
[15] Garry MI, Loftus A, summer JJ et al. Mirror, Mirror on The Wall: Viewing a Mirror
Reflection of Unilateral Hand Movements. Exp Brain Res (2005); 163: 118-122
[16] Matthys K, smiths M, Van der Geest JN, Van DLA, Seurinck R, Stam HJ, Selles RW.
Mirror-induced visual illusion of hand movement: a functional magnetic resonance
imaging study. Arch Phys Med Rehabil, 2009; 90: 675-81.
[17] Wolf SL, Binder-Macleod SA et al. Electromyographic Biofeedback Applications to
the Hemiplegic Patient. PHYS THER, 1983; 63: 1393-1403.
[18] Crown JL, Lincoln LB, Nouri FM, Weerdt WD et al The effectiveness of EMG
biofeedback in the treatment of arm function after stroke. Int disabil studies, 1989; 11:
155-160.
118
[19] Rizzolatti G, Fadiga L, Gallese V, Fogassi L. premotor cortex and the recognition of
motor actions. Conitive Brain Research; 3: 131-141.
[20] Yun GJ, Chun MH, Park Y, Kim BR. The Synergic effects of Mirror Therapy and
NMES for hand function in Stroke Patients. Ann Rehabil Med; 35:316-321, 2011
CORRESPONDENCES
*Dolphin (PG) Institute of Biomedical & Natural Sciences, Dehradun, H. N. B. Garhwal
University, Srinagar, Uttarakhand, India. Email: physiocare.baiju@gmail.com
**Department of physiotherapy, Assistant professor, Dolphin (PG) Institute of Biomedical
& Natural Sciences, Dehradun, H. N. B. Garhwal University, Srinagar, Uttarakhand, India.
Email: physiocare.sunil@gmail.com
***Department of physiotherapy, Manager, Max Super Specialty Hospital, Saket, New
Delhi. Email: shilpa.kumar@maxhealthcare.com
****Dolphin (PG) Institute of Biomedical & Natural Sciences, Dehradun, H. N. B.
Garhwal University, Srinagar, Uttarakhand, India. Email: prerna.max@gmail.com
119
CORRELATION BETWEEN TRUNK IMPAIRMENT SCALE AND

HISTORY OF FALLS IN STROKE PATIENTS: A RETROSPECTIVE
STUDY
Dr. Sumit Asthana*
ABSTRACT
Background and objective: Trunk impairment scale is a standardized scale to measure
balance specifically in Stroke patients but it has no predictability with respect to fall risk in
this population. To meet this goal, we sought to determine if there is any correlation of
history of fall with score on trunk impairment scale and to find the predictability of trunk
impairment scale with respect to risk of falls. Study design: Correlational study. Method:
48 subjects were chosen as per the inclusion and exclusion criteria through convenient
sampling from various hospitals and physiotherapy clinics in Dehradun and Lucknow, and
informed consent was obtained from all subjects after the procedure was explained to
them. After instructing the patient, demographic data and fall history were recorded.
Participants were assessed using trunk impairment scale (TIS). After examining the patient
by trunk impairment scale and finding the score, analyses and correlations with fall history
was done. Result: Result reveals negative correlation (-.745) between number of falls and
score of trunk impairment scale. It means as number of falls increases, score on trunk
impairment scale decreases. Significance of correlation (p value) is .000. Conclusion: On
the basis of this retrospective design we conclude that there is a good negative correlation
between trunk impairment scale and history of fall in Stroke patients. Consequently, trunk
impairment scale may be helpful in evaluating risk of fall in Stroke patients.
Key words: trunk impairment scale (TIS), fall, Stroke.
INTRODUCTION
blood flow to the brain.1 Motor deficits
Stroke is the sudden loss of neurological
are
function caused by an interruption of
(hemiplegic) or weakness (hemi paresis)
120
characterized
by
paralysis
typically on the side of the body opposite
disability.5 The disturbances in trunk
to the side of the lesion,1 the typical
movements shown by patients suffering
inability to move the arm and leg, the
from stroke sequel can be due to different
development
reasons, including praxis or postural
of
spasticity
in
mass
patterns and movement in stereotyped
problems, which
synergies.2
predominantly associated with left and
significant loss of selective activity in the
right-hemisphere lesions, respectively. In
muscles controlling the trunk, particularly
different
in those muscles responsible for flexion
have been studied as part of disorders of
rotation and lateral flexion. After onset of
axial
hemiplegia
balance against gravity and serves as a
In
addition,
the
patient
there
is
experiences
in
contexts,
turn
are
trunk impairments
movements.
Posture
difficulty in moving his trunk in relation
reference frame
to the pull of gravity, regardless of which
movements. Trunk muscles are crucial to
type of muscle action is required. The
postural stability. Postural deficits are
abdominal
frequently observed in clinical practice
remarkable loss of activity and tone. The
after brain lesions. Apraxia or postural
resultant loss of trunk control has far
unbalance
reaching effects and is to certain extent
movements.6 Trunk impairment leads to
more disabling than the involvement of
difficulty in balance, gait & functional
muscles
demonstrate
the arm and leg musculature.
for
ensures
could also
organizing
impair trunk
ability.3
Stroke
patients showed a significant decrease in

Balance is disturbed following stroke
level of trunk performance in comparison

to
age
and
sex
matched
with impairments in steadiness, symmetry
healthy
and dynamic stability.1 Thus the patient is
individuals even in non acute and chronic
unable to maintain balance in sitting or
phase post stroke.4 Trunk control has
standing or to move in a weight-bearing
been identified as an important early
posture.1 Balance impairment is a key risk
predictor of activities of daily living after
factor for falls.7 Falls are common
stroke.3
occurrence
There is a trunk flexion and extension

muscle
weakness
in
stability,
and
stroke
patients.
The
reported fall frequency rate is 14% in
unihemispheric
acute hospital and 25-39% in the acute
stroke patients, which can interfere with

balance,
in
rehabilitation
functional
setting.8
Patients
with
severe stroke-related disability in the

121
early period after stroke are prone to falls
considering the prognosis of stroke
during rehabilitation, multiple falls are
patients.12
most frequent in patients over 65 years
Although fall risks or predictability with
of age.9 In an earlier study, it was found
respect to risk of falls in stroke patients
that 14% of the stroke patients fell at least
has been associated with various balance
once during their hospital admission. A
measures like BBS (Berg Balance Scale),
very high incidence of falls (15.9/1000
TUG (Timed up and go) etc, but TIS
patients per day) was reported for a
being a specific measure of trunk
geriatric unit for stroke rehabilitation.10
performance has not been studied with
Although balance impairment neither a
respect to fall risk.13, 14 On the other hand
necessary nor a sufficient cause for falls,
trunk impairment scale is a standardised
numerous risk factors for falls have been
scale to measure balance specifically in
identified
in
These
stroke patients but it has no predictability
include
age,
lesion,
with respect to fall risk in this population.
impairment,
Accurate identification of individuals
severity of neurological impairment and
with stroke at risk for falls may assist
poor balance.8
clinicians
Trunk impairment scale (TIS) is a
therapeutic
standardised scale to evaluate the trunk
prevention that will ideally reduce fall
function in stroke patients. It is a 3-point
risk and fall related injury.
impulsivity,
stroke
patients.
hemisphere
cognitive
scale of 23 score, a higher score
individuals
impairment of trunk after stroke. TIS
clinicians
scale is sufficiently reliable and valid for
with
to
stroke
appropriately
can
assist
prescribe
sought to determine if there is any
healthy individuals.4 Trunk performance
correlation of history of fall with score on
is an important predictor of functional

TIS
fall
related injuries. To meet this goal, we
discriminates between stroke patients and
The
for
therapy for reduction of fall risk and fall
use in clinical practice.11 The TIS
stroke.
interventions
prescribe
that accurate screening of fall risk in
is a comprehensive tool to measure motor
after
appropriately
This study operated on the assumption
indicating a better trunk performance. It
outcome
to
trunk impairment scale.
is
recommended as a prediction instrument
We didnt come across any study that
in
correlates the trunk impairment scale with
the
rehabilitation
setting
when
122
risk of falls. No literature exists to our
4. Any other neurological disease
knowledge for trunk impairment scale
5. Mini Mental Status Examination
addressing fall risk in stroke patients.
(MMSE) scores less than 23
MATERIAL AND METHODS
Instrumentation and outcome

measures:
A total number of 48 subjects participated

in the study. Subjects were recruited
1. Bed or couch of appropriate height
through convenient sampling. They were

2. Chair without armrest
taken from various hospitals in Dehradun

(Doon hospital, National physiotherapy
Trunk impairment scale (TIS)
centre, Kiran memorial neuro centre),

cure
The TIS consists of 17separate items,
physiotherapy centre, Bone and Joint
score of each items are 0-1, 0-2 or 0-3
clinic,
physiotherapy
and total score range is 0-23Test-retest
centre) and community dwelling Stroke
and inter-observer reliability for the TIS
patients in and around Dehradun and
total score (ICC) is 0.96 and 0.99,
Lucknow.
respectively.
Study design: Correlation study
PROCEDURE
Inclusion criteria:
In this study we screened 52 stoke
1. Diagnosed Stroke patients
patients of sub acute and chronic stage
2. Stroke of at least 4 months duration
from two different places in which 48
3. Both genders
patients were included. The subjects were
Lucknow
(C.S.J.M.U,
Vivekananda
The
chosen as per the inclusion and exclusion

4. History of falls
criteria,
5. Ambulatory patients
obtained from all subjects after the
and
informed
consent
was
procedure was explained to them. After

Exclusion criteria:
instructing the patient, demographic data
1. Any history of lower extremity fracture
and
in past 1 year.
fall
history
were
recorded.
Participants were assessed for balance
2. Any known Spinal deformity
using trunk impairment scale (TIS).
3. History of spinal trauma or head injury
Trunk impairment scale examines static
123
and dynamic sitting balance and trunk co-
sitting balance and trunk co-ordination
ordination (3-subscales). Each subscale
subscale
contains
respectively. Total score ranges between
between
3and
10
items.
is
7,
10
and
points
Maximal score for static and dynamic
0 and 23 point.
For assessment first we positioned the
thighs were making full contact with the
patient in a comfortable position. The
bed or table; the feet were hip width apart
starting position for each item was same.
and placed flat on the floor. The knee
Now the patients were asked to sit on the
angle was 900. The arms rest on the legs.
side of a bed or a couch of appropriate
If hypertonia was present the position of
height without back and arm support. The
the hemiplegic arm was taken as the
124
starting position. The head and trunk
analyses and correlations with fall history
were in a midline position.
was done.
If the patient scores 0 on the first item,

the total score for the TIS was 0. Each
RESULT
item of the test was performed three

times. The highest score counts. No
The data was analyzed for 48 subjects
practice
The
between number of fall, since the time of
patients were corrected between the
stroke and score on trunk impairment
attempts.
The
tests
scale. Mean of age, duration of stroke
explained
to
the
session
was
allowed.
were
verbally
patient
onset, number of falls and score of trunk
and
impairment scale (TIS) was 61.1914.04,
demonstrated.
38.3346.79, 4.254.26 and 15.732.56

After examining the patient by trunk
respectively.
impairment scale and finding the score,

Table-5.1: Descriptives of age, duration, fall and TIS
Minimum
Maximum
Mean SD
Age(Years)
26
85
61.1914.04
Duration(Months)of
276
38.3346.79
Fall
25
4.254.26
TIS
20
15.732.56
Stroke
Table- 5.2: Correlation between number of fall and TIS
r (correlation)
-0.745
P(significance)
0.000
125
Result reveals negative correlation (-
correlation
0.745) between two variables i.e. no. of
Correlation was significant at the 0.01
falls and score of trunk impairment scale
level.
when correlation was made between these
Significance
was
to number of falls.
of
Figure-5.1: Correlation between fall and TIS

25
20
TIS
15
10
5
0
0
10
15
20
25
FALL
Figure-5.2: Categorization of TIS scores with respect to no. of falls

16
14
Mean of fall
12
10
8
6
4
2
0
18 to 20
0.000.
categorization of TIS scores with respect
increases, score on trunk impairment

decreases.
value)
On the basis of result we suggest the
two variables. It means as number of falls
scale
(p
15 to 17
11 to 14
Score of TIS
126
7 to 10
30
Above figure shows the categorization of
abilities
scores on TIS on the basis of falls. TIS
standing
score was categorized in 18-20, 15-17,
also provide stability in an antigravity fun
11-14 and 7-10 and the mean of fall in
ction. Following stroke, it is generally
each category were 1.54, 3, 8.09 and 13.5
accepted that the control of trunk muscle
respectively.
is severely impaired. More precisely,
such
as
or
reaching,
walking.
upright
They
even though the loss of muscular strength
DISCUSSION
is
larger
for
the
paretic
side
in
In our study we tried to find correlation
comparison to the non-paretic one, a
between
trunk
lower isometric strength in bilateral trunk
impairment scale in stroke patients. Our
muscles is however observed.41 Trunk
findings suggest that there is a good
muscle weakness and paralysis result in
negative
trunk
an inability to prevent movement and/or
impairment scale and history of fall in
an inability to quickly initiate postural
stroke
clinically
responses, and biomechanical constraints,
significant. This means trunk impairment
such as limited ROM and weight bearing
scale has an association with fall in stoke
activities, necessary to maintain postural
patients.
balance. It also results in poor motor
history of
fall
correlation
patients
and
between
which
is
coordination of the trunk and leg muscles

Trunk impairment in stroke patient may
into movement strategies with postural
cause disturbance in balance, because
control.
contribution of trunk for maintaining

balance is lost, due to which fall may
Some
occur or increase.3,
Stroke patients
tendency to deviate from the normal
frequently present balance abnormalities.
symmetrical trunk posture in sitting. They
Balance impairments increase fall risk. In
have reported more incidence of sitting
addition, poor trunk control negatively
imbalance.37 In the sitting position the
influences overall balance.32 Loss of trunk
body without trunk support, is unstable
control results in the inability to maintain
and its configuration has to be controlled
weight evenly over the pelvis that may
through muscle activity; when weight is
lead to fall. Trunk muscles are mostly
shifted in any plane, the trunk responds
involved in the construction of sitting
with a movement to counteract the
posture and also in more complex
change in the center of gravity. The CNS
5, 7
127
hemiplegic
patients
have
keeps the body center of mass within
clinicians, our finding indicates that those
specific spatial boundaries, referred to as
persons who scored above 20 on this
stability limits. Trunk stability also relies
assessment have a high probability of not
on correct perception of body attitude and
falling. The subjects who fall 1-2 times
on the development of adequate muscular
only were those who scored 18-20 and
responses.35 Thats why in stroke patients
those who scored 15-17 had a slightly
fall may occur at the time of movement
high frequency of fall. The subjects who
because trunk stability is lost and trunk is
fall most frequently were those who
not able to maintain center of gravity due
scored 7-10 and 11-14, not further away.
to CNS lesion.
That means as the score on trunk

impairment
Stability and dynamic stability are two
scale
increases,
the
probability of falling decreases and vice
important aspects of the sitting position.
versa.
Stability is the ability to reduce the

bodys motion or sway.35 Trunk Stability
We agree with some studies, who
requires appropriate muscle strength and
commented on the unclear relationship
neural control as well as adequate
between risk of falls and physical
position sense to provide a stable
impairments.13 A few of the subjects who
foundation
Trunk
scored in the most impaired range on the
spinal
balance test appeared to adopt strategies
stabilization, without adequate position
for minimizing their risk of falling (e.g.,
sense, the trunk cannot be stable. Even a
use of companions and assistive devices).
small impairment in trunk position sense
It may be due to so much of fear of fall,
may also contribute to trunk instability.36
thats why these patients have less history
As a consequence, independent sitting of
of fall. This finding emphasizes the
patients
generally
difference between risk of fall and the
disturbed, which may disturb balance and
presence of some physical impairment.
fall may occur.
Subjects who were the most physically
for
musculature
with
movement.
provides
stroke
some
is
impaired (limited in either ability to
So, on the basis of our finding we can say
ambulate or ability to transfer) did not
that trunk impairment is also an important
have the highest risk for falling because
factor responsible for balance disturbance
of their use of external supports. In
which may lead to fall incidence. For
comparison of others, some patients who
128
are not so much impaired but have more
I would like to express my gratitude and
falls may be due to some other factors.
sincerely thank to Dr. Naveen Ahuja

(Neuro-physician),
Here Trunk impairment scale (TIS)
physiotherapy
so it may be useful as a predictive tool.

importance
of
this
Shukla
improve
beneficial
for
individualized
designing
rehabilitation
(Physiotherapist),
Dr
Brijesh
their patients and to all the subjects who
trunk
participated in my study for their
performance and reduce the fall risk. This

is
Doon
the permission to carry out my study on
patients. Trunk impairment scale can be

to
department,
(Physiotherapist) Lucknow for giving me
evaluation of risk of falls in stroke
clinically
Wahidi
Hospital) Dehradun and Dr. Vijyendra
strong
correlation is that TIS will be helpful in
used
A.
(Physiotherapist), Dr. Tyagi (Head of the
shows a strong association with fall risk,
Clinical
Dr.
willingness and co-operation.
an
program
I would like to thank to Dr. Siddharth Sen
with emphasis on prevention of falls in
(Head
stroke patients.
physiotherapy) for his support. I sincerely

extend
ACKNOWLEDGEMENT
I
acknowledge
with
of
my
the
Department
respectful
gratitude
of
to
Dr.Umer Arfath for his constructive
gratitude
and
criticism and timely advice.
devotion to Almighty for bestowing me
I acknowledge gratefully for assistance
with knowledge and life that has enabled
extended by my friend Pallavi saxena. It
me to begin and complete this thesis
is my pleasure to thank my seniors, batch
successfully.
mates and juniors who directly or
It has been a privilege and a great
indirectly have helped me not only during
experience working under an esteemed
the study but also during the tenure of my
guide
lecturer,
course in the institute. Lastly, and
Department Of Physiotherapy Dolphin
importantly, I wish to express my deep
Institute Of Biomedical And Natural
sense of gratitude to my family, without
Sciences,
their
Dr.
Sunil
Dehradun,
Bhatt,
for
his
depth
unconditional
support
and
knowledge and constant support and
encouragement,
encouragement. I thank him for guiding
possible for me to reach this destination.
and supervising my work in every step.
129
it
would
not
been
REFERENCES
Davies PM, 2003. Right in the middle. 1st ed. New Delhi: Springer; p. 31-34.
Geert Verheyden and Alice Nieuwboer et al, 2007. Trunk performance after stroke: an eye
catching predictor of functional outcome. Neurology Neurosurgery and Psychiatry; 78:694698.
Muir SW et al, 2008. Use of the Berg Balance Scale for Predicting Multiple Falls in
Community-Dwelling Elderly People: A Prospective Study. Physical therapy; 88(4):449459.
Nieuwboer A et al, 2005. Discriminant ability of the Trunk Impairment Scale: a
comparison between stroke patients and healthy individuals. Disability & Rehabilitation;
27(17):1023-1028.
OSullivan SB and Schmitz TJ, 2007. Physical rehabilitation. 5th ed. New Delhi: Jaypee
Brothers; P. 705-722.
Suri P, K. and Kiely D et al, 2009. Trunk Muscle Attributes are Associated with Balance
and Mobility in Older Adults: A Pilot Study. PM R; 1(10): 916924.
Verheyden G and Nuyens G et al, 2006. Reliability and Validity of Trunk Assessment for
People with Multiple Sclerosis. Physical Therapy; 86(1):66-76.
Verheyden G et al, 2004. The Trunk Impairment Scale: a new tool to measure motor
impairment of the trunk after stroke. Clinical Rehabilitation; 18:326-334.
Verheyden G et al, 2006. Trunk performance after stroke and the relationship with balance
gait and functional ability. Clinical Rehabilitation; 20: 451_/458.
Verheyden G et al, 2007. Clinical tools to Measure Trunk Performance After Stroke: A
Systematic Review of the Literature. Clinical Rehabilitation; 21:387394.
CORRESPONDENCES
*M.P.T (Neurology), Dolphin (PG) Institute of Biomedical and Natural Sciences,
Dehradun, Uttaranchal. Address for Correspondence: C-158 Gita Niwas SectorA
Mahanagar Lucknow, Uttar Pradesh. Email: sumit.physio@gmail.com
**M.P.T (Neurology), Dolphin (PG) Institute of Biomedical and Natural Sciences,
Dehradun, Uttaranchal. Email: physiocare.sunil@gmail.com
130
EFFECT OF MUSCLE ENERGY TECHNIQUE AND SHOE

MODIFICATION ON THE RIGHT LATERAL TIBIAL SHIN PAIN IN
JOGGERS
Shahanawaz sd
ABSTRACT
Abstract: Background: 13-17% of runners are affected. Most commonly involved are male
runners. Anterior shin pain is more common and lateral shin pain more severe. So, my
purpose of study is to reduce the lateral shin pain in runners by using MET and shoe
modification. Hypothesis: There is a significant difference in applying the MET and shoe
modification in right lateral tibial shin pain.. Introduction: Shin splints syndrome of the
lower extremity encompasses several disorders that were previously considered unrelated
but today are viewed as belonging to the same spectrum of disorders which were once used
to describe any pain between the knee and ankle. The lower leg pain resulting from shin
splints is generally caused by very small tears in the leg muscles at their point of
attachment to the shin. Study Procedure: Experimental group is treated with MET of
posterior tibialis muscle of right leg and shoe modification along with RICE principle. The
patient is positioned in prone. The therapist should be near to the patient and apply the
pressure for the dorsiflexion and eversion repeating it 4 times in a session. Each patient is
also advised for self stretching. SHOES- Soft and flexible shoes may be comfortable at first.
Shoes should be rigid and bend only at the toes where the foot bends..The shoe should also
have wedged heel, to add a lift to heel and take stress off of the calf. The controlled group
is treated with only the RICE treatment. CONCLUSION: This study is being done to know
the effect of MET and shoe modifications on joggers right lateral tibial shin pain. While
there is evidence of pain reduction in the experimental group by MET technique and shoe
modification [mean value 2.4], the evidence of pain reduction in control group is very less
mean value is 6.2 .Shoes are soft and flexible shoes may be comfortable at first .Shoes
should be rigid and bend only at the toes where the foot bends .The shoe also have wedged
heel,to add a lift to heel and take stress off of the calf.
same spectrum of disorders which were

once used to describe any pain between
knee and ankle. The lower leg pain
resulting from shin splints is generally
caused by very small tears in the leg
INTRODUCTION
Shin splints syndrome of the lower
extremity encompasses several disorders
that were previously considered unrelated
but today are viewed as belonging to the
131
muscles at their point of attachment to the

shin.
Although the term shin splints
are often used to describe a variety of
lower leg problems, it specifically refers
to a condition called Medial Tibial Stress
Syndrome (MTSS). To better understand
shin splints, or MTSS, lets have a look at
the muscles, tendons and bones involved.
One of the most common injuries that are
experienced in Track and Cross- Country
is known as shin splints. 13-17% of
people are affected. Shin splints is a
common term used for a half a dozen
lower leg problems ranging from nerve
irritations to tendonitis to stress fractures.
The most common type experienced
involves the tearing away of the muscle
tissue that attaches to the front of the
lower leg. The connective sheath attached
to the muscles and bone of the lower leg
becomes irritated, resulting in a razorsharp pain in the lower leg along the
inside of the tibia or shin bone. Shin
splints can be felt anywhere from just
below the knee down to the ankle. The
pain may diminish after warming up but
then returns a few minutes after the
completion of a workout.
2/3rds. It may be caused by tendinitis of

the anterior compartment muscles,
especially the tibialis anterior. In stress
fracture of the tibia there is inflammation
of the periosteum around the tibia. The
tendinitis usually occurs where poorly
conditioned runners run on hard or
banked surfaces with poorly supporting
running shoes. This condition may also
occur with vigorous activity of the legs
following a period of relative inactivity.
The muscles in the anterior compartment
may be strengthened to balance the
stronger posterior compartment muscles
Review of Literature:
1. According to MELINA ANDREW,
AUSTRALIA.
Augmented low dye tape produces a
biomechanical effect which increases the
medial longitudinal arch height and
reduces the medial fore foot pressure
during walking and running.
2. According THACKER, GILCHRIST,
USA.
The use of shock absorbers in the sole of
foot wear reduces the shin splints in
runners.
A generic term for exercise related pain

in the lower leg, this may relate to
symptoms including stress fractures of
the tibia, and increased pressure inside
the muscular compartments of the leg,
amongst many other symptoms. Shin
splints are, an overuse type syndrome,
that may occur to anterior, posterior or
lateral muscle group of lower leg and are
caused by a similar mechanism of injury.
Shin splint syndrome or simply shin
splints refer to a pain or soreness along
the tibia, specifically the medial, distal
3. According to JOSHUA DUBIN, DC.

Shin splints are most successfully treated
with conservative care like rest, ice,
compression, and elevation.
4.
According
.MP,AUSTRALIA.
to
MOORE
Biomechanical
factors
that
are
correctable
by strengthening
and
flexibility exercises reduce the risk of
132
shin pain.
METHODOLOGY
Tapping technique is helpful to reduce

the shin pain in runners.
Experimental group was treated with

MET of posterior tibialis muscle of right
leg and shoe modification along with
RICE principle. The patient is positioned
in prone. The therapist should be near to
the patient and apply the pressure for the
dorsiflexion and eversion repeating it 4
times in a session. Each patient is also
advised for self stretching. SHOES- Soft
and flexible shoes may be comfortable at
first. Shoes should be rigid and bend only
at the toes where the foot bends..The shoe
should also have wedged heel, to add a
lift to heel and take stress off of the calf.
The controlled group is treated with only
The RICE treatment.
6. According to STEPHEN, UK.

Adding extra stress to the tibilais
posterior muscle with the torque test and
supporting any inhibition with a simple
taping procedure will assist the
physiotherapist greatly in getting the
patient well faster than ever before.
7. According to MATT CALLISION,
CANADA.
Acupuncture in athletes gives much pain
relief and is also more effective in
treating the shin pain
This study has been conducted to know

the effectiveness of the MET stretch in
right lateral tibial shin splints. In this
study, there are 2 groups. One
experimental group and another, a
controlled group. Each group consists of
15 patients.
Materials:
couch, pillows, Shoes ice cubes etc.
Study design: Experimental.
Study
setting:
Department
Physiotherapy, RK University.
of
The experimental group is treated with

MET stretching and shoe modification.
MET technique helps in reducing the pain
in the experimental group. Mean value of
2.4.
Study size: 30.

Groups: 2 groups.
1. Experimental
2. Controlled group.
Inclusive criteria:
The controlled group receives the

treatment in the form of rest, ice,
compression and elevation. Mean value is
6.2. On comparative analysis of both the
studies it is evident that there is greater
pain reduction with a mean value of 2.4
in experimental group.
Age group of 20-30 yrs.
DISCUSSION
Male joggers only.
The study is done to know the effect of
Study duration : 14 days.

2 sessions /day
5 days /week.
133
MET on reducing shin pain in joggers. In

this study the vas score is taken as 8.
There is reduction in the vas score to 5.
This may be due to the continuous
application of stretching and shoe
modification in the area of stress.
According to Stephen, department of
physical therapy USA, there is an
evidence that application of stretching
decreases shin pain. It has also been
observed that application of the MET
stretch helps in increasing the range of
motion of knee and ankle joints. This is
because of the proprioceptive stimulation
of muscles in focus
lateral tibial shin pain in joggers. This

study is being done to know the effect of
MET and shoe modifications on right
lateral tibial shin pain in joggers. While
there is evidence of pain reduction in the
experimental group by MET technique
and shoe modification [mean value 2.4],
the evidence of pain reduction in control
group is very less [mean value 6.2].
SHOES- Soft and flexible shoes may be
comfortable at first. Shoes should be rigid
and bend only at the toes where the foot
bends..The shoe should also have wedged
heel, to add a lift to heel and take stress
off of the calf
CONCLUSION
So, my hypothesis that pain can be

reduced using taping technique is
accepted and alternated hypothesis is
rejected.
The study is done to know the effect of

MET and shoe modifications on right
REFERENCES
1. Good ridge JP. Muscle Energy Technique; Definition, .J An osteopath
meathodology. Dec 1981: 81 (4) : 249-259.
2. Roberts BL. Soft tissue manipulation; Neuromusculmuscular and Muscle Energy
Technique. J Neuroscience Apr 1997; 29(2) : 123-27
3. Chai tow L.Muscle Energy Techniques. 3rd ede. Philadelphia: Churchill
Livingstone Elsevier 2006.
4. Susan S.ADLER, DOMINIEK BECKERS, MATH BUCK Proprioceptive
Neuromuscular Facilitation in Practice. An illustrated guide third edition.
5. Sara Cuccurullo, MD.Physical Medicine and Rehabilitation Board Review . Demos
Medical Publishing; 2004.ISBN-10: 1-888799-45-5
6. William Prentice Foundations of Sport and Exercise Psychology With Web Study
Guide- 5th edition
7. Robert Weinberg and Daniel Gould (Nov 15, 2010)Principles of Athletic Training:
A Competency- Based Approach
8. Chad Starkey PhD AT FNATA and Sara D. Brown MS Examination of Orthopedic
and Athletic Injuries by ATC (Sep 1, 2009)
CORRESPONDENCES
134
Assistant Professor, School of Physiotherapy, RK University. Shahanawaz.syed@rku.ac.in,

Shanu.neuropt@rku.ac.in; Mob :8238570233
135
SHORT COMMUNICATION
BELLS PALSY AND ITS IMPACT ON VARIOUS AREAS OF

OCCUPATION
Mr. Guruprasad.V*, Mrs. Banumathe.KR**
ABSTRACT
Abstract: Text here
Keywords: Text here
Areas of occupation are the various kinds
Areas of Occupation affected due to
of life activities in which people engage,
Bells palsy
such as Activities of Daily Living(ADL),
Activities of Daily Living (ADL) &
Instrumental Activities of Daily Living(I-
Instrumental Activities of Daily Living
ADL), rest and sleep, education, work,
(I-ADL)
play, leisure and social participation[1].
ADL are the activities that are oriented
Bell's palsy is a peripheral palsy of the
toward taking care of ones own body and
facial nerve that results in muscle

weakness
on
one
side
of
I-ADL are the activities to support daily
the
life within home and community that
face. Affected patients usually develop
often require more complex interactions
unilateral facial paralysis over one to
than self-care used in ADL [1].
three days with forehead involvement and
Clients
complain
with
Bells
Difficulties with eating such as
typically
food and saliva can pool in the
or complete
affected side of the mouth and
palsy
of weakness
[2]
no other neurological involvements
paralysis of one side of face, loss of facial
may spill out from the corner.
creases and nasolabial folds, mouth
Difficulty
deviation
side,
without spilling as water drools
drooping of corner of mouth and inability
from one side of mouth feel
to completely close the eyelids.
embarrassed to drink water in
towards
unaffected
136
in
drinking
water
common places as other people
Difficulties in giving a social
might watch.
smile
Difficulties in I-ADL such as
persons such as friends and
going out using public transport,
colleagues as to avoid facial
going for shopping groceries,
disfigurement.
participating
religious
Difficulties in going back to job/
observance such as going to
work due to disfigurement of face
temple or church due to facial
(face deviation
disfigurement.
especially people working with
Eye irritation, dryness and pain
public relations as they need to
affecting
explain each of them they met
in
the
quality
of
when
meeting
to
known
one side)
performance of daily tasks
about the condition
Feeling of numbness and pain
Subjectively clients with Bells
from paralysis causing general
palsy feels depressed and stays
discomfort.
hidden from others for even

months
Work and Social Participation
Not willing to attend or anxious to
Work includes activities needed for
attend functions as videos/ photo
engaging in remunerative employment or
sessions will be there.
volunteer activities. Social participation
Tears spills from the eye creating
is the organized patterns of behavior that
an appearance of crying causing
are characteristic and expected of an
discomfort.
individual or a given position within a
Causes psychological distress and
[1]
social system .
affects
self-esteem
and
self-
confidence
REFERENCES
1. Occupational therapy Practice Framework: Domain and Process. 2nd ed. American
Occupational Therapy Association, Inc.; 2008.
2. Jeffrey DT, Nandini K. Bells Palsy: Diagnosis and Management. American Family
Physician.2007; 76 (7): 997-1002.
137
CORRESPONDENCES
*Assistant Professor, Department of Occupational Therapy, School of Allied Health
Sciences, Manipal University, Manipal- 576104, Karnataka; PHONE: 09035120310; 0820
2922220; EMAIL: guruprasad.v@manipal.edu; guruprasad02@gmail.com
**Assistant Professor- Senior Scale, Department of Occupational Therapy, School of
Allied Health Sciences, Manipal University, Karnataka
138
CASE REPORT
Heterotropic Pregnancy-An Unusual Case Managed Successfully

Sudha Rani, E.Ramadevi, N.Mamata, N.C.Rama, G.B.Madhavi, Chandramathi,
V.Kavitha, Arjumand Bano, Neeraja, Loukya
ABSTRACT
Expectant management for tubal heterotopic pregnancy could be considered as a
successful option in a symptom-free patient where the ectopic embryo has a limited
craniocaudal length with no cardiac activity. We report the obstetric outcome after
expectant management for a left tubal heterotopic pregnancy. Heterotopic pregnancy was
recognized at 9 weeks gestation in a 25 year-old woman with one previous caesarean
section 3 yrs back who came with a presentation of ruptured ectopic pregnancy and was
managed expectantly.
Keywords: Expectant management, heterotopic pregnancy, pelvic inflammatory disease
assay, expectant management has been

successfully applied.[2,3] This form of
conservative management can also be
applied to heterotopic pregnancies having
a similar clinical appearance. In expectant
management, no treatment is given and
the patient is followed closely with
weekly transvaginal ultrasonography.[4]
We report a case of successful expectant
management of tubal heterotopic
pregnancy.
INTRODUCTION
Heterotopic
pregnancy,
a
rare
phenomenon in the past, is now becoming
more common because of assisted
reproductive technique. Heterotopic
pregnancies have increased alongside the
advent
of
assisted
reproductive
technique.[1] Ectopic pregnancy is a
gynecologic
emergency,
generally
requiring expeditious surgical or medical
treatment. However, in a small number of
cases in which the risk of tubal rupture is
minimal, expectant management is
appropriate. In patients in whom the
diagnosis of ectopic pregnancy can be
made without laparoscopy and who
sonographically demonstrate an unruptured gestation and a persistent
downward trend to the beta-human
chorionic gonadotrophin (beta-hCG)
CASE REPORT
25 yrs old P1L1 with one previous section
3years back came with the complaints of
2MA with pain abdomen. O/E patient
was pale and in a state of shock .On P/A
LIF tenderness was present,there was also
guarding and rigidity. On bimanual
examination uterus was 8-10 weeks size,
left fornicial tenderness was present, no
139
Hemoperitoneum was present (

500 ml)
Left tubal ectopic pregnancy was
present
Uterus bulky
Rt ovary, fallopian tube normal.
PROCEDURE- left tubal ectopic
resection & salpingectomy was done
laproscopically.
Post operatively patient was given INJ
HCG & kept on oral progesterone 200mg
at bed time & reviewed after 15 days.
bleeding.
USG was done and it showed LIVE intra

uterine fetus with average gestational age
of average
gestational age of 13weeks
2days. The histopathological examination
of tissue confirmed a left tubal ectopic
pregnancy. Pt was reviewed regularly in
our antenatal OP and USG was done
frequently. The intra uterine pregnancy
was terminated by El.LSCS at 38wks of
gestation for CPD and a live male baby of
b.wt 3.2kg is delivered.
USG was suggestive of 1) Single live

intrauterine
fetus
with
average
gestational age 9 weeks 3days with
adjacent perisac collection.
2) Mixed echogenic mass noted in left
adnexa. Mild free fluid with internal
echoes noted in peritoneal cavity. p/o left
ruptured ectopic pregnancy As it was a
ruptured ectopic pregnancy she was
posted for sugery .
DISCUSSION
Heterotopic pregnancy is a diagnostic
masquerader. A universal characteristic
of a good early diagnostic protocol is a
high index of suspicion. Spontaneous
heterotopic pregnancy is a rare event and
the incidence is 1: 30,000 pregnancies.[2]
As more and more infertile couples turn
to assisted reproductive technique, the
incidence of heterotopic pregnancy has
expectedly increased from 1.9% to
2.9%.[5] If the patient has had history of
previous pelvic inflammatory disease or
tubal pathology, there will be an obvious
increase in rate of occurence of
pregnancies.[7]
INTRA OPERATIVE FINDINGS
The most important aid in the diagnosis

of heterotopic pregnancy is the utilization
140
intrauterine gestations has been widely

used. More recently this approach has
been used to manage heterotopic
pregnancy. Wright et al. reported a case
of selective embryo reduction of the tubal
gestation of a heterotopic pregnancy
resulting from IVF-embryo transfer, but
this resulted in a hematosalpinx requiring
mini-laparotomy and salpingectomy.[12]
of
high-resolution
transvaginal
ultrasonography.[6,7]
In
high-risk
patients, especially those who have
conceived with assisted reproductive
technique, a routine ultrasound scanning
for ectopic or heterotopic pregnancy at 4
and 6 weeks after transfer of embryos is
recommended. On the other hand,
abdominal pain, rebound tenderness, fluid
in the POD at trans-vaginal scan (TVS)
examination and a low serum hemoglobin
percentage were independent predictors
of tubal ruptures or active bleeding.
CONCLUSION
We can conclude that HTP must always
be considered in patients presenting with
abdominopelvic pain in the face of a
documented IUP, because the presence of
an IUP can no longer be considered
reassuring and a HTP has to be ruled out.
Thus, we recommend that all patients
shown on USG to have an IUP should be
given a comprehensive pelvic ultrasound
so that the possibility of a simultaneous
HTP may be excluded. We also
emphasize the need for prompt and
immediate action at the first sign which
indicates a HTP, to avoid missing this
potentially life-threatening condition. A
HTP,though extremely rare,can still result
from a natural conception.It requires a
high index of suspicion for early and
timely diagnosis.A timely intervention
can result in a successful outcome of the
intrauterine fetus.
The
management
of
heterotopic
pregnancy still remains controversial.
Operative management is still a mainstay,
but it involves surgical and anesthetic risk
to both the mother and fetus.[8] Although
it has been reported that laparotomy does
not seem to interrupt intrauterine
pregnancy,[9] others have reported a 40%
loss of viable fetuses.[10] Several others
have mentioned the value and safety of
laparoscopy in the diagnosis and
treatment.[11] Methotrexate with its
potential adverse effects on the
intrauterine gestation and RU486 a
prostaglandins, with their potential effect
on uterine contractility, are not options in
the treatment of ongoing heterotopic
pregnancy. The injection of potassium
chloride to selectively reduce multiple
REFERENCES
1. Klipstein S, Oskowitz SP. Bilateral ectopic pregnancy after transfer of two embryos.
Fertil Steril. 2000;74:8878.
2. Yao M, Tulandi T. Current status of surgical and non-surgical treatment of ectopic
pregnancy. Fertil Steril. 1997;67:42133.
3. Lautmann K, Staboulidou I, Wstemann M, Gnter H, Scharf A, Hillemanns P.
141
Heterotopic pregnancy: Simultaneous intrauterine and ectopic pregnancy following IVF

treatment with the birth of a healthy child. Ultraschall Med. 2009;30:713.
4. Montilla F, Amar P, Boyer S, Karoubi R, Diquelou JY. Heterotopic pregnancy: A case
report with a rare symptomatology. J Gynecol Obstet Biol Reprod (Paris) 2007;36:3025.
5. Luo X, Lim CE, Huang C, Wu J, Wong WS, Cheng NC. Heterotopic pregnancy
following in vitro fertilization and embryo transfer: 12 cases report. Arch Gynecol Obstet.
2009;280:3259.
6. Dor J, Seidman DS, Levran D, Ben-Rafael Z, Ben-Schlomo I, Mashiach S. The
incidence of combined intrauterine and extrauterine pregnancy after in vitro fertilization
and embryo transfer. Fertil Steril. 1991;55:8334.
7. Seoud AA, Saleh MM, Yassin AH. Spontaneous heterotopic pregnancy: A successful
outcome. Clin Exp Obstet Gynecol. 2007;34:2523.
8. Demirel LC, Bodur H, Selam B, Lembet A, Ergin T. Laparoscopic management of
heterotopic cesarean scar pregnancy with preservation of intrauterine gestation and delivery
at term: Case report. Fertil Steril. 2009;91:1293.e57.
9. Divry V, Hadj S, Bordes A, Genod A, Salle B. Case of progressive intrauterine twin
pregnancy after surgical treatment of cornual pregnancy. Fertil Steril. 2007;87:190.e13.
10. Louis-Sylvestre C, Morice P, Chapron C. The role of laparoscopy in the diagnosis and
management of heterotopic pregnancies. Hum Reprod. 1997;12:11002.
11. Mol BW, Hajenius PJ, Engelsbel S, Ankum WM, Van der Veen F, Hemrik DJ, et al.
Can noninvasive diagnostic tools predict tubal rupture or active bleeding in patients with
tubal pregnancy? Fertil Steril. 1999b;71:16773.
12. Wright A, Kowalczyk CL, Quintero R, Leach RE. Selective embryo reduction in a
heterotopic pregnancy using potassium chloride injectionresulting in a hematosalpinx.
13. Wang YL, Yang TS, Chang SP, Ng HT. Heterotopic pregnancy after GIFT managed
with expectancy: A case report. Chin Med J (Taipei) 1996;58:21822.
14. Sentilhes L, Bouet PE, Gromez A, Poilblanc M, Lefebvre-Lacoeuille C, Descamps P.
Successful expectant management for a cornual heterotopic pregnancy. Fertil Steril.
2009;91:934.e113.
15. Verma U, Goharkhay N. Conservative management of cervical ectopic pregnancy.
16. Kirk E, Condous G, Bourne T. The non-surgical management of ectopic pregnancy.
Ultrasound Obstet Gynecol. 2006;27:91100.
142
CORRESPONDENCES
Dr. Sudha Rani, MD(OBG), Professor, Department of Obstetrics & Gynecology; Chalmeda
AnandRao institute of Medical Sciences, Karimnagar-505001, India. E-mail:
shanmugampt@rediffmail.com
143
HYPERTENSION IN PREGNANCY STUDY IN A TEACHING

HOSPITAL IN A RURAL AREA IN ANDHRA PRADESH, INDIA.
Kavitha Kothapally*, Ramdas J**, Srinivas S***, Srinivas Pallerla****, Madoori
Srinivas*****, Sandeep G******, Sindhu Y*******
ABSTRACT
In pregnant women hypertention is one of the common cause of mortality and morbidity in
Indian women. We conducted study on Two hundred and eight pregnant women consisting
of 101 primi gravidae, 74 Gravidae 2 and 33 multigravidae. We screened these pregnant
women for hypertension between January 2013 to July 2013 at Bhaskara General Hospital
and Bhaskara Medical College, Yenkapally, Moinabad mandal, Rangareddy District,
Hyderabad, Which is a tertiary Care Hospiral caters most of the rural areas of Hyderabad
& Nalgonda Districts. Hypertension was noted in 17 (8.2%) of pregnant women. Majority
of pregnant women in the study population were primi gravidae (48.56%). Nearly 80% of
hypertensive pregnant women were primi gravidae. 88.24% developed hypertension is III
trimester. Complications like preeclampsia was seen in 23.52%. We conclude that
pregnancy induced hypertension is the common variety of Hypertension in pregnant
women. It is commonly seen in primigravidae who are exposed to the trophoblastic tissue
for the first time.
Key words: Hypertension, Pregnancy, Complications
INTRODUCTION
Hypertension in pregnancy most common
Eclampsia) is difficult to treat. Eclampsia
medical complication. It ranges from a
and preeclampsia contribute to death of
mild to severe and major cause of
one women every 3 minutes world wide.
maternal & perinatal morbidity and
Hypertensive disorders in pregnancy are
9.
mortality
Hypertension
during
pregnancy
(Pregnancy
induced
Hypertension
(PIH),
the third leading cause of maternal

mortality
Preeclampsia,
after
other
causes
like
hemorrhage & sepsis. Preeclampsia is a

144
pregnancy specific syndrome. It occurs in
c)
Preeclampsia
5% of all pregnancies, 10% of first
superimposed
pregnancies and 20-25% of women with
Hypertension.
chronic hypertension. There are only
d)
syndrome
on
chronic
Chronic hypertension
isolated documentations of hypertension
Maternal diastolic blood pressure of more
in pregnancy in India1,3. Hypertension is
than 110 mm Hg is associated with an
present in 6-8% of young women of child
increased risk for abruptio placentae,
bearing age but the prevalence increases
intrauterine
with advancing age and in women with
premature delivery and intrauterine fetal
diabetes mellitus, primary renal disease
death4. Severe maternal complications
(or) collagen vascular disease reaching up
include eclamptic seizures, intracerebral
to 20% in such population 1. The question
haemorrhage, pulmonary edema, Acute
of whether hypertension in pregnancy and
renal failure, proteinuria greater than
specifically pre-eclampsia are a marker
4.5g/dl, liver dysfunction, disseminated
for cardio-vascular disease later in life
intravascular
has implications for health promotion in
consumptive coagulopathy
women, similar to the link between
mortality and morbidity are also high due
gestational
to chronic placental insufficiency and
diabetes
and
the
later
fetal
growth
retardation,
coagulation
and
perinatal
growth restriction of fetus.
development of a clinical diabetic state.

To evaluate such a risk, long follow up
will be necessary.
MATERIAL & METHODS
Working group of National High Blood
The present prospective study was carried
Pressure
out
Education
Program
2000
jointly
in
the
department
of
classification of hypertensive disease is as
Gynaecology & Obstetrics & Department
follows 2.
of General medicine between January
a)
Gestational
2013 to July 2013. About 208 pregnant
Hypertension
(formerly
added
PIH
(or)
transient
hypertension
of
women attending the antenatal out patient
pregnancy).
b)
Preeclampsia
&
department
were
screened
for
hypertension.
Blood
pressures
were
measured in the supine, left lateral and
Eclampsia
sitting positions in both the upper limbs.
syndrome
Systolic blood presence of more than
145
140mm Hg and diastolic blood pressure
<140/90mm
of more than 90mm Hg are taken as cut
Blood
Hg
off values for labeling a pregnant woman
Pressure
140/90 &
as
hypertensive.
Disappearance
of
17 (8.2%)
above
Kortakoff sound phase V was taken as cut

off
for
diastolic
blood
53 (25.48%)
Present
pressure
Edema
measurement. Age, parity, gestational age
Absent
at which blood pressures are recorded,
155 (74.52%)
previous obstetric history of pregnancy

induced
hypertension
complications,
hypertension
family
&
Edema with
and
its
Edema
hypertension
history
of
with
Present
hypertens
Edema with
ion
hypertension
diabetes
191 (91.83%)
mellitus,
presence of pedal edema (or) anasarca,
9 (52.94%)
8 (47.06%)
excess weight gain are noted. Relevant
Absent
laboratory investigations like complete
< 25
173 (83.17%)
> 25
35 (16.83%)
III Trimester
15 (88.24%)
II Trimester
1 (5.88%)
I Trimester
1 (5.88%)
BMI
urine examination, random blood sugar,

liver function tests, renal function tests
were done and values are noted, Results
obtained were tabulated and analysed.
Trimester
Table I Demographic charaeteristics

of pregnant women
Variables
No of cases
Age
20 & less Yrs.
70 (33.65%)
Group
21-34 Yrs.
138 (66-34%)
Primigravidae
101 (48.56%)
Parity
Table
(%)
II
Complications
of
Hypertension in Pregnancy in study

population
Gravida 2
Gravida3 &
above
74 (35.58% )
33 (15.87%)
146
Complications
No of Cases ( % )
Preeclampsia
4 (23.52%)
Eclampsia
1 (5.88%)
Severe HTN
1 (5.88%)
No complications
11 (64.71%)
increased risk of high blood pressure in

Table III
later life
Investigations in study
21, 22
. In the population studied,
blood pressure of 140/90 mm Hg &
population
Investigation
No. of cases
above was seen in 17 pregnant women.
(%)
This accounts to an incidence of 8.2%.
Present
4 (23.53%)
Absent
13 (76.47)
Hypertensive
Proteinuria
Serum uric acid > 40mg/dl
Abnormal LFT, RFT
Coagulation profile, ECG
disorders
complicating
pregnancies have been reported in 6-8%

and may go upto 20% 2. Proteinuria is
10 (58.82%)
seen in only 23.53% and majority of

hypertensive women had no proteinuria.
Normal
This shows that gestational hypertension

or pregnancy induced hypertension is the
RESULTS
type of hypertension commonly seen in
Out of 208 pregnant women, 33.65%
pregnancy.
were less than 20yrs, 66.34% were
hypertension and chronic hypertension
between 21-34 yrs. Privigravida (48.56%)
were responsible for hypertension in 96%
were more than gravidac 2 (35.58%) and
and 4% of cases respectively in an Indian
multigravida (15.87%), 17 (8.2%) were
study
hypertensive (Table - I). Edema is present
common. Edema is seen in upto 80% of
in 25.48% of pregnant women & 52.94%
normal
of hypertensive women had edema. Most
invariably in preeclampsia & eclampsia
of high blood pressures were noted in III
pathologic edema is the first sign of PIH.
trimester (88.24%). 83.17% of pregnant
Excess weight gain (gaining more than
women had normal BMI. Table II shows
kg per week of gestation) is the first
Preeclampsia is a common complication
symptom
(23.52%). Proteinuria was absent in
hypertension. Preeclampsia is seen in 10-
76.47%, raised serum uric acid was seen
15% of primigravidae with hypertension
in 58.82% & other investigations were
and
normal (Table III ).
Preeclampsia
Pregnancy
induced
, chronic hypertension is not
pregnant
of
women
pregnancy
5.7-7.3%
is
in
hence
&
seen
2
induced
multigravida6.
peculiar
to
pregnancy. Elevated serum uric acid

DISCUSSION
levels more than 4 mg/dl indicate fetal
Hypertension in pregnancy has
compromise and indicate need to deliver
long been suspected of heralding an

147
the fetus as early as possible. Serum uric
have since independently indicated a
acid level of more than 5.5 mg/dl is
significantly increased risk of myocardial
consistent with preeclampsia and above 6
ischaemia and related cardiovascular
indicates serious disease when liver
disease later in life in women who had
dysfunction and mild elevation of serum
hypertensive disorder in pregnancy13-16.
transaminases occurs 8. LFT, RFT Blood
Pregnancy hypertension may not only be
coagulation profile, ECG were normal in
an expression of underlying genotypic
the study population. Ophthalmoscopy
and phenotypic hypertensive tendency
showed
17,18
normal
fundus.
Retinal
but have its own adverse and long
vasospasm is a manifestation of severe
time effect on the endothelium and the
maternal disease. The study populations
cardiovascular system
with high blood pressures were picked up
with pre-eclampsia or eclampsia should,
early and hence they did not have
therefore receive follow up and health
complications. Incidence of preeclampsia
care advice with regard to lifestyle,
is increased with twins & previous
nutrition and weight control.
history
of
eclampsia
Pregnancy
Pregnancy
without serious sequelae, but a link to
population
of pre-eclamptic and eclamptic women10
pregnancy
requires
large
in sitting position with cuff at level of
et.al, study
heart. Majority of deaths are preventable

if pregnancy induced hypertension is
disease are higher in women who had

in
small
seen. Blood pressure should be measured
shown death rates from ischaemic heart
hypertension
is
Chronic Hypertension is less commonly
in
women who had suffered myocardial

23
is
population studies to confirm the same.
and from an increased incidence of
infarction11. Gerdur A
hypertension
In our study this is confirmed. But study
suggested from an early follow up study
observed
induced
predominant in Indian pregnant women.
cardio-vascular disease in later life was
pre-eclampsia
. Women
CONCLUSION
hypertension is usually thought to resolve
previous
19,20,21
detected and treated early.
when
compared with the general population,

and that this risk might be linked to
increasing severity of the disease in
pregnancy12. Four subsequent studies
148
REFERENCES
1. Hypertension in Pregnancy: Hospital based study J. Prakash, HK Panday, AK Singh,
Bhaskar; JAPI Vol .54, April 2006.
2. Report of NHBPEP Working group on high blood pressure in pregnancy, Am. J. Obst &
Gynaec 183:31:S22 2000
3. American College of Obstetrics & Gynaecology Hypetension in Pregnancy. ACOG
Technical bulletin No. 219, Washington DC 1996-8.
4. Hypetension in Pregnancy, Sandhya Akanath; JAPI Vol. 54 April 2006.
5. Long PA, Oats JN. Preeclampsia in Twin pregnancy, Severity & Pathogenesis - ACCST
NZJ Obst & Gynaec 1987:27:1-5
6. Long PA, Abell DA, Brischer NA, Parity & Preeclampsia ACCST NZJ Obst & Gyneac
1979
7. Yadav S, Saxena V, Yadav P, Gupta S, Hypertensive disorders of Pregnancy & Maternal
fetal outcome Case Controlled study JIMA 1997, 95:548 51.
8. Pallea MS Hypertension in Pregnancy, Journal of AM SOC Nephrol 1998 314-21.
9. Canadaian Hypertension society consensus conference, CMAJ. Sert.15.1997; 157 (6)
10. Chesley LC, Annitto JE. Cosgrove RA. The remote prognosis of eclamptic women. Sixth
periodic report. Am J Obstet Gynecol 1975; 124; 446 459.
11. Mann JL, Doll R, Thorogood M, Vessey MP, Waters WE. Risk factors for myocardial
infarction in young women. Br J Prev Soc Med 1976; 30; 94 100.
12. Hannaford P, Ferry S, Hirsch S. Cardiovascular sequelae of toxaemia of pregnancy. Heart
1997; 77; 154 158.
13. Jonsdottir LS, Arngrimsson R, Geirsson RT, Sigvaldason H, Sigfusson N, Death rates
from ischemic heart disease in women with a history of hypertension in pregnancy. Acta
Obstet Gynecol Scand 1995; 74; 772 776.
14. Smith CS, Dell JP, Walsh D, Pregnancy complications and maternal risk of ischanemic
heart disease: a retrospective cohort study of 129290 birth, Lancet 2001;357;2002 2006.
15. Irgens HU, Reisaeter L, Irgens L, Lie RT, Long term mortality of mothers and fathers
after pre-eclampsia: population based cohort study. BMJ 2001; 323; 1213 1216.
16. Wilson BJ, Watson MS, Prescott GJ, et al, Hypertensive diseases of pregnancy and risk of
hypertension and stroke in later life: results from a cohort study.BMJ 2003; 326; 845 851.
149
17. Roberts JM. Endothelial dysfunction in preeclampsia. Semin Reprod Endocrinol 1998;
16; 5 15.
18. Sattar N, Ramsay J, Crawford L, Cheyne H, Greer IA. Classic and novel risk factor
parameters in women with a history of preeclampsia. Hypertension 2003; 42; 39 - 42.
19. Ness RB, Roberts JM. Heterogenous causes constituting the single syndrome of
preeclampsia: a hypothesis and its implications. Am J Obstet Gynecol 1996; 175:1365
1370.
20. Levine RJ, Maynard SE, Qian C, et al. circulating angiogenic factors and the risk of
preeclampsia, N Engl J Med 2004;350;672 683
21. Svensson A, Andersch B, Hansson L, A clinical follow-up study of 260 women with
hypertension in pregnancy. Clin Exp Hypertens, B, Hypertens Pregnancy 1983; 2; 95 102.
22. Sibai BM, El-Nazer A, Gonzalez-Ruiz A, Severe preeclampsia-eclampsia in young
primigravid women: subsequent pregnancy out come and remote prognosis. Am J Obstet
Gynecol 1986; 155; 1011 1016.
23. Gerdur A. Arnadottir, et.al Cardiovascular death in women who had hypertension in
pregnancy: a case control study, International Journal of Obstetrics and Gynaecology, March
2005, vol.112, pp. 286-292s
ACKNOWLEDGMENT
We thank Management of Bhaskara Medical College allowing us to conduct this study, and
pregnant women who has given consent, DTP operator Mr.G.Ramesh helping in manuscript
typing and editing.
Contribution: KK- concept, guiding clinician, RJ - manuscript drafting; SS, SG, SY- Review
of literature; SP, MS - manuscript review, finalized manuscript
Conflict of interest: None
Role of funding source: None.
CORRESPONDENCES
* Professor of Obstetrics & Gynecology, Bhaskara Medical College, Yenkapally, Rangareddy
(Dist), Andhra Pradesh, India. Email: shanmugampt@rediffmail.com
**Assistant Professor, Department of Medicine, Bhaskara Medical College, Yenkapally,
150
Rangareddy District, Andhra Pradesh.

***Professor of Medicine, Fathima Institute of Medical Sciences, Kadapa, Andhra Pradesh.
****Assistant Professor of Medicine, Bhaskara Medical College, Yenkapally, Rangareddy
District, Andhra Pradesh.
*****Professor, Department of Paediatrics, CAIMS, Karimnagar, Andhra Pradesh.
******Resident, Department of Paediatrics, CAIMS, Karimnagar, Andhra Pradesh.
*******Internee, CAIMS, Karimnagar.
151
PHYTOCHEMICAL ANALYSIS AND ANTIMICROBIAL ACTIVITY

OF CHLOROPHYTUM BORIVILIANUM AGAINST BACTEIAL
PATHOGEN CAUSING DISEASE IN HUMANS
Syed Rehan Ahmad*, Dr. Abul Kalam**, Dr. Kishan Pal***
ABSTRACT
The present communication deals with in vitro analysis of Antibacterial activity of extract
of leaves and stem of Chlorophytum borivilianum Santapau and Fernandez ( Liliaceae ).
The result of the preliminary investigation revealed the presence of alkaloids, glycosides
nucleus, Saponins and tannins in leaves as well as in stem. The antimicrobial activity of
leaves and stem extract of Chlorophytum borivilianum was studied against four bacteria
among them two are Gram ve bacteria (Escherichia coli & Klebsiella pneumonia ) and
two are Gram +ve positive bacteria ( Staphylococcus aureus & Bacillus subtilis .) by agar
disc cup diffusion method . Zone of inhibition produced by different extracts was tabulated .
Only the aerial parts of plant inhibited the growth of bacteria at the concentration of
1000mg/ml and 500 mg/ml respectively . Extract Showed maximum antibacterial activity
against all organisms tested in order of sensitivity as Staphylococcus > Bacillus subtilis >
Klebsiella > Escherichia coli.
Keywords: Chlorophytum borivilianum, safed musli, leaves and stem extract, antibacterial
activity, zone of inhibition.
INTRODUCTION
maximum height of 40 to 47 cm. Tubers
The WHO estimated that 80% of the
can grow upto a depth of
worlds population depends on traditional
Chorophytum borivilianum is a little
medicines for meeting their primary health
annual herb that grows proficiently
care
Chlorophytum
tropical and sub-tropical climates with
is a wonderful medicinal
altitudes upto 1500 meters (Kaushik 2005
herb with sub-erect lanceolate leaves and
) . In India 17 species of Chlorophytum
tuberous root system belonging to the
borivilianum are found and 256 species
family Liliaceae. It can grow upto a
are found over the home planet, and out of
needs
borivilianum
[1].
152
26 cm .
in
17
species,
species
Chlorophytum
namely as
Pradesh etc. Based on agro climatic
borivillianum,
suitability, it can be cultivated in Eastern,
Chlorophytum
arundinaceam
and
Western, Central and Southern Plateau and
Chlorophytum
tuberosum
are
Hill regions, East and West Coast Plains
commercially cultivated by the Indian
and Hill regions and Gujarat Plains and
farmers but Chlorophytum borivillianum
Hill regions comprising the states of Bihar,
is the only species, which is under
Orissa,
commercial cultivation.
Karnataka, Kerala, Tamilnadu and Gujarat.
Chlorophytum borivilianum has good
The
market both indigenously and globally. It
recognized Safed musli as 6th important
is an annual crop capable of giving good
herb to be protected and promoted. The
returns
irrigated
Board encourages mainstream cultivation
conditions. Safed musli is found growing
of Safed musli by farmers by extending a
in thick forests in its natural form. The
subsidy
roots of safed musli are reported to contain
Horticultural Board on project cost.
2-15% saponin, which has the medicinal
C. borivilianum is a plant well known for
property
and
its aphrodisiac as well as immunodilatory
immunity to human beings. Because of its
activity [2]. C. borivilianum is traditionally
medicinal property, safed musli is known
used for treating oligospermia, pre- and
as divya aushadhi and ayurvedic plant.
postnatal infections, arthritis, diabetes and
Mainly its tuberous roots are used in
dysuria [35]. Its antiviral, anticancer,
ayurvedic medicines.
immunomodulatory,
to
farmers
of
under
enhancing
vitality
Safed musli is
Uttar
Pradesh,
Medicinal
of
Plants
20%
Rajasthan,
Board
through
has
National
antidiabetic,
cultivated in most states of the country, the
antistress,
and
anti-inflammatory
prominent amongst them being Madhya
properties have been
evaluated [611].
Pradesh, Maharashtra, Punjab, Andhra

Safed Musli contains carbohydrates (35-
glucose, fructose, galactose, mannose and
45%), fiber (25-35%), alkaloids (15-25%),
xylose.
saponins (2-20%), and proteins (5-10%). It
alkaloids are chief medicinal compounds
is a rich source of over 25 alkaloids,
presents in the roots . As a lot research
vitamins, proteins, carbohydrates, steroids,
work have been done on roots of C.
saponins, potassium, calcium, magnesium,
borivilianum that is why our interest
phenol,
and
restricted in extract of leaves and stem of
polysaccharides and also contains high
the said plant and its efficacy on bacteria .
resins,
mucilage,
quantity of simple sugars, mainly sucrose,

153
Among
them
Saponin
and
2.METERIALS AND METHODS
Air- dried and powdered plant materials
2.1. Plant collection and authentication
were
alkaloids, glycosides, saponin glycosides,
screened
for
the
presence
of
steroids and tannins using the methods

[3,4]
The leaves (120 g) and stem (550 g) of C.
described by
borivilianum was collected from the herbal
2.4. Microorganisms
garden of Shri Venkateshwra University,
Four human pathogenic bacteria made up
Gajraula, U.P and authenticated by Prof,
of two Gram- positive (Staphylococcus
Krishan Pal, Dept . Microbiology,
aureus and
Venkateshwra
University,
Shri
Gajraula,
Bacillus subtilis ) and two
Gram- negative bacteria (Escherichia coli
U.P,India - 244236 .
and Klebsiella pneumonia ) were used for
2.2.Plant preparation and extraction :
the
The leaves and stem of C. borivilianum
microorganisms were obtained from the
was washed thoroughly under running tap
laboratory stock , Dept. of Microbiology ,
water dried on paper towel then aerial
Shri Venkateshwra University, Gajraula,
parts of it blender, it was extracted in
U.P
petroleum
2.5. Media
ether
and
methanol
by
antibacterial
assay,
All
the
macerating at room temperature (30 C)
For culturing the bacteria we have used
for 72 hours respectively. The macerated
different media such as Nutrient broth,
product was filtered through vacuum and
nutrient agar, sabouraud dextrose agar
the filtrate was dried under reduced
(SDA), tryptone soya broth, tryptone soya
pressure. The percentage yields of extracts
agar (Oxoid Laboratories, U.K) in the
leaf (13.5 % w/v), stems (21.4 % w/v).
study. Dimethyl Sulfoxide DMSO) was
2.3.
used in solubilising the extracts and drugs
Preliminary
phytochemical
screening
and was used as the negative control in the

studies
. 2.6. Antimicrobial Agents

We have used Ampicillin, 1mg/ml, as the
We have used the agar cup diffusion
standard reference drug for antibacterial
method
assays
antimicrobial activity. From stored slopes,
2.7.Preparation of bacterial cultures
[7, 8]
to
test
the
fractions
for
5 ml single strength nutrient broth was
154
inoculated. The tubes were well shaken
hours for bacteria and. When seeded with
and incubated at 37C for 18-24 hours.
bacteria, each plate had wells filled with
Diameters of zones of inhibition were
DMSO.
determined as an indication of activity
reference drug for antibacterial studies.
after incubating the plates at 37C for 24
155
Ampicillin
was
used
as
Table 1 : Phytochemical analysis of extract

Phytochemical
C. borivilianum Leaf
C. borivilianum Stem
Alkaloids
+++
++
Glycosides
++
++
Saponins Glycosides
+++
Steroids
+++
+++
Phenols
++
Tannins
++
+++
( - ) : Absent, (+) : Slightly present, (++) Fairly present, ( +++ ) Abundant
Table 2 : Antimicrobial Activity of Leaf extracts C borivilianum

Extract
Staphylococcus
Escherichia
Klebsiella
S .sabtilis
C.borivilianum
Conc.
aureus
coli
Leaf
Mg/ml
250
500
++
1000
+++
++
++
+++
(-) : No Inhibition ( < 10 mm ), (+) : Low activity ( 10- 13 mm ), (++) : relative high
activity ( 14-20 mm ), (+++) : High Activity ( > 20 mm ), Not Done (ND )
Table 3 : Antimicrobial Activity of Stem extracts C borivilianum

Extract
Staphylococcus
Escherichia
Klebsiella
S.
C.borivilianum
Conc.
aureus
coli
Stem
Mg/ml
250
500
++
++
++
1000
+++
+++
+++
+++
sabtilis
Table 4 : Antimicrobial Activity of extracts (Petroleum Ether )
156
Extract
Staphylococcus
Escherichia
Klebsiella
S .sabtilis
C.
Conc.
aureus
coli
pneumoniae
borivilianum
Mg/ml
250
ND
Petroleum
500
ND
Ether
1000
ND
Table 5 : Antimicrobial Activity of extracts ( Methanol )
C.borivilianum
Extract
Staphylococcus
Escherichia
Klebsiella
S .sabtilis
Conc.
aureus
coli
pneumoniae
250
ND
500
ND
1000
++
ND
Mg/ml
Methanol
Table 6: Antimicrobial Activity in Ampicillin

Control
Ampicillin
1mg/ml
Staphylococcus
Aureus
+++
Escherichia
coli
Klebsiella
S . sabtilis
Pneumonia
++
+++
+++
(-) : No Inhibition ( < 10 mm ), (+) : Low activity ( 10- 13 mm ),

(++) : relative high activity ( 14-20 mm ), (+++) : High Activity ( >
20 mm ), Not Done (ND )
157
Ampicillin
Mathanol
B.sabtilis
Klebsiella
Pet. Ethr
E. coli
S.aureus
Stem Extrct.
Leaf Extrct.
Chat-11 : 1 Comparative antimicrobial activity against different extracts of C.

borivilianum in 1000 mg/ml
3.RESULT :
of
From the table : 1 it has been calculated
concentration
that
activities and this was comparable to that
the
leaves
and
stem
of
C.
borivilianum
contain
the
C.
borivilianum
displayed
dependent
antibacterial
of the reference drug ampicillin at 1

presence
of
alkaloids,
mg/ml as shown in Table 6 . Only the
glycosides, saponin glycosides, steroids
ethanol extract of the aerial parts of the
and tannins . For the antimicrobial
plant inhibited the growth of bacteria at
activity the diameters of the inhibition
concentration of 1000 mg/ml and 500
zones were measured and recorded in the
mg/ml
table 2, 3, 4, 5, and 6 . The comparative
extract of
study for diameter of inhibition zone for
sensitive to the bacteria at the test
all
ll four bacteria in different extract have
concentrations (Table 4 ). The results of
been measured and recorded in Chart -1 .
this study confirm the use of this plant as
respectively.
The
petroleum
C.borivilianum was less
remedies
medies for analgesic, anti-inflammatory
anti
DISCUSSION :
and arthiritic conditions. There is an
In the present investigation strongly
absolute need for bioactivity guided
demonstrated that the C. borivilianum has
fractionation and isolation of the active
potent antibacterial activity . The above
components in the plant extracts. The
result show that the leaf and stem extract
methanol extract of C. borivilianum had
158
not
very
impressive
positive and two Gram negative bacteria
antibacterial
properties ( Table 5 ). This therefore

becomes more relevant as the current
antibiotics in use are of fast loosing
Finally it can be concluded that the leaves
effectiveness due to its emergence of
and
resistant microorganisms. The isolation of
borivilianum can be used
the components of the aerial parts of C.
against certain bacteria causing disease in
borivilianum methanol extract is in
human beings
progress as very potent antimicrobial
antimicrobial agent .
stem
extract
of
Chlorophytum
effectively
as it is a
potent
agents.
4.CONCLUSION :
ACKNOWLEDGMENTS :
The authors would like to thanks
The above result in the table 1 to 6 and in

the chart -1 showed that C. borivilianum
to
have very potent antibacterial agent can
Chandra
be used as a potent antimicrobial agent
Mohanpur, Dist. Nadia,West Bengal,
for the treatment of diseases . Thus
India and Dr. Narain Gorai, Dept. of
further work can be carried out on the
Zoology, West Bengal State University,
isolation procedure for finding out the
Malikapur,
exact active moiety responsible for the
Berunanpukhuria, West Bengal 700126
biological activity. The extract of leaves
for giving valuable support while doing
and stem was tested against the two Gram
research
Dr. Arunava Samanta,

Krishi
North
Bidhan
Vishvavidyalaya,
24
Parganas,
REFERENCES
1. Deore S. L., Khadabadi S. S. Indian Journal of Natural Products & Resources.
March 2010.
1(1). 5356p.
2. Pullaiah T. Medicinal Plants of India, Regency Publications, New Delhi, 2002, pp
62.
3. Kokate CK. Practical Pharmacognosy, Vallabh Prakashan, New Delhi, 1994, pp
107.
4. Harbone JB, Phytochemical Methods: A guide to Modern Techniques of Plant
Analysis, Chapman and Hill, London, 1998, pp 60.
5. Nayar MP, Shastry. Chlorophytum borivilianum. In Nayar and Shastry, Red Data
Book of Indian Plants, (Botanical Survey of India, Calcutta, 1988, pp 42.
159
6. Tandon M, Yogendra Shukla N, Raghunath Thakur S. Steroid glycosides from

Asparagus adscendens, Phytochemistry 1990; 29 (9): 2957-2959.
7. Shabi M, Ramezanian M, Jaffari G,
Haravi G, Bahaeddini F, Aynehi Y. Survey
of Indian Medicinal plants for Saponins, Alkaloids, Flavonoids and Tannins, the
plant of Capparidaceae, International J Crude Drug Res 1895; 23 (4): 165-177.
8. Indian Pharmacopoeia. The controller of Publication, New Delhi, 1996.
9. Govindrajan R., Sreevidya N., .
Vijay Kumar M., et al . Natural Product
Science 2005.11(3).165-169p.
10. Jamal M. Arif. International Conference on Promotion and Development of
Botanicals with International Coordination: Exploring Quality, Safety Efficacy &
Regulation. School of Natural Products Study. Jadavpur University, Kolkata, India.
2526 Feb 2005.
11. Yunus M. Siddiqui. International Conference on Promotion and Development of
Botanicals with International Coordination: Exploring Quality, Safety Efficacy &
Regulation. School of Natural Products Study. Jadavpur University, Kolkata, India.
2526 Feb 2005.
12. Singh P., Gupta P. and Singh R. Chemistry Biology Interface. Synergestic New
Frontiers, New Delhi, India. Nov. 2004. 2126p.
13. Deore S. L., Khadabadi S. S. Indian Journal of Natural Products & Resources.
March 2010. 1(1). 5356p.
14. Hamond J. A., Fielding D, and Bishop S. C. Veterinary Research Communications.
1997. 21. 213228p.
15. Battacharjee S. K. Hand Book of Medicinal Plants. Jaipur. Pointer Publication.:4th
edn. 2000. 9293p.
16. Joshi A., Ganesh R. and Sharma A. Bionature. 2000. 4749p.
17. Shreevidya N. and Mehrotra S. National Seminar on New Millennium Strategies on
Quality Control, Safety and GMPS of Herbal Drugs or Products. NBRI, Lucknow.
1113 Nov 2003. 168p.
18. Dabur , R ., A. Gupta , T.K Mandal , D.D Singh , V. Bajpai , A.M . Gaurav and
G.S, Lavekar , 2007 . Antimicrobial activity of some Indian medicinal plants . Afr.
J. Tradit . Comple .Alter. Med., 4 : 313-318
19. Habeeb , F ., E. Shakir , F Bradbury , SP. Cameron and M.R. Taravati et al .,
2007 Screening methods used to determine the anti-microbial properties of Aloe
vera inner gel . Methods , 42: 315-320.
20. Deora , S. L. and S.S Khadabadi , 2009 .Screening of antistress properties of
Chlophytum borivilianum tuber . Pharmacologyonline , 1:320-328
21. Purohit SS, Prajapati ND. Agros Colour Atlas of Medicinal Plants, Agrobios
publications,
Jodhpur, 2003, pp 43
CORRESPONDENCES
160
* Syed Rehan Ahmad , Dept. of Microbiology, Bidhannagar Govt College, Sector-1, Salt
Lake City,
Kolkata,
West
Bengal-64
Ph.:
+91-9333593625
Email:
rehanbiotech1@gmail.com
**Dept. of Microbiology, Bidhannagar Govt College, Sector-1, Salt Lake City, Kolkata,
WB-64
***Dept of Microbiology, Shri Venkateshwara University, Gajraula, U.P , 244236, India
161
ECOLOGY OF THE ASIAN TAPEWORM, BOTHRIOCEPHALUS

ACHEILOGNATHI YAMAGUTI, 1934 OF FISHES IN THE DAL LAKE OF
SRINAGAR, KASHMIR
Bashir A. Sheikh*, Tanveer A. Sofi**, Fayaz Ahmad***
ABSTRACT
Seasonal surveys were conducted at the Dal Lake of Srinagar between April 2013 and
January 2014. Twenty Schizothorax niger and 20 Cyprinus carpio were collected with the
aid of gill nets. Surface water quality variables were included. The cestodes were identified
as either Bothriocephalus acheilognathi Yamaguti, 1934 or other cestode species. The
majority (99.8 %) of the cestodes found in both fish species were identified as B.
acheilognathi (Asian tapeworm). The prevalence, mean intensity and abundance of B.
acheilognathi in both fish species were calculated. Ecological parameters including
species specificity, seasonality, gender specificity and relationships between fish size and
the Asian tapeworm prevalence were also included. In this study, B. acheilognathi
preferred Schizothorax niger over Cyprinus carpio although a low intensity was observed
in Cyprinus carpio. Furthermore, the infection (in terms of prevalence, abundance and
mean intensity) in Schizothorax niger was markedly higher. Seasonal patterns observed in
the Asian tapeworms infection of Cyprinus carpio are attributed to breeding and
subsequent feeding patterns of this fish species with relatively high infections recorded in
winter and spring. For Schizothorax niger no explanation can be given regarding the
seasonal patterns observed for the mean intensity and abundance of B. acheilognathi. The
maximum and minimum mean intensity and abundance values in Schizothorax niger were
recorded in autumn and spring, respectively. In addition, the prevalence of B.
acheilognathi was consistently high in all four seasons.
Keywords: Asian tapeworm; Bothriocephalus acheilognathi; Schizothorax niger; Cyprinus

carpio; seasonal prevalence.
162
Province) (Van As, Schoonbee & Brandt
INTRODUCTION
Surveys
conducted
parasitology
group
by
fish
1981), Hartbeespoort Dam (North West
shown
Province), Piet Gouws Dam (Limpopo
the
have
unexpectedly high numbers of helminth
Province)
parasites in fish species in the Dal Lake
River (Limpopo Province) (Mashego
of Srinagar. The high number of helminth
1982), Glen Alpine Dam (Limpopo
parasites
Province) (Mashego 1982) and the Vaal
can
be
attributed
to
(Mashego
Dam
been introduced with cyprinid fish into
1982). The tapeworms presence in most
South Africa from Asia (Brandt, Van As,
of the localities mentioned above can be
Schoonbee & Hamilton-Attwell 1981).
attributed to the supply of common carp
The Asian tapeworm, originally a parasite
fry to commercial farmers (Boomker et
of
al.
Chinese
grass
carp
1980).
Province)
Olifants
Bothriocephalus acheilognathi which has
the
(Gauteng
1982),
However,
(Mashego
according
to
(Ctenopharyngodon idella Valenciennes,
Mashego (1982) its presence in the Vaal
1844)
carp
Dam cannot be accounted for. Brandt et
molitrix
al. (1981) mentioned the possibility that
Valenciennes, 1844) in the Southern parts
this tapeworm was imported into South
of China (Boomker, Huchzermeyer &
Africa with the common carp as long ago
Naud 1980), has spread rapidly to other
as
countries by means of infected fish (Pool
Aischgrund variety of the common carp
1987) and has adapted itself successfully
in 1952. Cyprinus carpio has been found
to the common carp (Cyprinus carpio
in the Dal Lake but its introduction date
Linnaeus, 1758) (Boomker et al. 1980).
is
In South Africa, bothriocephalid parasites
acheilognathi was originally described as
have been found in various dams and
three different species from wild fish in
freshwater systems in Gauteng Province.
Japan (as B. acheilognathi Yamaguti,
Localities in South Africa where B.
1934
acheilognathi has been found include the
opsariichthydis Yamaguti, 1934) and
Komatipoort
(Mpumalanga
from grass carp (C. idella) from South
Province) (Boomker et al. 1980), Marble
China (as Bothriocephalus gowkongensis
Hall (Mpumalanga Province) (Brandt et
Yeh, 1955) (Paperna 1996). These three
al. 1981), Boskop Dam (KwaZulu-Natal
species were later recognized as being
and
the
(Hypothalmichthys
area
silver
163
1859
or
with
uncertain.
and
the
Dinkelsbuhl
Bothriocephalus
Bothriocephalus
identical (Korting 1975; Molnar 1977)

with the name B. acheilognathi taking
MATERIALS AND METHODS
priority. Pool (1988) believes that the
Study location
three
Four surveys were conducted in the Dal
species,
B.
acheilognathi,
Bothriocephalus
kivuensis
and
Lake of Srinagar ofone per season,
Bothriocephalus
aegyptiacus,
are
namely in April 2013 (early spring), June
identical, with B. acheilognathi having
2013 (summer), October 2013 (late
priority. Various authorities (as cited by
autumn) and January 2014 (winter).
Pool & Chubb 1985 and Pool 1988) noted
Water quality
that
opsariichthydis
Water quality data for the duration of the
Bothriocephalus
project were obtained from the Water
Bothriocephalus
Yamaguti,
1934,
B.
Board, and were collected during routine
1955,
monitoring activities made by the Water
Bothriocephalus phoxini Molnr, 1968
Board. Standard techniques were used by
and Schyzocotyle fluviatilis Akhmerov,
the Water Board to analyse the water
1960 are the same species as B.
samples.
acheilognathi Yamaguti, 1934. Pool &
parameters were not
Chubb (1985) concluded that there is
reasons being that sampling and/ or
only
species
measuring instruments were either not in
parasitizing cyprinid fish and suggested
working order or being serviced. The
the continued use of the name B.
following surface water variables were
acheilognathi. Cestodes in this study
included:
were identified as either B. acheilognathi
conductivity, dissolved oxygen and light
or other cestode spp.. The purpose of
penetration.
this
Collection of fish and cestodes
fluviatilis
Yamaguti,
gowkongensis
one
article
1952,
Yeh,
Bothriocephalus
is
to
provide
brief
For
pH,
some
months
various
measured, the
temperature,
electrical
description of the parasites infection,
A field laboratory was set up for each
seasonality,
and
survey. The fish species collected during
species (host) specificity in the two fish
the four surveys were Cyprinus carpio
species sampled. A comparison between
and Schizothorax niger. The fish were
the parasites infection in Cyprinus
identified based on the size of the snout
carpio and its infection in Schizothorax
as suggested by Skelton (2001). Twenty
niger is also included.
Cyprinus carpio and 20 Schizothorax
gender
specificity
164
niger fishes per survey were collected
amount (equal to the amount of saline
using gill nets consisting of four sections
solution already present in the sampling
with varying stretched mesh sizes of 90,
bottle) of a hot alcohol-formaldehyde-
110 and 130 mm, respectively. They were
acetic acid (AFA) solution was added to
weighed (in grams) and measured (fork
kill and fix the specimens. Specimens
length in millimetres). The fish were
were then stored in 70 % alcohol.
killed by severing the spinal cord behind
Identification of cestodes
the head and were subsequently dissected
The
by making an insertion from the anus
Grenachers borax carmine stain (Pantin
towards the head. Once they had been
1964) and identified.
dissected, the intestines were removed
Statistical analyses
and placed in a normal saline solution in
All specimens were counted and the
petri dishes for examination. Methods
totals obtained were used for statistical
described by Khalil (1991) were used for
analyses which were conducted by the
processing the platyhelminth parasites
University of Kashmir Department of
found during the surveys. Parasites were
Statistics. Prevalence, abundance and
collected as soon as possible after the
mean intensity of B. acheilognathi were
death of the fish to prevent any
calculated per season for each fish
deterioration. The intestines were pulled
species.
open carefully using two sharp tweezers
calculated
by
to ensure that the cestodes were kept
definitions
set
intact. Each cestode was carefully and
Holmes, Kurtis & Schad (1982) and
slowly dislodged from the intestinal wall,
Bush, Lafferty, Lotz & Shostak (1997).
ensuring that it remained intact. They
Data was analysed to determine the
were transferred to a clean sampling
seasonality (using ANOVA and then
bottle containing normal saline solution,
Scheffe or Dunnet T3) and species and
which was then shaken vigorously for a
gender
few minutes to dislodge debris and
Chisquare
induce muscle fatigue in the helminths,
acheilognathi. A comparison between the
which in turn, deters strong contraction of
infections in the two fish species was
the scolices and relaxes them. While
done (using the T-test). In addition, the
swirling the sampling bottle, an equal
infection of B. acheilognathi (intensity)
165
cestodes
were
Infection
by
and
with
statistics
making
specificity
test
stained
use
Margolis,
(using
T-tests)
were
of
the
Esch,
Pearson
of
B.
in each fish species was compared to the
Murai 1973; Mashego 1982) as well as
size (fork length) of the fish sampled.
the diagnosis of B. acheilognathi (as B.
Regression
gowkongensis) by Yeh (1955), as cited by
analysis
was
used
to
determine if any correlations existed.
Paperna
Digital micrographs of stained specimens
sketches of B. acheilognathi collected
were taken using a Zeiss Axioplan 2
during the four surveys are presented in
Imaging microscope.
Fig.
1.
(1996).
Micrographs
When
reviewing
and
available
sketches it is the authors opinion that the

RESULTS
scolex of specimens from the current
Water quality
study compared fairly well with many of
Surface water variables and data obtained
the Bothriocephalus species that have a
in this study are presented in Table 1.
heart-shaped
Identification of cestodes
mentioned in Paperna (1996), the eggs
According
to
classification
Mashego
of
the
are operculated
(Fig.
(Fig.
1F)
1A).
and
As
the
bothriocephalid
vitellaria laterally scattered (Fig. 1D).
worms is based primarily on the shape of
According to the diagnosis given in
the scolex. Pool (1984) concluded from
Paperna (1996), mature and
his study on B. acheilognathi that the
segments vary in breadth and length.
identification of adults should be based
However, in this study this was not the
on the heart-shaped scolex and prominent
case. Most segments were broader than
square apical disc. The identification of
they were long (Fig. 1B and C). We
the bothriocephalid cestodes in this study
however, disagree with the system of
was
these
labelling the reproductive system as
characteristics. Specimens found in the
proposed by Yamaguti (1934), and
current study were compared to sketches
consider
provided
available literature; it should be as
therefore
by
the
(1982),
scolex
based
various
on
authorities
that,
after
gravid
reviewing
the
indicated in Fig. 1E.
(Yamaguti 1934; Yeh 1955; Molnar &
TABLE 1 Summary of water quality variables recorded seasonally at the Dal Lake of
Srinagar.
Survey
pH
Temperature Electrical
Dissolved Secchi
conductivity oxygen
166
disc
readings
(C)
(mS/m)
(mg/l O2)
(cm)
__
17.00
__
__
7.34
19.90
16.00
12.50
30.00
Spring (October 8.00
21.40
17.00
___
28.00
25.00
23.00
6.30
28.00
(pH
units)
Autumn
(April 7.60
2013)
Winter
(June2013)
2013)
Summer
8.26
(January 2014)
167
168
F
Fig. 1 Micrographs and sketches of Bothriocephalus acheilognathi collected during the
four seasons of the survey in the Dal Lake of Srinagar.
A) Heart-shaped
shaped scolex with bothria. B) Mature proglottid with reproductive organs
C) Young adult proglottid. D) Vitellaria scattered. E) Sketch of a young adult proglottid
F) Operculated egg
TABLE 2 Number of cestodes collected from Cyprinus carpio and Schizothorax niger at
the Dal Lake of Srinagar during the four seasons.
Survey
Cyprinus carpio (n=70)

B.
Other
Schizothorax niger (n=70)

cestode B. acheilognathi
acheilognathi spp.
Spring
Other
spp.
(April 4
417
(June 298
651
Autumn (October 256
120
40
2013)
Summer
2013)
2013)
Winter
(January 24
2014)
Total
582
132 8
Total cestodes
582
1336
169
cestode
Parasite numbers
Cyprinus carpio was fairly constant (10
The tapeworms encountered in this study
15%) in autumn, spring and summer
were grouped as either B. acheilognathi
followed by a considerable increase in
or other cestode spp.. The number of B.
winter (55 %) (Fig. 2). When comparing
acheilognathi and other cestode spp.
its prevalence in the two fish species, that
collected during the four seasons of the
in Schizothorax niger was considerably
survey is tabulated in Table 2. Of the 140
higher. Statistical analyses indicate that,
fish sampled, only 19 out of 80 Cyprinus
there was a significant difference (T-test,
carpio harboured B. acheilognathi while
P = 0.001) in its prevalence in the two
none harboured other cestode spp.; and
fish species.
68
Abundance (relative density)
out
of
80
Schizothorax
niger
harboured B. acheilognathi while only six
During all surveys, the abundance of the
harboured other cestode spp.
Asian tapeworm was considerably higher
Infection statistics of B. acheilognathi
in Schizothorax niger (Fig. 3). In this fish
The percentage of hosts (prevalence)
species, abundance values ranged from
infected with B. acheilognathi, and its
55.0 (spring) to 170.9 (autumn) while in
intensity (mean intensity) and abundance
Cyprinus carpio these values ranged from
(relative density) in both Cyprinus carpio
0.2 (autumn) to 14.9 (winter). The
and Schizothorax niger are illustrated
following seasonal trend was observed
graphically
4,
for Schizothorax niger: values decreased
respectively. A statistical comparison (T-
from autumn to winter and then again in
test) of the two fish species in terms of B.
spring. The latter was followed by an
acheilognathi prevalence, abundance and
increase in summer. For Cyprinus carpio
mean intensity is also included to
the opposite trend was observed. Values
determine whether or not there are
increased from autumn to winter and
significant
were followed by a decrease in spring and
in
Fig.
differences
2,
and
between
fish
species.
a further decrease in summer. Statistical
Prevalence
analyses
The prevalence of B. acheilognathi in
indicate that there was a significant
Schizothorax
relatively
difference (T-test, P = 0.011) between the
constant over all seasons, ranging from
relative densities of B. acheilognathi in
8090 %, whereas the prevalence in
the two fish species sampled.
niger
was
170
Mean intensity
in male and in female fish were 12.85 and
Excluding spring, the infection was
2.70, respectively. In Schizothorax niger
considerably
in
the average numbers were 91.43 and
Schizothorax niger (Fig. 4). The highest
107.42, respectively. In addition, the
value recorded for Schizothorax niger
presence or absence of B. acheilognathi is
was 213.6 in autumn and the lowest value
not dependent on the gender of fish
was 68.8 recorded in spring. During the
species (Pearson Chi-square test; P values
remaining seasons the mean intensity
for both fish species > 0.05). Similar
decreased to 102.2 and 85.8 in summer
numbers of male (7) and female (12)
and winter respectively. Similarly, the
Cyprinus carpio and male (37) and
mean intensities in Cyprinus carpio
female (31) Schizothorax niger were
differed
in
found to harbour B. acheilognathi. In
autumn to 78.7 in spring. During winter
Cyprinus carpio , the prevalence of B.
and summer a mean intensity of 27.1 and
acheilognathi in males and females was
4.3, respectively, was recorded. Statistical
0.21 and 0.26, respectively. Similarly, in
analyses indicate that, there could be a
Schizothorax niger the prevalence of B.
significant difference between the mean
acheilognathi was 0.84 in males and 0.86
intensities of B. acheilognathi in the two
in females.
fish species (T-test, P value was slightly
Seasonality
above 0.05 at 0.053) but due to either the
In Cyprinus carpio, the highest number of
sample size being too small or the
B. acheilognathi was observed during the
variance being too big this cannot be said
winter survey while in Schizothorax niger
for certain.
the highest number was observed during
Ecological parameters
the spring survey (Table 2). From the
Gender specificity
statistical analyses (Pearson Chi-square
In both fish species, there were no
test)
significant differences (T-test, P values >
presence/absence of B. acheilognathi in
0.05) in the average number of B.
Cyprinus carpio was dependent on the
acheilognathi found in males and females
season (P = 0.002) with the highest
even though the average number in males
number of infected fish (11) being in
and females differed. In Cyprinus carpio
those caught in winter and the lowest (2)
the average numbers of B. acheilognathi
being in autumn. This was not the case
more
considerably
intense
from
2.00
171
performed
on
the
data,
the
for Schizothorax niger. Similar numbers
(Pearson Chi-square) performed when
of Schizothorax niger (between 16 and
data is pooled according to fish species,
18) were infected with B. acheilognathi
the presence/absence of B. acheilognathi
during all four seasons of the survey.
was highly dependent on fish species, P
However, when conducting the ANOVA
values being 0.000.
test to determine if there were significant
Size specificity
differences between seasons, the results
No correlations were observed between
show that there were significant (P =
the sizes (fork lengths) of fishes (both
0.003) seasonal differences based on the
Schizothorax niger and Cyprinus carpio)
number of B. acheilognathi found in
sampled and the number of Asian
Schizothorax niger. Post hoc tests were
tapeworms recorded.
then undertaken to distinguish which of

the seasons differed significantly. The
results of the statistical analyses (Dunnet
T3 test) showed that autumn and spring
differed significantly with a P value of
0.011. No significant seasonal differences
were determined in the number of B.
Fig. 2 Graph depicting the prevalence of
acheilognathi found in Cyprinus carpio.
Bothriocephalus acheilognathi in
Species specificity
When
Cyprinus carpio and Schizothorax niger
comparing
fish
species,
during the four seasons
Schizothorax niger harboured a higher

number
of
B.
acheilognathi
than
Cyprinus carpio (Table 2). The number

of B. acheilognathi found in Schizothorax
niger totalled 1328, while Cyprinus
carpio only had a total of 582 B.
acheilognathi in the same number of
hosts (70). In addition, a higher number
of Schizothorax niger (68) were infected
Fig.3. Graph depicting the abundance
with B. acheilognathi than Cyprinus
(relative density) of Bothriocephalus
carpio (19). From the statistical analyses
acheilognathi in Cyprinus carpio and

Schizothorax niger during the four
172
niger and a noticeably higher number of
seasons of the survey
this fish species was infected. Similar

prevalence and mean intensity values to
those obtained
recorded
for
in
L.
this
study were
aeneus
and
L.
kimberleyensis in a separate preliminary

study conducted by Nickanor, Reynecke,
Avenant-Oldewage & Mashego (2002) in
Fig 4 Graph depicting the mean intensity
the Vaal Dam during 2001. The infection
of Bothriocephalus acheilognathi in
Cyprinus
statistics indicate that both prevalence
carpio and
and abundance of B. acheilognathi
Schizothorax niger during the four

seasons
differed
significantly
between
the
fish
(statistically)
species
with
Schizothorax niger exhibiting higher

values.
DISCUSSION
Exceptionally
The
mean
intensity
of
B.
acheilognathi was higher in Schizothorax

high
numbers
of
B.
niger for most seasons, except in spring
acheilognathi and low numbers (an
when the opposite was the case. In spring
insignificant amount) of other cestode
a small number of Cyprinus carpio were
spp. were found in the fish sampled. As
infected with a relatively high number of
highlighted by Khan & Thulin (1991),
tapeworms thereby increasing the mean
parasites are a natural part of the aquatic
intensity. It is possible that the mean
community and their distribution and
intensities of the fish species differ
abundance are potentially either directly
significantly but this is uncertain in this
or indirectly affected by a number of
study because either the sample size was
biotic and abiotic factors.
too small or the variance was too big to
Infection
distinguish between the fish species. It
The infection of B. acheilognathi (in
would be expected that the high numbers
terms of prevalence, abundance and mean
(and
intensity) in Schizothorax niger was
subsequently
high
prevalence,
abundance and mean intensity) of B.
greater than that observed in Cyprinus
acheilognathi
carpio. Noticeably higher numbers of this
found
in
Schizothorax
niger in this study are linked to the life
tapeworm were observed in Schizothorax

173
cycle of the tapeworm as the transmission
acheilognathi for this fish species should
of parasite to host is via an intermediate
be
host eaten by the fish (Paperna 1996).
tapeworm
has
Korting
successfully
to
(1975)
mentioned
that
the
determined.
This
opportunistic
already
the
adapted
common
carp,
intermediate host of the Asian tapeworm
Cyprinus carpio (Korting 1974; Boomker
for carp is a crustacean and that a number
et al. 1980) in South African waters. This
of crustaceans can act as intermediate
carp species feeds on a range of plant and
hosts.
food
animal matter (Skelton 2001) and, more
preference of largemouth yellowfish, it is
specifically, carp fry, which tend to be
found that it initially feeds on insects and
more heavily infected with the tapeworm,
crustaceans, but once it reaches a fork
feed on zooplankton (Boomker et al.
length of more than 300 mm it feeds on
1980). A better understanding of the
other fish (Skelton 2001). Although the
intermediate host could explain the high
majority of infected Schizothorax niger
infection
collected during the survey varied in fork
Schizothorax niger . Other authorities,
length between 360 and 420 mm, it is
such as Marcogliese & Esch (1989) and
possible that infected crustaceans are
Williams & Jones (1994), mention that
eaten
an
metacestodes use planktonic or benthic
infection in Schizothorax niger. It was
copepods as intermediate hosts. If this is
unexpected, however, to find an infection
the case, then L. aeneus should be the
as heavy as that obtained in this study.
preferred host as this fish species is
When considering the infection of B.
broadly omnivorous with zooplankton,
acheilognathi (in terms of prevalence,
benthic invertebrates, vegetation, algae
mean intensity and abundance) in relation
and detritus forming the major food of the
to fish size (fork length), no correlations
species (Dorgeloh 1985; Skelton 2001).
were recorded in Schizothorax niger. It is
Although L. aeneus is not the preferred
important to note that L. kimberleyensis
host (Nickanor et al. 2002), it still
was the first recorded host of B.
becomes infected (although low) with B.
acheilognathi (as B. gowkongensis) in
acheilognathi. Poulin (1998) mentioned
South Africa in 1978 (Brandt et al. 1981).
that parasites such as the Asian tapeworm
The type of crustacean or copepod acting
that enter their host through ingestion
as
cannot prevent non-host species from
When
considering
occasionally,
an
intermediate
the
resulting
host
in
for
B.
174
of
B.
acheilognathi
in
eating the infected intermediate hosts.
2). This could be due to a change in
This method of transmission (ingestion)
feeding regime, but during the four
enables more host species to become
seasonal surveys it has been found that
infected. Another reason why both fish
Cyprinus carpio fed well (Bertasso
species are infected with this tapeworm
2004). Korting (1974) indicated that early
could be that the intermediate copepod
spring, when plankton grows, is likely to
host species can vary considerably.
be a significant season in terms of
Various genera of copepods have been
seasonal incidence and infective period.
found to be compatible intermediate hosts
This was not the case, however, in
(Williams & Jones 1994; Paperna 1996)
Cyprinus carpio in this study. In spring,
and in this case it is possible that a larger
the prevalence was fairly low. The reason
crustacean, such as a crab, acts as a
could
paratenic hostthis would explain the
(copepods)
enigma behind the higher infection
particular winter than is usually the case.
observed in largemouth yellowfish. In a
Temperature data recorded during the
study conducted by De Leon, Garcia-
winter of this study (Table 1) were higher
Prieto, Leon-Regagnon & Choudhury
than
(2000) in Mexico it was found that
conducted in the Dal Lake (Crafford
helminth communities were generally
2000).
more abundant in carnivorous fish species
penetration) in the Dal Lake was at its
than in herbivores and detritivores. This
maximum although in the remaining three
matter needs to be researched further in
seasons similar (slightly lower) values
order to gain a better understanding of
were exhibited (Table 1). It can be
infections by the Asian tapeworm.
assumed that the finding of an increased
Seasonal trends
prevalence in winter is exceptional and
In Cyprinus carpio, the prevalence of B.
was caused by an external unknown
acheilognathi was fairly constant except
factor. Statistical analyses indicated that,
in
higher
as a result of this high prevalence in
were
winter, the presence of B. acheilognathi
infected. Prevalence values in winter
in Cyprinus carpio is dependent on the
were approximately four to five times
season. In Schizothorax niger, no trend
higher than in the remaining seasons (Fig.
was observed for prevalence of the Asian
winter
numbers
when
of
noticeably
Cyprinus
carpio
175
be
in
that
more
were
In
available
previous
winter
infected
in
separate
visibility
food
that
study
(light
tapeworm throughout the four seasons
mean that abundance values should be
(Fig. 2); a similar, very high number of
higher
fish being infected throughout the year.
nevertheless the opposite was observed
Abundance values in Cyprinus carpio
(Fig. 3). A sharp decrease in abundance
exhibited
the
values was recorded from autumn to
prevalence values observed in the same
winter after which abundance values
fish species (Fig. 3). Values increased
remained relatively constant decreasing
considerably from autumn to winter
slightly in spring but increasing again in
followed by a decline in spring and a
summer. This seasonal trend could be
further decline in summer. It is assumed
related to changes in the amount of food
that this seasonal trend is related to the
and subsequently infected food available.
breeding and subsequent feeding patterns
In autumn the high abundance relative to
of Cyprinus carpio. Feeding habits of the
the other three seasons was due to the
host account for a large percentage of the
considerably
variation in the total number of parasites
acheilognathi found in the Schizothorax
per host species (Williams & Jones
nigeer, in the survey. A similar pattern to
1994). The number of parasites in a host
that recorded for the abundance of B.
would depend on how much the host eats
acheilognathi in Schizothorax nigeer, was
and whether the food is infected. In
recorded for the mean intensity (Fig. 4).
winter, the fish eat enough food to sustain
This is due to the fact that most of the
them through the breeding season, which
fish sampled during the four seasons were
lasts from spring through to late summer
infected with B. acheilognathi. The mean
(Skelton 2001) and explains the decrease
intensity
in abundance recorded in spring and
exhibited a similar pattern to that of the
summer. As soon as the breeding season
abundance in Cyprinus carpio, except
ends fish start eating again. This results in
that the mean intensity peaked in spring
an increase in abundance from autumn to
rather than in winter (Fig. 4). Mean
winter.
intensities
In
pattern
similar
to
Schizothorax nigeer,
the
in
winter
higher
in
in
and
number
Cyprinus
the
spring,
carpio
Cyprinus
of
but
B.
also
carpio
seasonal trend in abundance could not be
increased considerably from autumn to
attributed to the fishs breeding patterns.
winter followed by a significant increase
Schizothorax nigeer breed in mid to late
(three times that of winter) in spring after
summer (Skelton 2001) which would
which the intensity decreased in summer
176
to an intensity similar to that recorded in
collected
autumn. In spring, the mean intensity
possibility. In addition, various studies
recorded in Cyprinus carpio was even
conducted in the Dal Lake systems, in
higher than that recorded in Schizothorax
which cestode endoparasites have been
niger. Opposite seasonal trends were
incorporated, have revealed either an
recorded for the mean intensity of the two
absence of cestodes or low infections of
fish species. Statistical analysis indicates
them in a range of fish species, namely
that the occurrence of B. acheilognathi in
Clarias gariepinus (Marx 1996; Crafford
Cyprinus carpio is dependent on the
2000;
season with the highest number of fish
marequensis
(Watson
infected
Oreochromis
mossambicus
in
winter.
However,
no
which
Watson
cancels
2001),
Labeobarbus
2001),
observed
B.
umbratus (Groenewald 2000). When
acheilognathi found during each season.
pooling the data according to the sex of
The opposite is true for the Schizothorax
the fish, the tapeworms exhibited no
nigeer sampled in this study. Statistical
preference for male or female fish.
analysis indicates that the occurrence of
Similar numbers of male and female
B. acheilognathi was not dependent on
Schizothorax nigeer were infected. Even
the season, even though there were
though there were noticeably lower
significant statistical differences between
numbers of infected female Cyprinus
the intensity of B. acheilognathi recorded
carpio when compared to males there
in autumn and that recorded in spring.
was no dependency (statistically) on fish
Fish gender and species specificity
gender.
Statistical analysis indicates that the
Size specificity
presence of B. acheilognathi is highly
In both fishes species sampled no
dependent on the species of fish with
correlations were observed between fish
Schizothorax nigeer, as mentioned above,
size and Asian tapeworm infection. The
having the highest infection of the two
statistical P values were closer to 0 than
fish species. Poulin (1998) noted that
1.
high host specificity could be an artefact
CONCLUSION
of inadequate sampling but in this study
In this study, the majority of the
20 fish per species per season were
tapeworms
intensity
of
177
were
and
(Watson
2001),
the
capensis
this
statistically meaningful differences were

in
Labeo
out
identified
Labeo
as
B.
acheilognathi based on the heartshaped
acheilognathi, however, varied seasonally
scolex and presence of bothria. This was
with the highest value being recorded in
achieved after comparing the specimens
autumn and the lowest value in spring.
collected
and
Statistical analyses indicate that there was
sketches in the literature. Bothriocephalus
a significant difference between the
acheilognathi in this study was species
presences of B. acheilognathi in these
(host) specific with a considerably higher
two seasons. The reason for the seasonal
infection
prevalence,
trends observed in Schizothorax nigeer
abundance and mean intensity) recorded
cannot be explained. Further research on
in Schizothorax nigeer. The reason for
Schizothorax nigeer concentrating on
this has still not been determined. The
factors such as post-spawning migrations
Asian tapeworm in this study was not
of the host, schooling behaviour, age of
fish-gender specific. Seasonal trends were
host,
observed for prevalence, abundance and
feeding
mean intensity of the tapeworm in
levels/state of maturity, immunological
Cyprinus
statistical
response of host, availability of infected
analyses indicate that no significant
intermediate hosts as food, site of
differences existed between seasons.
infection, negative interaction between
Seasonal trends in Cyprinus carpio were
parasites (as outlined by Williams &
attributed to breeding and subsequent
Jones 1994) should be conducted to
feeding
provide an explanation as to why there
with
(in
the descriptions
terms
carpio
patterns
of
although
of
the
fish.
In
reproductive
behaviour,
behaviour,
host
host
hormone
Schizothorax nigeer, no seasonal trend
are
was
acheilognathis infections in this fish
recorded
for
prevalence.
The
abundance and mean intensities of B.
seasonal
variations
in
B.
species.
REFERENCES
Bertasso, A. 2004. Ecological parameters of selected helminth species in Labeobarbus
aeneus and Labeobarbus kimberleyensis in the Vaal Dam, and an evaluation of their
influence on indicators of environmental health. M.Sc. dissertation, Rand Afrikaans
University.
Boomker, J., Huchzermeyer, F. W. & Naude, T. W. 1980. Bothriocephalosis in the
common carp in the Eastern Transvaal. Journal of the South African Veterinary
178
Association, 51: 263 264.

Brandt, F. DE W., Van AS, J. G., Schoonbee, H. J. & Hamilton- Attwell, V. L. 1981. The
occurrence and treatment of Bothriocephalus in the common carp, Cyprinus carpio in fish
ponds with notes on its presence in the largemouth yellowfish Barbus kimberleyensis from
the Vaal Dam, Transvaal. Water SA, 7: 3542.
Bush, A. O., Lafferty, K. D., Lotz, J. M. & Shostak, A. W. 1997. Parasitology meets
ecology on its own terms: Margolis et al. revisited. Journal of Parasitology, 83: 575583.
Crafford, D. 2000. Application of a Fish Health Assessment Index and associated parasite
index on Clarias gariepinus (sharptooth catfish) in the Vaal River System, with reference to
heavy metals. M.Sc. dissertation, Rand Afrikaans University.
De Leon, G. P. P., Garcia-Prieto, L., Leon-Regagnon, V. & Choudhury, A. 2000. Helminth
communities of native and introduced fishes in Lake Patzcuaro, Michoacan, Mexico.
Journal of Fish Biology, 57: 303325.
Dorgeloh, W. 1985. Food selection and competition for food among three fish species,
Salmo giardneri, Barbus aeneus and Clarias gariepinus. South African Journal of Science,
81: 693. Groenewald, M. 2000. Bioaccumulation of metals and the general health of fish
from the Vaal Dam and Vaal River Barrage. M.Sc. dissertation, Rand Afrikaans University.
Khalil, L. 1991. Techniques for identification and investigative helminthology. St Albans:
International Institute of Parasitology.
Khan, R. A. & Thulin, J. 1991. Influence of pollution on parasites of aquatic animals.
Advances in Parasitology, 30: 201 238.
Korting, W. 1974. Bothriocephalosis of the carp. Veterinary Medical Review, 2: 165171.
Korting, W. 1975. Larval development of Bothriocephalus sp. (Cestoda: Pseudophyllidea)
from carp (Cyprinus carpio L.) in Germany. Journal of Fish Biology, 7: 727733.
Marcogliese, D. J. & Esch, G. W. 1989. Experimental and natural infection of planktonic
and benthic copepods by the Asian tapeworm, Bothriocephalus acheilognathi. Proceedings
of the Helminthology Society of Washington, 56: 151 155.
Margolis, L., Esch, G. W., Holmes, J. C., Kurtis, A. M. & Schad, G. A. 1982. The use of
ecological terms in parasitology (Report of an ad hoc committee of the American Society
of Parasitologists). Journal of Parasitology, 68: 131 133.
Marx, H. M. 1996. Evaluation of a Health Assessment Index with reference to metal
bioaccumulation in Clarias gariepinus and aspects of the biology of the parasite
Lamproglena clariae. M.Sc. thesis, Rand Afrikaans University.
Mashego, S. N. 1982. A seasonal investigation of the helminth parasites of Barbus species
179
in water bodies in Lebowa and Venda, South Africa. Ph.D. thesis, University of the North.
Molnar, K. 1977. On the synonyms of Bothriocephalus acheilognathi Yamaguti, 1934.
Parasitologia Hungarica, 10: 6162
Molnar, K. & Murai, E. 1973. Morphological studies on Bothriocephalus gowkongensis
Yeh, 1955 and B. phoxini Molnr, 1968 (Cestoda, Pseudophyllidea). Parasitologia
Hungarica, 6: 99108.
Nickanor, N., Reynecke, D. P., Avenant-Oldewage, A. & Mashego, S. N. 2002. A
comparative study of stomach and intestine contents in Barbus aeneus and Barbus
kimberleyensis in the Vaal Dam to clarify variance in tapeworm infestation. Journal of
South African Veterinary Association, 73(3): 142159.
Pantin, C. F. A. 1964. Notes on microscopical techniques for zoologists. Cambridge:
Cambridge University Press.
Paperna, I. 1996. Parasites, infections and diseases of fish in AfricaAn update. Rome:
FAO (CIFA Technical Paper, no. 31).
Pool, D. 1984. A scanning electron microscope study of the life cycle of Bothriocephalus
acheilognathi Yamaguti, 1934. Journal of Fish Biology, 25: 361364.
Pool, D. W. & Chubb, J. C. 1985. A critical scanning electron microscope study of the
scolex of Bothriocephalus acheilognathi Yamaguti 1934, with a review of the taxonomic
history of the genus Bothriocephalus parasitizing cyprinid fish. Systematic Parasitology, 7:
199 211.
Pool, D. W. 1987. A note on the synonymy of Bothriocephalus acheilognathi Yamaguti
1934, B. aegyptiacus Rysavy and Moravec, 1975 and B. kivuensis Baer and Fain, 1958.
Parasitology Research, 73: 146150.
Pool, D. W. 1988. An experimental study of the biology of Bothriocephalus acheilognathi
Yamaguti 1934 (Cestoda: Pseadophyllidea). Abstract of thesis, University of Liverpool.
Poulin, R. 1998. Evolutionary ecology of parasites: From individuals to communities.
London: Chapman & Hall.
Skelton, P. 1993. A complete guide to the freshwater fishes of Southern Africa. Halfway
House: Southern Book Publishers.
Skelton, P. 2001. A complete guide to the freshwater fishes of Southern Africa, 2nd ed.
Halfway House: Southern Book Publishers.
Van As, J. G., Schoonbee, H. J. & Brandt, F. De W. 1981. Further records of the
occurrence of Bothriocephalus (Cestoda: Pseudophyllidea) in the Transvaal. South African
Journal of Science, 77: 343.
180
Watson, R. 2001. The evaluation of a Fish Health Assessment Index as a biomonitoring

tool for heavy metal contamination in the Olifants River catchment area. Ph.D. thesis, Rand
Afrikaans University.
Williams, H. & Jones, A. 1994. Parasitic worms of fish. London: Taylor & Francis.
Yamaguti, S. 1934. Studies on the helminth fauna of Japan. Part 4: Cestodes of fish.
Japanese Journal of Zoology, 6: 1 112.
Yeh, L. S. 1955. On a new tapeworm Bothriocephalus gowkongensis n. sp. (Cestoda:
Bothriocephalidae) from freshwater fish in China. Acta Zoologica Sinica, 7: 6974.
CORRESPONDENCES
*Post Graduate Department of Zoology, University of Kashmir, Srinagar 190 006. Email:
bashirzoology@gmail.com
**Post Graduate Department of Zoology, University of Kashmir, Srinagar 190 006
***Post Graduate Department of Zoology, University of Kashmir, Srinagar 190 006
181
ELECTRIC FIELD SWING ADSORPTION METHOD FOR

IMPROVED (CO2) CARBON CAPTURE
Noman Nisar*, Muhammad Junaid Aslam**
ABSTRACT
The modern era of technology and industrialization requires huge amount of power to run
it. Unfortunately it brings a lot of negatives with respect to environmental issues as well. The
increasing green house effect is largely due to undue release of greenhouse gases like Carbon
Dioxide (CO2). The major portion of population is getting benefitted out of energy produced using
Coal which consequently releases high amount of CO2 in the atmosphere. In order to lessen the CO2
released several CO2 capture methods are applied within physisorption and chemisorptions
domains. Electric field sorption methods for capturing CO2 are very effective way of capturing
CO2. In the later process electric field is applied through electrolyte to HSAC (High Surface Area
Carbon) plates [8].
The study of EFSA (Electric Field Swing Adsorption) Method incorporates understanding the work
of capturing CO2, extracting and then releasing it. In addition it requires equilibrium in the
selectivity of the gases with respect to CO2 and N2 (Nitrogen) [8]. Swing Adsorption method is found
to be very effective in achieving the goals. It provides luxury of adsorption and desorption
simply by switching the field at the same time without use of additional equipment. The
Carbon capture and storage is considered one of the options for mitigating emissions. The CCS
system includes four elements capture and compression of Carbon dioxide, transport injection and
storage. Therefore there are applied and developed technologies for CO2 capture to become more
efficient and low cost.
Keywords - CCS, carbon dioxide capture, electric field, physisorption, (super capacitive
swing absorption, SSA), (Electric Field Swing Absorption, EFSA).
Engineering issues of ESA (ESA is a

cyclic process comprising an adsorption
step (where CO2 is removed from the
flue gas) followed by desorption or
regeneration at high temperature. There is
not a given recipe for the regeneration.
The protocol and scheduling depends on
several aspects including the adsorbent
properties, feed and regeneration gas
composition [6], product specifications,
Objectives and identifying existing

possibilities:
increasing the magnitude of Carbon
Capture
Better Selectivity out of CO2 and N2
Realization of practical implementation
[6]
Materials for ESA [6]
182
energetic consumption, and others.
pressure-temperature swing adsorption PTSA or electric swing adsorption - ESA

(required sorbents which are electrical
conductivity) processes. [2]
Above are the major challenges to be

addressed in order to provide a
comprehensive proof of its utility.
The electric field swing adsorption

(EFSA) method deals with the capture of
carbon dioxide present in flue gas out of
Coal powered energy generation plants.
The purpose is to enhance the capability
of
capturing
the
CO2.
The
supercapacitive
swing
adsorption
technique is being developed in Lehigh
University, where High Surface Area
Carbon Capture method is developed.
The Major technique involved is about
creating
electric
field
between
supercapacitive pellets in the presence of
an electrolyte which offers Vander Waal's
and electrostatic forces to attract the CO2
elements present in the flue gas. The
selectivity of CO2 over N2 is enhanced
by the fact that N2 is lacking the center to
attract electrons which cause CO2 to
attract to pellets. This method provides a
luxury for desorption of the CO2 by
simply switching the field. The field
switching between two plates makes the
Captured CO2 to attract and release from
pellets. The removal of electric field
weakens the bond between carbon
absorbent, present in the form of pellets,
and CO2 elements to be stored.
There are five techniques of CO2

separation: chemical and physical
absorption, adsorption, membrane
separation and cryogenic separation.
Each technology has their optimal fields
to be applied to. Chemical absorption
suits low concentration of carbon dioxide
in flue gases. The physical absorption and
membrane separation are suitable for
capture of CO2 from syngas (gas under
high pressure). In case of the oxy-fuel
combustion where the CO2 concentration
is high the cryogenic capture is the
optimal solution, and oxygen enriched
combustion adsorption technology.
Each of mentioned technologies shows
advantages as well as disadvantages.
Chemical absorption process requires
large amounts of solvent it should be
periodically refilled, and thus this process
is connected with high investment costs
and energy consumption. The physical
absorption and membrane separation
involve high gas pressures. Additionally
membrane techniques have inherent
difficulty in achieving high degrees of
gas separation while cryogenic ones
require significant energy penalty.
The improvement can be made

considerably by increasing the area of
pellets hence applying greater electric
field to attract the CO2, but subsequently
it will require even better material
development to defy N2 element. The
increment in surface area will require
more equilibrium to be present between
electrolyte and absorbent properties. To
In general, the separation can be carried

out by pressure swing adsorption - PSA,
vacuum-pressure
swing
adsorption
(desorption is achieved by reducing the
pressure of the system [7]) - V-PSA,
temperature swing adsorption - TSA,
183
- Ions displace
(sweeping)
enhance the electric field over the pellets

a better electrolyte, which is more prone
to transfer charges to pellets, should be
developed whose more elaborative point
of view is explained further.
CO2
from
pores
- Electrostatic ion-molecule interaction

with surface ions increases adsorption
(enhancement)
Electric Field swing absorption for

carbon capture:
Direction of effect may depend on

electrode character (anode vs. cathode.
Electric field swing adsorption (EFSA)

involves using DC electric bias to modify
adsorption of CO2 on electrically
conducting high-surface area carbon
(HSAC)
Advantages Associated:
Simple: EFSA enables gas separation
and capture using electric fields to change
thermodynamics of adsorption
Sorbent can be switched in-place

between adsorption and desorption modes
by switching electric bias on and off
Reversible: Switching between ad/desorption achieved by reversing field

removes the need to transport or heat
sorbent materials
There are various categories involved in

this type of main stream which includes
Electric Field Driven Ion Sweeping
(EFDIS) [1], Static pressure method [1]
(pressure swing adsorption with novel
solid sorbents)
Efficient: Electrical current used during

charging is partially regenerated in
discharging, well-suited for CO2 capture
technology.
The figure below summarizes the overall
EFDIS process.
Specific Approach (EFDIS):

EFDIS uses mobile ions to reversibly
change interaction of CO2 molecules
with sorbent material
HSAC material combined with liquid or
solid electrolyte to form electric double
layer capacitor
In discharged (field off) state, HSAC
nano-pores yield high absorptivity for
CO2
In charged (field on) state, ions move
from electrolyte into nano-pores to form
electric double layer [1] [2]
Static pressure Method:
Two effects possible in principle:
184
Electrodes w/electrolyte sealed in

pressure cell filled w/gas for several
hours
Possible steps in Super-capacitive swing

adsorption technique include;
1. Providing a super-capacitive electric
capacitor; the capacitor having nanopores in at least one exposed surface of
an electrode, the electrode further
comprising an electrolyte in contact with
the electrode; contacting the capacitor
with a gas, the gas comprising an
adsorbate; and reversibly providing an
electric charge to the capacitor to cause
an electric double layer to form, thereby
altering an initial adsorption property of
the capacitor relative to the adsorbate.
Electrical potential (1.0 V) switched

on/off with certain duty cycle
Changes in amount of adsorbed gas is
reflected by change in pressure
Field induced effect for CO2 must
dominate of that for N2/H20, where; CO2
pressure corresponds to changes in
voltage.
2. In the step of reversibly providing an

electric charge to the capacitor, further
comprises removing the electric charge to
thereby restore the initial adsorption
property of the capacitor relative to the
adsorbate.
3. In the steps of charging the capacitor
there is a change in the chemical nature
or energy of the electrode that alters
adsorption property of the capacitor's
micro-pores relative to the adsorbate.
Static pressure method
4. Upon providing of an electric charge to

the capacitor, the electrolyte and the
adsorbent and electrode collectively form
contiguous pathways available for
transport of gas molecules, electrons, and
ions.
Super-capacitive Swing Adsorption: [3]

A relatively new approach to sorption
based gas separation using supercapacitive swing adsorption (SSA). This
approach is advantageous over traditional
gas separation techniques as it avoids the
need of pressure and temperature
changes.
Reusable
super-capacitive
energy is utilized to achieve gas
separation
suggesting
substantially
reduced cost. This development has real
potential is energy efficient, simple, and
reversible.
5. Ions are then released from the

electrolyte and are drawn into the micropores which then change the absorptivity
for the adsorbate.
6. Upon removal of the electric charge to
the capacitor, the ions return to the
electrolyte, thereby restoring the chemical
185
property among the micro-pores to

thereby approximately restore the initial
absorptivity of the adsorbate relative to
the capacitor [3]
Super-capacitive
technique:
swing
2006)(desorption is achieved by heating

up the adsorbent) [5] [7]. The main
inconvenience of TSA process is the
longtime of desorption cycles that can be
reduced maximizing the contact area of
the hot gas and the adsorbent (Bonnissel
et al., 2001; Merel et al., 2006). A process
that can increase very fast the
temperature of the adsorbent is Electric
Swing Adsorption [5]. If we compare
ESA with TSA we came to know that the
major difference b/w both is that in the
former temperature increase is achieved
by using electric power while in the latter
waste heat is employed. Generally ESA is
a five step cycle, the cycle comprised a
feed, an internal rinse where the column
started to be heated passing electricity but
allowing some gas to leave by the top,
electrification
(where
the
high
temperature is achieved by passing
electricity in the closed column),
depressurization and purge. A CO2purified stream is collected both in the
depressurization and purge steps. This is
applicable if we are interested in
producing a CO2 stream with 3-3.5% of
purity, but if we want to have CO2 stream
with >95% accuracy [4] then we must
have to select the material with higher
capacity also to modify some steps in the
previous five step process cycle. [4] [5]
adsorption
The technology involves systems for

executing methods of adsorbing and
separating components of a gas stream. In
an example, an apparatus for separating
components of a gas stream is provided,
the apparatus comprising: a) an electric
capacitor preferably having a capacitance
greater than about 0.1 F/g; the capacitor
having micro-pores in at least one
exposed surface of an electrode, the
capacitor in contact with an electrolyte;
and b) a gas stream in contact with the
capacitor, the gas stream containing at
least one adsorbate; and c) an electrical
power source communicably connected
to the capacitor for reversibly providing
an electric charge to the capacitor to
cause an electrolyte to migrate into the
micro-pores of the electrodes of the
capacitor, thereby removing the adsorbent
from the gas stream.
ESA process to capture CO2:
Electric Swing Adsorption (ESA) is the
name that was given to an adsorption
process where the regeneration is
performed by increasing the temperature
of the adsorbent using the Joule effect of
passing electricity through a conductor.
When the flue gas has a low CO2 content,
combined temperature and VPSA
(Ishibashi et al., 1996) and also
Temperature Swing Adsorption (TSA)
were
proposed
(Merel
et
al.,
Modified cycle for improved ESA

performance:
At the end of the feed step, the column
has the CO2 adsorbed and a large amount
of moles of N2 in the gas phase.
Afterwards, some of this adsorbed CO2 is
desorbed by heating the column,
displacing the N2 from the gas phase,
consuming electricity. Other important
186
observation noted before is that if we

decrease the duration of the purge step,
the decrease in recovery is drastic:
achieving purities around 90% will lead
to recoveries smaller than 50% [4].
Recycling a hot stream with a higher CO2
content will help reducing the N2 content
in the column prior to electrification and
also (once that the stream is hot) we will
be able to reduce the electricity
consumption once we are pre-heating the
column for desorption. As the content of
CO2 in the purge step decreases
exponentially with time, the purge can be
divided into two steps. In the first one,
the gas with high contents of CO2 is still
recovered as product while in the second
step, the stream is recycled. In the figure
below, seven steps are employed: feed,
rinse with recycled hot gas, internal rinse
to deploy nitrogen from the column,
electrification, depressurization, purge
and the final step that is the purge to
provide gas for the recycle. [4]
The gas inlet consists of a three-way

valve where either feed or purge gas is
admitted to the column where the
adsorbent is placed. After passing the
column, gas temperature and flow-rate is
measured.
The CO2 concentration is also measured
using an infrared continuous sensor. The
column is connected to the power source
that delivers constant voltage (12 V)
varying the current intensity according to
the resistance of the connection. All gases
employed were supplied by Air Liquide
[4]: CO2 and He [5]. The cycle was
operated according to the following
procedure: feed (CO2 + He) was
inserted to the column until CO2 is
detected at the outlet of the column. After
that, the feed stream is switched to an
inert stream together with passing electric
current until the temperature of the gas
exiting the column is close to 423 K (+/-5
K). When this temperature was achieved,
electricity circuit is opened and only the
inert gas is kept until no CO2 is detected
[5] in the gas stream.
Experimental Arrangement:
Experimental setup for Electrical swing

adsorption as in [7]
Schematic diagram of the set-up

employed
for
measurements
of
adsorption and desorption for ESA cycles
[5].
A mixture of CO2 and N2 was passed

through an adsorption cell where CO2
was captured by the carbon adsorbent
187
Initial value or the adsorbent was

saturated; an electrical voltage was
applied on the adsorption cell. The CO2
released was monitored as well as the
temperature inside the adsorbent.
4. Purge: after almost all CO2 is removed

from the column (to reach desired CO2
recovery), the amount of inert gas should
be increased to cool down the system as
fast as possible. This step does not
produce CO2 and is one of the sources of
CO2 emissions. This step or a similar one
is absolutely necessary to cool down the
temperature for the following cycle.
Electric swing adsorption technique:
Key aspect of ESA to work effectively:
1. Adsorption: the feed stream is allowed

to the column and the strongly adsorbed
compound (CO2) remains in the
adsorbent while a purified stream leaves
the column.
In order for ESA to work effectively, a

good adsorbent meeting the following
requirements is the key [7]:
(indicated by a decrease in
concentration).
When
the
concentration returned to its
CO2
CO2
1. High selectivity and

capacity for carbon dioxide.
2. Electrification: before CO2 breaks

through the bed, the feed is stopped and
electric current passes through the
column heating the column to the higher
temperature of the cycle. In this step the
inert is introduced in the product-end of
the column, counter to the feed step.
Other options like no inert gas or closing
the column for this step can be possible
[5]. Purified CO2 may be produced in
this step [5].
adsorption
2.
Adequate
adsorption/desorption
kinetics for carbon dioxide. The
adsorbent must be electrically conductive
and desorption process must be fast.
3. Stable adsorption and desorption
behaviors of carbon dioxide after
repeated adsorption/desorption cycles (or
good reversibility).
4. Adequate mechanical strength and
resistance of sorbent particles after
repeated adsorption/desorption cycles.
3. Desorption: some inert gas is allowed

to counter the feed stream. This gas
should remove the CO2 desorbed. In this
step, CO2 is obtained as purified product.
The duration of this step should be short
to avoid dilution of CO2.
5. Good regener-ability. The regeneration

efficiency as well as the energy efficiency
should be high.
REFERENCES
[1] Electric Field Swing Adsorption for Carbon Capture Applications Cong Liu, Nina K.
Finamore, Berenika A. Kokoszka, David T. Moore*, Kai Landskron* Department of
Chemistry, Lehigh University, Bethlehem, PA 18015.
[2] W. Nowak, D. Wawrzyczak, I. Majch Zak-Kucba, J. Pacyna, CO2 capture by
pressure swing adsorption with novel solids sorbents
188
[3] Super-capacitive swing adsorption technique, Lehigh University.

[4] Electric swing adsorption as emerging CO2 capture technique, Carlos A. Grande*, Rui
P. L. Ribeiro, Eduardo L. G. Oliveira, Alirio E. Rodrigues LSRE Laboratory of
Separation and Reaction Engineering. Associate laboratory faculdade de Engenharia,
University of Porto. Rua Dr. Roberto Frias (4200-465) Porto, PORTUGAL
[5] Electric Swing Adsorption for CO2 removal from flue gases, Carlos A. Grande *,
Alrio E. Rodrigues Laboratory of Separation and Reaction Engineering (LSRE),
Associate Laboratory LSRE/LCM, Department of Chemical Engineering, Faculty of
Engineering, University of Porto, Rua Dr. Roberto Frias s/n, 4200-465 Porto, Portugal
[6] Challenges of Electric Swing Adsorption for CO2 Capture Carlos A. Grande,* Rui P. P.
L. Ribeiro, and Al_rio E. Rodrigues
[7] ELECTRICAL SWING ADSORPTION OF CO2 USING CARBON COMPOSITE
MATERIALS, Bo Feng, Hui- An, Aitharaju Venkata, Jiang Chen, The University of
Queensland, Australia Ramesh thiruvenkatachari, Shi Su, CSIRO, Brisbane, Australia
[8] Carbon dioxide capture-related gas adsorption and separation in metal-organic
frameworks, Jian-Rong Li a, Yuguang Mab, M. Colin McCarthyb, Julian Sculleya, Jiamei
Yub c, Hae-Kwon Jeongb,c, Perla B. Balbuenab,c, Hong-Cai Zhoua,c,
CORRESPONDENCES
*Department of Electrical Engineering and Automation, CASP, Aalto University, Espoo
Finland University. Email: noman.nisar@aalto.fi
**Department of Electronics,
junaidaslam1@gmail.com
Government
189
College,
Lahore,
Pakistan.
Email:
THERMOELECTRIC GENERATION USING COMBINED

(CONCENTRATED) SOLAR TECHNOLOGY
Noman Nisar*, Muhammad Junaid Aslam**
ABSTRACT
In the present paper solar based thermoelectric technologies and the problems related to
these technologies and the benefits associated by these thermoelectric technologies are
outlined. The development processes of thermoelectric technologies are introduced in
combination with methods to gather sunlight for the solar thermo electric power
generation to show to the reader the extent of their applicability. The system design of
thermo power generator based on solar concentrator and cooling methods based on latent
energy storage are also introduced. Salinity gradient solar pond is capable of storing heat
up to a temperature of 80 degree C. Also in this paper temperature profile of salinity
gradient solar pond located at RMIT University is also presented suggesting that
thermoelectric technology can be an alternative direct way to convert solar radiation into
electricity using See-beck effect, which states that a voltage is induced when a temperature
gradient is applied to the junctions of two differing materials [1]. The thermoelectric effect
is the thus direct conversion of temperature differences to electric voltage and vice versa
[Wikipedia]. A thermoelectric device creates voltage when there is a temperature
difference or if we talk the other way round, when a voltage is applied to it, it creates a
temperature difference.
Keywords Thermoelectric generator, solar pond, power generation, solar parabolic dish
collector, modules, concentration solar
temperature of the absorber and finally
Concept of Thermoelectric Circuit
the voltage is measured across the load
For Thermoelectric generator (TEG), the

materials
are
thermoelectric
n-type
and
substrates.
point which is the open point in the
p-type
corresponding figure.
The
temperature junctions can be treated as
The
the substrate for the thermoelectric
proportional to the temperature difference
modules. T represents the temperature
T as given by the equation in [1]
of the heat sink, T+T represent the
190
induced
voltage
is
in
turn
gets converted into heat which is then

used to drive the heat engine [Wikipedia].
Concentrated
ted solar power systems are
divided into [1] [14]
Concentrated solar thermal (CST)
Concept of thermoelectric circuit
Concentrated photovoltaic (CPV)
Concentrating photovoltaic and thermal
(CPT)
2. Concentrated solar thermal (CST) is
used to produce renewable heat or cool or
Basic layout
electricity
ity (called solar thermoelectricity).
Where the see-beck
beck coefficients are
CST system uses lenses or mirrors and
related
then tracking systems to focus a large
to
material
properties
and
generally are assumed constant.
area of sunlight onto a small area. The

light concentrated in this manner can then
Similarly, the Peltier Effect [1] describes
be used as a heat source to drive a
the inverse of this behavior when an
conventional power plant.

pla A wide range
electrical current is passed through the
of
junction of two differing materials, heat is
concentrating
technologies
exist,
including the parabolic trough, Dish
either lost or absorbed at the junction
Stirling, Concentrating Linear Fresnel
according to the direction of the current
Reflector, solar chimney and solar power
[1].
tower [10] [14].

Methods to gather Sunlight
3.
Parabolic trough [14]: A parabolic
1. Concentrated solar power (CSP): CSP
trough consists of a LPR (linear

(line parabolic
is a system that uses lenses or mirrors

mirror to
reflector) that falls light onto the receiver
concentrate a large area of sunlight, or
which is positioned along the reflectors
solar thermal energy onto a small area.
focal axis by gathering (concentrating)
Electrical power is produced when the
light phenomena. The receiver is a tube
light concentrated at a particular point
positioned directly above the middle of
191
the parabolic mirror and is filled with a
Thermoelectric modules:
working fluid. The reflector follows the
In a typical thermoelectric module, the p-
Sun along the single axis during the
type as well as n-type thermoelectric
daytime [10].
elements are connected electrically in

series and thermally in parallel to
substrates. Heat is absorbed through the
top substrate and then it flows through the
thermoelectric elements; afterwards it is
then rejected at the bottom substrate.
Loads can be attached to the external
electrical connection [2]. There are also
Figure 1: Parabolic trough--- Source:
metal interconnections between them so
http://en.wikipedia.org/wiki/Solar_therma
as to allow conduction phenomena to
l_collector, 19.11.2010
happen and the current then follows as

can be seen in the figure below.
4. Parabolic Dish Stirling [14]: A Dish

Stirling or parabolic dish Stirling (dish
heat engine) consists of a stand-alone
parabolic reflector that falls light onto the
receiver which is positioned along the
reflectors
focal
axis
by
gathering
(concentrating) light phenomena. The

receiver which is filled with fluid is
heated to 250700C (523973 K (482
1,292F)) and then used by a Stirling
engine
to
generate
power
[10].The
Figure 2: Thermoelectric materials in
essential difference between the parabolic
thermoelectric module [2]
dish Stirling and parabolic trough is the

reflectors axis, in the former the reflector
The TEG can be modeled by some
follows the sun along the single axis
electrical analogy, where the open circuit
while in the latter the reflector tracks the
voltage V_oc and R_source represents the
sun along the two axis.
TEG, the load is a resistor R_Load and

output is the voltage drop across the
192
resistor R_Load (fig. shown below)
See-becks relation state that voltage

induced is proportional to the temperature
difference,
with
the
proportionality
constant represents the difference in the

See-beck coefficients of the p-type and ntype materials [1].
V
=(
)(
: See-beck coefficient for p-type
Figure 3: Basic analogy of TEG
thermoelectric material
: See-beck coefficient for n-type
thermoelectric material
: hot-side (absorber) temperature
:
Cold
side (heat
sink)
temperature
The resistance of thermoelectric module
is given by,
Figure 4: Electrical analogy of TEG
s= p*(
)+
n*(
By looking at the electrical equivalent

If we assume that the cross sectional
diagram, we can find the V as,
areas
V
= I(R + R )
of
the
p-type
and
n-type
thermoelectric elements are the same then

the above equation can be written as,
According to maximum power transfer

theorem, maximum power is transferred
s=
(2 /
TE)*( p+ n)
when source and load resistances are

equal, then the current in the above
Combining the equations for open circuit
expression becomes;
voltage &
the value of current
becomes,
I = V /2R
I =(
193
)(
TE/
(4 ( p+ n))
The amount of heat absorbed by the

absorber and then transferred to the
thermoelectric module is given by eq1 [5]
Figure 5: Energy balance across solar

Representing
x=0
the
hot
thermoelectric module and x=
side
of
absorber [5]
the cold
side, then the derivatives are expressed
Combined
photovoltaic-Thermo
as,
electric power generation:

Although fossil fuels are currently the
most economical source available for
power generation, the increasing price of
oil and the harmful emissions generated
Substituting the values of current and the
due to the combustion of fossil fuels have
above equation into eq1 the heat transfer
encouraged
equation becomes,
many
investigate
researchers
economical
methods
to
for
exploiting renewable energy sources all

over the world. Solar energy is known as
the most abundant source of energy on
The total energy across the absorber can
the earth. The direct conversion of solar
be expressed as a sum of solar radiation
energy
incident on the top of absorber, the heat
photovoltaic (PV) effects has been the
which is leaving the bottom of the
primary focus now for many years.
absorber to the thermoelectric module,
Owing to the remarkable progress in
losses which take place due to radiation
material
from the top of the absorber and the heat
nowadays the cost of solar electricity has
losses due to convection process (heat
significantly decreased. However, it is
lost due to radiation from bottom of the
still more expensive and less efficient
absorber)
than
[5].This
is
graphically
represented as,
to
electricity
sciences
conventional
based
and
on
engineering,
power
generation
methods like hydropower etc. Therefore,

exploring
194
methods
to
increase
the
conversion efficiency of PV systems is of

great importance.
Using mirrors and lenses to concentrate
sunlight on PV cells in order to increase
the intensity of incident irradiation is one
Figure 1
method used to achieve more power out

of unit area of Photovoltaic cells, referred
Although
to as concentrated photovoltaic (CPV)
irradiation results in a higher output
system and using CPV to produce viable
power for the PV cell, the temperature (of
electricity is referred to as concentrated
the
thermoelectric generator (CTEG) [8].
increase, which, in turn, reduces the cell
Basically, both CPV and CTEG use the
efficiency and leads to cell deterioration.
same solar concentrating principle by
The main challenge in this system is the
concentrating solar radiations on the solar
effectiveness of waste heat removal rate
cells with the help of some solar
at the cold side of the thermoelectric
concentrator such as Fresnel lens or
modules to achieve the ideal temperature
parabolic dishes for higher electrical
difference [8].
cell)
increasing
would
also
the
incident
significantly
generation [8]. However, CPV system is

not
advisable
to
operate
high
Using active cooling devices such as
temperature environment (~125 C) as it
electric fans and water pumps are not
will result in shortening of expensive
advisable in power generating systems as
silicon cell life due to long exposure and
they require energy while operating these
also consequently it will reduce the
devices, which will in turn reduce the
power conversion efficiencies. As for
total power generation. To overcome this
Concentrated thermo-electric generator
issue, an appropriate cooling method
system, it is designated to operate in
should be used in order to keep the PV
higher
cell panel within a specific temperature
temperature
in
environment,
operating temperature range from 150C
limit.
to 300C.
Several cooling methods have been

proposed and tested during the past few
decades, including passive cooling and
195
active cooling approaches [4]. In most of
system consisted of the thermoelectric
these methods the excess heat was
modules, the heat sink device, thermal
transferred away from the PV cells and
energy storage, the receiver plate, and
wasted to the environment.
manual tracking arrangement for the solar
The most common active cooling method
parabolic dish collector (parabolic sun
is either the use of photovoltaic thermal
tracking) [9].
collectors comprising of solar panel with
The
water or air channel available at the back
secondary
optics
included
hyperbolic mirror, folding mirrors, and a
side of TEG or by using the latent heat
compound parabolic concentrator. As
storage concept in combination with
back up for the primary solar energy
thermal storage tanks [8] where the phase
concentrating parts, an optional burner,
change material (PCM) is used (filled) in
using low grade fuel, gas or biomass, was
a thermal storage tanks for absorbing the
considered for operation under prolonged
dissipated heat from the cold side of the
bad
TEG module to achieve cooling. The
weather
conditions.
The
most
important parameters required for such
basic idea of interest is that heat is
systems were continuous operation, high
supplied at one side of the module and
reliability and low maintenance [9].
the other side is kept at a lower

temperature; as a result, the electrical
The
schematic
diagram
of
current flows through an external load,
experimental setup is given below,
the
which completes the circuit (as has been

described in the previous figure), but this
method does not take into account the
reflection losses.
Experimental setup of solar parabolic

dish thermoelectric generator: [6] [9]
[14]
Figure 2
A practical setup was made to establish

the generation of electricity using solar
Schematic view of solar thermal power
parabolic dish for TEG in 2010. The
plant [9]
196
aluminum sheet was to absorb the

The reflector in the above figure acts as a
concentrated
sun-tracking parabolic dish. In addition
absorbed heat energy in the receiver plate
the figure shows to be a unique design
was then transmitted to the hot side of
which combines the main axes of motion
thermoelectric
with
convection, radiation, and conduction.
optical
concentrated
axis,
solar
directing
radiation
the
onto
plate
circulated to the heat sink to maintain the
Generator
the
and
made
of
aluminum
sheet;
thermoelectric modules and the heat sink.
cold side temperature at minimum; the
Operating parameters such as receiver
cold water is drawn from the over-head
plate temperature, heat sink temperature
tank. The flow rate of cold water is

the
after
The TEG unit consisted of the receiver
heat sink (cold temp.). The cold water is
by
The
Measuring Unit:
losses [9]. The stainless steel box acts as
manually
radiation.
modules
Thermoelectric
stationary receiver with minimal optical
adjusted
solar
and ambient temperature were measured
valve
by
arrangement in order to maintain the
measuring
radiation
constant outlet temperature of the water.
was
devices.
Solar
measured
by
beam
the
pyranometer instrument (Make: Energy
So, in this way the mean temperature of
and Environmental Ltd, Cochin) with an
water is considered as the heat sink
accuracy of 0.1% and the wind velocity
temperature. The receiver plate was made
was measured by the wind anemometer).
aluminum with dull black paint to absorb
The water flow rates in the heat sink were
the concentrated solar radiation from
measured by volume of the collection
concentrator, and the receiver to be
over time methods in a closed vessel. The
attached to the hot side of thermoelectric
generated voltage, electrical current and
module.
the connected electrical load of TEG

were measured by using the digital
Solar Parabolic Dish Collector of the
multimeter.
setup under consideration:

The receiver plate was placed at the focus
to track all the light to a single point. A
RESULTS AND DISCUSSION:
manual tracking mechanism arranged at
Solar
the bottom of the dish helped to track the
generator was tested at outdoor condition
sun. The flat receiver plate made of
on clear sunny day at Tiruchirappalli,
197
parabolic
dish
thermoelectric
India. The main operating parameters like
range of operating conditions as follows;
receiver plate temperatures, solar beam
the
radiations and electrical powers (current x
varying between 350 K and 650 K and
voltage)
The
the mean temperature of heat sink b/w
performances of the TEG were evaluated
300 K to 310 K. The currents and
in terms of the electrical power output
voltages were measured for constant
and the conversion efficiency from the
resistance of 4 in terms of electrical
following
power generation.
were
recorded.
relations.
For
the
load
receiver
plate
temperature
was
resistance, the electrical power output

from the TEG and the voltage generated
The maximum power output of 68 W was
is given by the formulas [6],
obtained when the solar beam radiation

was at the maximum value at 950 W/m2
P=
with the receiver plate temperature of 602
V
R
K. The minimum power output of 11 W

was obtained when the solar beam
&
radiation value was at 430W/m2 with the

= P/Q
receiver plate temperature of 375 K [6].
Where P is Electrical power output from
Associated Drawbacks & Remedies:
TEG, V is generated voltage from TEG,
The above mentioned method purely
R is the connected electrical load, and Q
depends on the amount of solar radiation
is the heat input to TEG from the solar
on the disk collector. If for some weather
parabolic dish collector which can be
conditions (say) the amount of solar
computed from the following relation,
radiation falling is limited to drive the

TEG then the question arises WHAT WE
Q = C A! I"
[6]
SHOULD DO?
To answer this question [7] gives a very
Where : the optical efficiency of the
brief
solar dish collector, A! is the surface area
gradient solar pond which is capable of
of the receiver plate, I" is the beam of
storing heat at a temperature up to 80C
radiation, and C is the concentration
[7]. The temperature difference between
ratio. Experiments were conducted for a
the upper convective zone (UCZ) and
198
overview
regarding
Salinity
lower convective zone (LCZ) of a SGSP
Fig. shows the Salinity gradient solar
can be in the range of 40C 60C. This
pond (SGSP) at RMIT University. The
temperature difference can be used to
size of the solar pond is 50m2. Due to the
power thermoelectric generators (TEG)
salinity gradient established in the pond,
for electricity production.
heat is trapped at the bottom of the pond

due to the absence of convection in the
Solar pond is a simple and low cost solar
non convecting zone (NCZ). As seen
energy system which collects solar
from fig. below, the temperature at the
radiation and stores it as thermal energy
bottom of the pond is about 65C and the
for a relative longer period of time. When
top surface of the pond is only at 26C.
solar radiation penetrates through the
This enables the SGSP to provide both
solar pond surface, the infrared radiation
hot and cold water needed to produce
component is first absorbed in the upper
electricity
convective zone. However, this heat is
remaining
radiation
the
thermoelectric
generator [7].
lost to the atmosphere through radiation.

The
from
will
subsequently be absorbed in the lower

convective
zone.
Solar
radiation
penetrating to the bottom region is

absorbed there and temperature of this
region rises substantially since there is no
heat
loss
due
to
convection.
The
temperature difference created between

the top and the bottom of the solar ponds
Figure 9: Salinity gradient solar pond
can be as high as 4060C [7].
loacated at RMIT , Australia
Figure 8: Salinity gradient solar pond [7]

199
devices with no moving parts, which
[7]Figure 10
Optical
concentrated
greatly increase reliability and lifetime.
Solar
Additionally, Solar TEG is a scalable
Thermoelectric generator:
technology that can be used for small- or

large-scale applications.
While photovoltaics are limited to the
fraction of incident solar radiation above
the band-gap, Solar TEGs utilize a larger
portion of the solar radiation spectrum.
The total efficiency of a STEG depends
Figure 11
on optics, absorber, and thermoelectric

subsystem efficiencies. A Solar TEG can
be divided into several subsystems, as
seen in Fig. above. The first is an optical
system to concentrate the solar radiation.
Second:
thermal
absorber
which
converts the incident light to heat which

then flows to the thermoelectric module.
Figure 12
Finally the thermo-electric module and
As described previously, solar thermal
cooling system, encapsulated in a vacuum
technologies produce electric power from
enclosure to prevent conductive and
a temperature gradient, traditionally by
convective heat losses to the air [11].
using conventional heat engines [11].

Solid state heat engines, in the form of
thermoelectric generators (TEGs), can
also use this temperature difference to
generate Power. Solid state TEGs has
several
advantages
as
compared
to
existing solar technologies.

Unlike
traditional
solar
thermal
generators, Solar TEGs are solid state
200
the sunlight more efficiently, two copper

strips coated with a selective absorber are
soldered to the surface of the heat
collector. Two thermoelectric modules
are then attached, one on the top and one
on the bottom of the heat collector,
respectively.
The
modules
can
be
connected in series or parallel, depending

on the output voltage requirement.
The heat sinks are attached on the other
Figure 13: Optical concentration systems
end of the thermoelectric module to
for high efficiency STEGs

A
complete
concentrated
dissipate heat rejected from the cold

junctions which keeps them at a low
solar
thermoelectric generator system must
temperature.
include a sun tracking system, a sunlight
utilization of solar energy, cooling plates
concentrator, a heat collector, a set of
are used to remove waste heat from the
thermoelectric
modules to the coolant fluid. The coolant
modules,
cooling
For
comprehensive
is typically water, although other fluids
system, and other auxiliary equipment.
may be used in a closed circuit. The hot

The details of the CSTEG (concentrated
coolant
solar thermoelectric generator) unit are
leaving
the
thermoelectric
module is directed to a heat exchanger,
shown in fig 18. In this scheme, the
where the heat may be used as an
incident sunlight is first concentrated by
additional
two Fresnel lenses and then focused onto
energy
by
product,
for
example, to produce hot water for
a heat collector from both sides by means
domestic or industrial applications [12].
of a reflective mirror. In order to absorb
REFERENCES
[1]
MacDonald, D. K. C. Thermoelectricity: An introduction to the principles. 1962.
New York: John Wiley & Sons, Inc.
[2]
Thermo electrics, 2013. California Institute of Technology: Materials Science.
<http://thermoelectrics.caltech.edu/thermoelectrics/engineering.html>.
201
[3]
Telkes, M. The Efficiency of Thermoelectric Generators, Journal of Applied
Physics 18, 1116-27. 1947.
[4]
Modeling and Analysis of a Combined Photovoltaic- Thermoelectric Power
Generation System, Hamidreza Najafi, Keith A. Woodbury, [DOI: 10.1115/1.4023594],
Journal of Solar Energy Engineering Copyright VC 2013 by ASME AUGUST 2013, Vol.
135 / 031013-1
[5]
Kraemer, D., et al. Supplementary information: High-performance flat-panel solar
thermoelectric generators with high thermal concentration. Nature Materials 10 2011 May
1.
[6]
Experimental Study on Solar Parabolic Dish, Thermoelectric Generator
M.Eswaramoorthy1, S.Shanmugam2, AR.Veerappan3, International Journal of Energy
Engineering (IJEE) Jun. 2013, Vol. 3 Iss. 3, PP. 62-66
[7]
Power Generation from Salinity Gradient Solar Pond Using Thermoelectric
Generators for Renewable Energy Application, Baljit Singh, Lippong Tan, Abhijit Date,
Aliakbar Akbarzadeh, 2012 IEEE International conference on Power and Energy (PECon),
2-5 Dec 2012, Kota Kinabalu Sabah, Malaysia.
[8]
Sustainable Thermoelectric Power System Using Concentrated Solar Energy and
Latent Heat Storage, Lippong Tan, Baljit Singh, Abhijit Date, Aliakbar Akbarzadeh, 2012
IEEE International conference on Power and Energy (PECon), 2-5 Dec 2012, Kota
Kinabalu Sabah, Malaysia.
[9]
HIGH EFFICIENCY THERMOELECTRIC UNIT WITHIN AN AUTONOMOUS
SOLAR ENERGY CONVERTER, Z. Dashevsky, D. Kaitori, D.Rabinovich, 17th
international Conference on thermoelectric (1998)
[10] http://en.wikipedia.org/wiki/Concentrating_Solar_Power, 23.11.2010
http://en.wikipedia.org/wiki/Solar_thermal_collector, 25.11.2010
[11] Concentrated solar thermoelectric generators, Lauryn L. Baranowski, G. Jeffrey
Snyderb and Eric S. Toberer, Received 17th May 2012, Accepted 6th August 2012, DOI:
10.1039/c2ee22248e, Energy Environ. Sci., 2012, 5, 9055 www.rsc.org/ees
[12] Design of a Concentration Solar Thermoelectric Generator, PENG LI, LANLAN
CAI, PENGCHENG ZHAI, XINFENG TANG,QINGJIE ZHANG, and M. NIINO, Journal
of ELECTRONIC MATERIALS, Vol. 39, No. 9, 2010 DOI: 10.1007/s11664-010-1279-0
2010 TMS
[14] Technical and economical evaluation of solar thermal power generation, Theocharis
Tsoutsos, Vasilis Gekas, Katerina Marketaki, Renewable Energy 28 (2003) 873886,
www.elsevier.com/locate/rser
202
CORRESPONDENCES
*Department of Electrical Engineering and Automation, CASP, Aalto University, Espoo
Finland University. Email: noman.nisar@aalto.fi
**Department of Electronics,
junaidaslam1@gmail.com
Government
203
College,
Lahore,
Pakistan.
Email:
204

Scientific Research Journal of India SRJI Vol-3 Issue-3 Year 2014

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Scientific Research Journal of India SRJI Vol-3 Issue-3 Year 2014

Uploaded by

Copyright:

Available Formats

Scientific Research Journal of India

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

Jyoti Sharma, Jabalpur, India

Kuki Bordoloi, Guwahati, India

Mrityunjay Sharma, Varanasi, India

Neha Dewan, Canada

Ngeh Etienne Ngeh, Cameroon

Krishna N. Sharma, Cameroon

Piyush Jain, New Delhi, India

Popiha Bordoloi, Guwahati, India

Ankita Kashyap, Bhopal, India

Sushil S. Dubey, Mumabi, India

Florence Ngwanyam, Cameroon

Tufon Emmanuel, Cameroon

Gayatri Jadav Upadhyay, Bhopal, India

Waqar Naqvi, Saudi Arabia

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

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

FROM THE EDITOR IN CHIEF

A STUDY TO DETERMINE THE RELATIONSHIP

Meenakshi Verma, Amita

Juanita E. Soans Keerthi

Dr. Vivek H. Ramanandi

Amit Murli Patel

Nitika Anand, Sunil Bhatt

Sunil Bhatt, Jagun Tomar,

Shivam Karn, Sunil Bhatt,

Baiju Prasad Jaiswal, Sunil

Dr. Sumit Asthana

EFFECT OF JACOBSONS PROGRESSIVE

BULLYING ON CLINICAL INTERNSHIPS: A

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

BELLS PALSY AND ITS IMPACT ON VARIOUS

HETEROTROPIC PREGNANCY-AN UNUSUAL

Mr. Guruprasad.V, Mrs.

Sudha Rani, E.Ramadevi,

Kavitha Kothapally, Ramdas

Syed Rehan Ahmad, Dr.

Bashir A. Sheikh, Tanveer

Noman Nisar, Muhammad

Noman Nisar, Muhammad

PHYTOCHEMICAL ANALYSIS AND

ANTIMICROBIAL ACTIVITY OF CHLOROPHYTUM

FOR IMPROVED (CO2) CARBON CAPTURE

FROM THE EDITOR IN CHIEF

Like all our previous issues, this issue also remains a

Thanks for reading, and stay tuned for future editions.

A STUDY TO DETERMINE THE RELATIONSHIP BETWEEN THE

individuals (55%) are over the age of 65

The risk of falls of individuals with a fear

organizing a free camp in the health

muscle strength, and joint flexibility, are

Procedure- subjects were thoroughly

Limits of stability refers to the sway

A computer software package, SPSS.11

TUG and SF-36

Where, n= no. of subjects, x= each

Pearson correalation of two variables (X

Paired t test were also used

TABLE 1.1: Mean and Standard

TUG and SF36

BBS TUG SF-36

BBS and SF36

TABLE 1.2: Pearson correlation between