Philippine Journal of Allied Health Sciences Vol 4 Iss 1

Volume 4 Issue 1 • August 2020 Editorial In peer review we trust Ivan Neil Gomez, PJAHS Editor-in-Chief Letters to the Editor Teaching allied health courses in the time of COVID-19: challenges and opportunities Gian Carlo Torres, Earl Francis Sumile Speech language pathology services in a time of pandemic Candace Vickers Occupational therapy in the times of the pandemic The Philippine Academy of Occupational Therapists, Inc. Mental health in the times of the pandemic Alejandro Baroque, Gabriel Alejandro Baroque Original Articles Clinical audit on outcome measures used in examination of knee osteoarthritis in selected hospitals and clinics in the Philippines Jocel Magpili Regino, Cristine Rose Sanchez Versales, Jin Kaye Galupe Catalan, Edgar Maurice Gunda Bajado, Marielle Regine Del Rosario De Jesus, Orville Espiritu Hernandez, Gabriele Uriel Escalano Palisoc, Jaime Antonio Saile Rama, Alyssa Rae Samson Tungal Effect of non-elastic closed-basket weave ankle taping on muscle activity of tibialis anterior, peroneus longus, medial, and lateral gastrocnemius during jump landing on a hard, flat surface in healthy individuals: a pilot study Fe Therese Chavez, Emmanuel Carpio, Philip Andrew Aguilar, Daniella Ang, Blessie Busog, Rheine Canlas, Isabella Gonzales, Joan Marie Ibanez, Adrian Miclat, Mary Angelique Principe Muscle activation pattern of gluteus medius, tibialis anterior and peroneus longus during drop landing on different surfaces: a cross-sectional study Ken Erbvin Sosa, Kristina Devora, Rino Luis Santiago, Shyllah Trish Abando, Samuel John Chua, Ria Jasmine de Leon, Raphael Jose Maria R. Eala, Iana Joy Famy, Anselm Raphael Garvida, Liezelle Soriano



PJAHS • Volume 4 Issue 1 2020 Table of Contents Editorial Board Preface Ivan Neil Gomez 2 Preface to PJAHS Volume 4 Issue 1 Editor-in-Chief Editorial Catherine Escuadra 3 In peer review we trust Kim Gerald Medallon Ivan Neil Gomez, PJAHS Editor-in-Chief Managing Editors Letters to the Editor Donald Lipardo 5 Teaching allied health courses in the time of COVID-19: challenges and Donald Manlapaz opportunities Associate Editors Gian Carlo Torres, Earl Francis Sumile Valentin Dones III, Reil Vinard Espino, Paulin Grace 7 Speech language pathology services in a time of pandemic Morato-Espino, Karen Leslie Candace Vickers Pineda PJAHS Review Board 10 Occupational therapy in the times of the pandemic Consuelo Suarez The Philippine Academy of Occupational Therapists, Inc. Anne Marie Aseron Editorial Advisory Board 12 Mental health in the times of the pandemic Anna Lea Enriquez Alejandro Baroque, Gabriel Alejandro Baroque Ethics Consultant Original Articles Archelle Callejo, Zyra Clinical audit on outcome measures used in examination of knee Villamor, Lyle Patrick 15 osteoarthritis in selected hospitals and clinics in the Philippines Tancuangco, Jazzmine Gale Jocel Magpili Regino, Cristine Rose Sanchez Versales, Jin Kaye Galupe Catalan, Flores Edgar Maurice Gunda Bajado, Marielle Regine Del Rosario De Jesus, Orville Editorial Staff Espiritu Hernandez, Gabriele Uriel Escalano Palisoc, Jaime Antonio Saile Rama, Alyssa Rae Samson Tungal Genejane Adarlo, Stephanie Balid-Attwell, Rumpa Effect of non-elastic closed-basket weave ankle taping on muscle activity of tibialis anterior, peroneus longus, medial, and lateral Boonsinsukh, Sjan-Mari 22 gastrocnemius during jump landing on a hard, flat surface in healthy Brown, Ke-Vin Chang, Jesus individuals: a pilot study Alfonso Datu, Janine Fe Therese Chavez, Emmanuel Carpio, Philip Andrew Aguilar, Daniella Ang, Margarita Dizon, Karen Blessie Busog, Rheine Canlas, Isabella Gonzales, Joan Marie Ibanez, Adrian Miclat, Grimmer, Masayoshi Kubo, Mary Angelique Principe Cynthia YY Lai, Steve Muscle activation pattern of gluteus medius, tibialis anterior and Milanese, Ruth Segal, Sean peroneus longus during drop landing on different surfaces: a cross- Sullivan, Gian Carlo Torres, 31 sectional study Jeric Uy, Les Paul Valdez, Ken Erbvin Sosa, Kristina Devora, Rino Luis Santiago, Shyllah Trish Abando, Candance Vickers Samuel John Chua, Ria Jasmine de Leon, Raphael Jose Maria R. Eala, Iana Joy Famy, International Academic Editors Anselm Raphael Garvida, Liezelle Soriano The Philippine Journal of Allied Special Research Article health Sciences [ISSN: 1908-5044] 39 In gratitude for the PJAHS 2019 editorial board and reviewers is an Open Access, peer reviewed journal published by the Ivan Neil Gomez, Anne Marie Aseron University of Santo Tomas-College of Rehabilitation Sciences, Manila, PJAHS Call for Papers Philippines. 40 Regular Issue 41 Special Section 1

PJAHS • Volume 4 Issue 1 2020 • Preface to PJAHS Volume 4 Issue 1 Copyright © 2020 PJAHS. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The events in recent months have placed the The first article determines the evidence-based general public, including researchers, at a outcome measures clinicians utilize in their quandary. This pandemic has rendered some at a practice of taking care of patients with knee standstill. But more than ever, research should osteoarthritis. The author argues for be at the forefront of decision-making on how we opportunities to close the gap in the assessment can proceed with our lives despite and in spite of for knee osteoarthritis in the Philippines with the pandemic. Thus, we here at PJAHS remain global standards. The next two articles used steadfast in publishing relevant and up to date electrophysiological methods in further research that aims to improve the quality of lives understanding the mechanisms involved in jump of our stakeholders through high quality allied landing. These two articles remind us of health research articles. This is the first issue of continuously improving our research the fourth volume of PJAHS. In this issue, we are methodologies through physiology-based happy to announce the publication of six instrumentation. research articles. Essential to publishing high-quality research In an attempt to be relevant to the present needs articles entail going through the process of peer- of the society, we publish four letters to the review. In this edition’s editorial, PJAHS reflects editor that tackles various contexts in the times on the current changes and challenges related to of the pandemic. Specifically, our author the peer-review process. Regardless of the contributors discuss how allied health recent issues and controversies surrounding the professions, such as occupational therapy and peer review process, we remain steadfast in speech language pathology, can respond to the trusting the benefits and rationale behind peer health needs of their stakeholders. Another reviews. Of course, the peer review process will article presents a reflection on how allied health not move forward for a publication without the education can respond to these trying times. The support of their review board. That is why, in last letter to the editor argues how one’s mental this issue, we recognize the valiant and selfless can be compromised with the current situation efforts of the editorial members and staff of and provides recommendations on how to best PJAHS that made the publication of this issue cope with these uncertainties. possible. Three original research articles are included in this issue from different groups of physical therapy researchers. It came as a wonderful surprise how these three research articles all fall within the topic of lower extremity researches. 2

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.001) Editorial In peer review we trust Ivan Neil Gomez, Editor-in-Chief Article Received: June 30, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 Gomez. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. At the time of writing this article, it is estimated varied in the outcomes, unable to detect flaws that around 12 million people worldwide have and frauds within the research, and the thankless been diagnosed with COVID-19. Daily, we job of reviewing, among a few. Nevertheless, the experience varying spikes in the number of scientific journal community is in unison victims that fall prey to the pandemic. Families, supporting the utility of the peer review process; communities, and their socio-economic contexts hence it is upheld to this date. Peer review is an have been profoundly impacted in our fight essential and integral approach to improving against COVID-19. In an interesting turn of one’s scholarly work. events, the newest victim of the pandemic is an industry to whom we look to help address our Over the years, different models of peer review current condition. In June 2020, two prestigious have adopted by various scientific journals and scientific journals have been reported to have publishers. The variety spans rigorous blinding retracted controversial COVID-19 articles.1 models (i.e., single, double, triple-blind) to more These following events have cast doubts on the open options. Addressing the risk of bias in the peer review process of scientific journals and review process is more for the former compared questioned its integrity and utility. to the latter. Peer review is essentially a hurdle that researchers should prevail before having Peer review is a process adopted by scientific their manuscripts published. However, in recent journals that aim to evaluate the scientific years, the emergence of preprints and post- soundness of scholarly articles and evaluate publication reviews has challenged the whether it is deemed published to the scientific traditional tenors of peer review. As a scientific community. Peer review has been described as a journal and publisher, we must, therefore, roll necessary evil, highlighting possibly a negative with tides and keep up with the calls for experience while undergoing its processes. This innovation in the present to remain relevant. is not far from home. Conversations with colleagues reveal a variety of amusing anecdotes Here in PJAHS, we recognize these changes and on the rigorous process they had to endure to challenges. The coming few months shall be a publish an article. period for us to reflect and respond to the current needs of our stakeholders within the The seminal article by Smith2 provided greater socio-political landscape where we exist. interesting points on the flaws that gnaw the There is a need to re-examine our policies, peer review process. Its bad reputation owes to procedures, and policies in light of our product the fact that the peer review process may seem and prospects in the future. Regardless, we too time-consuming and resource-consuming, affirm our trust in peer review and recognize its 3

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.001) integral role in scientific and scholarly research publications. PJAHS joins the international scholastic community in celebrating Peer Review Week 2020, celebrated on September 21-25, 2020. The theme of this year’s celebration is dedicated to highlighting the integrity of peer review in research and its eventual publication. References: 1. Rabin RC. The Pandemic Claims New Victims: Prestigious Medical Journals. New York Times [newspaper on the internet]. 2020 Jun 16 [cited 2020 Jul 9]; Health [about 5 p.]. Available from https://www.nytimes.com/2020/06/14/health/virus -journals.html 2. Smith R. Peer review: a flawed process at the heart of science and journals. Journal of The Royal Society of Medicine. 2006 Apr;99(4):178-8 4

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.002) Letter to the Editor Teaching allied health courses in the time of COVID-19: challenges and opportunities Gian Carlo Torres1, Earl Francis Sumile1 1College of Nursing , University of Santo Tomas , Manila, Philippines Correspondence should be addressed to: Gian Carlo Torres1; [email protected] Article Received: June 30, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 Torres et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Allied health sciences are essential to an Philippines, this laudable goal is far from being organized society. It contributes to the reached. The lack of system, infrastructure, manpower that fuels global health and impacts processes, and technology exacerbates the people’s quality of life. The educational problem, which ultimately ends up on the pit of preparation of health professionals is highly inequity and injustice. The only option with this skill-based and high touch. However, in a digital howling limitation of society is to blindly cope era like today, the challenge of ensuring a and make do of whatever is available. balance between high tech and high touch is paramount. But it takes a whole new level of The health sciences have no immunity at all to challenge when a pandemic strikes. this predicament, and the challenge to this very day continues to perplex both educators and The number of cases of COVID-19 in the country learners. The current pandemic forced people to is continuously increasing, and the geographic drop their usual routines and to be distribution is widening. Scientists and incommunicado to a bigger social sphere. The healthcare experts from both local and loss of lives and livelihood, the fear of international agencies strongly advised the uncertainty has taken a toll on people’s mental suspension of mass gatherings, physical wellbeing, and students of allied health distancing, wearing of face masks, and limit professions suffered a great deal of this problem. movement of people thru quarantine. As a As a consequence, teaching and learning became consequence, in-campus activities in all schools, less relevant if not a priority to students and from basic to higher education has been teachers alike. suspended and shifted to online platforms. The sudden change in the mode of teaching and Striking a balance between producing a learning regrettably surprised all stakeholders. workforce to aid an ailing health system globally This global health crisis showed how all nations, and protecting public health by ensuring that both rich and underdeveloped, struggled to cope standards and competencies are achieved is a with the demands of satisfying learning concern that academics in the health sciences outcomes in an unprecedented environment. should bear in mind. Mere compliance to cover what the course syllabus dictates is a futile The use of online-based strategies in education exercise. The need to recalibrate our moral has long been accepted and established compass and to look thru the lens of our learners worldwide. This approach has been utilized to is as critical as achieving learning outcomes. help achieve learning beyond borders. Understanding our learners better is the first Unfortunately, for developing nations like the step in the long journey ahead. 5

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.002) The current generation of students in the health health care providers.3 Further, by developing an sciences is aged 21 years old and below or where advocacy of their own, learners deepen their born in 1995 who we call as generation Z sense of commitment and also nurtures learners. These learners have been raised in a leadership.4 The use of simulation to aid the hyper-connected, high technology, on-demand, learning of students in allied health professions and impatient culture with an attention span of is another viable option in lieu of clinical just 8 seconds compared to the 12 seconds of the rotations. Tele-health simulation is an approach millennial learners.1 Generation Z students that can be applied to allow students to perform utilize numerous amount of time online and history taking, assessment, apply critical prefers to communicate using short bursts of thinking skills, and utilize health education information over a certain duration instead of opportunities to demonstrate their clinical giving lengthy messages, they appear to be more competence. For educators, the use of this realistic, career-minded, responsible and more modality essentially requires designing “we” oriented.1 The profile of our students seems simulation-based experiences with measurable to be an opportunity rather than a challenge for objectives; it is contextualized, fidelity academics in the health sciences. However, how appropriate, and facilitative.5 to innovate our approaches remains to be a constant problem that needs a solution. Finally, though we are living in uncertain times, may we all find consolation in knowing that we Outcomes-based education (OBE) puts a big are instrumental in providing the nation with premium on assessment and evaluation of heroes working in the frontlines as healthcare learning. Allied health science educators mostly providers. To be firm but kind, to be facilitative employ pen and paper tests to do this. This adds than oppressive; these are things that our up to the list of challenges brought about by the students need the most from us now. With the pandemic. Hence, stripping ourselves of the rigid new academic year fast approaching, may we all metric of exams as a way to measure learning affirm our commitment as educators to build outcomes must be considered. Being open to the character and competence among our students. creativity of our learners will help us tap and unleash their potential. We need to capitalize on References: their skill sets. Developing video clips and the use of social media as an alternative form of 1. Hampton DC, Keys Y. Generation Z students: Will they evaluating students learning is a promising change our nursing classrooms? Journal of Nursing option. Education and Practice. 2017;7(4):111–5. It is also timely that we should start revisiting 2. Commission on Higher Education (CHED) (2012), our instructional design and realign with the Commission on Higher Education Memorandum Order tenets of outcomes-based education. This (CMO) No. 46 series of 2012: Policy-Standard to Enhanced approach to learning aims to produce graduates Quality Assurance (QA) in Philippine Higher education imbued with values that reflect human Through an Outcomes-Based and Typology-Based QA, orientation, analytical and critical thinkers, has retrieved from https://ched.gov.ph/cmo-46-s-2012/ ethical and social orientation, competent and engaged for lifelong learning, and national 3. Sumile, E.F. R. (2020) Community and Public Health development.2 This entails that we use this Nursing (2nd Philippine Edition). Elsevier Singapore. opportunity to formulate program outcomes that cater not only knowledge acquisition but to 4. Torres, G.C. (2020).Developing Advocacies in Nursing cultivate outcomes challenging higher-order thinking and building on compassion, leadership, Courses: Nurturing Compassion and and social consciousness among our future allied Leadership. In E.E.Ea & C.M.Alfes (Ed.), Innovative health professionals. As an example, let us Strategies in Teaching Nursing: Exemplars of Optimal challenge our learners to come up with their own Learning Outcomes (pp. 177-187). New York, NY: personal advocacies that can initiate change and Springer Publishing innovation in healthcare. Advocating for health and influencing policy is a role inherent among 5. Der Sahakian G, Buléon C, Alinier G, Battles JB, Shershneva M, Kim JH, et al. INACSL standards of best practice: Simulation Simulation design. Clinical Simulation in Nursing [Internet]. Vol. 46, Clinical Simulation in Nursing. 2017. 730–737 p. Available from: https://doi.org/10.1080/14703297.2017.1399808%0Ah ttps://doi.org/10.1016/j.nedt.2017.12.024%0Ahttp://dx .doi.org/10.1016/j.ecns.2016.09.005%0Ahttp://dx.doi.or g/10.1016/j.ecns.2017.05.008 6

PJAHS • Volume 4 Issue 1 2020 • (doi: 10.36413/pjahs.0401.003) Letter to the Editor Speech language pathology services in a time of pandemic Candace Vickers1 1Department of Allied Health Professions, California Baptist University, California, USA Correspondence should be addressed to: Candace Vickers1; [email protected] Article Received: July 27, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 Vickers. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. American Speech Language Hearing From students barred from attending school, Association (ASHA) is one of many to older adults with new grandchildren they organizations to affirm that communication cannot visit or hold, to individuals who live is a “human right.”1 The right to alone forced to isolate and shelter at home, communicate is contained in Article 19 of the the pain is widespread. According to the Universal Declaration of Human Rights.2 Centers for Disease Control and Prevention Though few would argue that (CDC), feelings of social isolation and communication should be a human right, loneliness affect many during a pandemic. access to communication opportunities Despite the fact that COVID19 restrictions through face-to-face interaction is severely aim to prevent exposure to infection and impacted by the ongoing crisis of the novel save lives, extended living under these coronavirus. Limitations on face-to-face restrictions can affect both physical health interaction also negatively affect the and mental health.3 provision of speech-language pathology services. Interaction in person is a primary mode of communication people use throughout their The speech language pathologist (SLP) seeks lives. Due to the pandemic, people across the to unlock access to communication for those world need to calculate risk to their health who struggle to communicate, regardless of and life just to shop for food or visit relatives age or type and severity of communication and gather with friends. Sitting in close disorder. This has become more challenging proximity to a client or patient during a for speech language pathologists to do speech language therapy session is during the pandemic caused by the novel considered risky during this time when it is coronavirus. As nations around the globe not possible to know who may be an close schools, clinics, and businesses due to asymptomatic carrier of the virus. COVID19, many who need speech language therapy may find themselves cut off from a Given the current pandemic’s universal lifeline to communication- a lifeline that was impact on the safety of engaging in social leading them to enhanced communication contact with even close friends and relatives and life participation before the pandemic. in groups, accessing needed speech language pathology services could become just one 7

PJAHS • Volume 4 Issue 1 2020 • (doi: 10.36413/pjahs.0401.003) more casualty of the coronavirus era if maintaining health and safety in the context adaptations are not made. Speech language of the coronavirus can be costly and therapy sessions typically present clients challenging. with a special time of the week where an understanding skilled clinician hears, Since March of 2020, ASHA has provided understands, encourages, and values their clinicians with printed resources, virtual communication efforts while addressing town halls, webinars, free online courses, specific treatment goals. Therapy sessions and tips for clients and families for SLP are a safe place to work on difficulty services in a coronavirus world,5 For those acquiring speech and language for those with working in medical settings, safety, and developmental communication disabilities. adequate access to appropriate personal For those with acquired communication protective equipment is an ongoing concern disorders caused by problems like stroke, for assisting hospitalized patients with brain injury, or neurodegenerative disease, stroke and dysphagia, for example.6 Using these sessions may be the only time each video conferencing platforms like Zoom and week the client receives direct assistance techniques such as “sharing the screen” and encouragement to continue the struggle during a therapy session are now familiar to to regain once effortless speech and SLPs practicing in schools, private and language skills. medical settings. Clinicians are treating children with communication disorders such How and where does speech language as articulation and language disorders, therapy fit into this new world of hopefully stuttering, and autism with telepractice. temporary, but necessary, social distancing Outpatients with aphasia, apraxia of speech, and sometimes social isolation? Depending dysarthria, or cognitive communication on one’s location, the answer varies. disorders are also able to receive both Conducting speech therapy service remotely, individual and group speech language or “telepractice,” is defined by ASHA as therapy through telepractice. using telecommunications technology to deliver speech language pathology and Still, the ability of clients and families to audiology professional services at a distance access service through telepractice cannot be to provide assessment, intervention and/or assumed and is affected by one’s location consultation.4 and economic opportunity. Receiving speech language services remotely requires Telepractice is no longer just the option for consistent access to internet and a computer persons living in remote rural areas. Due to or laptop or other devices with a built-in web the pandemic, SLPs across the U.S. are now camera and audio for teleconferencing. For regularly providing speech language therapy children and adults with disabilities, it is also via telepractice to very young children critical that a primary caregiver is present to through adult ages to provide services safely. provide technological or other support if University training programs for speech needed to access the therapy session and language pathology students are also striving successfully complete it. Speech language to maintain their students’ training pathologists need to continue reminding opportunities via telepractice, with very few clients and caregivers of the statement attempting to reopen on-campus clinics due widely used about the coronavirus: “We’re to the high costs associated with supplying all in this together.” Prioritizing the the needed personal protective equipment. importance of access to communication For those who want to hold therapy sessions practice through speech language therapy in in person, the protocols for establishing and 8

PJAHS • Volume 4 Issue 1 2020 • (doi: 10.36413/pjahs.0401.003) a safe manner during a pandemic is an important way to get there. References 1. American Speech Language Hearing Association. (2020). About the American Speech Language Hearing Association: Vision. Retrieved at: https://www.asha.org/about/ 2. United Nations (1948) Universal Declaration of Human Rights. Retrieved at https://www.un.org/en/universal-declaration- human-rights/ 3. Centers for Disease Control and Prevention. (2020). Pandemics can be stressful. Retrieved at: https://www.cdc.gov/coronavirus/2019-ncov/daily- life-coping/managing-stress-anxiety.html 4. ASHA. (2020) Telepractice. Retrieved at https://www.asha.org/practice-portal/professional- issues/telepractice/. 5. American Speech Language Hearing Association (ASHA) (2020). COVID 19 Resources for your clients and patients. Retrieved at: https://www.asha.org/public/COVID-19-Resources- for-Your-Clients-and-Patients/ 6. ASHA. (2020). SLP Service delivery considerations in healthcare during Coronavirus/COVID19. Retrieved at: https://www.asha.org/SLP/healthcare/SLP- Service-Delivery-Considerations-in-Health-Care- During-Coronavirus/ 9

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.004) Letter to the Editor Occupational therapy in the times of the pandemic The Philippine Academy of Occupational Therapists, Inc. Correspondence should be addressed to: [email protected] Article Received: July 23, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 PAOT. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We have witnessed how the COVID-19 pandemic need and possible lack of resources. With this, has stifled various social, economic, and health PAOT, Inc. released its interim guidelines on the structures and mechanisms on a large scale. practice of occupational therapy amidst the Everyone is on a survival mode complicated by a COVID-19 situation with the intent of ensuring political milieu characterized by divisiveness and that all services will be delivered in a safe, hate. All of these processes tend to be more humane, and ethical manner. Consistent in all of complex for persons with disabilities, who are these guidelines is the call for the Filipino OT to our primary stakeholders. Various restrictions look over one’s self and overall well-being before and prevailing apprehensions hinder the discharge of various functions. PAOT, Inc. opportunities for continuous occupational implemented a couple of programs to provide participation across all areas. monetary assistance to professionals and students who had difficulty in meeting their This complicated scenario reverberates the call basic needs due to the unforeseen for the profession and the Filipino OTs to step up discontinuance of their work, or that of their and accept the challenge of ensuring that all immediate families. A Mental Health Crisis stakeholders are still able to participate in Response Program is also conceptualized to various life situations through engagement in serve this purpose for the professionals who also meaningful occupation. This unfamiliar territory experience disruption of their routines and calls for innovations and alternative forms of participation in various occupations brought service provision. PAOT, Inc. released its about by this pandemic. guidelines on the utilization of telehealth to provide a safer service delivery option. True to On top of all these programs, PAOT, Inc. is its commitment to capacitating all its members continuously urging professionals to promote regardless of practice forms or settings, the the health and well-being of others, mediate in Academy organized OTalakayan with its first the redesign of one’s and other’s routines, season, comprised of 14 episodes covering the lifestyles, and role assumption, address the various tenets of providing occupational therapy psychosocial and mental health concerns services through telehealth. Best practices are inevitable during crisis situations and promote shared, and opportunities for dialogue among occupational justice of individuals who might be professionals are promoted. affected by the quarantine measures. These tasks go beyond conventional service delivery, and the Responsiveness and contextualization refine any current situation calls for such a bold stance. therapeutic process. Inevitably, there would still be clients who will benefit more from in-person Embedded in our Filipino psyche is upholding service delivery due to the presence of an urgent the spirit of bayanihan and now more than ever 10

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.004) with all these intentions in mind, the Filipino OTs need to look after one another and have a communal responsibility to ensure that all possible stakeholders will at least be given a chance to participate in things that matter to him/her despite these trying times. PARA SA PROPESYON. PARA SA BAYAN. 11

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.005) Letter to the Editor Mental health in the times of the pandemic Alejandro Baroque1,2, Gabriel Alejandro Baroque2 1Faculty of Medicine and Surgery , University of Santo Tomas , Manila, Philippines; 2University of Santo Tomas Hospital, Manila Philippines Correspondence should be addressed to: Alejandro Baroque1; [email protected] Article Received: June 30, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 Baroque et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. With over 18,439,731 cases and 697,083 dished out and readily believed by the confirmed deaths reported to date, and still unsuspecting lay individuals, eroding one’s counting, COVID-19 pandemic is by far seems to sense of control pushing the same in a fatal be an evolving most significant health crisis of tailspin that eventually causing catatonic freeze. the century afflicting not only the physical state, These unique challenges presented by living in a but more importantly includes adverse pandemic understandably could potentially consequences in the realm of mental health and unravel and/or exacerbate devastating well-being. psychological distress and serious clinically significant psychoses, depression, and anxiety, as Literally and figuratively, coronavirus fever is revealed in recent preliminary studies. gripping the world that has greatly influenced the trajectory and priorities of how we presently Vulnerable groups identified include those live our lives. Enormous changes have been afflicted with pre-existing psychiatric diseases, brought about by the many unfamiliar the OFWs, geriatric age-groups, pregnant challenges’ consequent to this novel coronavirus women, street-dwellers, and students studying pandemic, such as tremendous uncertainties as overseas from mainland China. In our local to the duration of the pandemic and setting, obviously, due to the very nature of their overwhelming worry of one’s own vulnerability work, the overseas contract workers, police, and to this novel unseen formidable enemy, total military personnel operating the checkpoints, rearrangements of activities of daily living, not to mention the health workers in the severe economic over-burdening that stares at a frontlines, are those who are the most vulnerable bleak future, and social isolation among other population. The risk for mental health things. These situation, lingering with no disturbances is magnified several folds optimistic quick fix in the horizon, wears down particularly for those who have confirmed Covid- easily the psychological and mental defenses that 19 affliction across the spectrum – asymptomatic pushes resiliency to a critical level favoring on one end, requiring at least just a mandatory longer-term psychological maladjustments and home quarantine for a good 14 days, to those even major clinically significant psychiatric who are critically ill for isolation in a COVID illnesses. hospital ward or intensive care unit. Additionally, and most disturbing of all, are the Limitation in social interaction brought about by disgusting inaccuracies and even false isolation during a simple quarantine is one of the information all together coming from even the significant stressors understandably causing traditional sources of news and information, unimaginable boredom and annoyances. The 12

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.005) locally stranded individuals (LSI) caught in the Additional stressors following quarantine and sudden city lockdown bore the greatest impact of isolation include: socioeconomic distress due to this abrupt curtailment, what with the loss of unforeseen financial difficulties, unemployment, liberty and literally forced to be isolated in an poverty, direct hospitalization costs, misplaced unfamiliar government designated areas of rejection and discrimination by people, even by questionable facilities for basic necessities ( food, family members and the pessimistic outlook of water, clothing, medical care and supplies). Add ever resuming a “normal” life after. up to this is the flagrant poor, if not outright failure, in proper coordination among concerned The WHO recognizes the same psychological health and LGU officials resulting in an over issues that burden the healthcare workers and extended period of quarantine due to various front liners. The pressure of knowing the hazards circumstances reflecting the government’s of the job, working under threats of being ineptness in effectively handling the pandemic. afflicted as well, intensified with the spaceman- Excessive and unavoidable worry of potentially like suits one is required to wear and rigid contracting the dreaded virus and the emergent procedures for personal protection and, guilt feelings of realistically transmitting the unfortunately, the valid fears of their family infection to others particularly the family members or even the community communicated members will incite numbing fear and dread. through avoidant behaviors…magnifies several folds an already challenging situation. Extremely difficult psychological challenges indeed confront more those in severe and critical To manage the identified stressors and enhance conditions necessitating ventilatory support and resiliency in addressing COVID-19 infection institution of isolation for containment of this adverse mental and psychological health highly infectious illness in the acute treatment consequences, gather and rely on factual phase. Rapid and drastic loss of respiratory information only from credible sources for functions requiring such patients to be put on a guidance and acknowledge the need to limit ventilator in the intensive care unit will undue worries by avoiding excessive exposure to exacerbate issues in loss of control. There would COVID-19 media coverages that are perceived to be immediate and complete segregation from the cause excessive worrying. Strategies you have family, therefore, feeling of isolation, being alone, used to resolve successfully previous life’s and intrusive self-pity and depressive thoughts, challenges and adversities can be captured and particularly if the prospects of fatality are readily implemented again to manage making the stricken more acutely aware every dysfunctions during the outbreak challenging tick of the second. Signs and symptoms of times. Most importantly, practice self-care, delirium that has been observed to predominate maintain a healthy diet, and a positive lifestyle. in the acute phase of coronavirus infections, This means not only adhering to grooming and associated with anxiety, depression, and hygiene routines and maintaining a healthy diet insomnia are all driven by these psychosocial and physical fitness routine, but also playing burdens (stigma, isolation, fear of death, and video games, eating chocolate, making or disruption of social life). These neuropsychiatric listening to music, watching your favorite outcomes are typical of many severely ill, movies, and snuggling with stuffed animals. intensive care unit populations. Treatment- emergent psychotic manifestations due to There are established psychiatric treatment steroid administration, most often part of the strategies designed to mitigate acute distress and acute phase management to combat the very assess the need for continued mental healthcare fatal cytokine storm associated with Covid-19, through compassionate and supportive presence are becoming evident a problem as well and in a state of utter social isolation. This is should pose an additional burden. After infection composed of well-trained psychiatric personnel resolution, neurocognitive symptoms and more- (psychiatrist and nurses) skillful in providing typical psychiatric syndromes (mood, anxiety, emergent and continuous pharmacologic and and PTSD) persist. non-pharmacologic interventions and psychosocial support to the severely afflicted and survivors. 13

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.005) The COVID-19 pandemic is not a hoax. The mental health consequences are as real in this time of the pandemic. 14

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.006) Original Article Clinical audit on outcome measures used in examination of knee osteoarthritis in selected hospitals and clinics in the Philippines Jocel Magpili Regino1,2, Cristine Rose Sanchez Versales1, Jin Kaye Galupe Catalan1, Edgar Maurice Gunda Bajado1, Marielle Regine Del Rosario De Jesus1, Orville Espiritu Hernandez1, Gabriele Uriel Escalano Palisoc1, Jaime Antonio Saile Rama1, Alyssa Rae Samson Tungal1 1Department of Physical Therapy, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines 2Center for Health Research and Movement Sciences, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines Correspondence should be addressed to: Jocel Magpili Regino1; [email protected] Article Received: December 1, 2019 Article Accepted: June 20, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 Regino et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Knee osteoarthritis is a degenerative joint disease affecting the aging Filipino population. Outcome measure tools are used to assess a patient’s health status for the quality of care improvement. With the increasing prevalence of knee osteoarthritis, it warrants the need to conduct a clinical audit to identify the most common outcome measure tools used by Filipino Physical Therapists. Objectives: To determine the outcome measure tools used by Filipino Physical Therapists in assessing knee osteoarthritis in hospitals and clinics and compare it to the current global standard of assessment. Methods: A retrospective record audit study design was used to determine the current assessment tool compared with standards of assessment. Results: Of the 45 of 285 charts reviewed, 80% were females and 73.33%, aged older than 60 years. The following were examination tools used by Physical Therapists: In Subjective; a. pain score (97.77%), b Functional status (80%), and c. stiffness ( 4.44%). In Objective; a. ocular inspection and palpation(97.77% ), b. range of motion and manual muscle testing (93.33%), c. posture ( 48.89%), d. special tests (33.33%), e. gait analysis ( 71.11%), and f. Functional assessment ( 91.11%). Physical Therapists did not use Western Ontario and McMaster Universities Osteoarthritis (WOMAC), Visual Analog Scale (VAS), Short Form-36 (SF-36), and Knee Injury and Osteoarthritis Outcome Score ( KOOS) outcome measures for assessing knee osteoarthritis. Conclusion: Physical Therapists did not use standardized outcome measure tools in the assessment for knee osteoarthritis. Thus, the study shows the gap in the assessment for knee osteoarthritis in the Philippines and global standards. Keywords: degenerative joint disease, standardized outcome measure tool, clinical audit INTRODUCTION Osteoarthritis (OA), moreover known as that there are around 10 million Filipinos with degenerative joint disease (DJD), is the foremost OA which is expected to double in the next 25 predominant chronic rheumatic disease and is a years.1 leading cause of pain and disability in most Knee OA is the most common form of arthritis countries worldwide.1 Most of OA affects the hips resulting in pain, mobility limitation, decrease and knees.2 It has been evaluated that the independence and quality of life in millions of percentage of people aged >65 years old in Asia people.3 Knee OA involves the three will twofold from 6.8% in 2008 to 16.2% in compartments of the knee joint (medial, lateral, 2040.3 In the Philippines, its prevalence is 0.5% and patellofemoral joint).4 It implicates most in individuals aged 20 years and above and adults aged >65 years old, with a prevalence in increases to 11% in the population aged 60 years the US of 33.6 %.2 Women have a greater and above. According to an international prevalence (42.1%) than do men (31.2%).4 database from the US Census Bureau, a summary demographic data for the Philippines estimated 15

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.006) The American Academy of Orthopaedic Surgeons organizational performance, and determines the (AAOS) published a clinical practice guideline most-effective treatment for particular recommending several interventions for the conditions.9 The USA and Netherlands management of knee osteoarthritis by standardized use of OMTs in healthcare practice. orthopedic surgeons. In the assessment of Specifically, in the USA, an effort to promote and treatments of knee OA, the domains of pain, standardize the use of OMTs was made by function, and stiffness were assessed with including its instruction in their academic greater frequency. Among the more common curriculum.9,10 domains assessed were pain and function, and the more common outcome measure tools This study determined the OMTs used by Filipino (OMTs) used were the Western Ontario and Physical Therapists in assessing knee OA among McMaster (WOMAC), McMaster Toronto patients in affiliated University of Santo Tomas – Arthritis Patient Preference Disability College of Rehabilitation Sciences (UST-CRS) Questionnaire (MACTAR), and the Lequesne hospitals and clinics. This study compared the Index.5 OMTs used by Filipino physical therapists with those recommended in published clinical Another Clinical Practice Guideline (CPG)used by practice guidelines. the researchers garnered a 12/14 score or 86% using the iCAHE Guideline Quality Checklist, assigned as excellent by the authors for METHODOLOGY garnering 75-100% of the total appraisal score Ethics Approval. Ethical approval was sought possible. Brosseau et al. considered functional from the University of Santo Tomas-College of status, physical function, self-efficacy, endurance, Rehabilitation Sciences, Ethics Review stiffness, strength, torque, body composition, Committee, and the University of Santo Tomas mental health, psychological well-being, and Hospital– Institutional Review Board. mobility as a result of vital interest. The Lequesne Index and the WOMAC were outcome Study Design. A retrospective study of clinical measure tools used for functional status, while audit was used to determine the current the Medical Outcomes Study 36-Item Short-Form assessment tool for knee osteoarthritis Health Survey questionnaire (SF-36) was used to compared with standards of assessment. measure physical function. Subdomains of respective outcome measure tools were also Study Setting. A list of University of Santo specifically used to measure particular outcomes Tomas– College of Rehabilitation Sciences (UST- of interest. The WOMAC stiffness score was CRS) affiliated hospitals and clinics was provided considered for stiffness while mental health was by the Internship Supervisor of the Department also measured using the SF-36 mental health of Physical Therapy of UST-CRS. Senior score.6 investigators sent invitation letters to medical directors and physical therapy heads of all health institutions included in the list from June 1, 2016 Outcome measure tools (OMTs) assess the health to July 31, 2016. The researchers sought status of patients. OMTs determine changes in approval from the hospitals and clinics in patients’ status after a series of treatments by accessing medical records of patients with knee comparing scores collected at baseline and osteoarthritis. succeeding periodic evaluation/s. Results from OMTs can be used for patient care decisions, Data Gathering Procedure. This research study research, and quality assurance.7 OMTs minimize consisted of inter-linked phases. Figure 1 miscommunication between allied health summarizes these phases and are subsequently professionals, facilitates the process of clinical explained in the preceding paragraphs. reasoning,8 classify patients who are at risk for adverse outcome, promote continuity of care for Phase 1: Review of Literature and Development of patients transitioning from one health care Data extraction tool. A literature search was done setting to another, identifies the most cost- in different databases such as Science Direct, effective settings for patients to receive Cochrane Library, Cinahl, Pubmed, and Medline rehabilitation services, appraise practitioner and to look for systematic reviews and clinical 16

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.006) Phase 3: Reliability Study. The senior investigator of this study trained four researchers on the use of the validated data extraction form. Inter-rater reliability of four researchers on the use of data extraction form was determined. The four researchers independently extracted data from the Subjective, Objective, Assessment, Plan (SOAP) notes written by a physical therapist on the PT chart of a patient who underwent physical therapy treatment. Inter-rater reliability was computed using the Kappa Coefficient, specifically Fleiss Kappa. A range from -1 to +1, where 0 represents the amount of agreement expected from random chance, and 1 represented a perfect agreement between the raters.12 Phase 4: Clinical Audit. Sample size calculation was done using a formula for the descriptive study of Open Epi©. Using the prevalence of osteoarthritis in the urban area– Manila in particular11 and proportion of patients with osteoarthritis who underwent physical therapy management in the country, a minimum of 102 records needs to be included in the study to achieve a beta power of 0.80 per of study with an alpha value of 0.05. Figure 1. Flowchart indicating Phases 1-4 of the research. Medical records were included in the study if these were: 1) medical records are written in the guidelines on the outcome measure tools in the Philippines; 2) medical records of patients examination for knee osteoarthritis. The data medically diagnosed with knee osteoarthritis extraction tool was developed on Microsoft Excel referred for physical therapy evaluation and ver. 16. (see Supplement File A). treatment; 3) medical records are written between June 2015 to June 2016 (i.e. active, Phase 2: Content Validation. Content validity of inactive files)13; 4) medical records of patients the data extraction tool was tested by three aged 40 years old and above.5 Medical records physical therapists who were graduates of without initial evaluation notes were excluded Master of Science in Physical Therapy and with from the study. clinical practice in evaluating and treating arthritis for at least three years. A requirement During the clinical audit, three researchers coded of 100% CVI (content validity index) per item the medical records. The codes ensured that the agreed among three physical therapists that assessors were blinded to the personal served as an expert panel in evaluating the information of the patients. Four researchers content validity of the data extraction tool. extracted data from the medical records. Content validity was evaluated since this type of validity would know the extent to which the The last phase of the study consisted of the items on the tool follow what the tool was actual chart review wherein one to two visits devised to measure.11 A letter of invitation was were conducted to the UST-CRS affiliated sent to this expert panel before the formulation hospitals or clinics for data gathering. Three of the data extraction tool, wherein they could members of the research team segregated the PT either decline or accept. charts by assigning codes. The four members who are part of the research team and were involved in the inter-rater reliability testing were 17

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.006) the ones who conducted the actual data Percentage of use on evaluation techniques by gathering. The coding system ensured the Filipino physical therapists. Pain (97.75%), blinding of assessors. For data analysis, the functional status (80%), and stiffness (4.44%) researchers utilized descriptive statistics to were reported in the subjective part of the SOAP include information on the distribution of data, notes of patients with knee OA. Ocular inspection the mean, or average in phase four of the study and palpation were the most commonly used evaluation techniques by Filipino physical RESULTS therapists in the objective part of SOAP notes. None of the reviewed SOAP notes utilized Phase I– A: Data Extraction Tool. The outcome measure tools such as WOMAC, VAS, SF- American Academy of Orthopedic Surgeons 36, and KOOS. (AAOS) published a CPG recommending several interventions for the treatment of knee Based on the results seen in Table 2, out of 45 osteoarthritis by orthopedic surgeons. Table 1 charts, 44 charts, or 97.77%, included ocular summarizes the domains including the outcome inspection and palpation in the initial evaluation, measure tools that are most commonly used in while 93.33%, or 42 charts, assessed for range of the assessment of knee OA.14,15 Objective motion and manual muscle testing. There were evaluation such as ocular inspection, palpation, 41 charts that included functional assessment range of motion, manual muscle testing, special and 32 charts that assessed for gait, which were tests, postural assessment, gait analysis, and represented by 91.1% and 71.1%, respectively. functional assessment were also included in the There were 22 charts that reported postural data extraction tool.16 assessment and only 15 charts reported the use of special tests in the evaluation, which were Phase I– B: Content Validity. Analysis of the equivalent to 48.89% and 33.3% of the charts replies of the three expert panelist showed that , reviewed. of the 7 items, 7 proved relevant (Item level content validity , I-CVI= 1). The scale–level DISCUSSION content validity index, universal agreement method (S-CVI /UA) for the entire 7 item This study aims to determine the OMTs used by developed extraction tool was 1. Filipino physical therapists in assessing knee OA. Based on the results, none of the 45 charts Phase II: Inter-rater Reliability. Analysis of the reviewed reported about the use of WOMAC, inter-rater reliability using the Kappa statistic VAS, SF-36, and KOOS as an OMT for knee OA was determined among four members for the assessment. According to the systematic reviews data extraction tool, which have resulted to 1.00 of Fransen et al.34 and Li et al.35 from CPGs in (100%) or a perfect agreement for each items on assessing pain, functional status, and stiffness the extraction tool. Data were statistically were WOMAC, VAS, SF-36, and KOOS as the most significant as (p< .01, alpha = 0.05) commonly used outcome measure tools. Phase III: Clinical Audit According to the AAOS, the domains of pain, function, and stiffness were assessed with higher Chart Review. Seven hospitals and clinics frequency in patients with knee OA.14 Based on affiliated with UST-CRS participated in the study. the results, assessment of pain in the subjective Of the 285 charts of knee OA patients assessed evaluation corresponded to 97.77% of the total by Filipino Physical Therapists from June 2015 – charts reviewed. Moreover, 80% reported the June 2016 in seven hospitals/clinics, only 45 patient’s functional status, while only 4.44% charts had an initial evaluation notes, while 240 assessed for stiffness. These results showed that charts had no initial evaluation. the following domains were assessed during subjective evaluation with pain and functional Demographics. Of the 45 of 285 charts assessed status, having higher frequency compared to in this study, 80% were females. 73.33% of stiffness. However, assessment of stiffness in the patients with knee OA were aged >60 years old, charts reviewed was in contrast with the whereas 26.67%) were aged 40-60 years old. 18

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.006) findings of AAOS since the three domains should practicing in the Philippines but only those in the be present with higher frequency in assessing participating hospitals and clinics. patients with knee OA. None of the 45 charts reviewed reported the According to Kettenbach, among the objective utilization of outcome measure tools in the evaluation used in proper documentation of assessment of knee OA which may be due to assessment of common musculoskeletal cases several factors. According to Jette et al includes ocular inspection, palpation, range of perceptions of barriers which include lack of motion, manual muscle testing, special test, time and inconvenience; limited knowledge and postural assessment, gait analysis, and functional training; and lack of resources such as staffing assessment.17 Based on the results, ocular and automation.9 Attitudes and perceptions inspection, as well as palpation, was the most related to use of outcome measures among other commonly used objective evaluation in the health care providers, including mental health documentation of knee OA, representing 97.77% practitioners, oncologists, general practitioners, of the total charts reviewed. These were followed and nurses, also have been reported.9 However, by ROM and MMT, which were documented in these factors were not recorded by the 93.33% of the charts reviewed. Functional researchers. Only the documentation of the assessment was documented in 91.1% of the objective evaluation was included in the study. charts, while gait analysis was only documented in 71.1% of the charts reviewed. Assessment of CONCLUSION posture and the special test had the lowest frequency in documentation used in 48.89%, and This study found that the most common way of 33.3% of the charts reviewed respectively. These assessing knee OA is through subjective reports results suggest that the 45 charts reviewed were of pain and objectively through ocular inspection able to comply with the proper documentation of and palpation, closely followed by range of musculoskeletal cases showing a high frequency motion and manual muscle testing assessments. of using objective evaluation.17 Filipino physical therapists did not utilize standardized outcome measure tools such Lawrence et al.36 found that osteoarthritis is WOMAC, VAS, SAF-36, and KOOS. Thus, this more prevalent among those aged 40 and older. study clearly shows the gap between the Klippel et al.37 adds that it is prevalent among assessment of knee OA in the Philippines and the men before the age of 50 and becomes more global standard. However, the results of the common among women older than 50 years. study may be used as baseline data for This was further supported by our data, which improvement of the clinical audit in the practice yielded a result of 80% of the population being of Filipino Physical Therapists in the quality of female and 73.33%, or 33 out of the 45 charts, care for patients with knee osteoarthritis. were patients aged older than 60 years. Limitation of the Study. Although the study was Individual Author’s Contributions successful in determining the practice of knee J.R., CR. V., JK .C; Conceptualization, designed and OA assessment by Filipino physical therapists in methodology, data analysis and co-wrote the UST-CRS affiliated hospitals and clinics paper. J.R.; Supervised the data collection. EM.B., MR. DJ., O.H., G.P., JA.R., AR. T.; data collection concurrent with the global standard of assessing and co-wrote the paper. knee OA, there are still limitations in the study. There were only 45 charts reviewed from June Disclosure Statement 2015 to June 2016 that came from only seven This paper did not receive any funding. hospitals and clinics. Sample size calculations identified that 102 case notes were required to achieve appropriate power. Due to the constrained number of charts reviewed, the findings may not be generalized to represent the whole population of physical therapists 19

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.006) Conflicts of Interest 11. Martin CR, Savage-McGlynn E. A ‘good practice’guide for the The authors of this paper declare no conflicting reporting of design and analysis for psychometric evaluation. interest. Journal of Reproductive and Infant Psychology. 2013;31(5):449-55. Acknowledgments The authors would like to express their gratitude 12. McHugh ML. Interrater reliability: the kappa statistic. to the hospitals and clinics that participated in Biochemia Medica. 2012;22(3):276-82. our study. We would like to thank all the parents of the authors for their support and 13. National Institute for Clinical Excellence (Great Britain). understanding during the period of the study. Principles for best practice in clinical audit. Radcliffe Publishing; 2002. Supplementary files Supplementary File A. Developed Data Extraction 14. Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz CJ, Tool Casimiro L, Bugnariu N, Welch VA, De Angelis G, Francoeur L, Milne S. Ottawa Panel evidence-based clinical practice References: guidelines for the management of osteoarthritis in adults who are obese or overweight. Physical Therapy. 1. World Health Organization. The world health report 2002: 2011;91(6):843-61. reducing risks, promoting healthy life. World Health Organization; 2002. 15. Brooks LO, Rolfe MI, Cheras PA, Myers SP. The comprehensive osteoarthritis test: a simple index for 2. Fransen M, Bridgett L, March L, Hoy D, Penserga E, Brooks P. measurement of treatment effects in clinical trials. The The epidemiology of osteoarthritis in Asia. International Journal of Rheumatology. 2004;31(6):1180-6. Journal of Rheumatic Diseases. 2011;14(2):113-21. 16. Kettenbach G, Schlomer SL. Writing patient/client notes: 3. Lespasio MJ, Piuzzi NS, Husni ME, Muschler GF, Guarino AJ, Ensuring accuracy in Documentation. FA Davis; 2009. Mont MA. Knee osteoarthritis: a primer. The Permanente Journal. 2017;21. 17. Basaran S, Guzel R, Seydaoglu G, Guler-Uysal F. Validity, reliability, and comparison of the WOMAC osteoarthritis 4. Roos EM, Arden NK. Strategies for the prevention of knee index and Lequesne algofunctional index in Turkish patients osteoarthritis. Nature Reviews Rheumatology. with hip or knee osteoarthritis. Clinical Rheumatology. 2016;12(2):92. 2010;29(7):749-56. 5. Jevsevar DS. Treatment of osteoarthritis of the knee: 18. Herr KA, Spratt K, Mobily PR, Richardson G. Pain intensity evidence-based guideline. JAAOS-Journal of the American assessment in older adults: use of experimental pain to Academy of Orthopaedic Surgeons. 2013;21(9):571-6. compare psychometric properties and usability of selected pain scales with younger adults. The Clinical Journal of Pain. 6. Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz CJ, 2004;20(4):207-19. Casimiro L, Bugnariu N, Welch VA, De Angelis G, Francoeur L, Milne S. Ottawa Panel evidence-based clinical practice 19. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally guidelines for the management of osteoarthritis in adults administered numerical rating scale of acute pain for use in who are obese or overweight. Physical Therapy. the emergency department. Academic Emergency Medicine. 2011;91(6):843-61. 2003;10(4):390-2. 7. O'Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. FA 20. Bryce TN, Budh CN, Cardenas DD, Dijkers M, Felix ER, Davis; 2014. Finnerup NB, Kennedy P, Lundeberg T, Richards JS, Rintala DH, Siddall P. Pain after spinal cord injury: an evidence-based 8. Swinkels RA, van Peppen RP, Wittink H, Custers JW, review for clinical practice and research: report of the Beurskens AJ. Current use and barriers and facilitators for National Institute on Disability and Rehabilitation Research implementation of standardised measures in physical Spinal Cord Injury Measures meeting. The Journal of Spinal therapy in the Netherlands. BMC Musculoskeletal Disorders. Cord Medicine. 2007;30(5):421. 2011;12(1):106. 21. Jensen MP, McFarland CA. Increasing the reliability and 9. Jette DU, Halbert J, Iverson C, Miceli E, Shah P. Use of validity of pain intensity measurement in chronic pain standardized outcome measures in physical therapist patients. Pain. 1993;55(2):195-203. practice: perceptions and applications. Physical Therapy. 2009;89(2):125-35. 22. Wilkinson PR, Wolfe CD, Warburton FG, Rudd AG, Howard RS, Ross-Russell RW, Beech R. Longer term quality of life and 10. American Physical Therapy Association. Commission on outcome in stroke patients: is the Barthel index alone an Accreditation in Physical Therapy Education. Evaluative adequate measure of outcome? BMJ Quality & Safety. criteria for accreditation of education programs for the 1997;6(3):125-30. preparation of physical therapists. 2013. 23. Lin MR, Hwang HF, Chen CY, Chiu WT. Comparisons of the brief form of the World Health Organization Quality of Life and Short Form-36 for persons with spinal cord injuries. American Journal of Physical Medicine & Rehabilitation. 2007;86(2):104-13. 24. Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36- item short-form health survey, and the unified Parkinson disease rating scale in people with parkinsonism. Physical Therapy. 2008;88(6):733-46. 25. Lohmander LS, Östenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional 20

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs.0401.006) limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2004;50(10):3145-52. 26. Salavati M, Akhbari B, Mohammadi F, Mazaheri M, Khorrami M. Knee injury and Osteoarthritis Outcome Score (KOOS); reliability and validity in competitive athletes after anterior cruciate ligament reconstruction. Osteoarthritis and Cartilage. 2011;19(4):406-10. 27. Roos EM, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS)–validation and comparison to the WOMAC in total knee replacement. Health and Quality of Life Outcomes. 2003;1(1):17. 28. Xie F, Li SC, Roos EM, Fong KY, Lo NN, Yeo SJ, Yang KY, Yeo W, Chong HC, Thumboo J. Cross-cultural adaptation and validation of Singapore English and Chinese versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) in Asians with knee osteoarthritis in Singapore. Osteoarthritis and cartilage. 2006;14(11):1098-103. 29. van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Archives of Physical Medicine and Rehabilitation. 2005;86(2):190-6. 30. Harada ND, Chiu V, Stewart AL. Mobility-related function in older adults: assessment with a 6-minute walk test. Archives of Physical Medicine and Rehabilitation. 1999;80(7):837-41. 31. Jackson A, Carnel C, Ditunno J, Read MS, Boninger M, Schmeler M, Williams S, Donovan W. Outcome measures for gait and ambulation in the spinal cord injury population. The Journal of Spinal Cord Medicine. 2008;31(5):487-99. 32. Moseley AM, Lanzarone S, Bosman JM, van Loo MA, de Bie RA, Hassett L, Caplan B. Ecological validity of walking speed assessment after traumatic brain injury: a pilot study. The Journal of Head Trauma Rehabilitation. 2004;19(4):341-8. 33. Kennedy DM, Stratford PW, Wessel J, Gollish JD, Penney D. Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty. BMC Musculoskeletal Disorders. 2005;6(1):3. 34. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2015(1). 35. Li Y, Su Y, Chen S, Zhang Y, Zhang Z, Liu C, Lu M, Liu F, Li S, He Z, Wang Y. The effects of resistance exercise in patients with knee osteoarthritis: a systematic review and meta-analysis. Clinical Rehabilitation. 2016;30(10):947-59. 36. Lawrence R, Felson D, Helmick C, Arnold L, Choi H, Deyo R, Gabriel S, Hirsch R, Hochberg M, Hunder G, Jordan J, Katz J, Kremers H, Wolfe F. Estimates of the prevalence of arthritis and other Rheumatic Conditions in the United States, Part II. Arthritis Rheumatology.2008;51(1):26-35. 37. Klippel J, Crofford L, Stone J, White P. Primer on the Rheumatic Diseases. Springer ;2008. 21

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) Original Article Effect of non-elastic closed-basket weave ankle taping on muscle activity of tibialis anterior, peroneus longus, medial, and lateral gastrocnemius during jump landing on a hard, flat surface in healthy individuals: a pilot study Fe Therese Chavez1, Emmanuel Carpio1, Philip Andrew Aguilar1, Daniella Ang1, Blessie Busog1, Rheine Canlas1, Isabella Gonzales1, Joan Marie Ibanez1, Adrian Miclat1, Mary Angelique Principe1 1College of rehabilitation Sciences- Department of Physical Therapy, University of Santo Tomas, Sampaloc, Manila, Philippines Correspondence should be addressed to: Fe Therese Chavez1; [email protected] Article Received: January 24, 2020 Article Accepted: June 20, 2020 Article Published: August 15, 2020 (Online) Copyright © 2020 Chavez et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Inversion ankle sprains are among the most common traumatic injuries for both men and women caused by jumping and landing activities. The ankle is protected by the static and dynamic stabilizers to reduce the incidences of injuries. Furthermore, using a non-elastic closed- basket weave taping technique is one of the common interventions to prevent it. Knowledge about the muscle activity reaction of the dynamic stabilizers upon application of tape is limited with varying results. Objectives: To determine the effect of non-elastic closed-basket weave ankle taping on the muscle activity of tibialis anterior, peroneus longus, medial, and lateral gastrocnemius on healthy individuals during jump landing on a hard, flat surface. Methods: This study is a quasi-experimental study using a pre- and post-test design. Peak amplitude muscle activity was assessed and analyzed using surface electromyography (sEMG) after landing from a jump. The pre-test was done by jump landing without tape, after which post-test data was immediately collected after applying the non-elastic closed-basket weave taping. Jump landing was done for three trials for both pre- and post-tests. A paired t-test was used to determine significant differences in pre-post taping. Results: Fifteen healthy participants were included in the study (9 females, 6 males) with a mean age of 21 + 1.03 years old and BMI of 22.74 + 1.63 kg/m2. No significant difference was observed on peak amplitude muscle activity of the tibialis anterior (p= 0.06), medial gastrocnemius (p= 0.32), and lateral gastrocnemius (p= 0.66) after application of tape. However, a significant difference was observed in the peroneus longus after the application of tape (p= 0.05) during jump landing. Conclusion: Non-elastic closed-basket weave taping decreased the peak amplitude muscle activity of the peroneus longus during jump landing. This research suggests that tape may influence the peroneus longus, and it may or may not be detrimental in reducing the risk of ankle sprains. Keywords: non-elastic taping, electromyography, jump landing, ankle taping INTRODUCTION Inversion ankle sprains are one of the most volleyball, tennis, and wrestling.2 Despite it being common traumatic injuries in the lower a common injury, there is little knowledge extremity for both men and women. This injury regarding the prevalence of ankle sprains in the affects adults and children, athletes and non- general population. The few studies investigating athletes, and occurs during activities such as the epidemiology of ankle sprains4 and the exact walking, stair negotiations, and sports-related mechanism of injury common to the general activities like twisting, jumping, or landing.1 population have not been scrutinized Studies revealed that the highest risk population thoroughly.5 for sustaining an ankle sprain are females and The most common mechanism of injury in children,2 and between the ages 14-37 years old,3 inversion ankle sprains is due to excessive with the highest risk activity occurring during inversion and plantarflexion, which are seen in indoor and outdoor sports such as basketball, 22

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) running, jumping, or sudden changes in muscles working to absorb the impact through directions since these motions stress the lateral the activation of the muscles surrounding the ligaments further, causing tears.1 Previous case ankle, knee, and hip. The leg muscles help studies have shown that jumping and drop stabilize the ankle in one fixed position during landing are often the mechanisms involved in the the landing phase, through which different acquisition of ankle sprains during cutting injuries can be prevented. Among these muscles maneuvers and jump landing tasks in field are the peroneus longus, which acts as a primary hockey, high jumps, tennis, and basketball defense mechanism of an injured ankle,10 the games.6 When an individual starts to jump, the gastrocnemius,8,9 and the tibialis anterior, which ankle moves from a dorsiflexed to a allows dorsiflexion to handle landing stability.11 plantarflexed position, then upon landing, it A study by Ebben10 showed a significant effect of moves from plantarflexion to dorsiflexion. This the gastrocnemius muscle to stabilize the ankle motion decreases the stability of the ankle in vertical jumps greater than 50 cm, aside from ligaments just when it is most needed. The ankle the involvement of the hip and knee muscles is protected by its static and dynamic stabilizers. during jumping and landing activities. In a study Static stabilizers are bone articulations and done by Walsh,8 wherein they observed the ligaments that support the ankle. In contrast, muscle activity immediately after contact in dynamic stabilizers are the muscles firing around jump landing. The gastrocnemius is seen to be the joint for stability.5 Eccentric control is noted contracting first for ankle stabilization, followed to lessen the forces acting between the ground by the contraction of the biceps femoris and and the ankle joint, which is the dynamic rectus femoris. Any alterations in the muscle stabilizer role. Synchronization of the muscles is activation may yield errors in the positioning of a factor that any imbalances may result to the ankle during dynamic activities. decrease in the distribution of forces surrounding the joint which can cause excessive Most studies have observed the ankle stress that may result in injury.7 biomechanics and kinetics during landing from a drop jump,12,13 and showed the use of the non- Jumping has different phases, namely: 1) take off elastic closed-basket weave taping technique for – the period of propelling the body off the the prevention strategies of an inversion ankle ground; 2) flight phase – the period where the sprain. Taping can increase kinesthetic body establishes contact with the ground; 3) awareness and limit the range of motion at the landing phase – the period where the body re- ankle joint, reducing inversion motion.14,15 establishes contact with the ground. In the first However, knowledge about the leg muscles’ phase, the ankle is put into dorsiflexion as the muscle activity upon application of tape is knee bends before propulsion. Furthermore, as limited and has varying results. Several studies the body is in the air, the ankle goes into have noted that after tape application, there was plantarflexion when the knee extends. Gravity increased activation of the peroneus longus;11,16 and the follow through of the calf and foot however, several studies have shown that the muscles put the foot into plantarflexion when it use of tape had a decrease in the muscle activity loses contact. This position carries over into the on the tibialis anterior, medial head of landing phase, wherein ankle sprain injury gastrocnemius, and peroneus longus.14,17 usually occurs. The foot contacts the ground Another study showed that the tape does not while the ankle is in plantarflexion and inversion affect the peroneus longus muscle activity and or its open-packed position. This position causes that it can be beneficial, allowing the evertor to the ligaments of the ankle to be lax and is forced develop torque.18 Due to the varying results and to absorb the high impact created by landing. the limited leg muscle activity observation in This mechanism can cause an excessive stretch most current studies, the researchers opted to or tear to the lateral ligaments and is considered include the lower leg stabilizers and determine as an ankle sprain.8,9 the effect of the tape during jump landing. Landing from a jump involves eccentric- To address this, we conducted a quasi- concentric contraction of lower extremity experimental study using peak amplitude muscle 23

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) activity measured with surface representing no dysfunction; 6) able to give electromyography (sEMG). Thus, this study’s objective is to determine the effect of non-elastic verbal and written consent; g) able to follow closed-basket weave ankle taping specifically on instructions. And the exclusion criteria were the the tibialis anterior, peroneus longus, medial, following: 1) flat-footed as assessed by the and lateral gastrocnemius muscle activities Navicular drop test; 2) with history of ankle during jump landing on a hard, flat surface. sprain or any other ankle injury; 3) with current musculoskeletal, neurological, or cardiovascular METHODOLOGY conditions; 4) allergic to non-elastic tape (MuellerTM); 5) athletes who participate in the competitive field. Ethical Approval. This study complied with the Setting. This study was conducted inside the Principles of the World Medical Association Physical Therapy Skills Laboratory of the College Declaration of Helsinki and the Good Clinical of Rehabilitation Sciences of the University of Practice Guidelines of the Philippines Health Santo Tomas. Research Ethics Board. Approval was sought from the Ethical Review Committee of the Outcome Measures. A surface College of Rehabilitation Sciences of the electromyography (sEMG) is a reliable way to University of Santo Tomas. Participants gave describe and determine the quality and muscle their written informed consent before the study. activation patterns during movement. Muscle activity was recorded with a wireless Study Design. This research utilized a quasi- electromyography processor unit (Delsys Trigno, experimental study using a pre- and post-test Boston, USA) using surface electrodes. It is an design. electrodiagnostic tool to measure electrical muscle activity during rest and movement or Sample Size. This is a pilot study and cannot contraction. It was used to measure the peak feasibly use a larger sample size and calculation amplitude muscle activity of the leg muscles for a higher alpha. The sample size was based on during landing from a vertical jump. The sEMG the study by Abian-Vicen.19 Seventeen has many time domains representing participants were recruited during the data myoelectric patterns such as mean absolute gathering; however, the data of the 2 value, zero crossings, waveform lengths, and a participants had problems in their sEMG results, Time-Frequency domain, which shows transient wherein the data were not recorded on specific myoelectric signal pattern classification. The muscles. Thus, only fifteen (15) participants’ surface electrodes were placed on specific data were analyzed. There were no dropouts, muscles of the lower leg with a 2 cm electrode injuries, nor adverse reactions to tape occurred, distance from each other. The muscles observed and there were no complaints nor reports of were the tibialis anterior (TA), peroneus longus discomfort and pain from the participants during (PL), medial gastrocnemius (MG), and lateral the duration of this research. gastrocnemius (LG) during jump landing. Results of the sEMG were gathered and analyzed Recruitment of Participants. Convenience using the SciLab analyzer. Assessors for sampling was used to recruit participants by participant screening were different from the sending out posters/fliers by a person and assessors for the data gathering. Two assessors sharing posts through social media. Participants underwent reliability testing on the electrode were screened using the following inclusion placement, and the interclass correlation criteria: 1) 14-37 years old; 2) BMI range of 18.5 coefficient agreement value of 0.7-0.8 was to 24.99 kg/m2; 3) individuals who engage at accepted. Researchers with high reliability were least a total of 150 minutes of moderate to the ones who placed the surface electrodes on vigorous aerobic physical activity per week, in the muscles of the dominant leg of the bouts of 10 minutes or more for at least three participants. times a week (non-consecutive); 4) normal balance by Berg Balance test; 5) Foot ankle Data Gathering Procedure. Participants who disability index (FADI) score of 100% met the sampling criteria were oriented of the 24

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) procedure and were notified that researchers Figure 1. Phases of vertical jump landing without tape on dominant leg. Succeeding images display the landing would record a video during the jump landing. phase in a frame-by-frame representation. The face of the participant was concealed to ensure anonymity. Video recording was done for Figure 2. Phases of vertical jump landing with closed documentation and verification during the basket weave ankle tape on dominant leg. Succeeding landing phase of the jump, where toes touch the images display the landing phase in a frame-by-frame ground to the sEMG muscle activation. representation. Participants were required to wear cycling shorts for the leg muscles to be properly participant. The participant was then asked to exposed, and any shirt and rubber-soled repeat the jump landing activity [Figure 2]. footwear to their comfort. On the day of data gathering, as a warm-up, each subject was taught Data Analysis. Baseline demographics were the fencer stretching for 15 seconds and repeat it analyzed using the Shapiro-Wilk test set at three times on each leg. The participants were p<0.05. The collected data and results were asked to kick a ball to determine their dominant interpreted and analyzed by the researchers leg. Electrode placement sites on the using SPSS. Muscle activity peak amplitude was participants’ dominant leg were cleaned and gathered from the time of landing from a jump shaved by the EMG standard procedures. Surface using a 500-ms window after contact were electrodes were placed on the specific locations analyzed. Data were analyzed using a Paired t- of the muscles of the dominant leg: 1/3 from the test, and a 95% confidence interval for the true muscle belly of the tibialis anterior, center of the mean difference was computed. muscle belly of the peroneus longus (parallel to the muscle fibers, the distal end of the muscle belly of the medial gastrocnemius, and 2/3 proximal end from the muscle belly of the lateral gastrocnemius.20 The Maximal Voluntary Isometric Contraction (MVIC) was done on each muscle to note that the placement of the sEMG electrode is in line with the tested muscle. Data were analyzed and recorded using EMGWorks by Delsys for all trials of jump landing. Data were sampled at 1000Hz and full-wave rectified and smoothed using a 500-ms moving window to get the peak amplitude. All data were exported using MS Office Excel for calculations. Participants did a trial of jump landing twice and RESULTS were instructed to jump as high as they can with both feet and landing on their toes with their The overall mean of the different demographic knees bent. With a metronome as a prompter, profiles is seen in Table 1 for the different each participant was instructed to jump on the participants (n=15) of the study. Fifteen third sound. The jump landing was done for participants (Females = 9, Males = 6) were three trials [Figure 1]. After the first 3 trials of included in the study with their dominant foot, jump landing without the non-elastic tape, the mostly on the right leg (87%). The age and BMI closed-basket weave taping technique was are homogenous at baseline for all the applied on the ankle of the same leg. A licensed participants. With a mean age of 21 + 1.03 years sports physical therapist, who has undergone old (p= 0.46) and BMI of 22.74 + 1.63 kg/m2 (p= seminars with taping and has been using tape on 0.29). Inter-reliability testing using intraclass individuals for at least two years applied the correlation results on the muscles of TA (0.94), tape. The duration of the tape application served PL (0.978), MG (1.00), and LG (0.98), showed as the allotted 5 minutes rest period for the high reliability for surface electrode placement. 25

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) Table 1. Demographics of participants. Significant level without tape to the application of tape during for Shapiro-Wilk Test of Normality is set at p<0.05. jump landing (Table 2). Characteristics Percentage DISCUSSION (n=15) Distribution (%) This study has shown the different effects of Sex 40 muscle activity peak amplitude also 60 demonstrated in the literature. The tibialis • Male anterior and peroneus longus had a decrease in 87 muscle activity during jump landing when the • Female 13 tape was applied on the ankle. However, only the Leg Dominance peroneus longus displayed a significant difference in pre- and post- taping. The findings • Right are consistent with the existing literature, wherein non-elastic taping has been found to • Left increase joint stiffness, thereby causing a decrease in muscle activity.14 The muscle Age (yrs.) Mean ± SD Shapiro-Wilk stiffness is due to the perception of the nervous BMI (kg/m2) 21.07 ± 1.03 0.46 system for increased support in the mechanical setting at the ankle joint. The adaptation of 22.74 ± 1.63 0.29 muscle activation is responsible for the decreased demand for dynamic stabilization and The average peak amplitude of the TA, PL, MG, improved stability in planned and unplanned and LG muscles of each of the participant’s tasks.21 In the closed-basket weave taping or dominant leg during jump landing with and prophylactic ankle taping using a non-elastic without tape are shown in Table 2. As presented, tape, the ankle is taped in a slightly everted there was a decrease in TA and PL muscle position for stability and promotes restriction. activities during jump landing when the tape was The tape can be perceived by the body of applied on the ankle, in contrast to an increase in increased support that may decrease the demand muscle activity for the MG and LG. Results also showed that of all the muscles observed, the medial gastrocnemius showed more drastic muscle activity with tape compared to the other muscles. Results showed that there is no significant difference pre- and post- tape on the peak Table 2. Statistical representation of the results of muscle activity peak amplitude (Paired t-test <0.05). Paired Samples Statistics 95 % Confidence Interval of the Differences Sig Peak Amplitude Mean Std. Deviation Std. Error Lower Upper 0.59 (microvolts) Mean 0.05* 0.32 TA without tape 1088.67 1389.36 358.73 -11.58 562.20 0.67 TA with tape 813.35 1302.91 336.41 PL without tape 405.82 123.14 31.79 1.649 120.43 PL with tape 344.78 153.34 39.59 MG without tape 1107.22 727.36 187.80 -1324.38 465.78 MG with tape 1536.52 1484.16 383.21 LG without tape 1110.27 1160.65 299.68 -1209.50 797.78 LG with tape 1316.13 1615.20 417.04 Note: *significant difference p<0.05 TA = tibialis anterior; PL = peroneus longus; MG = medial gastrocnemius; LG = lateral gastrocnemius amplitude muscle activity of the tibialis anterior on the muscles around the area especially (p= 0.06), medial gastrocnemius (p= 0.32), and towards eversion.17,22 lateral gastrocnemius (p= 0.67) muscles during jump landing. However, the peroneus longus (p= In an injured ankle, the peroneus longus acts as 0.05) showed a significant difference when it the primary defense mechanism during comes to peak amplitude muscle activation from movement. The reduced activation is consistent 26

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) with the findings by Delahunt, which identified and landing.9 The body uses the activity of these integrated EMG muscle activity during a single muscles as a strategy to enforce joint stability leg drop jump,9,23 and by Dodd17, along with the and protect the knee as well as the ankle from TA and MG following application of tape during potential injuries and external forces acting on landing from a netball pass, wherein the foot was it.29 Consequently, they are more important than taped in an everted position. Furthermore, it was the TAs, because of their ability to absorb shown that there is a higher muscle activity for eccentric forces.30,31 both tibialis anterior and peroneus longus The lateral gastrocnemius would have its without the application of tape during drop greatest peak during the early activity in drop landing.17 The increase in muscle activity is also landing for its role in stabilizing the ankle joint to shown in a study by McLoda,24 and that pre- prepare itself in landing from a jump.31,32 activation of the muscle is essential following However, in the study, there was a minimal dynamic activities.25 It is a neuromuscular difference between MG and LG in the average response to increase joint stability and maintain peak amplitude. Research has shown that an balance to avoid inversion and excessive externally rotated tibia prompted significantly pronation or eversion after contact to the greater MG activation during heel raises and an ground.26,27 Allowing dorsiflexion on the ankle internally rotated position would yield greater increases stability since eversion and LG activation.33 The MG has a shock-absorbing dorsiflexion are the closed- packed position of function as it rapidly stretches and stores elastic the ankle joint. However, research has shown energy which is released to the fascicles and varying results. There were increases in dissipated through active muscle lengthening.34 peroneus longus activity in people with ankle The increased activity of the gastrocnemius sprains following the application of tape when muscles can also be associated with the spinal the foot is stressed or forced into inversion.16 stretch reflex-induced activity or a stretch on the The tape provides support to the ankle by muscle spindle when the ankle moves from cutaneous cues and aggressive pulling, which plantarflexion to dorsiflexion upon contact, such could lead to increases in muscle activity because as in hopping and jump landing. This, in turn, of the sensory input. For individuals with chronic would produce an increase in muscle activity ankle instability, the tape enhances the muscle causing muscle stiffness and increased joint response on the area by maintaining high stability.35,36 During this study, the participants muscular activity during sudden inversion or were instructed to land on their toes with knees different dynamic movements.16,28 The tape had a bent after jumping with no particular instruction facilitatory effect on the PL with immediate or preference on foot placement. This may have weight-bearing, therefore enhancing the influenced MG and LG involvement, and the inversion position sense, resulting in a need to instructions may increase the cortical drive for counteract the force after landing.11 The greater anticipatory control contributing to researchers suggest obtaining the pre-landing increased activity in the posterior leg muscles.37 muscle activity to detect any anticipatory muscle activity strategies that would determine the Studies have shown that the taped ankle muscle activity following a jump landing and the diminished muscle activity and the rate of latency of muscle activity following ground inversion on the ankle.17,18,38 This is also contact. demonstrated by wearing an ankle brace, The medial and lateral gastrocnemius, together restricting dorsiflexion and plantarflexion39,40 as with the tibialis anterior, did not have any compared when there is no tape applied after significant differences in peak muscle activity ground contact during drop landing for LG.32 upon landing. However, it was shown that the Due to the restriction brought about by the tape at the ankle joint, the eccentric action of the MG and LG had a higher level of muscle activity gastrocnemius is limited, therefore less energy is than the other muscles, with or without tape. As absorbed to control the movement,38 and there is stated, an un-taped ankle has strong muscle a decreased need to provide mechanical contractions on both MG and LG, as they are the stability.41 However, in the study, the tape caused stabilizers of the ankle upon vertical jumping 27

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) an increase in gastrocnemius muscle activity. necessary to avoid deviation of results. Lastly, One possible explanation is an increasing the randomization of the application of tape demand for muscle activity during landing. There could be used to address the possible order was greater activation of 1b afferents, increasing effect from the application of tape. the muscle activity in a horizontal jump task.35 As stated, the gastrocnemius muscles act as a shock Implications. The results have shown that the absorber and increase muscle stability. The tape application of non-elastic tape would affect not enhanced gastrocnemius activity rather than only the musculoskeletal system providing diminishing it, thereby causing more stability on restriction on the ankle motion but also the the ankle joint upon landing. It may have caused nervous system, providing a perception of an increase in the cutaneous cues, thus creating increased support resulting in muscular an increase in muscle activity. The position of the adaptation. Taping has been an effective way of ankle when taped is also in slight eversion and stabilizing the ankle and reducing the risk of dorsiflexion, causing a slight stretch on the injuries,15 however, its effects in the muscle gastrocnemius muscle spindles. As the foot activity may warrant further investigation, contacts the ground, plantarflexion is limited, especially in its short- or long-term use. and there is a reflex-induced stretch activity from the gastrocnemius to protect and increase the joint stiffness upon landing.36,37 The CONCLUSIONS instructions given to the study participants during landing may have affected the peak The non-elastic closed-basket weave taping amplitude muscle activity. Also, the impact of the exhibited a significant effect on the peroneus forces and the range of motion at the knee and longus peak amplitude muscle activity, having a ankle joints may have influenced the amount of decreased activation after application. However, muscle activity during landing. The the other muscles showed no statistically gastrocnemius reduces the ground reaction force significant difference after the tape was applied during landing,41 and with taping, it increases the at the ankle. This study suggests that tape may force that the lower limb receives, especially if influence the peroneus longus by decreasing its there are repeated and accumulated jumps.19 The muscle activation during jump landing, which increase in muscle stiffness and increase in may or may not reduce the risk of ankle injury in a healthy individual. muscle activity may lead to an increased risk for Further research may be done to determine the injury, as this may also increase the ground effect of the non-elastic closed-basket weave on reaction force from landing. The evidence for the healthy individuals against those with recurrent gastrocnemius activity is conflicting and ankle sprains. Moreover, this study can be used warrants further investigation since it did not as a reference for future studies involving non- achieve any significant difference at pre- and elastic closed-basket weave taping and ankle post-taping and is therefore inconclusive. The stability involving dynamic ankle stabilizers. effects of taping on the muscles in terms of Furthermore, this may also serve as a basis for benefit or potential disadvantage for muscle whether ankle taping effect may have short or activity are inconclusive in this study as there long- term benefits or drawbacks by inhibiting were varying results with limited outcomes. the optimal contraction of the muscles Limitations. The outcomes in the study are surrounding the ankle during jump landing. limited by the small sample size and the number Lastly, it is suggested that training programs in of trials for jumping. Jump height performance or clinics and sports teams use the non-elastic jumping performance and ground reaction force closed-basket weave taping as an adjunct should be added as outcomes to determine the intervention but should focus more on impact of ankle taping in every individual. strengthening and conditioning the dynamic Furthermore, studies have shown varying stabilizers to increase the stability and reduce activation patterns of the lower extremity when the risk of ankle injuries. the drop height exceeds certain limits,18 and that Individual Author’s Contributions a standardization of the jump height should be 28

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) F.C.; Designed and performed experiments, hockey, ballet dancing, and running. Research in Sports supervised the research, analyzed data, and co- Medicine. 2009;17(4):205-216. wrote the paper. E.C., P.A., D.A., B.B., R.C., I.G., J.I., A.M., M.P.; Performed experiments, encoded data 7. Kaminski T, Hartsell H. Factors contributing to chronic and co-wrote the paper. ankle instability: a strength perspective. Journal of Athletic Training. 2002;37(4):394-405. Disclosure Statement 8. Walsh M, Arampatzis A, Schade F, Bruggerman GP. The This research paper is not funded by any effect of drop jump starting height and contact time on agencies. power, work performed, and moment of force. Journal of Strength and Conditioning Research Res. Conflicts of Interest 2004;18(3):561-6. The authors declare no conflict of interest. 9. Malmir K, Olyaei GR, Talebian S, Jamshidi AA, Ganguie MA. Effects of peroneal muscles fatigue on dynamic Acknowledgments stability following lateral hop landing: time to stabilization versus dynamic postural stability index. The researchers would like to thank the Journal of Sport Rehabilitation. 2018;1-7. participants for their contribution to this study. Special thanks to Dr. Valentin Dones III for his 10. Ebben WP, Simenz C, Jensen RL. Evaluation of patience as a reviewer and as an adviser plyometric intensity using electromyography. Journal throughout the entirety of our research; to Ma. of Strength and Conditioning Research. Roxanne Fernandez and Ken Erbvin Sosa for the 2008;22(3):861-868. guidance in using the sEMG. 11. Wilkerson GB. Biomechanical and neuromuscular References effects of ankle taping and bracing. Journal of Athletic Training. 2002;37(4):436—445. 1. Gans B, Walsh N, Robinson L, editors. DeLisa's Physical Medicine & Rehabilitation Principles and Practice. 5th 12. Capasso G, Maffuli N, Testa V. Ankle taping: support ed. Philadelphia: Lippincott Williams & Wilkins; 2010. given by different materials. British Journal of Sports Medicine. 1989;23(4):239-240. 2. Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle 13. Jun H, Chun Y, Kim J, Baker R, Seegmiller J, Lee SY. sprain injury: a systematic review and meta-analysis of Ankle biomechanics and jump performance in healthy prospective epidemiological studies. Sports Medicine. and chronic ankle instability individuals during 2014;44(1):123-140. landing: a triple-blind randomized clinical trial of ankle taping efficacy. British Journal of Sports Medicine. 3. Al Bimani SA, Gates LS, Warner M, Ewings S, Crouch R, 2017;51(4):337.2-337. Bowen C. Characteristics of patients with ankle sprain presenting to an emergency department in the south of 14. Jeffriess MD, Schultz AB, McGann TS, Callaghan SJ, England (UK): A seven-month review. International Lockie RG. Effects of preventative ankle taping on Emergency Nursing. 2018;41:38-44. planned change-of-direction and reactive agility performance and ankle muscle activity in 4. Waterman B, Owens B, Davey S, Zacchili M, Belmont P basketballers. Journal of Sports Science & Medicine. Jr. The Epidemiology of ankle sprains in the United 2015;14(4):864-876. States. The Journal of Bone and Joint Surgery. 2010;92(13):2279-2284. 15. Dizon J, Reyes J. A Systematic review on the effectiveness of external ankle support in the 5. Bonnel F, Toullec E, Mabit C, Tourne Y. Chronic ankle prevention of inversion ankle sprains among elite and instability: biomechanics and pathomechanics of recreational players. Journal of Science and Medicine in ligaments injury and associated lesions. Orthopedics & Sport. 2010;13(3):309-17. Traumatology: Surgery and Research. 2010;96(4):424- 432. 16. Briem K, Eythorsdottir H, Magnusdottir RG, Palmarsson R, Runarsdottir T, Sveinsson T. Effects of kinesio tape 6. Li JX, Xu DQ, Hoshizaki B. Proprioception of foot and compared with non-elastic sports tape and the untaped ankle complex in young regular practitioners of ice ankle during a sudden inversion perturbation in male athletes. Journal of Orthopedic & Sports Physical Therapy. 2011;41(5):328-335. 17. Dodd A, Dyson R, Peters R. Moderation of lower limb muscular activity during jump landing by application of ankle taping. In: Harrison AJ, Anderson R, Kenny Ian, editors. Methodology. 2002: Proceedings of the 27th International Conference on Biomechanics in Sports; 2009 Aug 17-20; Limerick, Ireland. Open Journal Systems; 2009. 18. Trégouët P, Merland F, Horodyski MB. A comparison of the effects of ankle taping styles on biomechanics 29

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.007) during ankle inversion. Annals of Physical and muscles during landing: a musculoskeletal modeling. Rehabilitation Medicine 56. 2013;56(2):113-122. Journal of Healthcare Engineering. 2018;1-8. 19. Abian-Vicen J, Alegre LM, Fernandez-Rodriguez JM, 31. Neubert A, Schwirtz A, Buhrle M. Muscular in the Lara AJ, Meana M, Aguado X. Ankle taping does not stretch-shortening (SSC): not only maximization but impair performance in jump or balance tests. Journal of optimization as necessary. 16 International Symposium Sports Science and Medicine. 2008;7(3):350-356. on Biomechanics in Sports. 1998;56-59. 20. De Luca CJ, Kuznetsov M, Gilmore LD, Roy SH. Inter- 32. Ambegaonkar JP, Sandra SJ, Perrin DH. A Subsequent electrode spacing of surface EMG sensors: Reduction of movement alters lower extremity muscle activity and crosstalk contamination during voluntary contractions. kinetics in drop jumps vs. drop landings. Journal of Journal of Biomechanics. 2012;45(3):555-561. Strength and Conditioning Research. 2011;25(10):2781-2788. 21. Lin YH, Whitney SL. Effect of ankle taping on the isometric muscle contraction of the ankle evertors. 33. Riemann BL, Schmitz RJ, Gale M, McCaw ST. Effect of Journal of Back and Musculoskeletal Rehabilitation. ankle taping and bracing on vertical ground reaction 2000;14(3):123-126. forces during drop landings before and after treadmill jogging. Journal of Orthopaedic & Sports Physical 22. Huang CY, Hsieh TH, Lu SC, Su FC. Effect of the kinesio Therapy. 2002;32(12):628-635. tape to muscle activity and vertical jump performance in healthy inactive people. BioMedical Engineering 34. Hollville E, Nordez A, Guilhelm G, Lecompte J, Rabita G. OnLine. 2011;10:70. Surface properties affect the interplay between fascicles and tendinous tissues during landing. 23. Delahunt E, Monaghan K, Caulfield B. Changes in lower European Journal of Applied Physiology. limb kinematics, kinetics, and muscle activity in 2020;120(1):203-217. subjects with functional instability of the ankle joint during a single leg drop jump. Journal of Orthopaedic 35. Prieske O, Muehlbauer T, Mueller T, Krueger T, Kibele Research. 2006; 24(10):1991-2000. A, Behm DG, et al. . Effects of surface instability on neuromuscular performance during drop jumps and 24. McLoda TA, Hansen AJ, Birrer DA. EMG analysis of landings. European Journal of Applied Physiology. peroneal and tibialis anterior muscle activity prior to 2013;113(12):2943-2951. foot contact during functional activities. Electromyography and Clinical Neurophysiology. 36. Hobara H, Kanosue K, Suzuki S. Changes in muscle in 2004;44(4):223-227. muscle activity with increased leg stiffness during hopping. Neuroscience letters. 2007;418(1):55-59. 25. Sinsurin K, Vachalathiti R, Jalayondeja W, Weerawat L. How to control ankle joint in various directions of one 37. Thompson CS, Schabrun S, Marshall PW. H-reflex leg jump-landing: frontal plane moment and EMG excitability is inhibited in soleus, but not study. In: Tzyy-Yuang S, Wei-Hua H, Huang PC, Chen-Lu gastrocnemius, at the short latency response of a T, editors. Muscle Skeleton mechanics. 2013: horizontal jump-landing task. Human Movement Proceedings of the 31st International Conference on Science. 2016;47:1-8. Biomechanics in Sports; 2013 Jul 7-11; Taipei, Taiwan. Open journal systems; 2013. 38. Yi CH, Brunt D, Kim HD, Fiolkowski P. Effect of Ankle Taping and Exercise on EMG and Kinetics during 26. Suda EY, Amorim CF, Sacco ICN. Influence of ankle Landing. Journal of Physical Therapy Science. functional instability on the ankle electromyography 2003;15(2): 81-85. during landing after volleyball blocking. Journal of Electromyography and Kinesiology. 2009;19(2):e84- 39. Henderson ZJ, Sanzo P, Zerpa C, Kivi D. The effects of e93. ankle braces on lower extremity electromyography and performance during vertical jumping: a pilot study. 27. Webster KA, Pietrosimone BG, Gribble PA. Muscle International Journal of Exercise Science. activation during landing before and after fatigue in 2019;12(1):15-23. individuals with or without chronic ankle instability. Journal of Athletic Training. 2016;51(8):629-636. 40. Smith B, Claiborne T, Liberi V. Ankle bracing decreases vertical jump height and alters lower extremity 28. Jaffar MR, Jaafar Z, Li GS. Peroneus longus activity in kinematics. International Journal of Athletic Therapy & different types of taping: athletes with ankle instability. Training. 2016;21(2):39-46. Revista Brasileira de Medicina do Esporte. 2016;22(3):216-221. 41. Hopper DM, McNair P, Elliott BC. Landing in netball: effects of taping and bracing the ankle. British Journal 29. Morgan KD, Donnelly CJ, Reinbolt JA. Elevated of Sports Medicine. 1999;33(6):409-413. gastrocnemius forces compensate for decreased hamstrings forces during the weight-acceptance phase of single-leg jump landing: implications for anterior cruciate ligament injury. Journal of Biomechanics. 2014;47(13):3295-3302. 30. Niu W, Wang L, Jiang C, Zhang M. Effect of dropping height on the forces of lower extremity joints and 30

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) Original Article Muscle activation pattern of gluteus medius, tibialis anterior and peroneus longus during drop landing on different surfaces: a cross-sectional study Ken Erbvin Sosa1, Kristina Devora1, Rino Luis Santiago1, Shyllah Trish Abando1, Samuel John Chua1, Ria Jasmine de Leon1, Raphael Jose Maria Eala1, Iana Joy Famy1, Anselm Raphael Garvida1, Liezelle Soriano1 1Physical Therapy Department, University of Santo Tomas, College of Rehabilitation Sciences, Manila, Metro Manila, Philippines Correspondence should be addressed to: Ken Erbvin R. Sosa1; [email protected] Article Received: May 14, 2020 Article Accepted: June 21, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 Sosa et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Gluteus medius (GMeds), peroneus longus (PL), and tibialis anterior (TA) help in maintaining frontal stability of the lower extremity, particularly, the ankle. Muscle activation must be sufficient to prevent the occurrence of an ankle sprain. The purpose of this study is to compare the muscle activation of the GMeds, TA, and PL during drop landing on stable and unstable surfaces of physically active individuals. Methods: Surface EMG (sEMG) was used to determine the muscle activation pattern of the GMeds, TA, and PL of fifteen (15) recreational athletes during drop landing. The mean percentage of maximum voluntary isometric contraction (%MVIC) was calculated for comparison. Wilcoxon signed-rank test was used to compare means. Results: There were no statistically significant differences in the muscle activity of GMeds (p=0.69), TA (p=0.26), and PL (p=0.23) on stable and unstable surfaces. However, a small effect size showed that GMeds (d=0.30) has higher activation in the unstable surface while TA (d=0.28) and PL (d=0.17) have lower activation on unstable surface. Conclusion: Landing surface does not significantly alter muscle activity of GMeds, TA, and PL. However, the magnitude of the difference in the mean %MVIC between groups shows the compensatory mechanism of the body when subjected to different surface conditions. This can be used when creating injury prevention programs of the lower extremity. Keywords: gluteus medius, tibialis anterior, peroneus longus, muscle activation, landing INTRODUCTION Landing is commonly performed in human and BOSU ball.14 Unstable surfaces are as equally locomotion1,2 especially in sports. Drop landing is important to be considered as stable surfaces an isolated landing with no subsequent motion.3 due to the modifications of musculoskeletal Examples include a gymnast performing a loading in response to changing surfaces.10 Due dismount, landing after a rebound of a basketball to large loads absorbed by the musculoskeletal player, or landing of a volleyball player after spiking the ball.3-6 This plays an important role in system upon landing, strategies to reduce and successful sports performance7,8 for it reduces control the reaction force must be initiated the total body momentum, absorbs impact load, before impact.10 Strategies including muscle and prevents injuries.9,10 It is also where most activation and segment kinematics before injuries, such as ankle sprain, occur. landing require synergistic work10,15 by multiple muscles and segments of the lower extremity In sports, landing occurs on stable and unstable specifically the hip and ankle16,17 to work in surfaces.11 The latter is defined as any surface synergy. The muscle activation pattern of the that is unsteady, not fixed or not firm.12 This can lower extremity during drop landing works for include trampolines, wobble boards13, foam11, absorbing the stress of the impact of landing and stabilization of the lower extremities to avoid 31

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) injuries.3,5 Improved muscle activation can Participants. The sample size was based on the provide stability, thus decreasing the risk for study conducted by Ambegaonkar, et.al.3 Fifteen injury to occur during landing.6,8,18-21 (15) physically active individuals within the age group of 18 - 25 years old24 from the University There is a relationship between the proximal and of Santo Tomas participated in the study. distal joints of our lower extremity.16,17 Following Physically active male or female individuals who the kinetic linking, ankle invertors, evertors, and participate in aerobic or anaerobic exercises for GMeds are responsible for movements and at least 1.5 – 3 hours a week were included in the stability in the frontal plane of the ankle joint. If study. An individual is excluded from the study if either the hip or the ankle presents with a he/she is a competitive athlete since they problem, the other is affected as well. One study undergo extensive training and participate in investigated the pre-fatigue and post-fatigue competitive physical activities or sports/games muscle activation pattern of the GMeds, ankle which require physical strength, agility, or evertors, and invertors during a lateral hop in stamina.25 These could all affect the data. The individuals with or without chronic ankle recruitment was administered in Room 134 at St. instability (CAI). It showed proximal and distal Martin de Porres Building, University of Santo muscle alteration in patients with CAI which is Tomas. attributed to a centralized feedforward mechanism developed from repetitive ankle A self-made screening tool was used to injuries.22 There were also studies on the effects determine the age and to classify whether they of chronic ankle sprain and functional instability were competitive athletes or not. The face on the activities of the TA, PL, gastrocnemius validity of the tool was done by showing it to lateralis, rectus femoris, vastus lateralis, and professionals and ten (10) random individuals to bicep femoris. These reported alteration in check if the tool was clear and valid. patterns of muscular activation of these muscles during landing, thereby increasing the risk of re- Physical Activity Readiness Questionnaire for injury of people with chronic ankle sprain.6,19 Everyone (2018 PAR-Q+) was used to determine the inclusion of the participant in the study. The Most studies on muscle activation of GMeds were previous and current health conditions of the done in either single-leg landings or lateral participants were determined using the same hops.21-23 Several studies used force plates also to tool in the study. This tool has an exceptionally gather the force generated by the muscles. good (r=0.99) reliability.26 Landing on a stable surface is also common in the literature. To the researchers’ knowledge, Outcome Measure. Surface electromyography there is no study yet that thoroughly discussed (sEMG) using the Trigno™ Surface EMG System the muscle activation of frontal plane muscles by Delsys® . was used to gather the muscle such as GMeds, TA, and PL during double leg activation pattern of GMeds, TA, and PL drop landing on stable and unstable surfaces. muscles.27 Muscle activation was calculated as a percentage of maximum voluntary isometric The purpose of this study is to compare the contraction (%MVIC). This allows the muscle activation pattern of the GMeds, TA, and assessment of the level of muscle activity of the PL during drop landing on stable and unstable task compared to the maximum activation surfaces. This study can establish a baseline in capacity of the muscle. According to a study by muscle activation pattern and future research for Benesch et.al28 which used EMG as a the prevention of ankle sprain. measurement tool for peroneal muscles, the coefficient of correlation (Spearman’s rho) METHODOLOGY between the peroneus brevis and days 1-5 was 0.67 (p=0.18) and for the PL 0.00 (p>0.999). Research Design. This is a cross-sectional study Procedures design that compared the mean percentage of muscle activation of the GMeds, TA, and PL of Reliability Testing Phase. Before the actual data physically active individuals during drop landing gathering, an interrater reliability testing was on stable and unstable surfaces. 32

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) done for the two assessors to ensure proper Adhesive tape was applied to the EMG surface placement of electrodes on the muscle of the electrodes for added security. subjects. The assessors made three (3) trials measuring the anatomical landmarks in After electrode placement, participants were millimeters based on the SENIAM protocol. asked to perform three (3) trials of maximum These were done on ten (10) random people. voluntary isometric contractions (MVIC) lasting for 3 seconds each with 30-second rest in- Recruitment Phase. After obtaining ethical between trials on GMeds, TA, and PL. The MVIC approval from the University of Santo Tomas served as the baseline to where the EMG College of Rehabilitation Sciences – Ethics activities during tasks were compared to. During Review Committee, the researchers recruited the MVIC of the GMeds, the participant was asked participants using flyers, word of mouth, and to abduct the leg against the wall. A goniometer social media platforms. Participants completed a was used to ensure that the leg is in 25˚ of self-made screening tool and the 2018 PAR-Q+ abduction.29 For the PL, the participant everted that determined their eligibility for the study. the ankle while the assessor applied manual resistance.30 For the TA, the participant inverted Data Gathering. The participants were informed the ankle in dorsiflexion while the assessor to wear cycling shorts, a shirt, and rubber shoes. applied manual resistance.30 The PL and TA The informed consent form was presented and measurements were done in a sitting position. explained by the assessors and the participants After the MVIC measurement, the participants were asked to read and voluntarily sign the form. were given a minute rest before the actual The assessors oriented the participants of the performance of the drop landing. The flow of the study. participants stood on a 30 cm high platform and were asked to perform the drop landing on a The correct drop-landing was demonstrated by cemented stable surface or a rubber mat. one of the assessors (See Figure 1). Starting position Initiation of drop landing Final position of drop landing Figure 1. Drop-landing technique. Participants were asked to perform three trials The rubber mat was made of a non-slid material until drop-landings were performed properly. and was one-fourth of an inch high. The areas of the skin to be tested were cleaned with isopropyl rubbing alcohol. The electrodes 33 were placed overlying the muscle bellies of the Gmeds, TA, and PL (See Table 1 for landmarks).

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) Table 1. Summary of electrode placement and participant Data were presented as group means ± standard position. deviations (SD) per muscle for each surface. The percentage of MVIC for each trial was computed. Muscle Anatomical Position of Wilcoxon Signed-Rank Test was used to analyze Gluteus landmarks and locating the the difference in the muscle activation of the medius reference line anatomical three muscles during drop landing on stable and landmarks unstable surfaces. The degree of difference Tibialis The percentage Sidelying between the two groups was determined using Anterior distance of 33.4 ± the effect size. The level of significance was set to 12.8% from the iliac Short sitting ɑ = 0.05. Peroneus crest to the greater Longus trochanter, starting Short sitting RESULTS from the greater trochanter (Rainoldi, Initially, forty (40) participants were recruited in et. al., 2004) the study. Out of the 40, nineteen (19) met the inclusion criteria. One of the participants backed The percentage out and three (3) did not respond to researchers difference of 15.5 ± after being contacted. A total of fifteen (15) 4.2% from the participants proceeded with the study. tuberosity of tibia to the inter-malleoli line, There were ten (10) males and (5) females with starting from the the mean age of 19.67 ± 1.6 years old. The mean tuberosity of tibia height is 165.3 ± 10 cm and the mean weight is (Rainoldi, et. al., 64.95 ± 13.49 kg. There were no statistically 2004) significant differences in the age, height, and The percentage weight variables of the participants (p > 0.05). distance of 17 ± 4% This means that the participants are from the head of homogenous at baseline. fibula to the lateral malleolus, starting from the head of fibula. (Rainoldi, et. al., 2004) Randomization using a flip coin method was Reliability Testing. There was an excellent used to determine the sequence of the landing agreement between the two assessors on the surface. The sequence was determined as electrode placement measurement of GMeds unstable, unstable, stable, stable, unstable, and (ICC= 0.97), TA (ICC = 0.98), and PL (ICC= 0.86). ending on a stable surface. This was done to There was no significant difference noted on the lessen the learning effect. Three trials11 were measurement of the landmark for electrode done, and each trial was documented using a placement of any of the three muscles among the smartphone simultaneously with sEMG. This assessors. enabled the researchers to synchronize the time of initial contact with EMG activity. Data Analysis. Multiple raters consistency, a Table 2. Mean and standard deviation for GMeds, TA and PL two-way mixed-effects model of intraclass electrode placement. correlation coefficient was used to determine the interrater reliability of the electrode placement. Mean ± SD (in cm) P value EMG signals were calculated using EMGWork Muscle RATER A RATER B Analysis software version 4 by Delsys® . (n=10) (n=10) Amplitude Analysis script was run at a Root Mean Square(RMS) window length of 0.125 GMeds 38.53 ± 3.5 38.86 ± 3.93 0.62 seconds with RMS window overlap of 0.0625 seconds to normalize the data and get the TA 47.48 ± 4.57 47. 95 ± 4.78 0.65 %MVIC. The %MVIC value corresponding to the time of initial contact of the foot upon landing PL 56.57 ± 5.51 56.29 ± 5.16 0.73 was recorded. 34

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) EMG Analysis. Figure 2 shows a representative stable and unstable surface. However, the mean EMG taken during the initial contact of the % MVIC of the GMeds is higher on the unstable participant. The red dot marks the normalized surface while the %MVIC of the TA and PL are %MVIC of TA at the initial contact of the foot on both higher in the stable surface. Small effect size the surface. was seen in both the GMeds and TA activation. Table 3 shows the summary of the %MVIC of the In the stable surface, the TA had the highest GMeds, TA, and PL during the initial contact of activation, followed by the PL and then the drop landing. GMeds. In the unstable surface, the GMeds exhibited the highest %MVIC, followed by the PL Results showed that there were no statistically and then the TA. significant differences in the muscle of GMeds, TA, and PL (p > 0.05) on both landings on a % MVIC 600 EMG Representation of TA during Drop Landing 500 0.5 1 1.5 2 2.5 3 Seconds 400 300 200 100 0 0 -100 Legend: - initial contact Figure 3. Sample normalized EMG of TA during drop landing Table 4. Percentage of MVIC during stable and unstable surface drop landing. Muscles Mean ± SD p-value Effect size CI (95%) GMeds Stable Surface Unstable Surface 0.69 0.30 -1.03,0.42 TA 0.26 0.28 -0.44,1.01 PL 29.46 ± 19.89 52.83 ± 105.01 0.23 0.17 -0.05,0.89 72.54 ± 121.76 44.06 ± 63.61 58.03 ± 69.33 47.83 ± 42.95 35

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) DISCUSSION drop jumps have been examined and results showed that increasing surface instability The primary findings of our study are as follows: decreases muscle activity.32 Another study (1) there was no significant difference between investigated the effects of surface instability on the EMG findings of the three muscles during muscle activity of leg muscles during drop jumps drop landing on stable and unstable surfaces; (2) and landings. Results showed decreased muscle the mean %MVIC activation of the GMeds is activity of the lower extremity during the pre- higher on an unstable surface; and (3) the mean activation phases of the drop jumps and landings %MVIC activation of TA and PL was lower on an when performed on an unstable surface.11 unstable surface. Decreased lower extremity muscle activity in the Muscle activation on the initial contact during TA and PL can be treated as a modified drop landing is important in reducing the total feedforward mechanism11 of the body for the body momentum, absorbing impact load, and unstable surface. The central nervous system stabilizing the lower extremity to prevent adjusts the mechanical properties of the injuries. The GMeds, TAs, and PL can stabilize the musculoskeletal system following the needs of hip and ankle10,15 and prevent possible injuries3 the body. During voluntary landing, the muscle such as ankle sprain. can alter itself from being spring to a damping unit.9 A highly stiff muscle will make it difficult Many sports take place on unstable surfaces11 and even impossible to absorb the ground which increases the need for necessary body reaction force. Meaning the decreased muscle modifications to minimize the reaction force activity can be associated with joint stiffness before impact.10 The GMeds controls the frontal regulation to modify for lower impact stress, plane stability by generating an abductor torque. caused by the damping of the landing as a The PL, with the TA, stabilizes the subtalar joint preventive measure.9,11 However, the decreased and prevents excessive rotation to maintain activity of the TA and PL during landing may balance during landing. The increased activation cause a considerably greater amount of force of GMeds on an unstable surface can be due to that will be absorbed by the knee. This can also the increased demand for stability. The increased cause alteration in the muscle firing on proximal activation is needed to make the lower limb muscles as an adaptation. If not rehabilitated, stable and in proper position upon landing and these can pose an additional injury risk. to prevent the excessive frontal plane destabilization brought about by the instability CONCLUSION of the surface. Activation of the GMeds will prevent the knee collapsing in valgus and thus Landing on an unstable and stable surface yields preventing injuries. no statistically significant differences in the muscle activation pattern of GMeds, TA, and PL. The decreased activation of TA and PL coincides However, the mean %MVIC of GMeds activation with the findings of several studies that reported is higher, while the mean %MVIC of TA and PL decreased muscle activity also of these muscles are lower on an unstable surface. The high during landing on an unstable surface.31,32 In a GMeds activation on an unstable surface can be a study that investigated the effect on the force compensatory mechanism to maintain stability output and muscle activity when subjected to on the lower extremity on landing, while the different surface conditions during isometric decreased activity of the TA and PLs can be the squats, it showed that there was a significantly neural mechanism of the body in absorbing the lower muscle activity when isometric squat was high impact force on the initial contact in performed on an unstable surface compared to a landing. Future studies may investigate the stable surface. Furthermore, the same study muscle activity of these muscles on patients with showed that squatting on an unstable surface has chronic ankle sprain. Since this study showed the equal or less benefit to improving or maximizing decrease in muscle activity on an unstable muscle activity during resistance training due to surface, it is suggested that future studies significantly lower muscle activity.31 In a more investigate this on patients with chronic ankle recent study, the effects of surface instability on neuromuscular activation of leg muscles during 36

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) sprain whose muscle activity may have Disclosure Statement decreased also. This can help clinicians change their approach in ankle rehabilitation. This paper is not funded by any Funding Agencies. Implication. This study showed that an unstable surface may not elicit a considerably high Conflicts of Interest amount of muscle activation on the ankle joint which initially absorbs the impact on initial The authors of this paper declare no conflicting contact in landing. The use of unstable surfaces interest. such as BOSU Ball and foam mats during exercises that promote and increase ankle References stability through co-activation of the frontal plane muscles may not be recommended in 1. Santello M, McDonagh MJ. The control of timing and preventing ankle injuries. The use of the unstable amplitude of EMG activity in landing movements in surface for increasing proprioception of the humans. Experimental Physiology: Translation and ankle may be considered but not when the Integration. 1998;83(6):857-74. purpose is to increase ankle stabilization. Stable surfaces are still preferred. 2. Kovacs I, Tihanyi J, Devita P, Racz LE, Barrier J, Hortobágyi T. Foot placement modifies kinematics and Limitation. The study is not without limitations. kinetics during drop jumping. Medicine and Science in First, the small sample decreases the power and Sports and Exercise. 1999;31:708-16. the generalizability of the results to the population. Second, the thickness of the unstable 3. Ambegaonkar JP, Shultz SJ, Perrin DH. A subsequent surface may play a big factor in the results. The movement alters lower extremity muscle activity and variability of the results of muscle activity in an kinetics in drop jumps vs. drop landings. The Journal of unstable surface in the literature may be due to Strength & Conditioning Research. 2011;25(10):2781- methodological differences especially on the type 8. of unstable surface used. Third, the kind of exercises that the participants engaged in were 4. Hackney JM, Clay RL, James M. Force-displacement not elaborated thus the difference in muscle differences in the lower extremities of young healthy strength of each participant was not taken into adults between drop jumps and drop landings. Human consideration. Movement Science. 2016;49:79-86. Recommendation. In line with the limitations of 5. Kulas AS, Schmitz RJ, Shultz SJ, Watson MA, Perrin DH. this study, few recommendations have been Energy absorption as a predictor of leg impedance in made for the continuing studies. First, the highly trained females. Journal of Applied electrode placement should be guided by a Biomechanics. 2006;22(3):177-85. musculoskeletal ultrasound to locate the muscle bellies accurately. The unstable surface that 6. Suda EY, Amorim CF, Sacco ID. Influence of ankle would be used should be thicker compared to the functional instability on the ankle electromyography one used in this study to put the body in a more during landing after volleyball blocking. Journal of unstable environment. Also, consider the lower Electromyography and Kinesiology. 2009;19(2):e84- extremity exercise regimen of the participants to 93. ensure that this will not affect the result of the EMG muscle activation pattern. 7. Esselman EM, Carpenter AL, Smith JD, Heise GD. Influence of Various Heights and Surfaces on Neuromuscular Strategies During Drop Landings. In: Proceedings of the American Society of Biomechanics Conference; 2012; Florida, USA. Available from http://w.asbweb.org/conferences/2012/abstracts/22 5.pdf Individual Author’s Contributions 8. Yeow CH, Lee PV, Goh JC. Effect of landing height on frontal plane kinematics, kinetics and energy K.S, K.D; Designed and performed experiments, dissipation at lower extremity joints. Journal of analyzed data and co-wrote the paper, Biomechanics. 2009;42(12):1967-73. supervised the research; R.S, S.A, S.C, R.D, R, E, I. F, A.G, L.S; Performed the experiment, analyzed 9. Dyhre‐Poulsen PO, Simonsen EB, Voigt M. Dynamic the data and co-wrote the paper. control of muscle stiffness and H reflex modulation during hopping and jumping in man. The Journal of Physiology. 1991;437(1):287-304. 37

PJAHS • Volume 4 Issue 1 2020 • (doi:10.36413/pjahs. 0401.008) 10. Zatsiorsky V, editor. Biomechanics in sport: 24. Waterman BR, Owens BD, Davey S, Zacchilli MA, performance enhancement and injury prevention. John Belmont Jr PJ. The epidemiology of ankle sprains in the Wiley & Sons; 2008. United States. JBJS. 2010;92(13):2279-84. 11. Prieske O, Muehlbauer T, Mueller S, Krueger T, Kibele 25. Laquale K. Nutritional needs of the recreational athlete. A, Behm DG, Granacher U. Effects of surface instability International Journal of Athletic Therapy and Training. on neuromuscular performance during drop jumps and 2009;14(1):12-5. landings. European Journal of Applied Physiology. 2013;113(12):2943-51. 26. Warburton DE, Bredin SS, Jamnik VK, Gledhill N. Validation of the PAR-Q+ and ePARmed-X+. The Health 12. Definition of UNSTABLE [Internet]. Merriam- & Fitness Journal of Canada. 2011;4(2):38-46. webster.com. 2020 [cited 16 July 2020]. Available from: https://www.merriam- 27. Gazzoni M, Celadon N, Mastrapasqua D, Paleari M, webster.com/dictionary/unstable Margaria V, Ariano P. Quantifying forearm muscle activity during wrist and finger movements by means 13. Kirby M. The effects of stable and unstable training of multi-channel electromyography. PloS one. surfaces on dynamic postural stability [Master’s 2014;9(10):e109943. Thesis]. Georgia, USA: Cedarville University; 2011. 28. Benesch S, Pütz W, Rosenbaum D, Becker HP. 14. Imai A, Kaneoka K, Okubo Y, Shiina I, Tatsumura M, Reliability of peroneal reaction time measurements. Izumi S, Shiraki H. Trunk muscle activity during lumbar Clinical Biomechanics. 2000;15(1):21-8. stabilization exercises on both a stable and unstable surface. Journal of Orthopaedic & Sports Physical 29. Simenz CJ, Garceau LR, Lutsch BN, Suchomel TJ, Ebben Therapy. 2010;40(6):369-75. WP. Electromyographical analysis of lower extremity muscle activation during variations of the loaded step- 15. Gross TS, Nelson RC. The shock attenuation role of the up exercise. The Journal of Strength & Conditioning ankle during landing from a vertical jump. Medicine Research. 2012;26(12):3398-405. and Science in Sports and Exercise. 1988;20(5):506-14. 30. Bhaskaran D. Effect of Tilted surfaces on Ankle 16. MacKinnon CD, Winter DA. Control of whole body Kinematics and EMG activities in landing [Master's balance in the frontal plane during human walking. Thesis]. University of Tennessee; 2010. Journal of Biomechanics. 1993;26(6):633-44. 31. McBride JM, Cormie P, Deane R. Isometric squat force 17. Gribble PA, Hertel J. Effect of hip and ankle muscle output and muscle activity in stable and unstable fatigue on unipedal postural control. Journal of conditions. Journal of Strength and Conditioning Electromyography and Kinesiology. 2004;14(6):641-6. Research. 2006;20(4):915. 18. Carcia CR, Martin RL. The influence of gender on 32. Lesinski M, Prieske O, Beurskens R, Behm DG, gluteus medius activity during a drop jump. Physical Granacher U. Effects of drop height and surface Therapy in Sport. 2007;8(4):169-76. instability on neuromuscular activation during drop jumps. Scandinavian Journal of Medicine & Science in 19. Li Y, Ko J, Walker MA, Brown CN, Schmidt JD, Kim SH, Sports. 2017;27(10):1090-8. Simpson KJ. Does chronic ankle instability influence lower extremity muscle activation of females during landing?. Journal of Electromyography and Kinesiology. 2018;38:81-7. 20. Kim K, Jeon K. Comparisons of knee and ankle joint angles and ground reaction force according to functional differences during single-leg drop landing. Journal of Physical Therapy Science. 2016;28(4):1150- 4. 21. Zazulak BT, Ponce PL, Straub SJ, Medvecky MJ, Avedisian L, Hewett TE. Gender comparison of hip muscle activity during single-leg landing. Journal of Orthopaedic & Sports Physical Therapy. 2005;35(5):292-9. 22. Webster KA, Pietrosimone BG, Gribble PA. Muscle activation during landing before and after fatigue in individuals with or without chronic ankle instability. Journal of Athletic Training. 2016;51(8):629-36. 23. Brazen DM, Todd MK, Ambegaonkar JP, Wunderlich R, Peterson C. The effect of fatigue on landing biomechanics in single-leg drop landings. Clinical Journal of Sport Medicine. 2010;20(4):286-92. 38

PJAHS • Volume 4 Issue 1 2020 • Special Research Article In gratitude for the PJAHS 2020 editorial board and reviewer Ivan Neil Gomez1,2, Anne Marie Aseron2 1Centerfor Health Research and Movement Sciences, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines; 2College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines Correspondence should be addressed to: Ivan Neil Gomez1,2; [email protected] Article Received: June 30, 2020 Article Published: August 15, 2020 (online) Copyright © 2020 Gomez. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Philippine Journal of Allied Health Sciences Supplementary Material (PJAHS) and our publisher, the College of S1_PJAHS_List_2020. Alphabetical List of Rehabilitation Sciences of the University of Santo PJAHS Editorial Board Members and Staff Tomas, extend our deepest gratitude to our editorial board and academic editors. They have graciously contributed to the journal’s peer- review process for the years 2019-2020. We recognize your selfless contribution in support of our aim to further research in the field of allied health science through the democratization of knowledge evidence by way of Open Access journals such as PJAHS. The names of the individual editorial board members, staff, and academic editors who performed excellent peer-review on the submitted manuscripts, some of which appear in this edition, appear in the supplementary file S1_PJAHS_List_2020. Your participation in the review process is duly recognized and appreciated. Thank you for embarking with us in this journey of informing and influencing allied health science clinical and research practice. We hope that our partnership continues to flourish and prosper in the future editions of PJAHS. Maraming Salamat po! 39

CALL FOR PAPERS (Regular Issue) The Philippine Journal of Allied Health Sciences (PJAHS), the official academic journal of the College of Rehabilitation Sciences- University of Santo Tomas is now accepting manuscripts to be reviewed for its upcoming Volume 4 Issue 2. PJAHS is an online Open Access peer-reviewed scholarly journal which encourages authors to publish original scholarly articles in the fields of physical therapy, occupational therapy, sports science, speech-language pathology, nursing, psychology, biomedical engineering, pharmacy, nutrition, education and other allied health sciences. PJAHS will consider submissions on the following topics: human biomechanics, exercise physiology, physical activity in pediatrics and geriatrics, ergonomics, physiologic profiling of athletes, sports injury monitoring and clinical practice patterns in the allied health sciences. PJAHS publishes original research, systematic reviews and meta-synthesis, short reports, and letters to the editor. Authors who wish to submit manuscripts for review can view the relevant information by visiting our journal website at https://pjahs.ust.edu.ph/. The deadline for submission for the upcoming regular issue is on October 31, 2020. Accepted manuscripts will be published by February 2021. For any inquiries, email us at [email protected]. 40

CALL FOR PAPERS (Special Section on “Health-Related Outcome Measures for the Filipino Population”) The Philippine Journal of Allied Health Sciences (PJAHS), the official academic journal of the College of Rehabilitation Sciences- University of Santo Tomas is now accepting manuscripts to be reviewed for the Special Section of its upcoming Volume 4 Issue 2. The Special Section shall be dedicated to “Health-Related Outcome Measures for the Filipino Population.” We will be accepting manuscripts with psychometric research study designs that reports on the development, reliability testing, validity testing and/or diagnostic testing of well-established health-related outcome measures (i.e. checklists, questionnaires, assessments, evaluation tools and methods, etc.) and its contextualization for the Filipino clientele. The author guidelines for submission shall be similar to that our regular issue. Authors who wish to submit manuscripts for review can view the relevant information by visiting our journal website at https://pjahs.ust.edu.ph/. The deadline for submission for the upcoming regular issue is on October 31, 2020. Accepted manuscripts will be published by February 2021. For any inquiries, email us at [email protected]. 41