Indian Association of Physiotherapist

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Editorial Access this article online Delivering high‑quality patient care Quick Response Code: using evidence‑based practice Tarang K. Jain, Sonia Rawal1 Website: We were at different time points need to first define what high‑quality patient www.pjiap.org invited for a brief discussion on the care is and how can we evaluate quality DOI: topic “How can health‑care professionals care in our health‑care settings. We need 10.4103/pjiap.pjiap_37_22 deliver high‑quality care to their patients.” to not only demonstrate the effectiveness Although physiotherapists provide care to of physiotherapeutic interventions but also Department of Physical patients in multiple health‑care settings, generate strong evidence that may influence Therapy and Athletic the concept of quality care is gaining more the perception of physiotherapeutic Training, College of attention in medicine and rehabilitation. care among multiple stakeholders. To Health and Human In the era of ever‑shrinking health‑care be able to do this, it is imperative that the resources and increased competition, we physiotherapy community must increase Services, Northern Arizona are always challenged to act in the best their engagement in describing, measuring, University, Flagstaff, interests of the patient while following the providing, and disseminating high‑quality principles of professional duty, excellence, patient care. Arizona, 1Stefani Doctor and accountability. As we started preparing of Physical Therapy for the discussion, we could not find formal Health‑care quality is a multidimensional quality care initiatives implemented in the concept and has evolved with time.[1] Despite Program, University of field of physiotherapy. Further, as we talked health‑care quality improvement issues Saint Mary, Leavenworth, more to colleagues and professionals in being described as early as 1860s, quality the field, I realized that the definition and health care remains a topic of discussion. Kansas, USA. understanding of quality care varied among The lack of a consistent definition and E‑mail: Tarang.Jain@nau. them and often therapists lacked knowledge clear conceptualization of quality care has on outcomes (such as clinical outcomes, affected our ability to provide high‑quality edu patient/caregiver satisfaction, costs, etc.) and health care. Merriam‑Webster’s Collegiate Submission: 23-06-2022 clinical practice components (effectiveness, Dictionary defines quality as how good or efficiency, patient‑centeredness, timeliness, bad something is, a characteristic or feature, Revision: 28-06-2022 equity, safety, etc.) that show the value a high level of value or excellence, and the Accepted: 29-06-2022 of physiotherapy care to multiple standard of something as measured against Published: 22-07-2022 stakeholders. If we are to demonstrate the other things of a similar kind.[2] In contrast to value of physiotherapy services to different the quality definition in lay terms, the term decision‑makers (government bodies, quality in health care has more broader and professional organizations, health‑care complex implications. For example, multiple professionals, patients, and their family stakeholders, such as patients, caregivers, members), we need to provide evidence physiotherapists, payers, or society may that physiotherapy care can deliver a better view patient care differently, leading to patient experience of care and improve different but overlapping perspectives on population health at affordable costs. quality patient care. In rehabilitation, the International Classification of Functioning, As we embark on establishing physiotherapy Disability, and Health framework is as an indispensable medical system and frequently utilized to assess domains providing quality care to our patients, we associated with functioning, health, and disability to assess patient‑centered This is an open access journal, and articles are distributed under the terms of the Creative Commons How to cite this article: Jain TK, Rawal S. Delivering Attribution‑NonCommercial‑ShareAlike 4.0 License, which high‑quality patient care using evidence‑based allows others to remix, tweak, and build upon the work practice. Physiother ‑ J Indian Assoc Physiother non‑commercially, as long as appropriate credit is given and the 2022;16:1-3. new creations are licensed under the identical terms. © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow 1

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Jain and Rawal: High-quality care using evidence-based practice care.[3] Allen‑Duck et al. recently analyzed the concept of the value of physiotherapy care is through economic health‑care quality and stated that “health‑care quality analysis (cost consequences, cost‑effectiveness, cost is the provision of effective and safe care, reflected in a minimization, cost–utility, and cost–benefit).[7] Although culture of excellence, resulting in the attainment of the difficult to perform health economic analyses in the optimal or desired outcome.”[1] fragmented Indian health‑care system, physiotherapists Since quality health care and associated outcomes should challenge themselves to collaborate with health are defined and measured by different stakeholders economists and provide comparative information on in different ways, it may be better to look at certain costs (direct and indirect), outcomes, risks/benefits attributes that characterize high‑quality patient care. associated with volume/intensity of physiotherapy Walker and Avant outlined four categorical themes service utilization (in short‑term as well as long‑term). for measuring the quality of patient care effectiveness, If physiotherapy community does not provide evidence safety, culture of excellence, and desired outcomes.[4] The to inform high‑quality care, we risk substandard clinical report described effectiveness as the use of equitable, care and stakeholders’ perception of physiotherapy consistent, and timely evidence‑based practices to being made on incomplete evidence. To ensure that provide the most beneficial interventions and procedures we produce sufficient evidence and continue to deliver to patients; safety as avoidance of environmental, high‑quality patient care, the Indian Association of physiological, and psychosocial injuries from care; culture Physiotherapy (IAP) and established educational of excellence as consideration of patients’ preferences institutions should collaborate and find ways to promote and ensuring that patients’ values, collaboration, and fund such research. communication, compassion, competence, advocacy, Not only IAP and established educational institutions respect, responsibility, and trustworthiness are included should lead this effort, but individual therapists could in the decision‑making for their care; and desired health also contribute and should collaborate with each other outcomes as engaging patients for goal achievement, toward promoting high‑quality patient care. We will the best possible results, shared decision‑making, need a collective effort of the physiotherapy community patient‑centered care, and patient satisfaction.[4] To to ensure that our patients get the best care. Although out ensure that physiotherapists are delivering high‑quality of scope for this editorial to describe research processes health care, they need to make sure that these attributes in detail, therapists can follow certain steps to establish are present in their health‑care delivery. Future research priorities and strategies to generate evidence for quality using these attributes, combined with the utilization care in their health‑care settings. of culturally appropriate condition‑specific functional 1. Identify the patient population and ask questions/ patient outcome tools, patient and caregiver satisfaction surveys, and cost assessment of care delivery may lead categorize evidence gaps in the literature about the to significant knowledge development in evidence‑based optimal patient care physiotherapy care, public safety, and trust. 2. Prioritize your clinical questions and identify the While searching for evidence for writing this editorial, we sequential way to answer those questions found many studies showing evidence reviews/efficacy 3. Identify collaborators, resources, and funding of physiotherapeutic interventions but could not find (if available) to generate evidence for high‑quality care any published study on demonstrating comparative 4. Share findings at the local, regional, and national effectiveness (pragmatic trials) or economic value of levels to implement the findings and disseminate physiotherapy care (value for money) in the current Indian research in relevant health‑care journals health‑care system. Physiotherapy community needs to 5. Work with local physiotherapy community, better describe their value to different stakeholders health‑care systems, and national physiotherapy and decision‑makers. Academicians in physiotherapy representative bodies to influence stakeholders and programs could partner with physiotherapists in physiotherapy practice. different health‑care settings to design more pragmatic Easier said than done but providing high‑quality patient and realistic real‑world studies and identify the care will challenge the status quo and requires therapists comparative effectiveness (benefits and risks) of different to restructure their approach toward providing patient physiotherapeutic interventions.[5] We can further care. If we are to achieve high‑quality patient care for demonstrate the value of physiotherapy by adding all, therapists will have to overcome their misaligned patient and stakeholders’ engagement in our studies. The financial incentives and ethical concerns by providing patient‑centered outcome research focuses on research substandard care. To better themselves as well as serve questions and outcomes that are meaningful to patients the physiotherapy profession, therapists will need to and caregivers, thus assisting multiple stakeholders in get actively involved in applying new knowledge, track their decision‑making.[6] An additional way to show patient outcomes, perform regular quality assurances, and continuously advocate for high‑quality patient care. 2 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Jain and Rawal: High-quality care using evidence-based practice Physiotherapists have the expertise and capabilities to World Health Organization; 2001. positively affect their patients and influence society’s health care/outcomes. 4. Walker L, Avant K. Strategies for Theory Construction in Nursing. 5th ed. Upper Saddle River, NJ: Pearson; 2011. References 5. Schneeweiss S, Seeger JD, Jackson JW, Smith SR. Methods for 1. Allen‑Duck A, Robinson JC, Stewart MW. Healthcare quality: comparative effectiveness research/patient‑centered outcomes A concept analysis. Nurs Forum 2017;52:377‑86. research: From efficacy to effectiveness. J  Clin Epidemiol 2013;66:S1‑4. 2. Staff MW. Merriam‑Webster’s Collegiate Dictionary. Springfield, Mass., U.S.A: Merriam‑Webster; 2005. 6. Lusk  JM, Fater  K. A  concept analysis of patient‑centered care. Nurs Forum 2013;48:89‑98. 3. World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: 7. Nixon J, Stoykova B, Glanville J, Christie J, Drummond M, Kleijnen J. The U.K. NHS economic evaluation database. Economic issues in evaluations of health technology. Int J Technol Assess Health Care 2000;16:731‑42. Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 3

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Review Article Access this article online Narrative review on effects of physical training on risk of cardiometabolic Quick Response Code: diseases Website: Richa Hirendra Rai, Vishal Mehta1, Sakhi, Mohd Asif2, Kajal Goyal2, www.pjiap.org Apoorva Balodhi2, Palak Manglik2 DOI: Abstract: 10.4103/pjiap.pjiap_1_22 Cardiometabolic diseases as defined by various expert bodies are a varied range of noncommunicable diseases that have slowly creeped in the community by inducing a dreadful combination of central School of Physiotherapy, adiposity, reduced insulin sensitivity, hypertension, and dyslipidemia which lead to cardiometabolic Delhi Pharmaceutical diseases, diabetes, renal disorders, and/or metabolic syndrome (MetS). Several authors have brought it to notice that alterations in lifestyle and environment leading to the disruption of circadian rhythm Sciences and Research trigger the pathophysiology leading to the development of multiple risk factors and cardiometabolic University, 2Banarsidas diseases. Statements very critically state that though MetS cannot be considered as an absolute risk indicator, patients with it are twice at the risk of developing cardiac ailment and at five times the Chandiwala Institute risk of developing insulin‑resistant diabetes in the near future. Collaboratively, be it WHO statement of Physiotherapy, New of 1999, “the National Cholesterol Education Program ATP3 2005,” or further ratification by “the Delhi, 1Department of International Diabetes Federation” 2006, “the American Association of Clinical Endocrinologist” 2003, Agricultural Statistics, “European Group for the study of Insulin Resistance,” “the European Society of Cardiology,” and College of Agriculture, the American College of Cardiology American Heart Association as discussed in this brief review, Acharya Narendra Deva all are continuously insisting on prevention and conducting awareness programs for the same. The University of Agriculture electronic database  (PubMed/MEDLINE, Embase, etc.,) was searched for available literature on and Technology, Ayodhya, different guidelines for exercise prescription ( Frequency, Intensity, Time, Type [FITT]) in January– April 2021. After reviewing the literature by different authors, a brief review was conceptualized from Uttar Pradesh, India the same. The different protocols suggested for health and fitness by different guidelines have been Address for presented here with the effect of physical activity discussed with literature support with respect to physiology, prevention, prophylaxis, and treatment. The burden of lifestyle disorders is increasing correspondence: tremendously and is also increasing the economic cost on society. It is high time that we understand Dr. Vishal Mehta, the seriousness and start observing the well‑stated advice offered by several guidelines over many Department of years and stay physically active. Keywords: Agricultural Statistics, Cardiometabolic diseases, fitness, guidelines, health, physical activity College of Agriculture, Acharya Narendra Deva Introduction which lead to cardiometabolic diseases, University of Agriculture diabetes, renal disorders, and/or metabolic Cardiometabolic diseases as defined syndrome (MetS). Several authors have and Technology, by various expert bodies are a varied brought it to notice that alterations Kumarganj, Ayodhya, range of noncommunicable diseases (NCD) in lifestyle and environment leading Uttar Pradesh, India. that have slowly creeped in the community to the disruption of circadian rhythm E‑mail: visdewas@gmail. by inducing a dreadful combination trigger the pathophysiology leading to of central adiposity, reduced insulin the development of multiple risk factors com sensitivity, hypertension, and dyslipidemia and cardiometabolic diseases.[1‑3] There Submission: 03-01-2022 are statements that very critically state This is an open access journal, and articles are that though MetS cannot be considered Accepted: 28-03-2022 distributed under the terms of the Creative Commons as an absolute risk indicator, patients Published: 22-07-2022 Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work How to cite this article: Rai RH, Mehta V, Sakhi,Asif M, non‑commercially, as long as appropriate credit is given and the Goyal K, Balodhi A, et al. Narrative review on effects of new creations are licensed under the identical terms. physical training on risk of cardiometabolic diseases. Physiother ‑ J Indian Assoc Physiother 2022;16:4-10. For reprints contact: [email protected] 4 © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Rai, et al.: Review on effects of physical training on risk of cardiometabolic diseases with MetS have twice the risk of developing cardiac grave situation, one should be all the more cautious ailment and are at five times the risk of developing as these statements are released with a disclaimer insulin‑resistant diabetes in the near future. Hence, that the thresholds should be made more sensitive collaboratively, be it WHO statement of 1999, “(the and this should be a continuous evolutionary process, National Cholesterol Education Program) ATP3 2005,” showing that with every passing decade the situation or further ratification by “International Diabetes is becoming all the more gloomy. Federation” 2006, “the American Association of Clinical Endocrinologist” 2003, “European Group for Impact of sedentary lifestyle on cardiometabolic the study of Insulin Resistance,” “the European Society risk of Cardiology (ESC),” and the American College The younger generation of society is slowly falling in of Cardiology American Heart Association all are the clutches of this dreaded syndrome which primarily continuously insisting on prevention and conducting originates from sedentary lifestyle and its associated awareness programs for the same. Ironically, the risk. With the change in lifestyle which has high screen experts worldwide, even after knowing the facts and time along with prolonged reclining posture, young practically visualising the serious consequences, are adults are going through several chronic stressors and still highly ignorant about the precise information in problems related to insomnia. This is making them prone the joint interim statements published from time to to develop autonomic system dysfunction in long run. time. Thus, an attempt has been made to discuss them Moreover, an unhealthy diet is also inducing obesity all together in this review. The various diagnostic additionally.[2,8‑12] It is more alarming than the COVID criteria are represented in Table 1.[4‑7] Visualizing the pandemic which has impacted the gross domestic Table 1: Diagnostic criteria for metabolic syndrome by different guidelines Guidelines by Year Diagnostic criteria Criteria Parameter Threshold WHO[5] 1999 Presence of insulin Abdominal obesity Waist/hip ratio >0.9 (men) or >0.85 (women) or BMI >30 kg/m2 resistance with any two or more of Insulin resistance WC ≥94 cm in men and others Glucose >6.1 mmol/L (110 mg/dl) 2 h glucose >7.8 mmol/L (140 mg/dl) (essential) Hypertension BP >140/90 mmHg Hyperlipidemia HDL‑C <0.9 mmol/L (35 mg/dl) in men HDL‑C <1.0 mmol/L (40 mg/dl) in women Triglycerides >1.7 mmol/L (150 mg/dl) NCEP ATP3[5] 2005 Presence of any Abdominal obesity WC >102 cm (men) or >88 cm (women) three or more of the following Insulin resistance Blood glucose >5.6 mmol/L (100 mg/dl) or drug therapy for elevated blood glucose Hypertension BP >130/85 mmHg or drug therapy for hypertension Hyperlipidemia HDL‑C <1.0 mmol/L (40 mg/dl) in men <1.3 mmol/L (50 mg/dl) in women or on drug therapy for low HDL Triglycerides >1.7 mmol/L (150 mg/dl) or drug therapy for elevated triglycerides IDF[5] 2006 Waist >94 cm Abdominal obesity Waist >94 cm (men) or >80 cm (women) (essential) (men) or >80 cm Insulin resistance (women) along with Blood glucose greater than 5.6 mmol/L (100 mg/dl) or diagnosed diabetes the presence of two Hypertension BP >130/85 mmHg or drug treatment for hypertension or more Hyperlipidemia HDL‑C <1.0 mmol/L (40 mg/dl) in men, <1.3 mmol/L (50 mg/dl) in women or treatment for low HDL‑C Blood triglycerides >1.7 mmol/L (150 mg/dl) or drug treatment for elevate trigylceride European 2016 To keep below the Abdominal obesity BMI >20-25 kg/m2 Guidelines on ranges to reduce cardiovascular the risk factor WC >94 cm in men and >80 cm in women disease Insulin resistance HbA1c >7% (>53 mmol/mol) prevention[36] Hypertension >140/90 mmHg Hyperlipidemia HDL‑C <40 mg/dL in men and <45 mg/dL in women Triglycerides >150 mg/dL ACC/AHA[7] 2019 A tally of 3 makes Abdominal obesity WC as≥40 inches (≥102 cm) in men and ≥35 inches (≥88 cm) in women (by the diagnosis ethnically appropriate cutpoints) along with BMI Insulin resistance HbA1c >6.5% Hypertension BP >130/80 mmHg Hyperlipidemia HDL‑C <40 mg/dL in men; <50 mg/dL in women Triglycerides >150 mg/dL, nonfasting NCEP: National Cholesterol Education Program, IDF: International diabetes federation, BMI: Body mass index, WC: Waist circumference, HDL: High‑density lipoprotein, HDL‑C: HDL‑cholesterol, HbA1c: Glycated hemoglobin, BP: Blood pressure, ACC: American College of Cardiology, AHA: American Heart Association Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 5

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Rai, et al.: Review on effects of physical training on risk of cardiometabolic diseases product globally, as this epidemic is increasing the It is astonishing to view the rising trend in adult burden and the cost of healthcare by hampering society’s BMI in a population‑based measurement study with physical, mental, social well‑being as well as affecting its 19.2 million participants conducted by NCD risk equity day by day. It has been concluded and suggested factor collaboration from the year 1975 to 2014. They by several authors that this needs continuous evaluation have suggested that if the same trend continued the and surveillance.[5] By the year 2015, it was predicted prevalence would surpass grave numbers in 2025 that an alarming number of “603.7 million adults and estimating them to reach 18% in males and over 21% 107.7 million children,” would have slowly fallen a prey in females and also further targeting the younger to this condition and as per the data suggested by the generation. It was reported in 2011 that South Asians author since 1980, the disease burden of obesity has also had high prevalence of MetS and another report in entrapped more than 70 countries and is still counting, 2012 suggested equally high prevalence of the same with the rate of increase observed more in childhood in American adults by quoting that almost one‑third obesity than in adult.[13] The consensus statement insisted of them had it already. Adding a word of precaution that abdominal obesity remains the most important here, that researchers have also identified some component of all the complex pathophysiologies causing metabolically active obese individuals and they claim MetS,[4] and according to the recent Center For Disease that these individuals do not develop more features Control and Prevention report, 38% of the US adults of this syndrome other than obesity.[5,23] However, were physically inactive and 50% of them have a Hb1c contradictory views coexist which state that no form >7.0% or higher.[14] of obesity is considered to be healthy and all obese It is jointly agreed that the major culprit in increasing are at risk of developing further morbidities[24-26] the prevalence of syndrome X noncommunicable considering the pro‑inflammatory state which exists. disorder is sedentary lifestyle, stress, and diet.[5,9‑11] As per the “WHO Global status report on NCDs 2010,” It is more prevalent in the urban population and is 3.2 million people surrender to death due to sedentary further affecting disability‑adjusted life years and lifestyle and have 20%–30% increase in risk for all‑cause increasing the burden on society as it causes further mortality, and as specified earlier, it is not only an risk of developing stroke, atherosclerosis, and other observation only in high‑income groups but also in life‑threatening disorders. Stress which is long term middle income and is most commonly observed in and becomes chronic slowly tends to disrupt the women.[27] hypothalamo–pituitary–adrenal axis and limbic system and induces a pro‑inflammatory state in the body and Data Source and Search Strategy impairs the quality of life. Moreover, the disruption of balance between the sympathetic and parasympathetic The electronic database (PubMed/MEDLINE, Embase, nervous system due to this state alters the various etc.,) was searched for available literature on different hormonal activities, leads to changes related to oxidative guidelines for exercise prescription (FITT) in Jan-April stress in the body, and also changes the dietary pattern. 2021. Four authors S, PM, AB, and KG conducted a All of these along with several other pollutants and literature search using keywords such as guidelines, stressors form a milieu which thrusts the chances of cardiometabolic risk, MetS, and recommendation. early mortality in an individual.[9,10,15‑17] Moreover, it Inconsistencies were verified by RHR, MA, and VM. has been admitted that it is no more the disease of the elite. Where the prevalence is increasing in the Western Study Selection and Screening countries at supersonic speed with the increase in the incidence of sedentary lifestyle and unhealthy diet, The included studies were only guidelines of reputed mimicking the west, the Asian men and women have organizations. The search was organized in discussion also demonstrated the greatest prevalence even though in the flow of physical inactivity and associated they had a lower body mass index (BMI).[14,18] It has been cardiometabolic risk as discussed by various authors, brought to notice that college‑going students who are effect of physical activity on the risk factors, regular considered to be moderate on physical activity level, physical training adaptations, and recommendations as objective measures in studies categorize these young per different guidelines. The PRISMA flow diagram also adults as having low level of fitness and are thus at high postulates information further inculcated in the selection risk of cardiometabolic diseases.[19‑21] process of studies [Figure 1]. As observed in various guidelines as well as suggested Information was gathered in an electronic spreadsheet by several authors, it is obesity and its related factors shared by the reviewers and included year‑wise such as diet, sleep, and physical inactivity which guidelines, diagnostic criteria, and physical activity need to be targeted to reduce the risk further.[4,5,18,20‑22] recommendations as shown in Tables 1 and 2. 6 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Rai, et al.: Review on effects of physical training on risk of cardiometabolic diseases Table 2: Recommendations as per guidelines to lower the risk of developing metabolic syndrome Guidelines and year of publication Physical activity Resistance training CSEP[40] 150 min per week moderate‑to‑vigorous aerobic exercise per At least twice a week for major week muscle group WHO recommendation for 18-64 Minimum 150-300 min of moderate‑intensity aerobic or 75-150 Major muscle group on two or more years[39] min of vigorous‑intensity aerobic throughout the week or a days a week combination of both. Minimum 10 min bout of exercise duration EAPC of the ESC 2016[37] 150-300 min a week moderate intensity or 75-150 min/week 8-12 reps at 60%-80% of 1 RM vigorous intensity, also accumulated in short bouts of at least minimum two times per week, 10 min to overall weekly goals balance and gait training 2019 ACC/AHA[7] 90-150 min of moderate exercise per week at 65%-75% of Dynamic resistance exercise heart rate reserve or 75 min of vigorous‑intensity aerobic 90-150 min/week, 50%-80% of 1 exercise per week Rep max CDC and prevention[41] At least, 150 min accumulated over a week moderate Intensity At least, twice a week or 75‑min vigorous intensity American Diabetes Association Moderate intensity, 3 days per week for 20-45 min to Yes 2019[38] accumulate to minimum of 150 min per week CSEP: Canadian Society for Exercise Physiology, EAPC: European Association of Preventive Cardiology, ESC: European Society of Cardiology, CDC: Center for disease control, ACC: American College of Cardiology, AHA: American Heart Association, 1RM: one-repetition maximum literature, and clinical review, the average quality of all the guidelines included was more than good. Study Characteristics and Discussion The primary aim of this narrative review is to enlist the different protocols suggested for health and fitness by different guidelines and the recommendations suggested by them. Finally, six major guidelines were identified and selected for this review. The procedure is depicted in the flowchart [Figure 1]. Figure 1: PRISMA flowchart Ekelund et al. collectively evaluated data from 14 studies with 20,871 children and young adults of the age 4–18 years Data Extraction and Study Quality from “the International Children’s Accelerometry Assessment Database.” By reanalysis of raw data obtained through accelerometry of the amount of time spent on physical The investigators (AB, PM, MA, and S) independently inactivity and moderate and vigorous physical activity, extracted key data from the included guideline in they concluded that time spent in moderate‑to‑vigorous a standardized template database, and the other exercise significantly associated with better cardiometabolic authors (KG, VM, and RHR) reviewed and validated the risk parameters, such as waist circumference, systolic extracted data. Peer discussions helped to remove the blood pressure (BP), high‑density lipoprotein cholesterol biasness; however, there was no blinding of reviewers and and insulin, independent of age, gender, sedentary time, journals. All the reviewers equally contributed scanning and waist circumference (when not used as outcome for guidelines and depicting the findings. As the data measure).[22,28] There are also other studies which reiterate from reputed guidelines were only included, which are that aerobic as well as aerobic plus resistance training conventionally based on unbiased and well‑documented reduces the prevalence of the development of MetS after 9 months of training and also caused reduction in MetS parameters such as waist circumference and systolic BP.[29] Authors have also seen better cardiometabolic profiles regardless of obesity or normal weight as an effect of involvement in regular physical exercise.[30,31] Campbell et al. conducted and represented one systematic review and two meta‑analyses between 2012 and 2017 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 7

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Rai, et al.: Review on effects of physical training on risk of cardiometabolic diseases having large number of studies in itself, after having is that with aging there is more risk of cardiometabolic searched around 260 articles, to conclude that there is “no disorders related to frailty and sarcopenia. This induces better effect of high‑intensity interval training (HIIT) than reduction in muscle power and increased visceral fat moderate‑intensity aerobic exercise on cardiometabolic and simultaneous reduction of myokines and increase in parameters in adults between the age of 20 and 77 years,” adipokines, respectively. These have also shown to have with moderate strength of evidence. However, they been positively impacted as dose‑dependent physical lamented that there is no specific definition for HIIT activity has shown reduction in morbidity and mortality in literature and to observe a significant effect on the even in elderly above the age of 70 years.[34] long‑term effectiveness on physiological mechanisms of Another mechanism postulated is the improvement the body and acceptability of a protocol, a clinical trial in β‑cell activity with exercise, which is otherwise should at least last for 6 months in duration. To be more compromised by overstimulation as a consequence specific, they found literature supporting improvement of impaired insulin sensitivity. This is studied by seen in normal‑weight individuals for cardiorespiratory various authors by analyzing the “Disposition cfiatnrdesisoamnedtVabOo2lmicax but not for the other factors signifying Index (DI = SI × acute insulin response to glucose.”[33] syndrome such as blood glucose Analyzing the seriousness of syndrome X, it was indices, BP, and anthropometric measures. However, discovered that all kinds of adipocytes were not same; patients in the overweight and obese category of BMI there were some which were brown, beige, and white. showed a significant improvement in both the indices Out of them, the cellular content of mitochondria which of BP and also body composition along with insulin varied in brown and beige adipocytes increased their sensitivity.[32] Moreover, physical activity has been found potential for thermogenesis with an increase amount of to be protective for reducing the risk for cancer as well adiponectin and thus having a positive effect on glucose as depression.[27] tolerance as well as β‑cell activity,[35] and thus, fat cells and their metabolic role are also equally important Exercise has over years demonstrated improvement in controlling MetS. Although there is still dearth of in insulin sensitivity with most of the time showing a literature and further elucidation is recommended, there dose–response relationship, though not always and also are also studies which have suggested that there are some not associated with aerobic fitness and improvement in myokines stimulated in an active muscle or after exercise VceOn2trmaaxl in certain studies. However, with the various which induces browning of fat and thermogenesis.[36] and peripheral adaptations happening with exercise, it has been reported that the role of increased Implications expression of insulin receptor substrate‑1 and GLUT4 Guidelines for physical activity: Prevention, translocation to sarcolemma and T tubules and thus prophylaxis, and treatment increase glucose uptake, as a consequence of deactivation of TBC1D1, is vital. Whereas, TBC1D4 phosphorylation Almost similar exercise prescription is advised by most causes its deactivation and activates the GLUT4 of the guidelines for physical activity as represented translocation postexercise, in both the cases the insulin in Table 2.[5‑7,14,37‑41] The Canadian Society for Exercise sensitivity increases. Physiology has asked one to remain active most of the time with limiting sedentary time to <8 hours/day and With regular physical training, this is a phenomena that interrupted by as many breaks in between. Moreover, happen at a continuous pace at rest in human body and it is equally important to take a good quality sleep of thus increases the insulin sensitivity even at rest.[33] The 7–9 h with consistent sleep and wake up timings.[40] This intramyocellular triglyceride concentrations are high in is definitely stressing on the sleep cycle and circadian both obese and after endurance training, but the insulin rhythm. sensitivity is different in both. Lipid intermediates, The “European Association for Cardiovascular namely diacylglycerols (DAGs) and ceramides, play Prevention and Rehabilitation” guidelines recommend a crucial role in this mechanism. Endurance athletes physical activity to lower the cardiovascular risk. “The generally have a high DAG content in comparison to European Association of Preventive Cardiology” of the physically inactive obese as well as normal‑weight ESC insists that a dose–response relationship exists and individuals. High‑ceramide content may disrupt the to set physical activity goals and self‑monitoring is of normal phosphorylation and activation mechanism and utmost importance along with behavioral strategies.[42] also affect GLUT4 translocation and thus affect insulin As shown in Table 2, most of the guidelines have sensitivity. However, physical training reduces ceramide resistance training added to the regime of aerobic levels and this plays a vital role on specifically “the exercise to improve insulin resistance. Most of the saturated fatty acid content (but not unsaturated fats) in skeletal muscle” and thus affects glucose tolerance.[33] Moreover, another aspect which draws attention here 8 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Rai, et al.: Review on effects of physical training on risk of cardiometabolic diseases recommendations also have the same guidelines for 7. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, adults who demonstrate the MetS criteria; however, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA Guideline on the once further complications develop they advocate to Primary Prevention of Cardiovascular Disease: A Report of the observe special precautions and further customization American College of Cardiology/American Heart Association of the exercise protocol. Task Force on Clinical Practice Guidelines. Circulation 2019;140:e596‑646. Conclusion 8. Singh  RB, Gupta  S, Dherange  P, De Meester  F, Wilczynska  A, The burden of lifestyle disorders is increasing Alam SE, et al. Metabolic syndrome: A brain disease. Can J Physiol tremendously and is also increasing the economic cost Pharmacol 2012;90:1171‑83. on the society. It is high time that we understand the seriousness and start observing the well‑stated advice 9. Levine AB, Levine LM, Levine TB. Posttraumatic stress disorder offered by several guidelines over many years and stay and cardiometabolic disease. Cardiology 2014;127:1‑19. physically active. 10. Kivimäki M, Pentti J, Ferrie JE, Batty GD, Nyberg ST, Jokela M, Furthermore, observing the variation in the different et al. Work stress and risk of death in men and women with and guidelines, there is a dire need to develop a common without cardiometabolic disease: A multicohort study. Lancet accurate as well as authentic monitoring criterion, for Diabetes Endocrinol 2018;6:705‑13. measuring the activity level of an individual so that its impact can be studied further. Moreover, this needs to 11. Pérez‑Torres  I, Soto  ME, Castrejón‑Tellez  V, Rubio‑Ruiz  ME, come as an obligatory measure from the government Manzano Pech  L, Guarner‑Lans  V. Oxidative, reductive, and and public health departments and monitored as a part nitrosative stress effects on epigenetics and on posttranslational of “Public Health Enforcement Majeure.” modification of enzymes in cardiometabolic diseases. Oxid Med Cell Longev 2020;2020:8819719. Financial support and sponsorship Nil. 12. Chau JY, Grunseit A, Midthjell K, Holmen J, Holmen TL, Bauman AE, et al. Sedentary behaviour and risk of mortality from Conflicts of interest all‑causes and cardiometabolic diseases in adults: Evidence from There are no conflicts of interest. the HUNT3 population cohort. Br J Sports Med 2015;49:737‑42. References 13. GBD 2015 Obesity Collaborators; Afshin  A, Forouzanfar  MH, Reitsma MB, Sur P, Estep K, et al. Health effects of overweight and 1. 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Sperling LS, Mechanick JI, Neeland IJ, Herrick CJ, Després JP, of cardiometabolic diseases: Prevalence and risk for mortality Ndumele CE, et al. The CardioMetabolic health alliance: Working from one million Chinese adults in a longitudinal cohort study. toward a new care model for the metabolic syndrome. J Am Coll BMJ Open 2019;9:e024476. Cardiol 2015;66:1050‑67. 17. Rao GHR. Cardiometabolic Diseases: A Global Perspective Type 2 4. Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Diabetes View Project; 2018. Donato KA, et al. Harmonizing the metabolic syndrome: A joint interim statement of the International Diabetes Federation 18. Palaniappan LP, Wong EC, Shin JJ, Fortmann SP, Lauderdale DS. Task Force on Epidemiology and Prevention; National Heart, Asian Americans have greater prevalence of metabolic syndrome Lung, and Blood Institute; American Heart Association; World despite lower body mass index. Int J Obes (Lond) 2011;35:393‑400. 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The treatment of acute and chronic heart failure: The Task Force for emergence of cardiometabolic disease risk in Chinese children the diagnosis and treatment of acute and chronic heart failure of and adults: Consequences of changes in diet, physical activity the European Society of Cardiology (ESC) Developed with the and obesity. Obes Rev 2014;15 Suppl 1:49‑59. special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129‑200. 22. Saunders TJ, Gray CE, Poitras VJ, Chaput JP, Janssen I, Katzmarzyk PT, et al. Combinations of physical activity, sedentary behaviour and sleep: Relationships with health indicators in school‑aged children and youth. Appl Physiol Nutr Metab 2016;41:S283‑93. 23. Wildman RP, Muntner P, Reynolds K, McGinn AP, Rajpathak S, Wylie‑Rosett J, et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: Prevalence and correlates of 2 phenotypes among the US population (NHANES 1999‑2004). Arch Intern Med 2008;168:1617‑24. 24. Ma  LZ, Sun  FR, Wang  ZT, Tan  L, Hou  XH, Ou  YN, et al. Metabolically healthy obesity and risk of stroke: A meta‑analysis of prospective cohort studies. Ann Transl Med 2021;9:197. 25. Twig G, Gerstein HC, Ben‑Ami Shor D, Derazne E, Tzur D, Afek A, et al. Coronary artery disease risk among obese metabolically healthy young men. Eur J Endocrinol 2015;173:305‑12. Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 9

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Rai, et al.: Review on effects of physical training on risk of cardiometabolic diseases 26. Ponikowski, PiotrVoors AA, Anker SD, Bueno H, Cleland JGF, 2014;54:89‑100. Coats AJS, Falk V, et al. 2016 ESC Guidelines for the diagnosis 36. Piepoli  MF, Hoes  AW, Agewall  S, Albus  C, Brotons  C, and treatment of acute and chronic heart failure. European Heart Journal 2016;37(27):2129–2200m Catapano AL, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task 27. Ekelund U, Luan J, Sherar LB, Esliger DW, Griew P, Cooper A, Force of the European Society of Cardiology and Other et al. Moderate to vigorous physical activity and sedentary time Societies on Cardiovascular Disease Prevention in Clinical and cardiometabolic risk factors in children and adolescents. Practice (constituted by representatives of 10 societies and by JAMA 2012;307:704‑12. invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & 28. Earnest  CP, Johannsen  NM, Swift  DL, Gillison  FB, Mikus  CR, Rehabilitation (EACPR). Eur Heart J 2016;37:2315‑81. Lucia A, et al. Aerobic and strength training in concomitant 37. American Diabetes Association. 7. Diabetes Technology: metabolic syndrome and type 2 diabetes. Med Sci Sports Exerc Standards of Medical Care in Diabetes‑2019. Diabetes Care 2014;46:1293‑301. 2019;42:S71‑80. 38. World Health Organisation. Global Recommendations on Physical 29. An SJ, Jung MH, Ihm SH, Yang YJ, Youn HJ. Effect of physical Activity for Health. WHO Press, World Health Organization, 20 activity on the cardiometabolic profiles of non‑obese and obese Avenue Appia, 1211 Geneva 27, Switzerland; 2010. subjects: Results from the Korea National Health and Nutritional 39. CSEP/SCPE Public Health Agency of Canada Queen’s Univeristy Examination Survey. PLoS One 2019;14:e0208189. Participation. Canadian – 24H Movement Guidelines – Adults 18‑64; 2020. 30. Dipietro L, Zhang Y, Mavredes M, Simmens SJ, Whiteley JA, 40. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Hayman LL, et al. Physical activity and cardiometabolic risk Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and factor clustering in young adults with obesity. Med Sci Sports treatment of acute and chronic heart failure: The Task Force for Exerc 2020;52:1050‑6. the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the 31. Campbell  WW, Kraus  WE, Powell  KE, Haskell  WL, Janz  KF, special contribution of the Heart Failure Association (HFA) of the Jakicic JM, et al. High‑intensity interval training for cardiometabolic ESC. Eur J Heart Fail 2016;18:891‑975. disease prevention. Med Sci Sports Exerc 2019;51:1220‑6. 41. How much Physical Activity do adults need? | Physical Activity | CDC. Available from: https://www.cdc.gov/ 32. Bird SR, Hawley JA. Update on the effects of physical activity physicalactivity/basics/adults/index.htm. [Last accessed on on insulin sensitivity in humans. BMJ Open Sport Exerc Med 2021 Mar 31]. 2016;2:e000143. 42. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Washington, DC, U.S: U.S. 33. Sinclair AJ, Abdelhafiz AH. Cardiometabolic disease in the older Department of Health and Human Services; 2018. person: Prediction and prevention for the generalist physician. Cardiovasc Endocrinol Metab 2020;9:90‑5. 34. Adamczak M, Wiecek A. The adipose tissue as an endocrine organ. Semin Nephrol 2013;33:2‑13. 35. Hofmann T, Elbelt U, Stengel A. Irisin as a muscle‑derived hormone stimulating thermogenesis – A critical update. Peptides 10 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Original Article Access this article online Translation of pain self‑efficacy questionnaire into Gujarati language Quick Response Code: and analysis of psychometric properties in subjects with Website: musculoskeletal pain www.pjiap.org DOI: Vidhi Paras Bhatt, Nehal Shah, Krishna M Bhrambhatt, Dharti Kapadia 10.4103/pjiap.pjiap_32_21 Department of Abstract: Orthopaedics, SBB BACKGROUND: Musculoskeletal disorders  (MSDs) are a leading cause of disability worldwide. College of Physiotherapy, Musculoskeletal conditions are typically characterized by pain which is often persistent and limits one’s V.S General Hospital mobility, dexterity, and functional ability, reducing people’s ability to work and participate in social Campus, Ahmedabad, roles with associated impacts on mental well‑being. The Pain Self‑Efficacy Questionnaire (PSEQ) is a 10‑item questionnaire, developed to assess the confidence of people with ongoing pain; in Gujarat, India performing activities with pain. The PSEQ scale is applicable to all persisting pain presentations. The study aims to translate PSEQ into Gujarati and analyze its psychometric properties in subjects Address for with musculoskeletal pain. correspondence: MATERIALS AND METHODS: Prior permission from the author was taken for the translation of Dr. Vidhi Paras Bhatt, PSEQ scale into Gujarati language. The translation procedure was carried out according to the No 8/B Veenakunj guidelines provided by the WHO with forward and backward translation. Thereafter to analyze the Society, Near Vastrapur psychometric properties of the scale, a total of 30 subjects (mean age of 45.43 ± 17.02) with different Railway Crossing, MSDs were enrolled in the study. The concurrent validity was obtained by establishing a correlation Opposite R. R Dwivedi between the Gujarati translated version of PSEQ (PSEQ‑G) and Visual Analog Scale (VAS). The High School, Vejalpur, intra‑rater reliability was established by test-retest method within a span of 2 days. The questionnaire Ahmedabad - 380 051, was again administered after 1 week by two different investigators to test the inter‑rater reliability. RESULTS: The concurrent validity was established with a moderate strength negative correlation Gujarat, India. between PSEQ‑G and VAS (r = -0.398, P < 0.05). The intra‑rater reliability was found between 0.887 E-mail: bhattvidhi068@ and 0.980 (intraclass correlation coefficient [ICC] = 0.955) and inter‑rater reliability was between 0.848 and 0.958 (ICC = 0. 917). There was a high internal consistency with Cronbach’s alpha 0.938. gmail.com Bland-Altman plot analysis was performed for PSEQ‑G scores between the two raters which showed agreement between the two scores within the limits of agreement with a 95% confidence interval. Submission: 07-11-2021 The linear regression showed no proportional bias. Revision: 15-05-2022 CONCLUSION: The results showed fair concurrent validity with a weak correlation between VAS Accepted: 17-05-2022 and PSEQ‑G scores  (Gujarati version of PSEQ) and excellent inter‑and intra‑rater reliability for PSEQ‑G in subjects with MSDs. Published: 22-07-2022 Keywords: Concurrent validity, Gujarati translated Pain Self‑Efficacy Questionnaire, inter‑and intra‑rater reliability This is an open access journal, and articles are Introduction distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which Musculoskeletal disorders (MSDs) are allows others to remix, tweak, and build upon the work one of the major causes of morbidity non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. How to cite this article: Bhatt VP, Shah N, Bhrambhatt KM, Kapadia D. Translation of pain For reprints contact: [email protected] self‑efficacy questionnaire into Gujarati language and analysis of psychometric properties in subjects with musculoskeletal pain. Physiother ‑ J Indian Assoc Physiother 2022;16:11-5. © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow 11

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt, et al.: Translation and psychometric analysis of PSEQ‑G and the second most common cause of disability majority of people communicate in Gujarati language. worldwide. The global prevalence of MSDs ranges The robust research on the psychological and behavioral from 14% to as high as 42%; on the other hand, in India, aspects of chronic pain arises a need for translation epidemiological studies indicate a community‑based of PSEQ in Gujarati for Gujarati population, which prevalence of about 20%.[1] The umbrella term of MSDs will prove helpful in objectifying the self‑efficacy and includes conditions such as neck pain, back pain, knee confidence in subjects with chronic MSDs for Gujarati pain, shoulder pain, and many other such etiologies. population. These etiologies bring in acute or chronic pain. The aim of the study is to translate the PSEQ scale into Gujarati  (PSEQ‑G) and to analyze the psychometric According to the international association for study of properties of PSEQ‑G in subjects with musculoskeletal pain (IASP) task force, pain is an “unpleasant sensory pain. and emotional experience associated with, or resembling that associated with actual or potential tissue damage.” Materials and Methods The pain can have a neuropathic, nociceptive, visceral, or autonomic origin. The nociceptive pain in many Before the commencement of the study, ethical clearance musculoskeletal conditions can be acute or chronic. was taken from the institute. Informed consent was taken The IASP defines chronic pain as a condition of pain from the subjects involved in the study [Table 1]. persisting for more than 3 months or after the actual A cross‑sectional study was carried out in the outpatient cause of pain is resolved.[2] Chronic pain is maintained in department setting, Physiotherapy Department of Suresh part by central sensitization, a phenomenon of synaptic Brahma Kumar Bhatt College of physiotherapy, Sardar plasticity, and increased neuronal responsiveness Vallabh Bhai Patel Hospital, Ahmedabad, Gujarat. The in central pain pathways after painful insults.[3] The study was conducted in two phases; phase 1 of translation components of pain perception are multidimensional followed by phase 2 of analysis of psychometric properties. and subjective in nature. These include perceptual, Initially, the scale was translated into Gujarati version. affective, cognitive, and behavioral.[4] For this, prior permission was obtained from the author Michael K. Nicholas et al. (pain management research The Pain Self‑Efficacy Questionnaire (PSEQ) is a clinical institute Sydney, Australia) of PSEQ scale. Thereafter, tool that measures self‑efficacy beliefs in subjects with the psychometric properties of the scale were analyzed. chronic pain. In PSEQ scale, the self‑efficacy beliefs in For this, subjects well acquainted with Gujarati language people with chronic pain were assessed either with and with the age group of 20–60 years were included reference to confidence in ability to perform specific in the study. Subjects with various MSDs such as tasks or with confidence in performing more generalized osteoarthritis (OA) knee, low back pain, sacroiliac joint constructs such as coping with pain. (SI) joint pain, adhesive capsulitis, bicipital tendinitis, and trapezitis, and chronic in nature with more than The PSEQ scale is applicable to all persisting pain 3 months were included in the study. The subjects unable presentations. The original version of PSEQ is in English to read and understand Gujarati language were excluded language. However, Gujarat is an Indian state where the from the study. Subjects with malignancy, pregnancy, lactation, cognitive impairment, and patients with TRANSLATION PSYCHOMETRIC ANALYSIS neurological disorders were excluded from the study. Pain Self‑Efficacy Questionnaire Permission from author for Followed By 30 subjects included The PSEQ is used to examine and assess self‑efficacy translation as per criteria beliefs in people with chronic pain. The scale consists of 10 items that were selected to reflect a wide variety of Forward translation Concurrent validity classes of activities and tasks, with indicative examples, (PSEQ-G and VAS) commonly reported as problematic by patients with Expert panel chronic pain. Backward translation Inter and intra rater The process of translation of PSEQ scale was carried out Pretesting and final version reliabity (test-retest in accordance with the guidelines of the WHO.[5] The translation and face validation of the PSEQ scale method) were done by following steps [Chart 1]. Chart 1: Procedural flow chart 12 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt, et al.: Translation and psychometric analysis of PSEQ‑G Step 1 – forward translation Steps for establishing concurrent validity For the forward translation of scale, a bilingual Gujarat For establishing concurrent validity, PSEQ‑G scale University accredited translator was approached who was compared with the standardized visual analog was conversant in both English and Gujarati language. scale (VAS). The scale was translated from English to Gujarati The VAS is a type of single‑item measure in which the language. patient indicates his or her quality of life on a line or scale, Step 2 – expert panel in which the anchors are usually “best possible quality of The scale was then given to an expert panel that life” and “worst possible quality of life.” VAS has been constituted of two orthopedic surgeons with more used in the measurement of health status and quality of than 10 years of experience and three senior physical life. When compared with other questionnaires assessing therapists working in the field of musculoskeletal health and quality of life, VAS showed high correlations rehabilitation with more than 10 years of experience. The with health perceptions scale (r = 0.70). The test‒retest panel was given the original as well as translated version reliability intra‑class correlation for the VAS was 0.87.[7] of the scale. Their inputs regarding the rectification and The analysis of psychometric properties was done by changes were provided which were put into the final recruiting 30 subjects with various MSDs such as OA version of the scale. knee, low back pain, SI joint pain, adhesive capsulitis, Step 3 – backward translation bicipital tendinitis, and trapezitis being chronic in the The scale was then backward translated from Gujarati to severity of more than 3 months. There were six subjects English by another translator who was blinded from the with OA knee, ten with trapezitis, one with SI joint original English version. Both the original and backward dysfunction, four with adhesive capsulitis, five with translated scales were compared by authors if there was bicipital tendinitis, and four with low back pain. any change in the original interpretation. The subjects were administered Gujarati translated PSEQ Step 4 – pretesting and final version preparation version along with VAS. In this step, a small population of 12 patients with various Reliability MSDs was administered the scale. They were asked To find the intra‑rater reliability, the test‒retest reliability to fill up the questionnaire and an in‑detail interview was assessed by administering the same scale to the was taken about how well they comprehended the same patient after 48 h. The inter‑rater reliability was components of the scale. The interview consisted of the determined by administering the scale to the same following questions. patient by other two different raters who were blinded • How well they understood the components of the by the initial readings after 1 week. The 1‑week time was elapsed to make sure the subjects do not remember scale their original scores. • If there was difficulty in interpretation about activities Statistical analysis The SPSS version 20 and Microsoft Excel 2007 were put into the scale? used to analyze the data obtained (statistical package • If they were able to score their self‑confidence at ease for the social sciences, SPSS version 20 by IBM, Bangalore). The concurrent validity was established on the scale anchors? with a negative correlation between PSEQ‑G and VAS They were to give a summed‑up impact on the clearness with Spearman’s correlation coefficient with data not of interpreted segments of scale. Their inputs were normally distributed. The intra‑and inter‑rater reliability regarded and the scale was modified accordingly. This were found with intraclass correlation coefficient (ICC). made the final version of Gujarati translated PSEQ Bland‒Altman test was applied to know the agreement scale (PSEQ‑G). between the scores of two different raters. The final version of PSEQ‑G was administered to 30 subjects with various MSDs. The respondents were Results asked to rate how confident they were that they can do each of the 10 activities or tasks at present despite Thirty patients participated in the study with the age the pain they were experiencing. Each item was rated of (45.43 ± 17.02) and with chronicity of pain (7.65 ± 5.67) by selecting a number on a seven‑point scale, where 0 having various MSDs. The severity of disease was equals “not at all confident” and 6 equals “completely recorded from VAS (4.95 ± 1.78). The gender distribution confident.” A total score was calculated by summing was 19 female and 11 male participants. There were six the scores for each of the 10 items, yielding a maximum possible score of 60. Higher scores reflect stronger self‑efficacy beliefs.[6] Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 13

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt, et al.: Translation and psychometric analysis of PSEQ‑G subjects with OA knee, ten with trapezitis, one with SI However, PSEQ has not been translated to Gujarati so far joint dysfunction, four with adhesive capsulitis, five with which is a local Indian language. The PSEQ scale has been bicipital tendinitis, and four with low back pain. originally developed to evaluate the self‑efficacy beliefs The concurrent validity was established with negative in patients with chronic pain. According to Bandura et al., Spearman’s correlation coefficient (r = ‒0.398, P < 0.05). This “self‑efficacy is defined as people’s judgments of their indicated a moderate strength negative correlation between capabilities to organize and execute courses of action VAS and PSEQ‑G.[8] The intra‑rater reliability was found required to attain designated types of performances.”[10] from 0.887 to 0.980 (ICC = 0.955) and inter‑rater reliability was from between 0.848 and 0.958  (ICC  =  0. 917). This Nicholas et al. described Self‑Efficacy Scale (the PSEQ) for showed good inter‑and intra‑rater reliability. There was people in chronic pain to take pain into account when rating a high internal consistency with Cronbach’s alpha 0.938. their self‑efficacy beliefs. The scale does not assess the ability A good correlation value does not signify a good of patient to do activities but rather how “confident” they agreement. Hence, the Bland‒Altman plot was plotted are in performing the activities in spite of pain.[6] between the PSEQ‑G scores of two different raters. The plot showed agreement between two different rater The results of the present study showed good concurrent scores of PSEQ‑G [Figure 1] with a mean of ‒0.8667 and validity of PSEQ‑G by moderate correlation with upper limit of 5.779 and lower limit of ‒7.513. The plot VAS (r = ‒0.39). The construct validity of the original showed scores to be within the limits of agreement (LOA) version of PSEQ was established with many health with a 95% confidence interval. assessing questionnaires such as Sickness Impact Linear regression analysis was done to ensure no PSEQ‑G Profile  (negative correlation) and Coping Strategies scores of one rater were higher or lower in proportion Questionnaire (positive correlation) that were significant to the scores of another rater (proportional bias). In in nature, unlike the present study that uses only VAS the analysis, the independent variable was the mean to establish concurrent validity. of two set of scores, whereas the dependent variable was the difference between two set of scores of two PSEQ‑G has an excellent inter‑and intra‑rater reliability different raters. The linear regression with P value of with a high Cronbach’s alpha of 0.938. This comes in 0.859 (P ≤ 0.05) showed no proportional bias.[9] concordance with the original English version of scale that has a high internal consistency with Cronbach’s Discussion alpha of 0.92. The Cronbach’s alpha was found at 0.93 in Chinese PSEQ,[11] whereas 0.88 in Portuguese PSEQ.[12] The present study aimed to translate the PSEQ into Gujarati language and to establish its psychometric The Bland‒Altman plot analysis showed a good properties. The PSEQ has been translated into Chinese, agreement between the two rater scores and within the Japanese, Dutch, Persian, and Portuguese languages. LOA with a 95% confidence interval. The present study has a limitation of smaller sample size compared to other versions such as Japanese PSEQ (n = 176) and Chinese PSEQ (n = 120). Furthermore, the present study validates Gujarati PSEQ with only VAS, unlike the other versions that compare with different Health Assessment Questionnaires. Future study Future studies should include a large sample size of patients with various MSDs. The Gujarati version Table 1: Minor changes suggested by the expert committee Item As mentioned in As mentioned in Changes made number English PSEQ Gujarati PSEQ by expert committee introduction Despite of pain દખુ ાવો પીડા Scale Not at all સંપૂરણ્ વિશ્વાસનથી બીલકુલ anchors confident 3 Socialize સામાજિકરણ હળવંમુ ળવંુ Figure 1: Bland–Altman plot analysis for inter‑rater Gujarati PSEQ scores. PSEQ: 10 Active સકર્ િય કાર્યશીલ Pain Self‑Efficacy Questionnaire PSEQ: Pain Self‑Efficacy Questionnaire 14 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt, et al.: Translation and psychometric analysis of PSEQ‑G of PSEQ can be validated with other quality of life Conflicts of interest questionnaires such as Pain Catastrophizing Scale, There are no conflicts of interest. Medical Outcome Study Short‑Form 36 (SF‑36), and SF McGill Pain Questionnaire. References Conclusion 1. Sharma R, editor. Epidemiology of Musculoskeletal Conditions in India. New Delhi, India: Indian Council of Medical Research; Gujarat is an Indian state where the majority of people 2012. communicate in Gujarati language. The translated version of PSEQ in Gujarati will help in objectively 2. Scholz  J, Finnerup  NB, Attal  N, Aziz  Q, Baron  R, Bennett  MI, defining the self‑efficacy beliefs and confidence of doing et al. The IASP classification of chronic pain for ICD‑11: Chronic activities despite pain in patients with chronic pain of neuropathic pain. Pain 2019;160:53‑9. Gujarati population. The PSEQ Gujarati version is a valid and highly reliable scale and very easy to administer in 3. Ji RR, Nackley A, Huh Y, Terrando N, Maixner W. clinical settings. The PSEQ Gujarati version can be also Neuroinflammation and central sensitization in chronic and useful in various research purposes. widespread pain. Anesthesiology 2018;129:343‑66. Acknowledgment The authors are very thankful to the original author 4. Umphred DA, Lazaro RT. Neurological Rehabilitation. St. Louis of English version of PSEQ, MK Nicholas et al. for his mosby: Elsevier Health Sciences; 2012. kind approval for translation of PSEQ into Gujarati language. The authors are very grateful to the patients 5. World Health Organization. Available from: https://www.who. who willingly participated in the study. The authors int/substance_abuse/research_tools/translation/en/. [Last provide sincere thanks to the expert panel member as accessed on 2021 Aug 30]. follows for sharing their knowledge and experience in the research work 6. Nicholas MK. The pain self‑efficacy questionnaire: Taking pain 1. Dr. Neel bhavsar (orthopedic surgeon) into account. Eur J Pain 2007;11:153‑63. 2. Dr. Tarkin amin (orthopedic surgeon) 3. Dr. Nipa shah (PT) (senior physiotherapist) 7. d e B o e r   A G , v a n L a n s c h o t   J J , S t a l m e i e r   P F , 4. Dr. Binal gajjar (PT) (senior physiotherapist) van Sandick JW, Hulscher JB, de Haes JC, et al. Is a single‑item 5. Dr. Komal shah (PT) (senior physiotherapist). visual analogue scale as valid, reliable and responsive as Financial support and sponsorship multi‑item scales in measuring quality of life? Qual Life Res Nil. 2004;13:311‑20. 8. Akoglu H. User’s guide to correlation coefficients. Turk J Emerg Med 2018;18:91‑3. 9. Giavarina  D. Understanding bland altman analysis. Biochem Med (Zagreb) 2015;25:141‑51. 10. Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Asian journal of social psychology; 1986. p. 23-8. 11. Lim HS, Chen PP, Wong TC, Gin T, Wong E, Chan IS, et al. Validation of the Chinese version of pain self‑efficacy questionnaire. Anesth Analg 2007;104:918‑23. 12. Ferreira‑Valente MA, Pais‑Ribeiro JL, Jensen MP. Psychometric properties of the portuguese version of the Pain Self‑Efficacy Questionnaire. Acta Reumatol Port 2011;36:260‑7. Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 15

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Original Article Access this article online Association of foot arch types with chronic low back pain among selected Quick Response Code: adults in Sri Lanka Shanaz F. Marikkar, Desha Rajni Fernando1, H. V. Yamuna Deepani Siriwardana2 Website: Abstract: www.pjiap.org BACKGROUND: Abnormal foot posture has been extensively discussed as a risk factor for chronic DOI: low back pain (CLBP). The present study aimed at assessing the association of foot arch types with 10.4103/pjiap.pjiap_6_22 CLBP in a selected population. METHODOLOGY: A descriptive study was conducted at the Department of Rheumatology and Spinal Cord Injury and Rehabilitation Clinic of National Hospital of Sri Lanka with employing a 100 of patients diagnosed with Rehabilitation Unit, CLBP (50 cases and 50 controls). The data were collected during December 1, 2019, and February Divisional Hospital 28, 2020. Foot arch type was detected using the arch index method. The modified Oswestry low back pain disability questionnaire was used to measure the disability level and Numerical Rating Wariaypola, 1Diabetes Scale (NRS) for pain. Chi‑square test and Pearson’s correlation tests were used for data analysis. Research Unit, RESULTS: Out of the patients with CLBP, 82% (n = 41) were with normal foot arch (NFA), 16% (n = 8) with low foot arch (LFA), and 2% (n = 1) with high foot arch (HFA). In the control group, there were Department of Clinical 94% (n = 47) with NFA, 4% (n = 2) with LFA, and 2% (n = 1) with HFA. Sample size was small to Medicine, Faculty of extract a significant P value for the observed difference between cases and controls with regard to the presence of LFA. The majority (66%) of the patients had severe disability followed with moderate Medicine, University of disability (28%), minimal disability (4%), and crippled (2%). A positive correlation was found between Colombo, 2Department disability level and the pain scale (P < 0.01). of Parasitology, Faculty CONCLUSIONS: Further research with large sample size is necessary to make firm conclusions of Medicine, University of on association of LFA type with low back pain. However, the pain and the disability level among the Colombo, University of patients with CLBP seems to be highly correlated. Keywords: Sri Lanka Chronic low back pain, foot arch types, low back pain, risk factors for low back pain Address for correspondence: Introduction low back pain (CLBP) is defined as pain in Mr. Shanaz F. Marikkar, the lower back that persists for 12 weeks or Spinal Cord Injury Lower back pain (LBP) is a highly longer.[7] It is also reported that the rural or and Rehabilitation prevalent musculoskeletal disorder.[1] suburbanized people are more prone to LBP Unit, Divisional The global point prevalence of LBP has been than urbanized people.[8] Hospital Wariyapola, estimated to be 9.4%[2] with considerably high Wariyapola, Sri Lanka. proportions of persons who experienced Treatment of low back pain presents E-mail: shanaz123mf@ LBP in different studies.[2‑4] Resultant a considerable challenge, as a specific health‑care costs and productivity loss are pathoanatomical diagnosis cannot be gmail.com also considered substantial.[5] The lower identified in most occasions.[5] The entire Submission: 18-03-2022 back includes the fifth vertebrae (L1‑L5) in human body acts as an integrated unit. Thus, the lumbar region, which supports much the lower back does not exist in isolation. Revision: 12-05-2022 of the weight of the upper body.[6] Chronic Alterations at any segment or body may Accepted: 13-05-2022 cause consequence in spine. A complex Published: 22-07-2022 This is an open access journal, and articles are array of risk factors is known to contribute distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Marikkar SF, Fernando DR, allows others to remix, tweak, and build upon the work Siriwardana YD. Association of foot arch types with non‑commercially, as long as appropriate credit is given and the chronic low back pain among selected adults in new creations are licensed under the identical terms. Sri Lanka. Physiother ‑ J Indian Assoc Physiother 2022;16:16-22. For reprints contact: [email protected] 16 © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Marikkar, et al.: Association of foot arch type with chronic low back pain to the condition, such as increased age, female sex, low studies, examination of different foot arches in patients educational status, obesity, occupation, and psychosocial with CLBP and healthy individuals would be assisted in factors. In addition to these well‑established risk factors, improving the methods of treating patients with CLBP. postural variations, such as decreased lumbar lordosis Further, a limited number of the latest world literatures and leg length inequality, have long been suspected to are available on explaining the mechanism and relation play a role in predisposition to low back pain by altering between foot arch and CLBP. Furthermore, there are the stresses placed on soft tissue structures around the no researches done in Sri Lanka to find the relationship spine. Abnormal foot posture and function have also between the foot arch type and CLBP. The present study been implicated.[5] Approximately 80% of the general aimed at comparing the types of foot arch between population have alterations in the feet.[9] Three types of patients with CLBP and healthy individuals and to foot arches have been described. They are low arch (flat identify the association between the disability score and feet; pes planus), normal arch (neutral foot), and high the score of numerical rating pain scale (NRS) of CLBP. arch (pes cavus).[10] A decrease in arch height leads to low arch (pes planus). The loss of arch height affects Methodology weight bearing of the foot, resulting in pain, irritation, Study setting or discomfort in the foot and other lower limb joints due to the synchrony in their biomechanics.[11] Hence, This hospital‑based case–control study was carried out unusual or prolonged stress in the foot can affect the in the general and special units of the Department of biomechanics and functioning of proximal joints, which Rheumatology and Rehabilitation (DRR) of National commonly translate into pain at the knee, hip, pelvis, and Hospital Sri Lanka (NHSL). This unit is the premier lower back.[11] Therefore, it is necessary to know whether clinical setting of the government for Rheumatology the feet are undergoing or generating changes which and Rehabilitation, in Colombo district as well as in Sri can ultimately lead to CLBP. Then, the hypothesis of the Lanka where the majority of patients with CLBP attend study was whether the changes in the height of the foot daily clinics. arch have an effect on the CLBP. Study sample Several authors suggest that individuals with low back Clinically diagnosed patients with CLBP aged between pain are more likely to have pes planus (low‑arched or 40 and 60 years were selected as cases. A consultant pronated) feet.[5] A retrospective study reported that rheumatologist diagnosed the patients for CLBP using those with moderate or severe pes planus (determined the ICD‑10 code. Patients with CLBP due to trauma by clinical observation) were almost twice as likely or other obvious mechanical causes, patients in a foot to report a history of intermittent low back pain.[5] In cast after a surgery, and patients with the presence contrast, evidence also indicated that those with low back of any spinal pathology and neuropathology and the pain were more likely to have a cavus (high‑arched or presence of any diagnosed pathology of back muscles supinated) foot posture.[5] Previously, some researchers other than CLBP were excluded. The control group have suggested that abnormalities such as flatfoot are included the gender‑ and age‑matched healthy persons associated with changes in gait and effects associated who accompanied patients to the DRR clinic in NHSL with lumbar region.[3] Despite this lack of evidence, an during the study period. Due to the limited resources association between foot posture, function, and low back and limited time constraint related to this undergraduate pain is biomechanically and physiologically plausible.[5] study, 50 subjects within the inclusion criteria were Several studies have surveyed the relationship between selected to each of the case and control groups. flatfoot and sometimes contradictory results were also Data collection obtained.[3] One of the latest studies conducted with The data were collected during December 1, 2019, pregnant women in the Nigerian community aimed at and February 28, 2020. An interviewer‑administered assessing the arch height index of and its correlation questionnaire was used. Participants who were filtered with foot pain, anterior knee pain, and LBP. They did through the inclusion and exclusion criteria were not find any relationship between foot arch heights and then selected for further investigations. Interview intensities of the foot, anterior knee, and lower back was conducted in a preferred language of the pain.[11] participant (either Sinhala or Tamil). A data collection Since a complex array of risk factors is known to be form consisted of questions on sociodemographic contributed to the condition, detecting the effect of foot features and clinical and diagnosis aspects of back pain. arch types on CLBP would be helpful in identifying the CLBP and impact of pain intensity on daily activities people at risk of CLBP; thereby, it would be easy for the were assessed according to the modified Oswestry low patients to seek for medical advice before achieving the back pain disability questionnaire (MODQ).  Cronbach’s severe disability level. With the evidence found in earlier Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 17

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Marikkar, et al.: Association of foot arch type with chronic low back pain α coefficient which is used to measure the reliability Each measurement was taken two times for each foot was 0.69 for the MODQ.[12] This was a self‑administered and the mean value was used for the analysis. According questionnaire that compromises of ten sections. Disability to the standard values for AI [Table 1], foot arches were score was calculated by evaluating the effect of pain on the categorized as high, normal, and low arch. The average personal care, lifting, walking, sitting, standing, sleeping, of the left and right feet was considered to classify the social life, traveling, and employment. Each question had foot arch type. to be marked on a five‑point Likert scale: 0 being no pain and 5 being the greatest pain when involved in activities. Data analysis The score of disability is the summation of rating scale. The data were analysed using the IBM Statistical The numerical rating scale (NRS) is the simplest and most Package for the Social Sciences (SPSS) trial version 24.0. commonly used numeric scale in which the individual Demographic characteristics of the study participants rates the pain from 0 (no pain) to 10 (worst pain).[13] The were presented with descriptive statistics. An association NRS was used to assess the pain at the data collection. between the foot arch types and two groups (cases and Intraclass correlation coefficient which used to test–retest controls) was assessed by Chi‑square test. A relationship the reliability was 0.991 for NRS.[14] between the disability score and the NRS was evaluated Determination of foot arch type with Pearson’s correlation test [Table 2]. To investigate the Foot arch type was detected using arch index  (AI) level of significance for this study was chosen at a P < 0.05. method. The type of foot arch was assessed using the AI method.[15] From the maximum peak pressure image Ethical clearance of the participant’s bipedal relaxed stance, AI was Ethical clearance was obtained under the undergraduate calculated as the ratio of the area of the middle third research study program, from the Ethics Reviewing of the foot print to the entire foot print area excluding Committee of the Faculty of Medicine, University of toes. Patients had to be in standing position (50% of Colombo, Sri Lanka. Written informed consent was bodyweight to each foot). Bilateral foot print was taken obtained before the recruitment. onto a graph paper using an easily removable ink and calculated the surface area in each third of foot [Figure 1]. Results Straight line was drawn between the center of the heel (K) and the tip of the second toe (J). Next perpendicular line The study employed a sample of 100 participants was drawn tangential to the most anterior point of the (n = 50 cases and n = 50 controls). The response rate main body of the foot print and their point of intersection was 100%. was marked (L). Then, the distance between L and K was equally divided into three parts. Finally, foot print was Demographic characteristics of the study divided as anterior, middle, and posterior parts. population AI = middle/(anterior + middle + posterior) The majority of the cases were female (n = 32, 64%). Gender distribution was similar among both cases and controls. The mean age of the CLBP group was AI = B/(A + B + C) Table 1: Arch index values for different foot arch types[16,17] Foot arch type Values for males Values for females High‑arched foot 0-0.171 0-0.157 Normal‑arched foot 0.172-0.294 0.158-0.286 Low‑arched foot 0.295-0.491 0.287-0.486 Table 2: Foot arch types between males and females among participants Foot arch type (%) Normal Low High Total Patients Females 24 (48) 7 (14) 1 (2) 32 (64) Males 17 (34) 1 (2) 0 18 (36) Total 41 (82) 8 (16) 1 (2) 50 (100) Controls Females 29 (58) 2 (4) 1 (2) 32 (64) Figure 1: Illustration of measuring foot arch type using AI method. AI: Arch Males 18 (36) 0 0 18 (36) Index[15] Total 47 (94) 2 (4) 1 (2) 50 (100) 18 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Marikkar, et al.: Association of foot arch type with chronic low back pain 52.94  years  (standard deviation  [SD], ±3.59) and 51.94 years (SD, ±4.16) in controls. The mean height and weight of the patients with CLBP were 157.62 cm (SD, ±5.16) and 64.16 kg (SD, ±7.31), respectively. In the control group, they were 157.26 cm (SD, ±5.03) and 62.48 kg (SD, ±7.09). No significance differences (P > 0.05) were found between the CLBP group and the control group with regard to the mean height and weight. Distribution of foot arch types of the study Figure 2: Frequency distribution of foot arch types among study participants participants Figure 3: Distribution of disability levels of chronic lower back pain among patients There were 82% (n = 41) of participants with normal with CLBP. CLBP: Chronic low back pain foot arch (NFA), 16% (n = 8) with low foot arch (LFA), and 2% (n = 1) of high foot arch among the patients with CLBP. There were 94% (n = 47) of participants with NFA, 4% (n = 2) with LFA, and 2% (n = 1) of high foot arch in the control group. Both cases and controls had NFA in majority. Foot AI values were not obviously different between left and right feet among patients with CLBP (P = 0.293). This was not different (P = 0.317) between left and right feet of the control group too. A clear difference was observed between cases and controls with regard to presence of LFA, though sample size was small to extract a significant P value (P = 0.091). However, the prevalence of LFA among cases was found to be significantly higher than that among controls (P = 0.04). LFA was more frequently observed among females in both patients and controls. There was no significant association between foot arch types with gender in patients with CLBP (P = 0.2307). The distribution of the calculated bilateral foot arch types of the two groups is shown in Figure 2. Distributions of disability levels and NRS among patients with chronic low back pain The mean value of the disability score of patients with CLBP was 22.88  (SD  +  5.89). Among the total 50 patients with CLBP, 4% (n = 2) had minimal disability, 28% (n = 14) had moderate disability, 66% (n = 33) had severe disability, and 2% (n = 1) were crippled [Figure 3]. Further, the mean numerical rating scale for pain (NRS) score for the patients with CLBP was 4.76 (SD, ±1.44). The correlation between back pain disability score and NRS was statistically significant (r = 0.54, P = 0.000) [Figure 4]. Table 3 describes the cross‑tabulation of foot arch types and disability level. Discussion Figure 4: Correlation between back pain disability score and NRS score in patients with CLBP. NRS: Numerical rating scale, CLBP: Chronic low back pain Aim of the study The aim of this preliminary study was to explore the Cases and control groups association between CLBP and types of foot arch in There were 50 patients with CLBP attended to the affected individuals. This study also aimed to identify the clinic at the DRR of NHSL. The control group of the association of severity of pain with a level of disability study included gender‑ and age‑matched healthy among the patients. Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 19

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Marikkar, et al.: Association of foot arch type with chronic low back pain Table 3: Frequencies of the types of foot arch related been observed in studies that measured the foot arch type to the levels of disability among patients with chronic in functional position.[5] Among the patients with CLBP, low back pain the females were predominantly higher (64%) than the males, indicating that the females are more susceptible Disability level of CLBP Foot arch type Total to CLBP than males. This finding was consistent with previous observations made in local and other study Normal Low High populations.[25‑28] The prevalence of CLBP in females may be attributed to various psychosocial factors such as less Minimal disability 2002 pain coping strategies, higher sensitivity, psychological distress, low economy, and less compliance to treatment. Moderate disability 13 0 1 14 Given the hormonal changes following menopause, females are more prone to have chronic diseases such Severe disability 26 7 0 33 as osteoporosis, osteopenia, and osteoarthritis which are identified as the risk factors for CLBP.[29] Crippled 0101 A complex array of risk factors is known to be contributed to the condition. Hence, detecting the effect of foot arch Total 41 8 1 50 types on CLBP would be assisted in identifying the people at risk of CLBP; thereby, it would be easy for the CLBP: Chronic low back pain patients to seek for medical advice before achieving the severe disability level. persons who accompanied patients to the DRR clinic in Level of disability NHSL during the study period. There was no obvious The level of disability (minimal, moderate, severe, difference in age among cases and controls. There was crippled, and bed‑bounded) among patients with no difference in height and weight among cases and CLBP was calculated according to the percentage scores controls also (P > 0.05). However, some other studies obtained in the Oswestry low back pain disability have indicated the significantly higher weight and body questionnaire (ODQ). No bed‑bounded patients were mass index of patients with CLBP when compared with found in this study as it was conducted among those the same in apparently healthy individuals.[18] This who physically attended the clinic. Instead of evaluating deviation may be due to the contrasting biopsychosocial the disability level of the patients with CLBP, most of factors of different study populations. the previous studies have reported only the disability scores out of 50 in the ODQ. Hence, it was difficult to Foot arch type and chronic low back pain place the findings of this study in the context of previous The present study found no significant association between literature. Observation of mean value of disability score deviated foot arch types with CLBP (P = 0.091). Some of 22.88 (SD + 5.89) in patients with CLBP was slightly other studies have also made similar observations,[5,11] exaggerated when compared with the previous research while a significant association of foot arch type and conducted among patients with CLBP worldwide,[30,31] CLBP had been reported at some other occasions.[3,19] A significant positive correlation was found between The interaction between bilateral foot posture and CLBP disability score and the NRS pain score (r = 0.54; lumbar‑pelvic alignment when standing was considered n = 50; P < 0.01), suggesting that pain and disability are as a cause for this. When the foot is experimentally made interrelated in CLBP. Similar observations have been into either low‑ or high‑arched position using wedges, made in the past.[32] Pain‑related fear and psychological there is an increased anterior or posterior pelvic tilt behavioral changes due to the low back pain might be which ultimately causes low back pain.[20] Large studies leading to limitations in activity levels or disability. including adequate sample sizes may provide more Results of the present study revealed no significant information. association between the foot arch type and the disability level of CLBP (P = 0.08), probably due to the reduced Furthermore, low‑arched foot type was more prevalent sample size. in patients with CLBP than among controls in this study. Similar results with small alterations and deviations Conclusions have been found among patients with CLBP in other studies.[3,21,22] This is explained in relation to biokinematic Further research with large sample size comprising factors in the human body. Previous studies have different geological locations, ages, both genders, and interpreted that there is a possibility of kinematic changes different ethnic groups in Sri Lanka are suggested to induced by low‑arched foot, which leads to increment in the already greater anterior pelvic tilt, thereby increasing the risk of the development of CLBP.[20,23] The increased anterior pelvic tilt leads to greater stress on lumbar pelvic region, thereby developing the low back pain.[24] The proportion of females with LFA (87.5%) was clearly greater than that of males (12.5%) among the patients with CLBP in the present study. All the measurements were taken in standing position. Significant associations of foot arch type with gender had 20 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Marikkar, et al.: Association of foot arch type with chronic low back pain make firm conclusions on association of LFA with Saleta Canosa JL, Bautista Casasnovas A, Tajes FA. The impact CLBP. There was no significant association between of foot arch height on quality of life in 6‑12 year olds. Colomb foot arch types and gender among patients with CLBP. Med (Cali) 2014;45:168‑72. The majority of CLBP patients had the severe level of 10. Sudhakar S, Kirthika SV, Padmanabhan K, Kumar GM, disability followed by the level of moderate disability. Nathan CV, Gopika R, et al. Impact of various foot arches on The pain and the disability level among the patients dynamic balance and speed performance in collegiate short with CLBP seems to be highly correlated. The majority distance runners: A cross‑sectional comparative study. J Orthop of the patients with CLBP sought treatment after 2018;15:114‑7. reaching the level of severe disability. Measures to raise 11. Ojukwu CP, Anyanwu EG, Nwafor GG. Correlation between foot awareness and motivational measures to encourage early arch index and the intensity of foot, knee, and lower back pain treatment‑seeking behaviors could also be suggested. among pregnant women in a South‑Eastern Nigerian community. Med Princ Pract 2017;26:480‑4. This was the first study done in Sri Lanka to evaluate 12. Baradaran A, Ebrahimzadeh MH, Birjandinejad A, Kachooei AR. the difference of the types of foot arch between CLBP Cross‑cultural adaptation, validation, and reliability testing of the patients and healthy people. Limitations in available time modified oswestry disability questionnaire in persian population and resources of this undergraduate study hindered the with low back pain. Asian Spine J 2016;10:215‑9. collection of data from a larger sample. Comparison of 13. Eliav E, Gracely RH. Measuring and assessing pain. In: Orofacial foot arch types of these groups with that of Asian and Pain and Headache. Philadelphia, PA: Elsevier Health Sciences; global populations will also be of value. 2008. p. 45‑56. 14. Yao M, Xu BP, Li ZJ, Zhu S, Tian ZR, Li DH, et al. A comparison Acknowledgment between the low back pain scales for patients with lumbar disc The authors would like to acknowledge the support herniation: Validity, reliability, and responsiveness. Health Qual given by the Research Stream of Physiotherapy Degree Life Outcomes 2020;18:175. Program of Faculty of Medicine, Colombo, special 15. Cavanagh PR, Rodgers MM. The arch index: A useful measure permissions granted by the director of NHSL, the from footprints. J Biomech 1987;20:547‑51. consultant rheumatologist of DRR of NHSL, and support 16. Murley  GS, Menz  HB, Landorf  KB. A  protocol for classifying given by the senior physiotherapist in DRR of NHSL. normal‑ and flat‑arched foot posture for research studies using clinical and radiographic measurements. J  Foot Ankle Res Financial support and sponsorship 2009;2:22. Nil. 17. Menz HB, Fotoohabadi MR, Wee E, Spink MJ. Visual categorisation of the arch index: A simplified measure of foot posture in older Conflicts of interest people. J Foot Ankle Res 2012;5:10. There are no conflicts of interest. 18. Durán‑Nah JJ, Benítez‑Rodríguez CR, Miam‑Viana EJ. Chronic low back pain and associated risk factors, in patients with social References security medical attention: A case‑control study. Rev Med Inst Mex Seguro Soc 2016;54:421‑8. 1. Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of 19. Bird  AR, Payne  CB. Foot function and low back pain. Foot low back pain. Best Pract Res Clin Rheumatol 2010;24:769‑81. 1999;9:175‑80. 20. Khamis  S, Yizhar  Z. Effect of feet hyperpronation on pelvic 2. Montgomery W, Sato M, Nagasaka Y, Vietri J. The economic and alignment in a standing position. Gait Posture 2007;25:127‑34. humanistic costs of chronic lower back pain in Japan. Clinicoecon 21. Cibulka MT. Low back pain and its relation to the hip and foot. Outcomes Res 2017;9:361‑71. J Orthop Sports Phys Ther 1999;29:595‑601. 22. Kosashvili  Y, Fridman  T, Backstein  D, Safir  O, Bar Ziv  Y. The 3. Amoozadeh  F, Kazemian  G, Rasi  AM, Kazemi  P, Safaeinik  F, correlation between pes planus and anterior knee or intermittent Khazanchin A. Surveying the relationship between flatfoot and low back pain. Foot Ankle Int 2008;29:910‑3. chronic mechanical low back pain. Age (year) 2014;13:57‑18. 23. Nguyen TH, Randolph DC. Nonspecific low back pain and return to work. Am Fam Physician 2007;76:1497‑502. 4. Warnakulasuriya SS, Peiris‑John RJ, Coggon D, Ntani G, 24. Levine D, Whittle MW. The effects of pelvic movement on lumbar Sathiakumar N, Wickremasinghe AR. Musculoskeletal pain in lordosis in the standing position. J Orthop Sports Phys Ther four occupational populations in Sri Lanka. Occup Med (Lond) 1996;24:130‑5. 2012;62:269‑72. 25. Karunanayake AL, Pathmeswaran A, Kasturiratne A, Wijeyaratne LS. Risk factors for chronic low back pain in a 5. Menz HB, Dufour AB, Riskowski JL, Hillstrom HJ, Hannan MT. sample of suburban Sri Lankan adult males. Int J Rheum Dis Foot posture, foot function and low back pain: The Framingham 2013;16:203‑10. Foot Study. Rheumatology (Oxford) 2013;52:2275‑82. 26. Thörneby A, Nordeman LM, Johanson EH. No association between level of vitamin D and chronic low back pain in Swedish 6. National Institute of Neurological Disorders and Stroke – National primary care: A cross‑sectional case‑control study. Scand J Prim Institutes of Health. Low back pain fact sheet for patients and the Health Care 2016;34:196‑204. public. J Pain Palliat Care Pharmacother 2004;18:95‑110. 27. Stewart Williams  J, Ng  N, Peltzer  K, Yawson  A, Biritwum  R, Maximova T, et al. Risk factors and disability associated with low 7. Chou R. Low back pain (chronic). BMJ Clin Evid 2010;2010:1116. back pain in older adults in low‑ and middle‑income countries. 8. Biglarian  A, Seifi  B, Bakhshi  E, Mohammad  K, Rahgozar  M, Results from the WHO Study on Global AGEing and Adult Health (SAGE). PLoS One 2015;10:e0127880. Karimlou M, et al. Low back pain prevalence and associated 28. J i m é n e z ‑ S á n c h e z S , F e r n á n d e z ‑ d e ‑ L a s ‑ P e ñ a s C , factors in Iranian population: Findings from the national health Carrasco‑Garrido P, Hernández‑Barrera V, Alonso‑Blanco C, survey. Pain Res Treat 2012;2012:653060. Palacios‑Ceña D, et al. Prevalence of chronic head, neck and 9. 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[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Marikkar, et al.: Association of foot arch type with chronic low back pain in the Autonomous Region of Madrid (Spain). Gac Sanit 31. Doualla  M, Aminde  J, Aminde  LN, Lekpa  FK, Kwedi  FM, 2012;26:534‑40. Yenshu EV, et al. Factors influencing disability in patients with 29. Kim  W, Jin  YS, Lee  CS, Hwang  CJ, Lee  SY, Chung  SG, et al. chronic low back pain attending a tertiary hospital in sub‑Saharan Relationship between the type and amount of physical activity Africa. BMC Musculoskelet Disord 2019;20:25. and low back pain in Koreans aged 50 years and older. PM R 2014;6:893‑9. 32. Grönblad M, Hupli M, Wennerstrand P, Järvinen E, Lukinmaa A, 30. Çalık Y, Aygün Ü. Evaluation of vitamin D levels in patients Kouri JP, et al. Intercorrelation and test‑retest reliability of with chronic low back‑leg pain. Acta Orthop Traumatol Turc the Pain Disability Index (PDI) and the Oswestry Disability 2017;51:243‑7. Questionnaire (ODQ) and their correlation with pain intensity in low back pain patients. Clin J Pain 1993;9:189‑95. 22 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Original Article Access this article online Effectiveness of neck flexors and extensors muscle strengthening Quick Response Code: exercises on pain and function in migraine patients Website: www.pjiap.org S. Priya, P. V. Abhilash, M. Gopika Sivasankaran DOI: Abstract: 10.4103/pjiap.pjiap_34_21 CONTEXT: Migraine is a primary episodic headache disorder, characterized by combinations of neurological, gastrointestinal, and autonomic changes in the body. Migraine patients are more likely Physiotherapy, Laxmi to self‑report neck pain, to have more cervical trigger points and tenderness over cervical muscles. Memorial College of Neck flexor and extensor muscles have shown decreased strength in migraine patients. Physiotherapy, Rajiv AIMS: To determine the effectiveness of neck flexors and extensors muscles strengthening exercises Gandhi University on pain and function in migraine patients. of Health Sciences, SETTING AND DESIGN: A  case–control study was conducted among 14 individuals of ages 20–30 years with Migraine in a Tertiary Care Hospital, India. Bengaluru, Karnataka, SUBJECTS AND METHODS: Fourteen migraine patients were selected for the study and neck flexor India and extensor strengthening exercises were administered for 4 weeks. The pain, cervical range of motion, and disability were measured using visual analog scale (VAS), universal goniometer, migraine Address for disability assessment score (MIDAS) before and after the intervention. correspondence: STATISTICAL ANALYSIS USED: Data were analyzed using SPSS v. 26.0. Values are expressed in terms of mean and standard deviation (X̅ ± SD). Statistical analysis to compare pre and post group Dr. M Gopika was done using paired t‑test. Sivasankaran, RESULTS: Paired t‑test was used to compare the interventions within the group. Statistical analysis Laxmi Memorial College showed significant improvement in pain and function on migraine patients after 4 weeks of treatment. of Physiotherapy, VAS (t = 6.358, P < 0.05), MIDAS (t = 3.798, P < 0.05), ROM (t = 5.014, 2.851, P < 0.05). CONCLUSION: The present study concluded that strengthening exercises of both neck flexors and Rajiv Gandhi extensors muscles reduced pain and improved function in migraine patients. University of Health Keywords: Sciences, Bengaluru, Migraine disorder, neck pain, strength Karnataka, India. Introduction of migraine pathophysiology, certain E-mail: gopikagopu188@ neuronal groups sensitization that is in the Migraine is a primary episodic headache brainstem leads to muscle sensitivity and gmail.com disorder characterized by neurological, allodynia causing muscle dysfunctions Submission: 12-11-2021 gastrointestinal, and autonomic changes in in craniocervical area, will trigger the body. The word migraine was derived migraine and increase their frequency. Revision: 20-05-2022 from a Greek word hemicrania.[1] The pathophysiology of migraine is not Accepted: 21-05-2022 completely understood.[3] Migraines are a Published: 22-07-2022 Migraine affects approximately 12% of complex neurovascular brain disorder that the world’s adult population.[2] As a part affects cortical, subcortical, and brainstem areas. During a migraine attack, carotid This is an open access journal, and articles are distributed under the terms of the Creative Commons How to cite this article: Priya S, Abhilash PV, Attribution‑NonCommercial‑ShareAlike 4.0 License, which Sivasankaran MG. Effectiveness of neck flexors and allows others to remix, tweak, and build upon the work extensors muscle strengthening exercises on pain non‑commercially, as long as appropriate credit is given and the and function in migraine patients. Physiother ‑ J Indian new creations are licensed under the identical terms. Assoc Physiother 2022;16:23-7. For reprints contact: [email protected] © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow 23

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Priya, et al.: Neck strengthening exercises in migraine patients vessels are dilated and vasoconstricting drugs are migraine patients using migraine criteria established effective treatments. by the International headache society, patients must have at least 5 headache attacks that lasted 4–72  h The prevalence of neck pain is 30%–50% in the general (untreated or unsuccessfully treated) and headache must population.[4] People with migraine are more likely to have at least 2 of the following characteristics: self‑report neck pain, have more trigger points (TrPs), 1. Unilateral location and tenderness over the cervical muscles. 2. Throbbing/pulsating 3. Worsening by movement Reports suggest that patients with neck pain will have 4. Moderate to severe intensity. weakness and fatigability. Among other factors that And any of the following: affect neck muscles performance, the pain has been 1. Nausea and vomiting considered important.[5] 2. Photophobia/phonophobia. We identify two measures to differentiate between Hence, if there is an improvement in neck muscle cervicogenic headache and migraine, there is reduced strength there will be a reduction of neck pain intensity range of rotation during Flexion– rotation test and neck and disability. flexion strength in patients with cervicogenic headache compared to those with migraine.[9] The muscular imbalance between the cervical extensors Fourteen patients with migraine were included in the and flexors can be negatively correlated with the study and the sample size was calculated to expect a mean stabilization of this region.[6] A feasible and practical difference of 8.8 in the migraine disability assessment measure to verify this imbalance in the ratio between the score (MIDAS) before and after treatment with a cervical muscles can be calculated based on the strength standard deviation (SD) of 5.9 assuming a 95% confidence and activity. It has shown a lower strength ratio between interval (CI), 90% power and 5% allowable error and was neck extensor and flexor muscles. estimated for the study is 14. From October 1, 2021, to October 3, 2021 convenience sampling technique was used According to international guidelines, the most effective to recruit the sample based on inclusion and exclusion treatment for migraine patients is pharmacological.[7] criteria. From October 04, 2021 patients were asked to do However, it is associated with various side effects, like neck flexor and extensor muscle strengthening exercises weight gain and adverse events such as cardiovascular for 4 weeks. On November 2, 2021, follow‑up were done disease. Therefore, the need of this study is to to measure the improvement in the outcome measures. reduce medication intake using nonpharmacological Patients with ages between 20 and 30, fulfilling migraine interventions like physiotherapy. criteria those who have episodic type of migraine, were selected for the study, and people suffering from tumors, A study conducted by Luedtke et  al., efficacy of underwent head‑ and neck‑related surgeries were interventions used by physiotherapists for patients with excluded from the study based on the exclusion criteria. headache and migraine, showed a significant reduction Patients relying on medication only during severe pain are in pain intensity, duration, and frequency in migraine included in this study thus by doing the regular neck flexor after physiotherapy interventions.[8] and extensor muscle strengthening exercises will help them to reduce the severity and number of attacks thereby Thus this study aims to determine the effectiveness of decreasing the medication intake and their side effects. neck flexor and extensor muscle‑strengthening exercise Other factors influencing biomechanical variations such as to reduce the intensity of pain, improve range of occupation, posture, time spend on mobile/computer, and motion (ROM), and function in migraine patients. number of pillow used while sleeping were recorded but posture, time spend on mobile/computer, and number of Subjects and Methods pillows used while sleeping cannot be recorded accurately as they vary each time depending on the convenience. All Study design and recruitment of patients participants were explained the intervention procedure A case–control study was conducted in a tertiary briefly and included in the study after written consent. care hospital, India. The study was approved by Outcome measures the “International Ethical Committee” (EC/NEW/ Patients with migraines were selected and cervical flexion, INST/2020/741). Moreover, this trial is registered extension ROM was measured using a goniometer, the under the clinical trial registry in India; members of the ethical committee include clinician, basic medical scientists, member/statistician, and legal expert. Dr. Priya S (Associate professor) and Dr. Abhilash PV (Associate professor) were involved in the diagnosis of 24 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Priya, et al.: Neck strengthening exercises in migraine patients pain was measured using a visual analog scale (VAS), interventions such as aerobic exercises, manual therapy, and disability was measured using MIDAS. All these and ultrasound therapy showed a reduction in migraine outcome measures are valid and reliable.[10‑12] Outcome frequency and intensity. Studies also show that there is measures are noted before and after the intervention. an imbalance in muscle strength over neck and shoulder Exercise intervention region but no studies succeeded in proving that neck Neck flexor and extensor strengthening exercises are flexors and extensors muscle strengthening exercises done for 4 weeks. The strengthening exercises include would reduce the frequency and intensity of pain and supine chin tuck, supine chin tuck with head elevation, improve in Rom and functions in migraine patients. prone head lift, forward isometric strengthening, Most of the migraine patients suffer more neck‑related backward isometric strengthening, neck extension in problems due to the same, thus this study proves that quadruped. Each exercise should be done with three strengthening of neck muscles especially flexors and sets, 15 repetitions. extensors is effective in reducing frequency and intensity Statistical analysis of pain, and improves ROM and functions in migraine Data were analyzed using  SPSS version. 26.0 (IBM Corp. patients. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp). values are expressed in The research hypothesis states that neck flexor and terms of mean and SD. Statistical analysis to compare extensor muscle strengthening exercises will reduce pre and post group was done using paired t‑test. The frequency, intensity of pain and improve ROM and test was applied 95% CI and a P < 0.05 is considered function in migraine patients. statistically significant. Thus this study will help the migraine patients to reduce Results migraine and neck‑related issues at home itself without spending much time and money and also helps them Fourteen patients were selected for the study and to reduce medications intake and their side effects. The treatment was administered for 4 weeks. The table people of the age group between 20 and 30 years are represents baseline and postinterventional data. The most commonly affected among them females are most result shows significant improvement in pain, function, commonly affected, hence this study was targeted on and ROM in people with migraines after 4 weeks of people between 20 and 30 years and people suffering treatment [Table 1]. with episodic type of migraine. The neck flexor and extensor muscle strength of migraine patients are Discussion reduced compared to the people without migraines. This raised the research question and the need to conduct the The study intended to determine the effectiveness of neck study to determine the effectiveness of the neck flexor flexors and extensors strengthening exercise on pain and and extensor muscles strengthening exercise on pain function in migraine patients. Various physiotherapy and function in migraine patients. Most of the migraine patients complained of self‑reported neck pain due to reduced muscle strength and also reduced cervical ROM Table 1: Effect in range of motion, visual analog scale and migraine disability assessment score before and after neck flexor and extensor muscle strengthening exercises Mean±SD (X̅±SD) t 95% CI of the difference Significance (P) Lower Upper Pair 1 Preflex 25.42±3.81 −1.92±1.43 5.01 2.75 1.09 0.000 Postflex 27.35±3.20 Pair 2 Preext 36.57±6.65 −3.64±4.78 2.85 6.40 0.88 0.014 Postext 40.21±3.66 Pair 3 Pre‑VAS 8.00±1.51 1.78±1.05 6.35 1.17 2.39 0.000 Post‑VAS 6.21±0.89 Pair 4 Pre‑MIDAS 10.50±6.95 3.85±3.79 3.79 1.66 6.05 0.002 Post‑MIDAS 6.64±4.58 Pair 1: Preflex and postflex ‑ Flexion before and after the intervention, Pair 2: Preext and postext ‑ Extension before and after the intervention, Pair 3: Pre‑VAS and post‑VAS ‑ VAS Scale before and after the intervention, Pair 4: Pre‑MIDAS and post‑MIDAS ‑ MIDAS Scale before and after the intervention. MIDAS: Migraine disability assessment score, VAS: Visual Analog Scale, CI: Confidence interval, SD: Standard deviation Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 25

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Priya, et al.: Neck strengthening exercises in migraine patients thus this study needs to find whether there is an increase A cross‑sectional study was done by Florencio et al., on in cervical ROM, reduced pain intensity, and improved neck pain and disability on the frequency of migraine function after the neck muscle‑strengthening exercise attacks and concluded that neck pain significantly adds are administered. Fourteen participants included to the overall disability of individuals with episodic and in the study had completed 4  weeks of neck flexors chronic migraines.[4] and extensors muscle strengthening exercises under supervision without fail. Limitations of the study This research, however, is subjected to limitations like We also record the factors such as occupation, time manual resistance given to each varied, elastic resistance spend in mobile/computer, posture, and number of such as therabands can be a better option than manual pillow used while sleeping but posture, time spend resistance which has not been administered. on mobile/computer, and number of pillows used while sleeping cannot be recorded accurately as they Conclusion vary each time depending upon the convenience of the patients. The participant was asked to alter the The present study concluded that strengthening exercise possible biomechanical factors such as the time spend of both neck flexors and extensors muscles reduced in mobile/computer, maintaining a proper posture, and pain intensity, improved cervical flexion and extension reducing the number of pillows used while sleeping, but ROM, and increased function in migraine patients. As there is no proper evidence that biomechanical factors the intensity of migraine decreases the people depending would influence the migraine patients. on medication during severe pain also decreases hence reducing medication intake. The significance of the The outcome measures like the pain were measured study was to decrease the use of medication intake in using a VAS, cervical ROM was measured using a migraine patients. goniometer, and disability was measured using MIDAS. Acknowledgment The study showed that the neck flexors and extensors The authors acknowledge Dr. Manjula Suvarna, muscle strengthening exercises administered for 4 weeks Assistant professor/statistician for her contribution was effective in reducing pain intensity, improving toward sample size calculation, data analysis, and cervical ROM and function in migraine patients. interpretation. I would like to extend my thanks to my parents and all those who have provided immense help A study done by Benatto et  al. on neck‑specific and guidance for the completion of this work. strengthening exercise compared with sham ultrasound when added to home stretching exercise in patients with Financial support and sponsorship migraine concluded that a neck‑specific exercise program Nil. may be effective in reducing the frequency and intensity of migraine attacks.[13] Conflicts of interest There are no conflicts of interest. A study was done by Luedtke et al. on neck treatment compared to aerobic exercise in migraine.[6] The study References concluded that both groups showed small reductions in headache frequency. Patients with pain referred to 1. Silberstein SD. Migraine. Lancet 2004;363:381‑91. the head responded best to physiotherapy intervention. 2. Bevilaqua‑Grossi D, Gonçalves MC, Carvalho GF, Florencio LL, A study was done by Luedtke and Gabler on the Dach F, Speciali JG, et al. Additional effects of a physical therapy Effectiveness of physiotherapy on intensity, duration, protocol on headache frequency, pressure pain threshold, and frequency, and quality of life on migraine and improvement perception in patients with migraine and associated concluded that Physiotherapeutic modalities such as neck pain: A randomized controlled trial. Arch Phys Med Rehabil different manipulative/mobilization techniques, TrP 2016;97:866‑74. therapy, lymphatic drainage, traditional massage, 3. Deneris A, Rosati Allen P, Hart Hayes E, Latendresse G. Migraines and stretching/strengthening techniques included in in women: Current evidence for management of episodic and this review seemed to be beneficial for investigated chronic migraines. J Midwifery Womens Health 2017;62:270‑85. outcomes for migraineurs.[14] Physiotherapeutic 4. Florencio  LL, Chaves  TC, Carvalho  GF, Gonçalves MC, treatment could enhance the effects of medical Casimiro EC, Dach F, et al. Neck pain disability is related to the treatment and may result in lowering the economic frequency of migraine attacks: A cross‑sectional study. Headache burden of migraine. 2014;54:1203‑10. 5. Tolentino GA, Bevilaqua‑Grossi D, Carvalho GF, Carnevalli AP, Dach F, Florencio LL. Relationship between headaches and neck pain characteristics with neck muscle strength. J Manipulative Physiol Ther 2018;41:650‑7. 6. Luedtke K, Starke W, Korn K von, Szikszay TM, Schwarz A, 26 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Priya, et al.: Neck strengthening exercises in migraine patients May A. Neck treatment compared to aerobic exercise in migraine: in a population‑based sample of headache sufferers. A preference-based clinical trial. Cephalalgia Rep 2020;3:1-9. Cephalalgia 1999;19:107‑14. 7. Benatto MT, Florencio LL, Bragatto MM, Lodovichi SS, Dach F, 11. Audette I, Dumas JP, Côté JN, De Serres SJ. Validity and Bevilaqua‑Grossi D. Extensor/flexor ratio of neck muscle strength between‑day reliability of the cervical range of motion (CROM) and electromyographic activity of individuals with migraine: device. J Orthop Sports Phys Ther 2010;40:318‑23. A cross‑sectional study. Eur Spine J 2019;28:2311‑8. 12. Begum R, Hossain MA. Validity and reliability of visual 8. Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions analogue scale(VAS) for pain measurement. J Med Case Rep used by physiotherapists for patients with headache and Rev 2019;16:87-101. migraine‑systematic review and meta‑analysis. Cephalalgia 13. B e n a t t o   M T , F l o r e n c i o   L L , B r a g a t t o   M M , D a c h   F , 2016;36:474‑92. Fernández‑de‑Las‑Peñas C, Bevilaqua‑Grossi  D. Neck‑specific 9. Anarte‑Lazo  E, Carvalho  GF, Schwarz  A, Luedtke  K, Falla  D. strengthening exercise compared with sham ultrasound when Differentiating migraine, cervicogenic headache and asymptomatic added to home‑stretching exercise in patients with migraine: individuals based on physical examination findings: A systematic Study protocol of a two‑armed, parallel‑groups randomized review and meta‑analysis. BMC Musculoskelet Disord controlled trial. Chiropr Man Therap 2020;28:22. 2021;22:755. 14. Gabler T, Lüdtke K. Effectiveness of physiotherapy on intensity, 10. Stewart  WF, Lipton  RB, Kolodner  K, Liberman  J, Sawyer  J. duration, frequency and quality of life on migraine–systematic Reliability of the migraine disability assessment score review.Res Gate 2020;47:1-29. Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 27

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Original Article Access this article online Correlation between presence of Lumbar Instability, Physical function Quick Response Code: and Balance in subjects with knee osteoarthritis: An observational Study Website: www.pjiap.org Urmi Bhatt, Yagna Shukla1 DOI: Abstract: 10.4103/pjiap.pjiap_11_21 BACKGROUND AND OBJECTIVES: Osteoarthritis (OA) of the knee is one of the most common musculoskeletal disorders that increase the global health burden. Various research aimed to improve PhD Scholar at pain and physical functions in individuals with OA knee have been conducted. However, there is a Gujarat University and dearth of research evaluating coexisting lumbar instability and its impact on physical function limitation and risk of fall in individuals with knee OA, while there is a pool of research on kinetic chain evaluation Associate Professor including lumbar spine for the athletic population for injury prevention. in Musculoskeletal METHODOLOGY: Twenty‑two individuals with OA knee, aged 50–65 years (male or female) willing to participate in the study were included in the study. Demographic details including age, body Department of C U Shah mass index (BMI), and duration of knee pain were recorded. All the individuals were screened for Physiotherapy College, the presence of lumbar segmental instability (using passive lumbar extension test), balance (using Saurashtra University, Dynamic Gait Index), and physical function using mWOMAC. Surendranagar, 1PhD RESULTS: Data were analyzed using SPSS. There were significantly greater (P < 0.05) deficits (Physiotherapy), Senior in balance and function of individuals with the presence of clinical lumbar segmental instability. In Lecturer, Government addition, BMI and duration of knee pain also correlated positively with balance and function deficits Physiotherapy College, in all individuals. CONCLUSION: The presence of lumbar segmental instability in individuals with OA knee puts them Ahmedabad, Gujarat, India at greater risk of falls due to altered balance and limits functional ability as well. Address for Keywords: Balance, knee osteoarthritis, lumbar instability, physical function correspondence: Dr. Urmi Bhatt, Introduction Nonsurgical management of knee OA as recommended by OA Research Society “Madhav”, Street No. 6, Osteoarthritis (OA) is a degenerative International includes biomechanical Behind Nilkanth Mahadev musculoskeletal disorder that intervention, patient education, strength commonly affects weight‑bearing joints training, and weight management as the Mandir, Joravarnagar, of the lower limb, especially the hip most appropriate therapy to manage the Surendranagar, and knee joints. OA is characterized by symptoms of knee OA.[2] Gujarat, India. pain, stiffness, and loss of normal joint function due to progressive cartilage Most individuals with knee OA manage E‑mail: urmibhatt.87@ destruction, osteophyte formation, and locomotive activities by compensatory gmail.com joint inflammation. OA of the knee is changes in gait, posture, and transfer a leading cause of pain and locomotor activities.[3] These adaptations appear to Submission: 14-06-2021 disability in the elderly population.[1] reduce the loading of painful arthritic Revision: 16-05-2022 limb and allows the individual to cope Accepted: 17-05-2022 This is an open access journal, and articles are distributed under the terms of the Creative Commons How to cite this article: Bhatt U, Shukla Y. Published: 22-07-2022 Attribution‑NonCommercial‑ShareAlike 4.0 License, which Correlation between presence of Lumbar Instability, allows others to remix, tweak, and build upon the work Physical function and Balance in subjects with knee non‑commercially, as long as appropriate credit is given and the osteoarthritis: An observational Study. Physiother ‑ J new creations are licensed under the identical terms. Indian Assoc Physiother 2022;16:28-32. For reprints contact: [email protected] 28 © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt and Shukla: Lumbar instability, physical function, and balance in knee OA with activities of daily living.[4] At the same time, these is a self‑administered questionnaire, that comprises adaptations, appear to increase the mechanical cost of 24 questions divided into three subscales: Pain  (five ambulation, fall risk, and loading of the proximal joints.[5] items), stiffness (two items), and physical function (17 Individuals with knee OA frequently suffer from chronic items). Each question is scored on a scale of 0–4, which low back pain, which seems to be secondary to adaptive corresponds to none (0), mild (1), moderate (2), severe (3), changes in locomotive activities. Any chronic low back and extreme (4). The mWOMAC takes <10 min to pain, without an obvious history of trauma or exact complete and can be taken on paper or over the telephone cause, is frequently caused by underlying segmental or computer. Higher the scores on mWOMAC, worse the instability.[6,7] Lumbar segmental instability, mechanical pain and functional limitations.[11] or functional has been shown to be an important risk Assessment of balance was done using the Dynamic factor for injury and predictor of poor performance in Gait Index (DGI) in all the individuals of both groups. various sports populations.[8,9] The DGI tests, the ability of the participant to maintain The aim of the present study is to see the impact of balance while walking and respond to different tasks lumbar instability on physical function and balance in during walking, throughout the test. Participants are individuals with knee OA. asked to walk on a 10 m walkway with eight different tasks. The eight items are: walking on level surfaces, Methodology altering speeds, head turns in horizontal and vertical directions, walking and turning 180° to stop, stepping The study was conducted at the institutional over and around obstacles, and stair ascent and descent. musculoskeletal physiotherapy department after Each of these tasks is scored on a scale of 0–3, where 3 obtaining ethical approval. Twenty‑two individuals indicates normal performance and 0 indicates severe with knee OA, within the age group of 50–65 years (male impairment. The test takes approximately 15 min to or female), willing to participate in the study were complete.[12] included in the study based on the selection criteria. Individuals were not included in the study, if they had Results any neurological or cardiac problems and history of trauma to the spine or lower limbs, visual or hearing Data were analyzed using the  Statistical Package for the impairments, and a history of falls in the past 1 year. Social Sciences (SPSS) software version 20 (IBM SPSS Written informed consent was taken from all the statistics for windows, version 20, N.Y., USA). The data individuals before obtaining any data. Demographic were screened for the presence of normal distribution, details including age, body mass index (BMI), and before applying any statistical tests. The confidence duration of knee pain (in months) were recorded. interval was 95% and the level of significance was kept Afterward, all the individuals were screened for the at 5% for all the tests. Table 1 shows the demographic presence of low back pain and the presence of segmental details and characteristics of all participants. Both the instability (using a passive lumbar extension test). For the groups were compared for age, BMI, and duration of passive lumbar extension test, the patient is placed in the knee pain to see if the data were equally distributed prone lying position. The therapist elevates the patient’s in both groups or not. BMI and duration of knee legs to a height of approximately 30 cm without bending pain (in months) of both the groups were compared the knees. If the patient complains of pain in the low using unpaired t‑tests, while pain levels (NPRS) were back region during the test, it is considered positive and compared using Mann–Whitney U‑test [Table 2]. indicates the presence of lumbar segmental instability.[10] Modified WOMAC and DGI scores of both the groups were compared using unpaired t‑tests [Table 2]. There were significantly greater (P < 0.05) deficits in balance Based on the presence or absence of lumbar Table 1: Demographic details of participants instability (positive or negative passive lumbar extension test), individuals were divided into two Charactristic Group A Group B groups: Group A (n = 10, without instability) and (without lumbar (with lumbar Group B (n = 12, with instability). instability) (n=10) instability) (n=12) Afterward, an assessment of levels of pain using the Numerical Pain Rating Scale (NPRS) and physical function BMI (kg/m2) 26.22±3.50 28.98±4.18 was done using the modified Western Ontario and McMaster Universities Arthritis Index (mWOMAC) in Duration (months) 17.9±8.67 22±9.86 all the individuals of both groups. Modified WOMAC NPRS 4.6±0.96 5.5±0.84 mWOMAC 36.6±12.36 51.33±16.89 DGI 17.7±2.00 11.58±3.94 BMI=Body mass index, NPRS=Numerical Pain Rating Scale, mWOMAC=Modified Western Ontario and McMaster Universities Arthritis Index, DGI=Dynamic Gait Index Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 29

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt and Shukla: Lumbar instability, physical function, and balance in knee OA and function of individuals with the presence of clinical accelerates the inflammatory process due to altered lumbar segmental instability. A correlational analysis metabolism.[14] Obesity causes forward shifting of the was made between BMI, levels of pain, duration of center of gravity and challenges balance further. This knee pain, and physical function and balance [Table 3]. increases the mechanical cost of daily living activities Pearson correlation test was used to analyze the and further increases the loading of lower limb joints relationship between all the variables, except for NPRS. and leads to greater difficulty in marinating balance and Duration of knee pain correlated moderately, yet loss of physical function. significantly with mWOMAC (r = 0.45, P < 0.05), and no The study also showed a moderate yet significant correlation was found between duration of knee pain and correlation between pain levels and balance, which is in DGI. NPRS correlated moderately, yet significantly with accordance with previous researches.[15] According to a DGI (r = 0.41, P < 0.05), and no correlation was found study by Docyung and others,[15] a more painful knee is between NPRS and mWOMAC. associated with weaker quadriceps, reduced lower limb function, and reduced balance. Pain can cause reflex Discussion inhibition of quadriceps muscle and thereby may alter with the locking mechanism of the knee. A  deficient The results of the present study indicate significant locking mechanism of the knee may predispose an impairments in physical function and balance in knee individual to frequent falls due to loss of balance. Hence, OA participants with lumbar segmental instability as although arthritic knee pain is chronic in nature and has compared to those without lumbar instability. The study behavioral components, it is an important symptom that found a moderate yet significant correlation between can interfere with the balance of the elderly and must be BMI and physical function as well as balance in knee addressed adequately during rehabilitation. OA participants. The study also showed a moderate yet The correlation between the duration of symptoms and significant correlation between pain levels and balance, physical function can be explained by the degenerative which is in accordance with previous researches. The nature of the disease. As the disease duration increases, study also found a moderate correlation between the it leads to progressive deficits in muscle strength and duration of symptoms and physical function. joint function, which can adversely affect the functional The correlation between higher BMI and physical status of the individual. functions and balance can be explained by the effect Significantly greater deficits in balance and physical of obesity on overall health of an individual. Various function in subjects with knee OA with lumbar segmental researches have linked higher BMI with poor physical function and balance in the knee OA population.[13] Higher BMI may cause increased mechanical loading of all the joints, including the knee joint, as well as it Table 2: Tests and their interpretation Outcomes Tests used to compare t/U P Groups A and B mWOMAC Unpaired t‑test −2.29 0.03 DGI Unpaired t‑test 4.44 <0.001 NPRS Mann–Whitney U‑test 35.5 0.091 BMI Unpaired t‑test −1.65 0.113 Duration Unpaired t‑test −1.025 0.318 BMI=Body mass index, NPRS=Numerical Pain Rating Scale, mWOMAC=Modified Western Ontario and McMaster Universities Arthritis Index, DGI=Dynamic Gait Index Table 3: Correlation between body mass index, duration of knee pain, Numerical Pain Rating Scale, and Modified Western Ontario and McMaster Universities Arthritis Index and DGI BMI Duration of knee pain NPRS rP r P rP mWOMAC 0.492 0.02 0.457 0.03 0.207 0.35 DGI −0.448 0.03 −0.375 0.08 −0.413 0.04 BMI=Body mass index, NPRS=Numerical Pain Rating Scale, Figure 1: Cascade of degeneration: from knee to spine via alterations in gait mWOMAC=Modified Western Ontario and McMaster Universities Arthritis Index, DGI=Dynamic Gait Index 30 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt and Shukla: Lumbar instability, physical function, and balance in knee OA instability can be explained by a direct mechanical link and to the management of C. U. Shah Physiotherapy between the spine and the lower extremities. College, Surendranagar, for their constant support and The lumbar spine and pelvis serve as a stable proximal base keen interest in research activities. around which both the lower limbs swing like a pendulum during normal level walking. If the proximal segment is not Financial support and sponsorship rigid and shakes easily upon weight shifts, it will increase This study was financially supported by Musculoskeletal energy consumption during day‑to‑day activities and this, physiotherapy OPD of C. U. Shah Physiotherapy College. in turn, will challenge the balance as well.[16] A stable and ergonomic upright standing position in Conflicts of interest ambulatory humans is achieved by intricate alignment There are no conflicts of interest. of the spine, pelvis, and lower extremity. Pathology in any one or more segments can disturb global References postural alignment, resulting in a mandatory change in alignment at other segments to maintain the equilibrium 1. Kloppenburg M, Berenbaum F. Osteoarthritis year in review 2019: [Figure 1].[17] Altered spinal alignment has been shown Epidemiology and therapy. Osteoarthritis Cartilage 2020;28:242‑8. to be linked with balance deficits in the elderly as well as middle‑aged population.[18] 2. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Restriction of knee extension in people with knee OA has Bierma‑Zeinstra SM, et al. OARSI guidelines for the non‑surgical been linked with altered lumbar lordosis. This change in management of knee, hip, and polyarticular osteoarthritis. lumbar alignment due to knee pathology is referred to as Osteoarthritis Cartilage 2019;27:1578‑89. “knee‑spine syndrome” by Yasuaki Murata and others.[19] The finding of the current study is in accordance 3. Mills K, Hunt MA, Ferber R. Biomechanical deviations during with numerous previous research that has identified level walking associated with knee osteoarthritis: A systematic lumbar segmental instability as an important cause review and meta‑analysis. Arthritis Care Res (Hoboken) of injury in the young athletic population. Lumbar 2013;65:1643‑65. segmental stability has been shown to be linked with lower extremity function and injury secondary 4. Metcalfe AJ, Stewart C, Postans N, Dodds AL, Holt CA, to loss of balance in various populations. Lumbar Roberts AP. The effect of osteoarthritis of the knee on the segmental stability or core stability is the ability of the biomechanics of other joints in the lower limbs. Bone Joint J lumbopelvic hip complex to prevent buckling and to 2013;95‑B: 348‑53. sustain equilibrium after perturbation. The lumbopelvic complex also provides a feedforward control to prepare 5. Bowd J, Biggs P, Holt C, Whatling G. Does gait retraining have the for upper or lower limb moment productions.[20,21] Hence, potential to reduce medial compartmental loading in individuals identifying and addressing lumbar segmental instability with knee osteoarthritis while not adversely affecting the other in OA knee individuals is very important to improve lower limb joints? A systematic review. Arch Rehabil Res Clin function and balance. Transl 2019;1:100022. Conclusion 6. Rahbar  M, Shimia  M, Toopchizadeh  V, Abed  M. Association between knee pain and low back pain. J Pak Med Assoc The present study indicates greater deficits in balance and 2015;65:626‑31. limitations in physical function in OA knee individuals with lumbar instability. Future studies addressing 7. Demoulin C, Distrée V, Tomasella M, Crielaard JM, lumbar segmental instability can give meaningful Vanderthommen M. Lumbar functional instability: insight into the rehabilitation of OA knee individuals. A critical appraisal of the literature. Ann Readapt Med Phys The findings of the study also indicate that higher BMI, 2007;50:677‑84, 669‑76. higher pain levels, and higher duration of symptoms can be contributors to reduced physical function and altered 8. McGill  SM. Low back stability: From formal description to balance in OA knee individuals. issues for performance and rehabilitation. Exerc Sport Sci Rev Acknowledgment 2001;29:26‑31. The authors are greatly thankful to all the participants for their enthusiasm and valuable time for the study 9. Leetun  DT, Ireland  ML, Willson  JD, Ballantyne  BT, Davis  IM. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc 2004;36:926‑34. 10. Ferrari S, Manni T, Bonetti F, Villafañe JH, Vanti C. A literature review of clinical tests for lumbar instability in low back pain: Validity and applicability in clinical practice. Chiropr Man Therap 2015;23:14. 11. Khuman R, Chavda D, Surbala L, Bhatt U. Reliability and validity of modified western Ontario and McMaster universities osteoarthritis index Gujarati version in participants with knee osteoarthritis. Physiotherapy 2018;12:8. 12. Herman T, Inbar‑Borovsky N, Brozgol M, Giladi N, Hausdorff JM. The Dynamic Gait Index in healthy older adults: The role of stair climbing, fear of falling and gender. Gait Posture 2009;29:237‑41. 13. Wluka AE, Lombard CB, Cicuttini FM. Tackling obesity in knee osteoarthritis. Nat Rev Rheumatol 2013;9:225‑35. 14. Sowers MR, Karvonen‑Gutierrez CA. The evolving role of obesity in knee osteoarthritis. Curr Opin Rheumatol 2010;22:533‑7. 15. Kim D, Park G, Kuo LT, Park W. The effects of pain on quadriceps strength, joint proprioception and dynamic balance among women aged 65 to 75 years with knee osteoarthritis. BMC Geriatr 2018;18:245. Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 31

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Bhatt and Shukla: Lumbar instability, physical function, and balance in knee OA 16. Akuthota  V, Nadler  SF. Core strengthening. Arch Phys Med 19. Murata Y, Takahashi K, Yamagata M, Hanaoka E, Moriya H. The Rehabil 2004;85:S86‑92. knee‑spine syndrome. Association between lumbar lordosis and extension of the knee. J Bone Joint Surg Br 2003;85:95‑9. 17. Wang WJ, Liu F, Zhu YW, Sun MH, Qiu Y, Weng WJ. Sagittal alignment of the spine‑pelvis‑lower extremity axis in patients with 20. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability severe knee osteoarthritis: A radiographic study. Bone Joint Res and its relationship to lower extremity function and injury. J Am 2016;5:198‑205. Assoc Orthop Surg 2005;13:316‑25. 18. Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, 21. Jull  GA, Richardson  CA. Rehabilitation of active stabilization et al. Influence of spinal sagittal alignment, body balance, muscle of the lumbar spine. In: Twomy LT, Taylor JR, editors. Physical strength, and physical ability on falling of middle‑aged and Therapy of the Lumbar Spine. 2nd ed. New York: Churchill elderly males. Eur Spine J 2013;22:1346‑53. Livingstone; 1994. 32 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Original Article Access this article online Comparison of effectiveness of electrical stimulation, myofascial Quick Response Code: release, and conventional physiotherapy over acupuncture Website: points (GB21, SI14) on upper trapezius www.pjiap.org in female basketball players DOI: 10.4103/pjiap.pjiap_29_21 Sanjiv Jha1, Sanket Bajpai2, Ruchi Mishra3, Vaishali Brahm4, Ananya Bhargava5 1Professor & HOD, Abstract: 2Professor, 3Professor, AIM: The aim of the study is to compare the effectiveness of electrical stimulation, myofascial 4Post Graduate Student, release (MFR), and conventional physiotherapy over acupuncture points (GB21, SI14) on the upper trapezius in female basketball players. Ujjain College of METHODOLOGY: The study included 30 patients with unilateral myofascial trigger points (MTrPs) Physiotherapy, Ujjain, present on acupuncture points GB2l (midway between shoulder and vertebral column) and SI14 (3 cm lateral to lower border of spinous process of first thoracic vertebra) on the upper trapezius, between Madhya Pradesh, the age group of 18 and 30 years. The patients were allotted alternatively to Group A, Group B, and 5Department of Dentistry, Group C, respectively. Preparticipation evaluation was done. Group A received electrical stimulation Ruxmaniben Deepchand with exercise, Group B received MFR with exercise, and Group C received cold pack with exercise. Posttreatment evaluation is conducted on the 7th day of treatment. Gardi Medical College, RESULTS: The results showed that Group B has significant decrease in pain and increase in lateral Ujjain, Madhya Pradesh, bending of the cervical spine to the opposite side at posttest values as compared to Group A and Group C. CONCLUSION: All three groups have got beneficial effects in reducing pain intensity and increasing India lateral bending of the cervical spine to the opposite side. Group B shows more significant effect in decrease in pain and increase in lateral bending of the cervical spine to the opposite side in female Address for basketball players with MTrP over acupoints GB21, SI14 on the upper trapezius. correspondence: Keywords: Dr. Ananya Bhargava, Acupuncture point, electrical stimulation, GB21, myofascial release, SI14 A-30/10, Vasant Vihar, Introduction of the skeletal muscle fibers and Ujjain - 456 010, is characterized by a specific Madhya Pradesh, India. Neck pain is a common problem in the pattern of referred pain and local twitch E-mail: drananyaortho@ general population with a prevalence responses.[2] between 10% and 15%. Population‑based gmail.com surveys have shown a lifetime prevalence The systematic practice of team sports at of neck pain between 67% and 87%.[1] an elite level, such as basketball, requiring Submission: 20-10-2021 overhead, or repetitive upper extremity Revision: 13-05-2022 Myofascial trigger point (MTrP) movements, is often associated with higher Accepted: 14-06-2022 is the most tender spot in taut band risk for injury. Published: 22-07-2022 This is an open access journal, and articles are How to cite this article: Jha S, Bajpai S, Mishra R, distributed under the terms of the Creative Commons Brahm V, Bhargava A. Comparison of effectiveness Attribution‑NonCommercial‑ShareAlike 4.0 License, which of electrical stimulation, myofascial release, and allows others to remix, tweak, and build upon the work conventional physiotherapy over acupuncture non‑commercially, as long as appropriate credit is given and the points (GB21, SI14) on upper trapezius in female new creations are licensed under the identical terms. basketball players. Physiother ‑ J Indian Assoc Physiother 2022;16:33-6. For reprints contact: [email protected] © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow 33

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Jha, et al.: To compare the effectiveness of electrical stimulation, myofascial release and conventional physiotherapy over acupuncture point (GB21, SI14). The shoulder and scapula regions including the upper Exclusion criteria trapezius muscle are the most common areas developing • History of referred pain due to cervical pathology myofascial pain syndrome among overhead sport • Dermatitis, wound over the upper back/neck region activities. MTrPs are characterized by the presence of • Degenerative cervical spine palpable taut band or spot within skeletal muscle; the • Upper limb pain, trauma history local inflammation caused by MTrPs can negatively • History cervical or shoulder surgery affect surrounding soft tissues, resulting in impairment • Administration of sedatives, analgesics, and other of entire muscle and surrounding fascia. The presence of MTrPs is therefore considered to be the first sign of medication overloading of the muscle.[3] • Sensory disturbance present in the upper trapezius. The MTrP in the trapezius is most commonly found at Materials used the midpoint of upper border of the muscle.[4] • EMS • Cold pack. Muscle spasms occur early after injury; this feels like Procedure tightness in the muscle and is sometimes painful. When The study included 30 patients with unilateral MTrPs basic injury is not treated, spasm causes formation knots present on acupuncture points GB2l (midway between of muscle knots called trigger points (TrPs).[1,5] shoulder and vertebral column) and SI14 (3 cm lateral to The purpose of our study was to see the effect of electrical lower border of spinous process of first thoracic vertebra) in muscle stimulation (EMS), myofascial release  (MFR), the upper trapezius, between the age of 18 and 30 years with and cold pack with exercise over acupoints on the upper permission from the institute, and informed consent was trapezius instead of TrPs in female basketball players obtained for the performance of this study. Demographic and to compare the effect of EMS, MFR, and cold pack data were collected from the participants. The patients were with exercise over acupoints GB21, SI14 on the upper allotted alternatively to Group A, Group B, and Group C, trapezius. respectively, that is, first patient to Group  A, second to Group B, and third to Group C, and so on. Methodology Each subject was asked to point to the most painful areas Source of data of the upper trapezius region and to determine the area of possible TrPs that matches with acupoints (GB21 and Madhav College Ground, Ujjain; Mahananda Ground, SI14). Examiner then palpates the region of the upper Ujjain. trapezius and marked all points that matched inclusion Sample size criteria with nonpermanent marker. Thirty. Preparticipation evaluation form consisted of chief Patients were divided into three groups: complaint, history, and range of motion (ROM) of the • Group A includes ten patients receiving electrical lateral side cervical flexion by using a goniometer chart. Each subject was allowed to ask questions to the examiner stimulation with exercise regarding the study. Then, the participant was asked to • Group B includes ten patients receiving MFR with mark a visual analog scale (VAS) with the average pain intensity for their pain over the past 24 h. Posttreatment exercise evaluation is conducted on the 7th day of treatment. • Group C includes ten patients receiving cold pack Intervention Group A with exercise. Participants were asked to expose the affected part and Study duration removed artificial material before applying of EMS. The July 2019 to December 2019. patient should be seated erect on chair with arms hang Inclusion criteria freely. Then, mark the TrPs that match with acupoints • Age: 18–30‑year‑old females (basketball players) GB21 and SI14. Muscle stimulator machine having faradic • Pain from the last 1 month current of systemic, surged biphasic pulses of duration • Limitation in neck movement due to pain 0.1–1 min with a frequency of 50 Hz is given for 15 min. • Unilateral muscle spasm with TrPs on acupoints Group B Participants were asked to expose the affected part and GB21, SI14. removed artificial material, before applying MFR technique. • Training workload of at least 20 h/week • Active MTrPs in dominant trapezius muscle • Willingness to participate. 34 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Jha, et al.: To compare the effectiveness of electrical stimulation, myofascial release and conventional physiotherapy over acupuncture point (GB21, SI14). The therapist should stand to the side and behind the Table 1: Mean score of pre ‑and post‑visual analog patient, close to the muscle to be treated. The therapists scale of groups forearm or lateral aspect of the palm glides slowly medially toward the base of the neck or scapula, while maintaining a Group Mean n SD T P firm pressure. As glide is given, the subject should equally side bending and turning the head away from the side being Group A 6.91 10 0.74 5.15 <0.001 treated while maintain erect sitting posture. MFR has to be pretest VAS given for 5 min included three palmer glides. Group C Group A 1.92 10 0.74 Participant should be seated erect on chair with the arm posttest VAS hanging freely. Cold pack was given over the upper trapezius in the sitting position for 20 min. Group B 7.14 10 0.88 16.11 <0.001 Exercises pretest VAS All participants in three groups were instructed for shoulder girdle exercises including scapular protraction, Group B 1.02 10 0.82 retraction, elevation, and depression, as well as active posttest VAS neck exercises including cervical flexion, extension, right and left rotation, and side flexion. All exercises are given Group C 7.73 10 0.67 10.15 <0.001 for 10 repetitions and 5 s hold. pretest VAS Variables 1. Dependent variables: VAS, ROM of lateral side flexion Group C 2.21 10 1.23 2. Independent variables: Electrical stimulation, MFR, posttest VAS cold pack exercises. SD=Standard deviation, VAS=Visual analog scale Instrumentation Goniometer. Table 2: Mean score pre‑ and post‑range of motion of Outcome measures groups Pain, cervical flexion ROM. Group Mean n SD T P Results Group A 24.51 10 4.43 5.30 <0.001 Analysis was done using SPSS software version 22 pretest ROM (IBM Corporation, Armonk, NY, USA). Descriptive analysis was used to calculate mean and standard Group A 33.64 10 3.13 deviation. Paired t‑test was used for intergroup posttest ROM analysis. Independent t‑test was used for intragroup analysis for all group variables. The level of significance Group B 20.52 10 4.30 13.26 <0.001 was set at 95%. When the comparison was made on pretest ROM the VAS and cervical side flexion ROM on day 1 and day 7, they show significant improvement in pain in Group B 40.61 10 2.12 all three groups [Tables 1 and 2]. However, there is posttest ROM more significant improvement in outcome measures in Group B compared to Group A and Group C. The Group C 6.71 10 0.67 2.01 0.06 results showed that Group B has significant decrease pretest ROM in pain and increase in lateral bending of the cervical spine to the opposite side at posttest values compared Group C 2.23 10 1.23 to Group A and Group C [Tables 3 and 4]. posttest ROM SD=Standard deviation, VAS=Visual analog scale Table 3: Comparison of posttest visual analog scale between groups Group Mean n SD T P Group A versus 1.91 10 0.74 Group B 1.01 10 0.82 2.59 0.02 Group B versus 1.02 10 0.82 Group C 2.23 10 1.23 2.57 0.02 Group C versus 2.23 10 1.23 Group A 1.94 10 0.74 0.66 0.5l SD=Standard deviation, VAS=Visual analog scale Table 4: Comparison of posttest range of motion between groups Group Mean n SD T P Group A versus 33.62 10 3.13 Group B 40.63 10 2.12 5.85 <0.001 Group B versus 40.63 10 2.12 Group C 25.61 10 4.20 10.09 <0.001 Group C versus 25.64 10 4.20 Group A 33.62 10 3.13 4.83 <0.001 SD=Standard deviation Discussion acupuncture points Gb21 and SI14 on the upper trapezius in female basketball players. This comparative The study was designed to compare the effectiveness study of seven sessions of electrical stimulation, MFR, of EMS, MFR, and conventional physiotherapy and conventional physiotherapy in combination Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 35

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Jha, et al.: To compare the effectiveness of electrical stimulation, myofascial release and conventional physiotherapy over acupuncture point (GB21, SI14). with shoulder girdle exercises led to the findings Conclusion that MFR has shown statistically significant decrease in pain and improvement in the lateral bending of This study provided evidence to support the use of the cervical spine to the opposite side than EMS and electrical stimulation, MFR, and cold pack along with conventional physiotherapy After analysis of baseline exercise over acupoints GB2l and SI14 on the trapezius. data and posttreatment scores, it reveals significant This study concluded by stating that all three groups improvement (P < 0.05) in Group B after seven treatment have got beneficial effects in reducing pain intensity and sessions. The possible mechanism is that MFR is a soft increasing lateral bending of the cervical spine to the tissue mobilization technique, and MFR involves opposite side, and Group B shows more significant effect specifically guided low‑load long‑duration mechanical in decrease in pain and increase in lateral bending of the forces to manipulate the myofascial complex, intended cervical spine to the opposite side in female basketball to restore optimal length, decrease pain, and improve players with MTrPs at acupoints GB2l and SI14 on the function. Myofascial utilizes the manual traction and upper trapezius. prolonged stretching of fascia and muscle to break down the adhesions, thus helping to decrease pain and Financial support and sponsorship increase flexibility and thereby increase ROM. When Nil. Myofascial Release is used on the TrPs, local chemistry changes due to blanching of nodules occurs which is Conflicts of interest followed by hyperemia. This flushes out the muscle There are no conflicts of interest. inflammatory exudates and pain metabolites, breaks down the scar tissue, desensitizes the nerve endings, References and reduces muscle tone. This study was in accordance with Chaudhary et al.[6] 1. Kumaresan A, Deepthi G, Anandh V, Prathap S. Effectiveness of who compared the effectiveness of MFR technique versus positional release therapy in treatment of trapezitis. Int J Pharm cold pack in relieving pain and improving cervical ROM Sci Health Care 2012;1:71‑81. and pressure pain threshold in the upper trapezius spasm patients and found that the MFR and cold pack 2. Hong Zern C. Myofascial trigger points: Pathophysiology and along with exercises are effective interventions in upper correlation with acupuncture points. Acupunct Med 2000;18:41‑7. trapezius muscle spasm. However, MFR shows greater effectiveness as compared with cold pack and exercises 3. Matsubara T, Arai PY, Shiro Y, Shimo K, Nishihara M, Sato J, in the treatment of upper trapezius spasm. Ushida T. Comparative effects of acupressure at local and distal This study was inconsistent with Mishra et al.[7] who acupuncture points on pain condition and autonomic function in compared the effect of active release technique (ART) female with chronic neck pain. Evid Based Complement Altern and MFR on the upper trapezius muscle spasm on pain Med 2011;1:1‑6. and cervical ROM and found that both techniques are effective in the alleviation of symptoms and associated 4. Chaudhary ES, Shah N, Vyas N, Khuman R, Chavda D, Nambi G. disability in the upper trapezius muscle spasm, and ART Comparative study of myofascial release and cold pack in upper gave better results as compared to MFR. trapezius spasm. Int J Health Sci Res 2013;3:20‑7. 5. Manheim CJ. The Myofascial Release Manual. 4th. Edition Charleston, SC: Slack Incorporated; 2008. 6. Chaudhary ES, Shah N, Vyas N. Comparative study of myofascial release and cold pack the upper trapezius spasms. Int J Health Sci Res 2013;3:20‑7. 7. Mishra D, Prakash R, Mehta J, Dhaduk A. Comparative study of active release technique in treatment of patient with upper trapezius spasm. J Clin Diagn Res 2018;12:YC01‑4. 36 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Case Report Access this article online Physiotherapeutic management of Quick Response Code: hirayama disease: A case report Lilima Patel, Bibhuti Sarkar1, Anil Kumar Oraon2 Website: Abstract: www.pjiap.org Hirayama disease  (HD) is a rare condition which is also known as juvenile muscular atrophy of distal upper extremities (JMADUE). The case study of a 22‑year‑old man is presented who reported DOI: weakness in his distal upper extremities and many of his clinical presentation, electrophysiological, 10.4103/pjiap.pjiap_10_22 and neuroimaging findings were consistent with HD. The purpose of this case study was to present a detailed assessment and evaluation of this rare disease and also to formulate a general physiotherapeutic intervention. Neurological examination demonstrated moderate‑to‑severe atrophy of distal muscles, preserved reflexes, and normal sensation in his both upper limbs. Electrophysiological studies revealed neurogenic changes in the muscles innervated by the lower cervical spinal cord. Magnetic resonance imaging showed atrophy of the midcervical cord with high signal intensity in the anterior horn cell region. These examination and investigation findings were compatible with the diagnosis of JMADUE also known as HD. A physiotherapeutic regimen of 6 weeks, consisting of strengthening exercises for the upper limbs and neck muscles, and the postural correction was carried out. Grip strength was measured by Jamar handheld dynamometer and functional disability by the disabilities of arm, shoulder, and hand (DASH) questionnaire. After 6 weeks of intervention, improvement in grip strength (left side 20.2 lbs to 25.6 lbs and right side 35.7 to 38.6 lbs) and many of his activities of daily life were noted along with DASH score (left side 90/125 to 76/125 and right side 55/125 to 30/125). HD is a self‑limiting disorder and there is no definitive treatment. Physiotherapy helps in preventing complications resulting from immobility such as joint stiffness and muscle wasting. A general strengthening exercise program can limit the disorder and improves the quality of life. Keywords: Cervical myelopathy, electromyography, magnetic resonance imaging, monomelic amyotrophy, neural conduction Department of Introduction mostly from Asian countries. The case of Physiotherapy, Apollo a 22‑year‑old man is presented here with Hirayama disease (HD) is a rare weakness in his distal upper extremities Institute of Medical condition which is also known as which progressed for several months before Sciences and Research, juvenile muscular atrophy of distal upper stabilizing. His clinical, electrophysiological, Hyderabad, Telangana, extremities. Other synonyms include and neuroimaging findings were consistent monomelic amyotrophy, benign focal with HD. 1Department of amyotrophy, juvenile asymmetric segmental Physiotherapy, National spinal muscular atrophy, and juvenile Case Report muscular atrophy of unilateral upper Institute for Locomotor extremity. This disease commonly occurs A 22‑year‑old male subject visited our Disabilities, Kolkata, West in Japan and India. This condition was first physiotherapy department with a 2‑year described by and named after, Hirayama in history of slowly progressive weakness Bengal, 2Department of 1959.[1,2] Several cases have been reported and atrophy of the left thumb, followed by Surgical Disciplines, All all other fingers, left hand, and forearm. India Institute of Medical This is an open access journal, and articles are After 1 year, it gradually progressed to the Sciences, New Delhi, India distributed under the terms of the Creative Commons left forearm and arm. Weakness of hand Attribution‑NonCommercial‑ShareAlike 4.0 License, which Address for allows others to remix, tweak, and build upon the work How to cite this article: Patel L, Sarkar B, Oraon AK. correspondence: non‑commercially, as long as appropriate credit is given and the Physiotherapeutic management of hirayama disease: Mr. Anil Kumar Oraon, new creations are licensed under the identical terms. A case report. Physiother‑J Indian Assoc Physiother Jr. Physiotherapist, 2022;16:37-40. Department of Surgical For reprints contact: [email protected] Disciplines, AIIMS, New Delhi, India. E-mail: anil9876physio@ gmail.com Submission: 18-05-2022 Revision: 15-06-2022 Accepted: 16-06-2022 Published: 22-07-2022 © 2022 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow 37

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Patel, et al.: Hirayama disease: A case study limited his many activities of daily living (ADLs). His Table 1: Strength of upper limb muscle according to past medical history had an incident of cold paresis, the Medical Research Council grading flexion type of injury of the neck, and a minor head injury suffered many years ago. The onset of symptoms was Left Muscle Right insidious; it had started initially with shaking of the left thumb, hand, and arm with weakness. No significant 5 Biceps brachii 5 apparent family history was evident. The subject has undergone conservative management but no significant 5 Triceps brachii 5 improvement was seen. Assessment and evaluation 3 Brachialis 5 On examination, the subject was conscious, cooperative, and well oriented to time, place, and person along 5 Brachioradialis 5 with normal cranial nerve function. All superficial and deep sensations were found to be intact across all the 4 Flexor digitorum superficialis 5 dermatomes. On motor evaluation, functions revealed normal tone in all four limbs but muscle girth of the 3 Flexor digitorum profundus 5 left upper limb was reduced. There was weakness and atrophy of the thenar, hypothenar, interosseous, 1 Extensor digitorum 4 forearm, and arm muscles except for brachioradialis. According to the Medical Research Council (MRC) 1 Extensor indicis 4 grading, there was poor strength in the left forearm and hand muscle compared to the right side [Table 1]. 3 Opponens pollicis 4 Grip strength was evaluated by Jamar handheld dynamometer and found fair (20.2 lbs) on the left side 3 Flexor policies longus 4 compared to the right side (35.7 lbs). Deep tendon reflexes were diminished for the left bicep, triceps, and 3 Flexor policies brevis 4 supinator. Balance, coordination, and gait were normal. Upper limb function was assessed by the disabilities of 1 Extensor policies longus 4 arm, shoulder, and hand (DASH) questionnaire which scored 90/125 on the left side and 55/125 on the right 1 Extensor policies brevis 4 side indicating problems with the left‑side upper limb activities. 3 Abductor policies longus 4 3 Abductor policies brevis 4 2 Adductor policies 4 1 Opponenss digiti minimi 3 1 Abductor digiti minim 3 1 Extensor digiti minimi 4 4 1,2,3,4, lumbricals 4 1 1,2,3,4 palmer interossei 3 1 1,2,3 dorsal interossei 3 Weakness of thenar, hypothenar, interosseous, forearm, and arm muscles except for brachioradialis (5=Normal strength, 4=Full range of motion against gravity with moderate resistance, 3=Full range of motion against gravity, 2=Full range of motion in gravity parallel plane, 1=Flickering/palpable muscular contraction, 0=No contraction of muscles) All blood investigations were within normal limits. Figure 1: T2‑weighted ‑MRI findings of the cervical spine in extension. The lateral Cervical spine X‑ray shows loss of cervical lordosis. view demonstrates atrophy of the spinal cord in the lower cervical segments. (left) Electromyography (EMG) study shows evidence of The transverse section at C5‑C6 levels shows asymmetrical flattening of the right denervation in the form of fasciculation in C7‑C8 distribution of both upper limb muscles but the left side half of the spinal cord. (right). MRI: Magnetic resonance imaging was more predominant as compared to the right side with sparing of the brachioradialis muscle. Lower limb by a gradual onset of progressive weakness and muscles show normal EMG study. A nerve conduction atrophy of the left hand and forearm with sparing of velocity study showed reduced Compound Motor Action brachioradialis muscle atrophy giving the appearance of Potential (CMAP) in the left ulnar nerve but all others oblique amyotrophy. No pyramidal and extrapyramidal were within normal range. Cervical magnetic resonance signs or abnormalities such as sweating and urination imaging (MRI) in a neutral position revealed asymmetric were noted. The cervical MRI along with EMG findings flattening of the left half of the cervical cord at the C5‑C6 were found to be consistent with this disease. This is a level with associated patchy areas of intramedullary rare disorder and to date, no study in the literature has hyperintensities on T2‑weighted axial images [Figure 1]. been found with specific physiotherapy intervention Early disc desiccation with mild posterior disc bulge at for this rare disease. Hence, the purpose of this study the C6‑C7 level was noted without any significant spinal was to build and formulate a specific physiotherapeutic canal narrowing or stenosis. intervention for this rare disease. The diagnosis of HD was made based on the age of onset which is 20 years of age, history of cold paresis, and history of flexion type injury of the neck, followed 38 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Patel, et al.: Hirayama disease: A case study Intervention was improved to 25.6 lbs on the left side and 38.6 lbs Regarding management, the application of a soft cervical on the right side. Similarly, at baseline, the DASH score collar was suggested as it is the main biomechanical on the left side was 90/125 and on the right side, it was correction required to limit the disease. Postural 55/125, which improved by 76/125 on the left side and correction and reeducation were also taught to the 30/125 on the right side after 6 weeks of intervention. subject so that his cervical spine can be maintained in a Although this improvement was not significant, the neutral position and avoid further progression. For this, overall quality of life had improved. Individual muscle conscious maintenance of the neck in a neutral position strength of the forearm and hand was again assessed during rest and while working was instructed to the according to MRC grading but no difference was found subject. Furthermore, while lying, the use of a low‑height compared to baseline. pillow or a neck roll was instructed. Conventional neck isometric strengthening was taught to the subject Discussion for which the subject sat in an upright position and placed their clasped hands at the back of the head. The HD is a particular type of cervical myelopathy affecting subject then tried to push the head backward while young people characterized by localized amyotrophy resisting backward motion with the hands (10 × 10 s/ in the forearm and hand that is initially progressive three times a day). This maneuver was repeated in a but stabilizes within a few years. The most common similar way over the frontal and sideways direction. pathology of this disorder is damage to the anterior horn The erect posture of the spine and neutral head position cell which may be induced by forward displacement was maintained throughout the exercise. Activation of the lower cervical dural sac and spinal cord on neck of the deep neck flexors by the Pressure Biofeedback flexion. We proposed that the forward displacement Unit (PBU) was trained. For this, the subjects were kept was one of the pathogenic factors, and reported that in a supine position, a PBU was placed between the therapeutic intervention using a cervical collar to back side of their upper cervical region and a therapy minimize neck flexion halted the progressive weakness table. With their head relaxed in a comfortable manner in some patients.[3] Normally, the spinal dura mater not to cause movements, the subjects were instructed to is loosely attached to the vertebral canal by the nerve hold a pressure gage with one hand to provide visual roots, the periosteum at the foramen magnum, the dorsal feedback of their contractile force produced using the surfaces of C2 and C3, and the coccyx. The dura mater pressure gauge connected to the PBU and to place the is loose enough to adjust with the increased length of other hand on their manubrium of sternum to limit the cervical spine during the flexion movement of the the movement of their ribs during the contraction of cervical spine. In patients with HD, the taut dural sac their deep cervical flexors. During the contraction separates the posterior dural sac from its adjacent lamina of the deep cervical flexors, they were instructed to and on neck flexion, cannot compensate for the increased draw their chin inward without the contraction of the length of the posterior wall. Thus, the posterior dural sternocleidomastoid muscle and apply a strain to the wall shifts anteriorly, compressing the cervical spinal abdominal muscle to restrict the movement of the ribs. cord against the posterior margin of adjacent vertebral These exercises were performed on a hard therapy table bodies. This compressive force also affects the anterior to measure changes in the pressure gauge accurately. spinal artery, leading to impaired microcirculatory The subjects maintained static contraction for 10 s, and disturbances in its territory in the lower cervical cord, then took a rest for 5 s which was defined as a one‑time and the anterior horn cells which are vulnerable to exercise. One set consisted of 10 repetitions, and a total ischemia begin to degenerate, resulting in localized cord of three sets were performed each day. Strengthening atrophy of the lower cervical region, weak and wasted exercises in the form of resistance training for the hands, and forearms. Similar cases have been reported forearm, wrist, and hand muscle was carried out for worldwide. The findings for this report were similar to 6 weeks. Strengthening exercises with the intensity of the diagnostic criteria of HD according to Tashiro et al.[4] 30% of 1  Repetition Maximum (RM) weight, three sets described in the literature.[5,6] of 10–12 repetitions with a proper rest interval of 5 min MRI picture reveals various findings such as localized between the sets were trained. lower cervical cord atrophy, asymmetric cord flattening, parenchymal changes in the lower cervical cord, Results abnormal cervical curvature, and loss of attachment between the posterior dural sac and subjacent lamina The subject’s body build was mesomorphic with a have been defined.[7] Out of these, localized lower cervical height of 1.7 m and a weight of about 58 kg which leads cord atrophy, asymmetric cord flattening, and loss of to a body mass index of 20.1 kg/m2. At baseline, grip attachment have an accuracy of 80% in the identification strength was 20.2 lbs on the left side and 35.7 lbs on the of the disease, loss of attachment is the most valuable right side. After 6 weeks of intervention, grip strength Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022 39

[Downloaded free from http://www.pjiap.org on Saturday, July 23, 2022, IP: 103.127.77.82] Patel, et al.: Hirayama disease: A case study finding for diagnosing HD in the neutral position.[8,9] In due efforts will be made to conceal his identity, but MRI with neck flexion, forward migration of the wall of anonymity cannot be guaranteed. the dura mater is observed with an enlarged posterior epidural space. A hyperintense, crescentic epidural Acknowledgment mass showing curvilinear flow voids and uniform The authors appreciate the cooperation of the subject for enhancement after administration of contrast are seen in following the instructions adequately and performing the posterior epidural space.[10,11] Disappearance of this the exercise regularly. The authors are also thankful to mass when the neck is in the neutral position suggests the institute for providing support and permission for congestion of the posterior internal vertebral venous this work. plexus.[12] Financial support and sponsorship In this study, a general physiotherapeutic intervention Nil. was given to improve the subject’s symptoms, muscle weakness, and ADL activity. To date, no study has been Conflicts of interest published regarding a specific treatment protocol for There are no conflicts of interest. this rare disorder. This is the first study which presents a detailed assessment and evaluation of this specific rare References disorder and also establishes general physiotherapeutic interventions. Strengthening exercises are helpful 1. Hirayama K. Juvenile muscular atrophy of unilateral upper in limiting muscle weakness and increasing overall extremity (Hirayama disease)‑half‑century progress and strength, maintaining muscle properties, and improving establishment since its discovery. Brain Nerve 2008;60:17‑29. overall outcomes. The exercises were performed 10–12 repetitions of three sets thrice weekly for a total of 2. Kira J, Ochi H. Juvenile muscular atrophy of the distal upper 6 weeks. There was a difference of 5.4 lbs on the left side limb (Hirayama disease) associated with atopy. J Neurol and 2.9 lbs on the right side compared to preintervention Neurosurg Psychiatry 2001;70:798‑801. status for grip strength. There was also a difference of 14 points on the left side and 25 points on the right side 3. Tokumaru Y, Hirayama K. Cervical collar therapy for juvenile in the DASH score. muscular atrophy of distal upper extremity (Hirayama disease): Results from 38 cases. Rinsho Shinkeigaku 2001;41:173‑8. In conclusion, HD is a self‑limiting disorder and there is no definitive treatment. However, early diagnosis 4. Tashiro K, Kikuchi S, Itoyama Y, Tokumaru Y, Sobue G, Mukai E, is necessary because a cervical collar may arrest the et al. Nationwide survey of juvenile muscular atrophy of distal progression of the disorder by limiting the neck flexion. upper extremity (Hirayama disease) in Japan. Amyotroph Lateral Physiotherapy helps in preventing complications Scler 2006;7:38-45. resulting from immobility such as joint stiffness and muscle wasting. In this study, a proper physiotherapy 5. Nascimento  OJ, Freitas  MR. Non‑progressive juvenile spinal protocol was built for this specific rare condition and muscular atrophy of the distal upper limb (Hirayama’s disease): showed that simple exercise with a biomechanical A clinical variant of the benign monomelic amyotrophy. Arq correction may correct the dural malalignment and can Neuropsiquiatr 2000;58:814‑9. limit the further progression of the disease. 6. Sitt CM, Fung LW, Yuen HY, Ahuja AT. Hirayama disease in a Informed consent 17‑year‑old Chinese man. Singapore Med J 2014;55:e87‑9. Informed consent written in the subject’s own language was taken before initiation of evaluation and management. 7. Chen CJ, Hsu HL, Tseng YC, Lyu RK, Chen CM, Huang YC, et al. Hirayama flexion myelopathy: Neutral‑position MR Declaration of patient consent imaging findings‑importance of loss of attachment. Radiology The authors certify that they have obtained all appropriate 2004;231:39‑44. patient consent forms. In the form, the patient has given his consent for his images and other clinical information 8. Mukai E, Matsuo T, Muto T, Takahashi A, Sobue I. Magnetic to be reported in the journal. The patient understands resonance imaging of juvenile‑type distal and segmental that his name and initials will not be published and muscular atrophy of the upper extremities. Rinsho Shinkeigaku 1987;27:99‑107. 9. Hirayama  K. Juvenile muscular atrophy of distal upper extremity  (Hirayama disease): Focal cervical ischemic poliomyelopathy. Neuropathology 2000;20 Suppl: S91‑4. 10. Pradhan S, Gupta RK. Magnetic resonance imaging in juvenile asymmetric segmental spinal muscular atrophy. J Neurol Sci 1997;146:133‑8. 11. Chen CJ, Chen CM, Wu CL, Ro LS, Chen ST, Lee TH. Hirayama disease: MR diagnosis. AJNR Am J Neuroradiol 1998;19:365‑8. 12. Kikuchi S, Tashiro K, Kitagawa M, Iwasaki Y, Abe H. A mechanism of juvenile muscular atrophy localized in the hand and forearm (Hirayama’s disease)‑flexion myelopathy with tight dural canal in flexion. Rinsho Shinkeigaku 1987;27:412‑9. 40 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 16, Issue 1, January-June 2022