Hong Kong Physiotherapy Journal

Research Paper Hong Kong Physiotherapy Journal Vol. 40, No. 1 (2020) 1–9 DOI: 10.1142/S1013702520500018 Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com Hong Kong Physiotherapy Journal by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. https://www.worldscientific.com/worldscinet/hkpj Experiences of occupational health doctors and nurses about the role of physiotherapists in occupational health rehabilitation: A qualitative study Laran Chetty Royal Free London NHS Foundation Trust Pond Street, London, UK [email protected] Received 1 February 2019; Accepted 21 August 2019; Published 13 September 2019 Background: Occupational health physiotherapy has been practiced in the UK over several decades. In the past decade, the role of occupational health physiotherapy has gained recognition as a profession that can be embedded within occupational health departments; however, limited information is known about the role of physiotherapists from professional groups outside the allied health domain in this context. Objective: The aim of this study is to explore the experiences of occupational health doctors and nurses about the role of physiotherapy in occupational health rehabilitation. Methods: This study is a qualitative investigation underpinned by an interpretative construct. Thirteen semi-structured interviews were conducted. Two occupational health doctors and 12 nurses were purposively recruited from two National Health Service (NHS) hospitals. Data were analyzed using thematic content analysis, coded manually and veri¯ed by member checking. Results: The bene¯ts of occupational health physiotherapists were rapid access intervention, advanced knowledge and clinical reasoning, evidence-based practice, and providing an additional perspective. The emerging themes of the challenges that occupational health physiotherapists may face include dealing with occupational health challenges, managing role con°icts, personal qualities and attributes, and role substitution. Conclusion: Participants described numerous roles of occupational health physiotherapists ranging from clinical to organizational components. On-going research is needed to support the role development of physiotherapists providing occupational health rehabilitation and to further advocate for its relevance in this setting. Keywords: Physiotherapy; occupational health; rehabilitation; role; experiences. Copyright@2020, Hong Kong Physiotherapy Association. This is an Open Access article published by World Scienti¯c Publishing Company. It is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY- NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly cited, the use is non-commercial and no modi¯cations or adaptations are made. 1

Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com 2 L. Chetty construct allowed for meaningful engagement and by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. dialogue with occupational health doctors and nur- Introduction ses and provides a unique opportunity to gather new insights about how they viewed the role of phy- Occupational health physiotherapy as a distinct siotherapists in this setting.6 discipline has been practiced in the United King- dom since the 1940s.1 Occupational health phy- The selection of study sites siotherapists are often described as clinicians dedicated to managing employees either autono- This study was undertaken at two NHS hospitals mously or in conjunction with other members of of which both o®ered in-house occupational health the team.2 Traditionally, occupational health services. The two NHS hospitals were strategically physiotherapy falls under the umbrella of muscu- chosen because the researcher is not employed by loskeletal physiotherapy as an advanced practi- these hospitals and does not line manage any tioner status due to the specialist knowledge and member of the occupational health team. This experience required in this specialty. However, the eliminates the e®ects of coercion and con°icts of `advanced' roles in which physiotherapists practice interest and provides the researcher with an out- in the occupational health setting is generally sider's perspective. The outsider's perspective is poorly documented in the literature. Furthermore, advantageous because the qualitative researcher there is no evidence about the experiences of oc- should preferably enter the research setting as a cupational health doctors and nurses with the stranger so that the setting can be viewed with contribution of physiotherapy to occupational greater insight and more sensitivity not having health rehabilitation.3 been decreased by familiarity.7 However, an out- sider needs to take more time to establish trust Occupational health doctors and nurses are core with participants which may delay the research.7 professions within the occupational health team and their specialist roles involve reducing the in- These two NHS hospitals are comparable in cidence of diseases and injuries, alleviating su®er- terms of size, bed availability, number of sta® ing and promoting and protecting the health and employed and patient throughput. Both also fea- well-being of people in the workplace.4 Their ture similar services and have the same structural experiences with occupational health physiothera- problems in that they have a combination of cen- py may re°ect di®erent insights of the role and tury-old buildings and new buildings. Each NHS could be used to help guide and market it among hospital serves a very di®erent population, with members of the occupational health team and to one situated in an a®luent area serving a largely clients and commissioners. Their insights could homogenous population while the other serving a also aid the acceptability of physiotherapy practice more culturally diverse population and is situated in occupational health rehabilitation where there is in a relatively deprived area. resistance and guide future training of phy- siotherapists working in occupational health Participants rehabilitation. Permission was sought from the occupational The aim of this study was therefore to explore health manager at each NHS hospital in order to the experiences of occupational health doctors and inform them of the study and to gain access to the nurses about the role of physiotherapists in occu- research sites and recruit participants. A date and pational health rehabilitation. time to attend one of their team meetings was agreed with each manager. At each team meeting, Methods the researcher met with members of the occupa- tional health team to explain the details of the Study design study and to hand out study packs to participants. Purposive sampling was used to recruit partici- This study used a qualitative framework and was pants to allow for the selection of only those par- underpinned by an interpretative construct.5,6 The ticipants that were considered suitable to the qualitative approach allows the researcher to ex- study. The recruitment process involved taking plore in-depth the experiences of occupational into account the professional group and those with health doctors and nurses about the role of phy- siotherapists providing occupational health rehabil- itation at two National Health Service (NHS) hospitals in the United Kingdom.5 The interpretative

Experiences of occupational health doctors and nurses about the role of physiotherapists 3 Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com at least three years of occupational health experi- another researcher to ensure accuracy of tran- by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. ence. Each study pack consisted of an information scription. Any discrepancies in transcription were sheet, consent form and a prepaid return envelope. resolved by discussion. Thematic content analysis Study packs were left with each manager to hand was used to analyze the data. Content analysis is a to those participants that were deemed as poten- process of identifying, coding and categorizing the tially suitable for the study but were not present at primary patterns of data.7 The transcriptions were the team meeting. Participants were excluded if carefully and repeatedly read, with initial ideas they were unwilling or unable, for any reason, to being noted. A list of all ideas was made and sim- give their written consent. Two occupational ilar topics were coded and grouped together to health doctors and 12 nurses returned their signed form the main themes. Topics not forming part of consent form and were included in the study. the main themes were re¯ned into relevant sub- themes. Quotes from the original transcript were Data collection `lifted' and arranged under the relevant sub- theme. A second reviewer independently reviewed Data were collected using semi-structured inter- the data and themes and any discrepancies in in- views. Each participant was interviewed in a con- terpretation were resolved by discussion. The ¯dential room onsite. The duration of each second reviewer was not inhibited by closeness to interview lasted up to an hour. At the start of the the study and therefore was able to view the data interview, the researcher con¯rmed if the partici- with real detachment and provide a fresh pant was still willing to take part in the study. The perspective.8 researcher also explained the purpose of the study and reassured participants that all information Trustworthiness of the study gathered during the interview would be handled con¯dentially. In addition, participants were in- Rigor was ensured through credibility, transfer- formed that the interviews will be audiotape ability, dependability and con¯rmability. The re- recorded to permit data analysis at a later point. searcher built trust by explaining to participants The interview questions were open-ended to allow the purpose of the study, utilization and dissemi- for fundamental lines of enquiry relevant to the nation of the information. Regular notes were kept topic to be pursued with each participant, while in a diary to re°ect on any emerging assumptions. also allowing participants the °exibility to freely Thick descriptions were used to enable readers to expand on questions.6 compare the inferences in the data with those they have seen in their own situation and determine how In order to gather in-depth insights of the role of far they can be con¯dent in transferring to their physiotherapists in occupational health rehabili- situation the ¯ndings of the study. A detailed de- tation, the following questions and prompts were scription of the study's operational details was formulated: (1) Can you tell me about your provided. The study was described in as much experiences with the physiotherapist who provides detail as possible to form an audit trail so that occupational health rehabilitation? (Prompts: readers could trace step-by-step the decisions knowledge, behaviors and skills; di®erences from made. Finally, data trustworthiness was estab- general outpatient physiotherapy); (2) What kind lished through a process of member checking of services do you expect a physiotherapist in oc- whereby all participants were sent their interview cupational health to o®er you? (Prompts: areas of transcripts for review and allowed to make mod- practice; clinical skills; organizational responsibili- i¯cations prior to data analysis to ensure its au- ties); (3) What do you expect physiotherapists in thenticity. No participant asked for any changes or occupational health to o®er occupational health modi¯cations to be made to their transcripts. services? (Prompts: expert opinion; new/innova- tive ways of working; on team, clients, managers Ethical approval and outcomes). Ethical clearance was obtained from Middlesex Data analysis University London Health and Social Care Ethics Committee (Reference: MH35). This study did not Interviews were transcribed verbatim by the re- require NHS ethical review under the terms of the searcher and then independently transcribed by

4 L. Chetty Rapid access intervention Governance Arrangements for Research Ethics Participants recognized that early contact with Committees (A Harmonized Edition) (Reference: physiotherapists could yield bene¯ts: 16/SS/0043). \\The fact that we have an occupational health Findings physio on-site helps us manage cases much faster, especially those that come in with acute The characteristics of participants are presented injuries.\" (Case 1, OH Nurse 2). in Table 1. Participants discussed several compo- nents about the role of physiotherapists in occu- \\I would like to have physios in occupational pational health rehabilitation. A list of the health, especially with all the injuries coming themes and sub-themes that emerged is presented in. It would be really nice if we could have access in Table 2. to physios sooner.\" (Case 2, OH Nurse 3). Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com Theme 1: Bene¯ts of Occupational Advanced knowledge and clinical by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Health Physiotherapy reasoning The four sub-themes under this theme are: (1) Physiotherapists have advanced levels of rapid access intervention; (2) advanced knowledge knowledge and clinical reasoning in complex cases: and clinical reasoning; (3) evidence-based practice; and (4) providing an additional perspective. \\Physiotherapists provide high-quality and systematic assessments and interventions. Table 1. Characteristics of participants. Site Occupation Gender Experience Employment status Case 1 OH Doctor Male 25 years Part-time Case 2 OH Nurse Female 16 years Part-time OH Nurse Female 8 years Full-time OH Nurse Female 4 years Part-time OH Nurse Female 5 years Full-time OH Nurse Female 12 years Full-time OH Nurse Female 3 years Full-time OH Nurse Male 3 years Full-time OH Nurse Female 6 years Full-time OH Doctor Female 14 years Part-time OH Nurse Female 13 years Full-time OH Nurse Male 8 years Full-time OH Nurse Female 17 years Full-time OH Nurse Female 12 years Full-time Table 2. List of themes and sub-themes. Theme 1: Bene¯ts of occupational health physiotherapy Sub-themes:  Rapid access intervention  Advanced knowledge and clinical reasoning Theme 2:  Evidence-based practice Sub-themes:  Providing an additional perspective Challenges of occupational health physiotherapy  Dealing with occupational health challenges  Managing role con°ict  Personal qualities and attributes  Role substitution

Experiences of occupational health doctors and nurses about the role of physiotherapists 5 Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com We call on them to problem solve complex \\A lot of the time, clients prefer to see the by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. cases, especially when we cannot sometimes physio because they know what to say and do make a decision ourselves.\" (Case 1, OH at week 1 of the injury and then week 2 and Doctor). then a few weeks later. If I see the same client, they don't get the same type of advice . . . we \\We don't expect the physiotherapist to pro- doctors tend to give the same advice . . . we are vide a generalist role. We have an occupa- probably not as consistent in our advice as tional health physio in the department because physiotherapists.\" (Case 2, OH Doctor). they have very speci¯c knowledge, so you get to tap into that knowledge to get a better idea of Occupational health nurses were of the view how injured the employee really is.\" (Case 1, that physiotherapists not only improve the quality OH Nurse 5). of care provided to clients, but also provide an evidence-based in°uence on the organization: Occupational health physiotherapists provide more specialized information compared to occu- \\The physio does not only provide care to our pational health doctors and nurses: clients, they also deal with issues within the organisation. I think it's very important they \\Sometimes, as a nurse, we are unable to get involved at this level because they have all provide the level of detail the employer wants. this knowledge about anatomy and physiology We tend to give only general advice, like for and they can justify why we say what we say . . . back pain we say keep active and don't do any if that makes sense.\" (Case 1, OH Nurse 1). heavy manual handling work, then the em- ployer says that the sta® member is already \\I suppose that physios are more involved doing this and they want more speci¯c advice. than we are in assessing because they under- I think there is a need for having physios in stand things like human function. We would occupational health departments who are probably just give clients a back booklet, better placed to deal with these types of cases.\" whereas the physio would know what the (Case 2, OH Nurse 1). latest information is and how to translate this into organisational requirements. We sort of \\They are able to evaluate in such detail the get the ball rolling . . . they are the ones with all e®ectiveness of interventions, so they are best the fancy interventions.\" (Case 2, OH placed to provide an accurate picture and Nurse 2). opinion about how to reduce work injuries.\" (Case 1, OH Nurse 7). Evidence-based practice Providing an additional perspective Participants felt that physiotherapists were better Participants expected physiotherapists to provide able to re¯ne and implement evidence-based an additional perspective in selected occupational protocols: health cases: \\I think physios are often better at simplifying \\It is better to have physios because they can the evidence and the general consensus is that o®er more expertise, which I ¯nd compliments they tend to use it more often.\" (Case 1, OH the doctor's advice.\" (Case 1, OH Nurse 4). Doctor). \\I think the more specialists there are on the \\Physios tend to follow protocols, so they team to assist sta® with all sorts of conditions, don't miss anything. I guess they are keen for the better . . . this will ensure that sta® get everyone to be treated according to a better care, so I think physiotherapists can standard.\" (Case 1, OH Nurse 6). help make care better.\" (Case 2, OH Nurse 1). One occupational health doctor viewed their Physiotherapists were also expected to work in workload as being too high and unpredictable to collaboration with occupational health doctors and follow guidelines strictly. They felt that phy- nurses and not in isolation: siotherapists had more time to o®er dedicated treatment according to evidence-based protocols: \\Physiotherapists would need to liaise directly with doctors and nurses if they want to o®er a di®erent opinion so that any disagreement can

Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com 6 L. Chetty occupational health departments as a potential by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. threat. Some occupational doctors and nurses were be resolved and the best advice is given to concerned that an advancing physiotherapy role sta®.\" (Case 1, OH Nurse 3). could make it more di±cult for them to justify their own positions: \\There is no doubt in my mind that phy- siotherapists have unique skills, so having \\There seems to be no structure these days them around makes the occupational health about who does what . . . our roles seems to be service more complete because they can sup- getting blurred all the time, ¯rst with nurse-led ply more input into the cases, which the doc- services and now with the addition of phy- tors might not have thought about.\" (Case 1, siotherapists. It's very di±cult to say I'm a OH Nurse 4). consultant and I do this because the physios and the nurses do it as well.\" (Case 2, OH Theme 2: Challenges of Occupa- Doctor). tional Health Physiotherapy \\I think if doctors do their bit, nurses do their The four sub-themes under this theme are: bit and similarly physios do their bit, and we (1) dealing with occupational health challenges; all work closely together, then it really works (2) managing role con°icts; (3) personal qualities well. I think it's only a problem when some and attributes; and (4) role substitution. professions try to go beyond what they are trained to do.\" (Case 2, OH Nurse 1). Dealing with occupational health challenges Although choosing the best candidate for a role is logical, the general view of the physiotherapy Participants agreed that occupational health role was that it would suit someone who was aware departments' deal with many challenges and phy- that their role was constantly under scrutiny by siotherapists had a crucial role in helping to alle- other professions within the team and that viate some of these challenges, such as the long they had to constantly clarify their position within waiting times and limited departmental resources: the team: \\One of the crucial issues in occupational \\As an occupational health nurse I have to health is the waiting times . . . and the nurses constantly clarify my position and show the are so busy with other things . . . they don't value and attributes I bring to the post. Oc- always have the time to deal with all of this. cupational health physiotherapists are not I think this is where the physiotherapist comes traditional members of the team, and so it is in . . . helping to reduce the wait to be seen.\" easy to get a bit confused about their special (Case 1, OH Nurse 2). traits.\" (Case 1, OH Nurse 8). Another challenge was the lack of specialized Personal qualities and attributes clinicians dealing with certain cases and the mul- tiple problems presenting to occupational health There were certain professional and personal departments: attributes that physiotherapists are required to possess. This involved being able to competently . . .\\especially for the acute musculoskeletal perform a range of physiotherapeutic treatment cases, I don't think the nurses and even the modalities, have good time management and can doctors are skilled enough to deal with some of demonstrate con°ict resolution skills. These attri- these. The physiotherapist can help with butes were even part of the recruitment process: early management to resolve these injuries.\" (Case 1, OH Nurse 4). \\While it is important to get someone with a range of skills, I think it is also necessary to Managing role con°icts get someone that has the attributes to cope with the demands of the job and be able to deal Some occupational health doctors and nurses with di±cult managers.\" (Case 1, OH viewed the advancement of physiotherapy's role in Nurse 5).

Experiences of occupational health doctors and nurses about the role of physiotherapists 7 Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com Role substitution health, beyond that of a generalist physiotherapist, by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. was perceived as an essential component of occu- Physiotherapists were also required to occasionally pational health physiotherapy practice. This ad- substitute for the role of an occupational health vanced level of knowledge and reasoning is required doctor or nurse as they acknowledged that phy- because physiotherapists in occupational health siotherapists had similar skills and knowledge: must provide an expert opinion on both clinical and organizational issues. One of the most e®ective \\We had a client who was having trouble with means of reducing resistance to a physiotherapy his hip and he didn't need to see the doctor role and showing it can make a di®erence is dem- because the physio could assess and tell his onstrating clinical e®ectiveness.10 Some of the oc- manager he could come back to work and what cupational health clinicians interviewed accepted should be avoided. So he really didn't need to they had limited knowledge with regards to mus- see the doctor.\" (Case 1, OH Nurse 2). culoskeletal injuries and it could be argued that physiotherapists add value to the occupational \\I see no reason why a physiotherapist cannot health service by providing advanced knowledge reassure sta® and tell them how to deal with and reasoning in the rehabilitation of these their injuries. Clients don't need to wait for injuries. the nurse or doctor.\" (Case 2, OH Nurse 4). The ability of physiotherapists to provide an Discussion additional perspective within an occupational health department was seen as an important role to The aim of this study was to explore the experi- help ¯lter the referrals coming into the service. ences of occupational health doctors and nurses This would involve identifying those that are at about the role of physiotherapists providing occu- high risk, those with complex injuries and may pational health rehabilitation. A higher number of have di±culty performing their job, and those that nurses participated in this study which is in keep- are potentially at risk of sustaining injuries. Ar- ing with the higher number of nurses employed in guably, one of the most important contributions occupational health departments. The semi- that physiotherapists can make to an occupational structured interviews were designed in a way that health department is providing appropriate advice all participants were asked similar questions while following a referral in order to avoid inappropriate allowing for more in-depth probing to cover a wide use of occupational health doctors and nurses' range of topics about the role of physiotherapists time, in particular occupational health doctors, to providing occupational health rehabilitation. focus on complex medical cases. Phillips et al. evaluated the cost-e®ectiveness of physiotherapy Occupational health doctors and nurses repor- support for NHS occupational health services and ted several bene¯ts of physiotherapists providing found that physiotherapists were not only skilled occupational health rehabilitation. In particular, to deal with a range of musculoskeletal disorders of rapid access to physiotherapists was perceived as the back, neck and upper and lower limbs, but this bene¯cial to clients attending an occupational service had a cost bene¯t which represents value health service so that they do not have to wait in for money.11 long queues for access to primary care physiother- apy. Furthermore, rapid access to physiotherapy Occupational health doctors and nurses also services is a national occupational health service reported challenges that physiotherapists may ex- quality requirement8 and physiotherapists should perience when providing occupational health re- be mindful that occupational health doctors and habilitation. Participants viewed the occupational nurses expect clients to have early access to their health department as a complex working environ- services to avoid being perceived as providing an ment that is in°uenced not only by clinical care, ine±cient service. A study by Addley et al. on the but by demanding occupational health challenges bene¯ts of a rapid access physiotherapy service in and organizational changes. In order to address an occupational health setting found signi¯cant these challenges, participants felt that phy- improvements in health outcomes and enabled siotherapists must be able to balance their clinical those absent from work to return to work earlier.9 role while meeting organizational needs and be able to deal with the presenting occupational health The advanced level of knowledge and clinical challenges. This will enhance the in°uence and reasoning of physiotherapists in occupational

Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com 8 L. Chetty performing, and how it threatened their own roles. by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Reed et al. (2009) did warn that when dealing with e®ectiveness of occupational health physiothera- di®erent stakeholders, con°icting and diverse pists on decision makers.12 agendas would come up and this had to be addressed. This is supported by the literature Participants anticipated that physiotherapists which recognizes that positive outcomes are at risk who were part of the occupational health depart- if departmental sta® do not work together to re- ment may experience role con°icts with the tradi- duce clinical errors.15 Furthermore, according to tional members of the occupational health team. In Atwal and Caldwell (2002), understanding the the context of this study, role identity is concep- roles of each other is essential to e®ectively col- tualized as the character people play (that is, the laborate on clinical management and avoid dupli- occupational health physiotherapist) when holding cation of professional roles, waste resources and speci¯c social positions in groups (that is, the oc- miss clinical signs in the interest of protecting cupational health team).13 Furthermore, according clinical turf.16 to Burke and Stets (2009) it is relational, since people interact with each other via their own role The limitation of the study is its generalizability identities. In this regard, the physiotherapist who given the restriction of the study to only two NHS is part of the occupational health team has the hospitals. Although only two cases were used, it is advantage of being constantly visible and easier to also an example of a broader group, and therefore access with the traditional members of the team to o®ers the prospect of transferability in which make certain there is a collective agreement on the readers can judge for themselves the applicability role of the physiotherapy and reduce any role of the ¯ndings to their own settings and context. con°icts. It will also ensure that the physiothera- pist is able to promote health and injury preven- Conclusion tion strategies from a rehabilitation perspective.14 The analysis of the qualitative data produced sub- The experience of participants was that al- themes that can be applied immediately to phys- though choosing the most appropriately quali¯ed iotherapy practice within occupational health and experienced candidate for a role is logical, the departments and can be used to further advocate recruitment of the occupational health physio- for its relevance in this setting. From the insights of therapy role is such that it would suit someone who occupational health doctors and nurses, phy- can demonstrate awareness that their role is con- siotherapists embedded within the occupational stantly under scrutiny by other professions within health team is likely to accomplish the key ele- the team. This involves having to constantly clarify ments of a safe, e®ective and quality occupational their position in the department, and being able to health service. Given the importance of team in- challenge medical opinions and those of the refer- tegration, future research should incorporate vari- ring manager, especially when it was contradictory ous other stakeholders to ascertain the role of to their own professional recommendations. physiotherapists within occupational health reha- bilitation. This information may then be used to It is also vital for physiotherapists to demon- build on the sub-themes generated in this study strate an advance level of clinical knowledge and and can be used to promote awareness of the con- reasoning because this may assist with fostering tribution of physiotherapists in line with the trust, respect and acceptance in occupational intended direction of occupational health services. health departments. Some participants felt that it was vital for physiotherapists working in occupa- Acknowledgment tional health rehabilitation to demonstrate an ad- vance level of clinical knowledge and reasoning The author would like to thank all participants for because it may allow them to con¯dently under- taking part in the research study. take some of the work traditionally performed by occupational health doctors and nurses. However, Con°ict of Interest there was concern that physiotherapists must re- ceive adequate training to carry out any new The author has no con°icts of interest to declare. components in their role so that they do not risk practicing outside the scope of their knowledge. There were some participants, however, that were concerned about the advanced clinical role that occupational health physiotherapists were

Experiences of occupational health doctors and nurses about the role of physiotherapists 9 Hong Kong Physiother. J. 2020.40:1-9. Downloaded from www.worldscientific.com Funding/Support Introduction%20to%20SEQOHS%20for%20OH% by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. 20physiotherapy%20services%20booklet%20V1.2. This work was supported by Arthritis Research pdf. UK. 9. Addley K, Burke C, McQuillan P. Impact of a di- rect access occupational physiotherapy treatment References service. Occup Med 2010;60:651–53. 10. Grimmer K, Beard M, Bell A, Chipchase L, 1. Daley D, Miller M. Moving forward in occupational Edwards E, Fulton I, Gill T. On the constructs of health physical therapy: The journey toward spe- quality physiotherapy. Aust J Physiother 2000; cialisation in the United States. Phys Ther Rev 46(1):3–7. 2013;18:316–26. 11. Phillips CJ, Phillips R, Main CJ, Watson PJ, Davies S, Farr A, Harper C, Noble G, Aylward M, 2. Chetty L. A critical review of physiotherapy as a Packman J, Downton M, Hale J. The cost e®ec- clinical service in occupational health departments. tiveness of NHS physiotherapy support for occu- Workplace Health Saf 2014;62:389–94. pational health services. BMC Musculoskeletal Disorders 2012;13:29–39. 3. Chetty L. Perceptions of workforce managers about 12. Chetty L. E®ectiveness of physiotherapy provision the role and responsibilities of physiotherapists in within an occupational health setting Indian. occupational health rehabilitation: A qualitative J Physiother Occup Ther 2011;5(3):50–3. study. Prog Med Sci 2017;1(1):14–18. 13. Burke PJ, Stets JE. Identity theory. New York: Oxford University Press, 2009. 4. Nicholson PJ. Occupational health services in the 14. Chetty L. Occupational health promotion and in- UK — challenges and opportunities. Occup Med jury prevention strategies: The rehabilitation per- 2004;54:147–52. spective. J Commun Health Sci 2011;6(1):60–6. 15. Reed MS, Graves A, Dandy N, Posthumus H, 5. Walsham G. Doing interpretive research. Eur J Inf Hubacek K, Morris J, Prell C, Quinn CH, Stringer Syst 2006;15:320–30. C. Who's in and why? A typology of stakeholder analysis methods for natural resource management. 6. Punch K. Introduction to social research: Quanti- J Environ Manage 2009;90:1933–49. tative and qualitative approaches. London: Sage, 16. Atwal A, Caldwell K. Do multidisciplinary 2005. integrated care pathways improve interpro- fessional collaboration? Scand J Caring Sci 2002; 7. Bonner A, Tolhurst G. Insider-outsider perspec- 16(4):360–67. tives of participant observation. Nurse Res 2002; 9(4):7–19. 8. Safe E®ective Quality Occupational Health Ser- vice (2015) Introduction to SEQOHS accreditation for OH physiotherapy services. Available from: https://www.physio.seqohs.org/CMS Documents/ Scheme/OH/171005%20%20document%20%20

Research Paper Hong Kong Physiotherapy Journal Vol. 40, No. 1 (2020) 11–17 DOI: 10.1142/S101370252050002X Hong Kong Physiother. J. 2020.40:11-17. Downloaded from www.worldscientific.com Hong Kong Physiotherapy Journal by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. https://www.worldscientific.com/worldscinet/hkpj Responsiveness of pain, functional capacity tests, and disability level in individuals with chronic nonspeci¯c low back pain Prasert Sakulsriprasert1, Roongtiwa Vachalathiti1,* and Pathaimas Kingcha2 1Division of Physical Therapy, Faculty of Physical Therapy Mahidol University, Nakhon Pathom, 73170, Thailand 2Physical Therapy Center, Faculty of Physical Therapy Mahidol University, Nakhon Pathom, 73170, Thailand *[email protected] Received 30 October 2018; Accepted 13 October 2019; Published 6 December 2019 Background: Clinical outcomes are very important in clinical assessment, and responsiveness is a compo- nent inside the outcome measures that needs to be investigated, particularly in chronic nonspeci¯c low back pain (CNSLBP). Objective: This study aimed to investigate the responsiveness of pain, functional capacity tests, and dis- ability in individuals with CNSLBP. Methods: Twenty subjects were assessed in pain using the following methods: visual analog scale (VAS) and numeric pain rating scale (NPRS), functional capacity tests: functional reach test (FRT), ¯ve-time sit-to-stand test (5 TSST), and two-minute step test (2 MST), and disability level: modi¯ed Oswestry Disability Ques- tionnaire (MODQ), Thai version before and after 2-week intervention session. For interventions, the subjects received education, spinal manipulative therapy, and individual therapeutic exercise twice a week, for a total of two weeks. The statistics analyzed were change scores, e®ect size (ES), and standardized response mean (SRM). Results: The most responsive parameter for individuals with CNSLBP was pain as measured by numeric pain rating scale (NPRS) (ES À0.986, SRM À0.928) and ¯ve-time sit-to-stand test (5 TSST) (SRM À0.846). Conclusion: This study found that NPRS pain and 5 TSST were responsive in individuals with CNSLBP at two weeks after the beginning of interventions. Keywords: Back pain; functional; test; capacity; sensitivity; disability. *Corresponding author. Copyright@2020, Hong Kong Physiotherapy Association. This is an Open Access article published by World Scienti¯c Publishing Company. It is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY- NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly cited, the use is non-commercial and no modi¯cations or adaptations are made. 11

Hong Kong Physiother. J. 2020.40:11-17. Downloaded from www.worldscientific.com 12 P. Sakulsriprasert, R. Vachalathiti & P. Kingcha et al., by using the standardized pattern of func- by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. tional tests, while minimal equipment is needed Introduction and the administration and interpretation are simple. The exemplary functional capacity tests Low back pain (LBP) is a major health problem are functional reach test (FRT), 5 TSST, and 2 internationally characterized by a range of bio- MST.15 These functional capacity tests have physical, psychological, and social dimensions af- advantages for clinical use, but the responsiveness fecting functioning, societal participation, and of each test needs to be investigated. personal ¯nancial prosperity.1,2 The reported prevalence of LBP was high, especially for chronic This study was therefore conducted to examine nonspeci¯c low back pain (CNSLBP), approxi- the responsiveness of pain, functional capacity test, mately 15.4% (Ref. 3) of which chronic low back and disability level in individuals with CNSLBP on pain was about 2.5 times more prevalent in work- 2-week interval of pre-test and post-test assess- ing population compared to nonworking group.4 ments for determining the responsiveness of the Nonspeci¯c low back pain is labeled so when the selected clinical outcome measures. speci¯c nociceptive source cannot be found5 while chronic is de¯ned so when the duration that the Materials and Methods pain persists is longer than 3 months.6 As afore- mentioned impacts are caused by LBP, the out- Subjects come assessments for individuals with LBP should therefore cover pain assessment, and also related Twenty individuals with CNSLBP with the dura- activities and disability. tion of their symptoms being at least 3 months with mild to moderate pain intensity (1–6 cm on Responsiveness is very important for clinicians visual analog scale, VAS) were recruited from to consider when the outcome measures are used Physical Therapy Center, Faculty of Physical clinically, by which the responsiveness is the ability Therapy, Mahidol University. The exclusion cri- of the outcome measures to detect the patient's teria were speci¯c for radicular LBP, neurological recovery or health status over time.7 The recom- or cardiovascular diseases, history of previous sur- mended methods for statistical analysis to repre- gery at the spine or lower extremity, pregnancy, sent the responsiveness consist of change score, and on menstruation. Written informed consent e®ect size (ES), and standardized response mean was obtained from each individual before partici- (SRM).8–11 It has been reported that for the indi- pation. The study protocol and informed consent viduals with acute nonspeci¯c low back pain, the have been approved by Mahidol University- responsive outcomes were pain and disability as Central Institutional Review Board (MU-CIRB), reported with ES. In addition, it was found that COA no. 2017/155.2808. most of the patients recovered in 2 weeks,12 to be comparable to the patients with acute LBP, the Outcome measures duration of 2 weeks between the baseline and after- intervention assessments gains attention for the Pain intensity: Visual analog scale (VAS) with study in the patients with chronic LBP. For 10 cm horizontal line anchored by `no pain' on the patients with chronic LBP, the responsiveness has left end and `worst pain imaginable' on the right been studied in various outcome measures such as was used. NPRS from 0 to 10 representing pain SF-36 and cooperative (COOP) chart system,13 intensity verbally was also used in this study.16,17 Oswestry Disability Index (ODI), EuroQol The individuals with CNSLBP reported their pain (EQ-5D), and Shuttle Walking Test (SWT).14 intensity on worst movement or activity on the However, the previous studies had the heteroge- tested day by marking on VAS and verbal neity of the recruited patients, di®erent time in- expression for NPRS. terval examinations, and various statistical analyses.13,14 In addition, the test such as SWT has Functional capacity tests some limitations for clinical use because of the ac- ceptability to patients and the cost for adminis- There were three functional capacity tests in this tration.14 However, the functional tests are very study comprising functional reach test, ¯ve-time important for the assessment because they can sit-to-stand test, and two-minute step test. The represent the individual's capacity for performing individuals with CNSLBP in comfortable clothes particular activities. The concepts of functional capacity tests have been developed by Simmonds

Responsiveness of pain, functional capacity tests, and disability level in CLBP individuals 13 Hong Kong Physiother. J. 2020.40:11-17. Downloaded from www.worldscientific.com and canvas shoes were given an explaination and percentage represented a greater level of disability by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. saw the demonstration before the test. de¯ned as follows: 0–20 minimal disability, 21–40 moderate disability, 41–60 severe disability, 61–80 FRT was used for assessing dynamic balance crippled, and 81–100 bed bound or symptom and °exibility of the trunk muscle. The researcher magni¯er.21 attached a ruler to the wall at participant's shoulder height and provided feet placement marks Procedures on the °oor. The individuals with CNSLBP stood sideways next to the wall without leaning against The individuals were assessed two times, the ¯rst the wall, feet apart as shoulder width, and raised time was at the beginning of the intervention both hands to 90, kept elbows straight and hands program, baseline or pre-test assessment. The ¯sting and the 3rd metacarpal head on the ruler second was at the end of the 2-week program, post- was recorded as the starting position. They were test assessment. The assessments were pain inten- then instructed to reach forward with arm out- sity during worst movement by VAS and NPRS, stretched remaining in shoulder height, as far as functional capacity tests comprising FRT 5 TSST, possible without stepping three times, the best and 2 MST, and disability level by MODQ, Thai distance reached was then recorded.18 version. All assessments had been done by a physical therapist who has been trained for all 5 TSST was used for assessing back and lower assessments for 1 week of didactic period and limb strength. The researcher placed a chair training session before this study. After ¯nishing against the wall for ¯xing the tested location. The pre-test assessment, the results were taken away individuals with CNSLBP were seated in the and kept by another researcher. The physical middle of the chair, back straight without support therapy intervention program was conducted in on the backrest and feet °at on the ground, both interim between the two-time assessments. The arms crossed to the chest. They were instructed to intervention program comprising education, spinal rise to fully stand and then returned to a fully manipulative therapy and therapeutic exercise23 seated position as fast as possible ¯ve times. The including stretching and strengthening for lower time spent to complete ¯ve times was recorded.19 back twice a week lasted for two weeks. 2 MST was used to measure the endurance Statistical analysis during dynamic weight shifting activity. The re- searcher measured the stepping height of each in- The descriptive statistics for demographic data of dividual which was equal to the mid-thigh level, the subjects were shown in number, means and halfway between the iliac crest and patella, and standard deviations, and percentage. The respon- marked the level on the wall. The individual was siveness in this study consisted of change score, then informed to step in the provided place with e®ect size, and standardized response mean. moving the knee up to the predetermined mark on Change scores were calculated by subtracting post- the wall alternately, started with the right leg and test value from pre-test value, representing the continued as many steps as possible within 2 magnitude of the di®erence between pre-test and minutes. The researcher counted the number of post-test, the greater the magnitude, the greater times the right knee reached the mark. If needed, the responsiveness or change. In this study, the the individual could be allowed to place one hand change score was calculated as post-test data on the table for balance.19 minus baseline data. ES has been recommended for determining the responsiveness.24 The calculation Disability level: The total score of modi¯ed is the change score divided by standard deviation Oswestry Disability Questionnaire (MODQ), Thai of the baseline score,25 the value below 0.2 is con- version, has been used by summarizing from 10 sidered small, 0.5 moderate, and 0.8 large accord- items; pain intensity, personal care, lifting, walk- ing to previous studies.8,10,11 SRM is similar to ES, ing, sitting, standing, sleeping, social life, travel- which is calculated by the change score divided by ing, employment/home making, which is standard deviation of the change. Therefore, SRM categorized into 6 levels of each item starting from indicates an estimate of change, which is stan- 0 (no disability) to 5 (highest disability) and dardized relative to the variability in change multiplied with two to gain the percentage of disability level.20 It can imply how pain a®ects various activities of daily living.20–22 The higher

14 P. Sakulsriprasert, R. Vachalathiti & P. Kingcha Table 2. Baseline and post-test data of the subjects. scores. The consideration for the calculated values Parameters Baseline Post-test is the same as ES, or 0.2, 0.5, and 0.8 representing small, moderate, and large, respectively.9 To com- Pain 3:2 Æ 1:6 1:9 Æ 1:9 pare the change scores between VAS and NPRS, Visual analog scale (VAS), cm 4:0 Æ 1:6 2:4 Æ 1:9 the independent t-test was used since the data were Numeric pain rating scale Hong Kong Physiother. J. 2020.40:11-17. Downloaded from www.worldscientific.com normally distributed with SPSS program version 34:4 Æ 5:7 35:3 Æ 6:1 by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. 23 (IBM Corp., Armonk, NY), the statistical sig- (NPRS), (0–10) 11:3 Æ 3:0 9:8 Æ 3:2 ni¯cance was set at p-value less than 0.05. 77:4 Æ 34:0 91:9 Æ 23:7 Functional capacity test Results Functional reach test (FRT), cm 14:0 Æ 11:3 8:9 Æ 7:9 Five-time sit to stand test Demographic data of all subjects are reported in Table 1. Baseline and post-test data of the subjects (5 TSST), sec are shown in Table 2. The results of change score, Two-minute step test (2 MST), ES, and SRM for all parameters are provided in Table 3. The change scores of pain intensity were rep À1.3 cm and À1.6 cm in VAS and NPRS, respec- Disability tively. The change scores of functional capacity MODQ total score, % tests were 0.9 cm for FRT, À1:5 s for 5TSST, and 14.5 repetitions for 2MST, respectively. The Table 3. Change score, e®ect size, and standardized response change score of disability as measured by MODQ mean of each parameter. total score was À5:1%. Standardized For the ES, the most responsive parameters were pain measured by NPRS (ES ¼ À0:986), and Change E®ect response VAS (ES ¼ À0:789). While 5TSST had the highest responsiveness for functional capacity test Parameters score size mean (ES ¼ À0:510). Visual analog scale (VAS) À1:3 À0:789 À0:781 For the SRM, the most responsive parameter Numeric pain rating scale À1:6 À0:986 À0:928 was NPRS (SRM ¼ À0:928), followed by 5TSST (SRM ¼ À0:846), and VAS (SRM ¼ À0:781). (NPRS) 0.9 0.158 0.184 Functional reach test À1:5 À0:510 À0:846 (FRT) 14.5 0.424 0.583 Five-time sit to stand test À5:1 À0:448 À0:487 (5 TSST) Two-minute step test (2 MST) MODQ total score Table 1. Demographic data of the subjects. Characteristics Summary The comparison of the change scores between VAS and NPRS showed no signi¯cant di®erence, Female/Male, number 13/7 t ¼ 0:559, p-value was 0.580. Age, years 43:15 Æ 2:03 Weight, kg 57:80 Æ 2:06 Discussion Height, cm 161:40 Æ 1:69 BMI, kg/m2 22:18 Æ 0:60 This study aimed to investigate the responsiveness Duration of symptom, months 32:30 Æ 35:50 of clinical outcomes regarding pain, functional ca- Location of LBP, % pacity tests, and disability level in individuals with Left or Right 35% CNSLBP over the period of 2weeks. The results of Left side this study showed that pain as reported by VAS Right side 20% and NPRS were responsive according to their Both sides or Centralized 45% change scores, ES, and SRM. Using Cohen's sug- Sacroiliac joint involvement gestions,8 the value of 0.8 or more is considered Yes 15% large for ES and SRM. The ES and SRM of NPRS No 85% were À0:986 and À0:928, respectively. These Working tasks, % values were therefore construed as large and Doing housework 10% Working in prolonged sitting 65% Working in prolonged standing 25%

Responsiveness of pain, functional capacity tests, and disability level in CLBP individuals 15 Hong Kong Physiother. J. 2020.40:11-17. Downloaded from www.worldscientific.com responsive. While VAS was little lower than NPRS the dynamic postural control training if the as- by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. in terms of change score, ES, and SRM. However, sessment pertaining to the dynamic postural con- the comparison of the change scores between VAS trol is included. and NPRS showed no signi¯cant di®erence. In addition, it has been proved that VAS and NPRS For disability level, the responsiveness data have good agreement when using both in acute using MODQ total score as reported with change pain assessment.26 The pain assessment in patients score, ES, and SRM were À5:1, À0:448, and with chronic LBP contains multiple factors. This À0:487, respectively, which were smaller than the study therefore used the functional capacity tests previous study12 with change score À16:2 and ES and the disability level additionally for better un- À0:930. The result could clearly be concluded as derstanding of the changes in the patients with that the individuals with CNSLBP had slower re- CNSLBP. covery as represented by decreased disability level. Therefore, the future study should provide longer The functional capacity tests, according to duration of post-test assessment for better result of SRM, 5TSST were proved to be most responsive responsiveness in disability level. This study was rather than FRT and two-minute step test. This designed to be 2-week interval assessment in order result might be because 5TSST involves the to be comparable to the previous study,12 by which strength of knee extensor in performing standing using the same methods of statistical analysis for up together with the activity of back extensor responsiveness, also, the clinical setting and inter- muscles for adjusting the trunk upright by extensor vention program were also as same as the previous moment.27 This responsiveness could be hypothe- study to investigate the behavior of the change in sized such that the function of back extensor individuals with CNSLBP compared to the acute muscles was perhaps better at the post-test ex- patients that had been taken as reference. The amination on the period of 2 weeks owing to de- results in this study were therefore can be con- creased pain contributing to increased speed of cluded such that the responsiveness in individuals movement, however, the change of back extensor with CNSLBP was lower than patients with acute strength should be investigated for further study. LBP in the clinical outcomes such as pain and disability level. While FRT and 2MST had small to moderate responsiveness reported as ES and SRM. FRT One of the limitations in this study is the re- involves the dynamic postural control for shifting sponsiveness analyses, which was internal respon- the center of mass (COM) towards the front edge siveness. The external responsiveness was not of the base of support as needed.18,28 Also, 2MST studied since another relevant outcome measure was used to investigate the dynamic postural con- was needed for correlation. However, the indivi- trol together with aerobic endurance requiring duals with CNSLBP had many clinical aspects weight shifting, lower limb movement, and stabil- which were di±cult to determine, requiring an- ity of the spine.19 Their lower responsiveness other relevant outcome to cover all. Another con- results could indicate that the improvement of sideration was the time interval. The future study dynamic postural control needs longer period than should take longer period for the responsiveness 2 weeks for this training in individuals with analysis to see greater change representing larger CNSLBP, the results therefore suggested the responsiveness. practitioners or therapists to understand the re- covery and set proper therapeutic time frame since Conclusion the responsiveness in dynamic postural control would take longer time to follow-up as measured by This study investigated the responsiveness of the FRT and 2 MST. In addition, the intervention clinical outcomes used to measure the changes in program in this study did not include the dynamic individuals with CNSLBP at 2 weeks after the postural control training, the active portion of the beginning of interventions. program was back stretching and strengthening exercise. The small responsiveness data might The most responsive parameter in this study represent the exercise speci¯city while the back was pain as presented with the highest values in ES strengthening exercise had minimal cross-over and standardized response mean. While the func- e®ect to dynamic postural control. The interven- tional capacity tests were less responsive than tion program for future study might include also pain, the longer duration of physical therapy in- tervention aiming to promote functional capacity

Hong Kong Physiother. J. 2020.40:11-17. Downloaded from www.worldscientific.com 16 P. Sakulsriprasert, R. Vachalathiti & P. Kingcha 8. Cohen J. Statistical Power Analysis for the by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Behavioural Sciences. New York: Academic Press, is needed which is also suggested for further 1977. investigation. 9. Liang M, Fossel A, Larson M. Comparisons of ¯ve Acknowledgments health status instruments for orthopedic evalua- tion. Med Care. 1990;28:632–42. The authors would like to thank all participants in this study from Physical Therapy Center, Faculty 10. Norman G, Stratford P, Regehr G. Methodological of Physical Therapy, Mahidol University, Thailand. problems in the retrospective computation of re- sponsiveness to change: The lesson of Cronbach. J Con°ict of Interest Clin Epidemiol. 1997;50:869–79. The authors declare no con°ict of interest. 11. Stucki G, Liang M, Fossel A, Katz J. Relative re- sponsiveness of condition-speci¯c and generic Author Contributions health status measures in degenerative lumbar spinal stenosis. J Clin Epidemiol 1995;48:1369–78. The preparation of the paper along with the liter- ature review and data analysis was carried out by 12. Sakulsriprasert P, Vachalathiti R, Vongsirinavarat Prasert Sakulsriprasert. M, Pichaisak W. Responsiveness of pain, active range of motion, and disability in patients with Roongtiwa Vachalathiti helped in preparation acute nonspeci¯c low back pain. Hong Kong Phy- of the paper, research design planning, results siother J. 2011;29:20–4. validation and research team training. Pathaimas Kingcha helped in data collection, literature review 13. Bronfort G, Bouter L. Responsiveness of general and team coordination. health status in chronic low back pain: A compar- ison of the COOP Charts and the SF-36. Pain. References 1999;83:201–9. 1. Hartvigsen J, Hancock M, Kongsted A, Louw Q, 14. Campbell H, Rivero-Arias O, Johnston K, Gray A, Ferreira M, Genevay S, et al. What low back pain is and why we need to pay attention. The Lancet Fairbank J, Frost H. Responsiveness of objective, 2018;391(10137):2356–67. disease-speci¯c, and generic outcome measures in 2. Koes B, van Tulder M, Ostelo R. Clinical guidelines for the management of low back pain in primary patients with chronic low back pain: An assessment care. Spine 2001;26(22):2504–14. for improving, stable, and deteriorating patients. 3. Iizuka Y, Iizuka H, Mieda T, Tsunoda D, Sasaki T, Spine. 2006;31(7):815–22. Tajika T, et al. Prevalence of chronic nonspeci¯c 15. Simmonds M, Olson S, Jones S, Hussein T, Lee C, low back pain and its associated factors among Novy D, et al. Psychometric characteristics and middle-aged and elderly people: An analysis based clinical usefulness of physical performance tests in on data from a musculoskeletal examination in patients with low back pain. Spine. 1998;23(22): Japan. Asian Spine J 2017;11(6):989–97. 2412–21. 16. Michener L, Snyder A, Leggin B. Responsiveness of 4. Jackson T, Thomas S, Stabile V, Shotwell M, Han X, McQueen K, A systematic review and meta- the numeric pain rating scale in patients with analysis of the global burden of chronic pain without clear etiology in low- and middle-income shoulder pain and the e®ect of surgical status. countries: Trends in heterogeneous data and a J Sport Rehabil 2011;20(1):115–28. proposal for new assessment methods. Anesth 17. Cha®ee A, Yakubo® M, Tanabe T. Responsiveness Analg 2016;123:739–48. of the VAS and McGill pain questionnaire in measuring changes in musculoskeletal pain. J Sport 5. Maher C, Underwood M, Buchbinder R. Non-spe- Rehabil 2011;20(2):250–5. ci¯c low back pain. Lancet 2017;389:736–47. 18. Duncan P, Weiner D, Chandler J, Studenski S. Functional reach: A new clinical measure of bal- 6. Chou R, Shekelle P. Will this patient develop per- ance. J Gerontol 1990;45(6):M192–7. sistent disabling low back pain? JAMA 19. Rikli R, Jones C. Development and validation of a 2010;303:1295–302. functional ¯tness test for community-residing older adults. J Aging Phys Act 1999;7(2):129–61. 7. Portney L, Watkins M. Foundations of clinical re- 20. Sakulsriprasert P, Vachalathiti R, Vongsirinavarat search: Applications to practice. 2nd ed. Upper M, Kantasorn J. Cross-cultural adaptation of Saddle River, New Jersey: Prentice-Hall, Inc., 2000. modi¯ed Oswestry low back pain disability ques- tionnaire to Thai and its reliability. J Med Assoc Thai 2006;89(10):1694–701. 21. Fairbanks J, Couper J, Davies J, O'Brien J. The Oswestry low back pain disability questionnaire. Physiotherapy 1980;66:271–3.

Responsiveness of pain, functional capacity tests, and disability level in CLBP individuals 17 22. Fritz J, Irrgang J. A comparison of a modi¯ed assessing change scores. Phys Ther 1996;76:1109– Oswestry low back pain disability questionnaire 23. and the Quebec back pain disability scale. Phys 26. Breivik E, Bjo€rnsson G, Skovlund E. A comparison Ther 2001;81:776–88. of pain rating scales by sampling from clinical trial data. Clin J Pain 2000;16:22–8. 23. Foster N, Anema J, Cherkin D, Chou R, Cohen S, 27. Bohannon RW, Bubela DJ, Magasi SR, Wang Y-C, Gross D, et al. Prevention and treatment of low Gershon RC. Sit-to-stand test: Performance and back pain: Evidence, challenges, and promising determinants across the age-span. Isokinet Exerc directions. The Lancet 2018;391(10137):2368–83. Sci 2010;18(4):235–40. 28. Weiner DK, Bongiorni DR, Studenski SA, Duncan 24. Beaton D, Hogg-Johnson S, Bombardier C. Eval- PW, Kochersberger GG. Does functional reach uating changes in health status: Reliability and improve with rehabilitation? Arch Phys Med responsiveness of ¯ve generic health status mea- Rehabil 1993;74(8):796–800. sures in workers with musculoskeletal disorders. Hong Kong Physiother. J. 2020.40:11-17. Downloaded from www.worldscientific.com J Clin Epidemiol 1997;50:79–93. by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. 25. Stratford P, Binkley J, Riddle D. Health status measures: Strategies and analytic methods for

Research Paper Hong Kong Physiotherapy Journal Vol. 40, No. 1 (2020) 19–27 DOI: 10.1142/S1013702520500031 Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com Hong Kong Physiotherapy Journal by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. https://www.worldscientific.com/worldscinet/hkpj Thai dance exercises bene¯ted functional mobility and fall rates among community-dwelling older individuals Chonticha Kaewjoho1,2, Lugkana Mato1,2, Thiwabhorn Thaweewannakij1,2, Saowanee Nakmareong1,2, Supaporn Phadungkit1,2, Chitanongk Gaogasigam2,3 and Sugalya Amatachaya1,2,* 1School of Physical Therapy Faculty of Associated Medical Sciences Khon Kaen University, Khon Kaen, Thailand 2Improvement of Physical Performance and Quality of Life (IPQ) Research Group, Khon Kaen University, Khon Kaen, Thailand 3Department of Physical Therapy Faculty of Allied Health Sciences Chulalongkorn University, Bangkok, Thailand *[email protected] Received 12 April 2019; Accepted 25 October 2019; Published 16 December 2019 Background: With dramatic increase in the number of older individuals, special e®orts have been made to promote the levels of independence and reduce fall rates among these individuals. Objective: To investigate the e®ects of Thai dance exercises over 6 weeks on functional mobility and fall rates in community-dwelling older individuals. Methods: Sixty-one community-dwelling older adults were interviewed and assessed for their demographics and fall data during 6 months prior to participation in the study. Then they completed the quasi-experi- mental Thai dance exercise program for 50 minutes/day, 3 days/week over 6 weeks. Their functional mobility relating to levels of independence and safety were assessed prior to training, at 3-week and 6-week training. After completing the program at 6 weeks, participants were prospectively monitored for fall data over 6 months. *Corresponding author. Copyright@2020, Hong Kong Physiotherapy Association. This is an Open Access article published by World Scienti¯c Publishing Company. It is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY- NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly cited, the use is non-commercial and no modi¯cations or adaptations are made. 19

20 C. Kaewjoho et al. Results: Participants improved their functional mobility signi¯cantly after 3- and 6-week training (p < 0:01). The number of faller individuals obviously decreased from 35% (n ¼ 21) prior to training to only 8% (n ¼ 5) after training (p < 0:01). Conclusion: The current ¯ndings further extend bene¯ts of Thai dance as an alternative musical exercise program to promote levels of independence and safety among community-dwelling older adults. Keywords: Older adult; fall; balance; walking; cultural dance. Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com Introduction individuals on variables necessary for being inde- by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. pendent and fall rates would extend the clinical Advancing age commonly accompanies many implication of the program for older adults. system declines that a®ect several contributors to Therefore, this study compared the e®ects of Thai independence and risk of falls among older indivi- dance exercises over 3 and 6 weeks on the func- duals, including a safe and e±cient ambulatory tional mobility necessary for being independent, status, good static and dynamic balance, adequate including the timed up and go test (TUG), ¯ve lower extremity muscle strength, and good func- times sit-to-stand test (FTSST), 10-meter tional endurance.1,2 Therefore, special e®orts have walk test (10 MWT), and 6-minute walk test been made to promote levels of independence and (6 MinWT)2,5 and fall rates among community- reduce fall rates among these individuals, particu- dwelling older individuals. larly in the current era, whereby the number of older adults has obviously increased. Materials and Methods Many exercise programs have been reported for Study design and population their e®ectiveness in promoting the physical per- formance of older individuals.1,3,4 Among existing This quasi-experimental study was conducted in programs, musical and dance exercise programs community-dwelling older adults, aged 65 years have been reported to enhance recruiting and and over, from several rural communities in Thai- retaining of older individuals in the exercise pro- land, during November 2016 and September 2018. grams.5 However, the existing reports on cultural The eligible participants had to walk indepen- dance programs — Brazilian, Turkish and Greek dently over at least 10 m without any assistive dances — have their own characteristics and devices, and had not participated in a regular ex- varying options based on the country of origin that ercise program prior to being involved in the study. are suitable for their populations.6,7 Thus, they Older individuals who presented any signs and may be di±cult to be applied for Thai older indi- symptoms that might a®ect walking and the ability viduals, i.e., need special and long training dura- to participate in this study, such as unstable medi- tion to be familiarized in the training programs. cal conditions, in°ammation in the joints of the lower extremities (with a pain scale of more than 5 By contrast, Thai dance exercise is well known out of 10 on a visual analog scale), and having se- and widely used by Thai people. The program is quelae of neurological de¯cits, were excluded from characterized by smooth, gentle, and coordinated the study.2,11,12 The study protocol was approved movements involving the whole body8 that might by the local ethics committee (HE 602099) and eli- be particularly challenging for the important con- gible individuals signed a written informed consent tributors to the independence, community partici- before taking part in the study (clinical trial regis- pation, and safety of older individuals such as tration number NCT02919514). balance and walking ability, lower limb muscle strength, and functional endurance.2,5 However, Sample size calculation there are few studies reporting bene¯ts of Thai dance exercises, and only in female individuals The sample size was estimated from data of a pilot without consideration of all variables needed for study (n ¼ 18) for the primary outcome, the 10 being independent, along with fall rates of the MWT, with the e®ect size of 0.09 m/s, power of participants.9,10 Further exploration on the e®ects of Thai dance exercises in both male and female

Thai dance exercises bene¯ted functional mobility and fall rates among community-dwelling older individuals 21 Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com test at 80%, alpha level of 0.05, and a dropout rate Thai dance exercise training by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. of 20%. The ¯ndings indicated that the study required at least 55 participants. The program consisted of a warm-up session for 10 min, Thai dance exercises for 30 min, and a cool- Research protocols down and muscle-stretching session for 10 min. The Thai dance exercises were performed with a video Older adults who agreed to be involved in the demonstration of the standard traditional Thai study were screened and assessed for their eligi- dance using eight songs, including the Ngam sang bility according to the study criteria. Then, the duan, Chaw Thai, Ram ma si ma ram, Dong jan eligible participants were interviewed and assessed wan pen, Dok mai kong chat, Ying Thai jai ngam, for their demographics, including age, gender, body Dong jan kwan fa, and Boo cha nak rop songs. mass index, health status, and fall data over the These songs required the participants to move and previous six months prior to participation in the rotate their bodies while moving their arms up- study, with data con¯rmation from their relatives ward, downward, and sideward alternately and related events (if any), i.e., the date, time, (Fig. 1). During these movements, both legs needed place, circumstances, consequences, and treatment to step forward and backward with slight °exion of required. On the next day, participants were the knees on either a single or double limb support assessed for functional outcomes of the study. period according to the rhythm of the songs.9 Then, they were trained using standard protocols Participants were able to take a period of rest of traditional Thai dance following video demon- during the training, as needed. However, after stration, and they subsequently became involved in being involved in the program, they were encour- a traditional Thai dance exercise program in their aged to increase training time or minimize resting communities. Details of the training and testing periods, as they could. The participants were protocols are as follows. trained for 50 min/day, 3 days a week for 6 weeks; thus, there were 18 sessions in total. Data of Fig. 1. Examples of Thai dance exercise maneuvers.

Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com 22 C. Kaewjoho et al. standing.20–23 Participants performed ¯ve repeti- by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. tive chair-rise cycles at the fastest speed and in a participants who participated in the training safe manner without using their arms. The test program for less than 15 sessions (80% of all records the time in seconds from the command training sessions) were excluded from the data \\go\" until the participant's back touches the analysis to clearly present the bene¯t of training backrest of the chair after the ¯fth repetition.2,12,22 over six weeks.9 6-minute walk test: The 6 MinWT is an excellent Outcome measures reliability test (ICC ¼ 0:95) that is commonly used to represent functional endurance in community- Participants were assessed for their functional dwelling older individuals.24 The test records the mobility necessary for being independent, includ- longest distance walked along a rectangular walk- ing the TUG, FTSST, 10 MWT, and 6 MinWT2,5 way (96 m) in 6 min. Every minute during the test, in a random sequence. Prior to the assessments, a participants were informed of the time remaining group of three raters were trained for the testing and encouraged to continue walking as soon as protocols and standard commands were used for they could. Then, the total distance covered after the tests. Then they practiced using the tests in 10 6 min was recorded.12,25 pilot older individuals, and the data showed that these rates had excellent inter-rater reliability The 6 MinWT was performed over one trial, and (intraclass correlation coe±cients ½ICCsŠ ¼ 0:88– the 10 MWT, TUG, and FTSST were assessed over 0.99). Subsequently, these raters were measured in three trials, where the average ¯ndings were used the outcomes of the study three times, including for data analysis. During the tests, an assessor was prior to training (pre-test), after 3 weeks of train- beside or walked alongside the participants with- ing (intermediate test), and after 6 weeks of out interruption to ensure the participants' safety training (post-test). Then, participants were and the accuracy of the outcomes. The participants monthly monitored for fall data over 6 months wore a proper size of sandal sport shoes that were using a fall diary and telephone interview. The prepared by the researchers, and they were given a details of each assessment are as follows. practice session so they could familiarize them- selves with the shoes. Participants were able to 10-meter walk test: The 10 MWT is a valid and take a period of rest during the study and the tests reliable test (ICC ¼ 0:88–0.97), and its outcomes as needed. re°ect the overall quality of gait, and ambulatory and health status of older individuals.13–17 The Fall surveillance: After completing the program participants walked at a comfortable and fastest over six weeks, participants received a fall diary to speed along a 10 m walkway, and the time used record fall data and related events daily over six over the 4 m in the middle of the walkway was months. A researcher phoned them every month to recorded to minimize acceleration and deceleration gather the fall data of the month. Each fall was e®ects.12–14 Then, the ¯ndings were converted to a con¯rmed by related events (including the date, walking speed in meters/second (m/s). time, place, circumstances, and consequences of the fall) and by their caregivers or relatives to promote Timed up and go test: The TUG is an excellent the accuracy of the interviewed data. A fall was reliability test (ICC ¼ 0:97–0.99) that is widely de¯ned as \\an unintentional event that resulted in used to measure the dynamic balance control, a person coming to rest on the ground from an mobility and fall risk of older adults.18,19 The upright standing or walking activity as a result of participants were instructed to rise from an arm- neither a major intrinsic event (stroke or syncope) rest chair, walk around a tra±c cone that was nor an extrinsic cause\".2,26 placed 3 m ahead of the front edge of the chair, and return to sit down on the chair in the fastest and Statistical analysis safe manner. The test recorded the time from the command \\go\" until the participant's back was Descriptive statistics were used to describe the against the backrest of the chair.2,12,19 demographics of the participants and ¯ndings of the study. The analysis of variance with repeated Five times sit-to-stand test: The FTSST is a measures (repeated measures ANOVA) was used valid and excellent reliability test (ICC ¼ 0:97– to analyze the di®erent ¯ndings among the three 0.99) where the outcomes re°ect functional lower measurement times of the participants. The Chi- extremity muscle strength and dynamic balance control while changing postures from sitting to

Thai dance exercises bene¯ted functional mobility and fall rates among community-dwelling older individuals 23 square test was used to compare fall data during 6 demographics between those who fell and did not months before and after training. The level of sig- fall showed no signi¯cant di®erences (p > 0:05). ni¯cant di®erence was set at p-value of < 0:05. Other baseline demographics are presented in Table 1. Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com Results Outcomes of the study by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Participants After training, the participants showed signi¯cant improvements in all functional outcomes at week 3 Sixty-one participants, with an average age of 73 and week 6 (p < 0:01). The improvement was years and a normal body mass index, completed particularly demonstrated for the FTSST where the study program (Fig. 2). Most were female the outcomes after the training di®ered signi¯- (n ¼ 41), and 21 participants (35%) experienced at cantly from both the pre-test and intermediate-test least one fall during 6 months prior to participation (p < 0:01; Table 2). Furthermore, the number of in the study, where most (n ¼ 20) had a single fall those who fell was signi¯cantly reduced as and one participant reported 2 falls (Table 1). The Fig. 2. Participation °owchart.

24 C. Kaewjoho et al. Table 1. Baseline demographics and fall data of the participants (N ¼ 61). Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com Variable Baseline datac Post-training d by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Agea (years) 72:9 Æ 5:7 56 (92) Weighta (kg) 57:1 Æ 7:7 4 (6) Heighta (cm) 155:1 Æ 7:2 1 (2) Body mass indexa (kg/m2) 23:7 Æ 2:9 Number of medicationsb 51 (84) Less than 4 types 10 (16) At least 4 types Gender b 41 (67) Female 20 (33) Male Fall databà 40 (65) No fall 20 (33) Single fall 1 (2) Multiple falls Notes: aThe data are presented using mean Æ standard deviation (95% con¯dence intervals), bthese variables were presented using number (%), cthe fall data were interviewed retrospectively over 6 months, dthe fall data were prospectively gathered over 6 months, ÃChi-square test indicated signi¯cant di®erence with p-value < 0:01. compared to the data prior to training (p < 0:01), participants.9,10 Thus, this study further assessed where only ¯ve participants (8%) experienced falls the e®ects of Thai dance exercises over 6 weeks on during the 6-month prospective follow-up period the functional mobility necessary for being inde- (4 participants reported a single fall, where 1 of pendent, including the TUG, FTSST, 10 MWT them was the same person who fell prior to train- and 6 MinWT, and fall rates over 6 months among ing, and another one participant experienced 2 community-dwelling older individuals. The ¯nd- falls, Table 1). ings indicated that participants improved all functional outcomes signi¯cantly since 3 weeks of Discussion training (p < 0:01), and their functional mobility at 6 weeks showed further improvement, but not Thai dance is a part of the traditional art and signi¯cantly di®erent from the data at 3 weeks, culture that is familiar to Thai people. However, except the FTSST (p < 0:01, Table 2). Moreover, little evidence supporting the bene¯t of Thai dance the number of faller individuals was obviously re- exercises in only female individuals was available duced (from 21 participants [35%] prior to training without the consideration of fall data of the to only ¯ve participants [8%] after training, p < 0:01). Table 2. Functional mobility of the subjects at baseline, week 3, and week 6 (N ¼ 61). Variable Baseline (week 0) Intermediate-test (weeks 3) Post-test (weeks 6) Ten meter walk test (m/s) Preferred speed 1:12 Æ 0:16 (1.08–1.16) 1:20 Æ 0:15 (1.17–1.24)bÃà 1:24 Æ 0:16 (1.20–1.28)bÃà Fastest speed 1:38 Æ 0:19 (1.32–1.42) 1:45 Æ 0:22 (1.39–1.50)bÃà 1:43 Æ 0:19 (1.38–1.48)bà Timed up and go test (s) 10:29 Æ 1:70 (9.86–10.73) 9:30 Æ 1:23 (8.99–9.63)bÃà 9:08 Æ 1:10 (8.80–9.36)bÃà Five times sit-to-stand test (s) 13:52 Æ 2:62 (12.85–14.19) 11:28 Æ 2:48 (10.64–11.92)bÃà 10:16 Æ 1:94 (9.67–10.66)bÃÃ; IÃà Six minute walk test (m) 332:2 Æ 48:8 (319.7–344.7) 349:9 Æ 47:7 (337.6–362.1)bÃà 354:7 Æ 46:6 (340.1–363.9)bÃà Notes: The data are presented using mean Æ standard deviation (95% con¯dence intervals). ÃIndicates the level of signi¯cant di®erence with the p-value < 0:05, ÃÃp-value < 0:01. Superscripts indicate the measurement time with signi¯cant di®erences from the indicated period where b ¼ baseline, and I ¼ intermediate-test.

Thai dance exercises bene¯ted functional mobility and fall rates among community-dwelling older individuals 25 Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com The signi¯cant improvement after training may individuals.2,19,21,25 Thus, the number of partici- by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. relate to characteristics of the Thai dance program pants who fell was signi¯cantly reduced from 21 that required participants to step forward and participants to only 5 participants (Table 1). backward repeatedly while raising and lowering Nonetheless, the fall data from retrospective and the body over the extended and bending of a single prospective follow-up may contain some sources of and double limb support period of the lower ex- bias, e.g., recalling bias and Hawthorne e®ects that tremities (Fig. 1).8 The moderate rhythms of the may a®ect data comparisons in the ¯ndings. In songs also provided auditory cues to guide the addition, fall events can occur due to various ex- participants to maintain their movement speed for trinsic causes, such as environmental hazards,2,19 over 30 min/day. Although some participants took that need to be taken into consideration for data a period of rest when they ¯rst became involved in interpretation. the training program, they were encouraged to increase their participation duration to 30 min The current ¯ndings were coherent with other continuously as they could. Such training pro- cultural dances, such as Greek, Brazilian, and grams attributed both psychological and physical Turkish on the improvement of balance and e®ects and are particularly challenging for impor- physical ability.6,7,33 However, the researchers6 tant contributors to be independent in their daily recommend that these dances are speci¯c to the living, such as lower limb muscle strength, balance country of origin, and thereby may not allow control, walking ability, and functional endur- generalization. The current ¯ndings further extend ance.21,25 Therefore, the participants showed sig- the bene¯t of Thai dance exercise for ability of ni¯cant improvement in all functional outcomes of being independent and on fall rates in participants the study (p < 0:01, Table 2). However, the inter- who had good adherence to the Thai dance pro- mediate assessments at 3 weeks further suggested gram (at least 80% of the total session (15 ses- that the bene¯t of Thai dance exercise was dem- sions).34,35 The intermediate assessments also onstrated within a short period after training. The suggest the bene¯t over a short training duration changes of these tests were also greater than the (3 weeks). Thus, the ¯ndings further con¯rm the levels of clinical signi¯cance, i.e., greater than 0.05 m/ use of Thai dance exercise as an alternative train- s for the 10 MWT,27> 9% changes for the TUG,28 and ing program familiar to Thai community-dwelling 20 m for the 6 MinWT.27 Therefore, the ¯ndings older individuals. However, the ¯ndings were de- further extend the bene¯t of Thai dance exercise rived from a quasi-experimental design without a program over 3 and 6 weeks on functional ability of control group to ensure time-frame e®ects due to older adults necessary for being independent. daily activities. Nevertheless, a previous report using a similar program found no signi¯cant dif- Of all the functional measures, an improve- ference in the control group that did not receive ment was obviously found for the FTSST, where any additional program over 6 weeks.9 Moreover, the improvement after 6 weeks was signi¯cantly with a single group study, the assessors were aware di®erent from their baseline ability (3.36 s) and of the training program received by participants. intermediate assessments (p < 0:01, Table 2). However, the researchers attempted to minimize This improvement was greater than that used to assessor-bias by using a group of excellent reli- determine clinical signi¯cance (2.3 s).29 The ability raters (ICCs ¼ 0:88–0.99). In addition, the ¯ndings may re°ect e®ects of the training pro- ¯ndings did not analyze the data on recruiting and gram that required the participants to bend the retaining rates, and did not measure the outcomes knees always while moving their arms and body over a retention period. Therefore, a further study forward, backward, and sideward. Repetitive should apply a randomized controlled trial with the practice in such tasks may particularly challenge assessments of recruiting and retaining rates and a the lower limb muscle strength and dynamic measurement during a retention period to thor- balance ability that is necessary to complete the oughly con¯rm the e®ects of Thai dance exercises. FTSST.20,30 The improvement of FTSST is im- portant as it is widely used to predict lower limb Conclusion disability and independent living among older individuals.20,22,31,32 Thai dance exercise program improved functional mobility of the participants after 3- and 6-week of The improvement in the outcomes of these tests training, as well as reduce the fall rates of older is also important for fall prevention among older

Hong Kong Physiother. J. 2020.40:19-27. Downloaded from www.worldscientific.com 26 C. Kaewjoho et al. 5. Means KM, Rodell DE, O'Sullivan PS. Balance, by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. mobility, and falls among community-dwelling el- individuals. Hence, the present ¯ndings further derly persons: E®ects of a rehabilitation exercise con¯rm the use of a Thai dance exercise program, program. Am J Phys Med Rehabil 2005;84:238–50, which is familiar to Thai individuals, as an alter- Doi: 10.1097/01.PHM.0000151944.22116.5A. native strategy to promote independence and safety among community-dwelling older adults. 6. Eyigor S, Karapolat H, Durmaz B, Ibisoglu U, Cakir S. A randomized controlled trial of Turkish Con°ict of Interests folklore dance on the physical performance, bal- ance, depression and quality of life in older women. The authors declared no potential con°ict of Arch Gerontol Geriatr 2009;48:84–8, Doi: 10.1016/ interests. j.archger.2007.10.008. Funding/Support 7. Serra MM, Alonso AC, Peterson M, Mochizuki L, Greve JMD, Garcez-Leme LE. Balance and muscle This study was funded by National Research strength in elderly women who dance samba. PLOS Council Thailand (6100119), and the Improvement ONE 2016;11:1–9, Doi: 10.1371/journal.pone. of Physical Performance and Quality of Life (IPQ) 0166105. Research Group (IPQ/SC-014), Khon Kaen Uni- versity, Khon Kaen, Thailand. 8. Khongprasert S, Bhidayasiri R, Kanungsukkasem V. A Thai dance exercise regimen for people with Author Contributions parkinson's disease. J Health Res 2012;26:125–9. All authors were responsible for research concep- 9. Janyacharoen T, Laophosri M, Kanpittaya J, tion and design, critical revision of the article for Auvichayapat P, Sawanyawisuth K. Physical per- important intellectual content, provision of study formance in recently aged adults after 6 weeks materials or patients. CK was additionally involved traditional Thai dance: A randomized controlled in the data acquisition, statistical analysis, and trial. Clin Interv Aging 2013;8:855–9, Doi: 10.2147/ drafting of the manuscript. SA was also responsible CIA.S41076. for project management, funding application, and ¯nalizing the manuscript. 10. Janyacharoen T, Phusririt C, Angkapattamakul S, Hurst CP, Sawanyawisuth K. Cardiopulmonary References e®ects of traditional Thai dance on menopausal women: A randomized controlled trial. J Phys Ther 1. Singh NA, Singh MAF. Exercise and depression in Sci 2015;27:2569–72, Doi: 10.1589/jpts.27.2569. the older adult. Nutr Clin Care 2000;3:197–208, Doi: 10.1046/j.1523-5408.2000.00052.x. 11. Toda H, Nagano A, Luo Z. Age-related di®erences in muscle control of the lower extremity for support 2. Thaweewannakij T, Suwannarat P, Mato L, and propulsion during walking. J Phys Ther Sci Amatachaya S. Functional ability and health 2016;28:794–801, doi: 10.1589/jpts.28.794. status of community-dwelling late age elderly peo- ple with and without a history of falls. Hong Kong 12. Suwannarat P, Thaweewannakij T, Kaewsanmung Physiother J 2016;34:1–9, Doi: 10.1016/j.hkpj. S, Mato L, Amatachaya S. Walking devices used by 2015.08.001. community-dwelling elderly: Proportion, types, and associated factors. Hong Kong Physiother 3. Joshua JA, Julie AG, Megan ES, Ingrid EL, Mat- J 2015;33:34–41, Doi: 10.1016/j.hkpj.2014.11.001. thew JD. E®ect of moderate intensity resistance training during weight loss on body composition 13. Amatachaya S, Kwanmongkolthong M, and physical performance in overweight older Thongjumroon A, Boonpew N, Amatachaya P, adults. Eur J Appl Physiol 2010;109:517–25, Doi: Saensook W et al. In°uence of timing protocols and 10.1007/s00421-010-1387-9. distance covered on the outcomes of the 10-meter walk test. Physiother Theory Pract 2019:1–6, Doi: 4. Taylor D. Physical activity is medicine for older 10.1080/09593985.2019.1570577. adults. Postgrad Med J 2014;90:26–32, Doi: 10. 1136/postgradmedj-2012-131366. 14. Finch E, Brooks D, Stratford P, Mayo N. Physical rehabilitation outcome measures: A guide to en- hanced clinical decision making. Vol. 2. Canada: Hamilton, Ont.: Baltimore, MD: BC Decker, Lip- pincott Williams & Wilkins, 2002. 15. Cesari M, Kritchevsky SB, Penninx BWHJ, Nick- las BJ, Simonsick EM, Newman AB et al. Prog- nostic value of usual gait speed in well-functioning older people-results from the health, aging and body composition study. J Am Geriatr Soc

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Research Paper Hong Kong Physiotherapy Journal Vol. 40, No. 1 (2020) 29–37 DOI: 10.1142/S1013702520500043 Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com Hong Kong Physiotherapy Journal by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. https://www.worldscientific.com/worldscinet/hkpj Association between lumbopelvic motion and muscle activation in patients with non-speci¯c low back pain during forward bending task: A cross-sectional study Peemongkon Wattananon1,*, Komsak Sinsurin2 and Sirikarn Somprasong3 1Motor Control and Neural Plasticity Laboratory, Faculty of Physical Therapy Mahidol University, Nakhon Pathom, Thailand 2Biomechanics and Sports Research Unit, Faculty of Physical Therapy Mahidol University, Nakhon Pathom, Thailand 3Faculty of Physical Therapy, Mahidol University, Nakhon Pathom, Thailand *[email protected] Received 18 June 2019; Accepted 27 November 2019; Published 30 December 2019 Background: Evidence suggests patients with non-speci¯c low back pain (NSLBP) have altered lumbar and pelvic movement patterns. These changes could be associated with altered patterns of muscle activation. Objective: The study aimed to determine: (1) di®erences in the relative contributions and velocity of lumbar and pelvic movements between people with and without NSLBP, (2) the di®erences in lumbopelvic muscle activation patterns between people with and without NSLBP, and (3) the association between lumbar and pelvic movements and lumbopelvic muscle activation patterns. Methods: Subjects (8 healthy individuals and 8 patients with NSLBP) performed 2 sets of 3 repetitions of active forward bending, while motion and muscle activity data were collected simultaneously. Data derived were lumbar and pelvic ranges of motion and velocity, and ipsilateral and contralateral lumbopelvic muscle activities (internal oblique/transverse abdominis (IO/TA), lumbar multi¯dus (LM), erector spinae (ES) and gluteus maximus (GM) muscles). Results: Lumbar and pelvic motions showed trends, but exceeded 95% con¯dence minimal detectable dif- ference (MDD95), for greater pelvic motion (p ¼ 0:06), less lumbar motion (p ¼ 0:23) among patients with NSLBP. Signi¯cantly less activity was observed in the GM muscles bilaterally (p < 0:05) in the NSLBP group. A signi¯cant association (r ¼ À0:8, p ¼ 0:02) was found between ipsilateral ES muscle activity and *Corresponding author. Copyright@2020, Hong Kong Physiotherapy Association. This is an Open Access article published by World Scienti¯c Publishing Company. It is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY- NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly cited, the use is non-commercial and no modi¯cations or adaptations are made. 29

30 P. Wattananon, K. Sinsurin & S. Somprasong lumbar motion, while moderate, but statistically non-signi¯cant associations, were found between GM muscle activity bilaterally and lumbar velocity (ipsilateral: r ¼ À0:6, p ¼ 0:14; contralateral: r ¼ À0:6, p ¼ 0:16) in the NSLBP group. Conclusion: Findings indicated patients had greater pelvic contribution, but less lumbar contribution which was associated with less activation of the GM bilaterally. Keywords: Lumbopelvic movement pattern; lumbopelvic muscle activation pattern; non-speci¯c low back pain. Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com Introduction provide dynamic stability during functional by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. movement.6,22–24 These functionally-impaired Low back pain is a common health problem in muscles should be responsible for changes in lum- many countries with high prevalence and recur- bar and pelvic movement patterns. However, the rence rates.1,2 Non-speci¯c low back pain (NSLBP) association between underlying lumbar and pelvic is assigned when a recognizable or known speci¯c movement patterns and lumbopelvic muscle acti- pathology cannot be identi¯ed.3 NSLBP is ac- vation patterns during active forward bending countable for approximately 85% of low back among patients with NSLBP has not been sys- pain.4 Inappropriate management of low back pain tematically investigated. can result in perpetuation and recurring low back episodes which can further cause ¯nancial burden Therefore, this study aimed to: (1) determine for health care systems.5–7 the di®erence in lumbar and pelvic movement patterns (relative contribution and velocity) be- Lack of understanding of underlying low back tween healthy individuals (CON) and patients pain mechanism is one contributing factor re- with NSLBP (LBP), (2) determine the extent of sponsible for such high recurrence rates.8,9 Current di®erences in lumbopelvic muscle activation pat- research studies have demonstrated that patients terns (IO/TA, LM, ES, and GM) between CON with NSLBP have altered lumbar and pelvic and LBP, and (3) determine association between movement patterns including relative contribution lumbar and pelvic movement patterns and lum- and velocity during an active forward bend.10–14 bopelvic muscle activation patterns. We hypothe- One systematic review indicated altered lumbar sized that patients with NSLBP would have and pelvic contribution among patients with altered lumbar and pelvic relative contribution and NSLBP during the active forward bend.11 This velocity, as well as lumbopelvic muscle activation systematic review also demonstrated consistent patterns. We also further hypothesized that asso- ¯ndings for reduced lumbar velocity during this ciations would be found between lumbar and pelvic task.11 Researchers interpreted slow lumbar movement patterns and lumbopelvic muscle acti- velocity as an indicator of coping strategy to min- vation patterns. Enhanced knowledge resulting imize excessive lumbar motion.15–17 However, from this study would provide a signi¯cant step results from the lumbar segment alone may be in- toward investigating underlying neuromuscular su±cient to describe this phenomenon. Therefore, mechanisms, and the ability of exercise interven- investigating the relative velocity of the lumbar tion to restore lumbar and pelvic movement pat- spine and pelvis should support the interpretation terns and lumbopelvic muscle activation patterns. in which patients with NSLBP use lumbar coping The long term outcomes of this research could help strategy to minimize excessive lumbar motion. improve physical therapy interventions speci¯c to patients with NSLBP; thereby, optimizing clinical In addition, clinicians have suggested that outcomes and preventing recurring symptoms. altered lumbar and pelvic relative contribution and velocity among patients with NSLBP are as- Methods sociated with lumbopelvic muscle activation de¯- cits.18–21 Lumbopelvic muscles include the bilateral Subjects internal oblique/transverse abdominis (IO/TA), lumbar multi¯dus (LM), lumbar erector spinae Eight patients with NSLBP between the ages of (ES), and gluteus maximus (GM) muscles. They 21 and 65, and 8 age-, sex-, and BMI-matched have been proposed as key contributors to

Association between lumbopelvic motion and muscle activation in patients with low back pain 31 Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com healthy individuals were recruited from the abrasive paper and cleaned using cotton with by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. University Physical Therapy Clinic. Additional alcohol to lower the skin impedance. IO/TA elec- inclusion criteria for patients with NSLBP trodes were placed at 2 cm medial to ASIS and on included current episode of back pain less than the inguinal line. LM electrodes were placed at three months causing them to seek medical or 2 cm lateral to the L5 spinous process. ES elec- physical therapy intervention and not receiving trodes were placed at 3 cm lateral to the L1 spinous any intervention involving the core stability in the process. GM electrodes were placed at midpoint last six months. Subjects were excluded if they between the greater trochanter and the last sacral presented clinical signs of systemic disease, de¯ni- vertebrae.24 Electrodes were placed parallel to the tive neurologic signs including weakness or numb- muscle ¯bers with an inter-electrode distance of ness in the lower extremity, previous spinal 2 cm. Analog EMG data included bandpass-¯ltered surgery, osteoporosis, severe spinal stenosis, or in- (10–1500 Hz), and di®erentially ampli¯ed to °ammatory joint disease, pregnancy, any lower þ= À 5 V. extremity condition that would potentially alter trunk movement in standing, vestibular dysfunc- Procedures tion, extreme psychosocial involvement, and BMI greater than 30 kg/m2. This study constituted one This study employed a cross-sectional design. The part of the intervention with a pre-speci¯ed sample institutional review board approval from the uni- size; therefore, we did not perform sample size versity was obtained (COA No. 2015/050.3004) calculation. However, sample size requirements before collecting data. Data were collected at the were derived for future replication of this study. university laboratory (Motor Control and Neural Plasticity Laboratory) from August 2016 to Instrumentation and measures October 2017. Each subject underwent the written informed consent process before providing data. Electromagnetic tracking system (3D Guidance Electromagnetic sensors and surface EMG elec- trakSTAR, Ascension Technology Corp., trodes were attached to the subjects' body land- Vermont, USA) was used for motion data collec- marks. Subjects were instructed to perform a tion. Criteria-related validity with known quantity modi¯ed Sorensen test at submaximal level (15% of has been reported by the manufacturer. The coef- body weight) to derive bilateral LM and ES refer- ¯cient of multiple determination demonstrated ence voluntary contraction (RVC). We used this excellent (R2 ¼ 0:98) test–retest reliability of this submaximal level to avoid aggravating pain, which system. Three sensors were attached to the sub- could change muscle activation patterns. In addi- jects at the following landmarks: (1) the right tion, subjects were asked to perform the maximal femur (bony prominence of the right femoral lat- contraction of the hip extension in a prone position eral epicondyle); (2) the pelvis (over the spinous with 90 knee °exion position, and maximal ab- process of S2); and (3) the lumbar spine (over the dominal hollowing in a crook lying position to de- spinous process of L1). These sensor placements rive RVC for GM and IO/TA, respectively.26,27 were based upon recommendations of the Interna- These RVC were further used to normalize EMG tional Society of Biomechanics.25 This tracking data for each muscle group. Subjects were system collected kinematic data at 100 Hz. Related instructed to perform 2 sets of 3 consecutive repe- work has demonstrated kinematics in conjunction titions of forward bending movement. The with a dynamic systems approach that could be instruction was \\please stand relaxed with equal used to quantify movement patterns that represent weight on both legs, and then try to reach toward clinically observed aberrant movement patterns.14 the °oor as far as you can at your comfortable pace and return to starting position\". Motion and EMG Electromyography (EMG) (TeleMyo 2400R data were simultaneously recorded. G2, Noraxon Inc., Arizona, USA; common mode rejection ratio > 100 dB, input impedance Data reduction > 100 MOhm, 500 gain) with pre-ampli¯ed bipolar electrodes (Kendall Medi-Trace 100, Kendall Inc.; Data reduction was performed using a customary Al/AgCl, disc-shaped, 1 cm diameter) was used to LabVIEW programming (National Instruments collect muscle activity from bilateral IO/TA, LM, Corp.). Motion data were converted to segment ES, and GM. Skin was lightly abraded using

Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com 32 P. Wattananon, K. Sinsurin & S. Somprasong demographic data were normally distributed, the by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. independent t-test was used. Otherwise, the Mann– angular rotations using Euler's angle in Cardan Whitney's U test was used. The Chi-square test sequence (x, y, and z). Segment angular rotations was used to compare sex. For motion data, a mixed included lumbopelvic motion (lumbar sensor in re- design ANOVA with post-hoc pairwise compar- spect to femur sensor), lumbar motion (lumbar isons (Bonferroni adjustment) was used for nor- sensor in respect to pelvic sensor), and pelvic motion mally distributed data, while non-parametric (pelvic sensor in respect to femur sensor). These statistics was used for non-normally distributed data were ¯ltered using a dual-pass Butterworth data. For EMG data, independent t-tests were (2nd order low pass frequency at 5 Hz). Lumbar and used when data were normally distributed; other- pelvic ranges of motion and velocity were obtained. wise, Mann– Whitney's U tests were used instead. Maximal range of motion, time to maximal range of To determine the association between motion and motion, maximal angular velocity, and time to muscle activity, Pearson's correlations were used maximal angular velocity for lumbar spine (MaxRL, when data were normally distributed, while TtoMaxRL, MaxVL, and TtoMaxVL), and pelvis Spearman's rank tests were used when data were (MaxRP , TtoMaxRP , MaxVP , and TtoMaxVLP) non-normally distributed. Con¯dence level () was for each repetition were derived. Averaged motion set at 0.05. parameters across the ¯rst 3 and the last 3 repeti- tions were used to establish test–retest reliability Results and 95% con¯dence minimal detectable di®erence (MDD95). All kinematics were analyzed and repor- Demographic data (Table 1) demonstrated no ted in the sagittal plane. signi¯cant di®erence (p > 0:05) in age, sex, BMI, as well as lumbar and pelvic ranges of motion and EMG data were ¯ltered using independent velocities between CON and LBP groups. Intra- component analysis to remove heart rate artifacts. class correlation coe±cient (ICC3;3) demonstrated Heart rate ¯ltered EMG were further ¯ltered using excellent test–retest reliability (ICC3;3 ranged be- a band pass ¯lter (2nd order Butterworth high pass tween 0.90 and 1.00) of EMG and motion para- at 20 Hz and low pass at 400 Hz) and a band stop meters, and a 95% con¯dence MDD95 was ¯lter (2nd order Butterworth at 50 Hz). These data established (Appendix). were full-wave recti¯ed and underwent data smoothing using root mean square (RMS) with a Table 2 demonstrates results from mixed time constant of 50 ms. RVC data between 2 and ANOVA with post-hoc pairwise comparisons. 4 s was used to normalize muscle activity during Results demonstrated a trend in the interaction the forward bending task. However, our prelimi- e®ect of Group * Segment (p ¼ 0:05), and a sig- nary data analysis demonstrated that pain location ni¯cant main e®ect of Segment (p < 0:001). Post- among patients with NSLBP could change muscle hoc comparisons showed that the LBP group activation patterns; therefore, we separately ana- exhibited a trend of greater MaxRP compared with lyzed muscle groups ipsilateral and contralateral to the CON group (p ¼ 0:06). The MaxRL was similar the pain location for the main analysis. Ipsilateral between the LBP and CON groups (p ¼ 0:23). No (I) and contralateral (C) peak EMG amplitudes for signi¯cant interaction e®ect was observed for ve- each muscle (IIO/TA, CIO/TA, ILM, CLM, IES, locity. The velocity result demonstrated only a CES, IGM, and CGM) were derived. Similar to signi¯cant main e®ect of Segment (p ¼ 0:03). Post- motion data, averaged EMG parameters across the hoc simple within-group comparisons demonstrat- ¯rst and last three repetitions were used to estab- ed signi¯cantly greater MaxVP compared with lish test–retest reliability and MDD95. MaxVL (p ¼ 0:03) in the LBP group only. Statistical analysis Non-parametric Mann–Whitney's U tests for EMG data showed signi¯cant lower activation of Statistical analysis was performed using SPSS both IGM and CGM in the LBP group compared Software, Version 21.0 (IBM Corp., New York, with CON (p ¼ 0:02 and 0.04, respectively); how- USA). Intra-class correlation coe±cients (ICC3;3) ever, only median IGM exceeded MDD95 (Table 3). were used to establish test–retest reliability of motion and EMG parameters, and MDD95 were Correlations between lumbar and pelvic move- calculated. The normality test was performed using ment patterns and muscle activation patterns were Kolmogorov–Smirnov goodness-of-¯t test. When determined using Spearman's rank test (Table 4).

Association between lumbopelvic motion and muscle activation in patients with low back pain 33 Table 1. Demographic data. Parameter CON (N ¼ 8) LBP (N ¼ 8) p-value Age Æ SD (years) 27.7 Æ 5.0 29.4 Æ 5.2 0.54 Sex (% female) 42.9 42.9 1.00 BMI (kg/m2) 22.1 Æ 2.3 24.5 Æ 2.2 0.08 MaxRLP Æ SD (degrees) 98.9 Æ 14.4 104.4 Æ 12.1 0.42 MaxVLP Æ SD (degrees/sec) 102.2 Æ 29.0 98.8 Æ 44.4 0.86 NPRS (out of 10) 5.7 Æ 1.9 N/A N/A 19.7 Æ 7.5 N/A ODI (percent) N/A Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com Notes: CON ¼ Healthy controls, LBP ¼ Low back pain, SD ¼ Standard deviation, by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. BMI ¼ Body mass index, MaxRLP ¼ Lumbopelvic maximal range of motion, MaxVLP ¼ Lumbopelvic maximal velocity, NPRS ¼ Numeric pain rating scale, ODI ¼ Oswestry disability index, N/A ¼ Not applicable. Correlation results in the LBP group demonstrated studies in which they found similar changes in that a strongly signi¯cant negative association lumbar and pelvic contributions.10–14 In addition, (r ¼ À0:8, p ¼ 0:02 was found between IES and within-group comparisons suggested that patients MaxRL. with NSLBP obviously used pelvic dominate movement patterns, while healthy individuals used When analyzing the CON group (Table 4), shared patterns between lumbar spine and pelvis strongly signi¯cant negative associations were during active forward bend.14 found between IIO/TA and MaxVL (r ¼ À0:8, p ¼ 0:02), ILM and MaxVL (r ¼ À1:0, p < 0:001), To our knowledge, no study has investigated the IGM and MaxVL (r ¼ À0:8, p ¼ 0:02), and CGM relative velocity of the lumbar spine and pelvis and MaxVL (r ¼ À0:8, p ¼ 0:01). during the active forward bend. Our ¯ndings sug- gested that patients with NSLBP may attempt to Discussion compensate slow lumbar motion by increased pel- vic velocity. In other words, slower lumbar motion Demographic data indicated both groups were among patients with NSLBP may indicate that comparable, and performed the same task. Test– they attempted to minimize lumbar motion to retest reliability of EMG and motion parameters prevent excessive lumbar motion.15–17 were excellent indicating that subjects consistently performed the active forward bend task and our Findings in muscle activation patterns sug- measurement was reliable, allowing us to con¯- gested that patients with NSLBP had lower muscle dently interpret our data as a true di®erence be- activation of the bilateral GM muscles. Our results tween group comparisons when di®erence exceeds were consistent with one related study in which MDD95.28 they found that GM muscles were more fatigable among patients with NSLBP.23 Lower bilateral We have simultaneously collected lumbar and GM muscle activation could alter body mechanics pelvic motion and lumbopelvic muscle activity during trunk °exion and extension, particularly data in this study. This allows us to comprehen- load transfer in the lumbar spine.23 This could sively explain altered lumbar and pelvic relative further lead to stress on the lumbar region; there- contributions, and changes in lumbopelvic muscle by, developing a low back symptom.17,29 activation responsible for those changes in relative contribution during an active forward bend. Patients with NSLBP demonstrated coping strategy by increased ipsilateral ES muscle acti- Although healthy individuals and patients with vation to minimize this shear force on the lumbar NSLBP performed the same active forward bend spine,17 which was supported by a strong negative task, we found that patients with NSLBP tended association between the ipsilateral ES muscle and to use lower lumbar contribution, but signi¯cantly maximal lumbar range of motion. greater pelvic contribution, than those among healthy individuals. Our motion results were con- Lumbar maximal velocity representing trunk sistent with several lumbar and pelvic motion neuromuscular control on the lumbar motion14 seemed to be modulated by all lumbopelvic muscles

Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Table 2. Interaction and main e®ects from mixed ANOVAs, as well as between groups and within group post-hoc pairwise comparisons. 34 P. Wattananon, K. Sinsurin & S. Somprasong CON LBP Between-group Kinematics Mixed ANOVA F value p-value 2 Parameters (Mean Æ SD) (Mean Æ SD) mean di® MDD95 p-value ROM Interaction Group  Segment 4.44 0.05 0.24 Post-hoc MaxRL (degrees) 42.5 Æ 11.3 36.0 Æ 9.6 6.53* 2.29 0.23 Velocity À12.03* 4.22 0.06 e®ect comparison 4.70 7.10 0.63 MaxRP (degrees) 56.4 Æ 12.6 68.4 Æ 10.5 À5.10 13.23 0.74 Main e®ect Group 0.68 0.42 0.05 Within-group À13.9 À32.4 Segment 27.70 < 0.001 0.66 mean di® p-value 0.04 < 0.001 58.1 Æ 13.0 53.3 Æ 23.4 Interaction Group  Segment 0.74 0.40 0.05 Post-hoc MaxVL (degrees/ e®ect comparison second) MaxVP (degrees/ 67.2 Æ 24.8 72.3 Æ 34.7 second) Main e®ect Group < 0.001 0.99 < 0.001 Within-group À9.1 À18.9 Segment 6.02 0.03 0.30 mean di® 0.28 0.03 p-value Notes: MaxRL ¼ Lumbar maximal range of motion, MaxRP ¼ Pelvic maximal range of motion, MaxVL ¼ Lumbar maximal velocity, MaxVP ¼ Pelvic maximal velocity, CON ¼ Healthy controls, LBP ¼ Low back pain, SD ¼ Standard deviation, Mean di® ¼ Mean di®erence, MDD95 ¼ 95% con¯dence minimal detectable di®erence. à ¼ Exceed 95% con¯dence minimal detectable di®erence. Table 3. Lumbopelvic muscle activation pattern comparison between groups. Muscle CON Median [ICR] LBP Median [ICR] Median di® MDD95 p-value IIO/TA 54.4 [14.5, 85.6] 21.5 [15.4, 68.6] 32.9 34.9 0.65 CIO/TA 53.8 [7.0, 76.4] 24.5 [14.0, 72.6] 29.3 29.4 0.96 ILM 77.6 [27.8, 179.1] 24.6 [20.0, 83.2] 53.0 274.7 0.33 CLM 51.6 [27.3, 84.5] 27.1 [24.1, 46.6] 24.5 31.9 0.44 IES 54.2 [37.6, 367.6] 62.2 [18.6, 265.1] À8.0 80.2 0.57 CES 175.3 [31.9, 316.4] 54.4 [22.2, 139.0] 121.0 95.9 0.51 IGM 59.6 [31.0, 107.3] 21.3 [12.2, 37.7] 38.4* 21.1 0.02 CGM 39.6 [30.7, 81.6] 18.6 [13.8, 30.6] 21.0 76.6 0.04 Notes: I ¼ Ipsilateral, C ¼ Contralateral, IO/TA ¼ Internal oblique/transverse abdominis, LM ¼ Lumbar multi¯dus, ES ¼ Erector spinae, GM ¼ Gluteus maximus, CON ¼ Healthy controls, LBP ¼ Low back pain, SD ¼ Standard deviation, ICR ¼ Interquartile range, Mean di® ¼ Mean di®erence, Median di® ¼ Median di®erence, MDD95 ¼ 95% con¯dence minimal detectable di®er- ence. à ¼ Exceed 95% con¯dence minimal detectable di®erence.

Association between lumbopelvic motion and muscle activation in patients with low back pain 35 Table 4. Correlation between lumbopelvic movement pattern (spatial and temporal) and lumbopelvic muscle acti- vation patterns based on all subjects. Group Muscle MaxRL Spatial parameter MaxVP TtoMaxRL Temporal parameter TtoMaxVP LBP MaxVL MaxRP TtoMaxRP TtoMaxVL IIO/TA 0.3 0.1 0.2 0.1 Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com CON CIO/TA À0.3 0.1 À0.3 0.4 À0.3 0.2 0.2 À0.2 by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. 0.2 À0.2 À0.1 À0.1 ILM 0 0.1 0.2 0.3 0.2 CLM À0.6* À0.2 À0.5 0.4 À0.4 0.1 0 À0.2 IES À0.8** À0.1 0.2 À0.2 À0.3 À0.3 À0.4 À0.1 CES À0.1 0.1 À0.4 À0.2 À0.2 IGM 0.3 À0.4 0.1 À0.2 À0.3 0 CGM À0.1 0.1 À0.4 0.5* 0.6 À0.4 À0.6* 0 0 0.2 0.6* 0.4 0.2 IIO/TA À0.6* 0 0 À0.1 CIO/TA À0.2 À0.5 À0.1 0.1 0 À0.4 À0.8** 0.3 0 À0.1 À0.1 À0.2 ILM À0.5* 0.1 0.2 0.1 À0.1 À0.1 CLM 0.1 À1.0** 0 0.1 À0.2 À0.2 0.1 IES À0.2 À0.6* 0.1 À0.1 À0.3 0 À0.5* À0.2 CES À0.2 À0.5* 0.2 À0.2 À0.1 À0.4 À0.4 IGM À0.4 À0.7* 0.3 0 À0.5* À0.3 0 CGM À0.8** 0 0.3 À0.2 À0.3 0 0.1 À0.8** 0 À0.2 À0.1 0.3 0.4 0 0.4 0.1 Notes: LBP ¼ Low back pain group, CON ¼ Healthy control group, I ¼ Ipsilateral, C ¼ Contralateral, IO/TA ¼ Internal oblique/transverse abdominis, LM ¼ Lumbar multi¯dus, ES ¼ Erector spinae, GM ¼ Gluteus maximus, L ¼ Lumbar spine, P ¼ Pelvis, MaxR ¼ Maximal range of motion, TtoMaxR ¼ Time to maximal range of motion, MaxV ¼ Maximal velocity, TtoMaxV ¼ Time to maximal velocity. Notes: Statistical analysis was performed using Spearman' rank test. ÃÃ ¼ Strong association (r > 0:70) with statistical signi¯cance (p < 0:05). Ã ¼ Moderate association (r between 0.50 and 0.69), but not statistical signi¯cance (p > 0:05). evident by a moderate to strong negative associa- be achieved by activating the bilateral lumbopelvic tion between each lumbopelvic muscle and maxi- muscles. Therefore, excessive load on the lumbar mal lumbar velocity among healthy individuals. spine would be minimized. This would also help to Notably, the bilateral GM muscles might be key prevent recurring episodes of low back symptoms. muscles that need to be considered when treating patients with NSLBP. Based upon our ¯ndings, The ¯ndings of this study should be considered the bilateral GM muscles were strongly associated in light of the following limitations. This study was with lumbar maximal velocity among both part of an intervention study that pre-speci¯ed a patients with NSLBP and healthy individuals in- sample size of 16 (8 subjects per group). Therefore, dicating the importance of these muscles to control ¯ndings associated between lumbar and pelvic lumbar spine motion. Inadequate activation of the motions and lumbopelvic muscle activation in our bilateral GM muscles could cause altered lumbar study tended to be under-powered. A minimum spine control, as well as excessive hip motion. This sample size of 24 would be required to detect sig- would in turn increase stress on the lumbar spine ni¯cant associations using a calculated e®ect size, leading to low back symptoms.17,29 80% power and con¯dence level of 0.05. Our study design, employed sub-maximal voluntary isometric Our ¯ndings suggest that clinicians should focus contractions of the back muscles (the bilateral on the lumbar and pelvic contribution by restoring lumbar multi¯dus and ES muscles) to avoid pain lumbopelvic muscle activation patterns among exacerbation, while we used maximal contractions patients with NSLBP. Speci¯cally, interventions for other muscles, which would have limited the should be designed to restore GM muscle activa- within-group comparisons. Therefore, we were tion to prevent excessive pelvic motion. Control of unable to compare the level of activation across the lumbar spine motion is also a key factor for man- lumbopelvic muscles. In addition, future studies aging patients with NSLBP. Restoring lumbar may incorporate our ¯ndings to re¯ne the inter- control would provide dynamic stability, and could vention that addresses the lumbar and pelvic

36 P. Wattananon, K. Sinsurin & S. Somprasong Appendix A contributions, as well as muscle activation pat- Table A.1. Test–retest reliability, standard error of mea- terns. An intervention study would provide evi- surement, and 95% con¯dence minimal detectable di®erence dence to support whether changes in those motions for each parameter. and muscle activation would be e®ective in Hong Kong Physiother. J. 2020.40:29-37. Downloaded from www.worldscientific.com managing patients with NSLBP and minimize Variable ICC3;3 lower upper SEM MDD95 by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. recurrence rate. ICC ICC IIO/TA 1.00 0.13 0.35 Our study concurrently investigated lumbar and CIO/TA 0.99 0.99 1.00 0.11 0.29 pelvic motions and lumbopelvic muscle activation ILM 0.92 0.96 1.00 0.99 2.75 to enable the comprehensive analysis of underlying CLM 1.00 0.77 0.97 0.12 0.32 mechanisms during active forward bend. We found IES 0.91 0.99 1.00 0.29 0.80 the di®erence in lumbar and pelvic contributions CES 1.00 0.74 0.97 0.35 0.96 between patients with NSLBP and healthy indi- IGM 0.96 0.99 1.00 0.08 0.21 viduals even though they were performing the CGM 0.90 0.88 0.99 0.28 0.77 same task. Patients with NSLBP had less activa- MaxRL 0.99 0.72 0.97 0.83 2.29 tion of the bilateral GM muscle associated with MaxRP 0.99 0.98 1.00 1.52 4.23 lumbar maximal velocity. These ¯ndings suggested MaxRLP 0.99 0.96 1.00 1.57 4.35 that contributions of the lumbar spine and pelvis, TtoMaxRL 0.96 0.96 1.00 17.29 47.92 as well as GM muscle activation should be TtoMaxRP 0.96 0.89 0.99 17.92 49.66 considered for managing patients with NSLBP. TtoMaxRLP 0.97 0.89 0.99 16.61 46.03 MaxVL 0.98 0.92 0.99 0.03 0.07 Acknowledgments MaxVP 0.97 0.95 0.99 0.05 0.13 MaxVLP 0.99 0.93 0.99 0.05 0.12 We would like to thank Motor Control and Neural TtoMaxVL 0.97 0.96 1.00 8.68 24.06 Plasticity Laboratory, Mahidol University for TtoMaxVP 0.96 0.91 0.99 14.73 40.83 providing data collection space and equipment. We TtoMaxVLP 0.97 0.87 0.99 8.44 23.38 would also like to thank Ms. Tanatta Chichakan 0.93 0.99 and Mr. Pisit Suwanimit for helping us in collect- ing data. We also wish to thank all the subjects Notes: ICC ¼ Intra-class correlation coe±cient, SEM ¼ Stan- who participated in this study. dard error of measurement, MDD95 ¼ 95% con¯dence minimal detectable di®erence, I ¼ Ipsilateral, C ¼ Contralateral, IO/ Con°ict of Interest TA ¼ Internal oblique/transverse abdominis, LM ¼ Lumbar multi¯dus, ES ¼ Erector spinae, GM ¼ Gluteus maximus, The authors declare that they have no con°ict of L ¼ Lumbar spine, P ¼ Pelvis, LP ¼ Lumbopelvic, interest. MaxR ¼ Maximal range of motion, TtoMaxR ¼ Time to maximal range of motion, MaxV ¼ Maximal velocity and TtoMaxV ¼ Time to maximal velocity. Funding/Support References This study was funded by the Thailand Research 1. Andersson GBJ. Epidemiological features of Fund (Grant No. TRG5880133, 2015). chronic low-back pain. The Lancet 1999;354:581–5. Author Contributions 2. Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: Systematic review of its PW substantially contributed to the concept, prognosis. BMJ 2003;327:323. research design, data collection and analysis, paper preparation and edition. KS and SS have signi¯- 3. Waddell G. 1987 Volvo award in clinical sciences: cantly contributed to data analysis and revising A new clinical model for the treatment of low back the paper. All authors read and approved the ¯nal pain. Spine (Phila Pa 1976) 1987;12:632–44. paper. 4. Carey TS, Garrett JM, Jackman AM. Beyond the good prognosis: Examination of an inception cohort of patients with chronic low back pain. Spine (Phila Pa 1976) 2000;25:115–20. 5. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the

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TAI CHI FOR PARKINSON’S DISEASE 1. ROCKING MOTION STAND WITH FEET APART. RAISE BOTH ARM TILL CHEST SLOWLY LOWER THE ARM ARMS BY THE SIDE. LEVEL. AND HEELS RAISE BOTH HEEL AND STAND REPEAT 5-10 TIMES 2. PUSH AND PULL ON THE TOES. STAND WITH RIGHT LEG FORWARD. SHIFT WEIGHT ON RIGHT LEG AND NOW SHIFT WEIGHT ON LEFT LEG. BOTH HANDS AT CHEST LEVEL. RAISE LEFT HEEL. BRING BOTH HANDS BACK. BRING BOTH HANDS FORWARD. REPEAT BY PLACING LEFT LEG FORWARD. REPEAT 5-10 TIMES 3. LOOKING BACK STAND WITH BOTH ARMS RAISED IN MOVE YOUR RIGHT HAND BEHND FRONT. TOWARDS YOUR BACK. TURN HEAD ALONG WITH HAND. THEN REPEAT ON LEFT SIDE. REPEAT EACH SIDE 5-10 TIMES.

4. PARTING THE MANE STAND WITH BOTH TAKE A STEP TO RIGHT. SLOWLY RETURN TO TAKE A STEP TO LEFT. STARTING POSITION SHIFT WEIGHT ON LEFT LEG. HANDS AT SHOULDER LEVEL . SHIFT WEIGHT ON RIGHT LEG. RAISE RIGHT HAND AT EYE LEVEL. REPEAT EACH SIDE 5-10 TIMES. RAISE RIGHT HAND AT EYE LEVEL. 5. WHITE CRANE SPREAD ITS WINGS STAND WITH BOTH TAKE A STEP TO LEFT RETURN TO STARTING TAKE A STEP TO RIGHT RAISE RIGHT HAND ABOVE HEAD HANDS AT CHEST LEVEL RAISE LEFT HAND ABOVE HEAD POSITION LIFT LEFT KNEE STAND ON RIGHT LEG REPEAT EACH SIDE 5-10 TIMES LIFT RIGHT KNEE STAND ON LEFT LEG 6. THE BEAR SIEZE THE BALL STAND WITH HANDS AT CHEST LEVEL OPEN HANDS AS YOU BEND BACK NOW SLOWLY BRING BOTH HAND CLOSE AND BEND FORWARD TAKE A STEP TO YOUR RIGHT AND TURN HEAD ALONG TO LOOK UP REPEAT 5-10 TIMES TURN BODY TO RIGHT

YOGA FOR PARKINSON’S DISEASE 1. THADASANAM STAND WITH FEET CLOSE TOGETHER. TAKE A DEEP BREATHE AND RAISE BOTH HANDS AND RAISE YOUR HEELS. MAINTAIN POSITION FOR 5-6 SECONDS. REPEAT 5-10 TIMES. 2. HASTH UDDHANASANAM STAND WITH FEET CLOSE TOGETHER. RAISE BOTH ARMS ABOVE HEAD. TAKE A DEEP BREATHE AND BEND BODY BACKWARD. MAINTAIN POSITION FOR 5-6 SECONDS. REPEAT 5-10 TIMES. 3. CHAKARASANAM (SIDEWAYS) STAND STRAIGHT. TAKE A DEEP BREATHE. EXAHLE AND BEND TO LEFT SIDE. RAISE RIGHT HAND. HOLD 5 SECONDS. REPEAT EACH SIDE 5-10 TIMES.

4. VEERABHADRASANAM STAND WITH FEET RAISE BOTH ARMS SIDEWAYS. TAKE A STEP TO RIGHT AND TURN APART. BODY TO RIGHT. BEND RIGHT KNEE AND SHIFT WEIGHT ON RIGHT LEG. HOLD 5 SECONDS. 5. JATHARA PARIVARTANAM REPEAT EACH SIDE 5-10 TIMES. LYING ON YOUR BACK. TURN KNEE TO NOW, SLOWLY TURN KNEES TO BOTH ARMS STRETCHED OUT RIGHT. YOUR LEFT. BOTH KNEES TO YOUR CHEST. REPEAT BOTH SIDES 5-10 TIMES. 6. BHUJANGASANAM LYING ON YOUR CHEST. BREATHE IN LIFT YOUR CHEST OFF THE PLACE BOTH HANDS AT SHOULDER GROUND AND BEND NECK BACKWARDS. LEVEL. HOLD 5 SECONDS. REPEAT 5-10 TIMES.

BALANCE EXERCISE FOR PARKINSON’S DISEASE 1. BACK EXTENSION STAND WITH FEET APART. PLACE HANDS ON YOUR BACK. GENTLY ARCH YOUR BACK. REPEAT 5-10 TIMES. 2. TRUNK ROTATION STAND WITH FEET APART. PLACE HANDS ON YOUR BACK. TURN RIGHT AS FAR AS YOU CAN AND THE TURN LEFT AS FAR AS YOU CAN. REPEAT 5-10 TIMES. 3. BACKWARD WALKING STAND. HOLD SUPPORT IF REQUIRED. TAKE 10 STEPS BACKWARD, TURN AROUND, TURN 10 STEPS BACKWARD. REPEAT 5-10 TIMES.

4. SIDEWAYS WALKING STAND NEAR A WALL. PLACE HANDS ON HIP. TAKE 10 STEPS TO RIGHT. THE TAKE 10 STEPS TO LEFT. REPEAT 5-10 TIMES. 5. HEEL TOE WALKING STAND HOLD A SUPPORT IF NEEDED PLACE ONE FOOT DIRECTLY IN FRONT OF OTHER. TAKE 10 STEPS, TURN AROUND. REPEAT 10 MORE STEPS. REPEAT 5-10 TIMES. 6. ONE LEG STANDING STAND HOLD A SUPPORT IF NEEDED LIFT RIGHT LEG AND STAND ON LEFT LEG. HOLD 10 SECONDS. CHANGE LEG. REPEAT 5-10 TIMES EACH SIDE.

Research Paper Hong Kong Physiotherapy Journal Vol. 40, No. 1 (2020) 39–49 DOI: 10.1142/S1013702520500055 Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com Hong Kong Physiotherapy Journal by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. https://www.worldscientific.com/worldscinet/hkpj E®ect of home-based Tai Chi, Yoga or conventional balance exercise on functional balance and mobility among persons with idiopathic Parkinson's disease: An experimental study Arva Khuzema1,*, A. Brammatha1,† and V. Arul Selvan2 1KMCH College of Physiotherapy Avinashi Road, Coimbatore, Tamil Nadu, India 2Kovai Medical Centre and Hospital Avinashi Road, Coimbatore, Tamil Nadu, India *[email protected] †[email protected] Received 29 March 2019; Accepted 5 December 2019; Published 20 February 2020 Background: Individuals with Parkinson's disease (PD) invariably experience functional decline in a number of motor and non-motor domains a®ecting posture, balance and gait. Numerous clinical studies have examined e®ects of various types of exercise on motor and non-motor problems. But still much gap remains in our understanding of various therapies and their e®ect on delaying or slowing the dopamine neuron degen- eration. Recently, Tai Chi and Yoga both have gained popularity as complementary therapies, since both have components for mind and body control. Objective: The aim of this study was to determine whether eight weeks of home-based Tai Chi or Yoga was more e®ective than regular balance exercises on functional balance and mobility. Methods: Twenty-seven individuals with Idiopathic PD (Modi¯ed Hoehn and Yahr stages 2.5–3) were randomly assigned to either Tai Chi, Yoga or Conventional exercise group. All the participants were eval- uated for Functional Balance and Mobility using Berg Balance Scale, Timed 10 m Walk test and Timed Up and Go test before and after eight weeks of training. *Corresponding author. Copyright@2020, Hong Kong Physiotherapy Association. This is an Open Access article published by World Scienti¯c Publishing Company. It is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY- NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly cited, the use is non-commercial and no modi¯cations or adaptations are made. 39

Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com 40 A. Khuzema et al. by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Results: The results were analyzed using two-way mixed ANOVA which showed that there was a signi¯cant main e®ect for time as F (1, 24) ¼ 74:18, p ¼ 0:000, p2 ¼ 0:76 for overall balance in Berg Balance Scale. There was also signi¯cant main e®ect of time on mobility overall as F(1, 24) ¼ 77:78, p ¼ 0:000, p2 ¼ 0:76 in Timed up and Go test and F(1, 24) ¼ 48:24, p ¼ 0:000, p2 ¼ 0:67 for 10 m Walk test. There was a signi¯cant interaction e®ect for time  group with F(2, 24) ¼ 8:67, p ¼ 0:001, p2 ¼ 0:420 for balance. With respect to mobility, the values F(2, 24) ¼ 5:92, p ¼ 0:008, p2 ¼ 0:330 in Timed Up and Go test and F(2, 24) ¼ 10:40, p ¼ 0:001, p2 ¼ 0:464 in 10 m Walk test showed a signi¯cant interaction. But there was no signi¯cant main e®ect between the groups for both balance and mobility. Conclusion: The ¯ndings of this study suggest that Tai Chi as well as Yoga are well adhered and are attractive options for a home-based setting. As any form of physical activity is considered bene¯cial for individuals with PD either Tai Chi, Yoga or conventional balance exercises could be used as therapeutic intervention to optimize balance and mobility. Further studies are necessary to understand the mind–body bene¯ts of Tai Chi and Yoga either as multicomponent physical activities or as individual therapies in various stages of PD. Keywords: Parkinson's disease; Tai Chi; yoga; balance; home-based setting. Introduction Early in the disease, dopamine-sensitive bradyki- nesia and rigidity progressively a®ect balance and Parkinson's disease (PD) is a chronic progressive gait and later in the disease, dopamine insensitive- neurodegenerative disorder of insidious onset balance problems like impaired kinaesthesia, characterized by the presence of predominantly in°exible postural set, lack of automaticity, and motor symptoms and a diversity of non-motor executive dysfunction aggravate the balance and symptoms.1 The Clinical Diagnostic Criteria pro- gait impairments.5 posed by UK Parkinson's Disease Society Brain Bank is Bradykinesia (slowness of initiation of Cochrane's updated review in 2014 included 43 voluntary movement with progressive reduction in trials which highlight that a wide range of phys- speed and amplitude of repetitive actions); And at iotherapy techniques have been tested to treat PD. least one of the following: Muscular rigidity, 4–6 Hz Considering the small number of participants, the resting tremor, Postural instability not caused by wide variety of physiotherapy interventions and primary visual, vestibular, cerebellar, or proprio- the outcomes assessed, there is insu±cient evidence ceptive dysfunction.2 to support the use of one approach of physiother- apy intervention over another for the treatment of PD is a universal disorder, with a crude inci- PD.6 There is a moderate evidence that physical dence rate of 4.5–19 per 100,000 population per activity and exercise will result in improvements in year and the total Daily Adjusted Life Years postural instability outcomes and to improve bal- (DALY) globally in 2015 was 1.76 million (0.12%) ance task performance in persons with mild to and is expected to increase up to 2.01 million moderate PD.7 A recent survey showed that Tai (0.13%) in 2030.3 In a door-to-door survey of the Chi and Yoga were the second most prevalent Parsi community in Bombay, the crude prevalence complimentary therapies utilized by individuals estimates were 328 per 100,000.4 with PD and the perceived e®ectiveness of Yoga and Tai Chi were reported to be 73.8% and 60.9%, The basal ganglia, a key pathologic structure in respectively.8 PD, is involved in control of balance via the tha- lamic-cortical-spinal loops, the brainstem ped- Tai Chi is a traditional Chinese martial art that unculopontine nucleus and the reticulospinal involves slow and graceful movements that can system. The basal ganglia is involved in controlling improve postural balance, °exibility, and mood.9 the °exibility of postural tone, scaling up the Tai Chi, as a mind–body exercise, consists of a magnitude of postural movements, selecting pos- series of dance-like movements linked in a contin- tural strategies for environmental context (central uous sequence, °owing slowly and smoothly from set), and automatizing postural responses and gait.

E®ect of home-based Tai Chi, Yoga or conventional balance exercise among individuals with PD 41 Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com one movement to another that emphasizes weight various neurological disorders. However, there is no by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. transfer and movement of the body. The Tai Chi recent literature evaluating the e®ects of home- stresses weight shifting that trains the ankle based Tai Chi or Yoga on individuals with PD. So, strategy to e®ectively move the person's center of this study focused on comparing the e®ects of gravity toward the limits of stability, also by home-based Tai Chi, Yoga or Conventional bal- alternating between a narrow stance and a wide ance exercise program on balance and functional stance, the dorsi°exor and plantar °exors are mobility among persons with idiopathic PD. strengthened.10 Methods Previous studies had reported that mind–body exercises like Tai Chi showed improvement in Participants motor and non-motor symptoms.11 Tai Chi has reported to have promising improvement in mo- G-power software (version 3.1.9.2) was used to bility and balance, also it is considered safe and calculate the number of patients required for this popular among individuals with PD at an early study to achieve a signi¯cant level of 0.05, power of stage along with medications.12 A meta-analysis 0.95, and e®ect size of 0.73. To achieve the required concluded that improvement in balance was power, 27 patients were included in this study. greater for Tai Chi plus medication than other Inclusion criteria was (a) Subjects within age 60–85 exercise plus medication and medication alone.13 years including both male and female. (b) Subjects But studies also have found that there was no who were in stage 2.5 (Mild bilateral disease with signi¯cant di®erence in the gait velocity between recovery on pull test) and 3 (Mild to moderate Tai Chi and other exercises.10,13 bilateral disease; some postural instability; physi- cally independent) of Modi¯ed Hoehn and Yahr's Yoga is a popular mind-and-body practice Parkinson's stage. (c) Patients who were able to which originated in ancient India. It concentrates understand and follow the instructions. (d) on meditation, breathing, and postures. The con- Patients who were interested to participate and trol of posture practice in Yoga involves stretch were not undergoing any other treatment other and balance while maintaining a stable sitting or than medication. standing position. The reported bene¯ts of Yoga training for healthy populations include improving Participants were excluded if they had (a) muscle strength and endurance, muscle power, Severe co-morbidity in°uencing mobility or life- °exibility, balance and coordination, and health- threatening disease. (b) Not interested to partici- related functions.14 Yoga may also have psycho- pate in any form of exercises. (c) Visual and ves- social bene¯ts through prevention and control of tibular disorder a®ecting balance. (d) History of common health and emotional problems linked osteoporosis, fracture or ankle instability, falls. (e) with aging.15 A 12-week study on 13 participants No care giver supervision or support. with PD reported that there was a signi¯cant im- provement in balance, strength, °exibility, and All patients underwent a routine neurological range of motion.16 A pilot study reported that assessment and were also assessed with Uni¯ed 3-month Yoga program signi¯cantly reduced bra- Parkinson's Disease Rating Scale (UPDRS) and dykinesia and rigidity, and increased muscle sternal nudge test to classify the Modi¯ed Hoehn strength and power in individuals with PD.17 and Yahr's stage of PD in the \\on\" phase of medication by the Neurologist with a 25 years of Based on an analysis of dose for intervention experience and Movement disorder specialist at the prescription, it was found that for home-based Department of neurology, Kovai Medical Center exercise for people with Idiopathic Parkinson's and Hospital and then were referred to the Phys- disease, a minimum 150 min per week for at least iotherapist for the study. Twenty seven subjects six weeks improved balance-related activities.18 who satis¯ed the selection criteria participated in Although India's ancient religious text brought this study and a written informed consent was forth the teachings and practice of Yoga, over time, obtained. These 27 patients were blinded to the it has been described as a way of uniting body and groups and were randomly allocated by the alter- mind which is yielding therapeutic bene¯ts. Based nate number method to the three groups. 9 on the available literature, both therapies can be patients were allocated to Group A: (Experimental considered as an adjuvant for the patients with

42 A. Khuzema et al. Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com Fig. 1. Study °owchart. by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Group I) who received Home-based Tai Chi exer- 10 years. Yoga was taught to the participants be- cise program, 9 patients were allocated to Group B: longing to the Yoga group by the Physiotherapist (Experimental Group II) who received Home-based who was certi¯ed in Yoga. General balance exer- Yoga exercise program and 9 Patients were allo- cises were taught to the participants in the control cated to Group C: (Control Group) who received group by the Physiotherapist. The ¯rst session was Home-based General Balance exercises (Fig. 1). conducted at the Department of Physical Therapy, Kovai Medical Center and Hospital, India. The Intervention subjects were given an exercise pamphlet (supple- ment) and a record sheet was also provided to rate Tai Chi, Yoga and Conventional exercise programs their adherence towards the exercise intervention were designed according to expert opinion and and to mention about any di±culties they faced from available literature for a duration of eight during the exercises which was collected after eight weeks. Participants in Tai Chi group were taught weeks. All the instructions and explanations to the exercises by the Physiotherapist under the guid- participants were given in the presence of a family ance of the Tai Chi instructor with an experience of member who aided the home intervention. They

E®ect of home-based Tai Chi, Yoga or conventional balance exercise among individuals with PD 43 Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com were advised to do the exercises for a ¯ve days/ mouth during the exercise. Each pose (Fig. 2(b)) by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. week at a slow and comfortable pace and within was repeated ¯ve times initially and gradually in- the intensity ranges of 11–15 (light to somewhat creased to 10 repetitions according to the subject's hard) on the Borg Rating of Perceived Exertion preference. Scale.19 The subjects were advised to perform all the exercises on non-slippery °oor and during the Conventional balance exercise \\on\" phase of the medication that is within one to program two hours after taking their medications preferably in the morning itself. The communication with the It included six conventional balance exercises patient and the family member was established by which were standing back extensions, standing means of a telephone call made every third day till trunk rotations, backward walking, side-ways the end of intervention. The patient and the family walking, tandem walking and single limb stance. member were advised to contact at any time dur- Each exercise was repeated ¯ve times initially and ing the intervention in case of any di±culty. gradually increased to 10 repetitions according to the subject's comfort. Subjects were advised to Tai Chi exercise program perform 10 steps in each repetition of Backward walking, Side-ways walking and Tandem walking. Each session of Tai Chi exercise program lasted for The exercise session lasted for about 40–45 min. about 30–40 min and it included six exercise poses. Each pose (Fig. 2(a)) was repeated about ¯ve times Outcome measures initially and were gradually increased to 10 repe- titions according to the subject comfort. All the All the outcome measures were assessed by the exercises were performed in a slow pace with ab- researcher who was not blinded. The balance was dominal breathing pattern. assessed by the Berg Balance Scale which com- prises of 14 items on a ¯ve-point scale, ranging Yoga exercise program from 0–4.20 \\0\" indicates the lowest level of func- tion and \\4\" the highest level of function for a total Each session of the Yoga exercise program lasted score of 56. The functional mobility was assessed 30–40 min and included six poses. Subjects were by the Timed 10-m Walk test and Timed Up and advised to breathe deeply and e®ortlessly with in- Go test. In Timed 10-m Walk test, the subjects halation through nose and exhalation through Fig. 2. Figure illustrating the exercises given to (a) Tai Chi Group and (b) Yoga Group.

Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com 44 A. Khuzema et al. conducted that examined the e®ect of eight weeks by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Tai Chi, Yoga or Conventional Balance exercises were instructed to walk on a 10-meter long path on Balance and Mobility. Alpha level of signi¯- and the time was measured in seconds for the in- cance was set at 0.05. termediate 6 m (19.7 feet) to allow for acceleration and deceleration.21 The Timed Up and Go test Results begins with the subject comfortably sitting on a standard chair with arm rest and then the subjects Twenty-seven individuals with Idiopathic PD were were instructed to stand up from the chair, walk to assigned to either Tai Chi, Yoga or conventional the line on the °oor three meters away, turn around exercise group who participated in this study. and walk back to the chair and sit down at a self- There was no di®erence in the baseline for age, selected pace, the time duration in seconds for this UPDRS motor score, Modi¯ed Hoehn and Yahr's was noted.22 The outcome measures were obtained stages, sex, time with PD, Balance score, timed up at baseline and after eight weeks as patients came for and go time and 10 m walk time (Table 1) analyzed review to the hospital in the same setting. using Mixed Model ANOVA. The Two-way mixed ANOVA analysis (Table 2) for overall balance in Data Analyses Berg Balance Scale scores showed that there was a signi¯cant main e®ect for time as Fð1; 24Þ ¼ 74:18, Data analysis was performed using SPSS Software (version 25). Mixed model ð3 Â 2Þ ANOVA was Table 1. Participant (n ¼ 27) characteristics at baseline of the eight weeks Tai Chi, Yoga or General balance exercise study. Sex Time with Motor subscale Modi¯ed H&Y stage 10 mWt time (s) Groups Age (in years) M F PD (years) score (UPDRS) 2.5 3 BBS score TUG time (s) Tai Chi 72 Æ 5.22 6 3 5.67 Æ 2.33 17.22 Æ 6.53 3 6 40.889 Æ 6.94 16.328 Æ 5.41 8.981 Æ 2.33 Yoga 68.11 Æ 4.23 6 3 6.2 Æ 1.67 17.67 Æ 6.30 3 6 44.222 Æ 4.79 20.094 Æ 13.18 10.497 Æ 8.27 Control 70.89 Æ 6.01 7 2 5.23 Æ 3.12 20.22 Æ 6.72 4 5 41.000 Æ 9.19 16.203 Æ 7.18 7.872 Æ 2.98 Notes: PD- Parkinson's Disease; H&Y- Hoehn & Yahr Stage; BBS- Berg Balance Scale: TUG- Timed Up and Go; 10 mWt- 10 m Walk test. Table 2. Pre-intervention values, Post-intervention values and p values assessed by Mixed Model ANOVA for Berg Balance Scale, Timed Up and Go and 10-m walk test. Outcome Treatment Pre-test means with Post-test means with p ¼ Main e®ects p ¼ Main p ¼ Time and measure groups standard deviation standard deviation for time e®ects for group groups interaction Berg Balance Tai Chi 40.889 Æ 6.94 53.333 Æ 1.32 0.000* 0.566 0.001* Scale (score) 0.000* Yoga 44.222 Æ 4.79 48.000 Æ 4.69 0.507 0.008* Timed Up and Control 41.000 Æ 9.19 47.333 Æ 7.70 Go Tai Chi 16.328 Æ 5.41 13.000 Æ 4.4 0.000* 0.053 0.001* (Seconds) Yoga 20.094 Æ 13.18 18.700 Æ 13.54 10-m Walk test Control 16.203 Æ 7.18 14.822 Æ 6.5 (Seconds) Tai Chi 8.981 Æ 2.33 7.023 Æ 2.13 Yoga 10.497 Æ 8.27 9.894 Æ 8.2 Control 7.872 Æ 2.98 7.195 Æ 2.79 Note: *Level of signi¯cance p 0:05.

E®ect of home-based Tai Chi, Yoga or conventional balance exercise among individuals with PD 45 Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com Fig. 3. Clustered bar graph depicting mean and standard deviation before and after eight weeks among three groups for Berg by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. Balance Scale, Timed Up and Go and 10-m Walk test among participants. p ¼ 0:000, p2 ¼ 0:76. There was also a signi¯cant Tai Chi, Yoga or Conventional balance exercise main e®ect of time on mobility overall as group, respectively (p < 0:05). The mean Timed up F(1, 24) ¼ 77:78, p ¼ 0:000, p2 ¼ 0:76 in Timed and go time decreased signi¯cantly by 22.695%, Up and Go test and F(1, 24) ¼ 48:24, p ¼ 0:000, 7.187% and 8.902% in Tai Chi, Yoga and Con- p2 ¼ 0:67 for 10 meter walk test. ventional balance exercise group, respectively (p < 0:05). The mean 10-m Walk Time decreased There was a signi¯cant interaction e®ect for signi¯cantly by 24.469%, 5.914% and 8.986% in time  group with F(2, 24) ¼ 8:67, p ¼ 0:001, Tai Chi, Yoga and Conventional balance exercise p2 ¼ 0:420 for balance. With respect to mobility, group, respectively (p < 0:05) (Fig. 3). the values F(2, 24) ¼ 5:92, p ¼ 0:008, p2 ¼ 0:330 in Timed Up and Go test and F(2, 24) ¼ 10:40, All the subjects reported good adherence with a p ¼ 0:001, p2 ¼ 0:464 in 10 m Walk test showed a 92.78% compliance in Tai Chi group, 90.28% compliance in Yoga group and 71.94% compliance signi¯cant interaction. in control group. All the participant (100%) com- pleted the program with 0% adverse events, inju- There was no signi¯cant main e®ect for group ries or falls. with F(2, 24) ¼ 0:583, p ¼ 0:566, p2 ¼ 0:046 on balance. Similarly, there was no signi¯cant main Discussion e®ect found between groups for mobility with F(2, The home-based Tai Chi, Yoga or Conventional 24) ¼ 0:699, p ¼ 0:507, p2 ¼ 0:055 in Timed Up balance exercise program for eight weeks (40 ses- and Go test and F(2, 24) ¼ 0:667, p ¼ 0:523, p2 ¼ sions) showed no signi¯cant di®erence in balance 0:053 in 10 m Walk test. Further, Post Hoc analysis and functional mobility between the three groups. was not done as there was no signi¯cant group e®ect. The mean Berg Balance score increased signi¯- cantly by 26.414%, 8.193% and 14.339% in

Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com 46 A. Khuzema et al. mobility remain less understood and needs future by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. exploration. However, all the three groups showed statistically signi¯cant improvement after eight weeks in bal- The Tai Chi group showed an increase in mean ance and functional mobility. BBS score by 26.414% while the Yoga group showed an increase in BBS score by only 8.193%. Xiaojia Ni et al.13 in their meta-analysis repor- This could be explained in many ways. The ¯rst is ted mean di®erence (MD ¼ 4:25, 95% CI 2.85– Tai Chi that has many styles. In this study, Tai 5.86) in the BBS score. In this study, the mean Chi was based on Qigong style, which was con- di®erence in the BBS score between Tai Chi and sidered easy to follow and had di®erent moves Yoga group was (MD ¼ 5:33, 95% CI 0.86–11.52) challenging balance.26 Similarly, the Yoga group in and between Tai Chi and Control group was this study had Thadasanam, Hastha Uddhanasa- (MD ¼ 6:00, 95% CI 0.19−12.19). Li et al.10 found nam, Chakrasanam, Veerabhadrasanam, Jathara that Tai Chi training reduces balance impairment Parivarthanam and Bhujangasanam Postures, in patients with mild to moderate Parkinson's which was mostly static and might not be su±cient Disease. Choi et al.9 found signi¯cant interaction in providing dynamic postural challenges. Second, e®ects in balance with 36 sessions of therapeutic di®erent forms of Yoga and Tai Chi exist, varying Tai Chi given for 12 weeks. Later, Gao et al.23 in intensity as well as bene¯ts. There is no stage found that 26-week Tai Chi training improved speci¯c standard Yoga protocol which could be more than control group on Berg Balance Scale, tested against other complementary or mind–body but not on Timed Up and Go Test. However, therapies.27 Third, Yoga could be considered as a our results showed that there was statistically spiritual intervention by the participants and Tai signi¯cant di®erence after eight weeks on both Chi as wellness intervention program. This study balance and mobility in all the three groups. focused only on balance and mobility, not on non- However, there was no statistically signi¯cant dif- motor symptoms like mood or depression which ference in balance and mobility among the three could have been in°uenced by Yoga. Cheung groups. et al.28 reported that Yoga is a safe, feasible and acceptable complimentary method for improving In 2017, review by Song et al.11 and in 2014, motor function in individuals with mild to moder- review by Yang et al.24 found improvement in ate Parkinson's disease. However, longer duration balance (E®ect size ¼ 0:544, p < 0:0001) and e±- or di®erent set of Yoga patterns may be necessary cacy of balance (SMD-1.22, 95% CI; 0.80–1.65, for improvement in motor and non-motor functions P < 0:00001), respectively. Berg Balance Scale in individuals with PD. (BBS) is mostly used to assess balance function in Parkinson's disease. It has been previously repor- The protocol of the conventional balance exer- ted that the Minimal Clinical Relevant Di®erence cise focused on the exercise that require the control of the BBS is the improvement by ¯ve points.25 In of the body's center of mass while performing this study, a clinical improvement of 12.44 Æ 6.19 destabilizing movements and during reduction in points in the Tai Chi group was observed for bal- base of support. Both static and the dynamic bal- ance after 40 sessions in eight weeks which is more ance exercises were included in the conventional than needed Minimal Clinical Relevant Di®erence. balance exercise program like single leg standing, standing back extension, standing trunk rotation, The Tai Chi protocol stresses weight shifting backward walking, heel walking and tandem and ankle sway to e®ectively move the person's walking. However, the conventional exercise group center of gravity toward the limits of stability, showed an increase in mean BBS score by 14.339% alternating between a narrow stance and a wide when compared to the Tai Chi group which showed stance to continually change the base of support, an increase in mean BBS score by 26.414%. This increasing support-leg standing time, engaging could be because the exercises may not be su±- rotational trunk movements with upright posture, ciently challenging for the subjects. and performing heel-to-toe (forward) and toe-to- heel (backward) stepping movements to strengthen Regarding mobility component, Song et al.11 in dorsi°exion and plantar °exion. Tai Chi also pro- their 2017 review concluded that Tai Chi groups poses improved °exibility and muscle strength.10 showed signi¯cant improvement in TUG Score Although these improvements indicate that Tai when compared to the control groups, with a Chi would be e®ective in enhancing neuromuscular small e®ect size (Hedges's g ¼ À0:341, 95% CI rehabilitation, the mechanisms behind the thera- peutic change in participant's motor control and

E®ect of home-based Tai Chi, Yoga or conventional balance exercise among individuals with PD 47 Hong Kong Physiother. J. 2020.40:39-49. Downloaded from www.worldscientific.com −0.578 to –0.104, p ¼ 0:005). However, Choi et al.9 Limitations by 27.58.229.138 on 05/28/22. Re-use and distribution is strictly not permitted, except for Open Access articles. concluded there was no signi¯cant change in TUG scores in both Tai Chi and Control group after 12 There were several limitations of this study that weeks of training. On the other hand, the results includes being mind and body exercises, the psy- of this study showed that there was statistically a chological aspect of Tai Chi and Yoga were not signi¯cant di®erence in TUG scores in all the assessed. The researcher was not blinded to the three groups. But there was no statistical signi¯- groups of participants. The exercises were needed cant di®erences in TUG scores after eight weeks to be performed under supervision for an initial among the three groups. Our ¯nding in this study period. The entire study was performed in the \\on\" by the 10 m Walk test showed that there was a phase. A long-term follow-up was not done. Exer- statistically signi¯cant di®erence in the scores cises for each group was established from previous after eight weeks of training in all the three studies, there was no stage speci¯c exercise sets groups, but no statistically signi¯cant di®erence available. was found among the three groups. The exercise protocol consisted of challenging movements in Suggestions multiple direction which require more complex coordination that might have contributed to im- Future research should focus on the e®ects of Tai proved mobility. Chi and Yoga therapy on non-motor symptoms of Parkinson's disease. Integrated exercise program Considering the di±culties in transport and for Balance can be established which can include cost, further follow up of participants were not either Tai Chi and Yoga together or separately. carried out in this study. The participants needed Future research should also focus on the e®ects of moderate supervision during the initial period but supervised versus unsupervised mode of exercise or however were able to perform all the exercise in- group versus individualized therapy. dependently once they became con¯dent. Acknowledgments Both Tai Chi and Yoga are increasingly gain- ing popularity as preferred Physical Activity. The We would like to thank Dr. Edmund M. D'couto \\2018 Physical Activity Guidelines for Amer- and Dr. Vennila for their assistance. We would like icans\" recommends Tai Chi and Yoga as muscle to acknowledge Mr. Kathiresan for supervising Tai strengthening exercise. This study found that Chi exercise program. though with eight weeks of training Tai Chi, Yoga or Conventional balance exercises did not Con°ict of Interest show statistical signi¯cance among the three groups, there were bene¯cial e®ects on balance The authors have no con°ict of interest. and mobility. Either Tai Chi or Yoga could be a good exercise strategy which individuals with PD can choose according to their preference and interest. Conclusion Funding/Support Both home-based Tai Chi or Yoga could be a po- This research did not receive any speci¯c grants tential therapy for improving Balance and Func- from any commercial, public, or non-pro¯t funding tional mobility for individuals with mild to agencies. moderate Idiopathic Parkinson's disease. These exercise programs are well adhered by the patient Author Contributions and can be an attractive option. Further, the e®ect of these therapies on various Hoehn and Yahr's AK and AB were involved in study conception and stages of disease, duration and progression must be design. AK and AS performed data acquisition and studied. Also, long term follow-up and large-scale test procedures. AK and AB performed the data studies are required to gain better insight and analysis and/or interpretation. AK and AB wrote understanding. the ¯rst draft of this paper and all the authors revised it critically for important intellectual

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