Scientific Research Journal of India SRJI Vol 3, Issue 2, Year 2014 Full Issue

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

ISSN: 2277-1700
Vol: 3, Issue: 2, Year: 2014

Editor in Chief
Mrityunjay Sharma, Varanasi, India
Executive Editor
Krishna N. Sharma, Cameroon
Editors
Ankita Kashyap, Bhopal, India
Florence Ngwanyam, Cameroon
Gayatri Jadav Upadhyay, Bhopal, India
Jyoti Sharma, Jabalpur, India
Kuki Bordoloi, Guwahati, India
Neha Dewan, Canada
Ngeh Etienne Ngeh, Cameroon
Nick Ngwanyam, Cameroon
Piyush Jain, New Delhi, India
Popiha Bordoloi, Guwahati, India
Sudeep Kale, Mumbai, India
Sushil S. Dubey, Mumabi, India
Tufon Emmanuel, Cameroon
Waqar Naqvi, Canada

Office
Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403
Website
http://srji.drkrishna.co.in
URL Forwarded to
http://sites.google.com/site/scientificrji
Email
editor.srji@gmail.com
Contact
+91-9839973156
Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the
editorial board will not be held responsible for the same.
Copyright 2014 Scientific Research Journal of India
All rights reserved.

CONTENTS

Title Author/s Department Page
Editorial Mrityunjay Sharma I
THE EFFICACY OF
KINESIOTAPING ON
LOCOMOTOR ABILITIES IN
CEREBRAL PALSY: A CASE
STUDY
Deepika P. Metange,
Madhavi V. Lokhande
Physiotherapy 1
EFFICACY OF RETROWALKING
IN PATIENTS WITH CHRONIC
KNEE OSTEOARTHRITIS: A
SINGLE GROUP EXPERIMENTAL
PILOT STUDY
Gauri Arun Gondhalekar,
Medha Vasant Deo
Physiotherapy 7
AN ANALYSIS OF MEMORY
RETRIEVAL AND
PERFORMANCES OF
PHYSIOTHERAPY EXERCISES IN
NON-SPECIFIC LOW BACK PAIN
PATIENTS
Disha Jacob, Varoon C
Jaiswal
Physiotherapy 16
TO ANALYSE THE SHORT TERM
EFFECT OF UPPER TRAPEZIUS
INHIBITION TAPING IN
PATIENTS WITH MECHANICAL
NECK PAIN
Meenakshi Verma, Nidhi
Gautam, Deepak Raghav,
Tanvi Aggarwal
Physiotherapy 23
ITO TEST: DOES HEIGHT OF
THE PAD AFFECT BACK
MUSCLE ENDURANCE?
Juanita E. Soans, Keerthi
Rao, Chandra Iyer, Dnyanda
Newasekar
Physiotherapy 31
TO COMPARE THE
EFFECTIVENESS BETWEEN PRE
EXERCISE TAPING AND POST
EXERCISE TAPING IN
IMPROVING PAIN AND
FUNCTIONAL OUTCOME IN
Parul R, Vishal G, Deepak R,
Monika S
Physiotherapy 38

ISSN: 2277-1700 Website: http://srji.drkrishna.co.in URL Forwarded to: http://sites.google.com/site/scientificrji
iv
KNEE OSTEOARTHRITIS
ATTITUDE AND AWARENESS
TOWARDS PHYSICAL ACTIVITY
IN PRAVARA RURAL HOSPITAL
AND COLLEGE
Shalu Bhardwaj, Nisha
Shinde
Physiotherapy 47
TO FIND OUT THE
EFFECTIVENESS OF MAITLAND
MOBILIZATION IN CONTEXT OF
ADDITIONAL BENEFIT OVER
ADVICE AND EXERCISE ALONE
FOR PATIENTS SUFFERING
FROM FREEZING STAGE OF
FROZEN SHOULDER A
RANDOMIZED CONTROL TRIAL
Amit Murli Patel Physiotherapy 55
PROFILE OF SEVERE
NUTRITIONAL ANEMIA IN
CHILDREN AT A TERTIARY
CARE HOSPITAL, SOUTH INDIA
Madoori Srinivas, Kapil
Challa, Mangat Bhukya,
Srikanth Darisetty, Radhika
Kodimela
Pediatrics 72
ANTIOXIDANT POTENTIALS OF
PARTHENIUM
HYSTEROPHORUS L LEAF
EXTRACTS
Sankar Narayan Sinha, Dipak
Paul
Environmental
Microbiology
80
COMPARATIVE STUDY ON s-
LPS AND bp26 BASED iELISA
FOR HUMAN BRUCELLOSIS
Narayana Rao.K , R Shome,
Jayapal Gowdu
B,Nagalingam M,
Balamurugan1V, B. R.
Shome, K Prabhudas,
Rahman.H
Microbiology 87
AUTOMATIC FILLING
MANAGEMENT SYSTEM FOR
INDUSTRIES
Saubhagya Tandon, Shreya
Srivastava, Sandeep Pal
Electrical
Engineering
100

Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014
v

i
ii
FROM EDITOR IN CHIEF

Dear Friends,
Greetings! First of all Ild like to apologize for the delay in publishing this issue due to few unforeseen
problems. Like all our previous issues, this issue also remains a multidisciplinary issue that contains total 8
papers from Physiotherapy, 1 paper from Pediatrics, 1 paper from Microbiology, 1 paper from Environmental
Microbiology, and 1 from Electrical Engineering. I hope youll find these papers informative.

Be aware that the journal also has a website, http://srji.drkrishna.co.in where subscribers can access the full
content and also submit papers for future publication.

Please send me informal comments directly, or formal letters we can publish, about the journal. I welcome new
ideas about topics (content) and process. Let me know your thoughts.

Thanks for the opportunity, and stay tuned for future editions.

-Mrityunjay Sharma

1

THE EFFICACY OF KINESIOTAPING ON LOCOMOTOR ABILITIES IN
CEREBRAL PALSY: A CASE STUDY

Deepika P. Metange*, Madhavi V. Lokhande

ABSTRACT
Abstract- Objective of the study was to investigate the effect of kinesiotaping along with conventional
treatment protocol on locomotor abilities in a patient with spastic diplegic cerebral palsy. Design: A
single case study. Patient: A 5 year 3 months old female patient diagnosed as cerebral palsy shortly
after birth. Intervention:Motor ability of the patient was assessed using clinical measures ankle and
knee tardieu scale, and Gross Motor Function Measure-88, [GMFM]. The goal area score was
71.66% which included standing and locomotion dimension. Intervention included a session of
conventional physical therapy consisting of 1 hour session repeated 3 days a week for a period of 4
weeks based on neurodevelopmental treatment. It included stretching, weak muscle strengthening
exercises, postural, balance and gait training exercises and kinesiotaping Taping was applied to
lateral hamstring muscle bilaterally using facilitatory approach. Changes in locomotor abilities were
observed by means of video recording and observing changes in the gait parameters. There was an
increase of 18.85% in the GMFM goal score. Also the gait pattern demonstrated more stable and
symmetrical locomotor pattern.. Conclusion: The findings show that kinesiotaping when combined
with conventional physical therapy can improve locomotor abilities and thereby can be a useful
adjunct to therapy.
Keywords: Kinesiotaping; cerebral palsy; locomotor abilities; gait
2
INTRODUCTION
Limitations in the motor activity of children
with cerebral palsy (CP) are the consequence of
a failure to acquire appropriate motor schemas,
caused by arrested normal brain maturation.
Nevertheless, some of these children,
exploiting their few available resources
1
,
manage to walk, thanks to the emergence of
atypical but still functional locomotor patterns
2,
3
. However, these patterns can lead to long-
term instability, contractures, and deformities
4
.
Common treatments for children with CP
include botulinum toxin, serial casting,
orthopaedic surgery, and orthoses
5
. These
interventions are designed to act at the
peripheral level, without particularly aiming at
promoting more normal motor development at
the central level. Kinesiotaping may be a
solution in trying to reach this objective. .
Although it has been used in the orthopaedic
and sports settings, it is gaining acceptance as
an adjunct in the treatment of other
impairments. The use of Kinesiotaping in
conjunction with the childs regular therapy
program may favourably influence the
cutaneous receptors of the sensorimotor system
resulting in subsequent improvement of
voluntary control and coordination
6, 7
. This
intervention could favour the integration of
therapy and daily activities and increase
participation in social life. Nevertheless, it has
been only applied infrequently in these
children
8, 9
. Important intervention objectives
are to strengthen weakened muscles, to
improve the quality and active range of motion,
and to improve the childs level of
independence with activities of daily living.
Kinesiotaping, when applied properly, can
theoretically improve the following: strengthen
weakened muscles, control joint instability,
assist with postural alignment, and relax an
over-used muscle. When the application
procedure is followed correctly, the taped area
can be used to facilitate a weakened muscle or
to relax an overused muscle. The method for
applying the tape varies depending on the
specific goals: improve active range of motion,
relieve pain, adjust malalignment, or improve
lymphatic circulation (Kase, Wallis, &Kase,
2003)
10
. The variables in tape application
include the amount of prestretch applied to the
tape, position of the area to be taped, treatment
goals (pain reduction, subcutaneous blood flow,
improved muscle function)
11
. Therefore the
purpose of the case study was to investigate the
efficacy of kinesiotaping along with
conventional physical therapy on gait in a
patient diagnosed as spastic diplegic cerebral
palsy.

METHODOLOGY

Patient was a 5 year 3 months old female
diagnosed as spastic diplegic cerebral palsy
shortly after birth. She was going to normal
school and parents came with chief complaints
of walking on toes and difficulty in
independent walking. She was on regular
physiotherapy treatment 2 years back which
3
was later stopped and was not using any
orthosis. Informed consent was taken from the
parents and the patient prior to the study. Motor
ability of the subject was assessed using
clinical measures ankle and knee tardieu scale,
and Gross Motor Function Measure-88,
[GMFM]
12.
On observational gait analysis the
patient walked on toes, had bilateral in toeing,
mild hip and knee flexion and scissoring gait.
The total score on GMFM was 46.8%. The
grand total score or goal area score was 71.66%
which included standing and locomotion
dimension. Intervention included a session of
conventional physical therapy consisting of 1
hour session repeated 3 days a week for a
period of 4 weeks based on
neurodevelopmental treatment (derived from
the Bobath concept)
13
. It included stretching,
weak muscle strengthening exercises, postural,
balance and gait training exercises and
kinesiotaping. After thorough assessment it was
found that lateral hamstrings on either side
were weak while medial hamstrings on both the
sides were overactive. Specifically right side
hamstring showed more hypertonia and over
activity while walking which was manifested as
in-toeing gait. Also bilateral plantar flexors
showed hypertonia, which manifested as toe
walking. Ankle plantar flexors showed more of
static component of spasticity, due to which
plantar flexors were not assessed for
kinesiotaping.
Prior to kinesiotaping, basic assessment was
done to decide on the technique of application.
Active knee flexion in prone position was used
as outcome measure. Active knee flexion in
prone showed excessive internal rotation of
tibia right more than left because of hyperactive
medial hamstrings which could be the cause of
bilateral scissoring during gait. Change in
lateral hamstring strength was assessed by
using muscle technique of kinesiotaping.
Assessment revealed that the muscle gliding
towards origin i.e. ischial tuberosity gave better
recruitment of lateral hamstrings and thus better
quality of active knee flexion.
2 Inches wide, pink coloured kinesio tape was
applied by using I technique. Pink coloured
tape was preferred as it has facilitatory effect
on a muscle performance. The length of the
tape was measured with the muscle in
maximally stretched position .Because of
balance issues in standing this measurement
was done in supine with hip knee flexion. Base
of the tape was applied in prone position near
ischeal tuberosity with the muscle in resting
position (without any stretch).The base of tape
was activated by rubbing a tape. The rest of the
tape was applied carefully over the lateral
hamstrings without giving any stretch to the
tape. Again tape was activated by rubbing it.
Lateral hamstring function was reassessed by
active knee flexion, which showed significant
improvement in prone as well as in standing &
walking. Changes in gait pattern were observed
by means of video recording.

4

Fig 1. Findings seen on observational gait analysis.

RESULTS AND DISCUSSION
Results showed the acquisition of more
incremented GMFM. The improvement in the
goal GMFM score was 90.4% which was with
the difference of 18.85% post treatment. Also
the gait pattern demonstrated more stable
(reduced step width) and symmetric (more
similar step length and reduced scissoring)
locomotor patterns. However, the equines foot
was not corrected by the taping. Muscles which
are usually tackled are antagonist to spastic
muscles. But as spastic muscles are also weak,
and there is need to work upon these weak
muscles too. Also, kinesiotaping increases
proprioceptive and tactile information and
therefore restores optimal muscle length,
thereby providing a foundation for normal
firing and recruitment patterns.
Observed functional improvements were not
accompanied by evident changes in the ankle
and knee tardieu scale values. This result could
represent a specific difference between
kinesiotaping and serial casting. Serial casting,
in fact, typically leads to short-term
improvements on passive range of motion, but
does not always improve active functioning
14, 15

since it may lead to muscle wasting, and
weakening spastic and non-spastic muscles
5
.
Kinesiotaping, conversely, provides support to
the weak muscles, facilitating their normal
activity. Further randomized controlled
investigations on wider samples are certainly
needed to assess effectively the effects of the
taping treatment. Nevertheless, the fact that
observed gait improvements occurred during
the treatment period, demonstrate the efficacy
of kinesiotaping along with conventional
physical therapy. Also, parents reported
positive feedback about the effects of the
kinesiotaping on childs participation in social
activities, locomotor ability, and tolerability to
the treatment which could also be an advantage
5
over use of orthosis. In conclusion,
kinesiotaping seems to be a promising
intervention for improving locomotor function
in children with CP and a very useful adjunct to
the conventional therapy.

Fig. 2. Graph demonstrating effect on GMFM
scores pre and post intervention.

Fig 3. Changes seen in the gait pattern pre and
post intervention.

REFERENCES
1. Fonseca ST, Holt KG, Fetters L, Saltzman E. Dynamic resources used in ambulation by children with spastic
hemiplegic cerebral palsy: relationship to kinematics, energetics and asymmetries. PhysTher 2004; 84: 34454.
2. Krageloh-Mann I, Cans C. Cerebral palsy update. Brain Dev 2009; 31: 53744.
3. Berger W. Characteristics of locomotor control in children with cerebral palsy. NeurosciBiobehav Rev 1998; 22:
57982.
4. Ferrari A, Cioni G. Paralisicerebraliinfantili. Storia natural e orientamentiriabilitativi. Tirrenia: Edizionidel
Cerro, 1993.
5. Berker AN, Yalcin MS. Cerebral palsy: orthopaedic aspect and rehabilitation. PediatrClin North Am 2008; 55:
1209 25.
6. Thornton JL,Webster JA. The Tape Cast functional taping for the injured athlete. J Athl Train 1996; 31: 17981.
6
7. Lohrer H, Wilfried A, Gollhofer A. Neuromuscular Properties and functional aspects of taped ankles. Am J Sports
Med 1999; 27: 6975.
8. Yasukawa A, Patel P, Sisung C. Pilot study: investigating the effects of kinesio taping in an acute pediatric
rehabilitation setting. Am J OccupTher 2006; 60: 10410.
9. Footer CB. The effects of therapeutic taping on gross motor function in children with cerebral palsy.
PediatrPhysTher 2006; 18: 24552.
10. Kase, K. (2000). Illustrated Kinesio Taping (3rd ed.). Albuquerque, NM: Universal Printing and Publishing.
11. Kase, K., Wallis, J., &Kase, T. (2003). Clinical therapeutic applications of the Kinesio Taping Method.
Albuquerque, NM:Kinesio Taping Association.
12. Annika L, Gun-Britt J, Christina G, Eva N. Longitudinal Construct Validity of the GMFM-88 Total Score and
Goal Total Score and the GMFM-66 Score in a 5-Year Follow-up Study. PhyTher 2009; 89: 342-350.
13. Butler C, Darrah J. Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence
report. Dev Med Child Neurol 2001; 43: 77890.
14. Autti-Rami I, Suoranta J, Anttila H, Malmivaara A, Makela M. Effectiveness of upper and lower limb casting and
orthoses in children with cerebral palsy: an overview of review articles. Am J Phys Med Rehabil 2006; 85: 89
103.
15. McNee AE, Will E, Lin JP, et al. The effect of serial casting on gait in children with cerebral palsy: preliminary
results from a crossover trial. Gait Posture 2007; 25: 4638.

CORRESPONDENCE
* Assistant professor, Terna Physiotherapy College, Nerul, Navi Mumbai, INDIA. Email:
deepikapuri12@gmail.com
7

EFFICACY OF RETROWALKING IN PATIENTS WITH CHRONIC KNEE
OSTEOARTHRITIS: A SINGLE GROUP EXPERIMENTAL PILOT STUDY

Gauri Arun Gondhalekar*, Medha Vasant Deo**

ABSTRACT
Background: Increased external knee adduction moment during ambulation is a strong predictor of
the severity of symptoms in patients with chronic knee osteoarthritis. Objectives: To assess the effects
of Retro-walking along with conventional treatment on pain and disability in patients with acute
exacerbation of chronic knee osteoarthritis. Methods: Twelve patients (6 men, 6 women) with chronic
knee osteoarthritis fulfilling the inclusion criteria received conventional treatment and Retro-walking.
Pain and disability were the primary outcomes and knee range of motion (ROM), hip abductor and
extensor strength were the secondary outcomes; measured pre-intervention, after 1 week and after 3
weeks of intervention. Results: One way analysis of variance was used for all the primary and
secondary outcomes. At the end of 3 weeks; the primary outcomes showed highly significant difference
(P < 0.0001), secondary outcomes showed significant difference ( P < 0.05). Conclusion:
Retrowalking is an effective adjunct to conventional treatment in decreasing pain and disability in
patients with knee osteoarthritis.
Keywords: Retrowalking, Backward-walking, Knee osteoarthritis, external knee adductor moment

INTRODUCTION
Osteoarthritis (OA) is a chronic degenerative disorder of multifactorial etiology characterized
8
by loss of articular cartilage, hypertrophy of
bone at the margins, subchondral sclerosis and
range of biochemical and morphological
alterations of the synovial membrane and joint
capsule.
1-5

Osteoarthritis is the most common form of
arthritis.
6,7
It is the most frequent joint disease
with a prevalence of 22-39% in India;
6,8
and
one of the leading causes of pain and disability
worldwide.
9-12
Knee is the most common site for OA
13
with
characteristic signs like pain during weight
bearing, limitation of knee range of motion
(ROM), crepitus, joint effusion, and local
inflammation.
11,14-16

In knee joint, OA affects the medial
compartment more frequently than the lateral.
This is attributed to higher transfer of loads
through the medial compartment than through
the lateral, resulting in higher external knee
adduction moment.
14

The external knee adduction moment (EKAM)
is the product of ground reaction force (GRF)
and the moment arm with respect to knee joint
center.
17-21
It leads to adduction at the
tibiofemoral joint causing compressive load at
the medial compartment of the knee joint. This
increase in joint forces results in a deleterious
effect on knee cartilage and leads to
development and progression of knee OA.
21-29
Various studies have stated that, the first peak
knee adduction moment during walking is a
strong predictor of the severity and rate of
progression of medial compartment of knee
OA.
14

Management of knee OA aims to control pain
and reduce disability.
30-32
A multidisciplinary
approach Is required with physiotherapy as the
main choice of conservative management;
which includes various strategies such as
exercises, patellar taping, manual therapy and
various electrical and thermal modalities for
pain relief.
6,31,32

Recently, weight bearing exercises have drawn
much attention in the management of knee
OA.
33-34
Studies suggest that these exercises are
more effective and functional than the
traditionally employed non weight bearing
exercises.
32
Weight bearing exercises for knee
joint can be incorporated in many ways; one of
them is Retro-walking.
30
Retro-walking is
walking backwards.
6
Since there is backward
propulsion, it leads to reversal of leg movement
in Retro-walking. This requires different
muscle activation patterns than in forward
walking.
33
Various studies have stated the
effects of backward walking and backward
running in strength gains and joint stress
reduction and facilitating rehabilitation.
6
Along
with a unique muscle activation pattern; Retro-
walking is leads to increased cadence,
decreased stride length and different joint
kinematics as compared to forward walking;
offering some benefits over forward walking
alone.
30,32

A growing body of evidence suggests the
importance of exercises in improvement of
symptoms and joint function in knee OA.
Precise guidelines as regards their type and
dosage have not been established. Hence,
9
Retro-walking may offer additional benefits in
this population. The current study aimed at
finding out the efficacy of Retro-walking as an
adjunct to conventional treatments on pain and
disability in patients with chronic knee OA.

MATERIALS AND METHODS:
Written informed consent was obtained from all
participants prior to screening and participation
in the study. The study was conducted at the
Department of Physiotherapy in Terna Hospital
and Research Center, Navi-Mumbai, India.
Out-patients with diagnosis of knee OA
referred by a physician or an orthopedic
surgeon were screened for inclusion criteria.

Participant selection
Patients having knee pain for more than 6
weeks and fulfilling three out of the six clinical
criteria listed by The American College of
Rheumatology were included in the study.
34-35
The inclusion criteria are:
Age >50 years,
Morning stiffness lasting <30 min,
Crepitus with active motion,
Bony tenderness,
Bony enlargement, and
No warmth to touch.
Exclusion criteria:
Patients with bilateral involvement, a history of
any lower extremity injury or underlying
pathology and a history of any inflammatory
joint disease and balance problems,
neurological problems and using an assistive
device for ambulation were excluded.
Testing instruments
For primary outcomes:
(1) A 10 cm visual analogue scale (VAS) for
rating the intensity of perceived pain. The scale
had 0 (no pain at all) and 10 (maximum pain
felt at this moment) at either ends. The patient
was asked to mark his/her pain where he felt it
would take its position in the scale.
(2) Western Ontario and McMaster Universities
Arthritis Index (WOMAC) of OA, a patient
reported scale, was used to assess pain,
stiffness and physical function levels in the
subjects. It measures five items for pain, two
for stiffness, and 17 for functional limitation.
Physical functioning questions cover activities
of daily living. Good test-retest reliability in
pain and physical function domain has been
established for WOMAC.
36

For secondary outcomes:
Medical Research Council grading was used to
assess concentric strength of hip abductors and
hip extensors and quadriceps muscles.
(2) Universal Goniometer was used to assess
knee joint ROM in prone position.

Methods
Twelve patients (6 men, 6 women) with chronic
knee osteoarthritis fulfilling the inclusion
criteria received conventional treatment and
Retro-walking.
Conventional treatment was in the form of deep
heating modality (Short Wave Diathermy)
(Electro Medical Control, Electrotherm 250 W)
10
for 20 minutes and exercises (static and
dynamic quadriceps, knee bending exercise in
prone lying, hip flexion exercise in supine, hip
abduction in side lying and hip extension in
prone lying position). All exercises were done
in sets of 10 repetitions; twice a day for 3
weeks.
Subjects also underwent two sessions of Retro-
walking per day (10 mins. per session) for 3
weeks on a flat surface at their maximum pace.

Data collection:
Pain and disability were the primary outcomes
and knee range of motion (ROM), hip abductor
and extensor, and quadriceps strength were the
secondary outcomes; measured pre-
intervention, after 1 week and after 3 weeks of
intervention

Statistical-analysis:
The outcomes were analyzed using one way
analysis of variance with level of significance
set at P < 0.05; using SPSS version 17.0 for
Windows.

RESULTS
Fifteen patients fulfilling the inclusion criteria
were screened and included in study after
obtaining their consent.
Three patients were lost to follow-up. The
study population thus had 12 adults (6 men, 6
women) of mean age 64.23 3.01 years [Table
1].
Scores were analyzed pre intervention, at the
end of 1 week and at the end of 3 weeks [Table
2]. VAS and WOMAC showed highly
significant difference over a period of time
[Table 3].
Knee joint ROM, Strength of hip abductor
muscles and hip extensor muscles, and
quadriceps muscles showed significant
improvement [Table 3].

Table 1: Demographic characteristics of participants
Characteristics
N 12
Age 64.23 3.01
Female % 50 %
N: Number of subjects

Table 2: Baseline parameters
11
PARAMETER PRE POST 1 WEEK POST 3 WEEKS
VAS 7.79 + 1.09 6.04 + 1.03 3.75 + 1.32
WOMAC 64.72 + 15.48 52.08 + 11.34 37.16 + 14.14
Knee ROM 72.11 + 11.09 88.78 + 14.99 90.32 + 13.22
Quadriceps Strength 3.55 + 0.32 4.2 + 0.88 4.43 + 0.11
Hip Extensors
Strength
3.22 + 0.78 3.59 + 0.32 4.11 + 0.2
Hip Abductor
Strength
3.8 + 0.43 4.17 + 0.71 4.63 + 0.19
VAS: Visual Analogue Scale, WOMAC: Western Ontario and McMaster Universities Arthritis Index ,
ROM: Range of Motion
Table 3: One way analysis of variance
Parameter F value df P value Significance
VAS 37.022 2 <0.0001 HS
WOMAC 12.059 2 <0.0001 HS
Knee ROM 7.027 2 0.001 Sig
Quadriceps Strength 8.436 2 0.001 Sig
Hip Extensors
Strength
9.585 2 0.001 Sig
Hip Abductor
Strength
8.584 2 0.001 Sig
F value: Observed F value; df: Degrees of freedom; P value: Significance level, HS: Highly significant;
Sig: Significant

12
DISCUSSION
Current pilot study examines the efficacy of
Retro-walking as an adjunct to conventional
treatment in reducing pain and disability in
patients with chronic knee OA.
Pain relief could be attributed to reduced
compressive forces on medial compartment of
knee joint by reduction of excess adductor
moment due to Retro-walking. Along with
thermal effects causing local hypoalgesia
29
and
muscle relaxation, improvement in strength of
musculature around knee and hip providing
steadiness in the knee and giving additional
joint protection from shock and stress as a
result of conventional treatment.
Improvement in function may be attributed to
the pain relief, improved ROM, improved
muscle activation pattern and reduction in
abnormal joint kinetics and kinematics during
functional movement. Several studies have
stated that compared to forward walking;
backward walking creates more muscle activity
in proportion to efforts.
37-43
It has also shown to reduce external adductor
moment at knee during stance phase of gait.
Due to a specific kinematics Retro-walking
leads to augmented stretch of hamstring muscle
groups during the stride. Other advantage of
Retro-walking includes improvement in muscle
activation pattern; all of these serve in reducing
disability thus leading to improved function.
Since it is a weight bearing exercise, it could
have led to proprioceptive and balance training,
adding to its benefits. Retro-walking also has
effect on preventing abnormal loading at knee
joint by improving strength of hip extensors
leading to reduced hip flexion moment during
stance phase and thus and, in turn, the
disability. As a result of exercises and Retro-
walking there was improvement in the strength
of muscles at knee and hip which may have
helped in improving functional ability.

There were certain limitations in the current
study. Effects of BMI, severity of knee
deformities (for eg. genu valgum/varum), lower
limb mal-alignments (for eg. flat foot),
footwear used, activities of daily living and
recreational activities of patients were not taken
into account. The compliance of patients with
the home exercise program was not monitored.

CONCLUSION
Retrowalking is an effective adjunct to
conventional treatment in decreasing pain and
disability in patients with chronic knee
osteoarthritis.

ACKNOWLEDGMENT
The author would like to acknowledge Dr.
Senthil P Kumar and Dr. Sujata S. Wagle for
their valuable guidance in preparation of this
manuscript.

13
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15. JAN MH, TANG PF, LIN JJ, TSENG SC, LIN YF, LIN DH. Efficacy of a Target-Matching Foot-Stepping Exercise
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CORRESPONDENCE
*Physiotherapist at Breach Candy Hospital Trust, Mumbai, email: gauri.physio@yahoo.com
**Professor and Principal, TPCTs Terna Physiotherpy College, Navi Mumbai. Email: medhadeoin@yahoo.com

16

AN ANALYSIS OF MEMORY RETRIEVAL AND PERFORMANCES OF
PHYSIOTHERAPY EXERCISES IN NON-SPECIFIC LOW BACK PAIN
PATIENTS

Disha Jacob*, Varoon C Jaiswal**

ABSTRACT
Objective-the goal of the current study was to analyze the memory retrieval and performance of exercises that
are prescribed in mechanical low back pain by using RATSALL scale (ten point exercise assessment scale).
Design-cross sectional study. Setting-JC Bamfordexcavators Ltd, talegaon, Pune. Method-60 subjects with the
problems of mechanical low back pain were selected and were divided into 3 groups, each group containing 20
subjects. Groups are: Group A-verbal instructions and self performance. Group B-written instructions and self
performance. GroupC-Human model demonstration and self performance. Exercises were prescribed to the
subjects as per above mentioned techniques and they were told to recall these exercises on 2
nd
and 5
th
day for
short term memory and long term memory respectively. Outcome was measured by RATSALL scale and points
were allotted. Result-Subjects in group A scored an average of 7.24 and 5.74(on 2
nd
and 5
th
day respectively)
out of 10 according to the rastsall scale. Subjects in group B scored an average on 5.32 and 3.74. Whereas,
Subjects in Group C scored an average of 9.45 and 39.17. Hence "demonstration by Human model and self
performance" has better memory retrieval of short term and long term memory in patients compared to other
two groups i.e. "Verbal Instructions and Self Performance & Pictorial Diagram / Written Material and Self
Performance". Conclusion-The study concluded that the best way of giving a home exercise program is by
demonstration on a Human model and then self performance, as in this way subject remembers most of the
exercises and hence will be effective.
17
Keywords- retrieval, short term memory, long term memory, RATSALL scale.

INTRODUCTION
Therapeutic exercise intervention is considered
the core of physiotherapy practices. Physical
therapy and home exercise are two parts of a
whole. To support a therapy program, patients
are provided with instructions over the
exercises that they should continue to perform
at home known as home exercises. Home
exercise program (HEP) is unique to each
patient that facilitates the desired movements,
reduces pain and/or centralizes the symptoms,
performed exclusively by the patient. HEP is an
integral part of achieving success in physical
therapy. Physiotherapist prescribing HEP
should be aware that unsupervised exercise can
hinder the patients goal. So prescribing
exercises for home program is very
challenging. Exercise performance can be
enhanced by multiple ways. Typically, physical
therapy incorporates some re-training and
strengthening of specific muscles to perform
according to individual functions. In order to
activate the muscle and begin responding
appropriately, frequent and consistent practice
is necessary, and hence it is important for the
patients to perform some set of exercises even
at home. For maximum benefit, it is important
for the patients to take a active role in home
exercise program
1
.
Non-specific low back pain is tension, soreness
and/or stiffness in the lower back region for
which it is not possible to identify a specific
cause of the pain. Several structures in the
back, including the joints, discs and connective
tissues, may contribute to symptoms.The lower
back is commonly defined as the area between
the bottom of the rib cage and the buttock
creases. Some people with non-specific low
back pain may also feel pain in their upper legs,
but the low back pain usually predominates
1
.
Those patients who are good about
performing their home exercise program are the
same patients who feel better, stronger, and
more functional. Those patients who dont
perform their home exercise program are often
not able to progress through therapy at the
expected rate
2
.

Background
When we look into the literature some of the
factors were elaborately used to prescribe a
home exercise program. Those factors are:
verbal cues
3
, written cues or pictorial
diagrams
3
, demonstration on a Human model
4
.
Pictorial diagrams are commonly used in the
clinics to teach exercises. The pictures usually
demonstrate the exercise in the start and finish
position. Arrow showing the direction of
movement with marks clearly indicating the
start and the end positions can be helpful. Often
pictures show positions midway through the
exercise and patient is unclear about the full
excursion of the movement
1
.
Practical demonstration is another one of
the most commonly used clinics to teach
exercises. In practical demonstration, there will
18
be a Human modeling of an action either by
videotape or by the teacher performing the
action, it will help the learner to develop and
helps to understand the conceptual
representation of the action. By observation the
leaner can know the amplitude of movement,
appreciate the timing and fluency of the action
and relationship between the body parts
2.

Lastly, Verbal instructions are most
commonly used for conveying information or
prescribing the exercises. Verbal instructions
mainly focus on kinematics description for
example angular displacement, oaths of the
body parts, which require an understanding by
the therapist of linked segment dynamics and
biomechanical necessities ofthe action to be
learned
5
.
Friedrich et al, (1996) concluded from the
study that exercises that are based only on
written instructions often are not performed
properly and therefore lead to poorer outcomes
compared with exercises learned under the
supervision of a physical therapist and hence
prescribing home exercises by written material
isnt the best method of giving a home exercise
program, yet it is found that many hospitals
prescribe home exercises in this way.
Very few studies have compared the methods
of prescribing home exercise program and their
memory retrieval in non-specific low back
pain, since home program plays a vital role in
achieving physiotherapy success, it is an utmost
important for a physiotherapy for proper
prescription of home exercises program.

METHODOLOGY
Patient Selection
Inclusion Criteria
1. Younger adults of age group from 20 to 35.
2. Subjects with mechanical low back pain
3. With no memory deficits (subjects were
screened with mini-mental scale, those who
scored zero only those patients were selected).
Exclusion Criteria
1. Neurological deficits.
2. Visual impairments.
3. Hearing impairments.
4. Cognitive problems.

Material Used
1. Human model To demonstrate the
exercises. The Human model was initially
trained to perform the given set of exercises for
each of the three conditions. When he was well
versed with all the exercises, he was asked to
demonstrate same for the subjects.
2. Plinth, Exercise instruction sheets.
3. Rastall scale.

Sample selection
Purposive sampling was done in this study.
Sample consists of 60 subjects in the age group
of 20-35 years. Subjects included in the study
were assessed for any impairment and/or
disabilities as per inclusion/exclusion criteria.
The total number of subjects in the study
design was 60. These 60 subjects were divided
into 3 groups with 20 subjects in each group.
Informed consent was obtained from the
subjects.
19

Data collection
A qualified physiotherapist [1] was engaged in
diagnosing and prescribing the exercise to low
back pain subjects. Another physiotherapist [2]
was trained to rate them on Rastall scale on 2
nd

& 5
th
day of exercise prescription.
Physiotherapist [2] was blinded to the
allocation. She jus calculated the mean and
standard deviation and the results were
obtained.

Outcome measure
Ten point exercise assessment scale
6
.

This scale
was developed by Maggie Rastall el at 2000.
This scale measure primarily four components
of an exercise. They are
1) Correct starting position of the exercise.
2) Exercise body components moving in
correct plane
3) No compensation or cheat movements.
4) Movements performed within correct range.
Every exercise performance had a maximum
scoring of 10 points.

Correct starting position for
exercise
2
Exercising body component
moving in the correct plane
3
No compensations or cheat
movements
3
Movement performed within 2
the correct range

On exercise performance a score of 8 points or
more, was seemed to be correctly done they
were considered as number of exercises
correctly performed by the subject.

Procedure
Subjects with mechanical low back pain were
selected. A set of five exercises were given to
each subject. These set of exercises were
explained in all three medium of instructions.
These exercises were performed in three
different ways, they are-
1) Verbal Instructions and Self Performance.
2) Pictorial Diagram, Written Material and Self
Performance.
3) Demonstration by Human model and Self
Performance.
Methods for verbal instructions and self
performance-
In this group, exercises were explained to the
patient verbally and were asked to remember
them and do it. Patients were asked whether he
or she understood all the exercises properly.
The subjects were told to recall the same
exercises on 2
nd
and 5
th
day for both short term
and long term memory respectively.
Methods for written material/pictorial
diagram and self performance-
In this group, exercises were told to the patients
by the therapist in the form of pictorial
diagrams/written material. Subjects were asked
whether he or she understood it properly or not.
They were told to recall exercises on
Contains of Maggie Rastall exercise scoring
table with points allotted.
20
subsequent 2
nd
and 5
th
day for short term and
long term memory respectively.
Methods for demonstration by Human
model and self performance-
In this group, exercises were demonstrated to
the patient by the help Human model who
demonstrated the exercise to the subject, as told
by the therapist. Patients were told to remember
and do it and recall them on 2
nd
and 5
th
day for
both short term and long term memory
respectively.

Statistical Analysis- we have used descriptive
statistics to analyze the results. Mean and
standard deviation- measures of descriptive
statistics were used to analyze the result.

RESULTS
The study shows that subjects in group
C(Human model and self performance) scored
the maximum on 2
nd
and 5
th
day. Whereas,
subjects given oral instructions and self
performance scored less as compared to
subjects in group C.

Figure 1

Figure 2

DISCUSSION
The aim of the study was to analyze the
memory retrieval of HEP in mechanical low
back pain patients and which is the best method
of prescribing a home program. The result of
the study was, subjects in group C had an
average of 9.45(SD=1) and 9.17(SD=), on
2
nd
and 5
th
day respectively) out of 10
according to the Rastall scale, which suggest
that subjects in this group were able to
remember most of the exercise components as
well the exercises.When given an exercise
program by performance on a Human model
and then self performance, subject remembers
most of the exercises and has better memory
retrieval of exercise performance.However,
patients in group A i.e. verbal instructions
performed well as compared to group C , they
had an average of 7.24(SD=1.7) and
5.74(SD=.5) on 2
nd
and 5
th
day respectively as
they couldn't remember exercises components
and even some of the exercises.
When exercises were prescribed by
performance on a Human model and then self
performance, subjects got a visual feedback.
Eye is the main organ of processing memory,
and hence the better memory retrieval
7
. It has
21
been found that vision also has an effect of
performance of a task
8
.
Also the subjects were more attentive when the
exercises were performed on the Human model.
It has been found that attention play a major
role in memory retrieval
9
.
Subjects in group B scored the least with an
average of 5.32(SD=1.8) and 3.74(SD=1.3)
on both 2
nd
and 5
th
day as they were not able to
recollect much of the exercises as compared to
subjects in the group A and C.
In most of the hospitals patients are given
handouts, and hence our study reveals that it
isn't the best method of giving a home exercise
program. Whereas, giving exercises by
performance on a Human model or oral
instructions are found to be more productive.

CONCLUSION
The study concluded that the best method of
giving a home exercise program is by Human
model and then self performance as in this way
patient remembers most of the exercises and
hence will be effective.
REFERENCES
1. Early management of persistent non-specific low back pain.NICE clinical guideline 88. Issued: May 2009.
2. Henchoz Y, de Goumons P, Norberg M, Paillex Role of physical exercise in low back pain rehabilitation: a
randomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary
rehabilitation. May 20, 2010;35(12)
3. Friedrich et al, 1996, The Effect of Brochure Use Verses Therapist Teaching on Patients Performing Therapeutic
Exercises and on Changes in impairment Status, Physical Therapy, 76(10): 1082-1088, Oct 1996.
4. Carr and Shepard 1998, NEUROLOGICAL REHABILITATION: optimizing Motor Performance, Ch-2, 34-35.
5. Park K, 1997, Effect of Age event Based and time Based Prospective Memory, Psychological Aging, 12(2): 314 -
327, June 1997.
6. An Investigation into Younger and Older Adults' Memory for Physiotherapy Exercises-Maggie Rastall MCSP, Ten
point exercise assessment scale (Rastall, et al., 1999)
7. Berryhill, M.(2008, May 09). Visual memory and brain.
8. Bhatt, E., Catteneo, Z., Merabet, L.B., Pece,A.(2008).The influence of reduced visual acuity on age-related decline
in spatial working memory. Neuropsychology and cognition.
9. Exploring the role of attention during memory retrieval: effects of semantic encoding and divided attention. Mem
cognit.2006 jul;34(5):986-89.
10. Indian Journal of Physiotherapy and Occupational Therapy - An International Journal Year : 2012, Volume : 6,
Issue : 3
11. Alexander, N. B., Fry-Welch, D. K., Marshall, L. M., Chung, C. C., & Kowalski.
12. Guidelines for Exercise Testing and Prescription, DN. (1991)..Journal of Gerontology A Biological Science and
Medicine and Science, 46(3), M91-M98.
13. Kristin D Henry et al (1999), Effect of Number ofHome Exercises on Compliance and Performancein Adults Over
65 Years of Age, Physical Therapy,Vol 79 No. 3, March 1999.
14. Peggy MC Guire (2000), A Performance Frame Work for Teaching and Learning with Equipped for Future
Content Standards. Adventures In Assessment, Vol 12, 2000.
22
15. Zimmer (2000), Pop Out Into Memory: A Retrieval Mechanism that is Enhanced with the Recall of Subject
Performed Tasks, Learning, Memory and Cognition, Vol 26(3), 658-670

CORRESPONDING AUTHOR:
*Intern, Maeers Physiotherapy College, Talegaon Dabhade Pune, Maharashtra, INDIA. Email:
dishajacob@ymail.com
**Asst. Professor, Maeers Physiotherapy College, Talegaon Dabhade Pune, Maharashtra, INDIA
23

TO ANALYSE THE SHORT TERM EFFECT OF UPPER TRAPEZIUS
INHIBITION TAPING IN PATIENTS WITH MECHANICAL NECK PAIN

Meenakshi Verma*, Nidhi Gautam**, Deepak Raghav***, Tanvi Aggarwal****

ABSTRACT
Background and Purpose: Improving pain & functional performance in patients with mechanical
neck pain is the priority. The purpose of the study was to visualize the effect of upper trapezius
Inhibition taping on pain score and functional outcome in mechanical neck pain. Method: Thirty
patients who were assessed and diagnosed by mechanical neck Pain were selected. Patients were
given hot pack, stretching strengthening exercises of neck and taping assessed of VAS & NDI score
on 0 sitting,5
th
sitting & 10
th
sitting during intervention . Results : The outcome measures (NDI and
VAS) over the periods were compared by one factor repeated measures analysis of variance (ANOVA)
using general linear models (GLM) and significance between groups (periods) was done by Turkey
HSD (honestly significance difference) post hoc test after ascertaining the normality by Shapiro-Wilk
test and the homogeneity of variance by Levenes test. Conclusion: the result of the study suggests that
upper trapezius inhibition taping shows significant improvement in visual analogue scale and neck
disability index in patients with mechanical neck pain in 2 weeks.

Keywords. Mechanical neck pain,upper trapezius inhibition taping,neck disability index,Visual
Analogue Scale Upper trapezius stretching, scalene(anterior) stretching,sternocleidomastoid
stretching,neck isometrics.
24
INTRODUCTION
Mechanical neck pain defines cervical spine
pain as pain perceived anywhere in the
posterior region of the cervical spine, from the
superior nuchal line to the first thoracic spinous
process
1
Mechanical neck pain commonly
arises insidiously and is generally multifactorial
in origin, including one or more of the
following: poor posture, anxiety, depression,
neck strain, and sporting or occupational
activities.
2,3

Neck pain affects 3050% of the general
population annually 15% of the general
population will experience mechanical neck
pain (>3 months) at some point in their
lives.1114% of the working population will
annually experience activity limitations due to
neck pain. Prevalence peaks at middle age, and
women are more often affected than men. Risk
factors include repetitive work, prolonged
periods of the cervical spine in flexion, high
psychological job strain, smoking, and previous
neck/shoulder injury.
4
Despite the prevalence,
less-than optimal prognosis, associated risk of
disability, and economic consequences of
individuals suffering from mechanical neck
pain, there remains a significant gap in the
literature, which fails to provide sufficient,
high-quality evidence to effectively guide the
conservative treatment of this patient
population
5

A biomechanical mechanism that may explain
this association involves impairment in
alignment of cervical spine and scapula are
commonly cited as possible source of pain and
dysfunction
6
and Range of motion
limitations
7
.The scapula and cervical spine are
anatomically linked through the upper trapezius
muscle,changes of the alignment of either the
scapula or cervical spine can potentially
influence the biomechanics of the other by
altering the tension at the upper trapezius
muscle
8
it has been suggested that an ideal
vertical scapular alignment is when the scapula
is located between the spinous process of
second and seventh thoracic vertebrae
9
.It has
been proposed that the depressed scapular
alignment affect neck function potentially
through increasing compressive loading in the
neck region . Mechanical pain occurs due to
changes in muscle length when assuming a
poor posture for a prolonged period and
performing repetitive movements
10
. Faulty
cervical spinal alignment, such as Forward
Head Posture(FHP), is usually associated with
shortening of the neck extensor muscles i.e.
trapezius, levator scapulae, serratus
anterior,rhomboids etc, and lengthning and
weakness of the anterior neck muscles i.e.
scalene,sternocleidomastoid,longus capitis
longus colli and , as well as the shoulder
muscles, affecting scapular position and
kinematics
11
.Weakness of anterior cervical
muscles is postulated to contribute to persistent
neck pain in patients with mechanical neck
pain, quantitation of weakness has never been
reported
12
. The trapezius muscle is divided into
3 areas upper fibers,middle fibers & lower
fibers. The significance of this division lies in
the variety of functions performed by this
25
muscle. The trapezius muscle has several
functions to move the shoulder blade in toward
the spine, to rotate the shoulder blade so that
the topmost part of the upper arm faces up,to
move the shoulder blade up and down,to bring
the head and neck in a backward direction, to
rotate and side bend the neck,to assist in
breathing etc. The trapezius muscle works to
move the neck in several directions, its degree
of tightness or looseness affects neck
flexibility. For people who work at desks and
computers, or who spend many hours driving,
the upper trapezius is the muscle on top of your
shoulder that becomes very sore and
painful
36,37,38

Postural deviations observed in FHP involve a
downwardly rotated, anteriorly tilted, and
protracted scapula leading to imbalanced
movement of neck.
13
Physiotherapists often
give advice about changing lifestyles with an
emphasis on posture, in addition to teaching
specific exercises. Exercises and certain
electrotherapeutic modalities are commonly
used to improve pain & neck muscle function
& thereby decrease pain or other symptoms.
Massage, manual therapy, neck strengthening
& stretching exercises have also improved pain
& neck functions
14
Elastic therapeutic taping
offers a unique combination of flexibility and
support, providing practitioners with a tool to
address a variety of conditions. Since 1973,
when Kenzo Kase, DC, began developing the
concepts in his practice, and then introduced its
use in the 1980s, the range of applications has
expanded tremendously
15
.
To the extent there is no evidence shows the
study about analysis of short term effect of
upper trapezius inhibition taping technique in
patients with mechanical neck pain.

METHODOLOGY
Subjects: 30 patients were taken in the study
with mechanical neck pain with duration of
symptoms for 2 week. The exclusion criteria
included that patient Cervical pathologies
Cervical spine Fracture, Migraine,
Cervicogenic Headache, Trigger points in neck
or scapular muscles, allergy to taping product.
Subjects were selected and received
conventional treatment of neck with upper
trapezius inhibition taping. Protocol : All
patients underwent a descriptive orthopaedic
assessment. A baseline measurement of all the
variables visual analogue scale , neck disability
index was taken.

Visual analogue scale
The VAS is presented as a 10 cm horizontal
line, anchored by verbal descriptors labeled
with no pain at point zero (0 cm) and worst
imaginable pain at point ten (10 cm). The
patient marks the line at the point
corresponding to the intensity of the pain
currently experienced. Using a 1 cm-per-point
scale to measure the patients score, the VAS
provides ten levels of pain intensity. The visual
analog scale (VAS) is a valid and reliable
measure of chronic pain Intensity.
19

Neck Disability Index
26
The NDI is the most widely used, translated
and oldest questionnaire for neck pain. It has
been shown to have high test-retest
reliability. It consists of 10 questions.
Questions include activities of daily living,
such as: personal care, lifting, reading, work,
driving, sleeping, recreational activities, pain
intensity, concentration and headache. Each
item scored from 0-5 and total score is
expressed as a percentage with high scores
corresponding to greater disabilities.
20,28,29

Upper trapezius Inhibition Taping
Elastic therapeutic taping offers a unique
combination of flexibility and support,
providing practitioners with a tool to address a
variety of conditions. Since 1973, when Kenzo
Kase, DC, began developing the concepts in his
practice, and then introduced its use in the
1980s, the range of applications has expanded
tremendously.

DATA ANALYSIS
The data were summarized as Mean SD. The
outcome measures (NDI and VAS) over the
periods (sitting 0, sitting 5th and 10th ) were
compared by one factor repeated measures
analysis of variance (ANOVA) using general
linear models (GLM) and significance between
groups (periods) was done by Tukey HSD
(honestly significance difference) post hoc test
after ascertaining the normality by Shapiro-
Wilk test and the homogeneity of variance by
Levenes test. All analyses were performed on
STATISTICA (window version 6.0).

RESULTS
Table shows the mean age and standard
deviation of patients.
Characteristics Statistics
Age (yrs) 25.30 2.84

Comparisons NDI
0 sitting vs. 5
th
sitting P<0.001
0 sitting vs. 10
th
sitting P<0.001
5
th
sitting vs. 10
th
0.149

Comparisons VAS
0 sitting vs. 5
th
sitting P<0.001
0 sitting vs. 10
th

sitting
P<0.001
5
th
sitting vs. 10
th

sitting
0.149

NDI (score)
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
day 1 day 5 day 10
Treatment periods
M
e
a
n

S
D

27
VAS (score)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
day 1 day 5 day 10
Treatment periods
M
e
a
n

S
D

DISCUSSION
The aim of the study was to analyze the short
term effects of upper trapezius inhibition taping
in patients with mechanical neck pain. The
results of the study suggest significant
differences in NDI & VAS score favouring the
upper trapezius inhibition taping. Upper
trapezius inhibition taping may be a viable
option for treating mechanical neck pain.
It has been observed and described how Pain
in the neck region may occur because of a
downward pull on the cervical vertebrae or
facets by the upper trapezius muscle as well as
by the weight of the upper extremity along with
mal-alignment or movement of scapula has the
potential to alter the biomechanics of the
cervical spine and produce neck pain..
Increased upper trapezius stiffness may
contribute increased compressive load and
shear force on the cervical spine during active
neck movement. Repetitive and excessive stress
on the upper trapezius muscle has the potential
to cause cumulative micro trauma in the
cervical region, neck pain, and limited neck
rotation range of motion. Upper trapezius
inhibition taping technique significantly
increased the maximum active neck rotation
range of motion ,neck pain and daily functions.
Taping the skin overlying the trapezius muscle,
as performed in this study, traction on the skin
Or the pressure of the tape provides cutaneous
sensory cues, thus providing additional
proprioceptive input to the central nervous
system. inhibits its reflexes therefore results in
reduction of swelling, Accelerate blood flow
,Contribute to optimizing movement patterns
34
,
therefore reduce mechanical stress on the
cervical spine, and does Promotion of optimal
inter joint coordination, modification of
scapular alignment is currently performed in
the clinical field and in studies. Effect of
Taping on posture is Inhibition of overactive
movement synergists and antagonists;
Facilitation of underactive movement
synergists; Direct optimization of joint
alignment during static postures or movement;
Offloading irritable neural tissue; Direct or
indirect reduction of pain associated with
movement.
31,40,17
. These findings are supported
by study done by Host HH et al a case reports
scapular taping can be used as an adjunctive
therapy to attempt to attain a more favorable
scapular alignment and alleviate pain
31
The
tape should never restrict a patients ROM
,Additionally it should allow the patient to
perform motions that would have been painful
without the tape in place thus providing an
immediate assessment of the tapes
effectiveness. upper trapezius inhibition taping
should be used in conjunction with other
intervention especially selected exercise and
28
patient education about modification of
performing neck movements. Taping along the
length of a muscle inhibits that muscles reflex
excitability
41
.
It is also supported by the study done by peter
miller et al they suggested there may be a
potential role for taping as an adjunct to usual
physiotherapy treatment in management of
people with mechanical neck pain.
35

CONCLUSION
The present study evaluates the short term
effect of upper trapezius inhibition taping and
hypothesized that it may be effective in
treatment of mechanical pain, was found to be
true. The neck related disability (NDI) and pain
(VAS) improved significantly by 85.4% and
74.5%, respectively in patients of mechanical
neck pain. The present study thus concluded
that there is a short term effect of upper
trapezius inhibition taping in mechanical neck
pain. The study states that null hypothesis is
rejected.

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*Assistant Professor, Santosh College of Physiotherapy, Ghaziabad
**Student MPT Musculoskeletal, Santosh College of Physiotherapy, Ghaziabad
***Principal, Associate Professor, Santosh College of Physiotherapy, Ghaziabad
****Assistant Professor, Santosh College of Physiotherapy, Ghaziabad
31

ITO TEST: DOES HEIGHT OF THE PAD AFFECT BACK MUSCLE
ENDURANCE?

Juanita E. Soans*, Keerthi Rao**, Chandra Iyer***, Dnyanda Newasekar****

ABSTRACT
Background: Decreased back muscle endurance is sometimes associated with high rates of low back
pain. Ito test is a safe and reliable test for assessing trunk extensor muscle endurance, however it limits
recognition due to lack of studies and absence of standardized testing procedure. Hence this study
aims to find out whether the height of the pad that is to be used while performing the test has any effect
on back muscle endurance in normal healthy individuals. Methodology: 84 healthy college volunteers
were recruited in the study. A pilot study was conducted to find out the optimal height of pad that can
be used for conducting Ito test. Back extensor endurance was evaluated using a foam pad of height 5,
6.5 and 8 centimeters. Results: There was no significant difference in trunk extensor endurance with
different height of the foam pad. Conclusion: Any height of the pad ranging from 5 to 8 centimeters
can be used for assessing back muscle endurance, however the self reported comfortable height of the
pad was 5 centimeters for most of the healthy participants.
Keywords: Ito test, back endurance, low back pain

INTRODUCTION
Muscular endurance is the ability of an isolated
muscle group to perform repeated contractions
over a period of time (dynamic endurance) or
sustain a contraction over time at a certain level
(static endurance)
1,2
.

Decreased static
endurance in back extensors is sometimes
32
associated with high rates of low back pain,
decreased proprioceptive awareness, poor
balance, decreased productivity at work place,
increased muscular fatigability and overload on
soft tissues and passive structures of the spine.
3
Therefore, measurement of trunk muscle
endurance is potentially important for
identifying the risk factors, as prognostic
indicators, for planning treatment goals and
measuring patients progress.
4
Hansen JW
developed the first test for evaluating isometric
back extensor endurance.
5
Troup and Chapman
evaluated muscle fatigability by surface
electromyography in patients during this test.
6

After a study of Bieiring- Sorensen in 1984,
which was published in the Spine journal, this
test came to be known as Sorensen test
structures of the spine
7
.
Although there are no gold standards for
measurement of trunk endurance, Sorensen test
is the most popular method of assessing trunk
extensor endurance. However there are some
disadvantages pertaining to the use of this test
in patients with chronic low back pain.
8
It
increases the lumbar lordosis because of
extended hip and knee during the test which
can produce bulging of intervertebral disc and
buckling of ligamentum flavum followed by
reducing the intervertebral foramen. The
hyperextension of lumbar spine may aggravate
pain.
9
Also a study by Callaghan et al,
estimated that the compression load imposed on
spine during Sorensen test was 4000N, slightly
above the value recommended by the National
Institute of Occupational Safety and Health in
1981.
10
To overcome these disadvantages Ito et
al developed a new method based on Sorensen
test and studied its reliability, safety in
application of this method and established its
validity by evaluating the endurance using this
test in 190 healthy individuals and in
individuals with chronic low back pain. The
reliability of this test in healthy individuals is,
ICC= 0.97 for trunk extensor muscles.
8
Also,
maximal neck flexion and gluteal muscle
contraction included in the test procedure are
supposed to be the most optimal position for
decreasing lumbar lordosis and for activating
the lumbar erector spinae muscle to the
maximum.
11
Muller et al in his study showed
that Ito test has a good criterion validity and it
can assess back extensor muscle endurance
more specifically as compared to Sorensen
test.
12

Although, Ito test had a very high test-retest
reliability and did not seem to induce pain or
increase spinal loads the factors that limit the
recognition of Ito test includes lack of studies,
absence of standardized test procedures like the
type of pad used and extent of raising the upper
body and theoretical risk of exaggerating the
lumbar lordosis.
8,10
Hence our study aims at
determining the most appropriate height of pad
to assess back muscle endurance during Ito test
in normal healthy individuals.

METHODOLOGY
Eighty-four healthy college volunteers (53
females and 31 males) between 18 25 years
of age who volunteered for the study from
33
College Of Physiotherapy, Pravara Institute of
Medical Sciences, Loni were recruited. The
study was conducted from March 2013 till June
2013. The participants were selected by
convenience sampling and were screened based
on the exclusion criteria by physiotherapist who
later were involved with data collection.
Exclusion criteria were a history of
symptomatic low back pain within one year to
the time of the study, any obvious spinal
deformity, individuals participating in high-
intensity regular exercise or elite sports at
competitive level or individuals involved in any
prior systematic exercise program of lumbar or
hip extensor muscles, a history of
cardiovascular disease representing
contraindications to exercise or any disability
limiting the ability to exercise. The participants
were informed about the study and a written
consent was obtained before any measurements
were taken. Anthropometric data like height,
weight, BMI and abdominal girth of the
participants were calculated. Height was
measured using a stadiometer to the nearest 0.1
cm. Body weight was taken with light clothes
and measured to nearest 0.1 kg using a
weighing scale caliberated from 0-120 kgs with
the participant in standing position and shoes
off. BMI was calculated using the above data.
Abdominal girth was calculated using a
measuring tape at the level of the umbilicus to
the nearest 0.1 cm.
Before taking the readings the participants were
demonstrated the procedure of the test and were
also asked to perform it themselves. They were
encouraged to clarify their queries, if any and
all queries were addressed for complete
familiarization of the test. For evaluating the
back extensor endurance the participants were
asked to lie in prone position with a foam pad
(figure 1) under the lower abdomen.

Figure 1: Foam pad used for the test
This foam is medium rubber, high density and
has a medium to soft feel depending on the
body weight of the sleeper. It offers a high
degree of comfort and will retain its shape and
density. Participants were made to perform the
test in the following manner. The foam pad was
first placed below the lower abdomen of the
participants and they were asked to lift the
sternum off the plinth and hold the position as
long as they could upto a maximum of 300
seconds
8
. While performing the test participants
were asked to maintain maximum flexion at
cervical spine with pelvic stabilization through
contraction of glutei, the most optimal position
for reducing lumbar lordosis and activating the
lumbar erector spinae (Figure 2).
34

Figure 2: Participant performing ITO test
The pattern of selection of height of the foam
pad with which the participants were to start the
test was done by block randomization method
which was computer generated. The time for
which the participants could hold the test
position with the height of the foam pad was
measured in seconds using a stop watch. After
a rest period of 10 minutes, the test was
repeated with the same height of the pad and
similarly 2 readings were taken. An average of
the two readings was calculated and
documented for that height of the foam pad to
obtain highest accuracy and decrease any
manual error. The criteria for stopping the tests
were trick movements, altered pain sensation
and pain tolerance. The participants were called
the next day and the same procedure was
repeated with the other height of the foam pad
on the consecutive day. The main purpose of
taking two readings was to decrease fatigability
and for obtaining the best value for each height
of the pad. Before starting with the data
collection a pilot study was conducted with ten
participants to find out the optimal height of the
pad that can be used as reference for this study.
For any height below 5 cms in height, the
participants reported an absence of fulcrum
through which they could maintain the upper
body in the desired position, and for any height
above 8 cms the participants felt excessive
pressure on their abdomen and pain in the low
back which averaged 5.3 on VAS. Any height
greater than 8 cms was also flattening the
lumbar lordosis more than that required while
performing the Ito test. The criteria for stopping
the test were trick movements, altered pain
sensations, and pain tolerance.
Based on the results obtained, the participants
performed the test with a foam pad of 5, 6.5
and 8 centimeters in height. All the tests were
performed two hours after the last meal taken
by the participants. After each test the
participants were asked to rate their level of
discomfort on VAS so as to find out the height
of foam pad which was most comfortable.

STATISTICAL ANALYSIS:
The statistical analysis was done using Graph
Pad Instat Trial Version 13.3. ANOVA with
repeated measures was used for data analysis
and p<0.05 was considered to be statistically
significant.

RESULTS:
The baseline data for participants are as follows
and represented in table 1.
Participants
Males
(n= 31
Females
(n=53)
Age
(years)
21.20 2.31 21.9 1.97
35
BMI
(kg/m
2
)
20.26 3.49 20.19 2.84
Abdominal
girth
(cms)

87.12 10.31

76.18
12.83
Table 1: Baseline demographic data of
participants
BMI of all participants were 20.26 3.49
kg/m
2
and 20.26 3.49 79 10.3 kg/m
2
for
male and female participants respectively and
did not show co-relation to discomfort
experienced by them while performing the test
with different heights of the foam pad. The
abdominal girth for both male and female
participants were 87.12 10.31 and 76.18
12.83 centimeters respectively. The mean
holding time of all participants with pad height
of 5, 6.5 and 8 centimeters were 69.54 36.79,
70.20 44.96 and 68.78 33.79 seconds
respectively.(figure 3)

Figure 3: Mean Holding Time
Statistical analysis was done using ANOVA
with repeated measures with p < 0.05. This
shows that results obtained were not
statistically significant leading us to conclude
that height of foam pad does not actually alter
the endurance. It was found that 72% of
participants self reported that a height of 5
centimeters of pad was most comfortable while
performing the test as compared to 6.5 and 8
cms.

DISCUSSION:
The results of the present study show that there
was n significant alteration in back muscle
endurance with different height of foam pads.
Also, most participants reported that 5
centimeter height of foam pad was most
comfortable. In our opinion the height of the
foam pad did not vary much with respect to
each other in order to change the kinematics or
coupled movements of the muscles. Time, as a
measure of endurance of low back musculature,
varies with intensity of loading and with
posture. The Ito test, as compared to Sorensen
test is safe, reliable and easy to perform and
doesnt require any other equipment apart from
a foam pad. In the present study, a pilot study
was initially conducted to find out the optimum
height of the pad that can be used. The height
of the pad was kept between 5cms and 8cms
beyond which the participants reported
discomfort while performing the test. On
interrogation participants reported that
increased height of the foam pad placed below
the lower abdomen created excessive
compression which made it difficult for them
to breathe and reduced their performance. In
our opinion this is because a trunk extension
from 45 degrees of trunk flexion needs
36
dynamic pelvic and trunk movement. The leg
muscle will extend the pelvis, and the lumbar
muscles will stabilize and extend the lumbar
region on the pelvis whereas thoracic muscles
will lift the trunk.
13
Therefore more the height
of the pillow the glutei muscles have to contract
more in order to stabilize the pelvis and the
thoracic muscles will work in order to clear the
sternum off the plinth during extension. Also
lesser the height of the pillow the compression
on the lower abdomen is less thus reducing the
discomfort in breathing. In another study
conducted by Muller et al, an EMG study to
find out the criterion validity of Ito test, a foam
roll of 0.2 m in diameter, the density of which
was not stated in the study was used to evaluate
the trunk extensor endurance.
12
However, in
our study participants felt abdominal
discomfort and pain with any height above 8
centimeters. Another interesting observation
was that participants with greater abdominal
girth reported more comfort with a greater
height of the pad as compared to other
participants however the co-relation of this was
beyond the scope of this study.
The participants in the study were healthy
young adults hence the results cannot be
generalized to population with low back pain.
Evaluating back endurance muscle in patients
with low back pain using different height of
pad would have been difficult for the patients
because of repeated test procedures resulting in
aggravation of pain, hence this study was
conducted on normal individuals to find out the
optimal length of pad that can be used while
performing the test which would be
comfortable to the patients. Future scope of the
study may include finding the co-relation
between the height of the pad and abdominal
girth. Lastly as proposed in the original study
lumbar lordosis during the test should be
evaluated either by radiography or by using a
flexicurve.

CONCLUSION:
It can be concluded that any height of the foam
pad made of medium rubber and high density
having soft feel ranging from 5 to 8 centimeters
can be used for assessing back muscle
endurance however the self reported
comfortable height of the pad was 5
centimeters for most of the healthy participants.

ACKNOWLEDGEMENT:
We would like to thank the participants in the
study for their kind co-operation.

REFRENCES
1. Karen H, Glenn TM. Principles of aerobic exercise. IN: Kisner C, Colby LA, Therapeutic Exercise: Foundations
and Techniques, 5th edition, Jaypee Brothers, New Delhi, 2007.
2. Mayer T, Gatchel R, Betancur J, Bovasso E. Trunk muscle endurance measurement: isometric contrasted to
isotonic testing in normal subjects. Spine, 1995:20:920-926.
3. Chidozie M, Olusola A, Rufus A.Reference values of static back extensor muscle endurance in healthy Nigerian
adults, Med Princ Pract, 2009:18: 345-350.
37
4. Julie M, Elspeth F, Paul S, Brad Br, Caroline G.Interrater Reliability of Six Tests of Trunk Muscle Function and
Endurance, JOSPT , 1997:26 (4): 203-208.
5. Hansen JW. Postoperative management in lumbar disc protrusions. I. Indications, method and results II. Follow-
up on a trained and an untrained group of patients, Acta Orthop Scand, 1964:17(Suppl 71):1-47
6. Troup JD, Chapman AE. Changes in the waveform of the electromyogram during fatiguing activity in the muscles
of the spine and hips: the analysis of postural stress. Electromyogr Clin Neurophysiol, 1972:12:347-365
7. Beiring S. Physical measurements as risk indicators for low back trouble over a one year period, Spine, 1984:9:
106-119.
8. T Ito, Osamu Shirado, Hideki Suzuki, Masaaki Tokahashi, Kiyoshi Kaneda. Lumbar trunk muscle endurance
testing: An inexpensive alternative to machine for evaluation, Arch Phys Med Rehab, 1996:77:75-9
9. White AA, Punjabi MM. Clinical biomechanics of spine, Philadelphia, Lippincott co.1990:379-474
10. Christophe D, Marc V, Christophe D, Jean MC. Spinal muscle evaluation using the Sorenson test: a critical
appraisal of literature. Joint Bone Spine, 2006:73:43-50.
11. Shirado O, Ito T, Kaneda K, Strax TE.Electromyographic analysis of four techniques for isometric trunk muscle
exercises. Arch Phys Med Rehab,1995: 76:2259.
12. Muller R, Strassle K, Wirth B. Isometric back extensor muscle endurance: An EMG study on the criterion validity
of the Ito test. J Electromyograph and Kinesiology, 2010:20:845-850
13. Eline MD, De Ridder, Jessica OV, Andry V, Guy V, Lieven D. Posterior muscle chain activity during various
extension exercises: an observational study, BMC Musculoskelet disord, 2013:14:204.

*Final year M.P.Th (Orthopaedics) student, College of Physiotherapy, Pravara Institute of Medical
Sciences(DU), Loni, Maharashtra, India. Email Id: soans_juanita@yahoo.co.in
**M.P.T, Associate Professor, College of Physiotherapy, Pravara Institute of Medical Sciences(DU),
Loni, Maharashtra, India.
***M.P.T, Assistant Professor, College of Physiotherapy, Pravara Institute of Medical Sciences(DU),
Loni, Maharashtra, India.
****B.P.Th, College of Physiotherapy, Pravara Institute of Medical Sciences(DU), Loni, Maharashtra,
India.

38

TO COMPARE THE EFFECTIVENESS BETWEEN PRE EXERCISE TAPING
AND POST EXERCISE TAPING IN IMPROVING PAIN AND FUNCTIONAL
OUTCOME IN KNEE OSTEOARTHRITIS

Parul R*, Vishal G**, Deepak R***, Monika S****

ABSTRACT
Aim: To compare the effectiveness between pre exercise taping and post exercise taping in improving
pain and functional outcome in knee osteoarthritis. Background: A large body of research has been
conducted to analyze the effect patellar taping in patients with knee osteoarthritis. But non e of the
studies have compared whether pre exercise taping or post exercise taping is beneficial in the
treatment of knee osteoarthritis. Thus in this study it is intended to check the efficacy of pre exercise
taping or post exercise taping to improve the pain and functional outcome of the patient. Methods: A
total of 30 subjects were selected with age group 40-60yrs. diagnosed osteoarthritis of knee. They
were randomly divided into three groups. Each groups having 10 subjects, Group A received
conventional treatment. Group B received conventional treatment and pre-exercise taping and group C
received conventional treatment and post- exercise taping. Result: The comparisons concluded that
for improving WOMAC in knee OA patients, both Group B and Group C are more effective than Group
A. The comparisons concluded that all three treatments are effective for improving pain in knee OA
patients. The significance level was set at p0.05. Conclusion: The Study concludes by stating that
null hypothesis is rejected as results of the study suggest that post exercise taping is more effective than
pre exercise taping and conventional treatment in reducing pain and improving functional outcome in
39
Key words: Taping, WOMAC scale, Osteoarthritis, knee etc.

INTRODUCTION
Knee osteoarthritis is a major public health
concern worldwide and one of the foremost
causes of chronic disability in older adults.
1
Osteoarthritis (OA) is a chronic degenerative
disorder of multifactorial etiology characterized
by loss of articular cartilage, hypertrophy of
bone at the margins, subchondral sclerosis and
range of biochemical and morphological
alterations of the synovial membrane and joint
capsule. Pathological changes in the late stage
of OA include softening, ulceration and focal
disintegration of the articular cartilage;
synovial inflammation also may occur.
2

Osteoarthritis is usually regarded as a non-
inflammatory disease.
3

Knee osteoarthritis was the most common type
(6% of all adults). The likelihood of developing
osteoarthritis increases with age. Studies have
shown that knee osteoarthritis in men aged 60
to 64 is more commonly found in the right knee
(23%) than in the left knee (16.3%), while its
distribution seems to be more evenly balanced
in women (right knee, 24.2%; left knee,
24.7%). The prevalence of osteoarthritis of the
knee is higher among 70- 74 year-olds, rising
as high as 40%.
4
Osteoarthritis (OA) affects
more than 21 million people in the U.S., with
36% of elderly Americans aged 70 or older
having some degree of radiographic knee OA.
The prevalence of OA continues to grow as the
population ages.
5
Arthritis affects around 3
million people in Australia, representing about
15% of the population.
6
There are a number of
possible causes for this increase in disease
prevalence with age. Metabolic changes in
cartilage that occur with aging do not parallel
the biochemical changes of osteoarthritis, but
they may make cartilage more susceptible to
fatigue fracture. Joints become increasingly
incongruent with age, and this may leave
previously protected areas vulnerable to injury
(more likely in the hip than in the knee). Bone
underneath the articular cartilage may be made
increasingly stiff from microfractures, and this
loss of compliance in bone may make overlying
cartilage susceptible. Finally, neuromuscular
decline occurs in the elderly years, leaving
joints unprotected by the muscles and tendons
that otherwise serve as shock absorbers.
7
The symptoms of OA, such as pain and
stiffness of the joints and muscle weakness, are
serious risk factors for mobility limitation and
impaired quality of life. Indirect evidence
suggests that muscle strength deficits may be
interrelated and that pain may have a
confounding influence on the measurement of
these factors in knee OA. However, these
relationships have never been clearly
evaluated.
8
The quadriceps weakness
commonly associated with osteoarthritis of the
knee is widely believed to result from disuse
atrophy secondary to pain in the involved joint.
However, quadriceps weakness may be an
40
etiologic factor in the development of
osteoarthritis.
9
There is no single treatment that is known to
cure OA. Most treatments have aimed at
reducing symptoms or slowing the progression
of the disease and its consequences.
10
In knee osteoarthritis acupuncture, capsaicin,
chondroitin, education to aid self-management,
exercise and physiotherapy, glucosamine,
insoles, intra-articular corticosteroids, intra-
articular hyaluronan, joint bracing, knee
replacement, non-steroidal anti-inflammatory
drugs (including topical non-steroidal anti-
inflammatory drugs), opioid analgesics,
osteotomy, simple analgesics, and taping can be
effective.
11

METHODS
Sample
Size: On the basis of inclusion & exclusion
criteria, 35 subjects were selected for the study
out of which only 30 completed the study.
Three patients were allergic to the tape and two
could not complete the duration of the study
Source : 70 osteoarthritis patients visiting the
MMJ physiotherapy clinic, Noida.
Inclusion Criteria
1, 20

Subjects with age group 40-60 years,
diagnosed by orthopedic surgeon with
unilateral osteoarthritis of knee.
WOMAC score more than 57.
Exclusion Criteria
1, 20

Subject having any deformity of hip and
back
Any neurological problems
Patients with back ache with radiating pain
to legs
Any history of fractures, trauma to knee
joint or muscles
Any metallic implants
Wound on/around knee or thigh
Peripheral vascular disease
Any local or systemic infection
Febrile and mentally deficit participants
Pregnancy
Auto immune disease (eg. Rheumatoid
arthritis, ankylosing spondylitis)
Tumors of hip, knee or leg region
Any spinal deformity
Contraindication to exercise therapy
(unstable angina, blood pressure,
myocardial infarction in previous 3 months,
cardiomyopathy, uncontrolled metabolic
disease, recent ECG changes, advanced
COPD)
VARIABLES
Dependent Variable: VAS, WOMAC scale.
Independent Variables: Pre exercise taping,
Post exercise taping, Conventional treatment
Research Design: Experimental study design.
Sampling Method: Simple randomized
sampling method was used for the selection of
patients and divided into 3 groups.
Study duration: 3 weeks.
INSTRUMENTS AND TOOLS
Quadriceps Table
Sports tape
Goniometer
WOMAC scale
41
Stepper

PROCEDURE:
Subjects who full filled the inclusion criteria
were randomly divided into three groups, 10
subjects in each group. The subjects were
requested to fill the consent form and the
voluntary participation form before taking part
in the research.
Group A received conventional treatment i.e.
Ultrasonic therapy (dosage 0.8 W/cm
2
), TENS
and Knee Exercises
Group B received conventional treatment i.e.
Ultrasonic therapy, TENS and Knee Exercises
and pre exercise taping ( Mcconnells Taping to
correct lateral patellar shift)
Group C received conventional treatment i.e.
Ultrasonic therapy, TENS and Knee Exercises
and post exercise taping
The subjects were asked to fill the WOMAC
scale and VAS scale before the start of the
treatment, on 5 sitting and on 10 sitting. After
giving the treatment the data was subjected to
statistical analysis.
RESULTS
The age of Group A, Group B and Group C
ranged from 49.50 3.87 yrs, 52.70 5.48 yrs
and 51.10 6.10 yrs, respectively. Pre and post
WOMAC score between the groups (Table 1).

Table 1: Pre and post WOMAC scores (Mean
SD, n=10) of three groups

Comparing the mean WOMAC scores within
the groups ( Fig. 1), the WOMAC score in all
three group decreased (improved) significantly
(p<0.01 or p<0.001) at both day 9 and day 21
(post treatment) as compared to day 1 (pre
treatment). Further, the mean WOMAC scores
in both groups Group B and Group C also
decreased significantly (p<0.001) at day 21 as
compared to day 9; however, not decreased
significantly (p>0.05) in Group A. The
comparisons concluded that for improving
WOMAC in knee OA patients, both Group B
and Group C are more effective than Group A.
WOMAC (score)
0.00
20.00
40.00
60.00
80.00
100.00
day 0 day 9 day 21
Treatment periods
M
e
a
n

S
D
Group A
Group B
Group C

Fig. 1: Comparative mean WOMAC scores
between the groups.

Similarly, comparing the mean WOMAC
scores between the groups ( Fig. 2), the
WOMAC score of three groups did not differed
(p>0.05) at day 0 i.e. found to be statistically
the same. In others words, WOMAC scores of
three groups were comparable. Further, the
mean WOMAC scores of three groups also not
differed (p>0.05) at both day 9 and day 0,
42
indicating that all the three treatments are
equally effective for improving WOMAC in
patients with knee OA.

WOMAC (score)
0.00
20.00
40.00
60.00
80.00
100.00
Group A Group B Group C
Treatment groups
M
e
a
n

S
D
day 0
day 9
day 21

Fig. 2: Comparative mean WOMAC scores
within the groups.
VAS (score)
0.00
2.00
4.00
6.00
8.00
10.00
12.00
Group A Group B Group C
Treatment groups
M
e
a
n

S
D
day 0
day 9
day 21

Fig. 3: Comparative mean VAS scores within
the groups.

Table 5: Pre and post VAS scores (Mean SD,
n=10) of three groups

Comparing the mean VAS scores within the
groups (Table 6 and 7), the VAS score in all
three group decreased (improved) significantly
(p<0.001) at both day 9 and day 21 (post
treatment) as compared to day 1 (pre
treatment). Further, the mean VAS scores in all
three groups also decreased significantly
(p<0.001) at day 21 as compared to day 9. The
comparisons concluded that all three treatments
are effective for improving pain in knee OA
patients.

Table 6: For each group, comparison (p value)
of mean VAS scores within groups (i.e. between
periods) by Tukey HSD test

Table 7: For each period, comparison (p value)
of mean VAS scores between the groups by
Tukey HSD test

DISCUSSION
The aim of the study was to compare the effect
of pre exercise taping with post exercise taping
on pain and functional outcome in patients with
knee osteoarthritis. The results of the study
suggest that all the three protocols were equally
effective in improvement of WOMAC score
within the groups but none proved to be
effective within the group. The VAS score also
showed significant improvements on
comparison within the three groups but Group
C i.e., post exercise taping showed significant
improvements when the results were compared
between the groups.
43
This suggests a decline, or even loss, in tape
effectiveness, possibly due to decreased tape
tensile strength or reduced adhesiveness to the
skin.
16
An increase in the stability of the body
or extremities, support or protection of the
joint, the correction of the alignment of the
body or limbs, the modification of the
biomechanics of movements and the promotion
of sensor-motor functions like the
proprioception influence and insignificance
sensory input inhibition might be reasons that
have contributed to the effects of elastic
taping
17.
The tape has been suggested to
stimulate neuromuscular pathways via afferent
feedback. Increased afferent stimulus to large-
diameter nerve fibers might reduce pain
perception level due to an input decrease from
the small diameter nerve fibers conducting
nociception. Many clinicians believe that
bracing and taping provide increased cutaneous
stimuli as well as external support to the joint
that they surround. The increased stimulation of
the cutaneous proprioceptors, provided through
direct or indirect contact between the skin and
the brace or tape, would enhance kinaesthetic
and joint position sense awareness and possibly
help prevent injuries.
18
Patellar taping may
enhance the onset of VMO activity, which may
result in improved patellar tracking. They
suggested that this early activation of the VMO
may be caused by cutaneous stimulation
brought by the patellar tape, although the
precise mechanisms for this phenomenon are
unclear. First, some have suggested that the
mechanical advantage of the quadriceps is
maximized because of increased leverage by
the patella via a medial shift as it returns to the
trochlear groove of the femur. Some
hypothesize that the application of patellar
taping may reduce neural inhibition of the
quadriceps and modulate pain via large afferent
fiber input. This may be attributed to the fact
that large afferent fibre input travels more
rapidly to the brain than pain signals, as
described in the gate control theory and
Castels level I pain theory. Herrington
proposed that patellar taping may lead to
altered large fibre afferent input to the dorsal
horn, decreasing the perceived pain that may be
contributing to quadriceps inhibition. With a
reduction in pain, Herrington27 suggested that
there is potential for restoration of quadriceps
function through increased alpha motor neuron
excitation. Many authors reported a significant
reduction in pain via tape application; however,
evidence is scarce to claim that the reduction in
pain is caused by increased alpha motor neuron
excitability.
19
The application of a simple
patellar taping technique covering 50% of skin
over the knee had effects on areas of the brain
associated with sensation, coordination,
decision making, and planning of complex
coordination tasks and the coordination of the
unconscious aspects of proprioception. There
was decreased activity in the anterior cingulate
and the cerebellum, which are the regions of
interest concerned with proprioception, the
decision making and planning of complex,
coordinated tasks, and the coordination of the
unconscious aspects of proprioception. This
44
finding indicates a relative decrease in activity
with the tape on, which could be interpreted as
participants perceiving the task to be easier to
perform with the tape and, as a result, the
activity of the cerebellum and anterior cingulate
was less because these areas did not have to
work as hard.
Because of quadriceps weakness in persons
with knee OA, strengthening exercises have
been demonstrated to benefit static and
dynamic muscle strength and also functional
performance during gait and stair climbing. In
general, strengthening exercises improve the
ability to control the forces at the joint during
dynamic movements, thus potentially reducing
the effects of loading and ensuing pain. The
ability to improve the speed of contraction is
also an important consideration to enhance
functional capabilities.
16
Resistance training
program can potentially counteract the
functional limitations seen in knee OA; positive
associations were found between increased
muscle strength and walking self-efficacy,
reduced pain, improved function, and total
WOMAC score.

Deyle et al demonstrated that
manual therapy techniques and exercises
applied by physical therapists for 8 clinical
visits produced a 52% improvement in self-
reports of function, stiffness, and pain as
measured by the Western Ontario and
McMaster Universities Osteoarthritis Index.
13

Future research
Future studies can be done by extending the
duration of the study.
Instrumental errors cannot be ruled out.
More functional variables could be assessed
to measure the effects of taping in patients
with knee osteoarthritis.
Electromyographic studies can be
conducted further to explain the effect of
taping

Relevance to Clinical Practice
Taping is one of the most commonly used
methods in physiotherapy treatment. The study
helps us to identify that application of tape after
the performance of exercise can help to
improve the pain and functional outcome in

CONCLUSION
The Study concludes by stating that null
hypothesis is rejected as results of the study
suggest that post exercise taping is more
effective than pre exercise taping and
conventional treatment in reducing pain and
improving functional outcome in patients with
knee osteoarthritis.

ACKNOWLEDGEMENT
The author acknowledges support of staff of
Santosh medical college and Hospital.

CONFLICT OF INTEREST
There is no conflict of interest.

45
REFERENCES
1. Neil A Segal, James Torner, David Felson, Jingbo Niu, Leena Sharma, Cora E. Lewis, MSPH, and Michael Nevitt,
The Effect of Thigh Strength on Incident Radiographic and Symptomatic Knee Osteoarthritis in the Multicenter
Osteoarthritis (MOST) Study. Arthritis Rheum. 2009 September 15; 61(9): 12101217. doi:10.1002/art.24541.
2. A Mahajan, S Verma, V Tandon. Osteoarthritis JAPI, VOL. 53 , JULY 2005.
3. Paul Dieppe, Inflammation In Osteoarthritis. January 30, 2011.
4. Joern W.-P. Michael, Klaus U. Schlter-Brust, Peer Eysel, The Epidemiology, Etiology, Diagnosis, and Treatment
of Osteoarthritis of the Knee. Dtsch Arztebl Int, 107(9): 15262, 2010.
5. Parastu S. Emrani, Jeffrey N. Katz, Courtenay L. Kessler, William M. Reichmann, Elizabeth A. Wright, Timothy E.
McAlindon, and Elena Losina. Joint Space Narrowing and Kellgren-Lawrence Progression in Knee Osteoarthritis.
PMC, 16(8): 873882, 2009.
6. Lynette M March and Hanish Bagga. Epidemiology of osteoarthritis in Australia. MJA 180: S6S10, 2004.
7. David T. Felson. Epidemiology Of Hip And Knee Osteoarthritis1. Johns Hopkins University School of Hygiene
and Public Health. Vol. 10, 1988.
8. N. Shakoor, S. Furmanov, D.E. Nelson, Y. Li, J.A. Block. Pain and its relationship with muscle strength and
proprioception in knee OA: Results of an 8-week home exercise pilot study. J Musculoskelet Neuronal Interact
8(1):35-42, 2008.
9. Charles Slemenda, DrPH; Kenneth D. Brandt. Quadriceps Weakness and Osteoarthritis of the Knee Ann Intern
Med. 127:97-104, 1997.
10. Mohammad A. Alkhazim Alghamdi, Sandra Olney, Patrick Costigan. Exercise Treatment for Osteoarthritis
Disability. Ann Saudi Med 24(5) September-October 2004.
11. David Scott and Anna Kowalczyk. Osteoarthritis of the knee. BMJ Publishing Group Clinical Evidence,09, 1121,
2007.
12. K L Bennell, R S Hinman, B R Metcalf, R Buchbinder, J McConnell, G McColl, S Green, K M Crossley Efficacy of
physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann
Rheum,64, 906912, 2005.
13. Jos M Quintana, Inmaculada Arostegui. Validation of a screening questionnaire for hip and knee osteoarthritis in
old people. BMC Musculoskeletal Disorders, 8:84, 2007
14. Leslie Ann Nobbs. The effect of electrical stimulation and isokinetic exercise on muscular power of quadriceps
muscle. UNIVERSITY OF BRITIS COLUMBIA, 1979.
15. Electrical Stimulation. American Medical Association, 2004.
16. H. D. Hartsell. Electrical Muscle Stimulation and Isometric Exercise Effects on Selected Quadriceps Parameters.
JOSPT, Vol. 8, No. 4 October 1986.
17. Marcin Krajczy, Katarzyna Bogacz, Jacek Luniewski, and Jan Szczegielniak. The Influence of Kinesio Taping on
the Effects of Physiotherapy in Patients after Laparoscopic Cholecystectomy. The ScientificWorld Journal Volume
2012, Article ID 948282.
18. Todd A. McLoda, PhD, ATC; Jennifer A. Carmack. Optimal Burst Duration During a Facilitated Quadriceps
Femoris Contraction. Journal of Athletic Training, Vol. 35, No 2, June 2000.
19. Shari M. Ling1, Robin A. Conwit. Electromyographic Patterns Suggest Changes in Motor Unit Physiology
Associated with Early Osteoarthritis of the Knee Osteoarthritis Cartilage. October, 15(10): 11341140, 2007.
46
20. Erik witvrouw, Lieven Danneels, Damien Van Tiggelen. Open Versus Close kinetic chain exercises in
patellofemoral pain syndrome. The American Journal of sports Medicine, Vol.32, NO.5, 2004.

*MPT (Cardio-Pulmonary), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad,
Uttar Pradesh. Address: Address: D-2, First floor , Adjacent chetak complex, pocket B & E market,
Dilshad garden, Delhi- 95. Email ID: physio.parul@gmail.com
**MPT (Musculoskeletal).Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh
***MPT (Musculoskeletal), Principal, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh.
****MPT (Neurology), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh
47

ATTITUDE AND AWARENESS TOWARDS PHYSICAL ACTIVITY IN
PRAVARA RURAL HOSPITAL AND COLLEGE

Shalu Bhardwaj*, Nisha Shinde**

ABSTRACT
Objective: To find out the attitude and awareness towards physical activity among clinical and non-
clinical staff of Pravara Rural Hospital and College.Design and Setting: It was a Questionnaire based
survey conducted in Pravara Rural Hospital and College, Pravara Deemed University, Loni,
Ahmednagar,Maharashtra. Methodology:170 participants from Pravara Rural Hospital and College,
aged between 23-60 yearswith graduation degree or diploma as their minimum level of education were
randomly selected. Questionnaires in printed format were handed over to all the participants and
werecollected by the principal investigator after four weeks.Results:31% participants does exercise 1
to 2 times a week, there were more participants engage in physical activity outside sports like walking,
cycling, etc., 29% participants like to involve in physical activity on the way to their home, 80% of
participants engage in physical activity to improve their health and 54% for weight reduction. Most the
participants gave lack of time as the main factor which prevents them from doing physical activity.
Conclusion: The survey concluded that the importance of physical activity is widely accepted across
the participants of the present study though there was some diversity among participants which
underserved when it comes to sporting opportunity.
KEYWORDS: Attitude, awareness, physical activity, sedentary life style

INTRODUCTION The key to augmentation of physical activity is
48
to understand the attitude of a population
towards exercise and health, together with any
change in such attitude induced by the
immediate rewards of training.
1
Physical
activity is defined as any bodily movement
produced by skeletal muscles that result in
energy expenditure.
2
Recommended physical
activity is reported as moderate-intensity
activities in a usualweek (i.e.,brisk walking,
bicycling, vacuuming, gardening, or anything
else that causes small increases in breathing or
heart rate) for greater than or equal to 60
minutes per day, greater than or equal to six
days per week.
3
Increased physical activity
improves quality of life, and individuals
reaching recommended level physical activity
are more likely to have better overall health
related quality of life.
Physical inactivity is a major public health
challenge in the developed world and is
recognized as a global epidemic.
4
In the long
run physical inactivity increases the risk of
many chronic diseases in adulthood, including
coronary heart disease, colon cancer, and
diabetes.
5
The National Center for Health
Statistics 2009 and Healthy People 2010lists
physical activity as one of its focus areas and
also as one of the leading health
indicators.
6
According to the World Health
Report 2000, physical inactivity was estimated
to cause 1.9 million deaths worldwide every
year.The prevalence of physical inactivity in
selected rural populations in nine Health and
Demographic Surveillance Sites (HDSS) in
Asia showed that 25% of the men and 35% of
the women were physically inactive.The same
study reported that less than 20% of
respondents in the HDSS in India engaged in
vigorous or moderate activities at work.
7

Physical activity has both health promoting and
disease prevention properties. If everyone
followed the recommendation of being
physically active on a daily basis, the health of
the population would improve considerably and
healthcare costs would drop dramatically.
8
To
achieve the health objectives in Healthy People
2010 and 2020, concentration should be on
motivating individuals to continue physical
activity programs throughout their life span.
This survey sought to determine the current
physical activity levels and the factors
influencing these levels in the clinical and non-
clinical staff. It will contribute to the
development of appropriate policy and
interventions that will promote an active and
healthy population.

METHODS
The study received approval from Ethical
Committee of Pravara Institute of Medical
Sciences, Loni. The survey was conducted
among clinical and non- clinical staff aged
between 23 and 60 years and those who have
sedentary lifestyle in Pravara Rural Hospital
and College.In this study, the minimum levels
of education for all the participants were
graduation degree or diploma. 170
participants,who were volunteered, included in
the study. Verbal consent was obtained from all
the participants. A brief explanation about the
49
study was given to all the participants.Well
trained study investigators visited the
participants in a randomized manner and
instructed them face-to-face on how to interpret
and answer the questionnaire. Participants were
given fourweeks time to complete the
questionnaire and it was collected from them
by the principal investigator. Confidentiality of
participants was maintained.

PROCEDURE

Questionnaire in a printed format was given to
each participants and one month time was
given to all the participants for completing the
questionnaire. Questionnaire consists of eight
questions with multiple choices answers. For
some questions,participants had to tick mark
only one answer and for questions like three,
four and seven questions participants had to
mark more than one answers.All the questions
were self-explanatory.The questions placesan
emphasis on the context in which people
exercise for example, whether they play
formal sports or are active in other,
moreinformal ways, as well as highlighting
how many individuals do the most (and the
least)physical activity. It also reveals how
Indian citizens perceive the opportunities to
engage insporting activity in their areas, as well
as how many people volunteer to help run
sporting activities in their communities and
how much time they spend on such activities.

RESULTS
The data analysis was done after calculating the
mean for all the answers of filled questionnaire
of each participant and accordingly pie-chart
and bar graph was plotted using Microsoft-
Excel Sheet. Incomplete questionnaires were
not included for the data analysis.
Questionnaire consists of eight questions with
multiple options.

Q1. How often do you exercise or play sports?

Q2. And how often do you engage in physical
activity outside sports such as cycling or
walking from a place to another, dancing,
gardening?
50

Q3.Where do you engage in physical activity?

Q4. Why do you engage in physical activity?

Q5. From the following reasons, what is currently preventing you the most to do physical activity more
regularly?

51
Q6. To what extent do you agree or disagree with the following statements about physical therapy?

Q7. Are you a member of any of the following
clubs where you participate in recreational
physical activity?

Q8. How much time do you spend on physical
activity?

DISCUSSION
According to the present analysis, 31%
participants actively participate in physical
activity 1 to 2 times a week, 25 % stated that,
they do it 3 to 4 times a week and no response
was given by 3%. WHO estimate that less than
one third of young people are sufficiently
active to benefit their present and future health
and well- being.
9
32% participants engage in
physical activity outside sports such as cycling,
walking from one place to another, dancing,
gardening, etc. for five times a week. 19%
participate for one to two weeks in physical
activity outside sports and 2% were not
involved. Increase in the dependence on
motorized reach jobs and other amenities, and
thus reduce opportunities for walking and
cycling.
10
Many participants are physically
active as part of their everyday routine and do
not have specific motivation for it. 29% of
participants involve in physical activity on the
way between home and work place, 25%
participants spend their time in school and
university, 21 % like to do it in nature out in the
park and 16% also says that they were involved
52
in somewhere else for the physical activity, it
differs from individual to individual where they
want to and how much time they want to give
for the physical activity. Exercise on the way to
and from home was the main factor
determining the usage of such facilities is
presumably quite simple.
In increasing health conscious world, it is
perhaps unsurprising that an 80% participant
does physical activity to improve their health.
The next most commonly cited reason for
exercising was to improve fitness. 50% does it
for weight reduction and some for relaxation.
As all participants, belong to medical
profession, they mention lack of time as a main
factor for not involving in physical activity.
And this place is in rural area, many
participants approximately 24% gave reason for
lack of infrastructure close to their residential
area. Even some of the participants belong to
50-60 years of age group their illness or
disabilities restrict them from doing physical
activity, 44% strongly agree that college had
provided many opportunities to be physically
active. Some studied in the past showed a
strong link between education and the amount
of sport that people play.
11
From the agegroup
25-35 years, 21% participants were the member
of health fitness club and 24% were not aware
of any fitness club near to their place. This
outcome suggests that many participants who
do it regularly prefer to exercise in other
context- perhaps just exercise on their own.
Man and women generally do very similar
amount of physical activity though with some
variation. Some studies suggest that women are
particularly health conscious or perhaps they
tend to have more time for exercise than men of
equivalent age.
11

According to this study, 59% participants spend
their time occasionally or at individual event
for sporting activities. Some 15% stated that
they spend 1 to 5 hours per month for voluntary
work or sporting activities. It has been studied
that if you live alone you are more likely to be
physically inactive.
11
At the start of the 21
st

century, however so much physical activity has
been removed from life that people may begin
to ignore how essential it is for health and well-
being.
10

CONCLUSION
This survey indicates that physical activity is an
area where big gains can be made by
identifying and spreading good practices
between different individuals with sedentary
lifestyle.The importance of physical activity is
widely accepted across the participants of the
present study though there was some diversity
among participants which underserved when it
comes to sporting opportunity.An increase in
physical activity is one of the measures that
would have the greatest positive impact on the
health of the population.

ACKNOWLEDGMENT
We would like to thank all the participants of
Pravara rural Hospital and College who had
given their time to take part in this survey.
Without their active participation this study
53
would not have been possible.
54
REFERENCES
1. Sidney K. and Shephard R. Attitudes towards health and physical activity in the elderly. Effects of physical
training program. Medicine and Science in Sports.1976; 8(4):246-252.
2. Steven Allender, Gill Cowburn and Charlie Foster.Understanding participation in sport and physical activity
among children and adults: a review of qualitative studies. Health education research.2006;21(6):826-835.
3. United States Department of Health and Human Services. Physical activity and health: A report of the Surgeon
General. Atlanta, GA: Centers for Disease Control and Prevention Printing Office.1996.
4. Allender S, Cowburn G and Foster C. Understanding participation in sport and physical activity among children
and adults: a review of qualitative studies. Health education research.2006; 21(6):826-835.
5. A D Christodoulou, H T Douda, M Polykratis, and S P Tokmakidis. Attitudes towards exercise and physical
activity behaviors in Greek schoolchildren after a year long health education intervention. Br J Sports Med.2006;
40(4): 367371
6. Center for Disease Control and Prevention (2008), National Center for Health Statistics. About Healthy People
2010 Retrieved, from http://www.cdc.gov/nccdphp/dnpa/obesity
7. Navi Ng, Hakimi M, Van Minh H et al. Prevalence of physical inactivity in nine rural in depth health and
demographic surveillance systems in five Asian countries. Glob Health Action.2009; 2: 44-53.
8. Carl John. Physical activity in the prevention and treatment of disease. Professional association for physical
activity.2010.Sweden.
9. National action plan on physical activity. Republic of Mauritius. 2011
10. Cavil N, Kahlmeir S and Racioppi F. Physical activity and health in Europe. Evidence for action. Denmark:
WHO; 2006.
11. Survey by European commission.Sports and Physical Activity. 2010

*Post graduate student, College of Physiotherapy, Pravara Institute of Medical Sciences, (PIMS),
Pravara Rural Hospital, Pravara Deemed University, Loni.413 736 Ahmednagar, Maharashtra, India.
Email: ssbphysio@gmail.com
**Associate Professor, College of Physiotherapy, Pravara Institute of Medical Sciences (PIMS),
Pravara Rural Hospital, Pravara Deemed University, Loni.413736 Ahmednagar, Maharashtra, India.
Email: nishakiranshinde63@gmail.com
55

TO FIND OUT THE EFFECTIVENESS OF MAITLAND MOBILIZATION IN
CONTEXT OF ADDITIONAL BENEFIT OVER ADVICE AND EXERCISE
ALONE FOR PATIENTS SUFFERING FROM FREEZING STAGE OF
FROZEN SHOULDER A RANDOMIZED CONTROL TRIAL

Amit Murli Patel*

ABSTRACT
Background: Maitland mobilization of shoulder region joints, often in conjunction with other
treatment modalities, is used for the treatment of people with shoulder pain and minimal movement
restriction. However, there is only limited evidence supporting the efficacy of this treatment modality.
Objective: The purpose of this study was to determine whether Maitland mobilization of shoulder
region joints adds treatment benefit over exercise and advice alone for people with shoulder pain and
minimal movement restriction. Design: This was a randomized controlled clinical trial with short-,
medium- and longer-term follow-up. Setting: The study was conducted in a Shivam Orthopaedic
hospital. Patients: Ninety-eight patients with shoulder pain of local mechanical origin and minimal
shoulder movement restriction were randomly allocated to either a control group (n = 51) or an
experimental group (n = 47). Intervention: Participants in both groups received advice and exercises
designed to restore neuromuscular control at the shoulder. In addition, participants in the
experimental group received Maitland Mobilization specifically applied to shoulder region joints.
Measurements: Outcome measurements of shoulder pain and functional impairment, self-rated change
in symptoms, and painful shoulder range of motion were obtained at 1, 3, and 6 months after entry into
the trial. All data were analyzed using the intention-to-treat principle by repeated-measures analyses
56
of covariance. Results: No statistically significant differences were detected in any of the outcome
measurements between the control and experimental groups at short-, medium-, or longer-term follow-
up. Limitations: Therapists and participants were not blinded to the treatment allocation. Conclusion:
This randomized controlled clinical trial does not provide evidence that the addition of passive
mobilization, applied to shoulder region joints, to exercise and advice is more effective than exercise
and advice alone in the treatment of people with shoulder pain and minimal movement restriction.
Key Words : Maitland Mobilization, Frozen Shoulder, Shoulder pain and functional impairment

INTRODUCTION
Shoulder pain is a common complaint, with the
prevalence ranging from 20% to 33% in the adult
population.
14
It has been reported that shoulder
pain is the third most frequent musculoskeletal
complaint, after back and knee pain, in the
general community.
4
In 2007, the Indian
statistical Bureau reported that injuries to the
shoulder in the workforce required the most
number of days off work, with a median of 18
days to recuperate.
With the exception of the knee and wrist, the
shoulder took at least twice the median time to
recover compared with all other body parts.
5

Nocturnal disturbance, the inability to sleep on
the affected side, functional disability, and a
reduction in the overall quality of life are
common complaints resulting from shoulder
pain.
6 8
.Manual therapy in the form of passive
joint mobilization is used by physical therapists
for the management of pain, including shoulder
pain, and often is used in conjunction with other
treatment modalities, including exercise
therapy.
911
For the management of shoulder
pain, mobilization techniques are commonly
applied to the joints of the shoulder region
(glenohumeral, acromioclavicular, and
sternoclavicular joints), to the scapula, to the
joints of the cervicothoracic vertebral column,
and to the ribs. Passive joint mobilization aims to
manage shoulder pain by physiological
mechanisms (eg, inducing hypoanalgesia)
12-13
or
by mechanical mechanisms (eg, restoring normal
biomechanical relationships by addressing
related joint stiffness).
14
Clinical trials that have
investigated the effectiveness of passive joint
mobilization therapy, which included
mobilization of the cervicothoracic vertebral
column and ribs, for the management of painful
shoulder dysfunction indicate that this form of
mobilization therapy is more effective than other
therapy modalities. Winters et al
15
demonstrated
greater, more rapid decrease in pain in patients
with acute and chronic shoulder pain who
received manipulation and mobilization of
vertebral column, ribs, or shoulder region joints
than those who received massage, exercises, and
electrotherapy. In addition, patients with chronic
shoulder pain demonstrated added treatment
benefit (greater decrease in pain intensity and
functional limitation) when passive mobilization
of vertebral column or shoulder region joints
were added to exercises.
16
In the only clinical
trial that has investigated mobilization and
57
manipulation therapy specifically applied to the
vertebral column and ribs for the management of
shoulder pain, patients who received the manual
therapy in addition to usual care reported
significantly greater overall improvement and
decrease in pain.
15

Despite their common use, little evidence is
available to support the contribution of passive
mobilization applied specifically to shoulder
region joints in the management of painful
shoulder conditions. Indeed, the results of a
recent well-powered randomized controlled trial
(RCT) indicate that this form of manual therapy
is not more effective than exercises and advice
from a physical therapist in the management of
the painfully restricted shoulder.
18
These results
support the findings of another study of a small
sample of participants in which passive
mobilizations of shoulder region joints were
found to be ineffective in the management of
adhesive capsulitis.
19
Only one RCT that
examined the effects of passive mobilization of
shoulder region joints in patients diagnosed with
impingement syndrome showed limited evidence
in support of the benefit of this treatment
modality.
20

Although the evidence indicating no additional
benefit of passive mobilizations of shoulder
region joints above exercise and advice in
painful, restricted shoulder conditions
18-19
is
mounting, little information is available
regarding the effectiveness of this modality for
the treatment of people with shoulder pain and
minimal movement restriction. Therefore, a clear
clinical rationale for the use of mobilization
therapy applied to shoulder region joints for the
management of non restricted painful shoulder
conditions has not been established. As passive
joint mobilization therapy is most commonly
used in conjunction with other treatment
modalities and with increasing evidence to
support the efficacy of exercise therapy in the
management of painful shoulder conditions,
21-26

the specific aim of the study was to determine
whether low-velocity passive joint mobilization
therapy specifically applied to shoulder region
joints (glenohumeral, acromioclavicular, and
sternoclavicular joints) and passive mobilization
of the scapula add benefit over exercise and
advice alone in the treatment of people with
shoulder pain and minimal movement restriction.

METHOD
Design Overview
This RCT compared passive mobilization of
shoulder region joints, exercise, and advice with
exercise and advice alone for the treatment of
people with shoulder pain and minimal
movement restriction. Prior to group allocation,
baseline outcome measurements were obtained.
Following measurements of pain, functional
ability, and painful active range of motion
(AROM), participants were randomly allocated
to an experimental or control group based on a
concealed assignment schedule that had been
generated by an investigator who was not
involved with recruitment, treatment, or outcome
measure assessment in the study.
Primary outcome measurements of pain,
functional impairment, and self-rated
58
improvement were obtained from participants
who were not blinded to treatment group
allocation at 1, 3, and 6 months after
randomization. Secondary outcome
measurements of painful AROM were obtained
by a researcher (R.Y.) blinded to group
allocation at the same time points.

Setting and Participants
All patients referred to the outpatient physical
therapy department at Shivam Orthopaedic
hospital with painful active flexion or abduction
shoulder movements of greater than 1 months
duration and minimal shoulder movement
restriction were eligible to participate in this
study. In addition, pain, tenderness, or restriction
during passive accessory movements at the
glenohumeral, acromioclavicular, or
sternoclavicular joint or during passive scapular
movements was required to be present.
Diagnostic classifications systems were not used
to select participants for inclusion in this study
because they lack reliability and uniformity, thus
causing confusion and miscommunication among
health care professionals.
2735
Participants were
excluded if: they were less than 18 years of age;
they were unable to understand spoken Gujarati
or Hindi; their shoulder symptoms were
reproduced during active cervical spine
movements or during palpation of cervical or
thoracic region joints; they reported paresthesia
in the affected upper limb; passive shoulder
region joint mobilization was contraindicated;
shoulder flexion or abduction range of motion
(ROM) was less than 140 degrees, as determined
from digital photographs; shoulder pain was due
to an inflammatory or neoplastic disorder; they
had had surgery or trauma to the shoulder in the
previous 4 weeks; or they reported a feeling of
shoulder instability.
Ninety-eight volunteers (47 men and 51 women)
were recruited for this study after providing
written informed consent. The sample size for
this study was calculated using data from the
Shoulder Pain and Disability Index (SPADI)
questionnaire, one of the primary outcome
measures in this trial. Statistical power
calculations indicated that a sample size of 98
participants would provide an 80% chance of
detecting a minimum change of 15 points in total
SPADI score, assuming a standard deviation of
25 points and a maximum 10% loss to follow-up.

Randomization and Interventions
All patients seen at the participating hospital who
were potentially eligible to participate in this
study were contacted by telephone. The aims of
the study and its procedures were explained, and
an appointment was arranged to conduct an
interview and physical assessment. At this
appointment, the patients were questioned and
examined to confirm that they fulfilled all
inclusion criteria. Suitable participants then
signed a consent form, and baseline outcome
measurements of pain, functional impairment,
and painful AROM were obtained. Additional
demographic information such as participants
age, sex, affected and dominant upper limb, and
duration of symptoms were recorded during the
interview.
59
Following initial assessment, participants were
randomly allocated to either the control group or
the experimental group. Random allocation of
participants was performed using a previously
determined treatment assignment schedule with
random numbers generated from the data
analysis function in Microsoft Excel.* To ensure
concealment, the randomization procedure was
carried out by a researcher (K.A.G.) not involved
in participant recruitment, treatment, or
assessment, and the treatment assignment
schedule was stored in consecutively numbered,
sealed opaque envelopes.
All participants received treatment in the form of
advice and exercises. Physiotherapists provided
advice on how to avoid or minimize painful
shoulder movements during activities of daily
living. This advice included: limiting movement
to the pain-free ROM; maintaining normal
scapulohumeral rhythm within painfree ROM;
using the affected upper limb in a slow, careful
manner; using techniques to minimize shoulder
pain (eg, during dressing and reaching); and
preferentially using the non affected upper limb.
Exercises were directed toward restoring
neuromuscular control mechanisms at the
shoulder. This exercise approach has been shown
to be effective in previous clinical trials,
22,23
and
all participating therapists were given
instructions in the implementation of this
treatment approach. The primary aim of the
exercises was to restore normal muscle function
in order to regain normal dynamic stability and
muscle force couple coordination at the shoulder
region, thus leading to restoration of function.
37

Stretching exercises to lengthen shortened
muscles, exercises to strengthen weakened
muscles and to improve muscle coordination, and
exercises aimed at restoring normal scapula
humeral rhythm could be included. Motor
retraining exercises were devised and upgraded
based on motor learning principles designed to
improve motor skills by incrementally
increasing the complexity of the exercise tasks.
Full range of shoulder movement requires the
coordination of a number of muscle force
couples.
Therefore, less-difficult exercises principally
involved muscles within one force couple (eg,
isolated rotation exercises for the rotator cuff
muscles or scapular depression exercises with the
arm by the side). The most difficult exercises
involved all shoulder muscle force couples (eg,
full range flexion and abduction exercises
requiring coordination of axiohumeral, rotator
cuff, and axioscapular muscles).
37
The exercises
were performed in a pain-free manner to
optimize normal muscle function and movement
patterns.
22

Exercises and advice were tailored by the
treating physical therapist to meet the
requirements of each participant. The exercise
treatment was administered as a daily home-
based program and reviewed by the treating
therapist 1 or 2 times per week. The purposes of
this review were to correct the performance of
the exercises if necessary and to increase the
intensity and complexity of the exercises as
muscle function improved. As motor skill
acquisition is a lengthy process that requires
60
regular practice to establish new habituated
motor patterns, participants were strongly
encouraged to do their exercises on a daily basis
at home and to continue them after formal
treatment had ceased.
37
In addition to this advice
and exercise therapy, participants allocated to the
experimental group received low-velocity
passive joint mobilizations applied to any of the
shoulder region joints (ie, glenohumeral,
sternoclavicular, and acromioclavicular joints)
and passive mobilization of the scapula.
Mobilization therapy was aimed at relieving pain
and restoring pain-free functional movements
14

Passive mobilizations could be applied in a
sustained or oscillatory manner. As per routine
clinical practice, the regions mobilized, as well
as the force, direction, and amplitude of the
mobilization techniques, were individually
determined and progressed by the treating
therapist based on each participants clinical
signs and symptoms. The study design required
that a minimum of 60% of all treatments
provided to participants in the experimental
group involved passive shoulder region
mobilization in order to ensure an adequate
dosage of the mobilization therapy under
evaluation.
Participants in both groups received 1 or 2
treatment sessions per week for the first month of
the trial, followed by additional treatment over
the next 4 weeks to a maximum of 12 treatment
sessions if deemed necessary by the treating
therapist. The physical therapists involved in the
trial recorded the number of treatment sessions
and the type of mobilization techniques applied
for each participant in a logbook. All participants
were requested to receive physical therapy
treatment only from the involved physical
therapy department and to refrain from seeking
any other form of therapy while participating in
this clinical trial.
Seventeen physical therapists were involved in
providing treatment to participants in this clinical
trial. Five of these Physiotherapists had
postgraduate qualifications in physical therapy:,
and two with Doctorate in Manipulative therapy.
The number of years of clinical experience for
therapists involved in this study ranged from 2 to
28 (X = 8.4, SD = 7.5). All therapists received
instructions regarding all treatment options and
clinical trial adherence, and all therapists were
involved in treating participants in both the
control and experimental treatment groups.

Outcomes and Follow-up
Two primary outcome measures were used in
this study. The first primary outcome measure,
shoulder pain intensity and functional
impairment during the previous week, was
assessed using the SPADI questionnaire.
36
This
self-administered questionnaire consists of 2
sections: the first section of 5 questions relates to
pain, and the second section of 8 questions
relates to function.
36
This questionnaire was
chosen because it has been shown to be reliable,
valid,
38,39
and responsive to change
3942
and has
no floor or ceiling effects.
40
The second primary
outcome measure, self-rated change in
symptoms, was measured with a 6-point Likert
scale. This scale consisted of a horizontal line
61
with 6 points, each with verbal anchors relating
to participants perceived change in symptoms
(ie, feeling much worse, slightly worse, the
same, slightly improved, greatly improved,
and fully recovered).
43
Participants were asked
to use this scale to indicate their perceived level
of change in symptoms since their last
assessment. A Likert scale was chosen because it
is easy to administer and interpret and it consists
of categories labeled with words, which assists
individuals to specifically relate to how they feel,
thus assisting in defining the change in their
symptoms.
44
Secondary outcome measurements
of AROM during shoulder flexion in the sagittal
plane and abduction in the coronal plane were
assessed using a photographic method shown to
be reliable in previous studies of patients with
shoulder pain.
18,22,23
Participants were instructed
to perform these movements, and photographs
were taken when pain was initiated and when
pain either resolved or when the maximal
achievable ROM was reached. Using markers
placed on bony landmarks,
22,23
shoulder joint
angles were measured on the photographs. The
painful ROM was recorded as the difference
between the shoulder angles in the 2
photographs. This method of measuring painful
AROM was used because it is quicker to perform
than standard goniometry and thus less likely to
exacerbate symptoms and influence
measurement.
18,22,23
The intrarater reliability of
these AROM measurements was established for
the blinded assessor (R.Y.) in this study prior to
the commencement of the trial. Intraclass
correlation coefficients (2,1) demonstrated
excellent intrarater reliability of .92 and .98 for
flexion and abduction, respectively.
45

Participants received between 4 and 8 treatment
sessions over a 1-month period. Primary outcome
measurements of pain and functional impairment
were reassessed, and self-rated change in
symptoms was obtained from participants who
were not blinded to treatment allocation.
Secondary outcome measurements of painful
AROM were reassessed by a researcher (R.Y.)
who was blinded to treatment allocation. To
ensure blinding, participants were instructed to
refrain from discussing their treatment with this
assessor.
Following assessment at 1 month, treatment
could continue for a maximum of 12 treatment
sessions over a maximum of 8 weeks.
Reassessment of all outcome measurements was
repeated at 3 and 6 months after baseline
measurements.

Data Analysis
All analyses were conducted using an intention-
to-treat approach. Missing data (lost to follow-
up) were replaced with values obtained by
imputation using regression models within each
variable and group at all available time points.
For the 2 control group participants who were
lost prior to reassessment at 1 month after
recruitment and, therefore, did not have a self-
rated change in symptoms score, the average of
the group was used for their missing scores. A
repeated-measures analysis of covariance was
used to analyze between group differences in
both primary (SPADI and self-rated
62
improvement) and secondary (painful AROM)
outcome measurements at 1, 3, and 6 months
following randomization. There was a
statistically significant difference in the mean
duration of current shoulder symptoms between
the experimental and control groups at baseline,
and this factor was used as the covariate in the
analysis.

RESULTS
A total of 230 patients referred to the outpatient
physical therapy department for the management
of shoulder dysfunction between May 2011 and
August 2013 were contacted via telephone
regarding potential inclusion in this clinical trial.
The flow of participants through the trial is
illustrated in Figure 1. Of the 230 patients
screened via telephone, 64 were not considered
eligible for inclusion in the clinical trial,
primarily because they indicated that they had
severely restricted shoulder flexion or abduction
ROM or because their pain was exacerbated by
neck movements suggesting referral from the
vertebral column. The remaining 166 patients
were invited to attend a physical assessment. Of
these patients, 68 failed to meet the inclusion
criteria. The reasons for exclusion were shoulder
flexion or abduction of less than 140 degrees of
AROM and shoulder symptoms reproduced
during active cervical spine movements or during
palpation of cervical or thoracic joints. The
remaining 98 patients who met the inclusion
criteria accepted the invitation and were recruited
for the study.
Baseline characteristics for the total cohort at the
commencement of this trial are presented in
Table 1. Groups were well matched at baseline,
with the only significant difference being a
longer duration of symptoms in the control group
(P<.03).

63

The study population consisted of a young
elderly cohort, with approximately equal numbers
of men and women with chronic shoulder pain.
At baseline, both groups reported a moderate
level of shoulder pain and functional impairment
(mean total SPADI score = 50% for both groups)
and approximately 30 degrees and 50 degrees of
painful shoulder flexion and abduction AROM,
respectively.
Four participants were unable to physically attend
the outpatient physical therapy department for
reassessment: 1 at both 1- and 3-month follow-
64
ups, 1 at the 3-month follow-up, and 2 at 3- and
6-month follow-ups. For these participants, data
relating to their shoulder pain and functional
impairment and self rated change in symptoms
were obtained via telephone. The SPADI has
been found to be suitable for administration via
telephone.
46
Therefore, primary outcome
measurement data were obtained for 98%
(control group = 96%, experimental group =
100%), 95% (control group = 96%, experimental
group = 94%), and 93% (control group = 92%,
experimental group = 94%) of all participants at
the 1-, 3-, and 6-month follow-ups, respectively.
Reasons for participant withdrawal are detailed in
Figure 1. Participants in both experimental and
control groups received a mean of 9 (SD = 5)
treatment sessions, ranging from 0 to 24 and 1 to
24 sessions, respectively. Participants in the
experimental group received a mean of 7
(Range= 216) treatment sessions involving
passive mobilization of shoulder region joints.
On average, 67% of the total number of treatment
sessions for the experimental group included
passive mobilization of shoulder region joints,
thus meeting the minimum dosage requirement
(60%) for this study. All but 1 participant in the
experimental group received some mobilization
therapy. However, 11 experimental group
participants had mobilization therapy in less than
60% of their treatment sessions, even though they
had up to 9 mobilization treatments. Of the
participants who received passive mobilization
therapy, 59% received mobilization solely to the
glenohumeral joint, 2% solely to the
acromioclavicular joint, 2% solely to the scapula,
and 35% to a combination of shoulder region
joints, including the glenohumeral,
acromioclavicular, and sternoclavicular joints.
Group data for all outcome measures at 1, 3, and
6 months following randomization for the
experimental and control groups are presented in
Table 2 and Figures 2, 3, and 4. Improvement
was seen in all outcome measurements in both
groups at 1, 3, and 6 months (P< .001).
Differences in mean total shoulder pain and
functional impairment scores (total SPADI
scores) between the control and experimental
groups at all follow-up periods were small and
statistically non significant. At the 1-month
follow-up, the experimental group had 1% (95%
CI [confidence interval] - 7% to 9%) less
shoulder pain and functional impairment than the
control group. The control group had 5% (95%
CI - 3% to 12%) and 0% (95% CI - 7% to 7%)
less shoulder pain and functional impairment than
the experimental group at 3 and 6 months,
respectively. Similarly, small and statistically non
significant differences in scores for self rated
change in symptoms between the control and
experimental groups were demonstrated at all
follow-up periods. The control group was 0.2 out
of 5 (95% CI = - 0.1 to 0.6) better than the
experimental group at the 1-month follow-up,
and the experimental group was 0.2 out of 5
(95% CI = - 0.3 to 0.6) and 0.1 out of 5 (95% CI=
- 0.2 to 0.5) better than the control group at 3-
and 6-month follow-ups, respectively. No
adverse
effects of any treatment intervention were
reported.
65

Discussion
This is the first adequately powered RCT that has
specifically evaluated the effectiveness of passive
joint mobilization specifically applied to shoulder
region joints for the treatment of people with
shoulder pain and minimal movement restriction.
Our results demonstrate that the addition of
passive mobilization of shoulder region joints to
exercise and advice is not more effective than
exercise and advice alone in decreasing pain and
painful ROM and improving function and self
rated change in symptoms in this cohort, with no
significant differences in any of the outcome
measurements between the 2 groups at short-,
medium-, or longer-term follow-up. The findings
of small, non significant differences in functional
impairment and AROM between the groups
receiving and not receiving passive mobilizations
to shoulder region joints in this study support the
findings of the only other clinical trial that
specifically evaluated the effectiveness of this
modality for the treatment of people with
shoulder impingement syndrome.
20
However,
although Conroy and Hayes
20
found passive
mobilization of shoulder region joints to be
effective in decreasing
the maximum pain level reported over a 24-hour
period and during an impingement test in this
cohort in the short term, the current study found
no differences in pain levels measured on the
SPADI questionnaire in the short, medium, or
longer term.

Table 2

The current well powered, longer-term study
66
confirms and extends the majority of findings of
this smaller short-term study (i.e. that passive
mobilizations applied to shoulder region joints do
not add clinical benefit in the management of
painful shoulder dysfunction). The results of the
current study also strongly support the findings of
previous RCTs investigating the effectiveness of
passive mobilizations specifically applied to
shoulder region joints for the management of
painful, restricted shoulder dysfunction.
18,19

Similar to the current study, these studies found
no significant differences in pain,
18,19
functional
impairment,
18
self-rated change in symptoms,
18

or AROM
18,19
between a group that received
passive mobilizations and a group that did not
receive passive mobilizations at short-term
follow-up
18,19
or longer term follow-up.
18
The
results of the current and other relevant RCTs,
therefore, indicate that passive joint mobilizations
specifically applied to shoulder region joints for
the management of shoulder pain of local
mechanical origin without instability do not
provide additional clinical benefit above exercise
and advice alone. Systematic reviews of clinical
trials investigating mobilization therapy have
concluded that there is limited evidence to
support the effectiveness of passive joint
mobilization therapy for the management of
shoulder pain.
11,47,48
Of the 3 available clinical
trials included in these reviews,
15,16,20
the
majority investigated mobilizations directed at
vertebral column or rib joints, as well as shoulder
region joints.
15,16
With the addition of more-
recent evidence from clinical trials conducted
since these reviews were performed, this
conclusion can be further refined.
The results of the current study and of the study
by Chen et al
18
considering the effectiveness of
passive mobilization specifically applied to
shoulder region joints provide strong evidence
that passive mobilization of shoulder region
joints does not add clinical benefit in the
treatment of people who have shoulder pain with
and without movement restriction. In addition,
Bergman et al
17
provided evidence that
mobilization or manipulation therapy specifically
applied to the vertebral column and ribs is more
effective than usual care in the management of
shoulder pain. It would appear, therefore, that the
conclusion that patients with painful shoulder
dysfunction gain clinical benefit from the
application of mobilization therapy only applies
to passive joint mobilization of the vertebral
column or rib joints.

Figure 2
Mean (95% confidence interval) Shoulder Pain
and Disability Index (SPADI) questionnaire
scores (%) for shoulder pain and functional
impairment for the control and experimental
groups at entry into the trial (baseline) and at 1-,
3-, and 6-month
follow-ups.
67
The design of the current study included several
features to minimize bias, thus enhancing the
internal validity of results obtained and
strengthening the conclusions that can be drawn
from this study. Participants were allocated to 1
of 2 treatment groups using a predetermined
random and concealed allocation process. An
exercise approach of proven efficacy was
implemented as the control treatment.
22,23
Passive
mobilization therapy was isolated to the shoulder
region joints in order to evaluate the contribution
of this specific component of the common group
of treatment modalities used by physical
therapists to treat people with shoulder pain.
Participants in both groups were provided with
the same mean number of treatments and thus the
same amount of
participant-therapist contact time. Short-,
medium-,and longer-term reassessments were
conducted. The number of participants
unavailable for reassessment was low at all
follow-up periods, thus preserving the successful
randomization achieved at the commencement of
the clinical trial. The sample size was large
enough to provide adequate power to detect
significant differences, and responsive, reliable
outcome measures were used. With the exception
of duration of symptoms,
which was taken into account in the analysis,
baseline demographics were similar at the
commencement of the trial, and baseline outcome
measurements were well matched. Finally, an
intention-to-treat analysis was implemented. In
addition, this RCT included features to enhance
the external validity of the study and thus
enhance the generalizability of the results
obtained. All treatments were specifically tailored
to the individual participant rather than following
a prescribed pattern and, therefore, were more
reflective of a typical clinical setting. Seventeen
physical therapists with varying clinical
experience ranging from 2 to 28 years were
involved in providing treatment in this study, and
all of these physical therapists provided treatment
for participants in both the experimental and
control groups.

Figure 3.
Scores for self-rated change in symptoms for the control (shaded) and experimental (unshaded) groups
at 1-, 3-, and 6-month follow-ups.
68

Figure 4.
Mean (95% confidence interval) painful flexion and abduction active range of motion for the control
and experimental groups at entry into the trial (baseline) and at 1-, 3-, and 6-month follow-ups.

The conclusion from this clinical trial, that the
addition of passive joint mobilizations of
shoulder region joints to exercise and advice is
not more effective than exercise and advice
alone for the treatment of people with shoulder
pain and minimal movement restriction,
however, does need to be viewed in light of
some limitations. The lack of a reliable
diagnostic classification system for shoulder
pain resulted in a heterogeneous study
population in the current study consisting of
patients with a mix of mechanical shoulder
symptoms, only excluding those with restricted
shoulder ROM. It is possible that specific
subgroups within this heterogeneous group, if
they can be reliably identified, may benefit
from mobilization therapy directed at the
shoulder region joints. In addition, the lack of
evidence to guide therapists in the choice of
passive mobilization technique may have
resulted in the choice of less-than-optimal
mobilization therapy for some participants.
Finally, although the loss to follow-up was
smaller than that assumed in the calculation of
the sample size for the current study, there is
the chance that significant differences between
the treatment groups were missed due to type 2
statistical error, and the possibility of bias due
to the lack of blinding of the treating therapists
and participants cannot be discounted.

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*BPT, MPT-Orthopaedics, Senior Physical therapist, Ahmedabad, Gujarat
72

PROFILE OF SEVERE NUTRITIONAL ANEMIA IN CHILDREN AT A
TERTIARY CARE HOSPITAL, SOUTH INDIA

Madoori Srinivas*, Kapil Challa, Mangat Bhukya, Srikanth Darisetty, Radhika Kodimela

ABSTRACT
Anemia is the most prevalent problem in the world particularly in the developing countries
1
NFH
survey (NFHS-3) data shows that 7 out of every 10 children age 6 to 59 months in India are anemia
2
.
Here we report study done to find out the profile of hospitalized children with severe nutritional
anemia, to compare the clinical, and laboratory profile of iron deficiency anemia (IDA) and vitamin
B12 deficiency. Methods: This retrospective study was carried out in a tertiary care hospital at
Karimnagar in children aged 1 year to 14 years, admitted with severe nutritional anemia from January
2012 to August 2013. The Chalmeda Anand Rao Institute of Medical Sciences is located in north
Telangana which caters low and middle class people from Karimnagar, Adilabad and part of
Warangal district. Hemoglobin level less than 7 gm/dl was considered as severe anemia and
categorized into iron deficiency anemia and vitamin B12 deficiency in the light of historical
information, physical examination and relevant laboratory investigations and were compared. Results:
Out of 62 children with severe nutritional anemia, males were 35.5% (n=20), and females were 64.5
%( n=42). Mean age of presentation was 8.7 years. The common presenting symptom was pallor
(90.3%), followed by fever (83.87%). IDA was observed in 85.48% ( n=53) and vitamin B12 deficiency
was observed in 14.5% ( n=9). Mean age of presentation in IDA and VitaminB12 deficiency was 8.7
years and 12.7 years respectively. Children with hemoglobin less than 3 grams/dl, 44% (n=4), more in
73
vitamin B12 deficiency. Blood transfusion was given to children with Hb less than 3gm/dl, Iron,
vitamin B12 supplementation given to children with Iron deficiency and vitamin B12 deficiency
respectively. Nutritional advice was given to parents and during the course of the hospital stay no
advance effects noted. There was statistically significant difference in mean hemoglobin (p=0.05),
weight percentile (p=0.021), RBC count (p=0.01), MCV (p=0.000), MCH (p=0.000), MCHC
(p=0.000) in between two groups. Conclusion: Nutritional anemias are conditions in which Hb
concentration of a given individual is below the normal level due to deficiency of one or more nutrients
needed for haematopoiesis. The main nutrients are Iron, Folate, vitamin B12, Proteins and vitamin E.
In this Iron deficiency anemia is currently the most wide spread micronutrient deficiency and affects
nearly 1.5 billion people globally. Children with severe anemia younger the age mostly due to Iron
deficiency and preadolescence age group vitamin B12 deficiency. Early identification, prompt
nutritional supplementation at the community level will decrease the hospitalization of children with
severe nutritional anemia, also aids in their growth and intellectual development. Early
supplementation of iron in younger children especially with malnutrition, preterm, LBW babies.
Exclusive breast feeding and nutritional advice will improve the anemia status in children. In
preadolescence and pure vegetarians with severe anemia suspect B12 deficiency and supplement with
Vitamin B12.

Keywords: Iron deficiency anemia (IDA), Vitamin B 12 deficiency, cognitive impairment
INTRODUCTION
Anemia continues to be a public health problem
of global proportions. It is the most common
preventable nutritional deficiency in children.
The WHO has estimated that, globally 1.62
billion people are anemic with the highest
prevalence of anemia (47.4%) among preschool
aged children, of these 293 million children, 89
million live in India while prevalence of
anemia among school children is 25.4%
3
. The
Term nutritional anemia encompasses all the
pathological conditions in which the blood
hemoglobin concentration drops to an
abnormally low level, due to one or more
several nutrients
4
. Iron deficiency is one of the
major causes of anemia among Indian
children
5
. Nutritional anemia develops
secondary to interplay of diverse factors like
poverty, malnutrition, large family size, faulty
dietary habits and repeated infections
6
. In our
study children with severe nutritional anemia
were identified and categorized into iron
deficiency anemia and vitamin B12 deficiency
and their clinical and laboratory profile were
compared.

MATERIALS AND METHODS
This study is a hospital based retrospective
74
cross sectional observational study. It is
conducted at Chalmeda Anand Rao Institute of
medical sciences, Karimnagar,AP, South India
between Jan 2012 to Aug 2013. Children with
severe pallor aged 1 year to 14 years admitted
in the paediatric wards were enrolled. Complete
blood picture was carried out in all these
children. Using the WHO cut-off values anemia
was defined as Hb <11.0gm/dl and severe
anemia was defined as Hb < 7gm/dl . Children
with severe nutritional anemia were identified
and categorized in to Iron deficiency
group[IDA] and B12 deficiency group [B12
Def] in the light of history, physical
examination, relevant laboratory investigations
and were compared. We measured serum iron,
total iron binding capacity, folic acid and
vitamin b12 as indicated. Bone marrow
aspiration was performed in children with
pancytopenia to rule out bone marrow failure
syndromes or neoplastic disorders. Children
with severe anemia secondary to non-
nutritional causes like leukemia , MDS,
bleeding disorders were excluded from the
study.
Frequency and 95% confidence interval were
calculated for categorical variables, median and
interquartile ranges (IQR) for continuous
variables were calculated. Man-Whitney U test
was applied to calculate the significant
difference between the medians of two groups.
Epi info versions 7, SPSS 19 were the
statistical software used for the study. P value
of 0.05 was taken as significant.

RESULTS
Out of 62 children admitted with severe
nutritional anemia, median age of presentation
with severe anemia was 8.7 years 4.44, males
were 35.5 % (n=20) and females were 64.5%
(n=42) . Among the severe nutritional anemia
cases 17.7% (n=11) belonged to 1 to 3 years of
age group, 17.7% (n=11) were 4 to 6 years
age group,64.5% (n=40) belonged to 7 to 14
years age group, The older children have
increased prevalence of vitamin B12 deficiency
The iron deficiency anemia was observed in
85.48% (n = 53) [95%CI 6.8-25.7] and B12
deficiency was observed in 14.5% (n=9) [95%
CI 74.2-93.14]. Median age of presentation
was 8.1 years with iron deficiency anemia and
12.7 years in vitamin B12 deficiency anemia.
Among 53 Iron deficiency anemia children
found 19(35.8%) were males, 34(64.2%) were
females, out of 9 children with B12 deficiency
3(33.3%) were males, 6(66.7%) were females.
In both groups females are more affected than
males.

TABLE 1 :Hemoglobin categorization in two groups i.e. comparison between IDA
& B12 deficiency
Hemoglobin(gm /dl)
Level
No(%) of children Total
B12Deficiency IDA

3 4 (44.4%) 12 (22.6%) 16 (25.8%)
4 - 6 5 (55.6%) 36 (67.9%) 41 (66.1%)
7 0 (0.0%) 5 (9.4%) 5 (8.1%)
Total 9 (100.0%) 53 (100.0%) 62 (100.0%)

We categorized hemoglobin of severe
nutritional anemia into three groups (group I<3
gm/dl , group II 4 to 6 gm/dl , group III 7
gm/dl) among these 67.9% (n=36) of iron
deficiency anemia and 55.6 % (n=5) of B12
deficiency group had hemoglobin of 4 to 6
gm/dl (group II) as shown in table 3. Children
with hemoglobin less than 3gm/dl were more in
vitamin B12 deficiency anemia as compared to
iron deficiency anemia as shown in table 1
Among the children with severe nutritional
anemia, pallor was present in 90.3% {(n=52)
followed by fever (83.8%), Generalized
weakness 58.06% (n=36, 95% CI, 44.85% to
70.49%) , Icterus 24.19% (n=10, 95% CI,14.22
to 36.74%) cough 19.35% (n=12, 95% CI,
10.42% to 31.37%), and pain abdomen 16.13%
(n=10,95% CI,8.02 to 27.67%), breathlessness
8.2% (n=5,95%CI 2.72 to 18.10%) as in Table
2.

TABLE (2): CLINCAL PROFILE ANALYSIS
S. NO SYMPTOM PRESENT ABSENT
1 Pallor 90.3% (n=56)
CI 80.12% to 96.37%
9.7% (n=6)
CI 3.63 to 19.88%
2 Fever

83.87% (n=52)
CI 8.02% to 27.67%
16.13% (n=10)
CI 72.33 to91 .98
3 Weakness 58.06% (n=36)
CI 44.85% to 70.49%
41.94% (n=26)
CI 44.85%to 70.49%
4 Icterus 24.19% (n=10)
CI 14.22 to 36.74%
75.81% (n=47)
CI 63.26 to 85.78%
5 Cough 19.35% (n=12)
CI10.42% to 31.37%
80.65% (n=50)
CI 10.42 to 31.37%
6 Pain abdomen 16.13% (n=10)
CI 8.02 to 27.67%
83.87% (n=52)
CI 72.33 to 91.98%
7 Hepatomegaly 11.29% (n=7)
CI 78.11 to95.34%
88.71% (n=55)
CI 78.11 to 95.34%
76
8 Breathlessness 8.20% (n=5)
CI 2.72 to 18.10%
91.80% (n=56)
CI 81.9 to 97.28%
9 Koilonychia 4.84% (n=3)
CI 1.01 to 13.5%
95.16% (n=59)
CI 86.5 to 98.99%
10 Previous blood transfusion 3.23% (n=2)
CI 0.39 to 11.17%
96.77% (n=60)
CI 88.83 to 99.61%
11 Lymphadenopathy 3.23% (n=2)
CI 0.39 to 11.17%
96.77% (n=60)
CI 88.83 to 99.61%
12 Hyperpigmentation 1.61% (n=1)
CI 0.04 to 8.66%
98.39% (n=61)
CI 91.34 to 99.96%

There is a significant statistical difference
between mean age at presentation (12.7 years
versus 8.11 years, p=0.008), mean hemoglobin
( 4.5 g/dl versus 3.5 gm/dl, p=0.05) mean
weight percentile ( 19.5 versus 43.33 p=0.021),
mean RBC count (2.70 versus 1.30, p=0.001),
mean WBC count (7433 versus 2711 ,p=
0.007), platelets (2.5 lakhs versus 0.79 lakhs,
p=0.00) and blood indices
(MCV,MCHC,MCH) between iron deficiency
anemia group and B12 deficiency anemia group
as shown in Table 3. Children treated
accordingly with iron, folic acid and Vitamin
B12 given, children with severe anemia were
give lasix, blood transfusion in the form of
packed cells, there is symptomatic
improvement. Vigorous counseling was given
regarding nutritional supplementation; there is
no mortality in our series.

TABLE (3): Comparison of variables in IDA& B12 deficiency anemia with P value
Variable B12 def IDA Pvalue
Mean std
(n)
Median[range]
(n)

Mean=std
(n)

Median[range]
(n)

Age at
presentation
12.77781.09
(9)
13
(9)
8.1132+4.449
(n=53)
9
(n=53)
0.08
RBC 1.306+0.8032
(n=9)
1.10
(n=9)
2.7057+1.225
(n=53)
2.7
(n=53)
0.01
Wt percentile 43.33+32.88
(n=9)
50
(n=9)
19.528+26.95
(n=53)
3
(n=53)
0.021
Hb% 3.51+1.03 3.80 4.5132+1.447 4.2 0.05

(n=9) (n=9) (n=53) (n=53)
WBC 2711.1+822.26
(n=9)
2900
(n=8)
7433.9+5010
(n=53)
6100
(n=53)
0.07
PLT 0.7911+0.3452
(n=8)
0.8
(n=8)
2.566+1.9199
(n=53)
2.0
(n=53)
0.000
MCV 104.512+7.150
(n=8)
104.35
(n=8)
65.74+17.922
(n=43)
58
(n=43)
0.000
MCH 35.925+1.923
(n=8)
35.9
(n=8)
18.381+7.585
(n=42)
15
(n=42)
0.000
MCHC 0.7911+0.3452
(n=8)
33.75
(n=8)
26.98+4.132
(n=42)
25.75
(n=42)
0.000

DISCUSSION
Nutritional anemia has major consequences not
only on the morbidity and mortality but also
affects their growth and the intellectual
development in children. The prevalence of
severe anemia among children varies between
1.3 to 11% in different regions of the world
6
.
Iron deficiency is the most prevalent
micronutrient deficiency which affects nearly
70% of under 5 children a per NFHS 3 survey.
In this study severe nutritional anemia of which
females (64.5%) were more compared to males
(35.5% respectively), our data is contradictory
to previous study which shows association
between low hemoglobin levels and male
gender
7
. Deeksha Kapoor et al have reported
that prevalence of severe anemia among Indian
children aged between 9 to 36 months was
7.8% but in our study 17.7% of children of
same age group had severe anemia
8
. Young
children aged 6 to 24 months are particularly at
high risk for severe anemia and a study done by
Nasera Bhatti et al reported that children aged
1 to 3 years constitute the highest risk group
(72.6%) which in comparison to our study,
children aged 7 to 14 years constituted the
highest risk group (64.5%)
6
. May be due to
nutritional supplementation anganwadi centers
for below 5years children
Severe nutritional anemia was identified as iron
deficiency in 85.4% and vitamin B12
deficiency in 14.5%, younger the age group (<6
years) iron deficiency anemia is the cause for
severe nutritional anemia as opposed to older
age group (7-12yrs), where B12 is the most
common cause. This is consistent with the
study done by Nasera et al
6
. A study done on
young Mexican
9
children and another study
conducted in Malawi
10
, iron deficiency is not a
predominant cause of severe nutritional anemia,
this is contradictory to the present study.
78
Majority of children with iron deficiency
anemia presented with symptoms of pallor
(90.6%) which is a similar finding by Rachana
Bhoite et al
11
who reported pallor in 78.3% of
the children aged 5 to 12 years. Anemia
significantly causes growth impairment and in
the present study, children with iron deficiency
anemia compare to vitamin B12 deficiency
anemia were more underweight (3
rd
to 25
th

percentile, Agarwal charts).
Pancytopenia is a consistent feature of
megaloblastic anemia as proved in earlier
studies and found in our studies, further
supported by Khunger et al who observed that
megaloblastic anemia accounted for over 72%
of cases presenting with pancytopenia
12
.
Limitations of the present study are findings
cannot be extrapolated to the community as it is
a hospital based cross sectional study.
Incidence and prevalence of anemia have not
been characterized because of nature of the
study. Though this study was done in small
sample we need to remember that children with
severe anemia younger age IDA is common
older children with B12 deficiency. To validate
this a population based study with the large
number of sample is required.

CONCLUSION
Severe anemia due to nutritional deficiency
more common in younger age . we need to
strength the anganwadi centre for Early
identification, prompt nutritional
supplementation at the community level which
will decrease the hospitalization of children
with severe nutritional anemia, and also aids in
their growth and intellectual development
Acknowledgement: We would like to thank
Chalmeda Anand Rao Institute of Medical
Sciences for granting permission to conduct our
study.
Conflict of Interest: None
Role of Funding Source: None

REFERENCE
1. DeMaeyer EM, Dallmen P, Gurney JM, Hallberg I, sood SK, Srikantia SH, Prevention of iron deficiency anemia
in: Preventing and controlling iron deficiency anemia through primary Health Care, Geneva, world Health
organization 1989, PP, 33 42 Anupamsachdeva, AK duth
2. Satya P Yadav, Ramesh Kumar Goyal, Ajay Arora, Devesh Aggarwal, Advances in Peadiatrics . 2012. PP. 760
3. Worldwide Prevalence of Anemia 19932005. Geneva, Switzerland: world Health Organization; 2008.
4. Nutritional Anemia in Young Children with Focus on Asia and India, Prakash V Kotecha, Indian J Community
Med. 2011 Jan-Mar; 36(1): 816.
5. World Health Organization. Iron Deficiency Anemia: Assessment, Prevention, and ControlA Guide for
Programme Managers.Geneva, Switzerland: World HealthOrganization; 2001.
6. Nasera Bhatti et.al Severe Nutritional Anemia in Hospitalized Children. Ann. Pak. Inst. Med. Sci. 2008; 4(2): 81-
84
7. Domello f M, Lonnerdal B, Dewey KG, et al. Gender differences in iron status during infancy. Pediatrics.
79
2002;110(3):545552
8. Deeksha Kapoor, Kailash N, Sushma Sharma, Kusum Kela, Iqbal Kaur. Iron statusof children aged 9-36 months
in an urban slumIntegrated Child Development Services Project in Delhi. Indian Pediatr. 2002; 39: 136-144.
9. Duque X, Flores-Hernandez S, Flores-Huerta S, et al. Prevalence of anemia and deficiency of iron, folic acid, and
zinc in children younger than 2 years of age who use the health services provided by the Mexican Social Security
Institute. BMC Public Health. 2007;7:345
10. Calis JC, Phiri KS, Faragher EB, et al. Severe anemia in Malawian children. N Engl J Med. 2008;358(9):888899
11. Magnitude of Malnutrition and Iron Deficiency Anemia among Rural School Children: An Appraisal Rachana
Bhoite, Uma Iyer ASIAN J. EXP. BIOL. SCI. VOL 2(2) 2011
12. Khunger JM, Arulselvi S, Sharma U, Ranga S, Talib VH. Pancytopenia- a clinicohematological study of 200 cases.
Indian J Pathol Microbiol 2002; 45: 375-379.

*Dr. Madoori Srinivas, Professor, Department of Pediatrics, Chalmeda Anand Rao Institute of Medical
Sciences, Karimnagar, Andhra Pradesh, Ph No: 9866535700, Email ID: madoorisrinivas@gmail.com
Contribution details:-
Concept and guarantor: Author Madoori Srinivas
Manuscript preparation: Mangat B, Radhika K, Srikanth D
Data compiled: Kapil C
80

ANTIOXIDANT POTENTIALS OF PARTHENIUM HYSTEROPHORUS L
LEAF EXTRACTS

Sankar Narayan Sinha*, Dipak Paul

ABSTRACT
Aim: Synthetic drugs are potentially toxic and are not free from side effects on the host. Therefore an
attempt has been made to study the antioxidant activity of plants. As plants and plant-based drugs are
less toxic and have acceptable side effects, hence in the present study the crude extracts of leaf of
Parthenium hysterophorus L were selected to study antioxidant activity. Methodology: The plant
extracts were prepared by using methanol and the activity was determined by DPPH and ABTS
scavenging assays. Results And Conclusion: It was found that this extract has considerable
antioxidant activity. Phytochemical analysis indicated the presence of flavonoids, tannins, phenolic
compounds, steroids, terpenoids, alkaloids and proteins along with other chemicals.
Key Words: Antioxidant activity, DPPH radical scavenging assay, Parthenium hysterophorus

INTRODUCTION
An antioxidant is a molecule that inhibits the
oxidation of other chemical substances. During
oxidation process transfers of electrons or
hydrogen from a substance to an oxidizing
agent occurs. Oxidation reactions can generate
free radicals which later on can start chain
reactions. When the chain reaction takes place
in a cell, cells may be damaged or dead.
Antioxidants inhibit and stop these chain
reactions by removing intermediary free
radicals, and terminate other oxidation
reactions. They act by being oxidized
81
themselves, so usually antioxidants are
reducing agents such as ascorbic acid,
polyphenols, thiols etc.
Reactive oxygen species (ROS) are major free
radicals generated in many redox processes,
which may cause oxidative damage to
biomolecules, including proteins, sugars, lipids
and DNA. Reactive oxygen species have an
impact on living cells, which help the
pathogenesis of several chronic diseases
1-7
.
The action of ROS is opposed by a balanced
system of antioxidant compounds produced in
vivo
8-10
. Endogenous antioxidants are
insufficient, and dietary antioxidants are
required to counter measure excess ROS
11
.
Hence there has been an increased interest in
the food industry and in preventive medicine in
the development of Natural antioxidants from
plant materials.
Parthenium hysterophorus Linn, also known as
carrot grass, congress grass, chatak chandini.
This plant was accidently introduced in India as
contaminants in PL-480 wheat imported from
the USA in the 1950s
12
. Plant used as an
analgesic in neuralgia, antipyretic tonic,
febrifuge and its root decoction was helpful in
amoebic dysentery. The leaf extracts have a
role in the fertility, fecundity and behavioral
response
13
. The whole plant possesses the
various pharmacological activities such as
anticancer activity on A549 cell line
14
, skeletal
muscle relaxant activity
15
and hypoglycaemic
activity
16
.
Though the plant is regarded as the allergy
causing agent and develop asthma, the study on
this herb as an alternative of antimicrobial
agents is still limited. Since Parthenium
hysterophorus are known with the herbs with
wide uses, this study therefore set out to assess
the antioxidant potentials and to determine the
phytochemical constituents of methanol extract
of the leaves of this plant.

Plant Description
Parthenium hysterophorus is a much-branched,
annual, erect herbaceous plant which forms a
basal rosette of leaves during initial phase of
growth. The height of the plant is 0.5-1.5 m,
but can occasionally reach up to 2 m or more.
Mature hirsute stems are greenish and
longitudinally grooved and become much
branched at maturity.
Leaves simple, petiolate of growth, lower
leaves relatively large (3-30 cm long and 2-12
cm wide) and are deeply divided. Leaves on the
top branches decrease in size and are also less
deeply divided than the lower leaves. Short,
stiff hairs are present in the lower surface of the
leaves, and to some extent upper surfaces.
Numerous small, white or creamy pedicellate
flowers are arranged in clusters (capitula).
Seeds are achenes, 1.5-2.5 mm long usually
with two or three small scales (a pappus)
produced in each flower-head (capitulum)
(Figure 1).

Taxonomic position of Parthenium
hysterophorus
Kingdom: Plantae
Order: Asterales
82
Family: Asteraceae
Genus: Parthenium
Species: P. hysterophorus

Figure 1: Parthenium hysterophorus Linn

MATERIAL AND METHODS
Collection of Plant Material
The fresh leaves of Parthenium hysterophorus
Linn was collected from Kalyani, West Bengal
(India) in the month of July, 2012 and the plant
was identified and authenticated.

Preparation of extracts
For the preparation of methanolic extract, the
leaves of Parthenium hysterophorus Linn was
cleaned, air dried and grinded into coarse
powder. 50 gm powder was packed into the
soxhlet extractor with methanol (170ml). The
extract was concentrated and dried by using
rotary evaporator and the extract was stored in
a refrigerator at 4
0
C.

Phytochemical Screening
The methanol extract of Parthenium
hysterophorus was studied for their
phytoconstituents using different
phytochemical tests
17
.
Antioxidant activity
1. Free radical-scavenging ability by the use
of a stable DPPH radical
The DPPH radical-scavenging activity was
determined using the method proposed by Yen
and Chen
18
.

2. Free radical-scavenging ability by the use
of a stable ABTS radical cation
The free radical-scavenging activity was
determined by ABTS radical cation
decolourization assay
19
.

RESULTS AND DISCUSSION
Results of phytochemical screening are shown
in Table 1. The leaves extract tested positive
for flavonoids, tannins and phenolic
compounds in both aqueous and methanolic
extract. The methanolic leaves extract
contained alkaloids and proteins, whereas, the
aqueous extract contained steroids and
terpenoids.
Phenolic compounds are important
phytoconstituents and have potential against
different disease because of their antioxidant
properties
20
. They are known to possess anti-
diarrheal, anti-inflammatory, antiulcer, anti-
secretary, anti-spasmodic, antitumor activities
and antiviral activities
21
. Radical scavenging
via hydrogen atom donation by phenols is
83
believed to be the predominant mechanism of antioxidant action.

Table 1: Qualitatively phytochemical analysis of Parthenium hysterophorus leaves extract
Test Reagents Observation Aqueous
extract
Methanolic
extract
Alkaloids Mayers reagent Creamy
precipitate
Negative Positive
Steroids Conc. H
2
SO
4
Reddish brown
precipitate
Positive Negative
Terpenoids Chloroform +
Conc. H
2
SO
4

Reddish brown
interface
Positive Negative
Flavonoids Alkaline reagent Yellow colour to
colourless
Positive Positive
Saponins Water+shake Foam formation Negative Negative
Phenolic
compounds
Alcohol+Ferric
chloride
Bluish green Positive Positive
Tannins Pb-acetate White
precipitate
Positive Positive
Proteins Conc. HNO
3
+
40% NaOH
Orange colour Negative Positive
Carbohydrates Barfoeds
reagent
Reddish brown
precipitate
Positive Positive
Amino acids Ninhydrine
reagent
Violet colour Positive Positive
Reducing sugar Benedicts
reagent
Red precipitate Positive Positive

84
The scavenging the stable DPPH radical is a
widely used method to evaluate the free radical
scavenging ability of various samples
22
which
can accommodate a large number of samples in
a short period of time and is sensitive enough to
detect natural compounds at low concentrations
so it was used in the present study for screening
of antioxidant activity. The present study
revealed that the radical- scavenging activities
of all the extracts increased with increasing
concentrations (Table 2).

Table 2: In vitro free radical scavenging activity of Parthenium hysterophorus leaves by DPPH method
Compounds % Scavenging IC
50

20g/ml 40g/ml 60g/ml 80g/ml 100g/ml
Standard
(Ascorbic acid)
6.30.52 16.20.92 29.90.76 33.80.84 48.60.32 54.410.22
Parthenium
hysterophorus
Linn
8.20.74 17.40.45 33.80.98 40.90.68 54.51.20 60.214.09

The ABTS scavenging assay, which employs a
specific absorbance (734 nm) at a wavelength
remote from the visible region and requires a
minimum reaction time and may be used as an
index that reflects the antioxidant activity of the
test samples
23
. In the following table (Table 3),
Parthenium hysterophorus extract was found to
be effective in scavenging radicals and the
increase was concentration-dependent. At
100g/ml, the inhibition of the extract was
93.2% (Table 3).

Table 3: In vitro free radical scavenging activity of Parthenium hysterophorus leaves by ABTS method
Compounds % Scavenging IC
50

20g/ml 40g/ml 60g/ml 80g/ml 100g/ml
Standard
(Ascorbic acid)
53.45.2 68.42.1 81.54.2 85.45.1 91.50.85 17.225.82
85
Parthenium
hysterophorus
Linn
45.83.8 56.26.01 68.82.4 78.63.05 93.20.72 33.610.6

CONCLUSIONS
Methanolic extracts of P. hysterophorus L.
showed significant antioxidant activity as
compared to the ascorbic acid. This might be
due to the presence of bioactive elements and
phenolic constituents present in the extract.
Based on the significant results obtained in this
study, further work is required for isolation and
purification of bioactive compounds so that
novel antioxidant drugs from this medicinal
plant can be exploited.

ACKNOWLEDGEMENT
The authors are thankful to University of
Kalyani, West Bengal, India for providing
necessary facilities for doing this research.
Authors acknowledge the financial support
received under the grant from DST PURSE,
New Delhi, India for this study.

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of the National Academy of Sciences of the United States of America. 1993;90(17): 7915-7922.
3. Harman D. Aging: phenomena and theories. Annals of the New York Academy of Sciences. 1998; 854:1-7.
4. Finkel T, Holbrook NJ. Oxidants, oxidative stress and the biology of ageing. Nature. 2000; 408: 239247.
5. McDermott JH. Antioxidant nutrients: current dietary recommendations and research update. Journal of the
American Pharmacists Association. 2000; 40(6): 785799.
6. Chahar MK, Sharma N, Dobhal MP, Joshi YC. Flavonoids: a versatile source of anticancer drugs.
Pharmacognosy Reviews. 2011;5(9): 1-12.
7. Wong FC, Chai TT, Hoo YW. Antioxidation and cytotoxic activities of selected medicinal herbs used in Malaysia.
Journal of Medicinal Plants Research. 2012;6(16): 3169-3175.
8. Halliwell B, Gutteridge JMC. Free radicals in biology and medicine (3rd ed). Oxford: Clarendon Press. 1999.
9. Khan RA, Khan MR, Sahreen S, Bokhari J. Prevention of CCl
4
-induced nephrotoxicity with Sonchus asper in rat.
Food and Chemical Toxicology. 2010;48(8-9): 2469-2476.
10. Khan RA, Khan MR, Sahreen S. Protective effect of Sonchus asper extracts against experimentally induced lung
injuries in rats: a novel study. Experimental and Toxicologic Pathology. 2012;64(7-8): 725-731.
11. Lim YY, Murtijaya J. Antioxidant properties of Phyllanthus amarus extracts as affected by different drying
methods. LWT-Food Science and Technology. 2007;40(9): 1664-1669.
12. Rao RS. Parthenium: A new record for India. Journal of the Bombay Natural History Society. 1956;54: 218-220.
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13. Kumar S, Singh AP, Nair G, Batra S, Seth A, Wahab N, Warikoo R. Impact of Parthenium hysterophorus leaf
extracts on the fecundity, fertility and behavioural response of Aedes aegypti L. Parasitology Research.
2011;108(4): 853859.
14. Ramamurthy SK, Pittu VP, Kotturi R, Devi P, Kumar S. In vitro cytotoxic activity of methanol and acetone extracts
of Parthenium hysterophorus Flower on A549 cell lines. International Journal of Pharmaceutical Sciences Review
and Research. 2011;10(2): 95-99.
15. Jha U, Chhajed PJ, Oswal RJ, Shelke TT. Skeletal muscle relaxant activity of methanolic extract of Parthenium
hysterophorus L. leaves in swiss albino mice. International Journal of Pharmacy and Life Sciences. 2011;2(11):
1211-1213.
16. Patel VS, Chitra V, Prasanna PL, Krishnaraju V. Hypoglycemic effect of aqueous extract Parthenium
hysterophorus L. in normal and alloxan induced diabetic rats. Indian Journal of Pharmacology. 2008;40(4): 183-
185.
17. Harborne JB. Phytochemical methods.3rd ed. London. Chapman and Hall. 1984.
18. Yen GC, Chen HY. Antioxidant activity of various tea extracts in relation to their antimutagenicity. Journal of the
Agricultural and Food Chemistry. 1995;43(1): 2732.
19. Re R, Pellegrini N, Proteggente A, Pannala A, Yang M, Rice-Evans C. Antioxidant activity applying an improved
ABTS radical cation decolorization assay. Free Radical Biology and Medicine. 1999;26(910): 12311237.
20. Rice-Evans C. Flavonoid antioxidants. Current Medicinal Chemistry. 2001;8(7): 797807.
21. Carlo GD, Mascolo N, Izzo AA, Capasso F. Flavonoids: old and new aspects of a class of natural therapeutic
drugs. Life Sciences. 1999; 65(4): 337353.
22. Lee SE, Hwang HJ, Ha JS, Jeong HS, Kim JH. Screening of medicinal plant extracts for antioxidant activity. Life
Sciences. 2003;73(2): 167-179.
23. Wu LC, Hsu HW, Chen YC, Chiu CC, Lin YI, Ho JA. Antioxidant and antiproliferative activities of red pitaya.
Food Chemistry. 2006;95(2): 319327.

CORRESPONDENCE
* Environmental Microbiology Research Laboratory, Department of Botany, University of Kalyani,
Kalyani-741235, West Bengal, India; Email: sinhasn62@yahoo.co.in
87

COMPARATIVE STUDY ON s-LPS AND bp26 BASED iELISA FOR HUMAN
BRUCELLOSIS

Narayana Rao.K *, R Shome, Jayapal Gowdu B**,Nagalingam M, Balamurugan1V, B. R.
Shome, K Prabhudas and Rahman.H

ABSTRACT
Brucellosis is an emerging zoonotic disease caused by members of the genus Brucella and remains a
serious cause of human illness from livestock. Presently used sero-diagnostic tests depend upon the
smooth lipopolysaccharide (sLPS), which cross react with other Gramnegative bacteria resulting in
low specificity. To overcome this, several recombinant outer membrane proteins (OMP) have been
tried as diagnostic antigen (s) in ELISA. In the present study, the ORF (753 bp product) of BP 26
protein was amplified from Brucella suis strain 1330, cloned in pET32a vector and expressed in BL21
E.coli hostcell. The expressed protein was purified by Ni-NTA column and characterized by SDS-
PAGE and Western blot analysis. The purified recombinant protein (rbp26) antigen was tested in
indirect ELISA (iELISA) and specificity was checked with E. coli (O157 H7), 17 salmonella and five
Yersinia entericolitica reference sera. Further, rbp26 based standardized ELISA was evaluated with
serum samples (n=626) collected from risk group individuals (veterinarians) using two conjugates IgM
and IgG for diagnosis of brucellosis. Comparative evaluation of the developed assay with RBPT and
sLPS based ELISA was carried out. In RBPT, 60 (9.5%) and in sLPS antigen based iELISA-IgM 36
(5.75%) and iELISA-IgG 122 (19.48%) were positive, respectively. Whereas in rbp26 based ELISA 18
(2.87%) and 66 (10.54%) were positive in IgM and IgG ELISA, respectively.
88
Keywords: RBPT, STAT, IgM ELISA, IgG ELISA, Human, Brucellosis, Blood donors, Risk group

INTRODUCTION
Brucellosis is a zoonosis caused by facultative
intracellular bacteria of the genus Brucella,
which are capable of surviving and multiplying
inside the cells of mononuclear phagocytic
system and are widely distributed in both
humans and animals
1
. Human brucellosis
varies from an acute fabrile illness to chronic,
low grade ill defined disease. It is a systemic
disease characherized by pausity of signs
accompanied with nocturnal sweating, malaise,
fatigue and backache
2
. The disease can be a
very debilitating, despite the fact that the
fatality rate is generally low. It often becomes
sub-clinical or chronic, especially if not
diagnosed early and properly treated. The
incidence in humans ranges widely between
different regions, with values of up to 200 cases
per 100,000 populations with high prevalence
in Middle East, Mexico, Central and South
America and the Indian subcontinents
2,3
.
High-risk groups include those exposed
through occupation in contexts where animal
infection occurs, such as slaughterhouse
workers, hunters, farmers and veterinarians.
The diagnosis of brucellosis can be
challenging, and its diagnosis demands
epidemimology, clinical and laboratory
information. Its routine biochemical and
hematological laboratory tests also overlap with
those of many other pathogens such as
Salmonella, Yersinia, and Vibrio
4
. Many tests
are reported for diagnosis of Brucella, ranging
from microbilogical culture to serodiagnostic
tests such as slide or tube agglutination, indirect
coombs test, enzyme-linked immunosorbent
assay (ELISA) and indirect fluorescent assays,
to the recent molecular techniques such as
polymerase chain reaction (PCR) are
available.
5, 6, 7
.
Isolation from blood, bone marrow and other
tissues of suspect is classical diagnostic (gold
standard) method for brucellosis. However, this
microbiological technique is having the draw
back of time consumption as the organism is
having incubation period of 6 weeks and
possibility of contamination to personnel
cannot be avoided
8
. Rose Bengal Plate test
(RBPT) is commonly used for the screening of
brucellosis however results may at times
inconclusive
9
. In standard tube agglutination
test (STAT), interpretation of the result is
difficult due to false positive reaction with
Salmonella, Yersinia and Vibrio species.
Further PCR is the molecular technique which
is employed for the detection of brucellosis,
but the technique is uneconomic and poorly
suited for the laboratory with limited resources.
In view of these limitations, robust, coast
effective and rapid ELISA has been found an
ideal tool for the diagnosis. Current serological
tests based mainly on s-LPS antigen, chances in
possible of false positivity due to cross-
reactivity. In view of all these facts, the present
study have been taken to develop recombinant
89
antigen based ELISA for diagnosis of
brucellosis in swine and humans. The
recombinant outer-membrane protein (rOmp26)
was purified from B.suis 1330 in pET-32a
bacterial expression system and used in an
indirect ELISA for the detection of Brucellosis.
Comparisons of recombinant antigen based
iELISA against RBPT, and s-LPS based
iELISA.
In brucellosis, titre of IgM usually raises from
day 5 to 7 with peak titre and IgG starts to
appear from day 14 to 21, reaching peak during
next 2 to 3 weeks in the infected individuals.
Clinical applications of IgM and IgG ELISA in
human disease have been reported
10, 11
. This
manuscript deals with the study on
development and evaluation of recombinant
bp26 antigen based indirect ELISA for the
sero-diagnosis of Brucella infection in human
beings and its comparison with laboratory
standardized IgM and IgG ELISA protocol.

MATERIALS AND METHODS
Collection of sera samples
During the course of the study, 2 ml of blood
samples without anticoagulant was collected
aseptically in vaccutainers. The samples were
sourced from risk group (veterinarians, para
veterinarians, farm workers, animal-handlers
and farmers), blood donors and patients with
pyrexia of unknown origin (PUO). The pyrexia
may be due to systemic cause of rheumatic
fever, jaundice, C reactive protein, hepatitis
etc., The samples were allowed to clot,
transported to laboratory immediately at 4C.
The serum was separated by centrifuging the
sample at 2500 r.p.m for 5 min and stored at
20C for further use.

Rose Bengal Plate Test (RBPT) and
Standard Tube Agglutination Test (STAT)
Sera samples received were initially subjected
to rapid screening RBPT according to standard
procedures
12
. Briefly, for the RBPT, undiluted
serum sample (30 l) was mixed with an equal
volume of colored antigen on a glass slide. The
results were rated negative when agglutination
was absent and 1+ to 4+ ratings as positive,
according to the strength of the agglutination
within 1 to 3 min.
Smooth Lipopolysaccharide (sLPS) antigen
extraction

Standard strain
Standard antigenic strain of B.suis 1330
procured from Indian Veterinary Research
Institute, Izatnagar, U.P., India and confirmed
as B.suis 1330 by biochemical tests, PCR,
cloning and sequencing in our was used for
antigen extraction
15
.
Large scale bacterial culturing
Freshly grown pure colonies were suspended in
10 ml of sterile PBS, after vortexing, the
bacterial suspension was overlaid on Tryptose
Agar (TA) in Roux flasks. Thirty flasks were
simultaneously inoculated from the same
master plate to provide the identical bacterial
population originating from a single colony.
90
After one-hour adsorption, Roux flasks were
inverted and incubated for 72 hours at 37
o
C.
The purity of the culture in every flask was
confirmed by Grams staining after 48 hours.
To each flask, 30 ml of 2% phenol saline was
added, gently agitated and incubated for 24
hours at 37
o
C. The suspensions were collected,
pooled, centrifuged at 14,000 r.p.m at 4
o
C for
20 min. The centrifugation was repeated and
pellets were carefully collected, weighed and
used for antigen extraction.
Preparation sLPS antigen extraction
Wet cells of Brucella (5 gm) were suspended in
17 ml of distilled water and followed by the
addition of 19 ml of 90% (v/v) phenol at 66C.
The mixture was stirred continuously at 66C
for 15 min, cooled and centrifuged at 10,000
rpm for 15 min at 4C. The brownish phenol in
the bottom layer was aspirated with a long
micro tip and large cell debris was removed by
filtration (using a Whatman No.1 filter).The
sLPS was precipitated by the addition of 50 ml
chilled methanol containing 0.5 ml methanol
saturated with sodium acetate. After 2 hours
incubation at 4C, the precipitate was removed
by centrifugation at 10,000 r.p.m for 10 min,
stirred with 8 ml of distilled water for 18 hours
and centrifuged at 10,000 r.p.m for 10 min. The
collected supernatant solution was kept at 4C
and this step was repeated twice for the best
recovery of antigen. Then, 0.8 g of
trifluroacetic acid was added to the 16 ml of
crude sLPS, stirred for 10 min and the
precipitate was removed by centrifugation. The
translucent supernatant solution was
concentrated and dialyzed against distilled
water (two changes of at least 4000 ml each)
and then freeze dried to get the final yield of 10
ml of sLPS containing the antigen
concentration of 3 mg/10ml.
16
.
The optimum concentration of antigen for
ELISA was standardized by checkerboard
titration against 1:100 and 1:200 dilution of
strong positive convalescent sera . The OD
values were plotted on a graph and the point
where there was sharp fall on the line graph
was taken as the optimum dilution of antigen.
Standardized ELISA protocol
The polysorp micro titer plates (Nunc,
Germany) were coated with 1:300 dilution of
sLPS antigen at 100 l per well in carbonate-
bicarbonate buffer (pH 9.6) and incubated 4C
for overnight. Antigen coated plates were
washed three times with PBST wash buffer
(Phosphate buffered saline containing 0.05 %
Tween 20) pH 7.2. Test and control sera diluted
in PBST blocking buffer (1:100) containing 2%
bovine gelatin was added to respective wells
(100 l) of the plates in duplicates (test sera)
and quadruplicate (controls) and incubated at
37C for 1hour. The plates were then washed as
mentioned earlier. The anti-human IgG and IgM
HRP conjugates (Pierce, Germany), diluted
1:8000 and 1:4000 respectively in PBST buffer
were added to all the wells (100 l) and
incubated for 1 hour at 37C on orbital shaker
(300 r.p.m./min). After washing, freshly
prepared o-Phenylenediaminedihydrochloride
(OPD) (Sigma, Germany) solution containing 5
91
mg OPD tablet in 12.5 ml of distilled water and
50 l of 3% H
2
O
2
was added and kept for color
development for 10 min. Enzyme-substrate
reaction was stopped by adding 1M H
2
SO
4
(50
l) and color development was read at 492 nm
using an ELISA micro plate reader (Biorad).
The optical density (OD) obtained for the
negative and positive samples were interpreted
by cutoff values set at 3 standard deviations
above the arithmetical mean of the OD obtained
for the healthy controls
17
.

Production and purification of recombinant
BP26 protein.
Standard antigenic strain, Brucella suis 1330
was procured from IVRI, Izatnagar. The
organism was grown in brucella selective agar
media at 37C for 48 hrs at 10% CO
2
. The
organism was identified as Gram negative,
coccobacillary rods on Grams staining. The
genomic DNA was extracted as per the standard
protocol, using the Bacterial genomic DNA
spin QIAamp. The PCR amplification was
carried out in 25l reaction volume containing
12.5l of 2X PCR master mix (4 mM MgCl
2
;

0.4 mM of each deoxynucleotide triphosphates
(dNTPs); 0.5U of Taq DNA polymerase; 150
mM Tris-HCl PCR buffer), primers and 2.5l of
template DNA. The Thermal cycler conditions
for BCSP31 are 93
0
C for 5min 1 cycle; 35
cycles of 90
0
C for 1min; 60
0
C for 30sec and
72
0
C for 1min with a final extension of 72
0
C for
7 min. The PCR amplicons (5l) were separated
by electrophoresis in 1.5% agarose gel with
TAE as running buffer and purified.
The purified Genomic DNA from B.suis 1330
was used for the amplification of the target
gene rbp26 using published primer sequences.
The cycling conditions followed were:
preheating at 95
0
C for 2min 1 cycle; 35 cycles
of 94
0
C for 45sec; 50
0
C - 60
0
C for 45sec and
72
0
C for 2min with a final extension of 72
0
C
for 10 min. The products were analysed by
agarose gel electrophoresis as mentioned
before. The amplified product was purified
from the gel using MinElute gel extraction
kit from QIAGEN and employed for further
sequencing and cloning
35,36
.

Cloning and expression of rbp26 gene :
The purified PCR product digested with EcoR1
and Not1 which was ligated with digested
pGEMT vector, was transferred into E. coli
Top10F competent cells and plated on LB amp
plates, incubated overnight at 37
o
C. Several
ampicillin resistant colonies appeared and were
streaked on LB amp plates for further
recombinant clones for the presence of rbp26
gene. After an incubation of 16 hours at 37
0
C,
both blue (non recombinant) and white colonies
(recombinant) were observed on LB Agar-amp
supplemented with IPTC and X-gal plate and
white colonies (recombinant clones) were
purified, used as template and confirmed by
Colony PCR. The amplified products were
analyzed by agarose gel electrophoresis and
further subjected to confirmation by restriction
enzyme (RE) digestion
40
.
The inserted rbp26 gene sequence is of 753bp
nucleotides. The cloned bp26 gene was
92
released from pGEMT bp26 by EcoR1 and
Not1, digestion. The fragment was sub cloned
into pET-32a vector and analyzed by agarose
gel electrophoresis then it was digested with
EcoR1 and Not1. After transformation of
pETBP26 into E. coli BL21 competent cells
several recombinant clones were formed on the
LB plate supplemented with ampicilin. Plasmid
DNA extracted from recombinant clone
digested with which was ligated with digested
pET-32a vector, was transferred into EcoR1
and Not1 released 753bp insert.
The transformed competent BL21 cells and
pET-32a vector as a control and pETBP26
recombinant clones of interest were induced
with 1mM IPTG and incubated for sixteen
hours at 37
0
C. The induced cell lysates were
collected at one hour interval. The lysates of
proteins were analyzed by 12 percent SDS
PAGE and followed by western blotting. The
size of the rbp26 gene is 753bp which
corresponded to 42kDa protein. Thus along
with fusion tag of 18kDa, the rbp26 protien
showed in the gel as 42kDa band. No reaction
was seen with respect to blots treated with
Yersinia enterocolitica O:9, and Escherichia
coli O:157 referral sera, This showed that the
expressed protein was of Brucella specific
epitope and there was no cross reaction with
positive and negative sera.
Standardized ELISA protocol
The polysorp micro titer plates (Nunc,
Germany) were coated with 200ng/well
antigen at 100 l per well in carbonate-
bicarbonate buffer (pH 9.6) and incubated 4C
for overnight. Antigen coated plates were
washed three times with PBST wash buffer
(Phosphate buffered saline containing 0.05 %
Tween 20) pH 7.2. Test and control sera
diluted in PBST blocking buffer (1:100)
containing 5% skim milk power was added to
respective wells (100 l) of the plates in
duplicates (test sera) and quadruplicate
(controls) and incubated at 37C for 1hour.
The plates were then washed as mentioned
earlier. The anti-human IgG and IgM HRP
conjugates (Pierce, Germany), diluted 1:5000
and 1:5000 respectively in PBST buffer were
added to all the wells (100 l) and incubated
for 1 hour at 37C on orbital shaker (300
r.p.m./min). After washing, freshly prepared o-
Phenylenediaminedihydrochloride (OPD)
(Sigma, Germany) solution containing 5 mg
OPD tablet in 12.5 ml of distilled water and 50
l of 3% H
2
O
2
was added and kept for color
development for 10 min. Enzyme-substrate
reaction was stopped by adding 1M H
2
SO
4
(50
l) and color development was read at 492 nm
using an ELISA micro plate reader (Biorad).

RESULTS
In ELISA, the 1 in 200 sLPS antigen
concentration was found optimum at serum
concentration of 1 in 100 (Fig 1). Similarly, the
conjugate dilutions were established by
checkerboard titration and IgM conjugate of 1
in 4000 and IgG conjugate at 1 in 8000 were
found optimum dilutions for the test (Fig. 2).
Similarly for rbp26 based ELISA antigen
concentration was 200ng / well was found
93
optimum at serum concentration of 1:32 and
the conjugate dilutions were established by
checkerboard titration at 1:5000 for both IgG
and IgM.
Among the 626 serum samples collected from
risk group individuals (veterinarians) using two
conjugates IgM and IgG for diagnosis of
brucellosis. Comparative evaluation of the
developed assay with RBPT and sLPS based
ELISA was carried out. In RBPT, 60 (9.5%)
and in sLPS antigen based iELISA-IgM 36
(5.75%) and iELISA-IgG 122 (19.48%) were
positive, respectively (Fig.6). Whereas in rbp26
based ELISA 18 (2.87%) and 66 (10.54%)
were positive in IgM and IgG ELISA
respectively (Fig.5). Similarly comparative
evaluation of the OD values of the both the
assays were documented. (Fig:7,8)

Antigen and antibody optimization
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
0 1000 2000 3000 4000
Antigen dilution
O
D

a
t

4
9
2

n
m
1 in 200
1 in 100

Figure 1. Optimization of antigen versus serum concentration for ELISA (All the dilution are at the rate
of 1 in 100, 1 in 200, 1 in 400, 1 in 800, 1 in 1600 and 1in 3200 respectively)

Conjugate titration curve
0
0.2
0.4
0.6
0.8
1
1.2
0 10000 20000 30000 40000
Antigen dilution
O
D

a
t

4
9
2

n
m
IgM Conjugate
IgG Conjugate

Figure 2. Optimization of conjugates for ELISA (All the dilutions are at the rate of 1 in 1000, 1 in
94
2000, 1 in 4000, 1 in 8000, 1 in 16000 and 1in 32000 respectively)

Fig 3: SDS-PAGE analysis of sequential elutes
of recombinant protein bp26 suis1330

Fig 4: Western blot analysis with swine
brucella positive and negative sera

Fig 5: Comparision of OD values with two
conjugates used in rbp26 based Human iELISA

Fig 6: Comparison of OD values with two
conjugates used in sLPS based Human iELISA

Fig 7: Comparison OD of values sLPS and
rbp26 based Human iELISA with anti human
IgG

95

Fig 8: Comparison OD of values sLPS and
rbp26 based Human iELISA with anti human
IgM

Fig 9: Standardization and cut-off PP for s-LPS
and rbp26 based Human iELISA

DISCUSSION
The true incidence of human brucellosis
however, is unknown for most countries and no
data are available for many parts of India. It has
been estimated that the true incidence may be
25 times higher than the reported incidence due
to misdiagnosis and under-reporting. Several
publications indicate that human brucellosis
can be a common disease in India. The ELISA
was first developed by Carlson et al, for the
diagnosis of human brucellosis and since then,
a large number of variations have been
described
18
. ELISA have a distinct advantage
over conventional serological tests in that, they
are primary binding assays that do not rely

on
secondary properties of antibodies such as their
ability to

agglutinate or to fix complement.
Secondly, ELISA can be tailored

to be more
specific by using highly purified reagents such
as

antigens and monoclonal antibodies.
The sLPS antigen of Brucella is considered the
most important antigen during immune
response and is the target for many serological
and immunological studies. It gives better
sensitivity and specificity with good
reproducibility. It also possesses a convenient
cut off value for diagnostic purposes. Finally, it
is not restricted to bovines alone and can be
adapted to different species of animals as well
as to humans beings
3
. The sLPS antigen coated
passively on to a polystyrene matrix is the
method commonly employed in the ELISA
19
.
The indirect ELISA and AB-ELISA have seen
standardized by several researchers using sLPS
antigen from B. abortus S
99
to screen the
livestock and humans for brucellosis
15, 19, 20, 21
.
Similar antigenic studies has been taken on the
bp26 by several researchers and previously
identified B.suis 1330 bp26 immunodominant
antigen
36
is nearly identical to the B. abortus
BP26 antigen reported by Rossetti et al
35
. The
name of BP26 should therefore be retained. The
fact that two independent laboratories have
identified the same immunodominant antigen
either in the field of bovine or ovine
37,38,39

brucellosis emphasizes the importance of BP26
96
as diagnostic antigen
40
.
The higher prevalence rates reported by various
researchers are in accordance with our present
findings in the high risk groups
21, 25, 30
. High
sero prevalence in the risk group is attributed to
constant exposure to infection due to
contamination of hands and arm while handling
animals and also human infection can occur
through aerosol, occupational exposure of
abattoir workers, veterinarians and laboratory
technicians. In addition, consumption of
infected raw milk, raw milk products and raw
meat can result in infection
25
.
The transmission of brucellosis to man is
primarily by direct contact with infected
animals or their products. However, the
organisms can also be transmitted by
transfusion of infected blood
31
. The blood
donors tested in the study, showed 1.62%
positivity by RBPT and 4.87%, by IgG ELISA.
Two such similar reports from Karnataka,

revealed the prevalence ranging from 1.8%
(out of 26,948 adult donors )
25
to 14.7% (out
of 353 donors) by RBPT
32
. These findings
are relatively identical to our findings. This
infection in the donors might be due to the
exposure of the donors unintentionally to the
animals or due to the consumption of raw milk,
or may be due to the cross reacting antibodies
such as vibrio or yersinia.
The basic knowledge of this study will help us
for the development of indigenous ELISA kit
for sero screening of the disease in humans and
to identify active infection (IgM ELISA). The
use of sLPS and rbp26 as antigen in the I-
ELISA might be one of the reasons for higher
sensitivity as the stronger immune responses
are elicited against sLPS and found that the
very specific immune response against rbp26 in
infected individual. The advantage of using the
indigenously developed kit/tests is that the
large number of samples can be analyzed
economically and it will also help to generate
seroepidemiological data of the disease in the
country. Screening of large number of sera
samples and validation as per OIE guidelines is
underway.

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35. OSVALDO L. ROSSETTI,* ALICIA I. ARESE, MARIA L. BOSCHIROLI, AND SILVIO L. CRAVERO Cloning of
Brucella abortus Gene and Characterization of Expressed 26-Kilodalton Periplasmic Protein: Potential Use for
Diagnosis JOURNAL OF CLINICAL MICROBIOLOGY, Jan. 1996, p. 165169
36. Xuan Z. Ding, Apurba Bhattacharjee, Mikeljon P. Nikolich, Ian T. Paulsen, Gary Myers, Rekha Seshadri and
David L. Hoover Cloning, expression, and purification of Brucella suis outer membrane proteins Division of
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99
CORRESPONDENCE
*Project Directorate on Animal Disease Monitoring and Surveillance, (PD_ADMAS), Hebbal, Bangalore-560
024, Karnataka, India
**Dept.of Microbiology, Yogi Vemana University, Kadapa, Andhra Pradesh
100

AUTOMATIC FILLING MANAGEMENT SYSTEM FOR INDUSTRIES

Saubhagya Tandon*, Shreya Srivastava**, Sandeep Pal***

ABSTRACT
In this era of industrialization, technological revolution/automation is fast shrinking the need of
humans to assist machinery. Looking at the current industrial scenario, birth of new products and
private brands is sharply raising the competition among industries. In order to hold out the promise of
timely delivery of product, high tech automated production is essential. The concept of automation is
so versatile that it can bring radical development in almost every field. Keeping view of present
requirements, this paper proposes a filling management system for industries which is a complete
application of automation. The notable thing about this project is its high degree of flexibility and its
remote control. A prototype of commercial bottle filling system, controlled using programmable logic
controller (PLC) is proposed and the whole process is monitored using supervisory control and data
acquisition (SCADA). This system provides the provision of mixing any number of liquids in any
proportion. Its remote control and monitoring makes the system easily accessible and warns the
operator in the event of any fault.
Keywords: PLC; SCADA; Bottling Plant; Automation

INTRODUCTION
Beverage market offers opportunities that can
be transformed into success only by those
companies that have technology to take it
beyond competition. High degree of flexibility
is its prior need. Also industries face many
other challenges. The pressure to continually
101
increase production volumes has stressed older
systems and has increased maintenance
requirements. For manufacturers, this creates
two problems: higher costs and increased
downtime. Production managers are being
challenged to reduce cost, wastage and
downtime. New technologies are required that
will reduce water usage, increase energy
efficiency and minimize downtime in high-
speed beverage production environments.
Increasing competitive pressures, ever more
stringent legal regulations, rising costs of
commodities and energy and consumers whose
preferences are subject to rapid change
beverage companies today are forced to
increase their flexibility and operate with
maximum efficiency at the same time. The key
to this problem is an integrated process
approach. After all, if all processes are
perfectly coordinated with each other and
reliable communications have been established
between all parts of the manufacturing plant, it
is much easier to address the big challenges
1
.
In small industries, the refilling system usually
operates in manual mode and even this is true
for some other industries also. Literature
suggests that microcontrollers are being used in
these industries as it brings a cost effective
solution for controlling the process
2
. Although
PLCs are costly, still those are also used in
industries. The implementation of PLC for
commercial bottle filling plants is not discussed
widely in literature, therefore in this work an
endeavor is made to bring out the important
facts about its commercial use. In addition the
use of SCADA is also implemented in this
project work which is a high-tech tool for
providing monitoring through the remote
location. The system developed in this work is
a complete package of filling management
system for industries. It provides flexibility
with reliability. It also provides an extra
advantage of production flexibility and ability
to extend or modify an existing plant. It
provides remote monitoring of the entire plant
that makes it easily accessible.
The paper has been discussed mainly in four
sections: first section gives the introduction
followed by the system description where the
general block diagram and process flow is
discussed. The complete prototype description
is discussed in section III and finally
conclusions are given in section IV.

SYSTEM DESCRIPTION
This project is a complete application of
automation. The various process of this system
is controlled by PLC and is remotely controlled
using SCADA. PLC and SCADA are heart of
the system. The system is controlled according
to the programmed PLC. To monitor the
processing of the entire plant SCADA is used.
Figure 1 shows the block diagram of the whole
process.
102

Fig. 1. Block Diagram of the whole process

There are two inputs to the PLC out of which
one is the output of the proximity sensor. The
proximity sensor senses the presence of the
bottle at the conveyor belt. In this work
metallic bottles are used which are detected by
a proximity sensor. Infra red sensor is another
choice that may be used in place of proximity
sensor. When the bottle is sensed by the
proximity sensor, a signal is sent to the PLC
through signal conditioning circuits. The PLC
then operates the two dc motors to start the
mixing process and deliver the mixture to the
third tank. In real time systems AC drives may
be used for the purpose. Depending upon the
need, proportion and amount of liquid to be
filled in bottle, the closing and opening
operation of valves connected to motors is
controlled through PLC. This section further
broadly discusses the main parts of the system:
A. Programmable Logic Controller, PLC
PLC is a programmable device developed to
replace mechanical relays, timers and counters.
PLCs are used successfully to execute
complicated control operations in a plant. The
PLCs helped reduce the changeover time from
a month to a matter of just few days. PLC
consists of an input/output (I/O) unit, central
processing unit (CPU) and memory. The I/O
unit acts as the interface between PLC and real
time systems. All logic and control operations,
data transfer and manipulation work is done by
CPU.
PLCs provide the advantages of high reliability
in operation, flexibility in control techniques,
small space and computing requirements,
expandability, high power handling, reduced
human efforts and complete programming and
reprogramming in a plant. The PLC is designed
to operate in the industrial environment with
wide ranges of ambient temperature, vibration,
and humidity and is not usually affected by the
electrical noise that is inherent in most
industrial locations. It also provides the cost
effective solution for controlling complex
systems
3
.
B. Supervisory Control And Data Acquisition,
SCADA
PLC & SCADA combination gives the
advantage of better monitoring and control of
the plant. SCADA enables engineers,
supervisors, managers and operators to view
and interact with workings of entire operations
through graphical representation of their
production process. SCADA runs on a PC and
is generally connected to various PLCs.
SCADA constantly gathers data from plant in
real time, stores and processes it in the
database, evaluates and generates alarms,
103
displays information to plant operators,
supervisors and managers and can issue
instructions to PLCs on the plant floor
4
.
C. Filling System
The filling system consists of three tanks where
liquids are kept and mixed according to
proportion given in PLC program. For large
industries any number of tanks can be used to
mix any number of liquids. Hence the system
using PLC provides large flexibility. AC drives
for main motors with valves and conveyor belt
arrangement is used in industries for filling
operation. At the appropriate timings motor
connected to valves is made ON and
accordingly the valve opens. The filling system
consists of subsystems that include Conveyor
system and Sensors. A sensor is a device,
which responds to an input quantity by
generating a functionally related output usually
in the form of an electrical or optical signal.
Sensors are designed to have a small effect on
what is measured; making the sensor smaller
often improves this and introduces other
advantages also. Here sensors are used to detect
the bottles so that there is no wastage. Hence
system has also given the advantage that even if
the program is running and there is no bottle on
the conveyor the motor 3 will not start and thus
valve 3 will also not open, so no spill of liquid
takes place. The valve 3 will open only when
there is a bottle and filling will be done.
Conveyors are especially useful in applications
involving the transportation of heavy or bulky
materials. Conveyor systems allow quick and
efficient transportation for a wide variety of
material. The conveyor system is used to
transport bottles from one end to other. At the
initiating end the bottle is empty while at the
destination end filled bottle reaches.

PROTOTYPE DESCRIPTION AND
CONTROL IMPLEMENTATION
In this project, a prototype illustrating the
commercial bottling plant automated using
PLC is developed and the whole process is
monitored using SCADA. The sensing
mechanism used in the system takes care of
unnecessary spill or wastage. The system
provides best accuracy and precision in the
mixing any number of liquid in any proportion.
The system is completely monitored using
SCADA and plant may be stopped or
controlled through SCADA in case of
emergency.
In this system, liquids can not only be filled but
this system can also mix liquids in desired
proportion. In this system, there are two
different liquids in two different tanks which
are mixed in third tank (final tank). The mixing
can be done in any proportion, say 2:3; 5:5; 4:6;
etc. Motor 1 and Motor 2 shown in Figure 1
control the proportion which gets mixed up in
the third tank. Finally, this liquid is filled in the
cans or bottles and the biggest advantage of this
system is with automation, it provides remote
monitoring and controlling. That is, the entire
working of the system or filling plant is
displayed on the SCADA screen from where
the whole plant can be monitored and
controlled.
104

Fig. 2. Process Monitoring through SCADA
Screen
The plant can be started from the SCADA
screen as well as it can be stopped from the
same screen only, in case of any fault. Thus no
waste or harm to the plant if any fault occurs.
Figure 2 shows the process visible on SCADA.
PLC is the main part of the automation plant.
The plant is automated by the programmed
PLC. PLC used is MICROLOGIX 100 and
supply to PLC is provided through SMPS.
Ladder programming is the main programming
method used for PLC. Ladder programming is
done using software RS LOGIX ENGLISH.
The program is then downloaded on PLC. As
per the program written for this work, when the
system is switched on, motor 1 starts and runs
for stipulated time and valve 1 opens and liquid
reaches in tank third. Then when motor 1 stops,
motor 2 starts and in the same way liquid from
tank 2 reaches third tank. The liquids get mixed
up in the third tank. When the bottle is present
in front of third tank motor 3 starts and valve 3
opens to fills the bottle. 24V solenoid valves
are used for the purpose and proximity sensor
in used for sensing the bottle. The bottles are
placed on the conveyor belt which is moved
using dc motor drive in this case. In industrial
systems ac drives are used. When the bottle is
sensed by the sensor, a signal is sent to the PLC
which stops the drive motors and after the
filling process is over, the PLC again starts the
drive motors to move the conveyor. The
conveyor moves till the presence of other bottle
is sensed by the proximity sensor.
This complete working is monitored on
SCADA screen interfaced with the PLC. RS
232 cable is used for the interference of PLC
and SCADA and wonderware Intouch software
is used for SCADA. SCADA screen shows all
the working of the plant i.e. the whole
movement of the conveyor/filling system is
visible on the SCADA screen. Here SCADA
provides the remote control operation of the
system. It is not necessary that the SCADA
screen be placed near to PLC. If there is any
error in the working of the plant, like if any
motor does not start at its set time or runs for
more time, will be displayed on the screen and
the plant can be immediately stopped from the
SCADA screen itself. This feature also helps
the system in avoiding any spill or wastage.

CONCLUSION
This paper has proposed an application of
automation illustrating a PLC based fully
automatic untouched liquid filling system. The
system meets the demand of high-speed
production using the least mechanism
requirements. The system has proved to work
105
effectively avoiding unnecessary spill or
wastage of liquids. The system also provides
high accuracy and precision in proportion of
liquids mixed. Although proposed system
illustrates the mixing process of two liquids,
any number of liquids may be mixed in varying
proportions. It is true that the use of PLC is a
costly affair particularly for small industries but
it offers many advantages that overcome its
cost. One of the additional features of the
proposed system is the use of SCADA that
makes it controlled through a remote location.
Complete monitoring of the system is possible
through SCADA and in fact the process may be
stopped or started by SCADA screen. This
feature is particularly very useful in case if
some fault occurs in the system.

REFERENCES
1. http://www.industry.siemens.com/verticals/global/en/food-beverage/bev erage-industry/Documents/E20001-A100-
T110-V1-7600.pdf
2. Ashwini P. Somavanshi, Supriya B. Asutkar and Sachin A. More, Automatic Bottle Filling Using Microcontroller
Volume Correction, International Journal of Engineering Research and Technology IJERT, vol. 2, Issue 3,
March 2013, pp. 1-4.
3. Ahmed Ullah Abu Saeed, Md. Al-Mamun and A. H. M. Zadidul Karim, Industrial Application of PLCs in
Bangladesh, International Journal of Scientific & Engineering Research, vol. 3, Issue 6, June 2012.
4. Stuart A. Boyer, Scada Supervisory Control and Data Acquisition, International Society of Automation USA, 4th
Edison, 2009.
5. Mallaradhya H. M., K. R. Prakash, Automatic Liquid Filling to Bottles of Different Height Using Programmable
Logic Controller, in proceedings of AECE-IRAJ International Conference, July 2013, pp. 122-124.
6. T. Kalaiselvi, R. Praveena, Aakanksha R. and Dhanya S., PLC Based Automatic Bottle Filling and Capping
System with User Defined Volume Selection, International Journal of Emerging Technology and Advanced
Engineering, vol. 2, Issue 8, August 2012, pp. 134-137
7. Shaukat N., PLC Based Automatic Liquid Filling Process, IEEE Multi Topic Conference, 2002.

CORRESPONDENCE
*Department of Electrical Engineering, Ideal Institute of Technology, Ghaziabad, India, Email:
saubhagyatandon@gmail.com
**Department of Electrical Engineering, Ideal Institute of Technology, Ghaziabad, India, Email:
shreya.srivastava18@gmail.com
***Department of Electrical Engineering, Ideal Institute of Technology, Ghaziabad, India, Email:
sandeepiit2011@gmail.com
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107
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