Cryotherapy and Steching in Hemiplegia
Cryotherapy and Steching in Hemiplegia
Cryotherapy and Steching in Hemiplegia
By
SUNIL VARGHESE
September – 2005
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A COMPARITIVE STUDY TO ASSESS THE EFFECT OF
CRYOTHERAPY OVER THERMOTHERAPY WITH COMMON
USE OF HOLD RELAX IN IMPROVING GAIT PARAMETERS ON
HEMIPLEGIC PATIENTS
By
SUNIL VARGHESE
September – 2005
Guided By:
Dr.J.Ramesh Kumar MPT
Associate Professor
Goutham College of Physiotherapy,
Bangalore – 560 010
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
DECLARATION
SUNIL VARGHESE
Place : Bangalore
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Certificate
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Endorsement by Principal
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COPYRIGHT
Declaration
I here by declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall
have the rights to preserve, use and disseminate this dissertation/thesis in print or
SUNIL VARGHESE
Place : Bangalore
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ACKNOWLEDGEMENT
I thank the Almighty God and my beloved parents who has been the foundation
It has been my privilege and honour to receive the able guidance of Dr.J.Ramesh
acknowledge my indebtedness to him, for his keen interest and guidance throughout the
work.
of physiotherapy, for his able guidance and constant encouragement throughout the
College of Physiotherapy for providing me all the facilities for this study.
College of Physiotherapy, for his timely suggestions, advice and for giving me all the
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My special thanks to Dr.P.B.Balamurugan MPT, Assistant Professor,
Dr.S.Saratha Devi, Lecturer, Goutham College of Physiotherapy for their support &
invaluable help, without which this project wouldn’t have been a success.
Garden City College of Physiotherapy for their valuable guidance. I am also very
helping hand on the statistical methods of Data Analysis & Research Methodology.
My thanks to all other contributors, whose names I have not mentioned, but
Last but not the least, my heartfelt and sincere thanks to all the subjects on whom
this study was carried out, my beloved juniors, my friends especially Dear Lourdhu Raj
for being there for me in every phase of my work , sanjay and vivek and lovings muthu
for giving me the support and relatives both far and near, for their kind co-operation
SUNIL VARGHESE
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CONTENTS
1. INTRODUCTION 1
3. REVIEW OF LITERATURE 9
4. HYPOTHESIS 16
Study Design
Sample Selection
Materials Used
Measurement tools
Procedure
Data Analysis
7. DISCUSSION 40
8. CONCLUSION 45
9. SUMMARY 46
10. REFERENCES 47
11. ANNEXURE 52
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ABSTRACT
Methods: Thirty male hemiplegic patients where divided into two groups , Group I
Results: After a 6-week treatment period, the Cryotherapy along with proprioceptive
neuromuscular stretching was the group that scored significantly higher with the
parameters of gait such as Stride length (0.05), Cadence (0.05) and Walking velocity
found much effective in reducing spasticity which helped in increasing the weight
10
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INTRODUCTION
during the rehabilitation process of stroke patients; Mobility is defined as the quality of
being able to move about in ones environment which automatically gains the functional
independence.
alignment of lower extremities provides both the mean of support to the proximal heavy
trunk segments and propulsion of entire mass through space, walking is a complex
systems that requires minimal conscious thoughts for most people. In the CVA
population involvement of one or more of the integrated physiological system can result
characterized by uncoordinated movements and lack of control of the contra lateral side
of the body. The severity of the lesion will determine the degree of motor and cognitive
involvement which produces hypertonicity of the muscles of arm and leg which disrupts
ambulatory abilities.
11
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Patients with such cerebrovascular accidents presents lower extremity extensor
synergy with equinovarus positioning of the foot and ankle complex, sustained plantar
flexion of the ankle, sustained hip and knee extension, and pelvis retraction on involved
side. Notable gait deviations include weight transfer on the lateral aspect of the foot, knee
As a result of this asymmetric gait pattern the various gait parameters like
walking velocity, stride length on involved limb, cadence, support time on the involved
limb, weight transfer through the limb are decreased thereby increasing the energy cost of
the gait.
Lehmann et al29 reported a reduction in walking speed, cadence and step length
walking speed will tend to increase energy costs associated with the ambulatory pattern.
In hemiplegic gait, initial loading of the limb occurs with a flat-footed or toe-heel
contact, secondary to motor deficits and an extensor synergy that produces a concentric
momentum of the body as a whole and a drastic decrease in velocity can often be
stability and postural compensations also appear in the form of increased hip external
12
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rotation and pelvic retraction, these postural adjustments serve to align the knee axis
assessment reveals the thigh and distal limb segment proceeding posteriorly while the
Initiation of the swing phase is difficult because a hyper extended hip alignment
during terminal stance is never obtained. Sustained pelvic retractions and anterior trunk
lean prevents prestretch to the hip flexors; as a result, the hip joint receptors do not
receive the proper signal to decrease extensor muscle activity and initiate flexor muscle
patterning. As a result lateral trunk deviation is often required to unload the limb toward
patients independence after stroke 50-80% of stroke survivors will walk independently.
This striking success however hides the fact that many of these patients walk slowly and
rarely venture outdoors. Gray CS et al30 (1990) in their study provided evidence for the
fact that the necessity of long-time institutional care for stroke patients is correlated to a
13
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Muscle relaxation and pain relief are closely related. Spasticity associated with
upper motor neuron lesions can be reduced by heating, but these effects are only short-
term and therefore the use of cold may be a more effective method of treatment in this
instance8.
It has been demonstrated both in experimental studies and clinical practice that
cooling a muscle reduces spasticity and this has proved to be a useful therapeutic tool in
the rehabilitation of patients with upper motor neuron lesions22; Price et al, 1993 13. In the
study there was statistically significant reduction in spasticity at the ankle that occurred
secondary to head injury following the application of liquid ice in a bag to the
The underlying physiology behind the reduction of spasticity using ice is not
totally understood, it may be due to slowing of conduction in both the muscle and motor
nerves, a reduction in the sensitivity of the muscle spindle, or impaired conduction in the
gamma efferents which are more susceptible to cooling than the alpha efferents. The
response is rapid occurring in a matter of seconds and it is clinically important that the
muscle is cooled thoroughly for at least 30 minutes in order to achieve a longer lasting
effect. There are also various studies supporting the duration of cryotherapy in reducing
spasticity.
giving stretching. Though many studies are there supporting passive stretching to reduce
14
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spasticity, only few studies were done with proprioceptive neuromuscular stretching that
Reflex relaxation is the goal of hold relax technique, relaxation may allow an
increase in passive range of motion and may help to decrease pain related to excessive
for inhibition of the antagonist during an agonist contraction and inhibition of a muscle
In hold relax technique after reaching the range of the agonist pattern a hold
(static) contract is performed against gradually building resistance and the goal is a pain
free response. After the entire phase the new agonist range is achieved and the process is
repeated. This sort of stretching is thus helping the therapists to slowly overcome the
pathologically evolved tightness of the muscles due to the excessive firing of the gamma
motor neurons.
The impairment of gait is one of the major handicaps after stroke and a prime aim
to recover for the patient since it is closely related to activities of daily living and
independence. In this study an attempt has been made to analyse the effects of
relax stretching in reducing the spasticity and improving the gait parameters of the stroke
15
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NEED OF THE STUDY
imbalance and loss of normal gait pattern. These are the main factors which affects the
Thermotherapy11 in reducing the increased muscle tone for these hemiplegic patients
there by favoring improvement in pathological gait. Also there are evidences supportive
16
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SIGNIFICANCE OF THE STUDY
1. The results of the study may help the physiotherapists to effectively use the
2. This study can help the therapists to understand the relation of excessive tone in
the Quadriceps and Plantar Flexors hampering the weight bearing and locomotion
neurological disorders.
17
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AIMS & OBJECTIVES OF THE STUDY
1. To assess the effect of cryotherapy with common use of hold relax technique in
2. To assess the effect of thermotherapy with common use of hold relax technique in
patients.
18
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REVIEW OF LITERATURE
Several studies by different group of researchers were going on to find out the
effective technique in the reduction of spasticity & improving the independence of the
training induced alteration in muscle fiber type and cross-sectional area of the vastus
lateralis muscle, considering 24 male university students and dividing them into two
training. Both groups performed 3 sets of 30 repetitions each for a period of eight weeks.
After the training they found that both proprioceptive neuromuscular facilitation and
isometric training alter fiber type distribution and mean cross-sectional area of the muscle
and these changes specifically occur in the type II fiber subgroup. Medicine, 1
active individuals without history of knee and hip injury. Each subject was randomly
assigned to a 3 second hold relax, 6 second and 10 second hold relax proprioceptive
neuromuscular facilitation stretch. They performed 3 trials. The results showed that all 3
19
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hold time conditions produced significant gains in the range of motion compared to
baseline measurements. 2
Feland JB and Marin HN, 2004 analyzed the effect of sub maximal contraction
isometric contractions using 60 male subjects in the Brigham Young University, USA.
The results were analyzed using paired t test which showed a significant change in
contractions.3
Funk DC et al, 2003 of the University of Texas at Austin, USA compared the
40 undergraduate student athletes. The duration of stretching was 5minutes in both the
after exercise enhanced hamstring flexibility and no differences were observed with static
Rowlands AV et al, 2003 from the School of Sport Health and Exercise Sciences
assessed the effect of isometric contraction durations during PNF stretching on gains in
flexion at hip using 43 subjects in the University of Water-Bangor, UK. The subjects
20
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control groups. The flexibility was assessed at the baseline and weeks 3 and 6. The
ANOVA was used to find out the significance and the results showed a longer
Psychiatry, Poland; using a sample of 3 patients with an average age of 64. After 3 weeks
of therapy specific characteristics of gait were examined. The results showed that the
subjects have considerably approached the standards of frequency and speed thereby
showing better rhythm of gait. However stride length and duration of single limb support
Hacettepe University, Ankara, Turkey. They selected 50 subjects and assigned into
groups receiving the traditional training or PNF and evaluated the outcome of both using
time distance parameters of gait from footprints. The results of the study suggested that
the prosthetic training based on proprioceptive feedback was more effective to improve
21
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ordination in spasticity by giving a repetitive movement (RM) test of the ankle while
patients. This test was carried on before and after cooling the muscle for duration of
20minutes. The results showed the reduction in spasticity with a slight increase in the
measure the duration of maintained hamstring flexibility after a one time modified hold
relax stretching protocol in 30 male subjects performed six warm ups active knee
extensions with the experimental group receiving 5 modified hold relax stretches. The
significantly increased hamstring flexibility that lasted 6min after the stretching protocol
ended. 9
Suzuki K et al, 1999 died the relationship between stride length and walking rate
in gait training for hemiparetic stroke subjects in Tohoku University graduate School of
Medicine, Japan. They took 63 male hemiparetic patients in the recovering stage and
were trained for period of 4 weeks. They found that the maximum walking speed for 10m
was significantly gained from 32.3 to 53.2m/min on average and the stride length and
walking rate also rose. However the ratio of stride length to walking rate did not change
significantly in 4 week. 10
22
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Preisinger E and Quittan M, 1994 of University of Physical Medicine &
resulting from upper motor neuron lesions. The results suggested that muscle spasm can
on the gait of patients with hemiplegia of long and short duration in the Department of
Physical Therapy, National Yang-Ming Medical College, Taiwan, China. The subjects
were 20 patients with hemiplegia of short duration or large duration and each received a
treatment lasting for 30 minutes. The results showed that in subjects with hemiplegia of
short duration gait, speed and cadence improved immediately after the therapy. 12
human ankle in 25 subjects with clinical signs of spasticity secondary to traumatic brain
injury, spinal cord injury and stroke. They did a baseline cryotherapy and one-hour post
cryotherapy measurements and found that there was a diminished spasticity relative to the
and cold with clinical applications and described that for topical application, cryotherapy
23
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has much greater potential for restorative and therapeutic effect, while topical heat is
almost exclusively limited palliative effects. He also suggested that the knowledge of the
of Oregon, Eugene. They studied the activity of quadriceps and hamstring muscle using
agonist contract-relax. The results showed the reduction in hamstring activity due to
15
proprioceptive neuromuscular facilitation stretching techniques.
Bell KR & Lehmann JF, 1987 studied the effect of cooling on H and T reflex in
16 subjects and recorded the reflexes via surface EMG on triceps surae. Skin and
intramuscular temperatures were also recorded and found that the muscle spindle activity
Deanna Fish M S and Cheryl S Kosta, 1986 has studied the effect on walking
impediments and gait inefficiencies in the cerebrovascular accident patients and revealed
that use of motor activity parameters for patient’s results in arbitrary values of acceptance
for measuring balance, alignment, range of motion, walking and other functional
activities. They also postulated that each patient must be evaluated individually to
24
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maintain the integrity of the structural components and produce the maximum level of
functional independence. 17
Hefland AE and Bruno J, 1984 also studied about the therapeutic modalities of
heat and cold. They concluded that cryotherapy has got the physiologic effects such as
sedation; refrigeration and tissue destruction based on the mode of application and
duration of exposure, whereas the therapeutic heat has the primary effects such as
resulting due to upper motor neuron lesions using stretching exercises. They found that
the stretching exercises and the elimination of nociceptive stimuli are the first steps in the
management of spasticity. They also did a detailed study on the other medical
spinal cord injury. He did an analysis of many techniques for modulation of spasticity
and found that the establishment of an effective daily stretching program forms the
25
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HYPOTHESIS
EXPERIMENTAL HYPOTHESIS:
NULL HYPOTHESIS:
26
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MATERIAL & METHODS
STUDY DESIGN:
with the subject being measured on dependable variables such as Stride length, Cadence
and Walking velocity before the study and after the third and sixth weeks respectively.
This study was conducted in GPRC, Bangalore; ESI, Rajajinagar, Bangalore and
Kirloskar Hospital, Bangalore during the first three months of the year 2005.
SAMPLE SELECTION:
Thirty male hemiplegic subjects aged between 40 to 60 years with a mean age of
randomly selected by way of simple random sampling and divided into two groups
mainly Group I and Group II with 15 subjects each. All these subjects participated in this
study voluntarily after signing a consent form. The demographic data was collected from
each subject; the purpose of the study was explained to all the subjects.
Inclusion criteria:
classification.
27
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Only male subjects.
Exclusion criteria:
Brunnstorm classification.
MATERIALS USED:
Treatment couch
Moist pack
Cold pack
Mackintosh sheet
Velcro Straps
Chalks
Stop watch
28
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Fig-1 Showing materials used such as moist pack, ice pack, stop watch, inch tape,
velcro straps, chalk pieces, chalk powder tray & marker pens.
Fig-2 Showing the subject receiving PNF hold-relax stretching for the plantarflexors
29
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MEASUREMENT TOOLS:
The parameters of gait 21 such as Stride length, Cadence and Walking velocity
were assessed to find out the effect of Cryotherapy over Thermotherapy with common
STRIDE LENGTH:
Stride length21 is the distance between two successive foot placements. Footwear
and a person’s height have a direct influence on stride length. This is calculated from the
start of a particular phase of gait cycle in an extremity to the same phase of the cycle of
The temporal parameters reflect the timing of events in the gait cycle and include
stance time, swing time, single support stance time, double support stance time and the
The combined temporal and spatial parameters allow the calculation of cadence
CADENCE:
21
Cadence is the number of steps in a given time i.e. steps per minute (a speed
dependent variable). In normal walking, each person adopts his own cadence and he will
change only when he changes speed. When his walking speed increases or decreases, his
30
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WALKING VELOCITY:
measured in distance travelled per time, usually meters per minute. It is important to
remember that velocity of gait will alter the dynamic joint ranges recorded.
Due to the fact that the analysis of temporal parameters requires a very observant
eye to measure it, there are chances for poor inter-rater reliability. However it can be
reliably used if video taping is available. In this study however the temporal parameters
are recorded only on researcher’s observation. The subjects were made to walk 3 times
and their best values utilized for study to bring the error margin to acceptable levels.
PROCEDURE:
Thirty male hemiplegic subjects were selected on the basis of inclusion and
exclusion criteria and were divided into two groups namely Group I and Group II
randomly. All of these subjects were assessed using a general neurological proforma
(Annexure-II) and the pre test values of the gait parameters such as stride length, cadence
by 6 seconds of proprioceptive neuromuscular hold relax stretching24 and the patient had
to be well prepared before application of cryotherapy. Before that it was essential to rule
out any contra indications for the cryotherapy procedure. The patient was positioned
31
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Following this, the ice pack wrapped in a towel fastened in position by means of
Velcro strap was applied in close approximation to the skin overlying the muscle belly of
the quadriceps1, 2 for 10 to 15 minutes. Preceding the ice pack application PNF stretching
was given. In this the patient was made to push against the palm of the therapist
maximally for 6 seconds. In this process the quadriceps muscle was made to contract
immediate relaxation during which the muscle was taken to the new lengthened position
Simultaneously the plantar flexors 8were treated with ice packs followed by PNF
stretching. Here the patient was positioned in supine with proper pillow support to ensure
relaxation. The foot was held in neutral position by proper support. Following
cryotherapy the PNF was given. Here too the patient was asked to push against the
therapist palm to his maximal capacity for 6 24seconds preceded by acquisition of the new
range (dorsi flexion) which was held for 10 seconds. The hold relax proprioceptive
neuromuscular stretching was given three times with a rest period of 20 seconds between
each stretch daily and the same was continued for a period of six weeks(six days a week).
manner as mentioned above for group I. They were also treated daily for a period of six
32
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To assess the gait parameters, the patients were asked to relax and walk from a
starting point marked on the floor after immersing the affected foot in a tray containing
chalk powder paste to gain the impressions of the foot. This procedure was repeated
twice for the reliability factor and the time was recorded in the stop watch for the number
of steps walked per minute and the stride length was measured using an inch tape21. The
formula mentioned above in the measurement tools with the values of the stride length
The gait parameters such as Cadence, Stride length and Walking Velocity11 were
assessed during the first day before treatment and at the end of third and sixth weeks
33
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Fig-3 Showing the subject measured for gait parameters
34
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DATA ANALYSIS:
In this study, independent‘t’ was used as a statistical tool for both the groups of
stretching. Descriptive statistics (mean and standard deviation) were calculated for both
the groups and for all the measurements. Then an independent‘t’ test was done to
interpret the findings. An alpha level of P<0.05 was the level of significance for the test.
ARITHMETIC MEAN:
_
X = x
N
__
where, X = Arithmetic Mean,
STANDARD DEVIATION(S.D):
________
S.D = √∑(X-X1) 2
√N
35
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ANOVA
technique that is used when multiple sample cases are involved. It is a technique that
enables us to examine the significance of the difference amongst more than two sample
means at the same time26. Here it is used to analyse the variance between the three
The basic principle of ANOVA is to test for differences among the means of the
populations by examining the amount of variation within each of these samples, relative
to the amount of variation between the samples25. It includes the following steps.
Step I :
SS between = Tc2 / n – [ x] 2 / N
T12, T22 & T32 are the square of the sum of the individual item in one sample.
[x]2 = Square of the sum of the total of the individual item in all
the samples.
36
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Step II :
SS within = x2 – Tc2 / n
Step III :
SS total = x2 – [ x] 2 / N
Correction Factor:
Step IV :
d.f. between = k – 1
d.f. within = N – k
37
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Step V :
To calculate F-ratio.
For this, Mean square (MS) between and within samples is calculated.
MS between = SS between
d.f. between
MS within = SS within
d.f. within
F-ratio = MS between
MS within
This ratio is used to judge whether the difference among several sample means is
significant or is just a matter of sampling fluctuations. For this purpose the table values of
worked out value of F, as stated above is less than the table value of F, the difference is
taken as insignificant.
In case the calculated value of F happens to be either equal or more than its table
value, the difference is considered as significant. The higher the calculated value of F is
above the table value, the more definite and sure one can be about his conclusions26.
38
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Step VI :
Total x2 – [ x] 2 / N (N – 1)
_ _
X1 – X2
t = __________________________________________________________
_________________________________________ __________
√{∑(X1)2 – [∑(X1)] 2 /n1} + {∑(X2)2 – [∑(X2)] 2 /n1} x √ 1/ n1 + 1/ n2
_________
√ n1 + n2 – 2
__ __
where, X1 , X2 = Mean of scores from I & II condition
respectively.
∑(X1)2 = Square of each individual score from
condition 1 to total.
∑(X2)2 = Square of each individual score from
condition 2 to total.
2
[∑(X1)] = Square of the sum of individual score
from condition 1.
2
[∑(X2)] = Square of the sum of individual score
from condition 2.
n1 = Number of samples in I condition.
n2 = Number of samples in II condition.
__ __
X1 = X1i – X1 X2 = X2i – X2
39
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RESULTS & INTERPRETATION
Thirty male hemiplegic subjects with a mean age of 53 (SD=2.46) years were
selected for the study. The number of subjects in each group and the mean values of age
are shown in Table-1. The Group I (Cryotherapy group) had a mean age of 53.06 years
and the Group II (Thermotherapy group) had a mean age of 52.93 years.
TABLE-1.1
Group I 15 53.06
Group II 15 52.93
40
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TABLE-1.2
Cadence 11 5.6
The above Table-2 shows the mean values of the gait parameters such as Stride
length, Cadence and Walking velocity of the Group I and Group II after the 6th week of
intervention.
41
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TABLE-1.3
The above table shows the standard deviations for the gains achieved in case of
42
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COMPARISON OF BOTH GROUPS FOR HOMOGENEITY
The homogeneity of the data in both the groups was analyzed for all the
TABLE-2.1
Total 806.400 14
INTERPRETATION:
The above Table-2.1 gives the details of ANOVA done for the homogeneity of
groups using the stride length, the calculated F-value shows significance for variance and
all the values have significance greater than 0.05 proving that the groups are
homogenous.
43
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TABLE-2.2
Total 2238.933 14
INTERPRETATION:
The above Table-2.2 gives the details of ANOVA done for the homogeneity of
groups using the Cadence, the calculated F-value shows significance for variance and all
the values have significance greater than 0.05 proving that the groups are homogenous.
44
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TABLE-2.3
Within 0.000 0 0
Groups
Total 230.299 14
INTERPRETATION:
Following this, to analyze the significance of each parameters between the two
groups, an independent‘t’ test was carried out with the values of pretest and post test.
45
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TABLE-3.1
1 28 38 10 40 44 4
2 42 50 8 35 39 4
3 35 44 9 37 40 3
4 40 49 9 49 53 4
5 25 34 9 29 33 4
6 38 48 10 40 44 4
7 37 46 9 43 47 4
8 29 36 7 34 40 6
9 46 55 9 25 30 5
10 29 41 12 28 32 4
11 30 42 12 52 58 6
12 47 59 12 38 42 4
13 42 52 10 29 35 6
14 41 51 10 32 38 6
15 49 59 10 44 50 6
Mean 9.733333 4.666667
S.D. 1.437591 1.046536
N1 15
N2 15
Factor 5.477226
Mean
Diff 5.066667
S 2.857537
‘t’ 9.7116
INTERPRETATION:
The above Table-3.1 shows the value of ‘t’ as 9.7116 for Stride Length at p<0.001, hence
46
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TABLE-3.2
1 32 45 13 56 62 6
2 64 76 12 52 59 7
3 52 60 8 50 55 5
4 60 72 12 60 65 5
5 30 41 11 38 43 5
6 48 58 10 58 63 5
7 48 59 11 60 66 6
8 34 44 10 36 42 6
9 62 73 11 30 35 5
10 34 45 11 38 45 7
11 36 46 10 68 73 5
12 60 72 12 50 56 6
13 56 66 10 36 42 6
14 56 68 12 38 43 5
15 64 76 12 62 67 5
Mean 11 5.6
S.D. 1.253566 0.736788
N1 15
N2 15
Factor 5.477226
Mean
Diff 5.4
S 2.926101
‘t’ 10.108
INTERPRETATION:
The above Table-3.2 shows the value of ‘t’ as 10.108 for Cadence at p<0.001, hence the
47
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TABLE-3.3
INTERPRETATION:
The above Table-3.2 shows the value of ‘t’ as 8.968 for Walking Velocity at p<0.001,
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GRAPH-1
The following graph (fig-4) and the table shows the representations of the mean
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DISCUSSION
In this study, totally 30 subjects were selected and assigned randomly to two
The two groups were analyzed with improved parameters of gait such as Stride
length, Cadence and Walking velocity. The mean was calculated and the statistical
analysis of the values showed considerable increase in mean improvement for the Group-
I than the Group-II which proved that the subjects who received Cryotherapy had a better
stretching thereby reducing the tone of spastic muscles such as the quadriceps and the
Thus the null hypothesis of this study can be rejected and the experimental
hypothesis stating that there is significant difference in the gait parameters in the
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To date, as per available information, this study seems to be the first objective
use of Proprioceptive neuromuscular hold relax technique. Also the study showed
thermotherapy for reducing spasticity and found cryotherapy had a superior hand in the
diminishment of the increased tone in the muscles13. Mainly the muscle group employed
for the study was Quadriceps and plantar flexors since it has been proven for increased
gamma motor neuron firing in the anti gravity muscles of the limbs during hemiplegia.
The natural study on patients did provide a proven insight into distinction of
which mode of treatment between both the groups was better and found cryotherapy
much proven for improving muscle output by reducing the abnormal tone. However,
there was a significant result when “t”test was performed to find out the effect of
Cryotherapy over Thermotherapy with common use hold relax technique was analysed in
These results strongly support the earlier findings of Harlaar J et al (2001) 8 that
the Cryotherapy reduces spasticity and studies done by Preisinger E and Quittan M
11
(1994) also supports the results of this study that there was a reduction of increased
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The study also showed that the common use of PNF hold relax stretching was
effective when given along with either thermotherapy or cryotherapy and this is
This study was done with only male subjects and all the patients found a
considerable decline in the increased tone and had a better outcome for the weight
bearing and increased cadence and stride length which ultimately increased walking
velocity.
The result of the present study indicates that effect of Cryotherapy had a proven
effect over Thermotherapy with common use of Proprioceptive neuromuscular hold relax
technique.
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LIMITATIONS
1. This study was done in hemiplegic subjects especially for the lower limbs
muscles spasticity and so the study does not validate its role in the Upper limbs
spastic muscles.
2. In this study subjects were tested only on those who presented only with extensor
type of spasticity in the lower limbs, flexor type of spasticity of lower limb were
not discussed.
3. Plantaris and its contribution as a plantar flexor are still under scrutiny.
4. As this study was done only in males, further studies should be done on females
5. This study was done only with the age group ranging from 40-60years, other age
6. Only three parameters of the gait was included in the study to assess the
improvement in the gait of the hemiplegic subjects; other parameters such as step
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SUGGESTIONS & RECOMMENDATIONS FOR FUTURE STUDIES
4. More research should be done on older ages to see how they fare by this
treatment.
5. Long term functional improvements can be measured for evolving a better insight
7. This study can be modified in future considering the functional outcome of the
hemiplegic subjects.
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CONCLUSION
This study had shown that in hemiplegic male subjects (40 to 60years) the group
15minutes,6 seconds stretch, repeated 3 times, once per day, 6 days a week for 6 weeks)
was better than with Thermotherapy along with proprioceptive neuromuscular hold relax
stretching Over the 6-week treatment, Group I showed considerable increase in all the
parameters of gait and in gaining independence and achieving weight bearing on the
The study was done on Quadriceps and Triceps surae muscles of the lower limb
and found the need of reducing spasticity in the Anti-gravity muscles to allow a proper
facilitation of a smooth and voluntary locomotion with the functional independence of the
patient.
treatment strategy to vary and to find an effective maneuver to reach the affected patients
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SUMMARY
the effect of Cryotherapy over Thermotherapy with common use of hold relax technique
use of hold relax technique and showed a sizeable decrease in the increased tone and
facilitated greater cadence and weight bearing capacity of the individual. Thereby the
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REFERENCES
4. Funk DC, Swank AM, Mikla BM, Fagan TA, Farr BK; Impact of prior exercise
on hamstring flexibility: a comparison of proprioceptive neuromuscular
facilitation and static stretching; J Strength Cond Res.; 2003 Aug; 17(3):489-92.
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7. Yigiter K, Sener G,Erbahceci F, Bayer K, Ulger OG, Akdogan S; A comparison
of traditional prosthetic training versus proprioceptive neuromuscular facilitation
resistive gait training with trans-femoral amputees; Prosthet Orthot Int;2002
Dec;26(3):213-7.
8. Harlaar J, Ten Katte JJ, Prevo Aj, Vogelaar TW, Lankhorst GJ; The effect of
cooling on muscle co-ordination in spasticity: assessment with the repetitive
movement test; Disabil Rehabil; 2001 Jul 20; 23(11): 453-61.
9. Spernoga SG, Uhl TL, Arnold BL, Gansneder BM; Duration of Maintained
Hamstring flexibility after a One-Time,Modified hold-relax stretching Protocol;J
Athl Train;2001 Mar;36(1):44-48.
14. Nanneman D; Thermal Modalities: heat and cold.A review of physiologic effects
with clinical applications; AAOHN J; 1991 Feb; 39(2):70-5.
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15. Osternig LR, Robertson R, Troxel R, Hansen P; Muscle activation during
proprioceptive neuromuscular facilitation (PNF) stretching techniques; Am J Phys
Med; 1987 Oct; 66(5): 298-307.
16. Bell KR, Lehmann JF; Effect of cooling on H- and T-reflexes in normal subjects;
Arch Phys Med Rehabil; 1987 Aug; 68(8): 490-3.
17. Deanna Fish, MS, Cheryl S, Kosta; Walking Impediments and Gait Inefficiencies
in the CVA patient;1986.
18. Helfand AE, Bruno J; Therapeutic modalities and procedures. Part I: Cold and
Heat; Clin Podiatry; 1984 Aug; 1(2):301-13.
19. DeLisa JA, Little J; Managing Spasticity;Am Fam Physician; 1982 Sept;
26(3):117-22.
20. Merrit JL; Management of spasticity in spinal cord injury; Mayo Clin Proc.; 1981
Oct; 56(10): 614-22.
22. John Low and Ann Reed; Electrotherapy Explained-Principles and Practise;
Butterworth-Heinemann publishing limited; 2nd Edition, 1994:197 & 233
23. Sheila kitchen and Sarah Bazin; Claytons Electrotherapy; W.B.Saunders company
limited; 10th Edition, 1996:129
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25. Carolyn M.Hicks; Research For Physiotherapists; Project Design and Analysis;
Churchill Livingstone; 2nd Edition;171-174.
27. Anne M.R.Agur & Ming J.Lee; Grant’s Atlas of Anatomy; Lippincott Williams &
Wilkins; 10th Edition;318-322.
28. Niegel Palastanga; Derek Field; Roger Soames; Anatomy & Human Movement-
Structure and function; Butterworth Heinemann Publications; 4th Edition;2002:
266-69.
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34. Knutsson E etal; Different types of distributed motor control in gait of
hemiplegic patients; Brain; 1979. 102:403.
35. Murray MP et al; Comparison of free and fast speed walking patterns in normal
men. Am J Phys Med; 1966; 45:8.
36. Carolyn Kisner, Lynn Allen Colby; Therapeutic exercise foundation and
techniques; Jaypee Brothers, 4 th edition, 2003, 171-216.
37. B.D. Chaurasia’s; Human anatomy Regional and applied; CBS Publishers &
distributers; 3 th edition, 2003, 96
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ANNEXURE-1
ASSESSMENT FORMAT
Demographic Data
Name:
Age:
Sex:
Occupation:
Address:
History
Duration of stroke :
Side of involvement :
Type of stroke :
Territory of involvement :
Personal history :
Socioeconomic history :
On observation
General condition :
Attitude of limbs-Lower limb :
Wasting if any :
On palpation
Tenderness :
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On examination
Level of consciousness :
Cranial Nerve examination :
Higher Mental functions :
Appearance -
Behavior -
Intelligence -
Judgment -
Memory -
Orientation -
Speech and language -
Perception -
Sensory Examination
Motor Examination
Tightness :
Contracture :
Deformity :
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Reflexes
Knee jerk :
Ankle jerk :
MMT
Gait Assessment :
Hand function
Grip and grasp
Release
ADL :
Eating -
Grooming -
Toileting -
Bathing -
Bed mobility -
Ambulation -
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ANNEXURE-2
CONSENT FORM
Place: Signature
Date: (Name)
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ANNEXURE-3
BRUNNSTORM STAGES
begin with a period of flaccidity immediately following the acute episode. No movement
STAGE 2: As recovery begins, the basic limb synergies or some of their components
STAGE 3: Thereafter, the patient gains voluntary control of the movement synergies,
although full range of all synergy components does not necessarily develop. Spasticity
STAGE 4: Some movement combinations that do not follow the paths of either synergy
are mastered, first with difficulty, then with ease and spasticity begins to decline.
the basic limb synergies lose their dominance over the motor acts.
STAGE 6: With the disappearance of the spasticity, individual joint movements become
possible and coordination approaches normal. From here on as the last recovery step,
normal motor function is restored, but this last stage is not achieved by all, for the
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ANNEXURE-4
MASTER CHART
MASTER CHART OF GROUP I TREATED BY CRYOTHERAPY WITH
PNF HOLD RELAX STRETCHING
Patient Age Stride Length in cms Cadence in steps/minute Walking Velocity in m/min
No. Pretest 3rd Wk 6th Wk Pretest 3rd Wk 6th Wk Pretest 3rd Wk 6th Wk
1 58 28 33 38 32 40 45 4.48 6.6 8.55
2 47 42 46 50 64 69 76 13.44 15.87 19
3 45 35 39 44 52 56 60 9.1 10.92 13.2
4 54 40 45 49 60 65 72 12 14.625 17.64
5 56 25 29 34 30 35 41 3.75 5.075 6.97
6 60 38 42 48 48 52 58 9.12 10.92 13.92
7 52 37 40 46 48 53 59 8.88 10.6 13.57
8 49 29 31 36 34 37 44 4.93 5.735 7.92
9 59 46 49 55 62 66 73 14.26 16.17 20.075
10 48 29 35 41 34 39 45 4.93 6.825 9.225
11 51 30 36 42 36 39 46 5.4 7.02 9.66
12 55 47 53 59 60 65 72 14.1 17.225 21.24
13 60 42 46 52 56 60 66 11.76 13.8 17.16
14 56 41 46 51 56 62 68 11.48 14.26 17.34
15 46 49 53 59 64 70 76 15.68 18.55 22.42
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LIST OF TABLES
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LIST OF FIGURES
1 Materials Used 19
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LIST OF ABBREVATIONS USED
EMG Electromyography
et al and others
SD Standard Deviation
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