Comparison Between the Effect of Craniocervical Flexion in Two Position on Disabilty &

COMPARISON BETWEEN THE EFFECT OF CRANIOCERVICAL FLEXION IN TWO POSITION ON DISABILTY & FORWARD HEAD POSTURE IN SUBJECTS WITH MECHANICAL NECK PAIN

A Protocol submitted to HOSMAT HOSPITAL EDUCATIONAL INSTITUTE Bangalore

DISSERTATION RESEARCH PROJECT

By HOMA KHANAM M.P.T. 1st year M.P.T (Musculoskeletal and sports)

Guide: Dr. R. Dev Anand (PT)

1 RESEARCH APPROVAL

COMPARISON BETWEEN THE EFFECT OF CRANIOCERVICAL FLEXION IN TWO POSITION ON DISABILTY & FORWARD HEAD POSTURE IN SUBJECTS WITH MECHANICAL NECK PAIN

Research proposal approved by Institutional ethics Committee On 19/11/2010

INSTITUTIONAL ETHICS COMMITTEE HOSMAT HOSPITAL EDUCATIONAL INSTITUTE BANGALORE -25.

2 CONTENTS

Page No. 1 INTRODUCTION 04 1.1 Background of the study 04 1.2 Statement of the problem 05 1.3 Objective of the study 05 1.4 Aim of the study 05 1.5 Hypothesis 05 1.6 Null Hypothesis 06

1.7 Operational Definition 06 1.8 Clinical significance 06 2 REVIEW OF LITERATURE 07 3 METHODOLOGY 09 3.1 Study Design 09 3.2 Study Setting 09 3.3 Inclusion Criteria 09 3.4 Exclusion Criteria 09 3.5 Materials 09 3.6 Sampling 10 3.7 Sample size 10 3.8 Procedure 10 3.9 Outcome measures 15 3.10 Data analysis 15 4 REFERENCES 16 5 APPENDIX Appendix I 20

Appendix II 21 Appendix III 23

3 Appendix IV 24

INTRODUCTION

1.1 Background of the study

Neck pain is a common complaint in general population. Among diverse neck pain ,mechanical neck pain is the most common type with pain confined in the area on posterior aspect of neck, that can be exacerbated by neck movement or sustained posture.1Along with considerable cost for individual and society neck pain is a frequent source of disability causing human suffering and affecting well being of individual.2

In an upright neutral posture of cervical spine, passive resistance to motion is minimal. Support of the cervical segments is provided by the muscular sleeve formed by the longus colli muscle anteriorly and the semispinalis cervicis & cervical multifidus muscle posteriorly. The importance of deep muscles for the maintenance of cervical posture is known, and region of local segmental instability results, if only the large superficial muscles of the neck (sternocleidomastoid & anterior scalene) are stimulated to produce movement. Deep cervical muscle activity is needed in synergy with superficial muscle activity to stabilize the cervical segments, especially in the functional mid range of cervical spine. 3

Cervical muscle impairment has been found in up to 70 percent of subject with neck pain. The cervical impairment which are commonly noted are cervical pain, loss of ROM, decreased strength &endurance and forward head posture.4.There is a growing evidence that subjects with neck pain have weakness or motor difficulty in facilitating the deep neck flexor (DNF).4The location of deep neck flexor (longus colli & longus capitis) suggest that they play an important role in stabilising cervical spine (Mayoux &Benhamour) in all position without being influenced by gravity.4

It is theorised that when muscle performance is impaired, the balance between the stabilisers on the posterior aspect of neck and deep neck flexor is disrupted, resulting in loss of proper alignment of head & neck posture. In the presence of neck pain, weakness has been identified in deep neck flexor muscles and subjects shows increased activity in their superficial flexor muscle, presumably as a compensation strategy. 5A poor forward head posture may occur as a result of loss of endurance of deep neck flexors.5

Many conservative treatment options are available for subjects with mechanical neck pain and they are widely accepted as a standard form of practice. Various treatment options available are exercises, manipulation, mobilisation, heat & cold therapy, IFT, TENS, US, pulsed electromagnetic therapy etc. 6

In current scenario, exercise which is most commonly prescribed is self resisted isometrics to neck muscles. According to Jayanth joshi &John Ebenezer, strong isometrics are indicated when mobility is contraindicated but strength, endurance & tone of muscles are

4 to be maintained. Self resisted isometrics are given for flexors, extensors, lateral flexors and rotators as a common practice. 7

O’ Leary et al ,(2007) stated that, coordination between superficial and deep flexors is considered safe progression of exercises in patient with mechanical neck pain.8.It is well known that sternocleidomastoid and anterior scalene together provide 83% of cervical flexion capacity.8If coordination between superficial & deep flexor is not corrected in the first instance, the overwork of superficial flexor might mask or substitute for any impaired performance of deep neck flexor in any premature progression to higher load exercises.

Jull et al showed improved deep neck flexor muscle activation following cranio cervical flexion. 9

1.2 Statement of problem:

 The practice of achieving coordination between superficial & deep neck flexor & extensors are usually overlooked.

 Clinician considered that self resisted isometric exercises for subjects with mechanical neck pain are worthwhile. But evidence for much standard treatment approach to neck pain is lacking.10

1.3 Objective of the study

 To find the improvement in pain, disability, forward head posture and endurance with isometric neck exercise in subject with non- specific neck pain.

 To find the improvement in pain disability, forward head posture and endurance with supine CCF using pressure bio-feedback in subject with non- specific neck pain.

 To find the improvement in pain disability, forward head posture and endurance with CCF in sphinx position

1.4 Aim of the study

The aim of this study is to compare the efficacy of craniocervical flexion exercises in supine & sphinx position( prone on elbow) against self resisted isometric training to neck musculature on pain, disability& forward head posture in subjects with non specific mechanical neck pain.

1.5 Hypothesis

5  Cranio cervical flexion in sphinx position(prone on elbow) is more effective than cranio cervical flexion in supine & self resisted isometric neck strength training on pain, disability & forward head posture in subjects with non specific mechanical neck pain.

 Craniocervical flexion in supine is more effective than craniocervical flexion in sphinx position( prone on elbow) & self resisted isometric neck strength training on pain, disability & forward head posture in subjects with non specific mechanical neck pain.

1.6 Null hypothesis

There is no significant difference between craniocervical flexion training in supine lying or in sphinx position( prone on elbow) & self resisted isometric neck strength training on pain disability & forward head cervical posture in subjects with non specific mechanical neck pain.

1.7 Operational definition

Mechanical neck pain is the general term that refers to any type of pain caused by placing abnormal stress & strain on muscles of cervical spine, in which movement of neck is restricted & moving the neck may make pain worse but taking rest will alleviate the pain.

1.8 Clinical significance

 The knowledge of efficacy & effectiveness of craniocervical flexion exercise in supine or in sphinx position (prone on elbow) over self resisted isometric to neck probably would be helpful in reducing the pain, disability, and forward head posture in subjects with mechanical neck pain

 CCF can be advised in various positions & can be incorporated as an additional exercise in the usual protocol for rehabilitation of mechanical neck pain.

6 Review of Literatures

Mechanical neck pain

 Ana Claudia et al, 2008, in their study reported, that mechanical neck pain has no detectable aetiology; it may be reproduced by provocating stimuli (stress).11

 In a study by Fabriana et al, 2008,stated that, mechanical stability is provided by surrounding musculature, and altered patterns of neck flexor synergy are known to be presented in individual with neck pain.18

 Jull et al, 2002, in their study quoted that, in the presence of neck pain, weakness has been identified in the deep neck flexor muscles & patient shows increased activity in the superficial flexors as a compensatory strategy.9

Cranio cervical flexion exercises

 Jull & Falla et al, 2002, concluded in their study that activation of deep neck flexor is increased at each stage of cranio cervical flexion & activity of sternocliedomastoid and anterior scalene reduced after training cranio cervical flexion.9

 In a study by O’Leary et al, 2007,stated that, coordination between the deep & superficial flexor is necessary for safe progression of exercises in subjects with neck pain.8

 Jull & Mehwa Kim et al 2007, in their study compared the cranio cervical flexion exercise & conventional exercise of cervical flexion in patients with neck pain on isometric neck muscle strength &found no differences between the two exercises.15

 Barbara Cagnie et al, 2008, in their study quoted that; MRI has demonstrated the CCF muscle contraction method elicits activation of deep cervical flexors longus colli & longus capitis. 12

 Jull G Trott et al 2008, in their study quoted that ,to train coordination of the deep & superficial extensors , craniocervical flexion can be performed with the patient in 4 point kneeling. 14

Self resisted isometric to neck muscles

7  Petri K Salo & Jari et al 2010,showed no statistical significant difference was observed between strength & endurance training group.2

 A rezasolthani et al 2010 in their study proved that traditional isometric strength training is found to be less effective than neuromuscular facilitation exercises.25

Analysis of neck posture

 Dennis et al 2000, in his study had done analysis of head & neck posture using camera & computer, measured normal head & neck angle as 43.7 degree, with a standard starting reference point.16

Neck Disability Index

-VernonH, Mior S et al, 1991, NDI was used to measure subjects perceived level of disability due to their neck pain.27 -The Neck Disability: the reliability and validity is proved with test retest=0.89 & ICC =0.68.26

METHODOLOGY 3.1 Study design

Intervention study

8 3.2 Study setting

Department of physiotherapy, HOSMAT HOSPITAL, Bangalore

3.3 Inclusion criteria

 Subjects with mechanical neck pain.

 Pain level of mild to moderate; VAS < or = 6

 Age 20 to 50 years.

 Inability to perform ADL without pain

3.4 Exclusion criteria

 Non musculoskeletal pain.

 Signs of neurological involvement

 Cervical disc prolapsed

 Spinal stenosis

 Previous neck surgery

 History of cervical trauma

 cHistory of whiplash disorder

 Spasmodic torticollis

 Frequent migraine

 Peripheral nerve entrapment

 Fibromyalgia

 Uncooperative patient

 Carcinoma

 Cervical radiculopathy

9 3.5 Materials:

 Digital camera

 Plumb line

 Pressure biofeedback device(Chattanooga group)

 NDI (Neck disability index)

 VAS (Visual analogue scale)

 MB ruler , a computer software

3.6 Sampling: Purposive sampling.

3.7 Sample size: 60(group A 20, group B 20, and group C 20)

The population would be all the subjects reporting to HOSMAT HOSPITAL, with complain of neck pain. The subjects with a history of neck pain reporting to department will be scrutinized for inclusion & exclusion criteria and only interested subjects will participate in the study sample.

3.8 Procedure:

Interested subjects shall be informed about aims & procedure of the study. They shall sign the written consent, to be considered a study subject. A general physiotherapy assessment shall be taken and the base line data shall be collected on the reporting date.

The subject shall be assigned into three groups by concealed allocation. Subject number and group name shall be typed on paper and a researcher (batch mate) who is not involved in the study will randomise the slips and put them in sealed cover. The subject shall undergo intervention in one of the three groups for 6 sessions within 1 week duration. After 6th session of intervention post treatment data will be collected.

Procedure to measure pain intensity (13)

Pain intensity will be evaluated by means of a visual analogue scale (VAS), ranging from 0 cm to 10 cm, wherein the subjects will mark a point according to their pain level, a higher pain score correspond to more intense pain. Resting pain and pain level after aggravating activity shall be taken for pre & post comparison.

10 Procedure to measure disability of subject (26)

NDI will be used to obtain the subject`s perceived level of disability due to their neck pain. Subject will be instructed to mark their level of disability on NDI .Any queries shall be answered to enable the subject to mark the components appropriately.

Procedure of measuring forward head posture

Subjects will be positioned in sitting with their knees in 90deg of flexion and their feet flat on the ground. A plumb line will be positioned in the background. The starting position will be standardised by placing the subject in an upright position that is a vertical pelvic position. A digital camera will be mounted on a stand and placed laterally one meter away from the subject. Bright colour markers will be placed on the C7 spinous process and over the tragus of ear. The resting forward head posture will be the outcome measure. The subject may change the resting forward head posture if he is conscious. To avoid this, the subject will be instructed to perform flexion & extension of neck 10 times. After which a lateral photograph will be taken, to avoid experimental bias. The same procedure shall be repeated for 5 trials with rest intervals of 15 seconds between each trial. The average of forward head posture will be considered for data analysis. The researcher shall analyse the lateral photograph, using computer software MB Ruler27 (Fig. 1) will be used to measure the degree of forward head posture.

Fig 1: analysis of forward head posture

The base of triangle of MB Ruler is adjusted on computer screen to overlap the plumb line. The vertical line is adjusted horizontally at the level of C7 spine. And the mobile angle (red line) is aligned to the line connecting C7 spinous process and tragus of ear. The angle shown as α in the MB Ruler program shall be considered for data recording.

Procedure to measure deep neck flexor endurance:(9)

11 The Cranio Cervical Flexion (CCF) test consists of five incremental movement of cranio cervical flexion,& the performance will be guided by visual feedback from an air filled pressure sensor (Chattanooga Group Inc, MA 01760-2098).The subject shall be positioned in supine crook lying with the neck in neutral position( no pillow).

The uninflated pressure sensor shall be placed behind the neck so that it abuts the occiput & it will be inflated to a stable baseline pressure of 20mm of hg, a standard pressure sufficient to fill the space between the testing surface & the neck but not put neck into lordosis. The subject will be instructed to put the tip of tongue over upper palate & nod the head into flexion (as in saying YES). The subject is instructed to raise the level of pressure in pressure biofeedback (PBFB) device from 20 mm Hg to 22 mm Hg and hold for a minimum of 10 seconds. One familiarization phase will be included. The trail is considered positive only if the subject is able to hold the target pressure without activating superficial neck muscles and able to sustain without fluctuations. If the subject is able to hold for 10 seconds, the subject shall be instructed to perform the same procedure and hold at 24mmHg for 10 seconds. In similar way increments of 2 mmHg will be added. If the subject meets the target pressure level and holds for 10 seconds, a rest interval of 30 seconds is given before proceeding to next level. The time of isometric hold on neck muscle will be calculated by summation of time periods held at various levels.

Description of intervention:

Each of the three training group will have 20 subjects. In each group, treatment regimens shall be for 6 sessions per week for 1 week duration, lasting approx 45 minute per session.

GROUP A: ISOMETRIC NECK GROUP

In this group, the subject shall be instructed to isometric contraction for neck flexors, extensors, and side flexors. The subject will be instructed to use both hands to press the forehead (backward force) and the subject should resist the force actively by not letting go the flexor contraction. Similarly, hands are placed over back of head and over temples to resist IM contractions of neck extensors and lateral flexors respectively. The instructions to the subject would be “Attempt to push your head backward but do not let your head move” and “Attempt to push your head sideways but do not let your head move” respectively.

 Repetition: 10 times for flexion, extension, side flexion to left & right, rotations to both the side.

 Hold time: 10 seconds

 Rest interval: 1 minute between each movement.

 subject will be instructed to inform any inconvenience felt during the exercise

 Patient will be instructed to continue the same as home exercise thrice a day.

12 GROUP B: DNF GROUP

The DNF endurance training will be given by, subject in supine crook lying with neck in neutral. The subject will be instructed to put the tip of tongue over the upper palate and nod the head in to flexion ( as in saying yes).the performance will be guided by feedback from an air filled pressure sensor placed behind the neck , to monitor subtle flattening of the cervical lordosis, which occurs with the contraction of longus colli.. The subject is instructed to raise the level of pressure in pressure biofeedback (PBFB) device from 20 mm Hg to 22 mm Hg and hold for 5 seconds. The subject is facilitated to hold the target pressure without activating superficial neck muscles and without fluctuations. IM hold is performed for 5 seconds x 10 repetitions, with rest intervals of 10 seconds between repetitions. Similarly 3 sets are given with gradual progression. If the subject is able to hold for 10 seconds with each of 10 repetitions, the target pressure is incremented by 2 mmHg. Patients will attempt to target progressive 2mm of Hg pressure increments from a base line of 20mm of Hg to the final target of 30mm Hg.

 5 sec hold 10 sec rest – 10 repetitions will be done

 3 sets.

 Rest interval: 1 minute between each difficulty level

 10 sec hold 20 sec rest – 10 repetitions

 3 sets

 Subject will be taken to next target level

 Note:

 Subject will be instructed to report, any inconvenience felt during the exercise session.

 The new target level will be incremented on every successive day.

The therapist will provide feedback about superficial neck muscle usage and correct the pattern of movement.

GROUP C: CCF IN PRONE ON ELBOW

In the 3rd group, craniocervical flexion training will be given. The subject shall be trained to perform ‘chin tucks’ in supine lying position as a part of familiarization of procedure. As the experimental treatment, the subject shall be positioned in sphinx position (prone on

13 elbow) with shoulder protracted & neck in neutral. A command “Tuck in your chin and hold” will be given to them by the researcher. This position shall be maintained for 10 seconds.

 10 second hold x 10 repetition x 3 set (per session)

 Rest interval of 1 minute between each series.

Note: subject will be instructed to report any inconvenience felt during exercise session.

Flow chart depicting procedure:

Screening for inclusion

& exclusion criteria

Baseline outcome

Collected

14 6 sessions 6 sessions 6sessions

3.9 outcome measure:

 Pain intensity using VAS

 Disability of patient using NDI

 Forward head posture. (in degrees)

 Endurance of deep neck flexor (Time period – seconds)

3.10 Data analysis:

After the intervention, difference (difference between pre & post measurement of data) in NDI, forward head posture, VAS, Time score in CCFT Test within the groups will be compared using Wilcoxon Sign Rank Test and between the group will be compared using Kruskal Wallis Test. And to find out the group having most significant improvement, between the group Kruskal wallis Test will be used. The mean difference & their 95% CI will be calculated.

15 REFERENCES

1. Rotasalai Kanlaynaphotpornl, Adit Chiradenant, Roongtiwa Vachalathiti. The immediate effects of mobilisation technique on pain and range of motion in patient presenting with unilateral neck pain: A RCT.Arch Phys Med Rehabil 2009;90:187- 92.

2. Petri K Salo, Arja H. Hakkinen, Hannu Kautiainen & Jari Ylinen. Effect of neck strength training on health – related quality of life in females with chronic neck pain.a RCT 1 year follow up, health & quality of life outcome 2010, 8:48.

3. Deborah Falla, G. Jull, Paul Dall`Alba, Alberto Rainoldi, Roberto Merletti. An electromyographic analysis of the deep cervical flexor muscle in performance of cranio cervical flexion. physical therapy 2003; 83(10):899-06.

4. Kevin a Harris, Darren M Heer, Tanja C Roy, Diane M Santos, Julie M Whitman. Reliability of a measurement of neck flexor muscle endurance. physical therapy. 2005; 85(12):1349-55.

16 5. Deborah Falla, Gwendolyn Jull, Trevor Russel, Bill Vicenzino, Paul Hodges. Effect of Neck Exercise on Sitting Posture in Patients with Chronic neck pain. Physical therapy.2007; 87(4):408-17.

6. Peter D Aker, Anita R Gross, Charles H Goldsmith, Paul Peloso. Conservative management of mechanical neck pain: systematic overview & Meta analysis. BMJ. 1996; 313:1291-6.

7. Professor Valerio Sansone, university department of orthopaeic & traumatology galleazzi orthopaedic institute. Exercises for neck pain.URL www.Valeriosansone.com/upload/datasheet/pdf/neck -pain-exs.pdf

8. Jull, D.Falla, B. Vicenzino, P.W. Hodge. .Effect of therapeutic exercise on activation of deep cervical flexor muscle in people with chronic neck pain. Manual therapy 2009; 14:696-01. 9. Jull G, Trott P, Potter H.A RCT of exercise & manipulative therapy for cervicogenic headache. Spine 2002, 27; 1835-45.

10. Jari linen, Esa Pekka Takala, Matti Nykanen. Active neck muscle training in the treatment of chronic neck pain in women. A RCT. JAMA, 2003, 289(19), 2509-16.

11. Ana Claudia, Violino Cunha, Thomaz Nogueira Burke, Fabio Jorge Renovato Franca, Amelia Pasqual Marques. Effect of global posture re education & of static stretching on pain, range of motion & quality of life in women with chronic neck pain.A RCT. Clinics 2008; 63(6) 763-70.

12. Barbara Cagnie,Nele Dickx, Ian Peeters, Jan Tuytens,Eric Achten, Dirk Cambier& Lieven Danneels. The use of functional MRI to evaluate cervical flexor activity during different cervical flexion exercises. J Appl Physiol, 2008; 104:230-35.

17 13. Shaun O` Leary, Deborah Falla, Paul W. Hodge, Gwendolyn Jull, Bill Vicenzino. A specific therapeutic exercise of the neck induces immediate local hypoalgesias. The journal of pain.2007; 8(11):832-39.

14. G. Jull, Shaun P O`Leary, Deborah L. Falla. Clinical assessment of the deep cervical flexor muscles: the cranio cervical flexion test. Journal of manipulative & physiological therapeutics .2008;31(7):525-33

15. Mehwa Kim, Shaun O`Leary, Gwendolyn Jull, Bill Vicenzino. Specificity in retraining cranio cervical flexor muscle performance.JOSPT.2007; 37(1):3-9.

16. Dennis R Ankrums, Kristie J. Nemeth. Head and neck posture at computer workstations- what`s neutral. 14th triennial congress of the international ergonomic association.2000; 5:565-68.

17. Jennifer Lyn Keating, Peter Kent, Megan Davidson, Ross Duke. Predicting short term response and non response to neck strengthening exercises for chronic neck pain. Journals of whiplash & related disorder.2005; 4:44-55.

18. Fabianna M. R. Jesus, Paulo H. Ferrira, Manuela L. Ferreira. Ultrasonographicss measurement of neck muscle recruitment: A preliminary investigation. The journal of manual & manipulative therapy.2008; 16(2):89-92.

19. Shaun P O`Leary, Bill T Vicenzino, G.Jull. A new method of isometric dynamometry for the craniocervical flexor muscles. Physical therapy.2005; 85(6):556-64.

18 20. Chantal HP de Koning,Sylvia P van den Heuvel, J Bart Stall .Clinometric evaluation of methods to measure muscle functioning in patients with non – specific neck pain: a system: a systematic review. BMC musculoskeletal.2008; 9:1471-2474.

21. Jari Y linen, Riku Nikander, Matti Nykanen, Hannu Kautiainen. Effect of neck exercises on cervicogenic headache: A RCT. J rehab Med 2010; 42: 344-49.

22. Ian A. Young, Lori A. Michener, Joshua A Cleland, Arnold J. Aguilera. Manual therapy, exercises, & traction for patient with cervical radiculopathy. Physical therapy.2009; 89(7):632-42.

23. Nicole H. Raney, Evan J. Peterson, Tracy A Smith et al, development of a clinical prediction rule to identify patient with neck pain likely to benefit from cervical traction & exercises.Eur Spine J.2009;18:382-91.

24. A.Rezasoltani, M. Khaleghifar, A. Ahmadi, H. Minoonejad. The effect of a proprioceptive neuromuscular facilitation program to increase neck muscle strength in patient with chronic non- specific neck pain. World J. Sport Sci.2010; 3(1):59-63.

25. David J.Magee, Orthopaedic physical assessment. 4th Ed.Elsevier:p.145-46.

26. , Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther.1991; 14(7):409-15.

27. MB Ruler software available from URL:http://download.cnet.com/MB-Ruler/3000- 2056-4-10304244.html

APPENDIX – I

HOSMAT College of Physiotherapy

Rajiv Gandhi University

Consent Form

I ______agree to take part in the research study conducted by HOMA KHANAM, Postgraduate student (M.P.T. Musculoskeletal & Sports), HOSMAT College of Physiotherapy, Rajiv Gandhi University, entitled “Comparison between the effect of craniocervical flexion in two position on disability and forward head posture in subjects with mechanical neck pain .”

I acknowledge that the research study has been explained to me and I understand that agreeing to participate in the research means that I am willing to

 Provide information about my health status to the researcher

 Allow the researcher to have access to my medical records, pertaining to purpose of the study

 Participate in evaluator program

 Make myself available for further follow up

I have been informed about the purpose; procedures, measurements and risks involved in the research and my queries towards the research have been clarified.

I provide consent to the researcher to use the information, video or audio recordings, for research and educational purpose only.

20 I understand that my participation is voluntary and can withdraw at any stage of the research project.

I understand that no monitory benefit will be given for participation in this research study.

Name of the applicant –

Signature Date

Signature of the researcher:

APPENDIX II

Assessment Form:

Name: age/ sex:

Occupation: patient number:

Hospital number:

Research study number:

Group(A/B/C/):

Chief complaint:

History:

Symptom characteristics: type of pain

Severity of pain

21 Area of pain

Irritability

Aggravating factor

Relieving factor

Scanning examination:

Foraminal compression test

Distraction test

Repeated movement testing

Cervical quadrant test

Outcomes:

Outcomes & Pre intervention Post intervention Difference Total score

VAS(10)

NDI(50)

FHP(in degree)

CCFT(in sec)

Appendix III

Appendix IV