Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
DISSERTATION SYNOPSIS SUBMITTED TO RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE TOWARD PARTIAL FULFILMENT OF MASTER OF PHYSIOTHERAPY DEGREE COURSE By CRISSY D’ ALMEIDA UNDER THE GUIDANCE OF B A BOOMADEVI VIKAS COLLEGE OF PHYSIOTHERAPY MARYHILL, KONCHADY, MANGALORE-575006 2009-11 RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE REGISTRATION OF SUBJECTS FOR DISSERTATION 1. Name of the Candidate and Address CRISSY D’ALMEIDA VIKAS COLLEGE OF PHYSIOTHERAPY AIRPORT ROAD MARYHILL, KONCHADY MANGALORE – 575008 2. Name of the Institution VIKAS COLLEGE OF PHYSIOTHERAPY Mangalore. 3. Course of study and subject Master of Physiotherapy (MPT) Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy 4. Date of admission to Course 19-06-2009 5. Title of the Topic THE EFFECTS OF TRANVERSUS ABDOMINIS, GLUTEUS AND BICEPS FEMORIS MUSCLE STRENGTHENING IN GOLFERS WITH SACROILIAC DYSFUNCTION 6. BRIEF RESUME OF THE INTENDED WORK 6.1 Need for the study Sacroiliac pain is a specific form of low back pain reported in approximately 40 percent patients which can occur separately or in conjunction with low back pain, lumbar disc herniation and lumbar facet syndrome. This occurs because the low back and pelvis rely on many common structures to ensure normal stability and function. Hence functionally the pelvis cannot be studied in isolation. Diagnosis of sacroiliac pain is difficult because the presenting complaints are similar to those of other causes of back pain. The typical anatomy of the sacroiliac joint which is characterized by a coarse cartilage texture, cartilage covered grooves and ridges, a wedge like shape of the sacrum and a propeller like shape of the joint surface leads to the highest coefficient of friction of diarthrodial human joints. This friction can be altered according to the loading situation and serves to stabilize the pelvic girdle. The main movements are forward rotation of the sacrum relative to the iliac bones and backward rotation of the sacrum relative to the ilia. Nutation of the sacrum (flexion of the sacrum relative to the ilia) is generally the result of load bearing and a functional adaptation to stabilize the pelvic girdle. More research is needed in patients with sacroiliac pain to verify whether counter nutation of the sacroiliac joint (anterior rotation of the ilia relative to the sacrum) in load bearing situation is a typical sign of non optimal stability of the pelvic girdle. One study on the relationship between lumbar curve, pelvic tilts, and joint mobility reported a high correlation between the angle of lumbar lordosis and pelvic tilt. Subjects who have reported low back pain have also shown an increase in lumbar lordosis.5 A study by Simpson examined subjects with and without low back pain and found that there is a significant difference in lumbar lordosis between the two groups, thus implying that pelvic positioning plays a role in low back pain. 6 We can conclude that the positioning of the pelvis is correlated with back pain. Pelvic tilt and lumbar stabilization exercises are frequently prescribed to patients to relieve low back pain.7 Focusing attention on abdominal muscles may not be the most efficient or effective way in training patients to normalize lumbopelvic alignment. Studies measuring the relationship between pelvic tilt and abdominal muscle performance have shown that there is no correlation between the two. This study hypothesizes that there are other muscles that are attached to the pelvis that affect the motion, stability, and position of the pelvis, or that neuromotor patterns determine posture. Multiple studies have examined the benefits of exercise in treating patients with low back pain; however, there have been very few published reports describing specific program designs as it relates to golfers. Golf injuries to the low back are the most common problems in both the professional and amateur player. It is the poor technique and the repetition of hitting balls that usually leads to an injury. Combine that with the typical sedentary lifestyle (in which people drive to/from work in a seated position and work in a seated position for most of the day) and we begin to understand why there is such a high incidence of back pain among golfers. A back injury results from excessive stress placed on the spine, usually when the body does not perform the correct sequence during the golf swing. Here is an astonishing fact: Eight times your body weight is forced through your spine as you make contact with the ball. So if you have poor mechanics combined with a weak back you are more likely to cause yourself a significant amount of injury. The golf swing is considered a very unnatural movement for most people, especially for people with a sedentary lifestyle. As with most sports, golf is a sport that requires a lot of rotary movement. When we sit for the most part of the day, certain muscles get used to that position and become “tight”, while other muscles get “stretched out”. This leads to significant muscle imbalances that then put unnecessary stress on the back. In all likelihood, their golf muscles have “shut down” due to sitting for long periods. Effectively, the muscles that absorb force and reduce load in a golf swing (that is, the lower and deep abdominals) are relatively weak and aren't able to work together. And if your hips and shoulders are tight, there is a greater chance of moving incorrectly. In an idealized pelvic alignment the anterior superior iliac spines (ASIS) are in a horizontal plane with the posterior superior iliac spines (PSIS) and on a vertical plane with the pubic symphysis. The most common deviation seen in golfers is excessive anterior tilt of the pelvis (PSIS significantly higher than the ASIS). A study by Levine and whittle showed that excessive anterior tilt caused increased lumbar lordosis. The common short/tight muscles in this mal-alignment are psoas major, quadratus lumborum and hip adductors. The common long/inhibited muscles are gluteus maximus, hamstrings, tranversus andominus and internal obliques. There has been research regarding the pelvis and its relationship to the lumbar spine. An excessive anterior tilt of the pelvis causes compression of the posterior vertebral bodies, which increases the posterior interdiscal pressure; especially at L5-S1. It also creates shearing forces at L5-S1 and a likelihood of forward slippage of L5 on S1. When the pelvis tilts forward, the lumbar vertebrae are displaced anteriorly, thereby increasing lumbar lordosis. Increases in the compressive forces of the posterior annuli and the tensile forces on the anterior annuli in the lumbar spine adversely affect the diffusion of nutrients to the posterior portion of the lumbar intervertebral disks and excessive compression may be applied to the zygapophyseal joints. To compensate for the increased anterior lumbar convexity, there is an increase in thoracic kyphosie and an anterior convexity of the cervical spine to bring the head over the sacrum. Research has shown that the pelvis can play a role in low back pain due to its influence on the lumbar spinal curvature. The position of the pelvis has also been shown to play a role in sacroiliac pain. Since the hamstrings attach to the ischial tuberosities, they play an important role in extrinsic pelvic stability and the lumbopelvic rhythm. The hamstrings can also play an important role in stability of the sacroiliac joint due to the common attachment sites of both the hamstrings and the sacrotuberous ligament on the ischial tuberosities. The long head of the biceps femoris frequently attaches to the sacrotuberous ligament through a tendon. Force of the biceps femoris can be transferred to the sacrotuberpus ligament. Since increased tension of the sacrotuberous ligament decreases sacroiliac joint range of motion, contraction of the biceps femoris can play a role in stabilization of the sacroiliacjoint. Specific spinal exercises were developed to target the local muscles of the lumbar–pelvic region. The local muscle system includes deep muscles such as the transverses abdominis and the lumbar multifidus that are attached to the lumbar vertebrae and sacrum and are capable of directly controlling the lumbar segments. By contrast, the global muscle system encompasses the larger and more superficial muscles of the trunk that are more concernedwith producing and controlling trunk movements (e.g., the external oblique and erector spinae muscles). Whereas conventional exercises generally work to increase the strength of the global muscles, the specific exercise approach aims to improve the dynamic stability role of the local muscles in providing stiffness to the segments of the spine and pelvis during functional postures and movements. The concept that has become the basis of the specific exercise treatment techniques is the ability to cocontract the transversus abdominis and the lumbar multifidus independently of the other larger trunk muscles. This exercise is based on evidence of the stability roles of the muscles as well as on evidence that the transverses abdominis functions independently of the other global abdominal muscles. The active co-contraction of these muscles is completed at a very low level of muscle activity and has been variously described as forming a deep muscle corset or performing self bracing. Progression of treatment has consisted, in principle, of increasing the patient’s efficiency at performing this independent deep corset action while at the same time minimizing the contribution of the global trunk muscles. These new specific spinal exercises have already been shown to be effective for patients with acute idiopathic LBP. The influence of this exercise approach on muscle size and function as well as on recurrence of symptoms has been investigated.7,8 Individuals in the intervention group performed gentle coactivation of the multifidus and transversus abdominis muscles with real-time ultrasound imaging as feedback. There were significantly fewer recurrences in the intervention group than in the control group.9,19 In addition, the specific exercises are effective in the treatment of patients with LBP associated with a specific diagnosis. O’Sullivan et al1 have demonstrated decreased pain and disability in patients with chronic LBP who have a radiologically confirmed diagnosis of spondylolysis or spondylolisthesis. The exercises are also proving beneficial in LBP conditions arising from the pelvic region. The specific co-contraction of the transversus abdominis and the multifidus is recommended on the basis of a biomechanical model of the stability of the lumbosacral region. 6.2 Review of Literature 1. Casey Moeller et al in an electromyographical study of the muscle activity during a posterior pelvic tilt concluded that the hamstrings (lateral hamstrings) are active during a static posterior pelvic tilt in the standing position, as well as the external abdominal oblique and the gluteus maximus. These muscles may be the most active due to the mechanical advantage they have on the pelvis. Since the hamstrings attach to the pelvis via the ischial tuberosity, they are capable of pulling the posterior half of the pelvis inferiorly, producing a posterior pelvic tilt during muscle contraction when the femur is fixed. The external abdominal oblique attaches to the anterior half of the iliac crest, which provides a lever arm for the muscle to pull the ASIS superiorly, producing a posterior pelvic tilt. The gluteus maximus’s major function is to extend the thigh, and like the hamstrings, when the femur is fixed the gluteus maximus is capable of pulling the posterior half of the pelvis inferiorly and producing a posterior pelvic tilt. 2. M.Hossain and L.D.M.Nokes proposed that sacroiliac joint dysfunction can result from malrecruitment of gluteus maximus motor units during weight bearing. This results in compensatory biceps over activation. The resulting soft tissue strain and joint instability may manifest itself in low back pain. 3. Hungerford et al. (2003) showed altered firing patterns of these muscles in SIJ patients. Higher tension of the hamstrings will force the pelvis as a unit to rotate backwards, leading to a flattening of the lumbar spine. 4. Van Wingerden et al. (2004) studied several muscles which could contribute to compression of the pelvic joints and influence the stiffness characteristics. SIJ stiffness was measured using DIV in six healthy women. SIJ stiffness was measured both in a relaxed situation and during EMG recorded isometric voluntary contractions. The biceps femoris, gluteus maximus, erector spinae, and contralateral latissimus dorsi were included in this study whereas the deeper lying muscles were not included. Pelvic stiffness significantly increased after activation of the erector spinae, the biceps femoris and the gluteus maximus muscles. Based on these data it is concluded that optimal function of the pelvic girdle during leg loading is based on tailored force closure/compression of the SIJ due to activation of multiple muscle slings. The study concludes that SIJ stiffness increased even with slight muscle activity, supporting the notion that effective load transfer from spine to legs is possible when muscle forces actively compress the SIJ preventing shear. 5. Vleeming et al. [31] defined the posterior layer of the thoracolumbar fascia as a mechanism of load transfer from the contralateral gluteus maximus (Fig. 3). This load transfer is critical during rotation of the trunk, helping to stabilize the lower lumbar spine and pelvis. This was demonstrated through cadaveric and electromyelographic (EMG) studies [32]. The stretched tissue of the posterior thoracolumbar fascia assists the muscles by generating an extensor influence, and by storing elastic energy during lifting to improve muscular efficiency. 6. Sullivan et al. looked at the effect of different positions of the pelvis while stretching the hamstrings. The results showed that if the pelvis was placed in an anterior tilt, it permitted increased hamstring elongation and this was significantly influential on the flexibility of the hamstrings during stretching exercises.13 They found that the anterior pelvic tilt position was significantly more effective in increasing hamstring muscle length than the posterior pelvic tilt position. Also, there was no significant effect of the stretching method or interaction of pelvic positions and stretching techniques.13 There appears to be a strong relationship between the hamstring muscle group and pelvic positioning. 7. Hodges and Richardson from an experimental model concluded, individuals with a history of low back pain show a delay in contraction of the transversus abdominis muscle during a trunk disturbance leading to an inappropriate stabilization pattern which causes recurrences. Spinal segmental stabilization exercises were developed (Richardson and Jull) with the aim of correcting the transversus abdominis contraction delay and also to recover the activation of lumbar multifidus muscle. This motor control approach focuses on an isolated cocontraction of such muscles while keeping the lumbar spine in a neutral position (Richardson et al.). 8. Ferreira et al conducted a systematic review of randomized clinical trials which demonstrated the efficacy of such exercises in relation to the chronic pain and recurrences in patients with low back pain and pelvic pain. 9. Comerford et al defend the training of the global system of stabilization muscles with the aim of correcting the movement impairment. This approach focuses on correcting the movement patterns as well as inappropriate postures and also the lumbopelvic imbalance through therapeutic exercises. 10. Richardson et al conducted a comparative study of tranversus abdominis contraction to bracing action of all abdominal muscles in relation to sacroiliac joint laxity. He concluded that the independent transversus abdominis contraction decreased sacroiliac joint laxity (or rather increased sacroiliac joint stiffness) to a significantly greater degree than the general abdominal exercise pattern. 11. O’Sullivan et al have demonstrated decreased pain and disability in patients with chronic LBP who have a radiologically confirmed diagnosis of spondylolysis or spondylolisthesis. The exercises are also proving beneficial in LBP conditions arising from the pelvic region. The specific cocontraction of the transversus abdominis and the multifidus is recommended on the basis of a biomechanical model of the stability of the lumbosacral region. 12. Van Wingerden et al proposed that active contraction of the long head of BF is considered to contribute towards force closure of the SIJ via force transmission through the sacrotuberous ligament, synergistically with other muscle groups inserting on structures of this joint. 13. A.Vleeming et al proposed that load application along the direction of hamstring and gluteus maximus muscles significantly diminished ventral rotation of the sacrum. The results imply that loading the sacrotuberous ligament restricts nutation of the sacrum. Consequently, muscles which attach to the sacrotuberous ligaments, such as the gluteus maximus, and in certain individuals the long head of the biceps, can dynamically influence movement and stability of the sacroiliac joints. 6.3 Objectives of the study The main objective of the study is to find out the effect of muscle strengthening in golfers with sacroiliac dysfunction specifically to determine the effects of 1. Strengthening of transversus abdominus in golfers with sacroiliac dysfunction 2. Strengthening of gluteus maximus in golfers with sacroiliac dysfunction 3. Strengthening of biceps femoris in golfers with sacroiliac dysfunction The study will formulate a rationale to support the proposition that sacroiliac pain is a specific form of back pain. 7. Materials and methods 7.1 Source of data Data will be collected from golfers, who are referred to the outpatients Physiotherapy department of Vikas College of Physiotherapy, Mangalore with diagnosis of sacroiliac pain after obtaining informed consent. 7.2 Method of collection of data Hypothesis: There is significant effect of transversus abdominus, gluteus and biceps femoris strengthening in golfers with sacroiliac dysfunction Null Hypothesis: There are no significant effect of transversus abdominus, gluteus and biceps femoris strengthening in golfers with sacroiliac dysfunction Research Design: Pre – post Experimental design will be used in this study. Significance of the study: 1. Results of the study may help health professionals to identify and use the best way of treating patients with chronic sacroiliac joint pain in order to reduce their functional limitation and impairments. 2. This study may also help professionals to plan adequate home exercise program for golfers as a preventive measure. 3. This study will help professionals to understand the cause provoking the pain and treat it suitably with static and dynamic exercises. Methodology 15 Golfers who are diagnosed to have sacroiliac pain and fulfilling the following inclusion and exclusion criteria will be selected for the study after obtaining informed written consent. Inclusion Criteria: 1. Clinically diagnosed patients of sacroiliac pain 2. History of pain in the sacroiliac joint (PSIS) for more than 2 months with or without radiating down to the buttocks 3. On initial assessment should exhibit pain on passive anterior pelvic tilt 4. Tenderness on palpation on the PSIS 5. Age group 40 to 60 years 6. Both male and female subjects 7. Positive following special tests Special tests: 1. Patrick’s (Faber) test 2. Gaenslen test 3. Iliac compression test 4. Yeoman’s test 5. Gillet test 6. Seated flexion test Exclusion Criteria: 1. Patients with back or hip pain other than sacroiliac joint pain like disc prolapse, spondyolisthesis, spondylosis, fracture or dislocation of the hip joint 2. Sacroiliac joint pain due to inflammatory disorders like spondyloarthropathies 3. Patients who have had local anaesthetic / corticosteroid injections in the last 3 months 4. Patients with history of spine surgery like stabilization, internal fixations, hip replacement, arthroscopy, etc. 5. Patients using analgesics, anti-inflammatory, steroid medications, spinal braces or corsets 6. Patients with cardiovascular instability and neuromuscular problems 9. Patients less than 40 years and more than 60 years of age 10. Fever 11. Neoplasms 12. Impaired sensations 13. Pregnancy 14. Acute TB 15. Acute inflammation before 72 hrs Study Design The selected subjects will be given 3 sessions per week for 2 weeks, isolated contraction of the transversus abdominis muscle in supine and in co-contraction with lumbar multifidus in prone as well as an isometric contraction exercise to gluteus maximus in prone (Richardson and Jull, 1995; Sahrmann, 2002; Richardson et al., 2004) ensuring trunk flexion via the hips kept a neutral lumbar lordosis (Sahrmann, 2002). To partially restrict the lumbar flexion in the first 48 hours, tape was placed on the patient’s lower back only at the first visit (Sahrmann, 2002). Mild resisted isotonic contractions of the hamstrings were also given. Evaluation: Before the beginning and immediately after exercises, all patients will be evaluated in the following outcome measures. 1. Pain measured in a 10 cm Visual Analog scale. VAS is a 10 cm line with pain descriptors marked “no pain” at 1 end and “the worst pain imaginable” at the other. The patients will be asked to report their perceived pain level, both at rest and on most painful movement, by marking the VAS with a perpendicular line. 2. Muscle power using Manual muscle testing (Oxford scale) 3. OSWESTRY functional ability scale Statistical tests: The following statistical tests will be used to analyze the collected data: Paired t-test, unpaired t-test, Wilcoxan sign rank test and Manwhitney U test will be used to analyze the data. 7.3 Nature of Investigations and Interventions: The study requires non-invasive investigations and interventions to be conducted on patients. They include physical examination like inspection, palpation, and measurement of range of motion, MMT, special tests, etc. Treatment interventions include bridging, static abdominal, gluteal and hamstring strengthening exercises. 7.4 Ethical clearance: Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and interventions on patients necessary for this study. 8. References: 1. Adams MA, Dolan P, Burton K, Bodguk N (2002) The biomechanics of back pain. Edinburgh:Churchill Livingstone 2. A. Vleeming, J.P. Van Wingerden, C.J. Snijders, R. Stoeckart, T. Stijnen. Load application to the sacrotuberous ligament; influences on sacroiliac joint mechanics. Clinical Biomechanics, Volume 4, Issue 4, November 1989, Pages 204-209. 3. C.J. Snijders, A. Vleeming, R. Stoeckart. Clinical Biomechanics, Volume 8, Issue 6, November 1993, Pages 285-294. Transfer of lumbosacral load to iliac bones and legs: Part 1: Biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise. 4. Broadhurst NA, Bond MJ (1998) Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord 11:341-345 5. Bakland O & JH Hansen (1984) The "axial sacroiliac joint". Anat Clin 6(1):2936. 6. Buyruk HM, Stam HJ, Snijders CJ, Vleeming A, Laméris JS, Holland WPJ (1995a) The Use of Colour Doppler Imaging for the Assessment of Sacroiliac Joint Stiffness: a Study on Embalmed Human Pelvises. Eur J Radiol 21:112-116 7. Fairbank JCT, Davies JB, Couper J, O`Brien JP (1980) The Oswestry Low Back Pain Disability Questionnaire, Physiotherapy 66: 271-273 8. Greenman PE (1992) Sacroiliac dysfunction in the failed low back pain. In: Vleeming A, Mooney V, Snijders C J, Dorman T (eds) First interdisciplinary world congress on low back pain and its relation to the sacroiliac joint. San Diego, CA, 5-6 November, 329-352 9. Hagen R (1974) Pelvic girdle relaxation from an orthopaedic point of view. Acta Orthop Scand 45:550-563 10. Hodges PW, Kaigle Holm A, Holm S, Ekstrom L, Cresswell A, Hansson T, Thorstensson A (2003) Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominus and the diaphragm in in vivo porcine studies. Spine 28:2594-2601 11. Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ (1999) The active straight leg raising test and mobility of the pelvic joints. Eur Spine J 8:468-473 12. Mens JMA, Stam HJ, Stoeckart R, Vleeming A, Snijders CJ (1992) Peripartum pelvic pain: a report of the analysis of an inquiry among patients of a Dutch patient society. In: Vleeming A, Mooney V, Snijders C J, Dorman T (eds) First interdisciplinary world congress on low back pain and its relation to the sacroiliac joint. San Diego, CA, 5–6 November, 521–533 13. Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D (2001) Exercise treatment for sacroiliac joint pain. Orthopedics , vol 24, no 1, 24:29-32 14. Panjabi MM (1992) The stabilizing system of the spine. Part I: Function, dysfunction, adaptation, and enhancement. J Spinal Dis 5: 383-389 15. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J (2002) The relationship between the transversus abdominus muscle, sacroiliac joint mechanics and low back pain. Spine 27: 399-405 16. Van Wingerden J P , Vleeming A, Snijders C J, Stoeckart R (1993) A functional-anatomical approach to the spine–pelvis mechanism: interaction between the biceps femoris muscle and the sacrotuberous ligament. Eur Spine J 2:140-144 17. Van Wingerden J P, Vleeming A, Buyruk H M, Raissadat K (2004) Stabilization of the Ssacroiliac joint in vivo: Verification of muscular contribution to force closure of the pelvis. Eur Spine J 13: 199-205 18. Walker ML, Rosthein JM, Finucane SD. Lamb RL. Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther. 1987; 67(4): 512-516. 19. Arnold GS. The Diagnosis and Treatment of Sacroiliac Joint. As cause of low back pain –The Management of Pain in the Butt. Jacksonville Medicine 1995 ; 1-5. 20. Levine D, Whittle MW. The effects of pelvic movement on lumbar lordosis in the standing position. J Orthop Sports Phys Ther. 1996; 24(3): 130-135 Wong TK, Lee RY. Effects of low back pain on the relationship between the movements of the lumbar spine and hip. Human Movement Science. 2004;23:21–34. [PubMed] 21. Grimshaw PN, Burden AM. Case report: Reduction of low back pain in a professional golfer. Medicine and Science in Sports and Exercise. 2000;32:1667– 1673. [PubMed 9. Signature of the candidate 10. Remarks of the Guide 11. Name and Designation of 12. : 11.1 Guide : B A BOOMADEVI M.P.T. Assoc Professor 11.2 Signature : 11.3 Co-Guide : 11.4 Signature : 11.5 Head of the Department : Prof. S. NATARAJAN M.P.T. 11.6 Signature : - 12.1 Remarks of the Chairman and Principal 12.2 Signature :