Download 6 Brief resume of the intended work: 6.1 Need for the study

6
Brief resume of the intended work:
6.1
Need for the study
Mechanical Low back pain is a common musculoskeletal problem, not only affecting the
individual’s sufferer but also society in general. In fact 80% of the population in the world is likely
to suffer from at least one episode of low back pain in their life time. People in the age group of 30
to 50 years are more prone to suffer.1,2,3,4
Mechanical Low back pain is the general term that refers to any type of back pain caused by placing
abnormal stress and strain on muscles of the vertebral column. Typically, mechanical low back pain
results from bad habits, such as poor posture, poorly-designed seating and incorrect bending and
lifting motions.5
Chronic mechanical low back pain associated with spondylotic disease is intermittent, well-localized
spinal pain with variable intensity. Most have consulted many health care providers, have undergone
a variety of treatments, and have used numerous pain medications in their search of a means to deal
with pain and disability.6 Studies have reported that specific stabilization exercises reduces pain and
disability in chronic but not in acute low back pain and can be helpful in the treatment of acute low
back pain by reducing recurrence rate. 7,8
The majority of low back pain arise from benign musculoskeletal problems and are referred to as
non-specific mechanical low back pain. This type of problem may be due to muscle or soft tissue
sprain or strain. It occurs particularly in instances where pain arises suddenly during physical
loading of the back with the pain traversing lateral to the spine.3
Causes for mechanical low back ache are varied. Over activity of these muscles of the back can lead
to injury or torn ligament, which in turn, leads to pain. An injury can also occur to one of the intervertebral discs. 2
To prevent these injuries, joint stability, specific training of the local muscles like the lumbar
multifidus and transverse abdominal muscles has to be achieved. Spinal stability can be achieved by
task and posture specific muscle recruitment patterns together with the co-activation of abdominal
muscles and intra abdominal pressure thereby it further improves spinal stability. The abdominals
acts in controlled pressure in the abdominal cavity preventing the viscera from popping out when the
muscle is put under mechanical stress. Various positions are recommended in order to stabilise the
abdomen and back for preventing mechanical stress and maintain spinal stability.9
Stability and movement are determined by the coordination of all the muscles that surround the
lumbar spine.9 In chronic mechanical low back pain patients with significant passive subsystem
damage adapt muscle recruitment to compensate for the loss of spinal stability.6 The main goal of
stabilization exercises is to protect spinal joint structures from further repetitive micro trauma,
recurrent pain and degenerative change. Long term results of various studies seem to indicate that
specific lumbar stabilizing therapy as a single therapy or combined with other treatments can reduce
the intensity of the pain and disability in low back pain. Several groups have claimed that training
specific muscles has been effective for stabilization.9
Many EMG studies have reported changes in spinal muscle recruitment patterns after short and longterm specific core stability intervention in patients with chronic low back pain.9 It has been reported
that temporal changes in pre-programmed feed forward adjustments firing patterns, amplitudes of
activation and reorganisation of trunk muscle representation at the motor cortex achieved after
specific stabilization exercises focused on transverses abdominis and multifidus co-contraction.7
A series of studies also showed that three forms of exercise produced stabilizing patterns,
specifically for flexion dominant challenges using a form of the curl-up, 5 frontal plane challenges
using the side bridge and extensor dominant challenges using the birddog. These resulted in
relatively lower spine loads than other exercises and have become components in several back
exercise programs and trials.11,12
Various positions are said to be proper for strengthening these muscles and to bring spinal stability.
The various positions like crook lying, prone lying, quadripod position and wall support standing
will bring stability to the spine and prevent further injury.9 Therefore, the purpose of the study is to
compare the effect of different positions to find out the most effective position to bring about spinal
stabilization in chronic mechanical low back pain.
Hypothesis:
Null Hypothesis:
There will be no significant difference in pain and disability after spinal stabilization in crook lying
in chronic mechanical low back pain patients.
There will be no significant difference in pain and disability after spinal stabilization in prone lying
in chronic mechanical low back pain patients.
There will be no significant difference in pain and disability after spinal stabilization in four point
kneeling in chronic mechanical low back pain patients.
There will be no significant difference in pain and disability after spinal stabilization in standing
with wall support in chronic mechanical low back pain patients.
Research Hypothesis:
There will be significant difference in pain and disability after spinal stabilization in crook lying in
chronic mechanical low back pain patients.
There will be significant difference in pain and disability after spinal stabilization in prone lying in
chronic mechanical low back pain patients.
There will be significant difference in pain and disability after spinal stabilization in four point
kneeling in chronic mechanical low back pain patients.
There will be significant difference in pain and disability after spinal stabilization in standing with
wall support in chronic mechanical low back pain patients.
6.2 Review of Literature:
Dujin Park, Hyonok Lee (2010): conducted a study on activation of abdominal muscles during
abdominal hollowing in four different positions by using EMG on 36 healthy male adults. All the
patients were tested in 4 different positions. They found that TrA/Io showed highest muscle activity
in prone lying and concluded that the external oblique shows maximum contraction in prone lying
position.9
Ramprasad Muthukrishnan, Shweta D Shenoy, Sandhu S Jaspal, Shankara Nellikunja and
Svetlana Fernandes (2010): conducted a study on the differential effects of core stabilization
exercise regime and conventional physiotherapy regime on postural control parameters during
perturbation in patients with movement and control impairment in chronic low back pain. Three
groups of 15 participants in each group were investigated during postural perturbations. In this
study, the core stability exercise group demonstrated significant improvements after intervention in
ground reaction forces indicating changes in load transfer patterns during perturbations similar to
HC group. 7
Stuart M. McGill, Amy Karpowicz (2009): conducted a study on Exercises for Spine Stabilization
to quantify several forms of the curl-up, sidebridge, and birddog exercises (muscle activity and 3dimensional spine position) including some corrective techniques to assist clinical decision-making.
The process was applied on 8 healthy men subjects. This study may be used to guide the clinical
decision process when choosing a specific exercise form together with selecting the correct starting
level, a logical progression, suitable dosage, and possible corrective technique to enhance tolerance
of a patient.11
Anne F. Mannion, Natascha Pulkovski, Deborah Gubler, Mark Gorelick, David O’Riordan,
Thanasis Loupas et al (2008): conducted a study on muscle thickness changes during abdominal
hollowing an assessment of between-day measurement errors in controls and patients with chronic
low back pain. 28 patients with chronic LBP performed abdominal hollowing exercises in hooklying, while M-mode ultrasound images. There were no significant differences between test days for
the mean values of absolute thickness for any muscle in either the control or the patient group.14
WF Peate, Gerry Bates, Karen Lunda, Smitha Francis and Kristen Bellamy (2007): conducted
a study on Core strength a new model for injury prediction and prevention. This study was
conducted on 433 fire fighters to see the injury prone awkward working positions. They concluded
that core strength and functional movement enhancement programs help to prevent injuries in
workers whose work involves awkward positions. 13
Veerle K Stevens, Katie G Bouche, Nele N Mahieu, Pascal L Coorevits, Guy G Vanderstraeten
and Lieven A Danneels (2006): conducted a study on Trunk muscle activity in healthy subjects
during bridging stabilization exercises. The purpose of this study was to investigate both relative (as
a percentage of maximal voluntary isometric contraction) muscle activity levels and ratios of local to
global muscle activity, during bridging stabilization exercises. 30 subjects were included in the
group. They concluded that all back muscles contribute in a similar way to control spine positions
and movements in a healthy population. 10
Paulo H Ferreira, Manuela L Ferreira, Christopher G Maher, Robert D Herbert and Kathryn
Refshauge (2006): conducted a study on specific stabilisation exercise for spinal and pelvic pain, a
systematic review. Outcomes were disability, pain, return to work, number of episodes, global
perceived effect, or health-related quality of life. Database searches identified 194 studies. The
available evidence suggests that specific stabilisation exercise is effective in reducing pain and
disability in chronic but not acute low back pain.8
George A Koumantakis, Paul J Watson, Jacqueline A Oldham (2005): The purpose of this
randomized controlled trial was to examine the usefulness of the addition of specific stabilization
exercises to a general back and abdominal muscle exercise approach for patients with subacute or
chronic nonspecific back pain by comparing a specific muscle stabilization–enhanced general
exercise approach with a general exercise only approach. 55 patients with subacute and cronic low
back ache were taken. Stabilization exercises do not appear to provide additional benefit to patients
with subacute or chronic low back pain. 15
6.3 Objectives of the study:
1. To determine the best position for spinal stabilization exercise in chronic mechanical low back pain.
2. To compare the effect of spinal stabilization exercises in different positions with chronic mechanical low
back pain.
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Materials and Methods:
7.1 Source of Data:
1.
Padmashree Clinic of Physiotherapy, Nagarbhavi,
Bangalore.
2.
ESI hospital, Rajaji Nagar, Bangalore.
3.
Padmashree Diagnostics, Bangalore
7.2 Method of collection of data:
Population
: Subjects with history of chronic mechanical low back pain
Sample design
: Convenience sampling
Sample size
: 40 (4 groups with 10 each)
Type of Study
: Experimental - pre-post design
Duration of study
: 3 sessions for 3 months
Inclusion and exclusion criteria:
Inclusion Criteria:
1. Patients with chronic mechanical low back pain
2. Age of 30 – 50 years
3. Both males and females.
Exclusion Criteria:
1. Severe osteoporosis
2. Spinal fractures
3. Referred pain from viscera
4. Malignancy/ tumours
5. Pregnancy
6. Patients with neck and back pain
7. Patients with acute or sub-acute mechanical low back pain
8. No previous history of spinal surgery
Materials required:
1. Oswestry disability questionnaire
2. VAS scale
3. Moist heat
4. Pelvic traction
5. IFT
6. Towel
7. Couch
7.3Methodology:
Subject who fulfils the inclusion and exclusion criteria will be included in the study. Pre-test
evaluation is done before starting treatment using VAS & Oswestry disability questionnaire. The
subjects are then randomly allocated into four different group’s i.e, Group A, Group B, Group C and
Group D respectively. Before the exercises are done, the subjects are instructed and demonstrated
with the procedure for proper understanding.
Group A: (N=10) Crook lying with knees flexed up to 900. 9
Group B: (N=10) Prone lying with the ankle supported by a towel, or a pillow placed underneath the
ankle. 9
Group C: (N=10) Four point kneeling with the line of sight directed at the floor, while the eyes and
shoulders of the subject are positioned horizontally to each other with wrist directed below the
shoulder and the knee below the hip. 9
Group D: (N=10) Wall support standing with the distance between the wall and the heel of the
subject maintained at 15 cm. 9
In each of the positions subjects will be asked to take his or her pelvis into an anterior and posterior
pelvic tilt through the range which is comfortable.1 Then the umbilicus will be drawn in actively as
though to reach the spine, the subjects are to be instructed to maintain the abdominal contraction for
10 sec. The hold time and the number of repetitions were increased accordingly, and subjects were
trained to maintain these contractions in various postures.7 In order to prevent fatigue the patients are
to be given rest time of 2 sec in between if necessary.9
All the groups will receive treatment with moist heat, pelvic traction and IFT each for 10 minutes.3
At the end of 3 months post test evaluation will be conducted for all the 4 groups using VAS and
Oswestry disability questionnaire. The differences of pre and post test values are compared within
the group and between the groups using statistical analysis.
Outcome Measures:
1. VAS scale
2. Oswestry disability questionnaire
Statistical Analysis:
1. Descriptive Statistics: mean, median and standard deviation
2. Inferential Statistics:
Wilcoxon’s test to compare within groups
Kruskal Wallis test to compare between groups
7.4 Ethical Clearance:
As this study involves human subjects, the ethical clearance has been obtained from the ethical
committee of Padmashree Institute of physiotherapy, Nagarbhavi, Bangalore, as per ethical
Guidelines research from biomedical research on human subjects, 2000, ICMR, New Delhi.
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List of References:
1. Kisner C, Colby L A. Therapeutic exercises: foundations and techniques. 4 th ed.
Jaypee
publications.2000. p-638-642.
2. Porterfield J A, Rosa C D. Mechanical low back pain: Perspectives infunctional anatomy. 2 nd ed.
Saunders.1998.
3. Perina D G. Back Pain[Online]. 2010 Nov 5; Available from URL
www.medicine.virginia.edu/clinical/.../copy_of Perina
4. Dugan S A. An active and cost conservative approach to the management of L.B.A[Online]. 2002Oct; Available from : URL www.turner-white.com
5. Spine-health.
Mechanical
Pain
[Online]
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Available
from:
URL:
http://www.spinehealth.com>Glossary>M
6. Pappagallo M, Breuer B, Schneider A, Sperber K. Treatment of Chronic Mechanical Spinal Pain with
Intravenous Pamidronate: A Review of Medical Records. Journal of Pain and Symptom
Management 2003 July1;26:678-683.
7. Muthukrishnan R, Shenoy S D, Jaspal S S, Nellikunja S, Fernandes S. Therdifferential effects of
core stabilization exercise regime and conventional physiotherapy regime on postural control
parameters during perturbation in patients with movement and control impairment chronic low back
pain. Sports Medicine, ArthroscopyRehabilitation Therapy&Technology Feb 2010;13:1-12.
8. Ferreira PH, Ferreira ML, Christopher GM, Herbert RD, Kathryn R: Specific stabilization exercises
for spinal and pelvic pain: a systematic review. Aust J Physiothera 2006, 52:70-88.
9. Park D, Lee H, Activation of abdominal muscles during abdominal hollowing in four different
positions. J.Phys.Ther.Sci. 2010(22):203-207.
10. Stevens V K, Bouche K G. Trunk muscle activity in healthy subjects during bridging stabilization
exercises. BMC Musculoskeletal Disorders 2006 Sep 20: 75(7); 1-12.
11. McGill S M, Karpowicz A. Exercises for Spine Stabilization to quantify several forms of the curlup, sidebridge, and birddog exercises. Arch Phys Med Rehabil 2009 Jan (90): 118-126.
12. Borenstein D. Diagnosis and Management of Low Back Pain Rheumatology & Musculoskeletal
Medicine
[Online]
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URL
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anesthesia.stanford.edu/pain/Low%20Back%20Pain/Low%20Back%20Pain.pdf
13. Peate WF, Bates G, Lunda K. Core strength a new model for injury prediction and prevention.
Journal of Occupational Medicine and Toxicology 2007 April 11; 2(3):1-9.
14. Mannion A F, Pulkovski N. Muscle thickness changes during abdominal hollowing an assessment
of between-day measurement error in controls and patients with chronic low back pain. Eur Spine J
2008 January 15; 17:494–501.
15. Koumantakis G A, Watson P J, Oldham J A. Trunk Muscle Stabilization Training Plus
General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients
With Recurrent Low Back Pain. Bone and Joint 2005 March; 85(3): 209-225.