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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. 7 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. 8 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] ; 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] 1998 Vol. 1 No. 3, Available from: URL http// www. 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.