Download rajiv gandhi university of health sciences

Rajiv Gandhi University of Health Sciences, Karnataka
Curriculum Development Cell
CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
Registration No.
:
Name of the Candidate
: Miss. RAGHANI PINKY.P.
: SDM College of Physiotherapy,
Manjushree Nagar, Sattur,
Dharwad-9.
: SDM College of Physiotherapy, Dharwad
Address
Name of the Institution
Course of Study and Subject
Date of Admission to Course
: MPT (PHYSIOTHERAPY IN
MUSCULOSKELETAL DISORDERS AND
SPORTS PHYSIOTHERAPY).
Brief resume of the intended work
: 2/06/2008
: TO STUDY THE COMBINED EFFECT OF
LUMBAR STABILIZATION EXERCISES AND
INTERFERENTIAL THERAPY IN SUBJECTS WITH
CHRONIC LOW BACK PAIN- AN EXPERIMENTAL
STUDY.
: Attached
Signature of the Student
:
Guide Name
Remarks of the Guide
:Mr. RAVI SAVADATTI
:
Title of the Topic
:
Signature of the Guide
HOD Name
Signature of the HOD
:Mrs. KIRAN SIRIGERI
:
Principal Name
Principal Mobile No.
Principal E-mail ID
Remarks of the Principal
:Mrs.KIRAN SIRIGERI
: 9886089451.
: [email protected]
:
Principal Signature
:
1
TITLE OF THE TOPIC:
TO STUDY THE COMBINED EFFECT OF LUMBAR STABILIZATION
EXERCISES AND INTERFERENTIAL THERAPY IN SUBJECTS WITH
CHRONIC LOW BACK PAIN - AN EXPERIMENTAL STUDY.
2
a)
BRIEF RESUME OF THE STUDY
Introduction:Low back pain can be defined as “The pain in the spine or muscles of the low back”.1
Over 80% people in developed countries will experience low back pain at sometime in their
lives. Its recurrence rate ranges from 60 to 85%.2
Early studies suggest that prevalence of low back pain is typically seen from third to fifth decade
of life, this prevalence tends to decrease in males after the age of 55 years but showed a slight
increase in females, might be due osteoporotic changes of the vertebrae.2
Back pain has now become not only a medical problem, but a social, legal, and political as well.
It has become a major cause of medical expenses , absenteeism and disability.2
Painful musculoskeletal health problems such as low back pain contribute significantly to
morbidity in general population and form a major part of the high costs of health care in
industrialized world.3
Chronic Low back pain is one that last for more than three months and is characterized by either
a slowly or suddenly occurring rather sharp pain with or without radiation over the buttocks or
slightly down the leg and concomitant restriction of motion.1
Until recently, the prevention and treatment of insidious-onset of chronic low back pain have
relied on the premise that cause of chronic low back pain is a gradual break down of joint
structures and associated soft tissues over period of time .4
Symptoms in these patients are usually characterized by diffusing pain which varies with
activities like bending, lifting, twisting. They experience pain in back more than leg pain and
there are no neurological signs present. Clinical instability refers to a significant decrease in
capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within
physiological limits which results in pain and disability.4
The Oswetry Disability Index deals with activities of daily living and therefore is based on the
patient’s response and concerns affecting daily life. It is the most commonly used back scale.
The disability index is calculated by dividing the total score (each section is worth 1to 6 points
3
by the numbers of sections answered and multiplying by 100).5
Visual analogue scale is a pain rating scale, where score zero stands for no pain and 10 stands
severe pain .5
A number of differing conventional treatment are given to subjects with chronic low back pain,
these include different types of exercise like isometric exercises for trunk flexors and extensors,
heavy resistance training, general conditioning approach teamed with lower body stretches,
William’s flexion exercises, McKenzie’s protocol and various other physical therapy modalities
like SWD,TENS ,IFT, Hot packs etc.3
Isometric exercises are a static form of exercise in which a muscle contracts and produces force
without an appreciable change in the length of muscle and without visible joint motion. Studies
have showed that repetitive isometric contractions (a set of 20 per day) held for 6 seconds each
against near maximal resistance consistently improved isometric strength.6
Interferential current delivers a medium frequency (4000HZ) electric current through superficial
electrode placed on the skin around the affected area more which is thought to penetrate the skin
more deeply and cause less discomfort to the patient. 7
There are 4 main clinical applications for which Interferential current is used, one of most
important amongst them is its use in pain relief, Higher frequencies of interferential current i.e.
(90-150Hz) is use to stimulate the pain gate mechanisms & thereby mask the pain symptoms.
Alternatively, stimulation with lower frequencies (1-5Hz) can be used to activate the opoid
mechanisms, by providing a degree of relief. These two different modes of action can be
explained physiologically & will have different latent periods & varying duration of effect. It
remains possible that relief of pain may be achieved by stimulation of the reticular formation at
frequencies of 10-25Hz or by blocking C fibre transmission at >50HZ.7
Interferential therapy has been shown to be beneficial, in reducing pain and inflammation, hence
in our study interferential therapy is included as treatment modality.7
A better understanding regarding the extent of physiological and functional effects of more
modern exercise techniques used in chronic low back pain rehabilitation, stabilization exercise
training is considered an important area of research.8
4
These exercise programs are varyingly referred to as Core stabilization, Lumbar stabilization or
Segmental stabilization exercises. Motor relearning, Motor control or Motor re-education are
among other terms that are aimed at improving the dynamic stability of spine, neuromuscular
control, strength and endurance of number of muscles in the trunk and pelvic floor. Several
groups of muscles are targeted in these exercises particularly the Transverse Abdominis ,Lumbar
Multifidi and other Paraspinal, Abdominal, Diaphragmatic and pelvic musculature .9
Much of the rationale for using exercise to enhance lumbar stability is derived from the work of
Bergmark and Punjabi.9
Bergmark characterized the trunk muscles into local and global muscles, The local system
includes, The deep muscles and the deep portions of some muscles that have their origin or
insertion on lumbar vertebrae these muscles control the stiffness and intervertebral relationship
of the spinal segment and the posture of lumbar segment. The local system, which consisted of
muscles that act directly on the lumbar vertebrae such as the Transverse abdominis and Multifidi,
maintained force control within the lumbar spine. The activity of local muscle system is vital in
providing stability of spinal segments.9
The global muscle system consist of superficial muscle of trunk that do not have direct
attachment to vertebrae and cross multiple segments these muscles are the torque generator for
spinal motion they control spinal orientation, balance the external loads applied to the trunk and
transfer load from thorax to pelvis. The global muscles are Obliqus internus abdominus, Obliqus
externus abdominus, The rectus abdominus, The lateral fibers of quadrates lumborum and
proportion of erector spinae.4
The development of clinical treatment program for core muscles, which was intended to provide
pain relief was proposed by Richardson and Jull.9
Richardson and Jull have described how joint protection and muscle control should ultimately
lead to pain control. He also states that exercise intervention will be enhanced if other treatment
modalities that relieve pain, inflammation and oedema are used in conjunction with segmental
stabilization.4
Biomechanical and ergonomic research has successfully focused on the ways of minimizing high
forces on the spine and has highlighted to the community the value of such factors as safe
working postures and furniture design in prevention of chronic back pain. The aim is to keep the
5
tissue loading as low as possible while the joint protection mechanism is being developed
through stages. Hence the ergonomic advice is appropriate at this stage to reduce the tissue
loading. So in our study we have included advice for back care in The form of ‘Do’s’ and
Dont’s.8
Need for the study:
Interferential therapy has been shown to be beneficial, in reducing pain and inflammation and a
close association between segmental stabilization and pain can be used for both prevention and
treatment purpose for low back pain.
Very few literatures have been found about the beneficial effects of lumbar Stabilization
Exercises in chronic low back pain.8
The effect of exercise intervention will be enhanced if other treatment modalities that relieve
pain and inflammation are used in conjunction with segmental stabilization training4
Hence this present study is done To study the combined effect of Interferential Therapy with
Lumbar Stabilization Exercises in subjects with Chronic low back pain.
RESEARCH HYPOTHESIS:
Alternate Hypothesis (Hi): The group receiving Lumbar Stabilization with Interferential
Therapy will show significant improvement as compared to the group receiving Interferential
Therapy in subjects with chronic low back pain.
Null hypothesis (Ho): The group receiving Lumbar stabilization with Interferential Therapy will
not show significant improvement as compared to the group receiving Interferential Therapy
alone in subjects with chronic low back pain
6
REVIEW OF LITERATURE:
In order to measure the pain Visual Analogue Scale (VAS) is a good and reliable tool in clinical
research. The pain can be measured using this scale. The VAS is a well studied method for
measuring both acute and chronic pain, and its usefulness has been validated by several
investigators.10
A reliability study was conducted to evaluate the test-retest reliability of self-reported functional
status and pain in chronic low back pain patients by postal questionnaires. Forty-two patients
with chronic low back pain (15 men, 27 women; mean age, 40 years; range, 20-61 years) agreed
to participate in the study. The mean duration of symptoms was 8.9 years. A postal questionnaire
was sent to the patients twice within a 2-week interval. The questionnaire included the following
items: work, back satisfaction, General Function Score (GFS), Oswestry Disability Index (ODI),
pain, fear-avoidance beliefs, life satisfaction and pain medication. They conclude that The
Oswetry Disability Index was highly reliable.11
A pilot study was done to investigate the effect of lumbar stabilization exercises in improving
quality of life and functional outcomes in patients with chronic low back pain. Forty one patients
with chronic low back pain participated in the study and were randomly assigned to a treatment
group (n=20) or a control group (n=21).The treatment group underwent lumbar stabilization
programme, whilst the control group received no intervention. The outcome measures include
Roland Morris Questionnaire, Oswetry Disability Questionnaire and SF-36. The results suggest
that a programme of lumbar stabilization is effective in improving quality of life and functional
outcome in patients with chronic low back pain.12
A study investigated people with chronic low back pain, in which one group received motor
relearning program and other was a control group. At the end of training and at the 30th month
after training, there was a significant reduction in pain and disability in subjects who received
motor relearning group when compared to control group.13
A Randomized Controlled Trial from Australia compared General Exercise with Motor control
(stabilization) Exercise and Spinal Manipulative Therapy (SMT) in patients of 18 to 80 years
with Chronic Low Back Pain greater than 3 months. The groups receiving general exercises
received supervised stretching, and strengthening of major muscle groups, aerobic fitness, and
the motor control group received training for Transverse Abdominals, Multifidus, Diaphragm,
7
and pelvic floor and the SMT group received joint mobilization and manipulation. Outcomes
included the Patient Specific Functional Scale, Visual Analogues Scale and the Roland Morris
Disability Questionnaire. The Authors concluded that Motor control exercise and Spinal
Manipulative Therapy result in better short term function and perception of effect than General
exercise for patients with Chronic Low Back Pain.14
A study compared specific spinal stabilization exercises, manual therapy and minimal care for
patients of age group 18-65 years, with Chronic Low Back Pain in the United Kingdom.
Randomization was stratified based on age gender and degree of pain. Total 302 patients
participated in this study and were divided into three groups. The spinal stabilization group, The
manual therapy group, and The minimal care group. Outcome measures included Oswetry
Disability Index and Nottingham Health Profile. The authors concluded that spinal stabilization
exercise was more effective than manual therapy or minimal care. 14
Lumbar stabilization exercise has been proved at improving pain and function in chronic low
back pain. 14
A Randomized Control Trial comparing General Endurance Exercise with Stabilization Training
and General Exercise alone in patients with Recurrent Low Back Pain was done. In this study
they had randomly divided subjects into 2 groups as: S&G group (n=29) and G group (n=26).
They concluded that Stabilization Exercise enhanced approach presented an equal benefit to a
General Endurance based exercise programme for patients with Recurrent Low Back Pain.13
A study randomly assigned 60 patients with back pain to one of three groups: Interferential
therapy of the painful area, Interferential therapy of the spinal nerve and control group, who
received no interferential therapy. There was no placebo group. All patients received educational
materials. Those assigned to active treatment groups received 2–3 treatments per week for
variable periods of time. The principal outcome measures were based on results of pain-rating
index and the Roland-Morris Disability Questionnaire. Placement of the interferential therapy
electrodes over the spinal nerve, compared to the painful area, resulted in a significantly larger
reduction in disability scores.15
A randomized double-blinded trial compared Interferential stimulation (IFS) or horizontal
therapy (HT) with sham stimulation in 105 older women with chronic low back pain due to
multiple vertebral fractures. All participants received a full therapeutic exercise program, and
8
blinded evaluation revealed no differences between the groups following 2 weeks of active or
sham stimulation. However, the active stimulation groups showed post-treatment improvements
of about 30% in visual analogue scores (VAS) for pain. The proportion of patients who
improved in the Horizontal Therapy group was greater than in the sham group .16
OBJECTIVE OF THE STUDY:
To study the combined effect of Lumbar Stabilization Exercises and Interferential Therapy in
subjects with Chronic Low Back Pain.
9
b)
PROCEDURE, MATERIALS AND METHODS:
SOURCE OF DATA COLLECTION:
Department of Physiotherapy,
S. D. M. College of Medical Sciences and Hospital, Dharwad.
METHOD OF DATA COLLECTION:
Material:
* Data collection sheet.
*Manipulation table.(High low treatment table IMI 3115)
*Vectrostim Interferential therapy unit.[Techno med Electronics]
*Static Bicycle, Mirror
Inclusion Criteria:
1. Age group of 20 to 50 years.
2. Subjects with and Chronic back pain (more than 3 months) of either gender diagnosed
and referred by the Orthopeadician of S.D.M. college of medical sciences and hospital.
Exclusion Criteria:
1. Any history of severe trauma or medical condition.[head injury, respiratory illness such
as asthma]
2. Contraindications for lumbar segmental exercises e.g. Disc lesions, Ankylosing
spondylitis, unstable spine.
3. Contraindications for Interferential therapy.
Study Design: Experimental Study.
Study duration: 1 year.
SAMPLE: Convenient sample of 30 patients diagnosed with chronic low back pain referred by
Orthopaedician of S.D.M. College of Medical sciences and Hospital, Dharwad and who were
willing to participate in the study will be taken.
Subjects will be divided into two equal groups.
10
Group A: (EXPERIMENTAL GROUP)
Will be treated with combination of Lumbar stabilization exercises and Interferential Therapy.
Group B: (CONTROL GROUP)
Will be treated with Isometric Exercises for back extensors and Interferential Therapy.
“DO s” and “DONTS” will be given for both the groups.17
PROCEDURE:
All the subjects with chronic low back pain who will report to S.D.M College of Medical
sciences and Hospital, Department of Physiotherapy, Dharwad will be screened as per inclusion
and exclusion criteria.
They will be requested to participate in the study. Subjects willing to participate in the study will
be briefed about the study and the intervention. After briefing their written consent will be taken
and their demographic data will be collected and initial evaluation for the pain profile using VAS
(visual analogue scale), Oswetry Disability Index will be taken before and after 6th week of
intervention.4
Interferential therapy will be given to both the groups at following parameters:
Carrier frequency: 4 KHZ.
Burst frequency:
Vector Sweep:
1 to 10 hertz.
900V.
Electrode arrangement: Quadripolar.
Electrode placement: Place around the area of pain in the back.
Treatment duration : 20 to 30 minutes.18
DO’s and DONT’s for back care will be given to subjects in both the groups.17
GROUP A: Patients in group A will be treated with lumbar stabilization exercises and
Interferential therapy.
Interferential Therapy will be given for pain relief at above described parameters.
Before starting with lumbar stabilization exercises subjects will be asked to do warm-up
(stretching exercise, static bike) for 10-15 minutes and CAT- CAMEL exercise will be given.(to
reduce viscosity and floss the nerve roots as they outlet at each lumbar level.19
11
PROCEDURE OF LUMBAR STABILIZATION EXERCISE
The goal is to reeducate the component missing in normal function (i.e. early tonic recruitment
of deep muscles) and reduce activity of superficial muscles followed by reeducation of normal
integration of activity of all trunk muscles into functions.
The treatment is given in 4 rehabilitation phases:4,19
Phase 1: Activation phase.
Here the patient is taught to cognitively perform skilled activation of deep muscle i.e. Transverse
Abdominis and Lumbar Multifidus alone while relaxing the superficial muscle. The patient is
asked to perform a gentle isometric contraction of Transverse Abdominis /Lumbar Multifidus
independently from superficial muscle and the focus of training is low level tonic activity.
Several techniques are available to access the inappropriate activity of superficial muscles during
the performance of Transverse Abdominis/Lumbar Multifidus contraction E.g. Palpatory
method, Visual feedback, EMG biofeedback, pressure bio feedback unit etc.4
Procedure to recruit Transverse Abdominis.
Patient is in supine or crook lying position, than patient is asked to gently contract the anterior
aspect of pelvic floor muscle as if trying to stop the flow of urine and the patient should not feel
the contraction at the back passage. The investigator feels for the deep tension developing in the
abdominal wall, once this is mastered the patient is taught to extend the contraction consciously
up into the lower abdominal wall and draw ‘in’ the lower abdominal wall toward the spine
During this process the investigator palpates for the slow inward movement of the lower
abdomen and its tightening. Self monitoring with palpation for desired response in the abdominal
wall is essential in the learning process for cognitive control of Transverse Abdominis.4
Feedback:
Palpatory method: For palpation of Transverse Abdominis the investigator fingers are placed
approximately 2 cms medial and lower to Anterior Superior Iliac Spine.
Visual feedback: done with the use of mirror, here the mirror is placed obliquely at the side of
patient to see the appearance of abdominal wall and practice at home.4
Procedure to recruit Lumbar Multifidus:
Pelvic floor contraction can also be used to teach and facilitate an isometric contraction of
lumbar multifidus.
Patient is in side lying or prone position. The investigator palpates the targeted vertebral level,
the patient is asked to draw up the pelvis floor slowly. A slow and gentle deep tensioning of
12
multifidus muscle is the desired response.4
Dosage for recruitment of Transverse Abdominis/Lumbar Multifidus:
5-10 isometric contraction of Transverse Abdominis/Lumbar Multifidus per session with 10
seconds hold time, done for 3 times per day for twice a week for 6 weeks.4
PHASE II: Skill Precision
Once the patient can perform independent contraction of local muscles (Transverse
Abdominis/Lumbar Multifidus) the next phase is to improve precision of task.4, 19
Goals of Precision task:
1. Co activation of deep muscles.
2. Co ordination with breathing.
3. Progression to static functional position.
4. Progression to light dynamic task.
Co activation of deep muscle: Co activation of one local muscle is associated with co activation
of the other muscles in the group. For instance, when Transverse Abdominis is active there is
often concurrent recruitment of Lumbar Multifidus for optimal control of intervertebral motion,
it is ideal for deep muscle to be co activate.4,19
Coordination with breathing: It is important to have normal diaphragmatic breathing (i.e.,bi
basal rib cage expansion, and abdominal movement.) while maintaining the contraction of local
muscle, here the patient is encouraged to contract the local muscles and then add breathing to the
tonic local muscle.4,19
Progression to static functional position: Progression into sitting and standing position is
commenced once the patient has achieved the above two goals in non weight bearing position.
This process causes activation of the superficial muscles to keep the body upright and overcome
the effects of gravity so the goal is to maintain the contraction of local muscles (Transverse
Abdominis & Lumbar Multifidus) relatively independent of global muscles. Hence the patient is
made to sit or stand with support to relax the global muscles and the progression will be to
reduce the amount of support.4,19
Here the patient is asked to relax the abdominal muscles and attention is directed to maintain the
static spinal neutral curve (Thoracic kyphosis and lumbar Lordosis), lumbar support is important
initially as the Multifidus lacks the endurance required to support Lumbar Lordosis. Later the
subject is asked to contract the pelvic floor muscle to get the desired effect of activation of
Transverse Abdominis/Lumbar Multifidus.4,19
13
Progression to light dynamic task: Once the local muscle contraction can be performed
confidently in upright posture, it is appropriate to begin the more complex task of adding spinal
movement. In this phase the goal is to maintain tonic contraction of deep muscles while spine is
moved.
To initiate this phase of training is ‘Walking’, here the subject is made aware that the goal is to
maintain the contraction of the local muscle in conjunction with small amplitude movement with
phasic contraction of the global muscle superimposed over the local muscle. Hence subject
should be aware of the perception of contraction of deep muscles.
Training for walking: Initially start with intermediate steps such as forward-backward and side to
side weight shifts, than stepping with support and finally unaided stepping. Conscious
contraction of local muscles is sustained throughout the tasks.4,19
PHASE III Superficial and deep muscle co activation:
Here the subject is asked to coordinate the activity of deep and superficial muscles without the
global muscle taking over. Once sitting and standing with local muscles control is achieved in
the next phase is fitness activities with local muscle training is given but prior assessment of
closed chain and open chain segmental control by local muscles is done .
Fitness activities is given with closed and open chain activities .The goal is to activate local
muscle (Transverse Abdominis /Lumbar Multifidus) into antigravity weight bearing function.
Closed chain segmental control stage involves following procedures:
1. Training individual part of the antigravity weight bearing holding postures.
2. Weight bearing exercise in flexed postures. (sitting, semisquat, forward lunge)4,19
Open chain segmental control involves exercises like leg loading with hip flexion, extension,
abduction or adduction in positions such as lying, sidelying, sitting or standing.4
Few exercises which activate other core muscles like Quadratus Lumborum, Psoas, rectus
abdominis, Erector spinae and are equally important for dynamic stability of the spine will also
be given to subjects.
DOSAGE:
These exercises will be given for 5-10 repetitions with a hold of 10 seconds for twice a week.4,9
The exercises will be given as follows:
CURL UPS: It activates rectus abdominis , patient is in supine position with hands under lumbar
14
region (to help stabilize the pelvis and preserve the neutral spine posture) and with one leg bent
and other leg straight to assist in pelvic lumbar stabilization than the patient is asked to raise the
head and shoulder off the ground .19
SIT UPS: It activates psoas muscle, patient in supine with knees bend, head and shoulder are
raised off the ground with hands under the head.19
SIDE BRIDGE: It activates Quadratus lumborum and obliques muscle, patient in side lying with
knee bend ,then raising horizontally with support on elbow and knees.19
BIRD DOG EXERCISES: It activates back extensors (Longissimus, Illiocostalis and Multifidi)
patient in quadripod position with elbows locked straight and head in neutral position patient
pulls in the belly button and lift one leg off the floor so that the limb is in line with the trunk and
the opposite side arm is lifted off the ground.19
PHASE IV: Functional reeducation
This is final phase of training and the patient is trained with lumbar stabilization exercises in the
specific function which is based on the demands of the patient. E.g. If the patient has difficulty
associated with tennis serve, the first step is to break the task into its component and each
component is practiced with tonic co activation of deep muscle till the perfection is gained.4, 19
GROUP B: will be treated with Isometric exercises for back and interferential therapy.
Interferential therapy will be given at above described parameters.
Isometric exercises for back extensors will be given as follows:
ISOMETRIC FOR BACK EXTENSORS: patient in supine with arms at the sides. Instruct the
patient to arch the back by pressing against the mat with the back of neck and sacrum.
Contraction will be held for 6-10 seconds ,as a set 0f 20 repetitions per day for 6 weeks.6
Statistical Test Used:
1. Paired t test.
2. Standard error of difference between two means.
3. Difference between standard error of two proportion.
15
DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE
CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? – YES.
HAS ETHICAL CLEARANCE BEEN OBTAINED BY YOU-YES.
16
c)
REFERENCE LIST:
1. McKenzie RA. Lumbar spine mechanical diagnosis and therapy. New Zeland:
Wright and Carman; 1997. p. 2.
2. Porterfield JA, Rosn CD. Mechanical low back pain, perspective in functional
anatomy. 2nd.W B Saunders Company; 1998. p. 1-4.
3. Rucker KS, Cole AJ, Weinstein SM. A symptom based approach to diagnosis and
treatment of low back pain. Woburn:Butterworth- Heinemann;2001. p. 6.
4. Richardson C, Hodges PW, Hides J. Therapeutic exercise for lumbopelvic
Stabilization.2nd ed:Churchill Livingstone;2004. p. 3,179,180,204-237.
5. Magee DJ. Orthopaedic physical assessment. 4th ed. New Delhi:Saunders;2006. p.
7,505.
6. Kisner C, Colby LA. Therapeutic exercise foundations and techniques. 4 ed.
NewDelhi:Jay Pee Brothers;2002. p. 81,662.
7. Low R, Reed A. Electrotherapy explained principles and practice. 3rd ed. New
York: Butterworth-Heinemann;2000. p. 53,63,65.
8.
Koumantakis GA, Watson PJ, Oldham JA, Supplementation of general endurance
exercise only physiological and functional outcomes of an randomized control Trial
of patients with recurrent low back pain, clinical biomechanics. 2005; 20:474-482.
9.
Standert CJ, Herring SA. Expert opinion and controversies in musculoskeletal and
sports medicine: core stabilization as treatment for low back pain. Arch physical
medicine rehabilitation. 2007 Dec; 88:1734-36.
10. Carlsson, Maria A: Assessment of pain. I. Aspects of the reliability and validity of
the visual analogue scale: Pain. 1983; 16:87-101.
11. Inger H, Astrid F,Storheim, Kjersti, Brox, Ivar J. Measuring Self-Reported
functional status and pain in patients with chronic low back pain by postal
questionnaires: A reliability study. Health services research spine. 2003 April 15;
28(8):828-833.
12. .Shaughnessy M and Caufield B. A pilot study to investigate the effect of lumbar
stabilization exercise training on functional ability and quality of life in patients
with chronic low back pain. International Journal of Rehabilitation Research. 2004;
27:297-301.
13. Koumantakis GA, Watson PJ, Odham JA. Trunk muscle stabilization training plus
general exercise versus general exercise only: randomised controlled trial of
patients with recurrent low back pain. Physical Therapy. 2005 Mar; 85(3):209-225.
14. Standaert CJ, Stein SM, Weinstein, Rumpeltes J. Evidence informed management
17
of chronic low back pain with lumbar stabilization exercises. The spine journal.
2008; 8:114-120.
15. Hurley DA, Minder PM, McDonough SM et al. Interferential therapy electrode
placement technique in acute low back pain: a preliminary investigation. Arch Phys
Med Rehabil 2001; 82(4):485-93.
16. Tabasam G, Johnson MI. International journal of therapy and rehabilitation. 2006
Aug 02; 18(8):357-364.
17. Braggins S. Back A Clinical Approach. Philadelphia: Church Livingstone; 2000. p.
248-252.
18. Starkey C. Therapeutic modalities. 3rd ed. Philadelphia: F.A. Davis company;
2004. p. 257.
19. Liebenson C. Rehabilitation of the spine. 2nd ed. Philadelphia: Lippincott Williams
& Wilkins; 2007. p. 585-611.
.
18
19
20