Download Rajiv Gandhi University of Health Sciences

Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1.
Name of the Candidate and
CHAUHAN MAYANK DINESH BHAI
Address
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
MAINA TOWERS, BALLALBAGH,
MANGALORE-3.
2.
Name of the Institution
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
MAINA TOWERS, BALLALBAGH,
MANGALORE- 3.
3.
Course of study and subject
MASTER OF PHYSIOTHERAPY (MPT)
2 YEARS DEGREE COURSE
PHYSIOTHERAPY IN SPORTS AND
MUSCULOSKELETAL INJURY
4.
Date of Admission to Course
15th APRIL 2008.
5.
Title of the Topic
“TO COMPARE THE EFFECTIVENESS OF TWO
DIFFERENT EXTENSORS EXERCISES IN
REDUCING PAIN AND IMPROVING
FUNCTIONAL ABILITY IN PATIENTS WITH
CHRONIC MECHANICAL LOW BACK PAIN”.
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6.
Brief resume of the intended work:
6.1 Need for the study
Low back pain an extremely common symptom in general population and among
athletes and has galaxy of causative factors both spinal and extraspinal like .non osseous
injury, inter-vertebral disc problems, stress fracture of pars inter-articularis, SI joint injury,
lumbar instability, spinal canal stenosis etc.
Low back can be of mechanical or non mechanical in nature. The some of peculiar
features of mechanical low back pain are
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: pain is cyclic in nature, low back pain is
referred to buttocks and thigh, morning stiffness or pain is uncommon, start pain (i.e. when
starting movement ) is common, there is pain on forward flexion and returning to erect
position, pain is often aggravated by extension , side bending, rotation, standing, exercise
in general ,pain usually becomes worse over the course of the day ,pain is relieved by a
change of position ,pain is relieved by lying down , especially in the fetal position.
According to duration of symptoms low back pain is classified :
Acute low back pain : less than 7 days
Sub acute low back pain: 7 days to 3 months.
Chronic low back pain: more than 3 months.
Low back pain is second leading cause of man power loss in many countries,
decreases or result in loss of working hours. . It is seen in 80% of general population
during any period of life 2, 3.
Low back pain progresses in an undulating pattern. In 90% of acute low back pain,
the symptoms resolve within 2-4 weeks, however in a study by Papageourgiu et al4, it has
showed second attack of pain within first year. The reason for those reoccurrence is
unclear. An important cause is considered to be hyper-mobility of moving segment of
lumbar vertebrae.5 And out of this 10%of population have chronic low back pain .4
Many authors have highlighted the importance of lumbar multifidus muscle..
Multifidus being medial most muscle in spine thus referred as local muscles ., Authors
have highlighted the importance of lumbar multifidus muscle in providing the dynamic
control.7,8,9,10,11
According to Bergmark, Back muscles are divided into local and global muscle
system by seeing muscle in isolation and not taking there intriniate functions. Local
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muscles are referred to those attaching directly to lumbar vertebrae and responsible for
segmental stability and controlling positions of lumbar segments12. Global muscles are
described as large torque producing muscles linking pelvis to thoracic cage. Thus helps in
trunk stabilization and help to minimize resulting force on spine.
Moreover some studies showed the atrophy of multifidus and erector spinae
muscles in patients with mechanical chronic low back pain patients, where multifidus
atrophy was more pronounced.6, 13, 14
Thus when multifidus was atrophied results in loss of strength, endurance, muscular
dysfunction shifts force from facet joints to inter-vertebral disc and ligament in forward
flexed posture further suggesting independence of stabilizing subsystem. However global
muscle fails to have local segmental attachment s necessary to create stability in normal
manner. Over activity of global muscle is in form of inappropriate co-contraction which
may result in excessive compressive forces and ultimately results fatigue 15.
The stabilization exercise are designed to improve function of muscles that are
believed to govern stability, when these muscles are functioning optimally , they will
protect the spine from trauma.17
Thus segmental stabilization exercises are commonly used in clinical practice to
treat patients with mechanical chronic low back pain.17, 19 A study shows recruitment of
above mentioned multifidus muscle in specific back extensor exercises18.
Hence the aim of the study is to compare the effectiveness of two different extensor
exercises in reducing pain and improving functional ability in patients with mechanical
chronic low back pain.
RESEARCH QUESTION :
Whether the exercise in quadruped position or the exercise in bridging position
will be effective in reducing pain and improving ADL in patients with mechanical chronic
low back pain.
NULL HYPOTHESIS:
There will be no significant difference between effectiveness of quadruped v\s
bridging exercises in patients in reducing pain and improving functional ability in patients
with mechanical chronic low back pain.
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ALTERNATE HYPOTHESIS:
There will be significant difference in effectiveness of quadruped v\s bridging
exercise in reducing pain and improving functional ability in patients with mechanical
chronic low back pain.
6.2 Review of literature
Low back pain is major cause of man power loss in many countries2. It is seen
in 80% of general population during any period of life.
In recent CT study, there is selective atrophy of multifidus muscle in Chronic
low back pain1. In another study by Kader et al, multifidus atrophy was present in 80% of
patients with low back pain. Parkola et al, found a higher amount of fat deposits in erector
spinae and multifidus muscles of patients with chronic low back pain than in healthy
controls on MRI sections6. Atrophy was most prominent in multifidus muscle of patients
with chronic low back pain to varying degrees14.
According to study by Bergmark, back muscles are divided into global and
local muscles system refers to functional classification to discriminate between muscles
responsible for intersegmental stability (local) and spine motion (global) based on anatomy
division proposed in 198912.
According C.A.Richardson and G.A. Jull, stated “Evidence of the importance
of local muscles in stabilization of lumbar spine as well as their proven dysfunction in low
back pain population, led us to focus in these muscles in rehabilitation of active
stabilization of lumbar spine19.
According to Bergmark in 1989, in his dissertation on lumbar spine stability
proposed a difference between local and global muscles. Global muscles are described as
large torque producing muscles linking pelvis to thoracic cage. Their role is to provide the
general trunk stabilization such muscles help to minimize the resulting force on spine.
Local muscles are referred to those attaching directly to lumbar vertebrae.
These muscles are considered to be responsible for segmental stability as well as
controlling the positions of lumbar segments19.
Low loads have another benefit in therapeutic exercise aimed at restoring joint
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stabilization. The restoration of tonic function in the muscles requires only low levels of
muscle contraction as tonic fibers operate at levels below approximately 30% to 40%
MVC. (MC Ardle et al 1991)16, additionally it has been argued that only low level of
muscle force approximately 25% of MVC are needed to develop increase muscle stiffness
require for enhancing spinal stability19.
Studies done by Richard A. et al, showed that the multifidus is recruited to
more than 25% Maximum Voluntary Contraction (MVC) that is in 4 points kneeling and
bridging exercises18.
The local muscles functions to control the segmental stiffness is independent of
global muscles which is responsible for balancing external load.19
6.3 Objectives of the study
1. To study the effectiveness of the extensor training in quadruped positions in
patients with mechanical chronic low back pain.
2. To study the effectiveness of the extensor training in bridging position in patients
with mechanical chronic low back pain.
3.
To compare the effectiveness of two different extensor exercises in patients with
mechanical chronic low back pain.
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7.
Material and methods:
7.1 Source of data
1. Government Wenlock District Hospital, Mangalore.
2. Shree Devi College of Physiotherapy, Mangalore.
7.2 Method of collection of data
.
40 chronic mechanical low back pain patients fulfilling inclusion criteria will be
asked to sign the consent form for voluntary participation in my study.
Study design: Cohort comparative study.
Sampling
: Block randomization sampling.
Methodology:
40 Chronic mechanical low back pain patients fulfilling inclusion criteria will be
divided into 2 groups, each group consists of 20 patients. All the data regarding patient’s
disease and symptoms will be collected and thorough examination of the patient will be
done. Pain and functional ability of patients will be checked before and after each session
of treatment. To measure pain by VAS scale and functional ability by Revised Oswestry
Disability Index will be used . During the treatment hold period and relaxation period will
be recorded by using the stop watch.VAS score and Oswestry Disability index score will
be taken before starting the treatment for the 1st week and then VAS and Oswestry
Disability Index score will be taken at the end of the 4th weeks. This pre and post scores
will be used for the statics analysis.
Group A:
Sessions will start with 10min of moist heat with the patients in prone position
then proceeds to a quadruped (4 points kneeling position) with contra lateral arm and leg
raise.
One set consists of 10 repetitions; one repetition is held for 10 seconds and
followed by 10 seconds rest between each successive repetition, and the rest period of 1
min between the 2 successive sets.
Patients are asked to perform 3 sets per session per day. This procedure is
performed on each alternate day for 4 weeks.
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Group B:
Sessions will start with 10min of moist heat with the patients in prone position
then proceeds to a bridging position.
One set consists of 10 repetitions; one repetition is held for 10 seconds and
followed by 10 seconds rest between each successive repetition, and the rest period of 1
min between the 2 successive sets.
Patients are asked to perform 3 sets per session per day. This procedure is
performed on each alternate day for 4 weeks.
Inclusion criteria:
1. Patients diagnosed as mechanical chronic low back pain by physical, orthopedic
and between the age group of 20-50years.
2. Patients are selected on the basis of Isometric extensor test.
3. Patients who have been suffering from low back pain since 3 months.
Exclusion criteria:
1. Previous lumbar surgery
2. Spinal abnormalities
3. Neuromuscular or joint diseases
4. Evidence of systemic diseases
5. Carcinoma of bones
6. Pregnancy
7. Evidence of spondylolisthesis.
8. Osteoporosis
9. Osteoarthritis of lower extremity
10. Disc Pathology and patients with nerve root or nerve compression symptoms.
11. Infectious diseases affecting spine like Tuberculosis of Spine, Osteomyelitis etc.
12. Patients with prolonged steroid therapy
13. Patients carrying out fitness training for low back muscles over the preceding 3
months.
14. Patients with acute low back pain.
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Statistical analysis:
1. Paired “t” test.
2. Unpaired “t” test.
Tools used:
1. Isometric Extensor test
2. Revised Oswestry disability index
3. Visual Analog Scale
4. Stop watch
Outcome measures:
1. Pain
2. Functional ability
7.3 Does the study require any investigations or any interventions to be conducted on
patients or other humans or animals? If so, please describe briefly.
Yes.
Patients will receive exercise programme with Quadruped and bridging exercises.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes
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8.
List of Reference:1. Waddell, G: The back pain resolution. New York , Churchill livingstone,1998.
2. Mayer T G, Vanharanta H, Gatechel RJ, et al. Comparison of C T scan muscle
measurement and isokinetic trunk strength in post operative patients. Spine
1989:14:33-36.
3. Glazer P A, Clamen L M. Differential diagnosis and management strategies of
low back pain .In Aronoff G M, ed. Evaluation and treatment of chronic pain,
3rd Baltimore: Williams and wilkins,1998;225-235.
4. Pagageorgiou A C, Croft P R, Thomas E, Ferry S, Jayson M J, Silman A J.
influence of previous pain experience or the episode incidence of low back
pain: results from the south Manchester back pain study. Pain 1996:66:181185.
5. Hodges P W. The role of motor system in spinal pain. Implications for
rehabilitation of athletes following low back pain. J Sci. med sports
2000:3:243-253.
6. Parkola R, Rytokoshi U, Kurmano M .Magnetic resonance imaging of the
discs and trunk muscles in patients with chronic low back pain healthy control
subjects .Spine 1993:18:830-836.
7. Kader D F, Wardlaw D, Smith F W. correlation between MRI in the lumbar
Multifidus muscles and leg pain. Clinical radiology 2000:55:145-149.
8. Punjabi M. The stabilizing system of the spine .Part 1 function, dysfunction,
adaptation and enhancement .J Spine Disoord 1992:5:383-9
9. O Sullivan P, Phyty G, Twoomey L, et al. Evaluation of specific stabilizing
exercise in treatment of chronic low back pain with radiological diagnosis of
spondylosis or spondylolisthesis . Spine 1997:22:2959-67.
10. Dannels L A, Vznderstraeten G, Chembier D C, et al. A functional subdivision
of Hip, abdominal, and back muscles. During asymmetric lifting. Spine 2001
:26:E 114-21
11. Goel V, Kong W, Hang J et al. A combined finite element and optimization
Investigation of lumbar mechanics with and without muscles. Spine
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1993:18:1531-41.
12. Bergmark A (1989) stability of lumbar spine. A study in mechanical
engineering. ACTA ORTHO SCAND 230 (SUPPL) 20-24
13. Rantanen J, Hurme M, Falck B, et al. The lumbar multifidus muscles five
years after surgery for lumbar I.V. disc hearniation. Spine 1993:18:568-574.
14. Muzeyyen Kamaz, et al. CT measurement of trunk muscle areas in patients
with chronic low back pain. Diagnostic and interventional radiology 2008:1-7.
15. Kenneth Edwards Learman. Treatment effects of spinal manipulation on
propioception in subjects with chronic low back pain. University of
pittsburg 2007.(unpublished dissertation).
16. Mc Ardle W D, Katch F L, Katch V L , 1991 exercise physiology, energy,
nutrition and human performance 3rd edition .Lea
and
febizer.
Philadelphia ch 20p 384-417.
17. Cholewici J, Van Vliet J J (2002). Relative contribution of trunk muscles to
the stability of the lumbar spine during the isometric exertions. Clinical
biomechanics17:99-105.
18. Richard A Estron, Robert A Donatelli, Kenji . C .Carp. Electromyographic
analysis of core trunk, hip and thigh muscles during 9 rehabilitation exercises.
J Ortho Sports Phys Ther 2007:37(12):754-762. Doi: 10.2519/jospt.2007.2471
19. C.A.Richardson and G.A.Jull. Muscle control –pain control. What exercises
would you prescribe? Manual therapy 1995:1:2-ISO.
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9.
Signature of the Candidate
10.
Remark of the Guide
11.
Name and Designation of
DR. MURALEEDHARAN
(In Block Letters)
VICE-PRINCIPAL,
11.1 Guide
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE- 3.
11.2 Signature
11.3 Co-guide
11.4 Signature
11.5 Head of department
DR. S. PADMAKUMAR
11.6 Signature
PRINCIPAL,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE- 3.
12.
12.1 Remark of the
Chairman and Principal
12.2 Signature
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