Rajiv Gandhi University of Health Sciences, Karnataka s40

Rajiv Gandhi University of Health Sciences, Karnataka Bangalore

ANNEXURE II

JAYANTA PHATOWALY 1. Name of the Candidate and DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY Address (in block letters) VIDYANAGAR KULOOR,MANGALORE-575013

2. Name of the Institution DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY

3. Course of Study and Subject MASTER OF PHYSIOTHERAPY MUSCULO SKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY

4. Date of Admission to Course 31st May 2010

5. Title of the Topic COMPARATIVE STUDY BETWEEN THE EFFECTIVENESS OF CERVICOTHORACIC MOBILIZATION WITH LASER AND CERVICOTHORACIC MOBILIZATION ALONE IN MECHANICAL NECK PAIN

6. BRIEF RESUME OF THE INTENDED WORK:

6.1) INTRODUCTION AND NEED OF THE STUDY:

Neck pain is a common musculoskeletal problem. Most often neck pain has no specific cause and hence regarded as non specific/mechanical neck pain.1 Mechanical neck pain affects 45% to 54% of the general population at some time during their lives2 and can result in severe pain and disability.3 There are various factors contributing to neck pain, the most common cause being postural abnormality. Posture plays an important role in cervical spine as it does in thoracic and lumber spine, and the role of cervical spine in postural control is well noted. Any attempts to alter the cervical spine posture must include an evaluation of the thoracic spine and shoulder region, as the muscles involve in postural control are multijoint muscles spanning these regions. Changes in the length of these muscles due to abnormal posture have a profound effect on cervical spine. Changes in the strength of scapula stabilizers also alter the resting position of the neck.12

Spinal manipulation or mobilization is commonly used in the management of mechanical neck disorders.4 Cervicothoracic mobilization helps in reducing mechanical neck pain to a greater extent compared to other forms of mobilization.5,8,9 Several studies have demonstrated that spinal manipulation aimed at cervical spine is an effective intervention for reducing pain and increasing mobility in patients with mechanical neck pain.6,7 Low level laser therapy has been proven to produce pain relief in mechanical neck pain which is well supported by literature10,11 But there is lack of experimental data regarding the comparative effectiveness of cervicothoracic mobilization with laser versus cervicothoracic mobilization alone in the treatment of mechanical neck pain.

Need of the study:

Previous studies have shown that low level laser therapy is an effective modality to decrease pain in patients with mechanical neck pain.10,11 Recent articles show that cervicothoracic mobilization is very effective in pain reduction in cervical region.5,8,9 But there is a lack of evidence revealing the comparative effectiveness of cervicothoracic mobilization in combination with laser therapy versus cervicothoracic mobilization alone in patients with mechanical neck pain. So there is a need to find out the comparative effectiveness of both the interventions.

Research Question:

Whether the combined treatment of cervicothoracic mobilization with laser therapy will bring out better improvement in patients with mechanical neck pain as compared with cervicothoracic mobilization alone?

Hypothesis:

Null hypotheses: There will be no significant difference in pain reduction following cervicothoracic mobilization in combination with laser therapy compared to cervicothoracic mobilization alone in patients with mechanical neck pain.

Alternative hypotheses: There will be a significant difference of pain reduction following cervicothoracic mobilization in combination with laser therapy compared to cervicothoracic mobilization alone in patients with mechanical neck pain.

6.2) REVIEW OF LITERATURE:

Bronfort G et al performed a study to check the effectiveness of various interventions in patients with neck pain and cervicogenic headache and has concluded that manual therapy is a superior form of intervention for treating patients with neck pain then compared to other forms of interventions.13,14,15,16

Porterfield and DeRosa, Greenmam conducted a study on the biomechanical relation of the cervical and thoracic spine as a causative factor in the development of neck disorder and the results suggested that there is a strong relationship between the disturbance of joint mobility in the thoracic spine and the development of neck disorder.17,18

Vicenzino et al,Gross AR et al did a study using mobilization/manipulation of the cervical region and the results demonstrated an immediate hypoalgesic effect in patients suffering from neck pain.19,20

Ceser Fernandez-de-las-Penas et al conducted a study on change in the pain threshold over C5-C6 Zygopophyseal joint after a cervicothoracic junction manipulation in healthy subjects andfound out that C7-T1 manipulation induced changes in pressure pain threshold in both right and left C5-C6 Zygapophyseal joints in healthy subjects.21

Flynn et al did a study on the effectiveness of thoracic spine mobilization on patients with primary neck dysfunctions and found out that thoracic spine manipulation/mobilization results in immediate reduction of pain and increase cervical range of motion.22

Efficacy of low level laser therapy in the management of neck pain: a systemic review and meta analysis of randomized placebo or active treatment was conducted by Roberta T Chow et al by identifying 16 randomized controlled trials including a total of 820 patients and the results suggested that low level laser therapy reduces pain immediately in patients with acute neck pain.23

Bijur PE et al carried out a study to determine the reliability and validity of visual analogue scale(VAS) for patients with acute neck pain and concluded that VAS is a reliable and valid instrument to access pain intensity in patients with acute neck pain.24

Vernon H, Mior S conducted a study to check the reliability and validity of Neck Disability Index(NDI) and the result demonstrated that NDI is a reliable and valid instrument for the assessment of disability in patients with neck pain.25 6.3) OBJECTIVES OF STUDY:

1) To find out whether the application of cervicothoracic mobilization with laser therapy can reduce pain and increase mobility in patients with mechanical neck pain.

2) To find out whether the application of cervicothoracic mobilization alone can reduce pain and improve mobility in patients with mechanical neck pain.

3) To compare the efficacy of cervicothoracic mobilization with laser versus cervicothoracic mobilization alone in reducing pain and improving mobility in mechanical neck pain. 7.

MATERIALS AND METHODS :

7.1) Study Design:

Comparative Study

7.2) Source of data:

Patients suffering from neck pain referred to physiotherapy by physician or orthopaedic surgeon in and around Mangalore.

7.2(I) Definition of Study Subjects:

Patients between 18 to 60 years of age with a primary complaint of non specific neck pain.

7.2(II) Inclusion and Exclusion Criteria:

Inclusion Criteria:

1) Both Male and Female 2) Age:18 to 60 years 3) Primary complaint of neck pain which increases with neck movements. 4) Informed consent by the patient.

Exclusion Criteria:

1) History of whiplash injury or any recent trauma. 2) Diagnosis of spinal stenosis, spondylolisthesis, spondylolysis. 3) Upper extremity syndrome, radicular signs and symptoms. 4) Evidence of CNS involvement-nystegmus, vertigo. 5) Spinal tumours, fractures. Infection, osteoporosis. 6) History of cervical or thoracic injury. 7) Hyper mobility of thoracic spine. 7.2(III) Study Sampling Design, Method and Size:

Sample design:

Purposive sampling technique.

Sample size:

40 symptomatic subjects fulfilling the inclusion and exclusion criteria.

7.2(IV) Follow Up:

Pre-Treatment assessment will be taken for pain and range of motion followed by intervention of frequency thrice a week for 4 weeks. Post intervention assessment will be taken for the same parameters.

7.2(V) Parameters used for comparison and statistical analysis used:

Paired‘t’ test and unpaired‘t’ test.

7.2(VI) Duration of study:

The study will be conducted over a duration of 12 months

7.2(VII) Methodology:

40 subjects fulfilling the inclusion and exclusion criteria will be recruited for the study. Informed consent will be obtained from the patients. Then the patients will be randomly divided in to 2 groups i.e. group A and group B, having 20 subjects in each group.

Pre treatment assessment of pain and neck movement will be noted for both the groups. Visual Analogue Scale and Neck Disability Index will be used to measure the pain intensity and range of motion.

After a brief introduction about cervicothoracic mobilization and laser therapy;

Group A subjects will receive cervicothoracic mobilization with laser. And

Group B subjects will receive cervicothoracic mobilization alone. On the same assessment parameters, post-treatment assessment of pain and range of motion will be taken at the end of the 4th week, for both the groups, for comparison with the pre- treatment assessment data.

PROCEDURE:

Cervicothoracic Mobilization:

1)Posteroanterior central vertebral pressure:

PATIENTS POSITION: Patient lies prone with his forhead resting on the back of his hand or with his head completely turned to one side and his arms lying by his side on the couch.

THERAPISTS POSITION:The therapist is at the head end of the patient with his shoulders over the area to be mobilized to enable the direction of the pressure to be at right angles to the surface of the body.

METHOD: The pads of the thumbs are placed on the spinous process pointing transversly across the vertebral coloumn and the fingers of each hand are spread out over the posterior chest wall to give stability to the thumb. The pressure is transmitted through the thumb so that the IP joints are hyperextended enabling the softest part of the pad to be flat over the spinous process and with a degree of flexion in metacarpophalangeal joints. The mobilization is carried out by an oscillating pressure on the spinous process produced by the body and transmitted through arms to the thumbs. It is important that this pressure be applied by the body weight over the hands and not by a squeezing action with the thumb themselves.

2)Posteroanterior unilateral vertebral pressure:

PATIENTS POSITION: Subject lies prone with head turned to any side. Because of the curve of the thoracic spine it is necessary when mobilizing the upper levels.

THERAPISTS POSITION: The therapist should stand either at the patients head end or towards the shoulder of the side being mobilized.

METHOD: A very steady application of pressure is necessary to be able to move some of the muscle belly out of the way to make bone to bone contact.Once the required depth has been reached the oscillating movement is produced by increasing and then decreasing the pressure produced by the trunk movement. It is done on the painful side. DURATION:

3 sessions per week on alternate days. 10 glide repetition Hold time- 5-10 seconds

PATIENTS POSITION: Patient will lie prone in position of maximum comfort. Marks are made on the surface of the skin with maximum discomfort. Whole body is covered except the part to be treated.

THERAPISTS POSITION: Therapist stands at the head end of the couch.

PRECAUTION: Both the patient and the therapist should wear protective goggles for safety.

PARAMETRES: Low Level Laser Therapy Dose: 820-830nm at 0.8-9.0J per point Irradiation time: 3 minutes 3 times per week for 4 weeks

7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly. N

Visual Analogue Scale (VAS)-For pain assessment.

Neck Disability Index (NDI) –For disability assessment in neck pain.

7.4) Has ethical clearance been obtained from your institution in case of 7.3.

YES 8. LIST OF REFERENCES:

1. Bogduc N, Aprill C. On the nature of mechanical neck pain, discography and cervical zygapophyseal joint blocks.Pain 1993;54:213-7.

2. Cote P, Cassidy JD,Carroll L. The factors associated with neck pain and its related disability in the Saskatchewan population.Spine 2000;25:1109-17

3. Cote P,Cassidy JD, Carroll L. The Saskatchewan health and back pain survey.The prevalence of neck pain and related disability in Saskatchewan adults.Spine 1998;23:1689-98.

4. Howing JL, Gross A, Gasner D,et al.A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain.Spine 2001;26:196-205.

5. Cleland J et al. Immediate effects of thoracic manipulation in patients with neck pain.Man Ther 2005;10:127-35.

6. Vernon HT et al. Pressure pain threshold evaluation of the effect of spinal manipulation in the treatment of chronic neck pain:A pilot study. J Manipulative physiol ther 1990;13:13-6.

7. Schalkwyk RV, Parkin Smith GF. A clinical trial investigating the possible effects of the spine. Cervical rotator manipulation and supine lateral break manipulation in the treatment of mechanical neck pain; A pilot study. J Manipulative Physiol Ther 2000;23:324-31.

8. Edmondston SJ, Singer KP. Thoracic spine :Anatomical and biomechanical considerations for manual therapy. Man Ther 1997;2:132-43.

9. Maitland G, Hengeveld E, Banks K, English K.Maitlands vertebral manipulation.6th ed London,England:butterworth Heineman;2000.

10. Enwemeka CS et al: The efficacy of low power laser in tissue repair and pain control:a meta analysis study. Photomed laser surge 2004;22:232-29

11. Walker J. Relief from chronic pain by low power irradiation. Neurosky Lett 1983;43:339- 44.

12. Carrie M Hall, Lori Thein Broody. Therapeutic exercise moving towards function, 2nd edition, Lippin Cott Williams and Wilkins 1999;pp-541

13. Bronfort G et al. Efficacy of spinal manipulation for chronic headache : A systematic review. Journal of manipulative and physiological therapeutics 2001a;24(7):457-66 14. Bronfort G et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001b;26(7):788-99.

15. Hoving JL et al. manual therapy, physical therapy or continued care by a general practitioner for patients with neck pain. Annals of internal medicine 2002;136(10):713- 22.

16. Jull G et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.spine 2002;27(17):1835-43.

17. Porterfield JA, DeRosa C. Mechanical neck pain: perspective in functional anatomy. Philadelphia, PA:W.B. Saunders;1995.

18. Greenman PE. Principles of manual medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins 1996.

19. Vicenzino B. Collins D, Benson H, Wright A. An investigation of the interrelationship between manual therapy-included hypoalgesia and sympathoexcitation. Journal of manipulative and physiological therapeutics. 1998;21(7):448-53

20. Gross AR, Kay T, Hondras m,et al. manual therapies for mechanical neck disorders A systemic review. Manther 2002;7:131-49.

21. Cesar Fernandez-de-las-penas et al. journal of physical therapy 2008.04 volume page no.006.

22. Flynn T, Wainner R, Whitman J,Childs JD. The immediate effect of thoracic spine manipulation on cervical range of motion in pain in patients with a primary complaint of neck pain-a technical note. Journal of orthopaedic and sports physical therapy,2004, in review.

23. Chow RT, Barnsley I. a systemic review of literature of low level laser therapy in management of neck pain laser surge med 2005;37:46-52.

24. Bijur PE, Siver W , Gallagher JE. reliability of visual analog scale for measurement of acute pain. Academy Emergency medicine 2001;8(12):1153-7.

25. Vernon H, Mior S. the neck disability index: a study of reliability and validity. Journal of manipulative and physiological therapeutics 1991;14(7):409-15.