Rajiv Gandhi University of Health Sciences s18

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

Annexure II

Proforma For Registration Of Subject For Dissertation

FIRDAUS NAZIRAHMED SHAIKH Name of the CITY COLLEGE OF PHYSIOTHERAPY, MANGLORE- 1. candidate and 575016 Address (In Block letters)

2. Name of institution: CITY COLLEGE OF PHYSIOTHERAPY

MASTER OF PHYSIOTHERAPY (MPT) 2 YEARS DEGREE 3. Course of study and COURSE MUSCULOSKELETAL AND SPORTS Subject: PHYSIOTHERAPY.

4. Date of Admission to 22/06/2012 course:

THE EFFECT OF SEGMENTAL STABILIZATION 5. Title of the topic: EXERCISES AND BACK MUSCLE STRENGTHENING EXERCISE ON FUNCTIONAL DISABILITY AND PAIN IN PATIENTS WITH CHRONIC LOW BACK PAIN.

6. Brief resume of the intended work: 6.1) Introduction and need of the study Chronic non-specific low-back pain is one of the most common and expensive musculoskeletal disorders in industrialized countries. Similar to other countries in the world, LBP is a common health and socioeconomic problem in India. Low back pain is defined as pain and discomfort in the lumbosacral region, below the twelfth rib and above the gluteal crease.1 Low back pain is the most frequent self-reported type of musculoskeletal pain, is often recurrent, and has important socio-economic consequences. Estimates of the prevalence of LBP and are as high as 33% for point prevalence, 65% for 1-year prevalence, and 84% for lifetime prevalence.2 According to the recommended diagnostic triage, three types of back pain can be defined: 1) non-specific low back pain; 2) back pain with nerve root symptoms; and 3) back pain resulting from serious pathology (e.g. malignancy, fracture, ankylosing spondylitis, infection). Non-specific LBP, in which there is no recognized patho-anatomic cause, is usually a benign condition but without appropriate management can develop into 1 chronic LBP. Using the traditional classification system, LBP is also categorized according to its duration from onset, as acute (<6 weeks), sub-acute (6 weeks - 12 weeks), and chronic (>12 weeks).3 Chronic LBP remains a common problem that many practitioners have to deal with in primary care, secondary care, and occupational health care. The main objective of treatment for chronic LBP is for the patient to return to their desired level of activities and participation, as well as the prevention of chronic complaints and recurrences. Many treatments are commonly used for LBP such as medication, physiotherapy, and surgery. Many of these interventions have been evaluated in randomized controlled trials and systematic reviews. Evidence shows that the effectiveness of some of the interventions is supported (e.g. exercise), while it shows that other interventions are not effective for LBP (e.g. laser therapy and traction).5 One important risk factor for low back pain is weakness of superficial trunk and abdominal muscles, and strengthening of these muscles is often associated with significant improvements of CLBP, as well as with decreased functional disability. Another independent risk factor for CLBP is the weakness and lack of motor control of deep trunk muscles, such as the lumbar multifidus and transversus abdominis muscles.6 Segmental stabilization exercises are means of achieving stability of the lumbar spine. Thus these exercises improve posture mobility and reduce pain thus improve the quality of life. Back strengthening exercises strengthens the abdominal muscles and extensors of the spine thus providing strong support for the spine, keeping it in alignment and facilitating movements that extend or twist the spine.7,8

Need of the study

A plausible contributing factor to CLBP is poor control of trunk muscles to the exigencies of day-to-day activities. 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.9It has been reported that temporal changes in preprogrammed feed forward adjustments firing patterns, amplitudes of activation and reorganization of trunk muscle representation at the motor cortex can be achieved after specific stabilization exercises focused on transversus abdominis and multifidus co-contraction.10 Improving functional performance in patients with CLBP is of primary importance. The evidence-based primary care options are exercise, laser, massage, and spinal manipulation; however, the latter three have small or transient effects that limit their value as therapies for chronic LBP. In contrast, exercise produces large reductions in pain and disability, a feature that suggests that exercise should play a major role Developing new, more powerful treatments and refining the current group of known effective treatments is the challenge for the future. In the management of chronic LBP.11,12 As there are less evidence on the effects of back muscles strengthening exercises and stabilization exercises on functional disability and pain in patients with CLBP hence the need of the study exists.

Research question

Is there a significant difference in functional disability and pain in patients with chronic low back pain following segmental stabilization exercises and back strengthening exercises?

2 Hypothesis

Alternate hypothesis - There will be significant change in pain and functional disability in patients with chronic low back pain following segmental stabilization exercises and back strengthening exercises.

Null hypothesis- There will be no significant change in pain and functional disability in patients with chronic low back pain following segmental stabilization exercises and back strengthening exercises.

6.2) REVIEW OF LITERATURE

1) Senthil P Kumar (2011) studied on efficacy of segmental stabilization exercise for lumbar segmental instability and classified low back pain into 3 stages and showed the importance of segmental stability exercise in mechanical low back pain.

2) Luque-Suárez., et.al. (2012) conducted a study on stabilization exercises management of low back pain and concluded that these exercises help in improving the stability of lumbar spine in mechanical low back pain.

3) Julie A. Hides., et. al. (2001) studied on long term effects of specific stabilizing exercise for first episode of low back pain and showed that exercise therapy with medical management is more effective than medical alone in treatment of low back pain.

4) Pedro Olavo de Paula Lima., et .al. (2011) showed that measurement from pressure bio feedback units can be used to evaluate the activity of transverses abdominus muscle indirectly and showed that stabilization of transverse abdominus improves low back pain.

5) Stephen Braybrook (2011) studied the function of transverse abdominus in low back pain stability and found no role of this muscle in reducing low back pain.

6) França FR., et .al .(2012) studied on the effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain and concluded that segmental stabilization exercises are more effective then stretching exercises.

7) Berid Rackwitz .,et.al.(2006) studied on the effect of segmental stabilization exercises on low back pain and found out segmental stabilization exercises more effective than treatment by general practitioners but are not effective than other physiotherapy intervention.

3 8) Vesa Lehtola., et .al. (2012) Efficacy of movement control exercises versus general exercises on recurrent sub-acute nonspecific low back pain in a sub-group of patients with movement control dysfunction and showed that the two exercise programs is more effective in reducing the disability associated with LBP.

9) Fábio Jorge Renovato França ., et .al. (2007) studied the lumbar stabilization , strengthening , stretching exercise in chronic low back pain and concluded that stabilization and strengthening exercises are more effective then stretching exercise.

10) Anita Stankovic .,et.al. (2008) studied on spinal segmental stabilization exercises combined with traditional strengthening exercise program in patient with chronic low back pain and proved that these exercises are means of achieving stability of lumbar spine segment and improves posture mobility and reduces pain and improves quality of life.

6.3) OBJECTIVES OF THE STUDY ·

 To assess the effects of segmental stabilization exercises on low back pain.  To assess the effects of back strengthening exercises on low back pain.

 To compare the effects of segmental stabilization exercises and back strengthening exercises on low back pain.

7. MATERIAL AND METHODS

7.1. STUDY DESIGN

Quasi experimental design.

7.2. SOURCE OF DATA

Low back pain patients referred to City Hospital Research And Diagnostic Centre Mangalore.

7.2(I) Definition of study subjects

Low back pain patient aged between 25-60 years.

4 7.2 (II) Inclusion and Exclusion criteria

INCLUSION CRITERIA

 Low back pain for more than 3 month.  Patients willing to participate and could participate in an exercise program safely and without cognitive impairments that would limit their participation.  Patients aged between 25-60 years.  Both male and female.  Informed consent will be taken from the patients.

EXCLUSION CRITERIA

 Past history of back surgery.  Rheumatologic disorders.  Spine infections.  Spine exercise training in the 3 months before study onset.  Non co-operative patients.  Recent traumatic injury to back.

7.2 (III) STUDY SAMPLING DESIGN, METHOD AND SIZE:

SAMPLE – DESIGN

Purposive sampling techniques.

METHOD OF COLLECTION OF DATA

Case study method.

SAMPLE – SIZE

Each group consists of 25 patients fulfilling the inclusion and exclusion criteria.

7.2(IV) Follow Up

Pre test assessment will be taken for functional disability and pain by visual analogical scale, Mc Gill questionnaire and Oswestry disability questionnaire. Post test taken with the same parameter after a period of 6 weeks.

5 .2(V) Parameters and statistical tests used .

Collected data will be analyzed by mean standard deviation and paired and unpaired T test.

2 (VI) Duration of study

Study conducted over duration of 12 months.

II) Methodology

50 patients of low back pain will be selected and randomly divided into two groups A and B.

Pre-test: Both the groups were tested for pain with visual analogical scale and Mc Gill pain questionnaire and functional disability tested by oswestry disability questionnaire. Post test: Patients attended 4 sessions in a week for 6 weeks and were evaluated for pain and functional disability with the same parameters. Group A: Subjects were given segmental stabilization exercises.

Group B: Subjects were given back strengthening exercises.

Procedure :-

Group A patients are taken individually and made to perform the following exercises.

Pilates Exercise:

1) Static Contraction exercise: The subject made to lie on his back with a neutral spine, arms relaxed at sides and palms facing down. Knees are positioned such that feet are flat on the floor and hips width apart. Instruct the patient to inhale and engage the abdominals by drawing navels towards the spine. As he exhales ask him to lift one leg from the hip joint till the knee is at right angle to the torso and shin parallel to the floor. Hold this position for 2 seconds and then bring the knee down. Repeat with other leg. Repeat ten times on each side.

2) Rolling like a ball: The Subject made to sit towards one end of the mat with knees bent close to his chest and a hand holding the outside of each ankle. Instruct the patient to round his spine into ‘C’ Curve and lift feet 1 to 2 inches of the mat so he is balanced on his sit-bones. Draw in the abdominals and exhale. Ask him to roll on his shoulders maintaining the rounded spine. Then ask him to roll forward to starting position. Ask him to inhale as he finds his balance on his sit-bones. Repeat 10 times.

6 3) Bird Dog exercise: The subject on all fours, knees hip width apart and under the hips, hands flat and shoulder width apart. Instruct the patient to squeeze the abdominals by pulling the belly towards the spine and keep the spine neutral. Ask him to extend the right leg back and lift left arm straight ahead. Hold for 2-3 seconds. Repeat 5-6.

Group B patients are taken individually and made to do the following exercises.

1) Bridge exercise: The subject made to lie on his back with knees bent, feet flat on the floor, hip width apart and arms relaxed on the sides. Instruct him to squeeze the buttocks as he lifts his hips creating a straight line from knees to shoulder. Hold for 2-3 seconds and return to starting position. Repeat 10 times.

2) Reverse Fly exercise: The subject made to stand with light dumbbells in hand with knees bent slightly. Instruct the patient to bend forward at the mats keeping back straight till he is parallel to the floor and then raise arms to the sides until they are even to the shoulders. Hold for 1-2 seconds and return to starting position. Repeat 10 times.

3) Lunge: (standing position) Instruct the patient to take a big step forward with his right foot with abdominals gently contracted and hands on the hips. Ask him to sink down so that his right knee is at 90°angle then push back to starting position without pausing. Repeat 10-12 times then switch legs and repeat.

4) Side Plank: The subject is made to lie on right side in a straight line, resting on his forearm and elbow under the shoulders instruct the patient to lift the hips off the floor maintaining the line and keeping the hips square and neck in line with the spine. Hold for 20-40 seconds and lower .Repeat 2-3 times alternating sides.

Outcome measure  Oswestry disability test.  Visual analog scale and Mc Gill pain questionnaire.

7.3 Does the study require any investigation to be conducted on patients or other human or Animal? If so, please describe briefly. Yes

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

7 LIST OF REFERENCES

1) Safoora Ebadi, Noureddin N Ansari, Nicholas Henschke, Soofia Naghdi and Maurits W van Tulder .The effect of continuous ultrasound on chronic low back pain: protocol of a randomized controlled trial. BMC Musculoskeletal Disorders 2011, 12:59.

2) Fabio Renovato França; Thomaz Nogueira Burke; Erica Sato Hanada; Amélia Pasqual Marques. Segmental stabilization and muscular strengthening in chronic low back pain - a comparative study. Sao Paulo 2010 Clinics vol.65 no.10.

3) Anita Lazovic, Kocic Zlatanovic, Stankovic Milica, Mirjan Dragan. Spinal segmental stabilization exercises combined with traditional strengthening exercise program in patients with chronic low back pain.ACTA FAC MED NAISS 2008; 25 (3): 165-170.

4) Dr. Ali Asghar Norasteh.Low Back Pain. Published in print edition May, 2012.

5) Pedro Olavo de Paula Lima, Rodrigo Ribeiro de Oliveira , Leonardo Oliveira Pena Costa ,Glória Elizabeth Carneiro Laurentino .Measurement properties of the pressure biofeedback unit in the evaluation of transversus abdominis muscle activity: a systematic review.Physiotherapy Volume 97, Issue 2, June 2011, Pages 100–106.

6) Julie A. Hides, PhD, MPhtySt, BPhty, Gwendolen A. Jull, MPhty, FACPand Carolyn A. Richardson, PhD, BPhty(Hons). Long-Term Effects of Specific Stabilizing Exercises for First-Episode Low Back Pain. SPINE Volume 26, Number 11, 2011: pp E243–E248.

7) Fábio Jorge Renovato França. Lumbar Stabilization, Strengthening and Stretching in Chronic Low Back Pain. Sao Paulo First Received: May 13, 2010.

8) Vesa Lehtola, Hannu Luomajoki, Ville Leinonen, Sean Gibbons4 and Olavi Airaksinen5. Efficacy of movement control exercises versus general exercises on recurrent sub-acute nonspecific low back pain in a sub-group of patients with movement control dysfunction. Protocol of a randomized controlled trial. BMC Musculoskeletal Disorders 2012, 13:55

9) Stephen Braybrook .Transverse Abdominis (TVA) and its Function in Lower Back Stability listed in back pain, originally published in issue 180 - March 2011.

10) França FR, Burke TN, Caffaro RR, Ramos LA, Marques AP. Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain. J Manipulative Physiol Ther. 2012 May; 35(4):279-85.

8 11) Peter F. Ullrich, Jr., MD.Back Strengthening Exercises.2010.

12) Senthil P Kumar. Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain. N Am J Med Sci. 2011 October; 3(10): 456–461.

13) Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975 Sep; 1(3):277-99.

14) Slade SC, Keating JL. Trunk-strengthening exercises for chronic low back pain: a systematic review. Journal of Manipulative and Physiological Therapeutics 2006, 29(2):163-173.

15) George A Koumantakis, Paul J Watson and Jacqueline A Oldham. Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain. Physical Therapy March 2005 vol. 85 no. 3; 209-225.

16) Rittweger, Jörn MD,; Just, Karsten MD,; Kautzsch, Katja MsPsych,‡; Reeg, Peter MD,; Felsenberg, Dieter PhD .Treatment of Chronic Lower Back Pain with Lumbar Extension and Whole-Body Vibration Exercise: A Randomized Controlled Trial(1) September 2002 - Volume 27 - Issue 17 - pp 1829-1834.

17) Petersen, Tom PT, BSc,; Kryger, Peter MD, PhD,; Ekdahl, C. PT, PhD,; Olsen, Steen PT, MDT; Jacobsen, Sore MD, PhD. The Effect of McKenzie Therapy as Compared With That of Intensive Strengthening Training for the Treatment of Patients With Sub acute or Chronic Low Back Pain: A Randomized Controlled Trial 15 August 2002 - Volume 27 - Issue 16 - pp 1702-1709.

18) Pedro Olavo de Paula Lima, Rodrigo Ribeiro de Oliveira, Leonardo Oliveira Pena Costa, Glória Elizabeth. Measurement properties of the pressure biofeedback unit in the evaluation of transversus abdominis muscle activity: a systematic review. Physiotherapy 1 June 2011 (volume 97 issue 2 Pages 100-106.

19) Luque-Suárez., et.al.A study on stabilization exercises management of low back pain .volume 17, 2012; 305-315.

20) Annette A Harte1, George D Baxter2 and Jacqueline H Gracey The effectiveness of motorized lumbar traction in the management of LBP with lumbo sacral nerve root involvement: a feasibility study BMC Musculoskeletal Disorders 2007, 8:118

9 21) Nick kofotolis and eliftherios kellies. Effects of Two 4-Week Proprioceptive Neuromuscular Facilitation Programs on Muscle Endurance, Flexibility, and Functional Performance in Women With Chronic Low Back Pain. Physical Therapy July 2006 vol. 86 no. 7 1001-1012

22) Lynne Shaw. The Best Transverse Exercise. Jun 27, 2011

23) Meg Campbell. Which Pilates Exercise Will Engage the Transverse Abs. Jun 10, 2011.

10 9 SIGNATURE OF THE CANDIDATE

Appropriate and feasible study 10 REMARKS OF GUIDE recommended

NAME AND DESIGNATION (in BHARATH K. H. 11 Block Letters) PRINCIPAL 11.1 GUIDE

11.2 SIGNATURE

ARUN KUMAR 11.3 CO GUIDE (If any) ASSISTANT PROFESSOR

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT NA

11.6 SIGNATURE ------

12.1 REMARKS OF THE TOPIC IS APPROPRIATE AND HAS 12 CLINICAL APPLICATIONS. CHAIRMAN AND PRINCIPAL RECOMMENDED.

12.2 SIGNATURE