Rajiv Gandhi University of Health Sciences s136

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE KARNATAKA

ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

BRIEF RESUME OF THE INTENDED WORK 1 NAME OF THE CANDIDATE SHYAMLI SHARMA

INTRODUCTIONAND ADDRESS #158/1 CHANNI HIMMAT JAMMU & KASHMIR

Back pain is common in normal pregnancy and high incidences have been described in several studies. Apart from classification according to incidence, frequency & intensity, it has been 2 NAME OF THE KRUPANIDHI COLLEGE OF PHYSIOTHERAPY, emphasized that back pain in pregnancy also should be classified as lumbar back pain and/ or pelvic INSTITUTION BANGALORE pain.7,9,2

3 COURSE OFThe THE risk STUDYof lumbopelvic pain in pregnancy is MASTERincreased in OF women PHYSIOTHERAPY with a history of back pain ANDbefore SUBJECT pregnancy2,6 & a correlation between menstrual( painMUSCULOSKELETAL & low back pain before AND and SPORTSduring pregnancy ) has been reported.

4 DATE OF ADMISSIONRegression of lumbopelvic pain after pregnancy has been15 FEBRUARY described to be2007 incomplete and 10% toTO 20% COURSE of women with chronic lumbopelvic pain claimed that the initial appearance was in connection with the pregnancy4. Post partum low back pain has been correlated with high pain intensity during pregnancy. 5 TITLE OF THE TOPIC:

Pregnancy – related pelvic girdle pain occur during pregnancy or within first 3 weeks after THE EFFICACY OF TREATMENT PROGRAM FOCUSING ON SPECIFIC delivery. Lumbar pain during pregnancy originates in the lumbar spine region and is a different syndrome STABILIZING EXERCISES FOR LOW BACK ACHE AFTER PREGNANCY. than pregnancy – related pelvic girdle pain.1,2

The etiology behind lumbopelvic pain is still unclear, but both biomechanical and/or hormonal factors are being discussed. The prevalence of back pain 2 to 18 months postpartum is reported to be from 2% to 65.7,8

The obvious cause of lower back pain is the biomechanical stress being placed on the mother by the added weight of body. As the baby gains weight the mother is pulled forward in order to compensate for this forward pull, the mother has to lean her upper body backward. This puts tremendous amount of pressure on the back & pelvis.

Pain commonly occurs because of the postural changes of pregnancy, increased ligamentous laxity & decreased abdominal functions.3

Most often the pain disappears within 1 to 3 moths after delivery5,6 however substantial numbers of women do not recover after delivery, lumbopelvic pain, especially after delivery may be a serious problem for the individual’s family and society. This is reflected by the inability to perform daily activities or to earn a living and by a reduced health related quality of life.

The aim of the present study is to evaluate whether specific stabilization exercises in the treatment of patient with low back pain after pregnancy reduce the pain, improve functional status, and improve health- related quality of life after the treatment.

6.1 NEED FOR THE STUDY

The incidence of low back ache is higher after pregnancy. Low back pain after pregnancy is a serious problem for individual, her family and society, there is the inability to perform daily activities.

Thus, the purpose of the intended study is to compare the effect of physical therapy with stabilization exercises and physical therapy without specific stabilization exercises on low back ache after pregnancy.

6.2 REVIEW OF LITERATURE

Pennick VE, Young G (2007) 10 in their study found that for women with low back ache specifically tailored strengthening exercises, sitting pelvic tilt exercise program &water gymnastics reduced pain better than usual prenatal care alone.

Rackwitz B, Limmh, Wessels T, Ewert T, Stucki G (2007)11 in their study found that specific stabilizing exercises can be learnt by majority of the participants of a group program for the prevention of low back pain. Additionally, specific stabilizing exercise reduces present low back pain and so can help people with low back pain to help themselves.

Paulo Hferreira, Manuela, L Ferrerira Christopher G Maher, Robert D Herbert (2006)12 compared specific stabilization exercise plus conventional physiotherapy program [ modalities, spinal manipulation &ergonomic advice] to a conventional physiotherapy alone for patients with pelvic girdle pain. When added to conventional physiotherapy program specific stabilization exercises were more effective than conventional physiotherapy alone

F. JM Whitman JM, Childs JD (2005)13 in their study found patient with low back pain judged to have lumbar hypomobility experienced greater benefit from an intervention including manipulation those judged to have hypermobility were more likely to benefit from stabilization exercise program.

Inger Halm, Britt Stuge and Ninavollestad (2005)14 in their study found that the individualized and supervised treatment program focusing on the local system with gradual addition of exercises for the global system showed better results and a high compliance.

Havden JA, Van Tulder MW, Tomlinson G (2005)15in their study found that exercise therapy that consists of individually designed programs, including stretching and strengthening and is delivered with supervision may improve pain and function in chronic low back pain.

Elden, Ladforsl, Olsen MF, Ostgaard HC, Hagberg H (2005)16 in their study found that stabilizing exercise constitute efficient comliments to standard treatment for the management of pelvic girdle pain during pregnancy.

Britt stuge, Even Laerum, Gitle Kirkesola and Nina Vallestad (2004)17 in their study found that after intervention and at one year post partum the specific stabilizing exercise group showed statistically and clinically significant lower pain intensity, lower disability and higher quality of life as compared to group without specific stabilizing exercises in women with pelvic girdle pain.

Stuge, Britt, Veierod, et al (2004)18 in their study found significant differences between the groups persisted with continued low levels of pain and disability in the specific stabilizing exercises group 2 years after delivery.

Hides, Julie a, Jull, et al (2001)19 in their study found that long term results suggest that specific stabilization exercise therapy is more effective in reducing low back pain recurrences than medical management and normal activity alone.

6.3 OBJECTIVE OF THE STUDY

a) OBJECTIVES  To assess the effectiveness of physical therapy with specific stabilization exercises in low back ache after pregnancy.  To assess the effectiveness of physical therapy without specific stabilization exercises in low back ache after pregnancy.  To compare the effect of physical therapy with specific stabilization exercises and physical therapy without specific stabilization exercises.

b) HYPOTHESIS

 NULL HYPOTHESIS: Both physical therapy with specific stabilization exercises and physical therapy without specific stabilization exercises are equally significant in improvement of low back ache after pregnancy.

 EXPERIMENTAL HYPOTHESIS: There is a significant improvement in low back ache after pregnancy with specific stabilization exercises.

MATERIAL AND METHODS

7.1 SOURCE OF DATA:

(a) POPULATION

 VARIOUS HOSPITALS IN BANGALORE.

(b) SAMPLE SIZE

 30 subjects of age 25-35 years satisfying the inclusion criteria are selected from the population and randomly assigned in 2 groups.

 Group 1 – Physical therapy with specific stabilization exercises group(15 subjects)

 Group 2 -- Physical therapy without specific stabilization exercises group(15 subjects)

7.2 METHOD OF DATA COLLECTION a) SAMPLING TECHNIQUE

 Simple random sampling

b) TOOLS

 Visual Analog Scale20  Modified oswestry disability scale for low back ache17  Sorensen test21 c) METHODOLOGY

I) STUDY DESIGN

 Experimental study

II) INCLUSION CRITERIA

 Age group 25 – 35 years.  Complaint of pain in the lumbar spine, buttock and/or lower extremity.  Pain onset during pregnancy or within 3 weeks after pregnancy  Lumbar segmental testing for pain provocation.  Lumbar segmental testing for mobility.  Gaenslen test positive.  Compression and distraction test positive.  Willingness to participate in either of the two groups.

III) EXCLUSION CRITERIA

 Pregnancy induced hyper tension.  Preterm labour.  Maternal heart diseases.  Low back pain indicating radiculopathy.  History of asthma.  Prior lumbar spine surgery.  History of osteoporosis and spinal fracture.

IV) PROCEDURE

The subjects after the preliminary medical assessment by the gynecologist, formal informed consent obtained and assigned randomly to either the group with specific stabilization exercises or without specific stabilization exercises.

Group1- Physical therapy with specific stabilization exercises. Attention will be paid to the body awareness and ergonomic advice in specific, real life situations (e.g. lifting & carrying a child.) and hot packs will be given. Specific stabilization exercises are included.

The program is based on exercise & training of the transversely oriented abdominal muscles with co activation of the lumbar multifidus at the lumbosacral region, training of the gluteus maximus , the latissimus dorsi, the oblique abdominal muscles, the quadratus lumborum & hip abductors & adductors.

PROCEDURE FOR SPECIFIC STABILIZATION EXERCISES

Transversely oriented abdominal muscles with coactivation of the lumbar multifidus. Drawing in maneuver - The patient will assume her neutral spinal position and will attempt to maintain it while gently drawing in and hollowing the abdominal muscles. The patient will be instructed to draw the belly button up and in toward the spine to hollow out the abdominal region as exhaling. The individual should not inhale nor lift the ribcage to mimic the activity.

Oblique abdominal muscles - Abdominal bracing - Abdominal bracing occurs by setting the abdominals and actively flaring out laterally around the waist. There will be no head or trunk flexion, no elevation of lower ribs, no protrusion of the abdomen or pressure through the feet. The patient should be able to hold the braced position while breathing in a relaxed manner.

Quadratus lumborum – Patient will be in side lying. Patient will be instructed to prop up on here elbow and will then lift the pelvis off the mat, supporting the lower body with the lateral side of the heel on the downward side.

Gluteus maximus – Bridging exercise - Patient will be in hook lying. The patient will be instructed to press the upper back and feet in to the mat and will elevate the hips.

Hip abductors - The patient will be in side lying. The patient will flex the bottom leg for balance. The patient will abduct the top leg. Patint will be instructed to keep the hip in neutral to rotation and in slight extension and to prevent the hip to flexor to the trunk to roll backward.

Hip adductors – Patient will be in side lying. Patient will flex the top leg forward with the foot on the floor. The patient will lift the bottom leg upward in adduction.

The women are required to exercise for 30 to 60 minutes; 3 days a week for 12 weeks.

Group 2- Physical therapy without specific stabilization exercises. The patients will receive ergonomic advice and hot packs. General strengthening exercises (flexion and extension exercises) are included. However, specific stabilization exercises will not be included.

PROCEDURE FOR GENERAL STRENGTHENING EXERCISES.

Flexion exercises-

 Patient will be in supine position with knee extended. Patient will be instructed to support the head at the back by both the hands and will raise the head and neck.  Patient will be instructed to raise the head and neck with both the knees bent and hands in front of the chest.  Patient will be in supine position and will be instructed to pull the thigh over the abdomen alternatively and hold for 10- 15 seconds.  Patient will be in supine position and will be instructed to pull both the knees towards the chest and hold for 15 seconds.  Patient will be in supine position and will be instructed to raise both the legs at 30 60 and 90 for 15 seconds each.

Extension exercises-  Patient will be in prone position and will be instructed to fold both the arms under the chin; patient will keep the knees straight and will lift the legs alternatively.  Patient will be in prone position and will be instructed to tuck hands behind the head and will lift both the legs straight.

 Patient will be in same position as mentioned above and will be instructed to lift the head, neck and legs simultaneously.  Patient will be in prone position and will be instructed to place both the hands at the level of the shoulder .patient will gradually push the upper body of the ground by straightening the arms .The hip should be placed firmly on the ground during this exercises.

V) STATISTICAL TEST

 The data tested will be statistically analyzed by student’s t test.

7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, describe briefly.

Yes, the study will be done on two groups of samples and prior consent will be taken.

7.4 Has ethical clearance been obtained from your institution incase of 7.3?

Yes, Ethical clearance has been obtained from the institution. LIST OF REFERENCES

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02 Kristiansson P ,Svardsudd K,Schowtz Vom B.back pain during pregnancy; Spine 1996,21:702-9

03. Carolyn kisner, Lynn Allen Colby, Therapeutic exercises foundation and techniques 4th; 2002.

04. Brynhidsen J Hansson A ,Persson A etal ,Follow- up of patient with low back pain during pregnancy ;Obstet gynecal 1998 ,91:1826

05. Postgraard Hc,roos –Hansson E,Zetherstrom Gregression of Back and posterior pelvic pain after pregnancy ;spine 1996,21:2777-80

06. Endresen E.pelvic pain and low back pain in pregnancy. an epidemiological study scand J;rhematoid 1995 ,24:135

07 Berg G Hammar M,moller –Nielsen J.Tharnblad J low back pain during pregnancy; obstet gynecal 1998;71 ;71-

08 Kogstad o pelvic instability .A controversial diagnosis In Norwegian Bekkenlosning En kontroversiell diagnose Tidsskrnor laegforen 1988

09. Mantle Mj Greenwood RM, currey HLF Back in pregnancy; rheumatoid Rehab. 1992 ;16:95-101

10. Pennick Ve, Young G. Intervention for pregnancy and treating pelvic and back pain in Pregnancy.;Cochran database system Rev. 2007 Ap 19(2)

11. Rackwitz B, Limmh, Wessels T, Ewert T, Stucki G. Practicability of segmental stabilizing exercises in the context of group program for the secondary prevention of low back pain; Eura Medicophys 2007 sep 43(3)359-67.

12. Paulo Hferreira, Manuela, Lferreira, Christopher G Maher, Robert D Herbet. Specific stabilization exercises for spinal & pelvic pain A systemic review; Australian journal of physiotherapy 2006 52:79-88.13. Fritz JM, Whitman JM, childs JD. Lumbar spine segmental mobility assessment and examination of validity for determining intervention strategies in patient with low back ache. Arch Phys. Med Rehabi 2005 sep 86 (9) 745-52.

13. Fritz JM, Whitman JM, childs JD. Lumbar spine segmental mobility assessment and examination of validity for determining intervention strategies in patient with low back ache; Arch Phys. Med Rehabi 2005 sep 86 (9) 745-52.

14. Inger Halm, Britt Stuge and Nina Vollestad. To treat or not to treat postpartum pelvic girdle pain with stabilization exercises; Australian journal of physiotherapy July 2005 337-343.

15. Havden J a, van Tulder Mw, Tomlinson G. Systemic review strategies for using exercise therapy to improve outcomes in chronic low back pain; Spine 2005 may 3, 142(9): 776, 86.

16. Elden H, Ladforsl, olsen MF, Ostgaard HC, Hagberg H. Effects of stabilizing exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain.;BMJ 2005Apr.2; 330(7494)

17. Britt stuge, Even Laerum, Gitle Kirkesola and Nina Vollestad. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy; Spine 2004 29:351- 359.

18. Stuge, Britt, Veierod, Marit Bragellien, Laerum, Even, Vollestad, Nina. The efficacy of a treatment program focusing on specific stabilization exercises For pelvic girdle pain after pregnancy. A two year follow-up of a Randomized clinical trial; Spine 15 may 2004, pp E 197-203

19. Hides, julieA, Gwendolen A, Richardson, Carolyn. Long term effects of specific stabilization for first episode low back pain; Spine26june2001

20. Coroline HG Bastiaene, Robadebie, Pieter Mj c walters, Johan Ws Valeyen. Treatment of pregnancy – related pelvic girdle and/or low back pain after delivery; BMC Public Health2004, 4:67

21. Demovilin c, Vander thommen m, Duvsens C, crielaard Jm Spinal muscle evaluations using the 9 SIGNATURE OF CANDIDATE Sorensen test: a critical appraisal of the literature; Joint Bone Spine, 2006 Jan, 73, 43-50 (SHYAMLI SHARMA)

10 REMARKS OF GUIDE

11 NAME AND DESIGNATION

11.1 GUIDE Mr. MASIH MOHAMMAD KHAN ASSOCIATE PROFESSOR

11.2 SIGNATURE

11.5 HEAD OF DEPARTMENT Mr. MASIH MOHAMMAD KHAN ASSOCIATE PROFESSOR

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE