Correlation Between Low Back Pain and Rectus

Khan U et al. Correlation Between LBP and Rectus Abdominis Muscle Weakness Using Kendall’s Grading Scale

RESEARCH REPORT INTRODUCTION healthy individuals14,15. Patients with stroke also have Duration of the Study 3 times after every 4 weeks, at the end of 3 months difficulties due to paralysis of ankle dorsi-flexors and The study is conducted over a period of 6 months. and after 6 months. Stroke is the progressive neurological disorder in plantar-flexors which decrease the motor function CORRELATION BETWEEN LOW BACK PAIN which there is a focal or global impairment of cere- and balance due to decrease in muscle strength16. Sampling Method Control Group bral function that lasts more than 24 hours and can Samples are selected through randomization by Conventional physiotherapy treatments were AND RECTUS ABDOMINIS MUSCLE WEAKNESS lead to long term disability that compromise the Commonly used scale for the assessment of motor envelop method. performed which are as follows: sensory and motor function1,2. American stroke functions is Fugl-Meryer assessment of physical • Active range of motion exercises. USING KENDALL’S GRADING SCALE association estimated that around 87% are performance (FMA), Functional Independence Data Analysis • Active assisted range of motion exercises. ischemic stroke and about 13% strokes are hemor- Measure (FIM) and the Barthel Index scale which is Data analyzed using SPSS version 20 and results are • Stretching of both upper and lower limbs. rhagic3. used worldwide and has excellent sensitivity, validity compared using chi-square test. • Weight bearing exercises. and reliability17. • Balancing and other functional task oriented ABSTRACT Urooj Khan Many patients with hemiplegic stroke encounter Data Collection Tool exercises without resistance were performed. Lecturer mobility restriction at home and in the community, The rehabilitation of stroke patient is a multidimen- Data is collected by distributing questionnaire BACKGROUND Dow IPM&R particularly have difficulty with independent walk- sional process encompassing interventions that are among patients. Ethical Concerns Kendall’s approach is used to test the muscles strength and to [email protected] ing4. Hemiplegia causes weakness, balance prob- aimed to ease the substitution of restriction in partic- • Respect for the dignity of research participants is determine the correct alignment of the muscle fibers. The lems which leads to gait disturbance. It has been ipation and activity performance18. In-spite of Data Collection Procedure prioritized. major causes of back pain are work related problem, Sana Kayenat revealed that muscle strength is related with gait severe disability and impairment during the early Patient enrolled in the study after meeting the inclu- • Full consent is obtained from the participants prior mechanical stress on muscles and faulty postures, which leads Physiotherapist performance5. Due to damage in the cerebral period of stroke many of the patients gain some sion criteria. Before performing the exercises, to the study. to core muscle weakness particularly rectus abdominis or may ACELP cortex, extremities function is poorly affected and degree of recovery over time19. The aim of rehabili- patient’s vital signs are assessed and initial data • The protection of the privacy of research partici- cause DRA. Thus the study aims to identify a causal relation- [email protected] the patient is unable to perform activity of daily tation is to focus on independence of patient which recorded using functional activity assessment from pants is ensured. ship between low back pain and rectus abdominis muscle Khadija Usman living (ADLS)6. As central nervous system is major can be achieved through pressure workload prior to treatment and then recorded post treat- • Anonymity of individuals and organizations partici- weakness using Kendall’s grading scale. Physiotherapist issue which cause abnormal muscle tone, muscular exercises that can improve muscle strength and ment at the end of each session. pating in the research is ensured. ACELP atrophy and weakness, balance and coordination reduce spasticity3,20. Scapular stabilization exercises STUDY DESIGN [email protected] problem postural disorders and asymmetrical program strengthen upper extremity function in Inclusion Criteria Cross Sectional Study 4 3 Vinesh Kumar movements . The motor impairments that a result patients with hemiplegic stroke . • Adults aged between 45 and 65 years. due to stroke interferes with the independence of • Single episode of cerebrovascular event. RESULTS SAMPLING TECHNIQUE Physiotherapist the patient while performing both functional activi- Postural shift to the more affected area with weight • Chronic stage of post stroke hemiparesis. Non-probability convenience sampling technique Aga Khan University Hospital [email protected] ties and ADLs7. Due to loss of motor function, patient bearing on the extended elbow and fingers and • No post stroke synergy pattern seen. Eighty individuals were assessed for study purposes does not recover and ultimately it results in perma- wrist in neutral position plays an important role in • Patient being able to walk themselves or with out of which a total of 60 subjects were selected, 32 METHODOLOGY nent disability6. Motor relearning can be done to enhancing the proximal stabilization17. Most of the assistive devices men and 28 women aged between 45 to 65 years 142 (men 33.80% and women 66.20%) participants with low improve function and spontaneous recovery which time trunk strengthening is neglected due to more • Medically stable and no other serious co-morbidi- of age. Baseline characteristics results indicate that back pain were recruited in the study. The Kendall grading causes neuroplasticity of brain by giving different focus place on extremities21. Trunk exercise have ties. out of 60 individuals, 31 individuals had right side scale test the strength of muscles of the upper and lower intensive task depending on the severity of stroke8. advantageous result in enhancing the stability and affected with 51.7%. On the contrary 29 individuals rectus abdominis muscles among the participants while movement in stroke patients, they are principally Exclusion Criteria had left side affected with 48.3% and 29 individuals self-administered questionnaire was used to identify the In most of the cases physiotherapist encounter effective in refining functional ability22. Bridging • Post stroke hemiparesis in acute stage (less than had upper limb involvement with 48.3% and 31 had nature of the back pain. difficulties in motor relearning due to shoulder pain exercises under an unbalanced support that used 30 days post cerebrovascular event). lower limb involvement with 51.7%. Likewise, the which is mostly experienced by hemiplegic patients sling equipment knowingly improves the lower • Spasticity with definite synergy pattern. cause of 47 individuals was infarction with 78.3% RESULT approximately 70-80% that hinders the patient to extremity muscle strength along with core • Patients being bed or wheelchair bound. and the cause of 13 individuals was hemorrhage Sperman’s rho coefficient of correlation was applied to find participate in rehabilitation program. The restricted strength23. In most of the studies it has been found • Active arthritis. with 21.1%. Since, no significant differences out the cause effective correlation between the two range of motion and pain in shoulder joint may limit that there is moderate relation between gait speed • Joint deformities. between groups at baseline were noticed as given variables, result shows no significant cause effective correla- the participation of individual in ADLs and IADLs9. and balance function24. A modified sit to stand • Spinal fracture caused by osteoporosis or any in table 1. tion between the upper and lower back pain and lower Weakened shoulder joint is a common problem for training improves the balance function in hemiple- other musculoskeletal condition. rectus abdominis muscles weakness (P>0.05) with r= 0.065 and the patient with hemiplegia10. Resisted manual gic stroke patient25. Hip extensor strengthening • Uncontrolled hypertension or cardiac condition r=0.031respectively. exercises for abductors and external rotators of exercise program improves symmetry index of determined by the physician. shoulder, trapezius, serratus anterior and supraspina- stance phase, walking speed and stride length and Interventions CONCLUSION tus of scapula significantly decrease lateral spinal there was minimal increase in the paretic side Although core muscle weaknesses are the source of back deviation angle in sitting position3. Approximately stance phase in patient with hemiplegia4,26. Experimental Group pain but no significant cause effective correlation exist one-third patient suffering from stroke have severe Pressure workload exercises were performed which between the two variables in this study. arm paresis. Therefore, active assisted movements are as follows: should be performed on affected limb. Somatosen- • Upper limb strengthening involving shoulder and sory deficit is seen in critically effected arm11. The METHODOLOGY arm muscles using theraband and tubing grips. The results of pre-treatment group represent that 12 paralysis of extremity makes difficult for patient to • Grip strengthening. males and 11 females were totally dependent and perform their routine activities like reaching, grasp- Study Design • Quadriceps strengthening. there were 9 males and 11 females who were very ing, eating, and bathing, combing and dressing12. Randomized control trial (RCT). • Hamstrings strengthening. dependent. Similarly, 9 males and 6 females were Hemiplegic patient experienced paralysis of both • Abductors and adductors of hip strengthening. partially dependent. Likewise, 2 males required [Khan U, Kayenat S, Usman K, sides of trunk which makes difficult for individual to Study Settings and Participants • Core stabilizers strengthening for back muscles. minimal helps with ADL and no one was indepen- Kumar V. Correlation Between LBP maintain erect posture during static and dynamic The patients are selected from the OPD setting of • Gait training for 20 minutes. dent. Post-treatment group conferring gender wise movements13. Several lower extremity muscles are Ziauddin Hospital, Saifee Hospital North Nazimabad All exercises were performed in functional ranges 3 males and 1 female was totally dependent and 11 KEYWORDS and Rectus Abdominis Muscle much affected for example knee flexor compart- and National Medical Centre, Karachi. with 12-15 repetitions each lasting for 30 minutes males and 7 females was very dependent. Similarly, Rectus Abdominis, low back pain, Kendall’s grading scale, Weakness Using Kendall’s Grad- ment has been shown to be severely worsen which once a day 3 times a week. Patients were also given 11 males and 13 females was partially dependent Numeric Pain Rating Scale, Spearman’s correlation, Abdomi- ing Scale. Pak. j. rehabil. in turns affects the walking ability of the patient and Sample Size home program which includes strengthening and 3 males and 6 females needs minimal helps nal Strength test. 2017;6(2):38-44] consumes double energy as compared to that of Sixty stroke patients. exercises. Consecutive improvement was recorded with ADL and there were 4 males and 1 female who

PAKISTAN JOURNAL OF REHABILITATION 2017 VOLUME 6 (ISSUE 2) 38

was independent as shown in table 2. several studies. Dong-Hyun Kim et al (2016) demon- the first factor in the study defines improvement strated upper extremity exercises by using skate- could be result of compelled weight shift training boards causes increase in the range of motion and achieved by adding lift to shoe on the lower limb of restore function of upper extremity which reduces non-affected side. According to other studies by compensatory movements of trunk and helps main- Rodriquez et al (2002), Suzuki M et al (2013), and tain upright posture28. Donaldson et al (2009) Kobayashi M et al (2015), the center of gravity conducted a randomized controlled trial with (COG) shifts from the affected limb side to the patients in the post-stroke sub-acute stage (3 midline by the shoe lift which lead to increase the months after the damage) correlate effects of stability and equal weight distributions over the conventional physical therapy with functional affected and non-affected lower limbs. The second muscle strengthening. Results showed improvement factor shows that repetitive training feedback of in shoulder flexion and handgrip strength associat- sensory input could improve planter pressure ed with upper extremity function29. distribution, and also improve gait parameter in patients with stroke33. As suggested by Sen SB et al The study conducted by Amina Awad et al in 2015 (2015) that there is a significant improvement in the reported that 6-weeks pressure workload exercises quality of life, mobility, gait and balance in stroke program for shoulder girdle muscles has beneficial patient after bilateral isokinetic strength training of effects in hemiparetic patients3. The study conduct- knee and ankle that only give emphasis on lower Table 4 indicates that out of 60 individuals, 31 ed by Chanuk Yoo et al (2015) assessed a method limbs, hence our study focuses on the improvement individuals had Right side affected and 29 individu- that is task-oriented training in improving ADL’S and of daily living activities through pressure workload als had Left side affected. Moreover a total of 4 hand function in stroke patients and he found signif- exercises on both upper and lower extremities in individuals were totally dependent, 18 individuals icant improvement in ADL’s and hand function by stroke patient that is not yet been emphasized in were very dependent, 24 individuals were partially task-oriented training30. previous studies on this subject5. dependent, 9 individuals need minimal help with ADLs and a total of 5 individuals were completely Hodges and Richardson (1997) said that contrac- independent. tion of multifidus and abdominals plays a critical role to stabilize spine in all the technical movements CONCLUSION of lower extremity. Further Kim et al in 2015 supported our study by showing evidence that weakening The study concluded that pressure workload of trunk muscles is considerable in patient with exercises are more effective in improving the quality DISCUSSION chronic stroke; therefore trunk activating exercises of life (QoL) among hemiplegic patients and are are crucial in the patient to promote their functional found to be more potent in comparison to conven- The results indicate positive outcome of the study abilities31. Eun et al (2016) concluded that in stroke tional physical therapy approach in improving the representing an increase in muscle strength with patient’s core muscle strengthening (CMS) and Activity of Daily livings among the stroke survivors. pressure workload exercises without increasing trunk neuromuscular electrical stimulation (tNMES) muscle tone. Kim et al (2009) provided evidence in causes improvement in trunk balance21. Verheyden his study that resistive exercises using elastic band G et al (2006) reported that truncal exercises had The result indicates that the pre-treatment score has improves muscle performance of paralytic side. played a vital role to improve gait abilities of hemi- REFERENCE 30.417 ± 13.06 with a total number of 60 individuals Teixeira-Salmela (1999) also reported muscle plegic stroke patients by performing four weeks of whereas post treatment score has 45.583 ± 17.4 with strength of paretic lower limb increased with muscle trunk exercises consisting of abdominal hollowing, a total number of 60 individuals. So it is concluded strength exercises27. A study by Shepherd (2001) also curl-up, bridge, and quadruped exercise affected that there is significant difference between pre and supported our results in the way that pressure work- muscle activity and spatiotemporal gait parame- post treatment scores shown in table 5. load exercises of affected muscles are favorable ters. The gait of stroke patients is characterized by training methods in regaining neuromotor function short stride length, slow gait velocity, and asymmet- and reducing the hyper activation of muscle and ric gait pattern. Truncal exercises can improve the stiffness while maintaining the functional extensibili- walking speed of stroke patients by increasing the ty of muscle in stroke patients28. Patten et al. (2006) stride length of the paretic side. However, the trunk demonstrated that the combination of functional training did not have a significant effect on improv- training and dynamic high-intensity resistance ing gait symmetry. Hence our study mainly focuses According to Barthel Index in table 6 and figure 1 training is able to cause significant clinical effects. on improving quality of life through resistance showed total of 23 individuals in pre-treatment This training also promotes improvement in upper strength training exercises in hemiplegic stroke group were totally dependent, 20 individuals were limb function and enhances quality of movement patients, so that they will perform activities of daily very dependent, 15 individuals were partially without side effects like aggravating spasticity and living independently32. dependent, 2 individuals need minimal help with musculoskeletal damage29. ADLs and none of the individual was independent The recent study conducted by Nam et al in 2017 where as in post-treatment group 4 of the individu- Hence our study specifically focuses on the investigated that gait parameters and planter als were totally dependent, 18 individuals were very improvement of activities daily living through pressure in stroke patients by compelled weight shift dependent, 24 individuals were partially depen- pressure workload exercises in hemiplegic patients training on the paretic lower limb side. This study dent, 9 individuals need minimal help with ADLs and and our concept of increasing strength with explained two main factors consisting of 5 days per 5 individuals were completely independent. pressure workload exercises was supported by week, 30 minutes per day, for a period of 4 weeks. Whereas this study was consists of 15-20 repetition 3 day per week for a period of 3 months. However, Khan U et al. Correlation Between LBP and Rectus Abdominis Muscle Weakness Using Kendall’s Grading Scale

INTRODUCTION The rationale of this study is to find prevalence or in post-menopausal women. They used VAS and Study Design slowly lowering the legs to horizontal; strength is Graph 1: gender distribution years were included in this study, keeping in view REFERENCES INTRODUCTION healthy individuals14,15. Patients with stroke also have Duration of the Study 3 times after every 4 weeks, at the end of 3 months contribution of rectus abdominis weakness in back Roland Morris questionnaire for disability and pain Study design was cross sectional study and informa- graded on the ability to keep the low back flat on Shiri study (2010) who concluded that Low back difficulties due to paralysis of ankle dorsi-flexors and The study is conducted over a period of 6 months. and after 6 months. Back pain considers expensive disease in modern pain patients. This study will contribute to decreas- and assessed for diastasis recti abdominis using tion was collected using questionnaire. the surface; the angle at which the back arches is pain is common in participants ages between 24 Stroke is the progressive neurological disorder in plantar-flexors which decrease the motor function society1. It is job related complaint2. Most people ing the incidence of preventable impairments in diastasis recti test19. noted and correlated with Kendall’s grading system –39 years26. which there is a focal or global impairment of cere- and balance due to decrease in muscle strength16. Sampling Method Control Group experience low back pain (LBP) at some point population. The purpose of rectus abdominis weak- Study Population (Kendall et al., 1993)15. bral function that lasts more than 24 hours and can Samples are selected through randomization by Conventional physiotherapy treatments were throughout their life span3. In United States, the ness tests in backache patients is to find strength of Chiarello in their study Consequences of exercise Men and women aged between 20 -40 years In the current study Kendall, upper abdominal and lead to long term disability that compromise the Commonly used scale for the assessment of motor envelop method. performed which are as follows: economic burden of disease ranges from 84 to 624 rectus abdominis in back pain patients. It will deter- regime on DRA in pregnant women resulted that having back pain since 3 months. • Abdominal Strength Test Kendall lower abdominal test were used as sensory and motor function1,2. American stroke functions is Fugl-Meryer assessment of physical • Active range of motion exercises. dollars per year4. The prevalence has been report- mine is rectus abdominis weakness could be cause about ninety percent of women who were not is a test of upper abdominal strength; subjects are outcome measure to assess muscle power of association estimated that around 87% are performance (FMA), Functional Independence Data Analysis • Active assisted range of motion exercises. ed from 6% to 19% for a first episode and recurrence of back pain. habitual of doing exercise or did not follow exercise Inclusion Criteria2 asked to lie supine on a firm surface with knees When we correlate the back pain and abdominal muscles. MacDonald (1998) concluded ischemic stroke and about 13% strokes are hemor- Measure (FIM) and the Barthel Index scale which is Data analyzed using SPSS version 20 and results are • Stretching of both upper and lower limbs. achieves up to 50% over a 5 years’ stage5. In the regime had DRA and remaining who did exercise • Both gender male and female extended; a roll is placed under the knees if the power/strength of rectus abdominis there were no in his pilot study on 63 that there is increased rhagic3. used worldwide and has excellent sensitivity, validity compared using chi-square test. • Weight bearing exercises. Western countries, back pain lifetime prevalence is Deenika conducted systemic review in which eight had only conditions. It was concluded that size and • Age 20-40 subject displays a positive Thomas Test; the subject is correlation shown between back pain and rectus incidence of low back pain that has been related and reliability17. • Balancing and other functional task oriented 60%–80% among adult population6. The incidence studies were included. All the studies incorporated prevalence of DRA was more in non-exercising • Having back pain then asked to place both hands behind the head abdominis power/strength. (table 6) with Lumbar lordosis, especially in women. The Many patients with hemiplegic stroke encounter Data Collection Tool exercises without resistance were performed. increases with age and is more prevalent between abdominal/core strengthening muscle exercises. group than in exercising group of women20. and proceed to slowly curl up to a sitting position posture stretches and weakens the abdominals mobility restriction at home and in the community, The rehabilitation of stroke patient is a multidimen- Data is collected by distributing questionnaire 30 to 50 years, thus associated with increased The study resulted that exercises done during ante- Exclusion Criteria13 completing spinal flexion range of motion; if this 2. Pain Characteristics of Participants (rectus abdominis, external and internal oblique’s) particularly have difficulty with independent walk- sional process encompassing interventions that are among patients. Ethical Concerns health care expenditures around the world7. The natal period reduced DRAM by 35%16. Chiarello conducted another research to compare • Pregnancy action cannot be achieved, the subject modifies Majority of participants were of acute back pain, while shortening the hip flexors and lumbar exten- ing4. Hemiplegia causes weakness, balance prob- aimed to ease the substitution of restriction in partic- • Respect for the dignity of research participants is prevalence of back pain in Bangladesh is 64.8%, in inter rectus distance of pregnant women with • Spinal cord injuries. the arm positions and a grade is assigned per Kend- followed by chronic back pain and most of the sors imbalance increases the stress to the low back, lems which leads to gait disturbance. It has been ipation and activity performance18. In-spite of Data Collection Procedure prioritized. India is 19.8%, in Nepal is 69.5%, in Pakistan is 40.6% A study on Effects of Basic Strength and Pelvic pelvic girdle pain with these of other types of preg- • Neurological diseased all’s muscle grading system (Kendall et al., 1993)15. participants were not taking any medicine as resulting in pain. He conducted fitness test among revealed that muscle strength is related with gait severe disability and impairment during the early Patient enrolled in the study after meeting the inclu- • Full consent is obtained from the participants prior and in Sri Lanka is 36.2% 6. The general prevalence is training on high school cross-country race times. He nancy related back pain, resulting in with inter • Spondylosis shown in table 2, school going children. He conducted Kendall’s performance5. Due to damage in the cerebral period of stroke many of the patients gain some sion criteria. Before performing the exercises, to the study. higher in females (48%) than in males (32%)8. performed four standardized isometric strength test rectus distance seen widest at umbilicus, narrowest Red flag for back pain: Data Analysis lower abdominal and Kendall’s upper abdominal cortex, extremities function is poorly affected and degree of recovery over time19. The aim of rehabili- patient’s vital signs are assessed and initial data • The protection of the privacy of research partici- at hip adductors, abductors, extensors and core below the umbilicus and decrease with a curl up, • Circulatory problems SPSS Version 21 was used for data analysis. All cate- test to check the strength of rectus abdominis the patient is unable to perform activity of daily tation is to focus on independence of patient which recorded using functional activity assessment from pants is ensured. Low back pain is defined as a pain or discomfort musculature for six weeks. He concluded that there and showed no significant difference in the IRD of • Tumors gorical variables were used for jotting down muscle15. In the current study, no relation found living (ADLS)6. As central nervous system is major can be achieved through pressure workload prior to treatment and then recorded post treat- • Anonymity of individuals and organizations partici- located below the margin of the 12th rib and was no interaction regarding increasing muscle pregnant women with pelvic girdle pain21. • Infections frequencies and percentages. The association back pain patients and weakness of rectus abdom- issue which cause abnormal muscle tone, muscular exercises that can improve muscle strength and ment at the end of each session. pating in the research is ensured. above the inferior gluteal fold, with or without leg strength and decreasing race times. Pelvic and Yellow flag for back pain: between two categorical variables was deter- inis. MOTA (2014) in her research concluded that atrophy and weakness, balance and coordination reduce spasticity3,20. Scapular stabilization exercises pain9. Back pain can be classified into acute (less core stability strengthening program routine trice a Monica conducted a multiple-baseline, single • Psychosocial problems mined by applying chi-square test for significance. women with DRA were not prone to develop back problem postural disorders and asymmetrical program strengthen upper extremity function in Inclusion Criteria than six weeks), subacute (6 to 12 weeks) or chronic week could decrease in race times17. subject experimental design research on 16 women The significant P-value was less than 0.05 pain than women without DRA, this study support movements4. The motor impairments that a result patients with hemiplegic stroke3. • Adults aged between 45 and 65 years. (longer than 12 weeks)4. Faulty posture and biome- with lumbar pelvic pain after delivery and stated Sampling Technique the present study14. In another study by Joran (2016) due to stroke interferes with the independence of • Single episode of cerebrovascular event. RESULTS chanics amendment are precursor to low back A study conducted on finding out the occurrence reduced pain and disability after an individually Non-probability Sampling Technique. Ethical Consideration showed no difference between women with and the patient while performing both functional activi- Postural shift to the more affected area with weight • Chronic stage of post stroke hemiparesis. pain development10. Faulty posture is often associ- of diastasis of rectus abdominal muscles instantly adjusted exercise intervention in women with • Confidential: Records of this study will be kept without DRA, and prevalence of low back and/or ties and ADLs7. Due to loss of motor function, patient bearing on the extended elbow and fingers and • No post stroke synergy pattern seen. Eighty individuals were assessed for study purposes ated with weak abdominal muscle11. Dysfunction of postpartum, having an outcome with the high post-delivery lumbar pelvic pain22. Sample Size secured. Any information that patient tells us will pelvic girdle pain27. According to Stephanie does not recover and ultimately it results in perma- wrist in neutral position plays an important role in • Patient being able to walk themselves or with out of which a total of 60 subjects were selected, 32 abdominal musculature (internal oblique and occurrence of DARM (68%) on top of the umbilicus. Sample size is calculated by using Epi software for remain confidential. The information’s will be kept Pain intensity was assessed on NPRS scale and most Mulhearn there is some evidence of a link between nent disability6. Motor relearning can be done to enhancing the proximal stabilization17. Most of the assistive devices men and 28 women aged between 45 to 65 years rectus abdominis) is one of the major causes of A DARM of above 2.5cm is measured unsafe as it Gerard conducted a study on functional therapeu- sample size calculation. A study conducted at in a locked file; only the researchers for this study will participants of the study were having moderate low back pain, postural muscle endurance in improve function and spontaneous recovery which time trunk strengthening is neglected due to more • Medically stable and no other serious co-morbidi- of age. Baseline characteristics results indicate that chronic low back pain (CLBP). The muscles of abdo- may hinder with the muscles of abdomen capabili- tic and core strengthening which postulated that South Asia titled as “Participant in physical activity have access to the records. pain followed by mild pain as shown in table 3 gymnasts and no cause and effect relationship causes neuroplasticity of brain by giving different focus place on extremities21. Trunk exercise have ties. out of 60 individuals, 31 individuals had right side men averagely enhanced activation by 1–3% and ty to stabilize the trunk, deprived lumbar stabilization athlete’s core strength, endurance, coordination and back pain among an elderly population in • Autonomy: participants were independent to determined28. intensive task depending on the severity of stroke8. advantageous result in enhancing the stability and affected with 51.7%. On the contrary 29 individuals the extensors enhanced by 13–31%, due to may influence the person to the increase the devel- flexibility and balance has the role in optimal sports South Asia” is used to calculate sample size. take his or her decision to enroll in study. movement in stroke patients, they are principally Exclusion Criteria had left side affected with 48.3% and 29 individuals increased load in CLBP12. Rectus abdominis (RA) opment of back pain18. performance, As of medical literature support core • Beneficence: participants were requested to On the contrary, Dalal khushboo (2014) conducted In most of the cases physiotherapist encounter effective in refining functional ability22. Bridging • Post stroke hemiparesis in acute stage (less than had upper limb involvement with 48.3% and 31 had eccentric activity is crucial to support the trunk and stability as a prevention of injury. So, exercises that Study Setting answer questions which may be private, but the research on 30 women aged greater than 18 years difficulties in motor relearning due to shoulder pain exercises under an unbalanced support that used 30 days post cerebrovascular event). lower limb involvement with 51.7%. Likewise, the evade too much spinal strain and back pain13. Greta conducted the pilot study on 63 children and promote neuromuscular re-educate in athletes with • Tertiary care hospitals data will not be shared with anyone else. Partici- to find correlation between diastasis rectus abdomi- which is mostly experienced by hemiplegic patients sling equipment knowingly improves the lower • Spasticity with definite synergy pattern. cause of 47 individuals was infarction with 78.3% concluded that there is increased incidence of low core dysfunction are crucial to preventing and pants may refuse to answer any questions on the nis and lumbopelvic pain. Subjects were assessed approximately 70-80% that hinders the patient to extremity muscle strength along with core • Patients being bed or wheelchair bound. and the cause of 13 individuals was hemorrhage Diastasis recti abdominis (DRA) is an injury measured back pain that has been related with Lumbar lordo- treating injury23. Study Duration form. We will not share with anyone, the specific on the Pelvic Floor Distress Inventory, Modified participate in rehabilitation program. The restricted strength23. In most of the studies it has been found • Active arthritis. with 21.1%. Since, no significant differences by a midline parting of the 2 rectus abdominis, this sis, especially in women. The posture stretches and 3 months details you tell us. Oswestry Low Back Pain Disability Questionnaire, range of motion and pain in shoulder joint may limit that there is moderate relation between gait speed • Joint deformities. between groups at baseline were noticed as given decrease strength of rectus abdominis. DRA occur weakens the abdominals (rectus abdominis, exter- Any pain or discomfort occurring in the low back • Justice: there was no harm of this research. Partici- Visual Analog Scales (VAS) for pain. Diastasis Rectus the participation of individual in ADLs and IADLs9. and balance function24. A modified sit to stand • Spinal fracture caused by osteoporosis or any in table 1. 30% to 70% in pregnant women. DRA also seen in nal and internal oblique) while shortening the hip region presently or a previous episode with a dura- Assessment Protocol pants were included without any biasness 3. Kendall’s Abdominal Test Score Abdominis measurement was taken. Dalal conclud- Weakened shoulder joint is a common problem for training improves the balance function in hemiple- other musculoskeletal condition. males. Condition is the consideration to be related flexors and lumbar extensors imbalance increases tion greater than 3 days within the last year that Back Patients were recruited from tertiary care Upper abdominal test score of most of the partici- DISCUSSION ed that the incidence for the DRA was 83.33%, and the patient with hemiplegia10. Resisted manual gic stroke patient25. Hip extensor strengthening • Uncontrolled hypertension or cardiac condition with growing age, hereditary weakness of the the stress to the low back, resulting in pain. He essential prolonged rest or medical consideration. hospitals after assessment and screening by consul- pant have grade 3 fair grade muscle power (45.8%) women with a DRA tend to have more lumbo-pelvic exercises for abductors and external rotators of exercise program improves symmetry index of determined by the physician. abdominal muscles, weight lifting, weight fluctua- conducted Kendall’s lower abdominal and Kend- tants. Consent was taken from participants. RESULTS followed by grade 2 poor muscle power (37.3%) Back pain considers expensive disease in modern pain29. shoulder, trapezius, serratus anterior and supraspina- stance phase, walking speed and stride length and Interventions tions, performing full sit-ups, intermittent or chronic all’s upper abdominal test to check the strength of Low back pain usually arises in the region of lumbar, Researcher re-examine patient and enrolled those which was found statistically non-significant at society. There are many causes/risks that leading to tus of scapula significantly decrease lateral spinal there was minimal increase in the paretic side abdominal distention, and actions that may stimu- rectus abdominis muscle. He concluded that thoracolumbar, or lumbosacral. Back pain mostly who were met inclusion and exclusion criteria. 1. Demographics P<0.509 (table 4). the occurrence of back pain. A cross sectional The strength of the study was, it was a randomized deviation angle in sitting position3. Approximately stance phase in patient with hemiplegia4,26. Experimental Group late immense intra-abdominal pressure14. Kendall’s strengthening exercises of rectus abdominis could effects working population. Back pain is Associated Researcher filled self-administered questionnaire of In the following table-1, the means and standard study was conducted to evaluate contribution of control trail, single blindness, both genders were one-third patient suffering from stroke have severe Pressure workload exercises were performed which Abdominal Strength test is a standard method to delay back pain15. with many symptoms and functional limitations. It those who fulfilled inclusion criteria. For rectus deviations of participant’s age and gender distribu- rectus abdominis muscle in the patients with the included in the study, and it was multi-centered arm paresis. Therefore, active assisted movements are as follows: assess abdominal strength in physical therapy15. may be due to any soft tissue injury of the trunk abdominis strength test researcher performed tion is shown. There were in total 140 participants in complain of back pain. This study included 142 study. The weakness of study is non-back pain should be performed on affected limb. Somatosen- • Upper limb strengthening involving shoulder and Patricia, concluded in his article about Risk factors including weakness or spasm or it occurs when the Kendell strength test and gave score as per perfor- this research study. The demographics showed the patients who were diagnosed with back pain, patients were not included in the study so no com- sory deficit is seen in critically effected arm11. The METHODOLOGY arm muscles using theraband and tubing grips. The results of pre-treatment group represent that 12 In Kendall’s abdominal strength test subjects lie and occurrence of diastasis recti abdominis from core muscle which is responsible for stabilization of mance. mean age of 29 years. There were 33.8% male and without any serious pathology. parison could have done between health and paralysis of extremity makes difficult for patient to • Grip strengthening. males and 11 females were totally dependent and supine on a firm surface with arms folded across the late pregnancy to 6 months postpartum and a lumbar region is weak2. 66.2% female among participants. back pain patients. perform their routine activities like reaching, grasp- Study Design • Quadriceps strengthening. there were 9 males and 11 females who were very chest; a tester assists in raising the legs up to a relationship with lumbo-pelvic pain, that diastasis Kendall’s Strength Test In this study, both genders participants were including, eating, and bathing, combing and dressing12. Randomized control trial (RCT). • Hamstrings strengthening. dependent. Similarly, 9 males and 6 females were vertical position, keeping the knees straight, then recti abdominis is not linked with lumbo–pelvic • Kendall’s Lower Abdominal Test ed. It was found that female participants ratio was Hemiplegic patient experienced paralysis of both • Abductors and adductors of hip strengthening. partially dependent. Likewise, 2 males required perform a posterior pelvic tilt and maintain this pain14. is a test used to evaluate lower abdominal strength; While performing lower abdominal test most partici- high in comparison to male participants. Buchbind- sides of trunk which makes difficult for individual to Study Settings and Participants • Core stabilizers strengthening for back muscles. minimal helps with ADL and no one was indepen- position while slowly lowering the legs to horizontal, METHODOLOGY subjects lie supine on a firm surface with arms pant have grade 3(fair grade) muscle power (50%) er (2013) in their systemic review stated that women CONCLUSION maintain erect posture during static and dynamic The patients are selected from the OPD setting of • Gait training for 20 minutes. dent. Post-treatment group conferring gender wise strength is graded on the ability to keep the low Study naming Correlation of low back pain and folded across the chest; a tester assists in raising the followed by grade 4 (good) muscle power (31.7%) suffered with back pain more than men24, whereas movements13. Several lower extremity muscles are Ziauddin Hospital, Saifee Hospital North Nazimabad All exercises were performed in functional ranges 3 males and 1 female was totally dependent and 11 back flat on the surface, the angle at which the diastasis rectus abdominis in post-menopausal 142 Participants was recruited in our study. Partici- legs up to a vertical position (subjects may actively which was found statistically significant at P<0.016, in other study Hoy (2014) stated that, men are more In the current study, the prevalence of back pain is much affected for example knee flexor compart- and National Medical Centre, Karachi. with 12-15 repetitions each lasting for 30 minutes males and 7 females was very dependent. Similarly, back arches is noted and correlated with Kendall’s women between the age group of 50-60 years, pants signed consent form. raise one lower extremity at a time, if needed) (table 5). prone to have back pain than women25. higher in females. There was no correlation found ment has been shown to be severely worsen which once a day 3 times a week. Patients were also given 11 males and 13 females was partially dependent grading system15. resulted that there was a partial positive correlation Questionnaires were filled by researcher after keeping the knees straight; subjects then perform a between back pain and rectus abdominis in turns affects the walking ability of the patient and Sample Size home program which includes strengthening and 3 males and 6 females needs minimal helps between diastasis of abdominis and Low back pain perform Kendell test. posterior pelvic tilt and maintain this position while The participants age group were between 20-40 consumes double energy as compared to that of Sixty stroke patients. exercises. Consecutive improvement was recorded with ADL and there were 4 males and 1 female who

39 PAKISTAN JOURNAL OF REHABILITATION 2017 VOLUME 6 (ISSUE 2)

PAKISTAN JOURNAL OF REHABILITATION 2017 VOLUME 6 (ISSUE 2) 40

INTRODUCTION The rationale of this study is to find prevalence or in post-menopausal women. They used VAS and Study Design EDITORIALslowly lowering the legs to horizontal; strength is Graph 1: gender distribution years were included in this study, keeping in view REFERENCES INTRODUCTION healthy individuals14,15. Patients with stroke also have Duration of the Study 3 times after every 4 weeks, at the end of 3 months contribution of rectus abdominis weakness in back Roland Morris questionnaire for disability and pain Study design was cross sectional study and informa- graded on the ability to keep the low back flat on Shiri study (2010) who concluded that Low back difficulties due to paralysis of ankle dorsi-flexors and The study is conducted over a period of 6 months. and after 6 months. Back pain considers expensive disease in modern pain patients. This study will contribute to decreas- and assessed for diastasis recti abdominis using tion was collected using questionnaire. the surface; the angle at which the back arches is Gender distribution pain is common in participants ages between 24 Stroke is the progressive neurological disorder in plantar-flexors which decrease the motor function society1. It is job related complaint2. Most people ing the incidence of preventable impairments in diastasis recti test19. noted and correlated with Kendall’s grading system –39 years26. which there is a focal or global impairment of cere- and balance due to decrease in muscle strength16. Sampling Method Control Group experience low back pain (LBP) at some point population. The purpose of rectus abdominis weak- Study Population (Kendall et al., 1993)15. bral function that lasts more than 24 hours and can Samples are selected through randomization by Conventional physiotherapy treatments were throughout their life span3. In United States, the ness tests in backache patients is to find strength of Chiarello in their study Consequences of exercise Men and women aged between 20 -40 years 33.80% In the current study Kendall, upper abdominal and lead to long term disability that compromise the Commonly used scale for the assessment of motor envelop method. performed which are as follows: economic burden of disease ranges from 84 to 624 rectus abdominis in back pain patients. It will deter- regime on DRA in pregnant women resulted that having back pain since 3 months. • Abdominal Strength Test Kendall lower abdominal test were used as sensory and motor function1,2. American stroke functions is Fugl-Meryer assessment of physical • Active range of motion exercises. dollars per year4. The prevalence has been report- mine is rectus abdominis weakness could be cause about ninety percent of women who were not is a test of upper abdominal strength; subjects are outcome measure to assess muscle power of association estimated that around 87% are performance (FMA), Functional Independence Data Analysis • Active assisted range of motion exercises. 2 asked to lie supine on a firm surface with knees When we correlate the back pain and abdominal muscles. MacDonald (1998) concluded ed from 6% to 19% for a first episode and recurrence of back pain. habitual of doing exercise or did not follow exercise Inclusion Criteria 66.20% ischemic stroke and about 13% strokes are hemor- Measure (FIM) and the Barthel Index scale which is Data analyzed using SPSS version 20 and results are • Stretching of both upper and lower limbs. achieves up to 50% over a 5 years’ stage5. In the regime had DRA and remaining who did exercise • Both gender male and female extended; a roll is placed under the knees if the power/strength of rectus abdominis there were no in his pilot study on 63 that there is increased rhagic3. used worldwide and has excellent sensitivity, validity compared using chi-square test. • Weight bearing exercises. 17 Western countries, back pain lifetime prevalence is Deenika conducted systemic review in which eight had only conditions. It was concluded that size and • Age 20-40 subject displays a positive Thomas Test; the subject is Male Female correlation shown between back pain and rectus incidence of low back pain that has been related and reliability . • Balancing and other functional task oriented 60%–80% among adult population6. The incidence studies were included. All the studies incorporated prevalence of DRA was more in non-exercising • Having back pain then asked to place both hands behind the head abdominis power/strength. (table 6) with Lumbar lordosis, especially in women. The Many patients with hemiplegic stroke encounter Data Collection Tool exercises without resistance were performed. increases with age and is more prevalent between abdominal/core strengthening muscle exercises. group than in exercising group of women20. and proceed to slowly curl up to a sitting position posture stretches and weakens the abdominals mobility restriction at home and in the community, The rehabilitation of stroke patient is a multidimen- Data is collected by distributing questionnaire 30 to 50 years, thus associated with increased The study resulted that exercises done during ante- Exclusion Criteria13 completing spinal flexion range of motion; if this 2. Pain Characteristics of Participants (rectus abdominis, external and internal oblique’s) particularly have difficulty with independent walk- sional process encompassing interventions that are among patients. Ethical Concerns health care expenditures around the world7. The natal period reduced DRAM by 35%16. Chiarello conducted another research to compare • Pregnancy action cannot be achieved, the subject modifies Majority of participants were of acute back pain, while shortening the hip flexors and lumbar exten- ing4. Hemiplegia causes weakness, balance prob- aimed to ease the substitution of restriction in partic- • Respect for the dignity of research participants is prevalence of back pain in Bangladesh is 64.8%, in inter rectus distance of pregnant women with • Spinal cord injuries. the arm positions and a grade is assigned per Kend- followed by chronic back pain and most of the sors imbalance increases the stress to the low back, lems which leads to gait disturbance. It has been ipation and activity performance18. In-spite of Data Collection Procedure prioritized. India is 19.8%, in Nepal is 69.5%, in Pakistan is 40.6% A study on Effects of Basic Strength and Pelvic pelvic girdle pain with these of other types of preg- • Neurological diseased all’s muscle grading system (Kendall et al., 1993)15. participants were not taking any medicine as resulting in pain. He conducted fitness test among revealed that muscle strength is related with gait severe disability and impairment during the early Patient enrolled in the study after meeting the inclu- • Full consent is obtained from the participants prior and in Sri Lanka is 36.2% 6. The general prevalence is training on high school cross-country race times. He nancy related back pain, resulting in with inter • Spondylosis shown in table 2, school going children. He conducted Kendall’s performance5. Due to damage in the cerebral period of stroke many of the patients gain some sion criteria. Before performing the exercises, to the study. higher in females (48%) than in males (32%)8. performed four standardized isometric strength test rectus distance seen widest at umbilicus, narrowest Red flag for back pain: Data Analysis lower abdominal and Kendall’s upper abdominal cortex, extremities function is poorly affected and degree of recovery over time19. The aim of rehabili- patient’s vital signs are assessed and initial data • The protection of the privacy of research partici- at hip adductors, abductors, extensors and core below the umbilicus and decrease with a curl up, • Circulatory problems SPSS Version 21 was used for data analysis. All cate- Table 2 Percentage distribution of Pain characteristics test to check the strength of rectus abdominis the patient is unable to perform activity of daily tation is to focus on independence of patient which recorded using functional activity assessment from pants is ensured. Low back pain is defined as a pain or discomfort musculature for six weeks. He concluded that there and showed no significant difference in the IRD of • Tumors gorical variables were used for jotting down of back pain patients muscle15. In the current study, no relation found living (ADLS)6. As central nervous system is major can be achieved through pressure workload prior to treatment and then recorded post treat- • Anonymity of individuals and organizations partici- located below the margin of the 12th rib and was no interaction regarding increasing muscle pregnant women with pelvic girdle pain21. • Infections frequencies and percentages. The association Pain characteristics n % back pain patients and weakness of rectus abdom- issue which cause abnormal muscle tone, muscular exercises that can improve muscle strength and ment at the end of each session. pating in the research is ensured. above the inferior gluteal fold, with or without leg strength and decreasing race times. Pelvic and Yellow flag for back pain: between two categorical variables was deter- Duration of backache inis. MOTA (2014) in her research concluded that atrophy and weakness, balance and coordination reduce spasticity3,20. Scapular stabilization exercises pain9. Back pain can be classified into acute (less core stability strengthening program routine trice a Monica conducted a multiple-baseline, single • Psychosocial problems mined by applying chi-square test for significance. less than 6 weeks 58 40.8 women with DRA were not prone to develop back problem postural disorders and asymmetrical program strengthen upper extremity function in Inclusion Criteria than six weeks), subacute (6 to 12 weeks) or chronic week could decrease in race times17. subject experimental design research on 16 women The significant P-value was less than 0.05 6 to 12 weeks 41 28.9 pain than women without DRA, this study support movements4. The motor impairments that a result patients with hemiplegic stroke3. • Adults aged between 45 and 65 years. (longer than 12 weeks)4. Faulty posture and biome- with lumbar pelvic pain after delivery and stated Sampling Technique more than 12 weeks 43 30.3 the present study14. In another study by Joran (2016) due to stroke interferes with the independence of • Single episode of cerebrovascular event. RESULTS Taking any treatment chanics amendment are precursor to low back A study conducted on finding out the occurrence reduced pain and disability after an individually Non-probability Sampling Technique. Ethical Consideration showed no difference between women with and the patient while performing both functional activi- Postural shift to the more affected area with weight • Chronic stage of post stroke hemiparesis. Yes 68 47.9 10 7 pain development . Faulty posture is often associ- of diastasis of rectus abdominal muscles instantly adjusted exercise intervention in women with • Confidential: Records of this study will be kept No 74 52.1 without DRA, and prevalence of low back and/or ties and ADLs . Due to loss of motor function, patient bearing on the extended elbow and fingers and • No post stroke synergy pattern seen. Eighty individuals were assessed for study purposes ated with weak abdominal muscle11. Dysfunction of postpartum, having an outcome with the high post-delivery lumbar pelvic pain22. Sample Size secured. Any information that patient tells us will pelvic girdle pain27. According to Stephanie does not recover and ultimately it results in perma- wrist in neutral position plays an important role in • Patient being able to walk themselves or with out of which a total of 60 subjects were selected, 32 abdominal musculature (internal oblique and occurrence of DARM (68%) on top of the umbilicus. Sample size is calculated by using Epi software for remain confidential. The information’s will be kept Pain intensity was assessed on NPRS scale and most Mulhearn there is some evidence of a link between nent disability6. Motor relearning can be done to enhancing the proximal stabilization17. Most of the assistive devices men and 28 women aged between 45 to 65 years rectus abdominis) is one of the major causes of A DARM of above 2.5cm is measured unsafe as it Gerard conducted a study on functional therapeu- sample size calculation. A study conducted at in a locked file; only the researchers for this study will participants of the study were having moderate low back pain, postural muscle endurance in improve function and spontaneous recovery which time trunk strengthening is neglected due to more • Medically stable and no other serious co-morbidi- of age. Baseline characteristics results indicate that chronic low back pain (CLBP). The muscles of abdo- may hinder with the muscles of abdomen capabili- tic and core strengthening which postulated that South Asia titled as “Participant in physical activity have access to the records. pain followed by mild pain as shown in table 3 gymnasts and no cause and effect relationship causes neuroplasticity of brain by giving different focus place on extremities21. Trunk exercise have ties. out of 60 individuals, 31 individuals had right side men averagely enhanced activation by 1–3% and ty to stabilize the trunk, deprived lumbar stabilization athlete’s core strength, endurance, coordination and back pain among an elderly population in • Autonomy: participants were independent to determined28. intensive task depending on the severity of stroke8. advantageous result in enhancing the stability and affected with 51.7%. On the contrary 29 individuals the extensors enhanced by 13–31%, due to may influence the person to the increase the devel- flexibility and balance has the role in optimal sports South Asia” is used to calculate sample size. take his or her decision to enroll in study. Table3. Percentage distribution of Pain Severity movement in stroke patients, they are principally Exclusion Criteria had left side affected with 48.3% and 29 individuals increased load in CLBP12. Rectus abdominis (RA) opment of back pain18. performance, As of medical literature support core • Beneficence: participants were requested to among back pain patients On the contrary, Dalal khushboo (2014) conducted In most of the cases physiotherapist encounter effective in refining functional ability22. Bridging • Post stroke hemiparesis in acute stage (less than had upper limb involvement with 48.3% and 31 had eccentric activity is crucial to support the trunk and stability as a prevention of injury. So, exercises that Study Setting answer questions which may be private, but the Pain Severity n % research on 30 women aged greater than 18 years difficulties in motor relearning due to shoulder pain exercises under an unbalanced support that used 30 days post cerebrovascular event). lower limb involvement with 51.7%. Likewise, the evade too much spinal strain and back pain13. Greta conducted the pilot study on 63 children and promote neuromuscular re-educate in athletes with • Tertiary care hospitals data will not be shared with anyone else. Partici- Pain(Mean±SD) years 5.16±2.53 to find correlation between diastasis rectus abdomi- which is mostly experienced by hemiplegic patients sling equipment knowingly improves the lower • Spasticity with definite synergy pattern. cause of 47 individuals was infarction with 78.3% concluded that there is increased incidence of low core dysfunction are crucial to preventing and pants may refuse to answer any questions on the Severity of pain nis and lumbopelvic pain. Subjects were assessed approximately 70-80% that hinders the patient to extremity muscle strength along with core • Patients being bed or wheelchair bound. and the cause of 13 individuals was hemorrhage Diastasis recti abdominis (DRA) is an injury measured back pain that has been related with Lumbar lordo- treating injury23. Study Duration form. We will not share with anyone, the specific Mild 52 36.6 on the Pelvic Floor Distress Inventory, Modified participate in rehabilitation program. The restricted strength23. In most of the studies it has been found • Active arthritis. with 21.1%. Since, no significant differences by a midline parting of the 2 rectus abdominis, this sis, especially in women. The posture stretches and 3 months details you tell us. Moderate 61 43.0 Oswestry Low Back Pain Disability Questionnaire, range of motion and pain in shoulder joint may limit that there is moderate relation between gait speed • Joint deformities. between groups at baseline were noticed as given Severe 29 20.4 decrease strength of rectus abdominis. DRA occur weakens the abdominals (rectus abdominis, exter- Any pain or discomfort occurring in the low back • Justice: there was no harm of this research. Partici- Visual Analog Scales (VAS) for pain. Diastasis Rectus the participation of individual in ADLs and IADLs9. and balance function24. A modified sit to stand • Spinal fracture caused by osteoporosis or any in table 1. 30% to 70% in pregnant women. DRA also seen in nal and internal oblique) while shortening the hip region presently or a previous episode with a dura- Assessment Protocol pants were included without any biasness 3. Kendall’s Abdominal Test Score Abdominis measurement was taken. Dalal conclud- Weakened shoulder joint is a common problem for training improves the balance function in hemiple- other musculoskeletal condition. males. Condition is the consideration to be related flexors and lumbar extensors imbalance increases tion greater than 3 days within the last year that Back Patients were recruited from tertiary care Upper abdominal test score of most of the partici- DISCUSSION ed that the incidence for the DRA was 83.33%, and the patient with hemiplegia10. Resisted manual gic stroke patient25. Hip extensor strengthening • Uncontrolled hypertension or cardiac condition with growing age, hereditary weakness of the the stress to the low back, resulting in pain. He essential prolonged rest or medical consideration. hospitals after assessment and screening by consul- pant have grade 3 fair grade muscle power (45.8%) women with a DRA tend to have more lumbo-pelvic exercises for abductors and external rotators of exercise program improves symmetry index of determined by the physician. abdominal muscles, weight lifting, weight fluctua- conducted Kendall’s lower abdominal and Kend- tants. Consent was taken from participants. RESULTS followed by grade 2 poor muscle power (37.3%) Back pain considers expensive disease in modern pain29. shoulder, trapezius, serratus anterior and supraspina- stance phase, walking speed and stride length and Interventions tions, performing full sit-ups, intermittent or chronic all’s upper abdominal test to check the strength of Low back pain usually arises in the region of lumbar, Researcher re-examine patient and enrolled those which was found statistically non-significant at society. There are many causes/risks that leading to tus of scapula significantly decrease lateral spinal there was minimal increase in the paretic side abdominal distention, and actions that may stimu- rectus abdominis muscle. He concluded that thoracolumbar, or lumbosacral. Back pain mostly who were met inclusion and exclusion criteria. 1. Demographics P<0.509 (table 4). the occurrence of back pain. A cross sectional The strength of the study was, it was a randomized deviation angle in sitting position3. Approximately stance phase in patient with hemiplegia4,26. Experimental Group late immense intra-abdominal pressure14. Kendall’s strengthening exercises of rectus abdominis could effects working population. Back pain is Associated Researcher filled self-administered questionnaire of In the following table-1, the means and standard study was conducted to evaluate contribution of control trail, single blindness, both genders were one-third patient suffering from stroke have severe Pressure workload exercises were performed which Abdominal Strength test is a standard method to delay back pain15. with many symptoms and functional limitations. It those who fulfilled inclusion criteria. For rectus deviations of participant’s age and gender distribu- Table 4. Kendall’s Upper Abdominal test score rectus abdominis muscle in the patients with the included in the study, and it was multi-centered arm paresis. Therefore, active assisted movements are as follows: assess abdominal strength in physical therapy15. may be due to any soft tissue injury of the trunk abdominis strength test researcher performed tion is shown. There were in total 140 participants in Upper Abdominal N % Chi- Square P value complain of back pain. This study included 142 study. The weakness of study is non-back pain should be performed on affected limb. Somatosen- • Upper limb strengthening involving shoulder and Patricia, concluded in his article about Risk factors including weakness or spasm or it occurs when the Kendell strength test and gave score as per perfor- this research study. The demographics showed the test Tests patients who were diagnosed with back pain, patients were not included in the study so no com- sory deficit is seen in critically effected arm11. The METHODOLOGY arm muscles using theraband and tubing grips. The results of pre-treatment group represent that 12 In Kendall’s abdominal strength test subjects lie and occurrence of diastasis recti abdominis from core muscle which is responsible for stabilization of mance. mean age of 29 years. There were 33.8% male and Poor 53 37.3 5.276 0.509 without any serious pathology. parison could have done between health and paralysis of extremity makes difficult for patient to • Grip strengthening. males and 11 females were totally dependent and Fair 65 45.8 supine on a firm surface with arms folded across the late pregnancy to 6 months postpartum and a lumbar region is weak2. 66.2% female among participants. back pain patients. perform their routine activities like reaching, grasp- Study Design • Quadriceps strengthening. there were 9 males and 11 females who were very Good 20 14.1 relationship with lumbo-pelvic pain, that diastasis Kendall’s Strength Test In this study, both genders participants were includ- 12 Randomized control trial (RCT). • Hamstrings strengthening. dependent. Similarly, 9 males and 6 females were chest; a tester assists in raising the legs up to a Normal 4 2.8 ing, eating, and bathing, combing and dressing . vertical position, keeping the knees straight, then recti abdominis is not linked with lumbo–pelvic • Kendall’s Lower Abdominal Test Table1. Percentage distribution of demographic ed. It was found that female participants ratio was Hemiplegic patient experienced paralysis of both • Abductors and adductors of hip strengthening. partially dependent. Likewise, 2 males required characteristics of back pain patients perform a posterior pelvic tilt and maintain this pain14. is a test used to evaluate lower abdominal strength; While performing lower abdominal test most partici- high in comparison to male participants. Buchbind- sides of trunk which makes difficult for individual to Study Settings and Participants • Core stabilizers strengthening for back muscles. minimal helps with ADL and no one was indepen- position while slowly lowering the legs to horizontal, METHODOLOGY subjects lie supine on a firm surface with arms Demographic n % pant have grade 3(fair grade) muscle power (50%) er (2013) in their systemic review stated that women CONCLUSION maintain erect posture during static and dynamic The patients are selected from the OPD setting of • Gait training for 20 minutes. dent. Post-treatment group conferring gender wise strength is graded on the ability to keep the low Study naming Correlation of low back pain and folded across the chest; a tester assists in raising the characteristics followed by grade 4 (good) muscle power (31.7%) suffered with back pain more than men24, whereas movements13. Several lower extremity muscles are Ziauddin Hospital, Saifee Hospital North Nazimabad All exercises were performed in functional ranges 3 males and 1 female was totally dependent and 11 back flat on the surface, the angle at which the diastasis rectus abdominis in post-menopausal 142 Participants was recruited in our study. Partici- legs up to a vertical position (subjects may actively Age (Mean±SD) years 29.01±5.76 which was found statistically significant at P<0.016, in other study Hoy (2014) stated that, men are more In the current study, the prevalence of back pain is much affected for example knee flexor compart- and National Medical Centre, Karachi. with 12-15 repetitions each lasting for 30 minutes males and 7 females was very dependent. Similarly, back arches is noted and correlated with Kendall’s women between the age group of 50-60 years, pants signed consent form. raise one lower extremity at a time, if needed) Gender (table 5). prone to have back pain than women25. higher in females. There was no correlation found ment has been shown to be severely worsen which once a day 3 times a week. Patients were also given 11 males and 13 females was partially dependent grading system15. resulted that there was a partial positive correlation Questionnaires were filled by researcher after keeping the knees straight; subjects then perform a Male 48 33.8 between back pain and rectus abdominis in turns affects the walking ability of the patient and Sample Size home program which includes strengthening and 3 males and 6 females needs minimal helps between diastasis of abdominis and Low back pain perform Kendell test. posterior pelvic tilt and maintain this position while Female 94 66.2 The participants age group were between 20-40 consumes double energy as compared to that of Sixty stroke patients. exercises. Consecutive improvement was recorded with ADL and there were 4 males and 1 female who

41 PAKISTAN JOURNAL OF REHABILITATION 2017 VOLUME 6 (ISSUE 2)

14,15 INTRODUCTION The rationale of this study is to find prevalence or in post-menopausal women. They used VAS and Study Design slowly lowering the legs to horizontal; strength is Graph 1: gender distribution Table5. Kendall’s Lower Abdominal test score years were included in this study, keeping in view REFERENCES INTRODUCTION healthy individuals . Patients with stroke also have Duration of the Study 3 times after every 4 weeks, at the end of 3 months contribution of rectus abdominis weakness in back Roland Morris questionnaire for disability and pain Study design was cross sectional study and informa- graded on the ability to keep the low back flat on Shiri study (2010) who concluded that Low back difficulties due to paralysis of ankle dorsi-flexors and The study is conducted over a period of 6 months. and after 6 months. Lower Abdominal N % Chi- Square P value pain patients. This study will contribute to decreas- and assessed for diastasis recti abdominis using tion was collected using questionnaire. the surface; the angle at which the back arches is pain is common in participants ages between 24 plantar-flexors which decrease the motor function Back pain considers expensive disease in modern test score Tests Stroke is the progressive neurological disorder in 1 2 19 26 16 society . It is job related complaint . Most people ing the incidence of preventable impairments in diastasis recti test . noted and correlated with Kendall’s grading system Poor 20 14.1 15.562 0.016 –39 years . which there is a focal or global impairment of cere- and balance due to decrease in muscle strength . Sampling Method Control Group 15 experience low back pain (LBP) at some point population. The purpose of rectus abdominis weak- Study Population (Kendall et al., 1993) . Fair 71 50.0 bral function that lasts more than 24 hours and can Samples are selected through randomization by Conventional physiotherapy treatments were throughout their life span3. In United States, the ness tests in backache patients is to find strength of Chiarello in their study Consequences of exercise Men and women aged between 20 -40 years Good 45 31.7 In the current study Kendall, upper abdominal and lead to long term disability that compromise the Commonly used scale for the assessment of motor envelop method. performed which are as follows: economic burden of disease ranges from 84 to 624 rectus abdominis in back pain patients. It will deter- regime on DRA in pregnant women resulted that having back pain since 3 months. • Abdominal Strength Test Normal 6 4.2 Kendall lower abdominal test were used as sensory and motor function1,2. American stroke functions is Fugl-Meryer assessment of physical • Active range of motion exercises. dollars per year4. The prevalence has been report- mine is rectus abdominis weakness could be cause about ninety percent of women who were not is a test of upper abdominal strength; subjects are outcome measure to assess muscle power of association estimated that around 87% are performance (FMA), Functional Independence Data Analysis • Active assisted range of motion exercises. ed from 6% to 19% for a first episode and recurrence of back pain. habitual of doing exercise or did not follow exercise Inclusion Criteria2 asked to lie supine on a firm surface with knees When we correlate the back pain and abdominal muscles. MacDonald (1998) concluded ischemic stroke and about 13% strokes are hemor- Measure (FIM) and the Barthel Index scale which is Data analyzed using SPSS version 20 and results are • Stretching of both upper and lower limbs. achieves up to 50% over a 5 years’ stage5. In the regime had DRA and remaining who did exercise • Both gender male and female extended; a roll is placed under the knees if the power/strength of rectus abdominis there were no in his pilot study on 63 that there is increased rhagic3. used worldwide and has excellent sensitivity, validity compared using chi-square test. • Weight bearing exercises. Western countries, back pain lifetime prevalence is Deenika conducted systemic review in which eight had only conditions. It was concluded that size and • Age 20-40 subject displays a positive Thomas Test; the subject is correlation shown between back pain and rectus incidence of low back pain that has been related and reliability17. • Balancing and other functional task oriented 60%–80% among adult population6. The incidence studies were included. All the studies incorporated prevalence of DRA was more in non-exercising • Having back pain then asked to place both hands behind the head abdominis power/strength. (table 6) with Lumbar lordosis, especially in women. The Many patients with hemiplegic stroke encounter Data Collection Tool exercises without resistance were performed. increases with age and is more prevalent between abdominal/core strengthening muscle exercises. group than in exercising group of women20. and proceed to slowly curl up to a sitting position posture stretches and weakens the abdominals mobility restriction at home and in the community, The rehabilitation of stroke patient is a multidimen- Data is collected by distributing questionnaire 30 to 50 years, thus associated with increased The study resulted that exercises done during ante- Exclusion Criteria13 completing spinal flexion range of motion; if this 2. Pain Characteristics of Participants Table 6. Spearman’s rho correlation pain score with (rectus abdominis, external and internal oblique’s) particularly have difficulty with independent walk- sional process encompassing interventions that are among patients. Ethical Concerns health care expenditures around the world7. The natal period reduced DRAM by 35%16. Chiarello conducted another research to compare • Pregnancy action cannot be achieved, the subject modifies Majority of participants were of acute back pain, Kendall’s Upper Abdominal test score and Kendall’s while shortening the hip flexors and lumbar exten- ing4. Hemiplegia causes weakness, balance prob- aimed to ease the substitution of restriction in partic- • Respect for the dignity of research participants is prevalence of back pain in Bangladesh is 64.8%, in inter rectus distance of pregnant women with • Spinal cord injuries. the arm positions and a grade is assigned per Kend- followed by chronic back pain and most of the Lower Abdominal test score sors imbalance increases the stress to the low back, lems which leads to gait disturbance. It has been ipation and activity performance18. In-spite of Data Collection Procedure prioritized. India is 19.8%, in Nepal is 69.5%, in Pakistan is 40.6% A study on Effects of Basic Strength and Pelvic pelvic girdle pain with these of other types of preg- • Neurological diseased all’s muscle grading system (Kendall et al., 1993)15. participants were not taking any medicine as Spearman's rho Kendall’s Upper Kendall’s Lower resulting in pain. He conducted fitness test among revealed that muscle strength is related with gait severe disability and impairment during the early Patient enrolled in the study after meeting the inclu- • Full consent is obtained from the participants prior and in Sri Lanka is 36.2% 6. The general prevalence is training on high school cross-country race times. He nancy related back pain, resulting in with inter • Spondylosis shown in table 2, Abdominal test Abdominal test school going children. He conducted Kendall’s performance5. Due to damage in the cerebral period of stroke many of the patients gain some sion criteria. Before performing the exercises, to the study. higher in females (48%) than in males (32%)8. performed four standardized isometric strength test rectus distance seen widest at umbilicus, narrowest Red flag for back pain: Data Analysis score score lower abdominal and Kendall’s upper abdominal cortex, extremities function is poorly affected and degree of recovery over time19. The aim of rehabili- patient’s vital signs are assessed and initial data • The protection of the privacy of research partici- Correlation 0.065 -0.031 at hip adductors, abductors, extensors and core below the umbilicus and decrease with a curl up, • Circulatory problems SPSS Version 21 was used for data analysis. All cate- test to check the strength of rectus abdominis tation is to focus on independence of patient which recorded using functional activity assessment from pants is ensured. Coefficient the patient is unable to perform activity of daily 15 6 Low back pain is defined as a pain or discomfort musculature for six weeks. He concluded that there and showed no significant difference in the IRD of • Tumors gorical variables were used for jotting down Sig. (2-tailed) 0.439 0.712 muscle . In the current study, no relation found living (ADLS) . As central nervous system is major can be achieved through pressure workload prior to treatment and then recorded post treat- • Anonymity of individuals and organizations partici- 21 located below the margin of the 12th rib and was no interaction regarding increasing muscle pregnant women with pelvic girdle pain . • Infections frequencies and percentages. The association N 142 142 back pain patients and weakness of rectus abdom- issue which cause abnormal muscle tone, muscular exercises that can improve muscle strength and ment at the end of each session. pating in the research is ensured. above the inferior gluteal fold, with or without leg strength and decreasing race times. Pelvic and Yellow flag for back pain: between two categorical variables was deter- inis. MOTA (2014) in her research concluded that atrophy and weakness, balance and coordination reduce spasticity3,20. Scapular stabilization exercises pain9. Back pain can be classified into acute (less core stability strengthening program routine trice a Monica conducted a multiple-baseline, single • Psychosocial problems mined by applying chi-square test for significance. women with DRA were not prone to develop back problem postural disorders and asymmetrical program strengthen upper extremity function in Inclusion Criteria than six weeks), subacute (6 to 12 weeks) or chronic week could decrease in race times17. subject experimental design research on 16 women The significant P-value was less than 0.05 pain than women without DRA, this study support movements4. The motor impairments that a result patients with hemiplegic stroke3. • Adults aged between 45 and 65 years. (longer than 12 weeks)4. Faulty posture and biome- with lumbar pelvic pain after delivery and stated Sampling Technique Kendall's abdominal strength test the present study14. In another study by Joran (2016) due to stroke interferes with the independence of • Single episode of cerebrovascular event. RESULTS chanics amendment are precursor to low back A study conducted on finding out the occurrence reduced pain and disability after an individually Non-probability Sampling Technique. Ethical Consideration showed no difference between women with and the patient while performing both functional activi- Postural shift to the more affected area with weight • Chronic stage of post stroke hemiparesis. 10 7 pain development . Faulty posture is often associ- of diastasis of rectus abdominal muscles instantly adjusted exercise intervention in women with • Confidential: Records of this study will be kept 50.00% without DRA, and prevalence of low back and/or ties and ADLs . Due to loss of motor function, patient bearing on the extended elbow and fingers and • No post stroke synergy pattern seen. Eighty individuals were assessed for study purposes 22 50.00% 27 ated with weak abdominal muscle11. Dysfunction of postpartum, having an outcome with the high post-delivery lumbar pelvic pain . Sample Size secured. Any information that patient tells us will 45.80% pelvic girdle pain . According to Stephanie does not recover and ultimately it results in perma- wrist in neutral position plays an important role in • Patient being able to walk themselves or with out of which a total of 60 subjects were selected, 32 6 17 abdominal musculature (internal oblique and occurrence of DARM (68%) on top of the umbilicus. Sample size is calculated by using Epi software for remain confidential. The information’s will be kept Pain intensity was assessed on NPRS scale and most 40.00% 37.30% Mulhearn there is some evidence of a link between nent disability . Motor relearning can be done to enhancing the proximal stabilization . Most of the assistive devices men and 28 women aged between 45 to 65 years A DARM of above 2.5cm is measured unsafe as it Gerard conducted a study on functional therapeu- sample size calculation. A study conducted at in a locked file; only the researchers for this study will participants of the study were having moderate 31.70% low back pain, postural muscle endurance in time trunk strengthening is neglected due to more • Medically stable and no other serious co-morbidi- of age. Baseline characteristics results indicate that rectus abdominis) is one of the major causes of 30.00% improve function and spontaneous recovery which chronic low back pain (CLBP). The muscles of abdo- may hinder with the muscles of abdomen capabili- tic and core strengthening which postulated that South Asia titled as “Participant in physical activity have access to the records. pain followed by mild pain as shown in table 3 gymnasts and no cause and effect relationship causes neuroplasticity of brain by giving different focus place on extremities21. Trunk exercise have ties. out of 60 individuals, 31 individuals had right side 20.00% 28 8 men averagely enhanced activation by 1–3% and ty to stabilize the trunk, deprived lumbar stabilization athlete’s core strength, endurance, coordination and back pain among an elderly population in • Autonomy: participants were independent to 14.10% 14.10% determined . intensive task depending on the severity of stroke . advantageous result in enhancing the stability and affected with 51.7%. On the contrary 29 individuals the extensors enhanced by 13–31%, due to may influence the person to the increase the devel- flexibility and balance has the role in optimal sports South Asia” is used to calculate sample size. take his or her decision to enroll in study. 10.00% movement in stroke patients, they are principally Exclusion Criteria had left side affected with 48.3% and 29 individuals increased load in CLBP12. Rectus abdominis (RA) opment of back pain18. performance, As of medical literature support core • Beneficence: participants were requested to 2.80% 4.20% On the contrary, Dalal khushboo (2014) conducted In most of the cases physiotherapist encounter effective in refining functional ability22. Bridging • Post stroke hemiparesis in acute stage (less than had upper limb involvement with 48.3% and 31 had 0.00% eccentric activity is crucial to support the trunk and stability as a prevention of injury. So, exercises that Study Setting answer questions which may be private, but the research on 30 women aged greater than 18 years difficulties in motor relearning due to shoulder pain exercises under an unbalanced support that used 30 days post cerebrovascular event). lower limb involvement with 51.7%. Likewise, the Fair Fair evade too much spinal strain and back pain13. Greta conducted the pilot study on 63 children and promote neuromuscular re-educate in athletes with • Tertiary care hospitals data will not be shared with anyone else. Partici- Poor Poor to find correlation between diastasis rectus abdomi- which is mostly experienced by hemiplegic patients sling equipment knowingly improves the lower • Spasticity with definite synergy pattern. cause of 47 individuals was infarction with 78.3% Good Good Normal Normal concluded that there is increased incidence of low core dysfunction are crucial to preventing and pants may refuse to answer any questions on the Upper... Upper... nis and lumbopelvic pain. Subjects were assessed approximately 70-80% that hinders the patient to extremity muscle strength along with core • Patients being bed or wheelchair bound. and the cause of 13 individuals was hemorrhage Diastasis recti abdominis (DRA) is an injury measured back pain that has been related with Lumbar lordo- treating injury23. Study Duration form. We will not share with anyone, the specific on the Pelvic Floor Distress Inventory, Modified participate in rehabilitation program. The restricted strength23. In most of the studies it has been found • Active arthritis. with 21.1%. Since, no significant differences by a midline parting of the 2 rectus abdominis, this sis, especially in women. The posture stretches and 3 months details you tell us. Oswestry Low Back Pain Disability Questionnaire, range of motion and pain in shoulder joint may limit that there is moderate relation between gait speed • Joint deformities. between groups at baseline were noticed as given decrease strength of rectus abdominis. DRA occur weakens the abdominals (rectus abdominis, exter- Any pain or discomfort occurring in the low back • Justice: there was no harm of this research. Partici- Visual Analog Scales (VAS) for pain. Diastasis Rectus the participation of individual in ADLs and IADLs9. and balance function24. A modified sit to stand • Spinal fracture caused by osteoporosis or any in table 1. 30% to 70% in pregnant women. DRA also seen in nal and internal oblique) while shortening the hip region presently or a previous episode with a dura- Assessment Protocol pants were included without any biasness 3. Kendall’s Abdominal Test Score Abdominis measurement was taken. Dalal conclud- Weakened shoulder joint is a common problem for training improves the balance function in hemiple- other musculoskeletal condition. males. Condition is the consideration to be related flexors and lumbar extensors imbalance increases tion greater than 3 days within the last year that Back Patients were recruited from tertiary care Upper abdominal test score of most of the partici- DISCUSSION ed that the incidence for the DRA was 83.33%, and the patient with hemiplegia10. Resisted manual gic stroke patient25. Hip extensor strengthening • Uncontrolled hypertension or cardiac condition with growing age, hereditary weakness of the the stress to the low back, resulting in pain. He essential prolonged rest or medical consideration. hospitals after assessment and screening by consul- pant have grade 3 fair grade muscle power (45.8%) women with a DRA tend to have more lumbo-pelvic exercises for abductors and external rotators of exercise program improves symmetry index of determined by the physician. abdominal muscles, weight lifting, weight fluctua- conducted Kendall’s lower abdominal and Kend- tants. Consent was taken from participants. RESULTS followed by grade 2 poor muscle power (37.3%) Back pain considers expensive disease in modern pain29. shoulder, trapezius, serratus anterior and supraspina- stance phase, walking speed and stride length and Interventions tions, performing full sit-ups, intermittent or chronic all’s upper abdominal test to check the strength of Low back pain usually arises in the region of lumbar, Researcher re-examine patient and enrolled those which was found statistically non-significant at society. There are many causes/risks that leading to tus of scapula significantly decrease lateral spinal there was minimal increase in the paretic side abdominal distention, and actions that may stimu- rectus abdominis muscle. He concluded that thoracolumbar, or lumbosacral. Back pain mostly who were met inclusion and exclusion criteria. 1. Demographics P<0.509 (table 4). the occurrence of back pain. A cross sectional The strength of the study was, it was a randomized deviation angle in sitting position3. Approximately stance phase in patient with hemiplegia4,26. Experimental Group late immense intra-abdominal pressure14. Kendall’s strengthening exercises of rectus abdominis could effects working population. Back pain is Associated Researcher filled self-administered questionnaire of In the following table-1, the means and standard study was conducted to evaluate contribution of control trail, single blindness, both genders were one-third patient suffering from stroke have severe Pressure workload exercises were performed which Abdominal Strength test is a standard method to delay back pain15. with many symptoms and functional limitations. It those who fulfilled inclusion criteria. For rectus deviations of participant’s age and gender distribu- rectus abdominis muscle in the patients with the included in the study, and it was multi-centered arm paresis. Therefore, active assisted movements are as follows: assess abdominal strength in physical therapy15. may be due to any soft tissue injury of the trunk abdominis strength test researcher performed tion is shown. There were in total 140 participants in complain of back pain. This study included 142 study. The weakness of study is non-back pain should be performed on affected limb. Somatosen- • Upper limb strengthening involving shoulder and Patricia, concluded in his article about Risk factors including weakness or spasm or it occurs when the Kendell strength test and gave score as per perfor- this research study. The demographics showed the patients who were diagnosed with back pain, patients were not included in the study so no com- sory deficit is seen in critically effected arm11. The METHODOLOGY arm muscles using theraband and tubing grips. The results of pre-treatment group represent that 12 In Kendall’s abdominal strength test subjects lie and occurrence of diastasis recti abdominis from core muscle which is responsible for stabilization of mance. mean age of 29 years. There were 33.8% male and without any serious pathology. parison could have done between health and paralysis of extremity makes difficult for patient to • Grip strengthening. males and 11 females were totally dependent and supine on a firm surface with arms folded across the late pregnancy to 6 months postpartum and a lumbar region is weak2. 66.2% female among participants. back pain patients. perform their routine activities like reaching, grasp- Study Design • Quadriceps strengthening. there were 9 males and 11 females who were very chest; a tester assists in raising the legs up to a relationship with lumbo-pelvic pain, that diastasis Kendall’s Strength Test In this study, both genders participants were including, eating, and bathing, combing and dressing12. Randomized control trial (RCT). • Hamstrings strengthening. dependent. Similarly, 9 males and 6 females were vertical position, keeping the knees straight, then recti abdominis is not linked with lumbo–pelvic • Kendall’s Lower Abdominal Test ed. It was found that female participants ratio was Hemiplegic patient experienced paralysis of both • Abductors and adductors of hip strengthening. partially dependent. Likewise, 2 males required perform a posterior pelvic tilt and maintain this pain14. is a test used to evaluate lower abdominal strength; While performing lower abdominal test most partici- high in comparison to male participants. Buchbind- sides of trunk which makes difficult for individual to Study Settings and Participants • Core stabilizers strengthening for back muscles. minimal helps with ADL and no one was indepen- position while slowly lowering the legs to horizontal, METHODOLOGY subjects lie supine on a firm surface with arms pant have grade 3(fair grade) muscle power (50%) er (2013) in their systemic review stated that women CONCLUSION maintain erect posture during static and dynamic The patients are selected from the OPD setting of • Gait training for 20 minutes. dent. Post-treatment group conferring gender wise strength is graded on the ability to keep the low Study naming Correlation of low back pain and folded across the chest; a tester assists in raising the followed by grade 4 (good) muscle power (31.7%) suffered with back pain more than men24, whereas movements13. Several lower extremity muscles are Ziauddin Hospital, Saifee Hospital North Nazimabad All exercises were performed in functional ranges 3 males and 1 female was totally dependent and 11 back flat on the surface, the angle at which the diastasis rectus abdominis in post-menopausal 142 Participants was recruited in our study. Partici- legs up to a vertical position (subjects may actively which was found statistically significant at P<0.016, in other study Hoy (2014) stated that, men are more In the current study, the prevalence of back pain is much affected for example knee flexor compart- and National Medical Centre, Karachi. with 12-15 repetitions each lasting for 30 minutes males and 7 females was very dependent. Similarly, back arches is noted and correlated with Kendall’s women between the age group of 50-60 years, pants signed consent form. raise one lower extremity at a time, if needed) (table 5). prone to have back pain than women25. higher in females. There was no correlation found ment has been shown to be severely worsen which once a day 3 times a week. Patients were also given 11 males and 13 females was partially dependent grading system15. resulted that there was a partial positive correlation Questionnaires were filled by researcher after keeping the knees straight; subjects then perform a between back pain and rectus abdominis in turns affects the walking ability of the patient and Sample Size home program which includes strengthening and 3 males and 6 females needs minimal helps between diastasis of abdominis and Low back pain perform Kendell test. posterior pelvic tilt and maintain this position while The participants age group were between 20-40 consumes double energy as compared to that of Sixty stroke patients. exercises. Consecutive improvement was recorded with ADL and there were 4 males and 1 female who

PAKISTAN JOURNAL OF REHABILITATION 2017 VOLUME 6 (ISSUE 2) 42

INTRODUCTION The rationale of this study is to find prevalence or in post-menopausal women. They used VAS and Study Design slowly lowering the legs to horizontal; strength is Graph 1: gender distribution years were included in this study, keeping in view REFERENCES [14] Da Mota PG, Pascoal AG, Carita AI, Bø K. Preva- lence, risk factors and report of lumbopelvic 1999;85(4):210-6 INTRODUCTION healthy individuals14,15. Patients with stroke also have Duration of the Study 3 times after every 4 weeks, at the end of 3 months contribution of rectus abdominis weakness in back Roland Morris questionnaire for disability and pain Study design was cross sectional study and informa- graded on the ability to keep the low back flat on Shiri study (2010) who concluded that Low back lence and risk factors of diastasis recti abdominis pain. Br J Sports Med. 2016: [29] Dalal K, Kaur A, Mitra M. Correlation between difficulties due to paralysis of ankle dorsi-flexors and The study is conducted over a period of 6 months. and after 6 months. pain patients. This study will contribute to decreas- and assessed for diastasis recti abdominis using tion was collected using questionnaire. the surface; the angle at which the back arches is pain is common in participants ages between 24 from late pregnancy to 6 months postpartum, [28] Mulhearn S, George K. Abdominal muscle diastasis rectus abdominis and lumbopelvic pain plantar-flexors which decrease the motor function Back pain considers expensive disease in modern [1] Arslan SA, Hadian MR, Olyaei G, Bagheri H, Yeka- Stroke is the progressive neurological disorder in 1 2 ing the incidence of preventable impairments in diastasis recti test19. noted and correlated with Kendall’s grading system –39 years26. and relationship with lumbo-pelvic pain. Man endurance and its association with posture and and dysfunction. Indian J Physiother Occup Ther. and balance due to decrease in muscle strength16. Sampling Method Control Group society . It is job related complaint . Most people ninejad MS, Ijaz S, Kheradmand AA. Prevalence which there is a focal or global impairment of cere- population. The purpose of rectus abdominis weak- Study Population (Kendall et al., 1993)15. Ther. 2015;20(1):200-5 low back pain: An initial investigation in male 2014;8(1):210 Samples are selected through randomization by Conventional physiotherapy treatments were experience low back pain (LBP) at some point and Risk Factors of Low Back Pain Among the bral function that lasts more than 24 hours and can 3 ness tests in backache patients is to find strength of Chiarello in their study Consequences of exercise Men and women aged between 20 -40 years In the current study Kendall, upper abdominal and [15] McDonald GL, Nederveld KL. The Effects of and female elite gymnasts. Physiotherapy. Commonly used scale for the assessment of motor envelop method. performed which are as follows: throughout their life span . In United States, the Office Workers of King Edward Medical University lead to long term disability that compromise the rectus abdominis in back pain patients. It will deter- regime on DRA in pregnant women resulted that having back pain since 3 months. • Abdominal Strength Test Kendall lower abdominal test were used as Abdominal Strength Exercises and Testing on 1,2 functions is Fugl-Meryer assessment of physical • Active range of motion exercises. economic burden of disease ranges from 84 to 624 Lahore, Pakistan. PTJ. 2016;6(3):161-168 sensory and motor function . American stroke 4 mine is rectus abdominis weakness could be cause about ninety percent of women who were not is a test of upper abdominal strength; subjects are outcome measure to assess muscle power of Posture in School Children.1998. Available from: performance (FMA), Functional Independence Data Analysis • Active assisted range of motion exercises. dollars per year . The prevalence has been report- [2] Lee M, Song C, Jo Y, Ha D, Han D. The effects of association estimated that around 87% are of back pain. habitual of doing exercise or did not follow exercise Inclusion Criteria2 asked to lie supine on a firm surface with knees When we correlate the back pain and abdominal muscles. MacDonald (1998) concluded https://scholarworks.gvsu.edu/theses/409 Measure (FIM) and the Barthel Index scale which is Data analyzed using SPSS version 20 and results are • Stretching of both upper and lower limbs. ed from 6% to 19% for a first episode and recurrence core muscle release technique on lumbar spine ischemic stroke and about 13% strokes are hemor- 5 regime had DRA and remaining who did exercise • Both gender male and female extended; a roll is placed under the knees if the power/strength of rectus abdominis there were no in his pilot study on 63 that there is increased [16] Benjamin DR, Van de Water AT, Peiris CL. Effects 3 used worldwide and has excellent sensitivity, validity compared using chi-square test. • Weight bearing exercises. achieves up to 50% over a 5 years’ stage . In the deformation and low back pain. J Phys Ther Sci. rhagic . Deenika conducted systemic review in which eight had only conditions. It was concluded that size and • Age 20-40 subject displays a positive Thomas Test; the subject is correlation shown between back pain and rectus incidence of low back pain that has been related of exercise on diastasis of the rectus abdominis and reliability17. • Balancing and other functional task oriented Western countries, back pain lifetime prevalence is 2015;27(5):1519-22 6 studies were included. All the studies incorporated prevalence of DRA was more in non-exercising • Having back pain then asked to place both hands behind the head abdominis power/strength. (table 6) with Lumbar lordosis, especially in women. The muscle in the antenatal and postnatal periods: a Data Collection Tool exercises without resistance were performed. 60%–80% among adult population . The incidence [3] Meucci RD, Fassa AG, Faria NM. Prevalence of Many patients with hemiplegic stroke encounter abdominal/core strengthening muscle exercises. group than in exercising group of women20. and proceed to slowly curl up to a sitting position posture stretches and weakens the abdominals systematic review. Physiotherapy. The rehabilitation of stroke patient is a multidimen- Data is collected by distributing questionnaire increases with age and is more prevalent between chronic low back pain: systematic review. Rev mobility restriction at home and in the community, The study resulted that exercises done during ante- Exclusion Criteria13 completing spinal flexion range of motion; if this 2. Pain Characteristics of Participants (rectus abdominis, external and internal oblique’s) 2014;100(1):1-8 sional process encompassing interventions that are among patients. Ethical Concerns 30 to 50 years, thus associated with increased Saude Publica. 2015;49 particularly have difficulty with independent walk- 7 natal period reduced DRAM by 35%16. Chiarello conducted another research to compare • Pregnancy action cannot be achieved, the subject modifies Majority of participants were of acute back pain, while shortening the hip flexors and lumbar exten- [17] Clark AW, Goedeke MK, Cunningham SR, Rock- 4 aimed to ease the substitution of restriction in partic- • Respect for the dignity of research participants is health care expenditures around the world . The [4] Mostagi FQ, Dias JM, Pereira LM, Obara K, ing . Hemiplegia causes weakness, balance prob- inter rectus distance of pregnant women with • Spinal cord injuries. the arm positions and a grade is assigned per Kend- followed by chronic back pain and most of the sors imbalance increases the stress to the low back, well DE, Lehecka BJ, Manske RC, Smith BS. Effects ipation and activity performance18. In-spite of Data Collection Procedure prioritized. prevalence of back pain in Bangladesh is 64.8%, in Mazuquin BF, Silva MF, Silva MA, de Campos RR, lems which leads to gait disturbance. It has been A study on Effects of Basic Strength and Pelvic pelvic girdle pain with these of other types of preg- • Neurological diseased all’s muscle grading system (Kendall et al., 1993)15. participants were not taking any medicine as resulting in pain. He conducted fitness test among of pelvic and core strength training on high severe disability and impairment during the early Patient enrolled in the study after meeting the inclu- • Full consent is obtained from the participants prior India is 19.8%, in Nepal is 69.5%, in Pakistan is 40.6% Barreto MS, Nogueira JF, Lima TB. Pilates versus revealed that muscle strength is related with gait 6 training on high school cross-country race times. He nancy related back pain, resulting in with inter • Spondylosis shown in table 2, school going children. He conducted Kendall’s school cross-country race times. J Strength Cond 5 period of stroke many of the patients gain some sion criteria. Before performing the exercises, to the study. and in Sri Lanka is 36.2% . The general prevalence is general exercise effectiveness on pain and performance . Due to damage in the cerebral 8 performed four standardized isometric strength test rectus distance seen widest at umbilicus, narrowest Red flag for back pain: Data Analysis lower abdominal and Kendall’s upper abdominal Res. 2017;31(8):2289-95 degree of recovery over time19. The aim of rehabili- patient’s vital signs are assessed and initial data • The protection of the privacy of research partici- higher in females (48%) than in males (32%) . functionality in non-specific chronic low back cortex, extremities function is poorly affected and at hip adductors, abductors, extensors and core below the umbilicus and decrease with a curl up, • Circulatory problems SPSS Version 21 was used for data analysis. All cate- test to check the strength of rectus abdominis [18] Rett MT, Braga MD, Bernardes NO, Andrade SC. tation is to focus on independence of patient which recorded using functional activity assessment from pants is ensured. pain subjects. J Bodyw Mov Ther. the patient is unable to perform activity of daily musculature for six weeks. He concluded that there and showed no significant difference in the IRD of • Tumors gorical variables were used for jotting down muscle15. In the current study, no relation found Prevalence of diastasis of the rectus abdominis 6 can be achieved through pressure workload prior to treatment and then recorded post treat- • Anonymity of individuals and organizations partici- Low back pain is defined as a pain or discomfort 2015;19(4):636-45 living (ADLS) . As central nervous system is major was no interaction regarding increasing muscle pregnant women with pelvic girdle pain21. • Infections frequencies and percentages. The association back pain patients and weakness of rectus abdom- muscles immediately postpartum: comparison exercises that can improve muscle strength and ment at the end of each session. pating in the research is ensured. located below the margin of the 12th rib and [5] Hirata RP, Salomoni SE, Christensen SW, Grav- issue which cause abnormal muscle tone, muscular strength and decreasing race times. Pelvic and Yellow flag for back pain: between two categorical variables was deter- inis. MOTA (2014) in her research concluded that between primiparae and multiparae. Braz J Phys reduce spasticity3,20. Scapular stabilization exercises above the inferior gluteal fold, with or without leg en-Nielsen T. Reorganised motor control strate- atrophy and weakness, balance and coordination 9 core stability strengthening program routine trice a Monica conducted a multiple-baseline, single • Psychosocial problems mined by applying chi-square test for significance. women with DRA were not prone to develop back Ther. 2009;13(4):275-80 program strengthen upper extremity function in Inclusion Criteria pain . Back pain can be classified into acute (less gies of trunk muscles due to acute low back problem postural disorders and asymmetrical week could decrease in race times17. subject experimental design research on 16 women The significant P-value was less than 0.05 pain than women without DRA, this study support [19] Shah SK, Honkalas P, Kumar A. Correlation of Low 4 patients with hemiplegic stroke3. • Adults aged between 45 and 65 years. than six weeks), subacute (6 to 12 weeks) or chronic pain. Hum Mov Sci. 2015;41:282-94 movements . The motor impairments that a result 4 with lumbar pelvic pain after delivery and stated Sampling Technique the present study14. In another study by Joran (2016) Back Pain and Diastasis Rectus Abdominis in • Single episode of cerebrovascular event. RESULTS (longer than 12 weeks) . Faulty posture and biome- [6] Bishwajit G, Tang S, Sanni Yaya ZF. Participation in due to stroke interferes with the independence of A study conducted on finding out the occurrence reduced pain and disability after an individually Non-probability Sampling Technique. Ethical Consideration showed no difference between women with and Post-Menopausal Women between the Age Postural shift to the more affected area with weight • Chronic stage of post stroke hemiparesis. chanics amendment are precursor to low back physical activity and back pain among an elder- the patient while performing both functional activi- 10 of diastasis of rectus abdominal muscles instantly adjusted exercise intervention in women with • Confidential: Records of this study will be kept without DRA, and prevalence of low back and/or Group of 50–60 Years. Indian J Physiother Occup 7 bearing on the extended elbow and fingers and • No post stroke synergy pattern seen. Eighty individuals were assessed for study purposes pain development . Faulty posture is often associ- ly population in South Asia. J Pain Res. 2017; ties and ADLs . Due to loss of motor function, patient 11 postpartum, having an outcome with the high post-delivery lumbar pelvic pain22. Sample Size secured. Any information that patient tells us will pelvic girdle pain27. According to Stephanie Ther. 2016;10(3):108-11 wrist in neutral position plays an important role in • Patient being able to walk themselves or with out of which a total of 60 subjects were selected, 32 ated with weak abdominal muscle . Dysfunction of 10:905 does not recover and ultimately it results in perma- occurrence of DARM (68%) on top of the umbilicus. Sample size is calculated by using Epi software for remain confidential. The information’s will be kept Pain intensity was assessed on NPRS scale and most Mulhearn there is some evidence of a link between [20] Chiarello CM, McAuley JA, Hartigan EH. Immedi- 6 enhancing the proximal stabilization17. Most of the assistive devices men and 28 women aged between 45 to 65 years abdominal musculature (internal oblique and [7] Zanuto EA, Codogno JS, Christófaro DG, nent disability . Motor relearning can be done to A DARM of above 2.5cm is measured unsafe as it Gerard conducted a study on functional therapeu- sample size calculation. A study conducted at in a locked file; only the researchers for this study will participants of the study were having moderate low back pain, postural muscle endurance in ate effect of active abdominal contraction on time trunk strengthening is neglected due to more • Medically stable and no other serious co-morbidi- of age. Baseline characteristics results indicate that rectus abdominis) is one of the major causes of Vanderlei LC, Cardoso JR, Fernandes RA. Preva- improve function and spontaneous recovery which may hinder with the muscles of abdomen capabili- tic and core strengthening which postulated that South Asia titled as “Participant in physical activity have access to the records. pain followed by mild pain as shown in table 3 gymnasts and no cause and effect relationship inter-recti distance. J Orthop Sports Phys Ther. focus place on extremities21. Trunk exercise have ties. out of 60 individuals, 31 individuals had right side chronic low back pain (CLBP). The muscles of abdo- lence of low back pain and associated factors in causes neuroplasticity of brain by giving different ty to stabilize the trunk, deprived lumbar stabilization athlete’s core strength, endurance, coordination and back pain among an elderly population in • Autonomy: participants were independent to determined28. 2016;46(3):177-83 8 advantageous result in enhancing the stability and affected with 51.7%. On the contrary 29 individuals men averagely enhanced activation by 1–3% and adults from a middle-size Brazilian city. Cien intensive task depending on the severity of stroke . may influence the person to the increase the devel- flexibility and balance has the role in optimal sports South Asia” is used to calculate sample size. take his or her decision to enroll in study. [21] Chiarello CM. Pregnancy-Related Pelvic Girdle movement in stroke patients, they are principally Exclusion Criteria had left side affected with 48.3% and 29 individuals the extensors enhanced by 13–31%, due to Saude Colet. 2015;20(5):1575-82 12 opment of back pain18. performance, As of medical literature support core • Beneficence: participants were requested to On the contrary, Dalal khushboo (2014) conducted Pain and Diastasis Rectus Abdominis. J Womens effective in refining functional ability22. Bridging • Post stroke hemiparesis in acute stage (less than had upper limb involvement with 48.3% and 31 had increased load in CLBP . Rectus abdominis (RA) [8] Nelson-Wong E, Callaghan JP. Is muscle co-acti- In most of the cases physiotherapist encounter stability as a prevention of injury. So, exercises that Study Setting answer questions which may be private, but the research on 30 women aged greater than 18 years Health Phys Therap. 2017;41(1):3-9 exercises under an unbalanced support that used 30 days post cerebrovascular event). lower limb involvement with 51.7%. Likewise, the eccentric activity is crucial to support the trunk and vation a predisposing factor for low back pain difficulties in motor relearning due to shoulder pain 13 Greta conducted the pilot study on 63 children and promote neuromuscular re-educate in athletes with • Tertiary care hospitals data will not be shared with anyone else. Partici- to find correlation between diastasis rectus abdomi- [22] Unsgaard-Tøndel M, Vasseljen O, Woodhouse A, sling equipment knowingly improves the lower • Spasticity with definite synergy pattern. cause of 47 individuals was infarction with 78.3% evade too much spinal strain and back pain . development during standing? A multifactorial which is mostly experienced by hemiplegic patients concluded that there is increased incidence of low core dysfunction are crucial to preventing and pants may refuse to answer any questions on the nis and lumbopelvic pain. Subjects were assessed Mørkved S. Exercises for women with persistent extremity muscle strength along with core • Patients being bed or wheelchair bound. and the cause of 13 individuals was hemorrhage approach for early identification of at-risk individ- approximately 70-80% that hinders the patient to back pain that has been related with Lumbar lordo- treating injury23. Study Duration form. We will not share with anyone, the specific on the Pelvic Floor Distress Inventory, Modified pelvic and low back pain after pregnancy. Glob strength23. In most of the studies it has been found • Active arthritis. with 21.1%. Since, no significant differences Diastasis recti abdominis (DRA) is an injury measured uals. J Electromyography Kinesiol. participate in rehabilitation program. The restricted sis, especially in women. The posture stretches and 3 months details you tell us. Oswestry Low Back Pain Disability Questionnaire, J Health Sci. 2016 ;8(9):107 that there is moderate relation between gait speed • Joint deformities. between groups at baseline were noticed as given by a midline parting of the 2 rectus abdominis, this 2010;20(2):256-63 range of motion and pain in shoulder joint may limit weakens the abdominals (rectus abdominis, exter- Any pain or discomfort occurring in the low back • Justice: there was no harm of this research. Partici- Visual Analog Scales (VAS) for pain. Diastasis Rectus [23] Malanga GA, Aydin SM, Holder EK, Petrin Z. Func- 9 and balance function24. A modified sit to stand • Spinal fracture caused by osteoporosis or any in table 1. decrease strength of rectus abdominis. DRA occur [9] Meucci RD, Fassa AG, Paniz VM, Silva MC, the participation of individual in ADLs and IADLs . nal and internal oblique) while shortening the hip region presently or a previous episode with a dura- Assessment Protocol pants were included without any biasness 3. Kendall’s Abdominal Test Score Abdominis measurement was taken. Dalal conclud- tional Therapeutic and Core Strengthening. In training improves the balance function in hemiple- other musculoskeletal condition. 30% to 70% in pregnant women. DRA also seen in Wegman DH. Increase of chronic low back pain Weakened shoulder joint is a common problem for flexors and lumbar extensors imbalance increases tion greater than 3 days within the last year that Back Patients were recruited from tertiary care Upper abdominal test score of most of the partici- DISCUSSION ed that the incidence for the DRA was 83.33%, and The Hip and Pelvis in Sports Medicine and Primary 10 gic stroke patient25. Hip extensor strengthening • Uncontrolled hypertension or cardiac condition males. Condition is the consideration to be related prevalence in a medium-sized city of southern the patient with hemiplegia . Resisted manual the stress to the low back, resulting in pain. He essential prolonged rest or medical consideration. hospitals after assessment and screening by consul- pant have grade 3 fair grade muscle power (45.8%) women with a DRA tend to have more lumbo-pelvic Care 2017 (pp. 185-214). Springer International exercise program improves symmetry index of determined by the physician. with growing age, hereditary weakness of the Brazil. BMC Musculoskelet Disord. 2013;14(1):155 exercises for abductors and external rotators of conducted Kendall’s lower abdominal and Kend- tants. Consent was taken from participants. RESULTS followed by grade 2 poor muscle power (37.3%) Back pain considers expensive disease in modern pain29. Publishing. stance phase, walking speed and stride length and Interventions abdominal muscles, weight lifting, weight fluctua- [10] Acharry N, Kutty RK. Abdominal exercise with shoulder, trapezius, serratus anterior and supraspina- all’s upper abdominal test to check the strength of Low back pain usually arises in the region of lumbar, Researcher re-examine patient and enrolled those which was found statistically non-significant at society. There are many causes/risks that leading to [24] Buchbinder R, Blyth FM, March LM, Brooks P, there was minimal increase in the paretic side tions, performing full sit-ups, intermittent or chronic bracing, a therapeutic efficacy in reducing tus of scapula significantly decrease lateral spinal rectus abdominis muscle. He concluded that thoracolumbar, or lumbosacral. Back pain mostly who were met inclusion and exclusion criteria. 1. Demographics P<0.509 (table 4). the occurrence of back pain. A cross sectional The strength of the study was, it was a randomized Woolf AD, Hoy DG. Placing the global burden of 3 stance phase in patient with hemiplegia4,26. Experimental Group abdominal distention, and actions that may stimu- diastasis-recti among postpartal females. Physio- deviation angle in sitting position . Approximately 14 strengthening exercises of rectus abdominis could effects working population. Back pain is Associated Researcher filled self-administered questionnaire of In the following table-1, the means and standard study was conducted to evaluate contribution of control trail, single blindness, both genders were low back pain in context. Best Pract Res Clin Pressure workload exercises were performed which late immense intra-abdominal pressure . Kendall’s ther Res Int. 2015;3(2):999-1005 one-third patient suffering from stroke have severe delay back pain15. with many symptoms and functional limitations. It those who fulfilled inclusion criteria. For rectus deviations of participant’s age and gender distribu- rectus abdominis muscle in the patients with the included in the study, and it was multi-centered Rheumatol. 2013; 27(5):575-89 are as follows: Abdominal Strength test is a standard method to [11] Gray J, Aginsky KD, Derman W, Vaughan CL, arm paresis. Therefore, active assisted movements 15 may be due to any soft tissue injury of the trunk abdominis strength test researcher performed tion is shown. There were in total 140 participants in complain of back pain. This study included 142 study. The weakness of study is non-back pain [25] Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, • Upper limb strengthening involving shoulder and assess abdominal strength in physical therapy . Hodges PW. Symmetry, not asymmetry, of should be performed on affected limb. Somatosen- Patricia, concluded in his article about Risk factors including weakness or spasm or it occurs when the Kendell strength test and gave score as per perfor- this research study. The demographics showed the patients who were diagnosed with back pain, patients were not included in the study so no com- Williams G, Smith E, Vos T, Barendregt J, Murray 11 METHODOLOGY arm muscles using theraband and tubing grips. The results of pre-treatment group represent that 12 abdominal muscle morphology is associated sory deficit is seen in critically effected arm . The and occurrence of diastasis recti abdominis from core muscle which is responsible for stabilization of mance. mean age of 29 years. There were 33.8% male and without any serious pathology. parison could have done between health and C. The global burden of low back pain: estimates • Grip strengthening. males and 11 females were totally dependent and In Kendall’s abdominal strength test subjects lie with low back pain in cricket fast bowlers. J paralysis of extremity makes difficult for patient to late pregnancy to 6 months postpartum and a lumbar region is weak2. 66.2% female among participants. back pain patients. from the Global Burden of Disease 2010 study. Study Design • Quadriceps strengthening. there were 9 males and 11 females who were very supine on a firm surface with arms folded across the Sports Sci Med. 2016;19(3):222-6 perform their routine activities like reaching, grasp- relationship with lumbo-pelvic pain, that diastasis Kendall’s Strength Test In this study, both genders participants were includ- Ann Rheum Dis. 2014: 73(6):968-974 12 Randomized control trial (RCT). • Hamstrings strengthening. dependent. Similarly, 9 males and 6 females were chest; a tester assists in raising the legs up to a [12] Silfies SP, Squillante D, Maurer P, Westcott S, ing, eating, and bathing, combing and dressing . recti abdominis is not linked with lumbo–pelvic • Kendall’s Lower Abdominal Test ed. It was found that female participants ratio was [26] Shiri R, Solovieva S, Husgafvel‐Pursiainen K, Viikari • Abductors and adductors of hip strengthening. partially dependent. Likewise, 2 males required vertical position, keeping the knees straight, then Karduna AR. Trunk muscle recruitment patterns in Hemiplegic patient experienced paralysis of both pain14. is a test used to evaluate lower abdominal strength; While performing lower abdominal test most partici- high in comparison to male participants. Buchbind- J, Raitakari OT, Viikari‐Juntura E. Incidence of Study Settings and Participants • Core stabilizers strengthening for back muscles. minimal helps with ADL and no one was indepen- perform a posterior pelvic tilt and maintain this specific chronic low back pain populations. Clin sides of trunk which makes difficult for individual to METHODOLOGY subjects lie supine on a firm surface with arms pant have grade 3(fair grade) muscle power (50%) er (2013) in their systemic review stated that women CONCLUSION nonspecific and radiating low back pain: The patients are selected from the OPD setting of • Gait training for 20 minutes. dent. Post-treatment group conferring gender wise position while slowly lowering the legs to horizontal, Biomech . 2005;20(5):465-73 maintain erect posture during static and dynamic Study naming Correlation of low back pain and folded across the chest; a tester assists in raising the followed by grade 4 (good) muscle power (31.7%) suffered with back pain more than men24, whereas followup of 24–39‐year‐old adults of the Young 13 Ziauddin Hospital, Saifee Hospital North Nazimabad All exercises were performed in functional ranges 3 males and 1 female was totally dependent and 11 strength is graded on the ability to keep the low [13] Correia JP, Oliveira R, Vaz JR, Silva L, Pezarat-Cor- movements . Several lower extremity muscles are diastasis rectus abdominis in post-menopausal 142 Participants was recruited in our study. Partici- legs up to a vertical position (subjects may actively which was found statistically significant at P<0.016, in other study Hoy (2014) stated that, men are more In the current study, the prevalence of back pain is Finns Study. Arthritis care Res. 2010;62(4):455-9 and National Medical Centre, Karachi. with 12-15 repetitions each lasting for 30 minutes males and 7 females was very dependent. Similarly, back flat on the surface, the angle at which the reia P. Trunk muscle activation, fatigue and low much affected for example knee flexor compart- women between the age group of 50-60 years, pants signed consent form. raise one lower extremity at a time, if needed) (table 5). prone to have back pain than women25. higher in females. There was no correlation found [27] Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh once a day 3 times a week. Patients were also given 11 males and 13 females was partially dependent back arches is noted and correlated with Kendall’s back pain in tennis players. J Sports Sci Med. ment has been shown to be severely worsen which 15 resulted that there was a partial positive correlation Questionnaires were filled by researcher after keeping the knees straight; subjects then perform a between back pain and rectus abdominis M, Bø K. Diastasis recti abdominis during preg- Sample Size home program which includes strengthening and 3 males and 6 females needs minimal helps grading system . 2016;19(4):311-316 in turns affects the walking ability of the patient and between diastasis of abdominis and Low back pain perform Kendell test. posterior pelvic tilt and maintain this position while The participants age group were between 20-40 nancy and 12 months after childbirth: preva- consumes double energy as compared to that of Sixty stroke patients. exercises. Consecutive improvement was recorded with ADL and there were 4 males and 1 female who

43 PAKISTAN JOURNAL OF REHABILITATION 2017 VOLUME 6 (ISSUE 2)

[14] Da Mota PG, Pascoal AG, Carita AI, Bø K. Preva- lence, risk factors and report of lumbopelvic 1999;85(4):210-6 INTRODUCTION healthy individuals14,15. Patients with stroke also have Duration of the Study 3 times after every 4 weeks, at the end of 3 months lence and risk factors of diastasis recti abdominis pain. Br J Sports Med. 2016: [29] Dalal K, Kaur A, Mitra M. Correlation between difficulties due to paralysis of ankle dorsi-flexors and The study is conducted over a period of 6 months. and after 6 months. from late pregnancy to 6 months postpartum, [28] Mulhearn S, George K. Abdominal muscle diastasis rectus abdominis and lumbopelvic pain plantar-flexors which decrease the motor function [1] Arslan SA, Hadian MR, Olyaei G, Bagheri H, Yeka- Stroke is the progressive neurological disorder in and relationship with lumbo-pelvic pain. Man endurance and its association with posture and and dysfunction. Indian J Physiother Occup Ther. and balance due to decrease in muscle strength16. Sampling Method Control Group ninejad MS, Ijaz S, Kheradmand AA. Prevalence which there is a focal or global impairment of cere- Ther. 2015;20(1):200-5 low back pain: An initial investigation in male 2014;8(1):210 Samples are selected through randomization by Conventional physiotherapy treatments were and Risk Factors of Low Back Pain Among the bral function that lasts more than 24 hours and can [15] McDonald GL, Nederveld KL. The Effects of and female elite gymnasts. Physiotherapy. Commonly used scale for the assessment of motor envelop method. performed which are as follows: Office Workers of King Edward Medical University lead to long term disability that compromise the Abdominal Strength Exercises and Testing on 1,2 functions is Fugl-Meryer assessment of physical • Active range of motion exercises. Lahore, Pakistan. PTJ. 2016;6(3):161-168 sensory and motor function . American stroke Posture in School Children.1998. Available from: performance (FMA), Functional Independence Data Analysis • Active assisted range of motion exercises. [2] Lee M, Song C, Jo Y, Ha D, Han D. The effects of association estimated that around 87% are https://scholarworks.gvsu.edu/theses/409 Measure (FIM) and the Barthel Index scale which is Data analyzed using SPSS version 20 and results are • Stretching of both upper and lower limbs. core muscle release technique on lumbar spine ischemic stroke and about 13% strokes are hemor- [16] Benjamin DR, Van de Water AT, Peiris CL. Effects 3 used worldwide and has excellent sensitivity, validity compared using chi-square test. • Weight bearing exercises. deformation and low back pain. J Phys Ther Sci. rhagic . of exercise on diastasis of the rectus abdominis and reliability17. • Balancing and other functional task oriented 2015;27(5):1519-22 muscle in the antenatal and postnatal periods: a Data Collection Tool exercises without resistance were performed. [3] Meucci RD, Fassa AG, Faria NM. Prevalence of Many patients with hemiplegic stroke encounter systematic review. Physiotherapy. The rehabilitation of stroke patient is a multidimen- Data is collected by distributing questionnaire chronic low back pain: systematic review. Rev mobility restriction at home and in the community, 2014;100(1):1-8 sional process encompassing interventions that are among patients. Ethical Concerns Saude Publica. 2015;49 particularly have difficulty with independent walk- [17] Clark AW, Goedeke MK, Cunningham SR, Rock- 4 aimed to ease the substitution of restriction in partic- • Respect for the dignity of research participants is [4] Mostagi FQ, Dias JM, Pereira LM, Obara K, ing . Hemiplegia causes weakness, balance prob- well DE, Lehecka BJ, Manske RC, Smith BS. Effects ipation and activity performance18. In-spite of Data Collection Procedure prioritized. Mazuquin BF, Silva MF, Silva MA, de Campos RR, lems which leads to gait disturbance. It has been of pelvic and core strength training on high severe disability and impairment during the early Patient enrolled in the study after meeting the inclu- • Full consent is obtained from the participants prior Barreto MS, Nogueira JF, Lima TB. Pilates versus revealed that muscle strength is related with gait school cross-country race times. J Strength Cond 5 period of stroke many of the patients gain some sion criteria. Before performing the exercises, to the study. general exercise effectiveness on pain and performance . Due to damage in the cerebral Res. 2017;31(8):2289-95 degree of recovery over time19. The aim of rehabili- patient’s vital signs are assessed and initial data • The protection of the privacy of research partici- functionality in non-specific chronic low back cortex, extremities function is poorly affected and [18] Rett MT, Braga MD, Bernardes NO, Andrade SC. tation is to focus on independence of patient which recorded using functional activity assessment from pants is ensured. pain subjects. J Bodyw Mov Ther. the patient is unable to perform activity of daily Prevalence of diastasis of the rectus abdominis 6 can be achieved through pressure workload prior to treatment and then recorded post treat- • Anonymity of individuals and organizations partici- 2015;19(4):636-45 living (ADLS) . As central nervous system is major muscles immediately postpartum: comparison exercises that can improve muscle strength and ment at the end of each session. pating in the research is ensured. [5] Hirata RP, Salomoni SE, Christensen SW, Grav- issue which cause abnormal muscle tone, muscular between primiparae and multiparae. Braz J Phys reduce spasticity3,20. Scapular stabilization exercises en-Nielsen T. Reorganised motor control strate- atrophy and weakness, balance and coordination Ther. 2009;13(4):275-80 program strengthen upper extremity function in Inclusion Criteria gies of trunk muscles due to acute low back problem postural disorders and asymmetrical [19] Shah SK, Honkalas P, Kumar A. Correlation of Low 4 patients with hemiplegic stroke3. • Adults aged between 45 and 65 years. pain. Hum Mov Sci. 2015;41:282-94 movements . The motor impairments that a result Back Pain and Diastasis Rectus Abdominis in • Single episode of cerebrovascular event. RESULTS [6] Bishwajit G, Tang S, Sanni Yaya ZF. Participation in due to stroke interferes with the independence of Post-Menopausal Women between the Age Postural shift to the more affected area with weight • Chronic stage of post stroke hemiparesis. physical activity and back pain among an elder- the patient while performing both functional activi- Group of 50–60 Years. Indian J Physiother Occup 7 bearing on the extended elbow and fingers and • No post stroke synergy pattern seen. Eighty individuals were assessed for study purposes ly population in South Asia. J Pain Res. 2017; ties and ADLs . Due to loss of motor function, patient Ther. 2016;10(3):108-11 wrist in neutral position plays an important role in • Patient being able to walk themselves or with out of which a total of 60 subjects were selected, 32 10:905 does not recover and ultimately it results in perma- [20] Chiarello CM, McAuley JA, Hartigan EH. Immedi- 6 enhancing the proximal stabilization17. Most of the assistive devices men and 28 women aged between 45 to 65 years [7] Zanuto EA, Codogno JS, Christófaro DG, nent disability . Motor relearning can be done to ate effect of active abdominal contraction on time trunk strengthening is neglected due to more • Medically stable and no other serious co-morbidi- of age. Baseline characteristics results indicate that Vanderlei LC, Cardoso JR, Fernandes RA. Preva- improve function and spontaneous recovery which inter-recti distance. J Orthop Sports Phys Ther. focus place on extremities21. Trunk exercise have ties. out of 60 individuals, 31 individuals had right side lence of low back pain and associated factors in causes neuroplasticity of brain by giving different 2016;46(3):177-83 8 advantageous result in enhancing the stability and affected with 51.7%. On the contrary 29 individuals adults from a middle-size Brazilian city. Cien intensive task depending on the severity of stroke . [21] Chiarello CM. Pregnancy-Related Pelvic Girdle movement in stroke patients, they are principally Exclusion Criteria had left side affected with 48.3% and 29 individuals Saude Colet. 2015;20(5):1575-82 Pain and Diastasis Rectus Abdominis. J Womens effective in refining functional ability22. Bridging • Post stroke hemiparesis in acute stage (less than had upper limb involvement with 48.3% and 31 had [8] Nelson-Wong E, Callaghan JP. Is muscle co-acti- In most of the cases physiotherapist encounter Health Phys Therap. 2017;41(1):3-9 exercises under an unbalanced support that used 30 days post cerebrovascular event). lower limb involvement with 51.7%. Likewise, the vation a predisposing factor for low back pain difficulties in motor relearning due to shoulder pain [22] Unsgaard-Tøndel M, Vasseljen O, Woodhouse A, sling equipment knowingly improves the lower • Spasticity with definite synergy pattern. cause of 47 individuals was infarction with 78.3% development during standing? A multifactorial which is mostly experienced by hemiplegic patients Mørkved S. Exercises for women with persistent extremity muscle strength along with core • Patients being bed or wheelchair bound. and the cause of 13 individuals was hemorrhage approach for early identification of at-risk individ- approximately 70-80% that hinders the patient to pelvic and low back pain after pregnancy. Glob strength23. In most of the studies it has been found • Active arthritis. with 21.1%. Since, no significant differences uals. J Electromyography Kinesiol. participate in rehabilitation program. The restricted J Health Sci. 2016 ;8(9):107 that there is moderate relation between gait speed • Joint deformities. between groups at baseline were noticed as given 2010;20(2):256-63 range of motion and pain in shoulder joint may limit [23] Malanga GA, Aydin SM, Holder EK, Petrin Z. Func- 9 and balance function24. A modified sit to stand • Spinal fracture caused by osteoporosis or any in table 1. [9] Meucci RD, Fassa AG, Paniz VM, Silva MC, the participation of individual in ADLs and IADLs . tional Therapeutic and Core Strengthening. In training improves the balance function in hemiple- other musculoskeletal condition. Wegman DH. Increase of chronic low back pain Weakened shoulder joint is a common problem for The Hip and Pelvis in Sports Medicine and Primary 10 gic stroke patient25. Hip extensor strengthening • Uncontrolled hypertension or cardiac condition prevalence in a medium-sized city of southern the patient with hemiplegia . Resisted manual Care 2017 (pp. 185-214). Springer International exercise program improves symmetry index of determined by the physician. Brazil. BMC Musculoskelet Disord. 2013;14(1):155 exercises for abductors and external rotators of Publishing. stance phase, walking speed and stride length and Interventions [10] Acharry N, Kutty RK. Abdominal exercise with shoulder, trapezius, serratus anterior and supraspina- [24] Buchbinder R, Blyth FM, March LM, Brooks P, there was minimal increase in the paretic side bracing, a therapeutic efficacy in reducing tus of scapula significantly decrease lateral spinal Woolf AD, Hoy DG. Placing the global burden of 3 stance phase in patient with hemiplegia4,26. Experimental Group diastasis-recti among postpartal females. Physio- deviation angle in sitting position . Approximately low back pain in context. Best Pract Res Clin Pressure workload exercises were performed which ther Res Int. 2015;3(2):999-1005 one-third patient suffering from stroke have severe Rheumatol. 2013; 27(5):575-89 are as follows: [11] Gray J, Aginsky KD, Derman W, Vaughan CL, arm paresis. Therefore, active assisted movements [25] Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, • Upper limb strengthening involving shoulder and Hodges PW. Symmetry, not asymmetry, of should be performed on affected limb. Somatosen- Williams G, Smith E, Vos T, Barendregt J, Murray 11 METHODOLOGY arm muscles using theraband and tubing grips. The results of pre-treatment group represent that 12 abdominal muscle morphology is associated sory deficit is seen in critically effected arm . The C. The global burden of low back pain: estimates • Grip strengthening. males and 11 females were totally dependent and with low back pain in cricket fast bowlers. J paralysis of extremity makes difficult for patient to from the Global Burden of Disease 2010 study. Study Design • Quadriceps strengthening. there were 9 males and 11 females who were very Sports Sci Med. 2016;19(3):222-6 perform their routine activities like reaching, grasp- Ann Rheum Dis. 2014: 73(6):968-974 12 Randomized control trial (RCT). • Hamstrings strengthening. dependent. Similarly, 9 males and 6 females were [12] Silfies SP, Squillante D, Maurer P, Westcott S, ing, eating, and bathing, combing and dressing . [26] Shiri R, Solovieva S, Husgafvel‐Pursiainen K, Viikari • Abductors and adductors of hip strengthening. partially dependent. Likewise, 2 males required Karduna AR. Trunk muscle recruitment patterns in Hemiplegic patient experienced paralysis of both J, Raitakari OT, Viikari‐Juntura E. Incidence of Study Settings and Participants • Core stabilizers strengthening for back muscles. minimal helps with ADL and no one was indepen- specific chronic low back pain populations. Clin sides of trunk which makes difficult for individual to nonspecific and radiating low back pain: The patients are selected from the OPD setting of • Gait training for 20 minutes. dent. Post-treatment group conferring gender wise Biomech . 2005;20(5):465-73 maintain erect posture during static and dynamic followup of 24–39‐year‐old adults of the Young 13 Ziauddin Hospital, Saifee Hospital North Nazimabad All exercises were performed in functional ranges 3 males and 1 female was totally dependent and 11 [13] Correia JP, Oliveira R, Vaz JR, Silva L, Pezarat-Cor- movements . Several lower extremity muscles are Finns Study. Arthritis care Res. 2010;62(4):455-9 and National Medical Centre, Karachi. with 12-15 repetitions each lasting for 30 minutes males and 7 females was very dependent. Similarly, reia P. Trunk muscle activation, fatigue and low much affected for example knee flexor compart- [27] Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh once a day 3 times a week. Patients were also given 11 males and 13 females was partially dependent back pain in tennis players. J Sports Sci Med. ment has been shown to be severely worsen which M, Bø K. Diastasis recti abdominis during preg- Sample Size home program which includes strengthening and 3 males and 6 females needs minimal helps 2016;19(4):311-316 in turns affects the walking ability of the patient and nancy and 12 months after childbirth: preva- consumes double energy as compared to that of Sixty stroke patients. exercises. Consecutive improvement was recorded with ADL and there were 4 males and 1 female who

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