DOI Number: 10.5958/0973-5674.2019.00020.0 The Effect of with Lumbar Stabilization Exercises in Subjects of Low with Adverse Neural Tension between the Age Group 20-50 Years

Mahesh Mitra1, Niharika Gaikwad2 1Principal, 2MPT, NDMVP College of Physiotherapy, N.D.M.V.P college of physiotherapy, Vasantdada Nagar, Adgaon, Nasik

ABSTRACT is a common disorder which involves muscles, nerves, and bones of the back. About 70% to 85% of population has low back pain at some point in life. Adverse neural tension is defined as physiological or mechanical response produced when structures of the nervous system exceed their normal range of movement. Mechanically or chemically sensitized nerves show abnormal mechano sensitivity. Purpose: purpose of the study was to find the effect of Straight Leg Raise With lumbar stabilization exercises in reducing pain, improving ROM and physical functions in low back pain subjects with adverse neural tension. Aim: To find the effect of Straight Leg Raise with lumbar stabilization exercises in reducing pain, improving ROM, and physical functions in low back pain subjects with adverse neural tension. Objective: To study the effect of straight leg raise with lumbar stabilization exercises in reducing pain, improving ROM, and physical functions in low back pain subjects with adverse neural tension between the age group 20-50 years. Method: This study was conducted on 30 lower back pain patients, age 20-50 years were taken from NDMVP Hospital and research centre, physiotherapy opd . Convenience sampling method was used. ROM, Numerical pain rating scale- pain and Modified oswestry disability questionnaire- disability was assessed. Results: P value is less than 0.05 for NPRS, ROM and modified ODI .The NPRS, PSLR and Modified ODI Questionnaire scores improved significantly by SLR with lumbar stabilization exercises after 3 weeks in subjects of low back pain with adverse neural tension. Conclusion: SLR with lumbar stabilization exercises is effective in reducing pain improving ROM, and physical functions in low back pain subjects with adverse neural tension.

Keywords: low back pain with adverse neural tension, SLR Stretching, lumbar stabilization exercises

INTRODUCTION movement3-5. Mechanically or chemically sensitize nerves show abnormal mechanosensitivity6. In India incidence of low back pain (LBP) has been reported to be 23.9% and has a life time prevalence of 60- Radiating low back pain or Lumbar 85%. There are various causes of low back pain(LBP) refers to the phenomenon in which the pain produced in producing radicular and non-radicular symptoms. Low the lumbar region radiates or travels down in one or both back pain (LBP) is a common disorder involving the lower limbs with the presence of neural dysfunction. muscles, nerves, and bones of the back. Pain can vary Radiating low back pain could be attributed to various from a dull constant ache to a sudden sharp feeling1. causes such as compression of one or more nerve roots Chronic low back pain is defined by pain persisting for caused by a direct pressure from a herniated disc, more than 12 weeks2. Adverse neural tension is defined degenerative changes in the lumbar spine that cause as physiological or mechanical response produced when irritation of nerve roots, or due to compression structures of the nervous system increases their normal of sciatic nerve roots, facetal hypertrophy that may 102 Indian Journal of Physiotherapy and Occupational Therapy, January-March 2019, Vol.13, No. 1 compress the nerve root at the lateral foraminal exit, OBJECTIVE foraminal stenosis (narrowing of spinal canal through which the spinal nerve exits due to bone spurs or arthritis) To study the effect of straight leg raise with lumbar – more common in elderly adults, diabetes, nerve root stabilization exercises in reducing pain, improving injuries, scar tissue from previous spinal surgery that is ROM, and physical functions in low back pain subjects affecting the nerve root7-9. with adverse neural tension between the age group 20- 50 years. Neural mobilization has a great role in management of radiculopathy and low back pain . The Straight Leg MATERIAL AND METHOD Raise (SLR) test is frequently used in the assessment of patients presenting with LBP. Improving the range of This experimental study was conducted on 30 SLR has a beneficial effect in storing normal movement lower back pain patients, aged between 20-50 years were taken from NDMVP Hospital and research centre, and decreasing the degree of impairment due to low physiotherapy OPD. Convenient sampling method was back disease 10. used for study. There is no formal definition of lumbar stabilization Inclusion Criteria: exercises , the approach is aimed at improving the neuromuscular control, strength, and endurance of the 1. Age group of both sexes with 20-50 years. muscles that are central to maintaining the dynamic 2. Pain referred distal to buttocks. spinal and trunk stability. Group of muscles particularly 3. SLR testing between 45-70 degree (painfull range). the transversus abdominis and lumbar multifidius, also other paraspinal, abdominal, diaphragmatic, and pelvic 4. Mild to moderate pain (2 to 6 on NPRS). muscles, lumbar stabilization exercise has been accepted 5. Modified oswestry score greater than 10%. as a more empiric therapeutic exercise method than any other exercise method. To improve spinal segment Exclusion Criteria: instability, lumbar stabilization exercises that strengthen 1. Red flags for a serious spinal condition (e.g. the local muscle group located deep in the trunk around infection, tumors, osteoporosis, spinal fracture, etc.) the lumbar vertebrae, which play an important role in 2. Pregnancy. providing dynamic stability for spinal segments, are useful for relieving functional disability of the spine. 3. history of spinal surgery. Lumbar stabilization is important for maintaining the 4. Osteoporosis. spine and performing extremity movements and is applied to adjust the imbalance between the abdominal and trunk 5. straight leg raise (SLR) test of less than 45°. extensor muscles. Such imbalance causes diseases in the 6. Spondylosis, Disc herniation, Cervicogenic lumbar vertebral region of the musculoskeletal system, headache. which must be treated to prevent low back pain11. PROCEDURE Hence the rationale of the present study was to check the effectiveness straight leg raising with lumbar Subjects clinically diagnosed low back pain with stabilization exercise in the treatment of low back pain adverse neural tension were screened according to with adverse neural tension. inclusion and exclusion criteria. Ethical clearance was obtained and informed consent was taken from each AIM subject. Subjects were briefed about the study & the intervention.30 Patients were recruited and were given To find the effect of Straight Leg Raise with lumbar straight leg raise stretching and lumbar stabilization stabilization exercises in reducing pain, improving exercises. The effect of intervention was measured using ROM, and physical functions in low back pain subjects outcome measures comprising of NPRS, PSLR and with adverse neural tension. Modified ODI before and after 3 weeks. Indian Journal of Physiotherapy and Occupational Therapy, January-March 2019, Vol.13, No. 1 103

Straight leg raise stretching: The subject is in supine and • Patient position: hook-lying relaxed in the center of the bed, with one pillow under the draw in your lower abdomen, hold head. Therapist will stand at the affected side and raised Patient instruction: the contraction and breath. Slide your one leg along the side which is perpendicular to the bed in straight leg the mat to straighten the knee and return to the starting raise test with one hand placed under the ankle joint and position. Do not release your abdominal contraction the other hand placed on the knee joints until either pain during the exercise. Repeat with your other leg. Dosage: in the back or referred pain to the leg is seen. 10 repetitions on each leg.

Week 2 zz Patient position: hook-lying

Patient instruction: draw in your lower abdomen, hold the contraction and breath. Squeeze your buttocks together and lift your pelvis up. Do not release your abdominal contraction. Hold this position for 5-10 seconds. Dosage: 5-10 seconds hold and 10 repetitions. zz Patient position: hook-lying

Patient instruction: draw in your lower abdomen. Lift one leg up without bending the knee upto approximately 45°. Hold the position for 5-10 seconds. Lower the leg. Figure 1: Straight leg raise stretching Repeat with other leg. Dosage: 5-10 seconds hold and 10 repetitions. Then the lower limb is taken down few degrees from this symptomatic point. The therapist will mobilize Week 3 the sciatic nerve by gentle oscillations alternatively zz Patient position: four-point kneeling toward ankle dorsiflexion and plantar flexion . This sequences is repeated several times, in which the Patient instruction: slowly pull your navel up, hold amplitude is increased according to the patient response. the contraction and breath. Raise your one leg up The technique progressed to a point where symptoms with the knee straight followed by the opposite arm where resistance of the movement was encountered. As without bending the . Hold this position for 5-10 seconds. Lower your arm and leg. Repeat with the other the pain is relieved, the therapist increase the range of diagonal leg and arm. Dosage: 5-10 seconds hold and 10 motion until reaching the maximum range of straight leg repetitions. raise with pain free. The position is held for 30seconds. Frequency: 2 times week for 3 weeks zz Patient position: prone

They were instructed to perform the stabilization Patient instruction: slowly pull your navel up hold the exercises at home twice a day on the days they did not contraction and breath. Slowly raise both your legs up come for their treatment sessions. Each exercises were straight without bending your knees. Hold this position carried forward each week. for 5-10 seconds. Lower your legs. Dosage: 5-10 seconds hold and 10 repetitions. LUMBAR STABILIZATION EXERCISES zz Patient position: prone

Week 1 Patient instruction: slowly pull your navel up hold the contraction and breath. Slowly raise both your zz Patient position: four-point kneeling position arms up straight without bending your . Do not zz Patient instruction: slowly pull your navel up, hold release your abdominal contraction during the exercise. the contraction and breath. Dosage: 10 seconds Hold this position for 5-10 seconds. Lower your arms. hold and 10 repetitions. Dosage: 5-10 seconds hold and 10 repetitions. 104 Indian Journal of Physiotherapy and Occupational Therapy, January-March 2019, Vol.13, No. 1

RESULT DISCUSSION

Table 1: The intra-group comparison of Pain The present study was carried out to see the effects of Straight Leg Raise With lumbar stabilization exercises (NPRS) in reducing pain, improving ROM and physical functions PARAMETER FOLLOW UP in low back pain subjects with adverse neural tension PRE between the age groups of 20-50 years. This study included 5.19 ± 0.63 TREATMENT 30 subjects with low back pain of both genders. Through NPRS convenient sampling they were recruited in the study. POST 2.69 ± 0.84 TREATMENT T VALUE 15.69 VARIABLE P VALUE (INTRA Pretreatment v/s <0.0001 Pain (NPRS), PSLR and Modified (ODI): On GROUP) Post-treatment (SIGNIFICANT) comparing score with paired t test, the p value obtained was <0.05 which implies that it is statistically significant Values are Mean ± Standard deviation. P-values are .This suggest that SLR with lumbar stabilization obtained using Paired‘t’ test (Parametric Paired analysis), exercises, had an effect in reducing pain improving after confirming the underlying normality assumption of ROM in patient with low back pain after 3 weeks of pre-treatment and post-treatment difference. P-value<0.05 treatment. The result found in our study is accordance is considered to be statistically significant. with study done by Neha Malik, Chitra Kataria (2012) on Comparative Effectiveness of Straight Leg Raise and Table 2: The intra-group comparison of Range of Slump Stretching in Subjects with Low Back Pain with motion (PSLR) Adverse Neural Tension concluded that both techniques straight leg raise and slump stretching are equally effective PARAMETER FOLLOW UP in reducing pain in patients with low back pain with PRE 12 51.58 ± 5.01 adverse neural tension .There are many physiological TREATMENT ROM benefits found with neural mobilization that reduces POST 65.42 ± 7.66 pain and improves ROM. In neural mobilization, there is TREATMENT oscillatory movement like straight leg stretching, there is T VALUE 15.51 elongation and shortening of the nerve which temporarily P VALUE increases the intra neural pressure followed by a period Pretreatment v/s <0.0001 (INTRA of relaxation in between . This repeated pumping action Post-treatment (SIGNIFICANT) GROUP) enhance dispersal of local inflammatory products in and around the nerve, thus alleviating hypoxia and reducing pain.( Brown et ) investigated this and found an increase Table 3: Intra-group comparison of Functional in fluid dispersion in the leg has been found secondary to Disability (Modified ODI) repeated ankle plantarflexion and dorsiflexion. (Dwornik PARAMETER FOLLOW UP GROUP A et al 2009) said that neural mobilization gives high analgesic effects based on the finding that the resting PRE 40.23 ± 6.46 muscle tone decreased post neural mobilization. TREATMENT Modified ODI POST The result found in our study is according to Sahar 21.62 ± 4.83 TREATMENT M. Adel(2011) on the Efficacy of Neural Mobilization T VALUE 16.55 in Treatment of Low Back Dysfunctions concluded that P VALUE Pretreatment v/s <0.0001 straight leg raising (SLR) stretching may be beneficial (INTRA GROUP) Post-treatment (SIGNIFICANT) in the management of patients with LBD. SLR stretching with lumbar spine mobilization and exercise was beneficial in improving pain, reducing short-term RESULT disability and promoting centralization of symptoms in this group of patients. The Pain (NPRS), PSLR and Modified ODI Questionnaire scores improved significantly after Among the abdominal muscles, the transverse treatment. abdominal abdominal, multifidus, and internal oblique Indian Journal of Physiotherapy and Occupational Therapy, January-March 2019, Vol.13, No. 1 105 muscles help to increase the intra-abdominal pressure, 3. Breig A. Adverse Mechanical Tension in the thereby con-tributing to the spinal and pelvic stability 13. Central Nervous System, an analysis of cause and Our lumbar stabilization exercise group included some effect. Almqvist&Wiksell International. 1978 lumbar dynamic exercises, which may have strengthened 4. Butler DS. Mobilization of the Nervous System. the lumbar extensors at the large lumbar flexion angle. Churchill Livingstone, 1991 Another study concluded that exercise 5. Turl SE, George KP. Adverse neural tension: A programs had significant effect on the patients factor in repetitive hamstring strain? Journal of with chronic low back pain. Back extension orthopaedic and sports physical therapy 1998; exercises had an additional effect in enhancing 27(1):16-21 the strength of the extensor muscles and also 6. Butler DS. Adverse Mechanical Tension in the in increasing the mobility of the lumbar spine. Nervous System: A model for assessment and This provides essential support for the spine treatment. The Australian Journal of Physiotherapy and thereby decreasing the associated pain and 7. Shah S, Mahapatra R K. Effect of Mulligan disability. In the presence of strong core and Spinal Mobilization with Leg Movement and back muscles, the possibility for low back pain Shacklock Neural Tissue Mobilization in Lumbar is minimal. Thus lumbar extension as well as Radiculopathy: A Randomised Controlled Trial. stabilization exercises are essential to strengthen Journal Medical Thesis 2015 May-Aug; 3(2):27-30. the core and reduce low back related pain and 8. Andrew W. Tarulli MD, Elizabeth M. Raynor disability in patients with chronic low back pain. MD. Lumbar Radiculopathy. Neurologic clinics R. Chitra,(2014)14 May 2007 Vol 25 (2):387-405 9. Priya Igatpurikar, Dr. Sona Kolke. Efficacy CONCLUSION of maitland’s spinal mobilization in lumbar spondylosis with radiculopathy. Ind J SLR with lumbar stabilization exercises is effective Physiotherapy and Occupational Therapy – An in reducing pain improving ROM, and physical functions International Journal Year .2013; 7(3):24-27 in low back pain subjects with adverse neural tension. 10. Sahar M. Effi cacy of Neural Mobilization in Limitations of the Study Treatment of Low Back Dysfunctions. Journal of 1. No follow up was done after the said duration of American Science 2011;7(4):566-573. study. 11. Panjabi MM: Clinical spinal instability and low 2. There is a wide variation in the age of the subjects back pain. J Electromyograph Kinesiol, 2003, 13: included in the study. 371–379. [Medline] 12. Neha Malik, Chitra Kataria, Nidhi Bhatia Sachdev 3. subjects from all professions were included and may be a source of variation in results. 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