<p> DISSERTATION SYNOPSIS</p><p>SUBMITTED TO</p><p>RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA</p><p>BANGALORE</p><p>TOWARD PARTIAL FULFILMENT OF</p><p>MASTER OF PHYSIOTHERAPY DEGREE COURSE</p><p>By</p><p>UNDER THE GUIDANCE OF</p><p>S NATARAJAN</p><p>VIKAS COLLEGE OF PHYSIOTHERAPY MARYHILL, KONCHADY, MANGALORE-575006</p><p>2010-12 RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA</p><p>BANGALORE</p><p>REGISTRATION OF SUBJECTS FOR DISSERTATION</p><p>1. Name of the Candidate PADASALA MEHULKUMAR MANJIBHAI and Address VIKAS COLLEGE OF PHYSIOTHERAPY AIRPORT ROAD MARYHILL, KONCHADY MANGALORE – 575008</p><p>2. Name of the Institution VIKAS COLLEGE OF PHYSIOTHERAPY Mangalore.</p><p>3. Course of study and subject Master of Physiotherapy (MPT) Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy</p><p>4. Date of admission to Course 01-03-2010</p><p>5. Title of the Topic</p><p>A COMPARATIVE STUDY OF EFFECT OF GLOBAL POSTURE REEDUCATION AND OF STATIC STRETCHING IN CHRONIC MECHANICAL NECK PAIN 6. BRIEF RESUME OF THE INTENDED WORK</p><p>6.1 Need for the study</p><p>Pain is an "unpleasant sensory and emotional experience associated with actual or potential tissue damage."1 In chronic pain, the sensorial process becomes abnormal, leading to detectable changes in central nervous system data processing, motor control, and the experience of pain itself.2 Pain may lead a person to stop working or exercising.3</p><p>Chronic neck pain is a sensation of hyperalgia to skin palpation, ligaments, and muscles during both active and passive movement.4 Mechanical neck pain has been described as having no detectable or specific etiology (such as inflammation or infection), and it may be reproduced by provocative stimuli. It is usually located at the lower neck region between the occipital region and the first thoracic vertebra.5</p><p>Neck pain is a common complaint in the general population with the lifetime prevalence of approximately 50%.6,7 Most patients who present with chronic neck pain symptoms fit into the category of nonspecific neck pain, having postural or mechanical basis.8 Aetiological factors include poor posture, neck strain or occupational or sporting activities, anxiety, depression, but are often multifactorial and poorly understood,8 and its exact pathology remains obscure. 9,10</p><p>Hanten et al.11 and Lee et al.12 observed that neck pain causes range of motion (ROM) reduction, which may be linked to mechanical restriction between two or more vertebrae. According to Barnsley,13 such restriction may be caused by pain, fiber contracture, bone ankylosis, or muscle spasm. A patient with neck pain may also present a posture imbalance resulting from shortening and increased activation of suboccipital, sternocleidomastoid, upper trapezius, pectoralis, and rotator cuff muscles.14</p><p>Pragmatic reviews have in the past extolled the virtues of a variety of treatments for neck pain.15,16,17 These include education, rest, collars, posture control, exercises, physical modalities, traction, mobilization, massage, analgesics, tricyclic antidepressants, psychological interventions, trigger point injections, occipital nerve blocks, epidural steroid injections, neurectomy, discectomy, fusion, soft tissue technique, muscle energy technique, thrust technique, myofascial release, manipulation under anaesthesia and craniosacral manipulation. None of the reviews, however, provided any scientific evidence of efficacy of any of these traditional interventions.18</p><p>Physical therapies for treating chronic pain include different exercises. Conventional physical therapy uses static muscle stretching, which consists of stretching a muscle up to a tolerable point and sustaining the position for a certain period of time. In Brazil, France, Italy, and Spain, therapists are increasingly resorting to a method called global posture reeducation (GPR),19 which focuses on entire muscle groups instead of targeting individual muscles. Based on the existence of muscle chains - didactically divided into posterior and anterior chains20 - this method proposes global stretching of antigravity muscles. While static stretching of a single muscle or a small group of muscles usually lasts 30 seconds,21 in GPR, all muscles of the same chain are simultaneously stretched during a 15 minute posture, avoiding compensations. Bertherat22 reported Meziere's attempts to decrease spinal curvature, observed that a different muscle had been stressed, and finally concluded that the cause of deformation was a shortening of the posterior muscle chain brought about by everyday activities.</p><p>Several physical therapists have been using the GPR method with satisfactory empiric results. Although the method is often clinically practiced, few studies show its efficacy, especially on its use in neck pain.23 In view of the high incidence of neck pain and its consequences, the purpose of the present study was to compare the effects of two kinds of stretching, GPR and static conventional stretching in relieving pain and improving ROM and health-related quality of life in patients with chronic neck pain.</p><p>6.2 Review of Literature</p><p>Vanti et al conducted a literature review for evidence of effectiveness of GPR in musculoskeltal disorder, in order to identify the most appropriate therapeutic contexts for its use. They concluded that the RPG method is an effective treatment technique for musculoskeletal diseases, in particular for ankylosing spondylitis, acute and chronic low back pain, and lumbar discherniation. They further stated that although the scarcity of rigorous experimental trials on a large scale does not allow the drawing of undisputable conclusions, the results gathered up to now are an encouragement to carry on research in the field of conservative treatment.24</p><p>Cunha et al compared the effect of conventional static stretching and muscle chain stretching, as proposed by the global posture reeducation method, along with manual therapy in patients with chronic neck pain. Results showed significant pain relief and improvement in ROM and Quality of life. They concluded that conventional stretching and muscle chain stretching in association with manual therapy were equally effective in reducing pain and improving the range of motion and quality of life of female patients with chronic neck pain, both immediately after treatment and at a six-week follow-up, suggesting that stretching exercises should be prescribed to chronic neck pain patients.23</p><p>Fernández-de-las-Peñas carried out a clinical trial to evaluate the impact of protocol of strengthening and flexibility exercises based on Global Posture Reeducation versus conventional motion and flexibility exercises for patients with Ankylosing Spondylitis (AS) on functional and mobility outcomes. They concluded that GPR method of specific strengthening and flexibility exercises of the muscle chains, offers promising results in the management of patients suffering from AS and further trials on this topic are required.25</p><p>Maluf et al conducted a study to compare global postural reeducation (GPR) and static stretching exercises (SS), in the treatment of women with temporomandibular disorders. The results showed that they equally reduced pain intensity, increased pain thresholds, and decreased electromyographic activity. They concluded that both GPR and SS were similarly effective for the treatment of TMDs with muscular component.26 </p><p>Moreno et al conducted a randomized study to evaluate the effect that respiratory muscle stretching using the global postural reeducation (GPR) method has on respiratory muscle strength, thoracic expansion and abdominal mobility in sedentary young males. Results showed no significant improvement in control group while for the GPR group, all values increased after the intervention. They concluded that respiratory muscle stretching using the GPR method was efficient in promoting an increase in maximal respiratory pressures, thoracic expansion and abdominal mobility, suggesting that it could be used as a physiotherapy resource to develop respiratory muscle strength, thoracic expansion and abdominal mobility.27</p><p>Fozzatti conducted a prospective non-randomized clinical trial to evaluate the effect of global postural reeducation (GPR) on stress urinary incontinence (SUI) and quality of life in SUI female patients. Results showed a significant improvement in Quality of Life in all domains, with emphasis on General Perception of Health, Incontinence Impact and number of leaking episodes. The Functional Evaluation of the Pelvic Floor and Pad Use also presented significant improvement. They concluded that GPR is an efficient alternative for treatment of stress urinary incontinence.28</p><p>Gross et al in a systematic review to assess the effects of physical medicine modalities for pain in adults with mechanical neck disorders concluded that there is little information available from trials to support the use of physical medicine modalities for mechanical neck pain except electromagnetic therapy.29 </p><p>Balogun et al evaluated the inter-and intra tester reliability of measuring six neck motions with tape measure (lM) and the Myrin gravity-reference goniometer (MG). Based on the results as well as its simplicity and low cost, the authors recommend the tape measuring method for wider clinical use. It could be used to assess gross limitation of motion of an individual suspected of having cervical dysfunction and for objectively monitoring the success of a therapeutic program.30</p><p>Hsieh and Yeung conducted a study to determine if the tape measuring method is a reliable method of measuring six active neck motions. This study indicated that the tape measuring method is a reliable means for clinicians to assess neck range of motion.31 </p><p>Scrimshaw and Maher compared the responsiveness of the McGill Pain Questionnaire with the Visual Analogue Scale (VAS). The study found that the VAS was more responsive than the McGill Pain Questionnaire and VAS may be a better tool than the McGill Pain Questionnaire for measuring pain in clinical trials and clinical practice.32</p><p>Kelly conducted a study to determine the minimum clinically significant difference in visual analog scale (VAS) pain scores. Results revealed that the minimum clinically significant difference in VAS pain scores is 9 mm and there is no statistically significant difference in VAS pain scores based on gender, age, or cause of pain.33 </p><p>6.3 Objectives of the study</p><p>The main objective of the study is to find out the effects of Global posture reeducation and static stretching on pain and range of motion in patients presenting with chronic mechanical neck pain. Specifically to determine the effects of</p><p>1. Global posture reeducation on pain and cervical range of motion in patients presenting with chronic mechanical neck pain 2. Static stretching on pain and cervical range of motion in patients presenting with chronic mechanical neck pain 3. Comparing the Global posture reeducation and static stretching on pain and cervical range of motion in patients presenting with chronic mechanical neck pain 7. Materials and methods</p><p>7.1 Source of data</p><p>Data will be collected from patients, who are referred to the outpatients Physiotherapy department of Vikas College of Physiotherapy, Mangalore, with diagnosis of nonspecific neck pain after obtaining informed consent</p><p>7.2 Method of collection of data</p><p>Hypothesis:</p><p>There are significant difference between the effects of Global posture reeducation and static stretching on pain and range of motion in patients presenting with nonspecific chronic neck pain.</p><p>Null Hypothesis:</p><p>There are no significant difference between the effects of Global posture reeducation and static stretching on pain and range of motion in patients presenting with nonspecific chronic neck pain.</p><p>Research Design:</p><p>Experimental design will be used in this study.</p><p>Sampling method</p><p>Random sampling method</p><p>Methodology</p><p>Patients who are diagnosed to have nonspecific neck pain and fulfilling the following inclusion and exclusion criteria will be selected for the study after obtaining informed written consent. </p><p>Inclusion Criteria:</p><p>1. Clinically diagnosed primary mechanical, either myogenous or arthrogenous, neck pain and pain lasting for over 12 weeks</p><p>2. Symptoms primarily confined in the area between the superior nuchal line and the tip of the first thoracic spinous process and provoked by neck movements or by sustained neck postures 3. Age group 40-60</p><p>4. Both males and females</p><p>Exclusion Criteria:</p><p>1. History of a significant trauma to the cervical spine</p><p>2. History of fracture and dislocation of the cervical spine</p><p>3. Disease of the spinal cord or cauda eaqina</p><p>4. Inflammatory or infective arthropathies of the vertebral column</p><p>5. Vertigo </p><p>6. Neurological signs and symptoms</p><p>7. History of spinal surgery </p><p>8. Presence of malignancy</p><p>Study Design</p><p>The selected subjects will be randomly assigned into one of two groups. Each group will consist of 15 patients of both genders within the age group of 40-60 years. </p><p>Group I: This will consist of 15 patients and they will undergo Global posture reeducation.</p><p>Group II: This will consist of 15 patients and they will undergo static stretching.</p><p>Interventions</p><p>Patients will attend three weekly physical therapy sessions during a six-week period. At each 45 minute individual session, the patient will receive moist heat therapy for 15 minutes and stretched for another 30 minutes.</p><p>GPR group: Will stretch muscle chains as described by Marques,20 keeping two stretching postures for 15 minutes each. </p><p>In order to stretch the posterior muscle chain (upper trapezius, levator scapulae, suboccipitalis, erector spinae, gluteus maximus, ischiotibials, triceps surae, and foot intrinsic muscles), the patient will lie in the supine position with the occipital, lumbar, and sacral spine stabilized, with the lower limbs at 90° hip flexion, and perform gradual knee extensions. </p><p>In order to stretch the anterior muscle chain (diaphragm, pectoralis minor, scalene, sternocleidomastoid, intercostalis, iliopsoas, arm, forearm, and hand flexors), the patient lies in the supine position with the upper limbs abducted at 30° and the forearms supine. The pelvis will be kept in retroversion, while the lumbar spine remains stabilized. Hips will be flexed, abducted, and laterally rotated, with the soles of the feet touching each other. Gradually, respecting the patient's limits, the lower limbs will be extended as much as possible while maintaining the tibiotarsal angle at 90º. </p><p>Conventional stretching group: Will perform stretching of upper trapezius, suboccipitalis and back of the neck, pectoralis major and minor, rhomboids, finger and wrist flexors, forearm pronators, finger and wrist extensors, forearm supinators, and paravertebral muscles.34 Each exercise was auto-passively repeated twice for 30 seconds and done slowly at normal breathing rhythm and with no compensations allowed. The total stretching time will be equivalent to that of the GPR group. </p><p>Evaluation: Before the beginning and after the 6 week intervention period, all patients will be evaluated in the following outcome measures.</p><p>1. Pain measured in a 10 cm Visual Analog scale. VAS is a 10 cm line with pain descriptors marked “no pain” at 1 end and “the worst pain imaginable” at the other. The patients will be asked to report their perceived pain level, both at rest and on most painful movement, by marking the VAS with a perpendicular line. </p><p>2. Cervical range of motion using a tape measure. Flexion and extension will be measured as the distance between the tip of the chin and sternal notch with subjects’ mouth closed. Side flexion will be measured as the distance between the mastoid process and the acromian process. Lateral rotation will be measure as the distance between the chin and acromian process.</p><p>Statistical tests: </p><p>The following statistical tests will be used to analyze the collected data:</p><p>The pain score data collected using VAS will be analyzed using non-parametric tests as the data are ordinal in nature. The intra group pre and post-test data will be analyzed using Wilcoxon sign rank test, while the post-test inter group data will be analyzed with Mannwhitney U test. </p><p>The Cervical ROM data collected using tape measure will be analyzed using parametric tests as the data are interval in nature. The intra group pre and post-test data will be analyzed using Unpaired t-test, while the post-test inter group data will be analyzed with Paired t-test. </p><p>7.3 Nature of Investigations and Interventions: </p><p>The study requires non-invasive investigations and interventions to be conducted on patients. They include physical examination like inspection, palpation, and measurement of range of motion, etc. Treatment interventions include Global posture reeducation and static stretching.</p><p>7.4 Ethical clearance:</p><p>Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and interventions on patients necessary for this study. 8. References</p><p>1. Merskey H, Bogduk N, editors. Classification of chronic pain. 2nd ed. Seattle: IASP Task Force on Taxonomy; 1994. 2. Farina S, Tinazzi M, Le Pera D, Valeriani M. Pain-related modulation of the human motor cortex. Neurol Res. 2003;25:130-42. 3. Häkkinen A, Salo P, Tarvainen U, Wiren K, Ylinen J. Effect of manual therapy and stretching on neck muscle strength and mobility in chronic neck pain. J Rehabil Med. 2007;39:575-9. 4. Ylinen J. Physical exercises and functional rehabilitation for the management of chronic neck pain. Eura Medicophys. 2007;43:119-32. 5. Bogduk N. Neck pain: an update. Aust Fam Physician. 1988;17:75-80. 6. Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population: a systematic critical review of the literature, Eur Spine J.2006; 15: 834–848. 7. Côté P, Cassidy JD, Carroll L. The Saskatchewan health and back pain survey: The prevalence of neck pain and related disability in Saskatchewan adults. Spine. 1998; 23: 1689–1698. 8. Binder A. The diagnosis and treatment of nonspecific neck pain and whiplash. Europa Medicophysica. 2007; 43(1): 79-89. 9. Maitland GD, Hengeveld E, Banks K, English K. Maitland's vertebral manipulation (7th ed.). 2005; Elsevier Butterworth Heinemann, Edinburgh. 10. Ahn NU, Ahn UM, Ipsen B, An HS. Mechanical neck pain and cervicogenic headache, Neurosurgery. 2007; 60(1 Suppl 1): S21–S27. 11. Hanten WP, Olson SL, Russel JL, Lucio RM, Campbell AH. Total head excursion and resting head posture: normal and patient comparisons. Arch Phys Med Rehabil. 2000;81:62-6. 12. Lee H, Nicholson LL, Adams RD. Cervical range of motion associations with subclinical neck pain. Spine. 2004;29:33-40. 13. Barnsley L. Neck pain. In: Klippel JH, Dieppe PA. Rheumatology. 2nd ed. London: Mosby-Year Book; 1998. p.41-2. 14. Wang WTJ, Olson SL, Campbell AH, Hanten WP, Gleeson PB. Effectiveness of physical therapy for patients with neck pain: an individual approach using a clinical decision-making algorithm. Am J Phys Med Rehabil. 2003;82:203-18. 15. Bisbee LA & Hartsell HD (1993) Physiotherapy management of whiplash injuries. Spine: State of the Art Reviews 7: 501–516. 16. Greenman PE (1993) Manual and manipulative therapy in whiplash injuries. Spine: State of the Art Reviews 7: 517–530. 17. Teasell RW, Shapiro AP & Mailis A (1993) Medical management of whiplash injuries. Spine: State of theArt Reviews 7: 481–499. 18. Bogduk N. The neck. Best Pract Res Clin Rheumatol. 1999; 13(2): 261– 285. 19. Souchard PE: Principes et originalité de la reéducation posturale globale. Paris: Le Pousoë; 2003. 20. Marques AP. Cadeias musculares: um programa para ensinar avaliação fisioterapêutica global. São Paulo: Manole; 2005. 21. Bandy WD, Irion JM, Briggler M. The effect of time and frequency of static stretching on flexibility of the hamstring muscles. Phys Ther. 1997;77:1090-6. 22. Bertherat T. Le corps a ses raisons: auto-guérison et anti-gymnastique. Paris: Seuil; 1976. 23. Cunha ACV, Burke TN, França FJR, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics. 2008; 63:6. 24. Vanti C, Generali A, Ferrari S, Nava T, Tosarelli D, Pillastrini P. General postural rehabilitation in musculoskeletal diseases: scientific evidence and clinical indications. Reumatismo. 2007 Jul-Sep;59(3):192-201. 25. Fernández-de-las-Peñas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis. Am J Phys Med Rehabil. 2005;84:407-19. 26. Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010 Sep; 33(7):500-7. 27. Moreno MA, Catai AM, Teodori RM, Borges BL, Cesar Mde C, Silva E. Effect of a muscle stretching program using the Global Postural Reeducation method on respiratory muscle strength and thoracoabdominal mobility of sedentary young males. J Bras Pneumol. 2007 Dec;33(6):679- 86. 28. Fozzatti MC, Palma P, Herrmann V, Dambros M. Impact of global postural reeducation for treatment of female stress urinary incontinence. Rev Assoc Med Bras. 2008 Jan-Feb;54(1):17-22. 29. Gross AR, Aker PD, Goldsmith CH, Peloso P. Physical medicine modalities for mechanical neck disorders. Cochrane Database Syst Rev. 2000; (2):CD000961. 30. Balogun JA, Abereoje OK, Olaogun MO, Obajuluwa VA. Inter- and lntratester Reliability of Measuring Neck Motions with Tape Measure and Myrin Gravity-Reference Goniometer. J Orthop Sports Phys Ther 1989; 10:248-53. 31. Hsieh CY, Yeung BW. Active neck motion measurements with a tape measure. J Orthop Sports Phys Ther. 1986;8(2):88-90. 32. Scrimshaw SV, Maher C: Responsiveness of visual analogue and McGill pain scale measures. Journal of Manipulative and Physiological Therapeutics 2001, 24(8):501-504. 33. Kelly AM. Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Acad Emerg Med. 1998 Nov;5(11):1086-90. 34. Kisner C, Colby LA. Exercícios terapêuticos - fundamentos e técnicas. São Paulo: Manole; 1992. 9. Signature of the candidate :</p><p>10. Remarks of the Guide</p><p>11. Name and Designation of</p><p>11.1 Guide : S NATARAJAN Professor</p><p>11.2 Signature : </p><p>11.3 Co-Guide : -</p><p>11.4 Signature : - </p><p>11.5 Head of the Department : Prof. S. NATARAJAN M.P.T. </p><p>11.6 Signature :</p><p>12. 12.1 Remarks of the Chairman and Principal</p><p>12.2 Signature :</p>