EFFECTIVENESS OF CORE STABILITY EXERCISE AND POSTURAL EDUCATION PROGRAM FOR LOW BACK PAIN IN BIKE RIDERS

By

REECHA BHARTI

Dissertation research proposal submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

In partial fulfillment of the requirements for the Degree of

MASTER OF PHYSIOTHERAPY (M.P.T)

IN

MUSCULOSKELETAL & SPORTS

Under the guidance of

Dr. DEV ANAND (PT)

Rajiv Gandhi University of Health Sciences, Karnataka,Bangalore

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name Of The Candidate and Address / REECHA BHARTI
33, 80 feet road , near laggere ring road bridge,
Banglore -58
2 /

Name Of The Institution

/ HOSMAT COLLEGE OF PHYSIOTHERAPY,
Laggere , Banglore
3 /

Course Of Study and Subject

/ MASTER OF PHYSIOTHERAPY
(Musculoskeletal Disorders and sports Physiotherapy)
4 /

Date of Admission To Course

/ 6 thJUNE 2013
5 /

Title of the Study: EFFECTIVENESS OF CORE STABILITY EXERCISE AND POSTURAL EDUCATION PROGRAM FOR LOW BACK PAIN IN BIKE RIDERS

6. INTRODUCTION

6.1 Need of study………………………..………………………….………04

6.2 Aim of the Study……………………...………………………………...06

6.3 Hypothesis …….…..……………………………………………………09

6.4 Literature Review………..……………………………………………...09

7. MATERIALS AND METHODS…………………………………...... 10

7.1 Study design……………………………………………………………..10

7.2 Study sample design……………………………………………………..10

7.3 Sample size………………………………………………………………10

7.4 Source of data……………………………………………………………10

7.5 Sampling methods………………………………………………………..10

7.6 Study duration…………………………………………………………....10

7.7 Selection criteria……………………………………………………….....11

7.8 Material used……………………………………………………………..10

7.9 Methodology……………………………………………………………...10

7.10 Procedure……………………………………………………………..….12

7.11. Outcome measure………………………………………………….....…13

7.12 Statisical tests…………………………………………………….…...…15

7.13 Ethical clearance……………………………………………………...... 15

8. LIST OF REFERENCES………………………………………….……...16

6. BRIEF RESUME OF THE INTENDED WORKS:

Introduction

Occupational driving has often been associated with a high prevalence of low back pain1. It is an immense burden for both industry and medicine2. It is the most common condition that impairs individual functional capacity in activity of daily living at work as well as general health and quality of life3. Epidemiological studies clearly indicate the role of mechanical load on the etiology of low back pain.

Fixed postures and prolonged seating like driving for a long time, bending activities might be the few of the commonest cause for LBP. Static loading of Spine and soft tissue leads to discomfort of the back and inactivity which further might lead to an accumulation of metabolites, acceleration of disk degeneration and increased probability of disc herniation. Road conditions also influence the mechanics of spine during driving.Irregular roads and traffic congestion adds to the loading of spine in improper postures. Riders should be aware of the precipitating factors for low back pain while riding motor bike. Prolonged riding/ sitting/ bending, riding on a rough terrain, weak back muscles and weak core musclesare few of the factors which riders must be aware of4.Motor bike riders are relatively exposed to sitting posture hazards. They are in a high risk group for spinal disorders including low back pain, neck pain andsciatica. Intra-discal pressure in lumbar region is greater in sitting position than in standing and worsen with driving on irregular roads5,6 .In addition to the predisposing factors poor coordination and motor system control, strength and endurance of the person, weak core muscles may result in more fatigue. Majority of the bike riders tend to have faulty posture while driving bike which includes flexed back/ slouched back, backward tilted pelvis, abducted and protracted shoulders and disengaged core muscles.7

Postural education and core stability program has been accepted as an important aspect of prevention of occupation related spinal pains. Some of the proposed benefits include enhanced postural stability, core strength, reduced magnitude & onset of postural discomfort and low back pain8.Though it has a positive effect on posture and knowledge about spine but the awareness of the importance of good posture is not effectively incorporated into habits of daily living9.

Poor postures are secondary to habituation over prolonged duration(months or years). This habituation later precipitates postural musculoskeletal issues10.It is noticeable that postural fitness is voluntary and likely to be instituted in activities which are likeable11.In other activities ,postural concern is less concentrated and may not be performed optimally.The key to improving posture and make it as a habit lies not only on effortful adherence to the training program but also on frequent practice and maintenance of correct posture. This can be also achieved by increasing self-awareness about the correct posture & activation of core muscles by following it regularly12. Conscious awareness of own posture and knowing what posture is correct helps in cognitivecorrection,that later becomes associative or automatic(Shumway Cook). With much practice the correct posture gradually replaces the poor habitual posture.

Although the ergonomics of sitting in a factory or office have been studied extensively but the biomechanics of automobile riders and passengers have received less attention5. So, the intended study is being done to establish the effectiveness of postural education program including core stability on Low Back Pain in Bike Riders Population. The goal of this programme is to train functional movement rather than individual muscles. This programme will be focusing on learning the maintenance of correct posture while driving bike through regular practice and enforcement by means of training and personal control techniques.

AIM OF THE STUDY:

  • To find out effectiveness of Postural education program and core stability exercise on low back pain in bike riders

OBJECTIVES

  1. To determine prevalence of LBP in Bike Riders.
  2. To determine effectiveness of PEP and Core stability exercises on LBP in bike riders.

HYPOTHESIS

  • There will be significant reduction in the occurrence and intensity of low back pain in bike riders following Postural education program and core stability exercise.

NULL HYPOTHESIS

  • There will be no significant effect of Postural education program and core stability exercises for Low back pain in bike riders.

RESEARCH QUESTION

  • Whether a set of PEP and core stability is effective in reducing prevalence of LBP in bike riders?

OPERATIONAL DEFINITION

  • Mechanical low back pain – Any type of back pain caused by placing abnormal stress and strain on muscles of vertebral column. It can be secondary to bad habits such as poor posture,poorly designed seating,incorrect bending and lifting motions.

Literature review

LBP in bike riders

Motor bike riders are more exposed to musculoskeletal disorders such as LBP. Long time driving is supposed to be the one of the predisposing factor for LBP. Driver’s populations are about 5 times more likely to develop a herniated lumbar disc than non-Riders population. Driving predisposes to LBP and degeneration13;Riders have little room to change posture because of being confined to small space constraints of control position.

Postural reason for LBP

Prolonged sitting imposes loads on lumbar disc and then stress the spine and results in LBP, postural stress increases during bending and flexed position of spine leading to LBP. Incorrect posture increases spinal load results in excessive mechanical strain leads to deformation of collagen network and perceived as pain. Incorrect posture is a function of poor engagement of core muscles which leads to back discomfort14. Sustained postures alters the mechanical properties of soft tissue, these tissues becomes more susceptible to fatigue much faster, chances of failure and insidious development of musculoskeletal symptoms despite no obvious trauma increases.

Effects of Postural Education Program( PEP)

PEP induces a greater improvement on pain and disability16. It has shown beneficial effects on postural stability and also associated with enhanced driving kinematics. It has seen that postural education enhances spinal stability and thereby helps in reduction in magnitude and onset of LBP. Educated or trained Riders have shown enhanced postural stability, core strength and reduced postural discomfort8. Lack of sufficient coordination in core musculature may lead to decreased efficiency of movement and compensatory patterns, resulting in increased strain and overuse injuries15-17.

Effects of Core Stability Exercise( CSE)

Core stability has been seen as more effective in reducing pain and improving functional status by decreasing disability of subjects in comparison with conventional exercises21. Strengthening of core includes curl ups, side bridging, and quadruped position with alternate arm/leg raises, prone plank and pelvic bridging which has shown good results in activating the para spinal muscles. It helps in recognition of neutral spine position(mid-range between lumbar flexion and extension20,23. It shows effective and efficient engaging of core muscles while doing particular work. It also shows important role in maintaining good body alignment14.A core stability exercise plays an important role in improving muscle tone and there by helps in avoiding back injuries. It also helps in improving physical performance, flattens and strengthens abdominal muscles, improves balance and coordination, enhances flexibility and promotes better breathing33

Outcome Measures

Visual analogue scale (VAS)

It is most commonly used scale for measurement of pain. Data have shown that VAS is sufficiently reliable to be used to assess pain. The interclass correlation coefficient appears to be high. [95% CI= 0.96 to 0.98]. In addition, it has high test retest reliability. It is believed to be reliable, valid and sensitive to change24.

Modified Oswestry disability scale (MODS)

It is one of the condition specific questionnaires recommended for the use of patients with low back pain. The English version of ODI is reliable and valid and shows good psychometric characteristics. It has shown good internal consistency [α=0.87] and test retest reliability [r=0.99]25,26,31.

Fatigue Severity Scale (FSS)

It appears one-dimensional and reliable. It can be quickly used in research to gain a basic understanding of fatigue symptoms. It also supports construct validity, satisfactory internal consistency, substantial test retest reliability and content validity27,28,30.

Core stability

Core endurance tests are the most reliable test to check the core stability followed by flexibility, strength, motor control and functional tests.And these test are-flexor indurancetest,extensor endurance test and lateral musculature endurance test.Muscularendurance are seems to be closely related to spinal stability and risk of injury of low back pain. Balance of muscular endurance among torso flexors,extensors and lateral musculature is most important in reducing injury risk37,38.

METHODOLOGY

  • STUDY DESIGN: Pre-Post interventional single group design
  • SAMPLE SIZE: 50
  • SELECTION OF SAMPLES: Subject will be given a questionnaire for LBP screening
  • SAMPLING DESIGN: Convenient sampling
  • STUDY SETTING:Outpatient department of HOSMAT HOSPITAL, IT companies in & around bangalore

INCLUSION CRITERIA:

  • AGE GROUP: 18-50 Years
  • GENDER: Both (Male and Female)
  • Bike Riders who drive 2-3 hours per day
  • LBP while driving
  • Mechanical back pain

EXCLUSION CRITERIA

  • Spinal deformities
  • Recent spinal injuries
  • Spinal fracture and surgery
  • Pelvic fracture
  • Hip pathology
  • Sciatica
  • Spinal stenosis
  • cuada equina
  • Low back pain secondary to systemic involvement

MATERIALS AND METHODS

  • Low Back Pain Screening Questionnaire (Orebro Musculoskeletal Pain Questionnaire)/ (Mckenzie Lumbar Spine Assessment)
  • VAS Scale
  • ODI Scale
  • FSS Scale
  • Plinth
  • Inch tape
  • Back rest
  • Pressure biofeedback Stabilizer – Chattanooga

Procedure

Thesubjects will be recruited from the outpatient department of HOSMAT hospital and some IT sectors in and around Bangalore city, subjects from IT sectors will be recruited with the written consent from HR department.The HR manager will forward a questionnaire to their employees through their official mailing system.The questionnaire shall be returned to the researcher within 2 days of forwarding the email.A reminder email will be forwarded through the HR manager,to those subjects who do not return the e-questionnaire within 2 days.Follow-up with the HR manager will be done,2 days after the reminder email.

A questionnaire will be distributed for the screening of LBP and the potential candidates having mechanical LBP will be scrutinized.The aim and objective of the study will be explained to the subject. They will be requested to participate in this study. Subjects willing to participate will be included on the basis of inclusion criteria’s of the study and requested to sign the consent form. Then the Pre-treatment outcome measures will be recorded and used for data analysis.

Outcome measures

Pain Severity –VAS

Disability – ODI

Fatigue – FSS

Core stability -Testing

Procedure to measure Outcome measures:

Visual Analogue Scale

Subjects will be instructed to provide their maximum perceived level of pain, on VAS, especially during driving and/or after driving within the last 48 hours. Subjects will be explained about the scale. They will be informed that the scale ranges from 0 to 10 where 0 is considered as no pain and 10 is severe pain24,29.

Modified Oswestry disability scale

Subjects will be instructed to complete the questionnaire and indicate the pain and its impact on activities of daily living. Subjects will be encouraged to complete the 10 sections, with each section being scored 0 to 5, with higher values indicating more severe impact25. Questions will be scored on a vertical scale. The total scorewill be divided by maximum score applicable (depends on number of sections unanswered by the subject) and converted into percentage disability.

Fatigue severity scale

This questionnaire contains 9 statements that attempt to explore severity of fatigue symptoms. Each statement will be scored from 1 to 727,28. Subjects will be asked to mark the appropriate point according to their level of pain which they felt during and after the riding and the pain should persists for 30 or more than 30 mins. The scoring will be done by calculating the average response to the question (adding up all the answers and dividing it by nine)

Core stability test

Core endurance tests are the most reliable measurement for checking core stability.Muscular endurance closely related to spinal stability and risk of injury38:

Flexor endurance test-Begins with subject in a sit-up posture with the back

  • Resting against a jig angled at 60 degrees
  • Knees and hip flexed at 90 degrees
  • Arms folded across chest
  • Hands on opposite shoulders
  • Toes are secured by examiner or toe straps
  • Test begins by pulling support back ten centimeters
  • Failure occurs when subjects falls back and touches jig
  • The time duration held by the subject without obvious correction will be measured in seconds.
  • Three trials will be conducted with a rest interval of 2-3 minutes and the average hold duration will be recorded for data analysis.

Pressure bio feedback test- begins with subject lying supine on plinth and the device will be

placed and inflated up to 40 mm Hg, under the lumbar spine. Subject will be instructed to “tuck their lower tummy insideor take navel towards your spine” that activates the deep stabilizing muscles of the spine. The subjects will be instructed to raise the pressure of the biofeedback device to 42mm Hg and sustain for a duration of 30 seconds. The subjects will be instructed “not to hold their breath during the procedure and to breathe normally”. The time of satisfactory core contraction will be recorded in seconds. Three trials will be performed with a rest interval of 1 minute, and the average will be recorded for data analysis. Changes in pressure during 30 sec hold reflects an inability to maintain isometric contraction and instability of lumbar spine39.

Procedure for Interventions

  • Postural education program
  • Core stability exercise

Postural education program

Subjects who are identified to participate in the study, will be intimated the time & venue of the program, which will be scheduled on a specific day of every subsequent week during the course of the research study. Subjects will be sequentially recruited from the clinical setting or they will randomly recruited from the same institution (if there are many participants with low back pain) to the program. Subjects from the same institution will be randomly selected (simple randomization) and recruited to participate in the program. The program shall be intimated to the participants via a official email and will be followed up through the HR manager. Subjects will be collected into a group of 5 – 10 members. The group will be addressed with posture related issues and the interactive session shall continue for a duration of approximately 45 minutes. Subjects will be allowed to ask their questions during the session about posture & correction methods. PEP will be discussed including but not limited to8-11

  • What is incorrect or poor postures? Explanation of how people knowingly and unknowingly acquire poor postures
  • Consequences of poor posture - Long term effects of poor posture, flexibility of soft tissue, abnormal movement patterns
  • How to correct the poor posture? - Spine musculature strength, flexibility and normal range of motion of spine
  • What is correct or good posture?- Correct body alignment supported by the right amount of muscle tension against gravity
  • Advantages of good posture – Physiological & therapeutic benefits (Reduces the stress on the ligament holding the spinal joint together)
  • Avoidance of habitual faulty posture? Emphasis on proper regular practice of correct posture
  • Self-awareness: conscious awareness of own posture and knowing what posture is correct will help in conscious correction
  • Feedback techniques: Rear image view and mobile applications which will give frequent beep sound a warning alarm for correcting posture while driving two wheeler. The subjects will be encouraged to view onto the rear mirror whenever they hear the timed beeps. The subjects will be instructed to adjust their posture, upon viewing the rear mirror. Such repeated posture corrections at timed intervals, shall enable them to avoid prolonged poor posture. Subjects will be encouraged to discuss their doubts about posture correction during driving while they attend follow up for core stability sessions.

Core stability exercise32-38–Subjects will be collected into a group of 5-10 members.This group will be addressedwith supervised session of core stability exercise trainingand the session will continue for a duration of approximately 45 minutes to 1 hour every week. Subjects will be instructed to perform the exercises at their homes at least 2 – 3 times a week. Subjects will be given a diary to enter their performance and to check their adherence with the exercise program. Subjects will be allowed to ask their doubts during or after the session. The training will be continued for a duration of 8 weeks.