Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the Candidate &Address / M.K KISHORE
MADANAPALLY
CHITTOR DIST
ANDRAPRADESH
2 / Name of the Institution / KTG COLLEGE OF PHYSIOTHERAPY
BANGALORE, KARNATAKA.
3 / Course of study & subject / MASTER OF PHYSIOTHERAPY IN MUSCULO-SKELETAL DISORDER AND SPORTS PHYSIOTHERAPY
4 / Date of admission to course / 28 TH JUNE 2011
5 / TITLE OF THE TOPIC
“EFFECT OF CORE STABLIZATION TRAINING IN IMPROVING THE QUALITY OF HEALTH REATED LIFE IN LUMBAR SURGERY PATIENTS”
6.
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8 / Brief Resume of Intended Work
Introduction
6.1 Need for study:
Lumbar spinal surgery is one of the most common types of surgeries performed in the United States with over 500,000 surgeries performed for lumbar herniated disks and lumbar spinal stenosis in 2004 [1]. Numerous studies have reported the clinical outcomes of spinal surgery. However, many studies have defined success rates in terms of medically-related outcomes, such as fusion rates and radiographic evidence, rather than the patient's perspective. Studies have demonstrated that patients' perspectives of their clinical outcomes are not necessarily the same as those of their clinicians'[2]. Although pain relief and improved health-related quality of life (HRQOL) are patient expectations following lumbar spinal surgery, there is limited research regarding this experience from the individual's perspective. In addition, no studies have examined the HRQOL of persons who have had this surgery using a comprehensive approach. Sciatica and surgery-induced pain has also an important role in dysfunction of the lumbar spine. Pain leads to delay in the onset of trunk muscle contraction (3). This change in muscular stabilization decreases the muscular support of the spine and may increase the risk of injury to the spine (4).
The reasons some people have persistent pain after surgery remain unclear, although results of recent studies indicate that microdiscectomy is less successful for protruding discs than for extruded or sequestrated discs.5, 6,7 Other investigators have shown that a long duration of work incapacity before surgery is significantly associated with a poor outcome.8,9 This could reflect the negative consequences of a longer period of nerve root compression.
Exercise has been shown to improve pain and disability in patients with nonspecific chronic low back pain, 10, 11,12,13,14 and it may also benefit patients recovering from disc surgery. As well as improving spinal function in the short-term, a controlled exercise program may increase patients’ confidence in their ability to exercise and perform manual work, and this could be of additional benefit in the longer term.
Dynamic lumbar stabilization exercises are important in both the conservative treatment oflumbar disc herniation and in post-operative rehabilitation programmes (15). These exercises are done in the so-called neutral position where the segmental forces between disc and facet joints are best balanced and the most effective stability is obtained in axial tension strength. The neutral position is conserved during exercises and lumbar stability is not disturbed even in motion. While muscle strength is increased, improper tension is avoided in these exercises.
Many studies related to pain, disability and functional status has been done but there is lack of evidence in terms of health related quality of life in lumbar disc surgery patients hence my study is intended to find out the effect of stabilization exercises in improving the health related quality of life in lumbar disc surgery patients.
6.2 REVIEW OF LITERATURE:
Karen Saban, et al 2007 : HRQOL using the Wilson and Cleary Model for Health-Related Quality of Life in persons who have undergone lumbar spinal surgery. Individuals completed questionnaires measuring perceived pain, mood, functional status, general health perceptions, social support and HRQOL preoperatively and three months following surgery. Preliminary results indicate overall perceived physical HRQOL was significantly improved postoperatively (t [56] = 6.45, p < .01), however, it was lower than the published norms for patients with low back pain. Both functional disability (t [56] = 10.47, p < .001) and pain (t [56] = 10.99, p< .001) were significantly improved after surgery. Excessive fatigue and low vigor may have implications for successful rehabilitation and return to work for patients following lumbar spinal surgery. Further research is needed with a larger sample size and subgroup analyses to confirm these results.
Patricia Dolan, PhD,et.all 2000: Microdiscectomy is often used successfully to treat prolapsed lumbar intervertebral disc. all patients postoperative care that included advice from a physiotherapist about exercise and a return to normal activities. Six weeks
after surgery, patients in the EXERCISE group undertook a 4-week exercise program that concentrated on improving strength and endurance of the back and abdominal muscles and mobility of the spine and hips. After the exercise program, the EXERCISE group showed further improvements in these measures and also in electromyographic measures of back muscle fatigability. A 4-week postoperative exercise program can improve pain, disability, and spinal function in patients who undergo microdiscectomy.
Jan M. Danielsen,et.all 2000: The training consisted of an8-week active rehabilitation program including a regimen of vigorous lumbar stabilizing exercises. Sixty-three of 65 eligible patients agreed to participate in the trial. Fifty-eight and 53 patients attended for evaluation at 6 and 12months, respectively. There was a significantly larger improvement in the mean Roland’s disability index (from 8.9 to 5.4 [P 5 0.02] at 6months and from 8.7 to 5.3 [P 5 0.03] at 12 months) and in reported pain (from 3.7 to 2.0 [P 5 0.04] at 6 months and from 3.2 to 1.8 [P 5 0.09]at 12 months) in the training group. Vigorous medical exercise therapy,started 4 weeks after surgery for lumbar disc herniation,reduced disability and pain after surgery.
Arja Ha¨kkinen,et.al. 2003 : To study associations between pain, trunk muscle strength, flexibility and disability .allin patients with lumbar disc herniation 2 months after surgery. Back and leg pain on Visual Analogue Scale,Oswestry Disability Index and Brief Depression Scale were applied to assess the subjectively perceived outcome.Isometric and dynamic strength of trunk muscles and mobility of the lumbar spine were measured to mirror physical impairment. Two months after the operation median leg pain had decreased by 87% and back pain by 81%, respectively. Pain, decreased trunk muscle strength and decreased mobility still remained in a considerable proportion of patients with lumbar disc herniation2 months after surgery. Early identification of those patients with restrictions is essential in order to commence rehabilitation.
Figen Y´lmaz, et.al. 2003: The aim of this study was to determine the efficacy of dynamic lumbar stabilization exercises in patients with lumbar microdiscectomy.Dynamic lumbar stabilization exercises were set for the first group and a home exercise program for the second. The third group given no exercises was considered as a control group. All patients were examined twice, once before the exercise program and once 8 weeks later. Dynamic lumbar stabilization exercises are an efficient and useful technique in the rehabilitation of patients who have undergone microdiscectomy. They relieve pain, improve functional parameters and strengthen trunk,abdominal and low back muscles.
Diane U Jette.et.al.1996:Little is known concerning the effects of physical therapy on health outcomes in patients with spinal impairments.This research examined the pattern of health outcomes inpatients with spinal impairments and the relationship of outcomes to the physical therapy provided. Multivariate analyses were used to determine which of the treatment variables, controlled for baseline health status and relevant patient characteristics, were related to outcomes, Inclusion of endurance exercise was most consistently associated with better out comes.Inclusion of heat or cold modalities was associated with poorer out comes. This study suggests that physical therapists take a broader view of patient-related goals and documentation of outcomes. It also provides evidence that the type of intervention is related to outcomes.
Raymond W. J. G. Ostelo,et.al.2009 :To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery.Several rehabilitation programs are available for individuals after lumbar disc surgery, however, little is known about the efficacy of these treatments. All randomized controlled trials without language limitations were included. Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence. Exercise programs starting 4 to 6 weeks post surgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster
decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the reoperation rate after first-time lumbar surgery.
Raymond WJG Ostelo1, et.al .2008:To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery. included randomised controlled trials (RCTs).Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence.Fourteen studies were included, seven of which had a low risk of bias. Most programs were only assessed in one study. Statistical pooling was only completed for three comparisons in which exercises were started four to six weeks post-surgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises.
Eyal Lederman 2010 :The principle of core stability has gained wide acceptance in training for the prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal conditions in particular of the lower back.
There has been surprisingly little criticism of this approach up to date. This article re-
examines the original findings and the principles of core stability/spinal stabilization approaches and how well they fare within the wider knowledge of motor control, prevention of injury and rehabilitation of neuromuscular and musculoskeletal systems following injury.
Stuart M. McGill 2001:Lumbar stability, “core stability,” and low back stabilizing exercises have emerged as popular topics related to optimal athletic/occupational performance and to the rehabilitation of painful backs. The concept of stability, together with notions of design and the application of stabilization exercise, is briefly synthesized. The objective is to challenge muscle systems to achieve sufficient
functional stability but in a way that spares the spine of excessive exacerbating load.
6.3 Objective of the Study :
To determine the effect of the core stabilization training in improving the quality of health related life in low back surgery patients.
6.4 Hypothesis :
Null hypothesis :
There is no significant effect on core stabilization training in improving the
quality of health related life in low back surgery patients . .
Alternate hypothesis :
There is significant effect on core stabilization training in improving the
quality of health related life in low back surgery patients . .
Materials and Methods :
7.1 Source of data :
Study will be conducted at K.T.G. Hospital , Bangalore ,
Sri Chandanamal Bothra Charitable Medical Hospital, Bangalore.
7.2 Study Design :
Experimental Study.
7.3 Convenient Sampling Method :
Study will be done on 30 subjects who will full fill the inclusion and exclusion criteria in general population.
7.4 Population :
Study will be conducted on low back surgery patients at the age group of 45 to 65 yrs.
7.5 Materials Used :
Mattress
Swiss ball
Examination table
7.6 Criteria for selection of the sample :
(a).Inclusion Criteria :
The symptoms persisting after surgery with the age group of 45 to 65 years of patients.
No change in VAS severity, before and after surgery.
Age group : 45-65 yrs.
Gender : Both males and females.
Pain intensity level between 4cm to 8cm on numerical pain rating scale.
(b).Exclusion Criteria :
There is a change in VAS severity before and after surgery.
Cardio vascular diseases.
Patients having any history of trauma.
(c).Evaluation tool :
Visual Analogue Scale
S F 36 questionnaire scale
Manual muscle testing
(d).Out come measure :
1. Numeric pain rating scale(0-10cm,horizontal)for pain.
2. Core muscle strength.
3. Quality of health related life scale
7.7 Methodology:
All the subjects will complete detailed assessment subjects, who fulfill the selection criteria, will be informed about the study and requested to sign consent forms. Pre-participation evaluation form consists of numerical pain rating scale of health related quality of life scale with the help of we can measuring the patient quality of life.
The patient will be divided into two groups. (A &B)
Group A (Control group):
The subjects will receive the post operative exercises for low back surgery.
The soft tissue flexibility and
Range of motion of exercises.
Group B (Experimental group):
Dynamic lumbar stabilization exercises will be administered to the patients. Before the exercise program, the soft tissue flexibility and range of motion of these patients will be increased through stretching exercises, with 5–10 minute relaxation periods. The exercise program will be performed 3 days a week with 5 repetitions in 3 sets to begin with and repetitions will be gradually increased until they reached 15. Exercises will conducted under the supervision of a physiotherapist who instruct the patients initially on an individual basis. They initially Performed the exercises individually as well. After the basic steps had been covered successfully, patients carry
out the exercises in groups of 2 or 3 for the duration of the program. During the exercises the importance of neutral spinal position will be repeatedly stressed. The entire program
last 8 weeks. The core stabilization exercises are i.e
MDICINAL BALL EXERCISES :
Sit up and throw
Sit and twist pass
45 degree sit , catch and pass
One leg twist pass
Side touches down
Kneeling twist pass
STATIC FLOOR EXERCISES :Plank
Side plank
Bridge
Superman
DYNAMIC FLOOR EXERCISES :
Side Lying Hip Abduction
Straight Leg Raising
Lying wind Screen Wipe
Oblique Crunch