Master of Physiotherapy in Musculoskeletal Disorders and Sports

RESEARCH PROPOSAL

Lumbar spine curvature and abdominal core strength analysis and its correlation with the prevalence of low back pain among Bharatanatyam dancers.

MASTER OF PHYSIOTHERAPY IN MUSCULOSKELETAL DISORDERS AND SPORTS

(MPT)

Ms. MANJULA N M

DEPARTMENT OF PHYSIOTHERAPY

FATHER MULLER MEDICAL COLLEGE

MANGALORE – 575002

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS (in block letters) / Ms. MANJULA N M
DEPARTMENT OF PHYSIOTHERAPY
FATHER MULLER MEDICAL COLLEGE
MANGALORE – 575002
2. / NAME OF THE INSTITUTION / DEPARTMENT OF PHYSIOTHERAPY
FATHER MULLER MEDICAL COLLEGE
MANGALORE – 575002
3. / COURSE OF STUDY AND SUBJECT / MASTER OF PHYSIOTHERAPY
(MUSCULOSKELETAL DISORDERS AND SPORTS)
4. / DATE OF ADMISSION TO COURSE / 26-07-2013
5. / TITLE OF THE TOPIC:
Lumbar spine curvature and abdominal core strength analysis and its correlation with the prevalence of low back pain among Bharatanatyam dancers.
6. / Brief resume of the intended work:
6.1 Need for the study
Musculoskeletal injury is found to be an important health issue for dancers at all skill levels. Although types and patterns of dance styles are different, it has been found that the most common injuries reported are of the back and lower extremities. Most of the studies done are on ballet dancers and very few studies on theatrical dancers, ice dancers, modern and Chinese traditional dancers.1There are no available articles on Indian classical dancers in order to assess the structural changes they undergo and the various musculoskeletal injuries they face due to their dance forms.
Bharatanatyam is one of the most ancient dance forms in India. It took its origin 2000 years ago in the state of Tamil Nadu, a southern state of India. The dance is performed on the stage as “Nrittam”, “Nrithyam” and “Natyam”.2The foundation of the pure dance form (Nritta) consists of basic steps known as “adavu”. “Sthanakam” (posture) is one of the components of adavu which comprises of 3 basic positions namely – “Araimandi” (half sitting position), “Muzhumandi” (full sitting position) and “Standing”. It has been noticed that, the half sitting position (“Araimandi”) is the main position maintained for the longest duration in the dance style. This position requires the dancer to compress one’s height to atleast 3/4th of their original height.3Wrong adaptation of this posture could impose an excessive stress on the spine, especially the lumbar spine, and result in pain, disability among the dancers and also result in increased absenteeism from dance training sessions. Practice of a faulty posture for a long time in one’s dancing career could also result in a permanent structural change and affect the external appearance. Hence this study will focus on studying the lumbar spine curvature in both standing and half sitting (Araimandi) posture, then will try to compare the changes in lordotic angle among the two postures and try to identify hyper or hypo lordosis imposed on the lumbar spine, if any. Although the gold standard method for assessing lumbar spine curvature is the standard radiograph method and by using the cobb’s angle measurement, in a community setting, a radiological investigation study would not be feasible.4Evidences suggest the use of a Flexi Curve ruler as a tool to assess the lumbar spine curvature. Very few research articles have been found, which establishes a relation between lumbar lordosis and prevalence of low back pain. Hence this study also will attempt to find out what will be the probable correlation between the alterations in lumbar curvature and prevalence of low back pain among the Bharatanatyam dancers.
It has been found that extreme physical demands imposed by dancing techniques causes musculoskeletal injuries in dancers. They also reveal that a majority of dance injuries are found to be chronic in nature and mainly seen affecting the low back and lower extremity.5Although it has been shown that decreased abdominal core strength negatively affects the lumbar spine and lower extremities, literature establishing this correlation is scanty. This relation needs to be understood in order to reduce the risk of dance injury and to improve performance. Thus, this study will also analyze the abdominal core strength among the Bharatanatyam dancers and then compare them with the established normative values and also try to correlate it with the prevalence of low back pain.
RESEARCH QUESTION:
 Is there a prevalence of low back pain among Bharatanatyam dancers?
 Does a change in lumbar lordosis and abdominal core strength correlate with the prevalence of low back pain among Bharatanatyam dancers?
HYPOTHESIS:
 There is a prevalence of low back pain among Bharatanatyam dancers.
 There is an increase in the lumbar spine curvature among the Bharatanatyam dancers causing alterations in the abdominal core strength and it correlates with the prevalence of low back pain.
NULL HYPOTHESIS:
 There is no prevalence of low back pain.
 There is no significant difference in the lumbar spine curvature among the Bharatanatyam dancers.
OPERATIONAL DEFINITIONS:
ARAIMANDI POSTURE:- “ Araimandi”, is an essential foundation posture assumed by the dancer which is a half sitting position where one compresses their height to atleast 3/4th of their original height. This tends to give the dancer a typical triangular shape and in turn stability to the dance form. Ideally in this posture, the dancer’s back should not jut out, the stomach should not protrude out and the torso should not bend forward. The posture should be such that “Brahmasutra” (the vertical imaginary line passing through the centre of the body) is in balance. Araimandi is also referred to as “Ayatam” and “Ardhamandalam”.3
LOW BACK PAIN: Low back pain has been defined as – “The pain perceived to be arising from the region bounded by the 12th rib and the inferior gluteal folds, which may or may not be associated with leg pain”.6
THE CORE: The musculoskeletal core of the body includes the spine, hips and pelvis, proximal lower limb and abdominal structures. The core musculature includes muscles of the trunk and pelvis that are responsible for the maintenance of stability of the spine and pelvis and provides the proximal stability for the distal mobility and function of the limbs.7
6.2 Review of literature
A systematic review was carried out by Hincapie A C and colleagues1 in order to assemble and synthesize the best evidence on the epidemiology, diagnosis, prognosis, treatment and prevention of musculoskeletal injuries and pain in dancers. Various data sources like Medline, CINAHL, Psych INFO, Embase and other electronic bases from the year 1966 to 2004 were reviewed. 1865 articles were obtained out of which 103 articles fit into the frame of inclusion criteria. The review concluded that irrespective of the skill levels, musculoskeletal injury is an important health issue for dancers and they also suggested that better quality research is needed in this specialized area.
Oliveira TS and colleagues4 did a clinical study in order to verify the validity and reproducibility of using the Flexicurve to measure the angles of the Thoracic and Lumbar Curvatures of the Spine in the Saggital Plane. The study comprised of 47 subjects whose thoracic and lumbar spine curvature by using a Flexi Curve and was compared with the Saggital view X-Ray (Cobb’s angle). The study concluded that there is no significant difference between the values obtained using the Flexi curve and the values obtained using the X-Ray. The study found an excellent inter and intra evaluator reproducibility of the results obtained using a Flexicurve and thus recommends its use in the clinical practice.
Rickman AM and colleagues5 in their review on the implication of core stability for dance injuries stated that Dancers experience a high incidence of injury due to the extreme physical demands of dancing. Majority of dance injuries are chronic in nature and occur in the lower extremities and low back. Researchers have indicated decreased core stability (CS) as a risk factor for these injuries. Decreased CS is suggested to negatively affect lower extremity joint motion and lumbar control during activity.
Rajabi R et al8 conducted a descriptive study based on quantitative data in order to see whether, high point or the midpoint method using Flexicurve is close to X-Ray method of assessing the lumbar curvature. The study revealed that the deep point method using the Flexicurve is close to the X-ray method for lordosis measurement. The study also states a formula for converting the height and length values obtained into degrees that is, θ = 4 Arctang 2H/L.
Cairns MC and co - workers9 conducted a blinded, naturalistic comparative study in order to compare between anterolateral abdominal muscle function using the pressure biofeedback unit and the ‘prone test’ of subjects who were either symptomatic, asymptomatic, or who had symptoms previously which had now resolved. They also tried to investigate the pressure biofeedback unit (PBU) as an assessment tool to identify the symptomatic status. This study suggested that the pressure biofeedback unit may be considered as a useful tool to act as an indicator of deep abdominal function.
Tsuji T and his colleagues10 conducted a study in which they tried to determine the prevalence of low back pain in elderly Japanese and to examine its correlation with lumbar lordosis in saggital plane radiographs. The result of this study showed that there was a significant difference in lumbar lordosis between the groups with and without low back pain. Lumbar lordosis was found to be 4 degrees less in the low back pain group and the VAS was significantly inversely correlated with lumbar lordosis.
6.3 Objectives of the study

1. To analyze the lumbar spine curvature in erect standing and half sitting (“Araimandi”) posture of the Bharatanatyam dancers.
2. To analyze the abdominal core strength of the Bharatanatyam dancers
3. To correlate the above findings to the prevalence of low back pain among Bharatanatyam dancers.

7. / Materials and methods:
7.1 Source of data:
This study will be conducted on Bharatanatyam dancers in various dance schools of Mangalore, Karnataka.
7.2 Method of collection of data (including sampling procedure, if any)
STUDY DESIGN:
A cross sectional study design
SAMPLE PROCEDURE:
Subjects will be obtained by convenience sampling technique.
INCLUSION CRITERIA:
 Bharatanatyam dancers in the age group of 16 to 25 years.
EXCLUSION CRITERIA:
 Any congenital deformities of the spine.
 Any history of trauma to the spine.
 Pregnant women
 Post partum – upto 1 year
TOOLS
 A mouldable flexi curve ruler (32 inches)
 Markers
 Stabilizer Pressure Biofeedback Unit (PBU, Chattanooga Group, Australia)
 Stopwatch
OUTCOME MEASURES:
 Lumbar lordotic curvature
 Core strength
PROCEDURE:
Subjects will be obtained by purposive sampling technique. Subjects will be explained in detail about the study and the procedure involved. If willing to participate in the study, written informed consent will be taken from the eligible subjects (Annexure 1) and then baseline screening for exclusion criteria will be done. Subjects falling within the inclusion criteria will be enrolled for the study. Following this baseline data will be assessed which will include personal details like: name, age, gender, profession, and years of dancing experience. Height and weight will be noted in order to calculate the Body Mass Index (BMI) (Annexure 2). Two techniques will be performed on the subjects. First will be assessing the lumbar spine curvature in two positions (first in “erect standing” position and then in “Araimandi” (half sitting) position using a mouldable flexi curve ruler (32 inches) and second will the assessment of abdominal core strength using Stabilizer Pressure Biofeedback Unit (PBU, Chattanooga Group, Australia). The procedures for assessing the two techniques are explained below.
Lumbar curvature assessment procedure:
 Subject’s lower back region will be exposed.
 T12 and S1 spinous processes will be identified and will be marked using stickers.
 The subject will be instructed to stand, initially, in normal erect standing. The flexi curve ruler is aligned to the lumbar spine curvature (from T12 to S1)
 The moulded flexi curve is then placed on A4 size white paper and outline of the curve is drawn.
 A straight line is drawn joining the two tips of the curve and another line is drawn perpendicular from deepest point in the curve intersecting the straight line.
 Then the procedure is repeated with the subject in “Araimandi” or “Half Sitting” position.
 Lumbar lordotic angle is then calculated using the formula:

= 4 x Arctan 2H/L 8


T12 – Twelfth thoracic vertebra
S1 – First Sacral vertebra
H - Height in cm
L - Length in cm
- Degrees
Arctan – A trigonometric function. The arctan function is the inverse of the tangent function. It returns the angle whose tangent is a given number. Represented as TAN-1
Core strength analysis procedure:
 A Stabilizer Pressure Biofeedback Unit (PBU, Chattanooga Group, Australia) and a stopwatch will be used to obtain the pressure readings.
 The Stabilizer Pressure Biofeedback Unit (PBU, Chattanooga Group, Australia) (PBU) consists of a combined gauge/ inflation bulb connected to a pressure cell. It is a simple device that registers changing pressure in an air-filled pressure cell allowing body movement, especially spinal movement, to be detected during exercise. The pressure cell measures from 0-200 mmHg, with a precision of 2 mmHg.11
 Subjects are asked to lie in crook lying position.
 The inflatable cell will be placed centrally beneath the abdomen with the lower edge at the level of the anterior superior iliac spine (ASIS).
 In the above mentioned position subjects will be asked to contract or “tighten” their abdominal muscles.
 The readings will be taken at full expiration.
 The Pressure Biofeedback Unit (PBU) will be zeroed to 70 mm Hg, before each contraction.
 The subjects will be allowed to practice for not more than 6 attempts, to prevent premature fatigue.
 No feedback will be given to the subject at the time of data collection.
 Readings will be taken before and after a 10 sec contraction, which will be timed using the stopwatch.
 3 consecutive readings will be taken.
 The mean value of the 3 contractions will be taken. 9
 The depression of the abdominal muscle typically decreases the pressure by 4 – 10 mm Hg.11
After the two assessments are done, the subject is then asked if they have any complaints of low back pain.

• If YES – then they are given a questionnaire which will question them about their type of low back pain (Localized/Radiating to lower limbs), duration of low back pain, what is the average intensity of pain they experience during the period of pain (using Numeric Pain Rating Scale), what He / She does to reduce the pain, does the pain force them to be absent from their regular dance practice sessions, etc.

DATA ANALYSIS:
The obtained data will be analyzed using Mean, Standard Deviation and Karl
Pearson Correlation Co-efficient.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
Yes. The subjects participating in the study will be assessed for their lumbar curvature in two positions using a mouldable flexi curve ruler (32 inches) and their abdominal core strength will be assessed using The Stabilizer Pressure Biofeedback Unit (PBU, Chattanooga Group, Australia).
7.4 Has ethical clearance been obtained from your institution in case of 7.3
Yes.
8. / List of reference

1. Hincapie A C, Morton J E, Cassidy D J. Musculoskeletal Injuries and Pain in Dancers: A Systematic Review. Archives of physical medicine and rehabilitation.2008 Sep;89(9):1819-29
2. NRITYAGRAM – expression - bharatanatyam [internet]. [updated 2004 Jan 19; cited 2013 Oct 14]. Available from:
3. Session 4 - Araimandi/ Introduction to adavus Online Bharatanatyam Academy [internet]. [updated 2013 Oct 14; cited 2013 Oct 14]. Available from:
4. Oliveira TS, Candotti TC, Torre LM, Pelinson TPP, Furlanetto ST, Kutchak MF, Loss FJ. Validity and Reproducibility of the Measurements Obtained Using the Flexicurve Instrument to Evaluate the Angles of Thoracic and Lumbar Curvatures of the Spine in the Sagittal Plane. Rehabilitation Research and Practice.2012 Feb; Article ID 186156, 9 pages
5. Rickman AM, Ambegaonkar JP, Cortes N. Core stability: implications for dance injuries. Medical problems for performing artists.2012 Sep;27(3):159-64
6. Krismer M, Tulder VM. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non – specific). Best practice & research. Clinical Rheumatology. 2007 Feb;21(1):77-91
7. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Medicine.2006;36(3):189-98
8. Rajabi R, Seidi F, Mohamadi F. Which Method Is Accurate When Using the Flexible Ruler to Measure the Lumbar Curvature Angle? Deep Pint or mid Point of Arch? World Applied Sciences Journal.2008;4(6):849-852
9. Cairns MC, Harrison K, Wright C. Pressure Biofeedback: A useful tool in the quantification of abdominal muscular dysfunction? Physiotherapy. 2000; 86(3):127-138
10. Tsuji T, Matsuyama Y, Sato K, Hasegawa Y, Yimin Y, Iwata H. Epidemiology of low back pain in the elderly: correlation with lumbar lordosis. Journal of Orthopaedic Science.2001;6(4):307-11
11. Franca FR, Burke TN, Hanada ES, Marques AP. Segmental stabilization and muscular strengthening in chronic low back pain- a comparative study. CLINICS. 2010; 65(10):1013-1017

9. / Signature of candidate
10. / Remarks of the guide
11. / Name and designation of
(in block letters)
11.1 Guide / Mr. SUDEEP M.J.PAIS
Assistant Professor
11.2 Signature
11.3 Head of Department / Mr. NARASIMMAN SWAMINATHAN
Professor
11.4 Signature
12. / 12.1 Remarks of the Chairman & Principal
12.2 Signature

ANNEXURE - 1

CONSENT FORM

You are requested to participate in a study titled – “Lumbar spine curvature and abdominal core strength analysis and its correlation with the prevalence of low back pain among Bharatanatyam dancers”, being conducted by Ms. Manjula N M, MPT (Musculoskeletal Disorders and Sports), Father Muller Medical College, Mangalore. This is a part of the curriculum of the MPT course, run by the Rajiv Gandhi University of Health Science. The purpose of this study is to analyze the lumbar spine curvature and abdominal core strength and correlate them with the prevalence of low back pain among Bharatanatyam dancers.