Bangalore
Annexure II
1. / Name of the candidate and address (in block letters) / VALENCIA AFONSO JOSE,
Dr. M. V. SHETTY COLLEGE OF PHYSIOTHERAPY,
VIDYA NAGAR, KULOOR,
MANGALORE-575013
2. / Name of the Institution / Dr. M. V. SHETTY COLLEGE OF PHYSIOTHERAPY.
3. / Course of study and subject / MASTER OF PHYSIOTHERAPY (MPT) IN MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY.
4. / Date of admission / 2nd JULY 2012
5. / Title of the Topic / EFFICACY OF PNF TECHNIQUE FOR HAMSTRING FLEXIBILITY IN THE REHABILITATION OF PATIENT WITH MECHANICAL BACK PAIN.
6. / Brief Resume of the Intended Work
6.1) Introduction and Need of the Study:
Back pain poses an enormous challenge to physicians and other health care providers. The problem in developing countries is compounded by ignorance to report for early Treatment and occupational compulsion in rural area. According to Borenstein, low back pain should be viewed as a medical disorder,with the goal being to return to regular physical activity as quickly as possible to enable the patient to receive the most beneficial care at optimal times.1low back pain affects men and women equally2There is evidence that 12% to 26% of children and adolescents experience low back pain although most cases of low back pain occur in persons between that ages of 25 and 60 years3.
Decreased muscle flexibility and trunk strength have been postulated as risk factors for low back pain4.Poor hamstring flexibility has been associated with low back pain in cross sectional studies in both adolescents and adults.5 Apart from the electrical modalities, exercises also form the integral part of rehabilitation and in fact, it is one of the most frequently used modality for (CLBP)6.
Physical exercises lead to gain in muscle strength (force- generating capacity),flexibility, endurance, restoration of the injured tissues, and also contribute to the ability to sustain normal
life activities, such as those at work.7 Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve back flexibility and strength, and to improve performance of endurance activities. The second goal of exercise is to reduce the intensity of back pain. The third and most important goal of exercise is the reduction of back pain–related disability.8
Propioceptive neuromuscular facilitation (PNF) stretching techniques are commonly used in the athletic and clinical environments to enhance both active and passive range of motion (ROM) with a view to optimize motor performance and rehabilitation. PNF stretching is positioned in the literature as the most effective stretching technique when the aim is to increase ROM, particularly in respect to short-term changes in ROM.9
Need of the study :
A key structure in low back pain is the hamstring muscles, the large muscles in the back of the thighs. Patients with tight hamstrings tend to develop low back pain, and those with lower back pain tend to develop tight hamstrings.
Previous studies state that tight hamstrings limit motion in the pelvis, so the motion gets transferred to the bottom lumbar motion segments and increases the stress in the low back.10However there is lack of studies regarding the efficacy of flexibility training programme in the rehabilitation of back pain ,hence arises the need for it.
Research Question:
Will hamstring flexibility exercise program using PNF technique prove beneficial in reduction of pain, increase in flexibility, functional status in patients suffering with chronic mechanical low back pain?
Hypothesis:
Alternate Hypothesis: There will be significant decrease in pain, increase in flexibility and functional status using PNF technique in the rehabilitation of patients with chronic mechanical low back pain
Null hypothesis: There will be no significant decrease in pain, increase in flexibility and functional status using PNF technique in the rehabilitation of patients with chronic mechanical low back pain.
6.2) REVIEW OF LITERATURE :
DC Funk, AM Swank, BM Mikla, TA Fagan( 2003)performed a study comparing the effects of Proprioceptive neuromuscular facilitation v/s static stretching and concluded that PNF performed after exercise enhanced acute hamstring flexibility, and implementing a PNF stretching routine following exercise may augment current stretching practices among athletes.
SG Spernoga, TL Uhl, BL Arnold.(2001)In their study was to measured the duration of maintained hamstring flexibility after a 1-time, modified hold-relax stretching protocol and concluded that a sequence of 5 modified hold-relax stretches produced significantly increased hamstring flexibility that lasted 6 minutes after the stretching protocol ended.
JB Feland, HN Marin( 2004)To determine if submaximal contractions used in contract-relax proprioceptive neuromuscular facilitation (CRPNF) stretching of the hamstrings yield comparable gains in hamstring flexibility to maximal voluntary isometric contractions (MVICs) it was concluded that CRPNF stretching using submaximal contractions is just as beneficial at improving hamstring flexibility as maximal contractions, and may reduce the risk of injury associated with PNF stretching.
JB Feland, JW Myrer, RM Merrill ( 2001)Performed a study on acute changes in hamstring flexibility PNF v/s static stretch in senior athletes and concludedstretching provides an acute increase in flexibility of the hamstrings. CRPNF and static stretches significantly improve flexibility. For men and women participants less than 65 years of age, CRPNF stretch appears more beneficial than static stretch.
DG Burke, LE Holt, R Rasmussee(2001)In their study they compared the changes in hamstring length resulting from modified proprioceptive neuromuscular facilitation flexibility training in combination with cold-water immersion, hot-water immersion, and stretching alone and concluded that No advantage was apparent in using complete hot or cold immersion to increase hamstring length in healthy subjects ,but hamstring length increased with the use of PNF.
D Hopper ,S Deacon ,S Das, A Jain, D Riddell, T Hall(2005)Some studies have proven that decreased hamstring flexibility is a risk factor for the development of patella tendinopathy and patellofemoral pain, hamstring strain injury ,and symptoms of muscle damage following eccentric exercise.Concluded that there are a number of associated benefits of flexibility including improved athletic performance, reduced injury risk, prevention or reduction of post-exercise soreness , and improved coordination.
Donald E. Harting and John M. Henderson(1999)Conducted a study, the purpose of the study was to prove that increasing flexibility of the hamstring musculotendinous unit would decrease the number of lower extremity overuse injuries that occur in military infantry basic trainees. Hamstring flexibility increased significantly in the intervention group compared with the control group. Thus, in this study the number of lower extremities overuse injuries was significantly lower in infantry basic trainees with increased hamstring flexibility.
N Kofotolis, E Kellis - Physical therapy,( 2006)The purpose of this study was to examine the effects of 2 proprioceptive neuromuscular facilitation (PNF) programs on trunk muscle endurance, flexibility, and functional performance in subjects with chronic low back pain (CLBP), concluded
that PNF programs may be appropriate for improving short-term trunk muscle endurance and trunk mobility in people with low back pain.
MA Esola, PW McClure ,et al,( 1996)The purposes of this study were to establish the amount and pattern of lumbar spine and hip motion during forward bending, and determine differences in motion in subjects with and without a history of low back pain, Results suggest that although people with a history of low back pain have amounts of lumbar spine and hip motion during forward bending similar to those of healthy subjects, It may be desirable to teach patients with a history of low back pain to use more hip motion during early forward bending, and hamstring stretching may be helpful for encouraging earlier hip motion.
PW McClure,(1997)Performed a study to determine the amount and pattern of lumbar spine and hip motion that occur as an individual rises from a forward, flexed position, to determine if differences exist in this measurement between individuals with and without a history of low back pain, and to determine if hamstring length is related to the pattern of motion , concluded that Although participants with a history of low back pain had significantly tighter hamstrings than participants with no history of low back pain, hamstring length was not correlated with any of the kinematic characteristics during extension.
DE Feldman – (2001)They conducted a study to determine the incidence of low back pain in a cohort of adolescents and to ascertain risk factors and thus concluded The outcome was low back pain occurrence at a frequency of at least once a week in the previous 6 months.Risk factors associated with development of low back pain were high growth, smoking, tight quadriceps femoris, tight hamstrings, and working during the school year. Modifying risk factors such as poor leg flexibility may potentially serve to prevent the development of low back pain in adolescents.
L Purcell – (2009)In his study reviewed some of the causes and management of low back pain in young athletes and concluded Recognition of risk factors, such as excessive training, improper technique and muscle imbalances/inflexibilities, is key to preventing injury .Training should be reduced during rapid growth. An emphasis should be placed on proper techniques. Injury risk can be reduced by core-strengthening exercises, and hamstring and hip flexor stretches.
Laura niedziocha –(2011)Performed a study if hamstring tightness effects low back pain, concluded that tight hamstrings can affect the lower back. Inflexible hamstrings can cause low back pain, sacroiliac problems and can even move your pelvis into an abnormal position. This can affect your posture, which also affects the lower back. Tight hamstrings can also increase your risk of injury. Adding a few exercises each day to increase your flexibility can keep your hamstrings and lower back healthy and functioning properly.
M A Jones G Stratton-(2004) In this study they matched case-control study to evaluate biological risk indicators for recurrent non-specific low back pain in adolescents.Adolescents with recurrent non-specific low back pain and matched controls with no history of non-specific low back pain
participated. Measures of stature, mass, sitting height, sexual maturity, lateral flexion of the spine, lumbar sagittal plane mobility, hip range of motion, back and hamstring flexibility, and trunk muscle endurance were performed using standardised procedures with established reliability were
taken thus, concluded ,Hip range of motion, trunk muscle endurance, lumbar sagittal plane mobility, and lateral flexion of the spine were identified as significant risk indicators of recurrent low back.
6.3) OBJECTIVES OF STUDY:
1)To determine the effectiveness of PNF Technique for pain reduction ,increasing hamstring flexibility and improving the functional status in patients with CLBP.
7. / MATERIALS AND METHODS:
7.1) STUDY DESIGN:
Quasi experimental.
7.2) SOURCE OF DATA :
Patients suffering from chronic mechanical low back pain referred for physiotherapy by physician or orthopaedic surgeon in Government Wenlock Hospital and Dr.M.V.Shetty Trust Hospital, Mangalore.
7.2 I DEFINITION OF THE STUDY SUBJECTS:
Patients with mechanical back pain in the age group of 25 to 60 years.
7.2 II INCLUSION AND EXCLUSION CRITERIA:
Inclusion criteria
- Non specific low back pain.
- Age group 25-60 years.
- Suffering from back pain for more than 3 months.
- Males and females
- Modified ODI score ≥30%
- Pathological or neurological changes in the spine
- Age less than 30 and more than 50 years
- Patient on anticoagulant treatment
- Radiotherapy of the spine
- Non-cooperative patients
- Previous surgery or trauma to the region
- History of fracture of the spine
- epilepsy
- Confused or disoriented patients
- Pregnancy
- Malignancy
Sample design and method :
Purposive sampling technique which is randomly assigned in 2 groups, Group A and Group B.
Sample size:
40 patients will be selected.
7.2 IV FOLLOW UP:
Pre-treatment assessment will be taken for pain ,functional status, hamstring flexibility .Post-intervention assessment will be taken after 4 weeks of intervention for the same parameters.
7.2 V PARAMETERS USE FOR COMPARISON AND STATISTICAL TEST:
Collective data will be analyzed by means of paired n unpaired ‘ t ‘test
7.2 VI DURATION OF STUDY:
Durationof the study will be 9-12 months.
7.2 VII METHODOLOGY:
40 subjects meeting the inclusion criteria will be recruited from various from various physiotherapy clinics and hospitals in and around mangalore for the study, informed consent will be obtained from the patients then the patients will be randomly assigned into 2 groups
Group A (experimental) Group B (control) having 20 subjects in each group.
Pre-treatment assessment of pain, hamstring flexibility, and functional status will be recorded for both the groups.
VAS,AKE TEST,ODI will be used to measure pain, flexibility and functional status respectively ,after a brief intro about PNF stretching.
GROUP A
Subjects will receive PNF stretching(contract-relax antagonist contract)
PNF hamstring stretch ,using a strap to stretch hamstring in supine position ,loop the strap around the ball of the patients foot holding the ends of the strap with both the hands, keep chin down and shoulders back .Exhale while pushing heel up towards ceiling hold for 20 to 30 seconds push down with heel toward floor for 3 to 6 sec ,then try and straighten knee actively push foot toward ceiling contracting your quadriceps hold for 3 to 6 sec, relax and hold your stretch for 20 to 30 seconds.
This treatment will be given for 3 times a week for a period of 4 weeks.
GROUP B
Subjects will receive conventional treatment for back pain which includes moist heat and pelvic bridging ,pelvic rolling.
7.3) Does the study require any investigations to be conducted on patients or other human or animal if so please describe briefly?
Yes.
- Visual analogue scale –pain
- Active knee extension test –hamstring flexibility
- Modified Oswestry disability questionnaire –fuctional status
Yes
8. / List of References :
1.Fidvi N May, S. Physiotherapy management of low back pain in india a survey of self –reported practice.2010;15(3):150-159.
2. Atlas SJ ,Chang Y, Kammanne ,Keller RB .long term disability and return to work among patients who have a herniated lumbar disc :the effect of disability compensation j bone joint surgeon am jan 2000 82(1)4-15.
3. Plowman, S. A. (1992). Physical activity, physical fitness, and low back pain. In J. O. Holloszy (Eds.), Exercise and Sport Sciences Reviews (pp. 221-242). Baltimore: Williams & Wilkins.
4.Kujala UM ,Taimela S ,Oksanen A, et al. lumbar mobility and low back pain duringadolscents AM J sports.1997;25:363-8.
5.Esola MA, Mcclure PW ,Fitzgerald GK ,et al. Analysis of lumbar spine and hip motion during forward bending in subjects with and without a history of low back pain.1996;21:71-8.
6.Nick Kofotolis, Eleftherios Kellis. Effects of Two 4-Week Proprioceptive Neuromuscular Facilitation Programs on Muscle Endurance, Flexibility, and Functional Performance in Women With Chronic Low Back Pain.2006(7)86.
7.Malkia E, Ljunggren AE. Exercise programs for subjects with low back disorders. Scand J Med Sci Sports. 1996, 6: 73-81.
8. J. Rainville, C. Hartigan. Exercise as a treatment for chronic low back pain. The Spine Journal. 2004, 4: 106-115 N15.
9.Sports medicine,vol 36 issue 2,2006 929-939.
10. Peter F Ullrich,JR.M D. Back muscles and low back pain.
11. Erica N Johnson,BS and James S ,Thomas.effect of hamstring flexibility on hip and lumbar spine joint excursion during forward reaching tasks in individuals with and without low back pain 2010july;91(7);1140-1142
12.Funk DC, Swank AM, Mikla BM, Fagan TA, Farr BK.Impact of prior exercise on hamstring flexibility: a comparison of proprioceptive neuromuscular facilitation and static stretching.2003 Aug;17(3):489-92.
13.Spernoga SG, Uhl TL, Arnold BL, Gansneder BM.Duration of Maintained Hamstring Flexibility After a One-Time, Modified Hold-Relax Stretching Protocol.2001 Mar;36(1):44-48.
14.Feland JB, Marin HN.Effect of submaximal contraction intensity in contract-relax proprioceptive neuromuscular facilitation stretching. 2004 Aug;38(4):E18.
15. J.Brent Feland, , J.W. Myrer, R.M. Merrill.Acute changes in hamstring flexibility: PNF versus static stretch in senior athletes. 2001 November 186-193.
16. Burke DG, Holt LE, Rasmussen R, MacKinnon NC, Vossen JF, Pelham TW.Effects of Hot or Cold Water Immersion and Modified Proprioceptive Neuromuscular Facilitation Flexibility Exercise on Hamstring Length.2001 Mar;36(1):16-19.
17. Nick Kofotolis and Eleftherios KellisEffects of Two 4-Week Proprioceptive Neuromuscular Facilitation Programs on Muscle Endurance, Flexibility, and Functional Performance in Women With Chronic Low Back Pain Physical Therapy July 2006 vol. 86 no. 7 1001-1012.
18. Esola MA, McClure PW, Fitzgerald GK, Siegler S.Analysis of lumbar spine and hip motion during forward bending in subjects with and without a history of low back pain.1996 Jan 1;21(1):71-8.
19. McClure PW, Esola M, Schreier R, Siegler S.Kinematic analysis of lumbar and hip motion while rising from a forward, flexed position in patients with and without a history of low back pain. 1997 Mar 1;22(5):552-8.
20.Debbie Ehrmann Feldman 1 , 2 , Ian Shrier 1 , Michel Rossignol 1 and Lucien Abenhaim 1Risk Factors for the Development of Low Back Pain in Adolescence Am. J. Epidemiol. (2001) 154 (1): 30-36.
21. Laura Purcell, MD*† and Lyle Micheli, MD Low Back Pain in Young AthletesMay/June 2009 vol. 1 no. 3 212-222.
22. Laura niedziocha –(2011) tight hamstring back painAug 20, 2011.
23. M A Jones G Stratton -(2004) Biological risk indicators for recurrent non-specific low back pain in adolescents 2005;39:137-140.