Rajiv Gandhi University of Health Science

Bangalore, Karnataka.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the Candidate
and Address / PRIYANKA GANESH PATIL
A/403, Shiv-Shakti appt, Sangitawadi, Shivmandir road, Dombivli (E) 401201.
2. /

Name of the Institution

and Address

/ K.T.G. COLLEGE OF PHYSIOTHERAPY
Hegganahalli cross, Vishwaneedam Post, Sunkadakatte via Magai Road.
Bangalore- 560 091
3. /

Course of study and subject

/ MASTER OF PHYSIOTHERAPY
(Musculoskeletal Disorders and Sports Physiotherapy)
4. /

Date of admission to course

/ 7th April 2012
5. /

TITLE OF THE TOPIC:

A COMPARATIVE STUDY ON MUSCLE ENERGY TECHNIQUE AND
POSITIONAL RELEASE THERAPY IN ACUTE LOW BACK ACHE
6. / Brief resume of the intended work:
6.1  Need for the study :
Low back pain is the largest cause of sick leave and half of the population will have experienced a significant incident of low back pain by age of 30. In India its incidence has been reported to be 23.09%. They are classically stratified into acute, sub acute and chronic, with respective cut-offs of <6 weeks, 6–12 weeks and >12 weeks. Acute low back pain is usually the result of various causes, such as postural abnormalities, muscle dysfunction (imbalances, shortening or weakening of muscle), overuse, instability, and articular dysfunction in the lower back, injury or accident, most often road vehicle accidents. 85-90% of all episodes of low back pain are non specific in nature.1 This is the most common type of back pain. About 19 in 20 cases of acute (sudden onset) low back pain are classed as non-specific. This is the type of back pain that most people will have at some point in their life. It is called non-specific because it is usually not clear what is actually causing the pain. In other words, there is no specific problem or disease that can be identified as to the cause of the pain. The severity of the pain can vary from mild to severe.2
The treatment of patients with back pain can be extremely interesting and rewarding. However, some patients with low back pain can be difficult to treat and care of these patients is quite often challenging. People who report LBP often have reduced spinal motion. When motion is limited, spinal extension is more restricted than flexion. Reduced spinal extension can be result of pain or stiffness and can be classified as being either general (total spine) or segmental (one vertebral level). The function and co-ordination of the muscles that stabilize the lumbar
spine, especially the back extensor muscles are often impaired in patients with low back pain. Sorensen found that good endurance of back extensor muscles in men appeared to protect them from low back pain. Erector spinae strain and fatigue is one of the causes of back pain. In general, positional release therapy and muscle energy techniques are the forms of manual therapy that are used in an effort to reduce pain and improve range of motion.1
Muscle Energy Technique is a direct technique originally developed by Fred Mitchel, Sr., DO. The purpose of this technique is to treat joint hypomobility (stiffness) and restore proper biomechanical and physiological function to the joint. Different patient positions are utilized to engage the restriction before asking the patient to perform an isometric contraction to pull the restricted segment into a new motion barrier. The isometric contraction is performed in a precisely controlled direction against a precisely controlled counterforce by the therapist. The result is improved spinal mobility without the need for passive manipulation.Muscle Energy Technique is effective for mobilizing restricted joints, relaxing hypertonic and spastic muscles as well as facilitating neuromuscular reorganization. It is an appropriate technique for patients whose symptoms are aggravated by certain postures or bodily positions.2 Greenman defined muscle energy technique as a manual medical treatment procedure controlled direction, at varying levels of intensity against a distinctly executed counter force applied by the operator. The goal is to increase joint mobilization and lengthen contracted muscles.1 Each treatment session begins and ends with a screening technique to assess the outcome of the manual techniques. This can be rewarding for the patient as the experience changes in mobility with concomitant reduction in pain.3
Positional Release Therapy is a manual technique that restores a muscle to its normal resting tone. Assessment of trigger points allows identification of hypertonic muscles that are creating somatic dysfunction. The tender point is used as a guide and the position of comfort is maintained.1 These efferent impulses were attempting to protect the tissue from being over stretched. By interrupting this pathway, the patient’s muscle is allowed to relax and assume a normal resting tone. The process is completed by slowly and passively returning the patient to an anatomical neutral position without firing of the muscle spindle.4 This position of minimal discomfort is usually a position where the muscle is at its shortest length. The position is held for 90 seconds and the joint is slowly and passively returned to the neutral position. This prolonged shortening of the muscle causes shortening of both the intrafusal (muscle spindle) and extrafusal fibers. These changes in turn result in a significant increase in function range of motion and a decrease in pain.1 Patients are placed in positions that approximate the origin and insertion of the hypertonic muscle. In doing so the muscle spindle activation is inhibited thereby decreasing the amount of afferent impulses to the brain. This leads to less efferent impulses to the same muscle. The patient is then instructed in appropriate.5
Even though both muscle energy technique and positional release therapy are beneficial for management of acute low back pain, optimal treatment intervention is not agreed upon till date. Hence, further research is necessary to find the most effective treatment option in the management of patients with acute low back pain. Therefore the purpose of the study is to compare the effectiveness of Muscle energy technique and Positional release therapy for reduction of pain and improving functional ability in subjects with acute low back pain.
Research Question:
Which form of manual therapy is more effective in improving functional ability and reducing pain in subjects with acute low back pain – Muscle Energy Technique or Positional Release Therapy?
Hypothesis:
Null hypothesis:
There will be no significant difference between Muscle Energy Technique and Positional Release Therapy in improving functional ability and reducing pain in subjects with acute low back pain.
Alternate hypothesis:
There will be significant difference between Muscle Energy Technique and Position Release Therapy in improving functional ability and reducing pain in subjects with acute low back pain.
6.2  Review of Literature:
P Naik Prashant, A Heggannavar et. al. (2010): studied the effects of MET and PRE on low back pain and concluded that both were helpful in improving lumbar mobility and decreasing pain in non specific low back pain.1
Wilson E, Payton O, Donegan-Shoaf L, Deck K et. al. (2003):studied effects of MET on non specific low back pain in a perspective pilot clinical trial on 20 subjects over a 4 week period and found that MET combined with supervised motor control and resistance exercises may be superior to neuromuscular re-education and resistance training for decreasing disability and improving function in patients with acute low back pain2
Nogelle M Selkow, Terry L Grindstaff, Kevin M Cross, Kelli Pugh, Jay Hertel, Susan Saliba K et. al. (2003): studied effects of MET in non specific lumbopelvic pain in a randomized control trial. The main finding of this study was that the MET group demonstrated a decrease in VAS worst pain. This technique can be accomplished without causing further pain or harm to the patient.3
Wong, Christopher Kevin, Schauer, Carrie e.t. al (2004): studied effect of Positional Therapy on pain and strength in hip musculature on 50 volunteers. They have concluded in their study that positional release therapy definitely reduces pain which indeed improves strength.4
Kerry J.D’Ambrogio, George B. Roth e.t. al (1997): suggested Positional release therapy also known as ‘’counter strain’’ is a helpful tool for Assessment & Treatment of Musculoskeletal Dysfunction. Although positional release was invented as a structural technique, physiologically it can be seen as a way of resetting proprioceptors, primarily at tendon-osseous junctions.5
S Stander- Acta Derm Venerol . et. al. (2012): studied validity and reliability of Visual Analogue Scale in comparison to Numerical Rating Scale and Verbal Rating Scale. They concluded that VAS is more sensitive and reliable tool than NRS and VRS for pain assessment.6
Boonstra, Anne M. Reneman, Michiel F. , Posthumus, Jitze B. , Stewart, Roy E. , Schiphorst Preuper, Henrica R. et. al. (2008):conducted a study to determine the reliability and concurrent validity of a visual analogue scale (VAS) for disability as a single-item instrument measuring disability in chronic pain patients. 52 patients in the reliability study, 344 patients in the validity study were selected. They concluded that the reliability of the VAS for disability is moderate to good.7
Julie M Fritz and James J Irrgang et. al. (2008): did a comparative study on reliability of Modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale on 60 subjects over a 4-week period and found that results for the modified OSW were superior than for the QUE. The modified OSW was more responsive than the QUE as assessed by GRI and in correlations between change scores and the global rating of change.8
H Breivik, S. M. Allen et. al. (2008): studied importance of validity and reliability of pain assessment. They concluded that any assessment of pain must take into account other factors, such as cognitive impairments or dementia and assessment tools validated in the specific patient group being studied. 9
6.3 Objectives:
To compare the effects of Muscle energy technique and Positional release therapy in Acute Low Back Ache on pain and disability.
7. / Material and Methods
7.1  Study design:
Comparative Study design with two groups- Group A(HMP+MET) and Group B(HMP+PRT)
7.2  Methodology:
Study subject :
Subjects with non specific low back pain for less than 3weeks.
Sample size:
Study will be done on 30 subjects (15 in Group A and 15 in Group B)
Study setting and source of data
Study will be conducted in K.T.G. Hospital, Bangalore and other Rehabilitation Centres.
Sampling method
Simple random sampling method.
Study duration:
2weeks study : daily sessions
Sample selection:
Inclusion Criteria:
·  Both male and females.1
·  Age group between 20 to 65 years.1
·  Non specific low back pain.1
·  Symptoms less than 3 weeks.1
·  Subjects who willing to participate.1
·  Low back pain without radiation to buttock, thigh or leg.1
Exclusion Criteria:
·  History of spinal surgery.1
·  Motor weakness .1
·  Spinal fractures or tumors.1
·  Lumbar radiculopathy.1
·  Altered sensation such as paraesthesia, numbness,hyperaesthesia, anesthesia.1
·  Altered deep tendon reflexes.1
·  Subjects receiving muscle relaxants.1
Material used:
·  Couch with pillow.
·  Assessment Performa
·  Measuring Tape
·  Pen and paper
7.3  Method of data collection:
·  Ethical Clearance-
As the study includes human subjects ethical clearance is obtained from ethical community of K.T.G college of Physiotherapy.
·  Subjects who meet the inclusion criteria will be assigned to two groups based on simple random sampling.
Group A : Hot moist pack and Muscle energy technique
Group B : Hot moist pack and Position release therapy
·  Pre interventions measurements such as pain using VAS, ROM and functional ability using MODQ will be measured.
Group A – In this group, subjects will be given Hot moist pack and Muscle energy technique.
Patients first will receive hot moist pack. The study participant was made to lie prone on the
couch comfortably. Hot moist pack was kept on the participant’s lumbar region for a period of
10 minutes.1
Muscle energy technique - After receiving hot moist pack therapy for 10 minutes, muscle energy
technique for erecter spinae was performed on the participant for 10 hold with 20 seconds
relaxation for 9 times i.e. total of 270 seconds in following way:
The participant sits with back to therapist on treatment couch, legs hanging over side and hands
clasped behind the neck. The therapist places knee on the couch close to the participant, at the
side towards which side bending and rotation will be introduced. The therapist passes a hand in
front of participant’s axilla on the side to which the participant is to be rotated, across the front
of participant’s neck, to rest on the shoulder opposite. The participant is drawn into flexion,
side bending and rotation over the therapist’s knee. The therapist’s free hand monitors the area
of tightness and ensures that the various forces localize at the point of maximum
contraction/tension. When the participant has been taken to a comfortable limit of flexion, is
asked to look towards the direction from which rotation has been made, whilst holding the
breath for 7 to 10 seconds, or to do this while also introducing a very slight degree of effort
towards rotating back to upright position, against firm resistance from the therapist. The patient
is then asked to release the breath, completely relax and to look towards the direction in which
side bending/ rotation is being introduced (i.e. towards the resistance barrier). The therapist waits
for the participant’s second full exhalation and then takes the participant further in all the
direction of restriction, towards new barrier, not through it.1.2.3
Group B – In this group, subjects will be given Hot moist pack and Position release therapy.
Patients first will receive hot moist pack. The study participant was made to lie prone on the
couch comfortably. Hot moist pack was kept on the participant’s lumbar region for a period of
10 minutes.
Position release therapy- After receiving hot moist pack therapy for 10 minutes, positional release therapy for erecter spinae for 90 seconds with 3 repetitions i.e. total of 270 seconds was given in following way. The participant is prone with trunk laterally flexed towards the tender side. The therapist stands on the side of the tender point. The therapist places his or her knee on the table and rests the participants affected leg on the therapist’s thigh. The participant’s hip is extended and adducted and slight rotation is used to fine tune.1,4,5