BANGALORE, KARNATAKA.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION1 / Name of the Candidate
and Address / AVISHEK KUMAR JHA
SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER,
PANDESHWARA,
MANGALORE-575001
2 /
Name of the Institute
/ SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, MANGALORE.3 /
Course of Study and
Subject / Master of Physiotherapy (MPT)2 years Degree Course.
“ Musculoskeletal and Sports”
4 /
Date of Admission
To Course / 19/03/20105 /
Title of the Topic
/ “EFFICACY OF STABILITY EXERCISES ON PRE-PROGRAMMED REACTIONS ANALYSED IN PATIENTS WITH CHRONIC LOW BACK PAIN”.6
7
8 /
Brief resume of the intended work:
6.1 Need for the study:Low back pain (LBP) is posterior trunk pain between the ribcage and the gluteal folds. Chronic LBP is defined as when a pain, and disability results restriction of the patients life activity more than 3 months. Recurrent LBP presented with an previous episodes of LBP from a similar location, with asymptomatic intervening intervals.¹
A common cause of chronicity in LBP is poor motor control of trunk muscles to varieties of postural challenges or perturbations.2 Recently a focus has been emphasized in literatures to train reflex latencies and incorporate into motor control training of trunk muscles.3 The postural and neuromuscular control responses differ between patients with LBP and healthy subjects during perturbation.4,5
During static tasks, such as standing, inconsistent levels of trunk muscle activation in CLBP populations have been found. Specifically, CLBP subjects have been reported to have increased, decreased and similar EMG amplitudes compared with controls.6
Short latency amplitude occurs before 40ms and voluntary response occurs after 120ms. A group of reactions to external stimuli (commonly to mechanical perturbations) that come at a latency longer than typical reflex latencies and shorter voluntary reaction time are called preprogrammed reactions (PPR). PPR come at an intermediate latency defined by both the travel time and the central processing time and can be scaled according to the magnitude of the perturbation, where as anticipatory responses occur prior to perturbations. PPR occur between short latency responses and voluntary muscles responses.7
It has been well documented in the literature that the PPR responses were found absent in patients with chronic Low back pain.8 It has also been well documented in the literature that the response latencies of trunk muscles are delayed in LBP patients.9
On other hand anticipatory postural responses (APA) are detected as the change in the activity of postural muscles approximately around 100ms before the posture is disturbed. APAs are reported defunct in CLBP patients.18,19 The LBP patients has significant increase in postural sway and are less likely to be able to balance on one leg with eyes closed.10
Set of local and global muscles have a role to play in controlling the stiffness and inter vertebral relationship of spinal segments and posture of the lumbar spine. Stability exercises will involve the training of local muscles with progression into phases. 11
Force plate and EMG are gold standard tools to measure PPR response and APA in LBP, and recruitment of muscle respectively.8,18
There exists, no study in literature reporting compound and differential effects of specific exercise intervention on Voluntary response, Preprogrammed reaction, Short latency amplitude and APA in patients with CLBP. Hence, this study will focus on the effect of specific exercise intervention on Voluntary response, Preprogrammed reactions, short latency amplitude and APAs in patients with CLBP.
6.2 Review of Literature
1.Ramprasad M et al. (2010) studied the magnitude of pre-programmed reaction dysfunction in back pain patients and concluded that Preprogrammed reaction responses were found absent in patients with CLBP. Further, patients with CLBP demonstrated lower Preprogrammed reaction amplitudes with higher peak voluntary responses compared to asymptomatic population, indicating difficulties in presetting of voluntary responses for regaining postural stability after perturbation.8
2.Ramprasad M et al. (2010) examined the differential effects of core stability exercise training and conventional physiotherapy regime on altered postural control parameters in patients with CLBP and concluded that there was significant improvements after intervention in ground reaction force in core stability exercise group.2
3.Arnaud Duperyon. et al. (2009) investigated the influence of back muscle fatigue on lumbar reflex adaptation during sudden external force perturbations in 10 healthy subjects. EMG reflex activity of erector spinae (ES) and external oblique muscle was recorded in expected and in unexpected (self pre-activation conditions). After fatigue the normalized reflex amplitude of ES increased in expected and unexpected condition (P0.05) of 25% in expected compared to unexpected condition. These findings suggest that a large external force perturbation would elicit higher paraspinal magnitude responses and possible earlier activation in order to compensate the loss of muscular force after fatigue.12
4. Jesse V. Jacobs et al (2009) investigated about the timing of anticipatory postural adjustments in people with chronic low back pain and concluded that people with chronic low back pain may be less capable of adapting their anticipatory postural adjustment to ensure postural stability during movement.19
5.Bazrgari B et al (2009) analyzed trunk response under sudden forward perturbations using a kinematics-driven model and Estimated large spinal loads highlight the risk of injury that likely further increases under larger perturbations, muscle fatigue and longer delays in activation.13
6.Tsao H, Hodges PW (2007) studied whether training involving voluntary muscle activity can change feedforward mechanisms, and whether this depends on the manner in which the muscle is trained and they reported that training isolated muscle activation leads to changes in feedforward postural strategies, also the magnitude of the effect is dependent on the type and quality of motor training.3
7.Lee CE et al (2007) studied the influence of pain distribution on vertical GRF of patients with low back problems during 2 walking speed conditions: preferred and fastest speeds and reported that pain distribution of people with low back problems differentially influences the vertical GRF they experience during walking.14
8. G. Lorimer Moseley et al (2004) examined the alteration of postural strategy observed in recurrent back pain patients and concluded that anticipation of experimental back pain evokes a protective postural strategy that stiffens the spine.18
9. Andrea et al (2001) studied whether patients with LBP will
exhibit poorer postural control which will be associated with longer average muscle response time and concluded that patients with CLBP demonstrated poorer postural control of lumbar spine and longer trunk muscle response time than healthy control volunteers.9
10. Ville Leinonen et al. (2001) studied reflex activation of paraspinal muscles during sudden upper limb loading and concluded that feedforward control of lumbar muscles in patients with sciatic was impaired.15
6.3 Objective of the study
To find out the effect of stability exercises on voluntary response, Preprogrammed reaction, short latency amplitude and APA in patients with CLBP.
6.4 Hypothesis:
Experimental hypothesis
There will be significant difference in the postural control responses after the stability exercises in subjects with LBP and non LBP.
Null hypothesis
There will not be any significant difference in the postural control responses after the stability exercises in subjects with LBP and non LBP.
Material and Methods:
7.1 Source of data:
Chronic low back pain patients between the age range of 18-60 years, who match the inclusion criteria will be selected in the study. Subjects will be taken from SCPTRC OPD, Srinivas General Hospital and Government wenlock hospital, Mangalore.
Sampling: Convenience sampling.
7.2 Method of collection of data:
Force plate variables of asymptomatic and CLBP patients on stable and unstable surface during expected and unexpected perturbation will be taken prior to and after exercise. The mean change in voluntary response window, PPR window, short latency window amplitude and APA window will be compared between the two groups, to find changes in LBP patients.
PROCEDURE8
SUBJECT POSITION: STANDING ON FORCEPLATE.
Electrode position:
1) For Rectus Abdominis, pair of recording electrodes will be placed on the right side of umbilicus and oriented parallel with the muscle fibres (30 mm lateral to the midline at the level of umbilicus).
2) For Erector Spinae pair of recording electrodes will be kept 3cm lateral to the midline on the right side on anywhere between L1, L2 and L3. The inter electrode distance will be kept at 2 cm.
TASK:
After the electrode positioning, the subjects will be put through the following tasks and forceplate activity will be measured.
All the subjects will be given perturbations by release of three kgs soft bedded dumbell on to the outstretched hand from a height of 3 inches unexpectedly and expectedly .The 3 kgs was standardized as the minimum amount of weight to bring about the perturbation.
PERTURBATIONS WILL BE GIVEN IN STABLE STANDING: i.e.
while standing on a forceplate.
1. STANDING- while standing the weight will be released without subject’s knowledge of when the weight will be released.
2. STANDING- while standing, the weight will be released with prior instruction of when the weight will be released i.e on third or fifth second count with digital stop watch. All the readings will be taken on unstable surface i.e. Foam surface with density (4 X 16).
All CLBP participants will be given stability exercises for at least 12 weeks based on their progress made in stability exercises.
EXERCISE PROTOCOL2,11,16,17 :
Stability exercises with progressive grading of phase I, phase II and phase III will be given to the participant according to their progression made in their levels. Phase I concentrate isolate local trunk muscle training (low tonic isometric co-contractions) and activation with more emphasize on breathing control. Phase II involves applying low loads to upper and lower extremities maintaining co-contraction of local trunk muscles. Phase III involves weight bearing, trunk loading and functional activitiy exercises. Considerable overlap between the phases will be introduced based on outcome and progression of the exercises by an individual patient.
Materials to be used:
ü Forceplate.
ü EMG and its accessories.
ü Soft bedded dumbel.
ü Soft foam .
ü Stop watch.
Inclusion Criteria
ü CLBP Patients with
1. Age: 18-60 years.
2. Pain history (with or without radiating not below buttocks) for last 3 months.
Exclusion criteria
ü Subjects with CNS impairment.
ü Fractures, Spondylolisthesis, PVD.
ü History of any lumbar, abdominal and limb surgery.
ü Patients hospitalized for issues related to spine.
Statistical analysis
Study design: Experimental parallel group study .TEST: 1. Independent t test .
2. ANOVA .
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 study intends to analyze the force plate responses in the subjects with chronic low back pain and asymptomatic control.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
Consent has been taken from the Institute ethical committee.
List of references.
1. George E. Ehrlich. Low back pain. Bulletin of the World Health Organization 2003;(81):671-676.
2. Ramprasad Muthukrishnan, Shweta D Shenoy, Sandhu S Jaspal, Shankara Nelikunja, and Swetlana Fernandes. The differential effects of core stabilization exercise regime and conventional physiotherapy regime on postural control parameters during perturbations in patients with movement and control impairment chronic low back pain. Journal of sports medicine, arthroscopy, rehabilitation, therapy and technology 2010; 2: 13
3. Tsao H, Hodges PW. Immediate changes in feedforward postural adjustments following voluntary motor training. Experimental Brain Research 2007;181(4):537-46.
4. Paul W. Hodges. Changes in motor planning of feedforward postural responses of the trunk muscles in low back pain. Experimental Brain Research 2001; 41:261–266.
5. Luoto Satu, Taimela Simo, Hurri Heikki, M,Aalto Heikki, Pyykkö Ilmari, Alaranta, Hannu . Psychomotor Speed and Postural Control in Chronic Low Back Pain Patients: A Controlled Follow-Up Study. Spine 1996;21(22):2621-2627.
6. Wim Dankaerts, Peter O’Sullivan, Angus Burnett, and Leon Straker. Altered Patterns of Superficial Trunk Muscle Activation During Sitting in Nonspecific Chronic Low Back Pain Patients.Spine 2006;31(17): 2017-2023.
7. Mark. L. Latash. Neurophysiological Basics of Movement; first edition: human kinetics:98-105.
8. Ramprasad M, Shenoy DS, Singh SJ, Sankara N, Joseley SR. The magnitude of pre-programmed reaction dysfunction in back pain patients: experimental pilot electromyography study. Journal of back musculoskeletal rehabilitation 2010; 23(2): 77-86.
9. Andrea Radebold, Jacek Cholewicki, Gert K. Polzhofer, and Hunter S. Greene. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. spine 2001; 26(7):724-730.
10.Nies N,Sinnott PL. Variations in balance and body sway in middle-aged adults. Subjects with healthy backs compared with subjects with low-back dysfunction. Spine 1991;16(3):325-30.
11.Richardson and Jull. Therapeutic Exercises for lumbopelvic stabilization In Low Back Pain:(1st edition): Churchill Livingstone: 1999.
12.Arnaud Dupeyron, Stephane Perrey, Jean-Paul Micallef, Jacques Pelissier. Influence of back muscle fatigue on lumbar reflex adaptation during sudden external force perturbations. Journal of electromyography and kinesiology 2009; 20(3): 426-432.
13.Bazrgari B, Shirazi-Adl A, LariviA f A re C. Trunk response analysis under sudden forward perturbations using a kinematics-driven model. Journal of Biomechanics 2009;42(9):1193-2000.
14.Lee CE, Simmonds MJ, Etnyre BR, Morris GS. Influence of pain distribution on gait characteristics in patients with low back pain: part 1: vertical ground reaction force. Spine 2007;32:1329-1336.15.Ville Leinonen, Markku Kankaapaa, Matti Luukkonen, Osmo Hanninen , Olavi Airaksinen and Simo Taimela. Disc Herniation-Related Back Pain Impairs Feed-Forward Control of Paraspinal Muscles. Spine 2001;26: 367-362.
16.P. B. O’ Sullivan. Lumbar segmental “ instability”: clinical presentation and specific stabilizing exercise management. Journal of manual therapy 2000; 5(1) 2-12.
17. Jari P. Arokoski, Taru Valta, Markku Kankaanpaa, Olavi Airaksinen. Activation of lumbar paraspinal and abdominal muscles during therapeutic exercises in chronic low back pain patients. Archives of physical medicine and rehabilitation 2005;85:823-832.
18.G. Lorimer Moseley, Michael K. Nicholas and Paul W. Hodges. Does anticipation of back pain predispose to back trouble? Brain 2004;127:2339-2347.
19. Jesse V. Jacobs, Sharon M. Henry and Keith J. Nagle. People With Chronic Low Back Pain Exhibit Decreased Variability in the Timing of Their Anticipatory Postural Adjustments. Journal of behavior neuroscience 2009;123(2):455-458.
9 /
Signature of the Candidate
/Avishek kumar Jha
10 /Remarks of the Guide
/Satisfactory
11 /Name & Designation of:
11.1 Guide11.2 Signature / DR. RAMPRASAD M.
Professor in Physiotherapy and Principal.
M.RAMPRASAD
11.3 Co-Guide (If Any)
11.4 Signature /
DR. PURUSOTHAM CHIPPALA
Assistant Professor in Physiotherapy.PURUSOTHAM CHIPPALA
11.5 Head of the Department
11.6 Signature
/DR. T.JOSELEY SUNDERRAJ PANDIAN
Associate Professor in Physiotherapy and P.G Coordinator.
JOSELEY SUNDERRAJ PANDIAN12 /
12.1 Remarks of Chairman and Principal
12.2 Signature /DR. RAMPRASAD M.
Professor in Physiotherapy and Principal.Accepted by scientific and ethical committee reviewers
M.RAMPRASAD.
1