Rajiv Gandhi University of Health Sciences
Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate andAddress / DIVYA.CHUNDURI
GARDEN CITY COLLEGE OF PHYSIOTHERAPY, 16th KM, OLD MADRAS ROAD,
VIRGONAGAR POST,
BANGALORE-49.
2. / Name of the Institution /
GARDEN CITY COLLEGE OF PHYSIOTHERAPY
3. / Course of study and subject / MASTER OF PHYSIOTHERAPY(MUSCULOSKELETAL AND SPORTS PHYSIOTHERAPY).
4. / Date of admission to course / 26-05-2010
5. / TITLE OF THE TOPIC:
A STUDY TO COMPARE THE EFFECTIVENESS OF MAITLAND’S THRUST MANIPULATION Vs NON-THRUST MANIPULATION IN MECHANICAL NECK PAIN.
6.
7.
8.
/ BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY
Pain is the most common symptom of which the human kind complaints. Pain from musculoskeletal system is very common internationally in modern sedentary society.1 Musculoskeletal pain constitutes mainly back pain, neck pain, shoulder pain, carpal tunnel syndrome, tenosynovitis etc in order of prevalence.2
Pain is defined as acute when its duration is less than 3 months and as chronic when it is more than 3 months.3 The sudden onset of neck pain that has lasted for a relatively short time, with or without injury, is referred to as acute mechanical neck pain. This is mainly by the abnormal mechanics of movement and dysfunction of variety of structures within the neck but specifically excludes systemic problems such as rheumatoid arthritis. It is usually associated with unspecified degenerative changes (cervical spondylosis) that include osteoarthritis.4
About 2/3rd of people will experience neck pain for some time in their lifetime. Prevalence rate is highest in middle age3 and women have more prevalence of neck pain than men.5Prevalence of neck pain varies widely between studies with a mean point prevalence of 7.6 %( range: 5.9-38.7%) and mean life time prevalence of 48.5 % (range: 14.2-7.0%).3
Neck pain is located between the occiput and 3rd thoracic vertebra.6 Neck pain usually resolves within days or weeks, but can recur or become chronic. The proportion of people in whom neck pain becomes chronic depends on the cause, but is thought to be about 10%. Neck pain causes severe disability in 5% of affected people.3
Pain in the neck region is often viewed as a simple clinical problem can rapidly develop into a complex disorder where physical, psychological, compensation, legal and societal forces all interact to cause disability.6With an increasing sedentary population, especially with reliance on computer technology in the work place, it is predicted that the prevalence rate of pain will continue to rise.7 Sitting at work more than 95% of the working time seems to be a risk factor for neck pain and there is a trend for a positive relation between neck flexion and neck pain.8
Conservative management for mechanical neck disorders (MND) like exercises and ergonomics demonstrated some intermediate and long term benefits. But optimal dosage of effective techniques and prognostic indicators for responders to care is not there.9Even with the management by electrotherapy modalities like ionotophoresis, transcutaneous electrical nerve stimulation, interferential therapy, pulsed electromagnetic field are lacking, limited or of conflicting evidence.10
Spinal manipulative therapy has evolved as an area of specialization within the field of physical therapy, providing management of pain in musculoskeletal disorders.11 It can be applied in the form of manipulation and mobilization.12 Manipulation is a high velocity, low amplitude (non-oscillatory) thrust performed by the therapist. Mobilization is an oscillatory non-thrust technique, which is performed slowly and passively.13 Muscle pain in chronic neck pain can contribute to the production of joint pain and motion abnormality in spinal segments.11 Evidence suggests that both the techniques improve range of motion and decreases pain intensity.12
There has not been much research in the application of manipulation and mobilization technique as well as neck ergonomics in treating the mechanical neck pain.
The purpose of this study is to compare the effectiveness of thrust manipulation
Vs non-thrust manipulation in mechanical neck pain.
6.2 REVIEW OF LITERATURE
1. Kanlayanaphotporn R, et al. (2010) conducted a study on the Immediate
effects of the central posteroanterior mobilization technique on pain and range of motion in patients with mechanical neck pain. They found that there has been a significant reduction in the pain after application of the technique in mechanical neck pain.14
2. Robert E. Boyles, et al. (2010) conducted a study on The Addition of Cervical Thrust Manipulations to a Manual Physical Therapy approach in patients treated for Mechanical Neck Pain. In this study, all patients received treatment up to 6 clinic sessions, twice weekly for 3 weeks. They found that meaningful and statistical improvements occur in both groups of manipulation and mobilization in short term as well as long term pain and in disability scores.15
3. Gross AR, et al. (2007) conducted a study on the Conservative management of neck disorders: a systematic review. They found that exercise combined with manipulation or mobilization, exercise alone demonstrated either intermediate or long term benefits.10
4. Hoving, Jan L, et al. (2006) conducted a study on the Manual therapy, physical therapy or continued care by the general practitioner for patients with neck pain: long term results from a pragmatic randomized clinical trial. They found that for short term results manual therapy showed best results than physical therapy and general practice.16
5. Martinez-SeguraR, et al. (2006) did a study on the Immediate effects on
neck pain and active range of motion after a single cervical high-velocity low-amplitude (HVLA) manipulation in subjects presenting with mechanical neck pain. They found that the manipulation is effective in reducing neck pain at rest, and in increasing active cervical range of motion.17
6. Ferna¡ndez-de-las-Peaasa, et al.(2005) did a study on the Immediate changes
in radiographically determined lateral flexion range of motion following a single
cervical HVLA manipulation in patients presenting with mechanical neck
pain.They demonstrated a trend toward an increase in inter-vertebral motion at the
hypo mobile segment, measured by functional radiography.18
7. Anita R, et al. (2004) did a study on the Cochrane review of manipulation and
mobilization for mechanical neck disorders. They found that mobilization and manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache.19
8. Birgitta Helmerson Ackelman, et al. (2002) conducted a study on the
reliability and validity of modified version of neck disability index (NDI). They found that NDI is a valid and reliable instrument for the measurement of disability due to neck pain.20
9. Alison M, et al. (2000) did a study on the changes in the chronic pain severity overtime: the von korff chronic pain grade is a valid measure. They found that von
korff chronic pain grade scale is a valid measure for measuring pain intensity.21
6.3 OBJECTIVE OF THE STUDY
1. To study the effectiveness of Maitland’s thrust manipulation and ergonomics in patients with mechanical neck pain.
2. To study the effectiveness of Maitland’s non-thrust manipulation and ergonomics in patients with mechanical neck pain.
3. To compare the effectiveness of Maitland’s thrust manipulation and ergonomics Vs non-thrust manipulation and ergonomics in patients with mechanical neck pain.
6.4 HYPOTHESIS
Null Hypothesis: There is no significant difference between Maitland’s thrust manipulation and ergonomics Vs non-thrust manipulation and ergonomics in patients with mechanical neck pain.
Alternate Hypothesis: There is significant difference between Maitland’s thrust manipulation and ergonomics Vs non-thrust manipulation and ergonomics in patients with mechanical neck pain.
MATERIALS AND METHODS:
7.1 SOURCE OF DATA
1. Patients referred to the physiotherapy department of Garden City College of physiotherapy, Bangalore.
7.2 METHOD OF COLLECTION OF DATA
30 subjects will be randomly assigned into two groups of 15 each by using simple random sampling method.
In case of any drop out during the study, subjects with same inclusion criteria will be selected.
STUDY DESIGN
Randomized clinical trial (experimental design).
SAMPLE SIZE
Thirty subjects.
SAMPLING TECHNIQUE
Simple random sampling method.
INCLUSION CRITERIA
1. Subject with diagnosis of mechanical neck pain.
2. Male and female subjects.
3. Age between 18 years to 60 years.
4. Subjects without radiating pain to shoulder.
5. Patients who are in chronic stage.
6. Subjects who are willing to participate in the study and willing to take treatment for 2 sessions in a week and for 3 consecutive weeks15.
EXCLUSION CRITERIA
1. Vertebro-basilar insufficiency.
2. Radiating pain with weakness, parasthesia, and decreased deep tendon reflexes in upper limb.
3. Any surgery around neck.
4. Severe disability.
5. Ankylosing spondylitis.
6. Any structural deformity of spine.
7. Any history of recent trauma around neck.
8. Presence of osteophytes in cervical spine.
7.3 ASSESSMENT TO BE DONE
METHODOLOGY:
30 subjects in the age group of 18 years to 60 years (both male & female) with mechanical neck pain will be selected. The samples will be randomly divided into two groups i.e., Group-A (n=15): experimental group, Group-B (n=15): experimental group.
Subjects in Group-A will be given Maitland’s cervical (C2-7) transverse thrust manipulation which is of high velocity and low amplitude. Patient will be in sitting position. Small oscillatory thrusting movements are employed by the physiotherapist through her right hand to ensure that the right degree of slack has been taken up. These small amplitude thrusting movements are countered by tiny tipping movements of the patient’s head, which is held in her left arm. A small-amplitude manipulative thrust with the body transmitted through the right hand directed towards the left and cauded effects the technique. The duration of the treatment will be 90 seconds or 45-60 repetitions.
Subjects in Group-B will receive Maitland’s postero-anterior central
vertebral mobilization. The patient will be placed in prone position and the
physiotherapist stands at the head of the patient with her thumbs held in opposition and
back to back, with the tips of the thumb pads on the spinous process of the vertebra to
be mobilized. The fingers straddle the sides of the patient’s neck and head. Extremely
gentle pressure must be applied which will produce a feeling of movement. The
alternating pressure should be applied by the arm combined with trunk. If the patient
has considerable pain, the palmar surfaces of the pads of the fingers can be used. the
duration of the treatment will be 30 seconds or 15-20 repetitions.
The patients of both the groups are advised with neck ergonomics,
precautions to be taken at the home and at the work place. Patients are asked to come
for the treatment for 2 days in a week and for 3 consecutive weeks.15
The outcome measures will be severity of pain measured by Questionnaire
of Von Korff, level of disability by modified version of Neck disability index and
range of motion of cervical spine (flexion and extension) by goniometer will be
calculated for pretest and after every 1 week.
DURATION
The duration of the study will be approximately 6 months.
STATISTICAL TOOL
The data will be analyzed by using analysis of variance (ANOVA).
7.4 ETHICAL CLEARENCE
Ethical clearance for the study has been obtained from the ethical committee of our
Institution.
LIST OF REFRENCES:
1. Editorial, issues with chronic musculoskeletal pain. Rheumatology 2005; 44:831-833.
2. Andersson I, Goran Ejlertsson, Leden and Claes Rosenberg. Chronic pain in a geographically defined population; studies of differences in age, gender, social class and pain localization. The clinical journal of pain 1993; 9:174-182.
3. Allan binder. Clinical evidence; musculoskeletal disorders; neck pain. British medical journal (BMJ) 2008; 0:1103.
4. Peter white, George lewith, Phil Prescott, joy Conway. Acupuncture versus placebo for the treatment of chronic mechanical neck pain; a randomized clinical trial. Annals of internal medicine 2004; 141:911-919.
5. Fejer R, kvvik KO, hartvigsen J. The prevalence of neck pain in world’s population; a systematic critical review of the literature. European spine journal.2006; 15(6):834-848.
6. Cote Pierre, J. David Cassidy and Linda carol. The epidemiology of neck pain; what we have learned from our population based studies. Journal of Canadian chiropractic association 2003; 47(4):284-290.
7. D.falla. Unraveling the complexity of muscle impairment in chronic neck pain. Manual therapy 2004; 9:125-133.
8. Ariens G A M, Bongers P M, M Douwes, M C Midema, W E Hoogendoorn,G Vander Wal, L M Bouter and Mechelen. Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occupational environment medicine 2001; 58:200-207.
9. Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P, Santaguida P, Myres C; Cervical overview group. Conservative management for mechanical neck disorders: a systematic review. J rheumatol, 2007; 34(5):1083-1092.
10. Kroeling P, Gross A, Houghton PE; cervical overview group. Electrotherapy for mechanical neck disorders. Cochrane database syst.rev.2005; 18(2):251.
11. Jull G. Management of cervicogenic headache. Manual therapy 1997; 2(4):182-190.
12. Causidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: A randomized clinical trial. J Manipulative physiol ther.1992; 15(9): 570-575.
13. Geoffrey D Maitland. Maitland’s vertebral manipulation.7th edition, 2005; 3-5.
14. Kanlayanaphotporn R, Chiradejnant A, Vachalathiti R. Immediate effects of the central posteroanterior mobilization technique on pain and range of motion in patients with mechanical neck pain. Disabil rehabil.2010; 32(8):622-8.
15. Boyles RE, Walker MJ, Young BA, Strunce J, Wainner RS. The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: a secondary analysis.J Orthop sports phys ther.2010; 40(3):133-40.
16. Hoving, Jan L, de vet, Henrica C.W.; Koes, Bart W.; Mameran, Henk van; Deville, Walter L.J.M.; Vander Windt, Danielle A.W.M.; Willem J.J.; Pool, Jan J.M.; Scholten, Rob J.P.M.; Korthals-deBos,Ingeborg B.C.;B outer, Lex M. Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized clinical trial. Clinical journal of pain. 2006; 22(4):370-77