DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By

CRISSY D’ ALMEIDA

UNDER THE GUIDANCE OF

B A BOOMADEVI

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006

2009-11

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the Candidate
and Address / CRISSY D’ALMEIDA
VIKAS COLLEGE OF PHYSIOTHERAPY
AIRPORT ROAD
MARYHILL, KONCHADY
MANGALORE – 575008
2. / Name of the Institution / VIKAS COLLEGE OF PHYSIOTHERAPY
Mangalore.
3. / Course of study and subject / Master of Physiotherapy (MPT)
Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy
4. / Date of admission to Course / 19-06-2009
5. / Title of the Topic
THE EFFECTS OF TRANVERSUS ABDOMINIS, GLUTEUS AND BICEPS FEMORIS MUSCLE STRENGTHENING IN GOLFERS WITH SACROILIAC DYSFUNCTION
6. / BRIEF RESUME OF THE INTENDED WORK
6.1 Need for the study
Sacroiliac pain is a specific form of low back pain reported in approximately 40 percent patients which can occur separately or in conjunction with low back pain, lumbar disc herniation and lumbar facet syndrome. This occurs because the low back and pelvis rely on many common structures to ensure normal stability and function. Hence functionally the pelvis cannot be studied in isolation. Diagnosis of sacroiliac pain is difficult because the presenting complaints are similar to those of other causes of back pain.
The typical anatomy of the sacroiliac joint which is characterized by a coarse cartilage texture, cartilage covered grooves and ridges, a wedge like shape of the sacrum and a propeller like shape of the joint surface leads to the highest co-efficient of friction of diarthrodial human joints. This friction can be altered according to the loading situation and serves to stabilize the pelvic girdle. The main movements are forward rotation of the sacrum relative to the iliac bones and backward rotation of the sacrum relative to the ilia. Nutation of the sacrum (flexion of the sacrum relative to the ilia) is generally the result of load bearing and a functional adaptation to stabilize the pelvic girdle. More research is needed in patients with sacroiliac pain to verify whether counter nutation of the sacroiliac joint (anterior rotation of the ilia relative to the sacrum) in load bearing situation is a typical sign of non optimal stability of the pelvic girdle.
One study on the relationship between lumbar curve, pelvic tilts, and joint mobility reported a high correlation between the angle of lumbar lordosis and pelvic tilt. Subjects who have reported low back pain have also shown an increase in lumbar lordosis.5 A study by Simpson examined subjects with and without low back pain and found that there is a significant difference in lumbar lordosis between the two groups, thus implying that pelvic positioning plays a role in low back pain.6 We can conclude that the positioning of the pelvis is correlated with back pain. Pelvic tilt and lumbar stabilization exercises are frequently prescribed to patients to relieve low back pain.7 Focusing attention on abdominal muscles may not be the most efficient or effective way in training patients to normalize lumbopelvic alignment. Studies measuring the relationship between pelvic tilt and abdominal muscle performance have shown that there is no correlation between the two. This study hypothesizes that there are other muscles that are attached to the pelvis that affect the motion, stability, and position of the pelvis, or that neuromotor patterns determine posture.
Multiple studies have examined the benefits of exercise in treating patients with low back pain; however, there have been very few published reports describing specific program designs as it relates to golfers. Golf injuries to the low back are the most common problems in both the professional and amateur player. It is the poor technique and the repetition of hitting balls that usually leads to an injury. Combine that with the typical sedentary lifestyle (in which people drive to/from work in a seated position and work in a seated position for most of the day) and we begin to understand why there is such a high incidence of back pain among golfers. A back injury results from excessive stress placed on the spine, usually when the body does not perform the correct sequence during the golf swing. Here is an astonishing fact: Eight times your body weight is forced through your spine as you make contact with the ball. So if you have poor mechanics combined with a weak back you are more likely to cause yourself a significant amount of injury. The golf swing is considered a very unnatural movement for most people, especially for people with a sedentary lifestyle. As with most sports, golf is a sport that requires a lot of rotary movement. When we sit for the most part of the day, certain muscles get used to that position and become “tight”, while other muscles get “stretched out”. This leads to significant muscle imbalances that then put unnecessary stress on the back. In all likelihood, their golf muscles have “shut down” due to sitting for long periods. Effectively, the muscles that absorb force and reduce load in a golf swing (that is, the lower and deep abdominals) are relatively weak and aren't able to work together. And if your hips and shoulders are tight, there is a greater chance of moving incorrectly.
In an idealized pelvic alignment the anterior superior iliac spines (ASIS) are in a horizontal plane with the posterior superior iliac spines (PSIS) and on a vertical plane with the pubic symphysis. The most common deviation seen in golfers is excessive anterior tilt of the pelvis (PSIS significantly higher than the ASIS). A study by Levine and whittle showed that excessive anterior tilt caused increased lumbar lordosis. The common short/tight muscles in this mal-alignment are psoas major, quadratus lumborum and hip adductors. The common long/inhibited muscles are gluteus maximus, hamstrings, tranversus andominus and internal obliques.
There has been research regarding the pelvis and its relationship to the lumbar spine. An excessive anterior tilt of the pelvis causes compression of the posterior vertebral bodies, which increases the posterior interdiscal pressure; especially at L5-S1. It also creates shearing forces at L5-S1 and a likelihood of forward slippage of L5 on S1. When the pelvis tilts forward, the lumbar vertebrae are displaced anteriorly, thereby increasing lumbar lordosis. Increases in the compressive forces of the posterior annuli and the tensile forces on the anterior annuli in the lumbar spine adversely affect the diffusion of nutrients to the posterior portion of the lumbar intervertebral disks and excessive compression may be applied to the zygapophyseal joints. To compensate for the increased anterior lumbar convexity, there is an increase in thoracic kyphosie and an anterior convexity of the cervical spine to bring the head over the sacrum.
Research has shown that the pelvis can play a role in low back pain due to its influence on the lumbar spinal curvature. The position of the pelvis has also been shown to play a role in sacroiliac pain. Since the hamstrings attach to the ischial tuberosities, they play an important role in extrinsic pelvic stability and the lumbopelvic rhythm. The hamstrings can also play an important role in stability of the sacroiliac joint due to the common attachment sites of both the hamstrings and the sacrotuberous ligament on the ischial tuberosities. The long head of the biceps femoris frequently attaches to the sacrotuberous ligament through a tendon. Force of the biceps femoris can be transferred to the sacrotuberpus ligament. Since increased tension of the sacrotuberous ligament decreases sacroiliac joint range of motion, contraction of the biceps femoris can play a role in stabilization of the sacroiliacjoint.
Specific spinal exercises were developed to target the local muscles of the lumbar–pelvic region. The local muscle system includes deep muscles such as the transverses abdominis and the lumbar multifidus that are attached to the lumbar vertebrae and sacrum and are capable of directly controlling the lumbar segments. By contrast, the global muscle system encompasses the larger and more superficial muscles of the trunk that are more concernedwith producing and controlling trunk movements (e.g., the external oblique and erector spinae muscles). Whereas conventional exercises generally work to increase the strength of the global muscles, the specific exercise approach aims to improve the dynamic stability role of the local muscles in providing stiffness to the segments of the spine and pelvis during functional postures and movements. The concept that has become the basis of the specific exercise treatment techniques is the ability to cocontract the transversus abdominis and the lumbar multifidus independently of the other larger trunk muscles. This exercise is based on evidence of the stability roles of the muscles as well as on evidence that the transverses abdominis functions independently of the other global abdominal muscles. The active co-contraction of these muscles is completed at a very low level of muscle activity and has been variously described as forming a deep muscle corset or performing self bracing. Progression of treatment has consisted, in principle, of increasing the patient’s efficiency at performing this independent deep corset action while at the same time minimizing the contribution of the global trunk muscles. These new specific spinal exercises have already been shown to be effective for patients with acute idiopathic LBP. The influence of this exercise approach on muscle size and function as well as on recurrence of symptoms has been investigated.7,8 Individuals in the intervention group performed gentle coactivation of the multifidus and transversus abdominis muscles with real-time ultrasound imaging as feedback. There were significantly fewer recurrences in the intervention group than in the control group.9,19 In addition, the specific exercises are effective in the
treatment of patients with LBP associated with a specific diagnosis. O’Sullivan et al1 have demonstrated decreased pain and disability in patients with chronic LBP
who have a radiologically confirmed diagnosis of spondylolysis or spondylolisthesis. The exercises are also proving beneficial in LBP conditions arising from the pelvic region. The specific co-contraction of the transversus abdominis and the multifidus is recommended on the basis of a biomechanical model of the stability of the lumbosacral region.
6.2 Review of Literature
1. Casey Moeller et al in an electromyographical study of the muscle activity during a posterior pelvic tilt concluded that the hamstrings (lateral hamstrings) are active during a static posterior pelvic tilt in the standing position, as well as the external abdominal oblique and the gluteus maximus. These muscles may be the most active due to the mechanical advantage they have on the pelvis. Since the hamstrings attach to the pelvis via the ischial tuberosity, they are capable of pulling the posterior half of the pelvis inferiorly, producing a posterior pelvic tilt during muscle contraction when the femur is fixed. The external abdominal oblique attaches to the anterior half of the iliac crest, which provides a lever arm for the muscle to pull the ASIS superiorly, producing a posterior pelvic tilt. The gluteus maximus’s major function is to extend the thigh, and like the hamstrings, when the femur is fixed the gluteus maximus is capable of pulling the posterior half of the pelvis inferiorly and producing a posterior pelvic tilt.
2. M.Hossain and L.D.M.Nokes proposed that sacroiliac joint dysfunction can result from malrecruitment of gluteus maximus motor units during weight bearing. This results in compensatory biceps over activation. The resulting soft tissue strain and joint instability may manifest itself in low back pain.
3. Hungerford et al. (2003) showed altered firing patterns of these muscles in SIJ patients. Higher tension of the hamstrings will force the pelvis as a unit to rotate backwards, leading to a flattening of the lumbar spine.
4. Van Wingerden et al. (2004) studied several muscles which could contribute to compression of the pelvic joints and influence the stiffness characteristics. SIJ stiffness was measured using DIV in six healthy women. SIJ stiffness was measured both in a relaxed situation and during EMG recorded isometric voluntary contractions. The biceps femoris, gluteus maximus, erector spinae, and contralateral latissimus dorsi were included in this study whereas the deeper lying muscles were not included. Pelvic stiffness significantly increased after activation of the erector spinae, the biceps femoris and the gluteus maximus muscles. Based on these data it is concluded that optimal function of the pelvic girdle during leg loading is based on tailored force closure/compression of the SIJ due to activation of multiple muscle slings. The study concludes that SIJ stiffness increased even with slight muscle activity, supporting the notion that effective load transfer from spine to legs is possible when muscle forces actively compress the SIJ preventing shear.
5. Vleeming et al. [31] defined the posterior layer of the thoracolumbar fascia as a mechanism of load transfer from the contralateral gluteus maximus (Fig. 3). This load transfer is critical during rotation of the trunk, helping to stabilize the lower lumbar spine and pelvis. This was demonstrated through cadaveric and electromyelographic (EMG) studies [32]. The stretched tissue of the posterior thoracolumbar fascia assists the muscles by generating an extensor influence, and by storing elastic energy during lifting to improve muscular efficiency.
6. Sullivan et al. looked at the effect of different positions of the pelvis while stretching the hamstrings. The results showed that if the pelvis was placed in an anterior tilt, it permitted increased hamstring elongation and this was significantly influential on the flexibility of the hamstrings during stretching exercises.13 They found that the anterior pelvic tilt position was significantly more effective in increasing hamstring muscle length than the posterior pelvic tilt position. Also, there was no significant effect of the stretching method or interaction of pelvic positions and stretching techniques.13 There appears to be a strong relationship between the hamstring muscle group and pelvic positioning.
7. Hodges and Richardson from an experimental model concluded, individuals with a history of low back pain show a delay in contraction of the transversus abdominis muscle during a trunk disturbance leading to an inappropriate stabilization pattern which causes recurrences. Spinal segmental stabilization exercises were developed (Richardson and Jull) with the aim of correcting the transversus abdominis contraction delay and also to recover the activation of lumbar multifidus muscle. This motor control approach focuses on an isolated cocontraction of such muscles while keeping the lumbar spine in