The Effect of Back Extension Exercise On

SYNOPSIS

“THE EFFECT OF BACK EXTENSION EXERCISE ON

H REFLEX IN PATIENTS WITH LUMBOSACRAL RADICULOPATHY”

SPECIALITY;

PHYSIOTHERAPY IN MUSCULOSKELETAL SCIENCE

BATCH: 2010-2011

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

Annexure ll

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of the candidates & address / NIMISHA K. PATEL
B/17 sunder van soc.,
Opp. Novino battery,
Near. New era school,
Makarpura road,
Baroda -10
2 / Name of institute / K.T.G COLLAGE OF PHYSIOTHERAPY
Hegganahalli cross,sunkadakatte
Post: viswaneedam
Banglore 560091
3 / Course of study & subject / MASTER IN PHYSIOTHERAPY
(musculoskeletal disorders and sports physiotherapy)
4 / Date of admission to the courses / 14th oct 2010
5 / Title of the topic :
“THE EFFECT OF REPETATIVE EXTENSION EXERCISE ON
H REFLEX IN PATIENTS WITH LUMBOSACRAL
RADICULOPATHY”
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12 / BRIEF RESUME OF INTENDED WORK:
6.1 NEED OF THE STUDY
Low back pain (LBP) is the most common musculo-skeletal disorder causing huge humanitarian and economical costs.1 The chronic LBP is a multidimensional problem including pain and functional disability with its associated socioeconomical consequences. There is increasing evidence that the impaired functions can recover with treatment and be restored by active rehabilitation.2
Pain radiates into the lower extremity (the thigh, calf, and may spread to the foot) directly along the course of a specific spinal nerve root. The most common symptom of Radicular pain is sciatica.3 Most of the chronic low back pain is due to lumber disc herniation. It is seen at L4- L5 and L5- S1 levels with a rate as high as 98%. It frequently develops in the weakest part of the disc which is the posterolateral side. LSR(lumbosacral radiculopathy) occurs as a result of disc herniation or acute injury in younger population and as a result of foraminal narrowing from osteophyte formation in older population. It may also result from spinal cord injuries, spinal stenosis, spinal diseases and other conditions.4,5.
Back extension exercise was commonly used in the treatment of low back pain. Many studies found extension of lumbar spine decreased pain more than flexion Centralization phenomenon (CP), first noticed by Robin McKenzie, has been considered as a good prognostic index in recent studies . McKenzie method utilizes back extension exercise for the management of LSR. As this is subjective, a need for a more objective method for evaluating the efficacy of the McKenzie back extension exercises has been a concern for researchers6,7.
Neurophysiological testing, in particular H-reflex described by Hoffman, has been used recently to assess the neurophysiological changes in the compromised nerve root and to evaluate the efficacy of some of non-surgical managements on patients with radiculopathy8. H-reflex has two parameters, amplitude and latency. The amplitude is used to monitor spinal activity whereas, latency usually assess the sensory and motor conductivity. The H-reflex has also been used to determine the position9.
Therefore this study will designe to use the H-reflex to evaluate the effect of the commonly practiced worldwide McKenzie back extension exercises on patients with chronic unilateral lumbosacral radiculopathy.
Hypothesis
Alternate hypothesis:
“There will be significant difference effect of Back extension exercise on H- reflex in patients with lumbosacral radiculopathy. ”
Null hypothesis:
“There will not be significant difference effect of Back extension exercise on H- reflex in patients with lumbosacral radiculopathy.”
6.2 REVIEW OF LITERATURE
Bybee F. et al. (2009) did a study on 42 patients with back pain were classified as centralised (30), centralising (3), non-centralised (9); there were significant differences between initial and final extension range in first 2 groups, but not in the latter. Patients who showed centralisation on initial visit also showed an increase of ROM during initial visit.9
Murphy DR. et al. (2009) Report on consecutive cohort study of patients with lumbar radiculopathy of who 62% demonstrated centralisation with repeated movements, and 8% peripheralisation. Centralisation was associated with functional improvement, especially at long-term follow-up.10
Balaji Ghugare et al. (2009) Current study was undertaken on 50 controls and 50 CLBP patients without clinical neurological deficit to evaluate the potential of nerve conduction studies, particularly H-reflex study for diagnosis of radiculopathy in these cases. concluded that subclinical cases might not have only partial conduction block but also secondary axonal loss due to compression of nerve roots. We further suggest inclusion of Soleus H-reflex study in evaluation of radiculopathy among early CLBP cases without clinical neurodeficit. 11
Werneke M. et al. (2008) Report of over 350 spine patients; 76% lumbar, 53% chronic symptoms (> 3 months), mean age 58 years. Overall rate of centralization at intake as measured on a body chart template was 17%, with higher rates in more acute and younger patients. For instance rates were 29% and 24% for acute (< 3 weeks) lumbar and cervical patients, and 32% and 30% for lumbar and cervical patients aged between 18 and 44. Centralization was much less common in those with chronic symptoms and those over 64 for lumbar problems and over 44 for those with cervical problems. Outcomes were better amongst centralizers and outcomes were worse amongst non-centralizers.12
Broetz D. et al. (2008) did a study on11 patients with MRI confirmed disc prolapse with over half having weakness and sensory loss were treated with repeated end-range movements and re-evaluated after 5 treatment sessions. 13
Matej Makovec et al. (2006) conducted a study to determine the changes in the tibial H reflex and spinal nerve root potentials (SRPs) of the S1 root during posterior discectomy and the effects of surgical manipulation. Unremarkable variations in H wave latency may be followed by increased SRP desynchronization. Monitoring of the epidurally recorded SRPs seems to be more sensitive to surgical manipulations of the spinal nerve root than the tibial H reflex recordings from the soleus muscle.14
Machado LAC. et al. (2006) Did a study on Systematic review that included 11 trials and concluded that there is some evidence that the McKenzie method is more effective than passive therapies for acute back pain, but the size of treatment effect is unlikely to be clinically worthwhile. There is limited evidence for the McKenzie method in chronic back pain and overall effectiveness is not established.6
Cook C. et al. (2005) This review uniquely only includes exercise trials for back pain in which patients were classified into exclusive, patient response groups based on physical examination findings.7
Clare HA. et al. (2004) conducted a study on Systematic review of 5 trials deemed to be truly evaluating McKenzie method with pooled data showing greater pain relief (8.6 on a 100 scale) and greater reduction in disability (5.4 on 100 scale) than comparison at short-term (less than 3 months). At 3 to 12 months results were unclear.15
Hahne AJ. et al. (2004) Record of pain intensity and range of movement was taken before and after treatment session and at the beginning of next session in 53 back pain patients. Those who improved in first session significantly more likely to return with further improvements compared to those showing no within-session changes. 67% to 88% (depending on measure) could be correctly classified as improvers / non-improvers at second session by their within-session response to treatment.16
Petersen T. et al. (2004) This classification system for LBP takes the mechanical syndromes of Mechanical Diagnosis and Therapy and adds in a few other categories, such as spinal stenosis, zygapophyseal or sacro-iliac joint pain. A lot of the literature used to demonstrate the validity and reliability of the system relates to studies of the McKenzie approach.17
Rathore S (2003) Case study of patient with cervical radicular pain, demonstrating centralisation in response to retraction and extension, categorised as derangement and treated with retraction and extension exercises.18
Young S. et al. (2003) Centralisation, midline pain, and pain on rising from sitting were significantly associated with a positive discogram. Sacro-iliac joint pain was strongly associated with 3 or more positive pain provocation tests, pain on rising from sitting, unilateral pain and absence of 17 mid-line or lumbar pain. Zygapophyseal pain was associated with absence of pain on rising from sitting.19
Kjellman G. et al. (2002) Trend towards greater improvements in McKenzie group compared to controls at certain times. Significant improvements in DRAM scores in McKenzie group only. 20
Riccardo Mazzocchio et al. (2001) The study of the recruitment curve of the soleus H-reflex may be usefully associated to F-wave and needle EMG studies to detect possible S1 root dysfunction in mild lumbosacral radiculopathies. An increase in H-threshold may be the earliest abnormality in the absence of focal neurological signs.21
Ali. A., Sabbahi M. A (2000) They studied the H reflex changes under spinal loading and unloading condition in normal subjects and concluded that there is a significant interplay between peripheral and central mechanisms and their effects on the spinal motoneurons. This in turn suggests that testing of the H-reflex amplitude and latency under functional conditions, such as standing may be useful in detecting subtle changes in root impingement.22
Abdulwahab SS et al. (2000) In a group of patients with neck and radicular pain a posture of sustained flexion caused a significant increase in peripheral pain and root compression as measured by H reflex amplitude. Repeated retractions caused a significant decrease in peripheral pain and decrease of nerve root compression.23
Delaney et al. (1999) Re-analysis of Donelson calculating accuracy of McKenzie assessment in diagnosis. Sensitivity and specificity for discogenic pain 94% and 82%; for incompetent annulus 100% and 86%. Compares favourably with most other establisshed tests.24
6.3 OBJECTIVE OF STUDY
1) To determine the effect of repeated back extension exercise (RBEE) on H-reflex in patients with lumbosacral radiculopathy.
2) To determine the effect of repeated back extension exercise (RBEE) on pain intensity and functional ability.
3) To determine the relationship between H-reflex, pain intensity and functional ability in patients with lumbosacral radiculopathy.
7.1 Sources of data:
Study will be conducted at K.C.General Hospital, K.T.G Hospital, Bangalore.
7.2 Methods of collection of data
Study design:
Cross sectional Study design
Sampling size & Technique:
Convenient Sampling Method.
Study will be done on 30 subjects who will fulfill the inclusion and exclusion criteria in general population.
Materials used:
- Electromyography machine (RMS EMG EPMK-2)
- Electrodes
a. Surface
b. Bar
- Conducting gel
- Adhesive tape
- Kidney tray
- Pillow
- Scissors
Inclusion Criteria:
- Age group:30- 50 years
- Patient with chronic unilateral lumbosacral radiculopathy (more than 3 months duration)
- Gender : Both females and males
- Willingness to Participate
Exclusion Criteria:
- Subjects with lumbosacral Surgery.
- Subjects with scoliosis and stenosis.
- Subjects with cancer and cardiac problem.
- Subjects with peripheral neuropathy.
Evaluation Tools:
-Sit to stand test:
Outcome measures:
Sit to stand functional test, pain intensity and soleus H-reflex will measured subsequently before RBEE from prone position.
The soleus H reflex stimulation and recording electrodes will adjusted and fitted immediately after sit-to-stand testing.
7.3 Intervention to be carried on participants (Methodology)
Sit to stand functional test, pain intensity and soleus H-reflex will measured subsequently before RBEE from prone position. The soleus H reflex stimulation and recording electrodes will adjusted and fitted immediately after sit-to-stand testing. After 30 repetitions of back extension exercise, the previous outcome measures will again assessed, starting with pain intensity, H-reflex parameters and then sit-to-stand test to avoid any displacement of the H-reflex recording and stimulating electrodes. The non-involved leg will be used as control for H-reflex parameters.
H-Reflex Stimulation:
Patient position: - Prone lying with upper extremities positioned symmetrically at side. The distal part of the legs placed on a comfortable pillow with feet suspended over the edge of the table. An electrical stimulation surface bar electrode placed with coupling gel on the poplitial fossa of both legs with the cathode electrode proximal to the anode electrode and in line with the posterior tibial nerve. A recording surface bar electrode will positioned over the soleus muscle 3 cm below the bifurcation of the gastrocnemius tendon; the cathode electrode placed proximal to anode with a fixed distance.
A ground surface metal electrodes positioned midway between the stimulation and recording electrodes. Electrodes will firmly secured with adhesive tape to maximize skin electrode contact. The used stimulation parameters will 1.0 ms pulse duration and intensity that elicited H-maximum with minimum and stable M-response. Four readings of the maximum H-reflex and stable minimum M-response with constant intensity will be recorded and averaged from each leg. H-reflex recording will measured first from left leg followed by right leg. The signals will amplified 500-2000 using differential amplification and will be filtered at 20-10,000 Hz bandwidth, digitized, stored on computer and printed for analysis.
Repeated Back Extension Exercise:
Three sets of ten repetitions will be performed in prone position with 1 min rest between the sets. The patient will asked to reach the maximum extension possible in all attempts and maintain for one second as described by McKenzie.
7.4 Statistical analysis:
Data analysis will performed using a paired and Unpaired t test to analyze the data of the study with p<0.05. Pearson correlation coefficient will use to determine the relationship between the recorded variables.
7.5 Ethical clearance:
As the study includes human subjects ethical clearance is obtained from committee of institution and institution where the subject belongs. Also a written consent will be taken from each subject who participates in the study .
List Of References:
1.Andersson, G.B. Epidemiological features of chronic low-back pain. Lancet 1999; 354:581-585.
2. Ebenbichler, G.R., Oddsson, L.I., Kollmitzer, J. and Erim, Z. Sensory-motor control of the lower back: implications for rehabilitation. Medicine and Science in Sports and Exercise 2001; 33, 1889-1898.
3. McCombe PF, Fairbank JCT, Cockersole BC. Reproducibility of physical signs in low back pain. Spine 1989; 14:908-918.
4. Valezquez-Perez L, Sanchez-cruz G, Perez-Gonzalez RM. Neurophysiological diagnosis of lumbosacral radiculopathy compression syndrome from late responsce. Rev Neurol 2002; 34(9):819-823.
5. Abdulwahab S, Sabbahi M. Neck retraction, cervical root decompression, and radiculopathy. J Ortho Sports Phys Ther.2000; 30(1):4-9.
6. Machado LAC, de Souza MvS, Ferreira PH, Ferreira ML; The McKenzie Method for low back pain. A systematic review of the literature with a meta-analysis approach. Spine 2006; 31:54-6
7. Cook C, Hegedus EJ, Ramey K ; Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature. J Man & Manip Ther 2005; 13:152-162.
8. Sabbahi M. Fixing lumbosacral radiculopathy with postural modification: a new method for evaluation and treatment based on electrodiagnostic testing. J Neurol Orthop Med Surg. 1997; 17:176-181.
9. Bybee F, Olsen D, Cantu-Boncser G, Condie Allen H, and Byars A; Centralization of symptoms and lumbar range of motion in patients with low back pain. Physio Theory Pract 2009; 25:257-267.
10. Murphy DR, Hurwitz EL, McGovern EE.; A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: a prospective observational cohort study with follow-up. J Manip Physiol Thera 2009; 32:723-733.
11. Balaji Ghugare, Piyalidas, Jayshri Ghate, Kisan Patond, Manisha Koranne and Ramji Singh; Assessment of Nerve conduction in evaluation of Radiculopathy among Chronic Low back pain patients without clinical neurodeficit. Indian J Physiol Pharmacol 2009; 54(1):63-68.
12. Werneke M, Hart DL, Resnik L, Stratford PW, Reyes A; Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports PhysTher 2008; 38:116-125.
13. Broetz D, Hahn U, Maschke E, Wick W, Kueker W, Weller M; Lumbar disc prolapse: response to mechanical physiotherapy in the absence of changes in magnetic resonance imaging. Report of 11 cases. NeuroRehab 2008; 23:289-294.
14. Matej Makovec, Mitja Benedičič, and Roman Bošnjak; H Wave and Spinal Root Potentials in Neuromonitoring of S1 Root Function during Evacuation of Herniated Disc: Preliminary Results. Croat Med J.2006; 47(2): 298–304.
15. Clare HA, Adams R, Maher CG; A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother 2004; 50(4):209-1
16. Hahne AJ, Keating JL, Wilson SC; Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain? Aust J Physiother 2004; 50:17-23.
17. Petersen T, Laslett M, Thorsen H, Manniche C, Ekdahl C, Jacobsen S ; Diagnostic classification of non-specific low back pain. A new system integrating patho-anatomic and clinical categories. Phys Ther Prac 2004; 19:213-237.
18. Rathore S; Use of McKenzie cervical protocol in the treatment of radicular neck pain in a machine operator. J Can Chiropr Assoc 2003; 47:291-297.
19. Young S, Aprill C, Laslett M; Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine 2003; 3.460-465.
20. Kjellman G, Oberg B:; A randomised clinical trial comparing general exercise, McKenzie treatment and a control group in patients with neck pain. J Rehabil Med 2002; 34:183-190.
21. Riccardo Mazzocchio, Giovanni Battista Scarfò, Aldo Mariottini, Vitaliano Francesco Muzii, and Lucio Palma; Recruitment curve of the soleus H-reflex in chronic back pain and lumbosacral radiculopathy. BMC Musculoskeletal Discord ;2001: 2: 4 doi:10.1186/1471-2474-2-4.
22.ali .a,sabahi M.A They studied the H reflex changes under spinal loading and unloading condition in normal subjects( 2000)21:231-234
23.Abdulwahab S. The effect of reading and traction on patient with cervical radiculopathy based on electrodiagnostic testing. Journal of the Neuromusculoskeletal System. 1999; 7(3):91-96.
24. Delaney Re-analysis of Donelson calculating accuracy of McKenzie assessment in diagnosis(1999)6(2):43-45
Signature of candidate:
Remarks for Guide:
Name and Designation of
(in block latter)
11.1 Guide: SAI KUMAR .N
11.2 Signature:
11.3 Co-guide:
11.4 Signature:
11.5 Head of department: SAI KUMAR .N
11.6 signature:

12.1 Remark of principal:
12.2 signature:
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Name: Nimisha kantilal patel