Curriculum Development Cell
CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
Registration No. / :
Name of the Candidate / :MR. HEMALKUMAR K SANGHAVI
Address / : 7 Dhake Colony, Opp. Shahu Complex, Jalgaon (Maharashtra).
Name of the Institution / : SDM College of Physiotherapy, Dharwad
Course of Study and Subject / : MPT
Date of Admission to Course / : 01/07/2011
Title of the Topic / : “TO COMPARE THE EFFECTIVENESS OF LUMBAR STABILISATION EXERCISE VERSUS CONVENTIONAL PHYSIOTHERAPY IN PATIENT AFTER LUMBAR DISC SURGERY” – A PROSPECTIVE RANDOMIZED CONTROL TRIAL.
Brief resume of the intended work / : Attached
Signature of the Student / :
Guide Name / : PRAMOD KSHIRSAGAR
Remarks of the Guide / :Recommended for Registration.
Signature of the Guide / :
Co-Guide Name / :
Signature of the Co-Guide / :
HOD Name / :
Signature of the HOD / :
Principal Name / : RAVI SAVADATTI
Principal Mobile No. / : 09845051209
Principal E-mail ID / :
Remarks of the Principal
/ :
a) / BRIEF RESUME OF THE STUDY
INTRODUCTION:
According to the WHO low back pain has reach epidemic proportion, being reported by about 80% of people at some time in their life.1 It does affect a large proportion of the population with a point prevalence of between 12-35% and a lifetime prevalence of 49-80%, it is the second leading cause of sick leave, impacting on health care utilization and contributing to disability and work loss. As such it is one of the most costly health problem facing society.2 Back problems accounted for a large proportion of health care expenditures.3In India occurrence of low back pain is alarming, nearly 60% of the people in India have significant back pain at some time or the other in lives.4Disc herniation is most commonly seen in age group of 20 – 55 and males are more commonly affected than females because disc herniation related to heavy and repeated work which is more commonly under taken by males than females.5 Intervertebral disc herniation is a common cause of sciatica,and has a prevalence of 3% - 4% in all back problems and a lifetime incidence reaching 40%, which makes it a major worldwidehealthproblem, disc herniation is most common in lumbar region – single level lumbar disc herniation seen in 88% and multiple level lumbar disc herniation seen in 12%,with L4/L5 being the most commonly affected level i.e. 60% followed closely by L5/S1 i.e. 44% and 13% disc involvement at levels other than L4/5 or L5/S1 levels in the lumbar region.6
Intervertebral discs are primary stabilizers of functional spinal unit and the amount of motion available at interbody and zygapophyseal joints are primarily determined by size of the disc and direction of motion is primarily determined by orientation of facet joints, intervertebral disc provides constrained mobility to the spine. Degeneration of intervertebral disc increases after 40 year of age and is a common cause of chronic low back pain. Degeneration leads to segmental instability of functional spinal unit, this unit can’t tolerate body load and movements becomes painful.7,8
Lumbar disc herniation is a common disease, the compression by the protruding disc on the dorsal and/or ventral rami of the nerve roots causes low back pain, leg pain (Sciatica/Lumbosacral Radicular Syndrome - LRS), muscle spasm, and restriction of trunk movement and sometimes with serious neurological symptoms.9,10
Lumbosacral Radicular Syndrome commonly results from disc herniation, characterized by radiating pain over an area of the buttocks or legs served by one or more lumbosacral nerve roots combined with phenomena associated with nerve root tension or neurological deficit. Lumbosacral Radicular Syndrome is most commonly caused by a lumbar disc herniation. It is estimated that there are between 60,000 and 75,000 new cases of Lumbosacral Radicular Syndrome in the Netherlands each year (HCN 1999), for which the direct and indirect costs are estimated at 1.6 billion US$ per annum (van Tulder 1995). Many patients with Lumbosacral Radicular Syndrome are treated conservatively, but surgery is a common option in patients with persistent symptoms. In the Netherlands, with a population of about 16 million people, it is estimated that 10,000 to 11,000 operations are performed each year because of the Lumbosacral Radicular Syndrome (HCN 1999) but surgery rates vary across countries.11
Many patients are treated effectively by a combination of non-surgical measures such as medication or physiotherapy. However, patients with persistent symptoms often need surgery. 90% of acute attacks of sciatica settle with conservative management. When the conservative treatment fails, symptoms persist and / or there are progressive neurological symptoms, in such a case surgery is the only option.12While 60% to 90% of patients will improve after surgery, rest will continue to have symptoms.It is estimated that 3% to 19% of patients who have disc surgery will develop another prolapsed disc and most of these patients will have surgery again.11,13
Recurrent disc herniation, considered as the major cause of fail back syndrome or surgical failure after lumbar discectomy.14,15Over the last several decades, two approaches have dominated the surgical treatment of primary lumbar disc herniation with radiculopathy resistant to conservative treatment. The first, described by O’Connell involved a large open incision with aggressive removal of the disc fragments and curettage of the disc space. The second, described by Spengler emphasized a smaller incision with removal of the disc fragment with little invasion of the disc.16
However, the clinical outcomes of disc surgery have been described as suboptimal due to recalcitrant pain, disability, and reduced quality of life that occur in some individuals following the procedure.9,17Consequently, some have described failed disc surgery as a major healthcare problem. Therefore, optimizing clinical outcomes following lumbar disc surgery has been recognized as a priority for future research.9,17,18Muscular impairment and clinical considerations in the postoperative management of this population have received less attention.
Low physical fitness and inadequate strength and endurance of the back muscles among the risk factors for back trouble.19A positive relationship between chronic low back pain and reduced endurance of the trunk musculature has been documented.20,21 Delayed or abnormal trunk muscle activation has been observed in patients with disc herniation and It has also seen that lumbar disc herniation leads to impaired lumbar proprioception and postural control &feed-forward mechanism. These changes also seen after operation. Feed forward mechanism refers to the activities of the central movement control system, which maintains postural stability and prepares the trunk to bear a potentially increasing load by activating certain trunk muscles. Those muscles include transverse abdominus and transversospinal, which become activated very shortly after a perturbation and before activation of the prime muscles responsible for gross limb movement.22,23
Trunk muscles, including transverse abdominus and lumbar multifidus muscles which are involving in maintaining dynamic spine stability.24The lumbar multifidus muscle is most medially located back muscle and the largest muscle that spans thelumbosacral junction, serves to maintain the erector posture of the trunk and to abduct and rotate the trunk; it is innervated by the dorsal rami of the lumbar spinal nerves.10Ultrasonography revealed that there is impaired morphological changes, decreased Para spinal cross-sectional area, decreased muscle density at lumbar multifidus, Furthermore, a higher proportion of intramuscular fat within the lumbar multifidus shows a strong relationship with the presence of low back pain and investigation following lumbar disc surgery have shown the same results.25,26,27
In addition patients requiring lumbar disc herniation surgery may experience a long period of inactivity before surgery, which in turn may cause decreased muscle strength and impairment of the voluntary neural activation rate.19 22These changes reported to result from disuse or reflex inhibition, may lead to a reduction in the explosive force production of a muscle or muscle group. Surgical operations as such also may affect the amount of muscle atrophy, and studies have Showed that recovery of back muscles is related directly to muscle retraction time during surgery. The damage to the multifidus muscle and other paraspinal muscle was more severe and the recovery of extensor muscle strength was delayed in the long-retraction-time group and also depend on type of surgery.25,28,29,30
Physical exercise appears to have a beneficial effect on healing tissue as tension exerted on the wound is thought to stimulate collagen synthesis and ensure that collagen is laid down in an organized manner, parallel to the direction of forces.31,32 Stress reduction through immobilization or lack or weight bearing during the healing process has been shown to affect tissue healing leading to impaired tissue function. The effect of posture and positioning on internal disc pressures may therefore be a factor influencing for re-injury of disc if patient present with poor ergonomics.33 It suggests that immediate commencement of exercise after lumbar disc surgery is advisable but it should be in proper ergonomic manner to prevent further disc injury.
Post-operative rehabilitation was recognized as having influence on surgical results as early as 1960s. Post-surgical conventional rehabilitation program were recommended to all the patients. Many hospitals have offered post-operative rehabilitation programs, general spinal and postural information and physical fitness recommendation during the years. Conventional low back training program have been proven capable of improving function and pain levels and increasing back muscle endurance in many patient present with low back pain. In addition, patients who previously would have had an operation for lumbar disc herniation have benefited from conventional training programs, thereby avoiding the post-operative physical deficits found in such patients.34
The principle of core stability has gained wide acceptance in training for the prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal conditions in particular of the lower back.The term has been used to connote lumbar stabilization, motor control training, etc. Core muscles are required around the lumbar spine to maintain functional stability. The “core” has been described as a box with the abdominals in the front, paraspinals and gluteals in the back, the diaphragm as the roof, and the pelvic floor and hip girdle musculature as the bottom. Particular attention has been paid to the core because it serves as a muscular corset that works as a unit to stabilize the body and spine, with and without limb movement. The Queensland research group1 has suggested the differentiation of local and global muscle groups to outline the postural segmental control function and general multisegmental stabilization function for these muscles groups, respectively.35,36
Vigorous Restoration of physical function following lumbar discectomy may be influenced by the postoperative care provided.Clinical trials demonstrating improved outcomes following postoperative rehabilitation of lumbar disc surgery with lumbar stabilization exercise, and initiate treatment early in the postoperative period.Immediate commencement of exercises following first-time lumbar discectomy enabled patients to become independently mobile more rapidly and return to work sooner. Immediate commencement of exercises may enable patients to be discharged earlier, with associated cost benefits to health care and no increase in the rate of revision surgery.27,37,38,39
Home based rehabilitation program for the patient with first time lumbar discectomy shows significant improve in outcomes provided patients receive both careful instructions from a physiotherapist and strategies for active pain coping, and have access to the physiotherapist if questions regarding training arise. This might be a convenient treatment arrangement for most patients.40
NEED FOR THE STUDY:
Low back pain is the very common condition, 80% of people at some time in their life suffer with low back pain, a point prevalence of between 12-35% and a lifetime prevalence of 49-80%, it is the second leading cause of sick leave.1,2Disc herniation most commonly seen in age group of 20 – 55 and male more commonly affected than female.5 3% -4% suffer from disc herniation and 90% recovers with conservative treatment, patients with persistence of symptom required surgery, 60% - 90% recovers from surgery 10% - 40% present with persistence of the symptoms.6 3% - 19% develops recurrence of disc herniation i.e. failed back syndrome.11,13
There is a correlation between low back pain and transverse abdominus, lumbar multifidus muscles. both muscles play important role in spinal stability and dynamic mobility.24 Radiological investigations like Magnetic Resonance Imaging, Computerized Tomography scan or Ultrasound imaging have demonstrated that atrophy or decreased cross sectional area or increased intra muscular fat or delayed contraction and abnormal activation of these muscles in chronic low back pain, lumbar disc herniation, and same results have been seen after lumbar disc surgery.19,23,26,27 Movement sensation and feed forward mechanism also impaired following lumbar disc surgery.22,23 In addition to above factors there will be repeated faulty movement because of muscular imbalance reinforcing further faulty movement,30 inactivity before surgery,19,22surgical factors like type of surgery, muscle retraction time in the surgery etc,9,17 and post-surgical rest period all these factors further add ups the muscular weakness, movement sensation and may leads to long term persistence of symptoms like pain, disability, decrease quality of life etc. following lumbar disc surgery.9,17
Appropriate muscular control and movement sensation are of vital importance in preventing low back injury.23Lumbar stabilization exercise improve the strength or transverse abdominus, lumbar multifidus & other Paraspinal muscles and also helps to activate the feed forward mechanism, lumbar positional sense which are the main finding following the lumbar disc surgery.
Abdominal and back muscle weakness & poor ergonomic aspects may be the one of the factor which can develop another disc herniation and most of these patients will have surgery again.Potentially important muscular impairments and clinical considerations in the postoperative management of disc surgery have received less attention, and also in India post-operative disc rehabilitation with conventional physiotherapy and lumbar stabilization exercise literatures are nil as per our knowledge, hence this study will be under taken to find effectiveness of lumbar stabilization exercise versus conventional physiotherapy in patient after lumbar disc surgery.
RESEARCH HYPOTHESIS;
NULL HYPOTHESIS (H0):
The group receiving Lumbar Stabilization exercise will not show significant improvement in the outcome measures as compared to the group receiving Conventional Rehabilitation Program in patient after lumbar disc surgery.
ALTERNATE HYPOTHESIS (H1):
The group receiving Lumbar Stabilization exercise will show significant improvement in the outcome measures as compared to the group receiving Conventional Rehabilitation Program in patient after lumbar disc surgery.
REVIEW OF LITERATURE:
Disc herniation most commonly seen in age group of 20 – 55 and males more commonly affected than females.5Intervertebral disc herniation is a common cause of sciatica, has a prevalence of 3% - 4% in all back problems and a lifetime incidence reaching 40%, disc herniation is most common in lumbar region – single level lumbar disc herniation seen in 88% and multiple level lumbar disc herniation seen in 12%,with L4/L5 being the most commonly affected level i.e. 60% followed closely by L5/S1 i.e. 44% and 13% disc involvement at the levels other than L4/5 or L5/S1 levels in the lumbar region.6Conservative as well as surgical approach are present for disc herniation. 90% of patients will improve with the conservative treatment and rest will need surgery. While 60% to 90% of patients will improve after surgery, rest will continue to have symptoms. It is estimated that 3% to 19% of patients who have disc surgery will develop another prolapsed disc and most of these patients will have surgery again.11
Disc prolapse accounts for 3% - 4% of low-back disorders and it is one of the most common reasons for surgery. Various surgical methods are utilized, such as standard discectomy, fenestration surgery and forms of minimally invasive therapy, including microdiscectomy, Chemonucleolysis, automated percutaneous discectomy, laser discectomy, percutaneous endoscopic discectomy, transforaminal endoscopic discectomy. In a meta-analysis of surgical interventions for lumbar disc prolapse, objectives were to assess the effects of surgical interventions for the treatment of lumbar disc prolapse. There were 40 articles selected for the study. Results of the articles were surgical discectomy for carefully selected patients with sciatica due to a prolapsed lumbar disc appears to provide faster relief from the acute attack than non-surgical management, discectomy produced better outcomes than chemonucleolysisand chemonucleolysis is better than placebo.41
The study conducted by Katarina Silverplats et. al., the objective of the study was Health-related quality of life in patient with surgically managed lumbar disc over the 10–15 years. Findings suggest that health related quality of life improved 2 years after lumbar disc herniation surgery, but there was no further improvement after 5 more years. Low quality of life and severe leg pain at baseline are important predictors of improvement in quality of life after lumbar disc herniation surgery.42 Surgery improves pain, disability, back muscle endurance capacity and reduction in hip and lumbar mobility.43
Various treatment programs are available following disc herniation that includes conventional physiotherapy,34 dynamic back extensor exercise,34 active rehabilitation,11 gym based esercise,34 lumbar stabilization exercise,38 hydrotherapy,33 home based esercise,40 intensive-progressive exercise program,44 early neuromuscular customized training program45 etc. The time duration of commencing the exercise following surgery varies with 2 hours after surgery37 to 6 week post-surgery11 and duration of exercise varies with 4 weeks43to 12 weeks.44Some articles suggests benefits from a home exercise programs. A 4-week postoperative exercise program that starts on post-operative day of 6 week can improve pain, disability and spinal function in patients who undergo microdiscectomy.43
A case study shows that change in transverse abdominus and lumbar multifidus muscles activation in a patient following lumbar disc surgery and the effect motor control exercise initiated in the early postoperative period, and quantification has been done using Ultra Sound. In case of low back pain, there is an impaired function and morphological change at lumbar multifidus, decreased activation and delayed contraction of lumbar multifidus. Atrophy of other Para-spinal muscles also observed. The transverse abdominus and lumbar multifidus muscles appear to play a unique role in lumbar spine stability, and may relate to clinical outcome following lumbar disc surgery. A 29 year old female after failure of conservative management underwent a L5-S1 microdiscectomy for lumbar disc herniation. Was treated in following manner, lumbar stabilization exercise started 10th post-operative day, 8 sessions, 1 session each week, and encourage patient to perform home exercise. Treatment approaches included stretching, range of motion, aerobic, and stabilization exercises; however, the focus of the rehabilitation program was the restoration of transverse abdominus and lumbar multifidus muscle function in two phases. In phase 1 – activation/volitional contractions of these muscles and in phase 2 - Exercises addressing transverse abdominus and lumbar multifidus function were applied. Rehabilitative ultrasound imaging to estimate muscle activation by assessing changes in thickness of the lumbar multifidus and transverse abdominus from rest to contraction. Recent research has demonstrated Rehabilitative Ultrasound Imaging estimates of lumbar multifidus and transverse abdominus activation to have good rater reliability. Three images were acquired of each muscle in each state (resting and contracted), and the values were averaged to reduce variability. Morphology of lumbar multifidus and transverse abdominus improved substantially after rehabilitation period of 8 weeks. Clinical trials demonstrating improved outcomes following postoperative rehabilitation emphasize the use of lumbar stabilization exercise, and initiate treatment sooner in the postoperative period. A study shows the positive outcome for the early postoperative stabilization exercises and it has proven objectively using ultra sound. Level of evidence of the study is level 4, but this was a single case study, need to perform on larger population.27