Rajiv Gandhi University of Health Sciences s153

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / Name of the candidate
and Address / GOVANI SATVIK KANTILAL
SRINIVAS COLLEGE OF PHYSIOTHERAPY,
PANDESHWAR,
MANGALORE-575001.
2 /

Name of the Institute

/ SRINIVAS COLLEGE OF PHYSIOTHERAPY, MANGALORE.
3 /

Course of study and

Subject / Master of Physiotherapy (MPT)
2 years Degree Course.
“ Physiotherapy in Musculo-skeletal conditions & Sports Physiotherapy”
4 /

Date of Admission

To course / 30.04.2007
5 /

Title of the Topic

/ “A COMPARATIVE STUDY TO FIND OUT THE EFFECTIVENESS OF CERVICAL MOBILIZATION AND DEEP NECK FLEXOR MUSCLES TRAINING IN PATIENTS WITH CHRONIC NON-SPECIFIC NECK PAIN”
6 /

Brief resume of the intended work:

6.1 Need for the study:
Chronic neck pain is becoming increasingly prevalent in society.1 Estimate indicates that 67% of individual will suffer neck pain at some stages of life.2 Despite the prevalence of neck pain, there is lack of evidence for commonly used rehabilitation interventions.
The conventional physiotherapy treatments includes active exercises and stretching exercises with addition of massage and manual traction optionally for neck pain patients.3
Studies have shown significant reduction in strength of the cervical muscles in people with neck pain when compared to controls.4,5 Deep neck flexor muscles mainly counteract the lordosis increment related to weight of head and stabilization of cervical spine.6

Even, Electromyography study during cranio-cervical flexion test demonstrates lower amplitude of deep neck flexor muscles and higher amplitude of superficial muscles, which suggest that patients with neck pain use an altered muscle strategy.1

The deep neck flexor muscles dysfunction is common in neck pain patients. so, it is important to activate and re-educate their tonic supporting capacity that becomes an essential component of treatment from the outset to both relieve and control joint pain.7 Specific cervical flexor muscle training has shown improvement in parameters of muscle function and reduction in the symptoms of neck pain.8,9

Many studies have been shown the effect of manual therapy on chronic neck pain. Evidence supports that Mobilization produce hypoalgesic effect on mechanical but not thermal nociception10 and inhibition of motor neuron pools that may result in the reduction of muscle spasm and hence local muscle pain.11 Cervical mobilization also demonstrates significant decreased EMG activity in superficial neck flexor muscles in cranio-cervical flexion test, implying improved activation of the deep flexor muscles.10
Deep neck flexor muscles training as well as Cervical mobilization help in chronic neck pain management. So, this study has been designed mainly to compare the effectiveness of deep neck flexor muscles training and cervical mobilization in patients with chronic non-specific neck pain and also to find the individual effect of deep neck flexor muscles training and cervical mobilization in management of chronic non-specific neck pain.
6.2 Review of Literature:
1. Thomas T W C et al. (2005) compared the performance of the deep neck flexor muscles on the cranio-cervical flexion test (CCFT) in individual with and without neck pain and found that Patient with chronic neck pain had a poorer ability to perform the cranio-cervical flexon test (CCFT) when compared with asymptomatic subjects.12
2. Jari Ylinen et al. (2004) conducted a study to compare neck flexion, extension, and especially, rotation strength in women with chronic neck pain with healthy controls. They have also evaluated the repeatability of peak isometric neck strength measurements in patients with neck pain and concluded that the group with neck pain had lower neck muscle strength in all the directions tested than the control group.13
3. Falla D. et al. (2004) compared the activity of deep and superficial cervical flexor muscles and cranio-cervical flexion range of motion during a test of cranio-cervical flexion between 10 patients with chronic neck pain and 10 controls and concluded that lower EMG amplitude in the deep cervical flexor muscles were associated with higher Electromyography amplitude values in the superficial muscles, which suggests that patients with chronic neck pain use an altered muscle strategy to perform the cranio-cervical flexion task.1
4. Falla D et al. (2003) conducted a study to quantify the sagittal angular displacement of the head (cranio-cervical flexion) for five incremental stages of the cranio-cervical flexion test (CCFT) and concluded that cranio-cervical flexion range is required to achieve the five incremental stages of cranio-cervical flexion test (CCFT). They have also found the inter-rater and intra-rater reliability for the angular head displacement measures assessed with digital imaging therapy technique.14
5. Ingeborg BC et al (2003) conducted a study to evaluate the cost effectiveness of physiotherapy, manual therapy and care by general practitioner and concluded that Manual therapy is more effective and less costlier than the care of General practitioners.3
6. Jari Ylinen et al. (2003) evaluated the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles on pain and disability in women with chronic Non-specific neck pain and concluded that both isometric strength training and dynamic endurance training were effective methods for decreasing pain and disability in women with chronic, non-specific neck pain during 1 year follow up period.8
7. Sterling M et al. (2001) conducted a study to investigate concurrent effects of spinal manipulative technique on pain levels, sympathetic nervous system activity and neck flexor muscle activity in subjects with chronic mid to lower cervical spine pain and concluded that spinal manipulative therapy using grade 3, postero-anterior mobilization technique applied to symptomatic side of the C5-C6 motion segment produced a hypoalgesic effect to mechanical but not thermal nociception and an excitatory effect on sympathetic nervous system activity. In conjunction with these effects, this study also have demonstrated significant reduction in EMG activity of the superficial neck flexor muscles in the staged cranio-cervical flexion test, implying improved activation of the deep neck flexor muscles.10
8. MA Mayoux- Benhamou et al (1994) conducted a study to determine the postural role of Longus colli and Dorsal neck muscles and found that Longus colli counteracts the lordosis increment related to the weight of the head and to the contraction of dorsal neck muscles.6
6.3 Objective of the study:
1. To find out the effect of Cervical mobilization in patients with chronic non-specific neck pain
2. To find out the effect of Deep neck flexor muscles training in patients with chronic non-specific neck pain
3. To compare the effects of Cervical mobilization and Deep neck flexor muscles training in patients with chronic non-specific neck pain
6.4 Hypothesis:
Experimental hypothesis:
There will be significant difference between Cervical mobilization and Deep neck flexor muscles training in patients with chronic non-specific neck pain.
Null Hypothesis:
There will not be significant difference between Cervical mobilization and Deep neck flexor muscles training in patients with chronic non specific neck pain.
7 / Material and Methods:
7.1 Source of data:
Patients from Srinivas OPD, Wenlock Hospital OPD, NMPT Hospital & ESI hospital; Mangalore.
7.2 Method of collection of data:
60 subjects will be selected, who will fulfill the inclusion and exclusion Criteria. They will be randomly divided in to three groups.
Sampling :
Simple random sampling
Measurement procedure:
Written consent will be taken from the selected patients. The procedure will be explained to them.
60 Patients will be randomly assigned into 3 groups, i.e., Group A, Group B and Group C of 20 patients each.
Group A: This group will be given conventional physical therapy that includes active exercises and stretching. Additional massage and manual traction are optional.3
Group B: This group will be given conventional therapy with Cervical mobilization using maitland approach.
Protocol will be as follows:
Patient will be in prone lying, with forehead resting on the palms of his hand. It will be necessary for the chin to be tucked well in. The Physical therapist will stand at the head end of the patient with thumbs held in opposition and back to back with the thumb tips on the spinous process of the vertebra or on articular process which will be mobilized. The fingers will straddle the sides of the patient’s neck and head. For mobilization of spinous process, extremely gentle pressure will be given in postero-anterior direction. For mobilization of articular process, the arm will be directed 300 medially to prevent the thumbs from slipping off the articular process.15 Mobilization will be given with grade 3 Postero-anterior glide which will involve three, 1 minute applications with a 1 minute interval between each. (Total time 6 minutes).10 Intervention will be given 3 times a week for 6 weeks.
Group C: This group will be given conventional therapy with Deep neck flexor muscles training. This program will use low load endurance exercises to train muscle control of the cervical region.7
Protocol will be as follows:
Patient will be in supine lying position. The exercise will be given by using air-filled pressure sensor (stabilizer), which will be placed sub-occipitally to monitor subtle flattening of the cervical lordosis. The patient will be guided by the feedback from the pressure sensor to reach five sequentially pressure targets in 2mm Hg increments from a base line of 20 mm Hg to 30 mm Hg. Patient will be instructed to do gentle cranio-cervical flexion. The physical therapist will identify the target level that subject will have to hold for 10 sec without restoring to retraction, without dominant use of superficial neck flexor muscles and without a jerky cranio-cervical flexion. Activation of superficial neck muscles will be monitored by therapist in all stages using palpation or observation.
The subject will be taught to perform slow and controlled cranio-cervical flexion. They will be trained to sustain progressively increasing ranges of cranio-cervical flexion using feed-back from the pressure sensor which will be placed behind the neck.16 Training will be given in 3 sets of 20 repetitions in one day for 6 weeks.8,9

Outcome measures:

1. Neck disability index

2. Questionnaire of Von corff et al for chronic pain

3. Cranio cervical flexion test

Materials to be used:

1. Pressure biofeedback unit/ stabilizer (Chattanooga Group, Australia.)
2. Towel
3. Pillow
4. Treatment table – Couch
5. Powder
Inclusion Criteria:
1. Subjects with Non specific neck pain
2. Pain for more than 3 months
3. Age group : 18 - 60 years
4. Gender : Both male and female
Exclusion Criteria:
1. Vertebro Basilar Insufficiency (VBI)
2. Radiating pain with weakness, paraesthesia and decreased deep tendon reflex 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

Statistical Analysis:

Study design: Randomized Control Trial
TEST: Paired t- Test, 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.
It is an intervention study to compare the effects of cervical mobilization and deep neck flexor muscles exercise in patients with Chronic non-specific neck pain.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
Consent has been taken from the college.
8 / List of references:
1. Deborah L. Falla, Gwendolen A. Jull, and Paul W. Hodges. Patients with Neck Pain Demonstrate Reduced Electromyographic activity of the Deep Cervical Flexor Muscles during Performance of the Cranio-cervical Flexion Test. Spine 2004; 29(19): 2108–14.
2. Côté, Pierre DC, Cassidy, J. David DC, Carroll, Linda. The Saskatchewan Health and Back Pain Survey: The prevalence of Neck Pain and Related Disability in Saskatchewan Adults. Spine 1998; 23(15): 1689-98.
3. Ingeborg, Korthals-de Bos, Jan L Hoving, Maurits W van Tulder, Maureen P, Rutten-van Mölken, Herman J Adèr, Henrica C W de Vet, BartWKoes, Hindrik Vondeling, Lex M Boute. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. British Medical Journal 2003; 326: 911-6.
4. D. Falla. Unraveling the complexity of muscle impairment in chronic neck pain. Manual Therapy 2004; 9: 125-33.
5. Silverman JL, Rodriquez AA, Agre JC. Quantitative cervical flexor strength in healthy subjects and in subjects with mechanical neck pain. Archive Physical Medicine Rehabilitation 1991. Aug; 72(9): 679-81.
6. MAMayoux-Benhamou, MRevel, CVallée, RRoudier, JPBarbet and FBargy. Longus colli has a postural function on cervical curvature. Surgical and radiological anatomy 1994; 16(4): 367-71.
7. Jull G. Management of cervical headache. Manual therapy 1997; 2(4): 182-90.
8. Ylinen J, Takala EP, Nykänen M, Häkkinen A, Mälkiä E, Pohjolainen T, Karppi SL, Kautiainen H, Airaksinen O. Jyväskylä, Jyväskylä. Active neck muscle training in the treatment of chronic neck pain in women: A randomized control trial. JAMA 2003 May; 289(19): 2509-16.
9. Jari Ylinen, Esa-Pekka Takala, Hannu Kautiainen, Matti Nyka nen, Arja Hakkinen, Timo Pohjolainen, Sirkka-Liisa Karppi, Olavi Airaksinen. Effect of long-term neck muscle training on pressure pain threshold: A randomized controlled trial. European Journal of Pain 2005; 9: 673–81.
10. M. Sterling, G. Jull, A. Wright. Cervical mobilization: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual Therapy 2001; 6(2): 72-81.
11. L. Katavich. Differential effects of spinal manipulative therapy on acute and chronic muscle spasm: a proposal for mechanisms and efficacy. Manual Therapy 1998; 3(3):132-9.
12. Thomas Tai wing chin, Elis yuk hung law, Tony hiu fai chiu. Performance of the cranio-cervical flexion test in subjects with and without chronic neck pain. Journal of Orthopedic and Sports Physical Therapy 2005; 35: 567-71.
13. Jari Ylinen, Petri Salo, Matti Nyka¨nen, Hannu Kautiainen, Arja Ha¨kkinen. Decreased Isometric Neck Strength in Women With ChronicNeck Pain and the Repeatability of Neck Strength Measurements. Archive Physical Medicine Rehabilitation 2004; 85: 1303-8.
14. Deborah L. Falla, Carolyn D. Campbell, Amy E. Fagan, David C. Thompson, Gwendolen A. Jull. Relationship between cranio-cervical flexion range of motion and pressure change during the cranio-cervical flexion test. Manual Therapy (2003); 8(2): 92–6.
15. Maitland GD, Maitland's vertebral manipulation. 5th edition, Boston: Butterworth–Heinemann; 1986. p. 205-12.
16. Deborah Falla, Gwendolen Jull, Trevor Russell, Bill Vicenzino, Paul Hodges. Effect of neck exercise on sitting posture in patients with chronic neck pain. Physical therapy 2007; 87(4): 408-17.
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Signature of the Candidate

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Remarks of the Guide

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11 / Name and Designation of :
11.1 Guide
11.2 Signature / Dr. K. SELVAMANI
Associate Professor in Physiotherapy