Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of the Candidate
& Address / SAMAHIR ABUARAKI ElBKHEET
Omdurman
Main Road, Alarda street
Sudan, Khartoum
2 /

Name of the Institution

/ Padmashree Institute of Physiotherapy, Bangalore.
3 /

Course of study and subject

/ MASTER OF PHYSIOTHERAPY(MPT)
(Physiotherapy in Musculoskeletal
Disorders & Sports)
4 /

Date of admission to course

/ 4th July, 2013
5 /

TITLE OF THE TOPIC:

MULLIGAN MOBILIZATION VERSUS STRETCHING ON THE MANAGEMENT OF PIRIFORMIS SYNDROME”
–A COMPARATIVE STUDY.
6 / Brief resume of the intended work:
6.1 Need for the Study:
Low back pain is a leading cause of disability. It occurs in similar proportions in all cultures, interferes with quality of life and work performance, and is the most common reason for medical consultations. Only a few cases of back pain are due to specific causes; most cases are non-specific.1 Low back pain results from trauma, osteoporotic fractures, infection, neoplasms and other mechanical derangements.2
More than 16% of all adult work disability evaluations and examinations are performed to rate the patient's partial or total disability associated with chronic low back pain. Approximately 6% of lower back pain and sciatica cases seen in a general practice may be caused by piriformis syndrome.3
According to recent studies, this percentage of piriformis associated with low back pain is found to be much higher. The modified FAIR test along with Lasegue's sign shows that 17.2% of low back pain are linked to piriformis syndrome.4
Many studies has been done which reported incidence rates for piriformis syndrome among patients with low back pain vary widely, from 5% to 36%. Piriformis syndrome is more common in women than men, possibly because of biomechanics associated with the wider quadriceps femoris muscle angle (“Q angle”) in the os coxae (pelvis) of women.4
Piriformis syndrome is a common cause of low back pain. It is often not included in the differential diagnosis of back, buttock, and leg pain.5
Piriformis syndrome is a peripheral neuritis of the sciatic nerve caused by an abnormal condition of the piriformis muscle. It is a relatively unusual condition arising due to the entrapment and irritation of the nerve in the greater sciatic notch as a result of inflammation, hypertrophy or anatomical anomaly of the muscle.6
The piriformis muscle acts as an external rotator, weak abductor, and weak flexor of the hip, providing postural stability during ambulation and standing.7 The piriformis muscle originates at the anterior surface of the sacrum, usually at the levels of vertebrae S2 through S4, at or near the sacroiliac joint capsule. The muscle attaches to the superior medial aspect of the greater trochanter via a round tendon that, in many individuals, is merged with the tendons of the obturator internus and gemelli musclesThe piriformis muscle is innervated by spinal nerves S1 and S2—and occasionally also by L5.8
Piriformis syndrome is characterized by radiating pain from the sacro-lumbar region to the buttocks and down to the lower limb. The causes of sciatica usually relate to degenerative changes in the spine and lesions to the intervertebral discs.9
There are two types of piriformis syndrome—primary and secondary. Primary piriformis syndrome has an anatomic cause, such as a split piriformis muscle, split sciatic nerve, or an anomalous sciatic nerve path. Secondary piriformis syndrome occurs as a result of a precipitating cause, including macrotrauma, microtrauma, ischemic mass effect, and local ischemia. Among patients with piriformis syndrome, fewer than 15% of cases have primary causes.4
Piriformis syndrome occurs most frequently during the fourth and fifth decades of life and affects individuals of all occupations and activity levels.10
In most cases of (unilateral) piriformis syndrome, the sacrum is anteriorly rotated toward the ipsilateral side on a contralateral oblique axis, resulting in compensatory rotation of the lower lumbar vertebrae in the opposite direction.11
Contracted piriformis muscle also causes ipsilateral external hip rotation. When a patient with piriformis syndrome is relaxed in the supine position, the ipsilateral foot is externally rotated , a feature referred to as a positive piriformis sign. Active efforts to bring the foot to midline result in pain.12
Piriformis syndrome can “masquerade” as other common somatic dysfunctions, such as intervertebral discitis, lumbar radiculopathy, primary sacral dysfunction, sacroiliitis, sciatica, and trochanteric bursitis.4
Piriformis syndrome is characterized by pain and paresthesias in the unilateral gluteal region radiating to the hip and posterior thigh in a sciatic radicular distribution. It frequently goes unrecognized or is misdiagnosed in clinical settings.13
Patients with piriformis syndrome typically exhibit weakness and atrophy only in distal musculature. Sacroiliitis, other sacroiliac joint dysfunction, and somatic dysfunction of the sacrum and innominates should be considered as possible causes or effects of piriformis syndrome and can be determined with a thorough osteopathic structural examination and radiographic testing.14
In most cases of piriformis syndrome, the sacrum is anteriorly rotated toward the ipsilateral side on a contralateral oblique axis, resulting in compensatory rotation of the lower lumbar vertebrae in the opposite direction.15For example, piriformis syndrome on the right side would cause a left-on-left forward sacral torsion with L5 rotated right. Sacral rotation often creates ipsilateral physiologic short leg.16
Certain case studies and reports indicate the dangers and ineffectiveness of surgical interventions like the decompression techniques. This mainly is due to the difficulty in the precise diagnosis of piriformis syndrome and the position of the sciatic nerve in relationship to the piriformis muscle.17 Systematic reviews in exploring the treatment, especially non-surgical interventions guarantee the need of further studies. clinical trials of the effectiveness of non-surgical measures in the management of this syndrome are indicated.18
Joint mobilization to the lumbar spine, sacroiliac joint, and hip as indicated to restore normal joint mobility, range of motion, and function.19
Mulligan’s therapy is amanual therapy technique which was developed by Brian Mulligan, for the treatment of musculoskeletal dysfunction It involves performing a sustained force (accessory glide)while a previously painful(problematic) movement is performed.20
There have been reports of clinical cases and case series which have describedthe success of MWMs (Movement with mobilisation) in the management of variousmusculoskeletal conditions including lumbar spinal dysfunctions.21
Manual and self-stretching activities to improve trunk and lower extremity flexibility, and range of motion.22
Many studies have shown improved effect of stretching on piriformis syndrome but there is no much literatures to know the effect of mulligan on piriformis syndrome.
So this study is aimed not only to know the effect of mulligan and also to compare the effect of stretching with mulligan mobilization.
HYPOTHESIS:
H1:
There will be a significant effect on mulligan mobilization in piriformis syndrome.
H0
There will not be a significant on mulligan mobilization in piriformis syndrome.
6.2 REVIEW OF LITERATURE:
Brad Walker (2013) conducted study about Piriformis Syndrome and Piriformis Muscle Stretches and stated that Piriformis syndrome is a condition where piriformis muscle becomes tight or there is spasm of piriformis muscle that irritates the sciatic nerve. This causes pain in the buttocks region and may even result in referred pain in the lower back and thigh. The study concluded that piriformis syndrome can be treated like any other soft tissue injury and stretching is the most accurate treatment for the tight piriformis muscle.
Lijec Vjesn (2013) conducted study on Piriformis muscle syndrome: etiology, pathogenesis, clinical manifestations, diagnosis, differential diagnosis and therapy. And concluded that the most common causes for piriformis syndrome are piriformis muscle spasm, shortening and hypertrophy and anatomic variations of piriformis muscle. In 5-6% of patients with low back pain and/or unilateral sciatica, the pain is caused by piriformis muscle disorders.
Ann Phys Rehabil Med. (2013) conducted study about Piriformis muscle syndrome: diagnostic criteria and treatment of a monocentric series of 250 patients. This study aimed to devise a clinical assessment score for PMS diagnosis and to develop a treatment strategy. The study also mentioned that rehabilitation has a major role associated in half of the cases treated with botulinum toxin injections. He concluded that the proposed evaluation score may facilitate PMS diagnosis and treatment standardisation.
Damian Hoy et al ( 2012) conducted study on A Systematic Review of the Global Prevalence of Low Back Pain. They conducted a new systematic review of the global prevalence of low back pain that included general population studies published between 1980 and 2009. A total of 165 studies from 54 countries were identified. Of these, 64% had been published since the last comparable review. Results concluded that Low back pain was shown to be a major problem throughout the world, with the highest prevalence among female individuals and those aged 40–80 years.
Lori A. Boyajian-O'Neill, Do et al (2007) conducted a study on Diagnosis and Management of Piriformis Syndrome. The study involved holistic approach to diagnosis through a thorough neurologic history and physical assessment of the patient, inclusive of the osteopathic structural examination, based on the pathologic characteristics of piriformis syndrome. And they concluded that Osteopathic manipulative treatment can be used as one of several possible non pharmacologic therapies for these patients.
Samborski W et al (2006) conducted a study about Piriformis muscle syndrome and stated that Sciatica which is realated to piriformis muscle syndrome is characterized by radiating pain from the sacro-lumbar region to the buttocks and down to the lower limb. They causes of sciatica usually relate to degenerative changes in the spine and lesions to the intervertebral discs. And concluded that The piriformis syndrome is primarily caused by fall injury, but other causes are possible, including pyomyositis, dystonia musculorum deformans, and fibrosis after deep injections. The right treatment can be started following a thorough investigation into the cause of symptoms.
Papadopoulos EC, Khan SN(2004) conducted study about piriformis syndrome and low back pain and stated that Piriformis syndrome is a common cause of low back pain. It is often not included in the differential diagnosis of back, buttock, and leg pain. And they also mentioned that Piriformis syndrome may constitute up to 5% of cases of low back, buttock, and leg pain. The study concluded that recognition and widespread appreciation of the clinical presentation is required for its early detection and accurate treatment.
George E. Ehrlich(2003) published a study in Bulletin of the World Health Organization on Low back pain. The primary task of the expert advisory panel of WHO that worked on the low back pain initiative was to try to determine how to assess improvement of back pain, by defining outcome measures relevant to all cultures and ensure uniformity of reporting and, to that end, the extant examinations and tests were evaluated and applied in studies in various parts of the world. The study concluded that back pain is both a major cause of temporary disability and a challenge
to medical and surgical treatment and the use of outcome measures recommended by the panel of WHO’s low back pain initiative should go far in clarifying the appropriate approach to this ubiquitous syndrome of regional pain.
Exelby ((2002) published a study in Manual therapy Elsevier publications on the Mulligan's concept in the application of spinal mobilisations. The Mulligan concept encompasses a number of mobilising treatment techniques that can be applied to the spine, these include ‘NAGs’ (natural apophyseal glides), ‘SNAGs’ (sustained natural apophyseal glides), and ‘SMWLMs’ (spinal mobilisations with limb movements). In this article, these techniques are described and the general principles of examination and treatment are outlined. Clinical examples were used to illustrate the concept’s application to the spine, on how it has evolved and been integrated into constantly changing physiotherapy practice. New applications were considered which can assist in the correction of dysfunctional movement. The paper reflected on the possible role that this concept has to play within evidence-based practice. A future research direction is proposed in the light of presently available preliminary research results.
Scott, Huskisson et al (1976) showed in their study of graphical representation of pain that, test-retest Reliability of VAS is 0.71 to 0.99 and convergent validity (McGill Pain Questionnaire, numeric pain Rating scale) is 0.85 with a confidence interval of 95% .17
Bijur PE, Silver W, Gallagher EJ (2001), showed in their study of reliability of visual analogue Scale for the measurement of acute pain that summary of intraclass correlation(ICC) for all paired VAS scores was 0.97 [95% CI = 0.96 to 0.98]. Reliability of the VAS for acute pain measurement as Assessed by the ICC appears to be high.18
6.3OBJECTIVE OF THE STUDY:
To find out the efficacy of mulligan mobilisations versus the stretching of piriformis muscle in relieving the symptoms of piriformis syndrome.
7. / Materials and Methods:
7.1 Source of Data
·  Padmashree institute of Physiotherapy clinic, Bangalore
·  ESI hospital, Rajajinagar
·  Ravi kirloskar,peenya
·  Padmashree diagnostics, vijayanagar
7.2Method of collection of data:
·  Population : People diagnosed with piriformis syndrome
·  Sample Design : convenient sampling
·  Sample size : 40
·  Type of Study : experimental study Pre-post test design.
·  Duration of study : 6 months
Inclusion criteria:
·  People with secondary piriformis syndrome and sciatic neuritis due to:
1.  Macro trauma and Micro trauma to piriformis muscle.
2.  ischemic mass effect and local ischemia to piriformis muscle.
·  Age group: 40-60 years.
·  Both male and female.
·  Unilateral piriformis syndrome.
Exclusion criteria:
·  Any hip joint (articular) pathology including pain, fracture, instability
·  Lumbar Disc herniation
·  Lumbar Spondylosis
·  Lumbar Ankylosing spondylitis
·  Lumbar Spinal stenosis
·  Bilateral piriformis syndrome
Materials Required
·  Treatment table
·  Lower limb functional scale
·  VAS scale
Methodology:
Intervention to be conducted on the participants:
-Informed consent will be taken from the subject.
-Subjects who fulfilled the inclusion criteria will be assigned into two groups based on
Simple random sampling.
- Subjects in both the groups will be assessed for following parameters before starting treatment.