RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / KAJAL BARMAN
SONARAM PATH, GEETA MANDIR, MOTHER TERESA ROAD, GUWAHATI, ASSAM.
2 / NAME OF THE INSTITUTION / KRUPANIDHI COLLEGE OF PHYSIOTHERAPY, BANGALORE
3 / COURSE OF THE STUDY AND SUBJECT / MASTER OF PHYSIOTHERAPY –
NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS
4 / DATE OF ADMISSION TO COURSE / 18 JUNE 2010
5 / TITLE OF THE TOPIC
EFFECTIVENESS OF BUTLER NEURAL MOBILIZATION OVER MULLIGAN TRACTION WITH STRAIGHT LEG RAISE TECHNIQUE ON FUNCTIONAL ABILITY IN LUMBAR RADICULOPATHY-A RANDOMIZED EXPERIMENTAL STUDY.
6. / BRIEF INTRODUCTION OF THE INTENDED WORK
6.0 INTRODUCTION
Low back pain (LBP) or lumbago is a common musculoskeletal disorder causing pain in the lumbosacral area. It could be an acute, sub acute and chronic in its clinical presentation (1). Usually the symptoms and signs of low back pain improve within two to three months from its onset. But in some individual, low back pain tends to be recurrent in nature with a waxing and waning quality to it. While in small portions of sufferers, this condition becomes chronic. Study has shown that the low back pain accounts for more sick leaves and disability than any other single medical condition. In USA, low back pain contributes to a substantial economy burden that exceeds nearly 50 billion dollars annually (2). In India, the number of people complaining low back pain is increasing and is a matter of concern.
The low back pain could be due to various reasons such as trauma, bad posture, abrupt or unwarranted movements, overloading, tumor, osteoporosis etc. The risk factors associated with the development of this pain are heavy manual labor, repetitive lifting, and twisting, postural stress, whole body vibration, monotonous work, poor physical fitness, poor inadequate trunk strength, and other psychosomatic factors. The most commonly affected structures in back ache are vertebral bodies, intervertebral disc, posterior intervertebral joints, ligaments and muscles, nerves et cetera. Usually these patients present with discomfort, pain, tenderness, muscle spasm, restriction of movements of lumbosacral spine, limitation of day to day activity etc in lumbosacral area. Sometime it may be associated with various signs and symptoms of neurological origin irrespective of its stage of clinical presentation that is acute, sub-acute, and chronic. The severity of this condition is assessed by routine clinical examination including neurodynamic tension testing such as straight leg raise (SLR), slump test, and modified slump test etc and various diagnostic procedures such as, plain x-ray scan, MRI scan, electromyography etc. Leg pain is a frequent accompaniment to low back pain, arising from disorders of neural or musculoskeletal structures of the lumbar spine.
Differentiating between different sources of radiating leg pain is important to make an appropriate diagnosis and identify the underlying pathology. Patients are commonly thought to be having altered neurodynamics that is the interaction between nervous system mechanics and physiology. These type of pain are called radiating pain and the condition is considered as radiculopathy. Mostly this radiculopathy means pain in the distribution of sciatic nerve and is invariably due to the disc herniation and this is called as sciatica. Pain usually begins in the lower back radiating to the sacro-iliac regions, buttocks, and thighs. Radicular pain usually extends below the knee and present with signs and symptoms of sensory, autonomic or motor nerve alone or in combination of all of these.
Presently these patients are treated by various systems of medicine such as, allopathy, homeopathy, ayurvedic, unani, yogic science, chiro practice, acupuncture etc. Conservative allopathic management includes bed rest, treatment of underlying cause, pain by NSAIDs, physiotherapy, orthotics, modification of activities and working environments and ergonomic and educational advices.
Physiotherapy management includes electrotherapeutics such as, superficial and deep heating modalities, transcutaneous electrical nerve stimulation (TENS), interferential therapy (IFT) et cetera and therapeutic exercises such as mobilization and manipulation techniques, stretching and strengthening exercises, neural mobilization, posture correction and ergonomic programs.
Neural mobilization is based on neurodynamics .Neurodynamics is now a more excepted term referring to the integrated biomechanical, physiological and morphological function of the nervous system. Neural mobilizations are used for treatment of adverse neurodynamics .The benefit of such technique include facilitation of nerve gliding, reduction of nerve adherence, dispersion of noxious fluids, increase in neurovascularity and axoplasmic flow (3) .
Neurodynamic assessment techniques are incorporated into treatment involving passive movement of the nerve relative to its environment. Such mobilizing techniques are described extensively throughout the physiotherapy and biomedical literature (4-7)
Treatment avoids pain and mobilizes nerve tissue in conjunction with the surrounding tissue to avoid painful stretching which will further mechano sensitize the nerve tissue. Treatment aims to decrease pain related to movement and bodily position and therefore restores normal movement, posture, and hence function.
Manipulation therapy such as Maitland, McKenzie, Mulligan techniques et cetera are also used in treatment of both neural and non-neural types of low back pain. Many authors have worked with Mulligan’s technique on Sustained natural apophyseal glides (SNAG), mobilization with movement (MWM), spinal mobilization with limb movement (SMWLM), and traction with straight leg raise (TSLR). The SNAG used to have beneficial effects on the low back pain .Very few studies has been taken place to study the effect of SNAG of Mulligan technique on low back pain with lumbar radiculopathy. Study has shown that Mulligan’s SNAG mobilization technique used to have decrease of pain or centralization of the pain. This phenomenon of centralization is recognized as a positive prognostic change and can be used as a treatment method in clinical practice (8).
Mulligan has described the traction with straight leg raise (TSLR), which is said to improve the range of straight leg raise in patients with low back pain with or without referred thigh pain .It is a single painless intervention said to have an immediate benefit. The traction with straight leg raise (TSLR) movement induces posterior pelvic rotation and thereby flexion of the lumbar spine as well as flexion of the hip.
This study is to find effectiveness of neural mobilization over mulligan traction with Straight Leg Raise technique in the treatment of lumbar radiculopathy.
6.1 NEED FOR THE STUDY
Low back pain is not only a disabling condition but also has significance impact on the sufferer. So, various systems of medicine are trying their best to give maximum functional recovery within short time. The various treatments used for non-radicular pain are little different from the radicular type of pain. The non-radicular pains are treated with conservative medical management procedure such as short wave diathermy (SWD), microwave diathermy (MWD),ultrasound therapy (UST), interferential therapy (IFT), transcutaneous electrical nerve stimulation (TENS), manual therapy, ergonomics, postural education etcetera. The principles of treating a radicular pain includes rest, anti-inflammatory medication such as NSAIDs, lumbar traction, superficial and deep heating modalities, manual therapy, neural mobilization principles, orthotics, ergonomics etc.
There are various studies that are Neural mobilization and Mulligan’s traction with straight leg raise technique (TSLR) have been proved to have some beneficial effects in lumbar radiculopathy. Most of these studies are having many limitations such as number of subjects participated in study, the actual effect of the techniques on neural tissue, the consistency of the effect in long run et cetera. This study would like to measure the above techniques effects. Till today there are no studies which have compared the effects of neural mobilization and Mulligan’s traction with straight leg raise technique (TSLR).
So this study is also primarily intended to compare the effects of Butler neural mobilization over the Mulligan’s traction with straight leg raise technique (TSLR) in lumbar radiculopathy.
6.2 OBJECTIVE OF STUDY
(A) OBJECTIVE :
1)  To study the effects of Butler neural mobilization on lumbar radiculopathy.
2)  To study the effects of Mulligan’s traction with straight leg raise technique (TSLR) on lumbar radiculopathy.
3)  To compare the effects of Butler neural mobilization over Mulligan’s traction with straight leg raise technique (TSLR) in lumbar radiculopathy.
(B)HYPOTHESIS
NULL HYPOTHESIS
There is no significant difference between Butler neural mobilization (Group I) over Mulligan traction with straight leg raise technique (Group II) on functional ability in lumbar radiculopathy.
ALTERNATIVE HYPOTHESIS
There is significant difference between Butler neural mobilization (Group I) over Mulligan traction with straight leg raise technique (Group II) on functional ability in lumbar radiculopathy.
6.3 REVIEW OF LITERATURE
REVIEW OF NEURAL MOBILIZATION
1)  Butler DS (1991) (9) stated that the neural system is a dynamic organ spanning the entire body. The mobility of this system is such that it can act dependently or independently of the structures it spans .When changes imparted in one area of the neural system it may affect the whole system. Therefore, distal mobilization of the sciatic nerve affects the nerve roots at lower lumbo sacral level.
2)  Shacklock (10) stated that the neuraxis, meninges and spinal canal forms a mechanical triad .The nervous system as a whole is a mechanically and physiologically continuous structure from the brain to the distal end of the peripheral nerves; therefore, movement at one end affects the whole system and concluded that movement at the ankle joint helped in mobilizing the sciatic nerve proximally at lumbosacral level.
3)  Kornberg, McCarthy (11) studied on a blood flow to the peripheral neural tissue under stretch and concluded that mobilization of the nervous tissue increases peripheral blood flow due to physiological shift towards the parasympathetic dominance, which resulted in reducing pain and inflammation.
4)  Nordin M(12) had done a study on somatosensory potential and reported that the mechanical stimulation of peripheral nerve had altered the outcome measures like pain , therefore they implicated that repositioning of the neural structures by neurodynamic movements can reduce pain .
5)  Hung GC(13) had done a review on peripheral nerve biomechanics and concluded that nerve mobilization was a therapeutic technique that had received favorable acceptance as a management approach for neurogenic pain syndromes, the anatomic and biomechanical considerations include: nerve mobility and stress /strain characteristics in both upper and lower extremities , and mechanism and consequences of trauma on nerve microcirculation as well as influence on axoplasmic and lymphatic flow within peripheral nerve .
6)  Lee Herington (14) concluded that mobilization of the nervous system had emerged as a significant adjunct to the treatment of peripheral nerve injuries .Two alternate techniques had been proposed; the sliders and tensioners technique and both of them had been found to have a positive effect on the range of motion and other outcome measures.
7)  Xavier AV and Farrel CE (15) studied the effects of neural mobilization of sciatic nerve in 21 subjects, and concluded that treatment of the distal portion of nerve by neural mobilization relieved distal pain and score of Visual analog scale (VAS) was decreased to 70%.
8)  Laessoe U , Paterson PM (16) studied on stretch tolerance on 10 healthy individuals and reported that nerve tissue might be a possible limiting factor in range of motion and suggested that the increase in range of motion (with no corresponding change in length of torque) by stretch exercise , could result from mobilization of a nervous tissue .
9)  Butler DS (2000) (6) stated that clinicians use neurodynamic mobilization for the treatment of nerve root and peripheral nerve related symptoms in the low back and the lower extremity pain.
10) Akalin (2002), Coppeiters (2004), Garfinkle (1998) and Rozmaryn (1998) (17-20) found out the efficacy of neural mobilization for peripheral nerves (mostly upper extremity) has been reported in the literature.
11) Jean-Michel Brismee et al (21) stated clinically refute the idea that neurodynamic mobilizations of the lower extremity resolve/prevent nerve root adhesions through movement (i.e., breaking or preventing scar tissue).
12) Butler and Gifford (1989) (22) reported that tissue specific effect such as, Change in blood flow (Rydevik 1992, Igarashi et al 2005); Flushing of metabolites (Chen 1997; Butler 2000); Restoration of axoplasmic transport (Rydevik 1984; Dahlin and Rydevik 1991), contribute to the overall health of the nerve and reduce symptoms.
Review of Mulligan traction SLR technique
1)  Hall T (23) had done a study on mulligan traction SLR technique, with 12 subjects in experimental group, this study aimed to determine the immediate effects of mulligan tractional leg raise technique on range of the SLR test, a further aim was to determine whether the presence of lower quarter mechanosensitive neural tissue influence the outcome .Following the intervention, there was a significant increase in range of SLR by 11 degree in experimental group.
2)  Kerry K. Gilbert et al (2008) (21) stated in their clinical considerations for lumbosacral nerve root displacement and strain during mobilization of the lower extremity that SLR traction and neurodynamic mobilization using the hip strategy produced statistically more displacement in the lateral recess compared to the ankle strategy and the strain values were minimal during the neurodynamic strategies evaluated in this study.
3)  Gilbert et al (21) stated that while straight leg raise traction the lumbosacral roots move the most with hip mobilization but it may require substantial range of motion to get the roots to move much .On the other hand the lumbosacral roots do not move substantially during conservative lower extremity neural mobilization. Clinically neurodynamic mobilization may be effective at reducing patient’s symptoms, however in lumbosacral root it is not likely that these mobilizations help due to the abolition of scar tissue.
4)  Meszaros et al (24) Investigated the effect of harness applied traction on the range of straight leg raise in subjects with low back pain. Their result indicated that 5 minutes of traction improved straight leg raise mobility by 12%.
Reviews related to SLR
1)  Boland and Adams (25) studied the effect of dorsiflexion on range of passive SLR and on inter rater reliability and concluded that dorsiflexion significantly reduce SLR range by a mean of 90, similarly, high inter rater reliability was found for SLR and SLR with dorsiflexion .Therefore it was implicate that dorsiflexion could be used as sensitization component in SLR while assessing sciatic nerve.
2)  Lasegue (1864) and Dyck (1983) (26-27) mentioned in their literature that straight raise leg technique have been used for over 100 years with low back pain patients.