Master of Physiotheapy in Musculoskeletal Disorders and Sports (Mpt)

RESEARCH PROPOSAL

A STUDY TO ASSESS THE EFFECTIVENESS OF PILATES AND THE CONVENTIONAL CORE STABILIZATION EXERCISES ON PAIN AND DISABILITY IN CHRONIC NON-SPECIFIC LOW BACK PAIN - A RANDOMIZED CONTROLLED STUDY

MASTER OF PHYSIOTHEAPY IN MUSCULOSKELETAL DISORDERS AND SPORTS (MPT)

MS. D’SA CASSANDRA FATIMA

DEPARTMENT OF PHYSIOTHERAPY

FATHER MULLERS MEDICAL COLLEGE

MANGALORE – 575002

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / MS. D’SA CASSANDRA FATIMA
DEPARTMENT OF PHYSIOTHERAPY
FATHER MULLER MEDICAL COLLEGE
MANGALORE-575002
2. / NAME OF THE INSTITUTION / FATHER MULLER MEDICAL COLLEGE
MANGALORE(PHYSIOTHERAPY)
3. / COURSE OF THE STUDY / MASTER OF PHYSIOTHERAPY (MUSCULOSKELETAL AND SPORTS PHYSIOTHERAPY)
4. / DATE OF ADMISSION TO THE COURSE / 31-05-2010
5. / TITLE OF THE TOPIC /

A STUDY TO ASSESS THE EFFECTIVENESS OF PILATES AND THE CONVENTIONAL CORE STABILIZATION EXERCISES ON PAIN AND DISABILITY IN CHRONIC NON-SPECIFIC LOW BACK PAIN – A RANDOMISED CONTROLLED STUDY

BRIEF RESUME OF THE INTENDED WORK.
6.1 NEED FOR THE STUDY:
Low Back Pain has been recognized as a common condition that affects public
health in adults and adolescents. In India nearly 60% of the population has significant low back pain at some point in life.1 Studies indicate that prevalence of symptoms of LBP in working aged adults is 50%.2
The vast majority of patients (upto 90%) are labeled as having non- specific low back pain; which is defined as symptoms without a clear specific cause that is low back pain of unknown origin. Non- specific low back pain is usually classified according to the duration as acute(less than 6 weeks), sub-acute(between 6 weeks and 3 months) or chronic (longer than 3 months) low back pain.3
There are different treatments given for low back pain out of which spinal stabilization exercises are found to be very effective. The spine consists of active, passive and neural elements. The active components are muscles that surround the spine. The muscles are the transverse abdominis, multifidus, diaphragm, pelvic floor muscles, quadrates lumborum, internal and external oblique. These muscles are found to play a very important role in spinal stability.4
Joseph H pilates developed the comprehensive program known as the pilates method in 1920. Pilates is being hailed as “the fastest growing exercise technique worldwide”. Pilates is a mind body conditioning exercise program that targets the deep postural muscles of the abdomen and spine to improve overall central core stability and posture. Pilates is a mind body centering technique in which movement is generated from the core and flows outwards. The key elements of modified Pilates include retraining of Neutral lumbo-pelvic alignment and activation of the key lumbo-pelvic stabilising muscles, Correct ribcage/thoracic alignment, Scapulo-thoracic stabilisation, Deep neck flexor retraining to stabilise the cervical spine.The modified pilates include exercise to improve spinal mobility, flexibility of the key trunk and lower limb muscle groups, body awareness and postural awareness.5
The medical world is now realizing the benefits of pilates method for the prevention and rehabilitation of back injuries. In order to prevent the occurrence of back pain, it is essential to retrain the deep abdominal muscles and spinal muscles. Pilates focuses on building an efficient central core. In pilates central core refers to the transverse abdominis, multifidus, pelvic floor muscles and the diaphragm. In pilates abdominal hallowing techniques are utilized to activate this central core. Pilates then challenges this central core by introducing graduated arm and leg movements.5
The diaphragm interdigitates with transverse abdominis, hence the diaphragm helps in maintaining core stability along with the transverse abdominis. If the diaphragm is used in breathing, it looses its function as a core stabilizer. In pilates, we use lateral breathing and not diaphragmatic breathing as we don’t want the diaphragm to be used in breathing.
Core stability is a generic description for the training of the abdominal and lumbo pelvic region. To define core stability, the combination of a global and local stability system has been used. The global stability system refers to the larger, superficial muscles around the abdominal and lumbar region, such as the rectus abdominis, paraspinals and external oblique. Local stability refers to the deep intrinsic muscles of the abdominal wall, such as the transverse abdominis and multifidus. These muscles are associated with the segmental stability of the lumbar spine during gross whole body movements.6
This study is being done to find out the effectiveness of pilates in the treatment of chronic non-specific low back pain.
OPERATIONAL DEFINITIONS
1.Chronic non specific low back pain
Chronic low back pain has been defined as pain and discomfort localized below the coastal margin and above the inferior gluteal folds with or without referred leg pain for at least 12 weeks that is not attributed to a recognisable known specific pathology is known as chronic non- specific low back pain.7
2.Pilates
Pilates is a mind body conditioning exercise program that targets the deep postural muscles of the abdomen and spine to improve overall central core stability and posture.5(Appendix-E)
3.Core Stability
Core stability is a generic description for the training for the abdominal and lumbo pelvic region. To define core stability, the combination of a global and local stability system has been used.
The global stability system refers to the larger, superficial muscles around the abdominal and lumbar region, such as the rectus abdominis, paraspinals and external obliques.
The local stability refers to the deep, intrinsic muscles of the abdominal wall, such as the transverse abdominis and multifidus.6(Appendix-F)
RESEARCH QUESTION:
Is Pilates effective in reducing pain and disability as a treatment of chronic non specific low back pain?
HYPOTHESIS:
Pilates is effective than the conventional core stabilization exercises as a treatment of chronic non-specific low back pain.
NULL HYPOTHESIS:
Pilates is not effective than the conventional core stabilization exercises as a treatment of chronic non-specific low back pain.
6.2 REVIEW OF LITERATURE:
Hodges and Richardson have added that the function and co-ordination of the muscles as stabilizers are reduced in low back patients.4
The Australian Physiotherapy and Pilates Institute have found delayed onset of activation and poor activation of transverse abdominis in low back pain patients compared to healthy controls.In healthy individuals the transverse abdominis activates prior to limb movement to provide postural support to the lumbar spine.In low back pain patients transverse abdominis activation occurs after the limb movement and therefore renders the lumbar spine unsupported during functional activities. A model for retraining motor control of the transverse abdominis is provided as a part of Modified Pilates.5
Hodges proposes that the transverse abdominis, multifidus, the diaphragm and the pelvic floor muscles are co-activated to form an enclosed abdominal ring termed a cylinder of stability. This closed cylinder of stability allows the contraction of transverse abdominis to generate an increased intra abdominal pressure to increase lumbar stability. Activation of these 4 muscles is required to increase the pressure in the abdominal cavity to increase spinal stability. This cylinder of stability is termed as the central core. Pilates focuses on building an efficient central core.6
In this review Roy La Touche and Karla Escalante demonstrated all positive effects, such as improving general functions and reduction in pain when applying the pilates method in treating non-specific chronic low back pain in adults.8
Joseph E. Muscolino and Simona Cipriani. The Pilates method of body conditioning may be generalized to have three major effects upon the powerhouse. First, Pilates affects the posture of the pelvis, which results in postural changes to the lumbar spine. Second, it works directly upon the musculoskeletal structure of the spine (the lumbar spine in particular) by strengthening, stretching, and lengthening the spine. Third, Pilates affects the structural integrity or tone of the abdominopelvic cavity as a whole.9
6.3 OBJECTIVES OF THE STUDY:
•  To study the effectiveness of Pilates as a treatment of chronic non specific low back pain.
•  To study the effectiveness of core stabilization exercises as a treatment of chronic non-specific low back pain.
•  To compare the effectiveness of Pilates and core stabilization exercises as a treatment of chronic non-specific low back pain.
7. MATERIALS AND METHODS:
7.1 SOURCE OF DATA :-
§  Patients with chronic non-specific low back pain, who come to the physiotherapy department will be taken for the study-Fr. Muller Medical College Hospital.
§  Patients with chronic non-specific low back pain all around mangalore will be taken for the study.
7.2 METHOD OF COLLECTION OF DATA :
STUDY DESIGN:-
Randomized controlled study
SAMPLE SIZE AND SAMPLE PROCEDURE:-
A sample of size 40 will be selected using purposive sampling technique. Informed consent (Appendix-A) will be taken from the subjects and preliminary data will be collected using the proforma (Appendix-B).
INCLUSION CRITERIA:
§  Chronic low back pain for at least 12 weeks
§  Age between 18-45 years
§  Patient is otherwise medically fit to perform exercises
EXCLUSION CRITERIA :
•  Back pain attributed to any other pathology
•  Malignancy’s
•  Major surgery within the past years
•  Radiating pain
OUTCOME MEASURES
·  Pain
Visual Analouge Scale10
·  Disability
Roland Morris Disability Questionnaire11
TOOLS :
§  Visual Analouge Scale
§  Roland Morris Disability Questionnaire
METHOD OF THE STUDY
The study will be conducted in the physiotherapy OPD, subjects with chronic non specific low back pain meeting the inclusion criteria will be taken for the study and randomized into two groups using www.randomisation.com. The pre intervention readings will be taken for pain with Visual Analouge Scale and for disability with Roland Morris Disability Questionnaire. Individuals in group 1 will receive pilates and hot moist pack, individuals in group 2 will receive core stabilization exercises and hot moist pack.
The duration of the exercise will be for 3 times in a week, for 2 weeks.
The outcome following the intervention will be measured at the end of 2 weeks.


RANDOMISATION









After 2 weeks

STATISTICAL ANALYSIS
Collected data will be analysed by paired and unpaired t-test.
7.3 Does the study require any investigation or intervention to be conducted on patients or animals?
Yes
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes
8. LIST OF REFERENCES :
1.  Koley S, Singh G , Sandhu R. Severity of Disability in Elderly Patients with Low Back Pain in Amritsar, Punjab. Anthropologist 2008;10(4): 265-268.
2.  Herrington L., Davies R. The influence of Pilates training on the ability to contract the transverse Abdominis muscle in asymptomatic individuals. Journal of bodywork and movement 2005; 9: 52-57.
3.  Middelkoop M.V., Rubinstein S.M., Verhagen A.P., Ostelo R.W., B.W. Koes, and Van Tulder M.W. Exercise therapy for chronic non specific low back pain. Doi:10.1016/j.berh.2010.01.002;24:193-204.
4.  Richardson C., Jull G., Hodges P., Hides J. Textbook of Therapeutic Exercise for spinal segmental stabilization in low back pain,Scientific basis and clinical approach.1999;Churchill Livingstone.
5.  The Australian Physiotherapy and Pilates Institute. Lower Ground Floor, 50-52 Kilburn High Road. London. NW6 4HJ.
6.  Marshall P.W. and Murphy B.A. Core stability exercises on and off a swiss ball.2005;86:242-9.
7.  O.Airaksinen; J. Hildebrandt; A.F. Mannion; H.Ursin; J.I. Brox; J. Klaber-Moffett; S.Reis; G. Zanoli; C. Cedraschi; F.Kovacs and J.B. Staal. European guidelines for the management of chronic non-specific low back pain.2004;2:30
8.  Touche R.L., Escalante K., Linares M.T. Treating non specific low back pain through the pilates method. Journal of bodywork and movement therapy 2007;11.004.
9.  Muscolino J.E., Cipriani S. Pilates and the “powerhouse”. Journal of bodywork and movement therapies 2004; 8: 15-24.
10.  Jensen M.P.; Turner J.A.; Romano J.M.; Fisher L.D. Comparative reliability and validity of chronic pain intensity measures.1999;83(2):157-162
11.  Brouwer S., Kuijer W.; Dijkstra P.U.; Goeken L.N.H.; Groothoff J.W.; Geertzen J.H.B. Reliability and stability of the Roland Morris Disability Questionnaire.2004;26(3):162-165

APPENDIX-A

CONSENT FORM

I, ______hereby agree to provide my fullest consent and co-operation as a subject for the dissertation work of Ms. Cassandra Fatima D’sa titled “To study the effectiveness of pilates compared to the conventional core stabilization exercises on pain and disability in chronic non specific low back pain ” as a part of her post- graduation in physiotherapy.

The possible benefits as well as the procedure and duration of the study have been explained to me. The questions and queries I have posed have been answered to my satisfaction and I am aware that my identity will be kept confidential. I am also aware that I can discontinue the study at anytime I wish to do so.

Place:

Date: Signature

APPENDIX-B

PROFORMA

Name
Age
Gender / Male/Female
Address
Date of assessment
History of trauma / Yes/no
Back pain?
Pain (Visual Analogue Scale)
Disability(Roland Morris Disability Questionnaire) /
Pre-Intervention Score:

Post-Intervention Score:
Pre-Intervention Score:

Post-Intervention Score

APPENDIX- C

Low Back Pain Disability Questionnaire of Roland and Morris

Overview: Roland and Morris developed a questionnaire for evaluating patients with low back pain. This can be used to determine the level of patient disability and can help measure outcome following therapeutic intervention. The authors are from St. Thomas' Hospital in London.

NOTE: The questionnaire is usually paired with a visual analogue scale (VAS) for pain rating ranging from no pain at all to unbearable pain.

Questions answered based on how they pertain to the patient today: (1) I stay at home most of the time because of my back.
(2) I change position frequently to try and get my back comfortable.
(3) I walk more slowly than usual because of my back.
(4) Because of my back I am not doing any of the jobs that I usually do around the house.
(5) Because of my back I use a handrail to get upstairs.
(6) Because of my back I lie down to rest more often.
(7) Because of my back I have to hold on to something to get out of an easy chair.
(8) Because of my back I try to get other people to do things for me.
(9) I get dressed more slowly than usual because of my back.
(10) I only stand up for short periods of time because of my back.
(11) Because of my back I try not to bend or kneel down.
(12) I find it difficult to get out of a chair because of my back.
(13) My back is painful almost all the time.
(14) I find it difficult to turn over in bed because of my back.
(15) My appetite is not very good because of my back pain.
(16) I have trouble putting on my socks (or stockings) because of pain in my back.
(17) I only walk short distances because of my back pain.
(18) I sleep less well because of my back.
(19) Because of my back pain I get dressed with help from someone else.
(20) I sit down for most of the day because of my back.
(21) I avoid heavy jobs around the house because of my back.
(22) Because of my back pain I am more irritable and bed tempered with people than usual.
(23) Because of my back I go upstairs more slowly than usual.
(24) I stay in bed most of the time because of my back.
Response / Points
Yes / 1
No / 0

APPENDIX-D