Comparison of Repeated Versus Sustained Lumbar Extension

COMPARISON OF REPEATED VERSUS SUSTAINED LUMBAR EXTENSION

WITH END – RANGE EXHALATION IN DERANGEMENT SYNDROME SUBJECTS

SANCHITA MUKHERJEE

Dissertation research proposal

SUBMITTED TO

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

In partial fulfilment of the requirements for the degree of

MASTER OF PHYSIOTHERAPY (M.P.T)

MUSCULOSKELETAL AND SPORTS

Under the guidance of

Dr. R. DEV ANAND (PT)

Department of physiotherapy

HOSMAT HOSPITAL EDUCATIONAL INSTITUTE

Bangalore

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE

ANNEXURE-ӀI

PROFORMA FOR REGISTERATION OF SUBJECTS FOR

DISSERTATION

1. / Name of the Candidate
and Address / SANCHITA MUKHERJEE
80 feet road , near laggere ring road bridge, Bangalore -58
2. / Name of the Institution / HOSMAT Hospital Education Institute
COLLEGE OF PHYSIOTHERAPY,
Laggere , Bangalore
3. / Course of study and subject / Master of Physiotherapy (MPT)
Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy
4. / Date of admission to Course / JUNE 2013
5. /

Tittle of The Topic:

Comparison of Repeated versus Sustained Lumbar extension with End – Range Exhalation – in Derangement syndrome subjects

CONTENTS

6. INTRODUCTION

6.1 Background of study……………………………………………………04

6.2 Statement of problem…………………………………………………...05

6.3. Aim of study …………………………………………………………...06

6.4 Hypothesis………………………………………………………………06

6.5 Clinical significance……………………………………………………06

6.6 Operational definition…………………………………………………..06

6.7 Review of literature……………………………………………………..07

7. METHODOLOGY…………………………………...... 10

7.1. Research Design………………………………………………………..10

7.2 Study setting…………………………………………………………….10

7.3 Inclusion criteria…………………………………………….…………..09

7.4 Exclusion Criteria………………………………………………………11

7.5 Sampling……………………………………………………..………….11

7.6 Outcome measures………...…………………………………………….12

7.7 Procedure …...………………………………………………………..…13

7.8 Procedure for Outcome measures……………………………………….13

7.9. Procedure for Intervention……………………………………………...16

7.10. Statistical analysis……………………………………………………..17

8. LIST OF REFERENCES………………………………………….……18

9. Appendix I ………………………………………………………………..21

10. Appendix II …………………………………………………………….. 22

11. Assessment Form ………………………………………………………..23

6. INTRODUCTION

6.1 Background of study

Low back pain (LBP) is the second most common reason for patients seeking primary care1. During any six month period, 72% of adults in general population will report LBP and 11% report disabling LBP 2. While many systems have been proposed for the classification and treatment of LBP, three of these , received considerable literature – the Delitto’s classification, the Mckenzie system and Quebec Task Force classification 3.Of these, the Mckenzie method has been one of the most widely used accepted physical therapy approaches with significant external validity and reliability in diagnosis and management.4,5

According to Mckenzie’s classification, spinal disorders can be classified as – derangement, dysfunction and postural syndrome. Of these, derangement syndrome is the most prevalent treatment classification. In a recent survey, 57 mckenzie trained therapists in 18 countries, collected details of 607 subjects with back pain and concluded that 83% were classified as having derangement syndrome6.

Repeated movements are diagnostic of derangement syndrome as well as confirms the directional preference of management strategy. Directional preference is closely related to pain centralisation and indicates direction of force required to centralise the pain7. The key symptomatic response that confirms derangement is centralisation; described as the progressive reduction and abolition of distal pain in response to therapeutic loading strategies like repeated end-range and static end- range loading7. Subjects who can centralise their pain, numbness or lower extremity tingling during repeated lumbar motion testing seem to function better than patients who cannot centralise. Centralisation has been correlated with excellent overall outcomes, greater reduction in pain intensity, higher return to work rates and greater functional improvement8.

In routine clinical practice, it is evident that certain factors like pain severity and irritability profoundly influence the therapeutic outcome during process of centralisation. Also, a significant barrier to effective treatment is the patient’s non – adherence9. Even if the information is communicated effectively, much of what is conveyed during follow up is forgotten9. Other factors associated with severity of back pain are abnormal psychological distress, fear – avoidance , cultural variations, beliefs and attitudes. Subjects usually become apprehensive to movement when they perform lumbar extension as they use their discretion, fearing the occurrence of lumbar pain and thus may not actually perform maximal extension10.

The various loading principles applied in managing derangement syndrome include – extension, flexion and side glide principle11. The preferred loading for 70 -80% population with derangement require the extension principle12.. It can be achieved with static loading or repeated extension. Though repeated extensions are preferred mode of treatment strategy, end – range exhalation with sustained loading is also performed to reach terminal extension limits. According to Robin Mckenzie, last 3 to 4 repetitions should be sustained with exhalation for 5 seconds ; in a fully relaxed sagged position. Allowing the abdomen to sag to the couch, produces maximum possible self – generated extension. Sustained lumbar extension with end-range exhalation (SLE-ERE), though routinely performed, has not been focussed much in literature as compared to repeated lumbar extension11. Additionally, literature suggests that exhaling deeply, activates deep stabilising muscles, by engaging transverse abdominis, thus facilitating the back to sag further.

Considering the clinical issues,the present study aims to evaluate the effectiveness of two strategies – repeated or SLE-ERE on subject’s low back pain and lumbar range of motion(ROM).

6.2.Statement of problem

There is insufficient literature regarding the effects of SLE – ERE on LBP & lumbar ROM in derangement syndrome subjects.

6.3 AIM OF STUDY

To evaluate the effect of SLE-ERE in improving lumbar ROM & LBP.
To evaluate the effect of repeated lumbar extensions (RLE) in improving lumbar ROM & LBP.
To compare the outcome of RLE versus SLE-ERE in LBP.

6.4 HYPOTHESIS

Null hypothesis

There will be no significant effect of SLE-ERE on LBP and lumbar ROM in derangement syndrome subjects.

Alternative hypothesis

The effect of SLE-ERE on LBP & lumbar ROM will be greater than or equal to the effects of RLE in derangement syndrome subjects.

6.5 Clinical significance

If the study proves SLE-ERE equally or better effective than RLE, it may be routinely utilized in management of derangement syndrome. Subject’s apprehension of movement may be minimized and focus on exhalation in extension may aid in achieving lumbar ROM and reduction of LBP.

6.6 Operational definition13

Moderate irritability: Refers to presence of moderate severity of LBP and/or referred pain (4 – 6 / 10 on VAS), with/without intermittent night or rest pain. Additionally, the pain may be through range or at end range with moderate disability in flexion.

6.7 Review of literature

Derangement syndrome & centralisation

Derangement syndrome refers to central symmetrical or unilateral asymmetrical spinal pain pattern that is produced, increased, peripheralized in one direction and abolished, decreased, centralized in another direction11. The centralization is also associated with restoration of normal movement, in response to therapeutic loading strategies.

The centralisation phenomenon occurs when distal limb pain emanating from spine, is immediately or eventually abolished in response to the application of loading strategies14

Directional preference is closely related to pain centralisation and indicates the direction of force required to centralise pain.14

The therapeutic loading strategies can be accomplished by subject (self - generated or overpressure) or by therapist’s intervention .16 Subjects may perform movements actively by recruiting muscular structures that specifically move or maintain positions of spinal joint structures concerned. It is divided into static and dynamic subject generated forces . Force introduced by the therapist may be combined with, or apart from subject -generated forces. Clinician-introduced forces range from overpressure, mobilization to manipulation.16

Posterior derangement – Extension Principle

Extension loading has beneficial mechanical or symptomatic responses at the mechanically impeded end – range only(including centralisation), the point at which the accumulated intradiscal nuclear material is compressed and returned to more central location.15,16

Extension is mechanically impeded because of the accumulation and compression from deranged intradiscal nuclear material.17

Lumbar extension tends to reduce stresses in posterior annulus in discs that exhibit the lowest compressive stress in neutral posture. The posterior annulus can be stress shielded by neural arch in extension.18,19, 20

Challenges to Subject’s Performance

Patient non- adherence can be a pervasive threat to health and wellbeing. Some crucial elements are beliefs, attitudes, cognitive, cultural context, subject’s involvement and participatory decision making , interpersonal factors and irritability.9

Irritability refers to the relationship among the amount of activity required to provoke patient’s symptoms, magnitude of those symptoms and time – taken to subside. When evaluating, subject’s pain severity and irritability interaction is used to guide the therapist’s examination and treatment decisions.21

Subject’s trust in their physicians and their beliefs incongruent with their therapist’s instruction also plays important role in fear – avoidance and affects the treatment outcome9.

Centralisation is found to be significant predictor of subject’s performance. Mckenzie hypothesised that movement of intervertebral disc is the mechanism underlying progressive movement of pain towards spinal midline.22

Repeated versus sustained lumbar extension with end – range exhalation

In derangement syndrome , repeated movements in the direction that produces greater deformation of spinal structures will produce, increase or peripheralise symptoms. Repeated movements are diagnostic of derangement syndrome as well as confirming the directional preference of the management strategy.15

The greatest extension stretch can be achieved in lying position when compared to extension in standing which is comparatively less.11

Sustained positions can be very important procedures in derangements. Some derangements respond better to sustained loading rather than repeated movement.

Administration of static loading with end range exhalation is hypothesised to facilitate the back to sag further and increase lumbar ROM11.

V . OUTCOME MEASURES

THE INCLINOMETER technique has been shown to be a reliable and valid method (intrarater correlations were proved to be high with correlation coefficients from 0.90 to 0.99) for measurement of lumbar ROM.24

The iHandy Level application – is a free application with a visual display similar to that of a digital inclinometer in regard to numeric size. The application uses the built – in accelerometer of mobile phones/tablet devices and a digital display for angle measured. It is both reliable and comparable to bubble inclinometry with good reliability and concurrent validity.25

VISUAL ANALOGUE SCALE (VAS) measures multiple dimensions of pain experience such as intensity, distress and pain anticipation.Reliability of the VAS for disability is moderate to good 26, 27

VAS has high test – retest reliability. Reliability of VAS for pain measurement as assessed by interclass correlation co-efficient appears to be high (95% CI = 0.96 to 0.98)26, 28

STRAIGHT LEG RAISE (SLR) - the most common lower quarter neurodynamics test is SLR 29

Fear avoidance belief questionnaire(FABQ) - The FABQ has high reliability and validity for both subscales when used with LBP subjects. FABQ have been shown to correlate with changes in disability following treatment. The total FABQ has excellent test-retest reliability

FABQ –PA (physical activity) = 0.77 and FABQ –W(work) = 0.8830

Modified Oswestry disability index - Modified Oswestry Disability Index (MODI) is a valid, reliable, and responsive condition-specific assessment tool commonly used outcome measures for individuals with LBP. Test-retest reliability has been shown to behigh (r = 0.83 to 0.99)and vary according to the time interval between measurements.31

7. Methodology

7.1. Research design

Randomised trial

7.2. Study setting –

Out – patient Department, department of physiotherapy, HOSMAT ,Bangalore

7.3. Inclusion criteria

Age – group– 20 -55 years at onset
Back pain with or without referred symptoms
Derangement syndrome – Central symmetrical
Intermittent back pain / mechanical LBP
Moderate irritability or more
Moderate severe or more

7.4. Exclusion criteria

Spinal stenosis
Subjects with side glide deformity
Subjects with dysfunction syndrome
Severe pain
LBP in pregnancy
Hip disorders
Spondylisthesis
Cauda – equine syndrome
Neurological deficits
Progressive motor weakness in lower limb
Bladder dysfunction
Possible serious spinal pathology (cancer, infection and fracture)
Inflammatory disorders
Psychological disorders
Osteoporosis

7.5. SAMPLING

Sample size - 60 subjects

Sample population - Any LBPsubjects referred to OPD , department of physiotherapy , Hosmat hospital between January 2014 – December 2014.

Method of sampling – Purposive Sampling

Materials –

a)Inclinometer – ihandy application of smart phone

b)Plinth

c)VAS

d)Questionnaire – FABQ and ODI

7.6. OUTCOME MEASURE

PRIMARY OUTCOME MEASURES

Lumbar extension ROM in prone lying (LE-PRONE) – iHandy / inclinometer
Lumbar flexion ROM in standing (LF-STAND) – iHandy / inclinometer
Pain severity (VAS)

SECONDARY OUTCOME MEASURES

Passive Straight leg raise (PSLR) – Inclinometer / iHandy
Fear – avoidance belief questionnaire (FABQ)
Modified Oswestry disability index (MODI)

7.7. Procedure –

The subjects will be recruited from OPD of HOSMAT hospital. The aim and objective of study will be explained to the subjects. Subjects will be evaluated according to Mckenzie evaluation form (Appendix VI) and classified into one of the three syndromes. The subjects willing to take part in study will be scrutinized for inclusion and exclusion criteria and included in study. The subjects meeting the inclusion and diagnostic criteria will be selected and will be requested to sign the consent form. The subjects will be measured the outcome measures for baseline assessment and then randomized into one of the two groups.

7.8. Procedure for measuring Outcome measures

The researcher will be handing the following questionnaires to the subject – VAS , MODI and FABQ . any questions regarding the questionnaire will be answered by the researcher to ensure subject appropriately answering the questionnaire.

PAIN (Appendix III)

Pain intensity will be explained and evaluated by means of visual analogue scale(VAS), ranging from 0 to 10cm, where the subjects will be instructed to mark a point according to their pain level during their worst position /lumbar flexion.

PERCIEVED DISABILITY (Appendix V)

MODI will be used to capture subjects perceived level of disability due to derangement syndrome. It consists of 10 – item scale, where each item is scored from 0 – 5 and a final score is expressed in percentage. In modified version of ODI, it is not necessary to score all the items given in the questionnaire. Subjects has to mark only the applicable items. The subjects will be requested to fill MODI. The scoring will be done by number of items scored divided by total maximum score multiplied by hundred. The level of disability will be calculated in percentage and will be used for data analysis.

FEAR – AVOIDANCE (APPENDIX IV)

FABQ will be used to quantify subject’s avoidance of ADL due to fear of worsening LBP. It consists of set of questions that give information about avoiding their activities due to fear of pain. FABQ consists of 2 components viz fear of work and fear for physical activity and 16 – items , where each item is scored from 0-6.

Subjects will be instructed about the scoring, where 0 represents “ doesn’t agree to mentioned statement” and 6 represents “completely agrees to mentioned statement.”

The subjects will be informed to score 3 if they are not sure about the statement given. The score is calculated for physical activity and work and expressed in percentage.

For physical activity item no. 6,7,9,10,12 & 15 are considered.

FABQ -PA = Max. score given by subject in items / 42 * 100

For work item no. 2,3,4 & 5 are considered

FABQ-W = Max. score given by the subject in items 2,3,4 & 5/24 *100

MEASURING LUMBAR ROM

Lumbar ROM includes flexion in standing and extension in prone lying. The subjects will be familiarised about the procedure before recording.

Flexion in standing – Lumbar ROM

It will be measured by ihandy application as inclinometer. The subject will be positioned in standing , sufficiently undressed to expose the low back and T12 and S1 will be marked.

The device will be placed on S1 and zeroed. It will be then placed on T12 and the readings will be noted. The change in inclinometer reading is the lumbar lordosis angle of the subject. The subject will be instructed to “bend forward your trunk without bending the knee” and then the device will be placed on S1 and T12 and the readings will be recorded. Three trials of the same procedure will be performed and average of the reading will be considered for data analysis. A rest interval of 5 minutes will be provided between the trials to avoid intolerance to the procedure.

ii) Extension in Prone – Lumbar ROM

In the similar way, to measure lumbar extension in prone, the subjects will be positioned in prone on a standardised plinth with palms down under the shoulder and will be asked to “lift the upper body by straightening your elbows, and arch your back. During the procedure keep the abdomen & spine relaxed, allowing low back to arc.” The readings will be noted.

Three trials of the same procedure will be performed and average of the reading will be considered for data analysis. A rest interval of 5 minutes will be provided between the trials to avoid intolerance to the procedure.

The formula to calculate Lumbar ROM =

[(Reading at T12 at end range – reading at T12 initial position) – (reading at S1 end – range reading at S1 initial position)]

STRAIGHT LEG RAISE 24

The subject will be positioned in supine lying and instructed “ relax and don’t rotate your hip either side”and “indicate when you start feeling pain as the movement is performed”. The inclinometer device will be placed on the shin of tibia to be tested and zeroed. Therapist will passively raise the affected leg till the first time subject complains pain(P1) and therapist also feel the initial resistance(R1) while performing passive SLR. The angle is measured. Three trials will be conducted and the average will be used for data analysis. A rest interval of 2 – 3 minutes will be provided between the trials to avoid intolerance to the procedure.

7.9. PROCEDURE FOR INTERVENTION

The subjects will be randomly assigned into group A(control) and group B (experimental), by 6 concealed allocation blocks of 10 each.

Group A (lumbar extension – repeated )

Position - The subjects starts in prone – lying position, with hands palm down under the shoulders.

Procedure - subjects will be instructed to perform prone – press ups ; such that top half of the body is only raised by straightening their arms , while the pelvis and thigh remain relaxed and are allowed to sag with gravity. The subject will be encouraged to stretch as much possible and stop immediately as the pain increases/ peripheralises / bothersome to subject and return to neutral. Wait for 5 minutes for the symptoms to subside. The subject shall be ensured about his/her status and asked if he/she wills to continue the procedure. In case of any event, the same shall be noted in subjects assessment form.