EFFECT OF SLUMP STRETCHING WITH STATIC SPINAL EXTENSORS FOR THE MANAGEMENT OF NON RADICULAR LOW BACK

EFFECT OF SLUMP STRETCHING WITH STATIC SPINAL EXTENSORS FOR THE MANAGEMENT OF NON RADICULAR LOW BACK PAIN AMONG NONACTIVE SPORTS PERSONS Thesis Submitted to the Ramakrishna Mission Vivekananda University for the award of the degree of DOCTOR OF PHILOSOPHY IN PHYSIOTHERAPY (Interdisciplinary)

Submitted by T.KARTHIKEYAN, M.P.T (Reg.No: V08PHDP011) Under the Guidance of Dr .S. JAIHIND JOTHIKARAN (Supervisor) DR.B.S.PRADEEP KIRAN (Co- Supervisor)

RAMAKRISHNA MISSION VIVEKANANDA UNIVERSITY FACULTY OF GENERAL AND ADAPTED PHYSICAL EDUCATION AND YOGA COIMBATORE-641020 INDIA OCT, 2011 1

T.KARTHIKEYAN, M.P.T Physiotherapist, (A Division of Neurological Rehabilitation Unit under D.P.N.R) National Institute of Mental Health and Neuro Sciences, (NIMHANS) (A Govt of India Deemed to be University, Institute Being National Importance) Bangalore-560029.

Karnataka,India

DECLARATION

I, T.KARTHIKEYAN hereby declare that the thesis entitled ―EFFECT OF

SLUMP STRETCHING WITH STATIC SPINAL EXERCISE FOR THE MANAGEMENT OF NON RADICULAR LOW BACK PAIN AMONG NON ACTIVE SPORTS PERSONS” submitted to the Ramakrishna Mission Vivekananda University in partial fulfilment of the requirements for the award of the Degree of Doctor of Philosophy in physiotherapy (Interdisplinary) is

record of

original and independent research work done by me during the period of 2008-2011 under the supervision and guidance of Dr.S.Jaihind Jothikaran, Former Professor, Faculty of General and Adapted Physical Education and Yoga Ramakrishna Mission Vivekananda University Coimbatore and it has not formed the basis for the award of any Degree/Diploma/ Associate ship/Fellowship or other similar title to any candidate of any University.

Signature of the Candidate

2

Dedicated to Shridi Sai Baba, My Family and Friends for their Unconditional Support 3

ACKNOWLEDGEMENT

I am deeply indebted to my guide Dr.S.Jai Hind Jothikaran (Former Prof) Faculty of General and Adapted Physical Education and Yoga, Ramakrishna Mission Vivekananda University, Coimbatore without whose unstinted guidance and suggestions, a study of such a magnitude would have not been materialized.

I am equally grateful to Dr. Pradeep Kiran B.S, Consultant sports Medicine Specialist, and Rhea health care, Bangalore, for his continuous support, able guidance and constant encouragement throughout the course of the study.

I am deeply indebted to Dr. S.Alagesan (Professor

& Head) Faculty of

General and Adapted Physical Education and Yoga Ramakrishna Mission Vivekananda University, Coimbatore without whose unstinted guidance and suggestions, a study of such a magnitude would have not been materialized.

I am extremely thankful to Swami Anuraganandhaji Maharaj, Ramakrishna Mission Vidyalaya, who initiated, encouraged and provided me the opportunity to complete this research work.

I am very thankful to Dr.V.Shanmugam, Research Assistant (Biostatistics) National Institute of Mental Health and Neuro Sciences, Bangalore for helping me in statistical analysis and providing me all the help to solve the problems I faced during my dissertation.

I am thankful to Dr. P.Satish Chandra (Director & Vice-chancellor), and Dr. A.P.Taly, HOD (Division of Neuro-Rehabilitation unit under D.P.N.R), NIMHANS, for providing me all the facilities for this study.

4

I am thankful to Dr. Anupam Gupta (Associate Prof/Division of NeuroRehabilitation unit under D.P.N.R), NIMHANS, for providing me all the facilities for this study.

My sincere thanks to Prof. B.N.Gangadhar, (Prof/ Dept of Psychiatry), and D.Nagaraja (Prof/Dept of Neurology) NIMHANS for encouraging me to do research work.

I am thankful to my parents, my elder brothers, his wife, his children and my brother in law (Er.I.Balamurugan).

I am extremely thankful to the Almighty GOD for giving me the opportunity and without him I could not have been here today.

My thanks to all other contributors, especially my parents, my beloved daughter (Ms.Sai Ghayathri) wife & whose names I have not mentioned, but though they all deserve my gratitude.

I

am

thankful

to

Mrs.

Pradnya

Rajesh

Dhargave

(Senior

Physiotherapist/Division of Neuro-rehabiltation unit under D.P.N.R), NIMHANS, providing me all the facilities for this study and also my colleagues Mr.NaveenVenkatesh,Mr.V.SelvaGanapathy,Mr.SujoeThomas,Mr.Sendhil Kumar, Mrs.M. Nithya Murali, Mrs.Valli Nayaki, and Mr.V.L.Rajesh.

Last but not least I would like to thank all the subjects of my study, without whom, this study would have not been possible.

T.KARTHIKEYAN 5

ABSTRACT Background: Low back pain is one of the commonest conditions which almost every person suffer. There are several techniques devised to manage low back pain. Many patients get relief with method of mobilization which is very popular. Another method is slump stretching which not only diagnoses the mechanosensitivity of spinal nerves but if used with appropriate techniques can be used as a form of treatment.

Objective: The aim of the study is to find out the effect of slump stretching for the management of non radicular low back pain among non active sports persons.

Method: 40 subjects were included in this study. They were equally divided in two groups. One group was given mobilization technique with static spinal exercise (20Control group with non- active sports subjects) and another was given slump stretching with static spinal exercises (20-Intervention group with non -active sports subjects).

Results: Percentage change in scores of NPRS for pain post intervention in mobilization

group

and

the

slump

stretching

group

was

found

to

be

significant(57.17%, 90.47%, respectively p value ≤ 0.001).Short term disability was assessed by ODI score. Percentage change in score post intervention in both groups was also found to be significant (83.16% -Intervention group, 82.46 % -Control group).

Conclusion: The present Study concluded that the slump stretching is beneficial in the management of patients with non- radicular low back pain. Along with Slump stretching, lumbar spine mobilization and exercise were beneficial in reducing pain, reducing short-term disability and promoting centralization of symptoms in the selected group of patients.

Key words: NPRS, FABQW, FABQPA, FABQT, and ODI, Slump Test, Neural Tissue, Slump stretching, lumbar mobilization 6

Chapter No 1 2 3 4 5 6 7 CHAPTER I 1.1 1.2 1.3 1.4 1.4.1 1.4.2 1.5 1.5.1 1.5.2 1.5.3 1.5.4 1.6 1.6.1 1.6.2 1.6.3 1.7 1.7.1 1.7.2 1.7.3 1.7.4 1.8 1.8.1

LIST OF CONTENT Title Declaration by scholar Dedication Acknowledgement Abstract List of Table List of figures List of Appendices

Page. No 2 3 4-5 6 16-19 20-21 22

INTRODUCTION The Problem and its settings Epidemiology of low back pain Low back pain statistics Anatomical and pathophysiological concepts The Minor IntervertebralDerangement theory of Maigne (MID) Comment Types of LBA Low back pain Acute low back pain Sub acute low back pain Chronic low back pain Other types of LBP Non specific low back pain Non radicular low back pain or spondylogenic referred pain Mechanical low back pain Aetiology Major causes of low back leg pain presenting in the author'general practice patients percentage Non-radicular pain (Spondylogenic referred pain) Vertebral dysfunction with non- radicular low back pain Causes of buttock pain Assessments of LBP Nature of the pain

23-53 23 23 24 25 25 27 27 27 27 27 28 28 28 28 28 28 29 30 31 31 31 31 7

1.8.2 1.8.3 1.8.4 1.8.5 1.8.6 1.8.7 1.8.8 1.9 1.9.1 1.9.2 1.9.3 1.9.4 1.10 1.10.1 1.10.2 1.10.3 1.10.4 1.10.5 1.10.6 1.10.7 1.10.8 1.10.9 1.11 1.11.1 1.11.2 1.11.3 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20

Key questions Physical examination The main components of the physical examination were Important landmarks Inspection Movements of the lumbar spine Palpation Diagnosis Neural Tension Tests Straight Leg Raise (SLR) Slump Test Diagnosing "Nerve Pain" and Understanding Neurodynamics Treatment Neurodynamics Neural structure Autonomic nervous system Stretching Ballistic stretching Dynamic stretching Active stretching Static stretching Isometric stretching General therapeutic effect stretching General relaxation of stretching General indications of stretching Contra indication Mechanical therapy Need for the study Objectives Significance of the study Statement of the Problem Hypothesis Delimitation of the study Inclusion criteria of the study Operational definition of terms

33 33 33 34 34 34 35 36 36 36 37 39 41 41 43 44 44 44 45 45 45 45 45 47 47 48 48 49 50 50 50 50 51 51 51 8

1.20.1 1.20.2 1.20.3 1.20.4 1.20.5 1.20.6 1.20.7 1.20 1.20.8 1.20.9 1.20.10 CHAPTER II 2.1 2.1.1 2.1.3 2.1.4 2.1.5 2.1.6 2.1.7 2.1.8 2.1.9 2.1.10 2.1.11

Slump test Stretching Non- active sports persons Centralization of symptoms Periperalization of symptoms Low back pain Difference between slump test and slump stretching Operational definition of terms Stress Physiotherapy Mobilization REVIEW OF RELATED LITERATURE Review related to the physiotherapeutic intervention targeting slump stretching

Review of related literature to SLR Test Reviews related to Neurodynamic tests Reviews related to Static (Isometric) spinal exercise Reviews related to Slump stretching Reviews related to Mobilization and exercise Reviews related to Manual therapy Reviews related to FABQW, FABQPA, FABQ Reviews related to ODI Review of related literature NPRS Review of related literature Bio-Mechanics of the spine 2.1.12 Review of related literature specific exercise protocols for LBP 2.1.13 Review of related literature to prevention low back pain 2.1.14 Review of related literature to phenomenon among spinal condition CHAPTER III METHODOLOGY 3.1 Introduction 3.2 Research design 3.2.1 Design of the study 3.2.2 Pilot study 3.3 Sampling 3.4 Description of the tools used for data collection

52 52 52 52 52 52 53 53 53 53 53 54- 76 54 55 59 59 60 64 67 70 71 72 73 74 75 76 77 - 89 77 77 77 77 77 78 9

3.5 3.5.1 3.5.2 3.5.3 3.5.4 3.5.5 3.5.6 3.6 3.6.1 3.6.2 3.6.3 3.6.4 3.6.5 3.6.6 3.7.

3.7.1 3.7.2 3.7.3 3.8 3.9 3.9.1 3.10 3.11 3.12 3.12.1 3.12.1.1 3.12.1.2 3.12.1.3 3.12.2 3.12.2.1 3.12.2.2 3.12.2.3 3.12.2.4 3.12.2.5 3.13 3.14

Numeric Pain Rating Scale 78 Pain assessment 78 Purpose 78 Administration 78 Scorin 79 Indicatio 79 Instructions 79 Fear Avoidance Beliefs Questionnaire (FABQW, 79 FABQPA (subscale), FABQT) Overview 79 Purpose 80 Administration 80 Scoring 80 Interpretation 80 Performance 80 Modified Oswestry Disability Index (ODI) 81 Administration 82 Interpretation 82 ODI Scoring 82 Materials 82 Methodology 82 Source of data 83 Sample selection 83 Administration of the scales 83 Treatment Procedure 83 Control group 83 Instructions 84 Indications 84 Contra indications 84 Intervention group 85 Instructions 85 Slump stretch Note 86 Warnings 86 Stretching do‘s 86 Stretching Don‘ts 86 Treatment procedure 87 Home programme 87 10

3.14.1 3.15 3.16 3.17 3.18 CHAPTER IV 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.7.1 4.8 4.8.1 4.8.2 4.8.3 4.8.4 4.8.5 4.9 4.9.1 4.9.2 4.9.3 4.9.4

Follow up Static spinal exercises Clinical utility Outcome measures Statistical technique used Ethical clearance RESULTS AND DISCUSSION Introduction about statistical methodology Results with frequency distribution in age both the groups Results with frequency distribution of both the group genders Results with frequency distribution in duration of illness for both the group Results with frequency distribution the treatment strategy both the group Results with Frequency distribution of two different types of sports for both the groups Comparison of pain outcome measures of the two groups Measurement scales Results of Numeric Pain Rating Scale Mean and standard deviations of NPRS (Control group) for the three stages Mean and standard deviations of NPRS (Intervention group)for the three stages Comparison between intervention and control group through NPRS Percentage of pain reduction in NPRS (Control group) Percentage of pain reduction in NPRS (Intervention group) Results of Fear Avoidance Belief Questionnaire Work subscale Mean and standard deviations of FABQW (Control group)subscale for three stages Mean and standard deviations of FABQW (Intervention group)subscale for three stages Comparison between intervention and control group through the(FABQW) sub scale Percentage of pain reduction in FABQW subscale (control group)

88 88 88 89 89 90- 160 90 91 92 92 93 94 95 95 96 96 98 100 101 102 102 102 104 106 107

11

4.9.5 4.10 4.10.1 4.10.2 4.10.3 4.10.4 4.10.5 4.11 4.11.1 4.11.2 4.11.3 4.11.4 4.11.5 4.12 4.12.1 4.12.2 4.13 4.13.1 4.13.2 4.13.3 4.13.4 4.13.5 4.14

Percentage of pain reduction in FABQW sub scale (Intervention group) Results of Fear Avoidance Belief Questionnaire Physical Activity Mean and standard deviations of FABQPA (Control group)subscale for three stages Mean and standard deviations of FABQPA (Intervention group)subscale for three stages Comparison between intervention and control group through the (FABQPA) sub scale Percentage of pain reduction in FABQPA sub scale (control group) Percentage of pain reduction in FABQPA Subscale (Intervention group) Results of Fear Avoidance Belief Questionnaire Total Mean and standard deviations of FABQT (Control group) for three stages Mean and standard deviations of FABQT (Intervention group) for three stages Comparison between intervention and control group through the (FABQT) Percentage of pain reduction in FABQT (control group) Percentage of pain reduction in FABQT (Intervention group) Results FABQ Mean of FABQW, FABQPA (subscale) and FABQT for three stages (Control group) Mean of FABQW, FABQPA (subscale) and FABQT for the three stages (Intervention group) Results of Oswestry Disability Index Mean and standard deviations of ODI (Control group) for three stages Mean and standard deviations of ODI (Intervention group) for three stages

108

Comparison between intervention and contro group through the (ODI) Percentage of pain reduction in ODI (Control group) Percentage of pain reduction in ODI (Intervention group) Results of Correlation analysis

127

108 108 110 113 114 115 115 115 117 119 120 121 122 122 122 123 123 125

128 129 130 12

4.14.1 4.14.2 4.15 4.15.1 4.15.2 4.16 4.16.1 4.16.2 4.17 4.17.1 4.17.2 4.18 4.18.1 4.18.2 4.19 4.19.1 4.19.2 4.20 4.20.1 4.20.2 4.21

Analysis of pearlson correlation for post intervention 2 scores (Control group) Analysis of pearlson correlation for post intervention 2 scores (Intervention group) Results & Analysis of genders through the post intervention 2NPRS Analysis of genders through the post intervention 2 NPRS(Control group) Analysis of genders through the post intervention 2 NPRS(Intervention group) Results & Analysis of genders through the post intervention 2FABQ Analysis of genders through the post intervention 2 FABQ (Control group) Analysis of genders through the post intervention 2 FABQ(Intervention group) Results & Analysis of genders through the post intervention 2ODI (control group) Analysis of genders through the post intervention 2 ODI (control group) Analysis of genders through the post intervention 2 ODI(Intervention group) Results & Analysis of two type of sports through the post intervention 2 NPRS Analysis of two type of sports through the post intervention 2 NPRS(Control group) Analysis of two different type of sports through the post intervention 2 NPRS (Intervention group) Results & Analysis of two types of sports through the post intervention 2 FABQ Analysis of two types of sports through the post intervention 2 FABQ(Control group) Analysis of two types of sports through the post intervention 2 FABQ (Intervention group) Results & Analysis of two types of sports through the post intervention 2 ODI Analysis of two types of sports through the post intervention 2 ODI (control group) Analysis of two types of sports through the post intervention 2 ODI (Intervention group) Results & Analysis of duration of illness through the post intervention 2 NPRS

130 130 131 131 131 132 132 132 133 133 133 134 134 135 135 135 136 136 136 137 138

13

4.21.1 4.21.2 4.22 4.22.1 4.22.2 4.23 4.23.1 4.23.2 4.24 4.24.1 4.24.2 4.25 4.25.1 4.25.2 4.26 4.26.1 4.26.2 4.27 4.28 4.29 4.30 4.31 4.32

Analysis of duration of illness through the post intervention 2 NPRS (Control group) Analysis of duration of illness through the post intervention 2 NPRS (Intervention group) Results & Analysis of duration of illness through the post intervention 2 FABQ Analysis of duration of illness through the post intervention 2 FABQ (Control group) Analysis of duration of illness through the post intervention 2FABQ (Intervention group) Results & Analysis of duration of illness through the post intervention 2 ODI Analysis of duration of illness through the post intervention 2 ODI (Control group) Analysis of duration of illness through the post intervention 2 ODI (Intervention group) Results & Analysis of treatment distribution through the post intervention 2 NPRS Analysis of treatment distribution through the post intervention 2 NPRS(Control group) Analysis of treatment distribution through the post intervention 2 NPRS (Intervention group) Results & Analysis of treatment distribution through the post intervention 2 FABQ Analysis of treatment distribution through the post intervention 2 FABQ (Control group) Analysis of treatment distribution through the post intervention 2 FABQ (Intervention group) Results & Analysis of treatment distribution through the post intervention 2 ODI Analysis of treatment distribution through the post intervention 2 ODI (Control group) Analysis of treatment distribution through the post intervention 2 ODI (Intervention group) Discussion on findings NPRS scale FABQ FABQPA FABQT ODI

138 139 140 140 141 142 142 142 143 143 144 144 144 145 145 145 146 147 147 149 150 151 153 14

4.33 4.34 4.35 4.36 4.37 CHAPTER V 5.1 5.2 5.2.1 5.2.2 5.3.

5.4

Socio demographic variables 154 Plausible physiological explanation for findings 157 Therapeutic effects 157 Slump test 158 Framing rationale behind existing system of slump 159 stretching SUMMARY, CONCLUSIONS & 160-166 RECOMMENDATIONS Summary 160 Conclusion 162 Reason for findings 163 Clinical findings 163 Suggestions and Implications of this study 164 Recommendations 164 BIBLIOGRAPHY 166-173 Books 167-168 Journals 168-173 Websites 173

15

LIST OF TABLES Table. No Title 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

Page.

No Comparison of the patterns of pain for Inflammatory 30 and mechanical causes of low back pain (The clinical approach) Common cause of non-radicular low back pain 31 Assessment part of low back pain population 36 Control group treatment protocols 83 (Mobilization and exercise group) Intervention group treatment protocols (Slump stretching 85 group) ANOVA summary table for the general simple Repeated 89 Measures ANOVA was as follows Frequency distribution of age in both group 91 Frequency distribution of both group genders 92 Frequency distribution of duration of illness for both the 92 groups Frequency distribution of the treatment strategy of both group 93 Frequency distribution of two types of sports for both the 94 group Mean and standard deviations of NPRS (Control group) for 96 the three stages One way Repeated Measure Anova 97 Post hoc comparisons 98 Mean and standard deviations of NPRS (Intervention group) 98 for the three stages One way Repeated Measure Anova 98 Post hoc comparisons 99 Comparison between intervention and Control group through 100 NPRS Repeated Measure Anova 100 Mean and standard deviations of FABQW (Control group) 102 subscale for three stages One way Repeated Measure Anova 103 Post hoc comparisons 104 Mean and standard deviations of FABQW (Intervention 104 group) subscale for three stages One way Repeated Measure Anova 104 Post hoc comparisons 105 Comparison between intervention and control group through 106 the(FABQW) sub scale Repeated Measure Anova 106 16

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

Mean and standard deviations of FABQPA (Control group) subscale for the three stages One way Repeated Measure Anova Post hoc comparisons Mean and standard deviations of FABQPA subscale (Intervention group) for the three stages One way Repeated Measure Anova Post hoc comparisons Comparison between intervention and control group through the FABQPA sub scale Repeated Measure Anova Mean and standard deviations of control group (FABQT) for the three stages One way Repeated Measure Anova Post hoc comparisons Mean and standard deviations of intervention group (FABQT) scale for the three stages One way Repeated Measure Anova Post hoc comparisons Comparison between Intervention and Control group through the FABQT Repeated Measure Anova Mean and standard deviations of ODI Score (Control group) for the three stages One way Repeated Measure Anova Post hoc comparisons Mean and standard deviations of ODI score (Intervention group) for three stages One way Repeated Measure Anova Post hoc comparisons Comparison between Interventions and Control group through the ODI Repeated Measure Anova Analysis of correlation between the scales (NPRS, FABQT and ODI for and Age in Control group post intervention 2 scores Analysis of correlation between the scales (NPRS, FABQT and ODI for and Age in Intervention group post intervention 2score Comparison of mean post intervention 2 NPRS scores between male and female in Control group (Independent sample t test)

108 109 110 110 111 112 113 113 115 116 117 117 118 119 119 120 123 124 125 125 126 127 127 128 130

130

131

17

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

Comparison of mean post intervention 2 NPRS scores between male and female in intervention group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between male and female in Control group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between male and female in Intervention group (Independent sample t test) Comparison of mean post intervention 2 ODI scores between male and female in Control group (Independent sample t test) Comparison of mean post intervention 2 ODI scores between male and female in Intervention group (Independent sample t test Comparison of mean post intervention 2 NPRS scores between contact and non contact sports in Control group (Independent sample t test) Comparison of mean post intervention 2 NPRS scores between contact and non contact sports in Intervention group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between contact and non contact sports in Control group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between contact and non- contact sports in Intervention group (Independent sample t test) Comparison of mean post intervention 2 ODI scores between contact and non- contact sports in control group Independent sample t test) Comparison of mean post intervention 2 ODI scores between contact and non-contact sports in Intervention group (Independent sample t test) Comparison of mean post intervention 2 NPRS scores between upto 2 months duration of illness and more than 2 months in Control group(Independent sample t test) Comparison of mean post intervention 2 NPRS scores between upto 2 months duration of illness and more than 2 months in Intervention group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between upto 2 months duration of illness and more than 2 months in Control group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between upto 2 months duration of illness and more than 2 months in Intervention group (Independent sample t test)

131

132

132

133 133

134

135

135

136

136

137

138

139

140

141

18

70.

71.

72.

73.

74.

75.

76.

77.

78.

Comparison of mean post intervention 2 ODI scores between upto 2 months duration of illness and more than 2 months in Control group (Independent sample t test) Comparison of mean post intervention 2 ODI scores between upto 2 months duration of illness and more than 2 months in Intervention group(Independent sample t test) Comparison of mean post intervention 2 NPRS scores between no previous therapy and undergone therapy in Control group (Independent sample t test) Comparison of mean post intervention 2 NPRS scores between no previous therapy and undergone therapy in Intervention group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between no previous therapy and undergone therapy in control group (Independent sample t test) Comparison of mean post intervention 2 FABQ scores between no previous therapy and undergone therapy in Intervention group (Independent sample t test) Comparison of mean post intervention 2 ODI scores between no previous therapy and undergone therapy in control group (Independent sample t test) Comparison of mean post intervention 2 ODI scores between no previous therapy and undergone therapy in Intervention group (Independent sample t test) Mean comparisons between J.A. Cleland et al 2006 and Present study

142

142

143

144

144

145

145

146

155

19

Figure.No 1 2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16 .

17.

18.

19.

20.

21.

22.

23.

24.

LIST OF FIGURES Title The epidemiology The anatomy of lumbar vertebrae Reflex activity from a MID in the intervertebral motion segment Relevant causes of back pain with associated buttock and leg pain The general history of low back pain The movements of the lumbar spine Illustration of SLR test (Neuro dynamic test) Illustration of slump test Column diagram showing the frequency Distribution of age (For both the groups) Coloumn diagram showing socio demographic variables of both genders Column diagram showing the duration of Illness (For both the groups) Column diagram showing the frequency distribution of treatment strategy (For both the groups) Column diagram showing the frequency distribution of type of sports (For both the groups) Line diagram showing the Mean score of NPRS (control group) Line diagram showing the mean score of NPRS (intervention group) Line diagram showing the mean score of NPRS (for both the groups) Column diagram showing the percentage of pain reduction in NPRS(control group) Column diagram below showing the percentage of pain reduction in NPRS(Intervention group) Line diagram showing the mean score of FABQW subscale (control group) Line diagram shows the mean score ofFABQW subscale (Intervention group) Line diagram showing the mean score of subscale FABQW (For both the groups) Column diagram shows the percentage of pain reduction in FABQW (Control group) subscale Column diagram showing the percentage of pain reduction in FABQW (Intervention group) subscale Line diagram showing the mean score of FABQPA subscale (Control group)

Page.No 24 25 26 29 32 35 37 38 91 92 93 94 95 97 99 101 101 102 103 105 107 107 108 110 20

25.

26.

27 .

28 29.

30.

31.

32 .

33.

34.

35.

36.

37.

38 39.

40.

Line diagram showing the mean score of FABQ (Intervention group) subscale Line diagram showing the mean score of FABQPA(For both the groups) subscale Column diagram showing the percentage of pain reduction in FABQPA subscale (Control group) Column diagram showing the percentage of pain reduction in FABQPA subscale (Intervention group) Line diagram showing the mean score of FABQT (Control group) Line diagram showing the mean score of FABQT (Intervention group) Line diagram showing the mean score of FABQT (For both the group) Line column diagram showing the percentage of pain reduction in FABQT (Control group) Column diagram showing the percentage of pain reduction in FABQT (Intervention group) Line diagram showing the mean score of FABQW, FABQPW & FABQT (Control group) Line diagram showing the mean score of FABQW, FABQPW & FABQT (Intervention group) Line diagram showing the mean score of ODI (Control group) Line diagram showing the mean score of ODI (Intervention group) Line diagram showing the mean score of ODI (For both the groups) Column diagram showing the percentage of pain reduction of ODI (Control group) Column diagram showing the percentage of pain reduction of ODI(Intervention group)

112 114 114

115 117 119 120 121 121 122 123 125 127 128 129 129

21

ANNEXURE

ANNEXURE

TITLE

PAGE NO

ANNEXURE ANNEXURE I ANNEXURE II ANNEXURE III ANNEXURE IV ANNEXURE V ANNEXURE VI ANNEXURE VII ANNEXURE VIII ANNEXURE IX ANNEXURE X ANNEXURE XI ANNEXURE XII ANNEXURE XIII ANNEXURE XIV ANNEXURE XV ANNEXURE XIV ANNEXUREXVII

I to XVII Assessments Performa Subject Consent form Subject information form Ethics committee approval letter NPRS (Numeric Pain Rating Scale) FABQ (Fear Avoidance Belief Questionnaires) ODI (Oswestry Disability Index) Copy of advertisement Guidelines of back care advice Raw data of NPRS Raw data of FABQ Raw data of ODI Illustration of slump stretching Slump stretching (Home Program) Illustration of pelvic tilt- 1 Illustration of pelvic tilt- 2 Permission letter from NIMHANS

173-197 173-175 176 177-179 180 181 182-183 184-186 187 188-189 190 191 192 193 194 195 196 197

22

CHAPTER I 1. INTRODUCTION Take up on one idea. Make that one idea in your life – Think of it, dream of it and live on that idea. Let the brain, muscles, nerves, every part of your body, be full of that idea, and just leave every idea alone. This is the way to success. The world is the great gymnasium where we come to make ourselves strong - Swami Vivekananda

1.1 The problem and its settings Low back ache (LBA) is the most common condition seen by a physiotherapist in the primary health care. The goal for the therapist in managing these patients is to select the appropriate treatment strategies for individual patients. The clinical reasoning process required to achieve this goal starts with a diagnostic classification that categorizes the patient into a recognizable group with a particular pattern of signs and symptoms. The medical professionals in primary care most commonly classify these patients as patho-anatomically labeled categories. However, there appears to be a wide diversity in the opinion as to the patterns of signs and symptoms that constitute a category (Kent et al. 2003).

LBA is a major public health problem seen all over the world. Back pain (sometimes referred to generally as lumbago) is a common musculoskeletal disorder causing pain in the lumbar vertebrae.

It can be classified as acute, sub-acute or chronic on the basis of its clinical presentation. Typically the symptoms of LBA do show significant improvement within two to three months from its onset. In a significant number of individuals, LBA tends to be recurrent in nature with a waxing and waning quality to it. In a small proportion among the patients, this condition can become chronically problematic. Population studies have shown that the back pain affects mostly adults at a productive, active phase of life and accounts for significant sickness absenteeism and disability than any other single medical condition (Waddell et al. 1998).

1.2 Epidemiology of low back ache Epidemiologic studies on LBA, conducted in a number of countries, strongly suggest that it is a very common condition seen internationally and imposes a significant social and economic burden on society. Of the total population, 60% to 90% will experience an episode of LBA at any time, the annual incidence being 5%. Statistics in the Netherlands show that 27% of all patients referred to physiotherapists have LBA. Most people suffer incapacitating back pain at some stages of their lives. On any given day, an estimated of 6.5 million people in the United States are bedridden due to back pain and approximately 1.5 million new cases of back pain are seen by physicians in each month. There has been growing concern about the low back disability in western society (Nachemson et al. 1976). In India, the occurrence of low back ache is also alarming; nearly 60% of the people in India have significant backache at some time or the other in the lives (Sharma et al. 1999).

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1.3 Low Back Ache statistics 15-20% of US adult population experience back pain every year. Out of that number, another 15-20% requires medical care for a minimum of 3 years (Sharma et al. 1999).  90% LBA resolve in 6 weeks.  5% LBA resolve in 12 weeks.  <1% LBA serious spinal disease.  <5% LBA true nerve root pain.

Figure 1: Diagram showing the epidemiology of LBA Disabilities associated with low back ache (LBA) continues to raise, contributing to a substantial economic burden on the society in excess of over 50 billion annually in the United States alone (Frymoyer et al. 1992).

Comparative studies have shown that the health care expenditures among individuals with LBP are 60% greater than those without LBA and physical therapy accounting for 37% of the costs (Luo et al. 2004).

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Physical therapists utilize a wide range of interventions in the management of LBA; however, evidence for the effectiveness of these interventions are limited (Philadelphia et al. 2001).

Given that LBA is a heterogeneous condition, it does not seem reasonable to expect that all patients will be benefited from a single treatment approach. Rather, the key is to identify subgroups of patients with a high probability of achieving a successful outcome with a particular intervention.

Evidence suggests that short and long term outcomes are improved when a classification based approach is used compared to decision- making based on clinical practice guidelines (Fritz et al.

2003).

To date, evidence for several subgroups of LBA exists, such as patients likely to benefit from manipulation, lumbar stabilization, and specific directional exercises (Childs et al.2004).

One subgroup that has not been readily examined is patients with more distal symptoms that are not improved with specific directional exercise (i.e. Flexion, or extension oriented exercise).These patients are commonly thought to be experiencing altered neuro-dynamics, the interaction between nervous system mechanics and physiology (Shacklock et al. 1995a, b).

Figure 2: Diagram showing the anatomy of lumbar vertebrae (Christopher Norris M. 1993) 1.4 Anatomical and pathophysiological concepts 1.4.1 The Minor Intervertebral Derangement theory of mine (MID) Recent evidence based studies have focused on the importance of disruption of the intervertebral disc which cause the back pain. A very plausible theory has been advanced by (Maigne et al. 1986) who proposes the existence, in the involved mobile segment, of a minor intervertebral derangement (MID). He defines it as an â&#x20AC;&#x2014;isolated pain in one intervertebral segment, of a mild 25

character, and due to minor mechanical causeâ&#x20AC;&#x2DC; which is usually reversed by manipulation. It is independent of radiological and anatomical disturbances of the segment. The most common clinical situation occurs where the vertebral level was found to be painful and yet have a normal static and radiological appearance (MID).

Figure 3: Diagram showing Reflex activity from a MID in the intervertebral motion segment (Peter Brukner and Karim Khan.1993) Reflex activity from a MID in the intervertebral motion segment Apart from the local effect caused by the disruption of the disc (A), interference can occur in the facet joint (B) and interspinous ligament (C) leading possibly to muscle spasm (D) and skin changes (E) via the posterior Rami reproduced with permission from C. Kenna and J. Murtagh.

1997).

The MID always one of the two epiphyseal joints in the mobile segment, thus initiating nociceptive activity in the posterior primary dermatomes and myotome. The overlying skin is tender to pinching and rolling, while the muscles are painful to palpation and feel cord like.

Maigne et al. (1986) Points out that the functional ability of the mobile segment depends upon the condition of the intervertebral disc, thus if the disc is injured, the other elements of the segment will be affected. Even a minimal disc lesion can produce epiphyseal joint dysfunction which is the reflex cause of protective muscle spasm and pain in the corresponding segment, with loss of function. The end result is the avoidance of painful pressure or movement of the involved segment.

This becomes fixed and the condition tends to be self-perpetuating. Similarly, any movement causing a false movement in that segment will re-initiate the process.

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1.4.2 Comment This case was the most common back problem. The precise pathophysiology was difficult to be pin pointed but invariably was dysfunction of one of the spinal joints, most likely an epiphyseal joint or MID as proposed by (Maigne et al. 1986).

1.5 Types of LBA 1.5.1 Low back Ache LBA is a feeling of pain, discomfort or disability which is commonly generated through the lower back area. It involves waist to the sacrum that is composed of bone, muscles, tendons, facet joint, discs, nerve root, blood vessels and skin. Pain can be experienced either locally at the site of injury, or transferred into more distant areas. There are different pain levels depending on the pathology occurred (Braggins et al. 2000). It is often due to spasm or stiffness in the muscle that run along the spine which are extended to the buttocks or thigh.

1.5.2 Acute low back ache Acute low back ache is defined as pain that occurs between 0 to 6 weeks duration (Quittan et al. 2002).

The common problem of low back ache caused by facet joint dysfunction and/or limited disc disruption usually responds well to the following treatment. The typical patients are aged 20-55 years, and experience no radiating pain below the knee. (Gibson et al. 2002) The basic management of the patient with uncomplicated chronic back pain should follow the following guidelines: 

Back education program.



Encouragement of normal daily activities according to the degree of comfort.



Regular non-opioid analgesics (e.g. Paracetamol).



Physical therapy: stretching of affected segment, muscle energy therapy, spinal Mobilization or manipulation (if no contra-indication on first visit).



Prescribe exercise protocols.



Review in about 5 days (probably the best time for physical therapy)



No investigation needed initially

Most of these patients can expect to be relatively pain free in fourteen days and can return to work early (some may not miss work and this should be encouraged). The evidence also supports spinal manipulation which helps to reduce the period of disability.

1.5.3 Sub-acute low back ache Sub-acute pain is defined as pain that occurs between 6 and 12 weeks of duration (Quittan et al. 2002).

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1.5.4 Chronic low back ache Chronic low back ache (CLBA) is defined as pain that occur more than twelve weeks of duration (Quittan et al. 2002).

The basic management of the patient with uncomplicated chronic back pain should follow the clinical guidelines: 

Back education program and on -going support.



Encouragement of normal activity.



Exercise program.



Analgesics (e.g. Paracetamol).



NSAIDs for fourteen days (if inflammation, i.e. Pain at rest—relieved by activity) and review.



Trial of mobilization or manipulation (at least three treatments).

1.6 Other types of low back ache 1.6.1 Nonspecific low back ache Nonspecific LBA is pain which occurs in the lumbosacral area of the spine that may or may not have referred pain. This usually characterized by a painful range of movement limitations. It is generally considered to occur as a result of mechanical causes and is not related to any underlying condition such as infection, fracture, tumor, osteoporosis, inflammatory process, enclosing sodalities, radicular syndrome or caudal equine syndrome (Phillips et al. 2003).

1.6.2 Non radicular low back ache or spondylogenic referred pain Pain originating from any component of vertebrae, ligament, muscle, tendon, vertebral joint, facet joint, the artificial joint which referred to non- radicular or spondylogenic referred pain (Francis et al. 1874).

1.6.3 Mechanical low back ache Most back pain in patients presenting to general Practices is thought to be due to dysfunction of elements of the mobile segment – the facet joint, intervertebral joint its ligaments and muscular attachment. This is often referred to as mechanical back pain, a term referred to radicular and nonradicular pain (Francis et al. 1874).

1.7 Aetiology Carmack et al. (1980) described a comprehensive diagnostic, treatment approach of which the practitioner should have a clear understanding of the possible causes of low back and leg pain and of the relative frequency of their clinical presentations. The major causes of LBA in several hundred patients presenting to the general practice were summarized as mentioned below.

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1.7.1 Major causes of low back, leg pain presenting in the author's general practice among the patient in clinical practice Vertebral dysfunction

71.8

Lumbar spondylosis

10.1

Depression

3.0

Urinary tract infection

2.2

Spondylolisthesis

2.0

Spondyloarthropathies

1.9

Musculoligamentous strains/tears

1.2

Malignant disease

0.8

Arterial occlusive disease

0.6

Other

6.4 100.0

Figure 4: Diagram illustrates relevant causes of back pain with associated buttock and leg pain (Nataraj. 1996)

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Table 1: Comparison etiology (inflammatory and mechanical) low back ache (The clinical approach- Peter Brukner and Karim Khan.1993) Feature

Inflammation

Mechanical

History

Insidious onset

Precipitating injury/previous episodes

Nature

Aching, throbbing

Deep dull ache, sharp if root Compression

Severe

Stiffness, Prolonged morning stiffness

Moderate, transient

Effect of rest

Exacerbates

Relieves

Effect of activity

Relieves

Exacerbates

More localized, bilateral or Alternating

Tends to be diffuse, unilateral

Radiation

Intensity

Night, early morning

End of the day, following activity

1.7.2 Non-radicular low back ache (Spondylogenic referred pain) Syndrome ( lumbar pain-unilateral, central or bilateral and diagnosis of disc protrusion or epiphyseal joint dysfunction) which is most common clinical and general practice. Most cases which can be treated and enable to subside within three weeks; spinal manipulation which will help shorten duration. A typical patient have middle-aged who complains frequently sudden onset (after twisting) of right-sided back pain, localized to the fourth or fifth level in the lumbar spine and the diagnosis of dural stretch test is negative.

Spondylogenic referred pain means which originates from any of the components of the vertebrae (spondyles) including joints, the intervertebral disc and ligaments, muscular attachments.

Clinically the pain experienced in the buttocks is due to a disorder of an epiphyseal joint. Although analogous to visceral referred pain such as appendicitis or renal colic, spondylogenic referred pain must be distinguished clinically from this type of pain. There are several causes of chronic low back ache, but present studies explain the most important and identify common causes. The outstanding

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common cause is uncomplicated vertebral dysfunction causing non-radicular low back ache. This study is considered to identify dysfunction of the pain-sensitive epiphyseal joint (Francis et al. 1874).

1.7.3 Vertebral dysfunction with non- radicular low back ache This common cause of low back pain which is considered to identify dysfunction of the painsensitive facet joint. The precise pathophysiology is difficult to pinpoint (Clive Kenna and John Murtagh. 1989).

Table 2: Common cause of non-radicular low back pain (Peter Brukner and Karim Khan.1993) Spondylogenic pain

Non-radicular low back pain

Origin Ligaments Muscles Apophyseal joint Intervetebral disc Dura mater

Causes Inflammation Mechanical (Compression& strain)

Clinical features Deep, dull, aching Relieved by rest No localizing features No dermatome reference No neurological signs

1.7.4 Causes of buttock pain Spondylogenic – Pain originating from any component of vertebrae, ligament, muscle and tendon referred to spondylogenic pain is due to bone – Mainly occur in the lumbar spine, pelvis, and femur Fracture, infection, tumors –Break or discontinue of the bone or joints –Mainly occur in the lumbar facets, SIJ, hip,Arthritis, infection –Inflammation of the joints or muscles – Mainly occur in the Piriformis, gluteus medius/minimus Tears, contractors –Injury of the muscle or tendons – Mainly occur in the hamstrings.

Tears, enthesopathies –Injury of the bursae due to any sports injuries the term referred to bursitis‐mainly occur in the trochanteric

1.8 Assessments of LBA 1.8.1 Nature of the low back ache Mashford et al. (2006) describes that the nature of the pain may reveal its likely origin.

Establishing where the pain is worst-whether it is central (proximal) or peripheral. The following is general characteristics and guides to diagnose: 

Aching throbbing pain = inflammation (e.g. Sacroiliitis) 31



Deep aching diffuse pain = referred pain (e.g. Dysmenorrhoea)



Superficial steady diffuse pain = local pain (e.g. Muscular strain)



Boring deep pain = bone disease (e.g. Neoplasia, Paget's disease)



Intense sharp or stabbing (superimposed on a dull ache) = radicular pain (e.g. Sciatica).

Analyzing the history invariably guides the clinician to the diagnosis. The pain patterns have

to be carefully evaluated and it is helpful to map the diurnal variations of pain to facilitate the diagnosis.

Figure 5: Diagram showing the general history of low back pain (Peter Brukner and Karim Khan.1993) Francis Kilvert et al. (1874) described typical daily patterns of pain for conditions causing back pain. Kindly note conditions that could wake patients from sleep and also the combined mechanical and inflammatory patterns.

It was important to note that the intensity of the pain and its relation to rest and activity. In particular, ask whether the pain was present during the night, it wakes the patient, is present on raising or whether it was associated with stiffness.

Continuous pain present during the day and night is suggestive of neoplasia or infection. Pain on waking suggests inflammation or depressive illness. Pain provoked by activity and relieved by rest suggests mechanical dysfunction, while pain worse at rest and relieved by moderate activity is typical of inflammation. In some patients the coexistence of mechanical and inflammatory complicates the pattern.

LBA aggravated by standing or walking that is relieved by sitting is suggestive of spondylolisthesis. Pain aggravated by sitting (usually) and improved by standing indicates a disc problem.

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LBA that travels proximally with walking indicates vascular claudication; pain in the buttock that descends with walking indicates neurogenic claudication. This latter problem is encountered more frequently in older people who have a tendency to spinal canal stenosis associated with spondylosis.

1.8.2 Key questions for assessments of LBA 1. What is your general health like?

2. Can you describe the nature of your back pain?

3. Was your pain brought on by an injury?

4. Is it worse when you wake in the morning or later in the day?

5. How do you sleep during the night?

6. What effect does rests have on the pain?

7. What effect does activity has on the pain?

8. Is the pain worse when sitting or standing?

9. What effect does cough or sneezing or straining at the toilet has?

10. What happens to the pain in your back or leg if you go for a long walk?

11. Do you have a history of psoriasis, diarrhea, penile discharge, eye trouble or severe pain in your joints?

12. Do you have any urinary symptoms?

13. What medications are you taking? Are you on anticoagulants?

14. Are you under any extra stress at work or home?

15. Do you feel tense or depressed or irritable?

1.8.3 Physical examination Kenna et al. (1997) describes that the basic objectives of the physical examination are to reproduce the patient's symptoms, detect the level of the lesion and determine the cause (if possible) by the provocation of the affected joints or tissues. This is done using the time-honored method of joint examinationâ&#x20AC;&#x201D;look, feel, move and test function. The patient should be stripped to a minimum of clothing so that careful examination of the back can be made. A neurological examination of the lower limb should be performed if symptoms extend below the buttocks.

It is important to perform a rectal examination to check for flaccidity in a patient with a suspected cauda equina syndrome.A useful screening test for a disc lesion and dural tethering is the slump test.

1.8.4 The main components of the physical examination are 1. Inspection 2. Active movements Forward flexion (to reproduce the patient's symptoms) Extension (to reproduce the patient's symptoms) 33

Lateral flexion (R & L) (to reproduce the patient's symptoms) 3. Provocative tests (to reproduce the patient's symptoms) 4. Palpation (to detect the level of pain) 5. Neurological testing of lower limbs (if appropriate) 6. Testing of the related joints (hip, sacroiliac) 7. Assessment of pelvis and lower limbs for any deformity (e.g. leg shortening) 8. General medical examination, including rectal examination

1.8.5 Important landmarks Kenna et al. (1997) describe the surface anatomy of the lumbar region is the basis for determining the vertebral level. Key anatomical landmarks include the iliac crest, spinous processes, the sacrum and the posterior superior iliac spines (PSISs). 

The tops of the iliac crest lie at the level of the L4–5 interspace (or the L4 spinous process).

1.8.6 Inspection The inspection begins from the moment the patient is sighted in the waiting room. A patient who is noted to be standing is likely to have a significant disc lesion. Considerable information can be obtained from the manner in which the patient rises from a chair, moves into the consulting room, removes the shoes and clothes, and gets onto the examination couch and moves when unaware of being watched (Kenna et al. 1997). 

The spine must be adequately exposed and inspected in good light.



Patients should undress to their underpants; women may retain their brassiere and it is proper to provide them with a gown that opens down the back.



Note the general contour and symmetry of the back and legs, including the buttock folds, and look for muscle wasting.



Note the lumbar lordosis and any abnormalities, such as lateral deviation. If lateral deviation (scoliosis) is present it is usually away from the painful side.



Note the presence of middlemen moles, tufts of hair or haemangioma that might indicate an underlying congenital anomaly, such as spinal bifida occulta.

1.8.7 Movements of the lumbar spine Kenna et al. (1989) describes three main movements of the lumbar spine as there is minimal rotation which mainly occurs in the thoracic spine. The movements that should be tested, and their normal ranges, were as follows: Extension (20°–30°) Lateral flexion, left and right (30°) Flexion (75°–90°: average 80°)

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Figure 6: The movements of the lumbar spine (Nataraj.1993) 1.8.8 Palpation Francis et al. (1874) Describes palpation (have the patient relaxed) in prone lying, with the head to one side and the arms by the sides. The levels of the spinous processes are identified by standing behind the patient and using your hands to identify the L4 and L5 spinous processes in relation to the top of the iliac crests. Mark the important reference points. Palpation, which is performed with the tips of the thumbs opposed, can commence on the spinous process of L1, systematically proceed distally to L5, over the sacrum and coccyx. Include the inter spinous spaces as well as the spinous processes. When the thumbs (or other part of the hand such as the pisiforms) are applied to the spinous processes, a firm pressure is transmitted to the vertebrae by a rocking movement for three or four ‗springs‘. Significant reproduction of pain is noted.

Palpation occurs at three main sites:  Centrally (spinous processes to coccyx)  Unilateral—right and left sides (1.5 cm from midline)  Transverse pressure to the sides of the spinous processes.

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Table 3: Assessment part of low back pain population (Peter Brukner and Karim Khan.1993) Age

Any age- late teens to old age, usually 30-60 Yes, lifting or twisting

History of injury Site of radiation

Unilateral lumbar (may be present) refers over the sacrum, SIJ areas, buttocks

Types of pain

Deep aching pain, episodic Activity, lifting, gardening, housework (vacuuming, etc.)

Aggravation Relief Associations Physical examination May be restricted Diagnosis confirmation

Rest, warmth May be stiffness, usually good health Localized tenderness Unilateral or central L4, L5 or S1 level Flexion, extension, lateral flexion Investigation usually normal

1.9 Diagnosis 1.9.1 Neural Tension Tests There are several physical examination maneuvers that have been developed to essentially stretch the nerve that is thought to be the source of the radicular pain. These tests include the Straight Leg Raise (SLR) test, the Crossed Straight Leg Raise (CSLR) test, the Slumped Sit test, and the Femoral Stretch test. The key element of these tests is to provoke the patientâ&#x20AC;&#x2DC;s typical symptoms.

Maneuvers such as dorsiflexion can be added to sensitize the tests. The straight leg raises and crossed straight leg raise tests have both been well studied to assess for sensitivity and specificity. Most of the studies have concluded that the SLR is more sensitive for disc pathology while the CSLR is more specific but less sensitive (Alessandro et al. 2007).

1.9.2 Straight Leg Raise (SLR) Deyo et al. (1992) Described the SLR test, which is also referred to as a Lasegueâ&#x20AC;&#x2DC;s test by some authors, stresses the lower lumbar and upper sacral (L5 and S1) nerve roots. During the straight leg raise test, the patient is positioned in the supine position on the examination table. The physician then raises the leg to be tested by holding the heel with one hand and maintaining the ipsilateral knee in the fully extended position. The foot is then slowly raised from the table while maintaining the leg in a straight position until pain is illicit. A typical SLR test is one which reproduces the patientâ&#x20AC;&#x2DC;s 36

radicular symptoms between 30 and 60 degrees of elevation from the horizontal the test can be further sensitized by adding neck flexion, internal rotation, adduction, or dorsiflexion. When dorsiflexion is the sensitizing maneuver, some refer to that as the Lasegue test, while others call it Bragardâ&#x20AC;&#x2DC;s test.

Pain after 70 degrees is more consistent with lumbar facet joint or sacroiliac pain. At 60 degrees of elevation; a positive SLR has 95% sensitivity for an L5-S1 radiculopathy. The lower the angle when the radicular pain is reproduced, the more specific the test.

Figure 7: Illustration of SLR test (Neuro dynamic test-Christopher Norris M. 1993) 1.9.3 Slump Test For many years, the concept of "neural tension" seemed perplexing to a lot of Therapists.

There was a definite reluctance on the part of Clinicians to attribute any signs and symptoms to this concept, as there was no proof that the nervous system itself could, in fact, be a causative factor in pain. The idea that nerves were the transporters of pain impulses, as well as being the creators of pain impulses, seemed too bizarre to even contemplate. Then came along some fresh ideas. Clinicians began looking at the spinal canal as a possible source of symptoms, which then led to the term "canal signs", which were signs of abnormal mobility of the pain sensitive structures within the vertebral canal and intervertebral foramina. These pain sensitive structures included the dura, the nerve root sleeves, the ventral nerve roots and the blood vessels in the epidural space. Pain sensitivity was not restricted to just the structures within the canal, but also consisted of the structures that made up the 37

canal itself i.e. the posterior longitudinal ligament, the posterior portion of the annulus fibrosis and the anterior portion of the lamina. The so-called "canal signs" could be identified utilizing the variety of tests available. The traditional "basic" tests included the straight leg raise (SLR) test, the passive neck flexion (PNF) test and the prone knee bend (PKB) test. A test nicknamed the "SLR of the arm", the so-called Upper Limb Tension Test, was also devised to evaluate the neural mobility of the upper limb. What was missing was a test that tied all the "basic" tests together, to allow for differentiation.

Then came along the "Slump Test"(Jeremy et al. 2007).

In essence, this test comprised the following components, performed in a sitting: ď&#x201A;ˇ

Thoracic and cervical flexion;

ď&#x201A;ˇ

Knee extension (pseudo-SLR);

ď&#x201A;ˇ

Foot dorsiflexion; and Release of cervical flexion (to determine symptom response).

Figure 8: Illustration of slump test (Christopher Norris. 1993) As can be seen by the photograph, the Slump Test may be quite uncomfortable and provocative, so care must be taken with the test, taking into account all of the contraindications to such a test, as well as clues from the subjective and objective examination. For most Clinicians unfamiliar with the test, this should not be undertaken unless they have been properly taught, supervised and their technique scrutinized, so as to provide them with the knowledge and handling skills necessary to perform this test/technique without adversely affecting the patient.

The ultimate aim of the Slump Test was to reproduce the subject's symptoms and then be able to alter the symptoms by releasing a component distant from the site of pain.

If a subject with pain in the posterior thigh, given all the subjective and objective findings indicates that a Slump Test should be performed, and that there are no contraindications to neural mobility testing, a Slump Test is performed. The subject is placed in Slump test position; the posterior thigh pain is reproduced. While maintaining all components with overpressure, the cervical flexion 38

component is released. Should the symptoms change, the test would be deemed Positive for "neural tension", as the symptoms were reproduced and then altered in movement of a distant component. On the other hand, should the pain be reproduced, but the release of the cervical flexion brings about no change, the test would be deemed Negative for "neural tension", as alteration of the distant component brought about no difference in symptoms.

The key to the success of the slump test was the ability to differentiate between local causes of the symptoms and distant causes. With hamstrings studies, the primary objective was to determine whether the hamstrings were at fault, or whether the nervous system was at fault. The conclusions drawn from all of these research papers indicate that a great number (~64%) of our so-called "hamstring strains" were, in fact, referred pain syndromes of the nervous system. This was further supported by research into the treatment of hamstring strain, which found that, if the slump stretching was added to the treatment of grade 1 hamstring strains, the patient would return, on average, two weeks earlier to their sport, when compared to patients who did not have slump stretching (Jeremy et al. 2007).

Difference between slump test and slump stretching as a treatment is in the duration of the hold. Slump test performed reproduction until symptoms felt by the patient. In contrast slump stretching involves a longer duration hold once symptoms reproduction felt by the patient.

The sitting slump test was a similar variation on the sitting straight leg raise. In this position, you could add lumbar flexion by increasing nerve tension or lumbar extension by decreasing nerve tension. The scholar asked the patient lean forward at the waist (maintaining lumbar lordosis), thus increasing nerve tension; or lean back, decreasing nerve tension. Butlerâ&#x20AC;&#x2DC;s work which is more sophisticated than the scholar's brief description. The scholar is just trying to give a quick synopsis.

What these tests tell was whether the sciatic nerve, its branches and/or the dura are somehow involved in this patient's problem. If the problem is limited to joint dysfunction, myofascial pain, ligament issues and/or core instability, these tests will be negative. When the neurodynamic tests are positive, it means the mobility of the nerve and its containers have been somehow compromised (Jeremy et al.

2007).

1.9.4 Diagnosing "Nerve Pain" and Understanding Neurodynamics Francis et al. (1874) Described how can we assess the state of the peripheral nerves? The researcher starts with the lower extremity, as the tests for the sciatic nerves are much simpler and most of us are already familiar with them. Research team starts by exploring Butler's work. Many evidences-oriented DCs are familiar with this work, although the Butler's group, the Neuro Orthopedic Institute (NOI), currently refuses to teach to DCs. You can still buy the DVD and his books. The main concept scholar gets from studying neurodynamics is that you can objectively test for nervous tension. The straight-leg raise and its variations are classic examples, which all of us are somewhat familiar. Butler fine-tunes the straight-leg raise, adding variations that increase or decrease 39

the tension on the dura and sciatic nerve via foot dorsiflexion or plantar flexion, femoral internal rotation and adduction, and passive cervical flexion.

Kornberg et al. (1987) used a sitting slump test to further assess the same dura/sciatic nerve axis. Butler has pioneered a set of similar tests for the upper body that isolate the median, radial and ulnar nerves. Here's what researchers can do on any lower back (or buttock or leg) pain patient to determine whether the sciatic nerve is involved. Perform a straight-leg raise. Does it cause pain or tightness? Does the leg feel heavy compared to the other side? Where is the pain or tightness? In classic severe sciatica, you'll elicit pain shooting down the leg, but you also can get tightness or pain in the hamstrings, buttock or lower back. Then either increase the tension on the nerve by dorsiflexing the foot and/or flexing the head and neck. Does this same pain or tightness increase? Now decrease the tension by extending the head and/or by plantar flexing the foot. If the tightness or pain is just hamstring tightness, it won't change much with these variations. If the tightness or pain is mediated through the nerves, it will change.

Butler has modified the straight-leg raise into a more sensitive test. The sitting slump test is a similar variation on the sitting straight-leg raise. In this position, the scholar can add lumbar flexion by increasing nerve tension or lumbar extension by decreasing nerve tension. The examiner asked the patient lean forward at the waist (maintaining lumbar lordosis), thus increasing nerve tension; or lean back, decreasing nerve tension. Butler's work is more sophisticated than my brief description. The examiner who is trying to give a quick synopsis. What these tests tell examiner is whether the sciatic nerve, its branches and/or the dura are somehow involved in this patient's problem. If the problem is limited to joint dysfunction, myofascial pain, ligament issues and/or core instability, these tests will be negative. When the neurodynamic tests are positive, it means the mobility of the nerve and its containers have been somehow compromised (Kornberg et al. 1987).

Butler goes on to teach a therapeutic model based on these tests. The doctor moves the subject through various motions that glide and/or stretch the involved nerves, and then teaches the patient to do these as home exercises. The idea is to free up the nerves through movement, helping the nerves glide through the spaces where they may be constricted.

The scholars have come to appreciate Butler's diagnostic model. It gives us a functional test for the mobility and state of the nerves. Most of us already do this when we have a subject with sciatica. The scholars measure changes in the straight-leg raise, telling us if the subject is improving.

The examiner can do much more if we study and use Butler's model (Also from an online post, spine docs).

The scholars have used the Butler's model for his diagnosis and as a "reality check." To improve the health of the nerves and used several different models were used including the following: ď&#x201A;ˇ

Release restrictions in the "container," the soft tissues and joints that surround the nerve. This is the classic chiropractic and soft-tissue model.

40



The McKenzie model: Find directional bias or preference and teach the patient Home exercises that reinforce this direction.



Butler's neurodynamics, both as in-office therapy and as home exercises.



Barral's approach of manual therapy (manipulating) directly to the nerve sheath.



Craniosacral techniques and when indicated, coccyx manipulation. These aims directly at the dura and its connections.

1.10 Treatment Kornberg et al. (1987) Described the patient should rest, especially for the first two days following injury, and then when necessary. Basic analgesics should be taken as required. These patients are usually more suitable for mobilization and manipulation if they do not settle within three or four days.

A large variety of treatment modalities that are used are generally dependent on the clinician‘s experience rather than on evidence from the literature. Traditionally, the aims of assessment are to localize the exact area of pain and ask questions about the site, nature, and severity of that pain. Physiotherapists then proceed with various forms of treatment in which the patient has a passive role, for example mobilization, manipulation, traction, Electrotherapy and heat. However, this may not always be the most effective and appropriate approach, especially for patients who have long-standing chronic pain. Evidence from existing review sources show that the services most likely to be effective are those that advise the patient to remain active during acute back pain and those that provide back exercises for chronic pain. Physiotherapists should be prepared to be open-minded and aware that passive treatment, as well as some advice, may in some patients lead to reduced activity and fear of spinal movement. Furthermore, whatever changes occur in the next decade, it seems clear that for physiotherapy to progress as a profession, more emphasis should be placed on the evaluation of current practice. Physiotherapists should consult international evidence-based guideline recommendations on LBP to improve their clinical practice.

1.10.1 Neurodynamics The nervous system as a whole is a mechanically and physiologically continuous structure of the brain to the end terminals in the periphery. The peripheral nervous system (PNS) and central nervous system (CNS) had to be considered as one since they form a continuous tissue tract. This continuum in three ways firstly, the connective tissues is continuous, although in different formats, such as epineurium and dura mater. A single axon can be associated with a number of these connective tissues. Secondly, neurons are interconnected electrically so that for example, an impulse generated at foot may be received in the brain. Lastly, the nervous system may be regarded as continuous chemically, the same neurotransmitters exist peripherally as centrally and there is a flow of cytoplasm inside axons.

41

This means that mechanical or physiological changes anywhere in the CNS can implicate the whole nervous system. This concept of mechanical and physiological continuity between CNS and PNS cannot be overemphasized (Cowell and Phillips et al. 2002). The stresses imposed upon the peripheral nervous system during movement are transmitted to the CNS. Conversely, tension can be conveyed from the CNS to PNS. The CNS responds dynamically to limb movement due to its mechanical continuity with the PNS. Humans are capable of highly skilled movements with the nervous system stretched or slack, stationary or mobile. The nervous system not only has to conduct impulses during a remarkable range and variety of movements, it has to adapt mechanically during the movements. Because of this continuous tissue tract, any limb movement must have mechanical consequences for nerve trunks and the Neuraxis. Neuraxis is a term used when the CNS is considered along its length irrespective of its bends and folds.

The nervous system adapts to lengthening by, the development of tension or increased pressure within the tissue i.e. Increased intradural pressure or increased intradural pressure. Spinal movements change the length and shape of the spinal canal and, by virtue of its attachments, the Neuraxis is pulled from all directions. This causes the Neuraxis to change shape and position in the canal.

Regular and appropriate movement of the Neuraxis is necessary for the optimum physiological function. This is supported by the fact that the vascular supply of the cord is affected by spinal movements. Also, regular stress would theoretically improve nutrition and removal of metabolic waste product. If the movement is reduced at a point along the tract, for example by an epidural adhesion, tension is no longer offset or dissipated adequately and neural mechanics are altered. Such alterations in mechanics are named pathomechanical changes.

The nervous system can be effectively and safely mobilized, the ultimate aim of treatment is to restore the patientâ&#x20AC;&#x2DC;s range of nervous system movement and stretch capabilities and to normalize the sensitivity of the system.

Mobilization of the nervous system has recently emerged as an adjunct to the assessment and treatment of pain syndromes. An important aspect of this approach is that healthy mechanics of the nervous system enable pain free posture and movement to be achieved.

The use of neural tension test is a major part of the mobilization of the nervous system approach. An aim of using these tests in assessment is to stimulate mechanically and move neural tissue in order to gain an impression of their mobility and sensitivity to mechanical stress. In the presence of abnormality, the purpose of the treatment via these tests is to improve their mechanisms and physiological function.

A number of neurodynamic tests have been purported to assess the mechanosensitivity of neurogenic structures (Cyriax et al. 1942). The originally this test which is used for neurodynamic 42

testing, specifically the straight-leg-raise (SLR), to identify the presence of perineuritis (Cyriax et al.

1942). It was further refined the technique and described the slump test, which incorporated cervical flexion and ankle dorsiflexion which was believed to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal (Maitland et al. 1985).

Since Maitland described the slump test it has been used as an assessment tool for the identification of possible altered neurodynamics and more recently has been suggested as a possible treatment technique (Butler et al. 2000). However, limited evidence exists to support the effectiveness of using the slump test as a treatment approach and has only been presented in the form of case reports or case studies (Cleland et al. 2004).

The dura within the spinal canal is firmly attached to the foramen magnum above and filum terminal below. Trunk flexion causes the spinal canal to lengthen and therefore stretches the dura, whereas extension, by shortening the canal, induces dural relaxation allowing sheath to fold. The neuromeningeal pathway is elastic, so tension imparted at one point will spread throughout the whole length of the spine (Grieve et al. 1970).

Isometric contractions will increase strength, but only at the joint angle at which the training carried out (Fleck and Schutt et al. 1985). For more general strength training, a variety of joint angles must be used. It takes approximately four seconds for the muscle to reach maximal tension, and this contraction should be maintained for six seconds (Astrand and Rodahl et al. 1986).

(Lindstorm and Zackrission. 1970) Explained an isometric occurs when a muscle contracts without associated movement of the joint on which the muscle acts.

Isometric exercises are often the first form strengthening exercise used after injury, especially if the region is excessively painful or if the area is immobilized. They are commenced as soon as the athlete can perform them without pain. Isometric exercise may also be used later in rehabilitation process when a muscle is too weak to perform range of motion exercise, in conditions where other forms of exercise are not possible, such as patellar dislocation and shoulder dislocation, or when isometric contraction is required in activities, for example stabilizing. Isometric exercise prevents atrophy by increasing static strength, lessens swelling through a pumping action to remove accumulated fluid and may also limit neural dissociation of proprioceptors.

Idealistâ&#x20AC;&#x2DC;s isometric exercises are held for 5 seconds with rest of 10 seconds. This should be performed frequently during the day in 10 sets of repetitions. The quality of exercise is more important than the quantity.

1.10.2 Neural structures Injury to the structures of the nervous system may be the major source of the subjectâ&#x20AC;&#x2DC;s perceived pain more commonly, however, injury to neural structures accompanies joint or muscle injuries. Like the other structures, neural structures have nociceptive nerve endings that may be stimulated chemically by local inflammation of surrounding injured structures or mechanically, either 43

by direct trauma or by acute or prolonged stretching. Alteration to the mechanics of nervous system, similar to joint and muscles may result in increased tension within the nervous system and thus pain (Sahar et al. 2011).

1.10.3 Autonomic nervous system Sahar et al. (2011) Described central and peripheral nervous system plays an important role in pain production and the autonomic nervous system must not be overlooked. Autonomic fibers in peripheral and central nervous systems are also affected by abnormal neural mechanics and increased tension. The autonomic nervous system is particularly susceptible to abnormal mechanics where it is separated from the rest of the nervous system, the trunks, Rami and ganglia. The sympathetic trunk, located just anterior to the mobile custom vertebral joints, is particularly susceptible to damage.

Involvement of sympathetic trunk may explain the presence of unusual symptoms such as nausea, temperature changes in the amount of sweating that may accompany the pain. These can affect altered neural tension.

1.10.4 Stretching Bob Anderson et al. (1998) described a therapeutic maneuver designed to lengthened or elongate pathologically shortened soft tissues and thereby increase range of motion. Assessing the mobility limitation that affects the soft tissues is called contraction. The soft tissue is represented on one hand by the muscles made of muscular tissue (of excellence contractile tissue) and fiber structure, non-contractile (epimissium, perimissium, endomissium) and on the other hand by non-contractile structures (skin, capsule, ligament, tendon).

The muscular contraction is called myostatic contraction and the articular muscular amplitude limitation of muscular cause can have as a base only the interest of muscular contractile tissue or simultaneous interest of contractile or non-contractile muscular tissue.

The stretching represents the base technique (as a method) in recovery physical therapy of articular mobility deficit determined by the soft tissue adaptive shortening and consist of its prolongation and the maintenance of this prolongation for a period. The so-called stretching starts only after it reaches the movement amplitude limitation point. The non-contractile soft tissue stretching is passive, mechanic, long duration (20-30 min). Following all the types of stretching.

1.10.5 Ballistic stretching It is actively accomplished, using the stretched muscle as a resort that will â&#x20AC;&#x2022;dashâ&#x20AC;&#x2013; the body (segment) in the opposite direction. Ex: flexion-extension exercises made in force, trying to pass brutally and quickly over the passive maximum amplitude. It is used mostly in sports. The practice of these techniques was diminished because the repeated and sudden stretching of muscles presents a potential danger to produce lesions (Bob Anderson et al. 1998).

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1.10.6 Dynamic stretching Bob Anderson et al. (1998) Described arching accomplished by slow voluntary movements of segments trying to pass gently over the maximum point of movement possible amplitude. The amplitude and speed are progressively increased. There are performed for 8 – 10 repetitions.

1.10.7 The active stretching (or static-active) These perform voluntary movements towards the maximum possible movement amplitude; in this position the segment is maintained 10 – 15 seconds by agonist‘s isometric contraction without any exterior help. The increased tension during agonist concentric contraction and then during the isometric contraction will induce reflex, by ―mutual inhibition‖, the antagonists relaxation (Bob Anderson et al. 1998).

1.10.8 Static stretching, also called passive Bob Anderson et al. (1998) Described static stretching is done by an exterior force: other body parts or the proper corporal weight (passive self-stretching), the physical therapist or by means of equipment. The most used in physical therapy is the manual, passive stretching, slowly performed (in order to avoid the stretch-reflex) maintaining in an easy discomfort the stretching for l5-60 seconds. In case of multiarticular muscles the stretching is applied first analytic, starting with distal articulation, ending with a global stretching for all articulations. Application of stretching means, the force is reduced gradually due to some specific reasons, (especially in patients that show an increased fear of pain), time reasons (and personally) and finally applied auto (self) stretching.

1.10.9 Isometric is stretching or (sportive) Bob Anderson et al. (1998) Who is the father of sport stretching, advise the following stretching formula (available for any muscle): in maximum position of passive stretching the patient makes an isometric contraction of the stretched muscle (resistance can be assured by a physical therapist) (maximum 6 seconds at maximum intensity); relaxation (3-4 seconds); passive stretching (20-30

seconds),

performed

at

pain

limit

(that

―pleasant‖,

supportable

pain).

1.11 General therapeutic effects of stretching Bob Anderson et al. (1998) Described about the effect of stretching stated that the noncontractile, soft tissue stretching is passive, mechanic, long duration (20-30 min) and it is based on collagen fibers crimps stretching (in relaxation these are crisped). This connective tissue stretching goes progressively through an elastic phase, than through a plastic one, followed by a ―choke‖ point, after that any tension that tries to prolong the tissue determine its break. If the elasticity is the property of tissue to return to its initial length after that a force has pulled it from its relax state, the plasticity is the tendency of a tissue that was distorted to not return to the position from which it started the deformation. The choke point can be removed; respectively the plastic area can be increased if it is 45

applied heat to the respective tissue. This application is performed during or 10 minutes before stretching starts, after that the heat source will be removed at the end of stretching and the tissue is left to ―cool down‖ in gaining prolonged position. The stretching force intensity must be increased very slowly, because when the stretching force is high and/or applied quickly, there is the danger of the structure to be stretched to break. In order to obtain an optimal prolongation of soft tissue, it will be considered the stress/strain curve of collagen fibers, so that the stretching to be placed in the plasticity area (but under the force point that cause the fibers breaking).

The stress defines the ratio between the traction force and the increasing of respective tissue section surface. The strain is given by the ratio between the prolongation (distortion) degrees of the tissue compared to its initial length. The immobilization or prolonged relaxation in bed (even if there weren‘t adaptive shorting phenomena), corticotherapy as well as the age determines an atrophy of connective tissue resistance, that will require the physical therapist to be prudent when applying the stretching. The muscle, as most of the biological tissues, has stringy-elastic properties. That is why it must be considered the fact that if the muscle is prolonged until the plastic area, and this prolongation is maintained for a too long time, the muscle will keep an inferior elastic degree. On the other hand, the muscle resistance to prolongation increasing is directly proportional to the stretching‘s frequency increasing (stretching‘s that are maintained in the limit zone of the stress - strain curve. To diminish the unpleasant consequences of immobilizations (when there are no contraindications – unconsolidated fracture, acute lesions etc) It uses Judet method.

This was accomplished by means of two bivalve plaster equipment, that position the affected patient‘s segment alternatively in maximum flexion and then in maximum extension; the equipment (positions) is 85 changed at 6 hours interval. While the connective tissue gain length, it must give enough time to produce a biologically repair phenomenon that re-models and re-adapt the new length of connective tissue, to its resistance tissue function.

The stretching of muscle‘s contractile tissue it is accomplished by several stretching modalities. The most used in physical therapy is the manual, passive stretching, slowly performed (in order to avoid stretch-reflex) with prolongation maintenance in a discomfort stretch for l5-60 Sec. (The best duration seems to be of 30 Sec). The stretching maintenance is explained by the fact that the neuromuscular axles response is immediate, in order to stimulate the best the Golgi organs (that will determine the reflex relaxation of respective muscle), the stretching must last minimum 6 Sec. The recent studies show that after the first four repetitions of the stretching (of a total of 10) there has been noted the most advantageous modifications, respectively an l0% increase of the initial relaxation length. In case of multi articular muscles, the stretching is applied first analytic, starting with distal articulation, ending with a global stretching for all articulations. Application of stretching means, the force is reduced gradually due to some specific reasons, (especially in patients that show an increased fear for pain), time reasons (and personally) and finally applied auto (self) stretching.

46

The mechanical, cyclic stretching was applied to patients with mobility limitation, recording good results, but the inconvenient was the fact that requires sophisticated equipment. When the patient participates actively, by the agonist contraction to the antagonistic musculature stretching, we have the active stretching. In physical therapy, stretching used randomly as pure active stretching, because it is difficult (and even not advisable) to maintain a isometric contraction of agonistic muscle at an efficient intensity, so that the antagonistic muscle can be maintained in the plastic area in order to benefit the advantages of an active stretching, the isometric contraction maintenance of agonistic for l0 –20 (at trained for 30) sec is combined (but not at maximum intensity, on muscular groups relatively well located and paying attention to breath block) with a passive stretching inducted by physical therapist or with a passive self-stretching (preferable from positions that use segment or subject weight).

In sports exercise (but also in physical therapy), at first (to warm out), it is advisable the perform the stretching on muscular groups that will be driven (specially the active-passive forms and only than the ballistic forms). At the end of exercise (session), for a quicker recovery, on the same muscle groups, it is advisable to perform the passive stretching forms.

The major risk of stretching exercises is the stretching performing speed. It must specially observe the articulations immobilized for a long time (it must consider the possibility of a structural incomplete recovery, or it may appear the immobilization osteoporosis), edema articulations, inflamed and/or infected, the reflex contraction muscles (their length stretching can cause lesions).

1.11.1 General relaxation of stretching 

Massage (deep) to be given after heat applying, but massage should be applied before stretching.



The initial position of the muscle to be stretched will be performed to be stable, relaxed and comfortable.



The exercises should be performed between 2.30 pm and 4.30pm, because this specific time provide maximum of articular mobility capacity.



Body general warming, by aerobic effort for minimum 5 minutes.

1.11.2 General indications of stretching 

The stretching is to be helped by active movements (working against thixotropy).



The breathing to be uniform and calm.



There will not be made any appreciations over the degree and duration of stretching (it is not a competition).



In case of both directions of limited movement, after one muscle group stretching, stretching is also applied to antagonistic muscles (it starts with the most contracted musculature).



The stretching should not be performed simultaneously on two muscle groups.

47



The stretching can be combined with the axle traction of the respective articulation.



The pain that appears after 2 relaxation hours (from stretching ending) shows that its intensity was too high, and the pain that persists over 24 hours shows that there were produced some fiber injuries.



After the treatment session (sessions) that had stretched, it must not appear muscular spasm, the muscular force must not decrease, and the muscular fatigue must not appear.

1.11.3 General Contra indication of stretching 1. Joint motion decrease by bony block 2. Recent fracture 3. Acute inflammatory or infectious process 4. Hematoma 5. Hyper mobility 6. Shortened soft tissues leads to increase joint stability 7. Shortened soft tissues leads to increase functional abilities.

1.12 Mechanical therapy Three mechanical conditions are recognized in the lower back, the postural syndrome, dysfunction and derangement (Mc Kenzie et al. 1981). The postural syndrome occurs when certain postures or body position place soft tissues around the lumbar spine under prolonged stress. Pain is intermittent, and only occurs when the particular posture is taken up, and ceases when the offending posture is changed .This can be frustrating for the patient because they can find nothing wrong .There is no deformity, vigorous activity is frequently painless, as the stress impose on the tissues are continually changing. The fault is usually poor sitting posture, which place lumbar spine in flexion.

After sport, the patient is warm and relaxed and so sits in a slumped position, perhaps in the bar after a game of squash. Discomfort occurs after some time and this gradually changes to pain. The patient often has an idea that sports make the pain worse, but this is not the case. The poor sitting posture used when relaxing after the sport creates a problem. Pain may also occur in sports due to an extreme position. Hyper flexion when lifting a weight from the ground or performing stretching exercises, Hyperextension when pressing a weight overhead or performing a back walkover by gymnasts are common examples.

Dysfunction pain is caused by overstretching adaptively shortened structures within the lumbar spine .The previously damaged structures have shortened due to prolonged disuse, or scar tissue formation. When the normal range motion is attempted at the affected segment the shortened soft tissues are stretched prematurely. The essential feature with dysfunction is pain at the end movement range which disappears as soon as the end range stretch is released. The position is selfperpetuating because the pain which occurs with stretching causes the patient to avoid full range 48

motion and so? Adaptive shortening is compounded. Dysfunction may occur secondary to trauma, or as a result of postural syndrome. Typically the patient is stiff in the morning and his or her back loosens through the day, so he or she generally does better with activity loss extension leads to reduced lordosis, and loss of flexion becomes apparent when the patient tries to touch his or her toes.

Frequently, he or she will deviate to the side of dysfunction. Once dysfunction has been detected, (static) stretching is required, and or joint mobilization procedures. The most common dysfunction following low back pain is the loss of function (Mc Kenzie et al. 1981).

Derangement occurs when the nucleus or annulus of the disc is distorted or damaged, altering the normal resting position of two adjacent vertebrae. Pain is usually constant and movement loss is apparent, so much so in some cases that the condition is completely disabled. Derangement of lumbar disc is a common cause of low back pain, to help our patients with chronic pain and/or radicular pain; we need to understand the physiology of pain. I'll quote Dr. Craig Liebenson (Also from online post spine docs online): "Neuropathic pain is associated with central sensitization. This is typified by (a) Allodynia – pain to non-noxious stimuli and (b) Hyperalgeisa – exaggerated pain responses.

Nociceptive pain is peripherally driven by chemical, thermal or mechanical insults to tissues housing nociceptors. It is not centrally maintained; however, it can be centrally influenced by descending modulation or inhibition via the enkephalin system."

Schafer et

al.

(2010)

Classified patients according to the following criteria:

"Patients were classified according to the findings of simple clinical tests into four distinct categories:  Neuropathic sensitization (NS) comprising major features of neuropathic pain with sensory sensitivities such as allodynia, hyperalgesia and paroxysmal pain.  Denervation (D) arising from significant axonal compromise with marked sensory and motor deficits.  Peripheral nerve sensitization (PNS) arising from nerve trunk inflammation with marked nerve mechanosensitivity.  Musculoskeletal (M) with pain referred from non-neural structures such as the disc or facet joints.‖

1.13 Need for the study 1. Disability associated with low back pain (LBP) continues to rise. Health care expenditure among individuals with LBP is also 60% greater than those without LBP. 2. Physical therapist utilizes a wide range of intervention in the management of LBP; however evidence for the effectiveness of these interventions is limited.

3. To date evidence for several subgroups of LBP exists, such as patients likely to benefit from manipulation lumbar stabilization and specific directional exercise.

49

4. Maitland described that the slump test has been used as an assessment tool for identification of possible altered neuro dynamics and more recently it has possible treatment technique. However, limited evidence

the

been suggested as a

exists to support the effectiveness of

using the slump test as a treatment approach and has only been presented in the form of case reports or case studies.

The evidence based practice supporting slump stretching is the only specific protocol for the management non radicular low back pain. Slump stretching could be utilized for other management of like grade hamstring injuries and nonspecific low back pain also. There are only a few studies in the field of evidence based practice in physiotherapy, thatâ&#x20AC;&#x2DC;s why present study is needed in this intervention approach.

1.14 Objectives of this research Thus this study was formulated to evaluate the effects of slump stretching with static spinal exercise for patients with LBP among non- active sports persons for the treatment of patients with non- radicular LBP, and to develop and evaluate a new LBP classification system of relevance to physiotherapy.

The specific aims were: 1. To investigate the effect of slump stretching compared with that of intensive mobilization training in a randomized controlled trial including patients with non- radicular LBP. 2. To develop a new classification system for patients with non- radicular integrating pathoanatomic and clinical categories of relevance to physiotherapy.

3. To provide the rationale behind the new system based on existing evidence.

4. To find out the relationship between the different scales (NPRS, FABQT and ODI with (Age , Gender, Type of sports and Treatment strategy distribution).

1.15 Significance of the study This study would enable the therapist to gain knowledge and realize the importance of certain clinical tests to evaluate therapeutic efficacy of the effectiveness slump stretching in clinical settings without sophisticated machines.

1.16 Statement of the problem To determine the effect of slump stretching with static spinal exercise for the management of non- radicular LBP among non- active sports persons.

1.17 Hypothesis ď&#x192;&#x2DC; It is hypothesized that there will be a significant effect of slump stretching followed by mobilization with static spinal extensors for the management of non- radicular LBP among non-active sports persons.

50

 It is hypothesized that there will be a significant effect of mobilization with static spinal extensors for the management of non- radicular LBP among non-active sports persons.  It is hypothesized that there will be a significant difference in NPRS, FABQT and ODI scores between intervention and control groups.  It is hypothesized that there will be a relationship between the different scales NPRS, FABQT and ODI with Age in intervention and control groups.  It is hypothesized that there will be significant differences in NPRS, FABQT and ODI score with related to gender, type of sports and treatment strategy.

1.18 Delimitation of the study Patients were excluded from participation if they met any one of the following exclusion criteria: 1. Subjects having pregnancy, have a history of spinal surgery, positive neurological sign or symptoms suggestive of nerve root involvement (diminished upper or lower extremity reflexes, sensation to sharp and dull, or strength), 2. Presence of any medical ―red flag‖ for a serious spinal condition (e.g., Cancer, compression fracture, osteoporosis, infection, etc. As determined by the initial therapist evaluation 3. Reflexes, sensation of sharp and dull, or strength.

4. Subjects with signs of nerve root involvement were excluded.

5. Subjects exhibited a straight leg raise (SLR) test of less than 45 degrees.

6. If they had any contraindications to exercise therapy such as uncontrolled hypertension, previous myocardial infarction, cerebrovascular disease, peripheral vascular disease, respiratory disorders.

7. If they were receiving medications other than analgesics and non-steroidal anti inflammatory drugs.

8. Obese subjects.

The reason(s) for a patient‘s ineligibility was monitored and recorded and eligibility rates were determined.

1.19 Inclusion criteria of the study The following inclusion criteria were used to determine eligibility for the study. Potential candidates must have satisfied all criteria, but consent to participate was not being required due to the type of exemption that was approved.

1. Subjects must have symptoms in the lumbo-pelvic region was included in this study.

2. Subjects with a chief complaint of LBP having age between 20 -45 years among non- active sports persons were included in this study.

51

3. Subjects were required to have symptoms that referred distal to the buttocks, reproduction of patient symptoms with slump testing were included in this study.

4. Subjects with a positive slump test with absence of radicular symptoms were included in this study.

5. Subjects with no change in symptoms with lumbar flexion or extension mobility testing were included in this study.

6. Oswestry disability scores greater than 10% were included in this study.

7. Straight leg raise (SLR) test at 45ยบ or greater were included in this study.

8. The onset of pain was between 7days and 3weeks before the study begun were included in this study.

9. Subjects had no history of back pain for periods of 6months prior to the current episode were included in this study.

10. Subjects were able to understand the English language were included in this study.

11. Both genders were included in this study.

1.20 Operational Definitions of terms 1.20.1 Slump test To perform this maneuver the patient sits unsupported over the couch side, with the knees flexed to 90 and the posterior thigh in contact with couch the patient is then instructed to relax the spine completely and slump forward. The therapist places overpressure onto the patient's shoulder to increase the movement. From this position the patient is asked to flex the neck and then straighten the leg on the affected side (Maitland et al. 1986).

1.20.2 Stretching A Therapeutic maneuver designed to lengthen or elongate pathologically shortened soft tissue structures and thereby increase the range of motion (Bob Anderson et al. 1998).

1.20.3 Non- active sports persons The term refers to considering subjects of the study indicate whoever actively participated and withdrew from sports after a period of 3 to 6 months (Gatterman et al. 1990).

1.20.4 Centralization of symptoms It is defined as the centralization of symptoms movement of the lumbar spine that abolishes lower extremity symptoms or makes the symptoms move towards the spine (John Mayer et al. 2008).

1.20.5 Periperalization of symptoms John Mayer et al. (2008) Described periperalization of symptoms is movement of the lumbar spine that produced lower extremity symptoms or makes the symptoms further away from the spine.

52

1.20.6 Low back pain This is defined as pain resulting from the inherent susceptibility of the spine to static loads, due to muscle gravity forces and to kinetic deviation from the normal function in the lower back and pelvic girdle (Gatterman et al. 1990).

1.20.7 Difference between slump test and slump stretching Slump test is performed until symptom reproduction felt by the patient. Slump stretching involves longer duration hold once symptoms reproduction felt by the patient (Michael et al. 2010).

1.20.8 Stress The stress defines the ratio between the traction force and the increasing of respective tissue section surface (Maitland et al. 1986).

1.20.9 Physiotherapy Physiotherapy is a systematic method of assisting Cardio respiratory, muscular skeletal, neurological including pain and psychosomatic disease to prevent illness by the way of manual therapy and physical ability (Struber et al. 2003). Also called physical therapy, physiotherapy is a dynamic profession with an established theoretical and scientific base and widespread clinical application in the restoration, maintenance, and promotion of optimal physical function (American Physical Therapy Association. 2001).

1.20.10 Mobilization Mobilization has been described as passive joint manipulation that does not employ a rapid thrust and is usually not accompanied by an audible crack associated with joint cavitation (Bergmann et al. 1993).

53

CHAPTER II 2. REVIEW OF RELATED LITERATURE For any study to be undertaken the review of previously

existing literature had been

thoroughly analyzed .The present study to find out the effect of slump stretching with static spinal extensors for the management of non- radicular LBP among non- active sports persons had been done after collecting and documented the literature from the following places.  Ramakrishna Mission Vivekananda University Library, Coimbatore  National Institute of Mental Health and Neuro sciences (NIMHANS) Library, Bangalore-29  Bangalore University Library, Bangalore  Tamilnadu Dr. M.G.R.,Medical University Library, Chennai  Lakshmibai National Institute of Physical Education,Gwalior  Sports Authority of India (SAI Centre,Bangalore)  Gardencity College of Physioterapy Library,Bangalore  Medline-Infotrieve Site(www.infotrieve.com)  Medscape Site (Search via.www.google.com)  Mercks Manual (Search via.www.google.com)  Pubmed website (via.link from www.infotrieve.com)  Website Journal of Biomechanics (www.jbiomech.com)  Website Journal of physician and sports medicine (www.physsportsmed.com)  Website Journal of American Journal of Physiotherapy (Link Via : www.apta.org)  Website Journal of Indian Association of Physiotherapy (www.iap.org)  Website

Journal

of

Indian

Association

of

Sports

Medicine

(www.sportsphysiotherapyindia.com)  British Council Library  www.bicycleaustralia.com

2.1 Reviews related to the physiotherapeutic interventions targeting slump stretching: 2.1.1 Review of related literature to SLR Test Toby et al. (2006) conducted a study to find out the mulligan bent leg raise technique with the preliminary randomized trial of immediate effects after a single intervention. The aim of this study was to investigate the effects assessed over twenty four hours, on range of motion and pain, of a single intervention of mulligan‘s bent leg raise (BLR) technique in subjects with limited straight leg raise (SLR) along with low back pain (LBP). Ninety-four subjects were contacted by telephone and 46 volunteered have undergone willingness for assessment among these subjects, twenty four fulfilled 54

inclusion criteria with unilateral SLR limitation LBP. All subjects were included in physiotherapy, blinded, and randomly allocated to either a BLR or a placebo group. The range of SLR was measured by an assessor blind to group allocation, prior to twenty four hours after the intervention. The pain level was assessed twenty four hours after the intervention. They found the differences in baseline values of SLR range and there was no difference between the two groups. After the intervention and twenty four hours later, there was a significant increase in the range of seventy one in the BLR group, which might be clinically important. An analysis of variance was used to determine the effect of treatment on pain and range of SLR immediately after the intervention measured. To ensure that the assumptions of the analysis of variance were satisfied, the residuals from each analysis were assessed for normality using the Kolmogorov– Smirnov and the Shapiro Wilk tests. In addition, homogeneity of variances was tested using a Levene‘s test. An intra-tester reliability assessment was performed on the first ten participants. Interclass Correlation Coefficients (ICC) for SLR was 0.99 (SD 1.2, SEM .12, 95% confidence interval 0.96–0.99) and for pelvic rotation was 0.98 (SD 8.9, SEM 1.3, 95% confidence interval 0.92–0.99). They have concluded that the SLR test which is more appropriate diagnosis tool to identify the nonspecific low back pain.

2.1.2 Reviews related to slump test Geoffrey and Maitland. (1985) conducted a study to investigate the slump test which is widely accepted in the form of examination and treatment procedure at the level of the vertebral column. This diagnosis tool which is more accurate and specific diagnosis prevents the recurrences of low back pain and chronic spinal pain. The objectives of this study measured the sensitivity and specificity of the slump test and compare it with the SLR test in patients with and without lumbar disc herniations. Methods used in prospective case control study considered seventy five patients with complaints suggestive of lumbar disc herniation was carried out in the outpatient clinics of the neurosurgery department at state teaching hospital. Seventy-five referred or self-admitted patients with low back, leg, or lower back and leg pain who had results of magnetic resonance imaging (MRI) of the lumbar spine were included in the study. Thirty-eight patients had signs of herniation confirmed

by MRI. Control group patients (n = 37) those who had no disc bulges or herniations on MRI. Both the Slump and SLR tests were performed during the assessment of all the patients by the second investigator. The MRI results were assessed and recorded by the first investigator. The results of the study shown that the slump test which is found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniations. The SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83). The author concluded that the Slump test might be used more frequently as a sensitive physical examination tool in patients with symptoms of lumbar disc herniations. In contrast, owing to its higher specificity, the SLR test may especially help identify patients who have herniations with root compression requiring surgery.

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Maitland. (1985) conducted a study to find out the technique of slump test, which is incorporated in cervical flexion and ankle dorsiflexion. Ninety-one subjects volunteered to take part in the study in response to advertisements placed on notice. Among the ninty one seven subjects were excluded from the study. Because four participantsâ&#x20AC;&#x2DC; sufferings due to chronic lower back problems, two subjects due to age restrictions, and one subject due to cervical pain. Among them ninety one, eighty four subjects were tested. Methodology used in this study those who attended seven physiotherapy sessions over four weeks duration. Those who participated advise to complete the Modified Oswestry Low Back Pain Disability Questionnaire (ODI) which used to measure at baseline (42%) and every other subsequent visit. The investigator used statistical tools as a repeated measure anova. Through Telephone follow-up reviewed over ten months period. An impairment-based treatment approach was implemented to address

lumbopelvic and hip restrictions and was

supplemented with a home exercise program (HEP) aimed at ROM limitations, targeted muscle stretching, and core stabilization exercises. By visiting for the ODI decreased to 36% and symptom resolution had plateaued. During the follow up period of 5th visit, a neurodynamic treatment procedure which has been introduced and monitored. The technique which performed by the patient in a supine position, the involved lower extremity was raised in a slight leg raising test position (biased with hip adduction and internal rotation) until the initial onset of discomfort. At that point, passive dorsiflexion of the ipsilateral ankle was performed, holding the end-range position 3â&#x20AC;&#x201C;4 seconds, followed by a rest (plantar flexed) position of equal duration. Ten repetitions of this maneuver were performed. The patient was instructed in a similar self-treatment technique that was included in the home exercise program. Results, at visit seven the ODI was 18%, a 58% improvement over the initial score. The patient also reported a marked decrease in the frequency of symptoms, had met all initial treatment goals, and was therefore discharged. These results were maintained at ten -month follow-up, with symptom frequency reportedly two times per month (versus five out of seven days of initial presentation) and 18% on the ODI. The slump test had become widely advocated as a neural tissue provocation test for assessment of patients with spinal and lower limb pain. The study concluded that slump used as a diagnostic as well as treatment purpose for low back pain population.

Maitland. (1986) conducted a study to find out the slump test which is used as an assessment tool for the identification of possible altered neurodynamics. Methods were single case report design.

Analyses made use of patient reported functional index scale (modified Oswestry back pain disability questionnaire) and numerical pain rating scale at the initial examination, through the course of treatment with positive slump test. The results of the patient reported no pain after eight physical therapy treatments over two and a half weeks and a 0% modified Oswestry disability score and all goals were achieved. The patient was able to return to full function and activity. At a ten month telephone follow-up, the patient remains symptom free. The author asked the subjects to perform a slump test, places traction on the neuromeningeal tract from head to foot. The traction on non56

neurological tissues also occur during testing. The researcher found to localize pathology to specific regions or structures, the test was performed in steps and the testing process, mechanisms for a variety of standard orthopedic and neurological maneuvers were duplicated, which there was increasing the number of possible clinical interpretations. The author concluded that the slump test provides information regarding the mechanics of the spine, pelvis, and lower extremities that it might be used to examine neurodynamic dysfunction as well as treatment.

Mink et al. (1998) conducted a study to find out the slump test .This technique widely accepted as an examination and treatment procedure for all levels of the vertebral column. This adopted study, which has been used in the case series. The purpose of this case series was to describe the eligibility criteria used to determine if patients were to receive slump stretch treatment within a treatment-based classification system and to describe selected symptom characteristics associated with these patients. Methods and measures of the study prior to recruitment, criteria were established to identify patients who would be considered appropriate to treat with slump stretching. Consecutive patients referred with a low back diagnosis or low-back-related diagnoses were then evaluated using a treatment-based classification system. Selected symptom characteristics were collected from patients treated with slump stretching. The results were out of eight consecutive patients with low back diagnoses or low-back-related diagnoses; six met the study's inclusion criteria and were treated with slump stretching. All pain diagrams were classified as "organic" or "possibly organic," and the most common symptom descriptor was "deep ache." At the discharge session of physical therapy, five of six patients had symptoms that were more proximally located and all patients reported a decrease in symptom intensity. The author concluded that the favorable changes in symptom intensity and location were observed in this case series, but definitive conclusions cannot be drawn from this study design. Additional research needs to be completed to determine if the slump test position is an effective evaluation and treatment technique.

Jeffrey Miller et al. (1999) conducted a study to examine the slump test, its clinical applications and interpretations. The slump test physical examination procedure used for evaluating patients with spinal and lower extremity complaints. Thirty year old male nurse who have been admitted in a local emergency department with a thirty day past history of an acute, insidious episode of lower back pain with radiating symptoms in left foot. Non-thrust mobilizations were increased from grade II to grade IV based on the patientâ&#x20AC;&#x2DC;s response. The patient had lightening of his radicular symptoms when in the side lying position. Second visit, the patient continued to experience a decrease in the intensity of his radicular symptoms. The patient did not experience muscle spasm at end-range or increase in his radicular symptoms, therefore thrust manipulation was performed. Follow up period the investigator advised home based exercise program, neurodynamic mobilizations and abdominal breathing. During the third visit the investigator which he included lumbar side lying thrusts manipulation and specific exercise progression for lumbar stabilization with continued neurodynamic 57

mobilizations. Baseline Measures show that Oswestry = 42%, NRPS = 3/10, numbness rating = 7/10, no clear directional preference, no aberrant movement and FABQ work subscale = 12. Baseline objective measures, right slump test (32° > 46°), lumbar flexion = 30°, mild left extensor hallucis longus weakness and 2+/4 deep tendon reflexes for ankle and knee jerk. Significant progress in subjective and objective measures was noted following three visits over three weeks (one visit per week). Final Measures of Oswestry score 6%, NPRS 0/10, numbness 1/10 intermittently and global rating of change +6. Final objective outcome measures, slump on the right 75 degrees and left 80 degrees. The patient returned to work with no limitation. The researcher found that the application of the slump test is described to assist the clinician with differential diagnosis of spinal and lower extremity complaints.

Jeremy et al. (2007) conducted a study to identify the normative sensory responses, apply the slump test in asymptomatic subjects. Eighty-four subjects were tested. Repeated measures analysis of variance (Friedman‘s test) was used to determine whether differences in prevalence and intensity of responses at the different stages of the slump test were statistically significant. Post-hoc pairwise analysis was performed using Wilcoxon‘s signed rank test to determine between which pairs of stages significant differences occurred. They used a standardized procedure by the same examiner to ensure consistency and the prevalence, intensity, location, and nature of responses at each stage of the slump test [slumped sitting (SS), knee extension (KE), ankle dorsiflexion (AD), and cervical extension (CE)] and they were recorded. Participants of the subjects of, 97.6% reported a sensory response during the slump test. The study concluded that the normal response to the slump test might be considered a neurogenic response. The examiner suggested that this normative data might be used as a reference point, when they used the slump test as an examination of leg and back pain disorders.

Lowry and Cleland. (2008) conducted a study to find out whether any changes, cervical thoracic manipulation and knee extension during the slump test. The studies examined the effectiveness of manual therapy in the management of patients with nonspecific LBP with positive the slump test. There existed no consensus for most efficacious treatment for neuropathic pain. Subjects were a single patient referred to physical therapy with twenty years a history of low back pain. The diagnosis was positive neurodynamic tests with symptom reproduction and limited knee extension during the slump test. Pre-test and post- test knee extension ROM were compared with statistical adopted tools in this study, the nonparametric paired sign test had been used a binomial distribution.

They used Modified Low Back Pain Disability Questionnaire (LBPDQ) measured at visits one and four. This patient was treated once weekly for seven weeks and demonstrated clinically meaningful improvements in all outcome measures during fourth visit. The author concluded that the management with cervicothoracic manipulation and slump stretching in this patient with mechanosensitivity yielded significant changes in pain and knee extension range of motion during the slump test with

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immediate effects might be related to manipulation. Overall effects could not be extrapolated to the general population from a case report.

2.1.3 Neurodynamic tests Cyriax et al. (1942) conducted a study to find out the number of neurodynamic tests. This study assesses the mechano sensitivity of neurogenic structures. Methods a quasi-experimental design was used. Participants received neural mobilization or sham neural mobilization three times a week for three weeks, followed by a one week period of no intervention. A-delta (first pain response) and C-fiber (temporal summation) mediated pain perception were determined via quantitative sensory testing (baseline, sessions one, nine, and one week post session nine). Elbow extension ROM and sensory descriptor measures were measured during median nerve biased neurodynamic positions (baseline, session nine, and one week post session nine). Analyses of the data were analyzed with repeated measures ANOVA with treatment (NM and sham NM) as among group factors and followup time as within factors. The study concluded that the neurodynamic test is used a diagnosis among low back pain population.

Braggins et al. (2000) conducted a study to find out the neurodynamic test utility in clinical services. Methods of the participants underwent baseline quantitative sensory testing (QST) specific to Aδ and c-fiber mediated pain sensitivity. Pain associated with the QST was quantified using either a mechanical visual analog scale (MVAS) or a numeric rating scale (NRS). Baseline self- report of CTS pain was assessed by a mechanical visual analog scale rating of current pain. Participants were then randomly assigned to receive either an ND technique or a sham technique. QST and self- report of CTS pain were reassessed immediately following the intervention. Analyses were used repeated measure ANOVAs were used to evaluate the interaction between pre and post pain perception and group (direct or sham ND). The study concluded that the neurodynamic test used as a fast, low-cost diagnostic tool in the evaluation of leg and back pain disorders.

2.1.4 Reviews related to static (Isometric) spinal exercise John Maurtagh and Clive Kenna. (1989) conducted a study to find out the static (Isometric) spinal exercise and splinting the lumbar spine (pelvic tilt). The effect of different training intensities on maximum voluntary isometric contraction (MVIC) strength was examined in a three week voluntary isometric exercise program. Eighteen healthy university students were randomly assigned to one of three training groups, Low Intensity (LI), High Intensity (HI) and Maximal Effort (ME) groups. The LI and HI groups trained by producing voluntary isometric knee extension torques equivalent to twenty five and fifty percentage of MVIC strength, respectively. The ME group produced maximal effort contractions during training. Only the HI and ME groups demonstrated significant (p<0.05) isometric strength gains. The HI group produced the greatest strength gain (45.8 per cent of MVIC), followed by the ME group (31.3 per cent) and the LI group (22.3 per cent). No 59

significant strength retention, cross transfer or isokinetic strength was seen in any group. The strength improvements were of the same magnitude as those previously obtained using electro-motor stimulation at equivalent training intensities. The author asked the patient lie on the floor with your feet flat on the floor, arms at your side and your knees bent and will be drawn in your stomach (abdomen) firmly and press your lumbar region (back of the waist) against the floor by tightening, slightly raising your buttocks and this will tilt your pelvis upwards. The author asked the patient to hold-count of seven-relaxes and then repeat five to ten times. The study concluded that the isometric exercise treatment strategy, exercise protocols helped to reduce pain and disability for the management of non- radicular low back pain.

2.1.5 Reviews related to slump stretching Charlie Kornberg and Paul Lew. (1989) conducted a study to find out the effect of stretching neural structures on grade one hamstring Injuries. A comparative study treatment method was performed in a group of professional Australian Rules football players. This study was conducted on players diagnosed who had grade I hamstring injuries, who demonstrated positive responses to the slump test (a neural tension test). The methodology of this study included twenty eight subjects that satisfied the above criteria, among the twenty eight, sixteen were treated traditionally, and remaining twelve were received slump stretch as an addition to the treatment regime. Using the means provided

by GANOVA. The uni variant F test for the three-way interaction was significant (F (3/27) = 5.597, p < 0.0I), but the more conservative multivariate F-test. The results of the study indicated that the traditional treatment plus slump stretch technique was more effective (p < 0.001) in returning the player to full function than the traditional regime alone. The authors suggested that the slump test should be a mandatory test in the assessment of a hamstring strain, so that the most effective treatment regime might be implemented and neurodynamic treatment used as treatment.

Charlie Kornberg and Tim McCarthy. (1992) conducted a study to find out the therapeutic treatment of slump stretching (a neural stretching technique) which is used as therapeutic management of grade one hamstring strains and to elucidate its physiological basis. This study was designed to examine the effect of slump stretch on sympathetic outflow to the lower limbs using tele thermography. This study was conducted on ten normal, elite track and field athletes and the temperature readings were taken using tele thermographic imaging at four locations before and after stretching, on both stretched and unstretched lower limbs. These results were indicated that a significant cutaneous vasodilator effect occurred in the stretched limb as evidenced by increased skin temperature, the unstretched control limb showed a slight decrement in temperatures (p <0.001).

Using the means provided by GANOVA, The analysis confirmed this impression, with a significant limb x test interaction effect (F (1/9) = 45.59, p < 0.001). There is a suggestion that this effect did not occur equally at all cursor locations. The uni variant F test for the three-way interaction was significant (F (3/27) = 5.597, p < 0.0I), but the more conservative multivariate F-test was not. This 60

study indicated that slump stretch had a sympathetic inhibitory effect; this effect could be the underlying physiological mechanism for the therapeutic effect of slump stretch in grade one hamstring strains. The present study demonstrates that physical maneuvers could produce neurogenic effects, which might account for slump stretching used as therapeutic value.

Bishop et al. (2006) conducted a study to find out the effect of neurodynamic intervention on pain perception a randomized, single blind trial. The purpose of the study was to find out whether neurodynamic techniques were a group of manual intervention techniques purported to address the neural tension dysfunction in the nervous system. There were the effectiveness and efficacy of one such technique, slump treatment (ST), had been demonstrated in groups of patients complaining of low back and leg pain. The author had several conclusions from these data first, in contrast to the control group whom appeared to habituate to first pain stimuli over time. The intervention groups‘ responses to standardized pain stimuli remain elevated at two months and this indicated that a possible net effect of relative hyperalgesia for subjects performing the interventions. The second, as the pain response from slump was not different from the same technique in our study, the observed difference from controls may be related to general factors rather than specific effects of the technique on peripheral nerve function. Neuro dynamic intervention techniques did not appear to affect pain perception as measured using psychophysical techniques different from same techniques in healthy subjects. The clinically noted benefits may occur through mechanisms other than modification of peripheral pain perception although a parallel finding in a group of patients with pain was required to confirm this assertion. The further implication of this research would be testing those subjects with positive signs of neurodynamic dysfunction. The study concluded that slump was used as treatment purpose for the management of sciatica and low back pain related disorders.

Joshua et al. (2006) conducted a study to find out the slump stretching results in a decrease in pain, centralization of symptoms, and disability in patients with non-radicular low back pain (LBP) with likely mild to moderate neural mechanosensitivity. Thirty consecutive patients referred to physical therapy by their primary care physician for LBP who met all eligibility criteria including a positive slump test but who had a negative straight-leg-raise test (SLR) agreed to participate in the study. All patients completed several self-report measures including a body diagram, numeric pain rating scale (NPRS), and the Modified Oswestry Disability Index (ODI) and the patients were randomized to receive lumbar spine mobilization and exercise (n ¼ 14) or lumbar spine mobilization, exercise, and slump stretching (n ¼ 16). All the patients were treated in physical therapy twice weekly for three weeks for a total of six visits and patients were discharged and the outcome measures were re-assessed. The independent t-tests were used to assess differences between groups at baseline and discharge and also there was no baseline differences existed between the groups and at discharge, patients who received slump stretching demonstrated significantly greater improvements in disability (9.7 points on the ODI, P ≤ 0.001), pain (0.93 points on the NPRS, P ¼: 001), and centralization of 61

symptoms (P â&#x2030;¤ 0.001) than patients who did not. The results of the study concluded that slump stretching was beneficial for improving short-term disability, pain, and centralization of symptoms and the future studies should examine whether these benefits were maintained at a longer-term follow-up.

Beneciuk et al. (2006) the use of passive slump stretching as an intervention in the treatment of a patient with signs and symptoms consistent with adverse neural tension. The Purpose of the study, which describes the treatment of a patient presenting with adverse neural tension with a past medical history of surgical intervention for a varicocele. Methods included a twenty four year old male student presented to a university outpatient physical therapy clinic with complaints of local right sacrococcygeal regional pain with forward-bending activities. Patient past medical history was negative for trauma to this region and positive for surgical intervention secondary to a left-sided varicocele. Subject developed pain localized to his right sacrococcygeal region with forward-bending movements, following a prolonged period of sitting three weeks earlier. A neurovascular examination of the lower quarter was insignificant for upper and lower motor neuron involvement. Passive straight-leg raise testing (SLR) was 60 degrees bilaterally, suggesting bilateral hamstring tightness.

Initial significant findings included: 1) positive slump test (right: on initiation of knee extension; left: 45degree of knee extension), 2) decreased ability to initiate left trunk rotation in a slump test position secondary to reproduction of current local symptoms, 3) reproduction of current local symptoms with initiation of passive cervicothoracic flexion, 4) Modified Oswestry Disability Questionnaire (ODQ) scored at thirty percentage , 5) Fear-Avoidance Beliefs Questionnaire work subscale score (FABQW29) and activity subscale score (FABQA-20). The patient was seen two times per week for six weeks.

Interventions consisted of passive slump stretching, passive slump stretching combined with left trunk rotation, modified SLR passive hamstring stretching, and passive/active neural mobilizations. Results have shown that the patient demonstrated: 1) a negative slump test (symptoms described as posterior calf muscle-pulling with passive dorsiflexion of the ankle), 2) 75% passive left trunk rotation in a slump test position, 3) asymptomatic passive cervicothoracic flexion, 4) decreased scores on the ODQ (8%), FABQW (4), and FABQA (1) demonstrating marked improvement in function and fear avoidance beliefs. Conclusion study stated that the improvements were demonstrated in objective outcome measures and functional questionnaire scores. This case report suggests the possible benefit of the slump test position as an examination procedure and intervention in a patient presenting with signs and symptoms consistent with adverse neural tension in the absence of a positive slight leg rising. The decision to apply interventions is based on suggested impairments in the subjective interview and physical examination. The patient responded to prior sessions and continual reevaluation supported the decision to continue with the treatment approach.

Jennifer et al. (2008) conducted a study to find out the modified treatment based classification system to treat an adolescent with imaging evidence of a herniated disc. The purpose 62

was to identify the recent research; lumbar disc herniation in the adolescent population was extremely rare and accounts for only 0.5% to 6.8% of total disc herniation. The link between the uses of pathology or a treatment based classification approach to guided treatment had yet to be determined in an adolescent population. The secondary purpose of this case study was to address how a modified treatment based classification system was used for guidance on determining interventions for an adolescent patient with a herniated disc. The case description given by the author and the patient was an adolescent male, aged seventeen, with low back pain and a documented herniated disc at L5-S1 and there was no centralization occurred with repeated lumbar movements. However, subject had positive results for the straight leg raise and slump test and Intervention strategy, the patient was instructed in neurodynamic exercises, including a straight leg raise activity with progression to a slump stretch, along with a lumbar stabilization program. The patients attended thirteen physical therapy visits over an eight -week period and he showed a clinically meaningful change in the Oswestry Low Back Disability Questionnaire, ROM for the straight leg raise, the SF-12, and pain intensity rating. The author had made the conclusion that the use of a treatment based classification system for an adolescent patient with a known herniated disc seems to be appropriate treatment based on the outcomes of this case report. The author suggested further research would be needed to determine if this type of rehabilitation would be beneficial to a larger group of adolescents with low back pain.

McCracking et al. (2008) conducted a study to find out the long-term effects of a neurodynamic treatment technique used a treatment-based classification approach to low back pain.

The purpose of this study stated that it describes the long-term effects of a neurodynamic treatment technique for a patient with non-specific low back pain (LBP) and lower extremity (LE) pain. Who met three out of five criteria for the lumbopelvic manipulation classification (although outside of the reported age range from the initial and validation CPR studies). The relevance of neurodynamics had received little attention in the literature on matching subgroups of patients with LBP to intervention.

The subjects with eighty five year old female presented to physical therapy with a primary complaint of insidious onset LBP radiating to the left posterolateral thigh. The symptom duration was approximately one year and affected the patient almost daily and the key physical examination findings included lumbar spine hypo mobility, 35 degree hip internal rotation range of motion (ROM) bilaterally, no symptoms distal to the knee, and lower quarter neural tension dysfunction (positive Straight Leg Raise (SLR) at 40 degrees and positive Slump Test) and the methods were the subject attended seven physiotherapy sessions over four weeks. Patients were completed the modified Oswestry low back pain disability questionnaire (ODI) at baseline (42%) and every other subsequent visit. A current study concluded that neurodynamic treatment technique, slump stretching, was shown to be effective in the management of patients with non-radicular LBP when combined with lumbar mobilization and exercise.

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Sahar et al. (2011) conducted a study to investigate the effect of lumbar mobilization techniques, neural mobilization technique on sciatic pain. Through this study the author identified Functional disabilities, centralization of symptoms in patients, latency of Hoffmann reflex, and of degree of nerve root compromise in chronic low back dysfunction (LBD). Pretest and posttest group design which was used. Sixty patients with chronic (LBD) from both sexes were involved, aged between thirty â&#x20AC;&#x201C;sixty years. They were divided into two equal groups, group (a) received lumbar spine mobilization and exercise intervention and group (b) received straight leg raising stretching (SLR) in addition to lumbar mobilization and exercise. The outcome measured were self-report measures included a body diagram to assess the distribution of symptoms, numeric pain rating scale (NPRS), Modified Oswestry Disability Index (ODI). The results of study revealed that there was a significant difference between both groups of pain (p = 0.006), functional disabilities improvement (0.001), location of symptoms (p = 0.083) and sciatic nerve root compression (p = 0.035). However there was no significant differences in H-reflex latency (p = 0.873) between group A and group B (post- test).

The study concluded that straight leg rising (SLR) stretching might be beneficial in the management of patients with LBD. SLR stretching in addition to lumbar spine mobilization and exercise was beneficial in improving pain, reducing short-term disability and promoting centralization of symptoms in this group of patients.

2.1.6 Reviews related to mobilization and exercise Indahl et al. (1998) conducted a study to find out whether the light mobilization was an informative approach to low back pain. The design of the study was controlled clinical trial. The objectives were to examine the long term effect of an informative approach to low back pain. Methods a five year follow-up study was done on patients included in a previous study. The outcome was measured by return to work or still on sick leave. The patients were allocated to an intervention group (n = 245) and control group, (n = 244) among the both groups only the intervention group was called for examination. Intervention group asked patients answered a battery of tests for psychological and health factors. The interventions consist of education in a "mini back school." The program was based on a new medical model for low back pain. The results were forty-seven (19%) of the patients in the intervention group, compared with 84 patients (34%) in the control group, were still on sick leave after five years (P < 0.001). Fewer recurrences of sick leave (P < 0.03) in the intervention group than in the control group. However, the results of the discriminated analyses were almost identical both with and without a logarithmic transformation. A significant Pearson Chi-squared statistic is necessary, but not sufficient to conclude that a rule yields better than chance classification. Inaccuracy of classification over chance for each sample was tested using a z test for the significance of a proportion. The researcher concluded that this study indicated that sub chronic low back pain might be managed successfully with an approach that included clinical examination combined with 64

information for patients about the nature of the problem, provided in a manner designed to reduce fear and they have given them reason to resume light activity.

Devasahayam et al. (2010) conducted a study to find out the effectiveness of symptom guided therapeutic approach in treating discogenic pain with radiculopathy used a combination of directional preference exercises, mobilization and neural mobility exercises. A case report of the study reported that various therapeutic approaches to treat patients with low back pain. Mechanical diagnosis and therapy as proposed by McKenzie, had been shown to be effective in diagnostic, therapeutic and prognostic inference was most often. The treatment options considered in these studies were directional preference exercises, manual procedures utilized movement and positions.

The effectiveness of symptom guided therapeutic approach in treating discogenic low back pain with radiculopathy used directional preference exercises, mobilization and neural mobility exercises was unknown. A case of a forty three-year-old male presenting with discogenic low back pain along with radiculopathy was assessed with McKenzie approach. The appropriate treatment strategy was selected, prescribed based on the initial assessment, the patient was re-evaluated each session, and treatment modification was made according to his symptom presentation during each visit. They proved to be symptom free after seven visits. Discogenic back pain due to disc regression and enhanced neural mobility obtained due to treatment. On reassessment, the patient still had 3/10 pain on the verbal rating scale during active lumbar extension. But during this visit, he had 6/10 pain on the verbal rating scale during active flexion, which was reproducible with overpressure. He also had restriction during the lumbar rotation to the left side when compared to the right side. Passive physiological intervertebral motion segment (PPIVMS) tests were performed and the patient was suspected to have restricted opening of the facet joint on L4/L5 level at the left side. As the symptoms differed from the regular presentation, an appropriate treatment strategy was decided according to the present clinical findings. The same protocol with the patient in prone lying and legs off the bed to the right side with overpressure on the sides was applied twice with rest in between. On reassessment after this maneuver, patient reported less pain 2/10 on the verbal rating scale during active lumbar flexion. Subjects also reported no pain during active lumbar extension. In order to cater to the above mentioned PPIVMS findings, aiming to improve the active range of motion in left lumbar rotating, Grade IV mobilization-lumbar rotation to the left was applied at L4/L5 level with the patient in right side lying for three times in a single session. This maneuver improved the range of active lumbar rotation. The patient was then advised to continue with the same prescribed exercises. Although the patient presented with less pain intensity on active lumbar extension and no pain on functional activities, he still had complaints of the right radicular pain. In order to relieve the residual 2/10 pain on active lumbar extension, same active lumbar extension exercise was done with the patient in prone along with counter pressure on the sides to aid right side glide of lumbar spine. This pain got relieved completely this time after three sessions of this exercise doing twice per session. As the provisional 65

classification suggested a change in directional preference, patient was instructed to perform flexion in lying (FIL) exercises for fifteen times. This change in preference was confirmed with the reassessment after the FIL exercises, which relieved the residual pain completely. FIL exercise with fifteen repetitions daily was added to the patientâ&#x20AC;&#x2DC;s home program.Although his slump test was considered positive, the neural tension, which the patient experienced, was very less and he demonstrated a gradual increase in neural mobility. As the patient was doing all the prescribed exercises so far, including directional preference exercises and neural mobility exercises, the recovery from discogenic pain with radiculopathy was gradual and consistent. The subject was advised to continue these exercises at home. A week later, the patient called up and informed the physiotherapist that he was fine and obtained a discharge at request. After his discharge, a verbal consent was obtained to write this manuscript. This case report demonstrates the effectiveness of symptom guided therapeutic management to treat patients with discogenic low back pain along with radiculopathy used appropriate treatment strategies. The author concluded that the treatment offered and discussed the possible explanation of the specific treatment strategies implemented, slump stretching used as a treatment for discogenic low back pain.

Shannon et al. (2010) conducted a study to find out the application of a system, combined manual therapy intervention with low back related leg pain. Low back pain and leg pain commonly occur with multiple factors could cause low back related leg pain. The author identified, the source of symptoms was required in order to develop an appropriate intervention program. The patient in this case presented with low back related leg pain. A patho-mechanism based classification was described in combination with the patientâ&#x20AC;&#x2DC;s subjective and objective examination findings to guide treatment.

Methodology forty-nine percentage of the subjects demonstrated a positive slump test but a negative SLR. Both the slump test and SLR test have been shown to have better specificity (0.83; 0.89) when used to examine patients with lumbar disc herniation, but the slump test is more sensitive (0.84) than the SLR (0.52). In this population clinical manifestation of the patientâ&#x20AC;&#x2DC;s symptoms improved marginally with intervention addressing primarily the musculoskeletal impairments. Intervention addressing primarily the neurodynamic impairments and full functional improvements was attained with a manual therapy intervention directed at both mechanisms. Simultaneously, the approach described in this case address a mixed pathology utilizing passive accessory and passive physiological lumbar mobilizations in combination with lower extremity neurodynamic mobilization. The patient reported complete resolution of symptoms after a total of seven visits over a period of six weeks; specific guidelines do not yet exist for treatment based on the classification approach utilized. Present study concluded that neurodynamic mobilization with manual therapy used to treat low back related leg pain and resolution of mixed pathology.

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2.1.7 Reviews related to manual therapy Bialosky et al. (2006) conducted a study to find out the manual therapy induced analgesia compared with healthy subjects, those who have low backache. The purpose of the study was to find out specific manual therapies (spinal manipulative therapy (SMT) and neural mobilization). Other purpose specific manual therapies (spinal manipulative therapy (SMT) and neural mobilization) have demonstrated efficacy in the treatment of low back pain (LBP), yet exact mechanisms remain largely unexplained. A recent study by our group reported a neurophysiological effect in healthy individuals receiving manual therapy. Specifically, healthy individuals receiving spinal manipulative therapy to their lower back experienced significantly greater C-fiber mediated analgesia than those riding a stationary bike. The present study furthered our investigation of this neurophysiological effect by comparing manual therapy induced analgesia in healthy individuals and those with LBP. The investigator made hypothesized that a similar analgesic effect would occur in both healthy individuals and those with low back pain following a manual therapy intervention. Methods, twenty nine subjects were included in this study from on -going pilot studies. Twenty subjects were pain free (six males, fourteen females, mean age = 24.1 years). Nine subjects were experiencing LBP (one male, eight females, means age = 41.2 years, means LBP duration = 59.8 months). Healthy subjects were recruited from graduate level classes and subjects with LBP were recruited from physical therapy clinics. Previously established protocols assessed Aδ and C-fiber mediated pain sensitivity using thermal stimuli. Pain sensitivity was assessed prior to and following the application of manual therapy to the lumbar spine. Subjects receiving SMT were re-assessed immediately after manipulation, whereas subjects receiving neural mobilization were re-assessed at four weeks. Repeated measure ANOVAs evaluated the interaction between pre and post pain sensitivity and group (healthy or low back pain). Group differences in pain sensitivity were investigated by post hoc testing, as appropriate.

The results of the study a significant group by time interaction was observed in Aδ-mediated pain perception at 47°C (F = 10.63, p < 0.01), but not 49ºC. (F = 2.75, p = 0.11). Paired t-tests indicated that significant analgesia was induced in healthy subjects (mean difference= 23.5, 95% CI =15. 4 to 31.6), but not for LBP subjects (mean difference = 170 /– 4.4, 95% CI = –26.4 to 17.6). A significant group by time interaction was observed in the C-fiber mediated pain perception (F = 4.28, p = 0. 05).

Significant analgesia was observed in the healthy subjects receiving manual therapy (mean difference = 10.2, 95% CI = 4.3 to 16.1), but no analgesia was noted in the LBP subjects (mean difference = 6.8, 95% CI = –33.4 to 19.8). Conclusion/Clinical Relevance: Healthy subject‘s demonstrated significant analgesia for both Aδ and C-fiber mediated pain sensitivity following manual therapy interventions. Unexpectedly, subjects with LBP demonstrated no change in Aδ and C-fiber mediated pain sensitivity. A reduction in C-fiber mediated pain perception has been proposed to partially account for the clinical effectiveness of manual therapy. Clinical intervention studies have generally reported more robust effects in patients with acute (shorter duration) LBP than those with chronic 67

(longer duration) LBP. Neoplastic changes in the central nervous system (i.e., Central sensitization) are speculated to result from continued exposure to tonic nociceptive input, especially when the input involves C-fibers. These neuroplastic changes are believed to be present in chronic LBP, but not in acute LBP. Therefore, we speculate that the differential effects we observed may be a preliminary indication that C-fiber mediated pain sensitivity for patients with chronic LBP is not effectively modulated by manual therapy. In contrast, there seems to be the potential to modulate C-fiber activity in pain free subjects. To properly test this hypothesis, future studies will test the analgesic response of subjects with acute LBP. Cleland et al. (2008) conducted a study to find out the generalizability of a clinical prediction rule, identifying patients with low back pain who were likely to respond rapidly and dramatically to thrust manipulation. The purpose of the study was a clinical prediction rule (CPR) that accurately identified a sub-group of patients with LBP likely to respond with rapid and prolonged reductions in pain and disability. Following thrust manipulation has been developed and validated in a single study; the examination of the generalizability to differentiate clinicians and practice settings was required.

They sought to explore the generalizability of the clinical prediction rule by examining the outcomes in different practice settings. Patients over a twenty eight month period attending physical therapy at an outpatient clinic with a primary report of LBP (with our analysis and all participants) presented with a clinical diagnosis of CT with complaints present for at least twelve weeks and the methods, participants underwent baseline quantitative sensory testing (QST) specific to Aδ and c-fiber mediated pain sensitivity. The pain associated with the QST was quantified using either a mechanical visual analog scale (MVAS) or a numeric rating scale (NRS). The results found that a significant group by time interaction was observed in a mediated pain perception at 49°C (F (1, 65) = 0, p= 0.05, partial η2= 0.06). The pairwise comparison indicated a none signify could not increase in pain perception in participants receiving the indirect technique (mean difference 4.19 (SD= 20.89)), p= 0.24, effect size= 0.17). A non- significant decrease in pain perception in individuals receiving the direct technique (mean difference 6.06 (SD= 19.75), p= 0.10, effect size= 0.23) neither group dependent changes nor main treatment effects was observed in c- fibers mediated pain (p> 0.05). A main treatment effect (F (1, 65) = 10.32, p< 0.01, partial η2= 0.14) independent of group assignment (p> 0.05) was observed for self-report of CTS pain immediately following ND. The author concluded a significant group by time effect was observed for Aδ mediated pain perception immediately following ND. Self- report of CTS pain showed a main treatment effect immediately following ND independent of group assignment. Present study concluded that manual therapy technique used as a treatment of low back pain.

Mintken et al. (2008) conducted a study to find out outcomes achieved by patient‘s status post ankle sprain treated with manual physical therapy and exercise interventions: A preliminary report has investigated the effectiveness of manual physical therapy interventions for patients with 68

ankle disorders, but the results have been contradictory and inconclusive. The purpose of this preliminary report is to describe short-term outcomes achieved by patients after inversion ankle sprain treated with a manual physical therapy treatment approach. Based on these data, we intend to develop a clinical prediction rule (CPR) to identify patients most likely to experience rapid and dramatic improvements from this intervention. Methods used in this study a prospective cohort study with consecutive patients aged between 16 – 60 with a primary history of Grade I-II inversion ankle sprain within the last year and pain scores over the past week of lesser 3/10 on a 10 point numeric pain rating scale (NPRS) were invited to participate. Subjects were recruited from four different clinical sites across the United States. Eligible patients, who consented to participate completed a series of selfreport measures, then underwent a detailed standardized history and physical examination consisting of a variety of tests and measures commonly used to assess patients who have experienced an ankle sprain. Regardless of the results of the clinical examination, all patients received a standardized treatment regimen consisting of manual physical therapy (including both thrust and non-thrust manipulation), exercise, and a standard ―RICE‖ program. At the follow-up session two business days later, patients again completed the self-report measures and depending on response to treatment, were either considered to have experienced a successful outcome or underwent a second treatment session.

At the third and final session (4 business days later), patients completed the self-report measures and were again classified as having experienced a successful outcome or not. We based the reference standard for success on the well-accepted patient-reported global rating of change (GROC). Success was defined a priori as a patient report of ―quite a bit better‖, ―a great deal better‖, or ―a very great deal better‖ compared to the initial examination (GROC scores of 5-7). Patients also completed the Foot and Ankle Ability Index (FAAI), Lower Extremity Functional Scale (LEFS), and NPRS at the initial exam and follow-up visits to compare differences in improved function between those who experienced a successful outcome and those who did not. Descriptive statistics were calculated to describe baseline characteristics and outcomes achieved by all subjects, as well as individually for those meetings and not meeting the threshold for success. The results were seventeen subjects (ten females; mean age 32.1 (12.2) years) have enrolled to date. 71% of all subjects (n=12) met the threshold for success. Of the five subjects who did not meet this threshold, 2 subjects reported being ―moderately better‖ (GORC=4), one reported being ―about the same‖ (GROC=0), and two worsened (GROC=-4). One of the subjects who worsened reported injuring his ankle while snowboarding during the course of the study. Baseline self-reports outcomes, values and improvements in self-report variables are included in the table below (Note: Values in the table represent the means (standard deviation) unless otherwise noted). Conclusions about the results of this analysis demonstrate that patients can achieve clinically meaningful improvements in pain, function, and disability after an ankle sprain when treated with a program including manual physical therapy interventions, exercise, and a ―RICE‖ protocol. Upon completion of the study, we will attempt to develop a CPR for 69

predicting those patients most likely to experience a successful outcome from this intervention. The criteria in the CPR may be used in future clinical trials to improve the power of clinical research in patients with an ankle sprain and serve as the basis for a future validation study.

Wayne Hoskins and Henry Pollard. (2010) conducted a study to find out a descriptive study of a manual therapy intervention within a randomized controlled trial for hamstring and lower limb injury prevention. Background of the study there is little literature describing the use of manual therapy performed on athletes. It was our purpose to document the usage of sports chiropractic manual therapy intervention within a randomized controlled trail by identifying the type, amount, frequency, location and reason for treatment provided. This information is useful for the uptake of the intervention into clinical settings and to allow clinicians to better understand a role that sports chiropractors offer. Methods of all treatment rendered to twenty nine semis-elite Australian Rules footballers in the sports chiropractic intervention group of an 8 month RCT investigating hamstring and lower-limb injury prevention was recorded. Treatment was pragmatically and individually determined and could consist of high-velocity, low-amplitude (HVLA) manipulation, mobilization and/or supporting soft tissue therapies. Descriptive statistics recorded the treatment rendered for symptomatic or asymptomatic benefit, delivered to joint or soft tissue structures and categorized into body regions. For the joint therapy, it was recorded whether treatment consisted of HVLA manipulation, HVLA manipulation and mobilization, or mobilization only. Breakdown of the HVLA technique was performed. The results: A total of 487 treatments was provided (mean 16.8 consultations/player) with 64% of treatment for asymptomatic benefit (73% joint therapies, 57% soft tissue therapies). Treatment was delivered to approximately 4 soft tissue and 4 joint regions each consultation. The most common asymptomatic regions treated with joint therapies were thoracic (22%), knee (20%), hip (19%), sacroiliac joint (13%) and lumbar (11%). For soft tissue therapies it was gluteal (22%), hip flexor (14%), knee (12%) and lumbar (11%). The most common symptomatic regions treated with joint therapies were lumbar (25%), thoracic (15%) and hip (14%). For soft tissue therapies it was gluteal (22%), lumbar (15%) and posterior thigh (8%). Of the joint therapy, 56% was HVLA manipulation only, 36% high-HVLA and mobilization and 9% mobilization only. Of the HVLA manipulation, 63% was mainly performed and 37% mechanically assisted. The author concluded that the intervention applied was multimodal and multi-regional. Most treatment was to asymptomatic benefit, particularly for joint based therapies, which consisted largely of HVLA manipulation techniques. Most treatment was applied to non-local hamstring structures, in particular the knee, hip, pelvis and spine.

2.1.8 Reviews related to FABQW, FABQPA, and FABQT Waddell et al. (1993) fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain. The purposes of this study were to 70

investigate the association between measures of fear-avoidance beliefs, pain intensity, and lumbar flexion and to determine if changes in these measures were predictive of treatment outcome following physical therapy for acute low back pain. It was hypothesized that items of the Fear-Avoidance Beliefs Questionnaire would be correlated with concurrent measures of pain intensity and lumbar flexion. In addition, it was hypothesized that changes in fear-avoidance beliefs would be predictive of changes in self-report of pain intensity and disability. Study design Patients underwent a standard examination that included measures of fear-avoidance beliefs, pain intensity, lumbar flexion, and disability from low back pain. Patients were then re-examined after four weeks of physical therapy treatment. Sixty-three patients with acute low back pain enrolled in a clinical trial of physical therapy treatment. The results of the study shown that the Fear-Avoidance Beliefs Questionnaire items were consistently correlated with lumbar flexion, but not with measures of pain intensity. Pearson correlations indicated that changes in disability were significantly associated with changes in fearavoidance beliefs and pain intensity, but not changes in lumbar flexion. Changes in fear-avoidance beliefs explained significant amounts of variance in changes in average pain intensity while controlling for changes in lumbar flexion. Changes in fear-avoidance beliefs explained significant amounts of variance in changes in disability while controlling for changes in average pain intensity.

The study concluded that these results suggest that fear-avoidance beliefs have a similar association with pain intensity, physical impairment, and disability for patients with acute and chronic low back pain. This study provides preliminary support for the use of the Fear-Avoidance Beliefs Questionnaire as an outcome measure for patients with acute low back pain.

Pfingsten et al. (2000) conducted a study to find out whether the FABQ scales had been found to have acceptable reliability. Test-retest reliability has been reported for the FABQ-PA (Pearson r = 0.84 to 0.88) and FABQ-W (Pearson r = 0.91 to 0.88) and the Cranachâ&#x20AC;&#x2DC;s alpha estimates for the FABQ-PA (ranging from 0.70 to 0.83) and FABQ-W (ranging from 0.71 to 0.88) Scores suggest both scales demonstrate internal consistency. The FABQ-W has demonstrated predictive validity for disability and work loss in patients with LBP. A suggested FABQ-W cut off score of >29 has been suggested as an indicator of return to work status in patients receiving physical therapy for acute occupational LBP99 and a cut off score of >22 has been suggested in non-working populations and an FABQ-PA cut off score of >14, based on a median-split of the FABQ has been suggested as an indicator of treatment outcomes in LBP patients seeking care from primary care or osteopathic physicians.35 Data from 2 separate physical therapy intervention clinical trials indicated that the FABQW cut off score (>29) was a better predictor of self-reported disability at 6-months in comparison to the FABQ-PA cut off score (>14).

2.1.9 Reviews related to ODI Fairbank et al. (1980) conducted a study to find out the number of reasons related to the responsiveness and ease of administration; region-specific measures are most commonly used in low 71

back pain treatment and research. The Oswestry Low Back Disability Index (ODI) was a commonly utilized outcome measure to capture perceived disability in patients with low back pain. Methods of all patients provided demographic information and completed a number of self-report questionnaires including the Oswestry Disability Questionnaire (ODQ). Analyses are made the differences between practices settings were explored by examining patients receiving the same manipulation technique using a linear model with repeated measures. The ODQ served as the dependent variable, by setting modelled as a fixed effect. The hypothesis of interest was the time by setting interaction which would indicate a differential response over time in different settings for patients receiving a thrust manipulation technique originally described the ODI contains 10 items, 8 related to activities of daily living, 2 related to pain. Each item is scored from 0-5 and the total score is expressed as a percentage, with higher scores corresponding to greater disability. The investigator concluded that The ODI has long-standing recognized as an acceptable standard, with numerous studies that speak to its reliability, validity and responsiveness.

Flynn et al. (2002) conducted a study to find out the subgroup of patients likely to have dramatic changes with application of thrust manipulation to the lumbar spine, advice to remain active, and mobility exercise and an initial derivation study of patients most likely to benefit from a general lumbopelvic thrust manipulation. Analyses show that the baseline variables were compared between groups using independent t-tests for continuous data and chi-square tests of independence for categorical data. The primary aim (effects of treatment for pain and disability) was examined with 2way repeated-measures analysis of variance (ANOVA), with treatment group (TRAD versus MTEX) as the between subjects variable and time (baseline and follow-up) as the within subjects varied.

Separate ANOVAs were performed with the NPRS, the LEFS and the FAAI as the dependent variable. For each ANOVA, the hypothesis of interest was the 2-way interaction. Planned pairwise comparisons were performed to examine the difference between baseline and follow-up periods using the Bonferroni equality at an alpha level of 0.05. Five variables were determined to be predictors of rapid treatment success, defined as a 50% reduction in Oswestry Disability Index (ODI) score within two visits and These predictors included that the duration of symptoms < 16 days, no symptoms distal to the knee, lumbar hypo mobility and at least one hip with >35 of internal rotation and the FABQ work score < 19 and the presence of 4 or more predictors increased the probability of success with thrust manipulation from 45% to 95%. The author concluded that the ODI reliable outcome measures for low back pain conditions.

2.1.10 Reviews of related literature NPRS Childs et al. (2005) conducted a study to find out the visual analog scales (VAS) and numeric pain rating scales (NRS) were in commonly used as an outcome measure. They used both in the literature and clinically. Methods of the subject attended seven physiotherapy sessions over 4 weeks and completed the Modified Oswestry Low Back Pain Disability Questionnaire (ODI) at baseline 72

(42%) and every other subsequent visit. Analyses were made baseline variables were compared between groups using independent t-tests for continuous data and chi-square tests of independence for categorical data. The primary aim (of effects of treatment for pain and disability) was examined with 2-way repeated-measures analysis of variance (ANOVA), with treatment group (TRAD versus MTEX) as the between subjects variable and time (baseline and follow-up) as the within subjects varied. Separate ANOVAs were performed with the NPRS, the LEFS and the FAAI as the dependent variable. For each ANOVA, the hypothesis of interest was the two way interaction (group time).

Planned pairwise comparisons were performed to examine the difference between baseline and follow-up periods using the Bonferroni equality at an alpha level of 0.05. An intention to treat analysis was used Telephone follow-up was conducted at 10 months. An impairment-based treatment approach was implemented to address lumbopelvic and hip restrictions and was supplemented with a home exercise program (HEP) aimed at ROM limitations, targeted muscle stretching, and core stabilization exercises. By visit 4 the ODI decreased to 36% and symptom resolution had plateaued.

These scales had the advantage of ease of administration, but fail to adequately capture the majority of the ―core‖ areas of outcome in low back pain assessment and they had done assess pain very specific, though, and had minimally important change of 15 for VAS and 2 for NPRS. The author concluded that the NPRS reliable outcome measures for low back pain condition.

2.1.11 Reviews of related literature bio-mechanics of the spine Michael and Adams. (2010) conducted a study to find out a mechanistic account of back pain which attempts to incorporate all of the most important recent advances in spinal research, the anatomical and pain-provocation studies. The motivation for writing this review paper, and indeed a book with a similar name, 3 is too attempt to put into context all of the influences which contribute to the natural history of back pain. The word ‗bio-mechanics‘ in the title is not intended to suggest a preoccupation with mechanical influences, but a desire to construct a mechanistic explanation of the various chains of events, including biological and psychological ones, that result in back pain. As we have argued previously: 3 ‗Back pain should be explained, not explained away!‘ In what follows, Sections 1 and 2 tackle the problem of where back pain comes from by considering the relevant functional anatomy, together with evidence of pain-provocation and pain-blocking studies. Section 3 attempts to distinguish spinal degeneration (and in particular, disc degeneration) from the more-orless inevitable consequences of ageing. Structural disruption is seen as a key component of ‗degeneration‘, and Section 4 considers how mechanical loading can most easily disrupt the tissues and structures of the lumbar spine. Section 5 points out that living tissue do not behave like inert engineering materials: they respond biologically to their mechanical environment and to mechanical damage, and these responses may mask the essentially mechanical origin of ‗degenerative‘ changes within them. Section 6 explains why certain individuals develop low back disorders while others, who may subject their backs to more severe mechanical loading, do not. The concept of a ‗vulnerable‘ 73

back is of major medico-legal importance. Section 7 suggests that the manner in which we sit and stand and move can create painful stress concentrations within innervated tissues, even though the tissues remain undamaged. Such ‗functional pathology‘ may explain a great deal of transient back pain.

The summary attempts to piece together all of the available evidence to form a simple and plausible account of the biomechanics of back pain. They had shown that severe and chronic back pain most often originates in the lumbar intervertebral discs, the apophyseal joints, and the sacroiliac joints and the psychosocial factors influence many aspects of back pain behaviour but they were not important determinants of who would experience back pain in the first place. The back pain was close (but not invariable) associated with structural pathology such as intervertebral disc prolapsed and endplate fractures, although age-related biochemical changes such as those revealed by a ‗dark disc‘ on MRI had little clinical relevance. All the features of structural pathology (including disc prolapsed) could be re-created in cadaveric specimens by severe or repetitive mechanical loading, with a combination of bending and compression being particularly harmful to the spine. Structural disruption alters the mechanical environment of disc cells in a manner that leads to cell-mediated degenerative changes, and animal experiments confirm that surgical disruption of a disc was followed by widespread disc degeneration. The researcher found that some people were more vulnerable to spinal degeneration than others, largely because of their genetic inheritance and the age-related biochemical changes and loading history could also affect tissue vulnerability. The author had given the concept of ‗functional pathology‘ according to which, back pain could arise because postural habits generate painful stress concentrations within innervated tissues, even though the stresses were not high enough to cause physical disruption. Summary Spinal tissues can age biochemically without becoming degenerated or painful. However a combination of genetic inheritance, ageing and loading history can make some tissues more vulnerable to injury or repetitive loading so that they become disrupted. Degenerative changes follow as cells respond to an unfavourable mechanical and nutritional environment, and a vicious circle of tissue weakening and further injury can develop, particularly within the intervertebral discs. Disrupted tissues give rise to localized stress concentrations which can be painful, but links between degenerative changes and pain are complicated by factors such as stress shielding and pain sensitization. Psychosocial factors largely determine subsequent pain behaviour. The author concluded that abnormal biomechanics leads to find out the aetiology of the spine.

2.1.12 Reviews of related literature specific exercise protocols for LBP Stephen May et al. (2004) conducted a study to find out the exercise prescription for low back pain. The systematic reviews and treatment guidelines have cast doubt on the need for a specific exercise prescription for patients with low back pain (LBP). The simple advice to ―remain active‖ and ―reassurance‖ had been shown to be effective while exercise trials in ―nonspecific‖ LBP populations tend to produce equivocal or conflicting results. The author stated that furthermore, little distinction 74

had been made between exercises aimed at cardiovascular and strength benefits versus exercise used as a pain management tool. The objectives of this paper were to determine whether there are subgroups within the LBP population who respond differently to different exercise prescriptions and whether these subgroups could be predicted by a dynamic mechanical assessment. The primary outcome measures included back and leg pain ratings, Roland-Morris Disability Questionnaire, and medication use and the Secondary outcomes included such as the Beck Depression Inventory, self ratings of work interference, need for further treatment, ability to return to work and recreational activities, and change in Quebec Task Force classification. The researcher concluded that this form of mechanical assessment identified patientsâ&#x20AC;&#x2DC; â&#x20AC;&#x2022;directional preferenceâ&#x20AC;&#x2013; and established directional subgroups for which effective, ineffective, and even counterproductive exercises were demonstrated among different types of LBP treated with specific protocols.

2.1.13 Reviews of related literature to prevention of low back pain Judge Group et al. (1984) conducted a study and found out the causes, prediction and prevention of back pain at work and the pain in the back and lower limbs due to lumbar disorders introduction: Low back pain (LBP) is a general health problem with a lifetime prevalence of 70- 80% in adults. Several studies investigated the possible risk factors for LBP in adults. There is growing evidence that adolescent LBP has a predictive value for the development of LBP in an adult. Studies on back pain prevalence in children, report an increase in back pain in the growing child, particularly at the time of the pubertal growth spurt. The aim of this study is to determine the risk factors, which may predispose the adolescent to LBP, such as race, gender, physical activity, socioeconomic background, emotional status, schoolbag handling and smoking. The method of the study population included 1000 adolescent secondary school children of both sexes between thirteen to eighteen years from both urban and rural areas in Northern Gauteng, South Africa. The sample size selected was according to specific inclusion and exclusion criteria, utilizing randomized, stratified, cluster sampling. Data were collected by means of a validated questionnaire and the reliability was tested by a test-retest reliability study on the main outcome variables. The questionnaire which was made which is prepared has translated through their four local languages available. The following data were collected: socioeconomic status; physical activity participation; sedentary activities; the prevalence of LBP, including the onset, frequency, area affected, disability and treatment; as well as the prevalence of other muscle-skeletal symptoms; type and mode of carrying schoolbags; smoking and emotional well- being. Data analysis of the including Risk factors will be determined to make use of logistic regression. Results and conclusion stated that the possible risk factors that predispose to LBP in the adolescent will be identified (results available in January 2004). The data will lead to suitable educational and preventative programs. The aim of these programs will be to empower adolescents; teachers and parents minimize potential risk factors that may predispose to LBP. 75

2.1.14 Reviews of related literature to centralization phenomenon among spinal conditions Alessandro et al. (2004) found the centralization phenomenon of spinal symptoms with systematic review. A review of current knowledge was appropriate and the selection criteria were established prior to a computer-aided search for published papers. The two reviewers independently extracted data and checked quality, a third reviewer resolved any disagreements and a narrative review was conducted based on the findings and

the review primarily considered prevalence,

reliability of assessment, and prognostic significance and Those had been most commonly reported are important to establish the clinical worth of this symptom response and fourteen studies were identified and the Quality of studies varied, Prognostic studies were given a mean score of 3.3 out of 6 by used established quality criteria and the prevalence rate of pure or partial centralization was 70% in 731 sub-acute back patients, and 52% in 325 chronic back patients. It was a symptom response that can be reliably assessed during examination (kappa values 0.51â&#x20AC;&#x201C;1.0) and the centralization was consistently associated with a range of good outcomes, and failure to centralize with a poor outcome and the centralization appears to identify a substantial sub-group of spinal patients. The study concluded that it could be reliably detected, associated with a good prognosis and the centralization of symptoms should be monitored in the examination of spinal patients.

The investigator observed the research abstracts had conclusive evidence that slump stretching is one of the critical therapeutic modality widely used in research. The specific slump stretching is beneficial for improving short-term disability, pain, and centralization of symptoms.

There are other research findings to show that other modalities like manipulation, mobilization and static spinal exercises also bring out major benefits among low back pain. Since there were not many research studies using slump stretching the investigator felt compelled to use slump stretching methods. Further slump stretching can also be used for assessment purposes.

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CHAPTER III 3. METHODOLOGY 3.1 Introduction This chapter describes the research setting and how the study performed to be carried out. It also examines the methods used in the study. The study design, study population and sampling method, instrumentation and data collection which are described. Description of the intervention, and data analysis, was given. Finally, the ethical considerations relating to the study were provided.

3.2 Research Design The present study was an experimental nature. The study which used for two group repeated measures design. This research design used to assess the effects of the treatment with the same group over a period of time over three stages. This study also compares the two groups and measure document between three stages.

3.2.1 Design of the study The study design which has made also considered baseline, pre-test and post-test group design. The dependent variables considered the pain level, functional disabilities, and degree of neurodynamic test (positive slump test and negative slight leg raising test and quantifying fear/felling of pain). The independent variables consists of neurodynamic techniques (slump stretching), and lumbar mobilization.

Control group

: Mobilization technique with static spinal exercises

Intervention group: Slump stretching followed by mobilization with static spinal exercises.

3.2.2 Pilot study Prior to the study, the pilot study conducted which involving five patients with confirmed diagnosed by non- radicular low back pain. NPRS, FABQW, FABQPA, FABQT and ODI scales were recorded through baseline, post intervention 1 and post intervention 2. The intervention group, the investigator administered slump stretching weekly thrice for one week duration. Based on the expert opinion on the findings of the pilot study objectives two and four were withdrawn. The experts opined that it was not feasible to find the relationship between the scales as well as classification of systems, integrating pathoanatomic and clinical categories of relevance of physiotherapy.

3.3 Sampling With regard to sample size, there was no similar study which gave guidelines to the size of samples required. There are no consistent recommendations for a minimum sample size for Repeated Measures ANOVA. According to Tabachnick and Fiedell, the minimum sample size is required is ten plus the number of dependent variables. In this case, based on these selection criteria, the minimum sample size was limited to 20+20 =40. So it was decided to keep the sample size twenty in each 77

group. The retrospective study of Cleland 2006, the same sample size used, which he performed to identify the efficacy of intervention. All patients briefed about the purpose of the study and signed informed consent approval forms. The ongoing study samples were selected from the four clinics.

Based on the study Cleland 2006 which he utilized the samples in twenty intervention subjects? The present study investigated limited the sample size up to twenty. Already the present proposed study to collect the samples in four clinics. To give equal representation to each clinic it was proposed to collect ten samples from each clinic considering five for the control group and twenty for the intervention group. The samples were selected from the follow up registers through below mentioned four clinics those who met the inclusion and exclusion criteria. Sita Bhateja Speciality hospital (Spectrum Physiotherapy Centre), Rajashri grandhim physiotherapy clinic, Rhea health care, Gokul physiotherapy clinic. Before starting consent form prepared and followed by the acceptance letter of all subjects which was obtained through their signature.

3.4 Description of the tools used for data collection The following tools were used for data collection.

1. Numeric Pain Rating Scale which used to measure Intensity pain (ANNEXURE V).

2. Fear Avoidance belief questionnaires which help to assess fear avoidance beliefs patient with regard to the effect of physical activity and work on their LBP (ANNEXURE VI).

3. Oswestry Disability Index to evaluate functional ability (ANNEXURE VII).

3.5 Numeric Pain Rating Scale 3.5.1 Pain assessment The 11-point NPRS ranges from 0 (‗‗no pain‘‘) 1to 3 (‗‗Mild pain‘‘) 4 to 6 (―Moderate pain‖) 7 to 10 (―Severe pain‖) was used to indicate the intensity of current pain and at its best and worst level over the last twenty four hours (Jensen et al. 1994). These three ratings were averaged to arrive at an overall pain score. The scale has been shown to have adequate reliability, validity, and responsiveness in patients with LBP when the 3 scores are averaged (Childs et al. 2004).

3.5.2 Purpose The Numeric pain rating scale provides qualitative ―measure‖ of a patient‘s experience of pain and symptoms. This instrument consists of before treatment, At the end of 1st week & 2nd week treatment (None, Mild, Moderate, Severe pain). It describes how the patient‘s experience of pain and symptoms. The scale which provides 10 numbers indicates 0 could be no pain, 1-3 could be mild pain, 4-6 could be moderate pain and 7- 10 could be severe pain.

3.5.3 Administration Patients were instructed to make a mark through number to represent the intensity of pain and symptoms which they experienced at the present time.

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3.5.4 Scoring 0 – 10 Numeric Pain Rating Scale    

0 = No Pain 1-3 = Mild Pain (nagging, annoying, interfering little with ADLs) 4–6 = Moderate Pain (interferes significantly with ADLs) 7-10 = Severe Pain (disabling; unable to perform ADLs)

3.5.5 Indications Adults and children (> 9 years old) in all patient care settings who were able to use numbers to rate the intensity of their pain.

3.5.6 Instructions 1. The patient was asked any one of the following questions:  

What number would you give your pain right now?

What number on a 0 to 10 scale would you give your pain when it is the worst that it gets and when it is the best that it gets?  At what number is the pain at an acceptable level for you?

2. When the explanation suggested above is not sufficient for the patient, it is sometimes helpful to further explain or conceptualize the Numeric Rating Scale in the following manner:  0 = No Pain  1-3 = Mild Pain (Nagging, Annoying, Interfering little with ADLs)  4–6 = Moderate Pain (Interferes significantly with ADLs)  7-10 = Severe Pain (Disabling; unable to perform ADLs).

3. The interdisciplinary team in collaboration with the patient/family (if appropriate), could determine appropriate interventions in response to Numeric Pain Ratings.

This was a scale to measure pain. 

0 indicates ‗no pain at all‘.



1-3 which is the numbers on the scale indicate increasing levels of mild pain.



4-6 which is the numbers on the scale indicate increasing levels of moderate pain.

 7-10 which is the numbers on the scale indicate increasing levels of indicating severe pain.

3.6. Fear Avoidance Belief Questionnaire (FABQW, FABQPA (subscale), FABQT) 3.6.1 Overview The Fear-Avoidance Beliefs Questionnaire (FABQ) which can help to measure the fear level of Pain, Work and Physical activity. The authors are from the Western Infirmary in Glasgow (Scotland) and the Hope Hospital in Salford (England).

3.6.2 Purpose The FABQ was used to quantify the patient‘s fear of pain and beliefs about Avoiding Activity (Waddell et al. 1993) The FABQ assesses patient beliefs with regard to the effect of physical 79

activity and work on their LBP. It consists of 16 items and patients rate their agreement with each statement on a 7- Point Likert scale (0 = completely disagree, 6 = completely agree). The original factor analysis revealed two subscales: the work (FABQW) subscale with 7 questions (Maximum score = 42) and the physical activity (FABQPA) subscale with 4 questions (Maximum score = 24).

This instrument consists of before treatment, 1st week& 2nd week treatment. A higher score indicates most strongly held fear avoidance beliefs. It takes approximately 10 minutes to complete. This measure was collected to assess the potential confounding effects of fear avoidance beliefs on outcome.

3.6.3 Administration Patients were instructed to make a mark through number to represent assesses patient beliefs with regard to the effect of physical activity and work on their LBP their experience at the present time.

3.6.4 Scoring  Fear-avoidance beliefs about work (scale 1) = (points for item 6) + (points for item 7) + (points for item 9) + (points for item 10) + (Points for item11) + (points for item 12) + (points for item 15).  Fear-avoidance beliefs about physical activity (scale 2) = (points for item 2) + (points for item 3) + (points for item 4) + (points for item 5).

Items not in scale 1 or 2: 1 8 13 14 16

3.6.5 Interpretation    

Minimal scale scores: 0 Maximum scale 1 score: 42 (7 items) Maximum scale 2 score: 24 (4 items) The higher the scale scores the greater the degree of fear and avoidance beliefs shown by the patient.

3.6.6 Performance Internal consistency (alpha) 0.88 for scale 1 and 0.77 for scale 2 The FABQ was a useful questionnaire to assess fear avoidance beliefs. The psychometric properties of the subscales were better established than the total FABQ so use of the subclass may be preferable. The FABQPA may be more appropriate for patients who did not work. However, (Kovacs et al. 2006) suggest that there may be a ceiling effect for the FABQPA as 23.9% of their sample scored the highest score possible. This was not seen for the FABQT or FABQW. The majority of reliability and validation studies had been undertaken in chronic LBP populations but recently there has been interest in its ability to predict long term disability in acute populations. Results had been contradictory in this area with some studies showing that it could be 80

used to identify acute low back pain patients at risk of poor outcome (Fritz and George. 2002). But others have shown it not to be a useful predictor in this patient group (Grotle et al. 2005).

At present there are no values to define what constitutes an elevated FABQ score. (Crombez et al. 1999) Suggest that a FABQPA lesser fifteen (based on the median score of the Population studied) should be considered an elevated score but this requires further Validation. (Fritz and George. 2002) Found that a FABQW lesser thirty four identified patients at risk of not returning to work four weeks post injury in patients with acute work-related LBP. The authors emphasized that more research is needed to establish cut off scores for ‗at risk‘ patients. Establishing such values would improve the usefulness of the instrument in the clinical setting.

The change in FABQ scores that reflects a clinically important change in beliefs has not been established. Changes in FABQ have been shown to correlate with changes in disability following treatment (Woby et al. 2004) Indicating a relationship between the two. Further research in this area may help to explain patient responses to treatment. The role of fear avoidance beliefs in the development of long term disability has been gaining importance in recent years. It is important that this psychological factor is assessed so that treatment can address unhelpful beliefs that may contribute to the development or maintenance of disability. The FABQ is a reliable and valid measurement that can be used for this purpose, although further research into its use as a diagnostic tool is warranted.

3.7 The Oswestry Disability Index (ODI) or Oswestry Low back pain Disability Questionnaire Oswestry Low back pain disability questionnaire was designed by Oswestry to provide a quantitative measure of low back pain functioning ability. The questionnaire consists of 10 statements. The statements were selected to cover a wide range of activities daily living. The phrase ―because of my back‖ was added to each statement in order to distinguish disability due to back pain from disability due to other causes.

The functional ability of each patient was assessed by Oswestry disability questionnaire. It consists of 10 multiple-choice questions of LBP included disability in daily function and leisure time activities, for each question the patient selects one sentence out of six that best describe his disability.

For each section of six statements the total score is five, if the first statement is marked, the score is zero, if the last is marked the score is five. The final score calculated as follows: Total score= (5 x numbers of questions answered) x 100%. The test–retest reliability of the modified ODI has been shown to be high (ICC ¼ .90) (Fritz et al. 2001).

3.7.1 Administration The questionnaire consists of ten statements, from which the patients were asked to select the statements, which describe him/her today and put a tick against it. If the statement does not describe, then leave the space blank and go on to the next one.

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3.7.2 Interpretation Now, simply add up your points for each section and plug it into the following formula in order to calculate your level of disability: point total / 50 X 100 = % disability (aka: 'point total' divided by '50' multiply by ' 100 = percentage disability) Example: on my last ODI I scored a 16. So, 16/50 x 100 = 32% disability:

3.7.3 ODI Scoring 

0% to 20% (minimal disability): Patients can cope with most activities of daily living. No treatment may be indicated except for suggestions on lifting, posture, physical fitness and diet. Patients with sedentary occupations (ex. Secretaries) may experience more problems than others.



21%-40% (moderate disability): Patients may experience more pain and problems with sitting, lifting and standing. Travel and social life are more difficult. Patients may be off work. Personal care, sleeping and sexual activity may not be grossly affected. Conservative treatment may be sufficient.



41%-60% (severe disability): Pain is a primary problem for these patients, but they may also be experiencing significant problems in travel, personal care, social life, sexual activity and sleep. A detailed evaluation is appropriate.



61%-80% (crippled): Back pain has an impact on all aspects of daily living and work. Active treatment is required.



81%-100%: These patients may be bed bound or exaggerating their symptoms. Careful evaluation is recommended.

3.8 Materials 

Examination table.



Assessment Performa



Numeric Pain Rating Scale (Appendix V)



Modified Oswestry Disability Questionnaire (Appendix VI)



Fear-Avoidance Beliefs Questionnaire (Appendix VII)

3.9 Methodology 3.9.1 Source of data 1. Sita Bhateja Speciality hospital (Spectrum physiotherapy centre) Bangalore-25.

2. Rajashri Grandhim Physiotherapy clinic, Bangalore-76.

3. Rhea Health Care, Bangalore.

4. Gokul Physiotherapy Clinic, Bangalore-76.

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3.10 Sample selection 1.

Population – subjects with non- radicular low back pain.

2.

Sample size –Forty non active sports subjects (Twenty subjects in intervention group and twenty subjects which belong to control group).

3.11 Administrations of the scales The scales were administered to the subjects at each of the four clinics before the first session, before the fourth session and after the sixth session. The data‘s were recorded and tabulated. The investigator visited each clinic one clinic per session per day and from Monday through Saturday.

3.12 Treatment procedure: 3.12.1 Control group Table 4: Control group treatment protocols (Mobilization with static spinal exercise) (Sahar M et al. 2011) Control group (Total duration -30 Minutes)

Day

Warm up

Rest

Mon/Wed/Fri (Under supervision of physiotherapist)

Static bicycle(Duration-5 Min)

Duration-5 Min

Tue/Thu/Sat (Home program)

Pelvic tilt (Duration-5 Min)

Duration-5 Min

Mobilization with static spinal exc Mobilization Grade III,IV followed by Static spinal exercise(15Min) Mobilization Grade III,IV followed by Static spinal exercise(15Min)

Warm down

5 Minutes of ‗Basic Run‘ Activity.

5 Minutes of ‗Basic Run‘ Activity.

3.12.1.1 Instructions  Perform each specific protocol activity to the best of your ability.  You must spend the noted time limit performing each specific prescribed protocol of exercises.  Study conductors will be monitoring them.  If you happen to finish the list of exercises in a certain category before the required time limit, you should continue to exercise until the student conductor notifies you that time has been reached.

83

 At this point you may choose what exercises you wish to perform, however they must fall under your current exercise category.

The lumbar spine mobilization and exercise intervention group performed a 5-min exercise warms up at the beginning of each treatment. Following the warm-up patients received lumbar spine mobilization and completed a standardized exercise regimen since a combination of manual therapy and exercise have been shown to be effective in reducing disability in patients with chronic LBP. The physical therapist performed postero anterior mobilizations to hypo mobile lumbar spine vertebrae segments as determined in the initial evaluation. Grades III–IV mobilizations were selected based upon the patient response and the physical therapist‘s clinical reasoning. Initially the investigator demonstrated Grades III–IV mobilizations the treatment protocols and then the patient were asked do it at home .the most of the patients were able do it on their own. The Patients also completed a standardized exercise program consisting of pelvic tilts, bridging, wall squats, quadruped alternate arms/legs activities which had been shown to result in clinically meaningful improvements in disability. Patients were asked to perform 2 sets of 10 repetitions of each exercise. The physical therapist monitored the patient‘s exercise routine chart according to the patient‘s symptoms.

Joint mobilization consists of passive movement involving an oscillatory motion to the vertebral segment (s). The passive mobility is performed in a graded manner (I, II, III, IV, or V) which depicts the speed, depth of joint motion during the maneuver. It may include skilled manual joint tissue stretching.

3.12.1.2 Indications 

To improve Joint play



Segmental alignment



To improve intracapular arthrokinematics



To reduce pain associated with tissue impingement

3.12.1.3 Contraindications 

Stenosis



Spondylosis



Disc herniation



Myelopathy



Fracture



Joint instability



Progressive metastatic cancer



Severe osteoporosis 84



Infection



Active inflammatory arthritis



Signs of progressive neurological deficits



Vertebrobasilar insufficiency



Carodit artery disease

3.12.2 Intervention group Table 5: Intervention group treatment protocols (Slump stretching followed by mobilization by static spinal exercise) Intervention group (Total duration -30 Minutes)

Day

Tue/Thu/Sat (Under supervision of physiotherapist)

Mon/Wed/Fri (Home program)

Warm up

Static bicycle(Duration-5 Min)

Pelvic tilt (Duration-5 Min)

Rest

Duration-5 Min

Duration-5 Min

Slump stretching, mobilization with static spinal exec Slump stretching (2 Min/1 Min Rest .Repeated 5 – Times/Day) followed

by Mobilization by Static spinal exercise (15Min) Self-slumps stretching followed by static spinal exercise (15Min)

Warm down

5 Minutes of ‗Basic Run‘ Activity.

5 Minutes of ‗Basic Run‘ Activity.

3.12.2.1 Instructions  Perform each specific protocol activity to the best of your ability.  You must spend the noted time limit performing each specific prescribed protocol of exercises.  Study conductors will be monitoring them.  If you happen to finish the list of exercises in a certain category before the required time limit, you should continue to exercise until the student conductor notifies you that time has been reached.

At this point you may choose what exercises you wish to perform, however, they must fall under your current exercise category.

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3.12.2.2 Slump stretches The slump stretches are performed to identify the affected tissues which are tight i.e., Nerves, fascia, muscles and joints. Get the position in the picture until you feel a mild tension anywhere (i.e.

Back, hamstrings, neck— whatever comes first). Once the position was attained, gently release the toes back towards the head in an on/of repetitive motion.

3.12.2.3 Warnings 

Do not do this stretch if it creates pins and needles or headaches.



Do not do this stretch first thing in the morning.



If you have had disc problems with your back, first consult your physiotherapist.

3.12.2.4 Stretching do‟s 

Do be gentle and slow with stretching, especially if you have not done much before.



Do hold stretches to muscles for at least thirty seconds. Nerve stretches can be ‗on-off‘ and joint stretches can be held for less time.



Do make stretching part of your training routine.



Do try to get at least one good stretch session per week (of around 45 minutes) maybe with some top-up during the week on your tight spots. As a guide, the AIS women‘s road team members used to stretch for about 90 minutes each afternoon following training session (although some did more than others!).



Most would do some morning stretches for twenty to thirty minutes prior to training also.

Alas we can‘t all treat our body as a temple like that!

3.12.2.5 Stretching Don‟ts 

Don‘t rush, never rush, stretching needs to be relaxed.



Don‘t do ballistic stretches. These were a fad of the 70‘s and they occasionally rear their ugly head. Ballistic stretching is dangerous as you may cause the muscle or joint to tear.



Don‘t force the area you are stretching into pain. You should feel ‗discomfort‘ only, not pain.



Don‘t cause distal symptoms during the stretch, i.e. Symptoms such as pins and needle in the foot—you may be depriving a nerve of its blood supply, which can cause permanent damage.

 Don‘t cause ‗after-pain‘. Stretching should feel ‗tight‘ at the time. This should ease fairly.

3.13 Treatment procedure Patients in the intervention group completed the identical warm-up followed by slump stretching followed by lumbar spine mobilization with static spinal exercise was provided by the physical therapist. The patient was supine and relaxed in the center of the bed, with one pillow under the head. The trunk and pelvis should be in neutral position. While the therapist was standing beside 86

the affected side, he began to raise the affected side perpendicular to the bed in the standard SLR test with one hand placed under the ankle joint and the other hand placed above the knee joints until either pain in the back or referred pain to the leg restricted the movement. Then the lower limb was taken down a few degrees from this symptomatic point. The number of these sequences was repeated several times, through which the amplitude of the technique was increased according to the patient response. The technique was progressing to a point where symptoms were reproduced, or it was taken to a point where the resistance of the movement was encountered. Patients in the slump-stretching with a static spinal exercise group completed the identical warm-up exercise program.

Slump stretching was performed with the patient in the long sitting position with the patient‘s feet against the wall to assure the ankle remained at 0 degrees of dorsiflexion. The therapist applied over pressure into cervical spine flexion to the point where the patient‘s symptoms were reproduced.

The position was held for thirty seconds. A total of five repetitions were completed. Patients with the slump stretching group completed and also performed similar self-slump stretching home exercise program, except patients actively flexed their neck and applied overpressure using their upper extremities until symptoms were reproduced. Patients completed five repetitions, maintaining this position for thirty seconds. The total duration of time spent the slump stretching which performed only 3–4 minutes over the treatment time.

3.14 Home program Slump stretching was performed in a high sitting position on a couch and the exercise intervention group performed a 5-min exercise warm-up at the beginning of each treatment.

Following the warm-up patients received a standardized exercise regimen since a combination mobilization therapy and exercise have been shown to be effective in reducing disability in patients with chronic LBP. Patients also completed a standardized exercise program consisting of pelvic tilts, bridging, wall squats, quadruped alternate arms/league's activities as described by, which has been shown to result in clinically meaningful improvements in disability. Patients were asked to perform two sets of ten repetitions of each exercise. The patient‘s exercise routine was progressing according to the patient‘s symptoms. Patients were instructed to perform the exercises at home once daily, and to maintain their usual activity level and refrain from initiating any new forms of exercise during the study. Home exercise program of two reps for thirty seconds. Following the baseline examination, patients were randomly assigned to receive slump stretching with static spinal exercises along with pelvic bridging.

3.14.1 Follow-up At the completion of 6 physical therapy sessions (thrice weekly for two weeks), an assistant who was unaware of group assignment or the nature of the study read ministered the self-report

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questionnaires. The obvious potential for bias is further minimized based on the use of patient completed outcome measures.

3.15 Static spinal exercises: „splinting‟ the lumbar spine It is a good idea to learn how to keep the lumbar spine in affixed position by using the abdominal muscles and the muscles around the spine. These are static (Isometric) exercises which can teach you to use them abdominals, low back and pelvic muscles. You can actually feel them tightening and relaxing as you keep lumbar spine immobile.

Exercise1: The pelvic tilt Lie on the floor with your feet flat on the floor, arms at your sides and your knees bent. Draw in your stomach (abdomen) firmly presses your lumbar region (back of your waist) against the floor by tightening and slightly raising your buttocks. This will tilt your pelvis upwards. Hold-count sevenrelax; repeat five to ten times.

Exercise2: body flattened Adopt the same position for exercise two and then stretch (extend) your legs by sliding your heels forwards while keeping your lumbar spine flat on the floor .You should feel your abdominal and back muscles tighten. Hold –count of seven-relax: repeat five to ten times.

3.16 Clinical utility of outcome measures 1.

Numeric pain rating scale (NPRS) at the time of entry into the study and the reassessment was carried out at the end of the first and second week.

2.

Fear Avoidance Belief Questionnaire (FABQ) used to assess patient beliefs performed at the time entry into the study and the reassessment was carried out at the end of the first and second week.

3.

Oswestry Disability Questionnaire (ODI) used for asses‘ functional ability evaluation performed at the time entry into the study and the reassessment was carried out at the end of the first and second week.

3.17 Statistical techniques used Data was collected from the NPRS, FABQ and the body diagram assesses the distribution of symptoms. Statistical analysis was completed under the guidance of a statistician. The subjective data was obtained using the Numerical Pain Rating Scale (Appendix V) and the Oswestry Disability Index Scale (Appendix VII). Data was entered and analyzed with SPSS version 15 (SPSS Inc. Chicago, Ill, USA). Baseline demographics and factors were compared between the two treatment groups using students‘ t-tests in the case of quantitative data, Pearson‘s chi square tests would be appropriate for categorical variables. Repeated Measures ANOVA was used to assess the presence of a treatment effect. Profile plots were used to interpret significant effects and trends, as well as the direction of the treatment effects.

88

Table 6: ANOVA summary table for the general simple Repeated Measures ANOVA was as follows Source

SS

df

MS

Individuals

SSI

n–1

SS I (n  1)

Occasions

SSO

K–1

SSO ( K  1)

Residual (Error)

SSRes

(K – 1)(n –1)

SSRe s ( K  1)(n  1)

Total

SST

N–1

F

MSO MS Re s

3.18 Ethical clearance As this study involved human subjects, the ethics clearance had been obtained from the ethics committee of Ramakrishna Mission Vivekananda University, Faculty of General & Adapted Physical Education and Yoga Coimbatore-20, as per ethical guidelines, research from bio-medical research on human subjects, 2000, ICMR New Delhi.

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CHAPTER IV 4. RESULTS AND DISCUSSION 4.1 Introduction about Statistical methodology SPSS version 15.0 (SPSS Inc, Chicago, Ill, USA) was used to analyze the data. A P value less than 0.05 was considered as statistically significant. Baseline outcome measures and demographics were compared between the two treatment groups to ensure that they were equivalent prior to the intervention, by using independent samplesâ&#x20AC;&#x2DC;t-tests and Chi square tests. For assessment of the effect of the intervention, Repeated Measures ANOVA followed by Bonferroni correction was used. To find the association between demographic variables and the post intervention outcome measures, correlation analysis and independent samplesâ&#x20AC;&#x2DC;t-tests were used. A significant time group effect indicated a statistically significant differential treatment effect. The direction and trend of the treatment effect was assessed using profile plots. .

All the patients who were attended at four selected clinics during the 12-month period (from

January 2009 to January 2010) were screened for eligibility to include in the study. Among the all patients, about sixty percent of patients were not satisfied with the inclusion and exclusion criteria for the study. The high rate of ineligibility was due to the stringent inclusion criteria requiring symptoms like distal to the buttock, a positive slump test and the exclusion of patients with a positive straight leg raise. Patients were randomly assigned to the intervention group and to the control group. One group receives slump stretching followed by lumbar spine mobilization with static spinal exercise (Intervention group) and the other group receives lumbar spine mobilization with static spinal exercise and exercise (Control group). The computer generated randomized table of numbers was used to determine the group membership. The eligible forty (40) patients were randomized into Control group and Intervention group and each of the group contains 20 patients. The Control group patients received the mobilization and static spinal exercise only. While the Intervention group patients received the mobilization, static spinal exercise along with slump stretching. All treatment sessions were conducted at four outpatient Orthopedics clinics by a single physiotherapist having ten years of clinical experience. All patients were scheduled thrice weekly for the duration of two weeks.

Description of demographic variables of the control group and Intervention group were presented in this section. The control group consists of twenty subjects had non radicular low back pain, out of which ten were male and ten were female. (Spinal mobilization with static spinal exercise) while the Intervention group consist of twenty subjects had non radicular low back pain out of which 13 were male and 7 were female (Slump stretching is followed by mobilization with static spinal exercise). This study was undertaken to assess the effects of the treatment on the above mentioned group over a period of time.

90

4.2 Results with frequency distribution of age in both groups Table 7: Frequency distribution of age in both groups Age in years

Control group

Intervention group

Frequency

Percent

Frequency

Percent

20-30 31-40

6 8

30.0 40.0

6 8

30.0 40.0

41-45

6

30.0

6

30.0

Total

20

100.0

20

100.0

Table 7 shows that the average age (SD) intervention group was 34.6(7.84) and the control group was 34.7(7.95) and there was no significant difference between the two groups=0.040, P=0.968. The frequency distribution of the above mentioned groups shows the age distribution in both the groups. In control group subject of age group 20-30 had a frequency of 6 (30%), the subject of age group 31-40 had a frequency of 8 (40%) and subject of age group 41-45 had a frequency of 6 (30%).

In intervention group subject of age group 20-30 had a frequency of 6 (30%) subject of age group 3140 had a frequency of 8 (40%) and subject of age group 41-45 had a frequency of 6 (30%).

Figure 9: Column diagram showing the frequency distribution of ages.

(For both the groups)

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4.3 Results with frequency distribution of gender in both groups Table 8: Frequency distribution of gender in both groups Gender Female Male Total

Control group Frequency Percent 10 50.0 10 50.0 20 100.0

Intervention group Percent Frequency 20.0 7 80.0 13 100.0 20 Chi square=0.921,P=0.337

Table 8 Shows that control group, gender consists of 10 males (50%) and 10 females (50%).

The intervention group gender consists of 13 males (65%) and 7 females (35%). The below column diagram shows the frequency distribution of both the group. There was no significant difference in gender between the two groups, chi square = 0.921,P=0.337.

Figure 10: Coloumn diagram showing gender 4.4 Results with frequency distribution of duration of illness for both the groups Table 9: Frequency distribution of duration of illness for both the groups Duration of Illness(Months)

Control group Frequency Percent

Up to 2 months

9

45.0

More than 2 months Total

11 20

55.0 100.0

Intervention group Frequency Percent 12

60

8 40.0 20 100.0 Chi square = 0.90,P=0.34 92

Table 9 shows that control group consists of duration of illness up to 2 months, with frequency 9 (45%) duration of illness more than 2 months with frequency 11 (55%). Intervention group consists of duration of illness up to 2 months, with frequency 12 (60%), duration of illness more than 2 months with frequency 8 (40%). There was no significant difference in duration of illness between the two groups, chi square = 0.90,P=0.34.

Figure 11: Column diagram showing the duration of illness (For both the groups) 4.5 Results with frequency distribution of the treatment strategy in both groups Table 10: Frequency distribution of the treatment strategy in both groups Control group

Intervention group

Treatment strategy Frequency

Percent

Frequency

Percent

No previous therapy

15

75.0

16

80.0

Undergone therapy

5

25.0

4

20.0

Total

20

100.0

20

100.0

chi square = 0.143,P=0.705

Table 10 shows that the treatment strategy distribution, for no previous therapy frequency was 15 (75%) and for the undergone therapy distribution, frequency was 5 (25%). present sample 93

intervention group shows the treatment strategy distribution, for no previous therapy frequency was 16 (80%) and for the undergone therapy, frequency was 4 (20%). There was no significant difference in treatment strategy distribution between the two groups, Chi square = 0.143,P=0.705.

Figure 12: Column diagram showing the frequency distribution of treatment strategy (For both the groups) 4.6 Results with frequency distribution of the two types of sports for both the groups Table 11: Frequency distribution of the two types of sports for both the groups

Control group

Intervention group

Types of Sports Frequency

Percent

Frequency

Percent

Contact sports

15

75.0

6

30.0

Non-contact sports

5

25.0

14

70.0

Total

20

100.0

20

100.0

Chi square = 0.125,P=0.723 Table 11 shows that the frequency distribution of both the group for two different types of sports i.e. for control group contact sports frequency was 15(75%), non contact sports frequency was 94

5(25%) and the overall total frequency was 20(100%). For the present sample intervention group, contact sports frequency was 6(30%), Non- contact sports frequency was 14(70%) and overall the total frequency 20(100%). There was no significant difference in treatment strategy, distribution between the two groups, Chi square = 0.125,P=0.723.

Figure 13: Column diagram showing the frequency distribution of type of sports (For both the groups) 4.7 Comparison of pain outcome measures of the two groups 4.7.1 Measurement scales All the patients were administered the NPRS scale to measure the intensity of pain. The NPRS range from 0 to 10.0 indicates no pain and score of 10 indicates severe pain. The 10-point NPRS ranges from 0 (‗‗no pain‘‘) 1 to 3 (‗‗Mild pain‘‘) 4 to 6 (―Moderate pain‖) 7 to 10(―Severe pain‖) was used to indicate the intensity of current pain and at its best and worst level over the last 24 hour.

The FABQ was used to quantify the patient‘s fear of pain and beliefs about avoiding activity.

Previous studies have found high level of test–retest reliability for both the physical activity (FABQPA) and work (FABQW) subscales. Fear avoidance beliefs have been associated with current and future disability and the amount of work loss in patients with acute and chronic LBP. This measure was collected to assess the potential confounding effects of fear avoidance beliefs on outcomes.

The modified ODI was used to measure disability and consists of 10 questions. Each question is scored from 0 to 5 and the highest scores indicate the greater disability. The scores were then

95

converted to a percentage out of 100. The testâ&#x20AC;&#x201C;retest reliability of the modified ODI has been shown to be high (ICC Âź .90).

Descriptive statistics, the mean, standard deviation of NPRS, FABQW, FABQPA (Subscale), FABQT, and ODI for baseline initial intervention, post intervention 1 and post intervention 2 were presented in this section.

Mean and standard deviations of NPRS scale for the three stages and results of Repeated Measure ANOVAs are presented below.

4.8 Results of Numeric Pain Rating Scale 4.8.1 Results of NPRS (Control group) for the three different stages Descriptive statistics, the mean, standard deviation of NPRS scale for baseline initial intervention, post intervention 1 and post intervention 2 were presented in this section.

Table 12: Mean and standard deviations of NPRS (Control group) for three different stages NPRS (Control group) N

Minimum Maximum Mean

Std. Deviation

Std. Error

Baseline intervention

20

8

10

9.10

0.912

0.204

Post intervention1

20

5

6

5.70

0.470

0.105

Post intervention 2

20

3

4

3.75

0.444

0.099

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Table 13: One way Repeated Measure ANOVA Type III Sum of Squares

df

Mean Square

293.233

2

146.617

395.137 0.000

293.233

1.603

182.908

395.137 0.000

293.233

1.728

169.685

395.137 0.000

293.233

1.000

293.233

395.137 0.000

14.100

38

0.371

GreenhouseGeisser

14.100

30.460

0.463

Huynh-Feldt Lower-bound

14.100 14.100

32.834 19.000

0.429 0.742

Source

Stage 1

Sphericity Assumed GreenhouseGeisser Huynh-Feldt Lower-bound Sphericity Assumed

Error(Stage1)

F

P value

Table 12 & 13 baseline means NPRS score for the control group was 9.10(0.912). At the end the first week, the mean NPRS score was 5.70(0.470). At the end of second week mean NPRS score was 3.75(0.444). One way Repeated measure ANOVA was applied to compare the mean values of three different stages of NPRS. The calculated One way Repeated Measures ANOVA F=395.137, P <0.001 and conclude that there was a significant difference between the three means at different stage levels. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2,2 and 3 and 3and 1(P<0.001). Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.752, Chi square=5.119, P=0.077, the sphericity assumption is not violated.

Figure 14: Line diagram showing the mean score of NPRS (control group) 97

Table 14: Post hoc comparisons Pair wise comparisons

Mean difference

P value

Stage1(9.1) vs Stage2(5.7)

3.4

P<0.01

Stage1(9.1) vs Stage3 (3.75)

5.35

P<0.01

Stage2(5.7) vs Stage3(3.75)

1.95

P<0.01

4.8.2 Results of NPRS (Intervention group) for the three stages Table 15: Mean and standard deviations of NPRS (Intervention group) for the three stages NPRS (Intervention group) N

Minimum

Maximum

Mean

Std. deviation

Std. Error

Base line intervention

20

7

10

8.85

1.226

0.274

Post intervention 1

20

2.0

5.0

3.40

1.0954

0.245

Post intervention 2

20

0

2

0.85

0.745

0.167

Table 16: One way Repeated measure ANOVA Source

Stage1

Error(Stage1)

Sphericity Assumed GreenhouseGeisser Huynh-Feldt Lower-bound Sphericity Assumed GreenhouseGeisser Huynh-Feldt Lower-bound

Type III Sum of Squares

df

Mean Square

F

P value

668.033

2

334.017

405.515

.000

668.033

1.418

471.151

405.515

.000

668.033 668.033

1.499 1.000

445.621 668.033

405.515 405.515

.000 .000

31.300

38

.824

31.300

26.940

1.162

31.300 31.300

28.483 19.000

1.099 1.647 98

Table 15 & 16 shows that initial mean NPRS score was 8.85(1.226). At the end the first week, mean NPRS score was 3.4(1.095). Second week means NPRS score was 0.85 (0.745). One way Repeated measure ANOVA was applied to compare the mean values of three different stages of NPRS. The calculated One way Repeated Measures ANOVA F=405. 515, P <0.001 and conclude that there was a significant difference between the three different stage levels. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3, 3 and 1 (P<0.001). Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.943, Chi square=2.235, P=0.327, the sphericity assumption is not violated.

Figure 15: Line diagram showing the mean score of NPRS (Intervention group) Table 17: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (8.85) vs Stage2 (3.4)

5.45

P<0.01

8.00

P<0.01

2.55

P<0.01

Stage1 (8.85) vs Stage3 (0.85) Stage2 (3.4) vs Stage3 (0.85)

99

4.8.3 Results of comparison between intervention and control group NPRS Table 18: Comparison between intervention and control group NPRS NPRS

Control group

Intervention group

N

Mean

Std. Deviation

Mean

Std. Deviation

Baseline intervention

20

9.10

0.912

8.85

1.226

Post intervention 1

20

5.70

0.470

3.40

1.095

Post intervention 2

20

3.75

0.444

0.85

0.745 F(1,38)=93.474, P<0.001

Table 19: Repeated Measure ANOVA Source

Type III Sum of Squares

df

Mean Square

F

P value

Intercept

3339.075

1

3339.075

3152.419

0.000

Group

99.008

1

99.008

93.474

0.000

Error

40.250

38

1.059

Table 18 & 19 show that Repeated measure ANOVA was applied to compare the mean values of three different stage level of NPRS for both the groups. Baseline assessment means NPRS score for the control group was 9.10 (0.912) and at the post intervention 2 mean NPRS score was 3.75 (0.444), Baseline assessment mean NPRS score for intervention group was 8.85 (1.226) and the last week mean NPRS score was 0.85 (0.745). The calculated Repeated Measures ANOVA F=93. 474, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together.

100

Figure 16: Line diagram showing the mean score of NPRS (For both the groups) 4.8.4 Percentage of pain reduction in NPRS (Control group) The baseline assessment found that the control group NPRS mean pain scores was 9.10.

First post intervention mean score for NPRS was 5.70 and the second post intervention mean score for NPRS was 3.75. The decrease in the NPRS scores for this study was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 37.37%.

The overall percentage of pain reduction from baseline in the second post intervention was 57.17%.

Figure 17: Column diagram showing the percentage of pain reduction in NPRS (control group) 101

4.8.5 Percentage of pain reduction in NPRS (Intervention group) The baseline assessment found that the intervention group NPRS mean pain scores was 8.85.

First post intervention means score NPRS was 3.40 and the second post intervention mean score NPRS was 0.85. The decrease in the NPRS scores for this study was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 61.9%.

The overall percentage of pain reduction from baseline in the second post intervention was 90.4%.

Figure 18: Column diagram below showing the percentage of pain reduction in NPRS (Intervention group) 4.9 Results of Fear Avoidance Belief Questionnaire subscale 4.9.1 Results of FABQW (Control group) subscale for three stages Table 20: Mean and standard deviations of FABQW (Control group) subscale for three stages FABQW subscale (Control group)

Baseline Intervention Post Intervention 1 Post Intervention 2

N

Minimum

Maximum

Mean

Std. Deviation

Std. Error

20

37.00

42.00

39.30

1.626

0.36346

20

21.00

25.00

23.50

1.100

0.24602

20

3.00

7.00

05.85

1.137

0.25418

102

Table 21: One way Repeated Measures ANOVA Source

Stage1

Error(Stage1)

Sphericity Assumed GreenhouseGeisser Huynh-Feldt Lower-bound Sphericity Assumed GreenhouseGeisser Huynh-Feldt Lower-bound

Type III Sum of Squares

df

Mean Square

11200.433

2

5600.217

3088.654 0.000

11200.433

1.794

6243.865

3088.654 0.000

11200.433 11200.433

1.969 1.000

5688.781 11200.433

3088.654 0.000 3088.654 0.000

68.900

38

1.813

68.900

34.083

2.022

68.900 68.900

37.408 19.000

1.842 3.626

F

P value

Table 20 & 21 shows that Repeated Measure ANOVA was applied to compare the mean values of three different durations of NPRS. Baseline assessment mean Control group FABQW subscale was 39.30 (1.626). At the end the first week, the mean FABQW score was 23.50 (1.100).

Second week means FABQW score was 05.85 (1.137). The calculated One way Repeated Measures ANOVA F=3088. 654, P <0.001 and from this we conclude that there was a significant difference between the three stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3,3 and 1.

(P<0.001). Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.885, Chi square=2.198, P=0.333, the sphericity assumption is not violated.

Figure 19: Line diagram showing the mean score of FABQW subscale (control group) 103

Table 22: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (39.3) vs Stage2 (23.5)

15.8

P<0.01

Stage1 (39.3) vs Stage3 (5.85)

33.45

P<0.01

Stage2 (23.5) vs Stage3 (5.85)

17.65

P<0.01

4.9.2 Results of FABQW (Intervention group) subscale for three stages Table 23: Mean and standard deviations of FABQW (Intervention group) subscale for three stages FABQW subscale (Intervention group)

Baseline Intervention Post Intervention 1 Post Intervention 2

N

Minimum

Maximum

Mean

Std. Deviation

Std. Error

20

37.00

40.00

38.55

0.945

0.27980

20

19.00

26.00

23.45

1.606

0.49987

20

1.00

5.00

2.85

1.387

0.33561

Table 24: One way Repeated measure ANOVA Source

Stage1

Error(Stage1)

Sphericity Assumed GreenhouseGeisser Huynh-Feldt Lower-bound Sphericity Assumed GreenhouseGeisser Huynh-Feldt Lower-bound

Type III Sum of Squares

df

Mean Square

12845.733

2

6422.867

4389.729 0.000

12845.733

1.850

6942.897

4389.729 0.000

12845.733 12845.733

2.000 1.000

6422.867 12845.733

4389.729 0.000 4389.729 0.000

55.600

38

1.463

55.600

35.154

1.582

55.600 55.600

38.000 19.000

1.463 2.926

F

P value

Table 23 & 24 shows that baseline assessment mean for intervention group in FABQW subscale was 38.55(0.945). At the end the first week, mean FABQW score was 23.45(1.606). Second week means FABQW score was 2.85 (1.387). One way Repeated measure ANOVA was applied to 104

compare the mean values of three different stages of FABQW. The calculated One way Repeated Measures ANOVA F=4389. 729, P <0.001. This showed that there was a significant difference between the three stages. All the pairs of three stages were compared by pairwise comparisons. The result showed there was a significant difference between stages 1 and 2, 2 and 3, 3 and 1. (P<0.001).

Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.919, Chi square=1.520, P=0.468, the sphericity assumption is not violated.

Figure 20: Line diagram shows the mean score of FABQW subscale Table 25: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (38.55) vs Stage2 (23.45)

15.1

P<0.01

Stage1 (38.55) vs Stage3 (2.85)

35.7

P<0.01

Stage2 (23.45) vs Stage3 (2.85)

20.6

P<0.01

105

4.9.3 Results of comparison between intervention and control group of (FABQW) subscale Table 26: Comparison between intervention and control group of (FABQW) subscale FABQW subscale

Control group

Intervention group

N

Mean

Std. Deviation

Mean

Std. Deviation

Baseline intervention

20

39.30

1.626

38.55

0.945

Post intervention1

20

23.50

1.100

23.45

1.606

Post intervention 2

20

05.85

1.137

2.85

1.387

F(1,38)=24.162,P<0.001

Table 27: Repeated Measure ANOVA Source

Type III Sum of Squares

df

Mean Square

F

P value

Intercept

59407.500

1

59407.500

29821.466

.000

group

48.133

1

48.133

24.162

.000

Error

75.700

38

1.992

Table 26 & 27 shows that both groups repeated measure ANOVA design was applied. This table which used to compare the mean values of three different stages of FABQW subscale. Baseline assessment means FABQW scores for the control group was 39.30 (1.626) and at second week mean FABQW score was 05.85 (1.137). Baseline assessment means FABQW scores for the intervention group was 38.55 (0.945) and at second week mean FABQW score was 2.85 (1.387). The calculated Repeated Measures ANOVA F=24. 162, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together.

106

Figure 21: Line diagram showing the mean score of subscale FABQW (For both the groups) 4.9.4 Percentage of pain reduction in FABQW subscale (control group) The baseline assessment found that the Control group FABQW mean pain scores was 39.30.

The first post intervention means score FABQW was 23.50 and the second post intervention means score FABQW was 5.85. The decrease in the FABQW scores for this study was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 40.21%. The overall percentage pain reduction pain from baseline to second post intervention was 85.12%.

Figure 22: Column diagram shows the percentage of pain reduction in FABQW (Control group) subscale 107

4.9.5 Percentage of pain reduction in FABQW (Intervention group) subscale The baseline assessment found that the intervention group FABQW mean pain scores was 38.55 First post intervention mean scores for FABQW was 23.45 and the second post intervention mean score for FABQW was 2.85. The decrease in the FABQW scores for this study was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 39.17%. The overall percentage pain reduction pain from baseline to second post intervention was 92.6%.

Figure 23: Column diagram showing the percentage of pain reduction in FABQW (Intervention group) subscale 4.10 Results of Fear Avoidance Belief Questionnaire Physical Activity subscale 4.10.1 Results of FABQPA (Control group) subscale for the three stages Table 28: Mean and standard deviations of FABQPA (Control group) subscale for the three stages FABQPA subscale (Control group)

Baseline Intervention Post Intervention 1 Post Intervention 2

N

Minimum

Maximum

Mean

Std. Deviation

Std. Error

20

21.00

24.00

22.55

0.945

0.21120

20

14.00

16.00

15.00

0.795

0.17770

20

2.00

4.00

03.60

0.681

0.15218 108

Table 29: One way Repeated Measures ANOVA Type III Sum of Squares

df

Mean Square

Sphericity Assumed

3640.433

2

1820.217

3309.485 0.000

GreenhouseGeisser

3640.433

1.904

1912.489

3309.485 0.000

Huynh-Feldt

3640.433

2.000

1820.217

3309.485 0.000

Lower-bound

3640.433

1.000

3640.433

3309.485 0.000

Sphericity Assumed

20.900

38

0.550

GreenhouseGeisser

20.900

36.167

0.578

Huynh-Feldt

20.900

38.000

0.550

Lower-bound

20.900

19.000

1.100

Source

Stage1

Error(Stage1)

F

P value

Table 28 & 29 shows that baseline assessment scores mean of control group FABQPA subscale was 22.55 (0.945). At the end the first week, the mean FABQPA score was 15.00 (0.795).

Second week means FABQPA score was 03.60 (0.681). One way Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQPA. The calculated One way Repeated Measures ANOVA F=3309. 485, P <0.001. This showed that there was a significant difference between the three stages. All the pairs of three sessions were compared by pairwise comparisons. The result shows there was a significant difference between stages 1 and 2,2 and 3 and 3 and 1 (P<0.001). Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.949, Chi square=0.936, P=0.626, the sphericity assumption is not violated.

109

Figure 24: Line diagram showing the Mean score of FABQPA subscale (Control group) Table 30: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (22.55) vs Stage2 (15)

7.55

P<0.01

Stage1 (22.55) vs Stage3 (3.6)

18.95

P<0.01

Stage2 (15) vs Stage3 (3.6)

11.4

P<0.01

4.10.2 Results of FABQPA subscale (Intervention group) for the three stages Table 31: Mean and standard deviations of FABQPA subscale (Intervention group) for the three stages FABQPA subscale (Intervention group) N Baseline Intervention Post Intervention 1 Post Intervention 2

Minimum Maximum

Mean

Std. Deviation

Std. Error

20

21.00

23.00

22.20

0.616

0.13765

20

10.00

16.00

13.50

1.235

0.27625

20

0.00

3.00

1.55

1.099

0.24575 110

Table 32: One way Repeated measure ANOVA Type III Sum of Squares

df

Mean Square

Sphericity Assumed

4299.433

2

2149.717

1889.497 0.000

GreenhouseGeisser

4299.433

1.515

2837.705

1889.497 0.000

Huynh-Feldt

4299.433

1.619

2656.160

1889.497 0.000

Lower-bound

4299.433

1.000

4299.433

1889.497 0.000

Sphericity Assumed

43.233

38

1.138

GreenhouseGeisser

43.233

28.787

1.502

Huynh-Feldt

43.233

30.755

1.406

Lower-bound

43.233

19.000

2.275

Source

Stage1

Error(Stage1)

F

P value

Table 31 & 32 show that baseline assessment means for intervention group in FABQPA subscale was 22.20(0.616). At the end of the first week, the mean FABQPA score was 13.50 (1.235).

Second week means FABQPA score was 1.55 (1.099). One way Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQPA. The calculated One way Repeated Measures ANOVA F=1899.497, P <0.001 which concluded that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3 and 3 and 1 (P<0.001). Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.970, Chi square=1.168, P=0.558, the sphericity assumption is not violated.

111

Figure 25: Line diagram showing the mean score of FABQ (Intervention group) subscale Table 33: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (22.2) vs Stage2 (13.5)

8.7

P<0.01

Stage1 (22.2) vs Stage3 (1.55)

20.65

P<0.01

Stage2 (13.5) vs Stage3 (1.55)

11.95

P<0.01

112

4.10.3 Results of comparison between intervention and control group of FABQPA subscale Table 34: Comparison between intervention and control group of FABQPA subscale

FABQPA subscale

Control group

Intervention group

N

Mean

Std. Deviation

Mean

Std. Deviation

Baseline intervention

20

22.55

0.945

22.20

0.616

Post intervention1

20

15.00

0.795

13.50

1.235

Post intervention 2

20

03.60

0.681

1.55

1.099

F(1,38)=58.798,P<0.001

Table 35: Repeated Measure ANOVA Source

Type III Sum of Squares

df

Mean Square

F

P value

Intercept

20488.533

1

20488.533

23760.863

0.000

Group

50.700

1

50.700

58.798

0.000

Error

32.767

38

0.862

Table 34 & 35 show that both groups repeated measure ANOVA was applied to compare the mean values of three different stages of FABQPA subscale. First week means FABQPA scores for the control group was 22.55 (0.945). Second week means FABQPA score was 03.60 (0.681). The initial mean FABQPA score for the intervention group was 22.20 (0.616). Post intervention 2 means FABQPA score was 1.55 (1.099). The calculated Repeated Measures ANOVA F=58.798, P <0.001.

This result shows that there was a significant difference between control and intervention group with respect to three stages together.

113

Figure 26: Line diagram showing the mean score of FABQPA (For both the groups) subscale 4.10.4 Percentage of pain reduction in FABQPA (Control group) subscale The baseline assessment found that the control group FABQPA mean pain scores was 22.55.

First post intervention mean score for FABQPA was 15.00 and the second post intervention mean score for FABQPA was 3.60. The decrease in the FABQPA scores for this study was statistically significant (P<0.001). The percentage of pain reduction from baseline to first post intervention was 33.49%. The overall percentage of pain reduction from baseline in the second post intervention was 84.03%.

Figure 27: Column diagram showing the percentage of pain reduction in FABQPA subscale (Control group) 114

4.10.5 Percentage of pain reduction in FABQPA (Intervention group) subscale The baseline assessment found that the Intervention group FABQPA mean pain scores was 22.20. First post intervention mean score for FABQPA was 13.50 and the second post intervention mean score of FABQPA was 1.55. The decrease in the FABQPA scores for this study was statistically significant (P<0.001). The percentage of pain reduction from baseline to first post intervention was 39.19%. The overall percentage of pain reduction from baseline in the second post intervention was 93.0%.

Figure 28: Column diagram showing the percentage of pain reduction in FABQPA subscale (Intervention group) 4.11 Results of (Fear Avoidance Belief Questionnaire Total) 4.11.1 Results of control group (FABQT) for the three stages Table 36: Mean and standard deviations of control group (FABQT) for the three stages FABQT (Control group) N Baseline Intervention Post Intervention 1 Post Intervention 2

Minimum Maximum

Mean

Std. Deviation

Std. Error

20

59.00

66.00

61.85

2.412

0.53937

20

36.00

41.00

38.50

1.433

0.32036

20

5.00

11.00

09.45

1.606

0.35891

115

Table 37: One way Repeated measure ANOVA Type III Sum of Squares

df

Mean Square

Sphericity Assumed

27565.900

2

13782.950

4153.466 0.000

GreenhouseGeisser

27565.900

1.664

16570.312

4153.466 0.000

Huynh-Feldt

27565.900

1.804

15282.136

4153.466 0.000

Lower-bound

27565.900

1.000

27565.900

4153.466 0.000

Sphericity Assumed

126.100

38

3.318

GreenhouseGeisser

126.100

31.608

3.990

Huynh-Feldt

126.100

34.272

3.679

Lower-bound

126.100

19.000

6.637

Source

Stage1

Error(Stage1)

F

P value

Table 36 & 37 show that baseline assessment means for the control group in FABQT subscale was 61.85 (2.412). At the end the first week, the mean FABQT score was 38.50 (1.433). Second week means FABQT score was 09.45 (1.606). One way Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQT. The calculated One way Repeated Measures ANOVA F=4153.466, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3, and 3 and 1 (P<0.001). Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.798, Chi square=4.067, P=0.131, the sphericity assumption is not violated.

116

Figure 29: Line diagram showing the mean score of FABQT (Control group) Table 38: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (61.85) vs Stage2 (38.5)

23.35

P<0.01

Stage1 (61.85) vs Stage3 (9.45)

52.4

P<0.01

Stage2 (38.5) vs Stage3 (9.45)

29.05

P<0.01

4.11.2 The Results of the intervention group (FABQT) scale for the three stages Table 39: Mean and standard deviations of intervention group (FABQT) scale for the three stages FABQT (Intervention group) N Baseline intervention Post Intervention 1 Post intervention 2

Minimum Maximum

Mean

Std. Deviation

Std. Error

20

59.00

63.00

60.75

1.252

0.27980

20

32.00

40.00

36.95

2.236

0.49987

20

1.00

7.00

4.40

1.501

0.33561

117

Table 40: One way Repeated measure ANOVA Type III Sum of Squares

df

Mean Square

Sphericity Assumed

32008.433

2

16004.217

6739.862 0.000

GreenhouseGeisser

32008.433

1.810

17686.636

6739.862 0.000

Huynh-Feldt

32008.433

1.989

16091.010

6739.862 0.000

Lower-bound

32008.433

1.000

32008.433

6739.862 0.000

Sphericity Assumed

90.233

38

2.375

GreenhouseGeisser

90.233

34.385

2.624

Huynh-Feldt

90.233

37.795

2.387

Lower-bound

90.233

19.000

4.749

Source

Stage1

Error(Stage1)

F

P value

Table 39 & 40 shows that baseline assessment mean for the Intervention group in FABQT subscale was 60.75(1.252). At the end the first week, the mean FABQT score was 36.95 (2.236).

Second week means FABQT score was 4.40 (1.501). One way Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQT. The calculated One way Repeated measure ANOVA F=6739.862, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3 and 3 and 1 (P<0.001). Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.895, Chi square=1.999, P=0.368, the sphericity assumption is not violated.

118

Figure 30: Line diagram showing the mean score of FABQT (Intervention group) Table 41: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (60.75) vs Stage2 (36.95)

23.8

P<0.01

Stage1 (60.75) vs Stage3 (4.4)

56.35

P<0.01

Stage2 (36.95) vs Stage3 (4.4)

32.55

P<0.01

4.11.3 Results of comparison between Intervention and Control group of FABQT Table 42: Comparison between Intervention and Control group of FABQT

FABQT

Control group

Intervention group

N

Mean

Std. Deviation

Mean

Std. Deviation

Baseline intervention

20

61.85

2.412

60.75

1.252

Post intervention1

20

38.50

1.433

36.95

2.236

Post intervention 2

20

09.45

1.606

4.40

1.501

F(1,38)=50.179,P<0.001

119

Table 43: Repeated Measure ANOVA Source

Type III Sum of Squares

df

Mean Square

F

P value

Intercept

149672.033

1

149672.033

38001.363

0.000

Group

197.633

1

197.633

50.179

0.000

Error

149.667

38

3.939

Table 42 & 43 shows that both groups repeated measure ANOVA design was applied. This table which helps to compare the mean values of three different stages of FABQT subscale. First week means FABQT score was 61.85 (2.412). Second week means FABQT score was 09.45 (1.606).

Baseline assessments mean FABQT score was 60.75 (1.252). Last week mean FABQT score was 4.40 (1.501). The calculated repeated measure ANOVA F=50.179, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together.

Figure 31: Line diagram showing the mean score of FABQT (For both the group) 4.11.4 Percentage of pain reduction in FABQT (Control group) The baseline assessment found that the Control group FABQT mean pain scores was 61.85.

First post intervention mean score for FABQT was 38.50 and the second post intervention mean score for FABQT was 9.45. The decrease in the FABQT scores for this study was statistically significant 120

(P<0.001). The total percentage of pain reduction from baseline to first post intervention was 37.76%.

The overall percentage of pain reduction from baseline in the second post intervention was 84.73%.

Figure 32: Line column diagram showing the percentage of pain reduction in FABQT (Control group) 4.11.5 Percentage of pain reduction in FABQT (Intervention group) The baseline assessment found that the Intervention group FABQT mean pain scores was 60.75. First post intervention mean score for FABQT was 36.95 and the second post intervention mean score for FABQT was 4.40. The decrease in the FABQT scores for this study was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 39.18%. The overall percentage of pain reduction from baseline in the second post intervention was 92.8%.

121

Figure 33: Column diagram showing the percentage of pain reduction in FABQT (Intervention group) 4.12 Results of Fear Avoidance Belief Questionnaire 4.12.1 Mean of FABQW, FABQPA (subscale) and FABQT for three stages (Control group) Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQ (Control group). Baseline assessment mean for control groups in FABQW subscale was 39.30 (1.626). At the end the first week, the mean FABQW score was 23.50 (1.100). Second week means FABQW score was 05.85 (1.137). Baseline assessment mean for control groups in FABQPA was 22.55 (0.945). At the end the first week, the mean FABQPA score was 15.00 (0.795). Second week means FABQPA score was 03.60 (0.681). Baseline assessment mean for control groups in FABQT score was 61.85 (2.412). At the end the first week, the mean FABQT score was 38.50 (1.433). Second week means FABQT score was 09.45 (1.606).

Figure 34: Line diagram showing the mean score of FABQW, FABQPW & FABQT (Control group) 4.12.2 Mean of FABQW, FABQPA (Subscale) and FABQT for the three stages (Intervention group) Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQ (Intervention group). Baseline assessment mean for intervention group in FABQW subscale was 38.55 (0.945). At the end the first week, the mean FABQW score was 23.45 (1.606). Second week means FABQW score was 2.85 (1.387). Repeated measure ANOVA was applied to compare the mean values of three different durations of FABQW. Baseline assessment mean for intervention group in FABQPA score was 22.20 (0.616). At the end the first week, the mean FABQPA score was 122

13.50 (1.235). Last week mean FABQPA score was 1.55 (1.099). Baseline assessment mean for intervention group in FABQT score was 61.85 (2.412). At the end the first week, the mean FABQT score was 38.50 (1.433). Second week means FABQT score was 09.45 (1.606). Baseline Intervention group means FABQT score was 60.75 (1.252). At the end the first week, the mean FABQT score was 36.95 (2.236). Second week means FABQT score was 4.40 (1.501).

Figure 35: Line diagram showing the mean score of FABQW, FABQPW & FABQT (Intervention group) 4.13 Results of Oswestry Disability Index 4.13.1 Results of ODI score (Control group) for the three stages Table 44: Mean and standard deviations of ODI score (Control group) for the three stages ODI score- Control group

Baseline Intervention Post Intervention 1 Post Intervention 2

N

Minimum

Maximum

Mean

Std. Deviation

Std. Error

20

44.00

50.00

46.90

2.469

0.55203

20

21.00

30.00

25.25

2.593

0.57981

20

4.00

10.00

07.90

1.447

0.32363

123

Table 45: One way Repeated Measures ANOVA Source

Type III Sum of Squares

df

Mean Square

F

P value

Sphericity Assumed

15271.633

2

7635.817 1973.437

0.000

GreenhouseGeisser

15271.633

1.560

9790.400 1973.437

0.000

Huynh-Feldt

15271.633

1.674

9122.102 1973.437

0.000

Lower-bound

15271.633

1.000

15271.633 1973.437

0.000

147.033

38

3.869

GreenhouseError(Stage1) Geisser

147.033 29.637

4.961

Huynh-Feldt

147.033 31.809

4.622

Lower-bound

147.033 19.000

7.739

Stage1

Sphericity Assumed

Table 44 & 45 shows that Repeated Measures ANOVA statistics tool which was applied. This table illustrated to compare the mean values of three different stages of ODI. Baseline assessment mean for control groups in ODI was 46.90 (2.469). At the end the first week, the mean ODI score was 25.25 (2.593). Second week means ODI score was 07.90 (1.447). The calculated One way Repeated Measures ANOVA F=1973.437, P <0.001. This showed that there was a significant difference between the three stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3 and 3 and 1 (P<0.001).

This table shows that ODI mean score reduced from baseline intervention was 46.90, post intervention1 mean score was 25.25 and mean difference gained score was 21.65. Similarly, the mean post intervention1 score was 25.25 and mean post intervention 2 score was 07.90 and mean difference gained score was 17.35. Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.718, Chi square=5.967, P=0.051, the sphericity assumption is not violated.

124

Figure 36: Line diagram showing the mean score of the ODI (Control group) Table 46: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1 (46.9) vs Stage2 (25.25)

21.65

P<0.01

Stage1 (46.9) vs Stage3 (7.9)

39.00

P<0.01

Stage2 (25.25) vs Stage3 (7.9)

17.35

P<0.01

4.13.2 Results of ODI score (Intervention group) for three stages Table 47: Mean and standard deviations of ODI score (Intervention group) for three stages ODI - Intervention group

Baseline Intervention Post Intervention 1 Post Intervention 2

N

Minimum

Maximum

Mean

Std. Deviation

Std. Error

20

44.00

50.00

46.00

2.248

0.50262

20

22.00

28.00

25.55

1.572

0.35150

20

00.00

7.00

3.45

1.878

0.41974

125

Table 48: One way Repeated Measures ANOVA Type III Sum of Squares

df

Mean Square

Sphericity Assumed

18114.100

2

9057.050

2690.914 0.000

GreenhouseGeisser

18114.100

1.937

9352.712

2690.914 0.000

Huynh-Feldt

18114.100

2.000

9057.050

2690.914 0.000

Lower-bound

18114.100

1.000

18114.100

2690.914 0.000

Sphericity Assumed

127.900

38

3.366

GreenhouseGeisser

127.900

36.799

3.476

Huynh-Feldt

127.900

38.000

3.366

Lower-bound

127.900

19.000

6.732

Source

factor1

Error(factor1)

F

P value

Table 47 & 48 shows that Repeated Measure ANOVA which was applied to compare the three different the duration of ODI. Initially for intervention group the mean ODI score was 46.00 (2.248). At the end the first week, the mean ODI score was 25.55 (1.572). Last week mean ODI score was 3.45 (1.878). The calculated One way Repeated Measures ANOVA F=2690.914, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3 and 3 and 1 (P<0.001).

This table shows that ODI mean score reduced from baseline, intervention was 46 and post intervention1 mean scores was 25.55 so the main difference gained was 20.45. Similarly means the post intervention1 score was 25.55 and mean post intervention 2 score was 3.45 so the main difference gained was 22.10. Mauchlyâ&#x20AC;&#x2DC;s for sphericity W=0.967, Chi square=0.597, P=0.742, the sphericity assumption is not violated.

126

Figure 37: Line diagram showing the mean score of ODI (Intervention group) Table 49: Post hoc comparisons Pairwise comparisons

Mean difference

P value

Stage1(46) vs Stage2(25.55)

20.45

P<0.01

Stage1(46) vs Stage39(3.45)

42.55

P<0.01

Stage2(25.55) vs Stage3(3.45)

22.1

P<0.01

4.13.3 Results of comparison between Intervention and Control group of ODI Table 50: Comparison between Intervention and Control group of ODI

ODI

Control group

Intervention group

N

Mean

Std. Deviation

Mean

Std. Deviation

Base line intervention

20

46.90

2.469

46.00

2.248

Post intervention1

20

25.25

2.593

25.55

1.572

Post intervention 2

20

07.90

1.447

3.45

1.878

F(1,38)=14.796,P<0.001 127

Table 51: Repeated Measure ANOVA Source

Type III Sum of Squares

df

Mean Square

F

P value

Intercept Group Error

80135.008 85.008 218.317

1 1 38

80135.008 85.008 5.745

13948.227 14.796

0.000 0.000

Table 50 & 51 shows that both groups computed through repeated measure ANOVA utilized.

This table also which is used to compare the mean values of three different stages of ODI. Baseline assessment mean for control groups in ODI was 46.90 (2.469). Second week means ODI score was 07.90 (1.447). Initial mean intervention group ODI score was 46.00 (2.248). Second week means ODI score was 3.45 (1.878). The calculated Repeated Measures ANOVA F=14.796, P < 0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together.

Figure 38: Line diagram showing the mean score of ODI (For both the groups) 4.13.4 Percentage of pain reduction in ODI (Control group) The baseline assessment found that the control group ODI mean pain scores was 46.90. First post intervention mean score for ODI was 25.25 and the second post intervention mean score for ODI was 7.90. The decrease in the ODI scores for this study was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 46.17%. The overall percentage of pain reduction from baseline in the second post intervention was 83.16%.

128

Figure 39: Column diagram showing the percentage of pain reduction of the ODI (Control group) 4.13.5 Percentage of pain reduction in ODI (Intervention group) The baseline assessment found that the intervention group ODI mean pain scores was 46.00.

First post intervention mean score for ODI was 25.55 and the second post intervention mean score for ODI was 3.45. The decrease in the ODI scores for this study was statistically significant (P<0.001).

The total

percentage of pain reduction from baseline to first post intervention was 44.6%. The

overall percentage of pain reduction from baseline in the second post intervention was 92.46%.

Figure 40: Column diagram showing the percentage of pain reduction of the ODI (Intervention group) 129

4.14. Results of Correlation analysis This analysis was used to study the correlation of ages (Control group & Intervention group) with NPRS, FABQW, FABQPA (sub scale), and FABQT and ODI along with post intervention 2 scores. The results were presented below.

4.14.1 Analysis of correlation between the scales (NPRS, FABQT and ODI for and Age in Control group post intervention 2 scores Table 52: Correlation between the scales (NPRS, FABQT and ODI) and Age in Control group post intervention 2 scores Age NPRS (Post intervention 2)

-.335

FABQ (Post intervention2)

-.121

ODI (Post intervention2)

.025

Table 52 shows that Correlation coefficients between age and NPRS, FABQT and ODI in Control group post intervention 2 scores. There was no significant correlation between age and post intervention scores. The correlation between age and NPRS is negative and not significant. The correlation between age and FABQ is negative and not significant. The correlation between age and ODI is positive and not significant.

4.14.2 Analysis of correlation between the scales (NPRS, FABQT and ODI) and Age in Intervention group of post intervention 2 scores Table 53: Correlation between the scales (NPRS, FABQT and ODI) and Age in Intervention group post intervention 2 scores Age NPRS (Post intervention 2)

-.146

FABQ (Post intervention2)

0.072

ODI (Post intervention2).

0.470*

*. The correlation was significant at the 0.05 levels Table 53 shows that Correlation coefficients between age and ODI was 0.470 (P=0. 036).

This significant positive correlation indicates that when the age increases, the ODI score increases.

130

The correlation between Age and NPRS is negative and not significant. The correlation between Age and FABQ is positive and not significant.

4.15 Results & Analysis of gender with the post intervention 2 NPRS 4.15.1 Analysis of gender with the post intervention 2 NPRS score (Control group) Table 54: Comparison of mean post intervention 2 NPRS scores between male and female in Control group (Independent sample t test) N

Mean

Std. Deviation

10

3.80

0.422

Genders Male

t

Female

10

3.70

P value & significance 0.628

0.493 NPRS

DF

18

Not significant

0.483

This table 54 shows that there was no influence of different gender on NPRS (Control group) scores. The mean score of gender female was 3.70 (4.83) and mean score of male was 3.80 (0.422).

This showed that there was no significant difference in mean scores between two genders.

4.15.2 Analysis of genders with the post intervention 2 NPRS score (Intervention group) Table 55: Comparison of mean post intervention 2 NPRS scores between male and female in Intervention group (Independent sample t test) N

Mean

Std. Deviation

13

0.62

0.650

Genders

Male

t

Female

7

1.29

P value & significance

0.052 2.080

NPRS

DF

18

Not significant

0.756

131

This table 55 shows that there was no influence of different gender on NPRS (Intervention group) scores. The mean score of gender male was 0.62 (0.650) and mean score of female was 1.29 (0.756). This showed that there was no significant difference in mean scores between two genders.

4.16 Results & Analysis of gender with the post intervention 2 FABQ 4.16.1 Analysis of gender with the post intervention 2 FABQ (Control group) Table 56: Comparison of mean post intervention 2 FABQ scores between male and female in Control group (Independent sample t test) N

Mean

Std. Deviation

10

9.7000

1.05935

Genders

Male

t

DF

0 .501

0.687

FABQ

18 Female

10

9.2000

P value & significance

2.04396

Not significant

This table shows 56 that there was no influence of different gender on FABQ scores. The mean score of gender male was 9.7 (1.05) and mean score of male was 9.2 (2.04). This showed that there was no significant difference in mean scores between two genders.

4.16.2 Analysis of gender with the post intervention 2 FABQ (Intervention group) Table 57: Comparison of mean post intervention 2 FABQ scores between male and female in Intervention group (Independent sample t test) N

Mean

Std. Deviation

13

4.0000

1.47196

Genders

Male FABQ

t

7

5.1429

1.34519

P value & significance

0.106 1.704

Female

DF

18

Not significant

132

This table 57 shows that there was no influence of different gender on FABQ (Intervention group) scores. The mean score of gender male was 4.00 (1.47) and mean score of female was 5.14 (1.34). This showed that there was no significant difference in mean scores between two genders.

4.17 Results & Analysis of gender with the post intervention 2 ODI (control group) 4.17.1 Analysis of gender with the post intervention 2 ODI (control group) Table 58: Comparison of mean post intervention 2 ODI scores between male and female in control group (Independent sample t test)

N

Mean

Std. Deviation

10

8.0000

1.41421

Gender

Male

t

DF

P value & significance

0.766 ODI

0.302 Female

10

7.8000

18

Not significant

1.54919

This table 58 shows that there was no influence of different gender on ODI (Control group) scores. The mean score of gender male was 8.00 (1.41) and mean score of female was 7.80 (1.54).

This showed that there was no significant difference in mean scores between two genders

4.17.2 Analysis of gender with the post intervention 2 ODI (Intervention group) Table 59: Comparison of mean post intervention 2 ODI scores between male and female in Intervention group (Independent sample t test) N

Mean

Std. Deviation

13

2.7692

1.36344

Genders

Male

t

DF

2.496

18

P value & significance

0.022

ODI

Significant Female

7

4.7143

2.13809

133

This table 59 shows that there was a marked influence of different gender on the ODI (Intervention group) scores. The mean score of gender male was 2.76 (1.36.) And a mean score of female was 4.71 (2.13). This showed that there was a significant difference in mean scores between two genders.

4.18 Results & Analysis of two types of sports with the post intervention 2 NPRS 4.18.1 Analysis of two types of sports with the post intervention 2 NPRS (Control group) Table 60: Comparison of mean post intervention 2 NPRS scores between contact and non- contact sports in Control group (Independent sample t test) Sports

Contact sports

N

Mean

Std. Deviation

5

3.80

0.447

t

DF

P value & significance

0.283

18

0.780 Not significant

NPRS Noncontact sports

15

3.73

0.458

This table 60 shows that there is no influence of different types of sports on NPRS (Control group) scores. The mean score of contact sports was 3.80 (0.447) and mean score of non- contact sports was 3.73 (0.458). This showed that there was no significant difference in mean scores between the two typeâ&#x20AC;&#x2DC;s sports.

134

4.18.2 Analysis of two types of sports with the post intervention 2 NPRS (Intervention group) Table 61: Comparison of mean post intervention 2 NPRS scores between contact and non -contact sports in Intervention group (Independent sample t test) Sports Contact sports

N

Mean

Std. Deviation

6

0.83

0.753

NPRS Noncontact sports

14

0.86

t

DF

P value & significance

0.064

18

0.950 Not significant

0.770

This table 61 shows that there was no influence of different types of sports on NPRS (Intervention group) scores. The mean score of contact sports was 0.83 (0.753) and the mean score of non -contact sports was 0.86 (0.770). This showed that there was no significant difference in mean scores between the two sports.

4.19 Results & Analysis of two types of sports with the post intervention 2 FABQ 4.19.1 Analysis of two different types of sports with the post intervention 2 FABQ (Control group) Table 62: Comparison of mean post intervention 2 FABQ scores between contact and non- contact sports in Control group (Independent sample t test) N

Mean

Std. Deviation

5

9.6000

1.34164

Sports Contact sports

t

DF

P value & significance

0.817 FABQ

Noncontact sports

15

9.4000

1.72378

0.235

18

Not significant

This table shows 62 that there was no influence of different types of sports on FABQ (Control group) scores. The mean score of contact sports was 9.60 (1.34164) and mean score of non- contact sports was 9.40 (1.72378). This showed that there was no significant difference in mean scores between the two sports.

135

4.19.2 Analysis of two types of sports with the post intervention 2 FABQ (Intervention group) Table 63: Comparison of mean post intervention 2 FABQ scores between contact and non- contact sports in Intervention group (Independent sample t test) N

Mean

Std. Deviation

6

5.0000

0.89443

Sports Contact sports

t

DF

P value & significance

0.252 FABQ

Noncontact sports

1.183 14

4.1429

18

1.65748

Not significant

This table 63 shows that there was no influence on FABQ (Intervention group) scores on different types of sports. The mean score of contact sports was 5.00 (0.89) and mean score of non contact sports was 4.14 (1.66). This showed that there was no significant difference in mean scores between the two sports.

4.20 Results & Analysis of two different types of sports with the post intervention 2 ODI 4.20.1 Analysis of two different types of sports with the post intervention 2 ODI (control group) Table 64: Comparison of mean post intervention 2 ODI scores between contact and non- contact sports in Control group (Independent sample t test) N

Mean

Std. Deviation

5

8.6000

.89443

Sports

Contact sports

t

DF

P value & significance

0.221 ODI Noncontact sports

1.269 15

7.6667

1.54303

18

Not significant

136

This table 64 shows that there was no influence of different types of sports on ODI (control group) scores. The mean score of contact sports was 8.60 (0.89) and mean score of non- contact sports was 7.66 (1.44). This showed that there was no significant difference in mean scores between the two sports.

4.20.2 Analysis of two different types of sports with the post intervention 2 ODI (Intervention group) Table 65: Comparison of mean post intervention 2 ODI scores between contact and non- contact sports in Intervention group (Independent sample t test) N

Mean

Std. Deviation

6

3.5000

2.07364

Sports

Contact sports

DF

P value & significance

0.940

ODI Noncontact sports

t

0.076 14

3.4286

18

Not significant

1.86936

This table 65 shows that there was no influence of different types of sports on ODI (Intervention group). The mean score of contact sports was 3.50 (2.08) and mean score of non contact sports was 3.42 (1.87). This showed that there was no significant difference in mean scores between the two sports.

137

4.21 Results & Analysis of duration of illness through the post intervention 2 NPRS 4.21.1 Analysis of duration of illness with the post intervention 2 NPRS (Control group) Table 66: Comparison of mean post intervention 2 NPRS scores between upto 2 months duration of illness and more than 2 months in Control group (Independent sample t test) Duration of illness

N

Mean

Std. Deviation

Up to 2 months

9

3.67

0.500

t

DF

P value & significance

0.463

NPRS 0.750 More than 2 months

11

3.82

18

Not significant

0.405

This table 66 shows that there was no influence on different duration of illness (Up to 2 months& More than 2 months) on NPRS scores. The mean score of up to 2 months was 3.67 (0.500) and mean score of more than 2 months was 3.82 (0.405). This showed that there was no significant difference in mean scores between duration of illness.

138

4.21.2 Analysis of duration of illness with the post intervention 2 NPRS score (Intervention group) Table 67: Comparison of mean post intervention 2 NPRS scores between up to 2 months duration of illness and more than 2 months in Intervention group (Independent sample t test) Duration of illness

N

Mean

Std. Deviation

Up to 2 months

12

0.75

0.754

t

DF

P value & significance

0.477

NPRS 0.726 More than 2 months

8

1.00

0.756

18

Not significant

This table 67 shows that there was no influence of different duration of illness (up to 2 months & more than 2 months) on NPRS scores. The mean score of less than 2 months was 0.75 (0.754) and mean score of more than 2 months was 1.00 (0.756). This showed that there was a significant difference in mean scores between duration of illness.

139

4.22 Results & Analysis of duration of illness with the post intervention 2 FABQ 4.22.1 Analysis of duration of illness with the post intervention 2 FABQ (Control group) Table 68: Comparison of mean post intervention 2 FABQ scores between upto 2 months duration of illness and more than 2 months in Control group (Independent sample t test) Duration of illness

N

Mean

Std. Deviation

Up to 2 months

9

9.4444

1.94365

t

DF

0.989

FABQ More than 2 months

0.014 11

9.4545

P value & significance

18

Not significant

1.36848

This table 68 shows that there is no influence on different duration of illness (up to 2 months and more than 2 months) on FABQ scores. The mean score of up to two months was 9.44 (1.94444) and mean score of more than two months was 9.45 (1.36848). This showed that there was no significant difference in mean scores between duration of illness.

140

4.22.2 Analysis of duration of illness with the post intervention 2 FABQ (Intervention group) Table 69: Comparison of mean post intervention 2 FABQ scores between upto 2 months duration of illness and more than 2 months in Intervention group (Independent sample t test) Duration of illness

N

Mean

Std. Deviation

Up to 2 months

12

3.7500

1.48477

t

DF

2.752

18

P value & significance

FABQ

0.013 More than 2 months

8

5.3750

0.91613

significant

This table 69 shows that there was a marked influence of different duration of illness (up to two months& more than two months) on FABQ scores. The mean score of up to two months was 3.75 (1.49) and the mean score of more than 2 months was 5.37 (0.92). This showed that there was a significant difference in mean scores between duration of illness (Intervention group- Up to two Months & More than two Months).

141

4.23 Results & Analysis of duration of illness through the post intervention 2 ODI 4.23.1 Analysis of duration of illness through the post intervention 2 ODI (Control group) Table 70: Comparison of mean post intervention two ODI scores between up to 2 months duration of illness and more than two months in Control group (Independent sample t test) Duration of illness

N

Mean

Std. Deviation

Up to 2 months

9

7.4444

1.87824

t

DF

0.211

ODI More than 2 months

1.296 11

8.2727

P value & significance

18

0.90453

Not significant

This table 70 shows that there was no influence on different duration of illness (up to two months& more than two months) on FABQ scores. The mean score of up to 2 months was 7.44 (1.87) and mean score of more than two months was 8.27 (0.904). This showed that there was no significant difference in mean scores between duration of illness.

4.23.2 Analysis of duration of illness through the post intervention 2 ODI (Intervention group) Table 71: Comparison of mean post intervention 2 ODI scores between upto two months duration of illness and more than two months in Intervention group (Independent sample t test) Duration of illness

N

Mean

Std. Deviation

Up to 2 months

12

3.6667

1.92275

t

DF

P value & significance

0.542

ODI More than 2 months

0.622 8

3.1250

18

Not significant

1.88509

142

This table shows 71 that there was no influence of different duration of illness (up to two months& more than two months) on FABQ scores. The mean score of up to two months was 3.67 (1.922) and the mean score of more than two months was 3.12 (1.88). This showed that there was a significant difference in mean scores between duration of illness (Intervention group).

4.24 Results & Analysis of previous treatment with post intervention 2 NPRS 4.24.1 Analysis of previous treatment with post intervention 2 NPRS (Control group) Table 72: Comparison of mean post intervention 2 NPRS scores between no previous therapy and undergone therapy in Control group (Independent sample t test) N

Mean

Std. Deviation

15

3.73

0.458

Therapy No Previous therapy

t

DF

P value & significance

0.780

NPRS 0.283 Undergone Therapy

5

3.80

18

Not significant

0.447

This table 72 shows that there was no influence on the treatment strategy distribution (No previous therapy & Undergone therapy) on NPRS (Control group) scores. The mean score of no previous therapy was 3.73 (0.458) and mean score of undergone therapy was 3.80 (0.447). This showed that there was no significant difference in mean scores between treatment strategy distributions.

143

4.24.2 Analysis of previous treatment with the post intervention 2 NPRS score (Intervention group) Table 73: Comparison of mean post intervention 2 NPRS scores between no previous therapy and undergone therapy in Intervention group (Independent sample t test) N

Mean

Std. Deviation

16

0.81

0.750

Therapy No Previous therapy

t

DF

0.665

NPRS Undergone Therapy

P value & significance

0.440 4

1.00

18

0.816

Not significant

This table 73 shows that there was no influence on the treatment strategy, distribution (No previous therapy & Undergone therapy) on NPRS (Intervention group) scores. The mean score of no previous therapy was 0.81 (0.750) and mean score of undergone therapy was 1.00 (0.816). This showed that there was no significant difference in mean scores between treatment strategy distributions.

4.25 Results & Analysis of previous treatment with post intervention 2 FABQ 4.25.1 Analysis of previous treatment with post intervention 2 FABQ (Control group) Table 74: Comparison of mean post intervention 2 FABQ scores between no previous therapy and undergone therapy in Control group (Independent sample t test) N

Mean

Std. Deviation

15

10.0000

1.06904

Therapy No Previous therapy

t

DF

3.257

18

FABQ

P value & significance

0.004 Undergone Therapy

5

7.8000

1.92354

Significant

144

This table 74 shows that there was marked influence on the treatment strategy distribution (No previous therapy & Undergone therapy) on FABQ (Control group) scores. The mean score of no previous therapy was 10.00 (1.06) and mean score of undergone therapy was 7.80 (1.92). This showed that there was a significant difference in mean scores between treatment strategy distributions.

4.25.2 Analysis of previous treatment with post intervention 2 FABQ (Intervention group) Table 75: Comparison of mean post intervention 2 FABQ scores between no previous therapy and undergone therapy in Intervention group (Independent sample t test) N

Mean

Std. Deviation

No Previous therapy

16

4.4375

1.63172

Undergone Therapy

4

Therapy

FABQ

t

DF

P value & significance

0.830 0.218 4.2500

18

0.95743

Not Significant

This table 75 shows that there was no influence on the treatment strategy, distribution (No previous therapy & Undergone therapy) on FABQ (Intervention group) scores. The mean score of no previous therapy was 4.43 (1.63) and mean score of undergone therapy was 4.25 (0.95). This showed that there was no significant difference in mean scores between treatment strategy distributions.

4.26 Results & Analysis of previous treatment with post intervention 2 ODI 4.26.1 Analysis of previous treatment with post intervention 2 ODI (Control group) Table 76: Comparison of mean post intervention 2 ODI scores between no previous therapy and undergone therapy in control group (Independent sample t test) N

Mean

Std. Deviation

15

8.2667

1.22280

Therapy No Previous therapy

t

DF

ODI 2.139 Undergone Therapy

5

6.8000

18

P value & significance

0.046 significant

1.64317

145

This table 76 shows that there was marked influence on the treatment strategy, distribution (No previous therapy & Undergone therapy) on ODI (Intervention group) scores. The mean score of no previous therapy was 8.26 (1.22) and mean score of undergone therapy was 6.80 (1.64). This showed that there was a significant difference in mean scores between treatment strategy distributions.

4.26.2 Analysis of previous treatment with post intervention 2 ODI (Intervention group) Table 77: Comparison of mean post intervention 2 ODI scores between no previous therapy and undergone therapy in Intervention group (Independent sample t test) N

Mean

Std. Deviation

16

3.0625

1.73085

Therapy No Previous therapy

t

DF

0.063

ODI 1.984 Undergone Therapy

P value & significance

4

5.0000

1.82574

18

Not Significant

This table 77 shows that there was no influence on the treatment strategy, distribution (No previous therapy & Undergone therapy) on ODI (Intervention group) scores. The mean score of no previous therapy was 3.06 (1.73) and mean score of undergone therapy was 5.00 (1.82). This showed that there was no significant difference in mean scores between treatment strategy distributions.

146

4.27 Discussion of Findings „‟ The nervous system was perhaps the last of the mobile tissues whose mechanical abilities and associated sensitivities had not been considered, although that the neural tissue must physically respond to movement is self -evident.”

Butler 1998 The results of the present study were discussed within the categories as presented in the results chapter. The results were discussed according to the statistical significance between groups as well as within the individual groups. Then the outcome measures like pain, disability, patient‘s fear of pain and beliefs about avoiding certain activity are discussed according to their numerical values and graphical representation. The results were discussed as follows; Demographic variables: 1- Gender (Control group, Intervention group and combined group) 2- Age (Control group, Intervention group and combined group), 3-Duration of Illness (Control group, Intervention group and combined group), 4-Treatment Strategy distribution (Control group, Intervention group and combined group) 5-Type of Sports (Control group, Intervention group and combined group), The three scales used in this study are Numeric Pain Rating Scale (NPRS), Fear Avoidance Belief Questionnaire (FABQW, FABQPA (subscale), and FABQT) and Oswestry Disability Index (ODI) Questionnaire.

The mean score of NPRS, FABQ (FABQW, FABQPA (sub scale) and FABQT) and ODI (Control group, Intervention group and combined group) were calculated. The mean scores of the three scales NPRS, FABQ (FABQW, FABQPA (subscale) and FABQT) and ODI (Control group, Intervention group and combined group) were compared and the correlation analysis was presented between  Age (Post intervention 2 of NPRS, FABQT and ODI)  Gender (Post intervention 2 of NPRS, FABQT and ODI)  Type of Sports (Post intervention 2 of NPRS, FABQT and ODI) 

Duration of Illness (Post intervention 2 of NPRS, FABQT and ODI).

 Treatment strategy distribution (Post intervention 2 of NPRS, FABQT and ODI).

4.28 NPRS scale The baseline means a control group of NPRS score was 9.10 (0.912). At the end of the first week, the mean NPRS score was 5.70 (0.470). At the end of the second week the mean NPRS score was 3.75 (0.444). The calculated value of One way Repeated Measures ANOVA was F=395.137, P <0.001. This showed that there was a significant difference in the mean pain scores for the three different stages. Then all the pairs of the three different stages were compared by pairwise comparisons and the result shows that there was a significant difference between stages 1 and 2, 2 and 147

3 and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

The baselines mean an intervention group of NPRS score was 8.85 (1.226). At the end first week the mean NPRS score was 3.4 (1.095) and at the second week mean NPRS score was 0.85 (0.745). The repeated measure ANOVA was applied to compare the mean values of three different stages of NPRS. The calculated One way Repeated Measures ANOVA was F=405.515, P <0.001. This showed that there was a significant difference between the three different stages. Then all the pairs of the three different stages were compared by pairwise comparisons and the result shows that there was a significant difference between stages 1 and 2, 2 and 3, and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

Repeated Measure ANOVA was applied to compare the mean values of three different stages of NPRS for both the groups. Baseline assessment means NPRS score for the control group was 9.10 (0.912) and at the post intervention 2 mean NPRS score was 3.75 (0.444), Baseline assessment mean intervention group NPRS score was 8.85 (1.226) and the last week mean NPRS score was 0.85 (0.745). The calculated Repeated Measures ANOVA F=93.174, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together. It is inferred that the intervention group had significantly reduced pain than the control group.

The baseline assessment found that the mean of the control group pain score obtained by NPRS was 9.10. The first post intervention mean score of NPRS was 5.70 and the second post intervention mean score of NPRS was 3.75. The decrease in the NPRS scores for this study was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 37.37%. So the overall percentage of pain reduction from baseline in the second post intervention was 57.17%.

The base line assessments found that the mean intervention group

pain score obtained by

NPRS was 8.85. The first post intervention mean score for NPRS is 3.40 and the second post intervention mean score for NPRS was 0.85. The decrease in the NPRS scores from 8.85 to 0.85 was statistically significant (P<0.001). So the total percentage of pain reduction from baseline to first post intervention was 61.6% while the overall percentage of pain reduction from baseline in the second post intervention was 90.4%.

This result highlights that the total percentage of pain reduction in the intervention group is more than the control group.

The 11-point NPRS ranges from 0 (‗‗none‘‘) 1 to 3 (‗‗Mild pain‘‘) 4 to 6 (―Moderate pain‖) 7 to 10 (―Severe pain‖) and it is used to Indicate the intensity of current pain at its best and worst level over the last 24 h (Jensen et al. 1994). These 3 ratings were averaged to arrive at an overall pain score.

When The 3 scores are averaged the scale has shown the adequate reliability, validity, and 148

responsiveness in patients with LBP (Childs et al. 2004).

It has been reported that if there is a 10 or greater than 10 points reduction in the NPRS then it is considered clinically meaningful (Fritz and Irrgang. 2001).

4.29 FABQW Subscale Repeated measure ANOVA was applied to compare the mean values of three occasions of FABQW subscale. Baseline assessment mean control group FABQW subscale

score was 39.30

(1.626). At the end the first week, mean FABQW score was 23.50 (1.100) and at the second week mean FABQW score was 05.85 (1.137). The calculated One way Repeated Measures ANOVA was F=3088.654, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three sessions were compared by pairwise comparisons and the result showed that there was a significant difference between stages 1 and 2, 2 and 3, and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

The baseline assessments mean intervention group FABQW subscale score was 38.55 (0.945). At the end first week the mean FABQW score was 23.45 (1.606) and at the end of second week the mean FABQW score was 2.85 (1.387). For comparing the mean values of FABQW subscale at three different stages, the repeated measure ANOVA was applied. The calculated One way Repeated measure ANOVA was F=4389.729, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3, and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

Repeated Measure ANOVA was applied to compare the mean values of three different stages of FABQW subscale for both the groups. Initially mean FABQW score was 39.30 (1.626) and at the last week the mean FABQW

score was 05.85 (1.137). Baseline assessment means FABQW score

was 38.55 (0.945) and of the last week the mean FABQW score was 2.85 (1.387). So the calculated Repeated Measure ANOVA was F=24.162, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together. It is inferred that the intervention group had significantly reduced pain than the control group.

The baseline assessment found that the control group means pain score obtained by FABQW subscale was 39.30. The first post intervention mean score for FABQW was 23.50 and the second post intervention means score for FABQW was 5.85. The decrease in the FABQW scores from 39.30 to 23.50 was statistically significant (P<0.001). The total percentage of pain reduction from baseline to first post intervention was 40.21%. So the overall percentage pain reduction pain from baseline to second post intervention was 85.12 %.

149

The baseline assessment found that the Intervention group means pain score obtained by FABQW was 38.55. The first post intervention mean score for FABQW was 23.45 and the second post intervention mean score for FABQW was 2.85. The decrease in the FABQW scores for this study was statistically significant (P<0.001). So the total percentage of pain reduction from base line in the first post intervention was 39.17%, while the overall percentage of pain reduction from base line in the second post intervention was 92.6%.

This result highlights that the total percentage of pain reduction in the intervention group is more than the control group.

The FABQ was used to quantify the patientâ&#x20AC;&#x2DC;s fear of pain and beliefs about avoiding any activity (Waddell et al. 1993). Previous studies have found that there was a high level of testâ&#x20AC;&#x201C;retest reliability on FABQW subscales (Jacob et al. 2001). Fear avoidance beliefs have been associated with current and future disability and work loss in patients with acute (Fritz and George.2002) and chronic (Crombez et al. 1999) LBP. This measure was collected to assess the potential confounding effects of fear avoidance beliefs on outcomes.

4.30 FABQPA subscale Baseline assessment means control group FABQPA subscale scores for was 22.55(0.945). At the end of the first week, the mean FABQPA score was 15.00(0.795) and at the second week mean FABQPA score was 03.60(0.681). The One way Repeated Measures ANOVA was applied to compare the mean values of three different stages of FABQPA. The calculated One way Repeated Measures ANOVA was F=3309.485, P <0.001 which concluded that there was a significant difference between the three different stages. All the pairs of three were compared by pairwise comparisons. The result showed that there was a significant difference between stage 1 and stage 2 (P<0.001) and stage 2 and stage 3 (P<0.001) while the stage 1 and stage 3 are significant (P<0.001).

The results show that pain had significantly reduced from baseline to post intervention 2.

Baseline assessment means intervention group FABQPA subscale scores for was 22.20 (0.616). At the end the first week, the mean FABQPA score was 13.50 (1.235) and at the second week mean FABQPA score was 1.55 (1.099). Repeated Measure ANOVA was applied to compare the mean values three different stages of FABQPA. The calculated Repeated Measures ANOVA was F =1899.497, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three sessions were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3, and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

150

Repeated measure ANOVA was applied to compare the mean values of three different durations of FABQPA subscale for both the groups. Initially the mean FABQPA score was 22.55 (0.945) and at the last week mean FABQPA score was 03.60 (0.681). Initially the mean FABQPA score was 22.20 (0.616) and the second post intervention mean FABQPA score was 1.55 (1.099) so the calculated repeated measure ANOVA was F=58.798, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together. It is inferred that the intervention group had significantly reduced pain than the control group.

The base line found that the control group FABQPA Subscale Obtained mean pain scores was 22.55. First post intervention mean score for FABQPA was 15.00 and the second post intervention means score FABQPA was 3.60. The decrease in the FABQPA statistically significant (P<0.001). The

scores from 22.55 to 3.60 was

percentage of pain reduction from baseline to first post

intervention was 33.49%. The overall percentage of pain reduction from baseline in the second post intervention was 84.03%.

The base line assessments found that the Intervention group means pain score obtained by FABQPA subscale was 22.20. The first post intervention mean score for FABQPA was 13.50 and the second post intervention mean score of FABQPA was 1.55. The decrease in the FABQPA scores for this study was statistically significant (P<0.001). So the percentage of pain reduction from baseline to first post intervention was 39.19% while the overall percentage of pain reduction from baseline in the second post intervention was 93.0%.

This result highlights that the total percentage of pain reduction in the intervention group is more than the control group.

The FABQ was used to quantify the patientâ&#x20AC;&#x2DC;s fear of pain and beliefs about avoiding any activity (Waddell et al. 1993). Previous studies have found that there was a high level of testâ&#x20AC;&#x201C;retest reliability on Physical Activity FABQPA subscales (Jacob et al. 2001). Fear avoidance beliefs have been associated with current and future disability and work loss in patients with acute (Fritz and George. 2002) and chronic (Crombez et al. 1999) LBP. This measure was collected to assess the potential confounding effects of fear avoidance beliefs on outcome.

4.31 FABQT Baseline assessment means control group FABQT scores for was 61.85 (2.412). At the end first week the mean FABQT score was 38.50 (1.433) and at the second week mean FABQT score was 09.45 (1.606). One way Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQT. The calculated One way Repeated Measures ANOVA was F=4153.466, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages1 and 2, 2 and 3, and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

151

Baseline assessment means Intervention group FABQT scores for was 60.75 (1.252). At the end the first week, the mean FABQT score was 36.95 (2.236) and at the second week mean FABQT score was 4.40 (1.501). One way Repeated Measures ANOVA was applied to compare the mean values of three different stages of FABQT. The calculated One way Repeated Measures ANOVA was F=6739.862, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result shows that there was a significant difference between stage 1 and stage 2 (P<0.001) and stage 2 and stage 3 (P<0.001) while the stage 1 and stage 3 are significant (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

Repeated measure ANOVA was applied to compare the mean values of three different stages of FABQT for both the groups. Initially the mean FABQT score was 61.85 (2.412) and at the second week mean FABQT score was 09.45 (1.606). Baseline assessments mean FABQT score for both the control and intervention group was 60.75 (1.252) and the second week mean FABQT score was 4.40 (1.501) so the calculated repeated measure ANOVA was F=50.179, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together. It is inferred that the intervention group had significantly reduced pain than the control group.

The baseline assessment found that the control group means pain scores obtained by FABQT was 61.85. The first post intervention mean score for FABQT was 38.50 and the second post intervention means scores of FABQT was 9.45. The decrease in the FABQT scores from 61.85 to 9.45 was statistically significant (P<0.001). So the total percentage of pain reduction from baseline to first post intervention was 37.76%. The overall percentage of pain reduction from baseline to the second post intervention was 84.73%.

The baseline assessment found that the mean Intervention group pain score obtained by FABQT was 60.75. The first post intervention mean score for FABQT was 36.95 and the second post intervention mean score for FABQT was 4.40.So the difference between in the first and second post intervention FABQT scores for this study was statistically significant (P<0.001). The total percentage of pain

reduction from baseline to first post intervention was 39.18%. While the overall percentage

of pain reduction from base line to second post intervention was 92.8%.

This result highlights that the total percentage of pain reduction in the intervention group is more than the control group.

The FABQ was used to quantify the patientâ&#x20AC;&#x2DC;s fear of pain and beliefs about avoiding any activity (Waddell et al. 1993). Previous studies have found high level of testâ&#x20AC;&#x201C;retest reliability for both the Physical Activity (FABQPA) and Work (FABQW) subscales (Jacobet et al. 2001). Fear avoidance beliefs have been associated with current and future disability and work loss in patients with acute (Fritz and George. 2002) and chronic (Crombez et al. 1999) LBP. This measure was 152

collected to assess the potential confounding effects of fear avoidance beliefs on outcomes.

4.32 ODI Repeated measure ANOVA was applied to compare the mean values of three different durations of ODI. Baseline assessment, control group means of ODI score were 46.90 (2.469). At the end of the first week the mean ODI score was 25.25(2.593) and at second week mean ODI score was 07.90(1.447). One way Repeated Measures ANOVA was applied to compare the mean value of three different stages of ODI. The calculated Repeated measure ANOVA was F=1973.437, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3, and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

The calculated Repeated Measure ANOVA was applied to compare the mean values of three different stages of ODI. Baseline assessment means Intervention group ODI scores for was 46.00 (2.248). At the end the first week, mean ODI score was 25.55(1.572) and at the last week mean ODI score was 3.45 (1.878) so the calculated One way Repeated Measures ANOVA was F=2690.914, P <0.001. This showed that there was a significant difference between the three different stages. All the pairs of three stages were compared by pairwise Comparisons. The result showed that there was a significant difference between stages 1 and 2, 2 and 3, and 3 and 1, (P<0.001). The results show that pain had significantly reduced from baseline to post intervention 2.

The calculated Repeated measure ANOVA was applied to compare the mean values of three different stages of ODI for both the groups. The baseline assessment found that the mean score obtained by ODI was 46.90(2.469) and the second week mean ODI score was 07.90 (1.447). Initially the mean ODI score was 46.00(2.248) and at Last week mean ODI score was 3.45 (1.878) so the calculated Repeated Measure ANOVA was F=14.796, P <0.001. This result shows that there was a significant difference between control and intervention group with respect to three stages together. It is inferred that the intervention group had significantly reduced pain than the control group.

The baseline assessment found that the control group mean pain score obtained by ODI was 46.90.The first post intervention mean score for ODI was 25.25 and the second post intervention mean score for ODI was 7.90.So, there was the difference between the first and second post intervention ODI scores from 46.90 to 7.90 was statistically significant (P<0.001). The total

percentage of pain

reduction from base line to first post intervention was 46.17%.So the overall percentage of pain reduction from base line to second post intervention was 83.16%.

The base line assessment found that the Intervention group means pain score obtained by ODI was 46.00. The first post intervention mean score for ODI was 25.55 and the second post intervention mean score for ODI was 3.45. So the difference between the first and second post intervention ODI 153

scores for this study was statistically significant (P<0.001). The total

percentage of pain reduction

from base line to first post intervention was 44.6%. So the overall percentage of pain reduction from baseline in the second post intervention was 92.46%.

This result highlights that the total percentage of pain reduction in the intervention group is more than the control group.

The modified ODI was used to measure disability and consists of 10 questions. Each question is scored from 0 to 5, with higher scores Indicating greater disability. The scores were then converted to a percentage out of 100. The Test–retest reliability of the modified ODI has been shown to be high (Fritz and Irrgang. 2001).

The mean ODI scores for both groups were statistically equivalent at baseline (P=0.001). It has been reported that reductions in the Oswestry of 6 points or greater are considered clinically meaningful (Fritz and Irrgang. 2001).

4.33 Socio demographic variables The mean score of NPRS, FABQ (FABQW, FABQPA (Sub scale) and FABQT) and ODI (Control group, Intervention group and combined group) were calculated. These mean scores of the three scales NPRS, FABQ (FABQW, FABQPA (Subscale) and FABQT) and ODI (Control group, Intervention group and Combined group) were compared. Correlation Analysis and chi square were presented between the five socio demographic variables via, Age, Age with Post intervention 2 of NPRS, FABQT and ODI – In this socio demographic variable, there was significant correlation in the ODI intervention group; and there was no significant correlation between age and NPRS, FABQT. In The control group the results show that there was no significant correlation between age with NPRS, FABQT and ODI. Chi square was presented between the four socio demographic variables via, Age, Type of sports, Duration of illness and Treatment strategy distribution.

Gender with Post intervention 2 of NPRS, FABQT and ODI –the results show that there was a significantly decreased the level of the score in the post intervention 2 between male and female. It is inferred that female got better relief than male. There was no significant decrease in NPRS and FABQT in the intervention group between male and female though it is not statistically significant among male and female. Female had better scores than male in NPRS, FABQT. The results also show that there was no significant decrease in ODI, NPRS and FABQT in the control group.

Type of Sports with Post intervention 2 of NPRS, FABQT and ODI – The results show that there was a significantly decreased the level of the score marked in the post intervention 2 between contact and non-contact sports. There was no significant decrease in NPRS, FABQ and FABQT in the intervention group though it is not statistically significant. The results also show that 154

there was no significant decrease in ODI, NPRS and FABQT in the control group.

Duration of Illness with NPRS, FABQT and ODI – The results show that there was marked FABQT significant decrease in the post intervention 2 between up to 3 months and more than 3 months. There was no significant decrease in NPRS, FABQ and FABQT in the intervention group though it is not statistically significant. The results also show that there was no significant decrease in ODI, NPRS and FABQT in the control group.

Treatment strategy distribution with NPRS, FABQT and ODI – The results show that there was marked FABQT and ODI significant decrease in the post intervention 2 between No previous therapy and Undergone therapy. There was no significant decrease in NPRS, in the intervention group though it is not statistically significant. The results also show that there was marked significant decrease in ODI, NPRS and FABQT in the control group.

Table 78: Mean comparisons between J.A. Cleland et al 2006 and Present study Control group

NPRS

ODI

Intervention group

Baseline

Post intervention

Baseline

Post intervention

J.A. Cleland et al.

3.80

2.70

4.00

1.70

Present study

9.10

3.75

8.85

0.85

J.A. Cleland et al.

24.40

17.60

26.20

7.90

Present study

46.90

7.90

46.00

3.45

Table 78 shows that the comparison of the above scores above shows the reduction of pain in the study score is higher than the J.A. Cleland et al 2006 study.

It should be recognized that the changes in score for a slump stretching group greatly surpassed this level. The slump stretching technique used in this study was designed to reproduce the patient‘s symptoms, which sometimes resulted in a peripheralization of their symptoms. The decision to proceed with treatment despite the peripheralization of symptoms in this group was consistent with the treatment approach used by (George et al. 2002). This study reveals that slump stretching is very significant for the improvement of disability, reducing the pain and centralization of symptoms.

A few studies (Cleland et al. 2004) had investigated the effects of neural mobilization techniques in patients with LBP and lower extremity symptoms.

However, with the exception of 2 studies (Kornberg and Lew. 1989) The others have been single case reports or a case series. Scrimshaw and Maher. (2001) investigated the effects of neural 155

mobilization following lumbar dissection, fusion, or laminectomy. The results of a 12-month followup demonstrated that the neural mobilization did not provide additional benefits to traditional postoperative care. However, the patients in this study exhibited a straight leg raise in the range of motion that was within normal limits suggesting that perhaps performing neural mobilizations on patients with a normal straight leg raise may not be beneficial in decreasing pain and disability.

Kornberg and Lew. (1989) determined that slump stretching combined with hamstring stretching in a group of Australian Rules football players expedited return to sport following a hamstring strain compared to patients who only received hamstring stretching exercises. However, this study was performed in individuals without LBP. This data supports that the impact of slump stretching with static spinal exercise for the management of non-radicular low back pain help to reduce disability and had a beneficial effect on the perception of pain, centralization of symptoms and to improve the functions. This had been shown by a reduction of NPRS, FABQ (FABQW, FABQPA Sub scale & FABQT) and ODI Scores respectively.

This impact exercise strategy protocol was most effective at two weeks.

In the present study the patients with post intervention had a trend towards a favorable outcome. It is interesting to note that through the baseline evaluation we can correlate the post intervention 1and post intervention 2 with the outcome.

This issue deserves further evidence based evaluation, the indication made by slump stretching. It remains to be evaluated if significant improvements have resulted with implementation of the guidelines.

As the aim of the study was to assess the effect of slump stretching cross over pattern could have confounded the results due to carry over effect.

The results of our study confirm our hypothesis that slump stretching may be beneficial in the management of patients with non-radicular LBP. Slump stretching in addition to lumbar spine Mobilization and exercise was beneficial in reducing short-term disability reducing the pain and promoting the centralization of symptoms in this subgroup of patients. The results of the study similar to those of it which concluded that straight leg rising (SLR) stretching may be beneficial in the management of patients with LBD. SLR stretching in addition to lumbar spine mobilization and exercise was beneficial in improving pain, reducing short-term disability and promoting centralization of symptoms in this group of patients (Sahar et al. 2011).

Since there were no supporting articles in evidence based research findings on particular topics, the investigator could not compare the studies with many other studies.

156

4.34 Plausible physiological explanations for findings There is currently a lack of evidence suggesting that any particular neurodynamic treatment technique results in changes of the mechanical or physiological function of nerve tissues. Determining the mechanism for why patients receiving slump stretching improved to a greater extent is beyond the scope of this study. However, it is useful to consider plausible physiological explanations for the findings. Perhaps the slump stretching was effective in reducing the patientâ&#x20AC;&#x2DC;s pain by dispersing intraneural edema, thus restoring pressure gradients, relieving hypoxia and reducing associated symptoms (Cowell and Phillips. 2002). Slump stretching may also have resulted in improved outcomes by reducing antidromic impulses generated in C-fibers at the dysfunctional site which result in the release of neuropeptides and subsequent inflammation in the tissues supplied by the nerve (Shacklock et al. 1995a). Hence if normal neurodynamics were restored by alleviating any sites of neural compression, excessive friction or tension, antidromically evoked impulses may perhaps be eliminated. It was also possible that slump stretching may have resulted in a reduction of scar tissue, which had adhered to neural tissue and its associated connective tissue structures (Turl and George.

1998).

4.35 Therapeutic effects Ellis and Hing. (2008) had written about neural mobilization techniques and analyses the success of various approaches. They suggested that, "When neural mobilization is used for treatment of adverse neurodynamics, the primary theoretical objective is to attempt to restore the dynamic balance between the relative movement of neural tissues and surrounding mechanical interfaces, thereby allowing reduced intrinsic pressures on the neural tissue and thus promoting optimum physiologic function. The hypothesized benefits of such techniques include facilitation of nerve gliding, reduction of nerve adherence, dispersion of noxious fluids, increased neural vascularity, and improvement of axoplasmic flow."

In physiotherapy literature slump stretching techniques are thought to affect neural structures either by increasing intramural tension or by altering mobility in relation to fixed anatomical structures, for example, ligaments and bony elements of the vertebral canal and intervertebral foramina. In early results reported by (Elvey et al. 1987), intramural pressure was seen to vary when a cadaveric radicular nerve was stretched and then relaxed. It can be postulated that this mobilization affects the physiology of the neural tissue by producing a variation in the intramural pressure, which, in itself, goes on to become therapeutic. (Blumberg and Wallin. 1987) showed that intraneural electrical stimulation in the human lower limb elicited pronounced ipsilateral cutaneous vasodilatation and very slight contralateral vasodilatation. The well-studied Lovin reflex in animals was very similar). The Lovin reflex was elicited in animal models by noxious cutaneous stimuli and results in ipsilatera1 cutaneous vasodilatation through inhibition of vasoconstrictor sympathetic tone. The 157

contralateral limb does not vasodilator. It has been thought that the Lovin reflex cannot be seen in man because the nociceptor stimulation elicits vasoconstrictor arousal effects, which override the vasodilatation. This vasoconstrictor arousal effect could account for the vasoconstriction apparent in the control limb of this study. The unilateral slump stretch, utilized in this study, elicited an ipsilateral cutaneous vasodilatation effect, analogous to that found by (Blumberg and Wallin. 1987). In the stretched limb, this vasodilatation appeared to override any vasoconstricting arousal effect of the slump stretch.

4.36 Slump test Although the slump test was used clinically to investigate the presence of altered neurodynamics, although preliminary evidence exists in support of the validity of the slump test in identifying neural tissue involvement (Coppieters et al. 2005), the possibility that the source of pain was derived from structures other than the neural tissues cannot be eliminated. Further research is necessary to examine the sensitivity and specificity of neurodynamic tests as well as the effectiveness of using such techniques in the management of altered neurodynamics.

The results of this study confirm the hypotheses that slump stretching might be beneficial in the management of patients with non-radicular LBP among non-active sports persons. Slump stretching with static spinal exercise in addition to lumbar spine mobilization and exercise was effective in improving the short-term disability, reducing pain and for the centralization of symptoms.

The results of both the groups indicate that the impact effect of slump stretches with static spinal exercise help to reduce pain, disability & centralization of symptoms in the subjects having nonradicular low back pain.

Further research was necessary to examine this hypothesis. Centralization of symptoms in patients with LBP indicates a favorable prognosis (Anne et al. 2004); (Werneke and Hart. 2001) and was typically used to guide treatment in patients with low back and lower extremity symptoms.

However, the slump stretching technique used in this study was designed to reproduce the patientâ&#x20AC;&#x2DC;s symptoms, which sometimes resulted in the peripheralization of their symptoms. The decision to proceed with treatment despite the peripheralization of symptoms in this group is consistent with the treatment approach used by (George et al. 2002).

In our study, slump stretching resulted in significant improvements in disability, pain and centralization of symptoms compared to a lumbar spine mobilization and exercise program without slump stretching Therefore, perhaps centralization is not prognostic for a favorable outcome among all subgroups of patients with LBP. A few limitations should be considered. First, patients with an SLR less than 45 degrees were excluded, thus potentially excluding patients with more severe neural mechanosensitivity, thus the results may not be generalizable to this patient population. This exclusion criterion was incorporated to enroll patients similar to those described by (George et al. 2002). This was also done based on the 158

concern that patients with more severe neural mechanosensitivity might be more likely to experience an adverse response to slump stretching. In addition, our sample size was small, and data were collected at three outpatient orthopedic physical therapy clinic, limiting the generalizability of the findings. Future studies should investigate the prognostic value of the characteristics used in this study to guide decision making regarding the use of slump stretching in a larger patient population with LBP.

4.37 Framing a rationale behind the existing system of slump stretching modality The present study using the new system (weekly thrice for two weeks) of slump stretching has given significant improvement among non- radicular low back pain. Compare to (table 78) shows the reduction of pain in this study is much higher than Cleland (2006) study with less frequency (weekly twice for three weeks). Hence a conclusion could be drawn that when the frequency of adopting slump stretching is increased better benefits can be achieved. Hence this system could be widely practiced universally among non -radicular low back pain population.

159

CHAPTER V 5. SUMMARY, CONCLUSION, AND RECOMMENDATIONS 5.1 Summary The problem and its settings Low back pain (LBP) is the common reason for seeing a physiotherapist in primary care. The goal for the therapist managing these patients is to select the appropriate treatment for each patient.

The clinical reasoning process required to achieve this goal starts with a diagnostic classification that places the patient into a recognizable group with a particular pattern of signs and symptoms. The medical professionals in primary care most commonly classify these patients with beta-anatomically labeled categories. However, there appears to be a wide diversity in the opinion about pattern of signs and symptoms that constitute a category (Kent et al. 2003).

LBP is a major public health problem all over the world. Back pain (sometimes referred to generally as lumbago) is a common musculoskeletal disorder causing pain in the lumbar vertebrae. It can be acute, sub-acute or chronic in its clinical presentation. Typically the symptoms of LBP do show significant improvement within two to three months from its onset. In a significant number of individuals, LBP tends to be recurrent in nature with a waxing and waning quality to it. In a small proportion of patients, this condition can become chronic. Population studies have shown that the back pain mostly affects adults at a productive, active phase of life and accounts for significant sickness absenteeism and disability than any other single medical condition (Waddell et al. 1998).

The purpose of the study was to assess the effect of slump stretching in the management of non- radicular low back pain among non- active sports persons.

The objective of the study is to find out the effect of slump stretching and analyze for any significant variation. The 40 subjects were divided into two equal groups: Control group: Mobilization technique with static spinal exercises Intervention group: Slump stretching followed by mobilization by static spinal exercises.

Alternative hypothesis were formulated with regard to treatment effect stating that there would be different between the groups. â&#x20AC;&#x153;There was significant difference produced between the mobilization technique and exercises & slump stretching in reducing pain & short term disability in non- radicular low back painâ&#x20AC;&#x2013;.

Both the groups were assessed on the first day and last day of the treatment session on the basis of NPRS, Oswestry Disability Index and FABQT. In both groups there was improvement in NPRS, Oswestry Disability Index and FABQT after the treatment. However, there was significant difference between the two groups, i.e. Control group (mobilization) and Intervention group (slump stretching).

160

The performance of Control group and Intervention group was compared using Repeated Measure ANOVAs followed by Bonferrani test. The data collected was analyzed for homogeneity between the groups and within the groups using t test. The student t test was used to test the association between the measured scales and demographic variables.

Forty (n=40) non radicular low back pain subjects (20=Control group, 20=Intervention group) participated in the study. 4 sports injury clinics were used as research settings for the study. The participants were non radicular low back pain subjects only. Outcome measures (NPRS, FABQW, FABQPA, FABQT and ODI) were used to identify the prognosis and the impact intervention strategy approach to determine non radicular LBP treated by sports physiotherapists, and also ―slump technique‖ used for diagnosis as well as treatment.

The study found that non radicular low back pain was the most common LBP condition seen by sports physiotherapists in the non- active sports community especially found in sports injury clinics. The most recent specific slump techniques used by physiotherapists to assess, diagnosis and the impact effect on patients with non -radicular low back pain was back inspection or palpation, lumbar spinal range of motion, slump test, and straight leg raises more than 45º and evaluating muscle strength. However, sensation testing was most frequently used for non- radicular low back patients.

Overall, patient education module and the exercises were appropriate modalities which are most frequently used by physiotherapists for all case studies. Physiotherapists were likely to use this specific intervention strategy approach which is highly effective for treatment methods.

Based on the findings of the study it was opined that it is possible for Indian physiotherapists to progress toward evidence-based practice despite the limitations.

Health care expenditures among individuals with LBP are 60% greater than those without LBP. To find a subgroup of patients: distal symptoms, not improved by directional exercise thought to have altered neurodynamics, interaction between the nervous system, neuromeningeal structures within the vertebral canal and the distal physiology (epineurium).

Plausible physiological explanations for findings 1. Perhaps the slump stretching was effective in reducing the patient‘s pain by dispersing intraneural edema, thus restoring pressure gradients, relieving hypoxia and reducing associated symptoms.

2. Slump stretching may also have resulted in improved outcomes by reducing antidromic impulses generated in C-fibers at the dysfunctional site which result in the release of neuropeptides and subsequent inflammation in the tissues supplied by the nerve.

3. It is also possible that slump stretching may have resulted in a reduction of scar tissue, which had adhered to neural tissue and its associated connective tissue structures.

161

Slump stretching is beneficial for improving short-term disability, decreasing pain, and centralization of symptoms compared to treatment without slump stretching.

Patients with distal symptoms who are unable to centralize their symptoms might be a distinct subgroup of patients with LBP that benefit from slump stretching exercise.

Neural mobilization in patients with normal SLR may not benefit in decreased pain and disability.

5.2 Conclusion The present study on the slump was done using the slump stretch for subjects with mechanical back pain. After two weeks of specific intervention Physiotherapy program slump stretching, the slumping group had 92.46 % and the control group percentage disability score was 83.16 % consequently the present study clinical findings determined that there was therapeutic slump stretching significantly greater improvements over those that did not slump, as measured by the Oswestry Disability Index. The control group of percentage of pain reduction was 57.17% and the slump stretching group percentage of pain reduction was 90.46 % consequently the present study researcher found the clinical evidence shown that there was a intensity of pain significantly reduced in slump stretching group, as measured by Numeric Pain Rating Scale (NPRS).Therapeutic slump stretching reduction fear of pain on any particular physical activity/work score was 92.80% and the control group had a fear of pain score was 84.73% and the clinical relevance, state that there was a slump stretching group significantly reduced the fear of pain, as measured by Fear Avoidance Belief Questionnaire (FABQ). It could be assumed that slump stretching was beneficial for improving short term disability, decreasing pain, and centralization of symptoms compared to treatment without slump stretching in a subgroup of patients.

Based on the results discussed here, the following could be stated with regard to the objectives and hypotheses, The mobilization group showed an improvement in subjective (NPRS, FABQW, FABQPA, FABQT and ODI Scale) clinical findings, and the slump stretching group showed an improvement in subjective (NPRS , FABQW, FABQPA, FABQT and ODI Scale) clinical findings which was in agreement with the hypothesis set out at the beginning of the study. However, when the relative effectiveness of slump stretching training was compared to mobilization exercise group did significantly outperform and the slump stretching group in terms of pain decreased and reduced disability were the slump stretching group showed significant improvement. Therefore, this study was only partially in keeping with the hypothesis set out at the beginning of the study, as it was hypothesized that slump stretching training was a more effective form in the management of non radicular low back pain.

Differentiating symptoms of canal origin from those arising from movements of the joints necessary for the physiotherapist to understand patientsâ&#x20AC;&#x2DC; problem. Slump test is essential for this differentiation which helps in giving inappropriate treatment with a clear aim in mind. Prognosis also 162

becomes more meaningful. Centralization of symptoms in patients with LBP indicates a favourable prognosis and was typically used to guide treatment in patients with low back and lower extremity symptoms. However, the slump stretching technique used in this study was designed to reproduce the patient‘s symptoms, which sometimes resulted in a peripheralization of their symptoms. The decision to proceed with treatment despite the peripheralization of symptoms in this group was consistent with the treatment approach used. Patients with distal symptoms who are unable to centralize their symptoms may be a distinct subgroup of patients with LBP that benefit from slump stretching exercise. Neural mobilization in patients with normal SLR may not benefit in decreased pain and disability. Future studies should examine whether these benefits are maintained at a longer-term follow-up or not. Slump stretching was shown to be effective in the management of patients with nonradicular LBP when combined with static spinal exercise.

At the end of the physiotherapy management slump stretching group exhibited significantly improved disability, overall perceived pain, and reduction of their thigh, lower leg, or foot symptoms.

5.2.1 Reason for findings 1. Perhaps the slump stretching was effective in reducing the patient‘s pain by dispersing intraneural edema, thus restoring pressure gradients, relieving hypoxia and reducing associated symptoms.

2. Slump stretching may also have resulted in improved outcomes by reducing antidromic impulses generated in C-fibers at the dysfunctional site which result in the release of neuropeptides and subsequent inflammation in the tissues supplied by the nerve.

3. Slump stretching was beneficial in decreased pain and disability and centralization of symptoms. Slump stretching was shown to be more effective in the management of patients with nonradicular LBP when combined with static spinal exercise.

5.2.2 Clinical finding 

Repeated Measure ANOVA of NPRS result shows that there was an overall significant difference between intervention and control group across the 3 stages together and intervention group means show significantly better improvement.



Repeated Measure ANOVA of FABQT result shows that there was an overall significant difference between intervention and control group across the 3 stages together and intervention group means show significantly better improvement.



Repeated Measure ANOVA of ODI result shows that there was an overall significant difference between intervention and control group across the 3 stages together and intervention group means show significantly better improvement.



Functional ability increased with age (ODI Intervention group only) and significantly more in females than males.

163



The functional ability of females was better than males.



Subject to pain of longer duration expressed less pain compared to subjects with pain for shorter duration, (FABQ only).

 Subjects who had already undergone therapy expressed less fear of pain compared to those subjects who did not have any previous therapy (FABQ –Control group only), Similarly Subjects who had already undergone therapy expressed less fear of pain compared to those who did not have any previous therapy (ODI –Control group only).

5.3 Suggestions and Implications of this study 1. Exclusion of patients with an SLR less than 45degree may have excluded, patients with more severe neural mechanosensitivity, hence results may not be generalizable to this subject population.

2. Our sample size was small; Data were collected at the few outpatient hospital and clinic, limiting the generalizability of the findings.

3. Improvement in long term disability of patients could not be assessed by using

outcome

measures used in the study.

4. Gender in both groups is not equally distributed.

5. It important to note the limitations and weaknesses of this study. There were some limitations that future researchers should consider when applying the findings. One of the limitations of this study was non radicular low back pain among non- active sports persons only.

6. Although the findings on treatment choices and their effect of slump stretching for the management of non- radicular LBP were based only on physiotherapists‘ practices, they could possibly have been based on the views of patients‘ satisfaction with specific treatment protocols used.

5.4 Recommendations Our belief that we cannot totally dismiss the greatest clinical importance … of neural provocation testing… simply because of lack of scientific addressing this topic (Coppieters & Butler 2002) Based on the findings of this study, the following recommendations which are offered for future actions:

1.

2.

Changes can make inclusion criteria in terms of SLR less than 45 degrees.

Sample size can be increased by inclusion criteria, which can be achieved more number of outpatient departments to generalize the effect in the larger population.

3.

Study can be done to assess the effect of long term disability of the patient.

4.

Gender distribution should be equal in both groups.

164

5.

Future research should focus on identifying whether this specific intervention approach would be applicable for longer-term follow up or not.

6.

There was a lack of insufficient information on the prevalence of LBP in India from documentations. Thus, more research on non- radicular LBP, impact and outcomes of treatments ought to be investigated. This will ease the control of the severity of LBP.

7.

Physiotherapists should periodically update their knowledge up to date, especially in clinical practice and treatments. Clinical guidelines which are widely used, and may increase physiotherapistsâ&#x20AC;&#x2DC; knowledge.

8.

Before administering any treatment, physiotherapists should be aware of the most recent research concerning specific treatment approach used for low back pain patients or not. This would make treatment more satisfaction with patients and the effect of treatment approach.

165

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Assessment Performa Name: Age Sex Occupation Date Address Chief complaints History: Past: Present: Personal: Smoking / alcohol / diabetic / HTN. Family: Workplace assessment: Backrest/ arm rest / pedestal base Intensity of work: mild/moderate/ severe Working hours: Type of work: Mechanical / sedentary Pain location: Pain Duration: 12/24 hrs Pain onset: Sudden / Gradual Duration of onset: Body diagram (enclosed) Aggravating factors: 173

Relieving factors: Types of pain: Localized/referred/ radiating Intermittent / Continuous: Pain on coughing / sneezing/ deep breathing: Influencing factors: Stress Pricking / aching/ burning/ shooting Pain behavior: improving/ worsening Family problems: Job satisfaction Intensity of pain: VAS Physical Examination An Observation: Body: Built Posture: Sitting

Standing

Anterior view Posterior view Lateral view Head: Shoulder: Spinal Pelvis Gait On palpation Skin â&#x20AC;&#x201C;warmth Texture 174

Tenderness Spasm Trigger points An Examination: ROM; MMT: Abdominal muscles Lumbar spine: SPECIAL TESTS: Straight leg raising test: Slump Test: Supported forward bending test: NEURAL TENSION TEST: Lower limbs Femoral Nerve: Sciatic Nerve: Obturator nerve: Modified Oswestry Disability Index Questionnaire TREATMENT PROTOCOL: Control group: mobilization with static spinal exercises Intervention group: slump stretching with static spinal exercises

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SUBJECT CONSENT FORM Study title “EFFECT OF SLUMP STRETCHING WITH STATIC SPINAL EXERCISE FOR THE MANAGEMENT OF NON RADICULAR LOW BACK PAIN AMONG NON ACTIVE SPORTS PERSONS” I have been informed about the procedure and purpose of the study. I have understood that I have the right to refuse my consent or withdraw it anytime during the study without adversely affecting the study.

I am aware that being subjected to this study, I will have to give some time to this study and this assessment does not interfere with the benefits I, Mr. /Mrs. __________________, the undersigned give my consent to be a participant of the study program.

Signature on the consent Date:

Signature of the investigator (Name and Address)

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SUBJECT INFORMATION FORM

RAMAKRISHNA MISSION VIVEKANANDA UNIVERSITY (Recognized by Government of India under Section 3 of the UGC Act, 1956) FACULTY OF GENERAL AND ADAPTED PHYSICAL EDUCATION AND YOGA SRKV Post, Periyanaickenpalayam, Coimbatore, Tamilnadu – 641020 Phone : 0422-2692667, Fax: 0422-2692582 Email: fgapedyecell@gmail.com

Dear Participant, welcome to my research project.

Title of Research: ―Effect of slump stretching with static spinal extensors for the management of non -radicular low back pain among non- active sports persons” An investigation which intend to identify the long term effectiveness of slump stretching with static spinal exercise for the treatment of non -radicular low back pain sufferers.

NAME OF RESEARCH STUDENT T. Karthikeyan

Contact number (9448343356)

NAME OF RESEARCH SUPERVISOR Dr. S.Jaihind Jothikaran

Contact Number (9741162553)

You have been selected and actively to take part in a study which investigating the short term efficacy of slump stretching with treatment of low back pain sufferers with regards to core muscle strength. Forty people will be required to complete this study. All participants, including you, will be randomly split into two equal groups. Among the forty subjects twenty subjects of control group will receive a mobilization with static spinal exercise and the remaining twenty subjects of intervention group will receive a standard clinical treatment of slump stretching with static spinal exercises for the treatment of this study.

Inclusion and Exclusion: If you are taking any medication, ask the patient to stop medication before taking part in the study. This is because medications may have an effect on the symptoms, and you may be excluded from the study. If you are undergoing any other form of treatment for your back pain you may be excluded from the study. Please try not to alter your normal lifestyle or daily activities in any way, as 177

this could interfere with the results of the study. Those taking part in the study must be between the ages of 20 and 45. Any patients with spinal tumors or metastases, recent fractures of the axial skeleton, inflammatory disease of the spine, cauda equina syndrome, progressive neurological deficits, heart failure, recent abdominal surgery, hip or knee Endoprosthesis or metal implants, recent venous thrombosis, arterial occlusive disease, pregnancy or epilepsy will be excluded from this study due to it being a contra-indication to slump stretching training.. Patients that are found to be dishonest in the history provided by them, that require further clinical testing for diagnosis, and all patients that fail to comply with the informed consent form will be excluded from the study.

Research process: At the first consultation you will be screened for suitability as a participant using a case history, physical examination and lumbar spine regional examination. You will be asked to complete a measurement of your low back pain Treatments: All treatments will be performed under the supervision of a qualified Physiotherapist by the research student and will be free of charge. Risks and discomfort: The treatment is safe and is unlikely to cause any adverse side effects.

Remuneration and costs: Treatment for the duration of the research process will be free of charge. Subjects taking part in the study will not be offered any other form of remuneration for taking part in the study. Upon completion of the research process, the normal cost of consultations will be charged for those patients wanting further treatment. All patient information is confidential and the results of the study will be made available in the Ramakrishna Mission Vivekananda University library in the form of a thesis

Implications of withdrawal from the research: You are free to withdraw at any stage. Benefits of the study: Your full co-operation will assist the Physiotherapy profession in expanding its knowledge of this condition and thus making future rehabilitation of patients suffering from non- radicular low back pain more successfully.

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Confidentiality and ethics: All patient information will be kept confidential and will be stored in the Physiotherapy Day Clinic for 5yrs, after which it will be shredded. Please do not hesitate to ask questions on any aspect of this study. Should you wish, you may contact my research supervisor at the above details or alternatively you could contact the Faculty of General and Adapted Physical Education and Yoga and Ethics Committee as per Dr. Alagesan (9443420801).

Thank you.

Yours sincerely, …………………………………..

T. Karthikeyan (Research student)

…………………………………

Dr. S. Jai Hind Jothikaran (Supervisor)

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MODIFIED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE1 Section 1: To be completed by patient Name:______________________________ Age:_______ Date:__________________ Occupation:_________________________ Number of days of back pain:_____________(this episode) Section 2: To be completed by patient This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by placing a mark on the line that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark only the line which most closely describes your current condition.

Pain Intensity _____The pain is mild and comes and goes. _____The pain is mild and does not very much. _____The pain is moderate and comes and goes. _____The pain is moderate and does not very much. _____The pain is severe and comes and goes. _____The pain is severe and does not very much.

Personal Care (Washing, Dressing, etc.) _____I do not have to change the way I wash and dress myself to avoid pain. _____I do not normally change the way I wash or dress myself even though it causes some pain. _____Washing and dressing increases my pain, but I can do it without changing my way of doing it. _____Washing and dressing increases my pain and I find it necessary to change the way I do it. _____Because of my pain I am partially unable to wash and dress without help. _____Because of my pain I am completely unable to wash or dress without help.

Lifting _____I can lift heavy weights without increased pain. _____I can lift heavy weights but it causes increased pain _____Pain prevents me from lifting heavy weights off of the floor, but I can manage if they are conveniently positioned (ex. on a table, etc.). _____Pain prevents me from lifting heavy weights off of the floor, but I can manage light to medium weights if they are conveniently positioned. _____I can lift only very light weights. _____I cannot lift or carry anything at all.

Walking _____I have no pain when walking. _____I have pain when walking, but I can still walk my required normal distances. _____Pain prevents me from walking long distances. _____Pain prevents me from walking intermediate distances. _____Pain prevents me from walking even short distances. _____Pain prevents me from walking at all.

Sitting _____Sitting does not cause me any pain. _____I can only sit as long as I like providing that I have my choice of seating surfaces. _____Pain prevents me from sitting for more than 1 hour. _____Pain prevents me from sitting for more than 1/2 hour. _____Pain prevents me from sitting for more than 10 minutes. _____Pain prevents me from sitting at all.

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OSWESTRY QUESTIONNAIRE, p. 2 Section 2 (conâ&#x20AC;&#x;t): To be completed by patient Standing _____I can stand as long as I want without increased pain. _____I can stand as long as I want but my pain increases with time. _____Pain prevents me from standing more than 1 hour. _____Pain prevents me from standing more than 1/2 hour. _____Pain prevents me from standing more than 10 minutes. _____I avoid standing because it increases my pain right away.

Sleeping _____I get no pain when I am in bed. _____I get pain in bed, but it does not prevent me from sleeping well. _____Because of my pain, my sleep is only 3/4 of my normal amount. _____Because of my pain, my sleep is only 1/2 of my normal amount. _____Because of my pain, my sleep is only 1/4 of my normal amount. _____Pain prevents me from sleeping at all.

Social Life _____My social life is normal and does not increase my pain. _____My social life is normal, but it increases my level of pain. _____Pain prevents me from participating in more energetic activities (ex. sports, dancing, etc.) _____Pain prevents me from going out very often. _____Pain has restricted my social life to my home. _____I have hardly any social life because of my pain.

Traveling _____I get no increased pain when traveling. _____I get some pain while traveling, but none of my usual forms of travel make it any worse. _____I get increased pain while traveling, but it does not cause me to seek alternative forms of travel. _____I get increased pain while traveling which causes me to seek alternative forms of travel. _____My pain restricts all forms of travel except that which is done while I am lying down. _____My pain restricts all forms of travel.

Employment/Homemaking _____My normal job/homemaking activities do not cause pain. _____My normal job/homemaking activities increase my pain, but I can still perform all that is required of me. _____I can perform most of my job/homemaking duties, but pain prevents me from performing more physically stressful activities (ex. lifting, vacuuming) _____Pain prevents me from doing anything but light duties. _____Pain prevents me from doing even light duties. _____Pain prevents me from performing any job or homemaking chores.

Section 3: To be completed by physical therapist/provider SCORE: Initial_____% Subsequent_____% Subsequent_____% Discharge_____% Number of treatment sessions:________________ Diagnosis/ICD-9 Code:_______________________

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ADVERTISEMENT

Are you aged between 18 - 45 years?

And suffer from LOW BACK PAIN? Research is currently being carried out at the 5. Sita Bhateja Speciality hospital (Spectrum Physiotherapy centre) Bangalore-25.

6. Rajashri grandhim physiotherapy clinic, Bangalore-76.

7. Rhea health care, Bangalore.

8. Gokul physiotherapy clinic, Bangalore-76.

FREE TREATMENT Is available ON COMPLETION OF THE STUDY for more information Contact T.karthikeyan On (080) 26995286/5286 9448343356

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BACK CARE ADVICE (Christopher Norris M. 1993) For Sitting

1.

2.

3.

4.

Do not sit for long periods.

5.

Sit with the feet flat on the floor and the knees above the levels of the hips. If unable to raise

Avoid sitting forward on a chair with back arched.

Sit on a firm, straight-backed chair.

Sit with the low back slightly rounded or positioned firmly against the back of the chair.

the knees, place the feet on a stool.

6.

Avoid sitting with legs straight and raised on a stool.

Standing 1. If standing for long periods. a) Shift position from one foot to another. b) Place one foot on a stool.

2. Stand tall, flatten low back, and relax knees.

3. Avoid arching back.

Lifting and carrying 1. To pick up on the object a) Bent at knees and not the waist b) Do not twist to pick up an object. Face it squarely. c) Tick in the buttocks and tighten the abdomen.

2. To carry on the object. a) Hold the object close to the body. b) Hold the object at waist level. c) Do not carry objects on one side of the body .If it must be carried unbalanced change from one side to another.

Sleeping

1.

2.

3.

4.

5.

6.

7.

Do not stay one position too long.

8.

Remember that the least strain on the back is in the fully recumbent position with the hips and

Use a bed that is flat and firm yet comfortable.

Do not sleep on the abdomen.

Do not sleep on the back with legs fully extended.

If sleeping on the back, place a pillow under the knees.

Ideally, sleep on the side with knees drawn up.

Never extended the arms overhead.

knees at an angle of 90 degrees. In case of chronic or a sub- acute lower back condition, use a firm matters, it will afford rest and relaxation of the lower back.

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Practice tips 

Back pain that is related to posture, aggravated by movement and sitting, and relieved by lying down is due to vertebral dysfunction, especially a disc disruption.



The pain from most disc lesions is generally relieved by rest.



Plain X-rays are of limited use, especially in younger patients, and may appear normal in disc prolapse.



Remember the possibility of depression as a cause of back pain; if suspected, consider a trial of antidepressants.



If back pain persists, possibly worse during bed rest at night, consider malignant disease, depressive illness or other systemic diseases.



Pain that is worse on standing and walking, but relieved by sitting, is probably caused by spondylolisthesis.



If pain and stiffness is present on waking and lasts longer than 30 minutes upon activity, consider inflammation. Avoid using strong analgesics (especially opioids) in any chronic non-malignant pain state.



Bilateral back pain is more typical of systemic diseases, while unilateral pain typifies mechanical causes.



Back pain at rest and morning stiffness in a young person demand careful investigation: consider inflammation such as ankylosing spondylitis and Reiter's syndrome.



A disc lesion of L5–S1 can involve both L5 and S1 roots. However, combined L5 and S1 root lesions should still be regarded with suspicion (e.g. consider malignancy).



A large central disc protrusion can cause bladder symptoms, either incontinence or retention.



Low back pain of very sudden onset with localised spasm and protective lateral deviation may indicate a facet joint syndrome.



The T12–L1 and L1–2 discs are the groin pain discs.



The L4–5 disc is the back pain disc.



The L5–S1 disc is the leg pain disc.



Severe limitation of SLR (especially to less than 30°) indicates lumbar disc prolapse.



A preventive program for dysfunctional back pain based on back care awareness and exercises is mandatory advice.



Remember that most back problems resolve within a few weeks, so avoid overtreatment.

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RAW DATA OF NPRS Intervention group

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Baseline

Post intervention 1

10

2

9

3

8

2

7

4

10

5

9

2

10

3

8

5

7

4

10

3

8

4

10

5

10

2

7

3

10

4

7

3

8

2

9

5

10

4

10

3

Control group

Post intervention 2 0 1 1 0 2 1 2 1 1 1 0 2 1 0 1 0 0 0 2 1

Baseline

Post intervention 1

Post intervention 2

10

5

3

9

5

4

8

6

4

9

5

4

10

6

4

9

5

4

10

6

4

8

6

3

8

6

3

10

6

4

8

5

4

10

6

4

10

5

4

8

6

4

10

6

4

8

6

3

8

6

3

9

6

4

10

6

4

10

6

4

190

RAW DATA OF FABQ Intervention group Baseline 1 2 3 4 5 6 7 8 9

63 59 59 62 62 60 61 61 61

10

61

11

61

12

60

13

61

14

59

15

62

16

61

17

63

18

60

19

59

20

60

Control group

Post intervention 1

Post intervention 2

Baseline

Post intervention1

Post intervention 2

40

4

63

38

5

38

4

59

40

11

33

5

59

39

11

39

4

66

41

10

37

6

62

40

9

32

4

60

37

11

36

3

61

39

7

37

5

61

36

11

34

3

66

39

9

6

61

39

9

4

61

39

8

7

60

39

11

5

61

39

8

3

66

38

11

5

62

38

11

1

61

38

10

6

63

37

9

2

60

37

10

6

59

36

9

5

66

41

9

37 37 36 39 38 36 35 40 38 37 40

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Raw Data of ODI Intervention group

Control group

Baseline

Post intervention 1

Post intervention 2

Baseline

Post intervention 1

Post intervention 2

44

25

6

44

26

4

46

25

4

46

23

8

46

25

3

46

27

9

44

26

2

50

22

9

50

23

4

50

28

7

44

27

0

44

22

6

46

25

3

46

28

8

46

28

1

46

22

8

44

23

2

50

30

10

50

26

6

50

25

8

44

26

3

44

28

9

46

22

1

46

24

9

46

25

4

46

27

8

44

26

4

50

23

8

50

28

3

50

26

10

44

26

5

44

21

6

46

26

3

46

28

9

18

46

27

46

24

7

19

44

27

44

27

8

20

50

25

50

24

7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

2 6 7

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ILLUSTRATION OF SLUMP STRETCHING

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ILLUSTRATION SELF SLUMP STRETCHING (HOME PROGRAMME)

194

ILLUSTRATION OF PELVIC TILT- 1

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ILLUSTRATION OF PELVIC TILT- 2

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