PROFORMA FOR REGISTATION OF SUBJECTS FOR DISSERTATION

DISSERTATION PROPOSAL

TOPIC

“A STUDY ON COMPARISON OF STANDARDIZED LUMBER CORE STABILITY EXERCISES VS “KAPALABHATI PRANAYAMA” ON LUMBER CORE STABILITY EXERCISES IN SUBJECTS WITH MECHANICAL LOW BACK PAIN.”

Submitted By:

Ajeesh U.

1 year MPT [2009-10 Batch]

Shridevi College of Physiotherapy

Sira road, Tumkur-572106

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

BANGALORE-41

ANNEXURE- II

Synopsis Proforma for registration of subject for Dissertation

1NAME OF THE CANDIDATE AND ADDRESS

AJEESH U.

1 ST YEAR MPT,

SHRIDEVI COLLEGE OF PHYSIOTHERAPY LINGAPURA, SIRA ROAD,

TUMKUR -572106

2 NAME OF THE INSTITUTION

SHRIDEVI COLLEGE OF PHYSIOTHERAPY, SIRA ROAD, TUMKUR

3 COURSE OF STUDY AND SUBJECT

MASTER OF PHYSIOTHERAPY (MPT)- [MUSCULO SKELETAL DISORDERS & SPORTS PHYSIOTHERAPY.]

4 DATE OF ADMISSION TO COURSE 08/06/2009

5 TITLE OF THE STUDY

“A STUDY ON COMPARISON OF STANDARDIZED LUMBER CORE STABILITY EXERCISES VS

“KAPALABHATI PRANAYAMA” ON LUMBER CORE STABILITY EXERCISES IN SUBJECTS WITH MECHANICAL LOW BACK PAIN.”

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION Whether it’s a dull, nagging ache or sharp, shooting pain, Low Back Pain is a Condition that plagues millions of people in the world.1

Pain in the lower back or Low Back Pain is a Common concern, affecting up to 90% of the people world wide at some point in their life time.2

The type and severity varies from person to person, but there is one common factor: Low back pain is a condition that affects every part of a person’s life. For many everyday activities such as sleeping, sitting, getting in and out of car or walking can suddenly become unbearable, because of Low Back Pain.3

The lower back or lumbar area serves a number of important functions for the human body. These functions include structural support, movement and protection of certain body tissues. When we stand, the lower back is functioning to support the weight of the upper body. When we bend, extent, or rotate at the waist, the lower back is involved in the movement. Therefore injury to the structures involved for weight bearing such as bony spine, muscle, tendons and ligaments can be detected.4

Low Back Pain reportedly occurs at least once in f adults younger than 50 years, and 15-20% of Americans have at least one episode of back pain per year. Low Back Pain affects men and women equally. The onset most frequently occurs in people aged 30-50yrs.5

Of all cases of Low Back pain, 70% are due to mechanical reasons. Mechanical Low back Pain is one of the most common patient complaints expressed to emergency physicians in the United States, accounting for more than 6 million cases annually. Approximately 2/3 of adults are affected by mechanical Low Back Pain at some point of their lives. Many cause of mechanical low back pain exist. The most common cause are, age-related degenerative disc and facet process, muscle or ligament related injuries.6

Physiotherapy is the first line treatment for Mechanical Low Back Pain. The physiotherapy treatment for mechanical low back pain often involves a wide range of techniques including Heat-therapy, Ultrasound therapy, Massage, Mobilization, Exercise and Education about Posture and Body Mechanics.7

Stabilization and strengthening of the lumbar spine through stabilization program is an important part of Rehabitation Program for the Low Back Pain subjects.8

Recent researchers has suggested that exercises designed to strengthen trunk muscles ( core stabilization) can effectively treat mechanical low back pain and help reduce future problems to the low back. Core stability is the name given to the strengthening of the corset of muscles surrounding the back and abdomen. These muscle are also known as the ‘core’ or ‘Power house’ muscles and provide a solid base upon which all other muscles can work upon to initiate movement. A Comprehensive Strengthening Program of these core muscles can be used for injury prevention, Rehabitation and performance- enhancement.9

Yoga is a science of right living and it works when integrated in our daily life. Practiced for more than 5000 years, yoga is one of the oldest forms of healing therapy. The amazing results of yoga exercises for back pain are now being studied by scientists all over the world.10

6.1 NEED FOR THE STUDY

Low Back Pain is the most common and most expensive cause of work-related disability in the United States. Because bio-mechanically the movements of Lumbar Spine consists of the cumulative motions of the vertebrae with 80-90% of Lumbar spine flexion and extension occurring at L4-L5 or L5-S1 Intervertebral disc Level.11

More than 80% of all adults will experience spinal pain at some point of their lives. It has been estimated that in 90% of these cases, the cause of the pain is simply muscular termed a mechanical low back pain.12

Mechanical low back pain is the most common and most expensive cause of work related disability in the United States. A significant number of patients are unable to return to their normal daily routine or function in a productive work environment secondary to mechanical Low Back Pain.

By2030, 65 million people (20% of total population of US) will be affected by musculo-skeletal impairments, with back pain, ranking among the most common problems in the world. Already, total direct and indirect cost for the treatment of Low Back Pain are estimated to be $ 100 billion annually.13

Mechanical Low Back Pain exist in every culture and country. A mechanical low Back Pain affects more than 70% of the population in developed countries and poses a major socio-economic burden, accounting for 13% of sickness absences in the United Kingdom.14

Thanks to medical advances and technology there are now numerous treatment options for the people who suffer from back pain. But just as each patient is an individual, not all options are available or appropriate for everyone.15

Among the numerous methods of rehabilitation, selecting the comprehensive, cost effective, appropriate rehabilitation rationale to bring back

the patients in to the normal as soon as possible is the uphill task for any physical therapist.

Over the past few years, the number of individuals found lacking sufficient core strength has propelled core stability to the fore front of recognized contributors of lower back pain. Lumbar core strengthening is an effective way to decrease lower back pain and to help prevent injury. A strong core acts as a foundation allowing to perform daily activities with greater ease and safety. 16 Yoga is an applied science of the mind and body. Yoga itself does not create health, rather it create, an internal environment that allows the individual to become to his own state of dynamic balance or health. Kapalabhati pranayama is the highly energizing yogic abdominal breathing exercise which strengthen the abdominal muscles and adds some advantages to the back strengthening exercises.17

In an effort to find out the comprehensive, appropriate rehabilitation rationale to treat the mechanical low back pain, this study is very much needed to compare the efficiency of standard lumbar core stabilizing exercise against the added efficiency of Kapalabhathi Pranayama along with core stability exercises, because previously there is no proper study reveals the added advantage of kapalbhati pranayama on lumbar core stability exercises.

6.2 OBJECTIVES OF THE STUDY

1. To find out the efficiency of standard lumbar core stability exercises on reducing pain and disability in subjects with mechanical low back pain.

2. To find out efficiency of “Kapalabhati Pranayama” on lumbar core stability

exercises on reducing pain and disability in subjects with mechanical low back pain.

3. To compare the efficiency of standard lumbar core stability exercises vs. “kapalabhati Pranayama” on lumbar core stability exercises on reducing pain and disability in subjects with mechanical low back pain

6.3 HYPOTHESIS

1) Null Hypothesis :

There is no significant difference exists between the efficacies of standard lumbar core stability exercises and ‘kapalabhati pranayama’ on lumbar core stability exercises on reducing pain and disability in subjects with mechanical low back pain.

2)Alternate hypothesis:- There is significant difference exists between the efficacies of

standard lumbar core stability exercises and ‘kapalabhati pranayama’ on lumbar core stability exercises on reducing pain and disability in subjects with mechanical low back pain.

6.4 REVIEW OF LITERATURE

1)Armstrong J et al

Mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the United States accounting for more than 6 million cases annually. Most etiologies of mechanical low back pain are not life threatening; however significant morbidity is associated with chronic low back pain syndromes.18

2) Foresell et al

Muscles supports the spine. A weakness in any of the muscles that supports the spine makes it difficult to maintain proper posture. Poor posture is a common cause of back pain due to muscle strain, especially lower back pain.19

3) Kelsey et al

Mechanical low back pain is the most common cause of work- related disability in persons younger than 45 yrs of age. The life time prevalence of mechanical low back pain in the United States is 60-80%. The prevalence of sessions mechanical low back pain (persisting>2wks) is 14%. 20

4) White et al

Patients with chronic mechanical back pain are treated with a combination of Medications, Physical therapy, and Occupational or life style

modification. The physical therapy is the first line treatment for mechanical low back pain. It includes regular exercises for fitness and flexibility.21

5) Lidstromet et al

Physiotherapists have suggested that the exercises for low back pain that strengthen the core muscles are helpful in increasing stability in the lower back and help to ease lower back pain. 22

6) Thomas E. Hyde et al

The latest craze in exercise program is core stabilization or core training. Core stabilization is aimed at the muscles of the trunk, abdomen, and pelvis. The goal is to improve the motor control, strength and endurance of core stabilization on patients with low back pain. The results show significant difference in the long-term out comes for patients treated with stabilization versus other treatment choices.23

7) Elor H Fydrich et al

The core stability exercises improve the muscular corset around the back and there by reduce the pain and disability. It is important to isolate the exact muscles for the desired effect.24

8) Williams PC et al

Core stability is now used widely for the prevention of injury, to improve balance, co-ordination, speed and power, Core stability reflects the functional activities enabling the muscles and joints to perform at their safest and most effective position.25

9) Hodges pw et al

The study concluded that the stability exercise is an evolving process, and refinement of the clinical rehabilitation strategies is ongoing. The major focus is on core stability programs, motor control and muscle capacity. The clinical efficiency of these approaches is being realized in clinical trials.26

10) Mellin G et al

Core stabilization is more than just a buzz word these days, it is a way of life. More and more trainees, physical therapists and orthopedic specialists are finding that by strengthening and balancing the work of such muscles as the back and hips, their patients can heal long standing back problem. 27

11) Ramdev et al

Of the many wonderful pranayamas that yoga gives us, kaparbhati is one of the much needed breathing exercise practiced overtime, kapalbhati pranayama helps reduce abdominal fat, fight obesity, tone abdominal muscle and bestow core abdominal strength and power. 28

12) Stiles et al

“Kapalbhati pranayama” breathing exercises is an excellent way of maintaining good health and fight disease.29

13) Bijus PE et al

Reliable and valid measures of pain are needed to advance research initiatives. The objective of the study was to assess the reliability of the VAS (Visual Analogue Scale) for measurement of pain. The study concluded that the reliability of the VAS for pain measurement appears to be high. Ninety percent of the pain ratings were reproducible.30

14) Lisa A et al

The study aimed to determine the test-retest reliability of a 0-10 Numerical Pain Rating Scale (NPRS) and a 0-10 cm visual Analogue Scale (VAS) when assessing the pain intensity. The study concluded that these two types of scales are used frequently and favored over other scales because of their ease of administration, time efficiency and positive, Negative test reliability.31

15) Davidson M et al

The aim of this study was to examine 5 commonly used scales for assessing disability in people with low back pain. The measurements obtained with the Oswestry Disability Index and Qubec Back Pain Disability scale were the most reliable and had sufficient width scale to reliably detect improvement or worsening in most subject.32

7.MATERIAL AND METHODOLOGY

7.1 Source of data

*Shridevi hospital, Tumkur. *Govt.District Hospital, Tumkur.

7.2 Method of data collection

7.2.1 Sampling design: The samples are selected by using Purposive Random Sampling Technique.

7.2.2 Study size:

Comparative study with pre test and post test design.

7.2.3 Sampling size: The sample size consists of 40 subjects with mechanical low back pain. They were assigned into two groups. Experimental group-1 Consists of 20 mechanical low back pain, to be treated with standard lumbar core stability exercise.

Experimental group-2

Consist of 20 mechanical low back pain subjects, to be treated with “Kapalabhati Pranayama” with lumbar core stability exercise.

7.3 Selection Criteria

(A) Inclusion Criteria

*Subjects with mechanical low back pain. *Both genders. *Age group of between 30-50 years. *Co-operative subjects. *subjects willing to participate.

(B)Exclusion criteria

*Low back pain with other than mechanical origin. *Age group of less than 30 yrs and more than 50 yrs. *subjects with heart disease. *Hypertensive subjects. *Subjects with hernia. *Subjects with asthmatic attack in progress.

* Unwilling subjects * Subjects with mental illness.

7.4 Duration of the study

20 days duration for each subjects.

7.5 Measurement tools

*Visual Analogue Scale (VAS) *Numerical Rating Scale *Oswesty Disability Index

Procedure:- After checking the inclusion and exclusion criteria, 40 subjects with mechanical low back pain were selected randomly and assigned into two groups with 20 subject each. The experimental group-1 consists of 20 mechanical low back pain subjects to be treated with standard lumbar core stability exercises. The experimental group 2 consists of 20 mechanical low back pain subjects to be treated with lumbar core stabilization combined with “kalpalbhati pranayama”.

After getting informed condent, a brief introduction about the treatment procedure to be explained to all the subjects. Before starting the treatment procedure, both the group to be evaluated for pain and disability by using Visual Analogue Scale, Numerical Rating Scale and Oswesty Disability Index.

TREATMENT PROCEDURE FOR EXPERIMENTAL GROUP-1

STANDARD LUMBAR CORE STABILITY EXERCISES

Core stability is the name given to the strengthening of the corset of muscles surrounding the back and abdomen.

These muscles are also known as the ‘core’ or power house muscles and provide a solid base upon which all other muscles can work upon to initiate movement.

A comprehensive strengthening program of these core muscles can be used for injury prevention, Rehabitation and sports performance-enhancement.

The core can be through of as a cylinder of muscles around the inner surface, of the abdomen. There are 4 main muscle groups considered

(1) Transverse Abdominus(2) Multifidus(3) Diaphragus(4) Pelvic floor

There are 3 main stages to attaining a strong core.

Stage-1: Independent cone contractionStage-2: Integrated focused core exercises.Stage-3: Incorporative into functional activities.

LUMBER CORE STABILITY EXERCISE PROGRAMME

1) Independent Core Contraction

This is the first stage of core stability exercises and sets the stage for all subsequent strengthening techniques.

Core contraction- Technique –(1) Core contraction- Technique –(2) Core contraction- Technique –(3)

Choose one of these techniques and practice.

2) Beginners core exercises Fort list

Knee extension Single leg fall-out Hip Flexion Side fall-out

3] Intermediate exercises Mini bridge Single leg stretch Front lift Toe positing Hip flexion with knee extension

4] Advanced exercises Medium bridge Side-kicks Abduction Front crawl Plank exercises

TREATMENT PROCEDURE FOR EXPERIMENTAL GROUP-2

LUMBAR CORE STABILIZATION COMBINED WITH “KAPALABHASTI PRANAYAMA”.

Kapalabhati Pranayama.

(Cleansing Breathing Exercise) Kapal- Forehead (Sanskrit)

Bhati- Shining.

Practicing kapalbhati on regular basis leads to shining face with inner radiance. Kapalbhati is highly energizing abdominal breathing exercise. In kapalabhati we do quick exhalation and natural inhalation. Normally exhalation takes ¼ of the time of initialization. Quick exhalation and natural inhalation follow each other.

Steps

1) Sit in comfortable crossed leg position with back straight. Hands resting on knees in either chin or gyana mudra. Face to be released.

2) Inhale deeply through both nostril, expanding abdomen and exhale3 with the forceful contraction of abdominal muscle.(pull the abdomen in by quickly contracting the abdominal muscle and exhale through the nose). The air is pushed at of lungs by contraction of the diaphragm.

3) After exhalation again inhalation but inhalation should not involve any

effort. To inhale just relax and the lungs will automatically expand and filled with air. One can begin with 15 respiration .After completing 15 quick exhalation and natural inhalation , inhale and exhale deeply. This is one round. One can start the practice of kapalbhati pranayama with 3 such rounds for practice. (3 -5 sessions per day ; 10-15 min per session)

Benefits

1) Kapalbhati cleanses the lungs and entire respiratory system.2) The blood is purified and body gets an increased supply of O2 to all

cells.3) Digestion is improved.4) Abdominal muscles are strengthened.5) Prepare the mind for medication.6) Energize the mind for mental work.

Both the groups to be given 2 sessions of treatment per day. For each session 30-50 minutes of lumbar core stability training to be given to be given to each subjects.

Statistical Test:-

Statistical tests to be used for data analysis are 1) Mean, standard deviation2) Paired and unpaired t- test 3) Wilcoxon’s Test4) Man- Whitney Test.

7.7 Does the study require any investigations or interventions to be conducted on patients or other human or animals/ If so please describe briefly.

Yes, this study requires interventions like lumbar core stability exercises and “kapalabhati Pranayama” Yogic exercises to be given to subjects with mechanical low back pain.

7.8 Ethical Clearance

The study will be conducted after the approval of research committee of the college .Permission will be obtained from the head of the institution The purpose and details of the study will be explained to the study subjects and assurance will be given regarding confidentiality of the data collected.

8. LIST OF REFERENCE:-

1. Basmajan JV: Low Back Pain and spasm: a controlled multicenter trial of treatment regimens, Spine 14:438,1989

2. Cherkin D, Deyo R : Evaluation of a physician education intervention to improve primary care for low-back pain.2. Impact on patients, Spine 16:2273, 1991.

3. Deyo RA, Non- operative treatments of low back pain disorders: The Adult Spine: Principles and Practice, New york,1991.

4. Dimaggio A, Morney A: conservative core for low back pain: What work? J.musculoskeletal med, P.65.Dec, 1987

5. Frymoyer Jw: Predicting disability from low back pain, clinical orthop 279: 102, 1992

6. Nactemson A: Natural history of low back disorders: The adult spine: Principles and Practice, New York, 1991

7. Kellett K, Nordholom L: Effects of an exercise program on sick leave due to back pain, Phys therapy 71:283, 1991

8. Robison R: The new back school prescription: Stabilization Training, part-1. Spine State Art Rev 5:341, 1991

9. Syms J: Stabilization training can help your back patients gain control, Back Pain mm 8:101, 1990.

10) Patricia: Kapalabhati pranayama: Benefits of Breathing exercises, Feb-13:2009.

11) Mckenzie R. Prophylaxis of mechanical low back pain. Newzealand med. Jomnd, 1979;76;484-492.

12) Oriyes-perez.s, Alonso M: mechanical low back pain- prevention. The internet journal of Neurology. 2008; vol-9, No-2.

13) Mom’s R; Allen k : chronic mechanical low back pain strategies for intervention; J. American Academy of Physicians Assistants July 1, 2004, mora.

14) Debra.G. perina,MD; Back pain, mechanical, e-medicine, Dept of Emergency Medicine, University of Virginia Health Science centre July 16, 2009.

15 Vest MD: Rehabitation and Exercise for a Health back, J. Physical therapy, Spine health 1982 :(2) 86-95.

16) Jaime Gozman, Rosmin Esmail: Multidisciplinary Rehabitation for chronic low back pain: Systemic review. BMT 2001; 322:1511-1516 (23 June)

17) Suboth Gupta: Kapalabhati pranayama My yoga online.com. Jan 24; 2007.

18) Armstrong J: Lumbar disc Lesions, ed1, London, 1958, E & R Livingston CTD.

19) Forrsell: The back school, spine 6:104, 1981.

20) Kelesey JL: An epidermiologic study of lifting and twisting on the job and risk for PIVD; J orthop Res 2:61, 1984.

21) White A , Matmiller A : Back school and other conservative approaches to low back pain, St. Lowis,1983, Mosby. Year book

22) Lidstorm A, Zachrission R: Physical therapy of low back pain. J. Rehab. Med. 1970

23) Thomas E. Hyide, DC: Core body strength exercise; J. physical therapy, Spine Health: 1982(2) 115-127.

24) Flor H, Fydrich T, Efficiency of Multidisciplinary pain treatment centres: a meta-analytic review. Pain 1992:49:221-231

25) Willians PC: The lumbosacral spine, emphasizing conservative management, New York, 1965, mc Gnaw-Hill.

26) Hodges PW, University of Queensland, Bribane: Core Stability Exercise in chronic low back pain; orthopedic clinical North Am 2003 Apr; 34(2):245-54.

27) Mellin G. A controlled study on the outcome of core stability training of Low back pain. Part -4 . Long- term effects on physical measurements. Scand J Rehabitation med 1990;22:189-194

28) Ramdev B: Practice of Pranayama- an overview; Text book of yoga; Jaypee. 2001(1): 23-46.

29) Stiles,mukunda and Rydes; structural Yoga Therapy :Physical exam manual, 2004

30) Bijivr PE: Reliability and validity of Visual Analogue Scale (VAS) J.phy. med, 2009.

31) Lisa A; Moran; Reliability pf two commonly used pain scales; Journal of Geriatric Physical Therapy, 2002

32) Davidson M, PT, Keating Jc, Comparison of five low back disability questionnaires: Reliability and Responsiveness. American Journal of medical Quality, Nov 1, 2009: 24(6).

9 Signature of the Candidate

10.

Remarks of the Guide

11.Name and Designation of (in block letters)

11.1. Guide

11.2. Signature

11.3. Co-guide (if any)

11.4. Signature

11.5. Head of the Department

11.6. Signature

12.12.1. Remarks of the Chairman and Principal

12.2. Signature