Vol 3 | Issue 2 | May - Aug 2015 | page:27-30 | Anupama Thakur, Ravinder Kaur Mahapatra.

Author: Anupama Thakur[1], Ravinder Kaur Mahapatra[1].

[1] Department of Musculoskeletal Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, ShivajiNagar, Pune - 411005, Maharashtra.
Institute at which research was conducted: Sancheti Institute of Orthopaedics and Rehabilitation, Kamla Nehru Hospital.
University Affiliation of Thesis: Research Hypothesis (Synopsis) submitted for MPTh Registration to Maharashtra University of Health Sciences (MUHS), Nashik.
Year of Acceptance: 2014.

Address of Correspondence
Dr. Ravinder Mahapatra
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, ShivajiNagar, Pune - 411005, Maharashtra.
Email: drravinder82@gmail.com

 Abstract

Background: Lumbar radiculopathy is a benign, often self-limiting condition, commonly managed by rest, pharmacotherapy, physical therapy or alternate medicine options. It is characterised by low back pain radiating into one or both lower limbs. Conventional physical therapy comprises electrotherapeutic devices, hot water fomentation and standard spinal exercises. Studies carried out in patients diagnosed with chronic low back pain reveal inhibition of the multifidii and transversus abdominis muscles. Some studies direct the probable causes of radicular symptoms towards adhesions along the mechanical interface of neural tissue, or presence of a positional fault at the corresponding vertebral level. In conjunction to electrotherapy, various methods of manual therapy are known to help alleviate pain, ie, mobilising the vertebra involved, or correcting pathomechanics of the neural tissue. However, studies establishing their effectiveness are scarce.
Purpose of the study: To assess which of the two methods of manual therapy- Mulligan's Spinal Mobilization With Leg Movements (SMWLMs) and Shacklock Neural Tissue Mobilization (NTM) is more effective in improving low back pain (VAS), radiating limb pain (SLR), lumbar spine stiffness (lumbar range of motion assessment with a dual inclinometer) and disability (ODI) in patients with Lumbar Radiculopathy.
Method: A Randomised Controlled Trial will be performed on 102 patients with lumbar radiculopathy. Both groups will receive conventional treatment in the form of hot packs, Lumbar core activation exercises and ergonomic advice. In addition, Group A will receive Mulligan's SMWLMs and group B will receive Shacklock NTMs, through randomised sampling by chit method. 3 sessions will be carried out in the first week on alternate days followed by two days in the next week, on alternate basis. At the end of 2 weeks, the follow-up assessment will be documented. A home-based exercise program will be given for further strengthening of the lumbar core stabilizers for the next two weeks and the patients must be assessed again at the end of 4 weeks. Outcome measures included Visual Analog Scale scores, Lumbar range of motion (ROM) assessment using dual inclinometer, Goniometric measurement of angle of the Straight Leg Raise and Oswestry Disability Index.
Results: Both groups show a significant improvement in VAS, spinal ROM, SLR range and ODI scores. However, SLR improves to a greater degree in the SMWLM group. Inter-group comparison of ODI scores will not show significant difference. Group A shows consistent pain relief on follow up at the end of 4 weeks.
Conclusion: Patients treated with Spinal Mobilization with Leg Movement technique produce more significant improvement than those treated with Shacklock Neural Tissue Mobilization in leg pain intensity, lumbar range of motion and back specific disability.
Keywords: Shacklock Neural Tissue Mobilization, Mulligan Spinal Mobilization with Leg Movement, Lumbar Radiculopathy, low back pain.

Introduction

Low back pain is neither a disease nor a diagnostic entity of any sort. In India, the incidence of low back pain has been reported to be 23.09% and has a lifetime prevalence of 60-85%.[4],[5] Causes of lower back pain are numerous, with or without accompanying radicular symptoms, constituting idiopathic, degenerative, traumatic, inflammatory, congenital, neoplastic, metabolic, postural and gynaecological, rectal or rectal systemic pathologies.[6] Lumbar radiculopathy may be described as pain originating in the lower back region, and radiating into one or both lower limbs. It usually follows a specific dermatomal distribution, indicating the level of spinal nerve root involvement. Sensory symptoms are pain, typically accompanied with paraesthesias, numbness; motor symptoms include muscle weakness, reduced deep tendon jerks. The pain may demonstrate multiple pathogenesis. Degenerative spondyloarthropathies form the principal underlying cause of radicular symptoms [1], [2] due to disc herniations, and facetal hypertrophy that may compress the nerve root at the lateral foraminal exit[3]. Other causes constitute idiopathic, traumatic, inflammatory, congenital, neoplastic, metabolic, postural and gynaecological, rectal or rectal systemic pathology[6]. Lumbosacral radiculopathy secondary to disc herniation forms one of the most common health related complaints[7]. Lumbar disc herniation with radiculopathy may be defined as localized displacement of disc material beyond the normal margins of the intervertebral disc space resulting in low back pain, and/or weakness, paraesthesiae or numbness in a myotomal or dermatomal distribution[5] . Sciatica refers to radiculitis or radiculopathy of the lumbosacral spine. The Mulligan concept has its foundation built on Kaltenborn's principles of restoring the accessory component of physiological joint movement. Mulligan proposed that injuries or sprains might result in a minor positional fault to a joint, thus altering the biomechanics at the joint, causing restrictions in physiological movement. Mobilization of the spine maybe done in the functional, weight bearing position by applying the force parallel to the spinal facet planes. It maybe oscillatory (Natural Apophyseal Glides- NAGs) or a sustained glide maintained coupled with the patient performing the offending spinal movement (Sustained NAGs- SNAGs). In 1990, Brian Mulligan introduced a technique known as: spinal mobilisations with limb movements (SMWLMs). Here, a sustained transverse glide is applied to the spinous process of a vertebra while the restricted peripheral upper or lower limb movement is performed, actively or passively. The foremost emphasis remains that the mobilization must result in symptom-free movement. Mulligan proposed that utilization of these mobilization techniques was indicated when peripheral joint limitation of movement is spinal in origin[8]. Neuromobilization is a set of techniques designed to restore plasticity of the nervous system, it may be defined as the ability of the nerve, its sheath and structures surrounding it to shift in relation to other such structures[7]. The goal of mobilization is to increase the flexibility of collagen that maintains the integrity of the nerve, thereby improving movement of the nerve in relation to its interface. Shacklock's method of Neurodynamics is based on The Sliding Principle, which consists of an alternation of combined movements of at least two joints, wherein one movement lengthens the nerve bed thus increasing tension in the nerve, while the other movement decreases the length of the nerve bed which unloads the nerve, keeping it in its slack position thereby reducing intraneural pressure. These techniques aim to mobilise a nerve with a minimal increase in tension and are thought to result in a larger longitudinal excursion than techniques which simply elongate the nerve bed, such as tensioning techniques[8]. Conventional method of treatment of low back pain with lumbar radiculopathy involves rest, pharmacotherapy in the form of NSAIDs, and physical therapy using a combination of intermittent lumbar traction, core stability exercises, TENS, superficial and deep heating modalities, manual therapy, neural mobilization principles, orthotics, ergonomics etc.[9] However, not always are these methods directed towards treating the primary cause of sciatica and the patient usually returns with residual symptoms.
Neural tissue mobilization targets breaking adhesions in the structures present along the course of the nerve, at the mechanical interface, thereby improving the gliding of the nerve by eliminating the cause of symptom-causing obstruction; while the Mulligan concept involves correcting the positional fault at the spinal level along with performing the offending physiological movement (here, the Straight Leg Raise). The clinical appropriateness and effectiveness of this technique is based on the immediate reduction in pain and increase in mobility[10]. Studies have been conducted to prove the significance of neural mobilization in treating patients with radiating neural symptoms. The Straight Leg Raise (SLR) test is a useful tool in assessing severity of symptoms. Improving the range of SLR has a beneficial effect in alleviating sensory symptoms, thereby restoring normal physiological spinal movements and reducing the degree of impairment due to low back dysfunction.

Need For Study
Studies have been conducted measuring the efficacy of Shacklock NTMs, showing the beneficial effects. However, data regarding the effects of SMWLM is scarce. This study aims to gain data regarding the effectiveness of Mulligan SMWLM and to obtain a comparison between the effects of the both techniques, thereby providing clinical therapists an evidence-based better choice of treatment.

Hypothesis

The study aims to assess and compare the effects of neurodynamics, and spinal mobilization with limb movement on the pain, lumbar spine range of motion, and level of disability of a patient diagnosed with lumbar radiculopathy, so as to draw a conclusion, regarding which technique yields better alleviation of symptoms and improves function It is hypothesized that there will be a difference in results of both treatment techniques, one yielding better outcomes than the other.  In this study, subjects will be screened as per the inclusion and exclusion criteria and allocated in either Group A or B using chit method of randomisation.
Group A: Spinal Mobilization With Leg Movement (SMWLM) & conventional therapy.
Group B: Shacklock neural tissue mobilization (NTM) & conventional therapy.
Pre-treatment evaluation will be carried out on the first day. A follow up evaluation will be done at the end of one week, two weeks and four weeks.
The data obtained will be recorded and statistically analysed with the Repeated Measures ANOVA test for SLR and spinal mobility readings; and Friedman's ANOVA test for VAS and ODI scales within each group. The Unpaired 'T' test will be used to analyse SLR and spinal mobility readings; Mann Whitney U test for VAS and ODI readings, for inter-group comparison.

Technique for Mulligan SMWLMs: 2 therapist method.
Let us assume, on evaluation, there is an L4-5 lesion with symptoms in the right leg.
The patient is taken in left side lying position.
The affected leg is abducted to approximately 10 degree and supported by the second therapist or an assistant.
The therapist places the thumb on the right side of the L4 spinous process and applies a downward glide, causing side flexion at that level, and rotation on the vertebra below.
The patient performs an active leg raise simultaneously. The motion must be pain free. As progress occurs, overpressure maybe applied. [11]
DOSAGE: Rule of 3, 3 days a week, for 2 weeks. (Rule of 3, i.e., 3 sets of 7-10 repetitions.)

Technique for Shacklock neural tissue mobilization.
The straight leg raise (SLR) will be done for inducing longitudinal tension as the sciatic nerve.
The leg is lifted upward passively beyond 350, as a solid lever, while maintaining extension at the knee.
To introduce additional traction (i.e., sensitization) into the proximal aspect of the sciatic nerve, hip adduction, medial rotation or ankle dorsiflexion is added to the SLR.
Step 1: Sliders- using unaffected joints (remote sequence, remote sliders); affected area is places in the neutral or symptom free position.
Step 2: Sliders- using unaffected joints (remote sequence, remote sliders); affected area is placed in some range of motion, but without or with minimal symptoms.
Step 3: sliders- move affected area and any other area, but with or without minimal symptoms (remote sequence, local sliders).
DOSAGE: 30seconds-2minutes, 5 sets for 3 days a week, for two weeks.

Conventional therapy.
Hot packs for 10 minutes.
Exercises:
Phase 1
Local Segmental Control. In patients with lower back pain, local core muscles undergo inhibition and are substituted by globalmuscle contraction. The aim of this phase is to reestablish local segmental control of multifidus and transverses abdominis. The therapist will palpate the local muscles to confirm their recruitment.
It includes
Transversus Abdominis contraction with pelvic floor muscle activation with lateral costal diaphragm breathing pattern in supine. Bilateral activation of multifidus with transverses abdominis activation, with controlled breathing.
Phase 2
Closed chain exercises with local segmental control with the patient in crook lying position.
Single leg slide with contra lateral limb supported:
Initially, ask the patient to perform the single leg slide with heel support, progress to single leg slide with the heel 5cms above the plinth.
Single leg slide with contra lateral leg unsupported:
Initially, ask the patient to perform the single leg slide with heel support, progress to single leg slide with the heel 5cms above the plinth.

The patient will be treated in the Out Patient Department for the first two weeks of intervention by superficial moist heat therapy and exercises for 5 sessions, along with SMWLM for group A and NTMs for group B, following the afore mentioned dosage.
Home exercise program for the next 2 weeks will be given to both groups, consisting of core strengthening exercises as per phase 2.

The outcome measures are as follows:
Pain rating using Visual Analogue Scale [VAS].
Hip range of movement (ROM) during SLR using goniometer.
Lumbar spine mobility using inclinometer.
Functional disability scores (Oswestry Disability Index).

Discussion

In SMWLMs group (A), the patients will report reduced pain, on Visual Analog Scale; and improved Lumbar range of motion (ROM), measured by dual inclinometer. In Shacklock Group B, patients will report reduced pain and improved Lumbar ROM. However, in group A, pain relief and improved mobility will be observed in the first follow up (at the end of one week), whereas Group B will obtain pain relief and improved Lumbar mobility by the second follow up (at the end of the second week). Both the findings will remain constant till the end of 4th week, at the third follow up. The pain relief and improved Lumbar mobility obtained in group A can be explained by the following mechanism. Mulligan's technique corrects the positional fault[12] at the spinal level and relieves pain by the neurophysiologic mechanism. A minor positional fault may cause pressure on pain-sensitive structures and the nerve root traversing closely. Mobilization at the spinal level itself corrects this fault and relieves the impingement occurring thereby reducing pain in the low back as well as freeing the nerve so as to relieve the radiating symptoms in the lower limbs. Hence improved VAS may be attributed to this effect. Absence of pain will then lead to improved range of motion in the hypo-mobile segments. Complete evaluation will reveal the following positive results: negative SLR at the end of first, second and third follow up in Group A; as compared to group B wherein SLR will be negative at second follow up (2 weeks). At the end of 4 weeks, SLR remains negative and ODI scores improve to the same extent in both groups. In Group A, where Mulligan mobilization was done, negative SLR may be attributed to the effect of a rotational glide being applied to the spinous process of the affected vertebral segment, that increases the diameter of the canal at that level on the opposite side[13], thereby allowing the nerve to glide freely; due to absence of the mechanical compression that had caused paraesthesia. Shacklock neural mobilization is thought to be effective due to its positive impact on restoring restricted mobility of the nerve, thereby improving neural tissue glide with respect to its interface[14]. Compression, that may cause altered blood flow and axonal transport dynamics within the neural tissue, is relieved due to breaking of adhesions[14], thereby correcting the pathophysiology, hence relieving pain, radiating symptoms and Lumbar ROM in patients of group B.

Conclusion

In conclusion, SMWLM in conjunction with conventional therapy produces significant improvement in the low back pain radiating to the limb, range of motion and function of the patients. A four week follow up will reveal maintenance of the beneficial effects achieved during therapy.
Shacklock neural tissue mobilization in conjunction with conventional therapy also shows improvement in pain in the low back region and in the lower limb, Range of motion and ODI scores. However Group A will show consistently quicker positive results in pain relief and lumbar mobility as compared to Group B.

Limitations
1. Unadvisable activities (gym, lifting heavy objects) carried out at home in spite of ergonomic advice will not be monitored.

Clinical Implications

The study will provide evidence for the beneficial effects of both Mulligan SMWLMs and Shacklock NTMs as an adjunct to Lumbar core strengthening and afore mentioned conventional therapy. Furthermore, it suggests that Mulligan spinal mobilization produces quicker relief of patient reported symptoms, as compared to neural mobilization. This may assist clinical physical therapists with a clearer approach while handling patients suffering from lumbar radiculopathy.

References

1. Andrew W. Tarulli MD, Elizabeth M. Raynor MD. Lumbar Radiculopathy. Neurologic clinics May 2007 Vol 25 (2):387-405 Neck and back pain.
2. Priya Igatpurikar, Dr. Sona Kolke. Efficacy of maitland's spinal mobilization in lumbar spondylosis with radiculopathy. Indian Journal of Physiotherapy and Occupational Therapy - An International Journal Year : 2013, Volume : 7, Issue : 3
Maher CO
3. 1, Henderson FC. Lateral exit-zone stenosis and lumbar radiculopathy. J Neurosurg. 1999 Jan
4. Sharma SC, Singh R, Sharma AK, Mittal R: Incidence of low back pain in workage adults in rural North India, Medical Journal of India 2003; 57(4):145-147.
5. M. Krismer M. Van Tulder: Low back pain (nonspecific), Best practice and research clinical rheumatology 2007; 21(1):77-91.
6. Patricia A Downie (FCSP): Cash's textbook of orthopaedics and rheumatology for physiotherapists, 1st Indian edition 1993.
7. Ibrahim M Moustafa PT, PhD and Aliaa A. Diab, PT, PhD. The effect of adding forward head posture corrective exercises in the management of lumbosacral radiculopathy: A randomized controlled study. Journal of Manipulative and Physiological Therapeutics.
8. Linda Exelby. The Mulligan Concept: Its application in Management in Spinal Conditions. Manual Therapy (2002) 7(2), 64–70
9. F Ellis and Wayne A Hing. Neural mobilization, The Journal of Manual and Manipulative Therapy. Volume-16, no-1(2008), 8-22.
10. Mulligan BR. Manual Therapy. “nags”, “Snags”, “MWMs”, etc 4th edition. Pgs 44-45.'
11. Mulligan Brian R., Spinal Mobilisations with Leg Movement, The Journal of Manual & Manipulative Therapy, Vol. 3 No.1 (1995), 25-27
12. Vincenzino et al. Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature, Manual Therapy 12 (2007) 98–108
13. Maitland GD. Vertebral manipulation. Butterworths- Heinemann. 1986.
14. Sarkari, E. and Multani, N.K. Efficacy of Neural Mobilisation in Sciatica. Journal of Exercise Science and Physiotherapy, 3(2): 136-141.

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Vol 3 | Issue 2 | May - Aug 2015 | page:23-26 | Bhakti Jamdade V, Apurv Shimpi, Savita Rairikar.

Author: Bhakti Jamdade V[1], Apurv Shimpi[1], Savita Rairikar[1].

[1] Department of Community Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, Thube Park, Shivaji Nagar, Pune, Maharashtra,India.
Institute at which research was conducted: Sancheti institute College of Physiotherapy, Thube park, Shivajinagar Pune 411005, Maharashtra.
University Affiliation of Thesis: Research hypothesis (synopsis) submitted for mpth registration to maharashtra university of health siences (MUHS), Nashik.
Year of Acceptance: 2015.

Address of Correspondence
Dr. Apurv Shimpi
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, Shivaji Nagar, Pune - 411005, Maharashtra.
Email: apurvshimpi@sha.edu.in

 Abstract

Background: Low back pain is a leading cause of disability and it occurs in similar proportions in all the sectors of working as well as non-working population. It also interferes with quality of life and work performance, and is the most common reason for medical consultations. Work related musculoskeletal disorders especially low back pain leads to substantial economic losses to individuals as well as community. In industrial population various factors like postural deviations, core strength, flexibility and psychosocial aspects are responsible for low back pain. There has also been a high prevalence of low back pain reported in the automobile industry. Although studies have been done to find the etiological factors for low back pain in industrial workers, but there is a dearth of literature in understanding the factors which have a high impact in development of low back pain and the relationship of these factors to the severity of the dysfunction present in this population. Thus, it becomes important to know which are the major factors leading to low back pain and other causative factors for postural deviations which in turn are leading to low back pain in automobile industrial sector. Present study hypothesized that various factors like work postures, core muscles strength, and flexibility of the workers have a major influence on the presence of low back pain in automobile industry workers in a varied proportion. 300 workers from automobile industry will be assessed using the outcome measures like core strength, flexibility, Rapid entire body assessment for high risk postures at work and Nordic musculoskeletal questionnaire for pain analysis. Statistical analysis will be done by Spearman's Correlation coefficient with alpha set at p<0.05.
Clinical importance: The assessment of the factors which contributes maximally to work related low back pain can help target the specific line of management while treating this patients and also prevention of those factors which are leading to low back pain in industrial workers.
Future research: On the basis of this factors contributing to work related low back pain in industrial workers a specific exercise protocol can be designed to minimize the disability and help them to cope up with increasing work demands. Also various environmental factors and psychological factors can be considered.
Keywords: Low back pain, musculoskeletal disorders, automobile workers.

Introduction

Low back pain is neither a disease nor a diagnostic entity of any sort. The term refers to pain of variable duration in an area of the anatomy afflicted so often that it is has become a paradigm of responses to external and internal stimuli [1]. Low back pain is an important public health, economic and social problem. It is a disorder with many aetiologies occurring in different age groups and it is also a common health condition in working population as well as non working population [2]. International surveys of low back pain report a point prevalence of 15–30%, and a 1-month prevalence of between 19 and 43% [3]. Worldwide estimates of lifetime prevalence of low back pain vary from 50 to 84% [2-6]. Back pain leads to high cost for individual, the workplace and society. The prevalence of low back pain is high among industrial workers [7,8]. The working environment may be hazardous and stressful [9,10]. Work schedule and the design of the working environment can lead to errors and accidents [11,12]. Several occupational injuries exist such as musculoskeletal injuries (MSIS), spinal disorders, gas burns, scalds, and respiratory complications [12]. MSIS are among the major occupational hazards facing the working population today, especially among the working class. Burdorf, Rossignol, Fathallah, et al reported that 80% of the adult working population, would experience back pain sometime during their active life because of their nature of work, which requires heavy physical work, awkward posture, or prolong periods in one posture [13]. In occupational health, the type and severity of spinal complaints have high relationship with workload [14,15]. In automobile industries, certain activities like manual handling of weights, lifting, pushing or pulling weights or heavy objects are co related with low back pain [16].There have been several studies done which confirm that manual handling of heavy objects in industries lead to spinal complaints [17-21]. In most of the automobile industries manual handling of weights, lifting, pushing or pulling of heavy object are constant part of work among workers in production part especially [22]. Several studies have reported incidence and prevalence of musculoskeletal disorders in industrial workers of which low back pain is reported much higher [17-21]. Many studies include various etiological factors for this low back pain like constant physical activity, reduced flexibility and core strength and also psychosocial factors [23]. Additional data on various factors predisposing to work related low back pain is very important for health promotion programmes. The main focus is to identify the work related factors for low back pain among industrial workers. This kind of knowledge is important for different levels from patients to employees, health professionals and clinical settings and finally for public health policy workers.

Hypothesis

Low back pain (LBP) is one of the most significant medical and socioeconomic problems in modern society [24]. The main predictors of back pain include physical stress (e.g., prolonged lifting, driving, forceful or repetitive movements involving the back). Low back pain prevalence is related to the type of occupations such as driving, manual handling and occupations that involve a lot of improper body movements [25]. Work-related physical exposures, especially heavy lifting and manual materials handling, working in awkward postures, and whole-body vibration, are well established risk factors for LBP [25-26]. Low back syndrome, although self-limiting in most cases, leads in a small percentage of patients to chronic problems that can be very costly to manage, and those cases that resolve are prone to recurrence at a rate of up to 90% [27]. The main risk factors for low back pain among production workers were extreme trunk flexion, as well as lifting of loads, pushing or pulling heavy loads and exposure to whole body vibration. Thus it becomes important to assess the various factors like work posture, core muscle strength and flexibility which influence the presence of low back pain in automobile industry workers and also to find the maximum extent to which this various factors influence the low back pain among industrial workers. This study is based on the hypothesis that some of the factors like core strength, high risk work postures and flexibility; causing work related low back pain industrial workers contribute more than the other factors to cause symptoms and disorders in automobile industry workers. To meet this purpose, an analytical cross sectional study will be conducted, the approval for which has been obtained from the institutional review board. The sample will be collected from an automobile industry that has an incidence report of low back pain as per the records available in the occupational health centre of the concerned industry by convenient sampling method. On the basis of incidence report of low back pain in past 1 year sample will be recruited. Workers working for more than 6 months in industry and having low back pain since 1 month within the age group of 20 – 50 years will be recruited in the study; this is done to eliminate the potential confounders in the study. Workers with any surgical intervention, diagnosed as prolapsed intervertebral disc or pain due to any metastatic or infective origin will be excluded from the study. The data collection, assessment and analysis shall be done as per STROBE statement guidelines. Study will include all the population of the workers having low back pain in the past 1 year. Factors like core strength, flexibility, postural analysis at work place and pain intensity will be assessed. Core strength will be assessed using pressure biofeedback device, flexibility will be assessed using sit and reach test, and postural analysis will be using rapid entire body assessment (REBA) with a photographic method. Pain intensity, severity and location will be assessed using Nordic musculoskeletal questionnaire (NMQ). Statistical analysis will be done by Spearman's Correlation coefficient with alpha set at p<0.05.

Discussion

Work related musculoskeletal disorders (WMSDS) continue to be a major source of disability and lost work time. Low back pain is not a disease but a constellation of symptoms that usually is acute or self limiting. A combination of physical, psychological and psychosocial workplace risk factors have been documented to be responsible for low back pain. Physical risk factors such as high forces, high repetition, and working with arms overhead, long-term static postures, local contact forces and vibration have been commonly identified [28]. Various intrinsic and extrinsic factors are responsible for the low back pain in industrial sector. Noor Sazarina Mad Isa et al (2014) conducted a study in automotive industry workers in Selangor to evaluate the prevalence and the risk factors of low back pain which included work postures and physical activity [29]. The study concluded that occupational risk factors mainly physical demands were significant risk for low back pain among manual material handling workers. This study included only the sustained work posture and physical demands of the manual material handling workers. Jonathan L Vandergrift et al (2011) conducted a study to examine the association between occupational physical and psychosocial ergonomic risk factors and low back pain. The study concluded that exposure to awkward back postures and hand force exertion in automotive industry increased the risk of low back pain also observed the impact of psychosocial work environment on risk of low back pain [30]. Murtezani A et al (2011) conducted the study to determine the prevalence of low back pain (LBP) in industrial workers, to check for possible low back pain related risk factors and investigate the associations between physical activity and severity of low back pain and concluded that work-related physical factors showed strong associations with low back pain. Above mentioned studies considered the extrinsic factors like physical activity demands of the workers working in automotive industry and its association with low back pain but none of them concentrates on the assessment of the intrinsic factors of the workers which includes core muscles strength, flexibility of the workers and also if the working posture of the worker is at risks, which are also the risk factors for low back pain. So this study concentrates on various intrinsic factors such core muscles strength, flexibility, work postures and pain intensity in the automobile industry population. Industrial workers have to adjust their postures according to the work assembly which includes manufacturing the parts, fixation of various parts, assemble the body, paint shop, quality assurance department. All this assemblies includes bending, twisting the trunk, overhead activities, forward leaning postures, slump sitting, stooping, kneeling, manual handling of weights in awkward positions, pushing or pulling of weights and transfer of which predispose them to be at high risk postures and all this postural deviations equally contribute to low back pain [29]. The core muscle strength is one of the contributing factors for low back pain. The core consists of the abdominal muscles groups (transverse abdomens, internal oblique, external oblique and rectus abdomens), hip abductors/ adductors, hip flexors, the pelvic floor, and lumbar spine. Core stability is important for the maintaining an upright posture and especially for movements and lifts that require extra effort such as lifting a heavy weight from the ground. Without core stability the lower back is not supported and can result in low back pain, poor posture. Workers in automobile industrial have to work in various awkward positions and static postures for long duration with repetition of activities [31]. Mehdi Ghasemkhani et al (2008) discussed that repetitive movements with awkward postures are hazardous when they involved the same joints and muscle groups and when workers do the same motion too often, too quickly and for too long. Manual workers have a static posture of the neck and back. A static posture can produce fatigue because constantly tensed muscles never have an opportunity to recover; thus the potential for discomfort increases [32]. Flexibility is another component that can lead to low back pain. Lack of flexibility in the lower body, particularly in the hamstrings and hip flexors, can cause low back pain [33]. Individuals with LBP commonly present decreased flexibility in the lumbar region, and lower limb muscles which in turn can cause low back pain. Reduced flexibility in low limbs especially in hamstrings and hip flexors due to prolonged sustained positions and lack of stretching leads to low back pain. The hamstrings, when tight, can pull on the pelvis and cause tightness and discomfort in the lower back. Also when hip flexor muscles such as iliopsoas are tight, they tilt your pelvis forward and compress your lower back and cause symptoms of low back pain. Piriformis tightness can also lead to back and leg pain [33].Thus flexibility can be one of the important factors leading to low back pain in industrial population. Thus this study will be concentrating on this various factors leading to low back pain in automobile industrial population and also find the impact of these factors in producing the symptoms and disorders.

Clinical Implication

Systematic study of all the causative factors of low back pain in automobile industry workers will help us to know the impact of core muscle strength, flexibility, and work posture in producing the symptoms of low back pain and also which of these factors contribute maximum in producing the symptoms. This in turn can help us to formulate a structured protocol for the treatment of such complaints which will target the specific factor leading to low back pain. Also various preventive measures can be taken to reduce the prevalence of low back pain in this population by taking extrinsic and intrinsic factors into consideration. Various motivational and informative lectures, group activities to maintain the flexibility, strength and endurance of muscles and training of manual material handling can be undertaken.

Future Direction

Specific exercise protocol can be designed for this population considering the factors that is maximally responsible for producing the symptoms. Various other factors like psychosocial and environmental factors can also be taken into consideration.

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Vol 3 | Issue 2 | May - Aug 2015 | page:19-22 | Shreya Shah, Ravinder Kaur Mahapatra.

Author: Shreya Shah[1], Ravinder Kaur Mahapatra[1].

[1] Department of Musculoskeletal Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, Thube Park, Shivaji Nagar, Pune, Maharashtra, India.
Institute at which research was conducted: Sancheti Institute of Orthopaedics and Rehabilitation.
University Affiliation of Thesis: Research Hypothesis (Synopsis) submitted for MPTh Registration to Maharashtra University of Health Sciences (MUHS), Nashik.
Year of Acceptance: 2015.

Address of Correspondence
Dr. Ravinder Mahapatra
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, ShivajiNagar, Pune - 411005, Maharashtra.
Email: drravinder82@gmail.com

 Abstract

Background: Anterior cruciate ligament (ACL) injury is the most commonly seen knee ligament injury during sporting or recreational activities causing severe functional problems. Injury to ACL causes balance disorders due to proprioceptive dysfunction and mechanical instability at the knee. Altered neuromuscular control of the hip and knee joints and deficits in postural stability increases the risk of re-injury after ACL reconstruction. Therefore, enhancement of the neuromuscular control of the knee after ACL reconstruction is suggested by the prescription of balance and proprioceptive exercises which will reduce the risk of re-injury and lead to better results in terms of return to the functional activities.Different techniques for improving balance in these patients include the conventional balance training using devices like therabolt, wobble board etc. However, development of a more effective rehabilitation program which will help to address these deficiencies is required. New technology based technique such as non-immersive virtual reality using Microsoft Xbox Kinect has been proved as a reliable tool in improving balance in neurological cases such as stroke, cerebral palsy, etc.Hence, the objective of this study is to compare the effect of non-immersive virtual reality training and conventional rehabilitation on balance in patients after Anterior Cruciate Ligament(ACL)Reconstruction.
Hypothesis: Non-immersive virtual reality training would be more effective than the conventional rehabilitation for improving balance in patients after anterior cruciate ligament reconstruction
Clinical Importance: Training with Microsoft Kinect Xbox (XbK) will lead to better improvements in balance of the patients after ACL reconstruction. It will help in an early return to the functional activities or sports and will also reduce the risk of re-injury.
Future Research: Non- immersive virtual reality training can be given to the patients with other sport injuries for improving their balance.
Key words: Virtual reality training, Xbox, ACL reconstruction, Balance..

Introduction

Anterior cruciate ligament (ACL) injury is the most commonly seen knee ligament injury during sporting or recreational activities causing severe functional problems [1]. Injury to ACL causes balance disorders due to proprioceptive dysfunction and mechanical instability at the knee [2]. It further compromises the sport and recreational activities. Balance disorders are also seen because of decreased dynamic joint stability and disturbed functional movement patterns. Loss of mechanoreceptors in ACL injury causes altered neuromuscular control in the knee joint [3].  Some authors have evaluated deficits in the neuromuscular control after ACL reconstruction [4]. Altered neuromuscular control of the hip and knee joints and deficits in postural stability increases the risk of re-injury after ACL reconstruction [4].  Activities of daily living and recreational activities require co-ordinated neuromuscular control and sufficient strength in the muscles to perform the functional activities. Therefore, enhancement of the neuromuscular control of the knee after ACL reconstruction is suggested by the prescription of balance and proprioceptive exercises which will reduce the risk of re-injury and lead to better results in terms of return to the functional activities[5]. Development of a more effective rehabilitation program which will help to address these deficiencies is required. New technology-based technique of rehabilitation such as virtual reality training is a technology with opportunities to engage in multidimensional and multisensory virtual environments which appear to be similar to the real events[6]. This approach is based on the assumption that the virtual reality training will lead to corresponding improvement in the participant while performing in the real world. As it provides distraction during the movement tasks, it can be used to restore the joint motion [7].Virtual reality training improves postural control, visuoperceptual processing, functional mobility and static and dynamic balance [8] [9]. Virtual reality training is of two types – Immersive and Non- Immersive. In immersive VR environments, the subjects are fully immersed in and interact with the environment [10]. In non- immersive VR environments, the interaction with the VR environment can occur by key- boards, mice and trackballs or may be enhanced by using 3D interaction devices [11]. However, the non- immersive VR is relatively inexpensive and easily accessible. It can be used as a home rehabilitation program and hence widely used in physical therapy.  Non-immersive virtual reality (VR) based rehabilitation has proved to be effective in improving balance in hemiparetic subjects [12]. VR training with Nintendo Wii gaming system has shown positive effects on balance adjustment in healthy individuals and also in knee ligament injuries [13]. Another example of this non-immersive virtual reality training is Microsoft Xbox Kinect (XbK). XbK is proved as a reliable tool in improving neuromuscular control in neurological cases such as stroke, cerebral palsy, etc.[14][15] [16] [17]. A study was done in elderly population to evaluate the efficiency of two gaming systems such as XbK and Nintendo Wii over the traditional exercise program[18] [19]. The study revealed that the gaming systems were perceived as less strenuous and more enjoyable as compared to the traditional exercise programs. However, with XbK the energy expenditure is more as compared to the other gaming systems. Also, XbK provides a wider base thus increasing the freedom of movement for the individual performing the balance training [19]. Research has shown that an easy access to a facility or equipment is a major factor in compliance to an exercise program [6]. Since, XbK is an easily accessible and relatively inexpensive tool, it can be used for improving balance if proven to be effective [19]. A study has proved the effectiveness of XbK intervention on balance ability in previously injured young competitive athletes over the traditional exercise program [20]. Hence, it is important to compare the effect of non-immersive virtual reality training with the conventional rehabilitation in improving balance in patients after ACL reconstruction.

Hypothesis

Non-immersive virtual reality training has been proven to be effective in improving the balance in patients with neurological disorders [14] [15]. An example of this technology is Microsoft Kinect Xbox (XbK). XbK has been used to improve balance in athletes with chronic ankle instability [20]. Hence, it becomes essential to study the effect of non-immersive virtual reality training on balance and to compare it with the conventional rehabilitation so that it helps to improve the balance and functional status of the patients post ACL reconstruction and enhances an early return to the functional activities and sports, also reducing the risk of re-injury. It is hypothesized that non-immersive virtual reality training would be more effective in improving balance as compared to the conventional rehabilitation in patients after ACL reconstruction. The current research aims at comparing the effect of non-immersive virtual reality training and conventional rehabilitation on balance in patients after ACL reconstruction. A prospective randomized controlled trial will be performed after the approval from the institutional ethical committee. Study would be carried out at a tertiary health care center. The sampling will be done by chit method without replacement. A written and verbal consent will be taken from the participants after screening them for the inclusion and exclusion criteria. The subjects between the age group of 18-35 years, at 6 weeks post ACL reconstruction would be included. The subjects who have undergone ACL reconstruction with meniscus excision or grade I meniscus injury would be included. Subjects should have a 0 to 120-130 degrees of knee range of motion of the affected knee and the strength of the lower limb muscles should be atleast from 3+ to 4 out of 5 on Manual Muscle Testing.  Subjects who have undergone ACL reconstruction with meniscus repair would be excluded from the study as the protocol after the surgery differs from that of the above mentioned inclusion criteria [21]. Also, subjects with fractures in the upper or lower extremities,collateral ligaments injury, traumatic cartilage injury, degenerative changes of the knee joint, injuries or surgical procedure to the opposite leg or any neurological disease would be excluded from the study. Before commencing the physiotherapy rehabilitation, the participants shall be evaluated and demographic data will be collected from each patient that includes age, sex, and occupation, date of the surgery and details of the surgery. The knee range of motion by goniometer and strength of the lower limb on manual muscle testing shall be evaluated to satisfy the inclusion criteria. For the assessment of balance, Y- Balance test would be used [22]. To assess the functional status and activity level of the knee, Modified Lysholm Knee Score and Tegner Activity Level will be used respectively[23]. Subjects will be assessed pre-intervention and after 4 weeks of the training program. The participants will be randomly allocated into two groups- Group A (non-immersive virtual reality training) and Group B (conventional rehabilitation). In group A, participants will be given virtual reality training by the means of Microsoft Kinect Xbox (XbK) and the games included in the study would be River Rush, 20,000 leaks, Reflex Ridge, Rally Ball and Space Pop[20].Progression would be in the form of increase in the difficulty level of the game, for example, basic, intermediate and advanced levels. Each game incorporates different static and dynamic postures which would help in improving the balance. In group B, the participants will be given conventional balance exercises which would include single leg standing on floor and on therabolt and standing on a wobble board [5]. Progression would be in the form of eyes closed while balancing on single leg and ball catch and throws on wobble board.  In both the groups, participants would be given strengthening exercises for quadriceps and hamstring muscles. The progression would be based on the De Lorme and Watkins regimen for progressive resistance training.
After each treatment session in both groups, participants shall be asked for the rate of perceived exertion in order to match the exercise intensity given in both the groups. The Borg category-ratio 10 will be used to assess RPE [24]. . In the initial week, the expected RPE in both groups is 3 (moderate). In the 2nd week, the expected RPE in both groups is 4 (somewhat hard) followed by 5 (hard) and 7(very hard) in the 3rd and 4th week respectively. Post intervention, assessment for balance and functional status of the knee shall be done. The collected data will be statistically analyzed. The within group analysis for Y- Balance test will be done by paired t-test and the between group analysis will be done by unpaired t-test. The within group analysis for Lysholm knee score-Tegner activity scale will be done by Wilcoxan sign rank test and between group analysis will be done by Mann- Whitney U test.

Discussion

Balance and proprioceptive training is an integral part of rehabilitation after ACL reconstruction. Balance training after ACL reconstruction has also shown reduction in the risk of re-injury in the patients [4]. Over the years, the neuromuscular training has been given by conventional balance exercises such as single leg standing, standing on wobble board etc. However, a new rehabilitative technique like non-immersive virtual reality training using the Microsoft Xbox Kinect (XbK) has been proven to be effective in improving balance and level of functional activity in geriatric patients and also in neurological cases. A research studied the effect of Xbox intervention on balance ability of competitive athletes with chronic ankle instability [20]. It was proved that XbK intervention is a valuable, feasible and pleasant method to improve the balance ability in those athletes. In a study on patients with ACL reconstruction, a different mode of non-immersive virtual reality training like Wii Fit Balance Board was used to improve visual-perceptual processing, co-ordination, proprioception and functional mobility [13]. The results showed that the Wii Fit Balance Board training had similar effects on all of the above parameters. In the current research, the balance program used in the XbK intervention would be task driven and would require problem solving. These features of the training have been shown to promote behavioral changes as well as the further changes in the physical abilities in young adults [20]. The improvements in the balance could be attributed to the fact that the Xbox intervention would allow the user to be an active participant in his own learning. Research has shown that for the acquisition of specific motor skills such as balance, the game should encourage intentional learning and should explicitly present and let the player sense the targeted skills through appropriate simulation [20]. The conventional balance training program leads to poor engagement and lack of interest by the patients due to repetitive practice of the same exercises [12]. Studies have shown that Xbox intervention induces a feeling of competitiveness, achievement and interest in the patients, which in turn helps in boosting the self-confidence of these patients [20].  Another reason for the improvement in balance in the Xbox intervention group would be the specificity and frequency of the feedback given by the system about the knowledge of their performance and the knowledge of the result of their actions. Augmented feedback in the form of either knowledge of performance or knowledge of results promotes motor skill learning and also motivates the player [12]. The Xbox adventure games would involve different postures and activities like squatting, side stepping, weight shifting, etc. These games would put greater demands and challenges on the neuromuscular system. Xbox adventure simulation games are effective in favoring the acquisition of the balance ability and their transfer to the real world contexts under certain conditions [20]. The Xbox adventure games would also providean immediate visual feedback of their performance and would empower them with a sense of control over their recovery as they would beengaged in more of a self-practice. Virtual reality training would also provide an additional element of fun and competitiveness which the conventional balance program lacks. In a study done on effect of virtual reality training on balance in older women suggests that virtual reality balance games retrains one's Centre of Pressure in different directions, ranges and speeds frequently and elicits effective ankle and hip postural control strategies to maintain functional mobility [12]. So, the Xbox intervention would also lead to an increase in the functional status of the patient by improving the functional mobility of the knee.
Also, virtual reality training would provide an additional wider base for the patient to perform the exercises as compared to the conventional balance training program which would assist in providing more freedom of movement [19].
Thus, the study hypothesis states that non-immersive virtual reality training would be more effective in improving balance in patients after ACL reconstruction than the conventional rehabilitation program.

Clinical Importance

The use of non-immersive virtual reality training by using Microsoft Kinect Xbox would be effective in improving the balance and the functional status of the patients after ACL reconstruction surgery more efficiently as compared to the conventional balance training program. It will help the patients in an early return to the functional activities or sport activities. Increase in balance will also minimize the risk of re-injury in these patients.

Future direction

Effectiveness of non-immersive virtual reality training should also be determined in other sport injuries and also in competitive athletes to aid in their rehabilitation.

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