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					                  RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
                                  BANGALORE
                                  KARNATAKA

                                 ANNEXURE – II
           PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION



1   NAME OF THE CANDIDATE                         SHYAMLI SHARMA
    AND ADDRESS                                  #158/1 CHANNI HIMMAT
                                                  JAMMU & KASHMIR




2   NAME OF THE                     KRUPANIDHI COLLEGE OF PHYSIOTHERAPY,
    INSTITUTION                                      BANGALORE




3   COURSE OF THE STUDY                    MASTER OF PHYSIOTHERAPY
    AND SUBJECT                         ( MUSCULOSKELETAL AND SPORTS )




4   DATE OF ADMISSION                              15 FEBRUARY 2007
    TO COURSE




5   TITLE OF THE TOPIC:


          EFFICACY OF SPECIFIC STABILIZATION EXERCISES FOR LOW BACK ACHE
    AFTER PREGNANCY.
BRIEF RESUME OF THE INTENDED WORK


INTRODUCTION


             Back pain is common in normal pregnancy and high incidences have been described in
several studies. Apart from classification according to incidence, frequency & intensity, it has been
emphasized that back pain in pregnancy also should be classified as lumbar back pain and/ or pelvic
pain.7,9,2


             The risk of lumbopelvic pain in pregnancy is increased in women with a history of back pain
before pregnancy2,6 & a correlation between menstrual pain & low back pain before and during pregnancy
has been reported.


             Regression of lumbopelvic pain after pregnancy has been described to be incomplete and 10%
to 20% of women with chronic lumbopelvic pain claimed that the initial appearance was in connection
with the pregnancy4. Post partum low back pain has been correlated with high pain intensity during
pregnancy.


             Pregnancy – related pelvic girdle pain occur during pregnancy or within first 3 weeks after
delivery. Lumbar pain during pregnancy originates in the lumbar spine region and is a different syndrome
than pregnancy – related pelvic girdle pain.1,2


             The etiology behind lumbopelvic pain is still unclear, but both biomechanical and/or
hormonal factors are being discussed. The prevalence of back pain 2 to 18 months postpartum is reported
to be from 2% to 65.7,8


             The obvious cause of lower back pain is the biomechanical stress being placed on the mother
by the added weight of body. As the baby gains weight the mother is pulled forward in order to
compensate for this forward pull, the mother has to lean her upper body backward. This puts tremendous
amount of pressure on the back & pelvis.


             Pain commonly occurs because of the postural changes of pregnancy, increased ligamentous
laxity & decreased abdominal functions.3


             Most often the pain disappears within 1 to 3 moths after delivery5,6 however substantial
numbers of women do not recover after delivery, lumbopelvic pain, especially after delivery may be a
serious problem for the individual’s family and society. This is reflected by the inability to perform daily
activities or to earn a living and by a reduced health related quality of life.


             The aim of the present study is to evaluate whether specific stabilization exercises in the
treatment of patient with low back pain after pregnancy reduce the pain, improve functional status, and
improve health- related quality of life after the treatment.


6.1 NEED FOR THE STUDY


             The incidence of low back ache is higher after pregnancy. Low back pain after pregnancy is a
serious problem for individual, her family and society, there is the inability to perform daily activities.


             Thus, the purpose of the intended study is to compare the effect of physical therapy with
stabilization exercises and physical therapy without specific stabilization exercises on low back ache after
pregnancy.


6.2 REVIEW OF LITERATURE


          Pennick VE, Young G (2007)10 in their study found that for women with low back ache
specifically tailored strengthening exercises, sitting pelvic tilt exercise program &water gymnastics
reduced pain better than usual prenatal care alone.


           Rackwitz B, Limmh, Wessels T, Ewert T, Stucki G (2007)11 in their study found that specific
stabilizing exercises can be learnt by majority of the participants of a group program for the prevention of
low back pain. Additionally, specific stabilizing exercise reduces present low back pain and so can help
people with low back pain to help themselves.


           Paulo Hferreira, Manuela, L Ferrerira Christopher G Maher, Robert D Herbert (2006)12
compared specific stabilization exercise plus conventional physiotherapy program [ modalities, spinal
manipulation &ergonomic advice] to a conventional physiotherapy alone for patients with pelvic girdle
pain. When added to conventional physiotherapy program specific stabilization exercises were more
effective than conventional physiotherapy alone


           F. JM Whitman JM, Childs JD (2005)13 in their study found patient with low back pain judged
to have lumbar hypomobility experienced greater benefit from an intervention including manipulation
those judged to have hypermobility were more likely to benefit from stabilization exercise program.
            Inger Halm, Britt Stuge and Ninavollestad (2005)14 in their study found that the
individualized and supervised treatment program focusing on the local system with gradual addition of
exercises for the global system showed better results and a high compliance.


            Havden JA, Van Tulder MW, Tomlinson G (2005)15in their study found that exercise therapy
that consists of individually designed programs, including stretching and strengthening and is delivered
with supervision may improve pain and function in chronic low back pain.


            Elden, Ladforsl, Olsen MF, Ostgaard HC, Hagberg H (2005)16 in their study found that
stabilizing exercise constitute efficient comliments to standard treatment for the management of pelvic
girdle pain during pregnancy.


            Britt stuge, Even Laerum, Gitle Kirkesola and Nina Vallestad (2004)17 in their study found
that after intervention and at one year post partum the specific stabilizing exercise group showed
statistically and clinically significant lower pain intensity, lower disability and higher quality of life as
compared to group without specific stabilizing exercises in women with pelvic girdle pain.


            Stuge, Britt, Veierod, et al (2004)18 in their study found significant differences between the
groups persisted with continued low levels of pain and disability in the specific stabilizing exercises group
2 years after delivery.


            Hides, Julie a, Jull, et al (2001)19 in their study found that long term results suggest that
specific stabilization exercise therapy is more effective in reducing low back pain recurrences than
medical management and normal activity alone.


6.3 OBJECTIVE OF THE STUDY


    a) OBJECTIVES


               To assess the effectiveness of physical therapy with specific stabilization exercises in low
                back ache after pregnancy.
               To assess the effectiveness of physical therapy without specific stabilization exercises in
                low back ache after pregnancy.
               To compare the effect of physical therapy with specific stabilization exercises and
                physical therapy without specific stabilization exercises.
   b) HYPOTHESIS


               NULL HYPOTHESIS: Both physical therapy with specific stabilization exercises and
                physical therapy without specific stabilization exercises are equally significant in
                improvement of low back ache after pregnancy.


               EXPERIMENTAL HYPOTHESIS: There is a significant improvement in low back ache
                after pregnancy with specific stabilization exercises.


MATERIAL AND METHODS


7.1 SOURCE OF DATA:


   (a) POPULATION


                VARIOUS HOSPITALS IN BANGALORE.


   (b) SAMPLE SIZE


                30 subjects of age 25-35 years satisfying the inclusion criteria are selected from the
                 population and randomly assigned in 2 groups.


                            Group 1 – Physical therapy with specific stabilization exercises group(15
                             subjects)


                            Group 2 -- Physical therapy without specific stabilization exercises group(15
                             subjects)


7.2 METHOD OF DATA COLLECTION


   a) SAMPLING TECHNIQUE


                Simple random sampling
b) TOOLS


             Visual Analog Scale20
             Modified oswestry disability scale for low back ache17
             Sorensen test21


c) METHODOLOGY


  I) STUDY DESIGN


               Experimental study


  II) INCLUSION CRITERIA


               Age group 25 – 35 years.
              Complaint of pain in the lumbar spine, buttock and/or lower extremity.
               Pain onset during pregnancy or within 3 weeks after pregnancy
               Lumbar segmental testing for pain provocation.
              Lumbar segmental testing for mobility.
              Gaenslen test positive.
              Compression and distraction test positive.
              Willingness to participate in either of the two groups.


  III) EXCLUSION CRITERIA


              Pregnancy induced hyper tension.
              Preterm labour.
              Maternal heart diseases.
              Low back pain indicating radiculopathy.
              History of asthma.
              Prior lumbar spine surgery.
              History of osteoporosis and spinal fracture.
     IV) PROCEDURE


               The subjects after the preliminary medical assessment by the gynecologist, formal
informed consent obtained and assigned randomly to either the group with specific stabilization
exercises or without specific stabilization exercises.


               Group1- Physical therapy with specific stabilization exercises. Attention will be paid to
the body awareness and ergonomic advice in specific, real life situations (e.g. lifting & carrying a
child.) and hot packs will be given. Specific stabilization exercises are included.


               The program is based on exercise & training of the transversely oriented abdominal
muscles with co activation of the lumbar multifidus at the lumbosacral region, training of the gluteus
maximus , the latissimus dorsi, the oblique abdominal muscles, the quadratus lumborum & hip
abductors & adductors.


PROCEDURE FOR SPECIFIC STABILIZATION EXERCISES


Transversely oriented abdominal muscles with coactivation of the lumbar multifidus.
Drawing in maneuver - The patient will assume her neutral spinal position and will attempt to
maintain it while gently drawing in and hollowing the abdominal muscles. The patient will be
instructed to draw the belly button up and in toward the spine to hollow out the abdominal region as
exhaling. The individual should not inhale nor lift the ribcage to mimic the activity.


Oblique abdominal muscles - Abdominal bracing - Abdominal bracing occurs by setting the
abdominals and actively flaring out laterally around the waist. There will be no head or trunk flexion,
no elevation of lower ribs, no protrusion of the abdomen or pressure through the feet. The patient
should be able to hold the braced position while breathing in a relaxed manner.


Quadratus lumborum – Patient will be in side lying. Patient will be instructed to prop up on here
elbow and will then lift the pelvis off the mat, supporting the lower body with the lateral side of the
heel on the downward side.


Gluteus maximus – Bridging exercise - Patient will be in hook lying. The patient will be instructed to
press the upper back and feet in to the mat and will elevate the hips.
Hip abductors - The patient will be in side lying. The patient will flex the bottom leg for balance. The
patient will abduct the top leg. Patint will be instructed to keep the hip in neutral to rotation and in
slight extension and to prevent the hip to flexor to the trunk to roll backward.


Hip adductors – Patient will be in side lying. Patient will flex the top leg forward with the foot on the
floor. The patient will lift the bottom leg upward in adduction.


The women are required to exercise for 30 to 60 minutes; 3 days a week for 12 weeks.


Group 2- Physical therapy without specific stabilization exercises. The patients will receive ergonomic
advice and hot packs. General strengthening exercises (flexion and extension exercises) are included.
However, specific stabilization exercises will not be included.


PROCEDURE FOR GENERAL STRENGTHENING EXERCISES.


Flexion exercises-


    Patient will be in supine position with knee extended. Patient will be instructed to support the
     head at the back by both the hands and will raise the head and neck.
    Patient will be instructed to raise the head and neck with both the knees bent and hands in front of
     the chest.
    Patient will be in supine position and will be instructed to pull the thigh over the abdomen
     alternatively and hold for 10- 15 seconds.
    Patient will be in supine position and will be instructed to pull both the knees towards the chest
     and hold for 15 seconds.
    Patient will be in supine position and will be instructed to raise both the legs at 30 60 and 90
     for 15 seconds each.


Extension exercises-


    Patient will be in prone position and will be instructed to fold both the arms under the chin;
     patient will keep the knees straight and will lift the legs alternatively.
    Patient will be in prone position and will be instructed to tuck hands behind the head and will lift
     both the legs straight.
      Patient will be in same position as mentioned above and will be instructed to lift the head, neck
       and legs simultaneously.
      Patient will be in prone position and will be instructed to place both the hands at the level of the
       shoulder .patient will gradually push the upper body of the ground by straightening the arms .The
       hip should be placed firmly on the ground during this exercises.


       V) STATISTICAL TEST


                  The data tested will be statistically analyzed by student’s t test.


7.3 Does the study require any investigations or interventions to be conducted on patients or other
humans or animals? If so, describe briefly.


      Yes, the study will be done on two groups of samples and prior consent will be taken.


7.4 Has ethical clearance been obtained from your institution incase of 7.3?


      Yes, Ethical clearance has been obtained from the institution.
LIST OF REFERENCES


01.Albert H,Godskesen M,Westergarad J.evaluation of clinical test used in classification procedures in
     pregnancy related pelvic joint pain; Eurspine J 2000:


02 Kristiansson P ,Svardsudd K,Schowtz Vom B.back pain during pregnancy; Spine 1996,21:702-9


03. Carolyn kisner, Lynn Allen Colby, Therapeutic exercises foundation and techniques 4th; 2002.


04. Brynhidsen J Hansson A ,Persson A etal ,Follow- up of patient with low back pain during pregnancy
     ;Obstet gynecal 1998 ,91:1826


05. Postgraard Hc,roos –Hansson E,Zetherstrom Gregression of Back and posterior pelvic pain after
     pregnancy ;spine 1996,21:2777-80


06. Endresen E.pelvic pain and low back pain in pregnancy. an epidemiological study scand J;rhematoid
     1995 ,24:135


07 Berg G Hammar M,moller –Nielsen J.Tharnblad J low back pain during pregnancy; obstet gynecal
     1998;71 ;71-


08     Kogstad o pelvic instability .A controversial diagnosis In Norwegian Bekkenlosning En
     kontroversiell diagnose Tidsskrnor laegforen 1988


09. Mantle Mj Greenwood RM, currey HLF Back in pregnancy; rheumatoid Rehab. 1992 ;16:95-101


10. Pennick Ve, Young G. Intervention for pregnancy and treating pelvic and back pain in
     Pregnancy.;Cochran database system Rev. 2007 Ap 19(2)


11. Rackwitz B, Limmh, Wessels T, Ewert T, Stucki G. Practicability of segmental stabilizing exercises
     in the context of group program for the secondary prevention of low back pain; Eura Medicophys
     2007 sep 43(3)359-67.


12. Paulo Hferreira, Manuela, Lferreira, Christopher G Maher, Robert D Herbet. Specific stabilization
     exercises for spinal & pelvic pain A systemic review; Australian journal of physiotherapy 2006
     52:79-88.13. Fritz JM, Whitman JM, childs JD. Lumbar spine segmental mobility assessment and
   examination of validity for determining intervention strategies in patient with low back ache. Arch
   Phys. Med Rehabi 2005 sep 86 (9) 745-52.




13. Fritz JM, Whitman JM, childs JD. Lumbar spine segmental mobility assessment and examination of
   validity for determining intervention strategies in patient with low back ache; Arch Phys. Med Rehabi
   2005 sep 86 (9) 745-52.


14. Inger Halm, Britt Stuge and Nina Vollestad. To treat or not to treat postpartum pelvic girdle pain with
   stabilization exercises; Australian journal of physiotherapy July 2005 337-343.


15. Havden J a, van Tulder Mw, Tomlinson G. Systemic review strategies for using exercise therapy to
   improve outcomes in chronic low back pain; Spine 2005 may 3, 142(9): 776, 86.


16. Elden H, Ladforsl, olsen MF, Ostgaard HC, Hagberg H. Effects of stabilizing exercises as adjunct to
   standard treatment in pregnant women with pelvic girdle pain.;BMJ 2005Apr.2; 330(7494)


17. Britt stuge, Even Laerum, Gitle Kirkesola and Nina Vollestad. The efficacy of a treatment program
   focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy; Spine 2004 29:351-
   359.




18. Stuge, Britt, Veierod, Marit Bragellien, Laerum, Even, Vollestad, Nina. The efficacy of a treatment
   program focusing on specific stabilization exercises For pelvic girdle pain after pregnancy. A two
   year follow-up of a Randomized clinical trial; Spine 15 may 2004, pp E 197-203


19. Hides, julieA, Gwendolen A, Richardson, Carolyn. Long term effects of specific stabilization for first
   episode low back pain; Spine26june2001


20. Coroline HG Bastiaene, Robadebie, Pieter Mj c walters, Johan Ws Valeyen. Treatment of pregnancy
   – related pelvic girdle and/or low back pain after delivery; BMC Public Health2004, 4:67


21. Demovilin c, Vander thommen m, Duvsens C, crielaard Jm Spinal muscle evaluations using the
   Sorensen test: a critical appraisal of the literature; Joint Bone Spine, 2006 Jan, 73, 43-50
9   SIGNATURE OF CANDIDATE
                                                (SHYAMLI SHARMA)


10 REMARKS OF GUIDE


11 NAME AND DESIGNATION


    11.1 GUIDE                           Mr. MASIH MOHAMMAD KHAN
                                           ASSOCIATE PROFESSOR




    11.2 SIGNATURE




    11.5 HEAD OF DEPARTMENT              Mr. MASIH MOHAMMAD KHAN
                                           ASSOCIATE PROFESSOR


    11.6 SIGNATURE




12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL




    12.2 SIGNATURE

				
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