Original Article
EFFECTI VEN ESS OF IN TERM ITTEN T PELVI C TRACTI ON VS
IN TERM ITTEN T PELVI C TRACTI ON W ITH SELF N EU RAL
M OBILIZATION ON LOW BACK PAIN – A COM PARATIVE STUDY
S.Dinesh Kumar,
M PT SportsProfessor, M adha college of Physiot herapy, Kundrat hur.
Background: Low Back pain is com m on clinical condit ion encount ered in a day t o day Physiot herapy pract ice. Ver y few aut hor has so far docum ent ed t he efficacy of self neural m obi lizat ion ,but no lit erat ure available SNM dur ing Int er m itt ent Pelvic Tract ion. Hence t o find out t he effect of sam e t his st udy is done. M aterials and M ethods: Pre & Post Test Experim ental Design, Physiot herapy Out Pat ient Depart m ent , M ADHA M edical Col-lege Hospital and Research Cent re, Kundrat hur – 600069. Participants and Intervention: 30 subject s, Tw o IPT prot ocol (w it h and w it hout Self Neural M obilizat ion) Procedure: 30 subject s w ere random ly sam pled and di-vided int o 2 groups (Group A & B). Group A received only IPT (20 m inut es, 20 seconds – Hold t im e, 5 seconds-rest t im e) w hereas Group B received IPT and self Neural M obi lizat ion( Act ive Ankle Plantar & Dorsi f lexion m ovem ent s) (only during Rest t im e). Results:Were analyzed w it h Visual Analogue Scale, Osw est r y Disabilit y Index, w hen com paring t he Pre t est and Post t est values of VAS and ODI t here is significant difference at 95% int erval (P < 0.05). Conclusion: Self Neural M obilizat ion during Int erm it t ent Pelvic Tract ion is effect ive in reducing Low back pain.
KEY W ORDS: INTERM ITTENT PELVIC TRACTION; SELF NEURAL M OBILIZATION(SNM ); VAS & ODI.
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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Received: 25 June 2013
Accepted: 05 July 2013 Published: 11 August 2013
ABSTRACT
INTRODUCTION
Address for correspondence: S.Dinesh Kumar, Professor, M adha College of Physiot herapy, Kundrat hur, Tamil Nadu- 600069 India. Email: [email protected].
Lumbar t ract ion is one of t he oldest t reat ment modalit y for LBP. Hippocrates described lumbar t ract ion in various form s has been used for cent uries and cont inues t o be used in t oday clinical environm ent . Recent clinical st udies, syst emat ic review of literat ure, and evidence b ased gu i del i nes hav e co n cl u d ed t hat preponderance of evidence fails t o support t he lumbar t ract ion as an effect ive t reat ment for pat ient s w it h LBP.
St ill t here are literat ure support s t he posit ive effect of t ract ion on LBP; some are reported t he lack of m et hodo logical design of previ ous research, have made t he lit erat ure regarding lumbar t ract ion st ill under debate.
The use and descript ion of neural mobilizat ion t o inf luen ce t he m ech ani cal pro per t ies of peripheral nerve gained popularit y from t he late 1970s t hrough1980s.
How ever t he underlying mechanism associated w it h cl i n ical i m p ro v em en t s f o ll o w in g neuralmobilizat ion remain unclear.
There are many t heories have been post ulated including physiological ef fect s (rem oval of int raneural edema) cent ral effect s (reduct ion of dorsal horn and supraspinal sensit izat ion) and mechanical effect s (enhanced nerve excursion)
M any st udies examined t he influence of neural mobilizat ion exercises on nerve mechanics in cadaver.
Cop iers et al exam i ned t he m ed ian ner ve excursion bet w een different t ypes of ner ve gli d i ng exer cises (i n cl u d in g sl i d er s an d tensioners) Sliders ut ilizes combinat ion of joint m ovem ent s t o encourage peripheral nerve excursion by increasing elongat ion at one end of nerve bed, t hereby creat ing tension in t he ner ve f rom t hat end w hi le sim ult aneously releasing tension from ot her and of nerve. In d o in g so excu r si o n i s pr o m ot ed w i t ho u t increasing nerve tension.
Sliders produce greater amount of median nerve excursion compared t o t ensioners.It has also b een sh o w n t h at sign i f i cant l y l ess n er v e excursion occurred during nerve gliding exercises initiated from one end of nerve bed using a single joint movement compared t o sliders.
Neural m obi lisat i on exercises der ived f rom neurodynamic test such as slump test , SLRtest have been advocated in clinical text s and as a result of published clinical t rials.
Neurodynam ic m obilizat ion t echnique oft en used clinically t o rest ore nerve m obilit y and decrease pain.
Richard F.Ellis PT Phd has demonst rated in vivo
M easurem ent of sciat ic ner ve excursion in norm al healt hy part icipant s during different t ypes of neural mobilizat ion exercises.26
Pat ient s w it h signs of ner ve root ir rit at ion represent a sub-group of t hose w it h low back pain w ho are at increased risk of persist ent sympt oms and progression t o costly and invasive management st rategies including surgery.
A per i od o f n o n-su rgi cal m an agem en t i s recommended for m ost pat ient s, but t here is lit t le evidence t o guide non-surgical decision-m aking. We conduct ed a prelidecision-m inar y st udy exam ining t he ef fect iveness of a t reat m ent p ro t o col of m ech ani cal t r act i o n w it h Sel f NeuralM obilizat ion(SNM ) for pat ient s w it h low back pain and signs of nerve root irritat ion.
To observe and evaluate t he clinical effect s of Int erm it t ent Pelvic Tract ion w it h Self Neural M obilizat ion( Act ive Ankle Dorsi and Plant ar flexion) on Low Back Pain.Low Back pain is
common clinical condit ion encountered in a day t o day Physiot herapy pract ice. NO aut hor has so far docum ent ed t he efficacy of SNM (Act ive ankle m ovem ent s) during Int ermit tent Pelvic Tract ion. Hence t o find out t he effect of same t his st udy is done.
M ATERIAL AND M ETHODS
A com parat ive St udy w as conduct ed w it h 30 sub j ect s by sim p l e r and o m sam pl i n g at M ADHA Physiot herapy Clinic, M ADHA M edical College, Hospital And Resesearch cent re,kovur, Thandalam.
Inclusion Criteria7: Pain and/ or parest hesia in
t h e l u m b ar sp i ne w it h a d i st r i b ut i o n o f sympt oms that has extended distal t o the gluteal fold on at least one low er ext remit y w it hin t he past 24 hours. Osw est ry disabilit y score of at least 20%, Age at least 18 years and less t han 60 years, At least one of the follow ing signs of nerve root compression:
1. Posit ive ipsilateral or cont ralateral st raight leg raise test (reproduct ion of leg sympt oms w it h st raight leg raise < 70 degrees)
2. Sensory deficit t o pinprick on t he ipsilateral low er ext remit y
3. Dim inished st rengt h of a m yot om e (hip flexion, knee extension, ankle dorsiflexion, great t oe ext en si o n , o r an k le ever sio n ) o f t h e ipsilateral low er ext remit y
4. Diminished low er ext remity reflex (Quadriceps or Achilles) of t he sympt omat ic low er ext remit y
Exclusion Criteria7: Red flags such as , t umor,
m et abolic diseases, RA, ost eoporosis, spinal com pression f ract ure, prolonged hist or y of st er o id u se, et c. cen t r al n er vo u s sy st em involvement such as cauda equina syndrome (i.e., loss of bow el/ bladder cont rol or saddle r egi o n p ar est h esi a) o r t h e p r esen ce o f pat hological reflexes (i.e., posit ive Babinski) complete absence of low back and leg sympt oms w hen seated, Recent surgery (< 6 mont hs) to the lumbar spine or butt ocks, Recent (< 2 w eeks) epidural steroid inject ion for low back, Current pregnancy, Inter vertebral Disc Prolapse, Inabilit y t o comply w it h t he t reat ment schedule.
M aterials: Traction Unit8. W it h int erm it t ent
mode for 20 minutes durat ions follow ed by 20 seconds and 5 Seconds Hold and Rest t im es respect ively.
Participants: Subject s eligible for t he st udy if t hey w ere aged bet w een 18 and 60years and must have reported LBP ,w it h t he presence of associated low er ext remit y pain/ paraest hesia t hat had an average intensit y of greater t han 4 on VAS.In addit ion ,all subject s had t o have a sco r e o f gr eat er t h an 20% o n t h e ODI quest ionnaire.
Subjects screening and intake measures Prior
t o t h e ad m issi on t o t h e st ud y su b j ect s underw ent a screening procedure t o verify t he ent ry and exclusion criteria. Subject s w ho met t he ent ry and exclusion criteria, and provided w ritten informed consent , w ere enrolled in t he st udy. At t his t ime t he subject s completed pre test measurement s. Each subject was scheduled for 15 days of IPT of 20 minutes.
I n te r ven t ion s2 1 Pat i en t s w ere al lo w ed t o
cont inue w it h t heir regular pain medicat ion,but o t h er co -in t er v en t i o n s (eg i n j ect io n s ,massage,exercises,physical modalit ies)w ere not allow ed.The t reat ment series could be ended if a pat ient was free of sympt oms before t he last session or if t he pain increased during t w o con secut iv e t reat m en t sessi o ns.Af t er t h e pat ient s lay dow n on t he t ract ion table in supine po si t i on ,t he canvas t r act io n br aces w ere att ached around t he iliac crest and t he low er t horacic cage.
In the Group A t he pat ient s w ere explicit ly asked t o tell w hen t hey felt dist inct pulling from t he braces. After unlocking t he t ract ion table t he t ract ion force was slow ly increased from 30 % of t otal body w eight unt il t he pat ient indicated a dist inct but t olerable pulling. The maximum force used w as set at 40% of t he t ot al body w eight . Group A ( 15 subject s ) received only IPT (20 minutes, 20 seconds Hold t ime, 5 seconds -rest t ime)
In t he Group B t he pat ient s w ere explicit ly asked t o tell w hen t hey felt dist inct pulling from t he braces.
After unlocking t he t ract ion table t he t ract ion force was slow ly increased from 30 % of t otal body w eight until the pat ient indicated a dist inct but t olerable pulling. The maximum force used was set at 40% of t he t otal body w eight . Group B ( 15 subject s ) received IPT (20 minutes, 20 seconds - Hold t ime, 5 seconds - rest t ime).The pat ient s in Group B advised t o do act ive ankle dorsi and plantar flexion during t he rest t ime at t heir ow n speed. Post test measurement s taken aft er t he Int ervent ion. M easurem ent Tools: Visual analogue scale (VAS) 10, Oswestry disability index (ODI) 11
RESULTS
Comparison of VAS betw een Group A and Group B(Table-1):
St d Error M ean
Pre t est 1 7.37 0.65 0.13603
Post t est 7.3 0.845
Pre t est 2 7 1 0.2146
Post t est 5 0.845
Significant level
VAS Type M ean SD t -value
Group A 1.522 0.139(NS)
Group B 14.929 0.000* * *
* * * :p<0.05
The above t able reveals t he mean, st andard deviat ion, independent t-test and significant p-value of VAS bet w een pre test and post test in Group A and Group B.
The mean value of Group B show s stat ist ically significant result bet w een t he pre test and post test (p<0.05).
Comparison of VAS betw een Group A & B
(Graph -1):
7.37 7
0 7
5
0 2 4 6 8
Group A Group B
Pre - Test
Post - Test
Co m p a r iso n o f OD I b et w e en Gro u p A & B(Table-2):
Std Error M ean
Pre test 1 59.6 8.626 0.13603
Post test 51.33 14.495
Pre test 2 44.27 9.938 0.2146
Post test 18.53 7.726
Significant level
Group A 1.898 0.068(NS)
Group B 7.917 0.000* * *
ODI Type M ean SD t-value
* * * :p<0.05
The above t able reveals t he mean, st andard deviat ion, independent t-test and significant p-value of ODI bet w een pre test and post test in Group A and Group B.
The mean value of Group B show s stat ist ically significant result bet w een t he pre test and post test (p<0.05).
Com parison of ODI bet w een Group A and Group B(Graph-2).
59.5
44.27
0 51.33
18.53
0 10 20 30 40 50 60 70
Group A Group B
Pre - Test
W hen com paring t he Pre t est and Post t est values of VAS and ODI t here is signif icant dif ference bet w een t he t w o scales at 95% ( P<0.05 ) in Group B t han in Group A.
DISCUSSION
The result s suggested in Group A w it h Only IPT co-relates with previous st udies which concluded t hat t ract ion is NOT effect ive (P < 0.05) in LBA.13
Where as in Group B, IPT w it h SNM (Act ive Ankle M ovement s) t here is a decrease in Pain and ODI. The under lying causes for t his m ay be t he sensit izat ion of Nerve root pain by performing Act ive DF.14
Peripheral nerves st raighten and stretch in order t o accommodate increases in bed lengt h during joint movement s23. The pain relief may also due t o t he St rain of Peripheral Nerves during Ankle movement s. How ever it can be confirmed only by t he Diagnost ic Ult ra sound w hich show s t he neural mobilit y.22,25
The IPT along w it h active ankle movement nerve mobilit y and stress/ strain characterist ics in lower ext rem it ies im proved; and m echanism s and co nseq uen ces o f t r aum a on n er v e m icr o ci r cul at io n as w el l as i nf l u en ce o n axoplasmic and lymphat ic flow wit hin peripheral nerve ident ified. M athew carrol et al quantified t he degree of longit udinal t ibial nerve excursion as t he ankle moved from dorsiflexion t o plantar flexion w hich support s t he st udy result .
Larissa sale teles versa et al conducted st udy in l ep r o sy pat i en t s w ho are un d ergo in g t h e t ech n iq u e o f neu r al m ob i l izat io n had improvement in elect romyography funct ion and muscle st rengt h, reducing disabilit y degree and p ai n . Phy si cal t h er ap y m anagem en t o f peripheral nerve dysfunct ion as reported by
Elvey and Butler is review ed. Guidelines for appropriate principles of clinical examination and t reat ment are out lined as w ell as possible areas for fut ure clinical research
It is interest ing t o note t hat even t hough st udies stat ing the lack of efficiency of Lumbar t ract ion15 for LBA, it is st ill a w idely used m odalit y in a clinical set up.14
Hence, it m u st be em phasized t hat Sp inal t ract ion is only a part of t he t otal management – treatment regimen, which includes other forms of Physical therapy. Wit hout a total management pr ogram , Spi nal t r act io n, l i ke m any o t h er methods has litt le chance of long range benefit .2
The result s suggest ed t his approach m ay be effect ive, part icularly in a m ore specific sub-group of pat ient s. The aim of t his st udy w ill be t o examine t he effect iveness of t reat ment t hat includes t ract ion for pat ient s w it h low back pain and signs of nerve root irritat ion, and w it hin t he pre-defined sub-group.
CONCLUSION
Tract ion t herapy effect ively m it igat es pain, enhances joint flexibi lit y, and im proves t he qualit y of life of pat ient s w it h lumbar pain. The equipment required t o administer intermittent pelvis t ract ion is simple and treatment technique is simpler t o perform by t he pat ient t hemselves.
Self Neural M obilizat ion (Act ive Ankle dorsi & plantar flexion movement s) during Intermittent Pelvic Tract ion is effect ive in reducing LBP w it h r ad i cul o p at hy. Ho w ev er t h is r eq u i res confirmat ion by furt her invest igat ion.
Lim itations: Present st udy is lim it ed in t he fallow ing areas: st udy was conducted in short durat ion, no cont rol group, shor t durat ion sympt oms, no radiological examinat ion.
Further recommendations: Similar st udy can be
carried out w it h t he Larger sample group, st udy design shift t o prospect ive, Shoe modificat ion, different age group, Combination t herapies such as UST and Cryot herapy, Iont ophoresis, M oist heat .
ACKNOW LEDGEM ENT
REFERENCES
I t h ank Alm i ght y f i r st f o r t h e su ccessf u l complet ion of t his st udy. And I t hank Principal, VicePrincipal M adha college of Physiot herapy and m y colleagues w ho are giving const ant support and encouragement . Never forget t he uncondit ional help from my st udent s, friends and my family members w ho are always w it h my all endeavors. I must Thank all my pat ient s for t heir kind co-operat ion for t his st udy.
1 Van m i d d l es e t al . Eu r Sp i n e J. 2 01 1 Jan;20(1):19-39.Epub 2010 Jul 18.
2 Sau n d e r s HD.Cl i n Or t h o p Re l at e
Res.1983.Oct ;( 179):31-8
3 But lers’ DS. The sensit ive nervous syst em .
Adelide ,Aust ralia:Noigroup publicat ions;2000.
4 Sh ackl o ck M O.N e u r o d y n am i cs
Physiot herapy.1995; 81:9-16.
5 Sh ack l o ck M O.Cl i n i cal Ap p l i cat i o n s Of Neurodynam ics. In: Shacklock M O,editor.M oving on
p ai n .Ch at sw o o d ,UK Bu t t e r w o r t h
Heinem ann;1995.PP.123-131.
6 Shacklock M O Clinical Neuro Dynam ics:
A new syst em of Neuro M usculoskeletal
Treat m ent . Oxford, UK: But t erw ort h Heinem ann; 2005.
7 The value of Tract ion in t reatm ent of Lum bar
radiculopat hy – ClinicalFeeds.org.
8 Elect rophysical Agent s. M ichelle Cam eroon
13t h Edi. 2013.
9 Sibrio Nussbaum er et al Validit y and t est –
r et est re l i ab i l i t y o f m an u al go n i o m et e rs f o r m easuring passive hip range of m ot ion in fem oro – acet abular im pingem ent s pat ient s. BM C M usculos kelet Disord. 2010; 11: 194.
10 Zan o l i , e t al . V i su al An al o g scal e f o r In t er p ret at io n o f Back an d Leg PaiIn t en si t y i n Pat i en t s o p e rat ed f o r d e ge n er ar i ve l u m b ar disorders. Spine. 2001: 2375-2380.
11 M ichael Vianin DC Psychom et ric propert ies
and clinical usefulness of t he Osw est ry Disabi lit y Index. Journal of Chiropract ic m edicine Volum e 7, Issue 4, Decem ber 2008, Pages 161-163.
12 Annet t e Agnes Hart e et al. Current use of
Lum bar t ract ion in t he M anagem ent of Low Back
pain. Result s of a survey of Physiot herapist s in
t he Unit ed Kingdom . Arch Phys M ed Rehabil
Vol. 86. June 2005.
13 Clarke JA, et al . Tract ion for low-back pain
w it h or w it hout sciat ica. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD003010.
14 Bejam in S. Boyd, et al M echanosensit ivit y
of t he Low er Ext rem it y NervousSyst em During St raight-Leg Raise Neurodynam ic Test ing in Healt hy Individuals. journal of ort hopaedic & sport s physical t herapy 2009, 39 (11):790.
15 John Albright , M D et al , Physical Therapy
Philadelphia Panel EvidenceBased Clinical Pract ice Guidelines on Select ed Rehabilitat ion Int ervent ions for Low Back Pain Philadelphia PanelM em bers .
16 M ait lan d GD. Negat ive disc explo rat ion:
posit ive canal signs. Aust J Physiot her 1979;25:129– 34.
17 M ait land GD. The Slum p Test : exam inat ion
– a comparat ive st udy.
19 But ler D. Th e sen sit ive ner vous syst em . Adelaide, SA: Noigroup; 2000.
20 Ekst rom RA, Holden K. Exam inat ion of and
int ervent ion for a pat ient w it h chronic lat eral elbow pain w it h signs of nerve ent rapm ent . Phys Ther 2002;82:1077–86
21 Th e Ef f i cacy o f Tract i o n f o r Backp ain :A Syst em at ic Review of Random ized cont rolled t rial. Annet t e Agnes Hart e ,George .D Baxt er et al. Arch Phys M ed Rehabil 2003;84:1452-53
22 Ellis RF, Hing WA. Neural m obi lizat ion: a syst em at ic review of random ized cont rolled t rials w ith an analysis of t herapeutic efficacy. J M an M anip Ther 2008;16:8–22.
18 Sh ackl o ck M . N e u r o d y n am i cs.
Physiot herapy 1995;81:9–16.
23 Dilley A, Sum m erhayes C, Lynn B. An in vivo
invest igation of ulnar nerve sliding during upper lim b m ovem ent s. Clin Biom ech 2007;22:774–9.
24 Gi lb ert KK, Apt e G, Jam es CR, Sm it h M . Neural and fluid dynam ics of t he lum bosacral nerve root s during low er lim b m ovem ent s in cadavers. 2010; t o be published.
25 Ellis R, Hing W, Dilley A, M cNair P. Reliabilit y of m easuring sciatic and t ibial nerve m ovem ent w it h diagnost ic ult rasound during a neural m obilisat ion t echnique. Ult rasound M ed Biol 2008;34:1209–8.
26 Richard F Ellis PT phd.J ort hop sport s phys
t her, 2012;42(8)667-8.
