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1 NAME OF
CANDIDATE
Nishanth O
2 GUIDE Mrs.Aparna. MPT(ortho)
3 INSTITUTION
Co-operative Institute of
Health Science, Thalassery
4 COURSE
Master of physiotherapy
Elective: Musculoskeletal
and sportsInjuries
5 DATE OF
ADMISSION
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TITLE
EFFECTIVENESS OF MUSCLE
ENERGY TECHNIQUE IN PATIENT
WITH ACUTE LOW BACK PAIN
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INTRODUCTION
Low back pain (LBP) is posterior trunk pain between the
ribcage and the gluteal folds. It also includes lower extremity
pain that results from low back disorder (sciatica/radiating low
back pain), whether there is trunk pain or not.
Acute LBP: Back pain 6 weeks but 3 months 1
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Acute low back pain(pain
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Another common treatment for acute low back pain is the use of manual
therapy. While under the broad umbrella of manual therapy, Muscle
Energy Technique (MET)2 does not fall into the subcategories ofmanipulation or mobilization
MET is an active technique in that the patient, instead of the
care provider, supplies the corrective force.
Greenman3 defined MET as a manual medicine treatment procedure
that involves the voluntary contraction of patient muscle in a precisely
controlled direction, at varying levels of intensity, against a distinctlyexecuted counterforce applied by the operator. It has been hypothesized
that MET can be used to lengthen and strengthen muscles, to increase
fluid mechanics and decrease local edema, and to mobilize a restricted
articulation.
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NEED OF THE STUDY
To determine whether patients with acute low back pain would demonstrate
a greater reduction in disability (disability is any restriction or lackresulting from an impairment of ability to perform an activity in the manner
or within the range considered normal for a human beingby UN )as assessed
by Oswestry Disability Index
To improve lumbar side bending restriction
AIM OF THE STUDY
To study the effect of MET in reducing pain and correcting the disabilityin patients with acute low back pain
To improve trunk side bending restriction
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REVIEW OF LITERATURE
1)Journal of Orthopedics & Sports Physical Therapy (JOSPT)
Capt. Eric Wilson, PT, DSc, OCS, SCS, CSCS1
Otto Payton, PT, PhD, FAPTA2
Lisa Donegan-Shoaf, PT, PhD3
Katherine Dec, MD4
stetes thatMET combined with supervised motor control and resistance
exercises may be superior to neuromuscular re-education and resistancetraining for decreasing disability and improving function in patients with
acute low back pain
2) Clinical application of neuromuscular techniques
Vol 2Leon Chaitow
Judit Walker DeLany
Explained the technique of MET in lumbar region
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3)Greenman20 defined
MET as a manual medicine treatment procedure that involves thevoluntary contraction of patient muscle in a precisely controlleddirection, at varying levels of intensity
Greenman P.Principles of Manual Therapy. 2nd ed.
Baltimore, MD: Williams & Wilkins; 1996.
4) ObjectiveAssessment with Establishment of Normal Valuesfor Lumbar Spinal Range of Motion
G. KELLEY FITZGERALD, KEVIN J. WYNVEEN, WENDY RHEAULT,
and BRUCE ROTHSCHILD
Described an objective and reliable method for measuring lumbar spinal range ofmotion and established normal values according to age for this method as indicatedby a 95 percent confidence interval.
5) University of Michigan Guidelines for Health System Low Back PainGuideline Team
Described the classification and treatment of low back pain according to severity of
back pain
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OBJECTIVES
1. To find out the efficacy of Muscle EnergyTechnique (MET) in correcting disability andimproving lumbar side bending restriction inpatients with acute low back pain
2. To find out efficacy of neuromuscularreeducation and resisted exercise in back pain
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HYPOTHESIS
NULL HYPOTHESIS
There is no significant effect of MET along with resisted exercise in
correcting the disability and improving lumbar side bending restrictionin patient with low back pain
ALTERNATE HYPOTHESIS
There is significant effect of MET along with resisted exercise in
correcting the disability and improving lumbar side bending restriction
in patient with low back pain
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MATERIALS AND METHOD
SOURCE OF DATA : CO-OPERATIVE INTITUION OF HEALTH SCIENCES
THALASSERY
SAMPLE SIZE : 30 patients (15 in each group)
RESEARCH DESIGN : pre test- post test
OUTCOME MEASURE : Oswestry Disability Questionnaire
Lumbar side bending Range of Motion
MATERIALS REQUIRED
1. Inch tape
2. Long lever goniometry
3. Oswestry Disability Questionnaire4. Dumbbells
5. Pulley exerciser with resistance
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METHODS OF COLLECTION OF DATA
Patients were placed into either the
experimental group or the control group upon
entering the study.A coin toss determined the
group placement of the first patient to enter the
study. Further patients were either randomlyassigned or matched to patients already
participating in the study according to initial
ODI score and side bending restriction.
Patients were matched by initial ODI score
according to the categories originally
described by Fairbank : moderate (20%-40%)
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INCLUSION CRITERIA
Inclusion criteria included
1. Low back pain of no more than 6weeks duration at the time of examination,2. A subject age range of 18 to 35years old, male patients
3. Initial ODI score of 20% to 40%,
4. Physical therapy diagnosis of low back pain without radiating symptoms.
5. The final inclusion criterion was a lumbar side bending restriction measured as
described by Fitzgerald et al.
EXCLUSION CRITERIA
Exclusion criteria included
1. Radiating pain, paresthesia or numbness into the buttocks or lower extremities,
2. Motor weakness, absent or diminished muscle stretch reflexes (MSRs),
3. Spondylolisthesis,
4. Chronic low back pain of more than 12 weeks, and
5. Previous back surgeries.
6. in co-operative patient
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VARIABLES OF THE STUDY
DEPENDENT VARIABLE
The dependent variable is
1. ODI
2. Lumbar side bending range of motion
INDEPENDENT VARIABLE
The independent variable is MET
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METHODOLOGY
Male patients diagnosed with acute low back pain were randomlyassigned. Patients were matched according to initial Oswestry score.
Lumbar side bending restriction was measured as described byFitzgerald et al.
The patient stood erect with feet shoulder-width apart and hands byhis/her side prior to performing 3 repetitions of maximal trunk side
bending, flexion, and extension. The mean of the 3 measures was usedto determine if an asymmetry existed in side bending. A subjectivereport of pain greater with flexion than extension was considered a
positive finding.
The control group received supervised placebo manual therapy andresistance training while the experimental group received resistancetraining coupled with MET. Both groups received the selectedtreatment 8 times over a 4-week period (2 times per week). Patientscompleted an Oswestry Disability Index on their first and eighthvisits and change scores were calculated.
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MET applicationby Leon Chaitow
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PROCEDURE
1)Patient lies on right side. Examiner palpates lumbar
spinous process and extends patients legs until motion ispalpated at restricted lumbar vertebra.
2)Examiner flexes patients trunk superiorly until motion
is palpated at restricted lumbar vertebra.
3)Examiner flexes trunk inferiorly until motion is
palpated restricted lumbar vertebra.
4)Examiner rotates patients trunk until motion is
palpated at restricted lumbar vertebra.
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Cont..
5)Examiner side-bends patients trunk until motion is
palpated at restricted lumbar vertebra. Upon command,
patient pushes her legs down into examiners hand for a
5-second isometric contraction. Entire process isrepeated 4 times. Restricted lumbar vertebra is re-
evaluated for alignment
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Placebo manual
therapy
The placebo manual therapy was performed for 2 reasons.
First, patients in both groups were informed that they were
participating in a manual therapy study at the time of inclusion.
The placebo treatment sought to control for the laying-on of
hands effect often associated with manual therapy research
Second, it was hoped that this would decrease any potential bias in the
subjects by further masking them to their group assignment.
Side-lying passive range of motion was selected as the placebo
manual therapy because it most closely mirrored the MET
intervention without resulting in any perceived therapeutic effect.The patient was instructed to lay on the side opposite of the
restriction diagnosed during the initial evaluation while the primary
investigator passively moved the patients lumbar spine into flexion
and rotation and side bending into the direction of the restriction.
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Resisted Exercises Performed
1 Drawing-in maneuver
Patient supine with hips/knees slightly flexed (20). Instructed
to draw the navel in towards the spine and cephalad towards
the head. To be held while respiration occurs until fatigue.
2 Standing extension stabilization
Utilizing a high pulley, the patient grasps the bar with hands
shoulder width apart. Performs drawing-in maneuver then anisometric gluteus maximus squeeze and holds these as the patient
extends his/her shoulders (elbows extended) bringing the bar to
the waist. Patient raises the bar to the starting position and relaxes
buttocks, then abdomen. 50 repetitions
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3. Simple supine obliques
Patient supine with hips/knees slightly flexed (20) and arms by the
side. Patient performs a drawing-in maneuver and holds it as he/shesimultaneously reaches for the right ankle with the right hand and
rotates the trunk to the right, bringing his/her left shoulder off the
mat until the inferior angle of the left scapula clears the mat. Holds for
a count of 1 and returns to starting position. Repeat on opposite side.
Cervical spine may not flex and shoulders may not protract. Performeduntil patients technique deteriorates.
4. Standing latissimus dorsi pull-down
The patient stands facing the high pulley and grasps the wide bar with
hands slightly wider than shoulder width apart. The patient performs
the drawing-in maneuver and an isometric gluteus maximus squeeze
prior to beginning each set of exercise. The bar is pulled down to a
point on the patients chest between the sternal notch and the nipple
line. The patient is not allowed to extend the back during the concentric
phaseor be pulled forward during the eccentric phase
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STATISTICAL ANALYSIS USED IN THE STUDY
A 2-tailed t test
REFERENCE
1. University of Michigan Guidelines for Health System Low Back PainGuideline Team
2. Journal of Orthopedics & Sports Physical Therapy (JOSPT)M
uscle Energy Technique in Patients With Acute Low Back Pain: A PilotClinical TrialCapt. Eric Wilson, PT, DSc, OCS, SCS, CSCS1 Otto Payton,PT, PhD, FAPTA2 Lisa Donegan-Shoaf, PT, PhD3 Katherine Dec, MD4.
3. Greenman P. Principles of Manual Therapy. 2nd ed Baltimore, MD: Williams& Wilkins; 1996.
4. ObjectiveAssessment with Establishment of Normal Values for Lumbar Spinal Range ofmotion
G. KELLEY FITZGERALD, KEVIN J. WYNVEEN, WENDY RHEAULT, and BRUCEROTHSCHILD
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5. Fairbank JCT & Pynsent, PB (2000)The Oswestry Disability Index. Spine,
25(22):2940-2953.DavidsonM & Keating J (2001) A comparison of five low back
disability questionnaires: reliability and responsiveness. Physical Therapy
2002;82:8-24.