DISSERTATION SYNOPSIS



DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By

GAIKWAID SHARDA GANESHRAO

UNDER THE GUIDANCE OF

Prof. NATARAJAN S.

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006

2009-11

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

| | | |

|1. |Name of the Candidate |GAIKWAID SHARDA GANESHRAO |

| |and Address | |

| | |VIKAS COLLEGE OF PHYSIOTHERAPY |

| | |AIRPORT ROAD |

| | |MARYHILL, KONCHADY |

| | |MANGALORE – 575008 |

| | | |

|2. |Name of the Institution |VIKAS COLLEGE OF PHYSIOTHERAPY |

| | |Mangalore. |

| | | |

|3. |Course of study and subject |Master of Physiotherapy (MPT) |

| | |Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy |

| | | |

|4. |Date of admission to Course |26-05-2009 |

| | |

|5. |Title of the Topic |

| | |

| |THE IMMEDIATE EFFECTS OF MOBILIZATION TECHNIQUE ON PAIN AND RANGE OF MOTION IN PATIENTS PRESENTING WITH UNILATERAL |

| |NONSPECIFIC NECK PAIN |

| | |

|6. |BRIEF RESUME OF THE INTENDED WORK |

| | |

| |6.1) Need for the study |

| | |

| |Neck pain is not synonymous with brachialgia or radicular pain.1 The latter are felt in the upper limb and are associated|

| |with objective signs of neurological impairment. Although they may be caused by lesions in the neck, they do not |

| |constitute neck pain. Neck pain is pain perceived dorsally in the cervical region of the spinal column, i.e. between the |

| |superior nuchal line and an imaginary transverse line through the spinous process of T1.2 Nevertheless, neck pain may be |

| |referred to the head, the upper limb, the dorsal scapular region or the anterior chest wall. Referred pain is perceived |

| |deeply and is aching or pressure-like in quality. It is thus clinically distinguishable from radicular pain, which is |

| |sharp, shooting or lancinating in quality and travels along the upper limb in a narrow band.2 |

| | |

| |Neck pain is a common complaint in the general population with the lifetime prevalence of approximately 50%.3,4 Most |

| |patients who present with chronic neck pain symptoms fit into the category of nonspecific neck pain, having postural or |

| |mechanical basis.5 Aetiological factors include poor posture, neck strain or occupational or sporting activities, |

| |anxiety, depression, but are often multifactorial and poorly understood.5 Its exact pathology remains obscure, but the |

| |source of symptoms has been asserted to involve mechanical dysfunction of the cervical spine, 6,7 particularly the |

| |zygapophysial joints.[5]8,9,10 |

| |The facet or zygapophysial joints are paired diarthrodial articulations between posterior elements of adjacent vertebrae.|

| |Spinal facet joints have been shown in normal volunteers to be a source of pain in the neck and referred pain in the head|

| |and upper extremities,11,12,13,14 upper back, mid back, and referred pain in the chest wall,15,16 and the low back and |

| |referred pain in the lower extremity.17,18,19,20,21 Facet joints are well innervated by the medial branches of the dorsal|

| |rami.22,23 Biomechanical studies have shown that lumbar and cervical facet joint capsules can undergo high strains during|

| |spine-loading.24 Neuroanatomic studies have demonstrated free and encapsulated nerve endings in facet joints, and also |

| |nerves containing substance P and calcitonin gene-related peptide.24 Neurophysiologic studies have shown that facet joint|

| |capsules contain low-threshold mechanoreceptors, mechanically sensitive nociceptors, and silent nociceptors.24 |

| |On the basis of controlled diagnostic blocks of facet joints, in accordance with the criteria established by the |

| |International Association for the Study of Pain,2 facet joints have been implicated as responsible for spinal pain in 15%|

| |to 45% of the patients with chronic low back pain,10,26,27,28,29,30 42% to 48% of patients with chronic thoracic |

| |pain,10,31 and 54% to 67% of patients with chronic neck pain.10,32,33,34 |

| | |

| |Among the diversity of neck pain, mechanical neck pain is the most common type, with the pain primarily confined in the |

| |area on the posterior aspect of the neck that can be exacerbated by neck movements or by sustained neck postures.2,36 The|

| |usual clinical presentation of this mechanical neck pain is a reduction in mobility of either a single segment or |

| |multiple segments of the cervical spine in association with pain.1,36 |

| | |

| |Pragmatic reviews have in the past extolled the virtues of a variety of treatments for neck pain.36,37,38 These include |

| |education, rest, collars, posture control, exercises, physical modalities, traction, mobilization, massage, analgesics, |

| |tricyclic antidepressants, psychological interventions, trigger point injections, occipital nerve blocks, epidural |

| |steroid injections, neurectomy, discectomy, fusion, soft tissue technique, muscle energy technique, thrust technique, |

| |myofascial release, manipulation under anaesthesia and craniosacral manipulation. None of the reviews, however, provided |

| |any scientific evidence of efficacy of any of these traditional interventions.1 |

| | |

| |Recent evidence39,40,41,42,42,44 suggests manipulation and mobilization to be the effective therapies for mechanical neck|

| |pain. Manipulation is defined as a high-velocity and small-amplitude movement applied at the end or just beyond an |

| |available joint range of motion (ROM), whereas mobilization is defined as a low-velocity and small- or large-amplitude |

| |movement applied anywhere within a joint ROM.6 For an immediate effect, cervical spine manipulation was shown to be more |

| |effective in reducing pain and increasing cervical ROM than cervical spine mobilization with muscle energy or sustained |

| |manipulated position.45,46 |

| | |

| |The mobilization technique in the form of an oscillatory movement targeted at a cervical segment yielded similar mean |

| |reductions in pain and disability as cervical spine manipulation.47 Nevertheless, adverse effects are more likely to be |

| |reported after cervical spine manipulation than mobilization.48,49 Therefore, it is suggested that the cervical spine |

| |manipulation should be used as a progression of the treatment when the cervical spine mobilization provides no further |

| |improvement.6 |

| | |

| |Among various cervical spine mobilization procedures, the manifestation of an oscillatory movement targeted at a cervical|

| |segment is widely used. With this mobilization procedure, an empiric guideline for the selection of the cervical |

| |mobilization technique is based on the distribution of the patient's symptoms.6 For patients whose symptoms are situated |

| |either in the midline or distributed evenly to each side of the neck, the central posteroanterior (PA) mobilization |

| |technique over the spinous process of the cervical spine is recommended.3 G.D. Maitland, E. Hengeveld, K. Banks and K. |

| |English, Maitland's vertebral manipulation (7th ed.), Elsevier Butterworth Heinemann, Edinburgh (2005).6 For the patients|

| |whose symptoms are unilaterally distributed, the ipsilateral unilateral PA mobilization technique over the zygapophysial |

| |joint of the cervical spine on the side of the symptoms is of most benefit.6 But a recent study has shown that the effect|

| |of the unilateral PA mobilization on the painful side does not have any significant difference compared to the central |

| |mobilization.50 Hence this study attempts to compare the immediate effects of unilateral cervical PA mobilization with |

| |central PA mobilization in patients presenting with unilateral nonspecific neck pain. |

| | |

| |6.2) Review of Literature |

| | |

| |Kanlayanaphotporn et al conducted a triple-blind, randomized controlled trial to determine the immediate effects on both|

| |pain and active ROM of the unilateral PA mobilization technique on the painful side in 60 mechanical neck pain patients |

| |presenting with unilateral symptoms. The subjects were randomly allocated into either ipsilateral unilateral PA or |

| |central PA or contralateral unilateral PA. Pain intensity, active cervical ROM, and global perceived effect were measured|

| |at baseline and 5 minutes posttreatment. Results showed that after mobilization, there were no apparent differences in |

| |pain and active cervical ROM between groups. However, within-group changes showed significant decreases in neck pain at |

| |rest and pain on most painful movement with a significant increase in active cervical ROM after mobilization on most |

| |painful movement.50 |

| | |

| |Gross et al conducted a systematic review of randomized trials to assess whether manipulation and mobilization relieve |

| |pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck |

| |disorders. Results showed that single or multiple (3-11) sessions of manipulation or mobilization showed no benefit in |

| |pain relief when assessed against placebo, control groups, or other treatments for acute/subacute/chronic mechanical neck|

| |disorders with or without headache. There was strong evidence of benefit favoring multimodal care (mobilization and/or |

| |manipulation plus exercise) over controls for pain reduction, improvement in function and global perceived effect for |

| |subacute/chronic mechanical neck disorders with or without headache. They concluded that mobilization and/or manipulation|

| |when used with exercise are beneficial for persistent mechanical neck disorders with or without headache, but alone, |

| |manipulation and/or mobilization were not beneficial and when compared to one another, neither was superior.41 |

| | |

| |Bronfort et al conducted a review to reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) |

| |for the management of low back pain (LBP) and neck pain (NP). Results showed that there is moderate evidence that SMT |

| |provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a |

| |commonly used physical therapy treatment strategy in LBP. The evidence is inconclusive in acute NP and there is moderate |

| |evidence that SMT/MOB is superior to general practitioner management in pain reduction but that SMT offers at most |

| |similar pain relief to high-technology rehabilitative exercise. The overall evidence is not clear in a mix of acute and |

| |chronic NP. They concluded that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a|

| |viable option for the treatment of both low back pain and NP.39 |

| |Sarigiovannis and Barbara conducted a review to assess the evidence for the effectiveness of cervical spine manipulation |

| |and mobilisation in the treatment of non-specific neck pain. The results revealed that the effectiveness of spinal manual|

| |therapy on non-specific neck pain remains inconclusive and the available evidence favoured spinal manual therapy when it |

| |was used in conjunction with exercise. They concluded that well-designed RCTs are needed to draw valid conclusions about |

| |the effectiveness of spinal manual therapy on nonspecific neck pain and psychosocial factors should be considered prior |

| |to randomisation of patients by using appropriate measures.43 |

| |Cassidy et al conducted a study to compare the immediate results of manipulation to mobilization in one hundred |

| |consecutive outpatients suffering from unilateral neck pain with referral into the trapezius muscle. The patients |

| |received either a single rotational manipulation or mobilization in the form of muscle energy technique. Prior to and |

| |immediately after the treatments, cervical spine ROM was recorded in three planes, and pain intensity was rated on the |

| |101-point numerical rating scale. The results showed that both treatments increased ROM, but manipulation has a |

| |significantly greater effect on pain intensity. They concluded that a single manipulation is more effective than |

| |mobilization in decreasing pain in patients with mechanical neck pain.45 |

| | |

| |Hurwitz et al in a study compared the relative effectiveness of cervical spine manipulation and mobilization for neck |

| |pain. 336 neck-pain patients were randomized to manipulation with or without heat, manipulation with or without |

| |electrical muscle stimulation, mobilization with or without heat, and mobilization with or without electrical muscle |

| |stimulation. Results showed that reductions in pain and disability were similar in the manipulation and mobilization |

| |groups. They concluded that cervical spine manipulation and mobilization yield comparable clinical outcomes.47 |

| | |

| |Gross et al conducted a systematic review to assess the effects of physical medicine modalities for pain in adults with |

| |mechanical neck disorders. Results showed that electromagnetic therapy produced a significant reduction in pain but laser|

| |therapy did not differ significantly from a placebo and not enough scientific testing exists to clearly determine the |

| |effectiveness exercise, traction, acupuncture, heat / cold applications, electrotherapies, cervical orthoses and chronic |

| |pain / cognitive behavioural rehabilitation strategies. They concluded that there is little information available from |

| |trials to support the use of physical medicine modalities for mechanical neck pain except electromagnetic therapy.51 |

| | |

| |Vernon et al conducted a systematic analysis of group change scores in randomized clinical trials of chronic neck pain |

| |not due to whiplash and not including headache or arm pain treated with manual therapy. Results revealed that there is |

| |moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and |

| |headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to|

| |104 weeks post-treatment but the current evidence does not support a similar level of benefit from massage.52 |

| | |

| |Vernon and Humphreys in a systematic analysis of group change scores of subjects with chronic neck pain not due to |

| |whiplash and without headache or arm pain, in randomized clinical trials of a single session of manual therapy report |

| |that there is moderate-to-high quality evidence that immediate clinically important improvements are obtained from a |

| |single session of spinal manipulation but the evidence for mobilization is less substantial, with fewer studies reporting|

| |smaller immediate changes. Further, they conclude that there is insufficient evidence for ischemic compression to draw |

| |conclusions and there is no evidence for a single session of massage or manual traction for chronic neck pain.53 |

| | |

| |Balogun et al designed a study to evaluate the inter- and intratester reliability of measuring six neck motions with tape|

| |measure (lM) and the Myrin gravity-reference goniometer (MG) in 21 healthy subjects by three physical therapists across |

| |several days. With the exception of the flexion motion, the inter- and intratester reliability coefficients (r) for both |

| |the TM and MG methods were moderately high. With the exception of the flexion motion, the tape measuring method and the |

| |Myrin gravity reference goniometer were found to be reliable when used to evaluate active neck motions. Based on these |

| |results as well as its simplicity and low cost, the authors recommend the tape measuring method for wider clinical use. |

| |It could be used to assess gross limitation of motion of an individual suspected of having cervical dysfunction and for |

| |objectively monitoring the success of a therapeutic program.54 |

| | |

| |Hsieh and Yeung conducted a study to determine if the tape measuring method is a reliable method of measuring six active |

| |neck motions, to estimate measurement errors, and to compare the intratester reliability between an experienced tester |

| |and an inexperienced tester by using this method. The intratester reliability coefficients, ranged from 0.80 to 0.95 for |

| |the experienced tester and 0.78 to 0.91 for the inexperienced tester. However, the intratester reliability did not differ|

| |significantly between testers for all motions except extension. This study indicated that the tape measuring method is a |

| |reliable means for clinicians to assess neck range of motion.55 |

| | |

| |Scrimshaw and Maher conducted a randomized controlled trial to compare the responsiveness of the McGill Pain |

| |Questionnaire with the Visual Analogue Scale (VAS). A repeated measures 2-group design was used, with seventy-five |

| |patients with low back pain divided into "improved" and "non-improved" groups. The external criterion to identify |

| |improved and non-improved patients was a 7-point global perceived effect scale. All patients completed both a VAS and |

| |McGill pain scale to describe their pain over the last 24 hours and a separate VAS to describe their current pain. |

| |Results showed that the VAS was less responsive to clinical change when used to rate current pain in comparison with pain|

| |over the last 24 hours. The study found that the VAS was more responsive than the McGill Pain Questionnaire when both |

| |instruments were used to rate pain over the last 24 hours. They concluded that the VAS may be a better tool than the |

| |McGill Pain Questionnaire for measuring pain in clinical trials and clinical practice.56 |

| | |

| |Kelly conducted a prospective, descriptive study of 152 adult patients presenting to the emergency department with acute |

| |pain to determine the minimum clinically significant difference in visual analog scale (VAS) pain scores for acute pain |

| |and whether this difference varies with gender, age, or cause of pain. Pain was measured at presentation and at 20-minute|

| |intervals to a maximum of three measurements, patients marked the level of their pain on a 100-mm, nonhatched VAS. |

| |Results revealed that the minimum clinically significant difference in VAS pain scores is 9 mm and there is no |

| |statistically significant difference in VAS pain scores based on gender, age, or cause of pain.57 |

| | |

| |6.3 Objectives of the study |

| | |

| |The main objective of the study is to find out the immediate effects of mobilization technique on pain and range of |

| |motion in patients presenting with unilateral nonspecific neck pain. Specifically to determine the immediate effects of |

| | |

| |Unilateral cervical PA mobilization on pain and cervical range of motion in patients presenting with unilateral |

| |nonspecific neck pain |

| |Central cervical PA mobilization on pain and cervical range of motion in patients presenting with unilateral nonspecific |

| |neck pain |

| |Comparing the unilateral and central cervical PA mobilization on pain and cervical range of motion in patients presenting|

| |with unilateral nonspecific neck pain |

| | |

| | |

|7. |Materials and methods |

| | |

| |7.1 Source of data |

| | |

| |Data will be collected from patients, who are referred to the outpatients Physiotherapy department of Vikas College of |

| |Physiotherapy, Mangalore, with diagnosis of nonspecific neck pain after obtaining informed consent |

| | |

| |7.2 Method of collection of data |

| | |

| |Hypothesis: |

| | |

| |There is significant immediate effects of mobilization technique on pain and range of motion in patients presenting with |

| |nonspecific neck pain. |

| | |

| |Null Hypothesis: |

| | |

| |There are no significant immediate effects of mobilization technique on pain and range of motion in patients presenting |

| |with nonspecific neck pain. |

| | |

| |Research Design: |

| | |

| |Experimental design will be used in this study. |

| | |

| |Methodology |

| | |

| |Patients who are diagnosed to have nonspecific neck pain and fulfilling the following inclusion and exclusion criteria |

| |will be selected for the study after obtaining informed written consent. |

| | |

| |Inclusion Criteria: |

| | |

| |1. Clinically diagnosed nonspecific neck pain patients of atleast one week duration |

| | |

| |2. Symptoms primarily confined in the area between the superior nuchal line and the tip of the first thoracic spinous |

| |process and provoked by neck movements or by sustained neck postures |

| | |

| |2. Age: group 40-60 |

| | |

| |3. Both: males and females |

| | |

| | |

| | |

| |Exclusion Criteria: |

| | |

| |1.History of a significant trauma to the cervical spine |

| | |

| |2. History of fracture and dislocation of the cervical spine |

| | |

| |3. Disease of the spinal cord or cauda eaqina |

| | |

| |4. Inflammatory or infective arthropathies of the vertebral column |

| | |

| |5. Vertigo |

| | |

| |6. Neurological signs and symptoms |

| | |

| |7. History of spinal surgery |

| | |

| |8. Presence of malignancy |

| | |

| |9. Osteoporosis of the vertebrae |

| | |

| |10. Subjects who have undergone spinal manualtherapy within the past month before the study |

| | |

| |Study Design |

| | |

| |The selected subjects will be randomly assigned into one of two groups. Each group will consist of 15 patients of both |

| |genders within the age group of 40-60 years. |

| | |

| |Group I: This will consist of 15 patients and they will be given unilateral posteroanterior mobilization. |

| | |

| |Group II: This will consist of 15 patients and they will be given central posteroanterior mobilization. |

| | |

| |Interventions |

| | |

| |For both groups, all patients will be asked to lay face downward on a plinth with two pillows positioned in an inverted V|

| |shape for their face to rest comfortably. The therapist will stand at the head of the patient with the thumbs held back |

| |to back and in opposition. The tips of the thumb pads will be placed on the articular process and the spinous process of |

| |the cervical vertebra to be mobilized when performing the unilateral PA and the central PA, respectively. The unilateral |

| |PA pressure will be performed by applying an oscillatory pressure through the thumbs directed posteroanteriorly against |

| |the articular process of the cervical vertebra to be mobilized. This similar procedure will also be performed for the |

| |central PA pressure except the therapist's thumbs will be placed on the spinous process of the cervical vertebra. |

| | |

| |Evaluation: Before the beginning and immediately after mobilization, all patients will be evaluated in the following |

| |outcome measures. |

| | |

| |1. Pain measured in a 10 cm Visual Analog scale. VAS is a 10 cm line with pain descriptors marked “no pain” at 1 end and |

| |“the worst pain imaginable” at the other. The patients will be asked to report their perceived pain level, both at rest |

| |and on most painful movement, by marking the VAS with a perpendicular line. |

| | |

| |2. Cervical range of motion using a tape measure. Flexion and extension will be measured as the distance between the tip |

| |of the chin and sternal notch with subjects’ mouth closed. Side flexion will be measured as the distance between the |

| |mastoid process and the acromian process. Lateral rotation will be measure as the distance between the chin and acromial |

| |process. |

| | |

| |Statistical tests: |

| | |

| |The following statistical tests will be used to analyze the collected data: |

| | |

| |The pain score data collected using VAS will be analyzed using non-parametric tests as the data are ordinal in nature. |

| |The intra group pre and post-test data will be analyzed using Wilcoxon sign rank test, while the post-test inter group |

| |data will be analyzed with Mannwhitney U test. |

| | |

| |The Cervical ROM data collected using tape measure will be analyzed using parametric tests as the data are interval in |

| |nature. The intra group pre and post-test data will be analyzed using Unpaired t-test, while the post-test inter group |

| |data will be analyzed with Paired t-test |

| | |

| |7.3 Nature of Investigations and Interventions: |

| | |

| |The study requires non-invasive investigations and interventions to be conducted on patients. They include physical |

| |examination like inspection, palpation, and measurement of range of motion, etc. Treatment interventions include spinal |

| |mobilization techniques. |

| | |

| |7.4 Ethical clearance: |

| | |

| |Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and |

| |interventions on patients necessary for this study. |

| | |

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|9. |Signature of the candidate : |

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|10. |Remarks of the Guide |

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|11. |Name and Designation of |

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| |Guide : S. NATARAJAN M.P.T. |

| |Professor |

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| |Signature : |

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| |Co-Guide : - |

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| |Signature : - |

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| |Head of the Department : Prof. S. NATARAJAN M.P.T. |

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| |Signature : |

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|12. |12.1 Remarks of the Chairman and Principal |

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| |12.2 Signature : |

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