Rajiv Gandhi University of Health sciences

Bangalore,Karnataka.

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate and Address

NIKITA RAVINDRA GHATGE

B/ 201, Sheetal Sarita, Sheetal Nagar,

Mira road (E), Thane- 401107.

2. Name of the Institution K.T.G COLLEGE OF PHYSIOTHERAPY Hegganahalli cross, Peenya 2nd stage,

Sunkadakatte main road, V.N. Post,

Bangalore.

3. Course of Study & Subject MASTER OF PHYSIOTHERAPY

(Musculoskeletal Disorders and Sports

Physiotherapy)

4. Date of Admission to the Course

12/7/ 2011

5. Title of the Topic :

EFFECT OF CORE MUSCLES STRENGTHENING EXERCISES IN PATIENTS WITH SACROILIAC JOINT DYSFUNCTION

6 Brief Resume of the Intended Work:

6.1 Need of study :

Sacroiliac joint dysfunction (SIJD) is a condition in which the joint is locked, partially

dislocated or ‘subluxated’ in a non-anatomically correct position due to hypermobility (too much

movement) or hypomobility (too little movement) within the joint. It is commonly characterized

by low back and gluteal pain and may be accompanied with referred groin, hip and sciatic leg

pain.2 It can affect bilaterally or unilaterally. It is reported to affect 15% to 38% of general

population with women being 3 to 4 times more likely to be affected than men. It has been

implicated as primary pain source in 10-25 % of patients with low back pain.1,3,4

The muscular and ligamentous relationships composing the lumbosacral connection are of

extreme importance in stabilizing the lumbar vertebrae with Sacoiliac joint and arrangement has

been termed a ‘self-bracing mechanism. The trunk muscles, the abdominals have been reported to

increase the stability of the lumbosacral and Sacoiliac joint, further controls excessive anterior tilt

of the pelvis.8,12

Studies have shown that part of core, i.e. transverses abdominalis contraction helps reduce the

laxity of the sacroiliac joint. It was revealed that all core are needed for optimal stabilization and

performance in sacroiliac mechanics.9,10

“CORE” is described as a box with the abdominals in the front, paraspinals and gluteus in

the back, the diaphragm as the roof, and the pelvic floor and hip girdle musculature as the bottom.

Particular attention has been paid to the core because it serves as a muscular corset that works as

a unit to stabilize the body and spine, with or without limb movement.8

The term core stability is a generic description for the training of the abdominal and lumbopelvic

region. Bergmark et al divided the active muscle subsystem (core) into "global" and "local"

groups, based on their primary roles in stabilizing the core. The global muscles (dynamic, phasic,

torque producing) which includes Rectus abdominis, External oblique, Internal oblique,

Iliocostalis (thoracic portion) which are superficial muscles that they are the prime movers for

the trunk, of hip flexion, extension, and rotation and the local muscles (postural, tonic, segmental

stabilizers) which are deep intrinsic ones include Multifidus, Psoas major, Transversus

abdominis, Quadratus lumborum, Diaphragm, Internal oblique (posterior fibers), Iliocostalis and

longissimus (lumbar portions) are associated with the segmental stability of the lumbar spine

during gross whole body movements and where postural adjustments are required. 9,16,17

Strengthening core muscles found to be effective in lumbosacral dysfunctions. But there are

no studies found on effectiveness of core muscle strengthening exercises in patients with SI joint

dysfunctions as the core muscle functions influence on Sacroiliac joint pathomechanics.

Therefore, there is a need to know the effect of Core muscle strengthening exercises in Sacroiliac

joint Dysfunction that clinically benefit in considering core strengthening exercises in SI joint

Dysfunction. Hence, the present study is aiming to study the effect of core muscle strengthening

exercises in patients with SI joint dysfunction on pain using VAS and functional disability using

modified Oswestry disability index scale.

6.2 Hypothesis:

Null hypothesis :

There will be no significant difference in the effect of core muscle strengthening exercises in

patients with sacroiliac joint dysfunction.

Alternate hypothesis :

There will be significant difference in the effect of core muscle strengthening exercises in

7

patients with sacroiliacjoint dysfunction.

6.3 Review of literature :

Carolyn A. Richardson, Chris J. Snijders et. al. (2002): studied the relation between the

transverses abdominis muscles, sacroiliac joint mechanics and low back pain proved that there is

significant decrease in the joint laxity in the sacroiliac joint when the transversus abdominis

muscle were trained.10

Eyal Lederman et. al. (2008): studied the myth of core stability, followed the principles of core

strengthening program and proved that it is essential in prevention as well as rehabilitation in case

of lower back pain.11

Barr KP, Griggs M, Cadby T et. al. (2005): in their study to assess the benefits of lumbar

stabilisation program to treat low back pain proved their point that the core muscles strengthening

does play a major role in the lumbar stabilization and hence reduces low back pain.18

Julie M Fritz, Julie M Whitman et. al. (2004): in their study about the factors related to

the inability of individuals with low back pain to improve with a spinal

manipulation established their idea about inability of the manipulative therapy only, to reduce

the low back pain.15

Christopher Norrisa, Martyn Matthewsb et. al. (2008): studied the role of an integrated back

stability program in patients with chronic low back pain and proved that the integrated back

stability program including core strengthening along with the other trunk stabilising exercises

improved the patients with chronic low back pain by reducing their pain and disability.19

Garry T. Allison, BApp Sci et. al. (2008): in his research reports to find whether the feed

forward response in transverses abdominis are directionally specific and act symetrical studied,

the feed forward transverse abdominalis activity is specific to the direction of the arm movement

and not bilaterally symmetrical which is to stabilize the spine and not contribute to the control of

the centre of mass or the individual task.20

Fabio Renovato Franca, Thomaz Nogueira Burke et. al. (2010): performed a study wherein he

took two groups into consideration where one group was trained with segmental stabilization

exercises and the other with only superficial strengthening regime and in which he proved that

both do reduce the pain but segmental stabilization of the core muscles was superior to superficial

strengthening regime in reducing the pain and disability in patients with chronic back pain, and

the superficial strengthening does not improve transverses abdominis activation capacity.21

Felipe Pivetta Carpes, Fernanda Beatriz Reinehr et. al. (2007): put up a study which was,

Effects of a program for trunk strength and stability on pain, low back and pelvis kinematics, and

body balance: A pilot study, wherein the results suggested that the recruitmentment of trunk

strength and stability has positive effect on low back and pelvis pain and kinematics as well as on

body balance.22

Venu Akuthota, Andrea Ferreiro et. al. (2007): described the available literature in core

strengthening and also with the available knowledge in motor learning using a theoretical

framework has mentioned that the core stability is essential for proper load balance within the

spine, pelvis, and kinetic chain.8

Craig Leibenson et. al. (2004): studied the relationship between the sacroiliac joint musculature

with lumbopelvic instability and showed that the exercises of the key stabilizers of the

lumbopelvic region do re-establish the pain.23

6.4 Objectives of study:

1. To measure pain and functional disability before intervention in study and control group.

2. To measure pain and functional disability after intervention in study and control group.

3. To compare pain and functional disability between study and control group.

MATERIALS AND METHODS:

7.1 Source of data:

Study will be conducted in K.T.G. Hospital, Bangalore and other rehabilitation centre.

7.2 Methods of data collection:

Study design- Experimental study

Sample size- 40 subjects (20 in control group and 20 in study group)

Sampling method- simple random sampling method

Duration of the study- 1 week study, 3 sessions per week.

Materials used:

Examination Table

Plinth

Pillow

Chair

Pressure Biofeedback Apparatus

Inclusion criteria-

1. Age group between 20 – 50 years

2. Both males and females

3. Patients diagnosed with SI joint dysfunction and referred to physiotherapy intervention

4. Positive provocation test – a. Gaeslen test

b. Post sheer test

c. Compression / distraction test

Exclusion Criteria:

Spinal injuries or post surgical for the past 6 months

Neurological Conditions

Cardiac Conditions

Spondylolysthesis

Bone TB (Pott’s Spine)

Metabolic Disorders

History of fractures in Pelvis or Spine.

Outcome measure:

1. Visual Analog Scale (VAS) for pain intensity.

2. Modified Oswestry low back pain disability index for functional disability.

7.3 Intervention to be carried out on patients:

All the subjects will undergo through complete assessment and those subjects fulfilling the

inclusion criteria will be explained in detail about the study and written consent will be taken

from them and randomly allocated to either study or control group.

After taking the baseline parameters, subjects were given the treatment according to the

groups allotted.

A) Study group - Patients who will be given core muscle strengthening protocol with

conventional treatment.

B) Control group – Patients who will be given only conventional treatment.

The conventional treatment includes ultrasound for 8-10 mins, followed with exercises

including mobility exercises, such as in supine static back exercise, where the patient presses his

back against the back support hold it for 2-3 secs, static abductors/ adductors, here the patients are

made to squeeze a pillow between his both knees, in prone- back extension here the patient is

8asked to lie on their stomach place the hands near your ears and raise the back slowly, hip

extension, in the same position the whole leg is asked to be lift straight up.

The core strengthening exercises protocol will include progression of the exercises:

Base position Cue: Supine with knees bent and feet on floor; spine stabilized in neutral

position with instructing the subject to get his “navel to spine”, also termed the Abdomen

Hollowing exercise, the tummy tuck or Bracing the abdomen.

Once the subject is through with this level of exercise the further progression are:

Base position with 1 foot lifted

Base position with 1 knee held to chest and other foot lifted

Base position with 1 knee held lightly to chest and other foot lifted

Base position with Knee to chest (at 90° of hip flexion) held actively and other foot lifted

Base position with Knee to chest (at 90° of hip flexion) held actively and other foot lifted

and slide on ground.

Base position with Knee to chest (at 90° of hip flexion) held actively and other foot lifted

and slide not on ground

Base position with Bilateral heel slides

Base position with Bilateral leg lifts to 90°

Bracing in standing

Bracing with standing row

Bracing with walking

Further the progression in Quadriped position wherein the subjects are made to go on both his

knees and his hands like the all four position.

Quadruped arm lifts with bracing

Quadruped leg lifts with bracing

Quadruped alternate arm and legs lifts with bracing.

Plank-patient asked to lie prone and go on their elbows without any other contact of the

body except the foot and elbow.

Oblique plank- the exercise of plank used in side lying

Further the abdominal exercises in supine: Trunk curl, oblique crunches

Controlled lowering and raising of legs together: here the patient lie’s supine and has to

raise both legs up to maximum and then gradually put it down.

Hundreds: Lie on your back with your arms by your sides. Raise your legs and bend them

so that you form a right angle at your hips and knees. Keeping your arms straight and

lifting your hands no more than a few inches, gently tap the floor 100 times.

Leg extensions in supine: ask the subject to move the limbs in a way that are riding a

bicycle.

Each exercise is performed with set of 30 times each. And then the exercises are performed

in the next progressions once the present exercise is performed successfully. Pre and Post these

sessions the VAS scale and disability index will be collected and used for data analysis..

Statistical Analysis:

1. Statistical analysis will be done by using SPSS statistical package and graphs will be made by

using Ms. Excel and Ms. Word.

2.Unpaired t test

3.Wilcoxon signed ranked test

4. Mann-Whitney u test

5. ANOVA

7.4 Ethical clearance :

As the study includes human subjects ethical clearance is obtained from ethical committee of

institution where the subject belongs if any. Also written consent will be taken from the

participants in the study.

List of references :

1. Sherman, Andrew, Gothin. Sacroiliac joint injury, 2011;1-3.

2. Gentile, Julie, What is Sacroiliac joint dysfunction, 2010;16-21.

3. Isaac, Zacharia, Denine, Jennifer. Sacroiliac joint dysfunctions. Essentials of Physical

medicine and Rehabilitation: Musculoskeletal disorders, pain and rehabilitation,

Saunders/ Elsevier.pg 26-30.

4. Sembrane; Jonathan N. Spine 2009 34(1): E27-E32.

5. Sims, Vicki, PT. The secret cause of low back pain, Georgia- Sipress. 2004

6. Don Tigny, RL: Sacroiliac 201; Dysfunctions and management, A Biomechanical

solution, 2011, 3:644-652.

7. Darin T. Leetun, Mary Lloyd Ireland, John D. Willson, Bryon T. Ballantyne and Irene

Mcclay Davis, Medicine & Science in sports and medicine, by the American College of

Sports Medicine 2004, pg.- 926-927.

8. Akuthota V, Nadler SF. Core strengthening. Arch Phys. Med Rehabilitation 2004;85 (3

Suppl 1): S86-92.

9. V. Akuthota, Nadler SF. Core strengthening. Arch Phys. Med Rehabilitation 2007;85 (3

Suppl 1): S86-92.

10. Carolyn A. Richardson PhD. Relation between the transverse abdominals muscles, SI

joint mechanics and low back pain- Spine Vol. 27, No.-4, 2002, pg 399-405.

11. Eyal Lederman. The myth of core stability- Journal of bodywork and movement

therapies, 4 Aug. 2009

12. Cusi M. F. Paradigm for assessment and treatment of Sacroiliac joint mechanism, and

Dysfunctions, Journal of bodywork and movement therapies, 2011.

13. Boris A. Zelle. Sacroiliac joint dysfunctions, evaluation and management- The clinical

journal of pain21, no. 5, Oct.-2005, 446-455.

14. Akuthota V., A. Ferreiro, T. Moore, Current sports medicine reports from American

college of sports medicine; 2008, 39-44.

15. Julie M. Fritz, Julie M. Whitman, factors related to the instability of individuals with low

back pain improve with a spinal manipulation, Physical Therapy, Vol. 84, No.-2, Feb-

2004.

16. Marshall PW, Murphy BA. Core stability exercises on and off a Swiss ball. Arch Phys

Med Rehabil 2005;86:242-9.

17. Willardson, J.M. Core stability training: Applications to sports conditioning programs. J.

Strength Cond. Res. 2007. 21(3):979-985.

18. Barr KP, Griggs M, Cadby T: Lumbar stabilization: Core concepts and current literature,

part 1. Am J Phys Med Rehabil 2005;84:473-480.

19. Christopher Norrisa, Martyn Matthewsb : The role of an integrated back stability program

in patients with chronic low back pain: Complementary therapies in clinical

practice.2008;14;4;255-263.

20. Garry T. Allison, BApp Sci : Feedforward Responses of Transversus Abdominis Are

Directionally Specific and Act Asymmetrically: Implications for Core Stability Theories.

journal of orthopaedic & sports physical therapy.2008;38;5;228-237.

21. Fabio Renovato Franca, Thomaz Nogueira Burke : Segmental stabilization and muscular

strengthening in chronic low back pain - a comparative study.2010;65;10.

22. Felipe Pivetta Carpes, Fernanda Beatriz Reinehr : Effects of a program for trunk strength

and stability on pain, low back and pelvis kinematics, and body balance: A pilot

study.2008;12;1;22-30.

23. Craig Leibenson: The relationship of the sacroiliac joint, stabilization musculature, and

lumbo-pelvic instability. Journal of Bodywork and Movement Therapies (2004) 8, 43–45.

ANNEXURE -1

CONSENT FORM

I Ms. NIKITA RAVINDRA GHATGE have explained to................... the purpose of the

research, the procedures required, and the possible risks and benefits to the best of my ability.

......................................... ...............................................

Investigator Signature Date

College: K.T.G. COLLEGE OF PHYSIOTHERAPYPlace: Bangalore

CONSENT TO PARTICIPATE IN THE STUDY

Purpose of Research

I .........................have been informed that this study will be for Sacroiliac joint dysfunction

problems like mine. Both approaches /techniques are acceptable Physiotherapy intervention

for this problem. This study will help physiotherapy better understand the use of

Physiotherapy services in management of The sacroiliac joint dysfunction with study of

Effect of core muscles strengthening exercises in patients with sacroiliac joint dysfunction.

Procedure

I understand that I will be assigned by lot to receive exercise therapy. I will be expected to

attend Physiotherapy treatment sessions two to three times in a week in addition to doing

exercises at home.

I am aware that in addition to ordinary care received, I will be examined and asked a series of

questions by a research Physiotherapist. The Physiotherapist examination consists of

measuring Visual analog scale and the Modified Oswestry scale. I have been asked to undergo

these tests at the beginning of the study, and after the study.

Risk and Discomforts

I understand that I may experience some pain or discomfort during the examination or during

my treatment. This is mainly the result of my condition, and the procedures of this study are

not expected to exaggerate these feelings which are associated with the usual course of

treatment.

Benefits

I understand that my participation in the study will have no direct benefit to me other than

potential benefit of the treatment which is planned to reduce my pain and increase my

shoulder function. The major potential benefit is to find out which treatment program is more

effective.

Confidentiality

I understand that the information produced by this study will became part of my research

record and will be subject to the confidentiality and privacy regulation, but will be stored in

the investigator’s research file.

If the data are used for publication in the literature or for the teaching purpose, no names will

be used, and other identifiers, such as photographs and audio or videotapes, will be used with

my special written permission.

Refusal or Withdrawal of Participation

I understand that my participation is voluntary and that I may refuse to participate or may

withdraw consent and discontinue participation in the study at any time without prejudice to

my present or future care at the Hospital. I also understand that Ms. Nikita Ravindra Ghatge

may terminate my participation in this study at any time after She/He explained the reasons

for doing so.

I confirmed that Ms. Nikita Ravindra Ghatge has explained to me the purpose of the research,

the study procedures that I will undergo, and the possible risks and discomforts as well as

benefits that I may experience. Alternatives to my participation in the study have also been

discussed. I have read and I understand this consent form. Therefore, I agree to give my

consent to participate as a subject in this research project.

............................................... ..........................................

Participant Signature Date

.............................................. ..........................................

Witness to Signature Date

MODIFIED OSWESTRY SCALE

To be completed by patient This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to manage in every day life. Please answer every question by placing a mark on the line that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark only the line which most closely describes your current condition.

Pain Intensity _____The pain is mild and comes and goes. _____The pain is mild and does not vary much. _____The pain is moderate and comes and goes. _____The pain is moderate and does not vary much. _____The pain is severe and comes and goes. _____The pain is severe and does not vary much. Personal Care (Washing, Dressing, etc.) _____I do not have to change the way I wash and dress myself to avoid pain. _____I do not normally change the way I wash or dress myself even though it causes some pain. _____Washing and dressing increases my pain, but I can do it without changing my way of doing it. _____Washing and dressing increases my pain, and I find it necessary to change the way I do it. _____Because of my pain I am partially unable to wash and dress without help. _____Because of my pain I am completely unable to wash or dress without help.Lifting _____I can lift heavy weights without increased pain. _____I can lift heavy weights but it causes increased pain _____Pain prevents me from lifting heavy weights off of the floor, but I can manage if theyare conveniently positioned (ex. on a table, etc.). _____Pain prevents me from lifting heavy weights off of the floor, but I can manage light to medium weights if they are conveniently positioned. _____I can lift only very light weights. _____I can not lift or carry anything at all. Walking _____I have no pain when walking. _____I have pain when walking, but I can still walk my required normal distances. _____Pain prevents me from walking long distances. _____Pain prevents me from walking intermediate distances. _____Pain prevents me from walking even short distances. _____Pain prevents me from walking at all. Sitting _____Sitting does not cause me any pain. _____I can only sit as long as I like providing that I have my choice of seating surfaces. _____Pain prevents me from sitting for more than 1 hour. _____Pain prevents me from sitting for more than 1/2 hour. _____Pain prevents me from sitting for more than 10 minutes. _____Pain prevents me from sitting at all.

To be completed by patient Standing _____I can stand as long as I want without increased pain. _____I can stand as long as I want but my pain increases with time. _____Pain prevents me from standing more than 1 hour. _____Pain prevents me from standing more than 1/2 hour. _____Pain prevents me from standing more than 10 minutes. _____I avoid standing because it increases my pain right away. Sleeping _____I get no pain when I am in bed. _____I get pain in bed, but it does not prevent me from sleeping well. _____Because of my pain, my sleep is only 3/4 of my normal amount. _____Because of my pain, my sleep is only 1/2 of my normal amount. _____Because of my pain, my sleep is only 1/4 of my normal amount. _____Pain prevents me from sleeping at all. Social Life _____My social life is normal and does not increase my pain. _____My social life is normal, but it increases my level of pain. _____Pain prevents me from participating in more energetic activities (ex. sports, dancing, etc.) _____Pain prevents me from going out very often. _____Pain has restricted my social life to my home. _____I have hardly any social life because of my pain. Traveling _____I get no increased pain when traveling. _____I get some pain while traveling, but none of my usual forms of travel make it any worse. _____I get increased pain while traveling, but it does not cause me to seek alternative forms of travel. _____I get increased pain while traveling which causes me to seek alternative forms of travel. _____My pain restricts all forms of travel except that which is done while I am lying down. _____My pain restricts all forms of travel. Employment/Homemaking _____My normal job/homemaking activities do not cause pain. _____My normal job/homemaking activities increase my pain, but I can still perform all that is required of me. _____I can perform most of my job/homemaking duties, but pain prevents me from performing more physically stressful activities (ex. lifting, vacuuming) _____Pain prevents me from doing anything but light duties. _____Pain prevents me from doing even light duties. _____Pain prevents me from performing any job or homemaking chores.

Section 3: To be completed by physical therapist/provider SCORE: Initial_____% Subsequent_____% Subsequent_____% Discharge_____% Number of treatment sessions:________________ Diagnosis/ICD-9 Code:_______________________