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Jul20
Physical Therapy for Low Back Pain Relief
The goals of physical therapy are to decrease back pain, increase function, and teach the patient a maintenance program to prevent future back problems.
Common forms of physical therapy include:
1.Passive physical therapy (modalities), which includes things done to the patient, such as heat application, ice packs and electrical stimulation. For example, a heating pad may be applied to warm up the muscles prior to doing exercising and stretching, and an ice pack may be used afterwards to sooth the muscles and soft tissues.
2.Active physical therapy, which focuses on specific exercises and stretching. For most low back pain treatments, active exercise is the focus of the physical therapy program.
Exercise Benefits for Low Back Pain:
Lumbar spine (low back) stability is largely dependent on the supporting abdominal (stomach) and low back musculature. The abdominal muscles provide the initial stabilizing support through their ability to generate pressure within the abdomen which is exerted posteriorly on the spine, thus providing an anterior support column (from the front of the spine). The low back muscles stabilize the spine from the back and lead to posterior support. The bony spine and discs are surrounded by muscles, and the stronger these specific muscles are, the less stress is placed on the discs and joints of the spine. The patients should develop a 'belt' of muscle around their spine.
Key Aspects:
In this section, we have briefly listed the key aspects of the role of physiotherapy in management of lower back pain.
1.Advice and early activity – There is significant evidence to prove that encouraging early movement in case of lower back pain is one of the most significant aspects of treatment in this condition.
2. Mobilization or Manipulative physiotherapy – This aspect concentrates on promoting mobilization of the specific affected area. The approach of manipulative physiotherapy is used to target the specific point of pain for the purpose.
3. Specific stabilization exercises – In this aspect of physiotherapy, stress is laid on improving the strength and stability of the muscles which have been weakened due to the lower back pain.
4. General exercises and stretches – A series of properly structured exercises and stretches are usually carried out in context of the patient’s individual condition and cause of the lower back pain.
5. Ergonomic advice – Since work-related hazards account for more than 65% of lower back problems, physiotherapists also concentrate on providing accurate ergonomic device, guiding the patient on using the appropriate infrastructure at work to avoid and cure lower back pain.
6. Postural guidelines – This aspect of physiotherapy focuses on guiding the patient about the correct postural habits and ways to maintain accurate posture to avoid lower back pain.
Contact your Physiotherapist for more detailed and case specific treatment.


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Aug17
THE MANAGEMENT OF INTRACTABLE- BACK & NECK PAIN : RECENT ADVANCES: Dr. NEERAJ JAIN M.D., FIPP (USA) , 9810033800 (M) ,
DR. NEERAJ JAIN M.B,B.S., M.D., FIPP (USA)
Interventional Pain Specialist ,Spine & Pain Clinic. RU-23 Pitampura,
& Consultant Incharge, Pain Clinic, Sri Balaji Action Medical Institute, New Delhi.
, 9810033800 (Mobile).

LOW BACK/ NECK PAIN (LBP) is a pandemic disease having 80% of lifetime prevalence, affecting 15-20% population at any point of time, being one of the commonest reason for visit to a doctor & young age morbidity/disability/work absenteeism.
AETIOLOGY OF LBP:
LBP is not just a disease but a symptom, a syndrome with combination of multiple possible abnormalities of anterior & posterior longitudinal ligaments, vertebral body, synovia / chondropathy/ osteoarthritis of articulating facets joints, sacroiliac joint, nerve roots & foramen, paraspinal muscles, related connective tissues eg.- ligamentum flavum , spinal canal, intervetebral disc at annulus ring. It may be due to mechanical, nonmechanical, referred pain, psychological & failed back surgery (FBSS).

PERCUTANEOUS LEAST INVASIVE INTERVENTIONAL
PAIN MANAGEMENT OF LBP:-
It has both diagnostic & therapeutic relevance( as there are significant false positive & negative imaging studies not correlating to symptoms)
Better results are obtained if treatment is started early.
. LESI-lumbar epidural steroid injections::
. interlamminar or transforaminal or caudal approach
- BALLOON NEUROPLASTY
SNRB- selective nerve root block
. Epidural adenolysis or percutaneous decompressive neuroplasty
. Trigger point injection
. Botox paraspinal muscle injection
. Facet joint or pericapsular injection
. Spine Prolotherapy & manipulation
. Facet RF thermal neurolysis
. SI joint injection or denervation
. Piriformis muscle block
. Diagnostic provocative discography
. Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis
- Dekompressor disc debulking
- IDET-intradiscal electrothermal therapy
- Coblation nucleoplasty
- Laser percutaneous discectomy
. Vertebroplasty & kyphoplasty
. Intrathecal pump neuraxial implants
. Augmentation or neuromodulation spinal cord stimulation
ONCE THE CONSERVATIVE TREATMENT FAILS:-
Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.
Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.
Using precision diagnostic & therapeutic blocks in chronic LBP , isolated facet joint pain in 40%, discogenic pain in 25%(95% in L4-5&L5S1) ,segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.
LESI : LUMBAR EPIDURAL STEROID INJECTION
Indicated in - Acute radicular pain due to irritation or inflammation.
- Symptomatic herniated disc with failed conservative therapy
- Acute exerbation of discogenic pain or pain of spinal stenosis
- Neoplastic infiteration of roots
- Epidural fibrosis
- Chronic LBP with acute radicular symptoms
ESI TREATMENT PLAN:
Compared to interlaminar approach better results are found with transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level .
SNRB- SELECTIVE NERVE ROOT BLOCK.
Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if
. There is minimal or no radiological finding.
. Multilevel imaging abnormalities
. Equivocal neurological examination finding or discrepancy between clinical & radiological signs
. Postop patient with unexplainable or recurrent pain
. Combined canal & lateral recess stenosis.
. To find out the pathological dermatome for more invasive procedures , if needed
EPIDURAL ADENOLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY for EPIDURAL FIBROSIS OR ADHESIONS IN FAILED BACK SURGERY SYNDROMES (FBSS)
A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach
After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPE.
FACET SYNDROME:- FACET JOINT INJECTION OR
RF MEDIAL BRANCH NEUROTOMY
It is due to mechanical stress on the Zygapophysial joints or traumatic/anatomical derangement & degenerative facet arthropathy. It is commoner in male of younger age group during active careers . CT/ MRI/ Bone scan show structural pathology, but diagnosis is confirmed by relief of pain with joint injection (1ml of LA+ 20 mg triamcinolone) which has therapeutic value also.After effective facet joint block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two level medial branches of dorsal ramus is a safe, effective & long term treatment.
SACROILIAC JOINT INJECTION & DENERVATION:
The only way to make a definitive diagnosis is pain relief with image guided joint injection of depo-steroid with L.A..This can be followed by joint denervation of L4-5 S1-3 branches to this joint providing long term pain relief.
INTRADISCAL PROCEDURES::
PROVOCATIVE DISCOGRAPHY: coupled with CT
A diagnostic procedure & prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines
PERCUTANEOUS DISC DECOMPRESSION (PDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed:--
OZONE-DISCOLYSIS: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.
DEKOMPRESSOR: A mechanical percutaneous nucleotome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.

INTRATHECAL (SPINAL) PUMP IMPLANTS:
Opted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter directly into CSF needing a very small dose (1/300 of oral dose). The programmable pump is implanted in ant. lower abdomen. It delivers the drug as per the patients needs. More powerful analgesia & spasticity control is achieved using lower doses, constant relief & fewer side effects as with oral doses eg. Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse.
NEUROMODULATION TECHNIQUES:
SPINAL CORD STIMULATION (SCS) IMPLANTS :
Done for FBSS( failed back surgery syndrome) & CRPS(comlex regional pain syndromes) inUSA. In Europe it is done for chronic intractable angina & pain of peripheral vascular diseases (PVD). The indications are expanding further in chronic pain states. A set of electrodes is placed in epidural space & connected to a pulse generator ( like a cardiac pacing device) that is implanted in upper buttock. Low level of electric impulses replace pain signals to the brain with mild tingling sensation. A trial stimulation is done before permanent SCS lead implant.
PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES
As life expectancy is increasing so is the incidence of vertebral body (VB) # now being the commonest # of the body. PVP is an established interventional techniques in which PMMA bone cement is injected under L.A. via a needle into a # VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.


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Aug17
Slip Disc with Sciatica – Newer Non-Surgical Treatment
Slip Disc with Sciatica – Newer Non-Surgical Treatment
Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi, India
Abstract: Patients who are not helped by weeks of conservative therapy are often referred for surgery on the premise that further non-operative care
is unlikely to help. Ideally, a patient with low back pain that has persisted beyond a four-week period should be referred to a multidisciplinary pain
centre. With interventional pain management patients are getting back to life. It has both diagnostic and treatment values, as sometimes all
investigations put together do not give the exact diagnosis. Early aggressive treatment plan of pain has to be implemented to prevent peripherally
induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery &
20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is
important even then. Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures
with time spacing depending upon patient‘s pathology & response to treatment.
INTRODUCTION
The inter-vertebral discs are made-up of two concentric layers, the inner
gel like Nucleus Pulposus and the outer Annulus fibrosus. As a result of
advancing age, the nucleus looses fluid, volume and resiliency and the
entire disc structure becomes more susceptible to trauma and compression.
This condition is called as degeneration of the disc. The disc then is highly
vulnerable to tears and as these occur, the inner nucleus pulposus protrudes
through the fibrous layer, producing a bulge in the inter-vertebral disc.
This condition is named as herniated disc. This can then cause compression
to the spinal cord or the emerging nerve roots and lead to associated
problems of Sciatica radiating pain from back to legs in the distribution
of the nerve. Other symptoms could be weakness, tingling or numbness
on the areas corresponding to the affected nerve. Sometimes bowel or
bladder sphincter compromise is also present, which is made evident for
urine retention and this need to be taken care as an emergency.
“Do not take your back for guaranteed” says Dr. Jain who is heading
Spine & Pain Clinic, New Delhi. One can prevent back pain with spine
care and avoiding risk factors like bad postures like slouch & couch,
osteoporosis, obesity, smoking, prolonged driving, sedentary lifestyle, too
heavy or too little exercise, bad spine postures and wrong way of pushing
or lifting heavy objects.
While spinal arthritis is the common reason of young age back pain at
prime of their carriers including some sports & film celebrities, disc
diseases including slip disc is prevalent in all age groups, in young age
due to trauma & in old age due to degeneration. Also, it has to be known
that those who had a herniated disc have 10 times more chances of having
another herniation than the rest of the population.
The first steps to deal with a herniated or prolapsed lumbar disc are
conservative. These include rest, analgesic and anti-inflammatory
medication and in some cases physical therapy. At this point it is convenient
to have some plain X-rays done, in search of some indirect evidence of
the disc problem, as well as of degenerative changes on the spine.
If in a few days these measures have failed, the diagnosis has to be
confirmed by means of examinations that give better detail over the troubled
area, as the MRI, CT which will show the disc, the space behind it and in
the first case, the nerves. In some instances the EMG (electromyography)
is also of great value, as this will show the functionality of the nerves and
muscles.
Provocative Discography: coupled with CT: A diagnostic procedure
& prognostic indicator for surgical outcome is necessary in the evaluation
of patients with suspected discogenic pain, its ability to reproduce
pain(even with normal radiological finding), to determine type of disc
herniation /tear, finding surgical options & in assessing previously
operated spines.
NEED FOR NON-SURGICAL OPTIONS
Outcome studies of lumber disc surgeries documents, a success rate
between 49% to 95% and re-operation after lumber disc surgeries ranging
from 4% to 15%, have been noted. “In case of surgery, the chance of
recurrence of pain is nearly 15%. In FBSS or failed back surgery the
subsequent open surgeries are unlikely to succeed.
Reasons for the failures of conventional surgeries are:
1. Dural fibrosis
2. Arachnoidal adhesions
3. Muscels and fascial fibrosis
4. Mechanical instability resulting from the partial removal of boney &
ligamentous structures required for surgical exposure &
decompression
5. Presence of Neuropathy.
6. Multifactorial etiologies of back & leg pain , some left unaddressed
surgically.
NON-SURGICAL TREATMENTS
Patients who are not helped by weeks of conservative therapy are often
referred for surgery on the premise that further non-operative care is
unlikely to help. Ideally, a patient with low back pain that has persisted
beyond a four-week period should be referred to a multidisciplinary pain
centre. Early aggressive treatment plan of pain has to be implemented to
prevent peripherally induced CNS changes that may intensify or prolong
pain making it a complex pain syndrome.
Depending upon the diagnosis one can perform & combine properly
selected percutaneous fluoroscopic guided procedures with time spacing
depending upon pt‘s pathology & response to treatment. Different non
surgical interventions can be employed successfully:
• Epidural Steroid Inj. Via interlamminar/ transforaminal or caudal
route.
• BALLOON NEUROPLASTY & Nerve root sleeve block.
• Epidurogram & Epidurolysis.
• Nucleoplasty- Laser, Coblation, Drill, RF Biacuplasty
decompressions.
• Ozone Discolysis
• Facet Joint Block & RF Denervation
• SI Joint Block
Once the diagnosis has been confirmed, one of the best alternatives existing
today is the Ozone Discolysis as the results obtained are excellent and
practically has no complications. In most patients left with pain killers as
the only treatment, the symptoms eventually disappear, only that this could
take weeks to months. Ozone speeds up these developments, seen the
same result in a few weeks. The problem has to be seen and approached
integrally and frequently the combination of therapies has to be used,
most frequently physiotherapy.
OZONE DISC TREATMENT
Ozone Disc Treatment a revolutionary newer technology cures many of
the patients of slip disc & sciatica, as ozone’s nascent oxygen atom shrinks
the disc, taking away pressure from pain sensitive nerves. It is non surgical,
safe & effective alternative to open spine surgery, now the treatment of
choice for prolapsed disc (PIVD) done under local anaesthesia in a day
care setting with success rate of 80% in early degenerative disc disease.
This procedure is ideally suited for cervical & lumbar disc herniation
with nerve compression. Total cost of the needle procedure is much less
than that of surgical discectomy. Patient does not require bed rest for
more than a day or two & prolonged absence from work realizing the
importance of time, at much lower cost with almost no complications.
This procedure is done under radiological guidance for precise needle
placement and best results. Then patient is given advice for spine care &
healthy habits. This technology is latest & many people including medical
caregivers don’t know about it. It has benefited millions in developed
world and is now available in India also.
Only 5% of total low back pain patients would need surgery & 20% of
Various Stages of Disc Disease
Sciatica- Back pain radiating to Leg
Cervical Disc Ozone Injection Disc Cervical Ozone Injection
Cervical Disc Pressing Nerve Disc – IDET
Postero-lateral Approach for Lumbar Disc AP & Lat. Views of Intradiscal needle
Needle Discectomy for Slip Disc Ozone Chemonucleolysis
discs rupture or hernia patient would need surgery. Non-operative treatment
is sufficient in most of the patients, although patient selection is important
even then. If despite the ozone therapy the symptoms persist, Percutaneous
intradiscal decompression can be done with Drill Discectomy/ Laser or
Coblation Nucleoplasty/ Biacuplasty are good alternatives before open
surgerical Discectomy which has to be contemplated in those true
emergencies, as mentioned above as the first choice.
DEKOMPRESSOR DRILL DISCECTOMY
A mechanical device cuts & drills out the disc material debulking the
disc reducing nerve compression curing Sciatica & Brachialgia. It comes
in needle size of 17G for lumbar discs & 19 G for cervical discs. In
lumbar region postero-lateral approach is used & in cervical discs anterolateral
approach is used. In Biacuplasty radiofrequency energy is used in
bipolar manner heating & shrinking the disc & making it harder as well
for weight bearing. In Laser or Coblation Nucleoplasty energy is used
to evaporate the disc thereby debulking to create space for disc to remodel
itself.
Dr. Neeraj Jain‘s massage is “pain is real and treatable- there is no merit
in suffering” “No one needs to suffer as so many good and effective
treatments are now available at specialty pain clinics”. You must see a
pain specialist if you still suffer from pain after a month of conservative
treatment. Sooner your pain is managed better are the overall results.
With interventional pain management patients are getting back to normal
life.
BIBLIOGRAPHY
1. Olmarker K, Rydevik B. Pathophysiology of sciatica. Orthop Clin North Am 1991; 22:223-234.
2. McCarron RF, Wimpee MW, Hudkins PG, Laros GS. The inflammatory effect of nucleus pulposus:
a possible element in the pathogenesis of low-back pain. Spine 1987; 12:760-764
3. Bogduk N, Aprill C, Derby R. Epidural steroid injections. In: White AH, eds. Spine care. Vol 1. St
Louis, Mo: Mosby, 1995; 322-343.
4. Dussault RG, Kaplan PA, Anderson MW. Fluoroscopy-guided sacroiliac joint injections. Radiology
2000; 214:273-277.
5. Kinard RE. Diagnostic spinal injection procedures. Neurosurg Clin N Am 1996; 7:151-165
6. Deer T, et al.. Initial experience with a new rechargeable generator: A report of twenty systems at
3 months status postimplant in patients with lumbar postlaminectomy syndrome. Abstracts of the
9th Annual Meeting of the North American Neuromodulation Society, Nov 10-12, 2005, Washington,
D.C.
7. Dr. Neeraj Jain. Balloon neuroplasty: expanding the scope and effectiveness of interventional
techniques for management of pivd with disco-radicular conflict in new and previously failed
interventions or surgeries. 1st WIPF 2013, 911939 _ WIPF_DEF.indd 67, 8/11/13 17:27
Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain
Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New
Delhi. e-mail: managepain@yahoo.com www.spinenpain.com


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Aug17
Vertebroplasty & Kyphoplasty: Novel Approach to Osteoporotic Spine Fractures
Vertebroplasty/Kyphoplasty: A Novel Approach for Treatment of Spine Fractures
Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi, India.
Abstract: As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body.
Percutaneous Vertebroplasty/ Kyphoplasty (PVP) is an established interventional technique in which bone cement is injected under local anaesthesia
via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines,
increased mobility with improved quality of life and early return to work in days. In this era of minimally access surgery replacing open surgeries, PVP
is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression
fracture spine. PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral
fractures. Vertebroplasty is a palliative procedure and does not correct the underlying cause of the vertebral fracture. Medical management of
osteoporosis or malignancy must therefore be initiated and continued.

INTRODUCTION
Discovering the fact that fracture /# vertebrae is the commonest # of
body, its incidence >the # hip, it becomes imperative to take it more
seriously. With increasing life span there is more of aged osteoporotic
population, more so due to sedentary indoor lifestyle and post menopausal
osteoporosis. Diabetics, smokers & alcoholics are at higher risk of
developing osteoporosis. I have seen such alcoholic patient developing
six spine fractures in just three months time from a single fracture being
on complete bed rest.
Stable VB # are normally treated conservatively with bed rest, strong
analgesics, removable braces, a programmed progressive ambulation and
physiotherapy. Fractures with > 50% of anterior VB collapse or > 20%
of sagital angulations are potentially unstable and may require posterior
instrumentation and fusion if not cemented in time. For burst # pedicle
instrumentation with extension segmental constructs are required. PVP
is not ideal for # dislocations or # distractions. Spine surgeon has to be
consulted if patient needs operative spine stabilization.
Quick fix of fracture spine makes patient walk back same day instead of
bed rest of months together avoiding morbidity & mortality of prolonged
bed rest, making bedridden patient walk, in a way bringing patient back
to normal life.
VERTEBROPLASTY: AN OVERVIEW
Percutaneous Vertebroplasty (PVP) is an established interventional
technique in which rapidly hardening surgical polymethyl methacrylate
bone cement is injected under local anesthesia via a large bore needle
into a vertebral body (VB) under imaging guidance providing increased
bone strength, stability, pain relief, decreased analgesics, increased
mobility with improved QOL and early return to work. Kyphoplasty has
the added advantage of addressing fracture with spinal deformity and
appears to be associated with fewer instances of bone cement
extravasations.
As per Greek mythology pain was thought to be due to intrusion of particles
into soul, now pain relief is done by intrusion of particles into bone. The
bone of content is to fill bone with content. In this era of MAS replacing
open surgeries, PVP is a novel procedure & should be in the first line of
management in place of painful conservatism or major spinal surgery
with a list of complications in polytrauma settings for painful
uncomplicated VB #; especially when the spine surgery is relatively
complicated or patient refuses due to surgery phobia or cost involved or
there may be comorbid conditions /injuries deterrent for surgery. PVP is
a big help in polytrauma setting when stabilizing spine does lot of good
to the patient’s overall management.
Collapsed 1 year old # Both spine & Implant fractured! # Spine with bowel & bladder
involved
INDICATIONS
Started in 1984 by Galibert PVP is done in host of indications: Senile
osteoporotic compression # remains the commonest Indication (83%).
Both men and women are at risk for spinal fractures, with over 700,000
new fractures occurring every year. In fact, one in four women over 50
will suffer an osteoporosis related spinal fracture. Even more startling,
spinal fractures are twice as likely as hip fractures. And they’re three
times more common than breast cancer. Yet as many as two-thirds of
spinal fractures go untreated.
• Painful new or progressive osteoporotic collapse # refractory to
medical therapy or dosage of analgesia leads to unacceptable side
effects.
• Complicating Co-morbid diseases, on steroids & received transplant.
• To reduce loss of vertebral height and possibility of continued collapse
• Metastatic VB #, Multiple Myeloma VB # (3%). Approximately 30%
of patients with various neoplastic conditions develop symptomatic
spinal metastases during the course of their illness & pain is the
presenting complaint in the majority of cases.
• Aggressive painful VB haemangioma
• Vertebral osteonecrosis
• For strengthening VB before major spinal surgery.
• The benefit has been extended to the traumatic uncomplicated VB
compression # (VCF) (14%) which is commoner in younger age
group with active life profile and prime of their career where strict
bed rest and acute or chronic pain are unacceptable and they are
more demanding for proactive treatment approach so as to be back
to work ASAP.
CONTRAINDICATIONS
• Pre-existing neurological deficit
• Burst fractures (relative C/I)
• Fracture related spinal canal stenosis
• Uncorrectable coagulation disorders
• Allergy against bone cement or contrast media
• Unable to lie prone
LONG-TERM MORBIDITY &
CONSEQUENCES OF VERTEBRAL
COMPRESSION FRACTURES
Whether painful or not, the long-term consequences of VCF can be
devastating and can include:
• Traumatic VB # is painful condition requiring bed rest restricting
daily activities markedly as “spine cripples”.
• Left untreated it can cause DVT, increase osteoporosis, loss of VB
height, respiratory & GI disturbances, emotional & social problems
secondary to unremitting pain, loss of independence with high cost
of rehabilitation.
• High risk of primary or consequential damage to neural, bony or disc
elements.
• Increased wedging, deformity & increase incidence of fall and
adjacent VB #.
• Chronic debilitating pain of kyphosis & altered spine mechanics.
• Uncomfortable braces & sleep disturbance because of pain &
discomfort with its sequels.
• Decreased pulmonary function and increased lung disorders , 9%
reduction in vital capacity per #
• Decreased appetite and potential for malnutrition due to stomach
compression & visceral crowding.
• Five-fold increased risk of future vertebral fractures after the first
and 75-fold increased risk after 2 or more vertebral fractures coupled
with low bone mass
• Increased dependence on family and friends
• 40% Clinical anxiety and/or depression
• Loss of self-esteem and compromised social roles
MORBIDITY & COMPLICATIONS OF SPINAL
SURGERY
• Cost of surgery and hospital treatment
• Cost of implants
• Phobia of surgery
• Prolonged recovery period & Extensive rehabilitation
• Changed spinal mechanics & transition syndrome
• Major surgery & anesthesia with its own complications
• Anaesthesia related • DVT • Mechanical Pulmonary
• Medical morbidity • Infection • Hardware related
Persistent pain
• Implant migration • Spinal cord/nerve injury
Pseudoarthrosis
• Sexual dysfunction • Transition syndrome
PRE-OPERATIVE WORKUP
Detailed history & investigation including coagulation profile.
Neurological battery checkup of motor / sensory / reflexes should be done
pre & post operatively & notified. In neurological deficiency wait for 72
hrs for spinal shock to wean off if there was any and then take decision
accordingly
X-ray spine in A/P & lat view. CT is more informative of bone & #
morphology. MRI is good for soft tissue injuries e.g. spinal cord/ root
damage, hematoma, canal stenosis and ligamentous injury
Ask for pedicle size in all dimensions and construct a 3D image aiming
needle placement and cement filling mentally in scan room itself as
rehearsal of PVP. This reduces operative time & gives better results.
Outcome with risk & complication should be well informed & consented
HOW TO PERFORM PVP STEP BY STEP
Sedate with fentanyl & midazolam. To have a feedback in case of any
eventuality instantly, only sedate the patient. Start oxygen, monitor vitals.
Prone positioning with adequate padding.
Fix fluoroscope view as desired & check for its movements.
Total aseptic precautions of major surgery. Cleaning & fully draping of
the patient and the C-Arm.
Do skin marking & measurements & Give liberal local anaesthesia from
skin up to the bone.
Adjust fluoroscope from P/ A to oblique to see “Scottie dog” with pedicle
in maximum oval view with flattened end plates, hit the superior lateral
quadrant of pedicle oval for transpedicular approach. Alternatively
parapedicular route is used in thoracic region & antero-lateral approach
for cervical vertebra.
• 23-34 % increased age adjusted mortality compared with patients
without VCF
• Women unaware that they have vertebral fractures have a 16%
increased mortality compared to women without fracture
• Nine-fold increased risk of mortality in 4 years, compared with 7-
fold increased risk with hip #
• Women with vertebral fractures are 2-3x more likely to die of
pulmonary causes than those without fractures

Conventionally PVP is done by hammering the vertebroplasty needle
through the bone. Here we used light weight drill to bore through the
vertebra. With drill one can do a graduated drilling starting from smaller
gauze wire, this allows extra scope for maneuvering needle to the desired
most location in VB which is difficult to attain with hammered bone
biopsy needle which by its impact cause unacceptable distraction of #
fragments & intense pain.
It is important to set the needle at exact entry site & side with right
trajectory aiming the # defects
In lateral view needle should go through middle of the pedicle going up
to anterior 1/3 of VB.
In P/A view the needle can be in midline or paramedian depending upon
# & if uni/bipedicular approach is planned
Wash haematoma of VB with saline. Do bone biopsy if there is any doubt
about # lession. Do dye test (vertebral venography). Always wash dye
with saline before injecting cement to have good view of cement flow.
Make cement more radiopaque by adding barium /or tungsten. Then inject
cement with 1 or 2 ml leurlock syringes strictly under fluoroscope in
lateral view & cross checking in P/A view. Stop injecting either there is
adequate filling or at the first sight of ectopic cement leak. Total cement
volume varies as per fracture morphology, osteoporotic cavitation & level
of vertebra. Keep sample cement to see for hardening. Remove needle
with rotational movement before cement hardens.
COMPLICATIONS OF PVP/ KYPHOPLASTY
• PVP is generally safe with low risk.
• Ectopic cement leak is frequent but generally inconsequential..
• Symptomatic cement extravasation incidence depends upon etiology
of fracture.
• Osteoporosis 1-2%
• Neoplasm 5-10%
• Location of ectopic cement leaks
• Epidural
• Foraminal
• Paravertebral
• Disc
OUTCOME
• PVP is a novel procedure with high benefit to risk ratio, which is
highly underutilized in relation to the high prevalence of the vertebral
#.
• Different studies show an immediate pain relief in (85 - 90)% of
patients with low complication rate ranging from (1-5)% depending
upon the type of lesion.
• PVP does augment height of VB but ideal would be kyphoplasty.
• Patient is either off medicine or on reduced doses.
• Patient feels so well that he almost forgets about VB #.
Pain relief is by virtue of different mechanisms postulated :
• Cementing of # fragments
• Thermal neurolysis of VB nerve ending, sinu-vertebral nerve & DRG
due to heat of polymerization
• Washing away of nociceptor chemicals
• Neurolytic action of liquid monomer
• By allowing early ambulation decreasing pains of immobility & bed
rest
NEW DEVELOPMENTS
• Non PMMA cements
• Bioactive glass
• Hydroxyapatite
• Osteoconductive coral granules
• Composite cements
• Ideal cement volumes
• Variations of technique
Kyphoplasty or Balloon Vertebroplasty is cementing the fractured
vertebra after creating cavity, is ideal for collapse osteoporotic # with
Varied Vertebrae Anatomy PVP in lat. view
PVP in A/P view Cross-section of PVP
Vertical collapse All six vertebrae cemented & secured
One & three year old # Cemented with preemptive fill in next Habitual #
osteoporotic patient
# Spine patient ventilated/ Normal after cementing

CONCLUSION
• With rich experience in osteoporotic PVP one can comfortably pass
the benefit to traumatic # where -it is more rewarding & satisfying.
• With PVP you just don’t manage pain rather you treat it. It is also
important to remember to address the underlying condition of
osteoporosis. Improve patients bone health and reduce risk for future
fractures through a combination of medication, diet, exercise and
lifestyle modifications.
• Very few people die of pain, many die in pain and even more live in
pain, some of them are sequel to spine traumatic fractures, a reversible
suffering.
• We have to keep pace with patients needs.
• PVP may be is the future of uncomplicated VCF management.
• kyphoplasty has the added advantage of addressing spinal deformity
and appears to be associated with fewer instances of bone cement
extravasation.
• Pain means punishment, we can avoid the chronic punishment of
VCF with PVP avoiding all D’s of disability, depression, drugs
dependence, deformity, dissociation & dejection.
• In future we are looking for high radiopaque biodegradable or
bioactive bone pastes or cement or glues with more procedural time
relaxation which will strengthen the bone while inducing new bone
growth.
• Vertebroplasty is a viable treatment and possible standard
management of the pain and disability of vertebral fractures needing,
height loss & can be employed in selected traumatic wedge collapse VB
# with height loss.
Balloon kyphoplasty
• Restores vertebral body height
• High pressure ballooning (150-400 psi) followed by cement injection
into cavity created by balloon
• fewer complications resulting from cement extravasation
• reduction in morbidity of kyphosis
Clinical outcome data
• 22 published observational studies
• Retrospective designs
• Short term follow up
• Concurrent treatment modalities
• Three series of >250 patients
• Gangi et al Radiographics 2003(868 patients)
Clinical outcome data balloon kyphoplasty
• Five published case series
• Largest describes 188 procedures in 78 patients with minimum 1
year follow up (Coumans JV et al J Neurosurg2003)
• No comparisons with vertebroplasty or conservative therapy
• Pain relief scores similar to those achieved by vertebroplasty
• Adequate training
• Meticulous technique
• Careful patient selection
• If you don’t take up the job the Robots will take over.
BIBLIOGRAPHY
1. Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral
angioma by percutaneous acrylic vertebroplasty [in French]. Neurochirurgie 1987;33:166-168
2. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous
polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression
fractures: technical aspects. AJNR Am J Neuroradiol 1997;18:1897-1904
3. Mathis JM, Petri M, Naff N. Percutaneous vertebroplasty treatment of steroid-induced osteoporotic
compression fractures. Arthritis Rheum 1998;41:171-175
4. Chiras J, Depriester C, Weill A, Sola-Martinez MT, Deramond H. Percutaneous vertebral surgery:
techniques and indications [in French]. J Neuroradiol 1997;24:45-59
5. Deramond H, Depriester C, Galibert P, Le Gars D. Percutaneous vertebroplasty with
polymethylmethacrylate: technique, indications, and results. Radiol Clin North Am 1998;36:533-
546
6. Gangi A, Kastler BA, Dietemann JL. Percutaneous vertebroplasty guided by a combination of CT
and fluoroscopy. AJNR Am J Neuroradiol 1994;15:83-86
7. Tohmeh AG, Mathis JM, Fenton DC, Levine AM, Belkoff SM. Biomechanical efficacy of
unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression
fractures. Spine 1999;24:1772-1776
8. D. H. Choe, E. M. Marom, K. Ahrar, M. T. Truong, and J. E. Madewell
Pulmonary Embolism of Polymethyl Methacrylate During Percutaneous Vertebroplasty and
Kyphoplasty Am. J. Roentgenol., October 1, 2004; 183(4): 1097 - 1102.
9. M. Mathis, A. O. Ortiz, and G. H. Zoarski Vertebroplasty versus Kyphoplasty: A Comparison and
Contrast AJNR Am. J. Neuroradiol., May 1, 2004; 25(5): 840 - 845.
10. D. F. Kallmes and M. E. Jensen. Percutaneous Vertebroplasty Radiology, October 1, 2003; 229(1):
27 - 36.
11. Padovani B, Kasriel O, Brunner P, Peretti-Viton P. Pulmonary embolism caused by acrylic cement:
a rare complication of percutaneous vertebroplasty. AJNR Am J Neuroradiol 1999;20:375-377
12. Belkoff SM, Fenton DC, Scribner RM, Reiley MA, Talmadge K, Mathis JM. An in vitro biomechanical
evaluation of an inflatable bone tamp used in the treatment of compression fracture.
Spine 2001;26:151-156
13. J. M. Mathis, J. D. Barr, S. M. Belkoff, M. S. Barr, M. E. Jensen, and H. Deramond
Percutaneous Vertebroplasty: A Developing Standard of Care for Vertebral Compression Fractures
AJNR Am. J. Neuroradiol., February 1, 2001; 22(2): 373 - 381.
14. K. Kim, M. E. Jensen, J. E. Dion, P. A. Schweickert, T. J. Kaufmann, and D. F. Kallmes
Unilateral Transpedicular Percutaneous Vertebroplasty: Initial ExperienceRadiology, March 1,
2002; 222(3): 737 - 741.

Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain
Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New
Delhi. e-mail: managepain@yahoo.com www.spinenpain.com


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Jan18
EFFECTIVENESS OF FALDENKRAIS THERAPY WITH ROLF’S MOBILIZATION ON PAIN AND DISABILITY IN CHRONIC LOW BACK PAIN- A COMPARATIVE STUDY”
EFFECTIVENESS OF FALDENKRAIS THERAPY WITH ROLF’S MOBILIZATION ON PAIN AND DISABILITY IN CHRONIC LOW BACK PAIN- A COMPARATIVE STUDY”
INTRODUCTION
Low back pain (LBP) is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain. LBP has a lifetime prevalence of 60–85%. At any one time, about 15% of adults have LBP. LBP poses an economic burden to society, mainly in terms of the large number of work days lost (indirect costs) and less so by direct treatment costs. A substantial proportion of individuals with chronic LBP has been found to have chronic widespread pain. LBP is often associated with other pain manifestations such as headache, abdominal pain and pain in different locations of the extremities. Widespread pain is associated with a worse prognosis compared to localized LBP.2
Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be aching, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe. Many times, the source of the pain is not known or cannot be clearly defined. In fact, in many instances, the condition or injury that triggered the pain may be completely healed and undetectable, but the pain may still continue to bother you. Even if the original cause of the pain is healed or unclear, the pain you feel is real. It is your health care provider’s job respect your experience of pain, regardless of its cause.1

There are enormous causes of low back pain. This constitutes congenital, traumatic, inflammatory, degenerative, neoplastic, metabolic, postural, idiopathic, pain referred from viscera, genitourinary diseases, pregnancy, gynaecological diseases etc.3

Low back pain (LBP) is the main cause of absenteeism and disability in industrialized societies. Approximately 10%-20% of patients with LBP develop chronic LBP,defined as pain and disability. 4
Chronic low back pain is a common symptom that presents as localised or widespread pain in the lower back, often accompanied by a lack of flexibility and tenderness in the lower back. This condition is defined by activity intolerance due to lower back or leg symptoms (sciatica) lasting more than three months.5

Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be achey, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe. Chronic low back pain may be the result by many different conditions. It may start from diseases, injuries or stresses to a number of different anatomic structures including bones, muscles, ligaments, joints, nerves or the spinal cord. The affected structure sends a signal through nerve endings, up the spinal cord and into the brain where it registers as pain.6
Psychological factors are even more important in people with chronic back pain. Dissatisfaction with a work situation, a supervisor, or a dead-end job and boredom contribute greatly to the onset and persistence of back pain7


Low back pain can be caused by a variety of conditions including musculoskeletal, osteoarticular and neurogenic disorders. Over the past 30 yrs, the rate of disability claims related to low lackache has increased by 14 times the rate of population growth.9

Low back pain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic. Eighty five percent of chronic low backpain (CLBP) disorders have no known diagnosis leading to a classification of ‘non-specific CLBP’ that leaves a diagnostic and management vacuum. Even when a specific radiological diagnosis is reached the underlying pain mechanism cannot always be assumed. It is now widely accepted that CLBP disorders are multi-factorial in nature. However the presence and dominance of the patho-anatomical, physical, neuro-physiological, psychological and social factors that can influence the disorder is different for each individual. Classification of CLBP pain disorders into sub-groups, based on the mechanism underlying the disorder, is considered critical to ensure appropriate management.10

Despite considerable efforts to solve the problem of chronic low back pain (CLBP), it still has a high prevalence and considerable socioeconomic consequences all over the industrialized world. It would be advantageous to identify at an early stage those patients at high risk of developing persistent or recurrent low back pain (LBP) and to direct the treatment (active or multidisciplinary) modalities to that group.11

Muscular dysfunction plays an important role in the pathogenesis of low back pain syndromes, and forms an essential part in postural defects . In response to mechanical derangement and pain certain muscle groups, the postural muscles, show a tendency to get hypertonic and tight, and are readily activated in most movement patterns . They are less liable to atrophy and have a pronounced postural function . They include the hamstrings, iliopsoas and trunk extensors. The opposite group, the phasic muscles, on the contrary, tend to react to a given situation by inhibition, atrophy and weakness . They include the abdominals, and the glutei.12

Back pain is among the commonest rheumatological complaints and is responsible for a substantial proportion of total morbidity and loss of work through illness.13

More than 85% of patients who present to primary care have low back pain that cannot reliably be attributed to a specific disease or spinal abnormality (nonspecific low back pain).14

About 60% to 80% of the population in the western world will experience low back pain (LBP) at some stage in life. Due to a favorable prognosis in the acute stages, 80% to 90% of the patients will improve considerably within 6 to 8 weeks.10,26,46 The prognosis for chronic LBP is considerably less favorable, causing potentially long-lasting suffering to the patient and significant socioeconomic costs.15

Treatment targets are reduction of pain and better activity/participation, including prevention of disability as well as maintainance of work capacity. The evidence from selected and appraised guidelines, systematic reviews and major clinical studies was classified into four levels, level Ia being the best level with evidence from meta-analysis of randomised controlled trials.2
The Feldenkrais Method was developed by Moshe Feldenkrais (1904-1984) (Reese 1985/86) after more than 40 years of refinement (Brice 1990). It is purely an educational approach, which claims neither to diagnose, treat nor cure (Rywerant 1983, p. 162). Feldenkrais believed that the cause of repeated injury, many pains and movement restrictions was predominantly the result of poor habitual use of oneself (Auburn 1985, Wanning 1993), brought about from half-learnt or badly learnt movement patterns.16

The Feldenkrais Method (FM) is an educational approach that focuses on expanding kinesthetic awareness as a basis for improving function (Stephens, 2000). FM has two different modes of instruction: Functional Integration (FI) and Awareness Through Movement (ATM). FI is individualized instruction where the individual receives hands on guidance through gentle touch. ATM consists of group lessons, verbally guided, where movements are self-directed and executed within each individual’s comfort range. ATM is the focus of this investigation.17

The Feldenkrais Method is a way of learning — learning to move more freely and easily, to carry less stress in your body, to stop doing the things that cause you pain. Through gentle movement and directed attention, it enhances your self-awareness to put you back in touch with yourself, with the fluid, easy movement that is your birthright. We call this kind of learning somatic education.18

The Feldenkrais Method is an approach to improve peoples' ability to learn and to function through simulating the exploratory style of learning natural to infants. people can learn new patterns of movement specifically designed to expand body awareness and to enhance the neuromuscular self-image through more efficient and comfortable movement.19

ATM lessons are 10 to 60 minutes in length and movements are performed slowly and gently. Pain and effort during the lesson (straining and compensatory motions) are avoided, as the occurrence of pain would trigger a defensive muscle pattern, which would interfere with improvement. ATM begins with simple, minute movements, which are used to reduce latent tonus (degree of involuntary muscle contractions) and to learn how to direct and maintain attention. As the individual progresses, the movements become more advanced in their complexity, speed, size, and trajectory of motion until the movements are functional and can be applied to daily activities (Houglum, 2005). 17,18

Some studies have suggested that ATM produces a change in the amount of muscular activity as measured by electromyography (EMG). Perceptual recognition of the change in muscular activity is produced and this recognition is not the direct result of the use of suggestion, imagery, and visualization.17

Stephens et al. (2001) investigated the effects of the ATM on balance and balance confidence in people with multiple sclerosis and found significantly improved balance confidence compared to controls.20

Lundblad, Elert, and Gerdle (1999), in a randomized controlled trial of 97 subjects, found significantdecrease in neck and shoulder pain and disability for participants in the Feldenkrais group (that included both modes ATM and FI) compared to the control and physiotherapy groups.21

Research by Bearman and Shafarman (1999), showed significant increases in functional mobility in seven participants, both immediately after an eight-week program of ATM lessons and in a one-year follow-up questionnaire. These studies demonstrate the benefits of the Feldenkrais Method on pain perception, mobility and improving body mechanics in participants with RA and neck and shoulder pain.22

Smith and colleagues (2001) assessed pain in three dimensions, affective, sensory and evaluative on 26 subjects. After a 30-minute ATM lesson, significant differences in pain reduction were found between the ATM and control groups in the affective dimension of pain. No significant differences were found in the sensory and evaluative dimensions.23

Rolfing Structural Integration is a form of bodywork that aims to align the body in the gravitational field by manual manipulation of the body’s neuro-myofascial system. Rolfing was developed by Ida P. Rolf, PhD, a biochemist who developed the 10-series of Structural Integration over 50 years ago. The series aims to get the major segments of the body aligned and coordinated so ease and comfort can be experienced in a client’s body. Rolfing can create a more effective use of muscles, thereby conserving energy during movement due to more refined, economical patterns.24

If you can imagine how it feels to live a fluid, light, balanced body, free of pain, stiffness and chronic stress, at ease with itself and the gravitational field, then you will understand the purpose of Rolfing.
Rolfing achieves its remarkable results by manipulating the myofascial system. The myofascial system is composed of muscle tissue and a form of connective tissue called fascia. it is not a form of massage, bodywork, deep tissue, myofascial or osseous release therapy. Rather, Rolfing is a form of holistic/integrative somatic education and manipulation that deals not just with the symptoms of distress, but with the whole person in relation to gravity.25








Figure 1.1: Rolf’s mobilization

Rolfing is well known for getting quick and long lasting results with a wide variety of problems, as well as dramatically changing posture and enhancing one's performance in many activities.
Here are a few examples of what Rolfing has been known help:
• Postural Correction
• Back Pain
• Neck Pain and Headaches
• TMJ
• Sports Injuries
• Auto Injuries
• Carpel Tunnel Syndrome
• Greater Flexibility and Freedom of Movement
• Increased Well-Being
• Performance Enhancement

Rolf (47) and Gordon (19) have proposed the use of soft tissue mobilization and guided movement techniques for treating low back pain conditions that have been correlated with pelvic asymmetry in the sagittal plane. They assume that sacroiliac joint dysfunction, including unilateral and bilateral rotations of the innominate bones, is a major contributing factor to biomechanically induced low back pain.26

The sacroiliac joints are often considered a source of low back pain 1-7 Debate has continued over the existence of sacroiliac joint dysfunction. Some view the sacroiliac joint as an insignificant contribution to low back pain & l0 whereas others believe the sacroiliac joint plays a major role in low back pain.27
A case study indicates that a holistic approach using Rolfing and movement education shows greater promise in treating low back pain than the corrective approach.25
Cottingham and Kent Richmond shows The effects of soft tissue manipulation (Rolfing method) were evaluated on young healthy men using two dependent variables: 1) angle of pelvic inclination and 2) parasympathetic activity. The results provide theoretical support for the reported clinical uses of soft tissue pelvic manipulation for 1) certain types of low back dysfunction and 2) musculoskeletal disorders associated with autonomic stress.28

Hence, this study was designed to determine the effectiveness of two forms of therapy interventions such as Feldenkrais therapy and Rolf’s mobilization in participants with chronic Low Back Pain on visual analogue scale and Modified oswestry Low Back Pain disability questionnaire.







AIMS AND OBJECTIVES OF STUDY
1. To study the effectiveness of feldenkrais therapy along with back exercises in chronic low back pain.
2. To study the effectiveness of rolf’s mobilization along with back exercises in chronic low back pain.
3. To compare the effectiveness between feldenkrais therapy and rolf’s mobilization along with back exercises in chronic low back pain.
HYPOTHESIS
(1) Null Hypothesis (H0):
There is no significant effect on pain and disability in subjects treated with feldenkrais therapy and rolf’s mobilization in low back pain.
(2) Experimental Hypothesis (H1):
There is significant effect on pain and disability in subjects treated with feldenkrais therapy and rolf’s mobilization in low back pain.
STATEMENT OF THE QUESTION

In patients with chronic low back pain,will feldenkrais therapy along with back exercises compared to of rolf’s mobilization along with back exercises,bring about reduction in VAS score for pain relief and reduction in MOLBPD questionnaire for improvement in functional ability?


OPERATIONAL DEFINITIONS
Pain: “An unpleasant sensation, occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder.”29
Chronic pain: Pain persisting beyond 7-12 weeks or beyond the usual course of an acute disease or reasonable time for an injury to heal, or it recurs at intervals for months or years.17
Low back pain: is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain.2
Feldenkrais therapy: Named after its originator, Dr. Moshe Feldenkrais, twentieth century physicist, judo expert, mechanical engineer and educator. The Feldenkrais Method is a form of Somatic Education that uses gentle movement and directed attention to improve movement and enhance human functioning. 17
Awareness Through Movement: Group classes where the therapist teacher verbally leads the student through a sequence of movements in basic positions: sitting or lying on the floor, standing or sitting in a chair.16
Rolf’s mobilization: Rolfing is a series of manual manipulations of the soft tissue, or neuro-myofascial system of the body focused on improving the alignment and the level of freedom or spaciousness in the body.24
Visual analouge scale: A horizontal/Vertical visual analogue scale is used for pain assesment.A 10 cm line was drawn on a paper and participants were asked to mark a point on the line that best defined the present pain level,where 0 indicated no pain and 10 indicated severe pain.29
Modified Oswestry Low back pain disability questionnaire: It includes 10 items with score ranging from 0-50; where better function is indicated by lower scores.30

Organization of the Remaining Chapters
The remaining chapter of this thesis are as follows. Chapter 2 deals with a review of literature. Chapter 3 describes the methodology used in the stydy, including a study design,description of subjects,equipment used and method of data collection,chapter 4 deals with observation and data analysis. The result of the study discussed in chapter 5,Chapter 6 contains a discussion of the result. Chapter 7 contains the conclusion of the study, Chapter 8 contains the summary of the study. References are given in chapter 9 and in the end are the annexure containing consent form, assessment form, data collection form, master chart, Modified Oswestry Low back pain disability questionnaire and data analysis sample, Chapter 10.

REVIEW OF LITERATURE
Definition:
Low back pain is pain affecting the lower part of the back and can be described as acute, sub acute, or chronic.31
Chronic LBP defined as pain and disability persisting for more than 3 months.4 Low backpain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic.10
Low back pain (LBP) is generally defined as a pain that occurs in an area with boundaries between the lowest rib and the creases of the buttocks.32
‘low back pain’ refers to ‘non-specific low back pain’, which is defined as low
back pain that does not have a specified physical cause, such as nerve root compression (the radicular syndrome), trauma, infection or the presence of a tumor. This is the case in about 90% of all low back pain patients.33
Low back pain (LBP) refers not to a diagnosis but to a clinical entity characterized by pain in the lumbar region which sometimes radiates to the lower extremities.34
Low back pain is considered to be chronic if it has been present for longer than three months.1






Figure 2.1: Anatomy




Epidemiology:
70–85% of all people have back pain at some time in life. The annual prevalence of back pain ranges from 15% to 45%, with point prevalences averaging 30%.35
Musculoskeletal impairment was the most prevalent impairment in people aged up to 65 years, and backand spine impairments the most frequently reported subcategory of musculoskeletal impairment (51•7%). The annual rates varied significantly by sex and age.35
Back pain of at least moderate intensity and duration has an annual incidence in the adult population of 10–15%, and a point prevalence of 15–30%. The prevalence rises with increasing age up to 65 years, after which age it drops off for unknown reasons.35
Low back pain is a complaint that many people have during some point in their lives. Overall chronic back pain affects over 25% of the bill population at any given time.31
Low back pain is a common medical problem but has decreased in frequency in the occupational setting over the past decade. The weather affects low back pain but to a minor degree. Physical factors, as well as job satisfaction, play a role in the development and perpetuation of low back pain.36
Murphy and Volinn reported good news regarding a decline in the frequency of occupational low back pain reported over a 9-year period. Data from a workers' compensation provider, Liberty Mutual Insurance Company (1987–1995), the Washington State Department of Labor and Industry (1991–1995), and the Bureau of Labor Statistics (1992–1995) were reviewed for frequency of low back claims from industrial settings. The US estimates of annual low back pain claims decreased by 34% between 1987 and 1995. More important, annual costs decreased during this time period by 58%. However, because the rate of filing remained 1.8 per 100 workers, the estimated cost of low back pain claims for 1995 was US$8.8 billion.37
In an attempt to determine the proportion of costs for components of back care, Williams et al. reported data derived from the National Council on Compensation Insurance on health care use and indemnity costs within the natural history of work-related low back pain disability. Health care costs were disproportionately distributed along the disability curve, with 20% of claimants with back pain for 4 months or more accounting for 60% ofhealth care costs. The most costly services were diagnostic procedures (25%), surgery (21%), and physical therapy (20%). Physician evaluation was 15% of the total, whereas medication costs were 2%.38

Etiology:
Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be aching, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe.1
The low back or lumbar spine is made up of five bones with this in between the bones. These discs function as shock absorbers and allow for motion within the spine. Behind these discs is yhe spinal canal for the spinal nerves to run through and exit at each level of the spine. Typically the lumbar region or lower area of the back is where pain is felt due to the increase pressure that the low back supports.31
The main symptoms to low back pain are some sort of sudden ache or pain that comes after an obvious strain or injury. The pain may be felt in other areas than the low back such as the buttock and both legs. The pain can go down to the foot and depending on the area which has been injured can’t seem to mess other areas. The pain often is worse with spending and prolong sitting. Many people also reports stiffness with getting up in the morning from their bed. Another complaint is also increased pain and stabbing with sneezing and coughing due to the spasms they can go on in the back.31
Genetic factors play a greater role than environmental factors in the perpetuation of low back pain. Obesity may a be a minor factor in the causation of back pain, but is associated with chronicity. Obesity may be associated with sedentary life-style, low occupational status, and psychological distress, as well as physical strain in spinal structures that facilitate the chronicity of back pain.36
The effect of weather on musculoskeletal conditions is one of the most frequently asked patient questions. McGorry et al. attempted to answer the question in regard to the relation between weather and back pain.39
Hunter et al. also evaluated the long-term outcomes of 178 railroad employees who completed a multidisciplinary rehabilitation program. Improved function and reduced pain after rehabilitation were not predictive of return to work.40
Thomas et al. performed a prospective 12-month study on 180 patients who developed low back pain and consulted a physician. The studies reported in this article
Seem to agree that a variety of factors, both genetic and environmental, play a role in the perpetuation of pain.41

Classification:
There are many structures in the lower back that can cause severe pain. These include muscles, ligaments, tendons, bones, joints and discs. The outer rim of the disc can be a source of significant back pain due to its rich nerve supply and tendency towards injury.
Back pain can be divided into three large classifications –
 Axial pain
 Referred pain
 Radicular pain.

The treatment options here are similar to those used in treating axial pain. Diagnostic and therapeutic measures are aimed at correcting abnormalities in the muscles, ligaments and small joints of the spine.
The most common type of back pain is known as referred pain. Here, patients complain of having an achy, dull type of pain that seems to move around. The discomfort comes and goes and varies in intensity. This achy pain starts in the low back area and commonly spreads into the groin, buttocks and upper thighs.
The last type of back pain is known as radicular pain. In this case, the pain is described as deep and usually constant. It follows the nerve down the leg and is often accompanied by numbness or tingling and muscle weakness.42
Low back pain is pain affecting the lower part of the back and can be described as acute, sub acute, or chronic. Per the national institutes of health, 1785% of all people who have back pain at some time in their life (OHSU 2006). This can be seen as acute back pain lasting less than six weeks, sub acute back pain lasting six to twelve weeks or chronic back pain which last more than twelve weeks.31
CLINICAL DISORDERS:
Kauppila et al. reviewed a cohort of 400 women and 217 men who were followed with lateral lumbar radiographs over a 25-year period: 25% of women and 12% of men had degenerative spondylolisthesis of 3 mm or more. At the time of the 2nd radiograph, 32% of individuals with slippage had pain, aching, and stiffness on most days, compared with 19% of controls. After adjustment for endplate sclerosis, which was also associated with pain, slippage still had association with daily back symptoms. However, subjects with slippage did not report more disability than controls. Although degenerative displacement is common and is associated with increased prevalence of daily back symptoms, two-thirds of subjects with this problem do not report ongoing back pain.43
Cheng et al. report on prognostic factors and treatment for 23 individuals with lumbosacral chordoma. Of the 23 subjects, 14 men and 9 women, the mean age was 55 years. The mean duration of preoperative symptoms was 22 months. The mean tumor size at diagnosis was 8.1 cm. Chordomas occurred in the lumbar spine in six patients. High involvement of the sacrum was always associated with lower sacral involvement, most at S3 or lower. The 5-year and 10-year survival rates were 86% and 49%, respectively. Individuals with lumbar spine involvement had a poorer prognosis compared with those with lower sacral disease. Wide surgical excision and early radiotherapy was associated with improved outcome. Bladder and rectal function can be preserved if both S3 nerve roots are spared.44

SYMPTOMS OF LOW BACK PAIN:
Symptoms coated by Irene Bookman BSN,31
 The main Symptoms to low back pain are some sort of sudden ache or pain that comes after an obvious strain or injury.
 The pain maybe felt in other areas than the low back such as the buttock and both legs.
 The pain can go down to the foot and depending on the area which has been injured can’t seem to mess other areas.
 The pain often is worse with spending and prolong sitting. Many people also reports stiffness with getting up in the morning from their bed.
 Another complaint is also increased pain and stabbing with sneezing and coughing due to the spasms they can go on in the back.


CAUSES OF LOW BACK PAIN:
Unfortunately even with the technological advances that we have today the cause of low back pain is often very confusing. In most cases,back pain may be a symptom of from any different causes:
• Overuse
• Strenuous
• Obesity
• Injury
• Infection
• Poor muscle tone in the back
• Muscle tension or spasm
• Strain or sprain
• Ligament or muscle tears
• Joint problems
• Smoking
• Herniated desks
• Disease
• Degeneration

This typically can be seen due to decreasing own strained muscle elasticity and tone which occurs as people age. Discs also tend to lose their flexibility due to loss of fluid which decreases their ability to cushion the spine.31

INVESTIGATION:

General:
 A good patient history and a thorough physical examination by a well-trained clinician are the most important aspects of the evaluation.1
 The physician will evaluate for nerve problems by casting your strains your strains sensation and reflexes.31
 The physician also roll out for blood circulation as a potential problem for back pain and see what exactly makes the pain worse and what helps relieve the pain.31
 Physical measurements and questionnaires as diagnostic tools can be asses in Low back pain.34

Radiography
The main purpose of x ray is to look for an explanation of the pain however the findings can be nonspecific such as narrowing, sparring, or decrease in lumbar lordosis. Unfortunately on x-rays, the disks are not seen; however, the radiologist can look at the space between the vertebrae.31

Figure 2.2 : A plain radiography of spine
Magnetic resonance imaging
A MRI can be done to see the discs and other bony structures. This is a diagnostic procedure which uses a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body.31


Figure 2.3 : Magnetic resonance imaging
Malko et al. through the use of magnetic resonance imaging, was able to measure disc volume during load cycles of five healthy volunteers, aged 27 to 52, without low back pain.45
Blood test
A full blood count and erythrocyte sedimentation rate are recommended in patients with bilateral disease or atypical clinical pictures.
Electromyography (EMG) studies
EMG or Electro diagnostic procedures can be done to assess the nerve. This can allow the doctor to see if the nerve is injured or pinched for the strain or injury which occurred. Typically this test uses small needles to pass a low level current through nerves for testing.31
Bone scan
Bone scan can be done to diagnose an infection in the low back along with fractures or other disorders of the bone. Typically a small amount of radioactive material is injected into the blood stream and will collect in the bones, particularly in areas with some abnormality.31
Computer tomography (CT) scan
CT scan can also be done since they are more detailed than general x-rays and can give a 3 dimensional view of the back.31
Diagnostic injections
Disco gram’s are done prior to surgery. This injects fluid into the disc’s to see which one is generating pain. This is then used to determine the level and type of surgery which must occur.31
Pressure transducer
Wilke et al. placed a pressure transducer in the nucleus pulposus of an asymptomatic 45-year-old man.46
Anesthetize of the zygapophysial joint
Kaplan et al. demonstrated the response of mechanical zygapophysial joint to lumbar medial branch nerve block.47

Main Outcome measures
For this purpose, pain intensity can be measured by means of Visual Analogue Scale (VAS). A 10- centimeter line marked with numbers 0 to 10 can be used where 0 symbolizes no pain and 10 is maximum pain. Subject is asked to mark his/her pain on this line as per the severity.48
A study done by Wewers & Lowe (1990), provide an informative discussion of the benefits & shortcomings of different styles of VAS.69 Price et al demonstrated the validity and reliability of the VAS to measure pain.49
A study done by boonstra et al. (2008), To determine the reliability and concurrent validity of a visual analogue scale (VAS) for disability as a single-item instrument measuring disability in chronic pain patients.50
To know how back pain has affected patients ability to manage in everyday life. The Modified Oswestry Low Back Pain Disability Questionnaire has been designed to give patient information to therapist as to how patient back pain has affected their ability to manage in everyday life.
The MOLBPDQ was designed to measure the impact of back pathology on function in terms of pain, disability and activity restriction in a low back pain population. During its validation Megan Davidson evaluate the methods currently available to measure the functional outcomes of physiotherapy treatment for low back problems. According to Davidson M: MOLBPDQ was one of the most reliable scales and had sufficient width scale to reliably detect improvement or worsening in most subjects with low back pain.51
In this questionnaire ask patient to answer every question by placing a mark in the one box that best describes their condition that day. Now, simply add up patient points for each section and plug it in to the following formula in order to calculate their level of disability: point total / 50 X 100 = % disability (aka: 'point total' divided by '50' multiply by ' 100 = percent disability) 52
ODI Scoring:
• 0% -20% : Minimal disability
• 21%-40% : Moderate disability
• 41%-60% : Severe disability
• 61%-80% : Crippled
• 81%-100% : Bed bound or exaggerating their symptoms.

Treatment:
The most favorable treatment for low back pain which is chronic in nature tends to be comprehensive. This should include focusing on functional the restoration, psycho-social factors, patient education, and pain management.31
Exercises are done to increase strength in both abdominal and spinal muscles. Other conservative treatment can include spinal manipulation, acupuncture biofeedback, traction, ultrasound, and transcutaneous electrical nerve stimulation (TENS) or steroid injections.31
There are several different general categories of treatment that are usually recommended for chronic back pain. These categories include physical therapy, medications, coping skills, procedures and alternative medicine treatments. The treating physician will tailor a program involving a combination of these options to address the patient’s needs. Involvement of a physician with special training in chronic pain management may be advisable in some cases. 6
Physical therapy includes patient education, and patient training in a variety of stretching and strengthening exercises, manual therapies and modalities (ice, heat, transcutaneous electrical nerve stimulation [TENS], ultrasound, etc.). Active therapies which the patient can continue on his or her own (such as exercise and strengthening) usually have the most permanent and long lasting effects. A home exercise program (HEP) is usually in place before the patient is discharged from therapy. Exercise and strengthening are designed to increase stability and strength around the structures in the back that are being stressed. These techniques also work to avoid deconditioning those results from decreased activity. Exercises are tailored specifically to the patient and the type of back pain being addressed. The goal of educating the patient is to prevent progressive loss of activity because of fear of movement. 6
Treatments for chronic back pain can vary greatly depending on the type and source of the pain. If a treatable source of the pain is found, then the underlying process should be treated. When the underlying cause is either not known or not treatable, then the symptoms are treated. The goals of the treatment are to reduce pain, improve quality of life and increase function.1
Treatment for chronic pain includes several different general categories. These categories include physical therapy, medications, coping skills, procedures and complementary medicine treatments. Medications used for treatment of pain are multiple and varied. They fall into several different categories. Both non-narcotic and, rarely, narcotic pain medications may be used in the treatment of chronic back pain.
Nonsteroidal antiinflammatory drugs (NSAIDs) are helpful with pain control and may help reduce inflammation. Muscle relaxants can also help with chronic pain and may enhance the effects of other pain medications. Nerve stabilizing drugs (antidepressants and antiseizure medications) are used to treat nerve-mediated pain. Coping skills are extremely important in the management of chronic back pain. Complementary medicine also provides a variety of treatments often helpful in the treatment of chronic pain. These treatments include acupuncture, dry needling, nutrition, magnets and many others.1
A new form of nonpharmacologic pain therapy for low back pain was reported by Ghoname et al.53
Jamison et al. reported on a pharmaceutical-sponsored study of 36 patients with back pain.54
Spinal manipulation involves a range of manual (hands-on) manoeuvres that stretch, mobilize or manipulate the spine, surrounding tissues and other joints in order to relieve spinal pain and improve mobility4. Treatment sometimes involves a high velocity thrust, a technique in which the joints are adjusted rapidly.5

Osteopathy
Osteopathy is an established system of diagnosis and treatment that places its main emphasis on the structural and functional integrity of the body.5, 73

Feldenkrais therapy
This technique postulate that habitual movements lead to movement problems. Pain or overall patterns of dysfunction. Through changing these patterns, the entire system or body functions better. The Alexander technique and Feldenkrais method suggest that the process by which these patterns are changed is a learning process. Feldenkrais often said his goal was to produce “flexible minds, not just flexible bodies.” This technique usually is taught in pasitions that eliminate gravity, such as lying down.21
Feldenkrais coined the terms awareness through movement and functional integration to define the teaching techniques of his method. One key difference between functional integration and awareness through movement consists primarily of verbal cues. Whereas functional integration mainly incorporates touch to facilitate movement and awareness. 56, 57,58
An example of an ATM lesson is one of the classical demonstrations of the Feldenkrais method. Moving the hand, eyes and chest in opposition without straining and streching muscles enables a person to increase their ability to rotate their trunk with less resistance describe by T.S.K.lyttle.16
It is a method of learning, rather than a form of bodywork, yet it often uses hands-on contact to communicate to the client. Other forms of bodywork such as transverse friction massage limit their purpose to the purely mechanical changes made in their target body tissues.59
In the body, the quality of movement of the bones and joints determines the efficiency of action. Our skeletal awareness either improves or degrades over the years.
With improved discernment, our actions may reach higher degrees of competency. Conversely, a blunted consciousness may lead us astray. We may harden into habitual
Postures; postures which may stiffen or pain us.60
The physics of Feldenkrais explores the concept of unstable equilibrium as a form of dynamic repose. This presumes that movement best complies with the Principle of Least Effort when the initial posture incorporates maximal potential energy with minimal inertia.61
Eva-britt malmgren-olsson indicated the group treatments using Body awareness therapy and Feldenkrais might be more effective than conventional treatment.62
A study done by Gretchen A. et al, on the ability of the Feldenkraiss Method to reduce state anxiety was investigated. Specifically, both a single Feldenkraiss Awareness through Movement lesson and a 10-week Feldenkrais.63
The effects of a Feldenkrais Awareness through Movement program and relaxation procedures were assessed on a volunteer sample of 54 undergraduate physiotherapy students over a 2-week period and found reducing anxiety.64
A study done by C. Hopper et al, on the effect of Feldenkrais awareness through movement on hamstring length, flexibility, and perceived exertion.65
A study done by Suzanne Ruth et al, showed Facilitating cervical flexion using a Feldenkrais method.66
A study done by Jeffrey C. Ives et al, on comments on “The Feldenkrais method, a dynamic approach to changing motor behavior.”67
A study done by Julie R. Dean et al, showed that the Feldenkrais Method has potential value as a possible adjunct to the physical therapy treatment of selected fibromyalgia patients.68,69
A study done by Glenna Batson et al, showed that gains in functional mobility are possible for individuals with chronic stroke using Feldenkrais movement therapy in a group setting.70
A study done by Iiana et al, on Feldenkrais in Movement Therapy for Children with Cerebral Palsy and Other Neurological Impairments.71

Rolfing Structural Integration
Rolfing is a series of manual manipulations of the soft tissue, or neuro-myofascial system of the body focused on improving the alignment and the level of freedom or spaciousness in the body. The Rolfing community refers to structural fixations in a body as lesions, which is addressed in this physical manipulation phase of the Rolfing process. One could envision the structural manipulation to be a cross between deep tissue massage and chiropractic work, where one tries to lengthen, hydrate, and relax muscles while aligning the body and redistributing the body ‘load’ in a more optimal way. The practitioner uses long, slow strokes using fingers, fists, or elbows in an attempt to free and release fascial holdings. The Rolf movement, similar to physical therapy, works to educate individuals of movement patterns and preferences, while giving the client additional options to explore. It is the Rolfer’s goal to weave both the structural/lesion and movement/inhibition work into an individualized process that encourages integration, motility, and coherence of the body.
Spinal manipulation involves a range of manual (hands-on) manoeuvres that stretch, mobilize or manipulate the spine, surrounding tissues and other joints in order to relieve spinal pain and improve mobility.5
A study done by John t. cottingham et al, on effects of a soft tissue mobilization procedure, the Rolfing pelvic lift, on parasympathetic tone was studied in healthy adult men. The results of this study contribute to understanding of pelvic mobilization techniques and may help to explain why these techniques have been clinically successful in treating myofascial pain syndromes and other musculoskeletal dysfunctions characterized by reduced parasympathetic tone and excessive sympathetic activity.72
A study done by MT Cibulka, et al, showed the Treatment of the Sacroiliac Joint Component to Low Back Pain.27
A study done by John t. cottingham et al, showed the effects of soft tissue manipulation (Rolfing method) were evaluated on young healthy men using two dependent variables: 1) angle of pelvic inclination and 2) parasympathetic activity.28

METHODOLOGY
Source of Data:
Data was collected from physiotherapy OPD of Doon Paramedical College & Hospital, Dehradun and, MDM hospital Jodhpur during the study period of December 2010 to May 2011.
Method of Data Collection:
The method of data collection used for this study was a primary method.
Study Design:
The study design used for this research was randomized comparative study.
Sample size:
The sample size used for this research study was 40. Sample selected was heterogeneous.
Study sample:
The study sample consisted of both male and female participants referred to the physiotherapy outpatient department with diagnosis of Chronic Low back pain.
Sampling design
Sampling design used for this research was random sampling (Envelope method) with allocation to 2 study groups.


Participants
There were 40 participants with Provisional diagnosis of Chronic LBP.
Inclusion Criteria:
1. Both male and female participants who reported experiencing Chronic LBP.
2. Provisionally diagnosed by therapist.
3. Age group between 35-45 years.
4. All subjects with symptoms for a duration of more than 3 months..
5. Participants willing to participate in the study.
Exclusion Criteria:
1. Experienced low back pain for less than 3 month of duration.
2. Sought professional treatment during the study.
3. Had acute injury or active neurological symptoms.
4. Patient who were heavily medicated
5. Subjects unwilling to participate in the study
Materials (Figure 3.1)
• Data collection sheet, Consent form & Assessment Sheets
• Measuring Tape
• Towel
• Weighing machine
• Miscellaneous – Couch (Plinth of size 6.5 feet length; 2 feet breath & 2.5 feet height.) & Chair.

3.1-: Instruments used










Variables:
1. Independent variable:
 Feldenkrais Method
 Rolf’s soft tissue Mobilization
 Back exercises
2. Dependent variable:
 Visual analog scale
 Modified Oswestry Low back pain disability questionnaire
Apparatus and Equipments
1. Measuring Tape: (Figure3.1)
A measuring tape of total length of 60 inches/152 centimeters was used to measure the height of each patient. The participant was made to stand against a wall, head and heel touching the wall and a mark was made on wall at the vertex of head. The distance between the floor and the mark was measured in centimeters and considered as of the participant.
2. Weighing machine: (Figure3.1)
A standard weighing machine with 1kg increment was used to measure the weight of each participant in kilograms.



Main Outcome Measures
Pain intensity:
By Visual analogue scale – A scale of 10 cm to evaluate intensity of pain where 0 represents no pain and 10 represent unbearable pain.
Physical Function outcome:
The Modified Oswestry Low back pain disability questionnaire includes 10 items with score ranging from 0-50; where better function is indicated by lower scores.
Procedure
Participants who reported to Doon Paramedical college & hospital, Dehradun, and MDM hospital Jodhpur, with Chronic low back pain with duration not less than 3 months were screened for their eligibility depending on inclusion and exclusion criteria to participate in this study. After finding their suitability, they were requested to participate in the study. Then the informed consent was obtained. Following this, a standardized history which consisted of demographic information including age, gender, body weight, height, nature of symptoms and occupation was collected. Weight (in kilograms) of the participants was recorded using a simple bathroom weighing machine. Height (in centimeters) of the participants was recorded using a measuring tape. Duration of the symptoms and initial evaluation of the pain profile was done using Visual Analogue Scale (VAS) and Modified Oswestry Low back pain disability questionnaire (MOLBPDQ) scoring was done. The pain was recorded by 10 cm horizontal visual analogue scale (VAS), the participants were asked to mark their intensity of pain on a 10 cm long line in the data collection sheet with numbers 0 to 10 where 0 symbolized no pain and 10 was severe pain. The Modified Oswestry Low back pain disability questionnaire includes 10 items with score ranging from 0-50; where better function is indicated by lower scores. This questionnaire has been designed to give information as to how patient back pain has affected his ability to manage in everyday life.
Thus the data collected was taken for further analysis.
After this initial evaluation, they were randomly allocated to one of the two study groups A and B.
Group A participants were treated with feldenkrais therapy for 20 minutes and back exercises. Group B participants were treated with Rolf’s mobilization for 90 seconds with 3 repetitions and back exercises.
Group A: Participants were treated with
1. Feldenkrais therapy by gently guides the patient, physically, through the patterns of movement involves subtle touch and direction. During the lesson the patient is able to feel their own relative patterns of holding, to discover which areas of the body are included in their image.
Each lesson had a specific learning theme:
Class 1: “Activating flexors” (supine exercises, flexion as a main theme), (Fig. 3.4-A)
Class 2: “Activating flexors” (adding larger and faster movements, such as rolling supine to sitting), (Fig. 3.4-B)
Class 3: “The pelvic clock” (supine differentiated movements of the pelvis, involving rolling and twisting), (Fig. 3.4-C)
Class 4: “Side lying lesson for improving the integration of arms, shoulders and spine” (reaching motion of shoulders in different directions), (Fig. 3.4-E)
Classes 5 & 6: “Transitioning from supine to side lying to sitting” (lying supine involving flexion, extension, and twisting), (Fig. 3.4-F)
Class 7: “Twisting on the side” (lying on each side to differentiate the movements of the rib cage from the movement of the shoulder blades), (Fig. 3.4-G)
Class 8: “Twisting from supine with head fixed to the side” (by limiting the movement of the head, the rib cage is forced to participate in the twisting motion), (Fig. 3.4-D)

2. Exercises for –
 Increase stability of the spine by strengthening of weakened muscles-
1. Pelvic Tilting
Starting position - crook lying on a firm surface. Exercise - the abdominals and the glutei are tightened and the patient "presses" his lower back down flat. Holding his back flat to the surface, the buttocks are elevated. This permits smooth pelvic tilting and gives the patient the kinesthetic concept of this tilting movement and at the same time stretches the lower back. (Fig. 3.3-A)


2. "Sit Up" From Supine Position with Hips and Knees Flexed
Starting position - Crook lying on a firm surface. Exercise - Head and shoulder are lifted with a gradual curl to touch the knees with the hands. (Fig. 3.3-B)

 Increase mobility of the spine by streching of tightened soft tissue
1. Low Back Stretching Exercise
Starting position - supine lying. Exercise - flex one hip and knee to touch the chest with rhythmically passive bouncing at end range. This is repeated for the other leg with emphasis on the lower back being stretched. (Fig. 3.3-C)
2. Hamstring Stretching Exercise
Starting position - sitting with hip and knee of one leg fully flexed and rotated outward, and the leg being stretched extended on the floor with the knee straight. Exercise - patient tries to reach towards the toes of his extended leg in a bouncing rhythmical manner. The flexed leg prevents stretching of the low back. (Fig.3.3-D)
Group B: Participants were treated with
1. Following the Back exercises as mentioned in group A participants were then treated with the Rolf’s mobilization.
2. Rolf’s mobilization where placing the patient supine with the spine laterally flexed to the left. Therapist stood on the right side of the patient. The patient’s hands were clasped behind his neck. Therapist threaded one arm through the patient’ clasped hands, rotating the upper trunk toward therapist. Therapist then placed own free hand on the patient's ASIS that was furthest away from therapist. Therapist applied a posterior force to the ASIS while the patient maintained full upper trunk rotation. This position is held for 90 sec with 3 repetitions i.e. total of 270 seconds was given.






3.2-: Rolf mobilization


All the subjects were advised:
 To use soft heel foot wear,
 Not to stand for long time,
 Not to walk bare foot,
 Participants were instructed not to do any stretching exercises at home.
All the participants received the selected treatment 8 sessions over a period of 4 weeks.
VAS score and Modified Oswestry Low back pain disability questionnaire (MOLBPDQ) were measured pre and post intervention.
After 4 weeks of intervention, post treatment outcome measures were recorded and data thus obtained was used for statistical analysis.

















3.3-A: Pelvic tilting


3.3-B: “Sit up”



3.3-C: Low back Stretching exercises





3.3-D: Hamstring stretching exercises






3.4-A: Activating flexor




3.4-B: Activating flexor


3.4-C: Pelvic clock



3.4-D: Class 8

3.4-E: Side lying lesson



3.4-F: Side lying lesson


3.4-G: Twisting on the side






PROTOCOL
Subjects meeting the inclusion criteria

Subjects included in the study (n=40)

Informed consent form & approval from ethical committe

Assessment was done & Filled by molbpdq

Subjects randomly assigned into two group




Group A (n=20)
Mean Age ±S.D
37.33±10.80 Group A (n=20)
Mean Age ±S.D
37.33±10.80

Feldenkrais therapy,
Back exercises. Rolf’s mobilization,
Back exercises.

1st & 8th Session 1st & 8th Session



Data collection


Analysis

OBSEVATION AND DATA ANALYSIS

Statistics are performed by using SPSS 13 and SIGMASTATE .Results are calculated using 0.05 level of significance.
Level of Significance → 95%
P < 0.05 → Significant
P > 0.05 → Not Significant
FORMULAE USED-

Paired t- test:
∑d2 _ (∑d)2 = s (in paired data)
n-1 n(n-1)


s.d. = s = ( x- x )2
n
∑d
d = n
tcal = | d | , d = x- y = difference in paired values
S. E.
S.E. = s / √ n
d.f. = n - 1
Where d = x- y = difference in pair values
n = no. of subjects,

Arithmatic Mean

∑x
x = n


∑y
y = n

Coefficient of correlation:



Σ(x-x). (y-y)
r =
Σ(x- x)2 Σ(y-y)2

t- test of independent mean:

Where




is an estimator of the common standard deviation of the two samples: it is defined in this way so that its square is an unbiased estimato of the common variance whether or not the population means are the same. In these formulae, n = number of participants, 1 = group one, 2 = group two. n − 1 is the number of degrees of freedom for either group, and the total sample size minus two (that is, n1 + n2 − 2) is the total number of degrees of freedom, which is used in significance testing.
Test of significance of correlation coefficient:



r

t = (1 – r2) / (n - 2)

Where r = correlation coefficient
n= no. of subjects
d.f. = n-2
GROUPS DESCRIPTION
Total Subjects ŕ 40
Group A ŕ 20 (FELDENKRAIS THERAPY)
Group B ŕ 20 (ROLF’S MOBILIZATION)
Level of Significance ŕ 95%
P < 0.05 ŕ Significant
P > 0.05 ŕ Not Significant
RESULTS
The present study was done to compare the effect of Feldenkrais therapy and Rolf’s mobilization in Chronic low back pain. The study included 40 participants, out of which 20 individuals participated in Group A who were treated by Feldenkrais therapy, Back exercises. While remaining 20 subjects participated in Group B who were treated by Rolf’s mobilization, Back exercises. A student t – test was used to compare the Performance of Group A and Group B for different treatments and to find their effectiveness’ within the groups we applied paired t – test. The t – values for Pre – VAS, Post- VAS, Pre –MOLBPDQ and Post- MOLBPDQ are 10.66, 10.3, 11.46 and 12.7 for Group A and Group B .
The results of the study suggest that t value is highly significant in each Pair of both Group A and Group B.Which reveals that the treatment given to both the Groups, Feldenkrais therapy and Rolf’s mobilization are effective. The mean ± s.d. values for Pre- VAS, Post- VAS, Pre- MOLBPDQ and Post- MOLBPDQ for Group A are 6.7±1.68, 1.9±2.1, 45.22±12.9 and 12.27±11.48 respectively. The mean ± s.d values for the same exercises for Group B are 7.3±1.41, 2.65± 2.2, 50.01± 10.32 and 17.14± 10.23 respectively. This result shows that the treatment given to the Patients in Group A is more effective than that of Group B. i.e. The Feldenkrais therapy is more effective than Rolf’s mobilization.




STATISTICAL ANALYSIS:
Statistical analysis for the present study was done manually as well as using the statistics software SPSS 13 and SIGMASTATE so as to verify the results obtained. For this purpose data was entered into an excel spread sheet, tabulated and subjected to statistical analysis. Various statistical measures such as mean, standard deviation and tests of significance such as paired‘t’ test were utilized for this purpose for all the available scores in all the participants. Nominal data from patient’s demographic data i.e. age, sex distribution were analyzed using‘t’ test. Intra group comparison of the pre interventional and post interventional outcome measures was done by using student paired‘t’ test . Probability values less than 0.05 were considered statistically significant and probability values less than 0.0001 were considered highly significant.
Statistical measures such as unpaired' test were used to analyze the data. The results were considered to be statistically significant with p<0.05.
Paired’t’ test was used to compare the significance of difference in pre & post treatment scores within the group.
Unpaired’t’ test was used to compare the significance of difference in pre - pre & post - post treatment scores between the group.
DEMOGRAPHIC PROFILE:
Sex distribution:
The gender ratio of Group A was 14:06 (14 males and 6 females) and Group B was 11:09 (11 males and 9 females) and this was not statistically significant (p=0.432). Therefore both the groups are matched with respect to age and gender. (Table No.5.1I)
Age distribution:
Age of the participants in this study was between 35 to 45 years. The mean age of the participants in group A was 38.45 years ± 3.54 and the mean age of participants in group B was 39.15 years ± 3.95. The difference in mean age of two groups was not statistically significant (p= 0.211). (Table No. 5.1)
Anthropometric measurements:-
Body weight:
The mean Body weight of the participants in Group A was 65.15 kgs ± 8.95 where as the mean weight of the participants in Group B was 64.0 kgs ± 7.61. The difference in mean body weight of two groups was not statistically significant (p= 0.543). (Table No. I5.1)
Height:
The mean height of the participants in Group A was 166.25 cms ± 9.13 where as the mean height of the participants in Group B was 162.85 cms ± 8.10. The difference in mean height of two groups was not statistically significant (p= 0.295). (Table No. 5.1)



Body Mass Index:
The mean BMI of the participants in Group A was 23.72 ± 2.90 where as the mean BMI of the participants in Group B was 24.12 ± 2.20. The difference in mean BMI of two groups was not statistically significant (p= 0.878). (Table No. 5.1)

 Outcome measures considered in this study were Visual Analogue Scale (VAS) score and Modified Oswestry Low back pain disability questionnaire (MOLBPDQ) :
Results were analyzed in terms of reduction in VAS score for pain relief and reduction in MOLBPDQ score for improvement in functional ability.
Visual Analogue Scale Score Analysis (VAS in cms):
In the Group A, the mean VAS score on pre session on the first day was 6.7 cms ± 1.68, which was reduced to a mean of 1.90 cms ± 2.1 on post session i.e. on the 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
In Group B, the mean VAS score on pre session on first day was 7.3 cms ± 1.41, which was reduced to a mean of 2.65 cms ± 2.25 on the post session i.e. on 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
On comparing the pre session and post session values, the results between the two groups using unpaired ‘t’ test revealed that there was no statistically significant difference seen with p values of 0.22 and 0.256 respectively.(Table 5.2, Table 5.3) (Graph 1 and 2)
Modified Oswestry Low back pain disability questionnaire (MOLBPDQ in %):
In the Group A, the mean MOLBPDQ on pre session on the first day was 45.22% ± 12.90, which was reduced to a mean of 12.27% ± 11.48 on post session i.e. on the 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
In Group B, the mean MOLBPDQ on pre session on the first day was 50.01% ± 10.32, which was reduced to a mean of 17.14% ± 10.23 on post session i.e. on the 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
On comparing the pre session and post session values, the results between the two groups using unpaired ‘t’ test revealed that there was no statistically significant difference seen with p values 0.870 and 0.545.(Table No.V, Table VI) (Fig 3 and 4)










Table 5.1: Mean & SD of Demographic Data for Group A & Group B





Group A
Group B

Mean
SD
Mean
SD

Age(yrs)
38.45
3.54
39.15
3.95

Height(cm)
166.25
9.13
162.85
8.10

Weight (Kg)
65.15
8.95
64.0
7.61

BMI (Kg/m2)
23.72
2.9
24.12
2.2









Table 5.2: Mean and SD of Pre VAS and Post VAS for Group A and Group B

Session
Group A
Group B


Mean

SD

Mean

SD

PRE VAS
6.7
1.68
7.3
1.41

POST VAS
1.90
2.1
2.65
2.25


Table 5.3: Comparison of mean values between Pre VAS and Post VAS within Group A and Group B

Session

Group A

Group B


t value

P value

t value

P value


PRE – VAS
VS
POST – VAS


10.68


P = 0.000

(P<0.05)


10.3
P= 0.000

(P < 0.05)
Table 5.4: Mean and SD of Pre MOLBPDQ (%) and Post MOLBPDQ (%) for Group A and Group B

Session

Group A

Group B


Mean

SD

Mean

SD

Pre FFI
45.22
12.90
50.01
10.32

Post FFI
12.27
11.48
17.14
10.23

Table 5.5: Comparison of mean values between Pre MOLBPDQ and Post FFI within Group A and Group B

Session

Group A

Group B


t value

P value

t value

P value

PRE – FFI
VS
POST – FFI


11.46
P = 0.028

(P<0.05)


12.7
P= 0.000

(P < 0.05)
Table 5.6: Mean and SD of Mean Difference Pre VAS- Post VAS and Pre MOLBPDQ- Post MOLBPDQ for Group A and Group B.






MD

Group A

Group B


Mean

SD

Mean

SD

Pre –Post(VAS)
4.85
2.03
4.6
2.0

Pre- Post(MOLBPDQ%)
32.99
12.82
32.8
11.35














Graph 5.7:





Graph 5.8:






Graph 5.9:





Graph 5.10:






Graph 5.11:





Graph 5.12:






Graph 5.13:





Graph 5.14:





Graph 5.15:






Graph 5.16:



DISCUSSION
The present clinical trial was conducted to compare the effectiveness of FALDENKRAIS THERAPY and ROLF’S MOBILIZATION in Chronic Low Back pain with a Back exercises to both the groups.
In the present study Group A received Feldenkrais Therapy and Back exercises and Group B received Rolf’s Mobilization and Back exercises. Both groups had equal number of participants and had shown no significant difference with respect to their gender distribution, which could have altered the results of the study.
The results from the statistical analysis of the present study supported experimental hypothesis which stated that there will be beneficial effect to the participants treated with Feldenkrais Therapy. The mean values of data from present study indicates that the group A treated Feldenkrais Therapy and Back exercises showed better reduction of pain and improvement in functional ability in terms of VAS and MOLBPDQ respectively.
In present study age group of participants was between 35 to 45 years, although the range has been reported to be 10 to 80 years of age.35 A study reported that low back pain is a common orthopedic problem that generally occurs in persons ranging from 20 to 70 years of age.35
Mean Body Mass Index (BMI) of the participants for both the groups were 23.72 ± 2.90 for group A and 24.12 ± 2.20 for group B (Table 5.1). According to WHO standard ideal BMI is in the range of 18.5 - 24.9.74
Analysis of pain relief was done by subjective VAS by statistical mean. Mean and standard deviation of pain in terms of VAS was done and found that the average of VAS score for group A on 1


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Jan17
LOW BACK PAIN,COMPERESION BETWEEN BUTLER NEURAL MOBILIZATION & MULLIGAN BEND LEG RAISE TECHNIQUE IN LOW BACK PAIN
COMPRESSION BETWEEN BUTLER NEURAL MOBILIZATION AND MULLIGAN LEND LEG RAISE TECHNIQUE IN LOW BACK PAIN PATIENT.

Low back pain is the most prevalent of all musculoskeletal conditions, afflicting everyone at some time in their life. Over the past century, low back syndromes have become increasingly problematic, receiving an escalating amount of attention and concern in the medical, industrial, and political world because of the burdens placed on health-care and social care systems. Because of the health-care world’s failure to bring low back syndromes under control, Waddell labeled back pain “a twentieth century medical disaster.” In India incidence of low back pain has been reported to be 23.09% and has a lifetime prevalence of 60-85%.1,2 Low back pain affects men and women equally, with onset most often between the age group of 30 to 50years. It is the most common cause of disability in individuals under 45 years of age and third most common cause in the age group of 45 to 65 years. Low back pain is believed to involve 60% to 90% of the adult population at some point in their life time. It has been reported that 37% of health care costs associated with low back pain are a direct result of physical therapy services.
There are enormous causes of low back pain. This constitutes congenital, traumatic, inflammatory, degenerative, neoplastic, metabolic, postural, idiopathic, pain referred from viscera, genitourinary diseases, pregnancy, gynecological diseases etc.3 Of these causes majority of sufferers seen by physiotherapists may involve those with lumbar spondylosis and prolapsed inter vertebral disc (PIVD).
Lumbar spondylosis and prolapsed inter vertebral disc can cause low back pain as well as low back pain with radiating pain often called sciatica. Back pain can occur as a consequence of deficits in control of lumbar spine when the stress on the spine causes compression or stretch on the neural structures or abnormal deformation due to faulty mechanics. The majority of people presenting with this symptom have no pathoanatomic diagnosis excluding severe pathology such as fractures, surgery, tumours and infections. Fear of movement and reinjures induce inactivity and, therefore, contribute to risks of chronic disability. Encouragement to return to work and normal activities may sound counterintuitive. However, the longer a patient is off work because of LBP, the greater the risk of chronic pain and the lower the chance of ever returning to work. In a Norwegian study, fear reduction and light activity had a significant effect on sick leave at 6 months follow-up and 5 years follow-up. Previously we have reported results from a study based on this “Indahl treatment.” We investigated the effect of an early intervention on LBP patients, including examination, information, and recommendations to stay active. Over a 12-month follow-up period there was a significant reduction of sick leave for LBP. Patients in the intervention group returned to work earlier compared with patients in the control group. Three months after granting sickness compensation, 52% in the intervention group and 36% in the control group were reported off sick leave. At 12 months, 68% in the intervention group were reported off sick leave, compared with 56% in the control group.

These Norwegian studies emphasized fear reduction, light activity, and avoiding focus on sickness behavior. The aim of this study was to investigate the long-term effects (3 y) of this intervention program.
Despite the prevalence of low back pain, there are several interventions and indications for which there is a lack of evidence regarding efficacy for commonly used physiotherapeutic interventions such as thermotherapy, manual or mechanical traction, Short Wave Diathermy, Transcutaneous Electrical Nerve Stimulation (TENS), massage, therapeutic ultrasound, electrical stimulation, EMG biofeedback, therapeutic exercises, neuromuscular education and combined rehabilitation interventions.
Manual therapy techniques were selected based on the presence of limitation in active or passive joint motions e.g. passive movement techniques, joint mobilization and manipulations are used to promote well being of clients. The Mulligan8 concept is now an integral component of many manual physiotherapists’ clinical practice. Brian Mulligan pioneered the techniques of this concept in New Zealand in the 1970s. The concepthas its foundation built on Kaltenborn’s (1989) principles of restoring the accessory component of physiological joint movement. Unique to this concept is the mobilization of the spine whilst the spine is in a weight bearing position and directing the mobilisation parallel to the spinal facet planes (Mulligan 1999). Passive oscillatory mobilisations called ‘NAGs’ (natural apophyseal glides) and sustained mobilisations with active movement ‘SNAGs’ (sustained natural apophyseal glides) are the mainstay of this concept’s spinal treatment (Mulligan 1999). The Mulligan concept of accessory gliding with active movement can befurther expanded in our clinical practice to justify its place in the assessment of muscle dysfunction.


The butler5 neural mobilization:- "Essentially the entire nervous system is a continuous structure and it moves and slides in the body as we move and the movement is related to critical physiological processes such as blood flow to neurons. This movement is quite dramatic and it is not hard to imagine that fluid such as blood in the nerve bed, a constricting scar, inflammation around the nerve or a nerve having to contend with arthritic changes or proximity to an unstable joint could have damaging effects, some of which could lead to pain."

"Neurdynamics is an innovative management tools involve conservative decompression of nerves, various neural mobilising techniques and patient education techniques. Neurodynamics offers a fresh understanding and management strategies for common syndromes such as plantar fasciitis, tennis elbow, nerve root disorders, carpal tunnel syndromes and spinal pain."

"Neuro mobilization is a method of conservative treatment of disorders of neural tissue. The rationale for using neuro mobilization in the treatment of musculoskeletal conditions is based on in vivo and in vitro studies which point to a high efficacy of neuro mobilization procedures. Appropriate use of neuro mobilization procedures depends on excellent knowledge of normal and pathological anatomy, differences between individual etiological factors, development of disease and symptom variability."














Aim and objective of the study


 The purpose of this study is to compare the outcomes between mulligan bent leg raise (BLR) and butler neural mobilization (NM) in straight leg raise (SLR) positive and low back pain (LBP) subjects.


Hypothesis

Null hypothesis (H0 ):

There will be no significant effect on pain and Rom in subjects treated with mulligan bend leg raise technique and butler neural mobilization with straight leg raise in low back pain subjects.

Experimental hypothesis (HA ):

There will be significant effect on pain and Rom in subjects treated
With mulligan bend leg raise technique and butler neural
Mobilization with straight leg raise in low back pain subjects.






ROL (review of literature)

 Toby hall (2005): there was a significant increase in the range by 70 in the BLR group which may be clinically important. In addition there was a one point reduction in pain. This results in improvement in range of SLR 24th later but immediately after the intervention. Pain also improved.6

 Robert J Nee (2005): neurodynamic technique can be effective in addressing musculoskeletal presentations of peripheral neuropathic pain. While a small amount of clinical evidence links some support to this proposal, much more clinical research is necessary to identify those patients with peripheral neuropathic pain that will respond most favorable to neurodynamic mobilization technique and clarify a specific treatment parameters that will be most effective. Neurodynamic mobilization technique can be effective in addressing musculoskeletal peripheral neuropathic pain.7

 L . Exelby(2002): this study illustrated the general use of this concepts principles and how it can also be incorporated with functional activities to assist in correcting joint positional faults within improved quality movement patterns.8



 Gert Brontfort(2004): spinal manipulative therapy/ mobilization provides either similar or better pain outcomes in the sort and long term when compare with placebo and with other treatments.9

 Chang yu Hsieh(1983): this study have a high reliability for measurements taken on the same day (intersession) of the hip flexion angle during passive SLR test. The goneometere and flexometer than the tape measure for measurements taken on different days(intersession).10



 Toby Hall(2006): the traction straight leg raising technique has been shown to increase the range of SLR by 110 in subjects with low back pain. This increase was attributable to hip flexion rather than pelvic rotation and was not influenced by the presence of neural tissue and was not influenced by the presence of neural tissue mechano sensitization. 11

 W. H. Kirkaldy-Willis (1985): In the treatment of acute low back pain, most studies show that manipulation tends to shorten the episode of pain,30 31 particularly over the short term. Long-term follow-up suggests that the initial advantage of manipulation over other therapies is lost with time.12

 P. B. O'Sullivan: The success of this approach depends on the skill and ability of the physiotherapist to accurately identify the clinical problem, the specific motor control dysfunction present and facilitate the correction of the faulty movement strategies. It will also be greatly induenced by the severity of the patient’s condition and their level of compliance.13

 David Butler: conservative management incorporating neurodynamic and neurobiology education, nonneural tissue interventions, and neurodynamic mobilization techniques can be effective in addressing musculoskeletal presentations of peripheral neuropathic pain. 7

 J.A. Cleland(2005): Slump stretching is beneficial for improving short-term disability, decreasing pain, and centralization of symptoms compared to treatment without slump stretching in a subgroup of patients hypothesized to benefit from this form of treatment.14




Methodology
Study design:
 The study design used in this research will be randomized control trial.
 Data will be taken from the the physiotherapy department of Doon P.G Paramedical college, dehradun.
 The size of the sample will be forty(40).
 Both male and female subjects with low back pain.
 Subjects will be randomly allocated into two groups i.e. group A and group B
Group A: mulligan’s bent leg raise (n=20).
Group B: butler’s neural mobilization (n=20).

Participants: - Participants with low back ache who will be referred to physiotherapy department and willing to take treatment for sessions will be recruit for study.
Source of data:-Data will be taken from physiotherapy OPD of “Doon (P.G.)Paramedical College and Hospital”,Dehradun and various Hospitals.


Inclusion criteria:
 Unilateral limitation of SLR more than 450.
 Age group between 35 -40 years.
 Reproduction of symptoms in SLUMP.
 No change of pain in lumber flexion and extension.

Exclusion Criteria:
 Patient with “Red flags” for serious spinal conditions such as infection, tumors, osteoporosis, spinal fracture.
 Pregnancy.
 History of spinal surgery.
 Diminished upper and lower extremity reflexes.
 Suggestive nerve root involvement.
 Presence of lower quarter neurological compromise.




Variables:
Independent variable:
 Mulligan’s bent leg raise technique
 Butler’s neural mobilization

Dependent variable:
 Pain (Visual analog scale)
 Range of motion(SLR)

Instrumentation :
 Universal goniometer.





MAIN OUTCOME MEASURES:
Pain intensity:
 By Visual analogue scale – A scale of 10 cm to evaluate intensity of pain where 0 represents no pain and 10 represent unbearable pain.

Range of motion:
 Range of motion will be measured by Goniometer to measure Lumbar range of motions.






INTERVENTIONS:
All the participants with low back pain, who will be report to the physiotherapy outpatient department will be screened clinically by considering inclusion and exclusion criteria; they will be request to participate in the study. Those willing to participate in the study will given brief idea about the method of the study and the intervention. The demographic data including age, gender, height, weight, side involved, occupation and duration of symptoms will collected through data collection sheet. Initial evaluation of pain intensity will be done using Visual analogue scale (VAS). Active and passive lumber movement will be measured by Bubble Goniometer. Then participants will be randomly allocated into 2 groups:
 Group A: Mulligan’s bent leg raise technique
 Group B: Butler’s neural mobilization
All 2 groups will receive the treatment for two times/weeks for 3 weeks.


PROCEDURE:
Prior to the commencement of the procedure, informed written consent will be taken from the participants. For both two groups.
The participants who will report to doon paramedical college and hospital with low back pain will be screened for their eligibility to participate in this study. The purpose of the study will be explained and a written informed consent will be obtained from all the participants. The subjects will be screened based on the inclusion and exclusion criteria.
Assessment of demographic data along with initial assessment of visual analogue scale (VAS), and range of motion (ROM) will be measured pre-treatment and post-treatment. Once all measurements will be obtained subjects will be randomly allocated into 2 groups viz. group A and group B.
Participants of both the groups i.e. group A and group B will receive the selected treatment for two times/weeks for 3 weeks.
Similarly pain will be assessed with VAS and ROM will be assessed with Universal Goniometer.

Group A, will be receive Mulligan’s bent leg raise technique4,6

This is a painless technique, when indicated ,and can be tried on any patient with low back pain who has limited and/ or painful straight leg raising(SLR).

I shall stand at the limited SLR side of the supine patient. I will place his flexed knee over my shoulder and ask him to push knee away with his leg and then relax at this point I will push his bend knee up as far as I can in the direction of his shoulder on the same side provided there is no pain. If it is painful alter the direction by taking his leg more medially or laterally. Sustained this streatch for several seconds and the lower the leg on the bed. With the bend knee over my shoulder I will include a traction with this technique.










Group B, will be receive Butler’s neural mobilisation14

The slump testing sequence as described by Maitland (1985)
Summary of slump test procedure
1. Patient was instructed to sit erect with knees in 900 of flexion. The presence or absence of symptoms was recorded.
2. Patients were instructed to ‘‘slump’’ shoulders and lower back while maintaining the cervical spine in neutral. The presence or absence of
symptoms was recorded.
3. While maintaining the position described in step 2 the patients was instructed to tuck their chin to the chest and the clinician applied overpressure
into cervical flexion. The presence or absence of symptoms was recorded.
4. While maintaining overpressure into cervical flexion the patient was instructed to extend the knee. The presence or absence of symptoms was
recorded.
5. Position 4 was maintained while the patient was instructed to actively dorsiflex the ankle. The presence or absence of symptoms was recorded.
6. Overpressure of the cervical spine was released and the patients were instructed to return the neck to a neutral position. The presence or absence
of symptoms was recorded.
The slump test is considered positive if the patient’s symptoms were reproduced in position 5 but alleviated when overpressure of the cervical spine
was released.


flowchart
Subjects meeting the inclusion criteria

Subjects included in the study (n=40)

Subjects randomly assigned into two group



Number of subjects randomly selected with low back pain to be treated with mulligan’s bent leg raise technique(n=20) Number of subjects randomly selected with low back pain to be treated with butler’s neural mobilisation(n=20)

Received allocated measurement(n=20) Received allocated measurement(n=20)

Data collected Data collected

Interpreted Interpreted

DATA COLLECTION FORM

Name of the participant:_____________________ O.P/I.P. No:_______________

Address and contact no. (If Any): _________________________________________
_________________________________________

Age: _______ Yrs Occupation _______________________________

Height: mts. Weight: kgs.

BMI:____________ kg/mt2.

Gender: Male Female

Date of Examination:
Study group : Group A Group B

Duration of symptoms (months) _______________________________

On Examination:
Pain intensity (Visual analogue scale 0-10cm):

0 10 Pre – Intervention


----------------------------------------------------------------
Pre treatment - Pain Post treatment - Pain


0 10 Post – Intervention




Pre treatment –SLR ROM Post treatment –SLR ROM



Remarks ________________________________________________________


Volunteer Subject’s Name
___________________
Guide’s Signature
CONSENT FORM
I, Debanjan Mondal doing M.P.T in musculoskeletal disorder at “Doon (PG) Paramedical College & Hospital”, Dehradun and I would like to invite you to participate in my study “COMPARISON OF MULLIGAN BEND LEG RAISE TECHNIQUE AND BUTLER NEURAL MOBILIZATION ON PAIN AND STRAIGHT LEG RAISE IN LOW BACK PAIN SUBJECTS” as part of fulfillment of master program in physical therapy at “Doon (PG) Paramedical College & Hospital”, Dehradun. As a part of the study you will be assessed for me.
I do not personally see any risk involved in this study as the inclusion criteria of the study selects, you only if you are fit enough. You have the right to withdraw from the research at any stage if you are uncomfortable with any procedure. All the about you will be kept strictly confidential limited of research DR. and me, and we will not shared with any other person.
I, voluntary agree to participate in this study. All my question have been satisfactorily answered and the risk involved has been explained to me. I reserve my right to withdraw at any point of time. I have the contact address of Mr. Debanjan Mondal, if I require any further information from him.
Name: Date:
Signature of the participant: Signature of Guide:

Address:
Contact Address:
[DEBANJAN MONDAL, M.P.T (Musculoskeletal),
Doon (P.G.) Paramedical College & Hospital,
Dehradun,Uttrakhand – 248001]

DATA COLLECTION:
All the required data will be collected by the research student under the supervision & guidance of the respective research guides.

DATA ANALYSIS:
Analysis and interpretation will be done using statistical procedures.















LIST OF REFERENCES:
1. Sharma SC, Singh R, Sharma AK, Mittal R: Incidence of low back pain in workage adults in rural North India, Medical journal of India 2003; 57(4):145-147.
2. M.Krismer M.Van Tulder: Low back pain (nonspecific), Best practice and research clinical rheumatology 2007; 21(1):77-91.
3. Patricia A Downie (FCSP): Cash’s textbook of orthopedics and rheumatology for physiotherapists,1st Indian edition 1993.
4. Manual therapy “NAGS”, “SNAGS”, “MWMS” etc. Brian R Mulligan 4th edition.
5. Mobilisation of nervous system David S Butler, Charchille Livingstone.
6. Toby Hall(2005) Mulligan bent leg raise technique—a preliminary randomized trial of immediate effects after a single intervention.


7. Robert J. Nee(2005) Management of peripheral neuropathic pain: Integrating neurobiology, neurodynamics, and clinical evidence.
8. L. Exelby(2002) The Mulligan concept: Its application in the management of spinal conditions
9.Gert Bronfort(2004) Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis



10. CHANG-YU HSIEH(1983) Straight-Leg-Raising Test Comparison of Three Instruments

11.Toby Hall(2006) Mulligan Traction Straight Leg Raise: A Pilot Study to Investigate Effects on Range of Motion in Patients with Low Back Pain.

12. W. H. Kirkaldy-Willis(1985) Spinal Manipulation in the Treatment of Low-Back Pain.

13. P. B. O'Sullivan(2000) Lumbar segmental `instability': clinical presentation and specific stabilizing exercise management.

14. Joshua A. Cleland(2005) Slump stretching in the management of non-radicular low back pain: A pilot clinical trial


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Jun07
Dental Abscess
Introduction
A dental abscess is a collection of pus that forms in your teeth or gums as a result of a bacterial infection.
The main symptom of a dental abscess is a severe, throbbing pain at the site of the abscess. The pain usually comes on suddenly and then gets gradually worse over a few hours or a few days.
ypes and causes of dental abscesses
There are two types of dental abscess:
periapical abscess – where bacteria infect the inside of the tooth (this is the most common type of dental abscess)
periodontal abscess – where bacteria infect the gums
Both types of dental abscess are caused when bacteria builds up inside your mouth. This usually occurs due to a combination of:
poor dental hygiene – not cleaning your teeth and gums properly and regularly (find out how to brush and floss your teeth)
consuming lots of sugary or starchy food and drink – the carbohydrates in these types of food and drink encourage bacteria to grow
Treating dental abscesses
You should make an appointment with Dr. B C Shah as soon as possible if you think you may have a dental abscess.
He will be able to drain away the pus from the abscess and, if necessary, remove any teeth that have been damaged by the infection.
This type of treatment should not be too painful because local anaesthetic will be used to numb the affected area of your mouth.
Unlike some other types of infection, a dental abscess will not get better on its own and must be treated immediately. With appropriate treatment, the bacterial infection that causes a dental abscess can usually be successfully cured.
Complications of dental abscesses
It is rare for complications to develop as a result of a dental abscess, but they can be serious if they do occur. For example, the infection may spread to nearby bone (osteomyelitis).
Emergency treatment
If you have severe pain, you may need emergency dental treatment. Depending on your individual circumstances, you may need to contact Dr. B C Shah for your treatment.
Symptoms of dental abscess
The main symptom of a dental abscess is an intense, throbbing pain in your affected tooth or area of gum.
The pain usually comes on suddenly and may gradually get worse over a few hours to a few days.
Sometimes, the pain may spread to your ear, lower jaw and neck on the same side as the affected tooth.
Other symptoms
Other symptoms of a dental abscess can include:
Tenderness of your tooth and surrounding area
Sensitivity to very hot or cold food and drink
An unpleasant taste in your mouth
A general feeling of being unwell
Difficulty opening your mouth
Dysphagia (difficulty swallowing)
Disturbed sleep
When to seek immediate medical help
The following symptoms can be a sign of the infection spreading to other parts of your body:
Swelling in your face
A high temperature (fever) of 38°C (100.4°F) or above
Severe pain that does not respond to treatment with painkillers
Breathing difficulties
If you develop any of these symptoms you will need to contact Dr. B C Shah immediately.
Causes of dental abscess
A dental abscess occurs when bacteria infect and spread inside a tooth or your gums.
Your mouth is full of bacteria, which combine with small particles of food and saliva to form a sticky film called plaque, which builds up on your teeth.
Eating and drinking food and drink high in carbohydrates (sugary or starchy) causes the bacteria in plaque to turn the carbohydrates into the energy they need to reproduce. Acid is also produced.
The combination of bacteria and excess acid can lead to the formation of a dental abscess. This can either occur when bacteria spread into:
The centre of a tooth (the pulp) through tiny holes in the tooth (dental caries) that are caused by the excess amount of acid – this is known as a periapical abscess and it is the most common type of dental abscess
An area of your gums underneath a tooth – this is known as a periodontal abscess
Periapical abscesses
When a periapical abscess develops, plaque bacteria infect your tooth as a result of dental caries (tiny holes caused by tooth decay) that form in the hard outer layer of your tooth (the enamel).
Dental caries break down the enamel and the softer layer of tissue underneath (dentine) and eventually reach the centre of your tooth (pulp). This is known as pulpitis. The dental pulp in the middle of the tooth dies and the pulp chamber becomes infected.
The bacteria continue to infect the pulp until it reaches the bone that surrounds and supports your tooth (alveolar bone), where the periapical abscess forms.
Periodontal abscesses
A periodontal abscess occurs when plaque bacteria affect your gums, causing severe gum disease (also known as periodontitis).
Periodontitis causes inflammation (redness and swelling) in your gums, which can make the tissue surrounding the root of your tooth separate from the base of your tooth.
The separation creates a tiny gap called a periodontal pocket, which allows bacteria to enter and spread and can be very difficult to keep clean.
The periodontal abscess is formed by the build-up of bacteria in the periodontal pocket. A periodontal abscess may also occur as a result of:
Dental procedures that create accidental periodontal pockets
The use of antibiotics in untreated periodontitis, which can mask the beginnings of an abscess
Gum damage, even if you do not have periodontitis
Risk factors
Risk factors for a dental abscess include:
Poor oral hygiene – if you do not brush your teeth and floss between them regularly, your risk of developing a dental abscess is increased
Having a diet high in sweet and sticky food and drink – such as chocolate, sweets, sugar and fizzy drinks and/or starchy foods, such as crisps, white bread, pretzels and biscuits
Having a weakened immune system – this may be due to having an underlying health condition, such as diabetes, or the side effects of treatments such as steroid medication (corticosteroids) or chemotherapy
Diagnosing a dental abscess
If you think that you may have a dental abscess, you must see Dr. B C Shah as soon as possible.
Dr. B C Shah will carry out some tests to determine whether your symptoms are being caused by a dental abscess. For example, they may:
Tap on the affected tooth or area of gum – if infection is present, your tooth or gum will be sensitive to any pressure
Examine your gums – an infection will usually cause an area of your gums to become red and swollen
Take an X-ray of the affected area to help assess the spread of infection
In some cases, he may be able to confirm a diagnosis by simply asking you about your symptoms.
Referral
Dr. B C Shah may refer you for treatment in hospital if you have a dental abscess and you:
Are feeling unwell with a high temperature, a rapid pulse rate or low blood pressure (hypotension) and rapid breathing
Are in severe pain despite taking painkillers
Have a spreading facial infection
Have a weakened immune system (for example, because you are having treatment such as chemotherapy)
Treating a dental abscess
The only way to cure a dental abscess is with dental treatment.
Dr. B C Shah will treat your abscess using dental procedures and, in some cases, surgery .
Painkillers
A dental abscess can be very painful, but you can use over-the-counter painkillers from your local pharmacy to control the pain while you are waiting for dental treatment.
Ibuprofen is the preferred painkiller for dental abscesses, but if you are unable to take ibuprofen for medical reasons, you can take paracetamol instead.
If one painkiller fails to relieve the pain, taking both paracetamol and ibuprofen at the same time can often be effective (this is safe for adults, but not for children under 16 years of age).
However, you should make sure you leave six hours before taking another combined dose.
Also, always read and follow the information on the packet about how much to take and how often, and do not exceed the maximum stated dose.
Accidental overdoses have been reported in people who take too many painkillers when trying to relieve the pain of a dental abscess.
Painkillers cannot treat or cure a dental abscess, so they should not be used to delay dental treatment.
Follow the advice below to take painkillers safely:
Do not take ibuprofen if you are asthmatic or if you have a stomach ulcer, or you have had one in the past
Do not take more than one painkiller at the same time without first checking with Dr. B C Shah as this can be dangerous because many over-the-counter products contain similar painkillers and it is possible to overdose when combining products
Ibuprofen and paracetamol are both available as liquid preparations for children
Aspirin is not suitable for children under 16 years of age
If you are pregnant or breastfeeding, you should take paracetamol
Self care
Other self care techniques that can help include:
Avoid anything that makes the pain worse, such as hot or cold foods or cold air
Holding cooled water or crushed ice around the tooth can sometimes ease the pain
The pain can often feel worse when you are lying flat, so lying propped up may help ease pain
Dental treatment
The first and most important step in treating a dental abscess is to cut out the abscess and drain away the pus containing the infectious bacteria.
Dr. B C Shah will carry this out under local anaesthetic. This means you will be awake throughout the procedure, but the affected area will be numb so you will feel little to no pain.
If the abscess is inside one of your teeth (a periapical abscess), root canal treatment will usually be recommended. This involves drilling into the affected tooth to release the pus and removing any damaged tissue from the centre (pulp). A filling will then be inserted into the space to prevent further infection.
If there is a pocket of pus inside an area of gum (a periodontal abscess), Dr. B C Shah will drain the pus and clean out the pocket. They will then smooth out the surfaces of the root of your tooth by filing below your gum line to help your tooth heal and prevent further infection.
Antibiotics
Antibiotics are not routinely prescribed to treat dental abscess because:
Draining the abscess is a more effective treatment
Using antibiotics to treat non-serious infections makes them less effective at treating more serious infections (this is known as antibiotic resistance)
Antibiotics are usually only required if:
There are signs that the infection is spreading, such as swelling of your face or neck
You have a weakened immune system
If antibiotics are required, an antibiotic called amoxicillin is usually recommended. If you are allergic to amoxicillin, which is a type of penicillin, metronidazole can usually be prescribed as a precaution.
Reoccurring infection
If you have a periapical abscess and your infection reoccurs, you may need to undergo a surgery to remove any further diseased tissue.
If you have a periodontal abscess and your infection reoccurs, Dr. B C Shah will surgically be able to reshape your gum tissue to permanently remove the periodontal pocket.
In some cases, a dental abscess infection can reoccur even after dental and surgical procedures. If this happens, or if your tooth is severely broken down, it may need to be removed altogether (extracted).
Complications of a dental abscess
With appropriate dental treatment, a dental abscess can usually be easily cured. However, in rare cases, complications can occur.
Most complications arise due to the spread of the bacterial infection when an abscess is left untreated. Some possible complications are outlined below.
Dental cysts
If a dental abscess is left untreated, a fluid-filled cavity may develop at the bottom of the root of your tooth. This is known as a dental cyst.
If a cyst becomes infected, treatment with antibiotics may be needed. A dental cyst can be surgically removed under local anaesthetic (where the affected area is numbed).
Osteomyelitis
Osteomyelitis is an infection of the bone. It is caused by the bacteria in a dental abscess spreading through your bloodstream.
Osteomyelitis can cause symptoms such as fever, nausea (feeling sick) and severe pain in the affected bone, which can often be in the area surrounding a dental abscess.
However, as the infection is spread through your blood, it is possible for it to affect any bone in your body. Osteomyelitis can be treated by taking oral antibiotics or injecting them into a vein.
Sinusitis
Sinusitis is an infection of the small air-filled cavities inside your skull.
It is usually the cavities behind your cheekbones that can become infected as a complication of a dental abscess. These are known as the maxillary sinuses.
Symptoms of sinusitis include:
A blocked or runny nose
Facial pain and tenderness
A high temperature (fever) of 38°C (100.4°F) or above
Sinusitis often clears up without treatment but, if necessary, antibiotics may be prescribed.


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May11
backache -laser treatment for disc problems
LASER treatment for disc disease
laser treatment for disc problems is called Percutaneous Laser Disc Decompression(PLDD). This treatment is now available in India.
PLDD is the minimally-invasive medical procedure developed by Dr. Daniel S.J. Choy in 1986 that uses a laser beam to treat back and neck pain caused by a herniated disc.
A herniated disc is like a balloon with a weak spot. Inflating it will cause a bulge (herniation). Pain results from the bulge pressing against nerves in the spinal column. The patients who have contained intervertebral disc on imaging and has not responded to medication for one month are suitable candidates for this treatment.
The PLDD treatment is performed using only local anesthesia. During the procedure, a thin needle is inserted into the herniated disc under x-ray guidance. SevenHills hospital has cathlab with CT scan capability by which we can precisely place the needle and check results after laser therapy. An optical fiber is inserted through the needle and laser energy is sent through the fiber, vaporizing a tiny portion of the disc nucleus. This creates a partial vacuum which draws the herniation away from the nerve root, thereby relieving the pain. The effect usually is immediate, but pain relief may be seen after a week or upto 2 months. In carefully selected cases 80% patients are benefitted.
Patients get off the table with just a small adhesive bandage. 24 hours of bed rest is advised. Then patients begin progressive ambulation and most return to work in four to five days.
Because only a thin needle is used, there is no cutting and no scarring; hence a very low risk procedure. Since only a tiny amount of disc is vaporized, there is no subsequent spinal instability. PLDD is different from open lumbar disc surgery because there is no damage to the back muscle, no bone removal or large skin incision. Most of the complications that may occur with open surgery are eliminated with the PLDD procedure. please visit my website www.irtreatments.com for further details


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Mar07
Hidradenitis Suppurativa
Hidradenitis suppurativa (sometimes known as acne inversa) is a painful long-term skin disease that causes abscesses and scarring on the skin – usually around the groin, buttocks, breasts and armpits.
It's not known exactly what causes hidradenitis suppurativa (HS), but the disease is linked to inflamed apocrine sweat glands and plugging of the hair follicles.
The apocrine sweat glands are found in places where we have the most hair follicles, which would explain why the skin in the groin and armpits is particularly affected.
An estimated 1% of the population has HS, but this may be an underestimate as some people may be too embarrassed to seek diagnosis and treatment.
What are the symptoms?
HS ranges from mild to severe.
It causes a mixture of red boil-like lumps, blackheads, cysts, scarring and channels in the skin that leak pus. These lumps and spots are found around the groin and armpits and sometimes under the breasts and in other areas (see below). HS may sometimes be mistaken for acne, folliculitis (inflammation of the hair follicles) or sexual diseases such as herpes.
Some of the lumps may become infected with bacteria, causing a secondary infection that will require antibiotics to treat. HS is very painful.
The disease tends to start with a firm pea-sized nodule (0.5-1.5cm) developing in one place, which either goes away on its own or ruptures after a few hours or days to ooze pus. This 'lesion' may return time and time again.
New lumps will often soon appear in an area nearby. If these are not controlled with medication, larger golfball-sized lumps may form and spread, and sinus tracts may develop. Sinus tracts are narrow channels under the skin that open up in the skin surface and leak pus.
This cycle continues and new lumps may continue to reappear. HS is a lifelong condition that requires constant management.
Stages of the disease
Doctors classify the disease into three distinct stages:
Stage 1 – single or a few isolated abscesses without scarring or sinus tracts.
Stage 2 – recurrent abscesses in more than one area and the beginning of the formation of sinus tracts.
Stage 3 – widespread abscesses with many interconnected sinus tracts under the skin. There may be severe scarring and continuous leaking.
Main affected areas
HS usually affects skin in the following areas:
Around the groin and genitals
In the armpits
Around the bottom (anus)
On the buttocks and inner thighs
Below the breasts
The abscesses may spread to the nape of the neck, waistband and inner thighs. Other isolated areas have been known, including the front or back of the legs, the sides, the back area and even the face.
Many people with HS develop a pilonodal sinus, which is a small hole or 'tunnel' in the skin usually at the top of the buttocks, where the buttocks separate.
What are the causes?
The exact cause of HS is not clear, but the bumps and spots appear to be the result of blocked apocrine sweat glands and hair follicles.
Sweat becomes trapped inside the tubes from the sweat glands, which swell up and either burst or become severely inflamed (see Symptoms section above).
However, the disease is not infectious and it is not caused by an infection. It is not linked to poor hygiene.
It is thought that HS may be caused by a problem with the immune system. This disease may be linked to Crohn's disease. Many HS patients also suffer from another underlying autoimmune disorder .
Who is affected?
HS usually starts around the age of puberty, but it can appear at any age.
It is less common for HS to occur before puberty or after the menopause, leading some experts to believe that the sex hormones have some sort of influence on the disease.
Sometimes, HS runs in families.
HS affects three times more women than men, for reasons that are not clear.
Many people with HS:
Are smokers
Are overweight
Also have hirsutism (excessive hair growth) and/or acne, both of which are linked to levels of sex hormones
Smoking and being obese are likely to make the condition worse.
Lifestyle changes
It's recommended that you lose any excess weight and stop smoking if you smoke – this can lead to an improvement in symptoms within several months.
It may help to wear loose-fitting clothes to reduce friction against your skin. Avoid shaving the skin and wearing perfume or perfumed deodorants in the affected area.
It's also a good idea to use antiseptic soap or an antiseptic wash to reduce skin bacteria (try 4% chlorhexidine wash), and to hold a warmed flannel to the spots to encourage the pus to drain.
How is it treated?
HS can be difficult to manage. The aim is to catch the disease in its early stages and prevent it getting worse. Therefore an early diagnosis is important.
In the early stages, the disease may be controlled with medication. Persistent and severe cases may require surgery. These treatments are outlined below.
Antibiotics
If your lumps are particularly painful, red and oozing pus, Dr. B C Shah may prescribe a two-week course of antibiotic tablets, as there may be a secondary infection present.
You can also try anti-acne antibiotic creams such as clindamycin or erythromycin, to use alongside benzoyl peroxide wash (a gel to help unblock the glands).
Some people may need a longer course of antibiotics to bring symptoms under control. For example, you may be prescribed a combination of rifampicin and clindamycin for two to three months if your HS is severe. This brings remission (a symptom-free period) for most patients.
You may also be tried on penicillin treatments such as flucloxacillin, amoxicillin or co-amoxiclav.
Corticosteroids
You may be prescribed steroid medicine (corticosteroids) such as prednisolone to reduce severely inflamed skin. Corticosteroids can be taken as tablets, or you may have an injection of the drug directly into your affected skin.
Possible side effects of corticosteroids are fluid retention, weight gain, constipation and mood swings.
Retinoids
Retinoids are vitamin-A based drugs such as isotretinoin. They are not as effective for HS as they are for acne, but a course for six-12 months may help to control some of the spots and lumps.
Isotretinoin should be used with caution, with the advice of a specialist. It cannot be taken during pregnancy and possible side effects include dry lips, skin and eyes.
Contraceptive pill
Women whose HS flares up before their period may benefit from taking the contraceptive pill for 12 months or more.
The pill contains an artificial version of oestrogen, which should help reduce secretions from the sweat glands and help control the lumps.
Ciclosporin
Ciclosporin is a powerful medication that suppresses the immune system. For some patients with HS, it can relieve symptoms for a few months.
However, this medicine can cause vomiting, diarrhoea, high blood pressure, numbness, and kidney and liver problems.
Infliximab and adalimumab
Biological drugs like infliximab or adalimumab, which also suppress the immune system, may be prescribed for severe cases of HS.
These powerful drugs are very effective but expensive. Dr. B C Shah usually only prescribe them if other treatments don't work for you.
Infliximab and adalimumab are given by injection at hospital or at a clinic. You may need to have the injections about every eight weeks.
Possible side effects include blood disorders, infection and tissue cancers. Speak to Dr. B C Shah about these side effects if you are considering taking this medication.
Surgery
A surgical procedure may be considered if your HS is not controlled with medication.
If you have some very large lumps that will not clear with antibiotics, you may be offered one of the following treatments:
Incision and drainage or removal – cutting off the lids of the lumps and draining or scraping out the contents inside, or removing the lumps altogether
Laser ablation – using a laser to remove the lumps (this has no proven benefit and is an experimental treatment)
Cryotherapy – freezing off the lumps with liquid nitrogen
Outlook
HS persists for many years and there is no cure, but symptoms may be improved with treatment if it is diagnosed early.
Not all people with HS progress to stage 3 – the disease can be controlled so it doesn't progress beyond stage 1.
However, HS can affect your life in many ways. Routinely changing dressings and living with the pain, discomfort and embarrassment of the symptoms can affect quality of life and lead to depression. If you are having problems coping, speak to Dr. B C Shah to see what support is available.


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Mar03
Underactive Thyroid
Introduction
An underactive thyroid means your thyroid gland, located in the neck, does not produce enough hormones.
Common signs of an underactive thyroid are tiredness, weight gain and feeling depressed.
Medically known as hypothyroidism, an underactive thyroid is not usually serious. It is easily treated by taking hormone tablets to replace the hormones that your thyroid isn't making.
The thyroid produces a hormone called thyroxine, which controls how much energy your body uses. When the thyroid does not produce enough thyroxine, many of the body's functions slow down.
An underactive thyroid cannot be prevented. Most cases of underactive thyroid are caused either by your immune system attacking your thyroid or a damaged thyroid.
Find out more about the causes of underactive thyroid.
When to see Dr. B C Shah
See Dr. B C Shah and ask to be tested for an underactive thyroid if you have symptoms including:
Tiredness
Weight gain
Depression
Being sensitive to the cold
Dry skin and hair
Muscle aches
Symptoms of an underactive thyroid are often confused for something else, by patients and doctors. Symptoms also usually begin slowly and you may not notice them for several years. The only accurate way to find out if you have a thyroid problem is to get a blood test to measure your hormone levels.
Who can it affect?
Both men and women can have an underactive thyroid. However, it's more common in women.
One in 4,500 babies are born with an underactive thyroid (called congenital hypothyroidism).
Treatment
Underactive thyroid is usually not serious, and taking hormone-replacement tablets, called levothyroxine, will raise your thyroxine levels. You will usually need treatment for the rest of your life. However, with careful management, you should be able to lead a normal, healthy life.
If it is not treated, an underactive thyroid can lead to complications, including swelling of the thyroid (a condition called goitre), heart disease, mental health problems and infertility.
Symptoms of underactive thyroid
Many symptoms of an underactive thyroid (hypothyroidism) are the same as those for other conditions, so they can easily be confused for something else.
Symptoms usually begin slowly and you may not realise you have a medical problem for several years.
Common symptoms include:
Being sensitive to cold
Weight gain
Constipation
Depression
Tiredness
Slowness in body and mind
Muscle aches and weakness
Muscle cramps
Dry and scaly skin
Brittle hair and nails
Heavy or irregular periods
Elderly people with an underactive thyroid may develop memory problems and depression. Children may experience slower growth and development. Teenagers may start puberty earlier than normal.
If you have any of these symptoms, see Dr. B C Shah and ask to be tested for an underactive thyroid.
Find out more about getting tested for an underactive thyroid.
If underactive thyroid is not treated
It is unlikely that you would have many of the later symptoms of an underactive thyroid as the condition is often spotted before more serious symptoms appear.
Later symptoms of underactive thyroid include:
A low-pitched and hoarse voice
Dull facial expressions and a puffy-looking face
Thinned or partly missing eyebrows
A slow heart rate
Deafness
Anaemia
Causes of underactive thyroid
An underactive thyroid (hypothyroidism) happens when your thyroid gland doesn't produce enough of the hormone thyroxine, also called T4.
Most cases of underactive thyroid are due to either the immune system attacking the thyroid gland or a damaged thyroid.
Immune system
Most cases of underactive thyroid happen when the immune system, which normally fights infection, attacks the thyroid gland. Doctors describe this as an autoimmune reaction. This damages the thyroid, which means it is not able to make enough of the hormone thyroxine, and leads to the symptoms of an underactive thyroid.
Hashimoto's disease is the most common type of autoimmune reaction that causes an underactive thyroid.
It is not clear what causes Hashimoto’s disease, but the condition runs in families. It is also common in people with another disorder related to the immune system, such as type 1 diabetes and vitiligo.
Treatment for overactive thyroid
An underactive thyroid can also be a side effect of treatment for an overactive thyroid, a condition where the thyroid gland produces too much hormone.
Treatment for an overactive thyroid, medically known as hyperthyroidism, can involve medication, radiotherapy or surgery, all of which can cause your thyroid to become underactive.
Other rare causes
A lack of iodine in your diet may cause an underactive thyroid. This is because your body needs iodine to make thyroxine.
A viral infection or some drugs used to treat other conditions, such as depression and heart disorders, can cause the thyroid to stop working properly.
A baby may be born with an underactive thyroid if the gland does not develop properly in the womb. However, this is usually picked up during neonatal screening.
A problem with the pituitary gland could lead to an underactive thyroid. The pituitary gland is located at the base of the brain and regulates the thyroid. Therefore, damage to the pituitary may lead to an underactive thyroid.
Diagnosing underactive thyroid
If you have symptoms of an underactive thyroid(hypothyroidism), see Dr. B C Shah and ask for a blood test.
A blood test measuring your hormone levels is the only accurate way to find out if there is a problem.
The test, called a thyroid function test, looks at levels of thyroid-stimulating hormone (TSH) and thyroxine in the blood.
A high level of TSH and a low level of thyroxine hormone in the blood could mean you have an underactive thyroid.
If your test shows raised TSH but normal thyroxine, it means you may be at risk of developing an underactive thyroid in the future.
Referral
Dr. B C Shah may refer you to a specialist in hormone disorders, known as an endocrinologist, if you:
Are younger than 16
Are pregnant or trying to get pregnant
Have just given birth
Have another health condition, such as heart disease, which may complicate your medication
Are taking amiodarone or lithium medication
Treating underactive thyroid
An underactive thyroid (hypothyroidism) is usually treated by taking hormone-replacement tablets called levothyroxine.
Levothyroxine replaces the thyroxine hormone which your thyroid does not make enough of.
A blood test measuring your levels of thyroid-stimulating hormone (TSH) will establish how much levothyroxine you need.
If the test detects high levels of TSH, it means you have an underactive thyroid and your doctor may advise you to take levothyroxine.
You may start on a low dose of levothyroxine, which may be increased gradually depending on how your body responds.
You will initially have regular blood tests until the correct dose of levothyroxine is reached. This can take a little while to get right.
If your symptoms are mild
If testing detects high levels of TSH but you do not have any symptoms or they are very mild, you may not need any treatment.
Dr. B C Shah will usually monitor your hormone levels every few months and may start you on levothyroxine if you develop symptoms.
Some people start to feel better soon after beginning treatment, while others can take several months.
An underactive thyroid is a lifelong condition, so you will probably need to take levothyroxine for the rest of your life.
Levothyroxine does not usually have any side effects as the tablets simply replace a missing hormone.
Once you are taking the correct dose, you will usually have a blood test once a year to monitor your TSH levels.
Complications of underactive thyroid
Several complications can occur if you have an underactive thyroid that is not treated.
An underactive thyroid can be caused by a problem with the immune system, the body’s natural defence system, which can attack the body's own cells, including the thyroid.
This disorder may raise your risk of developing other immune conditions, although this is unusual.
These conditions include:
B12 deficiency
vitiligo (patches on the skin caused by pigment loss)
kidney failure
premature failure of the ovaries or early menopause
goitre
heart disease
Coma risk
In very rare cases, a severe underactive thyroid may lead to a life-threatening condition known as myxedema coma.
Warning signs include:
low body temperature
shallow breathing
low blood pressure
low blood sugar
unresponsiveness

- See more at: http://drbcshah.com/underactive-thyroid/#sthash.mrpuqdYL.dpuf


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