Javaid Iqbal
-
Upload
juan-arononia -
Category
Documents
-
view
235 -
download
0
Transcript of Javaid Iqbal
-
7/29/2019 Javaid Iqbal
1/78
I
EFFECTIVENESS OF CORE STABILITY EXERCISES
ON AND OFF THE SWISS BALL IN REDUCING BACK
PAIN AND DISABILITY IN MECHANICAL LOW BACK
ACHE SUBJECTS-A Comparative study
By
Javaid Iqbal
Dissertation submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
In partial fulfillment of the requirements for the degree of
MASTER OF PHYSIOTHERAPY
IN
MUSCULOSKELETAL DISORDERS AND SPORTS
PHYSIOTHERAPY
Under the guidance of
Mr.G.R. Vikranth, M.P.T.
THE OXFORD COLLEGE OF PHYSIOTHERAPY
BANGALORE.
2010
-
7/29/2019 Javaid Iqbal
2/78
II
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE.DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation/thesis entitled Effectiveness
Of Core Stability Exercises On And Off The Swiss Ball In Reducing
Pain And Disability In Mechanical Low Back Ache Subjects-A
Comparative Study is a bonafide and genuine research work carried out
by me under the guidance of Mr. G.R.Vikranth. MPT, Assistant
Professor, The Oxford College of Physiotherapy, Bangalore.
Date: Signature of the Candidate
Place: Bangalore JAVAID IQBAL
-
7/29/2019 Javaid Iqbal
3/78
III
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE.
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled Effectiveness Of
Core Stability Exercises On And Off The Swiss Ball In Reducing Pain
And Disability In Mechanical Low Back Ache Subjects-A
Comparative Study is a bonafide research work done by JAVAID
IQBAL in partial fulfillment of the requirement for the degree of
MASTER OF PHYSIOTHERAPY.
Date: Signature of the Guide
Place: Bangalore Mr. G.R.VIKRANTH, M.P.T.S
Assistant Professor
-
7/29/2019 Javaid Iqbal
4/78
IV
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE.
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE
INSTITUTION
This is to certify that the dissertation entitled Effectiveness Of
Core Stability Exercises On And Off The Swiss Ball In Reducing Pain
And Disability In Mechanical Low Back Ache Subjects- A
Comparative study is a bonafide research work done by JAVAID
IQBAL under the guidance ofMr. G.R.VIKRANTH, M.P.T. Assistant
Professor, The Oxford College of Physiotherapy, Bangalore.
Date: Signature of the Principal
Mr. K.G.KIRUBAKARAN M.P.T.
Place: Bangalore The Oxford College of Physiotherapy
-
7/29/2019 Javaid Iqbal
5/78
V
COPYRIGHT
Declaration by the candidate
I hereby declare that the Rajiv Gandhi University of Health
Sciences, Karnataka shall have the rights to preserve, use and disseminate
this dissertation/thesis in print or electronic format for academic / research
purpose.
Date: Signature of the candidate
Place: Bangalore JAVAID IQBAL
Rajiv Gandhi University of Health Sciences, Karnataka
-
7/29/2019 Javaid Iqbal
6/78
VI
ACKNOWLEDGEMENT
I thank God and I take this opportunity to express my heartfelt
gratitude to my parents for their all time support, care, motivation and
encouragement.
I am sincerely thankful and grateful to Shri. S. Narasa Raju,
founder Chairman and Shri. S.N.V.L. Narasimha Raju, Director,
Childrens Education Society for providing me an opportunity to do my
M.P.T and providing me all the facilities for this study.
I am equally grateful Mr. K.G. KIRUBAKARAN, M.P.T.
Principal, The Oxford College of Physiotherapy, Bangalore, for his
guidance and support shown throughout the study.
I am deeply indebted to my guide Mr. G.R. VIKRANTH,
M.P.T., Assistant Professor, without whose unstinted guidance, constant
encouragement, suggestions and support, a study of such magnitude would
have not been materialized.
My sincere thanks to Mr. R.Vasanthan M.P.T., Mr. Pruthvi
M.P.T, Mr. C.Dinesh M.P.T, Mr. Paul Daniel M.P.T. and Mr.
Ramesh Prabhu M.P.T. for helping me in doing my dissertation work.
I am thankful to the librarian, whose support and patience gave me
time to use books and journals.
My heartfelt thanks to my friends, classmates, for their helping
hand shown through out the study.
-
7/29/2019 Javaid Iqbal
7/78
VII
Last but not the least I would like to thank all the subjects of my
study, without whom this task would not have been possible.
My thanks to all the contributors, whose names I have not
mentioned, though they all deserve my gratitude.
JAVAID IQBAL
-
7/29/2019 Javaid Iqbal
8/78
VIII
LIST OF ABBREVIATIONS USED
1. VAS - Visual Analog Scale2. ODI - Oswestry Disability Index3. LBA -Low Back Ache4. TA - Transverse Abdominus5. DRG -Dorsal Root Ganglion6. PLA2 -Phospholipase A27. EMG -Electromyograph
-
7/29/2019 Javaid Iqbal
9/78
IX
ABSTRACT
Objective &BackgroundWe all need good core stability program to prevent low back pain,
to initiate limb movements, for proper utilization of muscle forces and to
enhance performance. And also, there is lack of literature support in
normal subjects and the benefits of core endurance in everyday activities.
To compare the effectiveness of core stability exercises on and off the
Swiss ball in reducing pain and disability.
Method
A group of 30 subjects were selected for the study and randomly
divided into two equal groups of 15 each. All subjects were selected
between the age group of 30-45 years.
The group I subjects were asked to perform core stability exercises
on Swiss ball and group II performed same exercises on Floor. Both
groups were asked to perform 4 types of core stability exercises for 3 days
in a week, for 4 weeks.
The pain and disability were assessed Pre and Post intervention
using VAS and ODI respectively.
Results
Two groups were compared for the difference between the Pre-
Post test score and the result showed that there was statistically significant
difference between the pre-post mean scores of all the testing variables
with very large increase in effect size with P
-
7/29/2019 Javaid Iqbal
10/78
X
Conclusion
The Swiss ball exercises showed statistically significant
improvement in reducing back pain and disability when compared to the
floor exercises. Thus, performing core stability exercises on a Swiss ball
reduces pain and disability significantly compared to floor among
mechanical low back ache subjects.
.
Keywords
Core muscles; Abdominal muscles; Trunk muscles; Core
strengthening; Swiss ball; Pilates; Low Back Pain Rehabilitation
-
7/29/2019 Javaid Iqbal
11/78
XI
TABLE OF CONTENTS
Sl. No Title Pg. No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
INTRODUCTION
OBJECTIVES
REVIEW OF LITERATURE
METHODOLOGY
RESULTS
DISCUSSION
CONCLUSION
SUMMARY
BIBLIOGRAPHY
ANNEXURES
1-15
16
18-23
24-32
33-38
39-42
43
44
45-49
50-63
-
7/29/2019 Javaid Iqbal
12/78
XII
LIST OF TABLES
Sl
No.
Title of Tables Pg.No.
1.
2.
3.
4.
BASIC CHARACTERISTICS OF THE STUDY
COMPARISON OF VAS
COMPARISON OF ODI
COMPARISON OF IMPROVEMENT IN VAS AND
ODI BETWEEN GROUPS
35
36
37
38
-
7/29/2019 Javaid Iqbal
13/78
XIII
LIST OF FIGURES
Sl.No. List of Figures Pg.No.
1.
2.
3.
4
5
6
7
8
9
10
11
12
13
14
15
The inner unit
Core muscles
Relationship between inner and outer unit
Curl up on floor
bridging on floor
Side plank on floor
Front plank on floor
Curl up on ball
Bridging on ball
Side plank on ball
Front plank on ball
List of graphs
Age distribution
Comparision of vas
Comparision of odi
Comparison of improvement in vas and odi between groups
7
9
10
27
27
28
29
29
30
31
31
35
36
37
38
-
7/29/2019 Javaid Iqbal
14/78
XIV
-
7/29/2019 Javaid Iqbal
15/78
1
INTRODUCTION
LOW BACK ACHE
Low back pain has been and continues to be, one of the enigmas of modern medicine.
The epidemic of low back pain and the disability associated with it has appeared to
escalate, at the same time that the greatest technological advances related to diagnosis
treatment and rehabilitation have been made. Back pain has now become not only a
medical problem, but a social, legal and political one as well.1
In 1990, nearly 15 million office visits took place for mechanical Low Back Pain,
ranking this problem as the second most common symptom related reason for seeing a
physician. Survey suggests that the life time incidence of low back pain Ranges from
60% to 90% within 5% annual incidence. For persons younger than 45 years, mechanical
low back pain represents the most common cause of disability than in person aged older
than 45 years.2
Mechanical low back pain is described as a musculoskeletal pain which varies with
physical activities and not involving root compression or serious spinal diseases.
Definition: - unilateral pain with no referral below the knee may be caused by injury
to the muscles (strain) or ligaments (sprain), the facet joint, or in some cases, the
sacroiliac joint. This is called mechanical low back pain.3
Symptoms:-
1. Pain is usually cyclic.
-
7/29/2019 Javaid Iqbal
16/78
2
2. Low back pain is often referred to buttocks and thighs.3. Morning stiffness or pain is common.
4. Start pain (i.e., when starting the movement) is common.5. There is pain on forward flexion and often also in returning to erect position.6. Pain is often produced and aggravated by extension, side flexion, rotation, standing,
walking, sitting, and exercise in general.
7. Pain usually becomes worse over the course of the day.8. Pain is relieved by change in position.9. Pain is relieved by lying down especially in foetal position.
EPIDEMILOGY
Each year: About 35% to 40 % of adults get back pain.
About 5% to 10% have low back disability.
About 5% to 20% lose some time off work.
About 1% is permanently disabled.
About 6% to 10% seek health care for back pain.
RISK FACTORS FOR MECHANICAL LOW BACK PAIN
Physical work factor
Heavy manual work
-
7/29/2019 Javaid Iqbal
17/78
3
Lifting and twisting Postural stress sitting and driving Whole body vibration
Psychosocial work factors
Social influences Monotonous work Lack of personal control- tension, stress, anxiety, fear and depression Low job satisfaction
Physiological factor
Low physical fitness Inadequate trunk strength
PATHOPHYSIOLOGY:
The pathophysiology of mechanical low back pain is complex; multiple structures
and elements of lumbar spine are suspected to have a role. These components of lumbar
spine have sensory innervations and therefore, have potential to generate nociceptive
signals.2
-
7/29/2019 Javaid Iqbal
18/78
4
Biomechanically, the movement of elements of lumbar spine are the cumulative
motions of the vertebrae with 80-90% of lumbar flexion/ extension occurring at L4-L5
and L5-S1 intervertebral discs. The most risky position for the disk is with forward
flexion, rotation, and with lifting heavy load not held close to body. Axial loading of
short duration is resisted by annual fibres; long duration loads feature radical pressure to
the annulus fibrosis and increased pressure to the end plates. If the annulus and end plate
are intact, forces are resisted adequately. Due to compressive muscular force, bending
and lifting cause increased intradiscal pressure proportional to the distance of the load
from the body.
2
Compressive loading of the discs in flexion (e.g. lifting) puts the discs at risk for
an annular tear and internal disc disruption. Likewise, torsional forces on the discs can
produce shear forces that may induce annular tears. The contents of annulus fibrosis
(nucleus pulposus) may leak through these tears. Central fibres of the disc are pain free,
so early tears might not be painful.
The concept of biomechanical degenerative spiral has an appealing quality and is
gaining wider acceptance. This concept postulates the breakdown of the annular fibers
and allows PLA2 and glutamate, and possibly other as yet unknown compounds, to leak
onto the epidural space and diffuse to vibration and physical overloading resulting in the
compression of DRG stimulating release of Substance P. Substance P in turn, stimulates
histamine and leukotriene release, leading to an altering of nerve impulse transmission.
The neurons become sensitized further to mechanical stimulation, possibly ischemia,
which attracts polymorph nuclear cells and monocytes to areas that facilitate further disc
degeneration and produce more pain.
-
7/29/2019 Javaid Iqbal
19/78
5
Core training can serve as the starting foundation for all-around strength
and conditioning program.4
To maintain a strong and healthy back, we should exercise
the core muscles in ways specific to how they function in daily life.Stabilization
programmes attracted our interest with their aims of using muscle system to protect
spinal joint structures from further repetitive micro trauma, recurrent pain and
degenerative change.5
Definition of core:
According to Merriam-Websters dictionary core is a central and often
foundational part usually distinct from the enveloping part by a difference in nature.
Stability is the property of body that causes it when disturbed from a condition of
equilibrium or steady motion to develop forces or moments that restore the original
condition.
Paul W. Marshall says the term core stability is a generic description for training
of abdominal and lumbopelvic region. To define core stability, the combination of global
and local stability system has been used. The global; stability system refers to the larger,
superficial muscles around the abdominal and lumbar region, such as rectus abdominus,
paraspinals and external obliques. These muscles are the prime movers for trunk or hip
flexion, extension and rotation. Local stability refers to the deep, intrinsic muscles of
abdominal wall, such as transverses abdominus and multifidus. These muscles are
associated with segmental stability of lumbar spine during gross whole body movements
and where postural adjustments are required. There is a synergistic relation between the
global and local stability systems that elicit a satisfactory training effect.6, 7
-
7/29/2019 Javaid Iqbal
20/78
6
History of core
Core stabilization dates back 50 years ago and was introduced in the U.S. during 1960s to
treat neurological and spinal injuries. Today, using stability balls and balance boards
develops core stabilization.8
According to Joseph Pilates, in 1920s core training is developing a girdle of
strength by recruiting the deep trunk muscles. Today, Pilates has regained popularity and
fame as authoring an effective way to train the core.9
Core in daily life
We need to understand the benefits a good core conditioning programme can have
on our livelihood. A core conditioning programme will decrease the likelihood of back
and neck pain, incontinence, ruptured disks, muscle and ligamentous strains. Many
problems and orthopaedic injuries are a result of poor core endurance. The body is
designed to work at the most economic level thus saving energy for future use. We spend
more energy maintaining misalign posture thus creating a situation for muscular and joint
pain to arise.10
The use of labile surface underneath the subject for stability training of injured
low back demonstrate the importance of abdominal muscles in ensuring sufficient spine
stability to prevent buckling and enhancing function.11
Trunk is a kinetic chain, connecting all the parts of body together as a whole. A
problem or weakness in one part of the chain can lead to pain or injury in other part.12
-
7/29/2019 Javaid Iqbal
21/78
7
Anatomically speaking, the core is an integrated functional unit consisting of
lumbo-pelvic-hip complex and the thoracic and cervical spine. It is a muscular corset that
lends integrity and support to the body.4
THE CORE MUSCLES
The core has been described as a box with the abdominals in front, paraspinals
and gluteals in the back, the diaphragm as the roof, and the pelvic floor and hip girdle
musculature as the bottom. The core serves as a muscular corset that works as a unit to
stabilize the body and spine, with and without limb movement.13
The muscles involved are broken down into inner and outer units. A good core
programme should coordinate all these muscles
as one working unit.
THE INNER UNIT
Fig.1 Inner unit
The inner unit provides the necessary joint stabilization for the spine. If the inner
unit doesnt activate properly our spine, pelvis and joint structures are placed under
undue stress. This stress creates an atmosphere that leads to many injuries. The basic
inner unit consists of transverses abdominus, multifidus, pelvic floor and diaphragm.14, 15
-
7/29/2019 Javaid Iqbal
22/78
8
Transversus abdominus (TA) is the deepest, innermost layer of all abdominal
muscles. Consider the TA as our bodys personal weight belt. When the TA contracts it
causes hoop tension around midsection like a girdle or corset. TA will, if working
properly, contract before extremities will move, according to Diana Lee.
It also provides support for the abdominal wall, has a vital role in maintenance of
posture, allows for trunk movements (flexion, extension, lateral flexion), responsible for
raising intra-abdominal pressure.14
Multifidus lies deep in the spine spanning from three joint segments. The
multifidus works to provide joint stabilization at each segmental level. Each vertebrae
needs stiffness and stability to work effectively to reduce degeneration of joint structures.
Pelvic floor is our next set of muscles which spans the area underneath the pelvis.
It is important for the pelvic floor and the inner unit to work properly. By doing simple
yet important exercises we can re-establish communication, tighten and tone the muscle
group, prevent or diminish incontinence, leakage and pelvic dysfunction.10
Diaphragm plus each of these three muscles, is the target of inner unit
conditioning. The transverse abdominus forms the walls of cylinder while the muscles of
pelvic floor and diaphragm forms the base and lid respectively.10
THE OUTER UNIT
The outer unit musculature system aids in movement and function. The outer unit
muscles are basically the prime movers of the core and extremities such as the internal
oblique, external oblique, rectus abdominus, back, legs, shoulder girdle and more.10
-
7/29/2019 Javaid Iqbal
23/78
9
They each have vital function movement. An outer unit consists of exercises that
allow for multi-joint multi-plane activities.10
F
Fig.2 Core Muscles16
The Rectus Abdominus, which is the most superficial muscle group of the core area and
functions to flex the spine. The Rectus Abdominus works with all of the other core
muscles to stabilize the pelvis when walking.16
It originates from the pubic symphysis and pubic crest and inserts at the xyphoid
process and 5th
to 7th
costal cartilages. The two muscles are separated by linea alba.14
The internal and external obliques are located on the core area. When obliques
are activated on only one side of the body they operate to rotate the trunk and laterally
flex the body. When they contract on both sides concurrently, they aid in flexing the
vertebral column and compressing the abdominal wall.16
-
7/29/2019 Javaid Iqbal
24/78
10
Fig.3 Relationship between Inner and Outer unit.16
The big muscle (outer unit) becomes stronger and tighter, the delicate balances
between the inner and outer units become disrupted. This concept is easier to understand
using the pirate ship model.
Although the larger guy wires (outermost) support the most of the pirate ship, its
functionality is completely dependent upon the support provided by small guy wires
which represent the multifidus and inner unit muscles in this analogy.16
When the inner and outer unit works together as a cohesive unit we greatly
improve our daily lives by reducing the risks of joint injuries, ligamentous and muscular
strain and low back pain.10
Principles of core training.17
Stage 1 : core stabilization
Stage 2 : core strengthening
Stage 3 : core power
-
7/29/2019 Javaid Iqbal
25/78
11
Benefits of core training:1, 4
Improvement in posture, balance and peripheral mobility.
Increased endurance, strength and agility. Less chance of injury. Decrease in or prevention of low back pain. Enhance performance.
Allows doing more with less effort. Increase flexibility.
Importance of Core Training:4
A strong core is the basis for all human movement.
If the core is strong and stable, all other movements are more efficient and moreeffective.
Poor core stability means that power is wasted. Instead of forces being applied by arms orlegs to the movement, it is absorbed by a weak, sloppy trunk.
A strong core reduces the stress on particular muscle groups and joints. Poor core stability increases the likelihood of injury in these areas. Excess stress is placed
on these areas if the trunk is weak.
Swiss ball
-
7/29/2019 Javaid Iqbal
26/78
12
The term Swiss ball was coined because one of the earliest noted uses of an
exercise ball was 1965 in Switzerland where a group of physical therapists used it in their
work with children with cerebral palsy. The exercise ball may be referred to as gymnast
ball, stability ball, physio ball.18, 19
The Swiss ball is widely used in the recreational training environment to be a
training device for core stability exercises.
The Swiss ball is a conservative treatment
option for back pain sufferers and is designed to help prevent further episodes of low
back pain as part of a rehabilitation programme.18
Uses of Swiss ball18, 19
Improve muscle tone and endurance. Shed unwanted pounds and post-baby weight. Improve posture. Improve balance. Lessen the risk of osteoporosis. Lessen low back pain. Increase flexibility. Experience greater self confidence.
The body responds naturally and automatically to this instability to keep balanced on
the exercise ball. Over time, the muscles used to keep in balance on the Swiss ball
-
7/29/2019 Javaid Iqbal
27/78
13
become stronger. In essence, individuals build strength in important back muscles and
abdominal muscles without knowing it.18, 19
NEED FOR THE STUDY
Low back pain is becoming increasingly common. Approximately 70-90% of our
population suffers from low back pain or has suffered from multiple episodes of low back
pain. Low back pain can inhibit an individual from leading an active life style1. This is
because the back becomes deconditioned through lack of use, cumulative effects of
repetitive minor injuries and natural process of aging.20
For person younger than 45 years, mechanical low back pain represents the most
common cause of disability than in person aged older than 45 years3.
Chronic low back pain is the most expensive benign condition in industrialized
countries and the most expensive cause of activity limitation in persons younger than 45
years. It is second only to common cold as a cause of lost work time. It is fifth most
frequent cause for hospitalization.21
Mechanical low back pain is described as a musculoskeletal pain, which varies
with physical activities and not involving root compression or serious spinal diseases.
-
7/29/2019 Javaid Iqbal
28/78
14
Core strengthening has become a major trend in rehabilitation. The term has been
used to connote lumber stabilization, motor control training and other regimens. Core
strengthening is in essence, a description of muscular control required around lumbar
spine to maintain functional stability. Despite its wide spread use, core strengthening has
had a meager research. Core strengthening has had been promoted as a preventive
regimen, as a form of rehabilitation, and as performance enhancing program for various
lumbar spine and musculoskeletal injuries8.
The use of labile (Swiss ball) surface underneath the subject for stability training
of injured low back is becoming more popular. There has been considerable increase in
the use of gym ball or Swiss ball as an exercise tool in the last several years. The gym
ball is used by trainers in fitness programs and by therapist for injury rehabilitation. This
is due to an improved understanding of spinal stabilization and the role that it plays in
back pain.
The first use of gym ball was by Swiss therapist to help improve balance and
equilibrium in children with cerebral palsy18, 19
There are many core stability exercises but only a few exercises have been
evaluated on both mat and ball. The benefits reported for the ball have been equivocally
applied to all exercises. However there is little scientific evidence to support its use. Its
not clear whether performing an exercise on Swiss ball has greater benefit than
performing exercise on the stable surface.
Swiss balls have been incorporated into strength training regimens and as a means
to more effectively train the musculoskeletal system. Performing exercise on the ball has
been advocated on the belief that a labile surface:
-
7/29/2019 Javaid Iqbal
29/78
15
a) Will provide a greater challenge to trunk musculature.b) Increases the dynamic balance of the user.c) Possibly train users to stabilize their spines to prevent and treat injury.
Despite few studies, the research supporting these ideas is sparse. Adequate spinal
stability is important in the prevention and treatment of low back injuries. Stability is
achieved through the co activation of trunk muscles. Therefore any form of training has
been postulated to be beneficial in training trunk muscles to provide stability.
Contrarily, elevated muscle activation may be contraindicated in subjects with
low back injury or unstable spines. Co activation of trunk muscles has a compressive
loading cost that may outweigh the benefits of trunk muscle training.
We all need good core stability program because the core stability exercises
facilitate limb movements, prevent back injuries, facilitate proper utilization of muscle
forces and enhance performance. And also, there is back of literature support in
mechanical low back pain subjects and the benefits of core stability.
So its the aim of my study to determine the effectiveness of core stability
exercises on stable and labile (Swiss ball) surface. For making the core stability program
to be most effective and to understand the effect of different surfaces we need to know its
effect on both the stable and labile surface.
-
7/29/2019 Javaid Iqbal
30/78
16
OBJECTIVES
To compare the effectiveness of core stability exercises on labile and stable
surface in reducing pain and disability in mechanical low back ache subjects.
-
7/29/2019 Javaid Iqbal
31/78
17
HYPOTHESIS
1. Null Hypothesis:
There is no significant difference in pain and disability between patients treated with core
stability exercise on stable and labile surface.
2. Alternate hypothesis:
There is significant difference in pain and disability between patients treated with core
stability exercise on stable and labile surface.
-
7/29/2019 Javaid Iqbal
32/78
18
REVIEW OF LITERATURE
Low back ache
Dense M Oleske et al (2006) in his study stated that despite a large literature and
ergonomics initiatives in a variety of occupational sectors aimed at primary prevention of
low back pain, the incidence remains high and the prevalence increasing due to the
number of low back pain cases that persist or recur. The rate of recurrence of low back
pain is estimated to range from 3% to 86% within 1 year.22
Nicole van der Roer etal (2006) States that low back pain is a very common
health problem associated with considerable disability and costs to society. Many
different therapeutic interventions are used in the management of low back pain. For
clinicians, researchers, and policy makers, it is important to be able to determine the most
successful treatment.23
Core muscles
-
7/29/2019 Javaid Iqbal
33/78
19
Frederickson M, Moore T (2005) they concluded that, the purpose of basic core
stabilization exercises is not only to increase stability, but more importantly it is to gain
co- ordination and timings of the deep abdominal wall musculature.24
Edson O.Parker( 2000) in his article based on his lecture on A clinically and
cost effective lumbar exercise program postulated that lumbar extensor muscle strength
is not normally developed or maintained with routine lifestyles or with existing exercise
methods, i.e., the lumbar muscles atrophy from chronic disuse. With pelvis stabilized and
the lumbar muscles isolated, they can be fully developed with relatively brief, but intense
exercise. 25
Hause et al (1980) they stated that, in proportion to age it is found that both trunk
flexors and extensors become markedly weaker after the age of 40 years. In males the
weakening was at the same pace for flexors and extensors; in females, abdominal muscles
becoming weaker than extensors. However, trunk extensors and flexors strength remain
equivalent between persons in their third and fourth decades.
Richardson and Jull (1995) described the functional difference between local
and global muscles to know how muscles contribute to lumbar stabilization. Global
describes the large torque producing muscles linking the pelvis to the thoracic cage. Their
role is in providing general trunk stabilization. Local muscles refer to those attaching
directly to the lumbar vertebrae. They are responsible for segmental stability as well as
controlling the positions of the lumbar segments.26
Anderson and Winters (1990) they studied that, a mechanism for increasing
joint stability through enhanced muscle stiffness is co-contraction of agonist and
-
7/29/2019 Javaid Iqbal
34/78
20
antagonist muscles, which lie each side of joint. Recruiting muscles in co-contraction is
considered to provide support and joint stabilization even when contractions occur at very
low levels.27
Gollhofer and kyrolainen (1991) they analysed that, joint stabilization has
several muscle recruitment strategies, one of them is early pre-programmed recruitment
of particular muscles i.e., specific muscles are recruited before an action is commenced to
ensure that the joint is supported prior to a given movement.28
Core stability
Vence Akuthota, Scott F Nadler et al (2004) a review on core strengthening
gives a clear focused understanding of the core strengthening concept. The article gives
an overall view of core strengthening exercise and the tools used for strengthening i.e.,
use of physioball lunges, dumbbells and advanced core program used by Gambetta. The
article states that core strengthening has been promoted as a preventive regimen, as a
form of rehabilitation, and as a performance-enhancing program for various lumbar Spine
and musculoskeletal injures.29
Beverley Chok, Raymond Lee, Jane Latimer et al (1999) found that, muscle is
potential source of low back pain. Failure of muscles to protect passive structures from
excessive loading may result in damage to these pain sensitive structures and produce
pain.30
Chattanooga (2002) stated that, core stabilization training involves the re-
learning of co-activation of co-contraction patterns of transverse abdominis and lumbar
multifidus to provide local spinal segment support. When working normally the
-
7/29/2019 Javaid Iqbal
35/78
21
transverse abdominis and the lumbar multifidus act in concert, increasing tension on
thoracolumbar fascia acting like a corset, providing stability to lumbar spine.31
Paul W. Marshall, Bernadette A. Murphy(2005) on his study on core stability
exercises on and off Swiss ball on 8 healthy subjects with an intervention of 4 exercises
on and off Swiss ball came with a result that the performance of tasks on the Swiss ball
would lead to greater activation levels when compared with the stable surface. There was
no evidence to suggest that specific exercises involve different synergistic relationships
between the muscles and the Swiss ball can directly influence those relationships.32
Vern Gambetta (2002) stated that, as the centre of the body, the core works as a
unit that accelerates, decelerates, and dynamically stabilizes the body during the
movement. All movement is relayed through core. One should train the core before
training the extremities. A strong core will allow the extremities to better do their job.33
Cunningham (2004) analysed that, almost every movement we make involves
the core to some degree, keeping them in good shape is best way to prevent serious
injuries and the dreaded low back pain so many people experience as they age.34
David Giraffe 92006) concluded that when inner and outer units work together as
a cohesive unit we greatly improve our daily lives by reducing the risk of joint injuries,
ligamentous and muscular strain and low back pain.35
Hodges PW, Richardson CA (1996) stated that, the transverse abdominis has
been shown to activate before limb movement in healthy people, theoretically to stabilize
the lumbar spine, where as patients with low back pain have a delayed activation of the
transverse abdominis.36
-
7/29/2019 Javaid Iqbal
36/78
22
Swiss ball
Ludmilla M, Cosio-Lima, Katy L et al (2003) a study effects of physioball and
conventional floor exercises on early phase adaptation in back and abdominals core
stability and balance in women for 5 weeks and the physioball group was found to have
significantly greater mean change in EMG flexion and extension activity and greater
balance scores. Early adaptations in a short-term core exercise program using physioball
resulted in greater gains in torso balance and EMG neuronal activity in previously
untrained women when compared to performing exercise on floor.37
Francisco J Vera-Garcia, Sylvain G Grenier and Stuart M McGill (2000) in
his study on Abdominal Muscle Response During Curl-ups on Both Stable and Labile
Surfaces on 8 health subjects found that performing curl-ups on labile surface changes
both the level of muscle activity and the way that the muscles co-activate to stabilize the
spine and the whole body. This finding suggests a much higher demand on the motor
control system, which may be desirable for specific stages in a rehabilitation program.38
Janessa D.M Drake, Steve L Fischer, Stephen H.M Brown et al in a study Do
Exercise Ball Provide a Training Advantage for trunk extensor Exercises? A
biomechanical evaluation on 8 subjects came with the result that the use of an exercise
ball will always create a greater challenge for the musculoskeletal system was not
supported by this study. In young, healthy population, there doesnt appear to be any
training advantage to performing exercise on a ball versus mat. However, in a
rehabilitation scenario, these exercise performed on a ball could reduce low back loading
and hence reduce the potential for injury.
-
7/29/2019 Javaid Iqbal
37/78
23
Gregory J Lehman, Wajid Honda and Steven Oliver (2005) A study on
Trunk Muscle Activity During Bridging Exercise on and off a Swiss ball and found
that differences in trunk muscle activity are seen with the addition of Swiss ball to
bridging exercise on 11 male subjects and when analyzed with EMG it cant be
concluded that these differences are solely due to the different biomechanical demands of
these exercises.39
Hides, Julie A did study Long Term Effects of Specific Stabilizing Exercises
For First-Episodic Low Back Pain on 39 subjects and concluded that specific exercise
therapy in addition to medical management and resumption of normal activity may be
more effective in reducing low back pain recurrences than medical management and
normal activity alone.40
OSullivan PB, Twomy LT et al:
Evaluation Of specific stabilizing exercises in
the treatment of chronic low back pain with radiologic diagnosis spondylolisis or
spondylolisthesis on 44 CLBP patients and concluded that pain and disability were
significantly reduced in exercise group after a 10 week programme in addition the effect
was maintained at the 30 month follow-up assessment.41
Outcome measures
Fairbank JC, Pynsent PB. (2000) stated that modified Oswestry low back pain
disability questionnaire remains a valid and vigorous measure and has been a worthwhile
outcome measure. And should be the subject for further research.42
-
7/29/2019 Javaid Iqbal
38/78
24
Lauridsen HH, Hartvigsen J et al Stated that the Danish version of ODI has
comparable responsiveness to other commonly used function status measures and is
appropriate for use in low back pain patient.43
Lauridsen HH, Hartvigren J et al concluded that the Danish Version of ODI is
both a valid and reliable outcome instrument in the LBP population.43
METHODOLOGY
Population:Both male and female patients with mechanical low back ache in age group of 30 to 45
years.
Sample size:
30 subjects.
Sample design:Simple random sampling (lottery method).
Research design:
Comparative experimental study design.
Source of data:1. Rajlakashmi multispecialty hospital, JP Nagar, Bangalore
-
7/29/2019 Javaid Iqbal
39/78
25
2. Dr. Sudhir Pais Orthopaedic clinic in, 4th t block Bangalore3. Out-patient department of physiotherapy rehabilitation centre and clinic.
Inclusion criteria:1. Both males and females2. Age group of 30 -45 years3. Patients with diagnosed mechanical low back pain
4. Patients with minimum to moderate disability (up to 40%) on Oswestry DisabilityQuestionnaire.
5. Patients with VAS grade of below 5.
Exclusion criteria:
1. Any previous or current experience in core strengthening2. Subjects who are on regular fitness program3. Past history of fractures(spine, rib) or injury4. Past history of abdominal surgery5. Any other systemic illness6. Spinal or disc pathologies
-
7/29/2019 Javaid Iqbal
40/78
26
Materials used:1. Swiss ball(65cm, 75cm) depending on the height of subjects2. Floor mats3. Stop watch4. VAS scale and ODI questionnaire Procedure:
After obtaining ethical clearance 30 subjects were selected on the basis of inclusion
criteria and randomly allocated into 2 groups.
Subjects were assessed through Proforma and informed consent was taken. Pre-test low
back pain and disability was assessed by VAS and ODI respectively.
Group A - Core stability exercises given on Swiss ball. Group B - Core stability exercises given on floor mat.
Patients in both the groups were assessed for pain and disability on 1st
day and end of 4th
week.
Subjects were instructed to do warm up Exercises for 5 minutes, which consisted of spot
jogging, followed by some free exercises and light stretches held for 15 seconds.
Both the groups were asked to perform 5 types of core stability exercises for 8 reps for 1st
week and later on till 3rd
week the reps were increased by 50% of 1st
week performance.
In week 4 exercises will be continued with addition of 5 seconds holding time i.e.,
-
7/29/2019 Javaid Iqbal
41/78
27
o 1st week - 6 repso 2ndweek - 9 repso 3rdweek - 12 repso 4th week - 15reps with 5-10 sec hold
Exercise protocol:
1. Front plank.
2. Side Bridge.3. Abdominal crunch.4. Back bridging.
Duration of exercise program: 3 days/week for 4 weeks. Rest time: 2-3 minutes in between sets of exercises with appropriate stretch.
At the end of each day exercise program, subjects were asked to do cool down
exercises, which involve aerobic exercises followed by stretching exercises. Again before
starting the training for next session, the subjects were asked for any discomfort.
At the end of 4 weeks of core stability exercise program, post test scores were
measured for both the groups using same measurement tools.
At the end of the study, two groups were compared for the post test values.
-
7/29/2019 Javaid Iqbal
42/78
28
Exercises for control group
1. Curl-Up
Fig. 4 curl up on floor
Starting Position: Supine incline position with arms over the head. Procedure: Slowly curl your trunk, letting your shoulders and upper back
lift off the ground. Return slowly to starting position.
Instructions: Avoid pulling on the head or neck. Return to neutral posturebetween each repetition.
2. Bridging
Fig. 5 Bridging on floor
-
7/29/2019 Javaid Iqbal
43/78
29
Starting position: supine crook lying, with hands at the side of the body,palm facing downwards.
Procedure: slowly raise the hips off the ground so that only forearms andheels are touching the ground.
Instructions: weight is supported across the shoulder area. Avoid pressingthe cervical spine into the floor. Maintain neutral posture in the lumbar and cervical spine
throughout
3. Side plank
Fig. 6 side plank on floor
Starting position: subject assumes a side plank position with elbow underthe shoulder and upper arm perpendicular to the ground.
Procedure: slowly lift the shoulder and pelvis off the ground; supportingpoints will be on elbow and feet.
Instructions: balance the forearm under the shoulder and the same sidefoot while attempting to keep the body aligned in a straight line.
-
7/29/2019 Javaid Iqbal
44/78
30
4. Front plank:
Fig.7 front plank on floor
Starting position: subject assumes a front plank position with elbowunder the shoulder and upper arm perpendicular to the ground.
Procedure: slowly lift the shoulder and pelvis off the ground; supportingpoints will be on elbow and feet.
Instructions: balance the forearm under the shoulder and keeping yourspine neutral and drawing in your lower stomach.
Exercises for Experimental Group
1. Curl Up
-
7/29/2019 Javaid Iqbal
45/78
31
Fig. 8 curl up on ball
Starting position: start in supine position with lower back supported on the ball.Hands are clasped behind the head. Feet are shoulder width apart. Draw lower abdominal
muscles towards the spine.
Procedure: Slowly flex the spine while keeping abdominal muscles draw in. Returnto starting position.
Instructions: Keep cervical spine neutral by keeping the chin tucked.
2. Bridging
Fig. 9 bridging on ball
Starting position: Start in supine position with arms out to the side. Place feet onthe ball with toes pointed forward. Draw abdominal muscles in towards the spine.
Procedure: Contract the abs and gluteus and lift hips off the floor. Instructions: Avoid rotating toes outward.
-
7/29/2019 Javaid Iqbal
46/78
32
3. Side Plank
Fig. 10 side plank on ball
Starting Position: Lying on your side, keeping lateral surface of downleg on ball.
Procedure: Prop yourself on your right elbow placed directly under yourshoulder. Lift yourself off the ground supporting your body on your right elbow and ball
Instructions: Maintain neutral alignment of the hips, not allowing the tophip to roll front or back. Avoid laterally flexing the cervical spine or letting the head tip
to the side. Let the supporting arm assist with balance, but avoid pushing the body up
with the arm.
4. Front plank:
-
7/29/2019 Javaid Iqbal
47/78
-
7/29/2019 Javaid Iqbal
48/78
34
RESULTS
Study Design: A Experimental study consisting of 30 mechanical low back ache subjects
randomized in to two groups, 15 subjects in Group A (Swiss ball exercise) and 15
subjects in Group B (Floor Exercise) is undertaken to the compare the magnitude of
effect of both Swiss ball Exercise and the Floor exercise.
Statistical Methods: Sign test (two sample or sign test for paired data) has been used to
find the significance of Study parameters and outcomes within the groups for pre and
post comparison
1. Sign test.
Two sample sign test for paired data was used to investigate the significant difference
within groups where plus and minus ranks were given to individual scores obtained on
both VAS and ODI and were further analyzed for statistically significant difference using
the formula
With p =1/2
Whereas S is number of plus signs
-
7/29/2019 Javaid Iqbal
49/78
35
2. Mann- Whitney test (or U-test)
Mann Whitney test was used to investigate the significant difference between groups
where a rank is awarded for combined scores of 2 groups in the ascending order. After
this the ranks were summed up for each group.
Where:
U=Mann-Whitney U test
N1=sample size one
N2= Sample size two
Ri = Rank of the sample size
3. Effect Size
d =PooledSD
Meanmean 21
No effect d
-
7/29/2019 Javaid Iqbal
50/78
36
Very large effect d>1.20
4. Significant figures
+ Suggestive significance 0.05
-
7/29/2019 Javaid Iqbal
51/78
37
Group A Swiss ball Group
Group B floor Group
Table 2: Comparison of Pre and post scores of VAS within two groups
Results are presented in Mean SD (Min-Max)
VAS Group A Group B
Pre-Intervention 3.80.83(2-5) 3.731.06(2-5)
Post-Intervention 2.730.85(2-4) 3.21.06(2-4)
P value 0.01* 0.01*
Z score 2.14 1.80
Effect size 1.27 0.5
Figure 13: Comparison of pre and post scores of VAS within two groups
Figure 13 describes the comparison of pre and post scores of VAS within two groups. It
shows, in both the groups there was significant improvement between pre and post mean
-
7/29/2019 Javaid Iqbal
52/78
38
scores. In Group I (swiss ball) when compared for pre and post mean score there was
significant improvement from 3.80.83 to 2.730.85 with p value
-
7/29/2019 Javaid Iqbal
53/78
39
significant improvement from 18.86.56 to 16.534.76 with p
-
7/29/2019 Javaid Iqbal
54/78
40
DISCUSSION
The primary aim of this study was to determine if performing core stability
exercises on a Swiss ball rather than the floor resulted in reducing back pain and
disability more effectively.
The group I subjects were allowed to perform core stability exercises on Swiss
ball and group II performed same exercises on floor.
In order to check the effectiveness, the following parameters were taken for evaluation-
Visual Analog Scale: the pain reduction on VAS scale in Group I (Swiss ball) was
statistically significant compared to Group II with p
-
7/29/2019 Javaid Iqbal
55/78
41
Gregory J Lehman stated that, performing a bridge on the Swiss ball finds theparticipants in a more vertical position than floor. Therefore, more muscle activity is
required to produce secondary spinal stabilization due to labile surfaces.
The subjects were highly motivated during the training, probably due to the funnature of this program and also their desire to tone up their core muscles to improve their
body shapes.
The minimal changes could have been due to short duration exercise program i.e.,4 weeks.
Reason for minimal changes in floor group
In the current study some subjects showed significant changes in outcomemeasures. It is possible that some subjects volitionally contracted their trunk muscles to
provide stability. It is also possible that individuals may be able to influence through
verbal encouragement. Additionally, the variability may have been due to slight variation
in participant posture or task performance. While exercise standardization was sought
through verbal correction, it is possible that difference in task performance between the
subjects still occurs.
Effect of Exercises as a whole
No single muscle can be identified as being more important for spinal stability
than another during a range of trunk movement tasks. Therefore, current study assesses
the group of muscles or the effect of exercises on pain and disability as a whole and not
done separately. The influence of surface stability on muscle activity depends on type of
muscle and type of exercises.These results suggest that core stability exercise program
can effectively reduce back pain and disability in mechanical low back ache subjects.
-
7/29/2019 Javaid Iqbal
56/78
42
CLINICAL IMPLICATION
In a very short period of time there was a significant reduction in back pain anddisability associated with it.
It is an inexpensive method and helps in reducing pain and disability.
It doesnt require any sophisticated tools. It is not a time-consuming program, individuals can take out the time
conveniently even in their busy schedules.
It is easy to learn and perform these exercises, once learned assistance is notrequired.
-
7/29/2019 Javaid Iqbal
57/78
43
LIMITATIONS
1. In current study the sample size was small.2. Quantitative measures were not used to compare the effect of individual
exercises on isolated muscles to know which exercise gives better effect in reducing pain
and disability.
3. No measurements were made to determine the compressive or shear loadingon the spine during task. This type of kinematic is optimal when determining the safety
and tissue loading properties of various movements.
RECOMMENDATIONS
1. The confounding parameters like agility, speed, balance, motor control can beconsidered.
2. Further measures should be taken to check core muscle strength andendurance separately.
3. Further research may be done to determine the influence of the trunk muscleactivation levels during resistance exercise.
4. EMG biofeedback can be used for quantifying muscle activity.
-
7/29/2019 Javaid Iqbal
58/78
44
CONCLUSION
The Swiss ball exercises showed statistically significant improvement in reducing
back pain and disability when compared to the floor exercises. Thus, performing core
stability exercises on a Swiss ball reduces pain and disability significantly compared to
floor among mechanical low back ache subjects.
-
7/29/2019 Javaid Iqbal
59/78
45
SUMMARY
The study Objective was to find out the effect of core stability exercises on and
off the Swiss ball in reducing pain and disability in mechanical low back ache subjects.
30 subjects were selected for the study and were randomly divided into two equal groups
of 15 each with the age group of 30-45 years. The pain and disability was assessed Pre-
Post intervention using VAS and ODI respectively. The group I subjects were asked to
perform core stability exercises on Swiss ball and group II performed same exercises on
floor. Both groups were allowedto perform 4 types of core stability exercises for 3 days
in a week, for 4 weeks. At the end of 4 weeks two groups were compared for the
significant difference between the Pre-Post test scores.
Two groups were compared for the significant difference between the Pre-Post test score
and the result showed that there was statistically significant difference between the pre-
post mean scores of all the testing variables with very large increase in effect size with
P
-
7/29/2019 Javaid Iqbal
60/78
46
BIBLIOGRAPHY
1. Micheal A. Clark, Alan M. Russell. Article on Low Back Pain: A Functional
Perspective. 2005, May.Access on 2006, Jan 20
2. Anthony H Wheeler. Pathphysiology of Chronic Back Pain. 2007, july 9.
3. Everette Hills, Mechanical low back pain. 2005 April. [MEDLINE]
4. Vern Gambetta. The Core Of The Matter. Coaching Management 2002, Aug
10(5). Access on 2006, Jan 24
http://www.momentummedia.com/articles/cm/cm1005/core.htm5. David Grisaffi Womens Issues, Posture and Core Conditioning. 2002 July.
Access on 2006, Jan.
6. Marshall PW, Murphy BA. Core stability exercises on and off a Swiss ball.
Arch Phys Med Rehab 2005; 86:242-9. 2006 Jan
7. Carolyn Richardson, Gwendolen Jull, Paul Hodges, et al.
Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain,
Scientific Basis and Clinical Approach.Chapter-8,3rd
Edition, Churchill
Livingstone 1999. Pg. 105-123
8. Micheal A. clark, Akan M. Russell,BS. Strong To The Core. Article Available
on Your Body, 2006 July .Issue Espanol
9. Marc Sherry, Thomas Best, Bryan Heider Scheit. Article on The Core: Where
Are We and Where Are We going. Clin J Sport Med. 2005, January, Volume 15,
Number 1. Access on 2006 Feb.
-
7/29/2019 Javaid Iqbal
61/78
47
10. David Grisaffi Womens Issues, Posture and Core Conditioning. 2002 July.
Access on 2006, Jan.
11. Vera-Garcia FJ, Grenier SG, McGill SM. Abdominal Muscle Response
During Curl-Ups On Both Stable and Labile Surfaces. Phys Ther; 2000, June,
Vol 80, Number 6. Access on 2006 Jan
12. Wilson. Anatomical Breakdown of Targeted Anterior Abdominal Wall.2005.
http://www.bodybuilding.com/fun/rugby.htm13. Venu Akuthota MD, Scott F, Nadler DO. Core Strengthening. Arch Phys
Med Rehabil.2004, March, Vol 85, Suppl 1. Access on 2006, Jan 15
14. Adam Knowlden. Anabolic Drive Series: The Rectus Abdminis, External
Oblique, Internal Oblique And Transverse Abdominis: The Journal of
Hyperplasia Research. 2005, Vol19,No. 2
15. Paul chek. The Inner Unit, A New Frontier In Abdominal Training From: IAAF
Technical Quarterly: New Studies In Athletics 4/99 available on,
http://www.innerunit.com
16. Theresa Cochra. Article on Get Straight To The Core-Understanding
Abdominal Exercise Rising Women Magazine. BMJ, 1997, 12 Apr, 314:1062.
Access on 2006
17. Rick Corbett. Core stabilization and you how to bring the six pack, CSCE,
FALL 2003, Vol. 7, issue1. Access on 2006 Feb
18 Raphael Brandon. Swiss Balls: functional aid or fashion Accessory, 2004,
3 Nov, 16(1). Access on 2006, Jan14
-
7/29/2019 Javaid Iqbal
62/78
48
19. Beat Carriere. The Swiss Ball. Theory, Basic Exercises and Clinical Application.
Chapter-1, 2, 4. Springer-Verlag Berlin Heidelberg. 1997, October, Pg. 1-2, 30,
45-46.
20. Richardson & Jull. Muscle Control-Pain Control. What Exercises Would You
Prescribe. Manual Therapy 1995 1,2-10
21. Johansson H, Sojka P. Pathophysiological mechanisms involved in genesis and
spread of muscular tension in occupational muscle pain and in chronic
musculoskeletal pain syndromes: a hypothesis .1991 35:196-203
22. Denise M Oleske et al. Risk factors for Recurrent Episodes of Work Related
Low Back Disorders in an Industrial Population. SPINE 2006, Vol, 31, No.5,
pp 789-798
23. Nicola Vader Roer, Minimal Clinically Important Change for Pain Intensity,
Functional Status, and General Health Status in Patients with Nonspecific Low
Back Pain. SPINE 2006 Vol.31, No.5, pp 578 582.
24. Fredericson M,Moore T. Core Stabilization Training for Middle- and Long-
Distance Runners. IAAF New Studies in Athletics2005 March ; 1 (20): 25-37.
Access on 2006, Feb
25. Edson O. Parker. A Clinically and Cost Effective Lumbar Exercise Program.
2000 July 20.Access on 2006, Jan http://www.powerbackpgm.com/
26. Richardson & Jull. Muscle Control-Pain Control. What Exercises Would You
Prescribe. Manual Therapy 1995 1, 2-10
27. Andersson & Winters. Role of muscle in postural tasks: spinal loading and
postural stability. Springer-verlag, New York .Ch-23. 1990 , p375-395
-
7/29/2019 Javaid Iqbal
63/78
49
28. Gollhofer & Kyrolainen. Neuromuscular control of the human leg extensor
muscles in jump exercises under various stretch load conditions. International
Journal of Sports Medicine 1991, 12:34-40
29. Venu Akuthota MD, Scott F, Nadler DO. Core Strengthening. Arch Phys Med
Rehabil.2004, March, Vol 85, Suppl 1. Access on 2006, Jan 15
30. Beverley Cole, Elspeth Finch, Carolyn Gowland et al. Physical Rehabilitation
Outcome Measures.Williams & Wilkins.Ch-B-8, B9, 1995. Pg. 94-97, 1995
31. Chattanooga. Stabilizer Pressure Bio-Feedback 2002. Pg 3. Available on,
http://www.biotechindia.net
32. Marshall PW, Murphy BA. Core stability exercises on and off a Swiss ball.
Arch Phys Med Rehab 2005; 86:242-9. Access on 2006,Jan
33. Vern Gambetta. The Core Of The Matter. Coaching Management 2002, Aug
10(5). Access on 2006, Jan 24
http://www.momentummedia.com/articles/cm/cm1005/core.htm
34. Cunningham. Core Beyond The Crunch 2004, Jan 10, 32 (2). 2006 January.
35. David Grisaffi Womens Issues, Posture and Core Conditioning. 2002, July.
Access on 2006, Jan.
36. Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar
spine associated with low back pain. A motor control evaluation of transversus
abdominis.Spine 1996; 21:2640-50.
37. Ludmila M, Cosio-Lima, Katy L, et al. Effects Of Physioball and Conventional
Floor Exercises On Early Phase Adaptations In Back And Abdominal Core
-
7/29/2019 Javaid Iqbal
64/78
50
Stability and Balance In Women. The Journal Of Strength and Conditioning
Research; 2002 Feb,Vol. 17, No. 4, pp. 721-725.Acess on 2006, Jan15
38. Vera-Garcia FJ, Grenier SG, McGill SM. Abdominal Muscle Response During
Curl-Ups On Both Stable and Labile Surfaces.Phys Ther; 2000 June, Vol 80,
Number 6. Access on 2006, Jan10
39. Grejory J.Lehman, Wajid Hoda and Steven Oliver. Trunk Muscle Activity
During Bridging Exercises On and Off Swiss Ball, Chiropractic and Osteopathy
2005, 34; 4 -12Access on 2006, Jan
40. Hides, Julie A did study Long Term Effects of Specific Stabilizing Exercises
for First-Episodic Low Back PainSPINE 2006 Vol.31, No.5, 578 582.
41. OSullivan PB, Twomy LT et alEvaluation Of specific stabilizing exercises in
the treatment of chronic low back pain with radiologic diagnosis spondylolisis or
spondylolisthesis Chiropractic and Osteopathy, Vol 34; 4 -12. 2005Jan 10.
42. Fairbank Jeremy C.T. The Oswestry Disability Index. SPINE 2000, Vol 25,
No.22, 2940-2953 Nov15, 2000.
43. Lauridsen HH, Hart5vigson J et al.danish version of ODI for patients with
LBP. Cross cultural adaptations, reliability and validity in two different
populations Eur SPINE J 2003 Feb; 12(1): 12 -20 Epub 2002 Oct 24.
44. Martin R Underwood et al. Evaluation of Two Time Specific Back Pain
Outcome Measures. SPINE 1999; 24; 1104- 1112.
45. Bernard Rosner, Fundamentals of Biostatistics, 5th
Edition,
46. Hodges & Richardson. Contraction of the abdominal muscles associated with
movement of the lower limb. Phys. Ther.1997,77:132144
-
7/29/2019 Javaid Iqbal
65/78
51
ANNEXURE- I
PROFORMA
Name:
Age:
Address:
Ph:
Date of commencement:
Date of completion:
Inclusion criteria:
1. Do you have Mechanical low back pain?(Y/N)
2. Is the subject between 30 to 45 years?(Y/N)
3. Since how long you are having low backache?(Y/N)
4. Do your pain increases in standing and bending?(Y/N)
5. Do you feel stiffness in morning, usually becomes worse over the day?(Y/N)
6. Do you feel relieved by lying down?(Y/N)
-
7/29/2019 Javaid Iqbal
66/78
52
7. Is the subject VAS scored 6?(Y/N)
8. Is the subjects disability in moderate range (21%-40%) on ODI?(Y/N)
Exclusion criteria:
1. How did your pain start?
Was it a) insidious or b) episodic?
2. Does the subject is under Analgesic? If yes what?
3. Do you have radiating pain in thigh and leg?
4. Do you feel numbness, paresthesia in your lower limbs?
5. Do you feel increase in pain while coughing? Sneezing? Deep breathing? Laughing?
6. Has the subject any history of fractures (spine, rib)?
7. Has the subject any history of surgery (abdominal)?
8. Has the subject any systemic illness?
9. Has the subject any spinal /disc pathology?
10. Has the subject any past experience of core strengthening?
A)Oswestry Low Back Pain Disability Questionnaire
Prior to treatment- score After the treatment-score..
B) Visual Analog Scale
Prior to treatment-score After the treatment-score
-
7/29/2019 Javaid Iqbal
67/78
53
ANNEXURE-II
CONSENT FORM
TITLE OF THE PROJECT
EFFECTIVENESS OF CORE STABILITY EXERCISES ON
STABLE AND LABILE SURFACE (SWISS BALL) IN REDUCING
PAIN AND DISABILITY IN MECHANICAL LOW BACK PAIN
SUBJECTS-A Comparative study.
Investigator: Mr. Javaid Iqbal
Purpose of research:
I have been informed that this study, which is being conducted by researcher, is to
compare the effectiveness of core stability exercise on and off Swiss ball in reducing pain
and disability. The exercises what I am going to receive are acceptable way of improving
core stability this study will help health professionals to know about the effective way of
reducing pain and disability using appropriate core stability exercises in LBA subjects.
PROCEDURE:
I understand that there are two groups; one group will receive exercises on ball
and the other group on floor mat. If I am randomized to 1st
experimental group, I will
have to undergo exercise protocol on the Swiss ball and if I am randomized to 2ndgroup,
I will have to undergo exercise protocol on floor mat. The exercise, which I receive,
would be according to my tolerance and enough safety will be provided. I am aware that I
have to follow the physiotherapists instructions as has been told to me. As the follow up
-
7/29/2019 Javaid Iqbal
68/78
54
I have to practice the exercise for 3 days a week for 2 weeks duration, taught by
physiotherapist regularly under his supervision. I may withdraw from the study of any
discomfort is faced due to exercise.
RISK AND COMFORT:
I understand that there are adverse effects of over activity and I will inform any
discomfort experienced during exercises and javaid iqbal will accompany me and take
care of me during exercises.
BENEFITS:
The recorded readings obtained by the performance will be helpful to know the
effectiveness of exercises in reducing pain and disability in mechanical low backache
subjects.
CONFIDENTIALITY:
I understand that medical information produced by this study will be confidential
If the data are used for publication in medical literature or for teaching purpose, no names
will be used and other literatures such as permission.
REQUEST FOR MORE INFORMATION:
I understand that I ask any question about the study at any time.Javaid Iqbal is
available to answer my question. Copy of this concern form will be given to me.
-
7/29/2019 Javaid Iqbal
69/78
55
REFUSAL OR WITHDRAWAL OF PARTICIPATION:
I may refuse to withdraw consent and discontinue participation at any time .I also
understand that he may terminate my participation in the study at any time after he has
explained me the reasons for doing so.
INJURY STATEMENT:
I understand that the exercises, which I am going to perform, are most unlikely to
cause any injury or further deteriorate my condition if performed under the guidance of
my therapist. In case of injury medical attention will be provided, but no further
compensation will be provided. I understand my agreement to participate in this study
and I am not waiving any of my legal and ethical rights.
I confirm that Javaid Iqbal has explained me the purpose of the study, the study
procedure and the possible risk and the benefits that I may experience. I have read and
fully understood this study and voluntarily provide consent to be a subject in this study.
Name of subject: Date:
Signature:
Name of witness: Date:
-
7/29/2019 Javaid Iqbal
70/78
56
I have explained to sri/smt.. The purpose of the research,
the procedure required and the possible risks and benefits, to the best of my ability.
Name of investigator:
Signature: Date:
-
7/29/2019 Javaid Iqbal
71/78
57
Annexure -III
THE OXFORD COLLEGE OF PHYSIOTHERAPY
I Phase, J.P. Nagar, Bangalore 560 078
Review Board on Ethics for Research
We hereby declare that the project titled, EFFECTIVENESS OF CORE
STABILITY EXERCISES ON STABLE AND LABILE SURFACE (SWISS BALL) IN
REDUCING PAIN AND DISABILITY IN MECHANICAL LOW BACK PAIN
SUBJECT.-A COMPARATIVE STUDY, carried out by Mr. Javaid Iqbal of 2ndyear MPT has
been brought forward for scrutiny to the Board Members. After analyzing the objectives, subjects
involved and the methodology of the project, the following conclusions were drawn.
The project does not involve any mental or physical harm to the subjects
involved with the study. The performance of the study procedure will not cause any injury to the
subjects. The board has evaluated and confirmed that the experimenter is trained and qualified in
giving the intervention and / or measuring outcome. The informed consent form prepared ensures
that, the experimenter explains the procedure of the study to the subject; their voluntary
participation I confirmed and the identification of the subject are maintained confidential.
Furthermore the finding of the study will benefit similar subjects, the profession
and the society.
Hence the review board has no objection on the conduct of study.
Chairman of Departmental Review Board. Project guide
Principal.
-
7/29/2019 Javaid Iqbal
72/78
58
ANNEXURE-IV
VISUAL ANALOG SCALE
A tool used to help a person rate the intensity of certain sensations and feelings
such as pain. The visual analog scale for pain is a straight line with one end (0) meaning
no pain and the other end (10) meaning worst pain imaginable. A patient marks a point
on the line that matches the amount of pain he/she feels. It may be used to help choose
the right dose of pain medicine.
0 (no pain) 10 (worse pain)
Date ______________Start ______________ End ______________
-
7/29/2019 Javaid Iqbal
73/78
59
ANNEXURE-V
Modified Oswestry Low Back Pain Disability Questionnaire
This questionnaire has been designed to give your therapist information as to how
your back pain has affected your ability to manage in everyday life. Please answer every
question by placing a mark in the one box that best describes your condition today. We
realize you may feel that 2 of the statements may describe your condition, but please
mark only the box that most closely describes your current condition.
Pain Intensity
! I can tolerate the pain I have without having to use pain medication.
! The pain is bad, but I can manage without having to take pain medication.
! Pain medication provides me with complete relief from pain.
! Pain medication provides me with moderate relief from pain.
! Pain medication provides me with little relief from pain.
! Pain medication has no effect on my pain.
Personal Care (e.g., Washing, Dressing)
! I can take care of myself normally without causing increased pain.
! I can take care of myself normally, but it increases my pain.
! It is painful to take care of myself, and I am slow and careful.
! I need help, but I am able to manage most of my personal care.
! I need help every day in most aspects of my care.
! I do not get dressed, I wash with difficulty, and I stay in bed.
-
7/29/2019 Javaid Iqbal
74/78
-
7/29/2019 Javaid Iqbal
75/78
61
! Pain prevents me from sitting at all.
Standing
! I can stand as long as I want without increased pain.
! I can stand as long as I want, but it increases my pain.
! Pain prevents me from standing for more than 1 hour.
! Pain prevents me from standing for more than 1/2 hour.
! Pain prevents me from standing for more than 10 minutes.
! Pain prevents me from standing at all.
Sleeping
! Pain does not prevent me from sleeping well.
! I can sleep well only by using pain medication.
! Even when I take medication, I sleep less than 6 hours.
! Even when I take medication, I sleep less than 4 hours.
! Even when I take medication, I sleep less than 2 hours.
! Pain prevents me from sleeping at all.
Social Life
! My social life is normal and does not increase my pain.
! My social life is normal, but it increases my level of pain.
! Pain prevents me from participating in more energetic activities (e.g., sports,
dancing).
! Pain prevents me form going out very often.
! Pain has restricted my social life to my home.
-
7/29/2019 Javaid Iqbal
76/78
62
! I have hardly any social life because of my pain.
Traveling
! I can travel anywhere without increased pain.
! I can travel anywhere, but it increases my pain.
! My pain restricts my travel over 2 hours.
! My pain restricts my travel over 1 hour.
! My pain restricts my travel to short necessary journeys under 1/2 hour.
! My pain prevents all travel except for visits to the physician / therapist or
hospital.
Employment / Homemaking
! My normal homemaking / job activities do not cause pain.
! My normal homemaking / job activities increase my pain, but I can still perform
all that is required of me.
! I can perform most of my homemaking / job duties, but pain prevents me from
Performing more physically stressful activities (e.g., lifting, vacuuming).
! Pain prevents me from doing anything but light duties.
! Pain prevents me from doing even light duties.
! Pain prevents me from performing any job or homemaking chores.
-
7/29/2019 Javaid Iqbal
77/78
63
ANNEXURE VI
MASTER CHART
S.No. Age SEX VAS ODIPre Post Pre Post
EXP(SWISSBALL)GROUP1. 45 F 5 3 16 122. 41 F 4 2 12 143. 34 M 4 2 16 144. 35 M 5 3 28 245. 38 F 4 4 22 206. 36 F 4 2 22 207. 39 M 4 3 18 168. 36 M 3 4 6 89. 37 M 4 3 14 1210. 35 M 4 2 24 2011. 36 M 5 3 26 2212. 37 M 3 2 18 1413. 35 F 3 4 12 1414. 35 F 3 1 20 1615. 36 F 2 3 18 16
-
7/29/2019 Javaid Iqbal
78/78
S.No. Age SEX VAS ODIPre Post Pre Post
CONTROL(FLOOR)GROUP16. 41 M 4 3 28 2617. 30 M 4 3 40 3818. 35 F 4 3 30 2819. 35 M 3 2 22 2020. 35 M 4 3 22 2021. 39 M 5 4 36 3422. 39 F 3 4 16 1423. 30 F 5 4 28 2624. 37 F 2 3 14 1825. 42 M 4 3 26 2426. 38 M 2 3 18 2027. 36 M 2 3 18 2028. 39 F 4 3 38 3629. 39 F 5 4 24 2230. 41 M 5 3 28 26