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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


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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


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III


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


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IV


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


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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


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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.


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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


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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


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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


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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


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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


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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


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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


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XIV


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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.


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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


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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


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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.


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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


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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


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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


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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


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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


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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


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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


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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


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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.


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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:


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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.


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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.


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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.


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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


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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


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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


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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


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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.


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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


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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


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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


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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.,


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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.


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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


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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.


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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


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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.


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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:


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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


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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


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Very large effect d>1.20

4. Significant figures

+ Suggestive significance 0.05


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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


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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


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significant improvement from 18.86.56 to 16.534.76 with p


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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


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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.


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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.


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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.


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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.


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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


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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)


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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


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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


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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.


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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:


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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:


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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.


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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 ______________


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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.


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! 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.



! 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.


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! 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.


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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


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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

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