COMPRESSION BETWEEN BUTLER NEURAL MOBILIZATION AND MULLIGAN LEND LEG RAISE TECHNIQUE IN LOW BACK PAIN PATIENT.

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

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


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

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

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














Aim and objective of the study


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


Hypothesis

Null hypothesis (H0 ):

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

Experimental hypothesis (HA ):

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






ROL (review of literature)

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

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

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



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

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



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

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

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

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

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




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

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


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

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




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

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

Instrumentation :
 Universal goniometer.





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

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






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


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

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

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

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










Group B, will be receive Butler’s neural mobilisation14

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


flowchart
Subjects meeting the inclusion criteria

Subjects included in the study (n=40)

Subjects randomly assigned into two group



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

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

Data collected Data collected

Interpreted Interpreted

DATA COLLECTION FORM

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

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

Age: _______ Yrs Occupation _______________________________

Height: mts. Weight: kgs.

BMI:____________ kg/mt2.

Gender: Male Female

Date of Examination:
Study group : Group A Group B

Duration of symptoms (months) _______________________________

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

0 10 Pre – Intervention


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


0 10 Post – Intervention




Pre treatment –SLR ROM Post treatment –SLR ROM



Remarks ________________________________________________________


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

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

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

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















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


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



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

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

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

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

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