EFFECT OF POSTURAL SWAY SCALE AS A PROGNOSTIC TOOL IN LOW BACK PAIN MANAGEMENT.

Transcription

1 Original Research Article Allied Science International Journal of Pharma and Bio Sciences ISSN EFFECT OF POSTURAL SWAY SCALE AS A PROGNOSTIC TOOL IN LOW BACK PAIN MANAGEMENT. 1 MANJULADEVI.NB.P.T, 2 Dr.R.ARUNACHALAM MPT(Neuro), Ph.D, *3 B.PRUDHVI TEJASRI B.P.T, M.P.T 2 nd yr, 4 Dr.KUMARESAN MPT(Neuro), 5 Dr.KIRUTHIKA MPT(Neuro) 1,3 Saveetha College of Physiotherapy, Saveetha University.Chennai. 2 Associate Professor, Saveetha College of Physiotherapy, Saveetha University, Chennai. 4 Assistant professor, Saveetha College of Physiotherapy, Saveetha University, Chennai. 5 Tutor, Saveetha College of Physiotherapy, Saveetha University, Chennai. ABSTRACT A study to the postural sway in normal and subjects with low back pain, the influence of physiotherapy on postural sway and the effectiveness of postural scale as a prognostic tool. The study was done in three different phases as follows : PHASE 1- Sway measurement was done for the normal subjects and for the subject with low back pain on a stable ground using lord sway meter and a comparison was drawn between them. PHASE- 2- subjects with low back ache were provided with physiotherapy management, sway was measured before and after treatment. PHASE- 3 - The sway variations were also compared with Oswestry disability rating scales to assess the correlation between the prognostic values of the tools. There is significant difference in lateral sway and antero posterior sway between subject with low back pain and age related normal. (P =0.0001). Analysis of sway measures before and after physiotherapy intervention showed a significant difference ( P=0.0001). There was a high correlation between the sway values and the Oswestry disability rating scales. This study concluded that there is an altered sway pattern in subjects with low back pain, this pattern of sway can be normalised by physiotherapy intervention. This study also concludes that the postural sway meter can be used as one of the outcome measure in the low back pain rehabilitation. KEYWORDS: Sway, Postural Sway, Low back pain, Oswestry disability rating scales B.PRUDHVI TEJASRI B.P.T, M.P.T 2 nd yr * Saveetha College of Physiotherapy, Saveetha University, Chennai. Corresponding Author Received on: Revised and Accepted on: DOI: B-1021

2 INTRODUCTION Posture is the attitude assumed by an individual either with support during muscular in-activity or by means of co-ordinate action of many muscles working to maintain stability to form an essential basis which is being adapted constantly to the movement which is super imposed upon it. Postural sway is a measure of postural stability. 1 Postural sway is a low magnitude to and fro movements that happens even on quit stands which is due to the imbalance in the co contracting flexors and extensors. The factor that could contribute to increased postural sway are ageing (Beyond 4 th decade of life), poor physical fitness, overweight, occupational hazards, smoking, heavy labour, long standing and inherited disease or conditions. Literature shows that the sway increases in many pathological states and in ageing. 2 This is true in case of low back pain subjects who have decreased trunk extensor muscles activation levels. 3 Those extensor muscles of trunk are more essential for the stability of the vertebral column and maintenance of erect posture as they are the anti gravity muscles. Postural stability was measured with a vertical force platform. 4 An excellent way of checking the postural sway is to stand with each foot on a standard bathroom scale. If the weight differ by more than 51bs it is significant. 8 Postural control is generally viewed as a feedback loop in which sway is detected by sensory system and appropriate motor commands are generated to stabilize the body`s orientation 5. Postural sway measured either anterior-posterior or medial-lateral by the two oscillator components. The slow component accounts for the majority of sway variance which is due to the inability to estimate body dynamics accurately 6. Posture is important factor that determines the muscle skeletal disability though it is not related to joint range of motion 7. The subjects with low back pain demonstrate increased postural sway and causes poor posture control of lumbar spine. In this study efforts were taken to analyse the postural sway as an outcome measure by the sway meter which is reliable and valid equipment to measure postural sway 8. In order to achieve this objective it was necessary to find if there is any difference between the saw values of normal and subjects with low back pain. If there was a difference in sway pattern, then it has to be analysed weather the sway improved with physiotherapy intervention or not 9,10 METHODOLOGY 6 30 subjects aged between 20 years to 45 yrs, who had a history of mechanical low back pain in last 6 months and are able to walk without assistive devices were selected. All the subjects are informed about the study and given informed consent form. The study was approved by Saveetha university Study review board and Institutional ethical committee 008/04/2016/IEC/SU. The design of the study is a cross sectional study in phase 1 and quasi experimental design in phase 2 and the phase 3 was correlation study. The study setting was saveetha medical college and hospitals at physiotherapy outpatient department Saveetha University, Thandalam Chennai. Patients who can understand the treatment and procedure of both gender were selected. The subjects with history of spinal trauma, spinal inflection, multiple lesion of spine, inflammatory spinal diseases, spinal malignancy and spinal fractural, sacroiliac joint and hip joint dysfunction, associated lesion like cervical pathology, structural scoliosis and other neurological lesion affecting back and lower limb were excluded. The study was done in three different phases as follows. In the phase -1 of the study both anterior-posterior and lateral sway measurement was done for the 30 normal subjects and the selected 30 subject with low back pain on a stable ground using a postural sway meter. The subjects were made to wear the postural sway meter and were asked to stand with feet over the markings on ground for 2 minutes. The subjects were not given any instruction and the assessment environment was controlled from noise and external movements. Both anterior posterior and lateral sway measures were taken as data for interpretation. In the Phase- 2 of the study all the 30 subjects with low back ache are provided with physiotherapy management in the form of pain interferential therapy, spinal extension exercise and core-stabilization programme. As the subjects with low back pain in phase 1were selected for the phase 2, sway values of the phase 1 was taken as the pre test value. The similar saw analysis was done at the end of the intervention on 14 th day. Phase -3: The sway variations were also compared with Oswestry disability (ODI) rating scales which were assessed before the intervention and after the intervention of phase 2, to find the prognostic value of postural sway. Sway meter The sway meter consists of a moderate weighing metal rod fixed to a lumbar corset. The lumbar corset was double strapped and had metal implants that were designed to be moulded to the lumbar spine. The rod incorporates a holder at its distal end. A free rolling ball pen is fixed in the holder. The other end of the metal rod is fixed to the corset without any chance of inter segmental movement. RESULTS To assess the measures of variability the collected data was tabulated and analyzed using statistics. Paired-test and independent t-test was used to analyze the pre test and post test sway values within and between the groups of phase 1 and phase 2 Phase 1 The independent t test was done to analyse the difference between the AP and lateral sway values of normal subjects and subjects with low back pain. The results are shown in table 1. B-1022

3 Table 1 Independent t-test analysis - between group analyses of the AP lateral sway values Phase 1 Normals subject with AP sway low back pain AP sway Normals with lateral sway Low back pain lateral sway 60.8 Mean (cms) t value p value < <0.001 Phase 2 A paired t test analysis was made to find the difference between the pre test values and the post test values. The results are tabulated in table 2. Table 2 Within group analysis of the AP & lateral sway values using paired t-test Phase 2 low back pain AP sway Low back pain lateral sway Mean t value p value Pre test Post test <0.001 Pre test 60.8 Post test <0.001 Phase 3 was used to compare the pre test AP sway values and oswestry pre test values at 95% Confidence Intervals. The analysis showed that there was a significant positive correlation with R square = , P Value < (Significant). (Figure 1) Figure 1 Linear regression of pre AP sway value and Pre Oswestry Disability index. was used to compare the pre test lateral sway values and oswestry pre test values at 95% Confidence Intervals. The analysis showed that there was a significant positive correlation with R square = , P Value < (Significant). (Figure 2) B-1023

4 Figure 2 Linear regression of pre lateral sway value and Pre Oswestry Disability index. was used to compare the post test lateral sway values and oswestry pre test values at 95% Confidence Intervals. The analysis showed that there was a significant positive correlation with R square = 0.732, P Value < (Significant). (Figure 3) Figure 3 Linear regression of post AP sway value and Post Oswestry Disability index. was used to compare the post test lateral sway values and oswestry post test values at 95% Confidence Intervals. The analysis showed that there was a significant positive correlation with R square = , P Value < (Significant). (Figure 4) Figure 4 Linear regression of post lateral sway value and Post Oswestry Disability index. B-1024

5 DISCUSSION Back muscles are more powerful muscle that provide the stability and for erect posture of person. During standing there is a natural sway in backwards and forward direction and side to side direction.there are horizontal forces, and vertical forces acting on human body that results in sway, due to this the centre of pressure moves forwards, backwards and side to side between two feet. Sway back posture occurs when pelvis shifts forwards infront to centre of gravity and this is a chain reaction in posture as body attempts to compensate for shifts in alignment.. When these extensor muscle activation level becomes weak the person will have low back pain and increases postural sway, the extensors of the trunk also contribute for the stability of the vertebral column and also for erect posture as they are the anti gravity muscles. For this study oswestry disability rating scales was considered as it was a reliable and valid outcome measure in the analysis of low back pain prognosis 11,12,13. The postural sway meter is a reliable tool in the clinical set up to analyse the postural sway. In this study efforts are taken to standardise a new tool to measure the prognosis of low back pain and also to measure the strength of the lumbar extensors which are directly related to magnitude of the postural sway 8. The result of 6 the study clearly demonstrated and was in lines stating that there is clear difference in sway pattern among normal subjects and subjects with low back ache 6. It is also proved from our study that REFERENCES 1. Redebold, & et al Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Jrnl of biomechanics, 2001 April 26, (7); Fernie GR,The relationship of postural sway in standing to the incidence of falls in geriatric subjects, Oxford journals medicines, age and ageing. 1982, 11, (1); Luoto, One footed and externally disturbed two footed postural control in patients with chronic low back pain and healthy control subjects: A controlled study with follow- up. jrnl of Diagnostics October, 23, (19), ; Gill, The measurement lumbar proprioception in individuals with and without low back pain jrnl of spine 2000 April.25, ( 8),; Popa T,Adaptive changes on postural strategy selection in chronic low back pain, jrnl of Experiment brain research ,; Tim Kelvin,Slow dynamics of postural sway are in the feedback loop., jrnl of Kinesiology and Biology, 2005 September 195, ; physiotherapy can contribute to the recovery of low back pain and also reduces the magnitude of both AP and lateral sway. It is no surprise to know that AP sway had a better prognosis than the lateral sway as the strengthening was given to muscles which helped in frontal plane movements. Out of the both sway, APs sway has a better correlation strength compared to the lateral sway with oswestry scale. 7 The study concludes with a wide range of scope for future studies. Long term follow up of the subjects can be done. The effectiveness of postural sway can also be tested as a early prediction tool for LBA. A comparative study can be done between antero posterior sway and lateral sway prognosis. A study can be done on why there is a difference between lateral sway and antero posterior sway. CONCLUSION This study concluded that there is an altered sway pattern in subjects with low back pain, that pattern of sway can be normalised by physiotherapy intervention. This study also concludes that the postural sway meter can be used as one of the outcome measure in the low back pain rehabilitation. CONFLICT OF INTEREST Conflict of interest declared none 7. Hamaoui, Postural sway increase in low back pain subjects is not related to reduce spine range of motion. jrnl of Neuroscience February, 23, (3), Janakiraman Balamurugan, Intra Rater And Inter Rater Reliability Of Sway Graph In Elderly Subjects, Int J Cur Res Rev, 2012 Oct Vol 04 (20),; Tsai,KC, Chang ST, Chen LC, Effect of piroxican-beta-cyclodextrin sachets on abnormal postural sway in patients with chronic low back pain. J Clin Pharm Ther. and therapeutics October 33, (5), Paalanne N,Isometric trunk muscle strength and body sway in relation to low back pain in young adults, jrnl of sports medicine, 2008 June, 33, (13),; E435-E Davdison BS, Effect of lumbar extensor fatigue rate on postural sway, European jrnl of applied physiology2004 July, 93 (7) ; Della volpe R,Changes in co ordination of postural control dynamic stance in chronic low back pain patients. Jrnl of gait & posture, 2006 November, 24, i (3); Brumange S, Persons with recurrent low back pain exhibit a rigid postural control strategy, European spine journals,2008, 17; 9 B-1025

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