published_or_final_version / Community Medicine / Master / Master of Public Health

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban University of Technology, 2011. / Background: Wong and Deyo (2001) believe that 98% of the LBP cases are musculoskeletal (mechanical) in origin and 51,7% of these individuals are chronic sufferers (Andersson, 1999). Weak spinal stability muscles have shown to be an aetiological cause (Chok, Lee and Latimer, 1999). Wolff, Weinik and Maitin (2003) agree a combination of brace aided pelvic stabilization combined with a spinal stability programme may be the best treatment intervention for chronic low back pain (CLBP). Objective: The purpose of this research was to determine the relative effectiveness of three treatment protocols with (Group A-Groovi-SI-Belt®; Group B-standard SI belt) and without (Group C-control) brace aided pelvic stabilization in patients with CLBP. Method: Forty-six patients suffering from CLBP were randomly allocated to one of the three treatment groups. A spinal stability programme was progressively taught and enforced in all three groups. Weekly follow-up consultations were required to assess subjective and objective outcomes of the three treatment interventions. Outcomes were obtained by using the Numerical Pain Rating Scale (NRS); Quebec disability scale; Active straight leg raiser test; Biofeedback device and the static trunk extensor endurance test. Results: Data was analysed using the SPSS version 15.0 (SPSS Inc. Chicago, Ill, USA).Comparing pre and post outcome measurements using a p value <0.05 which was considered to be statistically significant. All three treatments improved most outcomes significantly over time. The Groovi-SI-Belt® showed non significant trends of quicker rates of improvement. . Conclusion: This study revealed that brace aided pelvic stabilization combined with a spinal stability programme was a beneficial treatment intervention with the Group A being superior to Group B.

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban Institute of Technology, Durban, 2006. / Core strengthening has become a major trend in the rehabilitation of patients suffering with lower back pain. Clinical trials have shown that core strengthening is beneficial for patients with low back pain. According to the literature, core strengthening consists of activating the trunk musculature in order to stabilize hypermobile symptomatic joints and thus lessen mechanical stress to the spine. Spinal manipulative therapy has also proved itself to be beneficial, particularly in the case of post-natal low back pain sufferers, as manipulation may correct hypomobility associated with spinal subluxations. Literature suggests that spinal manipulative correction of spinal subluxations in combination with core stability exercises, that stablise symptomatic hypermobile joints, may have more advantages than using these interventions singularly in the treatment of post-natal low back pain. However, the combination of a core stability muscle training program with spinal manipulative therapy has yet to be investigated. In order to choose the most appropriate therapy for managing this condition, it is essential for research to be carried out to identify the most effective treatment, which would allow for better overall management of low back pain during the post-natal period. Therefore this study was designed to establish the effectiveness of a combined protocol of spinal manipulation and core stability exercises in the treatment of post-natal mechanical low back pain and to establish whether this protocol should be utilized routinely in the management of this condition. / M

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban Institute of Technology, Durban, 2006. / Core strengthening has become a major trend in the rehabilitation of patients suffering with lower back pain. Clinical trials have shown that core strengthening is beneficial for patients with low back pain. According to the literature, core strengthening consists of activating the trunk musculature in order to stabilize hypermobile symptomatic joints and thus lessen mechanical stress to the spine. Spinal manipulative therapy has also proved itself to be beneficial, particularly in the case of post-natal low back pain sufferers, as manipulation may correct hypomobility associated with spinal subluxations. Literature suggests that spinal manipulative correction of spinal subluxations in combination with core stability exercises, that stablise symptomatic hypermobile joints, may have more advantages than using these interventions singularly in the treatment of post-natal low back pain. However, the combination of a core stability muscle training program with spinal manipulative therapy has yet to be investigated. In order to choose the most appropriate therapy for managing this condition, it is essential for research to be carried out to identify the most effective treatment, which would allow for better overall management of low back pain during the post-natal period. Therefore this study was designed to establish the effectiveness of a combined protocol of spinal manipulation and core stability exercises in the treatment of postnatal and mechanical low back pain and to establish whether this protocol should be utilized routinely in the management of this condition. / M

Background: Altered muscular function of the deep abdominal and back muscles has been implicated as a factor in the development and continuation of low back pain (LBP) and small-scale studies, on specific subgroups of LBP patients, have reported favourable outcomes when these dysfunctions are addressed using specific exercise training. However, these techniques are increasingly being incorporated into treatment packages for non-specific LBP in the UK despite little evidence of their effectiveness in this patient group. A multi-centered, pragmatic, randomized clinical trial, with 12-month follow-up, was therefore designed to investigate the effectiveness of incorporating specific spinal stabilisation exercises within a physiotherapy treatment package in the management of recurrent LBP patients. Methods: Following ethical approval, consenting patients with recurrent LBP, without significant levels of distress (as measured by the distress risk assessment method {DRAM}), were randomized to two groups; 'conventional' physiotherapy and the provision of an advice booklet (Cl) and 'conventional' physiotherapy, the provision of an advice booklet with the addition of specific spinal stabilisation exercises (SSSE). Randomisation was stratified for laterality, duration of symptoms and initial functional disability level {Roland Morris Disability Questionnaire—RMDQ} using a minimization procedure. Functional disability (RMDQ) was the main outcome, and generic, disease-specific and psychological measures were also collected. The trial was powered to detect a 5-point difference between groups using 90% power. A total of 221 patients were screened for entry into the trial and 97 were recruited from three metropolitan physiotherapy departments within the UK between May 1999 and September 2000. Results: All patients were between the ages of 19 and 60 years (mean 38.6, SD: 10.5) and had an average duration of symptoms of 8.7 (8.1) months. Over 30% of the patients screened for entry to the trial were excluded as they showed evidence of psychological distress. Both groups demonstrated improved functioning, reduced pain intensity and an improvement in the physical component of quality of life. Mean change (95% Cl) for RMDQ scores between baseline to 12-month follow-up were —4.5 (-6.2 to —3.6) for the SSSE group and -5.2 (-6.7 to —3.6) for the CT group. No statistically significant differences between the two groups were demonstrated for any of the outcome variables. Patients in the spinal stabilisation group received a slightly greater mean number of treatment sessions over a longer period than the conventional physiotherapy treatment group (7.5 (2.5) over 11 weeks compared to 5.9 (2.3) over 8 weeks respectively). Exploration of the content of each treatment package revealed a combination of treatments was used, most frequently active exercise and manual therapy, with little use of electrotherapy or mechanical lumbar traction. Discussion and Conclusion: This trial represents the largest to date investigating the effects of specific spinal stabilisation exercises, and the first examining their use in a recurrent LBP population. Results indicate that physiotherapy is effective in reducing functional disability and to a lesser extent pain intensity, with improvements maintained at one year following completion of treatment, but that the addition of spinal stabilisation exercises to conventional physiotherapy and an advice booklet, does not provide any obvious additional benefit in terms of functional disability or pain intensity. These findings are of importance as they support the ongoing use of physiotherapy treatment packages in the management of recurrent LBP patients, without significant levels of distress, but challenge the assumption that stabilisation training provides an additional benefit in this particular group of LBP patients.

Thesis (M.Tech.:Chiropractic)-Dept. of Chiropractic, Durban Institute of Technology, 2006 xvii, 176 leaves / Core strengthening has become a major trend in the rehabilitation of patients suffering with lower back pain. Clinical trials have shown that core strengthening is beneficial for patients with low back pain. According to the literature, core strengthening consists of activating the trunk musculature in order to stabilize hypermobile symptomatic joints and thus lessen mechanical stress to the spine. Spinal manipulative therapy has also proved itself to be beneficial, particularly in the case of post-natal low back pain sufferers, as manipulation may correct hypomobility associated with spinal subluxations. Literature suggests that spinal manipulative correction of spinal subluxations in combination with core stability exercises, that stablise symptomatic hypermobile joints, may have more advantages than using these interventions singularly in the treatment of post-natal low back pain. However, the combination of a core stability muscle training program with spinal manipulative therapy has yet to be investigated. In order to choose the most appropriate therapy for managing this condition, it is essential for research to be carried out to identify the most effective treatment, which would allow for better overall management of low back pain during the post-natal period. Therefore this study was designed to establish the effectiveness of a combined protocol of spinal manipulation and core stability exercises in the treatment of post-natal mechanical low back pain and to establish whether this protocol should be utilized routinely in the management of this condition.

Thesis (M.Tech.: Chiropractic)--Durban University of Technology, 2008 / Core strengthening has become a major trend in the rehabilitation of patients suffering with acute low back pain. Clinical trials have shown that core strengthening is beneficial for patients with low back pain. According to the literature, core strengthening consists of activating the trunk musculature in order to stabilize hypermobile symptomatic joints and thus, lessen mechanical stress to the spine. Literature suggests that vibration/acceleration training may be a more effective and sufficient method of core stability exercises, with regards to core muscle endurance and activation in treatment of acute low back pain. This may have more advantages than using traditional core stability exercises in the treatment of acute low back pain. However, vibration/acceleration training as core stability exercises has yet to be investigated. In order to choose the most appropriate treatment protocol for managing this condition, it is essential for research to be carried out to identify the most effective treatment, which would allow for better overall management of low back pain during the acute period. Therefore, this study was designed to establish the effectiveness of vibration/acceleration training as a core stability exercise in the treatment of acute low back pain and to establish whether this protocol should be utilized routinely in the management of this condition.

Low Back Pain (LBP) is a condition that most people experience at least once in their lifetime and for which many will seek physiotherapeutic intervention. Recently published and internationally recognised clinical guidelines for the management of LBP recommend the use of spinal manual and manipulative therapy techniques alongside exercise, advice, education and pharmaceutical therapies, particularly in the early stages. Other areas of development in the last decade include classification systems, clinical prediction rules (CPR’s), patient-reported outcome measures (PROMS’s) and minimum clinically important difference (MCID) thresholds. Additionally, sympathetic nervous system (SNS) measures of treatment responses are now recognised as providing quantifiable indicators of peripheral, spinal and central effects of manual therapy interventions although research in the lumbar spine is very limited with none providing data on a patient population. The aims of the study were; to determine the reliability and stability of the Biopac System in recording skin conductance (SC) activity levels and calculate the smallest real difference (SRD) statistic; to generate data on the magnitude of SC response to two commonly utilised treatments for LBP; and to observe the changes in a clinical population receiving guideline-endorsed physiotherapy treatment for the management of acute and sub-acute LBP. Furthermore, clinical data analysis sought to identify correlations of SC measures to PROM’s and evaluate the feasibility of using SC responses as a predictive tool for therapeutic outcome. The ability of the Biopac System to reliably record SNS activity was established by using SC measurements with 12 participants on two occasions, one-week apart. Data was recorded within a natural, non-laboratory setting. Results established that SC measurements could be reliably recorded between data sessions with a measurement variability of; ICC=0.99 (p<0.005) with an SRD value of 0.315 μmho’s (4.633%). In conclusion, any SC change above the SRD could be regarded as an SNS change that is independent of any measurement error or variability thus representing a real change ascribable to the intervention under investigation. The pre-clinical investigation compared the magnitude of SC response (SCR) of two, independently administered, specific MT techniques, applied, after randomisation, to the Lumbar 4/5 segment of 50 asymptomatic healthy volunteers. Treatments included; a rotatory lumbar manipulation technique or a repeated McKenzie extension in lying exercise. Findings revealed that both techniques produced statistically significant changes in SNS activity in the lower limbs (> SRD) with manipulative technique SCR’s (76%) that were twice the size of the McKenzie repeated extension in lying exercise (EIL) technique (35.7%)( p=0.0005). Only the manipulation technique had a lasting effect that was carried into the final rest period (p=0.012) but the SNS response was not a side-specific phenomenon (p= 0.76). The final clinical study recruited 60 acute and sub-acute LBP patients (symptoms of up to 12 weeks duration) who received guideline-recommended physiotherapy treatment within a hospital-based musculoskeletal out-patient physiotherapy department. SCRs were recorded throughout all treatment episodes with standardised, validated PROM’s used for comparison of status at inception, mid-point and at discharge. Functional impairment was determined using the Oswestry Disability Index (ODI) and the Roland Morris Disability Questionnaire (RMDQ) with pain intensity evaluated with the Narrative Pain Rating Score (NPRS). A preliminary comparison, between the asymptomatic population and a random selection from the patient population, revealed that patients had treatment SCR’s that were significantly greater (three-fold) than those of the asymptomatic groups (manipulation, p=0.003; EIL exercises p=0.001). Analysis of the patient data indicated that pre-treatment/baseline SC activity levels in the inception data capture point were lower than at discharge (18 µMho’s; p<0.0005) but, conversely, that treatment SC levels were initially high, but diminished in magnitude by discharge (230 to 172 µMho’s; p<0.0005) representing a SCR reduction of 125%. Correlational analyses of change scores of maximum SCR’s to PROM’s, from inception to discharge suggested weak positive correlations of SCR treatment responses to functional disability score improvements (rho 0.278) and pain intensity reductions (rho=0.229) that were significant for function (p=0.033) but not significant for pain (p=0.080). The final analyses indicated that there were trends in the magnitude of response to specific elements of treatment with manipulation having the largest SCR (266%). Further evaluative analysis of SC readings as a predictor, at inception, of functional outcome, at discharge indicated that a critical/cut-off value of 195% may indicate those patients least and most likely to respond positively to MT treatment. Preliminary logistic regression analysis indicated that the 195% SCR value was excellent at identifying poor responders but less successful at identifying good responders, functionally, to treatment. Nonetheless, SCR was a better predictor of outcome than duration of symptoms and patient age. Characteristically, patients achieving the 195% value were most likely to have higher functional disability and pain intensity scores at inception but by discharge had required fewer treatments, had greater overall functional improvement and lower pain intensities than those not achieving this threshold. In conclusion, SC activity levels and SCR’s may be a reliable, stable, alternative and objective measure of LBP patients’ SNS status and changes that occur as a result of symptom abatement throughout a course of physiotherapy treatment. SC readings may (indirectly) reflect the state of dorsal horn (DH) sensitisation and of the central nervous system (CNS) processing system and its facilitatory capacity to activate the descending pain inhibitory system (DPIS). Further research, in patient populations (including chronic LBP patients), is recommended to verify these findings and validate the 195% SCR cut-off point. Definitive RCT’s are indicated to further the understanding of guideline-endorsed physiotherapy treatment (a complex intervention –MRC, 2000) and to determine whether the SNS activity measurements can be used to help classify, predict, and ultimately, direct the care of patients with LBP.

Patient satisfaction is one of the indicators of the quality of care being given to the users of a service. It can also be used as benchmarks for ensuring the delivery of quality physiotherapy services in health facilities. Physiotherapists have been involved in treatment of persons suffering from low back pain for decades. Treatment approaches are varied, but all have the common goals of pain relief, rehabilitation, and prevention of recurrence of low back pain. The purpose of this study was to investigate the satisfaction of low back pain sufferers with the physiotherapy services they receive. The study was carried out in selected public hospitals in Nairobi and the Central Province in Kenya.

The aim of this study was to determine assessment and treatment choices of physiotherapists treating non-specific low back pain in Rwanda. The main objectives were to identify the common types of low back pain treated by physiotherapists, to determine the