CHAPTER - I

INTRODUCTION

Low Back Pain is the most relevant form of musculoskeletal disorder. 70 – 80% of
people experience low back pain at some stage of their life. Of these, only 39 – 76% of the
patients attain complete recovery.[1]

Chronic Non-specific Low Back Pain (CNLBP) occurs with about the same
frequency in people with sedentary occupations as in those doing heavy labor, although the
latter have a higher incidence of absence from work because they are unable to work with
their complaint. The great majority of patients with low back pain state that they have
increased pain while sitting or on arising from sitting.

According to Robin McKenzie Acute, sub-acute or chronic low back pain, which is
characterized by either a slowly or a suddenly occurring rather sharp pain with or without
radiation over the buttocks or slightly down the leg, and concomitant restriction of motion.
When subsiding to the chronic type, the pain will be a little less severe and continue for
more than two months.

Pain is produced by the application of mechanical forces as soon as the mechanical

deformation of structures containing the nociceptive receptor system is sufficient to irritate
free nerve endings. It is not necessary to actually damage tissues containing the free nerve
endings in order to provoke pain. Pain will also be produced by the application of forces
sufficient to stress or deform the ligamentous and capsular structures. Pain will disappear
when the application of that force is terminated, and this often occurs by a mere change of
position. A good example is the pain, incurred during prolonged sitting which disappears on
standing up.

Mechanical deformation is caused by mechanical stress which, when applied to soft

tissues, will lead to pain under certain circumstances. Some examples of mechanical
deformation were Abnormal stress applied to a normal tissue and normal stress applied to a
normal tissue.[2]

1
 Approximately 60% of patients with chronic low back pain did not consider
themselves recovered in a period of 1 year from the onset of symptoms with moderate levels
of pain and disability persisting over time.[3]

The goal of physiotherapy in patients with chronic low back pain includes
elimination of pain, restoration of the lost extent of movements, functional improvement and
improvement of the quality of life. These objectives are achieved by various protocols of
exercise, manipulation, massage, relaxation techniques and counseling.

Although numerous pervious articles or studies have dealt with various therapeutic
approaches of Low Back Pain, the evidence of their efficiency is highly in conclusive.
Despite extensive research the issue of the Spinal pain management still continues a
challenge for physicians, physiotherapists and researches chronic.[4-7]

In 1981, Robin McKenzie proposed a classification based treatment for Low back
pain labeled Mechanical diagnosis and Therapy or simply the McKenzie method. Among
the large number of classification systems developed in last 20 years, the McKenzie method
has the greatest empirical support (eg., validity, reliability and generalizability) among the
systems based on clinical features.

According to this method, the classification of CNLBP is based on patterns of pain

response noted during the assessment. The centralization phenomenon is the most important
pattern of pain response observed in McKenzie method. This method is focused on spinal
disc disorders.[19-25]

McKenzie method is based on the phenomenon of movement of the nucleus

pulposes outside the intervertebral disc, depending on the adopted position and direction of
the movement of the spine. The nucleus pulposus that is exposed to the pressure from both
surface of the vertebral bodies takes the shape of a spherical joint. This means it has the
ability to perform 3 rotatory movements in all directions and has 6 degrees of freedom of
movement. The nucleus pulposus performs the movements of flexion, extension, lateral
bend (left and right) rotation (right and left) linear displacement (ship) along sagittal axis

2
linear displacement along the transverse axis and separation or approximation along vertical
axis.[1]

Misconception of the McKenzie method is observed in a systematic review

evaluating the effectiveness of exercise therapy for CNLBP in which this method was
equated to extension exercises. This is incorrect because with the McKenzie exercise, the
direction of exercise is not always extension, but instead diluted in the directional
preference.[10-16]

Muscle energy technique (MET) is a common conservative treatment for pathology

around spine. Muscle Energy Technique are among the most popular therapeutic modalities
aimed at the improvement of elasticity in contractile and non – contractile tissues.[1]

It is considered as gentle manual therapy for restricted motion of the spine and
extremities. This consists of voluntary muscular contraction of the muscles of varying
intensity. MET and Proprioceptive neuromuscular facilitation techniques have been clearly
shown to bring about changes in joint range of motion and muscle extensibility than passive
& static stretching both in short term and long term.

Muscle energy technique is a manual technique that is being widely adopted because
it appears safe and gentle and it is believed to be effective in patients with variety of
symptoms.

For many years, Muscle energy technique has been advocated to treat muscle
imbalance of the Lumbo-pelvic region such as pelvis asymmetry.[17-21]

Strain Counter Strain technique (SCS) is an indirect manipulative osteopathic

technique to relive pain and restore function of muscle, bones and joints.

SCS is used in tender points in such a way that the pain is reduced at least by 70% to
find position of ease. It is suggested that a minimum period required to hold a position of
ease is 90 seconds. It is theorized that the shortening or folding over of aberrant tissues in
positional release is achieved by both proprioceptive and nociceptive mechanism.[1]

3
 Both of the techniques were used to reduce pain, improve the elasticity of the
muscles, to achieve the nociceptive and proprioceptive mechanisms via modifications.
Hence the study is performed to compare the efficiency of these techniques in CNLBP
patients.

1.1 AIM OF THE STUDY:

The aim of the present study was to compare McKenzie exercises enriched with
Muscle energy technique and McKenzie exercises enriched with Strain counter strain
technique in patients with chronic non-specific low back pain.

1.2 NEED FOR THE STUDY:

The study is to determine the efficiency of Chronic Non-specific Low back pain
intensity, functional disability, range of motion and quality of life using combined
manipulative techniques.

Here we have evaluated the pain intensity, amount of functional disability, range of motion
and quality of life of patients with Low Back pain.

1.3 OBJECTIVE:

To compare the combined treatment efficiency of McKenzie method with Muscle

energy technique and Strain counter strain technique on pain, range of motion, functional
disability and quality of life in patients with chronic non-specific low Back Pain.

1.4 HYPOTHESIS:

Null Hypothesis:
There will be no significant difference in the comparison of McKenzie method enriched by
muscle energy technique and strain counter strain technique in chronic non–specific low
back pain.

4
Alternate Hypothesis:

There will be a significant difference in the comparison of McKenzie method

enriched by muscle energy technique and strain counter strain technique in chronic non–
specific low back pain.

1.5 OPERATION DEFINITIONS:

Pain:
The international association for the study of pain (IASP) defines pain as an
unpleasant sensory and emotional experience associated with actual or potential tissue
damage pain is not just a physical sensation.

Range of Motion:
Range of motion is the measurement of movement around a specific joint body part.
It is the anatomical position to extreme limit of the joint.

Chronic Non-Specific Low Back Pain:

Robin McKenzie defined CNLBP as Acute, sub-acute or chronic low back pain,
which is characterized by either a slowly or a suddenly occurring rather sharp pain with or
without radiation over the buttocks or slightly down the leg, and concomitant restriction of
motion. When subsiding to the chronic type, the pain will be a little less severe and continue
for more than two months.

Muscle Energy Technique:

Muscle Energy Technique (MET) is a manual therapy technique which uses a
muscle‟s own energy in the form of gentle isometric contractions to relax the muscles via
autogenic or reciprocal inhibition, and lengthen the muscle.

McKenzie Method:

McKenzie method is a classification based treatment for spine pathology labeled

mechanical diagnosis and therapy or simply the “McKenzie Method”

5
Strain Counter Strain Technique:
Strain counter strain technique (SCS) is a manual therapy technique to treat muscle
and joint pain and dysfunction. The clinicians use only their hands to treat the patients.

Quebec Back Pain Disability Scale:

It is a condition specific questionnaire developed to measure the level of functional
disability for patients with low back pain (LBP) that was designed, developed and validated
by kopec et.al.,

WHO QOL – BREF Instrument:

It is an instrument developed by WHO that comprises of 26 items, which measures
physical health, psychological health, social relationship and environment. It is used to
measure the quality of life of the patients.

6
 CHAPTER - II

LITERATURE REVIEW

Malgorzata Waszak et al., 2015, conducted a randomized study on the impacts of

McKenzie method therapy enriched by muscular energy technique on subjective and objective
parameters to spine function in 60 patients with mean age of 44 years with chronic low back
pain. Subjects were randomly assigned into 3 groups. 10 daily sessions were performed during
5 consecutive weekdays. Electrogoniometer, Visual analogue scale and Magnetic Resonance
Imaging were used as outcome measures. Outcomes were evaluated and concluded that
combined application of McKenzie and MET proved more effective in individuals with chronic
low back pain.

Marzouk A Ellythy, July 2012, conducted an experimental study on the efficacy of

MET versus SCS on low back dysfunction patients. 30 patients with age range between 30-50
years were assigned into two groups and underwent a 4 weeks program of MET and SCS. Short
form McGill pain questionnaire, Range of motion using Schober‟s test and Oswestry disability
index were the scales used. Outcomes were valuated and concluded that both MET & SCS
proved to be effective in reducing pain and functional disability in patients with chronic low
back pain.

Alessandra NarcisoGracia, et al., June 2013, experimented the effectiveness of Back School
and McKenzie exercises in patients with Chronic non-specific low back pain. 148 patients were
randomly assigned with a blinded assessor into 2 groups. The study consists of a 4 week
treatment program one session per week. One group received exercises based on Back school
technique and the other group received McKenzie technique. NPRS, Roland morris
questionnaire and WHO QOL BREF instrument were used as outcome measures. Outcome
measures were evaluated and concluded that McKenzie is more effective than Back School
exercises.

Luciana Andrade Carneiro Machado, et al., 2006, conducted a systemic review of literature
with a meta-analysis approach. Eleven trials of most high quality were included. McKenzie
technique reduced pain and functional disability at 1 week follow-up when compared with

7
passive therapy for LBP. They concluded that there are some evidences proving McKenzie
method is more effective than passive therapy for Low back pain patients.

Noelle M.Selkow, et al., Journal of manipulative therapy vol-17, num-1., conducted a pilot
study on the short term effect of MET on pain in 20 individuals with Lumbo-pelvic pain. Tests
for current pain and worst pain with provocation were taken as baseline, immediately following
intervention and 24 hours after intervention. ANOVA was used to analyze the result and
concluded that MET can be useful in decreasing low back pain over 24 hours.

Stephen May, 2008., experimented an evidence informed management of chronic low back
pain with McKenzie method. The study explained the effects of McKenzie exercises and
combined treatment methods along with McKenzie technique. The centralizers were taken as
reliability. Two high quality studies reported high reliability but the third study has low
reliability. This concluded that there are no side effects or harm or adverse effects in applying
McKenzie technique in CNLBP. This study also concluded that Centralizers is a more
important predictor of outcome in CNLBP.

Helen A.Clare, 2004., experimented the Reliability of McKenzie spinal pain classification
using patient assessment of McKenzie. 50 patients with spinal pain were examined using
McKenzie assessment. The reliability of the judgments was expressed using multi-rater kappa
(k) and percentage agreement. The reliability analysis suggested that the patient assessment
forms evaluated in this study provided an adequate but not ideal clinical simulation and proved
further studies were required to prove the reliability of McKenzie assessment.

Raymond W.J.G.Ostelo, 2008., interpreted change scores for pain and functional status in low
back pain. This article provides practical guidelines for a range of commonly used back pain
outcome measures. The study interpreted the outcome measure for CNLBP in pain and
disability.3 studies on visual analogue scale, 5 studies on numerical pain rating scale, 17 studies
on Roland morris disability questionnaire and 5 studies on Quebec back pain disability
questionnaire were identified and included. The study concluded that Quebec back pain
disability scale is reliable for testing disability and Visual analogue scale is reliable in testing
pain intensity in patients with Chronic Non-specific Low back pain.

8
 CHAPTER-III

MATERIALS AND METHODS

3.1 MATERIALS:
Table and sheet
Chair
Pillow
Towel
Assessment chart & scales
Pen
Inch tape

3.2 STUDY DESIGN:

A Randomized clinical trial study design in which the subjects are randomly
allocated into 2 groups (Group A and Group B) by Computer generated random numbers
and pre test values of both groups were compared with post test values in selected
parameters over a period of time for within group analysis and both groups were analyzed
for between group analysis.

3.3 STUDY SETTING:

Department of Orthopedics and Outpatient PMR department PSG Hospitals,
Coimbatore.

3.4 HUMAN PARTICIPATION PROTECTION:

The study was reviewed and approved by institutional human ethics committee at
PSG IMSR.

9
3.5 POPULATION/PARTICIPANTS:
30 patients and Chronic Non Specific Low Back Pain were selected using Randomized
control trial and 15 individuals were allocated in each group.

Group A: 15 patients received McKenzie method with muscle energy technique.

Group B: 15 patients received McKenzie method with strain counter strain technique.

3.6 SAMPLING:
Computer generated random sampling

3.7 CRITERIA FOR SAMPLE SELECTION

3.7.1 Inclusion criteria:

Age: 20 to 50 years.
Diagnosed case of Non-specific Low back pain with or without radiating pain for at
least 8 weeks duration.
Protrusion of spinal disc.
Unilateral or bilateral radiating pain.
Able to understand& sign the consent form of the treatment technique.

3.7.2 Exclusion Criteria:

Red flags of manipulation like tumours, fracture, Infection, Spondylolisthesis, senile
osteoporosis .
Cardio respiratory illness, pregnancy, psychological illness.
Spinal canal stenosis, previous spinal surgeries, extrusion, sequestration & prolapse
Diagnosed referred visceral pain.
Received physiotherapy for the same problem in last 3 months.

3.8 STUDY DURATION:

Total duration of 8 months was adopted for this study.

10
3.9 TREATMENT DURATION:
40 minutes per session, 3 sessions per week for 4 weeks. A total of 12 sessions of
treatment will be performed.

3.10 INSTRUMENT& TOOL FOR DATA COLLECTION:

 Numerical pin rating scale (NPRS) for measuring pain

 Modified Schober‟s test for measuring active lumbar flexion & extension range of
motion
 Quebec disability questionnaire for measuring functional disability
 WHO BREF instrument for measuring quality of life

3.11 TECHNIQUES OF DATA COLLECTION:

Initial assessment was taken on the first day of intervention by using outcome measures.
After obtaining the informed consent form, the Intervention was given to each group separately
for 4 weeks. Final assessment was taken after the 4 weeks of treatment using same outcome
measures. Comparison of pretest and post test values within the group and between the groups
was done finally.

3.12 TECHNIQUES OF DATA ANALYSIS &INTERPRETATION:

Data collected from subjects were analyzed using paired„t‟ test to measure changes
between pretest and posttest values of outcome measures within the group. Independent„t‟
test was used to measure changes between the groups. The analysis was performed using
SPSS version 16.0.

11
Paired ‘t’ test 2
(d d )
SD
n 1

d n
t
SD

d = Calculated Mean Difference of pretest and posttest values

SD = Standard Deviation

n = Number of samples

d = Difference between pretest and posttest values

Independent ‘t’ test

| x1 x2 |
t
1 1
SD
n1 n2

Where,

(n 1 - 1)SD 12 (n 2 - 1)SD 22
SD
n1 n2 2

X1 = Mean difference in Group A

X2 = Mean difference in Group B

SD = Combined standard deviation of Group A and Group B

n1 = Number of patients in Group A

n2 = Number of patients in Group B

SD1 = Standard Deviation of Group A

SD2 = Standard Deviation of Group B

12
 METHODOLOGY FLOW CHART

Individuals with Chronic Non-specific low back pain

(n=57)

Patient selection Excluded

(Based on inclusion & exclusion criteria) (n=27)
(n=30)

Group allocation
(Computer generated random sampling method)

Obtain
Consent form

Group A Group B
[Mckenzie method with Muscle energy [Mckenzie method with Strain counterstrain
technique therapy] technique therapy]
(n=15) (n=15)

Pre treatment assessment

Measurement tools:
Numerical pin rating scale (NPRS)
Modified Schober‟stest
Quebec disability questionnaire
WHO BREF instrument

Each individual will receive 12 treatment sessions

(3 sessions / week for 4 weeks)

Post treatment assessment at the end of 12th treatment session

(Same measurement tools used)

Data Analysis

Results

13
 CHAPTER – IV

DATA ANALAYSIS AND INTERPRETATION

Data analysis is the systemic organization and synthesis of research data and testing
of research hypothesis using these data. Interpretation is the process of making sense of the
results of a study and examining the implication (Polit & Belt, 2004).

The pretest and posttest values for Groups A & B were obtained before and after
intervention. The improvement in Pain was assessed using Numeric Pain Rating Scale
(NPRS), the improvement in lumbar flexion & extension range of motion was assessed
using Modified Schober‟s Test, the improvement in Functional disability was assessed using
Quebec Back pain Disability Questionnaire (QDI) and the improvement in Quality of life
was assessed using WHO BREF instrument (WHO BREF). The mean, standard deviation
and Paired t test values were used to find out whether there was any significant difference
between pretest and posttest values within the groups.

Independent t test is used to find the significant differences between the groups after
intervention.

14
 TABLE 1:

PRE TEST AND POST TEST VALUES OF NPRS, MODIFIED

SCHOBER’S TEST, QUEBEC DISABILITY SCALE AND WHO BREF
INSTRUMENT OF GROUP A

Quebec Back
WHO
Numerical pain
BREF
Pain Rating Modified Schober’s test(Inches) disability
instrument
S.No. scale (cms) scale
(points)
(percentage)
Pre- Post- Pre-test Post-test Pre- Post- Pre- Post-
test test Flexion Extension Flexion Extension test test test test
1. 6 4 3 3 6 5 39 12 88 105

2. 8 5 3 4 5 6 75 45 66 91

3. 8 4 2 2 5 4 81 41 65 91

4. 6 3 3 2 5 5 41 9 91 118

5. 7 2 3 1 4 4 60 21 83 107

6. 5 2 4 5 7 7 63 24 70 90

7. 6 2 3 2 7 7 30 15 89 107

8. 6 3 3 4 6 5 43 15 89 115

9. 6 3 2 2 5 4 64 21 89 119

10. 7 4 3 3 5 4 60 18 87 103

11. 8 4 3 4 5 5 56 15 66 91

12. 7 5 3 3 5 6 81 15 69 92

13. 8 4 2 1 4 3 88 13 59 88

14. 8 5 3 3 5 5 74 25 92 116

15. 7 3 4 5 7 7 61 5 100 119

15
 TABLE 2:

PRE TEST AND POST TEST VALUES OF NPRS, MODIFIED

SCHOBER’S TEST, QUEBEC DISABILITY SCALE AND WHO BREF
INSTRUMENT OF GROUP B
Quebec Back
WHO
Numerical pain
BREF
Pain Rating Modified Schober’s test(Inches) disability
instrument
S.No. scale (cms) scale
(points)
(percentage)
Pre- Post- Pre-test Post-test Pre- Post- Pre- Post-
test test Flexion Extension Flexion Extension test test test test
1. 9 7 2 3 4 4 75 27.5 55 87

2. 6 5 3 1 6 5 40 0 89 104

3. 6 4 3 3 6 5 36.25 12.5 81 84

4. 8 6 3 2 4 3 40 17.5 93 117

5. 8 5 3 2 4 4 81.25 15 67 88

6. 7 3 5 4 6 5 77.5 35 67 99

7. 7 3 4 3 6 4 85 6.25 67 99

8. 7 4 4 3 6 5 61.25 36.25 99 113

9. 8 6 3 3 6 6 87.5 25 61 92

10. 5 2 4 4 7 6 50 26.5 66 87

11. 8 7 3 2 5 3 81.25 48.75 66 92

12. 9 6 2 2 3 3 87.5 38.75 58 103

13. 5 3 2 1 4 3 38.75 10 86 104

14. 5 3 3 2 5 5 35 13.75 77 108

15. 8 5 4 4 6 6 81.25 3.75 65 91

16
 TABLE 3:

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION ANDPAIRED

‘t’ TEST VALUES OF PAIN

MEAN ‘t’ p
GROUP PRE/POST MEAN SD
DIFFERENCE VALUE VALUE

PRE TEST 6.86

GROUP A 3.33 0.81 15.81 p<0.05
POST
(n=15) 3.53
TEST

PRE TEST 7.06

GROUP B 2.46 0.91 10.43 p<0.05
POST
(n=15) 4.60
TEST

Based on Table 1, the mean difference of group A was found to be 3.33, Standard
deviation was 0.81the „t‟ value using the paired „t‟ test was 15.81 which was greater than the
table value of 1.76 at p<0.05. In Group B the mean difference was 2.46, standard deviation
was 0.91, the „t‟ value using the paired „t‟ test was 10.43 which was greater than the table
value of 1.76at p<0.05. This shows there is a significant reduction in pain in both groups.

17
 TABLE 4:

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND

PAIRED ‘t’ TEST VALUES OF LUMBAR FLEXION RANGE OF
MOTION

MEAN ‘t’ p
GROUP PRE/POST MEAN SD
DIFFERENCE VALUE VALUE

PRE TEST 2.93

2.46 1.01 12.85 p<0.05
GROUP A
(n=15) POST
5.40
TEST

PRE TEST 3.20

2.00 0.75 10.24 p<0.05
GROUP B
(n=15) POST 5.20
TEST

Based on Table 2, the mean difference of group A was found to be 2.46, Standard
deviation was 1.01, the „t‟ value using the paired „t‟ test was 12.85 which was greater than
the table value of 1.76 at p<0.05. In Group B the mean difference was 2.00, standard
deviation was 0.75, the „t‟ value using the paired „t‟ test was 10.24 which was greater than
the table value of 1.76 at p<0.05. This shows there is a significant improvement in lumbar
flexion range of motion in both groups.

18
 TABLE 5:

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND

PAIRED ‘t’ TEST VALUES OFLUMBAR EXTENSION RANGE OF
MOTION

MEAN ‘t’ p
GROUP PRE/POST MEAN SD
DIFFERENCE VALUE VALUE

PRE TEST 2.93

2.20 1.01 8.40 p<0.05
GROUP A
(n=15) POST
5.13
TEST

PRE TEST 2.60

1.86 0.91 7.89 p<0.05
GROUP B
(n=15) POST
4.46
TEST

Based on Table 3, the mean difference of group A was found to be 2.20, Standard
deviation was 1.01, the „t‟ value using the paired „t‟ test was 8.40which was greater than the
table value of 1.76 at p<0.05. In Group B the mean difference was 1.86, standard deviation
was0.91, the „t‟ value using the paired „t‟ test was 7.89 which was greater than the table
value of 1.76 at p<0.05. This shows there is a significant improvement in lumbar extension
range of motion test in both groups.

19
 TABLE 6:

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND

PAIRED ‘t’ TEST VALUES OF FUNCTIONAL DISABILITY

MEAN ‘t’ p
GROUP PRE/POST MEAN SD
DIFFERENCE VALUE VALUE

PRE TEST 61.06

41.46 15.40 10.42 p<0.05
GROUP A
(n=15) POST
19.60
TEST

PRE TEST 63.80

42.53 20.36 8.08 p<0.05
GROUP B
(n=15) POST
21.26
TEST

Based on Table 4, the mean difference of group A was found to be 41.46, Standard
deviation was 15.40, the „t‟ value using the paired „t‟ test was 10.42 which was greater than
the table value of 1.76 at p<0.05. In Group B the mean difference was 42.53, standard
deviation was20.36, the „t‟ value using the paired „t‟ test was 8.08 which was greater than
the table value of 1.76 at p<0.05. This shows there is a significant reduction in functional
disability in both groups.

20
 TABLE 7:

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND

PAIRED ‘t’ TEST VALUES OF QUALITY OF LIFE

MEAN ‘t’ p
GROUP PRE/POST MEAN SD
DIFFERENCE VALUE VALUE

PRE TEST 80.20

23.27 4.33 20.79 p<0.05
GROUP A
(n=15) POST
103.47
TEST

PRE TEST 73.13

24.73 10.02 9.55 p<0.05
GROUP B
(n=15) POST
97.86
TEST

Based on Table 5, the mean difference of group A was found to be 23.27, Standard
deviation was 4.33, the „t‟ value using the paired „t‟ test was 20.79 which was greater than
the table value of 1.76 at p<0.05. In Group B the mean difference was 24.73, standard
deviation was 10.02, the „t‟ value using the paired „t‟ test was 9.55 which was greater than
the table value of 1.76at p<0.05. This shows there is a significant improvement in quality of
life in both groups.

21
 GRAPH 1:

PRE-TEST AND POST-TEST DIFFERENCE OF PAIN, LUMBAR

FLEXION & EXTENSION ROM, FUNCTIONAL DISABILITY AND
QUALITY OF LIFE OF MUSCLE ENERGY TECHNIQUE WITH
MCKENZIE TECHNIQUE OF GROUP A (n=15)

120

100

80

60
pre-test
40
post-test
20

22
 GRAPH 2:

PRE-TEST AND POST-TEST DIFFERENCE OF PAIN, LUMBAR

FLEXION & EXTENSION ROM, FUNCTIONAL DISABILITY AND
QUALITY OF LIFE OF STRAIN COUNTER STRAIN TECHNIQUE
WITH MCKENZIE TECHNIQUE OF GROUP B (n=15)

80

70

60

50

40 pre-test

30 post-test

20

10

0
NPRS FLEXION EXTENSION FD QOL
ROM ROM

23
 TABLE 8:

COMPARISON OF GROUP A & B USING INDEPENDENT ’t’ TEST

OUTCOME
GROUP MEAN SD ‘t’ VALUE p VALUE
PARAMETERS

A 3.53 0.81
PAIN
2.15 Significant
(cms) B 4.60 0.91

A 5.40 0.74
FLEXION ROM
0.51 NS*
(Inches)
B 5.20 0.75

A 5.13 1.01
EXTENSION
4.83 Significant
ROM (Inches)
B 4.46 0.91

A 19.60 15.40
FD
0.35 NS*
(Percentage) B 21.26 20.36

A 103.47 4.33
QOL
1.37 NS*
(Points) B 97.86 10.02

*NS= Non Significant

Table 6 shows the Independent „t„ test was performed between Group A and Group
B to analyze the significant difference for pain, range of motion, functional disability and
quality of life and hereby shows that there is significant difference in pain and lumbar
extension range of motion and there is no statistical difference in lumbar flexion range of
motion, functional disability and quality of life between Group A and Group B.

24
 GRAPH 3:

INDEPENDENT ‘t’ TEST DIFFERENCE OF PAIN,LUMBAR

FLEXION & EXTENSION ROM, FUNCTIONAL DISABILITY AND
QUALITY OF LIFE OF MUSCLE ENERGY TECHNIQUE WITH
MCKENZIE TECHNIQUE OF GROUP A AND STRAIN COUNTER
STRAIN TECHNIQUE WITH MCKENZIE TECHNIQUE OF GROUP B
(n=30)

100
90
80
70
60
50
40 GROUP A
30
GROUP B
20
10
0

25
 CHAPTER V

RESULTS AND DISCUSSION

The aim of the present study was to compare McKenzie exercises enriched with
Muscle energy technique and McKenzie exercises enriched with Strain counter strain
technique in patients with chronic non-specific low back pain.

A total of 30 patients in age group of 20-50 years with chronic nonspecific low back
pain were selected. The participants who satisfied the selection criteria were randomly
assigned into two groups. Measurements were taken at baseline using the Numerical pain
rating scale for pain(NPRS), Modified Schober‟s test for lumbar flexion & extension range
of motion, Quebec disability questionnaire for functional disability, WHO BREF instrument
for Quality of life. One group received Muscle energy technique with McKenzie technique
and another group received Strain counter strain technique with McKenzie technique for 4
weeks duration. At the end of 4 weeks, participants again underwent the evaluation using
same outcome measures. Statistical analysis for the present study was done using SPSS
version 16.0

Statistical analysis done using paired „t‟ test shows that there is a significant difference
between pretest and posttest analysis of Muscle energy technique with McKenzie technique of
Group A on pain, lumbar flexion and extension range of motion, functional disability and
quality of life. The „t‟ and p values of pain ware 15.81 and 0.000, lumbar flexion range of
motion are 12.85 and 0.000, lumbar extension range of motion are 8.40 and 0.000, functional
disability are 10.42 and 0.000, quality of life are 20.79 and 0.000 respectively. Hence there is
significant improvement in using Muscle energy technique with McKenzie technique in treating
patients with chronic non-specific low back pain.

Statistical analysis done using paired „t‟ test shows that there is a significant difference
between pre test and post test analysis of Strain counter strain technique with McKenzie
technique of Group B on pain, lumbar flexion and extension range of motion, functional
disability and quality of life. The „t‟ and p values of pain are 10.43 and 0.000, lumbar flexion
range of motion are 10.24 and 0.000, lumbar extension range of motion are 7.89 and 0.000,

26
functional disability are 8.08and 0.000, quality of life are 9.55 and 0.000 respectively. Hence
there is significant improvement in using Strain counter strain technique with McKenzie
technique in treating patients with chronic non-specific low back pain.

But the study is intended to compare the impacts of McKenzie technique with Muscle
energy technique and Strain counter strain technique in treatment of patients with chronic non-
specific low back pain. Statistical analysis done using Independent„t‟ test shows that only pain
& lumbar extension range of motion is effective on Muscle energy technique with McKenzie
technique of Group A than Strain counter strain technique with McKenzie technique of Group
B and there is no difference between groups on comparing lumbar flexion range of motion,
functional disability and quality of life.

The improvement in Group A would be because; Muscle energy technique has an

analgesic effect explained by both spinal and supraspinal mechanisms. Activation of both
muscle and joint mechanoceptors occur during an isometric contraction. This leads to
sympatho-excitation evoked by somatic efferents and localized activation of the peri aqueductal
grey that plays a role in descending modulation of pain. Nociceptive inhibition that occurs at
the dorsal horn of the spinal cord, as simultaneous gating takes place of nociceptive impulses in
the dorsal horn, due to mechanoceptor stimulation. MET stimulates joint proprioceptors, via the
production of joint movement, or the stretching of a joint capsule, may be capable of reducing
pain by inhibiting the smaller diameter nociceptive neuronal input at the spinal cord level.[21]
This is supported by Degenhard et al. (2007) who reported that concentrations of several
circulatory pain biomarkers (including endocannabinoids and endorphins) were altered
following osteopathic manipulative treatment incorporating muscle energy. The degree and
duration of these changes were greater in subjects with C LBP than in control subjects.
Moreover myofascial trigger point deactivation was shown to be enhanced by use of different
forms of MET.[22] Consistent with these findings, Selkow et al. (2009)[23] who described the
effectiveness of MET for hamstring muscle. Also the analgesic effect of MET is confirmed by
work Strunk, (2008),[24]Buchmann et al. (2005), and Wilson et al. (2003). On the other hand,
Ballentyne et al. (2003), still argue and hesitate about the efficacy of MET in form of post-
isometric relaxation. They suggested that the PIR theory and its consequent hypoalgesic effects
are poorly supported by research.[25]

27
 The analgesic effect of SCS technique could be attributed to Bailey and Dick (1992)
who proposed a nociceptive hypothesis that tissue damage in dysfunctional muscle can be
reduced by the positional release mechanism utilized by SCS. The result of the current study is
supported by Carlos et al. (2011), who proved reduction in pain and muscle tension in upper
trapezius, which confirm the assumptions that the application of SCS seems to relieve muscle
spasm and restore appropriate painless movement and tissue flexibility. Hutchinson (2008)
reported that there is significant improvement in VAS for pain intensity following SCS
[26]
intervention for tennis elbow . These finding was in agreement with Marc (2003), who
confirmed the analgesic effect of SCS intervention for CLBP. This result also was supported by
Meseguer et al. (2006),[27] who claimed that the application of SCS may be effective in
producing hypoalgesia and decreased reactivity of Tender Points in the upper trapezius in
subjects with neck pain. Moreover, Pedowitz (2005)[28] carried out a trial on the use of
positional release on iliotibial band friction syndrome and found that the use of SCS as a
treatment modality for the athlete can experience reductions in pain and be capable of returning
to full activity in less than three weeks from initiation of treatment, compared to an average of
4-6 weeks of conventional therapy. This result also was supported by work of Cleland et al.
(2005)[29] and Wong et al. (2004),[30] who confirmed the significant pain reduction in their
studies.

The current findings shows that only pain & lumbar extension range of motion is
effective on Muscle energy technique with McKenzie technique of Group A than other group
and there is no difference between the groups on lumbar flexion range of motion, functional
disability and quality of life. Hence both groups were equally effective in treating patients with
chronic non-specific low back pain.

5.1 LIMITATIONS OF THE STUDY:

• Lack of long term follow-up.

• Small sample size.

• No blinding was done.

• Smaller age group people have a lesser disability and lesser difference in their quality of
life.

28
5.2 SUGGESTION FOR FUTURE STUDIES:

• Duration of the study can be shortened to calculate the immediate effect of the treatment

• Large sample size can be used because greater the sample size greater would be the
significance

• Study can be performed with repeated measures with weekly assessment

• Study can be performed using McKenzie assessment.

• Study can be performed with different treatment techniques for elderly patients with low
back pain.

• Study can be performed including Lateral flexion and rotation of the lumbar vertebrae.

29
 CHAPTER VI

SUMMARY AND CONCLUSION

The study concludes that Muscle energy technique with McKenzie technique of Group
A and Strain counter strain technique with McKenzie technique of Group B are effective on
treating pain, flexion and extension range of motion, functional disability and quality of life.
But comparing both groups proved that only pain & lumbar extension range of motion is
effective on Muscle energy technique with McKenzie technique of Group A than Strain counter
strain technique with McKenzie technique of Group B and there is no difference between
groups on comparing lumbar flexion range of motion, functional disability and quality of life.
Hence both groups were equally effective in treating patients with chronic non-specific low
back pain.

30
 REFERENCES

1. Chaitow, L.: Muscle energy techniques, 3rd edition, London, Churchill Livingstone.
(1) 152-153, 2006.

2. Robin McKenzie, 1980: The Lumbar spine Mechanical Diagnosis and Therapy, Spinal
Publications 1981.

3. Alessandra Narciso, Luciola da cunhamenezes costa, et al: Journal of Physical

Therapy, june 2013, vol-93, No.6: Pg.no.729-747.

4. Lewandowski J, Szulc P, Boch-Kmieciak J et al: Epidemiology of low back pain in

students of physical education and physiotherapy. Studies in Physical Culture and
Tourism, 2011; 18(3): 265–69

5. Pereira LM, Obara K, Dias JM et al: Comparing the Pilates method with no exercise
or lumbar stabilization for pain and functionality in patients with chronic low back
pain: systematic review and meta-analysis. ClinRehabil, 2012; 26: 10–20

6. Werneke MW, Hart D, Oliver D et al: Prevalence of classification methods for

patients with lumbar impairments using the McKenzie syndromes, pain pattern,
manipulation, and stabilization clinical prediction rules. J Man ManipTher, 2010; 18:
197–204

7. da C Menezes Costa L, Maher CG, Hancock MJ et al: The prognosis of acute and
persistent low-back pain: a meta-analysis. CMAJ, 2012; 184: E613–24

8. Sufka A, Hauger B, Trenary M, et al. Centralization of low back pain and perceived
functional outcome. J Orthop Sports PhysTher1998;27:205–12.

9. Lisi AJ. The centralization phenomenon in chiropractic spinal manipulation of

discogenic low back pain and sciatica. J Manipulative PhysiolTher2001;24:596–
602.

31
10. Wetzel FT, Donelson R. The role of repeated end-range/pain response assessment
in the management of symptomatic lumbar discs.Spine J 2003;3:146–54.

11. Werneke M, Hart DL, Cook D. A descriptive study of the centralization

phenomenon: a prospective analysis. Spine 1999;24:676–83.

12. Werneke M, Hart DL.Centralization phenomenon as a prognostic factor for

chronic low back pain and disability.Spine2001;26:758–65.

13. Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms:a

systematic review. Man Ther2004;9:134–43.

14. Donelson R, Aprill C, Medcalf R, et al. A prospective study of centralization of

lumbar and referred pain: a predictor of symptomatic discs and anular
competence. Spine 1997;22:1115–22.

15. McKenzie R, May S: The lumbar spine: mechanical diagnosis and therapy. 2nd ed.
Waikanae: Spinal Publications, 2003

16. Laslett M, van Wijmen P: Low back and referred pain: diagnosis and a proposed
new system of classification. N Z J Physiother1999;27:5–14.

17. Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscle energy technique in

patients with acute low back pain: A pilot clinical trial. J Orthop Sports
PhysTher2003;33:502–512.

18. Cleland, J.A., Flynn, T.W. and Palmer, J.A.: Incorporation of manual therapy
directed at the cervicothoracic spine in patients with lateral epicondylalgia: A pilot
clinical trial. J Man Manipulative Ther, 13(3): 143-151, 2005.

19. Schenk R.: The effects of muscle energy technique on cervical range of motion. J
ManManipTher1994;2:149–155.

32
20. Schenk R.: The effects of muscle energy technique on lumbar range of motion.J
ManManipTher1997;5:179–183.

21. Freyer G, Ruszkowski W: The influence of contraction duration in muscle energy

technique applied to the atlanto-axial joint. J Osteopath Med. 2004;7:79–84.

22. Degenhardt, B., Darmani, N. and Johnson, J.: Role of Osteopathic

manipulative treatment in altering pain bio-markers: A pilot study. J Am
Osteopath ASSOC. 107:387-400, 2007.Leboeuf-Yde C, Lauritsen JM, Lauritzen T.
Why has the search for causes of low back pain largely been nonconclusive? Spine
1997;22:877–81.

23. Leboeuf-Yde C, Lauritsen JM, Lauritzen T. Why has the search for causes of
low back pain largely been nonconclusive? Spine 1997;22:877–81. Drozda K,
Lewandowski J, Górski P: Back pain in lower and upper secondary school pupils
living in urban areas of Poland. The case of Poznan. Ortopedia, Traumatologia,
Rehabilitacja, 2011; 13(5(6)): 489–503

24. Smith, M. and Fryer, G.: A comparison of two muscle energy techniques for
increasing flexibility of the hamstring muscle group. Journal of Bodywork and
Movement Therapies IN PRESS. Speed C. ABC of rheumatology: low back pain.
Br Med J.; 328(7448): 1119-1121, 2008. Dunsford A, Kumar S, Clarke S:
Integrating evidence into practice: use of McKenzie-based treatment for mechanical
low back pain. J MultidiscipHealthc, 2011; 4: 393–402

25. Shlenk, R., Adelman, K. and Rousselle, J.: The effects of muscle energy
technique technique on cervical range of motion. Journal of Manual &
Manipulative Therapy. 2(4): 149-155, 1994.

26. Bailey, M. and Dick, L.:Nocioceptive consideration in treating with counter strain.
J. Am. Osteopathic Association, 92(3): 334-341, 1992. Frankel BS, Moffett JK,
Keen S et al: Guidelines for low back pain: changes in GP management. FamPract,
1999; 16: 216–22

33
27. Meseguer, A.A., Fernández-De-Las-Peňas, C., Navarro-Poza, J.L., Rodrìguez-
Blanco, C., and Gandia, J.J.B.: Immediate effects of the straincounterstrain
technique in local pain evoked by tender points in the upper trapezius muscle.
ClinChiropr, 9(3): 112-118, 2006.

28. Pedowitz, R.N.: Use of osteopathic manipulative treatment for iliotibial band
friction syndrome. Journal of the American Osteopathic Association; 105(12): 563-
567, 2005.

29. Cleland, J.A., Flynn, T.W. and Palmer, J.A.: Incorporation of manual therapy
directed at the cervicothoracic spine in patients with lateral epicondylalgia: A pilot
clinical trial. J Man Manipulative Ther, 13(3): 143-151, 2005.

30. Maluf KS, Sahrmann SA, van Dillen LR: Use of a classification system to guide
nonsurgical management of a patient with chronic low back pain.
PhyTher2000;80:1097–111.

34