Cyriax Manipulation in Lumbar Derangement Syndrome

Study Overview
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Brief Summary
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the objective of the study was to determine the effect of Cyriax manipulation for Pain, range of motion and quality of life in lumbar internal derangement radiculopathy in single physical therapy session. Randomized control trails were carried out in Railway general hospital from February 2018 to July 2018 in which 43 patients with Low back pain were randomly divided by lottery method into control and experimental group. Single session of treatment was given. tools used in the study are visual analog scale, Oswestry disability index and lumber range of motion. data was analysed through SPSS (statistical package for social sciences) 21.

Detailed Description
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Human spine is a supporting structure of skeleton consisting of four curves cervical (lordosis), thoracic (kyphosis) , lumbar(lordosis) and sacrococcygeal (kyphosis). Cervical and lumbar being primary contributes for erect posture. Lumbar spine (lordotic curve) is the area of lower back of spine consisting of five vertebrae L1-L5 extending between thoracic and sacrum to accommodate progressively increasing loads.it is connected to pelvis where most weight bearing and body movement takes place. Over the last few decades, low-back pain has become increasingly problematic, placing significant burdens on economy and health system.the 2019 Global burden of Disease study estimated that low back pain is among the top ten diseases. low back pain is common that only a minority of individuals escape it. Eighty percent of anatomical and degenerative changes cause pain in lower back area .low back pain is extremely common having complex causes, may be acute sub-acute or chronic in nature depending upon severity of onset cause. Large forces acts on lumbar spine during functional activities such as lifting, running, walking and twisting causes repetitive micro traumas leading to low back pain which is distressing feelings.low back pain can be dull ache, shooting pain or burning sensation in nature originating from neuro-vascular, vertebral bones,facet joints or other vertebral structures. Low back pain which begin under 12th rib and on top of the inferior gluteal lines involving one or both lower extremities is called radiating low back pain which can be due to any internal derangement in anatomical structures of vertebral column. Internal derangement is disturbance of the regular order or arrangement of joint in which normal resting position of the articular surfaces of two adjacent vertebrae is disturbed as a result of a change in the position of fluid mechanics of disc, joint structure, ligaments, vascular and neuro-muscular system of lumbar spine due to mechanical or non mechanical stresses.Clinically lumbar internal derangement syndromes are .classified into mechanical and non mechanical based on origin internal derangement is disturbance of the regular order or arrangement of joint in which normal resting position of articular surfaces of two adjacent vertebrae is disturbed as a result of a change in position of fluid mechanics of disc, joint structures, ligaments, vascular and neuro-muscular system of lumbar spine due to mechanical or non mechanical stresses. Clinically lumbar internal derangement syndrome are classified into mechanical and non mechanical based on origin.Non mechanical internal derangement syndromes are due to non activity related disorders affecting spine such as inflammatory diseases (septic and hematological), tumors and infiltration lesions, metabolic disorders and acquired defects in neural arch whereas mechanical derangements are caused by placing abnormal stress on lower back disrupting normal order of lumbar spine anatomy. Physiotherapy treatments for low back pain includes myofascial release trigger point release, stretching of culprit muscles(hamstrings, lumbar erector spinae ,multifidus and piriformis), mobilization of vertebrae, traction of lumbar spine and Manipulation of lumbar spine (cyriax Manipulations, Osteopathic Manipulations and Chiropractor Manipulations). Manipulations is passive movements carried out by clinician with single thrust high velocity, low amplitude or sustained pressure not under control of patient in order to return displacement to its proper position.Manipulations are used to reduce pain and disability caused by any internal derangement and intervertebral cartilaginous structure. Manipulations are based on different theories of which reduction of disc protrusions, correction of posterior joint dysfunction, mobilization of blocked vertebral joints and reduction of nerve root compression are some of them. In 2012 John J Kuczynski conducted a systematic review on effectiveness of spinal manipulation therapy for treatment of chronic low back pain literature extracted from different data base concluded that spinal manipulations are safe and have significant clinical outcomes. A study published on 17th May 2018 on spinal manipulation in treatment of patient with MRI diagnosed lumbar disc herniation and sacroiliac hypermobility by Esmael Shokri et al concluded that lumbar and Sacro-iliac joint manipulations have significant effect on pain potential and disability. In March 2006 Muhammad A. Mohseni Bandpelet conducted randomized control trial study on spinal manipulation and ultrasound therapy in treatment of chronic low back pain. One hundred and twenty people were randomly allocated into manipulative group and ultrasound therapy group.They concluded that patient who received manipulative therapy showed greater decrease in pain intensity with increased spinal range of motions and functional qualities.

Official Title
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Cyriax Manipulation in Lumbar Internal Derangement Syndrome

Conditions
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Derangement; Low Back

Intervention / Treatment
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* Other: conventional physical therapy
* Other: cyriax lumber manipulation group


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: lumber pain, pain radiating to leg, motor deficits in legs, , dural signs and symptoms, impaired nerve root mobility(straight leg raise and L3 stretch), back pain effecting Quality of life, ODI score less than 30 and Limited range of motion . Exclusion Criteria: Osteoporosis of hip, Bilateral sciatica, having anticoagulant medication, pregnancy, patient with impaired mental status

Ages Eligible for Study
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Minimum Age: 30 Years
Maximum Age: 50 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: interventional
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: conventional physical therapy<br>Myofacial release Stretching of hamstring and Piriformis | Other: conventional physical therapy<br>* hot pack for 15 minutes Myofacial release (10 minutes) and Stretching of hamstrings and Piriformis (5 reps each with 2 second hold)<br>|
| Experimental: cyriax lumber manipulation group<br>Myofacial Release stretching of hamstrings and Piriformis Cyriax Lumbar Manipulation Techniques | Other: cyriax lumber manipulation group<br>* Hot Pack, Myofacial Release, stretching of hamstrings and Piriformis (five reps each with 2 seconds hold) and Cyriax Lumbar Manipulation Techniques<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Owstery disability index | ODI is self-reported tool used widely for measurement of functional disability related to. It was introduced by Fairbank et al in 1980 which gives guidelines for measuring functional disability due to LBP and considered gold standard. It is divided into 10 sections i.e. pain, personal care, sitting, walking, standing, travelling, weight lifting, sleeping, social life. Patient is guided to select one option according to their symptoms. Total score is 50.Once the individual score is calculated Percentage can be calculated by dividing it with total score i.e. 50 and then multiply it by 100.) In This study scores are calculated by filling the questionnaire before session and then filling it after two or three days after | 3rd day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| visual analog sclae | Visual Analogue Scale is an instrument used for measurement of characteristics that are in continuum manner and cannot be directly measured e.g. pain .it is simple and most widely used measurement for pain variations VAS is a horizontal line of 100 mm. Patient is asked to mark a point of their current status .it has 5-point description nil Mild' moderate severe and very severe | 1st day after session | 
| range of motion lumber spine (flexion) | changes from baseline lumber flexion range of motion was taken by the help of goniometer | 1st day after session | 
| range of motion lumber spine (extension) | changes from baseline lumber range of motion was taken by the help of goniometer | 1st day after session | 
| range of motion lumber spine (right side bending) | changes from baseline lumber range of motion was taken by the help of goniometer | 1st day after session | 
| range of motion lumber spine (left side bending) | changes from baseline lumber range of motion was taken by the help of goniometer | 1st day after session | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Conventional physical therapy(CPT), .Low back pain (LBP),, Oswestery disability index (ODI),, Quality of life (QOL),, Range of motion (ROM), Visual analogue scale (VAS)