Effects of Bilateral Asymmetrical Limbs Proprioceptive Neuromuscular Facilitation on Multifidus Muscle in CLBP.
Effects of Bilateral Asymmetrical Limbs Proprioceptive Neuromuscular Facilitation on Multifidus Muscle in CLBP.
The low back pain is a leading cause to limit individual functional activities worldwide and
 60%-80% of adults are probable to get low back pain at least once in life time. Whereas, the
 chronic low back pain prevalence is 10%.The current literature suggests that any exercise is
 beneficial for reducing chronic nonspecific low back pain. This limits evidence regarding
 superiority of specific exercise for low back pain treatment. Therefore, a randomized control
 trial will be conducted at department of physiotherapy to assess which treatment is more
 effective in chronic low back pain at department of physiotherapy, institute of physical
 medicine and rehabilitation, Dow University of Health Sciences after synopsis approval.
 Overall 150 participants with 18-40 years old having chronic low back pain will be eligible
 and they will be included through non-probability, purposive sampling technique. The written
 informed consent will be taken from all the participants. They will be divided through
 systematic random sampling method into two groups, 75 in each group. Group A (experimental
 group) will receive Bilateral, asymmetrical limbs PNF pattern exercises and group B (control
 group) will receive Swiss ball exercises. All participants will be assessed using assessment
 form. Pain and functional disability will be measured by subjective outcome tools, visual
 analogue scale with 0-10cm and Oswestry disability index , respectively. Range of movement of
 lumbar and multifidus muscle activity will be measured by objective outcome tool,
 modified-modified Schober's test and surface electromyography, respectively. The pre & post
 treatment outcomes will be collected and recorded. Treatment sessions will be given thrice a
 week for 5 weeks. A maximum drop-out rate of 20% is expected. The Mean ± SD will be
 calculated for quantitative variables and frequencies and percentages for qualitative
 variables. The recorded outcome variables before and after the five weeks of treatment will
 be compared and analysed. The p-value of 0.05 will be considered as level of significant.
Globally, Low back pain (LBP) is the commonest musculoskeletal pain, for which participants
 consult general practitioners. It is defined as "pain and discomfort, localized below the
 costal margin and above the inferior gluteal fold, with or without referred leg pain". The
 LBP with specific causes are rare (<15%). Whereas, majority (>80%) of LBP cases are
 non-specific LBP (NSLBP). The traditional temporal categorization comprises as acute LBP (<6
 weeks), sub-acute LBP (≤12 weeks) or chronic LBP (>12 weeks). It is based on the duration of
 the current episode. The LBP is experienced in 60% to 80% of adults at some point in
 lifetime. There is 15% annual worldwide incidence rate of LBP and 30% point prevalence. LBP
 is one of the five leading causes of YLDS that contributes 57•6 million. The estimation
 suggests 5% to 10% of LBP cases will develop chronic. This chronicity is responsible for high
 treatment expenses, sick leave, and different sufferings.

 The evidence based guidelines for LBP diagnosis suggest to first rule out any underlying
 pathology (spinal infection, cancer and fracture of spine and cauda equina syndrome). The LBP
 without any specific pathology is labelled as NSLBP. The routine use of radiologic imaging is
 not warranted based on clinical guidelines until presence of specific pathology. The goal of
 LBP treatment includes pain relief, function improvement, reduced work leave of absence, and
 chronicity prevention. The analgesics (topic or oral), exercise, manual therapy, traction,
 transcutaneous electrical nerve stimulation (TENS), back supports, acupuncture, biofeedback,
 spinal injections, and lastly, surgery may include in treatment options.Among exercise
 interventions the proprioceptive neuromuscular facilitation (PNF) exercise approach is
 designed to stimulate proprioceptors in order to enhance neuromuscular mechanism responses.
 The extremity patterns of PNF have diagonal direction with combination of movements, and
 these patterns are performed in line with the topographic arrangement of the muscles being
 used. Therefore, these exercises are thought to be suitable for muscles training
 anatomical-plane or anatomical-direction training programs. Moreover, PNF often have been
 used to improve the range of movement (ROM) and endurance. Various techniques of PNF training
 are used like rhythmic initiation, rhythmic stabilization, reversal of agonists, and reversal
 of antagonists.

 In the existing literature there is little direction with mixed evidence to physiotherapists
 that what intervention is more beneficial to apply for CLPB. According to author's knowledge,
 the base to rely on PNF techniques needs evidence related to PNF patterns specification, that
 which lower limb PNF pattern is more effective. A randomized clinical trial will be conducted
 to explore the effects of bilateral, asymmetrical lower limb PNF patterns in flexion and in
 extension on multifidus in CLBP to evaluate and stabilize evidence based physical therapy
 practice in Pakistan.

 Objectives:

 1. To explore the effects of limbs PNF pattern exercises and Swiss ball exercises on
 multifidus motor activity, lumbar ROM, pain and functional disability in CLBP.

 2. To determine the frequencies and statistical association of age, gender, body mass index
 (BMI) and occupation among participants in CLBP.

 3. To determine the statistical association among multifidus motor activity, lumbar ROM,
 pain and functional disability of participants with CLBP before and after the exercise
 treatment.

 4. T determine the effects of bilateral, asymmetrical limbs PNF pattern exercises and Swiss
 ball exercises in participants with CLBP

 5. To compare the effects of bilateral, asymmetrical limbs PNF pattern exercises and Swiss
 ball exercises in participants with CLBP

 Hypothesis:

 1. Null hypothesis: There is no difference between effects of bilateral asymmetrical limbs
 proprioceptive neuromuscular facilitation and Swiss ball exercises on multifidus muscle
 in chronic low back pain.

 2. Alternate Hypothesis: The effects of bilateral asymmetrical limbs proprioceptive
 neuromuscular facilitations are more beneficial than Swiss ball exercises on multifidus
 muscle in chronic low back pain.

 Methodology:

 Research design: The research design will be randomize control trial (RCT), experimental
 study.

 Sampling technique: Non probability purposive sampling technique will be used. Sample size:
 Initially, a sample size of 54 human subjects was calculated through open epi software with
 95% Confidence Interval and 80% power of test with post-test VAS mean (2.1) and standard
 deviation (0.85), in experimental group and post-test VAS mean (1.5) and standard deviation
 (0.69) in control group. Due to small sample size, it is increased to 150 with drop rate of
 20%. The 75 participants per group will be considered.

 Place of the study:

 Physiotherapy department, Institute of physical medicine and rehabilitation (IPM&R), Dow
 University of Health Sciences (DUHS), Chand Bibi road, Karachi, Pakistan.

 Data collection procedure:

 After taking consent, the objectives of study will be told to all participants.The
 participants will be randomly allocated into two groups. All the participants will be
 assessed with outcome measures before after 5 weeks of intervention.

 Interventions protocol: (half hour session, thrice a week for 5 weeks). Group A (experimental
 group) will receive, PNF rhythmic initiation with bilateral asymmetrical upper and lower limb
 pattern,

 -  The participant in supine position (on the back) with left arm in
 extension-adduction-internal rotation with right hand gripping his left wrist with right
 arm in modified extension-abduction-internal rotation. Neck will be in flexion looking
 at left hand.

 -  Therapist distal hand (hand away from head of the participant) will grip wrist of
 participant's left hand and the proximal hand (hand near to head of the participant)
 will be on top of the participant's head with fingers pointing towards the left side of
 participant neck.

 -  Participant will be asked to lift left arms and push the head back through the pattern
 of flexion -abduction-external rotation and neck in extension to the left in opposition
 of therapist hand resistance. At the end range of motion extensor muscles of back will
 start to contract.

 -  Then, participant will be asked to reverse the movement pattern to
 extension-adduction-internal rotation and neck flexion to right against the therapist
 resisting hands.

 -  It will be repeated on other side of participant.

 -  Then for lower limbs, participant's left leg will be in extension-abduction-internal
 rotation and right leg in extension-adduction-external rotation.

 -  Therapist will grasp the lateral and dorsal surfaces of both feet with distal hand.
 Proximal arm will be placed underneath the participant's thighs to hold them together.

 -  Then participant will be asked to lift both feet up, bend legs up and away towards right
 shoulder against therapist resistance.

 -  The right leg will go into flexion-abduction-internal rotation, the left leg into
 flexion-adduction-external rotation. At the end of range, the motion continues as lower
 trunk flexion with rotation and side-bending to the right.

 -  After that, participant will asked to reverse the left leg into
 extension-abduction-internal rotation and right leg in extension-adduction-external
 rotation against resistance. At end of range, the motion will carry on as trunk
 extension and elongation to the left with left rotation and side trunk flexion.

 -  It will be repeated on other side of participant.

 -  10 repetition and 3 sets for each side, 20 second rest between two sets.

 Group B (control group) will receive Swiss ball exercises :

 1. Supine position: A ball will be placed under participant neck, and will be asked to bend
 hip and knee up to 90°. 5 times, 10 seconds hold

 2. Supine position: With a ball below the pelvis, knees bent, the ball press will be done
 with pelvis. 5 times, for 10 seconds hold.

 3. Crawling position: With a ball below one knee while keeping toes away from contact with
 the floor, the participant will balance first to stabilize the posture and slowly raise
 the other lower limb. This exercise will be performed in turn for the two lower limbs 10
 times, with 10 seconds hold.

 4. Prone position: Participant will place a ball in front of pelvis and will repeatedly
 raise and lowered the two lower limbs alternately. There will be 10 repetitions, with 5
 sets, taking 15 seconds rest between each set.

 Data analysis:

 The Statistical package for the social sciences 21 version will be used for data analyzing.
 The mean and standard deviation will be calculated for quantitative variables like age. The
 qualitative variables will be shown through calculated frequencies and percentages. The
 outcome results of the study (decrease pain intensity, improve functional disability, improve
 range of movement and improve multifidus activity) taken before and after the treatment will
 be compared and analysed. The p-value of 0.05 will be considered as level of significant.
Inclusion Criteria:

 -  Chronic Low back pain (pain for > 3 month)

 Exclusion Criteria:

 -  Any history related to spinal surgery

 -  Previous administration of epidural injections.

 -  Low Back Pain due to specific pathology,

 -  Neurological deficits (like stroke)

 -  Clinical disorder contraindicated to exercise.