6 Brief resume of the intended work:

6.1 Need for the study

Low back pain (sometimes referred to generally as lumbago) is a common musculoskeletal disorder
causing back pain in the lumbar vertebrae. 1 Disability associated with low back pain (LBP) continues
to rise, contributing to a substantial economic burden that exceeds nearly 50 billion dollar annually in
the United States alone.2Low back pain is a symptom that affects 80% of the general United States
population at some point in life with sufficient severity to cause absence from work.

Non radicular low back pain is localized pain where the patient will feel soreness or discomfort when
an individual palpates, or presses on, a specific surface area of the lower back.

Physical therapists utilize a wide range of interventions in the management of LBP; however,
evidence for the effectiveness of these interventions is limited .8Given that LBP is a heterogeneous
condition, it does not seem reasonable to expect that all patients will benefit from a single treatment
approach. Rather, the key is to identify subgroups of patients with a high probability of achieving a
successful outcome with a particular intervention.

Evidence suggests that short and longer term outcomes are improved when a classification-based
approach is used compared to decision-making based on clinical practice guidelines .9To date,
evidence for several subgroups of LBP exist, such as patients likely to benefit from manipulation,
lumbar stabilization , and specific directional exercise.10,11,12

Mulligan manual therapy treatment techniques are frequently used in clinical practice. 3In spite of its
popularity, the efficacy of the Mulligan Concept has not been adequately established by clinical trials.
Konstantinou et al reported that 41% of physical therapist treated low back pain using mulligan
technique. The efficiency of the mulligan concept has not been adequately established by clinical
trials.4The intention of this technique is to restore normal mobility and reduce LBP and physical
impairment.5
The Mulligan bent leg raise (BLR) technique has been described as a means of improving range of
straight leg raise (SLR) in subjects with LBP and/or referred thigh pain and is used to restore normal
mobility and reduce LBP and physical impairment.3

Maitland described the slump test it has been used as an assessment tool for the identification of
possible altered neurodynamics and more recently Butler has suggested slump as an treatment tool.6,7
George recently described the outcomes in a subgroup of 6 patients hypothesized to respond
favourably to slump stretching.
Treatment was limited to those whose symptoms did not worsen or improve with lumbar flexion and
extension movements and who exhibited a positive slump test in the absence of radicular signs.
Although favorable outcomes were reported, the design of this study being a case series precludes
establishing a cause and effect relationship.

Therefore, the purpose of this study was to determine whether slump stretching is beneficial for the
subgroup of patients hypothesized to benefit from this form of treatment. They hypothesized that
patients who received slump stretching plus lumbar spine mobilization and exercise would experience
greater improvements in disability, pain, and centralization of symptoms than patients who received
lumbar spine mobilization and exercise only.13

Studies have shown that Mulligan bent leg raise (BLR) technique is useful in improving range of
straight leg raise (SLR) in subjects with LBP and thus mobilize the painful, sensitized, nerve tissues.
The intention of this technique is to restore normal mobility and reduce LBP and physical impairment.

Studies have also shown that slump stretching is beneficial for improving short-term disability, pain,
and centralization of symptoms. Few studies have been done to compare the effects of mulligan bent
leg raise and slump stretching on non radicular LBP. The aim of this study is to compare the
effectiveness of slump stretching and mulligan bent leg raise in patients with LBP.

Hypothesis :
Null hypothesis: There will no significant difference between slump stretching and mulligan bent
leg raise in management of non radicular low back pain.
Experimental hypothesis: There will be significant difference between slump stretching and
mulligan bent leg raise in non radicular low back pain.

6.2 Review of Literature:

Boonstra, Anne M. , Reneman, Michiel F. , Posthumus, Jitze B. , Stewart, Roy E. , Schiphorst
Preuper, Henrica R. (2008) conducted a study to determine the reliability and concurrent validity of
a visual analogue scale (VAS) for disability as a single-item instrument measuring disability in
chronic pain patients. For the reliability study a test-retest design and for the validity study a cross-
sectional design was used. 52 patients in the reliability study, 344 patients in the validity study were
selected. They concluded that the reliability of the VAS for disability is moderate to good. Because of
a weak correlation with other disability instruments and a strong correlation with the VAS
for pain, however, its validity is questionable.14

Bishop M,George S Z, Mc Nally A, Robinson M (2006) -investigated the effect of slump treatment
in healthy females and concluded that pain response from the slump stretching the was not different
from the sham technique so the neurodynamic intervention technique do not appear to affect pain
perception as measured using Psychophysical technique differently from sham techniques in healthy
subject.16
Joshua A Cleland,John D Childs, Jessica A Palmer, Sarah Eberhart. (2006)- done a clinical trial
stating that patient with non radicular |LBP may be benefited ,from slump Stretching along with
exercises, in the form of reducing short term disability, improving pain and promoting centralization
of symptoms in sub groups of patients.18

Toby hall, Sonja hardt, Axel Schafer, Lena wallin.. (2006) conducted a study to determine the
effects over 24 h, on range of motion and pain, of a single intervention of Mulligans bent leg raise
(BLR) technique in subjects with limited straight leg raise (SLR) and low back pain (LBP). 24
fulfilled inclusion criteria of unilateral SLR limitation and LBP. All subjects were randomly allocated
to either a BLR (n = 12) or placebo group (n = 12). Range of SLR was measured by an assessor blind
to group allocation, prior to, immediately following, and 24 h after the intervention.the result showed
an increase in the range by 7 in the BLR group, which may be clinically important.15

George SZ (2002) conducted a prospective case series to determine the characteristics of patients
with lower extremity symptoms treated with slump stretching. Out of 88 consecutive patients with
low back diagnoses or low-back-related diagnoses, 6 met the study's inclusion criteria and were
treated with slump stretching At the discharge session of physical therapy, 5 of 6 patients had
symptoms that were more proximally located and all patients reported a decrease in symptom
intensity.13

Kornberg C, McCarthy T (1992) conducted a study to examine the effect of slump stretch on
sympathetic outflow to the lower limbs using telethermography. The study was done on 10 normal,
elite track and field athletes. Temperature readings were taken using telethermographic imaging at
four locations before and after stretching, on both stretched and unstretched lower limbs. Results
indicated that a significant cutaneous vasodilator effect occurred in the stretched limb as evidenced by
 increased skin temperature, while the unstretched control limb showed a slight decrement in

temperatures (p < 0.001). The findings indicate that slump stretch has a sympathetic inhibitory effect.
This effect could be the underlying physiological mechanism for the therapeutic effect of slump
stretch in grade one hamstring strains.19

Kornberg and Lew (1989) conducted a comparative study of treatment methods was performed in a
group of professional Australian Rules football players diagnosed as having grade I hamstring
injuries, who demonstrated positive responses to the slump test (a neural tension test). Of 28 subjects
selected, 16 were treated traditionally, with the remaining 12 receiving slump stretch as an addition to
the treatment regime. Results indicated that traditional treatment plus slump stretch technique was
more effective (p < 0.001) in returning the player to full function than the traditional regime alone.17

6.3 Objectives of the study:

To compare the effects of slump stretching and bent leg raise technique with non radicular low back
pain

7 Materials and Methods:

7.1 Source of Data
1) Padmashree physiotherapy clinic, Nagarbhavi, Bangalore.
2) ESI Hospital, Rajajinagar, Bangalore.
3) K C General Hospital, Malleshwaram, Bangalore.

7.2 Method of collection of data:

Population :- subjects with low back pain
Sample design :- Simple random sampling
Sample size :- 30
Type of Study :- Experimental study
Duration of the study : 3 weeks
Inclusion Criteria:
Subjects with a chief complaint of LBP having age between 18 and 60 years.
Reproduction of patient symptoms with slump testing showing no radicular sign.
Subjects with no change in symptoms with lumbar flexion or extension and baseline oswestry
Score greater than 10%.
Exclusion Criteria:
Subjects with serious spinal conditions like infections, tumors, osteoporosis and spinal
fracture etc.
Subjects having pregnancy, have history of spinal surgery, positive neurological sign or
symptoms suggestive of nerve root involvement (Diminished upper or lower extremity
reflexes, sensation to sharp and dull, or strength).
Subjects with osteoporosis.
Subjects exhibited a straight leg raise (SLR) test of less than 45 degree.

Material used:
Couch
Paper
Pen

Measuring tools:
Visual Analogue Scale (VAS).
Modified Oswestry disability index (ODI).

Methodology
7.3 Intervention to be conducted on the participants:
Subjects who meet the inclusion criteria will be assigned to two groups based on simple
random sampling.
Group I In this group slump stretching will be performed with the patient in long sitting
position with feet against the wall to assure the ankle remain in neutral position. Hand will be
kept behind. The therapist will apply over pressure onto cervical spine flexion to the point
where the patients symptoms will reproduce, the position will be held for 30 seconds. Total of
 5 repetitions will be completed.

Group II- The BLR technique will consist of three repetitions of pain-free, 5 s, isometric
contraction of the hamstrings, performed in five progressively greater positions of hip flexion.
Along with the exercises consisted of pelvic tilts bridging wall squats, quadruped alternate
arm/leg activities will be given to both groups.
Intervention in both groups be given Exercycle warm-up followed by two sets of 10 repetition
of each exercises followed by either slump stretching or mulligan bent leg raise method of
mobilization.
Interventions are given for twice a week for three weeks.
At the completion of six physical therapy sessions outcome measures will be reevaluated and
pre and post scores are compared.

Outcome measures:
Visual Analogue Scale (VAS).
Modified Oswestry disability index (ODI).

Statistics:
Statistical analysis will be performed by using SPSS software for window (version 14) and p-
value will be set as 0.05.
Descriptive statistics will be used to analyze the baseline data for demographic and outcome
data.
Willcoxon signed rank test will be used to measure the ordinal scale within the group.
Mann-Whitney test will be used to measure the ordinal scale between the groups.

7.4 Ethical Clearance:-

As this study involve human subjects, the ethical clearance has been obtained from the ethical
committee of Padmashree institute of physiotherapy, Nagarbhavi, Bangalore, as per ethical
guidelines research from biomedical research on human subjects, 2000, ICMR, New Delhi.
8 List of References:
1. Van der Roer N, van Tulder M, Barendse J, Knol D, van Mechelen W, de Vet H.Intensive
group training protocol versus guideline physiotherapy for patients with chronic low back
pain: a randomised controlled trial. Eur Spine J. 2008 Sep;17(9):1193-200.

2. Luo X, Pietrobon R,Sun SX, Liu GG,Hey L. estimates and patterns of direct health care
Expenditure among individuals with back pain in United States. Spine 2004;29;79-86.

3. Mulligan BR. Other spinal therapies. In: Manual therapy: nags,snags, mwms etc.
4th. Wellington: Plane View Services; 1999.p. 6886.

4. Konstantinou K, Foster N, Rushton A, Baxter D. The use and reported effects of mobilization
with movement techniques in low back pain management: a cross-sectional descriptive survey
of physiotherapists in Britain. Manual Therapy 2002;7(4):20614.

5. American Physical Therapy Association. Guide to Physical Therapy practice. 2nd ed. Physical
Therapy 2001; 81(1): 746.

6. Maitland G. The slump test: examination and treatment. The Australian Journal of
Physiotherapy 1985;31:2159.

7. Butler DS. The sensitive nervous system. Adelaide: Noigroup Publications; 2000. p. 256310
[chapters 1011].

8. Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected

rehabilitation interventions for low backpain. Physical Therapy 2001;81:164174.

9. Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with
therapy based on clinical practice guidelines for patients with acute low back pain: a
randomized clinical trial. Spine 2003;28:136371.

10. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Butler B, RendeiroD, Garber M, Allison S.
A clinical prediction rule for classifying patients with low back pain who demonstrate short
 term improvement with spinal manipulation. Spine 2002;27:283543.

11. OSullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise
in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine 1997;22:295967.

12. Long AL, Donelson R, Fung T. Does it matter which exercise? Spine 2004;29:2593602.

13. George SZ. Characteristics of patients with lower extremity symptoms treated with slump
stretching: a case series. Journal of Orthopaedic and Sports Physical Therapy 2002;32:3918.

14. Boonstra, Anne M. , Reneman, Michiel F. , Posthumus, Jitze B. , Stewart, Roy E. , Schiphorst
Preuper, Henrica R. Reliability of the Life Satisfaction Questionnaire to assess patients with
chronic musculoskeletal pain 2008; International Journal of Rehabilitation Research:Volume
31(2);181-183.

15. Toby hall, Sonja hardt, Axel Schafer, Lena wallin. mulligan bent leg raise technique a
Preliminary randomized trial of immediate effects after a single intervention,2006. Manual
Therapy 11 (2006) 130-135.

16. Bishop M, George SZ,Mc Nally A, Robinson M. Effect of neurodynamic intervention on Pain
perception, A Randomized single blind trial. The Journal of Manual and Manipulative Therapy
2006 page 170.

17. Kornberg and Lew 1989. The effect of stretching neural structures on grade one hamstring
injuries. J Orthop Sports Phys Ther. 1989; 10(12):481-7.

18. Joshua A Cleland,John D Childs, Jessica A Palmer, Sarah Eberhart. Slump stretching in the
management of non-radicular low back pain: A pilot clinical trial, Manual Therapy 11 (2006)
279286.

19. Kornberg C, McCarthy T. The effect of neural stretching technique on sympathetic outflow to
the lower limbs. J Orthop Sports Phys Ther 1992;16(6):269-274