CHAPTER 1

INTRODUCTION

1
 INTRODUCTION

Low back pain is a major health and socioeconomic problem, and is a leading

cause of disability. Acute low back pain that lasts up to 3 months is the commonest

presentation and is frequently associated with reduced mobility of both the lumbar

spine and hips with consequential functional impairment. The low back pain victims

who go on to develop chronic symptoms also show deficits in reaction time,

coordination, and postural control1.

Low back pain is a prevalent and costly health concern with various etiologies.

Approximately 90% of adults will suffer from an episode of low back pain at some

time in their lives, 50% will have a recurrent episode and 5–10% will develop chronic

and potentially disabling low back pain. Mechanical low back pain is one of the

common causes of low back pain; however, there is no clear consensus on the best

treatment for this condition. Conservative treatment may include manipulation,

myofascial release, exercise, modalities, and a number of other treatment options.

Conservative treatment often includes flexibility exercises, especially of the

hamstrings. Many clinicians support this practice based on the theory that normal

hamstring length will prevent excessive lumbar flexion during postures that place the

hamstrings in a lengthened position such as forward bending. McGill has shown that

increased lumbar flexion during forward bending tasks increases anterior shearing

forces on the spine and increases risk of injury. Thus, if decreased hamstring

flexibility leads to increased lumbar flexion during forward bending tasks it may

increase the risk of injury to the spine from mechanical stresses 2. Epidemiological

studies provide important information regarding various risk factors of low back pain,

viz. age and sex, body composition, occupation, lifestyle and socio-economic status3.

2
 Low back pain may be related to patterns of lumbar postures and movements

used to perform different tasks, but it is unclear which patterns with which tasks

contribute to low back pain. For example, increases in both lumbar flexion and

extension have been linked to low back pain. Some studies have reported increased

lumbar flexion in people with low back pain during activities involving flexion, such

as golfing and cycling. Other studies have reported that increased lumbar extension is

associated with low back pain during sitting4.

Changes in body alignment (static posture) and alteration of movement

sequencing (dynamic posture) are considered to be common risk factors for low back

pain. Alteration in movement patterns could lead to excessive loading of lumbar

tissues predisposing the subject to LBP. Alteration in the sequencing of hip and

lumbar spine movement patterns during forward bending has been proposed as a risk

factor for the development of LBP. Changes in lumbar motion range and motion

velocity have been noted in individuals with LBP, and reduced hip mobility during

forward bending has also been shown. LBP subjects demonstrate a decreased

magnitude of hip flexion, but not other hip motions implying that an alteration in

activity level of the hamstrings may be present in symptomatic subjects. Alteration in

stretch tolerance rather than stiffness of the hamstrings has been shown to determine

this range of motion change in nonspecific low back pain subjects5.

The postural or mechanical disturbances are the most common cause of low

back pain. Certain postural and mobility characteristics may be related to the presence

or absence of low back pain. Clinicians commonly try to correct these postural and

movement faults by prescribing therapeutic exercise. Stretching of the hamstring

muscles appears to be commonly used and advocated. The alteration of the normal

relationship among the alignment of the spine, the position of the pelvis, and the

3
length of the muscles attaching to the spine and pelvis contributes to the development

of low back pain. Kendall and McCreary in 1983, argued that individuals with "flat"

backs (reduced lumbar curvature) while standing tend to have short hamstring

muscles. They presumed that short hamstring muscles rotate the pelvis posteriorly,

resulting in a concurrent reduction of lumbar lordosis. They suggested stretching the

short hamstring muscles to correct the faulty alignment. Toppenberg and Bullock

examined the interrelationships of spinal curves, pelvic tilt, and muscle lengths

(abdominal, erector spinae, iliopsoas, gluteal, rectus femoris, and hamstring muscles)

in asymptomatic female subjects. Although they found no relationship between pelvic

tilt and lumbar curvature, longer abdominal muscles and shorter erector spinae

muscles were associated with an increased lumbar curve. Of the lower- extremity

muscle groups studied, only the length of the hamstring muscles was related to the

lumbar curve, and it was negatively related (ie, shorter hamstring muscles were

associated with a greater degree of lumbar lordosis)6.

Hamstrings tightness is one of the most common findings in patients with low

back pain5,6,7 and it has been argued that lengthening the hamstrings may allow greater

motion to occur at the hips and therefore reduce stress on the lumbar spine 6. It is

thought that, due to the attachments of hamstrings to the ischial tuberosity, hamstrings

tightness generates posterior pelvic tilt and decreases lumbar lordosis, which can

result in low back pain7. Day et al, also demonstrated a correlation between changes

in the pelvic tilt and the lumbar curve 8. By lengthening and stretching the lumbar

spine, disc compression can be reduced, resulting in a change in pelvic tilt which has

been suggested to influence hamstring flexibility. Research has shown that inflexible

hamstring muscles limit anterior tilt of the pelvis during trunk flexion, and this

limitation can result in increased lumbar muscle and ligamentous tension, producing

4
considerably greater compressive stress on the lumbar spine 9. There is an accepted

relationship between low back pain and flexibility of the hamstrings 10 Van

Wingerden et al, suggested that hamstrings tightness in patients with low back pain is

a compensatory mechanism secondary to pelvic instability7,11.

Short hamstring muscles are often reported in patients with low back pain 11. In

low back pain subjects hamstring flexibility is reduced and greater electrical activity

in the hamstring muscles is seen5. The cause of such muscular tightness, however, has

not been fully understood. Some have attributed hamstring tightness in patients with

low back pain as a compensatory mechanism for controlling the excess lumbar

lordosis induced by specific patterns of muscle impairments known as ‘pelvic cross

syndrome’11.

Changing the direction of locomotion from normal forward progression to

backward is done rather readily by all people. In order to change the direction from

forward locomotion to backward, the pattern of muscle activation has to be changed

to produce a reversal of leg movement and propulsion in backward direction. Walking

backward means reversing leg movement trajectories. When walking backward, the

leg not only reverses its direction of movement but it travels in the opposite direction

along virtually the same path as in walking forward. Walking backward is nearly a

mirror image or time-reversed copy of walking forward. Winter, Plauck and Yang , in

an investigation of similarities and differences in forward and backward walking,

found that backward walking was 95% reversal of forward walking12.

Backward walking is an activity that results in joint kinematic patterns

different from those experienced during forward walking. An important difference is

the pre stretch of the hamstrings that occurs in backward walking prior to thigh

reversal due to greater hip flexion and lesser extension. Reduced flexibility and

5
limited motion of the low back is often a result in individuals who experience low

back pain, thus limiting function. This observation supports the conjecture that

hamstring flexibility and perhaps low back flexibility may increase when walking

backward, positing this form of exercise as a possible means to reduce tightness in the

hamstrings and as a mechanism to reduce low back pain for persons experiencing this

condition. This study also suggests that backward walking may positively influence

hamstring flexibility10.

The results of one of the preliminary study suggest that backward walking

may positively influence hamstring flexibility. There is an accepted relationship

between low back pain and flexibility of the hamstrings and it has been conjectured

that an increase in the flexibility of the hamstrings could possibly decrease low back

pain. This study presents preliminary information suggesting that a 3-week program

of backward walking may provide an appropriate stimulus to increase flexibility of

the hamstrings. So research is required to ascertain whether backward walking

intervention can also serve as a means to reduce low back pain10.

Hamstrings tightness is one of the most common findings in patients with low

back pain and by backward walking hamstring flexibility is increased. In this context

it is needed to check whether the backward walking reduces mechanical low back

pain in patients with tight hamstrings in terms of pain and disability.

6
 AIMS AND OBJECTIVES

Need of the Study

The need of this study was to investigate the effectiveness of a backward

walking exercise program in alleviating Non-specific low back pain and hamstring

tightness so as to decrease the level of disability.

Clinical Significance

The prevalence of low back pain among patients with hamstring tightness is

relatively high. So from the hypothesis the backward walking may be the tool for the

clinicians to treat the patients of low back pain with hamstring tightness.

HYPOTHESIS

Experimental Hypothesis

There may be significantly decrease in low back pain in patients with

hamstring tight by backward walking intervention.

Null Hypothesis

There may not be significantly decrease in low back pain in patients with

hamstring tight by backward walking intervention.

STATEMENT OF QUESTION

Does backward walking have a positive effect low back pain and disability on

patients with LBP and hamstring tightness?

7
 OPERATIONAL DEFINITION

BACKWARD WALKING: Walking backward means reversing leg

movement trajectories. When walking backward, the leg not only reverses its

direction of movement but it travels in the opposite direction along virtually the same

path as in walking forward.

NON-SPECIFIC LOW BACK PAIN: Non-specific low back pain is defined as

low back pain not attributable to a recognisable, known specific pathology (eg,

infection, tumour, osteoporosis, fracture, structural deformity, inflammatory disorder,

radicular syndrome, or cauda equina syndrome).

8
 CHAPTER 2

REVIEW OF LITERATURE

9
 NON-SPECIFIC LOW BACK PAIN

Low back pain (LBP) continues to be one of the most common and

challenging problems in primary care, stated by Hans Heneweer et al 2011113. They

added that Substantial costs are associated with LBP including lost productivity and

income from work, the expense of medical, rehabilitation and surgical interventions

and the costs of disabling pain and limited daily function. Safoora Ebadi et al 201214.

Stated that Low Back Pain is a major cause of morbidity in high, middle and low

income countries and affects 80-85% of people over their life time. According to

Adriane Vieira et al 201215. In industrialized societies, low back pain affects

approximately 70% to 80% of the adult population at some moment in their lives and

is considered one of the most common reasons for early retirement by total or partial

disability. According to Roy La Touche et al 200816. Chronic low back pain is the

most common cause for frequent absenteeism at work in the less than 45-years old

adult population. Michael J Schneider et al 2010 17. In their study said that Back pain

is the most common cause of disability for persons under the age of 45 and the second

most common reason for office visits to primary care physicians. Benedict M. Wand

et al 200818. In his study said that Low back pain (LBP) is a substantial health

problem.

Daniele Tatiane Lizier et al 2012 19. Defined LBP as pain localized below the

margin of the last ribs (costal margin) and above the inferior gluteal lines, with or

without lower limb pain. LBP may be classified as mechanical, non-mechanical, and

psychogenic. Mechanical LBP may be specific or nonspecific. Nonspecific Low Back

Pain is characterized by the absence of structural change; that is, there is no disc space

reduction, nerve root compression, bone or joint injuries, marked scoliosis or lordosis

10
that may lead to back pain29. Only 10% of LBP has a specific cause due to a particular

disease. The incidence of nonspecific LBP is higher in workers subjected to heavy

physical exertion, such as weight lifting, repetitive movements, and frequent static

postures19. Alexander Ruhe et al 201220, stated that increased postural sway is well

documented in patients suffering from non-specific low back pain, whereby a linear

relationship between higher pain intensities and increasing postural sway has been

described and concluded that Alterations in self-reported pain intensities are closely

related to changes in postural sway. Daniele Tatiane Lizier et al 201219. Added that at

some point in life, between 15% and 20% of adults have LBA. Most cases (90%) are

non-specific and occur in all age groups. According to Adriane Vieira et al 201215. It

is known that nonspecific low back pain can develop due to an unfavourable mechani-

cal-postural condition, with an imbalance between the effort required in daily life

activities and work activities and the capacity to perform such tasks. Alexander Ruhe

et al 201121. In their study concluded that Patients with non-specific LBP exhibit

greater postural instability than healthy controls. This difference is more pronounced

under visual obstruction and can be attributed to either acute pain inhibition or

diminished proprioceptive input from the lumbar spine and trunk muscles due to long

term neurological adaptations. Francisco M Kovacs et al 200322. Depicted that the

diagnosis sometimes imply that the syndrome is not related to underlying disorders,

such as fractures, spondylitis, direct trauma, or systemic processes. Luciana G

Macedo et al 200923. In his study depicted that Motor control exercise is superior to

minimal intervention and confers benefit when added to another therapy for pain in

patients with non specific low back pain.

11
 CLASSIFICATION OF LOW BACK PAIN SYNDROMES

It can be classified according to S. Brent Brotzman et al. Clinical Orthopaedic

Rehabilitation, 2nd Edition. Mosby: 199624.

Mechanical or Activity-related Causes

 Segmental and discal degeneration

 Myofascial or soft tissue injury/disorder/strain

 Disc herniation with possible radiculopathy

 Spinal instability with possible spondylolisthesis or fracture

 Vertebral body fracture

 Spinal canal or lateral recess stenosis

 Arachnoiditis, including postoperative scarring

 Spondylosis

 Facet syndrome

 Degenerative joint disease of spine

Systemic Disorders

 Primary or metastatic neoplasm, including myeloma

 Osseous, discal, or epidural infection

 Inflammatory spondyloarthropathy

 Metabolic bone disease, including osteoporosis

 Vascular disorders such as atherosclerosis or vasculitis.

12
Neurologic Syndromes

 Myelopathy from intrinsic or extrinsic processes

 Lumbosacral plexopathy, especially from diabetes

 Neuropathy, including inflammatory demyelinating type

(e.g., Guillain-Barre)

 Mononeuropathy, including causalgia

 Myopathy, including myositis and metabolic causes

Referred Pain or Psychogenic Etiology

 Gastrointestinal disorders

 Genitourinary disorders, including nephrolithiasis, prostatitis,

and pyelonephritis

 Gynecologic disorders, including ectopic pregnancy and

 pelvic inflammatory disease

 Abdominal aortic aneurysm

 Hip pathology

 Psychosocial causes

 Compensable injury

 Somatoform pain disorder

 Psychiatric syndromes, including delusional pain

 Drug seeking43.

13
 CLINICAL FEATURES OF LOW BACK PAIN (MECHANICAL)

These features are shown by Nicholas A. Boon. Davidson’s Principle & Practice of

Medicine, 20th Edition. Churchill Livingstone: 200625.

 Pain varies with physical activity (improved with rest).

 Sudden onset, precipitated by lifting or bending.

 Recurrent episodes.

 Pain limited to back or upper leg.

 No clear-cut nerve root distribution.

 Systemically well.

MANAGEMENT OF NON-SPECIFIC LOW BACK PAIN

Karla Escalante et al 200815. Their study says that pilates method can be used

in improving general functions and in reducing pain in treating non-specific chronic

low back pain.

Amanda J P Hutchinson et al 201226. Provided a systematic review of

literature in support of acupuncture and its effectiveness over other treatment

modalities in patients with chronic low back pain.

Daniele Tatiane Lizier et al, 201219. Concluded that therapeutic exercises are

probably the most widely used conservative treatment. Exercise standardization, as

well as duration, frequency and time of evaluation are necessary to reduce the risk of

14
misinterpretation in determining the most appropriate modality for a given population

affected by non-specific low back pain.

Annika Hauggaard and Ann L. Persson 200727. The result of their study

suggested that a programme of lumbar stabilization exercises can be effective in

improving quality of life and functional outcome in patients with chronic non-specific

low back pain.

Hye Jin Moon et al 201328. Both lumbar stabilization and dynamic

strengthening exercise strengthened the lumbar extensors and reduces non-specific

low back pain. However, the lumbar stabilization exercises was more effective in

lumbar extensor strengthening and functional improvement in patients with non-

specific chronic low back pain.

Niketa G. Patel et al 201229. Core stability exercises with swiss ball and core

stability exercises without swiss ball are effective in reducing pain and functional

disability in chronic non-specific low back pain.

15
 BACKWARD WALKING

Backward walking means a reversal of leg movement trajectories. During

backward walking leg not only reverse its direction of movements but it travels in the

opposite direction along virtually the same path as in forward walking, reversal is

accomplished by modification of normal motor program to a varying degree

depending on which joint is involved12.

The phases of backward gait cycle are initial contact (instant of toe switch

contact until heel switches contact), midstance (heel and toe switches contact until

instant of only heel switches contact), heel-off (from heel only contact until no switch

contact) and midswing (period during maximal knee flexion)30.

Backward walking stance begins with toe strike and ends at heel off whereas

forward walking stance begins with heel strike and ends at toe off 31.

Troy L. Hooper et al; 2004 studied the effects of forward walking (FW) and

backward walking (BW) on heart rate (HR) and oxygen consumption (VO2) at

treadmill grades of 5%, 7.5%, and 10%. Twenty-nine volunteers participated in this

study. VO2 and HR were measured using open-circuit calorimetry and

electrocardiogram, respectively. For both forward and backward walking, subjects

performed each of the 3 grades for 6 minutes, during which HR and VO2 were

measured and resulted that Percent maximum heart rate (HRmax) and percent

maximum oxygen consumption (VO2max) increased incrementally for treadmill

grades of 5% to 7.5% to 10% for both FW and BW (P < .00001). For each of the 3

treadmill grades, percent HRmax and percent VO2max was 17% to 20% higher for BW

than for FW (P < .00001). No statistically significant interactions were detected

16
between direction of walking and treadmill grade. They Concluded that backward

walking on a treadmill at 67.0 m/min (2.5 mph) and grades of 5%, 7.5%, and 10%

elicits a greater percent HRmax and percent VO2max than does forward walking

under the same conditions and, if incorporated into sustained training regimens,

would be expected to improve aerobic endurance32.

Timothy W. Flynn, et al. (1994) indicated that during backward walking,

VO2 and heart rate were 70% and 46% greater than during matched speed forward

walking respectively. This can benefit for the higher level of athlete interested in

alternative training method modalities to his/her activity specific training routine or

for the recreational athlete or individual interested in burning more calories in lesser

time50.

Edward C. Chaloupka, et al; 1997 studied the cardio respiratory and

metabolic stress of backward walking compared with forward walking. The

metabolic cost of backward incline walking above a 1 % grade has previously not

been reported. Seventeen volunteers (11 males and six females, age = 25±2 years)

underwent a forward maximal running test and four random-ordered 6-minute sub

maximal walking bouts at 93.8 m/min (3.5 mph). The bouts consisted of forward

walking at 0% and 5% elevation and backward walking at 0% and 5% elevation.

Measurements taken for each exercise session were oxygen uptake, expired

ventilation, heart rate, and ratings of perceived exertion. Statistical analysis of these

dependent variables indicates that: 1) at a given elevation, backward walking elicited

greater cardiorespiratory, metabolic, and perceptual responses than forward walking

and 2) backward walking at 5% elevation could provide a sufficient stimulus to

maintain cardio respiratory fitness33.

17
 Glen Myatt, et al; 1995 studied the Cardiopulmonary Cost of Backward

Walking at Selected Speeds. The primary purpose of this study was to determine the

relationship between the rate of oxygen consumption (VO 2) and backward walking

speed. Twenty-five healthy males, aged 18-35 years, participated in this study. The

rate of oxygen consumption and heart rate were measured at the backward walking

speeds of 0.89, 1.12, 1.34, 1.56, and 1.79 m/sec (2.0, 2.5, 3.0, 3.5, and 4.0 miles/hour,

respectively). Analysis revealed a direct, curvilinear relationship between VO2, and

backward walking speed. This research provides information that can be used to

prescribe a backward walking rehabilitation program which may be appropriate to

maintain aerobic fitness levels during rehabilitation of patients with patellofemoral

pain syndrome34.

Chet R. Whitley and Janet S. Dufek; 2011 studied the effects of Backward

Walking on Hamstring Flexibility and Low Back Range of Motion and suggested that

a 4-week intervention of backward walking appears to provide an appropriate

stimulus for an increase in flexibility of the hamstrings. A possible interaction

between backward walking velocity and sagittal plane ROM or coronal plane ROM

limited the interpretation of observed non-significant changes in low back motion9.

Janet Dufek, et al.; 2011 studied the Backward Walking: A Possible Active

Exercise for Low Back Pain Reduction and Enhanced Function in Athletes. His

results support backward walking to reduce pain and increase low back range of

motion for athletes with low back pain. Single-subject evaluation provides insight into

mechanistic changes elicited by the intervention for specific individuals with low

back pain, including an increase in stride length possibly accompanied by an increase

in sagittal plane ROM35.

18
 T. R. Nanda Kumar & Muddasir Ashraf; 2009 studied the effect of

backward walking treadmill training on kinematics of the trunk and lower limbs and

revealed that decrease in the angles for the hip and the knee and an increase in the

angle for the ankle joint after backward walking treadmill training. The decrease in

the ankle angle before backward walking treadmill training could have been due to

the gastrocnemius, a two-joint muscle, which, while acting on the knee to produce

more knee flexion, would show an active insufficiency at the ankle joint thus causing

a sharper ankle angle. Therefore, an increase in the ankle angle shown after backward

walking treadmill training was caused by less knee flexion allowing the

gastrocnemius to act more on the ankle joint and concluded that decrease in the hip

and knee angles and an increase in the ankle angle after 2 weeks of backward walking

treadmill training. The study has shown a variance in kinematics after backward

walking treadmill training due to the habituation process. Hence, designing a training

or rehabilitation protocols should be based on the values of post-training kinematic

analysis of backward walking12.

Wei-Ya Hao and Yan Chen Hao; 2011 studied the effects of backward

walking on balance in boys. Six control and six experimental boys participated in a

study comparing kinematics of lower limbs between forward walking and backward

walking after the training (week-12). They suggested that the balance of experimental

group was better than that of control group after 8 weeks of training (P < 0.01), and

was still better than that of control group (P < 0.05), when the backward walking

training program had finished for 12 weeks. The kinematic analysis indicated that

there was no difference between control and experimental groups in the kinematics of

both forward walking and backward walking gaits after the backward walking

training (P > 0.05). Compared to forward walking, the of stance phase of backward

19
walking tended to be longer, while the swing phase, stride length, walking speed, and

moving ranges of the thigh, calf and foot of backward walking decreased (P < 0.01).

They concluded that backward walking training in school-aged boys can improve

balance36.

Kenji Masumoto, et al.; 2005 studied to examine whether walking backward

in water and walking backward on dry land elicit different electromyographic (EMG)

activities in lower-extremity and trunk muscles. Surface EMG was used to evaluate

muscle activities while six healthy subjects walked backward in water (with and

without a water current) immersed to the level of the xiphoid process, and while they

walked backward on dry land and they revealed that % maximal voluntary

contractions from the muscles tested while walking backward in water (both with and

without a current) were all significantly lower than those obtained while walking

backward on dry land (P<0.05), with the exception of the paraspinal muscles but in

the case of the paraspinal muscles, the % maximal voluntary contractions while

walking backward with a water current was significantly greater than when walking

backward on dry land, or walking backward without a water current. Furthermore,

when walking backward in water, the % maximal voluntary contractions from the

muscles investigated were significantly greater in the presence of a water current than

without (P<0.05). They concluded that walking backward in water with a current

elicits the greatest muscle activation of the paraspinal muscles. These data may help

in the development of water-based exercise programs37.

R. R. Neptune, et al; 2000 studied Muscle contributions to specific

biomechanical functions do not change in forward versus backward pedaling and

observed that the muscles contributed to the same primary biomechanical functions in

both pedaling directions and that synergistic performance of certain functions

20
electively accelerated the crank. The gluteus maximus worked synergistically with the

soleus, the hip flexors worked synergistically with the tibialis anterior, and the vasti

and hamstrings functioned independently to accelerate the crank. The rectus femoris

used complex biomechanical mechanisms including negative muscle work to

accelerate the crank. The negative muscle work was used to transfer energy generated

elsewhere (primarily from other muscles) to the pedal reaction force in order to

accelerate the crank. Consistent with experimental data, a phase shift was required

from those muscles contributing to the Ant/Post functions as a result of the different

limb kinematics between forward and backward pedaling, although they performed

the same biomechanical function. The pedaling simulations proved necessary to

interpret the experimental data and identify motor control mechanisms used to

accomplish specific motor tasks, as the mechanisms were often complex and not

always intuitively obvious38.

Lena H. Ting, et al; 1999 studied Phase reversal of biomechanical functions

and muscle activity in backward pedaling and concluded that the phasing of only the

Ant and Post biomechanical functions are directionally sensitive. Further, they

suggest that task dependent modulation of the expression of the functions in the motor

output provides this biomechanics-based neural control scheme with the capability to

execute a variety of lower limb tasks, including walking39.

Franceska Zampeli, et al; 2010 examine the stride-to-stride variability of

anterior cruciate ligament deficient patients during backward walking. The variation

of how a motor behaviour emerges in time is best captured by tools derived from

nonlinear dynamics, for which the temporal sequence in a series of values is the facet

of interest. Fifteen patients with unilateral anterior cruciate ligament deficiency and

eleven healthy controls walked backwards at their self-selected speed on a treadmill

21
while three-dimensional knee kinematics was collected (100 Hz). A nonlinear

measure, the largest Lyapunov Exponent was calculated from the resulted knee joint

flexion–extension data of both groups to assess the stride-to-stride variability. Both

knees of the deficient patients exhibited significantly lower Lyapunov Exponent

values as compared to the healthy control group revealing more rigid movement

pattern. The intact knee of the deficient patients showed significantly lower Lyapunov

Exponent values as compared to the deficient knee. Interpretation: Anterior cruciate

ligament (ACL) deficiency leads to loss of optimal variability regardless of the

walking direction (forwards in previous studies or backwards here) as compared to

healthy individuals. This could imply diminished functional responsiveness to the

environmental demands for both knees of ACL deficient patients which could result in

the knees being more susceptible to injury40.

Cyril Schneider and Charles Capaday; 2003 studied the Progressive

adaptation of the soleus H-reflex with daily training at walking backward and

observed that during the swing phase of backward walking the soleus is inactive and

its antagonist, the tibialis anterior, is active. They suggested that the high amplitude of

the soleus H-reflex in late swing reflects task uncertainties, such as estimating the

moment of foot contact with the ground and losing balance. In support of this idea

they show that when untrained subjects held on to handrails the unexpected high-

amplitude H-reflex during midswing was no longer present. They therefore asked

whether daily training at this task without grasping the handrails would adaptively

modify the H-reflex modulation pattern. However, when adapted subjects were made

to walk backward with their eyes shut, the anticipatory reflex activity in midswing

returned immediately. The reflex changes as a result of training were not due to

changes in the motor activity or kinematics; they are likely part of the motor program

22
controlling backward walking. This adaptive phenomenon may prove to be a useful

model for studying the neural mechanisms of motor learning and adaptive plasticity in

humans and may be relevant to rehabilitation programs for neurological patients41.

HAMSTRING MUSCLE

Lack of hamstring flexibility has been associated with low back pain, postural

deviations, gait limitations, risk of falling and susceptibility to musculoskeletal

injuries 42. Hamstrings tightness is one of the most common findings in patients with

low back pain and it has been argued that lengthening the hamstrings may allow

greater motion to occur at the hips and therefore reduce stress on the lumbar spine 5,6.

It is thought that, due to the attachments of hamstrings to the ischial tuberosity,

hamstrings tightness generates posterior pelvic tilt and decreases lumbar lordosis,

which can result in low back pain7.

Reduced hamstring muscle flexibility has been implicated in lumbar spine

dysfunction, with a number of studies showing a strong positive correlation between

decreased hamstring flexibility and low back pain

Phalen GS and Dickson JA; 1961 studied the spondylolisthesis and tight

hamstrings in which he concluded that there is an accepted relationship between low

back pain and flexibility of the hamstrings10.

Jan P.K. et al; 2001 studied the extensibility and stiffness of the hamstrings in

patients with nonspecific low back pain (LBP). Forty subjects, a patient group (20)

and a healthy control group (20). Subjects laid supine on an examination table with a

lift frame, with left leg placed in a sling at the ankle. Straight leg raising, pulling force

and activity of hamstring and back muscles were recorded with electrodes. Patients
23
indicated when they experienced tension or pain and they concluded that the restricted

ROM and the decreased extensibility of the hamstrings in patients with non-specific

low back pain is not caused by increased muscle stiffness of the hamstrings, but

determined by the stretch tolerance of the patients43.

Mohammad Reza Nourbakhsh, Amir Massoud Arab; 2002 studied the

relationship between mechanical factors and incidence of low back pain and

concluded that among all the factors tested, endurance of the back extensor muscles

had the highest association with low back pain. Other factors such as the length of the

back extensor muscles, and the strength of the hip flexor, hip adductor, and abdominal

muscles also had a significant association with low back pain. Further, they concluded

that muscle endurance and weakness are associated with low back pain and that

structural factors such as the size of the lumbar lordosis, pelvic tilt, leg length

discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles are not

associated with the occurrence of low back pain7.

B Dadebo, et al; 2004 studied the relation between current flexibility training

protocols, including stretching, and hamstring strain rates (HSRs) in English

professional football clubs and observed that flexibility training protocols were

characterised by wide variability, with static stretching the most popular stretching

technique used. Hamstring strains represented 11% of all injuries and one third of all

muscle strains. About 14% of hamstring strains were reinjuries. HSRs were highest in

the Premiership (13.3 (9.4)/1000 hours) with the lowest rates in Division 2 (7.8

(2.9)/1000 hours); values are mean (SD). Most (97%) hamstring strains were grade I

and II, two thirds of which occurred late during training/matches. Forwards were

injured most often. Use of the standard stretching protocol (SSP) was the only factor

significantly related to HSR (r = 2 0.45, p = 0.031) in the correlation analysis,

24
suggesting that the more SSP is used, the lower the HSR. They concluded that

Flexibility training protocols in the professional clubs were variable and appeared to

depend on staffing expertise. Hamstring stretching was the most important training

factor associated with HSR. The use of SSP, STE, and SHT are probably involved in a

complex synergism which may reduce hamstring strains. Modification of current

training patterns, especially stretching protocols, may reduce HSRs in professional

footballers44.

D Hopper, et al; 2005 studied the effect of dynamic soft tissue mobilisation

(STM) on hamstring flexibility in healthy male subjects. Forty five males volunteered

to participate in a randomised, controlled single blind design study. Volunteers were

randomised to either control, classic STM, or dynamic STM intervention. The control

group was positioned prone for 5 min. The classic STM group received standard STM

techniques performed in a neutral prone position for 5 min. The dynamic STM group

received all elements of classic STM followed by distal to proximal longitudinal

strokes performed during passive, active, and eccentric loading of the hamstring. Only

specific areas of tissue tightness were treated during the dynamic phase. Hamstring

flexibility was quantified as hip flexion angle (HFA) which was the difference

between the total range of straight leg raise and the range of pelvic rotation. Pre- and

post-testing was conducted for the subjects in each group. Increase in hamstring

flexibility was significantly greater in the dynamic STM group than either the control

or classic STM groups with mean (standard deviation) increase in degrees in the HFA

measures of 4.7 (4.8), 2 0.04 (4.8), and 1.3 (3.8), respectively45.

25
 ENDURANCE EXERCISES FOR LOW BACK PAIN

Poor muscle function is often credited as a risk factor for low back pain

(LBP). Although research has not yet established a definitive relationship between

muscular strength of the spine and LBP but , it has been estimated that more than

80% of all LBP cases are caused by weak trunk muscles, as opposed to structural

disorders. Numerous studies have suggested that improved strength and endurance of

the trunk musculature will aid in the prevention and treatment of low back pain. These

findings have focused attention on programs designed to increase the strength and

mobility of the lumbar spine46.

Mary T Moffroid, et al; 1993 studied the effects of an endurance exercise

protocol on the isometric holding time of the trunk extensor muscles (mechanical

fatigue measure) and on the recorded median frequency (MF) measurements from

the surface electromyogram (physiologic fatigue measure). Twenty-eight healthy

female volunteers were selected to participate in the study. The subjects were

stratified by activity level and then assigned to an exercise or a control group and

tested at weeks 0,3, and 6 Reliability (r) of the measurements, established by testing

each subject twice at week 0, was .87 Exercise group subjects trained at home twice

daily for 6 weeks, progressing by established protocol. They resulted the exercise

group subjects increased their isometric holding time by 22% after 6 weeks. The

control group showed no significant changes. They concluded that the home program

26
was believed to be effective for increasing isometric endurance of the trunk extensors,

measured by holding time. The MF measurements prior to and just after a fatiguing

contraction remained stable over time. The change in the slope of the MF with fatigue

did not reach statistical significance. This physiologic measure of fatigue did not

show commensurate changes with training in this group of subjects47.

David M Carpenter, et al; 1991 studied the effect of varied training

frequencies on the development of isometric lumbar extension torque (strength) over

12- and 20-week training periods. Fifty-six subjects were randomly assigned to

training once each other week (training group I, n =lo), once per week (training

group 2, n = 12), twice per week (training group 3, n = 12), or three times per week

(training group 4, n = 7) or to a nontraining control group (n =15). Training

consisted of one set of 8 to 12 variable-resistance lumbar extensions to volitional

muscular fatigue. All training groups showed significant increases in lumbar

extension torque at 12 and 20 weeks of training, whereas no significant differences

were found among the groups with respect to the magnitude of torque gained. These

findings show that isometric lumbar extension torque increases occur mainly within

the first 12 weeks of training, although additional gains in the more extended

positions can be accepted when training is continued through 20 weeks46.

Markku Kankaanpaa, et al; 1998 studied to compare lumbar paraspinal

and gluteus maximus muscle fatigability between chronic low back pain patients and

healthy controls by using electromyographic (EMG) spectral analysis during a

maximal isometric endurance. Twenty women with nonspecific chronic low back pain

(longer than 3 months) and 15 healthy controls. Subjects performed maximal

voluntary isometric back extensions (MVC) at 30° forward flexion in a specially

designed measurement unit. A 50% MVC load was used in isometric endurance test.

27
Low back pain intensity was assessed by using the visual analogue scale and

functional disability by the Oswestry disability index. Time to endurance was

measured. They resulted that Pain intensity and functional disability were higher and

MVC and time to endurance were lower in the chronic low back pain group (p < .05).

Similar muscle activity levels (average EMG%) and initial spectral median

frequency (MFinit) indicated similar muscle loading in both groups at the

beginning of the endurance test. EMG spectral decreases (MF slope) indicated that

lumbar paraspinal muscle fatigability was similar in both groups. In the chronic low

back pain group, the gluteus maximus fatigued faster than in the control group

(greater MFslope, p < .05). However, the shorter endurance time indicated greater

fatigability in the chronic low back pain group in general (p < .05). They concluded

that the chronic low back pain patients were weaker and fatigued faster than the

healthy controls. The EMG fatigue analysis results suggest that the gluteus maximus

muscles are more fatigable in chronic low back pain patients than in healthy control

subjects during a sustained back extension endurance test48.

Stewart Bruce-Low; 2012 studied the one lumbar extension training session

per week is sufficient for strength gains and reductions in pain in patients with chronic

low back pain ergonomics. This study investigated training frequency for participants

with CLBP. Participants either trained once a week (1 × week, n = 31), or twice a

week (2 × week, n = 20) or did not (control group, n = 21). Participants were

isometric strength tested in weeks 1 and 12 and trained dynamically either 1 x week

(80% of maximum) or 2 × week (80% and 50%). The results (pre vs. post) showed

significant increases in maximal strength, range of motion and reductions in pain for

both training groups. Pain scores for the 1 × week and 2 × week both reached minimal

clinical improvement change unlike the control group. Thus, one lumbar extension

28
training session per week is sufficient for strength gains and reductions in pain in low

back pain in CLBP patients49.

CHAPTER 3

METHODOLOGY

29
 SAMPLE

A total number of 30 subjects participated in the study. The subjects were

recruited from Outpatient department of Dolphin (PG) Institute Of Biomedical and

Natural Sciences, Dehradun, O.P.D of Jankalayan, Sakya hospital and Dolphin Health

Centers in Dehradun, and various Health Centers and Rehabilitation Clinics in and

around Dehradun.

TYPE OF SAMPLING

 Convenient sampling.

STUDY DESIGN

 Experimental Case Control Pre Test Post Test Design

INCLUSION CRITERIA

1. Age:-18 - 30 years

2. Chronic mechanical low back pain

3. Positive sign of hamstring tightness by using Sit and Reach test

4. Positive sign of hamstring tightness by using Active Knee Extension Test

EXCLUSION CRITERIA

1. Acute lower extremity injuries (e.g. Rupture of tendons, Fractures,

Ligament injury)

30
2. Previous hamstring injuries (e.g. Strain, Rupture)

3. Back surgery or hip arthroplasty

4. Spondylolisthesis

5. Disc prolapsed

6. Spinal or pelvic fracture

7. Systemic disease, such as arthritis or tuberculosis

8. Neurological diseases (e.g. Motor Neurone Disease, Polyneuropathy)

9. Limb length discrepancy

10. Abnormal Gait

INSTRUMENTATION FOR DATA COLLECTION

1. One- meter plastic tape.

2. Paper.

3. Couch

4. Treadmill

5. Skin marker

6. Inclinometer.

OUTCOME MEASURES

1. VAS scale

2. Oswestry Low Back Pain Disability Questionnaire

3. Sit and Reach test

4. Tape Method Measurement of Lumbar Range of Motion

5. Active Knee Extension Test

31
Figure 3.1: Skin Marker & One Meter Inch Tape

32
Figure 3.2: Couch

33
 Figure 3.3: Treadmill

Figure 3.4: Inclinometer

PROTOCOL

Total 30 Subjects selected on the bases of inclusion and exclusion criteria.

Pre Assessment for

VAS, LROM, ANE, OLBPDI

and STR

15 Subjects 15 Subjects

Intervention Intervention
Backward Walking, Hot Pack Hot Pack and Low Back
and Low Back Isometrics Isometrics

Post Assessment for

34
VAS, LROM, ANET,
OLBPDI and STR
 Analysis of
data

RESULT

PROCEDURE

On the bases of inclusion and exclusion criteria subjects were selected. A

written consent form was signed by the subjects after explaining the procedure and

utility of the study was explained to them. Thirty volunteers 20–45 years of age with

history of low back pain were recruited for the study. The first 30 subjects who fulfil

inclusion criteria were taken into consideration. These 30 subjects were divided into

two groups by chit method of 15 each. The first group of 15 subjects was

experimental group and the second of 15 subjects was controlled group. The

experimental protocol was verbally explained and discussed prior to participation.

Pre intervention readings were taken for disability of low back, lumbar range

of motion, pain, sit and reach test and active knee extension test for hamstring

tightness

The treatment protocol consisted of backward walking, hot pack and lumbar

extension endurance exercises. The first group of 15 subjects (experimental group)

35
was treated with backward walking, hot pack and lumbar extension endurance

exercises and the second group of 15 subjects (control group) was treated with hot

pack and lumbar extension endurance exercises only.

Post intervention readings were taken in the same manner after the end of

three weeks.

PRE INTERVENTION READINGS

1. All the subjects were assessed by Oswestry Low Back Pain Disability Index for

the level of disability.

2. All the subjects were assessed by Visual Analog Scale for the level of pain.

3. All the subjects were measured by one meter plastic tape for lumbar range of

motion.

4. All the subjects were measured by one meter plastic tape for lumbar and

hamstring flexibility with the help of Sit and Reach Test.

5. All the subjects were measured by Active Knee Extention Test for the hamstring

flexibility with the help of Inclinometer.

Measurement of Disability

1. General LBP related disability was assessed with the Oswestry Disability Index.

36
2. The Oswestry Disability Index (also known as the Oswestry Low Back Pain

Disability Questionnaire) is an extremely important tool that researchers and

disability evaluators use to measure a patient's permanent functional disability.

The test is considered the ‘gold standard’ of low back functional outcome tools.

3. There were ten sections and six questions in each section.

4. In each section only one box was chosen for the statement which best applies to

patient.

5. For each section the total possible score is 5, if the first statement is marked, the

section score = 0; if the last statement is marked, it = 5 51.

Measurement of Pain

1. The visual analog scale (VAS) is a tool widely used to measure pain. A patient is

asked to indicate his/her perceived pain intensity (most commonly) along a 100

mm horizontal line, and this rating is then measured from the left edge and is more

reliable (p > 0.5)

2. The visual analog scale (VAS) has marking from 0 to 10. The 0 indicate no pain, 5

indicate moderate pain and 10 indicate maximum pain 52, 53.

Measurement of Hamstring Flexibility and Lumbar Spine

1. The sit-and-reach test (SRT) or a modified version of the SRT is a field tests

typically used to evaluate flexibility of the low back and hamstring muscles.

2. The YMCA Sit and Reach Test were performed to measure low back and

hamstring flexibility.

37
3. This test was administered following YMCA recommended procedures.

4. Specifically, a measuring tape was placed on the floor and a line placed

perpendicular to the tape at 45 cm, establishing a consistent reference for all

participants.

5. With shoes off, the participant sat on the floor and aligned their heels to this line.

6. Placing one hand on top of the other, instructions were given to keep hands on the

measuring tape and slowly bend forward, keeping the back straight.

7. To maintain consistency in measurement among participants, the same

investigator performed each sit-and-reach measurement.

8. The greatest displacement value over three repetitions of the test was retained for

analysis, per YMCA recommended procedures.

9. During execution of this test, shoulder motion was visually assessed to minimize

scapular protraction, and any trials which exhibited shoulder protraction to

improve the reach score were discarded 9, 54, 55.

Measurement of Hamstring Flexibility

1. The Active Knee Extension (AKE) test is an active test, the final position being

dependent on the tension developed by the subject’s quadriceps muscles and the

end point of the available joint motion. This is therefore arguably safer as the end

point is dictated by the users themselves.

2. The AKE test is often used to measure hamstring tightness as part of orthopedic

physical assessment, with normal values of knee motion to within 20 0 of full

extension being quoted.

3. The test has been recommended as an alternative to the Straight Leg Raising

(SLR) test for providing an indication of hamstring muscle length.

38
4. Each subject was positioned supine on an examination table, and the lower

extremity not being measured was maintained flat on the table.

5. With assistance from the subject, the hip was flexed 90 degrees (the angle was

confirmed with a universal goniometer). The subject actively held the position

with the knee relaxed in flexion and the ankle in plantar flexion.

6. This hip position was maintained while an inclinometer was placed on the leg 5

cm below the inferior border of the patella in line with the tibia. The subject then

slowly and actively extended the leg while maintaining the thigh at 90. The range

of restricted extension in the knee joint was measured by reading the inclinometer

(ie, total knee extension was recorded as 0 0). The AKE test was repeated two more

times, and these three measurements were averaged. The resulting mean AKE

angle was used to reflect hamstring muscle length.

7. Active knee extension stretched the hamstring muscles until these muscles

contracted to prevent further lengthening. Because of simultaneous effort to

continue knee extension, a temporary myoclonus of alternating contraction and

relaxation of the quadricep femoris and hamstring muscle groups occurred.

8. At this time, the subject was instructed not to force the leg past the point of initial,

mild resistance.

9. The subject was then told to slightly flex the knee until myoclonus stopped.

10. At the first point of no shaking, the degree reading of knee flexion was observed

and recorded. The angle of knee flexion represented the point of hamstring

tightness. Although each subject reported a stretch sensation and resistance when

myoclonus was initiated, these were not reported at the end point of motion.

11. During the instruction session we found that when the knee was extended and

forced past the end point of motion, the thigh naturally moved into slight

39
 extension. Therefore, during data collection each subject was instructed to

maintain the hip in 900 of flexion and not to move the hip joint to prevent this

unwanted movement.

12. This test was done for both the legs 56, 57.

Measurement of Lumbar Range of Motion

All the subjects entered an examination room, removed their shoes, and

disrobed, exposing their backs from the gluteal fold to the mid thoracic spine. All

subjects were instructed to stand erect with their eyes directed horizontally, their arms

at their sides, and their feet placed on a set of paper footprints that were secured to the

floor (the heels of the footprints were about 15 cm apart).

The Modified-Modified Schober Flexion Technique

1. The examiner knelt behind the standing subject and identified the PSISs by

marking the inferior margins of the subject's PSISs with his or her thumbs.

2. An ink mark was drawn along the midline of the lumbar spines horizontal to the

PSISs.

3. Another ink mark was made 15 cm above the original mark.

4. The tape measure was then lined up between the skin markings.

5. With the tape measure pressed firmly against the subject's skin and while holding

the tape measure with his or her fingertips, the therapist instructed the subject to

bend forward.

6. When the subject bent forward into full lumbar flexion, the new distance between

the superior and inferior skin markings was measured.

40
7. The distance between these marks after trunk flexion was measured, and the

change in the difference between the marks was used to indicate the amount of

lumbar flexion.

8. The therapist recorded measurements to the nearest 1 mm, the difference in the

initial length between skin markings (15 cm) and the length measured in forward

lumbar flexion.

9. After each measurement, all skin marks were removed with rubbing alcohol.

The Modified-Modified SchoberExtension Technique

1. The same landmarks and procedures described for the MMS flexion technique

were used for measuring lumbar extension.

2. With the subject in the erect standing position, the therapist lined up the tape

measure between the markings.

3. While holding the tape measure placed firmly against the subject's skin, the

therapist instructed the subject to place the palms of the hands on the buttocks and

to bend backward.

4. When the subject bent backward into full lumbar extension (Fig. 5), the new

distance between the superior and inferior skin markings was measured.

5. The distance between these marks after trunk extension was measured using the

tape measure, and the change in the difference between the marks was used to

indicate the amount of lumbar extension.

41
6. The therapist recorded measurements to the nearest 1 mm, the difference in the

initial length between skin markings (15 cm) and the length measured in forward

lumbar extension.

7. All skin marks were removed with rubbing alcohol 58, 59, 60.

INTERVENTION

The treatment protocol consisted of backward walking, hot pack and lumbar

extension endurance exercises. The first group of 15 subjects experimental group was

treated with backward walking, hot pack and lumbar extension endurance exercises

and the second group of 15 subjects- control group was treated with hot pack and

lumbar extension endurance exercises only

GROUP (A) – Experimental Group

The first group of 15 subjects’ experimental group was treated with backward

walking, hot pack and lumbar extension endurance exercises.

A motorized treadmill (Jogger 2.75HP /Fit line/ KMT-006) was used in the

study. The treadmill was initially set at the horizontal level. The subjects who were

unfamiliar with backward treadmill locomotion were habituated prior to the first

42
testing session by walking backward on the treadmill for a period of 15 min. The

velocity was established by communicating with the subject. During the training

session, subjects walked backward on the treadmill at a constant speed of 1.33 m/sec

(comfortable speed for adults). However, the subjects were advised to walk at

comfortable speed or at higher speed as per their comfort level on daily basis. But all

participants had to continue their required level of activity and not to modify the

activities. The participants were blinded to the treadmill speed, as they were facing

away from the treadmill consol. The selected walking velocity were recorded.

Following the pretest, participants needed to complete 3 weeks of backward walking

on a treadmill for 10-15 min per day (3 days per week) 7, 12.

The lumbar extension endurance exercises involved one set of approximately

25 repetitions. Repetitions performed slowly, the subjects could hold a given position

for 10 seconds and 3-second rest between efforts, they progressed themselves to the

next position. These extension exercises were carried out 3 days per week for three

weeks 47.

The hot pack was given for 10 – 15 minutes at a temperature of 45 degree 61.

GROUP (B) – Control Group

The second group of 15 subjects control group was treated with hot pack and

lumbar extension endurance exercise as was applied for experimental group.

43
 CHAPTER 4

DATA ANALYSIS

44
 Data analysis was done using SPSS 16.0 version.

 Descriptive analysis was done to calculate the mean for age and height of subjects.

 Paired t-test was applied to compare the pre and post intervention readings of pain, disability,

Sit and Reach Test, Active Knee Extension Test of both right and left knee, lumbar range of

motion of both flexion and extension within the group.

 Independent t-test was done to compare the pre and post intervention readings of pain,

disability, Sit and Reach Test, Active Knee Extension Test of both right and left knee, and

lumbar range of motion of both flexion and extension between the groups.

 The statistical significance was set at 95% confidence interval with p value < 0.05 was

considered significant.

45
CHAPTER 5

RESULTS

46
 The data was analysed for 30 subjects and were categorized into two groups–

Group A and Group B. Descriptive statistics was used to analyze demographic data.

Mean age and height for Group A was 22.6±1.919 (yrs) and 162.4±6.344 (cm)

respectively. For Group B mean age was 22.933±2.374 (yrs) and mean height was

162.13±4.501 (cm). [Table 5.1].

MEAN SD
GROUP GROUP GROUP GROUP
t p
A B A B
AGE 22.6 22.933 1.91982 2.37447 -.423 .676
HT 162.4 162.13 6.34485 4.50185 .133 .895

Table 5.1: Descriptive Analysis of the Demographic Data

47
 DEMOGRAPHIC DATA
180
160
140
120
GROUP A
100 GROUP B
80 162.4 162.13
60
40
20
22.6 22.93
0
AGE HEIGHT

Figure 5.1: Demographic Data

The pain was evaluated by VAS scores. The scores were compared within the

groups by using paired t-test. The result showed significant difference between pre

and post intervention readings for Group A and Group B (p=0.000 & p=0.000

respectively). [Table 5.2]

MEAN SD
t p
PRE POST PRE POST
GROUP
9.272 .000
A
6.2667 2.1333 1.33452 1.35576
GROUP
7.549 .000
B
6.4667 4.2 1.35576 1.14642

Table 5.2: Within Group Comparison of pain by VAS scores

48
 COMPARISON OF PRE&POST VAS FOR GROUP
A&B

7
6 PRE
5 POST
4
3 6.27 6.47
2 4.2
1 2.13
0
GROUP A GROUP B

Figure 5.2: Within Group Comparison of pain by VAS scores

Independent t-test was used to compare the VAS between Group A and Group

B. When pre intervention reading was compared, the result was found to be non-

significant (p=0.687). When post intervention readings was compared the results

showed significant difference between the means of Group A and Group B (p=0.000).

[Table 5.3]

MEAN SD
GROUP GROUP GROUP GROUP t p

A B A B
PRE -.407 .687
6.2667 6.4667 1.33452 1.35576
POST -4.508 .000
2.1333 4.2 1.35576 1.14642

Table 5.3: Between Group Comparison of pain by VAS scores

49
 COMPARISON OF PRE&POST VAS BETWEEN
GROUP A&B

7
6 GROUP A
5 GROUP B
4
3 6.27 6.47
2 4.2
1 2.13
0
PRE POST

Figure 5.3: Between Group Comparison of pain by VAS scores

The disability was evaluated by OLBPDI scores. The scores were compared

within the groups by using paired t-test. The result showed significant difference

between pre and post intervention readings for Group A and Group B (p=0.000 &

p=0.000 respectively). [Table 5.4]

MEAN SD t p
PRE POST PRE POST
GROU
5.999 .000
PA 27.106 8.736 12.4064 7.48657
GROU
6.574 .000
PB 27.403 19.255 11.4132 8.87566

Table 5.4: Within Group Comparison of OLBPDI scores

50
 COMPARISON OF PRE&POST OSWESTRY
SCORE FOR GROUP A&B

30
25 PRE
POST
20
15 27.4
27.11
10 19.26
5 8.74
0
GROUP A GROUP B

Figure 5.4: Within Group Comparison of OLBPDI score

Independent t-test was used to compare the OLBPDI between Group A and

Group B. When pre intervention reading was compared, the result was found to be

non-significant (p=0.946). When post intervention readings was compared the results

showed significant difference between the means of Group A and Group B (p=0.002).

[Table 5.5].

MEAN SD
GROUP GROUP GROUP GROUP t p

A B A B
PRE -.068 .946
27.106 27.403 12.4064 11.4132
POST -3.509 .002
8.736 19.255 7.48657 8.87566

Table 5.5: Between Group Comparison of OLBPDI scores

51
 COMPARISON OF PRE&POST OSWESTRY
SCORE BETWEEN GROUP A&B

GROUP A
30
GROUP B
25
20
15 27.11 27.4
10 19.26
5 8.74
0
PRE POST

Figure 5.5: Between Group Comparison of OLBPDI score

Lumbar and hamstring flexibility was measured using tape method with the

help of Sit and Reach Test. The data was analysed and the scores were compared

within the groups by using paired t-test. The result showed significant difference

between pre and post intervention readings for Group A and Group B (p=0.000 &

p=0.002 respectively). [Table 5.6]

MEAN SD t p
PRE POST PRE POST
GROU
10.599 .000
PA 26.6 16.9 8.12228 5.55556
GROU
3.685 .002
PB 26.067 24.467 7.24536 6.13964

Table 5.6: Within Group Comparison of SRT scores

52
 COMPARISON OF PRE&POST SIT &REACH TEST
FOR GROUP A&B
30

25
PRE
20
POST
15
26.6 26.07 24.47
10
16.9
5

0
GROUP A GROUP B

Figure 5.6: Within Group Comparison of SRT scores

Independent t-test was used to compare the Sit and Reach Test between Group

A and Group B. When pre intervention reading was compared, the result was found to

be non-significant (p=0.851). When post intervention readings was compared the

results showed significant difference between the means of Group A and Group B

(p=0.001). [Table 5.7]

MEAN SD
GROUP GROUP GROUP GROUP t p

A B A B
PRE 26.6 26.067 8.12228 7.24536 .190 .851
POST 16.9 24.467 5.55556 6.13964 -3.539 .001

Table 5.7: Between Group Comparison of SRT scores

53
 COMPARISON OF PRE&POST SIT &REACH TEST
BETWEEN GROUP A&B

30
25 GROUP A
GROUP B
20
15
26.6 26.07 24.47
10
16.9
5
0
PRE POST

Figure 5.7: Between Group Comparison of SRT scores

Hamstring flexibility was measured using inclinometer with the help of Active

Knee Extension Test for both the left and right knee.

Paired t-test was used to compare the data of Active Knee Extension Test for

right knee within the groups. The result showed significant difference between pre

and post intervention readings for Group A and Group B (p=0.000 & p=0.000

respectively). [Table 5.8]

MEAN SD
t p
PRE POST PRE POST
GROUP
13.367 .000
A 45.133 25.8 8.96714 6.13188
GROUP
4.785 .000
B 45.867 42.2 9.86239 9.02536

Table 5.8: Within Group Comparison of AKET right knee scores

54
 COMPARISON OF PRE&POST AKERT FOR
GROUP A&B

50
45 PRE
40
35 POST
30
25 45.13 45.87
20 42.2
15 25.8
10
5
0
GROUP A GROUP B

Figure 5.8: Within Group Comparison of AKET right knee scores

Independent t-test was used to compare the data of Active Knee Extension

Test for right knee between Group A and Group B. When pre intervention reading was

compared, the result was found to be non-significant (p=0.833). When post

intervention readings was compared the results showed significant difference between

the means of Group A and Group B (p=0.000). [Table 5.9]

MEAN SD
GROUP GROUP GROUP GROUP t p

A B A B
PRE 45.133 45.867 8.96714 9.86239 -.213 .833

POST -5.821 .000

25.8 42.2 6.13188 9.02536

Table 5.9: Between Group Comparison of AKET right knee scores

55
 COMPARISON OF PRE&POST AKE RT BETWEEN
GROUP A&B

50
45
40 GROUP A
35 GROUP B
30
25 45.87
45.13 42.2
20
15 25.8
10
5
0
PRE POST

Figure 5.9: Between Group Comparison of AKET right knee score

Paired t-test was used to compare the data of Active Knee Extension Test for

left knee within the groups. The result showed significant difference between pre and

post intervention readings for Group A and Group B (p=0.000 & p=0.003

respectively). [Table 5.10]

MEAN SD t p
PRE POST PRE POST
GROU
11.155 .000
PA 45.467 26.533 11.1411 8.04334
GROU
3.568 .003
PB
45.733 43.733 9.49787 10.2502

Table 5.10: Within Group Comparison of AKET left knee scores

56
 COMPARISON OF PRE&POST AKELT FOR
GROUP A&B

50
45
40 PRE
35 POST
30
25 45.73
45.47 43.73
20
15 26.53
10
5
0
GROUP A GROUP B

Figure 5.10: Within Group Comparison of AKET left knee scores

Independent t-test was used to compare the data of Active Knee Extension

Test for left knee between Group A and Group B. When pre intervention reading was

compared, the result was found to be non-significant (p=0.944). When post

intervention readings was compared the results showed significant difference between

the means of Group A and Group B (p=0.000). [Table 5.11]

MEAN SD
GROUP GROUP GROUP GROUP t p

A B A B
PRE -.071 .944
45.467 45.733 11.1411 9.49787
POST -5.113 .000
26.533 43.733 8.04334 10.2502

Table 5.11: Between Group Comparison of AKET left knee scores

57
 COMPARISON OF PRE&POST AKE LT BETWEEN
GROUP A&B
50
45
40
35
30 GROUP A
25 GROUP B
45.47 45.73 43.73
20
15 26.53
10
5
0
PRE POST

Figure 5.11: Between Group Comparison of AKET left knee score

Lumbar range of motion was measured using tape method for both the flexion

and extension.

Paired t-test was used to compare the data of flexion within the groups. The

result showed significant difference between pre and post intervention readings for

Group A and Group B (p=0.007 & p=0.028 respectively). [Table 5.12]

MEAN SD T p
PRE POST PRE POST
GROU
-3.162 .007
PA
6.2333 6.5667 0.97955 1.01536
GROU
-2.449 .028
PB
6.1 6.3 0.91026 0.86189

Table 5.12: Within Group Comparison of lumbar flexion ROM scores

58
 COMPARISON OF PRE&POST FLEXION FOR
GROUP A&B

6.7
6.6
PRE
6.5
POST
6.4
6.3
6.2 6.57
6.1
6.23 6.3
6
6.1
5.9
5.8
GROUP A GROUP B

Figure 5.12: Within Group Comparison of lumbar flexion ROM scores

Independent t-test was used to compare the data of flexion between Group A

and Group B. When pre intervention reading was compared, the result was found to

be non-significant (p=0.702). When post intervention readings was compared the

results showed non-significant difference between the means of Group A and Group B

(p=0.445). [Table 5.13]

MEAN SD
GROUP GROUP GROUP GROUP t p

A B A B
PRE .386 .702
6.2333 6.1 0.97955 0.91026
POST .775 .445
6.5667 6.3 1.01536 0.86189

Table 5.13: Between Group Comparison of lumbar flexion ROM scores

59
 COMPARISON OF PRE&POST FLEXION
BETWEEN GROUP A&B

6.7
6.6
GROUP A
6.5
GROUP B
6.4
6.3
6.2 6.57
6.1
6.23 6.3
6
6.1
5.9
5.8
PRE POST

Figure 5.13: Between Group Comparison of lumbar flexion ROM score

Paired t-test was used to compare the data of extension within the groups. The

result showed non-significant difference between pre and post intervention readings

for Group A (p=0.082), but the result showed significant difference between pre and

post intervention readings for Group B ( p=0.19). [Table 5.14]

MEAN SD
t p
PRE POST PRE POST
GROU
-1.871 .082
PA 2 2.1 0.59761 0.57321
GROU
-2.646 .019
PB
2.1333 2.3 0.6114 0.64918

Table 5.14: Within Group Comparison of lumbar extension ROM scores

60
 COMPARISON OF PRE&POST EXTENSION FOR
GROUP A&B

2.35
2.3
2.25 PRE
2.2 POST
2.15
2.1
2.3
2.05
2 2.13
2.1
1.95
2
1.9
1.85
GROUP A GROUP B

Figure 5.14: Within Group Comparison of lumbar extension ROM scores

Independent t-test was used to compare the data of extension between Group A

and Group B. When pre intervention reading was compared, the result was found to

be non-significant (p=0.551). When post intervention readings was compared the

results showed non-significant difference between the means of Group A and Group B

(p=0.379). [Table 5.15]

MEAN SD
GROUP GROUP GROUP GROUP t p

A B A B
PRE -.604 .551
2 2.1333 0.59761 0.6114
POST -.894 .379
2.1 2.3 0.57321 0.64918

Table 5.15: Between Group Comparison of lumbar extension ROM scores

61
 COMPARISON OF PRE&POST EXTENSION
2.35
BETWEEN GROUP A&B
2.3
2.25
2.2
GROUP A
2.15
GROUP B
2.1
2.3
2.05
2 2.13 2.1
1.95
2
1.9
1.85
PRE POST

Figure 5.15: Between Group Comparison of lumbar extension ROM score

CHAPTER 6

DISCUSSION

62
 Low back pain is a significant health problem that affects 80% of the general

population in their life time. Hamstrings tightness is one of the most common findings
5, 6, 7
in patients with low back pain and it has been argued that lengthening the

hamstrings may allow greater motion to occur at the hips and therefore, reduce stress

on the lumbar spine 6. The purpose of the present study was to investigate the

effectiveness of a backward walking exercise program in alleviating LBP in patients

with hamstring tightness. Low back pain presents a challenge for the clinicians, and it

is thought to be best managed by categorizing or matching treatments to particular

symptomatology. The results showed that both the groups (experimental and control)

had improvement and better improvement was experienced in experimental group as

compared to control group when pain, disability, hamstring flexibility and low back

range of motion were measured.

The present study indicated that the participants in experimental group

increased backward walking velocity following the intervention. Whether the general

63
increase in backward walking velocity was the result of a neurological adaptation to

the novel task or a muscular response to the intervention is unclear.

It is clearly apparent in the experimental group that there was a significant

decrease in pain and disability which may be due to the increase in the flexibility of

lumbar spine and correction of flat back by increasing the flexibility of hamstring

muscle. Because hamstring tightness will rotate the pelvic posteriorly and produce flat

back, due to this lumbar structures were in tension and produced low back pain.

Similar result was found by Chet and Janet 9 which reported that by lengthening and

stretching the lumbar spine, disc compression can be reduced, resulting in a change in

pelvic tilt which has been suggested to influence hamstring flexibility. Kramer 62,

Phalen and Dickson63 reported that inflexible hamstring muscles limit anterior tilt of

the pelvis during trunk flexion, and this limitation can result in increased lumbar

muscle and ligamentous tension, producing considerably greater compressive stress

64
on the lumbar spine. Kendall and McCreary argued that individuals with "flat"

backs (reduced lumbar curvature) while standing tend to have short hamstring

muscles. They presumed that short hamstring muscles rotate the pelvis posteriorly,

resulting in a concurrent reduction of lumbar lordosis.

Increase in hamstring flexibility in experimental group as measured by the

YMCA Sit-and-Reach Test and Active Knee Extension Test with all participants

showed an increase in reach distance following the backward walking intervention

which is due to the prestretch of the hamstrings that occurs in backward walking prior

to thigh reversal due to greater hip flexion and lesser extension. Similar result was

reported by Chet and Janet that backward walking may positively influence hamstring

flexibility for females.The average increase of hamstring flexibility across the

experimental group was 9.7 cm by YMCA Sit-and-Reach Test and by Active Knee

64
Extension Test it is 19.330 and 18.930 for right knee and left knee respectively

suggesting the effectiveness of the intervention in increasing hamstring flexibility. But

in control group there is very mild change in pain, disability and hamstring flexibility.

The average increase across the control group was 1.6 cm by YMCA Sit-and-Reach

Test and by Active Knee Extension Test for right knee and left knee it is 3.66 0 and 20

respectively.

The postural or mechanical disturbances are the most common cause of low

back pain. Alteration of the normal relationship among the alignment of the spine, the

position of the pelvis, and the length of the muscles attaching to the spine and pelvis

contributes to the development of low back pain. Short hamstring muscles rotate the

pelvis posteriorly, resulting in a concurrent reduction of lumbar lordosis. The

increasing in the flexibility of hamstring muscles by backward walking produce the

pelvis moves anteriorly and the flat backs is reduces, by this reduction of flat back the

compressive structures of the spine is relaxed. The reduction of these compressive

force leads to the reduction of pain and disability.

Furthermore, non-significant results were observed regarding low back ranges

of motion for sROM both flexion and extension. Most individuals increased ROM

values in flexion, yet some individuals displayed same but in extension, most

individuals displayed same ROM values, yet some individuals displayed increased

which could possibly be attributed to the intervention. The average group differences

between test sessions of experimental group for flexion and extension were 0.33 cm

and 0.1 cm respectively and average group differences between test sessions of

control group for flexion and extension were 0.2 cm and 0.1 cm, respectively. Given

the sagittal nature of walking, one would anticipate greater changes in flexion-

extension values. But differences between maximum flexion and extension positions

65
were not documented but only total range of motion. Knowledge of the specific

position of the trunk relative to the pelvis could be important relative to the pre-stretch

necessary to perform backward walking.

The result of the present study suggested that hamstring flexibility is increased

by backward walking and is an effective in reducing low back pain and disability in

patients with low back pain and hamstring tightness. So backward walking is a good

tool for the clinicians to treat the patients of low back pain with hamstring tightness.

CHAPTER 7

LIMITATIONS AND FUTURE STUDY

66
 LIMITATIONS

1. The sample size was small.

2. Only specific age group was taken (18-30 years).

3. Treating patients was not blinded to the group allocation.

FUTURE STUDY

1. Follow up could be added to the present study.

2. The study could be done on subjects above 30 years of age to increase its

efficacy.

3. The present technique could be applied for longer duration.

4. The pelvic tilt could be measured to prove the efficiency of backward walking

on increasing hamstring flexibility.

67
5. EMG study could be done for hamstring work before after backward walking

intervention.

CHAPTER 8

CONCLUSION & CLINICAL SIGNIFICANE

68
 CONCLUSION

Based on the findings of present study, it can be concluded that backward

walking intervention in subjects with non-specific low back pain induces

improvement in Pain, Disability and Hamstring muscle flexibility.

CLINICAL SIGNIFICANCE

The prevalence of low back pain among patients with hamstring tightness is

relatively high. By backward walking the hamstring flexibility gets increased, so the

backward walking is a good tool for the clinicians to treat the patients of low back

pain with hamstring tightness. Backward walking was found to have a positive effect

on Pain, Disability and Hamstring flexibility in non-specific low back pain. These

could be used in patients with LBP to ensure positive effect on postural asymmetry,

muscle responses, pain relief and disability. Backward walking can be used as home

exercise regimen for the patients who will not tolerate manual stretching. Backward

walking can also combine with therapeutics modalities to increase the effect and help

69
the patients in relieving the pain. Backward walking can be used as an effective

regimen for the patients with non-specific low back pain with hamstring tightness.

Backward walking is not only done on treadmill but also on the ground and produce

same effect.

CHAPTER 9

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79
80
 APPENDIX A

CONSENT FORM

81
 CONSENT FORM

TITLE

Effect of backward walking on back pain and disability in patients with low back pain

and hamstring tightness

INVITATION OF PARTICIPATION

You are invited to participate in the study, which is being done as a partial fulfilment

of Masters degree of Physiotherapy (musculoskeletal) in H. N. B. Garhwal University.

PURPOSES

Purposes of the study will be to determine the effect of backward walking on low

back pain

PROCEDURE

Before treadmill training sit and reach test will be done. The subjects will be given

backward walking treadmill training for 3 weeks for 3 sessions a week and hot pack

and lumbar extension endurance exercises is also given to some subjects. Every work

day subjects will walk for 10-15 minutes on treadmill with backward walking, hot

pack and lumbar extension endurance exercises. After 3 weeks of training Sit and

Reach test is done once again.

BENEFITS OF PARTICIPATION

There may be some monetary benefits after participation in this study.

RIGHT TO WITHDRAW

You have right to withdraw at any movement from research with stating any reason.

CONFIDENTIALITY

82
All information revealed by you will be kept strictly confidential limited to the

researcher guide Dr. Mohmmad Shaid and me and will not be shown to any person

without your consent. If you have any queries regarding this research contact me at:-

Address: ...................................

Phone no: .................................

DECLARATION

I ............................................................... here by voluntarily consent to participate in

this study. All my questions have been satisfactory answered and risks involved have

been explained to me. I reserve my right to withdraw at any instant. I have the contact

address of Naseer Ahmad, M.P.T. II Year

Signature: .................................................................

Address: ..................................................................

Phone no.: ...............................................................

Researcher Signature

83
 APPENDIX B

ASSESSMENT FORM

84
 ASSESSMENT FORM

Name:

Age:

Height:

Occupation:

Address:

Phone:

HISTORY:

1. H/O any injury/pain

2. H/O any present illness.
3. H/O any past illness
4. H/O any lower limb and trunk surgery.

POSTURAL EVALUATION IN STANDING

1. Anterior view
2. Posterior view
3. Lateral view

EXAMINATION
1. Range of Motion.
Trunk ROM
Hip ROM
Knee ROM
Ankle ROM
2. MMT
Trunk
Hip
Knee
Ankle
3. Leg Length Measurement

85
 APPENDIX C

DATA COLLECTION FORM

86
 DATA COLLECTION FORM

NAME:- ...........................
SIT AND REACH TEST
PRE TEST LENGTH OF HAMSTRING
POST TEST LENGTH OF HAMSTRING

VISUAL ANALOG SCALE (VAS) FOR LOW BACK PAIN

PRE TEST SCORE
POST TEST SCORE

OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE

PRE TEST SCORE
POST TEST SCORE

LOW BACK RANGE OF MOTION

MOVEMENTS PRE TEST LOW BACK POST TEST LOW
ROM BACK ROM
FLEXION
EXTENSION

ACTIVE KNEE EXTENSION TEST

ANGLES PRE TEST SCORE (n0) POST TEST SCORE
(n0)

LEFT KNEE ANGLE

RIGHT KNEE ANGLE

87
 APPENDIX D

MASTER CHART

88
S. No. OR AGE HEIGHT SIT AND VAS OSWESTRY LOW BACK RANGE OF ACTIVE KNEE
GROUP IN IN REACH LBP MOTION EXTENSION TEST
YEARS CENTIMETER TEST DISABILITY FLEXION EXTENSION RIGHT LEFT
S Pre Post Pre Pos Pre Post Pre Post Pre Post Pre Post Pre Post
t
A1 24 162 23 14 5 2 26.66 11.11 6.5 6.5 1.5 2 56 28 64 46
A2 23 154 24 16 5 3 24.44 13.33 5 5 1.5 1.5 41 28 42 29
A3 22 172 32 22 5 0 46.66 0 6 7.5 2 2 53 31 45 29
A4 23 157 40 27 7 5 35.55 28.88 5 5.5 2 2 55 34 63 32
A5 22 160 26 20 6 3 15.55 8.88 6 6 2.5 2.5 54 32 54 31
A6 22 152 22 14 5 2 17.77 4.44 7 7.5 2 2.5 42 30 40 28
A7 22 167 20 10 6 1 15.55 4.44 6.5 7 3.5 3.5 38 22 45 18
A8 22 162 35 20 7 2 33.33 6.66 4 4.5 1.5 1.5 34 18 41 22
A9 26 167 30 21 7 1 28.88 8.88 7 7.5 2 2 44 21 40 23
A 10 27 170 13 8 5 0 26.66 4.44 7.5 7.5 1.5 2 36 17 33 14
A 11 20 157 32 19 8 2 37.77 6.66 6 6 3 3 40 17 44 21
A 12 20 172 30 15 9 2 20 2.22 7.5 8 2 2 33 19 37 20
A 13 23 162 29 18 8 3 53.33 20 6 6.5 2 2 57 29 60 35
A 14 22 165 33 22 6 2 11.11 2.22 7 7 1.5 1.5 56 33 50 30
A 15 21 157 10 7.5 5 4 13.33 8.88 6.5 6.5 1.5 1.5 38 28 24 20

S. No. OR AGE HEIGHT SIT AND VAS OSWESTRY LOW BACK RANGE OF ACTIVE KNEE
GROUP IN IN REACH LBP MOTION EXTENSION TEST
YEARS CENTIMETERS TEST DISABILITY FLEXION EXTENSION RIGHT LEFT
Pre Post Pr Post Pre Post Pre Post Pre Post Pre Post Pre Post
e
B1 29 170 28 25 7 4 24.44 17.77 7 6.5 1.5 2 54 50 60 62
B2 25 162 33 33 5 4 31.11 22.22 6 6 2 2.5 39 35 40 38
B3 21 161 25 24 6 5 26.66 24.44 4.5 5 1.5 1.5 59 56 45 45
B4 23 158 38 34 5 2 44.44 31.11 5.5 5.5 2 2 49 47 54 53

89
B5 26 170 16 16 8 4 15.55 6.66 6 6.5 2.5 2.5 32 29 36 33
B6 24 165 25 25 5 3 28.88 22.22 7.5 7.5 3 3.5 41 41 39 36
B7 22 162 32 30 8 6 33.33 26.66 6.5 7 2.5 2.5 52 50 46 47
B8 23 159 17 17 6 3 11.11 11.11 5 5 1.5 1.5 30 30 32 29
B9 20 160 35 31 5 5 48.88 33.33 6 6.5 2.5 2.5 52 45 50 48
B 10 22 157 19 18 9 5 22.22 11.11 7.5 8 3.5 3.5 40 37 44 39
B 11 23 169 26 23 7 4 20 13.33 5.5 6 2 2 42 40 36 36
B 12 20 157 13 14 6 3 13.33 4.44 6 6 1.5 1.5 32 28 35 30
B 13 22 161 26 24 8 6 17.77 13.33 6.5 6.5 2 2 53 47 56 51
B 14 21 158 30 26 7 5 42.22 24.44 5 5.5 1.5 2 55 43 51 50
B 15 23 163 28 27 5 4 31.11 26.66 7 7 2.5 3 58 55 62 59

90
 APPENDIX D

DATA ANALYSIS

91
 DATA ANALYSIS OF BETWEEN GROUP DEMOGRAPHIC DATA

Group Statistics

VAR00003 N Mean Std. Deviation Std. Error Mean

AGE 1 15 2.2600E1 1.91982 .49570

2 15 2.2933E1 2.37447 .61308

HT 1 15 1.6240E2 6.34485 1.63823

2 15 1.6213E2 4.50185 1.16237

Independent Samples Test

Levene's Test
for Equality of
Variances t-test for Equality of Means

95% Confidence Interval

of the Difference
Sig. (2- Mean Std. Error
F Sig. t df tailed) Difference Difference Lower Upper

AGE Equal variances

.284 .598 -.423 28 .676 -.33333 .78841 -1.94831 1.28165
assumed

Equal variances
-.423 26.824 .676 -.33333 .78841 -1.95151 1.28484
not assumed

HT Equal variances
2.119 .157 .133 28 .895 .26667 2.00871 -3.84799 4.38133
assumed

Equal variances
.133 25.246 .895 .26667 2.00871 -3.86831 4.40164
not assumed

DATA ANALYSIS WITHEN GROUP A

92
 Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 srtpre 26.600 15 8.12228 2.09716

srtpost 16.900 15 5.55556 1.43444

Paired Samples Correlations

N Correlation Sig.

Pair 1 srtpre & srtpost 15 .934 .000

Paired Samples Test

Paired Differences

95% Confidence
Interval of the
Difference
Std. Std. Error Sig. (2-
Mean Deviation Mean Lower Upper T df tailed)

Pair 1 srtpre -
9.70000E0 3.54461 .91522 7.73706 11.66294 10.599 14 .000
srtpost

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 vaspre 6.2667 15 1.33452 .34457

vaspost 2.1333 15 1.35576 .35006

93
 Paired Samples Correlations

N Correlation Sig.

Pair 1 vaspre & vaspost 15 .176 .530

Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence Interval

Std. of the Difference
Std. Error
Mean Deviation Mean Lower Upper

Pair 1 vaspre -
4.13333E0 1.72654 .44579 3.17721 5.08946 9.272 14 .000
vaspost

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 oswespre 27.106 15 12.40639 3.20332

oswespost 8.7360 15 7.48657 1.93302

Paired Samples Correlations

N Correlation Sig.

Pair 1 oswespre & oswespost 15 .373 .171

94
 Paired Samples Test

Paired Differences

95% Confidence
Interval of the Sig. (2-
Difference t df tailed)
Std. Std. Error
Mean Deviation Mean Lower Upper

Pair 1 oswespre -
1.83700E1 11.86031 3.06232 11.80198 24.93802 5.999 14 .000
oswespost

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 flxpre 6.2333 15 .97955 .25292

flxpost 6.5667 15 1.01536 .26216

Paired Samples Correlations

N Correlation Sig.

Pair 1 flxpre & flxpost 15 .917 .000

Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence Interval

Std. of the Difference
Deviati Std. Error
Mean on Mean Lower Upper

Pair 1 flxpre -
-3.33333E-1 .40825 .10541 -.55941 -.10725 -3.162 14 .007
flxpost

95
 Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 extpre 2.0000 15 .59761 .15430

extpost 2.1000 15 .57321 .14800

Paired Samples Correlations

N Correlation Sig.

Pair 1 extpre & extpost 15 .938 .000

Paired Samples Test

Paired Differences

95% Confidence Interval

Std. of the Difference
Deviati Std. Error Sig. (2-
Mean on Mean Lower Upper t df tailed)

Pair 1 extpre - extpost -1.00000E-1 .20702 .05345 -.21464 .01464 -1.871 14 .082

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 akertpre 45.133 15 8.96714 2.31530

akertpost 25.800 15 6.13188 1.58325

96
 Paired Samples Correlations

N Correlation Sig.

Pair 1 akertpre & akertpost 15 .788 .000

Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence
Interval of the
Std. Difference
Std. Error
Mean Deviation Mean Lower Upper

Pair 1 akertpre -
1.93333E1 5.60187 1.44640 16.23112 22.43555 13.367 14 .000
akertpost

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 akeltpre 45.467 15 11.14109 2.87662

akeltpost 26.533 15 8.04334 2.07678

Paired Samples Correlations

N Correlation Sig.

Pair 1 akeltpre & akeltpost 15 .812 .000

97
 Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence Interval

Std. of the Difference
Std. Error
Mean Deviation Mean Lower Upper

Pair 1 akeltpre -
1.89333E1 6.57340 1.69724 15.29311 22.57356 11.155 14 .000
akeltpost

DATA ANALYSIS WITHEN GROUP B

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 srtpreb 26.067 15 7.24536 1.87074

srtpostb 24.467 15 6.13964 1.58525

Paired Samples Correlations

N Correlation Sig.

Pair 1 srtpreb & srtpostb 15 .982 .000

98
 Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence Interval

of the Difference
Std. Std. Error
Mean Deviation Mean Lower Upper

Pair 1 srtpreb - 1.60000

1.68184 .43425 .66863 2.53137 3.685 14 .002
srtpostb E0

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 Vaspreb 6.4667 15 1.35576 .35006

Vaspostb 4.2000 15 1.14642 .29601

Paired Samples Correlations

N Correlation Sig.

Pair 1 vaspreb & vaspostb 15 .579 .024

Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence Interval

Std. of the Difference
Std. Error
Mean Deviation Mean Lower Upper

Pair 1 vaspreb -
2.26667E0 1.16292 .30026 1.62266 2.91067 7.549 14 .000
vaspostb

99
 Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 oswespreb 27.403 15 11.41321 2.94688

oswespostb 19.255 15 8.87566 2.29169

Paired Samples Correlations

N Correlation Sig.

Pair 1 oswespreb & oswespostb 15 .918 .000

Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence Interval

of the Difference
Std. Std. Error
Mean Deviation Mean Lower Upper

Pair 1 oswespreb -
8.14800E0 4.80005 1.23937 5.48982 10.80618 6.574 14 .000
oswespostb

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 flxpreb 6.1000 15 .91026 .23503

flxpostb 6.3000 15 .86189 .22254

100
 Paired Samples Correlations

N Correlation Sig.

Pair 1 flxpreb & flxpostb 15 .938 .000

Paired Samples Test

Paired Differences

95% Confidence Interval Sig. (2-

Std. Std. of the Difference t df tailed)
Deviatio Error
Mean n Mean Lower Upper

Pair 1 flxpreb -
-2.00000E-1 .31623 .08165 -.37512 -.02488 -2.449 14 .028
flxpostb

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 extpreb 2.1333 15 .61140 .15786

extpostb 2.3000 15 .64918 .16762

Paired Samples Correlations

N Correlation Sig.

Pair 1 extpreb & extpostb 15 .927 .000

101
 Paired Samples Test

Paired Differences

95% Confidence Interval Sig. (2-

Std. of the Difference t df tailed)
Std. Error
Mean Deviation Mean Lower Upper

Pair 1 extpreb -
-1.66667E-1 .24398 .06299 -.30178 -.03156 -2.646 14 .019
extpostb

Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 akertpreb 45.867 15 9.86239 2.54646

akertpostb 42.200 15 9.02536 2.33034

Paired Samples Correlations

N Correlation Sig.

Pair 1 akertpreb & akertpostb 15 .954 .000

Paired Samples Test

Paired Differences

95% Confidence
Interval of the Sig. (2-
Std. Difference t df tailed)
Std. Error
Mean Deviation Mean Lower Upper

Pair 1 akertpreb -
3.66667E0 2.96808 .76636 2.02300 5.31034 4.785 14 .000
akertpostb

102
 Paired Samples Statistics

Mean N Std. Deviation Std. Error Mean

Pair 1 akeltpreb 45.733 15 9.49787 2.45234

akeltpostb 43.733 15 10.25020 2.64659

Paired Samples Correlations

N Correlation Sig.

Pair 1 akeltpreb & akeltpostb 15 .979 .000

Paired Samples Test

Sig. (2-
Paired Differences t df tailed)

95% Confidence
Interval of the
Std. Difference
Std. Error
Mean Deviation Mean Lower Upper

Pair 1 akeltpreb -
2.00000E0 2.17124 .56061 .79761 3.20239 3.568 14 .003
akeltpostb

DATA ANALYSIS OF BETWEEN THE GROUP A AND B

Group Statistics

103
 VAR0004
3 N Mean Std. Deviation Std. Error Mean

srtpre 1 15 2.6600E1 8.12228 2.09716

2 15 2.6067E1 7.24536 1.87074

srtpost 1 15 1.6900E1 5.55556 1.43444

2 15 2.4467E1 6.13964 1.58525

vaspre 1 15 6.2667 1.33452 .34457

2 15 6.4667 1.35576 .35006

vaspost 1 15 2.1333 1.35576 .35006

2 15 4.2000 1.14642 .29601

oswespre 1 15 2.7106E1 12.40639 3.20332

2 15 2.7403E1 11.41321 2.94688

oswespost 1 15 8.7360 7.48657 1.93302

2 15 1.9255E1 8.87566 2.29169

flxpre 1 15 6.2333 .97955 .25292

2 15 6.1000 .91026 .23503

flxpost 1 15 6.5667 1.01536 .26216

2 15 6.3000 .86189 .22254

extpre 1 15 2.0000 .59761 .15430

2 15 2.1333 .61140 .15786

extpost 1 15 2.1000 .57321 .14800

2 15 2.3000 .64918 .16762

akertpre 1 15 4.5133E1 8.96714 2.31530

2 15 4.5867E1 9.86239 2.54646

akertpost 1 15 2.5800E1 6.13188 1.58325

104
 2 15 4.2200E1 9.02536 2.33034

akeltpre 1 15 4.5467E1 11.14109 2.87662

2 15 4.5733E1 9.49787 2.45234

akeltpost 1 15 2.6533E1 8.04334 2.07678

2 15 4.3733E1 10.25020 2.64659

105
 Independent Samples Test

Levene's Test for

Equality of Variances t-test for Equality of Means

95% Confidence Interval of t

Difference
Sig. (2- Mean Std. Error
F Sig. t df tailed) Difference Difference Lower Upper

re Equal variances assumed .287 .597 .190 28 .851 .53333 2.81030 -5.22330 6.28

Equal variances not assumed .190 27.642 .851 .53333 2.81030 -5.22666 6.29

ost Equal variances assumed .025 .876 -3.539 28 .001 -7.56667 2.13790 -11.94597 -3.18

Equal variances not assumed -3.539 27.725 .001 -7.56667 2.13790 -11.94792 -3.18

pre Equal variances assumed .036 .851 -.407 28 .687 -.20000 .49119 -1.20616 .80

Equal variances not assumed -.407 27.993 .687 -.20000 .49119 -1.20617 .80

post Equal variances assumed .061 .807 -4.508 28 .000 -2.06667 .45843 -3.00572 -1.12

Equal variances not assumed -4.508 27.248 .000 -2.06667 .45843 -3.00689 -1.12

esp Equal variances assumed .063 .803 -.068 28 .946 -.29733 4.35262 -9.21327 8.61

Equal variances not assumed -.068 27.807 .946 -.29733 4.35262 -9.21606 8.62

esp Equal variances assumed 2.006 .168 -3.509 28 .002 -10.51933 2.99807 -16.66059 -4.37

Equal variances not assumed -3.509 27.226 .002 -10.51933 2.99807 -16.66847 -4.37

re Equal variances assumed .023 .880 .386 28 .702 .13333 .34526 -.57391 .84

Equal variances not assumed .386 27.851 .702 .13333 .34526 -.57408 .84

ost Equal variances assumed .397 .534 .775 28 .445 .26667 .34388 -.43774 .97

Equal variances not assumed .775 27.280 .445 .26667 .34388 -.43858 .97

pre Equal variances assumed .437 .514 -.604 28 .551 -.13333 .22075 -.58552 .31

Equal variances not assumed -.604 27.985 .551 -.13333 .22075 -.58553 .31

post Equal variances assumed .616 .439 -.894 28 .379 -.20000 .22361 -.65804 .25

Equal variances not assumed -.894 27.577 .379 -.20000 .22361 -.65835 .25

rtpr Equal variances assumed .226 .639 -.213 28 .833 -.73333 3.44167 -7.78327 6.31

Equal variances not assumed -.213 27.750 .833 -.73333 3.44167 -7.78613 6.31

rtpo Equal variances assumed 1.968 .172 -5.821 28 .000 -16.40000 2.81729 -22.17096 -10.62
106
Equal variances not assumed -5.821 24.654 .000 -16.40000 2.81729 -22.20645 -10.59

tpre Equal variances assumed .086 .771 -.071 28 .944 -.26667 3.78006 -8.00978 7.47
107
APPENDIX D

SCALE

108
 OSWESTRY LOW BACK PAIN DISABILIT QUESTIONNAIRE

The Oswestry Disability Index (also known as the Oswestry Low Back Pain

Disability Questionnaire) is an extremely important tool that researchers and disability

evaluators use to measure a patient's permanent functional disability. The test is

considered the ‘gold standard’ of low back functional outcome tools.

SCORING INSTRUCTIONS

For each section the total possible score is 5: if the first statement is marked

the section score = 0; if the last statement is marked, it = 5. If all 10 sectionsare

completed the score is calculated as follows:

Example: 16 (total scored)

50 (total possible score) x 100 = 32%

If one section is missed or not applicable the score is calculated:

16 (total scored)

45 (total possible score) x 100 = 35.5% .

INTERPRETATION OF SCORES

0% to 20%: The patient can cope with most living activities. Usually no
minimal treatment is indicated apart from advice on lifting sitting and
disability: exercise.
21%-40%: The patient experiences more pain and difficulty with sitting, lifting
moderate and standing. Travel and social life are more difficult and they may
disability: be disabled from work. Personal care, sexual activity and sleeping
are not grossly affected and the patient can usually be managed by
conservative means.
41%-60%: Pain remains the main problem in this group but activities of daily
severe disability: living are affected. These patients require a detailed investigation.
61%-80%: Back pain impinges on all aspects of the patient's life. Positive
crippled: intervention is required.
81%-100%: These patients are either bed-bound or exaggerating their symptoms.

109
 INSTRUCTIONS

This questionnaire has been designed to give us information as to how your

back or leg pain is affecting your ability to manage in everyday life. Please answer by

checking ONE box in each section for the statement which best applies to you. We

realise you may consider that two or more statements in any one section apply but

please just shade out the spot that indicates the statement which most clearly describes

your problem

Section 1 – Pain intensity

 I have no pain at the moment.

 The pain is very mild at the moment.

 The pain is moderate at the moment.

 The pain is fairly severe at the moment.

 The pain is very severe at the moment.

 The pain is the worst imaginable at the moment.

Section 2 – Personal care (washing, dressing etc)

 I can look after myself normally without causing extra pain.

 I can look after myself normally but it causes extra pain.

 It is painful to look after myself and I am slow and careful.

 I need some help but manage most of my personal care.

 I need help every day in most aspects of self-care.

 I do not get dressed, I wash with difficulty and stay in bed.

110
Section 3 – Lifting

 I can lift heavy weights without extra pain

 I can lift heavy weights but it gives extra pain

 Pain prevents me from lifting heavy weights off the floor, but I can

manage if they are conveniently placed eg. on a table

 Pain prevents me from lifting heavy weights, but I can manage light to

medium weights if they are conveniently positioned

 I can lift very light weights

 I cannot lift or carry anything at all

Section 4 – Walking*

 Pain does not prevent me walking any distance

 Pain prevents me from walking more than 2 kilometres

 Pain prevents me from walking more than 1 kilometre

 Pain prevents me from walking more than 500 metres

 I can only walk using a stick or crutches

 I am in bed most of the time

Section 5 – Sitting

 I can sit in any chair as long as I like

 I can only sit in my favourite chair as long as I like

 Pain prevents me sitting more than one hour

 Pain prevents me from sitting more than 30 minutes

 Pain prevents me from sitting more than 10 minutes

 Pain prevents me from sitting at all.

111
Section 6 – Standing

 I can stand as long as I want without extra pain

 I can stand as long as I want but it gives me extra pain

 Pain prevents me from standing for more than 1 hour

 Pain prevents me from standing for more than 3 minutes

 Pain prevents me from standing for more than 10 minutes

 Pain prevents me from standing at all

Section 7 – Sleeping

 My sleep is never disturbed by pain

 My sleep is occasionally disturbed by pain

 Because of pain I have less than 6 hours sleep

 Because of pain I have less than 4 hours sleep

 Because of pain I have less than 2 hours sleep

 Pain prevents me from sleeping at all

Section 8 – Sex life (if applicable)

 My sex life is normal and causes no extra pain

 My sex life is normal but causes some extra pain

 My sex life is nearly normal but is very painful

 My sex life is severely restricted by pain

 My sex life is nearly absent because of pain

 Pain prevents any sex life at all

112
Section 9 – Social life

 My social life is normal and gives me no extra pain

 My social life is normal but increases the degree of pain

 Pain has no significant effect on my social life apart from limiting my

more energetic interests eg, sport

 Pain has restricted my social life and I do not go out as often

 Pain has restricted my social life to my home

 I have no social life because of pain

Section 10 – Travelling

 I can travel anywhere without pain

 I can travel anywhere but it gives me extra pain

 Pain is bad but I manage journeys over two hours

 Pain restricts me to journeys of less than one hour

 Pain restricts me to short necessary journeys under 30 minutes

 Pain prevents me from travelling except to receive treatment

113