CHANCELLOR’S SUMMER RESEARCH FELLOWSHIP - 2021

Efficacy of Integrated Treatment of Yoga and McKenzie exercise program

among patients with non-specific low back pain

Summer Research Dissertation submitted by

SHRUTI SRI B C - INTERN

FACULTY OF PHYSIOTHERAPY
Sri Ramachandra Institute of Higher Education and Research
(Deemed to be University)

GUIDE
Mr. A D GOPALSWAMI
ASSOCIATE PROFESSOR
FACULTY OF PHYSIOTHERAPY

AUGUST 2022
 CHANCELLOR’S SUMMER RESEARCH FELLOWSHIP - 2021

Efficacy of Integrated Treatment of Yoga and McKenzie exercise program

among patients with non-specific low back pain

Summer Research Dissertation submitted by

SHRUTI SRI B C - INTERN

FACULTY OF PHYSIOTHERAPY
Sri Ramachandra Institute of Higher Education and Research
(Deemed to be University)

GUIDE
Mr. A D GOPALSWAMI
ASSOCIATE PROFESSOR
FACULTY OF PHYSIOTHERAPY
AUGUST 2022
_______________________________________________________________
Formerly known as Sri Ramachandra Medical College and Research Institute (Deemed to be
University) Accredited by NAAC with A++ grade and Graded by the UGC as ‘Category - I
University’

CHANCELLOR’S SUMMER RESEARCH FELLOWSHIP - 2021

Efficacy of Integrated Treatment of Yoga and McKenzie exercise

program among patients with non-specific low back pain

Summer Research Dissertation submitted by

SHRUTI SRI B C - INTERN

FACULTY OF PHYSIOTHERAPY
Sri Ramachandra Institute of Higher Education and Research
(Deemed to be University)

GUIDE
Mr. A D GOPALSWAMI
ASSOCIATE PROFESSOR
FACULTY OF PHYSIOTHERAPY
 AUGUST 2022

GUIDE PRINCIPAL

CHANCELLOR’S SUMMER RESEARCH FELLOWSHIP – 2021

AUGUST 2022

BONAFIDE CERTIFICATE

This is to certify that this dissertation entitled

“Efficacy of Integrated Treatment of Yoga and McKenzie exercise program

among patients with non-specific low back pain”

Is based on the Bonafide work carried out under my supervision during the
academic year 2021-2022.

GUIDE PRINCIPAL
 ACKNOWLEDGEMENT

It is my privilege to thank the management of, “Sri Ramachandra Institute of Higher

Education and Research” (Deemed to be University), and Dr. V. R. Venkataachalam Sir
for giving me this opportunity in my UG life to carry out the Summer Research Fellowship
Program by granting an amount of 10,000 rupees for my research purposes.

I am obliged to thank the Dean of Faculties Dr.Mahesh Vakamudi, Dean of Students Dr. K.
Balaji Singh and Dean Research Prof. Kalpana Balakrishnan for permitting us to carry out
this dissertation.

On the very outset of this report, I would like to extend my sincere and heartfelt obligation
towards all the personages who have helped me in this endeavor. At this juncture, I have many
people to thank with open arms for their help and probably words will fall short.

I am ineffably indebted to Mr. A D Gopalswami (Associate Professor) for his conscientious

guidance and constant supervision as well as for providing necessary information regarding the
research and also for his support in completing the research. Words can only inadequately
express my gratitude for his patience to help me think clearly and consistently by discussing
every point of this dissertation with me. He introduced me to this wonderful world of
“research”. In fact, most of my ideas have taken a preliminary shape owing to a number of
discussions with him. It was a real privilege to have him as my path finder. My time with him
has helped me ‘grow’ in many ways. His diligence and deep understanding of the subject and
willingness to share his vast knowledge made me understand this research and its
manifestations in great depths and helped me to complete the assigned tasks. I could not have
imagined having a better advisor and mentor for my summer research. I am truly grateful to
him.
I would like to express my gratitude and respect to Prof. N. Venkatesh, Course Chairman,
Sri Ramachandra Faculty of Physiotherapy, “Sri Ramachandra Institute of Higher Education
and Research” (Deemed to be University) for his guidance throughout the study.

No words of thanks can sum up the gratitude that I owe to the Principal Prof. R. Sivakumar,
Sri Ramachandra Faculty of Physiotherapy, “Sri Ramachandra Institute of Higher Education
and Research” (Deemed to be University), who has always been a key - person for me in
inculcating the learning attitude towards the cutting-edge research all through my under-
graduate.

I am highly obliged to the Vice Principal Prof. Antony Leo Aseer, Sri Ramachandra Faculty
of Physiotherapy, “Sri Ramachandra Institute of Higher Education and Research” (Deemed to
be University). He has always encouraged my academic life by cutting the Gordian knot.

I can barely express my gratefulness Mrs. C M Radhika (Assistant Professor). She is a good
Samaritan who has always promoted me for academic excellence and has always lend her hand
when in need.

I would like to reserve in memory lane Prof. Narasimman Swaminathan (Vice principal,
AHS) and Prof. T. Gayathri (statistician) for their warm back up in times of need.

I would like to express my sincere gratitude to my Mom and Dad for hearing my everyday
rants and sharing their valuable inputs and for never letting me face any difficulties alone both
mentally and physically during my course of research and my brother Pasu Pathan for being
my constant source of inspiration to do anything new in life and my co-intern Yogavarshini
for always having my back throughout my research journey.

I express my sincere thanks to all my study subjects who participated in this study, for lending
me their support and making this an enriching experience.

Truly thankful to GOD as he was in my every step of the way and making all things work for
the good and in my favor.
Finally, I thank myself for having the courage to never give up on my research even on my bad
days. The experiences I gained through this golden opportunity of summer research will be
taken as my life lessons.

- B.C. SHRUTI SRI

CONTENTS

S.NO TITLE PAGE NO.

1. Abstract 10

2. Introduction 11

3. Review of Literature 14

4. Hypothesis 17

5. Aims and Objectives 18

6. Methodology 19

7. Outcome measure 22

8. Study Procedure 23

9. Results 30
10. Discussion 33

11. Conclusion 35

12. Bibliography 36

LIST OF TABLES

S.NO TITLE PAGE NO.

1. Demographic data 31

2. Comparison within group (control 31

group)

3. Comparison within group (experimental 32

group)

4. Comparison between groups (control 32

group and experimental group)
 LIST OF ANNEXURES

S.NO TITLE

1. Award of Chancellor's Summer Research Fellowship Grant for 2021 –

selection letter

2. Ethics committee approval letter

3. Participant information

4. Informed consent

5. Certification of informed consent

6. Evaluation Performa

7. Oswestry Disability Index (Tamil)

8. Plates

LIST OF ABBREVIATIONS
 VAS Visual Analog Scale

ROM Range Of Motion

MMT Manual Muscle Testing

ODI Oswestry Disability Index

ABSTRACT

B.C. Shruti Sri, Intern

Guide: A.D. Gopalswami, Associate Professor Sri Ramachandra Faculty of Physiotherapy, Sri Ramachandra
Institute of Higher Education and Research, Chennai.

TITLE: Efficacy of Integrated Treatment of Yoga and McKenzie exercise program among patients with non-
specific low back pain.

BACKGROUND: Low back pain is a disorder affecting people of all ages, being among major diseases leading
individuals to seek Health professionals' help. Yoga offers a holistic approach to health and is now considered a
form of mind-body medicine within complementary and alternative medicine. Several randomized control trials
have proven Yoga to be an effective treatment. However, the comparative effectiveness of Yoga and physical
therapy, a common mainstream treatment for chronic low back pain, is not much explored.

BROAD AIM: The purpose is to assess the Integrated efficacy of Yoga and McKenzie exercise program in
individuals with non-specific low back pain.

OBJECTIVE: To compare the Integrated effect of Yoga along with McKenzie exercise program for patients
with non-specific low back ache on Pain using Visual Analog Scale (VAS) Lumbar range of motion (extension)
Functional performance using Oswestry Disability Index (Tamil)

HYPOTHESIS: Integration of Yoga would have better clinical and functional outcomes among experimental
group. Ho: There may not be any significant impact on integration of Yoga on clinical and functional outcomes
among experimental group.
MATERIALS AND METHODS: A total of 40 samples (n=40) would be recruited for the study. The patients
would be allocated to the control group (n=20) and the experimental group (n=20). Patients belonging to both
groups would be undergoing an intake evaluation in order to obtain baseline measures.

INTERVENTION: The control group (CG), would receive the referred physiotherapy treatment and McKenzie
exercise program. The experimental group (EG), would receive the referred Physiotherapy treatment and
McKenzie exercise program along with Yoga therapy. McKenzie Exercise Program - Lying prone, extension in
lying, extension in standing. Yoga Program - Bhujangasana, Marjari asana, Trikonasana, Ardha Chandrasana.
Study Duration - 2 weeks spread over 10 sessions.

ANTICIPATED OUTCOME: Integration of Yoga would have better clinical and functional outcomes among
experimental group.

INTRODUCTION:

Low back pain (LBP) is a major health problem in modern society. Though several risk factors
have been identified (including occupational posture, depressive moods, obesity, body height
and age), the causes of the onset of low back pain remain obscure and diagnosis difficult to
make. Back pain is not a disease but a constellation of symptoms. (1) In most cases, the origins
remain unknown. Low back pain affects people of all ages, from children to the elderly, and is
a very frequent reason for medical consultations. (2) The 2010 Global Burden of Disease Study
estimated that low back pain is among the top 10 diseases and injuries that account for the
highest burden worldwide. (3) It is difficult to estimate the incidence of low back pain as the
incidence of first-ever episodes of low back pain is already high by early adulthood and
symptoms tend to recur over time. (4)

Low Back Pain prevails with work of the patients, physical condition of the patient, age and
female preponderance. Low socioeconomic status, poor education, previous history of Low
Back Pain, physical factors such as lifting heavy loads, repetitive job, prolonged static posture
and awkward posture, psychosocial factors such as anxiety, depression, job dissatisfaction, lack
of job control and mental stress, working hours and obesity, muscle spasm have been found to
be associated with Low Back Pain. (5)Low back pain is a leading cause of disability. It occurs
in similar proportions in all cultures, interferes with quality of life and work performance, and
is the most common reason for medical consultations. Few cases of back pain are due to
specific causes; most cases are nonspecific. (3)

The conventional treatment involves Interferential therapy to the low back spine and McKenzie
exercise program curated for the patient’s needs. (4)

The McKenzie back exercises belong to an exercise protocol pioneered by physiotherapist

Robin Anthony McKenzie in the 1950s and popularized around 1985. The McKenzie method,
also known as Mechanical Diagnosis and Therapy (MDT), is widely used as a classification
system for the diagnosis and treatment of a variety of musculoskeletal conditions, including
lower back, neck, and extremity pain. (8) It stresses self-treatment through posture correction
and repeated exercise movements at end-range performed with high frequency. (4)

The hallmark of the McKenzie method for back pain involves the identification and
classification of nonspecific spinal pain into homogenous subgroups. These subgroups are
based on the similar responses of a patient's symptoms when subjected to mechanical forces.
The McKenzie method emphasizes the centralization phenomenon in the assessment and
treatment of spinal pain, in which pain originating from the spine refers distally, and through
targeted repetitive movements the pain migrates back toward the spine. (10)

Several randomized control trials have proven Yoga to be an effective treatment. However, the
comparative effectiveness of Yoga and physical therapy, a common mainstream treatment for
chronic low back pain, is not much explored. ((11)

Hence for the present study, we tried to compare the Integrated effect of Yoga along with
McKenzie exercise program for patients with non-specific low back ache on Pain using Visual
Analog Scale (VAS) Lumbar range of motion (extension) Functional performance using
Oswestry Disability Index (Tamil).

Modern Hatha yoga usually combines elements of postural positioning, breathing,

concentration, and meditation. A typical Hatha yoga program involves a group led by an
instructor for a ~ 30–60-minute session. The instructor provides guidance for correct postures,
breathing and focus. Iyengar style of yoga has a focus on holding postures, and the use of
modifications (such as blocks, belts, chairs, blankets) to accommodate individual physical
abilities. (12)

The effect of yoga on physical functioning has been described in two large randomized trials.
Sherman et al. studied yoga compared to stretching or a self-care book approach for patients
with chronic low back pain. In all the groups, function and symptoms improved over time. The
yoga and stretching groups reported similarly improved results compared to the self-care group.

The authors concluded that yoga benefits are due mainly to the benefits of physically stretching
and strengthening the body, and not due to yoga’s mental aspect. (6) Tilbrook et al. studied
the long-term effectiveness of a 12-week yoga program versus a back pain education booklet
for low back pain patients. The yoga group had significantly better back function (Roland-
Morris Disability Questionnaire) than the usual care group at 3-, 6-, and 12-months follow-up.
(14)

REVIEW OF LITERATURE:

The Search strategy for searching the articles in the electronic database was set up from 2010
to 2021. The literature search was done using key words such as low back, pain, functional
performance, range of motion, muscle power, McKenzie, Yoga and relevance of these
variables in search engine like Google scholar, Cochrane database, Pub med using Boolean
search tags such as AND, OR, NOT. The literature review process includes collection of
articles that are related to this study. Randomized control trial, systematic reviews and meta-
analysis, and one prospective case series study were included. Articles that are identified were
to support and execute the study.

The literature review is organized under the following headings:

• Non- Specific Low Back Pain

• Range of motion in Low back pain
• Functional performance in Low back pain
 • McKenzie exercise program for Low back pain
• Therapeutic Yoga program for Low back pain

Non- Specific Low Back Pain:

In general, the low back pain consists of two types, which is specific and nonspecific low back
pain (NSLBP). Low back pain with specific type can be divided into low back pain that related
to vertebrae and nonvertebrate. In the other hand, NSLBP described as low back pain with no
clear causal relationship between the symptoms, physical findings, and imaging findings. In
addition, NSLBP is classified into low back pain, which is not related to the neurological
problem and degenerative syndrome. (7)

Research by Tsuji et al. reported that the condition of pain was quite high and disturbances in
quality of life affected the decrease in productivity of workers with Non-Specific Low back
Pain. (15)

Range of motion in Low Back Pain:

Hip rotation range-of-motion (ROM) impairment has been proposed as a contributing

mechanical factor in the development of low back pain (LBP) symptoms. There is a hypothesis
which suggests that a limited range of hip rotation results in compensatory lumbar spine
rotation. Hence, LBP may develop as the result. This article reviews studies assessing hip
rotation ROM impairment in the LBP population. (16)

Functional performance in Low Back Pain:

Activities of daily living (ADL) are various functional activities that may range from basic
ones, such as walking or bending, to more complex activities (also called instrumental activities
of daily living, IADL), such as cooking, bathing or getting dressed, in other words activities
which enable independent living. There seems to be a consensus across studies that LBP is
associated with problems in ADL. (1)

A Thail cohort study (N = 42,785; 80% aged between 30 and 50 years) showed that 30% of the
cohort participants reported LBP, where approximately 6% of the cohort reported difficulties
in bending, 3.1% had difficulties in walking a 100 m, 2.2% could not climb stairs, and a further
2.9% had problems when dressing. This longitudinal cohort study reported a time-dependent
increasing gradient in the functional limitation across all activities. (17)

McKenzie Exercise program for Low back pain:

Kuppusamy et al. reported that the McKenzie exercises are considered to be frequently used
by physiotherapists in the treatment of LBP. Improvement in symptoms is successively
measured in terms of ‘centralization’, a phenomenon that has been commonly used. It combines
recurrent end range actions by examination; the classification of direction for exercise is
contingent upon the patient’s response to those recurring actions. Posture correction ensuring
the maintaining of the correction is a vital characteristic of the McKenzie exercise. (9)

Therapeutic Yoga program for Low back pain:

Williams et al. conducted a 24-week study that showed significantly greater reductions in
functional disability (Oswestry Disability Index), pain intensity (Visual Analog Scale) and
depression (Beck Depression Inventory-Second Edition) among the subjects randomized to the
yoga intervention group. (10)

80 patients with CLBP participated in an intensive seven day long, residential yoga program.
The effect of yoga on disability (Oswestry Disability Index), quality of life (World Health
Organization Quality of Life-BREF) and flexibility was studied. The intervention group
practiced daily meditation, yoga exercise, chanting and went to lectures. The control group
followed a daily routine of exercise, non-yogic breathing exercises, educational lectures and
additionally filled their time watching nature programs. This control is different than the usual
or no care control used in other studies. There was a significant difference in disability between
groups, with the yoga group experiencing a greater improvement than the control group. The
yoga group showed a greater increase in flexibility and reduction in pain (section 1 of the
Oswestry Disability Index) than the control group. (14)

HYPOTHESIS:

Integration of Yoga would have better clinical and functional outcomes among experimental
group.

There may not be any significant impact on integration of Yoga on clinical and functional
outcomes among experimental group

ALTERNATIVE HYPOTHESIS:

• Integration of Yoga would reduce the pain intensity and improve the functional performance
in subjects with Low Back Pain among experimental group.
• Integration of Yoga would improve the range of motion and muscle strength in subjects with
Low Back Pain among experimental group.

NULL HYPOTHESIS:

• Integration of Yoga may not produce any significant impact to reduce the pain intensity and
improve the functional outcomes among patients with Low Back Pain among experimental
group.

• Integration of Yoga may not produce any significant impact to improve the range of motion
and muscle strength in subjects with Low Back Pain among experimental group.

AIMS AND OBJECTIVE

AIM OF THE STUDY:

• The purpose is to assess the Integrated efficacy of Yoga and McKenzie exercise
program in individuals with non-specific low back pain.

OBJECTIVES OF THE STUDY:

To compare the Integrated effect of Yoga along with McKenzie exercise program for patients
with non-specific low back ache on
 • Pain using Visual Analog Scale (VAS)
• Lumbar range of motion (extension)
• Functional performance using Oswestry Disability Index (Tamil).

Materials and Methods

The study was approved by Research Advisory committee of Sri Ramachandra Faculty of
Physiotherapy, Sri Ramachandra Institute of Higher Education and Research.

Methodology

Group A (Experimental Group) - Referred Physiotherapy and McKenzie Exercise program and
Yoga therapy
Group B (Control Group) - Referred Physiotherapy and McKenzie Exercise program

Site of the study

Outpatient Physiotherapy clinic

Sri Ramachandra Institute of Higher education and Research Centre (DU)

Porur, Chennai.

Study Design

A comparative prospective study

Period of the study

2 weeks spread over 10 sessions

Sample size

A total of 40 samples (n=40) were recruited for the study. The patients were allocated to the
control group (n=20) and the experimental group (n=20).

The sample size was derived from nMaster 2.0 - Sample size software by using the standard
deviation in two groups from a similar research article titled “Yoga compared to non-exercise
or physical therapy exercise on pain, disability and quality of life with chronic back pain” found
in Research gate. The mean difference, effect size, power percentage were estimated, and the
sample size was found to be 20 per group.

Sampling design

Convenience Sampling method

Inclusion criteria

✓ Age group 17- 65 years

✓ Patients with non-specific low back pain

Exclusion criteria
 ✓ Patient with poor comprehension ability
✓ Past spinal surgeries
✓ Spinal instability
✓ Active infections

Method

A total of 40 samples (n=40) were recruited for the study. The patients were allocated to the
control group (n=20) and the experimental group (n=20). Patients belonging to both groups
underwent an intake evaluation in order to obtain baseline measures.

The control group (CG) received the referred physiotherapy treatment and McKenzie exercise
program. The experimental group (EG) received the referred physiotherapy treatment and
McKenzie exercise program along with Yoga therapy.

McKenzie Exercise Program – Lying prone, extension in lying, extension in standing.

Yoga Program – Bhujangasana, Marjari asana, Trikonasana, Ardha Chandrasana.

Outcome measures:

Pain-related measure:

Subjects were asked to mark their pain level on 10 cm Visual analog scale, with 0 representing
no pain and 10 worst imaginable pain.

Range of Motion-related measure:

Trunk extension Range of Motion was measured using Modified Schober's test. Using a skin-
marking pencil a mark was placed at the lumbosacral junction. A second mark was placed 10
cm above the first mark and a third mark 5 cm below the first mark (lumbosacral junction).
The tape measure was aligned between the most superior and the most inferior marks. The
subjects were asked to bend backward as far as possible. The distance between the most
superior and the most inferior marks at the end of the ROM was noted and the final readings
were obtained by subtracting the final from the initial measurement. The ROM is the difference
between 15 cm and the length measured at the end of the motion. (16)

Functional performance measure:

The total ODI (Oswestry Disability Index) score ranges from 0 (no disability) to 100
(maximum disability). The original developers of the ODI intended for scores from 0–20 to
indicate “minimal disability,” 20–40 to indicate “moderate disability,” 40–60 to indicate
“severe disability,” 60–80 to indicate “housebound,” and 80–100 to indicate “bedbound”. The
ODI is simple to read and can be completed by the respondent in 5 minutes and scoring takes
1 minute. The ODI was originally developed in English, but it has been culturally adapted and
is available in a range of languages. For the patient population, ODI translated in Tamil have
been used. (19)
INTERVENTION:

Subjects were assigned into control group and experimental group respectively.

Control group:

Control group, subjects received conventional therapy which included

Interferential therapy (IFT) with McKenzie exercise program.

Interferential therapy

All treatments to an individual subject were conducted by the same physiotherapist. After
routine physiotherapy assessment, subjects were positioned on a treatment plinth in their
preferred position of comfort, i.e., prone lying or side lying.

Two electrodes were placed unilaterally or bilaterally at the peripheries of the LBP painful
area. In subjects with unilateral pain, the cathode (−) electrode was positioned at the proximal
extent and the anode (+) electrode at the distal extent of the painful area. Treatment of subjects
with bilateral LBP involved paraspinal application of the cathode and anode electrodes at the
lateral limits of the painful area, parallel to the vertebral column. ((20)

After a detailed explanation by the treating physiotherapist, the IFT unit was switched on, and
the current amplitude gradually increased until the subject reported first a “mild tingling
sensation” and then a “strong but comfortable sensation.” To maintain a continuous level of
intensity, the amplitude was increased by the physiotherapist when the subject reported a
diminution of the IFT current sensation. All IFT treatments were 20 minutes long. (21)
McKenzie Exercise program

McKenzie Exercise Program Dosage

1. Prone position lying flat (patient lies
flat on their stomach)
2. Prone position propped on elbows
(patient lies flat on their stomach and
props themselves onto their elbows 3 sets 1 repetition (10 times) hold for
with the spine in extension) 6 seconds rest for 1-3 minutes
3. Prone position propped on hands between them
(patient lies flat on their stomach and
props themselves onto their hands
with elbows in full extension, with
the spine in extension)
4. Standing lumbar extension (patient
stands upright with feet shoulder-
width apart, and puts hands on the
lower back while extending the
spine)
Experimental group:

Subjects in experimental group received Yoga Therapy along with the conventional therapy
and McKenzie exercise program as received by the control group.

1) Child’s Pose:

"Child's pose takes the pressure off the lower back by elongating and aligning the spine, which
decompresses it and gives a nice stretch".

Procedure Duration
• Patient kneels on mat with their knees
hip-width apart and feet together
behind. A deep breath is taken in, and
as they exhale, they lay their torso
over their thighs. Hold 1-2 minutes
• Patient tries to lengthen their neck
and spine by drawing their ribs away
from their tailbone and the crown of
head away from the shoulders.
• Patient rest their forehead on the
ground, with arms extended out in
front of them.
2) Cat and Camel Pose:

It allows for a nice flexion and extension of the spine, promotes mobility, and "it also helps to
just relieve any tension in the lower back." Cat/cow also helps to get familiar with what neutral
spine is—not too arched and not too rounded—which can help improve posture.

Procedure Duration
• Start on all fours with your shoulders
over your wrists and hips over knees.
• Take a slow inhale, and on the exhale,
round your spine and drop your head Done for 2-3 minutes
toward the floor (this is the cat
posture).
• Inhale and lift your head, chest, and
tailbone toward the ceiling as you
arch your back for cow.
 3) Downward Facing Dog:

Sometimes, lower back pains because the backs of our legs are so tight. Downward facing dog
is a great way to stretch the hamstrings and calves.

Procedure Duration
• From Child's pose, patient keeps the
hands on the floor, sit up on their
knees, and then lift their back and
press back into downward-facing
dog. Hold for 30-60 seconds
• Fingers are kept wide apart. Patient is
instructed to work on straightening
their legs and lowering their heels
towards the ground.
• Head is kept relaxed between their
arms, and their gaze is instructed to
direct through their legs or up toward
their belly button.

4) Knee to Chest:

Procedure Duration
• Patient lies on their back.
• And is instructed to hug both knees
into their chest. Done for 1-2 minutes
• They must slowly rock their torso
back and forth while firmly holding
onto their legs.
 5) Upward facing Dog:

This works to activate the muscles around the spine, which better supports painful areas.

Procedure Duration
• Patient starts with low plank, then
lower halfway to the floor, keeping
their elbows in close to the body.
• From there, they must drop their hips
down to the floor and flip their toes
over so the top of their feet touches Hold for 30 seconds to 1 minute
the floor.
• They are instructed to tighten their
core and straighten their arms to push
their chest up. They must pull their
shoulders back, squeeze their
shoulder blades, and tilt their head
toward the ceiling, to open up their
chest.
6) Setubhandhasana/Setu Bandha Sarvangasana or the Bridge pose:

This variation also known as the Bridge pose stretches the chest, neck and spine. It not only
strengthens the back and hamstrings but also increases blood circulation, alleviates stress and
calms the brain.

Procedure Duration
• Patient lies down on their back with
legs straight on the floor, palms
beside their thighs.
• They are instructed to bend both their
knees while keeping the legs and hips
apart and bringing their heels closer
to the hips. Hold for 10-15 seconds and release
• Instructed to Inhale and lift their
stomach and chest up by taking their
hips off the floor.
• Support is given to lower back with
their hands. Legs are straightened
with their toes pointing in the front.
RESULTS:

The data was collected from 20 subjects. The collected data was analyzed with IBM.SPSS
statistics software 24.0 Version. The descriptive statistics, percentage analysis was used for
categorical variables and the mean & S.D was used for continuous variables. The normality
test was verified and confirmed normal distribution. The parametric test design was used to
analyze the group differences. The statistical tests were considered significant when the p-
value was less than 0.05.
TABLE 1: DEMOGRAPHIC DATA ANALYSIS

TOTAL (n) 40

MALE 17

FEMALE 23

TABLE 2: WITHIN GROUP ANALYSIS OF CONTROL GROUP

VARIABLES PRE – TEST POST – TEST p-value

(Mean, SD) (Mean, SD)
VAS 1.98 (1.098) 2.30 (1.302) <0.001
ROM 2.20 (0.951) 1.20 (0.768) <0.001
MMT (FLEXORS) 4.0 (0.795) 4.55 (0.510) <0.001

MMT 3.75 (0.716) 4.45 (0.686) <0.001

(EXTENSORS)
ODI 49.10 (12.937) 26.15 (4.738) <0.001

With p value <0.05 as significance, the unpaired t test shows that within group analysis of
control group are <0.05 and >0.001, has significant results.
TABLE 3: WITHIN GROUP ANALYSIS OF EXPERIMENTAL GROUP

VARIABLES PRE – TEST POST – TEST p-value

(MEAN, SD) (MEAN, SD)
VAS 2.98 (1.009) 3.25 (1.118) <0.001
ROM 2.70 (1.031) 1.65 (0.933) <0.001
MMT (FLEXORS) 3.90 (0.912) 4.05 (0.826) <0.001
MMT 4.0 (0.858) 4.35 (0.813) <0.001
(EXTENSORS)
ODI 46.65 (14.946) 30.65 (8.499) <0.001

With p value <0.05 as significance, the unpaired t test shows that within group analysis of
experimental group are <0.05 and >0.001, has significant results.

TABLE 4: BETWEEN GROUP ANALYSIS (POST TEST VALUES OF CONTROL

AND INTERVENTION)

VARIABLES CONTROL GROUP EXPERIMENTAL p-value

(MEAN, SD) GROUP
(MEAN, SD)
VAS 2.30 (1.302) 3.25 (1.118) <0.001
ROM 1.20 (0.768) 1.65 (0.933) <0.001

MMT (FLEXORS) 4.55 (0.510) 4.05 (0.826) <0.001

MMT 4.45 (0.686) 4.35 (0.813) <0.001

(EXTENSORS)
ODI 26.15 (4.738) 30.65 (8.499) <0.001
With p value <0.05 as significance, the unpaired t test shows that between group analysis of
experimental group and control group are <0.05 and >0.001, has significant results.
DISCUSSION:

This study was attempted in order to analyze the efficacy of Integrated Treatment of Yoga and
McKenzie exercise program among patients with non-specific low back pain. The variables
considered were Visual Analog Scale, Lumbar extension Range of motion, Lumbar Muscle
strength and Oswestry Disability Index score.

The primary aim was to assess the integrated efficacy of Yoga and McKenzie exercise program
in individuals with non-specific low back pain. The primary objective was to compare the
Integrated effect of Yoga along with McKenzie exercise program for patients with non-specific
low back ache on Pain using Visual Analog Scale (VAS), Lumbar range of motion (extension),
Functional performance using Oswestry Disability Index (Tamil). The participants had
undergone Mckenzie exercise program and Yoga program as per said parameters in
methodology.

Upon review of results, it is noted that both the experimental and control groups had
improvement in the clinical outcomes. Although, upon analysis statistically, the data revealed
that those who belonged to the experimental group had better improvement of functional status
30.65(8.499) than the control group 26.15(4.738) at the end of 10 session treatment, as depicted
in table 4.

Variables of within group was compared for both experimental and control group which was
carried out separately for VAS, ROM, MMT and ODI. The analysis of control group (n=20)
revealed that there was no significant improvement in post intervention after conventional
exercise program.

All the participants in the experimental group (n=20) underwent a well-structured Yoga
program along with the conventional treatment showed no significant improvement of ROM,
MMT during post intervention.

A past study was attempted to analyze effect of integrating Yoga in a Physiotherapy treatment
for the lower back pain. The main finding of the study suggests that Yoga can decrease pain
and increase functional ability in patients with lower back pain. (22)
According to Pence PG (2011), Yoga is an intervention that appears to be well-balanced and
should be included in the physiotherapy treatment.

Upon analysis of past study, it is found that yoga might decrease pain from short term to
intermediate term and improve functional disability status from short term to long term
compared with non-exercise (e.g., usual care, education). (14)(23)

LIMITATION:

This study has some limitations that need to be addressed.

• A long-term follow-up was not performed.

• Small sample size and potential methodological bias of this study.
CONCLUSION:

The present study reveals that, integrating Yoga program along with the conventional
physiotherapy treatment method had proven to significantly change the functional status with
improvement of lumbar extension range of motion among patients with non-specific low back
pain. Hence, the above factor proves the need to integrate a basic Yoga program to conventional
treatment techniques.
BIBLIOGRAPHY:

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2021; 14:2513–28.
2. Pal S, Sharda R. Patients with Chronic Non-Specific Low Back Pain [Internet]. Vol. 4,
J Physiother Res. 2020. Available from: www.imedpub.com
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Physiotherapy Intervention. International Journal Medical and Exercise Science. 2020
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5. Ansari A, Shahid Ali M. Prevalence of low back pain among females in physiotherapy
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2021;10(2):41–4.
6. Liddle SD, Baxter GD, Gracey JH. Chronic low back pain: Patients’ experiences,
opinions and expectations for clinical management. Disability and Rehabilitation. 2007
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7. Shipton EA. Physical Therapy Approaches in the Treatment of Low Back Pain. Pain and
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8. Alshehri MA, Alzahrani H, Alotaibi M, Alhowimel A, Khoja O. Physiotherapists’ pain
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Literature review with meta-analysis. Journal of Orthopaedic and Sports Physical
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PHYSIOTHERAPY 2022 Title of publication: Integration of Yoga in a Physiotherapy
Treatment of Lower Back Pain.
13. Saper RB, Lemaster C, Delitto A, Sherman KJ, Herman PM, Sadikova E, et al. Yoga,
physical therapy, or education for chronic low back pain: A randomized noninferiority
trial. Annals of Internal Medicine. 2017 Jul 18;167(2):85–94.
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or physical therapy exercise on pain, disability, and quality of life for patients with
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AWARD LETTER

Prof. Kalpana Balakrishnan

Dean (Research)
Date: 22.06.2021
To
Shruti Sri B C
BPT, IV year
Faculty of Physiotherapy
No. Chancellor’s Summer Research Fellowship for UG Students / 2021
Sub: Award of Chancellor’s Summer Research Grant UG Students in Sri Ramachandra
Institute of Higher Education and Research (DU) – 2021
We are happy to convey that Ms/Mr Shruti Sri B C has been selected for the award of
Chancellor’s Summer Research Fellowship Grant for the year 2021. We are delighted to
welcome you to the SRIHER community of student researchers. This fellowship has been
specifically created to provide seed support for developing your initial ideas and introduce you
to the numerous opportunities for health science/clinical/basic science research within and
outside SRIHER. We hope that this fellowship will facilitate your continued research
engagement throughout your academic tenure.
We have provided below a listing of terms of reference for the fellowship. We request you to
go over these conditions carefully so that you can discharge your responsibilities associated
with the fellowship in an effective manner.
1. You will be paid a fixed fellowship of Rs. 10,000. The fellowship is deemed to have been
fulfilled only upon the submission of the final project report and the award of a
Fellowship completion certificate by the Office of Dean (Research).
2. This year the fellowship will be tenable between 1 st July, 2021 to 31st December, 2021
3. The fellowship will require you to identify a supervisor in any of the constituent
departments/Faculties of SRIHER with the due approval of the respective
Dean/Principal. You may have already identified a supervisor at the time of submission.
You are requested to provide a formal acceptance by the supervisor and furnish a
joining report to the Office of Dean (Research).
4. All projects are required to secure Institutional Ethics Committee Clearance and the Office
of Dean (Research) will facilitate a quick turnaround for reviews so as to minimize
delays in project initiation.
5. The fellowship duration can be flexibly used between July 1, 2021 to December 31, 2021.
An interim progress report will be required to be submitted by September 30, 2021.
Projects that do not meet criteria of sufficient progress or feasibility of completion prior
to the deadlines may be discontinued after the interim review.
6. A limited number of projects that are judged to be of high quality will be supported with
additional supplemental funds to increase the impact (such as through additional data
or laboratory analyses/publications and conference presentations. The quantum of
support will be decided on a case to case to basis upon the submission of the final report.
7. The Office of Dean (Research) will offer periodic capacity building/networking
opportunities for fellows and you are encouraged to avail the same. There will also be
an annual dissemination event where you can showcase the results of your project and
compete for prizes and awards for research excellence.
8. Payment of the fellowship will be made based on the requisition sent by the fellow through
Supervisor/Head of the Department concerned.
9. Each fellow shall submit two copies of the final report to the Office of Dean (Research),
duly certified by the Supervisor and Head of the Department concerned.

(Kalpana Balakrishnan)
Dean (Research)
 PATIENT INFORMATION

Area: Date:

Case no: Age/ Gender:

Name: PT No:

OP No:

Occupation: ________________________________________

Contact number: _________________________

Chief complaints/ problem: ________________________________________________

HISTORY

Onset (How did the problem start?): __________________________________________

Duration: _______________________________________________________________

Intervention (Treatment): __________________________________________________

Outcome: ______________________________________________________________

MEDICAL HISTORY

Comorbidities (If any): ____________________________________________________

Current medications/ supplements/ vitamins: ___________________________________

Surgery (Please include year): ______________________________________________

Diagnostic Tests (Please check tests for current problem only):

X-ray: _________ CT scan: _________ MRI: _________ Bone Scan: ________

EMG: ________ Blood Test: ________ Myelogram: ________ Others: _________

Findings: _______________________________________________________________

Family History (If any): _____________________________________________________

INFORMED CONSENT
Title of the project - Efficacy of integrated treatment of Yoga and McKenzie exercise program
among patients with non-specific low back pain.
Name of the Principal Investigator -
Shruti Sri BC
BPT, 8th Semester (IV year)
Faculty of Physiotherapy
SRIHER, Chennai
Description of the Study:
• Nature and purpose of study stating it as research - The main purpose of this
study is to access the effectiveness of integrating Yoga and McKenzie exercise
program in non-specific low back pain patients and to achieve better outcomes in
terms of pain, range of motion and functional performance.
• Voluntary participation - Participation in this study is completely voluntary and
your consent is required before you can participate in the study.
• Duration of participation with number of participants - 40 participants will be
allocated among experimental and control group and the baseline values will be
taken and after 45 minutes of treatment, subject will be reassessed.
• Procedures to be followed
The patient who fulfils the inclusion criteria will undergo physical examination and will be
assigned into any of the two groups.
Experimental group subjects will receive intervention based on standard physiotherapy
treatment along with McKenzie exercise program and Yoga therapy.
Control group subjects will receive intervention based on standard physiotherapy and
McKenzie exercise program. The subjects will undergo a pre-test evaluation of pain, lumbar
range of motion and functional performance as baseline measures.
Followed by intervention, the subjects will undergo post-test evaluation after 45 minutes of
treatment.
• Investigations, if any, to be performed - No
• Any alternative procedures or courses of treatment that might be as
advantageous to the participant as the procedure or treatment to which s/he
is being subjected – No
• Storage period of biological sample and related data with choice offered to
participant regarding future use of sample, refusal for storage and receipt
of its results - No
Possible Risks to the participant: No risk anticipated. A mild discomfort on
evaluation may be experienced.
Possible Benefits to the participant: Patient will get to know the cause of pain and physical
performance after the intervention.
Cost and Payments to the participant: There is no cost for participation in this
study. Participation is completely voluntary and no payment will be provided.
Confidentiality: Information obtained in this study is strictly confidential. Your
name will not be used in reporting of information in publications or conference
presentations.
Participants’ right to withdraw from the study: You have the right to refuse to
participate in this study, the right to withdraw from the study and the right to have your data
destroyed at any point during or after the study, without penalty.
Voluntary consent by the participants: PARTICIPATION IN THIS STUDY IS
COMPLETELY VOLUNTARY AND YOUR CONSENT IS REQUIRED BEFORE YOU
CAN PARTICIPATE IN THIS STUDY.
I have read this consent form (or it has been read to me) and I fully understand the contents of
this document and voluntarily consent to participate in the study. All of my questions
concerning this study have been answered. If I have any questions in the future about this study,
they will be answered by the investigators listed below.
I understand that this consent ends at the conclusion of this study.

Contact Address with phone number:

PI – from SRMC Collaborator (if any) outside SRMC
Shruti Sri B C
Phone number: 8939463403

A copy of the participant/patient information sheet should be given to the participant for her/
his record.
[In case of illiterate participant, the information is explained and thumb impression is obtained,
in the presence of an unrelated witness. Left hand thumb impression for male and right-hand
thumb impression of female]
By signing this form, I agree to participate in this study. A copy of this form has
been given to me.

Date: Name:
Participant’s signature:
Thumb impression:

Witness name:

Witness signature:
Certification of INFORMED CONSENT

I certify that I have explained the nature and purpose of this study to the above-
named individual, and I have discussed the potential benefits of this study participation. The
questions the individual had about this study have been answered, and we will always be
available to address future questions.

Date: Signature of person obtaining consent

Name:

Signature of PI
EVALUATION PROFORMA:

Mark on the body-chart deformities or joint anomalies, back deformities or anomalies,

edema, shoulder subluxation etc.

REMARKS:
__________________________________________________________________________
__________________________________________________________________________

PAIN ASSESSMENT (Please rate your pain):

RANGE OF MOTION: [ Lumbar Region]

FLEXION

EXTENSION

LATERAL FLEXION (R)

LATERAL FLEXION (L)

MUSCLE PERFORMANCE:

TRUNK FLEXORS

TRUNK EXTENSORS

TRUNK ROTATION (R)

TRUNK ROTATION (L)

OSWESTRY DISABILITY INDEX SCALE FOR FUNCTIONAL PERFORMANCE:
PHOTOPLATES:

MARJARI ASANA

SETU BANDHA ASANA USHTRASANA

ARDHA CHAKRASANA BHUJANGASANA