LONG TERM EFFECTS OF MUSCLE ENERGY TECHNIQUE

ON PAIN IN INDIVIDUALS WITH NON-SPECIFIC

LUMBOPELVIC PAIN

Synopsis submitted

to

Shri Guru Ram Rai University In The Partial Fulfillment of The

Requirement For the award of

Master of Physiotherapy

By

Name Jyoti Sehrawat

Guide Co-Guide

Dr. Neeraj Kumar Dr. Surbhi Thapliyal

Phd Ortho MPT Cardio

Shri Guru Ram Rai University

School of Paramedical and Allied Health Sciences

Pathribag, Dehradun-248001, Uttarakhand, India (Estd. by Govt. of

Uttarakhand,vide Shri Guru Ram Rai University Act no. 03 of 2017)

 SHRI GURU RAM RAI UNIVERSITY
Pathribag, Dehradun-248001, Uttarakhand, India (Estd. by Govt. of

Uttarakhand,vide Shri Guru Ram Rai University Act no. 03 of 2017)

DECLARATION BY THE CANDIDATE

I hereby declare that the synopsis of the proposed research work entitled “Long Term

Effects Of Muscle Energy Technique On Pain In Individuals With Non-Specific

Lumbopelvic Pain” in fulfillment of the requirements for the award of degree of

Master of Physiotherapy in subject of Sports and submitted to Department of

Physiotherapy, School of Paramedical & Allied Health Sciences, Shri Guru Ram Rai

University, Patel Nagar, Dehradun, Uttarakhand is an authentic record of bonafide

research work will be carried out by me under the expert guidance as well as direct

supervision of Prof./Dr. Neeraj Kumar further declare that the material obtained from

other sources has been duly acknowledged in the synopsis.

Jyoti Sehrawat

Roll No. R220320003

Enrollment : R220320003
 SHRI GURU RAM RAI UNIVERSITY
Pathribag, Dehradun-248001, Uttarakhand, India (Estd. by Govt. of

Uttarakhand,vide Shri Guru Ram Rai University Act no. 03 of 2017)

ENDORSMENT BY THE HOD

This is to certify that Name Ms. Jyoti Sehrawat submitted synopsis under supervision

and guidance of Dr Neeraj Kumar MPT [Musculoskeletal Disorder]. Associate

Professor, Department of Physiotherapy, School of Paramedical & Allied Health

Sciences, Shri Guru Ram Rai University, Patel Nagar, Dehradun, Uttarakhand. She

will be work carried on the topic entitled “Long Term Effects Of Muscle Energy

Technique On Pain In Individuals With Non-Specific Lumbopelvic Pain” In

partial fulfillment of the requirement for the award of degree of Master of

Physiotherapy to Department of Physiotherapy, School of Paramedical & Allied

Health Sciences, Shri Guru Ram Rai University, Patel Nagar, Dehradun, Uttarakhand

Place: ( Name / Signature of HOD)

Date:
 SHRI GURU RAM RAI UNIVERSITY
Pathribag, Dehradun-248001, Uttarakhand, India (Estd. by Govt. of

Uttarakhand,vide Shri Guru Ram Rai University Act no. 03 of 2017)

Certificate

This is to certify that Name Ms. Jyoti Sehrawat submitted synopsis to Department of

Physiotherapy, School of Paramedical & Allied Health Sciences, Shri Guru Ram Rai

University, Patel Nagar, Dehradun, Uttarakhand. He/ She work will be carried on the

topic entitled “Long Term Effects Of Muscle Energy Technique On Pain In

Individuals With Non-Specific Lumbopelvic Pain”. Under my supervision and

guidance at Department of Physiotherapy, School of Paramedical & Allied Health

Sciences, Shri Guru Ram Rai University, Patel Nagar, Dehradun, Uttarakhand for the

partial fulfillment of requirement for the degree of Master of Physiotherapy.

Place: ( Name / Signature of Guide)

Date:
 Title LONG TERM EFFECTS OF MUSCLE ENERGY
TECHNIQUE ON PAIN IN INDIVIDUALS WITH NON-SPECIFIC
LUMBOPELVIC PAIN

Name of Students Jyoti Sehrawat

Name and designation of guide & co-guide/s:

1. Guide

Dr. Neeraj Kumar

Shri Guru Ram Rai Institute of Medical &

Health Sciences, College of Paramedical
Sciences, Patel Nagar, Dehradun

2. Co-guide

Dr. Surbhi Thapliyal

Shri Guru Ram Rai Institute of Medical &

Health Sciences, College of Paramedical
Sciences, Patel Nagar, Dehradun

Place of work:- Shri Mahant Indiresh Hospital / Shri Guru Ram Rai Institute of
Medical & Health Sciences, College of Paramedical Sciences, Patel Nagar,
Dehradun

Signature

1. Students 2. Guide 3. Co- guide 4. Dean 5. External 6. HOD

…………… ………… ……………… ………… ………. …………

 CONTENTS

S. No. Chapter
1 Introduction
2 Plan of work
3 Review of literature
4 Materials & methods
5 Future prospects
6 References
 INTRODUCTION

Low back pain is neither a disease nor a diagnostic entity of any sort.The term refers
to pain of variable duration in a paradigm of responses to external and internal
stimuli. Report of WHO’s own survey results that most of people can continue to
work despite of their back problem but that recognition of the prevention and
treatment to be offered. Although acute (and under some classifications, subacute)
episodes that last up to three months are the commonest presentation of low back
pain.1\

Non specific low back pain is defined as, The tension, soreness and stiffness in the
low back region for which is not possible to identify a specific cause of pain 2.Low
back pain and its related disabilities are major societal problem,80% of all people
experience low back pain at some in their lives.3

Back symptoms are the most frequent reason to seek consultation with orthopaedic
surgeon or neurosurgeon, they are the second leading person for physician visit 4 .In
other words10 of every 178 million north American adult experience low back pain in
any given day.5 Acute low back pain occur in people with a wide variety of
profession, including those, involving heavy labour, repetitive work activities and
extended sedentary posture6. The angel of pelvis in quite standing describe the
orientation of the pelvis in a saggital plan. It is determined by the muscular and
ligamentous force act between the pelvis and adjacent segement. A forward rotation
of pelvic ,referred to as anterior pelvic tilt,is accompanied by an increase in lumbar
lordosis7 and is believed to be associated with a number of common musculoskeletal
condition including low back pain8.So muscle energy technique is common
conservative treatment for pathology around the spine ,particularly lumbopelvic pain.
MET is considered a gentle manual therapy for restricted motion of the spine and
extremities and is an active technique where the patient, not the clinician ,control the
9,10
corrective force . This treatment require the patient to perform voluntary muscle
contraction of varying intensity ,in the precise direction while the clinician applies the
counterforce not allowing the movement to occur 10. For many year MET has been
advocate to treat muscle imbalance of lumbopelvic region such as pelvic asymmetry.
The theory behind MET suggest that the technique is used to correct an asymmetry by
targeting a contraction of hamstring or hip flexor on painful side of the low back and
moving the innominate in a correct direction .Based on anatomic relationship between
the pelvis and lumbar spine, it has been speculated that changes in the pelvic
inclination affects the size of the lumbar lordosis and cause low back pain 11.Althrough
Roncarati and Mcmullen12.found that there was an increase in anterior pelvic tilt in
patient in low back pain. Some studies also shown decrease the illiopsoas muscle
length12,13and strength14in patient in low back pain. Because the illiopsoas muscle
attached to the pelvis and lumbar spine .tension in this muscle would anteriorly tilt the
pelvis and pull the lumbar vertebrae anteriorly 15. and also increase the lumbar lordosis
and weakness of this muscle decrease lumbar lordosis which in result cause low back
pain16. muscle tightness is also one of cause of back pain 17.It is thought that, due to the
attachment of hamstring to the ischial tuberosity ,hamstring tightness generates
posterior pelvic tilt and decrease lumbar lordosis which can result in low back pain.18

Greenman (1996) states that early technique did speak of muscle relaxation with soft
tissue procedure, but specific manipulative approaches to muscle appear to be 20 th
century phenomena .One such approach which target the soft tissue primarily ,
although it also make a major contributation towards joint mobilization has been term
muscle energy technique in osteopathic medicine.

Craig Liebenson(1989-,1990) when he describe muscle energy technique as active

muscular relaxation technique MET evolved out of osteopathic procedure developed
by pioneer practitioners such as T.J Ruddy (1961) ,who termed his approach resistive
duction and Fred reciprocal inhibition.Muscle energy technique is postisometric
relaxation to the work of Karel

Lewit (1999) .The term PIR refer to the effect of the subsequent reduction in
experienced by a muscle ,or group of muscle after brief periods during which an
isometric contraction has been performed .(DiGiovanna1991)acknowledge that, apart
from the well understood processes of reciprocal inhibition .The precise reasons for
effectiveness of MET remain unclear- although in achieving PIR the effect of a
sustained contraction on the golgi tendon organs seems pivotal, since their response
to such a contraction seems to be to set the tendon and the muscle to a new length by
inhibiting it (Moritan 1987) . Lewit and Simmons (1984) agree that while reciprocal
inhibition is a factor in some form of therapy related to PIR technique ,it is not a
factor in PIR itself ,which is a phenomenon resulting from a neurological loop,
probably involving the golgi tendon oragans.

Liebenson (1996) discusses both the benefits of and the mechanism involved in, use
of muscle energy technique. Two fundamental neurophysiological principles account
for the neuromuscular inhibition that occurs during the application of these technique.

The first is post contraction inhibition, which state that after a muscle is contracted, it
is automatically in a relaxed state for a brief latent period .The second is reciprocal
inhibition which states that when one muscle is contracted, its antagonist is
automatically inhibition. Libenson suggests that there is evidence that the receptors
responsible for PIR lie within the muscle and in the skin or associated joints19.

Anatomy of lumbopelvic region:

The vertebral column typically consists of between 32 and 34 vertebrae. The

lumbopelvic portion consists of 13 to 15 vertebrae. The 5 lumbar vertebrae are
considered true or moveable vertebrae, whereas the 5 sacral and 3 to 5 coccygeal
vertebrae are known as the false or fixed vertebrae, because they fuse and form the 2
adult bones of sacrum and coccyx. 20 All lumbar vertebrae consist of a vertebral body
and a vertebral arch.20,21 The vertebral arch is also known as the neural arch, as it
encloses the conus medullaris and cauda equina in the vertebral foramen. 21 In the
upper lumbar spine this foramen is oval in shape; at the lower levels it is more
triangular. Sometimes the vertebral foramen of the lower lumbar vertebrae has a
trefoil shape: a triangular shape in which the basal angles are stretched. 22The laterally
located basal angles of the trefoil-shaped vertebral foramen are called the lateral
recesses.22

The lumbar vertebral bodies are oval or kidney-shaped in the transverse plane with a
concave posterior aspect and a larger transverse to sagittal diameter. 23 Vertebral body
height is greater anteriorly than posteriorly; this contributes to the sagittal plane
lordosis.23 The lateral and anterior surfaces of the vertebral bodies are slightly
concave.22 On the posterior surface there are 1 or more large foramina called the
nutrient foramina: they transmit the nutrient arteries and the basivertebral veins. The
anterolateral surfaces have similar, smaller foramina that transmit the equatorial
arteries.20,21 The top and bottom surfaces of the vertebral body serve as attachment
sites for the intervertebral disk (IVD); they are flat or slightly concave 20, covered with
smooth hyaline cartilage21, and perforated by tiny holes. A narrow rim of smooth, less
perforated bone marks the perimeter of both the top and bottom surface. This fused
ring apophysis represents a secondary ossification center of the vertebral body. 22 Each
lumbar vertebra has a multitude of bony processes. On either side a cranially
projecting superior articular process and a caudally directed inferior articular process
are located at the junction of lamina and pedicle. The articular surfaces or facets of
these processes are covered with hyaline cartilage and form the zygapophysial joints
(ZJ). The part of the lamina that connects the inferior and superior articular processes
is called the inter articular pars. Its location at the junction of the horizontally
projecting pedicle and the more vertically oriented lamina subjects it to considerable
bending forces thus making it a frequent site for a fatigue fracture 22. The spinous
process is the dorsal continuation of the fused laminae. In the lumbar spine it is
quadrilateral in shape and it is thicker in the lower vertebrae. Like the transverse
process it serves as an attachment site for muscles and ligaments. The transverse
process projects laterally on either side from the point where the pedicle joins the
lamina. The transverse processes of L1 to L3 are horizontal; the L4 to L5 transverse
processes incline somewhat dorsally.22 The sacrum is a triangular bone wedged
between the two innominate bones . Its wider cranial surface, the base, consists of the
upper surface of the body of S1, which articulates with the L5-S1 IVD. The ventral
border of the body of S1 projects into the pelvis and is called the promontory.
Posterior to the body of S1 lies the opening to the sacral canal, the caudal extension of
the spinal canal. The pelvic surface of the sacrum is smooth and concave. Four
transverse ridges cross its center indicating the original planes of separation between
the 5 sacral vertebrae. The ridges represent the ossified sacral IVDs. 20,21White and
Panjabi23 defined degrees of freedom as the number of independent coordinates, in a
coordinate system, needed to completely specify the position of an object in space.
They stated a vertebra has 6 degrees of freedom. This means it is capable of rotations
and translations in 3 different, orthogonal planes. The rotations correspond to the
clinically defined motions of flexion-extension, side bending, and (axial) rotation. The
3 translations occuring between vertebrae are anteroposterior glide, mediolateral
glide, and distraction-compression. Intervetebral is restrained by the posterior
elements of the vertebral arch and its ligaments, the ZJs, and the paravertebral
muscles.22
The disk has 3 functions: it stabilizes the spine by anchoring the vertebral bodies to
each other, it allows movement between vertebrae, and it absorbs and distributes loads
applied to the spine.24 The disk is able to perform these 3 functions as a result of the
interaction between PGs, water, and collagen in the NP, AF, and endplates. The AF is
able to withstand compression even without a nucleus present lamellae are held
together by the interactions with PGs and will resist buckling thereby sustaining
axially applied weight. Prolonged weight bearing, however, will expell water from the
AF and deform the AF by buckling of the collagen lamellae. The lumbar back
muscles are located behind the plane of the lumbar transverse processes; they are
innervated the dorsal rami of the lumbar spinal nerves.22 Bogduk distinguished 3
groups: short intersegmental muscles (interspinales and intertransversarii mediales),
polysegmental muscles attaching to the lumbar vertebrae (multifidus, longissimus
thoracis pars lumborum, and iliocostalis lumborum pars lumborum), and long
polysegmental muscles crossing the lumbar spine, but not attaching to the lumbar
vertebrae (longissimus thoracis pars thoracis and iliocostalis lumborum pars thoracis).
The thoracolumbar fascia (TLF) consists of 3 layers. The thin anterior layer is in fact
the ventral fascia of the quadratus lumborum. Medially it attaches to the ventral aspect
of the lumbar transverse processes. Here the anterior layer blends with the
intertransverse ligaments. Lateral to the quadratus lumborum, the anterior layer blends
with the other layers of the TLF. The middle layer attaches medially to the tips of the
transverse processes and is directly continuous with the intertransverse ligaments.
Laterally it serves as the origin for the aponeurosis of the transversus abdominis
muscle. The posterior layer of the TLF has its origin on the tips of the lumbar spinous
processes. It covers the lumbar back muscles posteriorly and blends with the middle
layer of the TLF lateral to the lateral margin of the iliocostalis lumborum. At the site
of this union the 2 fascial layers form a dense raphe known as the lateral raphe. 25 The
posterior layer of the TLF covers the back muscles from the sacral region, through the
thoracic region, as far cranially as the fascia nuchae. 25 It consists of a deep and a
superficial lamina. At the L4 to L5 level and dorsal to the sacrum strong connections
exist between both laminae. The transversus abdominis and internal oblique muscles
are attached indirectly to the posterior layer of the TLF by way of their insertion into
the lateral raphe sacral nutation as the motion in which the sacral promontory moves
anteroinferiorly and the coccyx and apex of the sacrum move posterosuperiorly. With
nutation the iliac crests approximate and the iliac tuberosities separate due to the
multiplanar orientation of the joint. During counternutation the opposite movements
occur.26 The innominate may rotate anteriorly or posteriorly on a fixed sacrum.
Inferior and superior innominate translation occurs in about 15% of the population55;
prerequisites are more planar and parallel oriented joint surfaces. A reversal of the
convex-concave relationship may allow the innominates to rotate about a vertical axis,
inflare and outflare. Nutation and counternutation of the sacrum occur around a
transverse axis; individual anatomic differences result in different locations for this
axis27.
 NEED OF STUDY

To best of our knowledge no study has been conducted on low lumbopelvic pain .So
this study is intended to see the effects of MET on low lumbopelvic pain.

AIM AND OBJECTIVES

1. To investigate the effect of muscle energy technique on non specific low

lumbopelvic pain.
2. To investigate the effect of muscle energy technique on anterior innominate
rotation.

HYPOTHESIS

Experimental hypothesis: Muscle energy technique will significantly improve non

specific lumbopelvic pain and anterior innominate rotation.

Null hypothesis: Muscle energy technique will not significantly improve non specific
lumbopelvic pain and anterior innominate rotation.
 REVIEW OF LITERATURE

Brattberg G et al 198920, carried out the survey study, 1009 randomly chosen
individuals of age 18-84, about their pain problems. The pain prevalence depended on
types of questions were asked. Any pain or discomfort, including even a problem of
short duration, was reported by 66% of those questioned. Forty percent reported pain
lasting more than 6 months. Pain problems of more than 6 months duration were
reported far more often than short-lasting problems. Continuous or nearly continuous
pain problems were reported as frequently as problems recurring regularly or
irregularly. Pains in the neck, shoulders, arms, lower back and legs were most
frequent. The prevalence of 'obvious pain' in these localizations was 15-20%. Pain
was reported most frequently in the age group 45-64, where the prevalence of
'obvious pain' was 50% among males as well as females. Over 65 years of age the
prevalence was less.

Harreby M et al 199621,This study is based on data gathered by means of a postal

questionnaire from a cohort of 640 subjects. At the age of 14 years these subjects
had been interviewed by their school doctor to ascertain whether any of them had a
history of low back pain (LBP), and X-rays of the thoracic and lumbar spine were
taken. The questionnaire contained questions related to LBP . This study identify
probable risk factors in developing LBP. The results show a cumulative life-time
prevalence of LBP of 70%, a 1-year prevalence of 63% and a point prevalence of
19%, independent of gender. Women reported a higher incidence of LBP than men
during the month and week before they filled out the questionnaire, they also reported
a higher incidence of sciatica and greater use of the health care system and analgestics
over the previous year. Heavy manual work was associated with LBP and sciatica,
and smoking (more than 16 cigarettes per day) was more common among
unemployed and sick-listed subjects, Severe LBP was associated with increased
morbidity, reduced work capacity, deterioration in social life, mental and sexual
problems, and increased smoking.

Schochat T et al 199822, Studies on selected populations lead to biased estimates of

the prevalence of back pain and associated factors. In order to obtain a valid picture of
the prevalence of back pain this review article focuses on epidemiological studies in
the general population. These studies can be divided into general health surveys and
surveys with specific reference to back pain. General health surveys including
questions on the prevalence of back pain and have the greatest methodological
differences because of different aims. Due to these different aims, different target
populations and different methods these studies depict prevalences between 0.8% and
41% and 1-year prevalences between 15% and 56%. These general health surveys are
contrasted with epidemiological studies especially designed to evaluate the prevalence
of back pain. In this study the prevalence ranges between 14% and 42% and the
lifetime period prevalence between 51% and 84%. Depending on the study reviewed
the highest prevalence is found at age 50 to 64. This prevalence pattern may be
explained by several effects that are discussed in this article. Severe forms of back
pain increase even in the higher age groups, especially in women. Beside this effect
the reviewed articles show either no difference between men and women or only a
slightly higher prevalence in women. The problems faced by epidemiological studies
on back pain, resulting from different definitions of "the back", severity, chronicity
and different methodology.

Leboeuf-Yde C at al 1998 29, carried out a prevalence study whose purpose was to
investigate whether there were any differences in the occurance of low back pain that
were related to age and gender ,especially in young individuals in general population.
A post questionnaire was sent to 34,076 twins who were born between 1953 and 1982
and listed in the population based Danish Twins register.The response rate was
86% .The prevalence of various definitions of low back pain increased greatly in the
early teen years (earlier for girls than for boys), and by the ages of 18 years (girls) and
20 years (boys) more than 50% had experienced at least one low back pain episode.
The pattern for the 1-year period prevalence of low back pain was very similar to that
for the lifetime prevalence; both started at 7% (95% confidence interval, 5-9%) for the
12-year-old individuals and reached 56% (95% confidence interval, 53-59%) and
67% (95% confidence interval, 62-71%), respectively, for the 41-year-old individuals.
The pattern for the point prevalence resembled that of the more than 30 days of low
back pain reported in the preceding year; the rate increased steadily from 1% (95%
confidence interval, 0-2%) to 1.7% (95% confidence interval, 14-20%). There was a
general tendency for more women to report low back pain than men, but this
difference generally was not statistically significant.
Peter R Croft at al 199830, carried out a prevalence study whose purpose was to
investigate 90% of episodes of low back pain resolved within one month. The study
population consist of all patients age between 1875 years have 490 subjects ,203 men
and 287 women in two general practices in south Manchester who consulted their
general practitioner about low back pain at least once in a 12 month period. Result
shows that out of the 463 patients who consulted with a new episode of low back
pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat
consultations confined to the 3 months after initial consultation. However, of those
interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%)
respectively had completely recovered in terms of pain and disability.

Mohammad Reza Nourbakhsh et al 200231,Collectively investigated the association

among 17 mechanical factors and occurrence of low back pain (LBP). Total of 600
subjects participated in this study. Subjects were categorized into 4 groups:
asymptomatic men (n = 150, age [mean ± SD] = 43 ± 15 years), asymptomatic
women (n = 150, age [mean ± SD] = 43 ± 13 years), men with LBP (n = 150, age
[mean ± SD] = 43 ± 14 years), and women with LBP (n = 150, age [mean ± SD] = 43
± 13 years). Seventeen physical characteristics were measured in each group and the
relative association of each characteristic with LBP was assessed. The chisquare
analysis showed a significant difference (P = 0.04) in the length of the iliotibial band
and no significant difference in the leg length discrepancy (P = 0.47) between the
symptomatic and asymptomatic subjects. Back extensor endurance, the length of the
hamstring muscles, iliotibial band tightness, back extensor muscle length, and the
strength of the hip flexor, hip extensor, hip adductor, hip abductor and abdominal
muscles were found to be significantly different between asymptomatic subjects and
those with LBP.

Kopec JA at al 200432,This is a survey study in which prediction models for back

pain in the general male and female household populations has taken all respondents
aged 18+ years who reported no back problems in the 1994-1995 National Population
Health Survey cycle (N = 11,063). Potential predictors of back pain were classified
into nine groups and entered into stepwise logistic regression models. Bootstrap
methods were used to derive the final models and assess their predictive power. So
finally result shows that overall incidence of back pain was 44.7 per 1,000 person-
years and was higher in women (47.0 per 1,000 person-years) compared with men
(42.2 per 1,000 person-years). In men, significant predictors of back pain were age
(peak effect in 45-64 years), height, self-rated health, usual pattern of activity
(especially heavy work), yard work or gardening (negative association), and general
chronic stress. In women, significant factors were self-reported restrictions in activity,
being diagnosed with arthritis, personal stress, and history of psychological trauma in
childhood or adolescence.

Cassidy JD at al 200533, This is a survey study in which incidence and course of

severity-graded low back pain (LBP) episodes seen in adults. An incidence cohort of
318 subjects free of LBP and a course cohort of 792 prevalent cases was formed from
respondents to a mailed survey. Incident, recurrent, persistent, aggravated, improved,
and resolved episodes were defined by the Chronic Pain Questionnaire. The follow-up
at 6 and 12 months was 74% and 62 Most LBP episodes were mild. Only 1.0% (95%
CI, 0.0%-2.2%) developed intense and 0.4% (95% CI, 0.0%-1.0%) developed
disabling LBP. Resolution occurred in 26.8% (95% CI, 23.7%-30.0%), and 40.2%
(95% CI, 36.7%-43.8%) of episodes persisted. The severity of LBP increased for
14.2% (95% CI, 11.5%-16.8%) and improved for 36.1% (95% CI, 29.7%-42.2%). Of
those that recovered, 28.7% (95% CI, 21.2%-36.2%)had a recurrence within
6months,and 82.4% of it was mild LBP. Younger subjects were less likely to have
persistent LBP (incidence rate ratio, 0.88; 95% CI, 0.80-0.97) .

Levent ALTINEL et al 200834, This study was designed to determine the prevalence
of and risk factors for low back pain (LBP) in a sample of Turkish population among
adults living in the Afyon region, Turkey . A field screening investigation was
performed in a total of 75 areas including the city center, 18 districts, and 57
associated small municipalities. Adequate sample size was determined as 1,990 and a
total of 2,035 individuals (1,194 females, 841 males) were enrolled. Participants were
inquired about age, occupation, sex, height, weight.history of LBP, hypertension,
diabetes, and smoking. The prevalence of lifetime LBP was 51%, and the prevalence
of chronic LBP was 13.1%. Overall, 63.2% of women and 33.8% of men had LBP at
least once in their lives (p=0.001). With regard to occupation, the highest incidence of
LBP was seen in housewives (64.2%; p=0.0001), whose age and body mass index
(BMI) were also higher compared to employed women. Depression (p=0.016) and
increased BMI (p=0.000) were found to increase the risk for LBP, whereas smoking,
hypertension, or diabetes were not correlated with the prevalence of LBP
Effects of MET :

Capt. Eric Wilson et al 200335, Investigated the outcomes of interventions using the
MET in symptomatic populations . Sixty four patient of age between 18 to 65 year
referred to single outpatient physical therapy clinic with diagnosis of low back pain
The results of this study add support to the hypothesized effects of MET in patients
with acute low back pain. In this study, the mean post treatment Oswestry score was
7% for patients in the experimental group compared to 15% in the control group .
This study also found that the mean number of MET procedures required for subjects
in the experimental group was 3 (range, 2-4). These data suggest that a relatively
small number of MET intervention scan result in significantly greater reductions in
self reported disability. .While this study is an important first step in validating the
efficacy of MET in patients with acute low back pain.

Lenehan KL et al 200336 ,demostrate the effect of MET on gross trunk range of

motion.59 asymptomatic volunteers in which 22 male and 37 female, ranging in age
from 19 to 33 years with a mean age 24 were recruited for this study after completing
a consent form and a questionnaire to exclude thoracic pathology. Volunteers (n = 48)
were randomly assigned (lottery draw) to either the treatment group (n=30) or the

control group (n=18). MET was applied to correct the participants restricted rotation.
The range of active trunk rotation was increased post-MET intervention for the
treatment group in the restricted direction (10.66°, SD 9.80°), whereas the untreated
non-restricted direction remained relatively unchanged (1.02°, SD 4.88°). The control
groups mean change in ROM following the ten minute latent period revealed a
minimal increase in trunk rotation (1.19°, SD 4.31°) for the restricted direction and
minimal decrease in trunk rotation (-0.5°, SD Finally, comparing the post-treatment
restricted direction with the post-non-restricted direction demonstrated that MET
treatment was effective in restoring symmetry in gross thoracic rotation (t(29)= 0.32,
p>0.25). 2.59°) in the non-restricted direction.

Gary Fryer et al 200437, This is a experimental study to investigate the effect of

various durations of MET isometric contractions on active atlanto-axial rotation
range of motion. 52 asymptomatic subjects (age range 18–43) who displayed a
unilateral active atlantoaxial rotation asymmetry of 4° or more were randomly
allocated to either a 5 (n=17) or 20-second (n=18) isometric contraction MET group,
or a same (n=17) treatment control group. Active atlanto-axial end-range
measurements were recorded pre and post-intervention. Analysis with a one-way
ANOVA revealed significant differences (P=0.04) in the mean change between the 5-
second MET group and the control, but not between the 20-second MET group and
control. MET using 5-second contractions produced the largest mean increase in
rotation, both to the restricted (+6.65°) and non-restricted sides (+0.71°). The 5-
second MET produced a large pre-post effect size (d=1.01), whereas the 20-second
MET (d=0.68) and control (d=0.33) produced moderate and small effect sizes. So this
study demonstrate a significant benefit in the use of a longer (20-second) isometric
contraction when treating the upper cervical spine with MET. The use of a 5-second
isometric contraction appeared to be more effective than longer contraction durations
for increasing cervical range with MET.

Denise K. Burns et al 200638 , States that Muscle energy technique is an established

osteopathic manipulative intervention often used to treat somatic dysfunctions of the
spine. To determine the efficacy of this osteopathic manipulative technique, the
authors compared active cervical range of motion among asymptomatic young and
middle-aged adults (n=18) before and after this treatment protocol, comparing those
results against matched control subjects (n=14) who received same manipulative
treatment. Range of motion was measured in three planes (flexion/extension, lateral
bending, rotation) on all subjects (N=32) using a motion-analysis system. Multiplanar
gross cervical motion restrictions were diagnosed in this asymptomatic population. In
the treatment group, cervical long restrictor muscles were treated with the muscle
energy technique in the sagittal, frontal, and horizontal planes. The control group had
relative restrictions addressed by means ofa same manipulative treatment protocol in
which the barriers to motion were not challenged therapeutically. The muscle energy
technique produced a significant increase in overall regional cervical range of motion
in the treatment group (approximately 4 degrees) when compared with control
subjects (P<.001). Significant differences were also observed in the magnitude of
change in the three planes of movement (rotation, P<.002; lateral bending, P<.01),
with flexion/extension being the least affected (P=.2). These data demonstrate that the
application of the muscle energy technique can produce acute increases in the active
cervical range of motion in asymptomatic subjects.
Gray Fryer et al 201039, Describe the evidence –based medicine approach and use of
MET in increasing muscle extensibility and spinal range of motion and for low back
and neck pain. MET (or similar isometric stretching techniques) is more effective than
passive stretching for increasing muscle extensibilityEvidence for the most effective
direction of contraction to increase flexibility in healthy muscle does exist. To gain
maximum ROM and muscle extensibility, the use of isometric variations that include
recruitment of the agonist muscle is suggested. Agonist contract (AC) and contract-
relax agonist-contract (CRAC) are variants of proprioceptive neuromuscular
facilitation, where the patient actively pushes further into the barrier (AC) or where
isometric contractions away from and into the barrier are alternated. These techniques
have been consistently effective for increasing flexibility. But are appropriate where
muscles are not painful. The duration of the stretch phase for maximum gains in
flexibility should be considered. Many recommend only a few seconds of relaxation
before re-engaging the new barrier, but Chaitow recommends a duration of up to 60 s
for chronically shortened muscles .Studies reporting that duration of stretch influences
the amount and longevity of ROM gains support this recommendation. Further,
longer stretching durations are more effective than short durations.A 60 sec. stretch is
more effective than 15 sec. stretch

PELVIC TILT :

RICHARD GAJDOSIK et al 198540 ,Conducted pilot study to examine intratester

reliability of a test designed to measure the standing pelvic-tilt angle, active posterior
and anterior pelvic-tilt angles and ranges of motion, and the total pelvic-tilt range of
motion . After an instruction session, the pelvic-tilt angles of the right side of 20 men
age between 19 to 34 years were calculated using trigonometric functions. Ranges of
motion were determined from the pelvic-tilt angles. Intratester reliability coefficients
(Pearson r) for test and retest measurements were .88 for the standing pelvic-tilt angle,
.88 for the posterior pelvic-tilt angle, .92 for the anterior pelvic-tilt angle, .62 for the
posterior pelvic-tilt ROM, .92 for the anterior pelvic-tilt ROM, and .87 for the total
ROM. They discuss the factors that may have influenced the reliability of the
measurements and the clinical implications and limitations of the test. . The
correlation coefficients were statistically significant (p < .05)
Michaelt. Cibulka et al 198841, Demostrated the relationship between innominate tilt
and muscle imbalance leading to LBP . Twenty-six patients referred to clinic for
treatment of LBP of nonspecific origin. Criteria for exclusion included pregnancy;
diagnosis of ankylosing spondylitis; and presence of neurological signs such as
anesthesia, absence of deep tendon reflexes, profound muscle weakness, and straight
leg raise of less than 45 degrees. Experimental Group was manipulated during the
intervention period, whereas the patients in the Control Group received no treatment.
The results show that the manipulative technique, which was always performed on the
innominate bone side with the most negative angle with respect to the horizontal
angle of the pelvis on the side to a more positive value (F = 24.46; df = 1,18; p < .05).
Concomitant with this change on the manipulated side was an opposite and almost
equal change in the innominate tilt of the nonmanipulated side, from a more positive
to less positive value (F = 161.74; df = 1,18; p < .05). The differences in pretest and
post test measurements of innominate tilt in the Control Group were not significant.

Levangie PK at al 199642, In this study a cross-sectional case-control approach was

used to estimate the association between low back pain of less than 12 months'
duration and pelvic asymmetry among 21-50-year-old patients seeking physical
therapy services. Pelvic landmark data were obtained in 144 cases and 138 control
subjects. The associations of low back pain with levels of pelvic asymmetry were
estimated by use of odds ratios and 95% confidence intervals. Results shows that
Pelvic asymmetry was not positively associated with low back pain in any way that
seemed clinically meaningful. Asymmetry of posterior superior iliac spine landmarks
showed some evidence of a weak positive association with low back pain.
 RESEARCH METHODOLOGY

Research setting: The study was conducted at Department of Physiotherapy AIIMS,

Delhi.

Source of date:

All patient was recruited from different physiotherapy clinics and hospital of Delhi.

Sampling and size :

60 subject participated in study. subject who fulfilled the inclusion criteria were
included in the study .All the subject were selected by random sampling method and
divided randomly in to two groups.

Inclusion criteria:

1. Acute Episode of low pelvic pain within the previous 6 week .

2. Pain in the lower back region

3. Both male and female

4. Age 20-45 yrs

5. Non specific low back pain

6. Anterior innominate rotation ( ± 11 degree )

7. VAS

8. Provocation test for sacroiliac joint pathology.(Gaensien’s test, Faber’s test etc)

Exclusion criteria:

1. Chonic low back pain more than 6 week.

2. Pain radiated past the knee.

3. Back surgery

4. Specific cause of low back pain(PIVD, Spinal stenosis, Ankylosing

spondylitis etc).
 5. Paresthesia or numbness in to the buttocks or lower extremities.

6. Motor weakness.

7. Spondylolisthesis

8. Sacroilliac pathology

9. Overactive TLF, Erector spinae and Quadratus lumborum associated muscle

shortness

Variables:

Independent -

1 Muscle energy technique

2 Moist heat

Dependent

1 VAS
2 Pelvic tilt

Outcome measure

1 VAS
2 Anterior innominate rotation

Instrumentation:

1. Measuring tape

2. Scale with slider

3. Caliper

4. Couch

5. Towel

6. Scale
 7. Measuring scale

Procedure:

Based on inclusion and exculsion criteria subjects were included in the study.
Random sampling was done and subject were divided in to two groups, A and B. A
was experimental and B was control group respectively.

Patient were given information of study and a written consent was signed . After a
verbal description of the test procedure, the method of testing was demonstrated to the
subject. The subjects were standing on plane floor the ASIS and PSIS were palpated
and marked with removable, small adhesive-backed stars .Then standing pelvic tilt
was measured on a tiled floor. The right ASIS and right PSIS were palpated and
marked with the adhesive-backed stars. We then placed a caliper over the stars.
which was compressed to "firm resistance," and observed and recorded the distance
between the ASIS and PSIS to the nearest centimeters by placing the caliper on
measuring scale . This point to point measurement on one innominate bone should
remain constant without any change in position of that bone. The measurement was
therefore, used to calculate the APT angles. After measuring the distance from the
right ASIS to the right PSIS, we used a sliding pointer on a meter stick mounted on a
wood base to measure the distances from the floor to the right ASIS and from the
floor to the right PSIS .

The slider scale was placed on the flat surface at the distance of 22cm. from the
medial malleolus of subject foot . Same procedure was done on other side .Then
asked the patient to relax and calculate the standing pelvic tilt in millimeters by
using a trigonometric calculation to determined the angel theta using formula:

SinØ = side opposite/Hypotenuse

Where side opposite = Ht. difference between the PSIS and ASIS and the floor

Where Hypotenuse = The distance between the ASIS and PSIS .

Experimental group : ( A )

Patients were asked to lie supine on the treatment table .Then patient placed the
buttock just off the edge of the table and therapist placed the hand on thigh to stabilize
it . The leg with anterior innominate rotation was placed on the therapist ’s shoulder
During the MET, the patients were asked to push their leg in to the therapist shoulder.
And push up with the opposite leg in to therapist hand.

Total four contraction were resisted by a force equal to the subject ’s , and was held
for 5sec with 5 sec rest between each contraction and then muscle was taken to the
new barrier and repeat the same procedure again. Then moist heat was given to
subject for 20 mints.

Control group: ( B )

Moist heat was given to control group for 20 min.

Treatment was given every alternate day ,that is 3 days a week. After 2 week pain
and innominate rotation has been assessed. All outcome measure take again at the
follow up of 4 week. Between the testing session ,subject instruct to only perform
normal activities of daily living and avoid vigorous exercise or heavy lift over 2 week.
Subject also instruct to abstain from pain killers.Three Reading of anterior
innominate and VAS has been taken pre treatment, after treatment ,post treatment.
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 ANNEXURE

CONSENT FORM

I willingly and voluntarily participate

in the research study entitled “LONG TERM EFFECTS OF MUSCLE ENERGY
TECHNIQUE ON PAIN IN INDIVIDUALS WITH NON-SPECIFIC
LUMBOPELVIC PAIN” being carried out by Jyoti Sehrawat M.P.T(Sports) 2 nd year
student of Shri Guru Ram Rai Institute of Medical Sciences. Dehradun.

I have been informed about the title, nature and procedure of the study.

I have been given the opportunity to ask any/all questions and I have been given an
option to withdraw myself from the study if I do not feel satisfied with the study.

I certify that the statement made in the above consent letter have been read and
explained to me in an easy language.

I fully understood the implication of the same.

Date: Signature of participants

Place:

Signature of investigator

Jyoti Sehrawat

M.P.T (Sports) 2nd year

SGRRIMS D.Dun
 ASSESSMENT FORM

Demographic data:

Name OPD/IPD NO.

Age Contact No.

Sex

Occupation

Chief complaint

HISTORY:

Present history

Past history

Medical history

Surgical history

PAIN ASSESSMENT:

Site of pain

Duration

Aggravating factor

Relieving factor

Intensity

VAS

ON PALPATION:

Tenderness

Swelling

Warmth
ON OBSERVATION:

Postural changes

ON EXAMINATION:

ROM

Flexion

Extension

Side rotation

Side flexion

MMT

Back flexors

Back extensors

Side rotation

Side flexors

Anterior innominate rotation

Gaensien’s test

Faber’s test

Rocker’s test

Thomson test

90-90 SLR
 DATA COLLECTION FORM

Name

Age/Sex

Pelvic tilt before treatment

Pelvic tilt after 2 weeks

Pelvic tilt after 4 weeks

VAS SCALE READING

Before treatment

After 2 weeks

After 4 weeks