Chronic Low Back Pain and Pelvic Floor Muscle Strengthening

Chronic Low Back Pain and Pelvic Floor Muscle Strengthening Introduction Chronic Low Back Pain is a common condition now a days and refers to pain localized to lower back or lumbar spine. It is common with in adult population and there is limited research available about using the Pelvic Floor Muscle Strengthening Exercise as a physiotherapy treatment for this condition. In this essay, Chronic Low Back Pain and Pelvic Floor Muscle Strengthening Exercise will be explained briefly and its significance to physiotherapy practice will be discussed with reference to a Randomised Control Trial (RCT) by Manisha Rathi (Appendix A). Furthermore, the philosophical assumptions underpinning this study will be analysed. Finally, by using a critiquing tool (Appendix B) ,the study will be then critiqued for its strengths and limitations. Significance of the Issue Chronic Low Back Pain is a common musculoskeletal problem in modern society. Around 70 % to 85% of population will experience low back pain at some time in their life; and 5% to 15% will develop chronic low back pain (Liddle, Baxter, Gracey, 2004). Low back pain is defined as pain, muscle tension, or stiffness below the costal margin and above the inferior gluteal folds, with or without leg pain (Koes, Tulder Thomas, 2006) and Chronic low back pain is classified as pain and disability lasting for more than 12 week duration (Philadelphia panel, 2001). It commonly occurs in young age when people are in their twenties. Back and spine impairments are common in women with the value of 70.3 per 1000 population than in man where there is 57.3 per 1000 population( Andersson Gunnar, 1999). The common causes of low back pain includes stressed or irritated muscle or ligament. The strain develops over a period of time due to poor posture and when posture is not corrected, strain builds up and eventually stretches or irritates muscle or ligament producing low back pain (E.R. Viera, S Kumar 2007). Another important cause related to the development of chronic low back pain includes imbalance between flexor and extensor muscles of trunk including respiratory muscles and muscles of continence, which are responsible for spinal and pelvic support (Hides et al.,2001, Cholewicki et al., 2005) . Most important symptoms of chronic low back pain are functional disability and pain (Koes et al.,2006). Exercise therapy is widely recommended for the treatment of low back pain (Rasmussen- Barr, Ang, Arvidsson and Nilsson Wikmar, 2009). Pelvic floor exercises that contribute to the contraction of abdominals and lumbopelvic stability seems to be more effective than conventional treatment.( Manisha Rathi,2013). Pelvic Floor Muscles (PFM) form the base of abdominal cavity. Except for, their importance in patients with urinary and faecal incontinence, PFM also play vital role in proper muscle activation for stabilization and unloading of lumbar spine. Furthermore, Pelvic floor muscle contraction have also shown to produce contraction of abdominal muscles and vice -versa (Sapsford and Hodges, 2001). Morkved et al.(2007) suggest that group training (Pelvic floor muscle exercises, aerobic exercises and additional exercises) during pregnancy also provide evidence of beneficial effects in preventing lumbopelvic pain. According to Manisha Rathi (2013), there are very little published evidence to measure the effect of Pelvic floor muscle exercises in the management of chronic low back pain and hence the study was conducted, which further supported the effectiveness of pelvic floor muscle exercise in females with chronic low back pain. Moreover, this physiotherapeutic intervention combined with conventional treatment seems to refurbish the functional ability as well as manage the pain in the females with chronic low back pain. Philosophical Assumptions Underpinning Quantitative Research Understanding of research can improve the depth of professional healthcare practice. Being a person trained in healthcare calls for clinical choices based on best existing research evidence (Polit and Beck 7th ed. p. 4). There are various research designs present, to offer us the appropriate information to support our clinical reasoning. This segment will discover the philosophical assumptions underpinning the research methodology used by Manisha Rathi (2013) in her study regarding the effect of Pelvic Floor Muscle strengthening exercises in chronic low back pain. This is a randomised control trial which is a true experimental type of research characterised by randomisation and control group to minimise systematic bias (Polit and Beck 7th ed. p. 225-226). The Positivist Paradigm The positivist paradigm underlies the existence of some reality and in this, much research activity is directed towards understanding and knowing it (Polit and Beck,7th ed. p.15). The recent evidence-based practice movement is an example of positivist approach to knowing (Grant Giddings, 2002, pg.14) . According to the Grant Giddings Knowledge is to be discovered so that people can explain, predict and control events. The knowledge can be acquired through research and helps with professional decision making and practice, which can lead us to best quality in health care (Polit Beck,7th ed., Grant and Giddings, 2002). Exploring the Research title Effect of Pelvic Floor Muscle strengthening exercises in chronic low back pain, the title makes it understand that the authors were trying to find out the effects of pelvic floor muscle exercises aspiring to improve the treatment plan for a group of individuals. It shows the approach of Manisha Rathi (2013) to be following the Positivist Para digm. In a positivist approach, RCT is valid to a great extent as its methodology is rated higher than others because of the type of evidence it produces(Grant and Giddings, 2002). This is another hint that Manisha Rathi(2013) was utilizing the positivist approach, as she is attempting to give information about a treatment plan by conducting a randomised control trial which is believed to produce the best evidence (Grant Giddings, 2002). Determinism Determinism is an assumption of positivist paradigm and refers to belief that phenomena i.e. observable facts and events are not haphazard or random but rather have antecedent causes (Polit and Beck, 7th ed.). Specifically, it can be said that all events occur pursuant to preceding laws or events. Manisha Rathi(2013) demonstrate determinism in her study by giving the evidence that chronic low back pain can be caused by imbalance between various muscles of trunk including respiratory muscles and muscles of continence (Pelvic floor muscles), which are responsible for spinal and pelvic support and that pelvic floor muscle exercise may show positive effects on the population suffering from this ailment. Deductive Reasoning Deductive reasoning is the process of developing specific predictions from general principles (Polit and Beck 7th ed. p.11). In other words, it is the formation of reasoning from various general statements and involves pre specified design and emphasis on specific concepts. According to Roberts and Burke (1989) It refers to an approach in which a narrow conclusion is reached, based on broader set of premises i.e. general knowledge or other research findings. For positivists, the deductive process is an approach from which one can become aware of a single reality and hypotheses are tested on the basis of a theory (DePoy Gitlins, 2005). Deductive reasoning was demonstrated by Manisha Rathi (2013), as a proper review of the study was done, which helped to form and test the hypotheses that Pelvic Floor Muscle exercise could be beneficial for patients with Chronic low back pain. Objectivity Objective methods are appreciated in quantitative research as much as possible. Objectivity is the extent to which two independent researchers would turn up to an identical or uniform conclusion i.e. judgements are not biased on the basis of personal beliefs (Polit and Beck, 7th ed. p. 340, 562). Manisha Rathis (2013) study demonstrates the basis of objectivity, as the participants had to undergo a particular inclusion and exclusion criteria which assured that only subjects (married females) of a particular age group with chronic low back pain, having persistent symptoms of pain and functional disability for more than twelve weeks must be included in the study. Pregnant females, females having Urogenital dysfunction, Pelvic inflammatory disease, Nerve injury to pelvic floor muscle, any pathology of spine or lower limb were excluded in order to avoid the bias. Defined Protocol and Empirical Evidence In Experimental research, researchers have the Independent variable, which means that the participants are exposed to different treatments or conditions. An Intervention protocol is necessary for the study to develop and specify exactly what intervention will entail i.e. who would administer it, how frequently and for how long a treatment would last. (Polit and Beck, 7th ed.). Manisha Rathi (2013) has followed a specific modules which included subjects enrolment process, their allocation of control group and treatment group and data analysis through different statistical methods. A proper treatment protocol was executed to confirm that the type of treatment and duration received by all the subjects were same. Empirical evidence, according to Polit et al. (7th ed.) is the evidence rooted in objective reality and collected through data collection, utilizing ones own senses rather than through personal beliefs or hunches. Evidence for a study in a positivist paradigm is gathered systematically, using formal instruments to collect the required information. In the study Manisha Rathi (2013) manipulated the independent variables to observe the results. The pain was determined by using the Visual Analogue Scale (VAS) and the functional disability was determined by Oswestry Disability Index. Critique According to Polit Beck,(7th ed.) A studys strengths and limitations can be assessed by critiquing of the research. The reviewers summary of the merits of the study, advice regarding the value of the evidence, and suggestions about improving the study or the report is concluded in a critique. According to Polit and Hungler (6th ed.), the quality of a research is closely related to the kinds of decisions the researcher has made in conceptualizing, designing, executing and interpreting the results of the study and critiquing further helps to provide a feedback. A Critiquing tool (ref. to Appendix B) has been used to explore and examine the strengths and limitations of the study done by Manisha Rathi (2013), which will be discussed in the following paragraphs. The Title, Abstract and Study Purpose The title of the study by Manisha Rathi (2013), is concise and gives us the information and indication about the content of study. It also reflects the research approach and the population examined. The abstract compiles the aim, research design, population, method used, results and a conclusion which provides us a brief information about the overview of the theoretical model underlying the research along with what a reader is going to find in the research paper. The result and conclusion provides a basis and creates a curiosity for a further detailed reading. Manisha Rathi (2013) has precisely determined the studys purpose of investigating the efficacy of a therapeutic exercise (Pelvic Floor Exercise) method, on a particular population, in the studys title and abstract. This is an important issue in the field of physiotherapy practice, as Chronic low back pain is a very common ailment within the adult population and the symptoms like increased pain and disability hampers the activities of daily living and is required to be addressed properly. Research Design and Research Hypotheses Manisha Rathi (2013) has applied a true-experimental design (pre test post test control group design ) and cause effect was tested through the hypothesis that PFM exercises could be of benefit for the patients with chronic low back pain. In this study the hypothesis was formulated, followed by a literature review, and then hypothesis was confirmed by process of various measurements and statistical methods. The research design was appropriate as per the research purpose and it also minimized bias and replication of this study is also possible as the study was well explained. Literature review The literature review done by Manisha Rathi (2013) was brief, up to date and included all the important information required for the study. It provides a solid basis for the new study. It was also portrayed and organised in an easy manner to understand, as it started with an introduction of low back pain, its classification, clinical factors and symptoms followed by brief information about the pelvic floor muscles exercises. Study Sample Manisha Rathi (2013) conducted a randomised control study on thirty married females, under the age group between 20- 40 years, with chronic low back pain. They were divided by random allocation into two groups i.e. an experimental and a control group. The researcher has given a good information and has well described the study sample of females with Chronic low back pain. She has followed a particular inclusion criteria and exclusion criteria for the selection of participants in order to minimize bias which strengthens the studys internal validity and also might help in getting efficient results. However, the trial was carried on a small sample size i.e. only on thirty females, 15 in each group (group A and group B). Ethical Considerations The ethical approval was granted for Manisha Rathis(2013) study by the Institutional Ethical Committee of Dr. D.Y. Patil College of Physiotherapy, Pune. The study was conducted in the Out Patient Department of the college and an informed consent was obtained from all the participants. However, it is not mentioned whether the participants were fully aware about the nature of the research or not. Data Collection and Analysis Methods of gathering data was appropriate. Pre intervention readings and post intervention readings were taken on the 1st day of visit and at the end of 4 weeks respectively. However, there were no follow ups. Manisha Rathi (2013), in her study, assessed pain intensity, in a subjective way, by utilizing Visual Analogue Scale and functional disability was also assessed in a subjective way, by utilizing Oswestry Disability Index , which is a reliable questionnaire. Study Results The study done by Manisha Rathi (2013) shows that the research hypotheses was adequately answered as there was improvement in pain and functional disability levels, following the treatment. Manisha Rathi(2013) has shown her findings in the graphs and has given the P value, which makes it easy to understand and co-relate the results with her conclusion. The Findings based on Manisha Rathis (2013) study would help physiotherapists to achieve better and efficient results while treating patients of Chronic low back pain with the help of Pelvic Floor Muscle exercises. However, limitations of the study includes that the pain intensity and functional disability were measured in a subjective way, on a small sample size and no follow up for treatment was done. Also, EMG and ultrasound was not done for objective outcome measures such as muscle activity and muscle thickness. Discussion The study done by Manisha Rathi(2013) supports the hypothesis that Pelvic Floor Muscle exercise could be of benefit for the patients with Chronic low back pain. Furthermore, the findings and results of her study were well linked to the facts and information provided by her in the literature review which forms a strong base of the study. Refrences Manisha Rathi (2013), has explored and gathered an ample amount of literature from various studies done in the past. This might be because low back ache is a very common condition and many studies have already been done on this ailment and its treatment. Appendix B Critiquing Tool The title Is it concise yet informative? Is the research approach suggesting the key phenomenon? Is the population group identified? The abstract Are the study area, methods, processes, conclusions and implications correctly and concisely described? Where the aims and/or objectives stated ? Does it provide a good basis for deciding whether or not the study is worth reading? Study purpose Is the purpose of the study/research problem clearly identified and relevant to your practice? Research design and research hypothesis Is there a framework/theory to guide the study? Is it appropriate? Who will be studied? What is the plan for conducting the study? Are all variables described? Does the hypothesis reflect the purpose of the study? Literature review Is the literature review provide a solid basis for the new study? Study sample Who is identified as the target population? How were the subjects chosen (e.g., randomly, conveniently)? Who is included? Who is excluded? Is the sample size sufficient? Ethical considerations Were the participants fully informed about the nature of the research? Was ethical permission granted for the study? Data collection and analysis What steps were taken to collect the data? How often was data collected and for how long? What instruments or tools were used? Are the tools adequately described for you to understand what the score means? Were data analysis procedures appropriate? Study results Is the research hypothesis answered? Could you make a change in your practice based on the results of this study? What are the strengths to using the information learned? What are the limitations or the gaps in the study? Discussion Are the findings linked back to the literature review? If a hypothesis was identified, was it supported? References Were all the books, journals and other media alluded to in the study accurately referenced? Sources Polit Beck.(2010) Essentials of nursing research: Appraising evidence for nursing practice(7th ed.) Lippincott.(pg no.102-103) Ryan, F., Coughlan , M., Cronin, P.(2007). Step-by-step guide to critiquing research. Part 2: qualitative research. British Journal of Nursing, 16, 11, 738-744. Schneider , Elliott , Lo Biondo Wood, Haber (2003), Nursing research methods, critical appraisal and utilisation. (2nd ed.). . 1