Effectiveness of bent leg raise technique and neurodynamics in patients with radiating low back pain

Objective: To compare the effectiveness of bent leg raise technique and neurodynamics in patients with low back pain that radiates up to the knee. Methods: The pre-test post-test control group study was conducted at Department of Physical therapy, Maqsood Medical Complex and General Hospital Peshawar from February to July 2019. Patients with radiating low back pain of both genders aged 18-60 years were included in the study. Patients were divided into Group-A and Group-B. Group-A patients received Mulligan bent leg raise technique while Group-B patients received neurodynamics. Both groups received five sessions per week, for four weeks. Numeric pain rating scale, Oswestry disability index and goniometer was used to assess pain, functional disability and straight leg raise range before and after the interventions. Data was analyzed using SPSS version 20. Results: Thirty-two participants with mean age of 38.81±9.94 years, participated in the study. There were no significant differences (P-value >0.05) between the two groups at baseline. Post-treatment, within Group-Analysis showed that all three variables (pain, functional disability and straight leg raise range) significantly (P<0.05) improved in both groups. However, post treatment between Group-Analysis showed that there were no significant differences (P>0.05) between the two groups. Conclusion: Both neurodynamics and bent leg raise technique significantly improved pain, functional disability and straight leg raise range in patients with low back pain that radiates up to the knee. However, there were no significant differences between the groups who received either neurodynamics or bent leg raise technique. doi: https://doi.org/10.12669/pjms.38.1.4010 How to cite this:Adnan M, Arsh A, Ali B, Ahmad S. Effectiveness of bent leg raise technique and neurodynamics in patients with radiating low back pain. Pak J Med Sci. 2022;38(1):---------. doi: https://doi.org/10.12669/pjms.38.1.4010 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Immediate Effect of Static Hamstring Stretching on Dynamic Balance and Gait Biomechanical Variables in Athletes With Hamstring Tightness: A Preliminary Study

Introduction: Flexibility is an essential component of muscle function, and insufficient muscle flexibility may lead to muscle injuries. Decreased hamstring flexibility is one of the frequently reported risk factors for a hamstring strain and diminished athletic performance. Stretching is a commonly used intervention for increasing muscle length. There is a lack of evidence concerning the possible effects of hamstring stretching in balance and gait biomechanics. So, this study was designed to investigate the potential effects of static hamstring stretching on the range of motion (ROM), dynamic balance, and biomechanical variables of gait in athletes with hamstring tightness. Materials and Methods: This study is a single-group, pretest-posttest clinical trial performed on semi-professional female athletes. Twelve female athletes aged 20 to 35 years with bilateral hamstring tightness received a single session of unilateral static hamstring stretching on their randomly selected side. All subjects were assessed for straight leg raise, popliteal angle (using standard goniometry), perceived hamstring tightness (using a visual analog scale). They completed single-leg standing and 15-m walking and running tasks before and immediately after the intervention. The biomechanical parameters, including gait-line length, swing duration, and stance duration in walking tasks, maximum total force and mean total force in running task, and center of pressure (COP) displacement and standard deviation during balance task were measured using OpenGo sensor insole system. The pre-post values were compared using the paired sample t-test, and the level of significance was 0.05. Results: The values for straight leg raise and popliteal angle significantly increased (P<0.05) compared with the baseline, while perceived tightness significantly decreased following stretching (P<0.001). The amplitude (P₌0.006) and standard deviation (P₌0.016) of COP displacement in the mediolateral direction during the single leg stance balance task were significantly decreased after the intervention. Stance duration in slow walking (P₌0.004), as well as stance duration (P₌0.012) and swing duration (P<0.001) in fast walking, were significantly decreased (P<0.05) after stretching. No change was observed in gait biomechanical variables during the running test (P>0.05). Conclusion: The results of this study indicate that static hamstring stretching can be a promising intervention not just for increasing hamstring flexibility but also for improving balance ability.

Scoliosis Secondary to Lumbar Spine Herniated Nucleus Pulposus in Adolescents: A Case Report

Introduction: Herniated nucleus pulposus (HNP) is infrequent among children and adolescents. The first case of surgical intervention for disc herniation was reported in a 12-year-old child. Since then, very few cases or series of cases have been published. The reactive scoliosis is frequently associated with lumbar HNPs, a compensatory effort to relieve nerve compression. Moreover, reactive scoliosis secondary to lumbar HNP is typically associated with children and usually resolves with effective management of lumbar HNP. Although the surgical intervention is frequently employed among adults, only 0.5% of discectomies are carried out in children <16 years old. The current case report is of a 15-year-old girl, with no history of spinal ailment, who presented with a large disc herniation at L4–L5 region, associated with a reactive secondary scoliosis, which was resolved following a successful surgical intervention. Case Report: A 15-year-old female with known case of scoliosis and a history of lower back pain for nine months following a fall while playing football presented at outpatient clinic. She sought medical opinion after two months of persistent pain with radiculopathy to the right side toward big toe. Similarly, there was normal plantar reflex and no clonus or Hoffman sign. There was positive straight leg raise test as well as positive contralateral straight leg raise test. Scoliosis is idiopathic in majority of young patients. However, it might also arise as a part or complication of a triggering health state. Although scoliosis has been frequently associated with lumbar HNP among adolescents, most patients with lumbar disc ailment in this age group might be underdiagnosed initially. Similarly, in our case study the patient was not diagnosed when medical opinion was sought after two months of persistent pain with radiculopathy to the right side toward big toe. The clinical characteristics of pediatric lumbar HNP are usually comparable to those seen in adults; however, one distinguishing feature is that up to 90% have a positive straight-leg raising test. The most common symptom is lumbar pain; limitation of lumbar motility and lassegue are the most common signs. The etiology, pathophysiology, and patterns of the scoliotic posture in cases secondary to HNP remain debated. It is highly recommended to do CT scan in cases of adolescent lumbar HNP to rule out apophyseal ring fracture; accurate diagnosis helps surgeon in planning the appropriate surgical intervention needed. Scoliosis secondary to lumbar disc herniation is observed occasionally, therefore, its clinical significance and pathophysiology are not well-established. However, it is well-recognized that children’s spines have superior adaptive capacity, which shields nervous tissue. An example of this could be scoliosis in patients with root compression, when they bend to the side contrary to the compression, causing an enlargement of the affected foramen and root release. It has been reported that 80% of the patients with disc herniation and scoliosis had the convexity on the side of the root compression. The MRI findings revealed that the scoliosis widened the foramen. Similarly, in our case report the X-ray depicted scoliotic deformity with convexity toward the right side. MRI is the best imaging technique to indicate disc herniation and eliminate other likelihoods in both children and adolescents. Surgical interventions, such as micro-endoscopy discectomy and percutaneous endoscopic lumbar discectomy, could achieve considerable pain relief and function improvement. Our case finding revealed that microscopic discectomy relieved the pain and improved the scoliosis. Conclusion: Lumbar disc herniation is a rare entity among both children and adolescent and may also result in scoliosis and lumbar pain with or without sciatica. Therefore, lumbar disc herniation in association with scoliosis need vigilant evaluation of signs and symptoms in addition to appropriate diagnostic imaging. Imaging has a vital role in the diagnosis of underlying disease state and helps in clinical management along with surgical planning. The appropriate treatment is discectomy.

Effect of Six-Week Traditional Resistance and Functional Training On Functional Performance in Female Netball Players

Background Improving quality of functional movements in athletes generally requires additional training targeting specific functional deficiencies. However, well-rounded, traditional strength and conducting program should also improve player’s movement quality. Therefore, the primary aim of this study was to compare the effect of two different six-week interventions on functional score of female netball players. Methods In a randomized controlled study, players were divided into control and intervention group. Both groups completed identical six-week strength and conditioning program, with the intervention group also completing additional corrective exercises three sessions per week during the same period. Results The results indicate significant main effect in total FMS® score (f= 9.85, p = 0.004). However, the differences in total score may be attributed mainly to differences between groups in active straight leg raise (p = 0.004) and trunk stability push-up test (p = 0.02), as other individual tests demonstrated similar time and group effect. Conclusions These results indicate that a well-rounded strength and conditioning program should result in functional as well as physical performance improvements. However, trainers may include additional functional or corrective exercises as part of the recovery training session to correct individual athlete’s movement patterns. More sport-specific research on functional movement scoring is required to devise effective and sport-specific interventions.

Quality of Knee Strengthening Exercises Performed at Home Deteriorates After One Week

Background: To compare the performance (as determined by lower extremity kinematics) of knee exercises in healthy middle-aged and older individuals immediately after instruction and one week later. Methods: This is a cross-sectional study in a laboratory setting. Nineteen healthy volunteers (age [y] 63.1 ± 8.6, mass [kg] 76.3 ± 14.7, height [m] 1.7 ± 0.1) participated in this study. High speed video and reflective markers were used to track motion during four exercises. The exercises were knee flexion, straight leg raise, and “V“ in supine position, and hip abduction in side lying position. All participants received verbal and tactile cues during the training phase and the therapist observed and, if necessary, corrected the exercises. Upon return a week later the participants performed the same exercises without any further instructions. Knee and hip sagittal and rotational angles were extracted from the motion capture. A repeated measures t-test was used to compare the motions between two visits. Results: Participants demonstrated more knee flexion during straight leg raise and “V in” exercises at the 2nd visit compared to the 1st visit (both p < 0.05). During the “V out” exercise, they performed more external rotation (p < 0.05) while they showed more internal rotation during the “V in” exercise at the 2nd visit compared to the 1st visit. Conclusions: Exercise performance declined significantly in healthy middle-aged and older individuals one week after instruction. This decline occurred despite an instructional exercise sheet being given to every participant. Improper execution of exercise programs might prolong the rehabilitation time and increase levels of pain and impairment unnecessarily.

Clinical and Radiographic Differentiation of Pediatric Patellar Sleeve Fractures and Other Inferior Pole Pathologies (165)

Objectives: Inferior pole patellar sleeve fractures (PSF) are rare injuries that occur in skeletally immature patients with sparse literature on the diagnosis, management, and outcomes of this injury. Diagnosis of PSF can be difficult based on radiographs alone, as only a small bony fragment is often seen. Consequently, PSFs may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larson-Johansson syndrome (SLJS) possibly leading to improper treatment and poor outcomes (Figure 1). The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF and SLJS to help improve diagnostic accuracy. Methods: This was a retrospective review of skeletally immature patients diagnosed with inferior pole patellar pathology between 2011-2019 at a single urban academic center. Patients were identified using both International Classification of Diseases 9th and 10th edition (ICD-9 and ICD-10) codes and Current Procedural Terminology (CPT) codes. Data from medical records (demographics, injury mechanism and physical exam) and lateral knee radiographs (fragment size, fragment displacement, number of fragments, Insall-Salvati, Caton-Deschamps, pre-patellar effusion, intra-articular effusion) was collected. ANOVA, Student’s t-test and Fisher’s exact test were used for comparisons between the three groups. Statistical significance was determined at p<0.05. This study was approved by our institutional review board. Results: A total of 125 patients were included: 82% male, average age 10.7 years (SD 2), 16 PSF, 51 IPF, 58 SLJS patients. There were no significant differences in patient demographics between the three groups (Table 1). Only 24% of SLJS patients presented with acute trauma compared to 100% of the PSF and IPF patients. Fewer PSF patients had an intact straight leg raise (37.5%) compared to IPF (94.1%) and SLJS (98.3%) (p<0.001). SLJS patients were less likely to present with knee swelling (41.4%) compared to PSF (93.8%) and IPF (94.1%) (p<0.001) . Knee effusion was more frequently seen in PSF (81.2%) compared to IPF (37.3%) and SLJS (3.4%) (p<0.001). More patients with SLJS were able to bear weight (87.9%) compared to IPF (11.8%) and PSF (0%) (p<0.001) (Table 2). Radiographically, compared to those with IFP and SLJS, patients with PSFs had increased mean prepatellar swelling (6.1 and 6.5 versus 12.9mm, p<0.001), intra-articular effusion (6.1 and 4.9 versus 9.2mm, p<0.001), maximum fragment size (26 and 17.7 versus 45.3mm, p<0.001) and maximum fragment displacement (1.24 and 1.45 versus 13.30mm, p<0.003) respectively. Compared to SLJS, PSF and IPF patients had higher patella alta with mean Insall-Salvati ratios > 1.2 (Table 3). Conclusions: Differences in clinical features such as straight leg raise, knee swelling, knee effusion, ability to bear weight and radiographic features such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location can all be helpful in improving the accuracy of diagnosing inferior pole injuries in pediatric patients.