RESEARCH PROPOSAL A COMPARATIVE STUDY OF THORACIC KYPHOTIC INDEX

research proposal a comparative study of thoracic kyphotic index measurement in patients with and without mechanical neck pain – a cross se

RESEARCH PROPOSAL
A COMPARATIVE STUDY OF THORACIC KYPHOTIC INDEX MEASUREMENT IN PATIENTS
WITH AND WITHOUT MECHANICAL NECK PAIN – A CROSS SECTIONAL STUDY
MASTER OF PHYSIOTHERAPY IN MUSCULOSKELETAL DISORDERS AND SPORTS
(MPT)

MR. CHATTERJEE RONNIE SWAPAN
DEPARTMENT OF PHYSIOTHERAPY
FR. MULLER MEDICAL COLLEGE
MANGALORE-575002
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
NAME OF CANDIDATE:
MR.CHATTERJEE RONNIE SWAPAN
DEPARTMENT OF PHYSIOTHERAPY
FATHER MULLER MEDICAL COLLEGE
MANGALORE-575002
2.
NAME OF INSTITUTION
FATHER MULLER MEDICAL COLLEGE (DEPARTMENT OF PHYSIOTHERAPY) MANGALORE
3.
COURSE OF STUDY AND SUBJECT
MASTERS OF PHYSIOTHERAPY (MUSCULOSKELETAL DISORDERS AND SPORTS)
4.
DATE OF ADDMISSION TO COURSE
01-06-2011
5.
TITLE OF TOPIC:
A COMPARATIVE STUDY OF THORACIC KYPHOTIC INDEX MEASUREMENT IN PATIENTS
WITH AND WITHOUT MECHANICAL NECK PAIN – A CROSS SECTIONAL STUDY
6.
7
8.
BRIEF RESUME OF THE INTENDED WORK.
6.1 NEED FOR THE STUDY:
Proper posture involves a minimal amount of stress and strain on the
body although correct posture is desired , an ideal posture is the one
with least expenditure and is said to exist when the external auditory
meatus corresponds with the vertical postural line.1
Neck pain is common in general population , with 70% of individuals
affected at some point of time in their lives, and often leads to
disability in 5%-10% of adults presenting with neck pain .2
Mechanical neck pain is common in European and North American
populations , approximately 33-54% of adults experience neck pain
during their live. The source of symptoms in mechanical neck pain is
not completely understood , but has been proposed to be related to
various anatomical structures , present within the cervical spine.3
One of the major factors that perpetuate cervical pain pathology is
postural dysfunction of the cervical and thoracic spine. Majority of
head, neck , jaw and thoracic pain is due to poor posture including
myofascial pain syndrome , fibro myalgia , temporo mandibular joint
dysfunctions and chronic fatigue syndromes.4
In the recent years much attention has been diverted to dysfunction in
the thoracic region which may contribute to pain in the cervical and
lumbar regions. The vertebral column has four curves in which thoracic
kyphosis is the primary curve of the vertebral column and comprises of
12 vertebrae. A normal posture is said to exist when the line of
gravity passes anterior to the thoracic vertebrae. Any change in the
normal kyphosis of the thoracic spine may alter the mechanics of the
entire vertebral column. Thoracic curvature has a influence on weight
bearing and stiffness of curvature may produce compensatory movements
in the mobile cervical and lumbar spine. Mechanical change in the
thoracic curvature and posture are more likely to develop cervical
pain.5
Thoracic kyphosis angle increases with age and is more in females than
compared to males. This increase may alter in the inter vertebral
height and imbalance in supporting anterior and posterior soft tissues
and musculatures. Posture and pain are present in that poor posture in
patients with chronic pain related conditions including lower back
pain and neck related conditions.4
Biomechanical data suggests that an increase in thoracic index may be
related significantly with higher cervical spine loads and trunk
muscle force in upright stance and this might contribute to
dysfunctions and pain.5A decreased thoracic index also contributes to
diminished physical activity , impairment in respiratory functions ,
cervico genic headaches and shoulder pain.4
Clinicians directing therapeutic interventions to the thoracic spine
in patients with neck pain have demonstrated improvement in outcomes
though the entire mechanism remains unclear. A understanding of
thoracic spine posture in patients with neck pain would give rise to
beneficial treatment interventions directed to minimize these
impairments in patients with neck pain. Currently literature does not
give concrete information on the relationship between neck pain and
sagittal posture of the spine.3
Thus the purpose of this study is to use flexi curve in order to
compare thoracic index in patients with and without mechanical neck
pain.
The gold standard method of measuring thoracic sagittal posture is the
standing radiograph. Using this method , the cobb’s angle , modified
cobb’s and computer assisted technique the sagittal posture of the
thoracic spine can be calculated. But , in clinical settings , a
radiological investigation for thoracic posture would not be
indicated. So a reliable , time efficient and simple method for
measuring thoracic kyphosis is beneficial.4
To better understand the consequences of spinal kyphosis , therapists
have begun to measure kyphosis using specialized equipment such as the
flexi curve. The flexi curve has demonstrated values in normal
individuals in assessing thoracic kyphosis.
RESEARCH QUESTION :
Is there a difference in thoracic kyphotic index measurement in
patients with and without mechanical neck pain ?
HYPOTHESIS :
There will be a significant difference in thoracic kyphotic index
measurement in patients with and without mechanical neck pain.
NULL HYPOTHESIS :
There will not be a significant difference in thoracic kyphotic index
measurement in patients with and without mechanical neck pain.
OPERATIONAL DEFINITION :
Mechanical Neck Pain - Pain present in the spinal structures which can
be reproduced with movement.
Thoracic kyphotic index - Anterior posterior diameter of thorax times
100 divided by transverse diameter of thorax.
6.2 AIMS AND OBJECTIVES OF THE STUDY :
1. To measure thoracic index in subjects with mechanical neck pain in
age group of 20-50 years.
2. To measure thoracic index in subjects without mechanical neck pain
in age group of 20-50 years.
3. To compare the same in both group.
4. To compare the thoracic index and neck disability index in subjects
with mechanical neck pain.
6.3 REVIEW OF LITERATURE :
Lewis J and Valentine R 4 did a study on clinical assessment of
thoracic spine and found out that an increase in thoracic kyphosis is
associated with higher spinal loads and trunk muscle force in upright
stance and this increases degenerative process and contributes to
dysfunction and mechanical neck pain. An increased thoracic kyphosis
angle has been associated with diminished physical activities ,
impairment of respiratory functions and cervical pain , headaches and
shoulder conditions.
Thoracic curvature influences movement and stiffness of thoracic spine
may produce compensatory changes in lumbar and cervical regions.
Mechanical consequence of thoracic posture is responsible for
developing spinal pain.5
Posture of thoracic spine is related to neck pain because thoracic
manipulation could restore the mobility in cervico thoracic regions.
The source of symptoms in mechanical neck pain is not completely
understood , but has been reported to be related to various anatomical
structures , particularly zygapophyseal or uncovertebral joints of the
cervical spine.6
Hardacker et al found 39% incidence of thoracic kyphosis in subjects
with neck pain without medications. Thus the findings of Hardacker et
al signifies , the incidence of thoracic kyphosis is more than 4 times
greater in patients with mechanical neck pain when compared with
normal subjects.7
It has been seen that prolonged forward neck posture might increase
loading to the non-contractile structures and abnormal stress on the
posterior cervical spine including the thoracic curvature and causes
myofascial pain. Though studies are required to find out whether this
50 of forward head posture could lead to a significant increase in
stress on posterior cervical region in subjects with mechanical neck
pain. 1
In standing postures , the line of gravity passes ventrally to the
vertebral bodies , with the axial load acting to increase the thoracic
spine. Changes in vertebral shape are likely to occur due to altered
loading patterns and changes in mechanical properties of vertebral
structures. Thus the reduction in thoracic mobility indicates to
modify the thoracic posture whereas compensatory changes are made in
lumbar spine and postural corrections are done in the cervical and
lumbar regions while the less mobile thoracic spine remains unaltered.
5
Goh and colleagues did a study comparing three methods for measuring
thoracic kyphosis including Cobb’s method , Modified Cobb’s and
Computer assisted curve assessment technique and found out that
modified cobb’s and computer assisted technique appears more
appropriate for examination of thoracic kyphosis.8
Lundon et al compared the flexi curve to DeBrunner’s kyphometer and
roentgenograph and no significant difference was found and hence he
concluded that flexi curve and DeBrunner’s kyphometer can be used
periodically, however, flexi curve is lighter , easier to position
accurately on spinal landmarks and less expensive than the kyphometer.
Flexi curve can be used for calculating thoracic kyphotic index as it
has got its own advantages over other methods of measuring kyphosis in
a clinical setup. Flexi curve is easier to measure , convenient ,
lightweight , less expensive and provides more accurate and
reproducible results than inclinometer , kyphometer and
roentgenograph.9
Martha Hinman in 2004 used flexi curve in assessing thoracic index and
postural stiffness in young and older females and found out that
thoracic stiffness was more in older females than young ones. She
recommends the use of flexi curve as very inexpensive and ready to use
instrument that can be used in a clinical setup , though it has got
errors in measurement as once the shape of the curve is lost its
difficult to calculate and co relate kyphotic index.10
The flexi curve has demonstrated values in assessing thoracic kyphosis
in a normal , healthy and elderly population. Poor posture predispose
an individual to accumulate the thoracic kyphosis. The use of flexi
curve instrument for repeated measurements is the need of the hour for
making absolute measurements. This instrument may be useful in
monitoring the change in spinal curvature over time as a consequence
of age and good health. 11
In addition , the measurement of kyphosis is a good indicator of the
effects of postural retraining. Therefore , a flexi curve may be used
in combination with the design of a physical therapy management
strategy for the purpose of postural retraining. Further more , it has
been suggested that the flexi curve allows less experienced
investigators to make reliable measurements. This is particularly
useful in a clinical setting , where , different therapists taking
measurements , the attainment of reliable spinal measurement should be
less dependant upon experts.9
Neck disability index is an outcome tool that contains 10 items to
measure , each item is scored from 0 to 5 and total is expressed in
percentage. The highest score is considered as higher disability. The
neck disability index is considered to be reliable and valid for
patients with mechanical neck pain.12
MATERIALS AND METHODS :
7.1 SOURCE OF DATA :
This study will be conducted in subjects with mechanical neck pain at
Father Muller Medical College Hospital , Physiotherapy Out Patient
Department , Mangalore.
7.2 METHODS OF COLLECTING DATA :
STUDY DESIGN :
A cross sectional study design
SAMPLE PROCEDURES AND SAMPLE SIZE :
104 subjects will be recruited for the study. Informed consent will be
taken from the included subjects.
INCLUSION CRITERIA :
*
Subjects with mechanical neck pain in age group of 20 – 50 years.
*
Normal subjects in age group of 20 – 50 years.
EXCLUSION CRITERIA :
*
Any traumatic injury.
*
Congenital defect of thoracic curvature.
*
Patients with structural and functional scoliosis.
OUTCOME MEASURES :
*
Thoracic kyphotic index.
*
Neck disability index.
TOOLS :
*
A moldable flexi curve ruler ( 32 inches ).
*
Stickers ( different colors).
PROCEDURE :
Subjects :
104 subjects with and without mechanical neck pain will be included
with their consent in Father Muller Medical College Hospital ,
Physiotherapy Out Patient Department , Mangalore.
Assessment :
*
Measurement of thoracic index will be done on patients with and
without mechanical neck pain.
*
Patient will be exposed posteriorly from T1 – L5 spinous process
with prior consent.
*
After palpation of the spine , stickers of different colours will
be used to mark the T1 and T12 spinous landmarks.
*
The patient will be instructed to stand in normal posture and as
tall as possible and flexi curve ruler is aligned to the
anterior-posterior curve of thoracic spine from T1-T12.
*
The moulded flexi curve is then placed on A4 size white paper and
outline of the curve is drawn.
*
Then a straight line is drawn joining the two tips of the curve
and another line is drawn perpendicular from highest point in the
curve intersecting the straight line.

T1
L Thoracic curve
H
T12
T1 - Thoracic spinal first vertebrae
T12 – Thoracic spinal twelth vertebrae
H - Height in cm
L - Length in cm
*
Thoracic index is then calculated by the formulae :
Height ( cm ) / Length ( cm ) of 100.
*
Patients with mechanical neck pain will be asked to rate the
disability of neck pain using Neck Disability Index ( NDI ).
Data Analysis :
Thoracic kyphotic index in patients with and without mechanical neck
pain will be compared using independent ‘t’ test.
Correlation of thoracic kyphotic index with disability of neck pain
will be done using Karl Pearson’s Correlation Co-efficient.
n = 2 [ ( Z α + Z β ) S /d ]2
where, n = sample size
Z α = 0.05 Z β = 0.96
S = Standard deviation
d = Clinical difference between two means
7.3 Does the study require any investigation or intervention to be
conducted on patients or animals ?
Yes
7.4 Has ethical clearance been obtained from your institution in case
of 7.3 ?
Yes
LIST OF REFERENCES :
1.Yip C , Chiu T , Poon A . The relationship between head posture and
severity and disability of patients with neck pain. Journal of manual
therapy.2008;13:148-154.
2.Lee H , Nicholson L , Adams R. Neck muscle endurance and range of
motion data from subjects with treated and untreated neck pain.
Australian journal of Physiotherapy.2004;12:25-32.
3.Lau KT , Cheung KY , Chan K , Chan M , Lo KY , Chiu T. Relationship
between sagittal postures of thoracic and cervical spine , presence of
neck pain , neck pain severity and disability. Journal of manual
therapy.2010;15:457-462.
4.Lewis J , Valentine R. Clinical measurement of thoracic kyphosis.
The study of intra-rater reliability in subjects with and without
shoulder pain. BMC musculoskeletal disorders.2010;11:39.
5.Edmondston S , Singer K. Thoracic spine- anatomical and
biomechanical considerations for manual therapy. Journal of manual
therapy. 1997;2:132-143.
6. Penas CF , Cerro LP , Blanco CR , Conesa A , Juan C , Page M.
Changes in neck pain and active range of motion after a single
thoracic spine manipulation in subjects presenting with mechanical
neck pain. National university of Health Sciences.2007;03:312-320.
7. McAviney J , Schulz D , Bock R , Harrison D , Holland B.
Determining the relationship between cervical lordosis and neck
complaints. Journal of manipulative Physiol Ther 2005;28:187-193.
8. Goh S , Price R , Leedman P , Singer K. A comparison of three
methods for measuring thoracic kyphosis : implications for clinical
studies. British society of Rheumatology.2000;39:310-315.
9.Yanagawa T , Maitland M , Burgess K , Young L , Hanley D. Assessment
of thoracic kyphosis using the flexi curve for individuals with
osteoporosis. Hong Kong Physiotherapy Journal.2000;18:53-57.
10. Hinman M. Comparison of thoracic kyphosis and postural stiffness
in younger and older women. The spine journal.2004;4:413-417.
11.Caneiro JP , O’Sullivan P , Burnett A , Barach A , O’Neil D , Tveit
O , Olafsdottir K. The influence of different sitting postures on head
and neck posture and muscle activity. Journal of manual
therapy.2010;15:54-60.
12. Cleland J , Fritz j , Whitman J , Palmer J. The reliability and
construct validity of the neck disability index and patients specific
functional scale in patients with cervical radiculopathy. The spine
journal.2006;31:598-602.
APPENDIX 1
CONSENT FORM
I, ___________________________________________hereby agree to provide
my fullest consent and co-operation as a subject for the dissertation
work of Mr.Chatterjee Ronnie Swapan titled “A comparative study of
thoracic kyphotic index measurement in patients with and without
mechanical neck pain – a cross sectional study” as a part of his post-
graduation in physiotherapy.
The possible benefits as well as the procedure and duration of the
study have been explained to me. The questions and queries i have
posed have been answered to my satisfaction and i am aware that my
identity will be kept confidential. I am also aware that i can
discontinue the study at anytime i wish to do so.
Date :
Place : Signature
APPENDIX 2
PROFORMA
NAME :
AGE :
GENDER :
DATE :
ANY MEDICATIONS UNDERGOING :
DURATION OF PAIN :

Height Length Formulae
( cm ) ( cm ) h/l of 100

THORACIC INDEX

NDI in %

NECK DISABILITY INDEX

9.
SIGNATURE OF THE
CANDIDATE
10.
REMARKS OF THE GUIDE
11.
NAME AND DESIGNATION OF
11.1 GUIDE
11.2 SIGNATURE
11.3 HEAD OF THE DEPARTMENT
11.4 SIGNATURE
MRS. KAVITHA VISHAL
ASSISTANT PROFESSOR
DEPT OF PHYSIOTHERAPY
MR. NARASIMMAN S.
PROFESSOR
DEPT OF PHYSIOTHERAPY
12.
12.1 REMARKS OF THE
CHAIRMAN AND PRINCIPAL
12.2 SIGNATURE