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The effectiveness of mechanical cervical traction combined with conventional therapy on patients with unilateral mechanical neck pain
 

The effectiveness of mechanical cervical traction combined with conventional therapy on patients with unilateral mechanical neck pain

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    The effectiveness of mechanical cervical traction combined with conventional therapy on patients with unilateral mechanical neck pain The effectiveness of mechanical cervical traction combined with conventional therapy on patients with unilateral mechanical neck pain Document Transcript

    • 1THE EFFECTIVENESS OF MECHANICAL CERVICAL TRACTION COMBINED WITHCONVENTIONAL THERAPY ON PATIENTS WITH UNILATERAL MECHANICAL NECK PAINA research project submitted byBhatt Jahnvi AshokkumarRathod Prerna NaranbhaiTandel Krupali VinodbhaiTandel Soniya SumanbhaiUnder the Guidance ofDr. DIBYENDUNARAYAN BID [PT]MPT (Ortho), PGDSPTSENIOR LECTURERThe Sarvajanik College of Physiotherapy,Rampura, Surat.
    • 2DeclarationThis is to certify that Project entitled ‘THE EFFECTIVENESS OF MECHANICALCERVICAL TRACTION COMBINED WITH CONVENTIONAL THERAPY ON PATIENTSWITH UNILATERAL MECHANICAL NECK PAIN’ is submitted by us in Bachelor ofPhysiotherapy to ‘The Sarvajanik College of Physiotherapy, Surat’ comprisesonly our original work and due acknowledgement has been made in the text to allother material used.Date: 18thJune, 2013 Bhatt Jahnvi AshokkumarRathod Prerna NaranbhaiTandel Krupali VinodbhaiTandel Soniya SumanbhaiApproved by: Dr. Dibyendunarayan Bid [PT]
    • 3CERTIFICATEThis is to certify that Project entitled ‘THE EFFECTIVENESS OF MECHANICALCERVICAL TRACTION COMBINED WITH CONVENTIONAL THERAPY ON PATIENTSWITH UNILATERAL MECHANICAL NECK PAIN’ which is submitted by Bhatt JahnviAshokkumar, Rathod Prerna Naranbhai, Tandel Krupali Vinodbhai and TandelSoniya Sumanbhai, is a record of the candidates’ work carried out by them undermy guidance and supervision.The concept, design and review for this project were provided by the guide.The data analysis and interpretation were provided by Dr. ThangamaniRamalingam A.The matter embodied in this project work is original.Date: 18thJune, 2013 Dr. Dibyendunarayan Bid [PT]Guide’s signature
    • 4ACKNOWLEDGEMENTWe owe our sincere thanks to Dr. Dibyendunarayan Bid [PT] for his constant guidanceand suggestions.We sincerely thank to Dr. Thangamani Ramalingam A. [PT] for helping us in dataanalyses and interpretation.We sincerely thank all our teachers who taught us the finesse of physiotherapy.It is indeed a matter of deep satisfaction to acknowledge our gratitude towardsAlmighty.We want to thank our respective dear parents who always held us high throughoutour study.Bhatt Jahnvi AshokkumarRathod Prerna NaranbhaiTandel Krupali VinodbhaiTandel Soniya Sumanbhai
    • 5ContentsCHAPTER 1 - INTRODUCTION........................................................................................................................91.1 The Problem and its Setting..................................................................................................................91.2 Aim of the Study .................................................................................................................................111.3 Hypothesis...........................................................................................................................................111.3.1 Null Hypothesis ..........................................................................................................................111.3.2 Alternate Hypothesis .................................................................................................................111.4 Benefits of the Study .......................................................................................................................... 12CHAPTER 2 – REVIEW OF THE RELATED LITERATURE .................................................................................132.1 Incidence and Prevalence of Neck Pain.............................................................................................. 132.2 Mechanical Neck Pain........................................................................................................................ 142.2.1 Definition, etiology, risk factors and diagnosis of mechanical neck pain..................................142.2.2 Clinical Presentation ..................................................................................................................162.3 Basic Normal Anatomy of Cervical spine............................................................................................ 162.4 Functional Biomechanics of Cervical Spine (Levangie & Norkin, 2005) ............................................ 182.4.1 Kinematics..................................................................................................................................182.4.2 Kinetics.......................................................................................................................................232.5 Cervical Spine Traction ......................................................................................................................252.5.1 Introduction ...............................................................................................................................252.5.2 Indication for Cervical Spine Traction........................................................................................262.5.3 Types of Cervical spine Traction ................................................................................................262.5.4 Most effective positions for applying cervical traction .............................................................272.5.5 Force to be used in cervical spine traction ................................................................................272.5.6 Optimum angle for cervical spine traction ................................................................................272.5.7 Effects of Cervical spine Traction...............................................................................................28CHAPTER 3 – METHODOLOGY ....................................................................................................................293.1 Introduction.........................................................................................................................................293.2 Aim of Study......................................................................................................................................29
    • 63.3 STUDY DESIGN ................................................................................................................................293.4 SUBJECT RECRUITMENT.................................................................................................................293.4.1 Sample and Selection Criteria....................................................................................................303.5 INCLUSION AND EXCLUSION CRITERIA .........................................................................................303.5.1 Inclusion criteria.........................................................................................................................303.5.2 Exclusion criteria........................................................................................................................323.6 RESEARCH METHODOLOGY/PROCEDURE....................................................................................323.6.1 Treatment Group A – Mechanical cervical traction with conventional therapy. ......................333.6.2 Treatment Group B – Conventional therapy alone. ..................................................................333.7 MEASUREMENTS..............................................................................................................................343.7.1 Objective measurements...........................................................................................................343.7.1.1 Universal Goniometer.............................................................................................................343.7.2 Subjective measurements..........................................................................................................353.7.2.1 Neck Disability Index (NDI)......................................................................................................353.7.2.2 Numerical Pain Rating Scale....................................................................................................35CHAPTER 4 – DATA ANALYSES AND INTERPRETATION...............................................................................364.1 Statistical analyses .............................................................................................................................364.2 Results...............................................................................................................................................364.2.1 One way repeated measure ANOVA for within group difference.............................................374.2.2 Independent t-test for between groups difference...................................................................464.2.3 NDI within Groups......................................................................................................................484.2.4 NDI between Groups..................................................................................................................484.2.5 Correlation analysis for both the groups at week 2...................................................................504.3 Limitations of Study............................................................................................................................ 514.4 Discussion.......................................................................................................................................... 514.5 Conclusion .........................................................................................................................................52CHAPTER 5 – RECOMMENDATIONS............................................................................................................545.1 Recommendations...............................................................................................................................54Bibliography ................................................................................................................................................56
    • 7Appendices..................................................................................................................................................60Appendix-I: Neck Disability Index - Gujarati Version.................................................................................60Appendix-II: Numerical Pain Rating Scale (NPRS)...................................................................................62Appendix –III: Consent Letter ...................................................................................................................63Appendix-IV: Raw Data ............................................................................................................................64List of TablesTable 1 : Demographical characteristics.....................................................................................................36Table 2 : Demographic & clinical characteristics ........................................................................................37Table 3 : Measure- Flexion- Traction Group ...............................................................................................38Table 4 : Measure- Flexion- Conventional Group.......................................................................................39Table 5 : Measure- Extension – Traction Group .........................................................................................40Table 6 : Measure- Extension – Conventional Group .................................................................................40Table 7 : Measure- Side Flexion – Traction Group......................................................................................41Table 8 : Measure- Side Flexion – Conventional Group..............................................................................42Table 9 : Measure- Rotation – Traction Group...........................................................................................43Table 10 : Measure- Rotation – Conventional Group.................................................................................43Table 11 : Measure- NPRS- Traction Group................................................................................................44Table 12 : Measure- NPRS – Conventional Group ......................................................................................45Table 13 : Between Groups differences independent t-test ......................................................................46Table 14 : Paired Sample t-test...................................................................................................................48Table 15 : Independent Sample t-Test........................................................................................................49Table 16 : Correlations (N=40)....................................................................................................................50
    • 8List of FiguresFigure 1 Nodding motions of the atlanto-occipital joints. A. Flexion. B. Extension....................................20Figure 2 Superior view of rotation at the atlantoaxial joints: The occiput and atlas pivot as one unitaround the dens of the axis. .......................................................................................................................21Figure 3 A. Flexion of the lower cervical spinecombines anterior translation and sagittal plane rotationof the superior vertebra. B. Extension combines posterior translation with sagittal plane rotation. ......22Figure 4 Motion at the lower cervical interbody joints occurs in the plane of the zygapophyseal jointsabout an axis perpendicular to the plane...................................................................................................23List of GraphsGraph 1: Comparison of NPRS between groups.........................................................................................45Graph 2: Comparison of NDI between groups............................................................................................49
    • 9CHAPTER 1 - INTRODUCTION1.1 The Problem and its SettingThe average amount of productive time lost due to individuals suffering fromneck pain ranges from 2.8-11.3%, with the annual incidence of neck pain amongthe working population ranging from 6-23 per 10,000 people (Côté et al., 2008). Itis found that 34% of the population suffers from neck pain, and 26-65% of thosesuffer from mechanical neck pain.Mechanical neck pain (MNP) is the most common type of cervical spine painencountered. It is also referred to as simple or non-specific neck pain, and iscommon in all groups of people. Often the exact cause of pain is unknown. It mayinclude discogenic pain, myofascial trigger points, ligaments in the cervical spine;cervical facet syndrome or poor posture may also contribute to this pain.The etiology of neck pain multifactorial and poorly understood (Binder, 2007)(Bergman & Peterson, 2002). The common factors include poor posture,depression, anxiety, aging, acute injury and occupational or sporting activities.This leads to altered joint mechanics, muscle structure or function and can resultin mechanical neck pain. Gatterman; and Peterson & Bergman stated that themost common cause of MNP is zygapophyseal joint locking and muscle strain(Gatterman, 1998) (Bergman & Peterson, 2002).According to Peloza, neck pain can be either intrinsic or extrinsic in nature.Intrinsic pain is broken down into mechanical neck pain, this type of neck pain isany neck pain which originates from the joints or intervertebral discs, whereasextrinsic conditions are conditions which cause pain in the cervical spine; they
    • 10include nerve root irritation, compression neuropathies, shoulder pathologies andcardiovascular condition (Peloza, May 02, 2007).An inflammatory reaction is initiated by musculoskeletal dysfunction; this isidentical to that for an infection. Pain accompanying inflammation may initiate alocal reflex muscle contraction, which over time may lead to ischemia andtherefore more pain (Bergman & Peterson, 2002).Cervical traction consists of administering a distracting force to the neck in orderto separate the cervical segments and relieve compression of nerve root byintervertebral discs. Several techniques and different durations have beenrecommended in the literature (Colachis & Strohm, 1965). However, due to poormethodological quality of the available data, there is currently little evidence tosuggest that individuals with MNP may benefit from physiotherapy combinedwith traction aimed at improving hand strength, neck discomfort and todecompress nerve impingement (Joghataei et al., 2004) (Jellad et al., 2009)(Young et al., 2009).In a similar type of study Joghataei et al. randomly assigned 30 patients with C7radiculopathy due to disc herniation and/or cervical spondylosis to take part in atreatment programme consisting of regular physiotherapy and exercises eitherwith or without intermittent cervical traction for 10 sessions. The group whoreceived intermittent cervical traction exhibited better improvements in gripstrength after 5 sessions, but not statistically significant differences wereobserved between the two groups after 10 treatment sessions. Since, the authorsdid not interpret the patients according to their etiology; the real benefits of thecervical traction could not be ascertained (Joghataei et al., 2004).With the above consideration, the present study was performed to compare theclinical parameters of cervical traction with conventional physiotherapy andconventional physiotherapy alone in the treatment of MNP.
    • 111.2 Aim of the StudyThe aim of the study is to compare the efficacy of ‘mechanical cervical tractionwith conventional physiotherapy’ and ‘conventional physiotherapy alone’ inmechanical neck pain. Here efficacy is measured on the basis of followingoutcome measures: Neck Disability Index (NDI), Numerical Pain Rating Scale(NPRS), and Goniometry for cervical range of motion.1.3 Hypothesis1.3.1 Null HypothesisH1: There will be no difference in pain relief due to ‘mechanical cervical tractionwith conventional physiotherapy’ and ‘conventional physiotherapy alone’ inmechanical neck pain.H2: There will be no difference in improvement of ROM of cervical spine i.e.flexion, extension, side flexion (affected side), rotation (affected side) due to the‘mechanical cervical traction with conventional physiotherapy’ and ‘conventionalphysiotherapy alone’ in mechanical neck pain.H3: There will be no difference in Neck Disability Index outcome measure of the‘mechanical cervical traction with conventional physiotherapy’ and ‘conventionalphysiotherapy alone’ in mechanical neck pain.H4: There will be no difference in Grip Strength improvement of the ‘mechanicalcervical traction with conventional physiotherapy’ and ‘conventionalphysiotherapy alone’ in mechanical neck pain.1.3.2 Alternate HypothesisA1: There will be difference in pain relief of the ‘mechanical cervical traction withconventional physiotherapy’ and ‘conventional physiotherapy alone’ inmechanical neck pain.
    • 12A2: There will be difference in improvement of ROM of cervical spine i.e. flexion,extension, side flexion (affected side), rotation (affected side) due to the‘mechanical cervical traction with conventional physiotherapy’ and ‘conventionalphysiotherapy alone’ in mechanical neck pain.A3: There will be difference in Neck Disability Index outcome measure of the‘mechanical cervical traction with conventional physiotherapy’ and ‘conventionalphysiotherapy alone’ in mechanical neck pain.A4: There will be difference in Grip Strength improvement of the ‘mechanicalcervical traction with conventional physiotherapy’ and ‘conventionalphysiotherapy alone’ in mechanical neck pain.1.4 Benefits of the StudyThis study will add to the growing body of knowledge regarding the benefit ofcombining the cervical traction with conventional physiotherapy in the treatmentof MNP.The expected outcome of this study was to show if these two therapy techniquesyield comparable outcomes and if one technique is superior to the next whichshould be the alternate choice of therapy.
    • 13CHAPTER 2 – REVIEW OF THE RELATED LITERATURE2.1 Incidence and Prevalence of Neck PainThe prevalence of neck pain in musculoskeletal practice is second only to that oflow back pain (Vernon et al., 2007). In a cross-sectional survey on neck painwithin the general Norwegian population, Bovim et al. found that 34.4% of the9918 responders had experienced neck pain within the last year and 13.8%reported neck pain lasting more than six months (Bovim et al., 1994). In aCanadian epidemiological neck pain study (n = 1133), Côte et al. found thatthe six month prevalence of neck pain was 54.2% (Côte et al., 2003).Guez et al. did a population-based study on the prevalence of neck pain innorthern Sweden (n = 6000) and found that 43% of the population reportedneck pain (48% woman and 38% men) and 18% of the population (19%woman and 13% men) had chronic neck pain (lasting longer than six months).Thirteen percent of these cases were of a non-traumatic origin and only 5% weretraumatic (Guez et al., 2002).In South Africa, Ndlovu did a survey (n = 1000) of the indigenous Africanpopulation within the greater Durban area and found that individuals betweenthe ages of 21 – 30 years of age had a 50% incidence of neck pain and individualsbetween the ages of 31 – 60 years of age had a 46.7% - 54.5% incidence of neckpain (Ndlovu, 2006).Due to the high incidence and prevalence of neck pain, internationally it is veryimportant to further evaluate efficacy of treatment techniques in the form ofclinical trials to improve the prognosis of mechanical neck pain.
    • 142.2 Mechanical Neck PainThere has been a slow but constant increase in the amount of attentionpaid to neck pain due to its escalating costs and burden on society (Côte etal., 2003). Twenty-six to 71% of the adult population can recall experiencing anepisode of neck pain or stiffness in their life time. Neck pain is more common infemales than in males, with rates reported as high as 77.8% (Graham et al., 2008).The natural history is unclear. Neck pain has a costly impact on society because ofvisits to health care providers, sick leave, disability and loss of productivity. Thereare a number of treatments available for neck pain, one of which is mechanicaltraction.2.2.1 Definition, etiology, risk factors and diagnosis of mechanical neckpainThe term mechanical neck pain (MNP) can be explained as the physical forcesacting upon the cervical spine.Pain can be caused by abnormal stress and strain on the vertebral columnand surrounding structures through poor posture, lifting and sitting habits.Gatterman; and Bergman et al. stated that the most common cause of mechanicalneck pain is zygapophyseal joint locking and muscle strain (Gatterman, 1998)(Bergman et al., 1993).According to Haldeman, the Bone and Joint Decade 2000-2010 Task Force onNeck Pain and Associated Disorders suggested the following classification systemfor neck pain (Haldeman et al., 2008):Grade I: Neck pain with no or minor interference with daily activitiesGrade II: Neck pain with major interference on activities of daily living
    • 15Grade III: Neck pain with neurological signs and symptomsGrade IV: Neck pain due to structural pathologyAccording to Binder, most patients present with “non-specific (simple) neckpain” where the signs and symptoms have a postural or mechanical basis.Therefore, for the purpose of this study mechanical neck pain will beclassified as either Grade I or Grade II according to the above classificationsystem (Binder, 2007).Peterson and Bergman stated that any event or condition (e.g. incorrectposture, ageing, acute injury, congenital or developmental defects) whichleads to altered joint mechanics or muscle structure or function, can resultin mechanical neck pain (Bergman & Peterson, 2002).Risk factors for mechanical neck pain include work that is physicallydemanding or of a repetitive static nature, those of lower socioeconomicstanding, individuals with a history of previous neck trauma and those with co-morbid pathologies. It has also been shown that the incidence of neck painincreases with age and is more common among woman (Côte et al., 2003).The diagnosis of mechanical neck pain can be made according to thefollowing criteria (Grieve, 1988):a) Local chronic cervical pain with or without arm painb) Juxtaposition of hypo- and hypermobile segments of the cervicalspine due to spondylitic changesc) Asymmetrical neck pain that gets worse as the day progresses and isaggravated by driving, reading etc.d) Unilateral occipital pain and neck pain
    • 16e) Restricted and painful movements, especially rotation and lateralflexion to the painful sidef) Prominent Levator Scapulae and upper and middle Trapezeus muscle2.2.2 Clinical PresentationPatients complaining of MNP may experience symptoms such as a dull aching painwhich may be sharp in character during inflammatory periods. There may beassociated symptoms of decreased cervical spine range of motion, musclehypertonicity, pain and /or headaches. MNP may be defined as pain which isaggravated by movement, relieved by rest and that is not associated with seriousunderlying pathology (Hubka & Hall, 1994). The pain is predominantly localized tothe cervical spine. The pain may radiate into the head, shoulder or between thescapulae, this is predominantly due to myofascial involvement (Travell et al.,1999).During the physical examination postural changes may be evident such as anantalgic position of the head compared to the shoulder position, wry neck,decreased cervical lordosis, and/or anterior head carriage (Vizniak & Carnes,2008). Active, passive and/or resisted isometric movements may be limitedand/or painful (Vizniak & Carnes, 2008).Probable causes of MNP may include cervical disc injuries/prolapse, whiplash,myofascial strains, ligamentous sprains, arthritis of the cervical spine, cervicalspine injury and occupational habits such as, poor posture (Vizniak & Carnes,2008), all pathologies that may have lead to instability and would be contra-indicated to cervical traction were ruled out by way of an extensive history andcervical spine regional examination.2.3 Basic Normal Anatomy of Cervical spine
    • 17The cervical spine consists of seven vertebrae, which are divided into typical(C3-C6) and atypical (C1, C2 and C7) vertebrae (Gatterman, 1990). The vertebralartery passes through the oval transverse foramina of C1 to C6 (Moore & Dalley,1999). The vertebral body of typical cervical vertebrae is small and longerfrom side to side than anteroposteriorly. The superior surface is concave(which forms the uncinate joints laterally) and convex inferiorly. The uncinatejoints are also known as the joints of Luschka. Some consider these joints to bedegenerative spaces in the discs that are filled with extracellular fluid, whileothers classify them as synovial type joints (Moore & Dalley, 1999) because theyhave articular cartilage, a joint space, a synovial membrane, subchondral boneand a joint capsule. These joints form a barrier to posterolateral discprotrusion, thereby protecting the spinal cord. However, if they hypertrophynarrowing of the intervertebral canal may occur which can lead to nerve rootentrapment (Porterfield & DeRosa, 1995).On the posterior aspect of the vertebrae, the two pedicles and two laminae formthe neural arch (Panjabi & White, 1990) which forms the boundaries of thetriangular vertebral foramen (Haldeman, 1992). The spinous process, as well asthe two transverse processes, arise from the laminae (Panjabi & White, 1990).The joints on the superior and inferior surfaces of the transverse processes areknown as zygapophyseal or facet joints. The facet joints are orientatedapproximately 45° to the horizontal and 90° to the sagittal plane(Haldeman, 1992). The superior facet of the facet joint is directed supero-posteriorly and the inferior facet is directed in an infero-posterior direction(Moore & Dalley, 1999). The joint capsules are richly innervated by thesinuvertebral or recurrent meningeal nerve and nociceptive fibers. Therefore,injury to this capsule will result in pain.Each of the atypical vertebrae is unique in their own way. The atlas is thefirst cervical vertebrae; it has no body or spinous process but instead twolateral masses connected by anterior and posterior arches. The superior
    • 18articular facets are concave to receive the occipital condyles of the skull.The C2 vertebrae, known as the axis, has a odontoid peg which projectssuperiorly from the body. The last cervical vertebrae (C7), also known asvertebra prominence due to its long spinous process, which is not bifid likethe rest of the cervical spine. The transverse processes of C7 are large but thetransverse foramina are too small for the vertebral artery to pass through (Moore& Dalley, 1999).There are intervertebral discs in between all cervical vertebrae except C1and C2. These discs make up one fourth of the length of the cervical spine.They are thicker anteriorly, thereby contributing to the cervical lordosis (Moore& Dalley, 1999).2.4 Functional Biomechanics of Cervical Spine (Levangie & Norkin, 2005)Although the cervical region demonstrates the most flexibility of any of theregions of the vertebral column, stability of the cervical region, especially of theatlanto-occipital and atlantoaxial joints, is essential for support of the head andprotection of the spinal cord and vertebral arteries. The design of the atlas is suchthat it provides more free space for the spinal cord than does any other vertebra.The extra space helps to ensure that the spinal cord is not impinged on during thelarge amount of motion that occurs here. The bony configuration of the atlanto-occipital articulation confers some stability, but the application of small loadsproduces large rotations across the occipito-atlanto-axial complex and also acrossthe lower cervical spine.2.4.1 Kinematics
    • 19The cervical spine is designed for a relatively large amount of mobility. Normally,the neck moves 600 times every hour whether we are awake or asleep. Themotions of flexion and extension, lateral flexion, and rotation are permitted in thecervical region. These motions are accompanied by translations that increase inmagnitude from C2 to C7. However, the predominant translation occurs in thesagittal plane during flexion and extension. Excessive anteroposterior translationis associated with damage to the spinal cord.The atlanto-occipital joints allow for only nodding movements between the headand the atlas (Fig. 1). In all other respects, the head and atlas move together andfunction as one unit. The deep walls of the atlantal sockets prevent translations,but the concave shape does allow rotation to occur. In flexion, the occipitalcondyles roll forward and slide backward. In extension, the occipital condyles rollbackward and slide forward. Axial rotation and lateral flexion are not physiologicalmotions at these joints, inasmuch as they cannot be produced by muscle action.
    • 20Figure 1 Nodding motions of the atlanto-occipital joints. A. Flexion. B. ExtensionThere is little agreement about the extent of the range of motion (ROM) availableat the atlanto-occipital joints. The combined ROM for flexion-extensionreportedly ranges from 10° to 30°. The total ROM available in both axial rotationand lateral flexion is extremely limited by tension in the joint capsules that occursas the occipital condyles rise up the walls of the atlantal sockets on thecontralateral side of either the rotation or lateral flexion.Motions at the atlantoaxial joint include rotation, lateral flexion, flexion, andextension. Approximately 55% to 58% of the total rotation of the cervical regionoccurs at the atlantoaxial joints (Fig. 2). The atlas pivots about 45° to either side,or a total of about 90°. The alar ligaments limit rotation at the atlantoaxial joints.
    • 21The remaining 40% of total rotation available to the cervical spine is distributedevenly in the lower joints.The shape of the zygapophyseal joints and the interbody joints dictates themotion at the lower cervical segments. Pure anterior translation does not occur,because it would cause the zygapophyseal joints to abut one another. Flexion ofthese segments must include anterior tilt of the cranial vertebral body coupledwith anterior translation. Given the 45° slope, tilt of the vertebral body, inaddition to anterior translation, is necessary to get full motion from these joints(Fig. 3). Extension includes posterior tilt of the cranial vertebral body, coupledwith posterior translation. Lateral flexion and rotation are also coupled motions,because movement of either alone would cause the zygapophyseal joints to abutone another and prevent motion. Lateral flexion is coupled with ipsilateralrotation, and rotation is coupled with ipsilateral lateral flexion. These motions arealso a combination of vertebral tilt to the ipsilateral side and translations at thezygapophyseal joints.Figure 2 Superior view of rotation at the atlantoaxial joints: The occiput and atlas pivot as oneunit around the dens of the axis.
    • 22Figure 3 A. Flexion of the lower cervical spinecombines anterior translation and sagittal planerotation of the superior vertebra. B. Extension combines posterior translation with sagittalplane rotation.Mercer and Bogduk suggested that the notion of lateral flexion and horizontalrotation are an artificial construct (Mercer & Bogduk, 2001). In their view,movement should be viewed as gliding that occurs in the plane of thezygapophyseal joints (Fig. 4). In this plane, the coupled motions are evident.Lower cervical segments generally favor flexion and extension ROM; however,there is great variability in reported ranges of motion in the individual cervicalsegments. In general, the range for flexion and extension increases from theC2/C3 segment to the C5/C6 segment, and decreases again at the C6/C7 segment.The zygapophyseal joint capsules and the ligaments, in addition to the shape ofthe joints, dictate motions at all of the cervical segments. The zygapophyseal jointcapsules are generally lax in the cervical region, which contributes to the largeamount of motion available here. The height in relation to the diameter of thedisks also plays an important role in determining the amount of motion availablein the cervical spine. The height is large in comparison with the anteroposteriorand transverse diameters of the cervical disks. Therefore, a large amount offlexion, extension, and lateral flexion may occur at each segment, especially inyoung persons, when there is a large amount of water in the disks.
    • 23Figure 4 Motion at the lower cervical interbody joints occurs in the plane of thezygapophyseal joints about an axis perpendicular to the plane.The disk at C5/C6 is subject to a greater amount of stress than other disksbecause C5/C6 has the greatest range of flexion-extension and is the area wherethe mechanical strain is greatest.2.4.2 KineticsAlthough the cervical region is subjected to axial compression, tension, bending,torsion, and shear stresses as in the remainder of the spinal column, there aresome regional differences. The cervical region differs from the thoracic andlumbar regions in that the cervical region bears less weight and is generally moremobile.No disks are present at either the atlanto-occipital or atlantoaxial articulations;therefore, the weight of the head (compressive load) must be transferred directlythrough the atlanto-occipital joint to the articular facets of the axis. These forcesare then transferred through the pedicles and laminae of the axis to the inferiorsurface of the body and to the two inferior zygapophyseal articular processes.Subsequently, the forces are transferred to the adjacent inferior disk. The laminae
    • 24of the axis are large, which reflects the adaptation in structure that is necessary totransmit these compressive loads. The trabeculae show that the laminae of boththe axis and C7 are heavily loaded, whereas the intervening ones are not. Loadsdiffuse into the lamina as they are transferred from superior to inferior articularfacets.The loads imposed on the cervical region vary with the position of the head andbody and are minimal in a well-supported reclining body posture. In the cervicalregion from C3 to C7 compressive forces are transmitted by three parallelcolumns: a single antero-central column formed by the vertebral bodies and disksand two rod-like posterolateral columns composed of the left and rightzygapophyseal joints. The compressive forces are transmitted mainly by thebodies and disks, with a little over one third transmitted by the two posterolateralcolumns. Compressive loads are relatively low during erect stance and sittingpostures and high during the end ranges of flexion and extension. Cervical motionsegments tested in bending and axial torsion exhibit less stiffness than do lumbarmotion segments but exhibit similar stiffness in compression. In an experimentwith cadaver specimens, combinations of sagittal loads in vitro demonstrated thatthe midcervical region from C2 to C5 is significantly stiffer in compression andextension from C5 to T1. Specimens that were axially rotated before being testedin flexion and compression failed at a lower flexion angle (17°) than at the meanangle (25°) of nonaxially rotated specimens. The implication is that the headshould be held in a nonrotated position during flexion/extension activities toreduce the risk of injury.
    • 252.5 Cervical Spine Traction2.5.1 IntroductionGatterman (1990) defines spinal traction as the application of a drawing or apulling force along the long axis of the spine in order to stretch the soft tissues,separate joint surfaces, and to separate bony fragments (Gatterman, 1990).Traction is a method in which a distracting force is applied in order to stretch softtissues and separate articulating surfaces. Traction is often used as preparationfor other mobilization or manipulation procedures, since it is believed thatstretching of the muscles will lead to relaxation, thus improving local circulationand diminishing pain.Traction’s main effects on the vertebral structures are mechanical, consisting ofstretching of muscles and ligaments, distraction of vertebral bodies, separation offacet joints, and enlargement of the intervertebral foramina. Although theetiology of long standing pain is often difficult to be established, traction as atherapeutic modality is frequently used with success (Tollison, 1989).The term traction refers to the process of pulling one body in relationship toanother, which results in separation of two bodies. Traction is passivetranslational movement of a joint, which occurs at right angles to the plane of thejoint between two bones, resulting in separation of joint surfaces (Bergman &Davis, 1998). If a traction force is applied to a non-uniform structure, the greateststretch will be found at the weakest link, which will be the cervical spine in ahuman body (Kekosz et al., 1986) .In the treatment of the cervical spine, traction may be applied either manually orby a mechanical apparatus. With mechanical traction the head is harnessed in ahalter that is attached to a crossbar that is either weighted or connected to amechanical device. Traction may be applied either in an upright sitting position orwith the patient in a supine lying position. In this position, the body and thesurface on which it lies provide the necessary counterforce. The angle of pull is
    • 26usually maintained at 20-25° of forward flexion, in an attempt to open theintervertebral foramina (Tollison, 1989).2.5.2 Indication for Cervical Spine TractionGeneral clinical indications for traction are degenerative disc disease, with orwithout nerve root irritation, herniated intervertebral disc (except central discherniation which may induce cord compression), and facet joint osteoarthritis andcapsulitis (Kekosz et al., 1986). Gatterman (1990) states that intervertebral discprotrusion, facet syndrome, nerve root compression, spondylolisthesis,retrolisthesis, discogenic spondyloarthrosis and muscle spasm are indications fortraction (Gatterman, 1990).2.5.3 Types of Cervical spine TractionTypes of spinal traction include continuous traction, sustained mechanicaltraction, intermittent mechanical traction, manual traction and gravitationaltraction. Continuous spinal traction can be applied for as long as several hours ata time, with this extended time of traction, small amount of traction should beused. Sustained mechanical traction involves traction that varies from a fewminutes to half an hour of traction, the shorter duration is accompanied withheavier weights. Intermittent mechanical traction utilizes a mechanical devicethat alternately applies and releases traction every few seconds. Manual tractionis applied for few seconds through the therapist grasping the patient.Gravitational traction utilizes the patient’s own weight or a percentage thereof totraction the segment, in need of traction (Saunders, 1985). Especially whentreating herniated disc or irritable conditions, static mode of traction is preferred(Saunders & Saunders, 1993). Sustained (static) mechanical traction involvesapplication of a constant amount of traction for periods varying from a fewminutes to half an hour (Saunders, 1985).
    • 272.5.4 Most effective positions for applying cervical tractionA comparative study was conducted between sitting and supine position forcervical traction. Eight female students, ranging in age from 21-27 years, weighingfrom 40-65 Kg, and with no history of cervical spine pathology were evaluated fortraction. The students were fitted with a 45° flexion halter designed to achievemaximum pull force when placed on the occiput. X-rays were taken at 0 Kg, 14 Kgand 18 Kg of traction force, and then measurement from C4-C7 vertebrae weretaken which determined the amount of separation. The result supported the useof the supine position when administering cervical traction. The advantages weregreater posterior vertebral separation, increased relaxation, decreased muscleguarding, increased stability, less force required to overcome head weight, anddiminished anterior anatomical curve of the cervical spine (Deets et al., 1977).2.5.5 Force to be used in cervical spine tractionWith regard to the increase in traction force, one study looked at the effects, thattraction produces. They state that with the initial traction force applied there isno appreciable joint separation because the force applied needs to nullify thecompressive forces that are the result of muscle tension and cohesive forcesbetween articular surfaces. Then, as the traction force increases, it producestightening in the tissues surrounding the joint, which is described as “taking upslack”. Also, with the traction force increased further, it produces a stretchingeffect into the tissues crossing the joint (Bergman & Davis, 1998).2.5.6 Optimum angle for cervical spine tractionTraditionally cervical traction is done with the neck in some degree of flexion.Some clinicians believe that the greater the angle of flexion, the greater theintervertebral separation in the lower cervical spine. With flexion at 20° and 24°
    • 28compression of the anterior structures actually occurs. The recommendedoptimum angle for cervical traction is 15° flexion of pull for nearly every clinicalcondition (Saunders & Saunders, 1993).2.5.7 Effects of Cervical spine TractionSaunders (1985) stated that spinal traction correctly performed can producemany positive effects. Among these are distractions or separations of vertebralbodies, a combination of distraction and gliding of facet joints, tensing ofligamentous structures of the spinal segment, widening of the intervertebralforamen, straightening of spinal curves, and stretching of spinal musculatures.Medical treatment of musculoskeletal neck pain involves either conservative orsurgical treatment. For conservative treatment, traction is thought to be effective,particularly in the treatment of neck pain with associated radicular symptoms.Seventy to eighty percent of patients with radicular symptoms can be treatedconservatively, which includes oral medication, soft collars, cervical traction, andother physiotherapy modalities (Alcantara et al., 2001).The human body is provided with certain inherent qualities that provide for theprotection, maintenance, and restoration of health, of which the normal functionof the nervous system is major integrating force. In view of this literature review itis clear to see that cervical spine traction have the potential to assist the body inmaintaining and restoring good health.
    • 29CHAPTER 3 – METHODOLOGY3.1 IntroductionThe purpose of this chapter is to describe the research, the participantrecruitment process and the treatment protocol followed as well as theassessments and the type of measurements recorded.3.2 Aim of StudyThe aim of the study is to compare the efficacy of ‘mechanical cervical tractionwith conventional physiotherapy’ and ‘conventional physiotherapy alone’ inmechanical neck pain. Here efficacy is measured on the basis of followingoutcome measures: Neck Disability Index (NDI), Numerical Pain Rating Scale(NPRS), and Goniometry for cervical range of motion.3.3 STUDY DESIGNThis was a randomized two group parallel controlled clinical trial, utilizingconvenience sampling. A sample group of 40 symptomatic participants was used.3.4 SUBJECT RECRUITMENTThis study was conducted using symptomatic participants only and all volunteerswere screened prior to their acceptance into the study based on the inclusion andexclusion criteria.
    • 303.4.1 Sample and Selection CriteriaNon-probability convenience sampling was used to obtain 40 participants withchronic mechanical neck pain. These participants were then randomly assignedinto one of the two treatment groups (20 per group) using a computergenerated random allocation randomized table.3.5 INCLUSION AND EXCLUSION CRITERIAThe following criteria were used to include/exclude subjects in the research:3.5.1 Inclusion criteria(a) Participants/patients had to be between the ages of 18 and 45 years as thiswould exclude those patients who are more likely to have osteoarthritis whichis most commonly seen in the fifth and sixth decade of life (Yochum &Rowe, 2005).(b) Neck pain of a minimum duration of six weeks. This classified the neck painas chronic (Grieve, 1988).(c) Signed informed consent form.(d) Numerical pain rating scale [0-10]: scores between 4-9 to ensure grouphomogeneity.(e) The diagnosis of mechanical neck pain was made using the followingcriteria (Grieve, 1988):o Local chronic cervical pain with or without arm pain
    • 31o Juxtaposition of hypo- and hypermobile segments of the cervical spinedue to spondylitic changeso Asymmetrical neck pain that gets worse as the day progress and isaggravated by driving, reading etco Unilateral occipital and neck paino Restricted and painful movements, especially rotation and lateral flexionto the painful side.(f) Special orthopedic tests: A positive test will indicate pain at the levelof dysfunction (Gatterman, 1998). Two of the following three tests had tobe present.Kemp’s test: Performed with the patient in the seated position with theresearcher behind them. The cervical spine was placed into a combinationof rotation, lateral flexion and extension. Pain was felt at the level ofdysfunction.Cervical compression test: performed by applying manual downwardpressure on top of the patient’s head.Lateral compression test: Performed with cervical spine in lateral flexionof the head toward the painful side and applying downward pressure.All three of these tests cause stress on the facet joint and narrowing of theintervertebral foramen. Pain radiating down the arm indicates aradiculopathy and local pain suggests a facet joint dysfunction (Magee,2006).
    • 323.5.2 Exclusion criteria(a) Neck pain that was not of mechanical origin (Doherty et al., 2002) e.g.: Inflammatory – infections, rheumatoid arthritis, spondylitis,polymyalgia rheumatica, juvenile idiopathic arthritis. Metabolic – osteoporosis, Paget’s disease, osteomalacia. Neoplasia – metastases, myeloma, intrathecal tumors. Other – fibromyalgia. Referred pain – pharynx, aortic aneurysm, Pancoast tumor,diaphragm, angina pectoris, teeth, cervical lymph nodes. Neurological – nerve root entrapment and disc herniations inthe cervical spine.(b) Patients with recent major trauma or fracture of the cervical spine.(c) Patients whose primary complaint is that of headaches or facialpain associated with neck pain.(d) Any patient taking anti-inflammatory or muscle relaxant medicationwould need to have a three day “wash out” period before participating inthe study (Seth, 1999).3.6 RESEARCH METHODOLOGY/PROCEDUREOnce the participant was diagnosed with chronic mechanical neck pain, they werethen given the opportunity to ask any further questions and were informedthat they may withdraw from the study should they wish to do so. Theparticipant was then randomly allocated via using a computer generated
    • 33random allocation randomized table into one of two groups; group A:Mechanical cervical traction with conventional therapy, group B: Conventionaltherapy alone.3.6.1 Treatment Group A – Mechanical cervical traction with conventionaltherapy.Group A participants; intervention will be given in the form of conventionaltherapy plus Mechanical cervical traction.Mechanical cervical traction will be given with a motorized traction machinein the form of intermittent traction for 20 minutes with hold time 40 secondsand rest time 10 seconds in supine position with 15° of neck flexion.For Ultrasound, position of the participant will be in sitting with headsupport. Participants will be treated with Ultrasound 1.5 Watt/cm2for 8minutes and after proper positioning of participant and therapist, ultrasoundis administered with proper instruction.For Isometric neck exercises, position of the participant will be in sitting andtherapist will stand behind the patient. Isometric neck exercises are appliedwith 15 repetitions for each of flexion, extension, lateral flexion and cervicalrotation with 5 seconds of hold time.Same isometric exercises will be repeated at home in the evening.3.6.2 Treatment Group B – Conventional therapy alone.Group B participants; intervention will be given in the form of conventionaltherapy. Participants will be treated with Ultrasound 1.5 Watt/cm2for 8minutes and for Ultrasound, position of the participant will be in sitting with
    • 34head support. After proper positioning of participant and therapist,ultrasound is administered with proper instruction.For Isometric neck exercises, position of the participant will be in sitting andtherapist will stand behind the patient. Isometric neck exercises are appliedwith 15 repetitions for each of flexion, extension, lateral flexion and cervicalrotation with 5 seconds of hold time.Same isometric exercises will be repeated at home in the evening, thatmeans isometric exercise is done twice daily.3.7 MEASUREMENTS3.7.1 Objective measurementsTo obtain objective measurements, the Universal Goniometer was used. Thisinstrument is discussed below:3.7.1.1 Universal GoniometerIt was found that goniometric measurements of AROM of the cervical spine madeby the same physical therapist had ICCs greater than .80 when made with theCROM device or the Universal Goniometer (UG). When different physicaltherapists measured the same patients cervical AROM, the CROM device hadICCs greater than .80, whereas the UG and Visual Estimation generally had ICCsless than .80 (Youdas et al., 1991). Though CROM device is better than universalgoniometer in measuring Cervical ROM but universal goniometer can be used assecond choice due to unavailability of CROM device.
    • 353.7.2 Subjective measurementsTo quantify subjective outcomes, the patients were asked to complete theNeck Disability Index form and the Numerical Pain Rating Scale form. Thesetwo measurement tools are described below:3.7.2.1 Neck Disability Index (NDI)The NDI is a 10-item questionnaire that measures a patient’s self-reported neckpain related disability. Questions include activities of daily living, such as: personalcare, lifting, reading, work, driving, sleeping, recreational activities, pain intensity,concentration and headache. The questions are measured on a six-point scalefrom 0 (no disability) to 5 (full disability). The numeric response for each item issummed for a total score ranging from 0 to 50 (MacDermid et al., 2009). A higherNDI score indicates a greater patient’s perceived disability. The reliability (intra-class correlation co-efficient [ICC]: 0.73 to 0.98), construct validity, andresponsiveness to change have all been demonstrated in various populations(MacDermid et al., 2009). For patients with cervical radiculopathy, the minimaldetectable change is 10 points, and the clinically important difference is 7 points(Cleland et al., 2006).3.7.2.2 Numerical Pain Rating ScaleThe level of upper limb and neck pain will be captured with the NPRS. Using an11-point scale, ranging from 0 (no pain) to 10 (worst pain imaginable),participants will be asked to answer the following question: “On a scale of 0 to 10,where 0 corresponds to no pain and 10 to the worst imaginable pain, evaluate the intensity of your neck pain at this moment”. The NPRS is frequently used inclinical studies in association with the NDI (Young et al., 2009), (Cleland et al.,2008), (Childs et al., 2005). The NPRS is moderately reliable (ICC = 0.76) (Clelandet al., 2008), and has a clinically important difference of 20% (Childs et al., 2005).
    • 36CHAPTER 4 – DATA ANALYSES AND INTERPRETATION4.1 Statistical analysesSince the outcome measures were measured at multiple time intervals andgenerated interval data, repeated measures of ANOVA was used as primarystatistical analysis for within-group comparisons. Between-group differences ateach follow-up period were investigated with unpaired t-tests and within groupwith paired t-test. For the total group correlation analysis was done. Statisticalsignificance was set at p<0.05 for all statistical analyses. Shapiro-Wilk test wasused to check the normality and all the data analysis was done in IBM SPSSversion 20.0.4.2 ResultsTable 1 : Demographical characteristicsGroup Frequency %Mechanical traction andconventional therapy20 50Conventional Therapy 20 50Sex - Traction GroupMale 11 55Female 9 45Sex - Conventional GroupMale 8 40Female 12 60
    • 37Table 2 : Demographic & clinical characteristicsCharacteristics of TreatmentGroupsMeanTractionGroupSD-TractionGroupMeanConventionalGroupSD-ConventionalGroupAge 37.9000 7.86665 47.0500 7.69467Height 158.2750 10.06489 156.0500 9.78976Weight 60.8500 6.59565 61.8500 8.47457Flex_Cx_Base_Active 26.5000 3.50188 27.4500 6.12566Ext_Cx_Base_Active 34.4500 4.52449 34.3500 4.63709Sd_Flex_Affectd_Base_Active 26.7500 1.86025 26.6500 1.87153Rot_Affectd_Base_Active 34.9500 5.07289 37.2500 7.72470Flex_Cx_wk1_Active 31.7000 3.06251 30.7500 6.49595Ext_Cx_wk1_Active 40.1000 3.66922 35.1500 4.02982Sd_Flex_Affectd_wk1_Active 35.6000 1.72901 31.1000 1.71372Rot_Affected_wk1_Active 44.7500 3.65449 39.1000 6.25679Flex_Cx_wk2_Active 36.5000 3.48682 34.6500 6.15822Ext_Cx_wk2_Active 46.1000 3.40124 39.4500 3.85903Sd_Flex_Afftectd_wk2_Active 37.9500 2.25890 35.7500 2.98901Rot_Affectd_wk2_Active 51.1500 2.79614 44.0000 7.25476NPRS_Base 8.2500 .55012 8.1500 .58714NPRS_wk1 5.1500 .93330 6.3500 .67082NPRS_wk2 3.2500 1.11803 4.8000 .83351NDI_Base 44.8870 7.58888 39.7725 11.45592NDI_Wk2 17.9005 2.54663 27.3810 7.369984.2.1 One way repeated measure ANOVA for within group differenceFlexionA repeated measures ANOVA with a Greenhouse-Geisser correction determinedthat in the traction group, the mean flexion scores differed statisticallysignificantly between measured time points i.e. baseline, week 1 and week 2; F(1.584, 30.103) = 346.90, p < 0.0005. We can, therefore, conclude that the
    • 38traction invention program elicits a significant improvement of 10othrough thebaseline to week 2.In conventional group, the mean flexion scores differed statistically significantlybetween measured time points i.e. baseline, week 1 and week 2; F (1.336,25.388) = 151.727, p<0.0005. We can, therefore, conclude that the conventionalprogram elicits a statistically significant improvement 7.2othrough the baselineto week 2.Pair-wise Comparisons of FlexionTable 3 : Measure- Flexion- Traction Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -5.200*.304 .000 -5.999 -4.4013 -10.000*.465 .000 -11.219 -8.78121 5.200*.304 .000 4.401 5.9993 -4.800*.352 .000 -5.725 -3.87531 10.000*.465 .000 8.781 11.2192 4.800*.352 .000 3.875 5.725Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.
    • 39Table 4 : Measure- Flexion- Conventional Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -3.300*.291 .000 -4.064 -2.5363 -7.200*.536 .000 -8.607 -5.79321 3.300*.291 .000 2.536 4.0643 -3.900*.376 .000 -4.888 -2.91231 7.200*.536 .000 5.793 8.6072 3.900*.376 .000 2.912 4.888Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.ExtensionA repeated measures ANOVA with a Greenhouse-Geisser correction determinedthat in the traction group, the mean extension scores differed statisticallysignificantly between measured time points i.e. baseline, week 1 and week 2; F(1.608, 30.550) = 152.603, P < 0.0005. We can, therefore, conclude that thetraction group elicits a statistically significant improvement of 11.65othrough thebaseline to week 2.In conventional group, the mean extension scores differed statisticallysignificantly between measured time points (F (1.411, 26.811) = 20.295.p<0.0005. We can, therefore, conclude that the conventional interventionprogram elicits a statistically significant improvement of 5.1othrough thebaseline to week 2.
    • 40Pair-wise Comparisons of ExtensionTable 5 : Measure- Extension – Traction Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -5.650*.670 .000 -7.409 -3.8913 -11.650*.796 .000 -13.739 -9.56121 5.650*.670 .000 3.891 7.4093 -6.000*.503 .000 -7.319 -4.68131 11.650*.796 .000 9.561 13.7392 6.000*.503 .000 4.681 7.319Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.Table 6 : Measure- Extension – Conventional Group(I) factor1 (J) factor1 MeanDifference (I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -.800 1.033 1.000 -3.511 1.9113 -5.100*.940 .000 -7.568 -2.63221 .800 1.033 1.000 -1.911 3.5113 -4.300*.524 .000 -5.675 -2.92531 5.100*.940 .000 2.632 7.5682 4.300*.524 .000 2.925 5.675Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.Side-FlexionA repeated measures ANOVA with a Greenhouse-Geisser correction determinedthat in the traction group, the mean side flexion scores differed statisticallysignificantly between measured time points i.e. baseline, week 1 and week 2; F(1.941, 36.874) = 270.229, p<0.0005. We can, therefore, conclude that the
    • 41traction group elicits a significant improvement of 11.2othrough the baseline toweek 2.In conventional group, the mean flexion scores differed statistically significantlybetween measured time points i.e. baseline, week 1 and week 2; F (1.214,23.074) = 134.385 p<0.0005. We can, therefore, conclude that the conventionalinvention program elicits a statistically significant improvement 9.1othrough thebaseline to week 2.Pair-wise Comparisons of Side FlexionTable 7 : Measure- Side Flexion – Traction Group(I) factor1 (J) factor1 MeanDifference (I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -8.850*.488 .000 -10.131 -7.5693 -11.200*.551 .000 -12.645 -9.75521 8.850*.488 .000 7.569 10.1313 -2.350*.483 .000 -3.617 -1.08331 11.200*.551 .000 9.755 12.6452 2.350*.483 .000 1.083 3.617Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.
    • 42Table 8 : Measure- Side Flexion – Conventional Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -4.450*.294 .000 -5.223 -3.6773 -9.100*.718 .000 -10.984 -7.21621 4.450*.294 .000 3.677 5.2233 -4.650*.568 .000 -6.141 -3.15931 9.100*.718 .000 7.216 10.9842 4.650*.568 .000 3.159 6.141Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.RotationA repeated measures ANOVA with a Greenhouse-Geisser correction determinedthat in the traction group, the mean rotation scores differed statisticallysignificantly between baseline, week 1 and week 2; F (1.806, 34.375) =254.165, p<0.0005. We can, therefore, conclude that the traction group elicits astatistically significant improvement of 16.2othrough the through the baseline toweek 2.In conventional group, the mean rotation scores differed statisticallysignificantly between baseline, week 1 and week 2; F (1.862, 35.370) = 127.181,p<0.0005. We can, therefore, conclude that the conventional invention programelicits a statistically significant improvement 6.789othrough the baseline to week2.
    • 43Pair-wise Comparisons of RotationTable 9 : Measure- Rotation – Traction Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -9.800*.698 .000 -11.633 -7.9673 -16.200*.829 .000 -18.376 -14.02421 9.800*.698 .000 7.967 11.6333 -6.400*.630 .000 -8.054 -4.74631 16.200*.829 .000 14.024 18.3762 6.400*.630 .000 4.746 8.054Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.Table 10 : Measure- Rotation – Conventional Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 -1.850*.393 .000 -2.880 -.8203 -6.750*.422 .000 -7.858 -5.64221 1.850*.393 .000 .820 2.8803 -4.900*.492 .000 -6.190 -3.61031 6.750*.422 .000 5.642 7.8582 4.900*.492 .000 3.610 6.190Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.
    • 44NPRSA repeated measures ANOVA with a Greenhouse-Geisser correction determinedthat in the traction group, the mean NPRS scores differed statisticallysignificantly between baseline, week 1 and week 2; F (1.872, 35.568) =261.216, p<0.0005. We can, therefore, conclude that the traction group elicits asignificant improvement of pain reduction -5.000 through the baseline to week2.In conventional group, the mean rotation scores differed statisticallysignificantly between measured time points (F (1.737, 33.004) = 143.371,p<0.0005. We can, therefore, conclude that the conventional group treatmentelicits a statistically significant improvement of pain reduction -3.330 throughthe baseline to week 2.Pair-wise Comparisons of NPRSTable 11 : Measure- NPRS- Traction Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 3.100*.191 .000 2.600 3.6003 5.000*.229 .000 4.398 5.60221 -3.100*.191 .000 -3.600 -2.6003 1.900*.240 .000 1.271 2.52931 -5.000*.229 .000 -5.602 -4.3982 -1.900*.240 .000 -2.529 -1.271Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.
    • 45Table 12 : Measure- NPRS – Conventional Group(I) factor1 (J) factor1 MeanDifference(I-J)Std. Error Sig.b95% Confidence Interval forDifferencebLower Bound Upper Bound12 1.800*.186 .000 1.311 2.2893 3.350*.233 .000 2.740 3.96021 -1.800*.186 .000 -2.289 -1.3113 1.550*.170 .000 1.104 1.99631 -3.350*.233 .000 -3.960 -2.7402 -1.550*.170 .000 -1.996 -1.104Based on estimated marginal means*. The mean difference is significant at the .05 level.b. Adjustment for multiple comparisons: Bonferroni.Graph 1: Comparison of NPRS between groups
    • 464.2.2 Independent t-test for between groups differenceThe value of two tailed significance is more than .05 (p>.05) for all baselineflexion, extension, side-flexion, rotation and NPRS. There is no significantdifference in between groups’ scores of week 1 and week 2 flexion scores. Thevalue of two tailed significance is less than .05 (p<.05) for extension week 1, side-flexion week 1, rotation week 1, extension week 2, side-flexion week 2, rotationweek 2 and NPRS week 1 and week 2 scores between groups shows that there isa significant difference in their scores.Table 13 : Between Groups differences independent t-testt df Sig. (2-tailed)Flex_Cx_Base_ActiveEqual variances assumed -.602 38 .551Equal variances notassumed-.602 30.220 .552Ext_Cx_Base_ActiveEqual variances assumed.069 38 .945Equal variances notassumed.069 37.977 .945Sd_Flex_Affectd_Base_ActiveEqual variances assumed.169 38 .866Equal variances notassumed .169 37.999 .866Rot_Affectd_Base_ActiveEqual variances assumed -1.113 38 .273Equal variances notassumed-1.113 32.818 .274Flex_Cx_wk1_ActiveEqual variances assumed.592 38 .558Equal variances notassumed .592 27.048 .559Ext_Cx_wk1_Active Equal variances assumed 4.062 38 .000
    • 47Equal variances notassumed 4.062 37.671 .000Sd_Flex_Affectd_wk1_ActiveEqual variances assumed 8.267 38 .000Equal variances notassumed 8.267 37.997 .000Rot_Affected_wk1_ActiveEqual variances assumed 3.487 38 .001Equal variances notassumed 3.487 30.612 .002Flex_Cx_wk2_ActiveEqual variances assumed 1.169 38 .250Equal variances notassumed 1.169 30.047 .252Ext_Cx_wk2_ActiveEqual variances assumed 5.781 38 .000Equal variances notassumed 5.781 37.410 .000Sd_Flex_Afftectd_wk2_ActiveEqual variances assumed 2.626 38 .012Equal variances notassumed2.626 35.365 .013Rot_Affectd_wk2_ActiveEqual variances assumed 4.113 38 .000Equal variances notassumed4.113 24.523 .000NPRS_BaseEqual variances assumed .556 38 .582Equal variances notassumed.556 37.840 .582NPRS_wk1Equal variances assumed -4.669 38 .000Equal variances notassumed-4.669 34.496 .000NPRS_wk2Equal variances assumed -4.971 38 .000Equal variances notassumed-4.971 35.136 .000
    • 484.2.3 NDI within GroupsThe value of two tailed significance is less than .05 (p<.05) for traction groupshows that there is a significant difference in NDI score through the baseline andweek two with t (19) = 15.759. The mean difference was 26.98.The value of two tailed significance is less than .05 (p<.05) for conventional groupshows that there is a significant difference in NDI score through the measuretimes between baseline and week two with t (19)=6.541. The mean differencewas 14.03.So it can be stated that the traction group benefited with more reduction of NDIscore.Table 14 : Paired Sample t-testPaired Differences t df Sig. (2-tailed)Mean Std.DeviationStd. ErrorMean95% Confidence Interval ofthe DifferenceLower UpperPair1NDIbasetrac -NDItracweek226.98650 7.65831 1.71245 23.40230 30.57070 15.759 19 .000Pair2NDIbasecon -NDIweek2con12.94700 8.85256 1.97949 8.80387 17.09013 6.541 19 .0004.2.4 NDI between GroupsThe value of two tailed significance is more than .05 (p>.05) for NDI baselinescores between groups shows that there is no significant difference in NDI scoret(38)=1.664. The value of two tail significance is less than .05 (p<.05) for week twoNDI scores between groups shows that there is a significant difference in NDIscore through the baseline and week 2 with t(38) = -5.437. The mean differencewas -9.480. So, the traction group benefited with more reduction of NDI score.
    • 49Graph 2: Comparison of NDI between groupsTable 15 : Independent Sample t-TestLevenes Test forEquality ofVariancest-test for Equality of MeansF Sig. t df Sig. (2-tailed)MeanDifferenceStd. ErrorDifference95% Confidence Intervalof the DifferenceLower UpperNDI_BaseEqual variancesassumed5.902 .020 1.664 38 .104 5.11450 3.07270 -1.10585 11.33485Equal variancesnot assumed1.664 32.983 .105 5.11450 3.07270 -1.13707 11.36607NDI_Wk2Equal variancesassumed14.047 .001 -5.437 38 .000 -9.48050 1.74359 -13.01021 -5.95079Equal variancesnot assumed-5.437 23.473 .000 -9.48050 1.74359 -13.08336 -5.87764
    • 504.2.5 Correlation analysis for both the groups at week 2The bivariate correlation analysis among the variables for both the two groupsshowed flexion and extension at week two negatively influencing NDI score(r= -.413, -.543). Flexion contributes to extension(r=.586) and extension and sideflexion contributes to rotation(r=.336, .443) positively. Extension negativelyinfluencing the NPRS scores(r=-.470) and NPRS score contributes positively to NDIscore at week two(r=.639).Table 16 : Correlations (N=40)Flex_Cx_wk2_ActiveExt_Cx_wk2_ActiveSd_Flex_Afftectd_wk2_ActiveRot_Affectd_wk2_ActiveNPRS_wk2NDI_Wk2Flex_Cx_wk2_Active1 .586**.015 -.157 -.304 -.413**.000 .926 .335 .056 .00840 40 40 40 40Ext_Cx_wk2_Active1 .135 .336*-.470**-.543**.406 .034 .002 .00040 40 40 40Sd_Flex_Afftectd_wk2_Active1 .433**-.165 -.281.005 .309 .07940 40 40Rot_Affectd_wk2_Active1 -.024 -.111.884 .49740 40NPRS_wk21 .639**.00040NDI_Wk21**. Correlation is significant at the 0.01 level (2-tailed).*. Correlation is significant at the 0.05 level (2-tailed).
    • 514.3 Limitations of StudyIn this study data should have been collected by independent observer, whichwas not feasible in this study.Misunderstanding of NPRS and NDI questionnaire may have affected theirresponse, and therefore the outcome of results.Regarding the objective measurements, the results from the study could havebeen faulty due to both human errors when reading calibrations and the possiblerisk of incorrect user methods.The outcome of the study could have been more significant when looking at thesample group; the small sample group may have failed to provide significantinformation that could have been available from a large sample size.4.4 DiscussionThe effect of cervical traction for mechanical neck pain in short term is subject todebate and controversies. The aim of the present study was to find out the realityand the present study showed some positive results in the traction group patientswith conventional physiotherapy treatment; compared with conventionalphysiotherapy alone. The difference of mean score of flexion, extension, sideflexion and rotation is 2.8o, 6.4o, 2.1oand 9.4obetween the traction group andconventional group at the end of two weeks treatment; which was gained byadding traction as treatment along with conventional physiotherapy treatment.The extension and rotation was also convincing in terms of improvement forinclusion of traction as treatment.Traction therapy for the cervical spine involves a tractive force applied to the neckvia a mechanical system which improves conduction disturbance primarily byincreasing the amount of blood flow from the nerve roots to the spinal
    • 52parenchyma. This can be applied intermittently or continuously. When we look atthe literature data, analysis reveals moderate evidence of benefit for intermittenttraction, but no benefit for continuous traction in mechanical neck disorders(Hattori et al., 2002) (Graham et al., 2006).Lecocq’s literature review (Lecocq et al., 2005) stated that cervical traction hasseveral different modes of action, with a very small increase in the intervertebralspace (a few tenths of a millimeter) and a reduction in intradiscal pressure, with apossible Herniated Disc [HD] suction effect. The HD can also be pushed back bytension in the posterior longitudinal ligament. In terms of the muscles, the effectof cervical traction is characterized by stabilization of (or even an increase in)activity of the trapezius muscle during the first 3 to 6 minutes. The inhibitory‘‘gate control’’ effect on nociceptive influx transmission requires experimentalconfirmation. Furthermore, placebo and psychological effects must be consideredwhen analyzing the effect of cervical traction.The NPRS scale mean score difference at the end of two weeks for traction andconventional treatment group was 1.7 on a scale of 0-10 for inclusion of tractionas treatment and between the group NDI score mean difference at the end oftwo weeks also showed contribution of 9.5% more reduction on NDI fordisability.The correlation analysis for the both groups showed significant relationshipbetween NPRS and NDI scores and flexion and extension contributes negatively toNDI score. Moreover extension negatively influences the NPRS score.4.5 ConclusionThe inclusion of cervical traction as a treatment tool along with the conventionalphysiotherapy treatment for mechanical neck pain proved beneficial in terms ofimproving cervical mobility, pain reduction and disability perception. Thereforecervical traction can be recommended as complimentary modality in mechanicalneck pain.
    • 53The mechanism by which ICT reduces neck and arm pain is possibly byunloading the components of the spine by stretching muscles, ligaments andfunctional units, reducing adhesions within the dural sleeve, nerve rootdecompression within the central foramina, and increasing joint mobility.Traction also decreases intervertebral disc pressure as stated by Saunders(Saunders & Saunders, 1993). Reduced tonic muscle contraction and improvedvascular status in the epidural space and perineural structures may alsoreduce pain.The study duration was short, only 2 weeks, and the results apply to short termonly, which might differ in the longer run. Sample size taken for the study issmall and bigger sample might have led to some differences in the results. Allthe measurements were taken manually and this may introduce human errorwhich might affect the reliability.However, in one study, no specific effect of traction over standardphysiotherapeutic interventions was observed in adults with chronic neck pain.Hence, it is suggested that clinicians should consider this chronic neck conditionand to focus on exercise therapy in the management of patients suffering fromchronic neck pain (Pinar et al., October 2008). Every research study has its ownset of confounding factors that may affect the study’s clinical outcome.Hence, we conclude that, intermittent cervical traction should have a placein the management of MNP along with neck exercises in reducing neck and armpain, neck disability and in improving activities of daily living.
    • 54CHAPTER 5 – RECOMMENDATIONS5.1 Recommendations1. MNP is variable by nature; therefore, subsequent studies should considermethods of producing a more uniform sample group, taking into accountthe patient’s age, gender, chronicity of neck pain, socio-economicbackground and emotional stress levels.2. A more extensive study should be performed, with a larger sample groupto allow for the general population to be more accurately represented.3. Have an equal ratio of males to females as participants and compare to theresults of the study.4. Isolate gender to either males or females, this may produce a differentoutcome or stronger statistical results; this may help determine whetherboth sexes respond similarly to treatment.5. Further objective measurements should be included with regards tomeasuring changes in pain during study. This might take the form of anAlgometer.6. The study could be performed isolating the level to be treated. This willallow a more specific reading.
    • 557. Objective and subjective reading should be taken before and immediatelyafter treatment sessions. This would allow for both the immediate andprolonged effects of the treatment to be investigated.8. A follow up, one month after the cessation of the treatment sessions todetermine the long term benefits of treatment with regards to pain,disability and cervical ROM should be included.9. This study can also include grip strength measurement using JamarDynamometer to observe the improvement in grip strength of participantsduring study at week 1 and week 2 etc.
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    • 60AppendicesAppendix-I: Neck Disability Index - Gujarati VersionUZNG V;DY"TF 5|`GFJ,LVF 5|`GFJ,L TDFZL UZNGGL 5L0FG[ ;DHJF DF8[ AGFJJFDF VFJL K[ VG[ T[GF äFZF TDFZF ZMH AZMHGL lS|IFDF YTF O[ZOFZGLDC[ZAFGL SZLG[ NZ[S lJEFUGL ;FY[ VF5[,L lJUT p5Z lGXFGL SZJL VG[ HF6LV[ KLV[ S[4 V[S H lJEFUGF A[ S[ +6 JFSIM ,FU] 50LXS[ K[P5ZT] H[ JFSI TDFZL 5L0FGL ;{FYL GHLS CMI4 T[GL ;FD[ lGXFGL SZJLP lJEFU v! s5L0FGL lTJ|TFf DG[ VF 1F6 SM. 5L0F GYLP DG[ VF 1F6 36L VMKL 5L0F K[P DG[ VF 1F6[ 5L0FGL lTJ|TFDF YM0M JWFZM K[P DG[ VF 1F6[ UZNGGL 5L0FDF 36M H JWFZM K[P DG[ VF 1F6[ UZNGGL 5L0FDF B]A H JWFZM K[P DG[ VF 1F6[ B]A H JWFZ[ 5L0F K[ H[ V;CI K[P lJEFUvZ s;FZ;EF/f C] JWFZFGL 5L0F l;JFI 5MTFGL ;FZ;EF/ ZFBL XS] K]P 5MTFGL ;FZ;EF/ ZFBL XS] K] 56 T[GF äFZF 5L0FDF JWFZM YFI K[P 5MTFGL ;FZ;EF/DF N]BFJM YFI K[ VG[ C] WLZH VG[ SF/HL ZFB] K]P 5MTFGL ;FZ;EF/ DF8[ VgIGF ;CFIGL H~Z 50[ K[P 5MTFGF ;FZ;EF/ DF8[ VgIGF ;CFIGL H~Z 50[ K[P C] S50F 5C[ZJFDF VG[ WMJFDF TS,LO VG]EJ] K]P VG[ 5YFZLJX K]P lJEFUv# spRSJ]Pf C] SM.56 N]BFJF JUZ EFZ[ ;FDFG pRSL XS] K]P C] EFZ[ ;FDFG N]BFJF ;FY[ pRSL XS] K]P DFZF UZNGGL 5L0F DG[ EFZ[ ;FDFG HDLG 5ZYL pRSJF DF8[ ZMS[ K[ 5ZT] C] C/JFYL YM0] JWFZ[ JHG pRSL XS] K]HM V[ IMuI HuIFV[ ZFB[, CMIP C] OST C/JM ;FDFG H pRSL XS] K]P C] S.56 pRSL XSTM GYLP lJEFU v$ sJFRGf C] DFZL .rKF D]HA S.56 N]BFJF JUZ JFRL XS] K]P C] YM0L 5L0F ;FY[ .rKF D]HA JFRL XS] K]P C] UZNGGL YM0L JWFZ[ 5L0FGL ;FY[ .rKF D]HA JFRL XSTM GYLP
    • 61 C] EFuI[H JFRL XS] K]P SFZ6 S[ DFZL 5L0FDF B]A H JWFZM K[P C] S. 56 JFRL XSTM GYLP lJEFU v5 sDFYFGM N]BFJMf DG[ DFYFGF N]BFJFGL ;D:IF GYLP DG[ SIFZ[S YM0F DFYFGF N]BFJFGL ;D:IF ZC[ K[ H[ SIFZ[S VFJ[ K[P DG[ YM0F JWFZ[ DFYFGF N]BFJFGL ;D:IF ZC[ K[ H[ SIFZ[S VFJ[ K[P DG[ YM0F JWFZ[ DFYFGF N]BFJFGL ;D:IF ZC[ K[ H[ SFIDL ZC[ K[P DG[ 5|tI[S 1F6 DFYFGF N]BFJFGL ;D:IF B]A JWFZ[ ZC[ K[P DG[ 5|tI[S 1F6 DFYFGF N]BFJFGL ;D:IF ZC[ H K[P lJEFU v& sV[SFU|TFf C] SM.56 D]XS[,L JUZ V[SFZU| ZCL XS] K]P C] YM0L D]XS[,L ;FY[ 5]ZTM V[SFU| ZCL XS] K]P V[SU|TF HF/JJFDF DG[ YM0L H DF+FDF D]xS[,L 50[ K[P DG[ V[SFU|TF HF/JJFDF B]A H D]xS[,L 50[ K[P C] V[SFU|TF HF/JL XSTM H GYLP lJEFU v * sSFI"f C] DFZL .rKF D]HA DFZ] AW] ZMHAZMHG] SFI" SZL XS] K]P C] DFZ] ;FDFgI ZMHAZMHG] SFI" SZL XS] K] 56 JWFZ[ GCLP C] DFZ] DM8FEFUG] SFI" SZL XS] K] 56 JWFZ[ GCLP C] DFZ] ZMHAZMHG] SFI" SZL XSTM GYLP C] EFuI[H S.S SFI" SZL XS] K]P C] DFZ] S.56 SFI" SZL XSTM GYLP lJEFU v(s 0=F.JLU qCSFZJ]f C] DFZL UF0L SM.56 N]BFJF JUZ R,FJL XS] K]P C] DFZF UZNGGF YM0F N]BFJF ;FY[ DFZL .rKF D]HA UF0L R,FJL XS] K]P C] DFZL .rKF D]HA UF0L R,FJL XS] K] 5ZT] T[GF äFZF DFZF UZNGGL 5L0FGL TLJ|TFDF YM0M JWFZM YFI K[P C] EFuI[H UF0L R,FJL XS] K]P SFZ6 S[ T[GF äFZF DFZL UZNGGL 5L0FGL TLJ|TFDF 36M JWFZM YFI K[P C] DFZL UF0L R,FJL H XSTM GYLP lJEFU v )slGãFf DG[ lGãFDF SM. TS,LO GYLp DG[ lGãFDF YM0L H B,[, 5CMR[ K[ sV[S S,FS SZTF VMKLf DG[ lGãFDF B,[, 5CMR[ K[P s! YL Z S,FSf
    • 62 DG[ lGãFDF YM0L JWFZ[ B,[, 5CMR[ K[P sZ YL # S,FSf DFZL lGãFDF B]A B,[, 5CMR[ K[ s # YL 5 S,FSf DFZL lGãFDF 5]Z[5]ZL B,[, 5CMR[ K[P s5v* S,FSf lJEFU v !_ sDGMZHGf C] DFZL AWL DGMZHG 5|JlTVM UZNGGF SM.56 N]BFJF JUZ SZL XS] K]P C] DFZL AWL DGMZHG 5|JlTVM UZNGGF YM0F N]BFJF ;FY[ SZL XS] K]P C] AWL GCL 5ZT] DM8FEFUGL DGMZHG 5|JlTVM SZL XS] K]P C] DFZL UZNGGL 5L0FG[ SFZ6[ YM0L 36L DGMZHG 5|JlTVM SZL XS] K]P C] DFZL UZNGGL 5L0FG[ SFZ6[ EFuI[ H DFZL DGMZHG 5|JlTVM SZL XS] K]P C] SM.56 DGMZHG 5|JlTVM SZL XSTM GYLPAppendix-II: Numerical Pain Rating Scale (NPRS).
    • 63Appendix –III: Consent Letterસંમિત પ કમ, .................................................. આ ફોમ માં મા હતી વાંચી છે (અથવા તે મને અ ય એવાંચી છે). ું કોઇ પણ ો ૂછવા માટ ુ ત હતો અને તેઓ એ જવાબ આ યો છે. માર મર18 વષની ઉપર છે અને, માર પસંદગી શ ત ઉપયોગ કર ને, આથી આ અ યાસ માં સહભાગીતર ક સમાવેશ સંમિત દાન ક ું ં ………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………. (અ યાસ શીષક).(1) મ આ સંમિત ફોમ વાંચી છે અને સમ છે અને મા હતી મને દાન કરવામાં આવેલ છે.(2) આ સંમિત દ તાવેજ મને સમ વામા આવી છે.(3) મારા અિધકારો અને જવાબદાર ઓ મને તપાસ કરનાર ારા સમ વામા આવી છે.(4) મને આ અ યાસ માં ભાગ લેવા સાથે સંકળાયેલ જોખમો ગે સલાહ આપેલ છે.(5) ું એ હક કત થી પ ર ચત ં ક ું કોઈપણ સમયે કોઈપણ કારણો આ યા િવના આ અ યાસમાંથી બહાર જઈ શ ુ ં અને તે આ હો પટલમાં માર ભિવ યમાં સારવાર પર અસર કરશે નહ .(6) ું અહ તપાસકતાઓને પરવાનગી આ ુ ં ક તેઓ આ અ યાસમાં ભાગ લેવા પ રણામેણકાર મેળવી છે તે િનયમનકાર સ ાવાળાઓ, સરકાર એજ સીઓ, અને નીિતશા સિમિત.સામે કાિશત કર શક છે.(7) જો માર મા હતી હરમાં ર ૂ કરવામાં આવે તો માર ઓળખ ુ ત રાખવામાં આવશે.આ સંમિત દ તાવેજ સાઇન કર ને, ું મા ણત ક ં ક આ દ તાવેજ માં આપેલ મા હતી મનેપ ટ કરવામાં આવેલ છે અને મને સમજ પડ છે.દદૉ ની સહ : Date:
    • 64Appendix-IV: Raw Data