Effects of Muscle Energy Techniques on non specific low back pain: A randomized control trial

A Protocol submitted to HOSMAT HOSPITAL EDUCATIONAL INSTITUTE Bangalore

RESEARCH PROJECT

By M.P.T. (Musculoskeletal and Sports) Guides Dr. R. Dev Anand (PT)

Submitted by: Bharati.k MPT 1st Year.

RESEARCH APPROVAL Effects of Muscle Energy Techniques on non specific low back pain: A randomized control trial

Research proposal approved by Institutional ethics Committee on 19/11/2010

INSTITUTIONAL ETHICS COMMITTEE HHEI BANGALORE - 25.

CONTENTS
Page No. 1 INTRODUCTION 1.1 1.2 1.3 1.4 2 3 Background of the study Statement of the problem Objective of the study Operational Definition 04 04 06 06 06 07 09 09 09 09 09 09 09 10 14 14 15 16 18 21

REVIEW OF LITERATURE METHODOLOGY 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Study Design Study Setting Sample Size Inclusion Criteria Exclusion Criteria Materials Procedure

3.8 Outcome Measure 3.9 Data analysis 4 5 REFERENCES APPENDIX 5.1 5.2 Consent form Assessment form

INTRODUCTION
1.1 BACKGROUND STUDY
DEFINITIONS Non-specific low back pain(LBP)is defined as LBP which is not attributed to recognisable, known specific pathology, e.g. Infection, tumour, osteoporosis, ankylosing spondylosis, fracture, inflammatory process, radicular syndrome or cauda equine syndrome (Burton et al 2004). Acute LBP refers to pain present for upto 6 weeks. Disorders of the low back are the leading cause of disability in people younger than 45 years of age.1 80% of LBP has been mentioned nonspecific.2It has been estimated that mechanical disorders of the spine, represent at least 98% of LBP.3 low back pain occurs in people with a wide variety of professions, including those involving heavy labor, repetitive work activities, and extended sedentary postures.4Ischemia, Trigger Points, Nerve Compression and Nerve Entrapment, Structural Imbalance, Postural Distortion & Dysfunctional Biomechanics are the 5 primary problems that causes non-specific low back pain.5 Low back region comprises of mainly three structures: the lumbar region, the pelvic girdle & the hip complex. The pelvic girdle maintains its stability via capsular ligaments, articular surface congruency and myofascial component. The articular cartilage & ligaments are very strong & covered by myfascial component, thus does not involve easily in nonspecific LBP. In normal individuals deep trunk muscles such as the transverse abdominis, multifidus, the lower fibers of the obliqus internus abdominis (OI) and the diaphragm activate before limb or trunk motion, and also help to control stability of intrapelvic motion for transference of loads as these muscles may also induce posterior rotation of the innominate relative to the sacrum, increasing spinal stability and compression, as well as stability of the sacroiliac joint. Non-specific LBP characteristically involves the signs of local tenderness, tissue texture change and asymmetrical contraction of muscles. Sustained muscle contraction is often a primary source of lumbopelvic dysfunction and pain.6 A number of factors that have been identified to contribute alignment patterns in subjects with non-specific low back pain2 which include neural & biomechanical factor. Neural factor includes timing or magnitude of trunk muscle activity both in static & dynamic state where as biomechanical factor include active & passive tissue characteristics of lumbar region. In individuals with non-specific LBP, due to prolong erect sitting the erector spinae is held in a sustained contraction & often tests weak. A muscle is weak in its shortened position, and sustained contraction weakens a muscle and Multifidus become inhibited35. Jull and Janda9 have discovered predictable patterns of muscle imbalance. Physical therapy intervention for the acute LBP consists of a wide spectrum of choices including manual therapy and exercises along with electrotherapeutic modalities. Exercises approach usually consists of neuro-muscular coordination and resistance training. But ironically there are not many randomized controlled trails which are focused on neuro4

muscular coordination and resistance training. Another common practice is manual therapy techniques i.e. Muscle energy technique, Myofascial release , trigger point release etc. though many clinicians use these techniques successfully to treat their subjects but still there is lack of strong or significant evidence suggesting recommendation or strong consensus among the experts. Though considered as a manual therapy, MET is not particularly a mobilization or manipulation technique. MET is an active technique in which subjects rather than therapist provides corrective force. Greenman9 , defined MET as a manual medicine treatment procedure that involves the voluntary contraction of the subjects muscle in a precisely controlled direction, at varying levels of intensity, against a distinctly executed counterforce applied by the therapist. MET is a versatile technique traditionally used to address muscular strain, PAIN, local edema and joint dysfunction. MET has shown improvements in range of motion10-15, reducing pain16, 34, reliving muscle tension & spasm, & increased strength of the muscle.16 Evidence to support the use of lumbar manipulation in patients with acute lumbopelvic pain with moderate severity has been reported17,18, yet, because the treatment pattern of manually trained clinicians varies, It would be useful to determine if MET offered similar benefits (albeit, short-term) in patients with acute LPP. Since very less study have been done on MET, the purpose of this study is to determine the effectiveness of MET for acute non-specific low back pain over the period of 1 week with 3-4 treatment sessions.

1.2 Statement problem

Clinically studies done on MET on non-specific low back pain are limited.

1.3 Aim of the study

The aim of the study is to find the effectiveness of MET on non-specific low back pain

1.4 Hypothesis
MET is effective for pain reduction, improving range& disability in non-specific low back ache.

1.5 Null hypothesis

There is no significant effect of MET on non- specific LBP.

1.6 OPERATIONAL DEFINITION

Non-specific low back pain is the term generally used to refer any type of pain that occurs due to abnormal stress & strain on muscles of lumbar region in which the lumbar movement is pain full without any neurological deficit.

REVIEW OF LITERATURE
Epidemiology of Non-specific low back pain
A large percentage of the adult population suffers from LBP, with a high frequency of recurrent episodes (Wasiak et al 2006). The prevalence of LBP in adults has been well documented with a life-time prevalence of over 70%, one-year period prevalence of over 50% and a point prevalence of over 20%, although some studies have reported it to be has high as 40% (Kovacs et al 2003; Leboeuf-Yde and Kyvik 1998). Recent evidence has indicated that non-specific acute LBP manifests in an unpredictable pattern of symptomatic periods, interspersed with less troublesome or symptom-free periods (Burton et al 2004).

Outcome tools for measuring non specific acute LBP

Clinicians and therapists can use a variety of tools to evaluate non-specific acute LBP. The common way to assess is self administered questionnaire which includes measure of disability, quality of life and tool to measure pain. To assess pain, Visual Analogue Scale(VAS) is used. It is used as self pain rating scale.19 Modified Owestry Disability Index (MODI) is used to assess the degree of functional scale( ICC 0.86). reliability & validity by Cronbachs alpha Fear avoidance belief questionnaire (FABQ) consists of 2 subscale: physical activity(FABQ-PA) & other is work related(FABQ-W). Reliability: FABQ-PA=0.77 and FABQ-W=0.88.20 The noninvasive inclinometer technique proved to be highly reliable and valid for lumbar range of motion(r = 0.94; P < 0.001)21

Muscle energy techniques

MET is a versatile technique that is traditionally used. There have been few articles published on the topic of MET23, 24, 25 and little has been published in the way of randomized controlled trials26,27 involving MET. Two studies exist in the peer-reviewed literature that have examined the effect of MET on cervical and lumbar motion, and have demonstrated increased range of motion
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(ROM) following treatment. Schenk et al. examined the effects of MET on ROM for cervical region over a four-week period involving multiple MET sessions. Cervical axial rotation was significantly increased following the treatment period. MET applied to the thoracic spine in the direction of restricted rotation significantly produced increased range of active trunk rotation (p<0.0005), but not on the non-restricted side or in the untreated controls. This study supports the use of MET to increase restricted spinal rotation range of motion.29

The immediate success of MET(isometric contraction followed by a passive stretch) in increasing hip extension, when applied to the iliopsoas muscle. No significant change was shown in the inhibition or control groups.30 One more study was done on the use of a 5-second isometric contraction appeared to be more effective than longer contraction durations for increasing cervical range with MET.28 Joint movement and isometric muscle contraction will stimulate joint and muscle
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proprioceptors. This may produce pain relief according to the Gate-control theory where mechanoreceptor afferents carried by large diameter axons inhibit nociceptor afferents at the dorsal horn of the spinal cord. Several studies have demonstrated mobilization and
31,33 31

manipulation to have analgesic effects. One of these studies compared manipulation to MET and suggested that while they both produced increases in range of motion, manipulation may be more effective for pain relief.

Methodology
3.1 Study design
Interventional design

3.2 Study setting

HOSMAT hospital, Bangalore.

3.3 SAMPLE
Sampling: purposive sampling Sample size: 30 The population would be all the subjects reporting to HOSMAT hospital with complain of low back pain. The subjects reporting to department will be screened for inclusion & exclusion criteria & with the knowledge and interest of subjects will participate.

3.4 Inclusion criteria

Low back pain of not more than 12 weeks duration (acute to subacute). Low back pain without radiating symptoms. A subject age range of 20 to 70 years old. MODI score of 20% to 60%. VAS score between 1-6.

3.5 Exclusion criteria

Chronic low back pain (LBP) lasted longer than 12 weeks. Neurological deficit such as tingling, paresthesia numbness, radiating pain into the buttocks or lower extremities, Motor weakness, absent or diminished muscle reflexes. History of disc prolapsed. History of previous back surgery. Specific cause of LPP such as space occupying lesions, congenital malformation. Degenerative changes Spondylolisthesis, Spondylosis, Ankylosing spondylosis.

Severe low back pain that is VAS score 8-10.

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3.6 Materials
Inclinometer MODI FABQ

3.7 Procedure:
Interested subjects shall be informed about aims and procedure of the study. They shall sign the written consent, to be considered a study subjects. A general physiotherapy assessment shall be taken with inclusion and exclusion criteria and the baseline data shall be collected on the reporting date. The selected 30 subjects will be randomly allotted by block method. Subjects will be divided into 15 each group i.e. Group A (treatment group) and Group B(control group). For allocation 5 blocks will be taken, were each blocks consist of 6 participants (3 Group A and 3 Group B). The intervention will be given to the subjects for a week for 3 sessions i.e. alternate days. After 6th day intervention the data will be collected.

PROCEDURE TO MEASURE PAIN

Pain intensity will be evaluated by means of visual analogue scale (VAS), ranging from 0 to 10 cm, were the subjects will mark a point according to their pain level.

PROCEDURE TO MEASURE DISABILITY OF SUBJECTS

ODI will be used to capture subjects perceived level of disability due their non specific LBP. It has shown valid and reliable. It consists of set questionnaire which gives information about how the LBP has affected the ability of the subjects to manage his or her ADL activity.

PROCEDURE TO MEASURE FABQ

FABQ will be used to capture subjects fear of avoidance due to their LBP. It is reliable and valid. It consists of questionnaire which information about avoiding their activities due to fear of pain.

PRODURE TO MEASURE LUMBAR ROM

Lumbar ranges which includes flexion, extension, left side flexion and right side flexion. It will be measured by using inclinometer. The subjects in standing position are instructed to bend forward, backward and sideways. While the movement the inclinometer will be placed at T12 S1[(T12 end range T12 initial range)-(S1 end range S1 initial range)]. Totally 3 trial will be taken to assess the range of motion and recorded.

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 Both the groups will receive physiotherapy treatment which includes electrotherapy such as SWD, IFT, Ultrasound TENS & Lumbar traction and exercises mainly extension exercises, stretching. Group A will be intervened with MET technique.

MET for the Low back region:

Technique 1 Position: Subject is in side lying in the fetal position, with a pillow between the knees and hips flexed to 90. The therapist places one hand on the anterior thigh just above the knee and the other hand on the lower back. Procedure: subject will be asked to resist the extension of hip that is subject is asked to maintain the position while therapist tries to extend the hip by saying, Dont let me move you. Hold for 5 seconds. This technique is repeated for 5 times for 3 sessions a week. Observation: The lumbar spine should not arch while performing MET. Hand placement on the subjects back should be in contact throughout while performing MET. Technique 2 Position: Subjects will lying on the edge of the couch, one leg will be placed over the examiners shoulder and the other leg will be placed under the examiners hand. Procedure: Subjects will be asked to press the leg on the shoulder which is on examiners shoulder and the therapist will resist the movement, and the other leg is asked to flex the hip while the therapist resists the movement. This movement will be hold for 5 seconds and this technique will be repeated for 5 times for 3 sessions a week. For both the groups core stability exercises are given after treatment session. Those are: Subject is in hook lying, ask the subjects to tuck in the tummy (posterior pelvic tilt). This position is maintained for 5 seconds & then relaxed. Subject is in sitting position, ask the subject to arch the low back(increase the lordosis) & hold it for 5 seconds and then relax. Subject is in quadruped position, ask the subject to hollow the tummy like camel for 5sec then increase the arch of the back like cat & hold this position for 5sec then relax. These exercises are repeated for 10 times twice a day.

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3.8 Outcome measures

Pain assessment VAS Range of motion of lumbar spine,rotation of pelvis & hip joint Owestry Disability Index d. Fear-Avoidance Beliefs Questionnaire (FABQ) for Patients with Back Pain

3.9 Data analysis

VAS- pre and post -Paired t test ROM- pre and post- Paired t test ODI and FABQ- pre and post- Wilcoxon Sign Rank Sum Test Demographic Data

Age groups(yrs) 20-30 31-40 41-50 51-60 61-70

Male

Female

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References:
1. Porterfield JA, DeRosa C. Mechanical Low Back Pain. Philadelphia: WB Saunders, 1991. 2. Mooney V. Sacroiliac joint dysfunction. In: Vleeming A,Mooney V, Dorman T, Snijders CJ, Stoeckart R, eds. Movement, Stability, and Low Back Pain. New York: Churchill Livingstone, 1997:3752. 3. Swenson R. A medical approach to the differential diagnosis of low back pain. Journal of the Neuromusculoskeletal System 1998;6:100113. 4. Faas A, Chavannes AW, van Eijk JT, Gubbels JW. A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine.1993;18:13881395. 5. St. John Neuromuscular Therapy training.

6. Kirkaldy-Willis WH, Bernard TN Jr. Managing Low Back Pain, 4th Ed. New York: Churchill Livingstone, 1999. 7. Greg McIntosh and Hamilton Hall

8. Chaitow.L, Liebenson C, Muscle Energy Techniques. Edinburgh, Churchill Livingstone. 1996: 9. Greenman PE, Principles of Manual Medicine 2nd Ed. Baltimore, Williams & Wilkins, 1996. 10. Mehta M, Hatton P. The Relationship Between the Duration of Sub-Maximal Isometric Contraction (MET) and Improvement in the Range of Passive Knee rd Extension. (Abstract) In: Abstracts from 3 International Conference for the Advancement of Osteopathic Research (ICAOR), Melbourne, 2002. Journal of Osteopathic Medicine. 2002;5(1):40. 11. Ferland J, Myer J, Merrill R. Acute Changes in Hamstring Flexibility: PNF versus Static Stretch in Senior Athletes. Physical Therapy in Sport. 2001;2(4):186-193. 12. Gajodsik R. Effects of Static Stretching on the Maximal Length and Resistance to Passive Stretch of Short Hamstring Muscles. Journal of Orthopedic Sports Physical Therapy. 1991;14(6):250-255. 13. Schenk R, Adelman K, Rousselle J. The Effects of Muscle Energy Technique on Cervical Range of Motion. Journal of Manual and Manipulative Therapy 1994; 2(4):149-155.

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14. Schenk R, MacDiarmid A, Rousselle J. The Effects of Muscle Energy Technique on Lumbar Range of Motion. Journal of Manual and Manipulative Therapy. 1997;5(4):179-183. 15. Lenehan KL, Fryer G, McLaughlin P. The effect of muscle energy technique on gross trunk range of motion. Journal of Osteopathic Medicine. 2003;6(1):13-18. 16. Roberts BL. Soft tissue manipulation: Neuromuscular and muscle energy techniques. J Neurosci Nurs 1997;29:123127. 17. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27:28352843. 18. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: A validation study. Ann Intern Med 2004;141:920928. 19. The visual analogue scale: Its use in pain measurement G. B, Langley and H. Sheppeard Medical Research Laboratory, Public Hospital, Palmerston North, New Zealand Received May 21, 1984 / Accepted September 20, 1984 20. Waddell G Newton M et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993; 52: 157-168 (Appendix page 166). 21. Lumbar Range of Motion: Reliability and Validity of the Inclinometer Technique in the Clinical Measurement of Trunk Flexibility: Saur, Petra M. M. MD; Ensink, FranzBernhard M. MD; Frese, Knut MD; Seeger, Dagmar PT; Hildebrandt, Jan MD. 22. Schenk R, MacDiarmid A, Rouselle J. The effects of Muscle Energy Technique on lumbar range of motion. J Man Manip Ther. 1997;5:179-183. 23. Dinnar U, Beal MC, Goodridge JP, et al. Classification of diagnostic tests used with osteopathic manipulation. J Osteopath Assoc. 1980;79:451-455. 24. Goodridge JP. Muscle energy technique: definition, explanation, methods of procedure. J Am Osteopath Assoc. 1981;81:249-254. 25. Kimberly PE. Formulating a prescription for osteopathic manipulative treatment. J Am Osteopath Assoc.1980;79:506-513 26. Schenk R, Adelman K, Rouselle J. The effects of Muscle Energy Technique on cervical range of motion. J Man Manip Ther. 1994;2:149-155. 27. Schenk R, MacDiarmid A, Rouselle J. The effects of Muscle Energy Technique on lumbar range of motion. J Man Manip Ther. 1997;5:179-183.

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28. The influence of contraction duration in muscle energy technique applied to the atlanto-axial joint :Fryer G, Ruszkowski W. The influence of contraction duration in muscle energy technique applied to the atlanto-axial joint. Journal of Osteopathic Medicine. 2004;7(2):79-84. 29. The effect of muscle energy technique on gross trunk range of motion. Lenehan KL, Fryer G, McLaughlin P. The effect of muscle energy technique on gross trunk range of motion. Journal of Osteopathic Medicine. 2003;6(1):13-18 30. A comparative study of the effects of muscle energy technique and inhibition, directed at iliopsoas muscle, on hip extension: Lisa Opie BSc (Hons) 31. Cassidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: A randomized controlled trial. Journal of Manipulative and Physiological Therapeutics. 1992;15:570-5 32. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965; 150:971 979 33. Vincenzo B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. 1996;68:69-74 34. Short-Term Effect of Muscle Energy Technique on Pain in Individuals with NonSpecific Lumbopelvic Pain: NoelleM. Selkow, MEd, ATC1; Terry L. Grindstaff, PT, DPT, ATC, SCS, CSCS2; Kevin M. Cross, MEd, ATC, PT2; Kelli Pugh, MS, ATC, CMT2; Jay Hertel, PhD, ATC, FACSM3; Susan Saliba, PhD, ATC, MPT4 35. Rehabilitation of the spine by Craig Liebenson.

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HOSMAT College of Physiotherapy

Rajiv Gandhi University

Consent Form
I ________________________________ agree to take part in the research study conducted by BHARATI K, Postgraduate student (M.P.T. Musculoskeletal & Sports), HOSMAT College of Physiotherapy, Rajiv Gandhi University, entitled Effects of MET on non specific low back pain: A randomised pilot trial. I acknowledge that the research study has been explained to me and I understand that agreeing to participate in the research means that I am willing to Provide information about my health status to the researcher Allow the researcher to have access to my medical records, pertaining to purpose of the study Participate in evaluator program Make myself available for further follow up

I have been informed about the purpose, procedures, measurements and risks involved in the research and my queries towards the research have been clarified. I provide consent to the researcher to use the information, video or audio recordings, for research and educational purpose only. I understand that my participation is voluntary and can withdraw at any stage of the research project. I understand that no monitory benefit will be given for participation in this research study.

Name of the applicant Signature Date

Signature of the researcher:

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Appendix I Assessment Form

Demographic Data Name: Age/Gender Occupation: Affected region: Chief complaints:Hospital no: Subjects no: Research subjects no: Research group:

History:-

Symptoms characteristic: Area of pain Worst pain Type of pain Clearance of other area Aggravating actor Relieving factor Severity of pain Precaution and contraindications
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Objective examination Observation Lumbar region ROM Flexion Extension Left side flexion Right side flexion Affected

Accessory movement testing

Pelvic girdle Muscle flexibility Erecter spine Quadrates lumborum Illiopsoas Hamstrings Myofacial trigger Muscle strength

VAS (Visual Analogue Scale):It is a self-pain rating scale. The scale consists 0-10,where the subject has to mark his pain on the scale given below.

Pre VAS

Post
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Range of Motion Pre Lumbar flexion Lumbar extension Lumbar Rt sideflexion Lumbar Lft sideflexion MODI and FABQ Pre MODI FABQ Post Post

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Fear-Avoidance Beliefs Questionnare(FABQ)

Instructions: There are 16 questions given below. For each statement subject has to document 0-6 to say how much physical activities affect or would affect back pain.

Statements: 1. My pain is caused by physical activity (_). 2. Physical activity makes my pain worse (_). 3. Physical activity might harm my back (_) 4. I should not do physical activities which (might) make my pain worse (_). 5. I cannot do physical activities which (might) make my pain worse (_).

The following statements are about how your normal work affects or would affect your back pain: 6. My pain was caused by my work or by an accident at work (_). 7. My work aggravated my pain (_). 8. I have to claim for compensation for my pain (_). 9. My work is too heavy for me (_). 10. My work makes or would make my pain worse (_). 11. My work might harm my back (_). 12. I should not do my normal work with my present pain (_). 13. I cannot do my normal work with my present pain (_). 14. I cannot do my normal work till my pain is treated (_) 15. I do not think that I will be back to my normal work within 3 months (_). 16. I do not thing that I will ever be able to go back that work (_).

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MODIFIED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE (MODI)

Section 1: To be completed by subject Name: Age: Date: Occupation: No.of days of back pain:

(this episode)

Section 2: To be completed by subject The subjects will be instructed to mark only the line which most closely describes your current condition. Pain intensity: The pain is mild and comes and goes. The pain is mild and does not vary much. The pain is moderate and comes and goes. The pain is moderate and does not vary much. The pain is severe and comes and goes. The pain is severe and does not very much.

Personal Care (Washing, Dressing, etc.) Lifting I can lift heavy weights without increased pain I can lift heavy weights but it causes increased pain
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I do not have to change the way I wash and dress myself to avoid pain. I do not normally change the way I wash or dress myself even though it causes some pain Washing and dressing increases my pain, but I can do it without changing my way of doing it Washing and dressing increase my pain, and i find it necessary to change the way I do it Because of my pain I am partially unable to wash and dress without help Because of my pain I am completely unable to wash and dress without help

Pain prevents me from lifting heavy weights off the floor but i can manage it if they are conviently positioned (table etc) Pain prevents me from lifting heavy weights off the floor but i can manage light to medium weights if they are conviently positioned (table etc) I can lift only very light weights I cannot lift or carry anything at all

Walking Sitting Sitting does not cause me any pain I can only sit as long as I like providing that i have my choice of sitting surface Pain prevents me from sitting for more than 1 hour Pain prevents me from sitting for more than half hour Pain prevents me from sitting for more than ten minutes Pain prevents me from sitting at all I have no pain while walking I have pain when walking but i can still work my required normal distance Pain prevents me from walking long distance Pain prevents me from walking intermediate distance Pain me prevents from walking even short distance Pain prevents me from at all

Standing I can stand as long as i want without increasing my pain I can stand as long as i want but my pain increases with time Pain prevents me from standing more than 1 hour Pain prevents me from standing more than half an hour Pain prevents me from standing more than ten minutes I avoid standing because it increases my pain right way
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Sleeping I get no pain when I m in bed I get pain in bed but it does not prevent me from sleeping well Because of my pain, my sleep is only 3/4th of my normal amount Because of my pain, my sleep is only 1/2 of my normal amount Because of my pain, my sleep is only 1/4th of my normal amount Pain prevents me from sleeping at all

Social Life My social life is normal and does not increase my pain My social life is normal but increases my level of pain Pain prevents me from participating in more energetic activities (exercises, dancing etc) Pain prevents me from going out very often Pain has restricted my social life at my home I have hardly any social life because of my pain

Travelling I get no increased pain when travelling I get some some pain while travelling, when none of my usual forms of travel make it any worse I get increase pain while travelling, but it does not cause me to seek alternate forms of travel I get increase pain while travelling which causes me to seek alternative forms of travel My pain restricts all form of travel except that which is done while I m lying down My pain restricts all form of travel

Employment/Home making My normal job or home making activities that do not cause pain My normal job or home making activities increase my pain, but i can still perform all that is required of me
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I can perform most of mine job or home making duties, but pain prevent me from performing more physically stressful activities (exercise, lifting etc) Pain prevents me from doing anything but light duties Pain prevents me from doing even light activities Pain prevents me from performing any job or home making chores

Section 3: To be filled by physical therapist

Score: Initial_____% Date______

Post______% Date _______

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