6

Rajiv Gandhi University Of Health Sciences,

Karnataka, Bangalore

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1

Name of the Candidate and

Address

BRAGANZA BRINELLE THOMAS

J.S.S COLLEGE OF PHYSIOTHERAPY

J.S.S HOSPITAL CAMPUS, RAMANUJA ROAD, MYSORE-570004

2

Name of the Institution

J. S. S. COLLEGE OF PHYSIOTHERAPY

JSS HOSPITAL CAMPUS,

RAMANUJA ROAD, MYSORE – 570004

3

Course of Study and Subject

MASTER OF PHYSIOTHERAPY

PHYSIOTHERAPY

IN

MUSCULOSKELETAL AND SPORTS INJURY

4

Date of admission to the course

12-7-2012

5

Title of the topic

A COMPARATIVE STUDY ON THE EFFECTS OF GLOBAL POSTURAL REEDUCATION VERSUS PILATES ON WORK RELATED LOW BACK ACHE IN DENTIST

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7

8

Brief resume of the intended work

6.1) INTRODUCTION

Work related musculoskeletal disorders (WRMSDs) refers to musculoskeletal disorders to which the environment contribute significantly, or to musculoskeletal disorders that are made much worse or longer lasting by work conditions or workplace risk factors.1 Musculoskeletal disorders ( MSK) are the most common cause of severe long term pain and disability and account for 23% of total cost of illness. An estimate of 50 -70% of workforce in developing countries is at a risk of developing MSK disorders owing to various ergonomic risk factors present at their workplace.2

The prevalence of WRMSDs in health professionals is high nurses being 91% , physiotherapist 32% to 91%, osteopaths 69.23% and dentist 64% to 93% .3,4,5,6 In the past 2 years there has been a rise in WRMSDs in dentist with the low back 36.3%-60% and the neck 19.8%-85% being the most affected regions.6 Worldwide self reported annual prevalence of low back ache (LBA) in dentist was found to be 50% and 55% for Danish and Israel dentist 7,8 ,54%for Australian9, 64% New south wales10 ,74% Saudi Arabia11 .In India prevalence is 75.5%.12

The risk factors for WRMSDs in dentistry have been shown to be stress , poor flexibility, improper positioning ,infrequent breaks ,repetitive movement ,weak postural muscles, prolonged awkward postures and improper adjustment of equipment1 .Even with the best of ergonomic equipment dentist can still find themselves in awkward postures.13

There are several studies enumerating the ways in which awkward postures have an effect on low back pain in dentists.

Walters et al conducted a study to predict the factors contributing to neck and back pain in dentist and found that stress and altered body mechanics that is bending and twisting trying to gain better access and visibility into the oral cavity all contribute to LBA in dentist.14

Slomonov M et al confirmed that slouched sitting posture adopted by dentist causes decrease in the spinal muscle activity and increase stress on the posterior ligamentous structures leading to creep, this places the back at an increased risk for LBA.15

Marklin R et al found that dentist have been found to assume a notably forward flexed posture greater than 50% of their time working, holding this position for prolonged periods will fatigue the posterior annulus of the disc , if it exceeds 4% irreversible damage will result leading to disc prolapsed.16,17

Naguvi et al while studying the mechanism of LBA in dentist found that the imbalance between abdominal and low back muscles are one of the principle reasons leading to LBA especially in seated posture. This abnormal posture leads to muscle necrosis, pain and protective muscle spasm.

Furthermore in sitting postures in dentist there are prolonged static contractions of low back extensor muscles which decreases its oxygen supply leading to ischemia .

These same muscles are required to maintain eccentric contraction during certain phases of treatment by dentist, this sudden eccentric pull on the ischemic muscles leads to tearing of muscle fibres leading to low back strain.

Due to the prolonged static postures (PSP) maintained by dentist synovial fluid production in the joint will be decreased this in long term leads to early degenerative changes in the joint and puts dentist operators at a risk of experiencing lumbar facet joint pain syndrome, lumbar disc prolapse , or lumbar spondylitis. 13

The above mechanisms have shown how imbalance of muscles that is between the ‘stabilizing’ muscles and the ‘moving’ muscles, awkward postures and weakness of core muscles can lead to neuromuscular imbalances that lead to LBA in dentist. Numerous choices exist for the treatment of spinal ailments including but not limited to massage, acupuncture, yoga, physical therapy, surgery. While all the above treatment techniques have been effective, for the dental professionals it is not sufficient to just reduce pain, but it is necessary to have a broader approach to rehabilitation, which can also act on neuromuscular imbalances induced by work. 18

Rationale and need for the study

Two techniques that are Global postural re-education and Pilates work on principles that can address this underlying cause for LBA in dentist.

Global Postural Re-education (GPR) is a physical therapy method developed in France by Philippe-Emmanuel Souchard. This therapeutic approach is based on an integrated idea of the muscular system as formed by muscle chains, which can face shortening resulting from constitutional, behavioural, and psychological factors.

The principle of GPR is to stretch the shortened muscles using the creep property of viscoelastic tissue and to enhance contraction of the antagonist muscles, thus avoiding postural asymmetry.19

Muscular chains are an ensemble of muscles defined according to their localization as well as their functional role which can explain posture alterations and movement dysfunctions.20

Neto j et al reported that specific posture patterns caused by muscle chain retractions have been associated with lower back or neck pain among elite athletes in muscular power competitions.21

A review of the literature on GPR suggested that this method may be effective for treating some musculoskeletal diseases and disorders such as ankylosing spondylitis, LBP and lumbar disc herniation22 as the GPR technique maintains muscular elasticity, particularly in the paravertebral muscles and the lower limbs which can reduce the risk of disc herniation.23

Pilates exercise training on the other hand is, based on the teachings of Joseph Pilates (1880-1967), claims to increase trunk muscle endurance, strength, flexibility and neuromuscular control. Its goal is to improve general body flexibility and health by emphasizing ‘core’ (truncal) strength, endurance, posture, and coordination of breathing with movement.24

As the individual progresses and develops improved trunk strength, endurance, and kinesthetic postural control, the level of force placed on the musculature increases so as to retrain proprioceptive mechanisms while fostering more efficient movement patterns.25

Decline in flexibility has been associated with a decline in functional ability, therefore aiding to the advancement of hypo kinetic disease states, such as chronic low back pain and debilitating associated wellness. Flexibility represents the ability to move a joint through its full range of motion (ROM) and is one of the key principles in the design of a Pilates programme.26

Lana strydom in her study on the effects of a Pilates program in computer professionals found that strengthening of the transverse abdominis and lumbar multifidus muscle through a Pilates program assisted in improving flexibility and posture. 26

Since avoiding the imbalance of muscles or gaining the symmetry of muscle activation and postural alignment are the main factors in overcoming LBA in dentist, and GPR and Pilates have been found to be effective in overcoming low back pain in generalized population, but their efficacy in overcoming work related LBA in dental professionals is not known, so the study is proposed to find the effectiveness of GPR versus Pilates application on work related LBA in dentist.

HYPOTHESIS

EXPERIMENTAL HYPOTHESIS

1. GPR will be significantly more effective than Pilates in work related LBA in dentist.

2. Pilates will be significantly more effective than GPR in work related LBA in dentist.

NULL HYPOTHESIS

There will be no significant difference between the effectiveness of GPR and Pilates on LBA in dentist.

6.2) REVIEW OF LITERATURE:

1. M J Hayes et al (2009): Conducted a systematic review of musculoskeletal disorders among dental professionals. All research studies or literature reviews, which have reported on the prevalence of musculoskeletal symptoms and/or potential risk factors for this problem in dentists, dental hygienists and dental students, were selected for inclusion. It was found that the prevalence of general musculoskeletal pain ranges between 64% and 93%. The most prevalent regions for pain in dentists have been shown to be the back (36.3–60.1%) and neck (19.8–85%), while the hand and wrist regions were the most prevalent regions for dental hygienists (60–69.5%). It was found that studies on MSDs among dental and dental hygiene students are quite limited. Many risk factors have been identified, including static and awkward posture and work practices. Overall, the review suggests that musculoskeletal problems represent a significant burden for the dental profession.6

2. Patel et al (2012): Conducted a study on the prevalence and associated factors of back pain among dentist in south Gujrat .In this cross sectional study, 154 randomly selected dentists were interviewed. Prevalence of pain was 63.6 percent. Back, neck and shoulder are the most common sites of pain and it was reported by 75.5%, 42.9% and 22.5% dentists respectively. Prolong sitting was reported to be the most common aggravating factor for pain, while correcting working posture relieved pain the most. Most of the dentists did not take any treatment for pain which adversely affected the condition and increased the severity of the pain. Regular daily exercise as well as physiotherapy was found helpful to relieve pain but very few did it regularly. Some dentists took pain killers while very few consulted orthopaedic surgeons for treatments.27

3. Teodori et al (2011): Conducted a literature review of physical therapy interventions that utilized the GPR method. Articles were searched from Medline, SciELO, LILACS and PeDRO, from 2000 to 2010. 25 studies, 13 about GPR and 8 about global and active stretching in addition to three books and a thesis were included .After analysis it was found that some studies showed that the GPR method was more effective than other physical therapy interventions, while others demonstrated similar results of GPR when compared to other physical therapy interventions. Studies showed benefits of the GPR in improving the respiratory muscle strength, chest expansion, maximal respiratory pressure and in reducing pain, loss of urine in incontinent women, increasing flexibility, the electromyographic activity in temporomandibular disorders and postural stability in lower limb orthopaedic alterations.28

4. Ferrari et al (2009): Conducted a case study to evaluate the efficacy of a multimodal rehabilitation program in a dental hygienist with upper quadrant disorders. Particular importance during treatment was given to postural re-education.via GPR The treatment lasted two months (8 sessions, 1 session per week). The outcomes introduced were Visual Analogue Scale, VAS (70/100 at the beginning and 0/100 at the end of treatment) and Neck Pain and Disability Scale, NPDS (62.5/100 at the beginning and 3/100 at the end of treatment); at 12-month follow-up, VAS was 10/100 and NPDS was 19/100. Hence they concluded that a multimodal rehabilitation, with emphasis on musculoskeletal imbalance correction, proved to be useful in a patient who maintained prolonged flexion and rotation of the spine, front shoulder closure, and arm suspension due to occupational daily activities. The improvements lasted over time.18

5. Bonetti et al (2010): Conducted a non-randomized controlled trial to evaluate the effectiveness of a Global Postural Reeducation (GPR) program as compared to a Stabilization Exercise (SE) program in subjects with persistent low back pain (LBP) at short- and mid-term follow-up (ie. 3 and 6 months). 100 subjects were taken 50 GPR and 50 SE. Primary outcome measures were Roland and Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI). Secondary outcome measures were lumbar Visual Analogue Scale (VAS) and Fingertip-to-floor test (FFT). the results revealed a significant reduction (from baseline) in all outcome measures (reduction from baseline of at least 30% in RMDQ and VAS scores) for the GPR group compared to the SE group.29

6. Gladwell et al (2006): Conducted a single blind randomized controlled trial. To evaluate the effect of a program of modified Pilates for active individuals with chronic non-specific low back pain. 49 individuals with chronic low back pain were randomly allocated to control (n = 24) or Pilates group (n = 25).outcome measures were Roland Morris pain rating visual analogue scale (RMVAS), Oswestry Low-Back Pain Disability Questionnaire (OSWDQ), SF-12, stork stand test. Improvements were seen in the Pilates group post- intervention period with increases (P < 0.05) in general health, sports functioning, flexibility, proprioception, and a decrease in pain, they felt that Pilates used in their study had been beneficial because it uses functional static-dynamic resistance exercise to aid “core muscle” strengthening and endurance and to improve sensory motor control of the trunk and additional limb movement.30

7. Davidson et al (2002): Conducted a study examining 5 commonly used questionnaires for assessing disability in people with low back pain. The modified Oswestry Disability Questionnaire, the Quebec Back Pain Disability Scale, the Roland-Morris Disability Questionnaire, the Waddell Disability Index, and the physical health scales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) in patients undergoing physical therapy for low back pain. They found that the modified Oswestry Disability Questionnaire, the SF-36 Physical Functioning scale, and the Quebec Back Pain Disability Scale were the most reliable (greater than .80) and had sufficient width scale to reliably detect improvement or worsening in most subjects . The reliability of measurements obtained with the Waddell Disability Index was moderate, but the scale appeared Morris Disability Questionnaire and the Role Limitations–Physical and Bodily Pain scales of the SF-36 appeared to lack sufficient reliability and scale width for clinical application.31

8. Fritz et al (2001): Conducted a study to examine the validity of a global rating of change as a reflection of meaningful change in patient status and to compare the measurement properties of a modified Oswestry Low Back Pain Disability Questionnaire (OSW) and the Quebec Back Pain Disability Scale. The MCID for the modified OSW was approximately 6 points and for the QUE was 15 points ,The modified OSW demonstrated superior measurement properties compared with the QUE.32

9. Perret et al (2001): Conducted a study to evaluate the reliability and validity of the fingertip to floor test to assess total mobility when bending forward in standing position. 10 patients with chroniclow back pain in the validity study; 32 LBP patients in the reliability study; and 72 LBP patients in the responsiveness study were taken Dynamic radiographs and fingertip-to-floor test were taken. For validity The Spearman’s correlation coefficient for trunk flexion assessed was excellent (rs 5 2.96). For reliability the intra- and inter observer reliability were excellent (ICC 5 .99). The Bland and Altman method showed no systematic trend. For responsiveness the values observed for the test were .97 for SRM and .87 for effect size. Hence they concluded that the fingertip-to-floor test has excellent validity, reliability, and responsiveness, it can be used in clinical practice and therapeutic trials.33

10. Bijur et al (2001): Conducted a study to evaluate the reliability of VAS for measurement of acute pain. Convenience sample of adults with acute pain presenting to two EDs was taken. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) and a Bland-Altman analysis were used to assess reliability of paired VAS measurements were obtained 1 minute apart every 30 minutes over two hours The summary ICC for all paired VAS scores was 0.97 [95% CI = 0.96 to 0.98]. The Bland-Altman analysis showed that 50% of the paired measurements were within 2 mm of one another, 90% were within 9 mm, and 95% were within 16 mm .Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high. Ninety percent of the pain ratings were reproducible within 9 mm. These data suggest that the VAS is sufficiently reliable to be used to assess acute pain.34

6.3) Objectives of the study:

1. To evaluate the effectiveness of GPR in low back ache in dentist

2. To evaluate the effectiveness of Pilates in low back ache in dentist

3. To compare the effectiveness of GPR and Pilates in low back ache in dentist

1. Materials and Method

7.1) Study design: Experimental study

Pre-test and Postest

Source of study: JSS hospital dental department

7.2) (I) Definition of study subject: Male and female dentist ,post graduate, intern dental students 22 yrs and above with 1st or 2nd stage MSD of low back with RULA score above 3

7.2) (II) Inclusion and exclusion criteria:

Inclusion Criteria

· Dentist ,postgraduate and intern dental students suffering 1ST or 2nd stage MSD of low back

· RULA score above 3

· Male M and Female F

· Age 22 and above

Exclusion Criteria

· Specific causes of LBP (disc herniation, lumbar stenosis, spinal deformity, fracture, spondylolisthesis)

· Central or peripheral neurologic signs,

· Systemic illness (tumour and rheumatologic diseases),

· Psychiatric and mental deficits.

· Patients who have undergone other physiotherapeutic interventions or surgical operations within 6 months prior to baseline assessment

7.2) ( III ) Study sampling design, method and size

Sample design: Simple random sampling

Method of collection of data: Personal structured interview.

Sample size: 40

7.2) (IV) Duration of study: 6 weeks

7.2) ( V ) Parameters used for comparison and statistical analysis :

Outcome measures:

1. Modified Oswestry Disability Index (ODI)

2. Visual Analogue Scale (VAS)

3. Fingertip to-floor test (FFT)

Statistical analysis:

· The data will be analyzed by Paired t test and independent sample t test

Materials required:

· Mats

· RULA worksheet

· Rulers

· Tape

7.2) (VII) METHODOLOGY:

40 subjects of both Male and Female who fulfil the inclusion criteria will be selected for the study and ethical clearance will be taken from JSS Physiotherapy ethical committee .The therapist will be predicting the RULA of each subject through observation at the work place All the subjects will be randomized in to 2 groups that is Group A and Group B. Group A will receive the Pilates program and Group B will receive the GPR program

The baseline data for the outcome measures VAS, FFT and ODI will be taken prior to the intervention for both the groups

GROUP A -The Pilates intervention group

Will receive the Stott Pilates program so as to include more preparatory exercise ,better safety and permit maintenance of a neutral spine.

The Pilates program will be conducted for two 1 hour session each week for 6 weeks.

The participants will learn selected exercises from the Stott Pilates mat program. In the first class, the basic principles of Pilates will be explained

In each one hour class, an educational aspect will be provided followed by specific Pilates exercises

Educational aspects include posture check (including neutral spine and pelvis), recruitment of “core muscles,” all aspects will be completed during controlled breathing.

All exercises will start at the base level and will be progressed by incorporating limb movement, when participants are able to maintain control of the spine. Additional exercises will be also added during each session.

The exercises taught within a class will also be repeated individually during two 30 minute sessions each week performed at home without supervision. The exercises are as follows

1. Abdominal prep: Lie on back, legs bent, arms toward ceiling. Exhale, pressing arms down to sides, curling up head and upper torso. Inhale, return to start position.

2. Hundred: Lie on back, legs bent, arms toward ceiling. Ex‐hale, pressing arms down to sides, curling up head and upper torso. Hold. Pump arms in small flutter movements.

3. Roll‐up: Lie on back, legs straight, arms overhead. Ex‐hale, bringing arms forward curling up from top of spine. Inhale as begin roll back, exhale as slowly completing roll back down.

4. One leg circle: Lie on back, leg extended on mat, other leg straight up. Inhale, circling leg across body and exhale as you finish circling down and around to beginning. Maintain still pelvis.

5. Rolling like a ball: Sit with knees to chest. Inhale, roll back to shoulders. Exhale, roll back to seat.

6. Single leg stretch: Lie on back, one leg knee to chest with the other leg at 45 degrees. Exhale, curling up head and upper torso. Holding torso position exchange leg positions .

7. Single leg stretch with obliques: Lie on back, legs bent to chest, hands behind head. Exhale, lifting head and upper torso. Twist torso and elbow to opposite knee, extending other leg to 45º. Inhale, twisting to other side, changing legs.

8. Double leg stretch: Lie on back, hand holding knees to chest. Exhale, curling up head and upper torso to knees. Hold curl, inhale and extend arms and legs toward ceiling. Exhale, bringing legs and arms back in.

9. Spine stretch forward: Sit up straight, bent legs open slightly wider than hips, feet flexed, hands behind on mat. Inhale. Exhale, rounding torso over. Inhale, sitting up.

10. Saw: Sit up straight, legs open slightly wider than hips. Extend arms to side. Exhale, rounding spine over leg, reach opposite hand toward outside of foot, other arm back, palm up.

11. Breast stroke prep: Lie on stomach, elbows bent, lower rib remaining on mat. Inhale, raising upper torso, coming up to forearms. Exhale, slowly lowering torso back to start position

12. Swan dive prep: Lie on stomach, elbows bent. Inhale, raising up‐per torso, coming up to palms. Exhale, lowering torso back to start position

13. Heel squeeze: Lie on stomach, legs apart. Supporting abdomen, bend knees and gently squeeze heels together.

14. Oblique roll back: Sit straight, legs bent with feet on the mat. Ex‐hale, slowly rounding back halfway. Reach arm behind. Inhale, returning.

15. Spine twist: Sit up straight, legs pressed together, feet flexed. Reach arms out to sides, palms forward. Exhale, twisting twice to one side. Inhale, returning. Keep arms straight, legs pressed together.

16. Side kicks: Lie on side, back straight in line with edge of mat, legs hinged 30 degrees in front of torso. Lift top leg to hip height. Bring top leg forward and then back without moving torso.

17. Side leg series: Lie on side, back straight in line with edge of mat, legs straight. Lift top leg to hip height, slowly return down to start position.

18. Teaser: Lie on back, legs on 45 degree diagonal. Exhale, curling up to V position, keeping legs in place. Inhale, holding V position, exhale slowly rolling back to start position.

19. Seal: Balance on seat, holding legs. Clap feet together three times. Inhale, rolling back to shoulder. Pause slightly to clap feet together three times. Exhale, roll back to start.

20. Push‐ups: Inhale, lowering to push‐up position, elbows next to ribs. Exhale, pushing up to arms straight. Repeat 3 times. Arms straight, inhale, walking hands back to feet. Hang over in forward bend. Exhale, rolling spine up to stand. Inhale. Re‐verse sequence into push‐up position.

.

Progression of exercise:

Week 1 :Posture check ,Lateral thoracic breathing ,Neutral spine and pelvis ,Recruitment of transversus

abdominis or pelvic floor, Enforcement of Pilates principles, Encouragement not to substitute

From global muscles. Exercises- Side Kick, One Leg Stretch, Shoulder Bridge

Week 2 : As week 1 plus: The Hundred

Week3 : As week 2 plus: progression of exercises

Week 4, 5, 6: As week 1 plus: Encouragement of flowing movements executed with precision & control progression of exercises: Swimming, Swan Dive, Roll Up, Spine Twist, Double Arm Stretch, One Leg circle

GROUP B-The GPR intervention group

Will be taught 2 postures which are found to be effective in lengthening the posterior chain, which is usually shortened in patients with LBP. The postures are

1. The lying posture with extension of the legs aimed to release the diaphragm muscle and to stretch the anterior muscle chain (diaphragm, pectoralis minor, scalene, sternocleidomastoid, intercostalis, iliopsoas, arm, forearm, and hand flexors). The patient lies in supine position with the upper limbs abducted about30° and the forearms supine. Hips are flexed, abducted, and laterally rotated, with foot soles touching each other. Manual traction is applied to the neck in order to align the dorsal and cervical curves of the spinal column, whereas sacral traction is used in order to straighten the lumbar spine

2. The standing posture with flexion of the trunk follows a progression from an upright posture to a bending forward position, while keeping the occiput, the thoracic spine, and the sacrum aligned. This posture is used in order to stretch the posterior chain.

Techniques integrating static and dynamic functions will also be employed for about five minutes to give patients the opportunity to experience and use the recovered flexibility in their functional activities (e.g. bending forward, wearing trousers or reaching items at the bottom) .

The duration will be twice weekly for 6 weeks each session will be 1 hour.

Each patient will be asked to repeat the exercises at home either in the morning or in the evening according to their capabilities

Both the groups will receive ergonomic training to be applied at their place of work

At the end of the week intervention period the outcome measures VAS ,FFT ,ODI will be taken again for both the groups

Inter and intra group data will be statistically analysed using paired t test and independent sample t test

7.3) Does the study require any investigations or interventions to be conducted on patients or other Human or animal?

Yes

7.4) Has ethical clearance been obtained from your institution in case of 7.3?

Yes.

LIST OF REFERENCES:

1. Gupta S .Ergonomic applications to dental practice Indian J Dent Res 2011; 22:816-22

2. Jacobson & Lindgren. What costs illness? National Board of Welfare. Stockholm Sweden; 1996.

3. Rajen N. Naidoo Occupational use syndromes. Best Practice & Research Clinical Rheumatology 2008 Vol. 22, No. 4, pp. 677–691

4. Bork, B., Cook, T., Rosecrance, J., Engelhardt, K., Thomason, M., Wauford, I., et al. Work-

related disorders among physical therapists. Physical Therapy, 1996 76(8), 827-835

5. Peat, C. L. (2004). Work related musculoskeletal disorders among osteopaths practicing in New

Zealand: The prevalence, perceived risk factors and consequences. UNITEC, Auckland

6. Hayes M ,Cockrel D, Smith DR. A systematic review of musculoskeletal disorders in dental professionals Int J Dent Hyg 2009;7 :159-65

7. L. Finsen, H. Christensen and M. Bakke, Musculoskeletal disorders among dentists and variation in dental work, Appl Ergon. 1988; 29(2), 119–125

8. Ratzon NZ, Yaros T, Mizlik A, Kanner T. Musculoskeletal symptoms among dentists in relation to work posture.Work; 15: 153-8.

9. Leggat PA, Smith DR. Musculoskeletal disorders self-reported by dentists in Queensland, Australia. Aust Dent J.2006; 51(4): 324-7.

10. Marshall E.D., Duncombe L.M.,.Robinson R.Q and. Kilbreath S.L, Musculoskeletal symptoms in New South Wales dentists. Aust Dent J. 1997;42: 240–6.

11. K.A. Al Wazzan, K. Almas, S.E. Al Shethri and M.Q. Al- Qahtani, Back & neck problems among dentists and dental auxiliaries. J Contemp Dent Prac.2001; 2: 17–30.

12. Sharma P ,Glochha V, Awareness among Indian dentist regarding the role of physical activity in prevention of work related musculoskeletal disorders Indian J Dent Res 2011;22:381-4

13. Waqar M. Naqvi, P.S Kulkarni, S.J Sumbh. Mechanisms leading to work related Musculoskeletal Disorders in Dental Professionals Pravara Med Rev 2008; 3(4)

14. Walters E. How to live with failure and stress. Dent Manage. 1976 Oct;16(11):20-4

15. Solomonow M, et al, Biomechanics and Electromyography of a Common Idiopathic Low Back Disorder, Spine 28(12): 1235-48. 2003

16. Marklin R., Cherney K, Working Postures of Dentists and Dental Hygienists, in press.

17. Hickey DS, Hukins DWL, Relation between the Structure of the Annulus Fibrosis and the Function and Failure of the Intervertebral disc.Spine 5(2): 106, 1980.

18. S. Ferrari1, M. Monticone Efficacy of a multimodal rehabilitation program in a dental hygienist with upper quadrant disorders. Description of a case report with one-year follow-up G Ital Med Lav Erg 2009; 31:4, 407-413

19. Souchard P-E, Meli O, Sgamma D, Pillastrini P: Rieducazione posturale globale EMC (Elsevier Masson SAS, Paris), Medicina Riabilitativa, 2009: 26-061-A-15

20. Fortin et al. Inter-rater reliability of the evaluation of muscular chains associated with posture alterations in scoliosis BMC Musculoskeletal Disorders 2012,

21. Neto J, Pastre CM, Monteiro EL: Postural alterations in male Brazilian athletes who have participated in international muscular power competitions. Rev Bras Med Esporte 2004, 10:199–201.

22. Vanti C, Generali A, Ferrari S, Nava T, Tosarelli D, Pillastrini P: Rééducation Posturale Globale in musculoskeletal diseases: scientific evidence and clinical practice Reumatismo 2007, 59(3):192-201

23. E di ciaccio, M polastr, E bianchini ,A gasbarrini :Herniated lumbar disc treated with Global Postural Reeducation.A middle-term evaluation .European Review for Medical and Pharmacological Sciences 2012

24. Kristie S. Kava, Cathy A. Larson, Christine H. Stiller and Sara F. Maher. Trunk endurance exercise and the effect on instrumental performance: a preliminary study comparing Pilates exercise and a trunk and proximal upper extremity endurance exercise program Music Performance Research Copyright © 2010 Royal Northern College of Music Vol 3 (1) Special Issue Music and Health: 1‐30

25. Segal, N., Hein, J., & Basford, J. (2004). The effects of Pilates training on flexibility and body composition: An observational study. Archives of Physical Medicine & Rehabilitation, 85, 1977-1981.

26. Lana atrydom .Pilates for postural stability in computer useres December 2008

27. Priyanka Patel, Marwadi Mehul R, Rupani Mihir .Prevalence and associated factors of back pain among dentists in south gujrat. National journal of medical research Apr- June 2012 Volume 2 Issue 2

28. Rosana M. Teodori, Júlia R. Negri, Mônica C. Cruz, Amélia P. Marques. Global Postural Re-education:a literature review. Rev Bras Fisioter, São Carlos, May/June 2011 v. 15, n. 3, p. 185-9

29. Bonetti et al.: Effectiveness of a ‘Global Postural Reeducation’ program for persistent Low Back Pain: a non-randomized controlled trial. BMC Musculoskeletal Disorders 2010 11:285

30. Valerie Gladwell, Samantha Head, Martin Haggar,and Ralph Beneke . Does a Program of Pilates Improve Chronic Non-Specific Low Back Pain? J Sport Rehabil. 2006,15, 338-350

31. Davidson M, Keating JL. A comparison of five low back disability questionnaires: reliability and responsiveness.Phys Ther. 2002;82:8 –24

32. Fritz JM, Irrgang JJ. A comparison of amodified Oswestry Low Back Pain Disability Questionnaire and theQuebec Back Pain Disability Scale. Phys Ther. 2001;81:776 –788.]

33. Perret C, Poiraudeau S, Fermanian J, Lefe`vre Colau MM, Mayoux Benhamou MA, Revel M. Validity,reliability, and responsiveness of the fingertip-to-floor test. Arch Phys Med Rehabil 2001;82:1566-70.

34. Polly e bijur ,wendy silver, E john gallaghere .Reliability of the Visual Analog Scale for Measurement of Acute Pain academic emergency medicine .December 2001, Volume 8, Number 12

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9

Name & Signature of the candidate

BRAGANZA BRINELLE THOMAS

10

Remarks of the guide

THIS STUDY WILL BE HIGHLY BENIFICIAL FOR DENTIST SUFFERING FROM LOWBACK PAIN AND IS STRONGLY RECOMMENDED.

11

Name and Designation of

11.1 Guide

11.2 Signature

11.3 Co-guide (if any)

11.4 Signature

11.5 Head of Department

11.6 Signature

PRADEEP SHANKAR

ASSOCIATE PROFESSOR

J.S.S. COLLEGE OF PHYSIOTHERAPY,

MYSORE

DR. MRUTHYUNJAYA

HOD, DEPT. OF PHYSIOTHERAPY

J.S.S.COLLEGE OF PHYSIOTHERAPY

MYSORE

12

12.1 Remarks of the Chairman &

Principal

12.2 Signature