|Year : 2015 | Volume
| Issue : 2 | Page : 608-615
The effectiveness of the proposed range-of-motion program on reducing sciatic pain
R Attalla Hanan PhD , H Soliman Gehan
Department of Adult Health Nursing, Faculty of Nursing, Menoufia University, Menufia, Egypt
|Date of Submission||12-Dec-2013|
|Date of Acceptance||30-Mar-2014|
|Date of Web Publication||31-Aug-2015|
R Attalla Hanan
Department of Medical Surgical Nursing, Faculty of Nursing, Menoufia University, Shebein Elkom 32511, Menufia
Source of Support: None, Conflict of Interest: None
This study was carried out to assess the effect of the proposed range-of-motion program on the reduction of low back pain among sciatic patients.
Exercises are superior to minimal intervention for the reduction of pain in individuals with nonspecific low back pain.
Materials and methods
A sample of 30 patients suffering from lower back pain due to sciatica were included in the study. The study was carried out at the Physical Therapy Outpatient Clinic at Menoufia University Hospital, Egypt. Three tools were utilized for data collection. Tool 1: a structured interviewing questionnaire to assess patients' knowledge and medical data. Tool 2: an observation check list, which was developed by the researcher to observe patient performance related to the performance of the proposed range of motion. Tool 3: a visual analogue pain scale (orthopedic pain management needs).
Results revealed that there was statistically significant improvement in the total knowledge score (P = 0.001) and the pain level of the studied participants after implementing educational intervention about the range of motions as compared with preintervention (P = 0.00).
The range-of-motion program had a highly significant effect on the knowledge and the pain among patients with sciatic pain.
Keywords: intervention, pain scale, range of motion, sciatic pain
|How to cite this article:|
Hanan R A, Gehan H S. The effectiveness of the proposed range-of-motion program on reducing sciatic pain
. Menoufia Med J 2015;28:608-15
|How to cite this URL:|
Hanan R A, Gehan H S. The effectiveness of the proposed range-of-motion program on reducing sciatic pain
. Menoufia Med J [serial online] 2015 [cited 2020 Jun 3];28:608-15. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/608/163927
| Introduction|| |
Sciatica affects many people. It is a symptom, and not a diagnosis. It is a nonspecific term commonly used to describe symptoms of pain radiating downward from the buttock over the posterior or the lateral sides of the lower limb. It is usually assumed to be caused by the compression of a nerve, the dynamics of the human spine, and lumbar disc syndrome  .
Exact data on the incidence and the prevalence of sciatica are lacking. In general, an estimated 5-10% of patients with low back pain have sciatica, whereas the reported lifetime prevalence of low back pain ranges from 49 to 70%. The annual prevalence of disc-related sciatica in the general population is estimated at 2.2%  . In about 90% of the cases, sciatica is caused by a herniated disc with nerve root compression, but lumbar stenosis and (less often) tumors are possible causes. The diagnosis of sciatica and its management varies considerably within and between countries  .
Low back pain is one of the most common causes of disability in the working population. Self-rated disability at work was strongly associated with the presence of musculoskeletal disorders or other musculoskeletal diseases  . Between 60 and 80% of adults will be affected with low back pain during their lifetime. It has been reported that between 30 and 40% of the individuals with acute low back pain never recover completely, developing chronic low back pain. In recent years, there has been a growing number of reports on the benefits of Pilates-based exercises for low back pain that is creating a large socioeconomic burden in developed countries  . Employees who are unable to work due to back pain spend a significant amount of time on sick leave, which impacts the productivity in the work place  .
Low back pain is a major health problem among populations, and a major cause of medical expenses, absenteeism, and disability  . One of the complications of low back pain is radiated or sciatic pain, which is similar to low back pain. It is more persistent and severe than low back pain and has a less favorable outcome, consuming more health resources. The main cause of symptoms is believed to be the inflammatory process, which results in irritation or compression of the affected nerve root by surrounding tissues  .
Although low back pain usually is a self-limiting and benign disease that tends to improve spontaneously over time, the effectiveness associated with most of these interventions has not yet been demonstrated beyond doubt, and consequently, the therapeutic management of low back pain varies widely. Exercise therapy is a widely used treatment for low back pain. It was found to be useful in the treatment of chronic low back pain if the aim was to improve return to normal daily activities and work. Exercise has become an attractive therapy because it is a cheaper alternative to manual therapies. There are many different types of exercise interventions that may be undertaken in many different ways. Sciatica exercises focus on relieving pain in the lower back and legs, which are associated with damage of the radicular nerve. In most cases, exercise is more beneficial than bed rest; the movement will promote the exchange of fluids in the spinal discs, while also strengthening the back muscles and providing support for the back. Exercises can also prevent the recurrence of the pain  .
Significance of the study
Back pain causes a loss of working time of 2% per month, 10% per year, and 25-30% over the adult working years. One of the major challenges for researchers in the field of low back pain is to provide evidence of which treatment, if any, is of the most benefit for subgroups of patients with low back pain. In this study, results on the effectiveness of the proposed range-of-motion program are presented.
Aim of the study
The aim of this study was to assess the effect of the proposed range-of-motion program on the reduction of low back pain among sciatic patients.
Sciatic pain will be reduced after performing the proposed range-of-motion program compared with before intervention.
| Participants and methods|| |
A Quasi experimental design was utilized for this study.
The current study was carried out at the Physical Therapy Outpatient Clinic at Menoufia University Hospital, Egypt.
A sample of 30 patients of both sexes was recruited on the basis of 80% suffering from lower back pain due to sciatica during the time of data collection. They were selected according to the following criteria:
- Age between 18 and 60 years.
- No disability to perform exercise.
- Not recommended for surgical intervention.
For the purpose of the study and to collect the necessary data, two tools were utilized by the researchers on the basis of a review of the related literature. Tool 1 consisted of an interviewing questionnaire: an Arabic structured interviewing sheet was constructed by the researcher depending on a review of the related literature , for the purpose of data collection. It included two parts. Part one consisted of sociodemographic data such as age, sex, the marital status, the education level, and the occupation.
Part two consisted of the patient's knowledge; it was used to assess the patient's knowledge about the disease process (definition, causes, signs, symptoms, treatment, complications), reasons for hospital admission, and the practice of exercise.
The scoring system consisted of nine questions: five questions were scored as 3 for a correct and complete answer, 2 for a correct and incomplete answer, and 1 for a wrong or don't know answer; one question was scored as 1 for yes and 0 for no answer; two questions were scored as 1 for choosing exercise, 2 for pain killer, and 3 for other; other questions included 1 for the physician, 2 for nurses, and 3 for researchers. The range of scores was from 8 to 22. All questions were summed, with higher scores indicating good knowledge: a score from 8 to less than 13 indicates poor knowledge, whereas a score from 13 to 22 indicates good knowledge.
Tool 2 consisted of an observation check list: it was developed by researcher to observe patient performance related to the performance of the proposed range of motion. It was composed of the performance of press-up exercises, which are beneficial for leg, back, and buttocks pain, extension exercises to relieve back and leg pain, curl-up exercises, which can strengthen the abdominal muscles, and leg raises to strengthen the lower abdominal muscles; the performance was classified and scored as follows: 3 marks were given for performing the exercise correctly and completely, 2 marks were given for performing them correctly and incompletely, and 1 mark was given when the patient did not perform the exercise at all or performed it incorrectly. The score ranged from 4 to 12. All questions were summed up, with a higher score ranging from 7 to 12 indicating good performance and a score less than 7 indicating bad performance.
Tool 3 was a visual analogue pain scale: this scale was developed by Coll et al.  to assess the pain level. It consisted of a horizontal 10-mm line on a piece of paper with 'no pain' at one end. The score was coded as none (0), mild (1-3), moderate (4-6), and severe (7-10).
- Written approval: an official approval was obtained from the responsible authorities after explaining the aim of the study.
- Tool development: study tool 1 was developed by the researchers after extensive review of the relevant literature. This tool was tested for the content validity by five experts in the field of nursing, physical therapy, and orthopedic specialities. Necessary modifications were carried out to ascertain relevance and competence. The third tool was developed by Coll and colleagues.
- Patient written informed consent: patients' written agreement to participate in this study was obtained after explanation of the purpose of the study. Each patient was reassured that any information obtained would be confidential and would be used only for the study purpose. Privacy, confidentiality, and right to withdraw at any time were assured.
- Reliability: all tools were tested for their reliability using the test-retest method (patient's knowledge r = 0.87; the visual analogue pain scale ranged from 0.97 to 0.99).
- A pilot study was carried out on 10% of the study sample (three patients) from a physical therapy outpatient clinic to test the feasibility and the applicability of the tools, and modification was carried out accordingly. Data obtained from the pilot study were excluded from the actual study.
- Data collection: data were collected from October 2010 to the end of April 2012.
- The researchers initiated data collection by first collecting sociodemographic and medical data; every patient was interviewed individually.
- Then, each participant's knowledge of the disease process and the pain level were assessed using tools 1 and 2.
- The data obtained were used as a pretest and to aid in the education of the proposed range-of-motion program.
- The researcher gave verbal instructions supplemented by written materials that were presented with pictures as an illustrative guide for more clarification to patients. This illustration handout was designed by the researchers on the basis of a review of the literature.
- The data obtained were meant to aid in formulating nursing management, which was tailored to suit patients' physical ability to perform the proposed range-of-motion program as follows.
- Press-up exercises are beneficial for leg, back, and buttocks pain. Lie on the stomach with arms bent and palms on the floor. The buttocks and legs should be relaxed, while the abdominal muscles can be contracted. Press the upper body up using the arms and the abdominal muscles, while the legs are resting on the floor. Stay in this position for 1-3 s. With time, one may stay in this position for 10 s. Repeat these exercises 10 times, twice per day.
- Extension exercises relieve back and leg pain. Lie on the stomach with arms and legs stretched out. Raise one arm and the opposite leg, holding them in this position for 3 s. Lower them to the ground, repeating the same movement with the other limbs. A series of 10 extensions, performed twice per day, is recommended.
- Curl-up exercises strengthen the abdominal muscles, which will provide support for the back, relieving the pain. Lie on the back with the knees bent. The arms may be folded on the chest or held at the back of the head, providing support for the neck (recommended if you have neck pain). Lift the head and shoulders from the ground and maintain this position for 3 s. For starters, 10 curl-ups are sufficient.
- Leg raises strengthen the lower abdominal muscles, which can support the back and diminish the pain. Lie on the back with hands behind the head; alternatively, one can place a pillow under the neck. While tightening the abdominal muscles, try to raise one leg a few inches above the ground. Hold the leg in this position for 2-5 s and then release it to the ground. Raise the other leg in the same manner. For a more intensive workout, circle the raised leg in the air five times in one direction and then five times in the opposite direction.
- Each patient was scheduled for a minimum of three teaching sessions in three consecutive visits to outpatient clinics. Each session lasted 15 min for each patient. Patients received an illustrative guide with pictures for more clarifications of the proposed range of motion.
- Patients were asked to repeat the knowledge and the proposed range-of-motion skills learned several times until the researchers made sure that it was mastered successfully.
- The other session was carried out after 2 weeks to reinforce the provided knowledge and respond to patients' exercises.
- A follow-up session was conducted after 2 months. Each patient was assessed and monitored three times (the prenursing management protocol, after 2 weeks, and after 2 months) using all tools to assess the effect of the proposed range-of-motion program on the level of pain.
Data were collected, tabulated, and statistically analyzed using the SPSS, version 12 statistical program (IBM Inc., Chicago, IL, USA). Comparison between patients' qualitative data before and after intervention of the proposed range of motions by 2 weeks and 2 months were carried out.
| Results|| |
[Table 1] reveals that the mean age of the study group was 39.97 ± 8.86 years; the majority of the participants in the study group were female (56.7%) and married (73.3%). Regarding the education level, it was observed that 50% of the study group had secondary education and less than one-third of the group (20%) had university education. It was also observed that most of the patients lived in rural areas (56.7). Regarding the reason for hospital admission among the studied group, it was observed that the most common reason for hospitalization (33.3%) was heavy lifting, followed by trauma or sudden movement. Also, two-thirds of the group (66.7%) did not practice exercises.
[Table 2] illustrates a comparison of the knowledge about sciatica in the studied group before, 2 weeks after, and 2 months after intervention. The finding revealed that there was a highly significant difference regarding the knowledge about sciatica, reasons of sciatica, signs of sciatica, the treatment of sciatica, dealing with complications, benefits of exercise, performing exercise, time to perform exercises, and the source of knowledge (P < 0.001); it was also observed that there was significant improvement in the total mean score of knowledge about sciatica pain in the studied group (P = 0.05).
[Table 3] shows a statistically significant difference regarding the mean knowledge score about sciatic pain at two different intervals (2 weeks and 2 months after intervention).
|Table 2 Comparison between the studied groups before intervention, after intervention, and at follow-up intervention regarding the knowledge about sciatica|
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|Table 3 Total knowledge of the participants before intervention, after intervention, and during follow-up intervention|
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[Table 4] reveals that the mean performance of the proposed range of motion in the study group improved from 5.2 ± 5.7 before intervention to 14.1 ± 2.3 after intervention to 15.5 ± 1.3 on follow-up intervention.
|Table 4 Distribution of the patients in the study group regarding exercise performance in three different intervals: before intervention, after intervention, and during follow-up intervention|
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[Table 5] shows that the majority of the sample (93.33%) suffered from severe pain before intervention, which was decreased to around half (18.9%) after 2 weeks of intervention. After 2 months of nursing intervention, the majority of the sample suffered from moderate pain and only 5.6% suffered from severe pain.
|Table 5 Comparison of the mean and SD of the pain score in the studied sample|
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| Discussion|| |
Low back pain is one of the most common conditions that impair individuals' functional capacity in activities of daily living and at work, as well as their general health and quality of life. The result of the present study revealed that the mean age of the study group was 39.97 ± 8.86 years, and the majority of the participants in the study group were female and married (56.7 and 73.3%, respectively). This finding was in line with the study by Prasad et al.  who reported that the most common age for back pain ranged between 30 and 50 years, whereas Ullah et al.  revealed that a total of 60 patients of nonspecific low back pain (LBP) were included in the study in which 66% of the participants were male and 34% were female. In the present study, it was observed that most of the patients lived in rural areas (56.7%), which is in contrast to the result of Wein  , who mentioned that lumber disc prolapse is more common among citizens of rural areas. This may be due to their heavier work compared with people in urban areas.
In the present study, it was observed that heavy lifting represented the most common reason for hospital admission. Two-thirds of the study group did not practice exercises. This finding was supported by Vong et al.  who reported that pain can occur when a person lifts something too heavy or over-stretches, causing sprain, strain, or spasm in the muscles or ligaments in the back. Similarly, Mercier  concluded that manual work and bad posture lead to back pain.
The finding of the present study regarding the knowledge about sciatica showed that there was significant improvement in the total mean score of knowledge about sciatica pain exercises in the studied group, with a statistically significant difference at two different intervals (2 weeks and 2 months after the proposed range of motion intervention). Supporting this result, Snow  reported that there was an improvement in the knowledge about disc prolapse and its treatment in the study group that received knowledge about disc prolapse. Jacques  , in his study, also reported that the majority of the physiotherapists (90%) believe in the effectiveness of patient education and exercise.
The present study has provided evidence that exercise has a positive effect on sciatic pain as the pain decreased after performing the proposed range of motion. This result was supported by Descarreaux et al.  , who reported that exercise prescription is one of the most popular approaches in the treatment of patients with nonspecific LBP. Also, Jacques  in his study showed that 82.4% of the physiotherapists used exercises at the clinic for acute LBP and 92.2% for patients with acute LBP with sciatica. Similarly, Ullah et al. (12) who reported that in his study, 73.68% of the patients in the exercise group improved after 6 weeks. Kraus et al.  found that 80% of their patients who performed general mobilizing, strengthening, and stretching exercises reported improvement after 6 weeks. Concerning the same result, Pengel et al.  showed that manipulation and exercise, combined with other treatment, might be effective. Zaman  reported that 64.71% of the patients improved after 6 weeks of exercise therapy. Also, Gladwell et al.  reported a high compliance rate with 90% of the participants in the Pilates group performing home exercises twice per week and 100% performing home exercises at least once a week  . In addition, Maurits  stated that exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision improved pain and function in the intervention group.
A recent study by Swinkels et al.  provided strong evidence that exercise programs reduced sick leave and improved pain and disability in people with non-acute non-specific low back pain. Liddle et al.  found that exercise resulted in improvement in measures of pain and function in 16 studies of patients with chronic low back pain.
In contrast, for symptoms of sciatica, one study comparing over 2000 workers without sciatic pain with 327 workers with sciatic pain for 1 year found that exercise and most sports activities had no effect on pain  . In a systematic review by Van Tulder et al.  that included 39 randomized controlled trials aiming to determine the effectiveness of exercise therapy for LBP, it was found that there was no indication that specific exercises are effective for the treatment of acute LBP. However, exercises may be helpful for chronic LBP patients to increase their return to normal daily activities and work  . Smith et al.  state that exercise has been given much attention in the chronic pain literature and that it has been shown to be an effective treatment option with good results. However, this has rarely been shown to be the case with acute LBP. According to Herbert et al.  , exercise is prescribed with equal frequency for acute and chronic LBP, but systematic reviews indicate that there is strong evidence that exercise therapy is effective for chronic, but not acute, LBP. Otherwise, most people appreciate that exercise can strengthen muscles, but they do not realize that exercise and movement also play a very important role in the healing of other structures such as ligaments and even bone  .
Moreover, Kerry  found that lower back pain exercises are very important for the treatment of back pain and to strengthen the back muscles. Simo et al.  found that therapeutic exercise programs are effective in decreasing the low back pain intensity and in improving the functional ability and the strength of the back in patients who received these programs compared with patients who did not receive such programs. Also Fordyce et al.  reported that patients who were instructed to perform exercises had lesser pain intensity. The more the exercise performance, the lesser the pain intensity. Hotyt  reported that physiotherapy had a considerable effect on low back pain. Moreover Stuarat  stated that exercise programs are basic programs for rehabilitation and maintenance of low back health and help in reducing the pain intensity [Figure 1].
|Figure 1: Effectiveness of proposed range of motion program on reducing sciatic pain|
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| Conclusion|| |
The range-of-motion program had a high significant effect on the knowledge and the pain among patients with sciatic pain.
On the basis of the findings of this study, the following recommendations are offered for future actions: future research should focus on identifying patient satisfaction on treatment modalities used for sciatica pain management.
(1) There was insufficient information on the prevalence of LBP in Egypt from documentations. Thus, more research on the impact and the outcomes of treatments ought to be investigated. This will ease the control of the severity of LBP.
(2) The introduction of journals in hospital physiotherapy departments could facilitate the use of research literature, which would lead to treatment being applied from evidence-based practice.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]