CONTENTS Introduction...................................................................................................................... 1 Background of the Study..................................................................................................2 Subjects Background.......................................................................................................3 Type of Injury................................................................................................................... 4 Treatment......................................................................................................................... 4 Fitness Evaluation............................................................................................................5 Study Design....................................................................................................................

6 Data collection..................................................................................................................6 Designing Training Program.............................................................................................6 Training Goals..............................................................................................................6 Type of Exercise .......................................................................................................... 7 Intensity........................................................................................................................ 7 Frequency.................................................................................................................... 7 Training Program.......................................................................................................... 7 Result............................................................................................................................. 25 Discussion...................................................................................................................... 26 Summary........................................................................................................................ 27 References..................................................................................................................... 28

TRAINING PROGRAM DESIGN FOR LOW BACK PAIN Introduction Nearly all adults experience back pain at some point in their working lives. This common problem is one of the leading causes of lost work days and individual suffering. If steps are not taken to maintain a healthy back, the pain can become long-term and disabling(Occupational Safety and Health Administration., 2007). Back pain is one of the

most common medical problems in America. Eight out of ten people will experience back pain at some point in their life. Back pain is ranked second only to headaches as the most frequent location of pain (Rice & Pollard, 2002). Normally back injuries tend to peak between the ages of 35 and 45 in people who are still active but less fit (Occupational Safety and Health Administration., 2007). However, it can experience by anyone who undergo injury on spine structure. Chronic low-back pain afflicts millions of persons each year and is associated with significant impairment in physical and psychosocial functioning. The chronic pain experience is recognized to be a multidimensional syndrome with many different causes, which is influenced by varying socio-environmental factors, predispositions, and personalities (Risch et al., 1993). A back problem can present as a dull ache or an excruciating stab, shooting pain or tenderness to the touch. There may be stiffness and pain in the lower back, or a person may experience pain and/or numbness radiating from the back, down into the legs (Shaari & Rahman, 2003). Exercise is one of the most frequently used modalities in the rehabilitation of subjects with chronic low back pain. The primary goals of physical exercise in the management of chronic low back pain are to gain muscle strength, flexibility and endurance, to restored injured tissues and to contribute to the ability to sustain normal life activities such as those at work (Kofotolis & Kellis, 2006). However, many of us still do not know causes, symptom and proper treatment for low back pain. Therefore, the purpose of this case study is to design proper training program for patient who suffer low back pain and examine its effect in more detail. Background of the Study The study was implemented at Kolej Matrikulasi Londang, Melaka. Initially this case study has selected subject with obese problem. The objective of this subject is to reduce fat and increase calorie expenditure. Thus, the researcher designs a training program for obese person with stated objective. Training program has been sustained for only four weeks before he has posting to Kolej Matrikulasi Gopeng, Perak. Although the appointment of posting date on 19 April 2009, the subject has refused to continue the program with reason can not commit with program. The letter of appointment to a job is attached in appendix A.

Picture 1: Gymnasium which is training program conducted. Therefore, in order to replace the subject the researcher takes one week to find a new subject. In one week time, the researcher was introduced with a new subject who suffered low back pain injury. Based on the discussion with the subject, he has agreed to follow the training program. At the same time, the subject is under supervision of physiotherapy treatment from Hospital Tentera Kem Terendak Melaka. Therefore, in order to cope with the treatment, the researcher has meeting with specialist doctor who supervise the subject. The objective of the meeting is to explain the training program and discuss the subjects condition and his level of injury in more depth. Based on the discussion, the doctor has agreed the subject to follow the program providing that the program does not worsen subjects condition. Subjects Background. The subject has suffered low back pain for eight months ago. Before he undergone low back pain, his lifestyle is quite active playing volleyball. It was started when he plays volleyball on August last year. Based on the discussion, he told that improper landing when he jumps for spike the ball is the causes of he suffers low back pain. Since then, his movement, range of motion and flexibility become limited. Besides that, since the Body Mass Index of the subject is classified as overweight (28.1), I do believe that overweight problem is one of the factors contributed to worse the injury. Consequently, the subject gets a treatment in Hospital Tentera Kem Terendak Melaka for five days in ward for the past seven months. Treatment in the hospital is based on traction for three times per day and followed by heat therapy three times per weeks. Here is the subjects personal biodata: Name : Sazuaranie b. Hanapiah Job : Lecturer

Age H/P

: 33 years old : 019-6653441

Gender: Male Height : 179 cm Weight : 90 kg BMI : 28.1 (Over weight) Experience in weight training: Never Medical history: Appendicitis (long time ago) According to the subject, he also takes calcium magnesium as his medication in order to cure his low back pain. The medication is provided by the hospital as part of a treatment. Type of Injury The subject has suffered chronic low back pain which the pain persists more than three months. According to the record of diagnosis by specialist doctor at 94 Hospital Angkatan Tentera, Kem Terendak Melaka, his low back pain injury is classified as prolapsed intervertebral disk which is known as herniated disk or slipped disk. The L4/5 and L5/S1 was slipped out of original structure which pressing on the nerve roots. Therefore, it causes back pain and sciatic pain cause severe pain spreading down on his left leg and often into the foot. The symptoms of the pain are limited in range of motion, pain on L4/5 and L5/S1 disk, hip muscle numbness, hard to stand in longer duration and limited in movement. This is supported by University of Missouri (2001), which stated that pinching and inflammation of these nerve roots (the long arms of the nerve that stretch out from the nerve body) are just likely to cause numbness, pain, or motor problem in the leg or arms to which they connect than to cause back pain at the side of the pinching. Based on the discussion with the subject, he claimed that the pain has affected his sleep and his life style. Treatment In order to treat the injury, the subject was referred to The 94 Hospital Angkatan Tentera, Kem Terendak Melaka on February and was investigated where Magnetic Resonance Imaging (MRI) done on 23 February 2009. Based on the investigation, his injury is classified as the impression of diffuse L4/5 and L5/S1 prolapsed intervertebral disk (PID). He was then referred to the Physical Rehabilitation and Physiotherapy

Department and was assessed using Oswestry Disability Index (ODI) with score 18% minimal disability. The treatments that were applied to the subject are traction, analgesic, electrotherapy (Short Wave Diathermy-SWD), medication, and exercise without supervision and proper training program. However, at the same time the subject also tries alternative treatment which traditional massage was chosen. Among all of these treatments, only Short Wave Diathermy (SWD) is still continues for once a week at the hospital. Based on the discussion with the doctor, the subject is in the phase of physiotherapy which SWD as a treatment to cure the injury. SWD has been applied on the site of injury for 20 minutes every session of treatment.

Picture 2: The subject is treating using Short Wave Diathermy (SWD). Fitness Evaluation The subject has been evaluated in order to examine the level of fitness and condition of pain. Screening tests to detect the level of seriousness in herniated disk include asking about the presence of sciatica, the straight leg raise, and the crossed straight leg raise (i.e., raising the contralateral, unaffected leg). The evaluation is based on the observation of flexibility and range of motion of hip and several basic movements. Based on the evaluation, the researcher found that, range of motion of hip joint is very limited. The range of motion is limited due to pain on back hip and sciatic pain on his left leg. Besides that, his average resting heart rate is about 80 beats per minute (bpm) which shows that his fitness is above normal heart rate. Oswestry Questionnaire also was used as an instrument to evaluate level of fitness of the subject. Based on the interview, since he suffer low back pain, his daily life become passive compared to before undergo low back pain.

The subject is also rare in applying physical exercise after he suffers low back pain. Although he was informed by physiotherapist to exercise, the subject seldom exercises or stretches his muscle. This is due to lack of knowledge and no proper training program to be followed. Therefore, based on the evaluation, I do believe that fitness level of the subject is very poor in term of fitness components and need to be trained in order to strengthen the core muscles and hip muscle to be functional.

Study Design The case study design was utilized experimental pre and post test design. The design include pre-test measured before training program followed by the treatment (training program) for six weeks. Then, when the training program was completed, post-test measured to examine the effect of training program on the subject. The reason why the duration of training program only planned for six weeks has been explained by the researcher in the background of the study. Data collection The data is collected by using Oswestry Low Back Pain Disability Questionnaire (r =.99) a self-assessment score for chronic back pain patients. The Oswestry index is based on a patients subjective impression on his or her own state of disability. Though the questionnaire is rather old, it has been validated and its reliability and sensitivity to changes in functional status have been proved (Niskanen, 2002). As discuss before, the data was gathered before training program (pre-test) and after training program (posttest). Designing Training Program The training program was designed based on the fitness evaluation and subjects background, medical history and depth discussion with the doctor who supervise the subject for the whole treatment. Therefore the researcher has design the training program and these variables are expected to influence the effect of training program. Training Goals The goal of this training program is to reduce pain which suffered by the subject for almost eight months. Meanwhile, other goals are to improve strength,

mobility, coordination, endurance, increase range of motion (ROM), increase blood flow and increase flexibility gradually. Type of Exercise Type of exercise in this training program is based on two strategies. The researcher has planned to design the program basically base on isometric and isotonic exercise. Unfortunately, isometric strengthening is joint-angle specific; that is, strength gains occur only at the angle used. Therefore, the training was performed isometric exercise at multiple angles. While isotonic exercise involves training with constant external resistances, the amount of force to move the resistance varies, depending primarily on joint angle and the length of each agonist muscle. Basically, the type of exercise that has been chosen is based on special consideration of low back pain injury. The exercises were identified by the journal and specialist as a specific exercise special for treat low back pain population.

Intensity Based on the type of injury and medical history of the subject, the researcher has planned the training program with low intensity and then increase gradually. This is because of to allow strength gain to occur with an intensity low enough that the newly formed collagen fibers are not disrupted. Frequency Since the program is designed with low intensity, the frequency of training is three days per week. The training was conducted on evening from 5.30 pm to 6.30 pm for the first four week and extended from 5.00 to 6.30 pm for the following weeks.

Training Program Training 1 The program for week 1 is designed to give the subject chances of adaptation. However, the subject is not forced if pain stressful. The objective of this week is

to develop foundation of training since the subject does not get use with resistance training. Week: 1 Day: Monday Warming Up: Cycling 10 minutes Stretching: Passive static stretching Time: 5.30-6.30 pm. Intensity: Very Low Target Muscle
Hamstring Abdominal muscle Lower back muscle Hamstring Quadriceps Lower back muscle

Exercise
Hip flexor stretch Partial curl Superman Gluteal stretch Seated leg raise Pelvic tilt

Set 1 Rep Time 5 sec 1 5 sec 1 5 sec 1 5 sec 1 5 sec 1 5 sec 1

Set 2 Rep Time

Cool Down: Static stretch (low intensity).

Training 2 Week: 1 Day: Wednesday Warming Up: Cycling 10 minutes Stretching: Static stretching Time: 5.30-6.30 Intensity: Very Low

Target Muscle
Lower back muscle Abdominal muscle Lower back muscle Hamstring Quadriceps Lower back muscle

Exercise
Hip flexor stretch Partial curl Superman Gluteal stretch Leg raise Pelvic tilt

Set 1 Rep Time

1 1 1 1 1 1 5 sec 5 sec 5 sec 5 sec 5 sec 5 sec

Set 2 Rep Time

Cool Down: Passive static stretch (low intensity)

Training 3 Week: 1 Day: Friday Warming Up: Cycling 10 minutes Stretching: Passive static stretching Time: 5.30-6.30 Intensity: Very Low

Target Muscle
Lower back muscle Abdominal muscle Lower back muscle Hamstring Quadriceps Lower back muscle

Exercise
Hip flexor stretch Partial curl Superman Gluteal stretch Leg raise Pelvic tilt

Set 1 Rep Time

1 1 1 1 1 1 5 sec 5 sec 5 sec 5 sec 5 sec 5 sec

Set 2 Rep Time

Cool Down: Passive static stretching (low intensity).

Training 4 Based on the observation and verbal communication with the subject, the subject has adapted to the initial program. Therefore, the intensity of the training is increased and variation has been added on for current training in relation to the principles of progression and individuality. PNF stretching also has been applied in order to generate isometric contraction. Week: 2 Day: Monday Warming Up: Cycling 15 minutes

10

Stretching: Static stretching Time: 5.30-6.30 pm. Intensity: Very Low Target Muscle
Lower back muscle Abdominal muscle Lower back muscle Hamstring Quadriceps Lower back muscle Lower back muscle Lower back muscle

Exercise
Cat and camel Partial curl Leg raise Gluteal stretch Leg raise Pelvic tilt PNF stretching Trunk flexion Trunk extension

Set 1 Rep Time

1 1 1 1 1 1 1 1 8 sec 8 sec 8 sec 8 sec 8 sec 8 sec 8 sec 8 sec

Set 2 Rep Time

Cool Down: Passive static stretching (low intensity)

Training 5 Week: 2 Day: Wednesday Warming Up: Cycling 15 minutes Stretching: Static stretching Time: 5.30-6.30 pm. Intensity: Low

11

Target Muscle
Lower back muscle Abdominal muscle Lower back muscle Hamstring Quadriceps Lower back muscle Lower back muscle Lower back muscle Hamstring Quadriceps

Exercise
Cat and camel Partial curl Superman Gluteal stretch Seated Leg raise Pelvic tilt PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

2 2 2 2 2 2 2 2 2 2 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec

Set 2 Rep Time

Cool Down: Static stretch (low intensity)

Training 6 Week: 2 Day: Friday Warming Up: Cycling 15 minutes Stretching: Static stretching Time: 5.30-6.30 pm. Intensity: Low

12

Target Muscle
Lower back muscle Quadriceps Lower back muscle Hamstring Abdominal muscle Lower back muscle Lower back muscle Lower back muscle Hamstring Quadriceps

Exercise
Cat and camel Seated Leg raise Superman Gluteal stretch Partial curl Pelvic tilt PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

2 2 2 2 2 2 2 2 2 2 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec 10 sec

Set 2 Rep Time

Cool down: Passive stretch (low intensity)

Training 7 The researcher found that the subject has been adapted with the previous program. Therefore, the variables (intensity and repetition) have been manipulated in this week in order to be more effective. Week: 3 Day: Monday Warming Up: Cycling 20 minutes Stretching: Static stretching Time: 5.30-6.30 pm. Intensity: Low

13

Target Muscle
Lower back muscle Quadriceps Abdominal muscle Soleus, Gastrocnemius Lower back muscle

Exercise
Superman Swiss ball squat Swiss ball partial curl Standing calf raise Swiss ball single leg bridge and curl PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

5 6 5 5 6 5 sec 5 sec 5 sec -

Set 2 Rep Time

Lower back muscle Lower back muscle Hamstring Quadriceps

3 3 3 3

10 sec 10 sec 10 sec 10 sec

Cool down: Passive stretch

Training 8 Week: 3 Day: Wednesday Warming Up: Cycling 20 minutes Stretching: Static stretching Time: 5.30-6.30 pm. Intensity: Low

14

Target Muscle
Lower back muscle Quadriceps Abdominal muscle Soleus, Gastrocnemius Lower back muscle

Exercise
Superman with plate (1kg) Swiss ball squat Swiss ball partial curl Standing calf raise Swiss ball single leg bridge and curl PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

4 8 4 8 4 8 sec 8 sec 8 sec

Set 2 Rep Time

Lower back muscle Lower back muscle Hamstring Quadriceps

4 4 4 4

7 sec 7 sec 7 sec 7 sec

Cool down: Passive stretch

Training 9 Week: 3 Day: Friday Warming Up: Cycling 20 minutes Stretching: Static stretching Time: 5.30-6.30 pm. Intensity: Low

15

Target Muscle
Lower back muscle Quadriceps Abdominal muscle Soleus, Gastrocnemius Lower back muscle

Exercise
Superman Swiss ball squat Swiss ball partial curl Standing calf raise Swiss ball single leg bridge and curl PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

5 10 5 10 5 5 sec 5 sec 5sec

Set 2 Rep Time

Lower back muscle Lower back muscle Hamstring Quadriceps

3 3 3 3

10 sec 10 sec 10 sec 10 sec

Cool down: Passive stretch

Training 10 Since the program has entered week 4, the researcher has designed to add on set of training. Based on the observation, the subject has improved in term of pain (reduced) and core strength (increased). Therefore, a little adjustment on training program has been made to cope with principle of variety and fun which swimming has been chosen as a part of training program. The chosen of exercise also mostly based on dynamic exercise. Week: 4 Day: Monday Warming Up: Cycling 25 minutes

16

Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate Target Muscle
Tricep External abdominal oblique, Lattisimus dorsi, erector spinae Quadriceps Abdominal muscle Soleus, Gastrocnemius Lower back muscle Lower back muscle Lower back muscle Hamstring Quadriceps Swiss ball squat with dumbbell (1 kg) Swiss ball partial curl Standing calf raise Swiss ball single leg bridge and curl PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor 8 5 5 5 3 3 3 3 2kg 5 sec 5 sec 5sec 10 sec 10 sec 10 sec 10 sec 8 5 5 5 3 3 3 3 2kg 5 sec 5 sec 5sec 10 sec 10 sec 10 sec 10 sec

Exercise
Standing Triceps Extension Swiss ball oblique

Set 1 Rep Time

8 8 2kg -

Set 2 Rep Time

8 8 2kg -

Cool down: Passive stretch

Training 11 Week: 4 Day: Wednesday Warming Up: Active movement. Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate Target Muscle
Whole muscle Lower back muscle Lower back muscle Hamstring Quadriceps

Exercise
Swimming Tg. Bidara Resort PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

1 3 3 3 3 10 min 10 sec 10 sec 10 sec 10 sec

Set 2 Rep Time

1 3 3 3 3 10 min 10 sec 10 sec 10 sec 10 sec

17

Cool down: Passive stretch

Training 12 Week: 4 Day: Friday Warming Up: Cycling 25 minutes Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate

18

Target Muscle
Tricep External abdominal oblique, Lattisimus dorsi, erector spinae Quadriceps Abdominal muscle Soleus, Gastrocnemius Lower back muscle

Exercise
Standing Triceps Extension Swiss ball oblique

Set 1 Rep Time

8 8 2kg -

Set 2 Rep Time

8 8 2kg -

Swiss ball squat with dumbbell (1 kg) Swiss ball partial curl Standing calf raise Swiss ball single leg bridge and curl PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

8 5 5 5

2kg 5 sec 5 sec 5sec

8 5 5 5

2kg 5 sec 5 sec 5sec

Lower back muscle Lower back muscle Hamstring Quadriceps

3 3 3 3

10 sec 10 sec 10 sec 10 sec

3 3 3 3

10 sec 10 sec 10 sec 10 sec

Cool down: Passive stretch

Training 13 The researcher still continues with manipulating the variables of training. The intensity and volume of the training has been reduced while repetition increases in order to increase subjects adaptation. Week: 5 Day: Monday Warming Up: Cycling 25 minutes Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate

19

Target Muscle
Pectoralis major External abdominal oblique, Lattisimus dorsi, erector spinae Quadriceps Abdominal muscle Soleus, Gastrocnemius Lower back muscle Hamstring Lower back muscle Lower back muscle Hamstring Quadriceps

Exercise
Standing Bench Press Swiss ball oblique Swiss ball squat with dumbbell (1 kg) Swiss ball oblique exercise Standing calf raise Swiss ball single leg bridge and curl Leg curl PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

10 10 1.5kg -

Set 2 Rep Time

10 10 1.5kg -

10 10 10 10 10 4 4 4 4

1.5kg 5 sec 5 sec 5sec 1.5kg 8 sec 8 sec 8 sec 8 sec

10 10 10 10 10 4 4 4 4

1.5kg 5 sec 5 sec 5sec 1.5kg 8 sec 8 sec 8 sec 8 sec

Cool down: Passive stretch

Training 14 Week: 4 Day: Wednesday Warming Up: Active movement. Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate Target Muscle
Whole muscle Lower back muscle Lower back muscle Hamstring Quadriceps

Exercise
Swimming Tg. Bidara Resort PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

1 3 3 3 3 12 min 10 sec 10 sec 10 sec 10 sec

Set 2 Rep Time

1 3 3 3 3 12 min 10 sec 10 sec 10 sec 10 sec

20

Cool down: Passive stretch

Training 15 Week: 5 Day: Friday Warming Up: Cycling 25 minutes Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate Target Muscle
Tricep External abdominal oblique, Lattisimus dorsi, erector spinae Quadriceps Abdominal muscle Swiss ball squat with dumbbell (1 kg) Swiss ball partial curl 8 5 2kg 5 sec 8 5 2kg 5 sec

Exercise
Standing Triceps Extension Swiss ball oblique

Set 1 Rep Time

8 8 2kg -

Set 2 Rep Time

8 8 2kg -

21

Soleus, Gastrocnemius Lower back muscle Lower back muscle Lower back muscle Hamstring Quadriceps

Standing calf raise Swiss ball single leg bridge and curl PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

5 5 3 3 3 3

5 sec 5sec 10 sec 10 sec 10 sec 10 sec

5 5 3 3 3 3

5 sec 5sec 10 sec 10 sec 10 sec 10 sec

Cool down: Passive stretch

Training 16 The subject has shown adaptability to resistance training program. Although, this is the last session of training program for the case study, training program will be continued soon in order to cope the subject needs. Oswestry Lower Back Pain Disability Questionnaire was conducted at the last training session in order to measure the effect of training program on low back pains impact on the activities of daily living. Week: 6 Day: Monday Warming Up: Cycling 25 minutes Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate

22

Target Muscle
Gluteus External abdominal oblique, Lattisimus dorsi, erector spinae Hamstring Abdominal muscle Soleus, Gastrocnemius Lower back muscle Quadricep

Exercise
Standing Hip abduction & adduction Swiss ball oblique Hamstring curl with Swiss ball Prone straight leg raised Seated calf raise on Swiss ball with 2kg weight Superman with weigh plate Swiss ball squat with dumbbell PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

12 -

Set 2 Rep Time

12 -

12

12

12 12 12 12 12

2kg 5 sec 5 sec 5sec 2kg

12 12 12 12 12

2kg 5 sec 5 sec 5sec 2kg

Lower back muscle Lower back muscle Hamstring Quadriceps

4 4 4 4

10 sec 10 sec 10 sec 10 sec

4 4 4 4

10 sec 10 sec 10 sec 10 sec

Cool down: Passive stretch Training 17 Week: 4 Day: Wednesday Warming Up: Active movement. Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate Target Muscle
Whole muscle Lower back muscle Lower back muscle Hamstring Quadriceps

Exercise
Swimming Tg. Bidara Resort PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

1 3 3 3 3 15 min 15 sec 15 sec 15 sec 15 sec

Set 2 Rep Time

1 3 3 3 3 15 min 15 sec 15 sec 15 sec 15 sec

Cool down: Passive stretch

23

Training 18 Week: 6 Day: Monday Warming Up: Cycling 25 minutes Stretching: Static stretching Time: 5.00-6.30 pm. Intensity: Low-moderate

24

Target Muscle
Gluteus External abdominal oblique, Lattisimus dorsi, erector spinae Hamstring Abdominal muscle Soleus, Gastrocnemius Lower back muscle Quadricep Lower back muscle Lower back muscle Hamstring Quadriceps

Exercise
Standing Hip abduction & adduction Swiss ball oblique Hamstring curl with Swiss ball Prone straight leg raised Seated calf raise on Swiss ball with 2kg weight Superman with weigh plate Swiss ball squat with dumbbell PNF stretching Trunk flexion Trunk extension Hip extensor Hip flexor

Set 1 Rep Time

12 -

Set 2 Rep Time

12 -

12

12

12 12 12 12 12 4 4 4 4

2kg 5 sec 5 sec 5sec 2kg 10 sec 10 sec 10 sec 10 sec

12 12 12 12 12 4 4 4 4

2kg 5 sec 5 sec 5sec 2kg 10 sec 10 sec 10 sec 10 sec

Cool down: Passive stretch

Result Of the 18 session in six weeks training program, the subject has completed all training session with successful. Based on the data collection for pre-test using the Oswestry Low Back Pain Disability Questionnaire (r=0.99), subject scored 24% of its impact on the activities of daily living. However, after doing the training program post-test indicates that the scored is 12%.

25

25 20 15 10 5 0 PreTest PostTest Test

Figure 1: Comparison of pre and post test data. Therefore, it is shows that the pain has significantly decreased to 12% of its impact on the activities of daily living after doing training program. Based on the interview with the subject, the researcher found that the feeling of comfortable and relaxation has increased compared to before training program. Discussion The main finding in this case study is that, by doing proper training program for person who undergone low back pain, its impact on the activities of daily living can be reduced. Through observation, for the first week of training program, the subject claimed that the pain being main constrain of doing exercise. However, when he has adapted to the program, the pain gradually reduced. However, the intensity of the program was designed from very low intensity and gradually increased to moderate. Since, the subject know his level of pain, thus the researcher does not force him to perform precisely to the training program. Another factor that influences reducing pain is a treatment at The 94 Hospital Angkatan Tentera, Kem Terendak Melaka.

26

Picture 3: Lt. Kol. Dr. Zainal b. Othman Based on the interview and discussion with the doctor who supervise the subject, he claimed that the subject show improvement. The doctor has evaluated the subject by using the same questionnaire and comparing the pre-test (administered on the day referred to rehabilitation department) and post-test (administered on the day of discussion) and found 10% improvement in disability. However, since the researcher also used the same questionnaire, and measured on different period, the researcher found 12% of improvement. The reason why both result is different because of after post-test measured by the doctor the subject still continue doing training program and measured again by the researcher a week after. Therefore, this may contribute to differentiation of the result. Summary The current study showed that specific exercise of the low-back in chronic low-back pain patients is important for increasing strength and reducing pain and psychosocial dysfunction. This treatment did not ameliorate psychological distress or socioenvironmental influences. This implies that physical rehabilitation is an important component of rehabilitation for chronic low-back pain patients and should be included with psychological rehabilitation for maximizing return to work and improved daily functioning. In conclusion, this study demonstrated that lumbar extension exercise strengthened the low-back extensor muscles in a population of chronic low-back pain patients. Associated improvements were also found in the experience of pain and perceived physical dysfunction as measured by the Oswestry Disability Index.

27

References

Kofotolis, N., & Kellis, E. (2006). Effects of two 4-week proprioceptive neuromuscular facilitation programs on muscle endurance, flexibility and functional performance in women with chronic low back pain. Physical Therapy, 86,(7). Niskanen, R. O. (2002). The oswestry low back pain disability questionnaire. A two-year follow-up of spine surgery patients. Scandinavian Journal of Surgery, 91. Occupational Safety and Health Administration. (2007). Back injury prevention for the landscaping and horticultural services industry. Kansas State University Agricultural Experiment Station and Cooperative Extension Service, 7(56). Rice, C. A., & Pollard, J. M. (2002). Back pain. Health Education Rural Outreach (HERO), 6(3). Risch, S. V., Norvell, N. K., Pollock, M. L., Risch, E. D., Langer, H., Fulton, M., et al. (1993). Lumbar strengthening in chronic low back pain patients physiologic and psychological benefits. SPINE 18( 2). Shaari, A. H., & Rahman, H. A. (2003). Sakit belakang dan faktor yang mempengaruhinya di kalangan penoreh getah di Pahang. Malaysian Journal of Public Health Medicine, 3(1). University of Missouri. (2001). Handbook of disabilities: Chronic low back pain: University of Missouri.

28

APPENDIX A

29

APPENDIX B
Medical Assessment Letter

30

APPENDIX C
Training Session

Picture 4: Subject doing Alternate Arm/ Leg Raises

Picture 5: PNF exercise

31

APPENDIX D
The Oswestry Disability Index (Pre and Post Test)

32