RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE AND

ADDRESS

KUMARI SUDHA

Q NO C/91, HINDU MISSION ROAD, MADA

COLONY, HIRAPUR, DHANABAD,

JHARKHAND

2. NAME OF THE INSTITUTIONK.T.G COLLEGE OF PHYSIOTHERAPY

HEGGANAHALLI CROSS,VISHWANEEDAM

POST,

SUNKADAKATTE VIA MAGADI ROAD,

BANGALORE 560-091

3. COURSE OF THE STUDY M.P.T. ( MUSCULOSKELETAL DISORDERS

AND SPORTS PHYSIOTHERAPY)

4. DATE OF ADMISSION 18TH JULY, 2012

5. TITLE OF THE TOPIC:

“A CROSS SECTIONAL STUDY OF ALTERED CERVICAL LORDOSIS AND ITS

ASSOCIATION WITH NECK PAIN IN CERVICAL SPONDYLOSIS”.

BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY

INTRODUCTION :-

At the top of our spine rests a 4 kilogram object called our "Head" that

bounces up and down with every body movement. The Cervical Spine which is also referred

as Neck region takes most of the compressive forces because of repeated or sustained

movements of neck in their activities of daily living. [5,26]

Cervical Spondylosis is known as degeneration of the cervical spine, the

onset of cervical Spondylosis occur gradual in manner and it is commonly accompanied

by reduction or loss of segmental or global lordosis of cervical region leads to Neck pain.[22]

Degenerative changes at cervical region are evident on radiographic

examination which describes the part of normal physiologic ageing process. The most

typical changes observed at cervical region include osteoarthritis of the facets with

reduced joint space and disc space. In contrast to radicular symptomology explains the

presence of the Osteophytes or narrowing of the inter-vertebral foramen at corresponding

vertebral level. [12,31]

Degenerative changes of the cervical spine are often accompanied by a

shortening of the anterior and posterior vertebral column [30,33] results in alteration of the

sagittal plane of the cervical spine[15] Systematic review reveals that degeneration shows

consistent weakness and pain at cervical or lumbar spine [16]. Some researchers have

identified a relationship between number of levels of the cervical spine degeneration and its

chronicity in women [23]. Other researchers had described asymptomatic individuals with

degenerative changes of C6-C7 were significantly develop neck pain in the future (10)

years. [12,17]

The literature from the bio-mechanical point of view the loss of the

physiological lordosis could be a possible cause of the neck pain due to muscular imbalance [10].structural deformity due to structural overload of the anterior part of the spine. [24,11]

So the aim of the present study is to measure the altered cervical lordosis and

to find out its association with neck pain in the Cervical Spondylosis,

Normal curvature of cervical spine:

The curve of the spine is usually measured in degrees.(According to university

of Maryland spine program)[41]

According to the study published in the JMPT" in 2005 [9], a "clinical normal

"range for Cervical Lordosis should be between 81-40 degrees.

A study done by Dr. Deed herisor[38] a chiropractor showed that a proper "C"

curve has 31-40 degrees.

VISUAL ANALOGUE SCALE:

Nicola, Wewers & Lowe et al, [29] A Visual Analogue Scale (VAS) is a

measurement instrument that tries to measure a characteristic or attitude that is believed to

range across a continuum of values and cannot easily be directly measured. For example, the

amount of pain that a patient feels ranges across a continuum from none to an extreme

amount of pain. From the patient's perspective this spectrum appears continuous ± their pain

does not take discrete jumps, as a categorization of none, mild, moderate and severe would

suggest. It was to capture this idea of an underlying continuum that the VAS was devised.

Operationally a VAS is usually a horizontal line, 100 mm in length, anchored

by word descriptors at each end, as illustrated in Figure. The patient marks on the line the

point that they feel represents their perception of their current state.

The VAS score is determined by measuring in millimetres from the left hand

end of the line to the point that the patient marks.

0 1 2 3 4 5 6 7 8 9 10

Operationally a VAS is usually a horizontal line, 100 mm in length, anchored

by word descriptors at each end, as illustrated in Figure. The patient marks on the line the

point that they feel represents their perception of their current state.

The VAS score is determined by measuring in millimeters from the left hand

end of the line to the point that the patient marks.

•Visual analogue scales (VAS) of season intensity and affective

magnitude were validated as ratio scale measures for both chronic and- experimental pain.

According to Donald D. Price, Patricia A. McGrath et al., 1982[27]

NECK DISABILITY INDEX:

The Neck Disability Index (NDI) was developed in 1989 by Howard

Vernon. The Index was developed as a modification of the Oswestry Low Back Pain

Disability Index with the permission of the original author (J.Fairbank, 1980) in 1991.[28]

Vernon and Mior[28] published the results of a study of reliability and

validity in the Journal of Manipulative and Physiologic Therapeutics. Since then,

approximately ten articles have appeared in the indexed, literature on the NDI. A/I of these

studies have confirmed the original reports of a high level of reliability and validity. We

currently know that the NDI consists of one factor - "physical disability" - although NDI

scores correlate well with SF-36 mental component scores as well. We know that the

minimum detectable score and the minimal clinically important difference amount to the

same figure - 5 NDI points.

The NDI has become a standard instrument for measuring self-rated disability

due to neck pain and is used by clinicians and researchers alike.

Each of the 10 items is scored from 0 - 5. The maximum score is here

therefore 50. The obtained score can be multiplied by 2 to produce a percentage score.

Occasionally, a respondent will not complete one question or another. The average of all

other items is then added to the completed items.

Scoring;- Simply count up the points and plug the total in below; for each question there is

a possible of 5 points; 0 for the first question; 1 for the second question2 for the third

question etc.

CATEGORIES:

Raw Score Level of disability

0-4 No Disability

5-14 Mild disability

15-24 Moderate Disability

25-34 Severe Disability

35-50 Completely DisabledDefinition of cervical spondylosis:-

Degenerative changes are part of the normal physiological process [12] or due

to over stressing the spine with load or strenuous positions. The most typical changes

observed include osteoarthritis of the facets with the reduced joint space and disc space

narrowing.

Neck pain is the commonest symptom that an individual will suffer at least

ones in their life. According to Paul and Hardacker J W, Shuford RF, Capicotto PN,

Pryor PW et el., (1997)[17] Mechanisms includes degenerative disk, direct nerve

compression and segmental instability. Pain can be perceived locally, or it may radiate to the

occiput, shoulder, scapula, or arm.

Elias F et al., 1958 Degenerative changes of the cervical spine are often

accompanied by the shortening of the anterior or posterior vertebral column which results in

alteration of the sagittal plane of the cervical spine[15]

Incidence for cervical spondylosis:- Cervical Spondylosis affects both men and

women. In that 90% of men over the age of 50 and 90% of woman over age of 60 years

show degeneration m spine [37]. The age-specific prevalence was consistently higher in

women according to G salemi et al[14]

Degenerative changes in the cervical spine generally begins from the age group

ranges between 20-60 years, or early degenerative changes was described by Dominique

Wilson et al.[37] but the mean age was concluded as around 40 years. As the age increases

the incidence rate also increases. 60% of the population older than 45 years of age account

for the case of cervical Spondylosis [37]

Benzel et al 2001 has shown through their studies that cervical Spondylosis is a

natural process of ageing is seen in 10% of individuals by the age of the 25 years and in

95% by the age of 65 years & it is often preceded by mild segmental instability [12,13,40].[

Prevalence for cervical spondylosis:- As per the study of Ferey doun, Jaleh et al.,

2009[2] Western literature reports a prevalence of neck pain ranges from 8-23%, An Indian

study reported the prevalence of 2.8% among Parsi adults in Mumbai. Interviews were

conducted by intervierws in randomly selected subjects from 5 villages in Tuyserkan

County, northwestern part of Iran accounted for 2.2%. Of Cervical Spondylosis. According

to the study report by Bhojo A,Ahsan et al, 2010[1] indicate that age is most likely the

greatest risk tor for cervical Spondylosis in female sex.

Research question:Present study is to measure the altered cervical lordosis and to find out its

association with neck pain in the Cervical Spondylosis..

PURPOSE OF THE STUDY: The purpose of the study is to measure the cervical curvature by lateral

cervical radiograph to find out its association with the neck pain in cervical Spondylosis.

HYPOTHESIS:NULL HYPOTHESIS:-

There is no significant association of pain due to cervical lordosis with neck

pain in cervical Spondylosis.

EXPERIMENTAL HYPOTHESIS:-

There is significant association of pain due to cervical lordosis with neck pain

in cervical Spondylosis.

6.2 REVIEW OF LITERATURE :

Beaton et al., 2000 concluded that the Degenerative changes are part of the

normal physiological process or due to over stressing the spine with load or strenuous

positions. The most typical changes observed include osteoarthritis of the facets with the

reduced disc and joint space.[12]

Boden et al., 1990 In contrast to the radicular symptomology cervical

Spondylosis was defined as presence of the Osteophytes or narrowing of the inter-vertebral

foramen at corresponding vertebral level.[31]

Paul and Hardacker J W, Shuford RF, Capicotto PN, Pryor PW et el.,

(1997) concluded that the Neck pain is the commonest symptom that an individual will

suffer at least ones in their life. Mechanisms of neck pain includes degenerative disk, direct

nerve compression and segmental instability. Pain can be perceived locally, or it may radiate

to the occipet, shoulder, scapula, or arm.[17]

Elias F et al., 1958 concluded that the Degenerative changes of the cervical

spine are often accompanied by the shortening of the anterior or posterior vertebral column

which results in alteration of the sagittal plane of the cervical spine[15]

Fineman S et aL, 2002 concluded that There is much discussion in the

literature from the bio-mechanical point of view which stated the loss of physiological

lordosis could be a possible cause of neck pain, due to muscular imbalance.[10]

Friedenberg ZB et al conclude that the case of structural overload of the

anterior parts of the spine induces cervical spondylosis.[10]

Paul & deiary et al have defined Cervical Spondylosis as a widely used but

non-specific term referring to the generalized degeneration of the cervical spine frequently

seen in older people although it begin at early age i.e. around 20years of age and over 3o

years of age. Characteristically x-ray changes can be identified. Patients present complaint

of neck pain, radiculopathy and myelopathy, though some may remain asymptomatic.

Symptoms may have been exacerbated by increased activity [34,37].

Tony et al concluded that the Cervical Spondylosis is an ageing process

which is defined as -"Osteophytosis secondary to degeneration of the Disc disease which

affect 50% of individuals older than 40 years of age & 95% of individuals older than 60

years of age have some degree of disc degeneration. Genetics, Repetitive motion Jobs /

Sports play an important role in development of degenerative disc disease. A defining

characteristic of the process is desiccation of inter-vertebral disc which affects height and

compliance. Cervical Spondylosis may present with varying degree of the Neck pain,

Radiculopathy and Myelopathy.[35]

Ayman ali stated that the Cervical Spondylosis is a common degenerative

joint disease that is due to ageing and time related wear and tear on the cervical vertebrae

(bones) of the neck. The deterioration of Cervical Spondylosis also affects the cartilage, a

slippery substance that help bones to move easily and the cervical discs which are pillow

like structures that allows for cushioning movements of the neck. Cervical Spondylosis can

lead to the abnormal growth (bone spurs) on the cervical vertebrae.[37]

Dominique Wilson et al concluded that Degenerative changes in the cervical

spine generally begin from the age ranged between 20-60 years. But the mean age was

around 40 years. As the age increases so the incidence rate also increased. upto 60% of the

population older than 45 years of age and 8% older than 65% of age account for the case of

cervical Spondylosis [37].

Benzel et al 2001 has shown through their studies that cervical Spondylosis is

a natural process of ageing was seen in 10% of individuals by the age of the 25 years and in

95% by the age of 65 years was often preceded by mild segmental instability [4].

Dominique Wilson et al concluded that the Cervical Spondylosis affects both

men and women. In that 90% of men over the age of 50 years and 90% of women, over age

of 60 years show degeneration of spine [21]. The age-specific prevalence was consistently

higher in women.[14,37]

Ferey doun, Jaleh et al., 2009 Western literature reports a prevalence of

neck pain from 8-23% while an Indian study reported the prevalence of 2.8% among Parsi

adults in Mumbai. Interviews were conducted in randomly to select subjects from 5 villages

in Tuyserkan County, northwestern part of Iran accounted for 2.2%. Of Cervical

Spondylosis.[2]

Bhojo A,Ahsan et al, 2010 Findings presented here indicate that age is most

likely the greatest risk for cervical radiculopathy in females.[1]

Bhojo A,Ahsan et al, 2010 Cervical Spondylosis can be caused by previous

repeated minor strains, fractures or dislocations of the joints of neck. These can cause

abnormal tear of joints, ligaments and the structures surrounding the joints.[1]

Dominique Wilson et al concluded that Incorrect posture adapted by habit

or due to poor skeletal set up in the neck predisposes to neck pain by abnormal tear of the

soft tissues of joints of the neck.[40]

Lasker and Mahbub et al., 2006 concluded that the physical discomfort,

which arises through an occupation, is occupational stress. The physical strain, intensity of

work and duration of working hours all constitutes the occupational strain. It is the result of

demands placed on the neck because of repeated or sustained movements because of daily

life activities. Coolies, who had worked for 10 to 15 year, or more than 15 yr, had higher

rates of cervical Spondylosis. In this study it was found that those who carried heavier loads

suffered more from cervical Spondylosis.[7,40]

M.Hag Berg et al concluded that the impact of occupational exposure

reveals cervical spondylosis in occupational groups such as meat carriers, dentists, soft

collar job people, miners.The truck drivers have high prevalence rates due to increased

stress to their cervical spine and strenuous positions. The various styles of activity adapted

in daily life can cause strain or tear of the structures of the neck and lead to cervical

Spondylosis.[7,39,40]

Howard S, Koichi M et al, September (2006) concluded that Trauma,

cigarette smoking, deposition of calcium crystal that disrupt the integrity of the endplates

may affect diffusion and disturb the nutrition of the disc cells. This will lead to early

degeneration of the Spine secondary to Degenerative Disc Disease.[25]

According to Hasan, Ayman Ali et al[42], The neck pain which is worst

when the patient is in certain abnormal positions.

6.3 OBJECTIVE OF THE STUDY: To Measure the Global Curvature of the Cervical Spine by using Cobb's double line

method in the x-rays of patients with Cervical Spondylosis.

To Quantify the Intensity of Neck pain levels in patients with Cervical Spondylosis

by using Visual Analogue Scale.

To find the association of the Global Cervical lordosis and neck pain in patients with

cervical Spondylosis.

7.0 MATERIAL AND METHODS;

7.1 STUDY DESIGN:- A CROSS SECTIONAL STUDY

7.2 SAMPLING METHOD AND SAMPLE SIZE:-

A sample group of 30 patients who are diagnosed as cervical Spondylosis are

included in the study. Patients were randomly selected in the study in accordance to pre

determinant inclusion and exclusion criteria to ensure homogeneity of patients.

7.3SOURCE OF DATA:-

A sample group of 30 individual who are diagnosed as cervical Spondylosis

referred to the physiotherapy from KTG hospital and KC general hospital, Bangalore

outptient unit were included in the study.

CRITERIA FOR SELECTION:

A. INCLUSION CRITERIA:

Patient with cervical Spondylosis only

Age: 20-60years

Sex: both male and female

Neck pain duration less than 6 months Neck pain following indirect trauma

Neck disability index score more than 20.

KELLGREN AND LAWRENCE INDEX SCORE [33] should not exceed grade 3

This classification is a five grade scale ranging from 0-4

0-Absence of degeneration.

1-Minimal anterior Osteophytes

2-Definite Osteophytes with possible narrowing of disc space and some sclerosis of

vertebral plates.

3-Moderate narrowing of joints space and definite sclerosis of vertebral plates and

Osteophytosis

4-Severe narrow of disc space, sclerosis of vertebral plates and multiple large

Osteophytosis

In this study we are following grade 3 KELLGREN AND LAWRENCE INDEX

SCORE

B)EXCLUSION CRITERIA: Radicular symptoms involving bilateral upper extremities. Serious pathological diagnosis of cervical canal stenosis or mylopathy.

Traumatic injury to the spine which can lead to instability of cervical spine.

Post operative conditions of cervical spine or shoulder.

Congenital abnormality of spine

Patients with history of low back pain.

Shoulder pathology.

Tumour and infection of spine.

Deformities of spine.

Cardiovascular condition such as angina.

MATERIALS USED IN THE STUDY:

Cervical lateral view X- ray

Protractor

Pencil

Scale

METHODOLOGY OF STUDY:

EVALUATION OF INTENSITY OF NECK PAIN BY VAS SCALE.

Vas- Scale is 0-10 point scale where “0” represents no pain and “10” represents

severe pain. The level of pain recorded by visual analogue scale proposed by MELZACK

AND WALL.

MESURMENT OF SAGITTAL CERVICAL CURVE :

The configuration of sagittal spinal curve has re emerged important outcome

measure of health care. In this study “COBB’S DOUBLE LINE METHOD ’’ was used to

measure the sagittal cervical angle in lateral view X-Ray.

METHOD OF MEASUREMENT OF SAGITTAL CERVICAL

CURVATURE: method of measurement of sagittal cervical spine angle from C1-C7

and C2-C7.

PROCEDURE:

C1-C7 measurement obtained by lined drawn by an X-Ray marker from

anterior arch of atlas approaching till the posterior arch and line drawn parallel to the inferior

end plates of C7 by joining perpendicular .

C2-C7 measurement obtained by joining the perpendicular line drawn to the

inferior end plates of C2 and C7.

The angle between them was measured using a standard protractor. If C7 is

not visualized on lateral film then inferior end plates of C6 can be used.

Methods described in methodology

Reliability and validity of Cobb's double line angle-In literature of Cote,

Joudas et al., 1997, 1991[20] The Cobb's angle has been the method of choice for

measurements of overall, lordosis and kyphosis of the sagittal curves on Lateral

Radiographs. Good to high I.C.C are reported for Cobb's double line angle analysis for inter

and intra examiner reliability.

As per Cote et al.,[21] studies

Reliability I.C.C = 0.45 Cobb's C2-C7 I.C.C = 0.96 error (on lateral cervical

radiographs)

As per Snodgrass SJ, Rivett Da et. el,(2008)[3] measuring posterior to

anterior Osteophytes stiffness of cervical spine also More Reliability ol measuring cervical

Lordosis from C2-C7.

Normal curvature of cervical spine:

The curve of the spine is usually measured in degrees.(According to university of Maryland

spine program)[41]

According to the study published in the JMPT" in 2005 [9], a "clinical normal

"range for Cervical Lordosis should be between 81-40 degrees.

A study done by Dr. Deed herisor[38] a chiropractor showed that a proper "C"

curve has 31-40 degrees.

VISUAL ANALOGUE SCALE :

Nicola, Wewers & Lowe et al.[29], A Visual Analogue Scale (VAS) is a

measurement instrument that tries to measure a characteristic or attitude that is believed to

range across a continuum of values and cannot easily be directly measured. For example, the

amount of pain that a patient feels ranges across a continuum from none to an extreme

amount of pain. From the patient's perspective this spectrum appears continuous ± their pain

does not take discrete jumps, as a categorization of none, mild, moderate and severe would

suggest. It was to capture this idea of an underlying continuum that the VAS was devised.

Operationally a VAS is usually a horizontal line, 100 mm in length, anchored

by word descriptors at each end, as illustrated in Figure. The patient marks on the line the

point that they feel represents their perception of their current state.

The VAS score is determined by measuring in millimetres from the left hand

end of the line to the point that the patient marks.

0 1 2 3 4 5 6 7 8 9 10

Operationally a VAS is usually a horizontal line, 100 mm in length, anchored

by word descriptors at each end, as illustrated in Figure. The patient marks on the line the

point that they feel represents their perception of their current state.

The VAS score is determined by measuring in millimeters from the left hand

end of the line to the point that the patient marks.

•Visual analogue scales (VAS) of season intensity and affective

magnitude were validated as ratio scale measures for both chronic and- experimental pain.

According to Donald D. Price, Patricia A. McGrath et al., 1982[27]

NECK DISABILITY INDEX:

The Neck Disability Index (NDI) was developed in 1989 by Howard

Vernon. The Index was developed as a modification of the Oswestry Low Back Pain

Disability Index with the permission of the original author (J.Fairbank, 1980). In 1991,

Vernon and Mior[28] published the results of a study of reliability and validity in the Journal

of Manipulative and Physiologic Therapeutics. Since then, approximately ten articles have

appeared in the indexed, literature on the NDI. A/I of these studies have confirmed the

original reports of a high level of reliability and validity. We currently know that the NDI

consists of one factor - "physical disability" - although NDI scores correlate well with SF-36

mental component scores as well. We know that the minimum detectable score and the

minimal clinically important difference amount to the same figure - 5 NDI points.

The NDI has become a standard instrument for measuring self-rated disability

due to neck pain and is used by clinicians and researchers alike.

Each of the 10 items is scored from 0 - 5. The maximum score is here

therefore 50. The obtained score can be multiplied by 2 to produce a percentage score.

Occasionally, a respondent will not complete one question or another. The average of all

other items is then added to the completed items.

Scoring;- Simply count up the points and plug the total in below; for each question there is

a possible of 5 points; 0 for the first question; 1 for the second question

2 for the third question Etc

CATEGORIES

Raw Score Level of disability

0-4 No Disability

5-14 Mild disability

15-24 Moderate Disability

25-34 Severe Disability

35-50 Completely Disabled

NECK DISABILITY INDEX

Section 1 ; pain intensity

A. I have no pain at the moment

(0 pts)

B. The pain is mild at the moment (1pts)

C. The pain comes and go and its

moderate

D. The pain moderate and does not vary

much(3 pts)

E. The pain is severe but comes and goes

(4pts)

F. The pain severe does not vary

much(5pts)

Section 2 ; personal care (washing

dressing etc)

A. I can look after myself without causing

extra pain (0 pts)

B. I can look after myself normally but it

causes extra pain ( 1pts)

C. It is painful to look after myself and I

am slow and careful (2 pts )

D. I need some help but manage most of

my personal care (3 pts )

E. I need help every day in most aspect

of self-care (4 pts )

F. I do not get dressed I wash with

difficulty and stay in bed (5 pts )

Section 3; lifting

A. I can left heavy weight extra pain(0

pts)

B. I can lift heavy weight but it causes

extra pain(1pts)

C. Pain prevents me from lifting heavy

weight of the floor but I can if try are

conveniently positioned for example

on a table (2pts)

Section 4 ; Concentration

A. I can concentrate fully when I want to

with no difficulty(0 pts)

B. I can concentrate fully when I want to

with slight difficulty (1pts)

C. I have a fair degree of difficulty in

concentrate when I want to(2pts)

D. I have a lot of difficulty in

D. Pain prevents me from lifting heavy

weight but I can manage lighting to

medium weight if they convenient

positioned (3pts)

E. I can only lift very light weights(4pts)

F. I can lift or carry anything at all.(5pts)

concentrating when I want to do (3pts)

E. I have a great deal of difficulty in

concentrating when I want to do (4pts)

F. I can’t concentrate at all (5pts)

Section 5 Sleeping

A. I have no trouble sleeping(0 pts)

B. My sleep is slight disturb in (less than 1

hour sleepless(1 pts)

C. My sleep is mild disturbed (1-2 hours

sleepless )(2 pts)

D. My sleep is moderate disturbed (2-3 hours

sleepless) (3 pts)

E. My sleep is greatly disturbed (3-5 hours

sleepless(4 pts)

F. My sleep is completely disturbed (5-7

hours sleepless)(5 pts)

Section 6 – Work

A. I can do as much work as I want to (0

pts)

B. I can only do my usual work but no

more(1 pts)

C. I can done most of my usual work but

no more(2 pts)

D. I cannot do my usual work (3 pts)

E. I can hardly do any work at all(4pts)

F. I can’t do any work at all (5 pts)

Section 7 –Driving

A. I can drive my car without neck pain (0

pts)

B. I can drive my car as long as I want

with slight pain in ny neck(1 pts)

C. I can drive my car long as I want with

moderate pain in my neck (2 pts)

D. I cannot drive my car as long as I want

because of moderate pain in my neck

(3 pts)

E. I can hardly drive my car at all because

of severe pain in my neck (4 pts)

F. I cannot drive my car at all(5 pts)

Section 8 -Reading

A. I can read as much as I want to with no

pain in my neck (0 pts)

B. I can read as much as I want with

slight pain in my neck (1 pts)

C. I can read as much as I want with

moderate pain in my neck(2 pts)

D. I cannot read as much I as I want

because of moderate pai n my neck(3

pts)

E. I cannot read as much I as I want

because of severe pain in my neck (4

pts)

F. I cannot read at all because of neck

pain(5 pts)

Section 9 – Headache

A. I have no headache vat all(0 pts)

B. I have slight headache that comes in

frequently (1 pts)

C. I have moderate headache that come in

frequently (2 pts)

D. I have moderate headache that come

frequently (3 pts)

E. I have severe headache that come

frequently (4 pts)

F. I have head ache almost all the time(5

pts)

Section 10 -Recreation

A. I am able to engage in all recreational

activities with no pain in my neck at all

(0 pts)

B. A am able to engage in all recreational

activities with some pain in my neck (1

pts)

C. I am able to engage in most but not

all recreational activities because of

pain in neck (2 pts)

D. I am able to engage in only a few of

my usual recreational activities

because of pain in my neck(3 pts)

E. I can hardly do any recreational

activities because of pain in my neck

(4 pts)

F. I cannot do any recreational activities

at all(5 pts)

Duration of the Study: 6 months

Statistical Analysis

This will be done using student t-test and chi square test for drawing valid

conclusion.

7.4 Ethical Clearance

As this study involve human subjects, the ethical clearance has been obtained

from research and ethical committee of K.T.G college of physiotherapy, Bangalore as per

the ethical guidelines for Bio-Medical research on human subjects, 2000 ICMR, New Delhi .

8.LIST OF REFERENCES:

1. Bhojo A, Ahsan Nauman et al., May (2010) Guidelines for evaluation and management of neuropathic pain. Official guidelines of Pakistan society of Neurology.2. Ferey down D, Jaleh Gholami et al.,(2009) The prevalence of musculoskeletal complaints in a rural area in iran: a W.H.O -iAR COPCORD study.(stage 1 rural study

in iran)3. Snodgrass SJ, Rivett Da et el.,(2008) measuring posterior to anterior osteophytes stiffness of cervical spine(Kpub)4. Benzel (2001), Shedid & Ben/el (2007).5. Md H. Mahbub, Md S Laskar, Farid A. Seikh, Md H. Altai', Tadaki Wakui and Noriaki Harada et el.,(2006) Prevalence of Cenical sondvlosis and Musculoskeletal Symptoms among Coolies in a City ol Bangladesh.6. Howards Koichi M et al., (2006) Intervertebral disc degeneration: Biological and Bio-mechanical Factors.7. Laskar, Mahbub MH et al., (2006) Prevalence of Cenical spondylosis and musculoskeletal symptoms among coolies in a city of Bangladesh.8. D groh, H Fraunenfrldr, A.F. Mannin et al July 2006 measurement of cervical X-rays 2006.9. Journal of manipulative therapy a "clinical normal range" for cervical lordosis published in 2005.

10. Kristjannson E, Jonsson H Jr et el., (2002)is the saggital configuration of the cervical spine changed in women with chronic whiplash syndrome.

11. Harrison DE, Bula JM, Gore DR (2002) Evaluation of axial and fiexural stresses in the vertebral body cortex trabecular bone in lordosis and two sagittal cervical translation configurations with an elliptical shell model.12. Gore DR (2001) Roentgen graphic findings in the cervical spine in asymptomatic persons a ten year follow up.13. David Burton et al., (2001), university of oxford, causes ol muscle spasm.14. G Salemi.G Saveltieri, F Meneghini et al., Prevalence of cervical radiculopathy A door-to-door survey in a silican municipality.(2000)15. Kleinn F (1998) Zur Rolle strukturell fixierter Kyphosen and Skoliosen bei Ruckenbeschwerden orthopraxis.16. Van Tudler MW, assendelft WJ, Koes BVV, Bouter LM (1997) Spinal Radiographic findings and non-specific low back pain history and lumbar MRI findings.17. Paul and Hardacker JW, Shuford RF,Capicotto PN, Pryor PW (1997) Radiogniphic standing cervical segmental alignment in adult volunteers without neck symptoms.18. Cote Pierre, J David, Yong-Hing, Ken et al, 15th April 1997 reliability of measuring sagittal curvature on lateral cervical spine radiographs.19. Joudas JW, Carey JR, Garret TR et al, (1997) Reliability of measurements of cervical spine range of motion. Vol – 71, Page No. 107.20. Cote & Joudas et al., 1997 & 199821. Cote et al., Lateral cenical reliability studies of geometric fine drawing radiographic analysis. 1997.22. D Grob, H. Frauenfelder, and A. F. Mannion et ai.,(1996) The relation between cervical spine curvature and muscle strain a retrospective study.23. Marchiori DM, Henderson CN (1996) A cross sectional study co- relating cenical radiographic degenerative findings to pain and disability.24. Dgv Harrison DD, Troyanovich SJ, Harrison DE, Janik TJ, Murphy DJ (1996) A normal

sagittal spinal configuration: a desirable clinical outcome.25. Leonard T Kurland, kurupath Radhakrishnan et al, (1993) Epidemiology of cervical radiculopathy - A population based study from Rochester,Minnesota.26. Patricia Grlegel-Morris, Keith Larson el al., (1992) Incidence ol'Common Postural

Abnormalities in theCervical, Shoulder, and Thoracic Regions and TheirAssociation with Pain in Two Age Groups of Healthy Subjects

27. Donald D. Patricia A Mc Grath et al. (1992) The validation of vas on the ratio scale measures for chronic and experimental pain.

28. Vernon and Mioret al., (1991) Study of reliability and validity of neck disability index in the Journal of Manipulative and Physiologic Therapeutics.

29. Wewers M, Lowe N K et al., (1990) A critical review of VAS in the measurement of clinical phenomenon. Nicholas Crichton article.

30. Weh, L Rottker H (1990) Functional analysis of the cenical spine in healthy persons.31. Boden SD, McCovvin PR, Davis DO, Dina TS, Mark AS, Wiesel S (1990) Abnormal magnetic - resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation32. Gore DR, Sepic SB, Gardner GM (1986) Roentgenographic findings of the cervical spine in asymptomatic people33. Kellgren JH, Ball J et al., (1986) atlas of standard radiographs, Vol. II Black well Scientific, Oxford.34. Paul A Banaszkiewicz, Deiary Kader et al., post-graduate orthopaedics: 'The

candidates guide to FRCS 2nd edition.35. Tony Y. Tanoury, Jarcd Tomah et al., consult orthopaedics book.36. Ayman Ali Galhom el al., emedicine cervical spondylosis.37.cervical Spondylosis,morphopaedics.38.A study done by Dr.Deed herisora chiropractic study.39. M Hagberg, DH Wegman et al,The Hypothesis of the Exposure causing cervical spondylosis that of a high load on the cervical spine.40. Galen et al., Cervical Spondylosis explore medindia.41. University of Maryland spine program.

42.Hasa Ahmed, Ayman Ali et al ,cervical Spondylosis clinical presentation.

9 SIGNATURE OF THE

CANDIDATE:

10. REMARKS OF THE GUIDE:

11 NAMES AND DESIGNATION OF:

11.1 GUIDE: Dr. SAIKUMAR. MPT, MIAP,

PRINCIPAL

11.2 SIGNATURE:

11.3 HEAD OF THE DEPARTMENT: Dr. SAIKUMAR. MPT, MIAP,

PRINCIPAL, K.T.G COLLEGE OF

PHYSIOTHERAPY

11.4 SIGNATURE :

12.

12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL:

12.2 Signature: