Efficacy of myofascial unwinding and myofascial release on somatic symptoms in patients with non-specific chronic low back pain – A study protocol for a single-blinded randomized clinical trial

Introduction: Numerous studies suggest a significant correlation between Chronic Low Back Pain (CLBP) and somatic symptoms. These symptoms often stem from altered fascial biomechanics. Implementing Soft Tissue Mobilisation (STM) techniques aimed at restoring fascial biomechanics can markedly alleviate somatic symptoms associated with CLBP. Aim: To assess the efficacy of STM in alleviating somatic symptoms in patients with Chronic Low Back Pain (CLBP). Materials and Methods: A pilot pretest post-test randomised clinical trial was conducted in the Department of Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana, India, from July 2023 to December 2023, on participants diagnosed with Non Specific Chronic Low Back Pain (NSCLBP) accompanied by somatic symptoms. The experimental group (Group 1), n=6 (41.00±6.29 years), received myofascial unwinding and myofascial release. In contrast, the clinical group (Group 2), n=6 (43.83±11.20 years), received conventional physiotherapy care, including structured exercises and electrophysical modalities, over 4 weeks. Both groups underwent three sessions per week, amounting to 12 sessions in total. The evaluation of somatic symptoms was conducted using the Hamilton Depression Rating Scale (HDRS) at baseline and after the 4 weeks. Results: The statistical analysis demonstrated significant withingroup differences in HDRS (p-value=0.002) in Group 1, and no statistically significant difference in Group 2 (p-value=0.749). The between-group analysis demonstrated a statistically significant difference in HDRS (p=0.035) with a large effect size (d=1.4). Conclusion: STM effectively improves somatic symptoms in NSCLBP patients. The beneficial effect of STM on somatic symptoms can be translated into clinical practice after strengthening results in the larger population.

Background and Objectives Non-specific chronic low back pain is common and complex and has a large impact on individuals and society. Inculcating physical exercise to promote healthy lifestyle has played an important role in the prevention and management of chronic health conditions. The purpose of this study is to review the published literature on lifestyle factors mainly physical exercise to combat nonspecific chronic low back pain. Material and Methods PubMed database was reviewed from 2000 and November 2018 and searched for ‘exercise and non-specific chronic low back pain’, ‘lifestyle and non-specific chronic low back pain’ and individual exercise interventions and non-specific chronic low back pain. Articles which fulfilled the criteria were included in the final review. Results The available evidences from existing systematic reviews and articles suggested that physical exercise does improve pain severity and physical function in chronic nonspecific low back pain. Regarding the type of exercises, strengthening or resistance exercises seem to be effective but no specific type of exercise is superior to others. Conclusion Incorporating physical exercise such as strengthening exercises as part of the lifestyle change could combat non-specific chronic low back pain.

Pre-diabetes, characterized by elevated glycemic indices, poses a high risk of diabetes development, and is increasingly linked to non-specific low back pain. While mechanisms remain incompletely understood, metabolic, inflammatory, and neurological factors are implicated. Dietary interventions, including low-glycemic and anti-inflammatory diets, alongside weight management, may improve outcomes in this population. In this non-randomized controlled trial, we aim to evaluate the influence of decreasing HbA1c levels on reducing chronic non-specific low back pain in pre-diabetic, non-obese individuals, as well as emphasizing the importance of such a study in supporting the literature. A non-randomized controlled single-blind clinical trial was conducted among 82 participants with chronic non-specific low back pain and pre-diabetes at an outpatient clinic in Baghdad from the 30th of January to the 22nd of September. The intervention methods aimed at reducing HbA1c levels to assess the reduction impact on alleviating chronic non-specific low back pain included dietary adjustments, sleep optimization, and correction of vitamins and minerals deficiencies. The follow-up process was conducted individually for each participant, with a monthly assessment over a period of six months. At 12 weeks a significant decrease in chronic non-specific low back pain severity was observed in patients with lower HbA1C levels yielding a P-value of .021. Similarly, at 24 weeks there was a decline in the number of patients who reported chronic non-specific low back pain, and the association to lower HbA1C levels was significant with a p-value of .005. This study suggests the presence of a statistically significant association between reduction of HbA1C levels and ensuing improvement in chronic non-specific low back pain symptoms in non-obese prediabetic patients.

Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional management of musculoskeletal disorders, including those that cause low back pain (LBP). Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as "The therapeutic application of manually guided forces by an osteopathic physician (U.S. Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques" (eAppendix). Somatic dysfunction is defined as "Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment." These guidelines update the AOA guidelines for osteopathic physicians to utilize OMT for patients with nonspecific acute or chronic LBP published in 2010 on the National Guideline Clearinghouse.1 METHODS: This update process commenced with literature searches that included electronic databases, personal contact with key researchers of OMT and low back pain, and Internet search engines. Early in the process, the Task Force on the Low Back Pain Clinical Practice Guidelines discovered the 2014 systematic literature review conducted by Franke et al2; this study serves as the basis for this updated guideline and further builds upon the literature used to support the previous guidelines. Findings from other eligible studies published after the search parameters of the Franke et al systematic review were also incorporated. The authors of the systematic review identified 307 studies. Thirty-one were evaluated and 16 were excluded. Of the 15 studies included in the review, 6 were retrieved from Germany, 5 from the United States, 2 from the United Kingdom, and 2 from Italy. Two additional studies published after the Franke et al review were also included. Osteopathic manipulative treatment significantly reduces pain and improves functional status in patients, including pregnant and postpartum women, with nonspecific acute and chronic LBP. Franke et al found that in acute and chronic nonspecific LBP, moderate-quality evidence suggested that OMT had a significant effect on pain relief (mean difference [MD], -12.91; 95% CI, -20.00 to -5.82) and functional status (standard mean difference [SMD], -0.36; 95% CI, -0.58 to -0.14). More specifically, in chronic nonspecific LBP, the evidence suggested a significant difference in favor of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). When examining nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favor of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23). Conversely for nonspecific LBP postpartum, Franke et al found that moderate-quality evidence suggested a significant difference in favor of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35).2 CONCLUSION: The conclusions of Franke et al further strengthen the findings that OMT reduces LBP. In a 2005 systematic review conducted by Licciardone et al3 and the basis of the LBP guidelines published in 2010, it was determined that OMT reduces pain more than expected from placebo effects alone, and these results had the potential to last beyond the first year of treatment. Franke et al specifically stated that clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women 3 months after treatment. Larger randomized controlled trials with robust comparison groups are needed to further validate the effects of OMT on LBP. In addition, more research is needed to understand the mechanics of OMT and its short- and long-term effects, as well as the cost-effectiveness of such treatment.

BackgroundPersonal convictions in referral to pain cause misbeliefs in health professionals, which can influence patients who suffer from non-specific chronic low back pain. Likewise, health professionals’ beliefs affect their advice and attitudes towards patients’ treatment, becoming a possible cause of greater disability. The development of educational interventions based on the best scientific evidence in neurophysiology of pain could be a way to provide information and advice to primary care health professionals to change their cognition towards chronic non-specific low back pain. The use of Information and Communication Technologies allows the development of web sites, which might be one of the effective resources to modify misbeliefs and attitudes, in relation to the origin and meaning of non-specific chronic low back pain, of primary care professionals and that may modify their attitudes in patients’ treatment.MethodsThe aim of this project is to identify misbeliefs and attitudes of primary care physicians and nurses about chronic non-specific low back pain to develop a web-based educational tool using different educational formats and gamification techniques. This study has a mixed-method sequential exploratory design. The participants are medical and nursing staff working in primary care centers in the city of Lleida, Spain. For the qualitative phase of this study, the authors will use personal semi-structured interviews. For the quantitative phase the authors will use an experimental study design. Subjects will be randomly allocated using a simple random sample technique. The intervention group will have access to the web site where they will find information related to non-specific chronic low back pain, based on the information obtained in the qualitative phase. The control group will have access to a video explaining the clinical practice guidelines on low back pain.DiscussionThis study has been designed to explore and modify the beliefs and attitudes about chronic low back pain of physicians and nurses working in primary care settings, using a web-based educational tool with different educational formats and gamification techniques. The aim of the educational intervention is to change their knowledge about the origin and meaning of pain, with the result of reducing their misbeliefs and attitudes of fear avoidance.Trial registrationClinicalTrials.gov Identifier: NCT02962817. Date of registration: 11/09/2016.

Video observation study. To establish the validity of determining effort level by visual observation of a lifting test. Determining effort level during a lifting test is critical for interpretation of test performance, yet the validity of these determinations has not been established in patients with chronic nonspecific low back pain. Fifteen healthy subjects and 16 patients with chronic nonspecific low back pain performed a standardized lifting test as outlined in the Isernhagen Work System Functional Capacity Evaluation. The lifts were videotaped and independently observed by 9 trained observers, who rated effort levels using an Isernhagen Work System categorical scale and a Borg Category Ratio scale. External effort indexes were established to control for effort at group level. Validity of the observer ratings was analyzed by means of a sensitivity and specificity analysis and correlations between performances and observer ratings. Interrater reliability was analyzed by means of intraclass correlation coefficients and Cohen kappa. External indexes differ significantly between patients with chronic low back pain and healthy subjects, indicating that at group level, patients did not perform maximally. Submaximal performances were correctly rated in 85% to 90% (healthy subjects) and in 100% (patients with chronic nonspecific low back pain) of the cases. "Maximal" performances were correctly rated in 46% to 53% (healthy subjects) and in 5% to 7% (patients with chronic nonspecific low back pain) of the cases. Correlations between performances and observer ratings were r = 0.90 to r = 0.92 (healthy subjects) and r = 0.82 (patients with chronic nonspecific low back pain). Reliability: intraclass correlation coefficient, r = 0.76 (patients with chronic nonspecific low back pain) to r = 0.87 (healthy), Kappa K = 0.50 (patients with chronic nonspecific low back pain) to r = 0.58 (healthy subjects). Effort level can be determined validly by means of visual observation.

Background: There is no specific cause of low back pain for eighty- five percent of cases and they were classified as non-specific low back pain. In this study, the size and symmetry of the lumbar multifidus muscles in industrial workers with non-specific chronic low back pain and healthy workers were investigated. Materials and Methods: In a cross-sectional comparative study, sixty industrial workers were divided into two groups of chronic low back pain and healthy, based on medical history and physical test. Roland-Morris Low Back Pain Questionnaire were filled by the group with chronic low back pain and dimensions of lumbar multifidus muscles in the L4-L5 level were measured by ultrasonography and the atrophy and asymmetry of two sides were examined. Results: Average size of right muscle in patients ranged between 2.5 and 4.3 CM? Inch? with average of 3.6 ± 0.43 and size of left muscle was in the range of 2.8 to 4.7 with the average of 3.9 ± 0.46. Size of right Muscle in healthy group was between 3.6 and 4.9 with the average of 4.3 ± 0.4 and left muscle size in healthy group was in the range of 3.9 to 5.09 and average of 4.4 ± 0.42 (p< 0.001). The proportion of symmetry, in the patient group was less (0.9) compared to those with no symptoms (0.95) (p<0.001). Conclusion: This study showed that the size of the multifidus muscle in patients with chronic non-specific low back pain at L4-L5 level was smaller compared to without back pain subjects on the basis of the average size of right and left muscle. Besides, in the patient group, muscle size in one side was smaller than the other side, in a way that there was a clearly and significantly asymmetry in muscle size between both sides.in addition, difference between size was observed between the two left and right waist size in the healthy group.

Introduction : Low back pain may cause clinical symptoms such as: reflex inhibition and atrophy of multifidus muscles, lumbar paraspinal muscles atrophy, dysfunction and disability. The atrophy of multifidus muscles could be a main cause of recurring back pain.. Therefore, present study compared the effect of stability and McKenzie exercises on pain, disability and multifidus size in women with chronic non-specific low back pain. Materials and Methods: 60 non-athletic women with chronic non-specific low back pain allocated in this research. They randomly and equally divided in to two experimental groups, 30 subjects (Mean ± SD age, 33.37 ± 7.92 year) in stabilization exercise group and 30 participants (Mean ± SD age, 37.00 ± 9.97 year) in McKenzie exercises group. Both groups performed exercise training for 6 weeks. The level of pain, disability, and the cross sectional area of lumbar multifidus muscle was respectively measured by visual analog scale (VAS), Ostwestry disability index and Ultrasonography imaging. These data were collected just before intervention, after 6 weeks of exercise intervention, and also at the end of 4 weeks follow-up period. Independent sample t-test was used to analyze the data and P 0.05). Conclusion: Stabilization and McKenzie exercises may improve pain and disability in patients with chronic non-specific low back pain, while stabilization exercise results in size improvement of lumbar multifidus muscles at L5 level. Therefore stabilization exercises may be more effective to prevent recurrent chronic low back pain. Keywords : Non-specific chronic low back pain, Stabilization exercises, McKenzie exercises, Lumbar multifidus muscle

BackgroundLow back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches.DiscussionMany clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient.An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention.SummaryThe disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed.

Background and Objectives Chronic low back pain is one of the most common and costly musculoskeletal disorders in societies and is an important clinical and socio-economic epidemic, mostly in industry and non-industry. The aim of this study was to a systematic review of the effectiveness of exercise protocols on lumbar proprioception in patients with chronic nonspecific low back pain. Subjects and Methods From internal and external search engines, including Scopus, Semantic Scholar, Google Scholar, Pubmed, ISC, SID, Magiran, Irandoc, and Doaj with time limit 2010 to 2021 and the keywords exercises, proprioception, non-specific, and chronic low back pain, the present study was done using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes). Results Nine articles were selected based on inclusion criteria. These studies mainly focused on systematic review effectiveness of exercise protocols on sensation and low back pain in people with non-specific chronic low back pain. Conclusion According to the research reviewed in the present study, it seems that exercise rehabilitation protocols activate, strengthen, maintain, and increase the central region of the body, especially deep muscles, particularly the multifidus and transverse abdomen, by retraining the pelvic lumbar region. The diaphragm and diagonal of the abdomen and pelvic floor, which play a role in the important segmental stability of the lumbar spine, improve the sense of depth and pain in patients with chronic nonspecific low back pain.

The McKenzie method is widely used as an active intervention in the treatment of patients with nonspecific low back pain. Although the McKenzie method has been compared with several other interventions, it is not yet known whether this method is superior to placebo in patients with chronic low back pain. The purpose of this trial is to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain. An assessor-blinded, 2-arm, randomized placebo-controlled trial will be conducted. This study will be conducted in physical therapy clinics in São Paulo, Brazil. The participants will be 148 patients seeking care for chronic nonspecific low back pain. Participants will be randomly allocated to 1 of 2 treatment groups: (1) McKenzie method or (2) placebo therapy (detuned ultrasound and shortwave therapy). Each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks). The clinical outcomes will be obtained at the completion of treatment (5 weeks) and at 3, 6, and 12 months after randomization. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale) and disability (measured with the Roland-Morris Disability Questionnaire) at the completion of treatment. The secondary outcomes will be pain intensity; disability and function; kinesiophobia and global perceived effect at 3, 6, and 12 months after randomization; and kinesiophobia and global perceived effect at completion of treatment. The data will be collected by a blinded assessor. Therapists will not be blinded. This will be the first trial to compare the McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. The results of this study will contribute to better management of this population.

BackgroundLow back pain is the most frequent cause of rheumatic diseases in Africa (1). However the studies are scarce, especially in sub-Saharan Africa.ObjectivesTo determine the main characteristics of non-specific chronic...

Background & Objective:Low back pain is a frequent problem faced by the majority of people at some point in their lifetime. Exercise therapy has been advocated an effective treatment for chronic low back pain. However, there is lack of consensus on the best exercise treatment and numerous studies are underway. Conclusive studies are lacking especially in this part of the world. Thisstudy was designed to compare the effectiveness of specific stabilization exercises with routine physical therapy exerciseprovided in patients with nonspecific chronic mechanical low back pain.Methods:This is single blinded randomized control trial that was conducted at the department of physical therapy Orthopedic and Spine Institute, Johar Town, Lahore in which 120 subjects with nonspecific chronic low back pain participated. Subjects with the age between 20 to 60 years and primary complaint of chronic low back pain were recruited after giving an informed consent. Participants were randomly assigned to two treatment groups A & B which were treated with core stabilization exercise and routine physical therapy exercise respectively. TENS and ultrasound were given as therapeutic modalities to both treatment groups. Outcomes of the treatment were recorded using Visual Analogue Scale (VAS) pretreatment, at 2nd, 4th and 6th week post treatment.Results:The results of this study illustrate that clinical and therapeutic effects of core stabilization exercise program over the period of six weeks are more effective in terms of reduction in pain, compared to routine physical therapy exercise for similar duration. This study found significant reduction in pain across the two groups at 2nd, 4th and 6th week of treatment with p value less than 0.05. There was a mean reduction of 3.08 and 1.71 on VAS across the core stabilization group and routine physical therapy exercise group respectively.Conclusion:Core stabilization exercise is more effective than routine physical therapy exercise in terms of greater reduction in pain in patients with non-specific low back pain.

Clinical Scenario: Low back pain is widely prevalent in the general population as well as in athletes. Therapeutic exercise is a low-risk and effective treatment option for chronic pain that can be utilized by all rehabilitation clinicians. However, therapeutic exercise alone does not address the psychosocial aspects that are associated with chronic low back pain. Pain education is the umbrella term utilized to encompass any type of education to the patient about their chronic pain. Therapeutic exercise in combination with pain education may allow for more well-rounded and effective treatment for patients with chronic nonspecific low back pain (NS-LBP). Clinical Question: Does pain education combined with therapeutic exercise, compared with therapeutic exercise alone, improve patient pain in adults with chronic NS-LBP over a 2- to 3-month treatment period? Summary of Key Findings: A thorough literature review yielded 8 studies potentially relevant to the clinical question, and 3 studies that met the inclusion criteria were included. The 3 studies included reports that exercise therapy reduced symptoms. Two of the 3 included studies support the claim that exercise therapy reduces the symptoms of chronic NS-LBP when combined with pain education, whereas one study found no difference between pain education with therapeutic exercise. Clinical Bottom Line: There is moderate evidence to support the use of pain education along with therapeutic exercise when attempting to reduce symptoms of pain and disability in patients with chronic NS-LBP. Educational interventions should be created to educate patients about the foundation of pain, and pain education should be implemented as a part of the clinician's strategy for the rehabilitation of patients with chronic NS-LBP. Strength of Recommendation: Grade B evidence exists to support the use of patient education with therapeutic exercise for decreasing pain in patients with chronic NS-LBP.

BackgroundLow-back pain is one of the most common health conditions worldwide. It is defined as pain below the costal margin and above the inferior gluteal folds. Current guidelines recommend management of chronic health (e.g., low back pain) conditions in older people at primary health care settings using active strategies (e.g., exercise). In non-specific low back pain, high quality evidence supports active strategies for general population. However, the management of non-specific low back pain in the older people has been overlooked and evidence is limited to a small number of low powered randomized controlled trials with high risk of bias.MethodsThis is a prospectively registered, open, two-arm randomised controlled trial comparing the group-based exercise and waiting list in pain intensity (11-item Pain Numerical Rating Scale) and disability (Roland Morris questionnaire) of older people (i.e., 60 years old or over) with chronic non-specific low back pain. One hundred and twenty patients will be recruited from Diamantina, Brazil. Follow-ups will be conducted in post-treatment (8 week) and 6- and 12-months post-randomisation.DiscussionOur hypothesis is that group-based exercise will be better than waiting list in reducing pain intensity and disability in older people with chronic non-specific low back pain.ImpactThe practice of individualized exercise has been studied for the management of chronic non-specific low back pain in older people. However, the group exercise, even showing high quality evidence for the improvement of several important outcomes in this population, has been ignored until now. Thus, the results of this study have the potential to indicate a viable and accessible strategy for managing chronic non-specific low back pain in the older people.Trial registrationThe study was prospectively registered at www.ensaiosclinicos.gov.br (RBR-9j5pqs). Date-11/18/2020.