Hong Kong Physiotherapy Journal

["Hong Kong Physiother. J. 2023.43:53-60. Downloaded from worldscientific.com Exclusion criteria were as follows: (1) Any back Muscle contraction exercise for low back pain 55 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. injury or pathology within the previous six months, (2) History of back surgery, (3) Rheumatologic when compared with a variety of sit-ups. Equip- disorder, and (4) Spine infection. ment's and Facilities: Mat, timer and a measuring strip are needed. The strip wide should be 12 cm < Isometric exercises 45 years and 8 cm > 45 years for measuring dis- tance. We used a timer of 40 s. Patient lies in a Curl up: Supine lying, one leg straight, the other supine position on the mat, knees bent at an angle leg \u00b0exed at 90\u0014, support lower back with hands, of approximately 140\u0014, feet \u00b0at on the \u00b0oor, legs elbow on the \u00b0oor, keep torso and neck in line, en- slightly apart, arms straight and parallel to the gage core in raising head, and shoulders slightly o\u00ae trunk with palms of hands resting on the mat. The the ground. Three repetitions, hold 10 s and rest 10 s. \u00afngers are stretched out and the head is in contact with the mat. Make sure patient has extended his Side bridge: Side lying, lie on side with knees feet as far as possible from the buttocks while still bent and prop upper body up on elbow, raise hips allowing feet to remain \u00b0at on \u00b0oor and when test o\u00ae the \u00b0oor, and three repetitions, hold 10 s and is started, Therapist counts curl-ups during 40 s rest 10 s. and determine percentiles according to age group and gender for partial curl-up. Bird dog: Quadruped position, both hands are under the shoulders and knees are under the hips, \\\\Percentiles by Age Group and Gender for Partial Curl-Up\\\" opposing arms and legs raised o\u00ae the \u00b0oor sepa- Age rately. Three repetitions, hold 10 s and rest 10 s. (20\u201329) (30\u201339) (40\u201349) (50\u201359) (60\u201369) Isotonic exercises PERCENTILES M F M F M F M F M F Bent knee sit-up: Supine lying, hands by side, 90 75 70 75 55 75 50 74 48 53 50 knee \u00b0exed 60\u0014, heels \u00b0at on \u00b0oor, head and upper 80 56 45 69 43 75 42 60 30 33 30 back raise. Three repetitions, hold 10 s and rest 10 s. 70 41 37 46 34 67 33 45 23 26 24 60 31 32 36 28 51 28 35 16 19 19 Cross curl up: Supine lying, bent knee about 50 27 27 31 21 39 25 27 9 16 13 60\u0014, feet \u00b0at on the \u00b0oor, hands placed behind 40 24 21 26 15 31 20 23 2 9 9 neck, one leg across the other, the participant 30 20 17 19 12 26 14 19 0 6 3 raised their contralateral elbow to the opposite 20 13 12 13 0 21 5 13 0 0 0 knee. Three repetitions, hold 10 s and rest 10 s. 10 4 5 0 0 13 0 0 0 0 0 Prone back extension: Prone lying, bodies Notes: *This table is from the NSCA's Essentials of Personal cantilevered over the end, lowered their upper Training, p. 257 body at 90\u0014 of table after feet were secured with a strap and return to starting position. Three repe- Data analysis titions, hold 10 s and rest 10 s. Statistical analysis of the data was made with 95% Post-intervention scoring was recorded on the con\u00afdence in the SPSS 15.0 for Windows package last day of treatment in the form of pain on visual program. Categorical variables were shown as analogue scale (VAS), functional disability on \\\\n\\\" and \\\\%\\\", and continuous variables as modi\u00afed Oswestry disability index (MODI), and \\\\Mean \u00c6 standard deviation\\\". Independent sam- strength on endurance test. The partial curl-up has ple's t-test was used to study the similarity of de- been recommended as a better test of abdominal mographic data between groups. Wilcoxon Signed muscular endurance. The curl-up with knees \u00b0exed Ranks Test was used to study the change between and feet unanchored has been selected because in- pre- and post-treatment. Mann\u2013Whitney Test was dividually these elements have been shown to (a) used to study the comparison between both groups. decrease movement of the \u00affth lumbar vertebra over the sacral vertebrae, (b) minimize the acti- Results vation of the hip \u00b0exors, (c) increase the activation of the external and internal oblique's and trans- For this study, 30 (n \u00bc 30) subjects, 53% of the verse abdominals, and (d) maximize abdominal participants were males and 47% were females, muscle activation of the lower and upper rectus they were selected to compare the e\u00aeectiveness of abdominals relative to disc compression (load)","56 A. Alarab, R. A. Shameh & M. S. Ahmad Table 1. Comparisons of demographic data between groups. Table 3. Comparison of pre- and post-MODI score within groups. Group A Group B Variables Mean (SD) Mean (SD) t-value p-value Pre-treatment Post-treatment Mean (SD) Mean (SD) p-value Group Age 30.13 (12.84) 30.47 (8.69) \u00c00.083 0.934 0.000 Weight (Kg) 76.33 (17.75) 71.87 (11.67) \u00c016.36 0.564 A (ISOMETRIC) 23.5 (14.8) 9.5 (9.48) 0.001 0.649 B (ISOTONIC) 34.4 (16.4) 14.0 (8.02) 0.001 Height (Cm) 169.5 (8.08) 167.3 (12.15) 0.583 BMI 26.7 (6.38) 25.8 (4.16) 0.460 Note: BMI: Body Mass Index; W: Weight; H: Height; SD: Note: MODI: Modi\u00afed Oswestry Disability Index and SD: standard deviation. Standard deviation. Hong Kong Physiother. J. 2023.43:53-60. Downloaded from worldscientific.com isometric and isotonic exercises for training core the treatment. This means that the two groups are by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. muscles in decreasing pain intensity, improving considerably identical. functional disability and abdominal endurance test for low-back pain patients. These subjects were In the results from the two approaches, the P then randomly divided into two groups, group A value in post-tests was equal to 0.838, which is (n \u00bc 15) and group B (n \u00bc 15). greater than 0.05. Therefore, we conclude that there is no statistically signi\u00afcant di\u00aeerence be- The demographic data is shown in Table 1. In tween the two approaches. This also means that both groups, there were no signi\u00afcant di\u00aeerences in they have the same e\u00aeect and reduce the pain. terms of age, height, and BMI; but there were Table 3 and Fig. 1 illustrate these \u00afndings. signi\u00afcant di\u00aeerences in weight. Within the groups, MODI scores were done Within groups, analysis of VAS score was done using Wilcoxon Signed Ranks Test. When com- using Wilcoxon Signed Ranks Test. The result of paring the pre- and post-MODI scores in group A the test in group A shows that the P value is (isometric treatment), the results showed that the (0.001) which is less than P \u00bc 0:05. The results P value is equal 0.001, this means that there is revealed that the average on pain pre-treatment statistically signi\u00afcant di\u00aeerence between pre- and was (6.67), while post-treatment decreased to (3). post-MODI scores. In group A, the average MODI Thus, we infer that isometric treatment reduces score pre-isometric treatment was 23.5%. While lower back pain signi\u00afcantly. In group B, the post-treatment decreased to 9.5%. Consequently, results revealed that P is equal to 0.019. Moreover, we can conclude that isometric treatment can the result showed that the average pain pre-iso- improve MODI scores signi\u00afcantly. tonic treatment was 5.9, whereas the average pain post-treatment reduced to 4.6. Table 2 presents Similarly, the P value in group B (isotonic these \u00afndings. treatment) was 0.001, which is less than 0.05. Hence, we conclude that there is statically signi\u00af- Between groups, analysis of VAS score was done cant di\u00aeerence between pre- and post-MODI using Mann\u2013Whitney Test for the pre- and post- scores. Examining the average score of MODI be- results of the both groups. In the pre-values, the fore and after the isotonic treatment revealed that results of the test disclosed that the P value before the average MODI score in group B before the the two approaches was 0.285. Thus, we conclude treatment was 34.4%. In the post-measures, the that there was no statistically signi\u00afcant di\u00aeerence average decreased to 14.0%. This also means that between the pain in group A and group B before isotonic treatment can improve MODI scores sig- ni\u00afcantly. Table 4 depicts these results. Table 2. Comparison between pre- and post-VAS score within groups. To compare pre- and post-MODI scores in be- tween groups, we used Mann\u2013Whitney Test. The Group Pre-treatment Post-treatment test on the pre-treatment scores revealed P value Mean (SD) Mean (SD) p-value of 0.061, which is greater than 0.05. A (ISOMETRIC) 6.67 (1.71) 3.0 (1.69) 0.001 Thus, we conclude that there is no statically B (ISOTONIC) 5.9 (1.3) 4.6 (5.8) 0.019 signi\u00afcant di\u00aeerence between the two groups in MODI scores before the treatment. Moreover, this Note: VAS: Visual analogue scale, SD: Standard deviation. means that the two groups are indistinguishable. In the same way, the test on the post-treatment scores revealed P value of 0.077. Again, this value is","Muscle contraction exercise for low back pain 57 Hong Kong Physiother. J. 2023.43:53-60. Downloaded from worldscientific.com Fig. 1. Comparison of pre- and post-VAS score in between groups. by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. Table 4. Comparison of pre- and post-abdominal endurance Comparing between groups, pre- and post-ab- test within groups. dominal endurance scores were done using the Mann\u2013Whitney Test. The test on the pre-treat- Group Pre-treatment Post-treatment ment scores revealed P value of 0.345, which is Mean (SD) Mean (SD) p-value greater than 0.05. Thus, we conclude that there is no statistical signi\u00afcant di\u00aeerence between the two A (ISOMETRIC) 35.9 (10.61) 47.5 (11.39) 0.001 groups in abdominal endurance scores before the B (ISOTONIC) 35.3 (18.46) 52.7 (17.09) 0.001 treatment. Moreover, this means that the two groups are indistinguishable. In the same way, the Note: SD: Standard deviation. test on the post-treatment scores revealed P value of 0.305. Again, this value is greater than 0.05, greater than 0.05, and thus we infer that there is no and thus we infer that there is no statistically statistically signi\u00afcant di\u00aeerence between group A signi\u00afcant di\u00aeerence between group A and group and group B in MODI scores after the treatment. B in abdominal endurance scores after the This also means that the two approaches improve treatment. Tables 5 and 6 and Fig. 3 show these patients MODI scores equally. Table 5 and Fig. 2 results. illustrate these \u00afndings. Fig. 2. Comparison of pre- and post-MODI score between groups.","58 A. Alarab, R. A. Shameh & M. S. Ahmad Table 5. Comparison of pre- and post- MODI score abdominal muscle endurance in patients with LBP. between groups. Intergroup analyses were done using Mann\u2013Whit- ney Test and the results of the study con\u00afrm the Group Pre-treatment Post-treatment hypothesis that there was no a signi\u00afcant di\u00aeer- Mean \u00c6 (SD) Mean \u00c6 (SD) ence between the two groups. A (ISOMETRIC) 23.5 \u00c6 14.8 9.5 \u00c6 9.48 Hye Jin Moon et al. reported the e\u00aeect of lum- B (ISOTONIC) 34.4 \u00c6 16.4 14.0 \u00c6 8.02 bar stabilization and dynamic lumbar strengthen- P value ing exercises in patients with CLBP. As a result, 0.061 0.077 both lumbar stabilization and dynamic strength- ening exercise (isometric strength) strengthened Hong Kong Physiother. J. 2023.43:53-60. Downloaded from worldscientific.com Note: Modi\u00afed Oswestry Disability Index, SD: the lumbar extensors and reduced LBP. However, by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. Standard deviation. the lumbar stabilization exercise was more e\u00aeective in lumbar extensor strengthening and functional Table 6. Comparison of pre- and post- abdominal improvement in patients with nonspeci\u00afc chronic endurance test between groups. LBP.12 In our study, results revealed that isometric and isotonic approaches have a positive value Group Pre-treatment Post-treatment for functional improvement in patients with non- Mean \u00c6 (SD) Mean \u00c6 (SD) speci\u00afc LBP. A (ISOMETRIC) 35.9 \u00c6 10.61 47.5 \u00c6 11.39 In isotonic exercises, when a body segment 52.7 \u00c6 17.09 moves through its available range, the tension that B (ISOTONIC) 35.3 \u00c6 18.46 the muscle is capable of generating shortens or 0.305 lengthens which is due to the changing length, P value 0.345 tension relationship of the muscle, and the chang- ing load. Hence, the isotonic exercise helps in re- Note: Standard deviation. lieving pain and improving strength by both of these mechanisms. Discussion Jill and colleagues reported that Exercise The purpose of this study is to compare the e\u00aeect Therapy for Nonspeci\u00afc Low Back Pain, exercise of isometric and isotonic exercises training in therapy seems to be slightly e\u00aeective at decreasing patients with non-speci\u00afc LBP. The results showed pain and improving function in adults with CLBP, that both isometric and isotonic exercises signi\u00af- particularly in health care populations. In subacute cantly reduce pain, and improve function and low-back pain populations, some evidence suggests that a graded activity program improves Fig. 3. Comparison of pre- and post-abdominal endurance test between groups.","Hong Kong Physiother. J. 2023.43:53-60. Downloaded from worldscientific.com absenteeism outcomes, although evidence for other Muscle contraction exercise for low back pain 59 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. types of exercise is unclear. In LBP populations, exercise therapy is as e\u00aeective as either no treat- Author contributions ment or other conservative treatments.13 The authors con\u00afrm contribution to the paper Leemans and his colleagues reported TENS and as follows: study conception and design: Azzam heat to reduce pain in a chronic LBP population, Alarab,; data collection: Azzam Alarab and Ratib the study results indicated that the combination of Abu Shameh; analysis and interpretation of results: heat and TENS does not reduce pain scores in Azzam Alarab and Muntaser S. Ahmed; draft patients with CLBP. Pressure pain threshold manuscript preparation: Azzam Alarab. All authors values signi\u00afcantly improved, showing bene\u00afcial reviewed the results and approved the \u00afnal version e\u00aeects of the experimental treatment.14 Our study of the manuscript. results indicated that the isotonic and isometric exercises with TENS and IR decrease the pain. References Park et al. indicated that an exercise program 1. Batti\u0013e MC, Cherkin DC, Dunn R, Ciol MA, that simultaneously strengthens the deep abdomi- Wheeler KJ. Managing low back pain: Attitudes nal muscles and muscles of trunk is an ideal and treatment preferences of physical therapists. method for maintaining spinal stability physical Phys Ther 1994;74(3):219\u201326. balance.15 In our study between groups, pre- and post-abdominal endurance scores were done using 2. Waddell G. Low back pain: A twentieth century the Mann\u2013Whitney test. We conclude that there is health care enigma. Spine 1996;21(24):2820\u20135. no statistically signi\u00afcant di\u00aeerence between group A and group B in abdominal endurance scores after 3. Chen SM, Liu MF, Cook J, Bass S, Lo SK. the treatment. It means that both isometric and Sedentary lifestyle as a risk factor for low back isotonic exercises increase the abdominal endurance. pain: A systematic review. Int Arch Occup Environ Health 2009;82:797\u2013806. The result from the statistical analysis of this study supported null hypothesis which stated that 4. Abushkadim MD, Amro A, Ahmad MS. Physical there will be no signi\u00afcant di\u00aeerence in isometric activity and health-related quality of life among and isotonic exercise training in core muscle in physiotherapists in Hebron\/West Bank. J Novel patient with non-speci\u00afc LBP for all other outcome Physiother Rehabil 2020;4(2):022\u20137. measures. Thus, it can be stated from the study that isometric and isotonic exercises along with 5. Shaheen H, Alarab A, Ahmad MS. E\u00aeectiveness of infrared and TENS are e\u00aeective in treating therapeutic ultrasound and kinesio tape in treat- patients with LBP. ment of tennis elbow. J. Novel Physiother Rehabil 2019;3(1):025\u201333. Conclusion 6. Skelton AM, Murphy EA, Murphy RJ, O'dowd From the \u00afnding of this study, we can conclude TC. Patients' views of low back pain and its that both isometric and isotonic exercises are ef- management in general practice. Br J General Prac fective when treating low-back pain. There was no 1996;46(404):153\u20136. di\u00aeerence between the e\u00aeects of isometric and iso- tonic exercises to decrease pain intensity, im- 7. Koes BW, Van Tulder M, Lin CW, Macedo LG, provement in disability, and abdominal muscles McAuley J, Maher C. An updated overview endurance. of clinical guidelines for the management of non- speci\u00afc low back pain in primary care. Eur Spine Conflict of Interest J 2010;19:2075\u201394. The author has no con\u00b0ict of interest. 8. Roelofs J, Sluiter JK, Frings-Dresen MH, Goossens M, Thibault P, Boersma K, Vlaeyen JW. Fear of Funding\/Support movement and (re) injury in chronic musculoskel- etal pain: Evidence for an invariant two-factor Funding for the scienti\u00afc paper was self-sponsored model of the Tampa Scale for Kinesiophobia across by the authors. pain diagnoses and Dutch, Swedish, and Canadian samples. Pain 2007;131(1\u20132):181\u201390. 9. Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-speci\u00afc low back pain contingent upon a corresponding improvement in the targeted aspect (s) of performance? A systematic review. Eur Spine J 2012;21:575\u201398. 10. Luomajoki H. Movement control impairment as a sub-group of non-speci\u00afc low back pain: Evaluation","Hong Kong Physiother. J. 2023.43:53-60. Downloaded from worldscientific.com 60 A. Alarab, R. A. Shameh & M. S. Ahmad 13. Hayden J, Van Tulder MW, Malmivaara A, Koes by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. BW. Exercise therapy for treatment of non-speci\u00afc of movement control test battery as a practical tool low back pain. Cochrane Database Syst Rev 2005 in the diagnosis of movement control impairment (3):CD000335. and treatment of this dysfunction (Doctoral disser- tation, It\u00e4-Suomen yliopisto). 14. Leemans L, Elma \u00d6, Nijs J, Wideman TH, Si\u00aeain 11. Lin CW, Haas M, Maher CG, Machado LA, Van C, den Bandt H, Van Laere S, Beckw\u0013ee D. Trans- Tulder MW. Cost-e\u00aeectiveness of general practice cutaneous electrical nerve stimulation and heat to care for low back pain: A systematic review. Eur reduce pain in a chronic low back pain population: Spine J 2011;20:1012\u201323. A randomized controlled clinical trial. Braz J Phys 12. Piligian G, Herbert R, Hearns M, Dropkin J, Ther 2021;25(1):86\u201396. Landsbergis P, Cherniack M. Evaluation and management of chronic work-related musculoskel- 15. Park J, Lee JC. E\u00aeects of complex rehabilitation etal disorders of the distal upper extremity. Am J training on low back strength in chronic low back Ind Med 2000;37(1):75\u201393. pain. J Phys Ther Sci 2016;28(11):3099\u2013104.","Research Paper Hong Kong Physiotherapy Journal Vol. 43, No. 1 (2023) 61\u201371 DOI: 10.1142\/S1013702523500087 Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com Hong Kong Physiotherapy Journal by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. https:\/\/www.worldscienti\ufb01c.com\/worldscinet\/hkpj Gross myofascial release of trunk with leg pull technique on low back pain with radiculopathy \u2014 A randomised controlled trial Abey P. Rajan* and Peeyoosha Gurudut\u2020 Department of Orthopaedic Physiotherapy KLE Institute of Physiotherapy Belagavi 590010, Karnataka State, India *[email protected] \[email protected] Received 2 November 2020; Accepted 21 February 2023; Published 31 March 2023 Background: Lower Back Pain (LBP) with radiculopathy is a potentially more serious form of mechanical low back pain. A paucity of literature exists about the e\u00aeect of the gross myofascial release (MFR) technique on the management of LBP. Objective: The study aimed to evaluate the e\u00aeect of gross MFR when given as an adjunct to conventional physical therapy in subjects with low back pain with radiculopathy. Methods: Forty subjects (n \u00bc 40) clinically diagnosed with LBP with radiculopathy were enrolled and randomly allocated to either the control group (n \u00bc 20) or the experimental group (n \u00bc 20). Both study groups received 5 sessions of intervention. The control group received conventional physical therapy while the experimental group received gross MFR of the trunk and lower limb along with conventional physical therapy. The outcome measures included were pressure pain threshold for the lower back and lower ex- tremity, lumbar \u00b0exion and extension range of motion (ROM), percentage disability, and patient satisfaction towards the treatment which were measured pre-intervention (day 1) and post-treatment (day 5). The interaction between group and time was analysed using two-way mixed ANOVA. Results: The results suggested that the experimental group was statistically signi\u00afcant over the control group in terms of pressure pain threshold in the lower back (p < 0:001) and lower limb (p \u00bc 0:003), disability \u2020Corresponding author. Copyright@2023, Hong Kong Physiotherapy Association. This is an Open Access article published by World Scienti\u00afc Publishing Company. It is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY- NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly cited, the use is non-commercial and no modi\u00afcations or adaptations are made. 61","62 A. P. Rajan & P. Gurudut (p < 0:001), and patient satisfaction (p \u00bc 0:034) and lumbar \u00b0exion (p \u00bc 0:002) except lumbar extension ROM (p \u00bc 0:973). Conclusion: When given as an adjuvant to conventional physical therapy, gross myofascial release proved to provide a signi\u00afcant and faster short-term improvement over conventional treatment alone in subjects di- agnosed with low back pain with radiculopathy. Keywords: Soft tissue; manual therapy; myofascia; lumbar spine; radiculopathy; trigger points. Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com Introduction muscles and organs.11\u201313 The hyperirritable by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. (hypersensitive) spots in a taut band of skeletal Low back pain (LBP) has been considered one of muscle \u00afbers are de\u00afned as myofascial trigger the important causes of disability in the general points.8,14 Patients with trigger points in the population.1 It is a complex multifactorial condi- hamstring muscle mimic symptoms of sciatica\/or tion a\u00aeecting most people at some point in their pseudo sciatica\/extraspinal sciatica because pain life. The condition has been identi\u00afed as the lead- extends down the posterior thigh within the dis- ing contributor to years of life lived with disability tribution of the sciatic nerve. Among patients with in the world. Estimates of the 1-year prevalence LBP, tightness of the hamstring muscles in one or range from 0.8% to 82.5%.2 The occurrence of LBP both lower limbs is common.1,10 in India is also alarming with nearly 60% of the people in India having su\u00aeered from LBP at some The clinical practice guidelines by American time during their lifespan.3 Physical Therapy Association recommend a com- bination of manual therapy, trunk exercises in- LBP may sometimes be associated with com- cluding endurance, coordination and strengthening plaints of radiating or referred pain. The radiating exercises, traction, and nerve mobilisation. Studies pain in either or both the lower extremities follows support the application of electrotherapeutic mo- a speci\u00afc dermatome or myotome with a rough dalities to manage pain for the treatment of LBP estimate of the prevalence being 3% to 5% com- with radiculopathy or referred pain.15\u201317 monly caused by lumbar disc herniation, piriformis syndrome, myofascial pain, spondylolisthesis, facet Myofascial release (MFR) therapy is a hands-on joint pathology, etc.4\u20137 The LBP that is associated technique, meaning that the therapist applies with referred pain is de\u00afned as pain that spreads to pressure with the hand onto, and into the client's the surrounding area not following a particular body.11,16 MFR can be given in two forms, Direct dermatome or myotome pattern on palpation that release and Indirect release. The Direct release usually is the pain arising from either the viscera or method uses force or weight, with practitioners myofascial \u00afbrous bands that are formed within using tools, knuckles, or elbows to slowly stretch the muscles due to pathological conditions. These the fascia, hoping to bring about elongation and painful bands are referred to as myofascial trigger mobility. The indirect release is a gentler method points (MTrP) that develop as a result of neuro- where the practitioner applies less pressure, en- muscular and musculoskeletal issues including couraging the fascia to slowly \\\\unwind\\\" itself until chronic repetitive strain injuries, postural pro- greater movement is achieved.11,18,19 The gross blems, systemic disease, or strain, sprain, degen- MFR for trunk (abdomen and lower back) and erative joint conditions, disc lesions, etc. These lower quarter Leg Pull are gross MFR techniques, MTrPs can often be identi\u00afed in the muscular which are used to release the myofascia of the an- fascia of the trunk and lower limb muscle on pal- terior abdominal wall, lower back, and lower pation which causes a referred pain or pseudo- limbs.13 radiculopathy.8\u201310 Fascia has been described as a body-wide tensional network, which consists of all Studies have been done on the e\u00aeect of gross \u00afbrous, collagenous, and soft connective tissues, myofascial release on mechanical neck pain, cervi- whose \u00afbrous architecture is dominantly shaped by cal radiculopathy, and non-speci\u00afc low back tensional strain rather than compression. This pain.10,20,21 There is a paucity of literature re- continuous network envelops and connects all garding gross myofascial release techniques in re- ducing lower back pain with lower limb radiculopathy. Hence, the need arises to identify","Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com the e\u00aeect of the gross myofascial release technique Myofascial release on lumbar pain and radiculopathy 63 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. in subjects with low back pain with radiculopathy on the trigger point, lumbar range of motion Karnataka, India between March 2017 and (ROM), and function. February 2018. Materials and Methods A total of 73 subjects with low back pain were assessed for eligibility to participate in the study. Study Subjects: Forty subjects who met the inclusion criteria were The study was a single-blinded randomised con- randomly assigned with concealed allocation to one trolled trial where the assessor who took outcome of the groups: the Control group (n \u00bc 20) and the measurement was blinded from the group alloca- Experimental group (n \u00bc 20). The subjects ran- tion of the study subjects. The study was con- domly chose one of the two labelled and sealed ducted at a tertiary care center in Belagavi city, envelopes to determine their group allocation (Fig. 1). The sample size was calculated using the formula n \u00bc 2\u00f0z\u000b \u00fe z\f\u00de2=d2, where z\u000b is the Z value for \u000b error that is 1.96, z\f is 0.84 with a Fig. 1. CONSORT \u00b0ow diagram.","Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com 64 A. P. Rajan & P. Gurudut maximum pain tolerated by the patient. If in the by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. case of multiple Trps, the most painful Trp was power of 80% and d is the mean di\u00aeerence of 4 on taken for the outcome measurement. The pain pain reduction score using the visual analog scale pressure measurements were expressed in pounds (VAS) taken from the reference article.20 To be (lbs). The readings were recorded pre-and post- included in the study the subject needed to ful\u00afll intervention. The interrater ICC value for the two or more of the following inclusion criteria: (1) measurements with pressure algometer was excel- Subjects with low back pain associated with radi- lent at 0.91 for assessing pressure pain.22,23 culopathy to unilateral lower limb between the age group of 20\u201360 years (2) Subjects with active\/la- Lumbar \u00b0exion and extension active ROMs tent trigger point with grade 2 and above tender- were assessed using a modi\u00afed Schober's test. For ness in any one of the Para-spinal areas: lumbar \u00b0exion ROM, subjects were standing with Thoracolumbar Fascia, Quadratus Lumborum, an erect posture and two landmarks marked on the and Piriformis (3) Subjects with active\/latent skin, which includes the point bisecting a line trigger point with grade 2 and above tenderness in connecting the two posterior superior iliac spines any one of the Lower limb area: Hamstring muscle, (PSIS) (baseline). A point was marked 15 cm Calf muscle and Gluteus with grade 2 and above. superior to the baseline landmark and the subjects The study excluded subjects (1) If the individuals were then asked to perform \u00b0exion movement as self-reported contraindications\/precautions to much as possible. The range of movement of the MFR: unstable medical conditions (blood pressure lumbar spine was measured using a measuring tape \u00b0uctuations\/blood sugar abnormalities; dermatitis; from the superior landmark to the mid-point of the contagious or infectious disease; mentally unstable; baseline in units of centimeters.24 inability to provide informed consent; the in\u00b0uence of drugs\/alcohol; recent fractures\/surgeries; For measuring lumbar extension ROM, the wounds\/ulcers; pregnancy13 (2) individuals with same landmarks were used. The range of move- unhealed open wounds at the treatment area ment measured was from the superior landmark to assessed on basis of observatory \u00afnding (3) Cauda the mid-point of the baseline landmark by asking equina syndrome or myelopathy as assessed by the the patient to perform lumbar extension move- researcher on the basis of signs and symptom ment. Modi\u00afed\u2013modi\u00afed Schober's method has screening (4) Any self-reported systemic diseases moderate validity (r \u00bc 0:67), and excellent reli- (5) history of lower limb trauma\/spinal trauma\/ ability (intra: ICC \u00bc 0:95; inter: ICC \u00bc 0:91) to fractures (6) Diagnosed cases of peripheral vascular assess lumbar sagittal ROM.24 disease as reported by the assessing\/referring doc- tor. Ethical clearance was obtained from the In- Oswestry Disability Index (ODI) consists of 10 stitutional Ethical Committee (KIPT\/129\/ items to assess the subject's pain, and functional 29.05.17). Written informed consent was obtained a\u00aeection so as to quantify the patient's level of before the enrolment and the purpose of the study disability that occurred due to low back pain. was explained to all the subjects. The present trial Under each of these items, there are six response is registered in the Clinical Trial Registry of India options with each response scored from 0 to 5, with (CTRI\/2018\/05\/013852) dated 14\/05\/2018. higher values interpreted as a greater disability giving a maximum score of 50. The total score is Procedures multiplied by 2 and expressed as a percentage. Pressure pain threshold (PPT) was the outcome Scores are categorised as per the percentage of used to assess the trigger point (Trp) pain of the disability calculated as 0\u201320 as a minimal disabil- low back and the lower limb muscles. For low back ity; 21\u201340 as a moderate disability; 41\u201360 as a se- muscles assessment, the subject was asked to ex- vere disability; 61\u201380 as crippling back pain; 81\u2013 pose the low back region and lie down in a prone 100 bed-bound disability. ODI has the reliability of position. The examiner palpated and marked the ICC \u00bc 0:90.25,26 trigger point in the lower back and lower extremity musculature following which the probe of a pres- Global Perceived E\u00aeect Questionnaire (GPEQ) sure algometer instrument (Baseliner Dolorimeter was used to assess patient satisfaction with the with Circular Probe) was placed perpendicularly treatment received for the particular condition. to the point identi\u00afed. Force is applied to the The GPE scale asks the patient to rate, on a nu- Trp through the pressure algometer up to the merical scale, how much their condition has im- proved or deteriorated since some prede\u00afned time point. The subject was asked the following","Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com question \\\\compare your current complaints with 1 Myofascial release on lumbar pain and radiculopathy 65 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. month ago?\\\" GPE demonstrated an intraclass correlation coe\u00b1cient value of 0.90\u20130.99 that the patient's foot until resistance was felt. The points to excellent reproducibility of the GPE position was held until release was felt and an in- scale.27 creased angle of dorsi\u00b0exion was achieved. The technique was stopped with the patient's foot in The subjects who were allocated to the control neutral or 90\u0014 positions, and the traction was in- group received conventional physical therapy, creased until the therapist felt resistance and the which included two-channel Transcutaneous Elec- end feel was reached. From here if the subject's trical Nerve Stimulation (TENS) applied in a se- knee permitted, the therapist maintained traction quential form for 20 min with frequencies ranging and slowly worked to increase the movements of from 80\u2013120 Hz with the electrodes placed at the hip in di\u00aeerent planes until release was noted. maximum painful points in the back and lower The movement sequence of the hip was neutral \u2014 limbs to treat the radicular pain, thermotherapy in \u00b0exion \u2014 hip abduction \u2014 external rotation of the form of Hot Moist Pack (HMP) placed on the knee \u2014 internal rotation of knee \u2014 external ro- lower back for 15 min for relieving paraspinal tation of hip \u2014 internal rotation of hip with the spasm. The static lower back exercise was taught knee in extension. The angle of motion was de- for which the subject was in a crook lying position creased at the point where the restriction was felt with a towel placed between the lower back and and the position was maintained until release oc- the plinth. The subject was asked to press the curred. Throughout the procedure, the therapist lower back against the towel. In addition, core waited at the point of restriction until the release strengthening exercises which included side bridg- was felt and then applied the stretch again, re- ing, bird dog exercise, and semi-squatting were also peating the sequence until the end feel is reached to be performed. Each strengthening exercise was (Fig. 2).13 given for 3 sets with 5 repetitions in each set with each exercise position to be held for 10 s with 5 s of The procedure for the fascial unwinding tech- rest time. The total duration of treatment session nique started \u00afrst with the myofascial release of lasted approximately 45 min. the right-side Psoas muscle as well as Iliacus muscle and then proceeded with the release of the Subjects enrolled in the experimental group re- left Psoas and Iliacus muscle (Fig. 3(a)). For re- ceived gross myofascial release of the trunk and leasing the Psoas muscle and the lumbar spine, the lower limb along with conventional physical ther- subject was side lying position with their knee apy (as explained above) with 45 min of conven- \u00b0exed. The position of the therapist was at the side tional followed by 15 min of MFR for each subject. of the treatment plinth facing the back of the The muscles targeted in this procedure were dor- subject. The caudal hand supported the subject's si\u00b0exion of the foot, hip \u00b0exors, extensors, abduc- thigh with a \u00b0exed knee and the cranial hand tors, adductors, internal rotators and external contacted the lumbar region. By using the subject's rotators. The position of the subject and the thigh as a lever and the cranial hand as a fulcrum, therapist changed according to the muscle myofascial unwinding was performed.10 targeted.11 For the release of the Iliacus muscle, the position The procedure began with the patient supine, of the subject was supine lying at the end of the leg adducted to neutral, the patella and foot plinth with both the lower extremities out of the pointed up and the entire leg in neutral rotation, plinth (Fig. 3(b)). The position of the therapist was and stretch was applied using traction equal to the at the contralateral side of the target muscle, that weight of the patient's leg. The heel of the foot was is if the therapist was releasing the right-side Ilia- cupped with the therapist's dominant hand and cus muscle, then the position of the therapist was the forefoot was held with the other hand. The on the left side of the subject. A cross-handed hold therapist's thumb rested on the bottom of the was applied along with the psoas until the release patient's foot proximal to the metatarsal head. was felt, with the cranial hand below the inferior Using the body weight, the therapist leaned back costal margin and the caudal hand above the until the elbows were fully extended till the weight inguinal region.10 of the subject's leg was counterbalanced ensuring no contact of the patient's leg with the treatment Statistical analysis table. Then slowly the therapist began to dorsi\u00b0ex The statistical analysis was done using SPSS version 22 (SPSS Inc., Chicago, IL). The normality","66 A. P. Rajan & P. Gurudut Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com Fig. 2. Lower quarter leg pull technique (a) Starting position (b) Flexion, (c) Hip abduction, (d) External rotation of knee (e) by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. Internal rotation of knee, (f) External rotation of hip (g) Internal rotation of hip. (a) (b) Fig. 3. (a) Fascial unwinding hold, (b) MFR hold. of data was evaluated by skewness and Kurtosis Z for pre- and post-intervention values using paired values and the Shapiro\u2013Wilk test, which indicated samples t-test after checking for normal distribu- the data, follows a normal distribution with 95% of tion within each group. In addition, the e\u00aeect of con\u00afdence. In addition, the homogeneity of var- the intervention between the experimental and the iances and covariance matrices was assessed by control group was compared by analysing the in- Levene's test for equality of variance and BOX's teraction between group and time on the outcome test, respectively. Intention-to-treat analysis was variables (ODI, PPT in low back and lower limb, applied, and all 20 participants were included for lumbar \u00b0exion and extension ROM) using a two- data analysis since the 2 dropouts in the experi- way mixed method Analysis of Variance mental group had completed 3 to 4 out of 5 sessions (ANOVA)\/split-plot ANOVA was used. Proba- of intervention (> 50% of sessions). All the quan- bility-values less than 0.05 were considered statis- titative variables were compared within the group tically signi\u00afcant.","Myofascial release on lumbar pain and radiculopathy 67 Table 1. Comparison of baseline demographic parameters between two groups (N \u00bc 40). Study group Control (N \u00bc 20) Experimental (N \u00bc 20) Demographic Mean \u00c6 SD Mean \u00c6 SD Chi-square p-value 0.935 Age (Years)a 39:65 \u00c6 10:41 39:95 \u00c6 12:58 \u2014 Gender b 0.197 Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com 10 (50%) 14 (70%) 1.667 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. Male 0.087 Female 10 (50%) 6 (30%) \u2014 0.274 Height (CM)a 164 \u00c6 7:93 167:95 \u00c6 6:19 \u2014 0.769 Weight (Kg)a 62:34 \u00c6 10:2 66:33 \u00c6 12:42 \u2014 BMI (Kg\/m2)a 23:85 \u00c6 4:27 23:47 \u00c6 3:85 0.744 A\u00aeected sideb 0.107 Right side 12 (60%) 13 (65%) Left side 8 (40%) 7 (35%) Notes: *Statistical signi\u00afcance (p-value < 0:05); a \u2014 Student's \\\\t\\\\ test; b \u2014 Chi square test. Results The GPEQ mean score for the control group was 2:2 \u00c6 1:24 and for the experimental group was Table 1 shows the comparison of baseline demo- 2:95 \u00c6 0:89. GPEQ values showed a statistically graphic characteristics between the two study signi\u00afcant di\u00aeerence (p \u00bc 0:034). In comparison groups. There was no statistically signi\u00afcant dif- between groups, the experimental group displayed ference observed between the groups in the demo- to be more bene\u00afcial than the control group. graphic characteristics. The analysis between the study group and time Within the group analysis comparing pre- to post- showed signi\u00afcant interaction for ODI (p < 0:001), intervention, values show statistically signi\u00afcant PPT for the lower back (< 0:001), PPT of the changes (p < 0:05) for all the outcome parameters lower limb (p \u00bc 0:003), and lumbar \u00b0exion ROM for both intervention groups. The level of signi\u00af- (p \u00bc 0:002). However, the lumbar extension ROM cance was p < 0:001 for the experimental group failed to show signi\u00afcant interaction (p \u00bc 0:973) using ODI, PPT (lower back and lower limb), and (Table 3). lumbar ROM (\u00b0exion and extension). The p-value for the control group also showed signi\u00afcance for These results suggest that, with time under ODI (p < 0:001), PPT for lower back (p \u00bc 0:027), consideration, 5 sessions (short term) of gross PPT for lower limb (p \u00bc 0:02), and lumbar \u00b0exion and extension ROM (p < 0:001) (Table 2). myofascial release technique when administered in adjunct to conventional physical therapy inter- vention demonstrated a signi\u00afcant e\u00aeect in the Table 2. Within the group comparison of outcome measures of two group (N \u00bc 40).# Outcome measures Group Before intervention After intervention P -value Mean \u00c6 SD Mean \u00c6 SD MODQ (In %) Control 54:30 \u00c6 8:81 40:95 \u00c6 11:55 < 0:001* Pain in the low back (In lbs) Experimental 56:55 \u00c6 14:36 26:25 \u00c6 10:46 < 0:001* Pain in the lower limb (In lbs) 9:90 \u00c6 4:90 11:25 \u00c6 5:25 Lumbar Flexion ROM (In CM) Control 6:60 \u00c6 3:66 10:75 \u00c6 4:48 0.027* Lumbar Extension ROM (In CM) Experimental 9:20 \u00c6 5:09 11:10 \u00c6 4:92 < 0:001* 5:60 \u00c6 3:27 9:74 \u00c6 3:61 Control 6:27 \u00c6 1:59 6:78 \u00c6 1:46 0.002* Experimental 5:78 \u00c6 2:03 7:23 \u00c6 1:79 < 0:001* 1:97 \u00c6 0:58 2:55 \u00c6 0:59 < 0:001* Control 2:01 \u00c6 0:66 2:58 \u00c6 0:77 < 0:001* Experimental < 0:001* < 0:001* Control Experimental Notes: *Statistical signi\u00afcance (p-value < 0:05); MODQ \u2014 Modi\u00afed Oswestry Disability Questionnaire; #paired t test.","68 A. P. Rajan & P. Gurudut Table 3. Interaction between group and time analysis.# Outcome parameter Interaction Partial eta squared F Statistic P -value Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com MODQ (In %) Time 0.765 123.369 < 0:001* by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. PPT in the low back (In lbs) Time \u00c3 Study Group 0.329 18.603 < 0:001* PPT in the lower limb (In lbs) 0.613 60.152 < 0:001* Lumbar \u00b0exion ROM (In CM) Time 0.291 15.590 < 0:001* Lumbar extension ROM (In CM) Time \u00c3 Study Group 0.663 74.674 < 0:001* 0.213 10.270 Time 0.570 50.312 0.003* Time \u00c3 Study Group 0.230 11.327 < 0:001* 0.618 61.563 Time 0.000 0.001 0.002* Time \u00c3 Study Group < 0:001* Time 0.973 Time \u00c3 Study Group Notes: *Statistical signi\u00afcance (p-value < 0:05); #Two-way mixed model ANOVA. short term as compared to conventional physical of motion could be secondary to the overall re- therapy alone for the management of low back pain duction in pain levels.29,30 Myofascial release has with radiculopathy. previously proven bene\u00afcial in improving soft tis- sue extensibility by reducing fascial adhesions and Discussion improving the local \u00b0uid dynamics.31,32 The results of this study support the alternative The sacral fascia is considered to be the struc- hypothesis, which stated that gross myofascial re- tural centre of the super\u00afcial back line (SBL) lease of trunk musculature and lower quarter leg which extends from the plantar surface to the ridge pull technique in addition to conventional physio- just above the eyebrows. A cadaveric study con- therapy will demonstrate a change in the pain, ducted to analyse force transmission across the mobility, and function of the lower back and lower lumbar fascia suggested that segmental motion can extremities indicating signi\u00afcant short-term be in\u00b0uenced due to the low-level transmissions bene\u00afts. occurring in the middle and posterior lumbar fas- cia.33 Fascial movements can be altered by the In this study, the pain pressure threshold was amount of force transmitted across the fascia. Since evaluated on the trigger points present in the lower the lumbar fascia is a part of the super\u00afcial back- back and the lower limbs. The post-intervention line, alterations in the movements of the lumbar values in both groups suggested that the pain fascia may in\u00b0uence the mobility of this entire sensitivity was reduced signi\u00afcantly in the experi- fascial meridian since the lumbosacral fascia com- mental group. A meta-analysis on the e\u00aeect of prises a part of the structural centre of this fascial massage therapy suggested that the reason for the network.33,34 Literature on the pathophysiological reduction of pain could be due to the mechanical model for chronic low back pain integrating con- stimulus in the form of pressure, applied through nective tissue and nervous system mechanisms manual soft tissue manipulation. Myofascial re- states that the application of myofascial release lease is one of the manual soft tissue manipulation produces a direct stretch on the contractile as well techniques which have similar physiological e\u00aeects as non-contractile structures at the target site, on the body. The impulse of mechanical stimulus, which have an impact on this study.35 which is known to travel faster as compared to the sensation of pain, may have blocked nociception at The analysis of ODI values indicated a signi\u00af- the level of the spinal cord.28 cant reduction of functional disability in the par- ticipants of both study groups. However, the MFR In this study on comparison between group group showed better results than the conventional analyses, MFR was found better than conventional group. Previous literature about low back pain physical therapy for lumbar \u00b0exion ROM. How- stated that there is a high correlation between pain ever, lumbar extension ROM was equally better in levels and functional disability. Precisely, the both study groups. The improvement in the range higher the pain levels, the higher the disability, and vice versa.21,29 The reason attributing to this","Hong Kong Physiother. J. 2023.43:61-71. Downloaded from worldscientific.com correlation could be the restriction of activities Myofascial release on lumbar pain and radiculopathy 69 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. because of pain. This may further lead to a re- duction in the available range of motion, thus Conclusion causing detrimental e\u00aeects on daily task perfor- mance. Thus, pain reduction may have improved In conclusion, the study provides preliminary evi- daily task performance, which may have further dence for the short-term e\u00aeects of gross myofascial reduced the individual's activity limitation. release along with the leg pull technique to be ef- fective for low back pain with radiculopathy. A statistically signi\u00afcant di\u00aeerence was ob- Hence, this technique can be included by manual served on the analysis of GPEQ, which indicates therapy\/physical therapy professionals as a prom- that the individuals who received experimental ising technique in the management of back-pain group intervention were more satis\u00afed as com- patients. pared to those who received the conventional in- tervention. A reason for patient satisfaction could Acknowledgements be a reduction in pain levels and an improvement in the overall functional status of the individual Authors sincerely acknowledge the \\\\Beyond P post-intervention. Another reason for an increased value\\\", Sai Ashra Enclave, Harlur, Bangalore- GPEQ score in the experimental group could be 560102, Karnataka, India for their assistance in due to the additional tactile stimulation produced performing statistical analysis of the data. by the myofascial release in the experimental group which may have increased the serotonin Con\u00b0ict of Interests levels in the body thereby producing a sense of well-being.36 The authors declare that they have no competing interests. This study had a few limitations. The treatment durations for both study groups varied due to the Funding\/Support study design being a controlled trial. A lack of follow-up to analyse the long-term e\u00aeect of the The authors did not receive any form of funding or intervention was due to time constraints and owing support for the study. to higher rates of dropouts. The strength of the back muscles was not assessed since only 5 sessions Author Contributions of treatment were given and to have any positive strength gains a minimum of 3 weeks of treatment AR was a principal investigator in collecting and is required. The calculation of sample size in this analysing the data along with performing the in- study was on the basis of a gross MFR technique tervention. PG majorly contributed to the con- applied on the neck and not on the lower back since ception and design, interpretation of data, the studies lacking in the literature. manuscript writing, and editing. Both AR and PG agree to be accountable for all aspects of the work In the future, the isolated e\u00aeect of gross myo- in ensuring that questions related to the accuracy fascial release can be assessed by comparing the or integrity of any part of the work are appropri- MFR technique against sham MFR application or ately investigated and resolved. Both authors read with other manual therapy techniques like neural and approved the \u00afnal manuscript. mobilisation, dry needling, Mulligan's mobilisa- tion, etc. in individuals with low back pain asso- References ciated with radiculopathy. The e\u00aeect of the intervention can be evaluated on the properties of 1. Kao MJ, Kuan TS, Hsieh YL, Yang JF, Hong CZ. the muscle and myofascial trigger points using Myofascial low back pain. Tw J Phys Med Rehabil more sophisticated tools like diagnostic ultraso- 2008;36:1\u201314. nography or biochemical analysis of trigger points (neuropeptides and in\u00b0ammatory mediators). It is 2. Hoy D, Brooks P, Blyth F, Buchbinder R. The also recommended to consider the application of epidemiology of low back pain. 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A meta-anal- Myofascial release on lumbar pain and radiculopathy 71 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. ysis of massage therapy research. Psychol Bull 2004;130(1):3\u201318, doi: 10.1037\/0033-2909.130.1.3. 33. Barker PJ, Briggs CA, Bogeski G. Tensile trans- mission across the lumbar fasciae in unembalmed 29. Oumeish OY. The philosophical, cultural, and cadavers: E\u00aeects of tension to various muscular historical aspects of complementary, alternative, attachments. Spine (Phila Pa 1976). 2004;29(2): unconventional, and integrative medicine in the 129\u201338, doi: 10.1097\/01.BRS.0000107005. Old World. Arch Dermatol 1998;134(11):1373\u201386. 62513.32. 30. Hernandez-Reif M, Field T, Krasnegor J, Theak- 34. Wilke J, Krause F, Vogt L, Banzer W. What is ston H. Lower back pain is reduced and range of evidence-based about myofascial chains: A sys- motion increased after massage therapy. 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Clin 2014.06.001. Rehabil 2018;32(4):440\u201350, doi: 10.1177\/ 0269215517732820.","Research Paper Hong Kong Physiotherapy Journal Vol. 43, No. 1 (2023) 73\u201380 DOI: 10.1142\/S1013702523500117 Hong Kong Physiother. J. 2023.43:73-80. Downloaded from worldscientific.com Hong Kong Physiotherapy Journal by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. https:\/\/www.worldscienti\ufb01c.com\/worldscinet\/hkpj E\u00aeect of myofascial cupping vs integrated neuromuscular inhibition techniques on pain and neck movement in individuals with latent trigger point in trapezius Preeti Gazbare1,*, Manisha Rathi1 and Dhanashree Channe1 1Dr. D.Y. Patil College of Physiotherapy, Dr. D.Y. Patil Vidyapeeth, Pune, India *[email protected]; [email protected] Received 22 September 2021; Accepted 12 March 2023; Published 4 May 2023 Background: Pain is the most common symptom for seeking therapeutic alternative to conventional medicine. Trigger points (TrP) being the most debilitating cause of nonspeci\u00afc neck pain, are found to be more prevalent in trapezius muscle. Various instrument-based and other manual therapy techniques are e\u00aeective in the treatment of TrP. Objective: To compare the e\u00aeect of Myofascial Cupping (MFC) and Integrated Neuromuscular Inhibition Tech- nique (INIT) on the upper trapezius latent TrP on pain intensity, pressure pain threshold (PPT) & cervical range. Method: A randomized trial controlled on 40 individuals aged 20\u201340 years, both gender with latent TrPs in upper trapezius excluding ones who have taken treatment for upper trapezius TrPs within 6 months. Participants were randomly allocated into 2 groups by chit method, one group received MFC and other INIT. Pre- and post-intervention assessment was done using NPRS, pressure algometer and goniometer. Result: Within group, pain has signi\u00afcantly reduced after MFC and INIT with mean di\u00aeerence of 6:05 \u00c6 0:8 and 4:95 \u00c6 0:7, respectively (p < 0:001). PPT increased in both groups (p < 0:001) with mean di\u00aeerence of 0:63 \u00c6 0:3 and 0:28 \u00c6 0:11, respectively. Comparison between the groups showed signi\u00afcant di\u00aeerence in pain intensity (p \u00bc 0:003) suggesting MFC was more e\u00aeective in reducing pain. However, a PPT (p=0.606) and neck lateral \u00b0exion to the contralateral side of TrP (p \u00bc 0:74) were not signi\u00afcant. Conclusion: MFC was more e\u00aeective than INITs in improving pain, however both interventions showed similar e\u00aeect on PPT and neck lateral \u00b0exion on latent TrP in trapezius. Keywords: Integrated neuromuscular inhibition; latent trigger point; myofascial cupping therapy; pressure pain threshold. *Corresponding author. Copyright@2023, Hong Kong Physiotherapy Association. This is an Open Access article published by World Scienti\u00afc Publishing Company. It is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY- NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly cited, the use is non-commercial and no modi\u00afcations or adaptations are made. 73","Hong Kong Physiother. J. 2023.43:73-80. Downloaded from worldscientific.com 74 P. Gazbare, M. Rathi & D. Channe technique lies in its multifaceted approach allowing by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. delivery of the techniques in a single coordinated Introduction manner.14 Pain is the most common symptom for seeking With day-to-day activities and lifestyle, people therapeutic alternative to conventional medicine.1 are prone for TrPs which are frequently seen in Pain is de\u00afned as an unpleasant sensory sensation trapezius muscle, as it is an anti-gravity muscle caused by injury or illness.2 Nonspeci\u00afc neck pain holding the head in upright position, leads to in- is typically caused by mechanical or myofascial e\u00b1cient posture and emotional stress adding on to disorders.3,4 Trigger point (TrP) is one of the most activate TrP.3 The psychological side e\u00aeects of widespread long-lasting muscle disorders a\u00aeecting living with chronic pain can be debilitating as pain all ages and social groups, regardless of occupation, itself. Thus, by reducing the pain, a person can physical build, or physical activity levels. A TrP is focus on his work more clearly. Literature suggests associated with a tender spot situated in a taut the need to explore myofascial cupping (MFC) on band of muscle. When this spot is manipulated, autonomous nervous system a\u00aeecting the pain impulsive or exertion pain may be experienced.3,5 sensitivity. However, these methods have not been TrP is classi\u00afed as latent or active. However, both critically evaluated or compared. Therefore, we types have the potential to create pain, limit ROM hypothesised that MFC therapy will show better and restrict functional activities3,6 therefore clini- e\u00aeect than INIT on pain, pressure pain threshold cally it is important to identify it and should be (PPT), and neck movement in individuals with addressed as part of a comprehensive physical latent TrP in trapezius. Thus, the study aimed to therapy program.7 evaluate the e\u00aeect of MFC therapy and INIT on these parameters. Several studies have attempted to examine TrP complications, which have resulted in the devel- Method opment of various treatments.7 Currently, instru- ment-based, and non-instrument-based manual An experimental study was carried in a tertiary therapy interventions exist for the deactivation of private hospital in Pune, India after an Institu- TrPs. Dry needling,8 cupping,9 ischemic compres- tional Ethical Committee approval, on 40 partici- sion,10 muscle energy techniques, Myofascial re- pants. The sample size was determined using lease, strain\u2013counterstrain are the most common Primer (version 7) statistical software, nineteen conventional treatment approaches for treating participants in each group was calculated based on TrP.11,12 a previous study3 with alpha \u00bc 0:05, power 80%, attrition was 10%, mean di\u00aeerence of 1.15 and Cupping therapy (CT), a traditional Chinese expected SD at 1.2. Therefore, total sample size medicine therapy, has been used for > 2000 years taken was 40. and uses a negative pressure mechanism on stimulating the acupuncture points. CT is an ef- Participants aged 20\u201340 years, males and fective way to manipulate soft tissues.3 The ra- females, with neck pain more than 3 months, tionale for use of cupping is not yet fully having latent TrPs in upper trapezius were in- understood; it is said that it works on various cluded. And participants excluded were one with: theories like re\u00b0ex zone theory, pain gate theory, increased blood circulation theory, Nitric oxide (a) Any other musculoskeletal problem at or theory and Genetic theory. It is described as a around cervical region like fracture, sprain. detoxi\u00afcation process by which waste matter and toxins are removed, and as a harmonization pro- (b) Systemic disorder, infection, progressive cess for the imbalanced vital energy.13 Today, disorder. cupping is widely used as a holistic treatment in foreign for inpatient care and the prevention and (c) Neurological condition like Parkinson's disease. treatment of various disorders, as well as for (d) Any psychological disorder where person might promotion of general health. not cooperate for the treatment. Chaitow suggested combination of Muscle en- (e) One who has taken treatment for TrPs within 6 ergy technique (MET), ischemic compression and Strain Counter-strain (SCS) producing a most ef- months. fective, targeted approach to TrP release. This method is termed as integrated neuromuscular Written informed consent was obtained from each inhibition technique (INIT). The bene\u00aft of the participant at the time of enrolment in the study. Participants were examined for TrP in upper","Hong Kong Physiother. J. 2023.43:73-80. Downloaded from worldscientific.com trapezius muscle with following diagnostic E\u00aeect of MFC vs INITs on pain and neck movement 75 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. criteria15,16: Materials Required: Three plastic cups with size (1) Taut band within the muscle. of anchoring cup of 2.5 cm in diameter i.e. size 2, (2) Exquisite tenderness at a point on the taut Treatment cup of 6 cm in diameter i.e. size 5 & counterbalance cup of 6 cm in diameter, One piston band. gun and a Pressure Algometer (Biotech). (3) Reproduction of the patient's pain. (4) Local twitch response. Myofascial cupping techniques13,17 (5) Referred pain. TrP in upper trapezius was identi\u00afed and marked. Baseline assessment was taken for pain intensity Then the participants were taken in prone position, using Numerical pain rating scale (NPRS), Pain lubrication was applied over the marked points and Pressure Threshold (PPT) by Pressure Algometer three cups were applied. Anchoring cup on C7 and cervical lateral \u00b0exion range of motion (Cx- spinous process area followed by treatment cup on LROM) to contralateral side of TrP by Universal marked area and the counterbalance cup was se- goniometer. Then participants were randomly al- cured on opposite side of treatment cup. Cups were located into two groups at 1:1 ratio. The respon- \u00afxed on the given area with the help of piston gun sible person for generating the randomization by creating a negative pressure (vacuum) inside assignment was independent. Group A (n \u00bc 20) the cups. 1 pump of air was removed from the cup was treated with MFC and group B (n \u00bc 20) with initially to \u00afx it on the area and after that INITs. Both the groups received isometric exercises according to the participant's feedback, more air for trapezius and retractors. Consort Flow Dia- was vacuumed with pump (Fig. 2). Participant gram is explained in Fig. 1. was asked for any discomfort during the session. Fig. 1. CONSORT \u00b0ow diagram.","Hong Kong Physiother. J. 2023.43:73-80. Downloaded from worldscientific.com 76 P. Gazbare, M. Rathi & D. Channe the VAS are the ability to be administered both by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. verbally and in writing, as well as its simplicity of Fig. 2. MFC therapy on trapezius. scoring.18 After 10 min, the cups were removed. Next session PPT: It is the minimal amount of pressure that was done after 3 days. produces pain. PPT was quantitively measured by a Wagner Algometer which is considered as a re- Integrated neuromuscular inhibition liable method in the assessment of TrPs sensitivity. technique7 It consisted of a 1 cm2 rubber tip and a dial that could display the pressure of up to 10 kg with Participants were assessed for TrPs and then in graduation with 100 g. Algometer was placed per- supine position, the participant's arm was placed pendicular on the marked TrP on the trapezius, in shoulder abduction, external rotation and head and then the pressure was applied until the pres- side \u00b0exed to the involved side with elbow \u00b0exion. sure caused a pain. The maximum pressure dis- Using the pincher grip, the therapist moves played by the Algometer was recorded. through the \u00afbres of trapezius on marked point. Ischemia compression was followed by the appli- Three measurements were obtained, and the cation of strain counter strain i.e. isometric con- mean value was calculated.19,20 traction of muscle and then MET was given. Each isometric contraction was held for 8\u201310 s and was Range of Motion (ROM): Cervical lateral \u00b0ex- followed by contralateral side bending, \u00b0exion and ion motion was measured using goniometer. Par- ipsilateral rotation to maintain the soft tissue ticipants were asked to sit upright and laterally \u00b0ex stretch for 30 s and was repeated for 5 times. their head towards opposite side of the TrP. The motion was stopped once the available ROM was The duration of treatment was 20 min per ses- completed, and care was taken to disallow shoulder sion, 3 times per week for 2 weeks. elevation. The cervical CROM device has demon- strated good to excellent inter-rater reliability Outcome measure (ICC 50.73\u20130.89).21 Pain intensity: It was assessed by Numerical Pain Single blinding was done for assessment & re- rating scale (NPRS), it's a segmented numeric cording of all the outcome measures which was version of the visual analogue scale in which a re- carried out by independent therapists. spondent selects a whole number (0\u201310 integers) that best re\u00b0ects the intensity of the pain. The 11- Statistical Analysis point numeric scale ranges from `0' representing no pain to `10' representing worst pain (Rodriguez Data was recorded and analyzed using medical et al.). NPRS is a valid and reliable scale to mea- statistics software (version 5). Quantitative data sure pain intensity. Strengths of this measure over were calculated by computing the mean and stan- dard deviation (SD). The normal distribution of the continuous variables by Shapiro-Wilk tests was determined. Using SPSS (Version 26), Repeated Measures analysis of variance-ANOVA was applied to com- pare the e\u00aeect of two intervention groups, namely MFC and INIT (independent variable) on pain, PPT and neck lateral \u00b0exion (dependent variable). Statistical signi\u00afcance level was accepted at p < 0:05. Result Sixty-two participants were screened for the study of which 17 didn't ful\u00afl the criteria and so were excluded, \u00afve participants were not ready to","Hong Kong Physiother. J. 2023.43:73-80. Downloaded from worldscientific.com participate. At the end of the study, all 40 parti- E\u00aeect of MFC vs INITs on pain and neck movement 77 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. cipants completed the study and were included in the analysis. There was no deviation in interven- For Pain tion given from the originally allotted group so Within-Subjects E\u00aeects \u00f0Pain\u00de \u00c0 F \u00f01; 38\u00de \u00bc intention to treat analysis was done. There was no such missing data in the study. 1775:29, Partial Eta Squared \u00bc 0:979, p < 0:0001 The baseline characteristics showed no signi\u00af- Pain Group \u00c0 F \u00f01; 38\u00de \u00bc 17:753, Partial Eta cant di\u00aeerence in two groups indicating randomi- Squared \u00bc 0:318, p < 0:0001 sation was carried out e\u00aeectively (Table 1). Between Group \u00c0 F \u00f01; 38\u00de \u00bc 12:37, Partial Eta Both groups individually demonstrated sig- Squared \u00bc 0:246, p < 0:0001 ni\u00afcant improvement in pain intensity on NPRS (p < 0:001), PPT score (p < 0:001), and There was a statistically signi\u00afcant di\u00aeerence cervical lateral \u00b0exion ROM (p < 0:001), after 2 seen. 97.9% of the variation (e\u00aeect size) was explained weeks (Table 2). Between-group analysis indi- by the time and 31.8% by the pain group. 24.6% by cated that there was signi\u00afcant di\u00aeerence the groups. (p < 0:05) in pain intensity, favouring MFC therapy (group A) than INIT (group B) Pain Pressure Threshold (PPT) whereas pain pressure threshold (p < 0:606) and Within-Subjects E\u00aeects \u00f0PPT\u00de \u00c0 F \u00f01;38\u00de \u00bc 165: neck lateral \u00b0exion range showed non-signi\u00afcant di\u00aeerence p \u00bc 0:74 (Table 3). 917, Partial Eta Squared \u00bc 0:814, p < 0:0001 Details of statistical analysis by repeated PPT \u00c2 Group \u00c0 F \u00f01; 38\u00de \u00bc 24:975, Partial Eta measures ANOVA are as follows: Squared \u00bc 0:397, p < 0:0001 Between Group \u00c0 F \u00f01; 38\u00de \u00bc 0:271, Partial Eta Squared \u00bc 0:007 p < 0:606 There was statistically no signi\u00afcant di\u00aeerence seen. 81.4% of e\u00aeect size was explained by time and 39.7% by PPT \u00c2 groups. 0.7% by groups. Table 1. Baseline characteristics of the participants. Group A Group B Variables Pre-Mean (SD) Pre-Mean (SD) Signi\u00afcance Male: Female 9:11 8: 12 Chi square \u00f0\u00c22\u00de \u00bc 0:102 Age in years 27.3 (6.30) 28.4 (7.48) p \u00bc 0:7491 Pain 8.1 (0.96) 8.3 (0.73) Pressure Pain tolerance 1.42 (0.34) 1.56 (0.25) U \u00bc 187:00, Z \u00bc 0:353 Neck Lateral \u00b0exion range 33.4 (3.05) 33.7 (2.73) p \u00bc 0:7242 U \u00bc 182, Z \u00bc 0:516 p \u00bc 0:60 T \u00bc 1:46 p \u00bc 0:675 T \u00bc 0:327 p \u00bc 0:1505 Table 2. Pre and post values for group A-MFC and Group B-INIT. Group A-MFC Group B- INIT Variables Mean SD 95% CI p-value Mean SD 95% CI p-value Pain Pre 8.1 0.96 7.0\u20139.0 p < 0:001* 8.3 0.73 8.0\u20139.0 p < 0:001* Post 2.05 0.68 2.0\u20132.5 3.3 0.74 3.0\u20134.0 Pressure Pain tolerance Pre 1.42 0.34 1.1\u20131.7 p < 0:001* 1.5 0.25 1.45\u20131.7 p < 0:001* Post 2.06 0.17 2.0\u20132.15 1.8 0.21 1.7\u20132.0 Neck Lateral \u00b0exion range Pre 33.4 3.05 31\u201336 p < 0:001* 33.7 2.73 31\u201335.5 p < 0:001* Post 43.8 2.41 42\u201345.0 43.0 1.94 41.5\u201345.0 Note: *Highly signi\u00afcant.","78 P. Gazbare, M. Rathi & D. Channe Table 3. Comparison of MFC and INIT for Pain, PPT and Neck lateral \u00b0exion range. Variables Groups Mean SD 95% CI P value Pain MFC \u00c06:05 0.88 \u00c06:5 to \u00c05.0 p < 0:001 Pressure Pain tolerance INIT Neck Lateral \u00b0exion range MFC \u00c04:95 0.75 \u00c05:3 to \u00c04.5 Signi\u00afcant INIT MFC 0.63 0.29 0.5 to 0.8 p < 0:606 INIT 0.28 0.11 0.2 to 0.3 Non-signi\u00afcant 10.4 1.39 10.0 to 11.0 p \u00bc 0:74 9.3 2.22 7.0 to 11.0 Non-signi\u00afcant Note: Statistical analysis done by Repeated Measures analysis of variance. Hong Kong Physiother. J. 2023.43:73-80. Downloaded from worldscientific.com Neck Range of Motion (ROM) neck movement, VAS, NDI, SF-36, PPT, vibra- by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. Within-Subjects E\u00aeects \u00f0ROM\u00de \u00c0 F \u00f01;38\u00de \u00bc tion-detection threshold.22 1125:757, Partial Eta Squared \u00bc 0:967, p < The author concluded that cupping also shows 0:0001 remarkable di\u00aeerence between the pre- and post- mobility, as it enhances other therapies by ROM \u00c2 Group \u00c0 F \u00f01; 38\u00de \u00bc 3:510, Partial Eta stretching muscle and connective tissue and Squared \u00bc 0:085, p < 0:069 thereby decreasing TGF-\f1 and collagen synthesis, it may further enhance microcirculation, cellular Between Group \u00c0 F \u00f01; 38\u00de \u00bc 0:109, Partial Eta metabolism, and regeneration. Evidence suggests Squared \u00bc 0:003, p < 0:74 removing LTrP normalises the Motor Action Potential.23 There was statistically no signi\u00afcant di\u00aeerence seen. 96.7% of variation can be explained by time One study conducted a systematic review and and 8.5% by ROM \u00c2 Groups. 0.3% by groups. meta-analysis by two independent researchers in national and international databases and con- Discussion cluded that cupping is a promising method for treatment of chronic back pain showing signi\u00afcant The study was conducted to \u00afnd the e\u00aeect of MFC reduction in pain intensity score (p \u00bc 0:001).24 and INITs on pain intensity, pain sensitivity and Also adding dry cupping on calf muscle myofascial lateral \u00b0exion ROM on latent TrP in upper tra- trigger points (MTrPs) in patients with plantar pezius muscle. heel pain was found to be superior to only self- stretching and active ankle dorsi\u00b0exion exercises in The study showed that the MFC has signi\u00afcant pain, ankle dorsi\u00b0exion ROM, and plantar \u00b0exor improvement in pain, increase in PPT and neck strength.25 lateral \u00b0exion ROM. According to the physiology of cupping based on pain gate theory, it increases Blood \u00b0ow to the skin increased (hyperaemia) the stimulation of A\f mechanoreceptor and deac- immediately after the removal of the cup and some tivates the TrP. Release of endorphins, encephalin visible discoloured patch due to erythema, edema and increase in blood circulation results by apply- and ecchymosis in a variety of circular arrange- ing negative pressure over the twisted bundle TrP, ments was seen with experienced warmth as result and adhesion broken painlessly without any force of vasodilation.26 Cupping may relieve stress and lead to hemodynamic changes and remove the in- pain perception not only by speci\u00afc e\u00aeect but also \u00b0ammatory products and toxins. The therapeutic by unspeci\u00afc e\u00aeect on regulation of autonomic conception of dry cupping gives detail of re\u00b0ex zone nervous system.27 Also it mimics analgesic e\u00aeect theory in which the perception of pain is blocked and has no side e\u00aeect which was signi\u00afcant and segmentally which stays for 6 h and if e\u00aeect remains e\u00aeective on neck and shoulder pain.28 The trigger for more than 12 h, it is due to release of GABA response is linked to hemoxygenerase expression, a\u00aeecting the end range of motion of a joint.13 which is associated with cytoprotective and anti- nociceptive e\u00aeects.29 The e\u00aeect of LTrP on the Similar \u00afnding was researched stating that TrP muscle activation and muscle e\u00b1cacy in scapular showed symptomatic improvement after cupping rotator muscles do alter the timing and decrease when given for 2 weeks i.e., \u00afve sessions of cupping seen on pain at rest and maximal pain related to","Hong Kong Physiother. J. 2023.43:73-80. Downloaded from worldscientific.com the consistency of MAP of muscle group and more E\u00aeect of MFC vs INITs on pain and neck movement 79 by Horizon College Physiotherapy on 07\/29\/23. Re-use and distribution is strictly not permitted, except for Open Access articles. muscles in upper limb chain.30 the long-term e\u00b1cacy of this technique. Interven- In this study, INIT also showed signi\u00afcant im- tions can be explored in various age groups, in provement in pain, increase in PPT and neck speci\u00afc gender and also considering control group. LROM. Chaitow stated INIT technique to be ef- fective in deactivating the TrPs.16 Our results are Conclusion consistent with the results of previous studies that showed the e\u00aeect of INIT and MET on NDI, VAS, Thus, the study concludes that MFC therapy is an lateral \u00b0exion of cervical for 4 weeks and concluded e\u00aeective treatment for latent TrP in trapezius than statistically that INIT showed better e\u00aeect in INITs in improving pain, PPT and neck lateral deactivating TrP and thus improving the \u00b0exion. variables.7 Acknowledgements Simons proposed that in INIT the local direct ischemic compression decreases the sensitivity of I am grateful to all my patients and thankful to Dr. painful nodules in muscle. Additionally, the sub- Tushar J Palekar for providing the necessary in- sequent tissue relaxation created by attaining a frastructure and research equipment. Also thankful position of TrP ease (SCS) has been proposed as a to Dr. Sudhir Jadhav for statistical analysis. mechanism of facilitating `unopposed arterial \u00afll- ing' which allows decrease in tone, ultimately Con\u00b0icts of Interest facilitating a resetting of the neural reporting structures, resulting in a more normal resting The authors have no con\u00b0icts of interest relevant length, enhanced circulation, and decreased to this paper. No funding was provided. pain.12,31 References A theory was hypothesised that the sequence of muscle and joint mechanoreceptor activation 1. Astin JA. Why patients use alternative medicine: evokes \u00afring of somatic e\u00aeerent leading to sym- Results of a national study. JAMA 1998;279 patho-excitation and activation of the periaque- (19):1548\u201353. ductal grey matter thus decreasing the modulation of pain.32 One proposed mechanism for bene\u00aft of 2. Travell J, Simons DG. 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