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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 54-58

Effectiveness of muscle energy technique versus positional release therapy on range of motion and pain in non-specific low back pain


1 Assistant Professor, UIAHS, Department of Physiotherapy, Chandigarh University, Punjab, India
2 Assistant Professor, Rama Medical College and Hospital and Research Center, Hapur, UP, India
3 Clinical Physiotherapist, Mumbai, India
4 Assistant Professor, Department of Physiotherapy, Chitkara University, Punjab, India

Date of Submission16-Jul-2021
Date of Decision23-Mar-2022
Date of Acceptance17-May-2022
Date of Web Publication05-Jul-2022

Correspondence Address:
Ms. Priya Chauhan
University Institute of Applied Health Science, Chandigarh University, Gharuan, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_62_21

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  Abstract 

Low back ache is the largest cause of sick leave, and half of the population will have experienced a significant incident of low back ache by the age of 30. In India, low back ache prevalence has been reported to be around 23.09%. Severe pain in the lower back is sequel of numerous causes, such as faulty posture, muscular dysfunction (e.g.: muscular imbalance and short or weak muscle), overuse, instability and articular dysfunction in the low back, accident or trauma and most commonly road vehicle accidents. In 85%–90% of cases of lower back ache are non-specific in nature. The function and co-ordination of the muscles that stabilise the lumbar spine, especially the back extensor muscles are often impaired in patients with low back pain. Erector spinae strain and fatigue is one of the causes of back pain. A total of 30 subjects with acute low back pain participated in this study. Group A were treated with hot moist pack and muscle energy technique (MET), whereas Group B were treated with hot moist pack and positional release therapy (PRT). Both the groups received a conventional training protocol for 3 days a week for 4 weeks. The result from these tables shows changes in both the groups, with statistically significant changes were noticed in Group B. The present study showed that both PRT and MET within hot moist packs could be of benefit in the treatment of acute low back pain associated erector spinae muscle spasm. There was significant difference in the intensity of pain within the groups and between the groups after 4 weeks of treatment. Reduction in pain intensity was significant in the PRT group. Pain relief was achieved with both Group A and Group B, but was appreciably more significant in the PRT group. There is a significant difference between both Groups A and B. Hence, PRT is more effective than MET.

Keywords: Back pain, hot moist pack, modified Oswestry Disability Questionnaire, muscle energy technique, positional release therapy


How to cite this article:
Chauhan P, Khare K, Vachchani K, Kapoor G. Effectiveness of muscle energy technique versus positional release therapy on range of motion and pain in non-specific low back pain. Indian J Cont Nsg Edn 2022;23:54-8

How to cite this URL:
Chauhan P, Khare K, Vachchani K, Kapoor G. Effectiveness of muscle energy technique versus positional release therapy on range of motion and pain in non-specific low back pain. Indian J Cont Nsg Edn [serial online] 2022 [cited 2022 Aug 20];23:54-8. Available from: https://www.ijcne.org/text.asp?2022/23/1/54/349824




  Introduction Top


Low back ache is the common cause of illness and more than half of the population has experienced a significant episodes of low back ache by the age of 30. In India, low back ache prevalence has been reported to be around 23.09% in general population.[1] Low back ache is classified into acute, subacute and chronic, with cut-offs period of 12 weeks. Severe pain in the lower back is sequel of numerous causes, such asfaulty posture, muscular dysfunction (e.g.: muscular imbalance and short or weak muscle), overuse, instability and articular dysfunction in the low back, accident or trauma, commonly road vehicle accidents. In 85%–90% of the cases of lower back ache are non-specific in nature. This is the most familiar type of backache. Around 20% of the cases of severe (sudden onset) low back ache are classified as non-specific in nature. This type of back ache, most people experience at some point in their life. It is called non-specific, because there is no specific problem or disease that can be identified as to the cause of the low backache.[2]

Pain or stiffness can be labelled as being either general (total spine) or specific (one vertebral level). The co-ordination and function of the lumbar stabiliser muscles, particularly the extensors are usually impaired in subjects with low backache.[3] Sorensen has found in his study that good endurance of back extensors in humans appeared to safeguard them from low back ache. Erector spinae muscle strain and fatigue is one of the most common causes of backache.[4]

Broadly, positional release therapy (PRT) and muscle energy techniques (MET) are manual therapy techniques used to relieve pain and enhance range of motion (ROM). The purpose of these techniques is to improve the mobility of joint and reinstate biomechanical and physiological function of the spine. Different patient postures are employed to undertake the control before making the subject to do an isometric contraction to draw the impeded segment into a new motion barrier. The isometric contraction is executed in a controlled direction against a specifically controlled counterforce by the physical therapist. The technique was imparted by the registered physiotherapist and the outcome which was measured was spinal mobility without the necessity for passive manipulation.

MET is productive in mobilising impeded joint motion, alleviating hypertonic and spastic muscles along with facilitating neuromuscular reorganisation. This is a suitable technique for subjects whose symptoms are aggravated by change in postures or body positions.[5] Green man defined MET as a manual medical treatment procedure-controlled direction, at varying levels of intensity against a distinctly executed counter force applied by the operator.[6] The goal is to increase joint mobilisation and lengthen contracted muscles. Every session starts and finishes with a screening to evaluate the end result of the manual techniques. This can be beneficial for the subjects as the mobility of spine improves with associated decline in pain.

PRT is a manual technique that reinstates normal resting tone of muscles. Evaluation of trigger points assists in identifying hypertonic muscles that are causing somatic dysfunction.[7] The tender point is used as a guide and the position of comfort is maintained. These efferent impulses were attempting to protect the tissue from being overstretched. By breaking off this pathway, the subject's muscle is permitted to relax and resume a normal resting tone. The procedure is accompanied by slowly and passively securing the subject to an anatomical neutral position without firing of the muscle spindle. This position of minimum inconvenience is normally a posture where the muscle is at its shortest length. The position is maintained for 90 s and the joint is slowly and passively reinstated to the neutral position. This extended shortening of the muscle leads to shortening of both the intrafusal and extrafusal fibres. The consequences of these changes are remarkable improvement in function ROM and reduction in pain. Subjects are positioned in posture that approximates the origin and insertion of the hypertonic muscle. In this way, the muscle spindle activation is inhibited thereby declining the amount of afferent impulses to the brain. This results in less efferent impulses to the same muscle. Both MET and PRT are advantageous for the management of severe low back ache; optimal choice of intervention is not agreed upon to date. Hence, further research is needed to find the most efficacious treatment methods in the management of patients with severe low back ache.


  Methods Top


This was a comparative study which was conducted at Chandigarh University, Gharuan, Punjab from July 2020 to December 2020. A total of 30 subjects with acute low back pain participated in this study were recruited from the institute's outpatient department. A detailed examination of the subjects was done and the population were recruited based on the inclusion and exclusion criteria. Inclusion criteria involved patients with acute non-specific low back pain lasting for < 2 weeks, without radiation to buttocks, thigh or leg, with an age range of 18–30 years and both males and females. The exclusion criteria comprised any history of spinal surgery, motor weakness and altered sensation such as paraesthesia, hyperaesthesia, anaesthesia and subjects receiving muscle relaxants or other pain medications.

The subjects were randomly assigned in two groups by chit system, 15 in each group. Participants were explained about the procedure of the study, and the informed consent was taken. Duration of symptoms and the side affected were noted. Group A were treated with hot moist pack and MET and Group B were treated with hot moist pack and PRT. Pre-intervention measurements such as pain, ROM and functional ability using modified Oswestry Disability Questionnaire (MODQ) were measured.

Protocol

Group A – In the Group A, subjects were given hot moist pack and MET. First, the subject was made to lie prone on the couch comfortably, and the hot moist pack was kept on the lumbar region for a period of 10 min. It is followed by MET for erector spinae, for 10 hold with 20 s relaxation for nine times that is total of 270 s in the following way:

The subject was made to sit with back facing towards physiotherapist on treatment couch, legs hanging over side and hands clasped behind the neck. The therapist placed his knee on the couch close to the subject, at the side towards which side flexion and rotation was done. The therapist passed a hand in front of subject's axilla on the side to which the subject is rotated, across the front of subject's neck, to rest on the shoulder opposite. The subject was drawn into forward flexion, side flexion and rotation over the physiotherapist's knee. The physiotherapist's free hand monitored the area of tightness and ensured that the various forces localise at the point of maximum contraction/tension. When the subject had been taken to a comfortable limit of flexion, was asked to look towards the direction from which rotation had been made, whilst holding the breath for 7–10 s, or made to do this while also introducing a very slight degree of effort towards rotating back to upright position, against firm resistance from the physiotherapist. The subject was then asked to release the breath, completely relax and to look towards the direction in which side flexion/rotation was introduced (i.e. towards the resistance barrier). The physiotherapist looked for the subject's second full exhalation and then took the subject further in all the direction of limitation, towards new barrier, not through it.

Group B – In the group, subjects were given hot moist pack and positional release therapy. The study subject was first made to lie prone on the couch comfortably and hot moist pack was kept on the lumbar region for a period of 10 min, followed by PRT for erector spinae for 90 s with three repetitions that is a total of 270 s was given in following way. The subject was made prone with trunk laterally flexed towards the tender side. The physiotherapist stood on the side of the tender point and placed her knee on the table and affected leg of the subject rested on the physiotherapist's thigh. The subject's hip was extended and adducted and slight rotation was used to fine tune. Lumbar ranges of motion (extension) were measured pre- and immediately post-intervention. All the subjects received the selected treatment daily over a period of 4 weeks. After 4 weeks of intervention, post-treatment outcome measures were recorded, and subjects were re-evaluated by the physiotherapist. As pain, lumbar extension ROM by Schober's method and functional ability using MODQ was measured at the initial phase before giving any intervention and after 4 weeks of intervention. The measured date was analysed.

Outcome measure

Range of motion

Lumbar flexion

Four inches is considered to be an average measurement for healthy adults. Use a skin marking pencil to mark the spinous processes and C7 and S1. Align the tape measure between the two processes and note the distance. Hold the tape measure in place as the subjects performs flexion ROM. Record the distance at the end of the ROM. The difference between the first and second measurement indicates the amount of lumbar flexion that is present.[8]

Lumbar extension

use a skin marking pencil to mark the spinous processes of C7 to S1. Align the tape measurement. Keep the tape measure aligned during the motion and record the measurement at the end of the ROM. The difference between the measurement taken at the beginning of the motion and that taken at the end indicates the amount of lumbar extension that is present.[8]

Modified Oswestry Low Back Pain Disability Questionnaire

Oswestry low back pain scales scores for the 10 items which are scored from 0 to 5 making a total score of 50 which were done by asking the subject to mark their ability to perform each of the 10 activities. It has become a standard instrument for measuring self-related disability due to back pain and has been used by clinicians and researchers.[9]


  Results Top


Basic characteristics of study subjects were tabulated according to gender, age, weight, height and body mass index [Table 1]. A statistically significant difference in pre- and post-intervention means values of lumbar flexion, extension and MODQ [Table 2], [Table 3], [Table 4], [Table 5] for Group A and Group B. However, [Table 3] and 1.6 compare the mean value of post-intervention for lumbar flexion, lumbar extension and MODQ among Group A and Group B with t-value. The result from the tables shows changes in both the groups, with remarkable changes were noticed in Group B.
Table 1: Characteristics of the study participants

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Table 2: Comparisons of pre- and post-lumbar flexion ROM analysis of Group A and Group B

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Table 3: Comparison of post-lumbar flexion ROM analysis of Group A and B

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Table 4: Comparison of pre- and post-modified Oswestry Disability Questionnaire analysis of Group A and Group B

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Table 5: Comparison of post-modified Oswestry Disability Questionnaire analysis of Group A and B

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  Discussion Top


The current study showed that both PRT and the MET could be of advantage in the treatment of intense low back pain-associated erector spine muscle spasm. There was critical difference in the force of pain within the groups and between the groups after 4th week of treatment. Decline in pain intensity as documented with improvement in lumbar ROM was huge in the PRT group. As found from the MODQ scale, relief from discomfort was accomplished with both Group A and Group B, in this study was considerably more critical in the PRT group. Here, MET helps in increase in blood supply, thus it decreases stiffness and restores the ROM. It helps in increasing mobility and strengthens the back muscles. While, hot moist packs helps in reducing erector spinae spasm as it is helpful in increasing vascular permeability, vasodilation and reducing inflammation. Thus, it leads to decease in pain and increasing mobility of back. PRT, used in this study had result in pain reduction. Pain reduction might have been due to the incongruent decline in the intrafusal and extrafusal fibres and reproduction of the undue proprioceptive activity.[10] Kaorr has given a conceptual model, how various manipulative methodologies such as isometric and stretching might be effective in the somatic dysfunction treatment. Erector spinae strain is one of the causes of the back pain.[11]

The use of MET and PRT probably worked in the resolution of inflammation and spasm of the erecter spinae muscle due to its effects similar to the soft-tissue techniques such as stretching of soft tissue in affected area, moving of fluids out of inflamed area reflexly relaxing or tonifying muscle.[12] Numerous studies have shown the benefits of MET and PRT in low back ache. However, no study compared both techniques along with MODQ scale for daily living activities. There was statistically significant improvement in active and passive lumbar extension ROM with in the groups on last day of treatment, after 4 weeks, however, there was no factual distinction when looked at between the two groups. Schenk et al.[13] performed a randomised controlled trial to decide the adequacy of MET in enhancing lumbar extension in symptomatic subjects and found that there was increase in ROM in experimental group[6] The study results on the current study are likewise agreeing with the study results of Schenk et al.[13] A study was done on the impact of rib cage rigidity on low back pain in which the subject got treatment with Integrative Manual Therapy as PRT after treatment was finished, the subject gave diminished pain and improved ranges of motion.[14]

In the present study, Schober's method (Modified) was used to evaluate the lumbar extension ROM. It is a valid and reliable method as many studies have been done in which Schober's method was used for evaluation of ROM.[15] In this study, MODQ was used to evaluate functional disability. A study done on a comparison of a Modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale by Fritz and Irrgang concluded that the MODQ demonstrated superior measurement properties compared with the QUE 24.[16]


  Conclusion Top


There is a significant difference due to additive effect of PRT in subjects with acute low back pain with erector spine spasm. In conclusion, the study on 30 subjects with a complain of acute low back pain erector spine spasm with interventions of hot moist packs, MET also PRT showed that PRT is helpful in easing the back pain and improve the functional capacity as far as ROM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ganesan S, Acharya AS, Chauhan R, Acharya S. Prevalence and risk factors for low back pain in 1,355 young adults: A cross-sectional study. Asian Spine J 2017;11:610-7.  Back to cited text no. 1
    
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Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CW, Chenot JF, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: An updated overview. Eur Spine J 2018;27:2791-803.  Back to cited text no. 2
    
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Russo M, Deckers K, Eldabe S, Kiesel K, Gilligan C, Vieceli J, et al. Muscle control and non-specific chronic low back pain. Neuromodulation 2018;21:1-9.  Back to cited text no. 3
    
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Souza CP, Monteiro-Junior RS, Silva EB. Reliability of the endurance test for the erector spinae muscle. Fisioterapia Mov 2016;29:369-75.  Back to cited text no. 4
    
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Roberts BL. Soft tissue manipulation: Neuromuscular and muscle energy techniques. J Neurosci Nurs 1997;29:123-7.  Back to cited text no. 5
    
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Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscle energy technique in patients with acute low back pain: A pilot clinical trial. J Orthop Sports Phys Ther 2003;33:502-12.  Back to cited text no. 6
    
7.
Saavedra FJ, Cordeiro MT, Alves JV, Fernandes HM, Reis VM, Mont'Alverne DG. The influence of positional release therapy on the myofascial tension of the upper trapezius muscle. Rev Bras Crescimento Desenvolv Hum 2014;16:191-9.  Back to cited text no. 7
    
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Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: Its causes, consequences, and management. J Orthop Sports Phys Ther 2010;40:352-60.  Back to cited text no. 8
    
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Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006;15 Suppl 1:S17-24.  Back to cited text no. 9
    
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Meier ML, Vrana A, Schweinhardt P. Low back pain: The potential contribution of supraspinal motor control and proprioception. Neuroscientist 2019;25:583-96.  Back to cited text no. 10
    
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Clark BC, Goss DA Jr., Walkowski S, Hoffman RL, Ross A, Thomas JS. Neurophysiologic effects of spinal manipulation in patients with chronic low back pain. BMC Musculoskelet Disord 2011;12:170.  Back to cited text no. 11
    
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Kannabiran B. A comparative study of the effectiveness of two manual therapy techniques on pain and lumbar range of motion in individuals with mechanical low back ache. EC Orthop 2015;2:36-42.  Back to cited text no. 12
    
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Schenk RJ, MacDiarmid A, Rousselle J. The effects of muscle energy technique on lumbar range of motion. Journal of Manual & Manipulative Therapy. 1997;5:179-83.  Back to cited text no. 13
    
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Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, et al. Low back pain: Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the american physical therapy association. J orthop sports phys ther 2012;42:A1-57.  Back to cited text no. 14
    
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MacDermid JC, Arumugam V, Vincent JI, Carroll KL. The reliability and validity of the computerized double inclinometer in measuring lumbar mobility. Open Orthop J 2014;8:355-60.  Back to cited text no. 15
    
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Fritz JM, Irrgang JJ. A comparison of a modified oswestry low back pain disability questionnaire and the quebec back pain disability scale. Phys Ther 2001;81:776-88.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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