Analysis of the Combined Effects of Myofascial Release and Postero Anterior Mobilization in Chronic Non-Specific Low Back Pain: A Randomized Control Trial

Introduction

Lumbar spine is commonly known as low back. Lumbar stiffness or low back stiffness is a very common condition. About 60%-80% of population suffer from this condition at any stage of life.¹ The frequency of low back pain in one year ranges between 4% to 14%. Low Back Pain (LBP) limits the activities in young adults. The possible aetiologies are divided into five categories Mechanical, degenerative, inflammatory, oncologic, and infectious.

The occurrence of Chronic Low Back Pain (CLBP) has been reported to be 15% to 45% annually, and the annual point prevalence was 30% of Chronic LBP.³ The approximate incidence occurs between 25-50 years. Back pain is very common in adults. According to some studies, up to 23% of the world’s adults suffer from chronic LBP with the repetition of 24% to 80% in one year. Some studies show a lifetime prevalence of 84% in adults. The reports in literature on its occurrence in the paediatric population is less. One Scandinavian study reported the point prevalence of back pain in a group of 12-year olds as approximately 1% and in 15-year olds as 5%, with a cumulative incidence of 50% by age 18 for females and age 20 for males. Adolescents suffer from back pain with an annual rate of 11.8% to 33% described by an extensive systematic review.

The major complaint in subjects with LBP is decrease in spinal mobility and can also lead to variations in the loading pattern of spine. Back stiffness is commonly caused by muscle spasm or lumbar arthritis. Differentiating the cause of lumbar spine stiffness depends upon the onset of symptoms. There are many causes of lumbar stiffness; tight hamstring, poor sitting posture, facet joint osteoarthritis.⁴ Prolonged sitting causes lumbar stiffness, leading to ill effects during lumbar flexion movements.⁵ Low back stiffness can be treated by various manual therapy techniques. It consists of joint mobilization and manipulation, passive stretching, myofascial release (MFR), soft tissue mobilization, manual traction, muscle energy technique.⁶

MFR is found to treat immobility and pain in skeletal muscles by enhancing circulation, relaxing contracted muscle and stimulating stretch reflex.⁷ Myofascial release technique was described as "designed to stretch and reflex release patterned soft tissue and joint-related restrictions".⁸ MFR is applied to restricted fascia. Direct MFR involves the practitioners using physical force and external pressure. Indirect MFR is applied with gentle stretch which is held for few seconds until the fascia loosens. Few grams of pressure/force is applied with the hand moving towards the direction of fascial restriction.^9–12

The combination of MFR with the conventional treatment is very effective in providing immediate relief for pain and tissue tenderness. The fascial continuity between the body parts impacts restriction.² MFR, an extensive osteopathic manipulative idea involves group of specific movements that are directed towards soft tissues of the body, particularly the muscle and fascia.^8,9,13-15

Mobilization is a slow, repetitive, rhythmical, oscillatory arthrokinematic and osteokinematic manual therapy movement. It is a passive movement of a skeletal joint used to restore the motion, relieve pain, and to treat joint dysfunctions.¹⁶ Grades of the mobilization was given by Maitland. Mobilization may affect pain through a number of possible mechanisms, because mobilization directly delivers an external force to soft tissues and joints of the body.¹⁷ Different dosages and various parameters of mobilization are used in the treatment; it consists of force, amplitude, rate, repetition, and time.^18,19 In the assessment of back pain and stiffness, Posteroanterior (PA) mobilization is frequently used by physiotherapists and PA force is applied by the therapist over the spinous process of the patient in prone position. Posteroanterior mobilization increases the lumbar mobility when applied on L3, L4 and L5 for three minutes.²⁰

This study intended to analyse the combined effects of myofascial release and postero anterior mobilization in patients with Chronic Non-Specific Low Back Pain (CNSLBP).

Materials & Methods

The present experimental study involved 60 subjects, both males and females, aged between 25 and 50 years, who had non-specific LBP of Grade 2, 3, or 4 and had been suffering for at least 12 weeks.²¹ Subjects with spondylolisthesis, spondylosis, previous back surgery (such as laminectomy, vertebroplasty, discectomy), lumbar spinal vertebra fractures, dislocation or structural defects of the lumbar region, and infectious diseases of the spine (such as vertebral osteomyelitis, spinal epidural abscess, tuberculosis of the spine) were excluded.¹⁴ The study was conducted in the outpatient department over a period of six months. The effects of MFR and PA mobilization on pain, lumbar range of motion (ROM), and disability were analyzed using the Visual Analog Scale (VAS),²² Modified Schober's test for lumbar flexion ROM,²³ and the Oswestry Low Back Pain and Disability questionnaire, respectively.^24-26

Procedure

After obtaining approval from the Local Ethical Committee and before initiating the study, the procedure, possible risks, and benefits were explained to the subjects, and signed approval was obtained. The 60 subjects included in the study were randomly assigned to two groups: Group A (n=30) and Group B (n=30). Group A (Control group) received conventional therapy, while Group B (Experimental group) received MFR, mobilization, and conventional therapy. The subjects were assessed before and after the treatment procedure, which lasted three days a week for four weeks.

Group A (Control group)

The patients received IFT (Interferential Therapy) and moist heat. IFT involved placing a 4-pole electrode over the lumbar area and stimulating it for 10 minutes at a modulated frequency of 200 Hz. This was followed by moist heat for 10 minutes. Patients were encouraged to perform flexor regime exercises, including pelvic tilt, knee-to-chest (single and bilateral), and partial sit-ups.

• Pelvic tilt – Subject lies on back, flexing the knees with planter flexed ankle. Subject then lifts the pelvis from the inferior part forward for posterior tilt of pelvis.
• Unilateral knee to chest – Subject lies on back and pulls the right/left knee towards chest. The same procedure is followed with contralateral knee.
• Bilateral knee to chest – Subject lies on back, pulling both knees towards the chest.
• Partial sit-up – In pelvic tilt position, head and shoulders are lifted away from the floor.

Each position was held for 5-10 seconds with 10 repetitions.

Group B (Experimental group)

Subjects were positioned in a prone lying position and assessed to determine the hypomobile level of the lumbar spine. PA mobilization was performed at the identified level using Low Velocity Large Amplitude oscillatory PA glides with grade 3 mobilization, following the Maitland and Edwards method. Three cycles, each lasting about 60 seconds, were performed. MFR was performed along the back functional line, targeting the latissimus dorsi, thoracolumbar fascia, contralateral gluteal maximus and vastus lateralis muscles. The therapist worked on the restricted fascia using digit force, followed by stretching and holding the stretch to loosen the fascia.

The same conventional therapy as Group A was given to the subjects, following the same frequency and duration of treatment i.e., three days in a week for four weeks.

Statistical analysis

To calculate mean and standard deviation for the demographic variables and outcome variables, descriptive statistics were performed. Significant difference within the groups was analysed used paired t test or between the groups, ANOVA was used for VAS, lumbar ROM and Oswestry score.* and NS indicate the significance and non-significance, respectively at 5% level.

Results

Table 1 and 2 shows the data of frequency of the age distribution with the cumulative percentage.

Table 3 data shows 60 participants, both males and females, divided into two groups with 30 participants in each group. The mean age of participants in Group A was 33.20 years and standard deviation (SD) was 6.277 with standard error mean of 1.146. In Group B, the mean age of the participants was 33.23 years and SD was 4.644, with the standard error mean of 0.848.

This study examined the effects of incorporating Myofascial Release (MFR) with Posterior Anterior (PA) mobilization in addition to conventional therapy on pain levels, lumbar flexion range of motion (ROM), and functional ability in patients with low back pain. The study included two groups: Group A (control) receiving conventional therapy alone and Group B (experimental) receiving MFR with PA mobilization in addition to conventional therapy.

In Group A, a statistically significant reduction in pain was observed, as indicated by a mean paired difference of 1.567 (SD = 0.568) on the Visual Analog Scale (VAS) with a p value <0.000. Similarly, in Group B, a significant reduction in pain was found, with a mean paired difference of 2.200 (SD = 0.610) on the VAS (p value <0.000). Group B showed greater improvement in pain reduction compared to Group A.

Regarding lumbar flexion ROM, both Group A and Group B showed significant improvement. In Group A, the mean paired difference was -1.067 (SD = 0.450) with a p value <0.000, indicating an increase in ROM. In Group B, the mean paired difference was -1.467 (SD = 0.819) on the modified Schober's test, showing a significant increase in lumbar flexion ROM. Group B exhibited greater improvement in lumbar flexion ROM compared to Group A.

Functional ability, assessed by the Oswestry Low Back Pain Disability Index questionnaire (ODI), showed significant improvement in both the groups. In Group A, the mean paired difference was 4.167 (SD = 1.877) on the ODI (p value <0.000), indicating reduced functional limitations. In Group B, the mean paired difference was 7.233 (SD = 2.609) on the ODI (p value <0.000), demonstrating significant improvement in functional ability. Group B exhibited greater improvement in functional ability compared to Group A.

However, no significant differences were found between the two groups in terms of VAS scores, lumbar flexion ROM, and Oswestry scores, as determined by the analysis of variance (ANOVA) (p >0.05).

Overall, the results suggest that incorporating MFR with PA mobilization in addition to conventional therapy leads to significant reductions in pain, improvements in lumbar flexion ROM, and enhanced functional ability in patients with low back pain.

Discussion

In young individuals, low back pain (LBP) is a major cause of activity limitation. One of the main complaints of individuals with LBP is a decrease in spinal mobility, which can lead to variations in the loading pattern of the spine. Back stiffness is commonly attributed to muscle spasm or lumbar arthritis. Differentiating the cause of lumbar spine stiffness depends on the onset of symptoms.

The aim of this investigation was to understand the combined effect of Myofascial Release (MFR) and Passive Accessory Mobilization (PAM) in patients with low back pain. Studies conducted by Maria Dolores Arguisuelas et al. have demonstrated that MFR intervention significantly reduces pain and disability in chronic low back pain (CLBP) patients.²⁷

Literature suggests that MFR is an effective technique for improving lumbar range of motion (ROM) in patients with LBP. A study by Marzouk A. Ellythy et al. provided evidence supporting the positive effects of MFR in relieving pain and improving lumbar ROM in patients with chronic low back pain.²⁸

Gary L. Shum et al. have validated that PA mobilization holds promise for reducing back pain.²⁹ Furthermore, a study by Paul Chesterton et al. concluded that central PA mobilization of L4 and L5 can increase lumbar ROM.³⁰ The present study demonstrated that both MFR and PA mobilization are effective in reducing pain, improving disability, and increasing range of motion. However, Group B, which received both MFR and PA mobilization along with conventional therapy, showed greater effectiveness in reducing pain in patients with chronic non-specific low back pain. It can be hypothesized that MFR and PA mobilizations contribute to improved range of motion and decreased disability. Therefore, these interventions can be implemented in a clinical setting for better outcomes.

The limitations of the present study include a relatively small sample size, with only 60 subjects included. The long-term carryover effects of the treatment have not been evaluated. Additionally, the absence of a control group receiving separate MFR and PA mobilization individually limits the accuracy of the intervention. Recommendations for future studies include increasing the sample size in each group, conducting long-term follow-up to assess the sustainability of treatment effects, exploring other techniques of mobilization and soft tissue interventions, and including a control group receiving individual therapies to enhance the accuracy of the intervention.

Conclusion

In conclusion, this study demonstrated that the combined application of MFR and PAM along with conventional therapy is effective in reducing pain and improving disability in patients with chronic non-specific low back pain. The results align with previous research supporting the positive effects of MFR and PA mobilization in managing LBP. The group receiving both interventions showed superior pain reduction compared to the control group. However, limitations such as the small sample size and absence of separate control groups for individual interventions should be acknowledged. Future studies with larger samples and long-term follow-up are recommended to validate the sustainability of treatment effects and explore additional mobilization techniques. Overall, MFR and PA mobilization hold promise as valuable interventions for improving outcomes in chronic non-specific LBP.

Conflicts of Interest

Nil

Acknowledgements

It has been my privilege to acknowledge, Dr. Gladies Kamalam S. (PT) madam. I sincerely acknowledge my indebtedness to madam for her support and our patients, who cooperated with us with so much of patience.