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The Efficacy of Thermotherapy and Cryotherapy on Pain Relief in Patients with Acute Low Back Pain, A Clinical Trial Study

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Abstract

Introduction: Acute low back pain is one of the most common health problems especially in industrialized countries where 75 per cent of the population develop it at least once during their life. This study examined the efficacy of thermotherapy and cryotherapy, alongside a routine pharmacologic treatment, on pain relief in patients with acute low back pain referring an orthopedic clinic in Shahrekord, Iran. Materials and methods: This clinical trial study was conducted on 87 patients randomly assigned to three (thermotherapy and cryotherapy as intervention, and naproxen as control) groups of 29 each. The first (thermotherapy) group underwent treatment with hot water bag and naproxen, the second (cryotherapy) group was treated with ice and naproxen, and the naproxen group was only treated with naproxen, all for one week. All patients were examined on 0, 3(rd), 8(th), and 15(th) day after the first visit and the data gathered by McGill Pain Questionnaire. The data were analyzed by SPSS software using paired t-test, ANOVA, and chi-square. Results: In this study, mean age of the patients was 34.48 (20-50) years and 51.72 per cent were female. Thermotherapy patients reported significantly less pain compared to cryotherapy and control (p≤0.05). In thermotherapy and cryotherapy groups, mean pain in the first visit was 12.70±3.7 and 12.06±2.6, and on the 15(th) day after intervention 0.75±0.37 and 2.20±2.12, respectively. Conclusion: The results indicated that the application of thermo-therapy and cryotherapy accompanied with a pharmacologic treatment could relieve pain in the patients with acute low back pain.
Journal of Clinical and Diagnostic Research. 2014 Sep, Vol-8(9): LC01-LC04 11
DOI: 10.7860/JCDR/2014/7404.4818 Original Article
The Efficacy of Thermotherapy and
Cryotherapy on Pain Relief in Patients with
Acute Low Back Pain, A Clinical Trial Study
Orthopaedic Section
MORTEZA DEHGHAN1, FARINAZ FARAHBOD2
INTRODUCTION
Low back pain is one of the most common musculoskeletal diseases
globally, with high financial burden especially in industrialized
countries where approximately 80 per cent of the population suffers
from it at least once during their life [1-3]. Low back pain, after
common cold, is the most widespread disease in human beings
and the second cause of referring the physicians [3].
In Iran, low back pain prevalence in 2006 was reported as 41.9
per cent [4]. Low back pain is referred to the pain between the
twelfth rib and the lower sciatic flexure, lasting for at least 24 hours
and impeding the daily regular activities [5]. Low back pains are
divided into three categories based on the pain duration. The
acute low back pain lasts for less than four weeks, subacute type
for four to eight weeks, and the chronic type for more than eight
weeks [6,7]. Treatment of low back pain could be pharmacologic
or nonpharmacologic. Pharmacologic treatment include analgesics,
anti-inflammatory drugs, muscle relaxants, etc. and nonpharmac-
ologic treatment could be surgical and nonsurgical [8] of nonphar-
ma cologic, nonsurgical treatments thermotherapy is an adjuvant
one used to relieve pains nowadays either in a superficial (for
skin) or deep (for joints and muscles) way [9]. Another method is
cryotherapy conducted in order to treat some diseases or some of
their symptoms by means of freezing materials. To treat, the body
temperature can be declined. If the decline in body temperature
occurs throughout the whole body, it is called hypothermia and if
it occurs topically, it is known as cryotherapy or ice therapy [10].
To treat low back pain, other methods including exercise therapy,
relaxation techniques, electrotherapy, manipulation, and soft tissue
manipulation such as massage have been proposed [11]. The
research on the treatment of low back pain indicated the efficacy of
thermotherapy and cryotherapy on the pain relief in the patients with
low back pain [12,13].
Acute low back pain intervenes in daily, physical, and work-related
activities [14]. Thus, it is crucial to find effective treatments to minim-
ize pain in these patients. This study aims to determine the efficacy of
thermotherapy and cryotherapy, alongside a routine pharmacologic
treatment (naproxen), on pain relief in the patients with acute low
back pain.
MATERIALS AND METHODS
The study protocol was approved by Ethics Committee of Faculty
of Medicine (ethics code: 90-10-32) and registration code of
IRCT201303106480N5 was issued by Iranian Registry of Clinical
Trials for this study. Sample population of this study consisted
of all male and female patients, 20-50-years-old, with acute low
back pain referring Orthopedic Clinic of Ayatollah Kashani Hospital,
Shahrekord (southwest of Iran). Inclusion criteria were as follows: 20-
to 50-year-old male and female patients with acute low back pain
complaint (developed less than one month ago) referring the Clinic
and completion of informed consent form and the questionnaire.
The exclusion criteria were underlying (cardiovascular, renal,
pulmonary, endocrine, and metabolic) diseases, trauma, taking
analgesics apart from naproxen, and undergoing physiotherapy.
Ninety patients suffering from acute low back pain were chosen by
convenience sampling method. Three patients were excluded from
the study because of refusal to receive treatment. The researcher
did homogenization through assigning participants randomly
in three groups of 29 each [Table/Fig-1]. All three groups were
simultaneously treated with naproxen 500 mg twice a day for one
week; we judged it as unethical to relieve the pain through only
cryotherapy and/or thermotherapy as these two therapies are
considered as supplementary ones for relieving pain. Group A
(thermotherapy) was treated with hot water bottle twice a day for
one week each time for 20 minutes, group B (cryotherapy) with ice
ABSTRACT
Introduction: Acute low back pain is one of the most common
health problems especially in industrialized countries where 75
per cent of the population develop it at least once during their
life. This study examined the efficacy of thermotherapy and
cryotherapy, alongside a routine pharmacologic treatment,
on pain relief in patients with acute low back pain referring an
orthopedic clinic in Shahrekord, Iran.
Materials and Methods: This clinical trial study was conducted
on 87 patients randomly assigned to three (thermotherapy and
cryotherapy as intervention, and naproxen as control) groups of
29 each. The first (thermotherapy) group underwent treatment
with hot water bag and naproxen, the second (cryotherapy) group
was treated with ice and naproxen, and the naproxen group was
only treated with naproxen, all for one week. All patients were
examined on 0, 3rd, 8th, and 15th day after the first visit and the data
gathered by McGill Pain Questionnaire. The data were analyzed
by SPSS software using paired t-test, ANOVA, and chi-square.
Results: In this study, mean age of the patients was 34.48 (20–50)
years and 51.72 per cent were female. Thermotherapy patients
reported significantly less pain compared to cryotherapy and
control (p0.05). In thermotherapy and cryotherapy groups, mean
pain in the first visit was 12.70±3.7 and 12.06±2.6, and on the 15th
day after intervention 0.75±0.37 and 2.20±2.12, respectively.
Conclusion: The results indicated that the application of thermo-
therapy and cryotherapy accompanied with a pharmacologic
treatment could relieve pain in the patients with acute low back
pain.
Keywords: Acute low back pain, Cryotherapy, Patients, Thermotherapy
Morteza Dehghan and Farinaz Farahbod, The Efficacy of Thermotherapy and Cryotherapy www.jcdr.net
Journal of Clinical and Diagnostic Research. 2014 Sep, Vol-8(9): LC01-LC04
22
twice a day for one week each time for 20 minutes, and group C
(naproxen), as control, only with naproxen. All patients were examined
on 0, 3rd, 8th, and 15th day after they received treatment.
The data were gathered using McGill Pain Questionnaire (MPQ).
MPQ includes two main components for pain assessment. The first
component consists of four measures: descriptive, examination,
evaluative, and behavioral. The second component of MPQ is
related to the pain measurement from an affective dimension. In
Iran, Adelmanesh examined the validity and reliability of MPQ and
measured its Cronbach’s alfa coefficient as 90 per cent, indicating
a scientifically high reliability [15]. The data were analyzed by SPSS
11 using paired t-test, ANOVA, and chi-square.
RESULTS
In this study, the age range of the patients was 20-50 years and
their mean age was 34.48 years, of the patients, 51.72 per cent
were female and each group consisted of 14 men and 15 women.
No significant difference in pain was observed between men and
women based on chi-square test (p 0.05). In terms of occupation,
age, and duration of symptoms there was no statistically significant
difference among the three groups (p 0.05).
In the first visit, the intensity of pain in all three groups was equal. In
the second visit (three days later), the intensity of pain was signifi-
cantly reduced in the intervention (thermotherapy and cryotherapy)
groups. In addition, the decrease in pain intensity, in terms of
pain examination, was higher in thermotherapy group compared
to cryotherapy in the second visit. The mean score of pain in
thermotherapy group ranged from 12.06 in the first visit to 7.27 in
the fourth visit, and in the cryotherapy group from 12.06 in the first
visit to 9.27 in the fourth visit. Meanwhile, no significant decrease
was observed in the intensity of pain in naproxen group. In the
second visit three groups were different regarding the descriptive,
examination, and evaluative measures and the second component
(affective dimension) of MPQ. Besides, in the third and fourth visits (8
and 15 days later, respectively) the intensity of overall pain decreased
and in the fourth visit, the intensity of pain in thermotherapy group,
group Thermotherapy Naproxen Cryotherapy
p-value
Variable Visit turns Mean ± SD* Mean ± SD* Mean ± SD*
Age (year) 33.66±8.24 36.41±8.214 33.38±8.364
Duration of symptoms (day) 16.38±8.769 13.17±6.612 17.72±9.471
Pain measures
Descriptive
measures
First 3.14±1.093 3.59±0.852 3.10±0.976 0.11
Second 03/2±778/0 2.66±0.721 2.55±0.985 0.01
Third 1.28±0.694 1.97±0.823 1.52±0.911 0.01
Fourth 0.45±0.506 1.38±0.677 0.79±0.774 0.00
Examination
measures
First 2.21±0.675 2.69±0.471 2.48±0.509 0.01
Second 1.45±0.736 14/2±639/0 1.97±0.499 0.00
Third 0.66±0.721 1.72±0.528 1±0.463 0.00
Fourth 0.17±0.384 1.31±0.541 0.48±0.688 0.00
Evaluative
measures
First 3.24±1.327 3.38±1.015 3.10±0.976 0.64
Second 1.86±1.026 2.66±0.857 2.31±0.806 0.05
Third 0.90±0.817 2±0.756 1.47±0.733 0.00
Fourth 0.03±0.184 1.48±0.634 0.52±0.688 0.00
Behavioral
measures
First 3.48±1.84 3.31±1.004 3.38±0.979 0.82
Second 1.93±1.223 2.41±0.733 2.45±1.055 0.12
Third 0.90±0.673 2.03±0.865 1.17±0.848 0.00
Fourth 0.10±0.310 1.41±0.733 0.41±0.568 0.00
Second component
of MPQ**
First 7.511±1.975 8.214±1.503 7.379±1.916 0.16
Second 4.758±1.704 6.551±1.594 4.931±2.051 0.00
Third 1.965±1.636 4.931±1.624 2.275±1.849 0.00
Fourth 0.682±0.413 3.827±1.774 1.241±1.550 0.00
Overall pain
First 12.0690±3.70262 12.9655±2.8092 12.06±2.63 0.44
Second 7.2759±3.18362 9.8621±2.26334 9.27±2.67 <0.05
Third 3.7241±2.37391 7.7241±2.50566 5.10±2.30 0.00
Fourth 0.7586±0.37946 5.5862±2.00922 2.20±2.12 0.01
[Table/Fig-1]: Flow Diagram
[Table/Fig-2]: Statistical analysis of the data using McGill Pain Questioannre
* Standard deviation
** McGill Pain Questionnaire
Journal of Clinical and Diagnostic Research. 2014 Sep, Vol-8(9): LC01-LC04 33
www.jcdr.net Morteza Dehghan and Farinaz Farahbod, The Efficacy of Thermotherapy and Cryotherapy
cryotherapy, and naproxen groups reached 0.75, 2.20, and 5.58
respectively. In evaluative measure, decrease in the intensity of pain
was higher in the thermotherapy group compared to the other two
groups (p<0.05). Less pain was reported in thermotherapy and
cryotherapy groups compared to naproxen (p<0.05). The results
are comprehensively shown in [Table/Fig-2].
Examining the pain through the second component of MPQ (affective
dimension) showed that in the first visit, no significant difference
was observed among the three groups (p > 0.05). However, in the
second, third, and fourth visits, there was a significant difference
among the three groups (p<0.05). Generally, less pain was reported
in thermotherapy and cryotherapy groups in comparison to
naproxen [Table/Fig-3]. [Table/Fig-4] compares overal mean pain
score among thermotherapy, cryotherapy, and naproxen groups
during treatment.
DISCUSSION
This clinical trial study showed the efficacy of thermotherapy and
cryotherapy alongside pharmacologic treatment on relieving pain.
Based on the findings of this study, various (examination, behavioral,
descriptive, and evaluative) measures and affective dimension were
different in the second, third, and fourth visits of the patients among
the three groups, which confirms that applying supplementary
methods (especially application of thermotherapy) could strengthen
the efficacy of pharmacologic treatment and minimize the pain in
patients.
There is little evidence on examining the effect of thermotherapy
and cryotherapy on low back pain and conflicting evidence on
appropriateness of these methods for this pain [16]. However, these
interventions seem to yield better outcomes if applied continuously
and in long term rather than frequently and in short term [17],
consistent with our study’s findings.
Ours findings are consistent with the results of some other studies
on the efficacy of thermotherapy and cryotherapy on low back pain
relief [12,16,18,19]. In most studies, thermotherapy and cryotherapy
were effective, in long term, on pain relief in the patients suffering
from low back pain [12,16, 20]. In this regard, a study by Khadilkar
et al., on treatment of chronic low back pain indicated that keeping
the pain site warm (wrapped up by a blanket) for a long term in
the patients with chronic low back pain reduced the pain efficiently
[16]. In the present study, thermotherapy minimized acute low
back pain in short term. This inconsistency may be due to different
instruments (blanket versus hot water bottle) for keeping the pain
site warm. Thermotherapy also decreased the intensity of pain in
[Table/Fig-3]: The comparison of pain among thermotherapy, cryotherapy,
and naproxen groups during treatment (Second component of McGill Pain
Questionnaire)
Mean pain score in cryotherapy group································
Mean pain score in thermotherapy group—·——·——·—
Mean pain score in naproxen group
[Table/Fig-4]: The comparison of overal mean pain score among thermotherapy,
cryotherapy, and naproxen groups during treatment.
Mean pain score in cryotherapy group································
Mean pain score in thermotherapy group—·——·——·—
Mean pain score in naproxen group
the first and second trimesters of pregnancy in various measures
[21]. Continuous application of thermotherapy in a low level was
effective on treating acute low back pain and nonspecific low back
pain [18], confirming our findings. The results of a study on low back
pain in adults showed that thermotherapy after five days reduced
pain significantly compared to oral placebo. In that study, acute low
back pain was relieved immediately after thermotherapy, confirming
the efficacy of thermotherapy (blanket wrapped up for two weeks)
on pain relief and inabilities associated with low back pain of shorter
than three months [12].
The application of thermotherapy and hot water leads to increase
in soft tissue flexibility, muscle resistance, easier and better con-
traction of smooth muscles, and improvement in the muscles’
motor function [22]. Besides, thermotherapy triggers decline in pain
especially low back pain through inhibiting pain signal and exerting
pressure on back muscles [18]. In a study in the USA, ice wrapped
in a wet handkerchief applied on pain site for 20 minutes caused
temporary pain relief and inflammation decrease [23]. In addition,
when hot water bottle (especially in case of providing deep heat)
was used, the patient’s focus was distracted from his/her pain,
the muscles relaxed, and hence the pain relieved. The studies on
the effect of thermotherapy illustrate that continued thermotherapy
leads to alleviating pain in the patients with acute low back pain,
which decreases muscles seizure and resolves inability [18,24].
Besides, cryotherapy leads to reduction in edema and inflammation
in the pain site and relief of pain [23].
In contrast to our study, French et al., obtained little evidence on
the effect of short-term thermotherapy on acute and subacute low
back pain. In their study, exercise was more effective on pain relief
and functional improvement [20]. In another study, cryotherapy
and thermotherapy as therapeutic methods in the patients with
acute and chronic low back pain had an equal effect on relieving
the pain based on evaluative and descriptive measures [12], which
is consistent with our findings. Kinkade’s study showed that the
application of ice and heat pack had an equal effect on the patients
suffering from low back pain [13]. Costello et al., concluded that
the application of cryotherapy relieved pain immediately and 15
minutes after muscle tone [10], which is similar to our study in terms
of efficacy but different considering evaluation time. Based on these
findings, further studies could measure combined effects of different
treatments including thermotherapy and cryotherapy, massage
therapy, acupuncture, stretching, etc. on pain in patients with low
back pain.
Morteza Dehghan and Farinaz Farahbod, The Efficacy of Thermotherapy and Cryotherapy www.jcdr.net
Journal of Clinical and Diagnostic Research. 2014 Sep, Vol-8(9): LC01-LC04
44
[10] Costello JT, Algar LA, Donnelly AE. Effects of whole-body cryotherapy (-110
degrees C) on proprioception and indices of muscle damage. Scand J Med Sci
Sports. 2012;22(2):190-98.
[11] Hall AM, Maher CG, Latimer J, Ferreira ML, Lam P. A randomized controlled
trial of tai chi for long-term low back pain (TAI CHI): study rationale, design, and
methods. BMC Musculoskelet Disord. 2009;10:55.
[12] French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. A Cochrane
review of superficial heat or cold for low back pain. Spine (Phila Pa 1976).
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[13] Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician.
2007;75(8):1181-88.
[14] Mayer JM, Ralph L, Look M, Erasala GN, Verna JL, Matheson LN, et al. Treating
acute low back pain with continuous low-level heat wrap therapy and/or exercise:
a randomized controlled trial. Spine J. 2005;5(4):395-403.
[15] Adelmanesh F, Arvantaj A, Rashki H, Ketabchi S, Montazeri A, Raissi G. Results
from the translation and adaptation of the Iranian Short-Form McGill Pain
Questionnaire (I-SF-MPQ): preliminary evidence of its reliability, construct validity
and sensitivity in an Iranian pain population. Sports Med Arthrosc Rehabil Ther
Technol. 2011;3(1):27.
[16] Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve
stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database
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[17] Nadler SF, Weingand K, Kruse RJ. The physiologic basis and clinical applications
of cryotherapy and thermotherapy for the pain practitioner. Pain Physician.
2004;7(3):395-99.
[18] Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Abeln SB, Weingand KW.
Continuous low-level heatwrap therapy for treating acute nonspecific low back
pain. Arch Phys Med Rehabil. 2003;84(3):329-34.
[19] Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Hinkle RT, Beth Goodale
M, et al. Continuous low-level heat wrap therapy provides more efficacy than
Ibuprofen and acetaminophen for acute low back pain. Spine (Phila Pa 1976).
2002;27(10):1012-17.
[20] French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat
or cold for low back pain. Cochrane Database Syst Rev. 2006 ;(1):CD004750.
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severity in primigravida women. Iran J Nurs Midwifery Res. 2011;16(1):113-16.
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CONCLUSION
Taken together, the findings of this study indicated that thermotherapy
and cryotherapy caused low back pain to be relieved. Since these
methods predictably have fewer side-effects and are economical
and accessible, they could be used, alongside pharmacologic
treatments, as supplementary ones for reducing pain in the patients
with low back pain.
ACKNOWLEDGEMENT
This work was obtained from the research project no. 1046-89-01-
91 supported by Research and Technology Deputy of Shahrekord
University of Medical Sciences with the grant no. 1147. We also
thank Clinical Research Development Unit at Ayatollah Kashani
Hospital of Shahrekord and all who assisted us, in some way, in
conducting this research.
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PARTICULARS OF CONTRIBUTORS:
1. Faculty, Department of Orthopaedics, Shahrekord University of Medical Sciences, Shahrekord, Iran.
2. Assistant Professor, Department of Obstetrics and Gynecology, Shahrekord University of Medical Sciences, Shahrekord, Iran.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Farinaz Farahbod,
Assistant Professor, Department of Obstetrics and Gynecology, Shahrekord University of Medical Sciences, Shahrekord, Iran.
Phone: +989131026041, Fax: +983812220255, P.O. Box Number: 8815713471
E-mail: farinaz.farahbod@gmail.com,
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Aug 20, 2013
Date of Peer Review: Jan 29, 2014
Date of Acceptance: Mar 12, 2014
Date of Publishing: Sep 20, 2014
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Introduction: Low back pain syndromes (LBPS) are common. One of the methods of treating LBPS is local cryotherapy, which can be based on various cooling substances. In the available literature, it is suggested that effective cold treatment may depend on the type and temperature of the cooling substance used. Research objective: The aim of the study was to evaluate the effectiveness of 2 local cryotherapy (Carbon Dioxide and Liquid Nitrogen) types among patients with low back pain syndrome (LBPS). Materials and methods: The study included 60 patients diagnosed with chronic LBPS of discopathic origin. Patients were randomised into 2 study groups. Local cryotherapy treatment with Carbon Dioxide was used in the 1st group (G1), while in the 2nd (G2), cryotherapy treatment with applied Liquid Nitrogen. Two measurements were taken, before and after 2 weeks treatment. The following were used for assessment: centralisation of symptoms (Pain Drawings), pain intensity (Numeral Rating Scale), duration of the current pain episode (Quebec Task Force Classification), level of disability (Roland-Morris Disability Questionnaire), quality and intensity of subjective pain (McGill Pain Questionnaire), patients’ emotional state (Adjectival Scale for Testing Emotions) and self-efficacy related to pain (Pain Self-Efficacy Questionnaire). Statistical analysis was performed via the Student’s t-test for dependent and independent samples. Results: In both study groups, the perceived pain was either completely eliminated or centralised to the spine, hip joint and buttock. The level of pain, disability and pain-related self-efficacy decreased significantly, regardless of the therapy used. In terms of these variables, no greater therapeutic efficacy was demonstrated with either cryostimulation treatment. Qualitative assessment of pain and emotions (especially anxiety and anger) decreased significantly in G1 and G2. However, in the nitrogen-treated group, a significantly greater improvement was noted for WOB:OC, anger and anxiety scores (for these variables, the G2 group started from a higher level prior to therapy). Conclusions: Both analysed treatments are equally effective in terms of variables such as: centralisation of symptoms, level of pain intensity, disability, joy, self-efficacy related to pain, as well as the majority of the analysed MPQ indicators. Cryostimulation with liquid nitrogen may be more effective, but only in improving the WOB: OC index of the MPQ questionnaire and the level of anger and anxiety. Nonetheless, the obtained results do not allow for definitive confirmation of these results. The use of both cryostimulation treatment methods may assist in the treatment process of LBPS.
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Objective The purpose of this study was to determine factors that affect compliance with various prescribed home therapies based on reported feedback from participants with spine pain. Methods This was a descriptive, quantitative, cross-sectional survey. A purposive sampling method was used to recruit 121 participants with neck and back pain attending the Durban University of Technology Chiropractic Day Clinic located in KwaZulu-Natal, South Africa. Data were collected using a self-administered questionnaire. Descriptive statistics, including frequencies and percentages, were used to summarize the data, and odds ratios (ORs) were calculated. Results Most participants presented with chronic pain, reporting an average severity of 6 out of 10 and little disability from the pain. Home therapy included stretches (92.2%), heat therapy (49.1%), and ice therapy (38.8%). Almost two-thirds (62.1%) of participants reported being fully compliant with the prescribed home therapy, while 32.8% reported partial compliance. The main factors that potentially affected compliance were laziness and forgetfulness. Participants who reported having depression were less compliant (OR, 0.181), while those with chronic pain were more compliant (OR, 3.74). Those who believed that home therapy would alleviate their pain were also more compliant (OR, 3.83). Conclusion The study found that a majority of participants with spine pain were compliant with prescribed chiropractic home treatment. Key factors that potentially influenced compliance were identified.
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Back pain is a common condition affecting millions of individuals each year. A biopsychosocial approach to back pain provides the best clinical framework. A detailed history and physical examination with a thorough workup are required to exclude emergent or nonoperative etiologies of back pain. The treatment of back pain first uses conventional therapies including lifestyle modifications, nonsteroidal anti-inflammatory drugs, physical therapy, and cognitive behavioral therapy. If these options have been exhausted and pain persists for greater than 6 weeks, imaging and a specialist referral may be indicated.
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Hot springs have been providing many health benefits to the people worldwide for a long time. This chapter presents interesting histories of soaking in hot waters in the U.S., Greece, Rome and Japan. A review of scientific literature gives an insight into the trend in clinical researches aimed at recognizing various diseases that can benefit from hot and healing springs. It also explores various therapies currently in use along with their mode of application. A case study of using Singa hot spring water for musculoskeletal problems is also presented. Various thermal sites in Nepal with the potential to serve as treatment centers have been identified.
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Low back pain may have different causes and one of the cause is anterolisthesis. Anterolisthesis is the anteriorly slippage of a vertebrae onto its caudal one. Its Grading is done using mayerding classification system on a plain radiograph in oblique view. Grade I is identified less than the 25% of slippage, in grade II its 25 to 50%, grade III of 51 to 75%, and grade IV having 76 to 100% of slippage. Sometimes it may be symptomatic as well as asymptomatic; pattern of pain is usually localized and/or referred to the dermatome of slipped vertebrae. Non-operative management is preferred as long as failure of non-operative management and neurological deficit. Case Summary: we presented the case of traumatic anterolisthesis of grade I with the preexisting idiopathic scoliosis. Cases with other conditions have been reported before like spondolysis but not with scoliosis. Case was diagnosed with plain radiography as well as physical examination. The condition was managed with physical therapy. Conclusion: Grade I anterolisthesis can be manageable with non-operative methods such as physical therapy. Cryotherapy is found to provide maximum relive of inflammation based pain than thermotherapy. Early diagnosis and treatment is beneficial to rescue patient from state of kinesophobia.
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This study set out to investigate the usefulness of an adapted physical activity protocol to improve pain and functional capacity through structured adapted exercises to muscular capacity on patients in a Functional Restoration program. Material and methods: 83 patients, aged between 19-63, who accepted to be included in this study and diagnosed as chronic low back pain. The patients were treated for a total of 12 weeks, 3 sessions per week. The level of pain severity of the participants was determined by Visual Pain Scale (VAS). Oswestry Disability Index for functional evaluation; Low Back Pain Disability Index (LBPDI). These assessments were performed at the beginning and end of the 12- week treatment program. In line with our study results, we anticipate that the planned physiotherapy and adapted physical activity (APA) protocol will reduce the health expenditures by finding a solution option for chronic low back pain commonly seen in societies.
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Pain is a common complaint precipitating emergency department (ED) visit, occurring in more than half of patient encounters. While opioids are effective for acute pain management in the Emergency Department (ED), the associated adverse effects, including respiratory and central nervous system depression, nausea, vomiting, and constipation, and physical manifestations of use, including tolerance, dependence and misuse leading to overdose and death, accentuate the need for non-opioid alternatives and/or multi-modal pain control. This review will provide examples of non-opioid pain management strategies and multimodal regimens for treatment of acute pain in the ED.
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The Short Form McGill Pain Questionnaire (SF-MPQ) is one of the most widely used instruments to assess pain. The aim of this study was to translate and culturally adapt the questionnaire for Farsi (the official language of Iran) speakers in order to test its reliability and sensitivity. We followed Guillemin's guidelines for cross-cultural adaption of health-related measures, which include forward-backward translations, expert committee meetings, and face validity testing in a pilot group. Subsequently, the questionnaire was administered to a sample of 100 diverse chronic pain patients attending a tertiary pain and rehabilitation clinic. In order to evaluate test-retest reliability, patients completed the questionnaire in the morning and early evening of their first visit. Finally, patients were asked to complete the questionnaire for the third time after completing a standardized treatment protocol three weeks later. Intraclass correlation coefficient (ICC) was used to evaluate reliability. We used principle component analysis to assess construct validity. Ninety-two subjects completed the questionnaire both in the morning and in the evening of the first visit (test-retest reliability), and after three weeks (sensitivity to change). Eight patients who did not finish treatment protocol were excluded from the study. Internal consistency was found by Cronbach's alpha to be 0.951, 0.832 and 0.840 for sensory, affective and total scores respectively. ICC resulted in 0.906 for sensory, 0.712 for affective and 0.912 for total pain score. Item to subscale score correlations supported the convergent validity of each item to its hypothesized subscale. Correlations were observed to range from r2 = 0.202 to r2 = 0.739. Sensitivity or responsiveness was evaluated by pair t-test, which exhibited a significant difference between pre- and post-treatment scores (p < 0.001). The results of this study indicate that the Iranian version of the SF-MPQ is a reliable questionnaire and responsive to changes in the subscale and total pain scores in Persian chronic pain patients over time.
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Labor pain relief has been considered since many years ago. Heat as a non pharmacological method of pain relief helps reducing the pain intensity and increases the pain consistency. The aim of the study was to determine the effect of the heat therapy on the labor pain in primigravida women. In this clinical trial study, 64 low risk nulliparous women were randomly divided into two heat therapy and routine care groups. In addition to the routine cares, warm bag were used for the heat therapy group for the low back, from cervix dilatation of 3-4 cm to the end of the labor's first stage and for perinea at the second stage. The pain intensity was determined by McGill pain questionnaire in dilatation of 3-4, 6-7 and 9-10 cm and at the end of the labor's second stage. Data was analyzed using t-test and chi square test by using SPSS 11. Results of research showed a significant decrease in the pain intensity in the heat therapy group at the first stage and the second stage of labor and comparing two groups showed significant difference(p < 0.001). According to the results of this study, it seems that heat therapy in addition to its beneficial effects, causes the mother to sense the labor pain in a lower pain severity.
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Low back pain persisting for longer than 3 months is a common and costly condition for which many current treatments have low-moderate success rates at best. Exercise is among the more successful treatments for this condition, however, the type and dosage of exercise that elicits the best results is not clearly defined. Tai chi is a gentle form of low intensity exercise that uses controlled movements in combination with relaxation techniques and is currently used as a safe form of exercise for people suffering from other chronic pain conditions such as arthritis. To date, there has been no scientific evaluation of tai chi as an intervention for people with back pain. Thus the aim of this study will be to examine the effects of a tai chi exercise program on pain and disability in people with long-term low back pain. The study will recruit 160 healthy individuals from the community setting to be randomised to either a tai chi intervention group or a wait-list control group. Individuals in the tai chi group will attend 2 tai chi sessions (40 minutes)/week for 8 weeks followed by 1 tai chi session/week for 2 weeks. The wait-list control will continue their usual health care practices and have the opportunity to participate in the tai chi program once they have completed the follow-up assessments. The primary outcome will be bothersomeness of back symptoms measured with a 0-10 numerical rating scale. Secondary outcomes include, self-reports of pain-related disability, health-related quality of life and global perceived effect of treatment. Statistical analysis of primary and secondary outcomes will be based on the intention to treat principle. Linear mixed models will be used to test for the effect of treatment on outcome at 10 weeks follow up. This trial has received ethics approval from The University of Sydney Human Research Ethics Committee. HREC Approval No.10452 This study will be the first trial in this area and the information on its effectiveness will allow patients, clinicians and treatment funders to make informed choices regarding this treatment. This trial has been registered with Australian New Zealand Clinical Trials Registry. ACTRN12608000270314.
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Descartes' concept that pain is produced by a direct, straight-through transmission system from injured tissues in the body to a pain centre in the brain has dominated pain research and therapy until recently. The gate control theory of pain, published in 1965, proposes that a mechanism in the dorsal horns of the spinal cord acts like a gate which inhibits or facilitates transmission from the body to the brain on the basis of the diameters of the active peripheral fibers as well as the dynamic action of brain processes. As a result, psychological variables such as past experience, attention and other cognitive activities have been integrated into current research and therapy on pain processes. The gate control theory, however, is not able to explain several chronic pain problems, such as phantom limb pain, which require a greater understanding of brain mechanisms. A new theory of brain function, together with recent research that has derived from it, are described. They throw light on complex pain problems and have important implications for basic assumptions in psychology.
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The purpose of this study was to investigate the effects of whole-body cryotherapy (WBC) on proprioceptive function, muscle force recovery following eccentric muscle contractions and tympanic temperature (T(TY) ). Thirty-six subjects were randomly assigned to a group receiving two 3-min treatments of -110 ± 3 °C or 15 ± 3 °C. Knee joint position sense (JPS), maximal voluntary isometric contraction (MVIC) of the knee extensors, force proprioception and T(TY) were recorded before, immediately after the exposure and again 15 min later. A convenience sample of 18 subjects also underwent an eccentric exercise protocol on their contralateral left leg 24 h before exposure. MVIC (left knee), peak power output (PPO) during a repeated sprint on a cycle ergometer and muscles soreness were measured pre-, 24, 48 and 72h post-treatment. WBC reduced T(TY) , by 0.3 °C, when compared with the control group (P<0.001). However, JPS, MVIC or force proprioception was not affected. Similarly, WBC did not effect MVIC, PPO or muscle soreness following eccentric exercise. WBC, administered 24 h after eccentric exercise, is ineffective in alleviating muscle soreness or enhancing muscle force recovery. The results of this study also indicate no increased risk of proprioceptive-related injury following WBC.
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GRADE A RECOMMENDATIONS (based on good-quality patient-oriented evidence): Advise patients to stay active and continue ordinary activity within the limits permitted by pain, avoid bed rest, and return to work early, which is associated with less disability. Consider McKenzie exercises, which are helpful for pain radiating below the knee. Recommend acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) if medication is necessary. COX-2 inhibitors, muscle relaxants, and opiate analgesics have not been shown to be more effective than NSAIDs for acute low back pain. Consider imaging if patients have no improvement after 6 weeks, although diagnostic tests or imaging is not usually required. GRADE B RECOMMENDATIONS (based on inconsistent or limited-quality patient-oriented evidence): Reassure patients that 90% of episodes resolve within 6 weeks-regardless of treatment. Advise patients that minor flares-ups may occur in the subsequent year. Consider a plain lumbosacral spine x-ray if there is suspicion of spinal fracture or compression. Consider a bone scan after 10 days, if fracture is still suspected or the patient has multiple sites of pain. Suspect cauda equina syndrome or severe or progressive neurological deficit if red flags are present. Obtain complete blood count, urinalysis, and sedimentation rate if cancer or infection are possibilities. If still suspicious, consider referral or perform other studies. Remember that a negative plain film x-ray does not rule out disease. GRADE C RECOMMENDATIONS (based on consensus, usual practice, opinion, disease-oriented evidence, or case series): Recommend ice for painful areas and stretching exercises. Discuss the use of proper body mechanics and safe back exercises for injury prevention. Refer for goal-directed manual physical therapy if there is no improvement in 1 to 2 weeks, not modalities such as heat, traction, ultrasound, or transcutaneous electrical nerve stimulation. Do not refer for surgery in the absence of red flags.
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The objective of this study is to study the prevalence of musculoskeletal complaints and disorders in a rural area in Iran. Interviews were conducted in randomly selected subjects from five villages in Tuyserkan County, northwestern part of Iran. The three phases of stage 1 Community Oriented Program for Control of Rheumatic Diseases were done during the same day. A total of 614 houses was visited, 1,565 persons interviewed, and 1,192 persons examined. Musculoskeletal complaints during the past 7 days were detected in 66.6% (shoulder 22.7%, wrist 17.4%, hands and fingers 14.9%, hip 13.9%, knee 39.2%, ankle 19.6%, toes 12.7%, cervical spine 17.9%, and dorsolumbar spine 41.9%). Degenerative joint diseases were detected in 20.5% (cervical spondylosis 2.2%, knee osteoarthritis [OA] 19.3%, hand OA 2.7%, and hip OA 0.13). Low back pain was detected in 23.4%, soft tissue rheumatism in 2.2%, rheumatoid arthritis in 0.19%, ankylosing spondylitis in 1.1%, systemic lupus erythematosus in 0.06%, and fibromyalgia in 0.06%. The prevalence of rheumatic complaints in rural Iran is very high and needs attention in the curricula of medical schools and in the planning of rural health care by the government.
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Systematic Review. To assess the effects of massage therapy for nonspecific low back pain. Low back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function. We searched MEDLINE, EMBASE, CINAHL from their beginning to May 2008. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 3), HealthSTAR and Dissertation abstracts up to 2006. There were no language restrictions. References in the included studies and in reviews of the literature were screened. The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. Two review authors selected the studies, assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. Both qualitative and meta-analyses were performed. Thirteen randomized trials were included. Eight had a high risk and 5 had a low risk of bias. One study was published in German and the rest in English. Massage was compared to an inert therapy (sham treatment) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups. In 8 studies, massage was compared to other active treatments. They showed that massage was similar to exercises, and massage was superior to joint mobilization, relaxation therapy, physical therapy, acupuncture, and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The beneficial effects of massage in patients with chronic low back pain lasted at least 1 year after the end of the treatment. Two studies compared 2 different techniques of massage. One concluded that acupuncture massage produces better results than classic (Swedish) massage and another concluded that Thai massage produces similar results to classic (Swedish) massage. Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.
Article
Background: Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as a therapeutic adjunct to the pharmacological management of pain. However, despite widespread use, its effectiveness in chronic low-back pain (LBP) is still controversial. Objectives: To determine whether TENS is more effective than placebo for the management of chronic LBP. Search strategy: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PEDro and CINAHL were searched up to July 19, 2007. Selection criteria: Only randomized controlled clinical trials (RCTs) comparing TENS to placebo in patients with chronic LBP were included. Data collection and analysis: Two review authors independently selected the trials, assessed their methodological quality and extracted relevant data. If quantitative meta-analysis was not possible, a qualitative synthesis was performed, taking into consideration 5 levels of evidence as recommended by the Cochrane Collaboration Back Review Group. Main results: Four high-quality RCTs (585 patients) met the selection criteria. Clinical heterogeneity prevented the use of meta-analysis. Therefore, a qualitative synthesis was completed. There was conflicting evidence about whether TENS was beneficial in reducing back pain intensity and consistent evidence in two trials (410 patients) that it did not improve back-specific functional status. There was moderate evidence that work status and the use of medical services did not change with treatment. Conflicting results were obtained from two studies regarding generic health status, with one study showing no improvement on the modified Sickness Impact Profile and another study showing significant improvements on several, but not all subsections of the SF-36 questionnaire. Multiple physical outcome measures lacked statistically significant improvement relative to placebo. In general, patients treated with acupuncture-like TENS responded similarly to those treated with conventional TENS. However, in two of the trials, an inadequate stimulation intensity was used for acupuncture-like TENS, given that muscle twitching was not induced. Optimal treatment schedules could not be reliably determined based on the available data. Adverse effects included minor skin irritation at the site of electrode placement. Authors' conclusions: At this time, the evidence from the small number of placebo-controlled trials does not support the use of TENS in the routine management of chronic LBP. Further research is encouraged.