EFFECT OF THERAPEUTIC EXERCISES WITH OR WITHOUT POSITIONAL RELEASE TECHNIQUE IN TREATMENT OF CHRONIC MECHANICAL LOW BACK PAIN PATIENTS: A RANDOMIZED CONTROLLED TRIAL

Abstract

Introduction: Chronic Mechanical Low Back Dysfunction (CMLBD) is the most common problem of the working-age population in modern industrial society; it causes a substantial economic burden due to the wide use of medical services and absence from work. Aim of work: To investigate the effect of positional release technique on patients with chronic mechanical low back pain. Materials and Methods: Thirty two patients from both sexes were diagnosed with CMLBP, aged 20 to 45 years and were divided randomly into two equal groups; sixteen patients each; group A (control group) received therapeutic exercises that include (Stretch and Strength exercises for back and abdominal muscles). Group B (experimental group) received therapeutic exercises with positional release technique; treatment was applied 3 days/week for 4 weeks. Pain was measured by Visual Analogue Scale, Lumbar range of motion was measured by Inclinometer and Functional disability was measured by Oswestry disability scale. Measurements were taken at two intervals pre-treatment and post-treatment. Results: Data obtained was analyzed via paired and unpaired t-Test. There were statistical differences between the 2 groups, where the experimental group showed greater improvement than control group. Conclusion: Positional release technique

Full text

Egyptian Journal of Occupational Medicine, 2014; 38 (2) : 125-139
125
EFFECT OF THERAPEUTIC EXERCISES WITH
OR WITHOUT POSITIONAL RELEASE TECHNIQUE
IN TREATMENT OF CHRONIC MECHANICAL LOW
BACK PAIN PATIENTS: A RANDOMIZED
CONTROLLED TRIAL
By
1Mohamed MN and 2El Shiwi AMF
1Department of Basic Science, 2Department of physical therapy for musculoskeletal disorders and its surgery,
Faculty of physical therapy, Cairo University.
Abstract
Introduction: Chronic Mechanical Low Back Dysfunction (CMLBD) is the most
common problem of the working-age population in modern industrial society; it causes
a substantial economic burden due to the wide use of medical services and absence
from work. Aim of work: To investigate the effect of positional release technique
on patients with chronic mechanical low back pain. Materials and Methods: Thirty
two patients from both sexes were diagnosed with CMLBP, aged 20 to 45 years and
were divided randomly into two equal groups; sixteen patients each; group A (control
group) received therapeutic exercises that include ( Stretch and Strength exercises
for back and abdominal muscles). Group B (experimental group) received therapeutic
exercises with positional release technique; treatment was applied 3 days/week for
4 weeks. Pain was measured by Visual Analogue Scale, Lumbar range of motion
was measured by Inclinometer and Functional disability was measured by Oswestry
disability scale. Measurements were taken at two intervals pre-treatment and post-
treatment. Results: Data obtained was analyzed via paired and unpaired t-Test. There
were statistical differences between the 2 groups, where the experimental group showed
greater improvement than control group. Conclusion: Positional release technique

Mohamed MN & El Shiwi AMF
126
Introduction
Chronic mechanical low back
dysfunction (CMLBD) is a major cause
of illness and disability, especially in
people of working age, and in most
cases there is no clearly demonstrable
underlying pathology(Endean et al.,
2011)
It is a common problem which
affects the majority of the population.
The lifetime prevalence of LBP varies
from 60 to 90 percent with an annual
incidence of 5% (Aroma and Koskinen,
2000).
In Egypt, gradually shifting from
agriculture to an industrial era, low
back pain is one of the leading causes
for seeking health care providers. It
is one of the most common reasons of
absenteeism from work, resulting in
high costs in terms of expenditure on
diagnosis and treatment and in days lost
from work (El-Sayyad, 2006).
In the majority of cases, back
problems tend to show the rst
symptoms before the age of twenty.
Usually, the pain is acute and heals by
itself in less than two months, but most
of these cases will experience relapses
with each episode becoming worse
and worse. Approximately 5 to 10% of
cases become chronic, lasting over two
months and creating a major medical
challenge (Leboeuf and Kyvik, 1998).
With careful analysis and with
consideration of the anatomy of the
vertebral column, the structure of its
components and its variety of functions,
it is clear that the causes of back ache are
numerous. These causes are: sedentary
life style, less physical activity among
young people and adults, over weight
and obesity which contribute to extra
stress on the spine, poor postural habits,
poor body mechanics in working
procedures, certain repetitive motion,
and the unavoidable accidents or trauma
induced injury to the back (Fryomer and
Selby, 1993).
Evaluation and treatment of low back
dysfunction is still insufcient. Patients
still have some degree of disability and
pain even after rehabilitation (Difabio
et al., 1996).
is considered as an effective treatment for reducing pain, functional disability and
increasing lumbar range of motion in individuals with chronic mechanical low back
pain.
Keywords: Chronic Mechanical Low back Pain, Traditional physical therapy program,
Positional release technique, Functional disability.

Effect of Therapeutic Exercises in LBP 127
Physiotherapy is the most
common method used to apply non-
operative treatment and may include
the use of modalities for pain relief,
manual therapy, bracing, exercise,
electrical stimulation and activity
modication. Physiotherapy treatment
is recommended to reduce pain, to
restore range of motion and function,
and to strengthen and stabilize the spine
(Hall and Brody, 1999).
Positional release technique (PRT)
is an osteopathic treatment technique
rst developed by Jones in 1981.
Positional release (also known as strain
counter-strain) is an indirect osteopathic
technique, whereby dysfunctional
joints and their muscle are moved
away from their restrictive barrier into
position of ease in the treatment of both
musculoskeletal (D’Ambrogio and
Roth, 1997).
The application of positional release
technique for somatic dysfunction
requires a practitioner to rst palpate
a tender point in the soft tissues. The
patient’s limb is then moved in such
a way that the pain associated with
pressure on the tender points is relieved
by at least 70 percent to nd position
of ease (Wong and Schauer, 2004).
Jones (1981) suggests a minimum
period required to hold a position of
ease as 90 seconds. It is theorized that
the shortening or “folding-over” of
aberrant tissue in positional release
achieves its therapeutic modications
via both propriceptive and nociceptive
mechanisms (Bailey and Dick, 1992).
Researches of various kinds of
treatments show strong evidence
that manual therapy has a positive
effect on patients with long term low
back dysfunction, but there is still no
evidence for the best type of modality
chosen (Harden et al., 2000).
Aim of work
To investigate the effect of
therapeutic exercises with or without
positional release technique in treatment
of chronic mechanical low back pain.
Materials and Methods
This study was conducted in the
outpatient clinic of physical therapy
department in New EL Kaser El Aini
teaching hospital to evaluate the
efcacy of therapeutic exercises with or
without positional release technique in
treatment of CMLBP.
Design of study
Pre-test post-test design was used.
Thirty two patients of both sexes with

Mohamed MN & El Shiwi AMF
128
low back dysfunction were randomly
assigned in two groups with sixteen
(16) subjects in each one.
Subjects:
Participants were identied and
recruited over 10-month period. Thirty
eight patients diagnosed clinically with
chronic mechanical low back pain
(according to location of trigger points
at lower back muscles and aggravation
of pain with back activities) were
examined for eligibility in the study
(Figure: 1)
-5-
Figure 1: Participant flow diagram
Inclusion Criteria:
- Patients (office workers) had low back pain for 3 months ago.
- Patients had moderate disability care (20-40%) determined through
Oswestry Low Back Pain Disability Questionnaire.
Assessed for eligibility
(n=38)
Discontinued intervention (n=0)
Discontinued intervention (n=0)
Analyzed (n=16)
Analyzed (n=16)
Allocated to intervention (n=16)
Received Allocated to intervention (n=16)
Did not Received Allocated to intervention
(n=16)
Allocated to intervention (n=16)
Received Allocated to intervention (n=16)
Did not Received Allocated to intervention
(n=15)
Excluded (n=6)
Not meeting the inclusion (n=4)
Refused to participate (n=
2)
Randomized (n=32)
Figure 1: Participant ow diagram

Effect of Therapeutic Exercises in LBP 129
Inclusion Criteria:
- Patients (ofce workers) had low
back pain for 3 months ago.
- Patients had moderate disability
care (20-40%) determined through
Oswestry Low Back Pain Disability
Questionnaire.
- Patients able to perform Range of
movement (ROM) test of Lumbar
Spine (exion, extension and side
binding) within limit of pain.
Exclusion Criteria:
- Pregnant women.
- History of previous back surgery.
- Current lower extremity symptoms.
- Cardiopulmonary disease with
decreased activity tolerance.
- Neuromuscular disease like multiple
sclerosis.
Thirty two patients (25 male and
7 female) was diagnosed as CMLBP,
their age ranges from 20 to 45 years
signed an informed consent and selected
randomly (one by one for each group).
Group A (Control) 16 patients received
therapeutic exercises (stretching
exercises and strengthening exercises
for back and abdominal muscles), and
Group B (experimental) 16 patients
with therapeutic exercises positional
release technique.
All patients were referred by
orthopedic surgeons who are responsible
for diagnosis of cases based on clinical
and radiological examinations.
Instrumentations:
A- Instrumentations used for
evaluation:
Patients were assessed just before
and after the treatment sessions. The
assessment procedures include the
following items.
1- Pain assessment:
Pain assessed by Visual analog
scale (VAS). VAS is a scale that allows
continuous data analysis and uses a
10cm line with 0 (no pain) and 10
(worst pain) on the other end. Patients
were asked to place a mark along the
line to denote their level of pain (Marc
A, 2001).
2- Functional disability:
Functional disability of each patient
was assessed by Oswestry disability
questionnaire .It is valid and reliable
tool. It consists of 10 multiple choice
questions for back pain, patient select
one sentence out of six that best
describe his pain. Higher scores indicate

Mohamed MN & El Shiwi AMF
130
great pain.[ Scores (0-20%) min i mal
disability, Scores (20%- 40%)
moderate, Scores (40% - 60%)
severe, Scores(60%-80%) crippled,
Scores (80% - 100%) patients are
conned to bed ] (Fair Bank and Ronald
et al., 2000).
3- Range of motion assessment:
The inclinometer was used, it is a
pendulum-based goniometry consisting
of a 360 degree scale protractor with a
counter weighted pointer maintained in
a constantly vertical position, it’s a hand
held, circular, air or uid disk, and it
used to measure spinal motion (Jackson
et al., 2006).
The double inclinometer technique
(two inclinometers) was used for
measuring lumber Range Of Movement
(ROM)
1) Assessment of lumbar exion
The starting position as the patient
was instructed to stand erect with feet
contact to each other. The examiner
palpates two points on the spine S1
and T12.The inclinometers were placed
(centered) on the two palpation points
and calibrated to zero. The patient was
instructed to slowly bend forward to
end of range within limit of pain. The
reading on each inclinometer was
recorded. The top inclinometer measures
total exion, the bottom inclinometer
measures sacral exion. Total exion
minus sacral exion is true exion.
True exion is the measurement usually
needed.
2) Assessment of lumbar
extension:
Repeat exion protocol for extension
having the patient extend back for full
extension or one inclinometer in mid of
lumber spine L3.
3) Side bending:
One inclinometer was placed on
sacrum for side bending, the patient was
instructed to stand erect with feet slight
apart, and the patient was instructed to
slowly side as his hand contact to his
ankle within limit of pain.
Treatment procedure:
Group (A):
Therapeutic exercises include:
- -Mild stretching exercises for 30
seconds for hamstring, calf muscles,
and back muscles from long setting
(El Naggar et al., 1991).
- -Strengthening exercises for back
muscles, bridging and active back
extension, (Jari et al., 2004) and
abdominal muscles, sit up exercise,

Effect of Therapeutic Exercises in LBP 131
and posterior pelvic tilt, (El Naggar
et al., 1991), 12 sessions, 3 sessions
per week for one month. Each
exercise was done 3 times at session
with hold for 6 seconds
Group (B):
1. Therapeutic exercises as group A.
2. Positional release technique: It’s
indirect (the body parts moves
away from the resistance barrier,
i.e. the direction of greatest ease)
and passive (the therapist performs
all the movement without help from
the patient) method of total body
evaluation and treatment using most
severe tender points and position of
comfort to resolve the associated
dysfunction, It was done 3 times
per session, for 12 sessions 3/week
every other day for one month.
Posterior lumbar tender points are
located on the spinous processes, in
the Para spinal area or the tips of the
transverse processes in attachment of
the quadrates lamborum and hold 90
seconds for each one and repeat three
times (D’Ambrogio and Roth, 1997).
- Location of tender points: These
tender points are located on lateral
aspect of transverse processes
from L1 to L5pressure is applied
interiorly and then medially (Figure
1).
Figure (1): Quadratus lamborum
muscle and its tender point adapted
from (D’Ambrogio and Roth, 1997).
The patient was prone with the
trunk laterally exed toward the tender
point side. The therapist was standing
on the side of the tender point. The
therapist placed his knee on the table
and rests the patient’s affected leg on
the therapist’s thigh. The patient’s hip
was extended and abducted, and slight
rotation was used to ne-tune.
Statistical analysis
Descriptive statistics was used to
give subject characters. Inferential
statistics was used in form: Paired t-Test
to examine the difference between two
groups pre & post treatment. Unpaired
t-Test to examine the difference between
two groups post treatment. Level of
signicance for all tests were set at P
value was 0.05.

Mohamed MN & El Shiwi AMF
132
Results
Table 1- Demographic data of patients.
P-valuest-test
Experimental
group
Control
group
Variables
.2 (N.S.)1.1650.94±3.1646.13±2.64Age (Year)
.1 (N.S.)1.4681±2.3386.31±2.79Weight (Kg)
.9 (N.S.).25169.88±3.29169.63±9.11Height (Cm)
N.S: Non signicant
A total of 32 patients participated in this study, they were assigned
randomly into two groups; the control group which consisted of 16
patients with mean age of 46.13 (± 2.64) years, mean weight of 86.31
(± 2.79) kg, mean height of 169. 63 (± 9.11) cm. The experimental group consisted
of 16 patients with a mean age of 50.94 (± 3.16) years, mean weight of 81 (±
2.33) Kg, mean height of 169.88 (± 3.29) cm. Using unpaired t-test showed that
there were no signicant differences between groups before treatment for these
demographic data (Table 1).

Effect of Therapeutic Exercises in LBP 133
Table 2- Comparison between groups before treatment.
P-valuesT
Experimental
group
Control
group
Variables
1.7 (N.S.)-1.397.37±.326.62±.42Pain Severity
.24 (N.S.)-1.221.18±1.2719±1.29Function disability
.2 (N.S.)1.1225.62±2.3229.06±.06Flexion
.08 (N.S.)-1.1712.06±1.229.81±.47Extension
.9 (N.S.).118.81±.758.93±.8Right side bending
.1 (N.S.)1.398.12±.129.68±.68Left side bending
N.S: Non signicant
Unpaired t-test was used was used to detect differences between groups before
treatment. There was no signicant differences between groups regarding pain
severity, functional disability, lumbar exion, lumbar extension, lumbar right
bending, and lumbar left bending (Table 2).

Mohamed MN & El Shiwi AMF
134
Table 3- Post treatment inter group difference:
P-valuesT
Experiment
group
Control groupVariables
.001**4.733.13±.255.56±.44Pain Severity
.05**1.8513.25±.8816.18±1.31Function disability
.04*-3.13 45.63±2.7334.37±2.32Flexion
.009**-2.912.63±.899.85±.34Extension
.5-.612.19±.0811.56±.8Right side bending
.4-.612.06±.7311.37±.66Left side bending
*Signicant at the .05 level ** Signicant at the .01 level
Unpaired t-test was used to detect differences between groups after treatment.
There was signicant difference in favor of experimental group than control group
of: pain severity, functional disability, lumbar exion, lumbar extension, but no
difference regarding lumbar right bending and lumbar lift bending (Table 3).

Effect of Therapeutic Exercises in LBP 135
Discussion
Chronic mechanical low back pain
(CMLBD) is one of the most common
causes of inappropriate back function.
Positional release technique has been
reported to be effective in the treatment
of patients with back pain. This study
was conducted to examine the effect of
therapeutic exercises with or without
positional release technique in treatment
of chronic mechanical low back pain
patients.
The ndings of this study
demonstrated that the experimental
group that received therapeutic exercises
and positional release technique showed
greater improvement in pain threshold,
functional disability and active lumbar
range of motion in both exion and
extension but no improvement in right
and left side bending than the control
group.
1- Therapeutic exercises:
The improvement may be
attributed to the effect of therapeutic
exercises used in this study in the form
strengthening and stretching exercises
of the back muscles. This nding has
been supported by (Bentsen et al., 1997;
Liddle et al., 2004; Jari et al., 2004 and
Jemmett, 2003)
Strengthening exercises for lower
back muscles increased the strength
of weak muscles which increased the
stability of the spine which helped in
reduction of pain level (Bentsen et al.,
1997).
The signicant reduction of pain
level may be due to the effect of
stretching on paravertebral muscles
and other back soft tissues which
reduced muscle tension and relieved the
compression on muscles nociceptors
and on nerve root and broke the vicious
circle. Also, it decreased cellular
connective tissues in paravertebral
muscles and decreased muscle stiffness
which lead to reduction of pain (Liddle
et al., 2004). Jari et al., (2004) reported
that increased trunk exion range of
motion after exion and extension
exercises due to increased exibility
and mobility of the trunk.
The patient’s functional activities
improved as the pain decreased and the
lumbar ROM increased. In addition,
the exercise program aimed to increase
individuals’ condence in the use of
their spine and overcome the fear of
physical activity (Jemmett, 2003).
2- Positional release technique:
To examine the analgesic effects

Mohamed MN & El Shiwi AMF
136
of positional release technique (PRT),
comparison between pre and post
results of pain assessment using visual
analogue scale for the (CMLBP)
patients in the experimental group
was done. The results showed a highly
signicant decrease in low back pain at
the end of treatment program.
The analgesic effect of positional
release technique could be attributed to
Bailey and Dick (1992). He proposed
a nociceptive hypothesis that tissue
damage in dysfunctional muscle can
be reduced by the positional release
mechanism utilized by PRT. They
suggested that relaxation of the damaged
tissues may be achieved by placing
patients in a position of ease which
may advance local perfusion of uids
(i.e. blood and lymph) and enhance the
removal of sensitizing inammatory
mediators.
This result also supported by Cleland
et al (2005) who produced evidence of
increased pain free grip strength and
decreased pain scores after treatment
applied to the area of lateral epicondyle
and the cervicothoracic spine.
This was supported by a study done
by (Wong and Schauer, 2004). The
study examines the reliability, validity
and effectiveness of strain counter-
stain, the experimental design employed
a convenience sample of 49 volunteers
with bilateral hip tender points. They
found signicant pain decrease in both
muscle groups demonstrated with the
VAS at end of treatment after application
of strain counter-stain.
These ndings were supported by
Collin (2007) who reports on the case
of 14 years with grade II ankle sprain,
and the benets recorded by way of the
analgesic effect of PRT in improving
function. A decrease of two points on a
numeric pain rating scale was reported
for overall pain after two months as was
as decrease in tenderness for 10 out of
13 tender points. This analgesic effect
was considered clinically signicant
and was suggestive of the need for more
formal investigation.
Concerning lumbar range of motion,
there was signicant increase at lumbar
exion, extension, Rt side bending
and Lt side bending after treatment of
patients by PRT, In comparison between
two groups there was signicant
increase in lumbar exion and extension
post treatment in experimental than
controlled but no signicant in Rt side
bending and Lt side bending between
them.

Effect of Therapeutic Exercises in LBP 137
As LBD seems to be due to tight
and contracted muscles, where muscle
bers respond to trauma or abnormal
stress by releasing calcium from the
sacroplasmic reticulum or through
the injured sacrolemma, which causes
uncontrolled shortening activity and
increased metabolism, this sustained
muscle contraction decreases the blood
supply, leading to an accumulation of
waste products, and eventual muscle
fatigue and also to the stimulation of
the nociceptors which leads to more
severe pain. This can lead to a self
perpetuating circle where shorting of
the muscle leads to loss of sarcomeres,
increase the proportion of the collagen
in the muscles which aggravates pain
and increases muscle stiffness, thus
decreasing active lumbar ROM (Hong,
1996).
This was supported by a study done
by (Eisenhart, 2003) who evaluate
the efcacy of osteopathic manual
therapy (OMT) for patients with acute
ankle sprain (OMT include myofacial
release, stretch and positional release).
Patients in the OMT study group had
a statistically signicant improvement
in edema, pain and trend toward
increased ROM immediately following
intervention with OMT.
In contrast, (Trevor et al., 2005)
provides study to investigate the
effect of positional release therapy
(PRT) technique to increase hamstring
exibility, Hamstring exibility was
assessed before and after each technique
by measuring the popliteal angle
during maximal active knee extension
performed in sitting, A blinded
evaluator measured popliteal angles on
digital photographs using a standard
protractor. The nding suggested that
the PRT technique is not effective to
increase knee extension in healthy
subjects who have decreased hamstring
exibility.
From all of the above, it was
approved that application of (PRT)
is effective as a treating method for
(CLBD) patients owing to its analgesic
effects so it helps in reducing pain and
functional disability and improving
lumbar range of motion.
To examine the effect of the (PRT)
on reducing functional disability,
comparison between pre and post
results of functional disability using
Oswestry disability questionnaire for
the (CLBD) patients of experimental
group there was highly signicant
decrease in functional disability at the
end of the treatment.

Mohamed MN & El Shiwi AMF
138
These ndings were in agreement
with Lewis and Flynn (2001) who
reported on four case studies of patients
with low back pain treated with
PRT protocols. The authors detected
improvements in the outcomes measured
for disability levels (Oswestry Low
Back Pain Disability Questionnaire)
and pain (Mc Gill Pain Questionnaire)
in all cases.
This was supported by a study done
by Dardinski et al. (2000) who founds
in a retrospective review of 20 patients
suffering from chronic localized
myofascial pain, the use of the PRT
could be benecial in reducing pain and
improving function.
Positional release technique
decreases joint and muscle pain,
decreases joint swelling and stiffness
and so increase mobility and a quality
of life (D’Ambrogio and Roth, 1997).
The improvement in functional
ability for (CMLBP) patients in this
study could be attributed to analgesic
effect of PRT which lead to decrease
pain and improve back functions.
Conclusion
Positional release technique is
effective in reducing pain, functional
disability and improving lumbar range
of motion in patients with chronic
mechanical low back pain.
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