Title: The effects of combined therapeutic protocol (kinesiotherapy and massage) on standing equilibrium in men with chronic low back pain due to lumbar disc herniation.
Author(s): Reza khanzadeh 1, Seyed Ali Akbar Hashemi-Javaheri 1, Farzad Omidi-Kashani 2, Amir Shahriar Ariamanesh 2*, Mahdi Mahjur 1
Affiliattion(s): 1- Facualty of physical education and sport sciences,, Ferdowsi University of Mashhad , Mashhad – Iran 2- Facualty of Orthopeadic Departmnet of Mashhad Medical University
* Corresponding Author
Vol 1, Num 1, July 2014
Introduction: Low back pain is one of the most common pains that most people will experience it at least for one time in their life. Based on past studies Patients with low back pain and sciatica have poor postural control and more postural fluctuations than normal individuals. The goal of this investigation was to study effects of the combined therapeutic protocol (kinesiotherapy and massage) on standing equilibrium in the patients with chronic low back pain due to lumbar disc herniation.
Materials and Methods: We conducted a semi experienced study in two groups (experimental and control), each composed of 15 male patients with average age of 41.61 ± 4.98 years. Combined protocol was performed for eight weeks on experimental group. Control group had no special activity during experiment period. Biodex system was used for evaluation of patients' standing equilibrium. Dependent and independent t-tests (p≤0.05) were used for data analysis.
Results: Results showed that the combined protocol had positive effect on improvement (p=0/005) of standing equilibrium in experimental group.
Conclusion: Based on these results, combined therapeutic protocol can be used to prevent or improve standing equilibrium in patients suffering from chronic low back pain.
Keywords: Chronic low back pain, Disc herniation, Standing equilibrium, Kinesiotherapy, Massage
Back pain is one of the most common pains which more than 80% of people experience it at least once during their life and is the most prevalent cause of referring to a doctor after respiratory diseases and also the third cause of inability at the age of work and activity (1, 2, 3). 97% of back pains are mechanical, 1% non-mechanical and 2% are due to hemal diseases. Meanwhile, intervertebral disc herniation is one of the main reasons for mechanical back pains. Due to extra motions of the back area which is located in the proximity of motionless area of sacrum, this area is exposed to mechanical pressures which may cause injury in the low back intervertebral disk and most disk herniations occur in the intervertebral disks L4-L5 and L5-S1.(4)
Old age, weight-gain, lifting heavy weights inappropriately, decrease in flexibility, decrement of fluid in the disks, i.e. poor physical condition altogether cause a disk to lose efficiency in the spinal column. At the present time, most traditional remedies fail to absolutely cure disk herniation because they only alleviate the symptoms of the disease, not the main cause of its appearance, whereas the long-term and effective approach is to deal with the major problem i.e. unsuitable posture and physical function which primarily cause the disease. Restoring the harmony, flexibility and power of the muscles by proper exercises will recover the balance and good physical function of the muscles and joints and therefore heal the disk herniation.(5)
It has been recently found that the instability of the spinal column and poor motion control are related to the musculoskeletal pain (6). Previous studies have shown that patients with back pain and sciatica have poorer control (7, 8) and more fluctuations in the standing position than healthy people (9). Balance is the ability to maintain the body's center of mass over a stable base of support. In the static and dynamic balance, the body position is controlled through the relocations of the center of mass and the start of proper responses for the body to return to a constant position. This is a complex process in which the sense of sight, somatic sense, vestibular sense and musculoskeletal system play an important role.
Although many studies have shown the relation between the body balance system and back pain, the ability of balance in these patients which reflexes the function of all body systems, is ignored during test, assessment and treatment process. Hence, injuries in the body balance system in back pain patients are not specifically cured (10, 11).
Ignoring some effective factors in the disease such as balance disorders of chronic back pain patients caused by lumbar disk herniation with a record of over 3 months of pain, may be one reason for the disease to relapse soon after the first treatment. Today it has been proved that suitable exercises and massage were useful for improving physical function and relieving the pain in chronic back pain patients (12), nevertheless, few studies in Iran have looked at the exercises role, type and rate of effect on reducing the side effects of disk herniation e.g. chronic sciatic pains. Therefore, considering the above mentioned, by studying the protocols of the movement therapy and combining it with massage therapy which reduce the back pain, rheumatoid arthritis, muscular pain and even migraine headaches, the researcher is to survey their effect on the static balance of the male patients with chronic back pain caused by lumbar disk herniation.
Materials and Methods
The present study is of semi-experimental type which includes 30 male patients with chronic back pain caused by lumbar disk herniation in L4-L5 or L5-S1 region. The examinees on average were 41.61±4.98 age, 78.55±11.3 kg weight, 175.81± 5.98 height and body mass index of 25.36±2.97 kg/m2 with a record of over 3 months of pain who were homogenized as diagnosed by the doctor by type, intensity, record and other effective conditions in the study and were voluntarily introduced to the sports clinic of the faculty of physical training and sport of Ferdowsi University of Mashhad.
After their demographic specifications were recorded, they were divided into 2 random groups of experimental (n=15) and control (n=15). The method of training was explained to the patients and afterwards, a written permission was received from each patient.
The experimental group received combined protocols of movement therapy and massage for 8 weeks, each week 3 sessions and each session 1 hour. The control group had no activity and followed the life's routine as usual. During the protocol 3 patients were removed from the experimental group owing to surgery, trip and high business activity. Also 1 patient was eliminated from the control group due to dissatisfaction with the study process.
All patients from both groups were under the some normal conditions without any sport activity and only the experimental group went through the planned process. Since the pain was chronic and the patients mentally endured the pain, none of them used any medicine and only when the pain intensified they could use sedatives. In order to prevent the above-mentioned medicines from affecting the experiments, patients were asked not to use any medicine 3 days prior to the experiments.
Biodex balance system was used to assess the static balance of the patients (fig. 1&2). (Balance system SD, 115 vac, 50/60 Hz 950-300). This system includes a graded circular platform, called "balance platform" located on a large ball with sensors which can easily change to different directions proportional to the force direction of feet pressure. The platform is adjustable in different levels of totally stable (level 12) and totally unstable (level 0).
In unstable levels the platform under the examinee's feet is sensitive to the smallest changes of center of mass and by changing the feet pressure, the platform direction changes proportional to the direction and size of the applied torque. But in the relatively stable level, the resistance of the platform decreases against the torque force caused by the patient's weight and direction change of the platform caused by the displacement of center of mass. Throughout the test, the patient stands on this platform and the deviations of the balance platform which is under the patient's feet are indicative of his deviations of center of mass. These deviations show the overall score and the standard deviation for the patient and are recorded as the static balance score.(14)
For the present study, considering the patients' conditions, in the Biodex system, the static level 8 was used which by default is set as full risk test for patients and elderly people. To begin the test, the patient as specified, stands on the balance platform, then the effect point in the gravity center of mass synchronized with the coordinates on the monitor of the balance platform and the platform was leveled with the horizon. When the patient is ready he pushes the start button and for 20 seconds the fluctuations on the platform were recorded in the system. During this time the patient must try to hold his effect point of mass force in the center of system coordinates. This was repeated 3 times at each 20 seconds with a 10-second interval for rest and finally, the average scores of the 3 tests were recorded as the total score of the patient's static balance.
The protocol of the movement therapy and massage included 3 phases: 1. Preliminary: 6 sessions were conducted to prepare the patient mentally and physically and partially strengthen the stabilizer muscles of the spinal column and also increase the movement amplitude of the lumbar and pelvic region. Each session contained: 15 minutes of massage therapy on the lumbar region by a massage therapist (including stroking, friction and kneading massage in the Russian style), stretching exercises of the lumbar-pelvic muscles for 10 to 12 minutes, strengthening exercises of the lumbar-pelvic muscles of the spinal column for 18 to 20 minutes, repeating the stretching exercises within a shorter time of 2 to 3 minutes and finally, having the patient sitting on the physioball for 5 minutes and performing sway forward and backward. 2. Main: 12 sessions were conducted to strengthen the stabilizer muscles more professionally, entirely restore the movement amplitude of the lumbar-pelvic region. Each session contained 15 minutes of massage by the same massage therapist in the preliminary phase, 5 minutes of cycling on a stationary bike, performing a military march on a mini trampoline for 2 minutes, stretching exercises of the lumbar muscles with increased force by the therapist in order to increase the amplitude of the lumbar and pelvic region for 9 to 10 minutes, strengthening exercises of the lumbar-pelvic muscles of the spinal column for 18 to 20 minutes with more contraction compared to the preliminary phase, repeating the stretching exercises for 2 minutes and finally, 5 minutes of sitting on the physioball and performing sway forward and backward. 3. Stabilization: 6 sessions were conducted to stabilize the patient's conditions and prepare him to continue the exercises throughout his life and during this time, his physical and mental condition was stabilized by continuing the exercises.
After this period, the tests were repeated and the results after the scores were found to be normally distributed and all variances by the Kolmogorov-smirnov and Leven's test by using correlated and independent T-test were analyzed.
Considering the results of the present study (table1), no significant difference between measures of static balance of the control group were found before and after the test (P=/0899), whereas in the experimental group, the difference in the scores of balance before after the test was statistically significant (P=0/005). The comparison of the variations in both groups (table2) shows a significant difference. The study results showed a decrease of 19/6% in the static balance of the experimental group which was statistically significant, but there was a 0/76% decrease in the control group which was not statistically significant.
Most pathophysiologists relate the back pain to the muscular system, connective tissue and the nervous system (15) as it has been proven that back pain comes with balance disorders (14).
It is very important to retain the standing position and measuring it in the laboratory or clinic is used as a tool to assess the stability and control the neuromuscular system in healthy and injured people (16). The body gravity center relocates continuously even in the static standing. Postural fluctuations as body improvement activity caused by the control of body condition are determined by measuring the location and level of variations of the vertical ground reaction force (VGRF) in the horizontal surface (17).
Proprioception is one of the most important somatic sensations which is damaged in soft tissue injuries. Ligament and joint capsule injuries, joint inflammation and premature arthritis lead to proprioception failure (18, 19) and consequently instability of the joint dynamics (20). Postural fluctuations in the stationary state and standing position usually show the body's attempt to preserve the balance in a desired posture. In other words, increase in the fluctuations is indicative of more attempt and therefore poorer balance (21). If the proprioception failure is remained due to being ignored in the rehabilitation programs, it may be the first factor in further injuries after the improvement surgeries (22).
Studies have shown that proprioception is tractable and despite the loose ligament, the rehabilitation programs which are mainly for instructing the proprioception cause the functional movements to progress (23). Therefore, the present study was conducted in order to assess the effect of combined protocol of movement therapy and massage on the static balance of male patients with chronic back pain caused by lumbar disk herniation. The study results showed that the combined protocol of movement therapy and massage is effective on the static balance of male patients with chronic back pain caused by lumbar disk herniation.
The results of the present study are consistent with those of Joshua et.al, examining the effects of the stabilizing exercises on relieving back pain and local instability of disk herniation patients (24), since the stabilizing exercises of the spinal column were used in this movement therapy protocol.
These results also were in agreement with the findings of Richardson and Hamilton (2002), studying the effects of modern non-medical methods e.g. massage and movement therapy on precautions, pain relief and increasing the ability of back pain patients and radicular pains (25). Recent studies have indicated that instability of the spinal column or movement control and poor balance are associated with and diagnosed by the musculoskeletal pain (26).
Harding et.al also mentioned a poor balance control in patients with chronic pains (27). Sinot et.al showed in their study that patients with chronic back pain have poorer balance in the standing position than healthy people and cannot balance on one foot (28). Therefore, it can be concluded that all researches which improved the patients' function and reduced the pain in the patients with chronic back pain also improved their balance, because as mentioned above, mechanical nociceptors of the joints and soft tissues around the back are affected when the spinal column is damaged and primary injuries of sense perceptions may change the muscle spindles, Golgi tendon organs and joint and skin nociceptors and provide false information about the body position and center of mass (29). These cases can confirm the combined protocol of movement therapy and massage in the present study, because the exercises in this protocol improved the muscle spindles, Golgi tendon organs and joint nociceptors by strengthening (contraction) and stretching exercises.
Golgi tendon organs are induced by stress and muscle spindles by the length change and send their sense information to all levels of the central nervous system. The deep sense information forms reflexive responses and is the base of balance and posture (30). The stretch reflex plays an important role in proprioception and increases the resilience of the muscle. Therefore, when the body posture changes, the muscles resist against being overstretched and in fact, people who lose their stretch reflex as a result of the nerve damage have much less ability to correct their posture that the body's deviations and fluctuations are distinctive as the speed increases.
Massage therapy plays an important role in improving the muscles function through increasing blood supply and threshold of stimulation in the proprioceptions. This was supported by the study of Olva Frod et.al (31) in relation to manual therapy and massage therapy. Massage reduces the pain and muscle fatigue (32) and also increases blood supply and speed of the muscles relief after the exercise (33). Other advantages of massage include: Its effect on reducing stress, depression and stress hormones such as norepinephrine and cortisol and also increasing the level of serotonin and dopamine. When the serotonin level increases through massage therapy, it can reduce depression and decrease in dopamine level reduces the chronic pain of the patients (34).
The study results showed an improvement of 19.6% in the static balance of the experimental group and 0.76% in the control group and this indicated that the improvement in the static balance of the patients may be the result of the combined protocol of movement therapy and massage.
Reza khanzadeh Facualty of physical education and sport sciences,, Ferdowsi University of Mashhad , Mashhad – Iran R.firstname.lastname@example.org
Seyed Ali Akbar Hashemi-Javaheri Facualty of physical education and sport sciences,, Ferdowsi University of Mashhad , Mashhad – Iran email@example.com
Farzad Omidi-Kashani MD Facualty of Orthopeadic Departmnet of Mashhad Medical University Kashani.firstname.lastname@example.org
Amir Shahriar Ariamanesh MD Facualty of Orthopeadic Departmnet of Mashhad Medical University Corresponding Author email@example.com
Mahdi Mahjur Facualty of physical education and sport sciences, Ferdowsi University of Mashhad , Mashhad – Iran firstname.lastname@example.org
Acknowledgements: None declared.
Financial disclosure: None declared.
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