Effectiveness of Self Myofascial Release Technique in the Management of Non-Specific Low Back Pain in Nursing Professionals

Nonspecific low back pain (NSLBP) is defined as low back pain not attributed to recognizable, known specific pathology (van Tulder 2006). The global prevalence of activity-limiting LBP was recently estimated to be approximately 39% for lifetime prevalence and 18% for point-prevalence (Hoy et al. 2012). In spite of an enormous increase in the health resources spent on LBP disorders, the disability relating to them continues to increase. (Deyo et al. 2009) NSLBP remains a common and exorbitant problem among the nursing profession with a lifetime prevalence extending between 73% and 90% (Maul et al., 2003), a major cause of suffering, disability, and days of work lost. The frequency of reported disability from back injuries in nurses is among the highest of all worker groups (Jensen 1987). It accounts for 16·2% of all sick leave for nurses (Stubbs et al. 1983) and impairs performance. Myofascial release (MFR) is a form of manual therapy which involves the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function (Barnes, 1990). It has been hypothesized that fascial restrictions in one part of the body cause undue tension in other parts of the body due to fascial continuity. This may result in stress on any structures that are enveloped, divided, or supported by fascia (Schleip, 2003). Self MFR involves the application of MFR by themselves with the help of fingers, hands or hand held devices. A recent study by Ajimsha et al (2015) found that MFR was more effective than a control intervention in the back pain management of nursing professionals. The main objective of this study was to investigate whether Self Myofascial Release (SMFR) technique can reduces pain and disability in non-specific low back pain (NSLBP) in comparison with a control group receiving a sham Myofascial release (Sham-MFR) in nursing professionals. Methods This study was designed as a Randomized, controlled, single blinded trial and carried out in the clinical wing of Myofascial Therapy and Research Foundation, Kerala, India. Inclusion criteria for this study was nursing professionals aged 30–50 years with a diagnosis of NSLBP of 3 or more month's duration. Patients were excluded if they displayed: 1) osteoporosis of the spine; 2) primary joint disease such as active rheumatoid arthritis; 3) metabolic bone disease; 4) malignant bone disease; 5) fracture; 6) hyper mobility of the lumbar/sacral spine; 7) cardiovascular or other medical disorder preventing the person from engaging in strenuous exercise; 8) evidence of radiculopathy, or primary complaint of radiating pain; 9) pregnancy; or 10) severe psychiatric disturbance. Use of oral/systemic steroids, use of analgesics on more than 10 days a month and any other treatment for LBP during the previous 6 months were also excluded from the study. The Research Ethics Committee of the Myofascial Therapy and Research Foundation and Medical Research wing of Mahatma Gandhi University, Kerala, India, reviewed the study and raised no objections from an ethical point of view. Between May 2013 and October 2014, 73 nursing professionals were referred to the Myofascial Therapy and Research Foundation with a diagnosis of NSLBP. Of these, 57 individuals who met the inclusion criteria and provided written informed consent were randomized to the Self MFR (SMFR) or to the control arm of the study. Participants were asked to maintain a pain and medication diary in which any medication or change in pain pattern during the treatment period was to be recorded with date and time. The SMFR were administered by the nurses themselves whereas the sham-MFR was applied by physical therapists in a predetermined dosage (12 sessions in 4 weeks). Main outcome measure The McGill Pain Questionnaire (MPQ) for subjective pain experience and Quebec Back Pain Disability Scale (QBPDS) to assess the disability associated with NSLBP. The primary outcome measure was the difference in MPQ and QBPDS scores between week 1 (pretest score), week 4 (posttest score), and follow-up at week 12 after randomization. Two evaluators blinded to the group to which the participants belonged analyzed scores from the MPQ and QBPDS. Procedure Subjects in each group received either SMFR, or a sham MFR program. The 2 interventions were provided for 3 times per week for 4 weeks (weeks 1–4), with a minimum of a 1 day gap between the 2 sessions; the duration of each treatment session was set as 45 min. A recorded audio which gives step wise instruction for the SMFR was given to the SMFR group with fixed daily timing for the release. A research assistant calls and confirms the SMFR adherence in a daily basis. MFR procedure We used the following treatment protocol for all the patients in the SMFR group derived from the protocol used by Ajimsha et al (2015) in his study. A normal tennis ball and a Rumble Roller® (RR 316, blue, original density) were the items given to the clients in the SMFR group. The clients in the SMFR group were given one hour training for the SMFR and were asked to demonstrate it on the very next day to a therapist who was not the instructor of the SMFR. Control intervention Patients in the control group received sham MFR over the same areas as the application of SMFR (in the other group) for same time and duration. Sham MFR were applied by gently placing the hand over the areas treated in the SMFR group just enough to maintain contact for the desired time. All study participants were advised to take medications only when there were any exacerbations, but were required to record them in their patient diaries, which were analyzed at weeks 4 and 12 after randomization SMFR protocol. a) MFR of the Gluteus Maximus and piriformis Client's Position: Supine with hips and knees bend Technique: By using a tennis ball at the area of release (between the posterior superior iliac spine and the greater trochanter, the client will be asked to slowly press the body against the ball in a way that it elicits an aching pain the region. The body has to be adjusted by using the weight transferred through the feet to roll the ball between the above positions. The client has to stop the rolling for 30 seconds at any point where he/she feels more pain. (Duration: 5 min × 2 sides = 10 min) b) Back work lower Client's Position: Supine with hips and knees flexed The client places themselves over a Rumble Roller so that the foam roller will be positioned at the lower back in the lumbosacral region. The client is trained in moving the lower back over the roller and releasing the muscles and fascia of the lower back by using the feet. (Duration: 4 minutes release, 2 minutes rest, 4 minutes release = 10 min). b) Back work upper Client's Position: Supine with hips and knees flexed. The Rumble Roller was positioned at the upper back in the thoracic region. The client is trained in moving the upper back over the roller and releasing the muscles and fascia of the lower back by using the feet. (Duration: 4 minutes release, 2 minutes rest, 4 minutes release = 10 min). c) The Trunk sides Client's Position: Side lying, head supported by a pillow. Hips in 450 of flexion, knees in 350 of flexion. The client places themselves over a Rumble Roller in a side line position so that the area between greater trochanter and lower ribs can be released. The client stabilizes himself over the form roller with the help of the upper and lower extremities opposite to the lying side. The feet will be used to move the lateral trunk over the roller. (Duration: 5 minutes × 2 sides = 10 minutes) d) Seated focused release Client's Position: Seated in a rolling stool with hips higher than the knees feet slightly forward of the knees and well connected to the ground. The client supports their back via their feet and legs. The client will use a tennis ball between the lower back and a wall and by moving the back against the ball by means of counter pressure, releases the deeper muscles of the back. The clients were encouraged to isolate the specific segments on which the pressure was applied. (Duration 5 minutes) Statistics Participants in both groups were comparable at baseline. The primary outcome measure was the difference in MPQ and QBPDS scores between baseline (pretest score), week 4 (posttest score), and follow-up at week 12 after randomization. Statistical analysis of the data was done by using a 2 × 3 (group × time) analysis of variance (ANOVA) and 2 × 2 (group × time) and 2 × 3 (group × time) repeated-measures ANOVA. The between groups (group), within-groups (time), and mixed-groups (group × time) interactions were examined; then, in accordance with the primary objective of the study, we compared the MPQ and QBPDS scores of the SMFR and control groups at different time intervals. A P < 0.05 was accepted as statistically significant. Results The mean differences between groups vary by time. This indicates the possible existence of their interaction effect. The simple main effects analysis showed that the SMFR group performed better than the control group in weeks 4 and 12 (P < 0.005). The patients in the SMFR group reported a 62.6% reduction in their pain and 36.3% reduction in functional disability as shown in the MPQ and QBPDS scores in week 4, which persisted as a 43.8% reduction of pain and 29.2% reduction of functional disability in the follow-up at week 12 in the SMFR group compared to the baseline. The patients in the control group reported a 9.5% and 3.6% reduction in their MPQ and QBPDS scores in week 4. The proportion of responders, defined as participants who had at least a 50% reduction in pain between weeks 1 and 4, was 63% in the SMFR group and 0 in the control group. The test's between subject effects showed a significant interaction between the effects of group and time

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