Chapter II Literature review

ChapterII: Literature review

NSLBPpatients represent approximately 85% of LBP patients presenting toprimary care facilities.8Although approximately 33% of patients with NSLBP will have recoveryin 3 months, pain may continue to be a problem in 65%of the patientsafter a year of treatment 21NSLBP may cause residual limitation of activities in about fifth ofthe patients.22Severalindividual, lifestyle, and work-related characteristics were shown tobe associated with LBP, including NSLBP.42Becauseof the multidimensionalnature of back pain, several therapeutic techniques were describedfor NSLBP, none of them is considered universallyeffective.28Kinesiotape applicationto lower back is a new therapeutic technique that hasbeen shown to be effective in decreasing the pain,increasing lumber ROM, and support joint function. 17,18Furthermore if facilitate or inhabits muscle function and provideproprioceptive feedback.17

    1. Risk and burden of NSLBP

      1. Global incidence and prevalence of NSLBP:

NSLBP isone of the most common public health problems affecting the generalpopulation. A systematic review of 20 studies from 7 Latin Americancountries included a total of 6,992 subjects showed a prevalence ofNSLBP of 31.3%.42Asubgroup analysis of 9 studies conducted in high risk populationsshowed a much higher prevalence of NSLBP at 65%.42Populationsat higher risk of LBP examined in this study included people workinglong hours in the sitting position, people with jobs that requirelifting and/or carrying heavy loads, pregnant women, and obeseindividuals.42A number of systematic reviews examined the life-time prevalence ofLBP which is closely related to NSLBP.43,44A systematic review of 165 studies from 54 countries around the worldto estimate the global prevalence of LBP showed an average life-timeprevalence of 38.9% (interquartile range 6.2% and66.4%).43Anothersystematic review of 6 African studies showed an average life-timeprevalence of 36% (rangefrom 28% to 74%).44There is rarity of incidence data about NSLBP. The annual incidenceof NSLBP among 7.5 million Dutch workers between 2005 and 2012 wasestimated approximately between 3.8% and 7.3%.23

      1. Local incidence and prevalence of NSLBP:

There isrelatively lack of data estimating the incidence and prevalence ofNSLBP among Saudi population. However, back pain is a significantproblem in Saudi Arabia. In a big household survey among the adultgeneral population of Al-Qaseem Central Province, back pain wasestimated at 18.8%.33Although the rate in general population was probably lower thanreported in many Western studies, work-related LBP was a muchsignificant problem in Saudi Arabia.34,35Ina cross-sectional study among secondary schools teachers(governmental and private school) in Al-Khobar area, LBP was reportedin 63.8% of the examined teachers and was considered the most commonmusculoskeletal pain.34Ina similar cross-sectional study among nurses at a tertiary carecenter in Jeddah, LBP was the most common musculoskeletal pain andwas reported in 65.7% of the examined nurses.35Additionally, a questionnaire study in Saudi Aramco health carefacility showed that 61% of the healthcare workers reported at least1 episode of back pain in the previous year, 73% of which wasLBP.36Finally,a cross-sectional study among 155 nurses working in a rehabilitationhospital in Saudi Arabia showed that approximately a third of themsuffer from LBP due to mechanical and organizational factors relatedto the hospital policy.45

    1. Risk factors of NSLBP

There areseveral individual, lifestyle, and work-related characteristics thathave been linked to LBP. A systematic review of 28 studies, themajority of which examined NSLBP, reported the following individualfactors (obesity and overweight, pregnancy, and advanced age),lifestyle factors (smoking and sedentary lifestyle), and work-relatedfactors (long working hours in the sitting position, lifting andcarrying heavy loads, duration of current employment, and domesticwork) to be significantly associated with LBP.42Few psychosocial risk factors such as depression, psychologicaldistress, passive coping strategies and fear-avoidance beliefs wereshown in some studies to be associated with poor outcome of LBPincluding NSLBP.46Additionally, a systematic review of studies examining risk factorsin NSLBP showed that the modifiable risk factors (psychosocial ratherthan biomedical) were less common in chronic compared to sub-acuteNSLBP. On the other hand, genetic contribution to the development ofLBP was shown to be unlikely and multiple cases seen in the samefamily are most probably due to shared environmental factors.47

InSaudi Arabia, there is lack of studies identifying risk factors ofNSLBP. However, risk factors of back pain and LBP were examined infew studies.33,36Back pain in adult population from the Central region was associatedwith older age, marriage, weight and height, lower education level,depression, family history of back pain, change in work ability,frequency of attendance at local doctor, use of medication andcertain occupational status (unemployed, farmers, professionalworkers and housewives).33In another big questionnaire study among healthcare workers in SaudiAramco health care facility, female gender, surgical occupation, andSaudi nationality were identified as risk factors for backpain.36

    1. Relevant Anatomy and Biomechanics of the Lumber Spine and Pelvis

Lumbarspine anatomy and biomechanics relevant to NSLBP will be discussedbelow. All the information was based on clinical anatomy books andarticles.48-50

      1. Bony Anatomy

Lumbarvertebrae:The bony skeleton of the lumbar spine is made up of five lumbarvertebrae. Each one is made up of a body, two pedicles, twoarticulating facets, two transverse processes, two laminae and asingle spinousprocess.Lumbarvertebrae are largerthan the other vertebrae to support the weight of the trunk.They arealso wider laterally and deep anteroposteriorly.48

Lumber vertebra (transverse view)

Lumber vertebra (side view)

Bonypelvis: Itconsists of the sacrum posteriorly, the hip bone laterally and thecoccyx posteroinferiorly. The sacrum is triangular in shape, with thebase superiorly and the apex inferiorly. The hip bone is formed bythe fusion of three bones, the ilium, the pubis and the ischium. Thetwo hip bones merge anterioly at the pubic symphysis.The coccyx is asmall triangular bone, consisting of three to five fused coccygealsegments.48

Bony pelvis (top view)

Sacrum (side view)

      1. Joints and Ligaments

Joints:Thereare several joints in the lumbosacral region. The lumbosacral jointlies between the last lumbar vertebra and the first sacral segment ofthe vertebral column. The intervertebral discs are secondarycartilaginous joints that connect the two adjacent vertebralbodies.Thezygapophyseal joints are plane synovial joints between thesuperior and inferior articular processes of adjacentvertebrae.Sacroiliac joints lie within the pelvic ring at an obliqueangle to the sagittal plane.48

Lumberligaments:The anterior longitudinal ligament attaches to the front of thevertebral bodies and the posterior longitudinal ligament to theback.Theligamentumflavum extend from one vertebral lamina to the nextinside the vertebral canal.Thesupraspinal ligament and interspinalligaments extend from one vertebral spine to the next.48

Lumberpelvic ligaments:The lumbo-sacral ligament connects the fifth lumber vertebra to theala of the sacrum and forms an osteofibrotic tunnel as an extensionof the intervertebral foramen.Theiliolumbar ligament connects the tipof the transverse process of the fifth lumbar vertebra to theposterior part of the inner lip of the iliac crest.48

Pelvicligaments:The anterior and posterior sacroiliac ligaments connect the back andfront of sacrum and ilium. The sacrospinous ligament connects theischial spine to the lateral margins of the sacrum and coccyx. Thesacrotuberous ligament is situated at the lower and back part of thepelvis and connects thesacrum to the tuberosity of the ischium.The posterior and lateralsacrococcygeal ligaments connect the sacrum to the coccyx.48

Vertebral ligaments

Pelvic ligaments

      1. Muscles and Innervation of the Lumbosacral Spine.

There are several muscles that help lumber extension, flexion, and rotation. Table 2.1 shows these muscles, their function, and their innervation.48

Table2.1: Lumbo-sacral muscles and their function and innervation

LUMBAR MUSCLES

FUNCTION

NERVE

Psoas Major

Flexes thigh at hip joint &amp vertebral column

L2, L3, sometimes L1 or L4

IntertransversariiLateralis

Lateral flexion of vertebral column

Ventral primary division of spinal nerves

QuadratusLumborum

Lateral flexion of vertebral column

T12, L1

Interspinales

Extends vertebral column

Dorsal primary divisions of spinal nerves

IntertransversariiMediales

Lateral flexion of vertebral column

Dorsal primary divisions of spinal nerves

Multifidus

Extends &amp rotates vertebral column

Dorsal primary divisions of spinal nerves

LongissimusLumborum

Extends &amp rotates vertebral column

Dorsal primary divisions of spinal nerves

IliocostalisLumborum

Extension, lateral flexion of vertebral column, rib rotation

Dorsal primary divisions of spinal nerves

Rotator muscles

Assist with local extension and rotatory movements of the vertebral column

Dorsal primary divisions of spinal nerves

      1. Factors Maintaining Stability of Lumbosacral Spine.

Thelumbosacral spine needs integrated functions of three subsystems(that formtogether the spine stabilizing system) to control its stability andmovement. These include passive, neural feedback, and activesubsystems. Passive subsystem consists of vertebrae, facet joints,intervertebral discs, spinal ligaments, joint capsules and passivemuscle support.Neural feedback contains force and motion transducersand the neural control centers. Active subsystem includes the musclesand tendons surrounding the spinal column.49

      1. Biomechanics of the Lumbosacral Spine.

Lumbarspine has more flexion and extension than rotation. During flexion ofthe lumbar spine, the weight line moves forward. During extension theweight line is shifted posteriorly.

Duringflexion, the anterior aspect of the intervertebral discs iscompressed while during extension the posterior aspect of theintervertebral discsis compressed.50The lumbosacral joint offers more flexion/extension motion than anyother lumbar segments. With regards to lateral bending in the lumbarspine, each lumbar segment presents with approximately the sameamount of movement. Likewise, axial rotation in the lumbar spine isvery limited and nearly equal among each segment.51SpinalInstability is defined as abnormal movement between one vertebra andanother and may manifest as LBPwith radiculair pain. It was suggested that2 mm of translation isnormal for the lumbar spine and translation beyond 4 mm should beevaluated for clinical instability.49،50Forexample, magnetic resonance imaging (MRI) or computed tomography (CT)showed be done for patientswith persistentLBP with signs or symptoms of radiculopathy orspinalstenosis if they are potential candidates for surgery or epiduralsteroid injection.22

    1. Diagnosis and Tests of Chronic Low Back Pain.

The firstrecommended diagnostic step for LBP and NSLBP is history and physicalexamination done by physician focusing on the duration of symptoms,risk factors for potentially serious conditions as cancers andinfections, symptoms suggestive of radiculopathy or spinal stenosis,presence of severe neurologic deficit, and psychological riskfactors.22Despite the large number of pathological conditions that are capableof causing back pain, a definite diagnosis is difficult to achieve in85% of patients, leading to a classification as NSLBP.7Since NSLBP is defined as LBP that is not attributable to arecognizable known specific pathology with or without leg paininvolvement,11radiological investigation does not show any specific origin of thepatients‘ signs and symptom.Currentguideline of the American College of Physicians and the American PainSociety are against routine obtaining imaging or other diagnostictests in patients with NSLBP and these diagnostic imaging and testingshould be performed for patients with LBP when severe or progressiveneurologic deficits are present or when serious underlying conditionsare suspected on the basis of history and physical examination.22

    1. Treatment of Chronic Low Back Pain.

Medicationsare the most frequently prescribed therapy forLBP.52Physiotherapyis central to the overall management of LBP in the sub-acute andchronic phases.53Several other treatment modalities are used for patients with NSLBP.

      1. Medical treatment

Analgesics,non-steroidal anti-inflammatory drugs (NSAIDs), skeletal musclerelaxants, tricyclic antidepressants,opioidanalgesics, and corticosteroids are commonly used medications for thetreatment of acute or chronic LBP.Systematic reviews showed thatanalgesics have mild to moderate relieving effect on NSLBP.15According to the American College of Physicians and the American PainSociety, NSAIDs,acetaminophen, skeletal muscle relaxants are effective for acute LBPwhiletricyclic antidepressants are effective for chronic LBP.52Additionally, fairevidence was found that opioids, tramadol, and benzodiazepines areeffective for pain relief.52

      1. Physiotherapy, exercise, and manipulative therapy

Physiotherapymanagement of long term LBP favours active low back treatmentprogrammes involving improving aerobic fitness, increasing thestrength and flexibility of the lumbar musculature and ensuringlumbar stability.53Approximately 80% of the Dutch patients with NSLBP treated withphysiotherapy receive exercise therapy was one of the maininterventions. Additionally, manual interventions (massage, manualmanipulation) are used frequently for 76% of all patients andinformation or advice for 32% of the patients.54It was shown that the use of physiotherapy modalities in Thailanddiffers according the type of healthcare facility with electrophysical modalities are commonly used in non-university hospitalswhereas manual therapies are commonly used in university hospitalsand private clinics.3Additionally, non-adherence of patients with scheduledphysiotherapeutic regimen and non-adherence of physiotherapist torecommended guidelines may be undermine the success of thetreatment.37,54Althoughexercise is widely used in the rehabilitation of NSCLBP patients,there is no consensus exists as to the most effective programmedesign based on RCTs and systematic review.55The current evidence for physiotherapy management of NSCLBP showsthat interventions such as manual therapy, exercise, spinalinjections and cognitive behavioral therapy as single interventionsare not superior to each other, have a limited long-term impact onthe disorder and small effect sizes.14,56-58On the other hand, functionalmultidisciplinary rehabilitation programme, including physical andergonomic training, psychological pain management, back school andinformation, was shown to be more effective than outpatientphysiotherapy in improving functional and work status of patientswith NSLBP.59

      1. Acupuncture

Recentlypublished guidelines support the use of acupuncture as an equivalentto a course of manual therapy for treating patients with NSLBP.60However, while the current evidence provide some support for the useacupuncture as more effective therapy than no treatment, there isstill no conclusive evidence about its effectiveness over othertreatment modalities.61

      1. Low Back Orthotics

Few studiesshowed that the use of customized foot orthotics in addition to usualcare for the management of chronic NSLBP or LBP is effective infurther improving the disability and reducing the need to useanalgesics.62,63howeverthe improvement is largely short-term and probably does not work forevery patient.

      1. Surgery

Currentevidence shows that surgery does not offer clinically relevantbenefits for treating patients with NSLBP over conservativeinterventions, such as multidisciplinary treatment.64Surgical discectomy for carefully selected patients with sciatica mayprovide faster relief from acute attack than conservativetreatment.65Surgical fusion for chronic LBP favoured a marginal improvement indisability compared to non-surgical intervention.66The evidence for other minimally invasive techniques remainsunclear.65After surgical operations, exercise programs starting 4 to 6 weekspost operation seem to lead to a faster decrease in pain anddisability, and high intensity programs seem better than lowintensity programs.66

    1. The Kinesio Taping Method

Theliterature reporting the methods, properties, effectiveness, and sideeffects kinesio taping are discussed here.

      1. Introduction to the Kinesio Tape.

KinesioKinesioTaping, developed by KenzoKase in the 1970s, is a technique that hasbeen used in the clinical management of people with chronic LBP andseveral other clinical conditions.67It is usually used to reduce pain and disability in patientssuffering from musculoskeletal, neurological and lymphaticpathologies.68The tape can be stretched over the skin to 120–140% of its originallength, producing a lesser mechanical restraint and less restrictionof mobility than conventional tape.17,69

      1. Kinesio Taping Method Concepts

It washypothesized that KT serves multiple functions: 1) improvement ofmuscle function 2) gathering fascia to align tissue in the desiredposition3) activation of the circulation (blood and lymph) by liftingthe skin over areas of inflammation, pain and edema 4) deactivationof the pain system by stimulating cutaneous mechanoreceptors 5)supporting the function of the joints by stimulating proprioceptors,correcting the direction of movement and increasing stability and 6)segmental influences.8,17,18,70,71Additionally,four beneficial effects have been claimed for Kinesio Tapingnormalization of muscular function, increase in lymphatic andvascular flow, reduction in pain and contribution to correctingpossible joint misalignments,17,69although the extent to which these mechanisms contribute to anyclinical effects is unknown.

      1. Properties of Kinesio Tape

Kinesiotape has been manufactured to mimic the qualities of the skin. Ittherefore has the same thickness as the epidermis layer of the skin,and has the capacity to longitudinally stretch 130-140% from itsstatic resting length.17This degree of stretch equates to the stretching ability of normalskin. The thickness of Kinesio tape was intended to limit the body`sperception of weight and avoid sensory stimuli when applied properly.After approximately 10 minutes, the patient will generally notperceive any feeling of the tape on the skin.17Kinesiotape is composed of a polymer elastic strand wrapped by 100% cottonfibers.17The fibers allow for evaporation of body moisture and enable fastdrying of Kinesio tape after showering, bathing or watersports.Kinesio tape is latex-free, whilst the adhesive is a 100% acrylic andheat-activated.17Heat-activation is achieved by vigorous rubbing of Kinesio tape afterapplication. The acrylic is designed in a wave-like pattern to mimicthe fingerprint of the fingertip. It is proposed that the acrylicbecomes more adhesive the longer the application remains on the skin.It can be comfortably worn for 3-5 consecutive days.17,18

      1. Therapeutic effects of the kinesio Taping Method

Theeffect of KT was examined in several clinical conditions, includingmusculoskeletal conditions, breast-cancer-related lymphedema, andstroke patients with muscle spasticity.72We have identified at least 10 studies that examined the effect of KTamong patients with NSLBP or chronic LBP.8,73-81Additionally, another study is still undergoing with no resultsreported yet.30The details of study designs, intervention, and findings are shown inTable 2.2. The majority of studies were single-blinded randomizedclinical trials with or without pre and post-tapping design. At leastthree randomized clinical trials and one case report showedeffectiveness of KT in reducing pain, disability, or ROM among adultpatients with NSLBP.8,75, 77, 78One of these studies found that the beneficial effect may be toosmall to be clinically worthwhile.77On the other hand, a number of studies found that both KT andconventional therapy (regular physiotherapy or exercise) havebeneficial effects on pain and disability but without significantdifference between the KT and conventional therapy.73,76, 79-81Therefore these studies failed to prove better effect thanconventional therapy. A non-randomized interventional study wasconducted to find out difference between I-shaped versus Y-shaped KTapplication among 20 patients with chronic LBP.74Musclestrength and endurance in extension but not flexion improved in bothI-shaped and Y-shaped KT. However, there were no significantdifferences between two applications as regards the studyoutcomes.74

Arecent systematic review of 6 studies examined the effectiveness ofKT in improving patient outcomes following musculoskeletalinjury.32The authors concluded that the available evidence is stillinsufficient to support the use of KT following musculoskeletalinjury, although a perceived benefit cannot be discounted.32A similar finding was reported by another systematic review.72Moreover, a very recent (2014) systematic review of 12 does notsupport the use of KT in patients with shoulder pain, knee pain,chronic LBP, neck pain, plantar fasciitis, and multiplemusculoskeletal conditions.82

      1. Adverse Reactions and Contraindication to Kinesio Tape Therapy

Themajority of the studies that examined the effect of kinesio tappinginthe management of clinical conditions did not comment on its sideeffects or at most say there was no serious side effects.72In a study that compared KT to standard short-stretch bandage for themanagement of breast-cancer-related lymphedema, the acceptance of KTwas better than the bandage with longer wearing time, less difficultyin usage, and increased comfort and convenience. However, wounddevelopment was significantly greater for the KT group.83Theuse of Kinesio Taping is absolutely contraindicated in places changedby cancers, inflammation of the connective tissue and skininfections, open wounds, deep vein thrombosis.71Theuse of Kinesio Taping is relatively contraindicated in diabetes,kidney diseases, congestive heart failure, coronary arterydisease,sensitive skin or during healing, pregnancy.71The use of tape in the above states may require medicalauthorization. 71

Table2.2: Therapeutic effects of the kinesio taping on chronic LBP orNSLBP

Study

Number of subjects

Study design

Intervention

Outcome

Main findings

Enciso (2009)73

8 patients 20-50 years old with chronic NSLBP

Single-blinded RCT with pre and post intervention design

1-KT (Y-shaped)

2-Exercise therapy

1-Disability (ODI and RMDQ)

2-Pain (QB)

Both groups had no significant differences in pain and disability measures before and after intervention. But the very small sample size was not enough to get proper conclusions

Hyung (2010)74

20 patients with chronic LBP

Non-RCT interventional study

Before and after I-shaped versus Y-shaped KT

ROM using Bio-Dex

Muscle strength and endurance in extension but not flexion improved in both I-shaped and Y-shaped KT

Paoloni (2011)76

39 patients 30-80 years old with chronic LBP

Single-blinded RCT

1-KT (erector spine) and Exercise

2-KT alone

3-Exercise alone

1-Pain (VAS)

2- Disability (RMDQ)

3-ROM (Flexion ability)

1-Signifcant reduction of pain in all 3 groups

2. KT did not significantly reduce pain or disability compared to exercises

Hwang-Bo and Lee (2011)75

36-year-old physical therapist

Case report of one patient

KT (different positions)

1-Pain (VAS)

2- Disability (ODI)

3-ROM

Following KT application VAS and ODI decreased and ROM increased

Castro-Sanchez et al (2012)77

60 patients 18-65 years old with chronic NSLBP

Single-blinded RCT

1- KT (Star-shaped)

2- Transverse Sham KT

1-Disability (ODI and RMDQ)

2-Pain (VAS)

3- Kinesiophobia (Tampa kinesiophobia scale)

4- ROM (Fleximeter)

5-Muscle endurance (McQuade test)

At 1 week: KT reduced disability and pain, but these effects may be too small to be clinically worthwhile

At 4 weeks: KT reduced pain (significant) and trunk muscle endurance (significant) but not disability at 4 weeks

Added et al. (2013)30

148 patients 18-60 years old with chronic NSLBP

Single-blinded RCT

1-Conventional

Physiotherapy

2- Conventional

Physiotherapy and KT

1-Pain (NRS)

2-Disability (RMDQ)

3-Perceibed recovery (Global Perceived Effect scale)

4-Satisfaction with Treatment

No results yet as the study is still under investigation

AlBahel et al. (2013)8

20 patients 25-45 years old with chronic NSLBP

Single-blinded RCT with pre and post intervention design

Intervention: stretching exercises and strengthening exercises using KT (erector spine)

1-Pain (VAS)

2- Disability (RMDQ)

3-ROM (MST)

Significant differences in VAS, RMDQ, trunk flexion and extension between pre and post-intervention measurements

Asthana et al. (2013)78

30 patients 20-50 years old with chronic NSLBP

RTC

1-conventional therapy

2-conventional therapy and KT (Y-shaped)

1-Pain (VAS)

2- Disability (RMDQ)

3-ROM (lumber extension)

Significant improvement in VAS and RMQ in KT group than conventional

group

Bae et al. (2013)79

20 patients with chronic LBP

RCT with pre and post phases

1-Ordinary physical therapy

2-KT (I-strip)

1-Postural control (EMG)

2- MRCP (EEG)

3-Pain (VAS)

4-Disability (ODI and RMDQ)

1-Both groups had significant reduction of VAS and ODI after intervention with no group difference

2-KT positively affected anticipatory postural control and MRCP

Kachanathu et al. (2014)80

40 patients with mean age of 35 years with chronic NSLBP

Single-blinded RCT with pre and post intervention design

1-Conventional physical therapy with KT (2 I-Tapes)

2-conventional physical therapy

1-Pain (VAS)

2- Disability (RMDQ)

3-ROM (MST)

Both groups had significant differences in VAS, RMDQ and trunk flexion and extension after intervention with no group difference

ParreiraPdo et al. (2014)81

148 patients 18-80 years old with chronic NSLBP

Single-blinded RCT

1- KT (I-shaped)

2- Sham KT (I-shaped)

1-Pain (NRS)

2-Disability (RMDQ)

3-Perceibed recovery (Global Perceived Effect scale)

No significant differences in pain and disability between groups with small non-sustained improvement in global perceived effect

RCT,randomized controlled trial KT, kinesio taping QB, Quebec Back PainDisability Scale ROM, range of motion MST, modified Schober’stest VAS, visual analog scale NRS, Pain Numerical Rating ScaleODI, Oswestry Disability Index RMDQ, Roland Morris DisabilityQuestionnaire MRCP, movement-related cortical potential EMG,electromyography EEG, electroencephalograph

    1. Clinical Outcomes Measurement Tools

Pain,disability, and ROM are consistently used by different studies toassess the efficacy of KT and other treatment modalities amongpatients with NSLBP.Therehave been a number of studies that were conducted in the UnitedStates, Europe and Russia which interprets that the population of 40%to 80% of grown-ups is more often than not expected to experience lowback pain (LBP)1,2,3,4,5,6,7.Nevertheless, even though there are substantial studies aimed atgetting proper solutions for preventing and treating lower back pain,a heated debate is still on among clinical officers as well asresearchers on the same matter. Perhaps this is because of the natureof this condition. Low back pain is a self-limiting andmulti-episodic disease that has great limitations of randomizedclinical trials. Pain,disability, and ROM are consistently used by different studies toassess the efficacy of KT and other treatment modalities amongpatients with NSLBP. Pain is a multifaceted as well as idiosyncraticexperience that poses a number of measurement complexities. To alarger extend, pain can be an impossible outcome to measure becauseof its multilayered as well as idiosyncratic nature. Nevertheless,due to an upsurge in demand for methodically effective determinationsof treatment efficacy in LBP, there is a great need for choosingappropriate outcome measurement tools. What are outcome measurementtools? These are methodologies and tools used to determine andmeasure the magnitude of pain as well as disability in clinicalarena. Presently, there is no evidence of existence of effective aswell as dependable methodology of ideally quantifying subjective painexperience. For patients with lower back pains (LPB), there are quitea number of clinical outcome measurement tools that physicians canuse to measure the degree of pain and disability, but mainlyself-report measures are relied on to ascertain an individual’sdegree of pain. Even though there are quite a number of challengesposed by pain measurement, a substantial amount of tools as well asapproaches can be used to come up with valuable assessments of pain.Various studies are used to anatomize and evaluate the effectivenessof treatment modalities in patients suffering from NSLBP. Due tolimited time as well as resources, pain clinicians for NSLBP areforced to come up with decisions on the type of outcome they have toinclude in their measurements. Relevance and validity of treatmentsare determined by most clinically outcomes. Here is the anatomy ofvarious clinical outcome measurement tools for patients with lowerback pain (LBP).

      1. Pain Measurement Scales: Algometer and Visual analogue scale

Briefdescription of Algometer and VAS

Deepcross-friction pressure with a finger or an elbow in the proximalgluteal region causes a sciatic like pain along the side of the thighand the leg as a clinical presence of referred pain (RP) in patientswith nonspecific low back pain (LBP). Theintensity of pain in patients with LBP is usually evaluated by visualanalogue scale (VAS)84,85or algometer.86,87VAS is usually presented as a horizontal line, 100 mm in length,anchored by word descriptors at each end. The patient marks on theline the point that they feel represents their perception of theircurrent state. The VAS score is determined by measuring inmillimeters from the left hand end of the line to the point that thepatient marks.85Usually,the patient is asked to report “current” pain intensity or painintensity “in the last 24 hours.Thevisual analogue scale (VAS) is used as an alternative to thenumerical rating scale (NRS). There are devices that are in the formof slide ruler which have been developed to assists in the scoringprocess of Visual analogue scale. The visual analogue scale has beenseen to give high degree of resolution. The studies show that visualanalogue scale (VAS) could be the most sensitive single item measuretool used for clinical pain research85.VASdelivers a high grade of determination and is possibly the mostsubtle single-item measure for clinical pain research.

Thealgometer is an objective instrument to measure pain pressurethreshold (PPT) and appears to be a reliable diagnostic tool toquantitatively capture the sensitivity of myofacial trigger points(MFTPs).88,89During PPT measurement, the assessor places the algometer’scircular probe (1 cm2 in area) perpendicularly to the skin and pressat increasing rate of approximately 1kg/second. The patient is askedto say “stop” when the sensation of pressure or discomfort becomea clear sensation of pain.86

Studiesabout Reliability and Validity of Algometer and VAS

Fortytwo patients with sub-acute LBP (3 to 12 wk) participated in aprospective clinical trial. The outcome was assessed by means of thestandard (perpendicular) pressure pain thresholds (PPT) measured withthe aid of a Fischer algometer on both sides of the gluteus medius,the provoked RP pain thresholds (PPT-RP) at the location of themedial superior cluneal nerve, the Oswestry Disability Index, and theMcGill Pain Questionnaire. The diagnostic criteria for the clinicalpresence of RP were determined by the patient on the pain chartdrawings of the McGill Pain Questionnaire. The criteria for provokedRP were determined by means of PPT-RP with the aid of a Fischeralgometer until the patient pointed out the RP zone in the thighand/or the leg86,87.Theparticipants The reliability of the algometer as an index of MFTPsensitivity was reported in studies by Potter et al (2006)90,Buchanan et al, (1987)91and Fischer (1987)92,who found both high inter- and intra-examiner reliability inmeasuring marked MFTPs.

Studiesabout Reliability and Validity of VAS

Twogroups were used for VAS study in patients with LBP. Pre-and posttest analysis of VAS in both groups showed that at baselinethe two groups showed no difference in VAS (P= 0.717), whereas, the MET intervention group B showed an extremelysignificant lower post intervention VAS (P&lt0.0001) compared to the SCS Group A (P= 0.691). Thus, MET intervention reduced pain intensity significantlymore than the SCS intervention. Thus, there is no statisticalsignificance achieved with Group A (SCS), while Pvalue of Group B was, and hence, MET was found to be extremelystatistically significant.

Studiesabout MCIDand MDC of Algometer and VAS

Theinter-observer reliability was sufficient for both sides with andwithout RP (intra-class correlation coefficient&gt0.97). Thetest-retest performed independently of the observers ranking, showeda perfect reliability of the PPT-RP measurements (intra-classcorrelation coefficient&gt0.98). The PPT-RP at the level of themedial superior cluneal nerve in the subgroup with a clinicalpresence of RP (N=20) was significantly higher (3.5 kg/cm2) than inthe subgroup patients without RP (N=22). The correlation between thefactor RP and the PPT-RP was high (R=0.91, P&lt0.001). Theclinically important difference between provoked and clinicalpresence of RP was found to be higher or lower than 5.6 kg/cm2. Thestandard PPT measurement of the gluteus medius revealed nosignificant differences between the subgroups with and without RP.

      1. Functional Disability Scales: Oswestory Disability Questionnaire

Briefdescription of ODI and RMDQ

TheOswestry Disability Index (ODI) and the Roland Morris DisabilityQuestionnaire (RMDQ) are the primary measures for the assessment ofLBP-related disability.93They focus on the specific symptoms or functional impact of LBP.

Studiesabout Reliability and Validity of ODI and RMDQ

Toevaluate test-retest reliability, the questionnaire that comprised ofRMDQand ODIwas administered on the first visit to the physiotherapyclinic for evaluation, and repeated on the first visit for treatment.No physiotherapy treatment was given between the 2 tests, which forlogistic reasons was the minimal time interval possible. The retestquestionnaires were completed from 2 to 14 days after the first test.

Inaddition, the retest comprised of an extra question over a personalchange in Low back pain. There was minimal detectable change to themost improved. The change sorts were ‘somewhat improved’,‘improved’, ‘got somewhat worse’, ‘got worse’, or‘remained the same’.

Studiesabout MCID &amp Minimal Detectable change of IDQ and RMDQ

TheRoland-Morris Disability Questionnaire (RMDQ)`s preeminence overother instruments with regard to realism as well as receptiveness wasstudied in some other places11.It was seen that just five minutes were needed to administer thismeasurement. Furthermore, RMDQ was seen to be the best forself-administration. Lately, Roland-Morris Disability Questionnaire(RMDQ) was endorsed for efficacy not only in studies but for clinicalpurposes as well,13.TheRoland-Morris Disability Questionnaire (RMDQ)comprises of 23 yes andno items which are used to describe various disabilities that areparticular to people suffering from LBP. Test-retest reliability ofthe Roland Morris Disability Questionnaire (RMDQ) was perfectlygood(r=.91) when the time interval between test and retest was short,8and good as the time interval was longer10(r=.83, .72, correspondingly). One patient who had lower back pain(LBP) reported a pleasingIntraclass correlation coefficient (ICC=.76) between test and retest for subjects who reported “no change”in pain after 3 months, and a very good internal consistency (α=.89). After change, the ability to detect modification or change inback pain enhanced from minimal change of 4 points on the originalRoland Morris Disability Questionnaire (RMDQ) to 2 points on theModified Roland Disability Questionnaire (MRMQ) 9.TheRMDQ is a measurement tool used to determine the degree of pain inpatients with LBP by a scale of 0-24 depending on the type of changethat is being measured. Roland recommends that a change in 2-3 pointson the RMDQ has to be considered the most minimal clinically vitalchange.Thepoor reliability and consequently large MDC for the Roland-Morrisquestionnaire severely reduces the scale width. At the time of theinitial measurements, 51% of the subjects scored less than the MDC.Therefore, the Roland-Morris questionnaire would not be able toreliably detect improvement in half of the sample.Even using theprevious best estimate by Stratford et al12of the MDC at scale extremes of 4 points, 19% of the subjects scoredless than 4 points at initial testing.On the basis of the poortest-retest reliability and consequently large MDC and limited scalewidth, I cannot recommend the use of the Roland-Morris questionnaireas a measure of functional outcome in a general clinical population.

TheOswestry Disability Index contains 10 items related to limitations indaily life activities (like personal care, lifting, walking, sitting,standing, sleeping, social life, traveling and work).Eachitem includes six potential responses that describe a greater degreeof disability in the activity, rating each on a 0–5-point scalethe points are added together and converted into a percentage.94Oswestryscores may be categorized as: minimally disabled (0–20%),moderately disabled (21–40%), severely disabled (41–60%),crippled (61–80%), or bedbound (81–100%).95Thequestionnaire was validated in many parts of the world, including theSaudi Arabia, showing good construct validity.96-99The degree of disability from LBP assessed using the OswestryDisability score is influenced by a pain severity and LBPtype.100There is no concise study that shows the MDC for the OswestryDisability and is therefore, in my view, more widely applicable sincenot all patients with LBP will have to take medications.

      1. Spinal Range of Motion.

BriefDescription of Spinal Range of Motion using Schober Test

Arange of motion measurement of lumbar flexion in LBP patientsdetermines the intensity of pain using schooner test. Pain-freeactive trunk flexion and extension are measured using the modifiedSchober test.20,101The modified Schober test showed a moderate validity but excellentreliability when compared to measurementscalculated on X-rays as the gold standard.101Theresults of the test are affected by the patient age, sex, height,ratio of standing height to sitting height, andobesity.102Therefore, any interpretation of normal, excessive, or diminished ROMmust take into account variations by the previous individualfactors.102

Studiesabout Reliability and Validity of Schober Test

Thestudy was conducted atthe main hospital in the Outaouais area, Quebéc, Canada. Two groupsofpatients with LBP from private and public hospitals partook in thestudy. These were group A and B. After a warm-up session,measurements with the schober test were taken in neutral position andan X-ray technician took an exposure in the same position101.Hence,group analysis of Schober`s test for flexion and extension showedthat there exists no difference between Groups A and B in improvingROM significantly. But, MET will be an effective intervention inreducing pain and disability than SCS intervention.

Studiesabout Minimally Clinically Important Differences and MinimalDetectable Changein LPB for Schober Test

Patient’sassociation test between measurements made with the Schober test andthe gold standard, intra-class correlation coefficient (ICC), minimummetrically detectable change (MMDC) and confidence interval (CI) wereused to analyze the data16. The Modified Schober testrevealed reasonable rationality (r=0.67 95%CI 0.44-0.84), excellentreliability (intra: ICC=0.95 95%CI 0.89-0.97 inter: ICC=0.91 95%CI0.83-0.96) and a MMDC of 1 cm. Group analysis of Schober`s test forflexion and extension showed that there exists no difference betweenGroups A and B in improving ROM significantly. MCID and MCD inpatients with LBP using schober analysis had no much difference asper our data.

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