Chapter I: introduction
LowBack Pain (LBP) refers to a pain localized between the thoracicvertebra 12th and inferior gluteal, and within the imaginary line atthe lateral borders located in the muscles of lumbar spinae [1, 2].Studies show that LBP is a very common health problem worldwide,affecting 70-85% of the adult population at any one time during theirlives [3-8]. LBP is mostly affecting the male and female equally atthe age group between 30 and 50 years [9, 10].
AcuteLBP is largely a self-limiting condition in the majority of patients,which usually resolves within four weeks [5, 11]. However, therecurrence rates are common and are approximately 24%-33% in the 12months following an episode of back pain [5, 12]. On the other handabout 10-40% of the patients will continue as chronic LBP [5, 11,13].
Thecauses of LBP are unclear, and the majority of patients are diagnosedas non-specific LBP for both acute and chronic conditions. Studiesdid not attribute it to a known pathology and established about 85%to 95% of all cases [3, 9, 14, 15]. However, non-specific LBP may berelated to mechanical strain or dysfunction, and it often developsspontaneously, and can be painful and disabling . Specific lowback pain may be attributed to degenerative diseases, disc injuries,spinal stenosis, infection, tumor, fracture, osteoporosis, andpsychogenic pain and constituted 5% to 15% of cases [9, 14, 17-20].
Non-Specific LBP is further subdivided based on duration of symptoms intothree stages: acute LBP persists for less than six weeks sub-acutelasts for 6‐12weeks, and chronic lasts more than 12 weeks and longer [8, 21, 22].However, the recurrences are common, happening within a year in up to70% of cases [19, 23, 24].
Non-specificchronic LBP (NSCLBP) is one of the most common challenges faced byphysical therapists, as it represents more than 50% of referrals tooutpatient physical therapy department [25-27]. NSCLBP can causepain in 65% of the patients after a year of treatment  withassociated substantial limitation in activities and mobilityrestrictions . Additionally, it is among the main causes of workabsenteeism, long-term disability, and quality of life impairment[30-32]. The high economic burden caused by NSCLBP is relatedparticularly to physical therapy (17%), followed by medication (13%)and other services primary health care (13%). However, these costsaccount less than 20% of the total cost, as the majority of the costsattributed to indirect expense with absenteeism from work and lowerproductivity [32, 33].
Thecurrent literature provides several treatment strategies for NSCLBP.These include pharmacological therapy , limited bed rest ,education and activity alterations . However, these are sometimesinadequate and additional therapeutic modalities are required, suchas electrotherapy [37, 38], manual therapy [38-40], exercise therapy[38, 41], and behavioral cognitive therapy [38, 42]. However, thereis mild to moderate evidence regarding the effectiveness of thesephysical therapy interventions, leading to controversy anduncertainty within medical and health allied professions [43-47].Thus, more effective treatments are needed for NSCLBP [48, 49].
Inrecent years, and in a response to these concerns, new approacheshave been considered as alternative treatments for LBP known asKinesio Taping (KT) [50-53]. KT developed by Kenzo Kase in the 1970s[38, 50-53]. This tape is a latex-free, an adhesive that is 100%heat-activated acrylic [51, 52]. It can be stretched to 120-140% ofits original length with 100% cotton fibers allow for evaporation andfast drying without restriction of range of motion [52, 54]. KTapplication is proposed to have the following therapeuticfunctions/effects: (1) correct muscles function by strengthening theweak muscles  (2) improvement of lymphatic and blood flowthrough enhanced lymphatic drainage  (3) unloading of painfuland inflamed tissue  (4) reduction in pain and correction ofpossible joint misalignments and posture [52,54,56].
1.1Purposes of the Study
Thepresent study’s aims include:
To investigate the clinical effectiveness of the KT as a single treatment on pain, functional disability and lumbar spine flexibility among patients with NSCLBP compared to sham/placebo KT application.
To determine the clinical effectiveness of different application techniques of KT, including erector spinal tapping, star taping, and packaged taping techniques in terms of pain reduction, improving functional disability, and lumbar spine flexibility among patients with NSCLBP.
1.3Significance of the Study
Thereis a relative lack of accurate data estimating the burden of LBPamong Saudi-Arabian population. However, back pain or LBP affects aconsiderable number of the general Saudi population . Theprevalence of back pain in al-Qaasem region of Saudi Arabia reportedto be approximately 18.8%  and 26.2% in Jeddah .Additionally, work-related LBP is probably a much significant problemin some occupations such as teaching (63.8%) , nursing 65.7%, physical therapy (33%),  and dentist (73.5), . Inaddition, retrospective study of teaching a hospital in the Westernregion revealed that, the prevalence rate of LBP ranged from 21.4% to63.3% among that attending a pain clinic over the 5years period (Ageranged 30-69 years), . Recently, a study of Hail region suggestedthat the prevalence of LBP is 19.2% among adolescents (aged range12-18years) .
Non-specificchronic LBP is one of the most common challenges faced by physicaltherapists, as it represents more than 50% of referrals to outpatientphysical therapy departments worldwide [25-27]. In Saudi Arabia,there is no clear estimation of the percentage of patients sufferingfrom LBP and referred to the physical clinical therapy. However,recent research reported a very high level of non-adherence (60%)among Saudi patients with LBP attending to the physical therapyclinic . The reasons for non-adherence remain unclear, and mightbe attributed to ineffective treatment outcome, or lack of theimmediate benefits of PT treatment . For this reason, usingtherapeutic intervention that is relatively easier to adhere willensure that home treatment for LBP is realized.
Kinesiotaping is relatively new treatment technique, which is widely used invarious musculoskeletal disorders, such as patellofemoral pain [66,67], shoulder impingement syndrome [68, 69], and planter fasciitis, and neck pain [71, 72]. A few published research works providepreliminary evidence that, KT may be beneficial in treating LBP [50,73-75]. In addition, a few randomized controlled trials showed thatKT might be effective in treating chronic non-specific LBP [38, 53,50, 76]. However, other clinical trials [77, 78] indicated that KThas no evidence and produced a less significant effect in theverities of the investigated outcome measurements. These included butnot limited to pain, functional disability, lumbar spine flexibility,muscular strength, and electromyography activities of spinal muscles.This was irrespective of whether KT compared with no treatment,placebo KT, or with other modalities. Moreover, none of the publishedresearches investigated the clinical effectiveness of differenttechniques of KT and how it relates to performance enhancement inpatients with LBP.
Recently,a systematic review of Parreira etal.,2014, concluded that there was no evidence supporting the use of KTin varieties of musculoskeletal conditions, including LBP .However, the conclusions derived from these reviews are based on thetwo clinical trials [53, 76] related to application of KT LBP. Thesestudies were characterized by low methodological quality, smallsample size, and the high possibility of bias [53, 76]. Moreover,systematic review conducted by Morris etal.,2013 reported limited to moderated evidence about clinicaleffectiveness of KT for a range of outcome, such as pain, muscleendurance, and functional disability in clients with chronic LBP,especially when compared with sham/usual care .
Therefore,the current study was conducted to detect whether different KTapplication techniques as alternative therapeutic modalities would beshown to be effective in the treatment of patients with chronicNSLBP. Specifically, the study attempted to determine if patientsreceiving KT applications could reduce their pain, level offunctional disability, and resume their lumbar spine flexibility.Moreover, the results from this study will increase the number ofeffective alternative treatment modalities available to thetherapists for treatment of chronic LBP. In addition, if this type oftherapy proves to be beneficial, then its utilization in clinicalsettings will help reduce the proportion of low back disabled adultsgenerally and will increase adherence to treatment for LBP.
1.3Limitation of Study
Thisstudy was limited by
The size of the present sample for this study is small (n = 80) increases the chances of a type II error occurring. This number is further subdivided, which may reduce the power of the research findings.
The study population is not a representative sample of all patients with chronic NSLBP in Saudi Arabia. Therefore, the findings should be generalized only to similar patients seeking care at physiotherapy clinics.
Self-reported outcome measures (ODI).
While having an adherence protocol to make sure that the study finding truly represents a Kinesio Taping effect, we cannot exclude the possibility of non-adherence, which if it happens may mask the positive effect of Kinesio Taping.
1.4Delimitation of the Study
Thisstudy was delimited by
Chronic NSLBP referrals among population in the central area of Riyadh province KSA.
Women who are not pregnant.
BMI was limited to 35Kg/m2.
The study evaluated the short-term effect of KT as a follow-up period limited to 4 weeks.
Thisstudy relied on the following assumptions:
Patients would be able to read and answer the informed consent, and report their health history honestly and completely.
Patients would answer and complete all sections of the questionnaires truthfully and accurately.
Patients would cooperative with the therapist in examination attend the session, and adherence.
Patients would complete treatment as assigned and would complete home instruction as prescribed.
Patients have not received any drugs that can affect measuring and treatment stages.
All functional and physical activities are at the same degree and dose.
Kinesia tape has the same durability and quality among all patients.
The researcher appropriately applied Kinesio tape.
The calibration of all equipment used in this study (measuring and testing equipment) was accurate, and this part of the procedure ensured the minimization of any source of error.
1.6.Definitions of Terms:
Thefollowing is operational definitions of terms used in this study:
Acutelow back painrefers to pain and/or stiffness in the lower back region that hasexisted for less than six weeks [3, 23, 24].
Chroniclow back painrefers to pain and/or stiffness in the lower back region that hasbeen present and lasted for more than 12 weeks, and it does not referto the severity or quality of pain [3, 23, 24].
Durationof Painis subjective information about the length of time (months) eachparticipant has experienced low back pain .
Kinesiotaping (KT)is thin, cotton, porous fabric with an acrylic adhesive that consistsof elastic properties, developed by Japanese chiropractor, Dr. KensoKase, in the 1970’s. It is applied in a given way to help musclefunction, decrease pain, increase circulation, or improveproprioception [52, 54, 55].
LowBack Pain (LBP)is defined as a pain localized between the thoracic vertebra 12th andinferior gluteal section folds, and laterally in an imaginary linethat borders the muscles of lumbar erector spinae irrespective ofwhere there is leg pain or not [1, 2].
Lumbarflexibility (ROM)is an angle through which the joint moves from its anatomicalposition to the other limit of segment motion in a given direction.Examination of the ROM for the lumbar spine is the most commonphysical examination used to assess the low back functions ofpatients with back pain .
ModifiedSchober Testis a valid and reliable test used to measure pain-free active truckflexion and extension in which horizontal lines are derived five cmbelow and ten cm above the lumbosacral junction with maximum forwardflexion, the distance in between these lines extend by about 5 cm tonormal clients .
Non-specificLBPis defined as LBP that is not attributed to a known pathology andestablished in about 85% to 95% of all cases [3, 9, 14, 15]. However,it may be related to mechanical strain or dysfunction, and it oftendevelops spontaneously, and can be painful and disabling .
Oswestrydisability index (ODI)is a disease-specific outcome measurement used to identify the levelof disability secondary to lower back pain. It is a self-administeredquestionnaire, it consists of 10-item: the first section gives therate of pain intensity, and the others give the description of itsdisabling effect. The score for each object ranges from 0 to 5, andthe sum of the ten scores is expressed as a percentage or aproportion of the maximum score and thus ranges from 0, whichrepresents a no disability to 100 representing the maximum disabilitymark [84, 85].
Rateof adherenceThe WHO defines adherence as the degree to which a one`s behavior,including following a diet, taking medication, or executing changesin life- style, corresponds with recommendations from a provider.
Relaxedposition techniquesis training to decrease tense muscle activity through practicing moreand more complex situations, e.g. from lying supine in a silentenvironment to applying the techniques in situations where themuscles usually get tense and painful .
Triggerpoint TrPsare focal and hyperirritable marks that are located in a taut sectionof skeletal muscle, and cause pain at rest as well as in generaldysfunction of the motor neurons .
Pressurepain threshold (PPT)PPT is defined as the minimum force applied, which induces pain ordiscomfort .
VisualAnalogue Scale (VAS)is a measurement tool that is 100 mm, where the mark of 100 mmrepresents the worst pain and 0 mm the least pain . It measuresthe intensity of pain.