Effectiveness of Physical Therapy and Exercise On Pain and Functional Status in Patients With Chronic Low Back Pain: A Randomized-Controlled Trial
Effectiveness of Physical Therapy and Exercise On Pain and Functional Status in Patients With Chronic Low Back Pain: A Randomized-Controlled Trial
Effectiveness of Physical Therapy and Exercise On Pain and Functional Status in Patients With Chronic Low Back Pain: A Randomized-Controlled Trial
DOI: 10.5606/tftrd.2018.1238
©Copyright 2018 by Turkish Society of Physical Medicine and Rehabilitation - Available online at www.ftrdergisi.com
Original Article
Received: December 27, 2016 Accepted: May 18, 2017 Published online: August 09, 2017
ABSTRACT
Objectives: This study aims to investigate the effect of physical therapy modalities on pain and functional status in patients with non-specific
low back pain.
Patients and methods: Between February 2011 and August 2013, a total of 104 patients (38 males, 66 females; mean age 49.3±12.5 years;
range 34 to 62 years) with non-specific chronic low back pain for more than 12 weeks without any neurological deficit were included in this
randomized-controlled study. The patients were divided into two groups: physical therapy group (n=52) and control group (n=52). Both
groups were given exercise and medical treatment; physiotherapy modalities were also applied in the physical therapy group. The patients
were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Istanbul Low Back Pain Disability Index (ILBP)
before treatment and at two weeks, three months, and one year after treatment.
Results: A total of 100 patients completed one-year follow-up. In both groups, the VAS, ODI, and ILBP significantly improved after treatment
(p<0.01), compared to before treatment values. There were statistically significant differences in the VAS, ODI, and ILBP scores at three
months and one year after treatment between the physical therapy group and control group (p<0.05).
Conclusion: Multidisciplinary approaches including physical therapy should be implemented to provide long-term improvement in pain and
functional status in the treatment of non-specific chronic low back pain.
Keywords: Exercise; non-specific chronic low back pain; physical therapy methods.
Low back pain is one of the major health problems treatment would be ineffective and treatment should
during life time with a prevalence of 80%, which causes include a multidisciplinary approach.[8]
functional loss and reduced productivity.[1,2] In 85% of
A variety of conservative treatment modalities,
patients with low back pain, the symptoms and signs
such as exercise, physical therapy, and medication are
are non-specific without a clear diagnosis, prognosis,
applied in the treatment of CLBP. These techniques
or treatment protocol.[3,4]
are intended to increase mobilization, decrease pain,
Chronic low back pain (CLBP) is back pain lasting and improve functional and psychological status.[9,10]
longer than 12 weeks. It has a negative impact on Exercising is one of the main treatments used for
functional, socioeconomic, and occupational activities CLBP and has been shown to reduce the duration
and on the psychological status.[5-7] Due to the multiple and frequency of back pain.[11-13] Previous studies
negative effects associated with CLBP, it has been have demonstrated that physiotherapy modalities such
argued that a single technique for low back pain as hot packs, ice massages, diathermy, ultrasound
Corresponding author: Nilay Şahin, MD. Balıkesir Üniversitesi Tıp Fakültesi, Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, 10145 Balıkesir, Turkey.
e-mail: nilaysahin@gmail.com
Cite this article as:
Şahin N, Karahan AY, Albayrak İ. Effectiveness of physical therapy and exercise on pain and functional status in patients with chronic low back pain: a randomized-controlled trial.
Turk J Phys Med Rehab 2018;64(1):52-58.
Effectiveness of physical therapy and exercise on pain and functional status in patients with chronic low back pain 53
therapy, and transcutaneous electrical nerve and rehabilitation clinic between February 2011 and
stimulation (TENS) reduce inflammation, relieve August 2013. The patients with CLBP of longer than 12
musculoskeletal symptoms and joint stiffness, thereby, weeks without any neurological deficit were included
providing symptomatic relief.[14-18] Additionally, in the study. Exclusion criteria were as follows: pain
medical treatment has been shown to be an effective severity of ≥8 according to the Visual Analog Scale
method for symptomatic improvement of CLBP.[19-21] (VAS), age ≤18 years, pregnancy, previous surgery,
However, the efficacy of a combined approach with structural abnormalities, spinal cord compression,
physical therapy and medical treatment for CLBP has serious instability, osteoporosis, body mass index
not yet been sufficiently demonstrated. (BMI) higher than 30 kg/m 2 , severe cardiovascular or
metabolic disease, and acute infection. Accordingly, a
In the present study, we aimed to evaluate the
total of 104 patients (38 males, 66 females; mean age
effectiveness of physical treatment modalities for pain
49.3±12.5 years; range 34 to 62 years) who met the
relief and functional status improvement in patients
inclusion criteria were included in this randomized-
with CLBP.
controlled study (Figure 1).
A detailed history of each patient was obtained
PATIENTS AND METHODS
and clinical examination was performed including
A total of 110 patients with CLBP were identified neurological and physical examination of the lumbar
from the hospital records of the physical medicine region with inspection and palpation, lumbar
Excluded (n=6)
• Two had the pregnancy symptoms
• Three had BMI of 36.6, 35.2 and 37.1, respectively
• One acute urinary infection diagnosis
Randomized (n=104)
PTG group
CG group
Received PT modalities given
Received only medical and Allocation
plus to medical and
exercise therapy (n=52)
exercise therapy (n=52)
Figure 1. Flow diagram. BMI: Body mass index; CG: Control group; PTG: Physiotherapy group; VAS: Visual Analog Scale;
ODI: Oswestry Disability Index; ILBP: Istanbul Low Back Pain Disability Index.
54 Turk J Phys Med Rehab
Table 2. Intra- and inter-group comparisons of results before, at two weeks, three months, and one year after treatment
Physiotherapy group (n=50) Control group (n=50) Inter-group
Mean±SD Mean±SD p F
VAS baseline 6.1±0.2 5.2±0.2 7.071
VAS 2nd week 4.3±0.2* 4.0±0.2* 0.032
VAS 3rd month 4.4±0.2* 4.2±0.2* 0.012
VAS 1st year 4.7±0.3 5.0±0.2 0.007
ODI baseline 50.6±1.0 45.2±1.3 6.690
ODI 2nd week 43.6±1.6* 33.3±2.3* 0.021
ODI 3rd month 43.7±1.7* 33.8±2.1* 0.011
ODI 1st year 46.6±2.1 45.3±1.5 0.011
ILBP baseline 30.7±1.8 24.0±2.0 9.615
ILBP 2nd week 21.7±1.5* 14.9±1.8* 0.037
ILBP 3rd month 22.6±1.7* 16.8±1.6* 0.019
ILBP 1st year 25.3±2.0 22.0±1.9 0.002
SD: Standard deviation; VAS: Visual Analog Scale; ODI: Oswestry Disability Index; ILBP: Istanbul Low Back Pain Disability Index; F: Test statistics (analysis of variance
with repeated measurements); * p<0.05 according to baseline values in intra-group comparison.
56 Turk J Phys Med Rehab
There was a statistically significant difference in compared to the patients who received no treatment or
the VAS, ODI, and ILBP scores at two week, three other conservative treatments.[36]
months, and one year of follow-up, compared to the
It has also been shown that inactivity leads to
baseline values between the groups, in favor of PTG
undesirable behaviors such as kinesophobia, anxiety,
(Table 2).
and difficulty in coping with pain, and exercise therapy
reduces these behaviors.[37,38] However, there is no
DISCUSSION precise information concerning the effect of exercise
In this randomized-controlled trial, we found types (i.e., flexion, stretching, or strengthening) on the
that the combination of physical therapy methods, patient outcomes.[34,37] In several studies, it has been
exercise, and medical treatment for non-specific shown that the pain relief due to exercise therapy in
CLBP improved pain and functional status than CLBP is limited to six-months duration.[39] In our study,
exercise and medical treatment without physical lumbar isometric, lumbar flexion, and lumbar and
therapy. This improvement sustained for three hamstring stretching exercises were applied. Pain and
months after the treatment. These results show that functional status both improved with physiotherapy,
physiotherapy combined with medical therapy and exercise therapy, and medical treatment prescribed in
exercise leads to better improvements in pain and this study. We also observed that this improvement
functional status at three months after the initiation lasted for one year.
of the treatment. During the study of CLBP patients, we concluded
The main goals of CLBP treatment are to reduce that pain and functional status were negatively
pain, to improve soft tissue flexibility due to spasm affected; therefore, the treatment was demonstrated to
and tension, to increase strength and endurance of be effective in improving the severity of the pain and
the trunk stabilizers, and to improve mobility and the function status.[40] In the present study, the VAS was
posture, thereby, leading to improved functional used to assess the pain severity and the ODI and ILBP
capacity, better ability to perform activities of daily were used to evaluate the functional status. We found
life, and prevention of work loss.[28,29] Many methods significantly higher improvements in the VAS, ODI,
such as resting, medical treatment, back school, and ILBP scores with the addition of physiotherapy at
exercise programs, physical therapy modalities, and three month and one year of follow-up, compared to
manipulation are used in the treatment of CLBP. It medical and exercise therapy alone.
has been shown that a multidisciplinary approach is Another method used in the treatment of patients
more effective than a single treatment modality.[30-32] with non-specific CLBP, which we also included
Therefore, a multidisciplinary approach including in this study, is physical therapy modalities. These
physical therapy, exercise, and medical treatment was modalities allow for short-term treatment, including
applied in our study. cold application, hot pack, ultrasound, diathermy,
and TENS.[2,16,18] These treatments are non-invasive,
Decreased paraspinal muscle strength and
safe, easy to administer, and rarely cause significant
endurance is an important risk factor for the
side effects, except mild skin irritation.[41,42] In several
development of low back pain. In addition, the body
studies, it has been shown that physical therapy is
muscle strength is lower in patients with low back pain
more effective than placebo.[34,42,43] One of the most
than in healthy people.[33] In patients with reduced
commonly used physical therapy methods is TENS.
muscle strength, the risk of lumbar pain is three
In one study, TENS was found to be more effective in
times higher. Therefore, exercise is one of the primary
reducing pain and increasing the range of motion of
treatment modalities for non-specific CLBP.[33] It aims
the joint, compared to placebo.[34] Marchand et al.[44]
to improve posture, to strengthen the trunk muscles,
divided 48 patients with low back pain into three
and to increase aerobic capacity, leading to reduced
groups as the control, placebo, and TENS. A 43%
pain and improved functional status.[13,34]
reduction in the pain severity was found in the TENS
In a study, Van Tulder et al.[35] reported that exercise group.[44] In another study evaluating hot and cold
for the treatment of low back pain was effective in applications, it was shown that warm application was
accelerating improvements in daily life activities and more successful than placebo in reducing pain in
return to work. In a meta-analysis, the patients with patients with acute and subacute lumbar pain, and cold
CLBP treated with exercise therapy showed a significant application provided pain control in the acute phase
improvement in terms of pain and functional status, and reduced the muscle tension.[16]
Effectiveness of physical therapy and exercise on pain and functional status in patients with chronic low back pain 57
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