artículo original/original article

http://dx.doi.org/10.14482/sun.34.1.9720

Impact of two therapeutic interventions in

patients with non-specific low back pain

Impacto de dos intervenciones terapéuticas

en pacientes con dolor lumbar inespecífico

Marco Antonio Morales Osorio1, Sergio Alejandro Kock Shulz2, Johana Milena
Mejia Mejia3, Heberto Suarez-Roca4

Abstract

Objective: To evaluate the impact of two therapeutic interventions in patients with non-specific
low back pain.
Materials and methods: Prospective study, in which in 20 subjects from both genders assigned
through consecutive sampling of the two interventions: Group 1: 10 sessions of conventional
physiotherapy treatment (CPT) (Ultrasound, TENS: Transcutaneous Electrical Nervous Sti-
mulation y HWC: Hot Wet Compresses) and Group 2: 10 sessions of Motor Control Exercises
(MCE). A numerical Pain Scale (NPS) was applied before and after each intervention.

Fecha de aceptación: 3 de octubre de 2017

Fecha de recepción: 12 de julio de 2017
Results: In the first group, it was found a 20% decrease the pain scores after 10 sessions
compared with the baseline measurements (before the intervention) (p=0.03). Similarly, in the
second group, pain score dimished 42% respect to baseline values at the end of the 10 therapeutic
sessions (p  = 0.03). When comparing the two interventions, the MCE were more effective than
the CPT, even from the first treatment session (p <0.05).
Discussion: a significant reduction of pain was found in both groups, although this reduction
was significantly in the group treated with MCE.
Keywords: Physical Therapy Specialty, Low Back Pain, Exercise Movement Techniques,
Exercise Therapy.

1
Fisioterapeuta. Magister en Terapia Manual Ortopédica. http://orcid.org/0000-0001-5227-7755
2
Kinesiólogo. Centro de Rehabilitación Kinex – Santiago Chile.
3
Médico, Especialista en Seguridad y Salud en el Trabajo.
4
Médico. Duke University Medical Center, Center for Translational Pain Medicine, Dept. of Anesthesiology,
Durham, NC 27210, USA https://orcid.org/0000-0002-6448-1064
Correspondence: Calle Real de Ternera No. 30-966 - PBX 653 5555 - 653 5530 - Fax 653 9590. mmoraleso@
Vol. 34, N° 1, 2018
ISSN 0120-5552 usbctg.edu.co
eISSN 2011-7531

338 Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348

 Impact of two therapeutic interventions in patients with non-specific low back pain

Resumen

Objetivo: Evaluar el impacto de dos intervenciones terapéuticas en pacientes con dolor

lumbar inespecífico.
Materiales y métodos: Estudio prospectivo, en 20 sujetos de ambos sexos asignados a través
de muestreo consecutivo a una de las dos intervenciones: Grupo 1: 10 sesiones de tratamien-
to de fisioterapia convencional (TFC) (Ultrasonido TENS: eléctrica transcutánea nerviosa
Estimulación y CHC: Compresa húmedo-calientes) y Grupo 2: 10 sesiones de ejercicios de
control motor (ECM). Se aplicó la Escala numérica del dolor (NPS) antes y después de cada
intervención.
Resultados: en el primer grupo, se encontró una disminución del 20% de las puntuaciones
de dolor después de 10 sesiones en comparación con las mediciones de referencia (antes de
la intervención) (p = 0,03). De forma similar, en el segundo grupo, la puntuación del dolor
disminuyó un 42% con respecto a los valores basales al final de las 10 sesiones terapéuticas
(p = 0,03). Al comparar las dos intervenciones, los ECM fueron más efectivos que el TFC,
incluso desde la primera sesión de tratamiento (p <0.05).
Discusión: se encontró una reducción significativa del dolor en ambos grupos, aunque esta
reducción fue significativamente en el grupo tratado con ECM.
Palabras clave: Fisioterapia, Dolor lumbar, Técnicas de Ejercicio con Movimientos,
Ejercicio terapéutico.

INTRODUCTION there is no precise definition of this pain in

the literature (8).
Low back pain (LBP) is the most common
musculoskeletal condition that affects the adult Current evidence does not provide guidan-
population, with a prevalence of up to 84% (1). ce in selecting an appropriate treatment
It is one of the most common conditions that approach or when specific treatments are
motivate individuals to seek medical attention. warranted. There is no clarity about the
Low back pain is associated with loss of work best treatments, while many treatments are
productivity, poor quality of life and high me- expensive and of unclear efficacy (9). The
dical expenses, and it is a substantial economic poor control of the pattern of activation of
burden for society. (2-4). Low back pain is one the deep muscles and an alteration of the
of the main causes of work absence causing trunk musculature, stability and control of
a considerable cost in societies (5), being the altered vertebral column have been propo-
main cause of disability and loss of work in sed as factors that contribute to the appea-
industrialized countries (6). According to the rance of low back pain and its persistence
Global Burden of Disease Study, lower back (10-12). Therefore, treatment protocols that
pain ranks first among the leading causes of address the control and coordination of the
disability worldwide (7). Lumbar pain is defi- lumbar muscles are believed to be effective
ned as pain between the 12th rib and the lower in the treatment of Non-specific Lumbar
gluteal fold with or without pain radiating Pain (NLBP) (13).
to the leg. Chronic low back pain is usually
defined by symptoms that persist for a period However, it is important to consider that
of more than 3 months (12 weeks). However, the pain is produced by the brain after a
person’s neural signature has been activated

Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348 339

 Marco Antonio Morales Osorio, Sergio Alejandro Kock Shulz,
Johana Milena Mejia Mejia, Heberto Suarez-Roca

and it concluded that the body is in danger The written informed consent of each
and that action is required (40, 41), that is why participant was obtained and the research
that new clinical trials for the treatment of low committee approved all the study proce-
back pain emphasize non-pharmacological dures, in accordance with the Declaration
approaches and indicates that drug treatments of Helsinki and current Colombian legal
should be used only when other methods are regulations. (Resolution 008430 of 1993 of
unsuccessful. The American Medical School the Ministry of Health).
recommends treatments that include superfi-
cial heat, massage, acupuncture and manual The participants were randomly assigned to
manipulation (14). On the other hand, the one of the two interventions of the study:
prescription of bed rest, which in some cases Group 1:10 sessions of conventional phy-
may be excessive, has been also recommended, siotherapy treatment (CPT) and Group 2: 10
the use of therapies with non-ionizing physi- sessions of Motor Control Exercises (MCE).
cal modalities (thermal, electromagnetic and The Numeric Pain Scale (NPS) was applied
mechanical) (15), until surgical interventions, before and after each intervention.
using techniques of advanced image, which as
a whole produce high costs for health systems Through the Shapiro Wilk test, the hypothe-
(16), even the direct and indirect costs derived sis of normal distribution of the data was
from this musculoskeletal disease exceed those rejected. An analysis of Mann Whitney U test
of highly prevalent diseases such as coronary and rank test with Wilcoxon sign, served to
heart disease (17). estimate the differences between and intra
groups, respectively. The data was tabulated
For this reason, the objective of this work and analyzed in the SPSS V.23 software for
was to evaluate the impact of two therapeu- Windows.
tic interventions in adults with nonspecific
lumbar pain. Clinical and pain assessment

MATERIALS AND METHODS The following data was obtained from each
patient: family and personal history; basic
A prospective intervention study was carried anthropometric measurement (weight and
out before and after the test. Twenty subjects of height) using standardized technique. The
both genders who presented the medical diag- numerical scale of pain (NSP) was intro-
nosis of non-specific lumbar pain were taken duced by Downie in 1978 (18) and it is one
by consecutive sampling, } by the specialist in of the most used scales. The patient must
orthopedic and traumatology deriving from assign to his pain a numeric value between
a Pain and Spine Center of Cartagena, in the two extreme points (0 = Absence of Pain,
period between June and December of 2016. 10 = Pain of Maximum Intensity). For the
application of the scale, patients needed to be
Minors, pregnant women and those people able to verbally list the number that defined
with difficulties in understanding the language their level of back pain (19, 20).
were excluded, people that had previously
performed the therapy.

340 Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348

 Impact of two therapeutic interventions in patients with non-specific low back pain

Interventions lation, improve connective tissue flexibility,

and accelerate tissue regeneration, which
1.- Conventional physiotherapy treatment could reduce pain and stiffness in NLP, while
(CPT) improving mobility (21.22).

Ultrasound (US) Continuous (Ultramax -CEC The first evidence-based guidelines for the
®) of 1 MHz - 2 W / cm2 was applied for 15 treatment of low back pain did not recom-
minutes. After this, Transcutaneous Electri- mend the use of US in the NLP. However,
cal Nerve Stimulation (TENS), Interferential ultrasound is commonly used in routine cli-
(Combi 8 Max-Electro Stimulator -CEC ®) nical practice for musculoskeletal problems,
4.000 Hz - 250 μs, for 20 minutes; then, finish such as back pain (23). Approximately 50% of
with 15 minutes of Wet / Hot Compresses physiotherapists in the United Kingdom, 65%
(HWC) (Chattanooga Hydrocollator- HotPac of physiotherapists in the United States, and
®) at 60 degrees Celsius. 94% of Canadian physiotherapists use the US
in their daily practice. In the United States,
It is considered that ultrasound (US) can 55% of primary care physicians recommend
increase local metabolism and blood circu- US as a form of treatment (24).

Table 1. Application parameters of physical modalities

Modality Duration Dosage Objective

Ability to penetrate the deeper layers
2 W/
Ultrasound (US) Continuous (Ultramax -CEC ®) 15 min 1 Mhz of tissues and produce vascular
cm2
changes.
Ability to penetrate the deeper layers
Transcutaneous Electrical Nerve Stimulation (TENS)
20 min 4.000 Hz 250 µs of tissues reducing skin resistance,
Interferential (Combi 8 Max-electroestimulador -CEC ®).
decreasing pain.
Ability to penetrate the superficial
Wet / Warm Compresses (HWC) (Chattanooga
15 min 60°C and deep layers of tissues and
Hydrocollator- HotPac ®)
produce vascular changes.
CEC ® Of. Central Córdoba - Argentina: Tel +54-03543- 440011/ 422492/ 422719/ 420986- Of. Buenos Aires-Argentina.

Transcutaneous Electrical Nerve Stimulation consisted in the use of physical non-ionizing

(TENS) is a non-invasive therapeutic modality modalities, such as: US and TENS, Wet /
that was implemented more than 30 years ago, Warm compresses (HWC), with the parame-
together with existing physical agents used in ters described in table 1, recommended by the
medicine and physiotherapy for the treatment medical literature and in rehabilitation (28).
of low back pain. The TENS units stimulate the
peripheral nerves by electrodes placed on the 2.- Motor Control Exercises (MCE)
surface of the skin; they have well-tolerated
intensities and can be self-administered (25- A protocol of motor control exercises was ca-
27). For the management of NLP, the CTP, rried out taking into consideration the guide-

Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348 341

 Marco Antonio Morales Osorio, Sergio Alejandro Kock Shulz,
Johana Milena Mejia Mejia, Heberto Suarez-Roca

lines and fundamentals described by Carolyn The etiology of NLBP is complex, and the cau-
Richardson, Paul Hodges, Julie Hides (29, 30) ses are not clearly known. Research indicates
for the activation of the lumbar stabilizing that weakness and loss of motor control of
muscles. These exercises were prescribed in the deep muscles of the trunk, such as deep
a progressive manner and named as follows: lumbar (DL) and transverse abdomen (TrA)
Spinal Swing, Abdominal Sink, Palms Down, multiplicity is common in subjects with NLBP
Elbows Down. Palms down Leg extended, (29). Hodges et al., (30) and Ferreira et al., (31)
Disturbances. demonstrated that individuals with NLBP are
more likely to have a delay in recruitment and
insufficient control of TrA.

Table 2. Periodization of the Motor Control Exercises (MCE)

Ejercicio Dosage Description Progression

Quadruped position and makes repetitive movements
Spinal Oscillation 5 minutes towards anterior / posterior avoiding flexion and maximum Session 1 to 10
extension.
10 seconds/ 10 Supine cubitus, knees in 45 °, sink the abdomen and
Abdominal Sinking Session 1 to 5
repetitions/ 3 series. maintain.
10 seconds/10 Supine cubitus, knees in 45 °, sink the abdomen and
Palms Down Session 1 to 10
repetitions/ 3 series. maintain with the palms doing inferior pressure.
10 seconds/10 Supine cubit, knees in 45 °, with its elbows in 90 ° will make
Elbows Down Session 3 to 10
repetitions/ 3 series. inferior pressure.
Supine cubit, knee in 45 ° attached to his contralateral and
Palms down Leg 10 seconds/10
the other fully extended. With the palms he will perform a Session 3 to 10
outstretched repetitions/ 3 series.
lower pressure.
10 seconds, 10 External forces will be applied to the therapist's arm, causing
Disturbance Session 5 to 10
repetitions, 3 series small imbalances. (Palms down-Elbows down).

The MCE performed in patients pretends to in a determined area, to progress towards the
maintain postural control in their activities of control of postures, movements of the trunk
daily living. At the beginning the exercises are and extremities in daily activities (32), as des-
directed to the isometric postural stabilization cribed in Table 2 and shown in Fig. 1, 2 and 3.

342 Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348

 Impact of two therapeutic interventions in patients with non-specific low back pain

Figure 1. Motor Control Excersises. Spinal oscillation

Figure 2. Motor Control Excersises. Palms down leg outstretched

Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348 343

 Marco Antonio Morales Osorio, Sergio Alejandro Kock Shulz,
Johana Milena Mejia Mejia, Heberto Suarez-Roca

Figure 3. Motor Control Excersises. Disturbance

RESULTS line anthropometric variables and the pain

scores (Table 3).
The average age of the participants was
41.8 ± 12.8. In general terms, there were not Yet, in the first group (n = 10; 7 women and
between-group differences regarding base- 3 men), a decrease in pain was found after
10 sessions of treatment (20% decrease, com-
pared with the baseline, p = 0.03) (Table 4).

Table 3. Anthropometric and pain results. Baseline. (n = 20)

Group 1 Group 2
Variable Value P
n=10 n=10
Age 41,8±12,8 38,8±12,8 0.63

Weight 67,8±11,0 66,6±9,1 0.85

Size 1,65±0,07 1,65±0,04 0.73

BMI 24,8±2,9 24,3±3,5 0.57

NSP 8,0±0,81 7,1±1,3 0.16

BMI: Body Mass Index; NSP: Numerical Scale of Pain.
Data presented in Average ± DE. Differences evaluated by analysis of
variance.

344 Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348

 Impact of two therapeutic interventions in patients with non-specific low back pain

A similar change was found in the second When comparing the two interventions, con-
group (n = 10, 4 women and 6 men), the parti- ventional physiotherapy treatment (CPT) ma-
cipants presented significant changes in pain nages to significantly reduce pain according
(42% decrease), at the end of the 10 sessions to NPS. However, the Motor Control Exercises
of treatment, compared to the baseline, p = (MCE) were more effective, even from the first
0.003 (Table 4). treatment session, p <0.05 (Table 5).

Table 4. Differences in NPS in the study groups. (n = 20)

Group Baseline 10 Session Z Value p

1 8.0±0.8 6.4±0.9 -2.97 0.03

2 7.1±1.3 4.1±2,1 -2.82 0.00

Data presented in Average ± DE. Differences evaluated with Test of the ranges with Sign of Wilcoxon.

Table 5. Differences between groups in the NPS according to treatment sessions. (n = 20)

Group 1 Group 2 P. U Mann-

Variable Value p
(n=10) (n=10) Whitney
10 Session 6.4±0.9 4.1±2.1 18.5 0.01
Data presented in Average ± DE. Differences evaluated by analysis of Mann-Whitney

DISCUSSION In our case, the results of the NPS in the first

group showed a significant improvement af-
The study executed by Cairns et al., 2006 ter 10 sessions of treatment (20% decreases).
(33) showed that specific spinal stabilization Our findings coincide with the reports of
does not provide additional benefits in terms Durmus et al., in 2010 (34) and Ebadi et al., in
of physical function, pain, psychological 2012 (35), who found a significant reduction
distress and quality of life compared to the of low back pain in the groups that received
conventional physiotherapy group in patients treatment with electrotherapy and US more
with recurrent LBP and in patients with than in a program of supervised exercises,
LBP. Although both groups had clinically respectively. However, the efficacy of these
significant improvements in function and therapeutic modalities in musculoskeletal
pain reduction, there were no statistically conditions remains controversial (36). On the
significant differences between groups. Even other hand, in the second group, treatment
so, in general there were a greater percentage with MCE significantly reduced pain in the
of improvements in the group that received study population (42% decreases). Data that
conventional physiotherapy than in the spe- coincide, with the reports of experimental
cific stabilization group with fewer treatment studies and well designed clinical trials,
sessions and in a shorter period of time, even which have recently demonstrated the use-
if it was not statistically significant. fulness and effectiveness of treatment with
MCE in subjects with low back pain (37,38),

Salud Uninorte. Barranquilla (Col.) 2018; 34 (2): 338-348 345

 Marco Antonio Morales Osorio, Sergio Alejandro Kock Shulz,
Johana Milena Mejia Mejia, Heberto Suarez-Roca

achieving changes in the timing of activation th American Spine Society, Rosemont, IL

and loss of co-contraction and feed-forward (2006), pp. 319–329
mechanisms (3). 4. Maher CG, Latimer J, Hodges PW, Refshau-
ge KM, Moseley GL, Herbert RD, Costa LO,
In conclusion, it was found in this study that McAuley J. The effect of motor control exer-
the greatest NLBP reduction occurred in the cise versus placebo in patients with chronic
group of subjects treated with MCE. For its low back pain [ACTRN012605000262606].
BMC Musculoskelet Disord. 2005: 4;6:54
part, we believe it is important to point out
http://dx.doi.org/10.1186/1471-2474-6-54
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continuum of care model on the rehabi-
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Flaxman AD, Michaud C, et al. Disability-ad-
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This study shows the same trend as in other injuries in 21 regions, 1990-2010: a systematic
studies on MCE in pain reduction, in which analysis for the Global Burden of Disease
they have shown significant changes, so fu- Study 2010. The Lancet 2012;380:2197–223.
ture studies with larger samples and other 7. Itz C. Geurts J. Kleef M, Nelemans P. Cli-
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offer greater evidence about the effectiveness a systematic review of prospective cohort
of physiotherapy in the NLBP. studies set in primary care. Eur J Pain.
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Financing and Conflict interests. j.1532-2149.2012.00170.x.
8. Pourahmadi MR, Ebrahimi Takamjani I,
The authors declare no conflict of interest or Jaberzadeh S, Sarrafzadeh J, Sanjari MA,
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