The Effect of Physical Therapy in Patients with Chronic Low Back Pain

Low back pain is the most common cause of disability. Epidemiological studies have generally considered that risk factors for starting backache are interrelated in three dimensions: individual factors and lifestyle, physical or biomechanical factors, and psychosocial factors. The main aim of this study was to evaluate the effi cacy of physical therapy in patients with chronic non-specifi c low back pain. This retrospective study was conducted at the Diagnostic Therapeutic Center Rezonanca, Department of Physiotherapy in Prishtina, Kosovo, during the period January-March 2017. Analyzed data were collected from year 2015-2016, included physiotherapeutic reports of patients of both sexes, Lasegue’s test and improvement of the patients after 10 sessions of physical therapy treatment. The main criteria for inclusion in the research was chronic non-specifi c low back pain with a duration of more than 6 months. According our results we found statistical signifi cance diff erence regarding the overall condition of treatment from the total number of patients (t=2.004, p<0.05). Based on this research we can conclude that physical therapy is highly eff ective treatment in reducing chronic non-specifi c low back pain.


Introduction
Low back pain (LBP) is a major health problem also the most common cause of disability (Garcia et al., 2013;Manek & McGregor, 2005).Low back pain is defi ned as any pain, muscule tension, or stiff ness localized below the costal margin and above the inferior gluteal fold, pain may be radiated through the leg or not.Epidemiological studies have generally considered that risk factors for starting backache are interrelated in three dimensions: individual factors and lifestyle, physical or biomechanical factors, and psychosocial factors (Maniadakis & Gray, 2000).Low Back Pain has a point prevalence of about 7 to 33% and lifetime prevalence of nearly 85%, it aff ects about 70-85% of individuals once in their lifetime (Unsgaard-Tondel, Fladmark, Salvesen, & Vasseljen, 2010;Al-Obaidi & Mahmoud, 2014;Davies et al., 2014;Dunsford, Kumar, & Clarke, 2011).
Th e purpose of this study was to evaluate the effi cacy of physical therapy in patients with chronic non-specifi c low back pain.

Methods
Th is retrospective study was conducted at the Diagnostic Th erapeutic Center Rezonanca, Department of Physiotherapy in Prishtina, Kosovo, during the period January-March 2017.Analyzed data were collected from year 2015-2016, including physiotherapeutic reports of patients of both sexes, Lasegue's test and improvement of the patients aft er 10 sessions of physical therapy treatment.
Total number of patients included in the study was 32 with chronic nonspecifi c low back pain, age 17-75.Th ese patients were treated with physical therapy.Physiotherapeutic reports were selected randomly and included in the study by analyzing the physical examination, lasegue's test and subjective evaluation aft er treatment regarding general condition and pain.Th e evaluation was done by physical therapist aft er 10 treatment sessions and the patients reported that aft er teatment they feel total improvement, some improvement and no improvement regarding pain and function.

Ethical clearance
Th e study was approved by Ethical Board of Diagnostic Th erapeutic Center "Rezonanca" Prishtina, Kosovo nr.24\14.

Treatment protocol of physical therapy
All patients were treated individualy by their physical therapist.Th ey were treated with Transcutan electrical nerve stimulation (TENS) 15-20 min in painful points on the lumbar region muscles, hot packs 15 min.deep transverse massage was applyied 15-20 min, passive mobilization of lumbar vertebrae, stretching and strengthening of abdominal and back exstenzors.
Th e main criteria for inclusion in the research was chronic non-specifi c low back pain with a duration of more than 6 months.We have excluded patients with other pathologies like hypertension, diabetes, pregnancy ect.
Presentation of data will be done through tables.Statistical parameters would be calculated: arithmetic mean, standard deviation, and minimum and maximum values.While for parametric data, t-test will be used.Verifi cation of tests for the degree of reliability should be 95% and 99%, respectively p<0.05 and p<0.01.

Results
Total number of patients included in the study was 32 with chronic nonspecifi c low back pain, higher frequency of age belonged to 40-49 (34.38%) while the lower frequency belonged to age group 0-19 (3.13%), regarding the sex, female patients showed with higher frequency (Table 1).Th e evaluation of patients aft er physical therapy treatment showed improvement in 18 patients, while relative improvement reported 10 patients and only 4 of them reported no improvement at all.Regarding our results in all of our patients with t-test, we found statistically signifi cant di-ff erence regarding the general condition of improvement of patient aft er physical therapy (t=2.004,p<0.05).Relation of general improvement aft er treatment with positive Lasegue's test was more related with group of patients who reported total improvement in 12 patients or 66.7% (Table 4).
Th e total average of age (Table 2) of all patiricipant included in the study was age 46.59 with (SD±12.42).Regarding the gender, the average of age in all female participans was 45.29 (DS±12.35age) while males were slighly older aged 48.07 (SD±12.77years).With t-test, we found statistically signifi cant diff erence regarding gender (t=1.699,p <0.05 ).
Before treatment Lasegue test was positive at 19 patients, or (59.4%) of all patients, while negative test was seen only in 13 patients or (40.6%) of all patients (Table 3).In all of our patients, with t-test, we found statistically signifi cant diff erence regarding the presence of a positive Lasegue's test (t=12.70,p<0.05 ).

Discussion
Low back pain is a major health problem in modern society.Th e condition has high prevalence in many countries around the world (Zheng et al., 2012).In this study were included 32 patients with low back pain, they were treated with physiotherapeutic modalities and exercises.From the overall patients our results showed with higher frequency the age group 40-49 years old while regarding the gender higher frequency belonged to female group, same data reported also other authors (Y.X.J. Wang, J.Q. Wang, & Kaplar, 2016), according they systematic review of 98 researches they concluded that female subjects were with higher prevalence in all age groups, while the highest prevalence of subjects with low back pain showed to be in middle age group.
Regarding the use of modalities like TENS, ultrasound, thermotherapy according the literature they showed to have a positive eff ect in general improvement for patients with low back pain, in our research these modalities also had a positive impact in patients, similar data reported also other authors (Deyo, Walsh, Martin, Schoenfeld, & Ramamurthy, 1990), they reported that application of modalities like TENS in combination with exercises in patients with low back pain resulted to be very eff ective in pain management and improvement in daily life activities.
According our results from all 32 patients with low back pain, the evaluation of patients aft er physical therapy treatment showed improvement in 18 patients, while relative improvement reported 10 patients and only 4 of them reported no improvement at all.Regarding our results in all of our patients with t-test, we found statistically signifi cant diff erence regarding the general condition of improvement of patient aft er physical therapy treatment .From these results we can conclude that beside the role of physiotherapeutic modalities a crucial role in general management of patients with LBP is also deep transverse massage, exercises for strength and stabilization of muscles in lumbar region and trunk.
Th ere is a strong evidence about the eff ectiveness of therapeutic exercises for patients with LBP, some authors reported that therapeutic exercises are very eff ective for back fl exibility, pain management and improvement of ability in daily life activities (Hayden, Tulder, & Tomlinson, 2005) (Garcia et al., 2013;Dunsford, Kumar, & Clarke, 2011;Kamali, Panahi, Ebrahimi, & Abbasi, 2014.According our survey we can conclude that is strong evidence about the eff ectiveness of deep tissue massage for patients with low back pain regarding the pain and mobility, although the evidence showed that is very little confi dence that massage is an eff ective treatment for chronic LBP (Farber & Wieland, 2016).But when massage is combined with therapeutic exercises and modalities showed to be very eff ective treatment for patients with chronic LBP (Bervoets, Lujisterburg, Alessie, & Bujis, 2015;Cherkin et al., 2011).
Regarding our results we can conclude that therapeutic exercises, modalities and deep transverese tissue massage are an effi cient treatment protocol for patients with chronic low back pain in reducing pain and general improvement.We recomend long term surveys with control goups and comparing with other techniques to confi rm the eff ectivenes of treatments protocols for partients with chronic low back pain.
Our recommendation consists of educating patients regarding posture in everyday life activities, the important role of physical therapy, and the irreplaceable role of therapeutic exercises for chronic low back pain.

Table 1 .
Patients included in the study regarding age and sex

Table 2 .
Statistical data of parameters of age by sex

Table 3 .
Values of Lasegue's test before treatment by sex

Table 4 .
The evaluation of patients after treatement and correlation with Lasegue's test