|Year : 2014 | Volume
| Issue : 2 | Page : 83-88
A randomized double-blinded study of effectiveness of strain counter-strain technique and muscle energy technique in reducing pain and disability in subjects with mechanical low back pain
Ravichandran Hariharasudhan1, Janakiraman Balamurugan2
1 Orthopaedic Physiotherapist, Department of Physical Medicine and Rehabilitation, Global Health City, Chennai 100, Tamil Nadu, India
2 Department of Physiotherapy, School of Medicine, University of Gondar, Gondar, Ethiopia
|Date of Web Publication||9-Oct-2014|
Consultant Physiotherapist, Department of Physical medicine and rehabilitation Global health city, Chennai 100, Tamil Nadu
Aims: To determine the efficacy of strain counterstrain (SCS) technique and muscle energy technique (MET) in limiting pain and disability among individuals with mechanical low back pain. To identify an effective treatment for earlier recovery from mechanical back pain to prevent further aggravation of the condition. Settings and Design: Randomized double-blinded study design in which 90 subjects were recruited using simple random sampling from 180 community dwelling mechanical low back pain subjects. Forty-five subjects randomized into each groups. Mean age of Groups A and B subjects were 37 and 40 years, respectively. Double blinded baseline and post interventional assessment was performed. Intervention includes moist hot pack for both groups, with group A receiving SCS and group B receiving MET. Outcome measures were visual analog scale (VAS), Modified Oswestry Disability Index, and lumbar flexion range of motion (ROM) using modified Schober's test. Statistical Analysis and Results: Data was coded and entered using EPI INFO version 3.5.1 and exported to Statistical Package for Social Sciences (SPSS) version 16. Statistical evidences suggest that Group B (MET) showed significant prognostic changes with all outcomes (P <0.0001) at 3 months. But, Group A (SCS) showed significant changes only with Schober's test and no trends favoring treatment were found with VAS and Modified Oswestry Disability Index. Conclusion: Hot moist pack with MET was effective in alleviating mechanical low back pain in terms of pain, increases in lumbar ROM, and reduces disability.
في الحد من (MET) و تقنيىة طاقة العضلات (SCS) دراسة عشوائية مزدوجة لتأثير تقنية الإجهاد الألم و العجز بين المرضى الذين تعانون الألم الميكانيكي في أسفل الظهر بين MET و تقنيىة SCS)) الهدف: كان الهدف من هذه الدراسة تحديد مدى فعالية تقنية الإجهاد الأفراد المصابين بالآلام الميكانيكية في أسفل الظهر في وقت مبكر منعا للمزيد من المضاعفات. المواد والطرق: أجريت الدراسة على ٠٩ فردا تم اختيارهم عشوائيا من بين ٠٨١ فردا يعانون ألما ميكانيكيا في أسفل الظهر . و قسموا إلى مجموعتين تم اختيار ٥٤ فردا عشوائيا لكل مجموعة ، و كان متوسط العمر في المجموعتين ٧٣ سنة للمجموعة (أ) و ٠٤ سنة للمجموعة ( ب). وتم تنفيذ الأساس المزدوج و التقييم بعد التدخل العلاجي ، و قد شمل التدخل العلاجي التسخين وخضعت المجموعة (ب) (SCS) الرطب للمجموعتين، حيث خضعت المجموعة(أ) لتقنية و باستخدام مقياس (VAS) وقد اظهرت نتائج القياس ظاهرة باستخدام مقياس ،(MET ) لتقنية (Shober) باستخدام اختبار ROM المعدل وقياس معدل الحركة (Oswestry) نتائج فعالة في تخفيف آلام أسفل الظهر الميكانيكية و زيادة معدل (MET) النتائج: أظهرت تقنية و بالتالي تقليل الاغاقة. (ROM) الحركة
Keywords: Jones tender points, mechanical low back pain, muscle energy technique, strain counter - strain
|How to cite this article:|
Hariharasudhan R, Balamurugan J. A randomized double-blinded study of effectiveness of strain counter-strain technique and muscle energy technique in reducing pain and disability in subjects with mechanical low back pain. Saudi J Sports Med 2014;14:83-8
|How to cite this URL:|
Hariharasudhan R, Balamurugan J. A randomized double-blinded study of effectiveness of strain counter-strain technique and muscle energy technique in reducing pain and disability in subjects with mechanical low back pain. Saudi J Sports Med [serial online] 2014 [cited 2022 Jan 24];14:83-8. Available from: https://www.sjosm.org/text.asp?2014/14/2/83/142380
| Introduction|| |
Low back pain remains a common disabling condition (Bogduk and Mcguirk 2002 Walker et al., 2004), with a lifetime prevalence of 60-90% and an annual incidence of 5%.  No population appears immune. Up to 35% of sedentary workers and 47% of physical laborers' relate a history of low back pain.  The cause of low back pain among 95% of population is mechanical and nonspecific (Hollingworth et al., 2002).  Work-related injuries are related to lumbar spine, and more than one-third of the costs for work injury claims are due to lumbosacral spine problems. Ten percent of the claims account for 80% of the costs of work-related low back pain.  Reports indicate that 40-50% of patient improved within 1 week, and 85-90% of hard workers who seek treatment improve within 6-12 weeks. Low back pain can be medically and economically devastating. Prevalence of Low Back Pain increased greatly in the early teen years 15 to 35. More than 50% had experienced at least one Low Back Pain episode.  It is the number one cause of disabilities in patients younger than 45 years of age and the number three cause of disability in those older than age 45 years. Between 2000 and 2010, a 14-fold increase in the rate of low back pain-related disability far exceeded the rate of population growth.  Direct medical costs to treat low back pain amount to more than $28 billion a year; the total cost for managing low back pain exceeds $50 billion annually in US (Rizzo et al., 1998). Recent surveys have stated that approximately 550 million days are lost annually as a result of low back pain.  Low back pain is a frequent phenomenon in all developing countries, owing to industrialization, urbanization, and sophistications. Epidemiological studies have linked low back pain to strain from lifting, heavy physical work, twisting and bending, and exposure to whole body vibration (Bernard 1997; National Research Council 2001). 
Physical therapy plays a major role in the management of mechanical low back pain. As many as one-fourth of total number of patients referred to physiotherapy, had low back pain. Modern physical therapist use spinal manipulative therapy as first-line intervention for treatment of nonspecific low back pain (Reid et al., 2002). Even though many physiotherapy interventions like exercise, modalities, bracing, massage therapy, ergonomics, and postural advises exists; there is still a need for an effective relief from mechanical low back pain.  Among subjects experiencing Mechanical Low back Pain, 90% have the possible recurrence of symptoms in their life due to improper follow up of Good posture, Exercises and Ergonomics.  Strain counterstrain (SCS) is a manual therapy intervention involving passive positioning of the body or limbs. It has been proposed as a treatment for musculoskeletal pain and dysfunction (Jones et al., 1995). The burden of low back pain on society continues to rise despite the vast amount of research and time devoted to its resolution. Despite the large variety of treatments which have been evaluated through randomized controlled trials and meta-analysis, the effect sizes are often small, even for commonly used treatments such as exercises for mechanical low back pain. 
The clinical questions of most importance to primary care practitioners may not yet have been thoroughly investigated regarding effective treatment of low back pain.  In order to determine a research agenda, that is, relevant to physiotherapy treatment, we conducted a study on low back pain, comparing SCS with muscle energy technique (MET). This study was intended to investigate the effect of SCS treatment for acute low back pain in a clinical setting. In this study, SCS, a positional release technique is used as a intervention in subjects with mechanical low back pain compared with MET intervention, while both groups received moist hot packs.
| Subjects and methods|| |
A total of 90 subjects were recruited using simple random sampling from 180 community dwelling mechanical low back pain subjects, with 45 subjects randomized into each groups. Approval for the study was granted by the hospital ethics committee. Mechanical low back pain patients approaching physiotherapy unit were considered for inclusion in the study. Patients diagnosed with other than mechanical low back pain with associated major illness were excluded. All subjects gave written informed consent. Patients were not recruited if physiotherapist were unable to see more patients at the time.
Outcome measures and procedures
Double-blinded baseline and post interventional assessment were performed by a senior physiotherapist with more than 10 years' experience, who is kept blinded regarding the subject's group. Subjects were provided a horizontal 10 cm scale, with both ends marked as no pain and worst imaginable pain without any markings in between. Subject is allowed to mark the line relative to the intensity of pain.  The therapist measures the line marked by the subject and converts into a score between 0 and 10.
Modified Oswestry Disability Index were provided and asked to choose the best answer that describes their pain and limitations. Subjects were instructed to choose only one answer for each question. If their limitation falls in between two items, they were instructed to mark in the item that best describes their condition today. 
In the Modified Schober's method for lumbar range of motion (ROM), a point is marked midway between the two posterior superior iliac spines (PSISs) (dimples of pelvis), which is the level of S2; then, points 5 cm below and 10 cm above that level are marked. Subject is asked to bend forwards maximally. The distance between the three points are measured before and after bending. The difference between the two measurements is an indication of the amount of flexion. A point is marked midway between the two PSIS's (dimples of pelvis), which is the level of S2; then, points 5 cm below and 10 cm above that level are marked.  Subject is asked to bend backwards maximally. The distance between the three points are measured before and after bending. The difference between the two measurements is an indication of the amount of extension. 
Following completion of all preintervention assessments, participants were randomly assigned to one of the two treatment groups via a computer-generated random number sequence. Randomization codes were kept in sealed envelopes with consecutive numbering. Participants were sequentially enrolled at the end of their second assessment visit.
Subjects of both groups received hot moist pack for 10 min prior to SCS technique and MET during every session. Group A was treated with SCS technique [Figure 1], where the patient is positioned in prone lying. By standing on right side of patient's lower limb tender points in the paraspinal muscle was palpated, while palpating over the tender point, patients right knee is flexed followed by hip extension until the tender point becomes soft. Care was taken not to aggravate pain or discomfort to patient. This position is termed as position of ease or position of maximum comfort. This position was held for 90 s, later fine tunings of hip rotation are added. The same procedure was repeated on patient's left lower limb. The treatment protocol included three repetitions per session with one session per day, five sessions in a week for 8 weeks. Group B was treated with MET, extensors of lumbar spine was maximally stretched by flexing the lumbar spine, hip, and knee joints. Patient is positioned in prone lying. By standing anterior to patient's trunk one hand over the sacrum and the other hand over spinous processes in the mid lumbar spine L3. During inhalation, the erector spinae muscle is isometrically contracted to optimum. During the post isometric relaxation phase, passive stretch is introduced by further flexing the lumbar spine (traction at the sacrum). Since the hip joints are also increasingly flexed, pelvic flexion is also introduced, in turn, providing further stretch indirectly. Isometric contraction is hold for 10s and relaxed for 5s.  The treatment protocol includes nine repetition per session, one session per day, and five sessions per week for 8 weeks; posttreatment outcome measures were recorded and data thus obtained was used for statistical analysis. Neither the subjects nor any of the investigators were aware of the identity of their groups. To evaluate the success of blinding, the investigators were asked at the end of the study to guess which patients belong to which group.
| Data analysis and results|| |
Data was coded and entered using EPI INFO version 3.5.1 and exported to Statistical Package for Social Sciences (SPSS) version 16. There were 45 subjects in the SCS intervention Group A and 45 subjects in the MET intervention Group B [Table 1]. No significant differences were found between the groups for the preintervention measures; visual analog scale (VAS; P = 0.717) [Table 2], modified Schober's (P = 0.851) [Table 3], and Modified Oswestry Disability Index (P = 0.866) [Table 4]. Therefore, it could be assumed that all groups were comparable at the start of the study.
|Table 1: Between-group baseline comparisons of participants' characteristics with independent sample's t tests|
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|Table 3: Changes in modified oswestry disability index among both groups|
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|Table 4: Changes in modified Schober's test for lumbar flexion and extension among Groups A and B|
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VAS for pain intensity
Pre- and posttest analysis of VAS in both groups showed that at baseline the two groups showed no difference in VAS (P = 0.717), whereas, the MET intervention group B showed an extremely significant lower postintervention VAS (P < 0.0001) compared to the SCS Group A (P = 0.691). Thus, MET intervention reduced pain intensity significantly more than the SCS intervention. Thus, there is no statistical significance achieved with Group A (SCS), while P value of Group B was, and hence, MET was found to be extremely statistically significant.
Changes in modified oswestry disability index
Analyses of pre- and post-values of groups showed that P value of Group A (SCS) was 0.2043, not less than 0.0001, and hence, there is no statistical significance achieved with Group A (SCS), while P value of Group B was < 0.0001, and hence, MET was found to be extremely statistically significant.
Changes in modified Schober's test
Comparison of pre- and posttest values of modified Schober's test for flexion and extension in both groups showed that P value of Group A (SCS) and Group B was < 0.0001, and hence, difference between both SCS and MET group was found to be statistically insignificant. Both interventions seem to have less effect on ROM of lower back to some extent. Hence, group analysis of Schober's test for flexion and extension showed that there exists no difference between Groups A and B in improving ROM significantly. But, MET will be an effective intervention in reducing pain and disability than SCS intervention.
| Discussion|| |
In this study, results showed that statistical significant difference exists between both interventions in reduction of pain and disability and improvement in ROM of lumbar spine. Group B treated with MET showed statistically significant result in reducing pain and improving disability among subjects with mechanical low back pain. Lewit et al.,  (1984) in their study found that MET when applied, while the spinal extensor muscle is in a stretched position, there was a greater relief in pain, spasm, and tenderness in the affected muscle.  Our study results are also coinciding with the study results of Lewit et al. However, Albert et al., (2006) compared immediate effects of SCS in the treatment of tender points in the upper trapezius muscle and found that it was effective in reducing tenderness of tender points in upper trapezius muscle.  In our study, we used moist heat pads before applying the intervention procedures. Likewise, Kathleen et al.,  in their study compared moist heating and spinal manipulation with moist heat alone in low back pain patients and proved that moist heat coupled with manipulation yields better results than applying moist heat alone and our study similarly employed this evidence-based practice.  Korr et al., has provided a conceptual model of how different manipulative techniques like isometrics and stretching may be effective in treatment of somatic dysfunctions. They concluded that pain relief could have occurred due to decrease in the intrafusal and extrafusal fiber disparity and reset of the inappropriate proprioceptive activity.  Jones (1981) described that there has been a variety of anecdotal evidence presented by assorted therapists in support of SCS technique but only limited experimental evidence to demonstrate its efficacy in the treatment of musculoskeletal pain and joint dysfunction.  Schenk et al., performed a randomized controlled trial to determine the effectiveness of MET in increasing lumbar extension in symptomatic individuals and reported a statistically significant difference (P < 0.05) for increase in lumbar extension.  Blanco et al., (2006) compared a MET with SCS technique in asymptomatic subjects with myofascial trigger points, their results concluded that a technique (MET) that stretches the whole muscle is found to be more effective than a technique like SCS in reducing latent trigger points.  Susan Lee performed a case study on the effect of rib cage rigidity on low back pain in which the patient received treatment with integrative manual therapy in the form of positional release therapy and MET, which focused on biomechanics as well as respiratory system. After treatment was completed, the patient presented with decreased pain and increased ROM.  Selkow et al., found that MET may be better than any other technique in decreasing pain for several reasons. It allows the clinician to have physical contact with the patient. It uses a low-force isometric contraction in a pain-free position. The time it takes to administer is very short (less than 1 min).  This technique can be accomplished without causing further pain or harm to the patient. Post-isometric relaxation technique uses a contract relax method with an added gentle stretch. Agonist contraction activates Golgi tendon organ, which in turn inhibits target muscle and breaks pain- spasm-pain cycle.  This study supports the validity of using post-isometric relaxation within lumbar spine to reduce pain and disability and to improve ROM. Lewis et al., compared SCS with exercise in acute low back pain subjects and found that there is no advantage in using this method as an intervention in acute low back pain subjects.  When compared with MET, SCS intervention did not achieve any substantial improvement in outcomes. So, our results concur with the findings of Selkow et al., and many other studies have also reported evidence in support of MET.
| Conclusion|| |
MET not only increases ROM of joints but also increases extensibility of muscle by means of a mechanism expressed as "increased tolerance to stretch". SCS is an indirect manipulation technique of extreme gentleness for the treatment of somatic dysfunctions. In this study, SCS intervention failed to achieve significance in reducing pain and disability when compared with MET. Hence, we conclude that SCS can make a significant contribution when integrated with other manual techniques. This randomized trial performed on mechanical low back pain in the form of hot moist pack with SCS and hot moist pack with MET showed that, hot moist pack with MET can be useful in alleviating mechanical low back pain in terms of pain, increase in lumbar ROM, and reduce disability.
| Acknowledgments|| |
The authors gratefully acknowledge the support of Madha Medical College Hospital, Chennai 69, India and Global health city, Chennai 100, India. We would like to express our gratitude to all the therapists and PT assistants involved in patient treatment and data collection. We would also like to thank Dr Porchelvan PhD for statistical advice.
| References|| |
Albert AM, Jose LN. Immediate effects of the strain counterstrain in local pain evoked by tender points in upper trapezius muscle. Clin chiropractic. 2006:9:3:112-118.
Bogduk N, McGuirk B (2002) Medical management of acute and chronic low back pain. An evidence based approach. Amsterdam: Elsevier.
Boonstra AM, Schiphorst Preuper HR, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res 2008;31:165-9.
Beverman KL, Palmerino MB, Zohn LE, Kane GM, Foster KA. Efficacy of treating low back pain and dysfunction secondary to osteoarthritis: Chiropractic care compared with moist heat alone. J Manipulative Physiol Ther 2006;29:107-14.
Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976) 2000;25:2940-52.
Gill K, Krag MH, Johnson GB, Haugh LD, Pope MH. Repeatability of 4 clinical methods for assessment of lumbar spinal motion. Spine (Phila Pa 1976) 1988;13:50-3.
Heggannavar A. Comparison of muscle energy technique and positional release therapy in acute low back pain. World confederation for physical therapy, June 2011.
Henschke N, Maher CG, Refshauge KM, Das A, McAuley JH. Low back pain research priorities: A survey of primary care practitioners. BMC Fam Pract 2007;8:51-9.
Hollingworth et al
. Primary care referrals for lumbar spine radiography; diagnostic yield and clinical guidelines. Br J Gen Pract.2002:Jun:52:479:475-480.
Hutchinsn JR. An investigation into the efficacy of strain counterstrain technique to produce immediate changes in pressure pain thresholds in symptomatic subjects. November 2008, School of Health Science Dissertations and Thesis.
James RH. An investigation into the efficacy of strain counterstrain technique to produce immediate changes in pressure pain thresholds in symptomatic subjects. School of health science dissertations and theses.2007.
Kominski GF, Heslin KC, Morgenstern H, Hurwitz EL, Harber PI. Economic evaluation of four treatments for low-back pain: Results from a randomized controlled trial. Med Care 2005;43:428-35.
Laman T. Intertester reliability of identifying Strain counter strain points. Clin Res 2004;112:343-52.
Leboeuf-Yde C, Kyvik KO. At what age does low back pain become a common problem? A study of 29,424 individuals aged 12-41 years. Spine (Phila Pa 1976) 1998;15:228-34.
Lewis C, Souvlis T, Sterling M. Strain-counter strain therapy combined with exercise is not more effective than exercise alone on pain and disability in people with acute low back pain: A randomized trial. J Physiother 2011;57:91-8.
Nicholas H. Low back pain research priorities: a survey of primary care practitioners. BMC family practice, 2007:8:40.
Patil PN, Basavaraj C. Effectiveness of muscle energy technique on quadratus lumborum in acute low back pain-randomized controlled trial. Indian J Physiother Occup Ther 2010;4:54-8
Punnett L, Prüss-Utün A, Nelson DI, Fingerhut MA, Leigh J, Tak S, et al
. Estimating the global burden of low back pain attributable to combined occupational exposures. Am J Ind Med 2005;48:459-69.
Schenk R, MacDiamid A, Rousselle J. The effects of muscle energy technique on lumbar range of motion. J Man Manipul Ther 1997;5:179-83.
Selkow NM, Grindstaff TL, Pugh K, Hertel J, Cross KM. Short term effect of muscle energy technique on pain in individuals with non specific lumbopelvic pain: a pilot study. J Man Manipul Ther 2009: 17:1:E14-18.
Susan L PT. The effect of rib cage rigidity in low back pain-A case study. The institute of integrative manual therapy.
Supriya L, Judith G, Charles L. Estimation of net costs for prevention of occupational low back pain: Three case studies from india. Am J Ind Med 2005;48:530-41.
Tousignant M, Poulin L, Marchand S, Viau A, Place C. The Modified-Modified Schober Test for range of motion assessment of lumbar flexion in patients with low back pain: A study of criterion validity, intra-and inter-rater reliability and minimum metrically detectable change. Disabil Rehabil 2005;27:553-9.
Wong CK, Schauer C. Reliability, validity and effectiveness of strain counter strain technique. J Man Manipulative Ther 2004;12:107-12.
[Table 1], [Table 2], [Table 3], [Table 4]