Superficial tissues can remain cool up to four hours from ice packs or cold water immersion. Enwemeka et al. found that cold pack treatment up to 20 min significantly decreased superficial tissue temperature by dulling and reducing the sensation of pain. They concluded that cold pack treatment limits the amount of swelling in acute injuries by slowing the metabolic rate by shunting less blood to the cold superficial area. Earlier research has shown that metabolites are cleared by the blood exchange from superficial to deep tissue. Incoming warm blood is diverted to the deeper tissues thereby slowing down the cooling effect of the deep tissues. A cooling effect also decreases nerve conduction velocity in superficial tissues by slowing the rate of firing of muscle spindle afferents and reflex responses thus decreasing muscle spasm and pain.
Background: Locally applied vibration has been recently proposed as a treatment for pain relief. Objective: The aim of this study was to assess the effect of specific vibration therapy using the Redcord Stimula device on reduction of pain in patients with chronic low backpain. Methods: The study included 14 subjects aged 16–59 years. Pain was assessed at the baseline and after the therapy using the Short Form McGill Pain Questionnaire as well as with Oswestry Disability Index, pressure pain thresholds were recorded by a mechanical algometer. All subjects received 8 therapy sessions, each session consisting of 7 proprioceptive exercises adapted for use in the Redcord suspension system with the Redcord Stimula device. Results: After completing the therapy, a statistically significant reduction in the pain score was recorded in both questionnaires. The average values decreased by 8.8% (p = .001) in the Short Form McGill Pain Questionnaire and by 7.6% (p = .001) in the Oswestry Disability Index. Pain thresholds measured by an algometer showed statistically significant increase in 3 of 5 measured sites. Conclusions: The results of the study suggest that locally applied vibration may be a viable option for treatment of chronicpain.
Regarding the second hypothesis, Jemeni (2008) suggests cognitive reconstruction is used to increase the self- efficacy of pain and to gain the essential psychological flexibility to fully engage in behaviors that cause fear and avoidance among painful patients . Most importantly, increasing self-efficacy and reducing helplessness is a secondary effect of hypnotherapy, which is caused by the increased pain control effect. Emphasizing that any hypnosis is a self-hypnosis, self-efficacy beliefs are reinforced in the cognitive conversations of the present intervention. Apart from the procedural aspect, hypnotherapy with imagery of pain works as a comparative subject and the imagery aimed at enhancing the Ego affect the increase of self-efficacy of pain. The level of benefiting from psychological interventions in patients with chronicpain is very low due to numerous barriers such as lack of knowledge, intolerance of patients, interdisciplinary gaps, resistance to psychological interventions, etc.. Since cognitive- behavioral therapy is the common psychological treatment approach in pain management, in order to overcome the above obstacles, it is suggested to combine Hypnotherapy with CBT, which leads to a dramatic
Exercise therapy is the most applied conservative approach in the clinic and it is the method recommended for acute and chronic low backpain in the studies [26-28], but the as the persons with backpain are demotivated, they do not only lose the interest for making exercises, they even lose the will to continue the treatment. In our study, we have obtained control of pain as a result of the regulation of circulation by increasing the clearance between superficial fascia and deep fascia through the skin by using kinesio taping, and also obtained relaxation by taping the sciatic nerve with the inhibition method. Here, the aim was to get through the painful period with taping in the short term by embarking the burden of exercise to the kinesio taping without forcing patients to exercise in their painful periods. Also, we wished to observe the effect of the kinesio taping as isolated in order to offer a different perspective for treatment as there are many studies examining the effect of kinesio taping together with the exercise. Another reason that we did not include the exercise in our study is that the period of treatment was so short as 10 sessions. When we review the literature, the effectiveness of exercise is usually evaluated by observing long term results [29-31].
Walkers with backpain may adopt a strategy whereby they modify their pattern of muscular activity in an attempt to reduce the sensation of pain, thus they exhibiting abnor- mal gait pattern, characterized by shorter stride length, greater step width.Thus they adopt a ‘protective guarding’ or ‘splinting’ strategy by restricting movements of the spine and also they exhibit poorer motor control, and suffer from reduced proprioception, which limits their ability to adapt their gait pattern to changing circumstances.As a result, the walkers compensate for their poorer motor control by deliberately adopting a slower and less flexible gait . The abdominal drawing-in maneuver has been described as the best way to activate the Transverse abdominis and is often a fundamental exercise in a traditional stabilization program for Low backpain . The Abdominal drawing in maneuver is an inward movement of the lower abdominal wall in which the patient is instructed to draw the umbili- cus toward the spine while maintaining a normal lumbar lordotic curve along with relaxation of the more superficial musculature. It was found to be associated with an uncon- scious co-contraction of the lower lumbar multifidi. This co-contraction of the Transverse abdominis and the Multi- fidi increased stability of the lumbar spine. The abdominal drawing in maneuver is often used to facilitate the re-edu- cation of neuromuscular control mechanisms provided by the local stabilizing muscles . The transverse abdominis muscle is an important unconscious motor activity to pro- vide a stabilizing force which increases intra-abdominal pressure and, through its insertion into the thoracolumbar fascia, resulted in increased stiffness of the lumbar spine . This training of the transverse abdominis has been shown to improve pain and the lower extremity function in patients with chronic low backpain by improving stabil- ity of the spine . Aim of the study is to know the effect of abdominal drawing in maneuver on gait parameters and pain reduction in patients with chronic low backpain. METHODOLOGY
Many factors are likely to have contributed to the incon- sistent results across trials. Importantly, interpretation of the results of exercise trials is difficult because most trials have been pragmatic trials, comparing two active treat- ments delivered in routine practice (e.g. exercise vs. usual medical care ; exercise vs. physiotherapy ) These comparisons cannot provide a clear estimate of the effects of exercise treatment because most of the comparison treatments are also of unknown efficacy. Secondly, there has been insufficient appreciation by researchers conduct- ing trials and by reviewers summarising trials of the wide variety of forms exercise can take and also trials do not control the quality of exercise intervention. While exercise is typically regarded as a single class of treatment we believe that this level of conception is inappropriate and analogous to not distinguishing between different classes and doses of drugs when prescribing medication. The types of exercise programs for chronic low backpain vary widely from land-based exercise versus exercise in water to isolated trunk exercise versus a walking program and it is unlikely that all programs are equally effective for all patients. Lastly, methodological quality varies greatly across previous exercise trials, for example in the Cochrane review  the least sound trial attended to none of the nine methodological criteria while the best attended to seven of the nine. Because methodological quality has been shown to affect the results of trials in other areas of health care  it is likely that a lack of rigor has contributed to the inconsistent results.
Low backpain (LBP) is a major medical, social, and economic problem in both developed and developing countries. It often affects all life domains from fairly basic self-care activities to advance and complex social interactions, work, and leisure activities and eventually has a profound impact on quality of life. The aim of the study was planned to investigate the health-related quality of life with chronic low backpainpatients and to examine the effect of clinical and activity Our study consisted of 400 patients who had a diagnosis of chronic low backpain in Orthopedics and Traumatology Department of DEU Medical Faculty Hospital. A total of 400 patients (200 male) and (200 female) were included, ranging in age from 18 to 62 years (mean ± SD 27.25 ± 10.68). Demographic data, occupational status, education status, body mass index (BMI). study. Visual analogue scale (VAS), functional status and quality of life were used in the Nottingham health profile questionnaire (NHP). Also the functional independence rding to demographic characteristics; There was no statistically significant difference between the groups in terms of the sex ratios of the cases and the BMI values (p> 0.05). There was a statistically significant difference between groups in terms of , occupation and educational status of the cases (p <0.05). The VAS, NHP scores of the patient age and VAS pain scores (p <0.05). The total ly higher than the total FIM scores of the control group (p <0.05). With the VAS values of the cases; There was a statistically significant correlation between NHP scores in the positive direction and total FIM score values in the negative 05). There was a statistically significant correlation between total FIM scores and all In patients with chronic low backpain, the increase in pain severity resulted in a
Our findings suggest that both protocols are effective in reduction of pain in chronic low backpain. It has been suggested in previous studies that a central widespread inhibitory mechanism is activated with muscle contractions. The central mechanisms include increased secretion of β- endorphins, attenuation mechanisms, activation of diffuse noxious inhibitory controls, or an interaction of the cardiovascular and pain regulatory systems causing hypo analgesia post exercise. In our study also exercises can be a reason to reduce pain. Therefore, after exercising, the muscles relax and there is a release in the spasm of hypertonic muscles along with release of neurotransmitters. These mechanisms of the central nervous system lead to alleviation in pain (Naugle et al., 2012). Mann Whitney u test for comparison of ODI scores between the groups, indicate Hip Extensor Strength training had an added effect as compared to General Trunk exercises in improving the functional ability of patients with chronic low backpain. Significant difference within the groups can be the result of pain relief and exercise regime for both the groups whereas significant difference between the Groups can be explained by the effect of strength training for Hip Extensors given to Group A causing efficient load transfer and adequately improved activation time enabling activities along with providing lumbar support, thus improving their daily functions. Many previous studies have shown improvements in ODI scores after resistance training in low backpain (Mose Monday Omoniyi et al., 2013). Results of functional status in chronic low backpainpatients match with the fact that Gluteus Maximus is the important muscle in lumbar pelvic region for load transfer from low back to lower extremity as required for activities of daily living (Rochenda Rydeard et al.,). Activities of daily living in healthy individuals show proper activation pattern of Gluteus Maximus in trunk flexion extension movements, thus providing bracing and support to the back through its attachments to thoracolumbar fascia (Leinonen et al., 2000). Proper activation patterns and effective load transfer achieved by training of Gluteus Maximus hence show improvements on ODI scores. According to a Finnish study,
treatment based on subgroups . These negative results may be explained by the fact that patients already pre- sented low levels of pain and disability and by the use of questionnaires with low responsiveness for low-risk pa- tients . Disability questionnaires frequently used to evaluate patients with low backpain are not sensible to detect a clinical change in patients with low level of dis- ability. For this kind of patients, it is recommended to use specific questionnaires of disability . In the treatment of these low-risk patients it is recommended that informa- tion and guidance be provided on correct diagnosis, prog- nosis, symptoms, physical activity levels, return to work and disease severity, preferably at the first contact with the health professional [9, 17, 18]. Considering the good prognosis of low-risk patients, some studies suggest a minimal intervention approach (counseling sessions and positive information) [7, 17]. This approach might be a quick and low-cost treatment option to the health system. Furthermore, identifying appropriate treatment for each patient may prevent the unnecessary use of expensive or extended resources . There is also the possibility of re- ducing the use of diagnostic procedures (imaging tests, for example), decreasing the number of consultations during the recovery process and consequently less use of finan- cial resources. Thus, some studies emphasize the need to develop more effective treatment strategies for this patient subgroup [7, 8, 14]. One of the possibilities of the nonsignificant results deriving from minimal inter- vention with these patients is that patients with low risk of developing chronic problems have low to medium levels of pain and disability. Therefore, it is necessary to evaluate patients using measurement instruments that are more responsive to this clinical condition .
Pain catastrophizing shares significant variance with the broader negative affect construct [11, 16], thus many study groups have discussed the differentiation between these two variables. We postulated that the significance of pain catastrophizing at t0 for pain treatment outcomes is greater than the significance of negative affectivity. This hypothesis has been confirmed in part: pain catastrophiz- ing at t0 is a risk factor for high negative affectivity at t1, while negative affectivity at t0 is not a risk factor for any of the outcomes considered in this research. This argues in favor of the uniqueness of the catastrophizing construct, and corresponds with other studies” results revealing catastrophizing’s influence on outcomes despite having adjusted for negative affectivity [3, 5–7, 17]. The present finding is also in line with the fear-avoidance model  as well as with more recent models for pain adaptation (i.e. ). However, other study groups have observed that catastrophizing accounted for minimal variance in pain outcomes beyond negative affectivity . Those investigations generally employed, however, only a cross- sectional design, making them not comparable with our approach.
Our study has also found that generalized anxiety disorder is a significant comorbidity among cases (14% in organic, 20% in functional group). 40 % cases and 15% controls had generalized anxiety disorder in a study conducted by Manchikanti et al. (Manchikanti, 2002). Whereas, other studies reported 15% and 20% of chronicpainpatients had thesimilar psychiatric disorder (Waddell, 2004 and Kostova, 2001). Our study results are consistent with another study that presented the comorbidity of anxiety disorder and musculoskeletal pain in 18% of patients (Dempsey, 1997). The analysis of other studies indicated that depression has significantly and highly reported/scored in patients with LBP compared to people with no pain (Bener, 2004 and Bener, 2006). Somatization was more prevalent in patients with LBP, followed by depression and then anxiety, regarding thetypes of psychological distress (Kostova, 2001). However the ranking is not consistent, where anxiety was highly prevalent, followed by somatization (second rank) and then depression in another study (Manchikanti, 2002). The study findings describe the association between psychological factors and LBP. In Iran, the coexistence of psychological disorder with LBP among patients has been an increased (Mirzamani-Bafghi, 2003). Another study in Australia also showed that depression and LBP are highly associated (Henschke, 2008). In general, psychological factors aggravate LBP (Burton, 2004). In contrast, a study that evaluated the impact of anxiety or somatization on the Lower backpain occurrence, found no association; however, it found that somatization can predict disability (Burton, 2004). The more predominant somatic symptom was headache and almost half of the patients with lower backpain were anxious and nervous. Psychological factors remain a challenge for LBP patients and or the health care providers. Depression and somatization are concurrent with LBP. The present study delivers epidemiological evidence about psychiatric illness in LBP patients who have anxiety, higher depression prevalence and highly severe depression, compared to patients with no LBP. This evidence urges health care providers to start considering and identifying the psychologicalchallengesin order to understand the mechanism of interference, to design effective preventive measures and to involve them in the treatment and recovery of LBP.
surface EMG, NPRS, ODI and FABQ. The study group (G1) received cognitive behavioral therapy (Neurophysiology education and EMG biofeedback) at rate of two one on one education sessions and one EMG biofeedback session, while the control group (G2) received selected conventional physical therapy program including (Ultrasound, TENS, back and abdominal strengthening). Our findings suggest that Cognitive behavioral therapy has a significant effect on chronic low backpain, disability and fear avoidance behavior related to its central sensitivity aspects which are neglected by conventional treatment physiotherapy. Our findings show a significant change in pain (30.02% compared to 6.91%), disability (34.15% compared to 2.95%) and fear avoidance beliefs (29.82% compared to 3.76%) in patients with chronic low backpain with central sensitivity after cognitive behavioral therapy compared to conventional treatment. This significant change may be due to a more focused approach targeting maladaptive thoughts and behavior, engaging the patient in their treatment rather than a hierarchical method of delivering treatment through applications and orders. The change could also be explained by including a targeted group in the study, which were only included if they had a 40 or more score in the Central Sensitivity Inventory. In a randomized controlled clinical trial in Bergen university by (Vibe Fersum et al., 2013) significant improvements were shown in disability (ODI), pain (NPRS) and Fear avoidance beliefs (FABQ) using a person- centered classification-based cognitive behavioral therapy approach comprising an education session and functional exercises. Improvements were shown immediately post treatment as well as 12 months post treatment. In the CINS trial it was shown that a brief educational session followed by a behavioral modification session was effective in improving anxiety, stress and disability as a secondary outcome in chronic low backpain (Harris et al., 2017), while (Louw et al., 2011) in a systematic review showed that a single neurophysiological education (NE) session improved pain and disability outcomes in a group or one on one methods and in group according to another (Lee et al., 2015). In a more recent systematic review, the effect of neurophysiology education (NPE) on chronic low backpain and disability was small to moderate immediately and in follow up post three months from treatment (Tegner et al., 2018), similar results were shown in a systematic review for the” American College of Physicians Clinical Practice Guideline” on the effect of biofeedback and cognitive behavioral therapy, which showed low to moderate evidence
This method permitted us to explain a question if a par- ticipant does not understand it and to collect detailed information. It also allowed more interaction between the respondents and the interviewers which can increase social desirability bias and fear of embarrassment. Self administered questionnaire is thus preferred in such sensible topic but it was limited in its use due to high non response. In fact, the effectiveness of a self administered questionnaire depends on the ability of the study popula- tion to read and comprehend the questions. However, because of the high percentage of illiteracy in our population, this method could not be envisaged in our context. Secondly, sexual activity is a very large con- cept and very a difficult one to define. It should be emphasized that physicians who deal with low backpain must be prepared and formed to deal with all aspects of their patient's sexual life difficulties. Finally, a sexologist participation in this study would be very interesting in broaching this delicate subject. It seems to be very useful to cooperate with the sexologist to manage sexual difficulties in CLBP patients. Further studies are clearly warranted and should include other facets of this subject, particularly psychosocial factors and partner’s experiences.
to measure the communication preferences of patients. This instrument comprises four scales (ie, patient participation and patient orientation, effective and open communication, emotionally supportive communication, and communica- tion about personal circumstances) that are unidimensional, fulfill the demands for a one-parameter item response theory model, and are reliable (Cronbach’s alpha 0.80–0.92). The patient participation and patient orientation scale (11 items) measures patient communication preferences with respect to the patient’s participation in treatment and consider- ation of their opinions and preferences. One typical item is “…weigh the advantages and disadvantages of different treatment options with you” (response categories: 1, not so important; 2, somewhat important; 3, important; 4, very important; 5, extremely important). The effective and open communication scale (10 items) measures preferences with respect to effectively collecting, conveying, and sharing information and open communication about negative events (eg, “listen carefully when you want to say something” and “… always tell you everything about your illness, even if it is unpleasant”). The emotionally supportive communication scale (six items) measures preferences regarding emotionally supportive communication (eg, “give you encouragement during talks” and “always be optimistic and upbeat during talks with you”). The communication about personal circum- stances scale (five items) measures preferences regarding a personal communication style that also includes private aspects (eg, “occasionally talk to you about private matters” and “sometimes talk with you about things that have nothing to do with your illness”). The KOPRA questionnaire, depend- ing on instructions, can be applied to different occupational groups. In our study, the patients were asked to apply it to communication preferences with respect to the physician in the pending rehabilitation.
Depression and other associated disorders caused by the low back injuries are often left undiagnosed and this is of concern because missing the diagnosis of depression, or a minor depressive disorder, may result in the lost opportunity to improve quality of life, the risk of suicide, shorten hospital stay, and improve treatment compliance. It is also of note that specialists seeing patients with low back injuries frequently are unaware of the patient’s emotional distress and needs to evaluate that. Some clinicians may fear that they lack a sufficient time or skill to manage the emotionality that may be triggered when they inquire about patient’s emotional reaction to the pain experience. Some patients may be reluctant to disclose depressive symptoms because of perceived stigma or perceived lack of interest by their primary medical caregivers . Also, some patients may not even recognise depressive symptoms that are present, or may attribute such symptoms to the effects of their only medical (physical) condition.
IL-1 β and IL-6 cytokine expression of lumbar disc hernia patients, suffering from chronic sciatic pain, did not differ from those of the painless healthy control group. Such a lack of correlation between systemic and local cytokine levels and pain is in line with the observation that some anti- inflammatory drugs perform poorly as a treatment for chronicpain. The minor effects of most current medications 46 could
Methods, Measurement, and Pain Assessment in Clini- cal Trials (IMMPACT) , we are using both a disease-specific measure, the Roland and Morris BackPain Disability Questionnaire (RDQ) index, and a gen- eric measure of pain-related functioning from the medi- cal outcomes study . We hypothesize that the intervention will decrease backpain-related disability and pain-related functional interference. The RDQ index is a 24-item scale that has been widely used in backpain studies as a measure of self-perceived disabil- ity. The scale has good internal consistency, discrimina- tive validity and is sensitive to change [66-69]. The medical outcomes study (MOS) pain measurement instrument assesses the effect of pain on mood and behaviors as well as the severity of pain over the past 4 weeks . There is limited information about how the MOS instrument compares with other pain assessments but it is easily understood by patients and produces scales that have relatively good internal consistency . Secondary outcomes include average daily steps, func- tional status, general health-related quality of life and pain intensity. Walking, which is a key aspect of the intervention, is measured as the number of average daily steps using the Omron HJ-720ITC pedometer. Rather than having to rely on self-reported step counts, the Omron allows us to upload the objectively recorded pedometer data directly to a database through the use of an embedded USB port. All data are time stamped by the pedometer. As an objective measure of function and to help validate the step count data obtained using the study pedometers we are conducting a six minute walk test at baseline and 12 months [70,71]. Participants are instructed to walk as far as they can in six minutes without running or jogging, with the primary measure- ment being the distance covered during those six min- utes. Patients ’ general physical and mental functioning is being measured using the SF-12® Health Survey  and pain intensity is evaluated using a numeric rating scale with standardized anchors (0 = “ no pain ” and 10 = “ worst pain imaginable ” ), as used in the VHA ’ s Pain as the Fifth Vital Sign initiative . Patients use this scale to rate their current level of pain and their average level of pain during the past four weeks.
Conservative and interventional medical treatments have a low to moderate effect in CLBP . Empirical evidence suggests that structural changes have a low impact in the treatment of CLBP . Catastrophizing and fear-avoidance beliefs seem to counteract the beneficial ef- fects of conventional and rehabilitation treatment [14,15]. Biopsychosocial perspectives propose taking into con- sideration structural alterations, as well as psychological and social factors. Although clinical guidelines recom- mend avoiding rest, promoting activity despite pain and an early return to work, these recommendations have low impact on the improvement of patients. A systematic re- view about the effect of written information on patients indicated that there was limited evidence of the superio- rity of a biopsychosocial information brochure compared to a biomedical one on modifying patients’ beliefs about physical activity. Moreover, this approach did not produce changes in pain and disability .
The results of this study support the initial hypothesis that specific exercise training of the "stability" muscles of the trunk is effective in reducing pain and functional disability in patients with chronically symptomatic low backpain. Analysis of the pain and functional disability revealed that there is a difference in improvements between both the groups. This treatment approach was more effective than other conservative treatment approaches which mainly involved conventional exercise programs.
There is a need to evaluate the effectiveness of this service to these patients using rigorous research that can be applied to practice. A comparative review of the clin- ical trial literature of SMT or massage or osteopathy in the treatment of low backpain reveals an evidence base for SMT and massage, both modalities in use by osteo- paths, but a lack of research into whole osteopathic practice as demonstrated in the survey data mentioned. A Cochrane review of SMT in low backpain concluded that despite over 800 publications addressing this issue, evidence for the effect on low backpain is equivocal . The Cochrane review of 13 clinical trials of massage found that there is evidence that it may be beneficial for subacute and chronic low backpain in conjunction with exercise . A systematic review and meta-analysis of osteopathic clinical trials up to 2003  concluded that patients had significant improvements from osteopathic intervention, but that many of the results are from trials with small numbers and the intervention is often a sin- gle modality or technique.