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Effects of physical therapy agents on pain, disability, quality of life, and lumbar paravertebral muscle stiffness via elastography in patients with chronic low back pain.

Superficial heat therapy, electrical current, and therapeutic ultrasound (US) are widely used for the treatment of chronic low back pain, although the benefits of all these treatment modalities still remain controversial. [1,2] Both superficial heat and deep heating agents increase the collagen extensibility owing to their thermal effects. [1,3] Increased skeletal muscle temperature has been reported to decrease gamma efferents and type II muscle spindle afferents, while increasing the Golgi tendon organ type 1b afferent fiber firing rates and decreasing the skeletal muscle tone. [4,5] Ultrasound has been also shown to enhance flexibility and reduce stiffness of connective tissue as well as muscle spasms. [2,6] Conventional transcutaneous electrical nerve stimulation (TENS) is used to attenuate pain perception via subsequent interruption of pain transmission at the dorsal horn via the gate control mechanism. [7]

Sonoelastography is a newly introduced US technique which evaluates the mechanical properties of tissues and is a quantitative method for measuring the muscle stiffness. [8,9] Although it was first developed in the 1990s, it has been increasingly used for muscle imaging in recent years. [10] This technique is based on the principle that stiff tissues exhibit a lower strain than soft tissues. [8,11] In strain elastography, which is a type of sonoelastographic method, mechanical stress is manually applied by compressing the skin with a transducer. [12] Tissue stiffness can be measured semi-quantitatively using strain elastography by calculating the strain ratio (SR), which is an index of the relative elasticity between an objective region of interest (ROI) and a reference ROI. [9]

Previous studies have demonstrated increased stiffness of the paravertebral muscle fibers in chronic low back pain. [13,14] It has been also reported that the multifidus muscle is stiffer in patients with chronic low back pain than in asymptomatic patients with reference to elastographic measurements. [15] However, to the best of our knowledge, there is no study investigating the effects of superficial heat and therapeutic US on stiffness of the paravertebral multifidus muscles, as assessed by elastography.

In the present study, we aimed to evaluate early results of combined superficial heat therapy, TENS, and the additional effect of therapeutic US to this combination on pain, disability, quality of life, and multifidus muscle stiffness in patients with chronic lower back pain.

PATIENTS AND METHODS

Patient selection and enrollment

This randomized-controlled trial (RCT) included a total of 75 patients with chronic low back pain admitted to the outpatient clinic of the Physical Medicine and Rehabilitation Department of Gaziosmanpasa Education and Research Hospital between December 2016 and March 2017. Six patients were excluded from the study, as they did not meet inclusion criteria or were not willing to participate in the study. Finally, 69 patients (36 females, 33 males; mean age 48.9[+ or -]10.9; range, 27 to 73 years) were included. A written informed consent was obtained from each patient. The study protocol was approved by the Gaziosmanpasa Taksim Training and Research Hospital Clinical Investigations Ethics Committee. The study was conducted in accordance with the principles of the Declaration of Helsinki.

All patients were classified according to their gender and were further divided into three groups as HT + TENS (Group H+T, n=23), HP + TENS + US (Group H+T+U, n=23), and controls receiving no treatment (control group, n=23) using the allocation of an equal number of patients to each group at a ratio of 1:1:1 by an electrotherapist. After allocation of the groups, the electrotherapist performed treatments. Both the physiatrist delivering the questionnaires and the radiologist measuring SR were blind to the study groups and treatments. The effect size was calculated based on the preliminary analysis results. Minimum 23 patients were needed for an effect size of 0.39 for the Oswestry Disability Index (ODI), 80% power, and 5% type 1 error.

The treatment groups were comprised of patients with non-specific chronic lower back pain lasting more than three months. The control group consisted of those with chronic lower back pain having no specific sign, compared to the other two groups. Inclusion criteria for all groups were as follows: (i) age [greater than or equal to]18 years; (ii) ability to provide an informed consent; and (iii) having low back pain for more than three months. Exclusion criteria for all groups were as follows: (i) the use of any physical therapy agent for low back pain over the last year; (ii) a history of trauma, fracture, operation, or presence of scar tissue at the lumbar region; (iii) presence of a disease which may affect stiffness of the muscle tissue such as collagen tissue diseases, hemiplegia, multiple sclerosis, or myopathies; (iv) any degree of myotomal weakness of the lower extremities which may affect the paravertebral muscles by innervation of the same muscle root; (v) malignancy, pregnancy, or severe hypertension; (vi) presence of a systemic disorder (i.e., liver or kidney insufficiency or endocrinopathies); (vii) previous or existing sacroiliitis; and (viii) diseases which may affect lumbar mobility and pain at baseline, such as leg length discrepancy, hip replacement, or scoliosis.

Physical therapy and outcome evaluation

All patients were prescribed paracetamol 500 mg three times a day during the study period, and they were advised not to exercise until the end of the treatment to prevent increases in the muscle stiffness, consistent with the literature showing alterations in the elastographic muscle stiffness of relevant muscles with exercise. ([16-18]) The patients in the control group did not undergo any therapy for three weeks. The patients in the second group were treated with HP for 20 min along with conventional TENS at 100 Hz (Chattanooga Intelect Advanced Monochromatic Combo, Chattanooga Medical Supply Inc., TN, USA) for 30 min in the lumbar region daily, five days a week for 15 sessions in total. The patients in the third group received US therapy in a circular motion at the paravertebral muscles of the lumbar region for 10 min (5 min at the left side and 5 min at the right side) at 1 MHz, 2 watt/[cm.sup.2] (Chattanooga Intelect Advanced Monochromatic Combo, Chattanooga Medical Supply Inc., TN, USA), in addition to HP and TENS daily, five days a week for 15 sessions in total. All patients were asked to fill out the Numeric Rating Scale (NRS) for movement, rest, and night, ODI, [19] and Short Form-36 (SF-36) v.2.0 questionnaire [20] at baseline and at the end of treatment.

Elastographic evaluation

The SR was measured by an experienced radiologist using an US machine (Aplio 500, Toshiba Medical Systems Corp., Tochigi, Japan) on the first and last days of the study. The patients were asked to lie prone on a couch, and a small pillow was placed below the abdomen to optimally position and minimize movements of the lumbar spine. The tip of the spinous process of the L4 vertebra was located by palpation, confirmed with a longitudinal scan, and cross-sectional images of the multifidus muscles on the left side of the L4 vertebra were acquired (Figure 1). The echogenic tip of the spinous process in the middle and vertebral lamina of the L4 vertebra at the anterior margin of the multifidus muscle served as a consistent landmark for locating multifidus muscle. After locating the multifidus muscle, the probe was longitudinally turned onto it, and the strain of the left multifidus muscle from the upper, middle, and lower parts of the fourth lumbar spinal level was considered objective ROI, and the strain of the subcutaneous fat tissue at the same level was considered reference ROI (Figures 2a-c). Three SRs were acquired at these levels and the mean value was calculated. The SR was calculated as the reference ROI strain divided by the multifidus muscle ROI strain. Therefore, a higher SR indicated a stiffer muscle.

Statistical analysis

Statistical analysis was performed using the IBM SPSS version 22.0 software (IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as mean [+ or -] standard deviation for variables with normal distribution; mean [+ or -] standard deviation, median, minimum-maximum, IQR for non-normal distributed variables; and frequency and percentage (n, %) for categorical variables. Distribution of variables was analyzed using the Kolmogorov-Smirnov test. One-way analysis of variance (ANOVA) (Tukey test), Kruskal-Wallis test, and Mann-Whitney U test were used to analyze quantitative data. Qualitative data were compared using the chi-square test. A p value of <0.05 was considered statistically significant.

RESULTS

The control group included 23 patients (12 females and 11 males) with a mean age of 46.3[+ or -]10.7 years, a Body Mass Index (BMI) of 26.3[+ or -]3.9 kg/[m.sup.2], and a pain duration of 71[+ or -]98.2 months. The H+T group included 23 patients (12 females and 11 males) with a mean age of 51.7[+ or -]10.7 years, a BMI of 29.2[+ or -]5.3 kg/[m.sup.2], and a pain duration of 79.6[+ or -]75.5 months. The H+T+U group included 23 patients (12 females and 11 males) with a mean age of 48.6[+ or -]11.0 years, a BMI of 28.3[+ or -]4.1 kg/[m.sup.2], and a pain duration of 49.3[+ or -]70.5 months. There were no significant differences among the three groups in terms of gender, mean age, mean height, mean weight, mean BMI, marital status, extent of education, or mean pain duration. Demographic characteristics of all patients are presented in Table 1.

There was a significant decrease in the NRS movement scores of the patients in the H+T and H+T+U groups after treatment, compared to baseline, whereas there was no change in the control group. However, decreases in the H+T and H+T+U groups were not statistically significant. In the NRS at rest, a significant decrease was observed in the H+T and H+T+U groups after treatment, compared to baseline, whereas there was no change in the control group. However, decreases in the H+T and H+T+U groups did not differ significantly. In the NRS at night, there was a significant decrease in the H+T and H+T+U groups after treatment, compared to baseline, whereas there was no significant difference in the control group. However, changes in the H+T and H+T+U groups did not differ significantly. Comparison of the changes in the NRS movement, at rest, and at night scores are presented in Table 2.

Using the ODI, a significant decrease was seen in the H+T and H+T+U groups after treatment, compared to baseline, whereas there was no significant difference in the control group. However, changes in the H+T and H+T+U groups did not differ significantly (Table 2).

In terms of the SR, there was no significant change in any of the groups after treatment, compared to baseline (Table 2).

In addition, there was no significant improvement in the SF-36 subscales (i.e., physical function, physical role function, pain, general health perceptions, vitality, social role function, emotional role function, and mental health) in the control group. However, in the H+T group, physical function, physical role function, pain, and general health perceptions improved after treatment compared to baseline. Similarly, in the H+T+U group, physical role function, pain, general health perceptions, social role function, and emotional role function improved after treatment, compared to baseline. However, there was no significant difference in the improvement of physical function, physical role function, pain, and general health perceptions between the H+T and H+T+U groups. The SF-36 results in all subscales are shown in Table 3.

DISCUSSION

In the present study, we evaluated the effects of combined hot pack and TENS treatment as well as the additional effect of therapeutic US on pain, disability, quality of life, and SR of the multifidus muscles as measured using elastography in patients with chronic low back pain. Although superficial heat therapy, TENS, and US are widely used for chronic low back pain, evidence-based guidelines for the treatment of chronic low back pain do not recommend any of these therapies due to lack of evidence. [21,22] According to our results, the combined superficial heat therapy and TENS treatment improved pain on movement, at rest, and at night, disability, physical functioning, physical role functioning, pain, and general health perception of the quality of life in patients with chronic low back pain. Addition of therapeutic US to the treatment, however, did not change the effects of the combined HP and TENS treatment on the aforementioned parameters, whereas it showed an additional benefit only on the social role functioning and emotional role functioning.

Chan et al. [15] investigated the change in multifidus muscle stiffness in patients with chronic lower back pain. They examined 12 male patients with chronic lower back pain and 12 healthy male controls using shear wave elastography and demonstrated that the multifidus muscles were stiffer in the patient group, compared to healthy controls. It is speculated that both superficial and deep heating agents reduce muscle tone and stiffness via their thermal effects. [2,5] In addition, a recent study by Turo et al. [23] suggested that stiffness of the taut bands in myofascial pain syndrome could be reduced by pain relief following dry needling, and this change in stiffness could be assessed using elastography. Therefore, in the present study, we hypothesized that superficial heat therapy and therapeutic US would reduce the multifidus muscle stiffness by relieving pain. However, our results did not confirm our hypothesis. To the best of our knowledge, there is no study available suggesting the normal range or values for multifidus muscle elastography. Although a change in the multifidus muscle stiffness would have allowed us to evaluate the effect of the therapy objectively, such a change was not be accomplished. To the best of our knowledge, this is the first study to evaluate the effects of physical therapy agents on the mechanical features of the paravertebral muscles.

In their study, Masaki et al. [24] examined the relationship between lower back pain and muscle stiffness in young and middle-aged medical workers. This study included 23 healthy controls and nine medical workers with lower back pain. The authors evaluated muscle stiffness using shear wave elastography from the lumbar erector spinae, quadratus lumborum at L3 level, and multifidus muscle at L4 level. Multiple regression analysis showed that only height and multifidus muscle stiffness were independent determinants of lower back pain and shear wave elastography showed higher stiffness in workers with lower back pain than asymptomatic control workers in a prone position. The authors, eventually, concluded that muscle spasm due to pain might be a possible reason for higher multifidus stiffness in lower back pain. [24] Similar to our study, the aforementioned authors also used the ODI and static and dynamic NRS to evaluate the status of lower back pain. In addition, we evaluated the quality of life using the SF-36 scale, while Masaki et al. [24] only demonstrated higher elastographic muscle stiffness with chronic lower back pain, but did not evaluate how the muscle stiffness changed after intervention.

In a Cochrane systemic review, Ebadi et al. [25] investigated the efficacy of therapeutic US alone and included seven RCTs comparing US treatment to other treatment methods or placebo. According to the results of three studies (n=100), there was moderatequality evidence that US improved function related to back pain. Two trials (n=58) revealed moderate-quality evidence that US treatment did not improve the extension range of motion, while the remaining two studies (n=79) demonstrated low-quality evidence that the addition of US to exercise did not improve pain, function, and lumbar flexion range of motion, compared to exercise alone. The authors concluded that therapeutic US alone was not superior to placebo with regard to short-term pain improvement. [25] Another Cochrane systematic review including four placebo-controlled RCTs (n=585) by Khadilkar et al. [26] showed that there was no evidence that TENS could relieve symptoms and reduce disability in chronic low back pain. Similarly, our study results demonstrated that the addition of US treatment to HP + TENS did not change the outcome in terms of pain, disability, and quality of life; however, the present study did not include a treatment group with US or TENS alone. Therefore, it is not possible to suggest that US treatment alone does not have an effect or improvement can be attributed to TENS alone.

In a study, Koldas et al. [27] compared home-based exercises alone, a combination of physical therapy agents (HP, TENS, and US treatment) and home-based exercises, and aerobic exercises alone to evaluate their effects on chronic low back pain and found that pain significantly decreased in all groups, whereas patients treated with physical therapy and home-based exercises experienced greater improvements in disability and physical disturbances at one month of follow-up. Differently from our study, there was no control group in this study. Our study also showed the short-term effects of combination therapy on pain, disability, and quality of life. Interestingly, our results support an improvement in the emotional role functioning and social role functioning, consistent with the results of the aforementioned study.

Guillemin et al. [28] studied short- and long-term effects of superficial heat therapy in patients with chronic low back pain. They used SPA therapy as superficial heat source and demonstrated an improvement in the spine mobility, functional scores, daily pain duration, pain intensity, and drug consumption. They also showed a moderate long-term effect after nine months. As their short-term effects are consistent with our results and our study did not include long-term outcomes, we were unable to conclude that the therapies we applied have long-term effects.

The neuroscience of pain has suggested three possible mechanisms for chronic low back pain: central sensitization, nociceptive, and neuropathic mechanisms. [29] On the contrary, TENS treatment is thought to be operating by facilitating the interruption of neural transmission of pain. [30] In our study, HP and TENS combination did not demonstrate a reduction of multifidus stiffness in patients with chronic lower back pain, although this combination relieved pain, thus putting central sensitization or neuropathic mechanisms forward as possible reasons for chronic low back pain. Therapeutic US is considered a potential tool for nociceptive pain, but is considered of limited or no use for central pain or chronic pain exacerbated by neuroplastic remodeling. [1] This may be the reason why US did not have an additional benefit for relieving chronic lower back pain.

The main limitations of our study include lack of long-term follow-up results and lack of a sham therapy group. Another limitation is its relatively small sample size. The sample size in this study was established according to power analysis of a clinical questionnaire (using ODI); however, the results in terms of elastographic muscle stiffness would be different with a larger sample size.

In conclusion, our study results demonstrate that combined superficial heat therapy and TENS treatment has a beneficial effect on pain, disability, and certain subscales of quality of life in the short term. In addition to this combination, US treatment, however, does not have an additional benefit in terms of pain, disability, physical function, physical role function, or general health perceptions of quality of life. Nonetheless, it may have a beneficial effect on social role functioning and emotional role functioning; however, as these functions are affected by various social factors, it is not possible to conclude that this is an effect of US alone, solely based on our study findings. Conversely, the combined HP+TENS treatment or HP+TENS+US treatment have no beneficial effects on stiffness of the multifidus muscles, although they can provide pain relief. In this context, muscle stiffness may not be the major reason for pain in patients with chronic low back pain, and physical treatment agents may alleviate pain through other mechanisms. We recommend further large-scale and long-term studies to confirm these findings.

Declaration of conflicting interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

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Ozan Volkan Yurdakul (1)[iD], Engin Beydogan (2)[iD], Ebru Yilmaz Yalcinkaya (3)[iD]

(1) Department of Physical Medicine and Rehabilitation, Bezmialem Vakif University Faculty of Medicine, Istanbul, Turkey

(2) Department of Radiology, Gaziosmanpasa Taksim Training and Research Hospital, Istanbul, Turkey

(3) Department of Physical Medicine and Rehabilitation, Gaziosmanpasa Taksim Training and Research Hospital, Istanbul, Turkey

Received: November 18, 2017 Accepted: January 25, 2018 Published online: January 30, 2019

Corresponding author: Ozan Volkan Yurdakul, MD. Bezmialem Vakif Universitesi Tip Fakultesi Fiziksel Tip ve Rehabilitasyon Anabilim Dali,

34093 Fatih, Istanbul, Turkey.

e-mail: yurdakul_ozan@yahoo.com

Cite this article as: Yurdakul OV, Beydogan E, Yilmaz Yalginkaya E. Effects of physical therapy agents on pain, disability, quality of life, and lumbar paravertebral muscle stiffness via elastography in patients with chronic low back pain. Turk J Phys Med Rehab 2019;65(1):30-39.

DOI: 10.5606/tftrd.2019.2373
Table 1. Demographic characteristics of study population

                                   Control group
                         n    %    Mean[+ or -]SD     Median   n     %

Age (year)                         46.3[+ or -]10.7   45.0
Gender
  Female                 12   52                               12    52
  Male                   11   48                               11    48
Height (m)                          1.7[+ or -]0.1     1.7
Weight (kg)                        73.7[+ or -]15.3   72.0
BMI (kg/[m.sup.2]                  26.3[+ or -]3.9    26.3
Martial status
  Single                  2    9                                2     9
  Married                21   91                               21    91
Educational status
  Elementary school      10   43                               14    61
  Secondary school       10   43                                0     0
  High school             4   17                                7    30
  University              3   13                                2     9
Occupational status
  Office                 10   43                                2     9
  Ambulatory              5   22                                7    30
  Not working             8   35                               14    61
Pain duration (months)             71.0[+ or -]98.2   24.0

                                    H+T group
                            Mean[+ or -]SD     Median   n     %

Age (year)                   51.7[+ or -]10.7   52.0
Gender
  Female                                                 12    52
  Male                                                   11    48
Height (m)                    l.6[+ or -]0.l     1.6
Weight (kg)                  77.0[+ or -]14.1   80.0
BMI (kg/[m.sup.2]            29.2[+ or -]5.3    29.4
Martial status
  Single                                                  3    13
  Married                                                20    87
Educational status
  Elementary school                                      17    74
  Secondary school                                        2     9
  High school                                             3    13
  University                                              1     4
Occupational status
  Office                                                  7    30
  Ambulatory                                              6    26
  Not working                                            10    43
Pain duration (months)       79.6[+ or -]75.5   48.0

                                 H+T+U group
                        Mean[+ or -]SD     Median  P

Age (year)              48.6[+ or -]11.0  47.0   0.249 (*)
Gender                                           1.000 ([dagger])
  Female
  Male
Height (m)               l.6[+ or -]0.l    1.6   0.314 (*)
Weight (kg)             76.5[+ or -]12.6  78.0   0.698 (*)
BMI (kg/[m.sup.2]       28.3[+ or -]4.1   29.1   0.090 (*)
Martial status                                   0.853 ([dagger])
  Single
  Married
Educational status                               0.070 ([dagger])
  Elementary school
  Secondary school
  High school
  University
Occupational status                              0.124 ([dagger])
  Office
  Ambulatory
  Not working
Pain duration (months)  49.3[+ or -]70.5  12.0   0.144 ([double dagger])

H+T: Hot pack and TENS treatment; H+T+U: Hot pack, TENS and therapeutic
ultrasound treatment; SD: Standard deviation; BMI: Body Mass Index; (*)
ANOVA; [dagger] Chi-square test; [double dagger] Kruskal-Wallis test.

Table 2. Numeric Rating Scale, Oswestry Disability Index, and strain
ratios before and after treatment among study groups

                                        Control group
                     Mean[+ or -]SD     Median         Min-Max     IQR

NRS movement
  Before treatment    6.2[+ or -]2.5     8.0           0-10         2
  After treatment     6.2[+ or -]2.4     6.0           4-8          1
  BT/AT change        0.0[+ or -]1.0     0.0
  BT/AT change (p)                          0.891 ([dagger])
NRS rest
  Before treatment    4.3[+ or -]2.6     4.0           0-8          2
  After treatment     4.5[+ or -]2.6     4.0           1-4          2
  BT/AT change        0.2[+ or -]1.2     0.0
  BT/AT change (p)                          0.339 ([dagger])
NRS night
  Before treatment    4.3[+ or -]2.4     5.0           0-10         3.5
  After treatment     4.1[+ or -]2.4     4.0           0-6          1
  BT/AT change       -0.2[+ or -]1.0     0.0
  BT/AT change (p)                          0.319 ([dagger])
Oswestry
  Before treatment   40.7[+ or -]14.0   44.0          14-64        20
  After treatment    37.4[+ or -]14.9   32.0          14-64        24
  BT/AT change       -3.3[+ or -]10.4    0.0
  BT/AT change (p)                          0.144 ([dagger])
Strain ratio
  Before treatment    0.8[+ or -]1.4     0.3           0.03-6.90    0.60
  After treatment     1.3[+ or -]1.8     0.4           0.05-8.88    1.58
  BT/AT change        0.6[+ or -]1.9     0.0
  BT/AT change (p)                          0.136 ([dagger])

                                        H+T group
                        Mean[+ or -]SD   Median        Min-Max     IQR

NRS movement
  Before treatment      6.2[+ or -]1.7    6.0           4-9         2.5
  After treatment       4.5[+ or -]2.0    5.0           2-8         2.5
  BT/AT change         -1.7+1.5          -2.0
  BT/AT change (p)                           <0.001 ([dagger])
NRS rest
  Before treatment      3.8[+ or -]2.1    4.0           0-8         4
  After treatment       2.9[+ or -]1.8    3.0           0-8         3.5
  BT/AT change         -0.9[+ or -]1.3   -1.0
  BT/AT change (p)                            0.003 ([dagger])
NRS night
  Before treatment      4.0[+ or -]2.9    4.0           0-10        4
  After treatment       2.2[+ or -]2.0    2.0           0-8         3.5
  BT/AT change         -1.8[+ or -]2.4   -1.0
  BT/AT change (p)                            0.002 ([dagger])
Oswestry
  Before treatment     45.6+12.9         48.0          26-72       18
  After treatment      29.3+16.0         20.0          12-72       27
  BT/AT change         16.3+16.8        -18.0
  BT/AT change (p)                            0.001 ([dagger])
Strain ratio
  Before treatment      0.6[+ or -]0.9   0.3            0.11-4.12   0.22
  After treatment       0.6[+ or -]0.8   0.3            0.00-3.51   0.64
  BT/AT change          0.0[+ or -]1.2   0.0
  BT/AT change (p)                            1.000 ([dagger])

                                     H+T+U group
                        Mean[+ or -]SD   Median        Min-Max      IQR

NRS movement
  Before treatment      5.9[+ or -]1.8     6.0           2-9        2
  After treatment       4.0[+ or -]1.5     4.0           0-6        1.5
  BT/AT change         -1.9+1.5           -2.0
  BT/AT change (p)                            <0.001 ([dagger])
NRS rest
  Before treatment      3.5[+ or -]2.3     4.0           0-8        2
  After treatment       2.1[+ or -]1.9     2.0           0-6        4
  BT/AT change         -1.4[+ or -]1.3    -1.0
  BT/AT change (p)                             0.001 ([dagger])
NRS night
  Before treatment      4.2[+ or -]3.1     4.0           0-9        5
  After treatment       2.0[+ or -]2.2     1.0           0-7        4
  BT/AT change         -2.3[+ or -]2.4    -2.0
  BT/AT change (p)                             0.001 ([dagger])
Oswestry
  Before treatment     42.9+16.3          44.0          12-76       0.5
  After treatment      22.9+8.6           24.0           2-50       3
  BT/AT change        -20.0+14.5         -20.0
  BT/AT change (p)                            <0.001 ([dagger])
Strain ratio
  Before treatment      0.6[+ or -]0.4     0.5           0.12-1.81  0.46
  After treatment       0.6[+ or -]0.6     0.5           0.07-2.07  0.75
  BT/AT change          0.1[+ or -]0.5    -0.1
  BT/AT change (p)                             0.761 ([dagger])

                      P (*)

NRS movement
  Before treatment     0.751
  After treatment      0.008
  BT/AT change        <0.00l
  BT/AT change (p)
NRS rest
  Before treatment     0.576
  After treatment      0.007
  BT/AT change        <0.00l
  BT/AT change (p)
NRS night
  Before treatment     0.878
  After treatment      0.005
  BT/AT change         0.002
  BT/AT change (p)
Oswestry
  Before treatment     0.592
  After treatment      0.007
  BT/AT change        <0.00l
  BT/AT change (p)
Strain ratio
  Before treatment     0.279
  After treatment      0.302
  BT/AT change         0.288
  BT/AT change (p)

H+T: Hot pack and TENS treatment; H+T+U: Hot pack, TENS and therapeutic
ultrasound treatment; SD: Standard deviation; Min: Minimum; Max:
Maximum; IQR: Interquartile range; NRS: Numeric Rating Scale; BT:
Before treatment; AT: After treatment; (*) Kruskal-Wallis test
(Mann-Whitney U test); ([dagger]) Wilcoxon test.

Table 3. Short-Form 36 results

                                        Control group
SF-36                  Mean[+ or -]SD    Median          Min-Max  IQR

Physical function      52.8[+ or -]21.6   50                0-85   30
  Before treatment
  After treatment      48.7[+ or -]21.2   55                0-80   25
  BT/AT change         -4.1[+ or -]19.1    0
  BT/AT change (p)                           0.476 ([dagger])
Physical role          32.6[+ or -]33.2   25                0-100  50
function
  Before treatment
  After treatment      30.4[+ or -]39.9    0                0-100  75
  BT/AT change         -2.2[+ or -]30.1    0
  BT/AT change (p)                           0.601 ([dagger])
Pain
  Before treatment     34.8[+ or -]23.5   32                0-74   29
  After treatment      36.8[+ or -]21.5   32                0-100  36.75
  BT/AT change          2.0[+ or -]7.5     0
  BT/AT change (p)                           0.304 ([dagger])
General health         39.1[+ or -]15.7   40               10-72   19.5
perceptions
  Before treatment
  After treatment      40.2[+ or -]16.1   47                5-82   15.75
  BT/AT change          2.8[+ or -]12.9    0
  BT/AT change (p)                           0.366 ([dagger])
Vitality               41.7[+ or -]21.1   40               10-90   30
  Before treatment
  After treatment      41.1[+ or -]19.8   45                5-85   20
  BT/AT change         -0.7[+ or -]16.7    0
  BT/AT change (p)                           0.984 ([dagger])
Social role
function
  Before treatment     54.3[+ or -]30.3   50                0-100  44
  After treatment      59.7[+ or -]29.2   50               12-100  43.75
  BT/AT change          5.4[+ or -]18.9   0
  BT/AT change (p)                           0.217 ([dagger])
Emotional role
function
  Before treatment     40.2[+ or -]29.9   33                0-100  49.5
  After treatment      37.4[+ or -]32.1   33                0-100  66
  BT/AT change         -2.8[+ or -]30.0    0
  BT/AT change (p)                           0.809 ([dagger])
  Mental health
  Before treatment     48.0[+ or -]21.5   52                0-88   20
  After treatment      52.2[+ or -]15.2   52               24-88   20
  BT/AT change          4.2[+ or -]14.0    4
  BT/AT change (p)                           0.l6l ([dagger])

                              H[+ or -]T group
SF-36                 Mean[+ or -]SD     Median      Min-Max   IQR

Physical function      48.3[+ or -]19.9   45          15-85    20
  Before treatment
  After treatment      64.1[+ or -]24.5   70          15-85    32.5
  BT/AT change        15.9[+ or -]19.3    15
  BT/AT change (p)                           0.00l ([dagger])
Physical role          30.4[+ or -]38.4    0           0-100   25
function
  Before treatment
  After treatment      45.4[+ or -]38.2   25           0-100   75
  BT/AT change         15.0[+ or -]26.8   25
  BT/AT change (p)                           0.009 ([dagger])
Pain
  Before treatment     31.7[+ or -]15.0   22          10-61    19.5
  After treatment      46.3[+ or -]20.3   51           0-84    20
  BT/AT change        14.6[+ or -]17.9    10
  BT/AT change (p)                           0.003 ([dagger])
General health         34.5[+ or -]18.5   30           0-82    20
perceptions
  Before treatment
  After treatment      50.1[+ or -]19.4   50           0-76    23.5
  BT/AT change          7.8[+ or -]13.1   10
  BT/AT change (p)                           0.008 ([dagger])
Vitality               30.0[+ or -]16.6   30           5-60    22.5
  Before treatment
  After treatment      34.6[+ or -]19.1   35           0-75    27.5
  BT/AT change          4.6[+ or -]15.5    0
  BT/AT change (p)                           0..253 ([dagger])
Social role
function
  Before treatment     53.7[+ or -]26.2   50           0-100   38
  After treatment      56.8[+ or -]25.5   50          12-100   38
  BT/AT change          3.2[+ or -]17.7    0
  BT/AT change (p)                           0.523 ([dagger])
Emotional role
function
  Before treatment     49.0[+ or -]33.1   33           0-100   33
  After treatment      43.2[+ or -]35.4   33           0-100   49.5
  BT/AT change         -5.7[+ or -]35.7    0
  BT/AT change (p)                           0.475 ([dagger])
  Mental health
  Before treatment     45.4[+ or -]17.5   48          12-80    22
  After treatment      47.5[+ or -]18.6   48           8-92    18
  BT/AT change          2.1[+ or -]14.7    0
  BT/AT change (p)                           0.599 ([dagger])

                            H[+ or -]T[+ or -]U group
SF-36                 Mean[+ or -]SD     Medan     Min-Max   IQR   P (*)

Physical function     53.3[+ or -]25.7   50        10-90    40     0.682
  Before treatment
  After treatment     69.8[+ or -]20.8   70        15-100   37.5   0.007
  BT/AT change        16.5[+ or -]21.9   10                        0.001
  BT/AT change (p)                          0.00l[dagger]
Physical role         30.4[+ or -]35.3   25         0-100   50     0.889
function
  Before treatment
  After treatment     51.5[+ or -]33.1   50         0-100   50     0.002
  BT/AT change        21.1[+ or -]24.9   25                        0.002
  BT/AT change (p)                          0.00l ([dagger])
Pain
  Before treatment    39.7[+ or -]21.5   32         0-84    25     0.442
  After treatment     58.0[+ or -]22.5   51        12-100   26     0.003
  BT/AT change        18.3[+ or -]16.3   16                        0.002
  BT/AT change (p)                         <0.00l ([dagger])
General health        39.8[+ or -]23.7   42         0-85    30.5   0.073
perceptions
  Before treatment
  After treatment     54.7[+ or -]18.9   50        22-92    24.5   0.002
  BT/AT change        14.2[+ or -]19.7    5                        0.009
  BT/AT change (p)                          0.002 ([dagger])
Vitality              41.7[+ or -]21.6   40        10-95    20     0.091
  Before treatment
  After treatment     45.4[+ or -]24.0   40        10-90    37.5   0.288
  BT/AT change         3.7[+ or -]19.7    0                        0.714
  BT/AT change (p)                          0.420 ([dagger])
Social role
function
  Before treatment    54.6[+ or -]28.5   62        12-100   38     1.000
  After treatment     63.4[+ or -]25.3   62        25-100   44     0.727
  BT/AT change         8.8[+ or -]20.8   12                        0.301
  BT/AT change (p)                          0.037 ([dagger])
Emotional role
function
  Before treatment    31.7[+ or -]29.2   33         0-100   26     0.156
  After treatment     46.1[+ or -]32.9   33         0-100   33     0.689
  BT/AT change        14.4[+ or -]29.8    0                        0.115
  BT/AT change (p)                          0.029 ([dagger])
  Mental health
  Before treatment    51.1[+ or -]20.0   52        16-100   33     0.649
  After treatment     57.4[+ or -]18.2   60        24-96    30     0.229
  BT/AT change         6.3[+ or -]16.7    8                        0.689
  BT/AT change (p)                          0.069 ([dagger])

H+T: Hot pack and TENS treatment; H+T+U: Hot pack, TENS and therapeutic
ultrasound treatment; SD: Standard deviation; Min: Minimum; Max:
Maximum; IQR: Interquartile range; NRS: Numeric Rating Scale; BT:
Before treatment; AT: After treatment; (*) Kruskal-Wallis test
(Mann-Whitney U test); ([dagger]) Wilcoxon test.
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Article Details
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Title Annotation:Original Article
Author:Yurdakul, Ozan Volkan; Beydogan, Engin; Yalcinkaya, Ebru Yilmaz
Publication:Turkish Journal of Physical Medicine and Rehabilitation
Article Type:Report
Date:Mar 1, 2019
Words:6680
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