Comparative efficacy of positional release technique and craniosacral therapy to improve pain in individuals with chronic low back pain

INTRODUCTION

BACKGROUND

Low back pain (LBP) is a common health problem globally, managed in primary healthcare settings. A person with LBP clinically presents with discomfort, tightening of the muscles, or stiffening below the costal border and over the lower folds of the gluteal muscles, with or without discomfort in the leg. Across all age groups, LBP is one of the most prevalent musculoskeletal conditions in the general population and is the most prevalent disability among middle aged adults. Patients experience pain following their initial episode of symptoms, along with a reduction in their quality of life. LBP affects between 4% and 33% of the population at any given time, with estimates of an 80% lifetime incidence, depending on population and methodology. Several factors can result in acute LBP, including individual stance deviations, improperly functioning muscles (muscle imbalance, atrophy, or weakness), instability, joint disorders in the lower lumbar area, and injury (most often from motor vehicle accidents).

Positional Release Therapy (PRT) on the other hand is a method which uses tender points and a position of comfort to relieve the associated dysfunction. The tender point is used as a guide and the position of comfort is maintained. This prolonged shortening of the muscle causes shortening of both the intrafusal (muscle spindle) and extrafusal fibres. These changes in tum result in a significant increase in function, range of motion and a decrease in pain. PRT is an indirect manual therapy technique because its action is away from the restricted barrier into the direction of greatest ease. One advantage of PRT is that because of its gentleness and effectiveness, it is appropriate for some selected patient populations such as paediatrics, geriatrics, sports injuries, auto accidents, general orthopaedic conditions, amputees, respiratory and neurological participants

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Craniosacral therapy (CST) is an alternative and complementary therapy which claimed to release the tension of the muscles, ligaments, and fascia in the sacral area. CST seems to activate central pain inhibitory centers. CST is suggested for all musculoskeletal conditions particularly back pain. It was shown that CST has an effect on non-specific chronic low back pain, pelvic pain, chronic neck pain, and acute lower back pain. Craniosacral Therapy intends to normalize sympathetic nerve activity, often increased in chronic pain patients, by modifying craniosacral rhythms. While the specific mechanisms of Craniosacral Therapy are still understudied, clinical trails have shown a preliminary evidence for Craniosacral Therapy on improving patient reported outcomes such as pain and function in subjects with Non-Specific Neck Pain.

Procedure And Protocol

Participants will be divided into two groups, Group A: PRT  and Group B: CST

**Group A: Positional Release Technique (PRT):**This group will receive the positional release therapy with the subject lying prone.

1.Quadratus lamborum muscle: The tender points will be located on the lateral aspect of transverse processes from L1 to L5. Pressure will be applied anteriorly and then medially. The patient will be in prone with the head of the table raised or pillow placed under the patient’s chest, the examiner will standing on the opposite side of the tender point and reach across to grasp the ilium of the affected site. The examiner will then instruct the patients to flex and abduct the ipsilateral hip to approximately 45 degrees.

2. Piriformis: The tender point will found in the belly of the muscle approximately halfway between the inferior lateral angle of the sacrum and the greater trochanter. Pressure will applied interiorly. the patient will prone, and the examiner will be  standing on the tender point side. The ipsilateral leg will suspended off the table with the bent knee resting on the therapist’s thigh. The hip will flexed to 60 to 90 degree and abducted; rotation willl be used to fine-tune the position.

**3. Erector spinae:**This group received the positional release therapy with the subject lying prone. The subject lay prone with trunk laterally flexed towards the tender side (Plate 2). The physiotherapist stood on the side of the tender point. The physiotherapist placed the knee on the table and rested the participant s affected leg on the physiotherapist’s thigh. The participant’s hip was extended and adducted, and slight rotation was used to fine tune the muscle . This technique as performed for the erector spinae for 90 sec with 3 repetitions (270 sec).

**Group B :**Craniosacral therapy (CST): Patients will be receive 10 session of CST in 2 weeks (3 sessions per week) and each session lasts 45 minutes. A session  will contains 4 phases including in prone position, in side-lying position behind the therapist, in side-lying in front of the therapist, and in supine position. Patients will be in each position for 10 minutes. To feel and follow craniosacral movements, craniosacral therapist put her both hands on two regions or bones.

Outcome Measure:

1.Numerical Pain Rating Scale ( NPRS) will measure pain.

2. The Oswestry Disability Index ( ODI) will measure perceived level of functional disability and quality of life impairment caused by low back pain.

3. Goniometer will measure the range of motion