Bull. Fac. Ph. Th. Cairo Univ., Vol. 17, No. (1) Jan.

2012 51

Efficacy of Muscle Energy Technique versus Myofascial

Release on Function Outcome Measures in Patients with
Chronic Low Back Pain
Marzouk A. Ellythy
Department of Basic Sciences, Faculty of Physical Therapy, Cairo University

ABSTRACT INTRODUCTION

L
Background: Low-back pain is one of the leading ow-back pain (LBP) has been identified
causes of disability. Manual therapy is a as one of the most costly disorders
specialization within physical therapy and among the worldwide working
provides comprehensive conservative management population30. LBP is a common problem
for pain and other symptoms of neuro-musculo- throughout the industrialized world. Lifetime
articular dysfunction in the spine and extremities.
prevalence is reported between 50% and 80%
Purpose: The primary objective of this study was
to assess the effectiveness of manual therapy with most studies reporting 50% to 60% of
techniques on outcome measures in patients with adults. The recurrence rate is reported to be
chronic low back pain. Methods: forty patients between 50% and 88%. LBP symptoms are
(male and female), their age range 30-55 years, major contributors to ambulatory visits,
with chronic low back pain (more than tree economic burden, and reduced readiness
months) were assigned randomly to two equal among military personnel and employers in the
treatment groups. The first group (A) underwent a civilian workplace as well14.
four weeks specific muscle energy treatment Muscle energy technique (MET) and
program in form of post-isometric relaxation (PIR) propioceptive neuoro-muscular facilitation
plus specific physical therapy program. The (PNF) stretching methods have been clearly
second group (B) underwent a four weeks specific
shown to bring about greater improvements in
myofascial release program plus specific physical
therapy program. Outcome measures include pain joint range of motion (ROM) and muscle
intensity, lumber movements and functional extensibility than passive, static stretching,
disability index were measured. Results: The both in the short and long term18. MET is a
present study revealed that although there was no safe, gentle and is believed to be in patients
statistical significance (P> 0.05) difference in pain with a variety of symptoms. The popularity of
intensity level, lumber range of motion and MET will justifiably increase for the benefit of
function disability level between both groups, practitioners and patients alike11. It was
patients in both groups showed statistical reported that post isometric relaxation is
significance P< 0.05 differences in all outcome considered a highly effective therapy for back
measures between pre group (A) pain level from dysfunction patients9.
(7.7±1.42) to (5±1.34), function disability from
A key component of pain-related
(56±12.06) to (30.35±9.16) and lumber movement
from (30.75±11.69) to (41.25±7.39). Pre treatment behavior is fear of pain with consequent
group (B) pain level from (8.31±1.59) to decrease in physical activity43,46. While rest
(5.36±1.56), function disability from (55±10.07) to may be initially important in acute low back
(33.57±11) and lumber movement from injury (e.g. disc herniation, muscle sprain), it
(27.89±12.7) to (41.05±8.36). Conclusion: The is increasingly recognized that timely
findings of this trial support the view that the resumption of physical activity is critical to
functional integration of specific manipulative successful rehabilitation44.
techniques are effective in reducing pain and Myofascial release techniques (MFR)
functional disability in patients with chronic low are a group of specific maneuvers that are
back pain. directed toward the soft tissues of the body,
Key words: Muscle energy, Myofascial Release,
particularly the muscles and fascia. Muscle
chronic low back pain, outcome measures.
and fascia are most commonly thought of as
the tissues treated by these techniques, but all
of the fibroelastic connective tissues, as well
52 Efficacy of Muscle Energy Technique versus Myofascial
Release on Function Outcome Measures in Patients with
Chronic Low Back Pain

as skin, tendons, ligaments, cartilage, blood, received PIR for Psoas group, Hamstring,
and lymph, may be affected16. Tensor Fascia Lata, Piriformis, Quadratus
Manual therapy is beneficial for patients lumborum and Erector Spinae muscles, while
with sub acute and chronic non-specific low group (B) was received MFR for the following
back pain, both reducing the symptoms and muscles; Psoas, Hamstring, Tensor Fascia
improving function21. Identifying which latae and Iliotibial Band, Piriformis, Lateral
treatment works best for whom' in low back abdominal muscles and quadratus lumborum
pain has been an on-going aim of clinicians and Erectro Spinea muscles1.
and has been a research priority over the last
decade34. RESULTS

SUBJECTS, Statistical analysis revealed no

MATERIALS AND METHODS statistically significant differences between
both groups on entry to the study. Analysis of
Subjects differences within each group after the
Criteria for inclusion in the study were intervention period revealed significant
restricted to 40 patients of either gender differences; in the PIR group, after the
between the ages of 30 and 55 years and had intervention period, there was a decrease in
persisted low back pain longer than 3 months8. pain intensity (t = 7.37, P < 0.0001) and a
reduction in functional disability levels (t =
Instrumentations: 9.05, P < 0.0001) and lumbar spine ROM
A- For Evaluation: improvement (flex, ext, R &L side bending)
1. Pain measures: The short form McGill pain where (t = 4.22, 4.97, 4.14, 5.05 and P <
questionnaire was used to assess each patient's 0.001, 0.001, 0.001, 0.001 respectively as
average symptoms32. shown in table (1).
2. Lumbar spine range of movement in PIR group revealed a statistical
standing: This was measured using significant difference between pre and post
inclinometers25. treatment; pain intensity level as the pain level
3. Functional measures: The Oswestry isability pre treatment was (7.7± 1.42) and for post
questionnaire was used to give a percentage treatment was (5±1.34) where the t-value was
score that indicated each patient's level of (7.37) and P-value was (0.0001), there was a
functional disability17. significant difference between pre and post
B- For intervention: treatment lumbar flexion ROM as the lumbar
1. Infrared Radiation (IRR): model is 2004/2 flexion ROM pre treatment was (30.75±
N, a power of 400 w, voltage 203 v and 11.96) and for post treatment was
frequency of 50/60 Hz. (41.25±7.39) where the t-value was (4.22) and
2. Ultrasonic Device: Phyaction U 190, 230 V, P-value was (0.001), there was a significant
300 mA/50-60 Hz, Plus: 8 w. difference between pre and post treatment
3. Transcutanous Electrical Nerve Stimulation lumbar extension ROM as the lumbar
(TENS): (Dc: 6 v, Watts: 6 w, CE: 0120). extension ROM pre treatment was (8.25±2.86)
Treatment Procedure: Both treatment group and for post treatment was (16.25±4.14) where
are received the following intervention the t-value was (4.97) and P-value was
protocols: (0.001), there was a significant difference
1. Infrared Radiation. between pre and post treatment lumbar (Rt)
2. Ultrasonic4. side bending ROM as the lumbar side bending
3. (TENS). ROM pre treatment was (6.25±3.49) and for
4. Therapeutic Exercise program: includes: post treatment was (11.75±2.91) where the t-
Finger to Toes, Bridging Exercise, Back value was (5.14) and P-value was (0.001), ),
Extension from Prone, Sit-Up Exercise, Knee there was a significant difference between pre
to Chest Exercise and Stretching of Lower and post treatment lumbar (Lt) side bending
Back Muscles. At this point group (A) was ROM as the lumbar side bending ROM pre
Bull. Fac. Ph. Th. Cairo Univ., Vol. 17, No. (1) Jan. 2012 53

treatment was (7±2.91) and for post treatment (27.89± 12.7) and for post treatment was
was (12±3.32) where the t-value was (5.05) (41.05±8.36) where the t-value was (4.77) and
and P-value was (0.001), and finally, there was P-value was (0.003), there was a significant
a significant difference between pre and post difference between pre and post treatment
treatment functional disability as the lumbar extension ROM as the lumbar
functional disability pre treatment was extension ROM pre treatment was (7.89±3.74)
(56±12.06) and for post treatment was and for post treatment was (15.78±6.74) where
(41.25±7.39) where the t-value was (9.05) and the t-value was (8.72) and P-value was
P-value was (0.0001) as shown in table (1). (0.001), there was a significant difference
While in the MFR group after the between pre and post treatment lumbar (Rt)
intervention period, there was a decrease in side bending ROM as the lumbar side bending
pain intensity (t = 7.15, P < 0.0001) and a ROM pre treatment was (6.57±3.64) and for
reduction in functional disability levels (t = post treatment was (10.52±3.58) where the t-
9.04, P < 0.0001) and lumbar spine ROM value was (7.68) and P-value was (0.002),
improvement (flex, ext, R and L side bending) there was a significant difference between pre
where (t = 4.77, 8.72, 7.68, 5.63 and P < and post treatment lumbar (Lt) side bending
0.003, 0.001, 0.002, 0.004 respectively) as ROM as the lumbar side bending ROM pre
shown in (Table 1). treatment was (6.89±3.68) and for post
MFR group revealed a statistical treatment was (11.05±4.16) where the t-value
significant difference between pre and post was (5.63) and P-value was (0.004), and
treatment; pain intensity level as the pain level finally, there was a significant difference
pre treatment was (8.31± 1.59) and for post between pre and post treatment functional
treatment was (5.36±1.56) where the t-value disability as the functional disability pre
was (7.15) and P-value was (0.0001), there treatment was (55±10.07) and for post
was a significant difference between pre and treatment was (33.57±11) where the t-value
post treatment lumbar flexion ROM as the was (9.04) and P-value was (0.0001) as shown
lumbar flexion ROM pre treatment was in table (1).

Table (1): Paired t-test of the dependant variables in each group.

Pre treatment Post treatment Paired t-test
Group Variable
Mean ±SD Mean ±SD t-value P-value Significance
Pain level 7.7± 1.42 5 ±1.34 7.37 0.0001 S
Lumbar flexion ROM 30.75±11.69 41.25±7.39 4.22 0.0001 S
Lumbar extension ROM 8.25±2.68 16.25±4.14 4.97 0.0001 S
Group (A) Lumbar RT side bending
6.25±3.49 11.75±3.27 5.14 0.0001 S
(PIR) ROM
Lumbar LT side bending
7±2.91 12±3.32 5.05 0.0001 S
ROM
Functional disability 56±12.06 30.35±9.16 9.05 0.0001 S
Pain level 8.31± 1.59 5.36±1.56 7.15 0.0001 S
Lumbar flexion ROM 27.89± 12.7 41.05±8.36 4.77 0.003 S
Lumbar extension ROM 7.89±3.74 15.78±6.74 8.72 0.001 S
Group (B) Lumbar RT side bending
6.57±3.64 10.52±3.58 7.68 0.002 S
(MFR) ROM
Lumbar LT side bending
6.89±3.68 11.05±4.16 5.63 0.004 S
ROM
Functional disa 55±10.07 33.57±11 9.04 0.0001 S
P-value = Probability S = Significance

Statistical analysis revealed no Pre treatment there was no significant

statistically significant differences between differences between group (A) and (B) in: (I)
both groups (A) and (B) in the combined pain intensity level where the t-value was
dependant variables both pre and post (1.94) and P-value was (0.069), (II) lumbar
treatment. flexion and extension, RT and LT side bending
ROM where the t-values were (0.74, 0.49,
54 Efficacy of Muscle Energy Technique versus Myofascial
Release on Function Outcome Measures in Patients with
Chronic Low Back Pain

0.21, 0.18) and P-values were (0.468, 0.639, (0.87) and P-value was (0.397), (II) lumbar
0.834, 0.861), and finally, (III) functional flexion and extension, RT and LT side bending
disability where the t-value was (0.12) and P- ROM where the T-values were (0.34, 0.45,
value was (0.908) as shown in table (2). 1.16, 0.85) and P-values were (0.737, 0.659,
Post treatment there was no significant 0.262, 0.408), and finally, (III) functional
differences between group (A) and (B) in: (I) disability where the t-value was (0.95) and P-
pain intensity level where the t-value was value was (0.365) as shown in table (2).

Table (2): Paired t-test of the dependant variables in both group.

Group(A) Group (B)
Time of Paired t-test
Variable (PIR) (MFR)
measurements
Mean ±SD Mean ±SD t-value P-value Significance
Pain level 7.7± 1.42 8.31± 1.59 1.94 0.069 NS
Lumbar flexion ROM 30.75±11.96 27.89±12.7 0.74 0.468 NS
Lumbar extension
8.25±2.86 7.89±3.74 0.49 0.629 NS
ROM
Pre
Lumbar RT side
treatment 6.25± 3.49 6.57± 3.64 0.21 0.834 NS
bending ROM
Lumbar LT side
7± 2.91 6.89± 3.68 0.18 0.861 NS
bending ROM
Functional disability 56±12.06 55±10.07 0.12 0.908 NS
Pain level 5±1.34 5.36±1.56 0.87 0.397 NS
Lumbar flexion ROM 41.25±7.39 41.05±8.36 0.34 0.737 NS
Lumbar extension
16.25±4.14 15.78±6.74 0.45 0.659 NS
ROM
Post
Lumbar RT side
treatment 11.75±3.27 10.52±3.58 1.16 0.262 NS
bending ROM
Lumbar LT side
12±3.32 11.05±4.16 0.85 0.408 NS
bending ROM
Functional disability 30.35±9.16 33.57±11 0.93 0.365 NS
P-value = Probability S = Significance NS = Non significance

DISCUSSION Degenhard et al., 200715, who reported that

concentrations of several circulatory pain
I. Pain intensity level: both PIR and MFR biomarkers (including endocannabinoids and
groups revealed a statistical significant endorphins) were altered following muscle
reduction in pain intensity level after the energy. The degree and duration of these
intervention period in patient with CLBP. For changes were greater in subjects with C LBP
PIR group, the analgesic effect of PIR could than in control subjects. Moreover myofascial
be explained by both spinal and supraspinal trigger point deactivation was shown to be
mechanisms; Activation of both muscle and enhanced by use of different forms of MET19.
joint mechanoreceptors occurs during an Consistent with these findings, Selkow et al.,
isometric contraction. This leads to sympatho- 200937, who described the effectiveness of
excitation evoked by somatic efferents and treating "lumbopelvic pain due to rotations of the
localized activation of the periaqueductal grey ilium" with PIR for hamstring muscle. Also the
that plays a role in descending modulation of analgesic effect of MET is confirmed by work
pain. Nociceptive inhibition then occurs at the Strunk, 200842, Buchmann et al., 20057, and
dorsal horn of the spinal cord, as simultaneous Wilson et al., 200345. On the other hand,
gating takes place of nociceptive impulses in Ballentyne et al., 20033, still argue and hesitate
the dorsal horn, due to mechanoreceptor about the efficacy of MET in form of post-
stimulation20. PIR stimulates joint isometric relaxation PIR.
proprioceptors, via the production of joint For MFR group, manual therapy may
movement, or the stretching of a joint have an effect on spinal cord5 and has been
capsule23. This is supported by the study of associated with hypoalgesia33. The
Bull. Fac. Ph. Th. Cairo Univ., Vol. 17, No. (1) Jan. 2012 55

hypoalgesia results from segmental widespread support40. The theoretical base for
postsynaptic inhibition on dorsal horn pain chosen MFR technique was to free barriers
pathway neuron during manual therapy. The within the deeper layers of fascia and the
analgesic effect of MFR could be explained by surrounding muscle fibers31. Through this
both spinal and supraspinal mechanisms; process it was believed that there would be
Activation of both muscle and joint significant increase in ROM and pain.
mechanoreceptors occurs during sustained III. Functional Disability: both PIR and MFR
release38,41,47. Nociceptive inhibition then groups revealed a statistical significant
occurs at the dorsal horn of the spinal cord, as reduction in Function disability level after the
simultaneous gating takes place of nociceptive intervention period in patient with CLBP. This
impulses in the dorsal horn, due to improvement is the resultant of combined
mechanoreceptor stimulation20. MFR findings of pain reduction and increasing of
procedures claim to encourage the circulation lumbar spine mobility. MET group is
of fluid in and around the tissues to enhance supported by a study of Wilson (2003)45
venous and lymphatic systems and aid in concluded that using MET may benefit a
decongesting areas of fluid stasis22. The result patient to reduce low back pain and improve
of the current study was supported by Cisler low back functional disabilities.
199712, who studied the possible use of
myofascial release in whiplash injuries. Conclusion
Another study revealed significant reduction in The findings of this study support the
pain of female runners who had extremely view that the functional integration of specific
chronic hamstring pain and deficit in manipulative techniques directed at the low
flexibility in leg. MFR stimulates joint back muscles are effective in reducing pain
proprioceptors, via stretching of a joint and functional disability and improving
capsule, may be capable of reducing pain by lumbar spine mobility in patients with CLBP.
inhibiting the smaller diameter nociceptive
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Chronic Low Back Pain

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‫الملخص العربي‬

‫مقارنة الطاقة العضلية واالنفراج العضلي الليفي على المخرجات الوظيفية لمرضى آالم أسفل الظهر المزمنة‬
%٨٠ - % ٥٠ ‫ تتراوح نسبة اإلصابة به بٌن‬. ‫ ٌعرف ألم أسفل الظهر بأنه األكثر كلفة من الناحٌة االقتصادٌة على مستوى العالم‬: ‫مقدمة‬
‫ تتعدد وسائل العالج الطبٌعً المستخدمة فً عالج ألم أسفل‬. %٨٨ - % ٥٠ ‫ كما تبلغ نسبة عودة األلم بعد الشفاء منه ما بٌن‬. ‫بٌن البالغٌن‬
‫الظهر إال أنه بدأ التركٌز فً ا آلونة األخٌرة على استخدام العالج الٌدوي فً صورة كل من تقنٌة طاقة االنقباض العضلً (عالج ٌدوي‬
‫ تهدف هذه الدراسة إلى‬: ‫ الهدف‬. ‫إٌجابً) وكذلك االنفراج العضلً اللٌفً (عالج ٌدوي سلبً) للتحكم والسٌطرة على هذا النوع من األلم‬
.‫تقٌٌم فاعلٌة كل من طاقة االنقباض العضلً وكذلك ا النفراج العضلً اللٌفً على المخرجات الوظٌفٌة لمرضى آالم أسفل الظهر المزمن‬
‫ عام وٌعانون من آالم أسفل الظهر لمدة تزٌد‬٥٥ – ٣٠‫ مرٌضا (رجال – نساء) تتراوح أعمارهم بٌن‬40 ‫ تم إجراء هذا البحث على‬: ‫الطريقة‬
‫ تم تقسٌم المرضى عشو ائٌا ً إلى مجموعتٌن متساوٌتٌن فً العدد حٌث تم عالج المجموعة األولى بواسطة تقنٌة طاقة‬. ‫عن ثالثة أشهر‬
، ‫ موجات فوق الصوتٌة‬، ‫االنقباض العضلً والثانٌة بطرٌقة ا النفراج العضلً اللٌفً وبرنامج عالج طبٌعً ٌتكون من أشعة تحت الحمراء‬
‫ أظهرت النتائج فروق ذات داللة‬: ‫ النتائج‬. ‫ جلسة‬١٢ ‫ أسابٌع لمدة‬٤ ‫ مرات لمدة‬٣ ‫ تمرٌنات عالجٌة لكلتا المجموعتٌن‬، ‫ذبذبات كهربائٌة‬
‫ المدى الحركً (الثنً والفرد) للفقرات القطنٌة وكذلك‬، ‫معنوٌة إحصائٌة فً كلتا المجموعتٌن بٌن المتغٌرات موضع الدراسة وهً شدة األلم‬
‫مقٌاس أوسوستري للعجز الوظٌفً قبل وبعد العالج إال أنها أوضحت أٌضا أنه لٌس هناك فروق ذات داللة معنوٌة إحصائٌة بٌن كل من تقنٌة‬
‫ التقنٌات العالجٌة الٌدوٌة لها تأثٌر فً التحكم والسٌطرة‬: ‫ الخالصة‬. ‫الطاقة العضلٌة واالنفراج العضلً اللٌفً على هذه المتغٌرات الثالثة‬
. ‫على آالم أسفل الظهر المزمن‬
. ‫ تقنٌة الطاقة العضلٌة – تقنٌة االنفراج العضلً اللٌفً – آالم أسفل الظهر المزمن‬: ‫الكلمات الدالة‬