Effectiveness of Myofascial Release, Muscle Energy Technique and Stretching of Quadrartus Lumborum Muscle in Patients with Non-Specific Low Back Pain

Background: Low back pain is attributed to be the most commonly encountered health condition and considered to be one of the leading cause of disability. It is known to occur in all age groups in both developed as well as developing countries. About 80% of the patients have moderate to severe pain affecting their activities of daily living, with females more affected than males. Almost 90% of low back pain is of non-specific type. Quadratus lumborum is one of the deep muscles located closer to center of rotation of spinal segment having an ideal muscle length controlling motion at spine. Activities like sustained repetitive movements, twisting, bending, and sedentary posture for prolong duration, muscle imbalance, etc. leads to trigger point formation making quadratus lumborum as a common source of low back pain. Aim : To determine the combined effect of myofascial release therapy, muscle energy technique and stretching of Quadratus Lumborum muscle in Non-specific low back pain in a short duration span. study design, two groups were divided as Control and Experimental group with a pre and post test format for both groups. 35 participants were selected and divided into 2 groups by using the Random Sampling Technique using the inclusion and exclusion criteria. Outcome measures assessed were Numerical Pain Rating Scale (NRPS), Oswestry Disability Index (ODI) and Lumbar Range of Motion with Modified Schober’s Test. A specifically designed treatment protocol for individual group was used for duration of 2 weeks. Statiscal Analysis: Paired and Unpaired t test were used for the analysis of the data. The results of the study showed extremely significant difference between both the groups for NPRS and ODI with p<0.0001 using unpaired t test considered extremely significant. The increase in mean values is extremely significant for Lumbar ROM while comparing the pre and post-test values for mean difference of experimental group than control. The improvement in lumbar flexion, side flexion is more marked than for extension with minimal to no difference in rotation.


Introduction
Low back pain is attributed to be one of the most commonly encountered health condition faced. It is considered to be the leading cause of disability affecting all age groups in both developing and developed countries. About 80% of the patients have moderate to severe pain intensity affecting their activities of daily living, with female individuals more affected than males. Almost 90% of low back pain is of non-specific type 1 .
Low Back Pain can be qualified as mechanical, nonmechanical and psychogenic. Mechanical pain is further qualified as specific and non-specific. A pain arising due to unknown cause or pathology is known as non-specific low back pain. Non-specific low back pain is defined as the pain which arises due to an unknown cause or pathology. The nonspecific low back pain varies with physical activity, duration and usually located to lumbosacral, buttock and thigh region with no radiating pain in leg or foot. It is localized to coastal margin, inferior gluteal folds and paraspinal region. The causes of low back pain are various such as myofascial pain or trigger points due to piriformis or quadratus lumborum, muscle spasm or strain, stiffness, altered biomechanics of the spine or body, limitation of movement, faulty posture, weak musculature, overuse like repetitive weight-lifting or carrying excessive weight with improper position of the body etc. Those with a higher Body Mass Index and individuals involved in sedentary work are considered at a higher risk for development of low back pain in general 2,3 . In most cases of low back pain, the initial source of pain is the soft tissue structures 3 .
The prevalence of low back pain is estimated to be around 60-70% whereas almost 70-85% of people will experience low back pain at some point in their life 4 . Hoe et al., stated that among the individuals complaining of low back pain, about 85% to 95% cases there is an unknown pathoanatomical cause and thus the diagnosis conclude non-specific low back pain. Various factors are found to influence the prevalence of low back pain including age, sex, body composition, education level and occupation of an individual 5 .
The musculature of the spine is divided into the global or superficial muscle system and deep or local muscle system. The superficial muscles have its attachment from the vertebrae of the spine to the ribs causing movement working together as a guy wire functioning for mobility and the deep muscles attaches one vertebra to another providing segmental stability to the vertebral column 6 .
Quadratus lumborum is one of the deep muscles located closer to center of rotation of spinal segment having an ideal muscle length controlling motion at spine. Located in the posterior abdominal wall present in pair, originating at posterior border of iliac crest and inserting on inferior border of twelfth rib and transverse process of L1 to L4 vertebrae. The deep medial portion of quadratus lumborum acts as a deep segmental muscle whereas the lateral portion acts as a global muscle. The muscle functions as lateral flexor of spine contracting unilaterally, bilaterally contracts for lumbar extension, as it attaches the 12 rib and some fibers merge with diaphragm it has a significant role in respiration mainly during exhalation. It also connects the pelvis to spine acting as a primary antagonist to quadratus lumborum on other side. Hence activities like sustained repetitive movements, twisting, bending, sedentary posture for prolonged duration, muscle imbalance, etc. leads to trigger point formation making quadratus lumborum as a common source of low back pain also there are major evidences stating the same 3,6,7,17,22 .
A case study conducted by Barge AS et al., stated that in most cases of low back pain may be acute or chronic the most common source of pain is missed or remains undiagnosed, very often the Quadratus Lumborum muscle compensates for weak back musculature leading to improper and powerful contractions causing painful spasms and myofascial pain syndrome in Quadratus Lumborum muscle 8 . Thus, it is necessary to take quadratus lumborum in consideration for low back pain owing to its significant role in spinal mobility as well as stability along with respiration.
A wider variety of interventions such as medical, surgical and rehabilitative have been used in management of back pain, one of which is the manual therapy techniques. A systematic review conducted by Van Middelkoop et al., suggested that exercise therapy has shown to improve various aspects of the symptoms experienced in low back pain such as pain, disability and functioning 9 . According to a study conducted by Jason Mallia et al., exercise therapy and manual therapy approaches are considered to be the first line and an integral part of management strategies in Low back pain. Also, myofascial release therapy showed to effective in reducing low back pain in about 53.3% participants of the study 10 .
Myofascial release therapy is defined as the facilitation of mechanical, neural and psycho physiological adaptive potentials as interfaced via myofascial system. The role of involvement of the fascial system in non-specific low back pain is quite evident and proved by many studies. The thoracolumbar fascia has a basal tension which helps it to sense and control of underlying muscles due to presence of mechanoreceptors. With trigger point formation this tension is altered affecting the fascial model leading to dysfunction 11 . A myofascial trigger point is defined as a hard, palpable, hyperirritable area or nodule present in a tight band of muscle which often leads to pain 12 . In this technique the feedback from the patient's body is important as it acts a source of guidance for the force generation, direction, duration and taking up the slack and reaching the next barrier or restriction. It has also proved to be effective in reducing anxiety, improving sleep and tackling depression to a certain extent 13,14 . Not only the muscles, fascia and somatic dysfunction, all the fibroelastic connective tissues as well as skin, ligaments, tendon blood vessels, lymphatics are affected by myofascial release. It has shown to improve muscle length, reduce pain, improve function, improve circulation along with stimulation of mechanoreceptors, breaking adhesions, etc. 15,16 .
Another manual therapy treatment approach is the Muscle Energy Technique which involves voluntary contraction of patient's muscle in a precisely controlled direction, at varying level of intensity against a distinctly executed counter force applied by therapist as stated by Chai tow. Lewit (1992) stated that in case of pain present at lumbodorsal junction use of post-Isometric relaxation techniques is beneficial to treat the involved muscles, as most of them are either shortened, overactive, sensitive on direct palpation. They become stretched and normalise post treatment so, automatically the rest of musculature functions in a normal manner 17 . MET stimulates the Golgi tendon organs within the muscle where afferent nerve impulse enters the dorsal root of spinal cord and meets with an inhibitory response. MET has been shown effective in lengthening, strengthening of the shortened muscle, increasing the fluid mechanics, decreasing edema thus improving flexibility of the muscle 18 . A study conducted by Kumar et al., proved MET to be effective in treatment of acute low back pain patients with involvement of QL muscle 19 .
The therapeutic maneuver designed to increase the extensibility of soft tissues and improving the flexibility along with range of motion by elongating structures that have adaptively shortened or became hypomobile overtime is known as Stretching. Muscular imbalances often arise due to faulty habitual postures, overuse leading to microtrauma causing chronic dysfunction. Usually, three repetitions are carried out by the participant performing stretching with a hold of 10-30 seconds during each repetition thus stimulating the stretch receptors within the muscle 6,20 . The self-static stretching involves elongation of the muscle slowly until tolerable and holding the position for a duration short of pain voluntarily by an individual. In a study conducted by Devi ZK et al., it was observed that stretching of lower back muscles had a shortterm effect upon improving pain, flexibility and functional disability among occupation related chronic low back pain 21 .
The previous studies showed the need for studies to be undertaken over various physiotherapy interventions focusing mainly the combined effect of manual therapy approaches adding on to scarcity in the literature. Thus, the purpose of this study is to know the combined effect of myofascial release therapy, muscle energy technique and stretching of Quadratus Lumborum muscle in Non-specific low back pain in a short duration span.

Participant Selection
A total of 35 participants were selected and divided in two groups i.e., Control and Experimental group with a pre and post test format for both, using Random sampling technique.

Duration and Type of Study
An experimental study was carried out in which a specifically designed treatment protocol for individual group was applied for duration of 2 weeks. Study duration was from December 2020 to May 2021.

Sampling Method
The participants were selected using the stratified sampling method, a method of simple random sampling technique according to the inclusion and exclusion criteria.

Sample size Calculation
Formula for sample size: Z = standard normal variate at 95% confidence interval p = estimated prevalence for migraine by using reference studies q = 100-p = no prevalence L = allowable error = 5% Ref: Luomajoki HA, Beltran MB, Careddu S, Bauer CM. Effectiveness of movement control exercises on patients with non-specific low back pain and movement control impairment: a systematic review and meta-analysis, Musculoskeletal Science and Practice 2018 Aug 1; 36:1-1.

Inclusion Criteria
Subject complaining low back pain or pain after maintaining a prolonged posture 1. Low back pain for more than 3-6 weeks 2. Age group:18-40 years 3. Limitation in range of motion of lumbar spine due to tightness of the muscle, tightness of QL, hypersensitive tender points on palpation along with pain localized para spinally were selected for the study.

Exclusion Criteria
1. Individuals with a history of any spinal surgery or pathology of spine like tuberculosis, tumor, osteoporosis, etc. 2. Patients with altered sensation or spinal cord injury, any pathological condition related to hip joint.

Data Collection Procedure
In this Experimental study design, two groups were divided as Control and Experimental group with a pre and post test format for both groups. The approval for the study was obtained from the Protocol committee and the Institutional Ethical committee of the KIMSDTU. Each subject was asked to sign a written informed consent after explanation regarding the study conducted. Outcome measures assessed were Numerical Pain Rating Scale (NRPS), ODI and Lumbar Range of Motion with Modified Schober's Test [23][24][25] . A specifically designed treatment protocol for individual group was given for duration of 2 weeks. Pre and post test values were documented.

Interventions
MFR -QL is palpated in prone and side lying for trigger points. The technique is applied by the patient positioned in side lying with a pillow under waist to exaggerate stretch of the muscle. The therapist stands at level of patient's hip posterior and cross hand technique or elbow is used. The elbow of the cranial arm placed above the iliac crest and lateral to lumbar par vertebral muscles and over QL region, the caudal hand is placed on subject's thigh. Low level pressure will be applied with elbow obliquely directed towards centre of spinal column while other hand exercises gentle traction along patient's leg. This technique is applied for 7-10 minutes 14-16.
MET -Patient is in side lying with therapist standing posterior at waist level, patients upper arm extended over head to firmly grasp top end of plinth, and on inhalation abducts the uppermost leg until QL action is felt (Usually at 30 degrees) the patient holds the leg isometrically, allowing gravity to provide resistance for 10 seconds the patient allows the leg to hang slightly behind him over the back of table. The therapist straddles this and cradles the pelvis with both hands, fingers interlocked over iliac crest and leans back to take up slack and ease the pelvis away from lower ribs during exhalation. The stretch is held for 10 to 30 seconds 17 .
STRETCHING -Self-stretching in standing position. For stretching the right QL the patient places the left foot in front of the right and then left laterally flexes the trunk with arm raised overhead and brought to left side 20 .

Results
Statistical analysis of the recorded data was done by using the software InStat version 3.2. Arithmetic mean and standard deviation were calculated for each outcome measure. Within the group comparison was done by applying 'Paired t-test' to pre and post training values of same group for all outcome measures and 'Unpaired t-test' for between the group analysis. Probability (P) was used to state the significance of the result. Study showed extremely significant difference between both the groups for NPRS and ODI with p<0.0001 unpaired t test using considered extremely significant. The increase in mean values is extremely significant for Lumbar ROM while comparing the pre and post test values for mean difference of experimental group than control.

Demographic characteristic Control Group Experimental Group
Number of subjects (n) 17 18 Age in years (mean ± SD) 26 Table1 and Figure 1 comparison of pain (NPRS) pre and post treatment using paired 't' test.    Figure 2 comparison of disability (ODI) pre and post treatment using paired 't' test.   Table 3 and Figure 3 comparison of lumbar rom pre and post treatment using paired 't' test in control group.

Discussion
Quadratus lumborum is a common source of low back pain which is often overlooked. It is necessary to take quadratus lumborum in consideration for low back pain owing to its role in spinal mobility and stability. There is limited literature regarding advanced management strategies for non-specific low back pain. Till date generic treatments are used with modest treatment effectiveness 1 . Hence proper identification of root cause through clinical reasoning opens new treatment approach to be used to treat the root cause directly targeting the source of pain and improving the condition within a shorter duration span. To our knowledge there are fewer literatures present specifically regarding the effectiveness of myofascial release therapy and muscle energy technique on quadratus lumborum in nonspecific low back pain? Few studies focus the need of research to be undertaken for proving the effect of exercise therapy approaches on specific subgroups of low back pain 1,9,10 . The previous literature has shown the effect of individual manual therapy approaches studied on patients with non-specific low back pain, this study aims at knowing the combined effectiveness of three manual therapy approaches in a short-term intervention.
The present study was an experimental carried out to know the combined effect of MFR, MET and stretching of Quadratus Lumborum muscle in patients with non-specific Low Back Pain within a short-term duration of 2 weeks. A total of 35 participants were selected for the study among which 17 were in control group and 18 were in experimental group. In Control group, 53% (9) were females whereas 47% (8) subjects were males. In Experimental group, 56% (10) were females whereas 44% (8) subjects were males. Both groups received hot moist pack prior to the treatment for 10-15 mins. Control group received TENS followed by supervised exercises. Experimental group received MFR for 7-10 mins. followed by MET, 3-5 repetitions completing with self-stretching as a home program along with other exercises for the purpose of maintenance in improved pain, disability and functioning.
The pain assessment was carried out using the NRPS scale. For control group, the pre-test Mean and SD was 6 19.15±0.91) than that of subjects in control group. Lumbar rotation was also slightly improved.
The individual application of MET, MFR and stretching for a longer duration has been shown to be effective on various parameters of low back pain such as pain, mobility and functioning by studies conducted previously focusing on Quadratus lumborum to be the source of pain [26][27][28][29][30] . Exercise therapy has shown to be beneficial in reducing pain and disability. 9 Bailosky et al., stated a model highlighting various potential mechanisms when use of combined treatment approaches were used in treatment of musculoskeletal disorders which supports the study where combined manual therapy techniques have shown to be effective in treatment of non-specific low back pain 31 . According to a study conducted by Chang-yu J. Hseih et al., the combined use of manual therapy approaches such as mobilization and MFR has shown to be effective in reducing low back pain and functional disability. It also suggests the need of research to be undertaken upon various manual therapy treatment approaches involved in treatment of low back pain to be compared with a specific control group to study the effectiveness of the interventions used 32 . Thus, result of the present study demonstrated that the experimental group which received combined treatment approach showed extremely significant improvement in NRPS, ODI and ROM within a short-term duration of 2 weeks compared to the control group.

Conclusion
The result of the study proved that there was extremely significant difference in improvement of pain, disability and functional assessment in Experimental group when compared to the Control group. Thus, to conclude the combined effect of Myofascial release, Muscle energy technique and stretching of Quadratus Lumborum has shown to be effective in treatment of patients with non-specific low back pain.

Ethics Approval and Patient Consent
The study was approved by the "Institutional Ethics Committee" of Krishna Institute of Medical Sciences, "Deemed to be" University, Karad, Maharashtra. The author had explained the study and the intervention to be given the participants and had taken participants consent prior to beginning of the study on every participant.