priest | Advanced manual therapy approach for the management of non-specific low back pain

The lower back region includes the lumbar and sacral regions of the spine. Low back pain (LBP) is one of the most common conditions, with approximately 50% of the population suffering from pain in the back region at least once a year. [1]. Low back pain affects the activities necessary for daily living and makes them much more difficult to perform. The pain can be at the lumbar, lumbosacral or sacroiliac level, depending on the region concerned. [2]. Depending on the cause, low back pain can be classified as specific or non-specific [3]. Low back pain can be classified as acute (0-14 days), subacute (two-12 weeks) or chronic (> three months) depending on the duration [3-5]. Low back pain should be managed at an earlier stage as it will lead to more biomechanical alterations in the future. Various non-pharmacological modalities should be used, and the best method to manage low back pain should be used. The Integrated Neuromuscular Inhibition Technique (INIT) is one of the techniques that can be used to manage low back pain. The INIT method involves three separate manual maneuvers [6]. The three techniques are trigger point release, counter effort technique and muscle energy technique (MET). In a trigger point release, compression is applied to the trigger point region and held for 15 seconds, while in the strain-on-strain technique, the superficial fascia is stretched. MET works on the principle of reciprocal inhibition. As it uses three distinct manual techniques, it can have a significant effect in reducing lower back pain. In this case report, INIT was used as a treatment approach to reduce low back pain.

A 22-year-old woman, a medical student by profession, presented to the physiotherapy department with a complaint of low back pain. The patient had had low back pain for 4 months, which was less in the morning and increased with prolonged standing or any activity. The patient had a history of heavy lifting and her occupation involved prolonged sitting. The onset of pain was abrupt, with gradual progression. Due to low back pain, the patient was unable to sit for a long time and had difficulty performing daily activities. The patient went to an orthopedic surgeon for the same reason. An MRI was recommended and a spasm in the paraspinal region with tightness of the thoracolumbar fascia was identified. Painkillers were administered, but the pain did not improve. She was therefore referred to the physiotherapy department.

Clinical discoveries

The patient was examined in prone position. Grade 3 tenderness was present laterally in the lumbar spine in the paraspinal region. A spasm was present in the paraspinal muscles and trigger points were present in the quadratus lumborum. She had a dull ache in the area. On the numerical pain rating scale, the pain was 5/10 at rest and 8/10 with activity. On the modified Oswestry Disability Index, the patient had a 70% disability due to low back pain. The modified Schober test showed 4.6 cm of lumbar flexion. The MRI, which was performed on February 9, 2021, showed normal spinal height and disc height. Bone alignment was normal. The sag test was negative.


Physiotherapy rehabilitation took place over six weeks with five sessions per week. Figure 1 shows a flowchart with the rehabilitation protocol for the patient.

Phase 1 (Week 1 to Week 2) focused on patient education, ergonomic counseling, pain reduction, and maintaining back muscle strength. The patient was educated about the condition, and the do’s and don’ts were explained. Proper lifting technique was taught to the patient. For pain management, interferential therapy (IFT) was given for 10 minutes on four poles in a scanning pattern. Isometric exercises for the back and abdomen were taught and the patient was asked to repeat them 10 times with a hold of 10 seconds twice a day. Trigger points were identified and trigger point release was performed by ischemic compression (Figure 2). The strain-to-strain method was used after the trigger point was released.


Phase 2 (week two to four weeks) focused on the gains made in phase 1 as well as strengthening the back muscles. The same rehabilitation protocol was continued as in phase 1. In phase 2, the integrated neuromuscular inhibition technique (INIT) was used, and the muscle energy technique (MET) was used for the quadratus lumborum. The reciprocal inhibition technique (RIT), a type of MET, was used for three repetitions. Myofascial release in the form of trigger point release was pursued with the strain versus strain technique.

Phase 3 (week four through week six) focused on maintaining and strengthening the functions and strengths established in phase 2. In phase 3, back muscle strengthening exercises were prescribed as well as core strengthening exercises. As part of the strengthening exercises, the patient was prescribed the pelvic bridge exercise and asked to do 10 repetitions with a hold of 10 seconds. This was followed by the unilateral pelvic bridge exercise performed for 10 reps on each side with a 10 second hold. The patient was taught curl-ups and asked to perform 10 repetitions of the exercise.

A summary of the treatment plan by phase along with treatment goals and interventions is presented in Table 1.

Phase Objective Therapeutic intervention
Phase 1 (week 1 to week 2) Patient education, ergonomic advice and pain reduction Proper lifting method taught with do’s and don’ts, interferential therapy for 10 minutes on four poles in a sweep pattern, trigger point release using ischemic compression.
Phase 2 (week two to four weeks) Strengthening the back muscles The muscle energy technique was used for three repetitions, the counterexertion technique and ischemic compression for trigger point release, and isometric exercises were taught to strengthen the back and abdomen.
Phase 3 (week four to week six) Maintain acquired strength and increase strength Pelvic bridges, unilateral pelvic bridges, and curl-ups have been taught to strengthen the back and core.

After six weeks, a home exercise program including core strengthening exercises was offered. In physiotherapy management, the primary goal was to reduce pain, decrease functional disability, and improve range of motion in the lower back.

Results monitoring and measurement

After the end of the physiotherapy treatment, a two-month follow-up was carried out. A home protocol was designed for the patient and modifications were made to the home protocol based on the assessment made at the time of follow-up. Modified Oswestry Disability Index taken before physiotherapy treatment showed 70% disability, while after treatment 30% disability was observed. A modified Schober test showed 4.6 cm of lumbar flexion before physical therapy sessions. After physiotherapy, a lumbar flexion of 6.1 cm was observed.

This case report concerns a 22-year-old woman with nonspecific and chronic low back pain. The goal of rehabilitation was to reduce pain and make the patient painless [7]. The cause of the pain was muscular as there were triggers present in the quadratus lumborum which restricted the range of motion and thus resulted in the pain. In a systematic review, it was concluded that an increase in back flexibility will lead to an increase in range of motion [8]. Flexibility was increased using muscle energy techniques and counterexertion techniques, while trigger points were treated with ischemic compression.

For long term effects, core strengthening exercises should be administered to maintain strength. Chronic low back pain may recur after discontinuation of treatment, so trunk stability is important in this regard. Evidence suggests trunk strengthening has a significant effect on pain levels in patients with low back pain [9]. Strengthening back and lower extremity muscles, compared to strengthening core muscles, was less effective in treating pain [10]. Non-specific low back pain is a broad term and contains various aspects in which trunk strengthening plays a major role [11].

In a 2020 randomized controlled trial, Santosh C. Metgud et al investigated the effect of INIT on trigger points in patients with low back pain. The study included 44 patients with low back pain. Stretching and strengthening were prescribed for group A, while INIT was used for group B. Regarding conventional physiotherapy methods, both groups received therapeutic ultrasound and hot fomentation. This treatment was done consecutively for five days. Pain pressure, functional disability and range of motion were the outcomes assessed before and at the end of the fifth session. The authors came to the conclusion that INIT has a better effect on reducing myofascial trigger point sensitivity and therefore on low back pain. [12]. INIT is a combination of three techniques; therefore, it gives a combined effect of the three techniques and thus reduces lower back pain.

Physiotherapy has a significant effect on maintaining and increasing strength. The integrated neuromuscular inhibition technique can be used to reduce low back pain and functional disability. Physiotherapy should be started early to maintain strength and reduce pain. INIT is a combination of MET, counter-strain and ischemic compression. Ischemic compression helped treat myofascial trigger points, MET helped with muscle strength and tension, and the counterstrain technique helped with both myofascial and muscle tension. The combined effect of the three techniques made it possible to reduce lower back pain.

While pain and functional disability were reduced, an increase in lumbar range of motion was also noted after rehabilitation. Besides pain and muscle stiffness, many factors can affect range of motion. With INIT, pain and muscle stiffness were treated and range of motion improved significantly.

About Irene J. O'Donnell

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