1 Marwa M. Mahfouz, 2 Magda G. Sedhom, 3 Mohamed M. Essa, 4Ragia M. Kamel, 5Ahmed H. Yosry1 Assistant Lecturer of Physical Therapy , Basic Science department, Faculty of Physical Therapy, Deraya University, Elminya, Egypt.

2 Assistant Professor of Physical Therapy, Basic Science department, Faculty of Physical Therapy, Cairo University, Cairo, Egypt.

3 Lecturer of Physical Therapy , Biomechanics department, Faculty of Physical Therapy, Deraya University, Elminya, Egypt.

4 Professor of Physical Therapy, Basic Science department, Faculty of Physical Therapy, Cairo University, Cairo, Egypt.

5 Assistant Professor of Orthopedic Surgery, Orthopedic Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.ABSTRACT
Background: Chronic LBP a frequent sign of back dysfunction. The recent literatures recorded that up to 90% of the world’s population complain from LBP which cause disability in people. This study conducted to compare between efficacy of aquatic and conventional therapy on pain level, functional limitation and lumbar ROM in subjects with CLBP.

Methods: forty CLBP were divided to 2 groups (A) control 20 subjects received conventional therapy. (B) experimental received 20 subjects received aquatic therapy the treatment was given for six weeks.
Results: Mixed MANOVA test showed statistically significant enhancement in values of post-treatment in either groups compared with pre-treatment in pain enhancement for group A was 54.86% and 57.74% for group B (P=0.0001), functional limitation enhancement for group A was 55.46% and 58.95% for group B (p=0.0001), and lumbar ROM enhancement for group A was 46.63%, 18.79%, for lumbar flexion, and extension, and for group B was 46.96%, 22.85% (p=0.0001).

Conclusion: It is concluded that aquatic and conventional therapies have alike result in reducing pain severity, functional limitation, and enhancing lumbar ROM in CLBP patients.

Keywords: Aquatic therapy, Conventional therapy, CLBP, Functional limitation, Inclinometer, Visual analogue scale.

Low back pain (LBP) is outlined as pain or tenderness in one or either sides of backs lumbar region, finally irradiating to buttocks. It is categorized as primary, secondary (; 10 % of cases), idiopathic, or simply LBP 1. Back pain is the main common reason of referral to physiotherapy clinic, and a chief reason of peoples’ complains 2. Physiotherapy is the main frequent modality used to maintain conservative treatment which uses different modalities to lessen ache, regain ROM and function, and strengthen, stabilize the spine as manual therapy, electrotherapy, bracing, and therapeutic exercises 3.

Hydrotherapy is known as underwater exercises. It is a frequent treatment for subjects suffer any painful neurologic or musculoskeletal problems 4.At earlier periods aquatic therapy used in treating musculoskeletal problems as LBP. Water immersion with its buoyancy effect reduces axial load of spine that permits the movements which are difficult or impossible on land 5. Water has several special characteristic that make it suitable medium for exercises resulting in that choice of aquatic therapy program has favorable advantages relatively than common modalities 6. The warmness and resilience of water acting on thermoreceptors and mechanical receptors result in block nociception, as a result influence spinal segmental mechanisms 7, 8.

There was enough evidence to recommend that aquatic therapy is probably beneficial to subjects complain from constant LBP and pregnancy-allied LBP. Many literatures recommended the necessity for trials with higher quality to support the benefits of therapeutic aquatic exercise in a clinical background 9. The point of this study is to compare between the effect of Hydro and conventional therapy on pain level, functional limitations and lumbar ROM in chronic LBP patients.

This study was done in Arab Contractor Medical Center, Cairo, Egypt. This study presented to compare effect of aquatic and conventional therapy on CLBP.
Design of study
A Randomized Controlled Trial compared different effects of therapies (Aquatic and Conventional) on pain, functional limitation, and lumbar mobility in CLBP.
A sample of forty CLBP was assigned randomly using a random sequence generator to a single group of the two study groups, concealed allocation by thick sealed covers. patients were submitted by a physician or an orthopedist. The study was approved by Faculty of Physical Therapy ethical committee, Cairo University all patients presented written informed consent. Subjects were included if their age ranged from thirty-fifty years, whatever their gender. Subjects in control group (A) twenty subjects had conventional physical therapy treatment whereas subjects in experimental group (B) twenty subjects had aquatic therapy. Subjects were excluded with any previous back surgery, neuromuscular disease like multiple sclerosis,spondylolisthesis, hip arthrosis, symptoms of vertigo or dizziness, cardiopulmonary disorders with reduced activity tolerance, pregnant women, any sensory disturbance and acute infection, and uncontrolled blood pressure & unstable epilepsy 10.

Patient’s weight ; height calculated just prior to and following intervention. The assessment procedures contain these items.

Visual Analogue Scale:
Valid and reliable scale that give continuous data analysis and apply a ten centimeter line where 0 (no pain) and 10 (worse pain). Examiner requires patients to place a sign along the line to determine pain level 11, 12.

Oswestry Disability Index
Calculates functional limitation level .It is separated to 10 sections selected from a group of experimental questionnaire seeks to estimate limitation of various ADL. Every sector includes six statements .Seven sections evaluate ADL, one section for pain, one for sex life (if applicable), and one for social life .Scores (0 -5), where 0 is optimum level of function and 5 least level of function. The higher the score the higher the degree of disability .Patients completed the ODI (score out of 50) limitations were recorded by the patient caused by their back pain 13.

Measuring lumbar ROM:
The inclinometer was utilized to calculate lumbar spine ROM. It is a pendulum-based goniometry containing of a 360 degree scale protractor with a counter weighted pointer maintained in a constantly vertical position. It is valid and reliable means for estimating spinal motion 14.

Lumbar flexion
The patient was asked to stand upright, his feet shoulders’ width apart .Examiner determine two points on the spine S1, and T12 palpated (fifteen centimeters above it).The inclinometer was set at zero degree and positioned on the S1 (base palpation point). The patient was asked to slowly bend forward to end of range within limit of pain, while maintaining knees fully extended, flexion ROM was recorded. Then move inclinometer to second point on T12 (superior palpation point) flexion ROM also recorded. The inclinometer on (T12) calculates total flexion and on (S1) calculates sacral flexion. Total flexion minus sacral flexion is true flexion 15.

Lumbar extension:
Repeat flexion protocol for extension having the patient extends back for full extension or can use one inclinometer in mid of L3.

Group A: Conventional Therapy
Subjects in group (A) were treated with Ultrasound waves, Infrared, Interferential current, and Therapeutic exercises.

Application of Ultrasound:
Using US device present in medical center was EnrafNonius – Model: Sonopuls 490U Made in Netherlands. The patient will relax in prone position and back free from clothes. It was done in the lower paraspinal back muscles at the maximum tender area. The output frequency set at 1 Hz, continuous mode of application 1.5w/cm2, duration of treatment 8 min/session estimated for each patient using Grey’s formula 16.

Application of Infrared radiation
Patient prone and infrared lamp was above the patient back. The distance of Infrared adjusted between 45-60 cm according to patient tolerance, for 15 minutes/session 17.

Application of IF current
The device used was Enraf- NoniusEndomed, B.V., PO Box 810 Made in Netherlands. Patient prone, the electrodes placed on lumbosacral area giving IFT paravertebral. The output frequency set at 90 – 100 Hz and current intensity differs from patient to another, duration of treatment for 20 min/ session 10.
Therapeutic exercises
The program of treatment adapted from 10.First: Warm up ex’s as: Flexion trunk exercises (sit-up exercises) and Extension trunk from prone exercise repetitions was ten times with hold for 6 seconds at the end of the range. Second: Stretching exercises as: Raising leg ex’s, Double knee to chest, Fingers to toes, repetitions was 3 times with hold for thirty seconds. Third: Strengthening exercises for Back muscles as Bridging ex’s and Push-up, Lift one arm with opposite leg alternatively exercise, for Abdominal muscle as Posterior pelvic tilt exercise repetitions was 3 times with hold for 6 seconds.

Group B: Aquatic Therapy
Subjects in experimental group (B) performed underwater exercise with the examiner supervision in a comfortable heated pool by using.
Hubbard Tank: F Series 270 Gallon Stationary Full Body Immersion Tank F-270-S is designed for treatment of upper and lower limbs allowing patients for full body immersion, motion and exercise. This Hubbard tank style with figure ”8” shape allows therapists to observe patient performance. Tank capacity is 270gallons; the water was heated to 34º to 36º C with duration of treatment 60 min/session. Every session contains 3 phases of exercises:
Phase (1) Warm up ex’s: ROM ex’s and relaxation for 5 min (Forward, backward, and sideway walking).

Phase (2)Progressive aquatic ex’s for 50 min (Range of motion of the joints of upper and lower extremities each ex’s done 10 repetitions, Stretching exercises each ex’s detained for twenty seconds then relaxed and repeated 3 times, ; Strengthening exercises for back, abdominal muscles, upper and lower limb).

Phase (3) Cool down ex’s for 5 min (Slow walking forward, sideways, and backward).

Statistical methods:
Descriptive statistics and t-test were done to measure mean age, weight and height of groups. Mixed MANOVA was done to examine treatment effect by Visual Analogue Scale, Oswestry Disability Index and lumbar ROM.
No difference between groups regarding physical characteristics concerning age, weight, and height, As P>0.05. MANOVA revealed no significant differences in general characteristics of the participants in the mean ages, heights, and weights, between two groups (p>0.05) table (1) .Table 1: Comparison of the mean age, weight and height between group A and B:
Group A Group B t- value p-value Sig
±SD ±SD Age (years) 39.2 ± 3.42 40.45 ± 3.66 -1.11 0.27 NS
Weight (kg) 82.15 ± 6.13 81.25 ± 8.67 0.37 0.7 NS
Height (cm) 172.45 ± 4.59 172.15 ± 6.22 0.17 0.86 NS
: Mean MD : Mean difference p value : Probability value
SD : Standard deviation t value : Unpaired t value NS : Non significant
Effect of aquatic and conventional therapy on VAS:
There was a significant reduce in the mean VAS following treatment in comparison with before treatment in both groups. Also, there was no significant difference in the mean values of the VAS pre & post treatment between group A and B Table (2)
Table 2: Effect of treatment on VAS.VAS Pre-treatment Post- treatment MD % of change p-value
±SD ±SD Group A 7.2 ± 1.05 3.25 ± 1.33 3.95 54.86 0.0001***
Group B 7.1 ± 1.02 3 ± 1.07 4.1 57.74 0.0001***
MD 0.1 0.25 p-value 0.76 0.51 : Mean SD: Standard Deviation MD: Mean difference
P: Probability *Significant (P<0.05) % :Percentage
Effect of aquatic and conventional therapy on ODI:
There was a significant reduce in the mean ODI post treatment compared with pre treatment in both groups. Also, there was no significant difference in the mean values of the ODI pre& post treatment between group A and B Table (3).

Table 3: Effect of treatment on ODI.ODI Pre-treatment Post- treatment MD % of change p-value
±SD ±SD Group A 30.65 ±4.05 13.65± 5.38 17 55.46 0.0001***
Group B 29.6 ± 5.83 12.15 ±4.97 17.45 58.95 0.0001***
MD 1.05 1.5 p-value 0.51 0.36 : Mean SD: Standard Deviation MD: Mean difference
P: Probability *Significant (P<0.05) % :Percentage
Effect of aquatic and conventional therapy on lumbar flexion ROM:
There was a significant raise in the mean lumbar flexion ROM post treatment. Also, there was no significant difference in the mean values of the lumbar flexion ROM pre& post treatment between group A and B Table (4).

Table 4: Effect of treatment on lumbar flexion ROM
Lumbar flexion ROM Pre-treatment Post- treatment MD % of change p-value
±SD ±SD Group A 27.45 ±3.41 40.25± 4.79 -12.8 46.63 0.0001***
Group B 26.4 ± 4.21 38.8 ±5.46 -12.4 46.96 0.0001***
MD 1.05 1.45 p-value 0.39 0.37 : Mean SD: Standard Deviation MD: Mean difference
P: Probability *Significant (P<0.05) % :Percentage
Effect of aquatic and conventional therapy on lumbar extension ROM:
There was a significant increase in the mean lumbar extension ROM post treatment. Also, there was no significant difference in the mean values of the lumbar extension ROM pre& post treatment between group A and B Table (5)
Table 5: Effect of treatment on lumbar extension ROM.Lumbar flexion ROM Pre-treatment Post- treatment MD % of change p-value
±SD ±SD Group A 13.3 ± 2.4 15.8 ± 2.94 -2.5 46.63 0.0001***
Group B 12.25 ± 2 15.05 ±2.85 2.8 46.96 0.0001***
MD 1.05 1.45 p-value 0.39 0.37 : Mean SD: Standard Deviation MD: Mean difference
P: Probability *Significant (P<0.05) % :Percentage
In current study conventional therapy treatment was efficient to decrease pain severity of CLBP. Pain reduction possibly related to infrared which was used as heat source. Also through increased endorphins will increase sensory responses, this could have an effect on pain gate mechanism 18. Heat application had been proofed to be of use in decreasing pain, muscle spasm & functional limitation in acute and chronic (LBP) 19.

Following usage of ultrasonic waves increase the threshold of pressure produced by pain receptors, increase conduction velocity of (A beta) nerve fibers, and decrease conduction velocity of (A delta) nerve fibers which are responsible for pain 20. Ultrasonic result increasing tissue heats that change the visco-elasticity characteristics of connective tissue making it precede extensible 16.

Spinal stability that reduces pain can be accomplished by increasing strength of weak back muscles 21, 22.

In current study stretching exercises for back muscles came out effectual on reduction of pain level as reflected by the outcomes acquired. This conclusion concur previous reported studies 23.Proved that slump stretching lead to enhancement in pain level in LBP patients than patients not receiving slump stretching.
Regarding to the ROM of lumbar region from the statistical analysis of previous to subsequent values a noticeable increase in lumbar ROM was found at conventional group.

Improved ROM was accompanied with symptoms of relief in subjects suffer chronic back problem after flexibility program 24,25. Moreover, by increasing flexibility and mobility of the trunk will lead to increase flexion ROM after using flexion and extension exercises 26.

In addition, the exercise program aimed to increase individuals’ trust in the use of their spine and get over the worry of physical activity 27. Also, there was remarkable advancement in functional activities resulting from application of stretching exercises for back muscles 28. This advancement was due to improvement of back muscles strength, increase ROM and reduction of pain. By comparing between 2 groups, the results acquired in this study showed a noticeable advancement in active lumbar ROM, lessening ache, and functional disability. The analgesic efficacy of aquatic therapy suggests that water atmosphere is probably useful for patients with LBP.

These results are similar with a study 29,30they found decrease in pain levels and remarkable enhancement in thoraco-lumbar mobility in four directions following hydrotherapy treatment for CLBP patients.

Moreover it was found that aquatic exercise seems to be secure and useful treatment mode for patients who complain from LBP 31. In contrast, it was found that no significant difference after hydrotherapy measures as McGill Pain Questionnaire, lumbar flexion, extension ROM, strength, light touch, reflexes, and SLRbutthey reported remarkable enhancement in function (ODQ) happened in the individuals in the hydrotherapy group for patient with CLBP and leg pain 32.
However, these previous studies analyzed that aquatic therapy effect is an option in treatment of CLBP patients. Both aquatic and land group revealed decrease of pain, ability for walking farther, and Oswestry scores revealed major enhance in functional capability, but no major difference between them in all measurements 33 . This study gives considerable data supporting the two types as helpful treatments for LBP. These outcomes are recommending exercise therapy. Also, data was ineffective to show if the exercise medium, land or water, had any effectiveness on patient results. A different study searched for any significant result of exercise environment on treatment success 34, 35. The conclusions couldn’t explore any significant difference among treatment groups. The two of them reported increase distances of walking, counts dynamical sit-up , flexibility of spine, and isometric trunk exercises, also reduced pain levels, and a slight body fat distribution.
This higher enhancement in the aquatic group could be due to low management level of free land-based therapy program. Yet, this study encourages that aquatic therapy is more effectual in improving physical components of life quality than free land-based therapy program. The end results were proven that aquatic therapy an effective treatment for reducing ache, and enhancing patient functional ADL in the short term 36. However, in the long run, land-based body weight rehabilitation therapy was proven to be more helpful in treating pain and disability due to LBP. The last study failed to show any difference in results between aquatic and land-based therapy a study conducted by Nemcic et al,2013 10compared effectiveness of underwater exercise in thermal mineral water and land-based exercise, outcomes showed statistically significant progress in two groups concerning both initially results measures for lumbar spine motion using flexible tape (standardized measures), and using the Physical Disability Index to measure physical disability.
It was concluded that in CLBP patients, aquatic therapy decreased pain severity, level of functional limitation, and enhance lumbar flexion and extension ROM. However, comparison between aquatic therapy and conventional therapy wasn’t able to find any significantly different result.
The authors express their sincere gratitude to all subjects who kindly participated in the study.
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