Employing randomized controlled clinical settings, research explores the impact of strain-counter-strain on the management of lower back myofascial pain syndrome

doi:10.21203/rs.3.rs-4326176/v1

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Employing randomized controlled clinical settings, research explores the impact of strain-counter-strain on the management of lower back myofascial pain syndrome

https://doi.org/10.21203/rs.3.rs-4326176/v1

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The purpose of this study is to analyse the impact of incorporating the strain-counter-strain (SCS) approach into physical therapy exercises for patients with lower back myofascial pain syndrome (MPS) on pain levels, ROM, and functional impairment.

Methods:The experimental group consisted of thirty individuals with lower back MPS, while the control group included forty patients. When it came to physical treatment, one group used the SCS method and exercised four days a week, whereas the other group only exercised three days a week. There was a pre- and post-test lasting four weeks for each and every outcome measure.

Results:After treatment, the study group outperformed the control group in most metrics (VAS, lumber ROM, and ODI) (p 0.001), except for left-side bending ROM (p > 0.05).

Conclusion: Lower back MPS patients may benefit more from a combination of physical therapy exercises and the SCS approach when it comes to pain, range of motion (ROM), and functional impairment than from individual physical therapy treatments.

low back pain

myofascial pain syndrome

strain-counter-strain

myofascial trigger points

With a yearly prevalence rate of roughly 15–45%, lower back pain (LBP) is one of the most common health problems, affecting 80–85% of individuals at a time in their lives. As patients' pain worsens, they face significant social and economic challenges in addition to activity restrictions (WHO, 2003) (Shin et al., 2015). While the notion that soft tissue can contribute to LBP pain is not new, there has been a recent push for a paradigm shift in LBP evaluation and treatment that places more emphasis on soft tissue sources of pain (Hansen & Marcus, 2016). This is because myofascial pain syndrome (MPS) is one of the clinical manifestations of LBP (Dayanćr et al., 2020).

MPS, or common local muscular pain syndrome, affects up to 95% of individuals with chronic pain disorders. It is believed to be the primary cause of pain for 85% of patients coming to a pain center. Hyperirritable tender spots, also known as myofascial trigger points (MTrPs), in palpable tense bands of muscular tissues and fascia distinguish MPS. Trigger points come in two sorts: active, which are tender and painful when stimulated, and latent, which are tender but do not produce pain on their own. The occurrence of MTrPs leads to a painfully limited range of motion, stiffness, radiating pain patterns, and neural dysfunction (Malanga & Colon, 2010).

According to Malanga and Colon (2010), the MTrPs of LBP may be in the iliocostalis lumborum, quadratus lumborum, longissimus thoracis, gluteus medius, and multifidus. Moreover, Iglesias-Gonza´lez et al. (2013) observed that patients with nonspecific LBP exhibited the highest prevalence of active MTrPs in the iliocostalis lumborum, quadratus lumborum, and gluteus medius muscles, and higher numbers of active MTrPs were linked to greater pain intensity.

Manual therapy frequently treats myofascial pain (Malanga & Colon, 2010). Dayan et al. (2020) utilise this nonpharmacologic intervention to alleviate pain and the complications of LBP associated with MTrPs. A form of this treatment known as strain-counter-strain (SCS) or positional release (PR) entails the passive placement of the body or extremities. By gently positioning the shortened and painful tissues, this can help activate the Golgi tendon organ, which relaxes the tensed and tightened muscle if the comfortable position is held for more than a minute (Segura-Ortí et al., 2016). Wong (2012) suggested SCS as a therapy for musculoskeletal pain and issues, and Dardzinski et al. (2000) found that SCS relieves pain and improves function in individuals with localised MPS.

Some studies (Ahmed et al., 2021; Lewis et al., 2011) found that SCS didn't have any extra benefits. Other studies (Ellythy, 2012; Ali et al., 2015; Dayanır et al., 2020) found that the SCS technique was helpful for MTrPs and helped patients with LBP feel better. Therefore, in order to ascertain the validity of this controversy, sufficiently powered randomised control studies are required. This study aimed to investigate the effect of adding the SCS technique to physical therapy exercises on pain intensity, lumber ROM, and functional disability in patients with lower back MPS. The goals were to determine how effective the SCS technique is and whether combining SCS and exercises is preferable to exercises alone.

2.1. Study design.

This trial adhered to CONSORT guidelines by following a randomized and double-blind design. Accepted by the ethical committee of King Khalid University (ECM#2023 − 1101; HAPO-06-B-001, Approval Date: March 22, 2023) and enrolled prospectively in ClinicalTrials.gov (NCT06138860, Date- 14th, November 2023). The outpatient clinic of Cairo University's Faculty of Physical Therapy served as the study site from December 2023 to the end of February 2024. We explained the study's goal and the participants' right to withdraw at any moment. Before taking part, the participants honestly gave their written consent. A written consent was also obtained from participants for publishing their photos and the data collected during the study.

2.2. Participants

Thirty patients were selected based on the following set of inclusion criteria: patients between the ages of 20 and 40, both genders, patients (office workers) with mechanical lower back pain for three months, with active MTrPS in the lower back muscles (existence of a hyperirritable spot in the tense band, the existence of a palpable firm band in the muscle, local twitch response obtained by the snapping touching of the tense band, and replication of participants' pain on palpation with the patient recognizing the symptom as familiar) (Dayanır et al., 2020), patients with moderate disability (20–40%) documented by the Oswestry LBP Disability Questionnaire plus the capacity to evaluate the lumbar spine's ROM (flexion, extension, and side binding) within the pain limit. We ruled out the following conditions: tumours, vertebral compression fractures, neurological, systemic, and infectious diseases, including rheumatologic diseases. We also excluded patients who had undergone previous surgery within the last six months, cardiopulmonary disease-related activity intolerance, psychiatric or mental deficiencies, pregnancy, or lactation.

A random distribution of thirty patients was made into two equal groups: Group A (experimental) was given the SCS technique plus physical therapy exercises (strengthening and stretching exercises), while Group B (control) received physical therapy exercises solely (strengthening and stretching exercises).

2.3. Sample Size

We applied the G*Power software version 3.1.9.7 (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany) to determine the sample size for this study. Back pain severity, as determined by the VAS, was the main outcome. We used a pilot study to determine the effect size (Cohen f (v)) of 0.6. The power of the study (1-β err prob) was adjusted to 0.8 and the alpha error of probability (α) to 0.05. Overall, we needed a sample size of at least 24. When we dropped 20% of the sample, the total sample size increased to 30 (15 in each group).

2.4. Randomization

We randomly assigned thirty patients who met the inclusion criteria to either Group A or Group B using a computer-generated block randomization program available at http://www.randomization.com/. We randomized patients in blocks of four using a 1:1 allocation ratio to reduce bias and variation between the two groups. An independent researcher carried out the randomization. We used sequentially numbered, sealed, opaque envelopes containing confidential randomization codes to ensure a secret allocation. The author, who was unaware of the group allocation, collected data both at the beginning and at the end of the period of intervention.

2.5. Outcome Measures

The VAS, a scaled line with the most intense pain ever felt at one end and no pain at all at the other, measured the intensity of pain. We advised the patient to point to the appropriate spot on the scale to indicate their level of pain. Finally, the assessor calculates the pain-free distance from the marked point to the left side. The VAS is a reliable and valid measure for determining the level of pain (Boonstra et al., 2008).
Using a dual inclinometer, we conducted Lumber ROM. We placed the first one on the T12 vertebrae, and the second one on the S1 vertebrae. We obtained the inclinometer readings while the patient was in an upright and relaxed position. Next, we instructed the patient to perform the necessary movement (forward flexion, backward extension, or lateral flexion) as far as it was possible. The lower inclinometer's reading indicates pelvic or hip motion, whereas the upper inclinometer measures gross motion. The lumbar motion reading differs between the two measures (Mbada et al., 2021).
Functional disability was assessed using the Arabic version of the ODI (Algarni et al., 2014), which is a valid, applicable, and reliable scale for assessing disability in LBP. The patient took about five minutes to complete the questionnaire, and the doctor took about one minute to score it. Each component receives a score ranging from 0 to 5, with a score of 5 signifying the most severe disability. We calculate the index by dividing the total score by the range of scores. To obtain a numerical representation of the index as a percentage, we multiply the result by 100. Consequently, for every unanswered query, the denominator decreases by 5 (Mehra et al., 2008). A score between 0 and 20% indicates minimal disability; 20 to 40% indicates moderate disability; 40 to 60% indicates severe disability; 60 to 80% indicates crippling LBP; and above 80%, the individual is bedridden (Algarni et al., 2014).

2.6. Intervention

2.6.1. Physical therapy exercises

Stretching exercises for the back, hamstring, and calf muscles were part of physical therapy (El Naggar et al., 1991), with each muscle receiving 30 seconds and four repetitions (Page, 2012). Exercises to strengthen the back muscles (achieve progress by adding arm weight) and the abdominal muscles (achieve progress by shifting arm positions). Exercises consisted of 15 repetitions, 3 times with rest periods in between (Yeung et al., 2020), for 12 sessions, with 3 sessions every week for a month.

2.6.2. SCS Techniques

Patients in Group A received the SCS technique three times a week for four weeks from a certified manual physical therapist with 8 years of clinical experience in manual therapy, following the guidelines provided by Jones et al. (1995). After manually localizing MTrP, the therapist asked the patient to rate their initial level of MTrP tenderness as "10" on a verbal scale, with "0" indicating no tenderness. This was the SCS intervention. The therapist then gradually increased the pressure on the MTrP until the pressure sensation merged with pain. The therapist defined the position of ease as the point at which pain decreased by at least 70%. The therapist frequently created the position of ease by utilizing a shortened or relaxed muscle position. Perceived tissue tension (PTT) and the patient's indicated discomfort upon intermittent probing led the therapist to the proper relieving position at MTrP. The therapist then gently and passively brought the patient back to a neutral position. The patient remained in this passive position for ninety seconds. Each treatment session involved three to five repetitions of the same maneuver, separated by a 30-second rest period.

Figure 1: PRT for Quadrates Lumborum Muscle***

To perform positional release (PR) of Quadratus Lumborum MTrP, the patient was in a prone position with his trunk laterally flexed towards the side of the tender point. The therapist stands on the side of the tender point, resting the patient's knee on the table and placing the affected leg on the patient's thigh. To achieve the desired result, the therapist abducted, extended, and rotated the hip slightly. For ninety seconds, this was the holding position. D'Ambrogio and Roth (1997) then place the patient in a relaxed, passive posture (Fig. 1).

Figure 2: PRT for Gluteus Medius Muscle***

The Gluteus Medius MTrP, located 3–5 cm on either side of the mid-axillary line and about 1 cm below the iliac crest, is the target for PR. When the patient was lying prone with the affected hip in extension or abduction and the therapist's thigh supporting it, the therapist stood on the affected side to achieve the position of comfort for the gluteus medius MTrP. The therapist held the position for ninety seconds, fine-tuning it with a small amount of hip rotation (D'Ambrogio and Roth, 1997), Fig. 2.

2.6.3. Statistical analysis

We tested the homogeneity of demographic data, including age, weight, height, and BMI, between the two tested groups (A and B) using an independent t-test. We used the chi-square test to analyze the gender distribution among the patients. Shapiro-Wilk’s test was utilized to examine the normality of the data. The homogeneity between groups was tested by Levene’s test for variances’ homogeneity. Furthermore, we conducted within and between-group comparisons using the two-way mixed-design MANOVA. We conducted multiple comparisons using a Bonferroni correction to prevent type 1 errors. We conducted all statistical measures using SPSS version 23 for Windows (Chicago, IL, USA). The level of significance for all statistical tests was set at p < 0.05.

The purpose of the study was to investigate the effect of the strain-counter-strain technique in the treatment of lower back myofascial pain syndrome.

Figure 3: Flow chart diagram according to CONSORT principles

Figure 3 presents the study flowchart. We recruited a total of fifty patients with lower back MPS for this study. Twenty patients were excluded; eleven patients declined to participate, and nine patients didn’t meet inclusion criteria. Therefore, we randomly allocated thirty eligible patients into two equal groups. The data in Table 1 showed no statistically significant difference between both groups in demographic and baseline characteristics of patients (p > 0.5).

Table 1

Baseline Demographic Characteristics of participants.
Items	Group A Mean ±SD		Group B Mean ±SD		Comparison t-test p-value		Significance level
Age (yrs.)	50.94	± 3.16	46.13	± 2.64	-1.16	0.25	Non-significant
Weight (kg)	81.0	± 2.33	86.31	± 2.79	1.46	0.15	Non-significant
Height (cm)	169.88	± 3.29	169.63	± 2.91	-0.25	0.95	Non-significant
SD: standard deviation

This study involved 30 patients, randomly assigned into two groups. The experimental group (A) consisted of 15 patients with a mean age of 50.94 (± 3.16) years, a mean weight of 81.0 (± 2.33) kg, a mean height of 169.88 (± 3.29) cm, and a mean body mass index (BMI) of 30.33 (± 3.12 kg/m2). The control group (B) consisted of 15 patients with a mean age of 46.13 (± 2.644) years, a mean weight of 86.31 (± 2.79) kg, a mean height of 169.63 (± 2.911) cm, and a mean body mass index (BMI) of 30.21 (± 2.65) kg/m2. In the experiment group, the subject's mean age of around 51 years was slightly higher in comparison to the control group’s mean age of about 46 years. Whereas in the control group, the subject's weight of 86.31 kg was slightly higher as compared to the experimental group's 81 kg. There was no significant difference between both the groups in their ages, weights, and heights, where their t and p values were (1.16, 0.25), (1.46, 0.15), and (0.25, 0.95) respectively (Table 1).

When the pre-test and post-test mean values were compared, the post-test mean values of all six measured dependent variables were significantly higher than the pre-test values (p < 0.05), except for extension in Group B (p < 0.05). These variables were pain severity, flexion, extension, right side bending, left side bending, and functional disability. Regarding group comparison, results revealed significantly higher values in the post-test mean values of all measured outcome variables in favor of Group A (p < 0.05), except for left side bending (p > 0.05). Meanwhile, the mean values of all measured outcomes didn’t show any significant differences in the pre-test between the two tested groups (A and B) (p > 0.05), as shown in Table 2.

Table 2

pre and post mean, SD of pain severity, flexion, Rt side bending, Lt side bending and functional disability of both groups:
Dependent Variable		Group A (Mean ± SD)	Group B (Mean ± SD)	P-value
Pain Severity	Pre treatment	6.40 ± 0.64	6.54 ± 0.31	0.477
	Post treatment	3 ± 0.75	5.63 ± 0.18	0.0001*
	p-value	0.0001*	0.0001*
Flexion	Pre treatment	28.8 ± 1.01	28.8 ± 0.86	0.999
	Post treatment	43.8 ± 1.26	34.06 ± 1.16	0.0001*
	p-value	0.0001*	0.0001*
Extension	Pre treatment	8.53 ± 1.56	8.93 ± 0.33	0.342
	Post treatment	11.46 ± 2.56	9.54 ± 0.27	0.007*
	p-value	0.0001*	0.0001*
Rt side bending	Pre treatment	9.04 ± 0.35	8.90 ± 0.14	0.185
	Post treatment	12.87 ± 0.17	11.12 ± 0.19	0.0001*
	p-value	0.0001*	0.0001*
Lt side bending	Pre treatment	9.14 ± 0.19	9.16 ± 0.22	0.797
	Post treatment	11.60 ± 2.57	11.36 ± 0.11	0.714
	p-value	0.0001*	0.0001*
Functional disability	Pre treatment	20.53 ± 1.13	20.46 ± 1.12	0.754
	Post treatment	13.33 ± 0.48	16.86 ± 0.83	0.0001*
	p-value	0.0001*	0.0001*

This study examined the effects of the SCS technique on patients with lower back MPS in terms of pain, lumbar ROM, and functional disability. The primary results of the study showed that every outcome measure compared between the two groups showed a statistically significant difference (p < 0.05) favoring Group B (SCS group), apart from left-side bending ROM (p > 0.05).

In terms of pain intensity, the current results showed a statistically significant difference in pain reduction between the groups post-treatment (p < 0.001), with the study group benefiting more. The SCS technique's analgesic effect, which passively and gradually positions the muscle in a relaxed position, could explain this. This position ceased aberrant and abnormal neurological signals, restored normal activity to the muscle spindle, and increased blood circulation to the muscle tissue (Meseguer et al., 2006; Kumar et al., 2015). Readjusting inappropriate proprioceptive activity and lessening the imbalance between intrafusal and extrafusal fibers result in pain relief (Naik Prashant et al., 2010). Additionally, the SCS technique can reduce pain by stimulating A-delta fibers (Meseguer et al., 2006).

By fine-tuning the muscle spindles, SCS produces hypoalgesia and reduces MTrP irritability, thereby improving and controlling the length and tone of the affected tissues (Meseguer et al., 2006; El-Khateeb et al., 2022). According to Wong and Schauer-Alvarez's (2004) research, the SCS technique reduces sensitivity to palpation and irritability when it comes to hip muscle tender spots.

Previous research by Ellythy (2012), Mohamed & El Shiwi (2014), and Ali et al. (2015), which documented the beneficial impact of SCS on pain in individuals with chronic lower back pain, aligns with the present study. Additionally, Koura et al. (2020) reported a favorable effect of SCS on pain for patients with acute nonspecific LBP. Dayanır et al.'s (2020) findings corroborated this one as well. They found that using SCS techniques on the quadratus lumborum, iliocostalis lumborum, and gluteal muscles helped lower the level of pain and the pain thresholds in people with chronic non-specific LBP. Additionally, the SCS technique slightly improved pain intensity during activity when compared to manual pressure release and the integrated neuromuscular inhibition technique.

Interestingly, it has been demonstrated that SCS can lessen pain in a variety of conditions, including neck pain (El-Khateeb et al., 2022), masseter muscle trigger points (Ibáñez-García et al., 2009), bilateral hip pain (Wong & Schauer-Alvarez, 2004), and plantar fasciitis (Pawar et al., 2017).

However, Ahmed and colleagues (2021) discovered that PR and traditional physical therapy are similar in the treatment of chronic LPB. Similarly, PR therapy plus exercise does not reduce pain in acute LBP patients any more effectively than exercise alone, according to Lewis et al. (2011). The current study applies a relatively long treatment period of four weeks to chronic LPB, which may account for this discrepancy. Furthermore, contrary to the current study, which focused on chronic LBP, Hariharasudhan & Balamurugan (2014) found no difference between PR and MET in acute mechanical LBP patients.

With regard to lumber ROM, the findings revealed statistically significant variations between the groups post-treatment (p < 0.001) favoring the study group except for left side bending (p > 0.05). The reasons for this may be due to SCS therapy, which affects joints by having the now-relaxed muscle function at its best, thereby decreasing pain in the affected muscles and increasing ROM (Yamini et al., 2024). Additionally, SCS passive positioning reduces swelling and ischemia, improves nutrient delivery, and eliminates metabolic waste. These actions can lessen dysfunction and pain and improve muscle function (Wong, 2012), all of which may increase ROM and mobility.

Previous research on chronic LBP (Ellythy, 2012; Mohamed & El Shiwi, 2014; Ali et al., 2015) found that the SCS technique improved lumber flexion and extension range of motion (ROM). Ahmed et al. (2021) also found that the SCS group had better lumbar flexion than the control group, which received conventional physiotherapy. Additionally, Hariharasudhan and Balamurugan (2014) and Koura et al. (2020) reported improvements in lumber flexion and extension, as well as lumber flexion, in cases of acute LPB.

Also, Ibáñez-García et al. (2009) discovered that applying SCS to trigger points in the masseter muscle made active mouth opening better, and Pawar et al. (2017) discovered that people with plantar fasciitis had an increase in their ankle dorsiflexion range.

In 2014, Mohamed and El Shiwi found that applying SCS only to the quadratus lamborum muscle MTrP did not change the way the lumbar spine bent to the right or lifted. However, this study found that SCS had extra effects on bending to the right only. The current study used SCS on the quadratus lamborum and gluteus medius MTrPs. Using both muscles together may be better for side-bending the lumber than using just one. In contrast, Ahmed et al. (2021) observed a significant improvement in left-side bending but no significant change in right-side bending or extension after using SCS for just two weeks, compared to traditional exercises. The short treatment duration may be the cause of this controversy.

Concerning functional disability, there was a statistically significant difference (p < 0.001) between the groups after treatment, with the study group experiencing greater benefits. Pain inhibition reduces disability and enhances daily living activities, which is the cause of this improvement (Cheatham et al., 2016). SCS effectively restores pain-free motion and tissue flexibility, thereby improving functional disability (Ali et al., 2015), (Dayanır et al., 2020), (Ahmed et al., 2021), and (Pawar et al., 2017). They also documented this function's notable improvement.

Further evidence that SCS therapy is effective comes from a case study that examined the effects of the therapy on 19 out of 20 patients, demonstrating a 50–100% improvement in functional status and a reduction in pain. These findings recommend further research on SCS techniques and their potential use as adjunctive therapy for patients who have not responded to standard MPS treatment (Dardzinski et al., 2000). This study supports the findings of the researchers' analysis, which demonstrated a significant improvement in the ODI score in the SCS group at the end of treatment.

Unfortunately, Lewis et al. (2011) noted that SCS plus exercise does not improve disability more in patients with acute LBP than exercise alone. Hariharasudhan and Balamurugan (2014) also found that SCS had no effect on function in acute LBP. Given that their study involved patients with acute LBP, this variation may have to do with how the LBP initially manifested in those patients.

However, the control group demonstrated gains in every outcome measure. Studies have shown that strengthening exercises can help ease pain by raising the levels of beta endorphins in the blood and activating delta fibers. These fibers then support enkephalinergic neurons in the thalamus, which in turn eases pain and improves function (Wittink and Takken, 2008). Exercises involving flexion and extension also increase trunk flexibility and mobility, which reduces pain and improves trunk range of motion and function (Jari et al., 2004; Ali et al., 2015). This concurs with previous research (McGill, 1998), (Liddle et al., 2004), (Koumantakis et al., 2005), (Hayden et al., 2005), and (Hayden et al., 2020).

4.1. Limitations and Recommendations

Further research with larger samples is required to ascertain the long-term effects of the SCS technique, as the current study lacked a long-term follow-up. Evaluations of changes in electromyography and ultrasonography may also provide insight into the observed effects. Further research is required to determine muscle strength after applying the technique. Further investigation is necessary for other categories of trigger points.

Patients with lower back myofascial pain syndrome (MPS) may benefit from a combination of conventional physical therapy exercises and the strain-counter-strain (SCS) technique, according to the findings of our study. This combination may improve range of motion, functional disability, and pain levels. In the musculoskeletal rehabilitation of lower back myofascial pain syndrome, the strain-counter-strain (SCS) technique may have additional beneficial effects and prove to be an extremely effective technique.

Table 3

Table of Abbreviations
S.N.	Abbreviation	Abbreviation Details
1	SCS	Strain Counter Strain
2	MPS	Myofascial Pain Syndrome
3	ROM	Range of Motion
4	VAS	Visal Analogue Scale
5	ODI	Oswestry Disability Index
6	LBP	Low Back Pain
7	WHO	World Health Organization
8	MTrPs	Myofascial Trigger Points
9	PR	Positional Release
10	T12	Thoracis12
11	S1	Sacral1
12	PTT	Perceived Tissue Tension
13	PRT	Positional Release Technique
14	SD	Standard Deviation
15	BMI	Body Mass Index
16	Rt/Lt	Right/Left
17	MET	Muscle Energy Technique

Author Contributions: “Conceptualization, G.M.R.K.: M.N.S.; A.B.M.A and R.H.J.A.; methodology, D.A.E., A.M.F.E, I.A., H.HA., M.A.A., and F.A..; software, G.M.R.K.: M.N.S.; A.B.M.A.; validation, A.M.F.E, I.A., H.HA., M.A.A., and H.HA..; formal analysis, , I.A., H.HA., M.A.A; investigation, D.A.E., A.M.F.E, I.A., H.HA., M.A.A.; resources, I.A., H.HA., M.A.A.; data curation, F.A. M.A.A; writing—original draft preparation, G.M.R.K.: M.N.S..; writing—review and editing, D.A.E., A.M.F.E, I.A..; visualization, G.M.R.K.: M.N.S.; supervision, G.M.R.K.; project administration, I.A..; funding acquisition, F.A. All authors have read and agreed to the published version of the manuscript.”

Institutional Review Board Statement: “The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of King Khalid University (Approval No-ECM#2023-1101; HAPO-06-B-001, Approval date- 22-3-2023) and enrolled prospectively in ClinicalTrials.gov (NCT06138860, Date- 14^th, November 2023).

Human Ethics and Consent to Participate declarations: “Informed consent was obtained from all subjects involved in the study. “Written informed consent has been obtained from the patient(s) who participated in this study for publishing their photos.

Data Availability Statement: The authors will transparently provide the primary data underpinning the findings or conclusions of this article, without any unjustified reluctance. If need from editorial team.

Acknowledgement: The authors extend their appreciation to the Deanship of Scientific Research, King Khalid University. Authors also acknowledge Beni Suef University and Cairo University.

Funding: This research was funded by King Khalid University, grant number: RGP 2/286/44.

Conflicts of Interest: “The authors declare no conflicts of interest.” Regarding the research, writing, and/or publication of this work, the authors of this research have declared that they have no potential conflicts of interest.

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No competing interests reported.

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Employing randomized controlled clinical settings, research explores the impact of strain-counter-strain on the management of lower back myofascial pain syndrome

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Abstract

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1. Introduction

2. Materials and Methods

2.1. Study design.

2.2. Participants

2.3. Sample Size

2.4. Randomization

2.5. Outcome Measures

2.6. Intervention

2.6.1. Physical therapy exercises

2.6.2. SCS Techniques

2.6.3. Statistical analysis

3. Results

4. Discussion

4.1. Limitations and Recommendations

5. Conclusions

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References

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