The effect of core stability training combined with fascial release on patients with nonspecific low back pain

Abstract

BACKGROUND:

Non-specific lower back pain (NLBP) is treated with a variety of therapies, including health education, exercise therapy, soft tissue release, psychological interventions, and shockwave therapy. However, some studies have shown that core stability training or fascial release therapy alone is not effective in the treatment of low back pain.

BJECTIVE:

The aim of this study was to investigate the effects of core stability training on patients’ inflammatory cytokine levels and lumbar muscle temperature when combined with fascial release for the treatment of non-specific low back pain.

METHODS:

In this study, a total of 60 patients with non-specific low back pain who were treated in Mindong Hospital of Ningde City between December 2021 and January 2023 were selected and randomly and equally divided into a control group (30 cases) and an experimental group (30 cases). The control group received core stability training, while the experimental group added fascial release surgery to this. We compared and assessed the pain visual analog score (VAS), Oswestry dysfunction index (ODI), lumbar spine mobility (including anterior flexion, posterior extension, left flexion, and right flexion), as well as levels of inflammatory factors IL-6, TNF-a, and muscle tissue temperature in the two groups.

RESULTS:

This study has been successfully implemented and covered 60 patients throughout the trials. Upon comparison, the two groups did not show statistically significant differences in baseline data such as age, gender and duration of disease ( $p>$ 0.05). After four weeks of treatment, the test group showed statistically significant ( $p<$ 0.05) differences in VAS scores, ODI scores, and IL-6 and TNF-a levels that were significantly lower than those of the control group. It is worth mentioning that the muscle tissue temperature of the patients in the test group, as well as their performance in lumbar anterior flexion, posterior extension, left flexion, and right flexion mobility, were significantly better than those of the control group, and these differences also showed statistical significance ( $p<$ 0.05).

CONCLUSION:

The combination of core stability training and fascial release demonstrates significant clinical results in the treatment of nonspecific lower back pain. Through medical thermography and serum inflammatory factor testing, we were able to assess the treatment effect more objectively, providing a strong basis for future clinical practice.

Keywords

Core stability training fascial release nonspecific low back pain inflammatory factors thermal imaging technology

1. Introduction

Nonspecific low back pain (NLBP) referred as to a musculoskeletal movement system disease that manifests with pain and dysfunction in the lumbar and above the transverse crease of the buttocks crease of unknown cause (fracture, infection, tumor, etc.). Up to nearly 85% of low back pain sufferers are categorized as having non-specific low back pain, meaning that these pains are not triggered by a clear single cause. Non-specific low back pain is a common type of low back pain that can stem from a combination of factors including, but not limited to, muscle strain, degenerative discs, osteoarthritis of the lumbar spine, and the effects of psychological states [1]. The overuse and structural impairment of the lumbar spine are the leading causes of low back pain. Weakened proprioception and reduced lumbar-related control are important causes of recurrence [2]. The treatments for NLBP include health education, exercise therapy, soft tissue release, psychological intervention, and shock wave therapy [3, 4, 5, 6, 7]. Relevant studies have shown that core stability training can effectively stabilize the patient’s core stability system and local core system, effectively reduce the pain of patients, enhance the muscle strength around the low back and spine, and improve the range of motion of trunk joints [8]. Relevant studies have found that dysfunction and pain in the lower back are associated with changes in fascial structure. The posterior surface and deep muscles of the body are connected by the thoracolumbar fascia [9]. Fascial release is used to treat NLBP, and through the rearrangement of fascial tension structure, the correction of abnormal biomechanics promotes the repair of damaged tissues, increases the coordination of body structures, relieves pain and restores function. However, one study showed traditional treatments alone, such as physical therapy, medication, or lifestyle modifications, have not demonstrated significant differences in the treatment of low back pain [10].

Given the diversity of treatments for NLBP and the uncertainty of their efficacy, this study adopts an innovative integrated treatment program that combines core stability training with fascial release therapy. This integrated therapy aims to reduce low back pain symptoms by strengthening and stabilizing the core muscles while relieving fascial tension. In order to more accurately assess the effectiveness of the treatment, this study introduced thermography to monitor changes in muscle temperature during the course of treatment. Through thermography, we were able to visualize the temperature distribution of the muscles during training and after treatment to understand the activity status and inflammatory response of the muscles. The application of this technique not only improves the objectivity of treatment assessment, but also provides a new perspective on low back pain treatment. In addition, this study analyzed the changes in serum inflammatory factors interleukin-6 (IL-6) and tumor necrosis factor-a (TNF-a) before and after treatment using biochemical techniques. These inflammatory factors play an important role in the onset and progression of low back pain, and by monitoring changes in their levels, we were able to gain a deeper understanding of the pathophysiologic process of low back pain and to assess the effect of treatment on the inflammatory response. By integrating core stability training, fascial release therapy, thermography, and biochemical analysis, this study aims to objectively analyze the clinical efficacy of this combined treatment protocol in the management of NLBP. We expect that this combination therapy will be more effective in relieving low back pain symptoms, improving patients’ quality of life, and providing new ideas and directions for the treatment of low back pain.

2. Materials and methods

2.1 General information

This study focused on a group of patients with chronic NLBP admitted to the Rehabilitation Department of Ningde Mindong Hospital during the period from December 2021 to January 2023, and a total of 60 cases were selected as the study sample. We equally assigned these patients to the control group (core stability training only) and the experimental group (receiving core stability training combined with fascial release) according to the randomized numerical table method. The inclusion criteria for participants strictly followed the following requirements: first, the internationally recognized diagnostic criteria for NLBP had to be met as outlined in the NLBP diagnosis and treatment guidelines of the Chinese Medical Association (2018 edition) and the NLBP diagnosis and treatment guidelines of the European Spinal Association (2021 edition) [11]; second, each patient was required to sign an informed consent form after being fully informed of the study and ensuring that they were able to cooperate with the entire treatment and observation process; third, the age of the patient is above 18 years. However, patients with the following conditions were excluded from the study: first, patients with specific low back pain symptoms, including neuropathic pain or overstress on the spine causing by the BMI $>$ 30 kg/m²; second, patients who had undergone spinal surgery; third, patients with lumbar disc herniation, lumbar spondylolisthesis, osteoporosis and other low back pain-related diseases; in addition, patients with tuberculosis or bone tumors; finally, pregnant and lactating women were also excluded from the study, taking into account their special circumstances. The study was conducted on the basis of the following criteria.

This study was approved by the Ethics Committee of Ningde Mindong Hospital (No. 2021-0114-03).

2.2 Research methods

2.2.1 Intervention methods

(1)
Control group: core stability training. SET suspension training was used during hospitalization for four weeks, 5 times a week. The movements were as follows: 1) Patient with supine pelvic elevation was lying on his back on the treatment couch, with the wide band under the pelvis. Suspend the elastic rope corresponding to the assisting ability on the lower extremity, and place the narrow belt on the calf or thigh on one or both sides to suspend the solid rope. The height is 30 cm from the bed, the lower limb is pressed down on the narrow belt, and the pelvis is lifted up to form a straight line. Keep your pelvis stable in a straight line. The difficulty can be increased by plucking the elastic cord by hand. 2) Prone position stability training: With the patient in the prone position, wide and narrow bands were placed above the patient. One lower limb was pressed down on the narrow rope, the other lower limb was lifted, and the pelvis was lifted up with force to make the body act like a plank and remain stable. 3) Adduction and abduction exercise in the lateral position
(2)
Experimental group: The treatment protocol for the trial group added a combined low back fascial release to the control group. Specifically, this fascial release procedure uses specialized fascial release techniques, focusing on the posterior chain, lateral chain, and spiral areas. During the procedure, the patient is placed in the prone position and the surgeon uses a fascial knife to perform a scraping operation along the posterior surface line, with special attention paid to the latissimus dorsi and lumbar square muscles to ensure the therapeutic effect. While releasing the latissimus dorsi-related fascia, the patient performed the circular movement of the ipsilateral shoulder joint, while the fascial knife released the quadratus lumbar muscle, the patient’s pelvis was tilted anterior and posteriorly, and the focus was placed on the gluteus medius and piriformis muscles in the buttocks region. and lumbosacral ligaments. Finally, the fascial knife loosened the helical thread, and the patient maintained abdominal breathing while the thoracolumbar fascia was loosened. If fascial trigger points are found during the treatment, trigger point manipulation should be performed using the fascial knife. The treatment was performed as a course of 5 days for 4 weeks.

2.2.2 Observation indicators

Efficacy was evaluated in the patients before treatment and 4 weeks and 12 weeks after the intervention. (1) Visual Analog Scale [12]: The VAS was composed of a 10-cm line, with 0 indicating no pain at one end and 10 indicating unbearable pain at the other end. The larger the score, the stronger the pain. (2) Trunk joint range of motion: the range of motion of lumbar joint flexion, posterior extension, left flexion, and right flexion were measured. (3) Oswestry Disability Index questionnaire [13]: ODI (Oswestry Disability Index): It includes 10 questions, with a score of 0–100%. A higher score indicated a higher score for the patient’s motor dysfunction and a greater impact on daily life. (4) To assess serum inflammatory factor levels, we performed precise assays for IL-6 and TNF-a in peripheral venous blood specimens using ELISA. (5) Thermal imaging of the lumbar muscle [14] was performed using an SP-9000 medical thermal imager. The test temperature was in the range of 10 $\sim$ 40^∘C, and the minimum resolution temperature difference was 0.05^∘C. Images were collected in a dedicated image acquisition cabin. The room temperature was 24 $\sim$ 25^∘C, and the relative humidity was 40% $\sim$ 60%. Patients were prohibited from drinking, smoking, taking medication and staying up late 1 day before the study. The patient rested for 10 min before the examination and then shot his bare lower back facing the thermal imaging outlet. Different temperatures are represented in different color scales for qualitative analysis, such as high-heat areas (white), hot areas (yellow within red or red), warm areas (yellow or red within yellow), cool areas (green or yellow within green), cold zones (green in blue or blue), and supercold zones (blue in purple or purple). The regional temperature of the thermal imaging image of the patient’s affected area was measured and quantitatively analyzed.

2.3 Statistical analysis

We analyzed the data in depth using IBM’s SPSS 23.0 statistical software (produced at IBM headquarters in Armonk, NY). Mean $\pm$ SD ( $\bar{x}\pm s$ ) presentation and utilized independent samples $t$ -tests to compare differences between groups before and after treatment, while within-group changes were assessed by paired samples $t$ -tests. For the count data, we chose number and/or percentage as the mode of presentation and compared the differences between the different groups by the $\chi$ 2 test. All tests were based on the two-sided test principle and the significance level was set at $\alpha=$ 0.05.

3. Results

3.1 Baseline data

Upon comparative analysis, the two groups of patients showed great similarity in general data such as age, gender and disease duration, and there was no statistically significant difference ( $p>$ 0.05), thus ensuring the comparability and validity of the results of this study. Specific data are detailed in Table 1.

Table 1
Comparison of general demographic data (number of cases/mean $\pm$ standard deviation)

Parameters	Experimental group ( $n=$ 25)	Control group ( $n=$ 25)	$t/Z/\chi^{2}$	$p$ value
Gender (female/male)	20/10	19/11	0.073	0.787
Age (years)	44.83 $\pm$ 12.65	48.73 $\pm$ 15.55	$-$ 1.065	0.291
Duration of disease (months)	18.40 $\pm$ 7.39	20.77 $\pm$ 10.86	$-$ 0.986	0.328

3.2 Comparison of the outcomes between the two groups

The study compared outcomes between an experimental group receiving combined fascial release and core stability training and a control group receiving standard care for non-specific low back pain, as shown in Table 2.

Table 2
Comparison of the outcomes between the two groups ( $\bar{x}\pm s$ )

Variable	Experimental group ( $n=$ 30)		Control group ( $n=$ 30)		$t$		$p$ value
Pain evaluation
VAS
Before	5.17	$\pm$ 0.68	5.07	$\pm$ 0.75	0.	538	0.	592
After	1.93	$\pm$ 0.48	2.89	$\pm$ 0.82	$-$ 5.	538	$<$ 0.	001
ODIs
Before	33.07	$\pm$ 5.48	33.20	$\pm$ 6.61	$-$ 0.	085	0.	933
After	14.27	$\pm$ 3.78	20.93	$\pm$ 5.53	$-$ 5.	454	$<$ 0.	001
Physical function
Forward flexion angle (^∘)
Before	55.93	$\pm$ 5.94	55.30	$\pm$ 7.87	0.	3500	0.	72763
After	77.13	$\pm$ 5.18	65.43	$\pm$ 8.34	6.	527	$<$ 0.	00001
Extension angle (^∘)
Before	13.17	$\pm$ 2.52	12.77	$\pm$ 2.99	0.	5603	0.	57744
After	22.26	$\pm$ 2.02	17.63	$\pm$ 3.80	5.	816	$<$ 0.	00001
Left flexion angle (^∘)
Before	10.97	$\pm$ 2.34	11.13	$\pm$ 2.19	0.	2734	0.	78548
After	22.80	$\pm$ 1.90^a	18.23	$\pm$ 3.41	6.	412	$<$ 0.	00001
Right side flexion angle (^∘)
Before	11.80	$\pm$ 2.27	11.57	$\pm$ 1.98	0.	4182	0.	67733
After	23.70	$\pm$ 1.99	19.07	$\pm$ 3.53	6.	258	$<$ 0.	00001
Inflammatory factor levelss
IL-6 (pg/ml)
Before	1.71	$\pm$ 0.66	1.85	$\pm$ 0.56	$-$ 0.	923	0.	360
After	1.03	$\pm$ 0.45^a	1.41	$\pm$ 0.46^a	$-$ 3.	275	0.	002
TNF-a (pg/ml)
Before	7.73	$\pm$ 1.27	7.65	$\pm$ 1.31	0.	229	0.	819
After	5.56	$\pm$ 0.85	6.21	$\pm$ 1.02	$-$ 2.	704	0.	009
Lumbar muscle temperature (^∘C)
Before	30.18	$\pm$ 0.89	30.15	$\pm$ 0.74	0.	1420	0.	88760
After	32.21	$\pm$ 0.71	31.65	$\pm$ 0.51	3.	509	0.	00087

Initially, both groups exhibited similar baseline characteristics: there were no significant differences in pain intensity (VAS scores), functional disability (ODI scores), lumbar spine mobility, or levels of inflammatory markers (IL-6 and TNF-a). Baseline measurements of lumbar muscle temperature were also comparable between groups.

Following treatment, notable differences emerged between the groups. The experimental group demonstrated substantial improvements across several metrics compared to the control group. Specifically, the experimental group reported significantly lower pain levels (VAS scores), indicating better pain management. Moreover, functional disability (ODI scores) showed greater improvement in the experimental group, highlighting enhanced overall function post-treatment. Objective measures of physical function, including lumbar spine mobility, also favored the experimental group, with significant improvements in both flexion and extension angles compared to the control group. Additionally, inflammatory markers (IL-6 and TNF-a) decreased significantly in the experimental group, suggesting a reduction in inflammation associated with the intervention. Interestingly, lumbar muscle temperature was notably higher in the experimental group post-treatment, reflecting potential physiological adaptations.

4. Discussion

In this study, the effects of combining core stability training with fascial release for treating non-specific low back pain were investigated. 60 patients were divided into a control group (core stability training only) and an experimental group (core stability training with fascial release). After four weeks of treatment, the experimental group showed significantly lower pain scores, better lumbar spine mobility, and lower levels of inflammatory factors IL-6 and TNF-a compared to the control group. Additionally, the muscle tissue temperature of the experimental group was better than that of the control group. These results indicate that the combination of core stability training and fascial release is more effective in treating non-specific low back pain, as objectively assessed through medical thermography and serum inflammatory factor testing. This finding provides a strong basis for future clinical practice.

NLBP refers to pain that has no specific cause or specific pathological changes. This disease has seriously affected our work and daily life, and in severe cases, psychological problems have also brought a great burden. Hypermobility of the vertebrae and structural impairment are the leading causes of low back pain. Weakness of proprioception and a decrease in lumbar control are important causes of recurrence. Nonspecific low back pain, decreased lumbar muscle contractility and fatigue have a reciprocal causal relationship. According to the imbalance theory, the occurrence of pain is closely related to the stability of the core stabilizing muscles toward instability. At present, stability can be divided into three aspects. The first is the passive system of structure, the second is the active system of active muscle groups, and the third is the nervous system controlled by nerves. In core training, the active system of the active muscle group is the main object of intervention. At present, core strength training in the active system is divided into local stabilizing muscle groups and core stabilizing muscle groups.

Myofascial chain theory believes that various structures of the human body are connected by fascia, including skeletal muscle and its internal organs. Currently, the West has summed up 12 fascial chains, which interact with each other and control its stability. It elaborates a holistic thinking mode. Multiple fascial chains are involved in the lumbar spine, with a focus on the posterior chain and the lateral chain. The posterior chain is the fascial chain on the back from the top of the head to the sole of the foot, and it plays an important role in systemic stability. It is significant for stabilizing the extrinsic system of the spine and maintaining the dynamic balance of the spine. The fascial chain is a whole, and local stress changes will cause compensatory adjustments in a certain link in the whole chain. When the stress exceeds a certain threshold, a certain balance of the human body is broken, causing structural changes and pain. The fascial release technique finds the myofascial trigger points and uses the fascial knife release technique or tendon regulation and plucking techniques to relieve muscle contracture and tension and restore the vitality of the fascial muscles [15]. Fascia does not "snap back" if it is released and stretched. Therefore, myofascial release treatment can effectively improve the stability of the patient’s core muscles, thereby reducing the pain symptoms of patients. At the same time, the myofascial release technique is also a core training method. This treatment is safe and effective and worthy of promotion in our clinical practice, especially at the grassroots level.

Core stability training can effectively stabilize the patient’s core stability system and local core system, effectively reduce the pain of patients, enhance the muscle strength around the low back spine, and improve the range of motion of the trunk joints [16]. Currently, the clinically approved core training methods include suspension training and mat training, and the effect of suspension training is better than that without auxiliary suspension tools. The bobath ball is generally used in core training [17]. The suspension training for low back pain mainly includes the following contents: pelvis elevation in the supine position, lumbar stability in the prone position, and body stability in the lateral position, which have all been confirmed to have a better effect [18]. The results of this study showed that after 4 weeks of core stability training combined with fascial release, the patient’s VAS pain score, range of motion of low back joints, and ODI score were all improved.

When tissue is damaged, the metabolism of cells in the affected area will change, and then the soft tissue temperature in the affected area and the normal area will be different. Infrared thermal imaging technology can display the distribution of human surface temperature in color thermal images. It intuitively reflects the metabolism and physiological changes of the patient’s soft tissues and cells. Chronic nonspecific low back pain leads to different degrees of abnormal changes in soft tissues such as muscles, fascia, and ligaments in the patient’s lower back, resulting in different degrees of changes in local blood circulation, metabolism, and function. The visible images formed by thermal imaging technology can precisely locate the lesion location, effectively guide clinical diagnosis and treatment, and evaluate the efficacy of treatment. The results of this study show that 4 weeks of core stability training combined with fascial release can increase the temperature of the lower back and effectively promote blood circulation and cell metabolism in the lower back, further suggesting that thermal imaging has disease assessment and good effects in the diagnosis and treatment of chronic nonspecific low back pain. Evaluation role.

The main cause of low back pain is the stimulation of inflammatory mediators [19]. Chronic nonspecific low back pain includes soft tissue injury, sacroiliac fasciitis and other diseases. In the process of sterile inflammation, immune cell infiltration and vascular permeability are increased. IL-6 is a common immune-inflammatory factor, while TNF- $\alpha$ is involved in the process of peripheral sensitization to pain [20]. It has a "burning-promoting" effect of inducing pain and impoves the levels of neurons in the primary transduction pathway of spinal dorsal horn pain sensation [21]. The sensitivity and excitability of pain increase the transduction process of nociceptive pain signals [21]. This study reveals that after four weeks of core stability training combined with fascial release therapy significantly modulates the levels of IL-6 and TNF- $\alpha$ in immune cells, a finding that provides strong evidence for an association between chronicNLBP and inflammatory factors.

The study has several limitations. Firstly, the sample size is relatively small, consisting of only 60 patients from a single hospital, which may limit the generalizability of the findings to a broader population. Additionally, the study duration was relatively short, with a treatment period of only four weeks. A longer-term follow-up would provide a more comprehensive understanding of the sustained effects of the combined therapy. Furthermore, the lack of a placebo or sham intervention group makes it challenging to attribute the observed effects solely to the combined treatment. Finally, the study did not explore potential confounding variables such as concurrent treatments or individual patient differences, which could have influenced the results. Addressing these limitations in future research would strengthen the validity and applicability of the findings.

5. Conclusion

The findings of this study support the use of a combination approach involving core stability training and fascial release therapy for the treatment of NLBP, suggesting that multi-modal treatment strategies may be more effective than single therapies alone. Clinicians and healthcare providers can consider incorporating these interventions into their NLBP treatment plans. Additionally, the study demonstrates the value of medical thermography and serum inflammatory factor testing as objective assessment tools for evaluating treatment efficacy. By measuring muscle tissue temperature and monitoring inflammatory cytokine levels, healthcare professionals can objectively analyze the effectiveness of the combined treatment approach. These implications have important ramifications for clinical practice and may contribute to improving the quality of care for individuals with NLBP.

Footnotes

Conflict of interest

None.

Funding

This work was supported by the Qihang Fund Project of Fujian Medical University (2020QH344).

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The effect of core stability training combined with fascial release on patients with nonspecific low back pain

Abstract

BACKGROUND:

BJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 General information

2.2 Research methods

2.2.1 Intervention methods

2.3 Statistical analysis

3. Results

3.1 Baseline data

Table 1 Comparison of general demographic data (number of cases/mean ± standard deviation)

Table 2 Comparison of the outcomes between the two groups ( x ¯ ± s )

5. Conclusion

Footnotes

Conflict of interest

Funding

References

Table 1
Comparison of general demographic data (number of cases/mean $\pm$ standard deviation)

Table 2
Comparison of the outcomes between the two groups ( $\bar{x}\pm s$ )