EFFECT OF STRAIN COUNTERSTRAIN TECHNIQUE AND

CORE STRENGTHENING EXERCISES ON PAIN AND

FUNCTIONAL STATUS AMONG MIDDLE AGED PEOPLE
WITH CHRONIC LOW BACK PAIN.

A
Project submitted to

SAVEETHA COLLEGE OF PHYSIOTHERAPY

SAVEETHA INSTITUTE OF MEDICAL AND TECHNICAL SCIENCES

CHENNAI-602105

In partial fulfillment of requirement for the degree of

BACHELOR OF PHYSIOTHERAPY

By

P. YAMINI

REG. NO: 181901056

BPT- lV YEAR
JULY-2023
 DECLARATION

I, P. YAMINI do hereby declare that this research work has been originally carried out under
the supervision and guidance of Dr. KAMALAKANNAN.M., MPT (Ortho)., Ph.D.,
COMT., Associate Professor in Saveetha College of Physiotherapy, Saveetha Institute of
Medical and Technical Sciences (SIMATS), Thandalam at Chennai and this work has not been
submitted elsewhere for any other degree or other similar titles.

STUDENT NAME:

P.YAMINI

181901056

BPT IV YEAR

SAVEETHA COLLEGE OF PHYSIOTHERAPY,

SAVEETHA INSTITUTE OF MEDICAL AND TECHNICAL SCIENCES.

 BONAFIDE CERTIFICATE

This is to certify that this Project titled EFFECT OF STRAIN COUNTERSTRAIN

TECHNIQUE AND CORE STRENGTHENING EXERCISES ON PAIN AND
FUNCTIONAL STATUS AMONG MIDDLE AGED PEOPLE WITH CHRONIC LOW
BACK PAIN is a bonafide research work carried out by P. YAMINI REG. NO: 181901056
in partial fulfillment of the regulation for the degree of Bachelor of Physiotherapy in July-
2023.

CO-GUIDE:

Dr. SURYA VISHNURAM, MPT (Neuro)., Ph.D.

TUTOR,
SAVEETHA COLLEGE OF PHYSIOTHERAPY,
SAVEETHA INSTITUTE OF MEDICAL AND TECHNICAL SCIENCES,
CHENNAI-602105.

GUIDE

Dr. KAMALAKANNAN.M., MPT (Ortho). Ph.D., COMT.

SAVEETHA COLLEGE OF PHYSIOTHERAPY,

SAVEETHA INSTITUTE OF MEDICAL AND TECHNICAL SCIENCES,
CHENNAI-602105.

PRINCIPAL

Dr. JAGATHEESAN ALAGESAN, MPT, PhD, FIAP,

SAVEETHA COLLEGE OF PHYSIOTHERAPY,
SAVEETHA INSTITUTE OF MEDICAL AND TECHNICAL SCIENCES,
CHENNAI-602105.
 COPYRIGHT TRANSFER CERTIFICATE
Date:

Title of the Research work: Effect of Strain Counterstrain technique and Core strengthening
exercises on pain and functional status among middle people with chronic low back pain

Candidate’s Name: P. YAMINI

Guide Name: Dr. KAMALAKANNAN.M., MPT (Ortho)., Ph.D., COMT.

Co-Guide Name: Dr. SURYA VISHNURAM

We hereby assign to the Saveetha College of Physiotherapy, Saveetha Institute of Medical and
Technical Sciences, Thandalam, Chennai, all the rights under copyright that may exist in the
above titled project submitted for the award of the BPT degree.

(Signature of the Candidate)

(Signature of the Co-Guide)

(Signature of the Guide)

 CERTIFICATE

This is to certify that this research Project titled “EFFECT OF STRAIN

COUNTERSTRAIN TECHNIQUE AND CORE STRENGTHENING EXERCISES ON
PAIN AND FUNCTIONAL STATUS AMONG MIDDLE PEOPLE WITH CHRONIC
LOW BACK PAIN by P.YAMINI (181901056) has been evaluated.

Approved/Not Approved

By

Internal Examiner External Examiner

Signature: Signature:

Date: Date:
 ACKNOWLEDGEMENT

It’s a pleasure to acknowledge the department and I owe to many people who have had an
influence on me & helped me to develop my foundation in this study work.
First, I wish to thank GOD, and ALMIGHTY for the abundant, divine blessings upon me to
complete this project successfully.
I would like to thank my Project Guide Dr. KAMALAKANAN.M, M.P.T (Ortho), Ph.D.,
who instilled a love for perfection in every work I did and was also instrumental in showing
the right path and correcting the factual mistakes in the study. I thank him sincerely for his
valuable guidance.
I would like to thank our principal Dr. JAGATHEESAN ALAGESAN PhD., who helped me
for the data collection procedure and supported me during the project.
My sincere thanks to the entire faculty members of Saveetha College of Physiotherapy for their
guidance and timely help throughout the project.
My special thanks to all the participants who participated in this study, without them this
project would not have been successful.
I am thankful to my friends and ALL MY CLASSMATES, who helped me during the course
of my study.
Of all I would like to thank my beloved parents who helped me and encouraged me to finish
this project.

P. YAMINI
CONTENTS
CHAPTER TITLE PAGE NO.

1.INTRODUCTION 1

1.1BACKGROUND AND NEED FOR STUDY 4

1.2STATEMENT OF PROBLEM 4
1
1.3AIM 4

1.4OBJECTIVE 5

1.5HYPOTHESIS 5

2 REVIEW OF LITERATURE 6

METHODOLOGY 8

3.1 STUDY DESIGN 8

3.2 SUBJECTS 8
3
3.3 SAMPLE METHOD 8

3.4 SAMPLE SIZE 8

3.5 SELECTION CRITERIA 8

3.6 STUDY PROCEDURE 9

3.7 OUTCOME MEASURES 10

4. 4.1 STATISTICAL ANALYSIS 16

4.2 RESULTS 21

5 DISCUSSION 22

6 LIMITATIONS AND RECOMMENDATIONS 24

7 CONCLUSION 25

8 REFERENCES 26

9. APPENDIX 29
 LIST OF TABLES

SI. NO. TITLE PAGE NO.

PRE AND POST - TEST VALUES OF

1 GROUP A AND GROUP B BY USING 17
VAS SCALE PARAMETER

COMPARISON OF PRE AND POST -

TEST VALUES OF GROUP A AND
2 18
GROUP B BY USING VAS SCALE
PARAMETER
PRE AND POST - TEST VALUES OF
GROUP A AND GROUP B BY USING
3 19
OSWESTRY DISABILITY
QUESTIONNAIRE
COMPARISON OF PRE AND POST -
TEST VALUES OF GROUP A AND B BY
4 20
USING OSWESTRY DISABILITY
QUESTIONNAIRE
 LIST OF FIGURES

SI. NO. TITLE PAGENO.

1 Cobra pose 11

2 Bridge pose 11

3 Side plank 12

4 Camel pose 12

5 Bird and Dog pose 13

6 Double knees to chest 13

7 Single knee to chest 14

8 Partial Curl 14

9 Plank 15
 LIST OF GRAPHS

Sl. NO. TITLE PAGENO.

Pre-test and Post-test mean value of Group A and

1 17
Group B by using the VAS scale parameter

Comparison of post mean value of Group A and Group

2 18
B by using the

Pre-test and Post-test mean value of Group A and

3 19
Group B by using the Oswestry disability questionnaire

Comparison of post mean value of Group A and Group

4 20
B by using the Oswestry disability questionnaire
ABSTRACT
 ABSTRACT

Background:

Low back pain (LBP) is characterized as "pain along the posterior portion of the body from
the lower border of the twelfth ribs to the lower gluteal folds. The burden of low back pain on
society is enormous. In their lifetimes, a lot of people will suffer from low back discomfort.
Some people experience persistent low back pain, which is quite incapacitating. A technique
called strain counterstrain method is used to treat musculoskeletal pain. Core strengthening
exercises can lead to significant improvements in pain reduction and functional status among
individuals with chronic low back pain. These exercises help to improve muscle strength,
stability, and coordination, leading to better support for the spine and reduced pain.

Aim:
The study's objective is to assess how well core strengthening exercises and the strain
counterstrain approach affect middle-aged people with persistent low back pain in terms of
their pain and functional status.

Objective:
a) To determine the effect of strain counterstrain technique on pain and functional status
among middle aged persons with chronic low back pain.
b) To determine the effect of core strengthening exercises on pain and functional status among
middle aged people with chronic low back pain.
c) To compare the effect of strain counterstrain technique and conventional physiotherapy on
pain and functional status among middle aged with chronic low back pain.
Methods:

Study design: Comparative study

Study settings: Subjects will be selected from Capital hospital, Vijayawada
Subjects: Middle aged persons (35 to 55 years) with chronic low back pain
Sampling techniques: Convenient Sampling
Sample size: 100 Subjects

Study Procedure:

A total of 100 participants were selected aged between 35 to 50 years from capital hospital
Vijayawada using convenient sampling technique based on inclusion and exclusion criteria.
Subjects will be randomly split into two groups. Group A and Group B, each group consists of
50 participants and briefed about the study and the intervention after which their informed
consent was taken. Demographic details along with VAS score and Oswestry Disability
questionnaire were done .In Group A (n=50) the patients were given the strain counterstrain
technique alone. In Group B (n=50) the patients were given the core strengthening exercises
along with strain counterstrain technique, with one session per day, five days per week, for a
duration of four weeks.

Results: The paired t-test and unpaired t-test were used to statistically analyze the values. A
statistically significant difference was found between Group A and Group B. According to the
statistical analysis performed on the quantitative data, the post-test mean value of the VAS
scale in Group A was 5.80, while in Group B it was 4.00. Additionally, the post-test mean
value of the Oswestry disability questionnaire in Group A was 18.56, whereas in Group B it
was 14.10. These values yielded a p-value of less than 0.001. This demonstrates that core
strengthening exercises, along with strain counterstrain, have a significant impact on
individuals with low back pain.

Conclusion: This study demonstrates an improvement in both strain counterstrain and core
strengthening. However (Group B) Strain counterstrain technique with core strengthening
exercises show extremely significant improvement than (Group A) strain counterstrain alone
in reduction of pain.

Key words: Strain counter strain technique, Core strengthening, chronic low back pain,
Functional status.
 1. INTRODUCTION

Pain in the region of the back from the lower edge of the twelfth rib to the lower gluteal folds
is referred to as low back pain (LBP). The burden of low back pain on society is enormous. In
their lifetimes, a lot of people will suffer from low back discomfort. Some people experience
(1)
persistent low back pain, which is quite incapacitating. Chronic low back pain (CLBP) is
described as pain in the lower back that lasts longer than three months. The spine, intervertebral
discs, and surrounding tissues are subjected to repetitive damage or overuse, which results in
low back discomfort. Herniated discs, spinal compression fractures, lumbar spondylosis,
spondylolisthesis, and strained lumbosacral muscles are all results of this. (2) Many people have
reported experiencing low back discomfort frequently, especially when it follows work-related
or occupational tasks. Low back pain affects 75-84% of the general population, and of those
who experience it, 5-10% are thought to be morbidity-related. Compared to men, women
exhibited a higher overall prevalence of persistent low back pain. Low back pain affects 30%
of adolescents and 70% of adults. The age group of 42-64 years saw the greatest reported rates
of lower back pain for both sexes (33.3%). (3) Mobility disability affects the majority of CLBP
sufferers. Additionally, the lower extremities may experience pain, dull pain in the pelvis or
hips. Lower back muscle spasms, tightness, and tingling feelings, stiffness early in the day and
deficits in coordination and movement. Particularly in cases with pain extending to the lower
extremities, patients found it challenging to maintain a standing, sitting, or lying position.
Bending or carrying objects in the arms can also cause discomfort. Cleaning, playing sports,
(4)
and other leisure activities might become difficult for people with CLBP. If neglected,
chronic low back discomfort can lead to complications. Cardiovascular - Chronic pain
negatively affects the condition of your heart. It interferes with blood pressure regulation,
increasing the risk of hypertension (high blood pressure), which can eventually result in a heart
attack, stroke, or even death. Musculoskeletal - Reconditioning of the limbs due to ongoing
discomfort and restricted motion is a typical risk factor for persistent pains. The patients may
also feel muscle, nerve, or joint weakness. As a result, mobility in the affected area may
generally be restricted.

1
Hormonal - Chronic pain can have an impact on the endocrine system, which regulates
metabolic processes and may function improperly, leading to various physiological problems
as a result of this hormonal imbalance. (5) Patients are typically diagnosed based on their history
and additional characteristics such Palpation: A doctor will use their hands to feel around the
low back to look for any tense or spasm muscles, sensitive spots, or abnormalities in the
joints. Neurologic examination: The diagnosis will probably include a motor exam, which
entails manual movement of the ankle, big toe, hip, and knee in both the forward and backward
directions. The patient's response to light touch, a pinprick, or other senses in the lower trunk,
buttock, and legs will likely be tested as part of a sensory examination. Test of range of motion:
The patient might be asked to bend or twist in specific ways. These exercises are performed to
identify postures that exacerbate or relieve discomfort. (6) Exercises to strengthen the core are
used to increase control over the pelvis and lumbar spine by regaining the coordination and
control of the trunk muscles. In order to satisfy the demands of control, these workouts seek to
rebuild the strength and stamina of the trunk muscles. (7) Although methods including electrical
nerve stimulation, low-level laser therapy, shortwave diathermy, and ultrasonography have not
been proven to be successful interventions, massage is currently advised in both the acute and
chronic stages of back pain. Exercises that improve flexibility and range of motion as well as
posture can all help to relieve discomfort. Spinal manipulation increases psychological
(8)
wellbeing while offering modest short- and long-term relief from back pain. CLBP is
characterized by weakened or insufficient motor control of the deep trunk muscles, including
the lumbar multifidus and transverse abdominis. These muscles play a crucial role in providing
both mobility and stability to the lumbo pelvic region. Therefore, alterations in trunk muscle
activity, particularly in the lumbar multifidus and transverse abdominis, are commonly
observed in individuals experiencing low back pain. (9) The core muscles, commonly referred
to as global stabilizing muscles, encompass various muscle groups such as the rectus
abdominis, internal and external oblique muscles, erector spinae, quadratus lumborum, and the
hip muscle group. (10) The positional release technique known as Strain Counterstain (SCS) is
the fourth most used osteopathic manipulative technique.

2
In order to treat chronic low back pain, this study sought to ascertain the effects of
strain counter strain on pain relief, ROM, MMT, and impairment. SCS is a passive positioning
treatment that uses indirect manual manipulation to treat musculoskeletal pain and dysfunction.
(11)

Strain counterstrain (SCS) is a passive soft tissue technique developed by Lawrence Jones in
1955 with the aim of treating musculoskeletal pain, restricted range of motion, and somatic
dysfunction. This technique works by inducing cellular changes in the targeted tissues to
alleviate the symptoms.(12) Orthopedic problems including pain, fascial tension, local edema,
joint hypo-mobility, muscular spasm, muscle dysfunction, or weakness are frequently treated
with SCS. By gently moving the afflicted muscles and joints and releasing the tension in the
muscle spindles, strain-counter strain repairs the muscle spindles. The purpose of strain-
counterstrain is to unblock the lymphatic system's pump mechanism so that it can function
normally, to restore fascia to its normal state so that it may stretch and move once more, and
(13)
to reduce tightness in muscles and other connective tissues. With Strain-Counterstrain
therapy, joints influenced by the now-relaxed muscle operate optimally, extending the range
of motion and reducing pain in the affected muscles.

3
1.1 BACKGROUND AND NEED FOR STUDY:

Low back pain (LBP) is characterized as "pain along the posterior portion of the body from
the lower border of the twelfth ribs to the lower gluteal folds. The burden of low back pain on
society is enormous. In their lifetimes, a lot of people will suffer from low back discomfort.
Some people experience persistent low back pain, which is quite incapacitating. The term
"chronic low back pain" (CLBP) refers to lower back pain that has persisted for more than
three months. A technique for therapy is the strain counterstrain method a positional release
technique helps to reduce the pain. Core strengthening exercises can lead to significant
improvements in pain reduction and functional status among individuals with chronic low back
pain. These exercises help to improve muscle strength, stability, and coordination, leading to
better support for the spine and reduced pain. Core exercises are often included as a component
of conventional physiotherapy

1.2 STATEMENT OF THE PROBLEM:

The problem addressed in this study is to check the effectiveness of Strain counterstrain
technique and Core strengthening for patients suffering from chronic low back pain. Low
back. The burden of low back pain on society is enormous so, Therefore there is a need to
assess and manage this efficiently.

1.3 AIM:

The study's objective is to assess how well core strengthening exercises and the strain-
counterstrain approach affect middle-aged people with persistent low back pain in terms of
their pain and functional status.

1.4 OBJECTIVE:
To determine the effect of strain counterstrain technique among middle aged people with
chronic low back pain.
4
To determine the effect of core strengthening exercises among middle aged with chronic low
back pain.
To compare the effectiveness of strain counterstrain technique and core strengthening
exercises among middle aged with chronic low back pain.

1.5 HYPOTHESIS
1.5.1 Null Hypothesis:

H01-There will be no significant effect of strain counterstrain technique and core

strengthening exercises in pain and functional status among middle aged.

1.5.2 Alternate Hypothesis:

H11-There will be significant effect of strain counterstrain technique and core strengthening
exercises in pain and functional status among middle aged.

5
REVIEW OF LITERATURE
2. REVIEW OF LITERATURE

1. Abdul gafoor Sajjad et.al (2014) concludes that one of the main effects of strain
counterstrain is the reduction of muscle spasm and tightness. By positioning the muscle into a
relaxed state, muscle fibers can release tension and the accompanying pain can be reduced.
This can be particularly beneficial in cases of low back pain caused by muscle strains or
spasms.

2. BrainJ Coulombe et.al.,(2003) concluded that Studies have shown that core stability
exercises can be more effective in treating low back pain compared to general exercises. Core
stability exercises specifically target the muscles of the core, including the abdominal muscles,
back muscles, and pelvic floor muscles. These exercises aim to improve core strength, stability,
and control, which can help alleviate low back pain and improve overall function.

3. Rodrigo Dalke Meucci et.al,(2011) study reveals that in terms of lifetime prevalence,
studies have suggested that up to 80% of the general population will experience at least one
episode of low back pain in their lifetime The prevalence of low back pain also increases with
age. Being more prevalent in women. Low back pain was the leading cause of disability
worldwide. It is estimated that approximately 540 million people suffer from low back pain at
any given time.

4. SN TANK et.al.,(2020) “Effect of Jandas Approach on pain and Function” In these

investigations, an interventional study found that adding stretching and strengthening to
conventional treatment improve pain and function.

5. PJ OWEN et.al.,(2020) “Which specific forms of exercise training are most effective for
treating low back pain .”In these study given it’s potential to improve physical function and
strength, mental health, these trail shows that a variety of exercise training regimens are helpful
and ought to be included in routine therapy of individuals with low back pain . However we
were unable to establish whether exercise training increased the muscle strength.

6
6. Luis Baerga-Varela et.al.,(2016)Concluded that core strengthening exercises can be
beneficial for individuals with functional disabilities as they help improve stability, balance,
and overall function. Several studies have shown that core strengthening exercises can lead to
significant improvements in pain reduction and functional status among individuals with
chronic low back pain. These exercises help to improve muscle strength, and coordination,
leading to better support for the spine and reduced pain. Core exercises are often included as a
component of conventional physiotherapy programs for low back pain.

7. Aline Mendonca Turci et.al.,(2014). Concluded that, people with chronic non-specific low
back pain, self-strengthening exercises had very similar effects to motor control exercises on
pain intensity, disability, fear avoidance, global perceived effect and flexibility up to 18 weeks
beyond the end of an 8-week program.

8. Safoora Ebadi et.al.,(2011)concluded that the effect of therapeutic ultrasound on pain in

individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic
ultrasound may have a small effect on improving low back function in the short term compared
to placebo, the certainty of evidence is very low.

9. Cynan Lewis et.al.,(2018)concluded that Strain counter strain may not be appropriate for
certain conditions or injuries. It is essential to have a proper diagnosis and evaluation from a
qualified healthcare professional to assess if this technique is suitable or if other treatment
approaches would be more beneficial. That there is no advantage in providing Strain-
Counterstrain treatment to patients with acute low back pain.

7
SUBJECTS & METHODS
3. METHODOLOGY

3.1 STUDY DESIGN: Experimental study

3.2 SUBJECTS: Subjects will be selected from Capital hospital, Vijayawada according to
inclusion and exclusion criteria.

3.3 SAMPLING TECHNIQUE: Convenient sampling

3.4 SAMPLE SIZE: 100 samples

3.5 SELECTION CRITERIA:

3.5.1 INCLUSION CRITERIA:
1) Middle aged persons (35 to 50 years) with chronic low back pain

2) People with severe back pain (VAS score above 6)

3) People with reduced Functional status (Back pain functional scale)

4) Duration: Greater than 3 months (pain)

3.5.2 EXCLUSION CRITERIA:

1) Subjects with any fractures, Cardiovascular, Nervous, Pulmonary or Metabolic
disorders will be excluded

2) Subjects who are not willing to participate will be excluded

3) Spinal surgery

4) Infection in spine.

8
3.6 STUDY PROCEDURE

The study participants who met the inclusion and exclusion criteria will be selected from the
capital hospital, Vijayawada. A total of 100 subjects will be selected which are divided into
two groups .Before beginning of the treatment procedures ,the individuals are educated well
about the study and obtained a formal informed consent. After obtaining the pre -test
measurement of VAS and Oswestry disability questionnaire the patients will be categorized
into two groups using random convenient sampling technique. Group A received the strain
counterstrain technique alone and Group B received the combined program of the strain
counterstrain technique and core strengthening exercises. After 4 weeks of training the scores
are re-evaluated and post-test was reported .The results, as well as the data gathered will be
tailed and examined .The pre-test and post-test values are compared and evaluated statistically.

3.6.1 Materials Required: Yoga Mat & Couch.

TREAMENT PROTOCOL:

Strain Counterstrain technique for Group A.

Group B: Core strengthening exercises along with strain counterstrain technique.

Exercise Regime for core strengthening exercises procedure:

1. Bird Dog:
- Duration: Start with 5-10 repetitions on each side, holding the position for 5-10 seconds.
Gradually increase to 10-15 repetitions with longer holds.
- Intensity: Begin on your hands and knees, extend one arm forward while simultaneously
extending the opposite leg backward, maintaining a stable core and neutral spine.
- Frequency: Aim for 2-3 sets, 2-3 times per week.

9
2. Cat-Camel Stretch:
- Duration: Perform slow, controlled movements, going through the range of motion for 10-15
repetitions.
- Intensity: Start on your hands and knees, arch your back up like a cat, and then lower your
belly and extend your spine downward.
- Frequency: Include this stretch in your routine daily or as needed for pain relief.

3. Pelvic Tilts:
- Duration: Perform 10-15 repetitions, holding the tilt for 5-10 seconds.
- Intensity: Lie on your back with knees bent, gently flatten your lower back against the floor
by tilting your pelvis backward.
- Frequency: Incorporate pelvic tilts into your routine daily or as recommended by your
healthcare professional.

4. Bridge:
- Duration: Start with 10-15 repetitions, holding the bridge position for 5-10 seconds.
Gradually increase to 15-20 repetitions with longer holds.
- Intensity: Lie on your back with knees bent, lift your hips off the floor, engaging your glutes
and core muscles.
- Frequency: Aim for 2-3 sets, 2-3 times per week.

5. Modified Side Plank:

- Duration: Begin with 10-15 seconds on each side, gradually increasing to 30-60 seconds.
- Intensity: Start by lying on your side, resting on your forearm with knees bent, lift your hips
off the ground, creating a straight line from your head to your knees.
- Frequency: Include modified side planks in your routine 2-3 times per week.

3.7 OUTCOME MEASURES: VAS scale & Oswestry disability questionnaire.

10
Figure- 1: Cobra pose.

Figure- 2: Bridge pose.

11
 Figure-3: Side plank.

Figure-4 Camel pose.

12
 Figure 5: Brid and Dog pose.

Figure-6: Double knees to chest.

13
Figure-7: Single knee to chest

Figure-8: Partial Curl.

14
Figure-9: Plank.

15
4.1STASTISTICAL PROCEDURE:
The gathered information was analyzed and examined. For each parameter, the mean and
standard deviation were utilized. The statistically significant differences between pre - test and
post-test measures were examined using the Paired t- test. The difference between the post-test
values was determined.

16
DATA ANALYSIS AND RESULTS
 STATISTICAL ANALYSIS:
Table 1: Pre and post-test values for GROUP A and GROUP B for VAS scale parameter

GROUP MEAN ± SD T-TEST P-VALUE

PRE-TEST 7.04 ±1.86 <0.0001
11.0023
GROUP A POST-TEST 5.80 ± 1.32
PRE-TEST 7.02 ± 1.88 13.7811 <0.0001
GROUP B
POST-TEST 4.00 ± 0.96

Graph 1: Pre and Post-test mean values of Group A & B for VAS scale parameter

17
TABLE 2: Comparison between the post-test values of GROUP A and GROUP B for VAS
scale parameter

MEAN ±
TEST (post-test) T-TEST P-VALUE
SD

GROUP A 5.80 ± 1.32 11.0023 <0.0001

GROUP B 4.00 ± 0.96 13.7811 <0.0001

Graph 3: Comparison between the post-test values of GROUP A and GROUP B for VAS
scale parameter

18
Table 2: Pre and Post-test values for the OSWESTRY DISABILITY QUESTIONNAIRE are
assessed and analyzed by using paired t test

GROUP MEAN ± SD T-TEST P-VALUE

GROUP PRE-TEST 23.50 ± 10.57

10.1111 <00001
A POST-TEST 18.56 ± 9.48

GROUP B PRE-TEST 22.50 ± 10.57 <0.0001

14.5399
POST-TEST 14.10 ± 7.23

Graph 2: Pre and Post-test mean values of GROUP A & B for Oswestry disability
questionnaire parameter.

19
TABLE 4: Comparison between the post-test values of GROUP A and GROUP B using
Oswestry disability questionnaire.

TEST (post-test) MEAN ± SD T-TEST P-VALUE

GROUP A 18.56 ± 9.48 10.1111 <0.0001

GROUP B 14.10 ± 7.23 14.5399 <0.0001

Graph 6: Comparison between the post-test values of GROUP A and GROUP B for Oswestry
disability questionnaire parameter

20
RESULTS
 4.2 RESULT:
When compared the pre-assessment, the post assessment shows there is a significant decrease
in the pain by using the VAS and Oswestry Disability Questionnaire. The statistical mean value
of VAS scale pre intervention was 7.04 and Oswestry Disability Questionnaire was 23.5 and
the mean value of VAS scale post intervention was 5.80 and Oswestry Disability Questionnaire
was 18.56 for the people who were given the Strain Counterstrain ,whereas the statistical
mean value for the people who were given the both strain counterstrain and core strengthening
exercises the VAS scale pre intervention was 7.02 and Oswestry Disability Questionnaire
was 22.5 and the mean value of VAS scale post intervention was 4.00 and Oswestry Disability
Questionnaire post intervention was 14.1 with p value<0.0001.

The VAS score in the people with combined therapy was 4.00 and it showed significance
difference than the people who were given the Strain counterstrain 5.80 with the t value
13.7811 The same way the Oswestry Disability Questionnaire in both groups are analyzed.
The group with strain counterstrain along with core strengthening exercises shows the
significant difference in the pain than the people who were given the Strain counterstrain.

The post mean value for VAS scale is 5.80 and the Oswestry disability questionnaire is 18.56
in the Strain counterstrain technique whereas the post mean value for the VAS scale is 4.00
and the questionnaire is 14.10 in the people with core strengthening exercises along with
strain counterstrain technique with t values 13.7811 in VAS and 14.5395 oswestry disability
questionnaire and p value is<0.0001

This demonstrates that the core strengthening exercises along with the strain counterstrain
technique group shows the final results in reduction of the pain compared with the Strain
counterstrain technique group.

21
DISCUSSION
 5 .DISCUSSSION

The goal of the study is to determine whether the Strain CounterStrain Technique and core
strengthening exercises are useful for treating middle-aged adults with chronic low back pain.
According to a recent systematic analysis, the likelihood of experiencing low back pain for the
first time in a year ranges between 6.3% and 15.3%, whereas the likelihood of experiencing
low back pain at any time in a year is estimated to be between 1.5% and 36%.In many parts of
the world, low back pain is the primary factor in activity restriction and work absence, and it
is also connected with a significant financial burden. Although the reported disparities in
prevalence between men and women for low back pain vary in size, women tend to experience
it more frequently. In past research, we discovered that obesity promotes the chronic low back
pain when compare with people who are having a habit of smoking

According to research by ChouR et al., people with chronic low back pain (CLBP) have less
muscle mass and more fatty infiltration in their lumbar extensors. Although decreases in pain
and impairment following Strain-Counterstrain treatment for low back pain have been
documented in case studies, Lewis and Flynn et al. (2001) claimed that there is no experimental
evidence to support the use of this technique for the treatment of acute low back pain. (11)

Core strengthening exercises are simpler for patients with CLBP. Additionally, patients can
freely conduct core strength training at home without any specific equipment, which is crucial
because home-based exercise regimens might provide additional advantages for determined
In contrast to the control group, the group given core exercises demonstrated a greater drop in
pain intensity and an increase in range of motion, according to a 2014 study.(15)

Some of the exercises performed include Pelvic Bridging, Plank, Cat and Camel, Bilateral
Straight Leg Raise, and other exercises that strengthen the muscles surrounding the lumbar
spine.Cramping is lessened as a result of them helping to improve blood circulation. Exercises
that involve aerobic activity include knee lifts, diagonal toe touches, lunges, criss-cross, and
others. According to Gatti et al. (2000), functional tasks that are a daily concern for CLBP
patients are the primary basis for evaluating the severity of a disability. Thus, while being
difficult exercises, core training and trunk balance training can lessen impairment.

22
In addition, the Strain-Counterstrain is referred tool of spinal manipulative therapy,(17)
according to Assesndelft et al. in 2003, since the pelvis, sacrum, and lower limbs are utilized
to passively position the lumbar and sacral regions in degrees of flexion, extension, lateral
flexion, and rotation. Its effectiveness in treating severe low back pain was not increased,
(16)
according to a systematic review. Thus, it is clear that for patients with chronic low back
pain, core strengthening activities are superior to the Strain counter strain method. Pain was
rated by participants on a 10-cm visual analogue scale, which has been shown to be valid and
reliable According to Price et al 1983, Duncan et al 1989, and Price et al 1994). Each
participant's pain was summarised as the mean of three ratings on the visual analogue scale:
(18)
minimum pain in the last 24 hours, current pain, and maximum in the last 24 hours.
According to this study wong CK and Schauer C (2004), were surveyed to examine the
reliability and validity of Strain Counterstrain (SCS). All organizations showed important pain
reductions with the VAS in both muscle groups by the end of the research. The SCS
organizations tended to reduce pain. (19)

According to the study conducted by Costa et al. established the superiority of motor control
exercises over electrotherapeutic modalities used to treat chronic nonspecific low back pain.
Subjects in treatment group were treated specific exercises targeting the activation of the
transversusabdominus and multifidus. When appropriate control was developed subjects
were progressed to more complex functional task. (20)

Recent research suggests that the strain counter strain method has an advantage over other
pain-relieving strategies such as the integrated neuromuscular inhibition method and manual
pressure release. This study had the same results showing that the Strain counter strain
technique was beneficial in reducing pain but slightly different in results when combined
with exercise therapy. (21)

23
 LIMITATIONS &
RECOMMENDATIONS
 LIMITATIONS & RECOMMENDANS:

5.1 LIMITATIONS:

1. The study was done in a short period with selection bias.

2. No proper follow up data was collected

3. Chronic low back pain people were only selected.

4. People with reduced functional status.

5.2 RECOMMENDATIONS

1. More outcome measures can be studied.

2. Intervention duration can be longer.

3. Regular follow-up should be done.

4. Acute and sub-acute pain can be considered.

24
CONCLUSION
 6. CONCLUSION

From the results obtained in the study it can be concluded that core strengthening exercises
along with strain counterstrain show significant effect on chronic low back pain among middle
aged people compared to the Strain-Counterstrain technique

25
REFERENCES
 7. REFERENCES

1) Lles ST. Low back pain: when and what to do. Orvosi Hetilap. 2015 Aug 1;156(33):1315-
20.

2) Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review.
Revista de saude public-a. 2015 Oct 20;49:73.

3) Andersson GB. Epidemiological features of chronic low-back pain. The lancet. 1999 Aug
14;354(9178):581-5.

4) Ramdas J, Jella V. Prevalence and risk factors of low back pain 2017 Aug;11(4):610-617.

5) Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review.
Revista de saude publica. 2015 Oct 20;49:73.

6) Abu-Nader SS, ALDAHDOOH R. Lower back pain expert system diagnosis and
treatment.2015Mar9;9(1):23.

7) Fryer G, Johnson JC, Possum C. The use of spinal and sacroiliac joint procedures within the
British osteopathic profession. Part 2: Treatment. International Journal of Osteopathic
Medicine. 2010 Dec 1;13(4):152-9.

8) Patel VD, Eupen C, Ceepee Z, Kamath R. Effect of muscle energy technique with and
without strain–counters-train technique in acute low back pain—A randomized clinical trial.
Hong Kong Physiotherapy Journal. 2018 June 4;38(01):41-51.

9) Kumar SP: Efficacy of segmental stabilization exercise for lumbar segmental instability in
patients with mechanical low back pain: a randomized placebo controlled crossover study. N
Am J Med Sci, 2011, 3: 456–461. [PMC free article] [PubMed] [Google Scholar]

10) Ekstrom RA, Donatelli RA, Carp KC: Electromyographic analysis of core trunk, hip, and
thigh muscles during 9 rehabilitation exercises. J Orthop Sports Phys Ther, 2007, 37: 754–762.
[PubMed] [Google Scholar]

26
11) Lewis C, Flynn TW. The use of strain-counters-train in the treatment of patients with low
back pain. Journal of Manual & Manipulative Therapy. 2001 Jan 1;9(2):92-8.

12) Wong CK. Strain counterstrain: current concepts and clinical evidence. Manual therapy.
2012 Feb 1;17(1):2-8.

13) Peck J, Grits I, Peoples S, Foster L, Malla A, Berger AA, Kornet EM, Kassel H, Herman
J, Kaye AD, Viswanath O. A comprehensive review of over the counter treatment for chronic
low back pain. Pain and Therapy. 2021 Jun;10(1):69-80.

14) Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint
clinical practice guideline from the American College of Physicians and the American Pain
Society. Ann Intern Med. 2007;147:478–491.

15) Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with
chronic low back pain: a randomized, controlled trial with 1-year follow-up. Spine.
2003;28:525–531. discussion 531–522.

16) Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy
for low back pain–a meta-analysis of effectiveness relative to other therapies.2010;38:653-
689.5

17) Gatti R, Faccendini S, Tettamanti A, et al. Efficacy of trunk balance exercises for
individuals with chronic low back pain: a randomized clinical trial. J Orthop Sports Phys Ther,
2011, 41: 542–552.

18) Duncan et al., 1989 G.H. Duncan, C. Bushnell, G.J. Lavigne Comparison of verbal and
visual analogue scales for measuring the intensity of experimental Pain, 37 (1989), pp. 295-
303

19) Wong CK, Schauer C. Reliability, validity and effectiveness of strain counterstrain
techniques. Journal of Manual & Manipulative Therapy. 2004;12(2):107-12.

27
20) Costa LO, Maher CG, Latimer J, Hodges PW, Herbert RD, Refshauge KM, et al. Motor
control exercise for chronic low back pain: a randomized placebo-controlled trial. Phys Ther.
2009;89(12):1275–1286. [PubMed] [Google Scholar]

21) Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual
therapy in the treatment of musculoskeletal pain: a comprehensive model. Man. Ther.
2009;14(5):531–538. [PMC free article] [PubMed] [Google Scholar]

28
APPENDICES
APPENDIX – A: ISRB CERTIFICATE:

29
 APPENDIX- B
ASSESSMENT FORM:

OSWESTRY LOW BACK DISABILITY QUESTIONNAIRE

1. PAIN INTENSITY
□ I can tolerate the pain I have without having to use pain killers
□ The pain is bad but I manage without taking pain killers
□ Pain killers give complete relief from pain
□ Pain killers give moderate relief from pain
□ Pain killers give very little relief from pain
□ Pain killers have no effect on the pain and I do not use them
2. PERSONAL CARE (e.g. Washing, Dressing)
□ I can look after myself normally without causing extra pain
□ I can look after myself normally but it causes extra pain
□ It is painful to look after myself and I am slow and careful
□ I need some help but manage most of my personal care
□ I need help every day in most aspects of self-care
□ I don’t get dressed, I was with difficulty and stay in bed

3. LIFTING
□ I can lift heavy weights without extra pain
□ I can lift heavy weights but it gives extra pain
□ Pain prevents me from lifting heavy weights off the floor, but I can manage if they
are conveniently positioned, i.e. on a table
□ Pain prevents me from lifting heavy weights, but I can manage light to medium weights
if they are conveniently positioned
□ I can lift very light weights
□ I cannot lift or carry anything at all

4. WALKING
□ Pain does not prevent me walking any distance
□ Pain prevents me walking more than one mile
□ Pain prevents me walking more than ½ mile
□ Pain prevents me walking more than ¼ mile
□ I can only walk using a stick or crutches
□ I am in bed most of the time and have to crawl to the toilet

5. SITTING
□ I can sit in any chair as long as I like
□ I can only sit in my favorite chair as long as I like
□ Pain prevents me from sitting more than one hour
□ Pain prevents me from sitting more than ½ hour
□ Pain prevents me from sitting more than 10 minutes
□ Pain prevents me from sitting at all
30
6. STANDING
□ I can stand as long as I want without extra pain
□ I can stand as long as I want but it gives me extra pain
□ Pain prevents me from standing for more than one hour
□ Pain prevents me from standing for more than 30 minutes
□ Pain prevents me from standing for more than 10 minutes
□ Pain prevents me from standing at all

7. SLEEPING
□ Pain does not prevent me from sleeping well
□ I can sleep well only by using medication
□ Even when I take medication, I have less than 6 hrs sleep
□ Even when I take medication, I have less than 4 hrs sleep
□ Even when I take medication, I have less than 2 hrs sleep
□ Pain prevents me from sleeping at all

8.SOCIAL LIFE
□ My social life is normal and gives me no extra pain
□ My social life is normal but increases the degree of pain
□ Pain has no significant effect on my social life apart from limiting my more
energetic interests, i.e. dancing, etc.
□ Pain has restricted my social life and I do not go out as often
□ Pain has restricted my social life to my home
□ I have no social life because of pain

9. TRAVELLING
□ I can travel anywhere without extra pain
□ I can travel anywhere but it gives me extra pain
□ Pain is bad, but I manage journeys over 2 hours
□ Pain restricts me to journeys of less than 1 hour
□ Pain restricts me to short necessary journeys under 30 minutes
□ Pain prevents me from traveling except to the doctor or hospital

10. EMPLOYMENT/ HOMEMAKING

□ My normal homemaking/ job activities do not cause pain.
□ My normal homemaking/ job activities increase my pain, but I can still perform all
that is required of me.
□ I can perform most of my homemaking/ job duties, but pain prevents me from
performing more physically stressful activities (e.g. lifting, vacuuming)
□ Pain prevents me from doing anything but light duties.
□ Pain prevents me from doing even light duties.
□ Pain prevents me from performing any job or homemaking chores.

31
VAS SCALE:

32
 APPENDIX C:

INFORMED CONSENT FORM

I am inviting you to participate in this research project titled

"THE EFFECT OF STRAIN COUNTERSTRAIN TECHNIQUE AND CORE

STRENGTHENING EXERCISES ON PAIN AND FUNCTIONAL STATUS AMONG
MIDDLE AGED PEOPLE WITH CHRONIC LOW BACK PAIN." Please declare your
agreement to participate in this research project. The data collected will provide useful
information regarding the prevalence and associated risk factors of performing cardiovascular
training and Pilates in breast cancer patients.

This will help fill the knowledge gap and provide helpful data and evidence. Please rest assured
that completing this questionnaire poses no physical risk or discomfort to you. As a result, no
compensation will be available. To prevent third-party misuse, all data collected will be kept
secret. Please do not hesitate to contact me if you require any extra information or have any
queries. Your involvement is much valued. Thank you very much.

Please read the following statement. If it is agreeable to you, please tick the options

● I confirm that I have read and understood the above information regarding the research
project and have had the opportunity to ask questions.

● I understand that my participation is voluntary, and I am free to withdraw at any time during
the study without giving a reason.

● I understand that all the information I have provided will be treated in confidence.

● I agree to take part in the research project.

Do you have /are you the… (For those who ticked the electronics of these exclusion criteria,
the survey will be terminated)

Place:

Date: Signature:

33
 சவீதா இயன் முறை மருத்துவக் கல் லூரி,

சவீதா பல் கறலக்கழகம் ,

சசன் றன - 602105
ஒப்புதல் படிவம் .

திரு/திருமதி/சசல் வன் / சசல் வி_____என் னும் நான்

இயன் முறை இளங் கறல பட்டப்படிப்பு, நான் காம் ஆண்டு படிக்கும்

மாணவியின் ஆராய் ச்சி படிப்பிை் காக என் றன ஈடுபடுத்திக் சகாள் ள
மனப்பூர்வமாக சம் மதிக்கிறைன் .

றமலும் அவர்களது ஆராய் ச்சி படிப்றப பை் றிய எல் லா சசயல் பாடுகள்

குறித்து என் னிடம் சதளிவாக அளிக்கப் பட்ட விளக்கங் கறள நான்

புரிந்து சகாண்டு கீழ் காணும் அறனத்து சசயல் களிலும் நான் என் றன

ஈடுப்படுத்தி சகாள் ள மணப்பூர்வமாக சம் மதிக்கிறைன் .

ஆராய் ச்சியாளர்கள் என் னுறடய உடல் நலத்றத பை் றி றகட்கும்

அறனத்து றகள் விக்கும் சதளிவாக பதில் அளிப்றபன் .

ஆராய் ச்சியாளர்கள் என் னுறடய மருத்துவ பதிவு ஏடுகறள

ஆராய் ச்சிப் பணிக்கு உபறயாகப்படுத்த சம் மதிக்கிறைன் .

ஆராய் ச்சியாளர்கள் ஆராய் ச்சியின் றபாது பரிந்துறரக்கும்

அறனத்து பயிை் சிகறளயும் சசய் றவன் .

இந்த ஆராய் ச்சியின் பலன் கள் இதனால் ஏை் படும் விறனவுகள் பை் றிய
அறனத்து றகள் விகளுக்கும் . சந்றதகங் களுக்கும் முறையான

விளக்கங் கறள ஆராய் ச்சியாளர் உரியமுறையில் அளித்தார்.

இடம் :___

றததி:____ இப்படிக்கு,

34
APPENDIX- D

GROUP A:

S.No VAS Owestry Disability

Questionnaire

Pre - Test Post-Test Pre-Test Post-Test

1. 8 7 9 7
2. 7 6 12 10
3. 9 7 10 8
4. 5 4 13 12
5. 4 4 15 11
6. 6 5 8 7
7. 9 7 6 5
8. 7 5 7 4
9. 8 6 9 8
10. 5 4 8 7
11. 6 5 20 17
12. 10 8 22 21
13. 8 7 24 22
14. 5 4 17 15
15. 7 5 19 16
16. 6 5 18 14
17. 9 8 30 20
18. 4 4 28 22
19. 8 7 30 27
20. 10 9 27 21
21. 5 4 23 20
22. 9 7 19 15
23. 4 4 21 18
24. 7 6 18 14
25. 8 5 17 13
26. 7 6 28 22
27. 6 5 35 28
28. 8 7 44 40
29. 5 5 31 26
30. 9 7 24 19
31. 4 4 36 29
32. 5 4 43 37
33. 6 5 40 36
34. 5 4 32 26
35. 7 6 29 19
36. 9 7 46 40
37. 8 6 17 14
38. 6 5 28 19
39. 5 4 19 12
40. 10 8 32 26
41. 8 7 48 39
42. 6 5 39 33
43. 9 7 25 21
44. 10 8 36 29
45. 7 5 20 15
46. 6 4 26 24
47. 4 4 33 28
48. 8 6 19 15
49. 6 5 38 32
50. 9 7 28 21

GROUP – B:

Oswestry
S.No: VAS Disability
Questionnaire
Pre-Test Post-Test Pre-Test Post-Test
1. 7 4 9 5
2. 6 3 6 4
3. 8 5 8 4
4. 9 6 9 5
5. 6 3 10 6
6. 5 3 12 8
7. 10 6 14 7
8. 8 5 13 9
9. 6 3 6 4
10. 9 5 20 14
11. 7 4 22 16
12. 5 3 8 5
13. 7 4 20 16
14. 4 2 28 14
15. 10 6 32 26
16. 9 5 27 17
17. 7 5 18 9
18. 6 4 24 12
19. 8 4 19 10
20. 9 7 26 18
21. 7 3 4 16
22. 5 2 35 28
23. 8 5 44 32
24. 9 6 28 17
25. 7 3 21 11
26. 4 2 29 20
27. 8 5 31 19
28. 10 7 46 34
29. 9 6 27 18
30. 8 5 30 21
31. 8 4 32 22
32. 7 5 36 24
33. 6 4 19 10
34. 9 5 43 34
35. 5 2 17 11
36. 6 3 28 19
37. 8 4 29 17
38. 7 4 37 29
39. 10 7 25 18
40. 9 4 21 12
41. 5 1 32 24
42. 4 2 39 32
43. 6 4 29 25
44. 7 5 24 14
45. 5 2 44 34
46. 4 1 26 17
47. 8 3 19 12
48. 7 4 35 27
49. 9 4 28 19
50. 6 3 46 32

PLAGARISM REPORT:

THE EFFECT OF STRAIN COUNTERSTRAIN TECHNIQUE AND CORE

STRENGTHENING EXERCISES ON PAIN AND FUNCTIONAL STATUS AMONG
MIDDLE AGED PEOPLE WITH CHRONIC LOW BACK PAIN."

39
40