A Study of 60 Patients with Low Back Pain to Compare Outcomes Following Magnetotherapy, Ultrasound, Laser, and Electrotherapy with and without Lumbosacral Kinesiotherapy

Abstract

Background

This study of 60 patients with low back pain (LBP) aimed to compare outcomes following magnetotherapy, ultrasound therapy, laser therapy, and electrotherapy, with and without lumbosacral kinesiotherapy, and used the Roland-Morris Disability Questionnaire (RMDQ) and the Oswestry Low Back Pain Disability Questionnaire (OLBPDQ). This was a randomized actively controlled intervention trial of adding kinesiotherapy to a standard physiotherapy for LBP.

Material/Methods

The research included 60 participants with a diagnosis of chronic non-specific lumbar pain syndrome (CNSLPS) (mean±SD age 58.3±15.4 years, 37 women) LBP randomly assigned (1: 1) to 2 treatment groups. In Group 1, 30 patients were treated with magnetotherapy, ultrasound therapy, laser therapy, and electrotherapy. In Group 2, 30 patients received the same treatments as in Group 1, and also performed kinesiotherapy exercises affecting the lumbosacral spine and adjacent muscles. At baseline and at the end of the study, all participants completed the RMDQ and the OLBPDQ.

Results

Both groups had significant improvement after therapy. Repeated-measures ANOVA indicated that at the end of treatment there was significantly greater progress and symptom reduction (P<0.001) in Group 2. Patients in Group 2 had a pain reduction of 52.5%, while Group 1 had 25.4% pain reduction (P=0.009).

Conclusions

For treatment of disability caused by CNSLPS, physical therapy combined with kinesiotherapy should be a treatment of choice.

Introduction

Back pain is a common chronic condition with symptoms such as numbness and pain around the spinal column [1]. The prevalence of low back pain (LBP) is high and it gradually increases with age [2]. Back pain has a high rate of recurrence and is the leading cause of physical disability [3]. In 2020, there were 619 million people worldwide with LBP, and by 2050 that number is expected to reach 843 million [4]. According to a meta-analysis conducted on 163 studies during the COVID-19 pandemic, the prevalence and intensity of LBP have increased. The reasons partly stem from the increased inactivity that occurred during the pandemic quarantine and the recommendation of social distancing. The social and economic burden of LBP is significant [4]. The 1-year relapse rate was reported to be 69% [5]. The burden of LBP generated annually at doctor’s visits cost the UK National Health Service nearly ≤5 billion. Absences from work, reduction in the quality of work, and early retirement are also common [4]. Chronic lower back pain can be caused by a variety of factors [5]. LBP can be caused by various inflammatory conditions, mechanical or structural problems with the spine, and various other medical conditions. Often, the exact cause of back pain cannot be determined [6]. In 90% of cases, LBP occurs when a problem develops in the spine, muscles, ligaments, and tendons in the back [7,8]. Mechanical back pain refers to back pain arising mainly from the spine, intervertebral discs, or surrounding soft tissue [9]. This includes lumbar strain, herniated disc, lumbar spondylosis, spondylolisthesis, spondylolysis, vertebral compression fractures, and acute or chronic traumatic injury [10]. The joints and discs of the cervical and lumbar spine are constructed to enable maximum mobility with sufficient stability of the spine [11]. These segments in particular bear dynamic loads, and the greatest stress concentration is on the transitions between the moveable segment of the (cervical and lumbar) spine and the relatively rigid thoracic spine, as well as between the moveable lumbar spine and the sacrum [11]. These are the locations where degenerative changes most commonly occur, caused by mechanical overload [12]. Vertebral LBP is characterized by local pain that is not transferred to the periphery, but remains limited to the area around the spinal column [13]. It can also be vertebrogenic, which is when pain is transferred to a different location away from the spine [13]. Non-specific LBP is defined as a symptom of an unknown cause, which cannot be clearly attributed to any pathology [14]. Although degenerative changes to intervertebral discs, arthritis, and other changes to the spine are commonly found in radiological imaging, such findings are also common in many persons without symptoms of back pain, while patients with severe symptoms can have normal radiological findings [15,16]. Radiography is not recommended for most patients with non-specific mechanical back pain [17]. The American College of Radiology recommends spinal imaging only if there are no improvements after 6 weeks of physical therapy [18]. Chronic back pain affects an estimated 23% of the population worldwide, with an estimated 24–80% of patients experiencing a recurrent episode within 1 year [19,20]. It is estimated that 50–80% of the population experiences low back pain at least once during their lifetime, which makes low back pain one of the most common reasons for requesting medical assistance [21].

There are few pain-related conditions and illnesses with as many causes as LBP, but the cause cannot be determined with certainty in approximately 90% of patients [19]. It is believed that more than 95% of LBP is of mechanical origin, and at least 10% is caused by herniated discs or intervertebral disc degeneration [22]. In most patients, LBP episodes are brief [23]. About 50% of patients with acute LBP experience no pain after 2 weeks, while 70% of them recover within 1 month [21]. Almost 90% of patients no longer experience LBP within 3 months, which is why no more than 10% experience chronic LBP [12,24]. Numerous randomized trials and guidelines for clinical practice support that in patients with chronic LBP, exercise reduces the level of disability and pain, improves general fitness and employment status, and reduces the rate of recurrence [24]. However, there is no clear evidence that one type of exercise is better than another [25]. Research shows that the best results are achieved through use of individually designed exercises performed under professional supervision [26]. Considering the different durations of LBP, acute LBP lasts up to 3 months and chronic LBP lasts longer than 3 months, while some authors recognize subacute low back pain, which lasts 7–12 weeks [27]. The complexity of duration and form of pain and conflicting results of physical therapy motivated us to conduct the present study.

Diagnosis and Management

Differential diagnosis of back pain in adults is complicated [18] and it can have many causes: lumbosacral muscle strains and sprains, lumbar spondylosis, disk herniation, spondylolysis, spondylolisthesis, repetitive spinal stress [28], vertebral compression fracture, spinal stenosis, and tumors – 97% of spinal tumors are metastatic [29] and many patients have infections [30].

Management of Back Pain in Adults

The first-line treatments are nonpharmacological and include [18] early return to normal routines, avoidance of activities that precipitate the pain, and patient education. Second-line options that may be offered to the patient include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, opioids, spinal manipulation, physical therapy, superficial heat application, and alternative treatments like acupuncture and massage. Patient education is crucial in preventing back pain aggravation or recurrence. The patient may be advised to follow up after 2 weeks [18]. If the cause is non-specific, advise the patient to remain active and avoid precipitating factors. Exercise therapy is also considered a first-line treatment [31,32].

Clinical Practice Guidelines

Exercise therapy is most effective, and most guidelines (10 of 14; 71%) recommend exercise therapy for patients with CNSLPS [25]. There are important differences in the type of exercise and the programs that are carried out, as well as the method of performance. Thus, we use a large selection of exercises such as water exercises, stretching, back schools, McKenzie approach to exercises, yoga, and tai-chi, then individually design supervised at-home exercise program and group exercises. Guidelines have been issued that make inconsistent recommendations about exercise therapy for acute LBP [25]. Most guidelines recommend the use of NSAIDs and antidepressants for the treatment of patients with CNSLPS, and prescribe exercise and psychosocial interventions. In case of more serious problems or no improvement after 4 weeks to 2 years, it is recommended that the patient consult a specialist [25]. The Oswestry Back Pain Disability Questionnaire (OLBPDQ) is considered the most important tool for use in research and assessment of permanent functional disability, and it is considered the criterion standard tool spondylolisthesis, repetitive [33]. The Roland-Morris Disability Questionnaire (RMDQ) is most sensitive for patients with mild to moderate disability caused by acute or chronic pain [34]. To assess patient health, 136 items are used, which cover all aspects of physical and mental functioning and serve as the basis for the RMDQ [34,35].

Our hypothesis in the present study was that physical therapy combined with kinesiotherapy would be more effective in treating chronic non-specific lumbar pain syndrome (CNSLPS) than physiotherapy alone in reducing pain [25]. Our primary objective was to determine which of these 2 therapeutic procedures provides better results in reducing pain in patients with LBP. Our secondary objective was to determine the effectiveness of these 2 therapeutic procedures. Therefore, this study of 60 patients with low back pain aimed to compare outcomes following magnetotherapy, ultrasound, laser, and electrotherapy with and without lumbosacral kinesiotherapy, and used the RMDQ and the OLBPDQ.

Material and Methods

Ethics Approval and Study design

The study was approved by a Local Ethics Committee, University of Rijeka, Faculty of Medicine (approval no. 2170-24-01-22-1/MJ). Patients were required to sign the informed consent form before any procedure was done. The study design and the informed consent were in accordance with the Nuremberg Code and the latest revision of the Declaration of Helsinki and national laws and bylaws.

This was a single-center, randomized, positive control intervention pilot study to assess the effectiveness of adding kinesitherapy to the usual physiotherapy care for LBP.

Participants and Groups

We recruited 60 participants referred to the polyclinic for physical therapy with a diagnosis of chronic non-specific lumbar pain syndrome (CNSLPS). The diagnosis was provided by the referring physician, who is a specialist in physical medicine and rehabilitation from another institution. The patients were assigned to a 1 of 2 treatment groups in a 1: 1 ratio using random assignment with numbers from a sealed envelope previously prepared by an independent statistician using an online randomizer program (https://www.randomizer.org/). Inclusion criteria were: 1) age 18–65 years, and 2) referral diagnosis of CNSLPS. Exclusion criteria were: 1) irregular attendance, missing more than 3 appointments. Each patient was assigned to 10 therapeutic cycles over 10 consecutive days excluding weekends (5 times a week).

The groups are defined by the type of therapy performed: Group 1 received a combination of physiotherapy procedures: 1) ultrasound (MedicalDevice EV 904), power 0.8–2 W/cm² with patient lying down on the table in prone position. Ultrasound was applied to the left and right lumbar area for 5 min (for a total for 10 min); 2) laser (ASV device), intensity 50%, frequencies 1500 Hz with the patient lying down on the table in prone position. Laser was applied to the left and right lumbar area for 3 min (for a total of 6 min). 3) IF current (MedicalDevice EV 904), maximal power 100 mA with the patient lying down in prone position. Electricity was applied to the area of the lumbar spine for 10 min. 4) Magnetotherapy (ASV device), frequencies 100 Hz, intensity 60%, with the patient lying down in supine position on the back. The coil of the magnet was placed on the lumbar part of the spine and activated for 20 min. The duration of a single-visit physiotherapy for group 1 was 46 min. Group 2 received a combination of the same physiotherapy procedures as in group 1 with the addition of kinesiotherapy of the lumbosacral spine. Kinesiotherapy was provided for 20 min. The exercises performed are presented in the supplemental material. Total treatment time for a single visit was 66 min.

Physical therapy for all patients was administered by a qualified physiotherapist with a Master of Physiotherapy degree.

Questionnaires

To assess the effectiveness of therapy in these 2 treatment groups, 2 questionnaires were used before and after treatment: the modified version of the Roland-Morris Disability Questionnaire (RMDQ) and the Oswestry Low Back Pain Disability Questionnaire (OLBPDQ).

The modified version of the RMDQ consists of 24 statements concerning different activities of everyday life. Each statement was assigned a score of 0 or 1, where the higher number of points indicates a higher degree of disability. The maximum number of points is 24 [34].

The OLBPDQ consists of 10 items – pain intensity, personal care (washing, dressing, etc.), lifting, walking, sitting, standing, sleeping, sex life, social life, travelling – for each of these items, there are 6 statements, with the score ranging from 0 to 5. The maximum number of points is 50 and a higher number of points indicates greater disability [33].

Statistical Methods

For data processing, the software package Statistica, version 13.5.0.17, was used (TIBCO Software, Inc. USA). Statistical significance was assessed based on the level of statistical significance P≤0.05 with 95% confidence limits. The t test was used to determine the arithmetic mean of the score before treatment in OLBPDQ.

The chi-square test was used to test the difference in the frequency of marked items in the RMDQ. Repeated-measures ANOVA was used to assess the difference in effectiveness between groups.

Results

Demographic Characteristic of Participants

The research included 60 participants – 37 women (62%) and 23 men (38%), with a mean age of 58.3 (standard deviation 15.4). The mean BMI of the patients was 22.6 with a standard deviation of 3.06 kg/m². The groups did not significantly differ based on sex (P=0.733) or age (P=0.733) distribution.

Oswestry Low Back Pain Disability Questionnaire

Results of the OLBPDQ showed that before treatment most participants had problems with everyday activities, such as in section 1, which concerns pain intensity, showing that analgesics provided moderate pain reduction in 31.7% of participants. Regarding personal care, 56.7% could look after themselves normally, but with pain; 43.3% had problems with lifting heavy objects; and 50% could not walk more than 1 km. Sitting was the greatest problem for the working-age participants – 40% experienced problems or felt pain when sitting. A third of the patients (33.3%) could stand as long as they wanted, but with pain. Many participants (51.7%) slept less than 6 h, regardless of the use of analgesics. Regarding physiological needs, sex life of the participants with LBP was very painful – 66.7% of them had painful or very painful sexual activity. Regarding social life, most participants (38.3%) had a normal social life, but social activities increased their degree of pain. Travel was possible for 41.7% of participants, but it caused increase pain.

Our participants could be divided into 2 categories of disability: 75% of them had minimal disability (0–10 points), while 25% had moderate disability (11–20 points). The total points in the questionnaire had an arithmetic mean of 15.83 and standard deviation of 6.19 points. Results for OLBPDQ compared between groups are presented in Table 1. We compared the points between our 2 groups, and the t test showed that there is no significant difference (P=0.592).

Table 1.

Results obtained using the Oswestry Low Back Pain Disability Questionnaire (N=60).

Disability questionnaire	Both groups (N=60)	Group 1 (N=30)		Group 2 (N=30)		P value
	Mean	Mean	SD	Mean	SD
1. Pain intensity	2.10	2.23	1.25	1.97	1.43	0.444
2. Personal care	0.82	0.50	0.51	1.13	0.68	0.001*
3. Lifting	1.58	1.37	0.80	1.80	0.76	0.036*
4. Walking	1.35	1.33	0.88	1.37	1.03	0.894
5. Sitting	1.73	1.77	0.72	1.70	1.24	0.799
6. Standing	1.92	2.13	1.33	1.70	1.29	0.205
7. Sleeping	1.25	1.67	1.44	0.83	0.69	0.006*
8. Sex life	1.58	1.80	1.67	1.37	1.54	0.294
9. Social life	1.85	1.83	1.17	1.87	1.29	0.917
10. Travelling	1.65	1.63	1.22	1.67	1.37	0.921
Total	15.83	16.26	6.38	15.4	6.06	0.591

N – number of participants; SD – standard deviation.

^*P≤0.05.

Roland-Morris Disability Questionnaire

The 2 groups of respondents do not differ in the number of points they received on the RMDQ questionnaire (t=0.97, P=0.063) before treatment. Table 2 contains answers based on the items at the beginning and end of therapy.

Table 2.

Results of the chi-square test on the Roland-Morris Disability Questionnaire before and after treatment. The frequency of marked answers was compared for each individual question between 2 group (N=60).

Score YES		Group 1 (N=30)		Group 2 (N=30)		chi-square P value*
		Before	After	Before	After
1.	I stay at home most of the time because of my back	8	5	7	1	1.08 0.298
2.	I change position frequently to try and get my back comfortable	20	12	17	2	2.63 0.101
3.	I walk more slowly than usual because of my back	17	13	20	15	0.12 0.729
4.	Because of my back I am not doing any of the jobs that I usually do around the house	2	2	4	1	3.08 0.079
5.	Because of my back, I use a handrail to get upstairs	11	5	16	14	2.14 0.143
6.	Because of my back, I lie down to rest more often	14	11	17	1	10.57 0.001**
7.	Because of my back, I have to hold on to something to get out of an easy chair	5	5	17	11	6.32 0.011**
8.	Because of my back, I try to get other people to do things for me	7	4	11	7	0.15 0.698
9.	I get dressed more slowly than usual because of my back	12	12	20	4	6.32 0.011**
10.	I only stand for short periods of time because of my back	8	8	7	3	4.14 0.042**
11.	Because of my back, I try not to bend or kneel down	20	18	21	20	0.34 0.559
12.	I find it difficult to get out of a chair because of my back	5	3	6	3	0.21 0.647
13.	My back is painful almost all the time	3	3	17	0	19.8 <0.001**
14.	I find it difficult to turn over in bed because of my back	6	5	13	2	6.98 0.008**
15.	My appetite is not very good because of my back pain	30	30	30	30	––– –––
16.	I have trouble putting on my socks (or stockings) because of the pain in my back	18	11	12	3	0.29 0.591
17.	I only walk short distances because of my back	10	5	8	1	0.37 0.540
18.	I sleep less well because of my back	10	8	7	0	3.00 0.081
19.	Because of my back pain, I get dressed with help from someone else	0	0	1	0	––– –––
20.	I sit down for most of the day because of my back	2	2	3	0	3.07 0.079
21.	I avoid heavy jobs around the house because of my back	18	14	5	5	4.13 0.043**
22.	Because of my back pain, I am more irritable and bad tempered with people than usual	6	5	11	2	6.98 0.008**
23.	Because of my back, I go upstairs more slowly than usual	15	13	19	15	0.70 0.407
24.	I stay in bed most of the time because of my back	3	0	2	0	0.21 0.647

N – number of participants.

^*Chi-square test refers to the comparison between groups;

^**P≤0.05.

Table 2 shows the data from RMDQ on the items marked by the respondents for both groups. After the therapy, there was a decrease in the scores of RMDQ, showing improvement in both groups. The chi-square test was used to compare the difference in the number of marked items in the questionnaire by group. Group 2 had significantly better results for questions 6, 7, 9, 10, 13, 14, 21, and 22, and there was no significant difference in the other questions (Table 2).

Group 1, which did not receive kinesiotherapy during rehabilitation, had equal or worse recovery results after treatment compared with before treatment. Group 2, which received kinesiotherapy, had significant progress and symptom reduction by end of treatment compared with the situation before treatment. Repeated-measures ANOVA was used to assess differences in improvement between groups (P<0.001) (Figure 1), showing significantly greater improvement in Group 2 after therapy (Figure 1).

Figure 1.

Comparison of the results of the Roland-Morris Disability Questionnaire between groups before (dark blue) and after (light blue) the treatment (P<0.001, repeated-measures ANOVA); boxes represent means and whiskers represent 95% confidence intervals of mean. Statistica version 13.5.0.17 was used (TIBCO Software, Inc., USA) to create the figure.

Discussion

LBP was a leading global cause of disability in most countries in 2015 [35], and most people experience back pain at some point in their lives [2,36]. The prevalence of LBP is increasing, particularly in older people and in men [37]. Back pain has 3 different sources: axial LBP, radicular pain, and referred pain. The annual prevalence of back pain in the general adult population in the USA is 10–30%, and in the elderly population it is 65–80% [38]. For reducing CNSLPS, prevention and education are extremely important, as confirmed by a study conducted on nurses [39]. Adequate education and proper vertical lifting techniques can prevent the onset of pain in nurses; the onset of pain in chronic non-specific low back pain was reduced by 88%, and the average CNSLPS intensity score on the visual analog scale decreased by 43% [39].

In our study, we did not address prevention of LBP, although each patient was educated on proper exercising, changing positions, standing up, sitting down, body posture during driving, proper sitting posture, and lifting weights from a surface and from the floor. We found that traditional physical therapy plus kinesiotherapy was the more effective treatment method for CNSLPS. Disability was reduced by >25% in both groups, while the kinesiotherapy group (Group 2) had 52% pain decrease from the start of treatment.

For subacute and chronic non-specific low back pain, the most effective treatment options were massage therapy and routine physical therapy, particularly if accompanied by exercise [40]. Exercise is advocated as the main part of treatment of chronic back pain, and a significant reduction of disability was observed in both groups at the end of the second, fourth, and sixth weeks of treatment [41].

A tailored exercise program and general recommendations appear to be more effective than mere general recommendations for improving lumbar flexion. Cimarras stated that a tailored exercise programme for chronic LBP can be effective treatment [42]. Ozkaraoglu et al indicated that high-intensity laser therapy is more effective than TENS in terms of pain reduction and that HILT can be used as an alternative to TENS for low back pain [43]. Our study did not compare instrumental techniques, as we used HILT in combination with all other treatment procedures. TENS had results comparable to placebo; that is, it was not effective in the treatment of CNSLPS [18], so instead we used interferential current. Electrotherapy is one the non-invasive procedure used to treat non-specific chronic LBP [19], in which interferential currents and transcutaneous electrical nerve stimulation are used. Interferential therapy is used to relieve pain and to increase blood flow to the tissues, and also is more useful than transcutaneous electrical nerve stimulation [19]. Low-energy laser and the physical properties of a pulsating magnetic field have been shown to be effective for pain treatment in Zdrodowska’s research, which emphasized the greater effectiveness of lasers for pain [44]. For people with degenerative diseases of the spine in the lower back, laser and magnet therapy help the most. A comparison of both methods showed a higher analgesic efficacy of the laser, and under the influence of a pulsating magnetic field, a higher mobility of the spine was shown [44]. In the field of rehabilitation, the biggest problem is the treatment of CNSLPS. The effects of ultrasound remain unknown. In the clinical practice of physical therapists, ultrasound therapy is most often used in the treatment of LBP. In most studies, the effect of ultrasound therapy was compared with other modalities, or was presented in a package of physiotherapy. The efficacy of therapeutic ultrasound for musculoskeletal conditions remains unclear. There is also a lack of evidence for clinical use in patients with CNSLPS [16]. Durmus et al showed greater improvement in reduction pain using therapeutic ultrasound than exercise only [45]. Lewis et al prescribed physiotherapy exercises such as general fitness and aerobic exercises, finding that flexibility exercises, stretches, muscle strengthening, and spinal stabilizing exercises were effective in reducing pain in patients with CNSLPS [26].

The key for LBP treatment in traditional Chinese medicine is to promote blood circulation, remove blood stasis, and relieve pain [3]. Acupuncture and moxibustion treatment may purify the blood by removing all harmful substances and toxins from the blood, soothing the nerve root through compression, improving blood circulation in the lumbar area, and eliminating edema by stimulating acupoints for pain relief [3]. In Croatia, traditional Chinese medicine is little used. There is currently no option for treatment of low back pain using moxibustion in national institutions and in most private clinics.

The greatest apparent increase of disability caused by back pain in the last few decades occurred in low- and middle-income countries, including Asia, Africa, and the Middle East [46], where healthcare and social welfare systems are poorly equipped to deal with the growing pressure of LBP when there are other priorities, such as infectious diseases [47]. Research conducted on 500 farmers in rural Nigeria revealed that more than half of the farmers reduced their farming activities due to back pain. Disability related to back pain may thus contribute to the cycle of poverty in the poorer regions of the world. However, this is true not only for poor countries. In 79% of the cases, women in the United Arab Emirates experience back pain after childbirth, unlike women in Europe [48]; their health-related quality of life (HRQOL) is reduced due to back and pelvic pain. Advancing age is also linked to greater prevalence of back pain. More severe forms of back pain continue to increase with age, and the overall prevalence increases by ages 60–65 [49]. Lower educational status is likewise associated with increased prevalence of LBP, as well as with longer episode duration and worse outcome of treatment. Occupational differences in prevalence of back pain have also been reported, indicating a link between greater physical activity and prevalence of back pain. Blue collar workers were reported to have a prevalence of LBP of 39%, while white collar workers classified as inactive were reported to have a prevalence of 18.3%. Although differences exist between different occupational groups, similar LBP prevalence rates have been reported between working and non-working groups [49].

Two recent randomized controlled trials showed no benefits of systemic corticosteroids in comparison with placebo in patients with acute back pain [50] or benefits of cyclobenzaprine (Flexeril) plus nonsteroidal anti-inflammatory drugs (NSAIDs) in comparison with NSAIDs in patients with non-radicular acute back pain [51,52]. Overuse of corticosteroids for pain or contusions increases the possibility of minimal vertebral fracture by 62% (49–74%) [53]. The probability of minimal vertebral fracture trauma was present when there were multiple risk factors, such as female sex, age >70, severe trauma, and prolonged use of glucocorticoids (90%) [17]. There were no minimal vertebral fractures in our group of patients during the treatment period.

Limitations of the Study

The limitations of our study are the small sample size, short duration of treatment, older age of the subjects (greater than 65 years), and lack of a follow-up period. The effect of physical therapy is different in older people; the therapeutic effect is achieved more slowly and pain reduction is more difficult to achieve. It would be interesting to call or contact patients who were in the study after 3 months so that the long-term effect of physical therapy could be assessed. The subjectivity of pain assessment is a limitation, but there are no objective measures of pain, so standardized pain questionnaires must be used so that the results can be comparable. Also, we used questionnaires that show the level of influence on everyday activities, which are important outcomes in pain syndromes. We did not use single-treatment procedures, so we do not know how a single procedure would work in providing benefit, because previous research shows both positive and negative effects on pain reduction in CNSLPS. For future studies, it would be interesting to investigate single procedures, which would need more patients, but also to compare the efficacy in the acute phase of lumbar pain syndrome and to compare it with CNSLPS.

Conclusions

Our study showed that adding kinesiotherapy to standard physiotherapy is superior to standard physiotherapy alone for CNSLPS. This is confirmed by the fact that the group with added kinesiotherapy experienced significantly greater improvement (52.5% vs 25.4%) after only 1 treatment cycle. Our results suggest that physical therapy combined with kinesiotherapy should be a treatment of choice for patients with disability due to CNSLPS. Further research is needed to assess duration of treatment and relapse of symptoms, and to answer questions about the associated individual characteristics important for success of treatment of CNSLPS.