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Journal of Back and Musculoskeletal Rehabilitation -1 (2017) 1–8
DOI 10.3233/BMR-169696
IOS Press
Effect of myofascial trigger point therapy
with an inflatable ball in elderlies with
chronic non-specific low back pain
Sejun Oha , Minhee Kima , Minyoung Leea , Taeyeong Kima , Dongshin Leeb and Bumchul Yoona,∗
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Department of Physical Therapy, College of Health Science, Major of Rehabilitation Science, Graduate School,
Korea University, Seoul, Korea
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Department of Physical Therapy, College of Health Science, Eulji University, Gyeonggido, Korea
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Abstract.
BACKGROUND: Myofascial trigger points (MTrPs) are related to low back pain and back muscle stiffening, and secondarily
to movement impairment. MTrP therapy with an inflatable ball would improve clinical outcomes for chronic non-specific low
back pain (CNSLBP) after 6 weeks.
OBJECTIVE: The aim of this study was to investigate the effects of MTrPs with an inflatable ball for the elderly with CNSLBP.
METHODS: Fifteen elderly patients with chronic non-specific low back pain were evaluated for pain, pressure sensitivity, and
physical function at baseline and 1, 3, and 6 weeks of therapy. The visual analog scale (VAS) and pressure pain threshold (PPT)
were used to measure pain intensity and sensitivity, respectively. Straight-leg-raise (SLR) test, back range of motion (BROM),
and Oswestry disability index were used to assess physical function.
RESULTS: Significant differences were observed between the 3- and 6-week VAS scores (−34.6%; p = 0.03); baseline and
1-week (7%; p = 0.02), 1- and 3-week (−14%; p = 0.01), and 3- and 6-week PPTs (18%; p = 0.01); 3- and 6-week BROMs
(Flexion, 7.1%; Extension, 41%; p = 0.048); baseline and 1-week (−6.9%; p = 0.02), 1- and 3-week (3%; p = 0.01), and 3and 6-week active SLR test scores (7%; p = 0.011); and baseline and 1-week (−2.6%; p = 0.03), 1- and 3-week (8.34%; p =
0.01), and 3- and 6-week passive SLR test scores (5.3%; p = 0.025).
CONCLUSION: Myofascial trigger point therapy with an inflatable ball relieved pain and improved physical function in the
elderly with CNSLBP.
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Keywords: Chronic non-specific low back pain, elderly, inflatable ball, myofascial trigger point, myofascial trigger point therapy
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1. Introduction
Chronic non-specific low back pain (CNSLBP) has
been reported to be a common musculoskeletal disorder in the elderly [1–3]. Decreased range of motion and
limited movements by CNSLBP lead to decline in the
quality of life and limited social participation of the
elderly [4,5].
∗ Corresponding
author: BumChul Yoon, Department of Physical
Therapy, College of Health Sciences, Korea University 145, Anamro, Sungbuk-gu, Seoul 136-701, Korea. Tel.: +82 29402833; Fax:
+82 29402830; E-mail: yoonbc@korea.ac.kr.
Myofascial trigger points (MTrPs) are related primarily to low back pain and back muscle stiffening, and secondarily to movement impairment [4,6].
In particular, a most common feature of movement
impairment is reduced movement control. The aforementioned symptoms are mainly observed in patients
with CNSLBP [7,8]. These fundamental causes of
movement impairment in patients with CNSLBP could
damage active movement control and lead to careless
movement due to abnormal habits [9].
Recently, a self-release therapy has been implemented for CNSLBP patients [10,11]. Especially gym
balls and foam rollers are used as tools to maintain
c 2017 – IOS Press and the authors. All rights reserved
ISSN 1053-8127/17/$35.00 8
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MMSE-K: Mini-Mental State Examination-Korean version, PCS:
physical component score, MCS: mental component score.
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posture and for muscle release [12,13]. In addition,
myofascial trigger points are useful for releasing taut
bands of skeletal muscles by using manual therapy
and the Graston technique [14]. However, in some
parts, gross muscle release is unsatisfactory and therapy for myofascial trigger points is insufficient. Moreover, treatment is limited only to passive therapy by a
therapist. In the recent clinical trends, self-release therapy used for MTrPs compensates for the defect [15].
However, inflatable balls can be applied softly and flexibly according to different ball pressures, and above all,
patients can directly self-release the applied inflatable
ball. A previous study has shown that when inflatable
balls were applied to elderly patients with myofascial
pain syndrome for 4 weeks, the effects of neck pain
and joint flexibility were similar to those in ultrasound
therapy [16]. However, evidence of the effect of an inflatable ball on CNSLBP is rarely reported.
Therefore, the aim of this study was to investigate
the effects of MTrPs with an inflatable ball for the elderly with CNSLBP. We hypothesized that MTrP therapy with an inflatable ball would improve clinical outcomes such as reducing pain, reducing sensitivity to
pressure, and increasing back flexibility after 6 weeks.
The present study was designed to reinvestigate the
clinical outcomes, in terms of pain and physical function, in patients treated for CNSLBP.
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n
Sex (female/male)
Age (years)
Height (cm)
Weight (kg)
MMSE-K
SF-36 PCS
SF-36 MCS
Myofascial trigger point therapy group
(n = 15)
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70.82 (5.64)
154.41 (3.84)
58.48 (6.58)
27.22 (2.33)
28.82 (2.31)
26.75 (2.27)
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Variables
ical function was assessed by using the straight-legraise (SLR) test and back range of motion (BROM).
Disability was measured by using the Oswestry disability index (ODI). Three physical therapists with at
least 6 years of clinical experience conducted the evaluation.
The study participants were 15 elderlies (Fig. 1).
Participants were recruited from community welfare
center. Their characteristics are presented in (Table 1).
All the participants had MTrPs in the gluteus maximus,
gluteus medius, iliopsoas, and quadratus lumborum on
at least one side that persisted for > 3 months. Before
performing the intervention, we reevaluated the eligibility of the participants related to orthopedist in neighboring hospital according to the following inclusion
criteria: (1) subjects aged 65 years or older; (2) having CNSLBP without any relevant ongoing pathologies such as compression fracture, a tumor or metastasis, ankylosing spondylitis, infection, or radiating pain;
and (3) willingness to participate in this study and informed consent. The exclusion criteria were as follows:
(1) other pain syndromes; (2) spinal and hip surgery in
the past 6 months or having to undergo surgery or invasive examinations during the study; (3) neurological
disease; (4) psychiatric disease; and (5) serious chronic
disease that could interfere with the outcomes (e.g.,
cardiovascular disease, rheumatoid arthritis, epilepsy,
or other disqualifying conditions).
The diagnosis of MTrPs was based on the following criteria: (1) palpable, hypersensitive tender spot in
a taut band, (2) pain reproduced by compression of the
tender spot, (3) local twitch response on muscle palpation, and (4) referred and spontaneous pain elicited by
firm compression [17,18]. The purpose and procedures
of this study were explained to all the participants, and
informed consent was obtained before participation in
this study. This study was approved by the Korea University Institutional Review Board.
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Table 1
Subjects’ demographic characteristics
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2.2. Treatments
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2. Methods
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2.1. Study design
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We planned a one-way repeated-measures design of
study. The participants received treatment 3 times per
week for 6 consecutive weeks, in exercise rooms in
the physical therapy department of the university. Subjective pain was measured by using the visual analog
scale (VAS) and pressure pain threshold (PPT). Phys-
We implemented the MTrP therapy program in all
the subjects. Two physical therapists with > 5 years’
clinical experience instructed the participants about
self-MTrPs therapy with an inflatable ball. They explained the purpose of the program by using a prepared document. The participants used a therapeutic
inflatable ball (Good Ball, Korean Association of SelfRelease, South Korea) 6.5 cm in diameter, made of
a smooth-surface and elastic silicone ball (Fig. 2). To
provide suitable pressure, the participants controlled
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Fig. 1. Flow diagram of the participants and measurements.
Fig. 2. The adjustable therapeutic inflatable ball for the elderly with
chronic non-specific low back pain. The participants self-massaged
their myofascial trigger points by using the therapeutic inflatable
ball.
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the compression of the inflatable ball by using an air
pump, depending on the sensitivity of the MTrPs. The
pressure should be as tolerable possible as for increasing soft tissue flexibility [16,19]. As the participants
began to experience less discomfort and pain with progressive sessions, we educated them to control the
strength applied to the inflatable ball by themselves.
MTrP therapy with an inflatable ball was focused on
releasing soft tissue tension, which was adjusted for
MTrPs in the back muscles, and performed in 4 stages,
for a total of 10 minutes. Each stage comprised 4 trials,
which were maintained for 1 min, with 1 min for rest
and changing position between each trial. The target
muscles were the gluteus maximus, gluteus medius, iliopsoas, and quadratus lumborum.
The first step was to select the gluteus maximus for
the main hip extension in the supine position. The second step was to select the gluteus medius for the main
hip abduction and adduction in the side-lying position.
The iliopsoas was responsible for the hip flexion in the
prone position in the third step, and the quadratus lumborum was responsible for the lateral flexion of the vertebral column in the fourth step. Each step was divided
into supine, side-lying, and prone according to the position change, and it was planned to concentrate hip
flexor and extensor related to low back pain.
In the first stage, we chose the gluteus maximus
because the inferior gluteal nerve relates to lumbar 5
nerve roots for indirect stimulation of the back muscle.
The gluteus maximus was adjusted to the supine position. The therapeutic inflatable ball was applied on the
same leg, with 45◦ hip abduction and 90◦ flexion knee.
The opposite side of leg was fully extended for enough
stimulation. In the second stage, we chose the gluteus
medius because the superior gluteus nerve is related to
lumbar 4 or 5 nerve roots. The gluteus medius was adjusted to a side sitting position. The therapeutic inflatable ball was applied on the same leg at full extension
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Fig. 3. A-B: Changes in mean pain intensity and sensitivity measured using the visual analog scale (left) and pressure pain threshold (right). C:
Changes in mean lumbar range of motion. D: Changes in mean Oswestry disability index. E-F: Changes in mean active (left) and passive straight
leg raising test scores (right). All values are expressed as mean standard deviation for baseline to 6 weeks data. *p < 0.05.
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Evaluations were conducted at baseline and after 1,
3, and 6 weeks of intervention. A physical therapist
with 8 years of clinical experience evaluated the participants for tender spots and then confirmed MTrPs
by palpation [21]. The MTrPs were marked on the
skin by using a pen. Medical tape was applied to
the MTrPs to ensure a consistent site for treatment
and measurement in each participant. The Mini-Mental
State Examination-Korean version (MMSE-K) and 36item Short-Form Health Survey (SF-36) were also used
to evaluate the participants for cognitive status and
health-related quality of life. Pressure pain threshold
(PPT), subjective pain intensity, and BROM were measured at baseline and at 1, 3, and 6 weeks of intervention. Outcome variables were measured 3 times at 30-s
intervals; the total measurement time was less than
20 min. The order of clinical outcome measurements
was as follows: BROM, subjective pain intensity, and
PPT. For all the measurements, the subjects sat on a
flat-surfaced stool with no arm or back supports.
Specifically, subjective pain intensity was measured
by using the VAS. This is a 10-cm horizontal line divided into 10 equal parts, where 0 indicates no pain and
10 indicates extreme pain. The participants were asked
to indicate the VAS score when a mechanical pressure
of 4.5 kg/cm2 was exerted on the marked MTrPs with
a pressure algometer (FPK 20; Effegi, Italy) [22].
PPT was measured by using a pressure algometer
with a dial gauge that could be set from 0 to 7.7 kg/cm2
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2.3. Clinical outcomes
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and a rod. The end of the rod was a 1-cm-wide plastic
plate; this was placed in direct contact with the marked
MTrPs. Vertical pressure was adjusted to these MTrPs
at a speed of 1 kg/s until the participant expressed the
first sensation of pain [21,23]. The evaluator recorded
the amount of pressure at the moment of pain. In the
present study, intra-examiner reliability showed high
repeatability (ICC3,1 = 0.83), and the 95% confidence
interval (CI) ranged from 0.74 to 0.90.
Physical function was assessed by using the SLR
test, BROM, and ODI. The SLR test was divided into
an active SLR (ASLR) test and a passive SLR (PSLR)
test and performed by using a goniometer (Goniometer, Teramedical, South Korea) for hamstring shortening related to CNSLBP according to lumbar lordorsis [24,25]. All SLR tests measured end of range
of motion or before the point of pain at both legs.
The mean value of 2 measurements in each leg was
recorded.
BROM was measured by using an electronic goniometer (Nippon Medical and Chemical Instruments
Co., Ltd., Japan), and the greatest range of motion
was recorded. With respect to the starting position for
measuring BROM, the proximal goniometer arm was
placed on the spinous process of the T12 vertebra and
perpendicular to the floor, and the central fulcrum of
the goniometer was placed on the spinous process of
T12 [26].
ODI was measured by using a self-completed questionnaire. Patients who could not read the questionnaire because of bad eyesight and those who lacked
comprehension were assisted in completing the questionnaire. The ODI questionnaire consisted of items
about pain, lifting, care, walking, sitting, sexual function, standing, social life, sleep, and travel. Each question is scored on a scale of 0–5 points. The scores for
all the questions were summed, and then the mean was
calculated (0–100 points) [27].
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and on the leg on the opposite side at 45◦ hip abduction with 90◦ flexion knee. In the third stage, we chose
the iliopsoas because of nerve branches from lumbar 1
to 3. The iliopsoas was adjusted to the prone position.
The therapeutic inflatable ball was applied on the same
leg at 45◦ hip abduction with 90◦ knee flexion and the
opposite leg at full extension. In the fourth stage, we
chose the quadratus lumborum because of the anterior
branches of the ventral rami of lumbars 1 to 4. The
quadratus lumborum was adjusted to the supine position, with the hip and knee at full flexion, pulled by
both hands, and the therapeutic inflatable ball was applied on the same leg. The opposite leg fully extended.
All the stages were adjusted for both sides. Further,
the physical therapists palpated the MTrPs of the gluteus maximus, gluteus medius, iliopsoas, and quadratus lumborum according to the manual [20], marked
the spot using a pen, and took an image to search the
same spot.
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2.4. Statistical analyses
The normal distribution of all clinical outcomes
was estimated with the Shapiro-Wilk test. One-way
repeated-measures analysis of variance was used to
compare the mean values of VAS, PPT, SLR, BROM,
and ODI according to the various time points (at baseline and at 1, 3, and 6 weeks of intervention). Independent t test and chi-square tests were conducted to assess the homogeneity of the demographic characteristics. Post hoc tests were conducted by using the Bonferroni correction to compare the means and adjust the
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confidence intervals. All the statistical analyses were
performed by using the Statistical Package for the Social Sciences (SPSS, Version 21.0, Chicago, IL, USA).
The level of significance was set at 0.05.
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3. Results
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3.1. Subjective pain
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3.2.3. PSLR test
The right-side PSLR test results decreased at baseline to 1 week (−3.8%), increased at 1 to 3 weeks
(9.1%), and increased at 3 to 6 weeks (5.2%), respectively. The left-side PSLR test results decreased at
baseline to 1 week (−1.4%), increased at 1 to 3 weeks
(7.5%), and increased at 3 to 6 weeks (5.5%), respectively. The mean PSLR test results decreased at baseline to 1 week (−2.6%), increased at 1 to 3 weeks
(8.34%), and increased at 3 to 6 weeks (5.3%), respectively. Significant differences in right- and leftside PSLR test scores were found between the baseline
and 1 week (F = 8.346; p = 0.03), 1 and 3 weeks
(F = 5.905; p = 0.01), and 3 and 6 weeks (F = 4.257;
p = 0.025).
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3.1.2. Pressure pain threshold
The right-side PPT values increased at baseline to
1 week (0.2%), increased at 1 to 3 weeks (29.2%),
and decreased at 3 to 6 weeks (−30%), respectively.
The left-side PPT values increased at baseline to 1
week (14%), decreased at 1 to 3 weeks (−20%), and
increased at 3 to 6 weeks (25.4%), respectively. The
mean PPT values increased at baseline to 1 week (7%),
decreased at 1 to 3 weeks (−14%), and increased at 3
to 6 weeks (18%), respectively. Significant differences
in right- and left-side PPT values were found between
the baseline and 1 week (F = 6.852; p = 0.02), 1 and
3 weeks (F = 7.355; p = 0.01), and 3 and 6 weeks
(F = 8.650; p = 0.01).
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3.1.1. VAS
The right-side VAS scores decreased at baseline to
1 week (−4.7%), increased at 1 to 3 weeks (1.6%),
and decreased at 3 to 6 weeks (−31.9%) (Fig. 3). The
left-side VAS scores increased at baseline to 1 week
(12.4%), increased at 1 to 3 weeks (5.6%), and decreased at 3 to 6 weeks (−37.2%). The mean VAS
values increased at baseline to 1 week (3.4%), increased at 1 to 3 weeks (3.7%), and decreased at 3
to 6 weeks (−34.6%), respectively. Right- and leftside VAS values significantly differed between 3 and
6 weeks (F = 9.050; p = 0.03). However, no significant differences were found between the periods from
baseline to 1 week and from 1 to 3 weeks.
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3.2.2. ASLR test
The right-side ASLR test results decreased at baseline to 1 week (−1.6%), increased at 1 to 3 weeks
(2.6%), and increased at 3 to 6 weeks (7%), respectively (Fig. 3). The left-side ASLR test results decreased at baseline to 1 week (−6.9%), increased at 1
to 3 weeks (4%), and increased at 3 to 6 weeks (7.1%),
respectively. The mean ASLR test results decreased at
baseline to 1 week (−4%), increased at 1 to 3 weeks
(3%), and increased at 3 to 6 weeks (7%), respectively.
Significant differences in right- and left-side ASLR test
results were found between the baseline and 1 week
(F = 7.352; p = 0.02), 1 and 3 weeks (F = 11.685;
p = 0.01), and 3 and 6 weeks (F = 8.257; p = 0.011).
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3.2. Physical function
3.2.1. Range of motion
The lumbar flexion ROM decreased at baseline to
1 week (−15%), decreased at 1 to 3 weeks (−1%), and
increased at 3 to 6 weeks (7.1%), respectively (Fig. 3).
The lumbar extension ROM increased at baseline to 1
week (11%), increased at 1 to 3 weeks (27.01%), and
increased at 3 to 6 weeks (41%), respectively. Significant differences in lumbar flexion and extension ROM
were observed between 3 and 6 weeks (F = 4.253;
p = 0.048). However, no significant differences were
found between the baseline and 1 week.
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3.2.4. Oswestry disability index
The ODIs decreased at baseline to 1 week (−32.3%),
increased at 1 to 3 weeks (16%), and decreased at 3
to 6 weeks (−35.2%), respectively (Fig. 3). Significant
differences in ODI were found between from baseline
to 1 week (F = 6.532; p = 0.025), and from 3 to
6 weeks (F = 12.425; p = 0.002).
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4. Discussion
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In our present study, we found that MTrP therapy
with an inflatable ball improved pain and physical
function in the elderly with CNSLBP after 6 weeks
of intervention. We targeted MTrPs in the self-release
therapy by direct stimulation using an inflatable ball
for the elderly with CNSLBP. No significant pain or
physical function was observed after 6 weeks as compared with the baseline. However, pain and physical
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5. Conclusion
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MTrP therapy with an inflatable ball was effective
in reducing pain and improving functionality in the elderly with CNSLBP. The present study was meaningful constraint on self-release therapy of MTrPs of elderly with CNSLBP by instruction of physical therapist. Further studies are required to investigate the applications of MTrP therapy in elderly patients with pain
in other areas of the body.
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Acknowledgments
The authors would like to thank all the participants
for their cooperation and assistance in the study.
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A limitation of the present study was the one-way
repeated-measures design of the quasi experiment that
did not include a control group. To complement this,
we planned a one-way repeated-measures design [37].
Further study is needed to compare between groups
with a larger number of participants.
Conflict of interest
The authors declare no conflict of interest related to
this work.
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function had improved at 1 and 3 weeks of intervention, but the differences were not significant.
Back pain on both sides was moderate. Pain was
evaluated by using the VAS for subjective analysis
of pressure on MTrPs and PPT for objective analysis [28,29]. The VAS pain score for both sides decreased at 1 week and that for the right side decreased
until 3 weeks. However, these decreases were not significant. PPT increased at 1 week and further decreased
at 3 weeks. However, no significant differences were
observed between 1 and 3 weeks. However, the PPT on
both sides significantly increased at 6 weeks.
The SLR results were somewhat normal range in
baseline. But, the SLR results for both sides were unchanged until 1 week but showed an increasing trend
at 3 and 6 weeks. A similar trend was observed for
both ASLR and PSLR results [30,31]. This means
that MTrP therapy related directly with the lumbar
and sacral joints [32–34]. In addition, lumbar flexion ROM and lumbar extension ROM significantly increased in 6 weeks. Especially lumbar extension ROM
significantly increased from 3 weeks. ODI significant
increased at 1 and 6 weeks. The lumbar extension
ROM significantly increased from 3 weeks. The ODI
also significantly increased at 1 and 6 weeks; it also
increased at 3 weeks but was not significant. However, the overall relaxation of the muscles can improve
movements with ROMs and back pain. We think that
muscle spasms may decrease from the relaxation of the
MTrPs and normalization of the movements related to
disability. As a result, disability was a good effect on
disability. Overall, physical functions such as ASLR
and PSLR significantly improved from 3 weeks. Consequently, we found that physical function improved
earlier than pain.
Based on our results, pain significantly improved at
6 weeks in terms of VAS score and PPT. However,
physical function was most significantly improved
from 3 weeks. The results also indicated that physical function improved earlier than pain. The common
belief is that physical function is improved according
to pain reduction [35,36]. However, the present study
shows that physical function improved before the gradual reduction in pain. We think that this was caused by
the release of muscle spasm and ligament through the
application of direct pressure on the trigger points by
using the inflatable ball. This might have led to the earlier improvement in functional restrictions. We think
that according to pain severity, secondly dysfunction
aspect can be occurs pre-problem of physical function
and post-problem of pain.
rre
333
co
332
7
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S. Oh et al. / Effect of myofascial trigger point therapy with an inflatable ball in elderlies with CNSLBP
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