STATE OF ART
PETSCH, Claudia Daniela da Silva Simon. FRIAS, Rondineli dos Santos. SOUZA, Isabel Fernandes de. Evidence of therapies applied to pain control in elderly people with low back pain, in the last five years. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 11, Vol. 15, pp. 138-151. November 2020. ISSN: 2448-0959, Access Link: https://www.nucleodoconhecimento.com.br/education-physics-en/low-back-pain
Pain in the lumbar region is seen as debilitating globally, as it affects a large part of the population, because it is directly related to aging. Low back pain is identified, at the moment a pain arises in the region under the costal margin and on the gluteal folds, causing beyond pain, other discomforts that can often come accompanied by stiffening and impossibility to move. This study aimed to identify the evidence of therapies applied in the control of low back pain in the elderly in the last five-year period. According to the results, it was found that kinesiotherapy is still the most appropriate method for the treatment of low back pain in the elderly.
Keywords: low back pain, elderly, pain, physiotherapy, therapy.
Pain in the lumbar region is seen as debilitating globally, as it affects a large part of the population, because it is directly related to aging (HARTVIGSEN, 2018). What leads her to lead among the dysfunctions, which cause the most musculoskeletal disabilities in this age group (SIMON, 2018; COYLE, 2016).
Low back pain is identified, when pain arises in the region under the costal margin and on the gluteal folds, causing other discomforts that can often be accompanied by stiffening and impossibility to move (SILVA, 2014; AGUIAR , 2016).
Low back pain can be characterized in three forms according to the duration period. Pain conditions, which appear suddenly and last approximately six weeks, are acute low back pain, since those that exceed the 12-week period are subacute and finally those that exceed this time are diagnosed as chronic low back pain (SILVA, 2014; MENEZES, 2019).
There are several factors that can contribute to the emergence of low back pain, among them we find psychosocial causes, physical inactivity, weight gain, emotional problems such as depression, poor posture adopted during working hours, smoking the option for a more urban lifestyle (SILVA, 2015). And in other circumstances, due to degenerative problems of intervertebral discs (CARGNIN, 2019).
The physical therapy treatment for low back pain, aims to reduce or eliminate discomfort and pain, returning well-being, in order to allow, as soon as possible, the resumption of the functions that the individual performs in his day to day (ALVARES, 2007).
To treat watery and sub-watery low back pain, rest and changes in daily living activity (DLAT) are initially recommended, which present factors that may further aggravate the clinical picture (BONETTI, 2018).
Therapies with drug implementation, physical therapy treatment, and patient awareness are the basis for the therapeutic method in low back pain (HELFENSTEIN, 2010).
Moreover, in cases that are identified as chronic, drugs such as muscle relaxers, antidepressants, opioids are always used for pain relief, drugs such as muscle relaxers, antidepressants, opioids always in conjunction with physiotherapeutic follow-up. Kinesiotherapy is an initial option, with the application of static stretching (PUPPIN, 2011). This list also includes manual therapy, electrotherapy, cryotherapy, thermotherapy, ultrasound and others (BONETTI, 2018).
It is observed that numerous techniques are used in the treatment of chronic low back pain in elderly patients, however, the effectiveness of therapeutic practices are not yet absolutely consolidated, since many factors can influence the results of each treatment method, so we have not clearly defined which techniques or strategies may be more effective in relieving the symptoms of low back pain (LIZIER , 2012).
Thus, the objective of the integrative review was to verify among the physiotherapeutic techniques applied in the last five-year period, which presented the most satisfactory result in the relief of low back pain in the elderly. Thus, this work may favor the professional when deciding the best strategy to be initially applied in reducing the pain presented by the patient.
MATERIAL AND METHOD
The integrative review is a method that aims to condense results acquired, through published research, on a given study in question, providing more detailed and comprehensive information on the subject.
This study carried out through the search in lilacs, pubmed and scielo databases presents scientific studies published in the last five-year period, focusing on low back pain in the elderly, aiming to identify the evidence of therapies applied in pain control.
For this research, the following descriptors were used: low back pain, physiotherapy, therapy, treatment, elderly person, aged, old, elderly and geronte, together with boolean operators and and or who were arranged in a structured spreadsheet, designed purely for the current study, as a tool for information collection.
Table 1 – System search results.
|Database||Terms used for searches that had satisfactory results||Found||Deleted||Used||Full reading of selected articles|
||low back pain OR
AND physiotherapy OR therapy OR treatment AND elderly person OR elderly OR third age OR geronte
|Pubmed||low back pain AND Physiotherapy AND aged OR old OR elderly||138||128||10||6|
|Scielo||low back pain OR physiotherapy OR therapy OR therapy OR treatment AND elderly person OR elderly OR third age OR geronte||10||10||0||0|
Source: elaborated by the author of the research herself.
For the development of the present study, we included all articles available in English and Portuguese, which correlated data on therapies in the control of low back pain in the elderly. This is regardless of the concept of low back pain established by the authors and their data collection instruments.
Inclusion criteria include: sample selected according to age 60 years or more, publications referring to the last five-year period 2015 to 2019; randomized controlled trial; clinical trial; quantitative research; and free full text.
It was adopted as exclusion criteria, review articles, publications that did not explore the theme of the study referring to physical therapy techniques applied in the elderly for low back pain relieve, studies with absence of relevant information, such as the age of the sample or that explore other areas of the body, articles only with individuals under the age of 60 years and paid articles.
Table 2: Flowchart databases.
After the analysis and selection of the articles, the studies were organized into sections, according to the type and design of the study. With the search strategy adopted, 228 eligible articles were identified. Of these, 222 were excluded because they did not fit the inclusion criteria. Of the total number of articles excluded, 126 studies did not explore the theme of the study regarding the physiotherapeutic techniques applied to relieve low back pain in the elderly; 17 others were absent from relevant information such as sample age; 22 had a sample of less than 60 years of age; 5 explored other areas of the body; and 3 items were paid, etc.
Among the selected studies that were eligible for this review, 3 used kinesiotherapy in order to verify pain relief in elderly with low back pain, of which 2 of these included other complementary techniques in their article with the same initial purpose.
Two other studies addressed electrostimulation, only 1 using TENS and another, application of whole body electrostimulation, plus the inclusion of exercises. And finally, a single study addressed a set of techniques for pain relief, using myofascial release, massage roller and core stabilization.
Table 3- Articles excluded and included after reading titles and abstracts.
|Article area or theme||Discarded||Article area or theme||Included|
|Evaluation, distribution and prevalence of low back pain||12||Kinesiotherapy||1|
|Triggering factors of low back pain||10||Electrostimulation (TENS)||1|
|Sarcopenia / low back pain||8||Myofascial release + massager roller + core stabilization exercises||1|
|Syndromes and other pathologies||15||Kinesiotherapy + electrostimulation||1|
|Sociodemographic profile of patients with low back pain||17||Kinesiotherapy + cognitive-behavioral therapy||1|
|Self-care program and guidance||12||Full Body Muscle Electrostimulation+ Kinesiotherapy||1|
|Functional disability, depression and low back pain||15|
|Chinese medicine and other complementary techniques||22|
|Brain electrical stimulation||4|
|Implementation of drugs||8|
|Study with only people under the age of 60||22|
Source: elaborated by the author of the research herself.
After applying the exclusion criteria, 10 articles remained. However, after a full reading, it was found that only 6 studies mentioned above were in agreement with the objective of verifying the therapeutic evidence applied in the control of pain in low back pain in the elderly in the last five-year period, besides observing which were the most relevant results in the rehabilitation of these patients. The search with the descriptors low back pain; Physiotherapy; aged; old; elderly had the highest number of articles (138 publications).
Table 4- Layout of the selected articles regarding the author, year, type of study, objective, method, results – 2015 to 2019.
|Author/Year||Type of Study||Goal||Methods|
|Kanas, et al 2018||A non-randomized clinical trial||Verify pain level, functional capacity and QOL in individuals with nonspecific chronic low back pain, after applying exercises performed at home, with different types of supervision||The sample was composed of 30 female and male people, aged 18 and 65 years, diagnosed with nonspecific chronic low back pain, who performed an exercise plan three times a week for eight weeks. Group A (N=17) performed the exercises only once supervised. Individuals in Group B (N=13) were followed up once a week.|
|Ozsoy G et al 2019||A randomized controlled, single-blind study||Evaluate the improvement after application of the myofascial release technique (TRM) with a massager roller plus core stabilization exercises (ECE) in elderly with low back pain||forty-five randomly separated individuals into two groups (CSE and CSE + MRT) participated. For the CSE group, a stabilization exercise program applied 3 times a week for 6 weeks was proposed together with the core stabilization exercises, myofascial relaxation technique with roller massager for the same period. The CSE + MRT group. The members were evaluated in terms of pain, lumbar disability, little flexibility, kinesiophobia, core stability, spine mobility, gait and quality of life before and after treatment.|
|Hicks et al 2016||A randomized preliminary trial||Verify the benefits of a trunk muscle training program + neuromuscular electrical stimulation for the rehabilitation of elderly with chronic low back pain by verifying how it could improve physical function and algia compared to a passive control intervention.||The sample consisted of patients aged 60 to 85 years allocated in two groups, one for TMT + NMES and another passive control intervention, consisting of passive treatments, i.e., with heat, ultrasound and massage application. The results were evaluated after 3 and 6 months of post-randomization included the Timed Up and Go test, gait speed, pain and functional limitation related to low back pain.|
|Simon et al 2016||Dose-response study stratified by age||The objective is to compare the effect of transcutaneous electrical nerve stimulation (TENS) in older adults with low back pain compared to younger adults.||The study included 60 individuals with axial PCDL 20 were young, 20 middle-aged and 20 elderly. All were submitted to four sessions of 20 minutes of high intensity and high frequency TENS for 2 to 3 weeks.|
|Weissenfels et al 2019||randomized controlled trial||The objective is to compare WB-EMS with already known strengthening exercises to determine the effects they generate on chronic and nonspecific low back pain||The study included 110 patients with nonspecific chronic low back pain, aged 40 to 70 years, were randomly allocated to two groups. Both completed a 12-week program dedicated to low back pain. Based on the principles of training, it uses electrical stimulation to train mainly strength and stabilization in a short time. The exercises were similar to both groups, focusing on trunk strengthening and stabilization.|
|Goode et al 2018||randomized pilot study||The study aimed to evaluate physical activity plus cognitive-behavioral therapy for pain among elderly veterans with CLBP.||The study participants were 60 elderly with DLC separated into groups one of BP intervention only by telephone of 12 weeks (BP group) or PA intervention group plus CBT-P (PA + CBT-P group) and a waiting list control group (WL group ) IN the PA intervention were included stretching, strengthening and aerobic activities; The CBT-P covered the rhythm of activity, relaxation techniques and cognitive restructuring.|
Source: elaborated by the author of the research herself.
There are many techniques currently applied in the area of physiotherapy, for the relief of low back pain in the elderly, as verified in the last five-year period. However, some procedures already known in the literature were integrated into the same study to verify which one has real efficacy.
Weissenfels, (2019) who developed a study to compare Whole Body Muscular Electrostimulation (WB-EMS) with a recognized protocol of strengthening exercises to determine the effects of analgesia on nonspecific chronic low back pain. The study had the participation of one hundred and ten patients diagnosed with nonspecific chronic low back pain, aged 40 to 70 years, which were randomly separated into two groups.
All members participated in the program for 12 weeks, and the selection of the content of the active control group was based on the principles of WB-EMS training, which uses electrical stimulation to train mainly strength and stabilization in a very short time. The exercises applied were similar in both groups, focusing on the strengthening and stabilization of the trunk. The result was considered good, since the intensity of low back pain decreased, with an increase in the muscles of the back of both groups, as well as similar alterations observed in the trunk flexors.
In the study carried out by Kanas (2018) used kinesiotherapy, in his non-randomized study, having as main objective, to evaluate functional capacity and quality of life, of 30 individuals aged between 18 and 65 years, who had a diagnosis of nonspecific chronic low back pain. Putting into practice a treatment plan, which consisted of the application of home exercises performed 3 times a week, for 8 weeks, which were accompanied by different types of supervisions.
At the end of this experiment, there was an occurrence of improvement in pain and functional capacity during the evaluation of the first and fourth week, in quality of life, a more significant improvement was obtained, only after 8 weeks of intervention. Thus, it was found that kinesiotherapy after 8 weeks of application obtained both improvement in pain and quality of life in the different types of supervision.
In the same way as Kanas; Goode (2018) used kinesiotherapy to control chronic low back pain, through a randomized pilot study, sought to evaluate the importance of physical activity, plus cognitive behavioral therapy for chronic low back pain in 60 elderly veterans for a period of 12 weeks, through telephone follow-up.
To put the study into practice, Goode suggested the application of home exercises, using a combination of physical strength and balance, stretching exercises, strengthening and aerobic activities. For cognitive behavioral, he proposed exercises that encompassed the rhythm of the activity, relaxation techniques and cognitive restructuring. The results showed that physical activity interventions with home support by telephone were viable, acceptable and safe for veteran adults. However, it was observed that there would be a need to continue the study in order to obtain information.
Like Weissenfels; Simon (2016) also used Electrotherapy in his age-stratified research, with a sample of 60 participants with chronic low back pain, of whom 20 were young and another 20 middle-aged, with the others elderly being elderly. Participants were submitted to four 20-minute sessions of high intensity and high frequency TENS over a period of 2 to 3 weeks.
It was verified that there was no significant response with this treatment, because there was no improvement in pain in any age group, during the application of the four sessions. However, it was observed that the group composed of the elderly needed greater intensities to match the response obtained by younger adults. Thus, it is perceived that, for the relief of low back pain in the elderly, it is necessary to take into account that the current parameters used in analgesia in this age group should be based on higher amplitude, but still within the tolerable, in to have a more satisfactory result in the analgesia of low back pain.
Hicks, (2016) following the same line as Weissenfelds, (2019) proposed a randomized preliminary trial in which it sought to evaluate a trunk muscle training program, together with the introduction of neuromuscular electrical stimulation for rehabilitation of elderly people who constantly suffer from chronic low back pain and also investigate preliminary whether trunk muscle training (TMT) + Neuro muscular electrostimulation (NMES) could improve physical function and pain compared to the application of a passive control intervention.
The sample consisted of patients aged 60 to 85 years, who 31 members were selected to test the TMT + NMES protocol and 33 for passive control intervention, which consisted of heat treatment, ultrasound and massage. The Timed Up and Go test, gait speed, pain and functional limitation related to low back pain were included for evaluation after 3 and 6 months.
After analyzing the results, it is noticed that both groups presented clinically important and similar reductions in pain. However, only the trunk muscle training group plus electrostimulation showed significant improvement regarding the gain of functions based on performance and the participants’ reports. In the general functional improvement requirement in the period of 6 months, the group that emerged in its results, was the one that had application of trunk muscle training and electro stimulation.
In another Ozsoy approach (2019) in a randomized, single-blind controlled study sought to evaluate through the myofascial release technique (TRM) with a massageroller combined with core stabilization exercises (ECE) the effects in the elderly with low back pain.
Forty-five elderly individuals participated in this study, randomly divided into two groups (CSE and CSE + MRT). In this analysis, a basic stabilization exercise program was applied with the participants of the CSE group for 3 days a week for 6 weeks. In the other CSE + MRT group, the myofascial relaxation technique with roller massager performed for 3 days a week for 6 weeks were added to the core stabilization exercises.
Participants were evaluated in terms of pain, lumbar disability, lower body flexibility, kinesiophobia, resistance to core stability, spinal mobility, gait characteristics and quality of life before and after treatment. It was found that the improvement in core stability resistance and spinal cord mobility (in the sagittal plane) was higher in the CSE + MRT group compared to the CSE group. There was no significant difference between the two groups in terms of pain, lumbar disability, lower body flexibility, kinesiophobia, gait characteristics and quality of life.
The studies by Weissenfelds (2019), Kanas (2018) and Simon (2016), although they present good results, may not reflect a reliable answer to the fundamental question of the present study, because the samples that comprised these studies include participants with age groups below the range researched by this study. However, we are shown possible treatment strategies that can be used for the group of elderly patients.
On the other hand, the studies by Goode (2018), Hicks (2016) and Ozsoy (2019) presented proposals that were applied to a sample exclusively composed of people over 60 years of age. The results of these studies showed that physical exercises present better results in relation to the elderly public. Although Hicks’ study was associated with kinesiotherapy and electrotherapy, focusing on muscle strengthening. It makes clear the efficiency of physical exercises, focusing on strengthening, as a treatment strategy for low back pain in elderly patients.
This research concludes, confirming that after analysis of the articles that were part of the research results, kinesiotherapy is the most appropriate method for the treatment of low back pain in the elderly.
As verified in Hicks’ study, which showed real improvement in the relief of low back pain. Considering that kinesiotherapy, when used with these individuals presents a better performance in the analgesia item, proving that the introduction of physical exercises, focused on trunk stabilization, increased muscle strength, stretching to gain flexibility and balance, present a more significant response in the improvement of pain.
Consequently it is noted that it is of great value, the implementation of other methods already existing together with these exercises, to promote the reduction of pain in the lumbar region shortening the treatment time.
Another relevant particularity verified through this review, which, there were few scientific studies, published in the last five-year period, aimed at this age group with emphasis on techniques used by physiotherapy professionals in the relief of low back pain. Thus, it is perceived, how much more directed attention is needed to this elderly public, referring to low back pain, which affects them so negatively.
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 Graduated in Physiotherapy; university center – Union of the Americas.
 Advisor. Specialization in Neurofunctional Physiotherapy. Graduation in Physiotherapy.
 Guidance counselor. PhD in Production Engineering. Master’s degree in Computing. Specialization in progress in MBA of Hybrid Education. Specialization in MBA in Active Learning Methodologies. Specialization in MBA in Learning Management. Specialization in Post Lato Sensu in Superior Teaching Computing. Degree in Computer Science.
Submitted: November, 2020.
Approved: November, 2020.