INTRODUCTION:

Non-Specific low back pain is a common health problem worldwide. In the age group of 25 to 45 year, nearly 60% to 80% populations are affected⁽¹⁾. Non-Specific low back pain is defined as low back pain due to a unrecognizable, known specific pathology, e.g.: infection, tumor, osteoporosis fracture, structural deformity, inflammation disorder radicular syndrome or cauda equinae syndrome. Most of the people will experience back pain at some point in their life. The prevalence of non- specific low back pain reported to be as high as 84%. The prevalence of chronic low back pain is above 23% with 11-12% of the population being disabled by low back pain⁽²⁾. Soft tissues around the spine also play a key role in low back pain. There is a large, complex group of muscles that works together to support the spine, in order to hold the body upright and allow the trunk of the body to move, twist and bend in many directions.

Laser has too low intensities and produce heating effect. Laser radiation is monochromatic in nature. Laser has the ability to alter the cellular function, has effect on tissues in the manner dependent on the wave length and coherence of light. The experimental evidence suggest that laser radiation enhances peripheral neural blockage, suppresses central synapatic activity and modulates neurotransmitters, which therefore reduce muscle spasm and interstitial oedema and produces an anti-inflammatory effect⁽⁹⁾. Laser therapy has a temperature not more than a few degrees. Ozdemir F (2001) concluded that Laser has a potential to reduce inflammation, pain and improve function⁽⁶⁾. Low level laser therapy significantly increases microcirculation, activates angiogenesis and stimulates immunological processes.

EMG Biofeedback promotes relaxation, which can help relieve a number of conditions that are related to stress. Biofeedback is a non-invasive procedure and does not involve the use of medication. Compared to other forms of treatment there is no side effect, and the skills learnt can be used to prevent symptoms rather than simply treating the patients. Biofeedback method control muscle tension, skin temperature, heart rate.The Idea behind biofeedback is that, by harnessing the power of patient mind and becoming aware of what going on inside the patient body, patient can gain more control about their health. The duration of treatment associated with biofeedback is limited to the time it takes patients to successfully learn self-regulation⁽¹²⁾. Richardson CA core stabilization exercise enhances neuromuscular co-ordination as it re-train muscles around the lumbar spine ⁽²⁾. Strengthening exercise includes abdominal curl ups, bridging on sides, and quadruped position with alternate arm/leg raises and pelvic bridging which has shown good results in activating the Paraspinal muscles because it control the neural spine⁽³⁾⁽⁸⁾.

The Oswestry Disability index is considered as the gold standard for measuring degree of disability and estimating quality of life in person with low back pain. Jeremy Fairbank et al in 1980 first published this questionnaire. The current version was published in the (2000). The visual analogue scale (VAS) is measurement instrument measures the characteristic or attitude that is believed to range across a continuum of value and cannot easily be directly measure it often used in epidemiologic and clinical research measure the intensity or frequency of various symptom.

PROCEDURE:

This experimental study was presented before the ethical committee and after obtaining the clearance from the Institutional Review board of ACS Medical college and Hopital, 30 patients who reported to outpatient Physiotherapy department ACS Medical College and Hospital were randomly grouped into Group-A, Group-B based on inclusion criteria and exclusion criteria. A detailed demography data, past medical history were collected from the patient. After detailed explanation about the treatment procedure, an informed consent was obtained. The outcome measures, VAS, ODQ was recorded before and after the treatment as pre and post test score.

Laser will be given for 15 minutes, patient will receive in scanning method, with 4 joules/sqr.cm, length of the area 5cm, width of area 4cm, depth of area 3cm, at lower back region, Anti-inflammation: laser therapy reduce inflammation with vasodilation, activation of the lymphatic drainage system, and reduction of pro-inflammation mediators. As a result, inflammation, erythema, bruising, and edema are reduced.

The EMG Biofeedback training, visual and auditory feedbacks were provided to stimulate their correct performance in addition to positive verbal reinforcement which was provided by the investigator to encourage learning muscle contraction during exercise Machines utilize surface electrodes which detect small voltage changes which arise from the working muscles. Core stability exercise are Quadruped Opposite arm/leg, Prayer, Cat andCamel, Abdominal Draw in with Double Knee to Chest, Supine Butt Lift with Arms across Chest, Superman’s exercise.

Pre-test measurements were recorded using VAS for the pain subjectively before initiation of 1^st session of treatment protocol and post-test values were measured at the end of 4^th week (24^th session) for both the groups respectively Oswestry Disability Index was measured before initiation of 1^st session of treatment protocol and post-test values were measured at the end of 4^th week (24^th session) for both the groups respectively.

· GROUP-A: Consists of 15 subjects and they received Laser, core stability exercises.

· GROUP-B: consists of 15 subjects and they received Laser, EMG Biofeedback and assisted Core stability exercise

DATA ANALYSIS:

The collected data was tabulated and analyzed using inferential mean and standard deviation were used to assess all the parameters. Paired t-test and independent t-test was adopted. Paired t-test was used to find out the significant different in improvement between pre and post treatment values for visual analogue scale (VAS), oswestry disability index (ODI) within the group. The patient independent t-test is used to compare the between the Group A and Group B

Table -1 Comparison between of pre test and post test value of visual analoguescale and oswestry disability index within the group- a

Group A	Pre test		Post test		t-test	Significance
Group A	Mean	SD	Mean	SD	t-test	Significance
VAS	5.33	0.81	4.33	0.97	10.24	.000
ODI	28.40	5.35	20.33	2.38	5.75	.000

VAS-visual analogue scale, ODI- oswestry disability index

(***p<0.001)

The above table reveals the mean, standard deviation (SD) t-value, and p-value of the visual analogue scale and oswestry disability index between pre-test and post-test within group-A (control group) Who received Laser and core stability exercise. In the visual analogue scale score, there is a significant difference between the pre-test mean value (5.33) and post-test mean values (4.33) (p***<0.001). In the oswestry disability index, there is a significant difference between the pre-test mean value (28.40) and post-test mean value (20.33) (p***<0.001). this table shows the significant difference in visual analogue scale, oswestry disability scale between pre-test and post-test weeks (***p<0.001)

Table-2 Comparison between pre-test and post-test value of visual analogue scale and Oswestry disability index with in the group- B

Group A	Pre test		Post test		t-test	Significance
Group A	Mean	SD	Mean	SD	t-test	Significance
VAS	5.53	0.83	2.27	0.45	15.83	.000
ODI	28.33	4.86	15.60	3.71	15.12	.000

VAS-Visual analogue scale, oswestry disability index scale

(***p<0.001)

The above table reveals the mean, standard deviation (SD) t-value, and p-value of the visual analogue scale and oswestry disability index between pre-test and post-test within Group-B (experimental group) Who received Laser, EMG Biofeedback and assisted core stability exercise. In the visual analogue scale score, there is a significant difference between the pre-test mean value (5.33) and post-test mean values (2.27) (p***<0.001). In the oswestry disability index, there is a significant difference between the pre-test and mean value (28.33) and post-test mean value (15.12) (p***<0.001). this table shows the significant difference in visual analogue scale, oswestry disability scale between pre-test and post-test value (***p<0.001)

Table-3 Comparison ofvisual analogue scale between Group- A and Group-B in pre and post test

Visual analogue scale	*Group-A		*Group-B		t-test	Significance
Visual analogue scale	Mean	SD	Mean	SD	t-test	Significance
pre test	5.33	0.81	5.53	0.83	6.64	.512
post test	4.33	0.97	2.27	0.45	7.42	.000

The above table reveals the mean, standard deviation (SD) t-value, and p-value of the visual analogue scale between (Group-A) and (Group-B) pre-test and post-test. This table shows that there is less significant difference between the pre-test values of visual analogue scale between Group-A (5.33) and Group B (5.53). This table also shows that there is statistically significant difference in post-test value of the visual analogue scale between Group-A and Group B. Both the Groups shows significant decrease in post-test mean value but Group B (2.27). Showed more different than Group-A (4.33).

Table-4 Comparison of oswestry disability index between group- A and group-B in pre and post test

ODQ	Group-A		*Group-B		t-test	Significance
ODQ	Mean	SD	Mean	SD	t-test	Significance
pre test	28.40	5.35	28.33	4.86	0.36	.972
post test	20.33	2.38	15.60	3.71	4.15	.000

The above table reveals the mean, standard deviation (SD) t-value, and p-value of the oswestry disability index between (Group-A) and (Group-B) within pre-test and post-test. This table shows that the there is no significant difference between the pre-test value of visual analogue scale between Group A and Group B (28.33). This table also show that there is statistically significant difference in post-test value of the visual analogue scale between Group A (20.33) and Group B (15.60). But group B (15.60) showed marked difference than group-A (28.40)

RESULT:

On comparing the post-test mean value of group A and Group B on visual analogue scale, Group B (2.27) shows significant reduction in post-test mean value than Group A (4.33) with p>0.00. On comparing the post-test mean value of Group A and Group B on Oswestry disability index, Group A(20.33) shows significant increase in the post-test mean value an group B (15.60) with p>0.00. Between Group analysis using independent “t” test p.0.05 showed significant difference between Group A and Group B. Hence Null hypothesis is rejected

DISCUSSION:

This study evaluated the effects of compare the effectiveness of Laser, EMG Biofeedback and Assisted Core stability exercise versus Laser and Core stability exercise alone on pain and disability in patients with Non-specific Low Back Pain. The result of these study period showed a strong evidence that Laser with EMG Biofeedback and Assisted Core stability exercise, should marked reduction in pain and Oswestry Disability Index (ODI). The result of the study was statistically significant as the descriptive data’s such as mean and standard deviation which indicated that improvement in terms of pain and disability at the end of the treatment session in both the Groups. Comparing the result obtained from the two Groups, the result of the study showed that Laser, EMB Biofeedback and Assisted Core stability exercise showed significant (p<0.00) improvement than Laser and Core stability exercise.

This result supported by Gurkirat Kaur et al June (2016), who concluded that EMG Biofeedback, Assisted Core stability exercise are helpful for treating patient with low back pain, as well as disability. The pre-test mean value of Visual Analogue Scale (VAS) between Group-A (5.33) and Group-B (5.53) does not showed a significant difference. However the post-test mean value showed a significant difference between Group-A (4.33) and Group-B (2.17). The pre-test mean value of Oswestry Disability Index between Group-A (28.40) and Group-B (28.33) does not showed a significant difference. At the end of the treatment session the post-test mean value of Oswestry Disability Index between Group-A (20.33) and Group-B (15.60) showed a significant difference. Group-B patient were treated with Laser, EMG Biofeedback Assisted core stability exercise showed better recovery than Group-A.

Moritiani and Deuries (1979) hypothesized that use of biofeedback in recognition of facilitation pattern is responsible for increasing the work of motor neuron that helps in improving strength and endurance. Radebold A (2000) stated that to maintain stability of lumbar spine, muscle recruitment and timing plays an important role. So in Group-B exercise emphasizing on EMG Biofeedback assisted lumbar multifidus contraction where preferred which proved to yield better results as compared to Group-A^(5)(11). Group-B showed that EMG Biofeedback along with Assisted Core stability exercise decrease the level of pain and strengthen the back muscles thus reducing the disability percentage⁽⁴⁾. Anti-inflammation: laser therapy reduces inflammation with vasodilation, activation of the lymphatic drainage system, and reduction of pro-inflammation mediators. As a result, inflammation, erythema, bruising, and edema are reduced. Analgesic effect: laser therapy produces a suppression of nociceptors, an increase of stimulation threshold, and as increase release of tissue endorphins. The result is a decreased patient perception of pain. Trigger point and acupuncture point: laser therapy stimulates muscle trigger and acupuncture point without mechanical invasion to provide musculoskeletal pain relief. Reduced fibrous tissue formation: laser therapy reduces formation of scar tissue. Improved nerve function: slow recovery of nerve functions in damage tissue results in numbness and impairment limbs. Laser therapy accelerates nerve cell regeneration. Immunoregulation: therapy laser photons have an effect on immunoglobins and lymphocytes.

Laser light stimulated fibroblast development. Collage is the essential protein required to replace old tissue or to repair tissue injuries. As a result, laser therapy is effective on open wounds and burns. The clinical improvement in the present study was evaluated by Visual Analogue Scale and Oswestry Disability Index scale. The present study indicates that the combined use of Laser, EMG Biofeedback Assisted Core stability exercise has shown a positive effect in relieving pain and disability. Physical therapist utilize a wide range of infatuation in the management of low back pain, however the effectiveness for these intervention is limited.⁽⁷⁾

CONCLUSION:

The present study concluded that 4-weeks treatment program using LASER, EMG Biofeedback assisted core stability exercise in subjects with pain and disability with non-specific low back pain showed better improvement than Laser and Core stability exercise.

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Received on 26.06.2019 Modified on 28.09.2019

Research J. Pharm. and Tech 2020; 13(6):2563-2566.

DOI: 10.5958/0974-360X.2020.00456.4