Using hardware myofascial release, longitudinal traction with thermal influence in patients with dorsal pain, caused by spine degenerative diseases

Objective. To investigate the effectiveness of the application of hardware myofascial release with thermal influence and longi - tudinal traction in patients with dorsal pain, caused by spine degenerative diseases. Methods. A prospective study of the results of treatment of 297 patients with dorsal pain, caused by spine degenerative diseases. All patients were divided into 3 groups: D (158) — dorsal pain; DIK (31) — dorsal pain with irradiation in the lower limb; DIS (108) — dorsal pain with irradiation in the buttock. The comparison group consisted of 43 volunteer athletes. With the help of the Nuga Best N5 device, all participants underwent a course of treatment (10 sessions within two weeks, thermal influence — 45‒60 °C, depending on the comfort of the pa - tient). Before and after treatment, patients were examined according to the visual analog scale (VAS), the Oswestry questionnaire, volunteers — according to the Oswestry scale. Statistical analysis was performed. The results. In patients of group D, after treat-ment, the Josw index decreased from 37.1 (24; 51) % to 9.1 (2; 14) % (QV, p < 0.01), VAS — from 29.6 (20; 40

According to a number of authors, dorsalgia occurs in the majority of the population of Europe and the USA, with a constant increase in manifestations in young people [3,5,6]. This trend has also been observed in Asian countries [7].
Chronic dorsalgia is caused by degenerative changes in the lumbar spine and the muscles stabilizing it. In addition, degenerative changes in these muscles can predict the course of degenerative diseases of the spine [8,9]. It has been established that many parameters of spine-pelvic balance are inextricably linked with degenerative changes in muscles and ligaments, back stabilizers, and the vertical position of the trunk [10]. Excess weight increases the risk of dorsalgia, as well as degenerative changes in the spine [5].
Development of dorsalgia affects other pathological conditions, such as depression, anxiety and sleep disorders [11,12].
Dorsalgias are inextricably linked with degenerative changes in such structures of the vertebral column as the intervertebral disc, arcuate joints, fascia and ligaments of the muscles of the stabilizers of the spine and the vertical position of the body, sacroiliac joints, their ligaments, nerve roots and muscles [13][14][15].
Some authors have concluded that physical exercises and loads are sufficient prevention of back pain. Studies prove that among individuals with regular intense loads, the number of cases with back pain decreases. Moreover, if physically fit people injure their back, they return to normal life much faster [12,16]. However, the question still arises as to why back pain develops even in people who regularly exercise. One of the possible answers to this question is the socalled «cumulative trauma» theory. It suggests that repeated compressive loads on the spine or caused by certain body positions (such as when driving a car) significantly affect the intervertebral discs and joints. They develop degenerative changes that cause back pain [17].
In the classification developed by the specialists of the State Institution Professor M. I. Sytenko Institute of Spine and Joint Pathology of the National Academy of Medical Sciences of Ukraine [18], pathological changes of the spine are considered in the unity and biomechanical connection of all constituent components. According to this classification, diseases of the spine are divided into degenerative, dysplastic, neoplastic and inflammatory ones. In turn, degenerative diseases of the spine are divided into degenerative diseases of the anterior and posterior support complexes of the spinal motor segment; total degeneration of the spinal motor segment, including the formation of spinal deformities.
Degeneration of intervertebral discs includes structural and functional changes. The first changes (fissures of the fibrous ring, protrusions and hernias of the intervertebral disc) cause a decrease in the height of the intervertebral disc, the development of uncovertebral costo-spinal arthrosis. Functional changes include blockade of the spinal motor segment, instability leading to spondyloarthrosis, degeneration of ligaments and muscles. Structural and functional disorders cause total degeneration and deformation of the spinal motor segment.
Specialists in restorative treatment use various technologies for the treatment of dorsalgia secondary to degenerative diseases of the spine, namely manual therapy, traction treatment, myofascial release, heat exposure, physical therapy, massage, insrumental physical therapy. The optimal combination of different impacts (myofascial release with thermal influence and longitudinal traction) has been successfully implemented in the personal low-frequency combined thermal stimulator Nuga Best N5. Such devices can be used at home.
The purpose of the study: to investigate the effectiveness of the application of instrumental myofascial release with thermal influence and longitudinal traction in patients with dorsalgia caused by degenerative diseases of the spine.

Material and methods
The study materials were discussed and ap- Characteristics of patients A prospective study of the results of treatment of 297 patients with dorsalgia caused by degenerative diseases of the spine was conducted from August to December 2021. The comparison group (B) included 43 volunteer athletes. With the help of the Nuga Best N5 device, both groups underwent a course of instrumental treatment (10 sessions over two weeks). Heat exposure was 45-60 °C, depending on the patient's comfort.
Patients were divided into 3 groups: -with dorsalgia (group D) -158 patients; the effect of instrumental myofascial release with heat and longitudinal traction was aimed at m. erector spinae, m. longissimus dorsi, m. ileocostalis and places of attachment of these muscles; -with dorsalgia and radiation in the lower limb (DRL) -31 patients; the impact was directed not only at m. erector spinae, m. longissimus dorsi, m. ileocostalis, m. quadratus lumborum and their attachment sites, but also at ligaments and muscles stabilizers of the sacroiliac joints and the vertical position of the trunk (lig. Aggravation of dorsalgia was observed in some patient of DRL and DRB groups after the first sessions. They had the intensity of myofascial release reduced or took a break for a day.
In volunteers, the effect of instrumental myofascial release with heat and longitudinal traction was aimed at m. erector spinae, m. longissimus dorsi, m. ileocostalis m. quadratus lumborum and places of attachment of these muscles.

Evaluation of results
All patients before and after treatment were examined according to the visual analog scale (VAS), the Oswestry questionnaire (Table 1) [19]. Athlete volunteers were interviewed according to the Oswestry scale. JOSW before and after treatment was calculated according to formula 1 and JREC according to formula 2.
Statistical analysis of the study results was carried out using non-parametric statistics methods in the STATISTICA software environment. For the analysis of related samples, the Wilcoxon test (WT) was used, for unrelated samples, the Mann-Whitney (MWT) test was used. In the text, indicators are given as M (LQ; UQ), where M is the median, LQ is the lower quartile, and UQ is the upper quartile.

Results and their discussion
The characteristics of all indicators of the study groups are given in Table 2. Statistically significant gender differences in the analyzed indicators were not found in any of the groups; therefore, the analysis was not conducted by gender.
In group D there were 80 women (50.6 %) and 78 men (49.4 %) aged 30 to 73 years with a median of 57 years. Before treatment, their presenting symptom was pain in the cervical, thoracic and lumbar regions of the spine, limited rotational movements in the back. After the treatment, patients noted a significant decrease in pain intensity and restoration of the usual range of motion. Statistically significant time course was observed according to Josw and VAS indicators (Fig. 1).
There were 26 women (83.9 %) and 5 men (16.1 %) aged 32 to 70 years with a median age of 51 years in the DRL group with statistically significant time course of Josw and VAS indicators (Fig. 2). Before treatment, patients had dorsalgia, lumbar pain that could radiate to the buttock and thigh on one side, limited movements of the lumbar spine in the sagittal and frontal planes. After the treatment, patients noted a significant decrease in the intensity of pain, restoration of normal mobility of the lumbar spine. As the box graphs (Fig. 2) show, a decrease in the Josw index of the DRL group was found from the level of 24.7 (12; 34) to 7.3 (2; 13) % (WT, p < 0.01), the VAS index decreased from 41.9 (20; 60) to 14.7 (10; 20) mm (WT, p < 0.01).
By gender, there were 71 women (65.7 %) and 37 men (34.3 %) aged 22 to 74 years with a median age of 56 years in the DRB group. Before treatment, patients had dorsalgia, lumbar pain that could radiate to the buttock on one or both sides, limited movements of the lumbar spine in the sagittal and frontal planes. After the treatment, patients noted a significant Scores J OSW = × 100 % , (1) 45 (50) J OSW before treat. -J OSW after treat. J REC = × 100 % .

Sector 8. Sexual activities (optionally)
Regular and does not cause pain 0 Regular, but makes the pain worse 1 Almost regular, but very painful 2 Very limited due to pain 3 Almost absent due to pain 4 Completely absent due to pain 5

Sector 9. Social activities (playing sports, attending meetings and other events)
Normal and does not make the pain worse 0 Regular, but makes the pain worse 1 The pain does not significantly affect my social life except for more active interests (e. g. sports) 2 Because of the pain, I cannot engage in social activities and therefore do not often leave the house 3 Pain limits my social activities outside the apartment (house) 4 Because of the pain, I do not engage in social activities 5

Sector 10. Travel
I can travel anywhere without making the pain worse 0 I can travel anywhere, but it makes the pain worse 1 Due to pain, I cannot make trips longer than: -2 hours 2 -1 hours 3 -30 min 4 The pain prevents me from going anywhere except for treatment 5 Sector 11. Have you received any treatment for back and/ or leg pain (pills, medication, etc.)?
As a result of the comparison of the groups, no significant differences were found in the VAS index in patients of groups D and DRB after treatment from the indicators of the group of volunteers at the beginning of treatment.

Discussion
In all patients with dorsalgia, the effect of myofascial release with heat and longitudinal traction was aimed at treating pain caused by tendopathy of ligaments and muscles. The task of complex action by physical factors for dorsalgia caused by degenerative diseases of the spine includes the gradual unloading of the ligaments and muscles of the stabilizers of the sacroiliac joints and the vertical position  of the body with the help of myofascial release, heat, longitudinal traction, reducing the tension of the interspinous, supraspinous, posterior sacroiliac, iliolumbar ligaments, iliotibial tract. This leads to the restoration of the bearing capacity of the sacroiliac joints and the spine. As a result of stretching, the inter-articular spaces of the arcuate joints of all parts of the spine expand.
In such a situation, in some cases, it is possible to eliminate the dislocation of the articular surfaces of the intervertebral joints and the functional blocks of the spinal motor segments. As a result, the degree of microtraumatization of the ligaments and capsules of the arcuate joints will decrease, muscle hypertonus and irritation of vascular and neural structures will reflexively decrease, respectively, the pain caused by tendopathy of the ligaments and muscles of the stabilizers In an experiment on 51 rats, the effect of deep massage on the injured medial collateral ligaments of the knee joints was investigated. Deep massage was used for one of the injured ligaments during the week after the injury, three times a week, lasting 1 minute. The ligament of the contralateral limb served as a control and healed independently. As a result, it was established that the effect of massage increased the strength limit of the ligament by 43.1 % (р < 0.05), rigidity by 39.7 % (р < 0.01), energy absorption under rupture conditions by 57.1 % (p < 0.05) compared to the control. The treated ligaments, according to the results of histological examination, contained more bundles of collagen fibers, clearly oriented along the lines of application of the load, than in the control [20]. Vascular expansion around the ligaments, as well as an increase in microvascularization in the ligament area of the knee joint, including an increase in the number of blood vessels, were detected in those areas where massage was applied. These changes persisted for one week after the last massage procedure [21].
Mechanical loads have a huge impact on the activity of fibroblasts and the orientation of collagen fibers. After overstrain or injury, the musculo-ligamentous apparatus must form new collagen fibers for recovery. At the same time, if the patient is in a position of immobilization (i.e. at rest), collagen fibers acquire a chaotic orientation. This will cause limited movement and increased recovery time. And only early movements will make it possible to form the correct orientation of collagen fibers along the functional line of force application.
It has been demonstrated that when the temperature of a body part is increased above 40°С, the threedimensional structure of hyaluronic acid chains is progressively destroyed due to inter-and intramolecular water bridges (van der Waals hydrophobic forces). This reduces its viscosity in the connective tissue that is present in the deep fascia of the muscles. This effect is directly reflected in movements, in particular, morning stiffness can be easily eliminated with the help of a warm shower [22].
Under the influence of gradual stretching of the spine, redressing of muscles, fascia, ligaments and joint capsules, some patients immediately experience muscle relaxant and analgesic effects. In other cases, pain may return 3-4 hours after the procedure, but subsequently regress.
In his report at the Fifth International Fascia Research Congress (5 th International Fascia Research Congress, Berlin, 2018), Professor Willard F. H. noted that in 70 % of all cases of dorsalgia, the pain is generated by ligaments, fascia and muscles. Hernias and disc protrusions cause dorsalgia in only 4 % of cases, osteoporosis in 4 %, osteoarthritis in 10 % [23]. On the basis of the given data, it is possible to recommend the treatment of dorsalgia caused by tendopathy of ligaments, fascia and muscle disorders with the help of hardware myofascial release with heat and longitudinal traction in the case of degenerative diseases of the spine and for their prevention.

Conclusions
The use of instrumental myofascial release with heat and longitudinal traction significantly reduces pain caused by tendopathies and structural and functional disorders in muscles, improves the quality of life of patients with dorsalgia caused by degenerative diseases of the spine.
In practically healthy people, instrumental myofascial release with heat and longitudinal traction can be used to restore work capacity, treat muscle pain and muscle balance after physical exertion, including at home.