Today, there is a great emphasis on evidence-based approaches in low back pain (LBP) for public health to reduce medical costs covering back injuries. LBP is an important issue due to its high occurrence, increased treatment costs, and the effect on the quality of life in a large population throughout the lifespan [1].

LBP is defined as pain in the lower portion of the back, which is persistent for at least 12 weeks without any specific cause. It is one of the most common musculoskeletal disorders and it has been stated that over 80% population worldwide will experience a LBP episode [2]. This pathology is related to functional limitation, disability, and pain in developed countries, which is associated with serious economic impact because of received health care and work absenteeism. The health care and social costs associated with LBP have been estimated to be between $100 to $200 billion annually with a majority of these costs due to lost wages and decreased productivity [3].

Management of LBP aims to control pain, return patients to work at early stages and prevent chronic disability. Pain relief is provided by conservative treatment, drugs administration including nonsteroid anti-inflammatory drugs, thermotherapy, and electrotherapy, and functional restoration of the spine is achieved through exercise [4-6]. Manual therapy [7-9], reflex therapy [10,11], and Kinesio Taping [12-14] techniques are some of the passive treatment methods for reducing pain and improving biomechanics of the lumbar region.

As a part of the active treatment, core stabilization exercises are one of the exercise programs for chronic LBP management [15]. As core muscles work in an effective and coordinated fashion, excessive movement of the pelvis and spine during movement of the limbs is prevented, and abnormal and excessive loads can be controlled and a proper posture maintained [16,17].

One of the newly developed treatment methods is reflex therapy, which is defined as the power of the body to heal itself with the help of manual deep stroking techniques applied to specific areas of the body, especially the feet [3]. Several researchers have studied this subject and revealed conflicting results. According to some research, reflex therapy appears to offer promise as a treatment in the management of LBP [10,18,19].

Kinesio Tape application is similar to corrective and basic techniques such as application/placement of hands onto the patient. The Kinesio Taping method allows the fascia to release tension and muscles to move properly [12]. Kinesio Taping methods applied to LBP have been studied by Paoloni et al. [20] and the researchers stated that Kinesio Taping led to pain relief and lumbar muscle function normalization shortly after its application. Moreover, Castro-Sanchez et al. [13] reported that Kinesio Taping reduced disability and pain in people with chronic non-specific LBP, but these effects seemed too weak to be clinically worthwhile. On the other hand, Kim et al. [14] showed that Kinesio Taping was more efficacious than placebo in patients with a non-specific LBP.

Although there are numerous studies on LBP management, there are no studies comparing the effects of most popular treatment approaches for rehabilitation. Therefore, the aim of our study was to compare the effectiveness of four physical therapy approaches including soft tissue manual therapy, Kinesio Taping techniques, stabilization exercises, and reflex therapy for treating lumbar disc pathologies without neurological deficits.

Altogether, 90 patients (44 females, 46 males) took part in the study and their respective data were analyzed. Characteristics of participants included in each group are presented in Table 1 and were homogenous for age, body weight, body height, smoking habits, and pain duration at baseline.

Tests of within-subject contrasts indicated that a general improvement was found in the intervention groups and such improvement was increasing over time reporting statistically significant differences among the groups, for all the aforementioned outcomes, excepted for the weight and VAS. Specifically, in these variables, statistically significant differences were found only between pain at rest during the day and pain at night (P=0.007) and between results, 95% confidence interval and significance level are summarized in Table 2. The manual therapy and exercise groups showed statistically significant greater improvements in pain intensity at night and at rest compared with the other groups at weeks 4 and 8 (P<0.05). There were no statistically significant differences in pain intensity among participants in the other groups (P>0.05)

No significant differences were found between participants in all groups in terms of stabilization, strength and functionality (P>0.05) (Tables 3, 4 and Figures 6, 7).

At baseline, medical history data of all patients were collected before enrollment. All the cases were stable at baseline. No adverse events or aggravation was observed in these patients. The physiotherapist who carried out the intervention was told to complete a list of attendance at the end of each session where adverse events were collected. There was no aggravation of symptoms in the lumbar spine.

LBP is a very common seen problem in clinics. Because there is no consensus regarding the best treatment for management of LBP, other alternative treatment options need to be explored for pain relief, increase of movement, and cure of the condition. Kinesio Taping is very effective in short term for the treatment of LBP; and manual therapy and exercise are also effective treatments as shown in literature. In this study, the effects of four different treatment approaches consisting of Kinesio Taping, manual therapy and reflex therapy versus spinal exercises on the pain, disability, strength, stabilization, and functionality were investigated in the patients with chronic LBP. Based on the findings, all programs were found sufficiently effective in decreasing pain and improving strength and functional levels.

In our study, we found that all groups showed a decrease in pain at the end of treatment compared to the baseline level. Reduction in pain was the most important criterion in our research, because people refrain from moving as soon as they feel pain, which also leads them to feel bad about themselves. Decreased pain showed the effectiveness of treatment. The Kinesio Taping and reflex therapy groups showed a decrease in pain during activity and relaxation right after the treatment. This outcome resulted in an increase in their exercise tolerance. During treatment, the values for pain at night were not as high as those were for pain during activity and at rest, while these values before treatment were higher. At the second and third evaluations, we were able to see that all values for pain at night were reported as zero; and therefore, we can conclude that this was a parameter showing the fastest improvement. Pain at night causes the person to wake up several times during the night or change positions, which adversely affects the performance and psychological status during the day. All applications used in this research study, when combined with exercise, allowed patients to feel more functionally and psychologically active and led to shorter periods of returning to work compared to the other groups.

Goldby et al. [5] stated that as a component of musculoskeletal physiotherapy a spinal stabilization program was more effective than manually applied therapy in treating chronic low back disorders over time. Both manual therapy and the spinal stabilization program are significantly effective in pain reduction. Koldas et al. [4] investigated the effects of three therapeutic approaches (aerobic exercise+home exercise, physical therapy+home exercise and home exercise only) to treat chronic PBP on pain levels, spinal mobility, disability, psychological state, and aerobic capacity. Their results showed that all of the three therapeutic approaches were effective in diminishing pain and thus increasing aerobic capacity in patients with chronic LBP. However, physical therapy+home exercise were found to be more effective in reducing disability and psychological disturbances. As we investigated the functional status, our results were found to be in agreement with the literature data, and exercises, including flexibility exercises, were found to be an essential part of the treatment program. Our Oswestry Disability Index results showed improvements at the second and third assessments, which indicated that patients’ functionality quickly improved after treatment, allowing the patients to feel less pain and be more functional when performing activities of daily living.

Spinal mobilization and manipulation have different mechanisms of action on pain and movement limitation [6-9]. For instance, mobilization intends to increase soft tissue extensibility and joint mobility using low velocity passive force to achieve pain modulation via reduced hyperexcitability of muscle spindles and endogenous pain inhibition in the central nervous system [26]. Manipulation applies a sudden thrust that intends to make cracking sound to induce cavitation of a joint to achieve improvement of joint mobility and pain modulation via intradiscal pressure changes [29]. In addition, spinal mobilization generally requires longer treatment time, gentler touch by the clinicians and a more comfortable position for the patient than manipulation, which might lead to different effects between these manual therapy techniques [30].

Marshall and Murphy [16] assessed lumbopelvic muscle activity during various core stability exercises with and without a Swiss ball. The researchers reported that although there was an evidence suggesting that the Swiss ball provided a training stimulus for the rectus abdominis, the relevance of this change to core stability training required further research because the focus of stabilization training was on minimizing rectus abdominis activity. A significant increase in rectus abdominis muscle strength was also found in our study in all groups at the end of treatment. The results showed that core stability exercises with and without a Swiss ball lessened pain and reduced disability. Segmental stabilization was superior to superficial strengthening for rectus abdominis muscle strength. Superficial strengthening did not improve transversus abdominis muscle activation capacity. In addition to these results, Jull and Richardson [17] reported that recent research on muscle dysfunction in patients with LBP led to discoveries of impairments in deep muscles of the trunk and back. These muscles have a functional role in enhancing spinal segmental support and control. The muscle impairments were not related to the strength but rather to the problems in motor control. These findings call for a different approach in therapeutic exercise, namely, a motor learning exercise protocol [17]. This specific exercise approach has an initial focus on retraining the co-contraction of the deep muscles (i.e., the transversus abdominis and lumbar multifidus). Initial clinical trials pointed to the effectiveness of this approach in patients with both acute and chronic LBP in terms of reducing the neuromuscular impairment and controlling pain. These studies showed that Swiss ball exercises were effective for LBP management and our results are in agreement with these findings.

Ferreira et al. [8] compared effects of general exercise, motor control exercise, and manipulative therapy on the function and perceived effect of intervention in patients with chronic back pain. The authors found that motor control exercise and spinal manipulative therapy produced slightly better short-term, but not medium- or long-term, effects in patients with chronic non-specific back pain. Senna and Machaly [30] determined the effectiveness of maintenance spinal mobilization therapy in long-term reduction of pain and disability levels associated with chronic low back conditions after an initial phase of treatments. They stated that spinal mobilization therapy was effective for the treatment of chronic non-specific LBP. To obtain a long-term benefit, they suggested using maintenance spinal mobilization after the initial intensive manipulative therapy. Similar to this, we observed that the manipulative therapy group showed faster pain relief. In our study, some patients who did not exercise regularly had an increased level of pain during 1 month after the treatment.

There were reductions in pain during activity, at rest and at night after treatments and at 4 weeks after the follow-up in all treatments in the present study. In earlier studies the reduction was greater—49.0% in the spinal mobilization therapy group after a 7-day residential manual therapy program [3]. Differences in the treatment programs for LBP could explain why the reduction observed was lower in this study. While in some studies [4,8,9,30], the efficacy of exercise treatment was demonstrated in comparison with the spinal exercise group, in this study, there was no placebo group because it was considered unethical to use a placebo group in such design.

A limited number of trials have assessed non-pharmacological treatments for the management of LBP and to our knowledge, this is the first randomized trial assessing the effectiveness of different kind of physiotherapy approaches in addition to a supervised spinal stabilization exercise program in this population. Our primary analysis showed that adding supervised spinal stabilization exercise program did not result in significant or meaningful advantages in pain severity over the course of 4 weeks. Secondary analyses showed that at the end of the 4-week treatment phase and a 4-week follow-up, group differences favored the addition of either Kinesio Taping, reflexology, or spinal manipulative therapy by 8%, 4%, and 4% points, respectively. Group differences following the end of treatment were smaller (0% to 3% points) and favored Kinesio Taping plus stabilization exercise program alone over the combined treatment groups. Differences in secondary patient-rated outcomes were small and did not show any clear pattern in favor of one treatment over another. An exception was the satisfaction with care, where participants in all soft tissue mobilization+stabilization exercise and Kinesio Tape+stabilization exercise and reflexology+stabilization exercise consistently reported greater satisfaction than those in the stabilization exercise group throughout the 8-week course.

Our trial has several strengths, including four different types of management, including homogenous groups and a rigorous design with emphasis on internal validity. We also had excellent engagement and follow-up rates. The findings of this study should be interpreted in the context of its limitations. Limitations of the study include inability to blind patients and providers to the nature of the interventions. First, the duration of intervention was brief (i.e., 4 weeks), thus the ‘dose’ of the treatment might have been insufficient to create quantitatively observable changes in some of the outcomes measured. Second, the sample size was small. The low number of patients included in this study is a limitation that could have decreased the power of statistical analysis. However, various methods of analysis were conducted to complement and strengthen the quantitative findings obtained from the small sample size of the study. The results from each analysis validated each other in several points and provided stronger evidence for the conclusions. In addition, utilization of both subjective and objective data collection and analysis techniques to compare/complement/validate results against each other should be used to increase the validity of the research findings. Therefore, more randomized controlled trials will be needed to establish efficacy and, subsequently, treatment effectiveness.

Adding supervised stabilization exercise program alone does not appear to improve pain or disability outcomes in either short- or long-term in patients with chronic LBP, but did enhance satisfaction with care. On the other hand, Kinesio Taping decreased immediate pain levels. When considered together, the findings of this study suggest that a 4-week program with different approaches is a viable treatment option for patients with chronic LBP. Therefore, we believe that stabilization exercises should be included in exercise prescription by physical therapists. The cost-effectiveness of these interventions needs to be assessed.