A COMPARATIVE STUDY OF PHYSIOTHERAPY OUTCOMES BETWEEN INFRARED-TENS COMBINATION AND PNF THERAPIES IN NPH PATIENTS

Background: The pain experienced by Nucleus Pulposus Herniation (NPH) patients can have an impact on productivity and may lead to disability. Therefore, non-pharmacological therapies can serve as alternatives in reducing pain levels for Grade I and Grade II NPH patients. Purpose: To compare the difference in effectiveness between Infrared-Transcutaneous Electrical Nerve Stimulation (IR-TENS) combination and Proprioceptive Neuromuscular Facilitation (PNF) therapies in reducing pain among NPH patients. Method: This research employed a quasi-experimental design with a two group before and after intervention conducted at the Physical Medicine and Rehabilitation Unit of Royal Prima Hospital in Medan. A total of 20 NPH patients were provided with interventions, consisting of a combination of IR and TENS therapies for 10 patients, and PNF therapy for the other 10 patients, administered eight times for one month. Pain measurement was conducted using a Visual Analogue Scale (VAS) questionnaire before and after the interventions. The statistical analysis employed an Independent Sample T test, with a significance level (α) set at 0.05. Result: There was a reduction in moderate and severe pain scales in both groups, and no subjects were experiencing severe pain anymore. However, the reduction in moderate pain scale was higher in the group receiving the combination of infrared and TENS therapies (80%) compared to the PNF therapy (70%). The Independent T test showed that there was no significant difference between the effectiveness of the combination of IR-TENS therapies and PNF therapy on pain in NPH patients (p-value = 0.075). Conclusion: Both groups of patients experienced a reduction in pain scale after the interventions, although there was no significant difference in the outcome between the two treatment groups. This implies that both therapies are equally effective in suppressing pain in NPH patients.

Introduction

Low Back Pain(LBP) is a common musculoskeletal issue that occurs worldwide and is estimated to be one of the most prevalent complaints experienced by 80% of the global population (Uritset al., 2019(Urits et al., 2019)). The Basic Health Research of 2018 reported the prevalence of musculoskeletal diseases in Indonesia to be 7.3% (Agency for Health Research and Development, 2020(Source Title, 2018)). One of the diseases frequently encountered in lower back pain isNucleus Pulposus Herniation(NPH), characterized by clinical symptoms such as lower back pain radiating to the lower extremities or even extending to the toes. If the condition worsens, it can lead to paralysis (Dydyk et al., 2024(Dydyk et al., 2024); Schroeder et al., 2016(Schroeder et al., 2016)). NPH is a medical condition where the cushion or intervertebral disc protrudes and compresses the spinal nerve fibers, causing lower back pain that predominantly occurs between the L4 and L5 vertebrae. Part or the entire nucleus pulposus protrudes toward the spinal canal (De Decker and Fenn, 2018(Decker & Fenn, 2018)).

Several literature sources identify risk factors for NPH, including older age, smoking habits,Body Mass Index(BMI), and occupation (workload, working positions, repetition, and duration) (Sørensen et al., 2011(Sørensen et al., 2011); Ahsan et al., 2013(Ahsan et al., 2013); Billy et al., 2014(Billy et al., 2014); Citko et al., 2018(Citko et al., 2018); Lan et al., 2016(Lan et al., 2016); Li et al., 2020(Li et al., 2020); Nordberg et al., 2021(Nordberg et al., 2021); Siccoli et al., 2022(Siccoli et al., 2022)). Previous literature reports that the treatment of NPH with severe pain intensity can be managed through interventions such as nerve root steroid injections or even surgery. However, many NPH patients can reduce their pain through conservative treatments such as analgesics, epidural injections, and physical therapies like traction, ultrasound, and low-level laser therapy (Alentado et al., 2014(Alentado et al., 2014); Altun and Yüksel, 2017(Altun & Yüksel, 2017); Benoist, 2002(Benoist, 2002); Suri et al., 2012(Suri et al., 2012); Unlu et al., 2008(Unlu et al., 2008)). Indeed, non-pharmacological therapies can also be employed to reduce pain in NPH patients, such asTranscutaneous Electrical Nerve Stimulation(TENS), ultrasound, infrared (IR) therapy, interferential therapy, short-wave diathermy, lumbar traction, McKenzie exercises, core stability exercises, andProprioceptive Neuromuscular Facilitation(PNF) (Chou et al., 2016(Chou et al., 2016); Barreto and Lin, 2017(Barreto & Lin, 2017); Gao et al., 2022(Gao et al., 2022)). In this research, the researchers selected three types of physiotherapy modalities to be applied to NPH patients, namely a combination of IR and TENS therapies, as well as PNF therapy.

Infrared(IR) therapy is a physical therapy modality that involves electromagnetic radiation with light rays that produce a heating effect when absorbed by the skin. The heat emitted by infrared has been shown to enhance tissue extensibility, aid in improving joint range of motion, reduce pain sensation, and promote the healing of soft tissue lesions (Anekwu, 2015(Anekwu, 2015); Ojeniweh et al., 2019(Ojeniweh et al., 2019)). TENS is an electrical stimulation method used to stimulate the posterior horn nerve cells and produce a sedative effect (American Physical Therapy Association, 2000(Source Title, 2000)). This method has been proven effective in reducing pain, alleviating clinical symptoms, and regulating peripheral oxygen radical levels. Additionally, it helps prevent oxidative damage to cardiac muscle tissue (Unterrainer et al., 2010(Unterrainer et al., 2010); Wang et al., 2018(Wang et al., 2018)). In addition to being cost-effective and easy to learn, TENS has a low risk of hazards, including toxicity or other side effects (Gladwell et al., 2015(Gladwell et al., 2015); Jauregui et al., 2016(Jauregui et al., 2016); Teoli and An, 2023(Teoli & An, 2024)). The PNF therapy is utilized to elicit neuromuscular responses by facilitating proprioceptors. PNF can stimulate proprioceptors in muscles and joints around the waist region, which may be beneficial in enhancing sensorimotor regulation and balance performance. This therapy has been shown to be quite effective in reducing pain (Kofotolis and Kellis, 2006(Kofotolis & Kellis, 2006); Westwater-Wood et al., 2010(Westwater-Wood et al., 2010); Young et al., 2015(Young et al., 2015); Areeudomwong et al., 2017(Areeudomwong et al., 2017)).

Based on the preliminary survey conducted at the Medical Record Installation of Royal Prima Hospital in Medan, the number of visits by NPH patients with complaints of lower back pain was recorded to be 50 patients per month from January to December 2022. The objective of this research was to compare the effectiveness of a combination of IR and TENS therapies, as well as PNF therapy in reducing pain among NPH patients.

Material and Method

This research has obtained ethical approval from the Research Ethics Committee of Universitas Prima Indonesia with registration number: 070/KEPK/UNPRI/VII/2023. This research employed a quasi-experimental design with a two group before and after intervention. The research was conducted at the Medical Rehabilitation Installation (Physiotherapy) of Royal Prima Hospital in Medan from January to May 2023. The average number ofNucleus Pulposus Herniation(NPH) patients accessing physiotherapy services ranged from 8 to 10 individuals per day, totaling approximately 160 patients in a

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