Introduction

Low back pain, which is a major problem in public health with a prevalence of 12%-15%, causes pain and anxiety to patients [1]. In adolescence, about 20% of people show mild symptoms of disc degeneration which gradually get increased with age, especially in men. So, 60% of people in their 70s suffer from severe disc degeneration [2]. Disc degeneration is asymptomatic in many cases, but is mainly associated with radicular pain in the lower extremities or weakness of the limbs and bladder sphincter disorders due to compression of the spinal cord [3,4]. Numerous factors have been suggested as causes of disc herniation, including weight gain, intense and frequent physical activity, chronic spinal stress, trauma, aging, smoking, nutritional deficiencies, genetic factors, and anatomical abnormalities [5,6]. In recent years, several studies have reported a strong familial genetic predisposition to discopathy [7,8]. Even the effect of genetics on the development of discopathy has been estimated about 60% [8]. Low back pain is the most common symptom of patients with lumbar disc herniation. Other symptoms include radicular pain, sensory and motor deficits, reflex abnormalities, sphincter defects, urinary and fecal disorders, and sexual dysfunction [1,9]. The most common disk space involvement is the space between the S1-L5 seals. Most pain occurs in a lower limb. Nerve root stimulation can cause pain in a distribution in the medulla, paresthesia and anesthesia in the nerve pathway involved [10]. Medical history and careful examination are the first step in clinical suspicion of diseases caused by lumbar discopathy. Examination of the sensation and movement of the legs and determination of distal and proximal muscular strength of the lower extremities, as well as examination of deep tendon reflexes and sphincters tone are the basic principles of determining the severity of the lesion and its prognosis [11,12].

Nowadays, MRI is the choice modality in the accurate diagnosis of this lesion [13]. Simple x-ray, and in case of necessity CT scan are used to prove diagnosis fractures or associated vertebral instabilities and to determine the treatment methods [14]. 90% of acute sciatica attacks are treated with supportive care [15,16]. In the treatment of symptomatic lumbar discopathy, in addition to rest, weight loss, smoking cessation, NSAIDs, physiotherapy, dynamic exercise and hydrotherapy complement the principles of treatment [17-19]. One of the major benefits of hydrotherapy is the reduction of forces related to weight bearing. Patients who get workout with water-walking feel lighter and easier in movement, and feel less strain on their joints due to floating. It seems that the feeling of weight loss in water, and the massage-therapy property of water, eliminates or significantly reduces muscle dehydration, and causes reduction of the muscle spasm occurred by disc herniation [20-22]. Therefore, according to the physical properties of water, including relieving pressure on the spine, relieving spasms, controlling gravity, strengthening muscles, etc., the researchers investigated the effect of hydrotherapy in the treatment of patients with lumbar disc herniation who referred to the orthopedic clinic of Imam Khomeini hospital of Ahvaz.

Materials and Methods

The present study is a case-control, clinical trial study. Among all patients with lumbar disc herniation in orthopedic clinic of Imam Khomeini Hospital in Ahvaz in 2018, 96 patients with the approval of an orthopedic specialist were considered to enter this study. After completing the consent form, patients are divided to two groups of hydrotherapy and medication (case) and medication (control), randomly. Patients were randomly selected in terms of age and gender and are visited and evaluated at the beginning of the visit and after 3 and 6 months of treatment. Data were collected by using questionnaires.

Inclusion Criteria:

• patients with low back pain,
• MRI showed evidence of mild to moderate disc bulging
• the patients with no indication for disc herniation surgery.

Exclusion Criteria:

• any spinal problems, recent surgery, any musculoskeletal problems,
• any unknown or unexamined pathology,
• combination of arthritis and rheumatoid arthritis.

The questionnaires include demographic information, visual pain scale questionnaire and the oswestry low back pain disability questionnaire and quality of life questionnaire. The analysis will be performed using SPSS statistical software version 22. Data are analyzed by descriptive statistics (mean and percentage) and analytical statistics (independent t-test) or its non-parametric equivalent. Also, figures and tables appropriate to the data will be used. Significance level will be less than 0.05.

Findings

A total of 96 patients referred to the orthopedic clinic of Imam Khomeini Hospital who had the inclusion criteria, writing, and signing consent forms, participated in the study. Patients were randomly divided into two groups: hydrotherapy and drug therapy (case) and drug therapy group (control). Figure 1 summarizes the steps of the study.

As it is seen in figure 1, the participants of drug group and hydrotherapy & drug group are 48 individuals in each group. And they are totally included in the analysis.

According to Table 1, the comparison of the mean age in the two groups was performed by independent t-test which showed a significant difference (P = 0.001); the case group was approximately 5 years older than control group. Comparing gender of the participants; the ratio is approximately similar. Chi Square test analysis did not show significant difference (P = 0.8). Comparison of levels of education in the case and control groups indicates the statistics of levels of education. Chi Square test analysis did not show significant difference (P = 0.3). Comparison of smoking history in case and control groups indicates smoking history in case and control groups. In this table, Chi-square test showed the same effect of smoking in both group (p = 1). Comparison of treatment history in case and control groups indicates treatment history in case and control groups. Previous treatment done in the case group was more than twice of the control group which showed to be a significant difference (P = 0.001). Comparison of past medical history in the case and control groups depicts comparison of past medical history in the case and control groups. Chi Square test analysis did not show significant difference (P = 0.8). In Table 2, the rates of low back pain in the case and control groups were compared; of course, the comparison is presented at the beginning and at the end of the study.

According to above Table 2, the average scale of low back pain was not significant before the study in the two groups (P = 0.3). But after the intervention, the difference was significant (P = 0.001). The comparison of mean pain rate in both groups also shows the significance (P = 0.007). Intra-group comparisons in both groups also indicate a significant decrease in pain compared to the beginning of the study (p = 0.001). Due to the considerable differences in ages and the history of treatment in the two groups, the repeated-measures test was applied for elimination of the effects of these two variables which shows the effectiveness of hydrotherapy in reducing low back pain significantly compared to the control group (P = 0.04).

Based on Figure 2 the rates of lower limb pain in the two groups were compared at the beginning and the end of the study by t-test. There is steady decrease in the lines of both groups indicating lower back pain at the end of the study in both groups.

Based on Table 3, there was a significant difference between the two treatment groups at the beginning of the study (P = 0.001). It was the post-study analysis which clarified significant difference and the reduction of pain in the hydrotherapy group compared with drug therapy group (p = 0.008). Intra-group comparison using paired t-test in both groups depicted a significant reduction in lower limb pain during the study period (P = 0.001). However, after adjusting the background variables (age and history of treatment) with Repeated-Measures test, the difference did not lose its significance (P = 0.03).

Figure 3 shows a decreasing trend from the beginning to the end; the extremity pain scores decrease from 6.25 and 5.75 to 3.85. It clearly depicts lower pain.

According to Table 4, the level of quality of life in the two groups at the beginning and end of the study was compared using independent t-test. Based on the findings, at the beginning of the study, there was no significant difference between the two groups in terms of quality of life (P = 0.97). At the end of the study, the case group had significantly (P <0.0001) better quality of life than the control group. Comparing the changes during the study period between the two groups, it was clear that the hydrotherapy group had better quality of life (P <0.0001). In-group comparison, both groups indicated a significant increase in their quality of life during the study period (P = 0.018). After adjusting the background variables (age and history of treatment), a significant difference was observed between the two groups (P = 0.001).

Figure 4 shows a steady increase in the quality of life throughout the time of the study; at the beginning of the study the rates of quality of life were lower.

Discussion

The aim of the present study was to investigate the effect of hydrotherapy in the treatment of patients with lumbar disc herniation referred to the orthopedic clinic of Imam Khomeini Hospital in Ahvaz during 2018-2019.

Comparing the rate of low back pain at the beginning and end of the study between the case and control groups indicated that there was no significant difference between the two treatment groups at the beginning of the study (P = 0.3). But after performing hydrotherapy intervention in the case group at the end of the study, there was a significant difference between the two groups in terms of reducing back pain (P = 0.001). However, after adjusting background variables (age and history of treatment), there is also a significant difference (P = 0.001). Comparison of the changes during the study period between the two groups also showed that hydrotherapy group experienced a greater reduction in low back pain (P = 0.007) and while entering the background moderating variables (age and history of treatment) there was also a significant difference (P = 0.004). Moreover, intragroup analysis reveals a significant reduction in lower extremity pain during the study period (P = 0.001). After adjusting the background variables (age and history of disease), these changes were statistically significant only in the hydrotherapy group (P = 0.006). Several studies on hydrotherapy program in patients with low back pain stated that exercise in water appears to be effective on decreasing pain and improving function in adults with chronic low-back pain [23-25].

The above findings are consistent with the results of Waller et al. that confirmed the effect of water-walking workout over improving chronic low back pain [26]. Two separate studies conducted in 2012 also expressed the effect of hydrotherapy and massage on pain and physical function in men with chronic low back pain due to lumbar disc herniation [27,28]. Lotfi et al. confirmed the effect of six weeks of supine movement on water reduces the rate of pain and functional disability in men with chronic back pain caused by lumber disc herniation [29]. Therefore, the results obtained from the mentioned studies are consistent with the results of the present study. Comparing the rate of lower limb pain at the beginning and end of the study between the case and control groups, the results showed a significant difference between the control and case groups (P = 0.001). However, after adjusting the effect of the background variables (age and history of treatment), there is also significant difference (P = 0.03). Also, at the end of the study, there was no significant difference between the two groups in terms of lower limb pain (P = 0.1). During the study it was observed that the subjects in the hydrotherapy group witnessed a greater reduction in lower extremity pain (P = 0.008). However, after adjusting the effect of the background variables (age and history of treatment), there was not also a significant difference (P = 0.1). Although intragroup comparison, both groups showed a significant reduction in lower limb pain during the study period (P = 0.001). And after adjusting the effect of background variables, the changes (age and history of treatment) were statistically significant only in the hydrotherapy group (P = 0.04).

Our findings are also consistent with the results of the study by You-sin Kim, et al. [21]. In the mentioned study, the results suggested that aquatic backward locomotion exercise is as beneficial as progressive resistance exercise for improving lumbar extension strength in patients after lumbar discectomy surgery. Despite the difference in the type and duration of training sessions (compared to this study), the similarity in results probably is the effect of physical properties of the water [21]. Khanjari et al. showed that an underwater environment allows early active mobilization, endurance and dynamic strengthening; thus, hydrotherapy can reduce pain. Their finding about the variables of pain and disability also was similar to the present study [22]. The results of the present research are in line with the results of Sedaghati, et al. They evaluated the effects of 12 weeks of water-strengthening exercises on the pain of women with chronic low back pain and concluded that that the core-muscle stabilization training of the spinal cord in water decreases the pain intensity [30]. The results of Barker's study are also similar to the results of the research, although their research evaluated the effect of aquatic exercise on low back pain and radicular pain due to intervertebral disc protrusion in women; the study also mentioned the positive effects of aquatic exercise on patients' pain [31]. Also, the results of this study were was in contrast with the findings of Lee et al. who reported that a course of hydrotherapy had no positive effect on reducing pain and disability while it reduced the favorite range of motion and the walking speed [1]. The results of comparing the level of quality of life at the beginning and end of the study between the case and control group showed that at the end of the study there was a significant difference between the two groups (P <0.0001) and the patients in the hydrotherapy group had better quality of life (P <0.0001). However, after adjusting the effect of the background variables (age and history of treatment), the difference did not lose its significance (P = 0.018).

Finally, in intragroup analysis, both groups showed a significant increase in their quality of life during the study period (P = 0.001). However, these changes remained statistically significant after adjusting for the effect of the underlying variables (age and treatment history). Therefore, according to the results, it can be said that hydrotherapy has been effective on the patients' quality of life. The results of the present study are consistent with the findings of other researchers. In a study, Heinman et al investigated the effect of hydrotherapy on patients with chronic low back, knee and thigh pain. After 6 weeks of hydrotherapy, pain decreased significantly and the physical function, strength, quality of life and muscle strength improved; they concluded that hydrotherapy reduced morning pain and dryness and increased motor function and other factors [2]. Also, the present study is also consistent with several similar studies that showed the effectiveness of hydrotherapy on the life function of patients with chronic low back and knee pain [1,32-36].

Conclusion

It can be declared that hydrotherapy generally increases the life expectancy and vitality of patients due to their feeling of relaxation. The mechanism of pain relief in these patients is due to the physical properties, temperature and massage properties of water. Finally, the result of all the above analysis includes the improvement and promotion in patients' quality of life, which leads to an increase in physical and mental health of patients. It is suggested that specialists compare hydrotherapy exercises with other training methods and evaluate the results. In addition, the effect of hydrotherapy exercises on other chronic diseases should be investigated. It is indeed suggested that the effect of hydrotherapy on the quality of working life be examined. The effectiveness of aquatic therapy on the patients' quality of life with knee pain can also be investigated in further researches.

Figures

Tables

References

1. Li H, Ma XL, Wang P (2011) The immunopathological observation of lumbar disc herniation. Chinese Journal of Orthopaedics 31 : 66-70.
2. Hinman RS, Heywood SE, Day AR (2007) Aquatic physical therapy for hip and knee osteoarthritis: results of a singleblind randomized controlled trial. Phys Ther 87: 32-43.
3. Kadir K, Mustafa E, Mustafa A (2006) Do the spinal pathologies that accompany lumbar disc disease affect surgical prognosis?.Turkish Neurosurg 16: 168-174.
4. Boos N, Weissbach S, Rohrbach H, Weiler C, Spratt KF, et al. (2002) Classification of age-related changes in lumbar intervertebral discs: 2002 Volvo Award in basic science. Spine 27: 2631-2644.
5. Pouriesa M, Fouladi RF, Mesbahi S (2013) Disproportion of end plates and the lumbar intervertebral disc herniation. Spine J 13: 402-407.
6. Varlotta GP, Brown MD, Kelsey JL, Golden AL (1991) Familial predispositionfor herniation of a lumbar disc in patients who areless than twenty-one years old. J Bone Joint Surg Am 73: 124-128.
7. Ala-Kokko L (2002) Genetic risk factors for lumbar disc disease. AnnMed 34: 42-47.
8. Paassilta P, Lohiniva J, Goring HH, Perala M, Raina SS, et al. (2001) Identification of a novel common genetic risk factor for lumbar disk disease. JAMA 285: 1843-1849.
9. Mehrazin M, Vafaei SH (2003) Surgical results in lumbar disc (analysis of 101 cases). Teb & Tazkieh 48: 32-38.
10. Deyo RA, Weinstein JN (2001) Low back pain. N Engl J Med 344: 363-370.
11. Ahn UM, Ahn NU, Buchowski JM (2000) Caudaequina syndrome secondary to lumbar disc herniation: a meta-analysis of outcomes. Spine 25: 1515-1522.
12. Weiler C, Nerlich AG, Zipperer J, Bachmeier BE, Boos N (2002) SSE Award Competition in Basic Science: expression of major matrix metalloproteinases is associated with intervertebraldisc degradation and resorption. Eur Spine J 11: 308- 320.
13. Kang JD, Georgescu HI, McIntyre Larkin L, Stefanovic-Racic M, Donaldson WF, et al. (1996) Herniated lumbar intervertebral discs spontaneously produced matrixmetalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2. Spine 21: 271-277.
14. Ma XL, Xu YQ, Zhang YX (2004) Study of autoimmune factors in lumbar disc herniation. Modern Journal of Neurology and Neurosurgery 4: 291-296.
15. Patel AT, Ogle AA (2000) Diagnosis and management of acute low back pain. Am Fam Physician 61: 1779-1786.
16. Thome C, Barth M, Scharf J (2005) Outcome after lumbar sequestrectomy compared with microdiscectomy: a prospective randomized study. J Neurosurg Spine 2: 271-278.
17. Janardhana AP, Rajagopal, Rao S, Kamath A (2010) Correlation between clinical features and magnetic resonance imaging findings in lumbar disc prolapse. Indian J Orthop 44: 263-269.
18. Jain S, Kumar S (2011) Correlation between clinical features and magnetic resonance imaging findings in lumbar disc prolapse. Indian J Orthop 45: 105.
19. Carragee EJ, Han MY, Suen PW (2003) Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am 85: 102-108.
20. Ariyoshi M, Sonoda K, Nagata K, Mashima T, Zenmyo M, et al. (1998) Efficacy of aquatic exercises for patients with low-back pain. The Kurume medical journal 46: 91-96.
21. Kim Y-S, Park J, Shim JK (2010) Effects of aquatic backward locomotion exercise and progressive resistance exercise on lumbar extension strength in patients who have undergone lumbar diskectomy. Arch Phys Med Rehabil 91: 208-214.
22. Yaser Khanjari, Jamal F Kalkhoran (2020) The Effects of Aquatic Exercise on Low Back Pain as for Herniated Disc in Elderly Men. Journal of Spine Research and Surgery 2: 023-029.
23. Hayden JA, Van Tulder MW, Malmivaara AV, Koes BW (2005) Meta-analysis: exercise therapy for nonspecific low back pain. Annals of internal medicine 142: 765-775.
24. Staal JB, Hlobil H, Twisk JW, Smid T, Köke ArJ, et al. (2004) Graded Activity for Low Back Pain in Occupational Health CareA Randomized, Controlled Trial. Annals of internal medicine 140: 77-84.
25. Shoja Aldin S, Sadeghi H, Bayat TM (2008) Relationship between the trunk muscles endurance and anthropometric characters with low back pain among athletes with lumbar lordosis. Journal of Movement Science 2008.
26. Omino K, hayashi Y (1992) Preparation of dynamic posture and occurrence of low back pain. Ergonomics 35: 693-707.
27. Khanzadeh R, Hashemi Javaheri A, Omidi-Kashani F, Zandi M, et al. (2012) The Effect of Combined Therapeutic Protocol (Therapeutic Exercises and Massage) on the Pain and Physical Performance in Men with Chronic Low Back Pain due to Lumbar Disc Herniation 2012.
28. Dimogerontas G, Paidakakos NA, Konstantinidis E (2012) Voluminous free disk fragment mimicking an extra dural tumor. Neurol Med Chir (Tokyo) 52: 656-658.
29. Lotfi HR, Ebrahimi Atri A, Norouzi K. The effect of six weeks of lying on your back on the water on pain intensity and disability in men with chronic low back pain due to lumbar disc herniation 1395.
30. Sedaghati N, Hematfar A, Behpour N (2013) The effect of a selected spinal core-muscle stabilization training in water on pain intensity and lumbar lordosis. Feyz 17: 267-274.
31. Barker KL, Dawes H, Hansford P, Shamley D (2003) Perceived and measured levels of exertion of patients with chronic back pain exercising in a hydrotherapy pool. Archives of physical medicine and rehabilitation 84: 1319-1323.
32. Shakeri M, KarimiYarandi K, Haddadi K, Sayyahmelli S (2009) Prevalence of Abdominal Aortic Aneurysm by Magnetic Resonance Images (MRI) in Men over 50 years with low back pain. Rawal Med J 34: 1-3.
33. Nikolaos Papadakos, Husam Georges, Naomi Sibtain, Christos M Tolias (2009) Thoracic Disc Prolapse Presenting with Abdominal Pain: Case Report. Ann R Coll Surg Engl 91: 4-6.
34. Hastreiter D, Ozuna RM, Spector M (2001) Regional variations incertain cellular characteristics in human lumbar intervertebral discs, including the presence of alpha-smooth muscle actin. J Orthop Res 19: 597-604.
35. Melrose J, Roberts S, Smith S, Menage J, Ghosh P (2002) Increased nerve and blood vessel ingrowth associated with proteoglycan depletion in an ovine annular lesion model of experimental disc degeneration. Spine 27: 1278-1285.
36. Johnson WE, Caterson B, Eisenstein SM, Hynds DL, Snow DM, et al. (2002) Human intervertebral disc aggrecan inhibits nerve growth in vitro. Arthritis Rheum 46: 2658-2664.