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Asian Spine J > Volume 16(6); 2022 > Article
Vaish and Saha: Letter to the Editor: An Updated Overview of Low Back Pain Management
We read the review article by Hong et al. [1] titled “An updated overview of low back pain management” with great interest. The authors have discussed the management of low back pain in a very informative and elaborative manner. We appreciate the authors for this; however, we wish to bring forth some additional therapeutic strategies available for the management of low back pain which are emerging as evidence in the present scenario.
Hu et al. [2] conducted a systemic review and meta-analysis based on an evaluation of the efficacy and safety of dry needling (DN) for treating low back pain. It was concluded that DN has a significant effect on relieving the intensity of pain and functional limitation than acupuncture, although follow-up of the studies showed equal effectiveness of DN and acupuncture on the same outcomes. When compared with the sham treatment group, DN showed a significant effect on reducing pain perception and functional disability, and improvement remains intact in follow-up except in functional disability.
Also, few evidences are available in the favour of cupping therapy. A systematic review and meta-analysis was conducted by Moura et al. [3], who reported cupping therapy as a promising method for the treatment of chronic back pain in adults. However, they also, emphasized that there is a need to establish standardized protocols for this intervention [3]. Cupping is applied based on the sucking and traction mechanism of the skin. A suction glass is used for the affected area and negative pressure is generated either mechanically by pumping or thermally by cooling heated air, extracting the air trapped under the cup. Relieve in symptoms occurs due to increased perfusion of the treatment area. Pulsatile cupping is an advancement in cupping therapy where a pulsatile negative pressure generates with a mechanical device. Also reported in another randomized controlled trial (RCT), it has been proved that both normal cupping and pulsatile cupping are effective in relieving chronic low back pain after 4 weeks of intervention compared to a group that only took medication for pain on demand [4].
Core muscle exercises have gained popularity in recent years in the management of low back pain [5]. One of the origins of low back pain could be credited to a motor control dysfunction in the abdominals and paraspinal muscles for a long [6]. The diaphragm, along with other muscles, forms the “core region” [7]. Effects of diaphragm training on chronic low back pain and thickness of stabilizer muscles of the lumbar spine were studied by Finta et al. [8] in two groups: complex training program with diaphragm training and complex training program alone. It was concluded that after the training, the severity of the pain was significantly reduced in complex but diaphragm training has an effect also on the thickness of other active stabilizers of the lumbar spine, such as transversus abdominis and lumbar multifidus muscles [8]. Another RCT by Otadi et al. [9] concluded that pain, function, static stability, and dynamic balance were improved in both groups (diaphragm training with transcutaneous electrical nerve stimulation [TENS] and TENS) following 12 intervention sessions. However, pain, dynamic balance, and static stability were improved to a larger extent in the diaphragm training group [9].
The emerging new evidence seems promising in the management of low back pain and needs further exploration.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.


Author Contributions

All the work was done by Hina Vaish and Shilpasree Saha.


1. Hong JY, Song KS, Cho JH, Lee JH, Kim NH. An updated overview of low back pain management. Asian Spine J 2022;16:968–82.
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2. Hu HT, Gao H, Ma RJ, Zhao XF, Tian HF, Li L. Is dry needling effective for low back pain?: a systematic review and PRISMA-compliant meta-analysis. Medicine (Baltimore) 2018;97:e11225.
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3. Moura CC, Chaves EC, Cardoso AC, Nogueira DA, Correa HP, Chianca TC. Cupping therapy and chronic back pain: systematic review and meta-analysis. Rev Lat Am Enfermagem 2018;26:e3094.
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4. Teut M, Ullmann A, Ortiz M, et al. Pulsatile dry cupping in chronic low back pain: a randomized three-armed controlled clinical trial. BMC Complement Altern Med 2018;18:115.
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5. Chang WD, Lin HY, Lai PT. Core strength training for patients with chronic low back pain. J Phys Ther Sci 2015;27:619–22.
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6. Bergmark A. Stability of the lumbar spine: a study in mechanical engineering. Acta Orthop Scand Suppl 1989;230:1–54.
7. Bliss LS, Teeple P. Core stability: the centerpiece of any training program. Curr Sports Med Rep 2005;4:179–83.
8. Finta R, Nagy E, Bender T. The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain. J Pain Res 2018;11:3031–45.
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9. Otadi K, Nakhostin Ansari N, Sharify S, et al. Effects of combining diaphragm training with electrical stimulation on pain, function, and balance in athletes with chronic low back pain: a randomized clinical trial. BMC Sports Sci Med Rehabil 2021;13:20.
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