Effects of the Iliopsoas Strain–Counterstrain Technique on Mechanical Chronic Low Back Pain: A Randomized Controlled Trial

Effects of the Iliopsoas Strain–Counterstrain Technique on Mechanical Chronic Low Back Pain: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of the Iliopsoas Strain–Counterstrain Technique on Mechanical Chronic Low Back Pain: A Randomized Controlled Trial Javad Hassanzadeh Bakhshkandi, Mohammad Javaherian, Osman Çoban, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7648408/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Mechanical chronic low back pain (MCLBP) often involves dysfunction in soft tissues, particularly in the iliopsoas muscle, which is crucial for lumbar stability and movement. This study aimed to evaluate the effects of the strain-counterstrain (SCS) technique applied to iliopsoas tender points (TPs) on pain reduction and lumbar mobility in individuals with MCLBP. Methods Between January and March 2025, this unmasked randomized controlled trial (RCT) Between January and March 2025 enrolled 36 volunteers aged 18–60 years with MCLBP and iliopsoas tenderness. Thereafter, they were randomly allocated (1:1) to either a control group (exercise only, 6 sessions) or SCS group (exercise + iliopsoas-targeted SCS, 6 sessions). The primary outcomes were pain at rest and during flexion, as measured by the visual analog scale (VAS). The secondary outcomes included lumbar flexion and extension range of motion (ROM), spinal mobility, iliopsoas muscle length, Oswestry Disability Index (ODI), and Short Form-36 (SF-36) score. Assessments were performed at baseline, after the first session, and after the sixth session. Results Thirty-six participants were randomly assigned to the SCS group (n = 18) or the control group (n = 18). Compared with those in the control group, the pain levels in the SCS group were significantly lower, with a between-group mean difference (MD) of -1.8 cm (95% CI: -2.98, 0.62) at rest and − 2.67 cm (95% CI: -3.97, -1.37) during lumbar flexion. After the sixth session, further reductions in pain at rest (MD -1.87 [95% CI -3.2, -0.54]) and during flexion (MD -3.32 [95% CI -5.17, -1.46]) were observed in the SCS group. Lumbar ROM improved significantly with increased flexion (MD 14.78 [95% CI 5.35, 24.25]) and extension (MD 8.17 [95% CI 2.57, 13.77]) after the sixth session. Spinal mobility, ODI scores, and SF-36 physical functioning scores improved after both sessions. No adverse events were reported. Conclusion The iliopsoas-targeted SCS technique combined with therapeutic exercises effectively reduced pain and improved lumbar mobility in patients with MCLBP, with notable improvements observed after the first and sixth sessions. Trial Registration The trial was prospectively registered at ClinicalTrials.gov (NCT06748859) on December 13, 2024. Available from: https://clinicaltrials.gov/ct2/show/NCT06748859 . Mechanical low back pain strain-counterstrain iliopsoas manual therapy Figures Figure 1 Figure 2 Figure 3 Introduction Low back pain (LBP) is one of the most common musculoskeletal disorders worldwide; it causes extensive long-term disability and creates substantial financial strain on healthcare systems ( 1 ). MCLBP is the primary cause of LBP since it persists for more than 12 weeks and results from spinal dysfunctions, intervertebral disc pathologies, and soft tissue impairments caused by repetitive strain or traumatic insult. The physical symptoms of chronic pain negatively affect quality of life (QOL) because they restrict functional abilities and prevent people from performing daily tasks ( 2 ). Among the muscles that attach to the lumbar spine, the iliopsoas plays a critical role in maintaining segmental stability and facilitating coordinated trunk–hip movements. Dysfunction or tenderness of the iliopsoas has been linked to restricted lumbar ROM and symptoms of LBP ( 3 , 4 ). In today’s sedentary lifestyle (characterized by prolonged sitting) the iliopsoas is chronically exposed to sustained mechanical loading, which may contribute to the development of pelvic tilt abnormalities, postural imbalances, and increased mechanical stress on the lumbar spine ( 5 ). These biomechanical alterations underscore the therapeutic value of targeting the iliopsoas in patients with MCLBP. The SCS technique alleviates musculoskeletal pain by targeting TPs through passive positioning and sustained, gentle pressure. Although SCS has shown efficacy in reducing pain and improving function in various musculoskeletal conditions, its specific application for iliopsoas-related dysfunction in MCLBP patients has not been explored ( 6 , 7 ). Given the central role of the iliopsoas in lumbar biomechanics, investigating the potential benefits of this targeted intervention is clinically relevant. Therefore, the present RCT aimed to investigate the effects of an SCS technique applied to iliopsoas TPs in combination with exercise therapy on pain reduction and lumbar mobility in individuals with MCLBP. We hypothesized that the addition of iliopsoas-targeted SCS would significantly improve pain, spinal mobility, and functional outcomes, that is, compared with exercise therapy alone, in patients with mechanical chronic low back pain. Materials and methods Study design The current study was a single-center, single-blind, prospective, two-parallel-armed RCT comparing the efficacy of the iliopsoas SCS technique combined with exercise therapy with that of exercise therapy alone in patients with CMLBP. The trial profile is presented in Fig. 1 . This investigation method follows the CONSORT (Consolidated Standards of Reporting Trials) 2025 guideline ( 8 ), which is available as an additional file (Additional file 1). This single-center study was conducted at the outpatient physiotherapy department of Biruni University Hospital, Istanbul, Turkey, between January 2025 and March 2025. The participants were randomly allocated to the iliopsoas SCS or control group via a blocked-balanced randomization method at a 1:1 ratio. Patients who presented to the clinic with LBP were initially assessed by a physical medicine and rehabilitation specialist. Patients diagnosed with CMLBP were further evaluated to determine the eligibility of the predefined inclusion criteria. After confirming eligibility, the specialist opened a sealed opaque envelope containing the random allocation to assign the patient to the respective group. This procedure ensured concealment during the randomization process. All the volunteers in both groups received six treatment sessions within two consecutive weeks. The physical therapy sessions lasted between 20 and 40 minutes under the supervision of an experienced physical therapist. The study design, which was part of a master’s thesis, required the same researcher to conduct both the intervention and outcome assessments, resulting in an unmasked trial. The lack of assessor blinding introduces a potential risk of detection bias, particularly in subjective outcomes such as pain intensity. To minimize this risk, standardized protocols were strictly followed for all outcome measures, including objective tools (e.g., TiltMeter© for lumbar ROM, validated questionnaires for disability, and QOL. Furthermore, multiple imputation (MI) and intention-to-treat analyses were employed to reduce analytical bias due to participant dropout. The outcome measures were assessed 1) before treatment, 2) 30 minutes after the first treatment session, and 3) after the last treatment session at the end of the second week. All the participants were provided complete details about the assessment and intervention procedures before providing written consent for study participation. The final analysis excluded participants who left the study at any point for any reason. Ethical approval was obtained from the Ethics Committee of the Faculty of Health Sciences, Marmara University (Approval No: 2024/157). Further details regarding the study methodology can be found in the full study protocol provided in Additional file 6. No interim analyses or stopping guidelines were planned due to the short intervention period and minimal expected risk. Participants All participants were diagnosed with MCLBP by a physical medicine and rehabilitation specialist, who subsequently referred them to physiotherapy services. The inclusion criteria for individuals were as follows: 1) aged between 18 and 60 years, 2) had a pain duration of ≥ 12 weeks ( 9 ), 3) had a numerical pain rating scale score of ≥ 3, 4) experienced pain during lumbar flexion, 5) had a positive Thomas test; and 6) had tenderness in the iliopsoas muscle that was at least four times greater than the ipsilateral quadratus lumborum. The exclusion criteria were as follows: 1) pregnancy; 2) medical diagnosis indicating candidacy for lumbar surgery; 3) history of fractures or trauma contraindicating manual therapy; 4) presence of any radicular pain at the lower extremity; and 5) progressive deterioration during the study period or intervention process. Patients were required to communicate and comprehend the instructions from the research team without barriers and provide voluntary consent to participate, and they could withdraw from the study at any stage. Randomization The participants were randomly assigned to two groups via the block-balanced randomization method (block size: 4). The study protocol adheres to the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) checklist ( 10 ), which is available as an additional file (Additional file 2) ( 11 ). A computer-generated random allocation sequence (block size = 4) was created via SealedEnvelope ( 12 ). Allocation concealment was ensured by using sealed, opaque envelopes, which were sequentially numbered and stamped by a researcher not involved in the assessment or treatment of the participants. Each envelope was opened precisely at the time of assignment to guarantee allocation integrity. Procedures On the first day, we conducted the enrollment, recruitment, and baseline assessments. After providing informed consent, we collected participants’ medical history and demographic data. A comprehensive baseline evaluation was then performed, including assessments of pain (at rest and during flexion), lumbar flexion and extension ROM, spinal mobility via the modified modified Schober test (MMST), and iliopsoas tightness via the Thomas test. Additionally, two validated questionnaires adapted to the Turkish population were administered to assess disability and QOL ( 13 , 14 ). The VAS for pain intensity is a widely accepted tool for evaluating pain severity. The participants were instructed to mark their perceived pain level on a 100 mm horizontal line, with “no pain” (score 0) on the left end and “worst imaginable pain” (score 10) on the right. The pain score was determined by measuring the distance from the left end to the patient’s mark. This method has demonstrated high validity and reliability across various clinical studies ( 15 , 16 ). Lumbar flexion and extension ROM were assessed via the TiltMeter© advanced level and inclinometer application (4.0.1 version; downloaded from Apple’s App Store), which is a reliable tool for quantifying isolated lumbar movement. An iPhone® model 14 pro (Apple, Inc., Cupertino, CA, USA) was positioned at the T12-L1 and S1-S2 levels. Each measurement was repeated three times, and the mean value was recorded. This method has demonstrated high reliability and is strongly correlated with traditional gravity-based inclinometers ( 17 ). The MMST was used to assess spinal mobility. In this test, a point is first marked midway between the posterior superior iliac spines, and a second point was marked 15 cm above this location. The change in distance between these two points is measured as the participant bent forward without flexing knees. This method has demonstrated strong validity and is highly correlated with radiographic assessments of lumbar flexion ( 18 , 19 ). The Thomas test was employed to assess iliopsoas muscle tightness. The participants were asked to lie supine with one leg straight and the other flexed at the hip and knee. If the straight leg remained parallel to the bed during the flexion of the other leg, no shortening was recorded. If the leg was raised from the bed, the angle was measured via a goniometer ( 20 ). The ODI was used to assess disability related to low back pain. The ODI consists of 10 sections, each assessing different aspects of daily activities. Each section was scored on a six-point scale, and the total score was calculated. Higher scores indicate greater disability. The Turkish version of the ODI has demonstrated reliability and validity ( 14 , 21 ). The SF-36 Turkish adaptation has demonstrated reliable and valid results in previous research ( 13 ). The SF-36 was used to assess QOL across eight domains: physical functioning, role limitations due to physical health, body pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health. Each domain is scored on a scale from 0 to 100, with higher scores indicating better health status. In addition, we calculated and reported both the mental component summary score and the physical component summary score. These scores reflect overall physical and mental health status, respectively. The scoring procedure followed the guidelines of the validated Turkish version of the SF-36 ( 22 ). Interventions Control group The control group participants underwent a standardized exercise therapy protocol that targeted LBP relief and improvement in lumbar stability. The exercise programme consisted of cat-camel movements (3 sets of 5 repetitions) ( 23 ), side-lying leg raises (3 sets of 10–12 repetitions) ( 24 ), bridging (3 sets of 5 repetitions) ( 25 ), and dead bug exercise (3 sets of 10–12 repetitions) ( 26 ). The exercises work to increase core strength while improving both pelvic stability and lumbar mobility. The participants completed their exercises with physiotherapist guidance during each clinic session. The participants were required to practice these exercises at home once per day. This concomitant care was standardized across both groups and considered part of the treatment protocol. The program was implemented three times per week over a two-week period. SCS group Participants in the SCS group received the iliopsoas strain–counterstrain intervention in addition to the control exercise protocol. The intervention was initiated on the same day as recruitment and applied prior to the exercise therapy at each treatment session. The intervention began with the participant in the supine position. A trained physiotherapist located the iliopsoas TPs through deep palpation, approximately 2 inches medial and slightly inferior to the anterior superior iliac spine based on established anatomical landmarks and clinical guidelines ( 27 ). Once a TP was identified, the participant’s hip was guided into flexion, abduction, and external rotation to achieve a position of ease, while light palpation pressure was maintained. The position of comfort was determined when a 70% reduction in tenderness was achieved (Fig. 2 ). This position was held passively for 90 seconds, after which the participant was passively and gently returned to a neutral position. The technique was applied three times to the affected side and twice to the contralateral side, with 30-second intervals between applications ( 6 , 28 ). To ensure consistency, the same therapist delivered all sessions via a standardized intervention protocol, although no formal fidelity checklist was implemented. Outcome measures The main result of this study was pain intensity during lumbar flexion, which was measured by the VAS at rest and during flexion. The secondary outcomes included lumbar spine flexion and extension, the MMST for evaluating spinal mobility, the Thomas test for measuring iliopsoas muscle shortness, the ODI for assessing functional disability, and the SF-36 for evaluating QOL. All outcome measures were assessed at baseline (pretest), immediately after the intervention (post-test), and after the sixth session (two weeks and six sessions post-intervention). Statistical analysis All the statistical analyses were conducted via Stata (version 17; StataCorp, College Station, TX, USA). The sample size was calculated on the basis of a minimal clinically important difference (MCID) of 3 cm on the VAS ( 29 ). The sample size was calculated using a standard deviation (SD) of 2.33 cm ( 30 ), an MCID of 3 cm, three steps of measurements (pretest, post-test, and after the sixth session), 0.01 as the alpha, 0.95 as the statistical power (1 − β), and a correlation among repeated measurements of 0.25, resulting in a calculation of 13 patients for each group. Ultimately, we estimated a 40% loss to follow-up and determined the sample size to be 36 patients. This trial was registered at ClinicalTrials.gov (NCT06748859). The means ± SDs and frequencies (%) are reported for continuous and categorical variables. Baseline characteristics were statistically compared between groups via two independent sample t tests and chi-square tests for continuous and categorical variables, respectively. All outcomes were analyzed under the intention-to-treat principle by retaining data from participants who did not complete the entire treatment or final assessments. Missing data were observed only at the third (post-sixth session) assessment point and were handled via multivariate chained multiple imputation (MI impute chained), considering 10 imputed datasets after imputing the baseline, after the first session, and after a sixth session of each variable, as well as the individuals’ treatment group, height, weight, body mass index, dominant hand side, smoking condition, occupation type, educational level, and duration of low back pain. The imputation model used a logit function, and convergence was visually assessed ( 31 ). The imputed datasets were reshaped into a long format for analysis. Mixed model regression analysis was used to evaluate the effects of group, time, and their interaction, i.e., time × group. The Bonferroni correction was also used to determine the statistical significance level between groups at the second and third assessments. After the model was estimated, the MD and its statistical significance were obtained via the “contrast” command with Bonferroni-adjusted confidence intervals. The beta coefficient was also presented as an effect size of regression analysis ( 32 ). Beta coefficients (95% CI) were reported as effect size estimates from the mixed-effects regression model. The researchers calculated the MD and standardized mean difference (SMD, using Cohen’s d) to determine between-group differences at the three assessment time points, which indicated the intervention effect size ( 33 ). The SMDs were categorized as trivial (0 to 0.19), small (0.2 to 0.49), medium (0.5 to 0.79), large (0.8 to 1.19), or very large (more than 1.2). Given that STATA software does not provide contrast analysis between groups following MIs, we pooled the amounts of MD and their confidence intervals to obtain a total MD for SMD calculation ( 32 ). The lgraph command was used to generate a diagram illustrating changes in outcome measurements from baseline to after the first and sixth sessions on the basis of the nonimputed dataset. All the statistical commands used in this study and the Excel files used for MD pooling are presented in Additional files 3 and 4. A p value < 0.05 was considered to indicate statistical significance. No important changes were made to the trial protocol, prespecified outcome measures or timing after trial commencement. The full anonymized raw dataset used for statistical analysis is available in Additional file 5. Results Between January and March 2025, 36 patients (age: 38.03 ± 10.91) met the eligibility criteria and were randomly assigned to the SCS (n = 18) or control (n = 18) group. All participants completed the initial assessment following the first treatment session, and no dropouts occurred before this point. Among the 18 patients allocated to the SCS group, three (16.67%) dropped out. Dropout occurred because two patients found the clinic too far from their location, and one patient whose pain completely resolved after the second session decided not to continue due to a very demanding work schedule. Four of the patients (22.22%) in the control group Table 1 Demographics and clinical characteristics of participants. Variables SCS Group (n = 18) Control Group (n = 18) Age (y) (Mean ± SD) 35 ± 9.38 41.05 ± 11.72 Sex Male, n (%) 8 (44.44) 8 (44.44) Female, n (%) 10 (55.56) 10 (55.56) Height (cm) (Mean ± SD) 167.33 ± 9.02 169.56 ± 8.9 Weight (kg) (Mean ± SD) 70.5 ± 8.41 73.53 ± 14.83 BMI (kg/m²) 25.27 ± 3.41 25.53 ± 3.3 Duration 13.11 ± 13.03 8.94 ± 11.53 Dominant Side n (%) Left n (%) 0 (0) 2 (11.11) Right n (%) 18 (100) 16 (88.89) Smoker, n (%) Yes 8 (44.44) 8 (44.44) No 10 (55.56) 10 (55.56) Occupation n (%) Employed n (%) 16 (88.89) 12 (66.67) Student n (%) 1 (5.56) 1 (5.56) Retired n (%) 0 (0) 3 (16.67) Housewife n (%) 1 (5.56) 2 (11.11) Education n (%) Illiterate n (%) 0 (0) 1 (5.56) Primary School n (%) 0 (0) 1 (5.56) Middle School n (%) 2 (11.11) 1 (5.56) High School n (%) 3 (16.67) 3 (16.67) University n (%) 12 (66.67) 10 (55.56) Postgraduate n (%) 1 (5.56) 2 (11.11) Baseline VAS (Mean ± SD) 6.39 ± 1.48 5.99 ± 1.77 SCS: iliopsoas strain-counterstrain technique; n: number; y: years; SD: standard deviation; cm: centimeter; kg: kilogram; BMI: body mass index; kg/m²: kilogram per square meter; VAS: visual analog pain scale. All characteristics were statistically similar between groups based on the t test and chi-square test. dropped out because of difficulties in reaching the clinic at a distance. However, two patients discontinued the study as their pain increased. Baseline and post-first session assessment data from all participants were included in the statistical analysis. The study participants maintained an adherence rate of 80.56%, while the attrition rate reached 19.44%. The demographic and clinical information of the participants is presented in Table 1 . The study of attrition bias required us to examine essential baseline characteristics between participants who finished the study (n = 29) and those who left the study (n = 7). There were no significant differences in age (p = 0.30), baseline VAS score (p = 0.36), or symptom duration (p = 0.44). The results indicate that the sample was not affected by systematic bias due to attrition. The mixed model regression analysis revealed a statistically significant interaction effect between time and group for among all the outcome measurements, with a moderate-to-large effect size. The results of the between-group analysis revealed large and very large decreases in the VAS score at rest and during flexion, respectively, between the groups after the first session. After the sixth session, participants allocated to the SCS group presented less pain with medium and large SMDs at rest and during flexion than did those in the control group (Table 1 ). The means with 95% CIs of the VAS score at rest and during flexion at the three assessment times are shown in Fig. 3 . All secondary outcome measurements presented statistically significant time × group interactions. Patients allocated to the SCS group had higher MMST, lumbar flexion, and extension ROM scores than did those in the control group, with large and medium effect sizes at the second and third assessments, respectively. After the second assessment, the ODI score of the SCS group was significantly lower than that of the control group, indicating a very large effect size. This difference was large after the sixth session. Although the level of iliopsoas muscle stiffness on the right and left sides was not significantly different, it was significantly lower after the sixth session. Table 2 details all the information related to the statistical analysis of these outcome measurements. * Table 2. Distribution of different outcomes according to two arms in addition to related effect sizes. (See Tables 2 and 3 for full table.) * The results of the SF-36 analysis revealed significantly greater scores in the physical functioning, physical health, pain, and physical component summary domains after the first and sixth sessions. Although emotional problems and energy scores were greater in the SCS group than in the control group immediately after the first session, no significant difference was observed at the sixth session. Table 3 presents the detailed scores and effect sizes of these analyses. * Table 3. Result of domains of SF-36 questionnaire according to two arms in addition to related effect sizes. (See Tables 2 and 3 for full table.) * Discussion The current investigation aimed to evaluate the short-term effect of applying an SCS technique targeting iliopsoas TPs in combination with exercise therapy and exercise therapy alone in patients with MCLBP. The intervention was found to be safe and effective, with no adverse events reported during the study period. The primary outcome of the VAS score demonstrated a large effect after the first session on the basis of the findings of standardized MDs, which decreased to a moderate effect by the sixth session. Similarly, the VAS score during lumbar flexion showed a large initial impact, staying in the moderate-to-large range by the sixth session. With clinically significant outcomes preserved throughout the intervention, these results point to a rapid and considerable decrease in both resting and movement-related pain. Among the secondary outcomes, the MMST improved with a moderately effect after the first session and remained moderate after the sixth session. Lumbar flexion and extension also resulted in moderate and sustained improvements. The ODI scores decreased substantially, with a large initial effect and a moderate effect still present by the end. Analysis of the SF-36 domains revealed, in terms of health-related QOL, that improvements were especially noticeable in the physical subdomains, including physical functioning, role limitations due to physical health, and pain. With modest to large effect sizes, these domains showed statistically significant increases in the intervention group compared with the control group following both the first and sixth therapy sessions. These results probably reflect the direct effects of pain reduction and improved spinal mobility on functional capacity and daily activity performance. In particular, the mental component summary revealed a larger effect size after the first session than after the sixth session. This first improvement could be related to early psychological reactions to clinical improvement, which may be mediated by sympathetic nervous system modulation or a strong sense of relief and hope in patients. These findings highlight the multifaceted therapeutic potential of the SCS technique, encompassing both somatic and potentially psychosomatic mechanisms. With an estimated 619 million people experiencing LBP globally in 2020, this number is expected to increase by 36% by 2050, indicating the importance of developing efficient treatments and preventative measures to address the growing prevalence of spinal disorders worldwide. Notably, more than 90% of these patients are classified as MCLBP, further emphasizing the urgent need for targeted therapeutic strategies ( 1 , 34 ). Three different manual therapy techniques—manual pressure release, SCS, and integrated neuromuscular inhibition—were used to treat patients with chronic nonspecific LBP and active myofascial trigger points in muscles, such as the quadratus lumborum and gluteal groups, in a comparative study by Dayanır et al. Their results indicated the possible superiority of this strategy since the SCS group had slightly better improvements pain intensity during activity and pain-related disability compared with the other groups ( 30 ). Similarly, in our study, the VAS scores revealed that applying SCS to the iliopsoas muscle clinically significantly reduced resting and activity-related pain. Given the strong and consistent analgesic response, the within-group changes exceeded the minimum clinically important difference (MCID) of 3 cm after just one session and continued to improve through the sixth session. The iliopsoas muscle has more complicated biomechanical effects on the lumbar spine. The psoas major muscle has been demonstrated in the literature to produce a minimal extension moment at the upper lumbar vertebrae (L1–L3) and a small flexion moment at the lower segments (L4–L5–S1). The main biomechanical effect of the lumbar spine, however, is high axial compression and anterior shear forces ( 35 ). In a study of swimmers with low back discomfort, Kitamura et al. proposed that greater stiffness of the psoas major might improve shear forces, especially at lower lumbar levels, helping to prevent intervertebral disc degeneration and the onset of chronic LBP ( 36 ). Similarly, Lee et al. noted the common occurrence of iliopsoas tightness in LBP sufferers and highlighted the importance of including this muscle in therapeutic interventions ( 37 ). The literature indicates that interventions aimed at the iliopsoas, such as myofascial release, stretching, and muscle energy techniques, significantly improve pain levels and movement range ( 38 – 40 ). In accordance with previous findings, the results of our study demonstrated that an iliopsoas-focused SCS approach effectively reduced the stiffness of the paraspinal muscle and improved spinal mobility, thus improving mechanical low back pain. The SCS technique targets TPs—localized areas of muscle spasm—arising from prolonged strain and impaired proprioceptive feedback, which can result in ischemia, metabolic imbalance, and increased nociceptor sensitivity. This technique involves positional release to reduce gamma motor neuron activity, restore proprioceptive balance, and interrupt the pain–spasm cycle. As a result, muscle relaxation occurs, along with reduced nociceptive input and improved blood flow, oxygenation, and metabolic function in the affected area ( 6 , 7 ). Recent research has demonstrated the effectiveness of SCS in treating anatomical conditions, such as neck pain ( 41 ), TPs in the rhomboid muscles ( 42 ), plantar fasciitis ( 43 ), and ankle injuries ( 44 ), which results in significant pain reduction, improved functional mobility, and increased patient satisfaction. Koura et al. demonstrated the effectiveness of SCSs targeting the gluteus medius and quadratus lumborum muscles in reducing pain intensity and improving disability levels in individuals with chronic low back pain ( 45 ). Given these findings and the technique’s clinical advantages over other manual therapy approaches, the present study revealed that iliopsoas-targeted SCS significantly improved functional capacity, reduced disability, and enhanced QOL in patients with MCLBP. These outcomes suggest that the SCS may contribute not only to pain relief but also to functional and psychosocial recovery, reinforcing its role as a valuable tool in modern orthopedic manual therapy. This study has several important strengths, including being the first RCT to specifically evaluate the effects of iliopsoas-targeted SCS therapy in patients with chronic mechanical low back pain. In addition to being prospective, it offers standardized clinical outcome assessments and MI techniques to address missing data, all of which augment its methodological rigor. However, there are a few very relevant limitations. The paper was written as a master's thesis, making it impossible to have a double-blind design since interventions and assessments were performed by the same investigator, thereby lending itself to bias in the trial. Additionally, some patients left the study because they experienced rapid clinical improvement; consequently, they chose to discontinue treatment, whereas others cited logistical challenges. MI was used to address missing data; however, this method assumes that the data are missing at random, an assumption that cannot be fully verified. Moreover, although a standardized treatment protocol was followed, no formal fidelity tracking system (e.g., checklist or observer validation) was used, which may be considered a methodological limitation. Finally, the short follow-up period makes it impossible to draw major conclusions concerning the lasting effects of such approaches. Future studies should be double-blinded, multicentric, and prolonged in their follow-up with objective imaging to confirm the physiological changes occurring due to iliopsoas SCS interventions and to better define optimal patient profiles. Conclusion The RCT demonstrated that adding iliopsoas-targeted SCS therapy to standard physiotherapy practices results in significant short-term benefits for pain reduction and lumbar mobility and functional improvement in patients with mechanical chronic low back pain. This study demonstrated the therapeutic benefits of treating iliopsoas dysfunction during musculoskeletal rehabilitation and supported additional research on developing evidence-based care pathways that incorporate specific manual techniques. This study provides promising results for improving nonpharmacological treatments for chronic low back pain despite its limitations regarding blinding and follow-up duration. Abbreviations LBP Low back pain MD Mean difference MCLBP Mechanical chronic low back pain MCID Minimal clinically important difference MMST Modified–modified Schober test MI Multiple imputation ODI Oswestry Disability Index QOL Quality of life RCT Randomized controlled trial ROM Range of motion SF 36–Short Form–36 SD Standard deviation SMD Standardized mean difference SCS Strain–counterstrain TP Tender point VAS Visual Analog Scale Declarations Ethics approval and consent to participate: Ethical approval was obtained from the Ethics Committee of the Faculty of Health Sciences, Marmara University (Approval No: 2024/157). Written informed consent was obtained from all participants prior to enrollment. The study was registered on (13/12/2024) ClinicalTrials.gov under the protocol number NCT06748859. Consent for publication: Not applicable Competing interests: The authors declare that they have no conflicts of interest. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution JHB conceived and designed the study protocol and coordinated the preparation of the manuscript. MJ and OÇ contributed to the methodological design, with a particular focus on the statistical approach. ÇÇ and GÇA contributed to the clinical planning of patient recruitment, eligibility assessment, and randomization procedures. OA critically reviewed the protocol for clarity and methodological accuracy. ZS supervised the protocol development and provided expert guidance throughout the process. All authors reviewed and approved the final version of the manuscript. Acknowledgement The authors gratefully acknowledge the generous support of Chiropractic Australia, the European Academy of Chiropractic, and The Royal College of Chiropractors, which provided coverage of the article processing charge (APC) for this manuscript. The authors also extend their sincere thanks to all study participants for their valuable contributions. Data Availability CONSORT and SPIRIT checklists are provided in Additional files 1 and 2, respectively. All the statistical commands used in this study are included in Additional file 3, and the Excel sheet used for mean difference (MD) pooling is available in Additional file 4. The detailed distributions of the outcome measures and between-group analyses are presented in Table 2 and 3. The dataset supporting the conclusions of this article is included within the article and its Additional file 5. The study protocol is provided in Additional file 6. 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Comparing the Therapeutic Impact of Strain-Counterstrain and Exercise on Low Back Myofascial Pain Syndrome: A Randomized Trial. J Multidisciplinary Healthc 2025;Volume 18:1–12. https://doi.org/10.2147/jmdh.s499927 Tables Table 2 and 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table2and3.xlsx Additionalfile1.docx Additionalfile2.docx Additionalfile3.txt Additionalfile4.xlsx Additionalfile5.xlsx Additionalfile6.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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20:14:33","extension":"html","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":157891,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/f1e41fa0e56e132d1bd99d73.html"},{"id":95414081,"identity":"b02d4cc9-8899-425c-9ded-62edfb146a7c","added_by":"auto","created_at":"2025-11-07 20:14:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1808495,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT flow diagram of participant enrollment, allocation, follow-up, and analysis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e* We employed multiple imputations following the sixth session's between-group analyses.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis flow diagram illustrates the progress of participants through the phases of the randomized controlled trial. A total of 133 patients were assessed for eligibility, 97 of whom were excluded because they did not meet the inclusion criteria (e.g., absence of a tender point, no pain during flexion, radicular pain, surgical history, no consent, or negative Thomas test). Thirty-six participants were randomized into two groups (SCS patients and controls), with dropout occurring prior to follow-up. Following the sixth session, multiple imputation was employed to address missing data for between-group analysis (n = 3 in the SCS group; n = 4 in the control group).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/1f62b43552001483f4302058.png"},{"id":95526773,"identity":"2ac7379c-a94f-4a32-be48-27030add84c7","added_by":"auto","created_at":"2025-11-10 10:07:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24533791,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eApplication of the iliopsoas strain‒counterstrain technique.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient was placed in the supine position, while the therapist palpated 2 inches medially and slightly inferiorly to the ASIS to locate the tender point. Once identified, the patient’s hip is passively placed in flexion, abduction, and external rotation to achieve a position of comfort. The position was maintained for 90 seconds before it was passively returned to neutral.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/6ed1414fb50853321d46baaa.png"},{"id":95414088,"identity":"63aeb359-7649-409f-b876-8378ea0ce10f","added_by":"auto","created_at":"2025-11-07 20:14:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2611592,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVAS scores at three time points: (A) at rest and (B) during lumbar flexion.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe panels depict the mean visual analog scale (VAS) scores at baseline, after the first session, and after the sixth session for the intervention and control groups.\u003c/p\u003e\n\u003cp\u003e(A) VAS scores at rest; (B) VAS scores during lumbar flexion.\u003c/p\u003e\n\u003cp\u003eThe error bars represent 95% confidence intervals. Compared with those in the control group, the pain levels in the intervention group were more prominently reduced, particularly after the first session.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/0e5ca4036dde12835d0ed379.png"},{"id":96247268,"identity":"cd9a1c83-5e14-4588-af7d-50e55a44af17","added_by":"auto","created_at":"2025-11-19 07:27:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":28936121,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/485b14ac-4772-4eec-8897-5c9e228d30bd.pdf"},{"id":95526821,"identity":"f0321ed0-52f0-44bc-8944-6e9415e08187","added_by":"auto","created_at":"2025-11-10 10:08:10","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17710,"visible":true,"origin":"","legend":"","description":"","filename":"Table2and3.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/346e7f66fb9dfd4be47626e9.xlsx"},{"id":95527564,"identity":"b985c42e-b09b-4106-b4d3-db56afd099cd","added_by":"auto","created_at":"2025-11-10 10:14:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":32640,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/3de74ac7d48bbe1c45ae54d7.docx"},{"id":95414087,"identity":"1fb689db-264f-4b46-8175-82f62896f777","added_by":"auto","created_at":"2025-11-07 20:14:33","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":35349,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/7ae5d8f10f5192fe5197a2bf.docx"},{"id":95414084,"identity":"0848e0fa-3089-4d66-af07-c8e5fb4c3686","added_by":"auto","created_at":"2025-11-07 20:14:33","extension":"txt","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":2465,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.txt","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/e80d54dfe35d4933a6c17346.txt"},{"id":95526832,"identity":"2ea99d03-1f32-4dd7-aa19-e6eef8e3fd83","added_by":"auto","created_at":"2025-11-10 10:08:10","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":12494,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile4.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/5590cd1404541173486d0cd8.xlsx"},{"id":95414098,"identity":"e629df61-4373-4807-8a39-f0f9857668b4","added_by":"auto","created_at":"2025-11-07 20:14:33","extension":"xlsx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":21361,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile5.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/aa58d8f8c9bb62c23325c388.xlsx"},{"id":95414099,"identity":"8abbf698-8a3d-4f3e-816e-634820049db5","added_by":"auto","created_at":"2025-11-07 20:14:33","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":86487,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile6.docx","url":"https://assets-eu.researchsquare.com/files/rs-7648408/v1/eae34e52ae23814f6fed9975.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of the Iliopsoas Strain–Counterstrain Technique on Mechanical Chronic Low Back Pain: A Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLow back pain (LBP) is one of the most common musculoskeletal disorders worldwide; it causes extensive long-term disability and creates substantial financial strain on healthcare systems (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). MCLBP is the primary cause of LBP since it persists for more than 12 weeks and results from spinal dysfunctions, intervertebral disc pathologies, and soft tissue impairments caused by repetitive strain or traumatic insult. The physical symptoms of chronic pain negatively affect quality of life (QOL) because they restrict functional abilities and prevent people from performing daily tasks (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAmong the muscles that attach to the lumbar spine, the iliopsoas plays a critical role in maintaining segmental stability and facilitating coordinated trunk\u0026ndash;hip movements. Dysfunction or tenderness of the iliopsoas has been linked to restricted lumbar ROM and symptoms of LBP (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In today\u0026rsquo;s sedentary lifestyle (characterized by prolonged sitting) the iliopsoas is chronically exposed to sustained mechanical loading, which may contribute to the development of pelvic tilt abnormalities, postural imbalances, and increased mechanical stress on the lumbar spine (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). These biomechanical alterations underscore the therapeutic value of targeting the iliopsoas in patients with MCLBP.\u003c/p\u003e\u003cp\u003eThe SCS technique alleviates musculoskeletal pain by targeting TPs through passive positioning and sustained, gentle pressure. Although SCS has shown efficacy in reducing pain and improving function in various musculoskeletal conditions, its specific application for iliopsoas-related dysfunction in MCLBP patients has not been explored (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Given the central role of the iliopsoas in lumbar biomechanics, investigating the potential benefits of this targeted intervention is clinically relevant.\u003c/p\u003e\u003cp\u003eTherefore, the present RCT aimed to investigate the effects of an SCS technique applied to iliopsoas TPs in combination with exercise therapy on pain reduction and lumbar mobility in individuals with MCLBP. We hypothesized that the addition of iliopsoas-targeted SCS would significantly improve pain, spinal mobility, and functional outcomes, that is, compared with exercise therapy alone, in patients with mechanical chronic low back pain.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThe current study was a single-center, single-blind, prospective, two-parallel-armed RCT comparing the efficacy of the iliopsoas SCS technique combined with exercise therapy with that of exercise therapy alone in patients with CMLBP. The trial profile is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. This investigation method follows the CONSORT (Consolidated Standards of Reporting Trials) 2025 guideline (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), which is available as an additional file (Additional file 1).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis single-center study was conducted at the outpatient physiotherapy department of Biruni University Hospital, Istanbul, Turkey, between January 2025 and March 2025. The participants were randomly allocated to the iliopsoas SCS or control group via a blocked-balanced randomization method at a 1:1 ratio. Patients who presented to the clinic with LBP were initially assessed by a physical medicine and rehabilitation specialist. Patients diagnosed with CMLBP were further evaluated to determine the eligibility of the predefined inclusion criteria. After confirming eligibility, the specialist opened a sealed opaque envelope containing the random allocation to assign the patient to the respective group. This procedure ensured concealment during the randomization process.\u003c/p\u003e\u003cp\u003eAll the volunteers in both groups received six treatment sessions within two consecutive weeks. The physical therapy sessions lasted between 20 and 40 minutes under the supervision of an experienced physical therapist. The study design, which was part of a master\u0026rsquo;s thesis, required the same researcher to conduct both the intervention and outcome assessments, resulting in an unmasked trial. The lack of assessor blinding introduces a potential risk of detection bias, particularly in subjective outcomes such as pain intensity. To minimize this risk, standardized protocols were strictly followed for all outcome measures, including objective tools (e.g., TiltMeter\u0026copy; for lumbar ROM, validated questionnaires for disability, and QOL. Furthermore, multiple imputation (MI) and intention-to-treat analyses were employed to reduce analytical bias due to participant dropout.\u003c/p\u003e\u003cp\u003eThe outcome measures were assessed 1) before treatment, 2) 30 minutes after the first treatment session, and 3) after the last treatment session at the end of the second week. All the participants were provided complete details about the assessment and intervention procedures before providing written consent for study participation. The final analysis excluded participants who left the study at any point for any reason. Ethical approval was obtained from the Ethics Committee of the Faculty of Health Sciences, Marmara University (Approval No: 2024/157). Further details regarding the study methodology can be found in the full study protocol provided in Additional file 6. No interim analyses or stopping guidelines were planned due to the short intervention period and minimal expected risk.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eAll participants were diagnosed with MCLBP by a physical medicine and rehabilitation specialist, who subsequently referred them to physiotherapy services. The inclusion criteria for individuals were as follows: 1) aged between 18 and 60 years, 2) had a pain duration of \u0026ge;\u0026thinsp;12 weeks (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), 3) had a numerical pain rating scale score of \u0026ge;\u0026thinsp;3, 4) experienced pain during lumbar flexion, 5) had a positive Thomas test; and 6) had tenderness in the iliopsoas muscle that was at least four times greater than the ipsilateral quadratus lumborum. The exclusion criteria were as follows: 1) pregnancy; 2) medical diagnosis indicating candidacy for lumbar surgery; 3) history of fractures or trauma contraindicating manual therapy; 4) presence of any radicular pain at the lower extremity; and 5) progressive deterioration during the study period or intervention process. Patients were required to communicate and comprehend the instructions from the research team without barriers and provide voluntary consent to participate, and they could withdraw from the study at any stage.\u003c/p\u003e\n\u003ch3\u003eRandomization\u003c/h3\u003e\n\u003cp\u003eThe participants were randomly assigned to two groups via the block-balanced randomization method (block size: 4). The study protocol adheres to the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) checklist (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), which is available as an additional file (Additional file 2) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). A computer-generated random allocation sequence (block size\u0026thinsp;=\u0026thinsp;4) was created via SealedEnvelope (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Allocation concealment was ensured by using sealed, opaque envelopes, which were sequentially numbered and stamped by a researcher not involved in the assessment or treatment of the participants. Each envelope was opened precisely at the time of assignment to guarantee allocation integrity.\u003c/p\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eOn the first day, we conducted the enrollment, recruitment, and baseline assessments. After providing informed consent, we collected participants\u0026rsquo; medical history and demographic data. A comprehensive baseline evaluation was then performed, including assessments of pain (at rest and during flexion), lumbar flexion and extension ROM, spinal mobility via the modified modified Schober test (MMST), and iliopsoas tightness via the Thomas test. Additionally, two validated questionnaires adapted to the Turkish population were administered to assess disability and QOL (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe VAS for pain intensity is a widely accepted tool for evaluating pain severity. The participants were instructed to mark their perceived pain level on a 100 mm horizontal line, with \u0026ldquo;no pain\u0026rdquo; (score 0) on the left end and \u0026ldquo;worst imaginable pain\u0026rdquo; (score 10) on the right. The pain score was determined by measuring the distance from the left end to the patient\u0026rsquo;s mark. This method has demonstrated high validity and reliability across various clinical studies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLumbar flexion and extension ROM were assessed via the TiltMeter\u0026copy; advanced level and inclinometer application (4.0.1 version; downloaded from Apple\u0026rsquo;s App Store), which is a reliable tool for quantifying isolated lumbar movement. An iPhone\u0026reg; model 14 pro (Apple, Inc., Cupertino, CA, USA) was positioned at the T12-L1 and S1-S2 levels. Each measurement was repeated three times, and the mean value was recorded. This method has demonstrated high reliability and is strongly correlated with traditional gravity-based inclinometers (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe MMST was used to assess spinal mobility. In this test, a point is first marked midway between the posterior superior iliac spines, and a second point was marked 15 cm above this location. The change in distance between these two points is measured as the participant bent forward without flexing knees. This method has demonstrated strong validity and is highly correlated with radiographic assessments of lumbar flexion (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Thomas test was employed to assess iliopsoas muscle tightness. The participants were asked to lie supine with one leg straight and the other flexed at the hip and knee. If the straight leg remained parallel to the bed during the flexion of the other leg, no shortening was recorded. If the leg was raised from the bed, the angle was measured via a goniometer (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe ODI was used to assess disability related to low back pain. The ODI consists of 10 sections, each assessing different aspects of daily activities. Each section was scored on a six-point scale, and the total score was calculated. Higher scores indicate greater disability. The Turkish version of the ODI has demonstrated reliability and validity (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe SF-36 Turkish adaptation has demonstrated reliable and valid results in previous research (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The SF-36 was used to assess QOL across eight domains: physical functioning, role limitations due to physical health, body pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health. Each domain is scored on a scale from 0 to 100, with higher scores indicating better health status. In addition, we calculated and reported both the mental component summary score and the physical component summary score. These scores reflect overall physical and mental health status, respectively. The scoring procedure followed the guidelines of the validated Turkish version of the SF-36 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eControl group\u003c/h2\u003e\u003cp\u003eThe control group participants underwent a standardized exercise therapy protocol that targeted LBP relief and improvement in lumbar stability. The exercise programme consisted of cat-camel movements (3 sets of 5 repetitions) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), side-lying leg raises (3 sets of 10\u0026ndash;12 repetitions) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), bridging (3 sets of 5 repetitions) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and dead bug exercise (3 sets of 10\u0026ndash;12 repetitions) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The exercises work to increase core strength while improving both pelvic stability and lumbar mobility. The participants completed their exercises with physiotherapist guidance during each clinic session. The participants were required to practice these exercises at home once per day. This concomitant care was standardized across both groups and considered part of the treatment protocol. The program was implemented three times per week over a two-week period.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSCS group\u003c/h3\u003e\n\u003cp\u003eParticipants in the SCS group received the iliopsoas strain\u0026ndash;counterstrain intervention in addition to the control exercise protocol. The intervention was initiated on the same day as recruitment and applied prior to the exercise therapy at each treatment session. The intervention began with the participant in the supine position. A trained physiotherapist located the iliopsoas TPs through deep palpation, approximately 2 inches medial and slightly inferior to the anterior superior iliac spine based on established anatomical landmarks and clinical guidelines (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Once a TP was identified, the participant\u0026rsquo;s hip was guided into flexion, abduction, and external rotation to achieve a position of ease, while light palpation pressure was maintained. The position of comfort was determined when a 70% reduction in tenderness was achieved (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This position was held passively for 90 seconds, after which the participant was passively and gently returned to a neutral position. The technique was applied three times to the affected side and twice to the contralateral side, with 30-second intervals between applications (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). To ensure consistency, the same therapist delivered all sessions via a standardized intervention protocol, although no formal fidelity checklist was implemented.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eThe main result of this study was pain intensity during lumbar flexion, which was measured by the VAS at rest and during flexion. The secondary outcomes included lumbar spine flexion and extension, the MMST for evaluating spinal mobility, the Thomas test for measuring iliopsoas muscle shortness, the ODI for assessing functional disability, and the SF-36 for evaluating QOL. All outcome measures were assessed at baseline (pretest), immediately after the intervention (post-test), and after the sixth session (two weeks and six sessions post-intervention).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll the statistical analyses were conducted via Stata (version 17; StataCorp, College Station, TX, USA). The sample size was calculated on the basis of a minimal clinically important difference (MCID) of 3 cm on the VAS (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The sample size was calculated using a standard deviation (SD) of 2.33 cm (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), an MCID of 3 cm, three steps of measurements (pretest, post-test, and after the sixth session), 0.01 as the alpha, 0.95 as the statistical power (1\u0026thinsp;\u0026minus;\u0026thinsp;β), and a correlation among repeated measurements of 0.25, resulting in a calculation of 13 patients for each group. Ultimately, we estimated a 40% loss to follow-up and determined the sample size to be 36 patients. This trial was registered at ClinicalTrials.gov (NCT06748859).\u003c/p\u003e\u003cp\u003eThe means\u0026thinsp;\u0026plusmn;\u0026thinsp;SDs and frequencies (%) are reported for continuous and categorical variables. Baseline characteristics were statistically compared between groups via two independent sample t tests and chi-square tests for continuous and categorical variables, respectively. All outcomes were analyzed under the intention-to-treat principle by retaining data from participants who did not complete the entire treatment or final assessments. Missing data were observed only at the third (post-sixth session) assessment point and were handled via multivariate chained multiple imputation (MI impute chained), considering 10 imputed datasets after imputing the baseline, after the first session, and after a sixth session of each variable, as well as the individuals\u0026rsquo; treatment group, height, weight, body mass index, dominant hand side, smoking condition, occupation type, educational level, and duration of low back pain. The imputation model used a logit function, and convergence was visually assessed (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe imputed datasets were reshaped into a long format for analysis. Mixed model regression analysis was used to evaluate the effects of group, time, and their interaction, i.e., time \u0026times; group. The Bonferroni correction was also used to determine the statistical significance level between groups at the second and third assessments. After the model was estimated, the MD and its statistical significance were obtained via the \u0026ldquo;contrast\u0026rdquo; command with Bonferroni-adjusted confidence intervals. The beta coefficient was also presented as an effect size of regression analysis (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBeta coefficients (95% CI) were reported as effect size estimates from the mixed-effects regression model. The researchers calculated the MD and standardized mean difference (SMD, using Cohen\u0026rsquo;s d) to determine between-group differences at the three assessment time points, which indicated the intervention effect size (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The SMDs were categorized as trivial (0 to 0.19), small (0.2 to 0.49), medium (0.5 to 0.79), large (0.8 to 1.19), or very large (more than 1.2). Given that STATA software does not provide contrast analysis between groups following MIs, we pooled the amounts of MD and their confidence intervals to obtain a total MD for SMD calculation (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The lgraph command was used to generate a diagram illustrating changes in outcome measurements from baseline to after the first and sixth sessions on the basis of the nonimputed dataset. All the statistical commands used in this study and the Excel files used for MD pooling are presented in Additional files 3 and 4. A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance. No important changes were made to the trial protocol, prespecified outcome measures or timing after trial commencement. The full anonymized raw dataset used for statistical analysis is available in Additional file 5.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween January and March 2025, 36 patients (age: 38.03\u0026thinsp;\u0026plusmn;\u0026thinsp;10.91) met the eligibility criteria and were randomly assigned to the SCS (n\u0026thinsp;=\u0026thinsp;18) or control (n\u0026thinsp;=\u0026thinsp;18) group. All participants completed the initial assessment following the first treatment session, and no dropouts occurred before this point. Among the 18 patients allocated to the SCS group, three (16.67%) dropped out. Dropout occurred because two patients found the clinic too far from their location, and\u003c/p\u003e\u003cp\u003eone patient whose pain completely resolved after the second session decided not to continue due to a very demanding work schedule. Four of the patients (22.22%) in the control group\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics and clinical characteristics of participants.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSCS Group (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (y) (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u0026thinsp;\u0026plusmn;\u0026thinsp;9.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.05\u0026thinsp;\u0026plusmn;\u0026thinsp;11.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (44.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (44.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (55.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (55.56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHeight (cm) (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e167.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e169.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWeight (kg) (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73.53\u0026thinsp;\u0026plusmn;\u0026thinsp;14.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDuration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.11\u0026thinsp;\u0026plusmn;\u0026thinsp;13.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.94\u0026thinsp;\u0026plusmn;\u0026thinsp;11.53\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDominant Side n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (11.11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (88.89)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoker, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (44.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (44.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (55.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (55.56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployed n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (88.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (66.67)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (5.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (5.56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetired n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (16.67)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHousewife n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (5.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (11.11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIlliterate n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (5.56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary School n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (5.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle School n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (11.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (5.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh School n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (16.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (16.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUniversity n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (66.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (55.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostgraduate n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (11.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBaseline VAS (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.99\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eSCS: iliopsoas strain-counterstrain technique; n: number; y: years; SD: standard deviation; cm: centimeter; kg: kilogram; BMI: body mass index; kg/m\u0026sup2;: kilogram per square meter; VAS: visual analog pain scale.\u003c/p\u003e\u003cp\u003eAll characteristics were statistically similar between groups based on the t test and chi-square test.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003edropped out because of difficulties in reaching the clinic at a distance. However, two patients discontinued the study as their pain increased. Baseline and post-first session assessment data from all participants were included in the statistical analysis. The study participants maintained an adherence rate of 80.56%, while the attrition rate reached 19.44%. The demographic and clinical information of the participants is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe study of attrition bias required us to examine essential baseline characteristics between participants who finished the study (n\u0026thinsp;=\u0026thinsp;29) and those who left the study (n\u0026thinsp;=\u0026thinsp;7). There were no significant differences in age (p\u0026thinsp;=\u0026thinsp;0.30), baseline VAS score (p\u0026thinsp;=\u0026thinsp;0.36), or symptom duration (p\u0026thinsp;=\u0026thinsp;0.44). The results indicate that the sample was not affected by systematic bias due to attrition.\u003c/p\u003e\u003cp\u003eThe mixed model regression analysis revealed a statistically significant interaction effect between time and group for among all the outcome measurements, with a moderate-to-large effect size.\u003c/p\u003e\u003cp\u003eThe results of the between-group analysis revealed large and very large decreases in the VAS score at rest and during flexion, respectively, between the groups after the first session. After the sixth session, participants allocated to the SCS group presented less pain with medium and large SMDs at rest and during flexion than did those in the control group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The means with 95% CIs of the VAS score at rest and during flexion at the three assessment times are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAll secondary outcome measurements presented statistically significant time \u0026times; group interactions. Patients allocated to the SCS group had higher MMST, lumbar flexion, and extension ROM scores than did those in the control group, with large and medium effect sizes at the second and third assessments, respectively.\u003c/p\u003e\u003cp\u003eAfter the second assessment, the ODI score of the SCS group was significantly lower than that of the control group, indicating a very large effect size. This difference was large after the sixth session. Although the level of iliopsoas muscle stiffness on the right and left sides was not significantly different, it was significantly lower after the sixth session. Table\u0026nbsp;2 details all the information related to the statistical analysis of these outcome measurements.\u003c/p\u003e\u003cp\u003e* Table\u0026nbsp;2. Distribution of different outcomes according to two arms in addition to related effect sizes. (See Tables\u0026nbsp;2 and 3 for full table.) *\u003c/p\u003e\u003cp\u003eThe results of the SF-36 analysis revealed significantly greater scores in the physical functioning, physical health, pain, and physical component summary domains after the first and sixth sessions. Although emotional problems and energy scores were greater in the SCS group than in the control group immediately after the first session, no significant difference was observed at the sixth session. Table\u0026nbsp;3 presents the detailed scores and effect sizes of these analyses.\u003c/p\u003e\u003cp\u003e* Table\u0026nbsp;3. Result of domains of SF-36 questionnaire according to two arms in addition to related effect sizes. (See Tables\u0026nbsp;2 and 3 for full table.) *\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current investigation aimed to evaluate the short-term effect of applying an SCS technique targeting iliopsoas TPs in combination with exercise therapy and exercise therapy alone in patients with MCLBP. The intervention was found to be safe and effective, with no adverse events reported during the study period.\u003c/p\u003e\u003cp\u003eThe primary outcome of the VAS score demonstrated a large effect after the first session on the basis of the findings of standardized MDs, which decreased to a moderate effect by the sixth session. Similarly, the VAS score during lumbar flexion showed a large initial impact, staying in the moderate-to-large range by the sixth session. With clinically significant outcomes preserved throughout the intervention, these results point to a rapid and considerable decrease in both resting and movement-related pain. Among the secondary outcomes, the MMST improved with a moderately effect after the first session and remained moderate after the sixth session. Lumbar flexion and extension also resulted in moderate and sustained improvements. The ODI scores decreased substantially, with a large initial effect and a moderate effect still present by the end. Analysis of the SF-36 domains revealed, in terms of health-related QOL, that improvements were especially noticeable in the physical subdomains, including physical functioning, role limitations due to physical health, and pain. With modest to large effect sizes, these domains showed statistically significant increases in the intervention group compared with the control group following both the first and sixth therapy sessions. These results probably reflect the direct effects of pain reduction and improved spinal mobility on functional capacity and daily activity performance. In particular, the mental component summary revealed a larger effect size after the first session than after the sixth session. This first improvement could be related to early psychological reactions to clinical improvement, which may be mediated by sympathetic nervous system modulation or a strong sense of relief and hope in patients. These findings highlight the multifaceted therapeutic potential of the SCS technique, encompassing both somatic and potentially psychosomatic mechanisms.\u003c/p\u003e\u003cp\u003eWith an estimated 619\u0026nbsp;million people experiencing LBP globally in 2020, this number is expected to increase by 36% by 2050, indicating the importance of developing efficient treatments and preventative measures to address the growing prevalence of spinal disorders worldwide. Notably, more than 90% of these patients are classified as MCLBP, further emphasizing the urgent need for targeted therapeutic strategies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Three different manual therapy techniques\u0026mdash;manual pressure release, SCS, and integrated neuromuscular inhibition\u0026mdash;were used to treat patients with chronic nonspecific LBP and active myofascial trigger points in muscles, such as the quadratus lumborum and gluteal groups, in a comparative study by Dayanır et al. Their results indicated the possible superiority of this strategy since the SCS group had slightly better improvements pain intensity during activity and pain-related disability compared with the other groups (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Similarly, in our study, the VAS scores revealed that applying SCS to the iliopsoas muscle clinically significantly reduced resting and activity-related pain. Given the strong and consistent analgesic response, the within-group changes exceeded the minimum clinically important difference (MCID) of 3 cm after just one session and continued to improve through the sixth session.\u003c/p\u003e\u003cp\u003eThe iliopsoas muscle has more complicated biomechanical effects on the lumbar spine. The psoas major muscle has been demonstrated in the literature to produce a minimal extension moment at the upper lumbar vertebrae (L1\u0026ndash;L3) and a small flexion moment at the lower segments (L4\u0026ndash;L5\u0026ndash;S1). The main biomechanical effect of the lumbar spine, however, is high axial compression and anterior shear forces (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In a study of swimmers with low back discomfort, Kitamura et al. proposed that greater stiffness of the psoas major might improve shear forces, especially at lower lumbar levels, helping to prevent intervertebral disc degeneration and the onset of chronic LBP (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Similarly, Lee et al. noted the common occurrence of iliopsoas tightness in LBP sufferers and highlighted the importance of including this muscle in therapeutic interventions (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). The literature indicates that interventions aimed at the iliopsoas, such as myofascial release, stretching, and muscle energy techniques, significantly improve pain levels and movement range (\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). In accordance with previous findings, the results of our study demonstrated that an iliopsoas-focused SCS approach effectively reduced the stiffness of the paraspinal muscle and improved spinal mobility, thus improving mechanical low back pain.\u003c/p\u003e\u003cp\u003eThe SCS technique targets TPs\u0026mdash;localized areas of muscle spasm\u0026mdash;arising from prolonged strain and impaired proprioceptive feedback, which can result in ischemia, metabolic imbalance, and increased nociceptor sensitivity. This technique involves positional release to reduce gamma motor neuron activity, restore proprioceptive balance, and interrupt the pain\u0026ndash;spasm cycle. As a result, muscle relaxation occurs, along with reduced nociceptive input and improved blood flow, oxygenation, and metabolic function in the affected area (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Recent research has demonstrated the effectiveness of SCS in treating anatomical conditions, such as neck pain (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), TPs in the rhomboid muscles (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), plantar fasciitis (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), and ankle injuries (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), which results in significant pain reduction, improved functional mobility, and increased patient satisfaction. Koura et al. demonstrated the effectiveness of SCSs targeting the gluteus medius and quadratus lumborum muscles in reducing pain intensity and improving disability levels in individuals with chronic low back pain (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Given these findings and the technique\u0026rsquo;s clinical advantages over other manual therapy approaches, the present study revealed that iliopsoas-targeted SCS significantly improved functional capacity, reduced disability, and enhanced QOL in patients with MCLBP. These outcomes suggest that the SCS may contribute not only to pain relief but also to functional and psychosocial recovery, reinforcing its role as a valuable tool in modern orthopedic manual therapy.\u003c/p\u003e\u003cp\u003eThis study has several important strengths, including being the first RCT to specifically evaluate the effects of iliopsoas-targeted SCS therapy in patients with chronic mechanical low back pain. In addition to being prospective, it offers standardized clinical outcome assessments and MI techniques to address missing data, all of which augment its methodological rigor. However, there are a few very relevant limitations. The paper was written as a master's thesis, making it impossible to have a double-blind design since interventions and assessments were performed by the same investigator, thereby lending itself to bias in the trial. Additionally, some patients left the study because they experienced rapid clinical improvement; consequently, they chose to discontinue treatment, whereas others cited logistical challenges. MI was used to address missing data; however, this method assumes that the data are missing at random, an assumption that cannot be fully verified. Moreover, although a standardized treatment protocol was followed, no formal fidelity tracking system (e.g., checklist or observer validation) was used, which may be considered a methodological limitation. Finally, the short follow-up period makes it impossible to draw major conclusions concerning the lasting effects of such approaches. Future studies should be double-blinded, multicentric, and prolonged in their follow-up with objective imaging to confirm the physiological changes occurring due to iliopsoas SCS interventions and to better define optimal patient profiles.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe RCT demonstrated that adding iliopsoas-targeted SCS therapy to standard physiotherapy practices results in significant short-term benefits for pain reduction and lumbar mobility and functional improvement in patients with mechanical chronic low back pain. This study demonstrated the therapeutic benefits of treating iliopsoas dysfunction during musculoskeletal rehabilitation and supported additional research on developing evidence-based care pathways that incorporate specific manual techniques. This study provides promising results for improving nonpharmacological treatments for chronic low back pain despite its limitations regarding blinding and follow-up duration.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLBP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow back pain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMean difference\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMCLBP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMechanical chronic low back pain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMCID\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMinimal clinically important difference\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMMST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eModified\u0026ndash;modified Schober test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultiple imputation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eODI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOswestry Disability Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRandomized controlled trial\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRange of motion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e36\u0026ndash;Short Form\u0026ndash;36\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSMD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandardized mean difference\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStrain\u0026ndash;counterstrain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTender point\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual Analog Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of the Faculty of Health Sciences, Marmara University (Approval No: 2024/157). Written informed consent was obtained from all participants prior to enrollment. The study was registered on (13/12/2024) ClinicalTrials.gov under the protocol number NCT06748859.\u003c/p\u003e\n\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eJHB conceived and designed the study protocol and coordinated the preparation of the manuscript. MJ and O\u0026Ccedil; contributed to the methodological design, with a particular focus on the statistical approach. \u0026Ccedil;\u0026Ccedil; and G\u0026Ccedil;A contributed to the clinical planning of patient recruitment, eligibility assessment, and randomization procedures. OA critically reviewed the protocol for clarity and methodological accuracy. ZS supervised the protocol development and provided expert guidance throughout the process. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors gratefully acknowledge the generous support of Chiropractic Australia, the European Academy of Chiropractic, and The Royal College of Chiropractors, which provided coverage of the article processing charge (APC) for this manuscript. The authors also extend their sincere thanks to all study participants for their valuable contributions.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eCONSORT and SPIRIT checklists are provided in Additional files 1 and 2, respectively. All the statistical commands used in this study are included in Additional file 3, and the Excel sheet used for mean difference (MD) pooling is available in Additional file 4. The detailed distributions of the outcome measures and between-group analyses are presented in Table 2 and 3. The dataset supporting the conclusions of this article is included within the article and its Additional file 5. The study protocol is provided in Additional file 6.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerreira ML, De Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M, et al. 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The effectiveness of strain counterstrain in the treatment of patients with chronic ankle instability: A randomized clinical trial. J Man Manipulative Therapy. 2014;22(3):119\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1179/2042618614y.0000000069\u003c/span\u003e\u003cspan address=\"10.1179/2042618614y.0000000069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoura GM, Elshiwi AM, Selim M, Asiri AA, Alqahtani RH, Elimy D et al. Comparing the Therapeutic Impact of Strain-Counterstrain and Exercise on Low Back Myofascial Pain Syndrome: A Randomized Trial. J Multidisciplinary Healthc 2025;Volume 18:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/jmdh.s499927\u003c/span\u003e\u003cspan address=\"10.2147/jmdh.s499927\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 2 and 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mechanical low back pain, strain-counterstrain, iliopsoas, manual therapy","lastPublishedDoi":"10.21203/rs.3.rs-7648408/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7648408/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMechanical chronic low back pain (MCLBP) often involves dysfunction in soft tissues, particularly in the iliopsoas muscle, which is crucial for lumbar stability and movement. This study aimed to evaluate the effects of the strain-counterstrain (SCS) technique applied to iliopsoas tender points (TPs) on pain reduction and lumbar mobility in individuals with MCLBP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eBetween January and March 2025, this unmasked randomized controlled trial (RCT) Between January and March 2025 enrolled 36 volunteers aged 18\u0026ndash;60 years with MCLBP and iliopsoas tenderness. Thereafter, they were randomly allocated (1:1) to either a control group (exercise only, 6 sessions) or SCS group (exercise\u0026thinsp;+\u0026thinsp;iliopsoas-targeted SCS, 6 sessions). The primary outcomes were pain at rest and during flexion, as measured by the visual analog scale (VAS). The secondary outcomes included lumbar flexion and extension range of motion (ROM), spinal mobility, iliopsoas muscle length, Oswestry Disability Index (ODI), and Short Form-36 (SF-36) score. Assessments were performed at baseline, after the first session, and after the sixth session.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThirty-six participants were randomly assigned to the SCS group (n\u0026thinsp;=\u0026thinsp;18) or the control group (n\u0026thinsp;=\u0026thinsp;18). Compared with those in the control group, the pain levels in the SCS group were significantly lower, with a between-group mean difference (MD) of -1.8 cm (95% CI: -2.98, 0.62) at rest and \u0026minus;\u0026thinsp;2.67 cm (95% CI: -3.97, -1.37) during lumbar flexion. After the sixth session, further reductions in pain at rest (MD -1.87 [95% CI -3.2, -0.54]) and during flexion (MD -3.32 [95% CI -5.17, -1.46]) were observed in the SCS group. Lumbar ROM improved significantly with increased flexion (MD 14.78 [95% CI 5.35, 24.25]) and extension (MD 8.17 [95% CI 2.57, 13.77]) after the sixth session. Spinal mobility, ODI scores, and SF-36 physical functioning scores improved after both sessions. No adverse events were reported.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe iliopsoas-targeted SCS technique combined with therapeutic exercises effectively reduced pain and improved lumbar mobility in patients with MCLBP, with notable improvements observed after the first and sixth sessions.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e\u003cp\u003eThe trial was prospectively registered at ClinicalTrials.gov (NCT06748859) on December 13, 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://clinicaltrials.gov/ct2/show/NCT06748859\u003c/span\u003e\u003cspan address=\"https://clinicaltrials.gov/ct2/show/NCT06748859\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e","manuscriptTitle":"Effects of the Iliopsoas Strain–Counterstrain Technique on Mechanical Chronic Low Back Pain: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-07 20:14:28","doi":"10.21203/rs.3.rs-7648408/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5de70b03-9a24-4e70-8020-fd9066b240ce","owner":[],"postedDate":"November 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T00:23:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-07 20:14:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7648408","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7648408","identity":"rs-7648408","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}