approximately 8085% of the adult population has experienced or suffers from lower back 
 pain , which results in difficulty while walking and turning in bed1 . in physical therapy in clinical settings ,
measures to 
 alleviate pain frequently include manipulative physiotherapy in addition to physiotherapy 
 and guidance for everyday management and exercise2 . however , some individuals who experience sudden onset of pain have 
 a good prognosis in which the pain is alleviated without the cause of the pain becoming 
 known .
this is known as nonspecific lower back pain , and this pain may originate in the 
 sacroiliac joints , the intervertebral joints , the muscles , or fascia or may arise from acute 
 trauma to the annulus fibrosus of the intervertebral disc3 . of these , pain originating from the intervertebral joints occurs 
 most commonly , and accounts for 7080% of all cases of lower back pain4 .
the first - line treatment for nonspecific lower back pain is 
 conservative therapy , with the main component being physical therapy5 .
typically , conservative therapy includes rest , drug 
 therapy , nerve blocks , traction therapy and physiotherapy .
williams flexion exercises , 
 exercises that focus on strengthening the abdominal muscles , and stretching are also 
 performed in combination with pain relief5 . since conservative therapy for acute lumbago
does not increase the 
 sensation of physical restraint or fear of moving compared with aggressive exercise therapy , 
 some reports state that it is best to continue everyday activities within acceptable pain 
 limits2 . on the other hand , conservative 
 therapy for chronic lower back pain
involves therapeutic exercises consisting mainly of 
 exercises for the trunk muscles and stretching , which are reported to be more effective than 
 anti - inflammatory analgesics6,7,8 .
when a noxious stimulus is applied to the area surrounding the intervertebral joints , 
 referred pain associated with muscle spasms occurrs at a high frequency from the gluteal 
 region to the tensor fasciae latae muscle ( including the iliotibial band ) .
if left 
 untreated , this can lead to muscle contraction , which exacerbates lower back pain . 

additionally , in the case of patients with chronic lower back pain who have no neurological 
 symptoms in the lower limbs , performing ds of the tflm and hamstrings can result in an 
 immediate improvement in posture and gait .
however , while there are several studies 
 regarding physical therapy for acute lower back pain that have focused on lower back pain 
 exercises and physiotherapy , there are very few studies focusing on interventions targeting 
 specific muscles , and we found no reports of 3-month follow - ups of subjects . in this study , we adopted a single patient with acute nonspecific lumbago as a subject .
the 
 subject performed ds of only the tflm , and the immediate effects thereof were analyzed using 
 a single - case study design .
we also conducted a 3-month follow - up study in order to 
 investigate the usefulness of this therapy .
the subject was a 60-year - old woman ( height , 157  cm ; weight , 58  kg ; body mass index , 23.6 ; 
 hairdresser ) diagnosed with acute lumbago ( nonspecific lower back pain ) originating in the 
 intervertebral joints .
the patient had not experienced any back pain before and reported 
 that the pain had occurred in the muscles near the 4th and 5th lumbar vertebrae due to long 
 periods of standing ( as more than 12 hours ) , and that the pain increased the following day , 
 rendering the patient unable to stand in the same position for longer than 5 minutes without 
 sitting down .
the purpose 
 of this study was fully explained to the patient and her consent to participate was obtained 
 in writing based on the principles of the helsinki declaration .
the subject voluntarily 
 agreed to participate in the experiment after listening to the purpose and methods of the 
 study . on examination by the doctor ,
the patient was found to be negative for lasgue s sign , and 
 was deemed to have no neurological symptoms such as weakening of the lower limbs or sensory 
 disturbance .
acute lumbago is defined as lower back pain that develops suddenly and that is 
 not associated with neurological symptoms or pain in the lower limbs either during the 
 initial examination or during the course of the illness .
patients complain of pain that 
 develops within a single day and a temporary inability to move the body or corresponding 
 pain , with the patient seeking medical advice within 14 days of onset9 . because there are no specific diagnostic criteria for lower 
 back pain originating from the intervertebral joints ,
diagnosis is made comprehensively 
 using physical findings and imaging findings based on previous research and plain x - rays . 

diagnostic criteria9 included findings of 
 localized tenderness approximately 2  cm from the midline in the area of the intervertebral 
 joints , particularly at the height of the interspinous processes , pain in the multifidus 
 muscle , an absence of trigger points in the affected and painful muscles , and anteflexion of 
 the trunk with notably restricted torsion and retroflexion .
differential diagnoses , which 
 included neurological symptoms , tumors , or general medical conditions , were all excluded . 

the subject did not exhibit any serious neurological symptoms or clinical symptoms ; thus , 
 the need for x - ray imaging was deemed to be low .
but 2 days after the examination , the back pain 
 remained unchanged , and the subject visited our offices .
the single - case study design systematically measures and evaluates patient performance by 
 providing planned treatment and is said to be a case study method with experimental elements 
 that allows new intervention methods to be assessed on a pilot study - basis10 .
the ab - type design involved repeating an a period ( primary basic significance level 
 period ) and a b period ( treatment introduction period ) , which is the most basic method of 
 verifying a treatment and its effectiveness .
various dependent variables can be assessed by 
 establishing periods in which conventional treatment is performed or not performed ( periods 
 a and b ) and by establishing a period in which a new treatment is performed . in this study 
 design , a position that alleviated the lower back pain
was adopted for 10 minutes during 
 period a , and ds of the left and right tflm was performed for approximately 10 minutes 
 during period b. during this time , treatment was performed in the first 5 minutes , and the 
 remaining 5 minutes were used for rest . during the treatment , a thumb was applied to the 
 muscle being treated while exerting as little pressure as possible , and the opposite hand 
 was used to press down on the thumb from above , which caused extension .
the main areas for treatment were the tflm 
 and the myotendinous junction of the iliotibial band .
the amount of pressure applied did not 
 exceed 5 on the vas . with the subject in the prone position ,
the hip joint was abducted to 
 45 degrees with the knee flexed at 90 degrees .
pain was measured using the visual analog scale ( vas ) , finger - to - floor distance ( ffd ) , and 
 degree of lumbar kyphosis .
after intervention in the a and b periods , the changes in the 
 vas , ffd , and lumbar kyphosis indices were measured 5 times a minute .
a 100  mm scale was used for the vas measurement , with the left end of the scale 
 indicating no pain at 0  mm and the right end of the scale indicating pain at 100  mm . during 
 ffd measurement ,
the subject was instructed to attempt to reach as far as possible toward 
 the tips of their toes with their fingertips without bending the knees , and to stop bending 
 forward when pain appeared in the lumbar region . at this point ,
the posterior lumbar flexibility ( plf ) test was used 
 to assess the range of posterior lumbar mobility .
the test starts with both hips at 45 
 degrees of flexion ; the hip joint of the leg placed superiorly is then flexed , and the thigh 
 is brought as close as possible to the chest until resistance is felt . during flexion ,
the 
 angle at which pain was reported was recorded and was used as an indicator of lumbar 
 flexibility .
we also used the 
 same indicators for the entire 3 months and performed a follow - up study of physical 
 function .
no interventions were added , and changes in the vas , ffd , and plf indices were 
 measured 5 times in 1 minute .
the patients were advised to stay active and continue ordinary daily activity as tolerated . 

she was also advised to maintain the pelvic tilt at all times , so that her lower back did 
 not sway forward . when doing any task where she would be standing for a long period of time , 
 such as ironing or doing dishes , shampooing , or , face sled , she was advised to put step 
 stool or to sit on a high stool .
her most 
 common sleeping position was on her side , with her legs and hips aligned and flexed .
because 
 this position leaves her upper leg unsupported , the top knee and thigh tend to slide forward 
 and rest on the mattress , rotating the lower spine .
this slight rotation may contribute to 
 back or hip pain . to prevent that problem ,
she was advised to place a pillow between her 
 knees and thighs . to determine the efficacy of the intervention , a statistical analysis of changes in the 
 vas , ffd and plf obtained during periods a and b was performed using the probability of 
 binomial distribution .
the probability of binomial distribution used in this study involved 
 creating a regression line using the least squares method from a data point in period a , 
 extending this regression line to period b , and statistically testing the number of data 
 points that fell above ( or below ) the line11 .
the binomial distribution was calculated using the formula 
 p(r)=n!/r!(n - r)!pq . in this formula ,
n was the total number of 
 data points in period b and p and q were the probability that the data points lay above or 
 below the regression line .
after the first treatment ( first day ) , we noted a 
 significant decrease in the vas and ffd and a significant increase in the plf test results .. 
 after the second treatment ( first week ) , we observed a significant decrease in the vas and 
 ffd and a significant increase in the plf test results .
after the third treatment ( second 
 week ) , we observed a significant decrease in the ffd and a significant increase in the plf 
 test results . after the fourth treatment ( third week ) and
fifth treatment ( fourth week ) , no 
 significant differences were observed in either the ffd or the plf test results .
the vas was 
 0  mm from the third treatment ( second week ) onwards ( table 1table 1 .
effects of direct stretching of the tensor fasciae latae musclefirst treatmentafter 1 weekafter 2 weeksafter 3 weeksafter 4 weekstermvasffdplfvasffdplfvasffdplfvasffdplfvasffdplf851511024101200101300514505145821511028101200101350514505145a861511023101200101350514505145891511022101200101300514505145841511024101200101300514505145251012005135051450514505145231012005135051450514505145b231012505135051450514505145251012505135051450514505145211012005135051450514505145a : primary basic significance level period , b : treatment introduction period , vas 
 ( mm ) : visual analog scale , ffd ( cm ) : finger - to - floor distance , plf (  ) : posterior 
 lumbar flexibility ) .
, no 
 significant differences were noted between the ffd and plf results in the second and third 
 months in period b ( table 2table 2 .
results from the 3-month follow - uptermvasffdplfvasffdplfvasffdplf051450514505145051450514505145a051450514505145051450514505145051450514505145a : primary basic significance level period , vas ( mm ) : visual analog scale , ffd ( cm ) : 
 finger - to - floor distance , plf (  ) : posterior lumbar flexibility ) . a : primary basic significance level period ,
b : treatment introduction period , vas 
 ( mm ) : visual analog scale , ffd ( cm ) : finger - to - floor distance , plf (  ) : posterior 
 lumbar flexibility a : primary basic significance level period , vas ( mm ) : visual analog scale , ffd ( cm ) : 
 finger - to - floor distance , plf (  ) : posterior lumbar flexibility
in order to determine the effect on lower back pain , we used the vas as the pain scale , ffd 
 for flexibility , and the plf test for posterior lumbar flexibility .
the vas and ffd are also 
 easy to use in clinical settings and are easily for patients to understand .
the plf test is 
 used to measure the range of motion of the lumbar spine , and negative conversion is only 
 considered to have occurred when sufficient posterior inclination of the pelvis is 
 permitted , at which point at which the flexibility of the lumbar spine first starts to 
 improve .
the plf test is a simple test of contracture to assess mobility of the lumbar 
 spine .
noxious stimulation of the intervertebral joints is the cause of reflexive spasms of the 
 multifidus muscle , and findings of multifidus muscle tenderness are important for the 
 assessment of lower back pain originating in the intervertebral joints11 .
the sudden onset of lower back pain in our subject was thought to have been caused by 
 mechanical stimulation of the intervertebral joints due to long periods of standing 
 triggering reflexive spasms of the multifidus muscle .
most cases of acute lumbago recover 
 spontaneously , but when the pain is inappropriately neglected , in addition to persistent 
 spasms of the multifidus muscle , the withdrawal reflex is enhanced due to increased 
 secondary hyperalgesia at the level of the spinal cord , which creates a new movement pattern 
 and ultimately results in a vicious cycle of pain .
severe pain associated 
 with reflexive spasms in the multifidus muscle due to noxious stimuli leads to immobility of 
 the lumbar region .
furthermore , a new movement pattern associated with enhanced withdrawal 
 reflex is formed , resulting in functional compensation by the hip joints below the lumbar 
 spine , and forcing the hip joints to move excessively .
the contraction and muscle spasms of 
 the tflm increase the tension in the iliotibial band , thereby promoting anterior inclination 
 of the pelvis .
contractions and muscle spasms in the hamstrings act to promote posterior 
 inclination of the pelvis . in other words ,
simultaneous contraction of both muscle groups 
 reduces the degree of freedom of the pelvis , and this increases the amount of stress placed 
 on the lumbar region during everyday activities .
the compensatory tflm spasms that result 
 from this can be understood as a secondary disorder , which enhances the lower back pain and 
 is assumed to be one cause of chronic lower back pain .
the reason the lower back pain not 
 progressing to chronic lower back pain in our subject is likely due to the compensatory tflm 
 spasms being assessed at an early stage and thus improving . in the present study , by only applying manipulative extension to the tflm ,
the range of 
 motion of the hip joint and pelvis significantly improved , which may have led to decreased 
 pain in the lumbar region .
kippers et al.13 noted a correlation with anteflexion of the trunk in a standing 
 position when the lower limbs were extended and elevated .
however , the correlation with 
 lumbar flexion was weak , and trunk anteflexion in a standing position was found to reflect 
 the extensibility of the hamstrings . in the present study ,
ffd improved immediately , 
 irrespective of the fact that no extension of the hamstrings was performed .
the tflm is 
 commonly connected to the hamstrings through the fasia14 . as a result
the 
 tflm fibers penetrate the fascia lata , the gluteus maximus muscle , the gluteus medius 
 muscle , and the vastus lateralis muscle14 .
we assume that the degree of tension on the tflm may indirectly 
 influence the muscle tension of the muscle groups that surround the thigh .
a significant 
 increase was also observed in the mean plf values . in general , in cases of lower back pain 
 originating from the lumbar intervertebral joints , posterior lumbar flexibility is reduced 
 due to persistent muscle spasms of the multifidus muscle and restriction of the 
 intervertebral joints themselves .
accordingly , multifidus muscle relaxation and improvement 
 of the range of motion of the lumbar intervertebral joints have been suggested in order to 
 increase the range of posterior lumbar flexibility . in this study ,
ds of the tflm had an immediate effect on acute lumbago , and results of a 
 3-month follow - up study showed that no recurrence of pain occurred during the 3 months , the 
 minimum period required to determine efficacy .
the above results suggest that ds of the tflm 
 not only has an immediate effect on acute , non - specific lumbago , but also has a long - term 
 effect .
   [ purpose ] a 3-month follow - up study was conducted on a patient diagnosed with acute 
 nonspecfic lumbago . 
 direct stretching ( ds ) of the tensor fasciae latae muscle ( tflm ) was 
 performed , and an immediate effect was confirmed . 
 [ subjects ] the case subject was a 
 60-year - old woman diagnosed with acute nonspecific lumbago . 
 [ methods ] we used a 
 single - case study design and an ab - type study structure , in which the leg was placed in 
 positions that relieved the back pain in period a and ds of the tflm was performed in 
 period b. the evaluation indices were the visual analog scale ( vas ) , finger - to - floor 
 distance ( ffd ) , and posterior lumbar flexibility ( plf ) , which were analyzed using the 
 binomial test . [ results ] the vas , ffd , and plf in period b showed significant improvement 
 when compared with period a. additionally , complaints of lower back pain ceased after 2 
 weeks , and the results of the follow - up study showed no recurrence of back pain during the 
 3 months . 
 [ conclusion ] the results of this study suggest that ds of the tflm has an 
 immediate effect on acute nonspecific lumbago in addition to long - term pain relief 
 effects . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION