Low back pain (LBP) refers to the discomfort or pain localized commonly in the lumbar region (lower rib cage to gluteal folds). It is one of the most common issues faced by our population and it can be classified into two types: specific low back pain (SLBP) and non-specific low back pain (NSLBP). SLBP is caused by identifiable structural problems, while NSLBP is caused by unidentifiable structural changes. Lumbar dysfunction plays an important role in the etiology of low back pain. The lumbar spine lies between the L1 and S3 segments and gives rise to major nerves that innervate the lower extremities. The complex anatomy of the lumbar spine is an incredible combination of strong vertebrae, many articulated bony elements, flexible ligaments/tendons, large muscles, and high blood pressure (1). It also has a complex innervation and vascular supply (2).Pain in the back, specifically the lower back region, occurs because of the following reasons: muscle tightness, joint stiffness, muscular spasm, joint issues and many more (3). One of the most common causes of lower back pain is sciatica, which accounts for around 60-80% of lower back pain cases. Emotional, psychosocial and socioeconomic statuses account for lower back pain as well. Lower back pain originating from any of the mentioned factors needs to be addressed accordingly (4).

Usually, low back pain is nonspecific or general in nature. Mechanical low back pain mainly arises from issues in the spine, intervertebral discs, or surrounding tissues. Medical history or the presence of red flags can help identify serious conditions that do not resolve on their own and may require further evaluation. These red flags include loss of movement or feeling, sudden or excessive urination, history of cancer, recent spinal surgery, and age-related injuries.

Chronic low back pain, usually caused by deep musculature dysfunction, results in the compromise of lower back structures. There are many ways to treat this disease, including surgery, medication, physical therapy, and exercise, but strong evidence of their effectiveness is often lacking (5). Among these treatments, both MFR and dynamic cupping have proven to be safe and effective treatment options.

Myofascial release is a technique that involves the application of light, sustained pressure to the tissues and fascia. Additionally, this method promotes the softening of scar tissue and helps restore normal tissue function. The effects of this treatment develop gradually over time. Studies show that MFR helps minimize pain by reducing adhesions, releasing trigger points, regulating the connective tissues, and regaining fascia tension (6). MFR is normally well-authorized, and most athletes experience some form of MFR when stretching.

Dynamic cupping is a process that involves placing cups on the affected area and generating a negative pressure in the cup, using a vacuum gun. The dynamic cupping is a method that uses suction (with or without incision) to address various health issues and medical conditions. The negative pressure results in increased blood flow to the affected area and puts a stretch on the spastic musculature, which relieves pain, eases soft structures and improves range of motion (7). It boosts blood circulation and production of endogenous opioids.

Generally, the complications of dynamic cupping can be categorized into two types: preventable and unavoidable. The most frequently observed side effects include erythema, edema and ecchymosis, which result directly from the treatment. Skin burns have also been reported. Prolonged exposure to high vacuum for more than 20 minutes when the cup is full can cause the skin layer to separate from the dermal base. This problem is only shown in cupping therapy(8).

The clinical trial was conducted at the Pakistan Sports Board, Lahore and the data was obtained over the course of 10 months. 28 participants were recruited using convenience sampling and were divided into two interventional groups: Group A (n=14) received Dynamic Cupping therapy, while Group B (n=14) was treated with the Myofascial Release technique. The sample consisted of both male and female athletic participants aged between 18 and 35 years. They were all experiencing non-specific low back pain with a Numeric Pain Rating Scale (NPRS) score between 3 to 10. Participants with systemic conditions (e.g., diabetes mellitus, tuberculosis, arthritis, scoliosis), a history of fracture within the past six months, disc bulges, or any other structural abnormalities were excluded. Additionally, it was ensured that each participant had not stayed out of sports for the last 6 months. The following data collection tools were used: Inclinometer: a sensor used to measure the magnitude of the inclination angle or deformation of any structure. It has a reliability and validity of (r = 0.93; P < 0.001) (13). Numeric PAIN Rating Scale: a pain screening tool, commonly used to assess pain severity at that moment in time using a 0–10 scale, with zero meaning “no pain” and 10 meaning “the worst pain imaginable”. It has a reliability and validity of (r=.79, p=.096). Informed consent was obtained from all participants in both English and Urdu before data collection began. The data was recorded using our questionnaire on two instances: Day 1 and after 6 weeks of treatment. This was a single-blinded study, with the assessor being blinded to group allocation. Data analysis was performed using SPSS for Windows software (version 25).

A total of 28 athletes participated in the trial, who were randomly divided into Group A and Group B. There were no dropouts, and all participants completed the study. After data collection, SPSS (version 21) was used for analysis. Means, standard deviations, and percentages were used to summarize demographic variables and categorical data. A significance level of 0.05 was established for all statistical tests. The data was examined for normality using the Shapiro-Wilk test. As the p-values were less than 0.05, non-parametric tests were applied for data analysis to account for deviations from normal distribution.

Table 1: This table indicates the frequency and percentage of gender, BMI, and sports in both the groups.

Table 2: Pre-treatment reading parametric (Independent t-test). Parametric t-test was applied on group 1 (cupping) to compare with group 2 (myofascial release). A non-significant result was obtained.

Table 3: Post-treatment reading parametric (Independent t-test). Parametric t-test was applied on group 1 (cupping) to compare with group 2 (myofascial release). A significant result was obtained.

Table 5: Non-Parametric Mann-Whitney U test was applied between groups pre-treatment.

Table 6: Non-Parametric Mann-Whitney U test was applied between groups pre-treatment. A significant result was obtained.

Table 7: Group A parametric test (paired sample test). Parametric test paired sample t-test was applied on group A (Cupping). A significant result was obtained.

Table 8: Group B Parametric test (paired sample test). Parametric test paired sample t-test was applied on group B. A significant result was obtained.

This study aimed to compare the effectiveness of Dynamic Cupping and Myofascial Release in managing non-specific low back pain among athletes. The study sample included 28 participants from various sports, including cricket, badminton, wrestling, running, and football. The mean age of participants was 26.78 ± 3.51 years in Group A and 25.14 ± 3.27 years in Group B. Across both the groups, the majority of the participants (85.7%) had a normal body mass index (BMI), while 14.3% were classified as overweight. In Group A, 21.45% were cricketers, 21.4% were badminton players, 28.6% were runners, 14.3% were footballers and wrestlers accounted for 14.3%. In Group B, 28.6% were cricketers, 14.3% were badminton players, 21.4% were runners, 21.4% were footballers and wrestlers accounted for 14.3%. To assess pain and range of motion, Numeric Pain Rating Scale (NPRS) and an inclinometer were used, respectively. Rotation was measured in inches using a tape measure. Previous research has examined various approaches to Myofascial Release (MFR) and Dynamic Cupping (DC); however, none has specifically focused on their effects within an athletic population. Hence, there has not been a direct comparison of their relative effectiveness in managing non-specific low back pain among athletes. Therefore, this study was conducted exclusively on athletes with the primary aim of comparing the effects of Dynamic Cupping and Myofascial Release on pain and range of motion in athletes with non-specific low back pain. The results of this study indicated that both interventions were effective in reducing pain and improving range of motion. However, Dynamic Cupping produced more rapid and significant improvements than Myofascial Release, with a statistically significant p-value of 0.05, highlighting its clinical relevance and efficacy. Nevertheless, the positive outcomes observed with Myofascial Release suggest that it remains a valid and beneficial alternative for treating low back pain in athletes. In conclusion, both Dynamic Cupping and Myofascial Release significantly help to manage low back pain, but dynamic cupping has demonstrated better results in comparison to myofascial release. In dynamic cupping, the application of a constant localized negative pressure with to-and-fro motion stimulates the chemoreceptors and promotes vasodilators through production of vasodilators like adenosine, norepinephrine and histamine. This physiological response enhances local blood circulation, facilitates the removal of excess fluids and toxins, reduces adhesions, and revitalizes connective tissue. In contrast, Myofascial Release primarily only relaxes or loosens up the muscle fibers. Henceforth, Dynamic Cupping may be a more efficient and targeted intervention for athletes experiencing non-specific low back pain.

When evaluating the effects of Dynamic Cupping and Myofascial Release on pain and range of motion in athletes with low back pain, within-group analyses revealed significant improvements with both interventions. However, between-group comparisons indicated that Dynamic Cupping was more effective than Myofascial Release.

ETHICAL APPROVAL: The study protocol was approved by Riphah Interantaional University’s Ethical Committee for Clinical Studies (Approval No. REC/RCR& AHS/23/0414) Dated: 02.01.2023).

PATIENTS’ CONSENT: Written informed consent was obtained from the legal guardians of all infants.

COMPETING INTEREST: The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION: Muhammad Umer Atif & Sidra Zafar contribute to the Design and concept of this study. Rahat Ayub contribute to the data Analysis of this manuscript. Hamna & Tamknat Ilyas contribute to the data collection for this study. Rabia Iqbal do work on the methodology & results section of this manuscript. Sania Maqbool contribute to the write up and review of this manuscript. Analysis or interpretation of the data and critical revision of the manuscript for important intellectual content. All authors approved the final version of the manuscript to be published.