Mulligan mobilization vs. spinal manipulation effect ‎on low back pain

Mohamed Nabil Fiaad¹*, Wadida H. Elsayed², Mary Kamal Nassif Takla²,  Aly M. El Zawahry^3‎

‎¹Department of Basic Science for Physical Therapy, Faculty of Physical Therapy, Modern University for Technology and Information University, Cairo, Egypt.‎ ^‎2Department of Basic Science for Physical Therapy, Faculty of Physical Therapy, Cairo University, Egypt.‎ ³Orthopedic Surgery Department, Faculty of Medicine, Cairo University, Egypt‎‎.

Correspondence: Mohamed Nabil Fiaad, Department of Basic Science for Physical Therapy, Faculty of Physical Therapy, Modern University for Technology and Information University, Cairo, ‎Egypt.‎‎ Email: dr.m_nabil @ yahoo.com

Introduction  

In relation to human suffering, non-specific low back pain (NSLBP) is the most prevalent complaint among working-age people; it creates a financial strain owing to the use of medical facilities and the lack of job ^[1].

Non-specific low back pain includes changes in the position of the spinal joint, movement features, and/or related palpable paraspinal soft tissue alternations with symptoms that vary with physical activity; includes any abnormality in the back function, describing back pain from innervated structures ^[2].

Spine manipulation (SM) is a method of manual therapy conducted to improve ROM in a joint with decreased joint play, with the aim of relieving pain in patients. SM includes a short-amplitude high-speed "impulse" or "thrust" applied to facet joints. In a recent systematic review, the efficacy of SM in dealing with musculoskeletal pain was summarized ^[3].

Overall, evidence indicates that SM provides greater pain relief and function improvement than a placebo or no therapy. Although SM is widely used in pain management, it continues unknown in the physiological foundation of its efficacy. It was suggested that the mechanical stimuli produced by SM should activate the release of many biochemical mediators from neural tissues ^[4-6].

Mulligan has developed a comparatively fresh idea in manual therapy with implementation in the management of LBD. The idea included a sustained mobilization along the facet treatment plane while the patient performs the painful physiological motion actively. The technique is known as mobilization with movement (MWM) or SNAG, an acronym for ‘sustained natural apophyseal glide’ which can be applied to all spinal joints, the rib cage, and the sacroiliac joint. The difference between MWM and other types of mobilization lies with the combination of passive accessory movement mobilization done by the therapist with the patient’s active movement. The manual mobilization was aimed to correct the faulty position of bones ^{[7, 8]}.

 Because of the proven impact of both Spinal Manipulation and Mulligan mobilization in the musculoskeletal system dysfunction, this research was performed to compare the impacts of spinal manipulation (SM) and Mulligan-mobilization with movement (MWM) in NSLBP.

Materials and Methods

Trial design and Participants

A single-blinded randomized controlled trial design was conducted, at the School of Physical Therapy, Cairo University, Giza, Egypt, from May 2017 until July 2018. We recruited 45 participants, 24 males and 21 females, with the ages ranging from 25 to 45 years, from the outpatient clinic of the School of Physical Therapy at Cairo University. Participants with NSLBP were randomized in blocks and assigned to three equal groups (fifteen patients per group); group A (control group) received conventional physical therapy program including Superficial heating and spinal stabilization exercises (SSE), (Group B) received SSE and SM technique. (Group C) received SSE and MWM technique. Treatment was applied for 3 sessions per week for 4 consecutive weeks. All participants provided written informed consent to participate in our study. The age and BMI of the patients were written and put a closed envelope containing the patient’s name and were randomly selected for each group.

Exclusion and inclusion criteria

Inclusion criteria: (1) must have experienced LBP consistently over the preceding 3 months before the investigation; (2) Oswestry disability score (ODI) of at least 25%; (3) stiffness in the lumbar spine ; (4) The cause of the back pain was chronic NSLBP that was diagnosed by an orthopedic physician. Exclusion criteria: (1) any kind of back or leg condition as hip arthrosis, previous lumbar surgery, lumbar radiculopathy or my­elopathy, (2) undertaken physical therapy interventions for the lumbar spine in the last 3 weeks.

Assessment procedure

Pain Intensity Level Measurement by using the VAS, which uses a line of 10 cm, divided from 0 to 10, 0 refers to no pain and 10 refers to the worst pain. The patients were asked to mark along the line at the point, which refers to their level of pain.

Functional Disability was measured by the Oswestry disability questionnaire, consisted of 10  multiple choice questions for back pain, which the patient selected one of the 6 sentences that best described his/her pain intensity level, higher scores indicated great pain ^[9].

Lumbar spine flexion ROM assessed by using an inclinometer, which consists of a circular, fluid-filled disk with a bubble that indicates the number of degrees on the scale of protractor ^[10].

Interventions

Spinal Manipulation

The therapist selected the spinal level towards which to direct the SM based on the assessment of segmental mobility in a prone position. The most painful side was manipulated first followed by the other sides, based on the participant's self-report. The therapist selected either side when the participant could not specify the most painful side.

With the participant side-lying with the more painful side up and the therapist standing in front of him, the therapist flexed the uppermost leg at the knee and hip until there was a movement at the selected segment (eg. L4–L5) interspace. The participant’s uppermost foot was then placed in the popliteal fossa of the lowermost leg. Next, the therapist grasped the participant’s lowermost arm pulling it towards him, creating left trunk side bending and right rotation until feeling the motion at the L4–L5 interspace. The right index of the therapist was then placed on the right side of the L4 spinous process and the left index on the right side of L5 spinous process. The participant’s arms were then positioned around the therapist's right arm. This setup position was sustained while the participant was turned toward the therapist. Finally, the left arm of the therapist was used to apply an HVLAT at the pelvis in the anterior direction.

Mulligan’s mobilization with movement

The therapist stood behind the participant with ulnar border on the relevant spinous process centrally, in the manner described by Mulligan. SNAGs were then applied in a direction parallel to the lumbar facet joints while the participant performed an active lumbar flexion. At the end of the flexion range, each SNAG was sustained for a few seconds. Four sets of 10 repetitions were performed after a pilot experiment for the participant’s familiarization and ensuring the desired comfort. A belt was used to allow a full active pain-free flexion and stabilize the pelvic girdle ^{[7, 8]}.

Standardized exercise program

All of the participants performed a daily strengthening and stabilization exercise program for 4 weeks. The exercises were done 3 times/week, comprising a sequence of 6-10 repetitions, for 1-3 sets. While on the remaining 4 days, where they did not receive the exercise program during the physical therapy session, the participants were directed to do the exercises at home. The exercise program targeted the trunk musculature that has been identified as crucial stabilizers of the spine including transversus abdominus, oblique abdominals, multifidus/erector spinae, diaphragm, and pelvic floor ^[11].

Statistical analysis

Descriptive statistics data including the standard deviation and mean were used for demographic data (age, weight, height, and BMI), ROM (Flexion), pain intensity level, and Oswestry score variables.

 3×2 mixed design Multivariate analysis of variance (MANOVA) was used to compare the tested variables of interest at different tested groups and measuring periods.

Bonferroni correction test was used to compare the pairs of groups for post-treatment of the tested variables, in which F was significant from the MANOVA test.

 All statistical analyses were significant at the 0.05 level of probability (P ≤ 0.05).

Results

1. Demographic data: The statistical analysis by (MANOVA -test) revealed no significant differences (P>0.05) in demographic data (age, weight, height, and BMI) among the groups A, B, and C (Table 1).

Note: Data are as mean (SD), NS= P> 0.05= not significant. Body mass index =BMI,

Spinal manipulation=SM, Mobilization with movement= MWM., 3×2 Mixed design MANOVA

1. Overall effect

The 3×2 mixed design MANOVA indicated that significant differences were (P=0.005; P<0.05) between the tested groups (the first independent variable) in all tested dependent variables; flexion ROM, pain intensity level, and Oswestry score. Moreover, significant differences (P=0.0001; P<0.05) were between the measuring periods (the second independent variable) in the tested dependent variables. Moreover, the interaction between the two independent variables was significant (P=0.0001; P<0.05), which indicated that the effect of the tested group (first independent variable) on the dependent variables was influenced by the measuring periods (second independent variable) (Table 2). 

2. Lumbar flexion ROM
   1. Comparison of pre- and post-flexion ROM between the groups

Table (3) represents the mean values of lumbar flexion ROM within each group (A, B, and C).                      

1. 2. Comparison of pre- and post-flexion ROM between the groups

A significant increase was in lumbar flexion ROM favor of group B than groups A and C (Table 3).    

1. 3. Bonferroni correction of post-lumbar flexion ROM between the groups

Mean differences between the groups showed that the spinal manipulation group (group B) had the highest scores in lumbar flexion ROM values (Table 4).

3. Pain intensity level
   1. Comparison of pre- and post-pain intensity level between the groups

Table (3) represents the mean values of pain intensity level within each group (A, B, and C).

1. 2. Comparison of pain intensity level between the groups A, B, and C

There was a significant improvement in the pain intensity level in favor of group B than group A and C.

1. 3. Bonferroni correction of post-pain intensity level between the groups

Mean differences between the groups showed that the spinal manipulation group (group B) had the lowest scores in pain intensity level values (Table 4).                  

4. Oswestry score
   1. Comparison of pre- and post-Oswestry score between the groups

Table (3) represents the mean values of the Oswestry score between the groups (A, B, and C).

1. 2. Comparison of Oswestry score between the groups A, B, and C

A significant decrease was observed in the Oswestry score in favor of group B than groups A and C (Table 3).                   

1. 3. Bonferroni correction of post-Oswestry score between the groups

 Mean differences between the groups showed that the spinal manipulation group (group B) had the lowest scores in the Oswestry score values (Table 4).

Note:Data are as mean, S=Significant= P-value < 0.05, NS= P> 0.05= not significant.

Spinal manipulation=SM, Mobilization with movement= MWM.

Note: Note: Data are as mean difference & confidence interval (CI 90%) and S=Significant= P-value < 0.05, NS= P> 0.05= not significant.