EFFICACY OF MULLIGAN’S MOBILIZATION

VERSUS STABILIZATION EXERCISE ON

CHRONIC NONSPECIFIC LOW BACK PAIN

A THESIS
Submitted by

MOHAN KUMAR.G
in partial fulfilment for the award of the degree
of

DOCTOR OF PHILOSOPHY

Department of Physiotherapy
FACULTY OF PHYSIOTHERAPY

Dr. M.G.R.
Educational and Research Institute
(Deemed to be University)
Maduravoyal, Chennai - 95
(An ISO 21001:2018 Certified Institution, Accredited by NAAC ‘A’ Grade)
University with Graded Autonomy Status

OCTOBER 2021
 DECLARATION BY THE CANDIDATE

I declare that the thesis entitled ‘EFFICACY OF MULLIGAN’S MOBILIZATION

VERSUS STABILIZATION EXERCISE ON CHRONIC NONSPECIFIC LOW
BACK PAIN’ submitted by me for the degree of Doctor of Philosophy is a bonafide
record of work carried out by me during the period from May 2017 to March 2021 under
the guidance of Dr. JIBI PAUL and has not formed the basis for the award of any degree,
diploma, associate-ship, fellowship, titles in this or any other University or other similar
institution of higher learning and without any plagiarism.

I have also published my papers in International Journals (Scopus rated) as per list of
publications in the Annexure.

Signature of the Research Scholar

(MOHAN KUMAR.G)

ii
 BONAFIDE CERTIFICATE

Certified that the thesis entitled ‘EFFICACY OF MULLIGAN’S MOBILIZATION

VERSUS STABILIZATION EXERCISE ON CHRONIC NONSPECIFIC LOW
BACK PAIN’ is the bonafide work of Mr. MOHAN KUMAR.G (Reg. No. PT17D003)
who had carried out the research under my supervision and without any plagiarism to the
best of my knowledge. Certified further, that to the best of my knowledge, the work
reported` herein does not form part of any other thesis or dissertation on the basis of which
a degree or diploma was conferred on an earlier occasion on this or any other scholar.

Signature of the Supervisor

Dr. JIBI PAUL
Professor
Faculty of Physiotherapy
Dr. M.G.R Educational and Research Institute
Vellappanchavadi, Chennai-600077.

iii
 ACKNOWLEDGMENT

First of all I praise the ALMIGHTY, who is above all for his glorious presence in me and
for his blessings to complete this research study.

I express my sincere gratitude to Honourable Founder Chancellor

Dr. A.C. SHANMUGAM, B.A., B.L. and our Honourable President Er. A.C.S. ARUN
KUMAR, B.Tech, M.B.A. and Honourable Secretary THIRU. A. RAVI KUMAR,
M.B.A., for all their encouragement and support extended to us during the tenure of this
Thesis and also our years of studies in this university. I express my sincere thanks to Vice
Chancellor Prof. Dr. S. GEETHALAKSHMI, MBBS., M.D., Ph.D., for her moral
support and encouragement. I would like to express my gratitude to
Dr. C.B. PALANIVELU, Registrar for providing us the necessary initiative and support.

I wish to express my thanks to our university Senior Director (Research)

Dr. A. THIRUNAVUKKARASU and Dean (Research) Dr. S. RAMAMOORTHY, for
his support during this study and for providing excellent facilities for my work and the
members of Dean-Research department for providing a friendly atmosphere to work
during the years of research.

I express my heartfelt thanks to my Research Supervisor Prof. Dr. JIBI PAUL, Ph.D.,
who extended both his time and effort, for his valuable suggestions, support and endless
patience in formulating the difficult task of the research and at every stage of my research
work.

I would like to thank Principal Prof. Dr. C.V. SENTHIL NATHAN, M.P.T.
(Geriatrics), PGDDR, MIAP, MHCPC, MISCP Faculty of Physiotherapy for allowing
me to assess the institution’s splendid infrastructures.

iv
I am grateful to my external expert member Prof. Dr. M.S. SUNDARAM, Ph.D., School
of Physiotherapy, Vels Institute of science, Technology & Advanced Studies and also I
thank my internal expert member Prof. Dr. MAHENDRANATH, MBBS, MD, ACS
Medical College & Hospital, Dr. M.G.R Educational and Research Institute.

I thank Prof. Dr. PORCHELVAN Medical Biostatistian for his support and expert
guidance to complete statistical analysis.

I extend my profound thanks to ALL FACULTY MEMBERS who gave their suggestions
for the successful completion of my research work.

I thank the LIBRARIAN of my college in providing all the needed books for making this
research work.

Finally, yet importantly, I would like to express my heartfelt thanks to my PARENTS, for
the blessings, WIFE & DAUGHTER for their support and my BELOVED FRIENDS
who have given many moments to cherish and treasure that has contributed to my progress.

MOHAN KUMAR.G

v
 TABLE OF CONTENTS

CHAPTER PAGE NO.

TITLE
NO.
ACKNOWLEDGEMENT iv
ABSTRACT vi
LIST OF TABLES xii
LIST OF FIGURES xv
LIST OF SYMBOLS & ABBREVIATIONS xvii
1 INTRODUCTION 1
1.1 Motivation for the present investigation 1
1.2 Anatomy and biomechanics of lower back 2
pain
1.3 Aetiology of low back pain 5
1.4 Psychological and social factors 5
1.5 Various types of available treatment approaches 6
1.6 Spinal mobilization 7
1.7 Understanding the mechanism of action of spinal 8
mobilisation
1.8 Proposed neurophysiological mechanism of action of 9
spinal mobilisation
1.9 Stabilization exercise 10
1.10 Conventional exercise 11
1.11 Scope of the study 12
1.12 Aim of the study 12
1.13 Objectives of the study 13
1.13.1 Primary objective 13
1.13.2 Secondary objectives 13
1.14 Hypothesis of the study 13

viii
2 REVIEW OF LITERATURE 15
2.1 Non-Specific Low Back Pain (NSLBP) 15
2.2 Applied anatomy and contributing factor of NSLBP 16
2.3 Prevalence of low back pain 17
2.4 Mulligan’s mobilization exercise 22
2.5 Stabilization exercise 26
2.6 Visual Analogue Scale (VAS) 32
2.7 Modified Oswestry Back Pain Disability 33
Questionnaire (MODQ)
2.8 Back Leg Chest Dynamometer (BLCD) 36
2.9 Modified Schober's Test (MST) 37
2.10 Biering Sorensen Test (BST) 40
3 METHODOLOGY 42
3.1 Research design of the study 42
3.2 Population of the study 42
3.3 Setting of the study 42
3.4 Sample size of the study 42
3.5 Sampling method and allocation of the study 42
3.6 Duration of the study 43
3.7 Variables of the study 43
3.7.1 Independent variable 43
3.7.2 Dependent variable 43
3.8 Ethical committee approval of the study 43
3.9 Sample size calculation of the study 44
3.10 Selection criteria of the study 44
3.10.1 Inclusion criteria 44
3.10.2 Exclusion criteria 44
3.11 Tools for data collection of the study 45
3.12 Materials used 45
3.13 Procedure for data collection 45
3.13.1 Phase I of the study 45
3.13.2 Phase II of the study 46
3.13.3 Phase III of the study 47

ix
 3.14 Physiotherapy intervention 48
3.14.1 Group A: Mulligan's mobilization 48
3.14.2 Group B: Stabilization exercises 49
3.14.3 Group C: Conventional exercises 49
3.14.4 Outcome measure 50
4 DATA ANALYSIS AND RESULT 58
4.1 Data analysis 58
4.1.1 Sample size calculation 58
4.1.2 Study data analysis report 58
4.2 Result 91
5 DISCUSSION AND CONCLUSION 94
5.1 Discussion 94
5.1.1 Physiological response associated with 94
mobilization
5.1.2 Physiological response associated with exercise 95
5.1.3 Visual Analogue Scale (VAS) comparisons 96
5.1.4 Modified Oswestry back pain Disability 97
Questionnaire (MODQ) comparisons
5.1.5 Modified Schober's Test (MST) comparisons 98
5.1.6 Back Leg Chest Dynamometer (BLCD) 98
comparisons
5.1.7 Biering Sorensen Test (BST) comparisons 99
5.1.8 Reporting the level of clinical significance in
100
dependent variables based on MCID
5.1.9 Clinical significance in terms of Effect Size
102
Index (ESI)
5.2 Summary 105
5.3 Conclusion 105
5.3.1 Limitation of the study 106
5.3.2 Suggestions to the future of the study 106

x
6 REFERENCES 107
BOOK REFERENCES 124
LIST OF PUBLICATIONS 125
ANNEXURE

xi
 LIST OF TABLES

Table No. Titles Page No.

4.1 Demographic data of study participants 59
4.2 Repeated measure ANOVA was adopted to find overall 60
changes in VAS Score within Groups
4.3 Repeated measure ANOVA was adopted to find overall 62
changes in MODQ Score within Groups
4.4 Repeated measure ANOVA was adopted to find overall 64
changes in Modified schober’s test (flexion) within Groups
4.5 Repeated measure ANOVA was adopted to find overall 66
changes in Modified schober’s test (extension) within
Groups
4.6 Repeated measure ANOVA was adopted to find overall 68
changes in BLC dynamometer within Groups
4.7 Repeated measure ANOVA was adopted to find overall 70
changes Biering sorensen within Groups
4.8 Comparison of pre & post VAS score between Group A, 72
Group B and Group C
4.9 Comparison of pre & post MODQ score between Group A, 73
Group B and Group C
4.10 Comparison of pre & post Modified schober’s test (flexion) 75
between Group A, Group B and Group C
4.11 Comparison of pre & post Modified schober’s test 76
(extension) between Group A, Group B and Group C
4.12 Comparison of pre & post BLC dynamometer between 78
Group A, Group B and Group C

xii
4.13 Comparison of pre & post Biering sorensen test between 79
Group A, Group B and Group C
4.14 Comparison of VAS using one ANOVA multiple 80
comparison post hoc tukey’s HSD test between Group A ,
Group B and Group C
4.15 Comparison of MODQ using one ANOVA multiple 81
comparison post hoc tukey’s HSD test between Group A ,
Group B and Group C
4.16 Comparison of Modified schober’s test (flexion) using one 82
ANOVA Multiple comparison post hoc tukey’s HSD test
between Group A , Group B and Group C
4.17 Comparison of Modified schober’s test (extension) using 83
one ANOVA multiple comparison post hoc tukey’s HSD
test between Group A , Group B and Group C
4.18 Comparison of BLC dynamometer using one ANOVA 84
multiple comparison post hoc tukey’s HSD test between
Group A , Group B and Group C
4.19 Comparison of Biering sorensen test using one ANOVA 85
multiple comparison post hoc tukey’s HSD test between
Group A , Group B and Group C
4.20 Partial eta squared, effect size index with power of the 86
study VAS changes at repeated measure ANOVA within
Group A, Group B and Group C
4.21 Partial eta squared, effect size index with power of the 87
study MODQ changes at repeated measure ANOVA within
Group A, Group B and Group C
4.22 Partial eta squared, effect size index with power of the 88
study Modified schober’s test (flexion) changes at
repeated measure ANOVA within Group A, Group B and
Group C

xiii
4.23 Partial eta squared, effect size index with power of the 89
study Modified schober’s test (extension) changes at
repeated measure ANOVA within Group A, Group B and
Group C
4.24 Partial eta squared, effect size index with power of the 90
study BLC dynamometer changes at repeated measure
ANOVA within Group A, Group B and Group C
4.25 Partial eta squared, effect size index with power of the 91
study Biering sorensen changes at repeated measure
ANOVA within Group A, Group B and Group C

xiv
 LIST OF FIGURES

Figure No. Titles Page No.

1.1 Normal lumbar Spine 3
1.2 Lumbar spinal muscles 4
3.1 Materials used in the study 51
3.2 Subject filling Self-administered questionnaire 51
3.3 Group A: Mulligan's mobilization (Lumbar flexion) 52
3.4 Group A: Mulligan's mobilization (Lumbar extension) 52
3.5 (a) Group B: Stabilization exercises (Prone leg extension) 53
3.5 (b) Group B: Stabilization exercises (Quadruped opposite 53
arm/leg)
3.6 (a) Group C: Conventional exercises (Cat stretch) 54
3.6 (b) Group C: Conventional exercises (Camel stretch) 54
3.7 Back leg chest dynamometer (Starting position) 55
3.8 Back leg chest dynamometer (Finishing position) 55
3.9 Biering sorensen test (Starting position) 56
3.10 Biering sorensen test (Finishing position) 56
3.11 Flow chart of study participants 57
4.1 Comparison of pre & post VAS score within Group A 60
4.2 Comparison of pre & post VAS score within Group B 61
4.3 Comparison of pre & post VAS score within Group C 61
4.4 Comparison of pre & post MODQ score within Group A 62
4.5 Comparison of pre & post MODQ score within Group B 63
4.6 Comparison of pre & post MODQ score within Group C 63
4.7 Comparison of pre & post Modified schober’s test (flexion) 64
score within Group A
4.8 Comparison of pre & post Modified schober’s test (flexion) 65
score within Group B

xv
4.9 Comparison of pre & post Modified schober’s test (flexion) 65
score within Group C
4.10 Comparison of pre & post Modified schober’s test (extension) 66
score within Group A
4.11 Comparison of pre & post Modified schober’s test (extension) 67
score within Group B
4.12 Comparison of pre & post Modified schober’s test (extension) 67
score within Group C
4.13 Comparison of pre & post BLC dynamometer score within 68
Group A
4.14 Comparison of pre & post BLC dynamometer score within 69
Group B
4.15 Comparison of pre & post BLC dynamometer score within 69
Group C
4.16 Comparison of pre & post Biering sorensen score within 70
Group A
4.17 Comparison of pre & post Biering sorensen score within 71
Group B
4.18 Comparison of pre & post Biering sorensen score within 71
Group C
4.19 Comparison of pre & post VAS score between Group A, 73
Group and Group C
4.20 Comparison of pre & post MODQ score between Group A, 74
Group B and Group C
4.21 Comparison of pre & post Modified schober’s test (flexion) 76
between Group A, Group B and Group C
4.22 Comparison of pre & post Modified schober’s test (extension) 77
between Group A, Group B and Group C
4.23 Comparison of pre & post BLC dynamometer between Group 78
A, Group B and Group C
4.24 Comparison of pre & post Biering sorensen test between 79
Group A, Group B and Group C

xvi
 CHAPTER - 1

INTRODUCTION

1.1 Motivation for the present investigation

Lower Back Pain (LBP) is widely recognized as a common reason for health care visits
with intensified economic and social consequences. The Non-Specific Low Back Pain
(NSLBP) can be defined as a tension, soreness and/or stiffness in the lower back region for
which it is not possible to identify a specific cause of the pain (Chenot et al. 2017).

Recent studies portrays that NSLBP occurs in general population at any age but it has been
experienced first at the age of nine and continues to the adulthood (Ganesan et al. 2017). In
India, about 60% of people were affected by low back pain and it has become one of the
leading causes which influences peoples at all levels in the society (Bansal et al. 2020).

Mostly conservative, symptomatic, goal-oriented management programs are recommended

by most, to emphasis the pain relief and for restoring the functional capacity. Prescribing
an exercise is considered as one of the most prominent approaches for the treatment of
chronic LBP. However till now, the efficiency of such approaches as has not been tested in
Indian population among chronic LBP. World widely, the Non-specific low back pain is a
major health problem which has been categorized by the back pain which is not owed to be
significant region pathology with or without leg pain e.g., fracture of the spine,
osteoporosis, anatomical distortion (radicular syndrome) and inflammatory disorders (Urits
et al. 2019).

Physiological and anatomical fragility in the lumbar region leads to the chronic nonspecific
low back pain and it is frequently exacerbated by poor posture, which is preferred as a live
functioning impairment. The lumbar spine and muscles gets weaken around the lumbar
spine and it is considered as the major cause, which keeps the whole body in alignment
(position and compatibility).

1
The space between physical capabilities and social needs is thought to cause low back pain
among young and middle-aged persons which is created by the need for maintaining a high
level of Activity of Daily Life (ADL) at a time when age-related changes in the lumbar
spine and the tissues around the lumbar spine begin. When compared to other age groups,
young and middle-aged persons were frequently characterized by Nonspecific low back
pain since the cause is difficult to define due to its emergence with such a background
(Wettstein et al. 2019).

There are numerous risk factors associated with LBP like life style (like physical activity,
inadequate muscle strength, obesity and smoking) and occupational (heavy lifting,
twisting, bending, stooping, extended sitting and awkward posture at work) are considered
as modifiable risk factors. Whereas a previous episode of LBP, increased age, the number
of children and significant spinal abnormalities are all categorized under non-modifiable
risk factors. LBP is a major public health concern that affects people all over the world,
causing pain, functional disability and a poor quality of life. It's a common illness that
makes individuals to miss their normal work. It is widely viewed as a significant financial
burden as well as a source of great personal anxiety. Low back pain is the major cause of
activity limitation among men and women. It has an effect on both daily activities and
work routine. Since acute LBP is usually considered as nonspecific, it cannot be related
with a specific reason. Repeated episodes are frequently more painful and have more
symptoms. LBP can be caused by a variety of factors. Its level is varied, for a variety of
racial and age groups. The cause of back pain not only affects the patient but also those
around him or her, family members, as well as society as a whole (Carregaro et al. 2020).

1.2 Anatomy and biomechanics of lower back pain

The lumbar spine comprises of five vertebrae (L1–L5) with complex anatomy as shown in
Fig. 1.1 and 1.2. It is a combination of all these strong vertebrae, linked by joint capsules,
ligaments, tendons and muscles with extensive innervations. In order to safegaurd the
spinal cord and spinal nerve roots, the spine is designed to be strong. But at the same time,
it is also extremely flexible, providing mobility in various diverse planes. The symphyseal
joints between the vertebral bodies provide mobility to the vertebral column, with an
Intervertebral Disc (IVD) in between. The facet joints are located among and behind
adjacent vertebrae, conferring spine stability.

2
They exist at each spinal level and offer about 20% of the torsional (twisting) stability in
the neck and low back segments (Kaiser, Reddy and Lugo-Pico 2019). Usually ligaments
assist in joint stability between movement and rest, preventing damage from
hyperextension and hyperflexion. The three main ligaments are the Anterior Longitudinal
Ligament (ALL), Posterior Longitudinal Ligament (PLL) and Ligamentum Flavum (LF).
The canal is bordered by vertebral bodies and discs anteriorly and by laminae and LF
posteriorly. The ALL will run the entire length of the spine anteriorly , whereas PLL run
the entire length of the spine posteriorly. Laterally, spinal nerves and vessels come out
from the intervertebral foramen. The corresponding foramen will be found underneath each
lumbar vertebra, from which spinal nerve roots exit. For example, the L1 neural foramina
are situated right below the L1 vertebra, from where the L1 nerve root exits (Ayodeji,
Deborah and Allen 2016).

Fig. 1.1 Normal Lumbar Spine

3
 Fig. 1.2 Lumbar spinal muscles

The Intervertebral Discs (IVDs) are situated between vertebrae with compressible
structures which are able to distribute compressive loads by osmotic pressurization. Inside
the IVD, there exists an Annulus Fibrosus (AF), a concentric ring structure composed of
organized lamellar collagen surrounding the proteoglycan-rich inner Nucleus Pulposus
(NP). During adulthood these discs are without blood vessels, except for the periphery.
During birth, the human disc has few vascular supplies but these vessels soon diminish,
leaving the disc with little direct blood supply in the healthy adult (Frost, Camarero-
Espinosa and Foster 2019). The extensors, flexors, lateral flexors and rotators are the four
functional groups of muscles which governs the lumbar spine. The lumbar vertebra gets
blood supply from lumbar arteries that originate in aorta. At every level, the spinal
branches of the lumbar arteries go through the intervertebral foramen separating
themselves into smaller anterior and posterior branches (Ali, Reddy and Dublin 2018).

4
1.3 Aetiology of low back pain
Nearly 70-80% of people experience low back pain once or more in the society (Fatoye,
Gebrye and Odeyemi 2019). Low back pain is based on the duration of pain that exist may
be classified as acute (less than 6 weeks), sub-acute (6-12 weeks) and chronic (more than
12 weeks). In recent years, the major cause of pain is mechanical as the greatest number of
cases, after analyzing the range of motion of each spinal segment in degenerated disc
patients. Few researchers have reported that the more common causes for low back pain
are spinal instability (Wong, Karppinen and Samartzis 2017). During 2019, in India nearly
about 8% of peoples are Year Lived with Disability (YLD) due to the low back pain
problem whereas 4.6% of peoples have disability-adjusted life in musculoskeletal disorder
(Jana and Paul 2019). Researchers have found that world widely nearly 8.2% people are
suffering from low back pain (Wu et al. 2020). Various studies have reported that low back
pain in male patients is higher than the female patients with the ratio >1 range (1.11-
17.29). Numerous risk factors are associated with low back pain such as smoking, obesity,
stress and family (Ganesan et al. 2017). Also few studies have reported that high-intensity
physical activity, high spinal load, twisting, lifting and bending activities are the risk
factors of low back pain (Fatoye, Gebrye and Odeyemi 2019).

If the risk factors have been identified in the early stage it will prevent the low back pain
progression which could not end up with the chronic disease condition, thereby improving
patient’s life quality and increased performance. Thus limiting the low back pain in the
early adolescence stage will prevent low back pain progression and decreases their
associated morbidities. Low back pain will expand the basics due to the degeneration of
intervertebral disc in aged peoples suggested by Institute of Health Metrics and Evaluation
(IHME) in the year 2013. In previous studies it has been reported that the high body mass
index is associated with increased low back pain incidence (Ganesan et al. 2017). A strip
of existing evidence depends on gender differentiation in postural control with chronic
non-specific low back pain (Kahraman et al. 2018).

1.4 Psychological and social factors

An increased number of researches have looked into the effects of psychological and social
factors on the central nervous system and pain mediated through forebrain (Yam et al.
2018). Depression, fear and abnormal anxiety about pain, behavioural avoidance is the

5
confronting techniques are the high levels of pain, disability and muscle guarding (Bunzli
et al. 2017). In spite of this enhanced knowledge on the proportional contributions of these
factors in negatively impacting pain disorders, there is much debate on whether these
factors support to or cause pain problems. On contrary positive factors like adaptive coping
skills, adequate pacing and diversion might have descending inhibitory influence (Yam et
al. 2018). In selected groups with NSLBP, there is proof that cognitive behavioural
therapies decrease impairment which is cost effective (Vibe Fersum et al. 2019). However
because of the lack of an alternative diagnosis, there appears to be a rising tendency in
physiotherapy to recognize patients with nonspecific chronic low back pain as mostly
psychological. Even though most of the CLBP appears to have psychological and social
cognitive difficulties, it appears that a small subset of patients have these disorders as the
major or essential pathological cause (Schiltenwolf et al. 2017).

1.5 Various types of available treatment approaches

People with low back pain experience difficulty in day to day activities daily living which
leads to life-threatening conditions. The lumbar spine constantly moves on its available
range of motion and high levels of functional limitation patients with low back pain
(Marich et al. 2017). Traction, angular joint mobilisation, flexibility techniques, joint play
techniques, strengthening exercises, transcutaneous electrical nerve stimulation and
relaxation techniques are some of the frequently used approaches for back pain conditions.
Several kinds of treatments were used by the therapist to treat these kinds of individuals,
e.g. exercise therapy, manipulative therapy, cognitive therapy and pain education as part of
the bio psychological approach (Owen et al. 2020).

Spine Manipulation (SM) is a technique under manual therapy employed 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. Overall evidence reveals that SM provides greater pain relief and function
improvement rather than a placebo or without any therapy. Even though SM is extensively
used in pain management, it continues to be unknown in the physiological foundation of its
efficacy. It was suggested that the mechanical stimuli produced by SM would initiate the
release of many biochemical mediators from neural tissues.

6
Mulligan has developed a comparatively fresh idea in manual therapy with an execution to
control LBD. The idea included a sustained mobilization along the facet treatment plane
whereas the patient performs the painful physiological motion actively. The technique is
termed 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 intended to correct the
defective position of bones.

1.6 Spinal mobilization

Spinal mobilization can reduce the pain and changes in levels of blood markers, then some
changes in a person’s motor control (Fatoye, Gebrye and Odeyemi 2019). The manual
therapy techniques as a skilled technique like passive movements of joints and soft tissues
it will boost the tissue extensibility then it enhances the range of motion, produce
relaxation and it will reduce the joint restriction, soft tissue swelling inflammation (Kolb et
al. 2020). In chronic low back pain, there is moderate evidence based on spinal
manipulative therapy has effective and prescribing the non-steroidal anti-inflammatory
drugs (Shipton 2018). It has reported that the acute low back pain cases are treathed with
the spinal manipulative therapy and it has medium improvements in pain and function are
up to six weeks (Coulter et al. 2018). Mulligan mobilization concept includes assisting the
terminal range force with the active motion in an affected direction which before occurs
with painful and now it is pain-free. This technique is called as Mobilization With
Movement (MWM) or Sustained Natural Apophyseal Glide (SNAG). MWM technique is
efficient and reduces the pain, improves range of motion and it gives the immediate
outcome (Nasir et al. 2018).

SNAG is performed in a weight-bearing position with the mobilization force apply over
the affected area while the patient performs the active movement. SNAG can reduce pain
and it enhances the range of motion and also re fix the faculty posture (Hussien et al.
2017). Few studies are have reported that the SNAGs has an effect on lumbar spine and
few studies have investigated SNAGs has effects on biomechanical too (Hussien et al.
2015). Many studies have been reported that the lumbar stabilization exercise provides

7
strengthening to the lumbar deep musculature for chronic low back pain. Patients with low
back pain will maintain the trunk posture and lumbar stability by contracting the transverse
abdominis, multifidus. They are responsible for lumbar stability whereas the lumbar
stabilization exercise enhances the postural balance in patients with chronic low back pain
(Frizziero et al. 2021).

1.7 Understanding the mechanism of action of spinal mobilisation

Regardless of acceptable range of documents to assist the importance of applying spinal
mobilizations treatment in musculoskeletal conditions like Non-Specific Chronic Low
Back Pain (NSCLBP), the mechanisms supporting it continues to be unknown (Coronado
et al. 2012). A broad understanding of these mechanisms is essential for several reasons.
The fruitful results stated in latest studies are dependent on the recognition of likely
respondents rather identification of a specific lesion. Responders to mobilisations could be
recognized by the combination of signs and symptoms. Even though this proposed trend
would be useful in clinical practice, the clinical outcomes cannot be calculated based on
the signs and symptoms only. On contrary, once the mechanisms behind the mobilisations
are inferred, it would be possible to recognize the prognostic factors based on which future
clinical choices to identify responders could be made easier. A well established
mobilisation mechanism might enhance its recognition in clinical practice. So that, any
healthcare provider may get to apply these techniques more precisely provided there were
familiar with their mechanism of action (Bialosky et al. 2018).

Theories like gate-control mechanism (stimulation by non-noxious input is able to close

the gate to painful input) can be used to elucidate the healing effects of mobilisation
particularly a decline in pain after spinal mobilisation in addition with other biomechanical
effects (Comitato and Bardoni 2021).

In recent times, the number of studies promoting the neurophysiological mechanism was
increased; especially the spinal and supraspinal mechanisms are generally accepted ones
(Sivanesan et al. 2019). Based on the findings of a range of examinations, it was projected
that a multi-system, centrally coordinated response is the mechanism beneath the
therapeutic effects of mobilisation (Comitato and Bardoni 2021). Numerous studies have
acknowledged few other modifications related with spinal mobilisation, like variations in

8
certain vasomotor, cutaneous and sudomotor measures; these findings specifies that spinal
mobilisations may stimulate SNS (Sympathetic Nervous System) responses (Rogan et al.
2019). Also these SNS responses have been verified in parallel to pain modulation
responses followed by mobilisation in animal and human studies (Zouikr and Karshikoff
2017).

1.8 Proposed neurophysiological mechanism of action of spinal mobilisation

Pain is one of the main indicators for spinal mobilisation. Although the clinical outcomes
of spinal mobilisation are widely known, the underlying mechanisms are unclear
(Coronado et al. 2012). An increasing number of studies have demonstrated that the effect
of mobilisation goes beyond biomechanical changes, and these studies have proposed
various neurophysiological theories to explain the clinical benefits of mobilisation. These
theories suggest that spinal mobilisation has the ability to turn on a various
neurophysiological responses in central and peripheral nervous system (Bialosky et al.
2018).

Most of the musculoskeletal injuries lead to inflammation those results in peripheral

healing process which in turn influences the processing of pain (Bialosky et al. 2018). The
synergy between peripheral nociceptors and inflammatory mediators is mostly influenced
by joint mobilisation. Actually, few authors have stated variations in blood levels of
endogenous cannabinoids, serotonin, anandamide and β-endorphine following joint
mobilisation (Zou and Kumar 2018). A decline in these inflammatory mediators following
mobilisation may influence their interaction with peripheral nociceptors and control the
pain processing (Bialosky et al. 2018).

Usually pain is transmitted to substantia gelatinosa in the dorsal horn of the spinal cord by
slow-conducting fibres (unmyelinated C and myelinated A delta fibres). Then, the
nociceptive afferents are modulated via the midbrain and thalamus to the cortical level
(Groh, Mease and Krieger 2017). In addition, the pain gating (stimulation by non-noxious
input is able to close the gate to painful input) could be influenced by the downward
control systems projected from the supraspinal centres to the spinal cord. The nociceptive
information pointing to the brain can be decreased by the mechanism of pain gating which
occurs when A beta fibres (large-diameter, fast-conducting fibres) restrain A delta and C-

9
fibres (small-diameter, slow-conducting fibres) in the substantia gelatinosa. It has been
proposed that the mobilisation techniques may stimulate the pain gate mechanism
(Chapman et al. 2021). Also, sensory inputs like touch and non-threatening inputs often
elicit the gate control mechanism. It is reported that mobilisation techniques can move the
multiple structures like joints, nerves, muscles and skin. Finally the articular, muscular,
cutaneous and neurovascular afferents are stimulated (Chapman et al. 2021). As a result,
mechanoreceptors cause discharges that are transmitted by beta fibres (large diameter) to
the spinal cord, ensuring a decline in pain awareness by lowering the input from
nociceptors. However, this privileged facility of the spinal mobilisation against stimulation
of the low threshold mechanoreceptors apart from high threshold neurons has been
interrogated. Additionally, the suggested hypoalgesic responses of spinal mobilisation
might be the result of the suggested ability of the recurring movement through the
application of mobilisation to reduce the activity of joint afferents.

Spinal Manual Therapy (SMT) is generally used to treat musculoskeletal pain. Several
studies have examined the effect of spinal mobilisation on the Sympathetic Nervous
System (SNS). Various studies have explored the effect of different forms of spinal
mobilisation by calculating the outcomes relevant to the SNS such as vasomotor,
cutaneous and sudomotor responses. Most of these studies have tested the instant effects of
a single mobilisation treatment on SNS at various spinal levels in participants with and
without mechanical spinal pain conditions. Skin Conductance (SC) which is also known as
sweat response, Skin Resistance (SR), Electro Dermal Activity (EDA) and Galvanic Skin
Response (GSR) has been exploited as a measure of sympathetic activity for the past 25
years in spinal mobilisation research (Picchiottino et al. 2019).

1.9 Stabilization exercise

The stabilization exercise helps to restore normal muscle function and improves the spinal
stability to reduce pain and impairment. At various speeds the transverse abdominis is
activated prior to a limb movement, but the activation is resisted in a record of low back
pain patients (Selkow, Eck and Rivas 2017). Usually stabilization training provides the
pressure likely on to small, deep and posterior group muscles of the spinal cord,
especifically multifidus and transverse abdominis muscles. For enhancing the endurance of
muscles, to stabilizes the muscles in appropriate position reinforcement, the stabilization

10
training helps much. It also reduces pain and increases the function of the spinal cord by
stabilizing static and dynamic balance training incorporate activities are performed by the
person to overcome with their balance limitation (Hosseinifar et al. 2018).

Stabilization exercises would reduce the effect of destruction force created in the spine
during the functional activities. Stabilization program gives a short term effect and
enhanced the global impression of recovery in patients with low back pain and its outcome
is maintained for 6 to 12 months (Sumaila and Sokunbi 2019). Stabilization exercises and
treadmill training proved to be effective among low back pain patients. Also, different
studies have been reported the detained activation of transverse abdominis with
consideration to erector spine with the significant atrophy of the multifidus muscle in
subjects with chronic low back pain (Akhtar, Karimi and Gilani 2017). Meralgia
paresthetica is a condition where the pregnant population is affected by the, it can be
treated conservatively. The treatment protocol which includes the soft tissue technique
such as active release technique and posts isometric relaxation technique and active release
technique which aids to decrease the soft tissue adhesion and enhances tissue sliding
reaction.

1.10 Conventional exercise

Post isometric relaxation technique helps to relax the overused muscles by decreasing in
muscle tone in a single or group of muscles and finally enhances the normal muscle
function. The exercise program includes the cat-camel exercise and lumbopelvic stability,
these two exercises amplify the normal tissue function and sliding abilities of the
nerve (Shamsi et al. 2016). Thus in order to increase the flexibility of lumbar spine with
respect to free movement of the lumbar segment, the cat-camel exercise is widely used.
These exercise have a relaxation effect in soft tissue located in and around the lumbar
spinal segment, as a result the extensibility on soft tissue play a crucial role in improving
the normal movement pattern into day to day living with no restrictions. Therefore the cat-
camel exercise has influence on both forward and backward actions of lower back spinal
region.

Generally, the Cat-Camel stretch provides gentle mobilization of the spine and works on
stretching and strengthening core muscles. Also, it can help with pain of the low or mid

11
back which should only be performed to tolerance. The Cat-Camel exercise could help to
avoid postural deficits, particularly for people who work at a desk or those who sit for
extended periods the entire day. The cat-camel back is a gentle exercise which stretches
and strengthens the muscles that stabilizes the spine, together with the back extensors and
abdominals. When performed daily, the exercise can help to improve the function of the
back and related ailments. The major benefits of cat-camel exercise are to help in
mobilizing the back, reduce stiffness and increase flexibility in the trunk without irritating
the neck. If the cat and camel exercise were followed on a regular basis it would increase
the endurance at work, athletic performance would be boosted and also improves the
posture. In addition, these exercises can aid to decrease or prevent back pain and injury.

Finally the goal of this study was to evaluate the comparative effect in reducing in pain and
enhancements mobility, betterments in functional activities, endurance and as well as in
strength while using Lumbar stabilization exercises over Mulligan mobilization and Cat-
Camel (conventional) exercises. Thus when applying these technique, it has more benefits
in patients with low back pain it improves the stability and strength to the lumbar region, to
restore the normal functional activities; patients return to normal life .

1.11 Scope of the study

Mulligan technique and stabilization exercises techniques are commonly applied for
chronic non-specific low back pain, but there is lack of evidence on comparing the efficacy
stabilization exercises and Mulligan technique in individuals with chronic non-specific low
back pain, so this study sought to compare the efficacy of Mulligan technique and
stabilization exercises on pain, functional activities, low back muscle strength, low back
muscle endurance and range of motion as outcome measures in subjects with chronic non-
specific low back pain.

1.12 Aim of the study

To find the efficacy of mulligan's mobilization and stabilization exercise on chronic
nonspecific low back pain ailment.

12
1.13 Objectives of the study
A research objective is a fair, compact definitive description, which gives guidance to
research the factors under the investigation. It is a reason that can be sensibly
accomplished inside the normal time span and with the accessible assets.

1.13.1 Primary objective

 To investigate the comparative effect of Mulligan's mobilization, Stabilization
exercise over Conventional exercises in reducing pain and improving functional
ability, endurance, strength of spinal extensor muscles, Lumbar spinal mobility
among chronic nonspecific low back pain patients

1.13.2 Secondary objectives

 To reduce the pain intensity among chronic nonspecific low back pain patients
 To improve the functional ability among chronic nonspecific low back pain patients
 To improve the endurance among chronic nonspecific low back pain patients
 To improve the strength of spinal extensor muscles among chronic nonspecific low
back pain patients
 To improve lumbar spinal mobility among chronic nonspecific low back pain
patients

1.14 Hypothesis of the study

Hypothesis is an assumption that is made on the basis of some evidence. This is the initial
point of any investigation that translates the research questions into a prediction. It includes
components like variables, population and the relation between the variables. A research
hypothesis is a hypothesis that is used to test the relationship between two or more
variables.

Null hypothesis (H0)

 There might be no significant difference between Mulligan’s mobilization,
Stabilization exercises and Conventional exercises in reducing pain and improving
functional ability, endurance, strength of spinal extensor muscles, Lumbar Spinal
mobility among Chronic Non Specific Low Back Pain

13
 There might be no significant difference between Mulligan’s mobilization,
Stabilization exercises and Conventional exercises in reducing pain intensity
among Chronic Non Specific Low Back Pain patients
 There might be no significant difference between Mulligan’s mobilization,
Stabilization exercises and Conventional exercises in improving the functional
ability, among Chronic Non Specific Low Back Pain patients
 There might be no significant difference between Mulligan’s mobilization,
Stabilization exercises and Conventional exercises in improving the endurance of
spinal extensor muscles among Chronic Non Specific Low Back Pain patients
 There might be no significant difference between Mulligan’s mobilization,
Stabilization exercises and Conventional exercises in improving the strength of
spinal extensor muscles among Chronic Non Specific Low Back Pain patients
 There might be no significant difference between Mulligan’s mobilization,
Stabilization exercises and Conventional exercises in improving the Lumbar Spinal
mobility among Chronic Non Specific Low Back Pain patients

14
 CHAPTER - 3

METHODOLOGY

3.1 Research design of the study

The Experimental design (pre-test & post-test) of comparative type was employed to find
the comparative effect of Mulligan’s mobilization Versus Stabilization exercise on chronic
nonspecific low back pain.

3.2 Population of the study

Chronic Nonspecific low back pain patients with age group within 20 to 40 years were
included in the present study.

3.3 Setting of the study

Outpatient Physiotherapy Department, Faculty of Physiotherapy, Dr. M.G.R Educational &
Research Institute, Vellapanchavadi, Chennai and Abinaya Physiotherapy Clinics,
Lakshmipuram, Chennai.

3.4 Sample size of the study

From the population 165 (N) samples (including 10% dropout samples) were taken as the
sample.

3.5 Sampling method and allocation of the study

Systematic random sampling method was used in the study; subjects were given a series of
numbers ranging from one to one hundred and sixty five. The randomization procedure
was followed using a computer-generated technique that randomly selected n out of N. The
intervention groups are formed by selecting cases from a population of N and they were
assigned into three study Groups (A, B & C), 55 samples in each groups, Mulligan's
mobilization - Group A (n=55), Stabilization exercises - Group B (n=55) and Conventional
Exercise - Group C - Control (n=55).

42
3.6 Duration of the study
Total study duration was 12 months (from August 2018 to July 2019) and intervention
duration was 6 months. Each subject is given intervention for 10 repetitions per exercise
for 30 minutes per session with 3 sessions / week for baseline with follow up at 4th week,
12th week and 24th week.

3.7 Variables of the study

Independent variables were used to treat the Chronic Nonspecific low back pain subjects
whereas the dependent variables were applied to evaluate the pain, functional ability,
endurance, strength and spinal mobility in patients with Chronic Nonspecific Low Back
Pain.

3.7.1 Independent variable

 Mulligan's mobilization
 Stabilization exercises
 Conventional exercise

3.7.2 Dependent variable

 Pain
 Functional ability
 Endurance
 Strength
 Spinal mobility (ROM)

3.8 Ethical committee approval of the study

The Institutional Ethical Committee belonging to ACS Medical College and Hospital
(version 1.0 formed on 27.04.2015) has approved this manuscript dated 12.07.2018
(Ref No: ACSMCH/Ethical (40)/07-2018). All the procedures were performed in
accordance with the ethical standards of the responsible ethics committee of both
(Institutional and national) on human experimentation and the Helsinki Declaration of
1964 (as revised in 2008).

43
3.9 Sample size calculation of the study
The sample of 50 per group was attained with the help of N-Master Software having 80%
power and 5% α error. In the follow up study, the sample 10% would be taken extra (5
subjects) in every group to balance the dropouts. The least requisite sample size was found
to be 55 per group.

3.10 Selection criteria of the Study

It denotes that the Chronic Nonspecific low back pain patients were recruited based on the
inclusion and exclusion criteria.

3.10.1 Inclusion criteria

Age group between 20 to 40 years, both male & female subjects, National Institutes of
Health Research Task Force - “Chronic LBP problem that has persisted at least 3 months
and has resulted in pain on at least half the days in the past 6 months”, Non-Specific Low
Back Pain (NSLBP) patients attending the Abinaya physiotherapy clinic and outpatient
physiotherapy department of ACS Hospital were evaluated and categorized into three
groups, n=55 in each group, Non-Specific Low Back Pain (NSLBP) associated with
Repetitive Motion, Torsion of spine, Pushing & Pulling activities, Stumbles, Falls, Static /
Sitting work postures. NSLBP associated with abnormal high levels of Muscle guarding,
Co-contraction of muscles of Lumbar spine & Pelvis, Movement restrictions.

3.10.2 Exclusion criteria

LBA associated with Inter vertebral disease , Facet joint degeneration, Annular tear, IVDP,
Foraminal/SpinalStenosis, Spondylolisthesis, Spondylolysis, Ankylosing spondylitis,
Spinal inflammatory diseases, Nerve root compression, Trunk neuromuscular disease,
Previous spinal surgery, Malignant tumor, Hypertension, Pregnancy, LBA associated with
Negative attitude, Fear avoidance, depression, Anxiety, distress related emotions. Social
factors (work place disputes, family tensions, cultural beliefs), LBA associated with
Bladder & Bowel dysfunction, LBA associated with Night pain or Nocturnal pain, LBA
associated with Ligamentous laxity, Spinal Fractures, Neuromuscular control deficit,
Damage to IVD, Structural deformity of spine (scoliosis, khyposcoliosis), LBA associated
with Cancer/Malignancy, Infection, Inflammatory disorders / Inflammatory Back Pain

44
(IBP), Cauda equina compression, LBA associated with Constitutional symptoms (fever,
fatigue, Nausea, diarrhoea, chills & weight loss).

3.11 Tools for data collection of the study

Visual Analog Scale (pain intensity), Modified Oswestry Back Pain Disability
Questionnaire (Functional activities), Back Chest Leg Dynamometer (Muscle Strength),
Modified Schober's Test (Range of movement), and Biering Sorensen test (Muscle
Endurance).

3.12 Materials used

Assessment sheet, Back Leg Chest Dynamometer, Couch, Mulligan’s Belt, Mat, Towel,
Pillow, Inch Tape, Marker Pen (Fig. 3.1).

3.13 Procedure for data collection

The research procedure relates in detail about the ethical statements, subjects recruitment,
allocation and interest of variables in patients with Chronic Non-Specific Low Back Pain.

3.13.1 Phase I of the study

A prevalence study was done to find out thenonspecific LBP, a cluster sample of over 480
subjects in like manner populations changing age groups between 18-60 years, where
haphazardly got from office workers and drivers to be taken an interest in the examination.
Overview through a survey for investigating general wellbeing, Body mass index, age,
gender, occupation, rate and span of nonspecific LBP taken after by examination of
information utilizing reasonable factual devices. We needed to reject couple of reactions
from our investigation as they were either from individuals younger than 18 years old or
more seasoned than 60 years old. The questionnaire was outlined in such a way, it would
be simple for all age’s groups to answer the inquiries. Result of the study concludes that
the vast majority of the members had no past history of lower back pain. Some of them
could have bring down back pain because of their wellbeing condition’s, some because of
inactive way of life, some because of movement and so forth. Smoking and liquor
addiction likewise could conceivably prompt lower back pain that is nonspecific (Kumar et
al. 2019).

45
The design of the study & exercise procedures in addition with outcome measures were
accepted by the Institutional Ethics committee of Reference Number: ACSMCH/Ethical
(40)/07-2018 of ACS Medical College & Hospital (version 1.0 formed on 27.4.2015) on
12.07.2018. The sample of 50 per group was attained with the help of N-Master Software
having 80% power and 5% α error we derived the sample number is 50 per each group, In
the follow up study, the sample 10% would be taken extra (5 subjects) in every group to
balance the dropouts. The least requisite sample size was found to be 55 per group, the
outcome measure Visual Analog Scale (VAS) was considered as primary outcome measure
with SD (1.81), sample mean (6.48), population mean (7.2) and the effect size (.3978) for
sample size calculation (Heggannavar and Kale 2015).

3.13.2 Phase II of the study

Pilot-scale study was carried out to bring out the efficacy of treatment procedure &
feasibleness of selected variables 10% of the entire sample size was used which represents
45 samples (15 samples per each Group A, B & C). The above procedure was carried out
in Outpatient physiotherapy department, ACS Medical College & Hospital and Abinaya
physiotherapy clinics with the comparative pre and post type. 45 samples with Chronic
Nonspecific Low Back Pain have been taken by Systematic Random Sampling method and
allocated with 15 subjects in each group. The subjects in Group A (n=15) received
Mulligan’s mobilization, the subjects in Group B (n=15) received stabilization exercises
and control Group C (n=15). The study duration was 6 months (Base line with 3 follows
up). The parameter such as Visual Analog Scale, Modified Oswestry Back Pain Disability
Questionnaire, Back Chest Leg Dynamometer, Modified Schober’s Test and
Biering-Sorensen test was used.

VAS score shows that there is a significant difference in post test values (.000) with mean
values at 4th week (4.47), 12th week (2.93) and 24th week (1.87), when significant
difference compared to the pre test values (.739) of all the three groups with mean value
(6.13). MODQ score shows that there is a significant difference in post test values (.000)
with mean values at 4 th week (40.73), 12th week (32.27) and 24th week (26.4), when
significant difference compared to the pre test values (.477) of all the three groups with
mean value (64.73). Modified schober’s test (flexion) shows that there is a significant
difference in post test values (.000) in 4th week (.021) with mean values at 4th week (3.86),

46
12th week (4.37) and 24th week (4.97), when significant difference compared to the pre test
values (.729) of all the three groups with mean value (3.43). Modified schober’s test
(extension) there is a significant difference in post test values (.000) in 4th week (.220) but
in the 1st day of pre test and 4th week of post test it shows no significant difference (.909).
BLC Dynamometer shows that there is a significant difference in post test values, in 4th
week (.778) with mean value (46.27), in 12th week (.41) with mean value (52.60), and in
24th week (.03) with mean value (61.67), when significant difference compared to pre test
value (.865) with mean value (39.60). Beiring Sorensen test shows that there is a
significant difference in post test values (.000) but in the 4 th week of post test value (.111)
and its shows no significant difference in the 1st day of pre test (.617), with mean values at
4th week (29.87), 12th week (36.07) and at 24th week (43.93).

Results of the pilot study showed that on comparing Mean values of Group A, Group B &
Group C there is a significant difference in the Post test Mean values at 4th week, 12th week
& 24th week but stabilization exercises (Group B) which has the Lower Mean value is
effective than Mulligan mobilisation (Group A) and followed by conventional (Group C) at
P ≤ 0.05 (Mohan Kumar et al. 2020).

3.13.3 Phase III of the study

The main study was started with a total of 165 subjects were selected for the study
according to the selection criteria, which are diagnosed to have chronic nonspecific low
back pain ascertained on the basis of Self-administered questionnaire and clinical
examinations. The main aims and benefits of the treatment were explained to the patients
and a brief understanding about the study is also given, thereafter informed consent was
obtained from all participants of the study. Prior performing the baseline data collection,
subjects were finally examined for verification of eligibility by a physiotherapist with over
20 years of expertise treating patients with musculoskeletal conditions and chronic pain, in
terms of selection criteria for inclusion and exclusion. The physiotherapist assessed the
subject’s pain issue using diagnostic triage method that took into account of red flags
aspects. The goal was to see if the Chronic LBP was predominately a nonspecific in nature
and considering that there were no signs or symptoms of other pain mechanisms.

47
Finally the subjects were allocated using systematic random sampling method; subjects
were given a series of numbers ranging from one to one hundred and sixty five. The
randomization was carried out by an investigator who was blind to the individual’s
characteristics after the inclusion process and baseline data collection. The randomization
procedure was followed using a computer-generated technique that randomly selected n
out of N. The intervention groups are formed by selecting cases from a population of N
and they were randomly assigned into three groups, 55 subjects assigned for Group A, 55
subjects assigned for Group B and 55 subjects assigned for conventional group
respectively. Before the treatment is started, for each patient an assessment is taken about
the baseline score of pain, functional ability, ROM, Spinal extensor endurance and strength
will be recorded using outcome measures. Each subject is given intervention for 10
repetitions per exercise for 30 minutes per session with 3 session/ week for baseline with
follow up at 4th week, 12th week and 24th week. In this study all of the patients were able to
finish the research, hence there were no dropouts.

3.14 Physiotherapy intervention

Physiotherapy intervention is the method of treating patients using different modalities and
exercises to improve patient’s functional wellbeing in their activities of daily living.

3.14.1 Group A: Mulligan's mobilization

Patient is positioned in high sitting with therapist standing postero-lateral to handle the
patient. During MWM with SNAG the mulligan’s Belt is secured around the pelvis at
ASIS and around therapist’s gluteal folds. Therapist glides on spinous process by pushing
it towards the eyeball direction (cephalic direction) on the individual, the mobilization was
delivered on the spinous process and towards the facet joint plane. The patients were
advised to lean forward to a great extent as possible during the mobilizing force application
and then come again to their starting posture while the therapist continued to administer the
mobilizing force. Patient is asked to execute the offending motion through the glide, which
should now be pain free, Each subject is given intervention for 30 minutes per session with
3 session/week for baseline with follow up at 4 th week 12th week and 24th week, 10 glides
per session per movement (Hing et al. 2014).

48
3.14.2 Group B: Stabilization exercises
Lumbar stabilization exercise protocol comprises of stretching as a warm up for 5min
using Press Ups: Lie down on your stomach over table or mat by legs extended plus hands
slightly above the shoulders and palms down; retract shoulder blades towards the middle of
your spine; sustaining that position, raise your chest of the ground; seize for seconds
maintaining the back of the neck lengthy and make clear front hip bones reside in touch
with mat during entire movement, Prone Cobra’s: Lie down on your stomach over table or
mat while keeping your arms at your sides; lift off your chest and head over table/mat; hold
your gluteus (buttock muscles) taut and squeeze your shoulder blades together; hold briefly
and return to starting position. Superman’s: Lie down on your stomach over table or mat
using arms and legs extended; draw back shoulder blades along and in the direction of your
spines midline and bring in abdominal muscles; maintaining this position, lift opposite
arm and opposite leg ensuring that your hips in touch with the ground. Quadruped
Opposite arm/leg: In the position of a quadruped (all on fours); remain head straight along
with 90 degrees of knees bent.

Retain your core to stay back straight during whole exercise and utilize your hamstrings,
gluteus and lower back muscles to raise your leg straight while simultaneously lifting
opposite arm. Pelvic Bridge: Lie down on your back over table or mat by means of hips
and knees flexed to 90 degrees with foot flat on ground and arms palm-down at sides;
bring in abdominal muscles and hold during exercise; gradually lift your butt off the
table/mat by using your gluteus and hamstrings until your torso is in line with thighs,
Abdominal draw In with Knee to Chest: Lie down on your back over table or mat, take one
knee towards the chest whereas holding the abdominal bring in; do not use your hand to
grab the knee. These exercises are done for 20 minutes and stretching as a cool down for
5 minutes (Kisner and Colby 2012). Each subject is given intervention for 10 repetitions
per exercise for 30 minutes per session with 3 session/ week for baseline with follow up at
4th week, 12th week and 24th week.

3.14.3 Group C: Conventional exercises

Conventional exercise consists of stretching as a warm up 5 minutes, Cat & Camel
exercise the subject is instructed be on all fours with knees under hips and hands under
shoulders. Inhale and allow belly drop downwards toward ground as you see up towards

49
direction of ceiling, Exhale and curve back up as extreme as it will go (you should not feel
pain, if you do you are going too high), At same time bend neck forward and look at belly
button, these are done for 20 minutes and stretching as a cool down for 5 minutes (Mcgill
2016). Each subject is given intervention for 10 repetitions per exercise for 30 minutes per
session with 3 session/ week for baseline with follow up at 4 th week, 12th week and 24th
week.

3.14.4 Outcome measure

The outcome measures Visual Analog Scale (VAS) was employed used in this study to
assess pain severity. This VAS is a line drawn starting 0 to 10 cm (100 mm) were 0 is
denoted as no pain end and 10 is denoted as extreme pain end. The patient is instructed to
mark a point in the 10 cm line from no pain end to extreme pain end which indicates his
pain intensity. The Modified Oswestry Back Pain Disability Questionnaire (MODQ) was
employed to evaluate functional activities. The MODQ has 10 items of questions which
indicates the activities of daily living among low back pain. Each 26 item has six responses
ranging from no difficulty to maximum difficulty in functional activities. The first
response is scored 0 and the last response is scored 5, remaining intervening responses are
scored according to the rank. The total score is obtained by 50 (total possible sore) x100
gives score in percentage. MODQ score ranges 0 (no disability) to 100 (maximum
disability). The low back strength of a muscle is measured using Back Chest Leg (BLC)
Dynamometer. The measurement was done by positioning the subject in body erect with
knees bent and hand grasped at optimal height. An angle of 60 degree inclination of
forward position of spine is done initially. Application of pulling force on handle by
stretching the knee erect and drawing the chain away from the dynamometer. The reading
in kilograms was recorded after trials of three on the dial of dynamometer of the low back
muscle strength. The Modified Schober’s Test (MST) was employed to assess the range of
motion at lumbar region. The examiner stands behind the patient and locates the horizontal
line which intersects the dimples mark of Venus at top, this line was the initial landmark.
Another line was drawn above 10 cm from the initial line along with the third line was
drawn below 5 cm from the initial line. The distance linking the initial horizontal line to
the 2nd line above and third line below was measured and recorded, for lumbar flexion
patient bends forward and lumbar extension patient bends backwards from standing
position. Biering Sorensen test was employed to assess low back muscle endurance in this

50
study. The each patient was positioned in prone over the examination table, the inferior
part of body was stabilized securely over the table by three straps placed around the hip,
knee and ankle regions. The upper part of the body was hanging a distance from the table’s
edge from iliac crest with the chair placed under it for support and feeling secured before
doing the offending movement. Measurement was recorded in seconds when the patient
was asked to maintain horizontal position of upper body holding isometrically straight by
letting off the chair. The outcome of the patient’s compliance and clinical improvement
will be assessed at base line with 3 follow up for 6 months (4 th week, 12th week and 24th
week). In order to identify the Normality test, pre & post test data were grouped to check
whether the sample data has been taken from a population which was normally distributed.
Since the sample size is above 50, for finding the Normality, Kolmogorov- Smirnov test is
used. At this conditions, P < 0.05 denotes the data is normally distributed resembling the
parametric test whereas P > 0.05 denotes the data is distributed non-normally thus
resembling non- Parametric test.

Fig. 3.1 Materials used in the study

Fig. 3.2 Subject filling self-administered questionnaire

51
 Fig. 3.3 Group A: Mulligan's mobilization (Lumbar flexion)

Fig. 3.4 Group A: Mulligan's mobilization (Lumbar extension)

52
 Fig. 3.5 (a) Group B: Stabilization exercises (Prone leg extension)

Fig. 3.5 (b) Group B: Stabilization exercises (Quadruped opposite arm/leg)

53
 Fig. 3.6 (a) Group C: Conventional exercises (Cat stretch)

Fig. 3.6 (b) Group C: Conventional exercises (Camel stretch)

54
Fig. 3.7 Back leg chest dynamometer (Starting position)

Fig. 3.8 Back leg chest dynamometer (Finishing position)

55
 Fig. 3.9 Biering sorensen test (Starting position)

Fig. 3.10 Biering sorensen test (Finishing position)

56
Fig. 3.11 Flow chart of study participants

57
 CHAPTER - 2

REVIEW OF LITERATURE

This chapter deals with the gathering of the supply of articles associated with the
diagnostic tools used for assessment, examination, physiotherapy interventions like
exercises, manual therapy and an appropriate outcome tool in Non-Specific Low Back
Pain (NSLBP). There’s an absolute got to summarize the available sources in
physiotherapy, outcomes, functional impairment associated with NSLBP and to spot the
literature reviews in physiotherapy.

2.1 Non-specific Low Back Pain (NSLBP)

Successful therapies for sub-acute and chronic non-specific LBP are exercise treatment,
behavioural treatment including pain, or a combination of these. Multidisciplinary projects
have to be conveyed for vague LBP if there is no improvement with exercise or
behavioural treatment. It is, at this point, hazy what the ideal substance of these projects is.
Restoration has to be embraced with due thought and contribution of the working
environment. LBP of known reason (specific LBP) requires precise administration.
Following this procedure, a decrease in symptomatology and fewer limits of exercises are
normal. Those without employment or one with limited work due to persistent LBP will
profit most and this will be seen from the main year of such a technique (Krismer and Van
Tulder 2007). Low back pain influences a huge extent of the population and is tough to
analyze. Medicos must acknowledge the indicative ambiguity that repeatedly goes with the
condition. Recognizable proof of etiological and hazard factors, cause for back agony and
kind of occupation and organizing preventive measures, just as recovery of patients can
prompt a significant decrease in the occurrence of incapacitating back pain (Nazeer et al.
2015).

15
2.2 Applied anatomy and contributing factor of NSLBP
Non-specific low back pain largely related with body posture or poor body mechanic. Also
various other features might cause the NSLBP with anatomical problem. Some anatomical
related factors can be added up to the occurrence of NSLBP. The Lumbar flexion motion is
performed by rectus abdominis, external and internal oblique. Whereas the extension
motion is executed by longissimus, illiocostalis, semi spinalis, multifidus. The lateral
flexion motion is performed by quardatus lumborum and also supported by illiocostalis
longissimus, spinalis. For rotation motion, the prime mover is tranversus abdominis and
multifidus work contralateral for every rotation motion. Some muscles of the back that
related with the low back pain are tranverse abdominis, internal obliques, erector spinae
and multifidus. Those muscles will show low back pain problem if the muscle has poor
muscular endurance, which is correlated with prolonged posture activity. At present,
multifidus muscle dysfunction is being concerned as a causative factor in the improvement
or recurrence of sub-acute and chronic back pain. Usually, NSLBP has been classified into
two; an acute stage, in which pain persists for less than 12 weeks and chronic stage, in
which pain persists for more than 12 weeks (Kisner and Colby 2012). According to
Taguchi, the improper posture and physiological structural fragility in lumbar region can
lead to chronic NSLBP which can be called as living functioning impairment
(Taguchi 2003).

A research showed that reduced spine mobility cause disorders in muscle synergies and
subsequently improved the energy cost of sustaining the postural ability (Gawda et al.
2015). Postural pain because of prolonged sitting activity for about 2 hours a day is one of
the causes of NSLBP (Waongenngarm, Rajaratnam and Janwantanakul 2016).

Sitting in a flaccid position which is also related with weakness in the internal oblique
muscles and/or transverse abdominis which keeps the spine in one position. In turn these
muscles were prone to injury by atrophy of the multifidus and para-spinal muscle
(Waongenngarm, Rajaratnam and Janwantanakul 2016). Another study also reports that
sitting in a position such as the excessive kyphotic posture with frequent lumbar flexion or
the excessive lordotic posture with too much extension can lead to low back pain
(Dankaerts et al. 2006). A study in Japan reveals that 22% of the population aged between
20-85 years had NSLBP (Suzuki et al. 2016). In addition, it was reported that students,

16
office workers and teachers also experience NSLBP as a result of prolonged sitting for
almost 3 hours a day. The pain produced by NSLBP in a population of students, teachers
and office workers can cause physiological and psychological stress and periodically
affects the secondary disturbances in the form of lessened quality of life (Taguchi 2003).

2.3 Prevalence of low back pain

Recently an investigative research work was conducted to identify the existing research
literature and to provide an up-to-date synthesis of the epidemiology of idiopathic
adolescent spinal pain. A systematic meta-synthesis perspective was done to categorize
secondary review articles and main epidemiological studies concerning idiopathic
adolescent spinal pain. A total of 56 primary cross-sectional studies were identified. Few
studies revealed that spinal or back pain was the most frequently reported measure with the
life time prevalence figures ranged from 4.7% to 74.4% and the life time prevalence of low
back pain ranged from 7% to 72%. Finally the study decided that life time prevalence rates
increase gradually corresponding with age and approximate adult levels of about 18 years
old (Jeffries, Milanese and Grimmer-Somers 2007).

In order to determine and identify the risk factors and the prevalence of disabling and non-
disabling back pain across age in older adults a prospective cohort study was conducted in
Cambridge city which involved with participants of age more than or equal to 75. With the
help of Poisson regression the Relative Risks (RRs) and 95% CIs were estimated. Also the
prevalence of disabling and non-disabling back pain was 6 and 23% respectively was
found out by this study. But it is also noted that the existence of non-disabling back pain
did not vary notably across age (:0.90; P = 0.34) and the prevalence of disabling back pain
increased with response to age (:4.02; P = 0.04).

Recent outset disabling and non-disabling back pain at follow-up was recorded as 15 and
5%, respectively. The list of risk factors found to expect the back pain onset at follow-ups
were; 1. Substandard self-rated health (RR 3.8; 95% CI 1.8, 8.0). 2. Depressive syndromes
(RR 2.2; 95% CI 1.3, 3.7). 3. Misuse of health or social services (RR 1.7; 95% CI 1.1, 2.7)
and earlier back pain history (RR 2.1; 95% CI 1.2–3.5). Finally, the study concluded that
older adults with Substandard self-rated health, depressive symptoms, increased and

17
misuse of health and social services and a previous episode of back pain are at greater risk
of reporting future back pain onset (Docking et al. 2011).

An investigation was conducted to calculate the occurrence of chronic back pain in the
general population of Hong Kong and to assess the correlation of chronic pain among
socio-demographic and lifestyle factors and also to express the pain characteristics
between the chronic pain sufferers. In this study, totally a group of adults nearly 5,001 with
the age greater than or equal to 18 years (response rate 58%) had used from the general
population of Hong Kong. To the above set of people the Chronic Pain Grade (CPG)
questionnaire was given and socio-demographic status were received using telephone
interviews.

The study revealed that 34.9% of people have reported pain endured for more than 3
months (chronic pain), with an average of 1.5 pain sites; in that 35.2% have experienced
various pain sites, commonly on the legs, back and head with leg and back being valued as
the most important pain areas between those with multiple pain problems. The CPG
criteria were classified as 21.5% of those with chronic pain symptoms with Grade III or
greater. Fully adjusted stepwise regression analyses identified as older age, female,
existing long-term health problems, having part-time employment, higher anxiety scores,
and low self-perceived health are extensively associated with chronic pain. The study
decided that chronic back pain is widespread among the general population of Hong Kong,
and the occurrence is highest with women and middle-aged adults (Wong and Fielding
2011).

In Israel a community based prolonged study was performed on low back pain incident
episodes in which a randomized group of individuals, without low back pain at a previous
cross-sectional survey were selected for the study. The list of baseline data consisted in the
study were perception of general health, physical activity, back pain history, smoking and
work satisfaction kept as demographic variables. The study results indicated the annual
event episodes of low back pain were 18.4% and those who experienced low back pain in
the duration of the past year had a lower baseline 16 but the observation of general health
were not engaged in sporting activities when compared with those without pain. The study
revealed that occurrence of low back pain is comparatively high and expresses

18
concomitantly to baseline perception of general health with the level of sporting activities
(Jacob 2006).

A study was performed to assess the incidence and the term of severity graded low back
pain episodes in the adult population. For this purpose, a population based, prospective
cohort study design was used. An incidence cohort of 318 subjects free of low back pain
and a course cohort of 792 prevalent cases were organized from responders from a mailed
assessment. Parameters like incident, persistent, recurrent, improved, aggravated and
resolved episodes were identified by the Chronic Pain Questionnaire. At the sixth moth and
twelfth month a follow-up was done and it was recorded as 74% and 62%, considerately.
An annual estimate age and sex were also standardized. The study exposed that the
collective incidence was 18.6% (95% confidence interval CI, 14.2%-23.0%) and most low
back pain episodes were found to be mild. In that nearly 1.0% (95% CI, 0.0%-2.2%)
developed intense and 0.4% (95% CI, 0.0%-1.0%) developed disabling low back pain.
Resolution occurred in 26.8% (95% CI, 23.7%-30.0%) and 40.2% (95% CI, 36.7%-43.8%)
of episodes persisted. Also the study revealed the severity of low back pain augmented for
14.2% (95% CI, 11.5%-16.8%) and enhanced for 36.1% (95% CI, 29.7%-42.2%). Of those
that recovered, 28.7% (95% CI, 21.2%-36.2%) had a repetition within six months and
82.4% of those were mild low back pain. The young aged subjects were not experienced to
have a persistent low back pain (incidence rate ratio, 0.88; 95% CI, 0.80- 0.97) but more
likely to have resolution (incidence rate ratio, 1.26; 95% CI, 17 1.02-1.56). The study
decided that low back pain episodes are more recurring and continual in only aged adult
(Cassidy et al. 2005).

A survey was done to recognize the association between smoking and occurrence of
low back pain. There were 41 original research reports reporting 47 studies published in
the period between 1947 and 1966 were analytically reviewed for strength of association.
The result pointed out that there was no consistency of statistically significant positive
associations between smoking and back pain (Leboeuf - Yde 1999).

In an Urban New Zealander population a study was done conducted to categorize the
incidence and prevalence of low back pain. Through random telephone survey, 314
subjects were assessed. The correlation between the frequency and severity of low back

19
pain and referred lower extremity pain and other variables such as occupation, recreation,
age, sex and predominant working posture were analysed. The study indicated that point
incidence was 17.5%, weekly incidence was 33.4%, yearly incidence was 63.7% and total
incidence was 79%. Frequent minor episodes and severe episodes of low back pain were
found out to be 28.3% and 6.4% respectively. It is also estimated that 50% suffer the initial
episode before the age of 30 years and those suffering from low back pain within the last
seven days, 14.3% experience reference below the knee and the total incidence of below
knee pain was 13.7%. Finally 51.6% of subjects had pain that had lasted seven days or less,
but a third had pain for longer than seven weeks. In the long run it was found that there is
no correlation between the incidence of low back pain and referred pain and occupational
posture. Nearly 18 Studies were conducted which was associated with health related
quality of life and disability due to discomfort low back area (Laslett et al. 2005).

A research work was carried out to calculate the Health-Related Quality Of Life (HRQOL)
and disability in adolescents with Low Back Pain (LBP) referred to a hospital and
compared it with adolescents those with and without LBP from the general population. A
study design with Paired case control was also used. All consecutive adolescents with
nonspecific LBP referred to a hospital outpatient clinic (cases-patients) between the period
of January 2006 and October 2007 were differentiated to two control groups: adolescents
with LBP and adolescents without LBP from a representative sample of students. From
each group 2 controls were randomly paired with each case by sex, age and city of
residence. All subjects and controls furnished the same self-administered questionnaires,
including a generic quality-of-life (KIDSCREEN-52) and 2 low back pain-specific
(Roland-Morris Disability Questionnaire, Hannover Functional Ability Questionnaire)
instruments. An external reference was created with a group of teenagers with juvenile
idiopathic arthritis having the same questionnaire. The samples were designed to identify a
variation of more than 4.68 units in KIDSCREEN scores. Comparisons were done using t
tests and effect size estimations. The study pointed out that Patient (n = 76) had more
frequent (P = 0.005) and intense (P < 0.001) LBP than adolescents with LBP in the general
population (n = 152) and a poorer score on the Roland-Morris (5.5 vs. 4.3, P = .023) and
Hanover (4.5 vs. 3.5, P = 0.032) questionnaires. The study concluded that Adolescents
with LBP seeking specialized medical attention have better 19 HRQOL than symptomatic

20
groups from the general population but report have poorer clinical and functional status
(Fontecha et al. 2011).

In Iran, a study done on low back pain education and short term quality of life. A
randomized controlled trial approach was used. Nearly 102 female patients with low back
pain (n - 102) were randomly divided into two groups, corresponding in terms of age,
education, occupation, weight, socioeconomic status and few aspects of risk behaviour.
Group 1 (back school group, n - 50) and Group 2 (clinic group, n - 52) were received the
'Back School Programme'. The quality of life using the Short Form Health Survey (SF-36)
was assessed at two time points: at baseline and at three months follow-up. The findings
were evaluated within and between two groups. The study indicated that the 'Back School
Programme' was efficient in improving patient’s quality of life also considerable
differences were found on all 8 subscales of the SF-36 for Group 1. In case of the clinic
group (Group 2), improvement was seen on three scales (bodily pain, vitality and mental
health) but these improvements were less than in Group 1. In Group 2, significant
improvements were exposed only on 3 subscales: bodily pain (P - 0.001), vitality (P - 0.02)
and mental health (P - 0.04). The mean improvement over all eight subscales of the SF-36
was significantly better for the 'Back School Programme' group. The study finalized that
the 'Back School Programme' is a successful interference and could improve the quality of
life over a period of 3 months in patients who experience chronic low back pain (Tavafian
et al. 2007).

A research study was conducted to examine the relation between depression and pain
related disability associated with Low Back Pain (LBP) in Turkey. Nearly 3800 samples
were randomly selected for this study. The demographic characteristics like socioeconomic
status, age etc. and low back pain parameters like frequency, intensity, duration features
were investigated along with pain-related factors in responding participants. The
participants who had reported LBP on their own during the study period were considered
as the study group. It was found hat at the time of interview nearly 807 (37.1%) of the
participants reported that they had low back pain. The study group had a score of
52.91 ± 24.20 mm for visual analogue scale, 52.30 ± 10.67 for the Zung Depression Scale
and 24.53 ± 17.22 for the Quebec Back Pain Disability Scale. Age, female gender,
smoking (> 20 cigarettes per day), low socio economical status and living in a rural habitat

21
were found to be associated with low back pain. Independent risk factors like depression
(P - 0.017) and disability (P - 0.002) were kept for visual analogue scale. The study
revealed that confirmation of the frequency and intensity of low back pain along with
related factors is essential for the management and prevention of pain. Also mood swings
and self reported restriction in daily activities should be screened in patients with low back
pain (Tucer et al. 2009).

2.4 Mulligan’s mobilization exercise

A study was done to demonstrate the effectiveness of snags mobilization in chronic
mechanical low back pain with 40 patients who were randomly assigned into two groups
each having 20 patients. Group A was given SNAG consisted of stretching and
strengthening exercises while Group B was given Ultrasound instead of stretching and
strengthening exercises for 4 weeks, 3 sessions per week one session per day. The patient’s
outcome measures were assessed by Visual Analog Scale, ODI and Goniometry of Lumbar
Range of Motion. Measurements were recorded before and after the end of the treatment
phases. This study suggests that both SNAG and Ultrasound improves the symptoms of
chronic Mechanical back pain. But it was found that a better improvement was exhibited
by SNAG group than Ultrasound group. Finally based on these results SNAG and Exercise
should be the treatment of preference for chronic Mechanical Low back pain rather than
Ultrasound with Exercise (AL-Muhanna and Khan 2018).

In another Randomized Pilot Study, patients were divided into 3 groups and were given
Postero-Anterior (PA) mobilization, SNAG and Sham SNAG treatment respectively. The
PA mobilization techniques (Grade III) were performed on prone lying position (four sets
of four repetitions; last 30 seconds for each technique). Whereas the SNAG techniques
were performed accompanying with active flexion in sitting position (four sets of six
repetitions) and the sham SNAG technique was applied in sitting position while therapist
touched gently patient’s back (three sets of four repetitions). Flexion and extension Range
of Motions (ROMs) were measured before and immediately after applied interventions (by
inclinometer). It was confirmed that there is an improved flexion ROM following the
SNAG technique and increased extension ROM followed by Maitland PA mobilization
(Javaherian et al. 2017).

22
In another study where, McKenzie treatment versus mulligan sustained natural apophyseal
glides for chronic mechanical low back pain Randomized Control Trial (RCT) was
conducted at Riphah Physical Rehabilitation Centre, Pakistan Railways General Hospital
Rawalpindi, the inclusion criteria was patients of both genders with age limit of 30-70
years with minimum 4 weeks history of CMLBP. A total of 37 patients were screened out
as per inclusion criteria and randomly placed into two groups. Twenty patients in Group A
were treated with Mulligan SNAGs and 17 patients in group B with McKenzie EEP for
four weeks at two session per week and single session per day. Visual Analogue Scale
(VAS), Oswestry Disability Scale (ODI) and lumber Range of Motion (ROM) were used
as an assessment technique and were measured at baseline and at the completion of 4
weeks intervention. It was confirmed that Mulligan SNAGs are more effective in the
improvement of lumbar ROM when compared with Mechanize Extension Exercise
Program in the management of Chronic Mechanical Low Back Pain (Waqqar, Shakil-ur-
Rehman and Ahmad 2016).

A study was done on patients with nonspecific low back pain with short-term effects of
mulligan mobilization with movement on pain, disability and kinematic spinal movements.
It was done as a randomized placebo-controlled trial. In this study, subjects were blinded to
allocation, were randomized to either a real-SNAG group (n - 16) or a sham-SNAG group
(n - 16). The entire patients were treated during a single session of real/sham SNAG (3 × 6
repetitions) to the lumbar spine from a sitting position in a flexion direction. Two new KA
from a validated kinematic spine model were used and recorded with an optoelectronic
device. Pain arising at rest, during flexion as well as functional disability and
kinesiophobia was recorded through self-reported measures. These outcomes were blindly
evaluated before, after treatment and at 2-week follow-up in both groups. This study
showed evidence that lumbar spine SNAGs had a short-term favourable effect on KA-R,
pain and function in patients with nonspecific low back pain (Hidalgo et al. 2015). The
comparison between pre-treatment and post treatment test scores showed that both study
and control groups had significant improvement in all dependent variables (P > .001).
However, adding SNAG to the conventional program resulted in higher improvement in
terms of repositioning error, pain and function (P - 0.02, 0.002, 0.008) respectively
(Hussein et al. 2017).

23
A randomized controlled trial was conducted to evaluate the comparative efficacy of
lumbar stabilization exercises versus Mulligan mobilization in LBP. In this study, the
participants in Mulligan mobilization group showed marked improvement when compared
to stabilization exercise group. There was a significant improvement in pain which was
found in Mulligan mobilization group versus stabilization exercise group by monitoring
pain rating scale. The range of motion in all direction was improvised in both groups but
the improvement was more evident in Mulligan mobilization group (Nasir et al. 2018).

A comparative study was done to evaluate the outcome of Mulligan Mobilization with
Movement (MWM) and Kinesio Taping (KT) on pain, lumbar ROM and functional
disability in chronic low back pain participants. The 2 weeks intervention of MWM &KT
program resulted in significant improvement (P < 0.05) but mulligan MWM was more
significant than KT in improving functional, lumbar ROM and reduction of pain in chronic
low back pain individuals which was not evident in control. The result of the study
indicates that MWM was found to be superior to KT in improving lumbar ROM and
functional and reduction of pain among chronic LBP individuals (Dhanakotti et al. 2016).

A comparative study was done to find the relative effectiveness of mulligan bent leg rising
compared to slump stretching in the treatment of patient with low back pain. Results of the
study shows that both the techniques MBLR and SLUMP are effective in reducing pain
and alter the ROM of PSLR. However, MBLR group shows greater improvement in pain
and ROM of PSLR, then the SLUMP group in patient with Low Back Pain (Slade et al.
2014).

A Randomized Control Trial was done to evaluate the effectiveness of SNAGS

Mobilization in Chronic Mechanical Low Back Pain. Results revealed that means and S.D
of both group were significant (P - .000) statically but clinically the Group of patients
treated with SNAGS along with stretching and strengthening exercises managed pain
(pre = 7.61±1.26, post = 0.45±0.47), ODI (pre = 40±20.57, post = 9±4.69) and range of
motion (flexion pre = 31±6.01, post = 52±10.12, extension pre = 16±2.23, post = 30±5.17
right side flexion pre = 11±2.17, post = 20±4.21 and side flexion pre = 10±2.85,
post = 21±4.33, right side rotation pre = 9±1.97, post = 18±2.15) side rotation
pre = 9±2.01, post = 18±2.47 better than group of patient treated with Ultrasound along

24
with stretching and strengthening exercises in terms of pain (pre = 6.67±1.51, post = 2.83 ±
1.17), ODI (pre = 43 ± 21.62, post = 25 ± 12.8) and range of motion (flexion pre = 25 ±
5.95, post = 37 ± 10.56, extension pre =14 ± 2.13, post = 21 ± 5.41, right side flexion pre
=10 ± 2.15, post = 15 ± 2.28, left Side flexion pre=12 ± 2.75, post = 18 ± 2.96, right side
rotation pre = 9 ± 1.90, post =15 ± 2.71, left Side rotation pre = 8 ± 1.85, post =16 ±
3.17. The result of the study shows that, SNAG and exercise should be the treatment of
choice for chronic Mechanical Low back pain rather than Ultrasound with exercise (AL-
Muhanna and Khan 2018).

A two-armed randomized placebo-controlled trial was done to compare the immediate-

and short-term effects of lumbar Mulligan Sustained Natural Apophyseal Glides (SNAGs)
on patients with nonspecific low back pain with respect to 2 new Kinematic Algorithms
(KA) for range of motion and speed as well as pain, functional disability and
kinesiophobia. In this study, out of 6 variables, 4 demonstrated significant improvement
with moderate-to-large Effect Sizes (ES) in favour of the real-SNAG group: KA-R
(P - 0.014, between-groups ES Cliff δ = - 0.52), pain at rest and during flexion (Visual
Analog Scale, P - .001; ES = - 0.73/- 0.75) and functional-disability (Oswestry Disability
Index, P - 0.003 and ES = - 0.61). Kinesiophobia was not considered to be significant
(Tampa scale, P - 0.03) but presented moderate ES = - 0.46. Kinematic algorithms for
speed were not significantly different between groups (P - 0.118) with a small ES - −0.33.
All 6 outcome measures were significantly different (P ≤ 0.008) during within-group
analysis (before and after treatment) only in the real-SNAG group. No serious or moderate
adverse events were reported (Hidalgo et al. 2015).

A pilot study was conducted to evaluate the immediate effect of modified lumbar SNAG
on pain, range of motion and Back performance Scale in non-specific chronic low back
patients. The study outcome showed that the mean difference between pre and post
treatment values for VAS, Lumbar flexion ROM and Back Performance Scale were 2.58 ±
1.44, 0.26 ± 0.19 and 4.4 ± 1.71 respectively. All outcome measures were highly
significant with P - 0.000. The results conclude that modified lumbar SNAG has an
immediate effect on reducing pain and Back performance scale score and an improvement
in lumbar flexion ROM (Heggannavar and Kale 2015).

25
A randomized trial was conducted to investigate the effect over 24 hour on range of motion
and pain, of a single intervention of mulligan’s Bend Leg Raise (BLR) technique in
subjects with limited straight leg raise and Low Back Pain (LBP), 24 subjects were blinded
and randomly allocated to either a BLR or placebo group. Pain and range of SLR and was
measured prior to immediately following and 24 hour after the interventions. There is a
marked difference between the two groups immediately after the interventions (Hall et al.
2006).

A comparative study was conducted to evaluate the efficacy of Maitland Grade 1 and 2
mobilizations with mulligan snags mobilization for treating nonspecific LBP patients.
Mean difference between pre and post treatment values for NPRS and Oswestry Disability
Index in Maitland Grade 1 and 2 groups were found to be 4.40 ± 1.31 and 24.95 ± 7.702,
respectively. While in mulligan snags mobilization group was 3.20 ± 1.105 and 22.60 ±
9.202, and it was found to be significant (P < 0.05). Thus the study result shows that
mulligan mobilization is more efficient when compared to Maitland mobilization for LBP
treatment. Mulligan mobilization not only reduced the pain but also improved the normal
spine functioning.

2.5 Stabilization exercise

Lumbar stabilization and dynamic strengthening exercises together helps to strengthen the
lumbar extensors and reduce the low back pain. However, the lumbar stabilization exercise
was more effective towards lumbar extensor strengthening and functional improvement in
patients with nonspecific chronic LBP (Moon et al. 2013). In reducing the pain and
improving functional status by decreasing disability of patients with non-specific low back
pain the core stabilization exercises were found to be more effective when compared with
conventional exercises (Inani and Selkar 2013). It shows that stabilization exercise has
significant outcome on activity pattern of deep muscles, postural control, muscle
endurance and range of motion that can be considered as an effective interference in the
treatment of patients with non-specific chronic LBP (Ehsani, Mohseni and Shanbeh 2013).
Stabilization exercise is more effective than routine conventional exercise in decreasing the
pain in chronic nonspecific low back pain greatly (Akhtar, Karimi and Gilani 2017).

26
An exercise therapy that consists of individually designed programs, including stretching
or strengthening, and is delivered with supervision may improve pain and function in
chronic nonspecific low back pain. Strategies should be used to encourage adherence
(Hayden, Van-Tulder and Tomlinson 2005), General exercise programme which combines
muscular strength, flexibility and aerobic fitness would be beneficial for rehabilitation of
NSCLBP. Further research is needed into the benefits of a combined exercise intervention
programme involving muscular strength, flexibility and aerobic fitness for NSCLBP
patients, as the literature has supported the use of each of these fitness areas individually,
but more research should be conducted combining all three (Gordon and Bloxham 2016).
The current study showed that, in the population studied, the Integrated Back Stability
(IBS) programme significantly reduced pain and disability as compared with that achieved
by a back pain advice leaflet. Patients reported a positive experience of using the
programme (Norris and Matthews 2008).

A blind randomized clinical trial was done to compare the effects of lumbar stabilisation
and treadmill walk on multifidus activation, pain and functional disability in individuals
with Chronic Mechanical Low Back Pain (CMLBP). Fifty-three individuals (23 females
and 30 males) with CMLBP participated. Consecutive participants were recruited and
randomly assigned to Lumbar Stabilisation Group (LSG; n - 27) and Treadmill Walk
Group (TWG: n - 26). However, 50 participants, (LSG: n - 25; and TWG: n - 25)
completed the three week study. Participants in the LSG had lumbar stabilisation exercises
using McGill protocol while those in the TWG had walking exercise on a treadmill using
the Bruce protocol. Outcomes assessed were: Pain Intensity (PI) using Visual Analogue
Scale, Functional Disability (FD) using Oswestry Disability Index Questionnaire; and
Multifidus Muscle Activation (MMA) level using a surface electromyography machine.
Data were analysed using descriptive statistics, paired and independent t tests at α 0.05.
Participants in both groups were comparable in age (46.60±11.60 vs 45.20±12.91) years.
At baseline, PI, FD and MMA values were comparable in both groups. At the end of eighth
week of the study, the LSG when compared with the TWG, had lower scores in PI
(2.60±0.48 vs 4.50±0.12), FD (24.20±4.06 vs 40.00±10.56), with a significant higher
MMA levels (40.00±4.16 vs 30 26.95±4.04). Lumbar stabilisation exercises are more
effective than treadmill walk in the activation of multifidus muscle, reduction in pain and
functional disability in individuals with CMLBP. Lumbar stabilisation exercises are

27
recommended in the management of chronic mechanical low back pain (Bello and Adeniyi
2018).

A prospective study was carried out to evaluate the effects of varying intensities of
isometric exercises on the severity of low back pain and functional disability in chronic
low back pain patients. Participants were divided into three groups: the control group,
which performed no exercises; the dynamic strengthening group, which performed
exercises for 8 weeks and the lumbar stabilization exercise group, which performed 1 hour
twice weekly. Using Med X, the efficiency of the lumbar extensors was calculated at
various angles ranging between 0° and 72° at intervals of 12°. To measure the severity of
LBP, Visual Analog Scale (VAS) was used and to measure functional disability Oswestry
low back pain Disability Questionnaire (ODQ) was used before and after the exercise.
Compared with the baseline, lumbar extension strength at all angles enhanced appreciably
for both groups after 8 weeks. The improvements were appreciably greater in the lumbar
stabilization exercise group at 0° and 12° of lumbar flexion. However, VAS got decreased
considerably following the treatment; however, the changes were not significantly different
between the groups. ODQ scores showed improvement in the stabilization exercise group
whereas; both lumbar stabilization and dynamic strengthening exercise strengthened the
lumbar extensors and reduced the LBP condition (Moon et al. 2013).

An experimental study was done to assess the combined effect of lumbar stabilization
exercise and interferential therapy or low frequency electrical therapy in subjects with
chronic low back pain was done in India. A convenient sample of 30 subjects undergoing
study was divided into control group and experimental group with mean age of 40 years,
the outcome measures were evaluated through Visual Analog Scale and Oswestry
Disability Index. The outcome measures were obtained on first and sixth week of post
treatment intervention. Result showed the significant (P - 0.0007) reduced pain and
improved disability of experimental group than control group. The research work
concluded that combined therapy of lumbar stabilization exercise with interferential
therapy was more efficient for the treatment of chronic low back pain (Pahilaj and Kumar
2020).

28
An experimental and interventional study in India was conducted to evaluate the efficacy
of lumbar stabilization exercises to reduce back pain among the ante-natal mothers
between 28 - 36 weeks of gestation. Total samples (60) were divided into two groups that
are experimental and control group each contain 30 samples. In this study, the activities are
performed to pull tightly and releasing the back muscles to lessen the pain and increase the
flexibility. This activity was carried over for 20 to 30 sec and repeated 10 times per days
for a period of 2 weeks. McGill and Quebec scale was used. These activities includes wall
thigh slide exercise, wall inner thigh slide, seated leg reach, back twist. There was
significant reduction in low back pain level after the intervention in experimental group at
pain (Bello and Adeniyi 2017).

A randomized controlled clinical trial study was done to measure the effect of an integrated
lumbar stabilization exercise programme on a chronic low back pain population; fifty nine
patients were included in the study and were divided into two groups The intervention
group was focused on addressing the dysfunction of the back and its related muscles
through a series of exercises. The second group was referred to as the control group. In
stage I, exercises targeted for posture and movement dysfunction and activated the muscle
which stabilizes the back. In stage II, progressive exercise principles were used to enhance
‘back fitness’. Finally, in stage III, exercises were emphasized on technique specific
actions. But the control participants group received a back care advice leaflet only. The
outcome was assessed through Quebec scale and McGill pain scale. They concluded that
combined back programme considerably reduced the pain and disability when compared
with that achieved by a back pain advice leaflet (Norris and Matthews 2008).

An organized review was conducted to evaluate the dose-response-relationship between

the stabilisation exercises on pain and disability in patients with chronic Non-Specific
LBP. The review outcome reveals that the meta-regression’s mean effect size was d - 1.80
(pain) and d - 1.70 (disability) and total R2 was 0.445 and 0.17. Reasonable quality
evidence (R2 - 0.231) exposed that a training duration of 20 to 30 min brought out the
largest effect both in pain and disability, logarithmic association. Low quality evidence
(R2 - 0.125) shown that training given for 3 to 5 times per week lead to the major outcome
of SE in chronic non-specific LBP patients (inverted U-shaped association). For patients
with non-specific chronic LBP, stabilization exercise with a training frequency of 3 to 5

29
times per week (Grade C) and a training time of 20 to 30 min per session (Grade A)
obtained the largest effect on pain and disability (Mueller and Niederer 2020).

A systematized evaluation was done for investigating the efficacy of stabilisation exercises
over the other forms of exercises for the treatment of NSLBP. Meta-analysis revealed
significant advantage for stabilisation exercises over other alternative treatment or control
for prolonged pain and disability with mean difference of -6.39 (95% CI -10.14 to -2.65)
and -3.92 (95% CI -7.25 to -0.59) respectively. It was found that the difference between
these groups were clinically insignificant. While comparing over other forms of exercise,
there was no statistical or clinically significant difference were exists. Also it was recorded
that the mean difference for pain was -3.06 (95% CI -6.74 to 0.63) and disability -1.89
(95% CI -5.10 to 1.33) (Smith, Littlewood and May 2014).

A randomized controlled trial was conducted to compare the general exercise with lumbar
(stabilization) exercise and Spinal Manipulative Therapy (SMT) in patients of 18 to 80
years with Chronic Low Back Pain greater than 3 months. 66 participants were selected, 33
in each group. The groups receiving general exercises received stretching and
strengthening of major muscle groups, aerobic fitness and the lumbar stabilization group
received training for Transverse abdominals, Diaphragm and pelvic floor and the SMT
group received joint mobilization and manipulation. Outcomes included the Patient
Specific Functional Scale, Visual Analogues Scale and the Roland Morris Disability
Questionnaire. The study concluded that lumbar stabilization exercise and Spinal 33
Manipulative Therapy result in better short term function and perception of effect than
General exercise for individuals having Chronic Low Back Pain (Standaert, Weinstein and
Rumpeltes 2008).

A randomized controlled experiment study was performed to measure the aerobic walking
programme against lumbar stabilization exercise programme for chronic low back pain.
There were fifty-two sedentary patients aged between 18-65 years with chronic low back
pain were participated in this study. They were administered lumbar stabilization exercise
to experimental group and intense treadmill walking to control group for thrice a week and
continued for 4 weeks. It was measured by Six-minute walking test, back and abdomen
muscle endurance tests, Low Back Pain Functional Scale (LBPFS), Oswestry Disability

30
Questionnaire. End of the experiment showed that there was significant progress were
observed in all outcome measures in both groups and with non-significant difference
among the groups. The mean distance in meters covered during 6 minutes increased by
70.7 (95% Confidence Interval (CI) 12.3-127.7) in the ‘walking’ group and by 43.8 (95%
CI 19.6-68.0) in the ‘exercise’ group. Significant improvement in both groups were
recorded in the trunk flexor endurance test which was increased by 0.6 (95% CI 0.0-1.1) in
‘walking’ group and by 2.2 (95% CI 0.3-1.8) in ‘exercise’ group. The experiment
concluded that the four weeks lumbar stabilization exercise programme was an effective
method to reduce the low back pain.

An incidental clinical experiment was conducted for comparing the 3 various forms of
exercises particularly dynamic lumbar strengthening, Pilates and stabilization on chronic
Low Back Pain (LBP) with respect to pain, range of motion, core strength and function.
The study outcome revealed significant decrease in pain, improved core strength,
functional ability and range of motion in all 3 exercise groups. In case of lumbar
stabilization group, the improvement was noticeably improved for all the outcome
measures, while comparing with post treatment after ten sessions. The Pilates group shows
reduction of disability when compared with dynamic strengthening group and it was
recorded by pair wise comparison method. For the case of chronic nonspecific LBP, it was
observed that the lumbar stabilization found to be more competent when correlated with
the dynamic strengthening and Pilates (Bhadauria and Gurudut 2017).

A quasi-experimental study was conducted to evaluate effect of the lumbar stabilization

exercises on selected attributes of patients prevailing with non-specific chronic low back
pain. There was significant reduction in pain intensity (experimental: 6.74±1.37;
3.48±1.09; control: 6.57±1.40; 2.96±1.13) and disability index (experimental:
46.60±16.67; 26.55±14.78; control: 32.10±16.16; 24.60±15.27) and raise in back muscle
endurance (experimental: 11.05±8.39; 14.30±19.24s; control: 10.85±9.79; 13.90±11.63s)
for both groups. Experimental group had significantly greater reduction (P < 0.05) in
disability index than the controls (P - 0.048) (Abass et al. 2020).

A potential randomized clinical study was performed to evaluate the outcome of lumbar
stabilization exercise stabilization exercises on pain reduction and improving functionality

31
in patients suffering from chronic low back pain. In this experiment, the patients were
divided as study groups, who had specific lumbar stabilization exercises, while the control
groups were subjected to strengthening and stretching of the large, superficial back
muscles. After the therapy, pain was successfully reduced in both groups with higher
statistical significance among the experiment group (P < 0.001). Improvement in ODI
score was statistically more significant within the experiment group compared to the
control group (P < 0.001). Stabilization exercises in addition to the traditional programs
are proven to be effective in pain reduction and functional improvement in patients with
CLBP (Stankovic et al. 2012).

2.6 Visual Analogue Scale (VAS)

It was proved that Visual Analogue Scale (VAS) as a one-dimensional measure of pain
intensity with a parallel or perpendicular line with altering time points and descriptor
anchors self-administered pencil/paper for a minute. It does not require any training and
just the capacity to utilize a ruler to evaluate the distance to attain VAS is required. Greater
the scores greater the pain intensity and shows good test–retest consistency and it was
higher with literate when compared with illiterate rheumatology outpatients (r 0.94 and
r 0.71, respectively). Similarly the viability of this assessment was also good; VAS scores
proved to be highly concurrent with other alternative pain measure scores range (r 0.62 -
0.91). The ability to distinguish the change was excellent with the sensitive to measure
variations in pain in response to treatment or time. The minimal change in pain score
recognized by patients as meaningful known as Minimal Clinically Important Difference
(MCID) of 1.37 cm on 10-cm pain VAS; change of 1.1 points on 11-point scale. Thus
VAS score is acceptable as a suitable and valid method to measure pain intensity, but it
may not be suitable to use in aged people and / or illiterate population (Hawker et al. 2011).

Visual Analogue Scale is world widely used procedure. In this study it is technically
apparent that VAS is a reliable and valid scale with people above 18 years. In many studies
it is proved that VAS is a reliable scale but for validity it showed moderate to strong
correlation for pain measurement (Begum 2019).

A systematic review was conducted to evaluate the measurement dynamics of Numeric

Rating Scale (NRS), Visual Analogue Scale (VAS) and Pain Severity subscale of the Brief

32
Pain Inventory (BPI-PS). More studies underwent to assess the VAS, the NRS and the
BPI-PS. The instruments showed a little or very low quality support for content validity.
High-quality evidence was merely offered for NRS insufficient measurement error.
Reasonable evidence was offered for NRS inconsistent responsiveness, BPI-PS sufficient
structural validity and internal consistency and BPI-PS inconsistent construct validity.
Every VAS measurement characters were underpinned by nil, less or very least quality
evidence. Finally the analysis conclude that in spite of their vast use, there is no support to
prove that one among VAS, NRS and BPI-PS has better measurement properties in low
back pain (Chiarotto et al. 2019).

To evaluate the effect of low back pain to individual life, the physiotherapist will carry out
several assessments to evaluate low back pain and its impact. Some researchers commonly
assess the pain, Range Of Motion (ROM), functional ability and life’s quality (Park and
Seo 2014). As a subjective measurement of pain, VAS consists of a 10 cm line with two
end-points representing ‘no pain’ and ‘worst imaginable pain’. Patient’s pain was rated by
placing a mark on the line related to their existing level of pain. The VAS is recognized as
an assessment tool for pain and recommended as a means of rating the subjective pain
(Casser, Seddigh and Rauschmann 2016).

2.7 Modified Oswestry Back Pain Disability Questionnaire (MODQ)

Most of the study results showed that the measurement features of the modified OSW are
recommended to those of the QUE in numerous areas. The modified OSW showed greater
test-retest reliability over the QUE over a 4-week period of time. The modified OSW was
more susceptive than the QUE as assessed by GRI and in correlations between difference
in scores and the global rating of change. The MCID value for the modified OSW was
around 6 points, which shows consistent with other reports in the literature. The MCID for
the QUE was around 15 points. It is important that the clinicians and researchers should be
aware of the measurement properties of disability scales while judging the patient
outcomes or while clinical trials designing (Fritz and Irrgang 2001).

The excellent test-retest reliability of this study strongly corresponds to earlier studies of
the Modified version of the MODQ when comparing with Quebec back pain disability
scale (Baradaran et al. 2016). In case of lumbar stabilization group, changes in scores of

33
VAS, lumbar flexion and extension, MODQ and core strength were considerable among
the group. However, a study between groups was done and lumbar stabilization group was
compared to other two group’s shows the pain was found to be significantly decreased in
the lumbar stabilization group with P-value of 0.0001 when compared to dynamic
strengthening exercises. MODQ scores were shown to be significantly reduced with
P-value of 0.0001 when compared to the dynamic strengthening group and when compared
to the Pilates group, P-value was reduced significantly 0.0001 (Bhadauria and Gurudut
2017).

However, the progression of ODQ scores tended to be higher for lumbar stabilization
exercise group than the dynamic lumbar strengthening exercise group. Moreover, the ODQ
scores improved significantly after lumbar stabilization exercise, whereas no difference in
ODQ scores before and after the dynamic lumbar strengthening exercise. These findings
are affirmed by other studies (Moon et al. 2013), there was a statistical significant
difference seen for both the scales, i.e., MODQ and ABPS showed significant values
indicating that were equally reliable and effective tools and either can be applied as
outcome measurement tool for patients suffering from LBP (Lamba and Upadhyay 2018).
Several early experiments have stated there is a reduction in the ODI following lumbar
stabilization protocols. In certain experiments, either group had considerable reductions in
ODI from 36.74% to 23.85% (Group A) and from 40.44% to 22.96% (Group B). Neither
group showed significant difference following 4 weeks of exercise, but it was seen that the
ODI was higher in Group B when compared with Group A (17.48% in Group B vs 12.89%
in Group A) (Woo and Kim 2016).

A literature search was conducted to evaluate the psychometric parameters of the ODI as a
valuable clinical tool. The ODI shows better construct validity, allowable internal
similarity, responsiveness and test-retest reliability have been exhibited to be elevated
while the burden of administration is less. The Outcomes of the Review Evaluation tool is
a reliable and responsive assessment tool that can be used for assessing conditions related
to therapy. It is commonly used by healthcare practitioners to monitor and score patient's
responses to treatment (Vianin 2008).

34
A prospective experiment was done to validate the Persian version of the modified ODI
among low back pain patients. Intra class correlation coefficient or unique items ranged
from 0.43 to 0.80 showed good reliability and reproducibility of each item. Cronbach’s α
coefficient was 0.69 showing excellent internal uniformity over all 10 items of the Persian
MODQ. Total MODQ score exhibited strong to moderate correlation with the eight
subscales and the two domains of the SF-36. The highest correlation was between the
MODQ and the physical functioning subscale of the SF-36 (r = -0.54, P < 0.001) and the
physical component domain of the SF-36 (r = -0.55, P < 0.001) showing that MODQ is
measuring what it is supposed to measure in terms of disability and physical function
(Baradaran et al. 2016).

An experiment was carried out to assess the responsiveness of Nepali version of ODI
(NODI) with non-specific low back pain participants. The study outcome revealed that the
Area Under Curve (AUC) of NODI was found to be 0.88. The fine cut-off point on the
NODI for enhancement on the GROC-NP or the Minimal clinical Important Change (MIC)
was found to be 4.22 and it was stretched between 3.11 and 6.34. The sensitivity and
specificity was found to be 77.4% and 84.2% respectively (Binaya et al. 2021).

A cross-sectional experiment was done to evaluate the psychometric characteristics of

Urdu version of ODI among the patients with lumber radiculopathy discomfort. Urdu
version of ODI revealed outstanding test-retest reliability for total score (ICC2,1 = 0.95)
and for all item (ICC2,1 = 0.72-0.98). Cronbach’s alpha of 0.89 showed excellent internal
reliability and moderate correlation between ODI-U total score and each item through
spearman’s correlation coefficient (r = 0.51-0.76). One factor structure was created,
explaining 52.5% variance. The floor and ceiling effect of total ODI-U score were found to
be nil. Content validity was estimated by conducting interviews with patients and
integrating the expert’s opinions. The discriminative validity was calculated by
independent sample t-test, where significant difference between healthy individuals and
patients (P < 0.001) was observed. The convergent validity was evaluated through
Pearson’s correlation exhibiting moderate positive correlation of ODI-U with VAS pain
(r = 0.49) and VAS disability (r = 0.51) but moderate negative correlation with all SF-36
domains (r = -0.43 to - 0.63) (Amjad et al. 2021).

35
An eventual longitudinal validation experiment was conducted to assess the reliability and
validity of Tamil version of ODI. The Tamil version of ODI displayed a high degree of
internal consistency, with a Cronbach's alpha of 0.92. The test-retest reliability was high
(n=30) with an ICC value of 0.92 (95% CI, 0.84 to 0.96) and a mean re-test difference of
2.6 points lower on re-test. The Tamil version of ODI scores showed a strong correlation
with the RMDQ scores (r = 0.82) P<0.01, VAS-P (r = 0.78) P<0.01 and VAS-D (r = 0.81)
P<0.01. Low to moderate correlations were observed between the ODI-T and lumbar ROM
(r = -0.27 to -0.53) (Vincent et al. 2014).

Patients with NSLBP can experience activity disorders outside of the home like walking,
climbing and descending stairs, eating, travelling, wearing clothes, using the toilet, using
public transportation and other social activities. Several studies suggest using the Oswestry
Disability Index (ODI) for evaluating the functional disability caused by LBP (Anggiat et
al. 2020). The Oswestry Disability Index (ODI) is aimed specifically at LBP conditions
and is the best standard in evaluating the functional activity of people with NSLBP both
before and after the intervention. In addition, a study from Fairbank and Pynsent stated that
ODI has been translated into several other languages including English that can be used
validly and reliably for examining conditions of back (Fairbank and Pynsent 2000).

2.8 Back Leg Chest Dynamometer (BLCD)

The BLC dynamometer affords reasonably dependable test-retest measurements of BLC
strength in healthy youngsters and adults and may thus be considered a suitable tool to
measure changes in muscle strength in research and clinical settings. In addition, HGS and
KES and are shown to be strong predictors of BLC strength in healthy adults, advocating
the utilization of the BLCD in examining over all limb muscle strength (Ten Hoor et al.
2016). The conclusions drawn from the study could be stated as there were higher mean
differences in the values of back strength while using BLC dynamometer among male
gymnasts. Also, when compared between genders and the level of game results are highly
significant (Kaur and Koley 2019).

The mean strength while using BLC dynamometer of Group A at baseline was
50.86 ± 8.6 kgs and for Group B was 49 ± 10.38 kgs with t-value of 0.286, which was
statistically not significant. The mean strength of Group A was 54.33 ± 10.3 kgs and

36
64.3 ± 8.2 kgs for Group B at week 2. The t-test value was -2.93, which was statistically
significant. The mean strength of Group A was 57±11.9 kgs and 69.6 ± 10.3 kgs at weeks
4. The t-test value was -3.11, which was statistically significant, showing that improvement
in strength was more in Group B (Verma, Goyal and Narkeesh 2013).

2.9 Modified Schober's Test (MST)

This study states that this technique is reliable, valid and suitable for both the therapist and
the subject since it does not require any landmarks and fixation which are easy to palpate.
Unlike radiographic technique which has health risks in non specific low back pain
(Shetty, Balasaravanan and Ravish 2020). This study used MST because of its excellent
reliability, validity and minimum metrically detectable change of only 1 cm. MST
measures ROM pertaining to spinal elongation because a tape is attached very close to the
spine for back flexion and extension; for this reason, MST was valid when the correlation
with radiography was made. Although MST is practical and uncomplicated for any
investigators, still novices, the current study suggests that the upcoming investigators who
use the MST should practice beforehand (Sakulsriprasert et al. 2011). In this study
modified scober’s test was utilized as an diagnostic algorithm for measuring spinal
mobility among chronic non-specific low back pain conditions (Moosajee and Kalla
2015).

As a result, this study provides the standardized values for MST flexion as 6.85±1.18 cm
and extension as 2.42 ± 0.74 cm which is used for evaluating LROM. even though these
scores finds dissimilar with gender, age and strata it was found an converse association
with age for MMST extension which is found to be decreased significantly with increase in
age. MST flexion values were found to be higher in males when compared with females.
Consequently, it was suggested that clinicians and physiotherapists should assess their
patient’s lumbar ROM with respect to the above mentioned standardized values,
considering the effects of age and individual variability (Malik et al. 2016).

In evaluation among the two groups, the grades got in the present study showed non-
significant difference around the point of pain VAS pre test (6.6±0.8) and post test
(2.4±1.05), active lumbar flexion MST pre test (20.5±1.1) and post test (21.3±1.14),
extension pre test (12.1±0.76) and post test (10.43±1.8) and bilateral side bending ROM

37
between Group A which received (Mulligan MWM) and Group B which received
(Maitland P-A mobilization) (Samir, Zak and Soliman 2016).

A study was conducted to evaluate the psychometric characteristics of the Modified-

Modified Schober Test (MMST) among the low back pain patients. The outcome of the
study shows that Pearson's correlation test (r) among the measurements done by the
MMST and the gold standard, Minimum Metrically Detectable Change (MMDC), Intra-
class Correlation Coefficient (ICC) and Confidence Interval (CI) were carried out to
interpret the data. The MMST revealed moderate validity (95% CI 0.44-0.84, r = 0.67),
inter: (95% CI 0.83-0.96, ICC =0.91); outstanding reliability (intra: 95% CI 0.89-0.97, ICC
= 0.95) and a MMDC showing 1.0 cm. The current study concludes that, MMST showed
reasonable validity but outstanding reliability and MMDC (Tousignant et al. 2006).

A prospective cross sectional research was done for assessing the normative scores of
Modified - Modified Schober Test to measure lumbar extension cum flexion. In case of
MMST flexion, the normative scores were observed to be 6.85±1.18cm, while for MMST
extension the normative scores were observed to be 2.42±0.74 cm. Strata 1 exhibits
statistically higher score for MMST extension when compared to strata 2. MMST flexion
was statistically higher in males than females with significance sensitivity set at P < .05
(Malik et al. 2016). Tape measurements were the least expensive method to measure spinal
movement and perhaps the easiest to use. Physiotherapist can use the modified Schober
method to measure the flexion and extension of lumbar, since some of the studies reported
that the Schober method was one of the good methods to assess the lumbar flexibility
(Sihawong, Waongenngarm and Janwantanakul 2020).

Schober Methods for using the tape measure for measuring range of motion of the lumbar
spine are several. The initial technique used was the Schober method, in which the distance
between the lumbosacral junction and a point 10 cm above the lumbosacral junction was
measured before and after the patient flexed and extended his or her spine. The original
Schober method has been modified by changing the landmarks used when range of motion
of the spine is measured. These changes in landmarks include measuring the distance
between points 5 cm inferior and 10 cm superior to the lumbosacral junction (known as the
modified Schober) and measuring from a point in the canter of a line connecting the two

38
posterior superior iliac spines to a mark 15 cm superior to this baseline landmark
(Williams et al. 1993).

In a study that examined lumbar range of motion of 172 individuals, the original Schober
method was used. Before data collection, reliability of the Schober technique was
determined by two independent testers, who used as subjects of 17 young age not involved
in the larger study. Inter-rater dependability of the original Schober technique was reported
to be 1.0 (Pearson’s r). Although no follow-up statistical test was performed after the
Pearson correlation analysis, as is appropriate, this study was included in this chapter
because it is the only reliability study performed by using the original Schober technique.
Before collecting values of back mobility in 282 children without disability, established
reliability in a pilot study. In one of the few studies conducted to examine intrarater
reliability of the Modified Schober test, one tester measured six children between the ages
of 5 and 9 years. Intrarater reliability was analysed statistically by using an ICC, yielding
results of 0.83. The authors reported that the test was not only accurate but was relatively
easy and quick to perform on young children (Fitzgerald et al. 1983).

Inter-rater reliability of the Modified Schober technique for measuring lumbar flexion was
reported by a study where 23 individuals between the ages of 20 and 40 years. The authors
reported inter-rater reliability of 0.72 using an ICC and 0.71 using Pearson’s r. Follow-up
testing with an Analysis Of Variance (ANOVA) indicated no significant difference
between testers (Burdett et al. 1986). A comprehensive study provided intra-rater and inter-
rater reliability on the Modified Schober test administered to measure lumbar flexion.
After examining 30 males using the modified Schober method, the authors reported intra-
rater reliability of .88 and inter-rater reliability of 0.87 (Pearson’s r). Follow-up testing
using a paired t-test indicated no considerable variation related to intra-rater or inter-rater
reliability. The authors concluded that the tape measure was simple to employ and need no
expensive equipment (Hyytiainen et al. 2013)

A study was done to check the intrarater and inter-rater reliability of the Modified-
Modified Schober method for measuring lumbar flexion by using three clinicians whose
clinical experience ranged from 3 to 12 years. Testing of 15 patients with low back pain
resulted in intra-rater reliability using Pearson correlation coefficients of 0.89 for clinician

39
no.1, 0.78 for clinician no.2, and 0.83 for clinician no.3. An ICC performed among three
clinicians resulted in general inter-tester reliability coefficient of 0.72 (Williams et al.
1993).

Also investigating the intra-tester reliability and validity of the Modified-modified

Schober, examined 31 adults with low back pain. Results indicated intra-tester reliability
for two testers to be 0.79 and 0.81; inter-tester reliability between the two testers was 0.91.
Examining validity by establishing the relationship of the range found by the Modified-
Modified Schober and x-ray exam, a Pearson’s correlation of 0.67 was found (Tousignant
et al. 2005).

Their contention that the Modified Schober was a better test than the original Schober by
comparing the correlations of lumbar flexion measurements obtained by both methods
versus measurements obtained radiographically (x-rays). The correlation coefficient
(Pearson’s r) between the original Schober and the x-ray (validity) was .90 (standard error
= 6.2 degrees), and between the Modified Schober technique and the x-ray (validity), .97
(standard error = 3.3 degrees). Though data on test-retest reliability were not achieved, the
authors stated that “the proposed modification was an improvement over the original
Schober’s” (Macrae and Wright 1969).

In a second study the Modified Schober was compared against radiographic examination of
lumbar flexion in an attempt to establish validity, evaluated 11 subjects. The reliability
correlation between the Modified Schober technique and x-ray (validity) was reported as
0.43 (Pearson’s r). However, a t-test revealed no significant variation among measures
obtained with the Modified Schober and with X-rays. In contrast to the study by Macrae
and Wright, demonstrated little correlation between clinical and radiographic techniques.
The authors concluded that the Modified Schober only gave indices of back movement
which did not reflect true intervertebral movement (Macrae and Wright 1969).

2.10 Biering Sorensen Test (BST)

It was found that when the Sorensen test, the pulling test or the prone isometric chest raise
was applied to test isometric extension endurance of the low back, subjects with LBP
demonstrated lower endurance times. On the basis of the literature reviewed, we feel that

40
the Sorensen test might be of value if employed as a screening tool for preventive
measures if it is used in subjects with a history of severe LBP the pulling test requires the
use of a strain-gauge dynamometer and garners few support from studies. The prone static
chest raise and the prone double straight-leg raise are simple to employ in the clinic, but
not either one has a very substantial research base to support it at thus the Sorensen method
enjoys abundant positive support in the literature. So this test seems to be a suitable,
trustworthy and practical outcome measure for following changes in isometric extension
endurance capacity in the clinical setting. The lower repeated intensification may be partly
explained by the great improvement of the progressive strength training program that had
above the musculoskeletal system as found in the Biering Sorensen test (from 35 s to 79 s;
values below 58 have been related with a double chance of having LBP (Calatayud et al.
2020).

Back muscle endurance was measured using the Biering Sorensen test, which has
established good test-retest reliability (intra-class correlation coefficient = 0.88; standard
error of measurement, 11.6 seconds in patients with LBP), validity and responsiveness
(Hagen et al. 2015), Biering-Sørensen back extensor endurance test with the Head Arm
Trunk (HAT) as the resistance that has been shown as a suitable and reliable evaluation of
back extensor endurance, also it has been found to be positively related to back health
(Pitcher, Behm and MacKinnon 2008)

41
 CHAPTER - 4

DATA ANALYSIS AND RESULT

4.1 Data analysis

Data Analysis is the cycle of deliberately applying factual as well as coherent strategies to
portray and represent, gather and recap and assess information. A fundamental segment of
guaranteeing information trustworthiness is the precise and suitable investigation of
exploration discoveries.

4.1.1 Sample size calculation

The sample of 50 per group was attained with the help of N-Master Software having 80%
power and 5% α error. In the follow up study, the sample 10% would be taken extra (5
subjects) in every group to balance the dropouts. The least requisite sample size was found
to be 55 per group.

4.1.2 Study data analysis report

The collected data were tabulated and analyzed using both descriptive and inferential
statistics. All statistical analysis was performed using Statistical Package for Social
Science (SPSS) version 24 for Microsoft windows. Descriptive statistics were presented as
numbers and percentages the data were expressed as Mean and SD. One way analysis of
variance with a post hoc Tukey HSD test was used for continuous data. Independent
sample student t test were used to compare continuous variables between two groups.

For normality, kolmogorovsmirnov test was used to test normality. Data were normally
distributed at P > 0.05, Visual Analog Scale (.757), Modified Oswestry Back Pain
Disability Questionnaire (.576), Back Leg Chest Dynamometer (.472), Modified Schober's
Test (.437) and Biering-Sorensen Test (.506).

58
 Table 4.1 Demographic data of study participants

Demographic Group A Group B Group C Sig.

Data Mean Std. Mean Std. Mean Std.
Deviation Deviation Deviation
AGE 31.96 5.706 31.96 5.706 31.02 7.054 .677
BMI 22.60 3.198 23.71 2.315 23.24 2.336 .091
Male Female Male Female Male Female
GENDER
COUNT 31 24 30 25 26 29 -

For within group comparison repeated analysis of variance test were used. The data is
presented in the form of tables and its interpretations are given below the respective tables.
To evaluate the clinical changes in ANOVA repeated measure, within-between interactions
were estimated using partial eta squared and to evaluate the clinical changes with Cohen’s
d was estimated by G* power version 3.1.9.4

The Table 4.1on top shows that Mean values of Group A, B and C were found to be 31.96,
31.96 and 31.02 respectively with the standard deviation of 5.70, 5.70, 7.05 for Group A, B
and C respectively with regards to age. In case of BMI, the mean values of Group A, B and
C were found to be 22.60, 23.71 and 23.24 respectively with standard deviation of 3.19,
2.31 and 2.33 for Group A, B and C respectively. However the gender (Male & Female) in
Group A (M=31, F=24), Group B (M=30, F=25) and Group C (M=26, F=29) with the
percentage of Male and Female is equal.

From the Table 4.2 Repeated measure ANOVA results shows that the VAS measures
overall changes within the groups for all the three groups were found to have difference
statistically significant at (P ≤ 0.05).

59
 Table 4.2 Repeated measure ANOVA was adopted to find overall changes in VAS
Score within Groups

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 6.22 .686 6.22 .782 6.35 .615
POST
th
4.62 .913 4.07 1.03 5.58 .712
4 Week
POST
3.07 .879 2.00 1.12 4.93 .716
12th week
POST
1.98 .757 .910 .701 3.87 .840
24th week

F value 1058.00 1872 332.00

significance .001** .001** .001**

(**-P ≤ 0.05) - Significant

VAS
8
7
6
5
MEAN ±

4
SD

3 GROUP
A
2
1
0
PRE POST 4th POST 12th POST
24th
Week week week

Fig. 4.1 Comparison of pre & post VAS score within Group A

60
 VAS
8
7
6
5
MEAN ±
4
3 GROUP
SD

B
2
1
0
-1 PR POST 4th POST 12th POST
E 24th
Week week week

Fig. 4.2 Comparison of pre & post VAS score within Group B

VAS
8
7

5
MEAN ±

4
SD

3 GROUP C
Fig. 4.3 Comparison2 of pre & post VAS score within Group C

0
PR POST 4th POST 12th POST
E 24th
Week week week

61
Table 4.3 Repeated measure ANOVA was adopted to find overall changes in MODQ
Score within Groups

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 64.33 7.03 62.60 4.44 63.75 6.34
POST 40.58 2.28 45.95 3.45 53.33 7.47
th
4 Week
POST 32.04 3.43 34.64 3.36 37.33 2.97
12th week
POST 26.04 4.15 14.98 4.01 32.15 3.54
24th week
F value 1406.00 2110.00 853.00

significance .001** .001** .001**

(**- P ≤ 0.05) - Significant

From the Table 4.3 Repeated measure ANOVA results exhibits that the MODQ measures
overall changes within the groups for all the three groups were found to have difference
statistically significant at (P ≤ 0.05).

MODQ
8
0
7
0
6
MEAN ±

0
5 GROUP
SD

0 A
4
0
3
PRE POST 4th POST 12th POST
24th
Week week week

Fig. 4.4 Comparison of pre & post MODQ score within Group A

62
 MODQ
8
0
7
0
6
MEAN ±
0
SD 5 GROUP
0 B
4
0
3
0
E
PRE POST 4th POST 12th POST
24th
Week week week

Fig. 4.5 Comparison of pre & post MODQ score within Group B

MODQ
8
0

7
0

6
0
MEAN ±

5
GROUP C
0
SD

4
0

3
0
PR POST 4th POST 12th POST
E 24th
Week week week

Fig. 4.6 Comparison of pre & post MODQ score within Group C

63
 Table 4.4 Repeated measure ANOVA was adopted to find overall changes in
Modified schober’s test (flexion) within Groups

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 3.44 .391 3.32 .465 3.41 .432
POST 3.87 .445 4.11 .383 3.63 .464
th
4 Week
POST 4.28 .602 5.01 .502 3.96 .431
12th week
POST 4.98 .450 5.86 .608 4.28 .453
24th week
F value 232.00 1128.00 134.00

significance .001** .001** .001**

(**- P ≤ 0.05) - Significant

From the Table 4.4 Repeated measure ANOVA results shows that the Modified schober’s
test (flexion) measures overall changes within the groups for all the three groups were
found to have difference statistically significant at (P ≤ 0.05).

Modified schober’s test (flexion)

6

4
MEAN ±

3
SD

GROUP
2 A

0
PR POST 4th POST 12th POST
E 24th
Week week week

Fig. 4.7 Comparison of pre & post Modified schober’s test (flexion) score within
Group A

64
 Modified schober’s test (flexion)
7

MEAN ±
4

SD 3
GRO UP
B
2

0
PRE POST 4th POST 12th POST
E 24th
Week week week

Fig. 4.8 Comparison of pre & post Modified schober’s test (flexion) score within
Group B

Modified schober’s test (flexion)

5
4.
5
4
3.
MEAN ±

5
3
SD

GROUP C
2.
Fig. 4.9 Comparison
5 of pre & post Modified schober’s test (flexion)
2
1.
5
PR POST POST 12th POST
E 4th 24th
wee wee
Week k k
score within
Group C

65
 Table 4.5 Repeated measure ANOVA was adopted to find overall changes in
Modified schober’s test (extension) within Groups

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 2.21 .242 2.19 .286 2.19 .075
POST 1.83 .246 1.74 .340 2.01 .068
th
4 Week
POST 1.61 .269 1.43 .310 1.84 .088
12th week
POST 1.30 .267 1.11 .156 1.61 .129
24th week
F value 234.00 336.00 138.00

significance .001** .001** .001**

(**- P ≤ 0.05) - Significant

From the Table 4.5 Repeated measure ANOVA results shows that the Modified schober’s
test (extension) measures overall changes within the groups for all the three groups were
found to have difference statistically significant at (P ≤ 0.05).

Modified schober’s test (extension)

3

2.
5

2
MEAN ±

1.
SD

GROUP
1 A

0.
5

0
PR POST POST 12th POST
E 4th 24th
Week week week

Fig. 4.10 Comparison of pre & post Modified schober’s test (extension) score within
Group A

66
 Modified schober’s test (extension)
3

2.
5

MEAN ± 2

1.
SD
GROUP
1 B

0.
5

0
PR POST POST 12th POST
E 4th 24th
Week week week

Fig. 4.11 Comparison of pre & post Modified schober’s test (extension) score within
Group B

Modified schober’s test (extension)

2.
5

1.
MEAN ±

5
SD

1 GROUP C
Fig. 4.12 Comparison of pre & post Modified schober’s test (extension)
0.
5

0
PR POST POST 12th POST
E 4th 24th
Week week week
score within
Group C

67
 Table 4.6 Repeated measure ANOVA was adopted to find overall changes in BLC
dynamometer within Groups

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 39.78 13.15 38.22 14.21 41.13 13.76
POST 46.44 12.34 47.87 16.22 44.42 13.92
th
4 Week
POST 52.84 1079 59.95 16.93 46.18 13.37
12th week
POST 61.82 9.26 68.33 16.99 49.38 14.30
24th week
F value 448.00 943.00 201.00

significance .001** .001** .001**

(**- P ≤ 0.05) - Significant

From the Table 4.6 Repeated measures ANOVA results reveals that the BLC dynamometer
measures overall changes within the groups for all the three groups were found to have
difference statistically significant at (P ≤ 0.05).

BLC dynamometer

7
0
6
0
MEAN ±

5
0 GR UP
SD

4 A O
0
3
0
PRE POST 4th POST 12th POST
24th
Week week week

Fig. 4.13 Comparison of pre & post BLC dynamometer score within Group A

68
 BLC dynamometer
8
0

7
0

6
0
MEAN ±

5 GROUP
SD

3 B
0

2
0

1
0
PR POST 4th Week POST 12th week POST
E 24th week

Fig. 4.14 Comparison of pre & post BLC dynamometer score within Group B

BLC dynamometer

6
0

5
0
MEAN ±

4
0 GROUP C
SD

3
0

2
0
PR POST 4th Week POST POST
E 12th 24th
week week

Fig. 4.15 Comparison of pre & post BLC dynamometer score within Group C

69
Table 4.7 Repeated measure ANOVA was adopted to find overall changes Biering
sorensen within Groups

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 25.49 4.57 24.31 4.55 23.96 4.78
POST 29.85 6.06 31.31 6.21 27.16 4.74
4th Week
POST 36.07 6.77 39.65 8.36 30.25 4.35
12th week
POST 43.98 8.47 47.60 10.63 33.71 4.18
24th week
F value 824.00 970.00 410.00

significance .001** .001** .001**

(**- P ≤ 0.05) - Significant

From the Table 4.7 Repeated measure ANOVA results shows that the changes in Biering
sorensen measures overall changes within the groups for all the three groups were found to
have difference statistically significant at (P ≤ 0.05).

Biering sorensen
6
0

5
0
MEAN ±

4
0
SD

GROUP
A
1
0

0
PR POST POST 12th POST
E 4th 24th
Week week week

Fig. 4.16 Comparison of pre & post Biering sorensen score within Group A

70
 Biering sorensen
6
0

5
0

4
0
MEAN ±

3
0
SD

GROUP
B
2
0

1
0

0
PR POST 4th Week POST POST
E 12th 24th
week week

Fig. 4.17 Comparison of pre & post Biering sorensen score within Group B

Biering sorensen
4
0

3
5

3
MEAN ±

2
SD

GROUP C
5

2
0

1
5
PR POST 4th Week POST POST
E 12th 24th
week week

Fig. 4.18 Comparison of pre & post Biering sorensen score within Group C

71
The Table 4.8 Comparison of pre & post VAS values among Group A, B and C reveals the
Mean, Standard Deviation (S.D), ANOVA test, Homogeneity variance, degree of freedom
(df), F -value & P value of the pre & post VAS values among Group A, B and C in post
test weeks.

Table 4.8 Comparison of pre & post VAS score between Group A, Group B and
Group C
Group A Group B Group C df
F
TEST Mean S.D Mean S.D Mean S.D df df2 significance
value
1
PRE 6.22 .686 6.22 .782 6.35 .615 2 162 .623 .538*
POST 4.62 .913 4.07 1.03 5.58 .712 2 162 39.99 .001**
4th Week
POST 3.07 .879 2.00 1.12 4.93 .716 2 162 142.20 .001**
12th week
POST 1.98 .757 .910 .701 3.87 .840 2 162 209.76 .001**
24th week

The above Table 4.8 shows the VAS readings among Groups (A, B & C) finds no
significant changes in pre test values (.538) (*- P > 0.05).

The Table 4.8 on top shows the VAS readings among Groups (A, B & C) reveals
significant changes among post test values (.001) (**- P ≤ 0.05).

72
 VAS
1
0

6
MEAN ± SD

0
PRE TEST 1 DAY POST TEST 4TH WEEK POST TEST 12TH WEEK POST
TEST24TH WEEK
MULLIGAN'S STABILIZATION CONVENTIONAL
MOBILIZATION EXERCISE EXERCISE

Fig. 4.19 Comparison of pre & post VAS score between Group A, Group and
Group C

Table 4.9 Comparison of pre & post MODQ score between Group A, Group B and
Group C
GROUP A GROUP B GROUP C df F
TEST significance
MEAN S.D MEAN S.D MEAN S.D df1 df2 value
PRE 64.33 7.03 62.60 4.44 63.75 6.34 2 162 1.16 .315*
POST 40.58 2.28 45.95 3.45 53.33 7.47 2 162 92.60 .001**
4th week
POST 32.04 3.43 34.64 3.36 37.33 2.97 2 162 37.37 .001**

12th
week
POST 26.04 4.15 14.98 4.01 32.15 3.54 2 162 271.94 .001**

24th
week

73
The Table 4.9 on top shows the Mean, Standard Deviation (S.D), ANOVA test,
Homogeneity variance, degree of freedom (df), F -value & P value of the pre & post
MODQ values among Groups (A, B & C) in post test weeks.

The Table 4.9 on top shows MODQ values among Groups (A, B & C) which reveals no
significant changes in pre test values (.315) (*- P > 0.05).

The Table 4.9 on top reveals MODQ values among Groups (A, B & C) which reveals a
significant changes in post test values (.001) (**- P ≤ 0.05).

MODQ
10
0

8
0

6
MEAN ± SD

4
0

2
0

0
PRE TEST 1 DAY POST TEST 4TH WEEK POST TEST 12TH WEEK POST
TEST24TH WEEK
MULLIGAN'S STABILIZATION CONVENTIONAL
MOBILIZATION EXERCISE EXERCISE

Fig. 4.20 Comparison of pre & post MODQ score between Group A, Group B and
Group C

74
 Table 4.10 Comparison of pre & post Modified schober’s test (flexion) between
Group A, Group B and Group C
GROUP A GROUP B GROUP C df F
TEST significance
MEAN S.D MEAN S.D MEAN S.D df1 df2 value
PRE 3.44 .391 3.32 .465 3.41 .432 2 162 1.24 .292*
POST 3.87 .445 4.11 .383 3.63 .464 2 162 16.37 .001**
4th week
POST 4.28 .602 5.01 .502 3.96 .431 2 162 59.65 .001**

12th
week
POST 4.98 .450 5.86 .608 4.28 .453 2 162 132.20 .001**

24th
week

The Table 4.10 on top exhibits the Mean, Standard Deviation (S.D), ANOVA test,
Homogeneity variance, degree of freedom (df), F-value & P value of pre & post Modified
schober’s test (flexion) values among Groups (A, B & C) in post test weeks.

The Table 4.10 on top shows Modified schober’s test (flexion) values among Groups
(A, B & C) which reveals no significant changes in pre test values (.292) (*- P > 0.05).

The Table 4.10 on top shows Modified schober’s test (flexion) values among Groups
(A, B & C) which reveals a significant changes in post test values (.001) (**- P ≤ 0.05).

75
 Modified schobers test (flexion)
1
0

6
MEAN ± SD

0
1ST DAY FLEXION 4TH WEEK FLEXION 12TH WEEK FLEXION 24TH WEEK
FLEXION
MULLIGAN'S STABILIZATION CONVENTIONAL
MOBILIZATION EXERCISE EXERCISE

Fig. 4.21 Comparison of pre & post Modified schober’s test (flexion) between
Group A, Group B and Group C

Table 4.11 Comparison of pre & post Modified schober’s test (extension) between
Group A, Group B and Group C
GROUP A GROUP B GROUP C df F
TEST significance
MEAN S.D MEAN S.D MEAN S.D df1 df2 value
PRE 2.21 .242 2.19 .286 2.19 .075 2 162 .172 .842*
POST 1.83 .246 1.74 .340 2.01 .068 2 162 16.36 .001**
4th week
POST 1.61 .269 1.43 .310 1.84 .088 2 162 37.73 .001**

12th
week
POST 1.30 .267 1.11 .156 1.61 .129 2 162 91.43 .001**

24th
week

76
The Table 4.11 on top reveals the Mean, Standard Deviation (S.D), ANOVA test,
Homogeneity variance, degree of freedom (df), F -value & P value of the pre & post
Modified schober’s test (extension) values among Groups (A, B & C) in post test weeks.

The Table 4.11 on top reveals Modified schober’s test (extension) values among Groups
(A, B & C) which reveals no significant variations in pre test values (.842) (*- P > 0.05).

The Table 4.11 on top exhibits Modified schober’s test (extension) values among Groups
(A, B & C) which reveals a significant variations in post test values (.001) (**- P ≤ 0.05).

Modified schober's test (extension)

4

3.
5

2.
MEAN ± SD

1.
5

0.
1st Day extension 4th week extension 12th week extension 24t
h week
extension
MULLIGAN'S STABILIZATION CONVENTIONAL
MOBILIZATION EXERCISE EXERCISE

Fig. 4.22 Comparison of pre & post Modified schober’s test (extension) between
Group A, Group B and Group C

77
 Table 4.12 Comparison of pre & post BLC dynamometer between Group A,
Group B and Group C
GROUP A GROUP B GROUP C df F
TEST significance
MEAN S.D MEAN S.D MEAN S.D df1 df2 value
PRE 39.78 13.15 38.22 14.21 41.13 13.76 2 162 .619 .540*

POST 46.44 12.34 47.87 16.22 44.42 13.92 2 162 .815 .444*

4th week
POST 52.84 1079 59.95 16.93 46.18 13.37 2 162 13.42 .001**

12th week
POST 61.82 9.26 68.33 16.99 49.38 14.30 2 162 26.39 .001**

24th week

The Table 4.12 on top exhibits the Mean, Standard Deviation (S.D), ANOVA test,
Homogeneity variance, degree of freedom (df), F -value & P value of the pre & post BLC
dynamometer values among Groups (A, B & C) in post test weeks. The Table 4.12 on top
exhibits BLC dynamometer values among Groups (A, B & C) which reveals no significant
changes in pre test values 1st day & 4th week in pre test (.540) & 4th week post test (.444)
(*- P > 0.05). The Table 4.12 on top shows BLC dynamometer values among Groups (A, B
& C) which reveals a significant changes in post test values (.001) (**- P ≤ 0.05).

BLC dynamometer
8
0
MEAN ± SD

6
0

4
0

2
1ST 4TH 12TH 24TH
DAY WEEK WEEK WEEK
MULLIGAN'S STABILIZATION CONVENTIONAL
MOBILIZATION EXERCISE EXERCISE

Fig. 4.23 Comparison of pre & post BLC dynamometer between Group A,
Group B and Group C

78
 Table 4.13 Comparison of pre & post Biering sorensen test between Group A,
Group B and Group C
GROUP A GROUP B GROUP C df F
TEST significance
MEAN S.D MEAN S.D MEAN S.D df1 df2 value
PRE 25.49 4.57 24.31 4.55 23.96 4.78 2 162 1.64 .197*
POST 29.85 6.06 31.31 6.21 27.16 4.74 2 162 7.45 .001*
4th
week
POST 36.07 6.77 39.65 8.36 30.25 4.35 2 162 27.54 .001**
12th
week
POST 43.98 8.47 47.60 10.63 33.71 4.18 2 162 42.33 .001**
24th
week

The Table 4.13 on top exhibits the Mean, Standard Deviation (S.D), ANOVA test,
Homogeneity variance, degree of freedom (df), F-value & P value of the pre & post
Biering sorensen test values among Groups (A, B & C) in post test weeks. The Table 4.13
on top shows Biering sorensen test values among Groups (A, B & C) which reveals no
significant changes in pre test values 1st day & 4th week in pre test (.197) & 4th week post
test (.001) (*- P > 0.05). The Table 4.13 on top shows Biering Sorensen Test values among
Groups (A, B & C) which reveals a significant changes in post test values (.001)
(**- P ≤ 0.05).

Biering sorensen test

6
0
5
MEAN ± SD

0
4
0
3
0
2
1ST 4TH 12TH 24TH
DAY WEEK WEEK WEEK
MULLIGAN'S STABILIZATION CONVENTIONAL
MOBILIZATION EXERCISE EXERCISE

Fig. 4.24 Comparison of pre & post Biering sorensen test between Group A, Group B
and Group C

79
 Table 4.14 Comparison of VAS using one ANOVA multiple comparison post hoc
tukey’s HSD test between Group A, Group B and Group C

Test Multiple group Mean Std. Sig. 95% Confidence

comparison Difference Error Interval
VAS Lower Upper
bound bound

GROUP A GROUP B 0.00000 0.13164 1.000 -0.3114 0.3114

GROUP C -0.12727 0.13164 0.599 -0.4387 0.1841
PRE
GROUP B GROUP A 0.00000 0.13164 1.000 -0.3114 0.3114
TEST GROUP C -0.12727 0.13164 0.599 -0.4387 0.1841
GROUP C GROUP A 0.12727 0.13164 0.599 -0.1841 0.4387
GROUP B 0.12727 0.13164 0.599 -0.1841 0.4387
*
GROUP A GROUP B 0.54545 0.17087 0.005 0.1413 0.9496
POST GROUP C -0.96364* 0.17087 0.000 -1.3678 -0.5594
TEST GROUP B GROUP A -0.54545* 0.17087 0.005 -0.9496 -0.1413
*
GROUP C -1.50909 0.17087 0.000 -1.9133 -1.1049
4th
*
week GROUP C GROUP A 0.96364 0.17087 0.000 0.5594 1.3678
*
GROUP B 1.50909 0.17087 0.000 1.1049 1.9133
*
GROUP A GROUP B 1.07272 0.17563 0.000 0.6573 1.4882
POST GROUP C -1.85455*
0.17563 0.000 -2.2700 -1.4391
TEST GROUP B GROUP A -1.07273*
0.17563 0.000 -1.4882 -0.6573
GROUP C -2.92727* 0.17563 0.000 -3.3427 -2.5118
12th
*
week GROUP C GROUP A 1.85455 0.17563 0.000 1.4391 2.2700
*
GROUP B 2.92727 0.17563 0.000 2.5118 3.3427
GROUP A GROUP B 1.07273 *
0.14651 0.000 0.7261 1.4193
POST *
GROUP C -1.89091 0.14651 0.000 -2.2375 -1.5443
TEST GROUP A -1.07271*
0.14651 0.000 -1.4193 -0.7261
GROUP B
th
24 GROUP C -2.96364*
0.14651 0.000 -3.3101 -2.6172
week GROUP C GROUP A 1.89092 *
0.14651 0.000 1.5442 2.2374
GROUP B 2.96365* 0.14651 0.000 2.6172 3.3101

The Table 4.14 on top shows the Mean difference, Standard Error, Multiple Group
Comparison Post Hoc Tukey test significance and P value among Groups (A, B & C). This
table exhibits that there is a significant changes in post test values among Groups
(A, B & C) (**- P ≤ 0.05).

80
Table 4.15 Comparison of MODQ using one ANOVA multiple comparison post hoc
tukey’s HSD test between Group A, Group B and Group C

Test Multiple Group Mean Std. Sig. 95% Confidence

Comparison Difference Error Interval
MODQ Lower Upper
bound bound

GROUP GROUP B 2.16363 1.16401 0.154 -.5897 4.9171

A GROUP C 0.58182 1.16401 0.871 -2.1715 3.3351
PRE GROUP GROUP A -2.16363 1.16401 0.153 -4.9171 .5897
TEST B GROUP C -1.58181 1.16401 0.364 -4.3351 1.1715
GROUP GROUP A -.58181 1.16401 0.870 -3.3351 2.1715
C GROUP B 1.58181 1.16401 0.364 -1.1715 4.3351
*
GROUP GROUP B -5.36363 .94045 0.000 -7.5882 -3.1391
A GROUP C -12.74544 *
.94045 0.000 -14.9700 -10.5207
POST
GROUP GROUP A 5.36363* .94045 0.000 3.1391 7.5882
TEST
B 0.000
th
GROUP C -7.38180* .94044 -9.6062 -5.1570
4
GROUP GROUP A 12.74544* .94045 0.000 10.5207 14.9700
week
C 0.000
GROUP B 7.38181* .94045 5.1571 9.6063

GROUP GROUP B -2.60001* .61202 0.000 -4.0476 -1.1522

A 0.000
GROUP C -5.29090* .61202 -6.7385 -3.8431
POST
GROUP GROUP A 2.60001* .61202 0.000 1.1522 4.0476
TEST
B 0.000
GROUP C -2.69090* .61202 -4.1385 -1.2431
12th
week GROUP GROUP A 5.29090* .61202 0.000 3.8431 6.7385
C 0.000
GROUP B 2.69091* .61203 1.2432 4.1386

GROUP GROUP B 11.05454* .74606 0.000 9.2897 12.8192

A 0.000
GROUP C -6.10908* .74606 -7.8738 -4.3442
POST
GROUP GROUP A -11.05454* .74606 0.000 -12.8192 -9.2897
TEST
B 0.000
24th GROUP C -17.16363* .74606 -18.9283 -15.3987
week 0.000
GROUP GROUP A 6.10908* .74606 4.3442 7.8738
C 0.000
GROUP B 17.16363* .74606 15.3987 18.9283

81
The Table 4.15 on top shows the Mean difference, Standard Error, Multiple Group
Comparison Post Hoc Tukey test significance and P value among Groups (A, B & C).
This table exhibits that there is a significant changes in post test values among Groups
(A, B & C) (**- P ≤ 0.05).

Table 4.16 Comparison of Modified schober’s test (flexion) using one ANOVA
multiple comparison post hoc tukey’s HSD test between Group A,
Group B and Group C

Test Multiple group Mean Std. Sig. 95% Confidence

comparison Difference Error Interval
Modified schober’s test - Lower Upper
Flexion bound bound

GROUP GROUP B .12201 .08221 0.301 -.0724 .3164

A GROUP C .02344 .08221 0.956 -.1711 .2178
PRE GROUP GROUP A -.12201 .08221 0.301 -.3164 .0724
TEST B GROUP C -.09854 .08221 0.456 -.2931 .0958
GROUP GROUP A -.02344 .08221 0.956 -.2178 .1711
C GROUP B .09854 .08221 0.456 -.0958 .2931
GROUP GROUP B -.23108* .08248 0.016 -.4261 -.0361
POST A GROUP C .24090* .08248 0.011 .0457 .4361
TEST GROUP GROUP A .23108 *
.08248 0.016 .0361 .4261
*
B GROUP C .47201 .08248 0.000 .2768 .6670
4th
*
week GROUP GROUP A -.24090 .08248 .011 -.4361 -.0457
C GROUP B -.47201* .08248 0.000 -.6670 -.2768
*
GROUP GROUP B -.73363 .09856 0.000 -.9667 -.5004
POST A GROUP C .31563 *
.09856 0.005 .0824 .5487
TEST GROUP GROUP A .73363 *
.09856 0.000 .5004 .9667
th B GROUP C 1.04926* .09856 0.000 .8160 1.2823
12
week GROUP GROUP A -.31563* .09856 0.005 -.5487 -.0824
*
C GROUP B -1.04927 .09857 0.000 -1.2824 -.8161
*
GROUP GROUP B -.88454 .09721 0.000 -1.1144 -.6545
POST
A GROUP C .69201* .09721 0.000 .4620 .9218
TEST *
GROUP GROUP A .88454 .09721 0.000 .6545 1.1144
th
24 B GROUP C 1.57655 *
.09720 0.000 1.3466 1.8065
week GROUP GROUP A -.69201 *
.09721 0.000 -.9218 -.4620
*
C GROUP B -1.57654 .09721 0.000 -1.8064 -1.3465

82
The Table 4.16 on top shows the Mean difference, Standard Error, Multiple Group
Comparison Post Hoc Tukey test significance and P value among Groups (A, B & C).
This table exhibits that there is a significant changes in post test values among Groups
(A, B & C) (**- P ≤ 0.05).

Table 4.17 Comparison of Modified schober’s test (extension) using one ANOVA
multiple comparison post hoc tukey’s HSD test between Group A,
Group B and Group C

Test Multiple Group Mean Std. Sig. 95% Confidence

Comparison Difference Error Interval
Modified Schober’s Test- Lower Upper
Extension bound bound
GROUP GROUP B .01816 .04214 0.903 -.0815 .1178
A
GROUP C .02363 .04215 0.840 -.0760 .1233

PRE GROUP GROUP A -.01817 .04215 0.902 -.1178 .0815

TEST B
GROUP C .00544 .04215 0.991 -.0942 .1051

GROUP GROUP A -.02363 .04215 0.841 -.1233 .0760

C GROUP B -.00544 .04215 0.991 -.1051 .0942
GROUP GROUP B .08581 .04690 0.163 -.0250 .1967
A
GROUP C -.17726* .04690 0.001 -.2881 -.0662
POST
TEST GROUP GROUP A -.08581 .04690 0.163 -.1967 .0250
4 th B
GROUP C -.26308* .04690 0.000 -.3741 -.1520
week
GROUP GROUP A .17726* .04690 0.001 .0662 .2881
C GROUP B .26308* .04690 0.000 .1520 .3741
GROUP GROUP B .17163* .04632 0.001 .0621 .2811
A
GROUP C -.22944* .04632 0.000 -.3391 -.1198
POST
TEST GROUP GROUP A -.17163* .04632 0.001 -.2811 -.0621
12 th B
GROUP C -.40108* .04632 0.000 -.5106 -.2914
week
GROUP GROUP A .22944* .04632 0.000 .1198 .3391
C GROUP B .40108* .04632 0.000 .2914 .5106
GROUP GROUP B .18672* .03700 0.000 .0991 .2742
POST A GROUP C -.30872* .03700 0.000 -.3962 -.2211
TEST GROUP GROUP A -.18672* .03700 0.000 -.2742 -.0991
24th B GROUP C -.49544* .03700 0.000 -.5831 -.4078
week GROUP GROUP A .30872* .03700 0.000 .2211 .3962
C GROUP B .49544* .03700 0.000 .4078 .5831

83
The Table 4.17 on top shows the Mean difference, Standard Error, Multiple Group
Comparison Post Hoc Tukey test significance and P value among Groups (A, B & C). The
above Table 4.17 exhibits that there is a significant changes in post test values among
Groups (A, B & C) (**- P ≤ 0.05).

Table 4.18 Comparison of BLC dynamometer using one ANOVA multiple

comparison post hoc tukey’s HSD test between Group A,
Group B and Group C

Test Multiple Group Mean Std. Sig. 95% Confidence

Comparison Difference Error Interval
BLC Dynamometer Lower Upper
bound bound
GROUP GROUP B 1.563 2.615 0.822 -4.61 7.74
A GROUP C -1.344 2.615 0.865 -7.52 4.83
PRE GROUP GROUP A -1.563 2.615 0.822 -7.74 4.61
TEST B GROUP C -2.908 2.615 0.508 -9.11 3.27
GROUP GROUP A 1.344 2.615 0.865 -4.83 7.52
C GROUP B 2.908 2.615 0.508 -3.27 9.11
GROUP GROUP B -1.435 2.717 0.858 -7.86 4.98
POST A GROUP C 2.017 2.717 0.739 -4.40 8.44
TEST GROUP GROUP A 1.435 2.717 0.858 -4.98 7.86

4th B GROUP C 3.454 2.717 0.414 -2.96 9.87

week GROUP GROUP A -2.017 2.717 0.739 -8.44 4.40
C GROUP B -3.454 2.717 0.414 -9.87 2.96
*
GROUP GROUP B -7.108 2.656 0.022 -13.38 -.81
*
POST A GROUP C 6.654 2.656 0.035 .36 12.93
*
TEST GROUP GROUP A 7.108 2.656 0.022 .81 13.38
*
12th B GROUP C 13.763 2.656 0.000 7.47 20.04
week GROUP GROUP A -6.654* 2.656 0.035 -12.93 -.36
C GROUP B -13.764* 2.657 0.000 -20.05 -7.48
*
GROUP GROUP B -6.508 2.651 0.040 -12.77 -.23
*
POST A GROUP C 12.435 2.651 0.000 6.16 18.71
*
TEST GROUP GROUP A 6.508 2.651 0.040 .23 12.77

24th B GROUP C 18.944 *

2.651 0.000 12.67 25.20
week GROUP GROUP A -12.435 *
2.651 0.000 -18.71 -6.16
C GROUP B -18.944* 2.651 0.000 -25.20 -12.67

84
The Table 4.18 on top shows the Mean difference, Standard Error, Multiple Group
Comparison Post Hoc Tukey test significance and p-value among Groups (A, B & C). also
it exhibits that there is a significant changes in post test values among Groups (A, B & C)
(**- P ≤ 0.05)

Table 4.19 Comparison of Biering sorensen test using one ANOVA multiple
comparison post hoc tukey’s HSD test between Group A,
Group B and Group C

Test Multiple Group Mean Std. Sig. 95% Confidence

Comparison Difference Error Interval
Biering Sorensen Test Lower Upper
bound bound

GROUP GROUP B 1.181 0.884 0.377 -.90 3.26

A GROUP C 1.526 0.884 0.198 -.55 3.61
PRE GROUP GROUP A -1.181 0.884 0.377 -3.26 .90
TEST B GROUP C .344 0.884 0.919 -1.74 2.43
GROUP GROUP A -1.526 0.884 0.198 -3.61 .55
C GROUP B -.344 0.884 0.919 -2.43 1.74
GROUP GROUP B -1.454 1.088 0.378 -4.02 1.11
POST A GROUP C 2.690* 1.088 0.038 .10 5.26
TEST GROUP GROUP A 1.454 1.088 0.378 -1.11 4.02
B GROUP C 4.144* 1.088 0.001 1.56 6.71
4th
week GROUP GROUP A -2.690* 1.088 0.038 -5.26 -.10
C GROUP B -4.144* 1.088 0.001 -6.71 -1.56
GROUP GROUP B -3.581* 1.277 0.016 -6.60 -.55
POST A GROUP C 5.817* 1.277 0.000 2.78 8.83
TEST GROUP GROUP A 3.581* 1.277 0.016 .57 6.60
th B GROUP C 9.401* 1.277 0.000 6.37 12.41
12
week GROUP GROUP A -5.817* 1.277 0.000 -8.83 -2.78
C GROUP B -9.400* 1.278 0.000 -12.42 -6.38
GROUP GROUP B -3.617 1.565 0.057 -7.31 .08
POST 10.272* 1.565 0.000 6.56 13.97
A GROUP C
TEST 3.617 1.565 0.057 -.08 7.31
GROUP GROUP A
24th
B GROUP C 13.890* 1.565 0.000 10.18 17.61
week GROUP GROUP A -10.272* 1.565 0.000 -13.97 -6.56
C GROUP B -13.890* 1.565 0.000 -17.61 -10.18

85
The Table 4.19 on top shows the Mean difference, Standard Error, Multiple Group
Comparison Post Hoc Tukey test significance and P value among Groups (A, B & C).

Also it shows that there is a significant changes in post test values among Groups
(A, B & C) (**- P ≤ 0.05).

Table 4.20 Partial eta squared, effect size index with power of the study VAS changes
at repeated measure ANOVA within Group A, Group B and Group C

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 6.22 .686 6.22 .782 6.35 .615
POST
4.62 .913 4.07 1.03 5.58 .712
4th Week
POST
3.07 .879 2.00 1.12 4.93 .716
12th week
POST
1.98 .757 .910 .701 3.87 .840
24th week
Partial Eta .951 .992 .860
Squared

ESI 4.34 5.78 2.43

*ESI – Effect Size Index, η P2 - Partial Eta Squared

In Table 4.20, post hoc power analysis for the outcome measure VAS changes was
estimated by G*power version 3.1.9.4 software using ANOVA repeated measures, within-
between interaction for Effect Size Index (ESI). Power was estimated to be 100%.

86
 Table 4.21 Partial eta squared, effect size index with power of the study MODQ
changes at repeated measure ANOVA within Group A, Group B and
Group C

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 64.33 7.03 62.60 4.44 63.75 6.34

POST 40.58 2.28 45.95 3.45 53.33 7.47

th
4 Week
POST 32.04 3.43 34.64 3.36 37.33 2.97
12th week
POST 26.04 4.15 14.98 4.01 32.15 3.54
24th week
Partial Eta .963 .975 .990
Squared

ESI 5.10 6.24 3.95

*ESI – Effect Size Index, η P2 - Partial Eta Squared

In Table 4.21, post hoc power analysis for the outcome measure MODQ changes was
estimated by G*power version 3.1.9.4 software using ANOVA repeated measures, within-
between interaction for Effect Size Index (ESI). Power was estimated to be 100%.

87
Table 4.22 Partial eta squared, effect size index with power of the study Modified
schober’s test (flexion) changes at repeated measure ANOVA within
Group A, Group B and Group C

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 3.44 .391 3.32 .465 3.41 .432
POST 3.87 .445 4.11 .383 3.63 .464
th
4 Week
POST 4.28 .602 5.01 .502 3.96 .431
12th week
POST 4.98 .450 5.86 .608 4.28 .453
24th week
Partial Eta .812 .954 .912
Squared

ESI 2.07 4.55 1.57

*ESI – Effect Size Index, η P2 - Partial Eta Squared

In Table 4.22, post hoc power analysis for the outcome measure Modified schober’s test
(flexion) changes was estimated by G*power version 3.1.9.4 software using ANOVA
repeated measures, within-between interaction for Effect Size Index (ESI). Power was
estimated to be 100%.

88
 Table 4.23 Partial eta squared, effect size index with power of the study Modified
schober’s test (extension) changes at repeated measure ANOVA
within Group A, Group B and Group C

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 2.21 .242 2.19 .286 2.19 .075
POST
1.83 .246 1.74 .340 2.01 .068
4th Week
POST
1.61 .269 1.43 .310 1.84 .088
12th week
POST
1.30 .267 1.11 .156 1.61 .129
24th week
Partial Eta
.813 .862 .718
Squared

ESI 2.08 2.49 1.59

*ESI – Effect Size Index, η P2 - Partial Eta Squared

In Table 4.23, post hoc power analysis for the outcome measure Modified schober’s test
(extension) changes was estimated by G*power version 3.1.9.4 software using ANOVA
repeated measures, within-between interaction for Effect Size Index (ESI). Power was
estimated to be 100%.

89
 Table 4.24 Partial eta squared, effect size index with power of the study BLC
dynamometer changes at repeated measure ANOVA within Group A,
Group B and Group C

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 39.78 13.15 38.22 14.21 41.13 13.76
POST 46.44 12.34 47.87 16.22 44.42 13.92
th
4 Week
POST 52.84 1079 59.95 16.93 46.18 13.37
12th week
POST 61.82 9.26 68.33 16.99 49.38 14.30
24th week
Partial Eta .892 .946 .789
Squared

ESI 2.87 4.18 1.93

*ESI – Effect Size Index, η P2 - Partial Eta Squared

In Table 4.24, post hoc power analysis for the outcome measure BLC dynamometer
changes was estimated by G*power version 3.1.9.4 software using ANOVA repeated
measures, within-between interaction for Effect Size Index (ESI). Power was estimated to
be 100%.

90
 Table 4.25 Partial eta squared, effect size index with power of the study Biering
sorensen changes at repeated measure ANOVA within Group A,
Group B and Group C

Group A Group B Group C

TEST
Mean S.D Mean S.D Mean S.D
PRE 25.49 4.57 24.31 4.55 23.96 4.78
POST 29.85 6.06 31.31 6.21 27.16 4.74
4th Week
POST 36.07 6.77 39.65 8.36 30.25 4.35
12th week
POST 43.98 8.47 47.60 10.63 33.71 4.18
24th week
Partial Eta .939 .947 .833
Squared

ESI 3.92 4.22 2.23

*ESI – Effect Size Index, η P2 - Partial Eta Squared

In Table 4.25, post hoc power analysis for the outcome measure Biering sorensen changes
was estimated by G*power version 3.1.9.4 software using ANOVA repeated measures,
within-between interaction for Effect Size Index (ESI). Power was estimated to be 100%.

4.2 Result
On comparing Mean values of Group A, Group B & Group C on VAS shows that there
was no significant difference in pre-test value (significance 0.538) but it was found there
was a significant decrease in Post test Mean values at 4 th week, 12th week & 24thweek
(significance 0.001). In addition stabilization exercises (Group B) which has the Lower
Mean value is effective than Mulligan MWM (Group A) and followed by conventional
(Group C) at P ≤ 0.05. Hence Null Hypothesis is rejected.

On comparing Mean values of Group A, Group B & Group C on MODQ shows that there
was no significant difference in pre-test value (significance 0.315) however, a significant
decrease was observed in the Post test Mean values at 4th week, 12th week & 24thweek

91
(significance 0.001). Moreover stabilization exercises (Group B) which has the Lower
Mean value is effective than Mulligan MWM (Group A) and followed by conventional
(Group C) at P ≤ 0.05. Hence Null Hypothesis is rejected.

On comparing Mean values of Group A, Group B & Group C on Modified schober’s test

(flexion) it was found that there was no significant difference in pre-test value

(significance 0.292) however, there was a significant increase in the Post test Mean values

at 4th week, 12th week & 24th week (significance 0.001). Also stabilization exercises

(Group B) which has the higher mean value is effective than Mulligan MWM (Group A)

and followed by conventional (Group C) at P ≤ 0.05. Hence Null Hypothesis is rejected.

On comparing Mean values of Group A, Group B & Group C on Modified schober’s test
(extension) it was found that there was no significant difference in pre-test value
(significance 0.842) but there was a significant decrease in the Post test Mean values at 4 th
week,12th week & 24th week (significance 0.001). However stabilization exercises (Group
B) which has the Lower Mean value is effective than Mulligan MWM (Group A) and
followed by conventional (Group C) at P ≤ 0.05. Hence Null Hypothesis is rejected.

On comparing Mean values of Group A, Group B & Group C on BLC Dynamometer

shows no significant difference in pre-test value (significance 0.540) rather a significant
increase was found in the Post test Mean values at 12 th week & 24th week (significance
0.001). Also stabilization exercises (Group B) which has the Higher Mean value is
effective than Mulligan MWM (Group A) and followed by conventional (Group C) at
P ≤ 0.05. Hence Null Hypothesis is rejected.

On comparing Mean values of Group A, Group B & Group C on Biering Sorensen Test
shows no significant difference in pre-test value (significance 0.197) but there was a
significant increase in the Post test Mean values at 12 th week & 24thweek (significance
0.001). Stabilization exercises (Group B) which has the Higher Mean value is effective
than Mulligan MWM (Group A) and followed by conventional (Group C) at
P ≤ 0.05. Hence Null Hypothesis is rejected.

92
Repeated Measure Anova results showed that the VAS, MODQ, Modified Schober's test,
BLC Dynamometer and Biering sorensen test measures overall changes within three
groups in repeated measures from baseline to 4th week, 12th week & 24th week were found
to have a statistically significant difference at P ≤ 0.05.

93
 CHAPTER - 5

DISCUSSION AND CONCLUSION

5.1 Discussion
In general population low back pain is considered as one of the major problems. In order to
reduce the chronic non-specific low back pain, this study focuses to determine the effects
of mulligan mobilization, stabilization exercise and conventional exercise.

Patients with low back pain were given the stability and strengthening exercise for the
muscles at that particular area to reduce the pain and to bring back to normal functional
activities. The treatment has given for 24 weeks using the mulligan mobilization (SNAG),
stabilization and Conventional exercise to the lumbar spine in three groups. After 24 weeks
of intervention the group of patients given stabilization exercise felt a remarkable
difference in reduction of chronic non- specific low back pain when compared to other two
groups. The measurement for nonspecific low back pain impaired is ruled out by using the
VAS, MODQ, BLC dynamometer, Modified schober's test and Biering sorensen test.

5.1.1 Physiological response associated with mobilization

The mechanical impacts of joint assembly identify with the reclamation of typical joint
versatility or scope of movement. This incorporates adaptability and versatility of capsular
and other delicate tissue designs like tendons and ligaments. Following injury and
immobilization, delicate tissues can become abbreviated and limit by and large joint
portability. Satisfactory power should be applied to the tissues to make mechanical
impacts. Higher grade mobilization might build the joint portability back to typical by re-
establishing relative measures of play in the once-confined joint movement.

94
The periaqueductal hazy situation is in a joint effort with an intricate organization of
frameworks including the nociceptive framework, the autonomic sensory system and the
engine framework. It has additionally been shown that type I and II mechanoreceptors
from joints, muscles and ligaments task to the periaqueductal hazy situation. Proof through
post manipulation thoughtful reaction joined with absence of pain in indicative and
asymptomatic subjects proposes a neurophysiologic reaction to spinal control by means of
mechanoreceptors. These impacts might lie in the incitement of the slipping aggravation
inhibitory arrangement of the focal sensory system from midbrain to spinal string.

The neurophysiological impact may likewise remember a change for muscle actuation
designs in which the engine framework might be restrained. The capacity of assembly and
control to repress muscle might fluctuate contingent upon method, area and nature of pain,
and surprisingly the given muscles designated with the control. On the off chance that
preparation or control influences muscles, the neurophysiologic impacts in all likelihood
happen locally at the designated joint or district and the relating innervation distally
connected with the common innervation. The impacts wanted from playing out the
preparation or control are to expand help of the more profound, more nearby muscles that
help with neuromuscular control of the space and in a perfect world, to repress the more
shallow, worldwide muscles that might be causing pain due to expanded guarding of the
joint or portions included.

5.1.2 Physiological response associated with exercise

When done in a controlled, reformist way, practices for mitigating back pain have many
advantages, including: Fortifying the muscles that help the spine, eliminating pressure
from the spinal plates and aspect joints Reducing solidness and further developing
versatility Further developing dissemination to all the more likely convey supplements
through the body, including to the spinal plates delivering endorphins, which can normally
mitigate pain. A successive arrival of endorphins can assist with decreasing dependence on
pain medicine. Endorphins can likewise raise mind-set and mitigate burdensome
manifestations, a typical impact of constant agony. Limiting the recurrence of back pain
scenes and decreasing the seriousness of pain when it happens.

95
Spine solidness and muscle oxygenation, to give some examples. These are a couple of
guides to start program. The objectives are to improve spine steadiness through scoring
movement and muscle enactment examples to plan for a wide range of difficulties.
Obviously, different activities might be required to improve day after day working,
however these will rely on the qualities and targets of the person.

Two different ideas should be underscored now. In the initial place, preparing approaches
expected to upgrade athletic execution are frequently counterproductive to the
methodologies utilized when preparing for wellbeing. An enormous count of patients are
restored utilizing athletic ways of thinking, or more terrible yet "lifting weights"
approaches planned principally to disengage and hypertrophy explicit muscles and in this
manner foil progress. Many terrible backs are made from utilizing improper execution
ways of thinking. Recognizing the preparation destinations is principal. The accentuation
here is on improving spine wellbeing – preparing for execution is another point. Second, a
large number of the preparation moves toward that are utilized at joints like the knee, hip,
shoulder and so on are erroneously applied for the back. The back is an altogether different
and complex construction, including an adaptable segment, with complex muscle and
ligamentous support. The spine contains the spinal line and parallel nerve roots and whose
musculature is personally associated with a few different capacities including breathing
mechanics, to give only one model. A considerable lot of the customary methodologies for
preparing different joints in the body are not fitting for the back - it is possible that they
don't deliver the ideal outcome or they make new patients.

The reason for the Cat - Camel practice is to help prepare the back, decrease firmness and
increment adaptability in your trunk without bothering your neck. When performed
consistently, the Cat - Camel exercise can likewise assist with expanding perseverance at
work, help your athletic exhibition and work on your stance. Moreover, the activity can
help diminish and forestall back pain and injury.

5.1.3 Visual Analogue Scale (VAS) comparisons

In the present study, the baseline parameters of Visual Analogue Scale (VAS) were within
the reference range in all the three groups. However, after post test of VAS, levels altered
within Group A, Group B and Group C in repeated measures from baseline analysis to 4th

96
week, 12th week & 24th week as shown in Table 4.2 & Fig. 4.1 for Group A, Fig. 4.2 for
Group B and Fig. 4.3 for Group C at P ≤ 0.05. The Visual Analogue Scale (VAS) level
began to reduce in all three groups and there was variation in recovery with respect to pain
immediately after intervention. It is noted that pain values have no significant difference
between the three groups from baseline Value at P > 0.05 shown in Table 4.8. But,
significant differences were observed at 4th week, 12th week & 24th week at P ≤ 0.05 as
shown in Table 4.8 and Fig. 4.19.

Likewise these outcomes were reconfirming with different analysts where they attempt to
think about the impacts of lumbar stabilization exercises practices and lumbar dynamic
strengthening works out, it shows that the VAS shows the lumbar stabilization exercises
showed imperceptibly preferable results over the overall exercise bunch (Moon et al.
2013).

5.1.4 Modified Oswestry back pain Disability Questionnaire (MODQ) comparisons

In the present study, the baseline parameters of Modified Oswestry back pain Disability
Questionnaire (MODQ) were within the reference range in all the three groups. However,
after post test of MODQ, levels altered within Group A, Group B and Group C in repeated
measures from baseline analysis to 4th week, 12th week & 24th week as shown in Table 4.3
and Fig. 4.4 for Group A, Fig. 4.5 for Group B and Fig. 4.6 for Group C at P ≤ 0.05. The
Functional activities level began to rise in all three groups and there was a variation in the
recovery period with respect to Functional activities immediately after intervention. It is
noted that Functional activities levels have no significant difference between the three
groups from baseline at P > 0.05 shown in Table 4.9. But, significant differences were
observed at 4th week, 12th week & 24th week at p ≤ 0.05 as shown in Table 4.9 and
Fig. 4.20.

Stabilisation exercise gets an improved score when compared to the other groups,
indicating that it is helpful in returning patients to their previous work or condition. When
comparing to others groups respectively, the MODQ score showed improvement following
the stabilisation exercise (Ostelo and De Vet 2005).

97
5.1.5 Modified Schober's Test (MST) comparisons
In the present study, the baseline parameters of Modified Schober's Test (MST) were
within the reference range in all the three groups. However, after post test of MST, levels
altered within Group A, Group B and Group C in repeated measures from baseline analysis
to 4th week, 12th week & 24th week as shown in Table 4.4 and Fig. 4.7 for Group A, Fig.
4.8 for Group B and Fig. 4.9 for Group C at P ≤ 0.05. The Flexion Range of Motion level
began to rise in all three groups and there was a variation in the recovery period with
respect to Flexion Range of Motion immediately after intervention. It is noted that Flexion
Range of Motion levels have no significant difference between the three groups from
baseline at P > 0.05 shown in Table 4.10. But, significant differences were observed at 4 th
week, 12th week & 24th week at P ≤ 0.05 as shown in Table 4.10 and Fig. 4.21.

In the present study, the baseline parameters of Modified Schober's Test (MST) were
within the reference range in all the three groups. However, after post test of MST, levels
altered within Group A, Group B and Group C in repeated measures from baseline analysis
to 4th week, 12th week & 24th week as shown in Table 4.5 and Fig. 4.10 for Group A, Fig.
4.11 for Group B and Fig. 4.12 for Group C at P ≤ 0.05. The Extension Range of Motion
level began to rise in all three groups and there was a variation in the recovery period with
respect to Extension Range of Motion immediately after intervention. It is noted that
Extension Range of Motion levels have no significant difference between the three groups
from baseline at P > 0.05shown in Table 4.11. But, significant differences were observed at
4th week, 12th week & 24th week at P ≤ 0.05 as shown in Table 4.11 and Fig. 4.22.

Lumbar dynamic exercises were performed in the lumbar stabilisation exercise group,
which strengthened the lumbar extensors at a large lumbar flexion angle in this group of
patients. However, in the stability exercise group, functional gains and lumbar extensor
strength at low lumbar flexion angles were both better, implying that these benefits were
related to the stabilization exercises (Moon et al. 2013).

5.1.6 Back Leg Chest Dynamometer (BLCD) comparisons

In the present study, the baseline parameters of Back Leg Chest dynamometer (BLCD)
were within the reference range in all the three groups. However, after post test of BLCD,
levels altered within Group A, Group B and Group C in repeated measures from baseline

98
analysis to 4th week, 12th week & 24th week as shown in Table 4.6 and Fig. 4.13 for Group
A, Fig. 4.14 for Group B and Fig. 4.15 for Group C at P ≤ 0.05. The Muscle strength level
began to rise in all three groups and there was a variation in the recovery period with
respect to Muscle strength immediately after intervention. It is noted that Muscle strength
levels have no significant difference between the three groups from baseline at
P > 0.05 shown in Table 4.12. But, significant differences were observed at 4 th week, 12th
week & 24th week at P ≤ 0.05 as shown in Table 4.12 and Fig. 4.23.

Various research findings support the use of the BLC dynamometer in examining overall
muscle strength because it provides reasonably reliable test-retest measurements in a
variety of subjects and is thus recognised as an appropriate means to evaluate changes in
muscle strength in research and clinical settings (Ten Hoor et al. 2016).

5.1.7 Biering Sorensen Test (BST) comparisons

In the present study, the baseline parameters of Biering Sorensen Test (BST) were within
the reference range in all the three groups. However, after post test of BST, levels altered
within Group A, Group B and Group C in repeated measures from baseline analysis to 4 th
week, 12th week & 24th week as shown in Table 4.7 and Fig. 4.16 for Group A, Fig. 4.17
for Group B and Fig. 4.18 for Group C at P ≤ 0.05. The Muscle Endurance level began to
rise in all three groups and there was a variation in the recovery period with respect to
Muscle Endurance immediately after intervention. It is noted that Muscle Endurance levels
have no significant difference between the three groups from baseline at P > 0.05 shown in
Table 4.13. But, significant differences were observed at 4th week, 12th week & 24th week
at P ≤ 0.05 as shown in Table 4.13 and Fig. 4.24.

Comparison of three group's isometric back endurance capacity before and after the
Biering Sorensen test (Moreau et al. 2001). When compared to other exercises, group B
cases hold for the longest time and demonstrate the usefulness of stability exercises for low
back pain cases.

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5.1.8 Reporting the level of clinical significance in dependent variables based on
MCID
Vas scale not only considered as one of the outcome measure based mechanism to grade
the intensity of pain but also more reliable and used to validate the disability in patients
with musculoskeletal pain (Verma, Goyal and Narkeesh 2013). In case of responsiveness,
VAS scales have been considered more consistent with the results, since it is considered
more sensitive to detect small differences (Hasson and Arnetz 2005). A remarkable
difference in pain relief was noted in both the experimental groups over the intervention
period. In the statistical analysis Table 4.8 and Fig. 4.19 shows the comparison of pre and
post of VAS score by using the homogeneity of variance and one ANOVA test between
three groups. This table makes clear of there is no significant difference in pre-test values
between three groups (*-P > 0.05) but there is a remarkable difference in post-test values
of VAS score in three groups (**-P ≤ 0.05) especially, Group B (stabilization exercises)
shows 4 fold decrease in pain score with Group C and 2 fold decrease in pain score with
Group A. Also, the mean value of post test in Group B shows 0.91which satisfies the
Minimal Clinically Important Differences (MCID) value (>2cm for chronic low back pain)
as mentioned by previous research studies (Ostelo and De Vet 2005), Group A (1.98) and
Group C (3.87) when compared with their respective pre-test mean values. This indicates
the effect of stabilization exercises on low back pain when compared to other exercises.
This was also proved previously by few researchers where they have compared the effects
of stabilization exercises with strengthening exercises and concluded that the stabilization
gives better results by improving abdominal muscle activation comparatively (Bhadauria
and Gurudut 2017). Also these results were reconfirming with other researchers where they
try to compare the effects of lumbar stabilization exercises and lumbar dynamic strength-
ening exercises, it shows that the VAS shows the lumbar stabilization exercises groups
showed marginally better outcomes than the general exercise group (Moon et al. 2013).

Responsiveness towards the pain reduction is considered as vital measurement

characteristic to examine the usefulness of a self-report disability scale, where the higher
value reflects the higher disability post exercises (Fritz and Irrgang 2001). It was
authenticated by previous researches that MODQ score can be used to confirm the
improvement in low back pain subjects after stabilization exercises (Bhadauria and
Gurudut 2017). In this study, we have used MODQ for comparing the effectiveness of

100
three exercises in low back pain cases. With that note, Table 4.9 and Fig. 4.20 expresses
the comparison of pre and post MODQ scores between the groups and revealed that there
is no noticeable difference in pre-test values (*- P > 0.05) but there is a remarkable
difference in post-test values of MODQ scores between the groups (**- P ≤ 0.05).
Noticeably, Group B has relatively lower score when compared with other group’s shows
its effectiveness in patients in rendering back to their normal work or condition. MODQ
score showed improvement after the stabilization exercise Group B with the reduced value
of 14.98 which shows >10 points with respective MCID value (Ostelo and De Vet 2005),
when compared to Group A and Group C with 26.04 and 32.15 respectively. This
reconfirms that the improvement after stabilization exercises can be confirmed by MODQ.

It is indeed to assess improvement of back pain, by defining outcome measures in easily

understandable way. The very fundamental thing is to determine the history of the
complaint and the physical examination, so the only additional physical measure
considered useful was a modified Schober’s test of spinal mobility (Ehrlich George 2003).
Generally, the Modified Schober’s test is adopted to assess the range of motion in lumbar
extension cum flexion used for subjects with low back discomfort, Since it provide
effective and reliable results with minimally metric detectable change (Manju et al. 2015).
As far as our study is concerned, exercises given for all three groups to reduce the intensity
of low back pain and the effectiveness were measured using Modified Schober's test. The
result shows high level of flexibility in patients (Post-test) were achieved with stabilization
exercises when compared to other two exercises (Table 4.10 and 4.11) (Fig. 4.21 and Fig.
4.22). The mean value of post test of Group B shows more than 1 cm differences when
compared to Pre-test values, which satisfies the MCID value of MST (Ostelo and De Vet
2005). Since the postures employed in lumbar stabilization group (Group B) was unique
and activates the lumbar flexors and extensors which tends to achieve more flexibility
among the other group (Bhadauria and Gurudut 2017). Since, it was suggested that among
the abdominal muscles, the transverse abdominal, multifidus and internal oblique muscles
facilitate to augment the intra-abdominal pressure, thereby contributing to the spinal and
pelvic stability. The lumbar stabilization exercise group were involved with few lumbar
dynamic exercises, which in turn strengthened the lumbar extensors at the large lumbar
flexion angle in this group of patients. However, functional improvements and lumbar
extensor strength at low lumbar flexion angles were both better in the stabilization exercise

101
group, suggesting that these improvements were due to the stabilization exercises (Moon et
al. 2013).

Muscle Strength is one of the accurate predictor determining the physical fitness of a
person whereas the back strength is one of the key features to keep the individuals at bay
from back pain (Kaur and Koley 2019). The use of the BLC dynamometer in examining
overall muscle strength was supported by various research findings, since it provides
reasonably reliable test-retest measurements in various subjects and thus be recognized an
appropriate means to evaluate changes in muscle strength in research and clinical settings
(Ten Hoor et al. 2016). Table 4.12 and Fig. 4.23 shows the BLC dynamometer test of all
three groups which measures isometric forces produced together by the back, leg and arm
muscles. The post-test values of the three groups showed increase strength, but in
particular Group B showed higher strength value among other two groups. This is
pretended to the specific exercises related to lumbar stabilization.

It was found that subjects having minimum lumbar extensor muscle endurance encounter
an increased prevalence of experiencing initial low back pain. Thus highlighting the
practice of like mobilization and stabilization exercises to counteract the back pain ( Das,
Kumar and Dutta 2016). Recently, exercises designed for core stabilization are considered
essential to maintain low back health particularly patients with LBP. These stabilization
exercises often target endurance training and require a prolonged hold, such as a full-plank
or side-plank of the Pilates maneuvers (Wang-Price et al. 2017). Table 4.13 and Fig. 4.24
shows the comparison of pre and post of Biering Sorensen test of three groups which
assesses the isometric back endurance capacity (Moreau et al. 2001). Among the other
groups, Group B cases hold for maximum seconds and show the effectiveness of
stabilization exercises for low back pain cases when compared to other exercises.

5.1.9 Clinical significance in terms of Effect Size Index (ESI)

Repeated measure ANOVA test describes the statistical significance in mean score over
three or more times within group and one way ANOVA test was used to find statistical
significance between the groups. Paired t test describes statistical significance within
groups when each entity measured twice. The Effect Size Index (ESI) calculation method
is applied in order to assess the clinical change in dependent variables within each group.

102
The benchmark set for the interpretation of effect size for repeated measure ANOVA using
Partial Eta Squared as follows: small effect (d = 0.01), medium effect (d = 0.06) and large
effect (d = 0.14) (Richardson 2011). The benchmark set for the interpretation of effect size
for paired sample t test, according to Cohen’s d criteria as follows: small effect (d = 0.2),
medium effect (d = 0.5) and large effect (d = 0.8) (Bakker et al. 2019). The effect size
between the groups was one of the attempts to confirm the clinical effectiveness confined
to particular group. The outcome measures were compared to confirm the clinical
significance of the treatment effect.

The effect size of Mobilization, Stabilization and conventional exercises in lowering the
low back pain intensity among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for VAS in Table 4.20,
According to repeated measure ANOVA Partial Eta Squared measures, the ESI: 4.34
(Group A), ESI: 5.78 (Group B) and ESI: 4.34 (Group C). On comparing the ESI values, it
is clearly understood that Group A shows moderate difference while Group B exhibits
higher efficacy in lowering the pain intensity with that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back Functional activities among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for MODQ in Table 4.21,
According to repeated measure ANOVA Partial Eta Squared measures, the ESI: 5.10
(Group A), ESI: 6.24 (Group B) and ESI: 3.95 (Group C). On comparing the ESI values, it
is clearly understood that Group A shows moderate difference while Group B exhibits
higher efficacy in increasing the Functional activities with that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back ROM among 3 Groups (A, B & C) were compiled using repeated measure
ANOVA Partial Eta Squared measures were tabulated for Flexion using Modified
Schober’s Test (MST) in Table 4.22, According to repeated measure ANOVA Partial Eta
Squared measures, the ESI: 2.07 (Group A), ESI: 4.55 (Group B) and ESI: 1.57 (Group C).
On comparing the ESI values, it is clearly understood that Group A shows moderate
difference while Group B exhibits higher efficacy in increasing the low back ROM with
that of Group C was noted.

103
The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back ROM among 3 Groups (A, B & C) were compiled using repeated measure
ANOVA Partial Eta Squared measures were tabulated for Extension using Modified
Schober’s Test (MST) in Table 4.23, According to repeated measure ANOVA Partial Eta
Squared measures, the ESI: 2.08 (Group A), ESI: 2.49 (Group B) and ESI: 1.59 (Group C).
On comparing the ESI values, it is clearly understood that Group A shows moderate
difference while Group B exhibits higher efficacy in increasing the low back ROM with
that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back Muscle strength among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for Back Leg Chest (BLC)
Dynamometer in Table 4.24, According to repeated measure ANOVA Partial Eta Squared
measures, the ESI: 2.87 (Group A), ESI: 4.18 (Group B) and ESI: 1.93 (Group C). On
comparing the ESI values, it is clearly understood that Group A shows moderate difference
while Group B exhibits higher efficacy in increasing the low back Muscle strength with
that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back Muscle endurance among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for Biering Sorensen test in
Table 4.25. According to repeated measure ANOVA Partial Eta Squared measures, the
ESI: 3.92 (Group A), ESI: 4.22 (Group B) and ESI: 2.23 (Group C). On comparing the ESI
values, it is clearly understood that Group A shows moderate difference while Group B
exhibits higher efficacy in increasing the low back Muscle endurance with that of Group C
was noted.

From the scores of above outcome measures performed with three groups of subjects, it
was clearly seen that stabilization exercises showed significant improvement comparable
to mulligan mobilization and conventional exercises.

104
5.2 Summary
In this study findings reveals there exists a significant decrease in pain, enhancements in
movement range, betterments in functional activities and increase in strength/endurance of
a muscle. Lumbar stabilization exercises have more effective than the mulligan
mobilization and Conventional exercises. In lumbar stabilization have more benefits in
patients suffering from low back discomfort, it improves the stability and strength to the
lumbar region, to restore the normal functional activities; patients return to normal life we
are proving the reduction of pain and functional development after exercise for lumbar
stabilization treatment.

In this study it was observed that even though all the 3 forms of exercises found to be
useful when pre-post intervention was compared with baseline score and 24 th week data of
intervention session, the between group comparison found lumbar stabilization exercise
seen to be wiser preference while compared to the mulligan mobilization exercises and the
conventional exercises. Since all the demographic data was matched the homogeneity of
the subjects was maintained.

5.3 Conclusion
The foremost purpose of this research work is to suggest the best exercises for people who
suffer from chronic low back discomfort by comparing various forms of exercises like
mulligan mobilization, stabilization and conventional exercises. To start with, we have
categorized three groups of individuals who suffer from chronic low back discomfort
ailment, each group received above said exercises respectively and the results were record
on pre-test and post-test patterns. Visual Analog Scale for pain, Modified Oswestry Back
Pain Disability Questionnaire for Functional activities, Back Chest Leg Dynamometer for
Muscle Strength, Modified schober's test for Range of movement, Biering sorensen test for
Muscle Endurance were considered as the parameters to appraise the effectiveness among
the triple exercises.

The post-test score values of all the above parameter revealed the visible decrease in the
degree of chronic low back pain by doing all three exercises. It was proved that the above
exercises involves in reinforcing the muscles that sustain spine, eliminates friction from the
spinal joints and facets, Stiffness relieving and enhancing mobility, improving circulation

105
to help the disperse the nutrients to the structure in and around, even to the spinal discs,
across the body with the release of endorphins, which can alleviate pain naturally.

But it was clearly evident from the inter group comparison that the exercises for lumbar
stabilization proved to be extra efficient among the other two exercises. Also the exercises
for lumbar stabilization provide a considerable decline in pain along with enhanced
movement range and betterments in functional activities.

Hence, seeing the outcome of the study is to reveal that the Lumbar stabilization exercises
have added competence than the mulligan mobilization and Conventional exercises. The
lumbar stabilization has more benefits in patients with low back pain it improves the
stability and strength to the lumbar region, to restore the normal functional activities;
patients return to normal life. Lumbar stabilization will improve the neuromuscular
control, muscle endurance and then it maintains the dynamic spinal stability and trunk
stability.

5.3.1 Limitation of the study

As specified in earlier chapters, this research work has some limitations that should be
acknowledged. 1) There may be some possible Visual errors in this study. 2) The subjects
included in this study were found to be representative of the South Indian population, but
their level of physical activity may not be typical of persons living in other countries.

5.3.2 Suggestions to the future of the study

A future study can investigate 1) the gender specific research analysis for the above
objective. 2) Efficacy can be determined using different outcome measures like postural
analysis software. 3) Future intention to study the effect of exercises among different
population by using different exercise protocols.

106
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EFFICACY OF MULLIGAN’S MOBILIZATION
VERSUS STABILIZATION EXERCISE ON
CHRONIC NONSPECIFIC LOW BACK PAIN

A THESIS
Submitted by

MOHAN KUMAR.G
in partial fulfilment for the award of the degree
of

DOCTOR OF PHILOSOPHY

Department of Physiotherapy
FACULTY OF PHYSIOTHERAPY

Dr. M.G.R.
Educational and Research Institute
(Deemed to be University)
Maduravoyal, Chennai - 95
(An ISO 21001:2018 Certified Institution, Accredited by NAAC ‘A’ Grade)
University with Graded Autonomy Status

OCTOBER 2021
 CHAPTER - 5

DISCUSSION AND CONCLUSION

5.1 Discussion
In general population low back pain is considered as one of the major problems. In order to
reduce the chronic non-specific low back pain, this study focuses to determine the effects
of mulligan mobilization, stabilization exercise and conventional exercise.

Patients with low back pain were given the stability and strengthening exercise for the
muscles at that particular area to reduce the pain and to bring back to normal functional
activities. The treatment has given for 24 weeks using the mulligan mobilization (SNAG),
stabilization and Conventional exercise to the lumbar spine in three groups. After 24 weeks
of intervention the group of patients given stabilization exercise felt a remarkable
difference in reduction of chronic non- specific low back pain when compared to other two
groups. The measurement for nonspecific low back pain impaired is ruled out by using the
VAS, MODQ, BLC dynamometer, Modified schober's test and Biering sorensen test.

5.1.1 Physiological response associated with mobilization

The mechanical impacts of joint assembly identify with the reclamation of typical joint
versatility or scope of movement. This incorporates adaptability and versatility of capsular
and other delicate tissue designs like tendons and ligaments. Following injury and
immobilization, delicate tissues can become abbreviated and limit by and large joint
portability. Satisfactory power should be applied to the tissues to make mechanical
impacts. Higher grade mobilization might build the joint portability back to typical by re-
establishing relative measures of play in the once-confined joint movement.

94
The periaqueductal hazy situation is in a joint effort with an intricate organization of
frameworks including the nociceptive framework, the autonomic sensory system and the
engine framework. It has additionally been shown that type I and II mechanoreceptors
from joints, muscles and ligaments task to the periaqueductal hazy situation. Proof through
post manipulation thoughtful reaction joined with absence of pain in indicative and
asymptomatic subjects proposes a neurophysiologic reaction to spinal control by means of
mechanoreceptors. These impacts might lie in the incitement of the slipping aggravation
inhibitory arrangement of the focal sensory system from midbrain to spinal string.

The neurophysiological impact may likewise remember a change for muscle actuation
designs in which the engine framework might be restrained. The capacity of assembly and
control to repress muscle might fluctuate contingent upon method, area and nature of pain,
and surprisingly the given muscles designated with the control. On the off chance that
preparation or control influences muscles, the neurophysiologic impacts in all likelihood
happen locally at the designated joint or district and the relating innervation distally
connected with the common innervation. The impacts wanted from playing out the
preparation or control are to expand help of the more profound, more nearby muscles that
help with neuromuscular control of the space and in a perfect world, to repress the more
shallow, worldwide muscles that might be causing pain due to expanded guarding of the
joint or portions included.

5.1.2 Physiological response associated with exercise

When done in a controlled, reformist way, practices for mitigating back pain have many
advantages, including: Fortifying the muscles that help the spine, eliminating pressure
from the spinal plates and aspect joints Reducing solidness and further developing
versatility Further developing dissemination to all the more likely convey supplements
through the body, including to the spinal plates delivering endorphins, which can normally
mitigate pain. A successive arrival of endorphins can assist with decreasing dependence on
pain medicine. Endorphins can likewise raise mind-set and mitigate burdensome
manifestations, a typical impact of constant agony. Limiting the recurrence of back pain
scenes and decreasing the seriousness of pain when it happens.

95
Spine solidness and muscle oxygenation, to give some examples. These are a couple of
guides to start program. The objectives are to improve spine steadiness through scoring
movement and muscle enactment examples to plan for a wide range of difficulties.
Obviously, different activities might be required to improve day after day working,
however these will rely on the qualities and targets of the person.

Two different ideas should be underscored now. In the initial place, preparing approaches
expected to upgrade athletic execution are frequently counterproductive to the
methodologies utilized when preparing for wellbeing. An enormous count of patients are
restored utilizing athletic ways of thinking, or more terrible yet "lifting weights"
approaches planned principally to disengage and hypertrophy explicit muscles and in this
manner foil progress. Many terrible backs are made from utilizing improper execution
ways of thinking. Recognizing the preparation destinations is principal. The accentuation
here is on improving spine wellbeing – preparing for execution is another point. Second, a
large number of the preparation moves toward that are utilized at joints like the knee, hip,
shoulder and so on are erroneously applied for the back. The back is an altogether different
and complex construction, including an adaptable segment, with complex muscle and
ligamentous support. The spine contains the spinal line and parallel nerve roots and whose
musculature is personally associated with a few different capacities including breathing
mechanics, to give only one model. A considerable lot of the customary methodologies for
preparing different joints in the body are not fitting for the back - it is possible that they
don't deliver the ideal outcome or they make new patients.

The reason for the Cat - Camel practice is to help prepare the back, decrease firmness and
increment adaptability in your trunk without bothering your neck. When performed
consistently, the Cat - Camel exercise can likewise assist with expanding perseverance at
work, help your athletic exhibition and work on your stance. Moreover, the activity can
help diminish and forestall back pain and injury.

5.1.3 Visual Analogue Scale (VAS) comparisons

In the present study, the baseline parameters of Visual Analogue Scale (VAS) were within
the reference range in all the three groups. However, after post test of VAS, levels altered
within Group A, Group B and Group C in repeated measures from baseline analysis to 4th

96
week, 12th week & 24th week as shown in Table 4.2 & Fig. 4.1 for Group A, Fig. 4.2 for
Group B and Fig. 4.3 for Group C at P ≤ 0.05. The Visual Analogue Scale (VAS) level
began to reduce in all three groups and there was variation in recovery with respect to pain
immediately after intervention. It is noted that pain values have no significant difference
between the three groups from baseline Value at P > 0.05 shown in Table 4.8. But,
significant differences were observed at 4th week, 12th week & 24th week at P ≤ 0.05 as
shown in Table 4.8 and Fig. 4.19.

Likewise these outcomes were reconfirming with different analysts where they attempt to
think about the impacts of lumbar stabilization exercises practices and lumbar dynamic
strengthening works out, it shows that the VAS shows the lumbar stabilization exercises
showed imperceptibly preferable results over the overall exercise bunch (Moon et al.
2013).

5.1.4 Modified Oswestry back pain Disability Questionnaire (MODQ) comparisons

In the present study, the baseline parameters of Modified Oswestry back pain Disability
Questionnaire (MODQ) were within the reference range in all the three groups. However,
after post test of MODQ, levels altered within Group A, Group B and Group C in repeated
measures from baseline analysis to 4th week, 12th week & 24th week as shown in Table 4.3
and Fig. 4.4 for Group A, Fig. 4.5 for Group B and Fig. 4.6 for Group C at P ≤ 0.05. The
Functional activities level began to rise in all three groups and there was a variation in the
recovery period with respect to Functional activities immediately after intervention. It is
noted that Functional activities levels have no significant difference between the three
groups from baseline at P > 0.05 shown in Table 4.9. But, significant differences were
observed at 4th week, 12th week & 24th week at p ≤ 0.05 as shown in Table 4.9 and
Fig. 4.20.

Stabilisation exercise gets an improved score when compared to the other groups,
indicating that it is helpful in returning patients to their previous work or condition. When
comparing to others groups respectively, the MODQ score showed improvement following
the stabilisation exercise (Ostelo and De Vet 2005).

97
5.1.5 Modified Schober's Test (MST) comparisons
In the present study, the baseline parameters of Modified Schober's Test (MST) were
within the reference range in all the three groups. However, after post test of MST, levels
altered within Group A, Group B and Group C in repeated measures from baseline analysis
to 4th week, 12th week & 24th week as shown in Table 4.4 and Fig. 4.7 for Group A, Fig.
4.8 for Group B and Fig. 4.9 for Group C at P ≤ 0.05. The Flexion Range of Motion level
began to rise in all three groups and there was a variation in the recovery period with
respect to Flexion Range of Motion immediately after intervention. It is noted that Flexion
Range of Motion levels have no significant difference between the three groups from
baseline at P > 0.05 shown in Table 4.10. But, significant differences were observed at 4 th
week, 12th week & 24th week at P ≤ 0.05 as shown in Table 4.10 and Fig. 4.21.

In the present study, the baseline parameters of Modified Schober's Test (MST) were
within the reference range in all the three groups. However, after post test of MST, levels
altered within Group A, Group B and Group C in repeated measures from baseline analysis
to 4th week, 12th week & 24th week as shown in Table 4.5 and Fig. 4.10 for Group A, Fig.
4.11 for Group B and Fig. 4.12 for Group C at P ≤ 0.05. The Extension Range of Motion
level began to rise in all three groups and there was a variation in the recovery period with
respect to Extension Range of Motion immediately after intervention. It is noted that
Extension Range of Motion levels have no significant difference between the three groups
from baseline at P > 0.05shown in Table 4.11. But, significant differences were observed at
4th week, 12th week & 24th week at P ≤ 0.05 as shown in Table 4.11 and Fig. 4.22.

Lumbar dynamic exercises were performed in the lumbar stabilisation exercise group,
which strengthened the lumbar extensors at a large lumbar flexion angle in this group of
patients. However, in the stability exercise group, functional gains and lumbar extensor
strength at low lumbar flexion angles were both better, implying that these benefits were
related to the stabilization exercises (Moon et al. 2013).

5.1.6 Back Leg Chest Dynamometer (BLCD) comparisons

In the present study, the baseline parameters of Back Leg Chest dynamometer (BLCD)
were within the reference range in all the three groups. However, after post test of BLCD,
levels altered within Group A, Group B and Group C in repeated measures from baseline

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analysis to 4th week, 12th week & 24th week as shown in Table 4.6 and Fig. 4.13 for Group
A, Fig. 4.14 for Group B and Fig. 4.15 for Group C at P ≤ 0.05. The Muscle strength level
began to rise in all three groups and there was a variation in the recovery period with
respect to Muscle strength immediately after intervention. It is noted that Muscle strength
levels have no significant difference between the three groups from baseline at
P > 0.05 shown in Table 4.12. But, significant differences were observed at 4 th week, 12th
week & 24th week at P ≤ 0.05 as shown in Table 4.12 and Fig. 4.23.

Various research findings support the use of the BLC dynamometer in examining overall
muscle strength because it provides reasonably reliable test-retest measurements in a
variety of subjects and is thus recognised as an appropriate means to evaluate changes in
muscle strength in research and clinical settings (Ten Hoor et al. 2016).

5.1.7 Biering Sorensen Test (BST) comparisons

In the present study, the baseline parameters of Biering Sorensen Test (BST) were within
the reference range in all the three groups. However, after post test of BST, levels altered
within Group A, Group B and Group C in repeated measures from baseline analysis to 4 th
week, 12th week & 24th week as shown in Table 4.7 and Fig. 4.16 for Group A, Fig. 4.17
for Group B and Fig. 4.18 for Group C at P ≤ 0.05. The Muscle Endurance level began to
rise in all three groups and there was a variation in the recovery period with respect to
Muscle Endurance immediately after intervention. It is noted that Muscle Endurance levels
have no significant difference between the three groups from baseline at P > 0.05 shown in
Table 4.13. But, significant differences were observed at 4th week, 12th week & 24th week
at P ≤ 0.05 as shown in Table 4.13 and Fig. 4.24.

Comparison of three group's isometric back endurance capacity before and after the
Biering Sorensen test (Moreau et al. 2001). When compared to other exercises, group B
cases hold for the longest time and demonstrate the usefulness of stability exercises for low
back pain cases.

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5.1.8 Reporting the level of clinical significance in dependent variables based on
MCID
Vas scale not only considered as one of the outcome measure based mechanism to grade
the intensity of pain but also more reliable and used to validate the disability in patients
with musculoskeletal pain (Verma, Goyal and Narkeesh 2013). In case of responsiveness,
VAS scales have been considered more consistent with the results, since it is considered
more sensitive to detect small differences (Hasson and Arnetz 2005). A remarkable
difference in pain relief was noted in both the experimental groups over the intervention
period. In the statistical analysis Table 4.8 and Fig. 4.19 shows the comparison of pre and
post of VAS score by using the homogeneity of variance and one ANOVA test between
three groups. This table makes clear of there is no significant difference in pre-test values
between three groups (*-P > 0.05) but there is a remarkable difference in post-test values
of VAS score in three groups (**-P ≤ 0.05) especially, Group B (stabilization exercises)
shows 4 fold decrease in pain score with Group C and 2 fold decrease in pain score with
Group A. Also, the mean value of post test in Group B shows 0.91which satisfies the
Minimal Clinically Important Differences (MCID) value (>2cm for chronic low back pain)
as mentioned by previous research studies (Ostelo and De Vet 2005), Group A (1.98) and
Group C (3.87) when compared with their respective pre-test mean values. This indicates
the effect of stabilization exercises on low back pain when compared to other exercises.
This was also proved previously by few researchers where they have compared the effects
of stabilization exercises with strengthening exercises and concluded that the stabilization
gives better results by improving abdominal muscle activation comparatively (Bhadauria
and Gurudut 2017). Also these results were reconfirming with other researchers where they
try to compare the effects of lumbar stabilization exercises and lumbar dynamic strength-
ening exercises, it shows that the VAS shows the lumbar stabilization exercises groups
showed marginally better outcomes than the general exercise group (Moon et al. 2013).

Responsiveness towards the pain reduction is considered as vital measurement

characteristic to examine the usefulness of a self-report disability scale, where the higher
value reflects the higher disability post exercises (Fritz and Irrgang 2001). It was
authenticated by previous researches that MODQ score can be used to confirm the
improvement in low back pain subjects after stabilization exercises (Bhadauria and
Gurudut 2017). In this study, we have used MODQ for comparing the effectiveness of

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three exercises in low back pain cases. With that note, Table 4.9 and Fig. 4.20 expresses
the comparison of pre and post MODQ scores between the groups and revealed that there
is no noticeable difference in pre-test values (*- P > 0.05) but there is a remarkable
difference in post-test values of MODQ scores between the groups (**- P ≤ 0.05).
Noticeably, Group B has relatively lower score when compared with other group’s shows
its effectiveness in patients in rendering back to their normal work or condition. MODQ
score showed improvement after the stabilization exercise Group B with the reduced value
of 14.98 which shows >10 points with respective MCID value (Ostelo and De Vet 2005),
when compared to Group A and Group C with 26.04 and 32.15 respectively. This
reconfirms that the improvement after stabilization exercises can be confirmed by MODQ.

It is indeed to assess improvement of back pain, by defining outcome measures in easily

understandable way. The very fundamental thing is to determine the history of the
complaint and the physical examination, so the only additional physical measure
considered useful was a modified Schober’s test of spinal mobility (Ehrlich George 2003).
Generally, the Modified Schober’s test is adopted to assess the range of motion in lumbar
extension cum flexion used for subjects with low back discomfort, Since it provide
effective and reliable results with minimally metric detectable change (Manju et al. 2015).
As far as our study is concerned, exercises given for all three groups to reduce the intensity
of low back pain and the effectiveness were measured using Modified Schober's test. The
result shows high level of flexibility in patients (Post-test) were achieved with stabilization
exercises when compared to other two exercises (Table 4.10 and 4.11) (Fig. 4.21 and Fig.
4.22). The mean value of post test of Group B shows more than 1 cm differences when
compared to Pre-test values, which satisfies the MCID value of MST (Ostelo and De Vet
2005). Since the postures employed in lumbar stabilization group (Group B) was unique
and activates the lumbar flexors and extensors which tends to achieve more flexibility
among the other group (Bhadauria and Gurudut 2017). Since, it was suggested that among
the abdominal muscles, the transverse abdominal, multifidus and internal oblique muscles
facilitate to augment the intra-abdominal pressure, thereby contributing to the spinal and
pelvic stability. The lumbar stabilization exercise group were involved with few lumbar
dynamic exercises, which in turn strengthened the lumbar extensors at the large lumbar
flexion angle in this group of patients. However, functional improvements and lumbar
extensor strength at low lumbar flexion angles were both better in the stabilization exercise

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group, suggesting that these improvements were due to the stabilization exercises (Moon et
al. 2013).

Muscle Strength is one of the accurate predictor determining the physical fitness of a
person whereas the back strength is one of the key features to keep the individuals at bay
from back pain (Kaur and Koley 2019). The use of the BLC dynamometer in examining
overall muscle strength was supported by various research findings, since it provides
reasonably reliable test-retest measurements in various subjects and thus be recognized an
appropriate means to evaluate changes in muscle strength in research and clinical settings
(Ten Hoor et al. 2016). Table 4.12 and Fig. 4.23 shows the BLC dynamometer test of all
three groups which measures isometric forces produced together by the back, leg and arm
muscles. The post-test values of the three groups showed increase strength, but in
particular Group B showed higher strength value among other two groups. This is
pretended to the specific exercises related to lumbar stabilization.

It was found that subjects having minimum lumbar extensor muscle endurance encounter
an increased prevalence of experiencing initial low back pain. Thus highlighting the
practice of like mobilization and stabilization exercises to counteract the back pain ( Das,
Kumar and Dutta 2016). Recently, exercises designed for core stabilization are considered
essential to maintain low back health particularly patients with LBP. These stabilization
exercises often target endurance training and require a prolonged hold, such as a full-plank
or side-plank of the Pilates maneuvers (Wang-Price et al. 2017). Table 4.13 and Fig. 4.24
shows the comparison of pre and post of Biering Sorensen test of three groups which
assesses the isometric back endurance capacity (Moreau et al. 2001). Among the other
groups, Group B cases hold for maximum seconds and show the effectiveness of
stabilization exercises for low back pain cases when compared to other exercises.

5.1.9 Clinical significance in terms of Effect Size Index (ESI)

Repeated measure ANOVA test describes the statistical significance in mean score over
three or more times within group and one way ANOVA test was used to find statistical
significance between the groups. Paired t test describes statistical significance within
groups when each entity measured twice. The Effect Size Index (ESI) calculation method
is applied in order to assess the clinical change in dependent variables within each group.

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The benchmark set for the interpretation of effect size for repeated measure ANOVA using
Partial Eta Squared as follows: small effect (d = 0.01), medium effect (d = 0.06) and large
effect (d = 0.14) (Richardson 2011). The benchmark set for the interpretation of effect size
for paired sample t test, according to Cohen’s d criteria as follows: small effect (d = 0.2),
medium effect (d = 0.5) and large effect (d = 0.8) (Bakker et al. 2019). The effect size
between the groups was one of the attempts to confirm the clinical effectiveness confined
to particular group. The outcome measures were compared to confirm the clinical
significance of the treatment effect.

The effect size of Mobilization, Stabilization and conventional exercises in lowering the
low back pain intensity among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for VAS in Table 4.20,
According to repeated measure ANOVA Partial Eta Squared measures, the ESI: 4.34
(Group A), ESI: 5.78 (Group B) and ESI: 4.34 (Group C). On comparing the ESI values, it
is clearly understood that Group A shows moderate difference while Group B exhibits
higher efficacy in lowering the pain intensity with that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back Functional activities among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for MODQ in Table 4.21,
According to repeated measure ANOVA Partial Eta Squared measures, the ESI: 5.10
(Group A), ESI: 6.24 (Group B) and ESI: 3.95 (Group C). On comparing the ESI values, it
is clearly understood that Group A shows moderate difference while Group B exhibits
higher efficacy in increasing the Functional activities with that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back ROM among 3 Groups (A, B & C) were compiled using repeated measure
ANOVA Partial Eta Squared measures were tabulated for Flexion using Modified
Schober’s Test (MST) in Table 4.22, According to repeated measure ANOVA Partial Eta
Squared measures, the ESI: 2.07 (Group A), ESI: 4.55 (Group B) and ESI: 1.57 (Group C).
On comparing the ESI values, it is clearly understood that Group A shows moderate
difference while Group B exhibits higher efficacy in increasing the low back ROM with
that of Group C was noted.

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The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back ROM among 3 Groups (A, B & C) were compiled using repeated measure
ANOVA Partial Eta Squared measures were tabulated for Extension using Modified
Schober’s Test (MST) in Table 4.23, According to repeated measure ANOVA Partial Eta
Squared measures, the ESI: 2.08 (Group A), ESI: 2.49 (Group B) and ESI: 1.59 (Group C).
On comparing the ESI values, it is clearly understood that Group A shows moderate
difference while Group B exhibits higher efficacy in increasing the low back ROM with
that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back Muscle strength among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for Back Leg Chest (BLC)
Dynamometer in Table 4.24, According to repeated measure ANOVA Partial Eta Squared
measures, the ESI: 2.87 (Group A), ESI: 4.18 (Group B) and ESI: 1.93 (Group C). On
comparing the ESI values, it is clearly understood that Group A shows moderate difference
while Group B exhibits higher efficacy in increasing the low back Muscle strength with
that of Group C was noted.

The effect size of Mobilization, Stabilization and conventional exercises in increasing the
low back Muscle endurance among 3 Groups (A, B & C) were compiled using repeated
measure ANOVA Partial Eta Squared measures were tabulated for Biering Sorensen test in
Table 4.25. According to repeated measure ANOVA Partial Eta Squared measures, the
ESI: 3.92 (Group A), ESI: 4.22 (Group B) and ESI: 2.23 (Group C). On comparing the ESI
values, it is clearly understood that Group A shows moderate difference while Group B
exhibits higher efficacy in increasing the low back Muscle endurance with that of Group C
was noted.

From the scores of above outcome measures performed with three groups of subjects, it
was clearly seen that stabilization exercises showed significant improvement comparable
to mulligan mobilization and conventional exercises.

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5.2 Summary
In this study findings reveals there exists a significant decrease in pain, enhancements in
movement range, betterments in functional activities and increase in strength/endurance of
a muscle. Lumbar stabilization exercises have more effective than the mulligan
mobilization and Conventional exercises. In lumbar stabilization have more benefits in
patients suffering from low back discomfort, it improves the stability and strength to the
lumbar region, to restore the normal functional activities; patients return to normal life we
are proving the reduction of pain and functional development after exercise for lumbar
stabilization treatment.

In this study it was observed that even though all the 3 forms of exercises found to be
useful when pre-post intervention was compared with baseline score and 24 th week data of
intervention session, the between group comparison found lumbar stabilization exercise
seen to be wiser preference while compared to the mulligan mobilization exercises and the
conventional exercises. Since all the demographic data was matched the homogeneity of
the subjects was maintained.

5.3 Conclusion
The foremost purpose of this research work is to suggest the best exercises for people who
suffer from chronic low back discomfort by comparing various forms of exercises like
mulligan mobilization, stabilization and conventional exercises. To start with, we have
categorized three groups of individuals who suffer from chronic low back discomfort
ailment, each group received above said exercises respectively and the results were record
on pre-test and post-test patterns. Visual Analog Scale for pain, Modified Oswestry Back
Pain Disability Questionnaire for Functional activities, Back Chest Leg Dynamometer for
Muscle Strength, Modified schober's test for Range of movement, Biering sorensen test for
Muscle Endurance were considered as the parameters to appraise the effectiveness among
the triple exercises.

The post-test score values of all the above parameter revealed the visible decrease in the
degree of chronic low back pain by doing all three exercises. It was proved that the above
exercises involves in reinforcing the muscles that sustain spine, eliminates friction from the
spinal joints and facets, Stiffness relieving and enhancing mobility, improving circulation

105
to help the disperse the nutrients to the structure in and around, even to the spinal discs,
across the body with the release of endorphins, which can alleviate pain naturally.

But it was clearly evident from the inter group comparison that the exercises for lumbar
stabilization proved to be extra efficient among the other two exercises. Also the exercises
for lumbar stabilization provide a considerable decline in pain along with enhanced
movement range and betterments in functional activities.

Hence, seeing the outcome of the study is to reveal that the Lumbar stabilization exercises
have added competence than the mulligan mobilization and Conventional exercises. The
lumbar stabilization has more benefits in patients with low back pain it improves the
stability and strength to the lumbar region, to restore the normal functional activities;
patients return to normal life. Lumbar stabilization will improve the neuromuscular
control, muscle endurance and then it maintains the dynamic spinal stability and trunk
stability.

5.3.1 Limitation of the study

As specified in earlier chapters, this research work has some limitations that should be
acknowledged. 1) There may be some possible Visual errors in this study. 2) The subjects
included in this study were found to be representative of the South Indian population, but
their level of physical activity may not be typical of persons living in other countries.

5.3.2 Suggestions to the future of the study

A future study can investigate 1) the gender specific research analysis for the above
objective. 2) Efficacy can be determined using different outcome measures like postural
analysis software. 3) Future intention to study the effect of exercises among different
population by using different exercise protocols.

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 LIST OF SYMBOLS & ABBREVIATIONS

% : Percentage

< : Less than

> : Greater than
≤ : Less than or equal to
≥ : Greater than or equal to

ACSMCH : ACS Medical College and Hospital

ADL : Activity of Daily Life

AF : Annulus Fibrosus

ALL : Anterior Longitudinal Ligament

ANOVA : Analysis of Variance

BLCD : Back Leg Chest Dynamometer

BLR : Bend Leg Raise

BST : Biering-Sorensen Test

CI : Confidence Interval

CLBP : Chronic Low Back Pain

CMLBP : Chronic Mechanical Low Back Pain

CPG : Chronic Pain Grade

EDA : Electro Dermal Activity

ESI : Effect Size Index

FD : Functional Disability

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GSR : Galvanic Skin Response

H0 : Null Hypothesis

HRQOL : Health-Related Quality Of Life

IBS : Integrated Back Stability

IHME : Low Back Pain Institute Of Health Metrics And Evaluation

IVD : Intervertebral Disc

KA : Kinematic Algorithms

KT : Kinesio Taping

LBA : Low Back Ache

LBP : Low Back Pain

LF : Ligamentum Flavum

MCID : Minimal Clinically Important Difference

MMA : Multifidus Muscle Activation

MMDC : Minimum Metrically Detectable Change

MODQ : Modified Oswestry Back Pain Disability Questionnaire

MST : Modified Schober's Test

MWM : Mobilization With Movement

NP : Nucleus Pulposus

NRS : Numeric Rating Scale

NSCLBP : Non-Specific Chronic Low Back Pain

NSLBP : Non-Specific Low Back Pain

ODI : Oswestry Disability Index

PI : Pain Intensity

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PLL : Posterior Longitudinal Ligament

QTF : Quebec Task Force

SC : Skin Conductance

SD : Standard Deviation

SM : Spine Manipulation

SMT : Spinal Manual Therapy

SNAG : Sustained Natural Apophyseal Glide

SNS : Sympathetic Nervous System

SR : Skin Resistance

VAS : Visual Analogue Scale

YLD : Year Lived with Disability

xix
 ABSTRACT

Background of the Study

Lower Back Pain (LBP) is widely recognized as a common reason for health care visits
with profound economic and social consequences. Non-Specific LBP is tension, soreness
and/ or stiffness in the lower back region for which it is not possible to identify a specific
cause of the pain (Chenot et al. 2017). Recent studies portrays that NSLBP occurs in
general population at any age it has been experienced first at the age of nine and continues
to the adulthood. In India, about 60% of people affected by means of low back pain in
addition it has become one of the major causes which affects peoples at all strata in the
society (Nazeer et al. 2015). A conservative, symptomatic, goal-oriented management
program is advocated by most emphasizing pain relief and restoration of functional
capacity. Exercise prescription is one of the ultimate popular approaches in the
management of individuals with chronic LBP. However till now, the value of such
approaches as it hasn’t been tested in Indian population among chronic LBP.

Objectives
Objective of the study is to seek the relative effect of mulligan's mobilization over
stabilization exercise, to reduce the intensity of pain, to improve the functional ability,
endurance, strength of spinal extensor muscles and lumbar spinal mobility among
nonspecific low back pain patients.

Methodology
It is an Experimental study design which was done in Outpatient Physiotherapy
Department, Faculty of Physiotherapy, Dr. M.G.R Educational & Research Institute and
Abinaya Physiotherapy Clinics with the comparative pre and post type. A number of 165
samples with Chronic Nonspecific Low Back Pain have been taken by Systematic Random
Sampling method and allocated with 55 subjects in each group.

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The subjects in Group A (n=55) received Mulligan's mobilization, the subjects in Group B
(n=55) received Stabilization exercises and conventional Group C (n=55). The study
duration was 6 months (Base line with 3 follows up).

Result
On comparing Mean values of Group A, Group B & Group C there is a significant
difference in the Post test Mean values at 4 th week, 12th week & 24th week, but stabilization
exercises (Group B) which has the Lower Mean value is effective than Mulligan MWM
(Group A) and followed by conventional (Group C) at P ≤ 0.05. Hence Null Hypothesis is
rejected.

Conclusion
The present study concluded that treatment program using mulligan mobilization and
stabilization exercise with non-specific chronic low back discomfort showed that both the
interventions were effective. This study suggested that stabilization exercise showed
statistically high significant improvement than mulligan mobilization.

Keywords: Nonspecific Low Back Pain, functional ability, strength, dynamometer,

endurance.

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