778321

research-article2018
CRE0010.1177/0269215518778321Clinical RehabilitationPourahmadi et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Effectiveness of mobilization 2018, Vol. 32(10) 1289­–1298

© The Author(s) 2018
Article reuse guidelines:
with movement (Mulligan concept sagepub.com/journals-permissions
DOI: 10.1177/0269215518778321
https://doi.org/10.1177/0269215518778321

techniques) on low back pain: journals.sagepub.com/home/cre

a systematic review

Mohammad Reza Pourahmadi1 , Holakoo Mohsenifar1 ,

Mozhdeh Dariush2, Amirreza Aftabi1 and Ali Amiri1

Abstract
Objective: To evaluate evidence on the effectiveness of Mulligan techniques on low back pain.
Data sources: PubMed/Medline, Scopus, Ovid, CINAHL, Embase, PEDro, Google Scholar, and Cochrane
Library were searched from inception to 31 March 2018 for randomized clinical trials reporting outcomes
of pain or disability in adult patients (⩾18 years) with low back pain.
Review methods: Two authors screened the results and extracted data for use in this review. The risk
of bias was evaluated using the Cochrane criteria. Basic information and treatment protocols were also
extracted. In addition, the level of evidence of each study and strength of conclusion for pain and disability
were determined.
Results: A total of 20 studies with 693 patients were included. Nine trials focused on sustained natural
apophyseal glide, three on spinal mobilization with limb movement and seven on bent leg raise. The results
showed that Mulligan techniques can decrease pain and disability and increase range of motion in patients
with low back pain; however, the strength of conclusion for pain and disability was moderate. Furthermore,
inconclusive results were observed for the effectiveness of Mulligan techniques on movement speed. In
this review, eight studies were categorized as low risk of bias, while 12 studies had high risk of bias. Level
of evidence analysis revealed that 17 studies were classified as level of evidence B, while three studies
were classified as level of evidence A2.
Conclusion: Current evidence is insufficient in supporting the benefits of Mulligan techniques on pain,
disability, and range of motion in low back pain patients.

Keywords
Low back pain, musculoskeletal manipulations, review

Date received: 30 September 2017; accepted: 30 April 2018

1Department of Physiotherapy, School of Rehabilitation Corresponding author:

Sciences, Iran University of Medical Sciences, Tehran, Iran Holakoo Mohsenifar, Assistant Professor, Department of
2Department of Physiotherapy, University of Social Welfare
Physiotherapy, School of Rehabilitation Sciences, Iran University
and Rehabilitation Sciences, Tehran, Iran of Medical Sciences, Madadkaran All., Shahnazari St., Madar Sq.,
Mirdamad Biv., P.O. Box 4391-15875, Tehran 1545913187, Iran.
Email: [email protected]
1290 Clinical Rehabilitation 32(10)

Introduction useful decision-making tools because they objec-

tively summarize large amounts of research evi-
Manual therapy comprises skilled hands-on move- dence and also identify gaps in medical research.8
ments designed to mobilize or manipulate joints Thus, this study aims to critically review the pub-
and soft tissues with the intent to improve range of lished literature in order to evaluate the effective-
motion, increase tissue extensibility, modulate ness of the Mulligan techniques in patients with
pain, and decrease tissue/joint swelling, inflamma- low back pain. It is hoped that this systematic
tion, or restriction.1 Manual therapy is the most review will be helpful in further understanding the
common therapeutic strategy used by clinicians in mobilization with movement effects on low back
various musculoskeletal dysfunctions such as low pain.
back pain.2
The Mulligan concept of mobilization with
movement is a specific manual therapy technique Methods
that has been developed to restore normal arthro-
kinematic and osteokinematic movements.3 This
Search strategy
therapeutic intervention combines a pain-free This systematic review was conducted in accord-
accessory mobilization with active and/or passive ance with the Preferred Reporting Items for
physiological movements.4 Mulligan proposed Systematic Reviews and Meta-analyses statement.9
that injuries or sprains result in a minor positional The protocol for this systematic review was regis-
fault to a joint and might affect the kinematics of tered on PROSPERO (International Prospective
the spine and peripheral joints.5 Therefore, the Register of Systematic Reviews; http://www.crd.
range of motion of the joint could be decreased york.ac.uk/PROSPERO/; identification no.
following the positional fault. The positional fault CRD42017077469).
is a sustained malalignment of a joint or a sub- Electronic search strategies were constructed
luxation that is too subtle to identify through pal- based on the combined keywords: mobilization
pation or to visualize on a radiograph (osteopathic with movement, low back pain, and clinical trial to
subluxation).6 identify English-language studies that examined
In the treatment of spinal dysfunctions using the the Mulligan techniques for adult (⩾18 years)
Mulligan concept, passive oscillatory mobilization patients with low back pain. PubMed/Medline
(i.e. the natural apophyseal glide) and sustained (NLM), Scopus, Ovid, CINAHL, Embase, PEDro,
mobilization with active movement (i.e. the sus- Google Scholar, and Cochrane Library were
tained natural apophyseal glide) are the most fre- searched from inception to 31 March 2018.
quently used techniques.5 Furthermore, in the late Medical subject heading (MeSH) terms were
1990s, the spinal mobilization with limb move- exhausted, and all subheadings were included to
ment was developed by Mulligan.6 It involves encompass all related search terms and also ensure
applying a sustained transverse glide to the spinous exhaustiveness. Therefore, the syntax of this
process of a vertebra while actively or passively review was a combination of MeSH terms and
performing the restricted peripheral joint move- free-text words. The Boolean command OR was
ment.6 All of the Mulligan techniques must result used to include synonyms. In retrieving all possible
in a symptom-free movement.5 variations of a specific root word, truncations were
While a growing number of studies regarding also used. To optimize the strategy for each of the
the effectiveness of the Mulligan techniques in other databases, appropriate changes were made in
patients with low back pain exist, to date no sys- the basic search strategy. Details of PubMed/
tematic review has been published on this topic. Medline (NLM) database search syntax are listed
According to Kozel et al.,7 conducting a systematic in on-line Supplementary Appendix 1. Moreover,
review is one step in the development of a clinical citation tracking and reference list scanning of
practice guideline. Systematic reviews can be very included articles and manual ahead-of-press
Pourahmadi et al. 1291

searches were performed to identify other eligible met and the risk of bias of a trial labeled as “high
studies. Hand searching of relevant journals was risk” if fewer than eight criteria were met. The
also conducted; these included the Journal of level of inter-rater agreement was measured using
Manual Therapy (now known as the Journal of Cohen’s kappa coefficient, with a method devel-
Musculoskeletal Science and Practice) and the oped for comparing the level of agreement with
Journal of Manipulative and Physiological categorical data along with their respective 95%
Therapeutics. confidence intervals (κ 0–0.20 = poor agreement;
0.21–0.40 = fair agreement; 0.41–0.60 = moderate
agreement; 0.61–0.80 = good agreement; and 0.81–
Eligibility criteria
1 = very good agreement).15 Consensus was reached
At the completion of the search, all references were in the case of disagreement. The results demon-
imported into the EndNote X7 software (Thomson strated that very good agreement was present
Reuters, New York, NY, USA) and duplicates were between the two reviewers (κ ± standard error was
removed. Titles and abstracts of all primary articles 0.87 ± 0.22).
that met the search strategy were screened by two
reviewers (M.R.P. and H.M.) in order to determine
Level of evidence and strength of
studies eligible for inclusion. In the absence of suf-
ficient information in the title and abstract of an conclusion
article, a full-text evaluation was undertaken. Then, Based on the study design and methodological
the same two reviewers independently assessed the quality, a level of evidence was determined for
full text of potentially relevant non-duplicated arti- each included study according to the 2005 classifi-
cles. Disagreements were resolved by discussion cation system of the Dutch Institute for Healthcare
between the reviewers. Studies were screened for Improvement (CBO;16 on-line Supplementary
selection according to the review objectives and Appendix 5). In addition, the strength of the con-
population, intervention, comparison, outcomes, clusion was determined for the present primary
and study design (PICOS) criteria (on-line outcomes (pain and disability) by considering the
Supplementary Appendices 2 and 3).10,11 level of evidence of the included studies and the
consistency of the reported results16 (on-line
Assessment of risk of bias in included Supplementary Appendix 6). The strength of con-
clusion was classified according to De
studies Meulemeester et al.17 as: 1—high, 2—moderate,
The risk of bias was evaluated independently by 3—low, and 4—very low.
two reviewers (M.R.P. and H.M.) using the 2015
updated Cochrane Back and Neck Review Group
Data extraction and analysis
13-item criteria.12,13 The guideline examines six
specific domains of bias, and the scoring criteria Data extraction from the included studies was per-
for each item in each of the domains are “Yes,” formed independently by two non-blinded review-
“No,” and “Unclear” if there is insufficient infor- ers (M.R.P. and H.M.) using a standardized data
mation to make an accurate judgment12,14 (on-line extraction form. The extracted data included the
Supplementary Appendix 4). Previous studies sug- description of study characteristics: first author’s
gested the use of this guideline for planning, con- name, year of publication, country in which the
ducting, and evaluating systematic reviews in the study was performed, description of study partici-
field of back and neck pain, and spinal disorders.12 pants (size of the sample, gender, mean age, body
Since a cutoff for stratifying studies was not rec- mass, height, body mass index (BMI), and status of
ommended by Furlan et al.12 as higher or lower risk health), study design, description of interventions,
of bias, the risk of bias of a trial was labeled as outcome measures, and conclusion. Following the
“low risk” if at least eight of the 13 criteria were completion of this process, the extracted data was
1292 Clinical Rehabilitation 32(10)

Figure 1. PRISMA flowchart of the study.

double-checked by one author (M.R.P.) to avoid of duplicates and review of titles and abstracts, 24
any omissions or inaccuracies in the extracted data. studies were considered eligible for inclusion in the
Meta-analysis was not performed because the present review. One study included participants
included studies were heterogeneous in low back with mild-to-moderate scoliosis,19 two studies uti-
pain sub-classification and methodologically dif- lized a pretest–posttest design and did not contain a
ferent (dosage of interventions). Therefore, this control group,20,21 and one study utilized a single-
review focused only on description and qualitative participant quasi experimental design.22 Thus, a
synthesis of the identified studies. total of 20 clinical trials were included in this sys-
tematic review18,23–41 (Figure 1).

Results
Risk of bias and level of evidence
Identification of studies Following the assessment of risk of bias using the
Initial query of the selected databases returned 207 2015 updated Cochrane Back and Neck Review
records (Figure 1). Furthermore, only one relevant Group 13-item criteria (on-line Supplementary
article was identified by a hand search of references Appendices 7 and 8), eight studies were catego-
provided in the included studies.18 After exclusion rized as low risk of bias (Figure 2). Method of
Pourahmadi et al. 1293

Figure 2. Risk of bias assessment results. The red rows are indicative of those studies deemed high risk of bias
(i.e. a mean score <8/13).

randomization was clearly reported in 11 stud- evidence B, while three studies26,27,29 were classified
ies.18,24,26–29,31,32,36,37,40 Patients were blinded in only as level of evidence A2.
four studies,26,27,29,35 and in no studies were the clini-
cians who administered the interventions blinded.
Overview of participant characteristics
However, due to the nature of interventions, it seems
that blinding of the clinicians was not feasible. On-line Supplementary Appendix 10 provides a
Moreover, only in three studies were the outcome summary of the total number of participants
assessors blinded.26,27,29 In this review, 13 studies did recruited, along with their health status, gender,
not report sufficient information about drop-out rate and age. A total of 693 low back pain patients were
or lost to follow-up.25,27,30–40 Other common areas of included in the eligible studies. Moreover, a wide
bias with the included trials were with treatment allo- variation existed in the type of low back pain stud-
cation concealment,18,23–25,28–30,33–41 two studies failed ied by the 20 trials. The majority of the included
to conduct an intention-to-treat analysis,18,23 while 13 trials (eight studies) enrolled low back pain patients
studies did not provide adequate information regard- with radiculopathy.18,31,35,37,38,40,41 Four studies
ing their intention-to-treat analysis,25,27,30–40 one recruited chronic low back pain patients,25,28,34,39
study had selective reporting bias,37 one study whereas one study included acute low back pain
failed to match intervention and control groups at patients,32 one study included acute, subacute, and
baseline,41 and in one trial the compliance was not chronic low back pain patients,27 one study
acceptable.38 On-line Supplementary Appendix 7 recruited non-specific low back pain patients,33 and
summarizes the risk of bias of the included studies. one trial included facet syndrome patients23.
The levels of evidence of the selected studies are pre- However, two studies did not provide detailed
sented in on-line Supplementary Appendix 9. From information on the low back pain subclassifica-
analysis of the level of evidence, the majority of the tion.26,29 The mean age of population of included
selected studies (17 trials) were classified as level of studies at baseline ranged from 27.1 to 50.2 years.
1294 Clinical Rehabilitation 32(10)

It seems that the participants in the study by Elrazik pain and disability and a significant increase in the
et al.25 were the same as those in the study by Samir duration of the Sorensen test compared to Maitland
et al.,34 because similar demographic characteris- mobilization or conventional physical therapy in
tics were reported by both the studies. In addition, patients with facet joint syndrome.
eight studies provided little or no information Ahmed et al.18 evaluated the effects of the spinal
regarding the patients’ demographic characteris- mobilization with limb movement technique in a
tics.23,24,29–31,33,36,41 Finally, calculation of sample side lying position versus neural mobilization in
size was apparent in three studies.18,27,29 patients with lumbar disk herniation. In this study,
the magnitude of response in relieving pain,
improving functional disability, and promoting
Methodology considerations and centralization was better in participants who
outcome measures received neural mobilization. Furthermore, no sig-
In all, 13 of the 20 included studies were conducted nificant difference was found in H-reflex latency
in India,18,23,24,30–33,35–38,40,41 while the remaining between the two techniques.18 In contrast, Thakur
clinical trials were from the United Kingdom,29 et al.36 discovered the Mulligan spinal mobilization
Australia,26 Belgium,27 Egypt,25,28,34 and Pakistan.39 with limb movement technique to be more effec-
The effects of various Mulligan techniques on low tive than Shacklock neural mobilization in reduc-
back pain were reported in the literature. Ten stud- ing leg pain intensity and improving lumbar range
ies investigated the effects of the sustained natural of motion and back-specific disability. Moreover, it
apophyseal glide techniques.23,25,27–29,34,37,39–41 has been shown that combining Mulligan spinal
Hussien et al.28 reported that the addition of sus- mobilization with limb movement technique with
tained natural apophyseal glide technique to con- conventional physical therapy can produce greater
ventional physical therapy could result in pain improvement in pain intensity, location of pain,
reduction and increased function in patients with and disability.41
chronic nonspecific low back pain. In addition, The bent leg raise technique was a common
Waqqar et al.39 indicated that the sustained natural Mulligan technique evaluated by seven stud-
apophyseal glide technique was more effective in ies.24,26,30–33,35 Tambekar et al.35 showed that both
increasing lumbar range of motion than McKenzie the bent leg raise technique and Butler neural
extension exercises, whereas McKenzie exercises mobilization were equally effective in increasing
produced greater improvement of pain and disabil- straight leg raise range and decreasing pain in
ity in patients with chronic mechanical low back patients with low back pain radiating to lower limb.
pain. On the contrary, according to Warude and However, the effects of the bent leg raise technique
Shanmugam,40 applying the Mulligan sustained and Butler neural mobilization were not evident
natural apophyseal glide technique in lumbar disk after 24 hours. It has been demonstrated that the
herniation patients provided greater pain reduction bent leg raise and two leg rotation techniques have
and function improvement compared to McKenzie equal effects on increasing hamstring flexibility.33
exercises. Moreover, a cross-over trial conducted by Dave
There were controversies over the effects of the et al.24 indicated a superior immediate effect of the
Mulligan techniques versus Maitland mobilization bent leg raise technique on hamstring flexibility
on low back pain. Elrazik et al.25 and Samir et al.34 compared to PNF stretching (contract-relax
observed no significant differences between the method) in individuals with mechanical low back
sustained natural apophyseal glide technique and pain and hamstring tightness. In 2014, Pawar and
posteroanterior glide mobilization in pain reduc- Metgud31 found that the bent leg raise technique
tion and function improvement of chronic low back was more effective than the traction straight leg
pain patients after four weeks. In another study by raise technique in relieving pain, improving range
Anap et al.,23 the sustained natural apophyseal of motion, and reducing disability in low back pain
glide technique resulted in a significant decrease in patients with radiculopathy. Furthermore, in a
Pourahmadi et al. 1295

study by Hall et al.26 it was reported that although activity) non-opioid endogenous pain inhibition
the range of straight leg raise and pelvic rotation in pathways, especially the descending pain inhibi-
low back pain patients was increased by the bent tory systems via the periaqueductal gray regions
leg raise technique with unilateral limitation of in the mid-brain.
straight leg raise, no difference was observed Various Mulligan techniques, such as the sus-
between this technique and soft tissue manipula- tained natural apophyseal glide and spinal mobili-
tion. Detailed information regarding the interven- zation with limb movement, might have a relieving
tion, outcome measures, and conclusion of the effect on the facet joint capsular strain, which
included studies are presented in on-line might decrease the pain sensation experienced by
Supplementary Appendix 10. On-line Supplementary low back pain patients.28 In addition, Mulligan6
Appendix 11 shows a synthesis of results for this hypothesized that lack of normal facet joints glid-
review’s outcomes. ing may distort the disk and provoke pain. In a
In this systematic review, the strength of conclu- double-blind randomized controlled trial by
sion was determined for our primary outcomes and Hidalgo et al.,27 the sustained natural apophyseal
the results showed that the strength of conclusion glide technique was indicated to improve facet
for pain and disability was moderate. joints gliding in flexion, normalized forces on the
disk, and relieved pain in patients with nonspecific
low back pain.
Discussion Zusman45,46 suggested a rationale for pain reduc-
Mulligan techniques are a kind of manual therapy tion provided by manual therapy based on the theory
interventions developed by Brian Mulligan (Dip. of habituation and extinction. According to this the-
M.T.), which combines a sustained manual “glid- ory, patients who experience pain during a move-
ing” force to a joint with concurrent physiologic ment usually have a conditional fear of any activity
(osteokinematic) motion of the joint, either involving that particular movement.27,28 During
actively performed by the patient or passively per- the sustained natural apophyseal glide technique,
formed by the physical therapist.6 According to patients are exposed to this fearful movement but in
Mulligan,6 these techniques produce immediate a graded manner, which results in no pain or even
improvements. immediate improvement.28 Progressive exposure to
From the results of this review, the Mulligan the fearful movement desensitizes the nervous sys-
techniques can decrease pain and improve disa- tem through habituation.27 The mechanism involves
bility in patients with low back pain (moderate a significant decline in the ability of the presynaptic
strength of conclusion). A review by Wilson42 nerve terminal to transmit impulses.27
stated that the Mulligan techniques can correct It has been suggested that the gap in the facet
positional faults that occur in the spine and, thus, joint opposite to direction of rotation is increased by
once the pain generator is released, normal func- the rotational movement of the lumbar spine.47
tion returns and the muscle guarding around the Using this fact, Yadav et al.41 concluded that spinal
affected joint is resolved. Several studies have mobilization with limb movement technique can
reported that along with the biomechanical address hypomobility of facet joint, consequently
changes, certain neurophysiological changes relieving pain. When an external force is applied to
exist that occur at the spinal level after applying a functional spinal unit, the nucleus pulposus is
the Mulligan techniques, including changes in capable of deformation in all directions. Rotation of
descending pain inhibitory systems and changes intervertebral segment produces simultaneous ten-
in central pain processing mechanisms.42,43 sion and approximation in alternate layers of annu-
Vincenzino et al.44 proposed that the immediate lus fibrosus.41 Theoretically the mechanical
effects of the Mulligan techniques on pain relief deformation in the lumbar spine is being reduced by
may be related to the activation of (as measured either the stretching or compressing action of
by recordings of sympathetic nervous system deformed soft tissue. Thus, rotational movements
1296 Clinical Rehabilitation 32(10)

of spinal mobilization with limb movement or the were available as full text in English were included.
two leg rotation techniques which are applied to the Finally, because of severe methodological hetero-
lumbar spine can unload nociceptive endings, geneity of the included studies meta-analysis was
decrease symptoms, and improve range of motion.41 not performed, so only a qualitative synthesis of
The results of existing articles indicated that the results is presented in this review.
improvement of straight leg raise range, by the bent In conclusion, from the 20 studies included in
leg raise technique, might be due to mobilization of this review, eight studies had low risk of bias.
the sensitized and painful nerve tissues, similar to Because 12 studies had high risk of bias based on
the “slider” effects described by Butler48 and Elvey the risk of bias assessment results, therefore, a
and Hall.49 Another positive effect of the bent leg definitive conclusion cannot be drawn from the
raise technique might be a change in stretch toler- results of those studies. However, the results of this
ance of the hamstrings via neurophysiological review demonstrated that there are moderate short-
responses. Hall et al.26 reported that an increase in term therapeutic effects of the Mulligan techniques
hamstring extensibility might reduce excessive on pain reduction and disability improvement in
loads on painful lumbar tissues and hence allow an patients with low back pain. In all, 17 studies had a
increase in posterior pelvic rotation, consequently level of evidence B, while three had a level of evi-
resulting in greater lumbar flexion range of motion. dence A2. The systematic appraisal of the current
From this review, a moderate strength of con- literature showed that some methodological flaws
clusion existed for pain and disability. Several were presented among the included trials. Thus,
important factors can explain this moderate further high-quality studies with low risk of bias
strength of conclusion. First, the majority of the are warranted to evaluate the long-term effects of
included trials (17 studies) did not perform any the Mulligan techniques on low back pain.
power analysis to calculate the number of partici-
pants needed to prevent type II statistical errors. Clinical messages
Therefore, the generalizability of their results is
limited due to low external validity. Second, in two •• The results of this review showed that
studies,26,29 the low back pain patients were not the Mulligan techniques of manual
sub-classified. Because low back pain is a hetero- therapy may reduce pain and disability
geneous disorder, it is necessary to create a homo- and improve range of motion in low
geneous sample by recruiting specific and back pain patients.
well-defined groups of low back pain patients in •• However, there was a high risk of bias
order to evaluate the effects of manual therapy in 12 studies, reducing the strength of
intervention. Third, many studies had some meth- any conclusions about the effective-
odological weaknesses such as not using allocation ness of the Mulligan techniques.
concealment and lack of blinded assessment and
participant blinding. Finally, none of the available Declaration of conflicting interests
studies examined the long-term effects of the The authors declared no potential conflicts of interest
Mulligan techniques on low back pain. Based on with respect to the research, authorship, and/or publica-
the systematic appraisal of the current literature, tion of this article.
any future research studies should consider the
limitations of the previous studies in order to Funding
improve the quality of evidence in this field. The authors received no financial support for the
Like other studies, this systematic review has research, authorship, and/or publication of this article.
some limitations. First, only studies published in
peer-review journals were included and, therefore, Supplementary Materials
a publication bias may have occurred. Second, a Supplementary Materials are available for this article
language bias is possible as only those studies that on-line.
Pourahmadi et al. 1297

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to review. 1st ed. Leuven; Den Haag: Acco, 2016.
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Holakoo Mohsenifar https://orcid.org/0000-0002- trapezius muscle in patients with work-related trape-
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