THE COMBINED EFFECT OF MAITLAND SPINAL
MOBILIZATION WITH MECHANICAL LUMBAR
TRACTION IN PATIENTS WITH CHRONIC NONSPECIFIC
LOW BACK PAIN
Hamdy E. Mohamed 1*; Wadida H. Elsayed 2 and Yasser M. Aneis 2
1 Physical therapist, ministry of health, Saqulta hospital, Sohag, Egypt.
2 Professor of Physical Therapy for Basic science department, Faculty of Physical
Therapy, Cairo University;
3 Assistant Professor of Physical Therapy for Basic science department, Faculty of
Physical Therapy, Cairo University.
* Corresponding author: Hamdy E. Mohamed
E-mail: drhamdy.elhawary.89@gmail.com
Key Words: Maitland spinal mobilization; lumbar mechanical traction;
combined effect; nonspecific low back pain.
ABSTRACT
Background: Non-specific low back pain (NSLBP) is pain not attributed
to a recognizable pathology, not attributable to a known cause, represents
90–95% of the cases of LBP. Objectives: to investigate the combined
effect of Maitland spinal mobilization and lumbar traction on pain
intensity, range of motion (ROM), and functional disability in patients
with chronic nonspecific low back pain. Design: A randomized
controlled trial. Subjects and Methods: Forty-four subjects with chronic
nonspecific low back pain participated in this study, their ages ranged
from 20 to 30 years. Participants were randomly subdivided into four
equal groups (each consist of 11 patient and received 3sessions per week
for 4 weeks): Group (A): received central posterior-anterior mobilization
in addition to conventional physical therapy and advices. Group (B):
received intermittent mechanical lumbar traction in addition to
conventional physical therapy and advices. Group (C): received
intermittent mechanical lumbar traction with central posterior-anterior
mobilization in addition to conventional physical therapy and advices.
Group (D) (Control group): received conventional physical therapy
(Transcutaneous electrical nerve stimulation, Infrared, and Isometric
exercise) and advices. outcome measures: Pain intensity assessed by
visual analogue scale (VAS), lumbar ROM assessed by Bubble
Inclinometer, and functional disability assessed by the Arabic version of
modified Oswestry disability questionnaire (MODQ). All outcomes were
taken pre and post treatment. Results: Multiple comparison analysis
showed a potential difference between groups in terms of the selected
parameters, while the major changes favored group C, where (P < 0.05).
Conclusion: The combined effect of Maitland spinal mobilization and
intermittent mechanical lumbar traction on pain intensity, lumbar ROM,
Egypt. J. of Appl. Sci., 35(12) 2020 136-150
and functional disability in patients with chronic nonspecific low back
pain is more effective than one of them alone.
INTRODUCTION
Low Back Pain (LBP) is that the commonest musculoskeletal disorder
that affects many of people during their lifetimes [1]. ]. one among the
foremost popular mechanical classification is labeling LBP as specific or
non-specific [2]. Non-specific low back pain is pain not attributed to a
recognizable pathology, not due to a known cause [3], represents 90–95% of
the cases of LBP [4]. For several years, LBP has been both the leading
explanation for days lost from work and the leading indication for medical
rehabilitation [5]. The entire direct and indirect costs for the treatment of
LBP are estimated to be $100 billion annually [6].
There are different methods for LBP treatment like surgery, oral
medication, injection at lumbar region, psychotherapy, chiropractic and
physiotherapy [7]. Physiotherapy modalities and techniques like
electrotherapy, low level laser, ultrasound, massage, shortwave, traction,
superficial hat, spinal manipulation and exercise therapy wont to treat such
cases [8].
Maitland mobilization technique are thought to profit patients with
lumbar mechanical pain through the stimulation of joint mechanoreceptors.
These receptors are believed to change the pain-spasm cycle through the
presynaptic inhibition of nociceptive fibers in associated structures and
therefore the inhibition of the hypertonic muscles, which ultimately improve
functional abilities [9].
Posterior-to-anterior (PA) mobilization technique is a sort of Maitland
vertebral mobilization applied in Maitland’s grading technique[10]. The
United Kingdom evidence report on the effectiveness of Manual Therapies
reviewed the literature and concluded that spinal manipulation and
mobilization has top quality positive evidence supporting its utilization in
the treatment of chronic low back pain [11].
There's moderate-quality evidence that manipulation and mobilization
are likely to decrease back pain and improve function for patients with
chronic low back pain. Multimodal programs could also be a promising
option [12]. Lumbar traction is a commonly used method to treat patients
with LBP with or without sciatica. Many clinicians also report the use of
traction for patients with low back and leg pain [13]. within the United
Kingdom and therefore the United States, lumbar traction is utilized by 41
and 77% of outpatient rehabilitation providers respectively [14].
Variety of RCTs suggest that traction are often an efficient
intervention within the management of patients with LBP [15, 16,17]. There
are many theories that describe how traction relieve low back pain, one
among them is that ligaments can become contracted or shortened from
injury or posture problems, so traction encourages adaptive changes in
137 Egypt. J. of Appl. Sci., 35(12) 2020
ligaments length and strength and another theory suppose that traction
activates the gating mechanism via proprioceptive fibers in ligaments [18].
In order to improve the functional status and quality of life in patients
with chronic non-specific low back pain(CNSLBP) , it's important to
understand which modalities are capable of reducing pain and disability.
Therefore, the present study aimed to investigate the combined effects of
mechanical traction with Maitland mobilization on pain intensity, ROM, and
functional disability in patients with CNSLBP. We hypothesized that
patients with CNSLBP who received mechanical traction combined with
Maitland mobilization would demonstrate greater reductions in pain, ROM,
and functional disability compared to patients who received mechanical
traction alone or Maitland mobilization alone.
METHODS
This randomized controlled trial was conducted to investigate the
effects of lumbar mechanical traction, posterior-anterior spinal mobilization
and their combined effect in treatment of patients with CNSLBP. It had
conducted in outpatient clinic of Sohag hospital. The study protocol was
approved by Research Ethical Committee of Faculty of Physical Therapy,
Cairo university, Egypt (NO: P. T. REC/012/002181).
Participants
Sample size calculation was performed prior to the study after doing a
pilot study using G*POWER statistical software and revealed that the
acceptable sample size for this study was N=44. Forty-four patients (21
females and 23 males) participated during this study, diagnosed by their
Physicians and referred as patient with CNSLBP. Their ages ranged from 20
to 30 years. They received verbal and written explanation for this study. If
they decided to participate during this study, they signed the consent form
(Appendix I) which accepted by the Faculty of Physical Therapy.
Consenting subjects were assigned randomly into four groups of equal
numbers. The randomization performed using a randomization table created
by a computer software program., they were randomly allocated into 4 equal
groups (each contains 11 patient and receive 3 sessions per week for one 4
weeks).
Group (A): received central posterior-anterior mobilization in addition to
conventional physical therapy and advices. Group (B): received intermittent
mechanical lumbar traction in addition to conventional physical therapy and
advices. Group (C): received intermittent mechanical lumbar traction with
central posterior-anterior mobilization in addition to conventional physical
therapy and advices. Group (D) (Control group): received conventional
physical therapy (Transcutaneous electrical nerve stimulation, Infrared, and
Isometric exercise) and advices.
Inclusion criteria: The patients were male and female with age ranged from
2o to 30 years old with body mass index less than 30, diagnosed by
Egypt. J. of Appl. Sci., 35(12) 2020 138
Physician as patient with CNSLBP, back pain with duration of a minimum
of three months ago, Conscious and ambulant patient and Pain is evenly
distributed to both sides of the body with Protective muscle spasm.
Exclusion criteria: patients with a history of diabetes, any back surgery or
deformity of the spine, pregnant woman, unconscious patients or inability to
be ambulant, patients with pain less than 3 months, history of epilepsy,
Piriformis syndrome, Leg length discrepancy, or cognitive impairment.
Outcome Measures
1. Visual analogue scale (VAS)
VAS is that the commonest feasible tool for the subjective assessment
of pain. It is a valid and reliable tool within the assessment of pain intensity
[19]. A 10-cm scale was marked with ―0‖ (no pain) to ―10‖ (worst
imaginable pain), and therefore the subjects were instructed to put a vertical
mark on the point indicate his/her pain [20].
2. Bubble Inclinometer
It's a non-invasive instrument utilized to measure lumbar range of
motion that has good reliability and criterion validity [21]. The Inclinometer
was calibrated before the study. Two landmarks were set at lumbar spine as
described by Waddell et al [22]. While the patient standing in an upright
position; first landmark was located between posterior superior iliac spines
at (S1vertebra) and therefore the other one at spinous process of the 12
thoracic vertebrae (T12) on bare skin. Center the inclinometer and zero over
the palpated land mark S1 together with your finger by spinning the dial
every measure. Have the patient flex forward as far as possible, note the
reading at S1. The patient asked to back to upright position and repeat
measurement of flexion at T12. The difference between the reading at S1
and T12 is true lumbar flexion. Repeat flexion protocol for extension having
the patient to extend back to full extension instead flexion and record the
value of true extension.
3. Arabic version of Modified Oswestry disability questionnaire
(MODQ) (appendix II)
The functional level was assessed employing a self- reported validated
Arabic version of the ODI [23]. MODQ is a condition-specific outcome
measure that helps quantify disability and measure the result of the treatment
received for low back pain in patients with low back pain. It is a 10-item
questionnaire, with 6 responses to every item numbered from zero to five. The
entire is calculated through multiplying the sum of the scores by 2, giving a
range of 0 to 100; a higher score reflects higher disability. These items include
pain intensity, personal care, lifting, walking, sitting, sleeping, sex life (if
applicable), and social life. The first version of the ODI has been revised since
its original development and since of the low response rate to items asking
about gender, authors made this modification on the first questionnaire. They
139 Egypt. J. of Appl. Sci., 35(12) 2020
replaced the gender item with an item describing employment and homemaking
and was translated into many languages [24, 25].
Intervention procedures
All participants were treated by the same physiotherapist.
1. Conventional physical therapy
a. Infrared
Superficial heating (infrared lamp), for 20min/session at distance of
60cm of the lumbar region, while patient in prone lying position, every other
day, for 4 weeks [26].
b. Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation(TENS) is a non-invasive
therapeutic modality. TENS units stimulate peripheral nerves via skin
surface electrodes at well-tolerated intensities and are capable of being selfadministered
[27]. The parameters are: 10 Hz, 200 Microsec, 30 min,
electrodes were positioned paraspinal at levels of L4-L5 and L5–S1. The
treatment was applied once a day, 3 times per week, day after day, for 4
weeks [28].
c. Isometric exercises for back and abdomen
Exercise has been considered one among the foremost evidence-based
modalities [29]. exercise programs supported a behavior-therapeutic
approach to improve physical functional ability, activate the deep muscles
and speed up the return to work [30]. From crock lying position, the patient
is instructed to contract his abdomen as he is flexing the trunk, within the
limits of pain with hold for 15 sec. the exercise is performed five
times\session, with hold for six sec with one minute rest between each
repetition then the patient is instructed to do the same with extension with
contracting the lower back muscles as he press the lumbar spine down [31].
2. Posterior- anterior mobilization
A Passive accessory intervertebral movement (PAIVM) is a
mobilization technique that produces movement of a mobile vertebral
segment without active participation of muscles associated with the
movement [32,33]. The appliance of central posterior-anterior (PA)
mobilizations of the lumbar spine as a type of Maitland mobilization is
achieved by applying a force on to a vertebral segment in a posterioranterior
direction (Back to front). The patient's position for the mobilization
intervention was prone on a treatment table with their hands beside and
Position of therapist is standing on side of patient placing their
pisiform/ulnar surface of hand over the chosen spinous process (SP) with
their wrist fully extension. Other hand placed on top of hand to reinforce.
Therapist's shoulders should be directly above the SP with elbows slightly
bent [32,33].
The therapist uses their weight to apply a PA force to the chosen SP
by leaning their body over their arms and performing rocking movements to
Egypt. J. of Appl. Sci., 35(12) 2020 140
supply oscillatory movements of the vertebra. The direction of mobilization
was posterior-anterior. Grade I and II joint oscillations for 30 seconds each
with frequency three bouts of 30 oscillations. Grade I joint mobilizations
were administered consecutively to the three spinous processes that
surround the painful area with 30 seconds of rest in between, followed by
grade II joint mobilizations [34,35].
3. Intermittent mechanical traction
Mechanical Traction is a non-surgical treatment directed to relieving
pressure on structures which will be the main source of pain [36]. The
patient position is supine with the hips and knees flexed on the traction table.
Therapist tighten any slack within the harness which will have occurred
during positioning. Therapist fit the acceptable traction harness on the
patient and attach the accessory Clip to the connection point of the traction
harness. The therapist Push and hold the Rope Release Button on the touch
screen and slowly pull the end of the Traction Cord out from the traction
unit.
Traction is applied through the (Tru-Trac) traction unit digital touch
screen. Traction force was decided by 40–50% of subject’s body weight,
Treatment duration is 20 min with 30 second hold and 10 sec relax
intermittent approach. For those subjects who couldn't tolerate the regime
above, the traction force was reduced according to his/her tolerance [37].
4. Advices
All groups were received the advices orally and written in paper.
Advices are about lifting, standing, sitting, sleeping and exercising, so
limiting the foremost confounding factors that may aggravate low back pain,
and this maintained the results of follow up accurate the maximum amount
as possible [38].
Statistical analysis
Statistical analysis was conducted using SPSS version 22 (SPSS, Inc.,
Chicago, IL). data were screened for assumption of normality using the
Shapiro-Wilk method which indicated that the data were normally
distributed and didn't contravene the parametric presumption. one-way
ANOVA tests were used to make sure that there was no statistically
significant difference between subjects regarding the base line
characteristics. Repeated univariate measurements and multivariate
ANOVA were used to compare the chosen parameters for different test
groups and measuring times. The significance level was set at p ≤ 0.05.
RESULTS
Data analysis revealed no significant differences between groups
regarding the base line characteristics where (P 0.05), as demonstrated
in Table 1.With regard to the selected parameters; VAS, Lumbar flexion
ROM, Lumbar extension ROM, and MODQ, between-group differences
were noteworthy where (P 0.009). Analysis within groups showed a
141 Egypt. J. of Appl. Sci., 35(12) 2020
considerable difference within the three groups after 4 weeks of
intervention compared to the baseline where (P < 0.0001). however,
pairwise comparisons analysis favored group C, where (P 0.04). Results
are illustrated in Table 1,2.
Table 1. Basic characteristics of participants.
Group A Group B Group C Group D
F
value
P
value
Sig.
Age
(years)
25.91±3.21 26.18±2.75 24.82±2.96 25.27±2.94 0.475 0.702 NS
BMI
(KG/m2)
25.08±1.34 25.61±1.85 25.66±2.24 25.51±2.22 0.202 0.895 NS
Male 6 6 6 5
0.273 0.965
Female 5 5 5 6
SD, standard deviation; p-value, level of significance; BMI, Body mass index
Table 2. Mean VAS, lumbar flexion, lumbar extension and MODQ
pre and post treatment of group A, B, C and D:
Group A Group B Group C Group D F Sig
Pre-VAS 4.64±0.92 4.73±1.01 4.73±0.79 4.73±0.9 0.027 0.994
Post-VAS 2.64±0.81 2.55±0.69 1.55±0.52 3.18±0.87 9.454 0.000
Change DE-43.1% DE-46.09% DE-67.23% DE-32.77%
Pre-LF 44.45±5.52 44.36±5.24 44.91±4.83 44.82±5.51 0.028 0.993
Post-LF 49.36±5.7 49.36±3.93 55±3.87 48.45±5.22 4.392 0.009
Change IN11.05% IN11.27% IN22.47% IN8.1%
Pre-LE 5.18±2.32 5.36±2.11 5±2.24 4.91±2.88 0.077 0.972
Post-LE 9.27±3.1 9.09±2.02 13.18±2.52 7.73±3.26 7.891 0.000
Change IN78.96% IN69.59% IN163.6% IN57.43%
Pre-MODQ 34.36±5.5 33.09±4.76 34±4.65 34.18±5.55 0.134 0.940
Post-MODQ 23.45±3.59 21.82±2.6 14.55±4.01 24.55±4.11 16.985 0.000
Change DE-31.75% DE-34.06% DE-57.21% DE-28.17%
SD, Standard deviation; MD, Mean difference; p-value, Level of significance;
VAS, Visual analogue scale; LF, Lumbar flexion; LE, Lumbar extension; MODQ,
Modified Oswestry disability questionnaire.
DISCUSSION
The findings of this study revealed that the combined treatment of
intermittent mechanical lumbar traction and central posterior-anterior
mobilization showed more significant improvement in pain intensity, ROM,
and functional disability, in comparison to patients who received mechanical
traction alone or Maitland mobilization alone.
Regarding PA mobilization results, a trial accept as true with the
present study, was conducted to research the immediate effect of posterioranterior
mobilization on back pain and thus the associated biomechanical
changes within the lumbar spine. The posterior-anterior mobilization was
found to cause immediate desirable effects in reducing spinal stiffness and
therefore the magnitude of back pain. The restoration of the mechanical
properties of the spine might be a possible mechanism that explains the
Egypt. J. of Appl. Sci., 35(12) 2020 142
decrease in pain after manual therapy [39]. On contrary, Stamos-
Papastamos et al., conducted a study to research the effects of lumbar
rotational manipulation and lumbar central posterior-anterior mobilization
on lumbar bending stiffness and flexion and extension ROM, and concluded
that manipulation had no significant effect on bending stiffness or flexion
and extension ROM [40]. This discrepancy in findings could even be
attributed to the high variability in subjects' characteristics and therefore the
assessment methods wont to evaluate lumbar stiffness.
Another study partially agrees with our findings, Abe et al. [41]
analyze the posterior chain’s flexibility, low back's mobility, trunk
extensor’s endurance and low back extensors' muscle strength after
performed one treatment session using the Maitland method on youth with
low back pain. All volunteers were evaluated consistent their perception of
pain, flexibility, mobility, muscular strength and muscular endurance. The
authors concluded that lumbar PA mobilization was effective for increasing
muscular strength and endurance, with stabilization of the level of pain,
flexibility and mobility.
Lumbar traction is a traditional treatment modality for CLBP in many
countries. few randomized controlled trials proving its effectiveness and
utility. Tadano et al. [42] conducted study that was planned as a preparatory
experiment for a randomized clinical trial, going to examine the
biomechanical change at the lumbar area under lumbar traction and ensure
its reproducibility and accuracy as a mechanical intervention, and to
reconfirm the clinical impression of the immediate effect of lumbar traction.
The authors concluded that lumbar traction can provide a distractive force at
the lumbar spine, and patients who experience the appliance of such force
show an instant response after traction.
Regarding traction results, Santos et al. [43] conducted study that
came in line with our findings aimed to compare the effect of mechanical
lumbar traction with low (10% of body weight) and high traction force (50%
of body weight) on the separation of the vertebrae in vivo using stature
variations as criterion. Stature was assessed before and immediately after the
traction and each five minutes for half-hour after traction ceased.
Immediately after the traction both protocols induced a significant increase
in stature, however the magnitude of the increase was significantly related to
the traction with 50% of body weight.
Another study supports our findings where it compared the effects of
high-force versus low-force lumbar traction within the treatment of acute
lumbar sciatica secondary to disc herniation. A randomized double-blind
trial was performed, and 17 subjects with acute lumbar sciatica secondary to
disc herniation were assigned to high-force traction at 50% body weight or
low force traction at 10% body weight for 10 sessions in 2 weeks. Radicular
pain, lumbo-pelvic-hip complex motion, lumbar-spine mobility, nerve root
143 Egypt. J. of Appl. Sci., 35(12) 2020
compression, disability, drug consumption, and overall evaluation of each
patient were measured at days 0, 7, 1, 4, and 28. For this preliminary study,
patients with acute lumbar sciatica secondary to disc herniation who
received 2 weeks of lumbar traction reported reduced radicular pain and
functional impairment and improved well-being no matter of the traction
force group to which they were assigned. The effects of the traction
treatment were independent of the initial level of medication and seemed to
be maintained at the 2-week follow-up [44].
Regarding the combined group findings, it was supported by a recent
study that conducted to determine the consequences of motorized spinal
decompression combined with spinal mobilization also as lumbar
stabilization exercises on patients with discogenic low back pain (LBP). A
complete of 30 adults with discogenic LBP volunteered to participate during
this study. The whole treatment consisted of 20 visits over a 4-week period.
Comparisons of changes within the Oswestry Disability Index (ODI) and
straight leg raise (SLR) test at pre-intervention, after 10 treatment sessions,
and at discharge (after 20 treatment sessions) were analyzed. The authors
conclude that Spinal decompression treatment combined with spinal
mobilization and lumbar stabilization exercises significantly improved the
clinical outcome measures of ODI score and SLR test in patients with LBP
secondary to intervertebral disc herniation [45].
The limitations of this research are worth mentioning; absence of
blinding, where all participants were evaluated by the same investigators
who implemented the intervention. Additionally, there aren't any follow-up
data on the participants' clinical status, which might help us monitor the
long-term effects of our intervention.
CONCLUSION
The combined effect of Maitland spinal mobilization and
intermittent mechanical lumbar traction on pain intensity, lumbar ROM,
and functional disability in patients with chronic nonspecific low back
pain is more effective than one of them alone.
Acknowledgements
Firstly, I would like to express foremost sincere thanks to ALLAH
for these great blessings to finish this study. Then, I would like to express
my sincere gratitude to all the patients who participated in this study and
each person for their direct or indirect help for providing us with the
privilege to complete this study without them this work wouldn't be
possible.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Egypt. J. of Appl. Sci., 35(12) 2020 144
Funding
The author(s) received no financial support for the research,
authorship and/or publication of this article.
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تأثير تحريک ميتلاند لمعمود الفقري مع الشد الميکانيکي لمفق ا رت القطنية عمى
المرضى المذين يعانون من ألام أسفل الظهر الغير محددة
حمدى السيد محمد حسن 1، وديدة حسن السيد 2، ياسر محمد انيس 3
1أخصائي علاج طبيعي لدي و ا زرة الصحة بمديرية الصحة سوهاج.
2استاذ العلاج الطبيعي بقسم العموم الاساسية، کمية العلاج الطبيعي، جامعة القاهرة.
3استاذ مساعد بقسم العموم الاساسية، کمية العلاج الطبيعي، جامعة القاهرة
الخمفية: ألم أسفل الظهر غير المحددة هو ألم لا يُنسب إلى مرض معروف ، ولا يُعزى إلى
05 ٪ من حالات الام اسفل الظهر. الأهداف: لاستقصاء آثار - سبب معروف ، ويمثل 09
تحريک ميتلاند لمعمود الفقري مع الشد الميکانيکي لمفق ا رت القطنية عمي شدة الألم و نطاق
الحرکة والإعاقة الوظيفية في المرضى الذين يعانون من آلام أسفل الظهر المزمنة غير
المحددة. التصميم: تجربة معشاة ذات شواهد. الأشخاص و الوسائل: شارک في هذه الد ا رسة
أربعة وأربع ون شخصًا يعانون من آلام أسفل الظهر المزمنة غير المحددة ، وت ا روحت أعمارهم
بين 29 إلى 39 عامًا. تم تقسيم المشارکين عشوائياً إلى أربع مجموعات متساوية )کل منها
تتکون من 11 مريضاً وتمقيت 3 جمسات في الأسبوع لمدة 4 أسابيع(: المجموعة )أ(: تمقت
تمقت تحريک مرکزي خمفي أمامي بالإضافة إلى العلاج الطبيعي التقميدي والنصائح. المجموعة
)ب(: تمقت الشد الميکانيکي المتقطع لمفق ا رت القطنية بالإضافة إلى العلاج الطبيعي التقميدي
والنصائح. المجموعة )ج(: تمقت الشد الميکانيکي المتقطع لمفق ا رت القطنية مع تحريک مرکزي
خمفي-أمامي بالإضافة إلى العلاج الطبيعي التقميدي والنصائح. المجموعة )د( )المجموعة
الضابطة(: تمقت العلاج الطبيعي التقميدي )التحفيز الکهربائي للأعصاب عبر الجمد ، والأشعة
تحت الحم ا رء ، والتمارين متساوي القياس( والنصائح. مقاييس النتائج: تم تقييم شدة الألم من
خلال المقياس التناظري البصري، المعدل الحرکي لاسفل الظهر التي تم تقييمها بواسطة مقياس
الميل الفقاعي ، والإعاقة الوظيفية التي تم تقييمها بواسطة النسخة العربية من استبيان الإعاقة
المعدل. تم أخذ جميع النتائج قبل وبعد العلاج. النتائج: أظهر تحميل المقارنة المتعددة وجود
149 Egypt. J. of Appl. Sci., 35(12) 2020
فرق محتمل بين المجموعات من حيث المعايير المختارة ، بينما فضمت التغيي ا رت الرئيسية
9.95 (. الخلاصة: إن التأثير المشترک لتحريک ميتلاند لمعمود الفقري < P( حيث C المجموعة
اولشد القطني الميکانيکي المتقطع عمى شدة الألم ، و معدل الحرکة لمفق ا رت القطنية ، والإعاقة
الوظيفية في المرضى الذين يعانون من آلام أسفل الظهر المزمنة غير المحددة أکثر فعالية من
واحد منهم وحده.
الکممات الأساسية: تحريک ميتلاند لمعمود الفقري؛ الشد الميکانيکي القطني ، التأثير المشترک،
آلام أسفل الظهر غير محددة.
Egypt. J. of Appl. Sci., 35(12) 2020 150
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