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Journal of Back and Musculoskeletal Rehabilitation 29 (2016) 55–63 55

DOI 10.3233/BMR-150598
IOS Press

Efficacy of lumbar mobilization on
postpartum low back pain in Egyptian
females: A randomized control trial
Dalia M. Kamel
a
a,*
, Neveen A. Abdel Raoof
b
and Sayed A. Tantawy
c,d
Department of Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University,
Cairo, Egypt
b
c
Department of Basic Sciences, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
Physiotherapy Department, College of Medical and Health Sciences, Ahlia University, Manama, Kingdom of
Bahrain
d
Department of Physiotherapy, Kaser El Aini Hospitals, Cairo University, Cairo, Egypt
Abstract.
BACKGROUND: Low back pain (LBP) is a common complaint in the postnatal period. Physiotherapy has many techniques to
apply for such cases.
OBJECTIVE: To investigate the effect of central postero-anterior (PA) lumbar mobilization on muscle activity in postpartum
LBP.
METHODS: Forty-five females with chronic LBP at least three months postnatal. Participants divided randomly and equally into
three groups. Group A (Study group) received PA lumbar mobilization plus traditional treatment which consisted of Ultrasonic
and Infra-red. Group B (Placebo group) received placebo mobilization plus traditional treatment. Group C (Control group)
received traditional treatment only. All patients received 3 sessions/week for 4 weeks. Pain intensity, functional disabilities and
Surface EMG for recording para spinal muscle activity were measured before and after intervention. Statistical analysis was done
by ANOVA and paired t-test.
RESULTS: Central PA mobilization showed a significant reduction (P<0.05) in the average surface EMG activity of the
erector spinae musculature compared with the other groups as well as improvement in functional ability and reduction in pain
intensity.
CONCLUSION: A central PA mobilization significantly reduced pain intensity and surface EMG activity of erector spinae
musculature as well as improvement in functional ability in mechanical low back pain in postnatal females.
Keywords: Mechanical low back pain, mobilization, postpartum, electromyography
1. Introduction
Low back pain (LBP) is a major problem which it
is suggested that 70% to 95% of adults will have LBP
at some time during their life [1]. 50% will experience
recurrent back pain, and 10% will develop chronic pain
*
Corresponding author: Dalia M. Kamel, Department of Physical
Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy,
Cairo University, Cairo, Egypt. Tel.: +973 36663084; Fax: +973
17 290083; E-mail: dr_daliakamel@yahoo. com.
ISSN 1053-8127/16/$35.00
c
_2016 – IOS Press and the authors. All rights reserved
and related disability [2]. LBP is the pain and discomfort
localized below the costal margin and above the
inferior gluteal folds, with or without leg pain [3]. In
general, women report more musculoskeletal pains [4],
about 10–28% of women relate their debut of LBP to
pregnancy [5].
Postpartum chronic backache was defined as backache
of at least 6 weeks duration beginning within
3 months after delivery [6]. It is estimated that 68%
of women experienced back pain during their pregnancy
[7]. The most common areas of low back to ex-
56 D.M. Kamel et al. / Low back pain and lumbar mobilization
perience pain postpartum are the sacroiliac joints and
lumbar spine [8].
Postpartum back pain is associated with many factors
such as history of back pain during pregnancy,
younger age and greater body weight, while the new
onset postpartum back pain was due to greater weight
and shorter stature [6]. Sedentary lifestyle by itself is
not associated with LBP [9]. Neither the epidural anesthesia
nor the mode of delivery showed any significant
impact in developing postpartumback pain [6,10].
Muscle function in pregnancy has been investigated
in one study using electromyography [11]. At the beginning
of pregnancy there is reduced back muscle
activity presented by the EMG, which leads to more
pain and disability throughout the pregnancy. Low endurance
of back and hip muscles has been reported in
women with long standing LBP after pregnancy [12].
It was indicated that muscular insufficiency may be
an important factor regarding persistent problems. It
is unknown if the reported insufficiency developed
due to longstanding problems or if the women already
had muscular insufficiency early on in the pregnancy.
Mechanical low back pain (MLBP) is commonly
treated conservatively with physical therapy.
Poor or delayed response to conservative treatment
will indicate surgery, which has its own poor outcomes
[13].
Spinal mobilization is one of the manual treatments
that are effective in adults for acute, sub-acute, and
chronic LBP [14]. It has been defined as a gentle oscillatory
passive movement applied to a spinal region or
segment, to increase range of motion in that segment
or region. Its rhythm and grade are such that the patient
can stop the movement [15]. It has been hypothesized
that the long term pain relieving effects of manual
therapies are mediated by activation of brain structures
including the periaqueductal grey matter (PAG)
in the Medulla Oblongata [16]. Spinal care via spinal
manipulation was found to have a pain fighting effect
(“a hypoalgesic effect”) as pain thresholds increased.
It was also found that the sympathetic nervous system,
which affects the functions of the internal organs, was
affected. The cervical mobilization technique also produced
a sympatho-excitatory effect with an increase
in skin conductance and a decrease in skin temperature
[17]. Subjects with LBP employed greater muscle
activation in static tasks, compared to a group without
back pain. The LBP subjects had greater muscle preactivation
prior to a force perturbation than the NLBP
subjects. Muscle activation and pre-activation patterns
were apparently an attempt to stiffen and stabilize the
trunk, although there was no evidence of lesser likelihood
of a response to the perturbation [18]. Electromyography
is the accepted technique to document
the level of muscular activation, but its specificity to
particular muscles depends on correct electrode placement.
For multifidus, intra-muscular electrodes are required
[19]. A patient with LBP often presents with reduced
lumbar spine mobility and this may be associated
with increased para spinal muscle activity [20].
Therapists may treat postero-anterior stiffness by
manually applying rhythmical oscillatory forces to the
lumbar spine, and all of the neuro-musculoskeletal tissues
in the region will be affected by the oscillatory
force. There will be movement of the inter-body and
zygopophyseal joints and their accompanying periarticular
tissues [21].
From a review of literature, there is a gap of knowl-
edge of the muscle activity response to PA mobilization
in the long term. All the studies showed immediate
effect after the mobilization session. In addition, no
previous study applied lumbar mobilization for postpartum
LBP. So our study focuses on the lasting effect
of PA mobilization on muscle activity, pain intensity
and functional disability in postpartum patients with
LBP, to cover that gap.
2. Methods
2.1. Participants
Forty five female patients who suffered from postpartum
LBP participated in this study. After Ethical
Committee approval of the Faculty of Physical Therapy,
Cairo University, participants were recruited via
advertisement in the orthopedic and obstetric outpatient
clinics in Cairo University Hospitals. Diagnosis
of their LBP was confirmed by an orthopedist to be
lasting more than 3 months [3] since their delivery. The
participants were asked about the incidence of their
LBP: it was either during pregnancy and/or after childbirth.
All of the females were primigravidae and primiparous
to avoid any confounding effects from previous
pregnancies and deliveries. Their age ranged from 25
to 35 years old with body mass index (BMI) less than
30 kg/m
. The BMI limit was chosen to obtain comparable
thickness of subcutaneous tissues between subjects
in order to enhance the accuracy of surface EMG
amplitude recordings [20].
2
Participants (n = 45) were classified randomly into
three groups of equal numbers, 15 patients in each
Enrollment

Group A (n = 15)
Received PA lumbar mobilization
plus traditional treatment which
consisted of Ultrasonic and Infra-red.
D.M. Kamel et al. / Low back pain and lumbar mobilization 57
Assessed for eligibility (n = 60)
Randomized (n = 45) equally to 3 experimental groups
Group B (n = 15)
Allocation
• Received tactile stimulation on L3
spinous process for 2 minutes without


applying force plus traditional
treatment.
Follow-Up
The 3 groups received their programs
accordingly for 3 sessions / week for 4 weeks.
Analysis
Outcome measures, for the 3 groups, were:
- sEMG for erector spine muscles
- Visual analogue scale (VAS)
- Oswestry Disability Index (ODI).
group. Group A (Study group), received PA lumbar
mobilization plus traditional treatment which consisted
of Ultrasonic and Infra-red. Group B (Placebo group),
to differ between the effect of tactile stimulation and
central PA mobilization, the right middle finger was
put on L3 spinous process for 2 minutes without applying
force plus traditional treatment. Finally, Group
C (Control group), received traditional treatment only.
All groups received 3 sessions per week for a period of
4 weeks (Fig. 1). Each patient in the three groups received
a full explanation about the type of intervention
accordingly and then signed an informed consent. Exclusion
criteria for this study were medical conditions
Fig. 1. Study flow diagram.
Excluded (n = 15)
Not meeting inclusion criteria (n = 4)
Declined to participate (n = 3)
Other reasons (n = 7)



Group C (n = 15)
Received traditional treatment
only consisted of Ultrasonic and
Infra-red.
that don’t allow the subject to lie prone comfortably,
such as cardiovascular disease, uncontrolled hypertension,
abdominal hernia and severe respiratory diseases,
as well as problems in the back e.g. previous low back
surgery, or spinal malignancy; in addition to known
rheumatic joint disease, and upper or lower motor neuron
lesion that affects lower limbs.
2.2. Assessment
The three groups were assessed pre intervention and
post 4 weeks of intervention using the following.
58 D.M. Kamel et al. / Low back pain and lumbar mobilization
2.2.1. Electromyography (EMG)
TOENNIES NeuroScreenK972419 (Erich Jaeger,
Inc. Hoechberg, Germany) was used to measure lumbar
muscle activity by evaluating and recording the
electrical activity produced by those skeletal muscles
(Fig. 2). From prone position, spinous process of T12
and L4 and L5 were palpated and marked. The area to
the left of each of the marked locations was cleaned
with isopropyl alcohol in preparation for electrode attachment.
The active bipolar electrodes were placed on
the belly of erector spine muscles 3.5 cm laterally from
the midline at the level of L3, and the ground electrode
was placed around subject’s left leg. The electrodes positions
were not changed until their removal at the end
of the experiment.
2.2.2. Visual Analogue Scale (VAS)
This is considered a valid way of assessing pain; it
allows graphic representation and numerical analysis
of the collected data [22].
2.2.3. Oswestry Disability Index (ODI)
This is used to assess functional disability. ODI is
one of the most reliable and had sufficient width scale
to reliably detect improvement or worsening of LBP
patients [23]. It consists of 10 multiple-choice questions
about back pain including disability in daily functions
and leisure time activities. The maximal score
is 50 (maximum disability) and the result was taken
as percentage from the total score. Higher scores indicate
greater disability [24]. The ODI was translated
into Arabic and this validated it for assessing low back
pain in the Arab population [25].
2.3. Treatment protocol
2.3.1. Treatment was done 3 sessions/week for 4
weeks, as following
Traditional treatment was applied for all the three
groups, in the form of the following:
i- Therapeutic Ultrasonic: using Ultrasonic device
Phyaction 190i, Uniphy P.O. Box 558, serial number
2745, End hoven, The Netherlands 230 V.
Continuous Ultrasonic was applied for 5 minutes
duration with 1W/cm
intensity, frequency
1 MHz and 100% duty cycle. Ultrasonic application
was on the paraspinal muscles of the lumbar
region. A stroking technique was used as one
2
stroke must overlap about 50% of the previous
stroke.
Fig. 2. EMG machine for measuring lumbar muscle activity.
Fig. 3. Hand placement for PA lumbar mobilization applied for
group A.
ii- Infrared device, 4004/2N, Verreet Quartz Dixwell,
France. The device has a power of 400 w,
voltage 220 V and a frequency of 50/60 Hz. The
infrared lamp was placed at 75 cm distance from
the patient’s back so that the radiation struck
the surface at or near a right angle to achieve
maximum penetration. Treatment duration was
15 minutes.
2.3.2. Central PA mobilization was applied only for
group A (study group)
The level of L3 was selected for central PA mobilization
because it has a central position in the lumbar
lordosis which suggested generalized movement of the
whole lumbar and lower thoracic spine [26]. Following
the protocol of Maitland 2005 [21], the patient was
in prone position while the therapist stood to the side
of the patient while placing the pisiform/ulnar surface
of the hand over the L3 spinous process (SP) with the
*
D.M. Kamel et al. / Low back pain and lumbar mobilization 59
Table 1
Demographic data of subjects in the three groups
Items Group (A) Group (B) Group (C) Comparison
Mean (± SD) Mean (± SD) Mean (± SD) F-value P-value S
Age (yrs) 37.4 (± 5.84) 38.33 (± 4.38) 37.46 (± 3.88) 0.17 0.83 NS
Weight (Kg) 75.73 (± 5.2) 76.2 (± 4.31) 74.6 (± 3.85) 0.50 0.60 NS
Height (cm) 167.33 (± 5.63) 168.53 (± 5.15) 166.73 (± 4.46) 0.48 0.62 NS
BMI (Kg/m
2
) 27.02 (± 0.79) 26.81 (± 0.52) 26.82 (± 0.69) 0.45 0.63 NS
Table 2
Pain intensity pre and post treatment of all groups (A, B & C)
Mean (± SD) Mean difference % of improvement t-value
Pain intensity Group A Pre Treatment 7.2(1.08) 4.8 66.66% 21.56
Post treatment 2.4(0.98)
Group B Pre Treatment 7.26(0.96) 3.6 49.58% 18.92
Post treatment 3.66(0.81)
Group C Pre treatment 7.53(1.06) 2.6 34.52% 12.16
Post treatment 4.93(1.27)
Functional disability Group A Pre Treatment 57.14(9.96) 34.32 60.06% 14.15
Post treatment 22.81(8.29)
Group B Pre treatment 56.72(7.63) 23.26 41.0% 9.83
Post treatment 33.45(7.12)
Group C Pre Treatment 53.63(11.58) 8.38 15.62% 13.37
Post treatment 45.25(10.45
Paraspinal muscle activity Group A Pre treatment 0.21(0.08) 0.13 61.90% 16.12
Post treatment 0.07(0.02)
Group B Pre treatment 0.2(0.06) 0.07 35% 13.14
Post treatment 0.12(0.05)
Group C Pre treatment 0.21(0.07) 0.04 19.04% 8.05
Post treatment 0.17(0.07)
SD: standard deviation, P: probability, S: significance, %: Percentage, S: significant.
wrist in full extension. The therapist’s other hand was
placed on top of the hand to reinforce (Fig. 3). The
therapist used own body weight to apply a PA force
to the L3 SP by leaning their body over their arms
and performing rocking movements to provide oscillatory
movements of the vertebra. On initial treatment,
if the patient had very limited movement, a pillow was
placed underneath her abdomen.
At the start, 1 or 2 small-amplitude movements
(grade I) were used, then subjects were asked to report
whether they perceived discomfort. If the subjects did
not report any discomfort from the pressure at a particular
vertebral level, then the therapist proceeded to the
next higher grade of movement, using slightly larger
amplitudes (grade IV). Three bouts of 40-second oscillations
were applied; the total time for the PA mobilization
intervention was approximately 2 minutes at
the level of L3.
Outcome measures for pretreatment and after 4
weeks of treatment were in terms of Oswestery dis-
ability scale, visual analogue scale (VAS) and surface
electromyography (sEMG).
2.4. Data analysis and statistical analysis
SPSS 14.0 for Windows Integrated Student Version
(SPSS Inc., Chicago, IL, USA) was used for statistical
analysis in the current study. Description statistics for
all measured parameters were in the form of mean and
standard deviation. In addition, inferential statistical
analysis in the form of paired t-test was used to compare
results of the same group before and after treatment.
Likewise, a one way ANOVA was used to compare
results between the three groups before and after
treatment. A Post-hoc Test in the form of least square
difference (LSD) was used to determine the difference
between the three groups for post treatment values. The
level of significance for all tests was set at P<0.05.
3. Results
3.1. General characteristics of the subjects
Regarding the time of developing LBP, 41 (91.1%)
out of 45 participants reported LBP during pregnancy
which continued after childbirth, while only 3 (8.8%)
*
*
*
*
*
*
*
*
*
60 D.M. Kamel et al. / Low back pain and lumbar mobilization
Table 3
Results of ANOVA among the three groups for pain intensity, functional disability and para-spinal muscles activity
SS MS F P value
Pain intensity Pre treatment Between groups 0.93 0.46
Within groups 45.06 1.07 0.43 0.65
Total 46.0
Post treatment Between groups 48.13 24.06
Within groups 45.86 1.09 22.03 0.001
Total 94.0
Functional disability Pre treatment Between groups 110.09 55.04
Within groups 4083.54 97.22 0.56 0.57
Total 4193.64
Post treatment Between groups 3778.42 1889.21
Within groups 3203.98 76.28 24.76 0.001
Total 6982.4
Paraspinal muscles activity Pre treatment Between groups 0.001 0.0005
Within groups 0.24 0.006 0.06 0.94
Total 0. 24
Post treatment Between groups 0.06 0.03
Within groups 0.11 0.003 12.15 0.001
Total 0. 18
SS: Sum of Square, MS: Mean Square, P: probability, S: significance, *: Significant.
reported LBP after childbirth. Out of the 41 patients 13
(31.7%) had developed LBP since the 1
trimester of
pregnancy and 8 (19.5%) and 20 (48.8%) since the 2
and 3
rd
st
trimesters respectively. Demographic characteristics
in Table 1 showed no significant differences
among the three groups.
3.2. Pain intensity, functional disability and
paraspinal muscle activity
i) Within groups, all the three outcome measures
showed significant difference (P<0.05) between
pre and post treatment in each group, Table
2.
ii) Between groups: there was no significant difference
among the three groups for the pretreatment
value (P>0.05), while there was
a significant difference for the post treatment
value (P<0.05) in all outcome measures, Table
3.
iii) Post treatment values Post-hoc Test:
– Pain intensity revealed significant difference
between groups A and B as the mean difference
value was (1.26) (P = 0.002). Also,
there was a significant difference between
groups A and C as the mean difference value
was (2.53) (P = 0.001), and finally, a significant
difference between groups B and C as
the mean difference value was (1.26) (P =
0.002).
nd
– Functional disability showed significant difference
(P = 0.002) between groups A and
B as the mean difference value was (10.63).
In addition, there was a significant difference
(P = 0.001) between groups A and C as the
mean difference value was (22.43). Finally,
there was a significant difference (P =0.001)
between groups B and C as the mean difference
value was (11.79).
– Paraspinal muscle activity revealed a significant
difference (P = 0.007) between groups
A and B as the mean difference value was
(0.05). In addition, there was a significant difference
(P = 0.001) between groups A and C
as the mean difference value was (0.09) and
there was a significant difference (P = 0.04)
between groups B and C as the mean difference
value was (0.04).
4. Discussion
The purpose of the study was to investigate the effect
of lumbar mobilization on muscle activity in postpartum
mechanical LBP; additionally pain intensity and
functional disability were also examined.
Concerning pain intensity and functional disability,
the result of the study revealed that PA mobilization
showed a superior effect and a significant reduction in
pain intensity and a significant improvement in function.
An understanding of the mechanism by which joint
mobilizations cause a hypalgesic response in patients
*
*
*
D.M. Kamel et al. / Low back pain and lumbar mobilization 61
is subject to further research and is currently far from
complete. A previous animal study [27] shed supplementary
light on the complex nature of pain relief following
mobilizations. They proposed that joint mobilization
may activate the descending suppression of
pain that involves a non-opioid form of analgesia, mediated
by spinal serotonergic and noradrenergic receptors
which may involve the periaqueductal grey matter
(PAG) and the sympathetic nervous system (SNS).
The improvement we achieved in the current study
in pain which reflected positively on the ODI scores
can be attributed to the spreading effect of the spinal
mobilization. This wider hypoalgesic effect was attributed
to the supraspinal pathways from the midbrain,
as the spinal projection from descending pathways
are bilateral [28]. This effect was supported with
previous research applied either on the spine [29–31]
or on other parts of the body [32], while other research
contradicted the wide hypoalgesic effect as with cervical
mobilizations [17] and on the lumbar spine [15].
They found that mobilization had a side-specific response.
The cause of this contrast may be due to application
of mobilization unilaterally while we applied
central mobilization. In addition, Sterling et al. [17]
used the pain pressure threshold (PPT) to assess the
pain but in the current study VAS was used. Perry
and Green [15] measured skin conductance in asymptomatic
subjects and no pain measures were taken. So,
therefore comparisons with this study cannot be made
for the spectrum of pain.
In the current study we used small amplitude oscillations
(grade I and IV). It has been suggested that large
amplitude oscillations (grade II and III) will stimulate
more mechanoreceptors and therefore be more effective
at decreasing pain than small amplitude oscillations
[33]. There is no evidence to support this view
and it appears to be based on anecdotal, physiological
reasoning [34]. Lumbar PA mobilizations produce an
immediate and significant widespread hypoalgesic effect,
regardless of the rates of mobilization [34,35].
Regarding the duration of the treatment lasting effect,
there was clinical significant reduction in pain at
rest in subjects with mechanical neck pain immediately
and 48 hours after a single thoracic manipulation. Although
increases in all tested ranges of motion were
obtained, none of them reached statistical significance
at either post treatment point [36]. The long-term effect
of repeated manual oscillation sessions is guaranteed
[37]. A single spinal manipulation (SM) treatment
does not systematically alter corticospinal or stretch re-
flex excitability of the erector spinae muscles (when
assessed ~ 10-minutes following SM) [38].
Regarding post intervention muscle activity to
sEMG, mechanical stimulation of both the paraspinal
musculature (transverse processes) and spinous processes
produced consistent, localized sEMG responses
over the L5 and L3 erector spinae musculature [39].
The EMG amplitude analysis revealed significant
differences between groups for some muscles (left
lumbar and thoracic erector spinae). The abnormal
(asymmetric) EMG patterns detected among CLBP
patients were not explained by postural asymmetries
[20]. Edwards et al. [40] found that passive movement
can have a profound effect on the excitability
of the cortico-motor pathway. It is suggested that impulses
from joint receptors can influence tension regulation
from Golgi tendon organs; if these receptors
are activated in the terminal phase of the movement
they may contribute a purposeful decrease of tension
and consequently of muscle tension [41]. There is a
contrast with Goodsell et al. [42] who stated that lumbar
PA mobilization did not produce any objectively
measurable change in the mechanical behavior of the
lumbar spine of patients with LBP. They observed improvement
in comparison with a control procedure, but
this may be due to a placebo effect. This placebo effect
was compensated for in the current study in group B
and it was clear from the results that the actual application
of PA lumbar mobilization has a superior effect
in comparison to the other groups.
5. Conclusion
Lumbar mobilization showed a significant effect on
reducing postpartum LBP as well functional disabilities.
Most postpartum females complain of LBP from
the impact of pregnancy and labor as well the physical
demands of the new born child. So, PA lumbar mobilization
can be included as one of the modalities applied
in these cases.
Conflict of interest
All authors confirmed that there are no competing
financial interests existing in this current research.
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