J Complement Integr Med 2020; ▪▪▪(▪▪▪): 20190327

Research Article

Divya, Adila Parveen, Shibili Nuhmani, Mohammed Ejaz Hussain and

Moazzam Hussain Khan*

Effect of lumbar stabilization exercises and

thoracic mobilization with strengthening
exercises on pain level, thoracic kyphosis, and
functional disability in chronic low back pain
https://doi.org/10.1515/jcim-2019-0327
Received January 13, 2020; accepted March 31, 2020
Abstract
Objectives: The purpose of this study was to compare the
effect of lumbar stabilization exercise and thoracic mobi-
lization with strengthening exercise on pain level, thoracic
kyphosis, and functional disability in patients with Chronic
Low Back Pain (CLBP).
Methods: Thirty patients with CLBP were recruited based
on inclusion and exclusion criteria. They were randomly
allocated into two groups i. e., Group A (n = 15) and B
(n = 15). Group A has received lumbar stabilization exercise
and thoracic mobilization with strengthening exercises
and Group B received only lumbar stabilization exercises,
three sessions per week for 4 weeks both the groups. The
conventional moist hot pack and interferential therapy was
given to both the groups before the administration of ex-
ercise. Pre- and post-treatment pain level, Thoracic
kyphosis, and functional disability were taken and statis-
tical analysis was done.
Results: The result of this study showed significant
improvement from pre-intervention to post-intervention on
pain level, thoracic kyphosis, and functional disability for
both the groups i. e., Group A and group B but Group A
*Corresponding author: Dr. Moazzam Hussain Khan, Assistant
Professor, Centre for Physiotherapy and Rehabilitation Sciences.
Jamia Millia Islamia, A Central University, Delhi, 110025, India, Mobile:
+919990307150, E-mail: drmhk5881@gmail.com
Divya, Adila Parveen and Mohammed Ejaz Hussain: Centre for
Physiotherapy and Rehabilitation Sciences Jamia Millia Islamia, A
Central University, Delhi, India, E-mail: drajput203@gmail.com
(Divya), adilaprvn@gmail.com (A. Parveen), ehusain@jmi.ac.in
(M. Ejaz Hussain)
Shibili Nuhmani: Department of Physical Therapy, College of Applied
Medical Sciences, Imam Abdulrahman Bin Faisal University,
Dammam, Saudi Arabia, E-mail: snuhmani@iau.edu.sa
showed greater changes in Numerical pain rating scale
(NPRS), Kyphotic index, and Oswestry disability index
(ODI), than Group B.
Conclusions: The 4 week of therapeutic intervention
including lumbar stabilization exercise with thoracic
mobilization and strengthening exercise showed signifi-
cantly reduction of the thoracic kyphosis, pain level and
functional disability in patients with Chronic Low Back
Pain.
Keyword: functional disability; lumbar stabilization
exercise; pain; thoracic mobilization.
Introduction
Low back pain (LBP) is a commonest problem in modern
society and about 70–80% of the population experienced it
once or more in their life time [1]. Despite of various factors
such associoeconomic, personal habits, occupation (or
work-related), and psychological factors, the mechanical
factors are usually reported as a cause of initial develop-
ment of low back pain (LBP) which also contributes further
in their recurrences and exacerbation [2]. These factors are
exposure to high loading activities, such as repetitive
bending and heavy lifting, sustained low load postures like
prolonged sitting or standing, sports specific, and manual
work conditions [2–4].
In recent studies, lumbar segmental instability in the
absence of any bony defects has been cited a significant
cause of chronic low back pain (CLBP) [5]. It has been found
that excessive movement of the lumbar spine is caused by
limited motion in thoracic spine segment [6]. Tuzan et al.,
studied postural aberration in LBP patients and found
significant correlation between all radiological parameters
i. e., Lumbar lordosis [LL], thoracic kyphosis and sacral
inclination [7].
2 Divya et al.: Stabilization exercises and thoracic mobilization in low back pain
The relationship between dysfunction of physiological
alignment and curvature of the spine in sagittal plane,
most commonly lumbar lordosis and thoracic kyphosis in
LBP has become one of important field of interest in re-
searchers [8, 9]. Roussouly and his colleagues found that
lumbar lordosis is mainly dependent on sacral spine
orientation and thoracic curvature. Thoracic curvature is
dependent on lumbar lordosis orientation and C7 posi-
tioning. On a reverse effect, structural changing of thoracic
kyphosis may affect the orientation of lumbar lordosis and
pelvis [10, 11]. Literature reported conflicting result sug-
gesting decreased, increased or normal lumbar lordosis in
LBP [12, 13]. Furthermore, thoracic kyphosis associated
motion reduction in the thoracic vertebrae increases the
abnormal movement in the intervertebral bodies of the
lumbar spine via compensatory mechanism, which further
lead to instability in the facets joints of the vertebrae, and
cause easily recurrence of LBP [14]. So, focus on this
postural dysfunction mainly thoracic kyphosis and hypo-
mobility at the thoracic spine, recent studies [15–19],
focused on to improved mobility at the thoracic spine along
with lumbar stability.
Recent evidence supports the role of thoracic mobili-
zation and lumbar stabilization exercises in patient with
CLBP in terms of improvement in thoracic segment range of
motion (ROM) [15], pain level, balance and lumbar stability
[16], proprioception [17], mental, and functional status [18],
lumbosacral alignment [19]. Kim has reported that trans-
verse abdominis muscle strengthening exercises increased
thoracic segment motion angle significantly than lumbar
segment motion angle alone in Patient with CLBP [20]. But
there has not been any study which shows the changes in
thoracic kyphosis alignment in patients with CLBP with
increase thoracic kyphosis.
So, the aim of this study was to investigate the effect of
lumbar stabilization exercise and thoracic mobilization
with strengthening exercise on pain level, thoracic
kyphosis, and functional disability in patients with CLBP.
Materials and methods
Design
Pre-test and Post-test experimental design.
Participants and procedure
Thirty subjects with CLBP were recruited based on inclusion and
exclusion criteria. All subject signed an informed consent form
approved by Human Subject Committee of Jamia Milia Islamia
University, New Delhi. Ethical clearance was taken from Institutional
Ethical Committee, proposal No 4/10/87/JMI/IEC/2016.
Inclusion criteria: history of Low back pain more than three
monthsbut no radiating pain to the leg, age 30–60 Years, both Male
and Female, Pain level between 3 and 6 on Numerical pain rating scale
(NPRS) scale, 20–40% disability scores on Oswestry disability index
(ODI) scale and Kyphotic index range from 8 to 13. Patients with his-
tory of any spine surgery, cardiovascular problem, neurological dis-
order, Red flags signs, History of specific pathology of spine (e. g.,
Ankylosing spondylitis, spondylosis, spondylolisthesis, Slipped
Intervertebral discs, spinal tumor, spinal stenosis, cauda equine
syndrome, and spine infection) and pregnant women were excluded
from the study.
All participants were recruited for 4-week of exercise protocol
and were instructed not to take any other treatment atleast for 4 weeks
of current study.
Measures and instruments
After taking down the demographic data (age, height, weight, and
BMI), the main Outcome measure i. e., Pain level, thoracic kyphosis,
and functional disability were assessed. The Numeric pain rating scale
(NPRS), 0–10 integer [21] was used to measure pain level. To measure
functional disability, Oswestry disability index (ODI) for LBP was used
[22, 23]. Flexible ruler was used to measure thoracic kyphosis via
kyphotic index [24, 25]. Flexible ruler has advantage over other
methods of measurement of thoracic kyphosis, as this is easy to use,
convenient, less expensive, reliable, no exposure to radiation, can use
in clinical settings and provide more accurate and reproducible result
[24].
For the thoracic kyphosis measurement, we asked the patient to
stand in your usual best posture, looks straight ahead. Palpate C7 and
T12 spinous process and mark it. Flexicurve ruler was aligned to the
patient’s spine from C7 to T12. The ruler was placed flat on paper & its
outline was traced. A straight line drawn from the ruler position of C7
to T12 indicates thoracic height (TH), and a perpendicular line from the
highest point in curve to the point at which it intersected the straight
line from C7 to T12 corresponds to thoracic width (TW). Then, thoracic
kyphosis was determined via formula of kyphotic index in centi-
meters:Kyphotic index (KI) = Thoracic width (TW)/Thoracic height
(TH) × 100.
Following completion of demographic data assessment and pre-
intervention measurement patients were randomly allocated into two
groups using convenience sampling, i. e., group A (n = 15): Lumbar
stabilization exercises and Thoracic mobilization with strengthening
exercises (LSE and TMSE) and group B (n = 15): Lumbar stabilization
exercises (LSE) only.
Treatments
Both groups received conventional treatment which included moist
heat pack for 10 min, Interferential therapy for 10 min with 80–100 Hz,
4PV at lower back area and Lumbar Stabilization Exercises (LSE). In
addition to this conventional treatment, Group A (LSE and TMSE) also
received Thoracic mobilization and has performed thoracic muscle
strengthening exercises.
Group A (LSE and TMSE): First, gentle spinal mobilization of the
thoracic spine by using Maitland’s technique (Posterior-Anterior
 Divya et al.: Stabilization exercises and thoracic mobilization in low back pain 3

glides), Grade 2 and 3 was applied to the patient for 60 s and repeated Data analysis
thrice [18]. Following by thoracic mobilization, patient has performed
additional exercise for thoracic mobility [26].
Data were analyzed using SPSS version 17.0. Shapiro–Wilk test were
– Chest stretching and Diaphragmatic breathing on foam roller to
used to check the normality of the distribution scores. Independent t-
lengthen pectoralis muscle and to expand ribcage (3 sets of three
test and Paired t-test was used to check the difference between pre and
reps, with 30 s hold of each exercise) followed by thoracic spinal
post intervention for kyphotic index (KI) and ODI. Wilcoxon-signed
muscle strengthening exercises. These are-
rank test was used to check the difference between pre and post
– Prone trunk lifts to neutral, progress from arms by side ‘T’ posi-
intervention for NPRS. Mixed-model ANOVA was used to compare the
tion, to arms in ‘Y’ position with 0 to 1 kg dumbbells (3 sets of 10
difference between two groups in change over time for KI, NPRS, and
reps of each exercise).
ODI. The significance level was set at p < 0.05 (see Figure 1).

Before performing each exercise, therapist provided detailed

verbal instruction or demonstration of exercise to patient
regarding the start, end position familiarizations of exercises Results
[27].
Lumbar stabilization exercises included: Isolated lumbar stabi- Patient demographics
lizing muscle training for transverse abdominis and multifidus mus-
cle. It was further progressed by precise repetition of the isolated
There was no significant difference for the demographic
isometric-specific co-contraction of the transverse abdominis muscles
in 4-point kneeling position, increasing their contraction time (15–20 s characteristics (age, height, weight, and BMI) between the
hold). For improving lumbopelvic control, we integrated light dy- groups and in the baseline values of KI, NPRS, and ODI in
namic functional activity. These are Single arm elevations from 4- both the groups, Table 1.
Point kneeling positions. Alternate arm and leg lift from 4-Point
kneeling positions. Lumbopelvic control during sitting on unstable
Base of support (Swiss Ball). Analysis of within group comparison
Progressed to heavy-load dynamic functional tasks which
included, alternate arm and leg lift with 1 kg weight cuff applied on
Within group comparison of the thoracic kyphosis (KI) and
elevated arm and leg (3 Sets of 10 reps, with 10 s hold of each exer-
functional status (ODI), before and after intervention, showed
cises).
Group B: Group B received only lumbar stabilization exercises. significant improvement in both groups after 4-weeks of
Duration of treatment: 3 sessions/week for total of 4 weeks for intervention (p < 0.001). Result of Wilcoxon – signed rank test
both the groups. for Pain level (NPRS) showed that both groups significantly

Figure 1: Pre- and post-treatment differences

in outcome measures of thoracic kyphosis,
Pain level, and Functional disability.
4 Divya et al.: Stabilization exercises and thoracic mobilization in low back pain

Table : Participants demographic data and baseline Mmeasures

for both groups.
Discussion
Variables Group A, Group B, Postural dysfunction is an one of the major causes of CLBP
Mean ± SD Mean ± SD [3, 28]. It has been reported that lumbar instability asso-
Age (years) . ± . . ± .
ciated with limited movement at the thoracic spine [6, 14].
Height (cm) . ± . . ± . Maintaining a sitting posture for long time, heavy lifting
Weight (kg) . ± . . ± . repetitive tasks and aging increases thoracic kyphosis [6].
BMI (kg/m) . ± . . ± . Kado and his colleagues suggested that increased thoracic
KI . ± . . ± . kyphosis has been significantly associated with high
NPRS . ± . . ± .
mortality, diminished functional status [29, 30], poor
ODI . ± . . ± .
postural control and balance problems [31], reduced res-
BMI, body mass index; M, mean; SD, standard deviation; significant piratory functions and impaired quality of life [32]. Indeed,
difference, p < . KI, Kyphotic index; NPRS, Numeric pain rating
it has been recommended that the mobility of the thoracic
scale; ODI, oswestry disability index.
spine and correction of increased thoracic kyphosis plays a
vital role in patient with CLBP with increased thoracic
changed from pre-intervention to post-intervention, p < 0.001 kyphosis to maintain long term improvement and stability
(see Table 2). to the spine [15–19]. This is a first study, which examined
the effect of lumbar stabilization exercises with thoracic
mobilization exercises and strengthening exercises on
Analysis of between group differences with thoracic kyphosis in patients with CLBP.
relation to time In this study, both groups showed statistically signif-
icant effect (p < 0.001) of intervention in terms of reduction
Between group differences for thoracic kyphosis showed in thoracic kyphosis, but clinically, group A (LSE and
significant difference with time in both the groups. The TMSE) showed more reduction in thoracic kyphotic cur-
interaction effect was non-significant which indicates that vature as compared to Group B. The result of this study was
both groups behaved similarly with time. For the Pain level comparable with the study done by Bautman. Bautman
(NPRS), the main effect of time was significant whereas the and his colleagues reported a significant reduction of
main effect of group was non-significant. Also, the inter- thoracic kyphosis from (52.5 ± 2.2) to (49.1 ± 2.0), p < 0.05 by
action effect was significant which indicates that both manual thoracic mobilization, taping and exercises appli-
groups behaved differently with respect to time. For func- cation [33]. We hypothesized that the thoracic kyphosis
tional disability (ODI), the main effect of time and group reduction occurred after application of thoracic mobiliza-
was significant. Also, the interaction effect was significant tion, because it helps in increasing mobility at spinal
which indicates that both groups behaved differently with segment, and in realignment of the normal curvature of the
respect to time. thoracic spine. Additionally, thoracic extensors muscles
strengthening exercise has also been performed by the
patients to maintain this alignment for long term. Katzman
Table : Between group differences with change over time [Degree
of freedom (df ), Mixed ANOVA, F – Value, Partial Eta Square]. also recommended that spinal mobilization techniques
increase postural alignment in hyperkyphotic patients.
Variables Source df F–Value p–Value Partial Besides those passive mobilizations, self-mobilization ex-
eta squared ercises are also effective in these patients. Considering the
KI Time  . <.* . tight muscles, especially pectoralis muscle, is important to
Group  . <.* . decrease the tightness of this muscle to correct the thoracic
Group time  . . . position as well as to improve the structural alignment and
NPRS Time  . <.* . stiffness of the thorax [26, 34]. Recently Woo and his col-
Group  . . .
leagues also observed the significant improvement in
Group time  . <.* .
ODI Time  . <.* . lumbosacral alignment and in ODI after 4 weeks of inter-
Group  . <.* . vention, p < 0.05 [10]. Since hyperkyphosis is associated
Group time  . <.* . with decreased respiratory functions or lungs capacity and
Kyphotic index; NPRS, Numeric pain rating scale; ODI, oswestry worsen quality of life, it has been assumed that the
disability index, *Significant difference p < .. correction of hyperkyphosis in early stage would improve
 Divya et al.: Stabilization exercises and thoracic mobilization in low back pain
the functional status of the patient and provide long term
stabilization [19].
The result of this study consistent with the previous
findings in terms of reducing low back pain and functional
disability. The pain level was improved significantly in
both the groups from pre to post intervention (p < 0.001)
and between group difference also showed significant
difference with time (p < 0.001). Heo et al. also showed a
significant reduction of pain from (7.1 ± 0.6) to (3.0 ± 0.4)
using thoracic mobilization exercises and lumbar stabili-
zation exercises and from (6.9 ± 0.6) to (3.1 ± 0.3), p < 0.05,
via lumbar stabilization exercises only in patients with
CLBP [16].The functional disability was reduced from
(33.07 ± 2.915) to (10.67 ± 5.525) in Group A and from
(34.13 ± 3.563) to (23.93 ± 3.51) in Group B. Both groups
showed significant improvement in functional disability
(p < 0.001), but greater improvement was observed in
group A. Sung and his colleagues also reported significant
change in ODI in all groups (p < 0.05). But thoracic mobi-
lization group and thoracic manipulation group, showed
significant difference from control group (Neurac exer-
cises) in terms of improvement in mental and functional
status p < 0.05 [18].
This study showed that the lumbar stabilization exer-
cises with thoracic mobilization and strengthening exer-
cises reduced the pain level, thoracic kyphosis and
functional disability in patients with chronic low back
pain. Both groups showed improvement in pain, kyphotic
index and ODI, but Group A showed better result than
Group B.
The study will have implication for patients with CLBP
with increased thoracic kyphosis and for those populations
who engage in such kind of physical activities, which
causes mechanical stress on the spinal column and can
prevent the further deterioration of posture, mobility at the
thoracic spine, respiratory function, balance, and mental
status of the patient by correcting abnormal posture
[thoracic kyphosis].
Limitation of the study is that cannot be generalized on
every population with CLBP because of limited number of
subjects with specific age groups and thoracic kyphosis
were recruited in this study.
Further study can be done on large number of subjects
with different age group and diverse population with
increased thoracic kyphosis.
Research funding: None declared.
Author contributions: All the authors have accepted
responsibility for the entire content of this submitted
manuscript and approved submission.
5
Competing interests: No declarations of interest.
Employment or leadership: None declared.
Honorarium: None declared.
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