EFFECT OF MULLIGAN SUSTAINED NATURAL
APOPHYSEAL GLIDES ON THORACIC COBB
ANGLEIN SUBJECTS WITH THORACIC KYPHOSIS
Mohamed Hussien Elgendy*; Shaimaa Ramadan Mohamed**;
Shimaa Taha Abuelkasem*** and Saher Ebrahim Mohamed****
*Professor Doctor of Physical Therapy and chairman of Basic Science Department ,
Faculty of physical therapy. Cairo University
** Researcher of physical therapy for Basic Science Department, Cairo University.
*** Lecturer of Physical Therapy forBasic Science Department, Faculty of physical
therapy, Cairo University
**** Assistant Professor of Diagnostic and Intervention Radiology, Faculty of
Medicine, Mansoura University.
Key Wards: Mulligan, thoracic kyphosis, Cobb Angle , digital x-ray.
ABSTRACT
Objective: This study was conducted to investigate the effect of mulligan
SNAGS on thoracic cobb angle in subjects with thoracic kyphosis.
Methods: A total of 40 subjects participated in this study aged from 18
to 28 year underwent 12sessions of a combination of Mulligan
techniques and traditional treatment (experimental group, n 20) or
traditional treatment only (control group, n 20). They were evaluated
before the treatment, and after 4 weeks, using digital x-ray. Results:
Mixed MANOVA revealed significant decrease of thoracic cobb angle
post treatment compared to pre treatmentfor both expermintal and control
group also it revealed significant decrease of thoracic cobb angle post
treatment in experimental group compared to control group.
Conclusion:Thoracic MWM improves thoracic kyphosis (decrease
kyphotic cobbs angle)
INTRODUCTION
The thoracic kyphosis is the primary curve of the vertebral
column which is consists of 12 vertebrae (Standring, 2005). The
thoracic kyphosis angle increases with age and the increase is greater in
females than in males (Nishiwaki et al.,2007).Normal values for the
thoracic kyphosis are between 20˚and 40˚ of angulations, When the curve
of the thoracic spine exceeds this, it is described as either a postural
kyphosis or Scheuermann's kyphosis (Shelton, 2007).
kyphosis can be found in all age groups 30% in teenagers(Eslami
and Hemati,2013), 35% in adults (Seidi et al.,2014), and 40% in the
elderly( Kado et al.,2007).Changes in lifestyles currently are prompting
people to reduce their levels of physical activity and spend a considerable
Egypt. J. of Appl. Sci., 35(11) 2020 108-117
amount of their time sitting with an extreme flexion posture. Such
changes may raise the development of kyphosis in early age groups. As
kyphosis angle increases, physical performance and quality of life often
decrease, making early intervention for hyperkyphosis is a priority
(Katzman et al.,2007).
Physical therapy usually use posture correction exercise, which
include strengthening and stretching exercises and positioning to treat
subjects with thoracic kyphosis. However, quality of evidence that
supports effective therapeutic exercise for this postural abnormality is
lacking (Morris and Bui.,2005).Bracing as conservative treatment is
effective in decreasing pain and fatigue until skeletal maturity is reached
in adolescent. But not sufficient for correction of hyperkyphosis so
combined treatment is recommended for best improvement ( Trevor et
al.,2015).
Mulligan mobilization technique can used to improve extension
range of motion in the thoracic spine using SNAGS. Mulligan SNAGS
provide immediate improvement in range of motion(ROM) as it corrects
the positional fault in facet joint (Mulligan,2004). As in mulligan
combination of mobilization in weight bearing position and active
movement of subject has good effect in correction of malalignment
between articular surfaces ( Hing et al., 2014).
So the aim of this study was to investigate the immediate effects of the
Mulligan SNAG on kyphotic angle in subjects with thoracic kyphosis
MATERIALS AND METHODS:
Design, setting, methods, and population
The current randomized single-blinded placebo-controlled trial was
performed in a private physical therapy clinic in the period between
February 2019 and September 2019. The design of the study was
approved by the local ethical committee board (P.T.REC/012/002219)
and was registered on the Pan African Clinical Trial Registration
(PACTR201907852069410).
Forty subjects diagnosed with postural thoracic kyphosis (cobb
angle ≥ 40°) and referred to receive physical therapy interventions were
included in this study. Subjects from both genders ranged from18 to 25
years old, and having a Cobb angle ≥ 40° were included in this study.
Pregnant females, obese persons (more than 30kg/m2), fixed
spinal or thoracic deformities, combined scoliokyphosis were excluded.
The recruitment process was summarized in the flow chart (figure1)
109 Egypt. J. of Appl. Sci., 35(11) 2020
Sample size
The sample size was estimated using the G*power 3.0.10 software
(Heinrich Heine University Düsseldorf, Düsseldorf, Germany). The
sample size was calculated based on a prior pilot study consisted of 10
subjects received the same interventions. F test-repeated measurements,
between factors α=0.05, β=0.2, and effect size=0.4 revealed that 40 (20
subjects per group) were the appropriate sample size.
Interventions
Group A( Experimental group): participants in this group underwent
thoracic SNAG manipulative therapy on thoracic region. The participants
were given mulligan mobilization 3 sets with 10 repetition using SNAG
technique to level affected of thoracic spine. 12 mobilization session
were given to the subjects over a period of 4 weeks, 3 session a week.
Position of the participant was seated , with both hands behind the neck
to protract the scapula and make the therapist make hand contact with
mid thoracic spine. Position of the therapist stand astride beside the
subject. With one arm of the therapist around the participant and guide
the motion. The other hand ulnar border has been placed on spinous
process on the level which would be mobilized and apply gliding force
along the facet plane while the patient extend his thoracic spine (figure
1). some strength required to support the subject extension movement as
well as providing facet glide( Mulligan ,2010).
Figure1:Thoracic extension SNAG with spinous process application
point
Egypt. J. of Appl. Sci., 35(11) 2020 110
Posture correction exercises :The exercise programme consisted
of 5 basic exercises, were performed under the supervision of the
physical therapist, who provided guidelines (verbal and/or written) to the
participants so that they could also perform the exercises alone (at home)
to have best result of the exercises .The exercise programme comprised a
daily session of 15–20 min(under the supervision of the therapist or alone
at hom (Bautmans et al.,2010)
The exercises consisted of :
1-Seated, lifting both hands together above the head (3 series of 10–15
movements, using a dumbbell if necessary).
2- Seated or standing with the back against a wall, straightening the back
as far as possible (3 series of 10–15 repetitions, maintaining the
upright position for 3–10 sec).
3- seated on a chair with both hands on the neck or crossed over the
thorax on the shoulders, lifting the arms and extending the upper back
without compensation in the hips or lumbar spine (3 series of 10–15
repetitions, maintaining the upright position for 3–10 sec).
4- Standing in front of a wall, scrolling with both hands as high as
possible over the wall (3 series of 10–15 repetitions, maintaining the
upright position for 3–10 sec).
5-lying on the back, knees and hips flexed and feet resting on the ground,
a small rolled-up towel under the 5th to 7th thoracic vertebrae
(perpendicular to the spinal processes), stretching the thoracic spine
for 30–180 sec(depending on the patient’s capacities, without
compensation of the lumbar spine or eliciting back pain)
Group (B) control group: were received postural correction exercise
only. FVC,FEV1,MVV,andkyphotic angle were measured for all
participants before and after treatments.
Outcomes measures:
Kyphotic angle were measured by digital X-ray. participants were
filmed for lateral spinal radiography over the area of the thoracic spine
[the first thoracic vertebral (T1) to the 12th thoracic vertebral (T12)] in
an upright standing position. The Cobb angle was subsequently analyzed
by four raters using the software .To achieve a Cobb angle, a digital Xray
file was uploaded to the prima console programme. Then, a straight
line was drawn that passed the upper border of the T4 vertebra, and
another line that passed the inferior border of the T12vertebra. Then, two
other lines were drawn perpendicularly with the first two lines, and the
intersection of these two lines produced the Cobb angle (Briggs et
al.,2007 andKatzman et al.,2007)
111 Egypt. J. of Appl. Sci., 35(11) 2020
Fig (2): (a) before treatment (b) after treatment
Statistical analysis
- Descriptive statistics and t-test was conducted for comparison of
the subject characteristics between both groups. Chi squared test were
conducted for comparison of sex distribution between both groups.
Mixed MANOVA was conducted to compare the effect of time (pre
versus post) and the effect of treatment (between groups), as well as the
interaction between time and treatment on mean valueof kyphotic angle.
The level of significance for all statistical tests was set at p < 0.05.
Statistical analysis was performed through the statistical package for
social studies (SPSS) version 25 for windows.
Table 1.Participant characteristics..
Group A Group B
p-value
mean ± SD mean ± SD
Age (years) 2.42 ±24.25 23.85± 2.56 0.61
Weight (kg) 74.25 ± 8.75 75.45± 6.84 0.63
Height (cm)
BMI(kg/m2)
168.25 ± 5.44
26.23±2.88
169.65 ± 3.81
26.22±2.28
0.35
Sex
Boys 8 (40%) 7 (35%)
0.73
Girls 12 (60%) 13 (65%)
SD, Standard deviation; p-value, Level of significance
Overall effect of treatment on FVC, FEV1, FEV1/FVC ratio, MVV
and kyphotic angle :
Mixed MANOVA was conducted to investigate the effect of
treatment on kyphotic angle. There was a significant interaction effect of
treatment and time (p = 0.0001). There was a significant main effect of
treatment (p = 0.002). There was a significant main effect time(p =
0.0001).
Egypt. J. of Appl. Sci., 35(11) 2020 112
Within group comparison
Within-group comparison between the before treatment and after
treatment revealed a significant increase in Kyphotic angle, in the group
A and B (p < 0.001), (table 2).
Table (2): within-group comparisons in both experimental and
control groups.
Variable Experimental group Control group
mean ± SD
MD P
mean ± SD
Pre- MD P
treatment
Post
treatment
Pretreatment
Post
treatment
Kyphotic
angle (°)
46.29 ±
5.32
39.46 ±
3.78
6.83 0.0001
45.95 ±
3.12
42.15 ±
4.19
3.80 0.0001
SD, standard deviation; MD,mean difference; P, level of significance
Between group comparison
There was no significant difference in the kyphotic anglepre
treatment between the study and control groups (p = 0.8). However, there
was a significant decrease in the mean values of kyphoticangleof the
study group post treatment compared with that of control group (p =
0.03).,(table 3).
Table(3): between groups comparisons for both real MWM and
sham MWM groups.
Variable Between groups pairwise comparison (Bonferroni correction)
Pre-treatment Post – treatment
Mean± SD
MD P Mean± SD
MD P
Experimental Control MD P- value Experimental Control MD P- value
Kyphotic
angle (°)
46.29 ± 5.32
45.95 ±
3.12
0.34 0.80
39.46 ± 3.78 42.15 ±
4.19
2.69 0.03
DISCUSSION
The current study revealed statistical significant decreasing in
thoracic cobb angle after Mulligan mobilization the possible explantions
for decreasing thoracic kyphotic angle are:
The first is that mulligan technique is given in sitting position
facing the challenge of the gravity effect on the thoracic vertebrae when
performing the mobilization maneuver and this enhance the corrective
effect of mobilization on kyphosis. It is important to give manual therapy
in weight bearing position when dealing with spinal deformity
(Lawrence and Bakkum,2000).
The second, the impairment in thoracic kyphosis not only in joints,
cartilage and ligaments but also there is impairment in muscle balance,
sense, postural awareness( Knight,2003). Mulligan SNAGS combine
between joint glide which improve the dysfunction in vertebral joints and
active movement of subject which improve muscle balance, postural
awareness and sense of movement (Hing et al., 2014)
113 Egypt. J. of Appl. Sci., 35(11) 2020
The third explanation, kyphosis is considered compensated
incongruent posture. Congruency is important for maintainance of
posture upright, and the degree to which someones posture is congruent
will influence body mass distribution and biomechanical environment of
spine. Applying SNAG on thoracic vertebrae restore the normal
congruence and weight distribution over vertebral body (Hing et
al.,2014).
The forth explanation is that postural kyphosis is accompanied with
incongruence of zygapophyseal joint that limit the range of rotation
movement. As the T8 vertebrae is coupled into left rotation, this would
enhance the widening of the T8/9. The advantage of the sustained
distraction glide is facilitation of the correct physiological motion in
weight bearing (Edmondston & Singer, 1997).
Additionally mulligan SNAG is effective in improve positional
fault, to explain the effect of Mulligan technique on
proprioception,Accessory gliding by SNAGS mobilizationcause
Stimulation of mechanoreceptors,also,increase thesensitivityof muscle
spindle within the muscle gammamotor neurons, lead to proprioceptive
facilitation (Sterling et al.,2001).
Further explanation Nagai et al.,2016, who concluded from his
studyconsiders the human fascia, whichhad mechanoreceptor nerve
endings. As active ROM increasesmovement from near mid-ROM to
end-ROM, it islikely that more mechanoreceptors are stimulated due toan
increase in tissue stretch surrounding the cervical spine.This increase in
afferent information near end-ROM mayultimately result in higher
precision in position sense than near mid-ROM ( Nagai et al.,2016).
Accessory movement associated with mulligan technique gives
more explanation forpatient improvement as it applied to the spinous
process of cervical vertebra, enhances the circulation and nutrition to the
joint, leading to washing out of nociceptive metabolitesand better heals
of minor injuries of the soft tissue,thus bringing out smooth and pain free
physiological movements ( Mulligan,2004).
Limitations:
The mean age of the study sample was relatively young. Consequently,
the results will be applicable only to this age group. The lack of followup
limits the ability to investigate the length of time these changes could
be persisting with the patients.
CONCLUSION:
Thoracic MWM improves thoracic kyphosis ( decreasekyphoticcobbs
angle)
Acknowledgement:
None
Egypt. J. of Appl. Sci., 35(11) 2020 114
Disclosure statement
The authors declare no conflict of interest.
Conflict of interest:
There was no conflict of interest.
REFERENCES
Bautmans, I. ; J. Arken and M. Mackelenberg (2010): Rehablitation
using manual mobilization for thoracic kyphosis in elderly
postmenopausal patients with osteoporosis. J Rehabil Med; 42:
129-135.
Briggs, A.M. ; T.V. Wrigley ; E.A. Tully ; P.E. Adams ; A.M. Greig
and K. L. Bennell (2007). Radiographic measures of thoracic
kyphosis in osteoporosis: Cobb and vertebral centroid
angles. Skeletal radiology, 36(8): 761-767.
Edmondston, J. and K. Singer (1997): Thoracic spine: anatomical and
biomechanical consideration for manual therapy. Manual
Therapy; 2:132-143.
Eslami, S. and J. Hemati(2013): Prevalence lordosis and dorsal
kyphosis deformity among girls 23e11 years and its relationship
to selected physical factors. Intl J Sport;3:924e9
Hing, W. ; T. Hall D. Rivett and B. Vicenzino (2014): Mulligan B.
Mulligan concept of manual therapy; 6thed, -540-558.
Kado, D. M. ; K. Prenovost and C. Crandall (2007). Narrative review:
hyperkyphosis in older persons. Annals of internal medicine,
147(5), 330-338.
Katzman, W.B. ; E. Vittinghoff and D.M. Kado (2007): Age-related
hyperkyphosis, independent of spinal osteoporosis, is associated
with impaired mobility in older community-dwelling women.
OsteoporosInt ;4:85e90
Knight, R. ; R. Jackson ; J. Killian and E. Stanley (2003): Scoliosis
research Society White Paper on Sagittal Plane Alignment.
Accessed from SRS. Org., 1(6):219-225.
Lawrence, J. and B. Bakkum (2000): Chiropractic management of
thoracic spine pain of mechanical origin. In: Giles LG, Singer
KP, eds. Clinical Anatomy and Management of Thoracic Pain.
Ox ord: Butterworth-Heinemann; 244-256.
Morris, Q. and M. Bui (2005): The effect of mode exercise instruction
on compliance with a home exercise program in older adults
with osteoarthritis , physiotherapy., 91(2):79-86.
Mulligan, B.(2004): Manual Therapy: NAGs, SNAGs, MWMs. . 4th ed.
Plane View Services Ltd: Wellington, NZ.
Mulligan, R. (2010): Manual Therapy NAGS , SNAGS, MWMS, etc,.
Wellington: Plane View Services Limited, 6thed, :35-37.
115 Egypt. J. of Appl. Sci., 35(11) 2020
Nagai, T. ; N. C. Clark ; J. P. Abt ; T. C. Sell ; N. R. Heebner ; B. W.
Smalley and S. M. Lephart (2016).The effect of target position
on the accuracy of cervical-spine-rotation active joint-position
sense. Journal of sport rehabilitation, 25(1): 58-63.
Nishiwaki, Y. ; Y. Kikuchi ; K. Araya ; M. Okamoto ; S. Miyaguchi ;
N. Yoshioka and T. Takebayashi, (2007).Association of
thoracic kyphosis with subjective poor health, functional activity
and blood pressure in the community-dwelling
elderly. Environmental Health and Preventive Medicine, 12(6):
246-250.
Seidi, F. ; R. Rajabi ; I. Ebrahimi ; M.H. Alizadeh and H.
Minoonejad (2014): The efficiency of corrective exercise
interventions on thoracic hyper-kyphosis angle. J Back
MusculoskeletRehabil;27:http://dx.doi.org/10.3233/BMR-
130411.
Shelton, Y. A. (2007). Scoliosis and kyphosis in adolescents: diagnosis
and management. Adolescent medicine: state of the art reviews,
18(1): 121-39.
Standring, S.(2005):Gray’s Anatomy, Elsevier Churchill Livingstone,
Edinburgh, UK, 39th edition.
Sterling, M. ; G. Jull and A. Wright (2001). Cervical mobilisation:
concurrent effects on pain, sympathetic nervous system activity
and motor activity. Manual therapy, 6(2): 72-81.
Trevor Axelrod, MSIV ; Fang Zhu D. and Laurie Lomasney (2015):
Scheuermans disease (Dysostosis) of the spine
orthopaedics.;38(1:4):66-71.
تأثير التحريک الطبيعي المستمر لممفاصل المسطحة لموليجان عمي ا زوية الحداب
الصدري في الاشخاص ذات التحديب الصدري
محمد حسين الجندي* شيماء رمضان محمد** شيماء طه ابوالقاسم***
ساهر اب ا رهيم محمد****
*أستاذ ورئيس قسم العموم الاساسيو ، کمية العلاج الطبيعي ، جامعة القاىرة
** باحث علاج طبيعى بقسم العموم الاساسيو .جامعو القاىره
***مدرس العلاج الطبيعي، قسم العموم الاساسيو، کمية العلاج الطبيعي، جامعة القاىرة
****أستاذ مساعد الأشعة التشخيصية والتداخمية بکمية الطب جامعة المنصورة
خمفيو: اليدف: أجريت ىذه الد ا رسة لمعرفة تأثير موليجان عمى ا زوية التحديب الصدري في
الأشخاص المصابين بحداب الصدر. الطريقة: ما مجموعو 04 شخصًا شارکوا في ىذه الد ا رسة
تت ا روح أعمارىم بين 81 و 81 عامًا خضعوا ل 88 جمسة من مزيج من تقنيات موليجان والعلاج
التقميدي )المجموعة التجريبية 84 شخصا( أو العلاج التقميدي فقط في )مجموعة التحکم
Egypt. J. of Appl. Sci., 35(11) 2020 116
شخصا 84 (. تم تقييميم قبل العلاج وبعد 0 أسابيع باستخدام الأشعة السينية الرقمية. النتائج:
أظيرت النتائج انخفاضًا معنويًا في علاج ما بعد العلاج ب ا زوية التحديب الصدري مقارنة
بالمعالجة المسبقة لکل من المجموعة التجريبية والمجموعة الضابطة ، کما أظيرت انخفاضًا
ممحوظًا في ا زوية کوب الصدر بعد العلاج في المجموعة التجريبية مقارنة بالمجموعة الضابطة.
الاستنتاج: التحريک الطبيعي المستمر لممفاصل المسطحو لموليجان لمنطقو الصدر يحسن
ويقمل من التحديب الصدري.
الکممات الداله: موليجان ، حداب صدري ، ا زوية کوب ، أشعة سينية رقمية.
117 Egypt. J. of Appl. Sci., 35(11) 2020
