Effects of Maitland and Mulligan Spinal Mobilizations Along With Canal Enlargement Exercises in Lumbar Spinal Stenosis

Comparative Effects of Maitland and Mulligan Spinal Mobilizations Along With Canal Enlargement Exercises in Patients of Lumbar Spinal Stenosis

This randomised controlled trial will evaluate the comparative effects of Maitland versus Mulligan spinal mobilization techniques, when combined with canal enlargement exercises, in patients with lumbar spinal stenosis (LSS). A total of 38 participants aged 25-40 years with confirmed unilateral LSS will be randomly assigned to receive either Maitland mobilizations or Mulligan mobilizations, along with standard physiotherapy and canal enlargement exercises. The intervention will be administered over three weeks, with four sessions per week. Primary outcomes will include pain intensity (measured by Numeric Pain Rating Scale), disability (Modified Oswestry Disability Index), and symptom severity (Swiss Spinal Stenosis Score), assessed at baseline and post-treatment. This study aims to inform physiotherapy practice by identifying the more effective manual therapy technique for improving functional outcomes in LSS.

Study Overview

• Status: Not yet recruiting
• Conditions: Low Back Pain; Spinal Stenosis
• Intervention / Treatment: Other: Maitland Mobilization Group; Other: Mulligan Mobilization Group

Detailed Description

This single-blinded, randomised controlled trial is designed to compare the effects of two manual therapy techniques, Maitland central posterior-anterior Grade III mobilizations and Mulligan spinal mobilizations (SNAGs), when combined with canal enlargement exercises and conventional physiotherapy. Thirty-eight participants with confirmed unilateral lumbar spinal stenosis will be recruited from the outpatient physiotherapy department at Allama Iqbal Memorial Teaching Hospital, Sialkot.

Participants will be randomly assigned to one of two intervention groups using sealed opaque envelopes. Group A will receive Maitland mobilizations in addition to canal enlargement exercises and conventional physiotherapy, while Group B will receive Mulligan mobilizations along with the same exercise and conventional therapy protocol. The intervention will be administered four times per week over a period of three weeks (total of 12 sessions).

The canal enlargement protocol includes bilateral knee-to-chest exercises, LION stretches, and cat-camel movements, all of which aim to increase lumbar flexion and spinal canal space. Conventional physiotherapy treatment will include the application of hot packs, transcutaneous electrical nerve stimulation (TENS), and stretching of the hamstrings and piriformis muscles.

Primary outcomes will be assessed at baseline and after the 3-week intervention. These include:

Pain intensity (Numeric Pain Rating Scale, NPRS)

Functional disability (Modified Oswestry Disability Index, MODI)

Symptom severity (Swiss Spinal Stenosis Score, SSSS)

Data will be analysed using appropriate parametric and non-parametric statistical tests, based on data distribution. The findings of this study will provide insight into which mobilization technique is more effective in reducing pain and disability and improving function in patients with lumbar spinal stenosis. This may contribute to the development of more evidence-based physiotherapy protocols for LSS management.

• Study Type: Interventional
• Enrollment (Estimated): 38
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Samrood Akram, Phd Scholar; Phone Number: 03324806143; Email: samood.akram@riphah.edu.pk
• Study Contact Backup: Name: Amna Zia, Phd Scholar; Phone Number: 03244686993; Email: amna_zia_17@live.com

Study Locations

• Pakistan
  • Punjab
    • Sialkot, Punjab, Pakistan, 1
      • Allama Iqbal memorial teaching hospital
      • Contact: Dr Zunaira; Phone Number: 03316630234

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age group between 25-40 years

  • Both males and females will be included
  • Patient with low back pain along with unilateral radiating symptoms
  • Having symptoms from at least 3 months with pain severity not more than 7 on NPRS
  • Diagnosed case of slipped disc or herniation causing spinal stenosis, confirmed by physical examination and/or MRI.

Exclusion Criteria:

• Chronic inflammatory or infectious disease, neoplasm, hematological disorders, traumatic vertebral injuries, Spondylitis

  • Any concurrent major disease like renal failure, diabetes, cancer, tumor.
  • Low back pain with bilateral radiating symptoms.
  • Pregnancy
  • Cognitive alteration and non-co-operative patient
  • Spinal surgery

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Maitland Mobilization Group; Participants in this group will receive Maitland Grade III central posterior-anterior spinal mobilizations targeting the lumbar spine. The intervention will be administered by a licensed physiotherapist with the patient in a prone position, applying oscillatory mobilization for 3 sets of 40 seconds with 1-minute rest intervals. This will be combined with:	Other: Maitland Mobilization Group; Participants in this group will receive Maitland Grade III central posterior-anterior spinal mobilizations targeting the lumbar spine. The intervention will be administered by a licensed physiotherapist with the patient in a prone position, applying oscillatory mobilization for 3 sets of 40 seconds with 1-minute rest intervals. Canal enlargement exercises (bilateral knee-to-chest, LION stretch, cat-camel exercise) The total treatment will be administered four sessions per week for three weeks (12 sessions total).
Experimental: Mulligan Mobilization Group; Participants in this group will receive Mulligan spinal mobilizations with lower limb movement (SNAGs). The therapist will apply sustained passive glides to the lumbar spinous process while the patient actively elevates the leg in a pain-free range. Mobilizations will be performed in 3 sets of 7-10 repetitions. This will be combined with:	Other: Mulligan Mobilization Group; Participants in this group will receive Mulligan spinal mobilizations with lower limb movement (SNAGs). The therapist will apply sustained passive glides to the lumbar spinous process while the patient actively elevates the leg in a pain-free range. Mobilizations will be performed in 3 sets of 7-10 repetitions. Canal enlargement exercises (bilateral knee-to-chest, LION stretch, cat-camel exercise) The total treatment will be administered four sessions per week for three weeks (12 sessions total).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Numeric Pain Rating Scale	Pain will be assessed using the 11-point Numeric Pain Rating Scale (NPRS), where 0 represents "no pain" and 10 represents "worst possible pain." The scale is a reliable self-reported tool for evaluating pain intensity in musculoskeletal conditions.	Baseline and at the end of 3 weeks (post-intervention)
Modified Oswestry Disability Index (MODI)	Functional disability will be assessed using the Modified Oswestry Disability Index (MODI), a validated questionnaire that measures the degree of disability related to low back pain. Scores range from 0% (no disability) to 100% (maximum disability).	Baseline and at 3 weeks post-intervention
Swiss Spinal Stenosis Score (SSSS)	The Swiss Spinal Stenosis Score (SSSS) will be used to assess symptom severity and physical function specific to lumbar spinal stenosis. The tool includes subscales for symptom intensity and function, with higher scores indicating greater impairment.	Baseline and at 3 weeks post-intervention

Collaborators and Investigators

• Sponsor: Riphah International University
• Investigators: Principal Investigator: Amna Zia, Phd Scholar, Riphah International University; Principal Investigator: Areej Ijaz, MSc Student, Riphah International University

Publications and helpful links

General Publications

• Munakomi S, Foris LA, Varacallo MA. Spinal Stenosis and Neurogenic Claudication. 2023 Aug 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from http://www.ncbi.nlm.nih.gov/books/NBK430872/
• Homayouni K, Naseri M, Zaravar F, Zaravar L, Karimian H. Comparison of the Effect of Aquatic Physical Therapy and Conventional Physical Therapy in Patients with Lumbar Spinal Stenosis (a Randomized Controlled Trial). Journal of Musculoskeletal Research. 2015;18(01)
• Gaur P, Goyal M, Singh G. Manual therapy and canal enlargement exercises versus conventional physiotherapy in lumbar stenosis - a study protocol. Revista Pesquisa em Fisioterapia. 2021;11
• Kumar S, A N. Effect of Integrated Exercise Protocol in Lumbar Spinal Stenosis as Compare with Conventional Physiotherapy- A Randomized Control Trial. International Journal of Neurorehabilitation. 2017;04(06).
• Maitland G. Management of lumbar spine disorder. Maitland's vertebral manipulation 8th ed United Kingdom: Churchill Livingstone. 2013:230-6.

Study record dates

Study Major Dates

• Study Start (Estimated): July 1, 2025
• Primary Completion (Estimated): November 15, 2025
• Study Completion (Estimated): November 30, 2025

Study Registration Dates

• First Submitted: July 14, 2025
• First Submitted That Met QC Criteria: July 14, 2025
• First Posted (Actual): July 23, 2025

Study Record Updates

• Last Update Posted (Actual): July 23, 2025
• Last Update Submitted That Met QC Criteria: July 14, 2025
• Last Verified: July 1, 2025

More Information

Terms related to this study

• Keywords: Pain; Disability; Manual Therapy; Canal Enlargement Exercises
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Bone Diseases; Musculoskeletal Diseases; Pathological Conditions, Anatomical; Spinal Diseases; Back Pain; Constriction, Pathologic; Spinal Stenosis; Hypertrophy; Low Back Pain
• Other Study ID Numbers: REC/RCR & AHS/24/0166 Areej

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No