The pain in the back region that lasts longer than 3 months is known as chronic lower back pain (CLBP). The lower back pain (LBP) is common across all age groups. About half of people experience back discomfort in the course of a year, and more than three-quarters of the population suffer from LBP during their lifetime 1. A study from 2015 revealed the prevalence worldwide of LBP at 7.3 percentage. The activities that are essential for daily life are affected by LBP. The importance of disability is a result of LBP. The sacroiliac, lumbosacral and the lumbar region are the primary regions affected by LBP [22. LBP may be caused by an identifiable cause, such as fractures that are persistent or it could be due to the unknown source of nociceptive cause, which is known as non-specific LBP [3 – 5]. LBP is extremely prevalent and requires special attention during treating. Evidence supports the effectiveness of exercise therapy for LBP However, very little studies provide information on the effects of manual treatment on LBP.

It is a distinct part of physiotherapy that manages the pain of neuromuscular muscles. Techniques for manual therapy are techniques like the Maitland mobilisation method, Kaltenborn mobilisation method, Mulligan technique [6,] activation release techniques, as well as other. The focus of manual therapy is osteokinematics as well as arthrokinematics in the joint. It is among the most effective strategies to treat LBP.

Mulligan is a method of manual therapy, which states that the osteokinematics and arthrokinematics of the joint could be brought back to normal through the movement of mobilization, because there are times when the problem can’t be resolved by moving in a stationary position. Mulligan believed that there were some postureal defects in the joint that are the result of injuries or long-term use and these postureal flaws lead to pain and decreased mobility. Mulligan’s theory helps correct the postural problems by performing mobilization by moving [7].

LBP is a condition that people of all ages groups is confronted with and there are a variety of methods to address LBP. Manual therapy techniques include mulligan mobilization Kaltenborn mobilisation Mckenzie techniques, activation release, other. LBP could be caused by spinal dysfunction as well as sacroiliac or sacroiliac muscle pathology as well as any other ligament-related strain8. The cause of LBP must be identified and addressed accordingly.

The pathophysiology behind LBP

The trunk muscles as well as the spinal collaborate for the movement of the spine. The primary movements are flexion, extension, lateralization, as well as rotation [99. Flexion and extension refers to rotations within the sagittal plane. In contrast, the term lateral bending is used to describe movements in frontal plane. Axial rotation is the turning in the spine around its vertical axis. Facet joints are crucial for maintaining the stability of the spine when flexing forward. Facet joints bear a lot of load in axial rotation, which allows the force generated to pass through the side that is posterior to the articulating surface. Any problem with the facet joint, or the intervertebral disc causes LBP. The spine’s stabilization is impeded in LBP to maintain the neutral zones between the vertebrae, which leads to deformities, pain and neurological impairment that result with an unstable spine being more unstable, and prone to excessive movement, which can lead to stretching of muscles, nerve pressure, as well as inflammation which can all be a contributing factor to LBP.

It is possible to cause spinal pain by a variety of causes which include structural, mechanical or functional, psychological, and neuromuscular issues. Most MTrPs can be found in quadratus lumborum as well as iliocostalis lum muscles. In addition, a greater amount of active MTrPs were associated with a higher pain intensity [1010. They are characterised by muscle stiffness, tenderness and pain that spreads into other areas or areas, which is known in referred pain11. The main causes of risk are that result from trauma-related factors and structural, as well as factors of structure and systemic factors [1212. These can occur because of exercise and strain on muscles or caused by an underlying physical issue. They’re typically diagnosed by examining a muscle for knots, or small areas of muscles spasm in a tense area of muscle that is painful and causes the pain that is referred. Trigger points fall into two groups that are active and latent.

Prevention of LBP

LBP is a condition that can occur regardless of age. It is caused by poor sitting posture, standing for a long time as well as improper lifting techniques. In light of this, LBP can be prevented by improving posture by using mirror feedback, increasing the strength of the core muscles as well as using the correct lifting techniques and when you are doing flexibility training [44.

NSLBP, also known as Non-specific (NSLBP)

The form of LBP in which the reason is unknown is known as NSLBP. There isn’t a specific cause of biomechanical or anatomical alteration within the back region, but the pain remains. Mechanical factors were thought for a long time to be a factor in LBP. According to the Bradford-Hill causality criteria and the Bradford-Hill causation criteria, there is no relationship between posture that is uncomfortable, standing for long periods or walking in a sway, handling, pulling, or twisting pushing or the way that things are transported. Mechanical LBP can be described as back discomfort that is caused by the increased strain and tension in the spinal muscles and the column typically due to unhealthful actions, such as bad posture, inadequate sitting, and unintentionally bending or lifting. The mechanical aspect of LBP within the back is defined by discomfort that causes movement and enhances rest [1313. Non-specific LBP mostly occurs due to weakening of back and core muscles back as well as the core muscle, or because of poor postural control and sacroiliac dislocation. Muscle activation is decreased in these cases, which leads to pain and limited movement (ROM) in the sense that the ROM is limited to daily activities are also difficult to complete which can lead to impairment.

Vlaeyen et al. examined LBP and found that LBP is typically defined by stiffness in the muscles and pain that is located in the gluteal region and LB region. Due to SI tendinitis and joint displacement, there is also inflammation of the SI joints stabilizers, such as the quadratuslumborum, the glutei and the piriformis and the iliopsoas and many others. A majority of those suffering from back pain experience no specific pain that is not accompanied by a source of pain or nociceptive cause. Back pain is a major negative effect upon the health for the people who suffer from it. The risk of back pain is increased of becoming disabled and the negative impact on QOL is exacerbated when the pain continues. It is linked to fear and anxieties, specifically in relation to the perception of (sense of) self-esteem and social interactions. Additionally, it becomes more severe when the discomfort lasts for longer than you anticipate [1414. A study was conducted regarding LBP by Violante and co. and defined LBP as “pain or muscle tension or stiffness that occurs in the gluteal area, leg region, and the sacroiliac region.” The clinical recommendations typically identify two kinds of LBP: NSLBP, which is defined as a condition that is that is caused by no known particular pathology, and a specific LBP that can be caused due to a specific pathology that is well-known [15]. In addition, even though the impairment and pain can last for longer periods in certain situations, LBP is once again classified by its subacute, acute and chronic. Acute is pain that is lasting for less than 6 weeks, sub-acute is between 6 and 12 weeks while chronic lasts longer than twelve weeks. Identifying the type of LBP, if it is acute/Subacute/chronic and specific or nonspecific is important for epidemiological research as well as a clinical treatment.

Sharan et al. in 2014 examined myofascial lBP (MLBP) therapy and reported that the role of muscle factors, particularly myofascial painful syndrome (MPS). MPS appears to be the most frequently causing factor in LBP which is easily treatable, and consequently is an important factor in the spectrum of LBP. Exercises can be effective in both the acute and chronic phase of MLBP. Physical exercises, as well in stretching and strength techniques are helpful. Exercises that reduce pain are improving the health of bones in terms of increasing bone mineralization and addressing the specific causes of aging in the muscles, keeping the muscles in good health. When training, biofeedback functions as a motivational and feedback source, allowing athletes to increase their performance towards the desired level [16].

Mulligan mobilization and movement

Mulligan’s theory states that pain is caused by an insignificant positional defect to the joint, which leads to the limitation. The biomechanical effect of a postural defect is change that causes discomfort [1717. In Mulligan mobilization, a natural apophyseal glide to patients with spine and extremities. This is followed by mobilization. Passive accessory movements are given to the spinous and transverse process, and the patient is required to perform movements such as extensions, flexion and flexion. The basic principles of Mulligan mobilization is that the motion must be painless [1818.

Hussien et al. conducted a study of the effects on Mulligan concept of the lumbar sustained natural apophyseal glide (SNAG) on chronic NSLBP. 42 participants were chosen who suffered from NSLBP and split between two different groups at random. Conventional physiotherapy that included stretching and strengthening of the muscles, was provided to both groups. The experimental group received Mulligan’s idea of SNAG at the region of the spine in which the greatest amount of affection was found. The treatment was offered for a period of a month and was followed by three sessions every week. The outcome was recorded with an isokinetic dynamometer with functional disability and pain as outcome measures. Prior to and following the treatment every outcome was documented. Improvement in post-statistical analysis was evident for both of the groups. SNAG alongside traditional programs as a treatment method for chronic non-specific LBP resulted in superior results in terms of relief from pain and improvements in functional outcomes [7,197.19].

Namnaqani et al. performed a systematic review of the effects on the Mckenzie method in comparison to manual therapy. The researchers included five studies within the study. The main outcome was pain, along with disability. The researchers concluded Mckenzie is a superior treatment option to lessen the pain in the short-term [2020. McKenzie relies on the principles of centralization and peripheralization, and the Mckenzie treatment method is based on the individual’s pre-treatment evaluation [2121.

McCaskey et al. carried out a systematic review the form of 18 studies on proprioceptive exercise for neck pain and LBP. They considered pain along with functional autonomy as outcomes. They concluded that there was no consistent benefits were observed from proprioceptive exercises for chronic neck pain and LBP [2223. Bialosky et al. studied the effects on the effects of spinal manipulative therapy LBP. The study involved 110 participants. were involved in the study. the numeric pain rating scale (NPRS) to measure pain as well as the Oswestry Disability Index for functional disability were used as the outcome. This study found it was spinal manipulative therapy was efficient [2323.

Rajfur et al. conducted a comparative study to test the impact the electrotherapy has on CLBP. The study included electrocutaneous nerve stimulation (TENS) and TENS with acupuncture, high-voltage electric stimulation as well as interferential current along with diadynamic and interferential currents as treatments. They concluded that interferencential current can be effective in relieving pain since it is more deeply absorbed, whereas High-voltage TENS as well as TENS are equally effective, but were not as efficient [2424. Central and peripheral stimulation are both non-invasive methods. Central stimulation is referred to as direct current transcranial stimulation. Both peripheral and central stimulation have analgesic properties. Therefore, it is helpful in the reduction of CLBP [2525.

Li et al. carried out a systematic review to determine the impact of kinesio-taping CLBP. The study included 10 studies, and pain as well as functional disability were evaluated. The Kinesio taping was observed over taping with placebo [2626.

Peerachotikphun et al. examined the effects the effects of water therapy on LBP. The properties of water are the properties of viscosity and surface tension buoyancy and hydrostatic pressure. assist in strengthening and stretching muscles. Water helps reduce the chance of injury and thus can be used as a substitute for exercises on land [27It is a great alternative to land exercises [27. Different kinds of exercise regimens are suitable for management of CLBP. Education in pain neurophysiology is the process of educating patients about discomfort and cognitive misalignment which aids in relieving the symptoms of pain and inflammation. (Table 1.) [2828.

Author Study Type Study Sample Intervention Results Intervention period Results Analysis
Namnaqani, et al. [20] Systematic Review 160 patients with back pain that is chronically back pain. back pain. McKenzie and Manual Therapy Visual Analogue Scale (VAS), Numeric Pain Rating Scale (NPRS), Symptom Bothersomeness scale, McGill Pain Questionnaire, Oswestry Disability index 4 times a week during 6 months After 6 months of follow-up, there was a variety of improvement observed across both groups, but it was found that there was a notable difference evident within those who used the McKenzie Method group. McKenzie is a highly effective treatment that is effective for short-term and therefore improves the effectiveness and long-term effects.
Peterson, et al. [21] A random control trail. 350 McKenzie, Spine manipulations Roland Morris Questionnaire, VAS, Oswestry Disability Index (ODI) Three sessions per week for 8 weeks Both treatments showed improvement, but after two months of monitoring following 2 months, the McKenzie group was more effective than the treatments. McKenzie is a specialist in centralization and peripheralization. McKenzie is a proven method.
McCaskey, et al. [22]. A systematic review 80 Exercises for proprioceptive awareness, stretching strengthening, endurance training NPRS, ODI, Neck Disability Index (NDI) Three sessions per week for 8 weeks. The combination of proprioceptive exercises alongside traditional exercises can lead to an improvement in pain as well as functional state of the subjects. There isn’t a consistent advantage to practicing proprioception exercises.
Biolosky, et al. [23] Randomized Control Trail 110 Spinal Manipulation Therapy TENS, Pain threshold modality. Pressure Algometer, VAS, pain-centered outcome questionnaire, ODI Twice per week, 15 minutes, for a month. Significant improvement in pain was noticed following spinal treatment was administered to all participants, and there was an improvement in functional performance was also noted. The technique of spinal manipulation has an impact on pain sensitivity which is linked to the central sensitization.
Rajfur, et al. [24] Comparitive Clinical Pilot study. 127 Conventional TENS, Accupunture TENS, Electrical stimulation with high voltage Interferential current stimulation Diadynamic current VAS, ODI Roland-Morris Disability Questionnaire The use of electrical stimulation using interference current has resulted in an effective and significant reduction of pain and improved the functional capacity of those suffering from lower back pain. Electrotherapy is an effective method to decrease disability and pain because it affects the pain gait system.
Hazime, et al. [25]. Randomized Control Trail 92 Transcranial direct current stimulation, transcutaneous electrical nerve stimulation NPRS, ODI Twelve sessions spread over four weeks. The research was designed to determine the effects of central and peripheral stimulation since both provide an ailment effect.
Yuejie, et al. [26]. Meta Analysis 60 Kinesiotape and stretching exercises. VAS,ODI Twice per week for six weeks The effects of Kinesio tape by itself was lower than when combined with the exercise program for physical therapy. Kinesiotaping can provide an esthetic and kinaesthetic stimulus that aids in posture maintenance.
Hussien, et al. [7]. Randomized Control Trail 42 Strengthening exercises, stretching exercises, SNAG mulligan concept Isokinetic Dynamometer, VAS, Oswestry Disability Index. Twice a week for one month In addition, adding SNAG to standard therapy yielded better results in the areas of postural error and pain as well as functional capability. SNAG aids in reducing the micro mal-alignment and thus decreases discomfort.
Sawant, et al. [27]. Randomized Control Trail 30 Extensor stretching exercises, as well as strengthening exercises to strengthen the back and the core. VAS, Modified Oswestry Disability Index . 30 minutes 5 times per week for four weeks There was a marked improvement in patients who had regular therapy and hydrotherapy. The body’s weight within the water because of buoyancy. This makes the activities simple to complete and thereby reducing the pain.
Pires, et al. [28]. Randomized Control Trail 62 Exercises in the water and range of motion exercises and pain treatment VAS, Quebec Back Pain Disability Scale, Tampa Scale of Kinesiophobia Six weeks of 12 sessions This study revealed that combining training in neurophysiology of pain using exercise in the water was beneficial to all participants. The pain can be greatly reduced by using water therapy. Due to the therapeutic properties of water.

Seo et al. conducted a pilot research study on the effects on the Effects of Mulligan Mobilization as well as low-level laser Therapy (LLLT) in relation to Physical Disabilities, Pain and ROM in patients with CLBP. In the study , a total of 49 subjects were taken and were separated into three categories.. Group A received SNAG and the LLLT treatment, Group B received SNAG, and Group C was the group that was the control. In Group A, SNAGs were given over 10 minutes and LLLT for 10 min as well as electrotherapy lasting 10 minutes. The group B was treated with SNAGs over 10 minutes along with electrotherapy that lasted 20 minutes while Group C was treated to 30 minutes of electrotherapy. The participants received electrotherapy 3 times per week during four weeks. The pain was measured with an analog scale that was visual and its range of motion for the lumbar spine was measured with the modified-modified Schober’s Test as well as it was the Roland Morris disability questionnaire was utilized to assess physical impairment. It was concluded by the study that there was significant benefits of the combination therapy by SNAGs and LLLT with regard to reducing in disability and pain to manage chronic pain [3].

Bontrupa et al. investigated LBP and the effects of sitting for long periods as well as a sedentary lifestyle. They observed a greater connection between the behaviors associated with sitting CLBP than disability due to those with CLBP being more aware elevated of sitting positions that is painless and activities that are trigger pain, as opposed to those who suffer from acute pain. There was a slight relationship between the overall behaviour of sitting as well as those who had CLBP and functional impairment that was due to discomfort [2929. In the year 2018 Kothawale and Rao performed a single and comparative study of results of PRT and the ART treatment on tightness in the hamstrings of females between the ages of 18 and 30 years old and demonstrate the injury cycle. it was found that muscles with tightness are more susceptible to injury because of tension in the myofascial structures. Art therapy helps relieve tension and release muscles, tendons and the fascia that surrounds the adhesions by breaking them up and maintaining the integrity of soft tissue. Does this happen by having contact with adhesions while shortening muscles and stretching the muscle over its fibers to break the adhesion? Muscles, tendons, as well as ligaments function more freely which relieves tension upon the nerve and alleviating discomfort. It was discovered that ART can be effective in instantly reducing tightness of the hamstring [30It is also effective in reducing tightness in the hamstring [30.

A comprehensive review of the Effects of Exercise and Physical Activity (PA) on non-specific CLBP was carried out in 2016 and they found that back pain can be classified as particular or not-specific. NSLBP is diagnosed in cases where the source of pain is not known, while specific back pain is caused due to a specific cause like fractures or an infection. The most well-known type that is used to describe back discomfort is called NSLBP. PAs increase blood flow to the back which is crucial in the healing process of soft tissues of the back. PAs as part of routine tasks has been proven to be important in aiding the healing of NSCLBP and acute. CLBP restricts trunk mobility to reduce lumbosacral pain however, it weakens the core and increases the risk of lumbar instability, which can lead to LBP. Exercises to strengthen the abdominal muscles deep, as well as the superficial muscles and transversus abdominis muscles, and multifidus, are essential. Core stability methods are thought to reduce CLBP and a muscle strength training program [31].

In 2022, an investigation carried out on MFR and MET. stretching of the quadratus lumborum muscle in patients with NSLBP. They included 35 participants , and then split between two categories. The treatment was offered during two weeks. The researchers concluded that stretching MFR and MET used together are beneficial for treating patients suffering from NSLBP as they assist to in treating tendinitis of the muscles that stabilize the sacroiliac joint [3232. Cirak et al. investigated the effect of SNAG on the muscles of the lumbar region, in regards to stiffness. Subjects with NSLBP received Mulligan Lumbar SAG. They sought to assess the impact that Mulligan SNAG on muscles’ stiffness in people who suffer from NSLBP with ultrasound waves. the impact on disability and pain was observed. They concluded that participants of group SNAG class had had a better outcome as compared to the subjects in the control group [3333.

Mistry et al. carried out a study of the effects of proprioceptive neural activation as well as active release techniques to improve the flexibility the hamstring muscles in subjects who suffer from CLBP and found that the goal of ART, as with all methods for soft tissue will be to break down these “adhesions” which would stop the cycle of injury when the tissue is moved from a muscle shortening to a totally extended position while the hand holds tension longitudinally around the fibers of soft tissue. The ART technique is used to restore normal movement of soft tissues, release trapped nerves and restore maximal soft tissue function. A modified version of the PNF Hold Relax as well as ART both increase the flexibility of the hamstring, thereby reducing the amount of pain and disability that occurs as time passes [34]. A systematic review of Mackenzie along with Manual therapies as an option was carried out by Mamnaqani and co. They concluded that, after six months of follow-up there were a few improvements in both groups, however it was noted that a significant improvement was evident within that of the McKenzie treatment group. Mulligan Concept SNAG enhances the flexibility of the spine It also helps reduce the discomfort by reducing any fractures of the facet joint due to which there is an increase in the activity of the sympathetic nerve. Mulligan’s SNAG is used for the treatment of LBP also helps in reducing stiffness and spasm of muscles because it activates an autonomic nerve system. The threshold for pain has also been found to decrease and lead to an increase in nerve-related inflammation. A few studies have suggested that there are changes in the substantia alba and the substantia grisea [33].

Material handling is traditionally associated with LBP manually. Manual handling of materials rather than just one threat factor has become a common practice that can result in spine overload (which is ultimately the main risk factor for low back pain). The treatment of huge structures can lead to spinal overload, particularly when they are used in an unorthodox posture or when the trunk is bent and twisting. Considering that managers are required to perform this job, it’s not surprising that handling and lifting manual materials is often utilized to exchange. Moving and lifting large objects could lead to spinal overload [15and. LBP has been linked to major diminutions in health and the quality of life, which is known as an incapacitating disease (HRQoL). Thus, the assessment of programs or therapies to treat LBP and the decision to allocate resources is essential by using reliable and valid HRQoL-related measures. By using generic or disease-based questionnaires, HRQoL can generally be measured. The generic instruments can be classified as preference and preference. The most popular measures for generics benefit from their extensive variety of health-related aspects which allows comparisons of different illnesses, treatments, and health programs.