Population: This review focuses on patients diagnosed with MLBP.

Intervention: The intervention of interest is Maitland mobilisation.

Comparison: Comparisons are made with other manual therapy techniques.

Outcome: The primary outcomes are the immediate effects on movements (flexion/extension/range of motion).

A systematic search was conducted across several electronic databases-PubMed, Cochrane Library, and Google Scholar-to locate studies published between January 2017 and March 2024. The primary keywords used were “Maitland mobilisation,” “mechanical low back pain,” and “RCTs.” Boolean operators (AND, OR) were employed, and the search was strategically expanded to capture a comprehensive range of studies without compromising relevance.

The study selection process is depicted in [Table/Fig-1]. The initial database search identified 71 studies. Titles and abstracts were screened for alignment with our review’s objectives, and duplicates were promptly removed. This screening phase ensured that studies not related to the objectives were excluded early. In the subsequent eligibility stage, full-text assessments were conducted to rigourously evaluate the remaining studies against our predefined criteria, resulting in the exclusion of those with insufficient data. Ultimately, only studies that fully met the inclusion and exclusion criteria were incorporated into the final review. An additional literature search was performed by assessing the references of the articles included in the systematic review.

[Table/Fig-1]:

Flow chart presenting the selection process of included studies.

Inclusion criteria: Studies evaluating interventions for MLBP, studies that specifically investigated the use of Maitland mobilisation, Randomised Controlled Trials (RCTs), studies published between January 2017 and March 2024 were included in the review.

Exclusion criteria: Studies not related to MLBP, non randomised studies, studies with insufficient data were excluded from the study.

A total of nine studies met the inclusion criteria and were included for further analysis.

Data extraction: To ensure consistent and accurate data collection, the researcher meticulously extracted information from each of the nine included studies using a standardised data extraction form. This form encompassed sections for study characteristics (e.g., authors, publication year, study design), intervention details (specific Maitland mobilisation techniques used, dosage, and comparator intervention details, if applicable), outcome measures (specific methods employed to assess lumbar spine flexion and extension range of motion), and results (key findings regarding the effects of the interventions on participants’ range of motion). By systematically extracting this information using the standardised form, the researcher ensured a comprehensive and reliable data collection process for the review.

Quality assessment: To rigourously evaluate the methodological quality and potential bias of the included studies, two established tools were employed: the Cochrane Collaboration’s Risk of Bias Tool for randomised trials and the Physiotherapy Evidence Database (PEDro) scale. The Cochrane tool assesses seven critical domains that could lead to bias, including random sequence generation, allocation concealment, blinding of participants and personnel (where applicable), blinding of outcome assessment, handling of incomplete outcome data, selective reporting, and other potential sources of bias. Each domain was rated as having a high, low, or unclear risk of bias based on the provided study details. In addition to the Cochrane tool, the PEDro scale was used to further ensure the methodological rigour of the studies. The PEDro scale, specifically designed for evaluating physiotherapy trials, includes 11 criteria such as eligibility criteria, random allocation, concealed allocation, baseline comparability, blinding of subjects, therapists, and assessors, adequate follow-up, intention-to-treat analysis, statistical comparisons between groups, and the reporting of point estimates and variability. Each criterion is scored as either met (1) or not met (0), with a maximum score of 10 (since the eligibility criterion is not included in the total score). By using these two complementary tools, a comprehensive assessment of the studies’ methodological quality and risk of bias was achieved. This approach ensures a thorough and reliable evaluation, providing a robust foundation for interpreting the findings and drawing meaningful conclusions from the included research [11,12].

Data synthesis: A narrative synthesis approach was used to summarise the findings of the included studies. This approach involved a comprehensive description and analysis of the data extracted from each study. Data on study characteristics (e.g., authors, publication year, study design), intervention details (specific techniques, dosage), outcome measures (methods used to assess range of motion), and risk of bias were synthesised descriptively. Additionally, quantitative data such as effect sizes and confidence intervals (if reported in the studies) were presented to provide further context and strengthen the narrative synthesis.

The current review focused on the immediate effects of Maitland mobilisation on flexion and extension ROM in patients with MLBP. Nine studies were included, investigating the impact of various interventions on ROM and related outcomes in these patients. Briefly, the studies employed various methodologies, including RCTs and cohort studies. Sample sizes ranged from 12 to 70 participants.

Interventions included Maitland mobilisation alone or combined with other therapies (e.g., core stability exercises) and were compared to exercise programs, sham manipulations, or other manual therapy techniques. Outcome measures varied across studies but commonly assessed pain intensity, functional disability, lumbar ROM, and other parameters [Table/Fig-2,3] [13-21].

The risk of bias assessment was conducted using the PEDro chart, and is described in [Table/Fig-4]. This review investigated the immediate effects of Maitland mobilisation on improving flexion and extension ROM in patients with MLBP. The findings presented mixed results regarding its effectiveness as a standalone intervention. Several studies (e.g., Ejaz R et al., 2024; Ibrahim A et al., 2023) demonstrated significant improvements in pain, disability, and ROM following Maitland mobilisation compared to controls [16,17]. These findings support the potential benefits of Maitland mobilisation for managing MLBP. This aligns with the theoretical principles of manual therapy, which suggest that improved joint mobility can reduce pain and muscle guarding, ultimately leading to better functional movement. However, other studies did not observe a significant difference in ROM or pain reduction between Maitland mobilisation and other interventions [17,18]. This inconsistency highlights the need for further exploration into specific protocols and techniques within Maitland mobilisation that may be most effective for improving ROM in MLBP patients.

Interestingly, several studies compared Maitland mobilisation to other techniques. Khan S et al., reported superior results for the Sustained Natural Apophyseal Glides (SNAG) technique compared to Maitland mobilisation in terms of ROM and pain reduction [13]. Similarly, Javaherian M et al., observed comparable improvements in ROM with both SNAG and PA mobilisation, but SNAG outperformed the sham treatment [14]. These findings suggest that SNAG might be a more effective approach for managing pain and improving ROM in some cases. Further research is needed to explore the mechanisms underlying these observed differences and to identify the most suitable technique for different patient presentations [13,14].

Tavares FA et al., observed a significant pain reduction within the sham mobilisation group, highlighting the potential for a placebo effect associated with manual therapy techniques for MLBP management. Future studies should consider robust blinding protocols to minimise this influence [15]. While the core focus was on ROM improvements, some studies explored broader outcomes. Ejaz R et al., compared Maitland mobilisation to shockwave therapy, finding both interventions effective, but Maitland mobilisation was superior in improving ROM [16]. This suggests potential benefits beyond pain reduction for Maitland mobilisation. protocols [19-21]. It is important to note that some studies had limitations. The studies by De Mèlo LC et al., Ahmed F et al., and Zaidi F and Ahmed I did not specify the exact techniques used within Maitland mobilisation, making it difficult to draw definitive conclusions about specific protocols [19-21].

The evidence regarding Maitland mobilisation for improving ROM in MLBP was mixed. While some studies show promise, particularly when combined with other interventions, further research is necessary to explore optimal protocols and techniques, understand the role of placebo effects, and determine long-term benefits. Additionally, investigating the mechanisms underlying the potential effectiveness of SNAG compared to Maitland mobilisation warrants further examination.

To overcome these methodological obstacles and strengthen the body of evidence, future research should prioritise well-designed RCTs with larger sample sizes and standardised Maitland mobilisation protocols. Blinding protocols and extended follow-up periods are crucial to minimise bias and understand long-term effects. Incorporating a broader range of outcome measures, including patient-reported outcomes, alongside comparisons to conventional treatments, will provide a more comprehensive understanding of Maitland mobilisation’s effectiveness and cost-effectiveness for managing MLBP across diverse patient populations.

This review was limited by the heterogeneity of the included studies, particularly regarding the specific techniques and protocols used within Maitland mobilisation. Additionally, the focus on immediate effects limits the understanding of long-term benefits.

The findings summarised here highlight the difficulty in conclusively establishing the effectiveness of Maitland mobilisation in treating MLBP. Although Maitland mobilisation showed some promise in terms of reducing pain, increasing ROM, and improving functional outcomes, the overall picture was complex, with different interventions and patient populations producing varying results. Mixed outcomes were observed in studies comparing alternative interventions to Maitland mobilisation. While some research claims that Maitland mobilisation significantly reduces pain intensity, ROM, and functional disability compared to exercise regimens alone, others suggest that when combined with conventional therapy, alternative therapies such as McKenzie therapy may reduce pain even more and improve ROM. Furthermore, studies comparing Maitland mobilisation to other modalities, like Feng Spinal Mobilisation (FSM), indicate that FSM may be more effective than Maitland mobilisation in lowering pain scores and enhancing functional outcomes. This underscores the importance of investigating different manual therapy modalities when managing MLBP. The body of evidence also emphasises the necessity of considering each patient’s unique characteristics and preferences when choosing a course of treatment. While Maitland mobilisation may be beneficial for some MLBP patients, others may respond better to alternative approaches.