Effects of Mulligan sustained natural apophyseal glide mobilizations on pain, mobility, and lumbar-related disability in chronic non-specific low back pain: A systematic review and meta-analysis

BACKGROUND: Chronic nonspecific low back pain (CNSLBP) is a major cause of disability worldwide. Mulligan sustained natural apophyseal glides (SNAGs) are commonly used by physiotherapists; however, evidence regarding their effectiveness remains inconclusive because of inconsistent findings across randomized controlled trials (RCTs). This systematic review and meta-analysis evaluated the effects of Mulligan SNAGs on pain, lumbar mobility, and disability in adults with CNSLBP. METHODS: A comprehensive search of 7 databases (PubMed, Scopus, Web of Science, MEDLINE, Embase, PEDro, and CINAHL) was conducted up to June 2025. Eligible studies were RCTs on SNAGs in CNSLBP, comparators including sham, standard physiotherapy, or other manual therapies, and outcomes on pain, lumbar range of motion (ROM), or disability. Study quality was assessed using the PEDro scale and the Cochrane Risk-of-Bias tool. Meta-analyses used random-effects models, reporting standardized mean differences (SMDs) with 95% confidence intervals. RESULTS: Seventeen RCTs involving 716 participants, published between 2015 and 2024, met the inclusion criteria. Methodological quality ranged from fair to good (PEDro scores 4-9; mean = 6.1), with an overall low-to-moderate risk of bias, primarily related to allocation concealment and blinding. Qualitative synthesis demonstrated consistent within-group improvements in pain, mobility, and disability following SNAG interventions. Meta-analysis showed significant effects on pain intensity (SMD = -0.78; P < .001; I2 = 92%) and functional disability (SMD = -0.60; P < .001; I2 = 83%), with larger effects when disability was measured by the Roland-Morris Disability Questionnaire. SNAGs also improved lumbar extension ROM (SMD = 0.75; P < .001; I2 = 93%), although results for flexion ROM were not significant. Considerable heterogeneity was observed across analyses, likely reflecting differences in intervention protocols, comparator treatments, and follow-up durations. Sensitivity analyses supported the robustness of the findings. Certainty of evidence was moderate for pain and low for disability and mobility. CONCLUSION: Mulligan SNAGs were associated with improvements in pain, disability, and lumbar extension mobility in adults with CNSLBP. However, substantial heterogeneity, low-to-moderate certainty of evidence, and limited long-term follow-up warrant cautious interpretation. Further high-quality RCTs are needed to confirm these findings and determine their long-term effectiveness.