Thoracic Mobility Versus Hip Mobility Exercises to Core Stabilization in Lumbar Spondylitis
Phase: NA
Conditions: Individuals With Lumbar Spondylosis
Sponsor: Cairo University

Study Protocol 
 
Official Title:Thoracic mobility versus hip mobility exercises to 
core stabilization in lumbar spondylitis. 
 
ClinicalTrials.gov Identifier (NCT): Pending 
 
Document Type: Study Protocol 
 
Document Date: March 6, 2026 
 
 
Principal Investigator: Yahya abdu s kulaybi. 
 
Institution: Faculty of Physical Therapy, Cairo University, Egyp 

THORACIC MOBILITY VERSUS HIP MOBILITY 
EXERCISES TO CORE STABILIZATION IN LUMBAR 
SPONDYLITIS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BY 
YAHYA ABDOH SOLIMAN KULAYBI 
 
 
 
 
 
 
 
 
 
 
 
Submitted in Partial Fulfilment of the Requirements for the Doctoral Degree in 
Physical Therapy for Musculoskeletal Disorders and its Surgery 
Faculty of Physical Therapy 
Cairo University 
2025 

2 
 
 
SUPERVISORS 
 
 
 
DR. NABIL ABDO ABDELLAH MOHAMED 
Assistant professor in Department of Physical Therapy for 
Musculoskeletal Disorders and its Surgery, Faculty of Physical 
Therapy, Cairo University 
 
Dr. MOAAZ RAGAB RIYAD 
Lecturer in Department of Physical Therapy for Musculoskeletal 
Disorders and its Surgery, Faculty of Physical Therapy, Cairo 
University 
 
Dr. IHAB ISMAIL HASSAN SAID 
Lecturer in Department of Orthopedic Surgery, Faculty of Medicine, 
Cairo University 

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CHAPTER I 
INTRODUCTION 
 
Low back pain (LBP) is one of the most prevalent musculoskeletal 
conditions and a leading cause of disability across all age groups (Cieza et al., 
2021; Ferreira et al., 2023). LBP can be classified as acute (lasting less than 6 
weeks), subacute (6–12 weeks), or chronic (more than 12 weeks) (Foster et al., 
2021). Lumbar spondylosis is a degenerative spinal disorder that primarily affects 
the lower back. It involves age-related changes such as intervertebral disc 
degeneration, facet joint osteoarthritis, and osteophytes formation (Ravindra et 
al., 2020; Jensen et al., 2021; Skundric et al., 2021). The incidence and 
prevalence of lumbar spondylosis increases with age. Radiographic evidence of 
spondylosis is present in more than 95% of individuals over the age of 65 (Jensen 
et al., 2021). Clinical manifestations often include chronic low back pain, 
stiffness, reduced spinal mobility (Schmidt et al., 2020; Adams et al., 2021; 
Skundric et al., 2021). Lumbar spondylosis can significantly impair daily 
function and quality of life. It also contributes to increased healthcare costs, 
absenteeism from work, reduced productivity and greater demands on health care 
systems (Ravindra et al., 2020; Skundric et al., 2021; Chen et al., 2022). 
 
The clinical manifestations of lumbar spondylosis generally consist of 
chronic low back pain, stiffness, and limited range of motion of the spine, that 
severely impact a patient's ability to carry out daily function and their overall 
quality of life (Schmidt et al., 2020; Adams et al., 2021; Skundric et al., 2021). 
These clinical manifestations result in greater healthcare costs, absenteeism from 
work and diminished productivity, and increased pressure on the healthcare 
system (Ravindra et al., 2020; Skundric et al., 2021; Chen et al., 2022). 
 
Treatments for lumbar spondylosis may involve pharmacological therapy, 
physiotherapy, or surgical interventions depending on severity and patient 
response (Foster et al., 2021; Skundric et al., 2021; Lin et al., 2022;). 
Conventional physiotherapy for lumbar spondylosis typically includes modalities 
such as heat, electrical stimulation, stretching, and core strengthening (George et 
al., 2020). A growing body of evidence supports a more holistic approach that 
incorporates multi-regional mobility training to address the root causes of 
dysfunctional movement (Page et al., 2020; Skundric et al., 2021). 
Exercise therapy, particularly core stabilization training, is an important 
intervention for patients with low back pain because it focuses on activating the 
deep stabilizing muscles of the trunk (e.g., transversus abdominis and multifidus), 
which are valuable for segmental control of the spine (Saragiotto et al., 2020). 
By focusing on strengthening these muscles, exercise therapy increases spinal 
stability, reduces mechanical loading, and improves postural control (Hodges et 

4 
 
al., 2020; García-López et al., 2023). The evidence supporting this intervention 
is abundant; core stabilization training has demonstrated significant reductions in 
pain intensity, improvement in functional outcomes, and reduction in the risk of 
recurrence in people with lumbar spondylosis (Liu et al., 2019; Park & Kim, 
2020). For instance, the meta-analysis conducted by Liu et al. (2019) showed 
effective use of progressive core activation programs in pain and disability scores 
compared to usual care. Additionally, the research by García-López et al. (2023) 
demonstrated that trunk stabilization training caused significantly decreased pain 
and disability as well as positively altered trunk muscle activation, demonstrating 
its core value in restoring functional movement, while managing chronic 
symptoms. 
Recently, the importance of thoracic spine and hip mobility exercises have 
been highlighted in treatment of patients with chronic low back pain (Sueki et 
al., 2013; Wainner et al., 2021). Limitation of thoracic spine and hip mobility 
has been associated with altered load distribution and increased mechanical stress 
on the lumbar vertebrae (Liebenson et al., 2020; Rose et al., 2020; Schmidt et 
al., 2020). This suggests that interventions addressing only the lumbar region may 
be insufficient in restoring functional movement patterns and alleviating 
symptoms in the long term (McGill, 2016). 
The thoracic spine contributes significantly to global spinal mobility, 
especially in rotation and extension (Johnson et al., 2012; Bordoni & Zanier, 
2021). Improving thoracic spine mobility has shown promising effects on 
reducing low back pain, enhancing dynamic trunk control and optimizing 
breathing patterns (Cook et al., 2020; Kumar & Singh, 2021; Chen et al., 2022). 
The hip joint provides essential mobility and stability during walking, 
squatting, and lifting. In individuals with lumbar spondylosis, limited hip 
mobility; particularly in extension and internal rotation, is often observed. This 
restriction leads to compensatory lumbar hyperextension or rotation, contributing 
to increased mechanical strain on the lumbar spine (Lewis et al., 2017; 
Thompson et al., 2021). Mobility exercises that restore hip joint range, reduce 
muscle tightness and improve pelvic control can positively influence lumbar 
biomechanics and reduce pain perception (Wilson & Clarke, 2023; Martinez- 
Calderon et al., 2020). 
While previous research has indicated strong effectiveness of core 
stabilization, thoracic mobility, and hip mobility exercises focused on lumbar 
conditions, the specific associated benefits of adding these interventions 
compared one-to-one has not been examined; generally, we observe a void in two 
specific comparative studies of the two combined approaches (adding thoracic 
mobility exercises to core stabilization and adding hip mobility exercises to core 

5 
 
stability) with lumbar spondylosis treatment (Radwan et al., 2024; Skundric et 
al., 2024). Therefore, it is not known if treating stiffness in the thoracic region, or 
restrictions in the hip joint, combined with a core stability program, produces 
more favorable outcomes in terms of pain relief, functional improvements, and 
biomechanical changes with regard to lumbar spondylosis. According to author 
knowledge there is lack of researches that compare between addition of thoracic 
mobility and hip mobility exercises to core stabilization .So this study seeks to 
fill this gap by comparing which approach to adjunctive treatment is more 
effective for lumbar spondylosis specifically. 
Statement of the Problem 
Which modality is superior when combined with core stabilization for 
treating individuals with lumbar spondylosis in terms of outcomes: thoracic 
mobility exercises or hip mobility exercises with regard to severity of pain, 
disability function, range of motion at the lumbar spine (flexion, extension, lateral 
flexion, and rotation), spinal mobility, quality of life, and fear of movement? 
Purpose of the Study 
This study is conducted to determine the effect of addition of thoracic 
mobility versus hip mobility exercises to core stabilization on pain severity 
(NPRS-Ar), functional disability (MODI-Ar), lumbar range of motion (BROM), 
spinal mobility (modified schober test), quality of life (SF-36-Ar) and fear of 
movement (Tampa-Ar) in treatment of patients with lumbar spondylosis. 
Significance of the Study 
Lumbar spondylosis is a prevalent degenerative condition affecting 27.2% 
to 37% of the adult population, with incidence increasing to 80% in individuals 
over age 40 (Skundric et al., 2021). The condition represents a significant 
contributor to functional disability and healthcare utilization globally (Ravindra 
et al., 2020). 
The research explores the principle of regional interdependence by 
examining thoracic spine and hip mobility contributions to lumbar function (Kose 
et al., 2023; Radwan et al., 2024). Thoracic mobility restrictions may lead to 
compensatory lumbar hypermobility and increased mechanical stress on lumbar 
segments (Radwan et al., 2024; Skundric et al., 2021). Limited hip mobility, 
particularly in extension and internal rotation, alters lumbopelvic rhythm and 
increases lumbar spine stress during functional activities (Radwan et al., 2024). 
Recent studies about thoracic mobility have shown a specific relationship 
that exists between improving thoracic function and improving low back pain. 
According to Park and Lee (2024), patients who participated in thoracic mobility 
exercise showed greater reductions in pain, greater proprioception and static 
balance than the group treated with stabilization exercises for low back pain. 

6 
 
Salah Eldeen et al. (2024) reported that adding thoracic spine mobilization, to 
usual physical therapy, had significantly lowered pain levels and better lumbar 
function in patients with chronic lumbosacral radiculopathy. Additionally, 
Kostadinović et al. (2020) reported grater reductions in pain and disability with 
with closed-chain thoracic mobilization. 
Recent studies about hip mobility have shown that addressing limitations 
in the hips is just as important. Kim et al. (2021) reported that improving hip 
hyperextension reduced the amount of compensatory pelvic tilt in patients with 
chronic low back pain. Ferraresi et al. (2022) reported that improving hip flexor 
flexibility and strength of the gluteal muscles could reduce mechanical overload 
on low back pain. Ceballos-Laita et al. (2023) reported significant short-term 
improvements in pain and function with addition of hip-based treatment 
modalities. 
By targeting restrictions beyond the lumbar spine, this integrated approach 
may enhance outcomes in term of pain severity, functional disability, lumbar 
range of motion, spinal mobility, quality of life, and fear of movement in patients 
with lumbar spondylosis. The current study may provide a more conclusive 
insight in treatment of patients with lumbar spondylosis. 
Delimitation 
This study will be delimited to: 
Patients: 60 patients diagnosed with lumbar spondylosis with age range 
from 40 to 60 years (Hodges et al., 2020). 
Assessment outcomes: Pain levels in participants were assessed using the 
Numerical Pain Rating Scale (NPRS-Ar). Functional disability was assessed 
using the Modified Oswestry Disability Index (MODI-Ar), Lumbar Range of 
Motion was evaluated using a Back Range of Motion (BROM) device, spinal 
mobility was assessed with the Modified Schober’s test, Health-Related Quality 
of Life was assessed with the Short Form 36 Health Survey (SF-36-Ar) and fear 
of movement was assessed using the Tampa scale for Kinesiophobia (Tampa-Ar). 
Treatment procedures: 
 Group A (Control Group): A program of core stabilization exercises 
including flexibility and strength of core muscle (multifidus and pelvic 
floor muscles).
 Group B (First Experimental Group): A program of core stabilization 
exercises combined with a program of thoracic mobility exercises 
including flexibility exercises in all directions of thoracic spine flexion, 
extension, lateral flexion, and rotation.

7 
 
 Group C (Second Experimental Group): A program of core stabilization 
exercises combined with a program of hip mobility exercises including 
flexibility exercises for extensor and internal rotators muscle groups.
 
Basic Assumptions 
 Participants will follow our instructions during assessment and treatment 
procedures
 They will refrain from additional physiotherapy during the study period.
Hypotheses 
1. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on pain severity in participants with lumbar 
spondylosis. 
2. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on functional disability in participants with lumbar 
spondylosis. 
3. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on lumbar flexion range of motion in participants 
with lumbar spondylosis. 
4. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on lumbar extension range of motion in 
participants with lumbar spondylosis. 
5. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on lumbar right lateral flexion range of motion 
in participants with lumbar spondylosis. 
6. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on lumbar left lateral flexion range of motion in 
participants with lumbar spondylosis. 
7. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on lumbar right rotation range of motion in 
participants with lumbar spondylosis. 
8. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on lumbar left rotation range of motion in 
participants with lumbar spondylosis. 

8 
 
9. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on spinal mobility in participants with lumbar 
spondylosis. 
10. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on quality of life in participants with lumbar 
spondylosis. 
11. There will be no significant difference between core stabilization, core 
stabilization with thoracic mobility exercises, and core stabilization with 
hip mobility exercises on fear of movement in participants with lumbar 
spondylosis. 

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CHAPTER II 
LITERATEARE REVIEW 
 
Anatomical and Functional Foundations of the Lumbar Spine 
The lumbar spine is a complex mechanical structure that aims to stabilize, 
allow movement, and transmit loads from the upper body to the pelvis. The 
lumbar spine typically comprises five vertebrae (L1 - L5), the largest of the 
mobile vertebrae, reflecting its primary function is weight-bearing (Adams et al., 
2021). Each lumbar vertebra has a vertebral body in the anterior portion that is 
designed to resist compressive loads, and a posterior vertebral arch that forms the 
vertebral foramen which creates a canal for the cauda equina, nerve roots traveling 
down to the sacrum. Important functionally are the intervertebral joints and the 
facet (zygapophyseal) joints. Intervertebral discs consist of a central gelatinous 
structure called a nucleus pulposus that is surrounded by a tough, laminated 
structure called an annulus fibrosus, which provides shock absorption, as well as 
motion between vertebral bodies. Degeneration of the intervertebral discs is a 
hallmark of lumbar spondylosis, with the degeneration often including 
desiccation and decreased disc height (Battié et al., 2014; Ravindra et al., 2020). 
The paired facet joints are synovial joints created by the inferior and superior 
articular processes of adjacent vertebrae and play a substantial part providing 
direction, as well as the limits to the range of motion of the spine, particularly if 
rotating or extending the spine. Osteoarthritis of these joints is another hallmark 
of the spondylotic process (Ravindra et al., 2020). 
 
The “core” musculature regulates the stability and dynamic control of this 
structure. Often speaking of this system in layers, we can speak of the deep local 
stabilizers (e.g., lumbar multifidus, transversus abdominis), which create 
segmental stability and proprioceptive information, and the global movers (e.g., 
rectus abdominis, erector spinae), which create gross trunk movement (Hodges 
et al., 2020). Proper coordination of these muscles is important for maintaining 
neutral spine position, distributing mechanical loads, and preventing excessive 
stress on passive structures. There is clear evidence that dysfunction of the deep 
stabilizers is a common risk factor for the onset and persistence of chronic 
nonspecific LB problems (Saragiotto et al., 2020). As a result, a core 
stabilization exercise aims to restore this muscle coordination in order to improve 
spinal stability, unload the spine, and improve postural control (García-López et 
al., 2023). 
 
Lumbar Spondylosis: Pain, Function, and Quality of Life 
Lumbar spondylosis refers to a degenerative disease process in the lower 
spine, which may involve intervertebral disc desiccation, osteophyte formation, 

10 
 
and facet joint arthropathy (Ravindra et al., 2020). The pathophysiological 
process of lumbar spondylosis is the gradual mechanical suboptimal processes 
which may develop overtime in lumbar discs and joints (Battié et al., 2014; 
Adams et al., 2021). Clinically, the individual may experience chronic low back 
pain, stiffness, and loss of motion in the spine (Schmidt et al., 2020; Adams et 
al., 2021). These clinical consequences result in increased cost to healthcare, time 
lost from work, reduced productivity, and increased demands on the healthcare 
system (Ravindra et al., 2020; Chen et al., 2022). 
 
Evaluation of the patient with lumbar spondylosis should be multidimensional to 
accurately assess the problems associated with the disease process. A provider 
would assess pain severity, functional disability, range of motion of the lumbar 
spine, and measures of health-related quality of life (Schmidt et al., 2020). Pain 
levels are an important, legitimate outcome that is usually assessed by a 
unidimensional scale such as the Numerical Pain Rating Scale (NPRS) which is 
a well-studied, popular 11-point scale with good test-retest reliability (r = 0.95 to 
0.96) and clinical applicability (Ferraz et al., 1990; Alghadir et al., 2018). 
 
Functional disability, specifically related to low back pain, can be accurately 
assessed using disease-specific questionnaires. The Modified Oswestry Disability 
Index (MODI) is one of the questionnaires to assess functional disabilities related 
to self-care, lifting, walking, and sitting. The MODI is comprised of 10 items. 
The MODI has excellent internal consistency (α = 0.94), and test-retest reliability 
(ICC = 0.91), making it a valid measure in this patient population (Fairbank & 
Pynsent, 2000; Alnahdi, 2025). 
Lastly, given that lumbar spondylosis has a significant effect on daily function 
and overall quality of life (Skundric et al., 2021), it is also important to assess 
health related quality of life (HRQoL). The Short Form 36 Health Survey (SF- 
36) is a general HRQoL measure that covers 8 domains including physical 
functioning, pain, and mental health. Together, the SF-36 offers a more complete 
picture of the patient’s health status that is not defined purely on physical 
impairment (Ware & Sherbourne, 1992). 
 
Instrumentation for Objective and Subjective Assessment 
This research will utilize a range of validated measures to represent the 
multidimensional nature of lumbar spondylosis. The patient-reported nature of 
the pain, disability, quality of life, and fear of movement experience will be 
measured employing the Arabic versions of the Numeric Pain Rating Scale 
(NPRS-Ar), the Modified Oswestry Disability Index (MODI-Ar), the Medical 
Outcomes Study 36-Item Short Form Survey (SF-36-Ar), and the Tampa Scale 

11 
 
for Kinesiophobia (Tampa-Ar), respectively, (El-Kalla, 2016; Alghadir et al., 
2018; Al-Shudifat et al., 2020; Alnahdi, 2025). 
 
The objective physical measurements will consist of lumbar Range of Motion 
(ROM), and spinal mobility. The Back Range of Motion (BROM) device is a dual 
inclinometer system dependent upon gravity to measure spinal ROM in the 
sagittal and frontal planes while preventing pelvic compensation. The BROM 
device has established inter-rater reliability ratings of ICC = 0.92-0.96, as well as 
concurrent validity against radiographic measurements of r = 0.87-0.93 (Kumar 
& Singh, 2021; Chen et al., 2022). The Modified Schober Test will be used to 
assess spinal mobility and is a clinical measure of lumbar flexion that has been 
shown to have inter-rater reliability ICC = 0.89-0.94, and intra-rater reliability 
ICC = 0.92-0.96 (Tousignant et al., 2005). Implementing these exact specific 
validated measures supports the scientific rigor and clinically meaningful 
outcomes of this study. 
 
Conventional physiotherapy and low back pain 
Conventional physiotherapy for LBP typically involves modalities such as heat, 
ultrasound, TENS, stretching, and general strengthening exercises. These 
methods aim to reduce pain, improve flexibility, and restore basic function. 
However, recent studies suggest limited long-term effectiveness when used in 
isolation. A recent systematic review reported that while conventional 
physiotherapy is beneficial in the acute phase, it may not address underlying 
motor control deficits or movement dysfunctions (Hayden et al., 2021). 
Recent evidence also emphasizes the need to integrate functional movement 
training and psychosocial interventions into traditional physiotherapy plans to 
enhance outcomes in chronic LBP patients (Kamper et al., 2015). 
Core stabilization and low back pain 
Core stabilization exercises play a pivotal part in the management of low back 
pain, as these exercise prescriptions focus on the deep trunk muscles, specifically 
transversus abdominis and multifidus, which are vital for achieving the spinal 
segmental control. Evidence clearly supports that dysfunction in these deep 
stabilizers is one important factor most associated with the onset and persistence 
of chronic LBP (Saragiotto et al., 2020). Therefore, the goal of core stabilization 
exercise is to restore that muscle coordination to improve spinal stability, 
minimize mechanical stress, and improve postural control to address symptoms, 
and of course prevent recurrence. 
This targeted approach has strong support from a wealth of evidence. Systematic 
reviews and meta-analysis demonstrate that core stability and motor control 

12 
 
training achieve better outcomes in reducing pain and improving function 
compared to general exercise or usual care (Shamsi et al., 2019; Wang et al., 
2020; Yamato et al., 2021). High-quality randomized controlled trials back this 
up. For example, García-López et al. (2023) found a statistically significantly 
greater reduction in pain and disability, and positive changes in trunk muscle 
activation patterns associated with primary outcomes of core stabilization 
compared to standard physiotherapy. A meta-analysis by Liu et al. (2019) across 
15 RCTs found progressive core stabilization programs provided clinically 
important decreases in pain intensity and symptom severity scores. The benefits 
can be observed on a structural basis, with Park and Kim's (2020) manuscript 
demonstrating real-time ultrasound guidance resulted in improved deep muscle 
thickness, which was positively associated with functional outcomes. 
The benefits of core stabilization are not limited to musculoskeletal changes, but 
it also impacts the central nervous system. A recent study by Ramirez-Velez et 
al. (2021) using functional MRI demonstrated that a 12-week core stabilization 
program led to neuroplasticity, as seen by increased cortical thickness in 
associated sensorimotor areas of the brain and connectivity in the brain. These 
neurological changes help explain the sustained patient reported and clinically 
significant improvements while also suggesting that core training may not just 
create more muscular strength but also affect how the brain processes pain and 
motor control. Thus, the literature supports that core stabilization is a 
multidimensional approach to address peripheral and central contributors to 
chronic low back pain. 
 
Thoracic mobility exercises and Lumbar Spondylosis: Underlying 
Mechanisms and Evidence 
 
Lumbar spondylosis is a degenerative condition of the spine often attributed to 
age-related changes in the lower back, including intervertebral disc desiccation, 
facet joint osteoarthritis, and osteophyte formation (Ravindra et al., 2020). The 
consequences of these changes can frequently include chronic low back pain, 
stiffness, reduced spinal mobility, and secondary to that, functional disability, 
ultimately leading to a diminished quality of life for the patient (Schmidt et al., 
2020; Skundric et al., 2021). The concept of regional interdependence describes 
the idea that dysfunction in one area of the kinetic chain may contribute to pain 
and disability elsewhere. In this regard, the thoracic spine has been noted to be a 
noteworthy contributor to lumbar pathology with respect to limited mobility. A 
hypomobile thoracic segment may place the lumbar spine at a physiological 
disadvantage of needing to compensate to achieve functional tasks through an 
exceeded range of motion and in turn, increased mechanical stress and 
compensatory hypermobility (Liebenson et al., 2020; Radwan et al., 2024). It is 
suggested that improving mobility of the thoracic spine would restore 

13 
 
normalized spinal biomechanical function, reducing compensation and strain in 
structures of the lumbar spine while alleviating symptoms of lumbar spondylosis. 
 
The pathophysiological mechanism underlying this context involves altered 
loading distribution within the spinal system. The thoracic spine is anatomically 
and biomechanically designed to contribute significantly to global spinal rotation 
and extension (Johnson et al., 2012; Bordoni & Zanier, 2021). When thoracic 
mobility is limited or restricted, there are inordinate kinematic demands during 
functional activities that places additional stress on lumbar segments of the spine 
(Rose et al., 2020). This motion demands the lumbar spine to enter normal ranges 
of motion that exceed the physiological design of the lumbar spine, especially 
with regards to rotation and extension. This can also lead to additional mechanical 
stress that contributes to intervertebral disc, facet joint and/or ligamentous injury. 
In an already compromised spine due to spondylosis, this forced adaptation can 
increase pain, accelerate structural degeneration, and result in a cycle of 
dysfunction and compensation with hypermobility (McGill, 2016). Thus, 
restoring mobility at thoracic segments of the spine promotes a more normal 
loading distribution on the lumbar spine which in turn may alleviate pain, and 
restore function (Cook et al., 2020; Kumar & Singh, 2021). 
 
The number of studies about thoracic mobility exercises as a treatment approach 
and for improving treatment outcomes in individuals with low back pain and 
degenerative conditions, to include spondylosis, is increasing. For example, 
Sivakumar & Hossain (2025) described a study of thoracic mobility exercise for 
upper back pain in young adults. Following a two-week protocol in which 
thoracic mobility exercises for two weeks were used in combination with 
breathing exercises, researchers found a reduction in pain intensity and an 
improvement in range of motion in thoracolumbar extension and extensor muscle 
strength relative to manual release therapy. These studies suggest meaningful 
effects of thoracic mobility exercises relative to posterior chain interventions. In 
a study involving middle-aged women with chronic pain (Hwang et al., 2023) 
found that, following four weeks of thoracic mobility exercises, there was an 
overall significant improvement in thoracic rotation range of motion, pain scores 
(NPRS), and disability (ODI) benefits for both pain and function. 
 
Further supporting the comparative effectiveness of thoracic-centered exercise is 
research by Park & Lee (2024) showing that patients with non-specific chronic 
low-back pain had statistically greater improvements in pain, proprioception, and 
static balance after 6 weeks of thoracic mobility exercise (TME) compared to the 
lumbar stabilization group. This suggests that somatosensory motor benefits may 
be enhanced through TME. Interesting results were found by integrating thoracic 
mobilization with core stabilization. In a study by Kostadinović et al. (2020) with 
patients with chronic LBP and radiculopathy, those who underwent lumbar 

14 
 
stabilization with closed-chain thoracic mobilization (e.g., cat-camel exercises) 
experienced greater reductions in pain and impairment compared to patients who 
underwent stabilization and open-chain thoracic exercises. 
The adjunctive value of manual thoracic mobilization has also been well 
documented. Salah Eldeen et al. (2024) have shown some of the greatest pain 
reduction and functional improvement in chronic lumbosacral radiculopathy 
patients when adding thoracic spine mobilization to conventional physiotherapy. 
In a related study, Rahman et al. (2023) observed that individuals who received 
the multimodal treatment that included thoracic mobilization achieved greater 
reductions in pain and less vertebral slippage than the group receiving 
conventional physiotherapy for treatment of lumbar spondylolisthesis. There 
were also benefits for compensatory mechanisms. Yasuda et al. (2023) used 
thoracic self-mobilization in lumbar hypermobility and had significant reductions 
in pain, improved spinal mobility, and increased lumbar rotation angle suggesting 
reduced compensatory strain in the lumbar spine region. 
 
Sung (2014) also considered the role of psychological mechanisms important in 
the management of chronic pain. This study demonstrated that thoracic 
mobilization and manipulation along with sling exercises resulted in 
improvements in functional disability (ODI), spinal extension ROM, and FABQ 
outcomes, suggesting that thoracic interventions may have an influence on fear 
avoidant behaviors in managing chronic low back pain. 
 
Together this evidence provides strong support for the use of thoracic mobility 
exercises and mobilizations, whether applied as a stand-alone treatment or in 
conjunction with core stabilization, to reduce pain, improve functional capacity 
and spinal mobility, improve sensorimotor control and at a minimum have a 
positive influence on psychological outcomes in patients with low back pain, 
which provides a solid basis to use these interventions in the management of 
lumbar spondylosis. 
 
Hip Mobility Exercises and Low Back Pain: Mechanisms and Efficacy 
The reason for implementing hip mobility exercises in the treatment of low back 
pain is based on the idea of regional interdependence, or how dysfunction in the 
hip joint impacts lumbopelvic biomechanics. Because mobility is limited in the 
hip joint, specifically with extension and internal rotation, the normal kinematic 
chain is disrupted during functional movements like walking, squatting, and 
bending (Vad et al., 2004; Scholtes et al., 2009). The restrictions inhibit normal 
ranges of motion in the hip and require the lumbar spine to maximize its motion 
and pelvic tilt, causing mechanical overload, increased stress to passive spinal 
structures, pain, and dysfunction (Kim et al., 2021; Ferraresi et al., 2022). 

15 
 
There is an increasing amount of evidence that supports targeting these hip 
restrictions. Clinical trials have shown that rehabilitation programs that 
emphasize hip mobility and motor control yield better outcomes in pain and 
function than lumbar-focused rehab alone (Selkowitz et al., 2013). This is 
corroborated by trials demonstrating that manual therapy directed toward the hip 
produced greater reductions in pain and disability than lumbar-focused treatment 
in certain cases, which further supports the clinical reasoning of a hip-based 
intervention (Geisser et al., 2005). There are also documented advantages of 
pairing hip training with core stabilization. Interventions that included hip 
stretching and strengthening have reportedly improved pain, balance, lumbar 
stability, and quality of life (Kim & Yim, 2020). 
 
Systematic reviews and meta-analyses summarize this literature declaring that hip 
mobility and gluteal strengthening interventions remove mechanical overload on 
the lumbar spine (Ferraresi et al., 2022). Limitations of the empirical literature 
remain; a recent meta-analysis identified that while hip-targeted interventions 
offer modest short-term improvements, long-term efficacy was ambiguous and 
overall evidence certainty was rated as low due to methodological heterogeneity 
(Ceballos-Laita et al., 2023). Overall, these findings support hip mobility work 
as a useful component of a multimodal treatment strategy for low back pain as it 
is recognized as a key peripheral mechanism in producing lumbar dysfunction. 
 
Combined thoracic and hip mobility exercises and low back pain 
 
Choi and Kim. (2023) examined the effects of combining thoracic and 
hip joint mobility exercises with lumbar stability training on pain and balance in 
20 adult women with chronic low back pain. Participants were divided into two 
groups: the experimental group received thoracic and hip mobility plus lumbar 
stability exercises, while the control group received lumbar stability and general 
exercises. The intervention lasted six weeks, with sessions held three times per 
week. Pain was assessed using the Visual Analog Scale (VAS), and balance was 
measured with Basic Therapy 4. Both groups experienced significant pain 
reduction; however, only the experimental group showed improvements in both 
static and dynamic balance, though intergroup differences were not statistically 
significant. Study limitations include a small, gender-specific sample and short 
intervention duration. 

16 
 
CHAPTER III 
MATERIALS AND METHODES 
 
This study will be conducted at the outpatient physical therapy clinic of the 
Faculty of Physical Therapy, Cairo University to investigate the effect of adding 
thoracic mobility versus hip mobility exercises to core stabilization on pain 
severity (NPRS-Ar), functional disability (MODI-Ar), lumbar range of motion 
(BROM), spinal mobility (modified schober test), quality of life (SF-36-Ar) and 
fear of movement (Tampa-Ar) in treatment of patients with lumbar spondylosis. 
 
Design of the study: 
Single blinded randomized controlled trial (examiner). 
Participants: 
This study will be conducted on 60 patients with lumbar spondylosis. 
Patients will be randomly assigned into 3 groups (https://www.randomizer.org). 
The control group (n=20) will receive core stabilization. The 1st experimental 
group (n=20) will receive core stabilization in addition to thoracic mobility 
exercises. The 2nd experimental group (n=20) will receive core stabilization in 
addition to hip mobility exercises. 
 
Inclusion criteria: 
1. Patients will be referred from an orthopedic surgeon with confirmed diagnosis 
of lumbar spondylosis with imaging findings (MRI, CT or X-ray reports 
within the last 6 months) (Battié et al., 2014). 
2. 2.Duration of patient’s symptoms will be more than 3 months (Oliveira et al., 
2022). 
3. 3.Patients' age will range from 40-60 years (Kalichman & Hunter, 2008). 
4. 4.Localized back pain and pain radiating to lower extremities with no distal 
involvement below knee with an NPRS more than 3 (Thompson et al., 2021). 
Exclusion Criteria: 
1. 1.Spinal or hip surgery history (Williams et al., 2022). 
2. 2.Red Flags: Cauda equina syndrome, fracture, infection, malignancy 
(Finucane et al., 2020). 
3. 3.Neurological Disorders: Parkinsonism, multiple sclerosis, or other 
neurological deficits (Odzimek et al., 2023). 
4. 4.Inflammatory Conditions: Rheumatoid arthritis, ankylosing spondylitis, or 
infectious spinal disorders (Lee et al., 2018). 
5. 5.Cognitive Impairment: Unable to understand or follow instructions 
(Martinez et al., 2024). 
6. 6.Pregnancy. 

17 
 
Sample Size Calculation: 
A priori power analysis for ANOVA, repeated measures, within-between 
interactions was used with an effect size of 0.28, alpha level (α) = 0.05, and power 
(1-β) = 0.95. The estimated sample size required was 54 participants, which was 
increased to account for potential dropouts as shown in (Figure 1). Thus, the total 
sample will include 60 participants, randomly allocated into 3 equal groups (n= 
20 per group). 
Sample size was calculated using G*Power software version 3.1.9.7, 
referencing effect size data of pain severity from a recent study studying the 
effects of thoracic and hip joint mobility exercise with lumbar stabilization 
exercise on pain and balance (Choi and Kim, 2023). 
 
 
Figure (1): Sample size calculation. 
Ethical Consideration: 
 The study's protocol will be reviewed and approved by the research ethical 
committee, faculty of physical therapy, Cairo University. 
 All patients will sign an informed consent form after receiving information 
on the purpose of the study, procedures, possible benefits and risks, privacy 
and use of data (Appendix I). 

18 
 
Instrumentations: 
1. Arabic version of numerical pain rating scale (NPRS-Ar): 
The Numerical Pain Rating Scale is an 11-point (0-10) pain intensity 
measuring scale, it is a highly sensitive pain measuring scale and is widely 
preferred over Visual Analog Scale (VAS) due to its simplicity and clinical 
applicability (Alghadir et al., 2018). It ranges from zero to ten where the score 
zero represents no pain while the score 10 represents the worst possible pain 
(Kahl and Cleland, 2005; Ishtiaq et al., 2023). NPRS has high test–retest 
reliability (r = 0.95 to 0.96) (Ferraz et al, 1990). Additionally, the NPRS 
demonstrates strong correlation with other established pain measurement scales, 
making it a reliable tool for clinical assessments (Alghadir et al., 2018). It has 
been translated and validated into Arabic language by Alghadir et al., (2016) 
(Appendix II). 
 
Figure (2): Arabic NPRS 
2. Modified Oswestry Disability Index Arabic Version (MODI-Ar): 
The Modified Oswestry Disability Index is a 10-item disease-specific 
questionnaire measuring functional disability caused by low back pain in the 
following categories: pain intensity, personal care, lifting, walking, sitting, 
standing, sleeping, social life, traveling, and employment/homemaking 
(Fairbank & Pynsent, 2000). 
The modified version was used as it replaced the "sex life" category with 
"employment/homemaking" that is more culturally appropriate and clinically 
relevant to multinational populations and particularly in Arabic-speaking 
populations where the issue of sexual relationships may be culturally sensitive 
(Ramzy, 2008). 
MODI-Ar has excellent internal consistency (Cronbach's α = 0.94) and 
test-retest reliability (ICC = 0.91). Construct validity demonstrates good 
correlation with SF-36 physical functioning (r = -0.82) and moderate correlation 
with pain intensity (r = 0.67) (Alnahdi, 2025). 
It was translated and validated into Arabic language by Alnahdi, (2025) 
(Appendix III). 
3. Back Range of Motion Device (BROM): 
The BROM device is a gravity-dependent dual inclinometer system that is 
used specifically to measure spinal range of motion in the sagittal and frontal 
planes with pelvic compensation movements excluded as shown in (figure 3) 
(Chen et al., 2022). BROM has high inter-rater reliability (ICC = 0.92-0.96) and 
intra-rater reliability (ICC = 0.94-0.98) for the measurement of lumbar flexion 
and extension. Concurrent validity with radiographic measurements is highly 
correlated (r = 0.87-0.93) (Kumar & Singh, 2021). It has the following 

19 
 
advantages; High accuracy, being portable and simple to use in the clinical 
setting. Model used in this study: BROM II Deluxe (Performance Attainment 
Associates, Roseville, MN, USA). 
 
Figure (3): Back Range of Motion Device (BROM). (Seo et al., 2022) 
4. Spinal Mobility Test (Modified Schober Test): 
The Modified Schober Test is a clinical measurement of lumbar spine 
flexion where 15cm above and 5cm below the lumbosacral junction (L5-S1) is 
marked and the difference in distance is measured on forward flexion (Kumar et 
al., 2019). Inter-rater reliability (ICC = 0.89-0.94) and intra-rater reliability (ICC 
= 0.92-0.96). Criterion validity with radiographic lumbar flexion measurements 
with strong correlation (r = 0.81-0.86) (Tousignant et al., 2005). Normal Values: 
5-7cm increase in distance is normal during full flexion in healthy adults 
(Hershkovich et al., 2022). 
5. Short Form 36 Health Survey Arabic version (SF-36-Ar): 
The SF-36 is a general health-related quality of life instrument measuring 
8 domains: physical functioning, role limitations caused by physical problems, 
pain, general health perceptions, vitality, social functioning, role limitations 
caused by emotional problems, and mental health (Ware & Sherbourne, 1992). 
Each domain is scored 0-100, and higher scores indicate better health status. 
Physical Component Summary (PCS) and Mental Component Summary (MCS) 
provide overall physical and mental health scores (Johnson et al., 2012). 
 
The Arabic version was validated by El-Kalla, (2016) to fit Arab 
populations, including simplifying language and providing culturally relevant 
examples (Appendix IV). SF-36 Arabic version demonstrated high internal 
consistency across all domains (Cronbach's α = 0.83-0.94) and test-retest 
reliability (ICC = 0.78-0.92). Construct validity confirmed through confirmatory 
factor analysis for the 8-factor structure (El-Kalla, 2016). 
 
6. Tampa Scale for Kinesiophobia Arabic Version (Tampa-Ar): 
The Tampa Scale for Kinesiophobia is a 17-item questionnaire that 
measures  fear  of  movement  and  re-injury  in  patients  with  chronic 

20 
 
musculoskeletal pain, on a 4-point Likert scale (1=strongly disagree to 4=strongly 
agree) (Weermeijer & Meulders, 2018). It varies from 17-68, where higher 
scores indicate a greater fear of movement. Cut-off point of ≥37 indicates high 
kinesiophobia in the Arabic-speaking population (Al-Shudifat et al., 2020). 
Adaptation into Arabic was done by Al-Shudifat et al., (2020) following 
guidelines with forward-backward translation, discussion with an expert panel, 
and pilot testing on chronic low back pain patients (Appendix V). Tampa-Ar 
shows good internal consistency (Cronbach's α = 0.86) and test-retest reliability 
(ICC = 0.84-0.89) (Al-Shudifat et al., 2020). 
 
Assessment Procedures 
All assessments will be conducted at baseline (pre-treatment) and after 6 weeks 
of intervention (post-treatment) by blinded assessors to ensure objectivity and 
minimize bias. Assessment procedures will include: 
1. Pain severity: 
Using the Arabic NPRS (Appendix II), Patients will select a value between (0- 
10) based on intensity of pain. Where (0) means no pain and (10) means 
maximum pain experienced (Kahl and Cleland, 2005; Ishtiaq et al., 2023). 
2. Disability: 
Using the Arabic MODI (Appendix III), Patients will be instructed to choose the 
best answer of the possible answers which describes the level of function and 
disability during daily activities in each of items of the questionnaire (Alnahdi, 
2025). 
 
3. Lumbar Range of motion: 
The Back Range of Motion (BROM) device will be utilized to measure the 
lumbar range of motion (ROM), as a valid and reliable measure of spinal motion 
(Kumar & Singh, 2021; Chen et al., 2022), according to established procedures 
(Madson et al., 1999). After palpating and marking the spinous processes of T- 
12 and S1 with adhesive dots, a warm-up trial for each plane of motion will be 
completed by patients. The BROM device will be used to measure active ROM 
in the order of flexion/extension, right/left lateral flexion, and right/left rotation. 
Once the data for each movement was taken, the BROM device was removed, 
and the skin markers were reapplied after a 10-15 second rest period. Each motion 
will have three trials, and data from the three trials will be averaged and used for 
analysis in order to maximize reliability. 
 
a- For flexion/extension measurements: 
Each patient will stand upright and assume a comfortable erect posture with 
body weight evenly distributed and feet shoulder-width apart. The BROM unit 
will be mounted by the examiner. The patient will be asked to grasp the ends of 

21 
 
each Velcro strap and cross them near the symphysis pubis, where they will be 
become firmly attached to each other. The removable L-shaped slide arm for the 
flexion and extension unit will be placed in the slot of the frame, and the short 
arm tip will be placed on the adhesive dot marking the T-12 spinous process. 
The therapist will record the starting position on the upper scale of the 
frame mounted to the sacrum. The examiner will hold the tip of the short side of 
the slide arm unit in constant contact with the patient's T-12 spinous process and 
will instruct to: "Bend forward as far as you can, trying to reach your fingertips 
to the floor. Do not bend farther than is comfortable, and do not cause any back 
pain". The examiner will stand on the opposite side of patient. The initial flexion 
reading will be subtracted from the full flexion reading to obtain full trunk flexion. 
Then the examiner will tell the patient to return to the starting position, as shown 
in (figure 4) (Madson et al., 1999). 
 
After that, the examiner will instruct the patient to, "Bend backward as far 
as you can, and keeping your hands alongside the back of your thighs. Do not 
bend farther than is comfortable, and do not cause back pain". The examiner will 
keep constant contact of the L-shaped arm against the red dot marking the T-12 
spinous process. The difference between the baseline measurement and the 
position of full extension will be recorded as trunk extension. Then the examiner 
will ask the patient to return to the starting position, as shown in (figure 4) 
(Madson et al., 1999). 
 
 
 
 
 
 
 
Figure (4): Flexion/extension measurements. (Madson et al., 1999) 
b- For lateral flexion measurements: 
Patients will stand parallel to a wall to avoid the substitution pattern of 
forward trunk flexion. The examiner will place the BROM unit parallel to and 
along a line over the red dot marking the T-12 spinous process. The lower ribs of 
the patient will be grasped by the examiner's fingers to keep the BROM unit in 
place. The needle of the inclinometer pointed to zero, marking the starting 
position for lateral flexion. When the patient flexes laterally, the BROM unit 
becomes a part of the patient’s truncal movement. Instructions will be given to 
the patient: "Slide your right hand down the side of your right thigh and try to 

22 
 
reach for your knee. Be sure to keep your weight on your left leg and foot to avoid 
hiking your left hip and lifting your left heel off the floor. Do not bend farther 
than is comfortable, and do not cause back pain". The examiner will stand behind 
the patient during measurement. The same commands will be given for left lateral 
flexion measurements except that the patient will place body weight on the right 
leg and foot, as shown in (figure 5) (Madson et al., 1999). 
 
 
 
 
 
 
 
Figure (5): Lateral flexion measurements. (Madson et al., 1999) 
c- For rotation measurements: 
During rotation measurements, the magnetic yoke will be placed around 
the patient’s pelvis at the level of the iliac crests. A buckle held the magnetic yoke 
in place. The patient will sit on a stool facing west so that the end of the magnet 
with north polarity will be aligned in the correct direction. The examiner will 
place the BROM unit parallel to the ground and along a line over the red dot 
marking the T-12 spinous process. The lower ribs of the patient will be grasped 
by the examiner's fingers to keep the BROM unit in place. During axial rotation 
of the spine, the BROM unit becomes a part of the patient’s truncal movement, 
as shown in (figure 6) (Madson et al., 1999). 
 
Each patient will be told to place hands across chest and then instructed, 
"Twist your trunk to the right as far as you can go. Do not twist farther than is 
comfortable, and do not cause back pain". The examiner will stand behind the 
patient. The same commands will be given for left rotation, as shown in (figure 
6) (Madson et al., 1999). 
 
Figure (6): Rotation measurements. (Madson et al., 1999) 

23 
 
4. Spinal mobility: 
Using the Modified Schober Test, Patient will be standing. The examiner 
will mark both posterior superior iliac spine (PSIS) and then will draw a 
horizontal line at the center of both marks. A second line is marked 5 cm below 
the first line. A third line is marked 10 cm above the first line. Patient will be 
instructed to flex forward as if attempting to touch his/her toes. The examiner re- 
measures the distance between the top and bottom line (Rezvani et al., 2012). 
Three trials will be conducted and the mean of the three trials will be chosen for 
the purpose of data analysis 
 
5. Health Related Quality of life: 
Using the Arabic SF-36 (Appendix IV), Patients will be asked to fill out 
the questionnaire (tick boxes) by themselves and then it is scored by a clinician 
or researcher (El-Kalla, 2016). 
6. Fear of movement 
Using the Arabic Tampa (Appendix V), Patients will be asked about any 
excessive, irrational, and debilitating fear of physical movement and activity 
resulting from a feeling of vulnerability to painful injury or re-injury (Al- 
Shudifat et al., 2020). 
 
7. Adherence 
Individuals will be followed in a checklist at each session with the date of 
the session. The absence of the participant for two sessions will lead to 
consideration of being drop out. 
Treatment Procedures: 
 The control group (n=20) will receive core stabilization (3 sessions/ week 
for 6 weeks) 
 The 1st experimental group (n=20) will receive core stabilization in 
addition to thoracic mobility exercises (3 sessions/ week for 6 weeks) 
 The 2nd experimental group (n=20) will receive core stabilization in 
addition to hip mobility exercises (3 sessions/ week for 6 weeks). 
 Adherence will be monitored using attendance logs and exercise checklists. 
 Any adverse effects or symptom exacerbation will be recorded. 
A) Core stabilization exercises (control group): 
All 3 groups will receive core stabilization exercises based on work of 
(Kuzu et al., 2025). Each exercise session will be performed for approximately 
35 minutes with 5 min warm-up. 
Before starting the exercise, patients will be taught to reduce the lumbar 
lordosis by contracting and drawing in the abdominal muscles and to find the 

24 
 
lumbar and pelvic neutral position by moving the pelvis forwards and backwards 
(pelvic tilt, bridge, bird-dog and plank etc.). 
 
In each session, the neutral position will be found first and attention will 
be paid to maintain the neutral position throughout the exercise. In addition, core 
stability exercises including simultaneous contractions of the multifidus and 
pelvic floor muscles will be given in different positions such as supine, prone, 
crawling, bridge, kneeling, sitting and standing, as shown in (figure 7). The exer- 
cises will consist of 3 levels (from easy to difficult). In the advanced level 
exercises, patients will be asked to maintain the neutral curvature of the lumbar 
spine, resistance limb exercises will be added and the exercises will be completed 
gradually. Each exercise will be performed for 3 sets of 8–10 repetitions, 
depending on the patient’s tolerance. 
 
Figure (7): Core stabilization exercises (Park & Kim, 2020) 
B) Thoracic Mobility Exercises (1st experimental group only): 
It was developed based on the exercise described by Henegahn et al., 
(2020) and Choi & Kim, (2023), the exercise will consist of movements in all 
directions of thoracic spine flexion, extension, lateral flexion, and rotation. 
 
In the thoracic spine extension exercise, both hands will be locked behind 
the wrists and the back will be placed on a foam roller with the feet positioned 

25 
 
flat on the floor. The knee will be maintained at 90° to perform the extension 
exercise on the foam roller, as shown in (figure 8A). Additionally, the hands will 
be locked with the elbow on a chair. After kneeling, the hip will be moved toward 
the heels to extend the thoracic spine, as shown in (figure 8B). 
In the thoracic spine flexion exercise, the thoracic spine will be flexed by 
moving backward until the hip touched the heels in a quadruped position, as 
shown in (figure 8C). 
The rotation exercise will be conducted with patients lying on their sides. 
The elbows will be straight and the palms will be held together. The leg facing 
the ceiling will be bent to the level of the stomach. Then, the arm facing the ceiling 
will be moved backward in a large arc to rotate the thoracic spine, as shown in 
(figure 8D). Another thoracic spine rotation exercise will be conducted as follows 
in a kneeling position, the hip will touch the heels; the hand in the direction of 
rotation will be placed behind the neck and the elbow of the opposite arm will be 
placed on the floor; then, the torso will be slowly rotated toward the ceiling, as 
shown in (figure 8E). 
For lateral flexion of the thoracic spine, both hands will be locked behind 
the neck with the participant seated on a chair and the torso will be then flexed 
laterally, as shown in (figure 8F). 
Each exercise will be performed for 3 sets of 10 repetitions. 
 
Figure (8): Thoracic Mobility Exercises; A) Thoracic extension with foam 
roller. (B) Thoracic extension with chair. (C) Thoracic flexion in 
quadruped position. (D) Thoracic rotation in side lying. (E) Thoracic 
rotation in a kneeling position. (F) Thoracic lateral flexion in sitting 
position. (Seo et al., 2022) 

26 
 
C) Hip Mobility Exercises (2nd experimental group only): 
It was conducted based on the exercise described by Demirtas et al., 
(2023) and Choi & Kim, (2023). The patients will perform 8 different hip 
mobility exercises; reverse v-ups, butterfly, frog, internal rotation with foot rise, 
pike, revolved crescent lunge, pigeon, lunge on the knee, as shown in (figure 9). 
Each exercise will be performed for 2 sets of 20 seconds. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure (9): Hip Mobility Exercises. (Demirtas et al., 2023) 
Data analysis and statistical design 
Statistical analysis will be performed using SPSS software for Windows, version 
25.0 (SPSS, Inc., Chicago, IL) with Alpha level set at 0.05. 
- Data will be screened for normality assumption, homogeneity of variance, 
and presence of extreme scores. 
- Descriptive statistics will be calculated for all groups at baseline and after 
6 weeks. 
- ANOVA, repeated measures, within-between interactions model will be 
utilized to determine any differences between the mean change scores of 
groups regarding all outcomes. 
- Bonferroni adjusted p-values for every outcome measure to protect against 
the possibility of type I error. 

27 
 
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