chronic low back pain ( clbp ) refers to chronic pain around the lumbar vertebra sustained 
 for over three months without serious pathological characteristics , regardless of the 
 existence of sciatalgia1 . clbp causes pain 
 and changes in the muscles , as well as decreases in contractile force and muscle activity . studies of therapeutic approaches to clbp pain reduction , muscular strength improvement , and 
 spinal movement enhancement have investigated the effects of myofacial release , osteopathy , 
 massage , lumbar stabilization exercises , and proprioceptive neuromuscular facilitation 
 ( pnf)5,6,7 . among these therapeutic approaches , joint mobilization using pnf has a positive effect on 
 pain , muscle strength , and range of motion ( rom)8 , 
 9 . it is applied as a passive movement by 
 therapists10 , 11 . in particular , kaltenborn - evjenth orthopedic manual therapy 
 ( keomt ) is an effective treatment for improving rom and pain . keomt is a safe and 
 well - established procedure that slowly utilizes the convex - concave rule ( traction or gliding 
 on the treatment side)10 , 12 . hindle et al . 
 reported pnf is effective at improving rom and muscular strength13 . kim et al . reported that lumbar stabilization therapy 
 using pnf for clbp significantly improved the thicknesses of the external oblique and 
 multifidus muscles , and the functional level8 . in addition , pnf has been used to improve the muscular strength of 
 athletes14 . this case study was a single patient with clbp and a lumbar transitional vertebra who has 
 six lumbar vertebrae ( not five ) . a lumbar transitional vertebra is defined as a congenital 
 malformation that appears as a deformation of the fifth lumbar ( l5 ) or first sacrum ( s1 ) 
 vertebra15 . vergauwen reported that 
 lumbar transitional vertebrae patients more commonly experience disc protrusion , 
 degeneration , and spinal stenosis than patients without lumbar transitional vertebrae16 . therefore , the 
 purpose of this study was to identify the effects of joint mobilization using keomt and pnf 
 on a patient with clbp and a lumbar transitional vertebra . the subject was selected from among the patients of sarang hospital ( yongin , south korea ) . the subject 
 agreed to participate in the study after receiving explanations regarding the purpose and 
 procedures of the experiment , and signed an informed consent statement before participation . the protocol for this study was approved by the local ethics committee of the namseoul 
 university of cheonan . computer 
 tomography ( ct ) showed six lumbar vertebrae , which is one more lumbar vertebra than a normal 
 person ( fig . the subject was aged 
 29 , and had a weight of 67  kg , a height of 158  cm , and a bmi of 26.90 . the initial symptom developed about two years earlier , and at the time of the 
 study the subject was not receiving any medical or physical therapy . the major complaint of 
 the subject was a numb feeling , especially in the hind part of the left leg . she also 
 complained of a stinging pain during daily activities , such as lifting , lumbar twist , and 
 flexion . the program consisted of a 40-min session , 3 days a week for 4 weeks ( october 131 , 2014 ) , 
 during which joint mobilization was performed using keomt and pnf techniques . joint mobilization using keomt lasted 20  min , and it included lumbar segmental traction and 
 lumbar segmental mobilization ( flexion , extension ) in a side - lying position . it was performed by a therapist who had 
 completed a keomt spine advance course . the pnf exercise included shoulder flexion , abduction , and 
 external rotation in a supine position , and dynamic reversal of the antagonist was 
 performed17 , which indirectly exercised 
 the abdominal muscle through irradiation of the shoulder muscle . it was performed by a 
 therapist who had completed the pnf level i , ii courses . the subject was assessed for spinal motion , low back pain , and thickness of the multifidus . spinal motion was assessed using a spinal mouse ( idiag , swiss ) , which measures the spinal 
 curvature , flexion , and extension ( thoracic and lumbar vertebrae ) . low back pain was 
 assessed using a visual analogue scale ( vas ) and the oswestry disability index ( odi ) . the 
 vas assesses subjective pain through a which has a possible range of 0 to 10 . the odi assesses low back pain , and has a possible range of 0 to 
 100% . it is composed of ten items , including pain severity , self - management , lifting , 
 sitting , standing , sleeping , etc . the thickness of the multifidus was measured using ct ( general electric , 
 korea ) . the multifidus muscles of the fourth lumbar vertebra ( l4)20 was scanned by a radiological thechnician at sarang 
 hospital . the spinal curvature , flexion , and extension of thoracic and lumbar vertebrae were 
 measured . in the thoracic vertebra , the rom of flexion increased from 14 to 20 , and the rom of 
 extension increased from 1 to 4. in the lumbar vertebra , the angle of spinal curvature 
 increased from 12 to 20. the rom in flexion increased from 33 to 47 , and the rom of 
 extension increased from 2 to 7 ( table 
 1table 1.change of thoracic and lumbar movementvariablecurvature ( )flexion ( )extension ( )prepostprepostprepostthoracic2632142014lumbar1220334727 ) . the subject mentioned she was less uncomfortable in 
 daily life , e.g. during face washing , dishwashing , hair washing , etc . the odi percentage 
 score decreased from 48.88 to 24.44 ( table 
 2table 2.change of vas and odivariablevas ( score)odi ( % ) prepostprepost7.5348.8824.44 ) . the thickness of the multifidus was measured at the fourth lumbar vertebra ( left and 
 right ) . the left multifidus increased from 572.09 to 662.09 mm , and the right 
 multifidus increased from 479.84 to 530.90 mm ( table 3table 3.change of multifidus thicknessvariableprepostmultifidus ( mm)l : 572.09l : 662.09r : 479.84r : 530.90l : left ; r : right ) . 3.multifidus thickness on a ct ( post ) show the multifidus thickness on a ct . multifidus thickness on a ct ( pre ) multifidus thickness on a ct ( post ) this study was a case study of a single patient with clbp and a lumbar transitional 
 vertebra . the purpose of this study was to identify the effects of joint mobilization using 
 keomt and pnf techniques in a patient with clbp and a lumbar transitional vertebra . the 
 spinal motion , pain , and thickness of the multifidus were evaluated and compared between 
 pre- and post - assessment . florentino et al . reported that most nurses possess at least one musculoskeletal disorder , 
 among which low back pain is the most frequent ( 60.9%)21 . after the intervention , the angle of spinal curvature increased , and the roms of flexion 
 and extension of the thoracic and lumbar vertebrae also increased , indication that joint 
 mobilization using keomt and pnf had a positive effect on spinal motion . ko et al . reported 
 that clbp patients in a thoracic joint mobilization group showed greater improvements in 
 spinal motion and pain reduction than a william exercise group22 . our present results were similar , suggesting that joint 
 mobilization has a positive effect on spinal motion . after the intervention , the vas score decreased 
 from 7.5 to 3 , and the odi score decreased from 48.88% to 24.44% . orthopedic manual therapy 
 has positive effects on the spinal function of clbp patients6 , especially items of self - management , such as bathing , dressing , and 
 sleeping . reported pain reduction after joint mobilization using keomt was performed for 
 osteoarthritic elderly people23 , and 
 lpez et al . reported joint postero - anterior mobilization had an effect on the pain and rom 
 of clbp patients9 . lee reported a pnf group demonstrated greater pain reduction and increased muscle activity 
 than a ball training group , and jung reported pnf reduced the pain of clbp patients24 , 25 . . therefore , the results 
 of previous studies agree with those of the present study . the spinal muscle contracts prior to 
 motion and controls the movement28 . in 
 particular , the multifidus muscle is important for lumbar stabilization . the superficial 
 multifidus plays a role in spinal direction control , and after the intervention , the 
 left multifidus increased from 572.09 to 662.09 mm , and the right multifidus was 
 increased from 479.84 to 530.90 mm . kim et al . reported a pnf group showed 
 greater increases in the thicknesses of the multifidus and external oblique muscles than a 
 general physiotherapy group and a lumbar stabilization group8 . in addition , a resistance exercise using pnf not only reinforced 
 muscular strength causing maximal muscular contraction , but it also stabilized the body 
 position30 . these results indicate pnf 
 has a positive effect on the thickness of the multifidus . according to our present results , joint mobilization using keomt and pnf had a positive 
 effect on the spinal motion , pain , and thickness of the multifidus of a patient with clbp 
 and a lumbar transitional vertebra . this study was a single subject case study , but it is 
 meaningful in that it presented spinal motion , pain , and muscle activity in a patient with a 
 lumbar transitional vertebra . a larger number of patients will need to be studied in the 
 future .
[ purpose ] the purpose of this case study was to identify the effects of 
 joint mobilization using kaltenborn - evjenth orthopedic manual therapy ( keomt ) and 
 proprioceptive neuromuscular facilitation ( pnf ) techniques on a patient with chronic low 
 back pain ( clbp ) and a lumbar transitional vertebra . 
 [ methods ] the intervention methods 
 were joint mobilization using keomt and pnf techniques . the program consisted of 40-min 
 sessions 3 days a week for 4 weeks . the spinal motion ( thoracic and lumbar vertebrae ) , 
 pain , and thickness of the multifidus were measured . 
 [ results ] the angle of spinal 
 curvature increased , and the range of motions ( roms ) flexion and extension increased in 
 the thoracic and lumbar vertebrae . the pain score as measured on a visual analogue scale 
 ( vas ) and the oswestry disability index ( odi ) score decreased . 
 the thickness of the 
 multifidus ( l4 ) increased on the left and right sides . 
 [ conclusion ] these results suggest 
 that joint mobilization using keomt and pnf techniques had a positive effect on the spinal 
 motion , pain , and thickness of the multifidus of a patient with chronic low back pain and 
 a lumbar transitional vertebra .