Original research

Effect of spinal mobilization with leg movement as an adjunct to

neural mobilization and conventional therapy in patients with
lumbar radiculopathy: Randomized controlled trial
Subarna Das MS1,*, Praveen Dowle2, and Raju Iyengar3
1
Nizam’s Institute of Medical Sciences (NIMS), Hyderabad, India
2
Musculoskeletal Sciences, Physiotherapy Faculty, College of Physiotherapy, Nizam’s Institute of Medical Sciences, Hyderabad, India
3
Department of Orthopaedics, Nizam’s Institute of Medical Sciences, Hyderabad, India

Abstract
Background: The purpose of the study was to find out whether spinal mobilization with leg movement as an
adjunct to neural mobilization and conventional therapy could bring better outcome in patients when compared
to conventional therapy or neural mobilization and conventional therapy.
Methods: 90 patients were selected randomly with lumbar radiculopathy. Duration of the study was for six
weeks. The study included 3 groups, control group received back extension exercises and hot pack, experimental
group 1 received neural mobilisation and conventional physiotherapy and experimental group 2 received
SMWLM along with neural mobilisation and conventional physiotherapy. The outcomes included NPRS, SLR
using goniometry and MOLBPQ which were assessed at day 1 and 2, 4, 6 week. ANOVA was done for inter group
analysis and paired t-test was done for intra group analysis.
Results: All the groups showed significant difference (P -0.000 < 0.05) at 2, 4, 6 weeks of NPRS, MOLBPQ
and SLR. The mean difference and paired t-test values of experimental group 2 was more when compared to
experimental group 1 and control group at the end of 6 weeks.
Conclusion: All the three groups showed improvement in pain, functional disability and straight leg raise (SLR).
SMWLM as an adjunct to neural mobilization and conventional therapy showed significantly better outcomes
in pain, functional disability and SLR when compared to conventional therapy or neural mobilization and
conventional therapy.
Keywords: lumbar radiculopathy; spinal mobilization; leg movement; neural mobilization; conventional
therapy

*Corresponding author: MS Subarna Das, Nizam’s Institute of conventional therapy in patients with lumbar radiculopathy:
Medical Sciences (NIMS), Punjagutta, Hyderabad, India. Email: Randomized controlled trial. J Med Sci Res. 2018; 6(1):11-19. DOI:
[email protected] http://dx.doi.org/10.17727/JMSR.2018/6-3

Received 06 September 2017; Revised 22 November 2017; Accepted Copyright: © 2018 Das SMS et al. Published by KIMS Foundation and
08 December 2017; Published 23 December 2017 Research Center. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits
Citation: Das SMS, Dowle P, Iyengar R. Effect of spinal mobilization unrestricted use, distribution, and reproduction in any medium,
with leg movement as an adjunct to neural mobilization and provided the original author and source are credited.

Vol. 6 | Issue 1 | January - March 2018 11

Introduction Sciences, Hyderabad, India. Subjects with subacute
Lumbar radiculopathy can be described as low back and chronic low back pain with unilateral lumbar
pain radiating to one or both lower extremity. The radiculopathy who were diagnosed with disc bulge,
level of spinal nerve root involvement indicates protruded/ prolapsed intervertebral disc were
specific dermatomes affected. Radicular pain and included in the study.
nerve root pain can occur as a single symptom
(pain) that can arise from one or more spinal Inclusion criteria: Age of 20-55 years of both sexes,
nerve roots [1]. Lumbar disc herniation contributes unilateral radiculopathy in the distribution of specific
60-80% of lifetime incidence of low back pain in nerve with positive straight leg raise (SLR), positive
general population [2]. Lumbar radiculopathy has slump test of specific nerve bias of lumbar region,
an incidence of 23.09% in India [3, 4]. Many physical positive prone knee bend test, mild to moderate
therapy interventions have been used to treat low pain on a scale of NPRS < 7, hypaesthesia in specific
back pain due to lumbar radiculopathy including dermatome of unilateral lower limb and impaired
traction, stretching, strengthening exercises, warm deep tendon reflex (knee jerk, ankle jerk).
water fermentation, modalities like IFT but with
varying degrees of success [5-7]. Though there are Exclusion criteria: Subjects diagnosed with rapidly
numerous treatments for lumbar radiculopathy, progressing neurological symptoms, extruded
no single intervention has been proven to be most disc, dementia or other cognitive impairment,
efficient. Brian Mulligan’s principle is based on inflammatory or other specific disorders of
“positional fault” [8]. In Mulligan’s spinal mobilization spine such as ankylosing spondylitis, paget’s
with limb movements (SMWLM’s) three therapist disease, vertebral collapse, rheumatoid arthritis,
technique a sustained transverse glide is applied spondylolisthesis, severe osteoporosis, Tb spine,
to the spinous process of specific spine while the intermittent claudication, diabetic neuropathy,
restricted lower extremity movement is done stenosis, sacroiliac joint pathology, previous spinal
simultaneously actively or passively. surgery, previous spinal injury causing radiculopathy,
pathology of hip, knee and ankle and patient with
Due to peripheral nerve compression the ability known pregnancy and severe pain (NPRS > 7).
of the nerve to stretch and slide may be disrupted. More than one nerve root involvement, muscular
Prolonged compression creates sequelae of involvement such as Piriformis syndrome, Red flags
intraneural events that may ultimately lead to such as trauma, cancer, constitutional symptoms
impaired nerve sliding [9]. Neural mobilisation (fever, malaise, weight loss), recent infection, mental
uses the Sliding Principle which was introduced by retardation, hemiparesis / hemiplegia.
Shacklock, which consists of alteration of combined
movements of two joints. These techniques aim to The subjects were randomly assigned into three
restore neural plasticity and lengthen the nerve groups by lottery method who met the inclusion and
bed by sliding the nerve. Neural tissue mobilization exclusion criteria. Institutional Ethical Committee
targets breaking adhesions in the structures present approval was taken. The allocations were concealed
along the course of the nerve at the mechanical from the principal investigator. The outcome
interface while the Mulligan concept corrects the measures were single blinded and were taken by
positional fault at the spine. The effectiveness of a physical therapist who was trained in taking the
these technique and clinical appropriateness is outcome measures. Informed consent was obtained
immediate reduction in pain and increase in mobility from patient who met the criteria. Outcome
[10]. Studies have been conducted measuring the measurements were Numeric Pain Rating Scale
efficacy of Shacklock neural tissue mobilization and (NPRS) for pain intensity [11-13], Hip ROM during
mulligan’s spinal mobilization with leg movement SLR- Universal Goniometer [14], back specific
separately. No studies have been conducted disability scores-Modified Oswestry Low Back
combining both the techniques. Pain Questionnaire (MOLBPQ) [15]. Pre-treatment
evaluation was done at the first day as baseline
Methods and study design measurement. Group 1 included conventional
90 subjects were recruited from Physiotherapy out- therapy, Group 2 included neural tissue mobilization
patient department, Nizam’s Institute of Medical (NTM) and conventional therapy, Group 3 included

12 Journal of Medical and Scientific Research

Spinal mobilization with leg movement (SMWLM) reported, further sessions were carried out. There
three therapist techniques along with NTM and were four dropouts. At six weeks final readings of
conventional therapy (Figure 1). At the end of all outcome measures were taken and data analysis
session (zero day), the subjects were assessed for was done for final results.
any increase in pain. If, no, adverse response was

Figure 1: Consort flow chart of study.

Group 1 conventional therapy (remote sequence, local sliders). Move affected area
Subjects received exercises which included back and any other area but with or without minimum
extension exercises: hyper extension of back symptoms.
(prone), hyper extension of back and flexion (kneel),
extension opposite arm and leg [16], transverse Dosage: 30 sec to 2 min × 5 sets. Three days per week
abdominus contraction with pelvic floor muscle for two weeks. Two days per week from 2-4 weeks.
activation, superficial moist heat (hot pack) for 10 One day per week from 4-6 weeks. Conventional
min, precaution and ergonomic advice [17]. These therapy was given as home program to patients.
exercises were given as home programme to the
subjects. Group 3 SMWLM – 3 therapist technique,
NTM & conventional therapy
Dosage: 5 sets × 10 repetition with 2 min rest SMWLM was performed according to norms/
between each set for six weeks [18]. guidelines by Mulligan’s concept.

Group 2 neural tissue mobilisation and Dosage: Three set × 7 to 10 reps three days per week
conventional therapy for two week. Two days per week from 2-4 weeks.
Neural tissue mobilization was performed according One day per week from 4-6 weeks. Neural tissue
to the norms/ guidelines by NDS, Australia [19]. mobilisation and conventional therapy was given as
Step 1- Sliders: Using unaffected joint (remote home program.
sequence, remote sliders). Affected joint is placed
in neutral or symptom free position. Step 2- Sliders: Results
Using unaffected joint (remote sequence, remote Pain
slider). Affected joint if placed some ROM but with There was no significant difference among control
or without minimal symptoms. Step 3- Sliders: group, experimental group 1 and experimental group

Vol. 6 | Issue 1 | January - March 2018 13

2 on day 1 since f-value is 0.220 and P- value 0.803 1 and experimental group 2 are 12.776, 19.501
is more than 0.05 (Table 1) (Figure 2). A significant and 33.899 respectively and mean difference is
difference exists among control group, group 1 and more in experimental group 2 (Table 2). Hence
group 2 at week 2, 4, 6 since P-value 0.000 is less there is significant improvement in pain reduction
than 0.05. Since the paired t-test values of day 1 in the experimental group 2 when compared to
versus week 6 in control group, experimental group experimental group 1 and control group.

Table 1: ANOVA test is used to test the significant mean difference between the groups of NPRS.
Sum of squares df Mean square F Significance
NPRS day 1
Between groups 0.309 2 0.154 0.220 0.803
Within groups 58.215 83 0.701
Total 58.523 85
nd
NPRS 2 week
Between groups 195.419 2 97.709 76.820 0.000
Within groups 105.569 83 1.272
Total 300.988 85
th
NPRS 4 week
Between groups 159.845 2 79.923 87.521 0.000
Within groups 75.794 83 0.913
Total 235.64 85
th
NPRS 6 week
Between groups 97.635 2 48.818 63.630 0.000
Within groups 63.679 83 0.767
Total 161.314 85

Figure 2: Paired t-test is used to test the significance mean difference in each group.

Modified oswestry low back pain questionnaire (Figure 3). A significant difference exists among
There was no significant difference among control control group, group 1 and group 2 at week 2, 4, 6
group, experimental group 1 and experimental since P-value 0.000 is less than 0.05. Since the paired
group 2 on day 1 since F-value is 1.517 and t-test values of day 1 versus week 6 in control group,
its P-value 0.225 is more than 0.05 (Table 3) experimental group 1 and experimental group 2 are

14 Journal of Medical and Scientific Research

Table 2: Paired t-test is used to test the effectiveness of day 1 vs week 6 significance mean difference in each group like control,
Experimental-1 and Experimental-2 of NPRS.
Standard Standard error
Group Mean N
deviation mean
Control NPRS day 1 5.63 27 0.884 0.170
th
NPRS 6 week 2.81 27 1.210 0.233

Experimental 1 NPRS day 1 5.77 30 0.817 0.149

th
NPRS 6 week 1.47 30 0.860 0.157

Experimental 2 NPRS day 1 5.66 29 0.814 0.151

th
NPRS 6 week 0.17 29 0.384 0.071

Significant
Group Paired differences mean t Df
(2-tailed)
th
Control NPRS day 1 - NPRS 6 week 2.815 12.776 26.000 0.000
th
Experimental 1 NPRS day 1 - NPRS 6 week 4.300 19.501 29.000 0.000
th
Experimental 2 NPRS day 1 - NPRS 6 week 5.483 33.899 28.000 0.000

Table 3: ANOVA test is used to test the significant mean difference between the groups of MOLBPQ.

Sum of squares df Mean square F Significance

MOLBPQ day 1

Between groups 232.838 2 116.419 1.517 0.225

Within groups 6371.499 83 76.765

Total 6604.337 85

MOLBPQ 2nd week

Between groups 866.921 2 433.461 7.361 0.001

Within groups 4887.834 83 58.890

Total 5754.756 85

MOLBPQ 4th week

Between groups 1140.277 2 570.139 12.987 0.000

Within groups 3643.862 83 43.902

Total 4784.14 85

MOLBPQ 6th week

Between groups 1781.062 2 890.531 25.470 0.000

Within groups 2901.972 83 34.964

Total 4683.035 85

9.421, 14.960 and 21.495 respectively and mean Straight leg raise
difference is more in experimental group 2 (Table 4). There was no significant difference among control
Hence there is significant improvement in MOLBPQ group, experimental group 1 and experimental group
in the experimental group 2 when compared to 2 on day 1 Since F-value is 2.733 and its P-value 0.071
experimental group 1 and control group. is more than 0.05 (Table 5) (Figure 4). A significant

Vol. 6 | Issue 1 | January - March 2018 15

 Figure 3: Paired t-test is used to test the significance mean difference in each group.

Table 4: Paired t-test is used to test the effectiveness of day1 Vs week 6 significance mean difference in each group like control,
Experimental-1 and Experimental-2 MOLBPQ.
Standard Standard Error
Group Mean N
Deviation mean

Control MOLBPQ day 1 38.19 27 9.249 1.78

MOLBPQ 6th week 22 27 7.805 1.502

Experimental 1 MOLBPQ day 1 41.67 30 8.616 1.573

MOLBPQ 6th week 20.2 30 5.517 1.007

Experimental 2 MOLBPQ DAY 1 41.79 29 8.44 1.567

MOLBPQ 6th week 11.55 29 3.942 0.732

Significant
Group Paired differences mean t df
(2-tailed)
MOLBPQ day 1 - MOLBPQ 6th
Control 16.185 9.421 26 0.000
week
th
MOLBPQ day 1 - MOLBPQ 6
Experimental 1 21.467 14.960 29 0.000
week
th
MOLBPQ day 1 - MOLBPQ 6
Experimental 2 30.241 21.495 28 0.000
week

difference exists among control group, group 1 and -20.810 respectively and mean difference is more
group 2 at week 2, 4, 6 since P-value 0.000 is less in experimental group 2 (Table 6). Hence there is
than 0.05. Since the paired t-test values of day 1 significant improvement in SLR in the experimental
versus week 6 in control group, experimental group group 2 when compared to experimental group 1
1 and experimental group 2 are -12.126, -13.102 and and control group.

16 Journal of Medical and Scientific Research

Table 5: ANOVA test is used to test the significant mean difference between the groups of SLR.

Sum of squares df Mean square F Significance

SLR day 1

Between groups 422.120 2 211.060 2.733 0.071

Within groups 6409.275 83 77.220

Total 6831.395 85
nd
SLR 2 week

Between groups 7295.524 2 3647.762 58.871 0.000

Within groups 5142.848 83 61.962

Total 12438.372 85
th
SLR 4 week

Between groups 3834.521 2 1917.260 35.992 0.000

Within groups 4421.293 83 53.269

Total 8255.814 85
th
SLR 6 week

Between groups 1124.600 2 562.300 13.361 0.000

Within groups 3493.132 83 42.086

Total 4617.733 85

Figure 4: Paired t-test is used to test the significance mean difference in each group.

Vol. 6 | Issue 1 | January - March 2018 17

Table 6: Paired t-test is used to test the effectiveness of day 1 Vs week 6 significance mean difference in each group like control,
Experimental-1 and Experimental-2 SLR.
Standard
Group Mean N Standard error mean
deviation
Control SLR day 1 56.48 27 7.944 1.529
th
SLR 6 week 80 27 9.405 1.81

Experimental 1 SLR day 1 57.5 30 8.068 1.473

th
SLR 6 week 84.83 30 5.645 1.031

Experimental 2 SLR day 1 52.41 29 10.144 1.884

th
SLR 6 week 88.97 29 3.099 0.576

Group Paired differences mean t df Significant (2-tailed)

th
SLR day 1 - SLR 6
Control -23.519 -12.126 26.000 0.000
week
th
SLR day 1 - SLR 6
Experimental 1 -27.333 -13.102 29.000 0.000
week
th
SLR day 1 - SLR 6
Experimental 2 -36.552 -20.810 28.000 0.000
week

Discussion and area at the side opposite to the rotation [21]. The
The findings of the study indicate that SMWLM neurophysiologic mechanism is another mechanism
three therapist technique as an adjunct to neural by which SMWLM has been believed to relieve pain
mobilization and conventional therapy (experimental [22].
group 2) showed significant improvement in pain,
functional disability and SLR when compared to Experimental group 1 and 2 were treated with
neural mobilization with conventional therapy neural mobilization technique showed improvement
(experimental group 1) and conventional therapy in pain and SLR as neural mobilization has a positive
(control group). This supports that both spinal impact on restoring mobility of the nerve and this
manipulation and neural mobilization techniques might have improved neural tissue gliding with
have a role in the treatment of lumbar radiculopathy. respect to its interface [23]. Gladson et al., mentioned
This is in agreement with Waleed who compared that compression of nerve root leads to decreased
the effect of neural mobilization versus spinal microcirculation resulting in neural edema and
mobilization in patients with radicular chronic demyelination. The short oscillatory movements
low back pain [20]. Spinal mobilization and neural in neural mobilization help to reduce neural tissue
mobilization both were effective in improving hypoxia and reduce inflammation. In addition, there
the symptoms but spinal mobilization showed an is a hypothesis that nerve movement within pain-
immediate effect. This might be due to correction of free variation can help to reduce mechanosensitivity
positional fault done by SMWLM at the spinal level of the nerve [24]. Therefore neural mobilization
whereas neural mobilization worked on restoring improves altered circulation to neural tissue and
the mobility of the nerve to its mechanical interface altered axonal transport dynamics by breaking
which was compressed due to herniated disc adhesions hence correcting pathophysiology and
resulting in pain. The minor positional fault might relieving pain and improving SLR in patients in
have caused pressure on pain-sensitive structures group 2 and 3.
and nerve roots. In SMWLM, rotation glide was
used which might have increased the space of Although conventional therapy, neural mobilization
intervertebral for amen by opening intervertebral have an effect in decreasing low back pain,
position and thereby decompressing the nerve functional disability and improving SLR, however
roots. This is in agreement with the biomechanical SMWLM as an adjunct to neural mobilization and
study done by Fujiwara et al. who showed that axial conventional therapy showed better results than
rotation increased intervertebral foramen height conventional therapy or neural mobilization with

18 Journal of Medical and Scientific Research

conventional therapy. It could be attributed to clear [12] Jensen MP, Turner JA, Romano JM. What is the maximum
number of levels needed in pain intensity measurement?
effect of SMWLM that produced greater hypoalgesia Pain. 1994; 58(3):387–392.
than other exercises. It was hypothesized that [13] Stratford PW, Spadoni GF. The reliability, consistency
manipulation inhibits pain at dorsal horn of spinal and clinical application of a numerical pain rating scale.
cord by altering neuroplasticity of the nerve and Physiothe Can. 2001; 53:88–91.
[14] Gajdosik RL, Bohannon RW. Clinical measurement of range
central sensitization. Spinal mobilization may
of motion: Review of goniometry emphasizing reliability
provide a stimulus that acts as counter-irritant to C and validity. Phys Ther. 1987; 67(12):1867–1872.
fiber-mediated pain [25]. [15] Fritz JM, George SZ, Delitto A. The role of fear avoidance
beliefs in acute low back pain: relationship with current and
future disability and work status. Pain. 2001; 94(1):7–15.
Conclusion
[16] John A McCulloch. Macnab’s backache; 3rd edition; chapter
All the three groups showed improvement in pain, 13; 408-409.
functional disability and SLR. SMWLM as an adjunct [17] Jean Olliver. Back Care &Illustrated guide. 3rd edition; chapter
3; 61-117.
to neural mobilization and conventional therapy
[18] Ronald J Schenk, Cherie Jozefczyk, Aric Kopf. A randomized
showed significantly better outcomes and was more trial comparing intervention in patients with lumbar
effective in improving pain, functional disability and posterior derangement. J Man Manip Ther. 2003; 11(2):95–
SLR when compared to conventional therapy or 102.
[19] Butler SD. Mobilization of the nervous system: tension
neural mobilization and conventional therapy.
testing- the lower limbs and trunk. 1991.
[20] El-din Mahmoud WS. Effect of neural mobilization versus
Conflicts of interest spinal manipulation in patients with radicular chronic low
back pain. European journal of scientific research. 2015;
Authors declare no conflicts of interest. 131(1):122–132.
[21] Fujiwara A, An HS, Lim TH, Haughton VM. Morphologic
References changes in the lumbar intervertebral foramen due to flexion-
extension, lateral bending, and axial rotation: an in vitro
[1] Murphy DR, Hurwitz EL, Gerrard JK, Clary R. Pain patterns anatomic and biomechanical study. Spine. 2001; 26(8):876–
and descriptions in patients with radicular pain: Does the 882.
pain necessarily follow a specific dermatome? Chiropr
[22] Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Hypoalgaesic
Osteopat. 2009; 17:9.
and sympathoexcitatory effects of mobilization with
[2] Nevan G. Baldwin. Lumbar disc disease: The natural history. movement for lateral epicondyalgia. Phys Ther. 2003;
Neurosurg Focus. 2002; 13(2):1–4. 83(4):374–383.
[3] M Krismer M. van Tulder. Low back pain (nonspecific). [23] Sarkari E, Multani NK. Efficacy of neural mobilisation in
Rheumatology. 2007; 21(1):77–91. sciatica. Journal of Exercise Science and Physiotherapy.
[4] Sharma SC, Singh R, Sharma AK, Mittal R. Incidence of low 2007; 3(2):136–141.
back pain in workage adults in rural North India. Indian J [24] Gladson RB, Taciane SS, Danilo LT, Adriano PC, Alberito RC.
Med Sci. 2003; 57(4):145–147. Neural mobilization and static stretching in an experimental
[5] Bogduk N. Management of chronic low back pain. Med J Sciatica model: An experimental study. Rev Bras Fisioter.
Aust. 2004; 180(2):79–83. 2009; 13(6):493–498.
[6] Kinkade S. Evaluation and treatment of acute low back pain. [25] Perry J, Green A, Singh S, Watson P. A preliminary investigation
American Family Physician. 2007. into the magnitude of effect of lumbar extension exercises
and a segmental rotatory manipulation on sympathetic
[7] Werners R, Pynsent PB, Bulstrode CJ. Randomized trial nervous system activity. Man Ther. 2011; 16(2):190–119.
comparing interferential therapy with motorized lumbar
traction and massage in the management of low back pain
in a primary care setting. Spine (Phila Pa 1976). 1999;
24(15):1579–1584.
[8] Exelby L. The mulligan concept: Its application in
management in spinal conditions. Man Ther. 2002; 7(2):64–
70.
[9] Carroll M, Yau J, Rome K, Hing W. Measurement of tibial
nerve excursion during ankle joint dorsiflexion in a weight
bearing position with ultrasound imaging. J Foot Ankle Res.
2012; 5(5):1–6.
[10] Mulligan BR. Manual therapy. “nags”, “Snags”, “MWMs”, etc
4th edition. Pg:44-45.
[11] Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, et al. A
clinical prediction rule to identify patients likely to benefit
from spinal manipulation: A validation study. Ann Intern
Med. 2004; 141(12):920–928.

Vol. 6 | Issue 1 | January - March 2018 19