Manual Therapy xxx (2014) 1e6

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

The effects of a modified spinal mobilisation with leg movement

(SMWLM) technique on sympathetic outflow to the lower limbs
Vasilis Tsirakis a, *, Jo Perry b
a
Physiotherapy Workplace, Koropi e Attiki (Athens), Georgiou Anagnostou 13 Street, Koropi 19400, Greece
b
Coventry University, UK

a r t i c l e i n f o a b s t r a c t

Article history: Physiotherapy management of lumbar disorders, based on Mulligan's mobilization techniques, is a
Received 3 February 2014 treatment of choice by many physiotherapists, however, there is only limited evidence of any neuro-
Received in revised form physiological effects and much of this has focused on the cervical spine and upper limbs. This study aims
25 May 2014
to extend the knowledge base underpinning the use of a modified Mulligan's spinal mobilisation with leg
Accepted 7 July 2014
movement technique (SMWLM) by exploring its effects on the peripheral sympathetic nervous system
(SNS) of the lower limbs. Using a single blind, placebo controlled, independent groups study design, 45
Keywords:
normal naive healthy males were randomly assigned to one of three experimental groups (control,
Mulligan
Mobilisation
placebo or treatment; SMWLM). SNS activity was determined by recording skin conductance (SC) ob-
Sympathetic outflow tained from lower limb electrodes connected to a BioPac unit. Validation of the placebo technique was
Lower limbs performed by post- intervention questionnaire. Results indicated that there was a significant change in
SC from baseline levels (30%) that was specific to the side treated for the treatment group during the
intervention period (compared to placebo and control conditions). This study provides preliminary ev-
idence that a modified SMWLM technique results in side-specific peripheral SNS changes in the lower
limbs.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction A critical review of the literature regarding the possible mecha-

Manual therapy techniques based on Mulligan's concept, are
gaining increasing popularity for use in musculoskeletal conditions,
such as low back pain (LBP) and other disorders (Konstantinou et al.,
2007). Mulligan's techniques include sustained natural apophyseal
glides (SNAG'S), natural apophyseal glides (NAG'S) and mobiliza-
tions with movement (MWM'S). The application of these techniques
consists of a manual force, usually in the form of a glide, applied to a
motion segment and sustained while the patient actively performs
their painful or restricted movement (Vicenzino et al., 2007).
Mulligan (1993) originally suggested an underlying biomechanical
mechanism by which these techniques were effective, based on the
assumption that after an injury or a trauma, positional faults
occurred in the joint with resultant pain and dysfunction. Mulligan
(1993) proposed that by performing MWM techniques, the posi-
tional fault could be corrected, normal joint motion restored and
symptoms abated. However, there remains a scarcity of quality ev-
idence to refute or support this proposed mechanism.
* Corresponding author. Tel.: þ30 2106628863, þ30 6948507377 (mobile).
E-mail address: tsirakis_vasilis@yahoo.gr (V. Tsirakis).
nisms underpinning the beneficial effects of Mulligan's techniques,
reported that the biomechanical hypothesis that MWM'S reverse
positional faults in not well established (Vicenzino et al., 2007).
Furthermore, despite patient reports of immediate pain relief, after
the performance of these techniques, magnetic resonance imaging
and X-rays have failed to confirm post-treatment “alterations” in the
position of the bones. Vicenzino et al. (2007) suggest that the im-
mediate effects of Mulligan's techniques on pain reduction may be
neurophysiologically based (as measured by recordings of sympa-
thetic nervous system e SNS- activity) by activating non-opioid
endogenous pain inhibition pathways. Specifically, the descending
pain inhibitory systems via the peri-aquaductal gray (PAG) regions
in the mid-brain (Wright, 1995; Bialosky et al., 2009).
This theory was originally based on animal studies conducted by
Reynolds (1969) and Lovick (1991) who demonstrated that activa-
tion of the dorsal peri-aquaductal gray (dPAG) resulted in analgesia
in association with an excitatory response of the sympathetic ner-
vous system (e.g. increased heart rate, increased blood pressure,
increase of respiration). Following that report, Wright (1995) and
Bialosky et al. (2009) advocate that manual therapy techniques may
activate these central inhibitory systems with resultant hypoalgesic

http://dx.doi.org/10.1016/j.math.2014.07.002
1356-689X/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Tsirakis V, Perry J, The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on
sympathetic outflow to the lower limbs, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.07.002
2 V. Tsirakis, J. Perry / Manual Therapy xxx (2014) 1e6

and sympathoexcitatory responses being recorded in both norma- between the ages of 18e35 (mean ¼ 23.6 years, SD ¼ ±4.58) with no
tive and patient groups (Vicenzino et al., 1995; Sterling et al., 2001). previous experience of spinal mobilization or any other physiother-
Supporting this concept, a number of authors have investigated apeutic intervention so as to not risk the placebo and control con-
the neurophysiological responses to a variety of manual therapy ditions. Furthermore, an all-male group was chosen, in order to avoid
techniques by observing the effects of these techniques on pain the effect of variance which the female hormone progesterone has on
and/or on the sympathetic nervous system (SNS) (Vicenzino et al., the skin conductance response (Venables and Christie, 1973 cited in;
1995, 1998; Sterling et al.,. 2001; Moulson and Watson, 2006; Perry Perry and Green, 2008). Table 1 summarizes the subjects anthropo-
and Green, 2008; Perry et al., 2011). The results from these studies metric characteristics. All volunteers were further assessed for their
suggested that manual therapy mobilization techniques induce an suitability using the exclusion criteria as described in the study by
immediate sympathoexcitatory response (Vicenzino et al., 1998; Moulson and Watson (2006).
Sterling et al., 2001; Moulson and Watson, 2006; Perry and Perry and Green (2008), were the first to investigate SNS activity
Green, 2008; Perry et al., 2011) that has been linked to a mechan- during a unilaterally applied lumbar spinal mobilization technique
ical hypoalgesic effect (Vicenzino et al., 1998; Sterling et al.,. 2001). recording SC values in control, placebo and treatment condition.
However, research on Mulligan's SNAG'S and SNS activity is Based on their intra-subject standard deviation of 20.3% (treat-
limited to two studies, one in the cervical spine by Moulson and ment), a power analysis calculation revealed that 45 subjects (15
Watson (2006), and the second in the lumbar spine by Moutzouri per group) would enable a difference in SC from baseline of 23.8% to
et al. (2012). Both of these studies suggested that SNAG'S per- be detected at a significance level of p ¼ 0.05 with 80% power.
formed on the cervical (C5/6 segment) and lumbar (L4/5 segment) Hence, the current study chose a 20.3% SC value difference as a
regions elicit immediate bilateral sympathoexcitatory responses. value that would represent a clinically significant change.
However, only Moutzouri et al. (2012) reported percentage changes
(PC) in skin conductance (SC) values (from baseline period to 2.2. Research design
treatment period) therefore limiting comparison to other studies.
Moutzouri et al. (2012) reported a PC in SC in the order of 11%. This A single-blind, independent (matched) group, between-subjects
response corresponds to other reports of PC in SC of 16%, for a experimental design was used. Fig. 1 illustrates the participants'
unilaterally applied cervical spine mobilization (Sterling et al., progress through the study. Each participant was randomly allo-
2001) and 13.5% for an uni-laterally applied lumbar mobilization cated to either the control, placebo or treatment group using the
(Perry and Green, 2008). Other authors, however, have documented third party concealed randomization method (Altman and Schulz,
percentage changes in SC responses of greater magnitude with both 2001). Specifically, randomization was done using sequentially
peripheral techniques (55% during an MWM to the elbow e numbered sealed envelopes each with a computer-generated
Paungmali et al., 2003) and for spinal treatments (35% for a random number inside with each number representing an inter-
repeated extension in prone lying exercise and 75% for a lumbar vention. This limits the potential for researcher and order bias (Sim
manipulative procedure e Perry et al., 2011). To date, no study has and Wright, 2002).
investigated the immediate SNS activity responses to Mulligan's To enhance the rigor of the study, a previously validated post-
lumbar spinal mobilisation with leg movement (SMWLM) tech- experiment questionnaire (Perry and Green, 2008) was utilized to
nique, which is a technique, described by Mulligan (2004: page 77), determine the validity of the placebo condition. Furthermore, the
indicated for patient with LBP and radiating leg pain. set-up of the equipment ensured that both the treating therapist
According to Mulligan (2004), this technique is performed by and the participant remained blind to SNS activity responses during
two practitioners working as a team with one performing the the experimental period (Fig. 2). The interventions were performed
sustained medial glide on the patient's lumbar spinous process by the principal researcher who is a manual therapist (member of
whilst the other moves, passively, the patient's uppermost leg into the MACP) and Certified Mulligan Practitioner (CMP). Ethical
hip flexion. Furthermore, Mulligan (2004) advocates that on the approval for the study was obtained from the Coventry University
patient's first visit, this technique should be performed only three ethics committee.
times (rule of three) as a precaution against any latent exacerba-
tion. Hence, following Mulligan's rule of three, after the perfor-
2.3. Research method and experimental conditions
mance of this technique, the patient's symptoms are eased and they
are able to achieve greater ROM in the straight-leg raise (SLR)
An independent group, placebo-controlled randomized
maneuver without radiating leg pain below the knee.
controlled trial design was employed to test the null hypotheses that
However, this study is looking at a modified version of this
there would be no difference within or between treatment groups
technique since it's being performed by only one practitioner with
the assistance of a belt. The reasoning behind this modification is
Table 1
that many physiotherapists work alone without having a second Comparisons of characteristics of participants (age, weight and height) in each
physiotherapist to assist them. Additionally, this modified technique experimental group (control, placebo and treatment group).
has, anecdotally, been found to be effective in reducing a patient's
All subjects Control group Placebo group Treatment group
pain that is radiating below knee when performed by the investi-
gator in a clinical setting. Thus, since the evidence for this technique Age (yrs)
Mean 23.6 23.6 23.4 23.8
is anecdotal, this study aims to contribute to the evolving evidence Range 18e34 18e33 18e31 19e34
regarding the effects of manual therapy mobilization techniques. SD ±4.58 ±4.46 ±4.67 ±4.93
Weight (kg)
2. Methodology Mean 75.2 78.4 72.6 74.4
Range 50e110 63e110 50e95 56e90
SD ±10.8 ±12.47 ±10.87 ±8.87
2.1. Participants Height (cm)
Mean 179.9 182.3 178.4 179
Data collection took place between September and November Range 160e198 170e198 160e188 160e193
2009. Forty five healthy male volunteers from the Coventry Univer- SD ±7.9 ±7.14 ±7.14 ±8.66

sity student population, consented to participate. Participants were Kg ¼ kilograms; cm ¼ centimeters; SD ¼ standard deviation.

Please cite this article in press as: Tsirakis V, Perry J, The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on
sympathetic outflow to the lower limbs, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.07.002
 V. Tsirakis, J. Perry / Manual Therapy xxx (2014) 1e6 3

Fig. 1. Consolidated Standards of Reporting Trials (CONSORT) flow chart of study participant enrollment, treatment allocation and analysis.

or between limbs in SC responses. Participants lay in a standardized
position on their left side on the treatment plinth. Bilateral lower
limb skin conductance (SC) readings were simultaneously recorded
before, during and after each intervention by using silver/silver
chloride electrodes (12 mm electrode gel contact area). The skin was
prepared in accordance with standard protocol for Biopac mea-
surement (Petersen, Vicenzino, & Wright, 1993, Chiu and Wright,
1996). The electrodes were applied to the plantar aspect of the
2nd and 3rd toes of both feet simultaneously, giving an indepen-
dent, single reading for each foot. The selection of these toes was
due to the cutaneous branch of the medial plantar nerve (L4/5
segment), which supplies the plantar aspect of the 2nd and 3rd toes.
Following the protocol of previous researchers (Petersen et al.,
1993; Chiu and Wright, 1996; Perry and Green, 2008), all partici-
pants underwent an initial 10 min stabilization period followed by a
2 min baseline period. After that, the participant received one of
the three experimental conditions of 2 min duration each (called
the intervention period). Recordings were continued for further
2 min and this period was termed as the post-intervention period.
The three experimental conditions which were used in this study
are described as follows.
2.4. Modified SMWLM treatment technique
In this modified technique, the investigator performed a sus-
tained medial glide on the side of the participant's fourth lumbar
spinous process through thumb pad pressure on the lamina. This
was sustained whilst the therapist passively moved the partici-
pants' uppermost (right) leg into hip flexion which was performed
with the assistance of the belt (Fig. 3). The investigator sustained
the medial glide on the spinous process throughout the leg
movement and only when the participant's leg was returned

Please cite this article in press as: Tsirakis V, Perry J, The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on
sympathetic outflow to the lower limbs, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.07.002
4 V. Tsirakis, J. Perry / Manual Therapy xxx (2014) 1e6
Fig. 2. Experimental area set up (the screen ensured blinding of the participant and
the treating therapist from the SC recordings).
passively to the starting position was the glide released. This whole
procedure was repeated three times in accordance to Mulligan
(2004) rule of three.
2.5. The placebo intervention
For the placebo intervention, the procedure described above
was repeated with the exception that the investigator only posi-
tioned his hand on the spine but did not apply the accessory medial
glide to the participant's spinal segment. Only minimal pressure
was exerted and the participant's leg was slightly lifted by the belt
without any movement taking place into hip flexion.
2.6. The control condition
For the control condition, the participant remained in the
standardized left side-lying neutral starting position. Furthermore,
in order to maintain the control condition parameters, the partic-
ipant received no manual contact nor was the belt placed around
their leg.
2.7. Data collection methods
Physiological recording of SNS activity were measured by a
Biopac GSR100B Electro-dermal Activity Amplifier (MP30, Biopac
Systems Inc., Santa Barbara, CA) utilizing SC activity measures.
Fig. 3. Modified sustained spinal (L4/5 segment) mobilization with passive leg
movement (SMWLM) technique.
Please cite this article in press as: Tsirakis V, Perry J, The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on
sympathetic outflow to the lower limbs, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.07.002
Analysis of the SC data involved calculation of the “Integral Mea-
surement” for baseline, intervention and final rest periods (Perry
and Green, 2008). Intervention and final rest period values were
then converted into percentage change (PC) from baseline, using
the mathematic formula below. The use of PC permits within and
between-participant comparisons of data and facilitates the com-
parison of data from this study with results in previous studies
(Perry and Green, 2008; Moutzouri et al., 2012):
Ny
PC ¼  100
y
(where y ¼ baseline reading; N ¼ new reading in the intervention
or final rest period.)
3. Data analysis
Statistical analysis of the data was designed to test the three
elements of the hypothesis: (1) that the modified SMWLM tech-
nique in the treatment group would result in a PC in SC values from
baseline that were greater than those of the placebo and control
groups, (2) that any PC change observed would be greatest during
the intervention period compared to the post-intervention period
and (3) that any PC would be specific to the leg treated (ipsilateral/
right leg).
Data was described using PC values (mean, range, standard
deviation) and inferentially analyzed using the one-way ANOVA
(unrelated) test, since a single dependent variable (skin conduc-
tance) is tested under three experimental conditions and since
different participants are used for each condition (Greene and
D'Oliveira, 1982). All data were analyzed using the SPSS statistical
package (SPSS v.20). Statistically significant differences between
the experimental groups were subjected to post hoc analyses to
identify where differences in SC responses and differences in the
post-treatment questionnaire results lay (Bonferroni test and
KruskaleWallis test, respectively). Throughout all analyses, the
statistical significant p-value was set at p < 0.05 (two-tailed test).
4. Results
Homogeneity of participant data was assured indicating that the
groups were well matched regarding age (p ¼ 0.767), weight
(p ¼ 0.537) and height (p ¼ 0.726).
4.1. Skin conductance (SC) differences between and within groups
Descriptive data analyses of percentage change in SC readings
from the baseline for each of the experimental conditions and for
each leg in each time period are provided in Table 2. Fig. 4 illustrates
the distribution of skin conductance PC (%) values for the three
experimental conditions during the intervention period for the
right and the left leg.
Inferential statistical analysis (ANOVA) of the percentage change
SC data (Table 2) indicated that there was a significant difference
between the three experimental conditions, the time periods and
the limbs (F ¼ 3.238; df ¼ 2; p ¼ 0.049). Post hoc analysis revealed
that this difference was with the treatment group (SMWLM tech-
nique) during the intervention period in the right leg (p ¼ 0.045).
Statistical analysis of the post-intervention (final rest) period
revealed that there was no statistically significant difference in
percentage change in SC values between the experimental groups
and the legs (right; F ¼ 0.711, df ¼ 2; p ¼ 0.497: Left; F ¼ 0.711,
df ¼ 2; p ¼ 0.497).
 V. Tsirakis, J. Perry / Manual Therapy xxx (2014) 1e6 5

Table 2
Percentage change (PC) in SC readings from the baseline period (mean) ± standard error (S.E.) for each experimental condition (including post-hoc analysis) during the
intervention (PC1) and post-intervention (PC2) periods.

Experimental group and SC response per side (right or left leg) ANOVA Post hoc analysis (Bonferroni)

Control Placebo Treatment p value (F value) Control/ Control/ Placebo/

df ¼ 2 Placebo Treatment Treatment
p value p value p value

Right Left Right Left Right Left Right Left Right Left Right Left Right Left

PC1 in SC 2.34 0.67 18.32 12.53 30.65a 15.42 0.049a (3.24) 0.146 (2.02) 0.478 0.946 0.045a 0.153 0.826 0.981
S.E. (±) 1.39 2.02 8.01 8.30 11.00 13.43
PC2 in SC 1.37 3.91 13.45 18.45 11.16 14.80 0.497 (0.71) 0.332 (0.33) 0.936 0.504 1.00 0.741 0.911 1.00
S.E. (±) 1.70 2.70 8.16 15.43 11.82 11.65

PC1: percentage change from baseline to intervention period.

PC2: percentage change from baseline to post-intervention period.
a
indicates a statistically significant p-value, where the level of significance is set at p  0.05.

4.2. Post-trial questionnaire
Analysis of the post-treatment questionnaire revealed that there
was no statistically significant difference in the perception of the
participants as to whether they had received the treatment or the
placebo condition with all p values exceeding the significance level
(p > 0.05).
5. Discussion
The results of this study suggest that a sustained medial glide on
the fourth lumbar spinous process (L4) with concurrent passive hip
flexion (modified SMWLM technique) results in statistically sig-
nificant side-specific changes in peripheral SNS (SC) activity during
the intervention period with the uppermost (right) leg having
double the response (PC ¼ 30%) than the underneath (left) leg
(PC ¼ 15%). Moreover, responses were greater than those of both
the placebo and control conditions with no responses being
significantly sustained (statistically) into the post-intervention
period. To the author's knowledge, no previous studies have
Fig. 4. Cluster boxplot illustrating the distribution of skin conductance percentage
change values for the three experimental conditions during the intervention period for
the right and left leg.
investigated whether Mulligan's SMWLM technique applied to the
lumbar spine would have a peripheral SNS effect in the lower limbs.
In the current study, the modified SMWLM technique presented
with an increase in SC of 30.6% (±11) which is in agreement with
Vicenzino, Collins, and Wright (1994) who reported increase of 33%
with a C5 lateral glide technique, during the intervention period,
and with Perry et al. (2011), who reported an increase of 35% (for a
lumbar extension in lying exercise technique) and 76% (during a
lumbar manipulation procedure). In contrast, the reported change
in SNS activity for a unilaterally applied technique, in the study by
Perry and Green (2008), was 13.5% and just 16% with the technique
used by Sterling et al. (2001). Compared to these results, the greater
SC change found in the current study may be attributed to the fact
that the modified SMWLM technique is a combination of move-
ments (a segmental glide mobilization technique and a passive hip
flexion). Indeed, while the use of a segmentally applied unilateral
technique may be comparable, in terms of the manual therapy
nature of application, with the sympathoexcitatory responses re-
ported by Perry and Green (2008) and Sterling et al. (2009), it is
unknown whether it is the spinal component that resulted in the
greater magnitude of response (almost twice that of the other re-
ported unilateral techniques) or the addition of the hip flexion
component in the current treatment. Consideration of these two
elements of the treatment may have implications regarding the
potential ‘neurodynamic component’ of the treatment however, to
date there are no published studies that have investigated the
neurophysiological (SNS) responses to SLR maneuvers nor has the
isolation of the hip flexion element been examined thereby making
data comparisons impracticable. Future studies are recommended
to investigate the potential for SLR maneuverrs, and the affects of
hip flexion components within treatments, on SNS (SC) changes.
However, in support of the segmental influence (over the limb
movement component) with respect to the SNS response recorded.
O'Leary et al. (2007) investigated the SNS responses to specific
cervical exercises and reported that no changes to SNS activity
levels were evoked with the treatment. Therefore, the “movement
component” does not appear to exert as great an effect as the
passive segmental mobilization although it may be argued that
cervical exercises are not comparable to the hip movement/excur-
sion in the current study with respect to the potential challenge to
neurodynamic mobility.
It is noteworthy that the modified SMWLM technique applied in
this study resulted in greatest response on the side of treatment,
meaning that greatest SC responses were recorded in the ipsilateral
(right) leg rather than the contra-lateral (left) leg. This finding is in
agreement with the study of Perry and Green (2008) who were
the first to report side-specific changes in SNS activity with the
application of a unilateral lumbar spine mobilization technique.

Please cite this article in press as: Tsirakis V, Perry J, The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on
sympathetic outflow to the lower limbs, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.07.002
6 V. Tsirakis, J. Perry / Manual Therapy xxx (2014) 1e6
However, other studies regarding the upper and lower quadrant
have reported bilateral responses (Sterling et al., 2001; Moulson
and Watson, 2006; Perry et al., 2011). A possible explanation for
this could be a difference in the spinal and central processing
mechanisms of the different treatment techniques (a unilaterally
applied technique versus a central SNAG or mobilization, a
segmental rotation technique versus a segmental lateral glide)
suggesting that different treatment techniques may induce either a
centrally mediated response (indicated by a bilateral response) or a
segmental spinal response (as indicated by a side-specific
response). Clearly, more research is required to support or
confirm these preliminary hypotheses and future research is rec-
ommended (on both healthy and symptomatic participants) to
develop and extrapolate these findings into patient populations
with lumbar symptoms (with or without radiating leg pain).
Clinically, the results of the current study have possible impli-
cations for physiotherapeutic treatment of patients presenting with
low back pain with (and without) radiating leg pain.
5.1. Limitations
A limitation of the study was the use of an asymptomatic pop-
ulation because any effects of the SMWLM technique on mechan-
ical hypoalgesia (and on symptoms) can only be speculated as
changes in pressure pain thresholds were not explored. Further-
more, the current study performed the treatment in accordance
with the fundamental treatment suggestions of Mulligans “rule of
3” dosage however, it is not known what effects any modifications
to the dosage (number and amplitude of repetitions) of the treat-
ment may have had on the nature, the magnitude or the longevity
of the SNS response recorded and is an area of investigation that is
recommended for further study.
5.2. Conclusions
In conclusion, the findings of this study did demonstrate a sig-
nificant sympatho-excitatory response during a SMWLM technique
and that significant differences occur within individuals (right and
left legs) and between treatment, placebo and control groups.
Clinically, this may imply that a greater SNS response may be
observed on the uppermost leg during the SMWLM technique
which could, theoretically, imply a spinal response that may result,
hypothetically, in side-specific hypoalgesia. However, further
extrapolation of these findings is highly recommended within a
clinical population.
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