Effect of Neural Mobilization Exercises in

Patients With Low Back-Related Leg Pain

With Peripheral Nerve Sensitization:
A Prospective, Controlled Trial
Ali M. Alshami, PhD, a Mohammed A. Alghamdi, MS, b and Mohammed S. Abdelsalam, PhD c
ABSTRACT

Objective: The aim of this study was to investigate the short-term effect of slider and tensioner exercises on pain and
range of motion (ROM) of straight leg raise (SLR) and slump tests in patients with low back−related leg pain with
peripheral nerve sensitization.
Methods: In this prospective, controlled trial, 51 patients with low back−related leg pain with peripheral nerve sensitization
were divided into 3 treatment groups: slider (slider neural mobilization exercise + transcutaneous electric nerve stimulation
[TENS]), tensioner (tensioner neural mobilization exercise + TENS), and control (only TENS). Each patient received 6
sessions over 2 weeks. The following outcomes were measured at baseline and after the first, third, and sixth sessions: visual
analog scale (VAS) for pain and ROM of SLR and slump tests were performed for the symptomatic side.
Results: Compared with controls, patients receiving the slider and tensioner exercises showed a greater decrease in
pain at the third and sixth sessions (mean difference: ≥1.54 cm; 95% CI, 0.1-3.9). There was a significant difference in
the ROM of the SLR test between the slider and controls at only the sixth session (mean difference: 16.7°; 95% CI,
-29.2 to -4.3). Patients in the slider and tensioner groups demonstrated greater improvements in the ROM of slump test
at all sessions compared with controls (mean difference: ≥12.5°; 95% CI, -32.1 to -6.4). There were no significant
differences between the slider and tensioner groups in any outcome at any session.
Conclusion: Patients in both slider and tensioner neural mobilization exercise groups demonstrated improvements in
pain and ROM in patients with low back−related leg pain with peripheral nerve sensitization compared to those in the
control group. (J Chiropr Med 2021;20;59-69)
Key Indexing Terms: Radiculopathy; Range of Motion; Sciatica; Low Back Pain

TAGEDH1INTRODUCTIONTAGEDEN and poorer function and quality of life.2 A systematic

Low back pain (LBP) is a very common symptom
worldwide that occurs in all age groups. In 2015, LBP was
responsible for 60.1 million disability-adjusted life-years,
and represented an increase of 54% since 1990.1 Low back
−related leg pain is present in approximately two-thirds of
patients with LBP and is associated with increased pain
a
Department of Physical Therapy, Imam Abdulrahman Bin
Faisal University, Dammam, Saudi Arabia.
b
Physical Therapy Department, Rehabilitation Center, Dam-
mam Medical Complex, Dammam, Saudi Arabia.
c
Department of Physical Therapy, Faculty of Physical Ther-
apy, Cairo University, Cairo, Egypt.
Corresponding author: Ali M. Alshami, PhD, Department of
Physical Therapy, College of Applied Medical Sciences, Imam
Abdulrahman Bin Faisal University, P.O. Box 2435 Dammam
31441 Saudi Arabia.
(e-mail: alshami@iau.edu.sa).
Paper submitted November 28, 2019; in revised form July 14,
2021; accepted July 16, 2021.
1556-3707
© 2021 by National University of Health Sciences.
https://doi.org/10.1016/j.jcm.2021.07.001
review appraised several systems that classified patients
with low back−related leg pain. One of the systems that
scored higher compared with other systems is the classifica-
tion system by Schafer and colleagues.3 Their system is a
pain mechanism classification system that classifies
patients with low back−related leg pain into 4 categories:
central sensitization, denervation, peripheral nerve sensiti-
zation, and musculoskeletal.4 Peripheral nerve sensitization
represents a reduced threshold and/or enhanced mechano-
sensitization that is arised from nerve root or nerve trunk
inflammation, resulting in adverse response to mechanical
provocation of nerve tissue.4,5
Neural tissue movement can be achieved by special techni-
ques such as neural mobilization. Neural mobilization maneu-
vers are treatment techniques that produce specific mechanical
changes in the nervous system, which may result in physio-
logical changes that help relieve symptoms.6,7 These physio-
logical changes may include decreased intraneural edema,8,9
reduced mechanical and thermal hyperalgesia, decreased allo-
dynia,10 and increased cutaneous vasodilation, as evidenced
by increased skin temperature, indicating a sympathetic
60 Alshami et al
Neural Mobilization in Radiculopathy
inhibitory effect.11 Basson et al.,12 in their systematic review,
concluded that neural mobilization improves pain and function
in groups of patients with nerve-related LBP and nerve-related
neck and arm pain.
A slider is a neural mobilization exercise that produces a
sliding movement of neural tissue relative to neighboring
tissue, in which a longitudinal force is applied at one end
of the nerve while tension is released at the other. A ten-
sioner is an exercise that increases tension in the neural tis-
sue, in which a longitudinal force is applied to increase the
distance between each end of the nerve.7 The difference
between slider and tensioner exercises in the application
method may result in different responses.13-17 Sliders may
be more useful to reduce pain and improve excursion of the
nerves, whereas tensioners may be used to improve the vis-
coelastic and physiological functions of neural structures.7
Previous studies have investigated the effect of slider
and tensioner exercises in isolation or in combination in
patients with carpal tunnel syndrome,18,19 cervical radicul-
opathy,20-22 and radicular LBP.23,24 Studies that have
investigated the differences between the slider and ten-
sioner exercises were conducted on cadavers, animals,13,15
or asymptomatic participants.14,17 To our best knowledge,
studies that have compared the 2 exercises in patients with
low back−related leg pain are lacking.
Therefore the aim of this study was to determine the
short-term effect of slider and tensioner exercises on pain
and range of motion (ROM) of straight leg raise (SLR) and
slump tests in patients with low back−related leg pain with
features of peripheral nerve sensitization compared with
control patients. The hypothesis was that there are statisti-
cally significant differences in pain and ROM of SLR and
slump tests among the groups (slider, tensioner, control).
TAGEDH1METHODSTAGEDEN
Study Design and Setting
This study was a prospective, controlled trial. The pri-
mary investigator was blinded to the patient’s measure-
ments, the examiner and independent observer were
blinded to the patients’ group, and patients were blinded to
the treatment assignment. Patients were alternately
assigned in a parallel design (1:1:1) to the slider, tensioner,
or control group. The first patient was assigned to slider
group, the second patient assigned to the tensioner group,
and the third patient to the control group, and so forth.
The study was conducted at the outpatient physical therapy
department in 3 secondary hospitals in Dammam, Saudi Ara-
bia; namely the Security Forces Hospital, King Fahd Hospital
of the University, and Dammam Medical Complex. This
study was approved by the institutional review board at Imam
Abdulrahman Bin Faisal University (IRB-2014-04-321) and
registered at ClinicalTrials.gov (NCT03621878). All patients
provided consent to participate.
Journal of Chiropractic Medicine
June 2021
Participants
The sample size was calculated using G*power software
version 3.0.10. Data from Tambeker et al.25 were used
(effect size = 0.82, a = 0.05, power = 0.95). The calculation
resulted in a total of 51 participants. The recruitment of
patients started on December 23, 2015, and the trial was
concluded on June 15, 2017. Patients with unilateral low
back-related leg pain with dominant peripheral nerve sensi-
tization were recruited. The patients were diagnosed with
peripheral nerve sensitization if they fulfilled the criteria
suggested by Sch€afer et al.,4 which included a self-reported
Leeds Assessment of Neuropathic Symptoms and Signs (S-
LANSS) score > 12, a negative sensory and motor neuro-
logic examination, and positive neural tissue provocation
tests (SLR test or slump test). Patients with peripheral nerve
sensitization were included if they were adults and had a
leg pain duration < 3 months. Patients, who sought treat-
ment for their symptoms, were included regardless of their
pain severity level. Patients with 1 or more of the following
criteria were excluded from this study: motor or sensory
deficits, history of back or lower-extremity surgeries, bilat-
eral referred pain, and patients with contraindications to
transcutaneous electrical nerve stimulation (TENS) as
described by Jones and Johnson.26
Physicians from the neurology and neurosurgery depart-
ments examined consecutive patients for sensory or motor
deficits and referred the patients with radicular pain and
without neurologic deficits to the physical therapy depart-
ment. In the initial visit, the primary investigator explained
to each patient the aims and the general procedures of the
study, and all patients provided written informed consent.
The examiner started examination for eligibility with S-
LANSS assessment and examination of SLR and slump
tests. If eligible, the patient was assigned to 1 of the 3 study
groups: slider, tensioner, or control.
Outcome Measurements
Outcomes were measured by the examiner. An indepen-
dent observer recorded hip and knee ROM for the symp-
tomatic side during the examination. The outcome
measurements were carried out at baseline, after the first
session, after the third session, and after the sixth session.
The visual analog scale (VAS) was used to measure pain
intensity. It consisted of a 10-cm horizontal line with “no
pain” at one end and “worst imaginable pain” at the other
end. The patient was asked to mark his current leg pain on
the line. VAS is a valid and reliable measurement of pain
intensity,27 with a minimal clinically important difference
of 1.8 to 1.9 cm.28
The ROM of the SLR test was measured as the angle of
hip flexion in relation to the horizontal. The SLR test has a
minimal detectable change (MDC) of 5.7° for hip flexion
angle29 and interrater reliability of 0.32 to 0.86.30 The
patient was in supine position with his neck in neutral
Journal of Chiropractic Medicine
Volume 20, Number 2
without pillows. The examiner supported the knee in full
extension using the proximal hand, whereas the distal hand
was used to maintain the ankle in a neutral position. The
examiner passively raised the leg until the patient reported
reproduction of symptoms or until the examiner felt signifi-
cant resistance to SLR.31,32 A bubble inclinometer (Fabri-
cation Enterprise Inc, White Plains, NY) was secured just
proximal to the ankle joint using double adhesive tape. The
inclinometer was directed toward the medial aspect of the
leg so that the examiner could not see it. The independent
observer adjusted the fluid to zero level before testing and
recorded the ROM during the test.
The slump test has an excellent reliability of 0.90 and an
MDC of 1.94° for knee flexion angle.16 In the slump test,
the patient was seated at the edge of the bed with legs dan-
gling freely and the knee at an angle of 90° flexion. The
patient’s trunk was placed in slump position with neck flex-
ion and hands together behind the back. The distal hand of
the examiner was used to maintain the ankle in neutral
position. The proximal hand was used to maintain the
slump position of the patient’s trunk. The examiner ver-
bally instructed the patient to maintain his or her neck in
flexed position. The examiner used his distal hand to pas-
sively extend the examined knee until the patient felt his or
her symptoms, or until the examiner felt significant resis-
tance.32 The bubble inclinometer was secured just proximal
to the ankle joint using double adhesive tape. The incli-
nometer was directed toward the medial aspect of the leg
so that the examiner could not see it. The independent
observer adjusted the inclinometer to 0° as a reference to
where the knee was in the start position of 90° knee flexion
and recorded the angle of knee extension during the test.
Interventions
Each patient received therapeutic sessions over 2 weeks
(3 sessions per week). Patients in all groups received TENS.
In addition, the tensioner group received the tensioner neural
mobilization exercise, and the slider group received the slider
neural mobilization exercise. Patients were not allowed to
take medication for pain during the study or to receive any
other form of treatment outside of the study.
A TENS device (Sonicplus 692V, ENRAF-NONIUS,
Rotterdam) was applied at a pulse frequency of 100 Hz.33
A single channel with 2 surface electrodes was used for
stimulation over a session period of 15 minutes.34 The elec-
trodes were placed on the painful paraspinal areas of the
back. The intensity was set to enable a clear tingling sensa-
tion above the sensory threshold of the patient.34
The patient performed the tensioner exercise in a sitting
slump position. The patient sat on the edge of the bed with
the neck and trunk in flexion, hips and knees in 90° flexion,
and ankles in resting plantar flexion. The patient was asked
to move the neck into flexion, the treated knee into exten-
sion, and the treated ankle into dorsiflexion simultaneously
Alshami et al 61
Neural Mobilization in Radiculopathy
(phase 1). Then the patient extended the neck, flexed the
knee, and plantar flexed the ankle simultaneously (phase
2). The patient was encouraged to achieve the exercise
with tolerated pain. The exercise was performed for 10 rep-
etitions over 2 sets. The patient was given a 2-minute rest-
ing time between the sets.7,16
The patient performed the slider exercise in a sitting
slump position. The patient sat on the edge of the bed with
the neck and trunk in flexion, hips and knees in 90° flexion,
and ankles in resting plantar flexion. The patient was asked
to move the neck into extension, the treated knee into exten-
sion, and the treated ankle into dorsiflexion simultaneously
(phase 1). Then the patient flexed the neck, flexed the knee,
and plantarflexed the ankle simultaneously (phase 2). The
patient was encouraged to achieve the exercise with tolerated
pain. The exercise was carried out for 10 repetitions over 2
sets, with a 2-minute rest between the sets.7,16
Statistical Analysis
SPSS software (version 23, IBM Corporation, New York)
was used for statistical analysis. Descriptive data of the mean
and SD were obtained for all data. The baseline between-
groups comparisons were performed using 1-way analysis of
variance. A 2-way mixed design analysis of variance with
post hoc (Bonferonni correction) was used to calculate the
differences in outcome measurements over time (baseline,
first, third, and sixth session) as a within-group factor and
groups (control, slider, and tensioner) as a between-group
factor. The effect size was also calculated with Cohen’s d to
estimate the magnitude of differences within and between
groups (small [d = 0.2], medium [d = 0.5], and large
[d = 0.8]).35 The significant level was set at P < .05.
TAGEDH1RESULTSTAGEDEN
Figure 1 is a flow diagram describing the patients’
recruitment. Table 1 shows that there were no significant
differences between the groups for all the demographic and
clinical variables at baseline, indicating homogenous
groups.
Regarding pain intensity, the 2-way mixed design analy-
sis of variance revealed a significant group-by-time interac-
tion (F [6,144] = 3.539, P = .003). Compared with the
baseline measurement, pain decreased significantly at all
sessions in the tensioner group and at sessions 3 and 6 in
the slider group. Although pain decreased significantly in
the control group at only session 6, there were significant
differences between the control group and both the slider
and tensioner groups in favor of the later groups. No signif-
icant differences were found between the slider group and
tensioner group at any session (Fig 2 and Table 2).
As for the ROM of the SLR test, a significant group-by-
time interaction was found (F [6,144] = 2.957, P = .009).
62 Alshami et al
Neural Mobilization in Radiculopathy
Fig 1. CONSORT diagram of patients’ enrolment. Rx, Treatment, TENS, Transcutaneous electrical nerve stimulation
Compared with the baseline measurement, the ROM of
SLR test increased significantly in both the slider and ten-
sioner groups at all sessions, with a moderate to high effect
size in the slider group, and a high effect size in the ten-
sioner group. In the control group, there was a significant
increase in the ROM of the SLR test at sessions 1 and 3 but
with a low to moderate effect size. Interestingly, the
improvement was progressive in the following sessions for
both the slider and tensioner groups, but not for the control
group. There were no significant differences between the
Journal of Chiropractic Medicine
June 2021
slider and tensioner groups at any session (Fig 3 and
Table 3).
Concerning the ROM of the slump test, significant
group-by-time interactions were found (F [6,144] = 2.521,
P = .024). The ROM of the slump test did not change in the
control group. On the other hand, the ROM of slump test
increased at all sessions compared with baseline in both the
slider and tensioner groups with a high effect size. There
were no significant differences between the slider and ten-
sioner groups at any session (Fig 4 and Table 4).
Journal of Chiropractic Medicine Alshami et al 63
Volume 20, Number 2 Neural Mobilization in Radiculopathy

Table 1. Baseline Characteristics of All Groups

Variables Slider Tensioner Control Statistics P Value
Age (y) 36.7 § 8.1 33.5 § 8.7 40.2 § 9.5 F(2.48) = 2.503 .092

Sex (M/F) (n) 17/0 17/0 17/0

BMI (kg/m2) 28.2 § 5.6 28.2 § 6.1 27.1 § 3.8 F(2.48) = 0.260 .772

VAS (cm) 5.1 § 2.2 5.1 § 2.0 5.6 § 1.8 F(2.48) = 0.475 .652

ROM (degrees)

Hip flexion in SLR 58 § 16 46 § 16 52 § 15 F(2.48) = 2.198 .122

Knee extension in slump 44 § 18 43 § 15 38 § 17 F(2.48) = 0.732 .486

Symptomatic side

Right (n) 6 9 6 x2 (2) = 1.457 .483

Left (n) 11 8 11

Values are expressed as mean § SD unless otherwise.

BMI, body mass index; ROM, range of motion; SLR, straight leg raise; VAS, visual analog scale.

TAGEDH1DISCUSSIONTAGEDEN showed significant improvements in all outcomes in favor of

To our best knowledge, this is the first clinical trial con-
ducted to investigate the difference between slider and ten-
sioner exercises on pain and ROM of neural tissue
provocation tests in patients with low back−related leg pain
with peripheral nerve sensitization. Generally, the results
the slider and tensioner groups but not the control group,
with no differences between the slider and tensioner groups.
Our findings showed that the VAS pain score
improved significantly and progressively in both the
slider (1.5-2.5 cm) and tensioner (1.5-3 cm) groups. In

Fig 2. Results of pain intensity. Bars indicates standard deviation. Solid line: p < .050, dotted line: p < .001. For more statistics values
see Table 2.
64 Alshami et al Journal of Chiropractic Medicine
Neural Mobilization in Radiculopathy June 2021

Table 2. Mean Difference in Within-Group and Between-Group for Pain (in centimeters)
Within-Group Mean Difference (95% CI) (Cohen’s d)
Control Group Slider Group Tensioner Group
C1-C2 C1-C3 C1-C4 S1-S2 S1-S3 S1-S4 T1-T2 T1-T3 T1-T4
0.7 0.5 1.0 a 0.3 1.5 a 2.4 a 1.5 a 2.5 a 3.0 a

(-0.1 to 1.6) (-0.4 to 1.5) (0.0-1.9) (-0.6 to 1.1) (0.6-2.4) (1.5-3.3) (5.7-18.8) (7.6-23.06) (13.2-29.9)

(0.41) (0.30) (0.56) (0.14) (0.68) (1.11) (0.73) (1.25) (1.71)

The between-group mean difference (95% CI) (Cohen’s d)

C2-S2 C2-T2 S2-T2 C3-S3 C3-T3 S3-T3 C4-S4 C4-T4 S4-T4

0.1 1.3 1.2 1.5a 2.5* 1.0 2.0 a 2.6 a 0.5

(-1.3 to 1.5) (-0.1 to 2.7) (-0.2 to 2.6) (0.1-2.0) (1.1-4.0) (-0.5 to 2.4) (0.7-2.3) (1.3-3.9) (-0.7 to 1.8)

(0.07) (0.64) (0.56) (0.75) (1.28) (0.45) (1.02) (1.56) (0.29)

C1, control group baseline measurement; C2, control group first session measurement; C3, control group third session measurement; C4, control group
sixth session measurement; CI, confidence interval; S1, slider group baseline measurement; S2, slider group first session measurement; S3, slider group
third session measurement; S4, slider group sixth session measurement; T1, tensioner group baseline measurement; T2, tensioner group first session mea-
surement; T3, tensioner group third session measurement; T4, tensioner group sixth session measurement.
a
Indicates significant P value.

Fig 3. Results of hip flexion range of motion of the straight leg raise test. Bars indicates standard deviation. Solid line: p < .050, dotted
line: p < .001. For more statistics values see Table 3.
Journal of Chiropractic Medicine Alshami et al 65
Volume 20, Number 2 Neural Mobilization in Radiculopathy

Table 3. Mean Difference in Within-Group and Between-Group for Hip Flexion Range of Motion of SLR Test (in degrees)
Within-Group Mean Difference (95% CI) (Cohen d)

Control Group Slider Group Tensioner Group

C1-C2 C1-C3 C1-C4 S1-S2 S1-S3 S1-S4 T1-T2 T1-T3 T1-T4
6.7* 7.4* 5.9 5.9* 9.8* 16.7* 12.5* 16.5* 22.2*

(-11.4 to -2.0) (-14.37 to -0.6) (-13.5 to 1.8) (-10.6 to -1.2) (-16.6 to -2.9) (-24.3 to -9.1) (-17.3 to -7.9) (-23.4 to -9.7) (-29.9 to -14.6)

(0.46) (0.50) (0.35) (0.37) (0.62) (0.87) (2.84) (1.09) (1.55)

The between-group mean difference (95% CI) (Cohen d)

C2-S2 C2-T2 S2-T2 C3-S3 C3-T3 S3-T3 C4-S4 C4-T4 S4-T4

5.1 0.4 -4.7 8.2 3.6 -4.6 16.7* 10.9 -5.8

(-15.7 to 5.6) (-11.0 to 10.3) (-5.9 to 15.3) (-18.3 to 1.8) (-13.6 to 6.5) (-5.4 to 14.7) (-29.2 to -4.3) (-23.3 to 1.67) (-6.6 to 18.3)

(0.34) (0.02) (0.29) (0.55) (0.25) (0.32) (0.83) (0.71) (0.33)

C1, control group baseline measurement; C2, control group first session measurement; C3, control group third session measurement; C4, control group
sixth session measurement; CI, confidence interval; S1, slider group baseline measurement; S2, slider group first session measurement; S3, slider group
third session measurement; S4, slider group sixth session measurement; SLR, straight leg raise; T1, tensioner group baseline measurement; T2, tensioner
group first session measurement; T3, tensioner group third session measurement; T4, tensioner group sixth session measurement.
*Indicates significant P value.

the control group, pain did not show any significant
improvement until the last session. However, this change
(0.9 cm) did not reach the minimal clinically important
difference of VAS (1.8-1.9 cm).28 In addition, the
decrease of pain in the last session was statistically ele-
vated in both treatment groups compared with the control
group. Patients in the tensioner group had the advantage
of an immediate reduction in pain after the first session
unlike the slider group.
Previous studies that have investigated slider and tensioner
exercises on patients with low back−related LBP are scarce.
Ali et al.23 and Pallipamula and Singaravelan24 found that the
slump slider exercise in combination with other treatments

improved pain. Colakovi c and Avdic36 applied the SLR ten-
sioner exercise in a side-lying position in combination with a
lumbar stabilization program and found a significant decrease
in pain compared with active ROM exercises and the lumbar
stabilization program. Applying slider or tensioner exercises
on other neurogenic conditions, such as cervical radiculop-
athy, also improved pain.20,22 Generally, slump and SLR
mobilization exercises are effective in reducing pain and
improving function in chronic nerve-related LBP.12 On the
other hand, there was no improvement in pain among patients
with LBP37 or carpal tunnel syndrome.19 In Patel’s study, the
slump stretching exercise was sustained for 30 seconds and
repeated 3 times per session.37 The difference in the results
may be attributed to the differences in the exercise used and
the patients’ diagnosis and characteristics.
In the current study, cumulative improvement in ROM of
SLR over sessions was demonstrated in both the slider
(range 6°-16°) and tensioner (range 13°-30°) groups. In the
control group, there was an improvement of only 7° after
the first session, which stayed the same until the last session.
Previous studies found improvement in ROM of SLR in
patients with radicular LBP after using slider24 or tensioner
exercises.24,25,36,38 Other studies, on the other hand, found
that adding slump tensioner did not improve the ROM of
the SLR test in patients with LBP who had no radicular
symptoms.37Again, the differences in interventions and
patients characteristics between our study and the study by
Patel37 may contribute to this discrepancy in the results.
In our study, the knee extension ROM of the slump test
improved significantly in both the slider (range 15°-19°)
and tensioner (range 12o-21°) groups but not in the control
group. This improvement was more than the MDC of
1.94°.16 In healthy participants, slider and/or tensioner
exercises improved the hip flexion ROM of SLR test and
the knee extension ROM of slump test.17,39,40
Understanding the physical and physiological effects of
both the slider and tensioner exercises is important to rec-
ognize the differences between these exercises. A limited
number of studies have been conducted to investigate the
differences between the 2 exercises. Most of these studies
focused on investigating the biomechanical aspects of these
exercises on nerves. The major biomechanical difference
between the 2 exercises is the amount of excursion and
strain produced by each. Cadaveric and in vivo studies
revealed that the tensioner exercise produced higher nerve
strain and the slider exercise was associated with higher
nerve excursion.13-15,41,42
66 Alshami et al
Neural Mobilization in Radiculopathy
Fig 4. Results of knee extension range of motion of the slump test. Bars indicates standard deviation. Solid line: p < .050, dotted line:
p < .001. For more statistics values see Table 4.
Neural mobilization is used to regain the movement of
the nerve tissue, restore nerve tissue homeostasis, and pro-
mote the nerve to return to its normal functions.43 The litera-
ture has hypothesized possible physiological changes that
may have led to the improvement of patients in this study
using neural mobilization. These changes may include
decreased intraneural edema, thus reducing hypoxia and
relieving symptoms; decreased neurogenic inflammation by
eliminating antidromic impulses generated in C-fibers at the
dysfunctional site; and reduced nociceptive input to the dor-
sal horns of the spinal cord.7,44 In the current study, the
improvements were demonstrated within 2 weeks of inter-
vention (3 sessions per week) with only 2 sets of 10 repeti-
tions of neural mobilization exercises. Because there is not
much evidence, it is recommended for future research to
address the effect of different doses of neural mobilization.
Limitations
A limitation with this study is the lack of randomization.
Randomization would have prevented selection and acci-
dental bias, and would have created more homogenous and
Journal of Chiropractic Medicine
June 2021
comparable groups, and would have eliminated potential
bias in treatment assignments. Therefore, there is a proba-
bility that the observed differences between group measure-
ments are owing to chance and that no true differences exist
between the treatment groups.45 Another limitation of the
study may be that we did not include nerve palpation as 1
of the criteria of peripheral nerve sensitization. However,
in addition to LANSS and the negative signs of neurologic
dysfunction, we relied primarily on SLR and slump tests as
neural tissue provocation tests. Walsh and Hall32 used SLR
and slump tests as the reference standard for sciatic nerve
mechanosensitivity. They considered patients, who were
positive on both SLR and slump tests, as positive for sciatic
nerve mechanosensitivity. Moreover, we used only pain
and ROM as outcomes. Adding functional and quality of
life measurements would have demonstrated the impact of
neural mobilization on patients’ activities and social lives.
In addition, general ROM exercises for the lower limb
were not added as a control intervention, taking into con-
sideration that the use of positive verbal communication
during the slider and tensioner exercises might produce a
placebo analgesic effect.46
 Volume 20, Number 2
Journal of Chiropractic Medicine
Table 4. Mean Difference in Within-Group and Between-Group for Knee Extension Range of Motion of Slump Test (in Degrees)
Within-Group Mean Difference (95% CI) (Cohen d)
Control Group Slider Group Tensioner Group
C1-C2 C1-C3 C1-C4 S1-S2 S1-S3 S1-S4 T1-T2 T1-T3 T1-T4
2.9 4.3 5.3 14.4* 14.2* 18.8* 12.2* 15.3* 21.5*

(-9.42 to 3.657) (-11.96 to 3.375) (-13.66 to 3.079) (-20.9 to -7.8) (-21.9 to -6.6) (-27.1 to -10.4) (-18.8 to -5.7) (-23.0 to -7.6) (-29.9 to -13.2)

(0.16) (0.27) (0.31) (0.94) (0.86) (1.11) (0.81) (1.06) (1.51)

The between-group mean difference (95% CI) (Cohen d)

C2-S2 C2-T2 S2-T2 C3-S3 C3-T3 S3-T3 C4-S4 C4-T4 S4-T4

18.1* 14.6* 3.5 16.6* 16.2* -0.4 20.1* 21.5* -1.4

(-28.6 to -7.6) (-25.1 to -4.1) (-14.046 to 6.98) (-26.5 to -6.7) (-26.1 to -6.4) (-10.2 to 9.5) (-30.8 to -9.5) (-32.1 to -10.8) (-9.3 to 12.0)

(1.22) (0.88) (0.26) (0.16) (1.15) (0.02) (1.25) (1.40) (0.09)

C1, control group baseline measurement; C2, control group first session measurement; C3, control group third session measurement; C4, control group sixth session measurement; CI, confidence interval; S1,
slider group baseline measurement; S2, slider group first session measurement; S3, slider group third session measurement; S4, slider group sixth session measurement; T1, tensioner group baseline measure-
ment; T2, tensioner group first session measurement; T3, tensioner group 3 third session measurement; T4, tensioner group sixth session measurement.
a
Indicates significant P value.

Neural Mobilization in Radiculopathy

67 Alshami et al
68 Alshami et al
Neural Mobilization in Radiculopathy
TAGEDH1CONCLUSIONTAGEDEN
This is the first study to our knowledge that investigated
the difference between the slider and tensioner exercises on
pain and ROM of SLR and slump tests in patients with low
back−related leg pain who demonstrated predominant
characteristics of peripheral nerve sensitization. Both exer-
cises demonstrated statistically and clinically meaningful
improvements compared with the control group. There
were no differences in the outcomes between the slider and
tensioner exercises.
TAGEDH1FUNDING SOURCES AND CONFLICTS OF INTERESTTAGEDEN
No funding sources or conflicts of interest were reported
for this study.
TAGEDH1CONTRIBUTORSHIP INFORMATIONTAGEDEN
Concept development (provided idea for the research):
M.A.A.
Design (planned the methods to generate the results):
M.A.A., M.S.A.
Supervision (provided oversight, responsible for organiza-
tion and implementation, writing of the manuscript):
M.S.A., A.M.A.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data):
M.A.A., A.M.A.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): M.A.A.,
M.S.A., A.M.A.
Literature search (performed the literature search): M.A.A.
Writing (responsible for writing a substantive part of the
manuscript): M.A.A., A.M.A.
Critical review (revised manuscript for intellectual content,
this does not relate to spelling and grammar checking):
M.A.A., M.S.A., A.M.A.
Practical Applications
 The findings of the study add insight into the
effect of the slider and tensioner techniques in
patients with lumbosacral radiculopathy.
 Three sessions per week for 2 weeks of slider
and tensioner techniques improved pain and
hip and knee ROM.
 Although the trend was in favor of the ten-
sioner, there were no significant differences
between the tensioner and slider techniques.
Journal of Chiropractic Medicine
June 2021
TAGEDH1ACKNOWLEDGMENTSTAGEDEN
The authors extend acknowledgements to colleagues
who helped in completing this study: Ibrahim Alwesaly,
Saleh Alyahia, Mohammed Alsunni, and Ghaithan Alkha-
thami for their roles as examiners, and also Abdulrahman
Aleinizi, Ahmed Alomar, and Ahmad bu Saleh for their
roles as independent observers.
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