ORIGINAL RESEARCH ARTICLE

Effects of Adding a Neurodynamic Mobilization to Motor Control

Training in Patients With Lumbar Radiculopathy Due to Disc
Herniation
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

A Randomized Clinical Trial

WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023

Gustavo Plaza-Manzano, PT, PhD, Ignacio Cancela-Cilleruelo, PT, MSc,

César Fernández-de-las-Peñas, PT, MSc, PhD, Dr med, Joshua A. Cleland, PT, PhD, José L. Arias-Buría, PT, PhD,
Marloes Thoomes-de-Graaf, PT, PhD, and Ricardo Ortega-Santiago, PT, PhD

Objective: The aim of the study was to investigate the effects of the
inclusion of neural mobilization into a motor control exercise program
on pain, related disability, neuropathic symptoms, straight leg raise,
and pressure pain threshold in lumbar radiculopathy.
Design: This is a randomized clinical trial.
Methods: Individuals with low back pain, with confirmed disc herni-
ation, and lumbar radiculopathy were randomly assigned to receive
eight sessions of either neurodynamic mobilization plus motor control
exercises (n = 16) or motor control exercises alone (n = 16). Outcomes
included pain, disability, neuropathic symptoms, straight leg raise, and
pressure pain threshold at baseline, after four visits, after eight visits,
and after 2 mos.
Results: There were no between-groups differences for pain, related
disability, or pressure pain threshold at any follow-up period because
both groups get similar and large improvements. Patients assigned to
the neurodynamic program group experienced better improvements
in neuropathic symptoms and the straight leg raise compared with
the motor control exercise group (P < 0.01).
Conclusions: The addition of neurodynamic mobilization to a motor
control exercise program leads to reductions in neuropathic symptoms
and mechanical sensitivity (straight leg raise) but did not result in
greater changes of pain, related disability, or pressure pain threshold
over motor control exercises program alone in subjects with lumbar
radiculopathy. Future trials are needed to further confirm these findings
because between-groups differences did not reach clinically relevance.
Key Words: Lumbar Radiculopathy, Exercise, Neurodynamic, Pain,
Disability
(Am J Phys Med Rehabil 2020;99:124–132)
ow back pain (LBP) is a common condition, resulting in a
Lity. The
significant impact on the patient in terms of pain and disabil-
costs associated with LBP are increasing exponentially.
What Is Known
• Motor control exercises are effective for the manage-
ment of low back pain. Some evidence supports the
use of neural mobilization in low back pain, but its ev-
idence for radicular pain is poor. We do not know
whether combined interventions would lead to better
outcomes.
What Is New
• The addition of neurodynamic mobilization to a mo-
tor control exercise program leads to some reduction
in neuropathic symptoms and mechanical sensitivity
but did not result in greater changes of pain, related
disability, or pressure pain sensitivity over the applica-
tion of motor control exercises program alone in sub-
jects with lumbar radiculopathy.
In addition, many individuals with LBP also experience the con-
sequence of a disk herniation, for example, radiating pain and
radicular symptoms, which may result in lower limb symptoms,
such as radiculopathy.2 Lumbar radiculopathy may be the result
of a herniated lumbar disc, which may irritate a lumbar nerve
trunk resulting in intraneural inflammation. A herniated disk
could cause lower limb numbness and weakness in addition
to pain experienced by the individuals. Unfortunately, lumbar
radiculopathy can progress to chronicity resulting in substan-
tial pain, disability, and burden.3
There are several treatment strategies for the management
of LBP and lumbar radiculopathy including disc surgery, in-
jections, analgesia, acupuncture, traction, manual therapy,
1
percutaneous discectomy, exercise, and/or orthosis.4 Although
optimal management strategy for lumbar stenosis, including

From the Department of Radiology, Rehabilitation and Physiotherapy, Universidad
Complutense de Madrid, Madrid, Spain (GP-M); Instituto de Investigación San-
itaria del Hospital Clínico San Carlos, Madrid, Spain (GP-M); Clínica Fisiofit,
Madrid, Spain (IC-C); Department of Physical Therapy, Occupational Therapy,
Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón,
Madrid, Spain (CF-d-l-P, JLA-B, RO-S); Cátedra de Investigación y Docencia en
Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapeútico, Universidad
Rey Juan Carlos, Alcorcón, Madrid, Spain (CF-d-l-P, JLA-B, RO-S); Physical
Therapist, Rehabilitation Services, Concord Hospital, Concord, New Hampshire
(JAC); Faculty, Manual Therapy Fellowship Program, Regis University, Denver,
Colorado (JAC); Department of Physical Therapy, Franklin Pierce University,
Manchester, New Hampshire (JAC); and Fysio-Experts, Hazerswoude-Rijndijk,
the Netherlands (MT-d-G).
All correspondence should be addressed to: César Fernández-de-las-Peñas, PT, MSc,
PhD, Dr med, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos,
Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain.
Trial registration: http://www.clinicaltrials.gov, ClinicalTrials.gov, NCT03620864.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001295

124 www.ajpmr.com American Journal of Physical Medicine & Rehabilitation • Volume 99, Number 2, February 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Volume 99, Number 2, February 2020
radiculopathy, remains to be elucidated, current trends are con-
servative interventions, such as physical therapy.5 Moreover,
according to an international survey, surgeons around the
world indicated one of the assumptions for an operative inter-
vention is the failure of conservative therapy, thereby implying
that conservative therapy is the first treatment option.6 Surgery
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
is not more effective than physical therapy after 1 yr on pain re-
lief and perceived recovery.7,8 Many physical therapy treat-
ment options exist, including manual therapies and exercises;
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023
however, the best method to decrease pain and improve func-
tion in people with LBP and leg pain associated with lumbar
radiculopathy is not currently known.9
The most recent Cochrane review found moderate- to
high-quality evidence supporting the use of motor control exer-
cises for the management of LBP, although no differences were
found with other forms of exercise.10 There also exists evi-
dence supporting the use of manual therapies, such as spinal
manipulation or mobilization for the management of LBP.11
However, different manual therapies, for example, soft tissue
interventions, spinal manipulation or mobilization, and neural
interventions, target different concepts.
A manual therapy technique that may potentially be used
for the management of patients with lumbar radiculopathy is
neurodynamic mobilization. Neural mobilization includes both
slider and tensioner maneuvers. The aim of a nerve slider inter-
vention is to induce a gliding movement of the nerve trunk in
relation to their adjacent tissues. The nerve slider technique ap-
plies joint movements to the targeted structure proximally
while releasing the movement distally, followed by a reverse
combination.10 In the contrary, the aim of a nerve tensioner in-
tervention is to induce tension of a nerve trunk in relation to
their adjacent tissues. The nerve tensioner technique applies
joint movements to the targeted structure proximally and dis-
tally at the same time and in the same direction toward an in-
crease in nerve tension.10 It has been postulated that if the
nervous system (lumbar nerve root) is irritated, the system
may present with neural edema, ischemia and fibrosis, leading
to further damage resulting in pain and decreased function.12,13
The underlying mechanisms of neural mobilization interven-
tions include restoration of homeostasis in and around the
nerve and reducing intraneural edema through intraneural fluid
dispersion in the nerve root and axon.14–16
Cleland et al.17 used a neurodynamic mobilization tech-
nique to manage a patient with lumbar radiculopathy in which
the individual experienced clinically meaningful reductions in
pain. However, no high-quality evidence exists in relation to
this particular approach individuals with lumbar radiculopathy.18
A recent meta-analysis reported that neural mobilization is ef-
fective for improving pain and disability in individuals with
LBP, but the evidence for the use of neural mobilization for ra-
dicular pain was found to be poor.19 Future trials examining
the effects of neural mobilization in people with lumbar
radiculopathy are necessary to determine its efficacy.
Therefore, the purpose of this randomized clinical trial
was to investigate the effects of the addition of neural mo-
bilization into a motor control exercises program on pain,
disability, and pressure sensitivity in individuals with
lumbar radiculopathy. Our hypothesis was that subjects
with lumbar radiculopathy receiving neural mobilization
combined with a motor control exercise program would
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Neurodynamic Intervention in Lumbar Radiculopathy
experience better outcomes than those receiving motor con-
trol exercise program alone.
METHODS
Study Design
A randomized, parallel-group, clinical trial was conducted
to compare the effects of adding a neurodynamic mobilization
into a motor control exercise program on pain intensity, neuro-
pathic symptoms, related disability, straight leg raise test, and
pressure pain sensitivity in individuals with lumbar radiculopathy.
The study was approved by the institutional review board of
Universidad Alcalá de Henares, Spain (CEIM/HU/201531) and
the trial was registered (ClinicalTrials.gov: NCT03620864). This
trial conforms to CONSORT guidelines and reports the required
information accordingly (see Supplemental Checklist, Supple-
mental Digital Content 1, http://links.lww.com/PHM/A859).
Participants
Between July and October 2018 consecutive patients
exhibiting LBP and radiculopathy (lower limb symptoms) were
screened for potential eligibility criteria from a local hospital in
Madrid, Spain. To be eligible to participate, patients (a) had to
be between 18 and 60 yrs old, (b) have a confirmed (via MRI)
disc herniation between L4-S1 levels, (c) had to exhibit lumbar
radiating pain to one lower limb including the foot, (d) have
had pain for at least 3 mos, (e) had increased leg pain on
coughing, sneezing, or straining, and ( f ) had a positive
straight leg raise with symptom reproduction between 40
and 70 degrees. All participants received a neurological clin-
ical examination including assessment of muscle weakness,
cutaneous sensitivity, and reflexes by an experienced neurolo-
gist for evaluating the integrity of the nervous system and
avoiding the presence of lumbar radiculopathy. Manual muscle
tests were performed to identify the presence of weakness
along L4-S1 myotome distribution by using the grading of 0
to 5 (0/5 no movement, 3/5 antigravity, 5/5 normal). Subjects
were excluded if they had any of the following criteria: (a) in-
dication for surgical intervention, for example, absence of re-
flexes, muscle atrophy, and signs compatible with lumbar
myelopathy, (b) had a confirmed disc herniation at other lumbar
levels, (c) have had any other spinal conditions such as spinal tu-
mors, spondylolisthesis, or cauda equina, (d) had received treat-
ment for this condition by a physical therapist the previous 6 mo,
or (e) pregnancy. Participants were also excluded if they exhib-
ited any contraindications to manual therapy or exercise as noted
in the patient’s Medical Screening Questionnaire, such as rheu-
matoid arthritis, osteoporosis, prolonged history of steroid use,
severe vascular disease, etc. All subjects signed an informed
consent before participation in the study.
All participants provided a detailed history, underwent a
physical examination, and completed a number of self-report
measures at baseline. The historical items included questions
pertaining to the onset of sensory symptoms including pain,
pins or needles, the distribution of the symptom, aggravating
and easing postures, mechanism of injury, previous treatments,
and history of low back or leg pain. These physical examina-
tion items were those that are routinely used in the physical
therapy examination of the lower limb.
www.ajpmr.com 125
 Plaza-Manzano et al. Volume 99, Number 2, February 2020

Randomization and Masking

Subjects were randomly assigned to receive either motor
control exercises plus neurodynamic mobilization or a motor con-
trol exercise program alone. Concealed allocation was performed
by an individual not involved in subject’s recruitment using a
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

computer-generated randomized table of numbers created before

the beginning of the trial. The group assignment was recorded on
an index card. This card was folded in half such that the label with
the patient’s group assignment was on the inside of the fold. The
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023

folded index card was then placed inside the envelope, and the
envelope was sealed. A second therapist blinded to the baseline
examination findings opened the envelope and proceeded with
treatment according to the group assignment.

Treatment Interventions
All interventions were applied by an experienced physical
therapist with more than 10 yrs of experience in the manage-
ment of patients with lumbar radiculopathy.
Both groups received 8 sessions of a motor control exer-
cise program of 30-min duration for 4 wks, twice a week, fol-
lowing expert recommendations,20,21 and as previously used
by Costa et al.22 On each session, the therapist corrected each
subject individually to ensure correct technique and ensured
that the participant was confident to perform the exercises
alone at home. Participants were asked to perform exercises
at home once daily for 20 mins for the 8-wk intervention period.
The motor control exercise program consisted of a progression
from isolated contraction of the transversus abdominis and/or iso-
lated contraction of the multifidi to combined contraction of both
transversus abdominis and multifidi muscles in different positions
from supine or prone to bridging or four-point kneeling (Fig. 1).
Each participant was progressed on exercises when they have
reached an independent activation of the transversus abdominis
and multifidus without overactivity of superficial muscles in an
individualized manner (visual observation by the therapist). Each
exercise was performed for 10 repetitions for 10 secs each as
previously described.22 The adherence to the exercise program
was collected on each subsequent session in a weekly diary.
Patients allocated to the neurodynamic group also re-
ceived a nerve neurodynamic slider intervention targeting the
main trunk of the sciatic nerve of the affected side. Previous
studies have suggested that nerve slider techniques are associ- FIGURE 1. Monitoring correct contraction of the transversus abdominis
ated with larger nerve excursion than nerve tensioner interven- (A), multifidi (B), or both combined (C) in different positions (supine,
prone, four-point kneeling).
tions.23,24 The nerve slider intervention applied in the current
study included flexion, adduction and medial rotation (if possi- (immediate follow-up), and 2 mos after the last treatment ses-
ble) of the hip, knee extension, and ankle dorsiflexion. From sion (follow-up) by an assessor blinded to the group allocation
this position, concurrent hip flexion and knee flexion were al- of the subjects.
ternated dynamically with concurrent hip and knee extension The primary outcome was the intensity of lower limb pain
(Fig. 2). During the intervention, the therapist alternated the symptoms. Participants rated the intensity of their lower limb
movement combination depending on the tissue resistance and pain at rest on an 11-point numeric pain rating scale (NPRS)
patient’s symptoms. Speed and amplitude of movement were where 0 represents no pain and 10 is the maximum pain.25 Be-
adjusted such that no pain was produced during the technique. cause there is no specific minimum clinically important differ-
The slider intervention was applied for 3 sets of 10 repetitions ence (MCID) for NPRS in individuals experiencing lumbar
on each treatment session for 8 wks, and it was applied 5 mins radiculopathy, we used the MCID established as 2 points for
before the motor control exercise program. patients with LBP.26 The cutoff of 2 points is usually consid-
ered an MCID for chronic pain in general.27
Outcome Measures Secondary outcomes included the Self-report Leeds Assess-
All outcomes were assessed at baseline, after four treat- ment of Neuropathic Symptoms and Signs Scale (S-LANSS), the
ment sessions (mid follow-up), after the treatment program Roland-Morris Disability Questionnaire (RMDQ), the straight

126 www.ajpmr.com © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Volume 99, Number 2, February 2020
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023
FIGURE 2. Nerve slider intervention targeting the sciatic nerve. First,
flexion, adduction and medial rotation (if permitted) of the hip, knee
extension, and ankle dorsiflexion are applied (A). From this position,
concurrent hip flexion and knee flexion (B) are alternated dynamically
with concurrent hip and knee extension (C).
leg raise test, and pressure pain sensitivity. The S-LANSS is a
simple and valid seven-item tool for identifying individuals whose
pain is dominated by neuropathic mechanisms.28 Each item is a
binary response (yes or no) to the presence of symptoms (five
items) or clinical signs (two items). The total score is 24 points
and a value of 12 points or higher is indicative of a neuropathic
component of pain. In the current trial, the validated Spanish ver-
sion of the S-LANSS was used.29
The RMDQ is one of the most comprehensively validated
outcome measures for LBP.30 To score the RMDQ, the number
of items checked by the patient is tallied (yes/no).31 If patients
indicate that an item is not applicable to them, the item is
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Neurodynamic Intervention in Lumbar Radiculopathy
scored “No,” i.e., the denominator remains. The score ranges
from 0 to 24 with higher scores indicative of higher related dis-
ability. The MCID for the RMDQ has been reported to range
from 2 to 8 points.32 Lauridsen et al.33 found that the RMDQ
also exhibited good responsiveness for patients with leg pain
showing a MCID of 5 points.
The straight leg raise test examines the sensitivity of the
sciatic nerve. It is performed passively with patients in supine.
The clinician lifts the leg while maintaining the knee extended.
Reproduction of the patient symptoms between 40 and 70 de-
grees is considered as indicative of a disc herniation compris-
ing a nerve root. The straight leg raise has shown a sensitivity
of 91% and specificity of 26%.34 Neto et al.35 found that
changes ranging from 7 to 8 degrees can be considered mini-
mal detectable difference for the straight leg raise test,
whereas Dixon and Keating36 reported that intersession mea-
surements need to change by more than 16 degrees to repre-
sent a relevant change.
Pressure pain sensitivity was assessed by pressure pain
thresholds (PPTs), that is, the minimal amount of pressure ap-
plied on a particular point for the pressure sensation to first
change to pain.37 A mechanical pressure algometer (Pain Diag-
nosis and Treatment Inc, New York) was used in this trial to as-
sess PPTs (kilogram per square centimeter) over the common
peroneal (where it passes behind the head of the fibula as it
winds forward around its neck) and tibial (where it bisects
the popliteal fossa, lateral to the popliteal artery) nerve trunks
of the affected leg. The reliability of PPT assessment over these
nerve trunks has been found to range from moderate to high.38
All participants were instructed to press the switch when the
sensation changed from pressure to pain. The mean of three tri-
als was calculated on each point and used for the analysis. A
30-sec resting period was allowed between each measure.
The order of assessment was randomized between subjects.
Treatment Adverse Effects
At each session, patients were asked to report any adverse
events that they experienced. In the current trial, an adverse
event was defined as sequelae of 1-wk duration with symptoms
perceived as distressing and unacceptable to the patient and re-
quired further treatment.39
Sample Size Determination
The sample size was calculated using Ene 3.0 software
(Autonomic University of Barcelona, Spain) and was based
on detecting between-groups difference of 2.0 points on a
NPRS,26,27 assuming a standard deviation of 1.4, a two-tailed
test, an α level of 0.05, and a desired power (β) of 80%. The
estimated desired sample size was calculated to be of 16 sub-
jects per group.
Statistical Analysis
Data were analyzed using the SPSS Version 21.0 (SPSS
Inc, Chicago, IL) program. Means, standard deviation, and
95% confidence intervals were calculated for each variable.
The Kolmogorov-Smirnov test revealed a normal distribution
of all the quantitative data (P > 0.05). Baseline demographic
and clinical variables between groups were compared using inde-
pendent t test for continuous data and χ2 tests of independence
www.ajpmr.com 127
 Plaza-Manzano et al.
for categorical data. A mixed-model 4  2 analysis of covariance
(ANCOVA) with time (before, mid follow-up, immediate follow-
up, 2 mos) as the within-subjects factor, group (motor control or
motor control plus neurodynamic) as the between-subjects factor,
and sex as covariate was used to examine the effects of the in-
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
terventions on each outcome (ie, pain intensity, S-LANSS,
straight leg raise, and PPTs). For each ANCOVA, the hypoth-
esis of interest was the group  time interaction. In general,
a P value of less than 0.05 was considered statistically signifi-
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023
cant, but post hoc analyses were conducted with a Bonferroni
test using a corrected α of 0.025 (2 independent samples).
The effect size was calculated when the η2p was significant.
To determine the clinical effect sizes, standardized mean score
differences (SMDs) were calculated by dividing the mean
score differences between groups by the pooled standard devi-
ation. In general, an SMD of 0.2 is considered small, 0.5 mod-
erate, and 0.8 large clinical effect size.
RESULTS
Forty consecutive subjects with symptoms in the lower
limb compatible with lumbar radiculopathy were screened
FIGURE 3. Flow diagram of participants throughout the course of the study.
128 www.ajpmr.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Volume 99, Number 2, February 2020
for potential eligibility between July and October 2018.
Thirty-two patients satisfied all criteria, agreed to partici-
pate, and were randomly allocated to the motor control exer-
cises (n = 16) or motor control exercise plus neurodynamic
intervention (n = 16) group. The reasons for ineligibility
are listed in the flow diagram of patient recruitment and re-
tention (Fig. 3). Baseline features between both groups were
similar for all outcomes (Table 1). None of the subjects re-
ceiving either intervention reported any adverse events. The
adherence to the exercise program was 96% as collected on
the weekly diary.
Pain Intensity
The ANCOVA did not find a significant group  time in-
teraction for lower limb pain (F = 1.269, P = 0.273, η2p =
0.043): patients receiving motor control exercises program
alone or combined with a neurodynamic intervention experi-
enced similar decreases in lower limb pain (Table 2, Fig. 4A).
Between-groups effect sizes were small (SMD = 0.2),
whereas within-group effect sizes were large for both groups
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 99, Number 2, February 2020 Neurodynamic Intervention in Lumbar Radiculopathy

TABLE 1. Baseline demographics and clinical data by treatment assignment*

Motor Control (n = 16) Motor Control + Neurodynamic (n = 16) P

Sex, male/female 8:8 8:8 0.999
Age, yr 45.5 ± 6.0 47.0 ± 8.0 0.605
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

History of pain, mo 17.3 ± 1.4 17.2 ± 1.5 0.781

Symptoms limb, left/right 8 (50%):8 (50%) 7 (44%):9 (56%) 0.682
Mean pain intensity (NPRS, 0–10) 6.0 ± 1.4 5.9 ± 1.4 0.912
S-LANSS (0–24) 12.0 ± 1.3 12.0 ± 1.1
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023

RMDQ (0–24) 10.5 ± 2.6 11.2 ± 1.5 0.998

Straight leg raise, degree 53.2 ± 10.0 55.2 ± 6.5 0.567
PPTs, kg/cm2
Common peroneal 2.3 ± 1.0 2.1 ± 0.9 0.565
Tibialis 3.4 ± 0.9 3.2 ± 0.6 0.521
*Data are expressed as means ± standard deviation, except for sex and symptoms limb.

(SMD > 1.25). Sex did not influence the effect in the main
analysis (F = 0.895, P = 0.355).
Neuropathic Symptomatology (S-LANSS)
The ANCOVA revealed a significant group  time interac-
tion for S-LANSS (F = 8.559, P = 0.008, η2p = 0.373): patients
in the motor control exercise plus neurodynamic intervention
group exhibited a greater decrease in the S-LANSS score (sug-
gesting a decrease of neuropathic symptoms) than those in the
motor control exercise alone group (Table 2, Fig. 4B). Between-
groups effect sizes were large immediately after treatment
(SMD = 0.95) and at 2 mos (SMD = 0.75). Sex did not influ-
ence the interaction on the S-LANSS (F = 0.211, P = 0.651).
Related Disability (RMDQ)
The results did not reveal a significant group  time inter-
action for the RMDQ (F = 2.970, P = 0.101, η2p = 0.023):
patients in both groups experienced similar decreases in related
disability (Table 2, Fig. 4C). Between-groups effect sizes were
small (SMD = 0.18), whereas within-group effect sizes were
large for both groups (SMD > 1.15). Sex did not influence the
main effect in the analysis (F = 0.202, P = 0.658).
Mechanical Pain Sensitivity (Straight Leg Raise
and PPT)
The ANCOVA revealed a significant group  time in-
teraction for the straight leg raise (F = 7.512, P = 0.013,
η2p = 0.220): individuals in the motor control exercise plus
neurodynamic intervention group exhibited greater improve-
ments in the straight leg raise test (suggesting a decrease of me-
chanical sensitivity) than those in the motor control exercise
alone group (Table 2, Fig. 4D). Between-groups effect sizes
were moderate (SMD = 0.55) after four treatment sessions
and large immediately after the treatment (SMD = 1.05) and

TABLE 2. Evolution of the outcomes by randomized treatment assignment

Outcome Group Baseline After 4 Sessions After 8 Sessions 2 mos

Pain intensity in the lower limb (NPRS, 0–10)
Motor control 6.0 ± 1.4 (5.1, 6.9) 4.7 ± 1.1 (4.0–5.4) 3.4 ± 0.9 (3.0–3.8) 3.2 ± 0.8 (2.8–3.6)
Motor control + NDS 5.9 ± 1.4 (5.0–6.8) 4.3 ± 1.0 (3.7–4.9) 2.5 ± 0.8 (2.0–3.0) 2.6 ± 0.8 (2.2–3.0)
S-LANSS (0–24)
Motor control 12.0 ± 1.3 (11.5–12.5) 10.7 ± 1.0 (9.8–11.6) 9.5 ± 0.9 (8.7–10.3) 8.4 ± 1.5 (7.2–9.6)
Motor control + NDS 12.0 ± 1.1 (11.8–12.2) 10.5 ± 1.1 (9.7–11.3) 6.6 ± 0.8 (5.8–7.4) 6.5 ± 1.6 (5.5–7.5)
RMDQ (0–24)
Motor control 10.5 ± 2.6 (9.5–11.5) 8.2 ± 1.3 (7.0–9.4) 6.2 ± 1.2 (5.2–7.2) 5.9 ± 1.2 (5.9–6.8)
Motor control + NDS 11.2 ± 1.5 (10.0–12.4) 7.7 ± 1.5 (6.6–8.8) 5.6 ± 1.1 (4.5–6.7) 5.2 ± 1.4 (4.4–6.0)
Straight leg raise, degree
Motor control 53.2 ± 10.0 (48.2–58.2) 58.9 ± 11.3 (52.9–64.9) 62.7 ± 12.7 (57.6–67.8) 63.1 ± 12.8 (56.9–69.3)
Motor control + NDS 55.2 ± 6.5 (51.2–59.2) 64.1 ± 11.2 (57.1–71.1) 73.9 ± 10.1 (67.9–79.9) 71.9 ± 9.8 (65.7–78.1)
PPTs over the tibial nerve, kg/cm2
Motor control 3.4 ± 0.9 (3.1–3.7) 3.7 ± 0.8 (3.3–4.1) 4.2 ± 1.0 (3.7–4.7) 4.0 ± 1.1 (3.5–4.5)
Motor control + NDS 3.2 ± 0.6 (2.9–3.6) 3.6 ± 0.7 (3.2–4.0) 4.1 ± 0.7 (3.7–4.5) 4.0 ± 0.8 (3.6–4.4)
PPTs over the common peroneal nerve, kg/cm2
Motor control 2.3 ± 1.0 (1.8–2.8) 2.5 ± 0.9 (2.1–2.9) 2.9 ± 0.8 (2.5–3.3) 2.8 ± 0.8 (2.4–3.2)
Motor control + NDS 2.1 ± 0.9 (1.7–2.5) 2.6 ± 0.4 (2.2–3.0) 3.0 ± 0.7 (2.6–3.4) 2.8 ± 0.5 (2.4–3.2)
Values are expressed as mean ± standard deviation (95% confidence interval).
NDS, neurodynamic intervention.

© 2019 Wolters Kluwer Health, Inc. All rights reserved. www.ajpmr.com 129

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Plaza-Manzano et al.
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023
FIGURE 4. Evolution of leg pain intensity (A), S-LANSS (B), RMDQ (C), and straight leg raise (D) throughout the course of the study stratified by
randomized treatment assignment. Data are means (standard error).
at 2-mo follow-up (SMD = 0.9). Sex did not influence the main
interaction on the straight leg raise (F = 0.994, P = 0.331).
Finally, no significant group  time interactions for
changes in PPTs in the tibial (F = 0.582, P = 0.454,
η2p = 0.026) or common peroneal (F = 0.658, P = 0.426,
η2p = 0.029) nerve trunks were observed: patients receiving mo-
tor control exercises alone or combined with a neurodynamic in-
tervention experienced similar increases in PPTs (Table 2).
Between-groups effect sizes were small (SMD = 0.14),
whereas within-group effect sizes were large for both groups
(SMD > 1.04). Sex did not influence the interaction effects
on PPTs (tibial: F = 0.678, P = 0.420; common peroneal:
F = 0.620, P = 0.440).
DISCUSSION
This is the first clinical trial examining the effects of
adding nerve neurodynamic mobilization to a program of mo-
tor control exercises compared with motor control exercises
alone in individuals with lumbar radiculopathy. Our results
demonstrated that the addition of nerve mobilizations did not
result in a greater change on leg pain, related disability, or
PPT over motor control exercises in this population; however,
those receiving motor control exercises/neurodynamic mobi-
lizations experienced significantly greater reductions in neu-
ropathic symptoms (S-LANSS) and mechanical sensitivity
130 www.ajpmr.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Volume 99, Number 2, February 2020
as measured by the straight leg raise test suggesting that
neurodynamic mobilizations may have a greater impact on
nerve tissue sensitivity.
Although the exact mechanisms underlying the effects of
manual therapies are uncertain,40 a number of potential theo-
ries exist as to how manual therapies, including neurodynamic
nerve mobilizations, might exert their therapeutic effects. It is
possible that neurodynamic mobilization may have the ability
to alter descending inhibitory pain mechanisms,41 to modify
blood flow to regions in the brain associated with pain,42 and
reduce activation of supraspinal pain centers.43 However, these
mechanisms would be expected to have an impact on patient-
centered outcomes, such as pain and disability, which has been
identified in studies using neurodynamic treatments for indi-
viduals with nerve entrapment of the upper limb, for example,
carpal tunnel syndrome.44 The fact that no between-groups dif-
ferences were observed for pain intensity and related disability
may be associated to the fact that there is evidence supporting
the application of motor control exercises for the management
of this population.10 Both groups obtained significant and
large clinical effects, which may support the positive effect of
motor control exercises; however, the lack of a control group
and the small sample size do not permit us to conclude this.
Participants receiving the neurodynamic intervention ex-
perienced large improvements in neuropathic symptoms and
the impact on neural sensitivity as assessed by the straight leg
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 99, Number 2, February 2020
raise. It should be noted that between-groups differences at
2-mo follow-up for the straight leg raise (8.8 degrees)
surpassed the minimal detectable difference reported by Neto
et al.35 but not the cutoff (16 degrees) determined by Dixon
and Keating36 supporting a potential, but small, effect of
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
the neurodynamic mobilization in this outcome. In addition,
it should be noted that the straight leg raise does not only as-
sess neural sensitivity because it can be also associated with
hamstring tightness.
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023
It is also important to note that both groups decreased sig-
nificantly their S-LANSS scores, although the neurodynamic
mobilization groups exhibited a greater and larger decrease.
After all treatment sessions, almost all participants in both
groups were below the 12-point cutoff that determines the pres-
ence of neuropathic symptoms supporting that both interven-
tions may be capable of reducing neuropathic symptoms,
although changes were superior when a neurodynamic mo-
bilization was included into the treatment program. Several
hypotheses explaining changes in these outcomes can be
proposed. For example, a cadaveric study performed on
the tibial nerve found that neurodynamic mobilization resulted
in dispersion of intraneural fluid,15 which might assist in a re-
duction of intraneural edema found in individuals experiencing
neural compression.45 Another cadaveric study examining a po-
tential impact of simulated neurodynamic mobilization tech-
nique on sections of the sciatic nerve also found dispersal of
intraneural fluid, which was hypothesized for resulting to de-
creased intraneural edema and intraneural pressure.14 However,
these hypothesis in people with actual nerve compression re-
quires further research. It is interesting to note that a study com-
paring nerve and tendon glides to splinting in subjects with
carpal tunnel syndrome, a neuropathic condition of the wrist,
showed that both interventions resulted in similar reduction on
intraneural edema.46 However, splinting is not a viable option
for individuals with lumbar radiculopathy.
It should also be noted that the effect sizes for changes in
the S-LANSS and straight leg raise test were much larger after
eight sessions as compared with when measured after just four
sessions. It is difficult to determine the dosage (number of
treatment sessions) necessary to maximize patient outcomes.
The topic of tolerance or a decrease in magnitude of effect over
time is an area of discussion. For example, Fernández-de-las-
Peñas et al.47 found that after receiving consecutive sessions
of thoracic manipulation, patients continued to receive added
benefit with additional visits. Another study comparing the
dose response of spinal manipulation, comparing 0, 6, 12,
and 18 sessions, found that 12 sessions of spinal manipulation
were best for maximizing changes in pain and disability in in-
dividuals with chronic LBP at a 12-wk follow-up.48 Therefore,
the ideal dose response for neurodynamic mobilizations re-
quires further investigation but from the current results, it
seems that eight treatments result in superior outcomes when
compared with four treatments.
Study Limitations
Finally, there are several limitations to the current study
that should be considered. Only one therapist provided all the
techniques at one geographical location. Although this enhances
the internal validity, it potentially reduces the generalizability of
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Neurodynamic Intervention in Lumbar Radiculopathy
current findings. Second, we included a relatively small sample
size, which could be underpowered to identify a difference on
some outcomes. Furthermore, the sample was restricted to pa-
tients with disc herniation between L4-S1 level, so we do not
know whether these results would be similar in patients with
disc problems at other lumbar levels. Similarly, the lack of con-
trol for the magnitude (size and spinal cord location) of the disc
herniation could limit the results. Finally, we only included a
2-mo follow-up. Future clinical trials should include additional
clinicians from different locations, larger sample sizes, and col-
lect outcome measures at long-term follow-up.
CONCLUSIONS
The results of the current trial performed on individuals
with LBP, confirmed disc herniation, and radiculopathy, ob-
served that they did not experience greater improvements in
pain, function or PPTwhen they received neurodynamic mobi-
lization in addition to motor control exercises. However, al-
though patients receiving neural mobilizations experienced
greater changes in neural mechanosensitivity as measured by
the S-LANSS and straight leg raise; these differences were
small and probably not clinically relevant. Future clinical trials
are needed to further confirm these findings.
REFERENCES
1. Martin BI, Deyo RA, Mirza SK, et al: Expenditures and health status among adults with back
and neck problems. JAMA 2008;299:656–64
2. van der Windt DAWM, Simons E, Riphagen II, et al: Physical examination for lumbar
radiculopathy due to disc herniation in patients with low-back pain (Review). Cochrane
Database Syst Rev 2010;2:CD007431
3. Konstantinou K, Hider SL, Jordan JL, et al: The impact of low back-related leg pain on
outcomes as compared with low back pain alone: a systematic review of the literature. Clin J
Pain 2013;29:644–54
4. Lewis RA, Williams NH, Sutton AJ, et al: Comparative clinical effectiveness of management
strategies for sciatica: systematic review and network meta-analyses. Spine J
2015;15:1461–77
5. Kreiner DS, Shaffer WO, Baisden JL, et al: An evidence-based clinical guideline for the
diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J
2013;13:734–43
6. Gadjradj PS, Arts MP, van Tulder MW, et al: Management of symptomatic lumbar disk
herniation: an international perspective. Spine (Phila Pa 1976) 2017;42:1826–34
7. Peul WC, van Houwelingen HC, van den Hout WB, et al: Surgery versus prolonged
conservative treatment for sciatica. N Engl J Med 2007;356:2245–56
8. Jacobs WC, van Tulder M, Arts M, et al: Surgery versus conservative management of sciatica
due to a lumbar herniated disc: a systematic review. Eur Spine J 2011;20:513–22
9. Wong JJ, Côté P, Sutton D, et al: Clinical practice guidelines for the noninvasive management
of low back pain: a systematic review by the Ontario Protocol for Traffic Injury Management
(OPTIMa) Collaboration. Eur J Pain 2017;21:201–16
10. Saragiotto BT, Maher CG, Yamato TP, et al: Motor control exercise for chronic non-specific
low-back pain. Cochrane Database Syst Rev 2016;1:CD012004
11. Coulter ID, Crawford C, Hurwitz EL, et al: Manipulation and mobilization for treating chronic
low back pain: a systematic review and meta-analysis. Spine J 2018;18:866–79
12. Butler DS: The Sensitive Nervous System. Adelaide, Australia, Noigroup Publications, 2000
13. Shacklock MO: Neurodynamics. Physiotherapy 1995;81:9–16
14. Gilbert KK, Roger James C, Apte G, et al: Effects of simulated neural mobilization on fluid
movement in cadaveric peripheral nerve sections: implications for the treatment of
neuropathic pain and dysfunction. J Man Manip Ther 2015;23:219–25
15. Brown CL, Gilbert KK, Brismee JM, et al: The effects of neurodynamic mobilization on fluid
dispersion within the tibial nerve at the ankle: an unembalmed cadaveric study. J Man Manip
Ther 2011;19:26–34
16. Boudier-Revéret M, Gilbert KK, Allégue DR, et al: Effect of neurodynamic mobilization on
fluid dispersion in median nerve at the level of the carpal tunnel: a cadaveric study.
Musculoskelet Sci Pract 2017;31:45–51
17. Cleland JA, Hunt G, Palmer J: Effectiveness of neural mobilization in the treatment of a
patient with lower extremity neurogenic pain: a single-case design. J Manual Manipul Ther
2004;12:143–52
18. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al: National Clinical Guidelines for non-surgical
treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J
2018;27:60–75
www.ajpmr.com 131
 Plaza-Manzano et al.
19. Basson A, Olivier B, Ellis R, et al: The effectiveness of neural mobilization for
neuromusculoskeletal conditions: a systematic review and meta-analysis. J Orthop Sports
Phys Ther 2017;47:593–615
20. Richardson CA, Jull GA, Hodges PW, et al: Therapeutic Exercise for Spinal Segmental
Stabilization in Low Back Pain. Edinburgh, United Kingdom, Churchill Livingstone, 1999
21. Hodges PW, Ferreira PH, Ferreira ML: Lumbar spine: treatment of instability and disorders of
movement control, in: Magee DJ, Zachazewski JE, Quillen WS (eds): Scientific Foundations
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
and Principles of Practice in Musculoskeletal Rehabilitation: Pathology and Intervention in
Musculoskeletal Rehabilitation. Philadelphia, PA, WB Saunders Co, 2009:398–425
22. Costa LO, Maher CG, Latimer J, et al: Motor control exercise for chronic low back pain: a
randomized placebo-controlled trial. Phys Ther 2009;89:1275–86
23. Coppieters MW, Butler DS: Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/28/2023
neurodynamic techniques and considerations regarding their application. Man Ther
2008;13:213–21
24. Coppieters MW, Hough AD, Dilley A: Different nerve-gliding exercises induce different
magnitudes of median nerve longitudinal excursion: an in vivo study using dynamic
ultrasound imaging. J Orthop Sports Phys Ther 2009;39:164–71
25. Jensen MP, Turner JA, Romano JM, et al: Comparative reliability and validity of chronic pain
intensity measures. Pain 1999;83:157–62
26. Childs JD, Piva SR, Fritz JM: Responsiveness of the numeric pain rating scale in patients with
low back pain. Spine 2005;30:1331–4
27. Farrar J, Young JJ, La Moreaux L, et al: Clinical importance of changes in chronic pain
intensity measured on an 11-pont numerical pain rating scale. Pain 2001;94:149–58
28. Bennett MI, Smith BH, Torrance N, et al: The S-LANSS score for identifying pain of
predominantly neuropathic origin: validation for use in clinical and postal research. J Pain
2005;6:149–58
29. López-de-Uralde-Villanueva I, Gil-Martínez A, Candelas-Fernández P, et al: Validity and
reliability of the Spanish-language version of the self-administered Leeds Assessment of
Neuropathic Symptoms and Signs (S-LANSS) pain scale. Neurologia 2018;33:505–14
30. Cleland JA, Gillani R, Bienen EJ, et al: Assessing dimensionality and responsiveness of
outcomes measures for patients with low back pain. Pain Pract 2011;11:57–69
31. Roland M, Morris R: A study of the natural history of back pain. Part I: development of a
reliable and sensitive measure of disability in low-back pain. Spine (Phila Pa 1976)
1983;8:141–4
32. Lee MK, Yost KJ, McDonald JS, et al: Item response theory analysis to evaluate reliability and
minimal clinically important change of the Roland-Morris Disability Questionnaire in patients
with severe disability due to back pain from vertebral compression fractures. Spine J
2017;17:821–9
132 www.ajpmr.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Volume 99, Number 2, February 2020
33. Lauridsen HH, Hartvigsen J, Manniche C, et al: Responsiveness and minimal clinically
important difference for pain and disability instruments in low back pain patients. BMC
Musculoskelet Disord 2006;7:82
34. Devillé WL, van der Windt DA, Dzaferagić A, et al: The test of Lasègue: systematic review of
the accuracy in diagnosing herniated discs. Spine (Phila Pa 1976) 2000;25:1140–7
35. Neto T, Jacobsohn L, Carita AI, et al: Reliability of the active-knee-extension and
straight-leg-raise tests in subjects with flexibility deficits. J Sport Rehabil 2015;24:4
36. Dixon JK, Keating JL: Variability in straight leg raise measurements. Physiother
2000;86:361–70
37. Vanderweeën L, Oostendorp RA, Vaes P, et al: Pressure algometry in manual therapy. Man
Ther 1996;1:258–65
38. Fingleton CP, Dempsey L, Smart K, et al: Intra-examiner and inter-examiner reliability of
manual palpation and pressure algometry of the lower limb nerves in asymptomatic subjects.
J Manipulative Physiol Ther 2014;37:97–104
39. Carlesso LC, Macdermid JC, Santaguida LP: Standardization of adverse event terminology
and reporting in orthopaedic physical therapy: application to the cervical spine. J Orthop
Sports Phys Ther 2010;40:455–63
40. Bialosky JE, Beneciuk JM, Bishop MD, et al: Unraveling the mechanisms of manual therapy:
modeling an approach. J Orthop Sports Phys Ther 2018;48:8–18
41. Sauro MD, Greenberg RP: Endogenous opiates and the placebo effect: a meta-analytic review.
J Psychosom Res 2005;58:115–20
42. Sparks CL, Liu WC, Cleland JA, et al: Functional magnetic resonance imaging of cerebral
hemodynamic responses to pain following thoracic thrust manipulation in individuals with
neck pain: a randomized trial. J Manipulative Physiol Ther 2017;40:625–34
43. Malisza KL, Stroman PW, Turner A, et al: Functional MRI of the rat lumbar spinal cord
involving painful stimulation and the effect of peripheral joint mobilization. J Magn Reson
Imaging 2003;18:152–9
44. Fernández-de-Las Peñas C, Ortega-Santiago R, de la Llave-Rincón AI, et al: Manual physical
therapy versus surgery for carpal tunnel syndrome: a randomized parallel-group trial. J Pain
2015;16:1087–94
45. Mackinnon SE: Pathophysiology of nerve compression. Hand Clin 2002;18:231–41
46. Schmid AB, Elliott JM, Strudwick MW, et al: Effect of splinting and exercise on intraneural
edema of the median nerve in carpal tunnel syndrome: an MRI study to reveal therapeutic
mechanisms. J Orthop Res 2012;30:1343–50
47. Fernández-De-Las-Peñas C, Cleland JA, Huijbregts P, et al: Repeated applications of thoracic
spine thrust manipulation do not lead to tolerance in patients presenting with acute mechanical
neck pain: a secondary analysis. J Man Manip Ther 2009;17:154–62
48. Haas M, Vavrek D, Peterson D, et al: Dose-response and efficacy of spinal manipulation for
care of chronic low back pain: a randomized controlled trial. Spine J 2014;14:1106–16
© 2019 Wolters Kluwer Health, Inc. All rights reserved.