Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2019;-:-------

ORIGINAL RESEARCH

The Effect of Spinal Mobilization With Leg Movement

in Patients With Lumbar RadiculopathydA Double-
Blind Randomized Controlled Trial
Kiran Satpute, MPTh, COMT,a Toby Hall, PhD, MSc, FACP,b Richa Bisen, MPT,c
Pramod Lokhande, MS DNB, MNAMS, FICS, FAAMISSd
From the aDepartment of Kinesiotherapy and Physical Diagnosis, Department of Musculoskeletal Physiotherapy, Smt. Kashibai Navale College
of Physiotherapy, Pune, Maharashtra, India; bSchool of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia;
c
Department of Electrotherapy and Electro Diagnosis, Department of Musculoskeletal Physiotherapy, Smt. Kashibai Navale College of
Physiotherapy, Pune, Maharashtra, India; and dDepartment of Orthopaedics, Smt. Kashibai Navale Medical College and General Hospital,
Pune, Maharashtra, India.

Abstract
Objectives: To evaluate the effect of spinal mobilization with leg movement (SMWLM) on low back and leg pain intensity, disability, pain
centralization, and patient satisfaction in participants with lumbar radiculopathy.
Design: A double-blind randomized controlled trial.
Setting: General hospital.
Participants: Adults (NZ60; mean age 44y) with subacute lumbar radiculopathy.
Interventions: Participants were randomly allocated to receive SMWLM, exercise and electrotherapy (nZ30), or exercise and electrotherapy
alone (nZ30). All participants received 6 sessions over 2 weeks.
Main Outcome Measures: The primary outcomes were leg pain intensity and Oswestry Disability Index score. Secondary variables were low
back pain intensity, global rating of change (GROC), straight leg raise (SLR), and lumbar range of motion (ROM). Variables were evaluated blind
at baseline, post-intervention, and at 3 and 6 months of follow-up.
Results: Significant and clinically meaningful improvement occurred in all outcome variables. At 2 weeks the SMWLM group had significantly
greater improvement than the control group in leg pain (MD 20; 95% confidence interval [95% CI], 1.4-2.6) and disability (MD 3.9; 95% CI, 5.5-
2.2). Similarly, at 6 months, the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.6; 95% CI, 1.9-
3.2) and disability (MD 4.7; 95% CI, 6.3-3.1). The SMWLM group also reported greater improvement in the GROC and in SLR ROM.
Conclusion: In patients with lumbar radiculopathy, the addition of SMWLM provided significantly improved benefits in leg and back pain,
disability, SLR ROM, and patient satisfaction in the short and long term.
Archives of Physical Medicine and Rehabilitation 2019;-:-------
ª 2018 by the American Congress of Rehabilitation Medicine

Low back pain (LBP) is a common musculoskeletal problem
affecting the general population1 with global prevalence up to
10.2%2 which is a major cause of years lived with disability.3
Recovery is less favorable if back pain is associated with leg
pain4,5 possibly due to the associated greater disability.6
Disclosures: Kiran Satpute and Toby Hall are accredited Mulligan Concept teachers and gain a
teaching fee when running these courses.
Clinical Trial Registration No.: CTRI/2015/09/006165.
Leg pain may originate from compromised lumbar spine
musculoskeletal or neural structures.7 In the case of neural
compromise, lumbar radiculopathy is considered as a possible
diagnosis,8,9 the lifetime prevalence of which ranges up to 43%.10
The diagnostic criterion includes sensory and motor deficits of a
specific nerve root, consistent with the distribution of leg symp-
toms.11,12 Pain associated with radiculopathy may result from
structural damage13,14 compromising nerve roots,15-17 which in
some cases may lead to neuropathic pain.18-20

0003-9993/19/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.11.004
2 K. Satpute et al
According to clinical practice guidelines (National Institute for
Health and Care Excellence 2016), conservative management is
recommended first and includes support and advice, exercise,
manual therapy, psychological therapies, and medication. Other
recommendations of physiotherapy have included mobilization,
electrotherapy, traction, taping, and exercise,21-27 with no evi-
dence clearly supporting any 1 method.28,29 A recent systemic
review reported low to moderate quality evidence in favor of
manual therapy for the management of lumbar radiculopathy.30
Mulligan has suggested spinal mobilization with leg movement
(SMWLM) for the management of low backerelated leg pain. A
transverse pressure to the spinous process is maintained while the
patient actively moves their leg in the direction of the impaired
neurodynamic movement.25 Although there are no studies that
have investigated this technique in lumbar radiculopathy, studies
have examined other Mulligan mobilization techniques for leg
pain with encouraging results.31,32 Despite this evidence, a recent
systematic review indicates low to moderate quality evidence for
effectiveness of Mulligan mobilization for LBP in general.33
The purpose of this study was to examine the additional benefit of
SMWLM in addition to traditional interventions in patients with
lumbar radiculopathy over a 6-month period. We hypothesized that
compared to standard treatment; the addition of SMWLM to standard
treatment would induce greater pain reduction and improved function.
Methods
This double-blind randomized controlled trial design that has been
reported according to the recommendations of the Consolidated
Standards of Reporting Trials statement investigated the efficacy
of SMWLM on participants with lumbar radiculopathy.
Participants with leg pain for >6 weeks were recruited from
Smt. Kashibai Navale Medical College and General Hopsital,
enrolled between November 2015 and November 2017 and eval-
uated for the presence of lumbar radiculopathy. The inclusion
criteria included unilateral radiating leg pain below the knee with
associated LBP, with hypoesthesia and/or myotomal weakness or
hyporeflexia indicative of L4, L5, or S1 nerve root compromise.
Additional criteria were reproduction of symptoms with straight
leg raise (SLR) and tenderness on palpation of sciatic, tibial, or
common peroneal nerves. Participants were included only if there
was an increase in SLR range after a single trial application of the
SMWLM technique.
Participants were excluded if they were not aged 18-60 years,
and if they had associated abnormality of bowel and bladder func-
tion, lower extremity vascular disease, physiotherapy or surgery for
leg pain within 6 months, any contraindications for manual therapy,
List of abbreviations:
95% CI 95% confidence interval
CG control group
GROC global rating of change
ICC intraclass correlation coefficient
LBP low back pain
MD mean difference
MDC minimal detectable change
ODI Oswestry Disability Index
ROM range of motion
SLR straight leg raise
SMWLM spinal mobilization with leg movement
TENS transcutaneous electrical nerve stimulation
VAS visual analog scale
and withdrawal of informed consent. The Leeds assessment of
neuropathic symptoms and signs scale (>12) was used to exclude
patients with positive features of neuropathic pain.34
All participants were provided with an information sheet explaining
the study protocol. SMWLM and neural mobilization techniques were
explained as routine physiotherapy procedures to ensure patient
blinding. All participants were asked not to reveal their group identity
at any time. At each treatment session, any increase in leg pain intensity
or peripheralization of pain was reported as an adverse event.
A chart indicating flow of participants through each stage of the
study is shown in fig 1. A total of 60 participants were enrolled and
provided informed consent with the right to withdraw from the study
at any time. Participants were randomly allocated to SWMLM group
or control group (CG) immediately after baseline assessment with the
help of a computer-generated randomization sequence placed in
sequentially numbered opaque sealed envelopes by administra-
tion staff.
Outcomes
Baseline demographic details, physical examination criteria, and
all outcome variables were assessed by a physiotherapist blind to
the group allocation. Reassessment occurred at the end of the sixth
treatment session, as well as at 3- and 6-month follow-up.
The primary outcome measures were intensity of leg pain
measured on visual analog scale (VAS) and Oswestry Disability
Index (ODI) score. LBP over the previous 24 hours measured on
VAS, global rating of change (GROC), passive SLR and active
lumbar flexion range of motion (ROM), and area of limb pain
recorded on a body chart were secondary outcome measures.
A single-item 10-cm horizontal VAS (anchored from 0 pain to a
maximum pain score of 10) was used to record average intensity of leg
pain and LBP during the previous 24 hours. The minimal detectable
change (MDC) for the VAS score is 20 mm.35 Active lumbar flexion
ROM to pain onset was measured with a bubble inclinometer in
standing. The difference between 2 sagittal rotation angles taken at
T12-L1 and S1-S2 was considered as total lumbar flexion ROM.
Intraclass correlation coefficient (ICC) values for intrarater reliability
for this measurement are 0.88, whereas the MDC is 9 .36
Passive SLR ROM with plantar-grade ankle position was
measured at the point leg symptoms occurred using a bubble
inclinometer. Intrarater reliability for this test is excellent with
ICC of 0.95, SEM 1.2 , and MDC 3.4 .37
The self-reported 10-item ODI was used to measure low backe
related disability,38 with the total raw score used for assessment.
The ODI has demonstrated responsiveness to change in in-
dividuals with low backerelated leg pain.39 The MDC is 10
points,35 and the ICC for test-retest reliability is >0.87.40
The GROC was used to assess change in status after initiation
of treatment. The participants identified their response from a 15-
point scale starting at a very great deal worse to a very great deal
better. The ICC is 0.90 and MDC 2 points.41
The area of limb pain was assessed by requesting participants to
mark their pain on a body chart. The leg was subsequently divided
into 3 zones: thigh, leg, and ankle or foot. Improvement was judged
by centralization of symptoms. The kappa value for assessing the
reliability of centralization phenomenon ranges upward from 0.51.42
Procedures
Interventions were provided by a qualified physiotherapist with 8
years of postgraduate experience. All participants attended the
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Spinal mobilization for lumbar radiculopathy
Fig 1 Flowchart of the participants through the study.
clinic for six 50-minute treatment sessions carried out over 2
consecutive weeks. Sessions comprised neural mobilization,
structured exercise, and transcutaneous electrical nerve stimula-
tion (TENS). In addition, participants in the SMWLM group
received SMWLM, which took approximately 5 minutes.25 After
this, participants were encouraged to continue with a home exer-
cise program. If an exacerbation of symptoms occurred, a record
was made and no further treatment was given on that day.
www.archives-pmr.org
3
Participants were encouraged to not seek other treatment until the
study was completed.
Spinal mobilization with leg movement
While laying on their nonaffected side participants were asked to
move their affected leg to the limit of pain-free range of SLR. At
the same time, the physiotherapist applied firm transverse
pressure to the superior vertebrae at the affected spinal level (eg,
4 K. Satpute et al

L4 in case of L4 or L5 and L5 in case of L5 or S1) away from Results

the painful side. Participants were instructed to stop the leg
movement at the point leg pain was provoked, easing back, and Sixty participants (35 women) were recruited and disability was
then maintaining the position for 3 seconds before returning to mostly rated as severe.38 Demographic details are shown in
the starting position. The technique was progressed from a single table 1. The flow of participants, reasons for ineligibility, and loss
set of 3 repetitions on the first occasion to 2-3 sets of 6-8 to follow-up are detailed in fig 1.
repetitions with a rest interval of 30 seconds between sets on There were no participants with neuropathic pain (see table 1)
subsequent applications. Progression was also achieved by indicating the study population could be categorized as
applying pain-free overpressure to the range of SLR. Progression compressive neuropathy or peripheral nerve sensitization.7
occurred when range of SLR achieved 50% of that on the un- All participants received all 6 treatment sessions during the 2
affected side. weeks without dropout. No adverse effects were reported.
A neural slider mobilization was applied next according to a Between group analysis revealed a significant effect of
previously published method.26 With the subject in side lying, a SMWLM on the 2 primary outcome variables (table 2). Leg pain
rhythmical movement of hip and knee flexion followed by hip and intensity reduced significantly more in the SMWLM group post-
knee extension was carried out for 30 seconds and repeated intervention (MD e2.4 points; 95% CI, e2.0 to 2.7), at 3-month
5 times. follow-up (MD e3.8 points; 95% CI, e3.4 to e4.3), and at
All participants received 2 sets of 5-7 repetitions of lumbar 6-month follow-up (MD e 4.4 points; 95% CI, e 4.0 to e 4.8).
spine ROM exercises in 4-point kneeling, comprising pelvic tilting The ODI score also reduced significantly more in the SMWLM
and heel sitting (lumbar flexion). Participants also received 4 pole group post-intervention (MD e3.9 points; 95% CI, e5.5 to 2.2),
conventional low-intensity, high-frequencies (80-100 Hz) TENS at 3-month follow-up (MD e5.0 points; 95% CI, e6.5 to e3.4),
with wave durations of 50-100 ms. Two electrodes were applied and at 6-month follow-up (MD e 4.7 points; 95% CI, e6.3
on the lumbar spine and 2 more on affected lower extremity in the to e3.1).
distribution of pain for 30 minutes.43 Within-group analysis revealed that leg pain intensity
Participants performed the exercise at home once per day with was significantly reduced post-intervention (MD e3.5 points; 95%
3 sets of 10 repetitions. Progression could be made by increasing CI, e3.0 to -4.1), at 3-month follow-up (MD from previous evalu-
the repetitions when comfortable. ation e1.9 points; 95% CI, e1.2 to e2.5) and at 6-month follow-up
Approval for this study was granted by the ethical com- (MD from previous evaluation e 0.4 points; 95% CI, e 0.1 to e 0.8).
mittee of Smt. Kashibai Navale Medical College and General
Hopsital. The trial was registered with the Clinical Trial Reg-
istry of India Ref. No. CTRI/2015/09/006165. Sample size was
Table 1 Baseline characteristics of the participants
determined a priori, based on data from a similar study.44 Sixty
participants were required to ensure that this trial was powered Characteristic SMWLM Group Control Group
to detect a difference of 1624 points out of 100 in leg pain Age (y), mean  SD 45.99.1 42.39.0
severity with 80%, a 2-tailed alpha of 5%, and an expected Sex, women, n (%) 1653.3 1963.3
dropout rate of 20%. This sample size also had 80% power to BMI (kg/m2), mean  SD 25.64.6 24.73.5
detect a difference of 912 points on the 100-point ODI. Duration of leg symptoms (d), 212.266.6 197.866.5
mean  SD
LANSS score (0-24), 8.41.3 8.11.6
Statistical analysis mean  SD
Neuropathic pain, n (%) 0 0
The Statistical Package for Social Sciences (SPSS 23) softwarea Lumbar flexion, mean  SD 38.904.54 39.674.13
was used for statistical analysis. Data were normally distributed Lumbar extension, 14.802.99 15.832.64
without outliers and with homogeneity of variances (P>.05). mean  SD
Descriptive statistics are presented and continuous variables are Lumbar side flexion (right), 14.833.03 15.13 (2.61)
summarized with means and SDs. Categorical or dichotomous mean  SD
data are summarized with frequencies. Lumbar side flexion (left), 14.802.88 14.303.30
A repeated measures general linear model (independent factor mean  SD
was group: CG vs SMWLM and repeated factor was time: pre- to SLR (affected side), 48.434.51 45.874.15
post-intervention and at 3 and 6mo of follow-up) was used to mean  SD
evaluate the differences in all outcome variables. Tukey post hoc SLR (nonaffected side), 70.037.45 69.576.17
test was used to evaluate for significant differences in the main mean  SD
effect for group, time, or interaction (group  time). The results LBP VAS (0-10), mean  SD 3.51.4 3.91.4
are presented as the mean difference (MD) and 95% confidence Leg pain VAS (0-10), 7.10.8 6.60.7
interval (95% CI) for all outcomes across all time points. Because mean  SD
dropouts were very low, data were analyzed after the intention-to- ODI (0-50), mean  SD 24.55.1 23.44.8
treat principle.45 Area of limb pain, n (%)
For area of limb pain, scores at each follow-up point were 1. Thigh 0 0
compared against baseline values and coded as centralized if the 2. Leg 10 (33.3) 11 (36.7)
symptoms cleared from their most distal area recorded on the 3. Ankle/foot 20 (66.7) 19 (63.3)
body chart or peripheralized when symptoms progressed to a more
Abbreviations: BMI, body mass index; LANSS, Leeds assessment of
distal area. For all analyses, statistical tests were 2 tailed and the neuropathic symptoms and signs.
P value<.05 was considered as significant.

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Spinal mobilization for lumbar radiculopathy 5

There was also a significant effect of treatment on ODI score post-

(4.9-13.3)
Table 2 Mean (SD) for continuous outcomes measured at baseline and at each follow-up time for each group, within-group mean differences (MD) with 95% CI, and between-group mean

(1.9-3.2)

(6.3-3.1)

(1.3-0.3)
intervention (MD e7.1 points; 95% CI, e5.3 to 9.4), at 3 months

SMWLM
Between-Group Difference

GdCG
6 mo
(MD from previous evaluation e2.3 points; 95% CI, e1.0 to -3.7),

2.6

4.7

0.8

9.1
as well as at 6 months (MD from previous evaluation e 0.5 points;

MD (95% CI)

(6.2-14.0)
(2.2-3.4)

(6.5-3.4)

(1.3-0.2)
95% CI, e0.1 to -1.1) as presented in table 2 and figs 2 and 3.

SMWLM
GdCG
3 mo
For the secondary outcome variables, SMWLM had a signifi-

10.1
2.8

0.8
cant effect on LBP intensity post-intervention (MD e1.2 points;

(5.7-14.3)
3.6) (1.4-2.6)

0.3) (5.5-2.2)

0.6) (1.5-0.2)
95% CI, e 0.8 to -1.7), at 3 months (MD from previous evaluation
SMWLM
GdCG
Wk 2

e0.5; 95% CI, e 0.1 to e1.0) and at 6 months (MD from previous

10
2.0

3.9

0.9
evaluation e0.4; 95% CI, e 0.1 to e 0.8). These results are
presented visually in fig 4.
There was also a significant effect of SMWLM on SLR ROM

(0.3-4.9)
0.8) ( 2.3 to

1.1) ( 1.2 to

0.8) ( 0.1 to
postintervention (MD 17.3 points; 95% CI, 19.6-15.1), at 3
2.9

0.8

0.3

2.6
6 vs 3 mo

CG

months (MD from previous evaluation 2.4 points; 95% CI, 0.3-
4.4), but not at 6 months (MD from previous evaluation 1.6 points;
95% CI, 0.1 to 3.3) as presented in table 2 and fig 5.
SMWLM G

(0.1-3.3)
( 0.1 to

( 0.1 to

( 0.1 to

Similarly, the GROC improved significantly in the group

0.4

0.5

0.4

1.6

receiving SMWLM post-intervention more than the CG (MD 2.1

points; 95% CI, 1.6-2.6) at 3 months (MD from previous evalu-
1.0) ( 0.1 to 1.2)
2.5) ( 1.7 to e2.8)

ation 1.2 points; 95% CI, .7-1.7) and at 6 months (MD from
3.7) ( 2.5 to 0)
Within-Group Difference

(0.7-3.7)

previous evaluation 1.6 points; 95% CI, 1.1-2.2), as presented

3 mo vs 2 wk
MD (95% CI)

2.2

1.2

0.6

2.2

in table 3.
CG

Between-group analysis revealed there was significant

improvement in all outcome measures at all the time points, as
presented in tables 2 and 3.
SMWLM G

(0.3-4.4)
( 1.2 to

( 1.0 to

( 0.1 to

With respect to the area of limb pain, immediately after the 2-

1.9

2.3

0.5

2.4

week intervention period, 23 of 27 (85%) participants in the

( 0.8 to 1.6)

( 0.2 to 1.2)
( 0.9 to e3.4)

SMWLM group and 14 of 29 (48%) participants in the CG re-

ported centralization of leg pain. At 6 months, 25 of 25 (100%)
(4.9-15.9)

participants in the SMWLM group and 22 of 25 (88%) partici-

1.2

2.1

0.7

9.9
Wk 2 vs 0

pants in the CG reported centralization of the leg pain with

CG

reference to the first evaluation time point.

( 3.0 to 4.1)

( 5.3 to 9.4)

( 0.8 to 1.7)

(19.6-15.1)
CG nZ30 SMWLM G
3.5

17.44 21.23.8 15 (3.9) 202.1 14.53.8 19.22.1 7.1

2.31.2 3.21.1 1.81.2 2.51.1 1.41.1 2.20.8 1.2

65.86.7 55.88.4 68.16.3 588.4 69.87.1 60.68 17.3

Discussion
1.21.2 3.81.3

This is the first randomized controlled trial evaluating the efficacy

of SMWLM in the management of patients with lumbar radicul-
6 mo

opathy. Both groups showed significant improvements in all

SMWLM G

outcome measures. However, in comparison to the CG, the group

CG nZ30 nZ30

receiving SMWLM showed significantly greater improvement

immediately after the intervention which was maintained even 6
1.61.5 4.51.2

months later.
3 mo

These results are consistent with previous intervention studies

SMWLM G

for lumbar radiculopathy where treatment comprised exercise,

CG nZ30 nZ30

traction, or neural tissue mobilization. These studies showed sig-

Mean  SD
Groups

nificant improvement in leg pain as well as disability 4-6 weeks

post-intervention27,44 and improvement was maintained at 6-
3.51.1 5.51

month follow-up.27 However, when compared to Ferreira et al,44

Wk 2

the addition of SMWLM in our study resulted in more rapid

SMWLM G

and greater improvements in leg pain severity.

CG nZ30 nZ30

Previous recommendations for the conservative management

70.78 6.70.69

of radiculopathy include exercise, neural and spinal mobilization

24.55.1 23.44.8

3.51.4 3.91.4

48.44.5 45.94.1

encouraging nerve root decompression and neural tissue desen-

sitization.7,26,46 Indeed, previous studies have shown preliminary
Abbreviation: G, group.
Wk 0
differences (95% CI)

evidence for the use of neural mobilization in the management of

SMWLM G

leg pain.26,44,47-49 Moreover, a recent systematic review was in

nZ30

favor of neural mobilization50 for the management of referred

limb pain. Previously it has been proposed that neural mobiliza-
score/50

Degrees
VAS/10

VAS/10
Back pain
Outcome

SLR ROM
Leg pain

tion should consist of slider movements without tension on nerve

Measure

tissue.51,52 However, SMWLM is a graded tensioning technique,

ODI

albeit in a pain-free range. Animal experimental evidence

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6 K. Satpute et al
Fig 2 Changes in mean values for leg pain intensity over time for
both treatment groups.
supports the use of neural tensioning techniques for experimen-
tally induced acute nerve pain in an animal model.53 However, in
humans, pain-free mobilization of the nerve is preferable and
hence SMWLM may be a useful tool in the management of
radiculopathy.
It has been suggested that neural mobilization induces hypo-
algesia54 by activation of the descending pain inhibitory system,55
reducing intraneural edema,56-58 and promoting nerve recovery59
which then help restore the neural tissues ability to tolerate
stresses during activities of daily living.13 The greater improve-
ment in leg and back pain in the SMWLM group compared to the
Fig 3 Changes in mean values for disability over time for both
treatment groups.
Fig 4 Changes in mean values for low back pain intensity over time
for both treatment groups. Abbreviation: VASBP, visual analog scale
back pain.
CG could be related to the combination of spinal mobilization
along with active leg moments providing a functional mobiliza-
tion toward increasing the pain-free range of SLR. Increasing
range of SLR is perhaps empowering to the patient because it
reduces fear of movement and extinguishes the movement or pain
association.
The benefits of SMWLM may also be due to the mechanical
manual force applied to the lumbar spine.60 It is postulated that
this facilitates a change in the volume of the intervertebral fora-
men decompressing the nerve root. The SLR movement compo-
nent of SMWLM may provide similar benefits to that of neural
Fig 5 Changes in mean values for SLR over time for both treatment
groups.
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Spinal mobilization for lumbar radiculopathy 7

mobilization. Moreover, SMWLM technique produces a signifi-

1.6 (1.1-2.2)
cant sympathoexcitatory response,61 which has been linked with

SMWLMdCG
(95% CI)
the hypoalgesic effect.62-64

6 mo MD
Improvements in both groups after 2 weeks of intervention,
which was maintained at 6-month follow-up might be explained
by natural resolution, but also by the simple exercises together

Between-Group Difference
with TENS. However, the efficacy of TENS application in patients

1.2 (0.7-1.7)
with lumbar radiculopathy is reported as low.43,65 It is reported

SMWLMdCG
Mean  SD for global perceived effect at each assessment point for each group and between-group mean difference (MD) (95% CI) at each assessment point

that spinal flexibility exercises66 similar to the present study may

(95% CI)
3 mo MD
be beneficial for lumbar radiculopathy, which is also the case for
people with LBP with or without leg pain.67 Lumbar flexion is
thought to increase the volume of the intervertebral foramen,
allowing nerve root swelling and edema to resolve, and may
therefore assist in spinal nerve root decompression.68
Postintervention

2.1 (1.6-2.6)
MD (95% CI)
SMWLMdCG

Study limitations
There are several limitations to the study’s findings. First, we did
not monitor whether participants adhered to the home exercise
protocol. Second, participants from the SMWLM group received a
CG nZ30

longer treatment session than the CG. Although the difference was
4.40.9

at most 5 minutes on top of a 50-minute treatment session. Third,

TENS was only administered for 30 minutes. Fourth, all in-
6 mo Mean  SD

terventions were administered by the same physiotherapist; how-

ever, this effect was limited by equal emphasis to the treatment in
both groups. Finally, we included only those participants who
SMWLMG nZ30

responded to a trial SMWLM. Despite this, only 11 of 71 patients

were found to not respond to SMWLM, providing some confi-
60.9

dence in the generalizability of these results.

Future studies are recommended to identify the mechanism of
action of SMWLM. In addition, studies should investigate the
relative efficacy of SMWLM compared to early surgery in the
short and long terms.
CG nZ30
4.20.8
3 mo Mean  SD

Conclusion
Groups

In the treatment of patients with subacute lumbar radiculopathy,

SMWLMG nZ30

the addition of SMWLM to exercise and TENS provided signifi-

cantly improved benefits in leg and back pain, disability, SLR
5.40.9

ROM, as well as patient satisfaction in the short and long terms.

Supplier
CG nZ30
1.91.0
Postintervention Mean  SD

a. SPSS, version 23; IBM.

Keywords
SMWLMG nZ30

Low back pain; Manual therapy; Radiculopathy; Rehabilitation

4.00.9
Abbreviation: G, group.

Corresponding author
GROC (-7 to 7)

Kiran Satpute, MPTh, COMT, Department of Kinesiotherapy and

Physical Diagnosis, Department of Musculoskeletal Physiotherapy,
Outcome

Smt. Kashibai Navale College of Physiotherapy, Off Westerly

Table 3

Bypass, Narhe Pune, Maharashtra 411041, India. E-mail address:

kiran_ptist@yahoo.co.in.

www.archives-pmr.org
8 K. Satpute et al
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