Effects of Adding A Neurodynamic Mobilization To Motor Control Training in Patients With Lumbar Radiculopathy Due To Disc

American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print
DOI: 10.1097/PHM.0000000000001295
Effects of Adding a Neurodynamic Mobilization to Motor Control Training in Patients
with Lumbar Radiculopathy due to Disc Herniation: A Randomized Clinical Trial
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Gustavo Plaza-Manzano1,2 PT, PhD; Ignacio Cancela-Cilleruelo3 PT, MSc; César Fernández-de-
las-Peñas4,5 PT, MSc, PhD, Dr med; Joshua A. Cleland6,7,8 PT, PhD; José L Arias-Buría2,3 PT,
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PhD; Marloes Thoomes-de Graaf9 PT, PhD; Ricardo Ortega-Santiago4,5 PT, PhD
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Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de
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Madrid, Madrid, Spain
2
Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
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Clínica Fisiofit, Madrid, Spain
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Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical
Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain

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Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual, Punción Seca y
Ejercicio Terapeútico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.

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Physical Therapist, Rehabilitation Services, Concord Hospital, NH, USA.
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Faculty, Manual Therapy Fellowship Program, Regis University, Denver, Colorado, USA.
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Department of Physical Therapy, Franklin Pierce University, Manchester, NH, USA.
9
Fysio-Experts, Hazerswoude-Rijndijk, the Netherlands.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Address for reprint requests / corresponding author.
César Fernández de las Peñas
Facultad de Ciencias de la Salud
Universidad Rey Juan Carlos
Avenida de Atenas s/n
28922 Alcorcón, Madrid, SPAIN
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E-mail address: cesarfdlp@yahoo.es
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Disclosures: The authors have no conflicts of interest to declare.
Funding: No funds were received for this study

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Trial registration: http://www.clinicaltrials.gov, ClinicalTrials.gov, NCT03620864
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Abstract
Objective: 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 (SLR), and
pressure pain threshold (PPT) in lumbar radiculopathy.
Design: A randomized clinical trial.
Methods: Individuals with LBP, with confirmed disc herniation, and lumbar radiculopathy were
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randomly assigned to receive 8 sessions of either neurodynamic mobilization plus motor control
exercises (n=16) or motor control exercises alone (n=16). Outcomes included pain, disability,
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neuropathic symptoms, SLR, and PPT at baseline, after 4 visits, after 8 visits, and after 2-
months.
Results: There were no between-groups differences for pain, related-disability, or PPT at any
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follow-up period since both groups get similar and large improvements. Patients assigned to the
neurodynamic program group experienced better improvements in neuropathic symptoms and
the SLR compared to the motor control exercise group (P<0.01).

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Conclusion: The addition of neurodynamic mobilization to a motor control exercise program
leads to reductions in neuropathic symptoms and mechanical sensitivity (SLR), but did not result
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in greater changes of pain, related-disability, or PPT over motor control exercises program alone
in subjects with lumbar radiculopathy. Future trials are needed to further confirm these findings
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since between-groups differences did not reach clinically relevance.
Key words: Lumbar radiculopathy, exercise, neurodynamic, pain, disability.
What is Known
Motor control exercise are effective for the management of low back pain. Some
evidence supports the use of neural mobilization in low back pain, but its evidence for radicular
pain is poor. We do not know if combined interventions would lead to better outcomes.
What is New
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The addition of neurodynamic mobilization to a motor control exercise program leads to
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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 application of motor
control exercises program alone in subjects with lumbar radiculopathy.

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Introduction
Low back pain (LBP) is a common condition, resulting in a significant impact on the patient
in terms of pain and disability. The costs associated with LBP are increasing exponentially.1 In
addition, many individuals with LBP also experience the consequence of a disk herniation e.g.
radiating pain and radicular symptoms, which may result in lower extremity symptoms such as
radiculopathy.2 Lumbar radiculopathy may be the result of a herniated lumbar disc which may
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irritate a lumbar nerve trunk resulting in intraneural inflammation. A herniated disk could cause
lower extremity numbness and weakness in addition to pain experienced by the individuals.
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Unfortunately, lumbar radiculopathy can progress to chronicity resulting in substantial pain,
disability, and burden.3

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There are several treatment strategies for the management of LBP and lumbar radiculopathy
including disc surgery, injections, analgesia, acupuncture, traction, manual therapy, percutaneous
discectomy, exercise and/or orthosis.4 Although optimal management strategy for lumbar
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stenosis, including radiculopathy, remains to be elucidate, current trends are conservative
interventions such as physical therapy.5 Moreover, according to an international survey, surgeons

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around the world indicated one of the assumptions for an operative intervention is the failure of
conservative therapy, thereby implying conservative therapy is the first treatment option. 6
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Surgery is not more effective than physical therapy after one year on pain relief and perceived
recovery.7,8 In fact, many physical therapy treatment options exist, including manual therapies
and exercises; however, the best method to decrease pain and improve function 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 exercises for the management of LBP, although no differences were found
with other forms of exercise.10 There also exists evidence supporting the use of manual therapies
such as spinal manipulation or mobilization for the management of LBP. 11 However, different
manual therapies, e.g., soft tissue interventions, spinal manipulation or mobilization, and neural
interventions, target different concepts.
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A manual therapy technique that may potentially be used for the management of patients
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with lumbar radiculopathy is neurodynamic mobilization. Neural mobilization includes both
slider and tensioner maneuvers. The aim of a nerve slider intervention is to induce a gliding
movement of the nerve trunk in relation to their adjacent tissues. The nerve slider technique
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applies 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
intervention 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 distally at
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the same time and in the same direction towards an increase in nerve tension.10 It has been
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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
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decreased function.12,13 The underlying mechanisms of neural mobilization interventions 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. utilized a neurodynamic mobilization technique to manage a patient with
lumbar radiculopathy in which the individual experienced clinically meaningful reductions in
pain.17 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 effective for improving pain and disability in individuals with LBP, but the
evidence for the use of neural mobilization for radicular pain was found to be poor.19 Future
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trials examining the effects of neural mobilization in people with lumbar radiculopathy are
necessary to determine its efficacy.
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Therefore, the purpose of this randomized clinical trial was to investigate the effects of
the addition of neural mobilization into a motor control exercises program on pain, disability,
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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 experience better outcomes than those receiving motor control exercise
program alone.
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Methods
Study Design
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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,
neuropathic 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 Supplementary Checklist; Supplemental Digital
Content, http://links.lww.com/PHM/A859)
Participants
Between July and October 2018 consecutive patients exhibiting LBP and radiculopathy
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(lower extremity symptoms) were screened for potential eligibility criteria from a local hospital
in Madrid, Spain. To be eligible to participate patients: 1, had to be between 18 and 60 years old;
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2, have a confirmed (via MRI) disc herniation between L4-S1 levels; 3, had to exhibit lumbar
radiating pain to one lower extremity including the foot; 4, have had pain for at least 3 months; 5,
had increased leg pain on coughing, sneezing, or straining; and 6, had a positive straight leg raise
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with symptom reproduction between 40-70 degrees. All participants received a neurological
clinical examination including assessment of muscle weakness, cutaneous sensitivity and
reflexes by an experienced neurologist for evaluating the integrity of the nervous system and
avoiding the presence of lumbar radiculopathy. Manual muscle tests were performed to identify
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the presence of weakness along L4-S1 myotome distribution by using the grading of 0 to 5 (0/5
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no movement; 3/5 antigravity; 5/5 normal). Subjects were excluded if they had any of the
following criteria: 1, indication for surgical intervention, e.g., absence of reflexes, muscle
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atrophy, signs compatible with lumbar myelopathy; 2, had a confirmed disc herniation at other
lumbar levels; 3, have had any other spinal conditions such as spinal tumors, spondylolisthesis or
cauda equina; 4, had received treatment for this condition by a physical therapist the previous 6
month; or, 5, pregnancy. Participants were also excluded if they exhibited any contraindications
to manual therapy or exercise as noted in the patient’s Medical Screening Questionnaire such as
rheumatoid arthritis, osteoporosis, prolonged history of steroid use, severe vascular disease, etc.
All subjects signed an informed consent prior to 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
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the symptom, aggravating and easing postures, mechanism of injury, prior treatments, and prior
history of low back or leg pain. These physical examination items were those that are routinely
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used in the physical therapy examination of the lower extremity.
Randomization and masking

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Subjects were randomly assigned to receive either motor control exercises plus neurodynamic
mobilization or a motor control exercise program alone. Concealed allocation was performed by
an individual not involved in subject’s recruitment using a computer-generated randomized table
of numbers created prior to the beginning of the trial. The group assignment was recorded on an
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index card. This card was folded in half such that the label with the patient’s group assignment
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was on the inside of the fold. The 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
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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
years of experience in the management of patients with lumbar radiculopathy.
Both groups received 8 sessions of a motor control exercise program of 30 min duration
for 4 weeks, twice a week, following 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 the participant was confident to perform the exercises alone at home.
Participants were asked to perform exercises at home once daily for 20 minutes over the 8-week
intervention period. The motor control exercise program consisted of a progression from isolated
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contraction of the transversus abdominis and/or isolated contraction of the multifidi to combined
contraction of both transversus abdominis and multifidi muscles in different positions from
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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 over-activity of superficial muscles in an individualized manner (visual

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observation by the therapist). Each exercise was performed for 10 repetitions for 10 seconds each
as previously described.22 The adherence to the exercise program was collected on each
subsequent session in a weekly diary.

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Patients allocated to the neurodynamic group also received a nerve neurodynamic slider
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intervention targeting the main trunk of the sciatic nerve of the affected side. Previous studies
have suggested that nerve slider techniques are associated with larger nerve excursion than nerve
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tensioner interventions.23,24 The nerve slider intervention applied in the current study included
flexion, adduction and medial rotation (if possible) of the hip, knee extension and ankle dorsi-
flexion. From this position, concurrent hip flexion and knee flexion were alternated dynamically
with concurrent hip and knee extension (Fig. 2). During the intervention, the therapist alternated
the movement combination depending on the tissue resistance and patient’s symptoms. Speed
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and amplitude of movement were adjusted such that no pain was produced during the technique.
The slider intervention was applied for 3 sets of 10 repetitions on each treatment session for 8
weeks and it was applied 5 minutes before the motor control exercise program.
Outcome Measures
All outcomes were assessed at baseline, after 4 treatment sessions (mid follow-up), after
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the treatment program (immediate follow-up), and 2 months after the last treatment session
(follow -up) by an assessor blinded to the group allocation of the subjects.
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The primary outcome was the intensity of lower extremity pain symptoms. Participants
rated the intensity of their lower extremity pain at rest on an 11-point numeric pain rating scale
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(NPRS) where 0 represents no pain and 10 is the maximum pain.25 Since there is no specific
minimum clinically important difference (MCID) for NPRS in individuals experiencing lumbar
radiculopathy, we used the MCID established as 2 points for patients with LBP.26 In fact, the cut-
off of 2 points is usually considered an MCID for chronic pain in general.27

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Secondary outcomes included the Self-report Leeds Assessment of Neuropathic Symptoms
and Signs Scale (S-LANSS), the Roland-Morris Disability Questionnaire (RMDQ), the straight
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leg raise test, and pressure pain sensitivity. The S-LANSS is a simple and valid 7-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 (5 items) or clinical signs (2 items). The
total score is 24 points and a value ≥ 12 points is indicative of a neuropathic component of pain.
In the current trial, the validated Spanish version of the S-LANSS was used.29
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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 scored ‘No’, i.e., the denominator
remains. The score ranges from 0-24 with higher scores indicative of higher related-disability.
The MCID for the RMDQ has been reported to range from 2 to 8 points.32 Lauridsen et al found
that the RMDQ also exhibited good responsiveness for patients with leg pain showing a MCID
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of 5 points.33
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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 degrees is considered as indicative of a

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disc herniation comprising a nerve root. The straight leg raise has shown a sensitivity of 91% and
specificity of 26%.34 Neto et al found that changes ranging from 7 to 8 degrees can be considered
minimal detectable difference for the straight leg raise test,35 whereas Dixon and Keating36
reported that inter-session measurements need to change by more than 16° to represent a relevant
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change.
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Pressure pain sensitivity was assessed by pressure pain thresholds (PPT), i.e., the minimal
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amount of pressure applied on a particular point for the pressure sensation to first change to
pain.37 A mechanical pressure algometer (Pain Diagnosis and Treatment Inc, New York, USA)
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was used in this trial to assess PPTs (kg/cm ) over the common peroneal (where it passes behind
the head of the fibula as it winds forwards 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
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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 3 trials was calculated on each point and used for the analysis. A 30-second
resting period was allowed between each measure. The order of assessment was randomized
between subjects.
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Treatment Side Effects
At each session patients were asked to report any adverse events that they experienced. In
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the current trial, an adverse event was defined as sequelae of 1-week duration with symptoms
perceived as distressing and unacceptable to the patient and required further treatment.39
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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
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NPRS,26,27 assuming a standard deviation of 1.4, a 2-tailed test, an alpha level (α) of 0.05, and a
desired power (β) of 80%. The estimated desired sample size was calculated to be of 16 subjects
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per group.
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Statistical analysis
Data were analyzed using the SPSS version 21.0 (SPSS Inc, Chicago, IL, USA) 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 independent
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t-test for continuous data and chi-square tests of independence for categorical data. A mixed-
model 4x2 analysis of covariance (ANCOVA) with time (before, mid-follow up, immediate
follow-up, 2 months) as the within-subjects factor, group (motor control or motor control plus
neurodynamic) as the between-subjects factor, and gender as covariate was used to examine the
effects of the interventions on each outcome (i.e., pain intensity, S-LANSS, straight leg raise,
and PPTs). For each ANCOVA, the hypotheses of interest was the Group * Time interaction. In
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general, a P value less than 0.05 was considered statistically significant, but post hoc analyses
were conducted with a Bonferroni test using a corrected alpha of 0.025 (2 independent-samples).
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The effect size was calculated when the Partial Eta Squared (ƞ 2 p) 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 deviation. In general, a SMD
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of 0.2 is considered small, 0.5 moderate, and 0.8 large clinical effect size.
Results
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Forty consecutive subjects with symptoms in the lower extremity compatible with lumbar
radiculopathy were screened for potential eligibility between July and October 2018. Thirty-two
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patients satisfied all criteria, agreed to participate, and were randomly allocated to the motor
control exercises (n=16) or motor control exercise plus neurodynamic intervention (n=16) group.
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The reasons for ineligibility are listed in the flow diagram of patient recruitment and retention
(Fig. 3). Baseline features between both groups were similar for all outcomes (Table 1). None of
the subjects receiving either intervention reported any adverse events. The adherence to the
exercise program was 96% as collected on the weekly diary.
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Pain Intensity
The ANCOVA did not find a significant group * time interaction for lower extremity pain
(F=1.269; P=0.273; ƞ 2 p: 0.043): patients receiving motor control exercises program alone or
combined with a neurodynamic intervention experienced similar decreases in lower extremity
pain (Table 2, Fig. 4A). Between-groups effect sizes were small (SMD: 0.2), whereas within-
group effect sizes were large for both groups (SMD>1.25). Gender did not influence the effect in
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the main analysis (F=0.895; P=0.355).
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Neuropathic Symptomatology (S-LANSS)
The ANCOVA revealed a significant group * time interaction for S-LANSS (F=8.559;
P=0.008; ƞ 2 p: 0.373): patients in the motor control exercise plus neurodynamic intervention
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group exhibited a greater decrease in the S-LANSS score (suggesting 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 months (SMD:
0.75). Gender did not influence the interaction on the S-LANSS (F=0.211; P=0.651).
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Related-Disability (RMDQ)
The results did not reveal a significant group * time interaction for the RMDQ (F=2.970;
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P=0.101; ƞ 2 p: 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). Gender did not influence the main effect in
the analysis (F=0.202; P=0.658).
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Mechanical pain sensitivity (SLR and PPT)
The ANCOVA revealed a significant group * time interaction for the straight leg raise
(F=7.512; P=0.013; ƞ 2 p: 0.220): individuals in the motor control exercise plus neurodynamic
intervention group exhibited greater improvements in the straight leg raise test (suggesting a
decrease of mechanical sensitivity) than those in the motor control exercise alone group (Table
2, Fig. 4D). Between-groups effect sizes were moderate (SMD: 0.55) after 4 treatment sessions
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and large immediately after the treatment (SMD: 1.05) and at 2 months follow-up (SMD: 0.9).
Gender did not influence the main interaction on te straight leg raise (F=0.994; P=0.331).
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Finally, no significant group * time interactions for changes in PPTs in the tibial (F=0.582;
P=0.454; ƞ 2 p: 0.026) or common peroneal (F=0.658; P=0.426; ƞ 2 p: 0.029) nerve trunks were
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observed: patients receiving motor control exercises alone or combined with a neurodynamic
intervention 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).
Gender did not influence the interaction effects on PPTs (tibial: F=0.678, P=0.420; common
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peroneal: F=0.620, P=0.440).

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Discussion
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This is the first clinical trial examining the effects of adding nerve neurodynamic
mobilization to a program of motor control exercises compared to 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
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exercises/neurodynamic mobilizations experienced significantly greater reductions in
neuropathic symptoms (S-LANSS) and mechanical sensitivity as measured by the straight leg
raise test suggesting that neurodynamic mobilizations may have a greater impact on nerve tissue
sensitivity.
While the exact mechanisms underlying the effects of manual therapies are uncertain,40 a
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number of potential theories exists as to how manual therapies, including neurodynamic nerve
mobilizations, might exert their therapeutic effects. It is possible that neurodynamic mobilization
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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 centres.43
However, these mechanisms would be expected to have an impact on patient centred outcomes
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such as pain and disability which has been identified in studies using neurodynamic treatments
for individuals with nerve entrapment of the upper extremity, e.g., carpal tunnel syndrome.44 The
fact that no between-groups differences were observed for pain intensity and related-disability
may be associated to the fact that there is evidence supporting the application of motor control
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exercises for the management of this population.10 In fact, both groups obtained significant and
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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.
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Participants receiving the neurodynamic intervention experienced large improvements in
neuropathic symptoms and the impact on neural sensitivity as assessed by the straight leg raise. It
should be noted that between-groups differences at two-month follow-up for the straight leg raise
(8.8º) surpassed the minimal detectable difference reported by Neto et al35 but not the cut-off
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(16º) determined by Dixon and Keating36 supporting a potential, but small, effect of the
neurodynamic mobilization in this outcome. Additionally, it should be noted that the straight leg
raise does not only assess neural sensitivity since it can be also associated with hamstring
tightness.
It is also important to note that both groups decreased significantly their S-LANSS
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scores, although the neurodynamic mobilization groups exhibited a greater and larger decrease.
In fact, after all treatment sessions, almost all participants in both groups were below the 12
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points cut-off that determines the presence of neuropathic symptoms supporting that both
interventions may be capable of reducing neuropathic symptoms, although changes were
superior when a neurodynamic mobilization was included into the treatment program. Several
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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 fluid15 which might assist in a reduction of intra-neural edema found in individuals
experiencing neural compression.45 Another cadaveric study examining a potential impact of

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simulated neurodynamic mobilization technique on sections of the sciatic nerve also found
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dispersal of intra-neural fluid which it was hypothesized for resulting in decreased intraneural
edema and intraneural pressure.14 However, these hypothesis in people with actual nerve
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compression requires further research. It is interesting to note that a study comparing 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
Though, splinting is not a viable option for individuals with lumbar radiculopathy.
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It should also be noted that the effect sizes for changes in the S-LANSS and straight leg
raise test were much larger after 8 sessions as compared to when measured after just 4 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 found that after receiving
consecutive sessions of thoracic manipulation, patients continued to receive added benefit with
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additional visits.47 Another study comparing the dose-response of spinal manipulation,
comparing 0, 6, 12, 18 sessions, found that 12 sessions of spinal manipulation was best for
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maximizing changes in pain and disability in individuals with chronic LBP at a 12-week follow-
up.48 Therefore, the ideal dose response for neurodynamic mobilizations requires further
investigation but from the current results it appears that 8 treatments result in superior outcomes
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when compared to 4 treatments.
Study Limitations
Finally, there are several limitations to the current study that should be considered. Only
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one therapist provided all the techniques at one geographical location. While this enhances the
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internal validity, it potentially reduces the generalizability of current findings. Second, we
included a relatively small sample size, which could be underpowered to identify a difference on
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some outcomes. Further, the sample was restricted to patients with disc herniation between L4-
S1 level, so we do not know if these results would be similar in patients with disc problems at
other lumbar levels. Similarly, the lack of control for the magnitude (size and spinal cord
location) of the disc herniation could limit the results. Finally, we only included a 2-month
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follow-up. Future clinical trials should include additional clinicians from different locations,
larger sample sizes, and collect outcome measures at long-term follow-up.
Conclusions
The results of the current trial performed on individuals with LBP, confirmed disc herniation,
and radiculopathy, observed that they did not experience greater improvements in pain, function
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or PPT when they received neurodynamic mobilization in addition to motor control exercises.
However, although patients receiving neural mobilizations experienced greater changes in neural
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mechano-sensitivity as measured by the S-LANNS and straight leg raise; these differences were
small and probably not clinically relevant. Future clinical trials are needed to further confirm
these findings.
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Legend of Figures
Figure 1: Monitoring correct contraction of the transversus abdominis (A), multifidi (B) or both
combined (C) in different positions (supine, prone, four-point kneeling).
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Figure 2: Nerve slider intervention targeting the sciatic nerve. First, flexion, adduction and
medial rotation (if permitted) of the hip, knee extension and ankle dorsi-flexion ss applied (A).
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From this position, concurrent hip flexion and knee flexion (B) are alternated dynamically with
concurrent hip and knee extension (C).
Figure 3: Flow diagram of participants throughout the course of the study.

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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
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means (standard error).

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Figure 1
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Table 1: Baseline demographics and clinical data by treatment assignment *
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Motor Control (n=16) Motor Control + Neurodynamic (n=16) P value
Gender (Male / Female) 8/8 8/8 0.999
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Age (years) 45.5 ± 6.0 47.0 ± 8.0 0.605
History of pain (months) 17.3 ± 1.4 17.2 ± 1.5 0.781
Symptoms extremity (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
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S-LANSS (0-24) 12.0 ± 1.3 12.0 ± 1.1
RMDQ (0-24) 10.5 ± 2.6 11.2 ± 1.5 0.998
Straight Leg Raise (degrees) 53.2 ± 10.0 55.2 ± 6.5 0.567
2
Pressure Pain Thresholds (kg/cm )
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Common peroneal 2.3 ± 1.0 2.1 ± 0.9 0.565
Tibialis
3.4 ± 0.9 3.2 ± 0.6 0.521
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* Data are expressed as means ± standard deviation except for gender and symptoms extremity
NPRS: Numerical Pain Rating Scale; S-LANSS: Self-report Leeds Assessment of Neuropathic Symptoms and Signs Scale: RMDQ: Roland-Morris
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Disability Questionnaire
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Table 2: Evolution of the outcomes by randomized treatment assignment
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Outcome Group Baseline After 4 sessions After 8 sessions 2 months
Pain intensity in the lower extremity (NPRS, 0-10)
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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)
Self-report Leeds Assessment of Neuropathic Symptoms and Signs Scale (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)
Roland-Morris Disability Questionnaire (RMDQ, 0-24)
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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)
Straight Leg Raise (degrees)
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)
2
Pressure Pain Thresholds over the Tibial Nerve (kg/cm )
Motor Control 3.7 ± 0.8 (3.3, 4.1) 4.2 ± 1.0 (3.7, 4.7) 4.0 ± 1.1 (3.5, 4.5)
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3.4 ± 0.9 (3.1, 3.7)
2
Pressure Pain Thresholds over the Common Peroneal Nerve (kg/cm )
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)
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Values are expressed as mean ± standard deviation (95% confidence interval);

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NDS: Neurodynamic intervention
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American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print

Effects of Adding a Neurodynamic Mobilization to Motor Control Training in Patients

with Lumbar Radiculopathy due to Disc Herniation: A Randomized Clinical Trial

Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain

Ejercicio Terapeútico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.

César Fernández de las Peñas

Facultad de Ciencias de la Salud

Universidad Rey Juan Carlos

Avenida de Atenas s/n

28922 Alcorcón, Madrid, SPAIN

Funding: No funds were received for this study

pressure pain threshold (PPT) in lumbar radiculopathy.

Design: A randomized clinical trial.

neurodynamic program group experienced better improvements in neuropathic symptoms and

the SLR compared to the motor control exercise group (P<0.01).

Conclusion: The addition of neurodynamic mobilization to a motor control exercise program

since between-groups differences did not reach clinically relevance.

Key words: Lumbar radiculopathy, exercise, neurodynamic, pain, disability.

control exercises program alone in subjects with lumbar radiculopathy.

disability, and burden.3

stenosis, including radiculopathy, remains to be elucidate, current trends are conservative

interventions such as physical therapy.5 Moreover, according to an international survey, surgeons

interventions, target different concepts.

decreased function.12,13 The underlying mechanisms of neural mobilization interventions include

intraneural fluid dispersion in the nerve root and axon.14-16

lumbar radiculopathy in which the individual experienced clinically meaningful reductions in

individuals with lumbar radiculopathy.18 A recent meta-analysis reported that neural

necessary to determine its efficacy.

a neurodynamic mobilization into a motor control exercise program on pain intensity,

the required information accordingly (see Supplementary Checklist; Supplemental Digital

clinical examination including assessment of muscle weakness, cutaneous sensitivity and

All subjects signed an informed consent prior to participation in the study.

All participants provided a detailed history, underwent a physical examination and

Randomization and masking

an individual not involved in subject’s recruitment using a computer-generated randomized table

envelope and proceeded with treatment according to the group assignment.

years of experience in the management of patients with lumbar radiculopathy.

multifidus without over-activity of superficial muscles in an individualized manner (visual

subsequent session in a weekly diary.

(follow -up) by an assessor blinded to the group allocation of the subjects.

off of 2 points is usually considered an MCID for chronic pain in general.27

Secondary outcomes included the Self-report Leeds Assessment of Neuropathic Symptoms

identifying individuals whose pain is dominated by neuropathic mechanisms.28 Each item is a

Reproduction of the patient symptoms between 40 and 70 degrees is considered as indicative of a

exercise program was 96% as collected on the weekly diary.

combined with a neurodynamic intervention experienced similar decreases in lower extremity

P=0.101; ƞ 2 p: 0.023): patients in both groups experienced similar decreases in related-disability

the analysis (F=0.202; P=0.658).

peroneal: F=0.620, P=0.440).

control exercises in this population; however, those receiving motor control

Participants receiving the neurodynamic intervention experienced large improvements in

interventions may be capable of reducing neuropathic symptoms, although changes were

experiencing neural compression.45 Another cadaveric study examining a potential impact of

It is difficult to determine the dosage (number of treatment sessions) necessary to maximize

area of discussion. For example, Fernández-de-las-Peñas et al found that after receiving

internal validity, it potentially reduces the generalizability of current findings. Second, we

larger sample sizes, and collect outcome measures at long-term follow-up.

combined (C) in different positions (supine, prone, four-point kneeling).