Journal of Bodywork & Movement Therapies 30 (2022) 140e147

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Prevention and Rehabilitation

Neurodynamic exercises provide no additional benefit to extension-

oriented exercises in people with chronic low back-related leg pain
and a directional preference: A randomized clinical trial
Luis Fernando Sousa Filho a, b, *, Marta Maria Barbosa Santos b,
Danielle Brito Matos Vasconcelos b, Erilaine Araujo Soares b,
Gabriel Henrique Freire dos Santos b, Walderi Monteiro da Silva Júnior a, b
a
Graduate Program in Physical Education, Federal University of Sergipe, Sa~o Cristova
~o, Sergipe, Brazil
b ~o Cristova
Department of Physical Therapy, Federal University of Sergipe, Sa ~o, Sergipe, Brazil

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

Article history: Background: Chronic low back-related leg pain may involve mixed pain mechanisms. A strategy to
Received 9 February 2021 address both neuropathic and nociceptive pain symptoms would be combining treatments.
Accepted 30 January 2022 Objective: To assess the effects of adding neurodynamic exercises to extension-oriented exercises in
patients with chronic low back-related leg pain and a directional preference.
Keywords: Design: Two arm, single blind, randomized clinical trial.
Chronic pain
Method: Eligible participants were aged between 18 and 65 years, had low back pain radiating below
Exercise therapy
gluteus for at least 3 months, pain intensity greater than 3 points in the numerical pain rating scale,
Sciatica
Low back pain
positive SLR test and a directional preference for lumbar extension movements. Thirty-one participants
were randomly allocated into one of two groups: extension-oriented exercises (EE) or extension exer-
cises plus neurodynamic exercises (EEN). Primary outcomes were leg pain intensity and function at 3
weeks. Secondary outcomes were low back pain intensity, disability, global perceived effect and quality
of life at 3 weeks and at 1 month.
Results: Retention rate was 100% (n ¼ 14) in EE and 94% (n ¼ 16) in EEN for primary outcome analysis.
There was no between-group difference for the primary outcomes and for low back pain intensity, GPE
and quality of life at 3 weeks. For some outcomes, EE was superior to EEN.
Conclusions: We found no benefits in adding neurodynamic exercises to extension-oriented exercises for
patients with nerve-related leg pain and a directional preference. As this study has a small and very
specific sample, results may be interpreted with caution.
© 2022 Elsevier Ltd. All rights reserved.

1. Introduction
Chronic low back-related leg pain (LBLP) is a common condition
among people with low back pain (LBP). It has been reported that
about 60% of patients with low back pain also have leg pain (Hill
et al., 2011). Chronic low back-related leg pain refers to the pain
that arises from the low back and radiates down the leg. It is
associated with increased pain intensity, disability, healthcare costs
* Corresponding author. Department of Physical Therapy, Federal University of
Sergipe, Av Marechal Rondon s/n, S~ao Cristov~
ao, Sergipe, Brazil.
E-mail address: luis.sousafilho@monash.edu (L.F. Sousa Filho).
and poor quality of life when compared to LBP alone (Hill et al.,
2011; Konstantinou et al., 2013; Hider et al., 2015). Although the
impact of chronic LBLP on pain and disability outcomes is high,
there are no clear guidelines to address the management of this
condition. It may be a consequence of the complex mechanisms
and pathways involved in chronic LBLP (Harrisson et al., 2017).
Low back-related leg pain has been classified into four main
categories: central sensitization, denervation, peripheral nerve
sensitization or musculoskeletal (Sch€
afer et al., 2009). However, it
is common to observe an overlap between these categories
because low back-related leg pain is likely to have mixed com-
ponents (Harrisson et al., 2017). Therefore, patients can exhibit
both neuropathic symptoms such as pain below the knee,
increased disability and depressive-anxious feelings and

https://doi.org/10.1016/j.jbmt.2022.01.007
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L.F. Sousa Filho, M.M. Barbosa Santos, D.B. Matos Vasconcelos et al.
nociceptive symptoms such as pain that improves with certain
movements or postures and persistent pain with pain attacks. In
this way, effective treatment for chronic low back pain-related leg
pain should address both nociceptive and neuropathic pain
mechanisms.
Physical exercise has been extensively recommended to manage
chronic pain (Oliveira et al., 2018). However, it is still not clear
which types of exercise are more effective in improving pain and
function of people with chronic low back-related leg pain. Some
studies have observed positive effects of the McKenzie method, an
approach that involves extension-oriented exercises in most cases,
on pain intensity and disability scores (Sakai et al., 2008; Garcia
et al., 2013, 2018). Extension-oriented exercises showed to be
effective in reducing pain and increasing function of individuals
with low back pain, especially those with a directional preference
(DP) for lumbar extension (Beowder et al., 2007; Thackeray et al.,
2016). A previous meta-analysis observed that the management
of low back pain based on the symptomatic response to specific
movements is superior to other interventions for improving pain
and disability (moderate to high evidence quality) (Lam et al.,
2018). However, this positive effect depends on the comparator
intervention (Lam et al., 2018).
Patients with low back-related leg pain and a directional pref-
erence for lumbar extension may present centralization of symp-
toms when extension movements are performed (Surkitt et al.,
2012). Centralization of symptoms refers to the abolition, reduc-
tion or change in location of symptoms as a response to specific
lumbar movements. When centralization occurs symptoms move
from distal to proximal toward the spine (Surkitt et al., 2012). Ac-
cording to McKenzie theory, extension exercises/movements
would cause nucleus pulposus deformation and promote intrinsic
adaptations, which would centralize the symptoms (McKenzie,
2003). These adaptations would only occur when the fibrous
annulus is intact and consequently there is no disc extrusion or
sequestration. However, a previous study observed that 93.5% of
patients with disc lesions where fibrous annulus was no longer
intact exhibited centralization of symptoms (Albert et al., 2012).
Therefore, there may be other unknown reasons why centralization
occurs and it may be further investigated.
An anterior study observed that patients with chronic low back-
related leg pain exhibited centralization of symptoms following
neurodynamic exercises (Cleland et al., 2006). Even though these
patients had not a directional preference, this finding indicates that
neurodynamic exercises would be beneficial to people with low
back-related leg pain. These exercises are hypothesized to increase
the nerve excursion and to change the intraneural flow (Basson
et al., 2017). Two meta-analyses found that the neurodynamic
therapy promotes improvements in pain and disability of in-
dividuals with low back pain conditions (Basson et al., 2017; Neto
et al., 2017). However, most included studies had a high risk of
bias, which reduces the quality of findings. Therefore, the effec-
tiveness of the neurodynamic therapy in people with chronic low
back pain or chronic low back-related leg pain is not supported by
moderate to high-quality evidence.
Given that patients with low back-related leg pain may have
mixed pain mechanisms, we have proposed to combine in-
terventions that would address both nociceptive and neuropathic
symptoms in order to manage this condition (Harrisson et al.,
2017). Therefore, the aim of this study was to verify the effects of
the addition of neurodynamic exercises to extension-oriented ex-
ercises in individuals with chronic low back-related leg pain and a
directional preference. We hypothesized that the combined inter-
vention would be more effective for reducing pain and increasing
function.
141
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Journal of Bodywork & Movement Therapies 30 (2022) 140e147
2. Materials and methods
2.1. Trial design
This study was a two-arm, single blind, randomized clinical trial
conducted in Brazil involving patients with chronic low back-
related leg pain. The study protocol was previously published and
registered with the Brazilian Registry of Clinical Trials (REBEC,
identifier RBR-4fr2gf) (Sousa Filho et al., 2019). This trial was re-
ported in accordance with the CONSORT (Consolidated Standards of
Reporting Trials) statement and the TIDieR (Template for Inter-
vention Description and Replication) checklist. It was approved by
the Research Ethics Committee of UFS (number 2.321.252).
Two points need to be discussed from the original study pro-
tocol (Sousa Filho et al., 2019). First, we should recruit 68 patients
considering a power of 80% and loss of follow-up of 20%. We had
internal difficulty on recruiting participants with a directional
preference. Therefore, we did not achieve the target sample size
and so the exact allocation ratio. The sample size of this study has
now a statistical power of about 60% to detect a difference of 2
points in NPRS (Numerical Pain Rating Scale). Second, we described
the allocation concealment through sequentially numbered opaque
sealed envelopes in the study protocol. However, we have achieved
full allocation concealment by using web-based central allocation.
2.2. Participants
Eligible participants were aged 18e65 years, had low back pain
radiating below to gluteus for at least 3 months, had leg pain in-
tensity greater than 3 points in NPRS, had a positive SLR test, had a
directional preference for extension lumbar, and had sufficient
understanding of Portuguese. Participants were recruited from an
outpatient clinic at removed for peer review. All participants signed
an informed consent to enroll in the study.
Individuals with any condition making exercise impossible,
serious spinal disease (cauda equine syndrome, spondilithesis,
spondilolysis), previous history of lumbar spinal surgery, severe
metabolic or cardiovascular disease, and pregnancy were excluded.
SLR test was performed bilaterally with the patient in the supine
position. The tested leg was passively elevated by flexing the hip
with the knee in full extension. The test was considered to be
positive if symptoms were elicited or aggravated between 30 and
70 degrees of hip flexion (Davis et al., 2020). SLR test should not
elicit symptoms in the non-affected side.
To identify the directional preference (DP) was used a test of
active movement (Browder et al., 2007). First, it was observed
whether lumbar flexion movements in lying and sitting positions
would aggravate or peripheralise patients’ symptoms. Then, pa-
tients were asked to perform a single active movement of lumbar
extension in prone position. Pain trajectory and intensity were
observed. Following, participants were asked to perform repeated
lumbar extension movements in prone and standing positions.
Directional preference for extension was judged to be present when
lumbar extension movements decreased, abolished, or centralized
symptoms and lumbar flexion movements induced symptoms to
worsen or peripheralise.
2.3. Randomization, allocation and blinding
Prior to enrollment, a research assistant not involved in the
eligibility process conducted the randomization. Eligible partici-
pants were randomized by a computer-generated random
sequence (http://www.randomization.com). Allocation conceal-
ment was achieved by using web-based central allocation. Out-
comes assessor was blinded to allocation groups. Given the nature
L.F. Sousa Filho, M.M. Barbosa Santos, D.B. Matos Vasconcelos et al.
of interventions, participant and therapist were not blinded to the
treatment. However, as both interventions were exercise-based,
participants were not aware whether they were receiving com-
bined intervention or not.
2.4. Enrollment and baseline measures
Baseline characteristics were collected and physical exams were
conducted in the initial assessment. In accordance to guidelines for
assessing people with low back pain (Chiarotto et al., 2016), medical
history, personnel data (age, sex, education, socioeconomic status,
comorbidities), low back and leg pain intensity (NPRS), disability
(RMDQ), quality of life (SF-36), pain catastrophizing (PCS), sleep
quality (PSQI) and anxiety, depression and social isolation (brief
screening questions) were assessed.
2.5. Interventions
Participants were randomly allocated to receive either extension
exercises (EE) or extension exercises plus neurodymamic exercises
(EEN). EE are believed to reduce nociceptive pain through inter-
vertebral disc adaptations. Neurodynamic exercises are hypothe-
sized to improve neuropathic pain by neural adaptations.
Participants from both EE and EEN groups received seven treatment
sessions, twice a week for 3 weeks. In the first week, three treat-
ment sessions were performed. Interventions were face-to-face
and individually delivered by trained physiotherapy graduates
under supervision of a specialist physiotherapist in an outpatient
clinic. These intervention providers attended a specific training
course directed toward the research interventions with theoretical
and practical classes related to exercise training schedule and
prescription. Intervention providers were not certified in the
McKenzie Method or Neurodynamics systems. Physiotherapy
graduates involved in this trial had at least 2 years of experience in
research on musculoskeletal conditions and were member of the
Institutional Program of Scientific Initiation and Technological
Development (PIBIC). There was no change in the intervention
delivery during the course of the study. It was delivered as planned
in the original protocol study (Sousa Filho et al., 2019).
Extension exercises were performed in prone and standing
positions. Initially, patients were asked to remain in a prone posi-
tion during 5 min. Following, they were asked to perform repeated
end-range extension movements in prone position. Then, they
were asked to execute repeated standing extension movements.
The patients performed 5 sets of 10 repetitions for each exercise.
Neurodynamic exercises were performed in lying and sitting
positions. In lying position, the patients were asked to flex and
extend the knee while holding the hip flexed at 90 . This exercise is
called ‘tensioning exercise’ because it elongates the entire nerve
bed. The other neurodynamic exercise was performed in a sitting
position. Patients were asked to extend the neck while extending
the knee from a knee and neck flexed position. This exercise is
called ‘sliding exercise’ because it combines movements at different
joints in order to attenuate nerve tension in one extremity while
tensioning the other one. In the study clinical registry was included
that neurodynamic protocol would consist of two tensioning and
two sliding exercises performed for 2 sets of 30 repetitions. How-
ever, the neurodynamic protocol used in this study consisted of one
tensioning and one sliding exercise, as illustrated in the original
study protocol (Sousa Filho et al., 2019). This change occurred
before patients' enrollment. Each exercise was performed for 3 sets
of 10 repetitions.
Patients were instructed to report any increase in their symp-
toms during the treatment session. Exercise would be discontinued
if pain scores were elevated (>2 points in NPRS) while exercising.
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Journal of Bodywork & Movement Therapies 30 (2022) 140e147
Patients also were instructed to execute the exercises at a low to
moderate movement velocity and to perform the exercises at home.
They should perform extension exercises for 5 sets of 10 repetitions,
3 to 5 times a day during the 3-weeks treatment period. Patients
from the EEN group should also perform 10 repetitions of each
neurodynamic exercise once a day. The adherence to home exer-
cises was not monitored.
2.6. Outcomes
Primary outcomes were leg pain intensity (NPRS) and function
(PSFS) at 3 weeks. Low back pain intensity, quality of life (SF-36),
disability (RMDQ), perceived effect (GPE) at 3 weeks (end of in-
terventions) and at follow-up (1 month after completion of the
interventions) were secondary outcomes. All outcomes were
measured at baseline, at 3 weeks and at 1-month follow-up. There
were no changes in outcomes after trial commencement. Tools
used to measure the outcomes have adequate levels of validity and
are recommended to assess individuals with chronic low back pain
(Chiarotto et al., 2016), as further detailed in the published study
protocol (Sousa Filho et al., 2019).
2.7. Statistical analysis
Baseline characteristics of the participants were presented as
descriptive statistics and were summarized by allocation group.
Descriptive statistics with central tendency measures (mean and
median) and variability (standard deviation and confidence inter-
val) were described for continuous variables. For categorical vari-
ables, frequency and percentages were used. Significance level was
set at 5%. Analyses were performed in the SPSS software version
22.0 (IBM Corporation, NY, EUA).
Primary and secondary outcomes were analyzed by using a
linear mixed model for repeated measures to investigate the
interaction between groups and time. Between groups difference
and 95% confidence intervals were calculated for all outcomes.
Cohen's effect size was provided for each outcome. The analysis
followed the intention-to-treat principle. Missing data were
imputed by using multiple imputation. No covariate was included
in the model because it was not found significant correlations in the
regression model, as detailed in the study protocol (Sousa Filho
et al., 2019).
Sample size was determined considering the minimal detect-
able change of 2 points (SD 2.6) on the NPRS for individuals with
chronic low back-related leg pain (Lauridsen et al., 2006). Our
sample has a statistical power of about 60% to detect a difference of
2 points on NPRS with an alpha level set at 0.05.
3. Results
From 79 eligible participants, 31 were recruited and randomly
allocated into EE (n ¼ 14) or EEN (n ¼ 17), as showed in Fig. 1.
Retention rate was 100% in EE and 94% in EEN at 3 weeks. At 1-
month follow-up, retention rate was 71% in EE and 76% in EEN.
There was no significant difference among baseline patient char-
acteristics. Most of participants were women with moderate levels
of pain and disability and poor sleep quality. They had high ex-
pectancies for recovery (Table 1).
There was no difference between EE and EEN for the primary
outcomes (at 3 weeks). Effect size was small for leg pain and null for
function. It was observed a significant reduction on disability scores
at 3 weeks favoring EE group (large effect size). At 1-month follow-
up, extension-oriented exercises alone were more effective than
when combined with neurodynamic exercises for reducing leg
pain, low back pain and disability, and increasing function (large
L.F. Sousa Filho, M.M. Barbosa Santos, D.B. Matos Vasconcelos et al. Journal of Bodywork & Movement Therapies 30 (2022) 140e147

Fig. 1. Flow of participants.

Table 1
Participant's characteristics.

Characteristics EE (n ¼ 14) EEN (n ¼ 17) P-value

Age, mean (SD) 34.5 (14.8) 42.5 (13.1) 0.12

Female, n (%) 10 (71.4) 12 (70.6) 0.98
BMI, mean (SD) 24.3 (4.1) 25.9 (4.8) 0.10
Education levels, n (%) 0.71
Less than a high school degree 2 (14.3) 3 (17.6)
High school 1 (7.1) 3 (17.6)
Higher education 11 (78.6) 11 (64.8)
Symptoms duration, months (SD) 30.0 (28.7) 37.2 (35.9) 0.54
Symptoms below the knee, n (%) 6 (42.9) 11 (64.7) 0.31
Alcohol use, n (%) 5 (35.7) 6 (35.3) 0.98
Tobacco use, n (%) 0 (0) 0 (0) 1.00
Hypertension, n (%) 1 (7.1) 2 (11.8) 0.83
Diabetes, n (%) 1 (7.1) 1 (5.9) 0.95
Depression, n (%) 5 (35.7) 8 (47.1) 0.55
Anxiety, n (%) 14 (100) 11 (64.7) 0.08
Social isolation, n (%) 1 (7.1) 0 (0) 0.74
Expectation for recovery (0e10), mean (SD) 8.5 (1.4) 8.2 (1.6) 0.66
Sleep quality (0e21), mean (SD) 8.1 (3.6) 8.2 (3.3) 0.94
Pain catastrophizing (0e52), mean (SD) 30.2 (9.7) 32.9 (7.5) 0.53
Leg pain intensity (0e10), mean (SD) 5.9 (2.0) 6.5 (2.0) 0.30
Low back pain intensity (0e10), mean (SD) 6.7 (2.0) 6.8 (1.8) 0.82
Disability (0e24), mean (SD) 10.9 (4.6) 13.4 (4.0) 0.11
Function (0e30), mean (SD) 11.8 (5.1) 11.1 (5.6) 0.63

EE: extension-oriented exercises. EEN: extension-oriented exercises plus neurodynamic exercises. BMI: body mass index.

effect size). Global perceived effect was unchanged at 3 weeks and
at 1-month follow-up (intermediate effect size). (Table 2).
No between-group differences at 3 weeks and at 1-month
follow-up were observed for five domains of health-related qual-
ity of life: role physical, general health, vitality, role emotional and
mental health (null to small effect size). There was a significant
difference in favor of EE at 1-month follow-up for three domains:
143
physical functioning, bodily pain and social functioning (large effect
size). (Table 3).
4. Discussion
This is the first study to investigate the effects of adding neu-
rodynamic exercises to extension exercises in patients with chronic

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Table 2
Within groups and between-groups means difference (95% CI) for leg pain, function, low back pain, disability and global perceived effect at 3 weeks and 1-month follow-up.

EE EEN EE versus EEN

Outcome Mean Mean change from baseline (95% Mean Mean change from baseline (95% Between-group difference (95% p- Effect size
(SD) CI) (SD) CI) CI) value (dCohen)

Leg pain (0e10)

Baseline 5.9 (2.0) 6.5 (2.0)
3 weeks 3.4 (2.2) 2.5 (3.9 to 1.0) 2.4 (2.5) 4.1 (6.3 to 1.8) 0.9 (2.8 to 0.9) 0.28 0.42
1-month 1.7 (1.6) 4.2 (6.0 to 2.3) 4.3 (3.3) 2.2 (4.6 to 0.2) 2.5 (0.9e4.2) <0.01 1.00
Function (0e30)
Baseline 11.8 (5.1) 11.1 (5.6)
3 weeks 18.8 (4.1) 6.9 (4.2e9.6) 18.4 (5.6) 7.2 (2.4e11.9) 0.4 (4.2 to 3.4) 0.81 0.08
1-month 23.4 (2.6) 11.5 (8.4e14.7) 19.1 (5.9) 7.9 (2.8e13.0) 4.3 (7.9 to 0.7) 0.02 0.94
Low back pain (0
e10)
Baseline 6.7 (2.0) 6.8 (1.8)
3 weeks 3.8 (2.2) 2.9 (4.4 to 1.4) 3.4 (2.4) 3.4 (5.3 to 1.4) 0.3 (1.4 to 0.8) 0.53 0.17
1-month 2.0 (1.6) 4.6 (6.0 to 3.3) 4.4 (2.6) 2.4 (4.6 to 0.3) 2.3 (0.8e3.8) <0.01 1.11
Disability (0e24)
Baseline 10.9 (4.6) 13.4 (4.0)
3 weeks 6.2 (4.5) 4.6 (6.7 to 2.6) 9.9 (4.4) 3.5 (6.8 to 0.2) 3.6 (1.2e6.0) <0.01 0.83
1-month 2.9 (1.7) 8.0 (10.7 to 5.3) 7.9 (5.6) 5.5 (9.8 to 1.2) 5.0 (2.0e8.0) <0.01 1.20
GPE (5 to þ5)
Baseline 1.2 1.0
(1.7) (1.7)
3 weeks 3.2 (0.7) 4.4 (3.0e5.7) 2.5 (1.7) 3.5 (1.7e5.3) 0.6 (1.5 to 0.2) 0.12 0.53
1-month 3.7 (0.8) 4.9 (3.4e6.4) 2.8 (2.0) 3.8 (1.9e5.7) 0.9 (1.9 to 0.1) 0.07 0.59

EE: extension-oriented exercises. EEN: extension-oriented exercises plus neurodynamic exercises. GPE: global perceived effect. Shaded cells ¼ primary outcomes.

low back-related leg pain. Our findings show that this combination
does not provide additional improvements in pain and function and
is inferior to extension exercises alone at follow-up. Some clinical
and research implications that may give directions regarding the
management of chronic low back-related leg pain were derived
from these findings.
At least two factors may be taken into account when assuming
that neurodynamic exercises add no value to an extension-oriented
exercise program. Firstly, it is not certain whether neurodynamic
exercises are quite effective for chronic low back-related leg pain.
Some previous meta-analyses have found positive effects of neu-
rodynamic therapy on musculoskeletal conditions, including low
back-related leg pain (Su and Lim, 2016; Basson et al., 2017; Neto
et al., 2017). However, half (or more) of the included studies in
these meta-analyses were judged to have a PEDro score equal or
lower than 5 or were rated at high risk of bias. Therefore, high-
quality studies are still needed in order to draw more appropriate
conclusions.
Secondly, neurodynamic therapy involves a wide range of
techniques and exercises that are used and investigated under
different protocols (Basson et al., 2017). As we aimed to explore
interventions that patients could perform by themselves, neuro-
dynamic therapy used in our study was purely based on exercise,
and passive techniques were not applied. Most studies have used a
neurodynamic protocol that either only involves passive maneu-
vers such as neural manual therapy and static stretching or com-
bines these maneuvers with active exercise (Cleland et al., 2006,
Colakovic & Avdic 2013; Ferreira et al., 2016, Almeida et al., 2019). In
addition, the types of neurodynamic exercise have also varied
across the studies. Tensioning and sliding exercises have been used
concomitantly in some studies and separately in others (Cleland
et al., 2006; Malik et al., 2012; Ferreira et al., 2016; Almeida et al.,
2019). Considering that these exercises and passive maneuvers
elicit different mechanical responses on the neural tissue
(Coppieters and Butler 2008), it is important to know whether and
to which extent the effects of neurodynamic therapy depend on the
components of the neurodynamic protocol. For instance, sliding
exercises seems to augment median nerve excursion at the
humerus along with an increase in nerve strain (Coppieters and
Butler 2008). As an increased rate of strain is suggested to impair
nerve function (Fleming et al., 2003), an overload of these exercises
in individuals exhibiting signs of elevated nerve mechanosensi-
tivity would cause deleterious instead of protective effects.
Another factor that may explain our findings is the subgroup of
patients that were included in this sample. The basis of this study
was the assumption that (1) people with chronic low back-related
leg pain may present a mixed mechanism involving neuropathic
and nociceptive symptoms, and (2) the combination of neuro-
dynamic and extension exercises would address both nociceptive
and neuropathic components. However, this combination was not
more effective than extension exercises alone. All patients enrolled
in our sample had a positive SLR test and a directional preference
for extension. As having symptoms aggravated or alleviated with
certain movements is a feature of nociceptive pain mechanisms, the
presence of a DP for extension is an indicative that patients in this
study had alterations in the nociceptive system (Tousignant-
Laflamme et al., 2017). It has been showed that patients with a
DP are more likely to have success with exercises based in that DP
(Donelson et al., 2012). In fact, extension-oriented exercises
exhibited a great effect on pain intensity in our study and this effect
was close to which observed in previous studies (Browder et al.,
2007; Thackeray et al., 2016). Browder et al. (2007) found a
within-group difference of 2.3 points and 2.5 points in NPRS
following 4 weeks and 6 months of extension exercises, respec-
tively. We have found a within-group change of 3.2 and 4.9 points
in NPRS at 3 weeks and 1-month follow-up, respectively. These
significant effects may be mostly due to the presence of a direc-
tional preference.
Although having a positive SLR test is not sufficiently discrimi-
native for the presence of neuropathic pain, as this diagnosis is
made upon the presence of more than one criteria (Finnerup et al.,
2016), participants in our sample also had feelings of anxiety and
depression and moderate to high pain catastrophizing, which are
an indicative of central nervous-related mechanisms. We have
proposed that the addition of neurodynamic exercises would be
beneficial for patients with these characteristics because previous

144

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Table 3
Within groups and between-groups means difference (95% CI) for health-related quality of life outcomes at 3 weeks and 1-month follow-up.

EE EEN EE versus EEN

Outcome Mean Mean change from baseline Mean (SD) Mean change from baseline Between-group difference p- Effect size
(SD) (95% CI) (95% CI) (95% CI) value (dCohen)

Physical functioning (0
e100)
Baseline 51.9 44.7
(16.3) (11.6)
3 weeks 64.8 12.9 (3.6e22.2) 60.0 15.3 (3.3e27.3) 4.7 (15.7 to 6.1) 0.36 0.27
(15.6) (19.7)
1-month 77.6 25.7 (17.6e33.9) 55.6 10.9 (0.7 to 22.6) 22.0 (33.7 to 10.2) <0.01 1.36
(11.3) (19.9)
Role physical (0e100)
Baseline 21.2 22.0
(24.8) (32.9)
3 weeks 47.3 26.0 (9.3e42.8) 44.6 22.5 (4.3 to 49.4) 2.7 (31.4 to 26.0) 0.84 0.07
(36.9) (33.3)
1-month 56.7 35.4 (9.3e61.5) 40.4 18.3 (10.4 to 47.1) 16.3 (45.8 to 13.2) 0.25 0.45
(38.9) (32.8)
Bodily pain (0e100)
Baseline 33.6 36.2
(15.4) (10.8)
3 weeks 49.3 15.7 (6.9e24.4) 53.7 17.5 (7.1e27.9) 4.4 (3.9 to 12.8) 0.27 0.33
(11.4) (14.5)
1-month 71.1 (9.5) 37.5 (27.1e47.9) 53.3 17.0 (4.1e30.0) 17.8 (29.1 to 6.5) <0.01 1.15
(19.6)
General Health (0e100)
Baseline 46.1 43.1 (15.9
(15.7)
3 weeks 55.1 8.9 (4.3 to 22.2) 53.6 10.5 (2.2 to 23.2) 1.4 (12.6 to 9.7) 0.78 0.09
(17.5) (15.4)
1-month 62.4 16.2 (3.9e28.5) 55.2 12.0 (1.1 to 25.3) 7.1 (16.9 to 2.6) 0.13 0.49
(10.7) (17.6)
Vitality (0e100)
Baseline 47.3 43.7
(11.3) (18.41)
3 weeks 52.8 5.5 (3.5 to 14.5) 52.8 9.1 (4.0 to 22.3) 0.0 (11.5 to 11.6) 0.99 0.00
(11.6) (17.6)
1-month 64.5 (4.5) 17.1 (10.0e24.2) 62.0 18.2 (2.6e33.8) 2.4 (10.8 to 5.9) 0.53 0.20
(16.3)
Social functioning (0
e100)
Baseline 59.0 53.6
(18.2) (22.7)
3 weeks 74.8 15.7 (2.9e28.6) 63.1 9.5 (9.5 to 28.5) 11.6 (26.3 to 2.9) 0.11 0.49
(16.8) (28.8)
1-month 79.5 (9.2) 20.4 (8.0e32.9) 66.2 12.6 (3.2 to 28.4) 13.2 (21.9 to 4.6) <0.01 0.99
(16.6)
Role emotional (0e100)
Baseline 38.2 44.4
(33.2) (39.1)
3 weeks 56.2 17.9 (10.5 to 46.4) 55.1 10.7 (21.2 to 42.7) 1.0 (28.2 to 26.1) 0.93 0.02
(36.3) (40.3)
1-month 56.3 18.0 (5.4 to 41.4) 58.8 14.3 (22.9 to 51.6) 2.4 (19.5 to 24.5) 0.81 0.09
(26.0) (28.7)
Mental health (0e100)
Baseline 61.0 60.0
(20.9) (15.0)
3 weeks 64.4 3.3 (8.1 to 14.9) 70.6 10.6 (0.6e20.7) 6.2 (4.8 to 17.4) 0.25 0.38
(12.9) (18.7)
1-month 67.9 (9.1) 6.8 (7.4 to 21.2) 68.1 8.1 (1.5 to 17.8) 0.2(-6.2 to 6.7) 0.94 0.01
(13.0)

EE: extension-oriented exercises. EEN: extension-oriented exercises plus neurodynamic exercises.

studies have found positive effects of neurodynamic therapy in
patients with chronic neuropathic conditions (Torres et al., 2015,
Altınbilek et al., 2019; Plaza-Manzano et al., 2020). Even though
Scha€fer et al. (2011) suggested that people with neuropathic pain
would be less likely to benefit from neurodynamic therapy, their
findings indicate that most responders to a neural therapy inter-
vention have characteristics of peripheral nerve sensitization. Ac-
cording to the LBLP classification system, low back-related leg pain
classified into ‘peripheral nerve sensitization’ category is believed
to present nociceptive and neuropathic features (Scha €fer et al.,
2009). Therefore, considering the aforementioned findings of
Scha€fer et al. (2011), patients with mixed mechanisms should
respond to neural therapy, which did not happen in our study.
The addition of neurodynamic treatment appeared to attenuate
the effect of extension exercises at 1-month follow-up. Although
the neural system is adaptive, it is also sensitive and irritable. In the
literature, there is no a consensus about the “safe limits” of the
nerve stretching (Mahan 2019). Perhaps, the combined

145

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L.F. Sousa Filho, M.M. Barbosa Santos, D.B. Matos Vasconcelos et al.
intervention in our protocol provided an overload stimulus on the
neural tissue, resulting in maladaptation. The dosage and the type
of neurodynamic exercises can play a role in this effect. While ex-
ercises in our protocol were based on repeated movements, other
studies have focused in static stretching or sustained postures
(Cleland et al., 2006; Nagrale et al., 2012). Furthermore, a slump-
based exercise was included in our neurodynamic therapy. As this
exercise is performed in a sitting position and the patients in the
sample had a directional preference for extension, it could cause
some discomfort. However, we believe that it has not happened
because most patients with radicular pain have a DP for extension
and previous studies has found benefit from slump stretching in
these patients (Malik et al., 2012, Surkitt et al., 2012, Colakovic &
Avdic 2013; Tambekar et al., 2016, Plaza-Manzano et al., 2020).
These assumptions may be further investigated in a larger ran-
domized clinical trial, especially because our results could be
influenced by the sample size. It is important to highlight that even
though the combined intervention was less effective than exten-
sion exercises alone at the follow-up, the changes from baseline
were still clinically significant.
4.1. Strengths and weaknesses
Strengths of this study were the previous publication of the
study protocol, blinded outcome assessment, concealed allocation
and intention-to-treat analysis. As this RCT was performed with a
sample size lower than the previously estimated, the power of our
results was also decreased. Another weakness of this study was that
we did not use specific instruments such as LANSS or painDETECT
to assess neuropathic pain (Finnerup et al., 2016).
Given that, attrition rate was 0% and 6% for EE and EEN groups at
3 weeks, respectively, attrition bias should not affect the primary
outcomes. However, attrition rate was 29% and 24% for EE and EEN
groups at 1-month follow-up, respectively. Even though these
attrition rates were high, our study design put efforts on mini-
mizing attrition bias by performing intention-to-treat analysis and
imputing missing data through multiple imputation.
5. Conclusion
In summary, our findings do not support the addition of neu-
rodynamic exercises to extension-oriented exercises in people with
chronic low back-related leg pain and a directional preference for
extension. The results may be interpreted with caution due to the
reduced sample size and the low capacity of generalization.
Trial registration
ReBEC number RBR-4fr2gf.
Declarations of interest
None.
Funding
~o de Aper-
This study was financed in part by the Coordenaça
feiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance
Code 001.
CRediT authorship contribution statement
Luis Fernando Sousa Filho: Conceptualization, Methodology,
Writing e original draft, Supervision. Marta Maria Barbosa Santos:
Conceptualization, Investigation, Writing e review & editing,
146
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Journal of Bodywork & Movement Therapies 30 (2022) 140e147
Visualization. Danielle Brito Matos Vasconcelos: Investigation,
Validation, Visualization. Erilaine Araujo Soares: Investigation,
Validation, Visualization. Gabriel Henrique Freire dos Santos:
Investigation, Validation, Visualization. Walderi Monteiro da Silva
Júnior: Methodology, Project administration, Writing e review &
editing.
Acknowledgements
We thank CAPES (Coordination for the Improvement of Higher
Education Personnel) for a master's degree scholarship awarded to
L.F.S.F.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jbmt.2022.01.007.
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