Effect of Neural Mobilization Techniques on Pain, and Hip and Knee Range of Motion on Lumbosacral Radiculopathy Patients With Peripheral Sensitization
Phase: NA
Conditions: Radiculopathy
Sponsor: Mohammed Al-Ghamdi

 
 
 
 
 
Effect of Neural Mobilization Techniques on Pain, and Hip 
and Knee Range of Motion on Lumbosacral Radiculopathy 
Patients with Peripheral Sensitization 
 
 
17/1/2019 
 
 
 
 

Methods and Materials 
 
1.1. Study design and setting 
 
This study was a double-blind case-control trial. In this study, the investigator was blind to the 
participant’s measurements, the examiner and the observer were blind to the participant group. 
The study was conducted at the Security Forces Hospital in Dammam (SFHD), King Fahd 
Hospital of the University (KFUH) and Dammam Medical Complex (DMC) in Dammam, Saudi 
Arabia. This study was approved by the Institutional Review Board (IRB) at Imam Abdulrahman 
bin Faisal University (Appendix A). 
 
1.2. Participants 
 
The sample size was calculated using G*power software Version 3.0.10. Data from Tambekar et 
al. (2016) was used (effect size 0.82, α = 0.05, power= 0.95). The calculation resulted in a total of 
51 participants. Lumbosacral radiculopathy patients with dominant peripheral sensitization of 
unilateral leg pain were recruited. The patient was diagnosed with peripheral sensitization if they 
fulfilled the criteria suggested by Schäfer et al. (2009) which included: S-LANSS score > 12, 
negative sensory and motor examination, and positive neural tissue provocation tests (straight leg 
raising test, slump test). The inclusion criteria were: adult, pain duration of more than 3 months, 
patients were diagnosed with peripheral sensitization. Patients with one or more of following 
criteria were excluded from this study: S-LANSS score ≥ 12, motor or sensory deficits, history of 
back or lower extremity surgeries, bilateral referred pain, patients with TENS contraindications as 
described in Jones and Johnson (2009) such as pacemakers and cardiovascular problems, epilepsy, 
active malignancy, dermatological conditions, and diminished pain sensation. 
 
At SFH, KFHU and DMC outpatients’ clinics, the physician referred patients diagnosed with 
lumbar radiculopathy or lumbosacral radiculopathy with negative dermatomes, myotomes and 
reflexes examinations finding to the primary investigator. In the initial appointment, the primary 
investigator explained to each participant the aims and the general procedures of the study. If 
agreed to participate, the patient signed the consent form (Appendix B, C). The independent 
examiner started the examination for eligibility with S-LANSS assessment (Appendix D) and an 

examination of SLR and slump tests. If eligible, the patient was assigned alternatively to one of 
the three study groups: tensioner group (T- group), slider group (S- group), or control group (C- 
group).  Patients were blinded to the intervention details until they were assigned to one of the 
study groups.  In the alteration type of allocation of groups allocation, the first patient was assigned 
to slider group, the second was assigned to the tensioner and the third to control group. This order 
continued even if there was any withdraw until we reached the end of the list then we started filling 
the gaps in the list from the top with new participants. 
 
1.3. Outcome measurements 
 
Evaluation procedures were carried out exactly the same for all the three group by an independent 
examiner. Another observer helped the examiner in recording hip and knee ROM during the 
examination. Both the examiner and observer were blinded to the study groups. The following 
measurements undertaken were carried out on four different occasions: baseline, after 1st session, 
after 3rd session, and after 6th session.  
 
1.3.1.  Pain intensity  
 
Visual analog scale (VAS) was used to measure pain intensity. It consisted of a 10-cm horizontal 
line with ‘No pain” at one end and "Worst imaginable pain" at the other end.  The patient was 
asked to mark his current leg pain level on the line. The Minimal clinically important difference 
(MCID) for VAS was reported to be 1.8 - 1.9 cm  (Hägg et al., 2003). VAS is a valid and reliable 
measurement of pain intensity (Ferreira-Valente et al., 2011).  
 
1.3.2. Hip ROM with SLR  
 
The patient was in supine position with their head in neutral and flat on the bed without pillows. 
The examiner supported the knee in full extension using his proximal hand, whereas distal hand 
was used to maintain the ankle position in a neutral position. The examiner passively raised the 
examined leg until the patient reported reproduction of his symptoms, or until the examiner felt 
significant resistance to SLR (Martin et al., 2014; Walsh and Hall, 2009a).  
 

The independent examiner performed the SLR test for asymptomatic then symptomatic limb. A 
bubble inclinometer (Fabrication Enterprise Inc., White Plains, New York 10602, and U.S.A) was 
secured just proximal to the ankle joint using double adhesive tape. The inclinometer was directed 
towards the medial aspect of the leg so that the examiner could not see it. The observer adjusted 
the fluid to zero level before testing. The observer recorded the ROM when the patient started 
feeling reproduction of his symptoms or the examiner felt significant resistance (Figure 1). 
 
3.3.3 Knee flexion ROM with the Slump test 
 
In the slump test, the patient seated at the edge of the bed with legs dangling freely and knee at an 
angle of 90o flexion.  The patient’s trunk was placed in slumped position with cervical flexion and 
hands were together behind the back. The distal hand of the examiner was used to maintain the 
ankle in neutral position. The examiner proximal hand was used to maintain the slump position of 
the patient trunk. The examiner instructs the patient verbally to maintain his head in flexed 
position. The examiner used his distal hand to passively extend the examined knee until the patient 
felt his symptoms, or until the examiner felt significant resistance  (Walsh and Hall, 2009a). The 
measurement of knee flexion ROM in a slump was taken for the asymptomatic then symptomatic 
limb. 
 
A bubble inclinometer was secured just proximal to the ankle joint using double adhesive tape. 
The inclinometer was directed towards the medial aspect of the leg so that the examiner could not 
see it. The observer adjusted the fluid to zero level before testing and recorded the angle during 
the test. The observer recorded the measurement of the inclinometer at the point of symptoms 
reproduction or the feeling of resistance  (Walsh and Hall, 2009b) (Figure 2). 
 
 
 
 
 
 
 
 

 
 
 
 
 
A 
B 
Figure 1: Straight leg raising test. showing the placement of inclinometer to measure hip range of motion from 
starting position (A) to end position (B). 

 
 
Figure 2: End position of the slump test. during which the observer was recording knee range of motion and the examiner performed 
the test. 
 
1.4. Interventions 
 
Each patient received therapeutic sessions over 2 weeks (3 sessions/ week).  All patients in all 
groups received Transcutaneous Electric Nerve Stimulation (TENS). In addition, T-group received 
tensioner neural mobilization technique and S-group received slider neural mobilization technique. 
 
1.4.1. TENS (All study groups) 
 
TENS device (Sonicplus 692V, ENRAF-NONIUS, Rotterdam)  was applied at a pulse frequency 
of 100 Hz (Thiese et al., 2013). A single channel, two surface electrodes, were used for stimulation 
over a session period of 15 minutes (Itoh et al., 2009). The device electrodes were placed on the 
painful paraspinal areas of the back. The intensity was set to enable a clear tingling sensation above 
the sensory threshold of the patient (Barker et al., 2008; Itoh et al., 2009) (Figure 3).  

 
 
Figure 3 : Transcutaneous electrical nerve stimulation (TENS). 
 
1.4.2. T-Group (Tensioner technique) 
 
This technique was done in a sitting slump position. The patient sat on the edge of the bed with 
the neck and trunk in neutral, hips and knees in 90o flexion and ankles in resting plantar flexion. 
The back of the patient’s knees touched the bed edge. The patient was asked to move the neck and 
trunk into flexion slouched position, the treated knee in extension, and ankle in dorsiflexed 
simultaneously (Phase 1). Then the patient extended the neck and trunk, flexed the knee, and 
plantarflexed the ankle simultaneously (Phase 2). Tensioner technique was performed for 10 

repetitions over 2 sets. The patient was given a 2-minutes resting time between the sets 
(Herrington, 2006; Shacklock, 2005) (Figure 4). 
 
 
A 
B 
C 
A 
Figure 4 : The tensioner technique: A) starting position, B) phase 1, and C) phase 2. 

S - Group (Slider technique)  
 
This technique was also done in a sitting slump position. The patient sat on the edge of the bed, 
with the neck and trunk in flexion, hips, and knees in 90o flexion and ankles in resting plantar 
flexion. The back of patient’s knees touched the bed edge. The patient was asked to move the neck 
into extension, the treated knee in extension, and ankle in dorsiflexion simultaneously (Phase 1). 
Then the patient flexed the neck and trunk, flexed the treated knee and plantarflexed the ankle 
Simultaneously (Phase 2). Slider technique was carried out for 10 repetitions over 2 sets. The 
patient was given a 2-minutes resting time between the sets (Herrington, 2006; Shacklock, 2005) 
(Figure 5). 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
B 
A 
C 
Figure 5 : The slider technique: A) starting position, B) phase 1, and C) phase 2. 

1.5. Statistical analysis 
  
SPSS software (version 23, IBM Corporation, New York) was used for statistical analysis. 
Descriptive data of mean and standard deviation was obtained for all data. The baseline between 
groups’ comparisons on clinical and demographic variables (BMI, age, and VAS) was performed 
using one-way analysis of variance (ANOVA). A two-way mixed design ANOVA (MANOVA) 
with post-hoc (Bonferonni Correction) was used to calculate the differences in outcomes 
measurements with TIME (baseline, 1st, 3rd, and 6th session) as a within-groups factor and GROUP 
(control, slider, and tensioner) as a between-group factor. The effect size was also calculated with 
Cohen’s d to estimate the magnitude of differences within and between groups [small (d = 0.2), 
medium (d = 0.5), and large (d = 0.8)]. Pearson's correlation was performed to assess the 
relationship between pains, hip flexion ROM in SLR, knee flexion ROM in slump. The significant 
level was set at P < 0. 05.