Translational Study of the Effects of Neural Mobilization in Patients With Lomboisquiatalgia
Phase: NA
Conditions: Low Back Pain, Mechanical, Pain, Neuropathic Pain
Sponsor: University of Sao Paulo

ADD NEW PROTOCOL AT THE SAME PATIENTS 
 
INTRODUCTION 
The term low back pain is characterized by pain in the lumbar spine region, a condition 
that affects individuals of both sexes and reduces their ability to perform activities in 
their daily lives, which results in a substantial economic cost to society 1. Notably, 
approximately 70% of the population of Brazil may have an episode of low back pain 
during their lifetime 2,3. 
 
The etiology regarding the development of low back pain is still unclear due to the 
innumerable factors that may lead to its onset, some of which may be related to 
repetitive work, pulling and pushing, falls, poor posture, squatting, heavy lifting, muscle 
imbalance, and compressive syndromes, among others. Chronic pain is among the main 
causes of absenteeism at work, medical leave, sick leave, workers' compensation, and 
low productivity at work 1,4–6. 
 
It is important to emphasize that limited mobility of the lumbar spine due to pain can 
often be associated with this condition 4. Another extremely relevant point with regard 
to spinal nerve injuries, particularly in the lumbar region, is that they are often caused 
by compressive syndromes such as discal hernias. Such compressions often result in 
neuropathic pain, which is characterized by spontaneous burning pain, followed by 
allodynia and hyperalgesia, which can be observed in the nerve pathways of the in the 
lower limbs 5. 
 
In addition to pharmacological and surgical treatments, there are noninvasive or 
nonpharmacological treatments such as physiotherapy. Physiotherapy treatments, which 
have countless approaches, facilitate a decrease in signs and symptoms, such as reduced 
pain and muscle tension and increased lumbar and hip range of motion, in individuals 
with chronic low back pain 7. One of the available treatments is neural mobilization 
(NM), which is characterized by a set of techniques that aim to impose greater tension 
on the nervous system through certain postures; slow and rhythmic movements are 
applied to the peripheral nerves and spinal cord, improving conduction of the nerve 
impulse 8. 
 

Studies have demonstrated the beneficial effects of NM, including improved joint pain 
in patients with rheumatoid arthritis 9 and improved cervicobrachial pain 10. Neural 
mobilization has demonstrated an excellent prognosis in patients with this type of pain, 
in addition to presenting other advantages such as low operational cost, easy application 
and no adverse effects. 
 
Results from the previous studies described above show the beneficial effects of NM 
treatment. There is a lack of clinical trials regarding the use of NM for different types of 
pain. 
The aim of this study was to compare pain intensity and functional capacity before and 
after treatment with NM in volunteers with chronic low back pain. 
 
The research questions were as follows: 
1. What are the effects of the neural mobilization technique on individuals with 
chronic low back pain? 
2. Is neural mobilization effective? 
 
METHOD 
 
Participants, therapists, center 
The participants were recruited for evaluation by establishing the inclusion and 
exclusion criteria of the study. Individuals of both sexes who met the following criteria 
were included in the study: chronic low back pain, radiating or not to one of the lower 
limbs; age 18 years or older; score ≥ 4 on the visual analog scale (VAS). 
 
We excluded individuals with acute low back pain; spondylolisthesis or fibromyalgia; 
previous spinal surgery; any sequelae that caused limitations in the range of motion of 
the lower limb or joint deformity; metal plates, screws, neurological disorders who 
present caution for neural mobilization; cancer; cognitive disturbances or apparent 
limitations; any type of pain in other regions that is not characteristic of low back pain; 
advanced diabetes mellitus; under physiotherapeutic treatment for the same reason; 
decompensated cardiovascular diseases; significant changes in sensitivity; edema in the 
lower limbs; and pregnant women. 
 

After eligibility was confirmed, all the procedures to be performed during the study 
were elucidated, and the subjects signed the Free and Informed Consent Terms, 
according to Resolution 466/12 of the National Health Council - Brazil, confirming 
their participation in the research. 
 
Sixteen volunteers, 8 women and 8 men, with a mean age of 30,45 ± 10,32 years, 
participated in this study. After being selected, the volunteers were allocated to Group 
NM, consisting of individuals with low back pain, and were treated with the technique. 
 
After fulfilling the eligibility criteria, a clinical evaluation and assessments of pain 
intensity, spinal mobility, peripheral sensitivity and hip goniometry were carried out, 
and a quality of life questionnaire was administered (details below). 
 
To preserve the accuracy of the intervention effectiveness, participants who missed 
more than two sessions were excluded from the study. All subjects were assessed by a 
blinded evaluator. Both participants and evaluators were encouraged not to discuss the 
intervention. 
 
Intervention 
The Neural Mobilization technique was performed by the same physiotherapist from the 
first to the last session on alternate days. Treatment with the technique consists of 
applying a total of 10 interventions in each patient, with a total duration of 10 minutes, 
divided into four series of 2 minutes each, with a 30 second interval between each 
series, according to the protocol proposed in 2012 by Santos et al. 11. 
 
The technique was applied with the participant seated in a suitable chair, with a flexed 
hip (90) and extended knees (Figure 1). Next, the physiotherapist applied the technique 
only to the lower limb in which the individual presented with some impairment due to 
low back pain, observed in the previous physical examination; in case of absence of 
pain radiation to any of the limbs, the technique was applied only to the right lower limb 
according to Santos et al. 2012 11. 
 
During the period from July 2016 until September 2017, we screened 60 subjects for 
eligibility; of those, only 16 individuals completed the entire study protocol according 

to the inclusion and exclusion criteria. Table 1 shows a flowchart of the study design 
that explains all the procedures implemented with the volunteers in all groups. 
 
Calculation of the sample 
 
The sample size was calculated based on the visual analog scale for pain, which was 
considered the primary end point. To this end, the variance reported in the study by 
Murphy et al., 2006, whose objective was to evaluate neural mobilization as a technique 
for treatment. Considering the mean and standard deviation of the pre-intervention and 
post-intervention of this study, with an alpha value (α) of 0.05 and 90%, it was 
determined that 20 subjects were required for the experimental group 12. 
 
Outcome measures 
 
First, all personal data from each subject were obtained, including age, occupation and 
education. After this first step, the participants submitted to two evaluations, one prior 
to and one at the end of the therapeutic program. Both evaluations were to assess pain 
intensity and mobility of the lumbar spine and to measure cytokines. 
Visual Analog Scale (VAS): 
A visual analog scale was used for the assessment of pain intensity; it consists of a line 
ranging from 0 to 10, where zero represents the absence of pain and ten represents the 
worst pain. After instruction in how to complete the scale, the volunteer was asked to 
mark a point on the line that indicated the intensity of the pain that he or she was feeling 
at the moment of evaluation 13. 
Mobility of the lumbar spine: 
Two tests were used to evaluate the mobility of the lumbar spine: the 3rd finger to the 
ground and goniometry. 
The test of the 3rd finger to the ground distance consists of an active test in which the 
individual is placed in an orthostatic position, with the feet separated in line with the 
hips, keeping the knee extended and heel touching the ground. Then, the participant is 
asked to perform trunk flexion with the arms extended and to try to bring his hand 

closer to the ground. Then, using a tape measure, the distance between the tip of the 3rd 
finger and the ground is measured, and the value in centimeters is considered the 
mobility of the volunteer’s lumbar spine 1,14. 
Goniometry refers to the measurement of individuals' joint angles; it was applied before 
the first session and after the last session of neural mobilization. To minimize 
measurement error, the physiotherapist in charge underwent training. Goniometric 
measurements of the hip joint of the participants in this study were used for both thigh 
flexion; the amplitude varies between 0 - 131° ± 6.4°, and the articular range varies 
from 0 to 13° ± 5.4°; measurements may vary from individual to individual more or less 
within these established values 15. 
 
Evaluation of Cytokines: 
Blood was collected from each group to evaluate the possible impact of the technique 
on pro- and anti-inflammatory cytokines. Two collections were performed: the initial 
measurement (I) and the final measurement after the last session (F) of treatment. To 
evaluate the cytokine concentration, the blood serum of the individuals was used for 
these analyses. 
 
For specific IL-1β, IL-4, IL-6, and FTN-α cytokines, specific reagents contained in the 
Milliplex®TM Map kit (Millipore Corporation, Darmstadt-Germany) were assessed by 
Multiplex (Enzime-Linked ImmunoSorbent Assay) according to the protocol specified 
by the manufacturer. 
 
Data analysis 
The statistical analysis consisted of ANOVA with repeated measures for the time factor, 
which was performed to test between-group differences (followed by the Tukey-Kramer 
post hoc test), and a paired t-test was performed to test within-group differences. The 
results were considered statistically significant if p≤0.05, using the standard error of the 
mean  SEM 18.