Effects of Neural Mobilization Augmented by Traditional Physical Therapy on Pain, Functional Disability and H-reflex in Patients After Lumbar Laminectomy: a Randomized Controlled Trial
Phase: NA
Conditions: Laminectomy
Sponsor: Cairo University

Effects of neural mobilization augmented by traditional physical therapy on pain, functional 
disability and H-reflex in patients after lumbar laminectomy: a randomized controlled trial 
 
 
March 19, 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Objective: The purpose of the study was to determine whether the addition of neural mobilization 
to a standard postoperative physical therapy program could improve the outcome of patients after 
lumbar laminectomy. 
Design: Randomized controlled trial with blinded evaluators. 
Setting: The study was conducted in outpatient physical therapy clinic. 
There are fewer studies examining physical therapy programs for post-operative 
rehabilitation after lumbar surgery. The aim of the current study was to establish whether the 
addition of neural mobilization to a standard postoperative physical therapy program is valuable for 
patients who had undergone lumbar decompressive laminectomy.  
Methods 
Participants 
Sixty patients of both sexes, aged from 35-50 years who underwent lumbar laminectomy of 
one or two levels shared in the study. They were recruited from the orthopedic surgery and 
neurosurgery departments, Cairo University hospitals. The purpose and procedures were explained 
to each patient before participation. A signed informed consent was taken from all patients who 
accept participation in the study. Approval of the Research Ethical Committee of the Faculty of 
Physical Therapy, Cairo University was obtained (P.T.REC/012/002241). This study followed the 
principles of Helsinki Declaration. 
Exclusion criteria   
- Patients who had arthritis in the joints of the lower limbs (which would limit walking). 
- Patients who had tumors, fractures or infections of the spine. 
- Patients who had diabetes mellitus. 
- Patients who had polyneuropathy 
- Patients who had evidence of spinal cord compression. 
- Patients who had previous spinal surgery, spinal stability problems (e.g. spondilo-listhesis, 
spondilolysis). 
- Patients who had sensory loss. 
Participants were randomly assigned through computer-generated random numbers into two 
groups. The study group consisted of 30 patients (15 females and 15 males). Patients in this group 
received neural mobilization in addition to a selected physical therapy program. The control group 
consisted of 30 patients (12 females and 18 males) and treated with the same selected physical 

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therapy program only. The treatment started after four weeks postoperative.21 All patients received 
their treatment three sessions/week for six successive weeks. 
Outcome measures 
All measurements were conducted by examiners who were blinded to the patient's group. 
All patients were evaluated for; 1) Leg pain intensity: It was evaluated through visual analogue 
scale (VAS). VAS is a 10-cm line with a "0" at the left end for "no pain" and 10 at the right end for 
"worst possible pain", each patient was asked to indicate on the line where his pain is in relation to 
the two extremes by circling the number. 2) Functional ability: It was evaluated by Oswestery 
disability index (ODI). The ODI is a valid and reliable tool for assessment of functional ability. 
3) Nerve root compression: It was assessed through assessment of latency of H-reflex of S1. 
The participant was in prone-lying position. The active recording electrode was located on the 
soleus between the two heads of the gastrocnemius, while reference recording electrode was located 
on the Achilles tendon. The stimulation was applied at the midline in the popliteal fossa on the tibial 
nerve. The active stimulating electrode was closer to the spine. Stimulation was performed 
manually every 2 seconds (sec) with a stimulus duration of 0.5 or 1.0 msec. The intensity of 
stimulation was increased gradually and H-reflex & M-wave were watched. The latency is 
measured automatically by the device from the beginning of stimulation to the beginning of the 
initial deflection of the H-reflex. Assessment was conducted after surgery by four weeks before 
starting the study (initial evaluation) and repeated after treatment (post-treatment evaluation). 
 
 
 
 
 
 

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Figure 1: Flow chart of participants 
Physical therapy intervention 
Patients in the study group received neural mobilization in the form of straight leg raising 
(SLR) and dorsiflexion with two-ended slider that were designed to mobilize the neural tissues. 
Both groups received a selected physical therapy treatment which included TENS and dynamic 
back and abdominal exercises. 
The neural mobilization was carried out in the steps described by Butler (1991) and 
Shacklock (2005). The patient was in supine lying position with symmetrical alignment of his body 
parts and no pillow under the head. The therapist was in stride-standing beside the patient's 
involved side with one hand under the patient's ankle, while the other hand placed above the 
patient's knee joint. The therapist began to elevate the affected lower limb in a standard straight leg 
raising (SLR) with full knee extension until there is back pain or pain referred to the leg. Then the 
 
 
 
 
Screened for eligibility (n= 84) 
The selected physical therapy program 3 
days/week for 6 weeks. 
(n= 30) 
Neural mobilization and the selected 
physical therapy program 3 days/week for 
6 weeks 
(n= 30) 
Study group 
(n= 30) 
Not fulfilling inclusion 
criteria (n=17) 
Decline to participate (n=7)  
Control group 
(n= 30) 
Random assignment (n= 60) 
Accept participation and signed informed consent 
(n= 60) 
Not eligible (n= 24) 
Eligible (n= 60) 
Post-treatment evaluation 
(n= 30) 
Post-treatment evaluation 
(n= 30) 
Initial evaluation 
(4 weeks post-operative) 
(n= 30) 
Initial evaluation 
(4 weeks post-operative) 
(n= 30) 

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therapist lowered the patient's limb few degrees. Then the therapist grasped the patient's foot and 
gently made dorsiflexion oscillations. Oscillations were repeated 5 to 10 times and can be repeated 
for 5 sets with one to two minutes rest in between sets. The amplitude of the technique can be 
increased gradually according to the patient tolerance and response. This technique was repeated 
with increasing the tension on the sciatic nerve gradually through making variations of the lower 
limb position as: hip adduction and hip medial rotation. These procedures were performed 3 
days/week for 6 successive weeks. The total time for applying this technique was about 10 to 15 
minutes according to tolerability of the patient. 
Two-ended slider was used before mobilizations and repeated after the mobilization. The 
two-ended slider was performed from side lying position on the non-painful side with his hips and 
knees flexed to about 45°. The neck is moved by the therapist into flexion and extension and the 
patient is asked to make bilateral active knee flexion during neck flexion and make bilateral active 
knee extension during neck extension. The two-ended slider was performed by the same procedure 
from sitting position (if this is more convenient for the patient). The two-ended slider was 
performed five sets of five repetitions with 20 to 30 seconds rest between sets (the total time for 
performing the two-ended slider was about 10 minutes).  
The selected physiotherapy treatment consisted of transcutaneous electrical nerve 
stimulation (TENs), pelvic tilt exercises, abdominal exercises, back exercises. For TENs 
application, one electrode was located over the origin of the sacral plexus and the other was located 
distally over the nerve trunk. The following settings for TENS was used: pulse width 260 msec, 
pulse frequency 150 Hz, Amplitude (or intensity) always set for the patient’s comfort level. TENs 
was applied for 30 minutes.  
The selected exercise program included: 
1) Drawing-in exercises from crook lying position: the patient was asked to contract 
transversus abdominus muscle and maintain contraction for 5 seconds (sec) and 5 sec rest. This 
exercise was repeat 5 times. 
2) Raising the head from crook lying position with hold this position for5 sec and 5 sec rest. 
This exercise was repeat 5 times. 
3) Bridging exercises from crook lying position: the patient was asked to raise his pelvis off 
the plinth with hold this position for 5 sec and 5 sec rest. This exercise was repeat 5 times. 
4) Raising the head and chest from prone-lying position: the patient was asked to raise his 
head with hold this position for 5 sec and 5 sec rest. This exercise was repeat 5 times. 

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5) Abdominal draw-in with double knee to chest from crook lying position: this exercise 
was started in the 6th week post-surgery. The patient was asked to bring his knees to his chest with 
maintain abdominal draw in throughout the entire exercise with maintaining this position for 5 sec. 
This exercise was repeat 5 times with 5 sec rest in between.  
6) Alternately raising one limb from quadruped position: this started at the 7th week post-
surgery. From quadruped position with maintaining the head and back straight, the patient was 
instructed to raise one upper limb till horizontal level and hold this position for 5 seconds then 
return it. Then he was asked to repeat this with the other upper limb after 5 seconds of rest then 
return. After that, the patient was asked to repeat this with one lower limb, then with the other lower 
limb after 5 seconds of rest. This exercise was repeat 2 times. 
7) Alternately raising two opposite limbs from quadruped position at the same time: this 
exercise was started at the 9th week post-surgery. From quadruped position with maintaining the 
head and back straight, the patient was instructed to raise both one upper limb with the opposite 
lower limb simultaneously till horizontal level and hold this position for 5 seconds then return them. 
Then, the patient was asked to repeat this with the other two limbs. This exercise was repeat 2 
times. 
Each the previous sets of exercises was done 5 sets with 30 seconds rest in between sets. 
During exercises, patients were instructed to keep normal respiration and avoid holding of 
breathing. The selected exercises was done for a total of 30 to 45 minutes according to the types of 
exercises given to the patient. 
 
 
 
 
 
 
 
 
 
 
 

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Effects of neural mobilization augmented by traditional physical therapy on pain, functional 
disability and H-reflex in patients after lumbar laminectomy: a randomized controlled trial 
Statistical Analysis 
March 19, 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Sample size 
The sample size was calculated prior to the study. Calculation was performed using 
G*POWER statistical software [F tests- MANOVA: Repeated measures, within-between 
interaction, α=0.05, β=0.2, effect size = 0.37] and revealed that the required sample was N=60.  
Statistical analysis 
All statistical analysis was out using the Statistical Package for Social Studies (SPSS) 
version 25 for windows (IBM SPSS, Chicago, IL, USA).  
Descriptive statistics and t-test were conducted for comparison of subject characteristics 
between both groups.  
Chi- squared test was used for comparison of sex distribution. Shapiro–Wilk test was used 
to explore the normality of data. Levene’s test was used to check the homogeneity between groups. 
Mixed MANOVA was conducted to compare within and between groups effects on visual 
analogue scale (VAS), Oswestry Disability Index (ODI) and H-reflex latency. Post-hoc tests using 
the Bonferroni correction were performed for subsequent multiple comparison. The level of 
significance for all statistical tests was set at p < 0.05.