Journal of Bodywork & Movement Therapies (2015) 19, 226e231

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SPINAL MANIPULATION: ORIGINAL NEURODYNAMIC STUDY

The immediate and 24-hour follow-up effect

of unilateral lumbar Z-joint mobilisation on
posterior chain neurodynamics
G. Shankar Ganesh, MPT*, Patitapaban Mohanty, PhD ,
Swati Smita Pattnaik, BPT
Department of Physiotherapy, SVNIRTAR, Olatpur, P.O.Bairoi, Cuttack Dt., Odisha 754010, India
Received 5 October 2013; received in revised form 4 April 2014; accepted 9 April 2014

KEYWORDS
Manual therapy;
Joint mobilization;
Neurodynamics

Summary Few studies have reported the effects of lumbar spine mobilization on neurodynamics. In a recent study, Szlezak et al. (2011) reported immediate improvement of posterior
chain neurodynamics [range of passive straight leg raise (SLR)] following ipsilateral lumbar
spine zygopophyseal (Z) joint mobilization. We re-duplicated the study with a 24 h follow-up
measurement. Sixty healthy college students were assigned to two groups, mobilization and
control. The mobilization group received ipsilateral grade 3 Maitland mobilizations to Z joint
at a frequency of 2 MHz for 3 min and the control group received no treatment. The SLR
was measured before and after the intervention for both the groups on the day of testing
and 24-h later. Repeated measures ANOVA showed statistically significant pre to post improvement in SLR range after mobilization. The improvement was retained at 24-h. The results of
the study are consistent with Szlezak et al. (2011).
2014 Elsevier Ltd. All rights reserved.

Introduction
Neurodynamics refers to the mechanical and physiological
components of the nervous system and the interconnections between them (Shacklock, 1995). The

* Corresponding author. Tel.: 91 9437279869 (mobile); fax: 91

671 2805862.
E-mail address: shankarpt@rediffmail.com (G. Shankar
Ganesh).
http://dx.doi.org/10.1016/j.jbmt.2014.04.009
1360-8592/ 2014 Elsevier Ltd. All rights reserved.

mechanical components of the nervous system must be

resilient enough to endure tension and compression, while
allowing sliding of the nerves (Shacklock, 2005). The neural
tension tests are used to move the neural tissues to gain an
impression of their mobility and sensitivity to mechanical
stresses. Structures that are affected with these tests
include the neuraxis, meninges, nerve roots (Breig, 1960,
1978; Louis, 1981) and peripheral nerves (Goddard and
Reid, 1965; McLellan and Swash, 1976; Millesi, 1986). One
of the most commonly used neural tension test is the
straight leg raise (SLR) test (Breig and Troup, 1979).

Lumbar Z-joint mobilization and neurodynamics

The SLR test is a common neurodynamic test used to
examine the mechanosensitivity of the lower extremity
nervous system (Boyd et al., 2009) in determining the
ability of the nerves to move and respond to the tensile and
compressive forces. The test procedures, underlying
mechanisms and interpretations of the test results has been
described by many different groups (Lasegue, 1864; Forst,
1881; De Beurmann, 1884; Fajersztajn, 1901; MoutardMartin and Parturier, 1907) all cited by Woodhall and
Hayes 1950. The SLR test is of great value in assessing
normality of the roots of the sciatic nerve (Breig and Troup,
1979; Urban, 1981) and tightness of the hamstring muscles
(Tanigawa, 1972; Medeiros et al., 1977; Erickson and Coney,
1979; Halkovich et al., 1981). Further, it has been suggested that improving SLR mobility reduces the degree of
impairment in patients with low back pain (Blunt et al.,
1997; Hall et al., 2001; Hanten and Chandler, 1994).
Various studies have reported greater improvement on
pain following a neurodynamic mobilization technique in
combination with other treatment protocols (Cleland et al.,
2006; Nagrale et al., 2011). Coppieters et al., 2003 investigated the response to cervical mobilizations in participants with cervicobrachial pain and found that the
participants who received lateral translations of the cervical spine demonstrated statistically significant improvement in elbow extension range of motion and intensity of
pain during a median nerve test. In a recent study, Szlezak
et al., 2011 reported that posterior chain neurodynamics
can be immediately restored with lumbar spine zygopophyseal (Z) joint mobilization on the same side. The authors
applied unilateral grade III oscillatory mobilizations at a
frequency of 2 Hz to the T12/L1, L1/L2, L2/L3, L3/L4, L4/
L5, and L5/S1 for 30 s per joint and found an improvement
in the same side mean SLR score.
We wanted to demonstrate the sustainability of the
Szlezak et al., 2011 results and see if any change in range
would be maintained 24 h later. This formed the focus of
our work and the aim of our study was to evaluate the
immediate and 24-h follow-up effect of unilateral lumbar Zjoint mobilisation on posterior chain neurodynamics in
normal subjects.

Materials and methods

The study design was a prospective trial using an experimental pre, post and follow up design. Thirty healthy
physiotherapy students (15 males and 15 females), with full
range of motion in ankle, knee and hip were recruited for
the study. The participants recruited had no history of any
neurological abnormalities, previous injuries, disorders and
surgeries to the spine and limbs. The mean age of the
participants was 22.03 (range 20e24). Another 30 (total
n Z 60) age, sex and height matched subjects served as
controls (mean age 22.06, range 20e24). Participants with
diabetes mellitus were excluded as a study by Boyd et al.
(2010) concluded that people with diabetes mellitus have
limited responses to SLR neurodynamic testing, and may be
at risk of harm from nerve overstretch. All the participants
were able to tolerate prone position (no breathing difficulties). Informed consent was signed by every participant
and the procedure was approved by the institutional ethics

227
committee. The procedure was adequately explained to
the participants and the consenting participants agreed
that they would not engage in any other lower limb exercises for a 24 h period except their usual routines.

Outcome variable
The straight-leg -raise (SLR) test was used to measure the
extensibility of posterior chain muscles. A goniometer was
used to measure the SLR range. This method was shown to
be reliable for both intrasession (Medeiros et al., 1977) and
intersession (Troup et al., 1968) measurements of the SLR.
Participants, wearing loose shorts, were positioned in
supine with the right side of the body parallel to the edge of
a firm treatment table. The tested hip was positioned in
neutral abduction, knee in extension and the ankle maintained in plantigrade position by an orthosis. The other leg
was maintained flat by strapping to the treatment table to
avoid excessive posterior pelvic tilt. The goniometer was
placed with the stationary arm parallel to the edge of the
treatment table, the moving arm along the lateral midline
of the thigh, and the axis over the superior half of the
greater trochanter. The goniometer was strapped to the
measuring limb (Fig. 1). Each participant was instructed to
relax as much as possible.
Three investigators blinded to the study completed all
the measurements. The investigators attended a training
session prior to the study, where they discussed the measurement procedure. All the data were collected in a private room with only the investigators present. To maintain
the uniformity, only the right limb was studied. The limb
was passively lifted by one of the independent investigators
to the initial point of limb resistance or a sensation of
discomfort, stretch, pulling, tension or pain by the participant, whichever was earlier. The second investigator
palpated for pelvic tilt to ensure that SLR was not accompanied by pelvic rocking movement (Fig. 2). Those participants who had pelvic tilt before the resistance was felt
were excluded from the study. Care was taken to avoid
transverse and coronal plane movements during passive hip
flexion. The measurement was recorded by the moveable
arm of goniometer by the third investigator. The limb was
then returned to the treatment table. The hip flexion angles were measured in whole degrees using a goniometer.
One trial movement was allowed to familiarize the participants to the testing procedure. Once the data were
collected, the investigators left the room and the authors
entered and applied one of the two interventions. The investigators were blinded to the interventions being undertaken, thereby eliminating potential bias. Successful
blinding was ensured as no communication occurred

Figure 1

Straight leg raise measurement e positioning.

228

G. Shankar Ganesh et al.

Figure 2

Straight leg raise measurement.

between the investigators and authors. The results of the

data were not handed to the authors until the final
collection of data.

Procedure
The procedure was explained to all participants verbally.
The initial SLR measurement was taken after the participants were positioned in supine position for 5 min. After the
measurement, the mobilization group participants were
mobilized in prone position with arms by their side on the
treatment table and with the head turned comfortably to
one side by one of the authors (researcher, hereafter).
Because the implementation of large-amplitude, oscillating
movements requires small forces, the researcher used his
hands rather than thumbs when applying mobilization to
the participant. Researcher stood to the right side of the
participant and placed his left ulnar border of the hand
between the pisiform and hook of the hamate over the Z
joint of the mobilizing vertebrae. The researchers shoulders were directly over the point of contact, and full wrist
extension was maintained with the forearm in neutral between supination and pronation. The researchers right
hand then reinforced the left by placing the carpus of the
right hand over the radial aspect of the left carpus at the
base of the left index finger through the approximation of
the right thenar and hypothenar eminences. This placed
the right middle, ring, and little fingers between the left
index finger and thumb, while the right index finger and

thumb were over the back of the left hand (Fig. 3). Stability
was maintained through grasping the palm of the researchers left hand between the thenar eminence and the
middle, ring, and little fingers of the left hand and through
sustained extension of his right wrist. The researchers
shoulders were directly over the contact point on the participants respective Z joint, while the elbows were slightly
flexed. The oscillating movement that accompanied joint
mobilization of the vertebra was obtained by a rocking
motion of the upper trunk in an up-and-down direction in
the vertical plane, with the transmission of pressure coming
through the researchers arms and shoulders. The direction
of the applied force was downward, avoiding any variations
in either the caudal or cranial directions. The researcher
applied a unilateral Maitland grade III mobilization at a
frequency of 2HZ to the T12/L1, L1/L2, L2/L3, L3/L4, L4/
L5 & L5/S1 Z joints for 30 s per joint. A grade III mobilization is a large amplitude movement that moves into the
resistance limiting the range of movement (Maitland,
1986). We controlled the frequency of mobilization (2 Hz)
by using a pre recorded mp3 metronome and the bar (one
cycle) was set at 120 beats per minute for a total duration
of 3 min and the duration of application was timed with a
stopwatch. The researcher practiced the mobilization while
listening to the metronome until he became proficient in
applying a postero-anterior mobilization at the set frequency of 2 Hz. This was the same dosage as administered
to the participants in the Szlezak et al., 2011 study. It took
3 min of duration to complete the mobilization. The SLR
was measured again.
The control group participants were asked to lie in supine
position. After the measurement of SLR, the participants
were asked to turn in to prone position using a side of their
choice and were instructed to stay in that position for 3 min.
At the end of 3 min, the participants returned to supine position and SLR was re-measured. The date and time was
noted down and all the participants were evaluated 24-h
later to measure their SLR. Those participants who failed to
report a day later were excluded from the study.
The experimental group and their matched controls
were measured during the same session to minimize the
effect of temperature and environment. The test environment was quiet at the time of testing to minimize distraction. The same procedure was repeated at each session. To
avoid bias, data for each session were recorded on a
separate page.

Data analysis
The data was analysed with SPSS (Statistical Package for
Social Sciences) SPSS 16.0 version. All data were analysed
using repeated measures 2  3 ANOVA. There was one between factor (group) with two levels (groups: manual therapy, control) and one within factor (time) with three levels
(pre, post and follow-up measure). P value was set at 0.05.

Results

Figure 3

Lumbar Z joint mobilization.

Thirty experimental and 30 control participants participated and completed the study. Each group had 15 males
and 15 females. All the participants in this study were

Lumbar Z-joint mobilization and neurodynamics

Table 1

229

Baseline characteristics of participants.

Measure

Mobilization group
(mean and S.D)

Control group
(mean and S.D)

Age
Height (in cm)
Weight (in kg)
SLR-pre (in deg)
SLR-post
SLR-follow-up

22.03
158.43
59.76
59.38
65.11
66.82

22.06
157.36
58.23
64.11
65.41
65.47

(1.03)
(9.43)
(10.31)
(11.52)
(11.39)
(10.91)

(1.08)
(9.39)
(9.79)
(12.70)
(12.32)
(12.59)

SLR e straight leg raise, cm e centimetres, kg e kilograms,

deg e degrees, S.D e standard deviation.

matched for age, sex, height and weight measures. The

mean age, height, weight, baseline and subsequent SLR are
shown in Table 1. A one-way ANOVA revealed that both the
groups did not differ in age, weight, height and baseline SLR
measures.
Results of the study (Graph 1) revealed statistically significant difference within groups. There was a main effect
for time F(1,58,0.05) Z 31.281, p Z 0.000, that was
qualified by time  group interaction F(1,58,0.05) Z
12.333, p Z 0.000. However, there was no significance
between the groups F(1, 58, 0.05) Z 0.828, p Z 0.367.

Discussion
The results of the study indicate that grade III same side
lumbar Z joint mobilization at a frequency of 2 Hz produced
significant changes on posterior chain neurodynamics.
The immediate improvement in SLR following Z joint
mobilization may be hypothesized to the effects of sympathetic nervous system activation (Perry and Green, 2008)
that might have led to an inhibition of alpha motor neurons
(Dishman and Bulbulian, 2000) reducing the posterior chain
muscle activity. Placebo response is known to be associated
with conditioning and expectancy, involving activation of
the limbic system and triggering analgesic centres (Wall,
1994). It is likely that PA mobilization technique will also
have a placebo response.
Nerves are exposed to different forces along their course
as they make contact with neighbouring bone, muscle and
fascia (Goddard and Reid, 1965). Displacement, strain,
80
70

SLR in degrees

60
50

Pre

40

Post

30

Follow-up

20
10
0

Experimental Group

Graph 1

Control Group

Graph showing changes in SLR between 2 groups.

intra-neural pressure and tension vary at different neural

sites, depending on the local anatomical and mechanical
characteristics. A Study by Kulig et al., 2004 found that the
effect of PA mobilization to the target lumbar segment was
always directed towards extension and the improvement of
SLR range, might be due to this slider effects of mobilization of the nerve tissues.
However, 24 h after the intervention, it is uncertain why
the improvement in range of SLR (7 ), from pre to follow-up
was sustained. This may be hypothesized to the stretch
tolerance of the hamstrings as some studies have found a
reduction in spinal motor excitability in the lower limb
(Cheng et al., 1995; Freeman and Wyke, 1967) following
lumbar spine mobilization. This immediate effect might
have been carried forwards to everyday activities resulting
in the maintenance of SLR 24 h after the mobilization.
Humans exhibit habitual asymmetrical use of the limbs
during daily function and recreation. This may create
asymmetries in the tolerance of the neural tissues to
movement. There is considerable evidence that habitual
use of our limbs is not symmetrical during activities such as
gait initiation (Dessery et al., 2011), walking (Nagano et al.,
2011; Senden et al., 2011) turning (Strike and Taylor, 2009),
jumping (Stephens et al., 2005, 2007; Pappas and Carpes,
2012), kicking (McLean and Tumilty, 1993), and crossing
legs (Reiss, 1994). The control group participants showed a
very small degree of improvement in SLR clinically which is
consistent with studies showing a limited conditioning effect of only 1 per trial with repeated measures of SLR
(Taylor et al., 1990).
However, the results of the study do not explain the biomechanical rationale behind SLR. During the initial phase of
the SLR, the nerves are wrinkled and sit loosely in their bed
and during movements nerves lose their slack (Sunderland
and Bradley, 1961a,b) and begin to slide (Breig, 1978).
These dynamic events begin at the joint where movement
is initiated and, with further limb movement, the mechanical effects spread progressively along the nerve to
remote areas. Neural movement remote from the joint
where movement is initiated will start only when the slack
along the nerve has been taken up. As limb movement
continues through the mid range, the nerves slide more
rapidly because there is sufficient tension to cause their
movement. Towards the end range of limb movement, the
amount of available neural sliding becomes depleted,
causing the neural tension to increase more markedly
(Charnley, 1951). The direction of neural sliding is also
influenced by the sequence of body movements. Knee
extension causes the neural structures to slide towards the
knee. With ankle in dorsiflexion, the nerves at the knee
slide towards the ankle (Smith, 1956). The role of ipsilateral PA mobilization to lumbar facet joints in influencing
these changes remains unclear.
A limitation of this study includes the randomization
process, which might be the reason for the difference in
mean range SLR prior to the intervention. In-addition, the
randomization process was not concealed from the
researcher applying the intervention. Other measures of
sympathetic activity such as skin temperature, conductance and EMG were not used as an outcome measure.
The results of Szelezak et al. (2011) study and this study
indicates that grade III oscillation mobilizations at a

230
frequency of 2HZ of 30 s duration per Z joint may be
beneficial in improving the range of SLR. Physiotherapists
routinely reassess patients immediately post-treatment.
This information guides treatment selection and predicts
possible longer-term outcomes (Hahne et al., 2004). The
SLR test is a useful measure, in this regard, because immediate effects of treatment can be determined. Studies
have found that altering the direction of force and amplitudes of mobilization produce similar hypoalgesic response
in asymptomatic populations (Chiradejnant et al., 2003;
Krouwel et al., 2010). Future studies with different dosages will add substantial evidence to these results.

Conclusion
The results of the study support the results of Szelezak
et al. An ispilaterally applied grade III oscillatory PAmobilisations at a frequency of 2 Hz to the T12/L1, L1/
L2, L2/L3, L3/L4, L4/L5 and L5/S1 Z-joints for 30 s per joint
cause an immediate increase in SLR range and the results
were sustained at 24- hour follow-up. A similar study on
patients with low back will help us understand how SLR
measures in subjects with pain would respond. This study
adds to the body of evidence that suggests that Z joint
mobilisations increase the SLR range and may have a systemic hypoalgesic effect.

Acknowledgement
We would like to acknowledge Mrs. Monalisa Pattnaik (Assistant Professor in Physiotherapy, SVNIRTAR), Mr. Chittaranjan Mishra (Senior Physiotherapist, SVNIRTAR) and Mr.
Pramod Tigga (Senior Physiotherapist, SVNIRTAR) who
served as investigators. Our special thanks to Mr. Benoy
Joseph for his assistance in manuscript preparation.

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