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Comparative Effectiveness of 2 Manual
Therapy Techniques in the Management of
Lumbar Radiculopathy: A Randomized
Clinical Trial
Bashir Bello, PhD, Musa Sani Danazumi, MSc, and Bashir Kaka, PhD
ABSTRACT
Objective: The purpose of this study was to compare the effectiveness of Dowling’s and Mulligan’s manual therapy
techniques on pain and disability in the management of lumbar disc herniation with radiculopathy (LDHR).
Methods: A total of 40 individuals with LDHR were randomly allocated into 2 groups, 20 participants each in PINS
and SMWLM groups. Each participant was assessed at baseline, 4 weeks, and 8 weeks postintervention. The primary
outcomes measured were pain (visual analog scale) and disability (Roland-Morris Disability Questionnaire).
Secondary variables were quality of life (Short-Form 36 Health Survey), sciatica bothersomeness (Sciatica
Bothersomeness Index), sciatica frequency (Sciatica Frequency Index), and general perception of recovery (Global
Rating of Change Scale). Repeated-measures analysis of variance was used to compute within-group and between-
groups interactions.
Results: No significant differences were observed in the baseline characteristics of participants in both groups. The
results indicate that there were significant time effects for all outcomes in the study (P<.001) within each group.
However, there was no significant difference between the 2 groups on any outcome variable (P >.05).
Conclusion: The findings indicate that there was no difference in pain or disability between the 2 manual therapy
techniques in the management of LDHR. (J Chiropr Med 2019;18;253-260)
Key Indexing Terms: Manual Therapy; Spine; Lumbosacral Region; Radiculopathy; Musculoskeletal Manipulations
TAGGEDH1INTRODUCTIONTAGGEDEND
The 2016 Global Burden of Disease Survey identified
low back pain (LBP) as a major health problem worldwide
that is getting worse.
1
LBP is a common reason patients
visit a physician or other musculoskeletal health care pro-
vider
2
and is among the most common symptoms of lumbar
disc herniation (LDH).
3
LDH is believed to be a major con-
tributor to the estimated 60% to 80% lifetime prevalence of
LBP in the general population and is among the most com-
mon causes of sciatica.
3
Sciatica, also known as radiculop-
athy, accompanies approximately 10% of cases of LBP,
with a lifetime prevalence ranging from 13% to 40%.
4
The importance of identifying effective treatment strate-
gies for sciatica has been emphasized in research indicating
that the presence of sciatica is associated with delayed
recovery, persistent disability, and increased health care
system utilization and costs.
4
Various treatment strategies
have been tried for lumbar radiculopathy with varying
degrees of success. In the last few years, studies have
shown that manual therapy is beneficial in the management
of many musculoskeletal disorders, including lumbar radi-
culopathy.
5-8
However, there are no standardized guide-
lines for appropriate manual therapy programs, which
suggests that more treatment options are urgently needed to
ameliorate lumbar radiculopathy.
9
Manual therapy is a conservative management that uses
different skilled hands-on techniques on a person’s body
(spine and extremities) for the purpose of assessing, diag-
nosing, and treating a variety of symptoms and condi-
tions.
5-8
Dowling
10
developed a manual therapy technique
that involves progressive inhibition of neuromuscular struc-
tures (PINS) for the management of recalcitrant somatic
dysfunctions. PINS has been hypothesized to resolve radi-
ating neuromuscular pain and normalize reflex activity
through progressive deactivation of myofascial trigger
points (MTrPs). It can be used as a sole treatment or in
combination with any other modality, and has been recog-
nized by some authors
11,12
in the management of many
neuromuscular dysfunctions. However, only a few case
studies have demonstrated the effectiveness of PINS in
Paper submitted January 24, 2019; in revised form October 22,
2019; accepted October 22, 2019.Department of Physiotherapy,
Faculty of Allied Health Sciences, Bayero University, Kano,
Kano, Nigeria.
Corresponding author: Bashir Bello, PhD, Physiotherapy
Department, Faculty of Allied Health Sciences, Bayero University
Kano, Nigeria. P.M.B. 3011, Kano, Nigeria.
(e-mail: bbello.pth@buk.edu.ng).
Paper submitted January 24, 2019; in revised form October 22,
2019; accepted October 22, 2019.
1556-3707
© 2020 by National University of Health Sciences.
https://doi.org/10.1016/j.jcm.2019.10.006
the management of sciatica.
10,13,14
Further randomized
controlled trials are needed to establish the efficacy of
PINS in the management of sciatica.
Mulligan
15
also developed a manual therapy technique
using spinal mobilization with leg movement (SMWLM) for
improvement of lumbar lesions resulting in pain and other
signs below the knee. Mulligan’s technique is postulated to
free nerve compression through increased vertebral rotation
and intervertebral disc space gapping. Thus, this technique
has the ability to correct positional faults, which takes pres-
sure off the structures that compress the nerve, and may
reduce the extent of pain by centralization.
16
However, avail-
able studies on the efficacy of Mulligan’s technique are
mainly case reports,
15-18
with only a few randomized con-
trolled trials.
19-21
In addition, these studies were based on
limited outcomes and durations, which suggests that more
studies on the efficacy of the technique are still needed.
Therefore, this study was carried out to compare the effec-
tiveness of Dowling’s and Mulligan’s manual therapy techni-
ques in the management of LDHR. It was hypothesized that
therewouldbesignificant differences between the 2 techni-
ques with regard to pain intensity and functional disability in
individuals with LDHR after 8 weeks of intervention.
TAGGEDH1METHODSTAGGEDEND
Study Design and Setting
This study was a single-blind randomized clinical trial,
approved by the Health Research Ethics Committee of the
Federal Medical Centre, Nguru, Yobe State, Nigeria in
accordance with the Declaration of Helsinki (FMC/N/CL.
SERV/355/VOL iii/197). The trial was registered with the
Pan African Clinical Trial Registry (trial number
PACTR201810520651000).
Eligibility Criteria
Individuals with LBP diagnosed with LDHR via mag-
netic resonance imaging were included in the study.
Criteria for inclusion were age between 18 and 65 years,
unilateral radiculopathy, and pain in the distribution of
the sciatic nerve. Exclusion criteria were any sign or
symptom of dementia or other cognitive impairments,
diagnosis of claudication, inflammatory or other specific
disorders of the spine such as ankylosing spondylitis,
vertebral collapse, rheumatoid arthritis, stenosis, spondy-
lolisthesis, osteoporosis, previous spinal surgery, a
known pregnancy, bilateral radiculopathy, and presence
of any of the spinal red flags.
Sample Size and Sampling Technique
The required sample size was calculated using G*Power
version 3.1.
21
The effect size (ES) used for calculating the
sample size was obtained from the previous study
22
using
pain as the primary outcome:
ES DðÞ¼m0m1=s;
where m
0
= mean effect for the experimental group,
m
1
= mean effect for the control/comparison group, and
s= standard deviation for the control group.
23
Based on the previous study,
22
the means and standard
deviations for pain in the Mulligan Mobilization group
(experimental group) and the Neural Mobilization group
(control group) were 0.57 (0.14) and 0.30 (0.21), respec-
tively.
ES ¼0:570:30=0:21:
Therefore, ES = 1.29.
The probability level (a), the power (p), and ES used
for the calculation were then set at 0.05, 0.95, and 1.29,
respectively, which yielded a sample size of 17 partici-
pants per group (a total of 34 participants), estimated
by independent ttest. The sample size was adjusted to
40 participants (20 participants per group) to cover up
for potential drop outs.
24
Participant Recruitment
Participants were first screened for eligibility by the
research assistant, and then those who met the inclusion
criteria were contacted by the principal investigator to
arrange for baseline assessment. Participants were pro-
vided with written informed consent on arrival at the
baseline assessment. Each participant who was willing
to participate and signed the consent form was recruited
into the study.
Randomization and Concealment
Participants were allocated to groups using a simple ran-
dom process. Forty (40) opaque envelopes with pieces of
paper, on which were written either “Dowling”or “Mulli-
gan,”were prepared by an assistant therapist who did not
have any other input into the study. The envelopes were
shuffled every time a new participant picked one. Each
sealed envelope was opened by the participant as the partic-
ipant was recruited. Neither the researcher nor the partici-
pants were aware of the contents of any specific envelope
until it was opened. See Figure 1 for participant screening
and group allocation.
Outcome Measures
In lumbosacral radicular symptoms, the most common
complaints are pain and inability to perform normal daily
activities.
25,26
Outcome measures were therefore classified
into primary and secondary.
Bello et al Journal of Chiropractic Medicine
Comparative Effect of 2 Manual Therapy Techniques December 2019
254
Primary Outcome Measures
.The Roland-Morris Disabil-
ity Questionnaire for Sciatica (RMDQ) is a 23-item illness-
specific functional assessment questionnaire that is fre-
quently used for low back pain and sciatica. Scores range
from 0 to 23, reflecting a simple unweighted sum of items
endorsed by the respondent. Individuals with high scores at
baseline have a severe disabling symptom. This tool has
been reported to have a high level of reliability and validity
and is responsive to change.
27,28
A visual analog scale (VAS) measured the intensity of
pain in the back and leg. Pain was assessed on a horizontal
100-mm scale ranging from 0 mm, “no pain in the leg,”to
100 mm, “the worst pain ever.”The VAS has been shown
to have a high interobserver reliability coefficient
(r= 0.88).
29
Secondary Outcome Measures
.The secondary outcome
measures are the Short-Form 36 Health Survey (SF-36),
which measures quality of life, the Sciatica Bothersome-
ness Index (SBI) for sciatica bothersomeness, the Sciatica
Frequency Index (SFI) to measure frequency of sciatica,
and the Global Rating of Change Scale (GROC) to assess
general perception of recovery.
Study Procedures
Initial assessment of each participant was carried out by
a coresearcher who was not involved in the administration
of interventions. This was to determine back and leg pain
intensity, functional limitation, sciatica bothersomeness,
sciatica frequency, general perception of recovery, and
quality of life, using VAS, RMDQ, SBI, SFI, GROC, and
SF-36, respectively. The participants were asked to com-
plete all questionnaires at the beginning of the study. In
addition, outcomes were assessed 4 and 8 weeks after inter-
vention.
The Dowling group received PINS, whereas the Mulli-
gan group received SMWLM. However, all participants
received therapeutic exercises in the form of lumbar stabili-
zation and stretching exercises as adjunct therapies. Each
participant had 2 treatment sessions per week for the 8
weeks of the study.
PINS Group
Participants in the PINS group received the PINS pro-
gram using Dowling’s protocol.
10
Two related points,
termed primary and secondary or endpoints, were palpated.
The points were areas of most and least sensitivity, respec-
tively, found along the continuum of a neuromuscular
structure. Once the area of least sensitivity (endpoint) was
found, a moderate ischemic compression was steadily
maintained with the index finger of 1 hand without reliev-
ing pressure until completion of the protocol. The index
finger of the other hand was used to apply pressure to the
primary point (area of most sensitivity) for 30 seconds,
after which another sensitive point was located with the
middle finger of the hand proximal to the endpoint without
relieving the pressure of the index finger. If the participant
indicated that the latter point was more sensitive than the
former, then pressure was maintained on the second point
and relieved on the first point without relieving the end-
point pressure. This was maintained for 30 seconds before
the third point was identified. The same pattern was fol-
lowed progressively along the dysfunctional neuromuscu-
lar structure until the last point, approximately 2 cm
proximal to the endpoint, was found. Pressure was main-
tained for 30 seconds simultaneously on the 2 points (the
last and the endpoint) and then relieved.
SMWLM Group
Participants in the SMWLM group received SMWLM
using Mulligan’s protocol.
30
The participant was laid on
his or her side, facing the therapist, with the affected leg
uppermost. An assistant therapist supported the affected
leg. The therapist then leaned over the subject and placed
1 thumb, reinforced with the other, on the spinous process
of the herniated vertebra as palpated with reference to the
posterior superior iliac crest. The therapist then pushed
down on the chosen spinous process. This pressure was
sustained while the participant actively performed the
straight leg raise for the leg supported by the assistant ther-
apist, provided this did not cause pain. This position was
maintained for 30 seconds, after which the therapist
Assessed for
Eligibility (n = 53)
Enrolment
Excluded (n = 13)
Reason: Not meeting
inclusion criteria
Randomized
(n = 40)
Allocation
Allocated to PINS
(n = 20)
Received allocated
intervention (n = 20)
Allocated to
SMWLM
(n = 20)
Received allocated
intervention (n = 20)
Completed Intervention
(n = 20)
Completed Intervention
(n = 20)
Analysis
Analyzed (n = 20)
Analyzed (n = 20)
Fig 1. Flowchart of the study.
Journal of Chiropractic Medicine Bello et al
Volume 18, Number 4 Comparative Effect of 2 Manual Therapy Techniques
255
released the pressure on the spinous process and the partic-
ipant lowered the supported leg to the couch. During the
first visit, 3 repetitions were applied. On subsequent visits,
as the participant improved, the assistant therapist applied
overpressure on the supported leg as the participant per-
formed the straight leg raise. This was also sustained for
30 seconds, after which the leg was lowered to the starting
position. This procedure was repeated 6 times on subse-
quent visits.
Therapeutic Exercises
Therapeutic exercises (lumbar stabilization and stretch-
ing exercises) were performed by all participants in both
groups.
Lumbar Stabilization Exercises
.McGill’s protocol
31
of
lumbar stabilization exercises (curl-ups, horizontal side
bridge, and bird dog) was given as adjunct treatment to
each group. These exercises were performed for 10
minutes: 6 repetitions for 6 seconds each followed by a rest
period of 30 seconds before successive repetitions. Each
participant had 2 sessions a week for 8 weeks.
Curl-ups
.The participant lay supine with hands sup-
porting the lumbar spine, both knees bent at 90° and the
hips bent at 45°. The participant then lifted up the thoracic
and cervical spine as 1 unit, maintaining a rigid block posi-
tion with no cervical motions (chin poking or chin tucking),
and held the position for 8 counts. This exercise trains the
rectus abdominis muscle.
Horizontal Side Bridge
.The participant assumed a side-
lying position and supported his or her body weight using
the ipsilateral elbow. The participant then crossed the con-
tralateral arm against the chest and the contralateral foot in
front of the ipsilateral foot, and bridged by lifting the hip
up while maintaining the trunk straight and supporting the
whole body on the elbow and feet. This position was held
for a count of 8, after which the participant returned to the
starting position before carrying out another repetition.
This exercise trains the quadratus lumborum, lateral obli-
ques, and transversus abdominis.
Bird Dog
.The participant went on hands and knees
(quadruped position), then simultaneously raised the con-
tralateral arm and ipsilateral leg and stretched them out
completely. After a count of 8, the participant switched
limbs and repeated the exercise for the same duration. This
exercise trains the back extensors, including longissimus,
iliocostalis, and multifidi.
Stretching Exercises
Myers’s protocol
32
of stretching exercises (plantar
stretching, calf stretching, and hamstring stretching) was
performed by each group. These exercises were performed
for 10 minutes at 2 sessions a week for 8 weeks.
Plantar Stretching
.The participant sat on a chair with
feet on the floor. A tennis ball was placed under the foot
and the participant put weight on various parts of the plan-
tar surface, rolling the ball from the front of the heel out to
the ball of the foot, to find places that hurt or feel tight.
Enough weight was then applied until the point between
pleasure and pain was reached. Pressure was sustained on
each point for 10 seconds.
Calf Stretching
.The participant stood erect and leaned
forward with forearms resting on the wall, then stretched
the lower leg section by putting 1 foot back and resting on
the heel. If the heel reached the floor easily, then the knee
was flexed forward toward the wall to increase the stretch
on the soleus.
Hamstring Stretching
.The forward bend described for
calf stretching was used to lengthen the hamstring group.
The upper body was swung left and right during bends to
ensure the entire hamstring muscle group was activated
and stretched.
Data Analysis
Data obtained from this study were analyzed using SPSS
20.0 (SPSS Inc., Chicago, Illinois). Descriptive statistics
were used to summarize the sociodemographic and clinical
parameters of the participants. The Shapiro-Wilk test was
used to assess normality of the data, whereas Levene’s test
was used to assess homogeneity of variances between
groups. A repeated-measures analysis of variance was used
to analyze treatment effects, with intervention (SMWLM,
PINS) as the between-participants variable and time (base-
line, week 4, week 8) as the within-participant variable. The
dependent variables analyzed were RMDQ, VAS leg, VAS
back, SBI, SFI, SF-36, and GROC. When significant intra-
group differences were detected by the analysis of variance,
Bonferroni post hoc analysis of variance was used to assess
differences across baseline and weeks 4 and 8. Differences
between the means were considered at a 5% probability
level (P<.05) with a 95% confidence interval.
TAGGEDH1RESULTSTAGGEDEND
A total of 40 participants completed the study. No sig-
nificant differences were observed in the baseline charac-
teristics between participants in either group (Table 1). The
analysis of effects of time and the intervention £time inter-
action on the variables is presented in Table 2. The results
indicate that there were significant time effects for all out-
comes (all Pvalues <.001) with large effect sizes. How-
ever, the effect of the intervention £time interaction was
not significant for all outcomes—RMDQ: P= .961; VAS
leg: P= .924; VAS back: P= .445; SBI: P= .212; SFI:
P= .098; SF-36: P= .135; GROC: P= .107—indicating
that the intervention was not time dependent.
Bello et al Journal of Chiropractic Medicine
Comparative Effect of 2 Manual Therapy Techniques December 2019
256
TaggedPThe Bonferroni post hoc analysis of time effects (Table 3)
indicates that there were significant increases for all out-
comes (except GROC) at all time points of intervention (P
values <.001, except P= 1.000 for GROC). Between-
groups comparisons (Table 4) did not reveal significant dif-
ference between the 2 groups on any measure—RMDQ:
P= .819; VAS leg: P= .689; VAS back: P= .241; SBI:
P= .082; SFI: P= .301; SF-36: P= .107; GROC: P= .806.
TAGGEDH1DISCUSSIONTAGGEDEND
This study investigated the effectiveness of Dowling
and Mulligan’s manual therapy techniques in the manage-
ment of lumbar disk herniation with radiculopathy. The
findings show that both techniques, alongside recom-
mended back care exercises, have great impact on pain,
functional disability, quality of life, and sciatica outcomes.
The findings indicate that there were significant time effects
for all outcomes (with the exception of GROC at week 8).
This indicates that all measures significantly improved over
time from baseline to week 8. The failure of GROC to
show significant increases at week 8 could be due to inap-
propriate item selection from the 15-point GROC Likert
scale or to recall bias by participants.
However, the effect of the intervention £time interac-
tion was not significant for any outcome, indicating that the
intervention was not time dependent. This means that indi-
viduals may improve significantly irrespective of number
of treatment sessions. In addition, the minimal time
required to observe significant changes in participants with
the 2 manual therapy techniques is 4 weeks, and this is
expected to be maintained if the treatment sessions are
increased.
The findings also revealed that there was no significant
difference between the 2 groups on any outcome. This indi-
cates that neither of the 2 manual treatment techniques was
better than the other in the management of LDHR. Individ-
uals with lumbosacral radiculopathy usually report leg pain
and sciatica as the factors most limiting functional ability.
25
The lack of a significant difference between the treatment
effects of the 2 techniques could be due to the fact that they
individually targeted all the structures that bring about leg
pain and sciatica. The mechanism through which PINS
reduces leg pain and sciatica may be due to its direct effects
on MTrPs. Following MTrP deactivation, the resultant
hyperemia may reduce the capacity of the nociceptive
receptors to process through washing away the metabolites
in the neuromuscular structures.
10
In addition, ischemic
compression applied on points near the greatest sensitivity
or at the location of the symptoms may act as
Table 1. Baseline Demographics and Clinical Parameters of the
Participants
Variable
SMWLM Group
(n = 20)
PINS Group
(n = 20)
Age (y) 45.44 (8.84) 49.51 (10.06)
BMI (kg/m
2
) 24.59 (1.83) 25.35 (2.52)
Duration of symptoms, y 2.25 (1.07) 2.10 (0.97)
RMDQ 11.40 (3.83) 11.25 (3.14)
VASL 5.75 (2.05) 5.50 (2.04)
VASB 5.55 (1.54) 6.00 (1.95)
SBI 10.35 (4.30) 10.35 (4.30)
SFI 10.95 (4.08) 13.15 (4.10)
SF-36 11.86 (3.99) 12.35 (3.36)
GROC 3.20 (1.58) 3.90 (1.02)
Data are presented as mean (SD).
BMI, body mass index; GROC, Global Rating of Change Scale; PINS,
progressive inhibition of neuromuscular structures; RMDQ, Roland-Mor-
ris Disability Questionnaire for Sciatica; SBI, Sciatica Bothersomeness
Index; SF-36, Short-Form 36 Health Survey; SFI, Sciatica Frequency
Index; SMWLM, spinal mobilization with leg movement; VASB, visual
analog scale back; VASL, visual analog scale le; y, years.
Table 2. Analysis of Effects of Time and Intervention £Time
Interaction
Variable Effect FPh
p
2
RMDQ Time 220.471 <.001 0.853
Intervention £Time 0.022 .961 0.001
VASL Time 51.670 <.001 0.576
Intervention £Time 0.079 .924 0.002
VASB Time 81.534 <.001 0.682
Intervention £Time 0.799 .445 0.021
SBI Time 80.933 <.001 0.680
Intervention £Time 1.605 .212 0.041
SFI Time 107.780 <.001 0.739
Intervention £Time 2.430 .098 0.060
SF-36 Time 63.199 <.001 0.625
Intervention £Time 2.201 .135 0.055
GROC Time 360.693 <.001 0.905
Intervention £Time 2.339 .107 0.058
GROC, Global Rating of Change Scale; RMDQ, Roland-Morris Disability
Questionnaire for Sciatica; SBI, Sciatica Bothersomeness Index; SF-36,
Short-Form 36 Health Survey; SFI, Sciatica Frequency Index; VASB,
visual analog scale back; VASL, visual analog scale leg.
Journal of Chiropractic Medicine Bello et al
Volume 18, Number 4 Comparative Effect of 2 Manual Therapy Techniques
257
counterirritant. Large, fast-conducting afferents gate trans-
mission in the dorsal horn and collateral fibers in the sub-
stantia gelatinosa or adjacent interneurons, then inhibit the
transmission of pain via the spinothalamic tract. In this
manner, pressure acts as a stimulant to neighboring tissues,
reducing the sensitivity of the original tender point, and
thus pain may resolve.
10
On the other hand, SMWLM has the ability to free nerve
compression through increased vertebral rotation and inter-
vertebral disc space gapping that can lead to nucleus deforma-
tion and simultaneous approximation in the alternate layers of
the annulus, thereby producing favorable therapeutic effects
on the intervertebral disc.
15
Thus, this technique has the abil-
ity to correct positional faults, which takes the pressure off
structures that compress the nerve and may also reduce the
extent of leg pain and disability by centralization.
15
Participants in SMWLM group had more improvement
in all outcomes compared to the PINS group. This is in
agreement with findings from previous studies.
19,20,22
The
current study also used more outcomes that previous stud-
ies did not explore, which strengthened the internal validity
of the study.
Although both techniques were equally effective, there
may be preferences in the choice of treatments in terms of
suitability and ease of administration. It was observed in
this study that participants in the PINS group complained
of increased pain postintervention, which gradually
declined 24 hours after treatment. This indicates that partic-
ipants are not likely to prefer this approach if given the
choice to select a treatment. This is common to all neuro-
muscular and trigger point release techniques.
10,11
In addi-
tion, administration of PINS was more stressful to the
researcher, as it involves localizing a painful spot continu-
ously, which is likely to cause fatigue in the hands of the
administrator. By contrast, the SMWLM involves 2 physio-
therapists (PTs) and is administered in a pain-free position,
which makes it more likely to be preferred by both partici-
pants and therapists, as there was no pain during adminis-
tration and no sign of fatigue from the PTs. However, this
technique is resource intensive, as there must be 2 PTs to
administer it, which put it at disadvantage in settings where
the number of the PTs is very limited.
Limitations and Future Studies
The absence of a true control group makes it difficult to
differentiate between the treatment effect and the natural
course of the disorder, thus threatening the internal validity
of the study. This study used a relatively small sample size
of only 40 patients, which is known to affect the validity
and generalizability of the results. Second, long-term out-
comes were not assessed, and it is not known whether the
differences observed after treatment could be maintained
over longer periods of time.
Future studies should focus on the effect of these techni-
ques on unilateral and bilateral low back pain with radicul-
opathy. Because both techniques produced clinically
meaningful results, future studies should be done to see the
combined effects of both techniques in individuals with
LDHR.
Table 3. Bonferroni Post Hoc Analysis of Time Effect
Variable Time Points (wk) Mean Difference (95% CI) P
RMDQ 0 vs 4 2.250 (0.736, 1.236) <.001
0 vs 8 0.100 (0.737, 0.937) <.001
VASL 0 vs 4 0.250 (0.399, 0.899) <.001
0 vs 8 0.500 (0.734, 0.834) <.001
VASB 0 vs 4 0.400 (1.225, 0.425) <.001
0vs8 0.400 (1.748, 0.152) <.001
SBI 0 vs 4 1.750 (3.038, 0.462) <.001
0vs8 0.350 (1.453, 0.753) <.001
SFI 0 vs 4 0.400 (1.662, 0.862) <.001
0 vs 8 0.300 (0.655, 1.255) <.001
SF-36 0 vs 4 0.850 (2.002, 0.302) <.001
0vs8 2.500 (3.735, 1.265) <.001
GROC 0 vs 4 0.300 (0.872, 0.272) <.001
0vs8 0.550 (0.087, 0.013) .000
GROC, Global Rating of Change Scale; RMDQ, Roland-Morris Disability
Questionnaire for Sciatica; SBI, Sciatica Bothersomeness Index; SF-36,
Short-Form 36 Health Survey; SFI, Sciatica Frequency Index; VASB,
visual analog scale back; VASL, visual analog scale leg.
Table 4. Between-Groups Comparison of Outcomes
Variable FPh
p
2
RMDQ 0.053 .819 0.001
VAS L 1.417 .241 0.036
VASB 0.163 .689 0.004
SBI 3.200 .082 0.078
SFI 1.098 .301 0.028
SF-36 2.731 .107 0.067
GROC 0.061 .806 0.002
GROC, Global Rating of Change Scale; RMDQ, Roland-Morris Disability
Questionnaire for Sciatica; SBI, Sciatica Bothersomeness Index; SF-36,
Short-Form 36 Health Survey; SFI, Sciatica Frequency Index; VASB,
visual analog scale back; VASL, visual analog scale leg.
Bello et al Journal of Chiropractic Medicine
Comparative Effect of 2 Manual Therapy Techniques December 2019
258
TAGGEDH1CONCLUSIONTAGGEDEND
The outcome of this study revealed that there was no
difference in pain and disability between the 2 manual ther-
apy techniques in the management of LDHR.
TAGGEDH1FUNDING SOURCES AND CONFLICTS OF INTERESTTAGGEDEND
No funding sources or conflicts of interest were reported
for this study.
TAGGEDH1CONTRIBUTORSHIP INFORMATIONTAGGEDEND
Concept development (provided idea for the research):
B.B., M.S.D.
Design (planned the methods to generate the results): B.B.,
M.S.D.
Supervision (provided oversight, responsible for organization
and implementation, writing of the manuscript): B.B., B.K.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): B.B.,
M.S.D.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): B.K., M.S.D.
Literature search (performed the literature search): B.B.,
M.S.D.
Writing (responsible for writing a substantive part of the
manuscript): B.B., M.S.D., B.K.
Critical review (revised manuscript for intellectual content,
this does not relate to spelling and grammar checking):
B.B., B.K.
Practical Applications
The study highlights the use of specific proto-
cols to ameliorate problems related to lumbar
radiculopathy.
The study highlights the effectiveness of a
nongadget therapy to manage symptoms of
lumbar radiculopathy.
The study also showed that a combined
nonoperative therapy is likely to give better
improvements in people with lumbar radicul-
opathy than individual protocols, as
highlighted by previous studies.
TAGGEDH1REFERENCESTAGGEDEND
1. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back
pain is and why we need to pay attention. Lancet. 2018;391
(10137):2356-2367.
2. Balagu
e F, Mannion AF, Pellis
e F, Cedraschi C. Non-specific
low back pain. Lancet. 2012;379(9814):482-491.
3. Awad JN, Moskovich R. Lumbar disc herniations: surgical
versus nonsurgical treatment. Clin Orthop Relat Res.
2006;443:183-197.
4. Tubach F, Beaut
e J, Leclerc A. Natural history and prognos-
tic indicators of sciatica. J Clin Epidemiol. 2004;57(2):174-
179.
5. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sut-
cliffe P. Clinical effectiveness of manual therapy for the man-
agement of musculoskeletal and nonmusculoskeletal
conditions: systematic review and update of UK evidence
report. Chiropr Man Therap. 2014;22(1):12.
6. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.
Spinal manipulative therapy for low back pain: a meta-analy-
sis of effectiveness relative to other therapies. Ann Intern
Med. 2003;138(11):871-881.
7. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spi-
nal manipulation and mobilization for low back pain and
neck pain: a systematic review and best evidence synthesis.
Spine J. 2004;4(3):335-356.
8. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effec-
tiveness of manual therapies: the UK evidence report. Chi-
ropr Osteopat. 2010;18:3.
9. Dan-Azumi MS, Bello B, Rufai SA, Abdurrahman MA. Sur-
gery versus conservative management for lumbar disc hernia-
tion with radiculopathy: a systematic review and meta-
analysis. J Health Sci. 2018;8(1):42-53.
10. Dowling DJ. Progressive inhibition of neuromuscular struc-
tures (PINS) technique. J Am Osteopath Assoc. 2000;100(5).
285-286,289-298.
11. Chaitow L, DeLany J, Dowling DJ, Evans H. Modern Neuro-
muscular Techniques. 3rd ed. Edinburgh, UK: Churchill Liv-
ingstone Elsevier; 2011.
12. Williamson JL. Progressive inhibition of neuromusculoskele-
tal structures (PINS) techniques. Available at:https://prezi.
com/v9fdnnasu9gp/progressive-inhibition-of-neuromusculos
keletal-structures-p/. Accessed September 19, 2018.
13. Dowling DJ. Progressive inhibition of neuromuscular struc-
tures technique. In: Ward RC, ed. Foundations for Osteo-
pathic Medicine. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2003:1026-1033.
14. DiGiovanna EL, Schiowitz S, Dowling DJ. An Osteopathic
Approach to Diagnosis and Treatment. 3rd ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2005.
15. Mulligan BR. Spinal mobilisations with leg movement (fur-
ther mobilisations with movement). J Man Manip Ther.
1995;3(1):25-27.
16. Mulligan BR. Update on spinal mobilisations with leg move-
ment. J Man Manip Ther. 1997;5(4):184-187.
17. Wilson E. Mobilisation with movement and adverse neural
tension: an exploration of possible links. Manip Physiother.
1995;27(1):40-46.
18. Wilson E. Central facilitation and remote effects: treating
both ends of the system. Man Ther. 1997;2(3):165-168.
19. Yadav S, Arora Nijhawan M, Panda P. Effectiveness of spi-
nal mobilization with leg movement (SMWLM) in patients
with lumbar radiculopathy (L5/S1 nerve root) in lumbar disc
herniation. Int J Physiother Res. 2014;2(5):712-718.
20. Das MSS, Dowle P, Iyengar R. Effect of spinal mobilization
with leg movement as an adjunct to neural mobilization and
conventional therapy in patients with lumbar radiculopathy:
randomized controlled trial. J Med Sci Clin Res. 2018;6
(4):356-364.
21. Faul F, Erdfelder E, Buchner A, Lang A-G. Statistical power
analyses using G*Power 3.1: tests for correlation and regres-
sion analyses. Behav Res Methods. 2009;41(4):1149-1160.
22. Ahmed N, Khan Z, Chawla C. Comparison of Mulligan’s spi-
nal mobilization with limb movement (SMWLM) and neural
Journal of Chiropractic Medicine Bello et al
Volume 18, Number 4 Comparative Effect of 2 Manual Therapy Techniques
259
tissue mobilization for the treatment of lumbar disc hernia-
tion: a randomized clinical trial. J Nov Physiother. 2016;
6(4):304.
23. Portney LG, Watkins MP. The Role of Theory in Clinical
Research. In: Foundations of Clinical Research: Applications
to Practice. 3rd ed. Philadelphia, PA: FA Davis; 2015:
167-170.
24. Sakpal TV. Sample size estimation in clinical trial. Perspect
Clin Res. 2010;1(2):67-69.
25. Peul WC, van Houwelingen HC, van den Hout WB, et al.
Surgery versus prolonged conservative treatment for sciatica.
N Engl J Med. 2007;356(22):2245-2256.
26. Peul WC, van den Hout WB, Brand R, Thomeer RTWM,
Koes BW. Prolonged conservative care versus early surgery
in patients with sciatica caused by lumbar disc herniation:
two year results of a randomised controlled trial. BMJ.
2008;336(7657):1355-1358.
27. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs non-
operative treatment for lumbar disk herniation: the Spine
Patient Outcomes Research Trial (SPORT) observational
cohort. JAMA. 2006;296(20):2451-2459.
28. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus
non-operative treatment for lumbar disc herniation: four-year
results for the Spine Patient Outcomes Research Trial
(SPORT). Spine (Phila Pa 1976). 2008;33(25):2789-2800.
29. Boonstra AM, Schiphorst Preuper HR, Reneman MF, Post-
humus JB, Stewart RE. Reliability and validity of the visual
analogue scale for disability in patients with chronic muscu-
loskeletal pain. Int J Rehabil Res. 2008;31(2):165-169.
30. Mulligan B. Manual Therapy: “NAGS,”“SNAGS,”,
“MWMS”etc, chapter 5. 5th ed. Wellington, New Zealand:
Plane View Services; 2004:76-80.
31. McGill S. Low Back Disorders: Evidence-Based Prevention
and Rehabilitation. 2nd ed. Champaign, IL: Human Kinetics;
2007.
32. Myers TW. Anatomy Trains: Myofascial Meridians for
Manual & Movement Therapists. 3rd ed. Edinburgh, UK:
Churchill Livingstone Elsevier; 2014:92.
Bello et al Journal of Chiropractic Medicine
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