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Journal of Bodywork & Movement Therapies (2015) xx, 1e6

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COMPARATIVE CLINICAL STUDY

Effect of Butler’s neural tissue mobilization

and Mulligan’s bent leg raise on pain and
straight leg raise in patients of low back ache
Neha Tambekar, MPT*, Shaila Sabnis, BPT,
Apoorva Phadke, MPT, Nilima Bedekar, PhD

Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, 12-Thube Park,

Shivajinagar, Pune 411 005, Maharashtra, India

Received 20 March 2015; received in revised form 26 July 2015; accepted 4 August 2015

KEYWORDS Summary Low back ache (LBA) is a common musculoskeletal disorder sometimes associated
Low back pain; with a positive limited Straight leg raise (SLR) test. Mulligan’s bent leg raise (BLR) and Butler’s
Mulligan bent leg neural tissue mobilization (NTM) are commonly used techniques for the treatment of low back
raise technique; ache where SLR is limited. The aim of this study was to evaluate the effect of both the tech-
Butler’s neural tissue niques on pain and limited SLR in patients with LBA. Thirty one patients with LBA with radicu-
mobilization; lopathy were randomly allocated into 2 groups; BLR [n Z 16] NTM [n Z 15]. The outcome
SLR measures i.e. visual analogue scale (VAS) for pain and universal goniometer for measuring
SLR range of motion (SROM) were assessed at the baseline, post intervention and after 24 h
(follow up). Within group analysis using paired t-test revealed a significant difference between
pre-treatment and post-treatment VAS and SROM score(p < 0.05). However no difference was
seen between pre-treatment and follow up (p > 0.05). The study showed that both techniques
produce immediate improvement in pain and SLR range but this effect was not maintained dur-
ing the follow up period.
ª 2015 Elsevier Ltd. All rights reserved.

Introduction identify any singular cause or even a single major factor

(Deyo, 2002).
Low back pain (LBP) is a complex condition, influenced by a Low back pain is a common musculoskeletal disorder
number of factors and often challenging when trying to with a lifetime prevalence reported to be as high as 84% by
World Health Organization (WHO) (Wilson et al., 2003).

* Corresponding author.
E-mail address: guptaneha2008@gmail.com (N. Tambekar).

http://dx.doi.org/10.1016/j.jbmt.2015.08.003
1360-8592/ª 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Tambekar, N., et al., Effect of Butler’s neural tissue mobilization and Mulligan’s bent leg raise on pain
and straight leg raise in patients of low back ache, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/
j.jbmt.2015.08.003
 + MODEL
2 N. Tambekar et al.
There are various causes of low back pain including:
congenital, traumatic, inflammatory, degenerative,
neoplastic, metabolic, pain referred from viscera, miscel-
laneous (Maheshwari, 2005). The diagnosis can be
confirmed following clinical examination and assessment.
In the clinical examination, the Straight Leg Raise (SLR) test
is of great value in assessing normality of roots of sciatic
nerve (Breig and Troup, 1979; Urban, 1981) and tightness of
hamstring muscles (Tanigawa, 1972; Medeiros et al., 1977;
Erickson and Coney, 1979; Halkovich et al., 1981). It is
used to test the movement and mechanical sensitivity of
lumbo-sacral neural structures and their distal extensions
which consist of the lumbo-sacral trunk and plexus in the
pelvis, sciatic and tibial nerves and their distal extensions
in the leg and foot (Shacklock, 2005a, b).
Various therapeutic techniques are used to treat LBA
amongst which Butler’s neural mobilization and Mulligan’s
Bent Leg Raise (BLR) are preferred by many. Butler’s neural
mobilization is an a neural mobilization technique which is
used in relation with pathologies of the nervous system. It
has been reported to be an effective intervention for
certain conditions including neck pain, carpal tunnel syn-
drome and low back pain (Nar, 2014; Basson et al., 2014;
Adel, 2011; Vijay et al., 2007; Manchanda, 2013).
Mulligan’s Mobilization With Movement (MWM) BLR can
be used in treatment of low back pain and/or painful
straight leg raise. It can be given with leg pain above the
knee.
Many studies have evaluated the effects of Mulligan’s
BLR technique in patients with low back pain (Hall, 2006;
Pawar and Metgud, 2010; Phansopkar and Kage, 2014; Kage
and Ratnam, 2014). However, only few Randomized
Controlled trials (RCTs) have specifically compared Mulli-
gan’s mobilization and Butler’s neural mobilization ap-
proaches individually for low back pain (Patel, 2014; Gupta
and Shenoy, 2013). Thus more research is required in
comparing the effectiveness of both these techniques in
patients with LBP.
Methods
Study design
Randomized controlled trial.
Participants
Patients with complaints of low back pain who were
referred to the physiotherapy OPDs were screened and
recruited in the study depending upon the inclusion
exclusion criteria.
Inclusion Criteria was: Patients with low back pain
radiating to lower limb (above knee), Unilateral SLR posi-
tive between 35 and 70 , onset of pain within 1 month.
Exclusion Criteria: Bilateral SLR positive, any malignant
condition, sensory motor deficits, articular pathology or
fractures of lower extremities, patient not under the in-
fluence of any analgesics such as NSAIDS/Opiates (with
permission from physicians).
After approval from the institutional ethics committee,
written consent was taken from each subject. 31 subjects
Please cite this article in press as: Tambekar, N., et al., Effect of Butler’s neural tissue mobilization and Mulligan’s bent leg raise on pain
and straight leg raise in patients of low back ache, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/
j.jbmt.2015.08.003
were selected and randomly allocated to one of the two
groups, where group A was given Mulligan bent leg raise
technique (n Z 16) and group B was given Butler’s neural
tissue mobilization technique (n Z 15).
All the subjects were assessed for intensity of pain on
VAS and SLR ranges by using universal goniometer at the
base line. Inter tester and intra tester reliability of gonio-
metric measurement for SLR was found to be 0.88 (Hsieh,
1983).
As the study was single blinded, the primary therapist
included the patient and delivered therapy while a sec-
ondary therapist assessed the outcome measures (pain and
ROM). Measurements for SLR range of motion and pain were
repeated immediately post treatment and after 24 h
(follow up).
SLR was considered positive where patients complained
of reproduction of the symptoms in the back.
Mulligan’s BLR (Mulligan, 2004) (See Fig. 1).
The therapist stood at limited SLR side of the patient.
Patient’s flexed knee was kept over therapist’s shoulder.
Therapist instructed patient to push her away with pa-
tient’s leg and then relax. At this point therapist extended
the patient’s bent knee up as far as possible in the direction
of patient’s ipsilateral shoulder provided there was no pain.
If it was painful the direction was altered by taking the leg
more medially or laterally. Sustained stretch for several
seconds was given and leg lowered down to the bed. This
technique was repeated 3 times.
Butler’s Neural Mobilization (Butler, 1991) (See Fig. 2).
Patient was in supine position. Therapist stood facing
the patient and placed one hand under the ankle to avoid
pressure on peripheral nerves and the other above the
patella. The knee was extended and hip was flexed in one
plane and the leg was taken to the point where symptoms
were reproduced.
Slow oscillations or sustained stretch was given by the
therapist for 10 s depending on the grade of mobilization
after which the leg was returned to a non-painful position.
This procedure was repeated three times.
Data analysis
Data was analysed using the Statistical Package for the
Social Sciences (SPSS) version 10. In within group analysis
Figure 1 Mulligan bent leg raise technique.
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Effect of Butler’s neural tissue mobilization and Mulligan’s bent leg raise on pain and straight leg raise 3

Table 6 and Table 7 show that there was no significant

difference seen between two groups in terms on VAS and
SLR range.

Discussion

The present study evaluated the effect of Butler neural

tissue mobilization and Mulligan BLR technique on pain and
SLR in patients with low back pain.
Overall 31 patients were recruited with unilateral SLR
positive with mean age of 34.06  8.28 in Mulligan group
and 32.26  4.81 in Butler group (Table 1).
As seen in Table 2, there was a significant difference
between pre-treatment and post treatment values of VAS in
BLR group (p < 0.05), but no significant difference between
the pre-treatment and follow up (p Z 0.38).
Figure 2 Butler’s neural tissue mobilization technique. This perceptible difference immediately after treatment
may be due to Mulligan’s premise that with repeated
symptom free movement, it bombards the agitated CNS
for SLR range of motion and pain was done using repeated
from the signals of joint and attendant structure; ulti-
measures ANOVA. While between group analysis for butler
mately to sedate the CNS, to re-establish dynamic neutral
and mulligan was done using unpaired t-test at level of
(Chaitow, 2002).
significance set at 0.05.
With tactile and compressive stimuli of mobilization with
movements (MWMs), it may influence spinal cord neurons,
Results inhibit nociperception and the motor neuron pool and thus
provide a way to retrain the spinal cord circuitry by
The demographic details are shown in Table 1. allowing the patient to experience the repetitive pain free
Significant difference between pre and post treatment motions (Abbott, 2001). A different surmise also reported
in ROM in BLR group (p < 0.05) while no significant differ- hypoalgesic and sympathoexcitatory effects of peripheral
ence was seen between pretreatment and follow up MWM (Paungmali et al., 2003).
(p Z 0.28) which is shown in Table 2. Significant difference in SLR range post treatment in
Significant difference between pretreatment and post Mulligan BLR group could be attributed to decrease in pain
treatment values of SLR ranges in Butler NTM group (Table 3). It could also be because of post isometric
(p < 0.05), while no significant difference was seen be- relaxation of hamstrings.
tween the pretreatment and follow up (p Z 0.08) as shown The term post isometric relaxation refers to the effect
in Table 3. of the subsequent reduction in tone experienced by a
Table 4 shows that there is a significant difference be- muscle, or group of muscles, after brief periods during
tween pretreatment and post treatment values of VAS in which an isometric contraction has been performed
BLR group (p < 0.05), but no significant difference between (Chaitow, 2001).
the pretreatment and follow up (p Z 0.38). Improvement in VAS and range of SLR is in accordance
From Table 5 it can be seen that there was a significant with the study done by Pawar A, Metgud S, wherein similar
difference between pretreatment and post treatment results using Mulligan BLR for pain and ROM were seen in
values of VAS in Butler NTM group (p < 0.05), but no sig- subjects with low back ache with radiculopathy (Pawar and
nificant difference between the pretreatment and follow Metgud, 2010).
up (p Z 0.18). This study also supports the results of a study done by
Phansopkar P, in which BLR lead to increase in the ham-
strings flexibility in subjects with acute nonspecific low
Table 1 Comparison of demographic data at baseline for back pain (Phansopkar and Kage, 2014).
mulligan and butler groups. As seen in Table 4, there was an immediate reduction of
pain on VAS in Butler neural tissue mobilization group which
Characteristic Mulligan Butler p value could be because of decrease in intraneural pressure which
Number of patients 16 15 accompanies neural mobilization. Thus symptoms were
Females Z 8 Females Z 7 seen to be reduced (Tal-Akabi and Rushton, 2000; Cowell
Males Z 8 Males Z 8 and Phillips, 2002).
Age 34.06  8.28 32.26  4.81 0.47 Also another reason can be that when neural mobiliza-
(Mean in years) tion is used for treatment of adverse neurodynamics.
Baseline VAS 3.69  1.25 4.00  0.75 0.41 Neurodynamics hypothesized the reduction in pain and in-
(Mean in cm) crease in ROM to facilitation of nerve gliding, reduction of
Baseline SLR 50.94  7.35 45.33  5.49 0.02 nerve adherence, dispersion of noxious fluids, increased
(Mean in degrees) neural vascularity and improvement of axoplasmic
flow (Shacklock, 1997; Butler, 2000; Shacklock, 1995;

Please cite this article in press as: Tambekar, N., et al., Effect of Butler’s neural tissue mobilization and Mulligan’s bent leg raise on pain
and straight leg raise in patients of low back ache, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/
j.jbmt.2015.08.003
 + MODEL
4 N. Tambekar et al.

Table 2 VAS score at pre-treatment, post-treatment and follow up in Mulligan BLR group.
Parameter Pre Post FyU Pre post p CI Pre FyU p CI
and group mean change mean change
VAS for Mulligan 3.68  1.25 2.37  1.14 3.43  1.20 1.31 0.0 0.84 to 1.77 0.25 0.38 0.35 to 0.85

Table 3 SLR score at pre-treatment, post-treatment and follow up in Mulligan BLR group.
Parameter Pre Post FyU Pre post p CI Pre FyU p CI
and group mean change mean change
SLR for Mulligan 50.93  7.35 66.25  10.24 52.81  9.65 15.31 0.0 19.01 1.87 0.28 5.49 to 1.74
to-11.61

Table 4 VAS score at pre-treatment, post-treatment and follow up in Butler NTM group.
Parameter Pre Post FyU Pre post p CI Pre FyU p CI
and group mean change mean change
VAS for Butler 4.00  0.75 2.13  0.63 3.80  0.86 1.86 0.0 1.45 to 2.27 0.20 0.18 0.11 to 0.51

Table 5 SLR score at pre-treatment, post-treatment and follow up in Butler NTM group.
Parameter Pre Post FyU Pre post p CI Pre FyU p CI
and group mean change mean change
SLR for Butler 45.33  5.49 57.66  6.51 47.33  7.28 12.33 0.0 14.64 to 10.02 0.2 0.08 4.29 to 0.29

Table 6 Comparison between VAS and SLR scores at Pre- Table 5 shows that there was a significant increase in SLR
Post treatment. range after treatment in Butler NTM group. This immediate
increase in the ROM of SLR can also be attributed to the
Parameter Mulligan Butler Mean p value
decrease in the pain.
difference
Improvement of the range might be due to mobilization
SLR 15.31  6.94 13  3.68 2.31 0.26 of the painful, sensitized nerve tissues similar to the slider
VAS 1.31  0.87 1.87  0.74 0.55 0.06 effects described by Butler, 1991 and Elvey and Hall, 1997
(Coppieters et al., 2004). Improvement seen in VAS and SLR
is supported by a study done by Adel, S. M. in 2011on effi-
Shacklock, 2005a, b; Butler et al., 1994; Gifford, 1998; cacy of neural mobilization low back pain dysfunction,
Kitteringham, 1996). concluded that patients treated with neural mobilization
Reduction in pain can also be attributed to sliding effect showed improvement in VAS scores and Straight Leg Test
wherein there is a combination of movements in which scores.
elongation of the nerve bed at one joint is simultaneously The effect of neural tissue mobilization in this study was
counterbalanced by reduction in the length of the nerve also supported by study done by Vijay. S et al. which
bed at an adjacent joint (Shacklock, 2005a, b; Scrimshaw concluded that neural mobilization along with conventional
and Maher, 2001). treatment was found to be more effective in relieving low
back pain as well as improving the range of SLR than con-
Table 7 Comparison between VAS and SLR score at Pre- ventional treatment alone (Vijay et al., 2011).
treatment and follow up. The follow up effect after 24 h was not maintained as
the intervention was given only once with no home
Parameter Mulligan Butler Mean p value program.
difference As seen in Tables 6 and 7, there was no significant dif-
SLR 3.75  5.91 7.33  7.03 3.58 0.13 ference seen in pain on VAS and range of SLR post treat-
VAS 0.63  0.95 0.2  0.56 0.42 0.14 ment as well as follow up between both groups. Results of
this study were similar to the study done by Gupta N et al.,

Please cite this article in press as: Tambekar, N., et al., Effect of Butler’s neural tissue mobilization and Mulligan’s bent leg raise on pain
and straight leg raise in patients of low back ache, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/
j.jbmt.2015.08.003
 + MODEL
Effect of Butler’s neural tissue mobilization and Mulligan’s bent leg raise on pain and straight leg raise
wherein both BLR and BNM resulted in statistically signifi-
cant improvement in both VAS scores and SLR ROM (Gupta
and Shenoy, 2013).
However, a further research using these techniques with
increased frequency could be done on larger sample size for
follow up effects.
Conclusion
Mulligan and Butler techniques both showed that SLR and
pain were improved immediately post intervention but this
effect was not maintained during the follow up period. Also
both the techniques were equally effective.
Conflict of interest
None.
Funding
None.
Acknowledgements
Authors acknowledge the immense help received from the
scholars whose articles were cited and included in refer-
ences of this manuscript. The authors are also grateful to
authors/editors/publishers of all those articles, journals
and books from where the literature for this article has
been reviewed and discussed. We would also like to thank
all our participants and for their valuable time and
participation.
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Please cite this article in press as: Tambekar, N., et al., Effect of Butler’s neural tissue mobilization and Mulligan’s bent leg raise on pain
and straight leg raise in patients of low back ache, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/
j.jbmt.2015.08.003