Journal of Back and Musculoskeletal Rehabilitation 23 (2010) 151159 DOI 10.

3233/BMR-2010-0260 IOS Press

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Case Report

Treatment of chronic radiculopathy of the rst sacral nerve root using neuromobilization techniques: A case study
Ghadam Ali Talebia, Mohammad Taghipour-Darzib, Amin Norouzi-Fashkhamic
a b

Department of Physiotherapy, Faculty of Rehabilitation, Tabriz University of Medical Sciences, Tabriz, Iran Department of Physiotherapy, Faculty of Medicine, Babol University of Medical Sciences, Babol, Mazandaran, Iran c Department of Physical Therapy, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract. Background and objectives: The engagement of the rst sacral nerve root is one of the most common etiologies in Sciatic Pain Syndrome (SPS). Different interfering methods are used in the physical therapy of people with SPS including physical modalities, exercise therapy, traction, and joint and neuromobilization, depending on the symptoms and radiculopathy phase. The present case study attempts to describe neuromobilization methods in treating chronic radiculopathy of the rst sacral nerve root, as well as its abnormal neurodynamic responses. The case: The patient was a 36-year-old man with lower back pain during construction work 9 months before, and presenting with complaint of burning pain and tingling in his left Posterior part of the thigh and leg. Active extension, rotation, and lateral exion of the trunk in standing position had a complete range with no pain. SLR and Slump neurodynamic tests revealed that with increasing sensitive elements, there appeared to be abnormal sciatic nerve tension, and complaint due to returning burn and tingling in the posterior part of the thigh and leg. MRI ndings revealed intervertebral disc dehydrations at L3-4, L4-5, and L5-S1 levels, as well as postero-lateral protrusion in L5-S1 intervertebral disc. Following three routine physical therapy sessions, with no improvement, neuromobilization technique was used for 6 sessions. Results: The usual routine physical therapy methods did have any visible impact in solving the patients problems during dailylife activities and physical diagnosis ndings, yet, following neuromobilization technique, the assessment at the beginning of the eleventh session and the patients follow-ups two months later showed that his problems during daily-life activities and in neurodynamic tests were totally solved. Discussion and conclusion: Abnormal neurodynamic responses and consequently symptoms in patients with chronic radiculopathy may be due to a pathomechanic problem and deciency in neural adjustment for movement and tension transfer. Neuromobilization techniques can increasingly useful in treatment of abnormal neural tensions and removing chronic radiculopathy symptoms. Keywords: Chronic radiculopathy of the rst sacral nerve root, posterior thigh pain, posterior leg pain, physical therapy, neuromobilization

1. Introduction
Address for correspondence: Mohammad Taghipour-Darzi (PhD, PT), Assistant Professor, Department of Physiotherapy, Faculty of Medicine, Babol University of Medical Sciences, Babol, Mazandaran, Post cod: 47176-47745, Iran. Tel.: +98 111 3290515; Fax: +98 111 2229936; E-mails: taghipourm@yahoo.com/taghipour@ mubabol.ac.ir.

Different reasons can cause engagement or damage to the lumbo-sacral nerve roots. Spondylosis, intervertebral foramen narrowness due to inter-vertebral disc volume and height reduction, brosis, arachnoiditis, adhesion and the spinal cord post-surgical com-

ISSN 1053-8127/10/$27.50 2010 IOS Press and the authors. All rights reserved

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plications, trauma, inter-vertebral disc hernia, spondylolisthesis, neuropathic diabetes, and infection are all among the main causes of engagement or damage to the nerve roots of the lumbo-sacral plexus [9,11,21,27]. Intervertebral disc hernia is one of the most prevalent causes of radiculopathy [20]. The relationships between intervertebral disc damage with parameters such as intradiscal pressure, excessive shearing forces, aggregated micro-traumas, as well as heavy trauma are well documented [14]. Direct mechanical effects due to pressures on the nerve root can include conductive blockage, axonal ow stoppage, and vascular problems such as hypoxia, and metabolic waste product aggregations [26,30]. The physical deformation of the nerve root increases the permeability of the microvasculature, leading to the formation of edema within the intraneuronal environment [17,23]. Olmarker et al. has demonstrated that pressure on the nerve root may develop short-term changes in the intraneural microcirculation [22]. Pressure damages, causing nerve root changes which may bring about edema formation, will enhance broblasts deposits as well as brosis inside the nerve root and intervertebral foramen. These interneuronal root and dural membrane brotic adhesions disrupt the normal movement and the elasticity potential of the nerve root and dural membrane. In such cases, the nerve root and dura matter are exposed to abnormal tensile stresses which will in turn bring about inammation. These brotic adhesions can cause microtraction damages to the nerve root against the pedicles and vertebral arches. The brosis of the nerve root sheath will also cause micro-aggregated damages and the appearance of formation of a morbid cycle of scarring tissue [8,15]. The painless movement of the limb depends on the normal biomechanics in the intervertebral foramen and elasticity of the nerve root [4]. Radiculopathy diagnosis and etiology are done based on the patients history, clinical examinations (including sense, movement, and reexes evaluations, as well as specic tests), blood tests, assessment of the cerebrospinal uid, electrodiagnosis, functional tests, and imaging ndings. These patients often complain of symptoms such as pain, paresthesia (tingling), or numbness of the segmental distribution of the related nerve root. Moreover, there are more sensory problems compared with sensory-motor signs, or pure involvement of the motor root. In numerous cases, radiculopathies occur mildly or even incompletely; hence less percentage of the motor units are denervated. Moreover, most lower limb muscles are fed by some segments, therefore, in single and mild radiculopathy, the weakness

may not show itself during the assessment of muscular strength with resistance tests [9,21]. There are some specic tests which try to nd out symptoms of radiculopathy through pressure or tensing nerve roots. These maneuvers evaluate the neural potentials for movement and sliding. Any external pathology, including intervertebral disc hernia, or intra-neural pathology, such as edema or brosis can disrupt the normal adaptation of the nerve system to the position or movement of vertebral column and limbs, and hence, bring about signs and symptoms during such maneuvers [2,4,9]. SRL and Slump are among the valuable tests to nd out radiculopathy of the lumbo-sacral roots. The addition of a sensitizing element to these clinical maneuvers, such as adding a dorsiexion of the ankle, may make the subclinical indications possible [4,19]. The S1 nerve root involvement is among the most prevalent sciatic nerve syndrome. Usually, patients with S1 radiculopathy complain of the referral pain in posterior thigh up to posterior calf and in lateral aspect of the foot. Cramp and pain in calf area as well as a feeling of tingling in the leg and electrically natured pain in posterior thigh and buttock are among the prevalent symptoms of S1 radiculopathy. Sensory deciencies and paresthesia usually involve the small toe, the outside area and the sole of the foot. Gastrocnemius and soleus muscles are the most important ones to be evaluated in the S1 nerve root involvements [9]. Researche has shown that the nerves move naturally in proportion with the structures and tissues around [4, 5,29]. The nerve root movement inside the intervertebral foramen, or a peripheral nerve inside a broosseous tunnel are among the nerve movement forms. Still another form of nerve system adaptation to the body movement and position is the sliding of the neural fascicules to the connective tissue inside the nerve [4]. Any pathology limiting the nerve movement and its strain can cause abnormal tension in nerves during some positions and movements of the spinal column or limbs [4,13]. Butler holds that using neuromobilization techniques, one can revive the limited longitudinal nerve movements. These techniques in fact, are movements which try to revive nerve system potentials to tolerate compressive, tensile and friction forces which normally occur in daily life activities [4]. It is believed that with improving the intraneural circulation, axoplasmic current, viscoelasticity of connective tissue, and reducing abnormal impulse-producing sensitivity locations, these techniques can have positive impacts on the symptoms [4,13]. Useful information is lacking in regard to identifying what non surgical and noninvasive treatment approach-

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es are most effective. Depending on the severity, phase, and level of the radioculopathy, different methods are used in the rehabilitation of the lumbo-sacral radioculopathy, including bed-rest, lumbo-sacral corsets, traction, physical modalities, manual therapy (manipulation, mobilization, soft tissue massage, and muscular energy techniques), exercise therapy, neuromobilization techniques [1,6,10,14].

bending while in standing position, stepping in and out of the car, and climbing the stairs had worsened his condition. The patient was, however, unable to describe his condition clearly and exactly. His pain severity, based on VAS Scale (Visual Analogue Scale) was 5 while in maximum pain. A VAS of 10 cm was used with 10 showing the intolerable pain and 0 with no pain sensed. He was asked to choose the maximum pain he experienced in a day. 3.2. Physical examination The active extension, rotation, and lateral trunk exion in standing position had a complete range and without pain. Active trunk exion movement in standing position was with some limitations, and with the maintaining of bending position, the posterior calf pain was initiated. Unilateral and central posterior-anterior pressure on lumbar vertebrae and sacrum, as well as application of deep pressure on the inside and inferior to the point of PSIS1 were painless. Deep palpation on piriformis muscle and thigh proximal and posterior area was sensitive and slightly painfull locally. The length of the piriformis muscle in prone position was assessed with evaluating the internal rotation range of the femur. With a reduction in the range on the left side compared with the right side, stiffness and shortness of the left-side piriformis muscle was diagnosed. In sensory testing, the light touch and Pin prick were normal. Deep tendon reexes of quadriceps and gastronemius muscles were normal. The strength of the ankle dorsi-exor, plantar- exor, and pronator and supinator muscles were all normal on manual muscle testing. SLR routine test, without adding sensitizing parameters, were painless and with complete ranges. Yet, with increasing dorsiexion of the ankle, and femur adduction (sensitizing parameters), and sustaining the position, the patient complained of tingling and burning sensation at the back of the thigh and calf area. In slump test following complete exion of the trunk, and head and neck, and with extension of knee joint, the pain and tingling in the back of the thigh and leg started. The pain aggravated with sustaining the slump position, and increasing the dorsiexion at the ankle; and would subside with extension of head and neck. 3.3. Paraclinical ndings MRI ndings had revealed inter-vertebral disc dehydrations at L3-4, L4-5, and L5-S1 levels, as well as
1 Posterior

2. Objectives The aim of the present article is to introduce a case with abnormal neurodynamic responses following probable repetitive and chronic damages to L5-S1 intervertebral disc; as well as providing a treatment strategy based on neuro-biomechanical principles, and analytical evaluations to eradicate abnormal tension of the nerve system.

3. The case 3.1. History The patient was a 36-year-old man, working as a staff at the Ministry of Energy (Water and Waste Department). He presented with burning pain and tingling in the posterior left thigh and leg at the physical therapy clinic in the Faculty of Rehabilitation in Tabriz, Iran. He reported that 6 months before, he had had low back pain due to a construction work which had subsided after a few days resting. Without paying attention to his own condition and receiving proper treatment, he had continued his construction work. With any kind of returning pain in the buttock and low back area, he had rested for a few days to subside the symptoms. Three months after the onset of the problem, his condition deteriorated, and in just a few days his pain transferred to back of the left thigh and calf area. At this time, his pain had been aggravated with coughing; hence he had been unable to sit due to his burning pain. Before referring to us, and under the prescription of a specialist, he had undergone drug therapy and 10 sessions of physical therapy. The physical therapy had included pain reducing modalities (TENS), ultrasound, Mackenzie exercises (back extension in prone position) and knee to chest exercise. He had improved following a period of resting and the nishing of the physical therapy. However, he had still been complaining of his occasional pain in the same areas as before. Sitting,

Superior of the Iliac Spine.

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intervertebral disc postero-lateral protrusion at the level of L5-S1. It has to be noted that the MRI images had been taken three months before the presentation at our clinic. 3.4. Diagnosis Based on the ndings in subjective and physical examinations, and the MRI ndings, his condition was related to a chronic and mild radioculopathy of the S1 neuronal root. 3.5. Physical Therapy 3.5.1. Step I (13 Sessions): Routine physical Therapy The therapy in the rst three sessions included TENS modalities, hot packs, ultrasound, passive stretching of the piriformis muscle, and the exercise of taking the knees towards the chest in supine position. The used TENS was of a conventional type ( with pulse duration of 50 s, pulse frequency of 100 Hz) , in which case, the intensity was at tingling level, being applied for 25 min along the sciatic nerve at the posterior part of the thigh and leg. Hot packs were located for 25 min on the TENS electrodes .Constant ultrasound for 5 min with a frequency of 1 MHz, and an intensity of 1 w/cm2 was applied on the piriformis area. As soon as the ultrasound had ended, mild passive stretching of the piriformis muscle and taking the knees towards the chest in supine position were performed. Evaluations at the end of the third session did not reveal any visible improvements in daily life activities and in physical examinations. Based on VAS ndings, the pain was still at level 5. 3.5.2. Step 2- (Sessions 410): Neuromobilization Therapy In the next 7 sessions, neuromobilization techniques were used. These techniques were different depending on the evaluations and objectives. In fact, from session four onward, a gradual form of neuromobilization technique was added. Based on the Maitland and Butler principles, the following was applied respectively: 1. Prior to using neuromobilization techniques, we rst worked on the mechanical interface structures, such as intervertebral foramen and piriformis muscle;

2. In the second step, gliding or sliding techniques were used for neuromobilization. These techniques try to facilitate the gliding movements or the general movements between the neural structures and adjacent non-neural tissues; 3. In the next step, tensile loading techniques were used for neuromobilization. Their aims were to revive the nerve tissue physical potentials to tolerate movements which cause nerve elongation. 3.5.3. Treatment in the 4th & 5th sessions: Vertebral moblization + removing piriformis stiffness In the 4th & 5th sessions, with the aim of treating the probable problems of the mechanical structures around the nerve (as a rst goal in this approach), a semi- specic joint mobilization of the L5-S1 vertebral segment was performed along with removing the stiffness and shortness of the piriformis muscle. Vertebral mobilization includes lumbar vertebral rotation mobilization in order to open the related intervertebral foramen, as a mechanical interface. To open the L5-S1 intervertebral foramen on the left side, the patient was lying on his right side in positional traction (combining of lumbar exion, rotation to the left side and lateral exion towards the right side). During vertebral mobilization, hip and knee joints were in bending position, while the ankle joints were in dorsiexion, therefore, the nerve roots of lumbosacral were under the lowest tension. Vertebral mobilization was rst applied at grade II, and then at grade III. The rotational mobilization in any session was applied 3 times and every time for 30 sec. (Fig. 1). Due to the probable impact of stiffness and shortness of the piriformis in developing adverse tension on the sciatic nerve, to remove its stiffness we rst applied the post isometric relaxation technique in prone position, and then passive stretching of the muscle in the same position (Fig. 2). This technique was applied 5 times, every session. At the end of the 5th session, the patient was reassessed. The pain intensity was still at level 5 (based on VAS) during daily life activities. Nevertheless, the patient was more comfortable during the sustained exion at the end of the range in standing position. Pain severity and tingling at the posterior part of the thigh and calf area in SLR position combined with ankle dorsiexion and femur adduction was reduced a bit, yet, no apparent improvement in the Slump test was reported. Any deep pressure on piriformis area and posterior thigh would still be painful.

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Fig. 3. Sliding neuromobilization technique using knee extension oscillatory movement. Fig. 1. Positional traction and positioning for applying rotational mobilization.

3. Lumbar lateral exion oscillatory movement while lying on the right side, and the hip and knee joints were in exion position. The sliding neuromobilization techniques were used 3 times a session, each containing 15 Oscillatory movements. The re-assessments at the end of the 7th session showed that he was relatively comfortable in his daily life activities, so that the pain severity had subsided from 5 to 3 (based on the VAS scale). Moreover, the pain severity at the back of the thigh and leg in SLR position along with ankle dorsiexion and femur adduction had subsided considerably. Tenderness and pain in the piriformis area upon deep pressure exertion and rest had also improved signicantly. But, pain at the back of the thigh and leg was not improved signicantly at complete Slump test.

Fig. 2. Post isometric relaxation technique for piriformis muscle.

3.5.4. Therapy at the 6th & 7th session: Gliding neuromobilization techniques In the 6th and 7th sessions the following neuromobilization techniques were used to improve the general nerve gliding in intervertebral foramen and general sliding of the sciatic nerve proximal portion: 1. Knee extension oscillatory movement in right side lying position, while the hip joint was in a mild exion, and the ankle joint was in dorsiexion (Fig. 3). 2. Hip adduction oscillatory movement while the patient was lying on his right side, and the hip and knee joints were in mild exion.

3.5.5. The therapy at the 8th, 9th & 10th sessions: Tensile loading neuromobilization techniques Aiming to remove the remaining symptoms and reviving the nerve potentials to tolerate the positions and movements which cause nerve elongation, the tensile neuromobilization techniques were used. To do so, rst in SLR position, and then in Slump position, and nally with the advancements, from distal to proximal, the techniques were used. These techniques were performed 3 times each session, each involving 15 repetitions of oscillatory movements. In order to perform neuromobilization techniques in SLR position, the patient was lying on his right side, with some rounded towels were put in his back, and the sciatic nerve had become under tension in other locations. In this posi-

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Fig. 4. Tensile Loading Neuromobilization Technique using oscillatory movements of the Femur Adduction in SLR Position.

tion, the tensile loading neuromobilization techniques were performed using the oscillatory movements of the ankle dorsoiexion, knee extension, and/or femur adduction (Fig. 4). The tensile neuromobilization technique in Slump position was applied using ankle dorsiexion oscillatory movements and knee extension. It has to be noted that the tensile neuromobilization techniques are not meant to stretching, rather, they are oscillatory movements of a joint used under nerve tensions. 3.6. Session 11: Evaluation of the therapy At the beginning of the session, the patient was evaluated, and since the subjective data ndings and those of physical examinations revealed improvement, the therapy was stopped. The pain severity was reduced to 0 (based on VAS scale). The patient had no pain during sustained exion in standing position. SLR movement and Slump test with sensitizing maneuvers were with no symptoms, and deep pressure exertion on piriformis and thigh posteriori proximal areas were painless. Two months post-neuromobilization therapy, the patient was contacted for follow-ups. He reported he had had no pain, and could do all his daily life activities painlessly.

4. Discussion Radioculopathy refers to those subjects with signs and symptoms related to dysfunction of the spinal nerve root(s). Disc herniation and lateral canal stenosis are the most common causes of radioculopathy. Interver-

tebral disc protrusion with chemical and mechanical effects (applying direct pressure), may cause radioculopathy [9,21]. Mechanical pressure on nerve root can block neuronal conduction, stop axonal transport, bring about vascular problems such as ischemia, and aggregate metabolic waste products. Moreover, the change in the physical form of the nerve root can enhance permeability of microvascular structures causing nerve edema. The formed edema can in turn result into broblast leakage and brosis in connective tissues of the nerve root. Murphy reports that the pain comes primarily from inammation and compression, whereas in chronic radiculopathy, pain more often comes as a result of brosis [21]. The painless movement of the extremity depends on the normal biomechanics in the intervertebral foramen and nerve root elasticity [4]. It is expected that through the rest and suitable intervention, the protruded disc was returned back to proper condition, and the nerve root inammation be removed. Yet, anytime this condition occurs, pathophysiological and pathomechanic changes occur in nerve root [9]. Probably, the preliminary outcomes of damages of the nerve root are pathophysiological ones; in other words, physiological changes without any scars or structural changes. In case the proper treatment is not performed for this physiological problem, the outcome will be a pathomechanic problem for nerve roots. Both pathophysiological and pathomechanical problems can affect nerve biomechanics, which can be corrected with neuromobilization techniques. Pressure on the nerves, including nerve roots with harmful mechanical tension on the nerves, can affect the general movement and their tension transfer potentials. The evaluation methods for these nerve system physical potentials are called nerve Tension Tests. Under pathological conditions, mechanical and physiological problems in nerve tissues and their surrounding structures can bring about pathodynamical problems for the nervous system. Bearing in mind that the nerves possess a viscoelastic structure, it seems that they too, like the musculoskeletal system, respond to the mobilization techniques [4,13]. Several studies have pointed the positive impacts of neuromobilization on nerve involvement [1,6,10,12,13,28]. It is said that these therapies, while improving the intraneural circulation, axoplasmic ow, viscoelasticity of the nerve connective tissue, and nally with reducing sensitivity in abnormal impulse generation sites, have a positive impact on the symptoms [4,13]. Dwornik et al. showed that, using neuromobilization treatment for 2 weeks on 108 patients with low back pain and neurogenic pain to the lower extremity, the clinical test re-

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sults (Laseque test and Bragard test) and clinical symptoms improved signicantly [10]. Christensen says: this process gradually releases the nerve from its impingement, perhaps by breaking down perineural adhesions in many cases, there are immediately results with improved, pain-free nerve root sliding and lengthening [7]. Clinical manifestations, and MRI ndings in the case reported here, support the notion of mild and chronic radioculopathy of the S1 root. Based on our patients report on pain recurrence and re-improvement, it seems that intervertebral disc damage had been repeatedly occurred without any normal treatment having occurred. Therefore, based on what can be deduced from the patients subjective report on his unfavorable condition, and from the disease process, as well as from the neurodynamic tests, it seems that the patients present problem is adverse tension due to pathomechanical problem in S1 nerve root. It is worthy of mentioning that there is no standard diagnostic method for nding out the pathomechanics and adverse neural tension in a nerve. The diagnoses are generally based on clinical trials and evaluations of the treatment impacts based on the performed interventions. Considering the fact that interventions and therapies during the rst three sessions had had no positive impacts on our patient, it seems that physical therapy routine including modalities and exercise do not have any effects on chronic and remaining symptoms, as well as on abnormal neurodynamic responses. Therefore, from the 4th session on, neuromobilization techniques, base on Butlers and Maitlands outlooks were used [4, 18]. Based on Maitlands opinion, the most significant element in choosing a technique is the change and improvement it can bring about, as well as analytical assessment of a patients condition to his position and movement. Moreover, when a patients problem is constant and not changeable, and his discomfort is demonstrated at the end of the range with sustaining the extreme position or adding sensitizing elements, the mobilization parameters can be so chosen that they can develop some of patients symptoms in a controlled manner. It should be noted that the neuromobilization as one of the manual therapy treatments is relatively new and still a lot of issues have risen about it that are not clear truly [24,25]. As a general rule and providing safety, However, it is better that prior to using specic neuromobilization techniques, we spend our time on improving the probable mechanical interfaces, such as joints and muscles [4,18]. The intervertebral foramen, and piriformis muscle as the two structures around the nerve were considered. So, rotational ver-

tebral mobilization under positional traction of L5-S1, and the post isometric relaxation technique and passive stretching of the piriformis were used in order to open the intervertebral foramen and removing the piriformis stiffness. The patients response evaluations to SLR and Slump neurodynamic tests at the end of the 5th session showed that the adverse nerve tension had been still available with no visible changes. This nding can show that most likely the abnormal neurodynamic nerve response in this patient was due to nerve pathomechanics. Therefore, to solve the problem, from the 6th session on, specic neuromobilization techniques were used. These techniques are generally categorized as gliding and tensile. The gliding techniques try to produce sliding motion between the nerve structures and the non-neural adjacent tissues. Generally, these techniques are used when there is a pathophysiological problem (high irritable condition). In tensile techniques, the goal is to revive the nerve tissue physical potentials to tolerate movements causing nerve elongation. It has to be noted that these techniques are not supposed to sustain the stretching manners. They are performed as oscillatory movements. When the irritability of symptoms was minimal, the tensile loading techniques are used [4]. Though in our patient it seemed that the abnormal nerve tension had been related to its pathomechanical problem, we decided to rst use gliding neuromobilization techniques which are safer. There is no concrete way to utilize the neuromobilization techniques, and each patient is different with the others clinically. Therefore, treatment strategies for our patient was rst to use gliding neuromobilization techniques, and then their tensile forms; in both cases, the advancement was from distal element towards proximal. So, during the 6th and 7th sessions the gliding neuromobilization techniques were used with the aim of improving general motion or slide of the nerve in intervertebral foramen, and the gliding of the sciatic nerve proximal portion. The advancement in the technique use was from the farther location (the knee) towards the involvement area (the spinal column). Therapies using gliding techniques are performed in a painless range and without any tensions. In these techniques, while the nerve is moved from one location (with oscillatory movement), it receives no tension in the other areas. Due to this, when the technique using the knee extension oscillatory motion was being performed, the hip joint had a little exion, while the ankle was in neutral position.

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In the same way, when gliding techniques using femur oscillatory adduction, or lumbar side exion was at hand, hip and knee joints were under relative exions. The relative improvement in our patient during daily life activities, pain and tingling reduction in the back of thigh and calf area in SLR tests combined with ankle dorsiexion and femur adduction at the end of the 7th session revealed that treatment path was proper. Yet, as there had been no visible change in pain and tingling levels in the back of the thigh and calf area during Slump complete test, we decided to use tensile neuromobilization techniques. In order to follow safety rules, at rst the targeted techniques were performed using SLR and then Slump with improvements from farther joints towards locations nearer to the problem site. Elvey believes that during nerve mobilization, one should not advance towards the end of the range; we should spend less time compared with joint mobilization. When a patients symptoms can not be stimulated, it is suggested that the engaged nerve get under tension up to the point of tissue barrier directly, or rst from a farther site and then in locations nearer to involvement site. May be mobility revival, or tension toleration potential in a farther site help reduce nerve tension in all its length, resulting into a reduction in the symptoms. The applied tensions may be increased in case of improvement, yet they should never aggravate a patients symptoms [13]. Based on butler opinion, the techniques that cause a painful response are invariably undesired. The patient condition, the pain mechanism in operation and the patient understanding of the pain may be such that a (mildly) painful response during, or for a short duration after activity or techniques, may not be problematic and may be the most optimal path to recovery [3]. For performing tensile techniques, rst the other joints were gently under sciatic nerve tension. In case the thigh and leg symptoms recurred, the range of that joint would be reduced, so that the symptoms were removed. Finally, nerve mobilization with application of oscillatory motion in the specic joint would be applied just up to the feeling of tension (and not the patients symptom production). If there were any symptoms, the range of the oscillatory motion would be reduced until the tension was sensed. The aims of the tensile neuromobilization techniques are to remove nerve pathomechanical problems, so that the nerve adaptation mechanism was revived. The total eradication of our patients symptoms during daily life activities and also in neurodynamic tests, at the beginning of the 11th session,

and the follow ups till 2 months later, showed the success in using neuromobilization techniques in treating abnormal tension and chronic S1 nerve root symptoms.

5. Limitations Numerous parameters, including the differences in patients demographic information, the severity and type of damage in intervertebral disc, irritability severity, and the presence of other ground parameters, etc., can limit generalizing the results of our study to all patients with lumbo-sacral nerve root radioculopathy.

6. Conclusion This case study described the abnormal neurodynamic responses, and using neuromobilization technique in treating S1 nerve root chronic radioculopathy. It seems that in patients with S1 radioculopathy, with their symptoms have low irritability and occurs occasionally in some activities, the intraneural pathomechanical problems justify the abnormal neurodynamic responses, and therefore, the patients remaining symptoms. Using a neuromobilization treatment strategy, with rst paying attention to the treatment of nerve surrounding structures, and then with gliding neuromobilization techniques, and nally with tensile neuromobilization techniques with advancement from farther areas (ankle or knee) towards the joints closer to the involvement sites (hip and spinal column) can bring about positive outcomes.

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