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L/O/G/O
LITERATURE REVIEW: EFEKTIVITAS SHORTWAVE
DIATHERMY DAN NEURODYNAMIC MOBILIZATION PADA
PENDERITA RADIKULOPATI LUMBOSAKRAL
Program Studi Magister Fisiologi Olahraga Konsentrasi Fisioterapi Fakultas Kedokteran Universitas Udayana
MADE HENDRA SATRIA NUGRAHA
SUSY PURNAWATI
MOH. IRFAN
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Latar Belakang
Radikulopati
Lumbosakral
Sindrom radikular adalah salah satu jenis penyakit yang
termasuk dalam kelainan sistem saraf perifer yang terjadi pada
radiks spinalis yang menimbulkan gangguan berupa defisit
sensorik, defisit motorik, defisit reflex.
Sindrom radikular pada umumnya terjadi pada segmen servikal
dan lumbal dari medulla spinalis. Sindrom radikular pada
segmen lumbal terjadi pada 3-5% populasi di dunia.
Baehr M., Frotscher M. 2010. Diagnosis Topik Neurologi DUUS : anatomi, fisiologi, tanda, gejala Ed. 4. Jakarta: EGC
Malanga A. Lumbosacral Radiculopathy (Online; diakses pada tanggal 7 Maret 2018). http://emedicine.medscape.com/
www.themegallery.com
• Sebagian besar Hernia Nucleus Pulposus (HNP) terjadi pada L4-L5 dan
L5-S1 karena:
1. Daerah lumbal, khususnya daerah L5-S1 mempunyai tugas yang berat, yaitu
menyangga berat badan. Diperkirakan 75% berat badan disangga oleh sendi L5-
S1.
2. Mobilitas daerah lumbal terutama untuk gerak fleksi dan ekstensi sangat tinggi.
Diperkirakan hampir 57% aktivitas fleksi dan ekstensi tubuh dilakukan pada sendi
L5-S1.
3. Daerah lumbal terutama L5-S1 merupakan daerah rawan karena ligamentum
longitudinal posterior hanya separuh menutupi permukaan posterior diskus. Arah
herniasi yang paling sering adalah postero lateral.
Lipert, LS. 2011. 4th Edition Clinical Kinesiology and Anatomy. USA: FA Davis Company
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• Radikulopati lumbosakral dapat bermanifestasi sebagai suatu sindrom
yang terdiri dari kumpulan gejala, seperti:
1. nyeri punggung bawah yang dapat meluas ke regio gluteal, paha
bagian posterior, regio cruris sampai ke regio pedis,
2. kekakuan akibat refleks spasme dari otot-otot paravertebral
sehingga mencegah pasien berdiri tegak dengan sempurna,
3. serta dapat timbul gejala berupa parestesia, kelemahan otot-otot
sekitar punggung dan kaki, atau kelemahan refleks tendo Achilles
yang mengarah kepada suatu disabilitas punggung.
Nasikhatussoraya, N. 2016. Hubungan Intensitas Nyeri dan Disabilitas Aktivitas Sehari-hari dengan
Kualitas Hidup. Semarang: Fakultas Kedokteran Universitas Diponegoro
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ELECTROPHYSICAL AGENTS
EXERCISE THERAPY
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Shortwave Diathermy
Pulsed Shortwave Diathermy
1. Pulsed Short Wave Diathermy dengan
average power 48 W dapat meningkatkan
suhu jaringan sampai kedalaman 3 cm
dengan peningkatan mencapai 4,6°C.
2. Penambahan shortwave diathermy pada
pelatihan yang diberikan pada subjek
dengan keluhan chronic back pain
mampu menurunkan nyeri setelah
dievaluasi dengan menggunakan Visual
Analogue Scale serta McGill Pain
Questionnaire.Draper, DO., Hawkes, AR., Johnson, AW., Diede, MT., dan Rigby, JH. 2013. Muscle Heating with
Megapulse II Shortwave Diathermy and Rebound Diathermy. J Ath Train 48($): p
477 – 482
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Prosedur Pelaksanaan
ShortwaveDiathermy
Intensitas mulai dari 48
W/cm2, arus pulsed, durasi
15 menit
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Penulis Sampel Intervensi Klp Kontrol Intervensi Klp
Perlakuan
Hasil
Khan, S.,
Shamsi, S.,
dan
Abdelkader
, S., 2013
n = 40
pasien
dengan
Chronic
Back Pain
n = 20 pasien
Terapi: Exercise therapy
(5 menit pemanasan
dengan aerobic steps
dilanjutkan dengan
stretching pada otot
punggung, hip, dan kaki
masing-masing selama
60 detik, 2 repetisi, 3
kali seminggu selama 6
minggu)
n = 20 pasien
Terapi: Exercise
therapy (dosis yang
sama dengan
kelompok kontrol) +
SWD (pad electrodes,
tebal handuk 1-2 inchi
diantara pad dan kulit,
durasi 15 menit, 3 kali
seminggu selama 6
minggu)
1. Kelompok kontrol :
PRI (p=0,000),
PPI = (p=0,000),
dan VAS =
(p=0,000)
2. Kelompok
perlakuan: PRI
(p=0,000), PPI
(p=0,000), dan
VAS (p=0,000)
3. Kelompok
perlakuan lebih
baik daripada
kelompok kontrol
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Ahmed, MS.,
Shakoor, MA.,
Khan, AK., 2009
n = 97 pasien
dengan Chronic
Low Back Pain
n = 47 pasien
Terapi: Obat NSAID (meloxicam
15 mg per hari), exercise, dan
intruksi untuk melakukan
Activity Daily Living (3 kali
seminggu selama 6 minggu)
n = 50 pasien
Terapi: Obat NSAID
(meloxicam 15 mg per hari),
exercise, dan intruksi untuk
melakukan Activity Daily Living
(3 kali seminggu selama 6
minggu) + SWD (durasi 15
menit, 3 kali seminggu selama
6 minggu)
1. Alat ukur yang
digunakan dalam
penelitian merupakan
gabungan antara
Lattinen’s test score
(intensitas nyeri,
frekuensi nyeri, intake
analgesic, disabilitas,
dan gangguan tidur +
tenderness score + skor
VAS. Hasil penelitian
menunjukkan bahwa
pada kelompok
perlakuan terlihat hasil
yang lebih signifikan
daripada kelompok
kontrol. Hasil yang
signifikan (p<0,05)
terlihat dari evaluasi
minggu ke-2 sampai
minggu ke-6 (total
evaluasi selama 6
minggu, 1 kali disetiap
minggunya).
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Shortwave Diathermy
Mekanisme Kerja Shortwave Diathermy
Michlovits, SL., Bellew, JW., dan Nolan, TP. 2012. Modalities for Therapeutic Intervention: Fifth Edition. Philadelphia: FA Davis Company
(1) Reaksi Metabolik
(2) Efek Vaskular
(3) Efek Neuromuskular
(4) Efek pada connective tissue
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• SWD yang diaplikasikan pada tubuh pasien, akan mengaktivasi termoreseptor pada kulit.
• Sistem sensory afferents ini akan menghantarkan informasi ke spinal cord dan sebagian lainnya
akan diteruskan ke percabangan pembuluh darah di kulit, serta pelepasan mediator vasoaktif.
• Hasilnya berupa vasodilatasi akibat refleks akson
Efek Vaskular
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• Panas juga akan memproduksi reaksi inflamasi yang ringan. Mediator kimia inflamasi seperti
histamin dan prostaglandin akan dilepaskan dan menyebabkan pembuluh darah bervasodilatasi.
Efek Vaskular
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• Refleks lokal pada spinal cord akan dilepaskan selama aktivasi dari serabut aferen di kulit. Refleks
ini terjadi akibat penurunan aktivitas saraf adrenergik pada postganglionic sympathetic ke
pembuluh darah pada otot polos.
Efek Vaskular
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• Therapeutic heat digunakan untuk menghasilkan efek analgesik dan membantu dalam meresolusi
nyeri serta muscle-guarding spasms.
Efek Neuromuskular
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The three part system
-Mechanical Interface
• Called as “Nerve Bed”.
• Anything resides next to the nervous system
-Tendon -Ligaments
-Muscle -Fascia
-Bone -Blood vessels
-IV Disc
• During ADL, the mechanical interface moves as the nerve
moves.
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The three part system
-Neural Structure
• Structure that constitute the nervous system
• Included brain, cranial nerves & spinal cord, nerve roots &
peripheral nerve.
• Connective tissue of the CNS Pia, arachnoid, dura
maters)
• Connective tissue of the PNS Epineurium, perineurium,
endoneurium.
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The three part system
-Neural Structure
Physiological Function Mechanical Function
• Tension
• Sliding
• Compression
• Intaneural Bloodflow
• Impulse Conduction
• Axonal Transport
• Imnflammation
• Mechanosentivity
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The three part system
-Innervated Tissue
• Provide the basis for some causal mechanism
• Provide a specific reference to the innervated tissue
• Treatment of innervated tissue is the best way to treat
the nerve!
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Mechanical Function of the Nervous System
• Tension
• Sliding
• Compression
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Tension
• The nerve are lengthened by elongation of the innervated
tissue.
• Stronger part of the nerve (e.g sciatic nerve) can
withstand over 50kg of tension)
• “Perineurium” The primary guardian of tension (18-
22% strain before failure)
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Tension
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Sliding
• Movement of neural structures relatives to their adjacent
tissues.
• Longitudinal & Transveral
• Serves to dissipate tension
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Sliding
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Compression• Neural structures can distort in many ways, including the
changing of shape according to the pressure exerted on them.
• E.g of compression :
– Wrist flexion pressing on the median nerve at the wrist in Phalen's sign
– Elbow flexion applying pressure on the ulnar nerve at the elbow.
• In these cases, bone and tendon combined with muscle and fascia are what press on the nerve
• “Epineurium” protects from excessive compression
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Compression
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How Nerves Move?
• Movement of the Mechanical Interface
– Closing Mechanism
– Opening Mechanism
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Closing Mechanism
• Many maneuvers are considerably as closing
maneuver such as Phalen’s Test, Extension +
ipsilateral lateral flexion of the spine
• Over contraction & stretch of the muscle can
increase the pressure of the nerve!
“Closing Mechanism are those that produce increased pressure on a neural
structure by way of reducing the space around it”
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Opening Mechanism
• In UE, opening mechanism such as scapular elevation
for TOS, releasing Piriformis muscle to reduce sciatic
nerve pressure.
• In the spine, flexion & cont.lat.flexion increase the IV
foramen.
“Opening Mechanism are those that reduce pressure on a neural structure
by increased space around neural structure with a particular maneuver”
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Links Between Mechanics & Physiology
Neurodynamic
Mechanics
Pathomechanics
Physiology
Pathophysiology
Pathodynamics
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Mechanical
Interface
Closers Tech
Openers Tech
Neural Structure
Sliders Tech
Tensioners Tech
Progression
Position away, move
away
Position toward, move
away
Position away, move
toward
Position toward, move
toward
www.themegallery.com
Prosedur Pelaksanaan
Neurodynamic Mobilizationditahan selama 30 kali
hitungan dan 5 kali repetisi
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DEFINISI OPERASIONAL VARIABEL
Opening dan Closing Technique
Position away,move
away
Position
toward,move away
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DEFINISI OPERASIONAL VARIABEL
Position away, move
toward
Position toward,
move toward
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Penulis Sampel Intervensi Grup
Kontrol
Intervensi Grup
Perlakuan
Hasil
Sahar, 2011 60 pasien dengan
low back pain
dysfunction
30 pasien
Terapi: lumbar spine
mobilization + exercise
(2 set, 10 repetisi, 2x per
minggu, selama 3
minggu)
30 pasien
Terapi: straight leg
raising stretching +
lumbar spine
mobilization + exercise
(2 set, 10 repetisi, 2x per
minggu, selama 3
minggu)
1. Numeric pain rating scale
(p=0,006)
2. Oswestry disability index
(p=0,001)
3. Location of symptoms
(p=0,083)
4. Sciatic nerve root
compression (p=0,035)
5. H-reflex latency (p=0,873)
Haris dan
Dijana, 2013
60 pasien dengan
radicular low back
pain
30 pasien
Terapi: active ROM +
lumbar stabilization
(selama 4 minggu)
30 pasien
Terapi: neural
mobilization + lumbar
stabilization (selama 4
minggu)
1. VAS scale (p=0,001)
2. SLR dengan goniometer
(p=0,001)
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Mudassar,
2015
40 pasien dengan
chronic radicular
low back pain
18 pasien
Terapi: Lumbar
stabilization exercise +
shortwave diathermy
(30 menit per sesi, 5x
per minggu, selama 3
minggu)
22 pasien
Terapi: Slump neural
mobilization technique
+ lumbar stabilization
exercise + shortwave
diathermy (30 menit per
sesi, 5x per minggu,
selama 3 minggu)
1. Four point pain scale
Kontrol (p<0,003)
Perlakuan (p<0,001)
1. Oswestry Disability Index
Kontrol (p<0,163)
Perlakuan (p<0,001)
Taher dan
Elsayed,
2016
60 pasien low back
pain dengan S1
radiculopathy
30 pasien
Terapi: rehabilitasi
konvensional dengan
infrared, ultrasound, dan
general exercise meliputi
stretching dan
strengthening (3x per
minggu selama 6
minggu)
30 pasien
Terapi: neural
mobilization + rehabilitasi
konvensional dengan
infrared, ultrasound, dan
general exercise meliputi
stretching dan
strengthening (3x per
minggu selama 6 minggu)
Kelompok perlakuan lebih baik
daripada kelompok control dari
semua aspek yang diukur.
1. H-reflex latency (p<0.01)
2. H-reflex amplitude (p<0.01)
3. H/M ratio (p<0.02)
4. VAS (p<0.001)
5. ODI (p<0.002)
www.themegallery.com
• Penjelasan yang tepat terhadap perbaikan tingkat nyeri
dan disabilitas fungsional yang dialami oleh pasien
dengan teknik intervensi mobilisasi saraf adalah bahwa
teknik neurodynamic yang dapat mempengaruhi fungsi
mekanik pada saraf perifer, dan perubahan fungsi
mekanis saraf ini berdampak langsung pada perubahan
fisiologis struktur saraf (Ellis, 2012; Kumar, Goyal,
Rajendran, dan Narkeesh, 2013).
www.themegallery.com
• Teknik mobilisasi saraf membantu memulihkan
pergerakan antara saraf dan struktur sekitarnya melalui
gerakan sliding. Oleh karena itu, tekanan intrinsik pada
jaringan saraf menurun yang kemudian meningkatkan
fungsi saraf (Ellis, Hing, 2008; Shacklock, 2005; Butler,
2000; Shacklock, 1995).
www.themegallery.com
• Kompresi akar saraf karena herniasi disk menghambat aliran darah di dalam
akar saraf (Kobayashi, Shizu, Suzuki, Asai, Yoshizawa, 2003), perubahan
mikrosirkulasi saraf ini menyebabkan rasa nyeri dan pelepasan mediator
inflamasi (Kobayashi, Yoshizawa, Yamada, 2004). Selebihnya, terjadi blok
pada sistem konduksi saraf, edema, dan sensitisasi mekanik juga dihasilkan
dari kompresi akar saraf (Kobayashi, Yoshizawa, Yamada, 2004; Chen,
et.al., 2003; Rempel, Dahlin, Lundborg, 1999).
• Teknik mobilisasi saraf meningkatkan aliran darah intraneural, aliran
axoplasmic, aktivasi simpatis yang selanjutnya, membantu dalam
penyerapan cairan pada jaringan dan mengurangi edema intraneural
(Shacklock, 2005; Butler, 2000; Shacklock, 1995; Coppieters, Hough, Dilley,
2009; Schmid, Elliott, Strudwick, Little, dan Coppieters, 2012; Coppieters,
Alshami, Barbi. 2006).
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DAFTAR PUSTAKA• Baehr M., Frotscher M. 2010. Diagnosis Topik Neurologi DUUS : anatomi, fisiologi, tanda, gejala Ed. 4. Jakarta: EGC
• Mardjono M., Sidharta P. 2012. Neurologi Klinis Dasar. Jakarta: Dian Rakyat
• Malanga A. Lumbosacral Radiculopathy (Online; diakses pada tanggal 7 November 2014 Pukul 23.05 WITA). http://emedicine.medscape.com/
• Neal SL, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician 2010; 81(2): 147-155
• McDonnell M, Lucas P. Cervical spondylosis, stenosis, and rheumatoid arthritis. Medicine and Health/Rhode Island 2012; 95(4). 105-109
• Nasikhatussoraya, N. 2016. Hubungan Intensitas Nyeri dan Disabilitas Aktivitas Sehari-hari dengan Kualitas Hidup. Semarang: Fakultas Kedokteran Universitas Diponegoro
• Prentice W, Quillen WS, Underwood F. 2002. Therapeutic Modalities forPhysical Therapy Second Edition. United States of America. The McGraw-Hill Company : 272-303
• Michlovits, SL., Bellew, JW., dan Nolan, TP. 2012. Modalities for TherapeuticIntervention: Fifth Edition. Philadelphia: FA Davis Company
• Draper, DO., Hawkes, AR., Johnson, AW., Diede, MT., dan Rigby, JH. 2013.Muscle Heating with Megapulse II Shortwave Diathermy and ReboundDiathermy. J Ath Train 48($): p 477 – 482
• Prentice W, Quillen WS, Underwood F. 2002. Therapeutic Modalities forPhysical Therapy Second Edition. United States of America. TheMcGraw-Hill Company : 272-303
• Shacklock MO. 2005. Clinical Neurodynamics: a New System of MusculoskeletalTreatment. Edinburg, UK. Elsevier Health Sciences
• Ellis RF, Hing WA. Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy.J Man ManipTher. 2008;16(1):8-22
• Kumar V , GoyalM, RajendranN, Narkeesh D. Effect of neural mobilization on monosynaptic reflex – a pretest posttest experimental design. International Journal of Physiotherapy and Research. 2013; (3):58- 62
• Coppieters MW, Hough AD, Dilley A. Different Nerve-Gliding Exercises Induce Different Magnitudes of Median Nerve Longitudinal Excursion: An In Vivo Study Using Dynamic Ultrasound Imaging. J Orthop Sports PhysTher. 2009;
39(3):164-71
• Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13:213-221
• Coppieters WM, Alshami AM, Barbi AS. Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test. J. Orthop. Res. 2006; 24: 1883-1889
• Butler DS. The Sensitive Nervous System. Noigroup Publications, Adelaide Australia. 2000
• Kobayashi S, Yoshizawa H, Yamada S. Pathology of lumbar nerve root compression part 2: morphological and immune histo chemical changes of dorsal root ganglion. J. Orthop. Res. 2004; 22(1):180-188
• Kobayashi S, Shizu N, Suzuki Y, Asai T, Yoshizawa H. Changes in nerve root motion and intraradicular blood flow during an intraoperative straight-leg-raising test. Spine.2003; 28(13): 1427-1434
• Chen C, Cavanaugh JM, Song Z, Takebayashi T, Kallakuri S, Wooley PH. Effects of nucleus pulposus on nerve root neural activity,mechanosensitivity, axonal morphology, and sodium channel expression. Spine. 2003; 29(1): 17-
25
• Rempel MD, Dahlin L, Lundborg G. Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J. Bone Jt. Surg. 1999; 81(11):1600-1610
• Coppieters WM, Alshami AM, Barbi AS. Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test. J. Orthop. Res. 2006; 24: 1883-1889
• Schmid AB, Elliott JM, Strudwick MW, Little M, Coppieters MW. Effect of splinting and exercise on intraneural edema of the median nerve in carpal tunnel syndrome-an MRI study to reveal therapeutic mechanisms. J Orthop Res.
2012; 30(8):1343-50
• Santos FM1, Silva JT, Giardini AC, Rocha PA, Achermann AP, Alves AS, Britto LR, Chacur M.. Neural mobilization reverses behavioral and cellular changes that characterize neuropathic pain in rats. Mol. Pain.2012; 8: 1-9
• Bertolini GR, Silva ST, Trindade LD, Ciena AP,Carvalho AR. Neural mobilization and static stretching in an experimental sciatic modelean experimental study. Braz. J. Phys. Ther. 2009;13:493-498
• Gladson R. B, Taciane S. S, Danilo L. T, Adriano P. C, Alberito R. C 2009: Neural mobilization and static stretching in an experimental sciatica model - an experimental study. Revista Brasileira de Fisioterapia; 13 (6)
• Brown CL, Gilbert KK, Brismee JM, Sizer PS, James CR, Smith MP. The effects of neurodynamic mobilization on fluid dispersion within the tibial nerve at the ankle: an unembalmed cadaveric study. J Man ManipTher. 2011;
19(1):26- 34
• Beneciuk MJ, Bishop DM, George ZS. Effects of upper extremity neural mobilization on thermal pain sensitivity: a sham-controlled study in asymptomatic participants. J. Orthop. Sports Phys. Ther.2009; 39(6): 428-438
• Murphy RD, Hurwitz LE, McGovern EE. A non-surgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: a prospective observational cohort study with follow-up. J. Manip.
Physiol.Ther. 2009; 32: 723-733
• Nagrale AV, Patil SP, Gandhi RA, Learman K. Effect of slump stretching versus lumbar mobilization with exercise in subjects with non-radicular low back pain: a randomized clinical trial. J. Man. Manip. Ther. 2012; 20(1): 35-42
• Adel, 2011. Efficacy of Neural Mobilization in Treatment of Low Back Dysfunction. Journal of American Science, 2011;7(4)
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