780 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy

[ RESEARCH REPORT ]
1
Assistant Professor, Samuel Merritt University, Department of Physical Therapy, Oakland, CA; Visiting Assistant Professor, University of California, San Francisco, San Francisco, CA;
Visiting Assistant Professor, San Francisco State University, Graduate Program in Physical Therapy, San Francisco, CA.
2
Professor and Director of Physical Therapy, San Francisco
State University, Department of Physical Therapy, San Francisco, CA.
3
Associate Professor in residence at the University of California, San Francisco, Department of Anesthesia,
San Francisco General Hospital, CA.
4
Professor and Director of Physical Therapy, University of California, San Francisco, Graduate Program in Physical Therapy, San Francisco, CA;
Professor, Department of Anatomy, San Francisco, CA. This project was supported by NIH/NCRR UCSF-CTSI Grant Number UL1 RR024131. Its contents are solely the responsibility
of the authors and do not necessarily represent the ofcial views of the NIH. Additional funding for this study was provided by a Graduate Student Research Award from the
University of California, San Francisco awarded to Benjamin Boyd and a Mary McMillan Doctoral Scholarship from the Foundation of Physical Therapy awarded to Benjamin Boyd.
The protocol of this study was approved by The Institutional Review Boards at University of California, San Francisco, San Francisco State University, and the Clinical Research Center
Advisory Committee at University of California, San Francisco. Address correspondence to Dr Benjamin S. Boyd, Assistant Professor, Department of Physical Therapy, Samuel Merritt
University, 450 30th Street, Oakland, CA 94609. E-mail: bboyd1@samuelmerritt.edu
BENJAMIN S. BOYD, PT, DPTSc Linda Wanek, PT, PhD
andreW T. Gray, MD, PhD kimberLy S. Topp, PT, PhD
4
Mechanosensitivity of the Lower
Extremity Nervous System During
Straight-Leg Raise Neurodynamic
Testing in Healthy Individuals
respond to the mechanical stresses im-
posed upon them during movement.
27

Neurodynamic tests are used to assess
the nervous systems mechanosensitiv-
ity through monitoring the response to
movements that are known to alter the
mechanical stresses acting on the ner-
vous system. The most common lower
quarter neurodynamic test is the passive
straight-leg raise (SLR) test.
13,31
The basic
SLR test consists of the tester performing
passive hip exion, with the patient in a
supine position and the knee held in full
extension.
9
A recent systematic review of SLR
testing indicated a lack of standardiza-
tion, including the use of various criteria
for determining the test end point.
31
The
authors of this review reintroduced stan-
dardized methodology proposed by Breig
and Troup
8
in 1979, including the use of
the rst onset of pain as the end point
during the SLR test.
31
Despite these rec-
ommendations, alternative end points,
such as maximally tolerated symptom,
are still utilized.
17
Because SLR testing
is performed in both symptomatic and
C
linical neurological examinations are an integral part of
clinical decision making for determining neural involvement
in individuals with altered physical function and activity
participation. One aspect of a standard neurological
examination involves assessing the sensitivity of peripheral nerves to
limb movement, termed mechanosensitivity. Mechanosensitivity is
thought to be a normal protective mechanism that allows the nerves to
t STudy deSiGn: Cross-sectional, observational
study.
t objecTiveS: To explore how ankle position
afects lower extremity neurodynamic testing.
t backGround: Upper extremity limb move-
ments that increase neural loading create a protec-
tive muscle action of the upper trapezius, resulting
in shoulder girdle elevation during neurodynamic
testing. A similar mechanism has been suggested
in the lower extremities.
t meThodS: Twenty healthy subjects without
low back pain participated in this study. Hip exion
angle and surface electromyographic measures
were taken and compared at the onset of symp-
toms (P1) and at the point of maximally tolerated
symptoms (P2) during straight-leg raise tests
performed with ankle dorsiexion (DF-SLR) and
plantar exion (PF-SLR).
t reSuLTS: Hip exion was reduced during
DF-SLR by a mean SD of 5.5 6.6 at P1 (P =
.001) and 10.1 9.7 at P2 (P.001), compared
to PF-SLR. DF-SLR induced distal muscle activation
and broader proximal muscle contractions at P1
compared to PF-SLR.
t concLuSion: These ndings support the
hypothesis that addition of ankle dorsiexion dur-
ing straight-leg raise testing induces earlier distal
muscle activation and reduces hip exion motion.
The straight-leg test, performed to the onset of
symptoms (P1) and with sensitizing maneuvers,
allows for identication of meaningful diferences
in test outcomes and is an appropriate end point
for lower extremity neurodynamic testing. J
Orthop Sports Phys Ther 2009;39(11):780-790.
doi:10.2519/jospt.2009.3002
t key WordS: neural provocation test, neural
tension, sciatic nerve, sensitizing maneuvers
01 Boyd.indd 780 10/15/09 4:25:35 PM
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 | 781
predened as the onset of symptoms (P1)
and maximally tolerated symptoms (P2).
Additionally, we analyzed the reliability
of repeated SLR testing.
meThodS
T
his cross-sectional study in-
cluded 20 healthy participants
recruited from local medical and
academic communities. Exclusion crite-
ria included low back or lower extremity
pain lasting longer than 3 consecutive
days in the past 6 months, peripheral
neuropathy, diabetes mellitus, complex
regional pain syndrome, lumbar spine
surgeries, chemical dependence or alco-
hol abuse, a history of lower extremity
nerve trauma, or chemotherapy in the
past year. Participants had to meet ex-
ibility requirements of hip exion of 90
or more with the knee exed, full knee ex-
tension, ankle dorsiexion of 0 or more,
and plantar exion of at least 30. The
Institutional Review Boards at University
of California, San Francisco, San Fran-
cisco State University, and the Clinical
Research Centers Advisory Committee
at University of California, San Francisco
approved this study. Written, informed
consent was obtained from the partici-
pants prior to testing. All participants
attended a single clinical assessment ses-
sion. A subset of subjects (n = 5) returned
within 1 to 2 weeks for an identical clini-
cal assessment session for reliability test-
ing. One examiner (B.B.) performed all
physical examinations.
Clinical Assessment Session
Participants completed a medical history
questionnaire. In addition, the subjects
were instructed in the use of a visual
symptom-reporting card, which included
a body chart, an 11-point pain scale, and
a list of qualitative descriptors adapted
from the McGill Pain Questionnaire.
25

The 11-point numeric pain rating scale
had the anchors of 0 (no pain) and 10
(worst pain possible). This type of scale
has good reliability and validity across
multiple ages and races.
20,38
shown at the maximum hip exion range
(determined by the tester) in contrast to
relative electrical silence through the rest
of the range in healthy individuals.
24
This
mean SD increased activation was only
3% 1% of maximal voluntary contrac-
tion and was not a statistically signicant
increase. Prepositioning in ankle dorsi-
exion induces hamstring muscle activa-
tion earlier in hip exion range during
SLR testing in healthy individuals.
18
This
study also did not include statistical anal-
ysis. Muscle activity provoked during the
sensitized SLR test is thought to provide
a protective mechanism to restrict further
movement and to help prevent overstretch
nerve injuries.
18
This is consistent with
ndings in the upper limb, where passive
neurodynamic testing has been shown
to induce muscle activity from adjacent
musculature.
2,11,14,36
No study to date has simultaneously
explored the diferences in range of mo-
tion, symptoms, and muscle responses
for SLR neurodynamic testing at both
the onset and maximally tolerated symp-
toms in healthy individuals. In addition,
no study has provided statistical analy-
sis of both proximal/distal and exor/
extensor muscle activity during SLR
neurodynamic testing. It is important to
understand the specic efects of sensi-
tizing maneuvers at each of these testing
end points in normal asymptomatic indi-
viduals to guide clinical decision making
and to help establish standardized test-
ing methodology in symptomatic popu-
lations. The same test end point should
be utilized in the uninvolved and involved
limbs in people with nerve injuries, which
necessitates understanding the normal
response of the nervous system on the
uninvolved limb.
In this study we attempted to elucidate
the specic efects of the ankle dorsiex-
ion sensitizing maneuvers on the mecha-
nosensitivity of lower extremity posterior
neural structures in healthy individuals.
The aims were to determine the amount
of hip motion and muscle activity during
2 versions of the SLR (including ankle
dorsiexion sensitization) at 2 end-points
asymptomatic limbs, it is important to
know the normal healthy response of the
nervous system at both end points to sup-
port this recommendation.
Interpretations of neurodynamic ex-
amination ndings are based primarily
on expert consensus.
27
The proposed in-
terpretations of a positive test include
considerations for whether the test (1)
reproduces the patients symptoms, (2)
identies asymmetry between limbs or
signicant deviation from norm, and (3)
induces changes in symptoms by distant
joint movement, also called sensitizing
movements.
27
The third consideration
is critical to identify the nervous system
as the source of limitations to move-
ment and is termed structural diferen-
tiation.
32
Sensitizing movements involve
adding a limb movement distant to the
location of symptoms that would afect
the neural structures in the limb without
afecting the nonneural tissue local to the
area of symptoms.
12
Ankle dorsiexion is a common sen-
sitizing maneuver for SLR testing.
5,12,18

Studies in rats and dogs have demon-
strated increased strain (elongation) in
the sciatic nerve at the proximal thigh
when ankle dorsiexion was added to
SLR testing.
1,7
Further support for the
use of ankle dorsiexion as a sensitizing
maneuver is provided by ndings from a
cadaveric study,
12
in which prepositioning
the ankle in dorsiexion created distal
movement in the tibial nerve at the knee
and ankle. Clinically, prepositioning the
ankle in dorsiexion leads to a reduction
of hip range of motion during SLR test-
ing, when taken to maximal resistance to
hip exion in people with low back pain
and healthy individuals.
5
Neurodynamic testing can also produce
increases in local muscle tone. SLR testing
without ankle dorsiexion has been shown
to induce hamstring and gluteal muscle
activity when the hip exion is held at
the maximally tolerated position.
17
How-
ever, this study was performed on a small
number of subjects and statistical analysis
was not performed. In another study, an
increase in hamstring muscle activity was
01 Boyd.indd 781 10/15/09 4:25:36 PM
782 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy
[ RESEARCH REPORT ]
SLr Testing
The subject was positioned in supine,
with a 2.5-cm-thick foam head support
as the standardized position for neurody-
namic SLR testing (FiGure 1). Additional
pillows were provided if requested. A
blood pressure cuf bladder was centered
under the subjects low back and was
inated to 40 mmHg, just prior to SLR
testing. Changes in cuf pressure were
documented at end of movement, dur-
ing SLR testing, as a gross assessment of
change in lumbar spine lordosis. Com-
parisons were made between the SLR
tests performed with the ankle in either
dorsiexion or plantar exion. The sub-
jects right ankle was placed in an APU
PRAFO ankle brace, with outrigger bar
and extra straps (Anatomical Concepts,
Inc, Poland, OH) to maintain a xed an-
kle position in either plantar exion (30)
or in neutral (0) dorsiexion. The SLR
performed with the ankle in 30 of plan-
tar exion (PF-SLR) was considered the
base or reference test, and the SLR per-
formed with the ankle in neutral position
(DF-SLR) was considered the sensitized
SLR test (FiGure 1a).
electromyography (emG) Setup
Standard 1-cm circular bipolar Ag/AgCl
surface EMG electrodes (Noraxon USA,
Inc, Scottsdale, AZ), with an interelec-
trode distance of 2 cm, were placed over
the gluteus maximus, semitendinosus, bi-
ceps femoris, medial gastrocnemius, so-
leus, rectus femoris, vastus medialis, and
tibialis anterior muscles of the right lower
extremity (FiGure 1b). Electrode placement
was in accordance with surface EMG for
noninvasive assessment of muscles (SE-
NIAM) guidelines.
19
A single reference
electrode was placed over the right patella.
Skin preparation included cleaning and
vigorous rubbing with an alcohol-soaked
gauze pad. Three repetitions of 5-second
maximal voluntary isometric muscle con-
tractions (MVC) were performed against
manually provided resistance, with the
subject in supine, for purposes of EMG
signal normalization.
33,39
During MVC
testing, the limb was supported on pil-
lows, if appropriate, and stabilized man-
ually immediately proximal to the joint
being tested. Similar to other studies, the
calf musculature was tested in a neutral
ankle position, the quadriceps and ham-
strings were tested with the knee in ap-
proximately 30 exion, and the gluteal
musculature was tested in approximately
neutral hip exion.
33,39
MVC procedures
included instructions to either push or
pull against the examiners resistance and
to not let the examiner move the limb.
EMG signals were amplied (2000)
and acquired with a bandwidth frequency
of 50 to 500 Hz, and a sampling rate of
2000 Hz, using a TeleMyo 900 System,
NorBNC and A/D USB converter using
MRXP Master Package software, Version
1.06.21 (Noraxon USA, Inc).
Goniometer Setup
Twin-axis electrogoniometers (Noraxon
USA, Inc) were placed laterally across
the hip and knee joints to measure sag-
ittal and coronal plane motion (FiGure
1B).
13,15,24,29
Coronal plane motions were
used to evaluate that neutral hip abduc-
tion and adduction were maintained
during testing. The hip goniometer was
placed with the proximal end parallel to
the subjects torso adjacent to the iliac
crest and the distal end on the lateral
thigh, in line with the lateral femoral
condyle. The knee goniometer was placed
with the proximal end aligned with the
greater trochanter of the femur and the
distal end aligned with the lateral mal-
leolus. Care was taken to ensure that the
middle of the goniometer coil was cen-
tered over the axis of rotation for each
joint. Goniometers were held in place
with double-sided tape and custom-
made neoprene straps (FiGure 1b). A wall
placard provided the tester with visual
input of 10 increments and was placed
so that the origin was aligned with the
subjects right greater trochanter. The
participants were given a custom-built
handheld electronic button (trigger),
which was held in the dominant hand
with both hands resting on the abdomen
(FiGure 1b). Goniometer and trigger data
were acquired at 2000 Hz and synchro-
nized with the EMG data, using the Nor-
BNC and A/D USB converter (Noraxon
USA, Inc).
Testing procedure
One instructional trial was performed
on the left lower extremity prior to for-
mal testing of the right lower extremity.
For the right limb, a total of 4 SLR tests
were performed, with 2 trials assigned in
a random order for each ankle position.
The order was randomized to minimize
the efects of test order on the SLR out-
comes. A metronome and wall placard
were used to facilitate consistent SLR
testing speed of approximately 5/s (FiG-
ure 1b). The tester placed the subjects
knee in full extension (dened as end
range resistance) without lifting the
FiGure 1. Neurodynamic testing set-up for the
straight-leg raise. (A) The subject's ankle was placed
in the adjustable ankle brace. (B) Electrogoniometers
were placed on the hip joint (EG1) and knee joint
(EG2). Surface electromyographic electrodes
(SEMGs) were placed over 8 right lower-extremity
muscles, including the biceps femoris, gluteus
maximus, medial gastrocnemius, rectus femoris,
semitendinosus, soleus, tibialis anterior, and vastus
medialis. A blood pressure cuf (BP cuf) was placed
under the lumbar spine. The subject was given a
custom-made joystick with a thumb switch that was
held with the subject's hands resting on the stomach.
The wall placard provided the tester with visual input
and was aligned with the axis in line with the subject's
right greater trochanter.
01 Boyd.indd 782 10/15/09 4:25:37 PM
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 | 783
Goniometer reliability Testing
The goniometers were attached to a rigid,
wood-hinged model to test the reliability
and validity of measurements compared
to xed metal angles of 0, 30, 45, 60,
and 90. Further reliability testing was
performed on a subset of 5 participants,
by performing 10 repeated SLR tests to
arbitrarily, but consistently, predeter-
mined hip exion positions. Specically,
the beam from a laser level, placed on a
xed wooden surface, was aimed hori-
zontally across the room at an angle per-
pendicular to the subjects limb and at
thigh of of the mat, and the subject was
instructed to indicate this start position
(start) by pressing the trigger 3 times.
While holding the knee in full extension,
the subjects hip was moved passively
into hip exion, while manually avoid-
ing rotation, abduction, or adduction of
the femur. The subject indicated the on-
set of symptoms (P1) and the symptom
limit (P2) during the SLR by pressing the
handheld trigger. Specically, the subject
was instructed to indicate the moment
you feel the rst onset of any symptoms
(P1) and when your symptoms become
too intense to continue and feel you can-
not tolerate any further movement (P2).
The motion was stopped at P2, and this
position was held for 5 seconds, before the
limb was returned to a resting position on
the plinth. Two-minute rests were given
between each SLR trial. Subjects were
asked to report symptom location, inten-
sity, and quality at the start position, at
P1 (delayed reporting until immediately
after P2 because motion was not stopped
at this position), at P2, and then after a
2-minute rest.
data processing
Surface EMG signals were converted
using a root-mean-squared (RMS) for-
mula, with a 50-millisecond interval.
Mean voltage for EMG and degrees for
hip range of motion were obtained for
a 100-millisecond window centered on
each of the following 3 time points: start,
P1, and P2. For each muscle, MVC mea-
surements were averaged from the center
3-second window of each of 3 repeated
MVC tests.
33
SLR testing surface EMG
values were converted into percent MVC
for each muscle. A triggered muscle
response was dened as an increase in
EMG activity (expressed as percent MVC)
of at least a 1.5-fold above the supine-
lying, resting levels (taken lying supine
prior to establishing the start position).
For example, if there was 3.0% MVC
activity of the hamstring muscle in rest-
ing, the muscle was considered activated
(triggered muscle response) at 4.5% MVC
during SLR testing.
an arbitrary height within the subjects
symptom-free hip exion range of mo-
tion. A second tester pressed the trigger
when the subjects limb blocked the laser
beam, and the hip exion angle was then
measured.
Statistical Analysis
All statistical analyses were performed
using SPSS software, Version 14.0 (SPSS
Inc, Chicago, IL). Descriptive statistics
were used to describe the mean SD for
all variables except frequency descriptive
statistics for symptom quality and loca-
0.3 0.9
3
.
2

1
.9
*
2
.
5

1
.
6
*
7
.
0

1
.
8
*
6
.
6

2
.
1
*
0.5 1.3
0.7 0.9*
0.1 0.3
0.4 0.9
10.1 9.7*
3
4
.
1

1
5
.0
*
3
9
.
6

1
3
.7
*
5
7
.
5

2
4
.
6
*
6
7
.
6

2
2
.
1
*
5.5 6.6*
P2
P1
P2
P1
Start
Start
A
B
Symptom Intensity
Range of Motion
FiGure 2. Straight-leg raise neurodynamic test results are presented for (A) symptom intensity (0-to-10 scale) and
(B) hip exion range of motion in degrees. Orange-lined body diagrams represent PF-SLR test and blue-lined body
diagrams represent DF-SLR test. Signicance between tests is indicated by an asterisk (*) and was set at P.05.
Start represents the start position, P1 represents the rst onset of symptoms, and P2 represents the maximally
tolerated symptoms. Data are mean SD.
01 Boyd.indd 783 10/15/09 4:25:39 PM
784 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy
[ RESEARCH REPORT ]
medialis (r = 0.71, P = .001), and dur-
ing DF-SLR for the semitendinosus (r =
0.49, P = .032). At P1 muscle activity was
signicantly correlated with symptoms
during PF-SLR for the gluteus maximus
(r = 0.48, P = .039). There were no other
signicant correlations between muscle
activity and symptom intensity at either
predened point in either SLR test.
Goniometric validity and
reliability Testing
Repeated goniometric measures on the
wooden hinged model were a mean
SD of 0.3 0.2 for the known 0
tion, which are reported as percentages.
Repeated-measures, general linear mod-
els were used for within-condition difer-
ences between the rest, start, P1, and P2
positions for EMG, range-of-motion, and
symptom intensity data. Between-test
comparisons (DF-SLR to PF-SLR) were
made using paired t tests. The general
linear model calculations were adjusted
due to nonsphericity using a Greenhouse-
Geisser correction. Pearson correlation
coefcients were calculated to assess the
relationship between the lumbar pres-
sure cuf measure and hip exion range
of motion at P2. An intraclass correlation
coefcient (ICC
3,1
) was used for repeated-
measures reliability analysis and reported
with the 95% condence interval (CI).
The minimal detectable change for hip
exion range of motion was calculated
using the standard error of the measure-
ment.
23
Alpha was set at .05. Signicance
was set at P.05.
reSuLTS
T
he average SD age of the 20
participants was 50.4 12.0 years
(range, 25-63 years) and included
14 women and 6 men. Height was 1.7
0.1 m, body mass was 71.2 24.8 kg, and
body mass index (BMI) was 25.9 8.8
kg/m
2
.
SLr neurodynamic Testing
The average SD for angular velocity of
the PF-SLR was 3.0/s 1.0/s and of the
DF-SLR was 2.8/s 0.9/s (P =.045).
Symptom intensity
As expected, the mean SD symptom
intensity at P1 and P2 was increased
above resting levels for both versions
of the SLR (P.001) (FiGure 2a). There
was also an increased symptom intensi-
ty from P1 to P2 for both versions of the
SLR (P.001). During PF-SLR the mean
SD symptom intensity went from 0.1
0.3 at the start position to 2.5 1.6
at P1 and to 6.6 2.1 at P2. In contrast,
during DF-SLR, the mean intensity went
from 0.4 0.9 at the start position to
3.2 1.9 at P1 and to 7.0 1.8 at P2.
The mean intensity at P1 was signi-
cantly higher by 0.7 0.9 points during
the DF-SLR compared to PF-SLR (P =
.002). There was no diference in mean
intensity between PF-SLR and DF-SLR
at the start position or at P2. In general,
symptom intensity was not correlated
with muscle activity (percent MVC), ex-
cept at the start position. Muscle activity
(percent MVC) and symptom intensity
were signicantly correlated at the start
position during the PF-SLR for the semi-
tendinosus (r = 0.56, P = .013), anterior
tibialis (r = 0.53, P = .021), and vastus
FiGure 3. Sample surface electromyographic (EMG) recordings are presented. (A) Representative EMG activity
during DF-SLR for semitendinosis (SemT). Line represents the EMG signal normalized to the maximal voluntary
isometric contraction (MVC) and is reported as percent of maximal voluntary isometric muscle contractions
(percent MVC). Vertical lines demarcate the start position, the onset of symptoms (P1), and the maximally
tolerated position (P2). (B) Raw EMG signals for 1 subject comparing PF-SLR and DF-SLR with biceps femoris
(BicF), gluteus maximus (GluM), medial gastrocnemius (MedG), rectus femoris (RecF), semitendinosus (SemT),
soleus (Sol), tibialis anterior (TibA), and vastus medialis (VasM) muscles (top 8 lines) and hip exion range of
motion (bottom line). Vertical lines demarcate the start position, the onset of symptoms (P1), and the maximally
tolerated position (P2).
01 Boyd.indd 784 10/15/09 4:25:40 PM
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 | 785
vated (P = .025), while additional muscle
activation was seen in gluteus maximus
(P = .045), vastus medialis (P = .010),
soleus (P = .013), medial gastrocnemius
(P = .018), biceps femoris (P = .049), and
tibialis anterior (P = .037).
The addition of ankle dorsiexion
created a diferent pattern of muscle ac-
tivation (TabLe). During DF-SLR, muscle
activation criteria was met for the soleus
(P = .015), semitendinosus (P = .005),
tibialis anterior (P = .003), and vastus
medialis (P = .027) at P1. When taken to
P2 during DF-SLR, these 4 muscles re-
mained activated (P = .010, P = .021, P =
.001, P = .014), and the medial gastrocne-
mius (P = .003) and rectus femoris (P =
.024) were triggered.
Between-test comparisons identied
a signicantly greater soleus and tibialis
anterior muscle activation at P1 during
DF-SLR compared to PF-SLR (P = .042
and P = .008). At P2, there was a sig-
nicantly higher activation of the tibialis
anterior and the vastus medialis during
DF-SLR compared to PF-SLR (P = .008
and P = .028).
Symptom Location
Eighty-ve percent of the subjects had
no symptoms at the start position in PF-
SLR and 75% in DF-SLR (FiGure 4). For
those subjects who reported symptoms in
less hip exion ROM at P1 during DF-
SLR compared to PF-SLR, with a 95% CI
from 2.4 to 8.6 (P = .001) (FiGure 2b). At
P2 there was 14.9% less hip exion ROM
in DF-SLR compared to PF-SLR, with
a 95% CI from 5.6 to 14.6 (P.001).
There was no diference in hip abduction/
adduction between PF-SLR and DF-SLR
at P1 (P = .318) or at P2 (P = .572). There
was no diference in knee exion/exten-
sion between PF-SLR and DF-SLR at P1
(P = .124) or at P2 (P = .260). There was
no diference in knee coronal plane posi-
tioning between PF-SLR and DF-SLR at
P1 (P = .648) or at P2 (P = .498). Repeated
testing between multiple testing sessions
(mean SD interval of 10.4 4.3 days)
performed on a subset of 5 subjects had
an ICC of 0.87 (95% CI: 0.68, 0.95) for
hip exion ROM measurement.
muscle activation
The coefcient of variation for repeated
MVC trials was 14.23%, which supported
use of averaging of the 3 trials. There was
relative EMG silence of the muscles un-
til muscle activation was triggered late
in the hip range of motion (FiGure 3).
During PF-SLR, rectus femoris became
activated at P1 (P = .021) (TabLe). When
the PF-SLR was taken to P2, a slightly
diferent pattern of muscle activation was
seen. The rectus femoris remained acti-
angle, 31.3 0.5 for the known 30
angle, 47.8 0.7 for the known 45
angle, 64.1 0.8 for the known 60
angle, and 95.9 1.3 for the known
90 angle. Reliability (ICC) of repeat-
ed goniometric measures in the sagit-
tal and coronal plane on the wooden
hinged model was 1.00 (95% CI: 1.00,
1.00). Using a subset of 5 participants,
the range of variability with repeated
goniometric testing of hip exion to ar-
bitrary but consistent positions in the
symptom-free range (up to a maximum
of 40) was from 1.0 0.3 to 2.4
0.7, with an ICC of 1.00 (95% CI: 0.99,
1.00). The minimal detectable change
for hip exion range of motion was 0.4
using this methodology.
range of motion
ICC
3,1
for hip exion range of motion
between trials were 0.87 (95% CI: 0.69,
0.95) for PF-SLR at P1, 0.96 (95% CI:
0.91, 0.99) for PF-SLR at P2, 0.78 (95%
CI: 0.50, 0.91) for DF-SLR at P1, and
0.88 (95% CI: 0.73, 0.95) for DF-SLR at
P2. The hip range of motion to P1 and to
P2 during the SLR test was greater than
the start position for both DF-SLR and
PF-SLR (P.001) (FiGure 2b). In addi-
tion, hip range of motion was signicant-
ly greater at P2 than P1 for both PF-SLR
and DF-SLR (P.001). There was 13.9%

TabLe Muscle Activation Pattern*
Abbreviations: DF, dorsiexion; MVC, maximal voluntary isometric muscle contraction; P1, onset of symptoms; P2, point of maximally tolerated symptoms;
PF, plantar exion; SLR, straight-leg raise.
* Values are mean SD percent MVC.

Statistically signicant increase (P.05) above resting levels for general linear model of repeated measures for within-test diferences.

Statistically signicant diference (P.05) between PF-SLR and DF-SLR tests, using paired t test comparison for start and P1 and P2.
muscle resting Start p1 p2 Start p1 p2
Soleus 6.8 2.8 9.0 6.0

9.5 6.7

11.8 9.6

9.6 6.7

11.1 9.1

12.7 10.6

Medial gastrocnemius 5.2 1.5 6.4 3.0

7.0 3.8

8.2 5.7

6.2 2.9

7.4 4.1

8.7 5.5

Tibialis anterior 2.7 1.1 3.1 1.4

3.6 1.8

4.1 3.4

5.6 5.6

5.6 4.4

6.1 4.4

Vastus medialis 7.2 4.1 9.1 7.3

12.0 13.7 17.0 16.7

5.6 2.8

12.3 13.7

13.8 12.3

Rectus femoris 6.8 3.6 7.0 3.9 10.4 7.5

10.9 8.2

7.3 3.8 9.7 6.7

10.7 6.9

Semitendinosus 3.8 1.3 3.7 1.2 4.9 2.8 8.3 11.9 3.8 1.1 6.1 4.1

10.0 11.4

Biceps femoris 4.5 1.5 5.4 2.3

6.3 3.9

10.6 12.6

5.3 2.6

6.1 2.9

9.6 11.5
Gluteus maximus 12.1 4.5 15.4 10.5 16.3 10.1

24.6 27.4

15.4 10.4 16.9 12.0

22.5 23.4
pF-SLr dF-SLr
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[ RESEARCH REPORT ]
(70% at P1 and 65% at P2), followed by
tight/tension (50% at P1 and 40% at P2),
and third most common was ache (10%
at P1 and 15% at P2). Pain and numbness
were reported infrequently during SLR,
and no subjects reported tingling or pins/
needles. After 2 minutes of rest following
the SLR test, 90% of the subjects report-
ed no symptoms following PF-SLR and
70% reported no symptoms following
DF-SLR. The symptoms that remained
after PF-SLR were most commonly ache
(15%) and dull (10%), and after DF-SLR
were most commonly ache (15%) and
stretch (10%).
Lumbar Spine pressure cuf measure
Repeated-measures reliability (ICC) of
the lumbar pressure cuf measurements
taken at P2 was 0.87 (95% CI: 0.69, 0.95)
for PF-SLR and 0.91 (95% CI: 0.78, 0.96)
for DF-SLR. Lumbar pressure cuf mea-
surements increased from 40 mmHg at
start position to a mean SD of 67.6
11.5 mmHg at P2 during PF-SLR and
66.5 12.6 mmHg at P2 during DF-SLR.
The pressure in the cuf at P2 was not sig-
nicantly diferent between PF-SLR and
DF-SLR (P = .298). Pearson correlations
between the lumbar pressure cuf mea-
surement and hip exion range of motion
at P2 were 0.77 (P.001) for the PF-SLR
and 0.79 (P.001) for the DF-SLR.
diScuSSion
T
his study further supports the
concept that ankle positions may be
used as sensitizing maneuvers to the
base SLR test. The quality and location
of symptoms were altered and a broader
muscular response was triggered with the
addition of the sensitizing maneuver of
ankle dorsiexion. The higher symptom
intensity that we observed in healthy sub-
jects at P1 during DF-SLR compared to
PF-SLR was statistically signicant but
did not meet the 2-point threshold for
clinical signicance and is therefore not a
meaningful diference.
10
Hip exion range
of motion was reduced during the dorsi-
exion version of the SLR test at both the
frequent at P1 and distal symptoms in the
right posterior leg and plantar foot were
more frequent at P2.
Symptom Quality
The frequencies of descriptors used by
the subjects to report symptom qual-
ity during both versions of the SLR are
presented in FiGure 4. During PF-SLR,
the most common descriptor used was
stretch (75% at P1 and P2) and the next
most frequent was tight/tension (25%
at P1 and 35% at P2), followed by ache
(15% at P1 and P2). During DF-SLR, the
most frequent descriptor was also stretch
the start position, the locations were the
right anterior leg, posterior hip, posterior
thigh, and posterior leg.
The frequencies of symptom locations
reported at P1 and P2 during SLR are
presented in FiGure 5. During PF-SLR, the
most frequent symptom location for P1
was in the right posterior thigh, followed
by the right posterior leg. When this test
was taken to P2, the right posterior thigh
remained the most frequent symptom lo-
cation, while the frequency of symptoms
in the right posterior leg increased. In
contrast, during DF-SLR, distal symp-
toms in the right posterior leg were more
Ache
Stretch
Tightness/tension
Burning
Pain
Numbness
Tingling
No symptoms
0 10 20 30 40 50 60 70 80 90 100
Percent (%)
Ache
Stretch
Tightness/tension
Burning
Pain
Numbness
Tingling
No symptoms
0 10 20 30 40 50 60 70 80 90 100
Percent (%)
Ache
Stretch
Tightness/tension
Burning
Pain
Numbness
Tingling
No symptoms
0 10 20 30 40 50 60 70 80 90 100
Percent (%)
Ache
Stretch
Tightness/tension
Burning
Pain
Numbness
Tingling
No symptoms
0 10 20 30 40 50 60 70 80 90 100
Percent (%)
Ache
Stretch
Tightness/tension
Burning
Pain
Numbness
Tingling
No symptoms
0 10 20 30 40 50 60 70 80 90 100
Percent (%)
Ache
Stretch
Tightness/tension
Burning
Pain
Numbness
Tingling
No symptoms
0 10 20 30 40 50 60 70 80 90 100
Percent (%)
Start
P1
P2
PF-SLR DF-SLR
10%
85%
15%
75%
25%
15%
75%
35%
15%
65%
40%
10%
70%
50%
15%
10%
75%
FiGure 4. Frequency of quality descriptors used to report symptoms during the PF-SLR and DF-SLR tests.
Histograms are presented for symptoms reported in at least 10% of the subjects at the start, onset of symptoms
(P1), and maximally tolerated position (P2), respectively.
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journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 | 787
onset and maximally tolerated symptoms.
The lower bound of the CI exceeded the
minimal detectable change, indicating
that this diference was a real diference
in range.
28
Our results are consistent with
a previous study that identied a signi-
cant 9 reduction in hip range of motion
by the addition of ankle dorsiexion.
5

We hypothesize that the SLR with ankle
plantar exion does not preload the sciat-
ic, tibial, and plantar nerves, thus allow-
ing the hip greater range of exion before
the nerve complex undergoes sufcient
mechanical stress to trigger a symptom-
atic or motor response. Furthermore, we
hypothesize that the SLR with ankle dor-
siexion triggers an earlier restriction to
movement during SLR testing through
preloading of these neural structures.
This is supported by previous ndings of
increased mechanical stress and strain on
the sciatic, tibial, and plantar nerves dur-
ing ankle dorsiexion.
12
Changes in muscle tone were expect-
ed to be small during SLR testing, and
an appropriate threshold was necessary
to determine meaningful diferences.
A previous study of an upper limb neu-
ral provocation test had documented a
statistically signicant increase of ap-
proximately 1.5 times the muscle activity
compared to resting levels in upper trape-
zius muscle.
2
We used this 50% increase
in muscle electrical activity over resting
muscle tone as a conservative threshold
to dene muscle activation. This crite-
rion was more stringent than previously
utilized thresholds of greater than 1, 2,
or 3 standard deviations above the rest-
ing mean electrical activity.
22,33,34,36
In
fact, the criterion used in our study led
to a higher threshold for activation by an
average of 1.5% MVC compared to the
previously utilized methodology. It was
expected that stretch-induced increases
in muscle tone would be no greater than
25% MVC.
2
This was indeed the case dur-
ing the passive SLR test for all muscles
measured in this study.
As expected, progression of the end
point of the SLR from P1 to P2 triggered
EMG activity in more muscles than had
been activated at P1. In the PF-SLR,
moving to P2 triggered activity in gluteus
maximus, vastus medialis, biceps femo-
ris, tibialis anterior, soleus, and gastroc-
nemius, in addition to the rectus femoris,
which was active at P1. Progression of the
SLR from P1 to P2 triggered cocontrac-
tions of antagonist muscle groups, as has
been documented in an upper limb neu-
rodynamic test.
36
Additionally, although
the intensity of symptoms increased from
P1 to P2, we did not observe a correlation
between the increase in symptom inten-
sity and the increase in muscle activation.
This is in agreement with the work of
Balster and Jull
2
in an upper limb neuro-
dynamic test of healthy subjects. In con-
trast, van der Heide et al
36
documented a
correlation between the onset of pain and
muscle activity in an upper limb neuro-
dynamic test in healthy subjects. In this
latter study, however, the correlation was
determined using only the subjects who
experienced pain consistently. It is pos-
sible that progression of the SLR from
the rst onset of symptoms to maximally
tolerated symptoms results in a global at-
tempt to stop the movement by stabilizing
the joints with cocontractions, as hypoth-
esized by van der Heide and colleagues
36

in their study of the response of biceps
brachii, triceps brachii, and trapezius in
an upper limb neurodynamic test.
The addition of dorsiexion to the
5%
5%
10%
5%
80%
35%
5%
15%
5%
75%
60%
5%
15%
20%
10%
85%
55%
10%
5%
15%
25%
80%
80%
PF-SLR at P1
DF-SLR at P1 DF-SLR at P2
PF-SLR at P2
91100%
8190%
7180%
6170%
5160%
4150%
3140%
2130%
1120%
110%
0%
FiGure 5. Body chart representations for frequencies of symptom location reported during the PF-SLR and DF-SLR
at the onset of symptoms (P1) and the maximally tolerated position (P2). Frequencies are reported in 10% intervals
from a white color of 0% frequency to 90% to 100% as dark red. There were more frequent distal symptoms in the
DF-SLR test when compared to the PF-SLR for both the P1 and the P2 time points.
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788 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy
[ RESEARCH REPORT ]
base SLR induced muscle activation in
both the soleus and the tibialis ante-
rior at P1. The distal muscle activation
was not seen at P1 in the PF-SLR. This
muscle response was not likely due to
volitional changes in muscle activation,
as the subjects were instructed to remain
relaxed throughout the SLR testing and
were masked from viewing the EMG
recordings. Distal muscle activity at the
rst onset of symptoms in the DF-SLR
leads us to hypothesize that this is a pro-
tective reexive mechanism of the local
muscle to stop further stress and strain
of the nerves by limiting further motion.
Such a local protective response has been
demonstrated in the upper limb, where-
in neurodynamic tests that elongate the
brachial plexus result in increased sur-
face EMG activity of the upper trapezius
muscle and increased contractile force of
muscles that elevate the shoulder.
2,36
Our
study demonstrated that the mass muscle
activation pattern presents earlier in the
SLR if the limb is in ankle dorsiexion.
As expected, during the SLR, symptoms
reported by healthy subjects difered from
those reported previously by people with
lower limb radicular pain.
6
In our study,
a few subjects described minimal dull,
ache, sore, or tenderness in the posterior
hip, thigh, or leg at the start position, in
which the knee was moved into full exten-
sion. It is likely that elongation of the soft
tissue in the posterior limb provoked the
symptoms. During the SLR testing, the
most frequent symptoms reported were
stretch or tension in the posterior thigh
or leg. The addition of ankle dorsiexion
to the base SLR provoked more tension,
tightness, and burning, and more distal
location of symptoms. In these healthy
subjects, pain and numbness were report-
ed infrequently (10%). In contrast, SLR
testing in people with lower limb radicular
pain has been found to provoke reports of
pain in 83% of the symptomatic limbs
at a mean of only 58 of hip exion.
6
This
study also identied the frequent report of
deep symptoms that may follow a myoto-
mal or sclerotomal pattern.
6
Some researchers have proposed the
rst onset of pelvic movement as an end
point for SLR testing when used as a low-
er extremity exibility assessment,
16,21,30,37

but it is unclear if this is an appropriate
end point for SLR neurodynamic test-
ing. One research study indicated that
pelvic movement occurred simultane-
ously with hip exion during the SLR
test even when the pelvis was strapped to
the table.
4
Another study found that pel-
vic motion began after the rst 10 and
that lumbar lordosis began to decrease
after 30 of hip exion motion during
the SLR.
17
Our study suggests that, as hip
range of motion increases during SLR,
the pressure under the lumbar spine also
increases. We found excellent reliability
of this measurement during SLR testing
and a strong relationship between hip
range of motion and the amount of pres-
sure measured under the low back at P2
(Pearson r = 0.77-0.79). Further research
is necessary to determine whether the
increase in pressure in the SLR is due to
movement of the lumbar spine and pel-
vis, or to changes in the muscle activity
of the erector spinae in the region of the
blood pressure cuf. Regardless of the
mechanism, it appears that movement of
the pelvis or lumbar spine would not be
an appropriate end point for the SLR test
when used as a neurodynamic test.
What end point should be used for stop-
ping neurodynamic tests of asymptom-
atic limbs that allows for both sufcient
information gathering and protection of
the person being tested? Our study has
shown excellent reliability of hip exion
measurements at the onset of symptoms
(P1) on the same day (ICC = 0.78-0.96)
and repeated testing in subsequent weeks
in subjects with healthy nervous systems
(ICC = 0.87). We found that the altered
ankle position of only 30 between the
PF-SLR and DF-SLR created diferenc-
es in hip ROM, symptom intensity, and
muscle activation that were measurable
at P1. In our study, taking the test to the
maximally tolerated position (P2) did
not provide additional clinically relevant
information. For example, the muscle re-
sponse was widespread and not specic to
ankle position, symptom intensity was not
discriminatory for ankle position, and P1
had already allowed for identifying reduc-
tions in range of hip exion motion with
ankle dorsiexion. Although testing to P2
had excellent repeatability, it carries with
it risks, such as overstretch and further ir-
ritation of the nervous system, particular-
ly when used with people in pain or with
suspected nerve injuries.
One of the limitations to our study is
extrapolating this information to people
who have pain. Our ndings are from
people with healthy nervous systems and
provide guidelines for expectations in the
asymptomatic limb of those patients with
pain down 1 lower extremity. The pres-
ence of pain or injury in the injured limb
may induce a diferent response in the
asymptomatic limb. Therefore, care
should be taken in extrapolating the out-
comes from this study to individuals who
have pain, even when testing their as-
ymptomatic limb. Future research should
consider the inuence of neuropathic and
nonneuropathic pain on the outcome of
the SLR in the asymptomatic limb.
Limitations of application of our
ndings to the clinical setting also in-
clude the precise measurement tools
and standardized protocols required to
determine small range-of-motion dif-
ferences between PF-SLR and DF-SLR.
The equipment used in this study is not
readily available to the clinician, and the
procedures are too time consuming to be
feasible in patient care. It is possible that
clinicians can detect this 5 diference
in hip exion range of motion between
PF-SLR and DF-SLR, as this is slightly
greater than the intraobserver variability
for standard hip goniometery of 3 and
inclinometry of 2.7.
3
It is possible that
hip rotation occurred during this SLR
testing, which could have inuenced our
outcomes (we did not measure this axis
of motion in this study). Nevertheless,
standardized procedures and precision
measurements can be used clinically
to minimize the risks of confounding
variables such as poorly controlled limb
movement, diferent patient instructions,
01 Boyd.indd 788 10/15/09 4:25:50 PM
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 | 789
and diferent range-of-motion measure-
ment tools. Clinically, full ankle dorsiex-
ion range of motion can be used during
SLR (compared to dorsiexion to 0 used
in our study) to increase the impact of
sensitizing maneuvers by, theoretically,
increasing the stress to the posterior el-
ements of the lower extremity nervous
system. In addition, a conceptual un-
derstanding of the impacts of sensitizing
maneuvers on symptoms, nerve mobility,
and muscle activity will assist with inter-
pretation of SLR outcome measures.
35
There is a limitation in making deni-
tive conclusions based on the variability
in the EMG data found in our study. Pos-
sible cross talk between muscles could
have inuenced the EMG ndings. Be-
cause not all subjects respond with the
same muscle activation pattern, extrapo-
lation of our ndings to clinical settings
could be unwarranted at this phase. A
better understanding of all of the possible
response patterns and why individuals
respond diferently is necessary to ensure
that the assessment of muscle response
is not misinterpreted in a clinical setting.
Further exploration of muscle responses
in the lower extremity in various popu-
lations of people with pain during neu-
rodynamic testing is warranted. Finally,
it is quite possible that structures other
than nerves and their associated connec-
tive tissue, such as blood vessels and fas-
cia that span multiple joints in the limbs,
could be contributing to the alteration
in range of motion, muscle activity, and
symptoms that were found in this study.
concLuSion
M
echanosensitivity of the ner-
vous system is a normal protec-
tive mechanism that includes
symptom production, increases in muscle
tone, and subsequent reductions in range
of motion in the lower limb during neu-
rodynamic testing. Performing the SLR
to the rst onset of symptoms is an as-
sessment tool that is highly reliable in as-
ymptomatic limbs of healthy individuals,
allowing for identication of meaningful
diferences in test outcomes through the
use of sensitizing maneuvers, and may
be of use in patients with irritable condi-
tions. Normal protective muscle guarding
induced by the nervous system to avoid
overstretch in healthy individuals should
be considered when assessing resistance
felt during SLR testing and considered
when prescribing muscle and soft tissue
stretches.
t
key poinTS
FindinGS: Ankle dorsiflexion, when used
as a sensitizing maneuver for SLR
neurodynamic testing, increases the
frequency of distal symptoms, triggers a
broader muscular response, and subse-
quently reduces the amount of hip flex-
ion range of motion when tested to the
first onset of symptoms.
impLicaTionS: The use of ankle dorsiflex-
ion is an appropriate sensitizing maneu-
ver for SLR neurodynamic testing, and
performing the test to the first onset of
symptoms provides sufficient informa-
tion to assist structural differentiation.
cauTion: This study was limited to indi-
viduals with no history of nerve injury
and the use of precise instrumentation
for assessing range of motion and mus-
cle activity. Caution should be exercised
in extrapolating these findings to clini-
cal measurement tools and to popula-
tions with nerve injury.
ACKNOWLEDGEMENTS: The authors would like
to thank Isabel Belkind, Stephanie Boyd, Ryan
Broms, Nancy Byl, Sean Darling, Romy Ha-
vard, Adriane Kauffman, Alyssa Keeney-Roe,
Stephanie Klitgord, Andrew Moon, Michael
Ng, Steve Paul, Sandra Radtka, and Zheng
Xu for their assistance with data collection and
processing, and manuscript editing.
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