Comparison of different treatment positions of nerve slider technique for patients with low back pain: a randomized control trial

Abstract

BACKGROUND

Low back pain (LBP) accompanied by sciatica is a widespread musculoskeletal issue with multifactorial etiology, impacting individuals across various demographics. Conservative treatments, notably physiotherapy, are key in managing LBP with sciatica, with neural mobilization techniques emerging as beneficial adjuncts.

AIM

This research aims to assess the effectiveness of utilizing the sciatic slider technique (SST) in both supine and slump positions, compared to conventional physiotherapy alone, in alleviating pain severity, improving lumbar flexibility, lumbar lordosis, lower limb muscle strength, and functional ability in patients with LBP associated with sciatica.

DESIGN

randomized controlled trial.

SETTING

Department of Physiotherapy at Alia Hospital.

POPULATION

Sixty participants with LBP associated with sciatica.

METHODS

The participants were randomly allocated into three groups: Group (A) N.=20 received the SST in a slump position alongside conventional physiotherapy, Group (B) N.=20 received the same technique in a supine position with conventional physiotherapy, and Group (C) or (control) N.=20 underwent only conventional physiotherapy. Each group underwent three sessions per week for four weeks. Outcome measures included pain intensity (Numerical Pain Rating Scale), functional disability (Oswestry Disability Index), lumbar flexibility (Modified Schober test), lower limb muscle strength (Hand-held dynamometry), and lumbar lordosis (Flexible ruler).

RESULTS

Analysis revealed significant differences between treatment groups. The slump position exhibited superior effectiveness in reducing pain intensity (P<0.001), and improving disability (P<0.001), with greater improvements in pain scores and disability index percentages. Additionally, slump position therapy led to significantly greater enhancements in range of motion (P<0.001), and hip abductor (P=0.007) when compared to the supine position. However, both techniques showed similar effects on lumbar lordosis angle and various lower limb muscle strength.

CONCLUSIONS

The sciatic nerve slider technique, whether applied in the slump or supine position, demonstrated superior outcomes compared to conventional physiotherapy alone in managing LBP with sciatica. Nevertheless, the slump position showed greater efficacy in reducing pain, improving disability, and enhancing certain functional parameters.

CLINICAL REHABILITATION IMPACT

These findings advocate for the inclusion of neural mobilization techniques, particularly in the slump position, in the management of LBP with sciatica.

Introduction

Low back pain (LBP) is one of the foremost musculoskeletal conditions in terms of prevalence that most people suffer throughout their lives and affects people of all ages.¹ The underlying causes of LBP are difficult to determine because it represents itself under various circumstances. According to research, the key individual and psychological risk factors for LPB are sex, age, Body Mass Index (BMI), heredity, stress, anxiety, and depression.² There are also several consequences of LBP, including an increase in lumbar lordosis, a reduction in the strength and flexibility of the back muscles, and an increase in the stiffness of the lower limb muscles.³

Sciatica denotes a compilation of symptoms resulting from the compression and inflammation of the sciatic nerve. These symptoms encompass pain, numbness, muscular weakness, and challenges in leg movement or control.⁴ Typically, symptoms manifest in the lower back, buttocks, and various dermatomes of the leg and foot.⁵ Possible causes include disc bulges or herniations, lumbar canal stenosis, spondylolisthesis, trauma, or spinal tumors.⁵ It tends to affect women more than men and those with sedentary lifestyles more than active ones.⁶ Onset may be sudden or gradual with physical activity, and it commonly appears unilaterally.⁷

Various treatment options exist for individuals experiencing LBP with sciatica, ranging from conservative approaches to surgical interventions.⁸ Physiotherapy is often hailed as the primary method for addressing LBP with sciatica.⁹ Neural mobilization, a technique focused on restoring equilibrium within the nervous system and its surrounding structures, is gaining recognition.¹⁰ Its principal objective is to enhance the nervous tissue’s capacity to endure tension and stress, thereby facilitating the restoration of normal physiological function, alleviating pain, and enhancing overall functionality.¹

Multiple studies have investigated the effects of neurodynamic mobilization on patients with LBP. All of these studies have consistently shown clinical improvement and positive therapeutic outcomes following treatment with various neural mobilization techniques.^11-14

The primary objective of this study is to assess and compare the impact of the sciatic slider technique (SST) when applied in various positions, specifically the supine and slump positions, and conventional physiotherapy in patients with LBP associated with sciatica on pain severity, lumbar flexibility, lumbar lordosis, muscle strength, and functional disability outcomes. We hypothesized that the SST in various positions is as effective as conventional physiotherapy in all outcomes among patients with LBP related to sciatica. The results of the current study will help guide therapeutic procedures for the treatment of sciatica and LBP by offering insightful information on the efficacy of neural slider mobilization treatments.

Materials and methods

Study design

The current research employed three arms in a randomized controlled trial which has been registered under the ID NCT05907356, and received approval from the Ethical Research Committee of the European University of Lefke, with the reference number REF: BAYEK022.06. The study adheres to the CONSORT guidelines for reporting trials.

Setting and participants

Patients with LBP were treated at Alia State Hospital in the city of Hebron, Palestine. during April and June 2023 were recommended for this research by their neurologist and orthopedic, all individuals participating in the study willingly signed informed consent forms before commencing, ensuring the protection of their rights throughout the research process.

Concerning inclusion criteria, the study included individuals aged between 45 and 60 years of both genders suffering from sciatica caused by a bulged or herniated disc who experience lower back pain (LBP) accompanied by unilateral radicular pain persisting for a period exceeding twelve weeks up to one year, without experiencing acute incidents within the previous four weeks, accompanied by weakness in lower limb muscles and reduced reflexes, provided they exhibited a Numerical Pain Rating Score (NPRS) of more than four out of ten and displayed positive results in the Straight Leg Raise test, with the repetition of neurological symptoms. Clinical examination and MRI were used to confirm the disc lesion and radiculopathy. Patients with sciatica caused by other disorders (e.g., lumbar canal stenosis, spondylolisthesis, piriformis syndrome, trauma, or spinal tumors), any prior spinal surgery, vertebral fracture or trauma, a negative SLR test, pregnant women, and any physiotherapy or other treatment before 6 months were excluded. Three of the recommended patients were rejected due to their advanced age and having negative Straight Leg Raise (SLR) test, and one patient did not consent to participate in the research.

Sample size

The determination of the sample size followed Cohen’s mathematical relationship.¹⁵ The minimal sample size for each group was calculated using the provided equation:

In the provided equation:

• n: the number of participants needed for each group.

• N: the total nbr. of groups, which is 3 in this context.

• Z_β: represents the desired statistical power, typically set at 0.84 for an 80% power level.

• Z_α/2: signifies the measure of statistical significance, commonly set at 1.96 for a 95% confidence level.

• ES²: denotes the effect size, using Cohen’s standard effect size of 1.1, as mentioned in Appendix IV.

Thus:

n=3 x (0.84 + 1.96)² / (1.1)2=19.48 ≈ 20.

So, the minimum sample size for each group is approximately 20. Previous studies have reported comparable effect sizes for outcomes in similar populations on neural mobilization techniques.¹ To ensure that our sample size was adequate, we performed a power analysis using G*Power version 3.1.9.4. The analysis confirmed that a sample size of 20 patients per group was sufficient to detect a statistically significant difference with a power of 80% and a significance level of 5%. This calculation ensures that the study is adequately powered to detect clinically significant differences in the outcomes.

Randomization

Eligible patients were given information about the study to decide whether to participate. Randomization was achieved using a simple method, where patients were instructed to choose one of three concealed cards, each representing a different treatment group: Group A (N.=20) received the SST in a slump position with conventional physiotherapy, Group B (N.=20) received the SST in a supine lying position with conventional physiotherapy, and Group C (control) (N.=20) received only conventional physical therapy. Allocation concealment was maintained through the use of an automatic random number generator. Because of the nature of the interventions, it was not feasible to blind the subjects to the types of intervention (exercises) in the study. This study involved 60 participants, all of whom fully adhered to their prescribed therapies, which is unusual for this type of trial. The randomization process is depicted in Figure 1.

Figure 1.

—Randomization process.

Outcome measurement

Participants underwent assessments at baseline and following the intervention, with the post-intervention evaluation conducted within 48 hours after the last session. Before the study, all participants were provided with comprehensive information regarding the study’s evaluation procedures. Sociodemographic data, including age, sex, weight height, and BMI, were documented in a patient information form at baseline. In addition, clinical examination and magnetic resonance imaging (MRI) to confirm disc lesions and the SLR test, were utilized as independent variables to assess patients’ study eligibility. Different assessments were utilized to measure pain intensity, lumbar flexibility, lumbar lordosis, functional disability, and lower limb muscle strength among the participants, to evaluate the efficacy of interventions. These assessments were conducted one day before the initiation of the program and were repeated at the end of 4 weeks of treatment, all the interventions, assessments, and pre-post-treatment measurements were conducted and recorded by the primary investigator to fulfill the requirement of PHD thesis. He has over 15 years of experience in physical therapy and has also undergone training in clinical neurodynamic techniques. The primary outcomes measured in this study are described below.

Pain intensity measurement

Pain intensity was assessed using a numerical pain rating scale (NPRS), which is a reliable and valid method, it is divided from 0 to 10 into 11 units. a score of 0 indicates no pain, while scores of 1 to 3 denote mild pain, 4 to 6 represent moderate pain, and 7 to 10 indicate severe pain.¹⁶

Functional disability measurement

Functional disability was evaluated using the Oswestry Disability Index (ODI) Arabic version, which is a commonly used, reliable, and valid measure.¹⁷ This scale is a 10-item that uses sequential scoring from 0 to 5 for each item, its categories include pain intensity, self-care, lifting, standing, sitting, walking, social life, sex life, sleeping, and travel. It was obtained by adding the scores from all the sections answered dividing the total by the total possible score and finally multiplying by 100 to get a percentage. If one or more of the sections are not answered, the total possible score or the denominator is deducted by five so that the percentage of disability is determined correctly based on the number of answered questions.¹⁸

Lumbar flexion flexibility

Lumbar flexion (LF) was assessed using the Schober test, a reliable and valid measure. During the test, participants stand while the examiner marks a horizontal line over their back, indicating the first sacrum spinous process. A marker is placed 10 cm above the first line to indicate the second line. The participant then leans forward, attempting to touch their toes. The difference in measurements between the upright and flexed postures determines the extent of LF.¹⁹

Lower limb muscle strength measurement

Lower limb muscular strength was measured using Hand-held dynamometry (Benvenuto in active force 2, dynamometer e inclinometer digital, Italy), These measures generally demonstrate high reliability and validity for assessing muscle strength. All values were documented in kilograms. An isometric muscle strength assessment was conducted with the patient positioned in three different postures: seated, supine, and prone. Hip flexors (HF), knee extensors (KE), and knee flexors (KF) were evaluated in a seated position. Ankle plantar flexors (PF), ankle dorsi-flexors (DF), and hip abductors (Hab) were assessed in a supine position, while hip extensors (HE) were evaluated in a prone position.²⁰

Lumbar lordosis measurement

The lumbar lordosis angle (LL Angle) was measured using a flexible ruler, a safe, easily portable, and inexpensive method for evaluating spinal curvature. This approach is both reliable and valid. During the examination, while the participant was in a standing position, the initial lumbar vertebra (L1) and the second sacral vertebrae (S2) served as reference points to assess lumbar curvature. Subsequently, a flexible ruler is positioned along L1 and S2, with gentle pressure applied to ensure contact with the skin. Placing the ruler on a sheet of paper, the curvature of the waist is then drawn. Following this, the angle of lumbar lordosis for each participant is determined using the formula θ=4Arctan 2H/L, where H represents the height of the curvature and L represents the length between L1 and S2.²¹

Intervention

All the intervention groups were performed three times per week for four weeks between April 2023 and December 2023. The session started with applying a moist hot pack (28×46 cm) for 15 minutes in the prone lying position. Following this, transcutaneous electrical nerve stimulation (TENS) was administered using a two-channel device set to the conventional mode. The TENS unit generated an asymmetrical biphasic waveform, featuring a frequency of 100 Hz and a pulse duration of 125 microseconds. Four carbon rubber electrodes (3.5×5 cm) were positioned above the lumbar Para spinal muscles and the other two over the sciatic nerve for 20 minutes. Additionally, a home exercise program focusing on back strengthening was prescribed, including quadruped alternating arms/legs exercises, bridging, pelvic tilts, and core bracing. For every exercise, participants were to complete two sets of ten repetitions.

In addition to conventional physiotherapy, participants in both groups A and B underwent a SST. Following the protocol outlined by Pallipamula and Singaravelan,²² comprised of five sets per session: the first set involved 10 repetitions, the second set 15 repetitions, the third set 20 repetitions, the fourth set 25 repetitions, and the fifth set 30 repetitions. Each repetition included a 5-second hold at the end position, with rest intervals of 1-2 minutes between sets.

For group (A) participants underwent an SST while in the slump position, in this technique, the patient was seated at the edge of a couch, assuming the slump position where the posterior aspect of the knee was positioned at the edge, with thighs parallel to each other, and flexion occurring at both the thoracic and lumbar spines (slouch position). The therapist stood beside the patient at the bedside, placing one arm proximally over the patient’s shoulder to guide neck movements, while the other hand directed the knee (Figure 2).

Figure 2.

—Sciatic nerve slider technique in slump position (A) start position (B) end position.

The therapist then passively facilitated cervical neck flexion and knee flexion, aiming to stretch the nerve proximally while inducing relaxation at the distal end. Subsequently, the therapist transitioned from cervical extension to knee extension.

For group (B) participants underwent an SST in the supine lying position, the therapist held the patient’s limb, starting with hip flexion while keeping the ankle in a plantarflexed position and the knee extended, along with neck flexion, aiming to stretch the hip nerve while facilitate relaxation at the ankle. Subsequently, this motion was reversed, with the hip extended while maintaining knee extension, ankle dorsiflexion, and neck extension. This approach aimed to relax the hip nerve while stretching the nerve at the ankle (Figure 3).

Figure 3.

—Sciatic nerve slider technique in the supine lying position (A) start position (B) end position.

Statistical analysis

The statistical analysis of the research data utilized SPSS version 24.0. Demographic data across groups was compared using the one-way ANOVA test. Additionally, Tukey’s HSD Test was employed as a post-hoc test for one-way ANOVA to identify the sources of differences among sample means. To determine the difference between pre- and post-measures for each group or treatment, the paired-samples t-test procedure (dependent samples t-test) was utilized. This test compares the mean of a single group at two different points in time. For comparing all dependent variables pre- and post-treatment between both groups, an Analysis of Covariance (MANOVA) test was employed. The significance level was set at 0.05 for all analyses.

Results

Examination of individuals’ sociodemographic characteristics

Sixty patients participated in this study, comprising 57% females and 43% males, with a mean age of 54.1±5.8 years. They were randomly allocated into three groups. There were no significant differences in age, weight, and BMI among the three groups (P>0.01). However, there were significant differences in height (P<0.01), with Tukey’s HSD post-hoc test indicating significant differences in height between Group A and Group B. This suggests that while the groups are generally comparable, there are differences in height between specific groups. The summarized data is presented in Table I.

Table I. —A comparison of demographic data among the three groups.

Variables	Group A Mean±SD	Group B Mean±SD	Control Group Mean±SD	F-value	P value
Age (Years)	52.6±5.8	55.4±6.6	54.3±4.8	1.135	0.328
Weight (Kg)	82.9±7.1	83±11.4	84.9±9.2	0.292	0.748
Height (Cm)	172.55±8.9	164.1±6.8	168±8.2	5.507	0.007
BMI (Kg/m2)	27.9±2.3	30.8±4.2	30.1±3.4	4.059	0.022

SD: standard deviation; P: probability. *P<0.01.

Analysis of the impact of the intervention

A comparison of pain intensity, lumbar flexibility, functional disability, lumbar lordosis, and lower limb muscle strength before and after the intervention revealed significant improvements in all outcome measurements across all groups (P<0.05). However, in the control group, there were no significant differences between pre-and post-measures for the LL Angle (P=0.41) and HF (P=0.246) parameters. The summarized data is presented in Table II, III.

Table II. —Analysis of significant differences in pre- and post-test across all groups.

Parameter	Group A (N.=20)				Group B (N.=20)				Control group (N.=20)
	Pre-Scores mean±SD	Post Scores mean±SD	t	Sig.	Pre-Scores mean±SD	Post Scores mean±SD	t	Sig.	Pre-Scores mean±SD	Post Scores mean±SD	t	Sig.
NPRS	8.1±1.1	1.1±0.9	36.47	0.000	8.3±1	4.1±1.5	18.78	0.000	8.3±0.9	4.5±0.9	19.71	0.000
ODI	0.71±0.2	0.08±0.1	16.01	0.000	0.8±0.1	0.4±0.2	13.72	0.000	0.8±0.1	0.4±0.1	18.70	0.000
LROM	2.9±0.9	4.8±0.3	-11.51	0.000	2.7±0.8	4±0.9	-8.79	0.000	2.5±0.6	3.4±0.7	-10.18	0.000
LL Angle	89.3±21.3	57.5±17.9	7.81	0.000	65.2±22.6	57.3±23.1	6.07	0.000	72±22.2	110.3±211.8	-0.84	0.410
DF	65.3±18.6	78.7±18.7	-5.09	0.000	99.8±19.8	105.5±18.7	-4.62	0.000	116.4±6.3	117.5±6.2	-6.74	0.000
PF	61.3±13.2	71.4±18.1	-5.28	0.000	105±16.5	113.2±16.2	-4.12	0.001	119.2±8	120±8	-4.69	0.000
KF	118.5±18.6	130.4±18.1	-6.13	0.000	144.5±40.3	154.7±45.3	-3.35	0.003	120.4±10.5	121.4±10.2	-4.55	0.000
KE	130.7±36.9	157.5±42.4	-3.86	0.001	142.8±32.3	152.7±37.5	-3.38	0.003	120±9.9	121.3±9.7	-4.43	0.000
HF	145.9±40.9	161.1±37.6	-2.68	0.015	141.6±31.2	157.6±33.3	-2.87	0.010	116.9±27.2	123.2±11	-1.20	0.246
HE	125.7±32.6	144±34.2	-3.77	0.001	126.1±23.5	131.1±25.3	-3.20	0.005	127.4±11.5	129.5±13.1	-3.36	0.003
Hab	93.9±10.7	105.8±13.3	-6.67	0.000	111.5±8.3	114.6±7.8	-4.01	0.001	117.9±11.8	118.7±11.4	-3.07	0.006

P>0.05. SD: standard deviation; P: probability; S: significance; t: paired-sample t-test; NPRS: Numeric Pain Rating Scale; ODI: Oswestry Disability Index; LROM: lumbar range of motion; LL: lumbar lordosis; DF: dorsiflexors; PF: planter flexors; KF: knee flexor; KE: knee extensors; HF: hip flexors; HE: hip extensors; Hab: hip abductors.

Table III. —Summary of treatment effects across three groups.

Group	Treatment Method	Parameters with Significant Improvement	Parameters without Significant Improvement
A	Sciatic Slider Technique in Slump Position + Conventional Physiotherapy	All parameters	-
B	Sciatic Slider Technique in Supine Lying Position + Conventional Physiotherapy	All parameters	-
C (control)	Conventional Physiotherapy	9 out of 11 parameters	LL Angle, HF

The study aimed to assess the effectiveness of different treatment modalities for LBP associated with sciatica, comparing the Sciatic Nerve Slider Technique in slump and supine positions with Conventional Physiotherapy. ANCOVA analyses were conducted on 11 parameters related to LBP with sciatica for each treatment group.

Results indicated a significant change between pre- and post-treatment in both Group A and the control group for 9 out of the 11 parameters studied. However, changes in DF and LL Angle were not deemed significant (Table IV). When comparing Group B with the control group, significant changes were observed between pre- and post-measures for 7 out of the 11 parameters studied. However, changes in NPRS, ODI, LL Angle, and HE were found to be insignificant (Table V).

Table IV. —Variables comparison between Group A and Control Group.

Parameter	Covariates (Pre score)	Estimated Mean Post Scores for Group A	Estimated Mean Post Scores for Control Group	Sig.	Meaning
NPRS	8.17	1.14	4.45	0.000	Significant difference
ODI	74%	9%	42.1%	0.000	Significant difference
LROM	2.7	4.8	3.5	0.000	Significant difference
LL Angle	80.7	37.8	129.9	0.069	Not significant
DF	90.9	99.7	96.9	0.557	Not significant
PF	90.2	105.1	86.3	0.001	Significant difference
KF	119.4	131.2	120.6	0.000	Significant difference
KE	125.4	153.1	125.6	0.000	Significant difference
HF	131.4	152.8	131.5	0.000	Significant difference
HE	126.5	144.8	128.8	0.002	Significant difference
Hab	105.9	117.5	107.1	0.000	Significant difference

P>0.05. S: significance; NPRS: Numeric Pain Rating Scale; ODI: Oswestry Disability Index; LROM: lumbar range of motion; LL: lumbar lordosis; DF: dorsiflexors; PF: planter flexors; KF: knee flexor; KE: knee extensors; HF: hip flexors; HE: hip extensors; Hab: hip abductors.

Table V. —Variables comparison between Group B and Control Group.

Parameter	Covariates (Pre score)	Estimated Mean Post Scores for Group 2	Estimated Mean Post Scores for Group 3	Sig.	Meaning
NPRS	8.25	4.1	4.5	0.182	Not significant
ODI	80.3%	40%	45%	0.231	Not significant
LROM	2.6	3.9	3.5	0.021	Significant difference
LL Angle	68.6	65.5	102.2	0.426	Not significant
DF	108.1	113.1	109.9	0.027	Significant difference
PF	112	119.4	113.8	0.018	Significant difference
KF	132.4	141.9	134.2	0.027	Significant difference
KE	131.4	140.5	133.6	0.041	Significant difference
HF	129.2	151.2	129.6	0.003	Significant difference
HE	126.8	131.8	128.8	0.083	Not significant
Hab	114.7	117.6	115.8	0.044	Significant difference

P>0.05. S: Significance; NPRS: Numeric Pain Rating Scale; ODI: Oswestry Disability Index; LROM: lumbar range of motion; LL: lumbar lordosis; DF: dorsiflexors; PF: planter flexors; KF: knee flexor; KE: knee extensors; HF: hip flexors; HE: hip extensors; Hab: hip abductors.

Table VI presents the comparative analysis of mean differences in outcome measurements between Group A and Group B. There were notable variations between the pre-and post-treatment in both groups for 7 out of the 11 parameters investigated. However, changes in LL Angle, PF, KF, and HF were statistically insignificant.

Table VI. —Variables comparison between Groups A and B.

Parameter	Covariates (Pre score)	Estimated Mean Post Scores slump position	Estimated Mean Post Scores supine position	Sig.	Meaning	Most effective position
NPRS	8.17	1.16	4.04	0.000	Significant difference	Slump
ODI	76%	10%	41%	0.000	Significant difference	Slump
L ROM	2.8	4.8	4.0	0.000	Significant difference	Slump
LL Angle	77.3	48.5	66.4	0.457	Not significant	The same effect
DF	82.6	93.5	90.8	0.027	Significant difference	Slump
PF	83	93	91	0.742	Not significant	The same effect
KF	131.4	143.9	141.3	0.514	Not significant	The same effect
KE	136	163	147	0.045	Significant difference	Slump
HF	143.8	159.5	159.2	0.972	Not significant	The same effect
HE	125.9	144.2	130.9	0.013	Significant difference	Slump
Hab	102.7	114.1	106.4	0.007	Significant difference	Slump

P>0.05. S: Significance; NPRS: Numeric Pain Rating Scale; ODI: Oswestry Disability Index; LROM: lumbar range of motion; LL: lumbar lordosis; DF: dorsiflexors; PF: Planter Flexors; KF: knee flexor; KE: knee extensors; HF: hip flexors; HE: hip extensors; Hab: hip abductors.

Initial investigation revealed a significant variation in baseline height between Groups A and B (P<0.05). The covariate height did not significantly influence any of the outcomes. For pain intensity, height was not a significant factor (F(1, 56)=1.34, P=0.25). Similarly, no significant effect was found for functional disability (F(1, 56)=1.61, P=0.28), lumbar flexibility (F(1, 56)=1.58, P=0.21), or lumbar lordosis (F(1, 56)=0.96, P=0.34). For lower limb muscle strength, height had no significant effect across all measured muscle groups, with F-values ranging from 0.90 to 1.70 and P values all greater than 0.20.

These results confirm that the observed improvements in all variables were primarily attributable to the therapeutic interventions, rather than being influenced by differences in the patients’ heights. The interventions were effective across individuals with varying heights, affirming the robustness of the findings.

In this study, all the outcome measures showed a significant improvement and all of them were greater than Minimum Clinically Important Difference (MCID). For pain intensity (NPRS), any change of 2 points has been deemed to be clinically important. The mean reduction was as follows: Group A by 7 points, Group B by 4. 2 points, and the control group by 3.8 points, which can be regarded as significant pain relief, especially in Group A; ODI was reduced by 63% in Group A and by 40% in Groups B and the control group, which is higher than the value of the 10-14% MCID threshold. No MCID is defined for LL Angle, however, the reduction of the same from 89.3° to 57.5° in Group A is clinically significant. Schober test which evaluates LF ROM was increased most in Group A from 2.9 cm to 4.8 cm showing functional change. There was more than 10% improvement in lower limb muscle strength in Group A while Group B showed moderate improvement and the control group showed minimal improvement. Based on these findings, the interventions, especially in Group A, were associated with clinically relevant improvements in pain, functional disability, lumbar flexibility, and muscle strength in support of the use of the SST with physiotherapy.

Discussion

The objective of the research was to assess and compare the efficacy of the SST conducted in supine and slump postures with conventional physiotherapy in the management of LBP with sciatica. The main aim was to identify which position provided better results about the participants’ pain intensity, lumbar mobility, lordosis, lower limb muscles strength, and functional disability. The study aimed to offer a better understanding of the best interventions to use in the management of sciatica-associated LBP by evaluating the changes in the identified physical health indicators.

The rationale for selecting a 48-hour follow-up period was deliberate in a bid to assess the effect of interventions on chronic LBP with sciatica. The studies have shown that pain and functional status may have early changes of potential importance for the assessment of long-term results. For example, it was found that estimates of change in pain and function after the first few consultations could predict treatment outcomes.²³ The follow-up one day after the intervention and the day after that enables one to determine the efficacy of the sciatic nerve slider technique and conventional physiotherapy before the subjects develop any complications or adapt to the new techniques.²⁴ It is crucial to determine how fast these interventions can alleviate pain and improve function as it allows for instant feedback on the efficacy of the interventions.²⁵ Further, it is possible to capture early responses that allow clinicians to make decisions on modifications of treatment regimens according to the preliminary outcomes of the patient, and enhance the effectiveness of therapeutic interventions.²⁶

The findings offered substantial proof that indicated the use of sciatic nerve slider techniques should be incorporated with regular physiotherapy. The results of the supine and slump positions showed it to be a better treatment model than physiotherapy alone for addressing the multiple issues that arise with sciatica. Of the two positions, the slump position was more beneficial in decreasing the level of pain, increasing lumbar lordosis, and reducing functional disability. These results stress the ability of the slump position to improve overall rehabilitation outcomes in patients with sciatica.

However, to explain why the sciatic nerve slider technique works so effectively it is necessary to focus on neurodynamic aspects of the presented method. The technique’s primary role is to increase nerve flexibility by modifying the pressure gradients, increasing the hypoxia state inside the nerve, and reducing the manifestations of nerve compression.²⁷ These mechanisms help in better functioning of nerves, decreased pain sensation, and better limb movements, especially of lower limbs. This is in support of the hypothesis that mobilization of the nerve to the surrounding structures helps in the resolution of inflammatory processes and increases blood flow to the affected area thus reducing sciatic pain.²⁸

The changes noted in the above-mentioned indicators of outcome are in agreement with the existing literature regarding the effectiveness of neural mobilization techniques in providing pain relief and functional improvement in patients with LBP, especially in those having sciatica. Bhatt and Shukla and Alshami et al. also shown the efficacy of the neural mobilization techniques in increasing the ROM and decreasing disability. Bhatt and Shukla identified that sciatic nerve mobilization through the SLR method helped in increasing the ROM and reducing the physical disability of the patient and Alshami et al. identified that both slider and tensioner mobilizations were effective in reducing the pain and increasing the ROM of the patients but there is no significant difference between both the methods.^{1, 29}

In addition, the therapeutic mechanism of the SST is based on the reduction of endoneurial fluid pressure, and pain and inflammation in the nerve. SST assists in the reduction of inflammation and pain around the compressed nerve by enabling the distribution of inflammatory mediators close to the area thus providing a great analgesic benefit.²⁷ It also increases the functional status of a patient and decreases his or her disability and ability to perform activities with less pain. These results support the findings of EL Nahass who pointed out that the patients who underwent slider and tensioner techniques had significantly less pain and improved functional disability of the lower back as compared to the chronic sciatica patients who performed stretching exercises. However, the study revealed that ankle dorsiflexion ROM was similar in all groups.⁴

The gains in lower limb muscle strength that were revealed after SST also support the concept that SST can enhance musculoskeletal performance. This could explain why the technique improves muscle performance by increasing cross-sectional area and number of muscle fibers resulting in real improvement in muscle strength and functionality.³⁰ These enhancements are particularly useful in the process of making a holistic rehabilitation of individuals with LBP so that they can gain strength and mobility. Chaudhary et al. also supported the neurodynamic slider techniques, where the NST was combined with CT and was reported to be more effective than CT only in terms of pain and function.³¹

SST was found to be more effective than conventional physiotherapy by the comparison between the two groups; moreover, SST was more effective when integrated with conventional therapeutic methods. These combined strategies provided a more favorable outcome for pain intensity reduction, better restoration of lumbar lordosis, improvement of lower limb muscle power, a decrease in functional disability, and better flexibility in the lumbar region. The additive effects of specific neural mobilization techniques to other conventional therapies also underline the importance of these techniques in improving the patient’s outcome as well as adding to the effectiveness of the broad spectrum of rehabilitation approaches.

Further evaluation of post-treatment results also revealed the variability of SST when used in a slump position compared with a supine position. The slump position was significantly superior to the supine position regarding pain and disability as well as the neural tissue. This indicates the slump position provides a comprehensive approach towards LBP and sciatica, and thus, may be a useful method for clinicians in an attempt to enhance the results in treating patients with sciatica. The results also show that trunk forward lean in SST is most beneficial for LBP related to sciatica.

Supporting evidence from Herrington reinforces the slump position’s efficacy, with better patient-reported outcomes compared to other positions. This technique likely reduces the sensitivity of the sciatic nerve and other neural structures to physical strain, thereby minimizing discomfort during daily activities.³² The impact of these findings on neural tissue health and their broader application in treating symptomatic individuals call for further research to explore their long-term benefits.

On the other hand, the supine position offers a different biomechanical approach for applying SST, as noted by Méndez-Sánchez et al. Their findings suggest that the supine position can still be effective, though the slump position may offer greater benefits in certain cases.³³ Ellis et al. examined the influence of spinal posture on sciatic nerve movement during seated neural mobilization exercises and found that spinal posture did not significantly affect nerve movement, indicating that therapists can adapt seated neural mobilization exercises to patient comfort without compromising effectiveness.³⁴

Nevertheless, there are certain gaps in the existing literature on neural mobilization techniques. The slump position’s effect on chronic radicular LBP was studied by Ali et al. and Rezk-Allah et al. and revealed positive changes in pain and disability, although the participants and assessors were not blind to the interventions that introduced performance and ascertainment bias. In addition, the majority of included trials failed to report diagnostic criteria of such disorders as radiculopathy and sciatica, which hinders the transferability of the results.^{35, 36} Similarly, the studies conducted by Ahmed et al. and Kaur and Sharma, which incorporated the use of sliders and tensioners with other therapies, also showed positive outcomes in pain and function, but like the above studies, had their methodological flaws.^37-39

To overcome these problems, future research needs to enhance the methodological quality of the trials through blinding, better definition of inclusion criteria, and diagnostic criteria for such conditions as sciatica or radiculopathy. This will make the findings more valid and relevant to clinical practice than in the case where patients are selected randomly. Also, regarding the method of adopting slump and supine positions for SST, these should be selected based on the biomechanics of the patient and his comfort level to optimize the effects of SST in the management of LBP and sciatica, to refine these techniques, establish standardized diagnostic criteria, and ensure the long-term efficacy of SST in clinical practice.

Conclusions

This study provides evidence that the sciatic nerve slider technique, especially when used in the slump and supine positions, is very efficient in alleviating pain, limiting functional impairment, increasing lumbar flexibility, and fortifying lower limb muscles in individuals suffering from sciatica-related low back pain. When used in conjunction with conventional physiotherapy, the intervention resulted in substantial enhancements in all outcome measures as compared to conventional physiotherapy alone.

Crucially, the study showed that height, while there were early variations between the groups, did not have a substantial impact on the treatment results. This finding suggests that the therapeutic advantages of the sciatic nerve slider method are strong and consistent across persons of different heights, therefore strengthening the suitability of this treatment in a wide range of patient groups.

The aforementioned results emphasize the possibility of including neural mobilization methods, particularly the sciatic nerve slider, into conventional physiotherapy protocols for the treatment of LBP using sciatica.