[ research report ]

Benjamin S. Boyd, PT, DPTSc1 • Linda Wanek, PT, PhD2

Andrew T. Gray, MD, PhD3 • Kimberly S. Topp, PT, PhD4

Mechanosensitivity of the Lower

Extremity Nervous System During
Straight-Leg Raise Neurodynamic
Testing in Healthy Individuals

C
linical neurological examinations are an integral part of respond to the mechanical stresses im-
clinical decision making for determining neural involvement posed upon them during movement.27
Neurodynamic tests are used to assess
in individuals with altered physical function and activity
the nervous system’s mechanosensitiv-
participation. One aspect of a standard neurological ity through monitoring the response to
examination involves assessing the sensitivity of peripheral nerves to movements that are known to alter the
limb movement, termed mechanosensitivity. Mechanosensitivity is mechanical stresses acting on the ner-
thought to be a normal protective mechanism that allows the nerves to vous system. The most common lower
quarter neurodynamic test is the passive
t Study Design: Cross-sectional, observational t RESULTS: Hip flexion was reduced during straight-leg raise (SLR) test.13,31 The basic
study. DF-SLR by a mean  SD of 5.5°  6.6° at P1 (P = SLR test consists of the tester performing
t Objectives: To explore how ankle position
.001) and 10.1°  9.7° at P2 (P.001), compared passive hip flexion, with the patient in a
to PF-SLR. DF-SLR induced distal muscle activation supine position and the knee held in full
affects lower extremity neurodynamic testing.
and broader proximal muscle contractions at P1 extension.9
t BACKGROUND: Upper extremity limb move- compared to PF-SLR.
A recent systematic review of SLR
t Conclusion: These findings support the
ments that increase neural loading create a protec-
tive muscle action of the upper trapezius, resulting testing indicated a lack of standardiza-
hypothesis that addition of ankle dorsiflexion dur-
in shoulder girdle elevation during neurodynamic tion, including the use of various criteria
ing straight-leg raise testing induces earlier distal
testing. A similar mechanism has been suggested muscle activation and reduces hip flexion motion. for determining the test end point.31 The
in the lower extremities. The straight-leg test, performed to the onset of authors of this review reintroduced stan-
t Methods: Twenty healthy subjects without symptoms (P1) and with sensitizing maneuvers, dardized methodology proposed by Breig
low back pain participated in this study. Hip flexion allows for identification of meaningful differences and Troup8 in 1979, including the use of
angle and surface electromyographic measures in test outcomes and is an appropriate end point the first onset of pain as the end point
were taken and compared at the onset of symp- for lower extremity neurodynamic testing. J
during the SLR test.31 Despite these rec-
toms (P1) and at the point of maximally tolerated Orthop Sports Phys Ther 2009;39(11):780-790.
doi:10.2519/jospt.2009.3002 ommendations, alternative end points,
symptoms (P2) during straight-leg raise tests
t Key words: neural provocation test, neural
such as maximally tolerated symptom,
performed with ankle dorsiflexion (DF-SLR) and
plantar flexion (PF-SLR). tension, sciatic nerve, sensitizing maneuvers are still utilized.17 Because SLR testing
is performed in both symptomatic and

Assistant Professor, Samuel Merritt University, Department of Physical Therapy, Oakland, CA; Visiting Assistant Professor, University of California, San Francisco, San Francisco, CA;
1 

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 official 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

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

01 Boyd.indd 780 10/15/09 4:25:35 PM

 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 findings are based primarily
on expert consensus.27 The proposed in-
terpretations of a “positive” test include
considerations for whether the test (1)
reproduces the patient’s symptoms, (2)
identifies asymmetry between limbs or
significant 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 differen-
tiation.”32 Sensitizing movements involve
adding a limb movement distant to the
location of symptoms that would affect
the neural structures in the limb without
affecting the nonneural tissue local to the
area of symptoms.12
Ankle dorsiflexion 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 dorsiflexion was added to
SLR testing.1,7 Further support for the
use of ankle dorsiflexion as a sensitizing
maneuver is provided by findings from a
cadaveric study,12 in which prepositioning
the ankle in dorsiflexion created distal
movement in the tibial nerve at the knee
and ankle. Clinically, prepositioning the
ankle in dorsiflexion leads to a reduction
of hip range of motion during SLR test-
ing, when taken to maximal resistance to
hip flexion in people with low back pain
and healthy individuals.5
Neurodynamic testing can also produce
increases in local muscle tone. SLR testing
without ankle dorsiflexion has been shown
to induce hamstring and gluteal muscle
activity when the hip flexion 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
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 |
01 Boyd.indd 781
shown at the maximum hip flexion 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 significant
increase. Prepositioning in ankle dorsi-
flexion induces hamstring muscle activa-
tion earlier in hip flexion 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
findings 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 differences 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 flexor/
extensor muscle activity during SLR
neurodynamic testing. It is important to
understand the specific effects 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 specific effects of the ankle dorsiflex-
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
dorsiflexion sensitization) at 2 end-points
predefined 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 flex-
ibility requirements of hip flexion of 90°
or more with the knee flexed, full knee ex-
tension, ankle dorsiflexion of 0° or more,
and plantar flexion of at least 30°. The
Institutional Review Boards at University
of California, San Francisco, San Fran-
cisco State University, and the Clinical
Research Center’s 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
781
10/15/09 4:25:36 PM
 [ research report
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 cuff (BP cuff) 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.
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 cuff bladder was centered
under the subject’s low back and was
inflated to 40 mmHg, just prior to SLR
testing. Changes in cuff 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
dorsiflexion or plantar flexion. The sub-
ject’s right ankle was placed in an APU
PRAFO ankle brace, with outrigger bar
and extra straps (Anatomical Concepts,
782 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy
01 Boyd.indd 782
Inc, Poland, OH) to maintain a fixed an-
kle position in either plantar flexion (30°)
or in neutral (0°) dorsiflexion. The SLR
performed with the ankle in 30° of plan-
tar flexion (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° flexion, and the gluteal
musculature was tested in approximately
neutral hip flexion.33,39 MVC procedures
included instructions to either push or
pull against the examiner’s resistance and
to not let the examiner move the limb.
EMG signals were amplified (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 subject’s 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
subject’s 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 effects 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 subject’s
knee in full extension (defined as end
range resistance) without lifting the
10/15/09 4:25:37 PM
 thigh off of the mat, and the subject was
A 0.5 � 1.3
instructed to indicate this start position
(“start”) by pressing the trigger 3 times. Symptom Intensity

.1*
While holding the knee in full extension,

�2

*
the subject’s hip was moved passively

1.8
6.6

�
into hip flexion, while manually avoid- 0.7 � 0.9*

7.0
ing rotation, abduction, or adduction of *
1.6
the femur. The subject indicated the on- � *
2.5 1.9
set of symptoms (P1) and the symptom �
3.2
limit (P2) during the SLR by pressing the P2
handheld trigger. Specifically, the subject
was instructed to indicate “the moment P1
you feel the first onset of any symptoms”
(P1) and when “your symptoms become Start 0.1 � 0.3
0.3 � 0.9
too intense to continue and feel you can- 0.4 � 0.9
not tolerate any further movement” (P2).
The motion was stopped at P2, and this
position was held for 5 seconds, before the B 10.1 � 9.7*
limb was returned to a resting position on
Range of Motion
the plinth. Two-minute rests were given

*
22.1
between each SLR trial. Subjects were

6*
�

24.
asked to report symptom location, inten-

67.6
5.5 � 6.6*

5�
sity, and quality at the start position, at

57.
*
P1 (delayed reporting until immediately 1 3.7
.6
� 0*
after P2 because motion was not stopped 3 9 15.
.1 �
at this position), at P2, and then after a 34
2-minute rest. P2

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 defined 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.
P1
Start
FIGURE 2. Straight-leg raise neurodynamic test results are presented for (A) symptom intensity (0-to-10 scale) and
(B) hip flexion range of motion in degrees. Orange-lined body diagrams represent PF-SLR test and blue-lined body
diagrams represent DF-SLR test. Significance between tests is indicated by an asterisk (*) and was set at P.05.
Start represents the start position, P1 represents the first onset of symptoms, and P2 represents the maximally
tolerated symptoms. Data are mean  SD.
Goniometer Reliability Testing an arbitrary height within the subject’s
The goniometers were attached to a rigid, symptom-free hip flexion range of mo-
wood-hinged model to test the reliability tion. A second tester pressed the trigger
and validity of measurements compared when the subject’s limb blocked the laser
to fixed metal angles of 0°, 30°, 45°, 60°, beam, and the hip flexion angle was then
and 90°. Further reliability testing was measured.
performed on a subset of 5 participants,
by performing 10 repeated SLR tests to Statistical Analysis
arbitrarily, but consistently, predeter- All statistical analyses were performed
mined hip flexion positions. Specifically, using SPSS software, Version 14.0 (SPSS
the beam from a laser level, placed on a Inc, Chicago, IL). Descriptive statistics
fixed wooden surface, was aimed hori- were used to describe the mean  SD for
zontally across the room at an angle per- all variables except frequency descriptive
pendicular to the subject’s limb and at statistics for symptom quality and loca-

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01 Boyd.indd 783 10/15/09 4:25:39 PM

 [ research report ]
tion, which are reported as percentages.
Repeated-measures, general linear mod-
els were used for within-condition differ-
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
coefficients were calculated to assess the
relationship between the lumbar pres-
sure cuff measure and hip flexion range
of motion at P2. An intraclass correlation
coefficient (ICC3,1) was used for repeated-
measures reliability analysis and reported
with the 95% confidence interval (CI).
The minimal detectable change for hip
flexion range of motion was calculated
using the standard error of the measure-
ment.23 Alpha was set at .05. Significance
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/m2.
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
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 flexion range of
motion (bottom line). Vertical lines demarcate the start position, the onset of symptoms (P1), and the maximally
tolerated position (P2).
3.2  1.9 at P1 and to 7.0  1.8 at P2. medialis (r = 0.71, P = .001), and dur-
The mean intensity at P1 was signifi- ing DF-SLR for the semitendinosus (r =
cantly higher by 0.7  0.9 points during 0.49, P = .032). At P1 muscle activity was
the DF-SLR compared to PF-SLR (P = significantly correlated with symptoms
.002). There was no difference in mean during PF-SLR for the gluteus maximus
intensity between PF-SLR and DF-SLR (r = 0.48, P = .039). There were no other
at the start position or at P2. In general, significant correlations between muscle
symptom intensity was not correlated activity and symptom intensity at either
with muscle activity (percent MVC), ex- predefined point in either SLR test.
cept at the start position. Muscle activity
(percent MVC) and symptom intensity Goniometric Validity and
were significantly correlated at the start Reliability Testing
position during the PF-SLR for the semi- Repeated goniometric measures on the
tendinosus (r = 0.56, P = .013), anterior wooden hinged model were a mean
tibialis (r = 0.53, P = .021), and vastus  SD of 0.3°  0.2° for the known 0°

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

01 Boyd.indd 784 10/15/09 4:25:40 PM


TABLE Muscle Activation Pattern*

PF-SLR DF-SLR

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
Abbreviations: DF, dorsiflexion; MVC, maximal voluntary isometric muscle contraction; P1, onset of symptoms; P2, point of maximally tolerated symptoms;
PF, plantar flexion; SLR, straight-leg raise.
* Values are mean  SD percent MVC.
†
Statistically significant increase (P.05) above resting levels for general linear model of repeated measures for within-test differences.
‡
Statistically significant difference (P.05) between PF-SLR and DF-SLR tests, using paired t test comparison for start and P1 and P2.

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 flexion 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 flexion range of motion was 0.4°
using this methodology.
Range of Motion
ICC3,1 for hip flexion 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 significant-
ly greater at P2 than P1 for both PF-SLR
and DF-SLR (P.001). There was 13.9%
less hip flexion 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 flexion ROM
in DF-SLR compared to PF-SLR, with
a 95% CI from 5.6° to 14.6° (P.001).
There was no difference in hip abduction/
adduction between PF-SLR and DF-SLR
at P1 (P = .318) or at P2 (P = .572). There
was no difference in knee flexion/exten-
sion between PF-SLR and DF-SLR at P1
(P = .124) or at P2 (P = .260). There was
no difference 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 flexion ROM measurement.
Muscle Activation
The coefficient 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
different pattern of muscle activation was
seen. The rectus femoris remained acti-
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 dorsiflexion
created a different 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 identified
a significantly 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-
nificantly 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-five 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

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01 Boyd.indd 785 10/15/09 4:25:41 PM

 [ research report ]
(70% at P1 and 65% at P2), followed by
Start
tight/tension (50% at P1 and 40% at P2),
Ache 10% Ache 10%
and third most common was ache (10%
Stretch Stretch
Tightness/tension Tightness/tension at P1 and 15% at P2). Pain and numbness
Burning Burning were reported infrequently during SLR,
Pain
Pain and no subjects reported tingling or pins/
Numbness Numbness
Tingling Tingling
needles. After 2 minutes of rest following
No symptoms 85% No symptoms 75% the SLR test, 90% of the subjects report-
ed no symptoms following PF-SLR and
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
70% reported no symptoms following
Percent (%) Percent (%)
DF-SLR. The symptoms that remained
P1
after PF-SLR were most commonly ache
Ache Ache
15% 10% (15%) and dull (10%), and after DF-SLR
Stretch 75% Stretch 70%
were most commonly ache (15%) and
Tightness/tension 25% Tightness/tension 50%
Burning Burning 15% stretch (10%).
Pain Pain
Numbness Numbness
Lumbar Spine Pressure Cuff Measure
Tingling Tingling
No symptoms No symptoms
Repeated-measures reliability (ICC) of
the lumbar pressure cuff measurements
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100 taken at P2 was 0.87 (95% CI: 0.69, 0.95)
Percent (%) Percent (%)
for PF-SLR and 0.91 (95% CI: 0.78, 0.96)
P2
for DF-SLR. Lumbar pressure cuff mea-
Ache 15% Ache 15% surements increased from 40 mmHg at
Stretch Stretch 65%
75% start position to a mean  SD of 67.6 
Tightness/tension 35% Tightness/tension 40%
Burning Burning
11.5 mmHg at P2 during PF-SLR and
Pain Pain 66.5  12.6 mmHg at P2 during DF-SLR.
Numbness Numbness The pressure in the cuff at P2 was not sig-
Tingling Tingling
nificantly different between PF-SLR and
No symptoms No symptoms
DF-SLR (P = .298). Pearson correlations
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100 between the lumbar pressure cuff mea-
Percent (%) Percent (%) surement and hip flexion range of motion
at P2 were 0.77 (P.001) for the PF-SLR
PF-SLR DF-SLR
and 0.79 (P.001) for the DF-SLR.

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
Discussion
(P1), and maximally tolerated position (P2), respectively.

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
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
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 dorsiflexion. The higher symptom
intensity that we observed in healthy sub-
jects at P1 during DF-SLR compared to
PF-SLR was statistically significant but
did not meet the 2-point threshold for
clinical significance and is therefore not a
meaningful difference.10 Hip flexion range
of motion was reduced during the dorsi-
flexion version of the SLR test at both the

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01 Boyd.indd 786 10/15/09 4:25:43 PM


5% 5%
5% 15%
80%
10% 35% 20%
91–100%
81–90%
5%
71–80%
61–70%
PF-SLR at P1 PF-SLR at P2
51–60%
41–50%
31–40%
21–30%
11–20%
1–10%
0%
5% 10%
75% 5%
15% 60% 15%
5%
DF-SLR at P1 DF-SLR at P2
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.
onset and maximally tolerated symptoms. movement during SLR testing through
The lower bound of the CI exceeded the preloading of these neural structures.
minimal detectable change, indicating This is supported by previous findings of
that this difference was a real difference increased mechanical stress and strain on
in range.28 Our results are consistent with the sciatic, tibial, and plantar nerves dur-
a previous study that identified a signifi- ing ankle dorsiflexion.12
cant 9° reduction in hip range of motion Changes in muscle tone were expect-
by the addition of ankle dorsiflexion.5 ed to be small during SLR testing, and
We hypothesize that the SLR with ankle an appropriate threshold was necessary
plantar flexion does not preload the sciat- to determine meaningful differences.
ic, tibial, and plantar nerves, thus allow- A previous study of an upper limb neu-
ing the hip greater range of flexion before ral provocation test had documented a
the nerve complex undergoes sufficient statistically significant increase of ap-
mechanical stress to trigger a symptom- proximately 1.5 times the muscle activity
atic or motor response. Furthermore, we compared to resting levels in upper trape-
hypothesize that the SLR with ankle dor- zius muscle.2 We used this 50% increase
siflexion triggers an earlier restriction to in muscle electrical activity over resting
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 |
01 Boyd.indd 787
muscle tone as a conservative threshold
to define “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
85%
to a higher threshold for activation by an
average of 1.5% MVC compared to the
55% previously utilized methodology. It was
expected that stretch-induced increases
10% 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,
80%
which was active at P1. Progression of the
SLR from P1 to P2 triggered cocontrac-
80%
tions of antagonist muscle groups, as has
25%
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 Jull2 in an upper limb neuro-
dynamic test of healthy subjects. In con-
trast, van der Heide et al36 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 first 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 colleagues36
in their study of the response of biceps
brachii, triceps brachii, and trapezius in
an upper limb neurodynamic test.
The addition of dorsiflexion to the
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10/15/09 4:25:49 PM
 [ 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
first onset of symptoms in the DF-SLR
leads us to hypothesize that this is a pro-
tective reflexive 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 dorsiflexion.
As expected, during the SLR, symptoms
reported by healthy subjects differed 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 dorsiflexion
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 flexion.6 This
study also identified the frequent report of
deep symptoms that may follow a myoto-
mal or sclerotomal pattern.6
Some researchers have proposed the
788 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy
01 Boyd.indd 788
first onset of pelvic movement as an end
point for SLR testing when used as a low-
er extremity flexibility 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 flexion during the SLR
test even when the pelvis was strapped to
the table.4 Another study found that pel-
vic motion began after the first 10° and
that lumbar lordosis began to decrease
after 30° of hip flexion 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 cuff. 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 sufficient
information gathering and protection of
the person being tested? Our study has
shown excellent reliability of hip flexion
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 differenc-
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 specific to
]
ankle position, symptom intensity was not
discriminatory for ankle position, and P1
had already allowed for identifying reduc-
tions in range of hip flexion motion with
ankle dorsiflexion. 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 findings 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 different 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 influence of neuropathic and
nonneuropathic pain on the outcome of
the SLR in the asymptomatic limb.
Limitations of application of our
findings 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° difference
in hip flexion 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 influenced 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, different patient instructions,
10/15/09 4:25:50 PM
 and different range-of-motion measure-
ment tools. Clinically, full ankle dorsiflex-
ion range of motion can be used during
SLR (compared to dorsiflexion 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 defini-
tive conclusions based on the variability
in the EMG data found in our study. Pos-
sible cross talk between muscles could
have influenced the EMG findings. Be-
cause not all subjects respond with the
same muscle activation pattern, extrapo-
lation of our findings to clinical settings
could be unwarranted at this phase. A
better understanding of all of the possible
response patterns and why individuals
respond differently 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 first onset of symptoms is an as-
sessment tool that is highly reliable in as-
ymptomatic limbs of healthy individuals,
allowing for identification of meaningful
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 |
01 Boyd.indd 789
differences 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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790 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy

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