Manual Therapy 20 (2015) 103e108

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

The effects of a modied spinal mobilisation with leg movement

(SMWLM) technique on sympathetic outow to the lower limbs
Vasilis Tsirakis a, *, Jo Perry b
a
b

Physiotherapy Workplace, Koropi e Attiki (Athens), Georgiou Anagnostou 13 Street, Koropi 19400, Greece
Coventry University, UK

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 3 February 2014
Received in revised form
25 May 2014
Accepted 7 July 2014

Physiotherapy management of lumbar disorders, based on Mulligan's mobilization techniques, is a

treatment of choice by many physiotherapists, however, there is only limited evidence of any neurophysiological effects and much of this has focused on the cervical spine and upper limbs. This study aims
to extend the knowledge base underpinning the use of a modied Mulligan's spinal mobilisation with leg
movement technique (SMWLM) by exploring its effects on the peripheral sympathetic nervous system
(SNS) of the lower limbs. Using a single blind, placebo controlled, independent groups study design, 45
normal naive healthy males were randomly assigned to one of three experimental groups (control,
placebo or treatment; SMWLM). SNS activity was determined by recording skin conductance (SC) obtained from lower limb electrodes connected to a BioPac unit. Validation of the placebo technique was
performed by post- intervention questionnaire. Results indicated that there was a signicant change in
SC from baseline levels (30%) that was specic to the side treated for the treatment group during the
intervention period (compared to placebo and control conditions). This study provides preliminary evidence that a modied SMWLM technique results in side-specic peripheral SNS changes in the lower
limbs.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Mulligan
Mobilisation
Sympathetic outow
Lower limbs

1. Introduction
Manual therapy techniques based on Mulligan's concept, are
gaining increasing popularity for use in musculoskeletal conditions,
such as low back pain (LBP) and other disorders (Konstantinou et al.,
2007). Mulligan's techniques include sustained natural apophyseal
glides (SNAG'S), natural apophyseal glides (NAG'S) and mobilizations with movement (MWM'S). The application of these techniques
consists of a manual force, usually in the form of a glide, applied to a
motion segment and sustained while the patient actively performs
their painful or restricted movement (Vicenzino et al., 2007).
Mulligan (1993) originally suggested an underlying biomechanical
mechanism by which these techniques were effective, based on the
assumption that after an injury or a trauma, positional faults
occurred in the joint with resultant pain and dysfunction. Mulligan
(1993) proposed that by performing MWM techniques, the positional fault could be corrected, normal joint motion restored and
symptoms abated. However, there remains a scarcity of quality evidence to refute or support this proposed mechanism.
* Corresponding author. Tel.: 30 2106628863, 30 6948507377 (mobile).
E-mail address: tsirakis_vasilis@yahoo.gr (V. Tsirakis).
http://dx.doi.org/10.1016/j.math.2014.07.002
1356-689X/ 2014 Elsevier Ltd. All rights reserved.

A critical review of the literature regarding the possible mechanisms underpinning the benecial effects of Mulligan's techniques,
reported that the biomechanical hypothesis that MWM'S reverse
positional faults in not well established (Vicenzino et al., 2007).
Furthermore, despite patient reports of immediate pain relief, after
the performance of these techniques, magnetic resonance imaging
and X-rays have failed to conrm post-treatment alterations in the
position of the bones. Vicenzino et al. (2007) suggest that the immediate effects of Mulligan's techniques on pain reduction may be
neurophysiologically based (as measured by recordings of sympathetic nervous system e SNS- activity) by activating non-opioid
endogenous pain inhibition pathways. Specically, the descending
pain inhibitory systems via the peri-aquaductal gray (PAG) regions
in the mid-brain (Wright, 1995; Bialosky et al., 2009).
This theory was originally based on animal studies conducted by
Reynolds (1969) and Lovick (1991) who demonstrated that activation of the dorsal peri-aquaductal gray (dPAG) resulted in analgesia
in association with an excitatory response of the sympathetic nervous system (e.g. increased heart rate, increased blood pressure,
increase of respiration). Following that report, Wright (1995) and
Bialosky et al. (2009) advocate that manual therapy techniques may
activate these central inhibitory systems with resultant hypoalgesic

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V. Tsirakis, J. Perry / Manual Therapy 20 (2015) 103e108

and sympathoexcitatory responses being recorded in both normative and patient groups (Vicenzino et al., 1995; Sterling et al., 2001).
Supporting this concept, a number of authors have investigated
the neurophysiological responses to a variety of manual therapy
techniques by observing the effects of these techniques on pain
and/or on the sympathetic nervous system (SNS) (Vicenzino et al.,
1995, 1998; Sterling et al.,. 2001; Moulson and Watson, 2006; Perry
and Green, 2008; Perry et al., 2011). The results from these studies
suggested that manual therapy mobilization techniques induce an
immediate sympathoexcitatory response (Vicenzino et al., 1998;
Sterling et al., 2001; Moulson and Watson, 2006; Perry and
Green, 2008; Perry et al., 2011) that has been linked to a mechanical hypoalgesic effect (Vicenzino et al., 1998; Sterling et al.,. 2001).
However, research on Mulligan's SNAG'S and SNS activity is
limited to two studies, one in the cervical spine by Moulson and
Watson (2006), and the second in the lumbar spine by Moutzouri
et al. (2012). Both of these studies suggested that SNAG'S performed on the cervical (C5/6 segment) and lumbar (L4/5 segment)
regions elicit immediate bilateral sympathoexcitatory responses.
However, only Moutzouri et al. (2012) reported percentage changes
(PC) in skin conductance (SC) values (from baseline period to
treatment period) therefore limiting comparison to other studies.
Moutzouri et al. (2012) reported a PC in SC in the order of 11%. This
response corresponds to other reports of PC in SC of 16%, for a
unilaterally applied cervical spine mobilization (Sterling et al.,
2001) and 13.5% for an uni-laterally applied lumbar mobilization
(Perry and Green, 2008). Other authors, however, have documented
percentage changes in SC responses of greater magnitude with both
peripheral techniques (55% during an MWM to the elbow e
Paungmali et al., 2003) and for spinal treatments (35% for a
repeated extension in prone lying exercise and 75% for a lumbar
manipulative procedure e Perry et al., 2011). To date, no study has
investigated the immediate SNS activity responses to Mulligan's
lumbar spinal mobilisation with leg movement (SMWLM) technique, which is a technique, described by Mulligan (2004: page 77),
indicated for patient with LBP and radiating leg pain.
According to Mulligan (2004), this technique is performed by
two practitioners working as a team with one performing the
sustained medial glide on the patient's lumbar spinous process
whilst the other moves, passively, the patient's uppermost leg into
hip exion. Furthermore, Mulligan (2004) advocates that on the
patient's rst visit, this technique should be performed only three
times (rule of three) as a precaution against any latent exacerbation. Hence, following Mulligan's rule of three, after the performance of this technique, the patient's symptoms are eased and they
are able to achieve greater ROM in the straight-leg raise (SLR)
maneuver without radiating leg pain below the knee.
However, this study is looking at a modied version of this
technique since it's being performed by only one practitioner with
the assistance of a belt. The reasoning behind this modication is
that many physiotherapists work alone without having a second
physiotherapist to assist them. Additionally, this modied technique
has, anecdotally, been found to be effective in reducing a patient's
pain that is radiating below knee when performed by the investigator in a clinical setting. Thus, since the evidence for this technique
is anecdotal, this study aims to contribute to the evolving evidence
regarding the effects of manual therapy mobilization techniques.
2. Methodology
2.1. Participants
Data collection took place between September and November
2009. Forty ve healthy male volunteers from the Coventry University student population, consented to participate. Participants were

between the ages of 18e35 (mean 23.6 years, SD 4.58) with no

previous experience of spinal mobilization or any other physiotherapeutic intervention so as to not risk the placebo and control conditions. Furthermore, an all-male group was chosen, in order to avoid
the effect of variance which the female hormone progesterone has on
the skin conductance response (Venables and Christie, 1973 cited in;
Perry and Green, 2008). Table 1 summarizes the subjects anthropometric characteristics. All volunteers were further assessed for their
suitability using the exclusion criteria as described in the study by
Moulson and Watson (2006).
Perry and Green (2008), were the rst to investigate SNS activity
during a unilaterally applied lumbar spinal mobilization technique
recording SC values in control, placebo and treatment condition.
Based on their intra-subject standard deviation of 20.3% (treatment), a power analysis calculation revealed that 45 subjects (15
per group) would enable a difference in SC from baseline of 23.8% to
be detected at a signicance level of p 0.05 with 80% power.
Hence, the current study chose a 20.3% SC value difference as a
value that would represent a clinically signicant change.
2.2. Research design
A single-blind, independent (matched) group, between-subjects
experimental design was used. Fig. 1 illustrates the participants'
progress through the study. Each participant was randomly allocated to either the control, placebo or treatment group using the
third party concealed randomization method (Altman and Schulz,
2001). Specically, randomization was done using sequentially
numbered sealed envelopes each with a computer-generated
random number inside with each number representing an intervention. This limits the potential for researcher and order bias (Sim
and Wright, 2002).
To enhance the rigor of the study, a previously validated postexperiment questionnaire (Perry and Green, 2008) was utilized to
determine the validity of the placebo condition. Furthermore, the
set-up of the equipment ensured that both the treating therapist
and the participant remained blind to SNS activity responses during
the experimental period (Fig. 2). The interventions were performed
by the principal researcher who is a manual therapist (member of
the MACP) and Certied Mulligan Practitioner (CMP). Ethical
approval for the study was obtained from the Coventry University
ethics committee.
2.3. Research method and experimental conditions
An independent group, placebo-controlled randomized
controlled trial design was employed to test the null hypotheses that
there would be no difference within or between treatment groups
Table 1
Comparisons of characteristics of participants (age, weight and height) in each
experimental group (control, placebo and treatment group).
All subjects
Age (yrs)
Mean
23.6
Range
18e34
SD
4.58
Weight (kg)
Mean
75.2
Range
50e110
SD
10.8
Height (cm)
Mean
179.9
Range
160e198
SD
7.9

Control group

Placebo group

Treatment group

23.6
18e33
4.46

23.4
18e31
4.67

23.8
19e34
4.93

78.4
63e110
12.47

72.6
50e95
10.87

74.4
56e90
8.87

182.3
170e198
7.14

178.4
160e188
7.14

179
160e193
8.66

Kg kilograms; cm centimeters; SD standard deviation.

V. Tsirakis, J. Perry / Manual Therapy 20 (2015) 103e108

105

Fig. 1. Consolidated Standards of Reporting Trials (CONSORT) ow chart of study participant enrollment, treatment allocation and analysis.

or between limbs in SC responses. Participants lay in a standardized

position on their left side on the treatment plinth. Bilateral lower
limb skin conductance (SC) readings were simultaneously recorded
before, during and after each intervention by using silver/silver
chloride electrodes (12 mm electrode gel contact area). The skin was
prepared in accordance with standard protocol for Biopac measurement (Petersen, Vicenzino, & Wright, 1993, Chiu and Wright,
1996). The electrodes were applied to the plantar aspect of the
2nd and 3rd toes of both feet simultaneously, giving an independent, single reading for each foot. The selection of these toes was
due to the cutaneous branch of the medial plantar nerve (L4/5
segment), which supplies the plantar aspect of the 2nd and 3rd toes.
Following the protocol of previous researchers (Petersen et al.,
1993; Chiu and Wright, 1996; Perry and Green, 2008), all participants underwent an initial 10 min stabilization period followed by a
2 min baseline period. After that, the participant received one of

the three experimental conditions of 2 min duration each (called

the intervention period). Recordings were continued for further
2 min and this period was termed as the post-intervention period.
The three experimental conditions which were used in this study
are described as follows.
2.4. Modied SMWLM treatment technique
In this modied technique, the investigator performed a sustained medial glide on the side of the participant's fourth lumbar
spinous process through thumb pad pressure on the lamina. This
was sustained whilst the therapist passively moved the participants' uppermost (right) leg into hip exion which was performed
with the assistance of the belt (Fig. 3). The investigator sustained
the medial glide on the spinous process throughout the leg
movement and only when the participant's leg was returned

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V. Tsirakis, J. Perry / Manual Therapy 20 (2015) 103e108

Analysis of the SC data involved calculation of the Integral Measurement for baseline, intervention and nal rest periods (Perry
and Green, 2008). Intervention and nal rest period values were
then converted into percentage change (PC) from baseline, using
the mathematic formula below. The use of PC permits within and
between-participant comparisons of data and facilitates the comparison of data from this study with results in previous studies
(Perry and Green, 2008; Moutzouri et al., 2012):

PC

Ny
 100
y

(where y baseline reading; N new reading in the intervention

or nal rest period.)

Fig. 2. Experimental area set up (the screen ensured blinding of the participant and
the treating therapist from the SC recordings).

passively to the starting position was the glide released. This whole
procedure was repeated three times in accordance to Mulligan
(2004) rule of three.
2.5. The placebo intervention
For the placebo intervention, the procedure described above
was repeated with the exception that the investigator only positioned his hand on the spine but did not apply the accessory medial
glide to the participant's spinal segment. Only minimal pressure
was exerted and the participant's leg was slightly lifted by the belt
without any movement taking place into hip exion.
2.6. The control condition
For the control condition, the participant remained in the
standardized left side-lying neutral starting position. Furthermore,
in order to maintain the control condition parameters, the participant received no manual contact nor was the belt placed around
their leg.
2.7. Data collection methods
Physiological recording of SNS activity were measured by a
Biopac GSR100B Electro-dermal Activity Amplier (MP30, Biopac
Systems Inc., Santa Barbara, CA) utilizing SC activity measures.

3. Data analysis
Statistical analysis of the data was designed to test the three
elements of the hypothesis: (1) that the modied SMWLM technique in the treatment group would result in a PC in SC values from
baseline that were greater than those of the placebo and control
groups, (2) that any PC change observed would be greatest during
the intervention period compared to the post-intervention period
and (3) that any PC would be specic to the leg treated (ipsilateral/
right leg).
Data was described using PC values (mean, range, standard
deviation) and inferentially analyzed using the one-way ANOVA
(unrelated) test, since a single dependent variable (skin conductance) is tested under three experimental conditions and since
different participants are used for each condition (Greene and
D'Oliveira, 1982). All data were analyzed using the SPSS statistical
package (SPSS v.20). Statistically signicant differences between
the experimental groups were subjected to post hoc analyses to
identify where differences in SC responses and differences in the
post-treatment questionnaire results lay (Bonferroni test and
KruskaleWallis test, respectively). Throughout all analyses, the
statistical signicant p-value was set at p < 0.05 (two-tailed test).
4. Results
Homogeneity of participant data was assured indicating that the
groups were well matched regarding age (p 0.767), weight
(p 0.537) and height (p 0.726).
4.1. Skin conductance (SC) differences between and within groups

Fig. 3. Modied sustained spinal (L4/5 segment) mobilization with passive leg
movement (SMWLM) technique.

Descriptive data analyses of percentage change in SC readings

from the baseline for each of the experimental conditions and for
each leg in each time period are provided in Table 2. Fig. 4 illustrates
the distribution of skin conductance PC (%) values for the three
experimental conditions during the intervention period for the
right and the left leg.
Inferential statistical analysis (ANOVA) of the percentage change
SC data (Table 2) indicated that there was a signicant difference
between the three experimental conditions, the time periods and
the limbs (F 3.238; df 2; p 0.049). Post hoc analysis revealed
that this difference was with the treatment group (SMWLM technique) during the intervention period in the right leg (p 0.045).
Statistical analysis of the post-intervention (nal rest) period
revealed that there was no statistically signicant difference in
percentage change in SC values between the experimental groups
and the legs (right; F 0.711, df 2; p 0.497: Left; F 0.711,
df 2; p 0.497).

V. Tsirakis, J. Perry / Manual Therapy 20 (2015) 103e108

107

Table 2
Percentage change (PC) in SC readings from the baseline period (mean) standard error (S.E.) for each experimental condition (including post-hoc analysis) during the
intervention (PC1) and post-intervention (PC2) periods.
Experimental group and SC response per side (right or left leg)
Control

PC1 in SC
S.E. ()
PC2 in SC
S.E. ()

Placebo

Treatment

ANOVA

Post hoc analysis (Bonferroni)

p value (F value)
df 2

Control/
Placebo
p value

Placebo/
Treatment
p value

Control/
Treatment
p value

Right

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

Left

2.34
1.39
1.37
1.70

0.67
2.02
3.91
2.70

18.32
8.01
13.45
8.16

12.53
8.30
18.45
15.43

30.65a
11.00
11.16
11.82

15.42
13.43
14.80
11.65

0.049a (3.24)

0.146 (2.02)

0.478

0.946

0.045a

0.153

0.826

0.981

0.497 (0.71)

0.332 (0.33)

0.936

0.504

1.00

0.741

0.911

1.00

PC1: percentage change from baseline to intervention period.

PC2: percentage change from baseline to post-intervention period.
a
indicates a statistically signicant p-value, where the level of signicance is set at p  0.05.

4.2. Post-trial questionnaire

Analysis of the post-treatment questionnaire revealed that there
was no statistically signicant difference in the perception of the
participants as to whether they had received the treatment or the
placebo condition with all p values exceeding the signicance level
(p > 0.05).
5. Discussion
The results of this study suggest that a sustained medial glide on
the fourth lumbar spinous process (L4) with concurrent passive hip
exion (modied SMWLM technique) results in statistically signicant side-specic changes in peripheral SNS (SC) activity during
the intervention period with the uppermost (right) leg having
double the response (PC 30%) than the underneath (left) leg
(PC 15%). Moreover, responses were greater than those of both
the placebo and control conditions with no responses being
signicantly sustained (statistically) into the post-intervention
period. To the author's knowledge, no previous studies have

Fig. 4. Cluster boxplot illustrating the distribution of skin conductance percentage

change values for the three experimental conditions during the intervention period for
the right and left leg.

investigated whether Mulligan's SMWLM technique applied to the

lumbar spine would have a peripheral SNS effect in the lower limbs.
In the current study, the modied SMWLM technique presented
with an increase in SC of 30.6% (11) which is in agreement with
Vicenzino, Collins, and Wright (1994) who reported increase of 33%
with a C5 lateral glide technique, during the intervention period,
and with Perry et al. (2011), who reported an increase of 35% (for a
lumbar extension in lying exercise technique) and 76% (during a
lumbar manipulation procedure). In contrast, the reported change
in SNS activity for a unilaterally applied technique, in the study by
Perry and Green (2008), was 13.5% and just 16% with the technique
used by Sterling et al. (2001). Compared to these results, the greater
SC change found in the current study may be attributed to the fact
that the modied SMWLM technique is a combination of movements (a segmental glide mobilization technique and a passive hip
exion). Indeed, while the use of a segmentally applied unilateral
technique may be comparable, in terms of the manual therapy
nature of application, with the sympathoexcitatory responses reported by Perry and Green (2008) and Sterling et al. (2009), it is
unknown whether it is the spinal component that resulted in the
greater magnitude of response (almost twice that of the other reported unilateral techniques) or the addition of the hip exion
component in the current treatment. Consideration of these two
elements of the treatment may have implications regarding the
potential neurodynamic component of the treatment however, to
date there are no published studies that have investigated the
neurophysiological (SNS) responses to SLR maneuvers nor has the
isolation of the hip exion element been examined thereby making
data comparisons impracticable. Future studies are recommended
to investigate the potential for SLR maneuverrs, and the affects of
hip exion components within treatments, on SNS (SC) changes.
However, in support of the segmental inuence (over the limb
movement component) with respect to the SNS response recorded.
O'Leary et al. (2007) investigated the SNS responses to specic
cervical exercises and reported that no changes to SNS activity
levels were evoked with the treatment. Therefore, the movement
component does not appear to exert as great an effect as the
passive segmental mobilization although it may be argued that
cervical exercises are not comparable to the hip movement/excursion in the current study with respect to the potential challenge to
neurodynamic mobility.
It is noteworthy that the modied SMWLM technique applied in
this study resulted in greatest response on the side of treatment,
meaning that greatest SC responses were recorded in the ipsilateral
(right) leg rather than the contra-lateral (left) leg. This nding is in
agreement with the study of Perry and Green (2008) who were
the rst to report side-specic changes in SNS activity with the
application of a unilateral lumbar spine mobilization technique.

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V. Tsirakis, J. Perry / Manual Therapy 20 (2015) 103e108

However, other studies regarding the upper and lower quadrant

have reported bilateral responses (Sterling et al., 2001; Moulson
and Watson, 2006; Perry et al., 2011). A possible explanation for
this could be a difference in the spinal and central processing
mechanisms of the different treatment techniques (a unilaterally
applied technique versus a central SNAG or mobilization, a
segmental rotation technique versus a segmental lateral glide)
suggesting that different treatment techniques may induce either a
centrally mediated response (indicated by a bilateral response) or a
segmental spinal response (as indicated by a side-specic
response). Clearly, more research is required to support or
conrm these preliminary hypotheses and future research is recommended (on both healthy and symptomatic participants) to
develop and extrapolate these ndings into patient populations
with lumbar symptoms (with or without radiating leg pain).
Clinically, the results of the current study have possible implications for physiotherapeutic treatment of patients presenting with
low back pain with (and without) radiating leg pain.
5.1. Limitations
A limitation of the study was the use of an asymptomatic population because any effects of the SMWLM technique on mechanical hypoalgesia (and on symptoms) can only be speculated as
changes in pressure pain thresholds were not explored. Furthermore, the current study performed the treatment in accordance
with the fundamental treatment suggestions of Mulligans rule of
3 dosage however, it is not known what effects any modications
to the dosage (number and amplitude of repetitions) of the treatment may have had on the nature, the magnitude or the longevity
of the SNS response recorded and is an area of investigation that is
recommended for further study.
5.2. Conclusions
In conclusion, the ndings of this study did demonstrate a signicant sympatho-excitatory response during a SMWLM technique
and that signicant differences occur within individuals (right and
left legs) and between treatment, placebo and control groups.
Clinically, this may imply that a greater SNS response may be
observed on the uppermost leg during the SMWLM technique
which could, theoretically, imply a spinal response that may result,
hypothetically, in side-specic hypoalgesia. However, further
extrapolation of these ndings is highly recommended within a
clinical population.
References
Altman DG, Schulz KF. Concealing treatment allocation in randomised trials. Br Med
J 2001;323(7310):446e7.
Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of
manual therapy in the treatment of musculoskeletal pain: a comprehensive
model. Man Ther 2009;14(5):531e8.

Chiu TW, Wright A. To compare the effects of different rates of application of cervical mobilization technique on sympathetic outow to the upper limb in
normal subjects. Manual Therapy 1996;1(4):198e203.
Greene J, D'Oliveira M. Learning to use statistical tests in psychology: a student's
guide. Milton Keynes (England): The Open University Press; 1982.
Konstantinou K, Foster N, Rushton A, Baxter D, Wright C, Math C, et al. Flexion
mobilization with movement techniques: the immediate effects on range of
movement and pain in subjects with low back pain, the immediate effects on
range of movement and pain in subjects with low back pain. J Manip Physiol
Ther 2007;30(3):178e85.
Lovick TA. Interactions between descending pathways from the dorsal and
ventrolateral periaqueductal grey matter in the rat. In: Depaulis A, Bandiler R,
editors. The midbrain periaqueductal gray matter: Functional, Anatomical and
Neurochemical Organization. New York: Plenum Press; 1991. pp. 101e20.
Moulson A, Watson T. A preliminary investigation into the relationship between
cervical snags and sympathetic nervous system activity in the upper limbs of an
asymptomatic population. Man Ther 2006;11(3):214e24.
Moutzouri M, Perry J, Billis E. Investigation of the effects of a centrally applied
lumbar sustained natural apophyseal glide mobilization on lower limb sympathetic nervous system activity in asymptomatic subjects. J Manip Physiol
Ther 2012;35(4):286e94.
Mulligan BR. Manual therapy: NAGS, SNAGS, MWMS etc. 5th ed. New Zealand:
Plane View Services Ltd; 2004.
Mulligan BR. Mobilisation with movement (MWM's). J Man Manip Ther 1993;1(4):
154e6.
O'Leary FD, Hodges P, Jull G, Vicenzino B. Specic therapeutic exercise of the neck
induces immediate local hypoalgesia. J Pain 2007;8:832e9.
Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory
effects of mobilization with movement for lateral epicondylalgia. Phys Ther
2003;83(4):374e83.
Perry J, Green A, Singh S, Watson P. A preliminary investigation into the magnitude
of effect of lumbar extension exercises and a segmental rotator manipulation on
sympathetic nervous system activity. Man Ther 2011;16(2):190e5.
Perry J, Green A. An investigation into the effects of a unilaterally applied lumbar
mobilization technique on peripheral sympathetic nervous system activity in
the lower limbs. Man Ther 2008;13(6):492e9.
Petersen N, Vicenzino B, Wright A. The effects of a cervical mobilization technique
on sympathetic outow to the upper limb in normal subjects. Physiotherapy
and Practice 1993;9(2):149e56.
Reynolds DV. Surgery in the rat during electrical analgesia by focal brain stimulation. Science 1969;164(878):444e5.
Sim J, Wright C. Research in health care: concepts, designs and methods. Cheltenham: Nelson Thornes Ltd; 2002.
Sterling M, Jull G, Wright A. Cervical mobilization: concurrent effect on pain,
sympathetic nervous system activity and motor activity. Man Ther 2001;6(2):
72e81.
Venables PH, Christie MJ. Mechanisms, instrumentation, recording techniques and
qualications of responses. In: Prokasy WF, Raskin DC, editors. Electrodermal
activity in psychological research. New York: Academic Press; 1973. pp. 41e73.
Cited in Perry, J., and Green, A. (2008) An investigation into the effects of a
unilaterally applied lumbar mobilization technique on peripheral sympathetic
nervous system activity in the lower limbs. Manual Therapy 13(6), 492e499.
Vicenzino B, Collins D, Wright A. Sudomotor changes induced by neural mobilization techniques in asymptomatic subjects. Journal of Manual and Manipulative
Therapy 1994;2(2):66e74.
Vicenzino B, Paungmali A, Teys P. Mulligan's mobilization-with-movement, positional faults and pain relief: current concepts from a critical review of literature.
Man Ther 2007;12(2):98e108.
Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship
between manipulative therapy-induced hypoalgesia and sympathoexcitation.
J Manip Physiol Ther 1998;21(7):448e53.
Vicenzino B, Gutschlag F, Collins D, Wright A. An investigation of the effects of
spinal manual therapy on forequarter pressure and thermal pain thresholds and
sympathetic nervous system activity in asymptomatic subjects: a preliminary
report. In: Shacklock M, editor. Moving in on pain. Sydney: Butterworth-Heinemann; 1995. pp. 185e93.
Wright A. Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Man Ther 1995;1(1):11e6.