neural mobilization-a systematic review of randomized controlled
TRANSCRIPT
8 / The Journal of Manual & Manipulative Therapy, 2008
Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Effi cacy
Richard F. Ellis, B. Phty, Post Grad DipWayne A. Hing, PT, PhD
Abstract: Neural mobilization is a treatment modality used in relation to pathologies of the nervous system. It has been suggested that neural mobilization is an effective treatment modality, although support of this suggestion is primarily anecdotal. The purpose of this paper was to provide a systematic review of the literature pertaining to the therapeutic effi cacy of neural mobilization. A search to identify randomized controlled trials investigating neural mobilization was conducted using the key words neu-ral mobilisation/mobilization, nerve mobilisation/mobilization, neural manipulative physical therapy, physical therapy, neural/nerve glide, nerve glide exercises, nerve/neural treatment, nerve/neural stretch-ing, neurodynamics, and nerve/neural physiotherapy. The titles and abstracts of the papers identifi ed were reviewed to select papers specifi cally detailing neural mobilization as a treatment modality. The PEDro scale, a systematic tool used to critique RCTs and grade methodological quality, was used to as-sess these trials. Methodological assessment allowed an analysis of research investigating therapeutic effi cacy of neural mobilization. Ten randomized clinical trials (discussed in 11 retrieved articles) were identifi ed that discussed the therapeutic effect of neural mobilization. This review highlights the lack in quantity and quality of the available research. Qualitative analysis of these studies revealed that there is only limited evidence to support the use of neural mobilization. Future research needs to re-examine the application of neural mobilization with use of more homogeneous study designs and pathologies; in addition, it should standardize the neural mobilization interventions used in the study.
Keywords: Neural Mobilization, Neurodynamics, Randomized Controlled Trial, Systematic Review, Therapeutic Effi cacy.
In the past, neural tension was used to describe dysfunc-tion of the peripheral nervous system. More recently, there has been a shift away from a purely mechanical
rationale to include physiological concepts such as structure and function of the nervous system. Neurodynamics is now a more accepted term referring to the integrated biome-chanical, physiological, and morphological functions of the nervous system1-4. Regardless of the underlying construct, it is vital that the nervous system is able to adapt to mechani-
cal loads, and it must undergo distinct mechanical events such as elongation, sliding, cross-sectional change, angula-tion, and compression. If these dynamic protective mecha-nisms fail, the nervous system is vulnerable to neural edema, ischaemia, fi brosis, and hypoxia, which may cause altered neurodynamics1,2.
When neural mobilization is used for treatment of ad-verse neurodynamics, the primary theoretical objective is to attempt to restore the dynamic balance between the relative movement of neural tissues and surrounding mechanical interfaces, thereby allowing reduced intrinsic pressures on the neural tissue and thus promoting optimum physiologic function1,2,4-7. The hypothesized benefi ts from such tech-niques include facilitation of nerve gliding, reduction of nerve adherence, dispersion of noxious fl uids, increased neural vas-cularity, and improvement of axoplasmic fl ow1,2,4-10. However, these etiological mechanisms for the clinically observed ef-fects of neural mobilization still require robust validation. At present, the positive clinically observed effect of neural mo-
Address all correspondence and requests for reprints to: Richard Ellis LecturerSchool of PhysiotherapyAuckland University of Technology (AUT)Private Bag 92006 Auckland New Zealand 1020E-mail: [email protected]
The Journal of Manual & Manipulative TherapyVol. 16 No. 1 (2008), 8–22
Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy / 9
bilization is mainly based on anecdotal evidence. Therefore, the purpose of this paper was to systematically review and assess the therapeutic effi cacy of neural mobilization for treatment of altered neurodynamics through evaluation of appropriate randomized controlled trials (RCTs). It was hy-pothesized that the fi ndings might guide evidence-based practice in the clinical application of neural mobilization.
Methods
Literature Search Strategy
A search to identify RCTs examining neural mobilization was conducted in March 2007. The following electronic databases were searched: MEDLINE via PubMed (from 1966 onwards), Cumulative Index to Nursing and Allied Health Literature
(CINAHL) (from 1982 onwards), the Cochrane Controlled Trials Register in the Cochrane Library (latest edition), SPORT-Discus (from 1830 onwards), Allied and Complemen-tary Medicine Database (AMED) (from 1985 onwards), Physiotherapy Evidence Database (PEDro) (from 1953 on-wards), ProQuest 5000 International, ProQuest Health and Medical Complete, EBSCO MegaFile Premier, Science Direct (from 1995 onwards) and Web of Science (from 1945 onwards).
The search strategy of these databases included terms and keywords related to the intervention: neural mobilisa-tion/mobilization, nerve mobilisation/mobilization, neural manipulative physical therapy, physical therapy, neural/nerve glide, nerve glide exercises, nerve/neural treatment, nerve/neural stretching, neurodynamics and nerve/neural physiotherapy. Randomized controlled trial or RCT was the key term used in relation to the methodology of the studies.
TABLE 1. PEDro Scale (modifi ed from Maher et al13).
Score
Criteria No Yes
1. Eligibility criteria were specifi ed*
2. Subjects randomly allocated to groups NO (0) YES (1)
3. Allocation was concealed NO (0) YES (1)
4. Groups similar at baseline regarding the most important prognostic factors NO (0) YES (1)
5. Blinding of all subjects NO (0) YES (1)
6. Blinding of all therapists who administered therapy NO (0) YES (1)
7. Blinding of all assessors who measured at least one outcome NO (0) YES (1)
8. Measures of at least one key outcome were obtained from more than 85% of initially allocated subjects NO (0) YES (1)
9. All subjects for whom outcome measures were available received treatment or control as allocated, or if this was not the case, at least one outcome measure analysed using “intention to treat” analysis NO (0) YES (1)
10. The results of between-group statistical comparisons are reported for at least one key outcome NO (0) YES (1)
11. The study provides both point measures and measures or variability for at least one key outcome NO (0) YES (1)
Total N/10
* Criteria 1 score is not included in the overall PEDro rating.
10 / The Journal of Manual & Manipulative Therapy, 2008
TABLE 2. Randomized controlled trials of neural mobilization as a treatment modality in order of PEDro score.
Scores for PEDro Criteria
Methodological 1* 2 3 4 5 6 7 8 9 10 11 QS Quality IVS
Cleland et al27 1 1 1 1 0 0 1 1 1 1 1 8 Moderate 5
Coppieters et al8
(Cervical lateral 1 1 1 1 0 0 1 1 1 1 1 8 Moderate 5 glide treatment)
Tal-Akabi & Rushton31 1 1 1 1 0 0 1 1 1 1 1 8 Moderate 5
Pinar et al30 1 1 1 1 0 0 1 1 1 1 1 8 Moderate 5
Baysal et al26 1 1 1 1 0 0 1 1 1 1 1 8 Moderate 5
Allison et al25 1 1 1 0 0 0 1 1 1 1 1 7 Moderate 5
Coppieters et al28
(Neural 1 1 1 0 0 0 1 1 1 1 0 6 Moderate 5 provocation)
Akalin et al24 1 1 0 1 0 0 0 1 1 1 1 6 Limited 3
Scrimshaw & Maher10 1 1 0 0 0 0 1 1 1 1 1 6 Moderate 4
Vicenzino et al32 1 1 0 0 0 0 1 1 1 1 1 6 Moderate 4
Drechsler et al29 1 1 0 0 0 0 0 1 1 1 1 5 Limited 3
Note: QS = overall quality score; IVS = internal validity score.
*Criteria 1 score is not included in the overall PEDro rating.
The titles and/or abstracts of these citations were reviewed to identify papers specifi cally detailing neural mobilization used as a treatment modality. The search was limited to stud-ies written in or translated to English and those utilizing human subjects. There was no limitation regarding the date the studies were published, other than the date limitations of each selected database. In addition, the reference lists of each paper were searched to identify other relevant papers.
Study Selection
The method for selection of relevant studies was consistent with suggested guidelines for conducting systematic re-views11. The following inclusion criteria were used to select relevant papers for the review:
• Type of participant: participants older than 18, of either gender, and with a clinical diagnosis consistent with neurodynamic dysfunction (musculoskeletal conditions with symptoms of pain and/or paresthesia indicative of compromise of the peripheral nervous system).
• Type of study design: randomized controlled trials.
• Type of intervention: use of a manual or exercise tech-nique designed to have a direct effect on neural tissue with the purpose of dynamically infl uencing (e.g., slid-ing, stretching, moving, mobilizing etc.) the neural tissue.
• Outcome measurements: at least one of the following outcome measurements used to assess the status of the nervous system: pain rating (e.g., Visual Analogue Scale [VAS], function-specifi c pain VAS (i.e., work- or sport-related pain), pain and or range of movement (ROM) during neural tissue provocation tests (NTPT), func-tional disability scores (e.g., Short-form McGill Pain Questionnaire, Northwick Park Questionnaire, and Os-westry Disability Index).
Methodological Quality Assessment
Three reviewers independently assessed the methodological quality of each RCT. The PEDro Scale (Table 1), developed by The Centre of Evidence-Based Physiotherapy (CEBP), was utilized to assess each paper12. The PEDro Scale, an 11-item scale, is a validated, reliable, and versatile tool used to rate
Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy / 11
RCTs for the PEDro Database13-15. The PEDro scale has been used as a measure of methodological quality in many systematic literature reviews16-20.
An overall score of methodological quality, or quality score (QS), was determined for each paper by each of the three reviewers as a total of positive scores for 10 of the 11 items (i.e., N/10). Unlike the other items, Criterion One of the PEDro scale relates to external validity and was not used in the fi nal total PEDro score13,15. A consensus method was used to discuss and resolve discrepancies between the mark-ings of each paper between the reviewers. The agreed QS for each paper is included in Table 2.
The various items of the PEDro Score deal with different aspects of RCT analysis including internal validity, external validity, and statistics. In order to allow quantitative analysis of the methodological quality of a systematic review, van Tul-der et al11 recommended the analysis of the internal validity criteria of any rating tool. For the PEDro Scale, seven items relating to internal validity were identifi ed. These seven items include items 2, 3, and 5 through 9 (Table 1). An inter-nal validity score (IVS) has also been used in other system-atic reviews21 to allow calculation of the number of internal validity criteria met for that particular rating system and to thereby give an assessment of methodological quality. It was decided to calculate an IVS for this review based on the rele-vant internal validity criteria of the PEDro Scale. The posi-tive scores of each of these seven items were added together to calculate the IVS (Table 2).
To stratify methodological quality, the summated score of the 7-item IVS, calculated from the initial PEDro score (QS), was divided into three categories. A study of high meth-odological quality obtained IVS values of 6–7, a moderatequality obtained IVS values between 4–5, and a limited qual-ity was scored between 0–3. This decision was made based on even cut-off points between 0 and 7.
Analysis of Therapeutic Effi cacy
When RCTs are heterogeneous, there is no available method to quantitatively assess the relative benefi t (or lack thereof) of one intervention versus another because the studies com-pare dissimilar patient populations or interventions. In situ-ations where the heterogeneity of primary studies prevents use of a quantitative meta-analysis to summarize the results, recommendations are typically made based on a qualitative assessment of the strength of the evidence21. The RCTs re-viewed for this paper were considered heterogeneous be-cause they explored a variety of pathologies and different types of neural mobilization techniques. Consequently, a quantitative meta-analysis was not appropriate and results were analyzed in a qualitative fashion. The qualitative assess-ment involved the following categories scored specifi cally for each type of intervention:
• Level 1: Strong evidence: provided by generally consis-tent fi ndings in multiple RCTs of high quality.
• Level 2: Moderate evidence: provided by generally con-sistent fi ndings in one RCT of high quality and one or more of lower quality.
• Level 3: Limited evidence: provided by generally consis-tent fi ndings in one RCT of moderate quality and one or more low-quality RCTs.
• Level 4: Insuffi cient evidence: provided by generally consistent fi ndings of one or more RCTs of limited qual-ity, or when no RCTs were available, or when studies provided confl icting results.
Clinical Benefi t
Lastly, to determine whether a clinical benefi t for neural mobilization could be concluded, a ranking system similar to that used by Linton and van Tulder11 was used. A positive effect was concluded if the intervention (i.e., neural mobilization) was statistically signifi cantly more benefi cial compared to the control for at least one key outcome variable, a negative effect if the intervention was less effective than the control, and a neutral effect was concluded where the intervention and control did not statistically differ signifi cantly for any of the outcome variables23.
Results
Selection of Studies
Ten RCTs, represented by 11 published articles8,10,24-32, satis-fi ed the inclusion criteria following the electronic and man-ual reference list searches. The articles published by Cop-pieters et al8,28 are from the same subject group and were thus classifi ed as one RCT.
Methodological Quality
The methodological quality for each paper, represented by the IVS, is detailed in Table 2. Nine of 11 studies8,10,25-28,30-32
reviewed were given an IVS of 4 or 5 and were of moderate methodological quality. Two of the studies24,29 were given an IVS of 3, suggesting limited methodological quality. Table 3 presents statistics relating to the percentage of each item that was satisfi ed for an IVS score.
All of the 11 studies satisfi ed the items relating to ran-dom allocation of subjects, measures of one key outcome taken from greater than 85% of the population, use of inten-tion-to-treat analysis (where this was required due to a drop-out group), and results of statistical analysis reported (items 2, 8, 9, and 10). All 11 studies did not satisfy items 5 and 6, which relate to subject and therapist blinding. Two stud-
12 / The Journal of Manual & Manipulative Therapy, 2008
ies24, 29 did not satisfy item 7, which relates to rater blinding. This suggests that these two studies lacked all three forms of blinding (subject, therapist, and rater). The other 9 studies were single-blinded (rater-blinded) studies. There was no clear trend established for item 4, which relates to concealed allocation of subjects.
Study Characteristics
All ten RCTs used different methods of application of neural mobilization (e.g., cervical lateral glide, slump sliders, pe-ripheral nerve sliders, etc.), and some studies chose to com-bine these techniques with home-based neural mobilization exercises. There were also differing neurodynamic dysfunc-tions examined, including lateral epicondylalgia, carpal tun-nel syndrome, post-operative spinal surgery, non-radicular low back pain, and neurogenic cervico-brachial pain syn-drome. Therefore, all ten RCTs were clinically and therapeu-tically heterogeneous, necessitating a qualitative analysis for summarizing the results. Table 4 contains details of study characteristics.
Therapeutic Effi cacy
Of the 11 studies identifi ed, 6 different categories or types of treatment were identifi ed (Table 5). Using the qualitative rat-ing system, as mentioned earlier, it appears there is limited evidence (Level 3) to support the use of neural mobilization that involves active nerve and fl exor tendon gliding exercises of the forearm24,26,30, cervical contralateral glides8,28,32, and
Upper Limb Tension Test 2b (ULTT2b) mobilization29,31 in the treatment of altered neurodynamics or neurodynamic dys-function. There was inconclusive evidence (Level 4) to sup-port the use of neural mobilization involving slump stretches27 and combinations of neural mobilization tech-niques10,25 in the treatment of altered neurodynamics or neu-rodynamic dysfunction.
Clinical Benefi t
Table 4 lists the study details of the 11 studies. More studies found a positive effect8,24-28,30,32 than a neutral effect10,29,31 .
Discussion
A search to identify RCTs investigating neural mobilization yielded 11 studies that met the inclusion criteria for this re-view. Analyses of these studies, using the criteria of Linton and van Tulder11, indicated that 8 of the 11 studies8,24-28,30,32
concluded a positive benefi t from using neural mobilization in the treatment of altered neurodynamics or neurodynamic dysfunction. Three of the 11 studies10,29,31 concluded a neu-tral benefi t, which suggests that neural mobilization was no more benefi cial than standard treatment or no treatment. Nine of the 11 studies8,10,25-28,30-32 reviewed demonstrated moderate methodological quality; the two remaining stud-ies24,29 yielded limited methodological quality. Studies exhib-ited weaknesses in random allocation, intention to treat, concealed allocation, and blinding; consequently, our ability
TABLE 3. Number and percentage of the studies meeting each PEDro criteria.
Number Percent meeting meetingPEDro Criteria criterion (N) criterion (%)
1 Eligibility criteria specifi ed (yes/no) 11 100
2. Subjects randomly allocated to groups (yes/no) 11 100
3. Allocation was concealed (yes/no) 7 64
4. Groups similar at baseline (yes/no) 6 55
5. Subjects were blinded to group allocation (yes/no) 0 0
6. Therapists who administered therapy were blinded (yes/no) 0 0
7. Assessors were blinded (yes/no) 9 82
8. Minimum 85% follow-up (yes/no) 9 100
9. Intent to treat analysis for at least 1 key variable (yes/no) 9 100
10. Results of statistical analysis between groups reported (yes/no) 9 100
11. Point measurements and variability reported (yes/no) 10 91
TAB
LE 4
. Ra
ndom
ized
con
trol
led
tria
ls o
f neu
ral m
obili
zati
on a
s a
trea
tmen
t mod
alit
y .
Pa
tien
t In
terv
enti
on
Com
pari
son
Aut
hor
dem
ogra
phic
s G
roup
(IG
) G
roup
(CG
) O
utco
me
Resu
lt
IVS
QS
Cle
land
et
al27
N=
30 (
9 m
ale,
21
fem
ale)
16
sub
ject
s w
ith
14 s
ubje
cts
wit
h O
utco
mes
wer
e m
easu
red
No
base
line
diffe
renc
es
5 8
—
Age
rang
e 18
–60
year
s lo
w b
ack
pain
lo
w b
ack
pain
pr
e- a
nd p
ost-
trea
tmen
t be
twee
n gr
oups
(p>
0.0
5).
—
Mea
n ag
e (y
ears
) Sa
me
as c
ontr
ol p
lus:
5-
min
ute
cycl
e 1)
Bod
y di
agra
m (
for
At d
isch
arge
, pat
ient
s w
ho
IG 4
0.0
( ±
12.2
),
Slum
ped
stre
tchi
ng
war
m-u
p di
stri
buti
on o
f sym
ptom
s)
rece
ived
slu
mpe
d st
retc
hing
C
G 3
9.4
(±11
.3)
ex
erci
se (
posi
tion
Lu
mba
r sp
ine
2)N
umer
ic p
ain
rati
ng
dem
onst
rate
d si
gnifi
cant
ly
Dur
atio
n sy
mpt
oms
held
30
seco
nds,
m
obili
zati
on
scal
e (N
PRS)
gr
eate
r im
prov
emen
ts
(wee
ks)
IG 1
4.5
(±8.
0),
5 re
peti
tion
s)
(Pos
teri
or-a
nter
ior
3)M
odifi
ed O
swes
try
in d
isab
ility
(9.
7 po
ints
C
G 1
8.5
(±12
.5)
H
ome
exer
cise
m
obili
zati
ons
to
disa
bilit
y in
dex
(OD
I)
on t
he O
DI,
p<
0.0
01),
sl
ump
stre
tche
s hy
pom
obile
lum
bar
4)Fe
ar a
void
ance
pa
in (
0.93
poi
nts
on t
he N
PRS,
(2
rep
etit
ions
se
gmen
ts, g
rade
3–4
) be
liefs
que
stio
nnai
re
p=0.
001)
, and
cen
tral
izat
ion
for
30 s
econ
ds)
Stan
dard
ized
of s
ympt
oms
(p<
0.01
) th
an
2
x w
eek
for
3 w
eeks
ex
erci
se p
rogr
am
pa
tien
ts w
ho d
id n
ot.
(p
elvi
c ti
lts,
bri
dgin
g,
Th
e be
twee
n-gr
oup
sq
uats
, qua
drup
ed
co
mpa
riso
ns s
ugge
st t
hat
al
tern
ate
arm
/leg
sl
ump
stre
tchi
ng is
ac
tivi
ties
; 2 s
ets
be
nefi c
ial f
or im
prov
ing
10
rep
etit
ions
shor
t-te
rm d
isab
ility
,
each
exe
rcis
e)
pa
in, a
nd c
entr
aliz
atio
n
2 x
wee
k fo
r 3
wee
ks
of
sym
ptom
s.
Bay
sal e
t al
26
N=
36 (
36 fe
mal
e
Gro
up 1
(N
=12
)
Exp
erim
enta
l gro
ups
All m
easu
res
No
sign
ifi ca
nt d
iffer
ence
s 4
8
pati
ents
—al
l wit
h cl
inic
al
cust
om m
ade
neut
ral
1 an
d 3
that
pr
e-R
x, e
nd o
f Rx,
be
twee
n gr
oups
at
the
an
d el
ectr
ophy
siol
ogic
al
vola
r sp
lint
(wor
n fo
r in
corp
orat
ed n
erve
an
d 8
wee
ks F
/U
end
of R
x an
d 8
wee
ks
evid
ence
of C
TS
3 w
eeks
); e
xerc
ise
glid
ing
exer
cise
s 1.
pai
n (V
AS)
follo
w-u
p of
all
mea
sure
s
All w
ith
bila
tera
l th
erap
y (n
erve
and
an
d a
com
pari
son
2. T
inel
’s si
gn
of T
reat
men
t E
ffect
in
volv
emen
t te
ndon
glid
ing
grou
p th
at d
id n
ot
3. P
hale
n’s
sign
(m
easu
res
1, 5
, 6, 7
, 8, 9
, 10)
M
ean
age—
ex
erci
ses
as d
escr
ibed
in
corp
orat
e th
ese
4.
mea
n st
atic
tw
o-po
int
Wit
hin
grou
p co
mpa
riso
ns
Grp
1 4
7.8
± 5
.5;
by T
otte
n &
Hun
ter,
exer
cise
s.
disc
rim
inat
ion—
pulp
sh
owed
sig
nifi c
ant
G
rp 2
50.
1 ±
7.3
; 19
91)
5 se
ssio
ns d
aily
, C
ompa
riso
n be
twee
n of
rad
ial t
hree
dig
its
impr
ovem
ent
seen
in a
ll
Grp
3 5
1.4
± 5
.2
each
exe
rcis
e re
peat
ed
grou
ps 2
and
3 a
s th
e 5.
han
d-gr
ip s
tren
gth—
3
grps
in T
inel
s an
d Ph
alen
’s
Mea
n du
rati
on o
f 10
x/se
ssio
n—fo
r 3
wee
ks
only
diff
eren
ce
hand
-hel
d dy
nam
omet
er
sign
s at
end
of R
x an
d 8
sy
mpt
oms
(yea
rs)—
G
roup
2—
(N=
12)
in
inte
rven
tion
6.
pin
ch s
tren
gth—
w
eeks
follo
w-u
p
Grp
1 1
.5 ±
1.6
; cu
stom
mad
e ne
utra
l pr
ogra
ms
was
tha
t be
twee
n th
umb
and
Sign
ifi ca
nt im
prov
emen
t
Grp
2 1
.4 ±
0.8
; vo
lar
splin
t (w
orn
for
grou
p 3
used
ner
ve
littl
e fi n
ger—
se
en in
all
3 gr
ps in
gri
p
Grp
3 1
.4 ±
0.8
3
wee
ks);
Ult
raso
und
gl
idin
g ex
erci
ses
dyna
mom
eter
an
d pi
nch
stre
ngth
at
8
8 ev
entu
al d
ropo
uts
(15m
in/s
essi
on t
o pa
lmar
an
d gr
oup
2 di
d no
t.
7. s
ympt
om-s
ever
ity
wee
ks fo
llow
-up.
carp
al t
unne
l, 1m
hz,
sc
ale
ques
tion
nair
e N
o ch
ange
s se
en in
tw
o-pt
(11
item
s)
disc
rim
inat
ion
TAB
LE 4
. Ra
ndom
ized
con
trol
led
tria
ls o
f neu
ral m
obili
zati
on a
s a
trea
tmen
t mod
alit
y (c
ontin
ued)
.
Pa
tien
t In
terv
enti
on
Com
pari
son
Aut
hor
dem
ogra
phic
s G
roup
(IG
) G
roup
(CG
) O
utco
me
Resu
lt
IVS
QS
1.0w
/cm
2, 1
:4, 5
cm2
8. fu
ncti
onal
sta
tus
scal
e W
ithi
n-gr
oup
anal
ysis
sho
wed
tran
sduc
er)
1 R
x/da
y,
qu
esti
onna
ire
(8 it
ems)
si
gnifi
cant
impr
ovem
ent
ever
y 5
days
for
3 w
eeks
9. m
edia
n m
otor
ner
ve
in p
ain,
sym
ptom
and
(tot
al 1
5 R
x’s)
cond
ucti
on—
mot
or
func
tion
al s
cale
s of
all
Gro
up 3
—(N
=12
)cu
stom
dist
al la
tenc
y E
MG
th
ree
grou
ps a
t en
d-R
xm
ade
neut
ral v
olar
spl
int
of a
bduc
tor
polli
cis
and
8 w
eeks
follo
w-u
p
(w
orn
for
3 w
eeks
);
10
. sen
sory
dis
tal
Grp
3 h
ad s
igni
fi can
tly
exer
cise
the
rapy
late
ncy—
EM
G o
f th
e be
st r
esul
ts a
t 8
wee
ks
(n
erve
and
ten
don
abdu
ctor
pol
licis
fo
llow
-up
pati
ent
glid
ing
exer
cise
s as
11. n
eedl
e E
MG
of
sati
sfac
tion
que
stio
nnai
re
de
scri
bed
by T
otte
n
ab
duct
or p
ollic
is
Med
ian
sens
ory
dist
al
&
Hun
ter,
1991
)
br
evis
—lo
okin
g fo
r la
tenc
y si
gnifi
cant
ly
5
sess
ions
dai
ly,
de
nerv
atio
n de
crea
sed
in g
rps
1 an
d 3
each
exe
rcis
e re
peat
ed
12
. pat
ient
sat
isfa
ctio
n at
end
-Rx
and
8 w
eeks
10x/
sess
ion—
cont
inue
d
su
rvey
(at
8w
eeks
fo
llow
-up
for
3 w
eeks
; Ult
raso
und
follo
w-u
p on
ly)
No
sign
ifi ca
nt c
hang
e
(1
5min
utes
/ses
sion
to
se
en in
med
ian
mot
or
pa
lmar
car
pal t
unne
l,
dist
al la
tenc
y of
all
3 gr
ps
1m
hz, 1
.0w
/cm
2, 1
:4,
P<0.
05
5c
m2
tran
sduc
er)
In
sum
mar
y, b
etw
een-
1 R
x/da
y, e
very
5 d
ays
gr
oup
anal
ysis
rev
eale
d
fo
r 3
wee
ks (
tota
l 15
Rx’
s)
no
diffe
renc
e be
twee
n gr
oups
,
but
wit
hin-
grou
p an
alys
is
sh
owed
tha
t al
l gro
ups
im
prov
ed a
sta
tist
ical
ly
si
gnifi
cant
am
ount
for
a
maj
orit
y of
out
com
e m
easu
res.
Pina
r et
al30
N
=26
( fe
mal
e)
14 p
atie
nts
(19
hand
s)
12 p
atie
nts
(16
hand
s)
Und
erta
ken
befo
re
Bet
wee
n-gr
oup
com
pari
sons
5
8
Age
rang
e 35
–55
year
s pa
tien
ts d
iagn
osed
pa
tien
ts d
iagn
osed
an
d af
ter
a 10
-wee
k fo
r th
ese
sam
e va
riab
les
D
urat
ion
of s
ympt
oms
w
ith
earl
y-m
iddl
e w
ith
earl
y-m
iddl
e tr
eatm
ent
prog
ram
. sh
owed
no
stat
isti
cally
(m
o)
stag
es C
TS
stag
es C
TS
1. T
inel
Tes
t si
gnifi
cant
diff
eren
ces
C
G 4
7.6
(± 6
.8),
In
add
itio
n to
spl
int
Trea
ted
in v
olar
2.
Pha
len
Test
pr
e-tr
eatm
ent
or p
ost-
trea
tmen
t,
IG
49.
6 (±
5.2
) w
eari
ng a
nd p
atie
nt
splin
t in
neu
tral
3
Pain
( V
AS)
over
a d
ay
so t
he g
roup
s w
ere
sim
ilar.
trai
ning
pro
gram
w
orn
day
& n
ight
4.
Mot
or F
unct
ion—
B
oth
grou
ps m
ade
stat
isti
cally
trea
ted
wit
h ne
rve
fo
r 6-
wee
ks, t
hen
man
ual m
uscl
e te
stin
g,
sign
ifi ca
nt im
prov
emen
ts
gl
idin
g ex
erci
ses
10
nigh
t on
ly fr
om
and
grip
str
engt
h in
pai
n, p
inch
& g
rip
stre
ngth
,
re
peti
tion
s 5
sets
a
wee
k 6-
10, a
nd a
(J
amar
han
d an
d se
nsit
ivit
y te
stin
g ac
cord
ing
day
for
10 w
eeks
, pa
tien
t tr
aini
ng
dyna
mom
eter
) to
intr
a-gr
oup
or “
wit
hin-
com
bine
d w
ith
a
prog
ram
for
the
5. S
enso
ry e
valu
atio
n gr
oup”
ana
lysi
s (p
< 0
.05)
.
co
nser
vati
ve t
reat
men
t
mod
ifi ca
tion
of
(Sem
mes
-Wei
stei
n A
stat
isti
cally
sig
nifi c
ant
prog
ram
fu
ncti
onal
act
ivit
ies
m
onofi
lam
ent
[SW
M]
resu
lt fa
vori
ng t
he
(avo
id r
epet
itiv
e
&2-
poin
t di
scri
min
atio
n in
corp
orat
ion
of n
eura
l
acti
viti
es, e
tc.)
wit
h
test
[2P
D])
gl
idin
g ex
erci
ses—
wit
h
a co
nser
vati
ve
6. E
lect
roph
ysio
logi
cal
mor
e ra
pid
pain
red
ucti
on,
tr
eatm
ent
prog
ram
. te
st—
med
ian
& u
lnar
an
d gr
eate
r fu
ncti
onal
nerv
e. d
ista
l lat
enci
es
impr
ovem
ent
espe
cial
ly in
grip
str
engt
h (p
< 0
.05)
.
Tabl
es 2
–4 p
rovi
de p
ost-
tr
eatm
ent
data
on
el
ectr
ophy
siol
ogic
,
Tine
l, an
d Ph
alen
tes
t
fi ndi
ngs.
Sin
ce a
ll su
bjec
ts
ha
d “p
osit
ive/
path
olog
ic”
fi n
ding
s pr
e-tr
eatm
ent,
the
auth
ors
coul
d us
e th
ese
2x
2 co
ntin
genc
y ta
bles
to
ge
nera
te a
num
ber
need
ed
to
tre
at t
o se
e w
heth
er t
here
was
a c
linic
ally
impo
rtan
t
effe
ct fa
vori
ng n
eura
l glid
ing
ex
erci
ses
on t
hese
par
ticu
lar
ou
tcom
es.
Cop
piet
ers
N
=20
(16
fem
ales
, 10
sub
ject
s w
ith
10
sub
ject
s w
ith
Out
com
es w
ere
mea
sure
d Si
gnifi
cant
diff
eren
ces
in
5 8
et a
l84
mal
es)
br
achi
al o
r
brac
hial
or
pre-
and
pos
t-tr
eatm
ent
trea
tmen
t ef
fect
s be
twee
n(c
ervi
cal
Age
rang
e
cerv
icob
rach
ial
cerv
icob
rach
ial
1)E
lbow
ext
ensi
on R
OM
tw
o gr
oups
cou
ld b
ela
tera
l glid
e)
35–6
5 ye
ars
neur
ogen
ic p
ain
neur
ogen
ic p
ain
duri
ng N
TPT1
ob
serv
ed fo
r al
l out
com
eR
efer
ence
s —
Mea
n ag
e (y
ears
) R
ecei
ved
neur
al
Rec
eive
d ul
tras
ound
2)
Pai
n (V
AS)
mea
sure
s (p
0.30
6).
desc
ribe
d
IG 4
9.1
(±14
.1),
m
obili
zati
on
dose
of 0
.5 W
/cm
²,
3) S
ympt
om d
istr
ibut
ion
For
the
mob
iliza
tion
gro
up,
toge
ther
C
G 4
6.6
(±12
.1)
trea
tmen
t
5 m
inut
es s
onat
ion
M
easu
rem
ents
tak
en
the
incr
ease
in e
lbow
due
to
—M
ean
dura
tion
(c
ontr
alat
eral
l gl
ide
ti
me,
20%
siz
e of
pr
e- a
nd p
ost-
trea
tmen
t ex
tens
ion
from
137
.3º
pape
rs’
of s
ympt
oms
of c
ervi
cal s
egm
ent)
he
ad 5
cm²,
1.
Elb
ow e
xten
sion
RO
M
to 1
56.7
º, th
e 43
% d
ecre
ase
diffe
rent
(m
o)
Cer
vica
l con
tral
ater
al
freq
uenc
y 1M
Hz.
du
ring
NTP
T1
in a
rea
of s
ympt
omou
tcom
es
IG 2
.7, C
G 3
.2
glid
e C
5-T1
. Pu
lsed
ult
raso
und
2.
Pai
n in
tens
ity
duri
ng
dist
ribu
tion
and
dec
reas
eon
the
As
abo
ve
Seve
ral c
ompo
nent
s fo
r 5
min
utes
ove
r th
e N
TPT1
VAS
in
pai
n fr
om 7
.3 t
o 5.
8sa
me
of
the
neu
ral
the
mos
t pa
infu
l
wer
e si
gnifi
cant
(p
.000
3).
subj
ect
tens
ion
prov
ocat
ion
area
(0.
5 W
/cm
²,
For
ultr
asou
nd g
roup
, sa
mpl
e
te
st o
f the
med
ian
1MH
z, t
reat
men
t
th
ere
wer
e no
sig
nifi c
ant
wit
h th
e sa
me
nerv
e (N
TPT1
)
head
5cm
²).
di
ffere
nces
inte
rven
tion
wer
e ap
plie
d.
Arm
was
in u
nloa
ded
O
n th
e in
volv
ed s
ide,
the
5
6te
chni
que.
Pati
ents
in s
upin
e po
siti
on. U
ltra
soun
d
shou
lder
gir
dle
elev
atio
n
TAB
LE 4
. Ra
ndom
ized
con
trol
led
tria
ls o
f neu
ral m
obili
zati
on a
s a
trea
tmen
t mod
alit
y (c
ontin
ued)
.
Pa
tien
t In
terv
enti
on
Com
pari
son
Aut
hor
dem
ogra
phic
s G
roup
(IG
) G
roup
(CG
) O
utco
me
Resu
lt
IVS
QS
Cop
piet
ers
rece
ived
a la
tera
l ch
osen
bec
ause
it d
oes
fo
rce
occu
rred
ear
lier
et a
l28
tr
ansl
atio
n
not
invo
lve
any
an
d th
e am
ount
of f
orce
at
(neu
ral
m
ovem
ent
away
m
ovem
ent
of
th
e en
d of
the
tes
tpr
ovoc
atio
n)
fr
om t
heir
invo
lved
pe
riph
eral
ner
ves.
was
sub
stan
tial
ly t
houg
h
si
de, w
hile
mim
icki
ng
not
sign
ifi ca
ntly
gre
ater
cerv
ical
sid
e fl e
xion
on
the
uni
nvol
ved
side
|or
rota
tion
.
at
the
cor
resp
ondi
ng R
OM
.
Af
ter
2 tr
ials
,
To
geth
er w
ith
a si
gnifi
cant
3 re
peti
tion
s
redu
ctio
n in
pai
n pe
rcep
tion
wer
e pe
rfor
med
.
af
ter
the
cerv
ical
mob
iliza
tion
s,
a
clea
r te
nden
cy t
owar
d
norm
aliz
atio
n of
the
forc
e
curv
e co
uld
be o
bser
ved,
nam
ely,
a s
igni
fi can
t de
crea
se
in
forc
e ge
nera
tion
and
a
dela
yed
onse
t. T
he c
ontr
ol g
roup
dem
onst
rate
d no
diff
eren
ces.
Allis
on e
t al
25 N
=30
(20
fem
ales
, N
eura
l tis
sue
man
ual
Rec
eive
d no
M
easu
rem
ents
tak
en
Bot
h in
terv
enti
on g
roup
s 5
7
10 m
ales
) th
erap
y (N
T)—
Cer
vica
l in
terv
enti
on
pre-
trea
tmen
t 4
wee
ks
wer
e ef
fect
ive
in im
prov
ing
Ag
e ra
nge
18–7
5 ye
ars
late
ral g
lide,
sho
ulde
r fo
r th
e in
itia
l in
to t
reat
men
t an
d pa
in in
tens
ity,
pai
n qu
alit
y
Med
ian
dura
tion
of
gird
le o
scill
atio
n,
8 w
eeks
po
st-t
reat
men
t.
scor
es, a
nd fu
ncti
onal
sy
mpt
oms
(mo)
m
uscl
e re
-edu
cati
on,
(The
n at
the
1.
McG
ill p
ain
disa
bilit
y le
vels
.
NT
12
IQR
48
hom
e m
obili
zati
on.
end
of t
he s
tudy
qu
esti
onna
ire
How
ever
, a g
roup
diff
eren
ce
AT 7
2 I
QR
72
For
8 w
eeks
. th
ey w
ere
2. N
orth
wic
k Pa
rk
was
obs
erve
d fo
r th
e VA
S
CG
12
IQ
R 9
1 Ar
ticu
lar
trea
tmen
t
give
n ne
ural
qu
esti
onna
ire
scor
es a
t 8
wee
ks w
ith
the
grou
p (A
T )
tr
eatm
ent
3. P
ain
(VAS
) “n
eura
l man
ual t
hera
py”
Gle
nohu
mer
al jo
int
as
a c
ross
-ove
r
grou
p ha
ving
a s
igni
fi can
tly
mob
iliza
tion
, tho
raci
c
prot
ocol
.)
lo
wer
sco
re.
mob
iliza
tion
and
hom
e
ex
erci
se.
For
8 w
eeks
.
Akal
in e
t al
24 N
=36
(2
mal
e,
18 s
ubje
cts
wit
h C
TS
18 s
ubje
cts
wit
h U
nder
take
n pr
e-
At t
he e
nd o
f tre
atm
ent,
3
6
34 fe
mal
e)
Sam
e as
con
trol
plu
s:
CTS
tr
eatm
ent
and
8 w
ithi
n-gr
oup
anal
ysis
Ag
e ra
nge
38–6
4
Tend
on g
lides
in 5
. C
usto
m-m
ade
wee
ks p
ost-
sh
owed
a s
igni
fi can
t
year
s
posi
tion
s ne
utra
l vol
ar
trea
tmen
t im
prov
emen
t w
as
M
ean
age
M
edia
n ne
rve
wri
st s
plin
t 1)
Pha
len’
s si
gn
obta
ined
in a
ll
51.9
3 ±
5.1
year
s ex
erci
ses
in 6
pos
itio
ns.
was
inst
ruct
ed
2) T
inel
’s si
gn
para
met
ers
in
Mea
n gr
oup
age
(E
ach
posi
tion
was
to
be
wor
n al
l 3)
2-p
oint
bo
th g
roup
s. T
he n
erve
(y
ears
)
mai
ntai
ned
for
5 ni
ght
and
disc
rim
inat
ion
and
tend
on g
lide
C
G 5
2.16
(±
5.6)
, se
cond
s; 1
0 re
peti
tion
s du
ring
the
day
4)
Gri
p st
reng
th
grou
p ha
d sl
ight
ly
IG 5
1.7
(±5.
5)
of e
ach
exer
cise
as
muc
h as
5)
Pin
ch s
tren
gth
grea
ter
scor
es b
ut t
he
Dur
atio
n of
w
ere
done
5 t
imes
po
ssib
le
6) S
ympt
om
diffe
renc
e be
twee
n
sym
ptom
s (m
o)
a da
y )
for
4 w
eeks
se
veri
ty s
core
gr
oups
was
not
sig
nifi c
ant
C
G 4
7.6
(± 6
.8),
Fo
r 4
wee
ks
7)
Fun
ctio
nal s
tatu
s ex
cept
for
late
ral p
inch
IG
49.
6 (±
5.2
)
sc
ore
stre
ngth
.
A
pati
ent
sati
sfac
tion
A
tota
l of 7
2% o
f the
con
trol
inve
stig
atio
n
grou
p an
d 93
% n
erve
unde
rtak
en b
y
and
tend
on s
lide
grou
p
te
leph
one
8.3
(± 2
.5)
re
port
ed g
ood
or e
xcel
lent
mon
ths
post
-tre
atm
ent
re
sult
s in
the
pat
ient
sati
sfac
tion
inve
stig
atio
n,
bu
t th
e di
ffere
nce
betw
een
th
e gr
oups
was
not
sig
nifi c
ant.
In
sum
mar
y, b
oth
grou
ps
im
prov
ed b
y a
stat
isti
cally
sign
ifi ca
nt a
mou
nt a
ccor
ding
to w
ithi
n-gr
oup
anal
ysis
com
pari
ng b
efor
e an
d af
ter
tr
eatm
ent,
but
exc
ept
for
la
tera
l pin
ch s
tren
gth,
bot
h
grou
ps im
prov
ed a
sim
ilar
am
ount
bec
ause
bet
wee
n-
grou
p an
alys
is r
evea
led
no
st
atis
tica
lly s
igni
fi can
t
diffe
renc
es a
fter
tre
atm
ent
W
hile
pat
ient
sat
isfa
ctio
n
perc
enta
ges
wer
e hi
gher
in
th
e ne
ural
mob
iliza
tion
gro
up,
th
is d
iffer
ence
bet
wee
n gr
oups
was
not
sta
tist
ical
ly s
igni
fi can
t.
Scri
msh
aw
N=
81 (
30 fe
mal
e,
35 s
ubje
cts
46 s
ubje
cts
M
easu
red
at
All p
atie
nts
rece
ived
the
4
6&
Mah
er10
51
mal
e)
unde
rgoi
ng
unde
rgoi
ng
base
line,
tr
eatm
ent
as a
lloca
ted
Mea
n ag
e (
year
s)
lum
bar
lum
bar
6
wee
ks, 6
mon
ths,
w
ith
12-m
onth
follo
w-u
p da
ta
IG 5
5 (±
17)
disc
ecto
my
disc
ecto
my
and
12 m
onth
s.
avai
labl
e fo
r 94
% o
f tho
se
CG
59
(±16
) (N
=9)
, fus
ion
(N=
7), f
usio
n
1. G
loba
l ra
ndom
ized
. The
re w
ere
no
(N
=6)
or
(N=
9) o
r pe
rcei
ved
stat
isti
cally
sig
nifi c
ant
or
la
min
ecto
my
lam
inec
tom
y
effe
ct (
GPE
) cl
inic
ally
sig
nifi c
ant
bene
fi ts
(N=
20)
(N=
30)
2. P
ain
(VAS
) pr
ovid
ed b
y th
e ne
ural
TAB
LE 4
. Ra
ndom
ized
con
trol
led
tria
ls o
f neu
ral m
obili
zati
on a
s a
trea
tmen
t mod
alit
y (c
ontin
ued)
.
Pa
tien
t In
terv
enti
on
Com
pari
son
Aut
hor
dem
ogra
phic
s G
roup
(IG
) G
roup
(CG
) O
utco
me
Resu
lt
IVS
QS
Sam
e as
con
trol
St
anda
rd p
ost-
3.
McG
ill p
ain
m
obili
zati
ons
trea
tmen
t
pl
us n
eura
l op
erat
ive
ques
tion
nair
e fo
r an
y ou
tcom
e.
m
obili
zati
on
care
(ex
erci
ses
4.
Que
bec
disa
bilit
y
ad
ded.
fo
r lo
wer
sc
ale
Exe
rcis
es w
ere
limb
and
trun
k)
5. S
trai
ght
leg
rais
e
6
wee
ks p
ost-
E
xerc
ises
wer
e 6.
Tim
e ta
ken
to
di
scha
rge
enco
urag
ed fo
r up
re
turn
to
wor
k
to 6
wee
ks p
ost-
disc
harg
e
Tal-
Akab
i &
N=
21R
usht
on31
Age
rang
e 29
–85
year
s G
roup
1: 7
sub
ject
s G
roup
3
All e
xcep
t PR
S An
effe
ct o
f neu
ral
5 8
M
ean
age
47.1
(±
14.8
) w
ith
CTS
rec
eive
d 7
subj
ects
wit
h C
TS
wer
e ta
ken
pre-
m
obili
zati
on o
n pa
in
Dur
atio
n of
sym
ptom
s
ULT
T 2a
mob
iliza
tion
re
ceiv
ed n
o an
d po
st-t
reat
men
t de
mon
stra
ted
a
(yea
rs)
Gro
up 2
–7 s
ubje
cts
inte
rven
tion
1.
Sym
ptom
s di
ary
stat
isti
cally
sig
nifi c
ant
2.
3 (±
2.5,
ran
ge 1
–3)
wit
h C
TS r
ecei
ved
(2
4hr
VAS)
di
ffere
nce
betw
een
Al
l sub
ject
s ar
e on
the
ca
rpal
bon
e
2. F
unct
iona
l box
th
e 3
grou
ps (
p<0.
01).
w
aiti
ng li
st fo
r su
rger
y m
obili
zati
on (
ante
rior
-
scal
e (F
BS)
H
owev
er, a
ltho
ugh
post
erio
r an
d or
3. R
ange
of m
otio
n th
is im
prov
emen
t w
as
po
ster
ior-
ante
rior
) an
d
(R
OM
)—w
rist
be
tter
tha
n no
tre
atm
ent,
a
fl exo
r re
tina
culu
m
fl e
xion
/ ext
ensi
on
it w
as n
ot s
uper
ior
to
st
retc
h
4. U
LTT2
a th
e ef
fect
tha
t co
uld
be
5.
Pai
n re
lief s
cale
ac
hiev
ed w
ith
carp
al b
one
(PR
S)
mob
iliza
tion
, wit
h no
6. C
onti
nuin
g on
to
st
atis
tica
l diff
eren
ce in
have
sur
gery
ef
fect
iven
ess
of t
reat
men
t
dem
onst
rate
d be
twee
n th
e
two
inte
rven
tion
gro
ups.
Vice
nzin
o
N=
15 w
ith
Trea
tmen
t gr
oup
C
ontr
ol g
roup
R
ecor
ded
The
trea
tmen
t gr
oup
4 6
et a
l32la
tera
l epi
cond
ylal
gia
Con
tral
ater
al g
lide
Subj
ect’s
arm
im
med
iate
ly
prod
uced
sig
nifi c
ant
(7
mal
e, 8
fem
ale)
C
5/6
grad
e 3
wit
h re
sted
be
fore
and
aft
er
impr
ovem
ents
in p
ress
ure
Ag
e ra
nge
22.5
–66
year
s af
fect
ed a
rm in
a
on a
bdom
en
trea
tmen
t pa
in t
hres
hold
, pai
n-fr
ee
Mea
n ag
e 44
± 2
yea
rs
pred
eter
min
ed
Subj
ects
rec
eive
d 1.
ULT
T2b
grip
str
engt
h,
Dur
atio
n of
sym
ptom
s
posi
tion
1
of t
he 3
(
mea
suri
ng d
egre
es
neur
odyn
amic
s, a
nd
8 ±
2 m
onth
s
trea
tmen
t of
abd
ucti
on)
pain
sco
res
rela
tive
R
ange
of d
urat
ion
Plac
ebo
grou
p co
ndit
ions
2.
Pai
n-fr
ee g
rip
to t
he p
lace
bo a
nd
2–36
mon
ths
Man
ual c
onta
ct
for
3 da
ys in
a
stre
ngth
co
ntro
l gro
ups
(p<
0.0
5)
w
as a
pplie
d as
in
rand
om o
rder
. (h
and
held
the
trea
tmen
t gr
oup
dyna
mom
eter
)
w
ith
pati
ent’s
arm
3. P
ress
ure
pain
rest
ed o
n ab
dom
en
th
resh
old
but
no g
lide
was
4. P
ain
via
VAS
appl
ied
(o
ver
24 h
ours
)
Al
l tre
atm
ents
wer
e
5.
func
tion
VAS
appl
ied
in 3
lots
of
(o
ver
24ho
urs)
30 s
econ
ds w
ith
60-
seco
nd r
est
peri
ods
Dre
chsl
er
N=
18 (
8 m
ale,
8
subj
ects
wit
h 10
sub
ject
s w
ith
Und
erta
ken
pre
Subj
ects
who
rec
eive
d 3
5et
al29
10 fe
mal
e)
late
ral e
pico
ndyl
itis
la
tera
l epi
cond
ylit
is
trea
tmen
t,
radi
al h
ead
mob
iliza
tion
s
Age
rang
e 30
–57
year
s N
eura
l ten
sion
gro
up
Stan
dard
tre
atm
ent
post
tre
atm
ent
impr
oved
ove
r ti
me
(p<
0.05
)
Mea
n ag
e 46
yea
rs
ULT
T 2b
wit
h . .
.
grou
p an
d 3
mon
th
Res
ults
from
neu
ral
M
ean
age
of g
roup
s
1. G
rade
d fl e
xion
and
2
tim
es a
wee
k
Follo
w u
p te
nsio
n gr
oup
wer
e lin
ked
(y
ears
)
or s
houl
der
abdu
ctio
n fo
r 6–
8 w
eeks
1.
Sel
f-re
port
to
rad
ial h
ead
trea
tmen
t
IG 4
6.4,
CG
45.
5 2.
Ant
erio
r-po
ster
ior
1. U
ltra
soun
d
ques
tion
nair
e an
d is
olat
ed e
ffect
s co
uld
mob
iliza
tion
s of
rad
ial
over
com
mon
2.
Gri
p st
reng
th
not
be d
eter
min
ed.
head
if r
adia
l hea
d
exte
nsor
ten
don
(han
d-he
ld
Ther
e w
ere
no lo
ng-t
erm
mob
ility
was
judg
ed
2. T
rans
vers
e
dyna
mom
eter
) po
siti
ve r
esul
ts in
the
hypo
mob
ile
fric
tion
to
tend
on
3.Ii
som
etri
c te
stin
g st
anda
rd t
reat
men
t gr
oup.
Hom
e ex
erci
se p
lan
to
(1
min
ute
exte
nsio
n of
3rd
fi ng
er
mim
ic U
LTT2
b 10
pe
r se
ssio
n)
4. U
LTT2
b
re
peti
tion
s a
day
3.
Str
etch
and
(m
easu
ring
incr
easi
ng b
ut n
ot
stre
ngth
en w
rist
ab
duct
ion)
exce
edin
g 2
sets
a
exte
nsor
s 5–
10
5. R
adia
l hea
d
da
y. 2
x w
eek
for
repe
titi
ons
30
mob
ility
(an
t/po
st
6–
8 w
eeks
se
cond
s.
glid
es, g
rade
d as
D
umbb
ells
hy
po/n
orm
al/
gr
adua
lly
hype
r
incr
easi
ng
6. E
lbow
ext
ensi
on
to
3 s
ets
15
RO
M d
urin
g U
LTT
re
peti
tion
s
4. H
ome
ex
erci
se
pr
ogra
m s
tret
ch
an
d st
reng
then
Lege
nd: N
= n
umbe
r of
sub
ject
s, I
G =
inte
rven
tion
gro
up, C
G =
con
trol
gro
up, V
AS =
vis
ual a
nalo
gue
scal
e, C
TS =
car
pal t
unne
l syn
drom
e, G
rp =
gro
up, R
x =
tre
atm
ent,
mH
z =
meg
a-he
rtz,
EM
G =
ele
c-
trom
yogr
aphy
, F/U
= fo
llow
-up,
NT
= n
eura
l tre
atm
ent,
AT
= a
rtic
ular
tre
atm
ent,
RO
M =
ran
ge o
f mov
emen
t, m
o =
mon
ths,
yrs
= y
ears
, ULT
T =
upp
er li
mb
tens
ion
test
s, a
nt =
ant
erio
r, po
st =
aft
er, I
QR
=
inte
rqua
rtile
ran
ge, U
LTT2
a =
med
ian
nerv
e bi
as n
euro
dyna
mic
tes
t, U
LTT2
b =
rad
ial n
erve
bia
s ne
urod
ynam
ic t
est.
20 / The Journal of Manual & Manipulative Therapy, 2008
to review and assess the therapeutic effi cacy of neural mobi-lization for treatment of altered neurodynamics through evaluation of appropriate randomized controlled trials was substantially limited.
Methodological weaknesses can lead to over- or under-estimations of actual outcomes. For example, blinding can signifi cantly eliminate bias and confounding, and is essential in maintaining the robustness of an RCT. Blinding is diffi cult for use in studies involving manual therapy33,34, although in this review only 9 of the 11 studies blinded the raters. Some have argued that blinding for use in manual therapy studies is useful34, although it is arguable that non-masked raters could bias outcome fi ndings.
The outcome measures used by the RCTs in this review also lacked homogeneity. A battery of different scales was used, and fi ndings are not transferable across populations. One method used to standardize measures of success is the use of a minimal clinically important different score (MCID). MCID relates to the smallest change in a clinical outcome measure, which correlates to a person feeling “slightly better” than the initially recorded state33. Findings can be dichoto-mized into success or failure. In research that analyzes the therapeutic benefi t of an intervention, the MCID is an impor-tant statistic, as it represents a level of therapeutic benefi t sig-nifi cant enough to change clinical practice34. MCIDs are pop-ulation- and pathology-specifi c, and they require analysis to determine a properly computed value. To our knowledge, all or a majority of the outcome scales used have not been evalu-ated for an MCID for the population examined in our study.
Due to the heterogeneity in respect to the neural mobi-lization interventions used in these RCTs, it is diffi cult to make general conclusions regarding neural mobilization as a general therapeutic tool. Over all, six different categories or types of neural mobilization treatments were identifi ed (Table 5). Of these, there was limited evidence to support the use of active nerve and fl exor tendon gliding exercises of the forearm24,26,30, cervical contralateral glides8,28,32, and Upper Limb Tension Test 2b (ULTT2b) mobilization29,31 in the treat-ment of altered neurodynamics or neurodynamic dysfunc-tion. There was inconclusive evidence to support the use of slump stretches27 and combinations of neural mobilization techniques10,25 in the treatment of altered neurodynamics or neurodynamic dysfunction.
Future studies are needed and a larger, more com-prehensive body of work is required before conclusive evidence is available. We found only 10 RCTs met the inclusion criteria for this systematic review. Unfortunately, all studies were clinically heterogeneous in that each looked at a number of different pathologies and different types of neural mobilization. This made quantitative analysis of therapeutic effi cacy impossible. As Reid and Rivett21 have stated, direct quantitative comparison, within the realms of systematic review, is very diffi cult when pathologies, interventions, and outcome measures are heterogeneous. For example, even for this review there were a number of studies that looked at neural mobilization in treatment for lateral epicondylalgia29,32,carpal tunnel syndrome24,26,30,31, and cervicobrachial pain8,25,28.The specifi c neural mobilization intervention differed be-
TABLE 5. Level of evidence for therapeutic effi cacy per intervention type.
Type of Studies per Evidence forNumber Intervention Intervention Intervention
1 Slump stretches Cleland et al27 Insuffi cient (Level 4)
2 Active nerve and fl exor tendon gliding Baysal et al26 Limited (Level 3) exercises (forearm) Pinar et al30
Akalin et al24
3 Cervical contralateral glide (nerve Coppieters et al8 Limited (Level 3) mobilization) Coppieters et al28
Vicenzino et al32
4 Combination (neural tissue manual Allison et al25 Insuffi cient (Level 4) therapy, cervical lateral glide, and shoulder girdle oscillations)
5 Combination (Straight leg raise, knee fl exion/ Scrimshaw & Maher10 Insuffi cient (Level 4) extension, and passive cervical fl exion)
6 Upper limb tension test 2b (ULTT 2b) neural Tal-Akabi & Rushton31 Limited (Level 3) mobilization Drechsler et al29
Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy / 21
tween studies, making, in these cases, the treatments too heterogeneous for statistical pooling.
With respect to the clinical implications of these fi nd-ings, it is interesting to note that generally all the RCTs that looked at neural mobilization for upper quadrant (i.e., cervi-cal spine, shoulder girdle, and upper limb) problems, with the exception of one study 25, concluded that there was lim-ited evidence for therapeutic effi cacy. This is in direct con-trast to studies that examined neural mobilization for lower quadrant (i.e., lumbar spine, pelvic girdle, and lower limb) problems10,25,27 in that all provided inconclusive evidence for therapeutic effi cacy. From a more specifi c pathological per-spective, for neural mobilization of cervical nerve roots, three papers supported the use of cervical contralateral glide mobilization. For neural mobilization of the median nerve in people with carpal tunnel syndrome, three papers supported the use of active nerve and fl exor tendon gliding exercises of the forearm24,26,30.
Future Research
Considering the results of the extensive literature search carried out for this review, there is an obvious paucity of re-search concerning the therapeutic use of neural mobiliza-tion. Not only is there a lack in quantity of such research, upon dissection of the scarce research that is available, there is also a lack of quality. Future research should look not only at similar pathologies but also at similar neural mobilization techniques.
Another key feature of these studies is that only clinical outcome measures were used. In the introduction, we dis-cussed the biomechanical, physiological, and morphological theories underlying neural mobilization. One of the key the-ories for using neural mobilization is to exploit the mechani-cal effect that this form of mobilization has on the neural tissue and its mechanical interface. It is possible to use ob-
jective in-vivo measurements of neural movement (i.e., glide, slide, stretch, etc.) via real-time diagnostic ultrasound. It will be important to eventually substantiate clinical im-provements with objective measurement of neural move-ment. For example, recent unpublished data have demon-strated that it is possible to visualize and quantify, with reasonable reliability, sciatic nerve movement during neural mobilization35. As it has been postulated that an improve-ment in nerve mobility may explain any perceived benefi ts of neural mobilization, it would be relevant to make a compari-son of clinical measures with objective measures (e.g., ROM and neural mobility) in an in-vivo situation in studies that examine neural mobilization. Such a comparison may give clues as to whether neural mobilization is more likely to im-pose a mechanical effect or a neurophysiological effect on the nervous system.
Conclusion
Neural mobilization is advocated for treatment of neurody-namic dysfunction. To date, the primary justifi cation for using neural mobilization has been based on a few clinical trials and primarily anecdotal evidence. Following a sys-tematic review of the literature examining the therapeutic effi cacy of neural mobilisation, 10 RCTs discussed in 11 studies were retrieved. A majority of these studies con-cluded a positive therapeutic benefi t from using neural mo-bilization. However, in consideration of their methodologi-cal quality, qualitative analysis of these studies revealed that there is only limited evidence to support the use of neural mobilization. Future research needs to examine more homogeneous studies (with regard to design, pathol-ogy, and intervention), and we suggest that they combine clinical outcome measures with in-vivo objective assess-ment of neural movement.
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