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The effectiveness of neural mobilizations in the treatment of musculoskeletal conditions: a systematic review protocol

Basson, Annalie MSc Physiotherapy; Olivier, Benita PhD; Ellis, Richard PhD; Coppieters, Michel PhD; Stewart, Aimee PhD; Mudzi, Witness PhD

JBI Database of Systematic Reviews and Implementation Reports: January 2015 - Volume 13 - Issue 1 - p 65–75
doi: 10.11124/jbisrir-2015-1401
SYSTEMATIC REVIEW PROTOCOLS
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Review question/objective The objective of this review is to identify the effectiveness of neural mobilization techniques in various neuro-musculoskeletal conditions. Outcomes will be analyzed in terms of subgroups such as low back pain, cervico-brachial pain and carpal tunnel syndrome.

Background Musculoskeletal disorders were ranked as the second largest contributor to disability worldwide in a study on the global burden of disease.1 Low back pain and neck pain contributed to 70% of disability in this comprehensive population-based study. Low back pain and neck pain are multifactorial, with heterogeneous populations. It has been proposed that targeting subgroups of patients may result in better treatment outcomes.2,3 Neck pain associated with upper limb pain is prevalent.4,5 These patients are more disabled than patients with neck pain alone.4 Similarly, low back pain with leg pain is a common phenomenon and is acknowledged as a predictor for chronicity.6

Neuropathic pain is often associated with musculoskeletal complaints7,8 including low back pain,9 whiplash associated disorders (WAD)10,11 and acute or chronic radiculopathy, and can be a feature of syndromes such as cervico-brachial pain syndrome.12 According to the International Association for the Study of Pain, neuropathic pain can be described as “pain caused by a lesion or disease of the somatosensory nervous system.”13 Leg pain associated with back pain can be caused by central sensitization, denervation, nerve sensitization or somatically referred pain.6 In patients with WAD, neck pain is the most common symptom, but upper limb pain, weakness, paraesthesia and anesthesia are often present.11,14 Other conditions in which neural tissue is thought to contribute to the clinical picture are, for instance, lateral epicondalalgia15 and carpal tunnel syndrome.16

Management strategies for back pain and neck pain are often multimodal.2,3 However, the evidence for effective treatment of nerve related pain is lacking.2,17,18 Neural mobilizations are often used to affect the neural structures in conditions with signs of neural involvement or neural mechano-sensitivity.19-21 Neural mobilizations are defined as interventions aimed at affecting the neural structures or surrounding tissue (interface) directly or indirectly through manual techniques or exercise.22,23 Neural mobilizations have been studied in various populations such as low back pain,24 carpal tunnel syndrome,16 lateral epicondalalgia15 and cervico-brachial pain.25,26 Neural mobilization techniques studied include cervical lateral glides for cervico-brachial pain,25,26 nerve gliding exercises for the treatment of carpal tunnel syndrome,16,27 cervical lateral glides for lateral epicondalalgia15 and the slump as a neural mobilization technique in the treatment of low back pain.3,24 No specialized equipment is needed in the performance of neural mobilization techniques, which contributes to its popularity.

Neural mobilization is said to affect the axoplasmic flow,28 movement of the nerve and its connective tissue29 and the circulation of the nerve30 by alteration of the pressure in the nervous system and dispersion of intraneural oedema.30,31 Neural mobilization decreases the excitability of dorsal horn cells.20 Neural mobilizations can be performed in various ways using passive movement, manual mobilization of the nerve or interface, and exercise. The aim of neural mobilization is to restore the mechanical and neurophysiological function of the nerve.28

Only one systematic review on the effectiveness of neural mobilizations could be identified in the literature.17 Since this review, several more studies have been published on this subject.32-34 The authors hypothesize that a review of the more recent literature (2008-2014) may confirm positive support for the use of neural mobilizations for neuro-musculoskeletal complaints as previously seen by Ellis and Hing.17 This review aims to include a meta-analysis and subgrouping of conditions which will be an extension of the previous review by Ellis and Hing.17 The outcomes of this systematic review may be used to inform clinical practice and the development of best practice guidelines.

1 Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, South Africa

2 The Witwatersrand Centre for Evidence-based Practice: a Collaborating Centre of the Joanna Briggs Institute, South Africa

3 School of Rehabilitation and Occupation Studies, Auckland University of Technology, New Zealand

4 Faculty of Human Movement Science, Vrije Universiteit Amsterdam, The Netherlands

Corresponding author: Benita Olivier

benita.olivier@wits.ac.za

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Inclusion criteria

Types of participants

This review will consider studies that include human participants over the age of 18 years suffering from a musculoskeletal condition consistent with neurodynamic dysfunction such as low back pain, sciatica, WAD, cervico-brachial pain, lateral epicondylalgia and carpal tunnel syndrome. Outcomes will be analyzed in terms of subgroups such as low back pain, cervico-brachial pain and carpal tunnel syndrome. Studies including conditions with long tract signs and those caused by other pathological diseases, neurological diseases, fractures or dislocations, stroke, cerebral palsy and paraplegia or quadriplegia will be excluded.

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Types of intervention(s)/phenomena of interest

This review will consider studies that evaluate the effectiveness of neural mobilization techniques. Neural mobilizations are defined as interventions aimed at affecting the neural structures or surrounding tissue (interface) directly or indirectly through exercise or manual techniques. Exercises are normally divided into “sliders” and “tensioners”.29 Sliders will elongate the nerve bed through movement at one joint whilst moving another joint to relieve tension in the nerve. With tensioners, joints are moved in such a way that the nerve bed is elongated and the tension in the nerves increase.35 Sliders and tensioners often use neurodynamic tests such as the Straight Leg Raise, Slump Test or Upper Limb Neurodynamic Tests as movement sequences. Manual techniques used include mobilization along the course of the nerve26 or techniques that will change the interface around a nerve such as cervical lateral glides.21,36 Neural mobilization performed on the intervention group will be compared to a control group where no neural mobilization has been performed.

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Types of outcomes

This review will consider studies that include the following primary outcome measures: pain (numerical pain rating scale, visual analogue scale) and pressure pain threshold (algometer), disability and function (Disability of the Arm, Shoulder and Hand Symptom Scale, Neck Disability Index, Roland Morris, Oswestry, Patient Specific Functional Scale), quality of life (SF36, Eurolqual5, WHOQOLF Physical Domain Score). Secondary outcome measures include: range of motion (inclinometer, goniometer), muscle strength (Oxford grading, Dynamometer), sensation (light touch, pinprick, two-point discrimination, thermal pain threshold), specific diagnostic tests (Tinel's sign, Phalen's manoeuvre) and neurodynamic test outcomes (Upper Limb Neurodynamic Test 1, 2a, 2b, 3, Straight Leg Raise, Slump, Prone Knee Bend, Passive Neck Flexion).

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Types of studies

Randomized controlled trials (RCTs) evaluating the effect of neural mobilization on euro-musculoskeletal conditions will be included. Studies not published in English will be excluded.

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Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published from 2008 to 2014 will be considered for inclusion in this review. All RCTs that were included in a previous review performed by Ellis and Hing (2008), will also be included in this systematic review and meta-analysis, if they comply with the inclusion criteria of this review.

The databases to be searched include: MEDLINE via PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Controlled Trials Register in the Cochrane Library, Physiotherapy Evidence Database (PEDro), ProQuest 5000 International, ProQuest Health and Medical Complete, EBSCO MegaFile Premier, Science Direct and SCOPUS. The search for unpublished studies will include: EBSCO MegaFile Premier.

Initial keywords to be used will be: neural, nerve, mobilization, mobilization, manipulation, physical therapy, physiotherapy, manual therapy, glide, exercises, treatment, intervention, management, modality, stretching, tension, neurodynamics

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Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

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Data collection

Data will be extracted independently by two reviewers. Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors will be contacted for clarification or missing data.

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Data synthesis

Quantitative data will, where possible, will be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Primary outcomes will be analyzed by subgroup using DerSirmonian Laird random effects method as it is expected that studies will be heterogeneous. Studies will be grouped together based on condition i.e. carpal tunnel syndrome low back pain, cervico-brachial pain and epicondylalgia. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

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Conflicts of interest

The authors declare that there are no conflicts of interests involved in this systematic review and meta-analysis.

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Acknowledgements

Elna Kruger, for assistance with searching and locating articles.

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References

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                Appendix I: Appraisal instruments

                MAStARI appraisal instrument

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                Appendix II: Data extraction instruments

                MAStARI data extraction instrument

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                Keywords:

                mobilization; musculoskeletal conditions; nerve, neural; physiotherapy; physical therapy

                © 2015 by Lippincott williams & Wilkins, Inc.