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.
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.
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).
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.
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
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.
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.
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.
Conflicts of interest
The authors declare that there are no conflicts of interests involved in this systematic review and meta-analysis.
Elna Kruger, for assistance with searching and locating articles.
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Appendix I: Appraisal instruments
MAStARI appraisal instrument
Appendix II: Data extraction instruments
MAStARI data extraction instrument