Research Review By Dr. Brynne Stainsby©


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Date Posted:

July 2018

Study Title:

Does evidence support the use of neural tissue management to reduce pain and disability in nerve-related chronic musculoskeletal pain? A systematic review with meta-analysis


Su Y & Lim ECW

Author's Affiliations:

Department of Physiotherapy, Singapore General Hospital, Singapore; Health and Social Sciences Cluster, Academic Programmes, Singapore Institute of Technology, Singapore.

Publication Information:

Clinical Journal of Pain 2016; 32: 991-1004.

Background Information:

Chronic musculoskeletal pain is a leading cause of impaired quality of life and socioeconomic burden (1, 2). Physically, it may result in abnormal muscle patterning and movement, or even immobility, and can also lead to cognitive decline and emotional changes (3-7). While the cause of chronic musculoskeletal pain is unclear (though it is generally thought to be multifactorial), neural mechanisms are commonly suspected (8).

One suggested approach to dealing with nerve-related musculoskeletal pain (NRMP) is neural tissue management (NTM), which is based on the theory of dynamic imbalance between the relative movement of neural tissues and surrounding interfaces (i.e. adverse neurodynamics) (8, 9). Theoretically, NTM (like ‘nerve-flossing’, for example) facilitates nerve gliding, improves axoplasmic flow, restores function and resolves symptoms by providing a healthy environment for the neural tissues (10-15).

The objective of this systematic review and meta-analysis was to quantify the magnitude of effect of NTM on pain and disability in patients with chronic musculoskeletal pain. The secondary objective of this study was to review treatment parameters (dosage) and investigate if these parameters affect the variability of observed outcomes.

Pertinent Results:

  • A total of 443 titles and abstracts were screened for eligibility, with 43 potentially relevant articles identified for detailed inspection. After final screening, 20 papers were included in the final analysis.
  • The average PEDro score was 6.15 (range 4-8 out of maximum score of 11), with allocation concealment and blinding of therapists and patients listed as the most commonly missed criteria.
  • Eight trials evaluated neck and arm pain (12, 16, 17, 22-26), seven trials evaluated low back and lower limb pain (27-32), two evaluated non-radicular low back pain (33, 34), two evaluated carpal tunnel syndrome (38, 39) and one evaluated lateral epicondylalgia (35).
  • When evaluating pain and disability outcomes, significant results were not found when NTM was compared to other interventions (something other than sham treatment).
  • When compared with minimal intervention (sham NTM or no treatment as controls), neural mobilization provided superior pain relief (pooled SMD = -0.77; 95% confidence interval [CI], -1.11 to -0.42; P < 0.0001), and reduction in disability (pooled SMD = -1.06; 95% CI, -1.97 to -0.14; P = 0.02), after post hoc sensitivity analyses.
  • When evaluating specific treatment parameters, treatments ranged from one to 20 sessions over a period of a single treatment session to an eight-week treatment plan. Multivariable meta-regression did identify duration (in weeks) or number of sessions as independent predictors of variability in effect size of reported pain scores.

Clinical Application & Conclusions:

While the results of this review did not find significant differences between interventions used in the treatment of NRMP, they may be interpreted to suggest that NTM is at least equivocal to other treatment options, meaning it may be considered an option for this patient population. Although the authors did not specifically comment on safety or adverse events, one included RCT did indicate there was no evidence to suggest that NTM is harmful for patients with NRMP (16).

Given the heterogeneity of the literature, optimal treatment parameters cannot be determined based on existing evidence. As always, clinicians should be encouraged to outline their intended plan of management with patients and ensure that clinical progress is monitored over the course of treatment.

Study Methods:

  • Eight databases were searched until January, 2015 using appropriate search terms for each database.
  • Two authors reviewed citations for eligibility based on the inclusion criteria.
  • Included studies were randomized, controlled, human trials that included individuals with chronic NRMP and compared treatment (including conservative decompression of nerves, NTM and/or patient education) to other interventions or control, and included outcome measures related to pain and/or disability.
  • Methodological quality was assessed by two reviewers using the 11-item PEDro scale (36).
  • One reviewer extracted data from low risk of bias studies using a standardized extraction form. When appropriate, means and standard deviations were calculated.
  • Where appropriate, results were pooled after calculating standardized mean differences (SMD) for pain and disability scores, along with 95% confidence intervals and tests for heterogeneity.

Study Strengths / Weaknesses:

  • The authors used a predetermined set of inclusion criteria, a standardized quality assessment tool and data extraction table in this review.
  • This study identifies the paucity of high-quality literature with respect to NTM for NRMP and will help to generate hypotheses and future research.
  • One of the initial weakness identified in this study was the presence of only two authors – atypical for a systematic review and meta-analysis. This may have introduced the potential for bias in the review.
  • Another primary weakness of this study was the paucity of high-quality research to inform it, as well as the variability within the literature that has been published.
  • Though standardized, using the PEDro scale does not always account for the presence of “fatal flaws” within a given study. As the authors stated, the most commonly missed criteria included allocation concealment and blinding (not uncommon for studies of this nature). However, this raises some issues about the overall quality of the included studies.
  • Given the heterogeneity of the included studies, the decision to perform meta-analysis may be questioned.
  • In a review of NTM, patient education should not have been included in the NTM intervention group possibilities.
  • Though the authors conclude that NTM is superior to minimal intervention, but the results do not universally support this conclusion (in some studies, the comparison intervention was superior, with confidence intervals that did not cross the ‘zero’ value). The authors were required to remove a number of studies and perform numerous statistical tests in order to identify statistical significance in some cases. This is a helpful reminder to focus carefully on the findings of the study rather than just relying on the conclusions!

Additional References:

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  2. Boonstra AM, Reneman MF, Stewart RE, et al. Life satisfaction in patients with chronic musculoskeletal pain and its predictors. Qual Life Res 2013; 22: 93–101.
  3. Neblett R, Mayer TG, Brede E, et al. Correcting abnormal flexion-relaxation in chronic lumbar pain: responsiveness to a new biofeedback training protocol. Clin J Pain 2010; 26: 403–409.
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  10. Elvey RL. Treatment of arm pain associated with abnormal brachial plexus tension. Aust J Physiother 1986; 32: 225–230.
  11. Kitteringham C. The effect of straight leg raise exercises after lumbar decompression surgery: a pilot study. Physiotherapy 1996; 82: 115–123.
  12. Coppieters MW, Stappaerts KH, Wouters LL, et al. The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. J Orthop Sports Phys Ther 2003; 33: 369–378.
  13. Rozmaryn LM, Dovelle S, Rothman ER, et al. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. J Hand Ther 1998; 11: 171–179.
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  15. Shacklock MO. Clinical Neurodynamics: A New System of Neuromusculoskeletal Treatment. Oxford, UK: Butterworth Heinemann; 2005.
  16. Nee RJ, Vicenzino B, Jull GA, et al. Neural tissue management provides immediate clinically relevant benefits without harmful effects for patients with nerve-related neck and arm pain: a randomised trial. J Physiother 2012; 58: 23–31.
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  19. Pallipamula K, Singaravelan RM. Efficacy of nerve flossing technique on improving sciatic nerve function in patients with sciatica—a randomized controlled trial. Revista Romana de Kinetoterapie 2012; 18: 13–22.
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