Chiropractic + Naturopathic Doctor

Research Review: Neural tissue management in MSK pain

Dr. Shawn   

Features Research

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The objective of this systematic review and meta-analysis was to quantify the magnitude of effect of neural tissue management (NTM) on pain and disability in patients with chronic musculoskeletal pain.

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
Authors: Su Y & Lim ECW
Publication Information: Clinical Journal of Pain 2016; 32: 991-1004.

Background Information
The objective of this systematic review and meta-analysis was to quantify the magnitude of effect of neural tissue management (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, seven trials evaluated low back and lower limb pain, two evaluated non-radicular low back pain (33, 34), two evaluated carpal tunnel syndrome and one evaluated lateral epicondylalgia.
  • 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 standardized mean differences (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.

Applications, conclusions
While the results of this review did not find significant differences between interventions used in the treatment of nerve-related musculoskeletal pain (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 random controlled trial did indicate there was no evidence to suggest that NTM is harmful for patients with NRMP.
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.
  • 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 (SMD) for pain and disability scores, along with 95% confidence intervals and tests for heterogeneity.

Additional References

  1. Oh IH, Yoon SJ, Seo HY, et al. The economic burden of musculoskeletal disease in Korea: a cross sectional study. BMC Musculoskelet Disord 2011; 12: 157.
  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.
  4. Bond M, Breivik H. Why pain control matters in a world full of killer diseases, Vol. 2009. A report from International Association For The Study of Pain (IASP) & European Federation of IASP Chapters (EFIC). Pain: Clinical Updates. 2004. Available at: News/NewsletterIssue.aspx?ItemNumber=2129. Accessed May 14, 2015.
  5. Shuchang H, Mingwei H, Hongxiao J, et al. Emotional and neurobehavioural status in chronic pain patients. Pain Res Manag 2011; 16: 41–43.
  6. Hassett AL, Williams DA. Non-pharmacological treatment of chronic widespread musculoskeletal pain. Best Pract Res Clin Rheumatol 2011; 25: 299–309.
  7. Wright A, Sluka KA. Nonpharmacological treatments for musculoskeletal pain. Clin J Pain 2001; 17: 33–46.
  8. Butler DS. The Sensitive Nervous System. Adelaide, Australia: Neuro Orthopaedic Institute-Group Publications; 2000.
  9. Shacklock MO. Neurodynamics. Physiotherapy. 1995; 81: 9–16.
  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.
  14. Scrimshaw SV, Maher CG. Randomized controlled trial of neural mobilization after spinal surgery. Spine 2001; 26: 2647–2652.
  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.
  17. Allison GT, Nagy BM, Hall T. A randomized clinical trial of manual therapy for cervico-brachial pain syndrome—a pilot study. Man Ther 2002; 7: 95–102.
  18. Sarkari E, Multani NK. Efficacy of neural mobilisation in sciatica. J Exerc Sci Physiother 2007; 3: 136–141.
  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.
  20. Baysal O, Altay Z, Ozcan C, et al. Comparison of three conservative treatment protocols in carpal tunnel syndrome. Int J Clin Pract 2006; 60: 820–828.
  21. Manchanda V. Effect of neural mobilization and splinting on carpal tunnel syndrome. International Journal of Physiotherapy and Rehabilitation 2013. Available at: article/effect-of-neural-mobilization-and-splinting-on-carpal-tun nel-syndrome/. Accessed January 2, 2015.
  22. Raval VR, Babu KV, Kumar NS, et al. Effect of simultaneous application of cervical traction and neural mobilization for subjects with unilateral cervical radiculopathy. Int J Physiother 2014; 1: 269–278.
  23. Sambyal S, Kumar S. Comparison between nerve mobilization and conventional physiotherapy in patients with cervical radiculopathy. Int J Innov Res Dev 2013; 2: 442–445.
  24. Kumar S. A prospective randomized controlled trial of neural mobilization and Mackenzie manipulation in cervical radiculopathy. Indian J Physiother Occup Ther 2010; 4: 69–75.
  25. Leonelli C, Zucchini E, Messora A, et al. Studio pilota sui benefici della tecnica neurodinamica nella radicolopatia Acervicale cronica [Neurodynamic technique benefits in patients with chronic cervical radiculopathy: a pilot study]. Scienza Riabilitativa 2013; 15: 19–28.
  26. Marks M, Schottker-Koniger T, Probst A. Efficacy of cervical spine mobilization versus peripheral nerve slider techniques in cervicobrachial pain syndrome—a randomized clinical trial. J Phys Ther 2011; 4: 9–17.
  27. Malik N, Kataria C, Sachdev NB. Comparative effectiveness of straight leg raise and slump stretching in subjects with low back pain with adverse neural tension. Int J Health Rehabil Sci 2012; 1: 2–10.
  28. Ali M, Ur Rehman SS, Ahmad S, et al. Effectiveness of slump neural mobilization technique for the management of chronic radicular low back pain. Rawal Med J 2015; 40: 41–43.
  29. Colakovic H, Avdic D. Effects of neural mobilization on pain, straight leg raise test and disability in patients with radicular low back pain. J Health Sci 2013; 3: 109–112.
  30. Kumar SD. Effectiveness of intermittent pelvic traction vs intermittent pelvic traction with self-neural mobilization on low back pain – A comparative study. Int J Physiother Res 2013; 3: 71–76.
  31. Ahmed N, Tufel S, Khan MH, et al. Effectiveness of neural mobilization in the management of sciatica. J Musculoskelet Res 2013; 16: 1–9.
  32. Machado GF, Bigolin SE. Comparative study of cases between neural mobilization and a muscular elongation program on chronic backache. Fisioterapia em Movimento 2010; 23: 545–554.
  33. Cleland JA, Childs JD, Palmer JA, et al. Slump stretching in the management of non-radicular low back pain: a pilot clinical trial. Man Ther 2006; 11: 279–286.
  34. Nagrale AV, Patil SP, Gandhi RA, et al. Effect of slump stretching versus lumbar mobilization with exercise in subjects with non-radicular low back pain: a randomized clinical trial. J Man Manip Ther 2012; 20: 35–42.
  35. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996; 68: 69–74.
  36. De Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 2009; 55: 129–133.

Dr. Shawn Thistle is a practicing chiropractor, educator, international speaker, knowledge-transfer leader, evidence-based health care advocate, entrepreneur & medicolegal consultant. He founded RRS Education in 2006 and currently acts as the company’s CEO. RRS Education helps chiropractors and other manual medicine clinicians around the world integrate research in to patient care via weekly Research Reviews, Online Courses and Seminars.  For more information, visit:

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