The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis

Median Nerve Neural Mobilization Adds No Additional Benefit When Combined with Cervical Lateral Glide in the Treatment of Neck Pain: A Randomized Clinical Trial

BACKGROUND

This study aimed to compare the effectiveness of cervical lateral glide (CLG) added to median nerve neural mobilization (MNNM) in patients with neck pain (NP).

METHODS

A single-blinded randomized controlled clinical trial was carried out in a Pain Management Unit from a Hospital. A total sample of 72 patients with NP was recruited from a hospital. Patients were randomized to receive isolated CLG (n = 36) or CLG + MNNM (n = 36). Bilateral elbow extension range of motion (ROM) on upper limb neurodynamic test 1 (ULNT1), bilateral pressure pain thresholds (PPT) on the median nerve at elbow joint, C6 zygapophyseal joint and tibialis anterior, Visual analogue scale (VAS), body chart distribution of pain, active cervical ROM (CROM), Neck Disability Index (NDI), and Tampa Scale of Kinesiophobia (TSK-11) were measured at baseline as well as immediately, 15 days, and 1 month after treatment.

RESULTS

There were no statistically significant interactions (p > 0.05) between treatment and time for median nerve mechanosensitivity outcomes, pain intensity, symptom distribution, and PPT of the widespread pain assessment, as well as cervical function, and kinesiophobia.

CONCLUSIONS

MNNM gave no additional benefit to CLG in patients with NP regarding pain intensity, symptom distribution, mechanosensitivity, functionality, and kinesiophobia. Only two treatment sessions and the short follow-up are important issues, therefore, justifying further studies to answer the research question with better methodology.

Effects of a preoperative neuromobilization program offered to individuals with carpal tunnel syndrome awaiting carpal tunnel decompression surgery: A pilot randomized controlled study

STUDY DESIGN

Pilot randomized controlled trial with parallel groups.

INTRODUCTION

Engaging individuals with carpal tunnel syndrome (CTS) awaiting carpal tunnel decompression surgery in a preoperative rehabilitation program may mitigate pain and sensorimotor impairments, enhance functional abilities before surgery, and improve postoperative outcomes.

PURPOSE OF THE STUDY

To assess the feasibility and the efficacy of a novel preoperative neuromobilization exercise program (NEP).

METHODS

Thirty individuals with CTS were randomly allocated into a four-week home-based neuromobilization exercise group or a standard care group while awaiting surgery. Outcome measures included feasibility (ie, recruitment, attrition, adherence, satisfaction, and safety) and efficacy metrics (ie, median nerve integrity and neurodynamics, tip pinch grip, pain, and upper limb functional abilities) collected before (ie, at the baseline and about four weeks later) and four weeks after surgery.

RESULTS

Thirty individuals with CTS were recruited (recruitment rate = 11.8%) and 25 completed the study (attrition rate = 16.7%). Adherence (94%) and satisfaction with the program (eg, enjoy the exercises and likeliness to repeat the NEP (≥4.2/5) were high and no serious adverse event was reported. NEP-related immediate pre- and post-surgery beneficial effects on pain interference were documented (P = .05, η² = .10), whereas an overall increased neurodynamics (P = .04, η² = .11) and decreased pain severity (P = .01, η² = .21) were observed.

DISCUSSION

Engaging in the proposed NEP has limited beneficial effect as a stand-alone intervention on pre- and post-surgery outcomes for individuals with CTS. Expanding the program's content and attribute by adding other components including desensitization maneuvers and novel therapies promoting corticospinal plasticity is recommended.

CONCLUSION

A preoperative NEP completed by individuals with CTS awaiting surgery is feasible, acceptable, and safe. However, given the limited beneficial effectsof the program, revision of its content and attributes is recommended before proceeding to large-scale trials.

Effectiveness of Neural Mobilisation Techniques in the Management of Musculoskeletal Neck Disorders with Nerve-Related Symptoms: A Systematic Review and Meta-Analysis with a Mapping Report

OBJECTIVE

The objective was to assess the effectiveness of neural mobilisation (NM) techniques in the management of musculoskeletal neck disorders with nerve-related symptoms (MND-NRS).

METHODS

We conducted a systematic review with meta-analysis, using pain intensity, disability, perceived function, cervical range of motion and mechanosensitivity as the main outcome measures.

RESULTS

The systematic review included 22 studies (n = 978). More favourable outcomes were observed for NM on pain intensity compared with control interventions (standardised mean differences (SMDs) -0.92; 95% CI - 1.66--0.18), but not compared with other treatments (OTs) (SMD 1.06; 95% CI - 0.02-2.15). Regarding neck pain intensity, no significant differences were found in favour of NM compared with OTs (SMD 0.37; 95% CI - 0.35-1.1). However, between-treatment differences were found in favour of OT on arm-pain intensity (SMD 0.57; 95% CI 0.08-1.05). In addition, the grouped MA did not show statistically significant differences between NM and OT outcomes on the cervical range of motion (SMD 0.16; 95% CI - 0.06-0.38). However, compared with no intervention, NM was associated with significantly improved outcomes in cervical rotation (SMD 0.91; 95% CI 0.61-1.22). Similar results were found regarding disability (SMD -0.08; 95% CI - 0.36--0.20, and SMD -1.44; 95% CI - 2.28--0.6, respectively). Finally, NM was associated with more favourable outcomes on mechanosensitivity compared with OT (SMD 0.79; 95% CI 0.15-1.42) and greater improvements in function compared with no intervention (SMD 0.89; 95% CI 0.16-1.62).

CONCLUSIONS

NM appeared to be effective to improve overall pain intensity when embedded in a physiotherapy treatment in the management of MND-NRS. When compared with no intervention, it was effective to improve neck rotation, disability, and function. However, it was not superior to other types of treatments in improving overall pain intensity, neck pain intensity, arm pain intensity, cervical range of motion and disability, except for mechanosensitivity.

Hypoalgesic and Motor Effects of Neural Mobilisation versus Soft-Tissue Interventions in Experimental Craniofacial Hyperalgesia: A Single-Blinded Randomised Controlled Trial

Objective: The present trial aimed to compare the effects of the mobilisation of the nervous system (NS) to those of a soft-tissue intervention in subjects exposed to an experimentally induced hyperalgesia of the masticatory muscles. Methods: The study was a single-blinded randomised controlled trial. A total of 49 participants (mean ± SD age: 41 ± 11 years; 61% female) with latent myofascial trigger points (LMTrPs) in the craniofacial region were randomly assigned to one of three groups: neural mobilisation (NM), soft-tissues techniques and stretching (STT-S), and control group (CG). An initial assessment (baseline) was performed before the provocation chewing masticatory test. The pre-treatment measurements were registered 24 h later. Next, the randomised intervention was applied, and afterwards, post-treatment data were obtained. Outcome measures included pain-free maximum mouth opening (MMO), pressure pain thresholds (PPTs) in the trigeminal and cervical region, and trigeminal and cervical two-point discrimination (TPD). Results: ANOVA revealed significant differences for the time × group interaction for pain-free MMO and PPTs. The results showed an improvement in the MMO and the PPTs for NM and STT-S groups but not for the CG. There were no differences between the NM and STT-S groups. However, the effect sizes were large for the NM and medium for the STT-S. No differences were found for TDP between groups nor over time. Conclusions: The results show that with NM and STT-S techniques, we could influence motor and sensory variables in asymptomatic subjects with LMTrPs after a masticatory provocation test. Both techniques increased MMO and PPTs in the short term. These beneficial effects lead us to consider the importance of including these methods in clinical practice.

Comparing the Effects of Early Versus Late Exercise Intervention on Pain and Neurodynamic Mobility Following Unilateral Lumbar Microdiscectomy: A Pilot Study

STUDY DESIGN

A pilot, two-group pretest-posttest randomized controlled, single blinded study.

OBJECTIVE

Our study aim was to compare the changes in low back pain level, fear avoidance, neurodynamic mobility, and function after early versus later exercise intervention following a unilateral lumbar microdiscectomy.

SUMMARY OF BACKGROUND DATA

Exercise is commonly recommended to patients following a lumbar microdiscectomy although controversy remains as to the timing and protocols for exercise intervention.

METHODS

Forty patients were randomly allocated to early (Group 1) or later (Group 2) exercise intervention group. The low back pain and fear avoidance were evaluated using Oswestry Low Back Pain Disability Questionnaire, Numeric Pain Rating Scale, and Fear-Avoidance Beliefs Questionnaire. The neurodynamic mobility and function were recorded with Dualer Pro IQ Inclinometer, 50-foot walk test, and Patient-Specific Functional Scale. Two-sided t test for continuous variables and chi-square or Fisher exact test for categorical variables were used to compare the two groups' demographic data. The Wilcoxon signed-rank and rank-sum tests were used to compare the changes and the differences, respectively, in low back pain, fear avoidance, neurodynamic mobility, and function between baseline (before surgery) and postoperative repeated measurements (at 1-2, 4-6, and 8-10 wks after surgery) within each study group, after exercise intervention.

RESULTS

Both groups showed a significant decrease in low back pain levels and fear avoidance as well as a significant improvement in neurodynamic mobility and function at 4 and 8 weeks after surgery. However, no significant difference was reported between the two groups.

CONCLUSION

Our study results showed that early exercise intervention after lumbar microdiscectomy is safe and may reduce the low back pain, decrease fear avoidance, and improve neurodynamic mobility and function. A randomized controlled trial is needed to evaluate the early exercise intervention's effectiveness after lumbar microdiscectomy, and thus validate our findings.Level of Evidence: 4.

[Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potenzial mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Effects of neural mobilizations through movement representation techniques for the improvement of neural mechanosensitivity of the median nerve region: a randomized controlled trial

PURPOSE

The main objective was to compare the effects of neural mobilization (NM), NM performed through mirror therapy (MT), NM performed through action observation (AO) training and finally classic rehabilitation program (mobility and strength) exercises on neural mechanosensitivity, widespread of proximal and distal pain and pressure pain thresholds (PPT). The second objective was to assess the effects of these interventions on handgrip strength, conditioned pain modulation, motor imagery ability and temporal summation.

MATERIALS AND METHODS

Single-blinded randomized controlled trial. Fifty-four healthy subjects were randomly assigned to each group. Neural mechanosensitivity, widespread pain and PPT were the main variables. The secondary variables included handgrip strength, conditioned pain modulation, motor imagery ability and temporal summation.

RESULTS

All groups showed significant differences in time*factor for neural mechanosensitivity (p = 0.001), PPT in the dermatome of the median nerve (p = 0.007), PPT at carpal tunnel (p < 0.05) and proximal widespread (p = 0.01). No differences were found for distal widespread, conditioned pain modulation, handgrip strength motor imagery ability or temporal summation (p > 0.05). There is an absence of statistically significant differences between groups.

CONCLUSIONS

NM through movement representation techniques can reduce mechanosensitivity and mechanical hyperalgesia in the median nerve dermatome and forearm, although no differences were found between groups.

Effects of adding neural mobilization to traditional physical therapy on pain, functional disability, and H-reflex in patients after lumbar laminectomy: A randomized controlled trial

OBJECTIVE

To investigate whether adding neural mobilization to a standard postoperative physical therapy program could improve the outcomes of patients after lumbar laminectomy.

DESIGN

A single blinded randomized controlled trial.

SETTING

Outpatient setting.

PARTICIPANTS

Sixty participants of both sexes who had undergone lumbar laminectomy.

INTERVENTIONS

Participants were allocated randomly to two groups; study and control groups. All patients received a standard postoperative physical therapy program. Those in the study group received additional neural mobilization in the form of straight leg raising and dorsiflexion with two-ended slider. Treatment was administered three times/week for six successive weeks.

OUTCOME MEASURES

Visual analog scale (VAS), Oswestry disability index (ODI), and H-reflex latency were measured pre and post-treatment.

RESULTS

The mean age of participants was 44.23 ± 4.64 and 45.3 ± 5.3 in study and control groups respectively (P > 0.05). There were statistically significant differences in VAS, ODI, and H-reflex latency in favor of the study group (P < 0.05). The mean ± SD for VAS, ODI, and H-reflex latency pre vs post treatment was 6.13 ± 1.22 vs 1.40 ± 0.77, 64.46 ± 4.05 vs 16.86 ± 2.55, and 32.07 ± 2.76 vs 27.46 ±1.79 in study group and 5.86 ± 1.07 vs 2.46 ± 0.73, 63.93 ± 3.91 vs 23.40 ± 2.93, and 31.76 ± 2.69 vs 29.4 ± 1.94 in control group, respectively.

CONCLUSIONS

Neural mobilization combined with traditional physical therapy program achieved better improvement in pain, functional disability and H-reflex in patients who underwent decompressive laminectomy than traditional physical therapy program only.

The Role of Dietary Nutrients in Peripheral Nerve Regeneration

Peripheral nerves are highly susceptible to injuries induced from everyday activities such as falling or work and sport accidents as well as more severe incidents such as car and motorcycle accidents. Many efforts have been made to improve nerve regeneration, but a satisfactory outcome is still unachieved, highlighting the need for easy to apply supportive strategies for stimulating nerve growth and functional recovery. Recent focus has been made on the effect of the consumed diet and its relation to healthy and well-functioning body systems. Normally, a balanced, healthy daily diet should provide our body with all the needed nutritional elements for maintaining correct function. The health of the central and peripheral nervous system is largely dependent on balanced nutrients supply. While already addressed in many reviews with different focus, we comprehensively review here the possible role of different nutrients in maintaining a healthy peripheral nervous system and their possible role in supporting the process of peripheral nerve regeneration. In fact, many dietary supplements have already demonstrated an important role in peripheral nerve development and regeneration; thus, a tailored dietary plan supplied to a patient following nerve injury could play a non-negotiable role in accelerating and promoting the process of nerve regeneration.

The neurodynamic treatment induces biological changes in sensory and motor neurons in vitro

Nerves are subjected to tensile forces in various paradigms such as injury and regeneration, joint movement, and rehabilitation treatments, as in the case of neurodynamic treatment (NDT). The NDT induces selective uniaxial repeated tension on the nerve and was described to be an effective treatment to reduce pain in patients. Nevertheless, the biological mechanisms activated by the NDT promoting the healing processes of the nerve are yet still unknown. Moreover, a dose-response analysis to define a standard protocol of treatment is unavailable. In this study, we aimed to define in vitro whether NDT protocols could induce selective biological effects on sensory and motor neurons, also investigating the possible involved molecular mechanisms taking a role behind this change. The obtained results demonstrate that NDT induced significant dose-dependent changes promoting cell differentiation, neurite outgrowth, and neuron survival, especially in nociceptive neurons. Notably, NDT significantly upregulated PIEZO1 gene expression. A gene that is coding for an ion channel that is expressed both in murine and human sensory neurons and is related to mechanical stimuli transduction and pain suppression. Other genes involved in mechanical allodynia related to neuroinflammation were not modified by NDT. The results of the present study contribute to increase the knowledge behind the biological mechanisms activated in response to NDT and to understand its efficacy in improving nerve regenerational physiological processes and pain reduction.

Effects of joint and nerve mobilisation on neuroimmune responses in animals and humans with neuromusculoskeletal conditions: a systematic review and meta-analysis

Supplemental Digital Content is Available in the Text.

There is evidence that joint and nerve mobilisations compared with sham or no intervention positively influence various neuroimmune responses in animal and human neuromusculoskeletal conditions.

Several animal and human studies revealed that joint and nerve mobilisations positively influence neuroimmune responses in neuromusculoskeletal conditions. However, no systematic review and meta-analysis has been performed. Therefore, this study aimed to synthesize the effects of joint and nerve mobilisation compared with sham or no intervention on neuroimmune responses in animals and humans with neuromusculoskeletal conditions. Four electronic databases were searched for controlled trials. Two reviewers independently selected studies, extracted data, assessed the risk of bias, and graded the certainty of the evidence. Where possible, meta-analyses using random effects models were used to pool the results. Preliminary evidence from 13 animal studies report neuroimmune responses after joint and nerve mobilisations. In neuropathic pain models, meta-analysis revealed decreased spinal cord levels of glial fibrillary acidic protein, dorsal root ganglion levels of interleukin-1β, number of dorsal root ganglion nonneuronal cells, and increased spinal cord interleukin-10 levels. The 5 included human studies showed mixed effects of spinal manipulation on salivary/serum cortisol levels in people with spinal pain, and no significant effects on serum β-endorphin or interleukin-1β levels in people with spinal pain. There is evidence that joint and nerve mobilisations positively influence various neuroimmune responses. However, as most findings are based on single studies, the certainty of the evidence is low to very low. Further studies are needed.

Validation of a sham novel neural mobilization technique in patients with non-specific low back pain: A randomized, placebo-controlled trial

BACKGROUND

There is no validated sham neural mobilization (NM) intervention for lower quadrant conditions. A suitable sham NM comparator will allow to blind patients with low back pain (LBP) and reduce bias by limiting the confounding effects of expectations.

OBJECTIVE

The primary aim was to develop a sham NM technique in patients with non-specific LBP and assess its validity in supplying a suitable blinding. Secondly, we compared the short-term effects of NM and the sham comparator on pain and the straight leg raise.

DESIGN

A randomized placebo-controlled trial in which participants and assessors were blinded.

METHOD

Fifty one patients (20 men,31 women), aged 22-65 years (43 ± 12y) were allocated randomly to a NM group (n = 26) or a sham NM group (n = 25). The primary outcome of believability of the sham technique was measured one week after the intervention. Secondary outcomes of pain intensity and the straight leg raise range-of-motion were assessed at baseline, immediately after the intervention and one week after.

RESULTS

The believability of the sham technique in terms of the frequencies of perceived group assignment showed no differences between groups. Eighteen participants believed they had received the experimental NM technique in the experimental group (69.2%) and 14 in the placebo NM group (56%). Pain and the straight leg raise changes did not show differences between groups.

CONCLUSIONS

The novel sham NM demonstrated to be a believable intervention, capable of supplying a suitable blinding. Both groups showed similar short term perceived effects on pain and the straight leg raise.

Mobilization of the neurodynamic system using proprioceptive neuromuscular facilitation decreases pain and increases mobility in lower extremities and Spine-A case report

INTRODUCTION

Different approaches are used in physical therapy when treating patients with peripheral nerve paralysis and pain syndrome, such as neuro-mobilization techniques, manual therapy, muscle strengthening, active mobilization and relaxation techniques. Proprioceptive neuromuscular facilitation (PNF) seems to be a promising therapy for mobilizing the neurodynamic system. This case report illustrates the clinical reasoning and feasibility of applying PNF based neuromobilization to a patient not responsive to standard physical therapy.

CASE DESCRIPTION

A 66-year-old male was diagnosed with neurofibrosarcoma grade II, paravertebral L4-L5 left (L) side. After laminectomy of the transverse process L4 and L5 L side and stent in the lumbar region, the patient presented pain and peripheral nerve paralysis. The patient's complaints 13 years later were chronic lower back, buttock and leg pain and weakness in the L leg.

PATIENT MANAGEMENT

Six treatment sessions with follow-up were provided during 3.5 months. The PNF-based-rehabilitation-approach applied the PNF philosophy, specific techniques, and facilitating principles and procedures using manual guidance in 3-dimensional PNF movement patterns in various positions, aiming to mobilize the neurodynamic system to decrease pain and achieve trunk and leg mobility.

DISCUSSION AND CONCLUSION

The PNF-based-rehabilitation-approach led to improvement in pain, nerve mobility and balance beyond or close to clinical relevance. This approach had positive effects, by supplying oxygen to the nerves, increasing nerve mobility and decreasing pain, hence restoring altered movement patterns, which all improved the patient's activities-of-daily-living. In a situation, where standard strengthening and mobilization techniques are not effective, PNF seems a feasible alternative to decrease chronic pain.

The Implementation of Therapeutic Alliance in the Rehabilitation of an Elite Pediatric Athlete with Salter-Harris Fracture: A Case Report

BACKGROUND/PURPOSE

Although research on the value of therapeutic alliance is prominent in other areas of health care, physical therapy research is limited. The purpose is to describe the incorporation of therapeutic alliance concepts throughout the rehabilitation of an elite pediatric athlete with a complicated recovery following a fracture to the distal femoral epiphysis.

CASE DESCRIPTION

A 14-year-old male was referred to physical therapy following an open reduction and internal fixation to address a type IV Salter-Harris fracture of the right distal femoral epiphysis. Post-operative care included immobilization in a brace for six weeks and he initiated physical therapy for four weeks (post-op weeks 6-10). At 10-weeks post-injury his range of motion and strength were severely limited compared to expected post-operative milestones. Due to these deficits an arthroscopic debridement of the subject's right knee, hardware removal, and manipulation under anesthesia was performed. The subject then reported to the physical therapist on post-operative day three for evaluation and treatment without bracing or weight-bearing restrictions.

OUTCOMES

The episode of care spanned 17 weeks and included 25 physical therapy sessions. To facilitate therapeutic alliance with the subject, clear communication and easily measurable goals were established and connected to the subject's relevant needs as an athlete. The plan of care was divided into three phases using "chunking" techniques to establish the rehabilitation priorities. The subject demonstrated improved range of motion, strength and was able to return to hydroplane racing and won a national championship in his age group.

DISCUSSION

The unique aspect of this case was the incorporation of therapeutic alliance concepts and techniques into the rehabilitative management of a subject with a complicated fracture to the distal femoral epiphysis. The physical therapist built trust with the subject and facilitated a successful return to elite hydroplane boat racing.

LEVEL OF EVIDENCE

4.

STUDY DESIGN

Case Report.

Excursion of the median nerve during a contra-lateral cervical lateral glide movement in people with and without cervical radiculopathy

BACKGROUND

A segmental, contra-lateral cervical lateral glide (CCLG) mobilization technique is effective for patients with cervical radiculopathy (CR). The CCLG technique induces median nerve sliding in healthy individuals, but this has not been assessed in patients with CR.

OBJECTIVE

This study aimed to 1) assess longitudinal excursion of the median nerve in patients with CR and asymptomatic participants during a CCLG movement, 2) reassess nerve excursions following an intervention at a 3-month follow-up in patients with CR and 3) correlate changes in nerve excursions with changes in clinical signs and symptoms.

DESIGN

Case-control study.

METHODS

During a computer-controlled mechanically induced CCLG, executed by the Occiflex™, longitudinal median nerve excursion was assessed at the wrist and elbow with ultrasound imaging (T0) in 20 patients with CR and 20 matched controls. Patients were re-assessed at a 3-month follow-up (T1), following conservative treatment including neurodynamic mobilization.

RESULTS

There was a significant difference between patients and controls in the excursion of the median nerve at both the wrist (Mdn = 0.50 mm; IQR = 0.13-1.30; 2.10 mm (IQR = 1.42-2.80, p < 0.05)) and elbow (Mdn = 1.21 mm (IQR = 0.85-1.94); 3.49 mm (IQR = 2.45-4.24, p < 0.05)) respectively at T0. There was also a significant increase in median nerve excursion at both sites between T0 and T1 in those with CR (Mdn = 1.96, 2.63 respectively). Wilcoxon Signed-Ranks Test indicated median pre-test ranks (Mdn = 0.5, 1.21; Z = - 3.82, p < 0.01; Z = -3.78, p < 0.01 respectively) and median post-test ranks. There was a strong correlation between improvement in median nerve excursion at the elbow at T1 and improvement in pain intensity (r = 0.7, p < 0.001) and functional limitations (r = 0.6, p < 0.01).

CONCLUSION

Longitudinal median nerve excursion differs significantly between patients with CR and asymptomatic volunteers at baseline, but this difference is no longer present after 3 months of conservative physiotherapy management. Improvement in nerve excursion correlates with improvement in clinical signs and symptoms.

Influence of Tensioner's Mobilization on the Centralization of Symptoms in Cervicobrachial Pain Syndrome: A Randomized Controlled Trial

Study Design

This study was designed as a randomized controlled trial.

Purpose

The present study aimed to determine the impact of neural mobilization by tensioner’s technique (NMTT) on the centralization of symptoms and pain in patients with cervicobrachial pain syndrome (CBPS).

Overview of Literature

CBPS is a disabling condition of the neck that is characterized by pain and paresthesia in the upper quarter. Several techniques have successfully provided immediate and long-term relief in CBPS; however, few studies have evaluated the effect of these techniques on the centralization of symptoms.

Methods

Thirty patients aged 18–45 years with a complaint of pain in the neck that had persisted for 2–12 weeks radiating to the arm and fulfilling Elvey’s criteria were randomly selected and divided into two groups. Group A received NMTT plus conventional treatment (hot pack and postural advice with cervical lateral glide), and group B received only conventional treatment 3 times a week for 2 weeks. The outcome measures were Wernicke’s scale score for the centralization of symptoms and Visual Analog Scale score for pain intensity. Within- and between-group comparisons were made before initiating treatment and at the end of the 3rd and 6th sessions. Within group analyses for the centralization values were performed using Friedmann test, and between-group analyses were performed using Mann-Whitney test. A 2×3 mixed model of the analysis of variance was used for analyzing the pain levels.

Results

There was a significant difference (p<0.05) within and between the groups for both the measures at the end of the 3rd and 6th sessions. Thus, NMTT may be beneficial in decreasing the peripheralization of symptoms and pain intensity in patients with CBPS.

Conclusions

NMTT can be used as an alternative and effective treatment option for patients with CBPS.

Carpal Tunnel Syndrome: A National Survey to Monitor Knowledge and Operating Methods

The aim of this article was to investigate the knowledge, management, and clinical practice of Italian physiotherapists concerning patients with carpal tunnel syndrome (CTS). A national cross-sectional survey consisted of 24 questions was administered from December 2019 until February 2020. A Chi-squared independence test was run to study any difference between subgroups of the sample and responses to the questionnaire. Five hundred and eight respondents completed the survey. Most respondents (n = 225/508; 44.3%) are under 29 years old, female (n = 256/508; 50.4%) and have been working as physiotherapists for less than 5 years (n = 213/508; 41.9%). Most of respondents correctly knows about the cause (n = 455/508, 89.6%), main signs and symptoms of CTS (n = 415/508, 81.70%) and administer education, manual therapy, myofascial techniques and therapeutic exercises (n = 457/508, 89.88%). Three hundred and sixty-four (71.68%) respondents were aware of the influence of psychosocial factors on the patient’s outcomes. The survey showed greater adherence to evidences by physiotherapists holding a master’s degree. The results are mostly comparable with other surveys structured all over the world on the same topic. Italian physiotherapists management of the CTS was not always in line with current evidence. Interventions such as education, manual therapy, therapeutic exercise, nerve and tendon glide techniques are widely used, while the orthotic is only offered by half of the sample.

Variables predicting prognosis following nerve mobilisation in individuals with cervicobrachial pain

Background/Aims

The causes of cervicobrachial pain are highly variable and it is often difficult to predict patient response to multimodal treatments, such as neural mobilisation. Little research has focused on identifying subgroups of patients who may show improvement following neural mobilisation. This study aimed to identify the variables that may influence response to nerve mobilisation in individuals with cervicobrachial pain.

Methods

A quasi-experimental prospective single-arm study was conducted with 50 participants. Data were collected on various potentially prognostic variables from baseline questionnaires, medical history and physical examination. Participants received 10 days of pain modulation treatment and nerve mobilisation exercises. The Neck Disability Index, Numeric Pain Rating Scale and Upper Limb Tension Test were performed before and after treatment to determine the effect of nerve mobilisation. Data were analysed using descriptive statistics, univariate correlation, multivariate stepwise logistic regression and non-parametric testing at α≤0.05.

Results

Four variables had a positive influence on treatment outcome: age <41 years, duration of symptoms ≤1 year, fasting blood glucose level ≤5.6 mmol/L (≤100 mg/dL) and systolic blood pressure ≤140 mmHg. On multiple linear regression, the presence of hypertension and diabetes were strongly associated with poor outcomes following nerve mobilisation.

Conclusions

Younger individuals with normal fasting blood glucose and systolic blood pressure who have had cervicobrachial pain for less than a year are more likely to benefit from pain modulation and neural mobilisation.

Treating low back pain - Bridging the gap between manual therapy and exercise

As therapists, we often recommend exercise to reduce patients' low-back pain, as well as increase their active range of motion and muscle strength. However, physical therapists face a challenge when recommending exercise to reduce low-back pain because the pain itself often inhibits the patient's ability to exercise or perform activities of daily living. This situation becomes even more challenging if the prescribed exercise program aggravates the individual's low-back pain. This article discusses a method which provides for the effective treatment of low back pain by allowing patients to exercise pain free earlier in the rehabilitation process. The method comprises a unique approach utilizing the following four components simultaneously from the onset of treatment: isometric muscle contraction (IMC); assisted active oscillatory mobilization; end-of-range passive stretch; and mindfulness.

Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review

BACKGROUND AND PURPOSE

Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events.

METHODS

Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events.

RESULTS

Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria.

CONCLUSION

There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.

Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis

IMPORTANCE

Cubital tunnel syndrome is the second most common compressive neuropathy, affecting 6% of the population. Numerous different operations are performed globally to treat it; however, prior conventional (pairwise) meta-analyses have been unable to determine which procedure is associated with the best outcomes and fewest complications.

OBJECTIVE

To evaluate which operation for cubital tunnel syndrome is associated with the greatest likelihood of symptomatic cure.

DATA SOURCES

PubMed, EMBASE, and CENTRAL were searched from database inception to March 2, 2019, with no restrictions on the setting or design of studies.

STUDY SELECTION

Experimental and observational studies directly comparing the outcomes of at least 2 surgical treatments for adults with primary cubital tunnel syndrome were included. Case reports were excluded, and when comparative studies had subgroups with 1 participant, the single-participant subgroup was excluded. The treatments had to be in situ decompression with or without medial epicondylectomy or an anterior subcutaneous, subfascial, intramuscular, or submuscular transposition. The access could be open, minimally invasive, or endoscopic. The comparator could be sham surgery or any operation mentioned earlier.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 independent reviewers, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the PRISMA Network Meta-analysis extension statement. Network meta-analysis was used to estimate the relative efficacy and safety associated with interventions using relative risks. Surgical techniques were ranked by their probability of being the best (P score) and interpreted in terms of their clinical impact.

MAIN OUTCOMES AND MEASURES

The primary outcome was response to treatment (ie, symptomatic improvement). The secondary outcomes were perioperative complications, reoperation, and recurrence.

RESULTS

A total of 30 studies of 2894 limbs undergoing 8 different operations were included. Across the studies, 56% of participants were men, the mean (SD) age was 48 (8) years, and patients had symptoms for a mean (SD) of 15 (7) months. Overall, 87% (95% CI, 92%-91%) of patients improved with surgery; all forms of in situ decompression were more effective than any type of transposition procedure; for example, open in situ decompression with epicondylectomy was associated with higher success rates than subcutaneous transposition (relative risk, 1.13; 95% CI, 1.01-1.25). Postoperatively, 3% (95% CI, 2%-4%) of patients developed complications, and in situ decompressions were ranked as the least risky, although there was considerable uncertainty in this outcome. Overall, 2% (95% CI, 1%-3%) of patients required reoperation; open in situ decompression was associated with the fewest reoperations; in comparison, submuscular transposition was associated with 5 times the risk of reoperation (relative risk, 5.08; 95% CI, 2.06-12.52). During surveillance, 3% (95% CI, 1%-4%) of patients developed recurrence, and open in situ decompression with epicondylectomy was ranked as the safest operation, although there was uncertainty in the estimates.

CONCLUSIONS AND RELEVANCE

In this network meta-analysis, open in situ decompression (with or without medial epicondylectomy) appeared to be the safest operation and also was associated with the best outcomes for patients with primary cubital tunnel syndrome. Future research should focus on better defining this disorder and developing core outcome measures.

Effect of Neural Mobilization on Nerve-Related Neck and Arm Pain: A Randomized Controlled Trial

Purpose: Neural mobilization (NM) is often used to treat nerve-related conditions, and its use is reasonable with nerve-related neck and arm pain (NNAP). The aims of this study were to establish the effect of NM on the pain, function, and quality of life (QOL) of patients with NNAP and to establish whether high catastrophizing and neuropathic pain influence treatment outcomes. Method: A randomized controlled trial compared a usual-care (UC; n = 26) group, who received cervical and thoracic mobilization, exercises, and advice, with an intervention (UCNM; n = 60) group, who received the same treatment but with the addition of NM. Soft tissue mobilization along the tract of the nerve was used as the NM technique. The primary outcomes were pain intensity (rated on the Numerical Pain Rating Scale), function (Patient-Specific Functional Scale), and QOL (EuroQol-5D) at 3 weeks, 6 weeks, 6 months, and 12 months. The secondary outcomes were the presence of neuropathic pain (using the Neuropathic Diagnostic Questionnaire) and catastrophizing (Pain Catastrophising Scale). Results: Both groups improved in terms of pain, function, and QOL over the 12-month period (p < 0.05). No between-groups differences were found at 12 months, but the UCNM group had significantly less pain at 6 months (p = 0.03). Patients who still presented with neuropathic pain (p < 0.001) and high pain catastrophizing (p = 0.02) at 6- and 12-mo follow-ups had more pain. Conclusions: Both groups had similar improvements in function and QOL at 12-month follow-up. The UCNM group had significantly less pain at 6-month follow-up and a lower mean pain rating at 12-month follow-up, although the difference between groups was not significant. Neuropathic pain is common among this population and, where it persisted, patients had more pain and functional limitations at 12-mo follow-up.

Effects of neural mobilization in patients after lumbar microdiscectomy due to intervertebral disc lesion

BACKGROUND

Neural mobilization (NM) techniques have been shown to improve the neural tissue's viscoelastic properties that may lead to recover of the function of the nerve after lumbar spine surgery. This study aimed to determine the effects of NM in addition to standard rehabilitation on lumbar and sciatic pain intensity, disability level, and quality of life in patients after receiving a microdiscectomy of the intervertebral lumbar disc (IVD).

METHODS

Twenty-four participants (age 41.3 ± 8.3 years old) within 3-4 weeks of a microdiscectomy of an IVD were randomly allocated to control (CTRL; n = 12) or NM group (n = 12). The CTRL group received ten standard rehabilitation sessions. The NM group received the same rehabilitation sessions with the addition of NM techniques. The intensity of lumbar and sciatic pain (visual analogue scale), disability level (Oswestry disability index), and health-related quality of life (SF-36 questionnaire) were measured before and after the intervention.

RESULTS

Within-group analysis revealed a significant reduction in lumbar (p < 0.05) and sciatic pain intensity (p < 0.001), disability level (p < 0.001), and improvement in the physical function and problems, vitality, emotional well-being, and pain SF-36 items (p < 0.05) in both groups. There were no statistical differences between groups in all outcomes.

CONCLUSION

A standard rehabilitation protocol alone or in combination with NM techniques are equally effective in reducing pain and disability level, as well as improving quality of life in patients after a microdiscectomy due to intervertebral lumbar disc lesion.

Effects of an active intervention based on myofascial release and neurodynamics in patients with chronic neck pain: a randomized controlled trial

BACKGROUND

While neck pain can be severely disabling and costly, treatment options have shown moderate evidence of effectiveness.

OBJECTIVE

The objective of this study was to explore the effects of a 4-week active program based on myofascial release and neurodynamics on trigger point (TrP) examination, pain, and functionality in patients with chronic neck pain.

METHODS

Randomized controlled trial. A total of 40 patients with chronic neck pain were randomly allocated to an experimental or a control group (n = 20). The primary outcome measure was TrP examination. Secondary outcomes were pain, assessed with the Brief Pain Inventory and a visual analogue scale, and functionality, evaluated with the Neck Outcome Score.

RESULTS

A between-group analysis showed significant differences (p < .05) in the percentage of active TrPs in the following muscles: suboccipital (50 vs. 92.4% in the right muscle and 37.5 vs. 89.6% in the left muscle), left scalene and levator scapulae. Significant differences (p < .05) were also found in pain severity, average pain, and functionality (i.e. symptoms, sleep, and participation).

CONCLUSIONS

A 4-week self-administered program for patients with chronic neck pain was effective in reducing the presence of active TrPs. Pain severity, average pain, and some aspects of functionality also improved significantly after the intervention.

Cervical traction combined with neural mobilization for patients with cervical radiculopathy: A randomized controlled trial

BACKGROUND

Although both neural mobilization (NM) and cervical traction (CT) are widely used interventions in cervical radiculopathy (CR), there is limited clinical data to support their use.

OBJECTIVE

To evaluate the effects of CT, with or without the addition of NM, on pain, function, and disability in patients with CR.

DESIGN

A randomized, double-blinded, placebo-controlled clinical trial.

METHODS

66 patients with CR were randomly allocated to: a group (n = 22) received CT combined with NM (CT + NM), a group (n = 22) received CT combined with sham NM (CT + shamNM) and a wait-list control (WLC) group (n = 22). The Neck Disability Index (NDI), the Patient-Specific Functional Scale, the Numeric Pain Rating Scale (NPRS), grip strength and cervical spine mobility were used as outcome measures. A two-way analysis of variance was used to evaluate differences between the three groups at baseline and at 4-week follow-up.

RESULTS

Statistically and clinically significant between-group differences at 4-week follow-up were found between CT + NM and WLC groups in favor of CT + NM group in NDI scores (d = 1.30), NRPS (d = 1.94), and active cervical rotation towards the opposite arm (d = 1.18) and between CT + NM and CT + shamNM groups in favor of CT + NM group in NRPS (d = 1.21). No significant differences were observed between CT + shamNM and WLC groups in all outcome measures. Clinically significant within-group improvements were found only for the CT + NM group.

CONCLUSION

At 4-week follow-up, CT in combination with NM resulted in improved outcomes in pain, function and disability in patients with CR.

Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety

Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.

Peripheral and Central Adaptations After a Median Nerve Neuromobilization Program Completed by Individuals With Carpal Tunnel Syndrome: An Exploratory Mechanistic Study Using Musculoskeletal Ultrasound Imaging and Transcranial Magnetic Stimulation

OBJECTIVE

Neuromobilization exercises are increasingly advocated in the conservative management of individuals with carpal tunnel syndrome (CTS), as they may mitigate CTS-related signs and symptoms via potential peripheral (ie, musculoskeletal) and central (ie, neurophysiological) adaptations. However, the mechanisms underlying these adaptations have not been studied extensively. Hence, this exploratory and mechanistic study aims to evaluate the potential peripheral and central adaptations that may result in individuals with CTS who have completed a neuromobilization program.

METHODS

Fourteen individuals with CTS were evaluated before and 1 week after the completion of a 4-week neuromobilization program that incorporated median nerve sliding exercises. Pain and upper limb functional abilities were assessed using standardized questionnaires. The biological integrity and mechanical properties of the median nerve and the corticospinal excitability were quantified using musculoskeletal ultrasound imaging and transcranial magnetic stimulation, respectively.

RESULTS

Upon completion of the program, participants reported both large and moderate improvements in pain (P ≤ .03) and upper limb functional abilities (P = .02), respectively. The biological integrity and mechanical properties of the median nerve remained unchanged (P ≥ .22), whereas a small significant increase in corticospinal excitability (P = .04) was observed.

CONCLUSION

The proposed neuromobilization program appears promising to improve pain and upper limb functional abilities in individuals with CTS. These improvements may be preferentially mediated via central, rather than peripheral, adaptations. Future studies, especially with a larger sample size, longer intervention duration, and additional measurement times, are needed to strengthen current evidence.

The Utilization of Joint Mobilization As Part of a Comprehensive Program to Manage Carpal Tunnel Syndrome: A Systematic Review

OBJECTIVE

The purpose of this review is to identify the role of joint mobilization for individuals with Carpal tunnel syndrome (CTS).

METHODS

A systematic search of 5 electronic databases (PubMed, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, and SPORTDiscus) was performed to identify eligible full-text randomized clinical trials related to the clinical question. Joint mobilization had to be included in one arm of the randomized clinical trials to be included. Two reviewers independently participated in each step of the screening process. A blinded third reviewer assisted in cases of discrepancy. The PEDro scale was used to assess quality.

RESULTS

Ten articles were included after screening 2068 titles. In each article where joint mobilization was used, positive effects in pain, function, or additional outcomes were noted. In most cases, the intervention group integrating joint mobilization performed better than the comparison group not receiving joint techniques.

CONCLUSION

In the articles reviewed, joint mobilization was associated with positive clinical effects for persons with CTS. No studies used joint mobilization in isolation; therefore, results must be interpreted cautiously. This review indicates that joint mobilization might be a useful adjunctive intervention in the management of CTS.

Effect of Adding Neural Mobilization Versus Myofascial Release to Stabilization Exercises after Lumbar Spine Fusion: A Randomized Controlled Trial

OBJECTIVES

To test the effect of adding neural mobilization (NM) versus myofascial release (MFR) to stabilization exercises (SE) on disability, pain, and lumbar range of motion (ROM) in patients with lumbar spine fusion (LSF).

DESIGN

A single blinded, parallel groups, randomized controlled trial.

SETTING

Outpatient public and governmental hospital clinics.

PARTICIPANTS

Patients (N=60) who had undergone LSF were randomly assigned into 3 equal groups.

INTERVENTION

Group I received NM plus SE, group II received MFR and SE, and group III received SE only. Each group visited the hospital 3 times a week for 4 weeks.

MAIN OUTCOME MEASURES

Oswestry disability index (ODI), visual analog scale, and back range of motion (BROM) were assessed before starting treatment, immediately after finishing treatment, and 1 month later.

RESULTS

There were statistically significant differences among the groups regarding the ODI and pain (P<.05) in favor of the study groups, but no statistically significant differences were found among groups regarding the BROM outcome (P>.05). Regarding the within-group effect, statistically significant differences were found in all outcomes after 1 month of treatment, as well as after 1 month of follow-up in each group (P<.05).

CONCLUSIONS

Patients who received NM or MFR combined with SE demonstrated better improvement, in favor of the NM group, regarding disability and pain than patients who received SE alone after LSF. No differences were found among the groups regarding lumbar ROM.

Neurovascular axillary variations: superficial brachial artery and single-corded brachial plexus

Variants of the axillary artery and brachial plexus were found bilaterally in the axilla of an 86-year-old Asian female. On the left, the cadaver donor had a high bifurcation of the second part of the axillary artery, creating a superficial brachial artery. Meanwhile, the right axilla presented with root, trunk, and cord variations in the formation of the brachial plexus, the most interesting feature being a single, unified cord. Presented in this case report are the structural relationships of the variants with considerations regarding anatomy, embryology, prevalence, and clinical importance.

Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

BACKGROUND

Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS.

METHODS

To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements.

RESULTS

During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS.

CONCLUSIONS

A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.

Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Reliability and accuracy of the brachial plexus neurodynamic test

STUDY DESIGN

Observational study.

INTRODUCTION

The brachial plexus neurodynamic test (BPNT), based on previous neurodynamic tests, is considered a clinically meaningful tool to objectively assess brachial plexus extensibility. This novel test's psychometric properties have yet to be determined.

PURPOSE OF THE STUDY

The primary study aim was to assess the inter- and intrarater reliability and accuracy of the BPNT, which biases the median nerve and brachial plexus, among clinicians of various professional experience levels and geographic US regions. The secondary study aim was to determine if professional experience or geographic region affects the accuracy levels of this test.

METHODS

In phase 1, inter-rater reliability and accuracy was determined. About 307 participants attending neural mobilization conferences and courses were instructed in the BPNT and asked to score 7 different videos of 14 possible test levels. In phase 2, intrarater reliability was determined via scoring the same test videos twice.

RESULTS

High inter-rater intraclass correlation coefficient (range, 0.98-0.99) and accuracy (range, 0.88-0.94) levels were determined for all clinical experience levels and geographic regions. Intrarater intraclass correlation coefficient values were high (range, 0.96-1.0) among all participants. One-way analysis of variance indicated no significant differences on test accuracy based on professional clinical experience (F = 0.104; P = .958) and geographic region (F = 0.416; P = .416) among all 307 participants.

DISCUSSION

Excellent inter- and intrarater reliability and accuracy levels may allow clinicians to correctly identify BPNT positions regardless of their professional experience or geographic location.

CONCLUSION

The BPNT can reliably and accurately quantify outcomes in neural mobility scoring.

Neural and visceral manipulation in infants with congenital muscular torticollis: a feasibility study

[Purpose] As an alternative to manual stretching, the aim of this study was to investigate the feasibility of using neural/visceral manipulation as a safe and effective intervention to increase neck range of motion of infants with congenital muscular torticollis. [Participants and Methods] Ten 4-month old infants with congenital muscular torticollis received eight sessions of neural/visceral manipulation administered for 30–50 minutes without observed pain. Specific palpation techniques addressed restricted tissue areas of neck, head, trunk and extremities. Neck rotation and lateral flexion were assessed by still photography and a computer program calculating ROM angles before, immediately following, and 4 months post intervention. Motor development and social competence were monitored over time using the Alberta Infant Motor Scale and Bayley-III Social Emotional Scale. [Results] Results of analysis of variances revealed significant improvements in passive and active neck rotation and lateral flexion. Significant increases were also found on the Alberta Infant Motor Scale and Bayley-III Social-Emotional scale. [Conclusion] Neural/visceral manipulation can be used safely in infants with congenital muscular torticollis to improve neck range of motion.

Nonpharmacologic Approaches to Pain, Engorgement, and Plugging in Lactation: Applying Physical Therapy Techniques From Breast Cancer Care to Breastfeeding Patients

Introduction

Breast and nipple pain is one of the most common reasons why mothers stop breastfeeding earlier than recommended. Once conditions such as subacute mastitis, oversupply, and dermatitis have been treated or ruled out, functional breast pain may persist.

Review

We describe validated physical therapy techniques that may reduce chronic pain in breastfeeding. These techniques include lymphatic massage, reverse-pressure softening, kinesiology taping, neural mobilization, cupping, and therapeutic ultrasound.

Conclusion

While more commonly used in the breast cancer population after radiation and surgery, we propose these techniques may also prove efficacious in breastfeeding patients as well.

Neck pain in South Africa: An overview of the prevalence, assessment and management for the contemporary clinician

BACKGROUND

Neck pain is a prevalent condition and is associated with high levels of disability and pain. The long-term prognosis can be poor, and therefore effective management in the acute stage is important.

OBJECTIVES

To provide an overview of the prevalence of neck pain and physiotherapy management and to provide evidence-informed recommendations for clinical practice within a South African context.

METHOD

The literature was reviewed considering prevalence, risk factors and examination. Management recommendations were derived from the highest levels of evidence of clinical practice guidelines, systematic reviews and randomised clinical trials.

RESULTS

Neck pain is classified into four grades, and three trajectories of recovery have been identified. Although the incidence of neck pain globally is high, in the South African context the majority of the population have limited access to physiotherapy management. Sound clinical reasoning is important in the assessment and decision-making process for management. Exercise, and mobilisation or manipulation are effective treatment options in the management of most types of neck pain. Other physical modalities such as needling, transcutaneous electrical nerve stimulation, laser and intermittent traction may be used as an adjunct to management.

CONCLUSION

The burden of neck pain globally is high; however, there is a lack of information on current practice, prevalence and burden of neck pain in the South African context. Sound evidence-informed clinical reasoning to inform a working diagnosis and to enable patient-centred management is important.

CLINICAL IMPLICATIONS

A thorough assessment is essential to gather information to formulate hypotheses regarding diagnosis and prognosis for neck pain. Exercise, and mobilisation or manipulation are effective management options.

Normalization of Spinal Cord Displacement With the Straight Leg Raise and Resolution of Sciatica in Patients With Lumbar Intervertebral Disc Herniation: A 1.5-year Follow-up Study

STUDY DESIGN

A controlled radiologic follow-up study.

OBJECTIVE

The aim of this study was to ascertain whether changes in cord excursion with straight leg raise test (SLR) at 1.5-year follow-up time accompany changes in clinical symptoms.

SUMMARY OF BACKGROUND DATA

Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously, we found that a significant limitation of neural displacement (66.6%) was evident with the SLR on the symptomatic side of patients with subacute single level posterolateral LIDH.

METHODS

Fourteen patients with significant sciatic symptoms due to a subacute single-level posterolateral LIDH were reassessed clinically and radiologically at 1.5 years follow-up with a 1.5T MRI scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with a decrease in low back pain (LBP) and radicular symptoms.

RESULTS

Compared with previously presented baseline values, the data showed a significant increase in neural sliding in all the quantified maneuvers (P ≤ 0.01), and particularly of 2.52 mm (P ≤ 0.001) with the symptomatic SLR.Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson = -0.719, P ≤ 0.001) and LBP (Pearson = -0.693, P ≤ 0.001). Multivariate regression models and backward variable selection method confirmed the improvement of neural sliding effects (P ≤ 0.004) as the main variable being associated with improvement of self-reported clinical symptoms.

CONCLUSION

To our knowledge, these are the first noninvasive data to objectively support the association between increase in magnitude of neural adaptive movement and resolution of both radicular and LBP symptoms in in vivo and structurally intact human subjects.

LEVEL OF EVIDENCE

2.

A Critical Analysis of the Exercise Prescription and Return to Activity Advice That Is Provided in Patient Information Leaflets Following Lumbar Spine Surgery

Background and objectives: Lumbar spine surgery may be considered if pharmacologic, rehabilitation and interventional approaches cannot provide sufficient recovery from low back-related pain. Postoperative physiotherapy treatment in England is often accompanied by patient information leaflets, which contain important rehabilitation advice. However, in order to be an effective instrument for patients, the information provided in these leaflets must be up to date and based on the best available evidence and clinical practice. This study aims to critically analyse the current postoperative aspects of rehabilitation (exercise prescription and return to normal activity) that are provided in patient information leaflets in England as part of an evaluation of current practice following lumbar spine surgery. Materials and Methods: Patient information leaflets from English National Health Service (NHS) hospitals performing lumbar spine surgery were sourced online. A content analysis was conducted to collect data on postoperative exercise prescription and return to normal activities. Results: Thirty-two patient information leaflets on lumbar surgery were sourced (fusion, n = 11; decompression, n = 15; all lumbar procedures, n = 6). Many of the exercises prescribed within the leaflets were not based on evidence of clinical best practice and lacked a relationship to functional activity. Return to normal activity advice was also wide ranging, with considerable variation in the recommendations and definitions provided. Conclusions: This study highlights a clear variation in the recommendations of exercise prescription, dosage and returning to normal activities following lumbar spine surgery. Future work should focus on providing a consistent and patient-centred approach to recovery.

The addition of neurodynamic exercises to extension-oriented exercises among patients with chronic back-related leg pain: A study protocol

BACKGROUND

Patients with back-related leg pain exhibit nociceptive and neuropathic characteristics. Few studies have investigated the combination of interventions considering these characteristics.

OBJECTIVES

To investigate if the addition of neurodynamic exercises (EEN) to extension-oriented exercises (EE) promotes additional benefits in individuals with back-related leg pain and a directional preference.

METHODS

Patients will be randomized to either EE or EEN. Patients from both groups will receive 7 sessions over 3 weeks. Low back and leg pain, function, quality of life, disability, and global perceived effect will be evaluated at baseline, 3 weeks after randomization and 1-month follow-up. A linear mixed model will be used for outcomes analysis.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

The Variation of Cross-Sectional Area of the Sciatic Nerve in Flexion-Distraction Technique: A Cross-Sectional Study

OBJECTIVE

The purpose of this study was to compare the cross-sectional area of the sciatic nerve in different positions of spinal manipulation using flexion-distraction technique.

METHODS

Thirty healthy participants were assessed in 6 different flexion-distraction technique positions of varying lumbar, knee, and ankle positions. Participants stood in the following 3 positions with the lumbar in the neutral position: (A) with knee extended, (B) with knee flexed, and (C) with the knee extended and ankle dorsiflexion. Participants then stood in the following 3 positions with the lumbar flexed: (D) with the knee extended, (E) with the knee flexed, and (F) with knee extended and ankle dorsiflexion. The cross-sectional area (CSA) of the sciatic nerve was measured with ultrasound imaging in transverse sections in the posterior medial region of the left thigh. The CSA values measured at each position were compared.

RESULTS

We analyzed 180 ultrasound images. The cross-sectional area of the sciatic nerve (in mm²) in position B (mean; standard deviation) (59.71-17.41) presented a higher mean cross-sectional area value compared with position D (51.18-13.81; P =.005), position F (48.71-15.16; P = .004), and position C (48.37-16.35; P = .009).

CONCLUSION

The combination of knee extension and ankle dorsiflexion reduced the CSA of the sciatic nerve, and flexing the knee and keeping the ankle in the neutral position increased it.

Pragmatic neural tissue management improves short-term pain and disability in patients with sciatica: a single-arm clinical trial

Objectives: To evaluate the clinical effect of sciatic neural mobilization in combination with the treatment of surrounding structures for sciatica patients. Secondly, we were also interested in identifying possible baseline characteristics that may be associated with improvements in pain and disability for sciatica patients. Methods: Twenty-eight patients with a clinical diagnosis of sciatica were treated with neural mobilization, joint mobilization and soft tissue techniques. Pain intensity and lumbar disability were assessed at baseline and after treatment using a Numerical Rating Scale (0-10) and the Oswestry Disability Index (0-100), respectively. The pre- and post-intervention data were compared. The research protocol was registered under the number NCT03663842. Results: Participants attended an average of 16 (SD±5.6) treatment
sessions over an average of 12 weeks. Decrease in pain scores (before median = 8, after median = 2; p < 0.001) and improvement in lumbar disability scores (before median = 33.3%, after median = 15.6%; p < 0.001) were observed. A multiple linear regression analysis showed that duration of pain and age of the patient predicted the disability improvement: F (2, 24) = 4.084, p < 0.030, R² = 0.254. Discussion: Patients with sciatica may benefit from neural mobilization in combination with manual therapy for pain and lumbar disability. Longer pain duration and younger age had a negative influence on lumbar disability improvement.

Minimal physical therapy utilization compared with higher physical therapy utilization for patients with low back pain: a systematic review

Aim: Currently there is a large and perhaps unwarranted variation regarding physical therapy utilization for individuals with low back pain (LBP).  The purpose of this systematic review was to compare the effects of minimal physical therapy utilization/education (two visits or less) versus typical physical therapy utilization (three visits or more) on patient-important outcomes for patients with LBP. Methods: Two independent reviewers searched Cochrane, Medline, CINAHL, Web of Science, and PEDro from database inception until March 2017. Eligible studies used a randomized design, included subjects with LBP, and compared minimal versus higher utilization. The GRADE approach was used to provide an overall level of evidence regarding utilization. Eight articles (1153 individual subjects) met the inclusion criteria. Effect sizes for each outcome measure were calculated using Hedge's g and were adjusted for baseline values at each time period. Findings: When compared with minimal utilization, higher utilization demonstrated no significant differences on pain, disability, or quality of life at the 1-year follow-up. However, two of the three studies that analyzed cost-effectiveness found higher utilization to be more cost-effective at 1-year follow-up. Moreover, there was insufficient evidence available to investigate patient subgroups (acuity, risk for chronicity), multiple levels of utilization dosage (low, typical, and high), or intervention type. Conclusions: This review identifies the need for further research on the dosage of physical therapy among various subgroups of patients with LBP. While higher utilization may not result in significant improvements in patient-important outcomes, it may be more cost-effective for patients with chronic or complex LBP conditions when compared to minimal utilization.

The Effect of Spinal Mobilization With Leg Movement in Patients With Lumbar Radiculopathy-A Double-Blind Randomized Controlled Trial

OBJECTIVES

To evaluate the effect of spinal mobilization with leg movement (SMWLM) on low back and leg pain intensity, disability, pain centralization, and patient satisfaction in participants with lumbar radiculopathy.

DESIGN

A double-blind randomized controlled trial.

SETTING

General hospital.

PARTICIPANTS

Adults (N=60; mean age 44y) with subacute lumbar radiculopathy.

INTERVENTIONS

Participants were randomly allocated to receive SMWLM, exercise and electrotherapy (n=30), or exercise and electrotherapy alone (n=30). All participants received 6 sessions over 2 weeks.

MAIN OUTCOME MEASURES

The primary outcomes were leg pain intensity and Oswestry Disability Index score. Secondary variables were low back pain intensity, global rating of change (GROC), straight leg raise (SLR), and lumbar range of motion (ROM). Variables were evaluated blind at baseline, post-intervention, and at 3 and 6 months of follow-up.

RESULTS

Significant and clinically meaningful improvement occurred in all outcome variables. At 2 weeks the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.0; 95% confidence interval [95% CI], 1.4-2.6) and disability (MD 3.9; 95% CI, 5.5-2.2). Similarly, at 6 months, the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.6; 95% CI, 1.9-3.2) and disability (MD 4.7; 95% CI, 6.3-3.1). The SMWLM group also reported greater improvement in the GROC and in SLR ROM.

CONCLUSION

In patients with lumbar radiculopathy, the addition of SMWLM provided significantly improved benefits in leg and back pain, disability, SLR ROM, and patient satisfaction in the short and long term.

Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis

OBJECTIVE

This case report describes the clinical features, complications, imaging characteristics, and management of postoperative spinal adhesive arachnoiditis.

CLINICAL FEATURES

A 54-year-old woman presented with right posterior thigh and leg pain after a lumbar spine fusion surgery to correct a degenerative spondylolisthesis of L3/4. Her pain was sharp and shooting and worsened with knee extension. A lumbar computed tomography myelogram demonstrated clumping and adhesion of the nerve rootlets in the cauda equina at the surgical fusion levels. Findings were consistent with spinal arachnoiditis.

INTERVENTION AND OUTCOME

The patient was treated with 2 sets of neural mobilization of the sciatic nerve with 15 repetitions each. Treatment was provided 2× per week for 3 weeks. The patient used the neural mobilization exercises at home and performed to tolerance. The patient's Oswestry Questionnaire was reduced significantly by 19% with decreased pain intensity of 2 points on the verbal analogue scale.

CONCLUSION

Neural mobilization was used successfully in the management of a patient with postoperative spinal arachnoiditis.

Ultrasound Elastographic Measurement of Sciatic Nerve Displacement and Shear Strain During Active and Passive Knee Extension

There is current need for objective measures of sciatic nerve mobility in patients with sciatic-type pain. The objective of the study was to assess the feasibility and reliability of ultrasound elastography to quantify sciatic nerve displacement and shear strain at the sciatic nerve-hamstring muscle interface during active and passive knee extension-flexion exercises performed while sitting in healthy people. Ultrasound elastography showed excellent intrarater within-session reliability for assessing sciatic nerve displacement and sciatic nerve-hamstring muscle interface shear strain during active knee extension-flexion exercises. These findings will inform similar future work conducted in patients with sciatic-type pain.