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The effectiveness of neural mobilizations in the treatment of

musculoskeletal conditions: a systematic review protocol

Annalie Basson, MSc Physiotherapy

2

Benita Olivier, PhD

Richard Ellis, PhD

Michel Coppieters, PhD

Aimee Stewart, PhD

Witness Mudzi, PhD

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

Africa
2 The Witwatersrand Centre for Evidence-based Practice: a Collaborating Centre of the Joanna Briggs
Institute, South Africa
3 School of Rehabilitation and Occupation Studies, Auckland University of Technology, New Zealand
4 Faculty of Human Movement Science, Vrije Universiteit Amsterdam, The Netherlands

Corresponding author:
Benita Olivier
benita.olivier@wits.ac.za

Review question/objective
The objective of this review is to identify the effectiveness of neural mobilization techniques in various
neuro-musculoskeletal conditions. Outcomes will be analyzed in terms of subgroups such as low back
pain, cervico-brachial pain and carpal tunnel syndrome.

Background
Musculoskeletal disorders were ranked as the second largest contributor to disability worldwide in a
1

study on the global burden of disease. Low back pain and neck pain contributed to 70% of disability in
this comprehensive population-based study. Low back pain and neck pain are multifactorial, with
heterogeneous populations. It has been proposed that targeting subgroups of patients may result in
better treatment outcomes.

2,3

Neck pain associated with upper limb pain is prevalent.

4,5

These patients

are more disabled than patients with neck pain alone. Similarly, low back pain with leg pain is a
common phenomenon and is acknowledged as a predictor for chronicity.

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Neuropathic pain is often associated with musculoskeletal complaints

whiplash associated disorders (WAD)

10,11

7,8

including low back pain,

and acute or chronic radiculopathy, and can be a feature of

12

syndromes such as cervico-brachial pain syndrome. According to the International Association for the
Study of Pain, neuropathic pain can be described as pain caused by a lesion or disease of the
somatosensory nervous system.

13

Leg pain associated with back pain can be caused by central

6

sensitization, denervation, nerve sensitization or somatically referred pain. In patients with WAD, neck
pain is the most common symptom, but upper limb pain, weakness, paraesthesia and anesthesia are
often present.

11,14

Other conditions in which neural tissue is thought to contribute to the clinical picture

are, for instance, lateral epicondalalgia

15

and carpal tunnel syndrome.

16

Management strategies for back pain and neck pain are often multimodal.
effective treatment of nerve related pain is lacking.

2,17,18

2,3

However, the evidence for

Neural mobilizations are often used to affect the

neural structures in conditions with signs of neural involvement or neural mechano-sensitivity.

19-21

Neural mobilizations are defined as interventions aimed at affecting the neural structures or surrounding
tissue (interface) directly or indirectly through manual techniques or exercise.

22,23

Neural mobilizations

24

have been studied in various populations such as low back pain, carpal tunnel syndrome,
15

epicondalalgia and cervico-brachial pain.

lateral glides for cervico-brachial pain,
syndrome,

16,27

25,26

25,26

lateral

Neural mobilization techniques studied include cervical

nerve gliding exercises for the treatment of carpal tunnel

cervical lateral glides for lateral epicondalalgia

technique in the treatment of low back pain.

16

3,24

15

and the slump as a neural mobilization

No specialized equipment is needed in the performance

of neural mobilization techniques, which contributes to its popularity.

Neural mobilization is said to affect the axoplasmic flow,
29

tissue

and the circulation of the nerve

dispersion of intraneural oedema.

cells.

20

30,31

30

28

movement of the nerve and its connective

by alteration of the pressure in the nervous system and

Neural mobilization decreases the excitability of dorsal horn

Neural mobilizations can be performed in various ways using passive movement, manual

mobilization of the nerve or interface, and exercise. The aim of neural mobilization is to restore the
mechanical and neurophysiological function of the nerve.

28

Only one systematic review on the effectiveness of neural mobilizations could be identified in the
literature.

17

Since this review, several more studies have been published on this subject.

32-34

The

authors hypothesize that a review of the more recent literature (2008-2014) may confirm positive
support for the use of neural mobilizations for neuro-musculoskeletal complaints as previously seen by
Ellis and Hing.

17

This review aims to include a meta-analysis and subgrouping of conditions which will
17

be an extension of the previous review by Ellis and Hing. The outcomes of this systematic review may
be used to inform clinical practice and the development of best practice guidelines.

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

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Inclusion criteria
Types of participants
This review will consider studies that include human participants over the age of 18 years suffering from
a musculoskeletal condition consistent with neurodynamic dysfunction such as low back pain, sciatica,
WAD, cervico-brachial pain, lateral epicondylalgia and carpal tunnel syndrome. Outcomes will be
analyzed in terms of subgroups such as low back pain, cervico-brachial pain and carpal tunnel
syndrome. Studies including conditions with long tract signs and those caused by other pathological
diseases, neurological diseases, fractures or dislocations, stroke, cerebral palsy and paraplegia or
quadriplegia will be excluded.
Types of intervention(s)/phenomena of interest
This review will consider studies that evaluate the effectiveness of neural mobilization techniques.
Neural mobilizations are defined as interventions aimed at affecting the neural structures or surrounding
tissue (interface) directly or indirectly through exercise or manual techniques. Exercises are normally
divided into sliders and tensioners.

29

Sliders will elongate the nerve bed through movement at one

joint whilst moving another joint to relieve tension in the nerve. With tensioners, joints are moved in such
a way that the nerve bed is elongated and the tension in the nerves increase.

35

Sliders and tensioners

often use neurodynamic tests such as the Straight Leg Raise, Slump Test or Upper Limb Neurodynamic
Tests as movement sequences. Manual techniques used include mobilization along the course of the
nerve

26

or techniques that will change the interface around a nerve such as cervical lateral glides.

21,36

Neural mobilization performed on the intervention group will be compared to a control group where no
neural mobilization has been performed.
Types of outcomes
This review will consider studies that include the following primary outcome measures: pain
(numerical pain rating scale, visual analogue scale) and pressure pain threshold (algometer), disability
and function (Disability of the Arm, Shoulder and Hand Symptom Scale, Neck Disability Index, Roland
Morris, Oswestry, Patient Specific Functional Scale), quality of life (SF36, Eurolqual5, WHOQOLF
Physical Domain Score). Secondary outcome measures include: range of motion (inclinometer,
goniometer), muscle strength (Oxford grading, Dynamometer), sensation (light touch, pinprick,
two-point discrimination, thermal pain threshold), specific diagnostic tests (Tinels sign, Phalens
manoeuvre) and neurodynamic test outcomes (Upper Limb Neurodynamic Test 1, 2a, 2b, 3, Straight
Leg Raise, Slump, Prone Knee Bend, Passive Neck Flexion).
Types of studies
Randomized

controlled

trials

(RCTs)

evaluating

the

effect

of

neural

mobilization

on

euro-musculoskeletal conditions will be included. Studies not published in English will be excluded.

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Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy
will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken
followed by analysis of the text words contained in the title and abstract, and of the index terms used to
describe the article. A second search using all identified keywords and index terms will then be
undertaken across all included databases. Thirdly, the reference list of all identified reports and articles
will be searched for additional studies. Studies published from 2008 to 2014 will be considered for
inclusion in this review. All RCTs that were included in a previous review performed by Ellis and Hing
(2008), will also be included in this systematic review and meta-analysis, if they comply with the
inclusion criteria of this review.
The databases to be searched include: MEDLINE via PubMed, Cumulative Index to Nursing and Allied
Health Literature (CINAHL), the Cochrane Controlled Trials Register in the Cochrane Library,
Physiotherapy Evidence Database (PEDro), ProQuest 5000 International, ProQuest Health and
Medical Complete, EBSCO MegaFile Premier, Science Direct and SCOPUS. The search for
unpublished studies will include: EBSCO MegaFile Premier.
Initial keywords to be used will be: neural, nerve, mobilization, mobilization, manipulation, physical
therapy, physiotherapy, manual therapy, glide, exercises, treatment, intervention, management,
modality, stretching, tension, neurodynamics

Assessment of methodological quality

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

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

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

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

Acknowledgements
Elna Kruger, for assistance with searching and locating articles.

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Appendix I: Appraisal instruments

MAStARI appraisal instrument

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Appendix II: Data extraction instruments

MAStARI data extraction instrument

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