‘Neurodynamics as a therapeutic intervention; the effectiveness and scientific evidence?’
1. Title
Name
Neurodynamics as a therapeutic
intervention; effectiveness and
scientific evidence
Dr Toby Hall
Specialist Musculoskeletal Physiotherapist
Adjunct Associate Professor (Curtin University)
Snr Teaching Fellow (The University of Western Australia)
Accredited Mulligan Concept Teacher
toby@manualconcepts.com
‘I cringe every time I hear a physical therapist claim
that they use neural mobilization’
‘We have assumed too much when it comes to neural tension
tests and the treatments associated with these assessments’
‘There is no plausible evidence that we can mobilize neural
tissue ….. or that "neural mobilization" is effective in the
treatment of musculoskeletal dysfunction’
Neural Mobilization: The
impossible?
Di Fabio Editorial JOSPT 2001
Presentation Outline
• Is neural mobilisation
the best way to
manage neural tissue
pain disorders: have
we assumed too
much?
– Drugs; Exercise;
Neural mobilisation;
Do nothing: advice?
Severe Mod
Nerve damage does
not always cause pain
Ishimoto, 2013
n=938
• Most common painful neuropathies,
pain present <20%
– Zusman, 2010; Bennea, 2006
• Traumacc nerve injury causes pain <10%
– Zusman, 2010; Marchedni, 2006
• Severe stenosis in 30% >40 years
– Ishimoto, 2013
• Neural mobilisacon not necessary in all
cases for nerve recovery
– Scrimshaw, 2001; Svernlov, 2009
3. Exercise reduces features of acute neuropathic pain
• Rat sciacc nerve CCI
– Daily progressive exercise on
treadmill (60 minutes) or
swimming (90 minutes with rests)
– Mechanical & thermal
hyperalgesia improved
– Aaenuated cytokine produccon
(TNF-α & IL-1β)
9
Chen, 2012
Thermal
hyperalgesia
Mechanical
hyperalgesia
Exercise reduces neuropathic pain
• Rat sciacc nerve chronic constriccon or
inflammatory model
– Treadmill daily progressive exercise 30 minutes 7 days
post surgery for 14 days
– Mechanical & thermal hyperalgesia improved
– Aaenuated pain within 3 weeks, sensory
hypersensicvity returned 5 days aher stopping exercise.
Effect of exercise reversed with opioid receptor
antagonist. Same effect if exercise delayed by 4 weeks.
• Exercise upregulates endogenous opioids
10
Stagg, 2011
CC
CCI NMI
Sham NM
Naive
Movement promotes nerve recovery: reduces NP
• Rat sciacc nerve CCI model
– 10 sessions NM under light anaestheczacon 14
days post injury
– Allodynia & hyperalgesia improved
– Significant change in glial cell density & nerve
growth factor expression in the DRG & spinal
cord
11
Santos, Molecular Pain 2011
Mechanical hyperalgesia
Exercise reduces NP post CCI
• Rat sciacc CCI
– Wheel running 6/52 prior to CCI & aher
CCI
– Allodynia improved aher injury
– Prior exercise decreased neuroimmune
signalling in DH & neuron injury.
Suppressed pro-inflammatory and
increased anc-inflammatory mediators
– Significant changes in glial cell density &
NGF expression in the DRG & spinal cord
• Exercise prevents pain, promotes
recovery & relieves pain
12
Grace, Pain 2016
Allodynia
4. Summary
Basic science
• Movement
– Exercise prevents development of NP
– Exercise aids nerve recovery aher injury & reduces NP in
animal models
• Passive limb movement
• Aerobic non-specific exercise: walking, running and swimming
• Neural mobilisacon
13
But…..
14
– Is movement effective in humans?
– Is movement effective for all
nerve disorders?
– Is movement effective for chronic
& acute nerve disorders?
– Is specific nerve movement (NM)
more effective than other forms
of movement/exercise?
What is the evidence in humans?
• Limited evidence
– SR of RCT’s for neural mobilization
– 20 trials identified; generally small scale
– Evidence NM more effective minimal treatment (pain &
disability), but no better than other treatments.
• Su, 2016
• SR identified 6 studies of NM for CTS
– NM better than no treatment: weak effect size
• McKeon, 2008
• Cochrane review found no benefit for NM
• Page, 2012
• European guidelines for management of CTS do not include
physiotherapy!
• Huisstede, 2014
15
Neural gliding exercise
• Limited & poor quality evidence for the effeccveness of
neural gliding exercises in CTS
16
Effectiveness of Nerve Gliding Exercises
on Carpal Tunnel Syndrome: A
Systematic Review
Ruth Ballestero-Pérez, PhD,a
Gustavo Plaza-Manzano, PhD,b
Alicia Urraca-Gesto, PT,c
Flor Romo-Romo, PT,c
María de los Ángeles Atín-Arratibel, MD,a
Daniel Pecos-Martín, PhD,d
Tomás Gallego-Izquierdo, PhD,d
and Natalia Romero-Franco, PhDe
ABSTRACT
Objective: The objective of this study was to review the literature regarding the effectiveness of neural gliding
exercises for the management of carpal tunnel syndrome (CTS).
Methods: A computer-based search was completed through May 2014 in PubMed, Physiotherapy Evidence Database
(PEDro), Web of Knowledge, Cochrane Plus, and CINAHL. The following key words were included: nerve tissue,
gliding, exercises, carpal tunnel syndrome, neural mobilization, and neurodynamic mobilization. Thirteen clinical
trials met the inclusion/exclusion criteria, which were: nerve gliding exercise management of participants aged
18 years or older; clinical or electrophysiological diagnostics of CTS; no prior surgical treatment; and absence of
systemic diseases, degenerative joint diseases, musculoskeletal affectations in upper limbs or spine, or pregnancy. All
studies were independently appraised using the PEDro scale.
Results: The majority of studies reported improvements in pain, pressure pain threshold, and function of CTS patients
after nerve gliding, combined or not with additional therapies. When comparing nerve gliding with other therapies, 2
studies reported better results from standard care and 1 from use of a wrist splint, whereas 3 studies reported greater
and earlier pain relief and function after nerve gliding in comparison with conservative techniques, such as ultrasound
and wrist splint. However, 6 of the 13 studies had a quality of 5 of 11 or less according to the PEDro scale.
Conclusion: Limited evidence is available on the effectiveness of neural gliding. Standard conservative care seems to
be the most appropriate option for pain relief, although neural gliding might be a complementary option to accelerate
recovery of function. More high-quality research is still necessary to determine its effectiveness and the subgroups of
patients who may respond better to this treatment. (J Manipulative Physiol Ther 2017;40:50-59)
Key Indexing Terms: Carpal Tunnel Syndrome; Nerve Tissue; Stress, Mechanical; Exercise Therapy; Movement
Effectiveness of Nerve Gliding Exercises
on Carpal Tunnel Syndrome: A
Systematic Review
Ruth Ballestero-Pérez, PhD,a
Gustavo Plaza-Manzano, PhD,b
Alicia Urraca-Gesto, PT,c
Flor Romo-Romo, PT,c
María de los Ángeles Atín-Arratibel, MD,a
Daniel Pecos-Martín, PhD,d
Tomás Gallego-Izquierdo, PhD,d
and Natalia Romero-Franco, PhDe
ABSTRACT
Objective: The objective of this study was to review the literature regarding the effectiveness of neural gliding
exercises for the management of carpal tunnel syndrome (CTS).
Methods: A computer-based search was completed through May 2014 in PubMed, Physiotherapy Evidence Database
(PEDro), Web of Knowledge, Cochrane Plus, and CINAHL. The following key words were included: nerve tissue,
gliding, exercises, carpal tunnel syndrome, neural mobilization, and neurodynamic mobilization. Thirteen clinical
trials met the inclusion/exclusion criteria, which were: nerve gliding exercise management of participants aged
18 years or older; clinical or electrophysiological diagnostics of CTS; no prior surgical treatment; and absence of
systemic diseases, degenerative joint diseases, musculoskeletal affectations in upper limbs or spine, or pregnancy. All
studies were independently appraised using the PEDro scale.
Results: The majority of studies reported improvements in pain, pressure pain threshold, and function of CTS patients
after nerve gliding, combined or not with additional therapies. When comparing nerve gliding with other therapies, 2
studies reported better results from standard care and 1 from use of a wrist splint, whereas 3 studies reported greater
and earlier pain relief and function after nerve gliding in comparison with conservative techniques, such as ultrasound
and wrist splint. However, 6 of the 13 studies had a quality of 5 of 11 or less according to the PEDro scale.
Conclusion: Limited evidence is available on the effectiveness of neural gliding. Standard conservative care seems to
be the most appropriate option for pain relief, although neural gliding might be a complementary option to accelerate
recovery of function. More high-quality research is still necessary to determine its effectiveness and the subgroups of
patients who may respond better to this treatment. (J Manipulative Physiol Ther 2017;40:50-59)
Key Indexing Terms: Carpal Tunnel Syndrome; Nerve Tissue; Stress, Mechanical; Exercise Therapy; Movement
Effectiveness of Nerve Gliding Exercises
on Carpal Tunnel Syndrome: A
Systematic Review
Ruth Ballestero-Pérez, PhD,a
Gustavo Plaza-Manzano, PhD,b
Alicia Urraca-Gesto, PT,c
Flor Romo-Romo, PT,c
María de los Ángeles Atín-Arratibel, MD,a
Daniel Pecos-Martín, PhD,d
Tomás Gallego-Izquierdo, PhD,d
and Natalia Romero-Franco, PhDe
ABSTRACT
Objective: The objective of this study was to review the literature regarding the effectiveness of neural gliding
exercises for the management of carpal tunnel syndrome (CTS).
Methods: A computer-based search was completed through May 2014 in PubMed, Physiotherapy Evidence Database
(PEDro), Web of Knowledge, Cochrane Plus, and CINAHL. The following key words were included: nerve tissue,
gliding, exercises, carpal tunnel syndrome, neural mobilization, and neurodynamic mobilization. Thirteen clinical
trials met the inclusion/exclusion criteria, which were: nerve gliding exercise management of participants aged
18 years or older; clinical or electrophysiological diagnostics of CTS; no prior surgical treatment; and absence of
systemic diseases, degenerative joint diseases, musculoskeletal affectations in upper limbs or spine, or pregnancy. All
studies were independently appraised using the PEDro scale.
Results: The majority of studies reported improvements in pain, pressure pain threshold, and function of CTS patients
after nerve gliding, combined or not with additional therapies. When comparing nerve gliding with other therapies, 2
studies reported better results from standard care and 1 from use of a wrist splint, whereas 3 studies reported greater
and earlier pain relief and function after nerve gliding in comparison with conservative techniques, such as ultrasound
and wrist splint. However, 6 of the 13 studies had a quality of 5 of 11 or less according to the PEDro scale.
Conclusion: Limited evidence is available on the effectiveness of neural gliding. Standard conservative care seems to
be the most appropriate option for pain relief, although neural gliding might be a complementary option to accelerate
recovery of function. More high-quality research is still necessary to determine its effectiveness and the subgroups of
patients who may respond better to this treatment. (J Manipulative Physiol Ther 2017;40:50-59)
Key Indexing Terms: Carpal Tunnel Syndrome; Nerve Tissue; Stress, Mechanical; Exercise Therapy; Movement
INTRODUCTION
Carpal tunnel syndrome (CTS) is the result of an
irritation, compression, or stretching of the median nerve
as it passes through the carpal tunnel in the wrist. Symptoms
range from pain (mainly nightly)1
and paresthesia to thenar
eminence muscle atrophy2-6
This syndrome represents the
most prevalent neural injury in the general population
(1-4%)7-9
and workers at risk (15-20%)10-12
(those requiring
a
Departamento de Medicina Física y Rehabilitación, Universidad
Complutense de Madrid, Madrid, Spain.
b
Departamento de Medicina Física y Rehabilitación, Facultad
de Medicina, Universidad Complutense de Madrid; Instituto de
Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC),
Madrid, Spain.
c
Departamento de Rehabilitación y Fisioterapia, Hospital
Universitario Fundación Alcorcón, Madrid, Spain.
d
Departamento de Enfermería y Fisioterapia, Universidad de
Alcalá, Madrid, Spain.
e
Department of Nursing and Physiotherapy, University of the
7. Sub-groups of neural disorders
• Some pacents respond well others not - Why ?
– Sub-groups?
• Schafer, 2008
Compressive neuropathy
sliding
Central sensiczacon
Other
Axonal mechanosensicvity
Musculoskeletal
transverse sliding
Nerve swelling
Neural sub-group classificaEon based on mechanisms
Trauma, compression, or chemical
irritaEon of nerve/nerve roots
Neuropathic
pain sensory
hypersensiEvity
InflammaEon
Peripheral nerve
sensiEsaEon
NegaEve featuresPosiEve features
“Neuropathic”
Compressive
neuropathy
Musculoskeletal
pain
DeafferentaEon, loss of inhibiEon,
facilitaEon etc
AMS or nervi nervorum
sensiEzaEon
If none
Convergence
Axonal damage
Neuropathic Mixed
Inflammatory
Mechanism?
Hall, 2011
Classification of Neural Pain
• Syndrome based classification
Peripheral neural pain
DN, PHN, MS, radiculopathy, CTS, CUTS
• Mechanism based classification
Aß
C
Dorsal root
ganglion
Dorsal horn
midline
Woolf, 1999
Central mechanism
Peripheral mechanism
Classification by syndrome
• Does not explain pain
• Does not help treatment
– Patients with similar
diagnoses have diverse
symptoms
– Resolution of the
pathology does not always
improve the disorder