‘Neurodynamics as a therapeutic intervention; the effectiveness and scientific evidence?’

Title

Name

Neurodynamics as a therapeutic intervention; effectiveness and scientific evidence

Dr Toby Hall SpecialistMusculoskeletalPhysiotherapistAdjunctAssociateProfessor(CurtinUniversity)SnrTeachingFellow(TheUniversityofWesternAustralia)[email protected]

‘IcringeeverytimeIhearaphysicaltherapistclaimthattheyuseneuralmobilization’

‘Wehaveassumedtoomuchwhenitcomestoneuraltensiontestsandthetreatmentsassociatedwiththeseassessments’

‘Thereisnoplausibleevidencethatwecanmobilizeneuraltissue…..orthat"neuralmobilization"iseffectiveinthetreatmentofmusculoskeletaldysfunction’

NeuralMobilization:Theimpossible?

DiFabioEditorialJOSPT2001

PresentationOutline

• Isneuralmobilisationthebestwaytomanageneuraltissuepaindisorders:haveweassumedtoomuch?– Drugs;Exercise;Neuralmobilisation;Donothing:advice?

Severe Mod

Nervedamagedoesnotalwayscausepain

Ishimoto,2013

n=938

• Mostcommonpainfulneuropathies,painpresent<20%– Zusman,2010;Bennea,2006

• Traumaccnerveinjurycausespain<10%– Zusman,2010;Marchedni,2006

• Severestenosisin30%>40years– Ishimoto,2013

• Neuralmobilisaconnotnecessaryinallcasesfornerverecovery– Scrimshaw,2001;Svernlov,2009

Whataboutdrugs?

Drugs

• Morphinefor5dayscommencing10daysaherCCIinratmodel– Doublestheduraconofneuropathicpainfromspinalmicrogliaaccvacon

• AncconvulsantPregabalin(Lyrica)noteffeccveforsciacca

6

GracePNAS2016

Mathieson2017

Movementisthebesttherapy

Passivemovementpromotesnerverecoveryposttrauma

• Ratsciaccnervecrushinjury(axonotmesis)– 15sessionsof3x3minpassiveankledorsiflexion1-daypostinjury

– Improvedmechanicalhyperalgesia,motorfunccon,histology,morphology,&immunohistochemicalfunccon

– Inhibiconofglialcellaccvacon

8Martins,Pain2011

Mechanicalhyperalgesia

Exercisereducesfeaturesofacuteneuropathicpain

• RatsciaccnerveCCI– Dailyprogressiveexerciseontreadmill(60minutes)orswimming(90minuteswithrests)

– Mechanical&thermalhyperalgesiaimproved

– Aaenuatedcytokineproduccon(TNF-α&IL-1β)

9

Chen,2012

Thermalhyperalgesia


Exercisereducesneuropathicpain

• Ratsciaccnervechronicconstricconorinflammatorymodel– Treadmilldailyprogressiveexercise30minutes7dayspostsurgeryfor14days

– Mechanical&thermalhyperalgesiaimproved– Aaenuatedpainwithin3weeks,sensoryhypersensicvityreturned5daysaherstoppingexercise.Effectofexercisereversedwithopioidreceptorantagonist.Sameeffectifexercisedelayedby4weeks.

• Exerciseupregulatesendogenousopioids

10

Stagg,2011

CCCCINMIShamNMNaive

Movementpromotesnerverecovery:reducesNP

• RatsciaccnerveCCImodel– 10sessionsNMunderlightanaestheczacon14dayspostinjury

– Allodynia&hyperalgesiaimproved– Significantchangeinglialcelldensity&nervegrowthfactorexpressionintheDRG&spinalcord

11

Santos,MolecularPain2011


ExercisereducesNPpostCCI

• RatsciaccCCI– Wheelrunning6/52priortoCCI&aherCCI

– Allodyniaimprovedaherinjury– PriorexercisedecreasedneuroimmunesignallinginDH&neuroninjury.Suppressedpro-inflammatoryandincreasedanc-inflammatorymediators

– Significantchangesinglialcelldensity&NGFexpressionintheDRG&spinalcord

• Exercisepreventspain,promotesrecovery&relievespain

12

Grace,Pain2016

Allodynia

SummaryBasicscience

• Movement– ExercisepreventsdevelopmentofNP– Exerciseaidsnerverecoveryaherinjury&reducesNPinanimalmodels• Passivelimbmovement• Aerobicnon-specificexercise:walking,runningandswimming• Neuralmobilisacon

13

But…..

14

– Ismovementeffectiveinhumans?– Ismovementeffectiveforallnervedisorders?

– Ismovementeffectiveforchronic&acutenervedisorders?

– Isspecificnervemovement(NM)moreeffectivethanotherformsofmovement/exercise?

Whatistheevidenceinhumans?

• Limitedevidence– SRofRCT’sforneuralmobilization– 20trialsidentified;generallysmallscale– EvidenceNMmoreeffectiveminimaltreatment(pain&disability),butnobetterthanothertreatments.

• Su,2016• SRidentified6studiesofNMforCTS

– NMbetterthannotreatment:weakeffectsize• McKeon,2008

• CochranereviewfoundnobenefitforNM• Page,2012

• EuropeanguidelinesformanagementofCTSdonotincludephysiotherapy!

• Huisstede,2014 15

Neuralglidingexercise

• Limited&poorqualityevidencefortheeffeccvenessofneuralglidingexercisesinCTS

16

Effectiveness of Nerve Gliding Exerciseson Carpal Tunnel Syndrome: ASystematic ReviewRuth Ballestero-Pérez, PhD,a Gustavo Plaza-Manzano, PhD,b Alicia Urraca-Gesto, PT, cFlor Romo-Romo, PT, c María de los Ángeles Atín-Arratibel, MD, a Daniel Pecos-Martín, PhD, dTomás 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 glidingexercises 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 clinicaltrials met the inclusion/exclusion criteria, which were: nerve gliding exercise management of participants aged18 years or older; clinical or electrophysiological diagnostics of CTS; no prior surgical treatment; and absence ofsystemic diseases, degenerative joint diseases, musculoskeletal affectations in upper limbs or spine, or pregnancy. Allstudies were independently appraised using the PEDro scale.Results: The majority of studies reported improvements in pain, pressure pain threshold, and function of CTS patientsafter nerve gliding, combined or not with additional therapies. When comparing nerve gliding with other therapies, 2studies reported better results from standard care and 1 from use of a wrist splint, whereas 3 studies reported greaterand earlier pain relief and function after nerve gliding in comparison with conservative techniques, such as ultrasoundand 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 tobe the most appropriate option for pain relief, although neural gliding might be a complementary option to acceleraterecovery of function. More high-quality research is still necessary to determine its effectiveness and the subgroups ofpatients 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 anirritation, compression, or stretching of the median nerveas it passes through the carpal tunnel in the wrist. Symptomsrange from pain (mainly nightly)1 and paresthesia to thenareminence muscle atrophy2-6 This syndrome represents themost prevalent neural injury in the general population(1-4%)7-9 and workers at risk (15-20%)10-12 (those requiringrepetitive movements of the wrist and fingers such astyping, nursing, and cleaning), whose tendency to becomechronic patients has an economic impact because ofwork absences and surgical treatments required to improvethe condition.7

The initial phases of the conservative treatment methodsrequire corrective splints in the wrist while neutral or in anextension position, electrotherapy with ultrasound or laser,or manual therapy and exercises.13-16 At severe stages,

a Departamento deMedicina Física y Rehabilitación, UniversidadComplutense de Madrid, Madrid, Spain.

b Departamento de Medicina Física y Rehabilitación, Facultadde Medicina, Universidad Complutense de Madrid; Instituto deInvestigación Sanitaria del Hospital Clínico San Carlos (IdISSC),Madrid, Spain.

c Departamento de Rehabilitación y Fisioterapia, HospitalUniversitario Fundación Alcorcón, Madrid, Spain.

d Departamento de Enfermería y Fisioterapia, Universidad deAlcalá, Madrid, Spain.

e Department of Nursing and Physiotherapy, University of theBalearic Islands, Palma, Spain.

Corresponding Author: Natalia Romero-Franco, PhD, Nursingand Physiotherapy Department, University of the Balearic Islands,University Campus—Beatriu de Pinos, Road Valldemossa, Km7.5, E-07122, Palma, Spain. Tel.: +34 971172916.(e-mail: [email protected]).

Paper submitted May 8, 2014; in revised form September 14,2016; accepted September 27, 2016.

0161-4754Copyright © 2016 by National University of Health Sciences.http://dx.doi.org/10.1016/j.jmpt.2016.10.004


ABSTRACT


INTRODUCTION












ABSTRACT


INTRODUCTION











Why?DootherfactorspredictpaininCTS?

• n=54CTSconfirmedbynerveconduccontests–Notelectrophysiologicaltescng

• Notextentofnervecompression

–Notage,sexorotherdemographicvariables– Illnessbehaviourpredictpain

• Depression&catastrophizaconaccountfor39%ofvarianceinpain• Nunez,2010

• n=82postsurgicalrecoveryfromCTS– Dissacsfacconandperceiveddisabilitypredictedbydepressionandpoorcopingskills&lessdegreebynervedamage

• LozanoCalderon,2008

Screenfor

psychoso

cialissues

Why?DootherfactorspredictpaininCTS?

• Casecontrolseriesof68patientswithCTS&138healthycontrols

– Matchedforage&gender&stratifiedforBMI

– SidelayingsleepingpositionstronglyassociatedwithpresenceofCTS

• McCabe,2011• Sleepqualitymostimportantpredictorofrecoveryneckdisorders

• Kovacs,2016

Screenfor

sleepposi

tion&qual

ity

Compressiveneuropathy<slidingCentralsensiczaconSleepissuesAxonalmechanosensicvityMusculoskeletalpain>transverseslidingNerveswelling

NotallwithCTSaresuitedtoneuralmobilisacon:wash-outeffect 2017

journal of orthopaedic & sports physical therapy | volume 47 | number 3 | march 2017 | 151

[ RESEARCH REPORT ]

Carpal tunnel syndrome (CTS), a pain condition associated with repetitive movements, accounts for

nearly 50% of all work-related injuries.31 The prevalence of CTSin the general population has been re-ported to range between 6% and 12%.32

Individuals diagnosed with CTS have been identified as significantly more likely to miss more work days than asymptomatic individuals, which results in a massive economic burden to the in-dividual and society.2

The management of CTS can be either conservative or surgical. Conservative management is often chosen as the first approach when symptoms are mild or

! STUDY DESIGN: Randomized parallel-group trial.

! BACKGROUND: Carpal tunnel syndrome (CTS) is a common pain condition that can be managed surgically or conservatively.

! OBJECTIVE: To compare the effectiveness of manual therapy versus surgery for improving self-reported function, cervical range of motion, and pinch-tip grip force in women with CTS.

! METHODS: In this randomized clinical trial, 100 women with CTS were randomly allocated to either a manual therapy (n = 50) or a surgery (n = 50) group. The primary outcome was self-rated hand function, assessed with the Boston Carpal Tunnel Questionnaire. Secondary outcomes included active cervical range of motion, pinch-tip grip force, and the symptom severity subscale of the Boston Carpal Tunnel Questionnaire. Patients were assessed at baseline and 1, 3, 6, and 12 months after the last treatment by an assessor unaware of group assignment. Analysis was by intention to treat, with mixed analyses of covariance adjusted for baseline scores.

! RESULTS: At 12 months, 94 women completed the follow-up. Analyses showed statistically sig-nificant differences in favor of manual therapy at

1 month for self-reported function (mean change, –0.8; 95% confidence interval [CI]: –1.1, –0.5) and pinch-tip grip force on the symptomatic side (thumb-index finger: mean change, 2.0; 95% CI: 1.1, 2.9 and thumb-little finger: mean change, 1.0; 95% CI: 0.5, 1.5). Improvements in self-reported function and pinch grip force were similar between the groups at 3, 6, and 12 months. Both groups reported improvements in symptom severity that were not significantly different at all follow-up periods. No significant changes were observed in pinch-tip grip force on the less symptomatic side and in cervical range of motion in either group.

! CONCLUSION: Manual therapy and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS. Neither manual therapy nor surgery resulted in changes in cervical range of motion.

! LEVEL OF EVIDENCE: Therapy, level 1b. Pro-spectively registered September 3, 2014 at www.clinicaltrials.gov (NCT02233660). J Orthop Sports Phys Ther 2017;47(3):151-161. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7090

! KEY WORDS: carpal tunnel syndrome, cervical spine, force, manual therapy, neck, surgery

1Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain. 2Department of Physical Therapy, Franklin Pierce University, Manchester, NH. 3Rehabilitation Services, Concord Hospital, Concord, NH. 4Manual Therapy Fellowship Program, Regis University, Denver, CO. 5Department of Neurology and Neurophysiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain. The local human research committee (HUFA PI-12/0023) approved the study project. The study was funded by a research project grant (FIS PI14/ 00364) from the Health Institute Carlos III (PN I+D+I 2014-2017; Spanish Government). The study was prospectively registered September 3, 2014 at www.clinicaltrials.gov (NCT02233660). The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr César Fernández de las Peñas, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain. E-mail: [email protected] ! Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy®

CÉSAR FERNÁNDEZ-DE-LAS-PEÑAS, PT, PhD, DMSc1 • JOSHUA CLELAND, PT, PhD, OCS, FAAOMPT2-4 • MARÍA PALACIOS-CEÑA, PT1

STELLA FUENSALIDA-NOVO, PT1 • JUAN A. PAREJA, MD, PhD5 • CRISTINA ALONSO-BLANCO, PT, PhD1

The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip

Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial

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journal of orthopaedic & sports physical therapy | volume 47 | number 3 | march 2017 | 151

[ RESEARCH REPORT ]

Carpal tunnel syndrome (CTS), a pain condition associated with repetitive movements, accounts for

nearly 50% of all work-related injuries.31 The prevalence of CTSin the general population has been re-ported to range between 6% and 12%.32

Individuals diagnosed with CTS have been identified as significantly more likely to miss more work days than asymptomatic individuals, which results in a massive economic burden to the in-dividual and society.2

The management of CTS can be either conservative or surgical. Conservative management is often chosen as the first approach when symptoms are mild or

! STUDY DESIGN: Randomized parallel-group trial.

! BACKGROUND: Carpal tunnel syndrome (CTS) is a common pain condition that can be managed surgically or conservatively.

! OBJECTIVE: To compare the effectiveness of manual therapy versus surgery for improving self-reported function, cervical range of motion, and pinch-tip grip force in women with CTS.

! METHODS: In this randomized clinical trial, 100 women with CTS were randomly allocated to either a manual therapy (n = 50) or a surgery (n = 50) group. The primary outcome was self-rated hand function, assessed with the Boston Carpal Tunnel Questionnaire. Secondary outcomes included active cervical range of motion, pinch-tip grip force, and the symptom severity subscale of the Boston Carpal Tunnel Questionnaire. Patients were assessed at baseline and 1, 3, 6, and 12 months after the last treatment by an assessor unaware of group assignment. Analysis was by intention to treat, with mixed analyses of covariance adjusted for baseline scores.

! RESULTS: At 12 months, 94 women completed the follow-up. Analyses showed statistically sig-nificant differences in favor of manual therapy at

1 month for self-reported function (mean change, –0.8; 95% confidence interval [CI]: –1.1, –0.5) and pinch-tip grip force on the symptomatic side (thumb-index finger: mean change, 2.0; 95% CI: 1.1, 2.9 and thumb-little finger: mean change, 1.0; 95% CI: 0.5, 1.5). Improvements in self-reported function and pinch grip force were similar between the groups at 3, 6, and 12 months. Both groups reported improvements in symptom severity that were not significantly different at all follow-up periods. No significant changes were observed in pinch-tip grip force on the less symptomatic side and in cervical range of motion in either group.

! CONCLUSION: Manual therapy and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS. Neither manual therapy nor surgery resulted in changes in cervical range of motion.

! LEVEL OF EVIDENCE: Therapy, level 1b. Pro-spectively registered September 3, 2014 at www.clinicaltrials.gov (NCT02233660). J Orthop Sports Phys Ther 2017;47(3):151-161. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7090

! KEY WORDS: carpal tunnel syndrome, cervical spine, force, manual therapy, neck, surgery

1Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain. 2Department of Physical Therapy, Franklin Pierce University, Manchester, NH. 3Rehabilitation Services, Concord Hospital, Concord, NH. 4Manual Therapy Fellowship Program, Regis University, Denver, CO. 5Department of Neurology and Neurophysiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain. The local human research committee (HUFA PI-12/0023) approved the study project. The study was funded by a research project grant (FIS PI14/ 00364) from the Health Institute Carlos III (PN I+D+I 2014-2017; Spanish Government). The study was prospectively registered September 3, 2014 at www.clinicaltrials.gov (NCT02233660). The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr César Fernández de las Peñas, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain. E-mail: [email protected] ! Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy®

CÉSAR FERNÁNDEZ-DE-LAS-PEÑAS, PT, PhD, DMSc1 • JOSHUA CLELAND, PT, PhD, OCS, FAAOMPT2-4 • MARÍA PALACIOS-CEÑA, PT1

STELLA FUENSALIDA-NOVO, PT1 • JUAN A. PAREJA, MD, PhD5 • CRISTINA ALONSO-BLANCO, PT, PhD1

The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip

Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial

47-03 Fernandez-de-las-Penas.indd 151 2/14/2017 5:00:09 PM

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MulcmodalmanualtherapyeffeccveinCTS

Neck/armpain

• RCT60Pacentswithneck/armpain– Randomizedtoneuralmobs+neuralex+advise(n=40)orcontrol(n=20,stayaccve)

– 4treatmentsessionover2weeks– 4weekfollow-up– GRC,NDI,pain,PSFS– NNT2.7to4– Neuralmobilizaconprovidesimmediate,clinicallyrelevantbenefitsbeyondadvicetostayaccve

• Nee,Coppieters2012

• Healthypeople– Increasesflexibility

• LBP– Improvespain&disability

Review article

Effects of lower body quadrant neural mobilization in healthy and lowback pain populations: A systematic review and meta-analysis

Tiago Neto a, Sandro R. Freitas a, b, *, Marta Marques c, Luis Gomes d, Ricardo Andrade e,Raúl Oliveira a

a Faculdade de Motricidade Humana, Universidade de Lisboa, Estrada da Costa, 1499-002, Cruz Quebrada, Dafundo, Portugalb Benfica LAB, Sport Lisboa e Benfica, Lisboa, Portugalc CIPER - Universidade de Lisboa, Faculdade de Motricidade Humana, Lisbon, Portugald Escola Superior de Saúde, Instituto Polit!ecnico de Setúbal, Portugale Laboratory “Movement, Interactions, Performance” (EA 4334), University of Nantes, UFR STAPS, Nantes, France

a r t i c l e i n f o

Article history:Received 18 March 2016Received in revised form10 November 2016Accepted 19 November 2016

Keywords:NeurodynamicsPeripheral nervesSlumpFlexibilityPainDisability

a b s t r a c t

Background: Neural mobilization (NM) is widely used to assess and treat several neuromuscular disor-ders. However, information regarding the NM effects targeting the lower body quadrant is scarce.Objectives: To determine the effects of NM techniques targeting the lower body quadrant in healthy andlow back pain (LBP) populations.Design: Systematic review with meta-analysis.Method: Randomized controlled trials were included if any form of NM was applied to the lower bodyquadrant. Pain, disability, and lower limb flexibility were the main outcomes. PEDro scale was used toassess methodological quality.Results: Forty-five studies were selected for full-text analysis, and ten were included in the meta-analysis, involving 502 participants. Overall, studies presented fair to good quality, with a mean PEDroscore of 6.3 (from 4 to 8). Five studies used healthy participants, and five targeted people with LBP. Amoderate effect size (g ¼ 0.73, 95% CI: 0.48e0.98) was determined, favoring the use of NM to increaseflexibility in healthy adults. Larger effect sizes were found for the effect of NM in pain reduction (g ¼ 0.82,95% CI 0.56e1.08) and disability improvement (g ¼ 1.59, 95% CI: 1.14e2.03), in people with LBP.Conclusion: Evidence suggests that there are positive effects from the application of NM to the lowerbody quadrant. Specifically, NM shows moderate effects on flexibility in healthy participants, and largeeffects on pain and disability in people with LBP. Nevertheless, more studies with high methodologicalquality are necessary to support these conclusions.

© 2016 Elsevier Ltd. All rights reserved.

1. Introduction

Neural mobilization (NM) techniques are widely used to eval-uate, and improve, themechanical and neurophysiological integrityof the peripheral nerves (Shacklock, 1995) in clinical populations(Butler, 2000). These techniques include combinations of jointmovements that promote either neural tensioning (i.e. throughdisplacement of the nerve endings in opposite directions) or sliding(i.e. through displacement of nerve endings in the same direction

(Coppieters et al., 2009). Several studies have successfully used NMto improve flexibility, in both healthy (Herrington and Lee, 2006)and clinical populations (Coppieters et al., 2003), and also to inducedifferent amounts of neural excursion (Coppieters et al., 2015). Thisis particularly relevant because it has been reported that nerveproperties (e.g. cross-sectional area) are altered in certain periph-eral neuropathies (Lee and Dauphin!ee, 2005), and in upper limbnerve entrapment syndromes (Hough et al., 2007; Kantarci et al.,2013). These changes in the nerve properties may be associatedwith a compromised nerve function (Li and Shi, 2007; Rickett et al.,2010). In addition, it has also been shown that people with pe-ripheral neuropathy have a higher lower body quadrant mecha-nosensitivity (Boyd et al., 2010). Consequently, the NM techniquesare used as treatment for different neuromuscular disorders.

* Corresponding author. Faculdade de Motricidade Humana, Estrada da Costa,1499-002, Cruz Quebrada - Dafundo, Universidade de Lisboa, Portugal.

E-mail addresses: [email protected] (T. Neto), [email protected](S.R. Freitas).

Contents lists available at ScienceDirect

Musculoskeletal Science and Practice

journal homepage: www.journals .e lsevier .com/aquaculture-and-fisheries/

http://dx.doi.org/10.1016/j.msksp.2016.11.0142468-7812/© 2016 Elsevier Ltd. All rights reserved.

Musculoskeletal Science and Practice 27 (2017) 14e22

12 Research

3 Neurodynamic treatment did not improve pain and disability at two weeks in4 patients with chronic nerve-related leg pain: a randomised trial

5 Giovanni E Ferreira a, Fabio F Stieven b, Francisco X Araujo c, Matheus Wiebusch c,6 Carolina G Rosa c, Rodrigo Della Mea Plentz d, Marcelo F Silva d

7 a Master’s Program in Rehabilitation Sciences, Universidade Federal de Ciencias da Saude de Porto Alegre; b Doctoral Program in Health Sciences, Universidade Federal de Ciencias da8 Saude de Porto Alegre; c Universidade Federal de Ciencias da Saude de Porto Alegre; d Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciencias da Saude de Porto9 Alegre, Porto Alegre, Brazil

1011 Introduction

12 Low back pain is a highly prevalent and disabling condition that13 represents the major cause of years lived with disability in both14 developed and developing countries.1 Among the wide array of15 clinical presentations, the prevalence of radiating leg pain can be16 up to 60% in primary care.2 In addition, people with low back pain17 and radiating leg pain present higher levels of work-related18 disability, lower levels of quality of life and a poorer prognosis than19 those with low back pain only.3

20 To date, there is no consensus on the most appropriate21 management strategy for people with nerve-related leg pain. A22 recent network meta-analysis found that a range of widely used23 conservative treatments, such as acupuncture, exercise therapy,24 traction, passive physiotherapy modalities (eg, ultrasound and25 transcutaneous electrical nerve stimulation), and advice/education26 alone were not effective in reducing leg pain compared with no

27treatment.4 Despite the high risk of bias of several included studies,28as well as moderate-to-high levels of between-study heterogene-29ity, this network meta-analysis provided evidence that commonly30used conservative interventions were not capable of altering the31natural history of leg pain. Therefore, other conservative treatment32strategies should be investigated in this population as a research33priority, given the cost-effectiveness of stepped-care approaches34compared with direct referral for surgery.4

35One conservative intervention that warrants further investiga-36tion is neurodynamic treatment. This approach has been consid-37ered to be effective for patients with signs of nerve38mechanosensitivity,5 which can be clinically assessed by provoca-39tive tests that challenge the ability of the nerve tissue to tolerate40tension.6 In neurodynamic treatment, specific positions, and active41and passive movements of the lumbar spine and legs are used to42mobilise structures around the nervous system and the nervous43system itself.7

Journal of Physiotherapy xxx (2016) xxx–xxx

K E Y W O R D S

Low back painSciaticaManual therapyNeurodynamic treatmentSlump test

A B S T R A C T

Question: In people with nerve-related leg pain, does adding neurodynamic treatment to advice toremain active improve leg pain, disability, low back pain, function, global perceived effect and location ofsymptoms?. Design: Randomised trial with concealed allocation and intention-to-treat analysis.Participants: Sixty participants with nerve-related leg pain recruited from the community.Interventions: The experimental group received four sessions of neurodynamic treatment. Bothgroups received advice to remain active. Outcome measures: Leg pain and low back pain (0 none to10 worst), Oswestry Disability Index (0 none to 100 worst), Patient-Specific Functional Scale (0 unable toperform to 30 able to perform), global perceived effect (–5 to 5) and location of symptoms weremeasured at 2 and 4 weeks after randomisation. Continuous outcomes were analysed by linear mixedmodels. Location of symptoms was assessed by relative risk (95% CI). Results: At 2 weeks, theexperimental group did not have significantly greater improvement that the control group in leg pain(MD –1.1, 95% CI –2.3 to 0.1) or disability (MD –3.3, 95% CI –9.6 to 2.9). At 4 weeks, the experimentalgroup experienced a significantly greater reduction in leg pain (MD –2.4, 95% CI –3.6 to –1.2) and lowback pain (MD –1.5, 95% CI –2.8 to –0.2). The experimental group also improved significantly more infunction at 2 weeks (MD 5.2, 95% CI 2.2 to 8.2) and 4 weeks (MD 4.7, 95% CI 1.7 to 7.8), as well as globalperceived effect at 2 weeks (MD 2.5, 95% CI 1.6 to 3.5) and 4 weeks (MD 2.9, 95% CI 1.9 to 3.9). Nosignificant between-group differences occurred in disability at 4 weeks and location of symptoms.Conclusion: Adding neurodynamic treatment to advice to remain active did not improve leg pain anddisability at 2 weeks. Trial registration: NCT01954199. [Ferreira GE, Stieven FF, Araujo FX, WiebuschM, Rosa CG, Della Mea Plentz R, et al. (2016) Neurodynamic treatment did not improve pain anddisability at two weeks in patients with chronic nerve-related leg pain: a randomised trial. Journalof Physiotherapy XX: XX-XX]! 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article

under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

G Model

JPHYS 275 1–6

Please cite this article in press as: Ferreira GE, et al. Neurodynamic treatment did not improve pain and disability at two weeks inpatients with chronic nerve-related leg pain: a randomised trial. J Physiother. (2016), http://dx.doi.org/10.1016/j.jphys.2016.08.007

J o u r n a l o fPHYSIOTHERAPY

jou r nal h o mep age: w ww.els evier . co m/lo c ate / jp hys

http://dx.doi.org/10.1016/j.jphys.2016.08.0071836-9553/! 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

2016

12 Research

3 Neurodynamic treatment did not improve pain and disability at two weeks in4 patients with chronic nerve-related leg pain: a randomised trial

5 Giovanni E Ferreira a, Fabio F Stieven b, Francisco X Araujo c, Matheus Wiebusch c,6 Carolina G Rosa c, Rodrigo Della Mea Plentz d, Marcelo F Silva d

7 a Master’s Program in Rehabilitation Sciences, Universidade Federal de Ciencias da Saude de Porto Alegre; b Doctoral Program in Health Sciences, Universidade Federal de Ciencias da8 Saude de Porto Alegre; c Universidade Federal de Ciencias da Saude de Porto Alegre; d Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciencias da Saude de Porto9 Alegre, Porto Alegre, Brazil

1011 Introduction

12 Low back pain is a highly prevalent and disabling condition that13 represents the major cause of years lived with disability in both14 developed and developing countries.1 Among the wide array of15 clinical presentations, the prevalence of radiating leg pain can be16 up to 60% in primary care.2 In addition, people with low back pain17 and radiating leg pain present higher levels of work-related18 disability, lower levels of quality of life and a poorer prognosis than19 those with low back pain only.3

20 To date, there is no consensus on the most appropriate21 management strategy for people with nerve-related leg pain. A22 recent network meta-analysis found that a range of widely used23 conservative treatments, such as acupuncture, exercise therapy,24 traction, passive physiotherapy modalities (eg, ultrasound and25 transcutaneous electrical nerve stimulation), and advice/education26 alone were not effective in reducing leg pain compared with no

27treatment.4 Despite the high risk of bias of several included studies,28as well as moderate-to-high levels of between-study heterogene-29ity, this network meta-analysis provided evidence that commonly30used conservative interventions were not capable of altering the31natural history of leg pain. Therefore, other conservative treatment32strategies should be investigated in this population as a research33priority, given the cost-effectiveness of stepped-care approaches34compared with direct referral for surgery.4

35One conservative intervention that warrants further investiga-36tion is neurodynamic treatment. This approach has been consid-37ered to be effective for patients with signs of nerve38mechanosensitivity,5 which can be clinically assessed by provoca-39tive tests that challenge the ability of the nerve tissue to tolerate40tension.6 In neurodynamic treatment, specific positions, and active41and passive movements of the lumbar spine and legs are used to42mobilise structures around the nervous system and the nervous43system itself.7

Journal of Physiotherapy xxx (2016) xxx–xxx

K E Y W O R D S

Low back painSciaticaManual therapyNeurodynamic treatmentSlump test

A B S T R A C T

Question: In people with nerve-related leg pain, does adding neurodynamic treatment to advice toremain active improve leg pain, disability, low back pain, function, global perceived effect and location ofsymptoms?. Design: Randomised trial with concealed allocation and intention-to-treat analysis.Participants: Sixty participants with nerve-related leg pain recruited from the community.Interventions: The experimental group received four sessions of neurodynamic treatment. Bothgroups received advice to remain active. Outcome measures: Leg pain and low back pain (0 none to10 worst), Oswestry Disability Index (0 none to 100 worst), Patient-Specific Functional Scale (0 unable toperform to 30 able to perform), global perceived effect (–5 to 5) and location of symptoms weremeasured at 2 and 4 weeks after randomisation. Continuous outcomes were analysed by linear mixedmodels. Location of symptoms was assessed by relative risk (95% CI). Results: At 2 weeks, theexperimental group did not have significantly greater improvement that the control group in leg pain(MD –1.1, 95% CI –2.3 to 0.1) or disability (MD –3.3, 95% CI –9.6 to 2.9). At 4 weeks, the experimentalgroup experienced a significantly greater reduction in leg pain (MD –2.4, 95% CI –3.6 to –1.2) and lowback pain (MD –1.5, 95% CI –2.8 to –0.2). The experimental group also improved significantly more infunction at 2 weeks (MD 5.2, 95% CI 2.2 to 8.2) and 4 weeks (MD 4.7, 95% CI 1.7 to 7.8), as well as globalperceived effect at 2 weeks (MD 2.5, 95% CI 1.6 to 3.5) and 4 weeks (MD 2.9, 95% CI 1.9 to 3.9). Nosignificant between-group differences occurred in disability at 4 weeks and location of symptoms.Conclusion: Adding neurodynamic treatment to advice to remain active did not improve leg pain anddisability at 2 weeks. Trial registration: NCT01954199. [Ferreira GE, Stieven FF, Araujo FX, WiebuschM, Rosa CG, Della Mea Plentz R, et al. (2016) Neurodynamic treatment did not improve pain anddisability at two weeks in patients with chronic nerve-related leg pain: a randomised trial. Journalof Physiotherapy XX: XX-XX]! 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article

under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

G Model

JPHYS 275 1–6

Please cite this article in press as: Ferreira GE, et al. Neurodynamic treatment did not improve pain and disability at two weeks inpatients with chronic nerve-related leg pain: a randomised trial. J Physiother. (2016), http://dx.doi.org/10.1016/j.jphys.2016.08.007

J o u r n a l o fPHYSIOTHERAPY

journal homepage: www.elsev ier .com/ locate / jphys

http://dx.doi.org/10.1016/j.jphys.2016.08.0071836-9553/! 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conclusion: NM not recommended for the treatment of chronic nerve-related leg pain!!!!!!!

sample size = 60

4 sessions NM

SummaryEvidenceofeffectinhumanswithandwithoutpain.Pacentselecconmaybeafactor,notall

neuraldisorderssuitable?

Sub-groupsofneuraldisorders

• Somepacentsrespondwellothersnot-Why?– Sub-groups?

• Schafer,2008

Compressiveneuropathy<slidingCentralsensiczaconOtherAxonalmechanosensicvityMusculoskeletal>transverseslidingNerveswelling

Neuralsub-groupclassificaEonbasedonmechanisms

Trauma,compression,orchemicalirritaEonofnerve/nerveroots

Neuropathic painsensory

hypersensiEvity

InflammaEon

PeripheralnervesensiEsaEon

NegaEvefeaturesPosiEvefeatures

“Neuropathic”Compressiveneuropathy

Musculoskeletalpain

DeafferentaEon,lossofinhibiEon,facilitaEonetc

AMSornervinervorumsensiEzaEon

IfnoneConvergence

Axonaldamage

Neuropathic Mixed Inflammatory

Mechanism?

Hall,2011

ClassificationofNeuralPain

•SyndromebasedclassificationPeripheralneuralpain

DN,PHN,MS,radiculopathy,CTS,CUTS•Mechanismbasedclassification

Aß

C

Dorsalrootganglion

Dorsalhornmidline

Woolf,1999Centralmechanism Peripheralmechanism

Classificationbysyndrome

• Doesnotexplainpain

• Doesnothelptreatment– Patientswithsimilardiagnoseshavediversesymptoms

– Resolutionofthepathologydoesnotalwaysimprovethedisorder

NPcompressiveneuropathy

Nervetrunkmechanosensicvity?

NPsensoryhypersensicvity

Peripheralnervesensiczacon Musculoskeletal

yes

noNegacvefeaturesConducconloss

PosicvefeaturesSensorygain&conducconloss

no

yes yes

no

yesMusculoskeletal

Peripheral nervesensiEzaEon

NPcompressionneuropathy

NPsensoryhypersensiEvity

Hierarchicalordertoclassificacon

1

2

3

4

OrderofclassificaEon

Respondtophysicaltreatment

Non-respondtophysical

intervenEons

Compressionneuropathy

Nervetrunksensicvity?

Neuropathicpain-Sensory

hypersensicvity

Peripheralnerve

sensiczaconMusculoskeletal

yes

noNeurologicaldeficit?

LANSSSCALE>12?

Hierarchicalclassificaconofneuralpaindisorders

no

yes yes

no

•Reliable&validclassificaconsysteminchroniclumbarradicularpain,cervicalradiculopathy,&NSAP

Schäfer,2008;2009;2010;2014Moloney,2013;2014;2015Tampin,2014

Treatment• Treatment:NM,educacon,homeex

– Significantlymoreresponders&greaterimprovementinPNScomparedtoothergroups

• GroupPNSshowedgreaterimprovementinCfibrefuncconfollowingintervencon– Decreasedsensicvitytocoldpain– Decreasedwindupraco.

• GroupsensoryhypersensicvityexhibitedlossofCfibrefunccon&increasedpressurepainsensicvity

• Schäfer,2009;2011

Treatment-PNS• Responderstoneuralmobilization

– PositiveLANSS,<age,largeROMdeficitsonmediannerveneurodynamictestspredict10%chanceofrecovery

– NegativeLANSS,>age,smallROMdeficitspredicts90%chanceofrecovery

• Nee,Coppietersetal2013

Original Research Article

Cervical Lateral Glide Neural Mobilization IsEffective in Treating Cervicobrachial Pain: ARandomized Waiting List Controlled ClinicalTrial

David Rodr!ıguez-Sanz, PhD, PT, DP,* CesarCalvo-Lobo, PhD, PT,† Francisco Unda-Solano,MSc, PT,* Irene Sanz-Corbal!an, PhD, DP,‡

Carlos Romero-Morales, PhD, PT,* andDaniel L!opez-L!opez, PhD, DP§

*Faculty of Health, Exercise and Sport, Department of

Physical Therapy and Podiatry, Physical Therapy &

Health Sciences Research group, Universidad

Europea de Madrid, Villaviciosa de Od!on, Madrid,

Spain; †Department of Physical Therapy, School of

Health Sciences, University of Leon, Ponferrada,

Leon, Spain; ‡Podiatry, Nursing and Physical Therapy

Department, Universidad Complutense de Madrid,

Madrid, Spain; §Research, Health and Podiatry Unit,

Department of Health Sciences, Faculty of Nursing

and Podiatry, Universidade da Coru~na, Coru~na, Spain

Correspondence to: Cesar Calvo Lobo, PhD, MSc, PT

Nursing and Physical Therapy Department, Faculty of

Health Sciences, University of Le!on, Av. Astorga, s/n,

24401 Ponferrada, Le!on, Spain (e-mail: cecalvo19@

hotmail.com). Tel: 912-115-268, ext. 5268.

Funding sources: None.

Conflicts of interest: All authors have no conflicts of

interest to report. None of the authors of the manu-

script received any remuneration. Further, the authors

have not received any reimbursement or honorarium

in any other manner. The authors are not affiliated in

any manner.

Ethics committee board approval review of study

protocol: The “Centro Policlinico Valencia” Research

Ethics Committe approved the study (CE0072015).

Public trial registry: Registered at Clinical Trials

NCT02595294.

Trial registration: NCT02595294.

Abstract

Background. Cervicobrachial pain (CP) is a high-incidence and prevalent condition. Cervical lateralglide (CLG) is a firstline treatment of CP. There is a cur-rent lack of enough high-quality randomized controlleddouble-blind clinical trials that measure the effective-ness of neural tissue mobilization techniques such asthe CLG and its specific effect over CP.

Objectives. The aim of the present study was to as-sess the effect of CLG neural mobilization in treat-ing subjects who suffer from CP, compared with thecomplete absence of treatment.

Study Design. This investigation was a single-center, blinded, parallel randomized controlled clin-ical trial (RCT).

Setting. One hundred forty-seven individuals werescreened in a medical center from July to November2015. Fifty-eight participants were diagnosed with CP.

Methods. Participants were recruited and randomlyassigned into two groups of 29 subjects. The inter-vention group received CLG treatment, and thecontrol group (CG) was assigned to a six-weekwaiting list to receive treatment. Randomizationwas carried out by concealed computer softwarerandomized printed cards. The primary outcomewas pain intensity, reported through the NumericRating Scale for Pain (NRSP). Secondary outcomeswere physical function involving the affected upperlimb using the Quick DASH scale and ipsilateralcervical rotation (ICR) using a CROM device.Assessments were made at baseline and one hourafter treatment.

Results. The CLG group NRSP mean value was sig-nificantly (P < 0.0001) superior to those obtained bythe CG. Subjects treated with CLG reported an

VC 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected] 1

Pain Medicine 2017; 00: 1–12doi: 10.1093/pm/pnx011



























any manner.





NCT02595294.


Abstract



































any manner.





NCT02595294.


Abstract









Open Journal of Therapy and Rehabilitation, 2016, 4, 132-145Published Online August 2016 in SciRes. http://www.scirp.org/journal/ojtrhttp://dx.doi.org/10.4236/ojtr.2016.43012

How to cite this paper: Salt, E., Kelly, S. and Soundy, A. (2016) Randomised Controlled Trial for the Efficacy of Cervical Lat-eral Glide Mobilisation in the Management of Cervicobrachial Pain. Open Journal of Therapy and Rehabilitation, 4, 132-145.http://dx.doi.org/10.4236/ojtr.2016.43012

Randomised Controlled Trial for the Efficacy of Cervical Lateral Glide Mobilisation in the Management of Cervicobrachial Pain Emma Salt1*, Sue Kelly2, Andrew Soundy2 1Physiotherapy Department, Queen’s Hospital Foundation Trust, Burton on Trent, UK 2School of Sport, Exercise and Rehabilitation Sciences, The University of Birmingham, Birmingham, UK

Received 26 May 2016; accepted 31 July 2016; published 3 August 2016

Copyright © 2016 by authors and Scientific Research Publishing Inc.This work is licensed under the Creative Commons Attribution International License (CC BY).http://creativecommons.org/licenses/by/4.0/

AbstractObjectives: To investigate the long-term efficacy of lateral glide mobilisation for patients withchronic Cervicobrachial Pain (CP). Methods: A randomised controlled trial which involved ninety-nine participants with chronic CP. Participants were randomised to receive either the lateral glidewith self-management (n = 49) or self-management alone (n = 50). Four assessments were made(at baseline and 6, 26 and 52 weeks post intervention). The primary outcome measure was theVisual Analogue Scale (VAS) for pain. Patient perceived recovery used the Global Rating of Changescore (GROC). Functional outcomes included the Neck and Upper Limb Index score (NULI) and theShort-From 36 (SF36). Costs and reported number of harmful effects in response to intervention were evaluated. An intention to treat approach was followed for data analysis. Results: No statis-tically significant between-group differences were found for pain (using VAS) in the short-term atsix weeks (p = 0.52; 95% CI −14.72 to 7.44) or long-term at one year (p = 0.37; 95% CI −17.76 to6.61) post-intervention. The VAS outcomes correlated well with GROC scores (p < 0.001). Therewas a statistically significant difference in NULI scores favouring self-management alone (p =0.03), but no between-group differences for SF36 (p = 0.07). The cost of providing lateral glide andself-management was twice that of providing self-management alone. Minor harm was reported inboth groups, with 11% more harm being associated with the lateral glide. Conclusion: In patientswith chronic CP, the addition of a lateral-glide mobilization to a self-management program did not produce improved outcomes and resulted in higher health-care costs.

KeywordsCervical Radiculopathy, Physiotherapy, Manual Therapy

*Corresponding author.



Randomised Controlled Trial for the Efficacyof Cervical Lateral Glide Mobilisation in theManagement of Cervicobrachial PainEmma Salt1*, Sue Kelly2, Andrew Soundy2

1Physiotherapy Department, Queen’s Hospital Foundation Trust, Burton on Trent, UK2School of Sport, Exercise and Rehabilitation Sciences, The University of Birmingham, Birmingham, UK



Abstract Objectives: To investigate the long-term efficacy of lateral glide mobilisation for patients with chronic Cervicobrachial Pain (CP). Methods: A randomised controlled trial which involved ninety-nine participants with chronic CP. Participants were randomised to receive either the lateral glidewith self-management (n = 49) or self-management alone (n = 50). Four assessments were made(at baseline and 6, 26 and 52 weeks post intervention). The primary outcome measure was theVisual Analogue Scale (VAS) for pain. Patient perceived recovery used the Global Rating of Changescore (GROC). Functional outcomes included the Neck and Upper Limb Index score (NULI) and theShort-From 36 (SF36). Costs and reported number of harmful effects in response to intervention were evaluated. An intention to treat approach was followed for data analysis. Results: No statis-tically significant between-group differences were found for pain (using VAS) in the short-term atsix weeks (p = 0.52; 95% CI −14.72 to 7.44) or long-term at one year (p = 0.37; 95% CI −17.76 to6.61) post-intervention. The VAS outcomes correlated well with GROC scores (p < 0.001). Therewas a statistically significant difference in NULI scores favouring self-management alone (p =0.03), but no between-group differences for SF36 (p = 0.07). The cost of providing lateral glide andself-management was twice that of providing self-management alone. Minor harm was reported inboth groups, with 11% more harm being associated with the lateral glide. Conclusion: In patientswith chronic CP, the addition of a lateral-glide mobilization to a self-management program did not produce improved outcomes and resulted in higher health-care costs.



Open Journal of Therapy and Rehabilitation, 2016, 4, 132-145 Published Online August 2016 in SciRes. http://www.scirp.org/journal/ojtrhttp://dx.doi.org/10.4236/ojtr.2016.43012


















• Issues:– C5/6only– CBP,notspecificPNS– Didnottargetneuralcssue

– Didnotprogress– Didnoteliminate+veLANSS

– Max6Rxsessionsover6/52!

– 3x60seconds







AbstractObjectives: To investigate the long-term efficacy of lateral glide mobilisation for patients withchronic Cervicobrachial Pain (CP). Methods: A randomised controlled trial which involved ninety-nine participants with chronic CP. Participants were randomised to receive either the lateral glidewith self-management (n = 49) or self-management alone (n = 50). Four assessments were made(at baseline and 6, 26 and 52 weeks post intervention). The primary outcome measure was theVisual Analogue Scale (VAS) for pain. Patient perceived recovery used the Global Rating of Changescore (GROC). Functional outcomes included the Neck and Upper Limb Index score (NULI) and theShort-From 36 (SF36). Costs and reported number of harmful effects in response to intervention were evaluated. An intention to treat approach was followed for data analysis. Results: No statis-tically significant between-group differences were found for pain (using VAS) in the short-term at six weeks (p = 0.52; 95% CI −14.72 to 7.44) or long-term at one year (p = 0.37; 95% CI −17.76 to 6.61) post-intervention. The VAS outcomes correlated well with GROC scores (p < 0.001). There was a statistically significant difference in NULI scores favouring self-management alone (p = 0.03), but no between-group differences for SF36 (p = 0.07). The cost of providing lateral glide and self-management was twice that of providing self-management alone. Minor harm was reported in both groups, with 11% more harm being associated with the lateral glide. Conclusion: In patients with chronic CP, the addition of a lateral-glide mobilization to a self-management program did not produce improved outcomes and resulted in higher health-care costs.



SummaryNeuralmobilisaconislikelytobemoreeffeccveforPNS,withanegacveLANSS

Sliderortensioner?

• Inflammaconblocksaxoplasmictransport

• Cfiberaxonalmechanicalsensicvitydistaltoinflammacon– 1weekmaximumsensicvity(18%ofaxons)

– 4weeks(12%)8weeks(2%)

• Importantfortreatment?

Dilley,2008b

Dilley,2008

Relevancetointervencon?• Howtoresolveaxonalmechanicalsensitivity?

– “Tensioners”• Raiseintraneuralpressure&reduceaxoplasmicflow

• Increasednerveconductionfailure,Sodiumchannelblock(CTS)

• Gianneschi,2015• 3%changeinlengthtriggersectopicimpulsegeneration

– “Sliders”• Minimalchangeinlength&intraneuralpressurebutgreaterexcursionofthenerve

• promotesde-sensitization

Whataboutcompressiveneuropathy?

Song,2007

EquivalentinHumans

• Caseseries– lumbarspinalstenosisn=57– Distractionmanipulation&neuralmobilization+exercise

– Mean13treatments(2-50)– Clinicallymeaningfulimprovementinpain&disabilityaftertreatmentandlong-termfollow-up

• Murphy,2006

Are“opening”techniquesbeaerfor

CN?

Thankyou!

Health & Medicine

‘Neurodynamics as a therapeutic intervention; the effectiveness and scientific evidence?’