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Abstract: Neural mobilization is a treatment modality used in relation to pathologies of the nervous
system. It has been suggested that neural mobilization is an effective treatment modality, although
support of this suggestion is primarily anecdotal. The purpose of this paper was to provide a systematic
review of the literature pertaining to the therapeutic efficacy of neural mobilization. A search to identify
randomized controlled trials investigating neural mobilization was conducted using the key words neu-
ral mobilisation/mobilization, nerve mobilisation/mobilization, neural manipulative physical therapy,
physical therapy, neural/nerve glide, nerve glide exercises, nerve/neural treatment, nerve/neural stretch-
ing, neurodynamics, and nerve/neural physiotherapy. The titles and abstracts of the papers identified
were reviewed to select papers specifically detailing neural mobilization as a treatment modality. The
PEDro scale, a systematic tool used to critique RCTs and grade methodological quality, was used to as-
sess these trials. Methodological assessment allowed an analysis of research investigating therapeutic
efficacy of neural mobilization. Ten randomized clinical trials (discussed in 11 retrieved articles) were
identified that discussed the therapeutic effect of neural mobilization. This review highlights the lack
in quantity and quality of the available research. Qualitative analysis of these studies revealed that there
is only limited evidence to support the use of neural mobilization. Future research needs to re-examine
the application of neural mobilization with use of more homogeneous study designs and pathologies;
in addition, it should standardize the neural mobilization interventions used in the study.
I
n the past, neural tension was used to describe dysfunc- cal loads, and it must undergo distinct mechanical events
tion of the peripheral nervous system. More recently, such as elongation, sliding, cross-sectional change, angula-
there has been a shift away from a purely mechanical tion, and compression. If these dynamic protective mecha-
rationale to include physiological concepts such as structure nisms fail, the nervous system is vulnerable to neural edema,
and function of the nervous system. Neurodynamics is now ischaemia, fibrosis, and hypoxia, which may cause altered
a more accepted term referring to the integrated biome- neurodynamics1,2.
chanical, physiological, and morphological functions of the When neural mobilization is used for treatment of ad-
nervous system1-4. Regardless of the underlying construct, verse neurodynamics, the primary theoretical objective is to
it is vital that the nervous system is able to adapt to mechani- attempt to restore the dynamic balance between the relative
movement of neural tissues and surrounding mechanical
interfaces, thereby allowing reduced intrinsic pressures on
Address all correspondence and requests for reprints to:
the neural tissue and thus promoting optimum physiologic
Richard Ellis
function1,2,4-7. The hypothesized benefits from such tech-
Lecturer
niques include facilitation of nerve gliding, reduction of nerve
School of Physiotherapy
adherence, dispersion of noxious fluids, increased neural vas-
Auckland University of Technology (AUT)
cularity, and improvement of axoplasmic flow1,2,4-10. However,
Private Bag 92006
these etiological mechanisms for the clinically observed ef-
Auckland New Zealand 1020
fects of neural mobilization still require robust validation. At
E-mail: richard.ellis@aut.ac.nz
present, the positive clinically observed effect of neural mo-
Score
Criteria No Yes
1. Eligibility criteria were specified*
Total N/10
Methodological
1* 2 3 4 5 6 7 8 9 10 11 QS Quality IVS
Cleland et al27 1 1 1 1 0 0 1 1 1 1 1 8 Moderate 5
Coppieters et al8
(Cervical lateral 1 1 1 1 0 0 1 1 1 1 1 8 Moderate 5
glide treatment)
Coppieters et al28
(Neural 1 1 1 0 0 0 1 1 1 1 0 6 Moderate 5
provocation)
The titles and/or abstracts of these citations were reviewed to • Type of intervention: use of a manual or exercise tech-
identify papers specifically detailing neural mobilization nique designed to have a direct effect on neural tissue
used as a treatment modality. The search was limited to stud- with the purpose of dynamically influencing (e.g., slid-
ies written in or translated to English and those utilizing ing, stretching, moving, mobilizing etc.) the neural
human subjects. There was no limitation regarding the date tissue.
the studies were published, other than the date limitations of • Outcome measurements: at least one of the following
each selected database. In addition, the reference lists of outcome measurements used to assess the status of the
each paper were searched to identify other relevant papers. nervous system: pain rating (e.g., Visual Analogue Scale
[VAS], function-specific pain VAS (i.e., work- or sport-
related pain), pain and or range of movement (ROM)
Study Selection
during neural tissue provocation tests (NTPT), func-
tional disability scores (e.g., Short-form McGill Pain
The method for selection of relevant studies was consistent
Questionnaire, Northwick Park Questionnaire, and Os-
with suggested guidelines for conducting systematic re-
westry Disability Index).
views11. The following inclusion criteria were used to select
relevant papers for the review:
Methodological Quality Assessment
• Type of participant: participants older than 18, of either
gender, and with a clinical diagnosis consistent with Three reviewers independently assessed the methodological
neurodynamic dysfunction (musculoskeletal conditions quality of each RCT. The PEDro Scale (Table 1), developed by
with symptoms of pain and/or paresthesia indicative of The Centre of Evidence-Based Physiotherapy (CEBP), was
compromise of the peripheral nervous system). utilized to assess each paper12. The PEDro Scale, an 11-item
• Type of study design: randomized controlled trials. scale, is a validated, reliable, and versatile tool used to rate
Number Percent
meeting meeting
PEDro Criteria criterion (N) criterion (%)
1 Eligibility criteria specified (yes/no) 11 100
ies24, 29 did not satisfy item 7, which relates to rater blinding. Upper Limb Tension Test 2b (ULTT2b) mobilization29,31 in the
This suggests that these two studies lacked all three forms of treatment of altered neurodynamics or neurodynamic dys-
blinding (subject, therapist, and rater). The other 9 studies function. There was inconclusive evidence (Level 4) to sup-
were single-blinded (rater-blinded) studies. There was no port the use of neural mobilization involving slump
clear trend established for item 4, which relates to concealed stretches27 and combinations of neural mobilization tech-
allocation of subjects. niques10,25 in the treatment of altered neurodynamics or neu-
rodynamic dysfunction.
Study Characteristics
Clinical Benefit
All ten RCTs used different methods of application of neural
mobilization (e.g., cervical lateral glide, slump sliders, pe- Table 4 lists the study details of the 11 studies. More studies
ripheral nerve sliders, etc.), and some studies chose to com- found a positive effect8,24-28,30,32 than a neutral effect10,29,31 .
bine these techniques with home-based neural mobilization
exercises. There were also differing neurodynamic dysfunc-
tions examined, including lateral epicondylalgia, carpal tun-
nel syndrome, post-operative spinal surgery, non-radicular
Discussion
low back pain, and neurogenic cervico-brachial pain syn-
A search to identify RCTs investigating neural mobilization
drome. Therefore, all ten RCTs were clinically and therapeu-
yielded 11 studies that met the inclusion criteria for this re-
tically heterogeneous, necessitating a qualitative analysis for
view. Analyses of these studies, using the criteria of Linton
summarizing the results. Table 4 contains details of study
and van Tulder11, indicated that 8 of the 11 studies8,24-28,30,32
characteristics.
concluded a positive benefit from using neural mobilization
in the treatment of altered neurodynamics or neurodynamic
Therapeutic Efficacy dysfunction. Three of the 11 studies10,29,31 concluded a neu-
tral benefit, which suggests that neural mobilization was no
Of the 11 studies identified, 6 different categories or types of more beneficial than standard treatment or no treatment.
treatment were identified (Table 5). Using the qualitative rat- Nine of the 11 studies8,10,25-28,30-32 reviewed demonstrated
ing system, as mentioned earlier, it appears there is limited moderate methodological quality; the two remaining stud-
evidence (Level 3) to support the use of neural mobilization ies24,29 yielded limited methodological quality. Studies exhib-
that involves active nerve and flexor tendon gliding exercises ited weaknesses in random allocation, intention to treat,
of the forearm24,26,30, cervical contralateral glides8,28,32, and concealed allocation, and blinding; consequently, our ability
Baysal et al26 N=36 (36 female Group 1 (N=12) Experimental groups All measures No significant differences 4 8
patients—all with clinical custom made neutral 1 and 3 that pre-Rx, end of Rx, between groups at the
and electrophysiological volar splint (worn for incorporated nerve and 8 weeks F/U end of Rx and 8 weeks
evidence of CTS 3 weeks); exercise gliding exercises 1. pain (VAS) follow-up of all measures
All with bilateral therapy (nerve and and a comparison 2. Tinel’s sign of Treatment Effect
involvement tendon gliding group that did not 3. Phalen’s sign (measures 1, 5, 6, 7, 8, 9, 10)
Mean age— exercises as described incorporate these 4. mean static two-point Within group comparisons
Grp 1 47.8 ± 5.5; by Totten & Hunter, exercises. discrimination—pulp showed significant
Grp 2 50.1 ± 7.3; 1991) 5 sessions daily, Comparison between of radial three digits improvement seen in all
Grp 3 51.4 ± 5.2 each exercise repeated groups 2 and 3 as the 5. hand-grip strength— 3 grps in Tinels and Phalen’s
Mean duration of 10x/session—for 3 weeks only difference hand-held dynamometer signs at end of Rx and 8
symptoms (years)— Group 2—(N=12) in intervention 6. pinch strength— weeks follow-up
Grp 1 1.5 ± 1.6; custom made neutral programs was that between thumb and Significant improvement
Grp 2 1.4 ± 0.8; volar splint (worn for group 3 used nerve little finger— seen in all 3 grps in grip
Grp 3 1.4 ± 0.8 3 weeks); Ultrasound gliding exercises dynamometer and pinch strength at 8
8 eventual dropouts (15min/session to palmar and group 2 did not. 7. symptom-severity weeks follow-up.
carpal tunnel, 1mhz, scale questionnaire No changes seen in two-pt
(11 items) discrimination
Table 4. Randomized controlled trials of neural mobilization as a treatment modality (continued).
Pinar et al30 N =26 ( female) 14 patients (19 hands) 12 patients (16 hands) Undertaken before Between-group comparisons 5 8
Age range 35–55 years patients diagnosed patients diagnosed and after a 10-week for these same variables
Duration of symptoms with early-middle with early-middle treatment program. showed no statistically
(mo) stages CTS stages CTS 1. Tinel Test significant differences
CG 47.6 (± 6.8), In addition to splint Treated in volar 2. Phalen Test pre-treatment or post-treatment,
IG 49.6 (± 5.2) wearing and patient splint in neutral 3 Pain ( VAS) over a day so the groups were similar.
training program worn day & night 4. Motor Function— Both groups made statistically
treated with nerve for 6-weeks, then manual muscle testing, significant improvements
gliding exercises 10 night only from and grip strength in pain, pinch & grip strength,
repetitions 5 sets a week 6-10, and a (Jamar hand and sensitivity testing according
day for 10 weeks, patient training dynamometer) to intra-group or “within-
combined with a program for the 5. Sensory evaluation group” analysis (p< 0.05).
conservative treatment modification of (Semmes-Weistein A statistically significant
program functional activities monofilament [SWM] result favoring the
(avoid repetitive &2-point discrimination incorporation of neural
activities, etc.) with test [2PD]) gliding exercises—with
a conservative 6. Electrophysiological more rapid pain reduction,
treatment program. test—median & ulnar and greater functional
nerve. distal latencies improvement especially in
grip strength (p< 0.05).
Tables 2–4 provide post-
treatment data on
electrophysiologic,
Tinel, and Phalen test
findings. Since all subjects
had “positive/pathologic”
findings pre-treatment,
the authors could use these
2x2 contingency tables to
generate a number needed
to treat to see whether there
was a clinically important
effect favoring neural gliding
exercises on these particular
outcomes.
Coppieters N=20 (16 females, 10 subjects with 10 subjects with Outcomes were measured Significant differences in 5 8
et al8 4 males) brachial or brachial or pre- and post-treatment treatment effects between
(cervical Age range cervicobrachial cervicobrachial 1)Elbow extension ROM two groups could be
lateral glide) 35–65 years neurogenic pain neurogenic pain during NTPT1 observed for all outcome
References —Mean age (years) Received neural Received ultrasound 2) Pain (VAS) measures (p≤0.306).
described IG 49.1 (±14.1), mobilization dose of 0.5 W/cm², 3) Symptom distribution For the mobilization group,
together CG 46.6 (±12.1) treatment 5 minutes sonation Measurements taken the increase in elbow
due to —Mean duration (contralateral l glide time, 20% size of pre- and post-treatment extension from 137.3º
papers’ of symptoms of cervical segment) head 5cm², 1. Elbow extension ROM to 156.7º, the 43% decrease
different (mo) Cervical contralateral frequency 1MHz. during NTPT1 in area of symptom
outcomes IG 2.7, CG 3.2 glide C5-T1. Pulsed ultrasound 2. Pain intensity during distribution and decrease
on the As above Several components for 5 minutes over the NTPT1 VAS in pain from 7.3 to 5.8
same of the neural the most painful were significant (p≤.0003).
subject tension provocation area (0.5 W/cm², For ultrasound group,
sample test of the median 1MHz, treatment there were no significant
with the same nerve (NTPT1) head 5cm²). differences
intervention were applied. Arm was in unloaded On the involved side, the 5 6
technique. Patients in supine position. Ultrasound shoulder girdle elevation
Table 4. Randomized controlled trials of neural mobilization as a treatment modality (continued).
Allison et al25 N=30 (20 females, Neural tissue manual Received no Measurements taken Both intervention groups 5 7
10 males) therapy (NT)—Cervical intervention pre-treatment 4 weeks were effective in improving
Age range 18–75 years lateral glide, shoulder for the initial into treatment and pain intensity, pain quality
Median duration of girdle oscillation, 8 weeks post-treatment. scores, and functional
symptoms (mo) muscle re-education, (Then at the 1. McGill pain disability levels.
NT 12 IQR 48 home mobilization. end of the study questionnaire However, a group difference
AT 72 IQR 72 For 8 weeks. they were 2. Northwick Park was observed for the VAS
CG 12 IQR 91 Articular treatment given neural questionnaire scores at 8 weeks with the
group (AT ) treatment 3. Pain (VAS) “neural manual therapy”
Glenohumeral joint as a cross-over group having a significantly
mobilization, thoracic protocol.) lower score.
mobilization and home
exercise.
For 8 weeks.
Akalin et al24 N=36 (2 male, 18 subjects with CTS 18 subjects with Undertaken pre- At the end of treatment, 3 6
34 female) Same as control plus: CTS treatment and 8 within-group analysis
Age range 38–64 Tendon glides in 5. Custom-made weeks post- showed a significant
years positions neutral volar treatment improvement was
Mean age Median nerve wrist splint 1) Phalen’s sign obtained in all
51.93 ±5.1 years exercises in 6 positions. was instructed 2) Tinel’s sign parameters in
Mean group age (Each position was to be worn all 3) 2-point both groups. The nerve
(years) maintained for 5 night and discrimination and tendon glide
CG 52.16 (±5.6), seconds; 10 repetitions during the day 4) Grip strength group had slightly
IG 51.7 (±5.5) of each exercise as much as 5) Pinch strength greater scores but the
Duration of were done 5 times possible 6) Symptom difference between
symptoms (mo) a day ) for 4 weeks severity score groups was not significant
CG 47.6 (± 6.8), For 4 weeks 7) Functional status except for lateral pinch
IG 49.6 (± 5.2) score strength.
A patient satisfaction A total of 72% of the control
investigation group and 93% nerve
undertaken by and tendon slide group
telephone 8.3 (± 2.5) reported good or excellent
months post-treatment results in the patient
satisfaction investigation,
but the difference between
the groups was not significant.
In summary, both groups
improved by a statistically
significant amount according
to within-group analysis
comparing before and after
treatment, but except for
lateral pinch strength, both
groups improved a similar
amount because between-
group analysis revealed no
statistically significant
differences after treatment
While patient satisfaction
percentages were higher in
the neural mobilization group,
this difference between groups
was not statistically significant.
Scrimshaw N=81 (30 female, 35 subjects 46 subjects Measured at All patients received the 4 6
& Maher10 51 male) undergoing undergoing baseline, treatment as allocated
Mean age ( years) lumbar lumbar 6 weeks, 6 months, with 12-month follow-up data
IG 55 (±17) discectomy discectomy and 12 months. available for 94% of those
CG 59 (±16) (N=9), fusion (N=7), fusion 1. Global randomized. There were no
(N=6) or (N=9) or perceived statistically significant or
laminectomy laminectomy effect (GPE) clinically significant benefits
(N=20) (N=30) 2. Pain (VAS) provided by the neural
Table 4. Randomized controlled trials of neural mobilization as a treatment modality (continued).
Vicenzino N=15 with Treatment group Control group Recorded The treatment group 4 6
et al32 lateral epicondylalgia Contralateral glide Subject’s arm immediately produced significant
(7 male, 8 female) C5/6 grade 3 with rested before and after improvements in pressure
Age range 22.5–66 years affected arm in a on abdomen treatment pain threshold, pain-free
Mean age 44 ± 2 years predetermined Subjects received 1. ULTT2b grip strength,
Duration of symptoms position 1 of the 3 (measuring degrees neurodynamics, and
8 ± 2 months treatment of abduction) pain scores relative
Range of duration Placebo group conditions 2. Pain-free grip to the placebo and
2–36 months Manual contact for 3 days in a strength control groups (p< 0.05)
was applied as in random order. (hand held
the treatment group dynamometer)
with patient’s arm 3. Pressure pain
rested on abdomen threshold
but no glide was 4. Pain via VAS
applied (over 24 hours)
All treatments were 5. function VAS
applied in 3 lots of (over 24hours)
30 seconds with 60-
second rest periods
Drechsler N=18 (8 male, 8 subjects with 10 subjects with Undertaken pre Subjects who received 3 5
et al29 10 female) lateral epicondylitis lateral epicondylitis treatment, radial head mobilizations
Age range 30–57 years Neural tension group Standard treatment post treatment improved over time (p<0.05)
Mean age 46 years ULTT 2b with . . . group and 3 month Results from neural
Mean age of groups 1. Graded flexion and 2 times a week Follow up tension group were linked
(years) or shoulder abduction for 6–8 weeks 1. Self-report to radial head treatment
IG 46.4, CG 45.5 2. Anterior-posterior 1. Ultrasound questionnaire and isolated effects could
mobilizations of radial over common 2. Grip strength not be determined.
head if radial head extensor tendon (hand-held There were no long-term
mobility was judged 2. Transverse dynamometer) positive results in the
hypomobile friction to tendon 3.Iisometric testing standard treatment group.
Home exercise plan to (1 minute extension of 3rd finger
mimic ULTT2b 10 per session) 4. ULTT2b
repetitions a day 3. Stretch and (measuring
increasing but not strengthen wrist abduction)
exceeding 2 sets a extensors 5–10 5. Radial head
day. 2x week for repetitions 30 mobility (ant/post
6–8 weeks seconds. glides, graded as
Dumbbells hypo/normal/
gradually hyper
increasing 6. Elbow extension
to 3 sets 15 ROM during ULTT
repetitions
4. Home
exercise
program stretch
and strengthen
Legend: N = number of subjects, IG = intervention group, CG = control group, VAS = visual analogue scale, CTS = carpal tunnel syndrome, Grp = group, Rx = treatment, mHz = mega-hertz, EMG = elec-
tromyography, F/U = follow-up, NT = neural treatment, AT = articular treatment, ROM = range of movement, mo = months, yrs = years, ULTT = upper limb tension tests, ant = anterior, post = after, IQR =
interquartile range, ULTT2a = median nerve bias neurodynamic test, ULTT2b = radial nerve bias neurodynamic test.
to review and assess the therapeutic efficacy of neural mobi- Due to the heterogeneity in respect to the neural mobi-
lization for treatment of altered neurodynamics through lization interventions used in these RCTs, it is difficult to
evaluation of appropriate randomized controlled trials was make general conclusions regarding neural mobilization as
substantially limited. a general therapeutic tool. Over all, six different categories
Methodological weaknesses can lead to over- or under- or types of neural mobilization treatments were identified
estimations of actual outcomes. For example, blinding can (Table 5). Of these, there was limited evidence to support the
significantly eliminate bias and confounding, and is essential use of active nerve and flexor tendon gliding exercises of the
in maintaining the robustness of an RCT. Blinding is difficult forearm24,26,30, cervical contralateral glides8,28,32, and Upper
for use in studies involving manual therapy33,34, although in Limb Tension Test 2b (ULTT2b) mobilization29,31 in the treat-
this review only 9 of the 11 studies blinded the raters. Some ment of altered neurodynamics or neurodynamic dysfunc-
have argued that blinding for use in manual therapy studies tion. There was inconclusive evidence to support the use of
is useful34, although it is arguable that non-masked raters slump stretches27 and combinations of neural mobilization
could bias outcome findings. techniques10,25 in the treatment of altered neurodynamics or
The outcome measures used by the RCTs in this review neurodynamic dysfunction.
also lacked homogeneity. A battery of different scales was Future studies are needed and a larger, more com
used, and findings are not transferable across populations. prehensive body of work is required before conclusive
One method used to standardize measures of success is the evidence is available. We found only 10 RCTs met the inclusion
use of a minimal clinically important different score (MCID). criteria for this systematic review. Unfortunately, all studies
MCID relates to the smallest change in a clinical outcome were clinically heterogeneous in that each looked at a number
measure, which correlates to a person feeling “slightly better” of different pathologies and different types of neural
than the initially recorded state33. Findings can be dichoto- mobilization. This made quantitative analysis of therapeutic
mized into success or failure. In research that analyzes the efficacy impossible. As Reid and Rivett21 have stated, direct
therapeutic benefit of an intervention, the MCID is an impor- quantitative comparison, within the realms of systematic
tant statistic, as it represents a level of therapeutic benefit sig- review, is very difficult when pathologies, interventions, and
nificant enough to change clinical practice34. MCIDs are pop- outcome measures are heterogeneous. For example, even for
ulation- and pathology-specific, and they require analysis to this review there were a number of studies that looked at
determine a properly computed value. To our knowledge, all neural mobilization in treatment for lateral epicondylalgia29,32,
or a majority of the outcome scales used have not been evalu- carpal tunnel syndrome24,26,30,31, and cervicobrachial pain8,25,28.
ated for an MCID for the population examined in our study. The specific neural mobilization intervention differed be
2 Active nerve and flexor tendon gliding Baysal et al26 Limited (Level 3)
exercises (forearm) Pinar et al30
Akalin et al24
5 Combination (Straight leg raise, knee flexion/ Scrimshaw & Maher10 Insufficient (Level 4)
extension, and passive cervical flexion)
6 Upper limb tension test 2b (ULTT 2b) neural Tal-Akabi & Rushton31 Limited (Level 3)
mobilization Drechsler et al29