Study Design: Systematic review with meta-analysis. Objectives: To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component. Background: Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown. Methods: A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-analysis, with pain, disability, and function as the primary outcomes. Results: Forty studies were included in this review, of which 17 had a low risk of bias. Meta-analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0–50]: mean difference, −9.26; 95% confidence interval [CI]: −14.50, −4.01; P<.001) and pain (intensity [0–10]: mean difference, −1.78; 95% CI: −2.55, −1.01; P<.001) improved following NM. For chronic neck-arm pain, pain improved (intensity: mean difference, −1.89; 95% CI: −3.14, −0.64; P<.001) following NM. For most of the clinical outcomes in individuals with carpal tunnel syndrome, NM was not effective (P>.11) but showed some positive neurophysiological effects (eg, reduced intraneural edema). Due to a scarcity of studies or conflicting results, the effect of NM remains uncertain for various conditions, such as postoperative low back pain, cubital tunnel syndrome, and lateral epicondylalgia. Conclusion: This review reveals benefits of NM for back and neck pain, but the effect of NM on other conditions remains unclear. Due to the limited evidence and varying methodological quality, conclusions may change over time. Level of Evidence: Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(9):593–615. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7117

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 study on the global burden of disease.1 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.4 Similarly, low back pain with leg pain is a common phenomenon and is acknowledged as a predictor for chronicity.6 Background Neuropathic pain is often associated with musculoskeletal complaints7,8 including low back pain,9 whiplash associated disorders (WAD)10,11 and acute or chronic radiculopathy, and can be a feature of syndromes such as cervico-brachial pain syndrome.12 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 sensitization, denervation, nerve sensitization or somatically referred pain.6 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 epicondalalgia15 and carpal tunnel syndrome.16 Background Management strategies for back pain and neck pain are often multimodal.2,3 However, the evidence for effective treatment of nerve related pain is lacking.2,17,18 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 have been studied in various populations such as low back pain,24 carpal tunnel syndrome,16 lateral epicondalalgia15 and cervico-brachial pain.25,26 Neural mobilization techniques studied include cervical lateral glides for cervico-brachial pain,25,26 nerve gliding exercises for the treatment of carpal tunnel syndrome,16,27 cervical lateral glides for lateral epicondalalgia15 and the slump as a neural mobilization technique in the treatment of low back pain.3,24 No specialized equipment is needed in the performance of neural mobilization techniques, which contributes to its popularity. Background Neural mobilization is said to affect the axoplasmic flow,28 movement of the nerve and its connective tissue29 and the circulation of the nerve30 by alteration of the pressure in the nervous system and dispersion of intraneural oedema.30,31 Neural mobilization decreases the excitability of dorsal horn cells.20 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 Background 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 be an extension of the previous review by Ellis and Hing.17 The outcomes of this systematic review may be used to inform clinical practice and the development of best practice guidelines.

The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels.Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic).Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels. Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

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

Carpal tunnel syndrome (CTS) has been traditionally classified as primarily a neuropathic condition with or without pain. Precision medicine refers to an evidence-based method of grouping patients based on their susceptibility to biology, prognosis of a particular disease, or in their response to a specific treatment, and tailoring specific treatments accordingly. In 2021, the International Association for the Study of Pain (IASP) proposed a grading system for classifying patients into nociceptive, neuropathic, or nociplastic phenotypes. This position paper presents data supporting the possibility of subgrouping individuals with specific CTS related-pain into nociceptive, neuropathic, nociplastic or mixed-type phenotypes. Carpal tunnel syndrome is a neuropathic condition but can also be comorbid with a nociplastic pain condition. The presence of extra-median symptoms and the development of facilitated pain processing seem to be signs suggesting that specific CTS cases can be classified as the nociplastic pain phenotype. The clinical responses of therapeutic approaches for the management of CTS are inconclusive. Accordingly, the ability to identify the predominant pain phenotype in patients with CTS could likely be problematic for producing efficient treatment outcomes. In fact, the presence of a nociplastic or mixed-type pain phenotype would explain the lack of clinical effect of treatment interventions targeting the carpal tunnel area selectively. We propose a clinical decision tree by using the 2021 IASP classification criteria for identifying the predominant pain phenotype in people with CTS-related pain, albeit CTS being a priori a neuropathic pain condition. The identification of a nociplastic-associated condition requires a more nuanced multimodal treatment approach to achieve better treatment outcomes.