Neurodynamics or neural mobilisation is an intervention aimed at restoring the altered homeostasis in and around the nervous system (Coppieters and Nee 2015). Mobilisation may focus on the nervous system itself or on the structures that surround the nervous system (Coppieters and Butler 2008). It is commonly used in clinical practice in the management of patients with nerve-related musculoskeletal conditions. Despite a number of reviews (Ellis and Hing 2008; Medina McKeon and Yancosek 2008; Su et al. 2016) there are no recent comprehensive systematic reviews evaluating the evidence for its efficacy.
We investigated whether neurodynamics improved pain and disability in patients with nerve-related conditions, such as nerve-related low back and leg pain (N-LBP), nerve-related neck and arm pain (N-NAP), carpal tunnel syndrome (CTS), and lateral epicondylalgia.
Forty studies met the criteria to be included in this systematic review (Basson et al. 2017). There were 12 studies for CTS, 11 for N-LBP, 10 for N-NAP, 3 for lateral epicondylalgia and 1 for cubital and tarsal tunnel syndrome, plantar heel pain and post-operative low back pain. Nineteen studies could be included in a meta-analysis for either CTS, N-LBP or N-NAP. The most commonly used neurodynamic techniques were nerve mobilisation exercises for CTS, cervical contralateral glides for N-NAP and lateral epicondylalgia, mobilisation in a slump position for N-LBP, and SLR mobilisation for N-LBP, tarsal tunnel syndrome, plantar heel pain and post-operative low back pain.
The review revealed that neurodynamic techniques are associated with an improvement in pain and disability in patients with N-LBP. They also improve pain in N-NAP and plantar heel pain. Tensioning techniques are not effective in CTS, however neurodynamic techniques have positive neurophysiological effects in patients with CTS, such as a decrease in intra-neural oedema and temporal summation. The positive neurophysiological effects identified in the review are supported by studies on unembalmed cadavers and in animal studies (Brown et al. 2011; Gilbert et al. 2015; Santos et al. 2014). The effect of neural mobilisation in cubital tunnel syndrome, lateral epicondylalgia and post-lumbar surgery remains uncertain due to the small number of studies.
Considering the pathophysiology following nerve entrapment, neural mobilisation is a biologically plausible intervention and seems effective for various neuro-musculoskeletal conditions, such as N-LBP, and N-NAP. For some other conditions the evidence is less clear. Whether the effectiveness of neural mobilisation depends on the condition, or on the way neural mobilisation is delivered (e.g., dosage, technique/exercise selection, etc.) remains uncertain. More high-quality trials are needed to improve the strength of the conclusions and gain better insight how neurodynamics should optimally be delivered. Judicious clinical reasoning should continue to guide clinical practice and future research so that neural mobilisation can be appropriately targeted to maximise efficacy.
Annalie Basson, Benita Olivier, Richard Ellis, Michel Coppieters, Aimee Stewart, Witness Mudzi
References and further reading:
Coppieters MW, Nee R. Neurodynamic management of the peripheral nervous system. 4th Edition ed. Jull G, Moore AP, Falla D, Lewis D, McCarthy C, Sterling M, editors. Edinburgh, UK.: Elsevier; 2015.
Coppieters MW, Butler DS. Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13(3):213-21.
Ellis RF, Hing WA. Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther. 2008;16(1):8-22.
Medina McKeon JM, Yancosek KE. Neural gliding techniques for the treatment of carpal tunnel syndrome: a systematic review. J Sport Rehabil. 2008;17(3):324-41.
Su Y, Lim E, Choon, Wyn., Srbely J, Vadasz B, Shah J, Gerber N, Lynn., et al. Does Evidence Support the Use of Neural Tissue Management to Reduce Pain and Disability in Nerve-related Chronic Musculoskeletal Pain? A Systematic Review With Meta-Analysis. Clinical Journal of pain. 2016;32(11):991-1004.
Basson A, Olivier B, Ellis RF, Coppieters MW, Stewart A, Mudzi W. The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2017;47(9):593-615.
Brown CL, Gilbert KK, Brismee J-M, Sizer PS, Roger James C, Smith MP. The effects of neurodynamic mobilization on fluid dispersion within the tibial nerve at the ankle: an unembalmed cadaveric study. Journal of Manual & Manipilutave Therapy. 2011;19(1):26-34.
Gilbert KK, James CR, Apte G, Brown C, Sizer PS, Brismée J-M, et al. Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: implications for the treatment of neuropathic pain and dysfunction. J Man Manip Ther. 2015;23(4):219-25.
Santos FM, Grecco LH, Pereira MG, Oliveira ME, Rocha PA, Silva JT, et al. The neural mobilization technique modulates the expression of endogenous opioids in the periaqueductal gray and improves muscle strength and mobility in rats with neuropathic pain. Molecular Pain. 2014;10(19):1-8.