YJMT_31_2065599

Prévia do material em texto

Neural mobilization in low back and radicular pain: a systematic review
Mica Peacock*, Samuel Douglas* and Preeti Nair
Samuel Merritt University, Department of Physical Therapy, Oakland, CA, USA
ABSTRACT
Background: Low back pain can present with radicular pain caused by lumbosacral nerve root 
pathology. Neural mobilization (NM) is a treatment technique used to treat low back and 
radicular pain (LBRP).
Purpose: To evaluate the effectiveness of NM interventions in improving pain, disability, and 
function in adults with LBRP.
Data Sources: CINAHL Plus, MEDLINE (Ovid), Physiotherapy Evidence Database, and Cochrane 
databases were searched.
Study Selection: Randomized controlled trials assessing the effect of NM on pain, disability, 
and/or function in adults with LBRP.
Data Extraction: Authors reviewed studies and used the PEDro scale and the revised Cochrane 
risk-of-bias tool to assess methodological quality and risk of bias.
Data Synthesis: Eight studies were included. Six of the eight studies found the addition of NM 
to conservative treatment improved all measured outcomes. One study found improvements 
in some but not all functional measures, and delayed improvements in pain. One study found 
improvements in measures of neural sensitivity, but not overall pain and disability.
Conclusions: NM may be an effective tool for short-term improvements in pain, function, and 
disability associated with LBRP. Additional high quality research is needed.
Study registration: : This systematic review protocol was registered with PROSPERO (registra-
tion number: CRD42020192338).
KEYWORDS 
Neural mobilization; nerve 
root; low back pain; sciatica; 
radicular
Introduction
Low Back and Radicular Pain (LBRP), defined as pain 
due to compression, irritation, or other pathology of 
one or more lumbosacral nerve roots, is one of the 
most common forms of low back pain [1–3]. Annual 
prevalence has been reported as high as 25% and 
lifetime prevalence as high as 43% [1,4]. Not only is 
LBRP common it is significantly debilitating. Compared 
to other forms of low back pain, LBRP is associated with 
a variety of poor outcomes. These outcomes include 
more severe and persistent pain, increased cost of care, 
and longer periods of disability and absence from work 
[1,5–7]. Therefore there is a need to treat this promptly 
and effectively.
In terms of isolating the cause of pain, lumbar disc 
herniation is widely considered the most common 
cause of LBRP [8–10]. However, LBRP may also be 
caused by osteophytes, spondylolisthesis, and other 
local factors. Symptom presentation of LBRP usually 
involves pain characterized as sharp, burning, dull, 
aching or lancinating that radiates from the lower 
back below the gluteal fold and follows 
a dermatomal distribution based on the level of spinal 
root pathology[11]. In addition to pain, other 
symptoms may also exist and include paresthesia, 
weakness, and diminished ankle and/or knee reflexes 
[9]. No single assessment serves as the gold standard 
for diagnosis of LBRP, so a medical diagnosis of LBRP is 
therefore only reached after a combination of imaging 
studies, a detailed review of the patient’s symptoms, 
and the performance of a physical examination[9]. 
Given the variety of causative factors involved, range 
of symptom presentation, and difficulty in reaching an 
accurate diagnosis, LBRP is a challenging condition to 
diagnose and treat.
Treatment options for LBRP include conservative 
care, pharmaceutical interventions and surgery. 
Conservative care options are varied and may include 
a variety of exercise protocols, electrical modalities 
such as transcutaneous electrical nerve stimulation, 
and techniques aimed at mobilizing the affected tissue 
such as spinal mobilization, and neural mobilization 
(NM)[12].
Neural mobilization refers to the therapeutic prac-
tice of applying mechanical forces to nerves in the 
body, with the goal of restoring healthy movement. 
Nerves must be able to move within the nerve bed (i.e. 
surrounding tissue) for normal movement to occur, 
CONTACT Mica Peacock mica.peacock@samuelmerritt.edu Samuel Merritt University, Department of Physical Therapy, 3100 Telegraph Avenue 
Oakland, Oakland, CA 94609, USA
The authors report no conflict of interest.
*Both authors contributed equally to this work and are co-first authors
Supplemental data for this article can be accessed here.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 
2023, VOL. 31, NO. 1, 4–12 
https://doi.org/10.1080/10669817.2022.2065599
© 2022 Informa UK Limited, trading as Taylor & Francis Group 
http://orcid.org/0000-0002-1609-0050
https://doi.org/10.1080/10669817.2022.2065599
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and tolerate strain, compression, and transverse move-
ment along the nerve bed[13]. Some NM techniques 
directly mobilize the neural tissue (e.g. nerve glide, 
nerve flossing) via either active (e.g. exercise) or pas-
sive (e.g. manual therapy) techniques[14]. Others indir-
ectly mobilize the nerves via movement of the 
surrounding tissues (e.g. spinal mobilization)[15].
NM may be helpful for decreasing pain and 
restoring nerve function in a variety of musculos-
keletal conditions, but its effects on LBRP are not 
well-studied[16–21]. A 2014 critical review by 
Efstathiou et al [22] concluded that the existing 
literature was too sparse and low-quality in deter-
mining the effectiveness of treating lumbar radi-
culopathy with NM. More recently, a 2016 
systematic review by Su and Lim [23] found that 
NM interventions provided pain relief and reduc-
tion in disability for people with nerve-related 
chronic musculoskeletal disorders, but found no 
significant differences between NM and other con-
servative treatments. Finally, a 2017 systematic 
review by Basson et al [14] on the efficacy of 
treating various musculoskeletal conditions with 
NM found that a variety of NM techniques can 
improve pain and disability in these participants.
Given the lack of consensus on the functional 
effects of NM on LBRP, this field of research would 
benefit from a systematic review focused solely on 
a population with lumbar radicular pain. The objec-
tive of this systematic review was to evaluate the 
effectiveness of NM interventions in improving pain, 
disability, and function in adults with LBRP.
Methods
Study registration
Study registration: This systematic review protocol 
was registered with PROSPERO (registration number: 
CRD42020192338), and was performed in line with the 
PRISMA declaration guidelines.
Search strategy
The databases searched in this systematic review 
were CINAHL Plus, MEDLINE (Ovid), Physiotherapy 
Evidence Database, and Cochrane Central Register 
of Controlled Trials. All searches were performed in 
May 2020. Our search strategy targeted clinical trials 
with two primary variables of interest, a specific 
participant population (people with LBRP) and our 
specific intervention (neural mobilizations). Our 
search strategy included terms related to LBRP, 
including sciatica, neurogenic, and disc herniation, 
as well as related terms for neural mobilization 
interventions, including nerve modality, nerve ten-
sion, and nerve flossing. For CINAHL Plus, we also 
limited our searches to randomized controlled trials 
(RCTs) and excluded MEDLINE records. No filters 
related to publication date were used for any of 
our searches, and no limitations on outcome mea-
surement timeline were applied prospectively. See 
Appendix 1 for an example search strategy.
Eligibility criteria
RCTs, available in English, assessing the effect of NM 
on pain, function, or disability in adults with LBRP 
were eligible for inclusion.
Included studies met the following criteria: (1) 
Participant populations presented with symptoms, 
radiological findings, or other clinical findings of 
LBRP. These included radiological findings of lumbar 
disc herniation or degeneration,back pain radiating 
down into at least one lower extremity, reproduc-
tion of symptoms with passive straight leg raise 
(PSLR) or slump test, myotomal weakness, dermato-
mal change in sensation, or hyporeflexia in 
a lumbosacral innervation pattern. (2) NM interven-
tion was provided using methods that directly 
mobilize the neural tissue (e.g. nerve glide, nerve 
flossing) via either active (e.g. exercise) or passive 
(e.g. manual therapy) techniques. Eligible compara-
tor/control conditions included no treatment, sham 
treatment, or conservative treatment not involving 
neural mobilization. (3) Outcomes assessed at least 
one of our primary outcomes of interest (pain, dis-
ability, and function), via scales such as the Numeric 
Pain Rating Scale (NPRS), Visual Analog Scale (VAS), 
Oswestry Disability Index (ODI), Roland-Morris 
Disability Questionnaire (RMDQ), or the Short Form 
Health Survey (SF-36 or SF-12).
Animal studies, case reports, cohort studies, and 
studies on healthy participants were excluded. 
Studies with patient populations including evidence 
or indication of specific spinal pathology (including 
but not limited to vertebral fracture, neoplasm, cauda 
equina syndrome, and spinal infection), systemic neu-
rological disorders or lesions, or low back pain without 
radicular qualities were also excluded. Studies compar-
ing two separate interventions with no control condi-
tion were excluded, as were studies assessing NM only 
performed by indirect mobilization of the nerves via 
movement of the surrounding tissues (e.g. spinal 
mobilization).
Two reviewers (SD and MP) independently 
screened titles and abstracts of records identified 
via the described search strategy using these inclu-
sion and exclusion criteria. Full-text of appropriate 
studies were screened independently for inclusion 
by both reviewers. Discrepancies were resolved by 
consensus meeting. In the case of continued dis-
agreement, a third reviewer would have been used 
to determine eligibility for inclusion.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 5
Data extraction and quality assessment
Data were systematically extracted from the 
abstract and full-text of each study. The following 
items were included: author name and year of pub-
lication, participant demographics, experimental 
and control treatment protocols, all outcome para-
meters including assessment timing, and main 
results.
Articles that met the inclusion criteria were assessed 
using the PEDro scale and the revised Cochrane risk-of- 
bias tool (RoB2). The PEDro scale is a valid and reliable 
tool for measuring the methodological quality of clinical 
trials[24]. The scale provides a rating for each study 
between zero and ten based on a series of “yes or ‘no’ 
questions, with a score of >8 considered excellent, a score 
of 6 to 8 considered good, a score of 4 to 5 considered 
fair, and a score of 35 degrees[27], while two papers 
[32,33] excluded participants with a positive PSLR of 
14 female, 16 
male
n = 15 35.1 (6.4) 
years
– n = 15 41.6 (11.1) 
years
–
Nagrale et al. 2013 n = 60: 39 female, 21 
male
n = 30 38.2 (3.47) 
years
66.31 (11.16) weeks n = 30 37.76 (4.70) 
years
64.14 (7.78) weeks
Pallipamula & 
Singaravelan 2012
n = 42 n = 21 42.53 (6.99) 
years
9.09 (1.89) weeks n = 21 40.2 (7.55) 
years
8.91 (1.80) weeks
Plaza-Manzano et al. 
2020
n = 32: 16 female, 16 
male
n = 16 45.4 (6.0) 
years
75.2 (6.1) weeks n = 16 47.0 (8.0) 
years
74.7 (6.5) weeks
Satishkumar et al. 2017 n = 38 n = 19 34.11 (8.36) 
years
32.02 (12.38) weeks n = 19 35.47 (8.40) 
years
31.55 (11.12) weeks
SD: standard deviation
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 7
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8 M. PEACOCK ET AL.
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JOURNAL OF MANUAL & MANIPULATIVE THERAPY 9
quality assessments, with the fair and poor quality 
papers judged to be high risk, and the four good 
quality studies judged to have some concerns. 
Quality assessment scores for all studies are available 
in Table 3.
No trials were able to blind the therapist to the 
intervention they were delivering. This reflects an 
ongoing challenge in the field rather than a failing of 
these studies in particular. Several studies that per-
formed physical assessments as outcome measures 
did not specify whether the assessor was blinded to 
the intervention group. Only one paper [28] pre- 
published their study design in order to allow assess-
ment of result reporting bias.
Results
Table 2 describes the results of each individual study 
included in this systematic review. All eight included 
studies measured disability or function as a primary 
outcome. Four [28,29,32,33] used the standard, mod-
ified, or revised version of the ODI, two [30,31] used the 
RMDQ, and one study each used the Patient Specific 
Functional Scale (PSFS)[28], SF-12[27], and select sub-
scales of the SF-36[34]. Seven of the studies included 
pain as a primary outcome measure, with six [27,28,30– 
33] using the 11-point NPRS. Only three studies 
[28,30,33] re-assessed outcomes at a follow-up later 
than the final treatment session, and only one [30] 
assessed any outcomes later than six weeks following 
initial treatment.
Disability/Function
Five of the eight included studies found significant 
between-group differences favoring NM treatment for 
all outcomes related to function or disability at all post- 
baseline measurements [27,29,31,32,34]. Of the remain-
ing three studies, Nagrale et al [33] found significant 
between-group differences favoring NM treatment for 
the ODI after weeks 3 and 6. Ferreira et al [28] had 
mixed results, with the PSFS showing significant 
between-group differences favoring NM treatment 
after week 2 and week 4, but no significant differences 
for the ODI. Plaza-Manzano et al [30] found no signifi-
cant group*time interaction for the RMDQ.
Pain
Of the seven studies that included at least one mea-
sure of pain, five found significant between-group dif-
ferences favoring NM treatment for all outcomes 
related to function or disability at all post-baseline 
measurements [27,29,31–33]. Of the remaining two 
studies, Ferreira et al [28] found significant between- 
group differences favoring NM treatment after week 4 
in leg and low back NPRS scores. Plaza-Manzano et al 
[30] found significant group*time interactions for the 
PSLR and the Leeds Assessment of Neuropathic 
Symptoms and Signs (a measure of neuropathic 
pain), but not for the NPRS or pressure pain threshold.
Discussion
The goal of this systematic review was to determine 
the effectiveness of NM in treating adults with LBRP. 
This subset of low back pain patients experiences 
worse outcomes on average[1], but has been inconsis-
tently defined pathologically in prior research, limiting 
the ability to draw conclusions about effective treat-
ments. NM was chosen as the intervention of interest 
because it has been shown to be effective in treating 
nerve-related pain in other body regions[14], but evi-
dence related to lumbosacral pain is limited.
Six of the eight RCTs included in this review found 
that adding an NM intervention to a conservative treat-
ment plan improved all outcomes. The results of the 
remaining two papers favored NM treatment for some 
outcomes; Plaza-Manzano et al [30] found improve-
ments in measures of neural sensitivity, but not overall 
pain and disability, while Ferreira et al [28] found 
improvements in some but not all functional measures, 
and delayed improvements in pain. Furthermore, no 
studies found any evidence of NM treatment having 
a detrimental effect on any outcomes. Overall, the 
collective results of these eight studies indicate that 
NM may be recommended for treatment of LBRP, 
although data are still too limited to determine the 
extent to which NM contributes to the effectiveness 
of a multi-modal treatment plan.
The low quality and inconsistent rigor of the 
included studies is a limitation of this review. Only 
four of the eight included studies achieved a quality 
rating of good on the PEDro scale and a RoB2 risk 
assessment lower than ‘high.’ Several studies failed to 
include critical information such as the proportion of 
randomized participants who completed the entire 
study, and the details of the concealed allocation pro-
cess used for randomization. Ahmed et al [27] stated 
that participants were given a home exercise program 
but gave no information about the frequency with 
which they performed it. Jeong et al [34] described 
the steps of the NM technique performed, but gave 
no indication of whether the technique was performed 
for multiple repetitions within a treatment session, and 
provided no rationale for their choice of the general 
health and physical functioning subscales of the SF-36 
as sole outcome measures.
The substantial variability in intervention design, 
frequency, and duration, as well as symptom intensity 
and duration in participant populations, limits our abil-
ity to draw conclusions about the efficacy of the use of 
any specific NM protocol. Our conclusions regarding 
long-term effects are also limited because only three 
10 M. PEACOCK ET AL.
studies re-assessed outcomes after the final treatment 
session. The breadth of positive findings when NM is 
added to a wide variety of control interventions does 
confirm that NM can be an appropriate part of a multi- 
modal treatment plan for people with LBRP.
The lack of consensus regardinglanguage to 
describe LBRP limits the ability of researchers and clin-
icians to understand and discuss this unique population. 
The term ‘sciatica,’ while easily recognized, is not anato-
mically descriptive. Its continued use to describe both 
nerve root pathology and peripheral nerve involvement 
conflates two very different clinical presentations. The 
use of the term ‘radicular’ is also inconsistent across 
studies. The word’s literal meaning is ‘pertaining to the 
nerve root,’ but it has been conflated with ‘radiculopa-
thy’ and therefore assumed to only apply to severe 
nerve root compromise. For example, Cleland et al [32] 
and Nagrale et al [33] go so far as to claim that their 
study populations have ‘non-radicular low back pain’ by 
nature of excluding participants who have diminished 
reflexes, sensation, or strength, despite all participants 
exhibiting low back pain that radiates below the gluteal 
fold and is reproduced with slump testing. This level of 
inconsistency in the use of the word radicular has the 
potential to actively create confusion.
Additional high quality RCTs on this subject are 
necessary to further explore the treatment of LBRP 
with NM. It is especially important that future RCTs 
on this topic use precise and consistent criteria to 
define the participant population. We recommend 
future studies use a predetermined duration of symp-
toms, a standardized method of identifying radicular 
symptoms, and longer follow-up periods. Standardized 
intervention protocols would also significantly reduce 
the overall study heterogeneity and improve the 
extent to which these findings can be generalized.
In conclusion, our findings suggest that NM may be 
an effective tool for short-term improvements in pain, 
function, and disability associated with LBRP. Robust 
claims regarding the utility of particular intervention 
protocols will require publication of additional high- 
quality RCTs with detailed, homogenous study 
protocols.
Notes on Contributors
Mica Peacock earned her Bachelor of Arts in Biology from 
Reed College, and received her Doctor of Physical Therapy 
degree at Samuel Merritt University.
Samuel Douglas received his Bachelor of Arts in 
Neuroscience and Behavior from Wesleyan University, and 
received his Doctor of Physical Therapy degree at Samuel 
Merritt University.
Preeti Nair earned her Bachelor of Physiotherapy at Pune 
University in India. She then earned a PhD in Rehabilitation 
Sciences at the University of Florida, with a research focus on 
Biomechanics and Neurophysiology of walking in individuals 
with neurological impairment. She is currently an Associate 
Professor in the Department of Physical Therapy at Samuel 
Merritt University.
Disclosure statement
Authors report no conflict of interest.
ORCID
Preeti Nair http://orcid.org/0000-0002-1609-0050
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12 M. PEACOCK ET AL.
https://doi.org/10.1016/s1836-9553(12)70069-3
https://doi.org/10.1016/s1836-9553(12)70069-3
https://doi.org/10.1097/PHM.0000000000001295
https://doi.org/10.1097/PHM.0000000000001295
	Abstract
	Introduction
	Methods
	Study registration
	Search strategy
	Eligibility criteria
	Data extraction and quality assessment
	Data synthesis and analysis
	Study selection
	Study characteristics
	Methodological quality
	Results
	Disability/Function
	Pain
	Discussion
	Notes on Contributors
	Disclosure statement
	ORCID
	References