Neuromobilization in the treatment of UE radicular symptoms

This weekend, I was working on some projects for my fellowship at Sports Medicine of Atlanta, and I thought I would share a quality of literature review I did on an article for neural mobilizations of the upper extremity. I believe that we should all have a critical eye when reading medical literature. This study was pretty good…
Journal: Journal of Physiotherapy
Title: Neural tissue management provides immediate clinically relevant benefits without harmful effects for patients with nerve-related neck and arm pain: a randomized trial
Authors: Nee RJ, Vicenzino B, Jull G, Cleland J, Coppieters MW.
Volume: 58
1. Identify the research problem.
(In this study, there were 3)
a. Are nerve gliding exercises effective and safe in the treatment of nerve-related neck and arm pain?
b. What are the characteristics of adverse events related to nerve gliding exercises?
c. Does the experience of an adverse event limit the individual’s ability to benefit from neural tissue management?
2. Identify whether the literature review was comprehensive.
a. Yes. It was concise yet comprehensive in describing the background of the independent and dependent variables.
3. Identify the research Ho and Null Ho.
a. Nerve gliding exercises will be effective and safe in the treatment of nerve related neck and arm pain.
b. Nerve gliding exercises will not be effective but will be safe in the treatment of nerve related neck and arm pain.
c. Nerve gliding exercises will not be effective or safe in the treatment of nerve related neck and arm pain.
4. Describe the type of research that was conducted.
a. This was a 2:1 randomized controlled trial.
5. Identify the research design.
a. 60 subjects were recruited through advertisements. All of these subjects had non-traumatic, neck and unilateral arm pain and were randomized 2:1 (40 experimental: 20 control). The experimental group received four treatments of education, neural gliding exercises (gliding and tensioning of the median nerve and cervical nerve roots) and a home exercise program. At the start of each session, the tester would administer a patient specific functional scale, verbal pain scale and pain diagram to assess for worsening of symptoms. If they worsened, the tester would recheck for a change in neural signs such as strength, reflexes, sensation to make sure the patient did not have two or more present, indicating an adverse reaction. Primary outcomes were measured on a Global Ratings of Change scale. Secondary outcomes were measured based upon perceived arm pain, neck pain, Neck and Disability Index, the Patient Specific Functional Scale and adverse events related to treatment.
6. Identify the dependent and independent variables.
a. Independent: Education, Nerve glides and tensioning (in clinic and home)
b. Dependent: pain, disability (NDI and Patient Specific Functional Scale), perceived change in symptoms, adverse events
7. Identify the population sample.
a. 60 participants (47 years old +-9) with non-traumatic neck pain and unilateral arm pain were recruited through advertising
8. Critique the research methods and procedures.
a. Participants were recruited for the study
b. Once screened for inclusion/exclusion criteria, it was found that out of 587 subjects, only 527 were eligible for enrollment.
c. Eligible subjects were randomized, into one of two groups, and baseline measures were taken.
d. The experimental group then received education, exercises and a home exercise program
e. The experimental group repeated this for four treatments over two weeks and measurements were taken
Overall, this research design appeared to rather good and little to be critical about.
9. Critically evaluate the data findings.
a. Overall, there was a statistically significant difference in the experimental group vs. the control group. It appears that neural mobilizations demonstrated an improvement in participant reported improvement, pain intensity and activity limitations.
b. There was no evidence to show that neural mobilization is harmful to this subgroup of individuals.
10. Critically evaluate the conclusions.
a. The authors rightfully conclude that this trial should enable physical therapists to have discussions with patients about the short-term benefits of neural mobilizations. They do state that they are unable to conclude if the benefit was truly from the neural mobilizations or simply the interaction with the practitioner.
11. Summarize the relevance of the findings to general practice.
a. This study supports the notion that education in addition to interaction with the patients nervous system is beneficial in the treatment of confirmed neural dysfunctions of the UE in individuals with neck pain. The subjects of this study were recruited which does pose threats to validity but all subjects of this study had active symptoms.
12. Specify the relevance of this research to specialty practice.
a. This study demonstrates the importance of clinicians in an orthopedic setting to understand the nervous system because arm pain could be misconstrued as a multitude of disorders. We should always look at the peripheral nervous system through upper limb tension testing and treat the symptoms appropriately when present.

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