Neurodynamics Is an Effective Intervention for Carpal Tunnel Syndrome

in Journal of Sport Rehabilitation
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Clinical Scenario: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper-extremity. Due to the involvement of the median nerve, long-term compression of this nerve can lead to hand dysfunction and disability that can impact work and daily life. As such, early treatment is warranted to prevent any long-term damage to the median nerve. Conservative management is utilized in those with mild to moderate CTS. Neural mobilizations can aid in the reduction of neural edema, neural mobility, and neural adhesion while improving nerve conduction. Clinical Question: Is neurodynamics effective in reducing pain and reported symptoms in those with CTS? Summary of Key Findings: Four studies were included, with 2 studies utilizing passive neural mobilizations, one study using active techniques, and one study using active neural mobilizations with splinting. All studies showed large effect size for pain, symptom severity, and physical function. Clinical Bottom Line: Neurodynamics is an effective treatment for CTS. Splinting is only effective when combined with neurodynamics. Strength of Recommendation: Level B evidence to support the use of neurodynamics for the treatment of CTS.

Clinical Scenario

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper-extremity. The condition involves compression of the median nerve within the carpal tunnel of the wrist.1,2 Typical presentation of CTS includes pain, numbness and tingling within the hands, and a loss of function.1,2 To help decrease the negative cascade of events that follow CTS, identifying modifiable risk factors and providing timely treatment can help prevent further damage to the median nerve that can lead to permanent dysfunction and disability. Several conservative measures have been utilized in the management of CTS, including rest, activity modification, splinting, and neurodynamics. It is believed that the compression of the nerve leads to limited neural mobility and neural edema.3 Implementing various neurodynamic techniques can also potentially restore the mobility and physiological functions of the nerve as well as decrease adhesion, improve blood supply and nerve nutrition, nerve conduction, and decrease in nociception.35 Neural gliding, or neural flossing, as it may be called, aims to elongate the nerve bed, which induces neural gliding. Sliding of the nerve is essential to nerve function as it helps to dissipate tension.6 Sliding or tensioning techniques are commonly utilized to help promote excursion of the nerve and to restore normal physiological function.7

Focused Clinical Question

Is neurodynamics effective in reducing pain and reported symptoms in those with CTS?

Search Strategy

The initial database search included the following sequence of terms and Boolean operators:

Terms Used to Guide Search Strategy

  1. Patient/Client Group: Carpal tunnel syndrome OR carpal tunnel OR CTS OR median nerve entrapment
  2. Intervention: Nerve mobilization OR neural mobilization OR nerve gliding OR nerve flossing OR neurodynamics
  3. Comparison: N/A
  4. Outcome(s): Pain OR numbness OR tingling OR function

Sources of Evidence Searched

  1. SPORTDiscus
  2. Cochrane Central Register of Controlled Trials
  3. CINAHL
  4. Google Scholar

Inclusion Criteria

  1. Human studies
  2. English language
  3. CEBM Level 2 or higher
  4. Peer-reviewed journal articles
  5. Publication between 2014 and March 2021
  6. Patients aged 18 years and older
  7. Physician-diagnosed CTS
  8. Treatment providing neurodynamics

Exclusion Criteria

  1. Studies of patients with CTS presurgery and postsurgery
  2. Studies combining nerve glides with other modalities or treatments
  3. Studies performing nerve glides of the spine and lower-extremity
  4. Treatment parameters not identified
  5. Outcome measures for pain or symptom severity not identified
  6. Data not included for effect size calculation

Evidence of Quality Assessment

The Physiotherapy Evidence Database rating scale was used to gauge the quality of the studies.

Summary of Search and Key Findings Best Evidence

A computerized search of the SPORTDiscus, Cochrane Register of Controlled Trials, and CINAHL databases, as well as Google Scholar, was performed. Initially, 348 studies were received, leaving 343 studies after the duplicate studies were removed. Titles of these studies were then screened, removing an additional 238 studies. Abstracts of the remaining 105 studies were reviewed, and 92 were excluded; 8 studies compared outcomes presurgery and postsurgery, 3 studies utilized bone mobilization, 33 studied the effects of modalities on CTS, 9 studies reported different outcome measures, and 39 were literature reviews and those looking at lower-extremity neural conditions. The remaining 13 studies were fully reviewed. Two studies were systematic reviews that did not include data for effect size calculation. Eight studies incorporated interventions of manual therapy and modalities in combination with neural mobilizations with no control of neural mobilizations alone, leaving 3 randomized controlled trials for inclusion in this critically appraised topic (CAT; Table 1). Within the randomized controlled trials, one compared neurodynamic techniques to sham therapy,3 neurodynamic techniques to no treatment,8 and neural mobilization to therapeutic ultrasound4 (Table 2).6 The studies listed in Tables 1 and 2 present the best available evidence for this review. The level of evidence from the Centre for Evidence-Based Medicine’s9 criteria is Level 2 in all of the included studies.

Table 1

Summary Results

Level of evidenceStudy designNumber locatedAuthor (year)
2Randomized controlled trial3Wolny and Linek3 (2018)

Wolny and Linek8 (2019)

Goyal et al4 (2016)
Table 2

Characteristics of Included Studies

Wolny and Linek3Wolny and Linek8Goyal et al4
Study designRandomized control trialRandomized control trialRandomized control trial
Participants150 people (135 women and 15 men) with clinical and electrophysiological methods of diagnosis of CTS were included.122 patients who were diagnosed with mild to moderate CTS with diminished nerve conduction velocity and/or increased motor latency were included.30 females were included who had acute to subacute unilateral CTS due to hypothyroidism that was idiopathic in nature.
Exclusion criteriaPatients were excluded if they had surgery or prior therapy for CTS, cervical radiculopathy, tendon sheath inflammation, rheumatoid disease, diabetes, pregnancy, past trauma to wrist, or muscular atrophy of thenar eminence.Patients were excluded for lack of consent or cooperation; previous surgical, conservative, or pharmacological therapy; cervical radiculopathy; diabetes; pregnancy; past trauma to wrist; muscular atrophy of thenar eminence; and rheumatoid diseases.Patients were excluded who had sensory or motor deficit for the ulnar or radial nerve, previous carpal tunnel release or injection, cervical or upper-extremity pathology, pregnancy, diabetes, and systematic musculoskeletal pathology.
Intervention investigatedThe EX received passive gliding and sliding tension techniques compared with ST. The EX performed techniques in proximal and distal directions for 3 series of 60 repetitions with 15-s interseries intervals twice a week for 10 wk for 20 min each session. The technique included passive arm abduction to 90°, arm external rotation, wrist and finger extension, forearm supination, and elbow extension.The EX received both passive sliding and tensioning techniques compared with CT. Techniques were performed in proximal and distal directions in a supine position. There were 3 series of 60 repetitions with 15-s interseries intervals. Each session was 20 min and was performed twice weekly for 10 wk, for a total of 20 sessions. The technique included passive arm abduction to 90°, arm external rotation, wrist and finger extension, forearm supination, and elbow extension.The EX received active sliding techniques performed with loading of the median nerve distally and unloading proximally. Treatment was twice a week for 3 wk. The technique included elbow extension and cervical ipsilateral lateral flexion. The CT received conventional ultrasound for twice a week for 3 wk.
Outcome measuresPain using NPRS, SSS, and physical capacity (FSS) with the BCTQ.Pain using NPRS, SSS, and physical capacity (FSS) with the BCTQ.Pain using NPRS, SSS, and physical capacity (FSS) with the BCTQ.
ResultsPain, symptom severity, and physical capacity all showed significant improvements within the neurodynamic group compared with ST.

NPRS: NT 3.49 (3.15 to 3.72); ST 0.14 (−0.15 to 0.37)

SSS: NT 2.11 (1.96 to 2.21); ST 0.03 (−0.14 to 0.19)

FSS: NT 1.36 (1.20 to 1.49); ST −0.08 (−0.22 to 0.08)
Significant changes were seen in the EX compared with the CT with pain, symptom severity, and physical capacity.

NPRS: EX 3.6 (3.22 to 3.86); CT 0.21 (−0.18 to 0.52)

SSS: EX 2.96 (2.79 to 3.13); CT 0.07 (−0.13 to 0.27)

FSS: EX 1.28 (1.10 to 1.45); CT 0.18 (−0.02 to 0.38)
Both groups showed improvements across all outcome measures; however, neural mobilization showed significantly more improvement than ultrasound.

NPRS: EX 6.57 (6.15 to 6.83); CT 3.22 (2.88 to 3.59)

SSS: EX 7.84 (7.64 to 7.93); CT 3.75 (3.64 to 3.94)

FSS: EX 6.42 (6.25 to 6.57); CT 3.05 (2.92 to 3.28)
Level of evidence222
Quality assessment score (PEDro)5/106/107/10
ConclusionNeural glides and tension techniques are beneficial in reducing pain and symptom severity in those with CTS.Neural glides and tension techniques are beneficial in reducing pain and symptom severity in those with CTS.Sliding techniques are effective in reducing pain and improving functional status in those with CTS.
Contribution to CAT4/54/53/5

Abbreviations: BCTQ, Boston Carpal tunnel questionnaire; CAT, critically appraised topic; CT, control group; CTS, carpal tunnel syndrome; EX, experimental group; FSS, functional status scale; NT, neurodynamic therapy; NPRS, numeric pain rating scale; SSS, symptom severity scale; PEDro, Physiotherapy Evidence Database; SS, sustained symptomatic group;  SSS, symptom severity scale; ST, sham therapy. Note: Values are therapeutic effect Cohen d (confidence interval).

Results of Quality Assessment From Best Available Evidence

Three articles met the inclusion criteria, and they are presented in Table 1. Of the included studies, the critical appraisal scores were 5/10,3 6/10,8 and 7/10,4 indicating good to excellent quality evidence. Wolny and Linek8 examined passive sliding and tensioning techniques compared with sham therapy3 and no treatment. Goyal et al4 examined active sliding techniques to ultrasound treatment. Characteristics of the articles are listed in Table 2. There is Level 2 evidence to support the use of neural mobilizations for the treatment of CTS.

Clinical Bottom Line

There is medium-quality evidence to support the use of neurodynamics for the treatment of mild to moderate CTS in order to improve outcomes of pain, symptom severity, and function. Active or passive movements may be utilized for both sliding and tensioning techniques. Individuals should be encouraged to perform nerve gliding techniques for a minimum of 20 repetitions each, twice a week, or daily as a part of a 5- to 10-minute preactivity routine. Collectively, the body of evidence that was included to answer the clinical question aligns with the strength of recommendation B.

Implications for Practice, Education, and Future Research

Based on the results of this CAT, there is clear evidence to support the use of neural mobilizations for the treatment of CTS. While pain, symptom severity, and functional tasks such as gripping and utilization of fine motor skills are common complaints of those with CTS, greater effects are seen within each outcome in all neurodynamic groups.3,4,8

In the 2 studies by Wolny and Linek,3,8 the same treatment parameters and technique were utilized; however, the comparison group was changed (sham to no treatment). Large effect sizes were seen in both studies across all outcome measures in the neurodynamic groups and were very similar for pain (d = 3.493; d = 3.68), symptom severity (d = 2.113; d = 2.968), and physical capacity (d = 1.363; d = 1.288). While there was no effect at all in the sham and no treatment groups across outcome measures, it is interesting to note that the effect sizes for the no treatment group were slightly larger than those receiving the sham therapy. Therefore, it is essential that proper application of the neurodynamic technique is applied to ensure that the patient is receiving the full effect from the treatment, as improperly doing so will result in less benefit than not treating the patient altogether. Studies3,8 included multisegmented movements across the upper-extremity incorporating the fingers and hand, wrist, elbow, and shoulder. Additionally, passive movements were performed by Wolny and Linek,3,8 compared with active movements by Goyal et al.4 Repetitions performed between the studies varied with no clear understanding of how many repetitions were performed by Goyal et al,4 as they were not included within the study protocol. One systematic review10 performed on the effectiveness of neural mobilizations also showed inconsistent parameters, making the most effective dosage unknown. The included studies within this CAT and the systematic review had participants perform neural mobilizations at least twice a week, with a range of 10 to 60 repetitions twice a day. Based off the current evidence presented, this defined our recommendation of a minimum of 20 repetitions per day at least twice a week.

There are several recommendations for future research from the evidence included within this CAT. Recent research is limited in the comparison of neural mobilizations against a control or placebo group. Many studies combine neural mobilizations with additional treatment measures, including bone mobilizations, manual therapy, exercise therapy, or modalities, limiting the understanding of the true effect of neural mobilizations to neural conditions like CTS. Treatment parameters are also not consistent, as they varied in the intervention period of 3 weeks4 to 10 weeks,3,7 dosage times and repetitions, passive techniques to active techniques, and elbow and hand movements to full upper-extremity movements. Only 2 of the articles3,8 performed the same methods; however, they were performed by the same researchers. Research should additionally compare neurodynamics alone to other modalities or in conjunction with other modalities to see if there is an added benefit. Furthermore, current research is lacking utilizing neural mobilizations as a preventative measure. While it can be hypothesized that the treatment can become the prevention, more research needs to be conducted to identify its true effect on the prevention of CTS.

References

  • 1.

    Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review of the recent literature. Open Orthop J. 2012;6:6976. PubMed ID: 22470412 doi:10.2174/1874325001206010069

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Wolny T, Saulicz E, Linek P, Shacklock M, Myśliwiec A. Efficacy of manual therapy including neurodynamic techniques for the treatment of carpal tunnel syndrome: a randomized controlled trial. J Manipulative Physiol Ther. 2017;40(4):263272. PubMed ID: 28395984 doi:10.1016/j.jmpt.2017.02.004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Wolny T, Linek P. Neurodynamic techniques versus “sham” therapy in the treatment of carpal tunnel syndrome: a randomized placebo-controlled trial. Arch Phys Med Rehabil. 2018;99(5):843854. PubMed ID: 29307812 doi:10.1016/j.apmr.2017.12.005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Goyal M, Mehta SK, Rana N, et al. Motor nerve conduction velocity and function in carpal tunnel syndrome following neural mobilization: A randomized clinical trial. Int J Health Allied Sci. 2016;5(2):104. doi:10.4103/2278-344X.180434

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Ballestero-Pérez R, Plaza-Manzano G, Urraca-Gesto A, et al. Effectiveness of nerve gliding exercises on carpal tunnel syndrome: a systematic review. J Manipulative Physiol Ther. 2017;40(1):5059. PubMed ID: 27842937 doi:10.1016/j.jmpt.2016.10.004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Shacklock M. Clinical Neurodynamics: A System of Musculoskeletal Treatment. Philadelphia, PA: Elselvier; 2005.

  • 7.

    Coppieters MW, Butler DS. Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13:213221. PubMed ID: 17398140

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Wolny T, Linek P. Is manual therapy based on neurodynamic techniques effective in the treatment of carpal tunnel syndrome? A randomized controlled trial. Clin Rehabil. 2019;33(3):408417. PubMed ID: 30306805 doi:10.1177/0269215518805213

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2. Oxford Centre for Evidence-Based Medicine. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence

    • Search Google Scholar
    • Export Citation
  • 10.

    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):822. PubMed ID: 19119380 doi:10.1149/106698108790818594

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

The authors are with Moravian College, Methodist University, Bethlehem, PA, USA.

Wise (wises@moravian.edu) is corresponding author.
  • 1.

    Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review of the recent literature. Open Orthop J. 2012;6:6976. PubMed ID: 22470412 doi:10.2174/1874325001206010069

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Wolny T, Saulicz E, Linek P, Shacklock M, Myśliwiec A. Efficacy of manual therapy including neurodynamic techniques for the treatment of carpal tunnel syndrome: a randomized controlled trial. J Manipulative Physiol Ther. 2017;40(4):263272. PubMed ID: 28395984 doi:10.1016/j.jmpt.2017.02.004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Wolny T, Linek P. Neurodynamic techniques versus “sham” therapy in the treatment of carpal tunnel syndrome: a randomized placebo-controlled trial. Arch Phys Med Rehabil. 2018;99(5):843854. PubMed ID: 29307812 doi:10.1016/j.apmr.2017.12.005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Goyal M, Mehta SK, Rana N, et al. Motor nerve conduction velocity and function in carpal tunnel syndrome following neural mobilization: A randomized clinical trial. Int J Health Allied Sci. 2016;5(2):104. doi:10.4103/2278-344X.180434

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Ballestero-Pérez R, Plaza-Manzano G, Urraca-Gesto A, et al. Effectiveness of nerve gliding exercises on carpal tunnel syndrome: a systematic review. J Manipulative Physiol Ther. 2017;40(1):5059. PubMed ID: 27842937 doi:10.1016/j.jmpt.2016.10.004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Shacklock M. Clinical Neurodynamics: A System of Musculoskeletal Treatment. Philadelphia, PA: Elselvier; 2005.

  • 7.

    Coppieters MW, Butler DS. Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13:213221. PubMed ID: 17398140

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Wolny T, Linek P. Is manual therapy based on neurodynamic techniques effective in the treatment of carpal tunnel syndrome? A randomized controlled trial. Clin Rehabil. 2019;33(3):408417. PubMed ID: 30306805 doi:10.1177/0269215518805213

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2. Oxford Centre for Evidence-Based Medicine. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence

    • Search Google Scholar
    • Export Citation
  • 10.

    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):822. PubMed ID: 19119380 doi:10.1149/106698108790818594

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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