Research Review: Neural tissue management in MSK pain

Dr. Shawn Thistle
September 25, 2018
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Research Review: Neural tissue management in MSK pain
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The objective of this systematic review and meta-analysis was to quantify the magnitude of effect of neural tissue management (NTM) on pain and disability in patients with chronic musculoskeletal pain.

Study title: 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
Authors: Su Y & Lim ECW
Publication Information: Clinical Journal of Pain 2016; 32: 991-1004.

Background Information
The objective of this systematic review and meta-analysis was to quantify the magnitude of effect of neural tissue management (NTM) on pain and disability in patients with chronic musculoskeletal pain. The secondary objective of this study was to review treatment parameters (dosage) and investigate if these parameters affect the variability of observed outcomes.

Pertinent results

  • A total of 443 titles and abstracts were screened for eligibility, with 43 potentially relevant articles identified for detailed inspection. After final screening, 20 papers were included in the final analysis.
  • The average PEDro score was 6.15 (range 4-8 out of maximum score of 11), with allocation concealment and blinding of therapists and patients listed as the most commonly missed criteria.
  • Eight trials evaluated neck and arm pain, seven trials evaluated low back and lower limb pain, two evaluated non-radicular low back pain (33, 34), two evaluated carpal tunnel syndrome and one evaluated lateral epicondylalgia.
  • When evaluating pain and disability outcomes, significant results were not found when NTM was compared to other interventions (something other than sham treatment).
  • When compared with minimal intervention (sham NTM or no treatment as controls), neural mobilization provided superior pain relief (pooled standardized mean differences (SMD) = -0.77; 95% confidence interval [CI], -1.11 to -0.42; P < 0.0001), and reduction in disability (pooled SMD = -1.06; 95% CI, -1.97 to -0.14; P = 0.02), after post hoc sensitivity analyses.
  • When evaluating specific treatment parameters, treatments ranged from one to 20 sessions over a period of a single treatment session to an eight-week treatment plan. Multivariable meta-regression did identify duration (in weeks) or number of sessions as independent predictors of variability in effect size of reported pain scores.
Applications, conclusions
While the results of this review did not find significant differences between interventions used in the treatment of nerve-related musculoskeletal pain (NRMP), they may be interpreted to suggest that NTM is at least equivocal to other treatment options, meaning it may be considered an option for this patient population. Although the authors did not specifically comment on safety or adverse events, one included random controlled trial did indicate there was no evidence to suggest that NTM is harmful for patients with NRMP.
Given the heterogeneity of the literature, optimal treatment parameters cannot be determined based on existing evidence. As always, clinicians should be encouraged to outline their intended plan of management with patients and ensure that clinical progress is monitored over the course of treatment.

Study methods
  • Eight databases were searched until January 2015 using appropriate search terms for each database.
  • Two authors reviewed citations for eligibility based on the inclusion criteria.
  • Included studies were randomized, controlled, human trials that included individuals with chronic NRMP and compared treatment (including conservative decompression of nerves, NTM and/or patient education) to other interventions or control, and included outcome measures related to pain and/or disability.
  • Methodological quality was assessed by two reviewers using the 11-item PEDro scale.
  • One reviewer extracted data from low risk of bias studies using a standardized extraction form. When appropriate, means and standard deviations were calculated.
  • Where appropriate, results were pooled after calculating (SMD) for pain and disability scores, along with 95% confidence intervals and tests for heterogeneity.

Additional References

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  34. Nagrale AV, Patil SP, Gandhi RA, et al. Effect of slump stretching versus lumbar mobilization with exercise in subjects with non-radicular low back pain: a randomized clinical trial. J Man Manip Ther 2012; 20: 35–42.
  35. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996; 68: 69–74.
  36. De Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 2009; 55: 129–133.

Dr. Shawn Thistle is a practicing chiropractor, educator, international speaker, knowledge-transfer leader, evidence-based health care advocate, entrepreneur & medicolegal consultant. He founded RRS Education in 2006 and currently acts as the company’s CEO. RRS Education helps chiropractors and other manual medicine clinicians around the world integrate research in to patient care via weekly Research Reviews, Online Courses and Seminars.  For more information, visit: www.rrseducation.com.

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