THE BACK PAGE RESEARCH REVIEW Neural tissue management in MSK pain REVIEWED BY SHAWN THISTLE 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 mus-culoskeletal pain. The secondary objec-tive of this study was to review treat-ment parameters (dosage) and investigate if these parameters affect the variability of observed outcomes. • 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 syn-drome 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). Pertinent results • When compared with minimal inter-vention (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. Given the heterogeneity of the liter-ature, optimal treatment parameters cannot be determined based on exist-ing evidence. As always, clinicians should be encouraged to outline their intended plan of management with patients and ensure that clinical pro-gress is monitored over the course of treatment. • 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 in-cluded individuals with chronic NRMP and compared treatment (including conservative decompres-sion of nerves, NTM and/or patient education) to other interventions or control, and included outcome measures related to pain and/or dis-ability. • 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 stand-ardized extraction form. When ap-propriate, means and standard devi-ations were calculated. • Where appropriate, results were pooled after calculating (SMD) for pain and disability scores, along with 95% confidence intervals and tests for heterogeneity. Study methods 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 au-thors 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. SHAWN THISTLE, BKIN (HONS), DC, CSCS, practises full time in Toronto. He is the founder and president of Research Review Service Inc., an online, subscription-based service designed to help busy practitioners integrate current, relevant, scientific evidence into their practice (www.researchreviewservice.com). 26 Canadian Chiropractor October 2018 Visit canadianchiropractor.ca/ research to read the full review with references. www.canadianchiropractor.ca
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