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Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review

Published:November 11, 2016DOI:https://doi.org/10.1016/j.jmpt.2016.10.004

      Abstract

      Objective

      The objective of this study was to review the literature regarding the effectiveness of neural gliding exercises for the management of carpal tunnel syndrome (CTS).

      Methods

      A computer-based search was completed through May 2014 in PubMed, Physiotherapy Evidence Database (PEDro), Web of Knowledge, Cochrane Plus, and CINAHL. The following key words were included: nerve tissue, gliding, exercises, carpal tunnel syndrome, neural mobilization, and neurodynamic mobilization. Thirteen clinical trials met the inclusion/exclusion criteria, which were: nerve gliding exercise management of participants aged 18 years or older; clinical or electrophysiological diagnostics of CTS; no prior surgical treatment; and absence of systemic diseases, degenerative joint diseases, musculoskeletal affectations in upper limbs or spine, or pregnancy. All studies were independently appraised using the PEDro scale.

      Results

      The majority of studies reported improvements in pain, pressure pain threshold, and function of CTS patients after nerve gliding, combined or not with additional therapies. When comparing nerve gliding with other therapies, 2 studies reported better results from standard care and 1 from use of a wrist splint, whereas 3 studies reported greater and earlier pain relief and function after nerve gliding in comparison with conservative techniques, such as ultrasound and wrist splint. However, 6 of the 13 studies had a quality of 5 of 11 or less according to the PEDro scale.

      Conclusion

      Limited evidence is available on the effectiveness of neural gliding. Standard conservative care seems to be the most appropriate option for pain relief, although neural gliding might be a complementary option to accelerate recovery of function. More high-quality research is still necessary to determine its effectiveness and the subgroups of patients who may respond better to this treatment.

      Key Indexing Terms

      Introduction

      Carpal tunnel syndrome (CTS) is the result of an irritation, compression, or stretching of the median nerve as it passes through the carpal tunnel in the wrist. Symptoms range from pain (mainly nightly)
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      Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome.
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      This syndrome represents the most prevalent neural injury in the general population (1-4%)
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      Reduced longitudinal excursion of the median nerve in carpal tunnel syndrome.
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      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      (those requiring repetitive movements of the wrist and fingers such as typing, nursing, and cleaning), whose tendency to become chronic patients has an economic impact because of work absences and surgical treatments required to improve the condition.
      • Ortega-Santiago R.
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      • Fernández-de-las-Peñas C.
      Tratamiento fisioterápico basado en la neuromodulación de la sensibilización central en el síndrome del túnel del carpo, a propósito del un caso.
      The initial phases of the conservative treatment methods require corrective splints in the wrist while neutral or in an extension position, electrotherapy with ultrasound or laser, or manual therapy and exercises.
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      • Verdugo R.J.
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      • Cea J.G.
      Surgical versus non-surgical treatment for carpal tunnel syndrome.
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      Effects of iontophoresis current magnitude and duration on dexamethasone deposition and localized drug retention.
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      Management of carpal tunnel syndrome.
      At severe stages, authors recommend surgical procedures.
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      • Castillo J.
      • Cea J.G.
      Surgical versus non-surgical treatment for carpal tunnel syndrome.
      However, the unclear etiology and the frequent chronicity of CTS make its clinical approach controversial.
      Recently, several studies reported optimum results with the use of neurodynamic mobilization as a conservative treatment, with neural slipping helping nerve mobilization in relation to musculoskeletal tissues.
      • Muller M.
      • Tsui D.
      • Schnurr R.
      • Biddulph-Deisroth L.
      • Hard J.
      • MacDermid J.C.
      Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review.
      • Duymaz T.
      • Sindel D.
      • Kesiktaş N.
      • Müslümanoğlu L.
      Efficacy of some combined conservative methods in the treatment of carpal tunnel syndrome: a randomized controlled clinical and electrophysiological trial.
      The biomechanical effect of the treatment would restore neural mobilization by decreasing the edema and adhesion in the carpal tunnel.
      • Ortega-Santiago R.
      • de-la-Llave-Rincón A.I.
      • Ambite-Quesada S.
      • Fernández-de-las-Peñas C.
      Tratamiento fisioterápico basado en la neuromodulación de la sensibilización central en el síndrome del túnel del carpo, a propósito del un caso.
      • Oh J.
      • Zhao C.
      • Zobitz M.E.
      • Wold L.E.
      • An K.N.
      • Amadio P.C.
      Morphological changes of collagen fibrils in the subsynovial connective tissue in carpal tunnel syndrome.
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      Because of the chronicity of CTS, studies also described neuromodulator effects from neural mobilization techniques such as the decrease in nociception of the median nerve; reduction in algogenic and pro-inflammatory substances
      • Butler D.S.
      Movilización del Sistema Nervioso.
      ; and reversibility in the pain pathways previously modified. Consequently, peripheral and central sensitization may decrease and descending pain modulation might occur.
      • Souvlis T.
      • Vicenzino B.
      • Wright A.
      Neurophysiological effect of spinal manual therapy [Internet].
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      To our knowledge, however, the clinical effectiveness of the neurodynamic approach remains unclear because very few studies to date have analyzed this approach to the treatment of CTS.
      • Oh J.
      • Zhao C.
      • Zobitz M.E.
      • Wold L.E.
      • An K.N.
      • Amadio P.C.
      Morphological changes of collagen fibrils in the subsynovial connective tissue in carpal tunnel syndrome.
      The aim of the present study was to review clinical trials regarding the effectiveness of neurodynamic mobilization of the median nerve in patients with CTS.

      Methods

      Our systematic review was guided by the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      The research strategy included all clinical trials regarding the neurodynamic treatment of CTS. The following criteria were included: articles on participants aged ≥18 years with a clinical or electrophysiological diagnosis of CTS; and articles on neurodynamic mobilization as a conservative method for CTS treatment. Excluded from this review were articles on participants with systematic diseases, degenerative joint diseases, musculoskeletal affectations of the upper limbs or spine, or pregnancy; and articles on surgery as a treatment method for CTS.
      In the computer-based search, authors considered MEDLINE, Physiotherapy Evidence Database (PEDro), Web of Knowledge, Cochrane Plus and CINAHL, up to May 2014. The following key words were employed: nerve tissue [MeSH], gliding, exercises, carpal tunnel syndrome [MeSH], neural mobilization, and neurodynamic mobilization. These terms were combined with the Boolean operator AND. We limited the search strategy to studies in English, Spanish, French, and Portuguese. We did not consider any limit in the publication date.
      The PEDro scale was employed to measure the methodologic quality of the articles (Table 1). The validity of this scale was reported in previous studies.
      • Maher C.G.
      • Sherrington C.
      • Herbert R.D.
      • Moseley A.M.
      • Elkins M.
      Reliability of the PEDro scale for rating quality of randomized controlled trials.
      A score of 5 points represents high quality; a score between 4 and 5 points, moderate quality; and scores lower than 4 points, low quality.
      • Maher C.G.
      • Sherrington C.
      • Herbert R.D.
      • Moseley A.M.
      • Elkins M.
      Reliability of the PEDro scale for rating quality of randomized controlled trials.
      Table 1Methodological Quality of Studies Included According to PEDro Scale
      Publication1234567891011Total
      De-la-Llave-Rincón et al., 2012
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      5/11
      Horng et al., 2011
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      7/11
      Fernández-de-las-Peñas et al, 2010
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      4/11
      Bardak et al, 2009
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.
      8/11
      Bialosky et al, 2009
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      9/11
      Heebner and Roddey, 2008
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      8/11
      Brininger et al, 2007
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      6/11
      Baysal et al, 2006
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      7/11
      Pinar et al, 2005
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      5/11
      Akalin et al, 2002
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      6/11
      Seradge et al, 2002
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      4/11
      Tal-Akabi and Rushton, 2000
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      5/11
      Rozmaryn et al, 1998
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      4/11
      ✓, no; ✗, yes; 1, eligibility criteria were specified; 2, subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated in order in which treatments were received); 3, allocation was concealed; 4, groups were similar at baseline with respect to most important prognostic indicators; 5, there was blinding of all subjects; 6, there was blinding of all therapists who administered the therapy; 7, there was blinding of all assessors who measured at least one key outcome; 8, measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups; 9, all subjects for whom outcome measures were available received the treatment or control condition as allocated, or, where this was not the case, data for at least one key outcome were analyzed by “intention to treat”; 10, results of between-group statistical comparisons are reported for at least one key outcome; 11, study provides both point measures and measures of variability for at least one key outcome.

      Results

      The research strategy initially produced 118 articles. After analysis, 13 clinical trials were considered according to the inclusion criteria (Fig 1). The characteristics of all the studies selected are summarized in Table 2.
      Table 2Main Aspects of Studies Considered
      AuthorsDesignInterventionCharacteristic of SampleVariablesResultsQuality (PEDro)
      De-la-Llave-Rincón et al, 2012
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      RCT

      Prospective
      1 session (30 min) of soft tissue mobilization and nerve slider neurodynamic exercisesN = 18 (34 hands)

      Gender: women

      Age: 44 ± 10 y

      Patients grouped according to severity of symptoms in CTSQ:

      mild, moderate, and severe
      Pain (NPRS)

      PPT over median, radial, and ulnar nerves; C5-6 zygapophyseal joint; carpal tunnel; and tibialis anterior muscle



      Baseline, after treatment and 1-wk follow-up
      Patients had less hand pain and higher PPT over C6 Zygapophyseal joint after 1 wk (P < .01 and P < .001, respectively)

      Any other difference on PPT was found (P > .05)
      5/11
      Horng et al, 2011
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      RCT

      Single blind
      8 wk of paraffin, splinting, and tendon and nerve gliding exercisesN = 53

      Gender: 3 men; 50 women

      Age: 51.1 ± 9.1 y

      Group 1: splint, paraffin, and tendon gliding exercises

      Group 2: splint, paraffin, and nerve gliding exercises

      Group 3: splint and paraffin
      Pain (BCTSQ)

      Function (DASHQ)

      Life quality (WHOQOL-BREF)

      Nerve conduction (NCS)

      Semmes-Weinstein monofilament test

      Grasp power test

      Pinch power test
      All patients improved symptom severity and pain, but group 1 improved more in DASHQ and WHOQOL-BREF7/11
      Fernández-de-las-Peñas et al, 2010
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      RCT

      Prospective

      Single blind
      1 session (30 min) of soft tissue mobilization and nerve slider neurodynamic exercisesN=72

      Gender: women

      Age: 44.7 ± 8.7 y

      Patients grouped according to severity of symptoms in CTSQ:

      mild, moderate, and severe
      Thermal detection and pain threshold (NPRS)

      PPT over median, radial, and ulnar nerves; C5-6

      Pain (NPRS)

      Function (BCTQ: Functional Status and Symptom Severity scales)

      Quality life (SF36)

      Baseline, after treatment
      48% of patients improved PPT and function over C6 zygapophyseal joint, heat pain threshold, and quality life

      93.3% improved taking into account only two of these three parameters
      4/11
      Bardak et al, 2009
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.
      RCT

      Prospective

      Single blind
      6 wk of SCT vs. tendon and nerve gliding exercisesN = 111

      Gender nonspecified

      Age: not specified

      Intervention group 1 (n = 41): CTS

      Intervention group 2 (n = 35): CTS + tendon and nerve gliding exercises

      Intervention group 3 (n = 35): tendon and nerve gliding exercises
      Symptoms total point score

      Functional status

      Tinel test

      Phalen test

      Reverse Phalen test

      Compression test

      Patients satisfaction 11 months later
      All patients improved symptoms and functionality, but groups 1 and 2 had greater results than group 3 (P < .001)

      Percentage of asymptomatic patients from groups 1 and 2 were higher than group 3 (P < .02 and P < .04, respectively)
      8/11
      Bialosky et al, 2009
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      RCT

      Single blind
      3 wk of nerve gliding exercises, stressing nerveN = 40

      Gender: women

      Age: 18-70

      Intervention group (n = 20): mobilization stressing median nerve

      Control group (n = 20): mobilization minimizing stress to the median nerve
      Pain (MVAS)

      PPT

      Thermal pain: threshold and temporal summation

      Function (DASHQ)

      Grip strength

      Semmes-Weinstein monofilament test

      Nerve conduction (NCS)
      All patients improved pain and function at 3 wk, but only intervention group improved temporal summation (P < .01)9/11
      Heebner and Roddey 2008
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      RCTTendon and nerve gliding exerciseN = 60 (76 hands)

      Gender: 9 men, 51 women

      Age average: 52 y

      Group I (n = 28): standard care

      Group II (n = 32): standard care and tendon and nerve gliding
      Function (DASHQ)

      CTSQ

      Nerve irritability (NIMN)



      Baseline and 1 and 6 mo
      Group 1 had higher CTSQ score at 6 mo (P = .016)

      Any between-group difference was found in the rest of variables
      8/11
      Brininger et al, 2007
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      RCT4 wk of neutral wrist and metacarpo-phalangeal splint, wrist cocked up, and tendon and nerve gliding exercisesN = 51

      Gender: not specified

      Age non-specified

      Intervention group 1 (n = 14): neutral wrist and metacarpophalangeal splint

      Intervention group 2 (n = 13): neutral wrist and metacarpophalangeal splint + tendon and nerve gliding exercises

      Intervention group 3 (n = 11): wrist cocked-up

      Intervention group 4 (n = 13) wrist cocked-up + tendon and nerve gliding exercises
      Symptom Severity scale

      Functional Status scale



      Baseline, at 4 weeks and 8 weeks later
      All patients improved symptoms and functional status, but those wearing neutral wrist and metacarpophalangeal splint had greater results (independently if they performed tendon and neural gliding)

      Improvements remained 8 weeks later
      6/11
      Baysal et al, 2006
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      RCT

      Prospective

      Double blind
      3 wk of ultrasound, splinting, and tendon and nerve gliding exercisesN = 28 (56 hands)

      Gender: women

      Age: 49.8 ± 6.0 y

      Group 1 (n = 12): splinting and tendon and nerve gliding exercises

      Group 2 (n = 8): splinting and ultrasound

      Group 3 (n = 8): splinting, tendon and nerve gliding, and ultrasound



      Most of patients were homemakers
      Pain (VAS)

      Static 2-point discrimination

      Grip strength

      Pinch strength

      Phalen test

      Tinel test

      Symptom Severity scale

      Functional Status scale

      Electroneurography: MDL, SDL

      Patients satisfaction 11 months later



      Baseline and 4 and 8 wk later
      All patients improved physical examination at 4 and 8 wk and Symptom Severity scale (P < .05), but 2-point discrimination (P > .05)

      Group III had better results on functional status

      Group I decreased SDL at 4 and 8 wk

      No group improved MDL at 8 wk
      7/11
      Pinar et al, 2005
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      RCT6 wk of volar wrist splint, conservative method, and an additional 4 wk of nerve gliding exercisesN = 26 (35 hands)

      Gender: not specified

      Age: not specified

      Control group (n =13): wrist splint and conservative method

      Intervention group (n = 13): wrist splint, conservative method, and nerve gliding exercises
      Pain (VAS)

      Muscle strength

      Grip strength (Tinel test) Pinch strength (Phalen test)

      Electrophysiological measurements
      All patients improved pain, although intervention group had more rapid pain reduction and greater functional improvements, especially grip strength (P < .05)5/11
      Akalin et al, 2002
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      RCT prospective

      Pre-post treatment
      4 weeks of volar neutral wrist splint and neural and tendon gliding exercisesN = 28 (36 hands)

      Gender: not specified

      Age: not specified

      Control group (n = 14): neutral wrist splint during night and functional task

      Intervention group (n = 14): neutral wrist splint during night and functional task + neural and tendon gliding exercises
      Clinical parameters

      Functional status scale

      Fischer test

      Symptoms severity scale

      Patient satisfaction after 8 wk
      All patients improved, but intervention group had higher lateral pinch strength value (P = .026)

      72% of patients from control group and 93% from intervention group had excellent results
      6/11
      Seradge et al, 2002
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      CT

      Prospective
      SCT and carpal tunnel decompression exercisesN = 28 (33 hands)

      Gender: not specified

      Age: not specified

      Patients grouped according to severity of symptoms in CTSQ:

      mild, moderate, and severe
      Functional Status scale

      Symptoms Severity scale



      At 1 wk, 2 wk, and 1 mo from beginning of treatment
      80% and 71% of patients with mild and moderate symptoms, respectively, improved

      All patients with severe symptoms underwent surgery
      4/11
      Tal-Akabi and Rushton, 2000
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      RCTNeurodynamic mobilization vs carpal bone mobilizationN = 21 (30 hands)

      Gender: 14 women, 7 men

      Age: 29-85

      Intervention group 1 (n = 7): neurodynamic mobilization

      Intervention group 2 (n = 7): carpal bone mobilization

      Control group (n = 7): no treatment
      24-h symptom diary

      Pain (VAS)

      Functional box scale

      Pain relief scale

      Active ROM (wrist flexion and extension)

      Median nerve biased test

      Patients to surgery
      Both treatment groups improved pain (P < .02 and P < .01)

      Any difference was found on functional box scale, pain relief scale, and median nerve test

      Patients to surgery: 2 from intervention 1; 1 from intervention 2; 6 from control group
      5/11
      Rozmaryn et al, 1998
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      CT

      Retrospective
      Standard conservative methods and nerve and tendon gliding exercisesN = 197 (240 hands)

      Gender: not specified

      Age: not specified

      Control group (n = 124): standard conservative method

      Intervention group (n = 116): standard conservative method + neural and tendon gliding exercises

      Groups incomparable in baseline: more manual jobs (control), more administrative jobs (intervention)
      Undergo surgery

      Interview about symptoms to intervention group who did not undergo surgery after 23 mo
      Patients underwent surgery: 71.2% of control group; 43.0% of intervention group

      Of patients responding to detailed interview after 23 mo, 70.2% had excellent results; 19.2% remained symptomatic; 10.6% were noncompliant
      4/11
      BCTSQ, Boston Carpal Tunnel Specific Questionnaire (the same as CTSQ); CT, clinical trial; CTS, carpal tunnel syndrome; CTSQ, Carpal Tunnel Specific Questionnaire; DASHQ, Disabilities of the Arm, Shoulder, and Hand Questionnaire; MDL, motor distance latency; MVAS, mechanical visual analog scale; NCS, nerve conduction study; NIMN, neurodynamic irritability of median nerve; NPRS, Numerical Pain Rating Scale; PCOQ, Patient-Centered Outcome Questionnaire; PPT, pressure pain threshold; RCT, randomized clinical trial; ROM, range of motion; SCT, standard conservative treatment (splinting and local steroid injections); SDL, sensitive distance latency; Standard care, patient education, splinting, and tendon gliding; WHOQOL-BREF, The World Health Organization Quality of Life Questionnaire Brief; VAS, visual analog scale.
      According to the evaluation of the quality of the studies selected, the PEDro scale indicated that all of the articles had study limitations. Almost half of the studies scored a 4 or 5 out of 11, and only 2 studies had a 9 of 11. No studies satisfied 100% of the questions of PEDro scale (Table 1).

      Participants

      The number of participants varied from 18 to 197. Among the articles that provided the gender of the participants, 4 involved only women
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      and 3 involved women and men
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      ; the remaining studies did not specify gender. Five articles assessed middle-aged adults (30-59),
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      2 articles involved mixed-age groups of participants (aged 18–80),
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      and 6 articles did not specify the age range.

      Study Procedure

      Almost all of the studies applied neural mobilization by nerve gliding, and 1 study compared neural mobilization with increasing stress on the nerve to neural mobilization with decreasing stress on the nerve.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      Eight articles compared nerve gliding with standard care consisting of volar wrist splint and medication
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.
      ; 2 articles compared nerve gliding with carpal or tendon mobilization
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      ; 1 article compared nerve gliding with ultrasound therapy
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      ; and 3 articles did not compare the nerve gliding method with any additional intervention.
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      With respect to methods assessing pain and function, the studies exhibited high variability. Two studies assessed the level of pain with the numerical pain rating scale
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      ; 4 studies used a visual analog scale
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      ; and 1 study used the pain relief scale.
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      For function, 3 studies used the Disabilities of the Arm, Shoulder, and Hand Questionnaire
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      ; 6 studies employed the Functional Status scale
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.
      ; and 1 study used the Functional Status box.
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      Four articles also considered pinch and grip strength as a functional parameter.
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      Other studies assessed pain and function at the same time with the Symptom Severity Scale,
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      24-hour symptom diary,
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      Carpal Tunnel Specific Questionnaire,
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      or Symptom Total Point Score.
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.

      Pain and Pressure Pain Threshold

      All articles that compared nerve gliding with standard care, such as splint or tendon/carpal mobilization, reported that all participants improved independently of nerve gliding application; in fact, 2 studies reported better results from standard care without nerve gliding,
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.
      and only 1 reported earlier pain relief in the nerve gliding group.
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      All studies that analyzed nerve gliding as a unique treatment reported significant pain relief in all patients.
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.

      Function

      From investigations that compared nerve gliding with standard care, 4 studies reported better scores of function after standard care without nerve gliding exercises
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.
      or the same results independently of the nerve gliding application,
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      and 3 studies reported better function status in those participants receiving nerve gliding.
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      Studies that analyzed the nerve gliding exercises as an isolated treatment reported that between 71% and 93% of patients improved function.
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.

      Additional Outcomes

      Two articles analyzed the percentage of CTS patients who underwent surgery as a main outcome of effectiveness of the nerve gliding exercises.
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      Both studies reported that almost all the participants receiving nerve gliding avoided the surgical intervention.

      Discussion

      The main findings in this systematic review refer to positive effects from median nerve mobilization. However, some studies reported similar effects of this neural technique compared with other conservative methods for treatment of CTS, and even better results from standard care. However, the low-quality methodology of some studies might have influenced the results.
      Studies including neural mobilization as a clinical approach to CTS treatment reported greater and faster pain relief, decreased sensitive distal latency, time summation, and improvement of functions such as pinch grip, which avoided surgical intervention in the majority of cases.
      • Ortega-Santiago R.
      • de-la-Llave-Rincón A.I.
      • Ambite-Quesada S.
      • Fernández-de-las-Peñas C.
      Tratamiento fisioterápico basado en la neuromodulación de la sensibilización central en el síndrome del túnel del carpo, a propósito del un caso.
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      Fernandez-de-las-Peñas et al.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      and Ortega-Santiago et al.
      • Ortega-Santiago R.
      • de-la-Llave-Rincón A.I.
      • Ambite-Quesada S.
      • Fernández-de-las-Peñas C.
      Tratamiento fisioterápico basado en la neuromodulación de la sensibilización central en el síndrome del túnel del carpo, a propósito del un caso.
      reported greater pain relief in patients undergoing neural mobilization. However, the lack of a control group and the study of only one case, respectively, weakened the scientific evidence of these results. Other authors reported pain improvement only for patients performing neural mobilization
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      and decreased numbers of patients undergoing surgical treatments in all patients receiving any mobilization (neural and carpal).
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      The reduced sample may explain the lack of differences among the remaining variables.
      • Tal-Akabi A.
      • Rushton A.
      An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.
      Pinar et al.,
      • Pinar L.
      • Enhos A.
      • Ada S.
      • Gungor N.
      Can we use nerve gliding exercises in women with carpal tunnel syndrome?.
      Akalin et al.,
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      and Baysal et al.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      reported improved grip and pinch strength after tendon and nerve gliding. Because of the functional tasks the tests involve, these authors obtained higher Functional Status scores, although the treatment was combined with splinting.
      • Akalin E.
      • El O.
      • Peker O.
      • et al.
      Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
      Also, Baysal et al. assessed the group electroneurographically, finding improved sensitive distal latency that remained 4 to 8 weeks after treatment in patients performing nerve and tendon gliding exercises.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      This finding represents the most objective measure supporting the beneficial effects of the neurodynamic approach. Supporting this finding, Park et al. reported a terminal latency index difference between median and ulnar nerves as a factor assessing the severity of CTS.
      • Park K.M.
      • Shin K.J.
      • Park J.
      • Ha S.Y.
      • Kim S.E.
      The usefulness of terminal latency index of median nerve and f-wave difference between median and ulnar nerves in assessing the severity of carpal tunnel syndrome.
      Thus, the improvement of this variable may directly decrease the severity status of CTS patients. However, the small sample size of the Baysal et al. study and the lack of methodologic quality in other similar studies make a solid conclusion difficult.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      Therefore, although neural mobilization may represent a good option as an additional conservative method in CTS patients, it should be considered with caution.
      With respect to patients that undergo surgical treatments, studies found a significant decrease in symptoms after tendon and nerve gliding exercises.
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      However, the lack of randomization and of a control group prevents this study from strongly concluding this as a clinical approach.
      • Rozmaryn L.M.
      • Dovelle S.
      • Rothman E.R.
      • Gorman K.
      • Olvey K.M.
      • Bartko J.J.
      Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.
      In contrast, some studies comparing nerve gliding exercises with other conservative methods reported similar results without any differences with the neural approach. Brininger et al.
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      found similar function status and pain levels in all patients wearing a specific wrist splint with and without nerve gliding exercises.
      • Brininger T.L.
      • Rogers J.C.
      • Holm M.B.
      • Baker N.A.
      • Li Z.M.
      • Goitz R.J.
      Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
      However, the main limitation concerned the severity of symptoms in patients, which might make for a more difficult resolution of CTS: several authors consider severe symptomatology a factor limiting the benefit from conservative methods in CTS.
      • Verdugo R.J.
      • Salinas R.S.
      • Castillo J.
      • Cea J.G.
      Surgical versus non-surgical treatment for carpal tunnel syndrome.
      Bardak et al. also obtained similar results for those patients undergoing standard conservative treatments with and without nerve gliding, and these results were superior to those obtained after treatments in which nerve gliding exercises were isolated.
      • Bardak A.N.
      • Alp M.
      • Erhan B.
      • Paker N.
      • Kaya B.
      • Onal A.E.
      Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome.
      Other studies support this finding because they report better results for patients without nerve gliding, with which most of the studies today disagree.
      • Heebner M.L.
      • Roddey T.S.
      The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      Although Bialosky et al. obtained similar results when comparing sham and nerve gliding, they reported improvement in time summation only after nerve gliding exercises.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      Because time summation is mediated by type C fibers, which involve chronic pain progression and maintenance, this finding could lead to an effective intervention to decrease the excitability of dorsal horn cells.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      The controversy over neural mobilization as a conservative method in the treatment of CTS responds to different parameters added during the neural techniques: most studies used neural mobilization exercises that progressively stretch the nerve context,
      • Totten P.A.
      • Hunter J.M.
      Therapeutic techniques to enhance nerve gliding in thoracic outlet syndrome and carpal tunnel syndrome.
      without considering that the previous position of closer joints and the nervous system continuity may add tension to the technique. Authors related the increased tension because of a wrist extension with negative effects after neural mobilization
      • Wright T.W.
      • Glowczewskie F.
      • Wheeler D.
      • Miller G.
      • Cowin D.
      Excursion and strain of the median nerve.
      : the increased neural stress caused by stretching of its context along with a high mechanosensitivity may produce ectopic discharges.
      • Dilley A.
      • Lynn B.
      • Pang S.J.
      Pressure and stretch mechanosensitivity of peripheral nerve fibres following local inflammation of the nerve trunk.
      Thus, authors using neural mobilization should avoid stretching the median nerve excessively when extending fingers in wrist extension. Some authors recommend alternate extension and flexion for the wrist with flexion and extension of the fingers, respectively, to minimize median nerve tension during exercising.
      • Coppieters M.W.
      • Alshami A.M.
      Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome.
      Several studies forgot to control the nerve gliding, including stress to the median nerve when it is advised against.
      • Seradge H.
      • Parker W.
      • Baer C.
      • Mayfield K.
      • Schall L.
      Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      As no studies to date have considered this difference as a possible mechanism producing different effects, we found motley results from neural mobilization in CTS symptoms.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      Also, the participants in studies regarding CTS had heterogeneous anthropometric and social characteristics, such as female gender only, that make the comparison and extrapolation of results difficult.
      • De-la-Llave-Rincon A.I.
      • Ortega-Santiago R.
      • Ambite-Quesada S.
      • et al.
      Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome.
      • Bialosky J.E.
      • Bishop M.D.
      • Price D.D.
      • Robinson M.E.
      • Vincent K.R.
      • George S.Z.
      A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome.
      • Baysal O.
      • Altay Z.
      • Ozcan C.
      • Ertem K.
      • Yologlu S.
      • Kayhan A.
      Comparison of three conservative treatment protocols in carpal tunnel syndrome.
      • Horng Y.S.
      • Hsieh S.F.
      • Tu Y.K.
      • Lin M.C.
      • Wang J.D.
      The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial.
      Despite the controversy, Totten et al. identified factors limiting the conservative method as a beneficial clinical approach: age ≥50 years, symptom duration >10 months, positive Phalen test <30 seconds, continuous paresthesia, and tenosynovitis in flexor muscles.
      • Totten P.A.
      • Hunter J.M.
      Therapeutic techniques to enhance nerve gliding in thoracic outlet syndrome and carpal tunnel syndrome.
      In fact, Vysata et al. reported that as CTS patients age, a longer time for recovery of distal motor latency is required, even after surgery.
      • Vysata O.
      • Prochazka A.
      • Kunc P.
      • et al.
      Age delays the recovery of distal motor latency after carpal tunnel syndrome surgery.
      Fernandez-de-las-Peñas et al. also considered factors determining earlier clinical improvement: pain pressure threshold over the C5–6 zygapophyseal <137 K Pa, heat pressure pain over the carpal tunnel <39.6°, and general health <66 points on the 36-item Short Form Health Survey (SF-36).
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      This finding could relate the peripheral sensitization to beneficial effects of treatments in CTS patients, instead of central sensitization.
      • Fernandez-de-Las-Penas C.
      • Cleland J.A.
      • Ortega-Santiago R.
      • de-la-Llave-Rincon A.I.
      • Martinez-Perez A.
      • Pareja J.A.
      Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.
      In future research, authors should distinguish neural mobilization with the glissade or tension parameter to analyze the effects of both neural techniques separately, as well as include patients with homogeneous anthropometric and social characteristics.
      Another important question arising from this systematic review is the low quality of the literature addressing the conservative management of CTS patients. According to the PEDro scale, 6 of the 13 studies selected in this review had 4 of 5 of the 11 items possible, and no studies satisfied the highest quality (11 items). The highest score among the studies was 9 of 11 possible. The main aspects missing referred to blinding during treatment, concealed allocation, and comparison with a control intervention. Future studies should consider these aspects to improve the quality of the studies and the subsequent results.
      Despite the controversial results for nerve gliding exercises and the lack of high-quality studies, standard conservative methods had beneficial effects in CTS patients. Thus, nerve gliding exercises might be a therapy to consider as an addition to a standard conservative approach.

      Limitations

      This study had some limitations. Because of the strict inclusion criteria, some studies might have been excluded. However, we preferred to guarantee the existence of CTS pathology by including its electrophysiological diagnosis. Also, because we considered only those studies in English, Spanish, French, and Portuguese, studies in other languages were not included.

      Conclusion

      Neural mobilization effects remain unclear because of the glissade or tension parameter added during mobilization. Mechanical effects may differ because of the incomparability of the 2 types of mobilization. Standard conservative care seems to be the most appropriate option to improve the pain and function of individuals with CTS patients, but addition of nerve gliding exercises may improve this recovery by accelerating the rehabilitation process and avoiding the surgical intervention.

      Funding Sources and Conflicts of Interest

      No funding sources or conflicts of interest were reported for this study.

      Contributorship Information

      • Concept development (provided idea for the research): A.U.G., R.B.P., M.A.A.A.
      • Design (planned the methods to generate the results): A.U.G., R.B.P., F.R.R.
      • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): N.R.F., G.P.M., A.U.G.
      • Data collection/processing (responsible for experiments, patient management, organization, or reporting data): N.R.F., R.B.P., F.R.R.
      • Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): G.P.M., D.P.M., T.G.I.
      • Literature search (performed the literature search): N.R.F., R.B.P., F.R.R.
      • Writing (responsible for writing a substantive part of the manuscript): N.R.F., M.A.A.A.
      • Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): G.P.M., D.P.M., T.G.I.

        Practical Applications

        • Standard conservative methods such as corrective splinting showed beneficial effects in CTS patients.
        • Neural mobilization may improve pain and function in CTS patients as therapy to add to the conservative approach.
        • Age, symptom duration and intensity concern parameters that may limit the effectiveness of conservative methods in CTS patients.

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