Objectives Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive nonpharmacological treatments for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment. Data sources Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews) through November 2017, reference lists, and ClinicalTrials.gov . Review methods Using predefined criteria, we selected randomized controlled trials of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to Results Two hundred eighteen publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain : At short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: low), and psychological therapies (SOE: moderate). Improvements in pain continued into intermediate term for exercise, massage, and yoga (moderate effect, SOE: low); mindfulness-based stress reduction (small effect, SOE: low); spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than non–high-intensity programs. Chronic neck pain : At short and intermediate terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: low), but no improvement in pain was seen at any time (SOE: llow). Short-term low-level laser therapy was associated with moderate improvement in function and pain (SOE: moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long term (SOE: low). Osteoarthritis : For knee osteoarthritis, exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (SOE: moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (SOE: low). Exercise was also associated with moderate improvement in pain (SOE: low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: low). Evidence was sparse on interventions for hip and hand osteoarthritis. Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: low). The effect on function was sustained intermediate term (SOE: low). Fibromyalgia : In the short term, acupuncture (SOE: moderate), CBT, tai chi, qigong, and exercise (SOE: low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (SOE: moderate) and CBT improved pain slightly, and tai chi and qigong (SOE: low) improved pain moderately in the short term. At intermediate term for exercise (SOE: moderate), acupuncture, and CBT (SOE: low), slight functional improvements persisted; they were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (SOE: low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: low for all); massage (SOE: low) improved long-term pain slightly, but no clear impact on pain for exercise (SOE: moderate) or multidisciplinary rehabilitation (SOE: low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache : Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short term versus usual care, and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE: low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited. Conclusions Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.

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Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Study Design Systematic review with meta-analysis. Objectives To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component. Background Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown. Methods A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-analysis, with pain, disability, and function as the primary outcomes. Results Forty studies were included in this review, of which 17 had a low risk of bias. Meta-analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0-50]: mean difference, -9.26; 95% confidence interval [CI]: -14.50, -4.01; P .11) but showed some positive neurophysiological effects (eg, reduced intraneural edema). Due to a scarcity of studies or conflicting results, the effect of NM remains uncertain for various conditions, such as postoperative low back pain, cubital tunnel syndrome, and lateral epicondylalgia. Conclusion This review reveals benefits of NM for back and neck pain, but the effect of NM on other conditions remains unclear. Due to the limited evidence and varying methodological quality, conclusions may change over time. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(9):593-615. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7117.

The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis

The term “self-myofascial release” is ubiquitous in the rehabilitation and training literature and purports that the use of foam rollers and other similar devices release myofascial constrictions accumulated from scar tissue, ischaemia-induced muscle spasms and other pathologies. Myofascial tone can be modulated with rollers by changes in thixotropic properties, blood flow, and fascial hydration affecting tissue stiffness. While rollers are commonly used as a treatment for myofascial trigger points, the identification of trigger points is reported to not be highly reliable. Rolling mechanisms underlying their effect on pain suppression are not well elucidated. Other rolling-induced mechanisms to increase range of motion or reduce pain include the activation of cutaneous and fascial mechanoreceptors and interstitial type III and IV afferents that modulate sympathetic/parasympathetic activation as well as the activation of global pain modulatory systems and reflex-induced reductions in muscle and myofascial tone. This review submits that there is insufficient evidence to support that the primary mechanisms underlying rolling and other similar devices are the release of myofascial restrictions and thus the term “self-myofascial release” devices is misleading.

Do Self-Myofascial Release Devices Release Myofascia? Rolling Mechanisms: A Narrative Review.

Background Neural mobilization (NM) is widely used to assess and treat several neuromuscular disorders. However, information regarding the NM effects targeting the lower body quadrant is scarce. Objectives To determine the effects of NM techniques targeting the lower body quadrant in healthy and low back pain (LBP) populations. Design Systematic review with meta-analysis. Method Randomized controlled trials were included if any form of NM was applied to the lower body quadrant. Pain, disability, and lower limb flexibility were the main outcomes. PEDro scale was used to assess methodological quality. Results Forty-five studies were selected for full-text analysis, and ten were included in the meta-analysis, involving 502 participants. Overall, studies presented fair to good quality, with a mean PEDro score of 6.3 (from 4 to 8). Five studies used healthy participants, and five targeted people with LBP. A moderate effect size (g = 0.73, 95% CI: 0.48–0.98) was determined, favoring the use of NM to increase flexibility in healthy adults. Larger effect sizes were found for the effect of NM in pain reduction (g = 0.82, 95% CI 0.56–1.08) and disability improvement (g = 1.59, 95% CI: 1.14–2.03), in people with LBP. Conclusion Evidence suggests that there are positive effects from the application of NM to the lower body quadrant. Specifically, NM shows moderate effects on flexibility in healthy participants, and large effects on pain and disability in people with LBP. Nevertheless, more studies with high methodological quality are necessary to support these conclusions.

Effects of lower body quadrant neural mobilization in healthy and low back pain populations: A systematic review and meta-analysis.

Bioactive components and biological properties of cornelian cherry (Cornus mas L.): A comprehensive review

Short term effectiveness of neural sliders and neural tensioners as an adjunct to static stretching of hamstrings on knee extension angle in healthy individuals: A randomized controlled trial

Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals - A randomized clinical trial.

Neck pain is a common condition with several proposed biomechanical contributing factors. Thoracic spine dysfunction is hypothesized as one of the predisposing factors, which necessitates the need to explore the contribution of thoracic posture and mobility toward neck pain. Accordingly, the present work aimed to review the existing literature investigating the presence of thoracic spine dysfunction in individuals with neck pain. A literature search was conducted in the three electronic databases of PubMed, CINAHL, and Web of Science. Studies published between 1990 and 2017 were considered. After reviewing the abstracts, two authors independently scrutinized the full-text documents for their relevance. The initial search yielded 2,167 articles, of which nine studies involving comparisons of neck pain patients and healthy controls were identified for the review. Increased thoracic kyphosis was positively correlated with the presence of forward head posture but not uniformly associated with neck pain intensity and disability. Thoracic mobility was reduced in the neck pain population, and the role of thoracic kyphosis as a risk factor for pain development could not be confirmed. Thus, an association exists between thoracic kyphosis and postural alteration in the cervical spine. The review favors the inclusion of thoracic spine assessment and treatment in mechanical neck pain patients. Further studies are needed to investigate the cause-effect relationship between thoracic posture and cervical dysfunction.

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Thoracic Posture and Mobility in Mechanical Neck Pain Population: A Review of the Literature

Immediate effects of Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized Crossover trial

Cervicothoracic (CT) junction hypomobility has been proposed as a contributing factor for neck pain. However, there are limited studies that compared the effect of CT junction mobilization against an effective intervention in neck pain. Thoracic spine manipulation is a nonspecific intervention for neck pain where remote spinal segments are treated based on the concept of regional interdependence. The effectiveness of segment-specific spinal mobilization in the cervical spine has been researched in the last few years, and no definite conclusions could be made from the previous studies. The above reasons warrant the investigation of the effects of a specific CT junction mobilization against a nonspecific thoracic manipulation intervention in neck pain. The present study aims to compare the immediate effects of C7-T1 Maitland mobilization with thoracic manipulation in individuals with mechanical neck pain presenting with CT junction dysfunction specifically. A randomized clinical trial is conducted where participants with complaints of mechanical neck pain and CT junction dysfunction randomly assigned to either C7-T1 level Maitland mobilization group or mid-thoracic (T3-T6) manipulation group (active control group). In both the groups, the post graduate student (SJ) pursuing Master’s in orthopedic physiotherapy delivered the intervention. The outcomes of cervical flexion, extension, side flexion & rotation range of motion (ROM) were measured before & after the intervention with a cervical range of motion (CROM) device. Self-reported pain intensity was measured with the numerical pain rating scale (NPRS). The post-intervention between-group comparison was performed using a one-way ANCOVA test. Forty-two participants with mean age CT junction group: 35.14 ± 10.13 and Thoracic manipulation group: 38.47 ± 11.47 were recruited for the study. No significant differences in the post-intervention baseline adjusted outcomes of cervical ROM & self-reported pain intensity were identified between the groups after the treatment (p = 0.08, 0.95, 0.01, 0.39, 0.29, 0.27for flexion, extension, bilateral lateral flexion & rotations respectively) & neck pain intensity (p = 0.68). However, within-group, pre, and post comparison showed significant improvements in cervical ROM and pain in both groups. This preliminary study identified that CT junction mobilization is not superior to thoracic manipulation on the outcomes of cervical ROM and neck pain when level-specific CT junction mobilization was compared with remote mid-thoracic manipulation in individuals with mechanical neck pain and CT junction dysfunction. CTRI: 2018/04/013088, Registered 6 April 2018, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=24418

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Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: a pilot randomized controlled trial.

Ganesh M Balthillaya

Papers

Short term effectiveness of neural sliders and neural tensioners as an adjunct to static stretching of hamstrings on knee extension angle in healthy individuals: A randomized controlled trial

Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals - A randomized clinical trial.

Thoracic Posture and Mobility in Mechanical Neck Pain Population: A Review of the Literature

Immediate effects of Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized Crossover trial

Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: a pilot randomized controlled trial.