Other

Author Names

Valenzuela, P. Mchiro, S. Lucia, A. Germain, F.

Reviewer Name

Alexandra Yeardley, SPT

Reviewer Affiliation(s)

Duke University, Doctor of Physical Therapy division

Paper Abstract

Study Design.  A randomized, double blind, parallel groups, sham-controlled trial.  Objective.  The aim of this study was to analyze the acute effects of spinal manipulative therapy (SMT) on performance and autonomic modulation.  Summary of Background Data.  The use of SMT is progressively spreading from the clinical to the sporting context owing to its purported ergogenic effects. However, its effects remain unclear.  Methods.  Thirty-seven male recreational athletes (aged 37 ± 9 years) who had never received SMT were assigned to a sham (n = 19) or actual SMT group (n = 18). Study endpoints included autonomic modulation (heart rate variability), handgrip strength, jumping ability, and cycling performance [8-minute time trial (TT)]. Differences in custom effects between interventions were determined using magnitude-based inferences.  Results.  A significant and very likely lower value of a marker of sympathetic modulation, the stress score, was observed in response to actual compared with sham SMT [P = 0.007; effect size (ES) = -0.97]. A trend toward a significant and likely lower sympathetic:parasympathetic ratio (P = 0.055; ES = -0.96) and a likely higher natural logarithm of the root-mean-square differences of successive heartbeat intervals [(LnRMSSD), P = 0.12; ES = 0.36] was also found with actual SMT. Moreover, a significantly lower mean power output was observed during the TT with actual compared with sham SMT (P = 0.035; ES = -0.28). Nonsignificant (P > 0.05) and unclear or likely trivial differences (ES < 0.2) were found for the rest of endpoints, including handgrip strength, heart rate during the TT, and jump loss thereafter.  Conclusion.  A single pre-exercise SMT session induced an acute shift toward parasympathetic dominance and slightly impaired performance in recreational healthy athletes.  Level of Evidence: 2

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• No

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Cannot Determine, Not Reported, or Not Applicable

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Cannot Determine, Not Reported, or Not Applicable

9. Was there high adherence to the intervention protocols for each treatment group?

• Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Cannot Determine, Not Reported, or Not Applicable

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• Yes

Key Finding #1

A single Spinal manipulative therapy session induced an acute shift toward parasympathetic dominance and slightly decreased cycling performance. The state of relaxation induced by increased parasympathetic activity by spinal manipulative therapy can decrease exercise performance on those that have never received spinal manipulative therapy before.

Key Finding #2

A single spinal manipulative therapy session decreased power output during an 8 minute time trial on a cycle ergometer as well as jumping height ability on those that had never received spinal manipulative therapy before.

Paper Summary:

This study was only done on a total of 37 subjects which is not a large population. However, the methods used to administer the spinal manipulative therapy were consistent and measurable as they used an Activator IV adjusting instrument set to transmit different levels of force throughout the spine for the experimental group and they used the same device with a level 0 of force for the control group with the machine still making the same noise as it would if it was transmitting force. Analysis of autonomic regulation included HR before the start of each testing session as well as parasympathetic modulation calculated while looking at successive heartbeat intervals (LnRMSSD), an analysis of Poincare-plot was performed to calculate stress score, a measure of sympathetic modulation and sympathetic; parasympathetic ratio was measured as an indicator of autonomic balance. Handgrip strength was used as an indicator of muscular strength. Performance was measured after a warm up looking at an 8-minute time trial on a cycle ergometer due to the participant population consisting of criteria specific to local triathlon and cycling participants. Jumping ability was also assessed immediately before and after treatment in which specific instructions were provided.  A lower sympathetic to parasympathetic ratio and higher parasympathetic modulation in the experimental group was found. A lower power output during the minute time trial was observed with nonsignificant or unclear results regarding handgrip.  There are many studies regarding spinal manipulative therapy and athletic performance, many that are contrary to this study which indicates the need for increased research.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

This study supports not using spinal manipulative therapy for recreational athletes before competition. This could decrease it’s use during this time of an athletes competing period. However, due to it’s parasympathetic effects, spinal manipulative therapy could be more beneficial when implemented in an athletes recovery phase in which there is a specific time period before competition begins. A lot of athletes will receive treatment before and after competition, and this study could create a better guideline of when it is appropriate and not appropriate to use spinal manipulative therapy for athletes or induce more research to help with this.  When treating a patient that is hypersensitive but responds well to spinal manipulative therapy, incorporating a Activator IV adjusting instrument to administer spinal manipulations may be beneficial because it can prevent administering too much force which is often variable when administered manually. This could potentially increase therapeutic effects and create an objective measurement in which a physical therapist can use to not induce pain. It could also offer more objective measurements for how much a patient can tolerate from one treatment session to another.

Author Names

Milne, N. , Longeri, L. , Patel, A. , Pool, J. , Olson, K. , Basson, A. , Gross, A.

Reviewer Name

Sophia Razzi, SPT

Reviewer Affiliation(s)

Duke University School of Medicine Doctor of Physical Therapy Division

Paper Abstract

Purpose: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use.  Design: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4th February 2021.  Participants: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition.  Intervention: Spinal manipulation and mobilisation OUTCOME MEASURES: Outcomes relating to common childhood conditions were explored.  Method: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach.  Results: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition.  Conclusion: Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described?

• Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Yes

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Through the synthesis of 87 articles, it was found that there is insufficient evidence to support the use of spinal manipulation and mobilization in the pediatric population.

Key Finding #2

Although there is insufficient evidence to support the use of spinal mobilization and manipulation in addressing many pediatric diagnoses, it was determined that there is strong to very strong evidence that proposes that these interventions are not beneficial for managing headaches, nocturnal enuresis, and asthma in the pediatric population.

Key Finding #3

There is a great need for high-level RCTs to determine the risks and benefits of spinal mobilization and manipulation in the pediatric population.

Paper Summary:

This systematic scoping review synthesized the findings of 87 articles to determine the effects of spinal manipulation and mobilization in the management of various pediatric conditions such as adolescent idiopathic scoliosis, asthma, ADHD, ASD, back/neck pain, breastfeeding difficulties, dysfunctional voiding, CP, headaches, excessive crying, infantile colic, nocturnal enuresis, kinematic imbalance due to suboccipital strain (KISS), otitis media, plagiocephaly, and torticollis. It was found that there is insufficient evidence to support the use of spinal manipulation and mobilization in the pediatric population for the majority of conditions examined; however, there is strong evidence that these techniques are not effective in managing headaches, nocturnal enuresis, and asthma. Additionally, four systematic reviews included in this article outlined the adverse effects of utilizing spinal manipulation and mobilization in the pediatric population and these adverse events ranged from mild (e.g. muscle soreness) to severe (e.g. death). More research needs to be conducted in this area to determine the risks and benefits of the use of this intervention in the pediatric population.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

Due to the fact that the majority of the literature examining the effects of spinal manipulation and mobilization in the pediatric population is established on the basis of low-level studies (e.g. case reports), their findings are unable to be generalized to larger populations. However, the findings of these studies do outline various safety concerns that should be taken into account in clinical practice. Due to the lack of research as well as reported risks, the majority of clinicians may not feel comfortable utilizing spinal manipulation or mobilization in pediatric clinical practice. However, if through more research it was determined that spinal manipulation and mobilization are effective in the treatment or management of various pediatric diagnoses, thorough medical screening would be warranted to determine the presence of underlying pathologies that may lead to a contraindication of these techniques. It is evident that additional research must be conducted prior to the widespread implementation of spinal manipulation and mobilization in pediatric clinical practice.

Author Names

Castro-Sánchez A.M., Aguilar-Ferrándiz M.E., Matarán-Peñarrocha G.A., Sánchez-Joya Mdel M., Arroyo-Morales M., Fernández-de-las-Peñas C.

Reviewer Name

Natalia Hanabergh, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Yes

6. Were the groups similar at baseline on important characteristics that could affect
   outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number
   allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage
   points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background
    treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently
    across all study participants?

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a
    difference in the main outcome between groups with at least 80% power?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before
    analyses were conducted)?

• Cannot Determine, Not Reported, or Not Applicable

14. Were all randomized participants analyzed in the group to which they were originally
    assigned, i.e., did they use an intention-to-treat analysis?

• Yes

Key Finding #1

Patients with FMS receiving the experimental protocol exhibited greater improvements in pain, tender point count, sleep quality, and depressive symptoms than those receiving the control condition.

Key Finding #2

Women and men get similar improvements in quality of sleep and tender point count after manual therapy.

Key Finding #3

Women showed a greater reduction in pain and impact of FMS symptoms than men

Key Finding #4

Men reported higher decreases in depressive symptoms and pressure hypersensitivity than women.

Please provide your summary of the paper

The purpose of this study was to determine the short-term therapeutic effects of a manual therapy (MT) protocol for improving pain unction, pressure pain thresholds (PPT), quality of sleep, and depressive symptoms in women and men with fibromyalgia syndrome (FMS). 89 patients, male and female, previously diagnosed with fibromyalgia syndrome were recruited. Inclusion criteria included being between the ages of 18-70 years, no regular physical activity limitations of activities due to pain in the recent 30 days, and agreement to evening therapy sessions. Patients were divided into either an experimental group or control group. The experimental group underwent manual therapy for 45-minutes/week for 5 weeks. Intervention protocol included Suboccipital release, Release of the pectoral region, Diaphragm release, Lumbosacral decompression, Release of the psoas fascia, and Thoracic spine extension manipulation in prone (high- velocity low-amplitude). The control group received not intervention. Patient reported outcome measures and tools included Pressure Pain Thresholds (digital pressure algometer), Impact of FMS Symptoms (FIQ-Spanish version), Pain (McGill Pain Questionnaire), Quality of Sleep (PSQI), and Depression (CES-D). These reported measures were recorded at baseline prior to intervention commencement and 48 ours following the final session at the 5-week mark. This RCT did find the application of a MT protocol to be a positive tool to improve pain intensity, widespread pressure pain sensitivity, impact of FMS symptoms, sleep quality, and depressive symptoms in individuals with FMS. Sex differences were also identified: both men and women get similar improvements in quality of sleep and tender point count with an MT protocol; however, women showed a greater reduction in pain and impact of FMS symptoms compared to men, but men reported higher decreased in depressive symptoms and pressure hypersensitivity compared to women.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

The application of a manual therapy protocol can be beneficial to a patient with fibromyalgia syndrome to improve quality of life. As noted in the study, both sexes with fibromyalgia syndrome found improvements in various aspects of their condition experience. Being a chronic pain condition, and one with no known cure, finding that adding manual therapy to treatment sessions may improve an individual’s experience, whether it be pain level, pressure sensitivity, impact of FMS symptoms, sleep quality and /or depressive symptoms is hopeful for symptom management. It is an additional tool that can assist with a treatment plan and one that offers various approaches and outcomes. Additional research is needed to identify the differences in responses towards interventions on sex-specific psychological and sociological circumstances.

Article: Iñaki Pastor-Pons, César Hidalgo-García, María Orosia Lucha-López, Marta BarrauLalmolda, Iñaki Rodes-Pastor, Ángel Luis Rodríguez-Fernández, José Miguel Tricás-Moreno. Effectiveness of pediatric integrative manual therapy in cervical movement limitation in infants with positional plagiocephaly: a randomized controlled trial. Ital J Pediatr. 2021 Feb 25;47(1):41.

Full Article

Study Design: Randomized Controlled Trial Abstract: Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.

Thirty-four children with PP and less than 28-week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen’s d.

All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) (p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.

The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program.

NIH Risk of Bias Score: 13/14 (Low Risk of Bias) Key Findings of the Study: 1. The addition of manual therapy to a caregiver educational program is associated with increased active cervical rotation range of motion after 10 weeks of treatment in infants with positional plagiocephaly.

Key Findings of the Study:

1. The addition of manual therapy to a caregiver educational program is associated with increased active cervical rotation range of motion after 10 weeks of treatment in infants with positional plagiocephaly.

2. No outcome differences in neuromotor development were found by adding manual therapy to a caregiver educational program after 10 weeks of treatment in infants with positional plagiocephaly.

3. Static photography measuring the head position of children showed good reliability comparable to other studies of children with torticollis in which photography was used to measure range of motion.

Reviewer Summary:

This study examined the effects of manual therapy in infants with positional plagiocephaly. The aims were two-fold, assessing the effect of manual intervention on both active cervical rotation and neuromotor development in 34 infants. The control group received an educational program for caregivers, while the intervention group received ten sessions of manual therapy in addition to the program.

Mobilizations targeted the occiput, atlas, and axis with the goal of restoring motion. The increase in right rotation was notably larger in the intervention group than the increase in left rotation potentially due to a lower baseline for right rotation measures. While there is no significant increase between groups for left rotation, there is a significant increase for right and total cervical rotation. Therefore, mobilizations addressing the upper cervical spine should be considered as a primary treatment option and feasible alternative to more risky interventions like surgery or chiropractic manipulation.

No long-term data was collected, and therefore, outcomes greater than 10 weeks cannot be analyzed at this time.

Author Names

Joshi, D., Shah S., Shinde, S., Patil S.

Reviewer Name

Erik Furseth SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Breast surgery, Axillary Lymph Node Dissection (ALND), radiation and chemotherapy may develop several complications such as axillary web syndrome, frozen shoulder, numbness, shoulder pain and range of motion restriction, lymphostasis, and lymphedema. Up to 77% report sensory disturbance in the breast or arm after breast surgery. These short- and long-term consequences have dramatic impact on physical function and quality of life in this population. Aims: The aim of the study was to determine the effect of neural tissue mobilization on sensory-motor impairments in breast cancer survivors with lymphedema. Subjects and Methods: This study was carried out by analyzing total 100 breast cancer survivor women, with lymphedema aged between 30-65 years of age who had undergone breast surgery mostly lumpectomy along with chemotherapy or radiation therapy. Participants were divided into two groups by random allocation. One group underwent neurodynamic mobilization and the other group conventional physiotherapy.The treatment protocol was given for 6 weeks. Parameters such ROM, pain, lymphedema and sensory-motor impairments were assessed at the baseline before the treatment and 6 weeks after the treatment.Result: The result from this study shows that there is significant improvement (p<0.0001, t-value 4.69) in mTNS of patients undergoing neural tissue mobilization, whereas there was no significant improvement (p=0.05, t-value 1.951) seen in patients undergoing conventional physiotherapy. Conclusion: This study concludes that effect of neural tissue mobilization has significant impact on sensory motor impairments as compared to conventional treatment protocol in breast cancer survivors with lymphedema.Pain and ROM showed similar difference with both the treatment protocols. It was also observed that patients with mild and moderate lymphedema showed significant improvement as compared to patients with severe lymphedema.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Cannot Determine, Not Reported, or Not Applicable

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Cannot Determine, Not Reported, or Not Applicable

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Cannot Determine, Not Reported, or Not Applicable

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Yes

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• Yes

Key Finding #1

The use of neural tension treatments is significant for those with mild to moderate lymphadema swelling, but there still shows some benefit with severe.

Key Finding #2

The use of neural tissue mobilization has a significant impact on sensory motor impairments when compared to conventional treatment protocols in breast cancer survivors with lymphedema.

Key Finding #3

Pain scores significantly improved with conventional physical therapy as well as neural tissue mobilizations, but there was no significant differences between the two.

Paper Summary:

The purpose of this study was to determine the effects of neural tissue mobilization of sensory-motor impairments in breast cancer survivors with lymphedema. 100 women who were survivors of breast cancer and had lymphedema, between 30-65 years old, and who had breast surgery along with chemotherapy or radiation therapy. The patients were divided into 2 groups, 1 group that did the neural tissue mobilization technique and the other did conventional physical therapy techniques to treat pain, ROM, lymphedema and sensory-motor impairments. Pain was reported using a 10-point scale to assess their intensity of axillary/shoulder pain. Shoulder flexion and abduction ROM was assessed. Lymphedema was assessed on the effected limb and subsequently compared to the non-affected side. The modified Total Neuropathy Score was used to assess sensory-motor impairments. All impairments were assessed before and after the 6-week interventions. In conclusion to the study, they found a significant difference in both groups for pain level and ROM post intervention. The patients that had mild and moderate lymphedema saw a significant decrease in lymphatic swelling, but the patients with severe swelling still saw some decreases in arm-to-arm measurements.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

The use of neural tissue mobilization should be used in breast cancer survivors as a therapeutic exercise to help reduce pain, increase ROM, and help to decrease lymphedema. Although patients in this study had specific requirements, since the results showed significant increases in many aspects, neurodynamic mobility could be used in a more broad population and monitored for similar effects. The results found could help with patient buy-in, reduce pain to allow for more physical therapy interventions, potentially increasing the patient’s recovery. More research should be done to determine the effects of using neurodynamic treatment in addition to conventional physical therapy to determine if there are greater effects seen when both are done simultaneously.