Systematic review protocol: Neurodynamics for pain intensity in adults with carpal

tunnel síndrome
Diana Castilla Álvarez 1
Heidy Parra Guerrero 2
Jessica Pino Noguera 3

Justification
Carpal tunnel syndrome is considered the peripheral nerve entrapment that occurs most
frequently in adults of working age(1) . Recent studies show that STC is increasing in
recent years, causing a significant socioeconomic cost. CTS patients often report pain,
paresthesia, sensory disturbances, weakness in the hand and wrist, leading to decreased
physical function affecting activities of daily living(2)
The increase in this disease leads to higher costs for the health system. According to the
United States Bureau of Labor Statistics, the annual cost of the pathology can increase to $1
billion dollars with an average cost of $30,000 USD per worker, in addition to significantly
deteriorating the quality of life of the patient. Several investigations have shown
deterioration in daily, domestic and work activities, as well as an increased risk of
depression and anxiety. (3)
Regarding treatment, the authors agree that it should be established according to the
severity of the symptoms. If the CTS is severe, the treatment of choice is surgery, while if
the CTS is mild or moderate, conservative treatment will be chosen. There are numerous
conservative treatments for CTS, however, there is no consensus on the best non-surgical
techniques available for patients with mild or moderate involvement.(2)
According to the literature There are different treatments focused on reducing symptoms
and increasing functionality in patients with CTS, in which neurodynamic techniques are
found. This intervention corresponds to a manual therapy technique that consists of a non-
invasive technique that is based on mobilizing neural structures through movements
performing a neural tension, which allows an improvement of the musculoskeletal system,
helping the patient to improve their quality of life. life. This non-invasive technique, which
can be carried out on its own and means are not required for its execution, is why we
believe that it could become a fundamental tool.(4)

1
Estudiante de fisioterapia Universidad Pamplona. Correo:
heidy.parra@unipamplona.edu.co
2
Estudiante de fisioterapia Universidad Pamplona. Correo:
jessica.pino@unipamplona.edu.co
3
Docente de fisioterapia Universidad Pamplona. Correo:
Diana.castilla2@unipamplona.edu.co
Currently, the use of neurodynamics is being carried out mainly to improve patient
evolution during interventions and reduce clinical symptoms. But other studies report that it
is not as effective, for this reason neurodynamics has been questionable regarding the
recurrence of carpal tunnel syndrome(4). The present investigation is viable since the
economic resources and bibliographical sources are available to carry it out. Therefore, the
present systematic review is carried out, which allows us to investigate the available
literature regarding neurodynamics as a treatment for adult patients diagnosed with carpal
tunnel syndrome.
Table 1. Systematic reviews available in PROSPERO and Cochrane.
Registration Title
date

2023 effectiveness of personalized multimodal physiotherapy care compared to

surgery in patients with a cervical radiculopathy: a systematic review.

2022
A systematic review looking at the relationship between sciatic nerve
loading and hamstring muscle injury using neurodynamic testing
2017

A systematic review looking at the relationship between sciatic nerve

loading and hamstring muscle injury using neurodynamic testing

2021
Effect of neurodynamic self-mobilizations on functional variables: a
systematic review and meta-analysis
2022

The effectiveness of manual therapy on pain, physical function, and nerve

conduction studies in carpal tunnel syndrome patients: a systematic
review and meta-analysis

2021 Short-term Effects of Neurodynamic Techniques for Treating Carpal

Tunnel Syndrome: A Systematic Review With Meta-analysis
Objective and research question
To determine the effectiveness of neurodynamics for pain intensity in adults with carpal
tunnel syndrome from scientific evidence.

Therefore, the PICO research question is: What is the effectiveness of applying
neurodynamics for pain intensity in adults with carpal tunnel syndrome?

Methodology
This protocol is developed in accordance with the PRISMA 2020 statement, which provides
a checklist of 27 elements to adapt the methodological process to the guidelines for the
preparation and publication of systematic reviews REFERENCE PDF. Likewise, this
protocol will be registered in the International prospective register of systematic reviews
(PROSPERO) of the National Institute for Health Research (NIHR), for consultation by
other researchers interested in the subject of the study.
(https://www.crd.york.ac.uk/prospero/).

1. Study sources.

The available literature will be identified during the month ofMarch to June 2023. The
sources of the studies will be electronic databases specialized in health sciences, will be
carried out in PubMed, PEDro, Cochrane, Sciencedirect, google scholar. In addition, there
will be manual consultation in Google Scholar that will be used to identify any gray
literature.

2. Search strategy.

We ran a search of current literature in the last 10 years (2012-2022) using the following
databases: National Library of Medicine National Institutes of Health (PubMed),
Physiotherapy Evidence Database (PEDro), Sciencedirect and Cochrane, and a handsearch
that was conducted during the month of January and February 2023. The search equation
was designed by combining the keywords and terms of the Medical Subject Headings
(MeSH) list with Boolean descriptors OR and AND as follows: ((("carpal tunnel
syndrome") OR ("nerve therapy") OR ("nerve treatment")) AND (("neurodynamic") OR
("manual therapy") OR ("nerve stretch") OR ("nerve gliding exercises") OR
("neuromobilization maneuver") OR ("neurodynamic techniques")))

3. Types of studies to include:

Studies will be selected based on the following criteria:

 Randomised clinical trials (ECA).

 Patients with a medical diagnosis of carpal tunnel syndrome
 Those who provide information on the application of neurodynamics in patients
with carpal tunnel syndrome.
 Patients who are adults over 18 years of age.

Articles with the following conditions shall be excluded:

 Studies that are not reported in the years between2,012 and 2022.

 Studies in animals, pregnant women, patients with sciatica, cadavers and patients
with diabetes mellitus who report pain at the wrist level
 Trials that combine the application of neurodynamics with othermodality.
 Articles that are not available in full text.

We will include randomised controlled trials, people with carpal tunnel syndrome who
were ≥18 years of age and assessed with the Visual Analogue Scale (EVA), Numerical Pain
Scale (NRS) and Boston Carpal Tunnel Questionario (BTC).

4. Types of participants

We will include adults over the age of 18 and younger than 60 with a diagnosis of carpal
tunnel syndrome. Studies combining the application of neurodynamics with othermodality
will be excluded.

5. Types of intervention

Experimental intervention
Interventions may include neurodynamics in its two modalities: neural tension techniques
and neural slippage techniques..
Comparison intervention
Comparison interventions will include sham therapy, electrophysical modalities and
therapeutic exercise.

6. Subgroup analysis and heterogeneity investigation

If possible, it is intended to perform a subgroup analysis in case of heterogeneity

considering the following variables:

7. Types of outcome measures

Primary outcome
The primary outcome measure will be pain intensity, assessed using (Visual Analogue
Scale (EVA), Numerical Pain Scale (NRS) and Boston Carpal Tunnel Questionary (BTC)

 Visual Analogue Scale (EVA) It allows to measure the intensity of the pain in
which they use a horizontal line of 10 cm, where the left side is the absence or
smaller size and the right the one of greater magnitude. The patient is obliged to
check on the line the point indicating the size, measured with a millimeter ruler. The
size is given in cm or millimeters. (5)
 Numerical Pain Scale (NRS) A scale numbered from 1-10, where 0 is the absence
and 10 the highest intensity; the patient selects the number that best evaluates the
intensity of the symptom. It is the simplest and the most used (5)
 Boston Carpal Tunnel Questionario ( BCTQ) The Boston Questionnaire includes 11
questions about pain, discomfort, loss of sensation, weakness, tingling, hand and
wrist function that patients must answer ( 6)

8. Data collection and analysis.

Selection of studies

Two blinded independent reviewers (JP and HP) will independently evaluate the titles and
abstracts of the studies in the bibliographic search taking into account the inclusion and
exclusion criteria. Duplicates will be omitted using Rayyan software. In case of
disagreement they will be resolved by a third evaluated (DC). Subsequently, articles that
met the eligibility criteria were reviewed in their entirety for inclusion in the study. The
selection process is illustrated by the PRISMA diagram.

9. Data extraction

Each researcher (HP and JP) will extract the relevant data from the studies included in this
research, through an Excel template with a design as follows:

• Reference: author and year of publication.

• Sample information: description of participants and location.

• Intervention: description and frequency.

• Main results.

10. Assessment of study quality and risk of bias

The evaluation of methodological quality will be carried out according to the PEDro scale
(Physiotherapeutic Evidence Database). The scale is a tool composed of 11 items: item 1
refers to the external validity of the study, items 2 to 9 refer to internal validity, and items
10 and 11 refer to whether the statistical information provided by the authors allows the
results to be interpreted appropriately.

We will also assess risk of bias using the Cochrane Handbook for Systematic Reviews of
Interventions version 5.1.0. The following characteristics will be evaluated: (1) random
sequence generation, (2) allocation concealment, (3) blinding of participants and
personnel, (4) blinding of outcome assessors, (5) incomplete outcome data, and (6)
selective reporting of results. Studies that meet all criteria will be classified at low risk of
bias, studies that do not meet any of the criteria will be classified as at high risk of bias,
and studies will be classified as unclear risk if the information acquired is insufficient to
issue the ruling. Both processes will be performed independently by 2 reviewers (HP and
JP) and disagreements will be resolved by a sixth researcher (DC).

11. Summary of results

The selected studies will be described by grouping them according to the categories
defined in the numeral. The analyses will be differentiated according to the characteristics
of the participants and the results will be presented through a meta-analysis depending on
the number of studies and the level of heterogeneity of the results

12. Ethics and dissemination

Ethical approval is not required because primary participant data is not collected. This
review will provide a comprehensive assessment regarding the effectiveness of cupping on
pain intensity in the adult population.
References

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síndrome del túnel carpiano atendidos en un centro de alta complejidad en Cali ,
Colombia. 2015;37(2):125–40.
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movilización neurodinámica en el dolor y funcionalidad en sujetos con síndrome del
túnel carpiano: revisión sistemática. 2018;25(1):26–36.
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cuestionarios. 2018;25(4):228–36.
6. Joaquin Andani Cervera MBT. Valoración del cuestionario de Boston como
screening en patología laboral por síndrome del tunel carpiano. 2017;31–8.