I was really struck by the coincidence of reading in the same week that Bob Elvey had passed away, and that Bob Nee, Michel Coppieters and their team (Bill Vicenzino, Gwen Jull, and Josh Cleland) had won the prestigious Journal of Physiotherapy ‘Paper of the Year’ award with a randomised controlled trial that included ‘Elvey techniques’ (Nee et al. 2012).
I didn’t know Bob Elvey well; we only met 3 or 4 times, shared a few beers at conferences and I subscribe to the general consensus of a ‘damn good bloke’. Early on in my career, I read everything I could about his pioneering work with the Upper Limb Neurodynamic Test and his novel management strategies for patients with neuropathic pain. His death stimulated me to reread his papers in old proceedings from Manipulative Physiotherapy Association of Australia symposia in from the 70s and 80s. These were the days when clinicians ruled the roost and I still think these symposia were full of great thinking! Bob always reinforced attention to handling skills, reasoning and, somewhat unique for the time, he always questioned what might be happening physiologically. It was ‘out there’ stuff.
Some 30 plus years later, Bob Nee et al. used a parcel of interventions in their clinical trial on 60 patients with nerve related neck and arm pain. The parcel included de-threatening education (albeit brief), nerve mobilisation using ‘sliders’ and ‘tensioners’, as well as some ‘Elvey techniques’. For details of the study protocol, something I would recommend for any young researcher, please read Nee et al. (2011).
In the image you can see the elegant Michel Coppieters performing one of Elvey’s techniques (a cervical contralateral lateral glide mobilisation). From the base position shown, the neck (either with or without the cranial cervical segments and head) is translated (no rotation or lateral flexion) away from the sore side. The technique can be applied to specific levels, for example C4-C5. The mobilisation can also be performed with the elbow extended to preload the nervous system. Note that this is an attempt to mobilise structures around the nervous system, rather than a direct nervous system mobilisation. The technique is well described (Nee et al. 2011) and has previously shown beneficial effects (Allison et al. 2002, Coppieters et al. 2003). Other techniques recommended by Bob Elvey involve oscillatory shoulder girdle depression while gently abducting the arm, or combining a lateral glide of the neck away from the painful side with mobilisation of the shoulder girdle (as in sliding or tensioning techniques).
In the clinical trial, symptoms were not provoked during treatment. Techniques were performed so that participants only felt a gentle stretching or pulling sensation.
Following four sessions and a home exercise program, 53% of participants in the treatment group had improved compared to only 15% of participants in the advice to remain active control group (ie, a number needed to treat (NNT) between 2 and 3).
Nee et al. concluded that “these results enable physiotherapists to inform patients that neural tissue management provides immediate clinically relevant benefits (…) with no evidence of harmful effects”. Simply said ‘it works’. I think the finding of “no evidence of harmful effects” when performed by skilled clinicians is even more powerful. I know some practitioners are wary of mobilising the nervous system, but I am already aware from my post graduate student discussion sites of practitioners now handling patients far more confidently since this research emerged.
I think Bob Elvey would have predicted and surely been delighted with the results of the Nee et al. study. Although I believe we should never use surnames to refer to techniques, in this blog I happily make an exception and refer to the techniques as ‘Elvey techniques’ as a tribute to one of physiotherapy’s greatest.
Allison, G. T., B. M. Nagy, and T. Hall. 2002. A randomised clinical trial of manual therapy for cervico-brachial pain syndrome- a pilot study. Manual Therapy 7:95-102.
Coppieters, M. W., K. H. Stappaerts, L. L. Wouters, and K. Janssens. 2003. The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain Journal of Orthopaedic and Sports Physical Therapy 33:369-378.
Nee, R. J., B. Vincenzino, G. A. Jull, J. A. Cleland, and M. W. Copieters. 2011. A novel protocol to develop a prediction model that identifies patients with nerve related neck and arm pain who benefit from the early introduction of neural tissue management Contemporary Clinical Trials 32:760-770.
Nee, R. J., B. Vincenzino, G. A. Jull, J. A. Cleland, and M. W. Coppieters. 2012. Neural tissue management provides immediate clinically relevant benefits without harmful effects for patietns with nerve-related neck and arm pain: a randomised trial. Journal of Physiotherapy 58:23-31.
– David Butler