The Effectiveness of Neural Mobilization Combined with Cervical Traction in the Treatment of Cervical Spondylotic Radiculopathy: A Meta-Analysis

The Effectiveness of Neural Mobilization Combined with Cervical Traction in the Treatment of Cervical Spondylotic Radiculopathy: A Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Effectiveness of Neural Mobilization Combined with Cervical Traction in the Treatment of Cervical Spondylotic Radiculopathy: A Meta-Analysis Guojun Zhang, Yueyue Liu, Jingyu Zhang, Xia Zhang, Yuye Lin, Chufan Zeng, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4193987/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Cervical Spondylosis Radiculopathy (CSR), a degenerative condition affecting the cervical spine,characterized by the irritation and compression of nerve roots, leading to a range of clinical symptoms such as numbness and pain in the neck, shoulders, upper limbs, and fingers. Neural Mobilization (NM)combined with Cervical Traction (CT) has emerged as a noteworthy therapeutic approach for CSR, gaining recognition for its effectiveness. This study endeavors to conduct a comprehensive and systematic review of available randomized controlled trials (RCTs) on NMCT. The objective is to critically assess the efficacy and safety of NM as a treatment modality for CSR.The study will analyze the methodologies, results, and any specific findings from the RCTs, providing a comprehensive assessment of the role of NMCT in managing CSR. Health sciences/Diseases/Neurological disorders/Neurodegenerative diseases Health sciences/Diseases/Neurological disorders/Neuromuscular disease Health sciences/Diseases/Neurological disorders/Neuropathic pain Cervical Spondylosis Radiculopathy Neural mobilization cervical traction Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Introduction Cervical Spondylotic Radiculopathy (CSR) is primarily defined as degenerative changes occurring in the cervical spine, particularly affecting the intervertebral disc and joints. This degeneration exerts undue pressure on the corresponding cervical nerve roots, leading to root compression or irritation symptoms [1] . As the most prevalent form of cervical spondylosis, CSR's incidence rate, currently between 50% and 60%, is on an upward trajectory. The disease's impact extends beyond physical symptoms like pain, numbness, and muscle weakness in the neck and regions innervated by the nerve roots [2] . It significantly impairs patients' functionality in both work and daily activities. More concerning are its psychological repercussions, including reduced sleep quality and emotional disturbances, with severe cases potentially escalating to bowel and bladder dysfunctions or limb paralysis [3] . Thus, effectively preventing and treating CSR is imperative for mitigating its substantial health implications [4] . Treatment modalities for CSR are broadly categorized into non-surgical and surgical interventions. Non-surgical treatments and preferred approaches encompass cervical traction, physical therapy, pharmacotherapy, and lifestyle changes [21] . However, limitations arise due to the variable quality of evidence and potential adverse reactions from drugs [6] . For example, oral non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for severe pain relief [5] . Yet, their prolonged usage raises concerns about increased risks of hypertension, cardiovascular events, gastrointestinal ulcers, acute renal failure, and deterioration of existing heart failure conditions [7] . Many CSR patients gravitate towards specific conservative treatments, particularly Neural Mobilization combined with Cervical Traction (NMCT) [8] . NMCT, a manual therapy technique, aims to alleviate nerve-related pain by enhancing nerve circulation and reducing nerve tension [9] . This approach effectively mobilizes median, radial, and ulnar nerves, thus relieving pain. What sets NMCT apart is its adaptability; treatment dosage is finely tuned to each patient's unique response, ensuring a comfortable range of both duration and intensity of therapy. NMCT is relatively novel yet rapidly evolving compared to other treatments, offering exceptional benefits in managing peripheral nerve injuries and showing immediate effectiveness in relieving entrapment-related pain [8] [9] . Despite NMCT's application in CSR treatment, more comprehensive evidence of its efficacy and safety must be provided. Consequently, existing literature are critically evaluated in this study to determine the effectiveness and safety of NMCT as a therapeutic strategy for CSR. Methods It was according to the methodological guidelines described in the Cochrane Handbook for Systematic Reviews of Interventions that this systematic review was conducted [10] , as well as in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The review protocol was registered in the PROSPERO database (registration code: CRD42024522227). Search Strategy The search strategy used in this study was developed to encompass three primary aspects: the participants (patients with Cervical Spondylotic Radiculopathy or CSR), the intervention (neural mobilization combined with traction treatment in the treatment group versus traction treatment alone in the control group), and the study type (Randomized Controlled Trials or RCTs). A comprehensive literature search used keywords and free-text terms to identify pertinent studies. The timeframe for this search extended from each database's inception until February 28, 2024. The included databases were PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), China Biology Medicine Disc (CBM), Wanfang Database, and the China Science and Technology Journal Database (VIP). Our search terms, utilized in both Chinese and English, included phrases such as "cervical spine radiculopathy," "Cervical Radiculopathy," "neural mobilization," and "randomized controlled trials" among others. The complete search strategy is detailed in Supplementary File 1. Modifications were made to this strategy as required for compatibility with other electronic databases. Data extraction The processes of selecting studies and extracting data were carried out by two review authors (GJZ, YYL), independently. Results from all searches, such as titles, abstracts, and full references, were managed using Endnote X9 to identify and eliminate duplicates. Subsequently, in order to ensure alignment with our inclusion criteria, the titles, abstracts, and full texts of these studies were independently screened and meticulously analyzed(Fig.1). Quality Assessment The risk of bias assessment tool recommended by Cochrane was employed to ensure rigorous quality and bias assessment of all included studies. Two expert reviewers independently examined the full texts with the use of a standardized data extraction form. Discrepancies between reviewers were sorted out through discussion or, if necessary, by involving a third reviewer. Study Selection Types of Studies: This review includes published randomized controlled trials (RCTs). No restrictions were imposed on the date of publication or language. Focus was put on studies relevant to clinical prediction rules and with symptoms associated with CSR, such as arm pain, and whether there is presence of accompanying motor or sensory dysfunction. Types of participants. All participating subjects must be symptomatic adults aged 18 years and older, and no limitation was imposed regarding gender. Participants need to have a diagnosis of CSR based on at least one of the following: 1) diagnosis based on magnetic resonance imaging, electromyography, or nerve conduction velocity testing; 2) not less than three positive results should be obtained out of four tests (Spurling's test, Distraction test, Upper Limb Neurodynamic Test 1, and ipsilateral cervical rotation of less than 60°) based on clinical prediction rules; and 3) symptoms related to CSR, such as radiating pain to the arms, with or without presence of motor or sensory dysfunction. Types of Interventions: The scope of our review encompassed RCTs that contrasted the effects of nerve relaxation therapy combined with CT versus CT alone. In the experimental groups, participants received a combination of nerve relaxation and cervical traction. Control groups were treated with CT exclusively. We considered studies involving manual and mechanical traction methods, including continuous and intermittent applications. The traction positions employed needed to be consistent across the studies. Types of Outcome Measures: Our inclusion criteria for RCTs were based on the utilization of at the minimum one of the following outcome measures: pain intensity, gauged using tools like a Visual Analog Scale (VAS) or Numeric Pain Rating Scale (NPRS); the craniocervical flexion test (CCFT); functional/disability assessments conducted using validated scales such as the Neck Disability Index (NDI) or measurements of the range of motion (ROM). Data Synthesis and Analysis By using a specially designed form, the process of data extraction was meticulously carried out by two reviewers. This form captured critical details including (1) authorship and year of publication; (2) basic participant information for each group, such as number of participants, gender and age of the participants; (3) differences in treatment methods and duration between the experimental and control groups; and (4) study results, focusing on outcome indicators crucial for evaluating results. The Review Manager (RevMan) software version 5.4 was utilized for the meta-analysis. Binary variables were analyzed using risk ratios (RR) and continuous variables using mean differences (MD), both with a 95% confidence interval (CI). Heterogeneity was assessed, and a fixed-effects model was applied when P > 0.1 and I2 < 50%, which indicates low heterogeneity. On the contrary, a random-effects model was chosen if significant heterogeneity was observed, and sensitivity analyses were carried out to identify heterogeneity sources. Subgroup analyses were also performed as required. The results of these analyses were visually represented in forest plots and funnel plots. Table 1 ①Visual analogue scale，VAS②Tanaka Yasushi cervical spondylitis symptom scale 20 score③The Neck Disability Index (NDI) ④The Numeric Pain Rating Scale (NPRS) ⑤The Patient-Specific Functional Scale (PSFS)⑥Grip strength (GS) ⑦ROM⑧The craniocervical flexion test (CCFT).⑨36 items short form health survey (SF-36)⑩The upper limb tension test-1 Study ID Characteristics of participants Authors Study (Year) design Sample size (n) Mean age (SD) Female n (%) Outcome timing Outcomes Tang RCT Total(72) Total:no informed Total:27 Post-intervention: ①② Fang-ming EG(36) EG:44.43 (37.50%) 2 sessions （2018） CG(36) (±3.03) EG:14 Follow-up:3-month CG:45.13 (38.89%) post-intervention (±2.87) CG:13 (36.11%) Christos RCT Total(44) Total:no informed Total:20 Post-intervention ③④⑤⑥⑦ Savva EG(22) EG:47.70 (45.45%) 4 weeks (2020) CG(22) (±10.80) EG:11 CG:48.10 (50%) (±11.90) CG:9 (40.91%) Shazia RCT Total(88) Total:no informed Total:60 Post-intervention ③④⑦ Rafiq EG(44) EG:41.09 (68.18%) 4 weeks (2020) CG(44) (±6.05) EG:29 CG:42.22 (65.91%) (±5.62) CG:31 (70.45%) Shazia RCT Total(88) Total:no informed Total:60 Post-intervention .⑧⑨ Rafiq EG(44) EG:41.09 (68.18%) 4 weeks (2022) CG(44) (±6.05) EG:29 CG:42.22 (65.91%) (±5.62) CG:31 (70.45%) Dong RCT Total(30) Total:no informed Total:19 Post-intervention ③④⑦⑧ Gyu Kim EG(15) EG:29.27 (63.33%) 4 weeks and 8 weeks （2017） CG(15) (±3.34) EG:9 CG:29.33 (60.00%) (±3.07) CG:10 (66.67%) Asmaa Omer RCT Total(40) No informed No informed Post-intervention ①⑩ Ibrahim EG(20) 3 weeks (2021) CG(20) Li Wen-li RCT Total(48) No informed Total:22 Post-intervention ①② EG(26) (45.83%) 5 days and 10 days CG(22) EG:12 (46.15%) CG:10 (45.45%) RESULTS Literature Search Results Our comprehensive database search initially yielded 785 potentially relevant studies, which were imported into EndNote X9 for organization and review. Of these, 275 duplicates were identified and excluded. Through reviewing the titles and abstracts, 441 studies were further excluded. Then, according to our inclusion and exclusion criteria, an additional 68 studies were eliminated. After rigorously filtering out non-randomized controlled trials and studies not aligning with our research focus, seven articles remained for inclusion [11][12][13][14][15][16][17]. The process of literature search and selection is illustrated through a flow chart in Figure 1. The final sample comprised 410 patients, who were divided into a treatment group of 207 subjects (receiving NM combined with CT) and a control group of 203 subjects (receiving CT alone). Table 1 details the essential characteristics of these studies. Assessment of Risk of Bias All included studies randomly assigned patients into either the experimental or control group. However, three studies needed more detailed information on the randomization process [14][16][17]. Blinded analysis of outcome assessors was reported in three studies [11][12][13]. Regarding selective reporting bias, all trials reported the anticipated outcomes. Figures 2 and 3 display the risk-of-bias assessment for these studies (Fig.2,3). Visual Analogue Scale (VAS Score) A meta-analysis was conducted to evaluate the impact of NM and CT treatments on pain and functional improvement in CSR patients by employing the clinical Visual Analogue Scale (VAS). This analysis incorporated three data sets of continuous variables[13-14-15]. The pooled analysis, involving 160 cases, revealed a statistically significant combined effect [MD = -0.99, 95% CI (-1.38, -0.60), Z = 4.93, P = 0.003]. These results suggest that the combination of NM and CT treatments is significantly more effective than CT treatment alone (Fig4). The Numeric Pain Rating Scale (NPRS) Three randomized controlled trials [9, 10, 12] involving 162 subjects compared the effectiveness of different interventions using the Numeric Pain Rating Scale (NPRS). The pooled data analysis indicated a remarkable reduction in pain scores for the NMCT group [MD = -0.70, 95% CI (-1.02, -0.38), Z = 4.27, P = 0.09], as shown in Figure 5. Neck Disability Index (NDI) The Neck Disability Index (NDI) scores were compared across three randomized controlled trials [9, 10, 12], encompassing 162 subjects. The results demonstrated statistically significant differences in NDI scores between the intervention methods (Figure 6) [MD = -5.13, 95% CI (-6.99, -3.27), Z = 5.40, P = 0.03]. The Craniocervical Flexion Test (CCFT) Two randomized controlled trials [11, 12] with 118 subjects compared the craniocervical flexion test (CCFT) outcomes under different interventions. The results did not show statistically significant differences in cervical flexion between the interventions (Figure 7) [MD = 1.37, 95% CI (0.41, 2.33), Z = 2.80, P = 0.65]. The absence of important difference may be due to the substantial variation in subject numbers across the studies. However, the data suggest that NMCT may be more effective than CT alone. Active Range of Cervical Motion (ROM) The Active Range of Cervical Motion (ROM) was assessed using a hydraulic dynamometer and a general goniometer. This assessment measured grip strength and ROM regarding extension, flexion, side flexion, and rotation of the affected and contralateral arms. Three studies [9, 10, 12] involving 162 subjects reported on ROM, including cervical extension, flexion, and rotation. The results, however, did not reach statistical significance, possibly due to the small effect sizes. Specific ROM outcomes are detailed as follows: ROM-Cervical extension [MD = 3.90, 95% CI (1.54, 6.27), Z = 3.23, P = 0.06], ROM-Cervical flexion [MD = 2.56, 95% CI (0.43, 4.70), Z = 2.35, P = 0.31], and others as shown in the study (Fig8,9,10,11,12). Discussion Substantial evidence supporting the effectiveness of neurodynamic techniques as interventions for cervical radiculopathy is presented in this systematic review and meta-analysis. These techniques have shown considerable efficacy in alleviating symptoms such as dizziness, numbness in the extremities, pain, and restricted range of motion. Notably, improvements observed in the Visual Analog Scale (VAS) and Neck Disability Index (NDI) scores underscore neurodynamic mobilization's capability to significantly reduce localized pain and enhance cervical range of motion among the affected patients. Neural Mobilization (NM) involves the passive manipulation of neural structures within limbs to restore normal movement and structural integrity [ 18 ] . This technique has also been effective in mitigating pain associated with neuropathic conditions like leprosy [ 19 ] and other disorders such as rheumatoid arthritis [ 20 ] . Despite its therapeutic potential, the broader understanding and application of neural mobilization in clinical practice still need to be improved. To address this gap, our meta-analysis specifically compared the effectiveness of the combined use of Neural Mobilization and Cervical Traction (NMCT) versus the use of CT alone in the treatment of pain and functional impairment in Cervical Spondylotic Radiculopathy (CSR). Our findings, derived from an analysis of 410 CSR patients, revealed significant reduction in pain and enhancement in functional performance post-neural mobilization. The study showed statistically significant improvements in VAS and NDI scores. In contrast, results for the Numeric Pain Rating Scale (NPRS), Craniocervical Flexion Test (CCFT), and Range of Motion (ROM) were not statistically significant. This outcome indicates that while neural mobilization demonstrates beneficial effects, its full therapeutic potential is yet to be completely realized. Consequently, further large-scale clinical randomized controlled trials are necessary in order to more comprehensively assess the efficacy of neural mobilization in the treatment of CSR. This meta-analysis has revealed that Neural Mobilization (NM) treatment offers significant benefits for Cervical Spondylotic Radiculopathy (CSR) patients. It notably improves clinical symptoms, neurological function, and overall quality of life. Compared to traditional conservative treatments, NM demonstrates greater efficacy in symptom reduction and enhancement of treatment outcomes. However, the current body of high-quality Randomized Controlled Trials (RCTs) on NM treatment for CSR is relatively limited. This lack of robust literature has resulted in some outcome indicators failing to achieve statistical significance, leading to biased and tentative conclusions. Therefore, to substantiate and broaden these findings, conducting additional high-quality RCTs focusing on NM treatment for CSR is crucial. Conclusion In this study, our meta-analysis revealed that the combined approach of NM and CT outperformed the use of CT alone in treating CSR. Notably, patients receiving the combined NMCT therapy exhibited significantly reduced Visual Analog Scale (VAS) and Neck Disability Index (NDI) scores compared to those receiving CT alone. These findings highlight the potential therapeutic benefits of incorporating NM into the standard CT protocol for CSR, thereby enhancing treatment outcomes. Declarations Data availability All data generated or analyzed during this study are included within the manuscript or supplementary information file Author contributions Study conception and design: Guojun Zhang,Yueyue Liu,Jingyu Zhang. Acquisition of data: Guojun Zhang,Yueyue Liu,Jingyu Zhang. Analysis and interpretation of data: Guojun Zhang,Yueyue Liu,Jingyu Zhang. Draft of manuscript: Guojun Zhang,Yueyue Liu,Jingyu Zhang.Critical revision of manuscript: Guojun Zhang,Yueyue Liu,Jingyu Zhang.All authors reviewed the manuscript. Funding Open access funding provided by The National Natural Science Foundation of China.The National Natural Science Foundation of China: A Study on the Mechanism of Electroacupuncture in Promoting the Repair of Chronic Muscle Injury in the Neck of Rats, Grant Number: 82074181,and anti-inflammatory analgesia mechanism of acupuncture regulating FMS glial cell-neuron crosstalk through CX3CL1/CX3CR1axis to alleviate central sensitization,Grant Number:82374202. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4193987","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":293070403,"identity":"38b6e991-c69f-4e25-bb7a-56dcedaadb16","order_by":0,"name":"Guojun Zhang","email":"","orcid":"","institution":"College of acupuncture and moxibustion and Massage, Fujian University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Guojun","middleName":"","lastName":"Zhang","suffix":""},{"id":293070406,"identity":"0071c36d-de1e-40eb-833d-acb4ebd69a0c","order_by":1,"name":"Yueyue 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Fang","email":"","orcid":"","institution":"College of acupuncture and moxibustion and Massage, Fujian University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yanping","middleName":"","lastName":"Fang","suffix":""},{"id":293070421,"identity":"a0f236e5-26d8-4034-aea8-e23db200ea02","order_by":12,"name":"Xiubing Tong","email":"","orcid":"","institution":"College of acupuncture and moxibustion and Massage, Fujian University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiubing","middleName":"","lastName":"Tong","suffix":""},{"id":293070422,"identity":"3192a174-92f4-42bd-8322-cb42070440bb","order_by":13,"name":"Yu Kan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACfmbGxgcJP/7JsTccAAswNhDSItne3GzwseeAMc+Bw0RqMThzvE1yBtuBxJ4DzERqYbiR2CbNw3MnvYfx/MFPNxhsZDccYH72AJ8OxhmJzdY8Fs9yexgOM0vnMKQZbzjAZm6ATwuzRGLjbR4e5tz9DIfZmHMYDiduOMDDJoFPC5tEYoM0DxtzOg9Ey3/CWnh4DjYBvX84AarlAGEtEuyNoEBOMwT6xVg6xyDZeOZhNjO8WuwPsz8ERqWNPI/EwYefcyrsZPuONz/DqwXJvgNAAhRUzMSpBwL+BqKVjoJRMApGwQgDAPeWTSzYeY3/AAAAAElFTkSuQmCC","orcid":"","institution":"College of acupuncture and moxibustion and Massage, Fujian University of Traditional Chinese Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Kan","suffix":""},{"id":293070423,"identity":"f4b1c36a-ffcd-475a-a29a-5f704b7b57b0","order_by":14,"name":"Jun Liao","email":"","orcid":"","institution":"College of acupuncture and moxibustion and Massage, Fujian University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Liao","suffix":""}],"badges":[],"createdAt":"2024-03-31 02:44:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4193987/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4193987/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55088453,"identity":"69faae22-c663-4d22-b527-458c4ee6f1a9","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":192211,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/43b50a3222c79778eecd86f5.png"},{"id":55088456,"identity":"4bc2f91a-ef73-498c-a9ef-b70ed807e2fe","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":137376,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2,3.\u003c/strong\u003e Assessment of risk of bias. Green circles suggest a low risk of bias, yellow circles suggest an unclear risk of bias, and red circles suggest a high risk of bias.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/e6d81da8ffc598842e27120b.png"},{"id":55088451,"identity":"439a5f4e-e558-4c48-ac92-2629eb24a322","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":997050,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2,3.\u003c/strong\u003e Assessment of risk of bias. Green circles suggest a low risk of bias, yellow circles suggest an unclear risk of bias, and red circles suggest a high risk of bias.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/d69ddd7c5ac7ba0475cd958f.png"},{"id":55088450,"identity":"ac97a3ab-f56d-4547-8a97-87f072bbd824","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":142299,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of VAS scores (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/2bffef750ad989fa2c765d43.png"},{"id":55088455,"identity":"a2b8515f-5037-4461-8eaf-3b4856e40cc2","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":152919,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of NPRS scores (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/a39ee08830ae8d5d4a6141a2.png"},{"id":55089073,"identity":"6cbbaeb8-d09a-4308-9118-0a00da7105be","added_by":"auto","created_at":"2024-04-22 12:01:35","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":154402,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of NDI scores (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/28820c1bc46fcc678fbbef66.png"},{"id":55089072,"identity":"0f61f955-0ef4-4941-9676-8002a4afb550","added_by":"auto","created_at":"2024-04-22 12:01:35","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":127123,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of CCFT (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/8dc61040c1a7d38a4bec558f.png"},{"id":55088461,"identity":"9de199c6-5bb1-4d63-973b-e433f9b056cd","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":155142,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of CROM-Cervical flexion toward the affected and opposite arm (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/d92ce6c56813c023d0e1d37a.png"},{"id":55088458,"identity":"ed26d55d-879d-4fe0-82d1-e2458d0dd7ea","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":120799,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of CROM-Cervical left rotation (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/c8932e5f6995f368e14f4dd0.png"},{"id":55088463,"identity":"91e5081b-11b8-4013-b03e-5fa6556e170d","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":158840,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of CROM-Cervical left side flexion (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/c50ef0febde9b8c36c76b8fd.png"},{"id":55089074,"identity":"ee0b21be-c9d9-479f-a510-ecb526f4575b","added_by":"auto","created_at":"2024-04-22 12:01:35","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":156902,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of CROM-Cervical right rotation (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage10.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/a8ba03cdb783cdc94b68086a.png"},{"id":55088460,"identity":"a1b2f02f-fbd7-403b-8c87-b5f7f4ef1dbf","added_by":"auto","created_at":"2024-04-22 11:53:35","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":164318,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis forest plots of CROM-Cervical right side flexion (continuous type variables) for the three included studies.\u003c/p\u003e","description":"","filename":"floatimage11.png","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/3a0adbb87f35a0ab8c247807.png"},{"id":60040367,"identity":"6209fa2e-9ac3-4e8a-b508-353bfb199050","added_by":"auto","created_at":"2024-07-11 02:44:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3371065,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/e44074f9-70fd-4b47-976a-e7e5dc822a31.pdf"},{"id":55089071,"identity":"9050cea7-9a0d-4a83-8935-704cd2de34c3","added_by":"auto","created_at":"2024-04-22 12:01:35","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":35328,"visible":true,"origin":"","legend":"","description":"","filename":"file1.doc","url":"https://assets-eu.researchsquare.com/files/rs-4193987/v1/2f57988635317b535d207c72.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effectiveness of Neural Mobilization Combined with Cervical Traction in the Treatment of Cervical Spondylotic Radiculopathy: A Meta-Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical Spondylotic Radiculopathy (CSR) is primarily defined as degenerative changes occurring in the cervical spine, particularly affecting the intervertebral disc and joints. This degeneration exerts undue pressure on the corresponding cervical nerve roots, leading to root compression or irritation symptoms\u003csup\u003e[1]\u003c/sup\u003e. As the most prevalent form of cervical spondylosis, CSR\u0026apos;s incidence rate, currently between 50% and 60%, is on an upward trajectory. The disease\u0026apos;s impact extends beyond physical symptoms like pain, numbness, and muscle weakness in the neck and regions innervated by the nerve roots\u003csup\u003e[2]\u003c/sup\u003e. It significantly impairs patients\u0026apos; functionality in both work and daily activities. More concerning are its psychological repercussions, including reduced sleep quality and emotional disturbances, with severe cases potentially escalating to bowel and bladder dysfunctions or limb paralysis\u003csup\u003e[3]\u003c/sup\u003e. Thus, effectively preventing and treating CSR is imperative for mitigating its substantial health implications\u003csup\u003e[4]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTreatment modalities for CSR are broadly categorized into non-surgical and surgical interventions. Non-surgical treatments and preferred approaches encompass cervical traction, physical therapy, pharmacotherapy, and lifestyle changes\u003csup\u003e[21]\u003c/sup\u003e. However, limitations arise due to the variable quality of evidence and potential adverse reactions from drugs\u003csup\u003e[6]\u003c/sup\u003e. For example, oral non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for severe pain relief\u003csup\u003e[5]\u003c/sup\u003e. Yet, their prolonged usage raises concerns about increased risks of hypertension, cardiovascular events, gastrointestinal ulcers, acute renal failure, and deterioration of existing heart failure conditions\u003csup\u003e[7]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eMany CSR patients gravitate towards specific conservative treatments, particularly Neural Mobilization combined with Cervical Traction \u0026nbsp;(NMCT)\u003csup\u003e[8]\u003c/sup\u003e. NMCT, a manual therapy technique, aims to alleviate nerve-related pain by enhancing nerve circulation and reducing nerve tension\u003csup\u003e[9]\u003c/sup\u003e. This approach effectively mobilizes median, radial, and ulnar nerves, thus relieving pain. What sets NMCT apart is its adaptability; treatment dosage is finely tuned to each patient\u0026apos;s unique response, ensuring a comfortable range of both duration and intensity of therapy. NMCT is relatively novel yet rapidly evolving compared to other treatments, offering exceptional benefits in managing peripheral nerve injuries and showing immediate effectiveness in relieving entrapment-related pain\u003csup\u003e[8]\u003c/sup\u003e\u003csup\u003e[9]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eDespite NMCT\u0026apos;s application in CSR treatment, more comprehensive evidence of its efficacy and safety must be provided. Consequently, existing literature are critically evaluated in this study to determine the effectiveness and safety of NMCT as a therapeutic strategy for CSR.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIt was according to the methodological guidelines described in the Cochrane Handbook for Systematic Reviews of Interventions that this systematic review was conducted\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003e[10]\u003c/sup\u003e, as well as in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The review protocol was registered in the PROSPERO database (registration code: CRD42024522227).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch Strategy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe search strategy used in this study was developed to encompass three primary aspects: the participants (patients with Cervical Spondylotic Radiculopathy or CSR), the intervention (neural mobilization combined with traction treatment in the treatment group versus traction treatment alone in the control group), and the study type (Randomized Controlled Trials or RCTs).\u003c/p\u003e\n\u003cp\u003eA comprehensive literature search used keywords and free-text terms to identify pertinent studies. The timeframe for this search extended from each database\u0026apos;s inception until February 28, 2024. The included databases were PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), China Biology Medicine Disc (CBM), Wanfang Database, and the China Science and Technology Journal Database (VIP). Our search terms, utilized in both Chinese and English, included phrases such as \u0026quot;cervical spine radiculopathy,\u0026quot; \u0026quot;Cervical Radiculopathy,\u0026quot; \u0026quot;neural mobilization,\u0026quot; and \u0026quot;randomized controlled trials\u0026quot; among others. The complete search strategy is detailed in Supplementary File 1. Modifications were made to this strategy as required for compatibility with other electronic databases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe processes of selecting studies and extracting data were carried out by two review authors (GJZ, YYL), independently. Results from all searches, such as titles, abstracts, and full references, were managed using Endnote X9 to identify and eliminate duplicates. Subsequently, in order to ensure alignment with our inclusion criteria, the titles, abstracts, and full texts of these studies were independently screened and meticulously analyzed(Fig.1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe risk of bias assessment tool recommended by Cochrane was employed to ensure rigorous quality and bias assessment of all included studies. Two expert reviewers independently examined the full texts with the use of a standardized data extraction form. Discrepancies between reviewers were sorted out through discussion or, if necessary, by involving a third reviewer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTypes of Studies:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review includes published randomized controlled trials (RCTs). No restrictions were imposed on the date of publication or language. Focus was put on studies relevant to clinical prediction rules and with symptoms associated with CSR, such as arm pain, and whether there is presence of accompanying motor or sensory dysfunction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTypes of participants.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participating subjects must be symptomatic adults aged 18 years and older, and no limitation was imposed regarding gender. Participants need to have a diagnosis of CSR based on at least one of the following: 1) diagnosis based on magnetic resonance imaging, electromyography, or nerve conduction velocity testing; 2) not less than three positive results should be obtained out of four tests (Spurling\u0026apos;s test, Distraction test, Upper Limb Neurodynamic Test 1, and ipsilateral cervical rotation of less than 60\u0026deg;) based on clinical prediction rules; and 3) symptoms related to CSR, such as radiating pain to the arms, with or without presence of motor or sensory dysfunction. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTypes of Interventions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe scope of our review encompassed RCTs that contrasted the effects of nerve relaxation therapy combined with CT versus CT alone. In the experimental groups, participants received a combination of nerve relaxation and cervical traction. Control groups were treated with CT exclusively. We considered studies involving manual and mechanical traction methods, including continuous and intermittent applications. The traction positions employed needed to be consistent across the studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTypes of Outcome Measures:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur inclusion criteria for RCTs were based on the utilization of at the minimum one of the following outcome measures: pain intensity, gauged using tools like a Visual Analog Scale (VAS) or Numeric Pain Rating Scale (NPRS); the craniocervical flexion test (CCFT); functional/disability assessments conducted using validated scales such as the Neck Disability Index (NDI) or measurements of the range of motion (ROM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Synthesis and Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy using a specially designed form, the process of data extraction was meticulously carried out by two reviewers. This form captured critical details including (1) authorship and year of publication; (2) basic participant information for each group, such as number of participants, gender and age of the participants; (3) differences in treatment methods and duration between the experimental and control groups; and (4) study results, focusing on outcome indicators crucial for evaluating results.\u003c/p\u003e\n\u003cp\u003eThe Review Manager (RevMan) software version 5.4 was utilized for the meta-analysis. Binary variables were analyzed using risk ratios (RR) and continuous variables using mean differences (MD), both with a 95% confidence interval (CI). Heterogeneity was assessed, and a fixed-effects model was applied when P \u0026gt; 0.1 and I2 \u0026lt; 50%, which indicates low heterogeneity. On the contrary, a random-effects model was chosen if significant heterogeneity was observed, and sensitivity analyses were carried out to identify heterogeneity sources. Subgroup analyses were also performed as required. The results of these analyses were visually represented in forest plots and funnel plots.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e ①Visual analogue scale，VAS②Tanaka Yasushi cervical spondylitis symptom scale 20 score③The Neck Disability Index (NDI) ④The Numeric Pain Rating Scale (NPRS) ⑤The Patient-Specific Functional Scale (PSFS)⑥Grip strength (GS) ⑦ROM⑧The craniocervical flexion test (CCFT).⑨36 items short form health survey (SF-36)⑩The upper limb tension test-1\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"513\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eStudy ID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.16374269005848%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristics of participants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eAuthors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e(Year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003edesign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eSample size (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eMean age (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eFemale n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003eOutcome timing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003eOutcomes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eTang\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eTotal(72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:no informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e①②\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eFang-ming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eEG(36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eEG:44.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(37.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e2 sessions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e（2018）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eCG(36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eEG:14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003eFollow-up:3-month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eCG:45.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(38.89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003epost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;2.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eCG:13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(36.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eChristos\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eTotal(44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:no informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;③④⑤⑥⑦\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eSavva\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eEG(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eEG:47.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(45.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e(2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eCG(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;10.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eEG:11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eCG:48.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;11.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eCG:9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(40.91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eShazia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eTotal(88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:no informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e③④⑦\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eRafiq\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eEG(44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eEG:41.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(68.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e(2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eCG(44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;6.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eEG:29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eCG:42.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(65.91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;5.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eCG:31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(70.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eShazia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eTotal(88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:no informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e.⑧⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eRafiq\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eEG(44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eEG:41.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(68.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e(2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eCG(44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;6.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eEG:29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eCG:42.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(65.91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;5.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eCG:31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(70.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eDong\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eTotal(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:no informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e③④⑦⑧\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eGyu Kim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eEG(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eEG:29.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(63.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e4 weeks and 8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e（2017）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eCG(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;3.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eEG:9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eCG:29.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(60.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e(\u0026plusmn;3.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eCG:10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(66.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eAsmaa Omer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eTotal(40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eNo informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eNo informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e①⑩\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eIbrahim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eEG(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e3 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e(2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eCG(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003eLi Wen-li\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eTotal(48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003eNo informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eTotal:22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e①②\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eEG(26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(45.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e5 days and 10 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003eCG(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eEG:12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(46.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003eCG:10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.695906432748538%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.161793372319687%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.009746588693957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.153996101364523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.619883040935672%\" valign=\"top\"\u003e\n \u003cp\u003e(45.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.128654970760234%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.230019493177387%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eLiterature Search Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur comprehensive database search initially yielded 785 potentially relevant studies, which were imported into EndNote X9 for organization and review. Of these, 275 duplicates were identified and excluded. Through reviewing the titles and abstracts, 441 studies were further excluded. Then, according to our inclusion and exclusion criteria, an additional 68 studies were eliminated. After rigorously filtering out non-randomized controlled trials and studies not aligning with our research focus, seven articles remained for inclusion\u0026nbsp;[11][12][13][14][15][16][17]. The process of literature search and selection is illustrated through a flow chart in Figure 1. The final sample comprised 410 patients, who were divided into a treatment group of 207 subjects (receiving NM combined with CT) and a control group of 203 subjects (receiving CT alone). Table 1 details the essential characteristics of these studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Risk of Bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll included studies randomly assigned patients into either the experimental or control group. However, three studies needed more detailed information on the randomization process\u0026nbsp;[14][16][17]. Blinded analysis of outcome assessors was reported in three studies\u0026nbsp;[11][12][13]. Regarding selective reporting bias, all trials reported the anticipated outcomes. Figures 2 and 3 display the risk-of-bias assessment for these studies (Fig.2,3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVisual Analogue Scale (VAS Score)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA meta-analysis was conducted to evaluate the impact of NM and CT treatments on pain and functional improvement in CSR patients by employing the clinical Visual Analogue Scale (VAS). This analysis incorporated three data sets of continuous variables[13-14-15]. The pooled analysis, involving 160 cases, revealed a statistically significant combined effect [MD = -0.99, 95% CI (-1.38, -0.60), Z = 4.93, P = 0.003]. These results suggest that the combination of NM and CT treatments is significantly more effective than CT treatment alone (Fig4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Numeric Pain Rating Scale (NPRS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree randomized controlled trials [9, 10, 12] involving 162 subjects compared the effectiveness of different interventions using the Numeric Pain Rating Scale (NPRS). The pooled data analysis indicated a remarkable reduction in pain scores for the NMCT group [MD = -0.70, 95% CI (-1.02, -0.38), Z = 4.27, P = 0.09], as shown in Figure 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeck Disability Index (NDI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Neck Disability Index (NDI) scores were compared across three randomized controlled trials [9, 10, 12], encompassing 162 subjects. The results demonstrated statistically significant differences in NDI scores between the intervention methods (Figure 6) [MD = -5.13, 95% CI (-6.99, -3.27), Z = 5.40, P = 0.03].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Craniocervical Flexion Test (CCFT)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo randomized controlled trials [11, 12] with 118 subjects compared the craniocervical flexion test (CCFT) outcomes under different interventions. The results did not show statistically significant differences in cervical flexion between the interventions (Figure 7) [MD = 1.37, 95% CI (0.41, 2.33), Z = 2.80, P = 0.65]. The absence of important difference may be due to the substantial variation in subject numbers across the studies. However, the data suggest that NMCT may be more effective than CT alone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eActive Range of Cervical Motion (ROM)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Active Range of Cervical Motion (ROM) was assessed using a hydraulic dynamometer and a general goniometer. This assessment measured grip strength and ROM regarding extension, flexion, side flexion, and rotation of the affected and contralateral arms. Three studies [9, 10, 12] involving 162 subjects reported on ROM, including cervical extension, flexion, and rotation. The results, however, did not reach statistical significance, possibly due to the small effect sizes. Specific ROM outcomes are detailed as follows: ROM-Cervical extension [MD = 3.90, 95% CI (1.54, 6.27), Z = 3.23, P = 0.06], ROM-Cervical flexion [MD = 2.56, 95% CI (0.43, 4.70), Z = 2.35, P = 0.31], and others as shown in the study (Fig8,9,10,11,12).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSubstantial evidence supporting the effectiveness of neurodynamic techniques as interventions for cervical radiculopathy is presented in this systematic review and meta-analysis. These techniques have shown considerable efficacy in alleviating symptoms such as dizziness, numbness in the extremities, pain, and restricted range of motion. Notably, improvements observed in the Visual Analog Scale (VAS) and Neck Disability Index (NDI) scores underscore neurodynamic mobilization's capability to significantly reduce localized pain and enhance cervical range of motion among the affected patients.\u003c/p\u003e \u003cp\u003eNeural Mobilization (NM) involves the passive manipulation of neural structures within limbs to restore normal movement and structural integrity \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. This technique has also been effective in mitigating pain associated with neuropathic conditions like leprosy \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e and other disorders such as rheumatoid arthritis \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Despite its therapeutic potential, the broader understanding and application of neural mobilization in clinical practice still need to be improved.\u003c/p\u003e \u003cp\u003eTo address this gap, our meta-analysis specifically compared the effectiveness of the combined use of Neural Mobilization and Cervical Traction (NMCT) versus the use of CT alone in the treatment of pain and functional impairment in Cervical Spondylotic Radiculopathy (CSR). Our findings, derived from an analysis of 410 CSR patients, revealed significant reduction in pain and enhancement in functional performance post-neural mobilization. The study showed statistically significant improvements in VAS and NDI scores. In contrast, results for the Numeric Pain Rating Scale (NPRS), Craniocervical Flexion Test (CCFT), and Range of Motion (ROM) were not statistically significant. This outcome indicates that while neural mobilization demonstrates beneficial effects, its full therapeutic potential is yet to be completely realized. Consequently, further large-scale clinical randomized controlled trials are necessary in order to more comprehensively assess the efficacy of neural mobilization in the treatment of CSR.\u003c/p\u003e \u003cp\u003eThis meta-analysis has revealed that Neural Mobilization (NM) treatment offers significant benefits for Cervical Spondylotic Radiculopathy (CSR) patients. It notably improves clinical symptoms, neurological function, and overall quality of life. Compared to traditional conservative treatments, NM demonstrates greater efficacy in symptom reduction and enhancement of treatment outcomes. However, the current body of high-quality Randomized Controlled Trials (RCTs) on NM treatment for CSR is relatively limited. This lack of robust literature has resulted in some outcome indicators failing to achieve statistical significance, leading to biased and tentative conclusions. Therefore, to substantiate and broaden these findings, conducting additional high-quality RCTs focusing on NM treatment for CSR is crucial.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, our meta-analysis revealed that the combined approach of NM and CT outperformed the use of CT alone in treating CSR. Notably, patients receiving the combined NMCT therapy exhibited significantly reduced Visual Analog Scale (VAS) and Neck Disability Index (NDI) scores compared to those receiving CT alone. These findings highlight the potential therapeutic benefits of incorporating NM into the standard CT protocol for CSR, thereby enhancing treatment outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included within the manuscript or supplementary information file\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: Guojun Zhang,Yueyue Liu,Jingyu Zhang. Acquisition of data: Guojun Zhang,Yueyue Liu,Jingyu Zhang. Analysis and interpretation of data: Guojun Zhang,Yueyue Liu,Jingyu Zhang. Draft of manuscript: Guojun Zhang,Yueyue Liu,Jingyu Zhang.Critical revision of manuscript: Guojun Zhang,Yueyue Liu,Jingyu Zhang.All authors reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOpen access funding provided by The National Natural Science Foundation of China.The National Natural Science Foundation of China: A Study on the Mechanism of Electroacupuncture in Promoting the Repair of Chronic Muscle Injury in the Neck of Rats, Grant Number: 82074181,and anti-inflammatory analgesia mechanism of acupuncture regulating FMS glial cell-neuron crosstalk through CX3CL1/CX3CR1axis to alleviate central sensitization,Grant Number:82374202.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKurupath Radhakrishnan, William J. 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Prim Care 2013;40:837\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cervical Spondylosis Radiculopathy, Neural mobilization, cervical traction","lastPublishedDoi":"10.21203/rs.3.rs-4193987/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4193987/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCervical Spondylosis Radiculopathy (CSR), a degenerative condition affecting the cervical spine,characterized by the irritation and compression of nerve roots, leading to a range of clinical symptoms such as numbness and pain in the neck, shoulders, upper limbs, and fingers. Neural Mobilization (NM)combined with Cervical Traction (CT) has emerged as a noteworthy therapeutic approach for CSR, gaining recognition for its effectiveness. This study endeavors to conduct a comprehensive and systematic review of available randomized controlled trials (RCTs) on NMCT. The objective is to critically assess the efficacy and safety of NM as a treatment modality for CSR.The study will analyze the methodologies, results, and any specific findings from the RCTs, providing a comprehensive assessment of the role of NMCT in managing CSR.\u003c/p\u003e","manuscriptTitle":"The Effectiveness of Neural Mobilization Combined with Cervical Traction in the Treatment of Cervical Spondylotic Radiculopathy: A Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-22 11:53:30","doi":"10.21203/rs.3.rs-4193987/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"76e4adce-c571-4732-929b-00ab3c937c89","owner":[],"postedDate":"April 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30883164,"name":"Health sciences/Diseases/Neurological disorders/Neurodegenerative diseases"},{"id":30883165,"name":"Health sciences/Diseases/Neurological disorders/Neuromuscular disease"},{"id":30883166,"name":"Health sciences/Diseases/Neurological disorders/Neuropathic pain"}],"tags":[],"updatedAt":"2024-07-11T02:36:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-22 11:53:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4193987","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4193987","identity":"rs-4193987","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}