Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome

Impact of the Order of Movement on the Median Nerve Root Function: A Neurophysiological Study with Implications for Neurodynamic Exercise Sequencing

Background: Neurodynamic exercise is a common clinical practice used to restore neural dynamic balance. The order in which movements are performed during these exercises is believed to play a crucial role in their effectiveness. This study aimed to investigate the impact of different sequences of neurodynamic exercise on nerve root function, with a specific focus on the median nerve. Methods: Participants were assigned randomly to three experimental groups, each undergoing a different test sequence: standard, proximal-to-distal, and distal-to-proximal. Dermatomal somatosensory evoked potentials (DSSEPs) were recorded at key levels (C6, C7, C8, and T1). Results: The findings revealed a significant influence of the movement sequence on DSSEP amplitudes. The execution of neurodynamic exercise in the proximal-to-distal sequence was associated with a notable reduction in amplitudes (p < 0.05). Conversely, the distal-to-proximal sequence resulted in increased amplitudes compared to the standard sequence (p < 0.05). Conclusions: This study underscores the importance of carefully considering the order of movements during neurodynamic exercising, particularly when evaluating nerve roots that lack the protective perineurium. The choice of sequence appears to have a substantial impact on nerve function, with implications for optimizing clinical neurodynamic exercise techniques.

The effectiveness of mobilization with movement on patients with mild and moderate carpal tunnel syndrome: A single-blinded, randomized controlled study

STUDY DESIGN

Single-blinded, randomized controlled study.

INTRODUCTION

Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders.

PURPOSE OF THE STUDY

This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS.

METHODS

A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome.

RESULTS

We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group.

DISCUSSION

This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients.

CONCLUSIONS

MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program.

The consequences of a thoracic outlet syndrome's entrapment model on the biomechanics of the ulnar nerve - Cadaveric study

STUDY DESIGN

A cross sectional cadaveric measurement study.

INTRODUCTION

The etiology of entrapment neuropathies, such as carpal tunnel syndromes or thoracic outlet syndromes (TOS), is usually not only linked with the compressive lesion of the nerve but can also be associated with fibrosis and traction neuropathy.

PURPOSE OF THE STUDY

This work studies the biomechanics of the ulnar nerve in a cadaveric model of thoracic outlet syndrome (TOS). We explored the biomechanical impact of a restriction of mobility of the ulnar nerve. We measured if it could significantly affect the deformation undergone by the nerve on the rest of its path.

METHODS

We studied 14 ulnar nerves from 7 embalmed cadavers. We opened three 6.5cm windows (at the wrist, forearm, and arm), and two optical markers 2cm apart were sutured to the ulnar nerve. We then studied the deformation of the ulnar nerve in three successive tensioning positions inspired by the ULNT3 manoeuvre (Upper Limb Neural Test 3). We then fixed the brachial plexus to the clavicle to mimic a nerve adhesion at the thoracic outlet.

RESULTS

Fixing the brachial plexus to the clavicle bone had significant effects on ulnar nerve mobility. In the position of intermediate tension, the nerve deformation increased by +0.68% / +1.43% compared to the control measure. In the position of maximum tension, it increased by +1.16% / +1.94%, pushing the nerve beyond the traumatic threshold of 8% of deformation causing reversible damage to axonal transport and vascularization.

CONCLUSIONS

Our nerve adhesion at the thoracic outlet showed significant effects on the mobility of the ulnar nerve compared to the control situation, by significantly increasing the deformation undergone throughout the rest of the nerve's course, and by taking it over the 8% of physiological traumatic deformation.

Effectiveness of physiotherapy plus acupuncture compared with physiotherapy alone on pain, disability and grip strength in people with carpal tunnel syndrome: A randomized clinical trial

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome in the upper extremities. Acupuncture is often used as a treatment method in CTS and numerous studies consider it effective. However, no study has yet compared the efficacy of physical therapy including bone and neural mobilization, exercise and electrotherapy with and without acupuncture in CTS patients.

PURPOSE

comparing the effect of physiotherapy plus acupuncture with physiotherapy alone on pain, disability and grip strength in CTS patients.

METHOD

Forty patients with mild to moderate CTS were randomly divided into two equal groups. Both groups received exercise and manual techniques for 10 sessions. Patients in the physiotherapy plus acupuncture group also received 30 min of acupuncture in every session. The visual analog scale (VAS) score, the score on the Boston carpal tunnel questionnaire for functional status and symptom severity, shortened disability of arm, shoulder, hand (Quick-DASH) score and grip strength were evaluated at pre-test and post-test.

RESULTS

According to ANOVA results, there is a significant interaction between group and time for VAS, BCTQ and Quick-DASH parameters. At the post-test, while the parameters of VAS, BCTQ and Quick-DASH in the physiotherapy plus acupuncture group had a statistically significant difference compared to the physiotherapy group, no significant difference was observed between the two groups in the pre-test. Moreover, there is no significant difference between groups in grip strength improvement.

CONCLUSION

This study shows preliminary evidence that physiotherapy plus acupuncture, was more effective than physiotherapy alone in pain relief and improving disability of patients suffering from CTS.

Mechanical Effects of a Specific Neurodynamic Mobilization of the Superficial Fibular Nerve: A Cadaveric Study

CONTEXT

A specific neurodynamic mobilization for the superficial fibular nerve (SFN) has been suggested in the reference literature for manual therapists to evaluate nerve mechanosensitivity in patients. However, no authors of biomechanical studies have examined the ability of this technique to produce nerve strain. Therefore, the mechanical specificity of this technique is not yet established.

OBJECTIVES

To test whether this examination and treatment technique produced nerve strain in the fresh frozen cadaver and the contribution of each motion to total longitudinal strain.

DESIGN

Controlled laboratory study.

SETTING

Laboratory.

MAIN OUTCOME MEASURE(S)

A differential variable reluctance transducer was inserted in 10 SFNs from 6 fresh cadavers to measure strain during the mobilization. A specific sequence of plantar flexion, ankle inversion, straight-leg raise position, and 30° of hip adduction was applied to the lower limb. The mobilization was repeated at 0°, 30°, 60°, and 90° of the straight-leg raise position to measure the effect of hip-flexion position.

RESULTS

Compared with a resting position, this neurodynamic mobilization produced a significant amount of strain in the SFN (7.93% ± 0.51%, P < .001). Plantar flexion (59.34% ± 25.82%) and ankle inversion (32.80% ± 21.41%) accounted for the biggest proportions of total strain during the mobilization. No difference was noted among different hip-flexion positions. Hip adduction did not significantly contribute to final strain (0.39% ± 10.42%, P > .05), although high variability among limbs existed.

CONCLUSIONS

Ankle motion should be considered the most important factor during neurodynamic assessment of the SFN for distal entrapment. These results suggest that this technique produces sufficient strain in the SFN and could therefore be evaluated in vivo for correlation with mechanosensitivity.

Multiple Concurrent Decompressions for the Treatment of Upper Extremity Pain

Purpose

Neuropathic pain can be life altering and difficult to treat. Nerves can be compressed along their path in the upper extremities, resulting in chronic neuropathic pain. This study was performed to evaluate the effectiveness and safety of multiple concomitant distal nerve decompressions for the treatment of upper extremity nerve pain.

Methods

A retrospective review of patients from a single surgeon's academic practice was performed to identify those undergoing nerve decompressions for an indication of "pain" as the referring diagnosis between April 2020 and June 2021. The primary outcomes included patient-reported severity of pain using the Visual Analog Scale and quality-of-life measures, including level of frustration, depression, and impact on quality of life attributable to pain on a similar 0-10 Likert scale. Complications, if any, were also determined.

Results

Eleven patients were identified to have undergone multiple concurrent nerve decompressions for the indication of upper extremity pain. All sites chosen for decompression were found to be provocative, ie, elicited increased pain on examination with compression. The median number of decompressions performed was 5 (interquartile range, 4-6), ranging from 3 to 7. The mean follow-up time was 5 months (SD, 3.43 months). The average pain over the last month and the average pain over the past week had significant improvement at the final follow-up, and there was a statistically significant decrease in the patient-reported mean impact of pain on quality of life following decompressions (preoperative, 5.8; postoperative, 3.6; P = .017; 95% confidence interval, 0.2-4.3). No complications were identified.

Conclusions

Performing multiple concomitant nerve decompressions of the upper extremities is safe and effective in the treatment of chronic neuropathic pain following upper extremity trauma.

Type of study/level of evidence

Therapeutic IV.

Comparison of Two Manual Therapy Programs, including Tendon Gliding Exercises as a Common Adjunct, While Managing the Participants with Chronic Carpal Tunnel Syndrome

Background

Carpal tunnel syndrome (CTS) is the symptomatic compression neuropathy of the median nerve at the wrist level that may become a reason for upper limb disability, in the women and men population.

Objective

This study aimed to compare the efficacy of the neurodynamic technique (NT) and carpal bone mobilization technique (CBMT) incorporated with tendon gliding exercises (TGE) as an effect-enhancing adjunct while managing the participants with chronic CTS.

Methods

The study followed a two-arm parallel-group randomized comparative design. Thirty participants (aged 30–59 years) with chronic CTS were recruited randomly to both the NT and CBMT groups. In addition to the TGE (a common adjunct), NT and CBMT were performed in the NT and CBMT groups, respectively, for three weeks. The primary outcome measures including pain intensity, functional status, grip strength, and motor nerve conduction study were assessed using a visual analogue scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), hand-held dynamometer, and electromyograph, respectively, at baseline, 3 weeks postintervention, and follow-up at one week post end of the intervention. Paired and unpaired t-test were used to calculate the differences in intervention effects within and between the groups with keeping the level of significance α at 0.05.

Results

The data analysis revealed a significant (95% CI, p < 0.05) difference for all outcomes within each group compared across different time intervals. Similarly, a significant difference was found for all outcomes except pain and grip strength compared between groups at 3 weeks postintervention and follow-up at one week post end of the intervention.

Conclusions

The NT revealed more effectiveness than the CBMT when incorporated with TGE to improve nerve conduction velocity and functional status of the hand. However, both NT and CBMT were equally effective in improving pain and grip strength while managing the participants with chronic CTS. In addition, the TGE contributed as a beneficial, effect-enhancing adjunct to the NT and CBMT differently. Significance. The study will guide the physiotherapist in applying either of the combination techniques suitable for achieving treatment objectives while managing the participants with chronic CTS.

Quantifying the Elasticity Properties of the Median Nerve during the Upper Limb Neurodynamic Test 1

Background

The upper limb neurodynamic test 1 (ULNT1) consists of a series of movements that are thought to detect an increase in neuromechanical sensitivity. In vivo, no trail was made to quantify the association between the nerve elasticity and different limb postures during ULNT1.

Objectives

(1) To investigate the relationship between nerve elasticity and limb postures during ULNT1 and (2) to investigate the intra- and interoperator reliabilities of shear wave elastography (SWE) in quantifying the elasticity of median nerve.

Methods

Twenty healthy subjects (mean age: 19.9 ± 1.4 years old) participated in this study. The median nerve was imaged during elbow extension in the following postures: (1) with neutral posture, (2) with wrist extension (WE), (3) with contralateral cervical flexion (CCF), and (4) with both WE and CCF. The intra- and interoperator reliabilities measured by two operators at NP and CCF+WE and intraclass correlation coefficients (ICCs) were calculated.

Results

The intraoperator (ICC = 0.72–0.75) and interoperator (ICC = 0.89–0.94) reliabilities for measuring the elasticity of the median nerve ranged from good to excellent. The mean shear modulus of the median nerve increased by 53.68% from NP to WE+CCF.

Conclusion

SWE is a reliable tool to quantify the elasticity of the median nerve. There was acute modulation in the elasticity of the median nerve during the ULNT1 when healthy participants reported substantial discomfort. Further studies need to focus on the elasticity properties of the median nerve in patients with peripheral neuropathic pain.

Comparative Effects of Tensioning and Sliding Neural Mobilization on Peripheral and Autonomic Nervous System Function: A Randomized Controlled Trial

Background:

Although different types of neural mobilization (NM) exercises induce different amounts of longitudinal nerve excursion and strain, the question whether the increased longitudinal stress and nerve excursion from sliding or tensioning intervention may subtly affect the neural functions has not been answered yet.

Objective:

To compare the effects of tensioning NM versus sliding NM of the median nerve on peripheral and autonomic nervous system function.

Methods:

In this randomized controlled trial, 90 participants were randomly assigned to tensioning NM, sliding NM, or sham NM. The neurophysiological outcome measures included peak-to-peak amplitude of the dermatomal somatosensory evoked potential (DSSEP) for dermatomes C6, C7, C8, and T1. Secondary outcome measures included amplitude and latency of skin sympathetic response. All outcome measures were assessed pretreatment, immediately after the two weeks of treatment and one week after the last session of the treatment.

Results:

A 2-way repeated measures ANOVA revealed significant differences between the three groups. The post hoc analysis indicated that tensioning NM significantly decreased the dermatomal amplitude for C6, C7, C8, and T1 (p<0.005). Sympathetic skin responses in the gliding NM group showed lower amplitudes and prolonged latencies post-treatment when compared to tensioning NM group (p<0.05). In contrast, no significant changes were observed in the DSSEPs and skin sympathetic responses for participants in the sham treatment group (p>0.05).

Conclusions:

A tensioning NM on the median nerve had a possible adverse effect on the neurophysiology variables of the nerves involved in the neural mobilization. Thus, tensioning NM with the current parameters that place increased stress and strain on the peripheral nervous system should be avoided.

Effect of Neural Mobilization Exercises in Patients With Low Back-Related Leg Pain With Peripheral Nerve Sensitization: A Prospective, Controlled Trial

Objective

The aim of this study was to investigate the short-term effect of slider and tensioner exercises on pain and range of motion (ROM) of straight leg raise (SLR) and slump tests in patients with low back-related leg pain with peripheral nerve sensitization.

Methods

In this prospective, controlled trial, 51 patients with low back-related leg pain with peripheral nerve sensitization were divided into 3 treatment groups: slider (slider neural mobilization exercise + transcutaneous electric nerve stimulation [TENS]), tensioner (tensioner neural mobilization exercise + TENS), and control (only TENS). Each patient received 6 sessions over 2 weeks. The following outcomes were measured at baseline and after the first, third, and sixth sessions: visual analog scale (VAS) for pain and ROM of SLR and slump tests were performed for the symptomatic side.

Results

Compared with controls, patients receiving the slider and tensioner exercises showed a greater decrease in pain at the third and sixth sessions (mean difference: ≥1.54 cm; 95% CI, 0.1-3.9). There was a significant difference in the ROM of the SLR test between the slider and controls at only the sixth session (mean difference: 16.7°; 95% CI, -29.2 to -4.3). Patients in the slider and tensioner groups demonstrated greater improvements in the ROM of slump test at all sessions compared with controls (mean difference: ≥12.5°; 95% CI, -32.1 to -6.4). There were no significant differences between the slider and tensioner groups in any outcome at any session.

Conclusion

Patients in both slider and tensioner neural mobilization exercise groups demonstrated improvements in pain and ROM in patients with low back-related leg pain with peripheral nerve sensitization compared to those in the control group.

The long-term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial

INTRODUCTION

Carpal tunnel syndrome (CTS) is a common disorder that limits function and quality of life. Little evidence is available on the long-term effect of neurodynamics and exercise therapy.

PURPOSE OF THE STUDY

This study aimed to examine the long-term effect of neurodynamic techniques vs exercise therapy in managing patients with CTS.

STUDY DESIGN

Parallel group randomized clinical trial.

METHODS

Of 57 patients screened, 51 were randomly assigned to either receiving four sessions of neurodynamics and exercise or home exercise therapy alone as a control. Blinded assessment was performed before treatment allocation, at treatment completion, and 6 months posttreatment. Outcome measures included Symptom Severity Scale (SSS), Functional Status Scale (FSS), Shortened version of the Disabilities of the Arm, Shoulder, and Hand (DASH), Numerical Pain Rating Scale, grip strength and range of motion.

RESULTS

Data from 41 individuals (52 hands) were analyzed. The neurodynamics group demonstrated significant improvement in all outcome measures at 1 and 6 months (P < .05). Mean difference in SSS was 1.4 (95% CI= 0.9-1.4) at 1 month and 1.6 (95% CI = 0.9-2.2) at 6 months. Mean difference in FSS was 0.9 (95% CI = 0.4-1.4) at 1 month and 1.4 (95% CI = 0.7-2.0) at 6 months. Significant between-group differences were found in pain score at 1 month (-1.93) and in FSS (-0.5) and Shortened version of DASH (-12.6) at 6 months (P < .05). No patient needed surgery 1 year after treatment.

CONCLUSIONS

Although both treatments led to positive outcomes, neurodynamics therapy was superior in improving function and strength and in decreasing pain.

Neurodynamics: is tension contentious?

Tensioning techniqueswere the first neurodynamic techniques used therapeutically in the management of people with neuropathies. This article aims to provide a balanced evidence-informed view on the effects of optimal tensile loading on peripheral nerves and the use of tensioning techniques. Whilst the early use of neurodynamics was centered within a mechanical paradigm, research into the working mechanisms of tensioning techniques revealed neuroimmune, neurophysiological, and neurochemical effects. In-vitro and ex-vivo research confirms that tensile loading is required for mechanical adaptation of healthy and healing neurons and nerves. Moreover, elimination of tensile load can have detrimental effects on the nervous system. Beneficial effects of tensile loading and tensioning techniques, contributing to restored homeostasis at the entrapment site, dorsal root ganglia and spinal cord, include neuronal cell differentiation, neurite outgrowth and orientation, increased endogenous opioid receptors, reduced fibrosis and intraneural scar formation, improved nerve regeneration and remyelination, increased muscle power and locomotion, less mechanical and thermal hyperalgesia and allodynia, and improved conditioned pain modulation. However, animal and cellular models also show that ‘excessive’ tensile forces have negative effects on the nervous system. Although robust and designed to withstand mechanical load, the nervous system is equally a delicate system. Mechanical loads that can be easily handled by a healthy nervous system, may be sufficient to aggravate clinical symptoms in patients. This paper aims to contribute to a more balanced view regarding the use of neurodynamics and more specifically tensioning techniques.

Sensory Nerve Conduction Velocity Predicts Improvement of Hand Function with Nerve Gliding Exercise Following Carpal Tunnel Release Surgery

This study aims to investigate the effects of nerve gliding exercise following carpal tunnel release surgery (NGE-CTRS) and the probing factors affecting the effect of NGE-CTRS on hand function. A total of 86 patients after CTRS participated. Grip strength (grip-s), pinch strength (pinch-s), Semmes-Weinstein monofilament test (SWMT), two-point discrimination (2PD), numbness, pain, and Phalen test (Phalen) were measured and compared between pre- and post-NGE-CTRS. The results showed that the combination of surgery and NGE significantly improved the postoperative grip-s, pinch-s, SWMT, 2PD, numbness, and Phalen; however, no improvement was observed in pain. Background factors that influenced the improved grip-s and pinch-s included gender and preoperative sensory nerve conduction velocity (SCV). Additionally, numbness and Phalen were not affected by age, gender, fault side, bilateral, trigger finger, dialysis, thenar eminence atrophy, motor nerve conduction velocity, SCV, the start of treatment, and occupational therapy intervention. In conclusion, the combination of surgical procedures and NGE showed a high improvement. SCV and time-to-start treatment of intervention for carpal tunnel syndrome may be useful in predicting the function after the intervention.

High-resolution ultrasound demonstrates in vivo effects of wrist movement on the median nerve along the forearm

INTRODUCTION/AIMS

High-resolution ultrasound (HRUS) is the imaging method of choice to visualize peripheral nerve size, structure, and biomechanical performance. The purpose of this study was to show and quantify the effects of active and passive wrist alignment on median nerve (MN) cross-sectional area (CSA) along the forearm in a healthy population.

METHODS

Sixteen healthy volunteers underwent HRUS of their dominant forearm (n = 16, 10 males, 6 females, 18-55 y of age). Median nerve's CSA was assessed at four defined areas on the forearm in relation to active and passive wrist alignment.

RESULTS

Changes in wrist alignment were significantly associated with MN CSA (P < .001), regardless if the wrist was moved actively or passively. MN CSA was lowest during passive extension of the wrist joint and highest during passive flexion of the wrist joint (range: 4.5-23.2 mm² ).

DISCUSSION

The elasticity of nerve tissue, the loose connective tissue between the fascicles, and the paraneurium allow peripheral nerves to adapt to longitudinal strain. HRUS enables the demonstration of significant median nerve CSA changes along the forearm during active and passive wrist movement in healthy volunteers.

Effects of joint and nerve mobilisation on neuroimmune responses in animals and humans with neuromusculoskeletal conditions: a systematic review and meta-analysis

Supplemental Digital Content is Available in the Text.

There is evidence that joint and nerve mobilisations compared with sham or no intervention positively influence various neuroimmune responses in animal and human neuromusculoskeletal conditions.

Several animal and human studies revealed that joint and nerve mobilisations positively influence neuroimmune responses in neuromusculoskeletal conditions. However, no systematic review and meta-analysis has been performed. Therefore, this study aimed to synthesize the effects of joint and nerve mobilisation compared with sham or no intervention on neuroimmune responses in animals and humans with neuromusculoskeletal conditions. Four electronic databases were searched for controlled trials. Two reviewers independently selected studies, extracted data, assessed the risk of bias, and graded the certainty of the evidence. Where possible, meta-analyses using random effects models were used to pool the results. Preliminary evidence from 13 animal studies report neuroimmune responses after joint and nerve mobilisations. In neuropathic pain models, meta-analysis revealed decreased spinal cord levels of glial fibrillary acidic protein, dorsal root ganglion levels of interleukin-1β, number of dorsal root ganglion nonneuronal cells, and increased spinal cord interleukin-10 levels. The 5 included human studies showed mixed effects of spinal manipulation on salivary/serum cortisol levels in people with spinal pain, and no significant effects on serum β-endorphin or interleukin-1β levels in people with spinal pain. There is evidence that joint and nerve mobilisations positively influence various neuroimmune responses. However, as most findings are based on single studies, the certainty of the evidence is low to very low. Further studies are needed.

Effects of wrist extension on median nerve and flexor tendon excursions in patients with carpal tunnel syndrome: a case control study

Background

Reduced gliding ability of the median nerve in the carpal tunnel has been observed in patients with carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the gliding abilities of the median nerve and flexor tendon in patients with CTS and healthy participants in the neutral and 30° extended positions of the wrist and to compare the gliding between the finger flexion and extension phases.

Methods

Patients with CTS and healthy participants were consecutively recruited in a community hospital. All the subjects received the Boston CTS questionnaire, physical examinations, nerve conduction study (NCS), and ultrasonography of the upper extremities. Duplex Doppler ultrasonography was performed to evaluate the gliding abilities of the median nerve and flexor tendon when the subjects continuously moved their index finger in the neutral and 30° extension positions of the wrist.

Results

Forty-nine patients with CTS and 48 healthy volunteers were consecutively recruited. Significant differences in the Boston CTS questionnaire, physical examination and NCS results and the cross-sectional area of the median nerve were found between the patients and the healthy controls. The degree of median nerve gliding and the ratio of median nerve excursion to flexor tendon excursion in the CTS group were significantly lower than those in the healthy control group in both the neutral and 30° wrist extension positions. Significantly increased excursion of both the median nerve and flexor tendon from the neutral to the extended positions were found in the CTS group. The ratio of median nerve excursion to flexor tendon excursion was significantly higher in the finger flexion phase than in the extended phase in both groups, and this ratio had mild to moderate correlations with answers on the Boston CTS Questionnaire and with the NCS results.

Conclusions

Reduced excursion of the median nerve was found in the patients with CTS. The ratio of median nerve excursion to flexor tendon excursion was significantly lower in the patients with CTS than in the healthy volunteers. The median nerve excursion was increased while the wrist joint was extended to 30° in the patients with CTS. Wrist extension may be applied as part of the gliding exercise regimen for patients with CTS to improve median nerve mobilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04349-8.

Excursion of the median nerve during a contra-lateral cervical lateral glide movement in people with and without cervical radiculopathy

BACKGROUND

A segmental, contra-lateral cervical lateral glide (CCLG) mobilization technique is effective for patients with cervical radiculopathy (CR). The CCLG technique induces median nerve sliding in healthy individuals, but this has not been assessed in patients with CR.

OBJECTIVE

This study aimed to 1) assess longitudinal excursion of the median nerve in patients with CR and asymptomatic participants during a CCLG movement, 2) reassess nerve excursions following an intervention at a 3-month follow-up in patients with CR and 3) correlate changes in nerve excursions with changes in clinical signs and symptoms.

DESIGN

Case-control study.

METHODS

During a computer-controlled mechanically induced CCLG, executed by the Occiflex™, longitudinal median nerve excursion was assessed at the wrist and elbow with ultrasound imaging (T0) in 20 patients with CR and 20 matched controls. Patients were re-assessed at a 3-month follow-up (T1), following conservative treatment including neurodynamic mobilization.

RESULTS

There was a significant difference between patients and controls in the excursion of the median nerve at both the wrist (Mdn = 0.50 mm; IQR = 0.13-1.30; 2.10 mm (IQR = 1.42-2.80, p < 0.05)) and elbow (Mdn = 1.21 mm (IQR = 0.85-1.94); 3.49 mm (IQR = 2.45-4.24, p < 0.05)) respectively at T0. There was also a significant increase in median nerve excursion at both sites between T0 and T1 in those with CR (Mdn = 1.96, 2.63 respectively). Wilcoxon Signed-Ranks Test indicated median pre-test ranks (Mdn = 0.5, 1.21; Z = - 3.82, p < 0.01; Z = -3.78, p < 0.01 respectively) and median post-test ranks. There was a strong correlation between improvement in median nerve excursion at the elbow at T1 and improvement in pain intensity (r = 0.7, p < 0.001) and functional limitations (r = 0.6, p < 0.01).

CONCLUSION

Longitudinal median nerve excursion differs significantly between patients with CR and asymptomatic volunteers at baseline, but this difference is no longer present after 3 months of conservative physiotherapy management. Improvement in nerve excursion correlates with improvement in clinical signs and symptoms.

The Effect of High-Power and Low-Power Lasers on Symptoms and the Nerve Conduction Study in Patients With Carpal Tunnel Syndrome. A Prospective Randomized Single-Blind Clinical Trial

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment. Various treatments have been suggested for CTS and there is no consensus on their superiority and the order of their use. Laser therapy is a non-invasive treatment method for many musculoskeletal diseases, including CTS. This study aimed to determine and compare the effect of high-power lasers (HPLs) and low-power lasers (LPLs) on pain severity, function, pinch strength, and nerve conduction study findings in patients aged 30-50 years with mild or moderate CTS. Methods: This is a prospective, randomized, single-blind clinical trial. The study population included 45 patients aged 30-50 years who came to the physical medicine and rehabilitation clinic of Shohada-e-Tajrish hospital and mild or moderate CTS was confirmed for them. Patients were randomly assigned to control, LPL therapy, and HPL therapy groups. Pain, function, pinch strength, and nerve conduction study findings were recorded in all groups before, immediately and 12 weeks after the treatment. All data were compared using SPSS version 21. Results: All groups showed improvement regarding pain, function, and pinch strength. Laser therapy showed significantly better results compared to a wrist splint, but no significant difference was seen between high-power and LPL therapy groups. Nerve conduction evaluation findings did not reveal any significant difference. Conclusion: Both the wrist splint and laser therapy can improve the symptoms of carpal tunnel syndrome. HPL therapy showed better results, although not significantly different from LPL therapy.

Effect of cervical contralateral lateral flexion on displacement and strain in the median nerve and flexor digitorum superficialis at the wrist during the ULNT1 - Cadaveric study

INTRODUCTION

A key issue in neurodynamic testing is whether a manoeuvre designed to produce differential biomechanical behaviour (structural differentiation) of nerve compared to adjacent muscle is mechanically accurate. The aim of this study was to investigate the capacity of cervical contralateral lateral flexion to produce differential biomechanical behaviour of the median nerve at the wrist (mechanical specificity) in relation to the adjacent muscle (flexor digitorum superficialis) at different ranges of upper limb neurodynamic test 1 in cadavers.

MATERIAL AND METHODS

A cross-sectional study was carried out. In fresh frozen cadavers, with microstrain devices and Vernier calipers, strain and excursion in the median nerve and flexor digitorum superficialis muscle were measured during cervical contralateral lateral flexion at 0°, 30°, 60° and 90° of elbow flexion of the upper limb neurodynamic test 1.

RESULTS

The cervical movement resulted in proximal excursion and significant changes in strain in the median nerve at 0°, 30° and 60° of elbow flexion during the upper limb neurodynamic test 1 (p < 0.05). In contrast, the structural differentiation manoeuvre did not affect the strain nor the excursion in the muscle at any position of the elbow (p > 0.05).

CONCLUSION

Adding CCLF to each ULNT1 median elbow angle increased strain and created proximal excursion of the median nerve at the wrist. Neck movement produced no changes in strain nor excursion of the flexor digitorum superficialis. This study adds to evidence that, in certain circumstances, neck movement may be used in differentiation of nerve and muscle disorders in the wrist.

Non-Surgical Management and Post-Surgical Rehabilitation of Carpal Tunnel Syndrome: An Algorithmic Approach and Practical Guideline

: One of the most common forms of entrapment neuropathy is Carpal Tunnel Syndrome (CTS). There are various treatment options for CTS. However, there are no clear and structured guidelines. This review classified the existing treatments and developed an algorithm to help physicians to choose the best option for their patients. Treatment options were summarized in three sections: non-surgical management of CTS, post-operative management of CTS, and practical open carpal tunnel release post-op protocol. The physicians can prescribe multiple treatment options to CTS patients. Corticosteroid in oral or injectable form has strong evidence in pain control and functional improvement in the short term. Shockwave therapy and nocturnal wrist splints display moderate therapeutic effects. Post carpal tunnel release rehabilitation can be started a few days after the operation.

Location-dependent change of median nerve mobility in the carpal tunnel of patients with carpal tunnel syndrome

INTRODUCTION

The purpose of this study was to investigate in vivo median nerve longitudinal mobility in different segments of the carpal tunnel associated with active finger motion in carpal tunnel syndrome (CTS) patients in a comparison with healthy controls.

METHODS

Eleven healthy volunteers and 11 CTS patients participated in this study. Dynamic ultrasound images captured location-dependent longitudinal median nerve mobility within the carpal tunnel during finger flexion at the metacarpophalangeal joints using a speckle cross-correlation algorithm.

RESULTS

Median nerve longitudinal mobility in the carpal tunnel was significantly smaller in CTS patients (0.0037 ± 0.0011 mm/degree) compared with controls (0.0082 ± 0.0026 mm/degree) (P < .05), especially in the proximal (0.0064 vs 0.0132 mm/degree on average) and middle (0.0033 vs 0.0074 mm/degree on average) carpal tunnel sections.

DISCUSSION

Median nerve mobility can potentially serve as a biomechanical marker when diagnosing CTS, or when assessing the effectiveness of surgical and conservative treatments.

Effect of ankle dorsiflexion on displacement and strain in the tibial nerve and biceps femoris muscle at the posterior knee during the straight leg raise: Investigation of specificity of nerve movement

BACKGROUND

A structural differentiation maneuver has been proposed to differentiate between muscle and nerve involvement during the straight leg raise test. However, to date, the mechanical specificity of this maneuver for the tibial nerve at the posterior knee has not been tested. The aim of this study was to investigate the specificity of ankle dorsiflexion as a differentiation maneuver between the tibial nerve and the biceps femoris muscle at the posterior knee during the straight leg raise in cadavers.

METHODS

A cross-sectional study was carried out. In fresh frozen cadavers, with microstrain devices and Vernier calipers, strain and excursion in the tibial nerve and distal biceps femoris muscle were measured during ankle dorsiflexion at 0°, 30°, 60° and 90° of hip flexion of the straight leg raise.

FINDINGS

Ankle dorsiflexion resulted in significant distal excursion and increased strain in the tibial nerve (p < 0.05) whilst the muscle was not affected by the dorsiflexion (p > 0.05) at all hip flexion angles.

INTERPRETATION

Ankle dorsiflexion was mechanically specific between the tibial nerve and biceps femoris during the straight leg raise. This study adds to evidence that, in certain circumstances, dorsiflexion may be used in differentiation of nerve and muscle disorders in the posterior knee.

Subclinical Peroneal Neuropathy Affects Ambulatory, Community-Dwelling Adults and Is Associated with Falling

BACKGROUND

Peroneal neuropathy with an overt foot drop is a known risk factor for falling. Subclinical peroneal neuropathy caused by compression at the fibular neck is subtler and does not have foot drop. A previous study found subclinical peroneal neuropathy in 31 percent of hospitalized patients. This was associated with having fallen. The purpose of this study was to determine the prevalence of subclinical peroneal neuropathy in ambulatory adults and investigate if it is associated with falling.

METHODS

A cross-sectional study of 397 ambulatory adults presenting to outpatient clinics at a large academic hospital was conducted from 2016 to 2017. Patients were examined for dorsiflexion weakness and signs of localizing peroneal nerve compression to the fibular neck. Fall risk was assessed with the Activities-Specific Balance Confidence Scale and self-reported history of falling. Multivariate logistic regression was used to correlate subclinical peroneal neuropathy with fall risk and a history of falls.

RESULTS

The mean patient age was 54 ± 15 years and 248 patients (62 percent) were women. Thirteen patients (3.3 percent) were found to have subclinical peroneal neuropathy. After controlling for various factors known to increase fall risk, patients with subclinical peroneal neuropathy were 3.74 times (95 percent CI, 1.06 to 13.14) (p = 0.04) more likely to report having fallen multiple times in the past year than patients without subclinical peroneal neuropathy. Similarly, patients with subclinical peroneal neuropathy were 7.22 times (95 percent CI, 1.48 to 35.30) (p = 0.02) more likely to have an elevated fall risk on the Activities-Specific Balance Confidence fall risk scale.

CONCLUSION

Subclinical peroneal neuropathy affects 3.3 percent of adult outpatients and may predispose them to falling.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Short-term clinical outcome of orthosis alone vs combination of orthosis, nerve, and tendon gliding exercises and ultrasound therapy for treatment of carpal tunnel syndrome

STUDY DESIGN

Prospective randomized study.

INTRODUCTION

Carpal tunnel syndrome (CTS) has been described as the most common compression neuropathy. Many modalities exist for conservative treatment. Efficacy of each modality has been described in the literature. However, the effectiveness of combination of these modalities is not well established. The purpose of this study is to assess the short-term clinical outcome of conservative treatment for CTS comparing orthosis alone with combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy.

METHODS

Forty-one patients who presented to Upper Limb Reconstructive and Microsurgery Clinic, University Malaya Medical Centre with CTS and positive electrodiagnostic study were recruited. Fifteen patients had bilateral CTS. Fifty-six wrists were equally randomized to orthosis alone and a combined therapy of orthosis, nerve/tendon gliding exercise, and ultrasound therapy. All patients were required to complete the Boston Carpal Tunnel Questionnaire during the first visit and 2 months after treatment.

RESULTS

Both the orthosis and combined therapy groups showed a significant improvement in symptoms and function after treatment. The mean difference of symptoms in the orthosis group was 0.53; 95% confidence interval [CI]: 0.23-0.83 (P = .001) and in the combined therapy group was 0.48; 95% CI: 0.24-0.72 (P < .001). Mean difference of function in the orthosis group was 0.59; 95% CI: 0.28-0.91 (P = .001) and combined group was 0.69; 95% CI: 0.49-0.89 (P < .001). However, there was no significant difference in symptom severity and functional status scores between the groups.

DISCUSSION

Our findings support other findings where orthosis and exercises improved symptom severity and functional status scores, however, there was no significant difference between orthosis alone and combined treatment.

CONCLUSION

Patients who underwent conservative management for CTS showed improvement in symptoms and function. However, the combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy did not offer additional benefit compared to orthosis alone.

Reliability and accuracy of the brachial plexus neurodynamic test

STUDY DESIGN

Observational study.

INTRODUCTION

The brachial plexus neurodynamic test (BPNT), based on previous neurodynamic tests, is considered a clinically meaningful tool to objectively assess brachial plexus extensibility. This novel test's psychometric properties have yet to be determined.

PURPOSE OF THE STUDY

The primary study aim was to assess the inter- and intrarater reliability and accuracy of the BPNT, which biases the median nerve and brachial plexus, among clinicians of various professional experience levels and geographic US regions. The secondary study aim was to determine if professional experience or geographic region affects the accuracy levels of this test.

METHODS

In phase 1, inter-rater reliability and accuracy was determined. About 307 participants attending neural mobilization conferences and courses were instructed in the BPNT and asked to score 7 different videos of 14 possible test levels. In phase 2, intrarater reliability was determined via scoring the same test videos twice.

RESULTS

High inter-rater intraclass correlation coefficient (range, 0.98-0.99) and accuracy (range, 0.88-0.94) levels were determined for all clinical experience levels and geographic regions. Intrarater intraclass correlation coefficient values were high (range, 0.96-1.0) among all participants. One-way analysis of variance indicated no significant differences on test accuracy based on professional clinical experience (F = 0.104; P = .958) and geographic region (F = 0.416; P = .416) among all 307 participants.

DISCUSSION

Excellent inter- and intrarater reliability and accuracy levels may allow clinicians to correctly identify BPNT positions regardless of their professional experience or geographic location.

CONCLUSION

The BPNT can reliably and accurately quantify outcomes in neural mobility scoring.

Ultrasound measurements of the median nerve at the carpal tunnel in ambulant chronic stroke patients: comparison between paretic and non-paretic sides

[Purpose] The purpose of this study was to examine the cross-sectional area (CSA) and longitudinal sliding length (LSL) of the median nerve bilaterally in patients with ambulant chronic hemiplegia and to compare these measurements with those in healthy controls using ultrasound. [Participants and Methods] Forty patients with hemiplegia who developed a non-functional hand on the paretic side after one year or more of stroke and 25 asymptomatic controls were included. To obtain the CSA of the median nerve at the wrist in the neutral position and the LSL of the median nerve during wrist extension, the participants underwent bilateral ultrasound examination. [Results] The non-paretic side of stroke patients had the largest median nerve CSA, followed by the paretic side and then the controls; the median nerve CSA in the non-paretic side and the controls differed significantly. The CSA of the median nerve was significantly larger in the non-paretic sides of patients, evaluated at more than 5.5 years post-stroke relative to those evaluated at less than 5.5 years. The LSL of the paretic side was significantly shorter than the non-paretic side and the controls. [Conclusion] Compared to the controls, the CSA of the median nerve was enlarged in the non-paretic hand of ambulant chronic stroke patients and the LSL were identical. As such, entrapment neuropathy of the median nerve may follow long-term chronic stroke due to overuse. This study indicates the usefulness of ultrasound in the potential identification of such cases.

H-reflex latency changes after combined application of traction and neural mobilization in cervical radiculopathy

Background

Cervical radiculopathy is a pathology of the cervical nerve root and mostly caused by a cervical disk herniation leading to chronic pain and disability.

Objectives

This study was conducted to show the effect of the combined application of intermittent cervical traction with median nerve mobilization on flexor carpi radialis (FCR) muscle H-reflex latency of median nerve in patients with unilateral cervical radiculopathy due to disk lesion in a pre-post design.

Methods

Fifteen patients (10 females and 5 males) with a mean age of 38.07 ± 5.85 years received simultaneous application of intermittent cervical traction and median nerve mobilization. Six sessions were given every other day for 2 weeks. Also, patients perormed chin in exercises and upper back extension with scapular retraction. FCR H-reflex latency was measured pre- and post-treatment.

Results

Statistical analysis showed that there was a significant reduction of H-reflex latency at post-treatment in comparison to pretreatment (t = 5.447, p value = 0.0001*).

Conclusion

Simultaneous application of intermittent cervical traction and median nerve mobilization are effective in improving FCR H-reflex latency in patients with unilateral cervical radiculopathy.

Differential movement of the sciatic nerve and hamstrings during the straight leg raise with ankle dorsiflexion: Implications for diagnosis of neural aspect to hamstring disorders

INTRODUCTION

In hamstrings injuries, sciatic nerve and muscle disorders can coexist. Therefore, differential diagnosis to include or exclude nerve involvement is an important aspect of evaluation. The objective of this paper is to investigate the mechanical behaviour of the sciatic nerve and biceps femoris muscle in the proximal thigh with the ankle dorsiflexion manoeuvre at different degrees of hip flexion during the straight leg raise in cadavers.

MATERIAL AND METHODS

A cross-sectional study was carried out. Linear displacement transducers were inserted into the sciatic nerve and the biceps femoris muscle of 11 lower extremities from 6 fresh cadavers to measure potential strain of both structures during ankle dorsiflexion at 0°, 30°, 60° and 90° of hip flexion during the straight leg raise. Excursion was also measured with a digital calliper.

RESULTS

Ankle dorsiflexion resulted in significant strain and distal excursion of the sciatic nerve at all ranges of hip flexion during the straight leg raise (p < 0.05). In contrast, the ankle movement did not affect the strain in biceps femoris at any position of the hip (p > 0.05).

CONCLUSION

Ankle dorsiflexion at different degrees of hip flexion during the straight leg raise produces changes in the strain and excursion of the sciatic nerve in the upper thigh. In contrast, the biceps femoris muscle at the same location was not affected by ankle movement. These findings show differential behaviour between the nerve and muscle with ankle dorsiflexion at this location that could be used as differential diagnosis in posterior hip pain.

Changes of median nerve conduction, cross-sectional area and mobility by radioulnar wrist compression intervention in patients with carpal tunnel syndrome

Background

Owing to the compressive nature of the neuropathy, patients with carpal tunnel syndrome (CTS) have prolonged distal motor latency (DML), sensory nerve latency (SNL), median nerve swelling and restricted median nerve mobility. The purpose of this study was to noninvasively augment carpal tunnel space using radioulnar wrist compression (RWC) and evaluate its effects on median nerve pathological properties in patients with CTS. It was hypothesized that the RWC intervention would reduce the median nerve DML, SNL and cross-sectional area (CSA) and enhance longitudinal median nerve mobility in patients. with CTS.

Methods

Eleven patients diagnosed with CTS participated in this study. A portable RWC intervention splint was developed to apply 10 N of compressive force across the wrist. Three daily sessions of RWC were performed over 4 weeks of intervention (15 min per session, 45 min per day, 7 days per week). Each 15-min session consisted of three 5-min blocks of RWC, with a 1-min rest in between consecutive blocks. Patients were evaluated at Week 0 (baseline), Week 2 (mid-intervention) and Week 4 (end of intervention). DML and SNL of the median nerve were evaluated using established nerve conduction study techniques. Median nerve CSA at the distal wrist crease was obtained by ultrasound imaging. Median nerve motion associated with finger flexion/extension was captured by dynamic ultrasound imaging and quantified using a speckle cross-correlation algorithm. Finger flexion/extension was recorded using an electrogoniometer. The slope of the regressed linear equation of median nerve displacement as a function of finger flexion angle was used to quantify nerve mobility.

Results

Patients with CTS showed significantly decreased DML (p = 0.048) and median nerve CSA (p < 0.001) and increased nerve mobility (p < 0.001) at mid-intervention compared to baseline. However, DML, CSA and mobility of the median nerve did not differ significantly between Weeks 2 and 4 (p = 0.574, 1.00 and 0.139, respectively). Median nerve SNL was not significantly affected throughout the 4-week intervention (p = 0.330 for Week 0 vs. 2; p = 1.00 for Week 2 vs. 4).

Conclusion

This study revealed that RWC intervention with 10-N force applied to the wrist in the radioulnar direction could restore impaired neurophysiological and biomechanical functions of the median nerve. The beneficial effects of RWC intervention for the median nerve were in evidence after a relatively short period of two weeks. These functional improvements could be explained by intermittent decompression of the median nerve via RWC-induced augmentation of the carpal arch.

The translational potential of this article

Biomechanically manipulating the carpal tunnel by RWC decompresses the median nerve and has the potential to become an alternative treatment for CTS.

Thumb carpometacarpal osteoarthritis: A musculoskeletal physiotherapy perspective

PROPOSAL

To perform a literature review to provide the practitioner with a description of the information and techniques to enhance the provision of conservative interventions in clinical practice.

METHODS

Studies were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2017. Authors independently selected studies, conducted quality assessment, and extracted results.

RESULTS

There is evidence to support a multimodal approach to the therapeutic management of the patient with CMC OA. This distinct approach includes: patient education, manual therapy, therapeutic exercise programs, and orthotic provision.

CONCLUSION

There is evidence to support some of the commonly performed conservative interventions to improve hand function and decrease hand pain.

Enhancement in median nerve mobility during radioulnar wrist compression in carpal tunnel syndrome patients

BACKGROUND

Carpal tunnel syndrome is a compression neuropathy at the wrist associated with compromised median nerve mobility. The purpose of this study was to investigate the effects of radioulnar wrist compression on median nerve longitudinal mobility within the carpal tunnel in carpal tunnel syndrome patients as well as healthy subjects.

METHODS

Dynamic ultrasound images captured longitudinal median nerve motion in the carpal tunnel during radioulnar wrist compression force application in 11 healthy subjects and 11 carpal tunnel syndrome patients.

FINDINGS

We found that median nerve mobility was not significantly affected by radioulnar wrist compression in healthy subjects (P = 0.34), but improved by 10 N radioulnar wrist compression in carpal tunnel syndrome patients (P < 0.05). Analysis of segmental median nerve mobility in carpal tunnel syndrome patients showed significantly improved mobility in the proximal tunnel section under 10 N radioulnar wrist compression force condition compared to the no compression condition (P < 0.05).

INTERPRETATION

Moderate radioulnar wrist compression force application helps restore impaired median nerve mobility and may be effective in improve nerve function and symptoms associated with carpal tunnel syndrome.

Median nerve mobilization techniques in the treatment of carpal tunnel syndrome: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Median nerve mobilization is one of the interventions used in the treatment of carpal tunnel syndrome (CTS). However, it is uncertain how many types of mobilization techniques are described in the current literature or the relative effectiveness of these techniques in treating CTS.

PURPOSE OF THE STUDY

The aim of this review was to describe the types and effectiveness of median nerve mobilization techniques studied in the CTS literature.

METHODS

Electronic searches of 5 databases and manual searches of references lists located randomized controlled trials studies published between 2000 and April 2015. Quality appraisal for each study was conducted using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields by 2 independent reviewers.

RESULTS

Nine randomized controlled trial studies describing various median nerve mobilization techniques used in the treatment of CTS were included. All studies were rated as of "adequate", "good", or "strong" quality for the Standard Quality Assessment Criteria. Three techniques of median nerve mobilization were described. Treatment outcomes included measures of electrodiagnostic testing, functional performance, pain, physical examination, sensation, and strength. Standardized mean differences for the treatment outcomes ranged from very small to large (0.05-1.71).

CONCLUSION

The findings are inconclusive regarding the effectiveness of each mobilization technique due to methodological limitations in the current body of research. Therefore, there is a clear need for high-quality controlled studies to examine various approaches to median nerve mobilization techniques in the treatment of CTS.

LEVEL OF EVIDENCE

2a.

Reliability of measurement of the carpal tunnel and median nerve in asymptomatic subjects with ultrasound

BACKGROUND

Morphology of the carpal tunnel changes with varying wrist postures and compressive forces applied to the wrist. These changes may affect the morphology and pressure on the median nerve and could be used as part of the treatment of the carpal tunnel syndrome patients. Reliability of the ultrasonographic measurements of the median nerve has been widely studied. However, there is a lack of investigation regarding reliability of ultrasonographic measurements of the carpal tunnel.

OBJECTIVE

The purpose of this study was to assess intra-tester and inter-tester reliability of measurement of dimensions of the carpal tunnel and median nerve with ultrasound in asymptomatic volunteers.

DESIGN

A cross-sectional methodological study.

METHODS

Aspects measured were mediolateral and anteroposterior diameters, flattening ratio, circularity, perimeter and cross-section area of the carpal tunnel and median nerve.

RESULTS

Intra-tester reliability was excellent for the carpal tunnel (ICCs from 0.91 to 0.97) and for the median nerve (ICCs from 0.79 to 0.94) measurements. The flattening ratio of the median nerve showed good agreement (ICC = 0.68). Inter-tester reliability was excellent for the carpal tunnel measurements (ICCs from 0.76 to 0.95) and, for the cross sectional area, the perimeter and mediolateral diameter of the median nerve, the ICC values were 0.89, 0.84 and 0.81, respectively.

CONCLUSION

In the context of this study, ultrasound was a reliable instrument for measuring carpal tunnel and median nerve dimensions in asymptomatic subjects.

LEVEL OF EVIDENCE

1b.

In vivo effects of limb movement on nerve stretch, strain, and tension: A systematic review

BACKROUND

The mechanical behavior of the peripheral nervous system under elongation and tension has not been adequately established in vivo.

OBJECTIVE

The purpose of this review is to investigate the mechanical behavior of the peripheral nervous system in vivo.

METHODS

In vivo studies which evaluated the effects of limb movement and neurodynamic tests on peripheral nerve biomechanics were systematically searched in PubMed (Medline), the Cochrane Database, CINAHL, PEDro, Embase and Web of Science. Studies fulfilling the search criteria were assessed for methodological quality with a modified version of the Down & Blacks scale by two reviewers.

RESULTS

This review includes the results of 22 studies, of which 15 examined limb movement influencing the median nerve, four the sciatic nerve, two the tibial nerve; and one each the ulnar and peroneal nerves respectively. Substantial nerve longitudinal and transverse excursion and changes in diameter were reported. Despite this, increased nerve strain was not a major finding.

CONCLUSION

The heterogeneity of included studies, including wide variety of nerves tested, measurement location and joint position prevented comparisons between studies and also amalgamation of data. Limb movement induces complex biomechanical effects of which nerve elongation plays only a minor role.

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

Study Design Systematic review with meta-analysis. Objectives To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component. Background Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown. Methods A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-analysis, with pain, disability, and function as the primary outcomes. Results Forty studies were included in this review, of which 17 had a low risk of bias. Meta-analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0-50]: mean difference, -9.26; 95% confidence interval [CI]: -14.50, -4.01; P<.001) and pain (intensity [0-10]: mean difference, -1.78; 95% CI: -2.55, -1.01; P<.001) improved following NM. For chronic neck-arm pain, pain improved (intensity: mean difference, -1.89; 95% CI: -3.14, -0.64; P<.001) following NM. For most of the clinical outcomes in individuals with carpal tunnel syndrome, NM was not effective (P>.11) but showed some positive neurophysiological effects (eg, reduced intraneural edema). Due to a scarcity of studies or conflicting results, the effect of NM remains uncertain for various conditions, such as postoperative low back pain, cubital tunnel syndrome, and lateral epicondylalgia. Conclusion This review reveals benefits of NM for back and neck pain, but the effect of NM on other conditions remains unclear. Due to the limited evidence and varying methodological quality, conclusions may change over time. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(9):593-615. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7117.

Efficacy of Manual Therapy Including Neurodynamic Techniques for the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial

OBJECTIVE

The purpose of this randomized trial was to compare the efficacy of manual therapy, including the use of neurodynamic techniques, with electrophysical modalities on patients with mild and moderate carpal tunnel syndrome (CTS).

METHODS

The study included 140 CTS patients who were randomly assigned to the manual therapy (MT) group, which included the use of neurodynamic techniques, functional massage, and carpal bone mobilizations techniques, or to the electrophysical modalities (EM) group, which included laser and ultrasound therapy. Nerve conduction, pain severity, symptom severity, and functional status measured by the Boston Carpal Tunnel Questionnaire were assessed before and after treatment. Therapy was conducted twice weekly and both groups received 20 therapy sessions.

RESULTS

A baseline assessment revealed group differences in sensory conduction of the median nerve (P < .01) but not in motor conduction (P = .82). Four weeks after the last treatment procedure, nerve conduction was examined again. In the MT group, median nerve sensory conduction velocity increased by 34% and motor conduction velocity by 6% (in both cases, P < .01). There was no change in median nerve sensory and motor conduction velocities in the EM. Distal motor latency was decreased (P < .01) in both groups. A baseline assessment revealed no group differences in pain severity, symptom severity, or functional status. Immediately after therapy, analysis of variance revealed group differences in pain severity (P < .01), with a reduction in pain in both groups (MT: 290%, P < .01; EM: 47%, P < .01). There were group differences in symptom severity (P < .01) and function (P < .01) on the Boston Carpal Tunnel Questionnaire. Both groups had an improvement in functional status (MT: 47%, P < .01; EM: 9%, P < .01) and a reduction in subjective CTS symptoms (MT: 67%, P < .01; EM: 15%, P < .01).

CONCLUSION

Both therapies had a positive effect on nerve conduction, pain reduction, functional status, and subjective symptoms in individuals with CTS. However, the results regarding pain reduction, subjective symptoms, and functional status were better in the MT group.

Effectiveness of manual therapy versus surgery in pain processing due to carpal tunnel syndrome: A randomized clinical trial

BACKGROUND

People with carpal tunnel syndrome (CTS) exhibit widespread pressure pain and thermal pain hypersensitivity as a manifestation of central sensitization. The aim of our study was to compare the effectiveness of manual therapy versus surgery for improving pain and nociceptive gain processing in people with CTS.

METHODS

The trial was conducted at a local regional Hospital in Madrid, Spain from August 2014 to February 2015. In this randomized parallel-group, blinded, clinical trial, 100 women with CTS were randomly allocated to either manual therapy (n = 50), who received three sessions (once/week) of manual therapies including desensitization manoeuvres of the central nervous system, or surgical intervention (n = 50) group. Outcomes including pressure pain thresholds (PPT), thermal pain thresholds (HPT or CPT), and pain intensity which were assessed at baseline, and 3, 6, 9 and 12 months after the intervention by an assessor unaware of group assignment. Analysis was by intention to treat with mixed ANCOVAs adjusted for baseline scores.

RESULTS

At 12 months, 95 women completed the follow-up. Patients receiving manual therapy exhibited higher increases in PPT over the carpal tunnel at 3, 6 and 9 months (all, p < 0.01) and higher decrease of pain intensity at 3 month follow-up (p < 0.001) than those receiving surgery. No significant differences were observed between groups for the remaining outcomes.

CONCLUSIONS

Manual therapy and surgery have similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with CTS. Neither manual therapy nor surgery resulted in changes in thermal pain sensitivity.

SIGNIFICANCE

The current study found that manual therapy and surgery exhibited similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with carpal tunnel syndrome at medium- and long-term follow-ups investigating changes in nociceptive gain processing after treatment in carpal tunnel syndrome.

Safety of lower extremity neurodynamic exercises in adults with diabetes mellitus: a feasibility study

OBJECTIVES

Neurodynamic exercises aim to improve neural mechanosensitivity in order to promote pain-free movement and function. People with diabetes mellitus (DM) may be candidates for neurodynamic exercises to address common DM-related impairments such as reduced lower extremity range of motion (ROM) and altered neural mechanosensitivity. However, no studies have examined the safety and immediate effects of neurodynamic exercise in people with DM. This study aims to determine the feasibility of applying neurodynamic exercises in adults with DM by evaluating the rate of adverse events and quantifying immediate changes in straight leg raise (SLR) ROM.

METHODS

This quasi-experimental study included 20 people with DM who performed a series of neurodynamic exercises on their right leg. Their left leg was used as an internal control. SLR testing was performed before and immediately after these exercises. Adverse events were monitored, including provocation of their neuropathy symptoms or discomfort or pain.

RESULTS

All participants completed the neurodynamic exercises without provocation of their neuropathy symptoms. No pain was reported and only one participant had minor discomfort with one exercise; a <30-s calf cramp. The right SLR ROM increased by an average of 5.2°-5.3° (p < 0.01) with no change on the left.

DISCUSSION

This study demonstrated that lower extremity neurodynamic exercises are safe in adults with DM and may create small immediate improvements in SLR testing. Further research is indicated to investigate the safety and efficacy of neurodynamic exercises performed over multiple sessions.

LEVEL OF EVIDENCE

3b.

Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review

OBJECTIVE

The objective of this study was to review the literature regarding the effectiveness of neural gliding exercises for the management of carpal tunnel syndrome (CTS).

METHODS

A computer-based search was completed through May 2014 in PubMed, Physiotherapy Evidence Database (PEDro), Web of Knowledge, Cochrane Plus, and CINAHL. The following key words were included: nerve tissue, gliding, exercises, carpal tunnel syndrome, neural mobilization, and neurodynamic mobilization. Thirteen clinical trials met the inclusion/exclusion criteria, which were: nerve gliding exercise management of participants aged 18 years or older; clinical or electrophysiological diagnostics of CTS; no prior surgical treatment; and absence of systemic diseases, degenerative joint diseases, musculoskeletal affectations in upper limbs or spine, or pregnancy. All studies were independently appraised using the PEDro scale.

RESULTS

The majority of studies reported improvements in pain, pressure pain threshold, and function of CTS patients after nerve gliding, combined or not with additional therapies. When comparing nerve gliding with other therapies, 2 studies reported better results from standard care and 1 from use of a wrist splint, whereas 3 studies reported greater and earlier pain relief and function after nerve gliding in comparison with conservative techniques, such as ultrasound and wrist splint. However, 6 of the 13 studies had a quality of 5 of 11 or less according to the PEDro scale.

CONCLUSION

Limited evidence is available on the effectiveness of neural gliding. Standard conservative care seems to be the most appropriate option for pain relief, although neural gliding might be a complementary option to accelerate recovery of function. More high-quality research is still necessary to determine its effectiveness and the subgroups of patients who may respond better to this treatment.

Education, night splinting and exercise versus usual care on recovery and conversion to surgery for people awaiting carpal tunnel surgery: a protocol for a randomised controlled trial

INTRODUCTION

Carpal tunnel syndrome (CTS) is a prevalent upper limb condition that results in significant individual and socioeconomic costs. Large patient numbers, long outpatient waiting times and traditional referral pathways in public health systems create delays in accessing treatment for this condition. Alternative care pathways aimed at streamlining access to treatment and reducing the need for surgical intervention warrant further investigation.

METHODS

A randomised, single-blind controlled clinical trial will be conducted. 128 participants aged 18-75 years with CTS will be recruited from the carpal tunnel surgery waitlists of participating public hospitals. Suitable participants will be stratified for severity and randomly allocated to either receive therapy (education, provision of splints and a home exercise programme) or standard care (continuing on the waitlist without hand therapy intervention for the duration of the study). Outcomes will be measured at baseline and after 6 weeks and 6 months. Primary outcomes are conversion to surgery ratio and perceived effect via the Global Rating of Change Scale.Secondary measures include patient satisfaction, and monitoring of symptoms and function using outcome measures including the Boston CTS Questionnaire, Disability of Arm, Shoulder and Hand Questionnaire, Patient-Specific Functional Scale, patient completed diagram of symptoms and Self-reported Leeds Assessment of Neuropathic Symptoms and Signs pain scale.

DISCUSSION

This paper outlines the design and rationale for a randomised controlled trial that aims to assess the efficacy of an alternative care pathway for the management of patients with CTS while on the surgery waitlist. It is anticipated that the outcomes of this study will contribute to improved and expedited management of this common condition in a public hospital setting.

ETHICS AND DISSEMINATION

Ethics approval was granted by the Princess Alexandra Hospital Centres for Health Research (HREC/13/QPAH/434-SSA/13/QPAH/447) and the Medical Research Ethics Committee at the University of Queensland. Results will be disseminated via conferences and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ACTRN12613001095752.

The effect of spinal position on sciatic nerve excursion during seated neural mobilisation exercises: an in vivo study using ultrasound imaging

Objectives

Research has established that the amount of inherent tension a peripheral nerve tract is exposed to influences nerve excursion and joint range of movement (ROM). The effect that spinal posture has on sciatic nerve excursion during neural mobilisation exercises has yet to be determined. The purpose of this research was to examine the influence of different sitting positions (slump-sitting versus upright-sitting) on the amount of longitudinal sciatic nerve movement during different neural mobilisation exercises commonly used in clinical practice.

Methods

High-resolution ultrasound imaging followed by frame-by-frame cross-correlation analysis was used to assess sciatic nerve excursion. Thirty-four healthy participants each performed three different neural mobilisation exercises in slump-sitting and upright-sitting. Means comparisons were used to examine the influence of sitting position on sciatic nerve excursion for the three mobilisation exercises. Linear regression analysis was used to determine whether any of the demographic data represented predictive variables for longitudinal sciatic nerve excursion.

Results

There was no significant difference in sciatic nerve excursion (across all neural mobilisation exercises) observed between upright-sitting and slump-sitting positions (P = 0.26). Although greater body mass index, greater knee ROM and younger age were associated with higher levels of sciatic nerve excursion, this model of variables offered weak predictability (R² = 0.22).

Discussion

Following this study, there is no evidence that, in healthy people, longitudinal sciatic nerve excursion differs significantly with regards to the spinal posture (slump-sitting and upright-sitting). Furthermore, although some demographic variables are weak predictors, the high variance suggests that there are other unknown variables that may predict sciatic nerve excursion. It can be inferred from this research that clinicians can individualise the design of seated neural mobilisation exercises, using different seated positions, based upon patient comfort and minimisation of neural mechanosensitivity with the knowledge that sciatic nerve excursion will not be significantly influenced.

Comparison of Hypoalgesic Effects of Neural Stretching vs Neural Gliding: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to evaluate the immediate mechanical hypoalgesic effect of neural mobilization in asymptomatic subjects. We also compared neural gliding vs neural stretching to see which produced greater hypoalgesic effects in asymptomatic subjects.

METHODS

Forty-five asymptomatic subjects (20 men and 25 women; mean ± SD age, 20.8 ± 2.83 years) were randomly allocated into 3 groups: the neural glide group, the neural stretch group, and the placebo group. Each subject received 1 treatment session. Outcome measures included bilateral pressure pain threshold measured at the trigeminal, cervical, and tibialis anterior points, assessed pre-treatment and immediately post-treatment by a blinded assessor. Three-way repeated-measures analysis of variance was used to evaluate changes in pressure pain threshold, with group (experimental or control) as the between-subjects variable and time (pre-, post-treatment) or side (dominant, nondominant) as the within-subjects variable.

RESULTS

Group differences were identified between neural mobilization groups and the placebo group. Changes occurred in all of the pressure pain threshold measures for neural gliding, and in all but the trigeminal point for neural stretch. No changes in the pressure pain threshold measures occurred in the placebo group.

CONCLUSIONS

This research provides new experimental evidence that neural mobilization produces an immediate widespread hypoalgesic effect vs placebo but neural gliding produces hypoalgesic effects in more body sites than neural stretching.