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Quantitative in vivo longitudinal nerve excursion and strain in responsoe tojoint movement: a systematic literature review

Ana Silva, Andre Manso, Ricardo Andrade, Vanessa Domingues, MariaPiedade Brandao, Anabela G. Silva

PII: S0268-0033(14)00192-2DOI: doi: 10.1016/j.clinbiomech.2014.07.006Reference: JCLB 3825

To appear in: Clinical Biomechanics

Received date: 15 April 2014Revised date: 30 July 2014Accepted date: 30 July 2014

Please cite this article as: Silva, Ana, Manso, Andre, Andrade, Ricardo, Domingues,Vanessa, Brandao, Maria Piedade, Silva, Anabela G., Quantitative in vivo longitudinalnerve excursion and strain in responsoe to joint movement: a systematic literature review,Clinical Biomechanics (2014), doi: 10.1016/j.clinbiomech.2014.07.006

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Quantitative in vivo longitudinal nerve excursion and strain in response to joint

movement: a systematic literature review

Ana Silvaa, BSc, André Mansoa, BSc, Ricardo Andradea MSc, Vanessa Dominguesa,

BSc, Maria Piedade Brandãoa, b, PhD, Anabela G. Silvaa, b, PhD

Affiliations

a School of Health Sciences, University of Aveiro, Portugal

Address: Escola Superior de Saúde da Universidade de Aveiro, Campus Universitário

de Santiago, 3810-193 Aveiro - Portugal

bCenter for Health Technology and Services Research (CINTESIS), Piso 2, edifício

nascente, Rua Dr. Plácido da Costa, s/n, 4200-450 Porto, Portugal

Corresponding author Anabela G. Silva (PhD) –

School of Health Sciences, University of Aveiro, Portugal

Address: Escola Superior de Saúde da Universidade de Aveiro, Campus Universitário

de Santiago, 3810-193 Aveiro - Portugal

Telephone: +351 234247119, extension: 27120 Fax: +351 234 401597

e-mail: asilva@ua.pt

Abstract word count – 245

Manuscript word count - 4594

Number of figures – 4

Number of tables - 2

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Abstract

Background – Neural system mobilization is widely used in the treatment of several

painful conditions. Data on nerve biomechanics is crucial to inform the design of

mobilization exercises. Therefore, the aim of this review is to characterise normal

nervous system biomechanics in terms of excursion and strain.

Methods - Studies were sought from Pubmed, Physiotherapy Evidence Database,

Cochrane Library, Web of Science and Scielo. Two reviewers’ screened titles and

abstracts, assessed full reports for potentially eligible studies, extracted information on

studies’ characteristics and assessed its methodological quality.

Findings – Twelve studies were included in this review that assessed the median nerve

(n=8), the ulnar nerve (n=1), the tibial nerve (n=1), the sciatic nerve (n=1) and both the

tibial and the sciatic nerves (n=1). All included studies assessed longitudinal nerve

excursion and one assessed nerve strain. Absolute values varied between 0.1 mm and

12.5 mm for median nerve excursion, between 0.1 mm and 4.0 mm for ulnar nerve

excursion, between 0.7 mm and 5.2 mm for tibial nerve excursion and between 0.1 mm

and 3.5 mm for sciatic nerve excursion. Maximum reported median nerve strain was

2.0%.

Interpretation - Range of motion for the moving joint, distance from the moving joint to

the site of the lesion, position of adjacent joints, number of moving joints and whether

joint movement stretches or shortens the nerve bed need to be considered when

designing neural mobilization exercises as all of these factors seem to have an impact

on nerve excursion.

Key words: Biomechanics, Neural mobilization, Excursion, Strain

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1. Introduction

Body movements and postures induce tensile, shear, and compressive stresses to the

nervous system. The normal nervous system is able to adapt to these stresses through

a variety of mechanisms, such as gliding (excursion) relative to adjacent structures,

stretching (increasing strain) and its capacity to tolerate compression from adjacent

structures, while maintaining its main function, the transmission of neural impulses

[1,2]. If something interferes with the normal biomechanical responses of the nervous

system to body movements and postures, imposed stresses may reach levels that

compromise the nervous system functioning, for example, reducing axonal transport

and intraneural blood supply [3,4].

Changes in the normal biomechanics of the nervous system have been associated with

painful disorders such as carpal tunnel syndrome, thoracic outlet syndrome, cubital

tunnel syndrome or diabetes [5–8]. This has contributed to a greater popularity of

nervous system mobilization as part of a conservative treatment approach aiming at

restoring the normal biomechanics of the nervous system [9–11]. In fact, it has been

shown that mobilizing the nerve in relation to the surrounding structures contributes to

reverse behavioral and cellular changes associated with neuropathic pain in rats [12]

and favours intraneural fluid dispersion in cadavers [13]. Furthermore, nervous system

mobilization has been shown to result in immediate C-fiber mediated hypoalgesia and

increased range of motion [14]. However, the mechanisms behind nervous system

mobilization are not completely clear [13]. There are several theories, including

physiological effects, such as reduction of edema, central effects, such as the reduction

of the central sensitization as well as mechanical effects such as the excursion of the

nervous system [15].

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Individual studies investigating the effect of neural mobilization are either unclear or

very different in terms of the specific procedures of neural mobilization used [16,17].

However, previous studies have suggested that the joints mobilized, the sequence of

joint movement or the position of adjacent joints influence the quantity of nervous

system strain and gliding and the direction of gliding [5,15,18–20]. Therefore,

effectiveness of nervous system mobilization might depend on these factors. An

important step to help define protocols for clinical trials and inform the interpretation of

results is to clarify how different patterns of movement impact the normal biomechanics

of the nervous system. This will help define the most appropriate pattern of movement

to attain a specific treatment aim and inform studies aiming to assess the efficacy of

different patterns of nervous system mobilization.

Thus the aims of this systematic review are i) to determine quantity and direction of

normal nervous system longitudinal excursion and tension in response to joint

movement and ii) to identify which factors are likely to impact nerve longitudinal

excursion and tension.

2. Methods

2.1. Data sources and searches

Studies were sought using Pubmed, Physiotherapy Evidence Database (PEDro),

Cochrane Library, Web of Science and Scielo. The search was conducted on May

2010 and updated on February 2013 and included references published since 1975.

Combinations of the following key words were used for all databases with the exception

of Scielo database: neural mobilization, mobilization, nerve mobilization, neural

manipulative physical therapy, nerve glide, nerve biomechanics, nerve gliding

exercises, nerve mobilization exercises, neural treatment, neural stretching,

neurodynamics, neural physiotherapy, upper limb neurodynamic test, straight leg

raising, slump, prone knee bend. Equivalent key words in Portuguese were used for

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Scielo database. The reference list of retrieved articles was also screened for reports

not identified through electronic searches.

To be included in this review studies must have:

Been published as a full article or an abstract with sufficient detail to extract the

main attributes of the study;

Been written either in English or in Portuguese;

Assessed either longitudinal excursion or tension (or both) of any component of

the peripheral nervous system in response to any movement of one or several

segments of the body;

Been conducted in human participants (in vivo) without known nervous system

pathology;

Reported the position of at least one joint adjacent to the one being mobilized.

Studies were excluded if:

Participants had been submitted to a surgery or any other invasive event likely

to affect nerve biomechanics.

2.2. Assessment of methodological quality of studies

Two authors (AGS and MPB) independently evaluated the quality of the studies using a

modified version of the quality assessment tool by Downs and Black [21], previously

used in a study aiming to synthesise the biomechanical characteristics of peripheral

diabetic neuropathy [22]. Individual items were scored either 1, if appropriately

addressed in the study, or 0, if not addressed in the study or if assessors were unable

to determine it. The total quality scores were reported as an average score between

the two assessors for a maximum score of 17 (Table 1). The scoring system for the tool

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was that described by Fernando et al. [22]: a score of 7 or less was considered low

quality, 8–11 as fair quality and greater than 11 as good quality.

2.3. Data extraction, synthesis and analysis

Titles and abstracts were screened by at least two of the first four authors (AS, AM, RA

and VD). Potentially eligible studies were identified and their respective full reports

obtained. Full reports were also assessed separately by at least two of the first four

authors (AS, AM, RA and VD) against the eligibility criteria. Discrepancies in judgement

were discussed with a third reviewer (AGS) who acted as arbiter.

The reviewers independently extracted the following information from each included

study: i) sample characteristics (number of participants, age and sex); ii) involved joint

and movement performed; iii) position of participant and position of joints adjacent to

the moving joint; iv) site where measurements of excursion and/or strain were taken

and v) mean values for excursion and/or strain in millimetres and percentage of change

from baseline, respectively. Data were described using counts, minimum and maximum

values and presented using tables and graphs. Graphs were used only for data on the

median nerve due to the limited number of data on the other nerves. Additionally, the

95% confidence interval (CI) of the minimal detectable change (MDC) was calculated

for individual measurements of nerve gliding. This calculation was only performed for

studies reporting the standard error of measurement (SEM). The equation used was

MDC95%= SEM * √2 * 1.96 [23].

3. Results

The search strategy retrieved 4008 references. After excluding for duplicates (n=1004),

a total of 3004 references were screened by title and/or abstract for relevance. Of

these, 2958 were excluded for not meeting the inclusion criteria and 46 full reports

were retrieved for further analysis. No study was excluded based on language of

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publication. The reference lists of the 46 full reports were also screened for potential

eligible studies. A total of 12 studies were included in this systematic review (Figure 1).

3.1. Included studies

Of the 12 studies included in this review, eight reported on the median nerve

[11,19,24–29], one on the ulnar nerve [30], one on the tibial nerve [5], one on the

sciatic nerve [15] and one on both the tibial and the sciatic nerves [31]. All included

studies used ultrasound to acquire nerve images and 10 out of the 12 included studies

reported to use the cross correlation analysis as described by Dilley et al [32] to

analyse these images and quantify nerve movement [5,11,15,19,26–31]. Of the 10

studies that used this method of image analysis, 5 reported on its reliability and found

an intra-class correlation coefficient (ICC) of 0.75 or greater [5,11,15,19,26–31]. Hough

et al [24] used the Scion Image program (www.scioncorp.com) for quantification of nerve

gliding and reported an ICC of 0.92. Hough et al. [25] used the Java-based image

processing program (ImageJ) and reported an ICC of 0.89. These ICC values indicate

that measurement procedures had excellent reliability [33].

3.2. Study quality

There were minor differences in ratings between assessors for included studies

(maximum difference in the final score between assessors is 1) as illustrated in Table

1. No study scored 7 or less. Six studies were of fair quality (scored 8 to 11) and

another six were of good quality (>11). Included studies failed mostly in terms of

reporting of actual p values, sample representativeness, blinding of the assessors and

a priori sample size calculation.

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3.3. MDC 95% for individual measurements of nerve gliding

MDC 95% was calculated for individual measurements of nerve gliding for nine out of

the 12 included studies (Table 2). MDC 95% values varied between 0.03 mm and 2.2

mm across measurements and studies. Overall, the MDC 95% for individual

measurements of nerve gliding was less than or equal to nerve gliding mean values.

For example, in the study of Brochwicz et al. [11] mean nerve gliding varied between

1.9 mm and 3.3 mm and the MDC 95% associated with these measurements varied

between 0.3 mm and 0.8 mm. These results suggest that nerve gliding measurements

were above the measurement error associated with it. In addition, we used the MDC

95% associated with nerve gliding measurements to inform the comparison between

different combinations of joint movement and positioning described in section 3.4. We

considered that differences between nerve gliding measurements induced by different

combinations of joint movement and positioning were attributed to random error if <

MDC 95% [34].

3.4. Median nerve longitudinal gliding

The eight studies assessing the median nerve reported on longitudinal excursion in

response to joint movement [11,19,24–29]. Additionally, Dilley et al. [26] also reported

on nerve strain. All studies assessed nerve excursion and/or strain in response to the

movement of a single body segment while adjacent joints were stationary. Additionally,

one study also reported on nerve excursion in response to simultaneous movement of

two body segments [19]. Detailed characterization of each study and results are

presented in Table 2.

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3.4.1. Impact of finger movement on median nerve gliding

One study assessed the effect of finger flexion on median nerve gliding at the forearm

and reported mean values for proximal longitudinal gliding of 0.8 mm and 1.3 mm [29].

Measurements were taken with the shoulder at 30º abduction, elbow extended and

forearm supinated. The effect of finger extension was assessed in two studies [25,27].

Erel et al. [27] measured median nerve gliding at the forearm with the shoulder at

45º/90º abduction, elbow extended and forearm supinated. They reported a mean

distal nerve gliding of 2.6 mm. Hough et al. [25] measured median nerve gliding at the

wrist. The mean distal nerve gliding was 12.5 mm when finger extension was

performed with the elbow flexed, and 11.2 mm when finger extension was performed

with the elbow extended. The mean difference between measurements of nerve gliding

with the elbow extended and flexed is within the MDC 95% (0.9 mm and 1.4

mm).Taken together, these results suggest that finger flexion and finger extension

induce median nerve gliding in opposite directions and that gliding increases with

proximity to the finger joints.

3.4.2. Impact of wrist movement on median nerve gliding

Three studies reported on the impact of wrist extension on median nerve gliding

[24,26,29] and measured it in the arm (mean values between 0.2 mm and 2.4 mm), in

the elbow (mean value for the only measurement made - 9 mm) and in the forearm

(mean values between 1.9 mm and 4.7 mm). The direction of the median nerve gliding

was distal for all measurements. When considering similar combinations of wrist

movement and adjacent joint positioning, data suggest that nerve gliding is higher at

the forearm compared to the arm (as illustrated in Figure 2).

Wrist movements from 40º flexion to 0º extension induce less median nerve gliding,

particularly in the arm (arm: 0.2 mm to 0.6 mm; forearm: 3.1 mm to 5.6 mm), than wrist

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movements from 0º to 40º/60º/70º extension (arm: 1.8 mm to 2.4 mm; forearm: 1.9 mm

to 4.7 mm; elbow: 9.0 mm) [24,26,29] (Figure 3). The MDC 95% was only calculated

for measurements taken at the elbow and was 1.7 mm [24]. Performing wrist extension

with the forearm supinated seems to favour nerve gliding when the shoulder is at 30º

abduction and the elbow is extended (supination: 3 mm; pronation: 1.9 mm) and also

when the shoulder is at 30º abduction and the elbow is flexed (supination: 3 mm;

pronation: 2.2 mm) [29]. No study assessed the impact of wrist flexion on median nerve

gliding.

In addition, 45º and 90º of shoulder abduction seem to facilitate nerve gliding at the

forearm when wrist extension was performed from 0º to 40º/70º compared to 30º of

shoulder abduction (30º abduction: 1.9 mm to 3.0 mm; 45º abduction: 4.7 mm; 90º

abduction: 4.2 mm) [26,29]. This is illustrated in Figure 4.

3.4.3. Impact of elbow movement on median nerve gliding

Two studies assessed how elbow extension affected the median nerve gliding [19,26].

Elbow extension with the wrist in neutral position induced a mean of 10.4 mm of distal

gliding in the arm and 3.0 mm of proximal gliding in the forearm. Elbow extension with

the wrist at 45º extension induced a mean of 4.2 mm of proximal gliding in the forearm

[26].

Elbow extension with the neck in either ipsilateral or contralateral lateral flexion induced

similar distal median nerve gliding (ipsilateral=5.5 mm, contralateral=5.6mm; MDC 95%

=1.8 mm) [19]. However, elbow extension performed simultaneously to ipsilateral

lateral neck flexion induced more gliding than elbow extension performed

simultaneously to contralateral lateral neck flexion (elbow extension+ipsilateral neck

flexion=10.2 mm; elbow extension+contralateral neck flexion= 1.8 mm; MDC 95%=1.8

mm) [19].

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Taken together, results suggest that when performing elbow extension: i) the median

nerve glides in opposite directions in the arm and forearm, ii) positioning the wrist in

extension increases median nerve gliding compared to positioning the wrist in neutral,

iii) simultaneously performing a movement of the neck that shortens nerve bed

increases nerve gliding, and iv) simultaneously performing a movement of the neck that

elongates nerve bed decreases nerve gliding.

No study assessed the impact of elbow flexion on median nerve gliding.

3.4.4. Impact of shoulder movement on median nerve gliding

Two studies assessed the effect of shoulder movements on median nerve gliding

[26,28]. Shoulder abduction (10º-90º) and shoulder protraction induced proximal gliding

of the median nerve both at the arm and forearm. Mean values were similar for both

movements (abduction: 5.2 mm in the arm and 3.4 mm in the forearm; protraction: 5.9

mm in the arm and 3.5 mm in the forearm; MDC 95% for shoulder protraction = 1.7 mm

in the arm and 0.8 mm in the forearm).

3.4.5. Impact of neck movement on median nerve gliding

The impact of neck contralateral lateral flexion on median nerve gliding was

investigated in three studies [11,19,28]. Mean values for proximal nerve gliding varied

between 0.9 mm and 3.4 mm in the arm and between 0.6 mm and 2.3 mm in the

forearm. Cervical contralateral lateral flexion induced slightly less gliding than a cervical

lateral glide (away from the side to be tested) at C5/C6 both at the middle (glide=3.3

mm; lateral flexion=2.3 mm; MDC 95% = 0.3 mm and 0.8 mm) and at the distal forearm

(glide=2.5 mm; lateral flexion=1.9 mm; MDC 95%= 0.6) [11].

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Performing cervical contralateral lateral flexion with the shoulder abducted or in a

neutral position seems to increase median nerve gliding compared to performing the

same movement with the shoulder protracted (protraction: arm = 0.9 mm, forearm = 0.6

mm; neutral: arm = 2.3 mm, forearm = 1.5 mm; abduction: forearm = 1.9 mm to 2.3

mm; MDC 95% ≤ 0.8 mm) [11,28]. Elbow position does not seem to affect the gliding of

the median nerve in response to lateral flexion of the neck (flexion = 3.4 mm; extension

= 3.3 mm; MDC 95%=1.8 mm) [19].

The impact of neck flexion on median nerve gliding was assessed in one study [26].

Mean values for gliding of the median nerve in the arm were higher than mean values

in the forearm and at 90º of shoulder abduction compared to 30º of shoulder abduction

(30º abduction: arm=0.5 mm, forearm=0.3 mm; 90º abduction: arm=1.3 mm,

forearm=0.8 mm).

Forward head posture seems to induce virtually no nerve gliding at both the arm and

forearm [28].

3.4.6. Impact of trunk movement on median nerve gliding

Trunk flexion seems to have virtually no effect on median nerve excursion at the

forearm [28]. Key findings in relation to median nerve gliding are summarized in Table

2.

3.5. Median nerve strain

Dilley et al. [26] was the only study that reported on median nerve strain.

Measurements were taken at the forearm in response to wrist, elbow, shoulder and

neck movements. Wrist extension from neutral to 40º induced similar strain when the

shoulder was at 45º and at 90º abduction (between 1.1 % and 2.0%). Study authors

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reported that it was not possible to calculate strain induced by wrist extension from 40º

flexion to neutral and they suggested that the nerve might be unloaded in these

positions. Shoulder abduction (10º - 90º) when the elbow and wrist were in neutral

positions was associated to an increase in strain of 1%. Elbow extension from 90º

flexion to neutral when the shoulder was at 90º abduction and the wrist was neutral

was associated to an increase in strain of 0.6%. Neck flexion induced virtually no

increase in strain.

3.6. Ulnar nerve longitudinal gliding

One study reported on ulnar nerve gliding [30]. The ulnar nerve glided distally at the

forearm with wrist extension (1.1 mm to 3.0 mm; MDC 95% ≤ 1.4 mm). Elbow flexion

induced proximal gliding at the forearm (0.8 mm; MDC 95%=0.6 mm) and virtually no

movement at the upper arm. Shoulder abduction (40º to 90º) induced virtually no

longitudinal excursion of the ulnar nerve (Table 2).

3.7. Tibial nerve longitudinal gliding

Two studies assessed the tibial nerve gliding at the popliteal fossa and in response to

ankle dorsiflexion either alone [5] or performed simultaneously to neck extension [31].

The tibial nerve glided distally in both studies. Nerve gliding in response to ankle

dorsiflexion alone was assessed in side lying and mean values decreased with an

increase in hip flexion (hip at 20º flexion=2.2 mm hip at 62º flexion=0.7 mm) [5]. Nerve

gliding in response to ankle dorsiflexion performed simultaneously to neck extension

was assessed in a seated position and induced a mean gliding of 5.2 mm (MDC 95% =

1.4 mm) [31] (Table 2).

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3.8. Sciatic nerve longitudinal gliding

Two studies measured gliding of the sciatic nerve at the mid-thigh when participants

were in a seated position [15,31]. Performing neck extension simultaneously to ankle

dorsiflexion (sitting upright) induced similar gliding of the sciatic nerve to performing

neck extension simultaneously to knee extension (slumped spinal posture) (neck

extension+ankle dorsiflexion=3.5 mm; neck extension+knee extension=3.3 mm; MDC

95% ≤ 2.2 mm) [15,31]. Neck flexion performed simultaneously to knee extension

induced a similar amount of gliding to knee extension with the neck in a neutral position

(neck flexion+knee extension=knee extension=2.6 mm; MDC 95% = 0.6 mm) [15].

Neck flexion alone with the knee also in flexion induced virtually no nerve movement

[15].

4. Discussion

This systematic review showed that there are a limited number of in vivo studies

investigating the effect of joint movement on normal nerve longitudinal excursion for

nerves other than the median nerve. Furthermore, we found one study only that

investigated the impact of joint movement on nerve strain. Despite this, this systematic

review also shows that different combinations of movement and adjacent joint

positioning impact differently on the biomechanics of the peripheral nervous system.

Simultaneous joint movements that elongate the nerve bed at one end and shorten it at

the other, i.e. sliding techniques, seem to promote the greatest nerve excursion. In

contrast, combinations of joint movements that elongate the nerve at both ends,

tensioning techniques, seem to induce the least amount of nerve excursion. For

example, simultaneous elbow extension and cervical ipsilateral lateral flexion induced

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10.2 mm of median nerve gliding while simultaneous elbow extension and cervical

contralateral lateral flexion induced 1.8 mm of median nerve gliding [19]. A similar

behavior was reported by Ellis et al. [15] for the sciatic nerve: simultaneous knee

extension and neck extension induced 3.3 mm of gliding while knee extension with

neck flexion induced 2.6 mm of gliding. In addition, joint movements performed at

different angles seem to impact nerve biomechanics differently. For example, there is

less median nerve gliding in response to wrist extension when wrist movement is

performed from 40º flexion to a neutral position compared to when it is performed from

neutral to 40º extension (e.g. 3.1 mm vs. 4.7 mm at the forearm) [26]. Furthermore,

findings of the same authors [26] showed that strain for the median nerve varied

between 1.1% and 2.0% when wrist extension was performed from 0º to 40º and that

the nerve was unloaded when wrist extension was performed from 40º flexion to

neutral.

Results also suggest that nerve gliding decreases as the distance from the moving joint

increases. For example, wrist extension from 0º to 40º induced nerve gliding between

0.2 mm and 2.4 mm in the arm and between 4.6 mm and 5.6 mm in the forearm [26]

and a cervical lateral glide induced 2.5 mm of nerve gliding in the distal forearm and

3.3 mm in the middle forearm [11]. This highlights the need to accurately describe the

site of measurement in future studies. For example, 7 to 10 cm proximal to the medial

epicondyle as described by Coppieters et al. [19]. Additionally, it suggests that nerve

bed length should be considered when defining the site of measurement.

The direction of nerve gliding (proximal or distal nerve excursion) seems to be

influenced by the joint movements being performed. Finger flexion induces proximal

median nerve gliding at both the arm and the forearm, while finger extension induces

distal median nerve gliding. Wrist extension induces distal nerve gliding at the arm the

elbow and the forearm. These findings suggest that wrist and finger movements that

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elongate the nerve bed are associated with median nerve distal excursion through the

whole upper limb, while movements that shorten the nerve bed are associated with

proximal median nerve excursion. The nerve behaves slightly differently with elbow

movement. Elbow extension induces distal median nerve gliding at the arm and

proximal median nerve gliding at the forearm, suggesting that the median nerve

converges towards the elbow. This is in accordance with the convergence mechanism,

according to which when the nerve bed lengthens at the elbow the nerve sections

above and below the joint converge towards it [2]. Shoulder abduction and neck

contralateral lateral flexion seem to induce proximal median nerve gliding at both the

arm and the forearm when adjacent joints are stationary, suggesting that shoulder and

neck movements that elongate the nerve bed are associated with proximal excursion of

the nerve through the whole upper limb. How nervous structures behave in response to

movement between the shoulder and the neck was not measured in any of the studies

included in this systematic review and needs to be investigated as it is of relevance to

nerve entrapments located in this body segment. Taken together the results suggest

that nerves glide towards the joint if the movement elongates the nerve bed and away

from the joint if the movement shortens it, in line with the conclusions of a previous

review [2].

The MDC is an estimate of the amount of change between two points in time that

indicates a true change and, therefore, could be used to inform the clinical significance

of measurements [23]. MDC 95% for individual measurements of included studies was

smaller than the respective nerve gliding. Additionally, differences between the mean

values of nerve gliding induced by different joint movements were also above the MDC

95%. Both findings suggest that joint movement induces nerve gliding above

measurement error.

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The findings of this systematic review identify a set of variables that affect nerve

gliding. We believe that this information will help clinicians in their rationale when

selecting a specific combination of movements to perform neural mobilization, justifying

the progression of treatment or judging its outcome. Similarly, the findings of this

systematic review will inform researchers when designing studies aiming to compare

different techniques of nervous system mobilization or assess its effectiveness. The

variables likely to influence nerve gliding are: i) range of movement, ii) moving joint, iii)

distance from the moving joint to the site of the lesion, iv) position of adjacent joints, v)

number of moving joints and vi) whether joint movement stretches or shortens nerve

bed. Therefore, these variables need to be considered when designing and justifying

neural mobilization based interventions. Furthermore, they can be manipulated in order

to suit patients’ needs. The number of variables that need to be considered make

neural mobilization very flexible and adaptable to patients’ conditions, but also

challenges standardization.

Included studies failed mostly in terms of sample representativeness, blinding of the

assessors and a priori sample size calculation. No study was considered to include a

sample that was representative of the population. Studies either use convenience

samples, or fail to identify the source population for participants and describe how they

were selected. Only five studies were considered to use a blinded assessor (out of the

12 included studies). Sample sizes varied between 1 and 37 participants, but 8 studies

had a sample size of less than 20 participants. These methodological limitations may

compromise the validity of the findings and the precision of the estimates. To improve

the evidence-base, these factors should be taken into consideration during the design

of future studies.

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Future research needs to investigate whether combinations of joint movements that

impact nerve biomechanics differently also have different physiological consequences,

are more efficient in certain stages of disease or for certain patients. More research is

also needed investigating the relationship between gliding and strain so that clinicians

are informed on how to induce the highest gliding without considerable increases in

strain. For example, Coppieters and Butler [35] have found that sliding techniques

result in a substantially larger excursion of the nerves than tensioning techniques and

that this larger excursion is associated with a much smaller increase in strain. High

levels of strain may affect neural function, in particular vascularization and axonal

transport [36]. However, both studies were conducted in embalmed cadavers [35,36].

Furthermore, it has been shown that a strain of 5%-10% affects vascularization and at

15% intraneural vascularization is completely blocked in rats [37]. Strain levels for the

median nerve reported by Dilley et al. [26] were below the harmful levels of strain

previously reported in cadaver studies [20,36,38], suggesting that nervous system

mobilization is unlikely to reach strain levels that affect nerve functioning. However, this

was the only study found investigating strain in human healthy participants [26].

Whether personal factors such as sex or age affect nerve gliding was not explored in

included studies and might be considered in future studies.

Review limitations

This review should be seen in light of its limitations. Heterogeneity of included studies,

in particular in terms of moving joints, positioning of adjacent joints and measurement

site prevented meta-analysis. Additional limitations were the small number of included

studies and the small number of participants in some studies. We used USA spelling

for databases’ search (e.g. mobilization) and this might have influenced the outcome of

the search.

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5. Conclusions

This systematic review showed that joint movement might induce up to 12. 5 mm of

nerve gliding, which seem to vary according to range of motion for the moving joint,

distance from the moving joint to the site of the lesion, position of adjacent joints,

number of moving joints and whether joint movement stretches or shortens nerve bed.

Therefore, these factors need to be considered when designing neural mobilization

exercises for both clinical practice and research.

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References

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14. Beneciuk J, Bishop M, George S. Effects of upper extremity neural mobilization on thermal pain sensitivity: a sham-controlled study in asymptomatic participants. J Orthop Sport Phys Ther. 39 (2009) 428–38.

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26. Dilley A, Lynn B, Greening J, DeLeon N. Quantitative in vivo studies of median nerve sliding in response to wrist, elbow, shoulder and neck movements. Clin Biomech. 18 (2003) 899–907.

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27. Erel E, Dilley A, Greening J, Morris V, Cohen B, Lynn B. Longitudinal sliding of the median nerve in patients with carpal tunnel syndrome. J Hand Surg Br. 28 (2003) 439–43.

28. Julius A, Lees R, Dilley A, Lynn B. Shoulder posture and median nerve sliding. BMC Musculoskelet Disord. 5 (2004) 23.

29. Echigo A, Aoki M, Ishiai S, Yamaguchi M, Nakamura M, Sawada Y. The excursion of the median nerve during nerve gliding exercise: an observation with high-resolution ultrasonography. J Hand Ther. 21 (2008) 221–7.

30. Dilley A, Summerhayes C, Lynn B. An in vivo investigation of ulnar nerve sliding during upper limb movements. Clin Biomech. 22 (2007) 774–9.

31. Ellis R, Hing W, Dilley A, McNair P. Reliability of measuring sciatic and tibial nerve movement with diagnostic ultrasound during a neural mobilisation technique. Ultrasound Med Biol. 34 (2008) 1209–16.

32. Dilley A, Greening J, Lynn B, Leary R, Morris V. The use of cross-correlation analysis between high-frequency ultrasound images to measure longitudinal median nerve movement. Ultrasound Med Biol. 27 (2001) 1211–8.

33. Fleiss J. The design and analysis of clinical experiments. New York: John Wiley and Sons; 1986.

34. Haley S, Fragala-Pinkham M. Interpreting change scores of tests and measures used in physical therapy. Phys Ther. 86 (2006) 735–43.

35. Coppieters MW, Butler DS. Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 13 (2008) 213–21.

36. Coppieters MW, Alshami AM, Babri AS, Souvlis T, Kippers V, Hodges PW. Strain and Excursion of the Sciatic , Tibial , and Plantar Nerves during a Modified Straight Leg Raising Test. J Orthop Res.24 (2006) 1883–9.

37. Ogata K, Naito M. Blood flow of peripheral nerve effects of dissection stretching and compression. J Hand Surg Br. 11 (1986) 4.

38. Wright TW, Glowczewskie F, Wheeler D, Miller G, Cowin D. Excursion and strain of the median nerve. J Bone Joint Surg Am. 78 (1996) 1897–903.

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Figure 1 – Flow chart for the systematic review.

Figure 2 – Mean and standard deviation for median nerve gliding during wrist extension

in relation to measurement site (data from Dilley et al. 26 and Echigo et al. 29).

Figure 3 – Mean and standard deviation for median nerve gliding during wrist extension

in relation to wrist range of motion and measurement site (data from Dilley et al. 26).

Figure 4 – Mean and standard deviation for median nerve gliding measured at the

forearm during wrist extension in relation to shoulder abduction (data from Dilley et al. 26 and Echigo et al. 29).

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Figure 1

Data sources and references found:

PubMed

PEDro

Scielo

Cochrane

Web of Science

Total: n=4008

Titles/abstracts screened for

inclusion (n=3004).

Duplicates

(n=1004).

Publications retrieved for

detailed evaluation, including

manual screening of retrieved

papers (n=46).

Identified by

title/abstract as not

relevant (n=2959).

Publications to be included in

analysis (n=12).

Failed to meet the eligibility criteria (n=34), mainly due to being:

Opinion papers;

Studies conducted in animals or cadavers;

Studies that used invasive procedures.

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Figure 2

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Figure 3

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Figure 4

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Tables

Table 1 – Assessment of methodological quality of included studies.

Question Hough et al.,

24

Dilley et al.,

26

Erel et al.,

27

Julius et al.,

28

Hough et al.,

25

Echigo et al.,

29

Coppieters et al.,

19

Brochwicz et al.,

11

Dilley et al.,

29

Boyd et al.,

5

Ellis et al.,

31

Ellis et al.,

15

1. Hypothesis/aim/objective 1 1 1 1 1 1 1 1 1 1 1 1

2. Main outcomes 1 1 1 1 1 1 1 1 1 1 1 1

3. Participants characteristics 1 1 1 1 1 1 1 1 1 1 1 1

5. Confounders 0 0 0 0 01 01 1 01 01 01 01 1

6. Findings 1 1 1 1 1 1 1 1 1 1 1 1

7. Estimates of the random variability 1 1 1 1 1 1 1 1 1 1 1 1

10. Actual probability values 0 0 0 0 1 01 1 0 0 1 0 1

11. Subjects representative population (asked) 0 0 0 0 0 0 0 0 0 0 0 0

12. Subjects representative population (agreed) 0 0 0 0 0 0 0 0 0 0 0 0

15. Blinding of assessors 1 0 0 0 1 01 0 0 0 0 1 1

16. Data dredging 1 1 1 1 1 1 1 1 1 1 1 1

18. Apropriate statistical tests 1 1 1 1 1 1 1 1 1 1 1 1

20. Outcome measures valid and reliable 1 1 1 1 1 1 1 1 1 1 1 1

21. Internal validity (selection bias) 0 0 0 0 1 1 1 1 01 1 1 1

22. Recruitment time period 0 0 0 0 1 1 1 01 01 1 1 1

25. Adjustment for confounding 0 1 0 1 1 1 1 01 1 1 1 1

27. Statistical power determined 0 0 0 0 1 0 01 0 0 0 0 1

Total (Assessor AGS) vs (Assessor MPB) (9) vs

(9) (9) vs

(9) (8) vs

(8) (9) vs

(9) (15) vs

(14) (13) vs

(12) (14) vs

(13) (10) vs

(11) (10) vs

(11) (13) vs

(12) (13) vs

(12) (15) vs

(15)

1 - considered appropriately addressed by both assessors; 0 - considered inappropriately addressed by both assessors; 01 - considered appropriately addressed by one assessor and in appropriately addressed by the other.

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Table 2 – Longitudinal excursion and strain of the median nerve.

AUTHORS SAMPLE SIZE

& CHARACTERISTICS

MOVEMENT & INVOLVED JOINTS

PARTICIPANT POSITION & POSITION OF ADJACENT JOINTS

SITE OF MEASUREMENT

RESULTS

LONGITUDINAL EXCURSION

MEAN (SD) (MM)

MDC 95% CI (MM)

STRAIN (%) (MINIMUM TO

MAXIMAL CHANGE)

MEDIAN NERVE

HOUGH ET AL.

23

N=16 AGE=26-61Y

WRIST EXTENSION (0º-60º) SUPINE; SHOULDER AT 45º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED

ELBOW 9.0 (2.1) 1.7

DILLEY,ET AL.

26

N=10

WRIST EXTENSION (0º - 40º)

SUPINE; SHOULDER AT 45º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

DISTAL UPPER ARM

2.4 (1.8)

MID-FOREARM 4.7 (0.5) P=1.1 D=1.5

SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

DISTAL UPPER ARM

1.8 (0.4)

MID-FOREARM 4.2 (0.6) P=1.1 D=2.0

N=4

WRIST EXTENSION (40º - 0º)

SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW AT 90º FLEXION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS IN NEUTRAL

DISTAL UPPER ARM

0.2 (0.2)

MID-FOREARM 5.6 (0.9)

STRAIN NOT DETERMINED; NERVE MAY BE UNLOADED

N=6 SUPINE; SHOULDER AT 45º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

DISTAL UPPER ARM

0.5 (0.4)

MID-FOREARM 3.1 (0.3)

STRAIN NOT DETERMINED; NERVE MAY BE UNLOADED

N=3 SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

DISTAL UPPER ARM

0.6 (0.4)

MID-FOREARM 3.1 (0.2)

STRAIN NOT DETERMINED; NERVE MAY BE UNLOADED

N=4 SHOULDER ABDUCTION (10º-90º)

SUPINE; ELBOW IN FULL EXTENSION, WRIST NEUTRAL (0º); FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

DISTAL UPPER ARM

- 5.2 (0.7)

MID-FOREARM - 3.4 (0.8) 1.0

N=7 ELBOW EXTENSION (90º-0º) SUPINE; SHOULDER AT 90º ABDUCTION; WRIST NEUTRAL (0º); FOREARM SUPINATED; DIGITS AND

DISTAL UPPER ARM

10.4 (2.3)

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METACARPOPHALANGEAL JOINTS NEUTRAL MID-FOREARM - 3.0 (1.0) 0.6

N=4 SUPINE; SHOULDER AT 90º ABDUCTION; FOREARM SUPINATED, WRIST AT 45º EXTENSION; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

MID-FOREARM - 4.2 (1.1)

N=8

NECK FLEXION (0-35º)

SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW IN FULL EXTENSION; WRIST NEUTRAL (0º); FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS IN NEUTRAL

DISTAL UPPER ARM

- 0.5 (0.8)

MID-FOREARM - 0.3 (0.6) 0.1

N=9

SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN FULL EXTENSION; WRIST NEUTRAL (0º); FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS IN NEUTRAL

DISTAL UPPER ARM

- 1.3 (0.7)

MID-FOREARM - 0.8 (0.3) 0.2

EREL ET AL. 27

N=19 AGE=41.3±9.9Y

EXTENSION OF THE METACARPOPHALANGEAL JOINTS OF FINGERS 2 TO 5 (90º FLEXION TO 0º)

SUPINE; SHOULDER AT 45º/90ºABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED; INTERPHALANGEAL JOINTS EXTENDED

5-15 CM PROXIMAL FROM THE DISTAL WRIST CREASE

2.6 0.4

JULIUS ET AL.

28

N=8

FORWARD HEAD POSITION MOVEMENT (LOWER CERVICAL FLEXION AND UPPER CERVICAL EXTENSION)

SEATED; SHOULDER AT 90º FLEXION AND 20º ABDUCTION; ELBOW IN FULL EXTENSION, FOREARM SUPINATED (45º); WRIST, HAND AND FINGERS NEUTRAL PROXIMAL

FOREARM

- 0.1 0.03

N=8 TRUNK FLEXION

SEATED; SHOULDER AT 90º FLEXION AND 20º ABDUCTION; ELBOW IN FULL EXTENSION, FOREARM SUPINATED (45º); WRIST, HAND AND FINGERS NEUTRAL

- 0.1 0.3

N=13 SHOULDER PROTRACTION

SEATED; SHOULDER AT 90º FLEXION AND 20º ABDUCTION; ELBOW IN FULL EXTENSION, FOREARM SUPINATED (45º); WRIST, HAND AND FINGERS IN NEUTRAL

UPPER ARM - 5.9 1.7

PROXIMAL FOREARM

- 3.5 0.8

N=11

CONTRALATERAL NECK LATERAL FLEXION (35º)

SUPINE; SHOULDER AT 90º ABDUCTION; SCAPULOTHORACIC JOINT NEUTRAL; ELBOW IN FULL EXTENSION, FOREARM SUPINATED (45º); WRIST, HAND AND FINGERS NEUTRAL

UPPER ARM - 2.3 0.6

PROXIMAL FOREARM

- 1.5 0.6

CONTRALATERAL NECK LATERAL FLEXION (35º)

SUPINE; SHOULDER AT 90º ABDUCTION; SCAPULOTHORACIC JOINT IN FULL PROTRACTION; ELBOW IN FULL EXTENSION, FOREARM SUPINATED (45º); WRIST, HAND AND FINGERS NEUTRAL

UPPER ARM - 0.9 0.6

PROXIMAL FOREARM

- 0.6 0.3

HOUGH ET AL.

25 #

N=37; AGE=48.0±10.0Y

FULL FINGERS AND THUMB EXTENSION (FROM FULL FINGERS FLEXION AND THUMB FLEXION)

ELBOW FLEXION

WRIST

12.5 (2.5) 0.9

ELBOW EXTENSION 11.2 (2.8) 1.4

ECHIGO ET AL.

29

N=34 ♀ WRIST EXTENSION (0º-70º) SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM AT 80º SUPINATION

VOLAR ASPECT OF THE

3.0 (1.8)

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SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM AT 70º PRONATION

PROXIMAL THIRD OF FOREARM

1.9 (1.4)

SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW FLEXED; FOREARM AT 80º SUPINATION

3.0 (1.3)

SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW FLEXED; FOREARM AT 70º PRONATION

2.2 (1.7)

FLEXION OF THE PROXIMAL AND DISTAL INTERPHALANGEAL JOINTS OF FINGERS 1 TO 4

SHOULDER AT 30º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM AT 80º SUPINATION

- 0.8 (0.8)

FLEXION OF THE METACARPOPHALANGEAL JOINTS AND PROXIMAL AND DISTAL INTERPHALANGEAL JOINTS OF FINGERS 1 TO 4

SHOULDER AT 30º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM AT 80º SUPINATION

-1.3 (1.0)

COPPIETERS, ET AL.

19

N=15 (7♂+ 8♀) AGE=30 ±8Y

SIMULTANEOUS ELBOW EXTENSION (≈83º) AND CERVICAL IPSILATERAL LATERAL FLEXION (≈29º)

SHOULDER AT 90º ABDUCTION AND EXTERNAL ROTATION: FOREARM SUPINATED

7 TO 10 CM PROXIMAL TO THE MEDIAL EPICONDYLE

10.2 (2.8)

1.8

SIMULTANEOUS ELBOW EXTENSION (≈141º) AND CERVICAL CONTRALATERAL LATERAL FLEXION (≈29º)

1.8 (4.0)

ELBOW EXTENSION (≈141º) NECK IN CONTRALATERAL LATERAL FLEXION (≈29º), SHOULDER AT 90º ABDUCTION AND EXTERNAL ROTATION; FOREARM SUPINATED

5.6 (2.1)

ELBOW EXTENSION (≈141º) NECK IN IPSILATERAL LATERAL FLEXION (≈29º); SHOULDER AT 90º ABDUCTION AND EXTERNAL ROTATION; FOREARM SUPINATED

5.5 (2.9)

CERVICAL CONTRALATERAL LATERAL FLEXION (≈29º)

SHOULDER AT 90º ABDUCTION AND EXTERNAL ROTATION; ELBOW IN EXTENSION (≈141º); FOREARM SUPINATED

-3.3 (1.3)

CERVICAL CONTRALATERAL LATERAL FLEXION (≈29º)

SHOULDER AT 90º ABDUCTION AND EXTERNAL ROTATION; ELBOW IN FLEXION (≈81º; FOREARM SUPINATED)

- 3.4 (0.9)

BROCHWICZ ET AL

11 #

N=11 (5♂+ 6♀) AGE=25.6 ±2.3Y

CERVICAL LATERAL GLIDE AT C5/C6 (TRANSLATIONAL MOVEMENT AWAY FROM THE SIDE TO BE TESTED)

SHOULDER AT 30º ABDUCTION, DEPRESSION AND EXTERNAL ROTATION; ELBOW IN FULL EXTENSION, FOREARM IN FULL SUPINATION

MIDDLE FOREARM

3.3 0.8

DISTAL FOREARM

2.5 0.6

CERVICAL CONTRALATERAL LATERAL FLEXION

MIDDLE FOREARM

2.3 0.3

DISTAL FOREARM

1.9 0.6

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ULNAR NERVE

DILLEY,ET AL.

29

N=6

WRIST EXTENSION (0º - 40º)

SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

PROXIMAL FOREARM

1.1 1.4

DISTAL-FOREARM

2.1 1.4

N=4 SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW AT 90º FLEXION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

PROXIMAL FOREARM

2.3 1.4

DISTAL-FOREARM

4.0 0.8

N= 2 WRIST EXTENSION (0º - 40º) SUPINE; SHOULDER AT 40º ABDUCTION; ELBOW IN FULL EXTENSION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

PROXIMAL FOREARM

1.6 0.8

DISTAL-FOREARM

3.0 1.4

N=1 ELBOW FLEXION (0º-90º) SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW AT 90º FLEXION; FOREARM SUPINATED; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

PROXIMAL UPPER ARM

0.1 0.8

DISTAL FOREARM

- 0.8 0.6

PROXIMAL

FOREARM# 2.7 -- N=5

ELBOW FLEXION (90º-140º)

N= 2 SHOULDER ABDUCTION (40º-90º)

SUPINE; ELBOW IN FULL EXTENSION; DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

UPPER ARM 0.1 0.6

FOREARM 0.1 0.6

SUPINE; ELBOW FLEXED (90º); DIGITS AND METACARPOPHALANGEAL JOINTS NEUTRAL

UPPER ARM 0.1 0.6

FOREARM 0.1 0.6

TIBIAL NERVE

BOYD ET AL. 5

N=5 (4♀+ 1♂) AGE=40.0±11.8

FROM > 30º PLANTAR FLEXION TO > 0º DORSAL FLEXION

SIDE LYING; SPINE IN NEUTRAL; HIP FLEXION (20º), KNEE EXTENDED (0º) POPLITEAL

FOSSA

2.2 (0.5)

SIDE LYING; SPINE IN NEUTRAL; HIP FLEXION (≈62º), KNEE EXTENDED (0º)

0.7 (0.3)

ELLIS ET AL. 31

N=27 (14♀+13♂) AGE=22.82±4.61Y

SIMULTANEOUS NECK EXTENSION (FROM FULL NECK FLEXION TO 40/70º NECK EXTENSION) AND ANKLE DORSIFLEXION (FROM FULL PLANTAR FLEXION TO 20º/40º DORSIFLEXION)

SEATED, HIP FLEXED (90º), KNEE FLEXED (50º) POPLITEAL FOSSA

5.2 1.4

SCIATIC NERVE

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Positive value (no sign) – distal excursion; Negative value (negative sign) – proximal excursion; p – proximal strain; D – distal strain; MDC – minimal detectable change; SD –

standard deviation; # - study authors do not report on movement direction; ≈ approximately; R – range; y – years; ♂ - males; ♀ - females

ELLIS ET AL. 31

N=27 (14♀+13♂) AGE=22.82±4.61Y

SIMULTANEOUS NECK EXTENSION (FROM FULL NECK FLEXION TO 40/70º NECK EXTENSION) AND ANKLE DORSIFLEXION (FROM FULL PLANTAR FLEXION TO 20º/40º DORSIFLEXION)

SEATED, HIP FLEXED (90º), KNEE FLEXED (50º) POSTERIOR MID -THIGH

3.5 2.2

ELLIS ET AL. 15

N=31 (22♀+9♂) AGE=29.0±9.0Y

SIMULTANEOUS KNEE EXTENSION (FROM 80 TO 0º FLEXION) AND NECK EXTENSION (FROM FULL FLEXION TO FULL EXTENSION)

SEATED; SLUMPED SPINAL POSTURE, HIPS FLEXED (90º)

POSTERIOR MID-THIGH

3.3 (2.0)

0.6

KNEE EXTENSION (FROM 80 TO 0º FLEXION) WHILE NECK IN NEUTRAL

2.6 (1.4)

NECK FLEXION (FROM FULL EXTENSION TO FULL FLEXION) WHILE THE KNEE WAS AT 80º FLEXION

- 0.1 (0.1)

SIMULTANEOUS KNEE EXTENSION (FROM 80 TO 0º FLEXION) AND NECK FLEXION (FROM FULL EXTENSION TO FULL FLEXION)

2.6 (1.5)

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34

Highlights

Overall mean gliding varies between virtually no gliding to 12.5 mm

Gliding is greatest proximal to the moving joint

Nerves glide towards the moving joint when the nerve bed is elongated and

away from the moving joint when the nerve bed is shortened

When there is only one moving joint: movements that elongate the nerve bed

seem to increase nerve gliding

When there are two moving joints moving simultaneously: combinations of joint

movements that elongate the nerve bed at one end and shorten it at the other

end (sliding techniques) seem to promote the greatest nerve excursion