[

RESEARCH REPORT

MICHEL W. COPPIETERS, PT, PhD7B7D:$>EK=>"Grad Dip Phys, PhD7D:H;M:?BB;O"PhD

Different Nerve-Gliding Exercises Induce

Different Magnitudes of Median Nerve
Longitudinal Excursion: An In Vivo Study
Using Dynamic Ultrasound Imaging
xercises that aim to mobilize the peripheral nervous system have
been advocated as part of the management of various
upper limb nerve entrapment syndromes, such as
carpal tunnel syndrome,2,6,21,23,26 cubital tunnel SUPPLEMENTAL
VIDEO ONLINE
syndrome,8,28 and nonacute cervical radiculopathy.24 The
aim of these exercises can be to mobilize the nervous system

TIJK:O:;I?=D0 Controlled laboratory study

TH;IKBJI0 Different exercises induced dif-

using single-group, within-subject comparisons.

ferent amounts of longitudinal nerve excursion

(P.0001). The sliding technique was associated
with the largest excursion (mean  SD, 10.2  2.8
mm; P = .0001). The amount of nerve movement
associated with the tensioning technique (mean
 SD, 1.8  4.0 mm) was smaller than the nerve
excursion induced with individual movements of
the neck or elbow (mean  SD range, 3.4  0.9
to 5.6  2.1 mm; P = .0001).

TE8@;9J?L;I0 To determine in an in vivo study

whether different types of nerve-gliding exercises
are associated with different amounts of longitudinal nerve excursion.

T879A=HEKD:0 Different types of nerve-gliding

exercises have been proposed. It is assumed that
different exercises produce different amounts of
excursion and strain in the peripheral nervous
system. Although this has been conrmed in
cadaveric experiments, in vivo studies are lacking.

TC;J>E:I7D:C;7IKH;I0 High-resolution
ultrasound was used to measure longitudinal
excursion of the median nerve in the upper arm
during 6 different nerve-gliding exercises. Nerve
mobilization techniques that involved the elbow
and neck were evaluated in 15 asymptomatic
volunteers (mean  SD age, 30  8 years).
Nerve longitudinal excursion was calculated using
a frame-by-frame cross-correlation analysis. A
repeated-measures analysis of variance was used
to analyze the data.

T9ED9BKI?ED0 These ndings conrm that

different types of neurodynamic techniques have
different mechanical effects on the nervous system. Recognition of these differences may assist
in the selection of treatment techniques. Having
demonstrated differences in mechanical effects,
future research will have to evaluate whether these
different techniques are also associated with different physiological and therapeutic effects. J Orthop
Sports Phys Ther 2009;39(3):164-171. doi:10.2519/
jospt.2009.2913

TA;OMEH:I0 diagnostic ultrasound, nerve biomechanics, neurodynamic test, ultrasonography

itself or the structures that surround the

nerve, such as neighboring
muscles and joints.4,17
When mobilization of
the nervous system was
introduced as a treatment
modality approximately 25
years ago,16 techniques that closely resembled neurodynamic tests were advocated.3
It was assumed that the neurodynamic
test or components thereof induced nerve
movement by elongation of the nerve bed
(the tract formed by the structures that
surround the nerve). There is ample evidence to support the notion that neurodynamic tests elongate the nerve bed and
that this elongation is associated with
nerve gliding.5,7,13,29,30 Lengthening of the
nerve bed may also elongate the nerve,
which may result in an increase in tension and intraneural pressure.22 Animal
experiments have demonstrated that local
nerve inammation results in increased
mechanical sensitivity of otherwise intact
axons.1 When a nerve is inamed, minimal
elongation (3%) or locally applied pressure can trigger ectopic impulse generation,14 which may lead to the provocation
of pain and other symptoms. Although
these recent insights in pathophysiology

1
Research Fellow, Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. 2 Lecturer in Physiotherapy, Division
of Physiotherapy, Peninsular Allied Health Centre, School of Health Professions, The University of Plymouth, Plymouth, UK. 3 Lecturer in Anatomy, Division of Clinical and
Laboratory Investigation, Brighton and Sussex Medical School, Medical School Building, University of Sussex, Brighton, UK. This project was approved by The Human Ethics
Committee of The University of Plymouth and the Medical Research Ethics Committee of The University of Queensland, and supported by project grant #511161 from the National
Health and Medical Research Council, Australia. Address correspondence to Michel Coppieters, Division of Physiotherapy, School of Health and Rehabilitation Sciences, Building
84A, The University of Queensland, QLD 4072 St Lucia, Australia. E-mail: m.coppieters@uq.edu.au

164 | march 2009 | volume 39 | number 3 | journal of orthopaedic & sports physical therapy

were not yet available at the conception

of neural mobilization, careful and gentle
mobilization techniques often not taken
to the end of range, were already advocated when neural mobilization was
conceptualized.16
Proper clinical reasoning, together
with advances in neurobiology and biomechanics, has led to a diversication of
neural mobilization techniques. Techniques that facilitate nerve gliding by
elongation of the nerve bed no longer
cover the wide spectrum of nerve-gliding
exercises currently advocated. Combinations of movements in which elongation
of the nerve bed at one joint is simultaneously counterbalanced by a reduction in the length of the nerve bed at an
adjacent joint have been promoted.4,8,27
These techniques are commonly referred
to as sliding techniques. In contrast, the
term tensioning technique is used to refer to techniques that aim to mobilize a
nerve by elongation of the nerve bed.4,8,27
The clinical assumption is that a sliding
technique results in a larger longitudinal
excursion of the nerve than a tensioning
technique, and that a sliding technique
is associated with a minimal increase in
nerve tension. Verifying these assumptions is important, as it has been argued
that sliding techniques are less aggressive
and may be more appropriate for more
acute conditions, provided that mobilization is indicated.9 Note that throughout
this manuscript we use the term nervegliding exercises to refer to a variety of
different techniques, whereas the term
sliding technique is exclusively used to refer to the type of technique that involves
simultaneous movements at 2 or more
joints that have opposite effects on the
stress in the nervous system.
Strain and excursion in peripheral
nerves during different types of nervegliding exercises have been investigated in
cadaveric studies.6,9 The ndings of these
studies have conrmed the above-mentioned assumptions that different types
of nerve-gliding exercises have different
biomechanical effects on the nervous
system. A limitation of these studies is,

however, that embalmed human cadavers

were used. The effect of embalmment on
mechanical properties of nerves and other
structures, and on the gliding mechanism
of the nervous system relative to its surrounding structures, remains largely unknown. Therefore, the aim of the present
study was to evaluate longitudinal nerve
excursion in vivo, using high-resolution
ultrasound during different types of nervegliding exercises. In line with the previous
ndings from cadaveric studies,6,9 we hypothesized that signicant differences in
longitudinal nerve movement would be
observed with different mobilization exercises. Furthermore, we hypothesized that a
sliding technique would produce the largest excursion, and a tensioning technique
would produce the smallest excursion.

C;J>E:I
Participants

ifteen healthy volunteers participated in this study (8 females,

7 males; mean  SD age, 30  8
years; height, 169  12 cm; body mass,
64 13 kg). The selection of healthy volunteers, rather than patients with nerve
pathology, was prompted by our intent to
reveal normal nerve biomechanics associated with different mobilization exercises
and to eliminate potentially confounding
variables associated with dysfunction.
To determine the sample size, the differences and variability in longitudinal
nerve excursion reported in a previously
published cadaveric study were used.6 In
that study, the mean  SD nerve excursion for the sliding technique (the technique with the largest excursion) was
12.4  2.6 mm and the excursion for the
technique which resulted in the second
largest excursion was 8.9  1.0 mm. Because similar trends were anticipated for
in vivo measurements, sample size calculation revealed that 13 participants were
required to be able to detect signicant
differences in nerve excursion between
the sliding technique and other mobilization techniques (power, 90%; B = .01;
dependent-samples t test).

All participants were free of symptoms

without signicant arm or neck pain in
the preceding 2 years. Participants with
a history of neurological disorders or
known conditions that negatively affect the nervous system, such as diabetes, were excluded from the study. An
informed consent form was signed by
all participants prior to participating in
the study. The experiment was approved
by the Human Ethics Committee of The
University of Plymouth and the Medical
Research Ethics Committee of The University of Queensland. The rights of the
subjects were protected.

D[hl[#=b_Z_d];n[hY_i[i
Excursion of the median nerve at the level
of the upper arm was measured for 6 mobilization exercises (<?=KH;'"EDB?D;L?:;E).
The rst technique (<?=KH;'7) was selected as an example of a sliding technique.
This technique consisted of 2 simultaneously performed active movements, in
which one movement loaded the median
nerve distally (elbow extension), while
the other movement unloaded the nervous system proximally (cervical ipsilateral lateral exion). The second technique
(<?=KH;'8) was included as a paradigm for
a tensioning technique, as both movements at the elbow and neck resulted in
an increase in length of the nerve bed. In
this exercise, elbow extension and cervical contralateral lateral exion were
simultaneously performed. The effect of
single-joint movements was analyzed in
4 additional techniques (<?=KH;I '9#'<).
Elbow extension was performed while
maintaining the neck in contralateral
(<?=KH;'9) and ipsilateral (<?=KH;':) lateral exion. Cervical contralateral lateral
exion was performed with the elbow in a
more extended position (<?=KH;';) and in
a more exed position (<?=KH;'<).
For all techniques, the participant
was lying supine on a plinth with the
right shoulder in 90 of abduction and
external rotation. A shoulder girdle restraint was positioned over the acromioclavicular joint to prevent shoulder
girdle elevation during shoulder abduc-

journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 165

RESEARCH REPORT

]
90 shoulder abduction and external
rotation, 90 elbow exion, forearm supination, wrist in neutral, and ngers in
extension). With the neck in contralateral
lateral exion, the elbow was moved into
extension. The maximal range without
causing discomfort was regarded as the
available range of elbow motion. The
same range of cervical contralateral lateral exion was used for ipsilateral lateral
exion. Mechanical restraints were used
to control the range of movement of both
the neck and elbow. The techniques were
performed in random order using a counterbalanced approach to minimize possible order effects and were all performed
on the right upper extremity.

KbjhWiekdZC[Wikh[c[dji

<?=KH;'$Illustration of the 6 mobilization techniques: sliding technique (A), tensioning technique (B), elbow
extension with the neck in contralateral (C) and ipsilateral (D) lateral exion; cervical contralateral lateral exion
with the elbow in a more extended (E) and a more exed (F) position. The grey shading illustrates the starting
position. The arrows indicate the movement to reach the end position (unshaded). The electrogoniometer at the
elbow is also shown.

tion. To further stabilize the arm, the

lateral side of the distal end of the upper arm rested on an arm support. A
splint was used to maintain the wrist
and hand in a neutral position and the
ngers in extension. The forearm was
positioned in supination. The range of
elbow movement was measured with a
twin-axis electrogoniometer, which was
attached with double-sided tape to the
dorsal side of the arm (model SG150B;
Biometrics Ltd, Gwent, UK). To facilitate
and standardize cervical lateral exion,
the participants head was positioned on
a pivoting support that was connected
to the plinth. The axis of rotation of the
pivoting head support was positioned at
the level of the spinous processes of C6C7. The range of cervical lateral exion

was measured by attaching the moving

end block of an electrogoniometer to the
pivoting head support and the xed end
block to the plinth (model SG150; Biometrics Ltd).
Because of the large variation between
healthy participants in available range of
motion during neurodynamic tests,10,11 we
decided to allow differences in range of
movement between participants. However, the range of motion through which
the elbow and neck were moved within
an individual participant was identical
for the various techniques. To determine
the available range of neck movement,
the amount of cervical contralateral lateral exion without causing discomfort
was measured with the right arm in the
test position (shoulder girdle xation,

Imaging was performed with either a

Sonoace Pico ultrasound system with a
wideband linear array transducer with
a center frequency of 7.5 MHz (Medison SA-6000C; Kretztechnik-AG, Zipf,
Austria) or a GE Logic 9 with a 12-MHz
linear transducer (GE Medical Systems,
Milwaukee, WI). The image resolution
was 21.0 and 21.7 pixels/mm, respectively. To assist in the identication of
the median nerve, a transverse scan was
made at the elbow and the median nerve
was followed proximally into the upper
arm. Transverse movement of the nerve
was assessed during arm and neck movements, and an area in the upper arm was
identied where this transverse movement was minimal or absent for the
range of joint movement under investigation. Transverse movement can cause
the nerve to move out of plane of the
transducer during longitudinal imaging
and, therefore, it was important to nd a
location where this transverse movement
was absent or minimal. The ultrasound
transducer was then turned 90 and
aligned longitudinally with the median
nerve. This location was consistently in
the medial bicipital furrow, 7 to 10 cm
proximal to the medial epicondyle. The
base of the investigators hand that held
the ultrasound transducer was rested on
a support to minimize movement of the

166 | march 2009 | volume 39 | number 3 | journal of orthopaedic & sports physical therapy

C


Dist

Prox




MN

Humerus













<?=KH;($(A) Ultrasound image of the median nerve in the upper arm. The rectangular box represents the selected region of interest. (B) Enlargement of the selected region of
interest (top panel) and the same region captured 0.06 s later (lower panel) during the sliding technique. The ends of the vertical lines indicate the ne structure of the nerve.
Note the left-to-right shift of the features. This movement was tracked using the cross-correlation algorithm. The program calculates the correlation coefficient (r) between pixel
grey levels in the 2 images. The coordinates of the second region are offset along the horizontal image plane by a pixel at a time within a predetermined range, and a correlation
coefficient is calculated for each individual pixel shift. (C) Plot of the correlation coefficient against the pixel shift. A quadratic equation tted to the peak correlation coefficient
gives the pixel shift to subpixel precision (3.7 pixels in this example [arrow]), which corresponds to the movement between the 2 frames. With an image resolution of 21 pixels
per mm, the region of interest has moved 0.176 mm. Note: bar, 5 mm; MN, median nerve.

probe relative to the upper arm of the

participant.
Sequences of images were captured
at a frame rate of 15 images per second.
The images were converted into a digital
format (bitmap) and analyzed offline using software developed in Matlab.12 The
software employs a cross-correlation
algorithm to measure the motion of
ne speckle features in selected regions
of interest (in this case, in the median
nerve) between adjacent frames of the
image sequence (refer to <?=KH;( for further methodological detail). This method
has a high reliability and small measurement error when measuring nerve12,15
and muscle19 movements. Three regions
of interest in the nerve of approximately
50 80 pixels were selected (center of
the image and left and right of the center). Regions of interest that resulted in
aberrant velocity proles were excluded.
More details on the method are described
by Dilley et al.12

:WjW9ebb[Yj_edWdZ7dWboi_i
Data from the electrogoniometers were
collected with a DataLink acquisition

system at 50 Hz (Biometrics Ltd). A

repeated-measures analysis of variance (ANOVA) was used to test for systematic differences in the start or end
positions between the 6 mobilization
techniques.
Although previous studies revealed
high reliability for the measurement
of longitudinal nerve movement using
high-resolution ultrasound, 12,15,19 we
decided to also evaluate the reliability specically for this experiment. To
evaluate intertester reliability, 3 assessors analyzed the ultrasound sequences
of the sliding technique for the rst 10
participants. The intraclass correlation
coefficient (ICC2,1), standard error of
measurement (SEM = SDpooled 1- ICC),
and minimal detectable change (MDC)
at a 95% confidence interval (CI) (MDC
= 1.96  2 SEM) were calculated.
Differences in longitudinal nerve
excursion between the 6 mobilization
techniques were analyzed with a repeated-measures ANOVA. The dependent
variables were the excursions associated
with the different types of exercises (6
levels). In a rst analysis, the direction

of the nerve movement was taken into

consideration by allocating a negative
sign to a proximal excursion and a positive sign to a distal excursion. In a second
analysis, the absolute value of the excursion was used to compare the amount of
movement irrespective of the direction.
Duncans multiple range tests were used
for post hoc analysis. All amplitudes were
compared. The level of signicance was
set at P.05.

H;IKBJI
he mean  SD start and end positions for cervical contralateral and
ipsilateral lateral exion were 29.0
 2.9 and 28.9  2.7, respectively.
The mean elbow exion angle was 82.6
 7.5; the mean elbow extension angle
was 140.8  6.7 (full elbow extension
equal 180). These start and end positions show that both the neck and elbow
were moved through a range of motion
of approximately 60. The exact ranges
for each technique are displayed in <?=KH;
3. For the techniques in which the elbow
and neck were moved, there were no sig-

journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 167

[
80
60

58.7

57.7

58.4

58.2

40
20
0

0.3

0.4
A

Range of Motion (deg)

60

58.8

58.9

58.6

58.9

40
20
0.0

0
A

0.2
D

<?=KH;)$The range of motion through which the

elbow (top panel) and neck (lower panel) were
moved during the different mobilization techniques.
Letters A through F correspond with the techniques
demonstrated in FIGURE 1: sliding technique (A),
tensioning technique (B), elbow extension with the
neck in contralateral (C) and ipsilateral (D) lateral
exion, cervical contralateral lateral exion with the
elbow in a more extended (E) and a more exed (F)
position. There were no signicant differences in
amplitude for the 4 techniques in which the elbow (P
= .82) or neck (P = .26) were moved.

nicant differences in range of motion

(neck, P = .20; elbow, P = .78).
Excellent intertester reliability of the
measurements was demonstrated with

J78B;
;nYkhi_ed
A (10.2  2.8)

14
12
10
8
6
4
2
0
2
4

<?=KH;* (top panel) shows the direction and amount of the longitudinal nerve
excursion for the different techniques. Elbow extension and the sliding technique
always resulted in a distal excursion.
Contralateral lateral exion of the neck
always resulted in a proximal excursion.
The tensioning technique resulted in a
distal excursion in 10 of 15 participants
and in a proximal excursion in 5 of 15
participants.
The analysis of variance revealed
signicant differences in the amount of
nerve movement among the techniques
(P.0001). The excursion associated with
the sliding technique (mean  SD, 10.2
 2.8 mm) was signicantly larger than
the excursion with any other techniques
(P = .0001) (J78B;). The tensioning technique (mean  SD, 1.8  4.0) resulted in
the smallest excursion (P = .0001). Elbow
movements resulted in larger excursions
of the median nerve at the humerus than
movements of the neck (P.0001).
The absolute amount of nerve excursion (ie, the amount of movement regardless of the direction of the movement) is
presented in the lower panel of <?=KH; *.
The analysis of variance based on these
values also revealed signicant differences

Excursion (Median Nerve)

10.2
10.2
A

1.8
1.8

5.6
5.6
C

5.5
D

3.3

3.4

Amplitude Neck

80

Longitudinal Excursion (mm)

A
Amplitude Elbow

Longitudinal Excursion (mm)

Range of Motion (deg)

RESEARCH REPORT

14
12
10
8
6
4
2
0

Absolute Excursion (Median Nerve)

10.2
10.2
A

3.6
3.6
B

5.6
5.6
C

5.5
5.5
D

3.3
3.3
E

3.4
3.4
F

<?=KH;*$The top panel shows the longitudinal

excursion of the median nerve taking into
consideration the direction of movement (positive
values for distal movement; negative values for
proximal movements). The lower panel shows the
absolute excursion (ie, the amount of excursion
irrespective of the direction). Please refer to TABLE
for an overview of the statistical comparisons.

an ICC2,1 of 0.96 (95% CI: 0.883, 0.988;

SEM, 0.66 mm; MDC, 1.84 mm). As a
result of the small measurement error,
relatively small differences could be interpreted reliably.

Differences in Nerve Excursion (Top Table) and Absolute Excursion (Bottom Table)
Between Techniques and the Results From the Statistical Comparison*
7'&$(($.

8'$.*$&

9+$,($'

:+$+($/

;)$)'$)

<)$*&$/

...

8.4

4.6

4.7

13.5

13.5

5.1

5.2

B (1.8  4.0)

...

...

3.8

3.7

C (5.6  2.1)

...

...

...

0.1

8.9

9.0

D (5.5  2.9)

...

...

...

...

8.8

8.9

E (3.3  1.3)

...

...

...

...

...

0.1

7Xiebkj[;nYkhi_ed
A (10.2  2.8)
B (3.6  2.3)
C (5.6  2.1)

7'&$(($.

8)$,($)

9+$,($'

:+$+($/

;)$)'$)

<)$*&$/

...

6.6

4.6

4.7

6.9

6.8

0.2

2.3

...
...

...
...

2.0
...

1.9

0.1

0.3

2.4

D (5.5  2.9)

...

...

...

...

2.3

2.2

E (3.3  1.3)

...

...

...

...

...

0.1

* The mean p SD longitudinal nerve excursion (in mm) for each technique is presented. Letters A through F correspond with the techniques demonstrated in
FIGURE 1: sliding technique (A), tensioning technique (B), elbow extension with the neck in contralateral (C), and ipsilateral (D) lateral exion, cervical
contralateral lateral exion with the elbow in a more extended (E) and a more exed (F) position.

Pg.0001.

Not signicant.

Pg.005.

168 | march 2009 | volume 39 | number 3 | journal of orthopaedic & sports physical therapy

among techniques (P.0001). The sliding

technique was still associated with the largest excursion (P = .0001). Elbow extension
still resulted in a larger amount of nerve
movement in the upper arm than the tensioning technique (Pg.004) or movements
of the neck (Pg.002). There was no longer
a difference in the amount of nerve excursion between the tensioning technique and
the neck movements (P.65).

:?I9KII?ED

he results of this in vivo study

demonstrate that different types of
nerve-gliding exercises are associated with different amounts of longitudinal nerve excursion. Given the excellent
reliability and the magnitude of the differences, the authors are condent that
the identied differences in longitudinal
nerve movement are true differences
and are not due to measurement error.
In agreement with clinical assumptions
and cadaveric studies, the sliding technique resulted in the largest excursion.
The amount of nerve movement with this
technique was nearly twice as large as the
excursion in any of the other techniques.
A cumulative effect is likely because the
neck and elbow movements both facilitated nerve movement in the same direction. For the single-joint movements
under investigation, elbow movements
resulted in larger nerve excursions than
neck movements. This can, at least partially, be explained by the fact that nerve
excursion was measured closer to the elbow than to the neck. This may also explain why in the majority of participants
the tensioning technique resulted in a
movement towards the elbow rather than
towards the neck.
The differences in the amount of median nerve movement demonstrated in
this study, together with the marked differences in strain observed in cadaveric
studies,6,9 shows that different types of
nerve-gliding exercises have very different effects on the nervous system. While
awaiting more clinical trials, appreciation
of these biomechanical differences may

be part of a basis clinicians can use for

technique selection. For example, a sliding technique, which produces greater
movement but less tension, seems less
aggressive and may be more appropriate
for acute injuries, postoperative management, and situations such as bleeding and
inammation around the nerve, provided
that mobilization is indicated.9 Acknowledgement of the different mechanical effects on the nervous system also implies
that we can no longer state in general
terms that nerve-gliding exercises are or
are not effective for a certain condition.
Due to the largely different effects on the
nervous system, one type of technique
may be highly successful, whereas another
technique may have limited or no effect,
or may even be contraindicated. Until we
have more evidence from clinical trials
that demonstrate what type of exercise has
what clinical effect in what stage of a particular pathology, sound clinical reasoning
will remain of cardinal importance.
The results from this experiment and
previous studies5,18,30 suggest that the
mechanical effect of joint movement
on a healthy nervous system is typically
predictable. The direction of the excursion can be inferred and the relative
amount of movement and strain can be
estimated. It is important to emphasize,
though, that the described mechanical
behavior associated with a sliding technique applies predominantly to the section of the peripheral nerve between the
2 moving joints. The sliding technique
studied in this experiment resulted in
substantial gliding of the median nerve
in the upper arm and likely the shoulder;
however, based on a previous cadaveric
experiment,6 a relatively small longitudinal excursion can be expected distal
to the elbow. These differences in excursion are probably important to consider
when designing exercises. If a large nerve
movement in the lower arm is aimed for
without a signicant increase in strain,
the sliding technique could involve the
elbow and wrist.6
One element that is less predictable is
the effect of the position of a neighbor-

ing joint on the amount of nerve movement during single-joint movements. It

is logical to assume that the amount of
nerve excursion produced with a singlejoint movement will be less if the nervous
system is pretensioned by the positioning of an adjacent joint; but this was not
observed in the present study and has
not systematically been found in a previous cadaveric study.6 The position of the
nerve as a consequence of the pretensioning position in the adjacent joint relative
to the ultrasound transducer, the amount
of slack and tension in the nervous system, and the location of the measurements may all play a role in the amount
of excursion observed.
Although the ndings conrm the hypothesis that different mobilization techniques have different mechanical effects
on the nervous system, we had anticipated larger excursions across all techniques. A direct comparison of some of
our ndings with previous results is difcult because in different studies joints
are moved through different ranges of
motion and longitudinal nerve excursion
measurements are not taken at the same
locations. In addition, quantication
methods have been different. Bearing in
mind these limitations, Wright et al31 reported a mean  SD longitudinal excursion of the median nerve of 12.3  4.2
mm when the elbow was moved from 10
to 90 exion. These ndings obtained
at the elbow in fresh-frozen cadavers are
comparable with measurements recorded at the humerus in embalmed cadavers (10.3  1.4 mm) when the elbow was
moved through a similar range of motion.6 Similar ndings were reported for
in vivo measurements in a small sample
(10.4  2.3 mm).13 These excursions are
substantially larger than the excursions
observed with elbow movements in the
present study (mean  SD, 5.6  2.1 mm
and 5.5  2.9 mm). The present ndings
are more consistent with the results of
another in vivo study which estimated
nerve excursion in the upper arm (4.3
mm).20 It should be noted, however, that
the range of elbow movement in the lat-

journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 169

[
ter study was smaller (45) and that the
positions of the shoulder and shoulder
girdle were markedly different. Wilgis
and Murphy29 reported a mean excursion
of the median nerve just proximal to the
elbow of 7.3 mm in fresh cadavers when
the elbow was moved from full exion
to full extension. Discrepancies between
study ndings may be due to differences
in methods, possible changes in nerve
properties postmortem, or they may
simply reect the large between-subject
variability in nerve excursion. Although it
would be worthwhile to explore these discrepancies, it is important to emphasize
that the absolute amount of nerve excursion associated with a certain technique
or joint movement was not the main goal
of this study. We were especially interested in the relative differences in nerve
movement between techniques.
Neural mobilization exercises of the
brachial plexus and proximal parts of the
median nerve have been suggested for patients with CTS, especially if CTS coexists
with a more proximal lesion.25 We would
like to emphasize that we did not aim to
evaluate specic techniques for a specic
disorder. We aimed to test the assumption that different types of nerve-gliding
exercises produce different mechanical
effects on the nervous system. Because of
the relatively large differences in excursion between techniques, and because
it is unclear whether nerve entrapment
affects longitudinal nerve movement, we
assume that different techniques are also
associated with different biomechanical
effects in patient populations. With this
now conrmed in both cadaveric and in
vivo studies, future studies will have to
investigate possible different physiological and therapeutic effects of different
types of nerve-gliding exercises. T

A;OFE?DJI
<?D:?D=I0 Different types of nerve-gliding

exercises produce markedly different

amounts of longitudinal median nerve
excursion. The simultaneous movement of an adjacent joint may strongly
facilitate or limit the longitudinal nerve

RESEARCH REPORT
excursion associated with a single-joint
movement.
?CFB?97J?ED0 Within a sound clinical reasoning framework, acknowledgement
of these biomechanical differences may
assist in exercise selection. Given these
largely different mechanical effects, a
recommendation regarding the clinical efficacy of nerve-gliding exercises in
general, or lack thereof, is most likely an
oversimplification in both clinical practice and research. Future studies must
determine whether different mechanical effects are associated with different
physiological and therapeutic effects.
97KJ?ED0 The described mechanical behavior of a nerve associated with a sliding or tensioning technique only applies
to the section of the peripheral nerve
between the 2 moving joints. The excursion proximal or distal to this section
may be markedly different.

]
7.

8.

9.

'&$

11.

12.

ACKNOWLEDGEMENTS: This study was sup-

ported by project grant #511161 from the National Health and Medical Research Council,
Australia. The authors would like to thank
Annina Schmid and Robert Nee for their assistance with the measurements.

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CEH;?D<EHC7J?ED
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journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 171