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

Ana Silva, André Manso, Ricardo Andrade, Vanessa Domingues, Maria

Piedade Brandão, Anabela G. Silva

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

To appear in: Clinical Biomechanics

Received date: 15 April 2014

Revised date: 30 July 2014
Accepted date: 30 July 2014

Please cite this article as: Silva, Ana, Manso, André, Andrade, Ricardo, Domingues,
Vanessa, Brandão, Maria Piedade, Silva, Anabela G., Quantitative in vivo longitudinal
nerve 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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 ACCEPTED MANUSCRIPT

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,

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

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Affiliations

a
School of Health Sciences, University of Aveiro, Portugal

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

de Santiago, 3810-193 Aveiro - Portugal

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b
Center for Health Technology and Services Research (CINTESIS), Piso 2, edifício
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nascente, Rua Dr. Plácido da Costa, s/n, 4200-450 Porto, Portugal

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Corresponding author Anabela G. Silva (PhD) –

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School of Health Sciences, University of Aveiro, Portugal

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

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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

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nervous system biomechanics in terms of excursion and strain.

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

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

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

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studies’ characteristics and assessed its methodological quality.

Findings – Twelve studies were included in this review that assessed the median nerve
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(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
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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
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and 3.5 mm for sciatic nerve excursion. Maximum reported median nerve strain was
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2.0%.

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

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

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

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

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[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

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

and intraneural blood supply [3,4].

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

painful disorders such as carpal tunnel syndrome, thoracic outlet syndrome, cubital
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tunnel syndrome or diabetes [5–8]. This has contributed to a greater popularity of

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

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

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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

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

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

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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
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different patterns of nervous system mobilization.

Thus the aims of this systematic review are i) to determine quantity and direction of
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normal nervous system longitudinal excursion and tension in response to joint

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

excursion and tension.

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2. Methods
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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:

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

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

main attributes of the study;

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 Been written either in English or in Portuguese;

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

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

segments of the body;

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

pathology;


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Reported the position of at least one joint adjacent to the one being mobilized.
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Studies were excluded if:

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 Participants had been submitted to a surgery or any other invasive event likely
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to affect nerve biomechanics.

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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

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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

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

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

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

The reviewers independently extracted the following information from each included
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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
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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
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values and presented using tables and graphs. Graphs were used only for data on the
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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
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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

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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

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

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

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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

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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
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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
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that measurement procedures had excellent reliability [33].

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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

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

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

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

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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

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

considered that differences between nerve gliding measurements induced by different

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combinations of joint movement and positioning were attributed to random error if <
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MDC 95% [34].

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3.4. Median nerve longitudinal gliding

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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].

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

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

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

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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

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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
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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
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mm).Taken together, these results suggest that finger flexion and finger extension
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induce median nerve gliding in opposite directions and that gliding increases with

proximity to the finger joints.

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3.4.2. Impact of wrist movement on median nerve gliding

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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

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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;

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

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gliding.

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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
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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.

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3.4.3. Impact of elbow movement on median nerve gliding

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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
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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

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

elongates nerve bed decreases nerve gliding.

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

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3.4.4. Impact of shoulder movement on median nerve gliding
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Two studies assessed the effect of shoulder movements on median nerve gliding

[26,28]. Shoulder abduction (10º-90º) and shoulder protraction induced proximal gliding
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of the median nerve both at the arm and forearm. Mean values were similar for both
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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
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in the arm and 0.8 mm in the forearm).

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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

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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

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

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

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

forearm=0.8 mm).
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Forward head posture seems to induce virtually no nerve gliding at both the arm and
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forearm [28].
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3.4.6. Impact of trunk movement on median nerve gliding

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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

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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

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increase in strain.

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3.6. Ulnar nerve longitudinal gliding
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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
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induced proximal gliding at the forearm (0.8 mm; MDC 95%=0.6 mm) and virtually no
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movement at the upper arm. Shoulder abduction (40º to 90º) induced virtually no

longitudinal excursion of the ulnar nerve (Table 2).

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3.7. Tibial nerve longitudinal gliding

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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

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

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

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

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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

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(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
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[15].
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4. Discussion

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

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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

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

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

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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
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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.
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Results also suggest that nerve gliding decreases as the distance from the moving joint
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increases. For example, wrist extension from 0º to 40º induced nerve gliding between
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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
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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

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

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

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

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

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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
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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
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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
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that nerves glide towards the joint if the movement elongates the nerve bed and away
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from the joint if the movement shortens it, in line with the conclusions of a previous

review [2].
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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

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systematic review will inform researchers when designing studies aiming to compare

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

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

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

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

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

T
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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

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

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

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

transport [36]. However, both studies were conducted in embalmed cadavers [35,36].
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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
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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
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was the only study found investigating strain in human healthy participants [26].
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Whether personal factors such as sex or age affect nerve gliding was not explored in

included studies and might be considered in future studies.

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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,

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

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

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

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exercises for both clinical practice and research.

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nerve sliding in response to wrist, elbow, shoulder and neck movements. Clin
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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.

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29. Echigo A, Aoki M, Ishiai S, Yamaguchi M, Nakamura M, Sawada Y. The

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30. Dilley A, Summerhayes C, Lynn B. An in vivo investigation of ulnar nerve sliding

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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

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technique. Ultrasound Med Biol. 34 (2008) 1209–16.

32. Dilley A, Greening J, Lynn B, Leary R, Morris V. The use of cross-correlation

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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
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34. Haley S, Fragala-Pinkham M. Interpreting change scores of tests and measures

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used in physical therapy. Phys Ther. 86 (2006) 735–43.

35. Coppieters MW, Butler DS. Do “sliders” slide and “tensioners” tension? An
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analysis of neurodynamic techniques and considerations regarding their

application. Man Ther. 13 (2008) 213–21.
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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
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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).

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

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

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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

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Scielo

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Cochrane

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Web of Science

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Total: n=4008

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Duplicates
(n=1004).
Titles/abstracts screened for
inclusion (n=3004).
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Identified by
title/abstract as not
relevant (n=2959).
Publications retrieved for
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detailed evaluation, including

manual screening of retrieved
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papers (n=46).
Failed to meet the eligibility criteria
(n=34), mainly due to being:
 Opinion papers;
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 Studies conducted in
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animals or cadavers;
Publications to be included in
 Studies that used invasive
analysis (n=12).
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.

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Hough Dilley et Erel et Julius et Hough Echigo Coppieters Brochwicz Dilley et Boyd et Ellis et Ellis et
Question
et al., 24 al., 26 al., 27 al., 28 et al., 25 et al., 29 et al., 19 et al., 11 al., 29 al.,5 al., 31 al., 15

CR
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

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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

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

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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

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

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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

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18. Apropriate statistical tests 1 1 1 1 1 1 1 1 1 1 1 1
20. Outcome measures valid and reliable
21. Internal validity (selection bias)
1
0
CE1
0
1
0
1
0
1
1
1
1
1
1
1
1
1
01
1
1
1
1
1
1
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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
(9) vs (9) vs (8) vs (9) vs (15) vs (13) vs (14) vs (10) vs (10) vs (13) vs (13) vs (15) vs
Total (Assessor AGS) vs (Assessor MPB)
(9) (9) (8) (9) (14) (12) (13) (11) (11) (12) (12) (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.

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RESULTS

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SAMPLE SIZE STRAIN (%)
MOVEMENT & INVOLVED PARTICIPANT POSITION & POSITION OF ADJACENT SITE OF LONGITUDINAL
AUTHORS & MDC 95% (MINIMUM TO
JOINTS JOINTS MEASUREMENT EXCURSION
CHARACTERISTICS

CR
CI (MM) MAXIMAL
MEAN (SD) (MM)
CHANGE)
MEDIAN NERVE

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HOUGH ET N=16 SUPINE; SHOULDER AT 45º ABDUCTION; ELBOW IN
WRIST EXTENSION (0º-60º) ELBOW 9.0 (2.1) 1.7
AL. 23 AGE=26-61Y FULL EXTENSION; FOREARM SUPINATED
DISTAL UPPER

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SUPINE; SHOULDER AT 45º ABDUCTION; ELBOW IN 2.4 (1.8)
ARM
FULL EXTENSION; FOREARM SUPINATED; DIGITS

MA
N=10 AND METACARPOPHALANGEAL JOINTS NEUTRAL P=1.1
MID-FOREARM 4.7 (0.5)
WRIST EXTENSION (0º - 40º) D=1.5
DISTAL UPPER
SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN 1.8 (0.4)
ARM
FULL EXTENSION; FOREARM SUPINATED; DIGITS
P=1.1

D
AND METACARPOPHALANGEAL JOINTS NEUTRAL MID-FOREARM 4.2 (0.6)
D=2.0

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DISTAL UPPER
0.2 (0.2)
ARM
SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW AT
STRAIN NOT
N=4 90º FLEXION; FOREARM SUPINATED; DIGITS AND
DETERMINED;

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METACARPOPHALANGEAL JOINTS IN NEUTRAL MID-FOREARM 5.6 (0.9)
NERVE MAY BE

DILLEY,ET
CE DISTAL UPPER
0.5 (0.4)
UNLOADED

AL. 26 SUPINE; SHOULDER AT 45º ABDUCTION; ELBOW IN

ARM
STRAIN NOT
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N=6 WRIST EXTENSION (40º - 0º) FULL EXTENSION; FOREARM SUPINATED; DIGITS
DETERMINED;
AND METACARPOPHALANGEAL JOINTS NEUTRAL MID-FOREARM 3.1 (0.3)
NERVE MAY BE
UNLOADED
DISTAL UPPER
0.6 (0.4)
ARM
SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN
STRAIN NOT
N=3 FULL EXTENSION; FOREARM SUPINATED; DIGITS
DETERMINED;
AND METACARPOPHALANGEAL JOINTS NEUTRAL MID-FOREARM 3.1 (0.2)
NERVE MAY BE
UNLOADED
SUPINE; ELBOW IN FULL EXTENSION, WRIST DISTAL UPPER
SHOULDER ABDUCTION - 5.2 (0.7)
N=4 NEUTRAL (0º); FOREARM SUPINATED; DIGITS AND ARM
(10º-90º)
METACARPOPHALANGEAL JOINTS NEUTRAL MID-FOREARM - 3.4 (0.8) 1.0
SUPINE; SHOULDER AT 90º ABDUCTION; WRIST DISTAL UPPER
N=7 ELBOW EXTENSION (90º-0º) 10.4 (2.3)
NEUTRAL (0º); FOREARM SUPINATED; DIGITS AND ARM

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

SUPINE; SHOULDER AT 90º ABDUCTION; FOREARM

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N=4 SUPINATED, WRIST AT 45º EXTENSION; DIGITS AND MID-FOREARM - 4.2 (1.1)
METACARPOPHALANGEAL JOINTS NEUTRAL

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SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW IN DISTAL UPPER
FULL EXTENSION; WRIST NEUTRAL (0º); FOREARM - 0.5 (0.8)
N=8 ARM

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SUPINATED; DIGITS AND METACARPOPHALANGEAL
JOINTS IN NEUTRAL MID-FOREARM - 0.3 (0.6) 0.1
NECK FLEXION (0-35º)
SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN DISTAL UPPER
- 1.3 (0.7)
FULL EXTENSION; WRIST NEUTRAL (0º); FOREARM ARM

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N=9
SUPINATED; DIGITS AND METACARPOPHALANGEAL
MID-FOREARM - 0.8 (0.3) 0.2
JOINTS IN NEUTRAL
5-15 CM
EXTENSION OF THE

N
SUPINE; SHOULDER AT 45º/90ºABDUCTION; ELBOW PROXIMAL
EREL ET AL. N=19 METACARPOPHALANGEAL
27 IN FULL EXTENSION; FOREARM SUPINATED; FROM THE 2.6 0.4

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AGE=41.3±9.9Y JOINTS OF FINGERS 2 TO 5
INTERPHALANGEAL JOINTS EXTENDED DISTAL WRIST
(90º FLEXION TO 0º)
CREASE
FORWARD HEAD POSITION
SEATED; SHOULDER AT 90º FLEXION AND 20º
MOVEMENT (LOWER
ABDUCTION; ELBOW IN FULL EXTENSION, FOREARM

D
N=8 CERVICAL FLEXION AND - 0.1 0.03
SUPINATED (45º); WRIST, HAND AND FINGERS
UPPER CERVICAL
NEUTRAL PROXIMAL

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EXTENSION)
FOREARM
SEATED; SHOULDER AT 90º FLEXION AND 20º
ABDUCTION; ELBOW IN FULL EXTENSION, FOREARM
N=8 TRUNK FLEXION - 0.1 0.3

P
SUPINATED (45º); WRIST, HAND AND FINGERS
NEUTRAL
JULIUS
AL. 28
ET
N=13 SHOULDER PROTRACTION
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SEATED; SHOULDER AT 90º FLEXION AND 20º
ABDUCTION; ELBOW IN FULL EXTENSION, FOREARM
UPPER ARM - 5.9 1.7
SUPINATED (45º); WRIST, HAND AND FINGERS IN PROXIMAL
- 3.5 0.8
AC
NEUTRAL FOREARM
SUPINE; SHOULDER AT 90º ABDUCTION; UPPER ARM - 2.3 0.6
CONTRALATERAL NECK SCAPULOTHORACIC JOINT NEUTRAL; ELBOW IN
LATERAL FLEXION (35º) FULL EXTENSION, FOREARM SUPINATED (45º); PROXIMAL
- 1.5 0.6
WRIST, HAND AND FINGERS NEUTRAL FOREARM
N=11
SUPINE; SHOULDER AT 90º ABDUCTION; UPPER ARM - 0.9 0.6
CONTRALATERAL NECK SCAPULOTHORACIC JOINT IN FULL PROTRACTION;
LATERAL FLEXION (35º) ELBOW IN FULL EXTENSION, FOREARM SUPINATED PROXIMAL
- 0.6 0.3
(45º); WRIST, HAND AND FINGERS NEUTRAL FOREARM
FULL FINGERS AND THUMB ELBOW FLEXION 12.5 (2.5) 0.9
HOUGH ET N=37; EXTENSION (FROM FULL
WRIST
AL. 25 # AGE=48.0±10.0Y FINGERS FLEXION AND ELBOW EXTENSION 11.2 (2.8) 1.4
THUMB FLEXION)
ECHIGO ET SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW IN VOLAR ASPECT
N=34 ♀ WRIST EXTENSION (0º-70º) 3.0 (1.8)
AL. 29 FULL EXTENSION; FOREARM AT 80º SUPINATION OF THE

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SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW IN PROXIMAL

THIRD OF 1.9 (1.4)
FULL EXTENSION; FOREARM AT 70º PRONATION
FOREARM

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SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW
3.0 (1.3)
FLEXED; FOREARM AT 80º SUPINATION

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SUPINE; SHOULDER AT 30º ABDUCTION; ELBOW
2.2 (1.7)
FLEXED; FOREARM AT 70º PRONATION

FLEXION OF THE PROXIMAL
AND DISTAL
INTERPHALANGEAL JOINTS
OF FINGERS 1 TO 4
CR
SHOULDER AT 30º ABDUCTION; ELBOW IN FULL
- 0.8 (0.8)
EXTENSION; FOREARM AT 80º SUPINATION

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FLEXION OF THE
METACARPOPHALANGEAL
SHOULDER AT 30º ABDUCTION; ELBOW IN FULL
JOINTS AND PROXIMAL AND -1.3 (1.0)
EXTENSION; FOREARM AT 80º SUPINATION

N
DISTAL INTERPHALANGEAL
JOINTS OF FINGERS 1 TO 4

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SIMULTANEOUS ELBOW
EXTENSION (≈83º) AND
10.2 (2.8)
CERVICAL IPSILATERAL
LATERAL FLEXION (≈29º)
SHOULDER AT 90º ABDUCTION AND EXTERNAL

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SIMULTANEOUS ELBOW
ROTATION: FOREARM SUPINATED
EXTENSION (≈141º) AND

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CERVICAL 1.8 (4.0)
CONTRALATERAL LATERAL
FLEXION (≈29º)
7 TO 10 CM
NECK IN CONTRALATERAL LATERAL FLEXION (≈29º),

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COPPIETERS, N=15 (7♂+ 8♀) PROXIMAL TO
ELBOW EXTENSION (≈141º) SHOULDER AT 90º ABDUCTION AND EXTERNAL 5.6 (2.1) 1.8
ET AL. 19 AGE=30 ±8Y THE MEDIAL
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ROTATION; FOREARM SUPINATED
NECK IN IPSILATERAL LATERAL FLEXION (≈29º);
EPICONDYLE
ELBOW EXTENSION (≈141º) SHOULDER AT 90º ABDUCTION AND EXTERNAL 5.5 (2.9)
ROTATION; FOREARM SUPINATED
AC

CERVICAL SHOULDER AT 90º ABDUCTION AND EXTERNAL

CONTRALATERAL LATERAL ROTATION; ELBOW IN EXTENSION (≈141º); FOREARM -3.3 (1.3)
FLEXION (≈29º) SUPINATED
CERVICAL SHOULDER AT 90º ABDUCTION AND EXTERNAL
CONTRALATERAL LATERAL ROTATION; ELBOW IN FLEXION (≈81º; FOREARM - 3.4 (0.9)
FLEXION (≈29º) SUPINATED)
CERVICAL LATERAL GLIDE MIDDLE
3.3 0.8
AT C5/C6 (TRANSLATIONAL FOREARM
MOVEMENT AWAY FROM DISTAL
SHOULDER AT 30º ABDUCTION, DEPRESSION AND 2.5 0.6
BROCHWICZ N=11 (5♂+ 6♀) THE SIDE TO BE TESTED) FOREARM
EXTERNAL ROTATION; ELBOW IN FULL EXTENSION,
ET AL 11 # AGE=25.6 ±2.3Y MIDDLE
CERVICAL FOREARM IN FULL SUPINATION 2.3 0.3
FOREARM
CONTRALATERAL LATERAL
DISTAL
FLEXION 1.9 0.6
FOREARM

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ULNAR NERVE

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PROXIMAL
SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW IN 1.1 1.4
FOREARM

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N=6 FULL EXTENSION; FOREARM SUPINATED; DIGITS
DISTAL-
AND METACARPOPHALANGEAL JOINTS NEUTRAL 2.1 1.4
FOREARM
WRIST EXTENSION (0º - 40º)

CR
PROXIMAL
SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW AT 2.3 1.4
FOREARM
N=4 90º FLEXION; FOREARM SUPINATED; DIGITS AND
DISTAL-
METACARPOPHALANGEAL JOINTS NEUTRAL 4.0 0.8
FOREARM

US
PROXIMAL
SUPINE; SHOULDER AT 40º ABDUCTION; ELBOW IN 1.6 0.8
FOREARM
N= 2 WRIST EXTENSION (0º - 40º) FULL EXTENSION; FOREARM SUPINATED; DIGITS
DISTAL-
AND METACARPOPHALANGEAL JOINTS NEUTRAL 3.0 1.4

N
DILLEY,ET FOREARM
AL. 29 PROXIMAL

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0.1 0.8
UPPER ARM
N=1 ELBOW FLEXION (0º-90º) SUPINE; SHOULDER AT 90º ABDUCTION; ELBOW AT DISTAL
- 0.8 0.6
90º FLEXION; FOREARM SUPINATED; DIGITS AND FOREARM
METACARPOPHALANGEAL JOINTS NEUTRAL

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PROXIMAL

TE
N=5 ELBOW FLEXION (90º-140º) FOREARM# 2.7 --
SUPINE; ELBOW IN FULL EXTENSION; DIGITS AND UPPER ARM 0.1 0.6

P
SHOULDER ABDUCTION METACARPOPHALANGEAL JOINTS NEUTRAL FOREARM 0.1 0.6
N= 2
(40º-90º)
CE
SUPINE; ELBOW FLEXED (90º); DIGITS
METACARPOPHALANGEAL JOINTS NEUTRAL
AND UPPER ARM
FOREARM
0.1
0.1
0.6
0.6
TIBIAL NERVE
AC

SIDE LYING; SPINE IN NEUTRAL; HIP FLEXION (20º),

FROM > 30º PLANTAR 2.2 (0.5)
BOYD ET AL. N=5 (4♀+ 1♂) KNEE EXTENDED (0º) POPLITEAL
5 FLEXION TO > 0º DORSAL
AGE=40.0±11.8 SIDE LYING; SPINE IN NEUTRAL; HIP FLEXION (≈62º), FOSSA
FLEXION 0.7 (0.3)
KNEE EXTENDED (0º)
SIMULTANEOUS NECK
EXTENSION (FROM FULL
NECK FLEXION TO 40/70º
ELLIS ET AL. N=27 (14♀+13♂) NECK EXTENSION) AND POPLITEAL
31 SEATED, HIP FLEXED (90º), KNEE FLEXED (50º) 5.2 1.4
AGE=22.82±4.61Y ANKLE DORSIFLEXION FOSSA
(FROM FULL PLANTAR
FLEXION TO 20º/40º
DORSIFLEXION)

SCIATIC NERVE

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 ACCEPTED MANUSCRIPT

SIMULTANEOUS NECK
EXTENSION (FROM FULL
NECK FLEXION TO 40/70º

T
ELLIS ET AL. N=27 (14♀+13♂) NECK EXTENSION) AND POSTERIOR MID
SEATED, HIP FLEXED (90º), KNEE FLEXED (50º) 3.5 2.2

IP
31
AGE=22.82±4.61Y ANKLE DORSIFLEXION -THIGH
(FROM FULL PLANTAR
FLEXION TO 20º/40º

CR
DORSIFLEXION)
SIMULTANEOUS KNEE
EXTENSION (FROM 80 TO 0º

US
FLEXION) AND NECK
3.3 (2.0)
EXTENSION (FROM FULL
FLEXION TO FULL
EXTENSION)

N
KNEE EXTENSION (FROM 80
TO 0º FLEXION) WHILE NECK 2.6 (1.4)

MA
IN NEUTRAL
ELLIS ET AL. N=31 (22♀+9♂) SEATED; SLUMPED SPINAL POSTURE, HIPS FLEXED POSTERIOR
15 NECK FLEXION (FROM FULL 0.6
AGE=29.0±9.0Y (90º) MID-THIGH
EXTENSION TO FULL
- 0.1 (0.1)
FLEXION) WHILE THE KNEE

D
WAS AT 80º FLEXION
SIMULTANEOUS KNEE

TE
EXTENSION (FROM 80 TO 0º
FLEXION) AND NECK
2.6 (1.5)
FLEXION (FROM FULL

P
EXTENSION TO FULL
FLEXION)
CE
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
AC

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 ACCEPTED MANUSCRIPT

Highlights

 Overall mean gliding varies between virtually no gliding to 12.5 mm

 Gliding is greatest proximal to the moving joint

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

IP
away from the moving joint when the nerve bed is shortened

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

SC
seem to increase nerve gliding

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

NU
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

MA
D
P TE
CE
AC

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