Radial nerve mobilization reduces lateral elbow pain and provides short-term relief in computer users

Efficacy of neural mobilization and Maitland accessory mobilization in patients with tennis elbow- randomized controlled trial

OBJECTIVE

The objective of the study was to evaluate the efficacy of Maitland accessory mobilization and neural mobilization in patients with tennis elbow.

METHOD

Twenty-five patients meeting the selection criteria were randomly assigned to three experimental groups: Group C (conventional treatment), Group B (neural mobilization), and Group A (Maitland mobilization). Quality of life was assessed using the Patient Rated Tennis Elbow Evaluation (PRTEE), while pain, range of motion, and grip strength were evaluated using the Visual Analog Scale (VAS), a universal goniometer, and a handheld dynamometer. The interventions were administered three times per week for four weeks to the respective groups.

RESULTS

Non-parametric tests were employed to analyze the results due to the non-normal distribution of the data (p < 0.05). Both the Wilcoxon signed-rank test and the Kruskal-Wallis test were utilized to assess differences within and between groups. The results of the between-group analysis demonstrated significant differences in pain (p = 0.018) and quality of life (p = 0.045) among the three groups.

CONCLUSION

After a 4-week intervention, all three groups exhibited notable improvements in discomfort levels, grip strength, and quality of life. Notably, Group B demonstrated the most substantial increase in range of motion (ROM) compared to Groups A and C. Consequently, incorporating neural mobilization into the treatment plan is recommended for patients experiencing Tennis Elbow.

Peripheral and central changes induced by neural mobilization in animal models of neuropathic pain: a systematic review

Introduction

Neural mobilization (NM) is a physiotherapy technique involving the passive mobilization of limb nerve structures with the aim to attempt to restore normal movement and structural properties. In recent years, human studies have shown pain relief in various neuropathic diseases and other pathologies as a result of this technique. Improvement in the range of motion (ROM), muscle strength and endurance, limb function, and postural control were considered beneficial effects of NM. To determine which systems generate these effects, it is necessary to conduct studies using animal models. The objective of this study was to gather information on the physiological effects of NM on the peripheral and central nervous systems (PNS and CNS) in animal models.

Methods

The search was performed in Medline, Pubmed and Web of Science and included 8 studies according to the inclusion criteria.

Results

The physiological effects found in the nervous system included the analgesic, particularly the endogenous opioid pathway, the inflammatory, by modulation of cytokines, and the immune system.

Conclusion

On the basis of these results, we can conclude that NM physiologically modifies the peripheral and central nervous systems in animal models.

Neurodynamic Treatment Promotes Mechanical Pain Modulation in Sensory Neurons and Nerve Regeneration in Rats

Background: Somatic nerve injuries are a rising problem leading to disability associated with neuropathic pain commonly reported as mechanical allodynia (MA) and hyperalgesia. These symptoms are strongly dependent on specific processes in the dorsal root ganglia (DRG). Neurodynamic treatment (NDT), consisting of selective uniaxial nerve repeated tension protocols, effectively reduces pain and disability in neuropathic pain patients even though the biological mechanisms remain poorly characterized. We aimed to define, both in vivo and ex vivo, how NDT could promote nerve regeneration and modulate some processes in the DRG linked to MA and hyperalgesia. Methods: We examined in Wistar rats, after unilateral median and ulnar nerve crush, the therapeutic effects of NDT and the possible protective effects of NDT administered for 10 days before the injury. We adopted an ex vivo model of DRG organotypic explant subjected to NDT to explore the selective effects on DRG cells. Results: Behavioural tests, morphological and morphometrical analyses, and gene and protein expression analyses were performed, and these tests revealed that NDT promotes nerve regeneration processes, speeds up sensory motor recovery, and modulates mechanical pain by affecting, in the DRG, the expression of TACAN, a mechanosensitive receptor shared between humans and rats responsible for MA and hyperalgesia. The ex vivo experiments have shown that NDT increases neurite regrowth and confirmed the modulation of TACAN. Conclusions: The results obtained in this study on the biological and molecular mechanisms induced by NDT will allow the exploration, in future clinical trials, of its efficacy in different conditions of neuropathic pain.

Comparative Effect of Dry Needling and Neural Mobilization on Pain, Strength, Range of Motion, and Quality of Life in Patients With Lateral Epicondylitis: Protocol for Randomized Clinical Trial

Objective

The purpose of this article is to describe a study protocol that will aim to assess the effectiveness of adding dry needling or neural mobilization to conventional physiotherapy in the treatment of lateral epicondylitis.

Methods

We propose to conduct a 2-group, participant-blinded, randomized clinical trial with recruitment of 36 participants with lateral epicondylitis from a recognized super-speciality tertiary care hospital. After fulfilling eligibility criteria, consenting participants will be randomized to either a dry needling group or a neural mobilization group, both with conventional therapy as well. The outcome measures will be the Patient-Rated Tennis Elbow Evaluation questionnaire, pain pressure threshold, grip strength, and range of motion.

Results

Data analysis will be done by Wilcoxon signed-rank test or paired t test and Mann-Whitney U test or independent t test. The significance level will be set at 0.05. All outcome measures will be recorded at baseline and after 2 weeks of intervention.

Conclusion

This study protocol will provide data regarding the effects of dry needling and neural mobilization in people with lateral epicondylitis.

Neurodynamics: is tension contentious?

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

Chiropractic Management of a Patient With Radial Nerve Entrapment Symptoms: A Case Study

Objective

This report describes the case of a patient with chronic radial nerve entrapment symptoms managed with chiropractic care. We propose a complementary functional neurologic assessment of muscle function in different positions that could reveal muscle dysfunctions absent with standard test position.

Clinical Features

A 45-year-old man presented to a private chiropractic clinic with a throbbing pain 5 cm above the right lateral elbow epicondyle radiating onto the back of the lower arm and increasing after using a mouse when working on a computer. A Mill test and a Cozen test created pain near the lateral epicondylitis. The use of complementary functional neurologic assessment for radial nerve entrapment showed changes in manual muscle testing after tests were done in different positions to increase the compression on the nerve.

Intervention and Outcome

Chiropractic management was performed, including myofascial therapy, spinal and proximal radioulnar joint adjustments, neural mobilization, and the use of a splint. After 7 days (2 treatments), the patient showed no elbow pain even if he worked on his computer using a mouse. After a 2-year follow-up, no recurrence was reported.

Conclusion

In this case of radial nerve entrapment symptoms, the patient benefited from chiropractic management using standard chiropractic, applied kinesiology, and neural mobilization techniques. The complementary functional neurologic assessment of radial nerve entrapment proposed revealed muscles dysfunctions absent with the standard test position. These changes in manual muscle testing were useful to determine the possible sites of entrapment in order to direct the therapeutic efforts to these locations.

Ultrasound-Guided Percutaneous Electrical Nerve Stimulation of the Radial Nerve for a Patient With Lateral Elbow Pain: A Case Report With a 2-Year Follow-up

BACKGROUND

Patients with lateral elbow pain are often diagnosed with lateral epicondylalgia. Lateral elbow pain is often associated with dysfunction of the wrist extensor muscles; however, in some cases, it can also mimic signs and symptoms of radial nerve dysfunction.

CASE DESCRIPTION

In this case report, a 43-year-old man, who was originally referred with a diagnosis of lateral epicondylalgia as a result of playing table tennis and who previously responded favorably to manual therapy and exercise, presented to the clinic for treatment. An exacerbation while participating in a table tennis match resulted in a return of his lateral epicondylalgia symptoms, which did not respond favorably to the same interventions used in his prior course of therapy. Further examination revealed sensitization of the radial nerve, which was treated with 2 sessions of ultrasound-guided percutaneous electrical nerve stimulation and 4 weeks of a low-load, concentric/eccentric exercise program for the wrist extensors.

OUTCOMES

Following this intervention, the patient experienced clinically meaningful improvement in pain intensity (numeric pain-rating scale), function (Patient-Rated Tennis Elbow Evaluation), and related disability (Disabilities of the Arm, Shoulder and Hand questionnaire). The patient progressively exhibited complete resolution of pain and function, which was maintained at 2 years.

DISCUSSION

This case report demonstrates the outcomes of a patient with lateral elbow pain who did not respond to manual therapy and exercise. Once radial nerve trunk sensitivity was identified and the intervention, consisting of ultrasound-guided percutaneous electrical nerve stimulation targeting the radial nerve combined with a low-load exercise program, was applied, a full resolution of pain and function occurred rapidly. Future clinical trials should examine the effect of percutaneous electrical nerve stimulation in the management of nerve-related symptoms associated with musculoskeletal pain conditions.

LEVEL OF EVIDENCE

Therapy, level 5. J Orthop Sports Phys Ther 2019;49(5):347-354. Epub 18 Jan 2019. doi:10.2519/jospt.2019.8570.