efecto glide cervical sobre el ultt physiotherapy)

8/14/2019 Efecto Glide Cervical Sobre El Ultt Physiotherapy)

1/7PhysiotherapyNovember 2003/vol 89/no 11

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Introduction

Examination of the nervous systemthrough assessment of reflexes, musclepower and sensation has been common

practice in the neuromusculoskeletaldiscipline for many years. More recentlythere has been a trend, particularly withinthe physiotherapy profession, also toinclude palpation of peripheral nerves,as well as neurodynamic tests as partof this assessment (Elvey, 1986; Butler,1991, 2000; Selvaratnam, 1995; Fidel et al,1996; Vicenzino et al, 1996, 1998; Wainneret al, 2003).

In the upper limb, four tests have beenproposed, collectively called the upper

limb tension tests (Butler, 1991), morerecently the upper limb neurodynamictest in order to encourage a shift awayfrom a purely mechanical (tension,provocation) view of these tests (Butler,2000).

Over the past decade various treatmentapproaches have been advocated once thepresence of restricted neural tissue hasbeen identified. These techniques haveincluded neural stretches and neuralmobilisation techniques (Butler, 1991;Butler and Slater, 1995; Selvaratnam,

1995), as well as treatment directed at theadjacent structures that might impede onneural tissue mobility (Elvey, 1986; Butler,1991; Selvaratnam, 1995; Vicenzino et al,1996, 1998). The cervical intervertebralforamen is one such structure, and Elvey(1986 page 229) recommended that acervical lateral gliding technique wouldallow movement of structures within theintervertebral foramen without unduetension being applied to the neuraltissues. Since its description the cervical

lateral glide has been used extensively as atechnique to improve neural mobility(Vicenzino et al, 1994, 1996, 1998;Coppieters and Stappaerts, 2000).

In a study on the effect of the cervical

Effect of a Cervical Lateral

Glide on the Upper LimbNeurodynamic Test 1A blinded placebo-controlled investigation

Summary

Background and Purpose This study investigated the effect

of the cervical lateral glide technique applied at the facet

joint between the fifth and sixth cervical vertebrae, on the

range of elbow extension, a component of the upper limbneurodynamic test 1.

Methods Twenty asymptomatic subjects, nave to the effects

of manual therapy, were randomly allocated to a varied order

of procedures that included cervical lateral glide technique,

placebo technique, and control procedure. Elbow extension

range was measured with an electrogoniometer before and

after each procedure. The lead investigator was blinded to

the data output. A pilot study before the main investigation

established the reliability and accuracy of measuring elbow

extension range with the electrogoniometer.

Results The results of a Friedmans analysis of variance

suggested that there was a significant difference between the

three conditions (p < 0.0001). Results of multiple comparison

analysis using the Wilcoxon signed rank test suggested that

the cervical lateral glide technique resulted in a change in

elbow extension over 7 (p < 0.001) where minimal change

occurred in the placebo and control conditions.

Conclusions The cervical lateral glide technique applied tothe facet joint between the fifth and sixth cervical vertebrae

significantly increased the elbow extension component of the

upper limb neurodynamic test 1 in asymptomatic subjects,

compared with those receiving a placebo technique and a

control group. It is hypothesised that two mechanisms may

have led to this increase. The first involves a change to the

nerve root interface at the cervical intervetebral foramen. The

second is that the cervical lateral glide technique reduced the

tone of muscles supplied by the mobilised segment resulting

in the observed increase in elbow extension.

Key WordsMobilisation, cervical spine,elbow extension,neural tissue.

by Jacob SarangaAnn GreenJeremy LewisChris Worsfold

Saranga, J, Green, A, Lewis, J and Worsfold, C (2003). Effect of acervical lateral glide on the upper limb neurodynamic test 1: A blindedplacebo-controlled investigation, Physiotherapy, 89, 11, 678-684.



679Research report

Authors

Jacob Saranga BPTMCSP MMACPMSc(ManipulativeTherapy) is a senior

lecturer andAnnGreen MSc MCSPILTM is associatehead of physiotherapyand dietetics in theSchool of Health andSocial Sciences,Coventry University.

Jeremy Lewis PhDMCSP MAPA MMPAMMACPMSc(ManipulativePhysiotherapy) is a

research co-ordinatorand Chris WorsfoldMSc MCSPPGDip(ManipulativePhysiotherapy) is asenior physiotherapistin Chelsea and

WestminsterHealthcare NHSTrust.

Address forCorrespondence

Jacob Saranga MSc,Senior Lecturer,Physiotherapyand Dieteticssubject group,School of Health andSocial Sciences,Coventry University,Priory Street,Coventry CV1 5FB.

[email protected].

uk

lateral glide technique on 34 asympt-omatic subjects Vicenzino et al (1994)reported that the technique producedsignificantly greater increases in skinconductance, but not on skin temp-erature, than did placebo or control intwo different positions of neural tensiontesting (upper limb neuro-dynamic test 1and 2b). Vicenzino et al(1996) examinedthe effect of the cervical lateral glidetechnique applied to the motion segmentconsisting of the fifth and sixth cervical

vertebrae on 15 patients suffering fromlateral epicondylalgia. A number of

variables were measured including theeffect of the technique on the flexibilityof the upper limb neurodynamic test 2b

(Butler, 1991), reflected as a change inglenohumeral abduction range. Theirresults suggested that the cervical lateralglide produced significant increases inabduction range (measured using anelectrogoniometer) and concluded thatthe technique had an influence on theflexibility of the upper limb neuro-dynamic test 2b.

More recently, Vicenzino et al(1998)investigated the effect of a cervical lateralglide, directed contralaterally to the

affected upper limb at the fith and sixthcervical vertebrae on the flexibility of theupper limb neurodynamic test 2b in 24subjects with lateral epicondylalgia. Theresults suggested that the techniquesignificantly increased the flexibility of theneural tissues when compared to a controlprocedure and placebo technique.

The upper limb neurodynamic testassesses the mobility of the upperquadrant neural tissues by applying asequence of movements that mechanicallyelongate the nerves being tested (Elvey,

1986; Maitland, 1986; Butler, 1991, 2000;Selvaratnam, 1995; Shacklock, 1995;Magee, 1997; Lewis et al, 1998). Butler(2000) suggests that the upper limbneurodynamic test also produces move-ment of the nervous system in relation tointerfacing structures. These are thestructures that are anatomically related tothe neural tissue and have the potential torestrict normal neural mobility (Penning,1992). The test described by Selvaratnam(1995), known as the upper limb neuro-

dynamic test 1, involves shoulder de-pression, glenohumeral abduction andexternal rotation, forearm supination,

wrist and finger extension and elbowextension. Selvaratnam (1995) recom-

mends elbow extension as the finalmanoeuvre of the test due to the relativeclinical ease of measuring elbowextension range.

The results of the upper limb neuro-dynamic test 1 determine whether sub-sequent tests should be performed(Butler, 2000). Furthermore the test hasbeen found to be positive in the presenceof minor peripheral neuropathies andcervical radiculopathies (Greening andLynn, 2000; Wainner et al, 2003). Thepurpose of this study was to investigatethe effect of the cervical lateral glidetechnique on elbow extension in theupper limb neurodynamic test 1.

The experimental hypothesis for this

study was that the cervical lateral glidetechnique applied to the facet jointbetween the fifth and sixth cervical

vertebrae would increase the flexibilityof the structures tested by the upperlimb neurodynamic test 1.

MethodsDesign

A single-blind study was designed whichincluded an experimental condition, aplacebo and a control condition.

Participants were subjected to all threeconditions in a randomised order. Theupper limb neurodynamic test 1, assessedby measuring range of elbow extension,

was the selected outcome measure(Butler, 2000). The experimentalcondition was the cervical lateral glidedescribed by Maitland (1986).

Ethical Approval and Patient ConsentEthical approval for this study was grantedby Coventry University Ethics Committee.Each subject was provided with an

information document and signed aninformed consent sheet before takingpart. All subjects were able to withdraw atany stage of the investigation.

SubjectsTwenty asymptomatic subjects (12 womenand 8 men) with a mean age of 32 years(SD 8.6), a mean height of 167 cm (SD8.2), and a mean weight of 67 kg (SD14.2) participated in the investigation.Subjects were nave to the effects of

manual therapy, therefore anyone withprevious experience of manual therapy

was excluded as well as subjects withcurrent cervical and upper quadrantsymptoms.



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Procedure

Each subject was randomly allocated to apresentation order of the threeprocedures. The investigator was unawareof the treatment allocation as she did notobserve the procedure and collected theelbow extension measures independently.

A physiotherapist with a postgraduatedegree in manipulative physiotherapyperformed each of the techniques on allthe subjects and was blinded to themeasured elbow extension range.

Subjects were investigated in the supineposition on the same treatment plinth. Anelectrogoniometer (Penny and Giles,Biometrics Ltd, UK) was attached to thesubjects dominant arm and was used to

measure elbow extension range. Shouldergirdle depression was maintained at60 mm Hg using a pressure biofeed-back device (Chattanooga, Australia).This method of maintaining a constantshoulder position has been reported(Edgar et al, 1994; Lewis et al, 1998). Thesubjects glenohumeral joint was passivelypositioned at 110 abduction and thisangle was maintained using a universalgoniometer (Baseline, UK) with onearm of the device held along the lateral

border of the trunk and the other alongthe humerus. The subjects forearm wasthen passively taken to the end range ofavailable supination, wrist and fingerextension, and glenohumeral externalrotation. The final movement was passiveelbow extension taken to the point of

maximum resistance confirmed by thesubject (Maitland, 1986). Following apilot study before the main investigation,the procedure was repeated five times andelbow extension range was measured onthe sixth occasion.

The second measurement of elbowextension was made after applicationof the cervical lateral glide (fig 1), theplacebo technique and the controltechnique. The cervical lateral glide tech-nique (Maitland, 1986) was performed onthe facet joint between the fifth andsixth cervical vertebral segment on thecontralateral side and directed towardsthe side of the arm being investigated forthree repetitions, each of 60 seconds. The

technique, a grade III mobilisation(Maitland, 1986), was repeated threetimes, each set of mobilisations lasting for60 seconds. There was an interval of oneminute between each repetition. Thehead and cervical spine were kept in aneutral position. The facet joint wasidentified by palpation (Elvey, 1986;Maitland, 1986).

The placebo technique (fig 2a) wasdesigned to imitate the experimentaltechnique and involved placing the

investigators hands lightly over thesubjects neck in the same position as thecervical lateral glide without anymovement being elicited. The controltechnique (fig 2b) involved the samesubject position with the investigatorstanding motionless at the end of the bed

without having any physical contact withthe subject, similar to a techniquereported by Vicenzino et al(1996).

Pilot StudyTo give some indication of the error

measurement using the electrogonimeter,ten measurements of elbow extensionrange were made on each of threeconsecutive days, on one subject, by oneassessor. The intraclass correlationcoefficient of these measurements was0.92 with a 95% confidence interval of0.77-0.98 (although the limitations ofthe intraclass correlation coefficient asan indication of reliability should beacknowledged) and the standard error ofmeasurement (SEM) was 0.5. This

suggests that a change of greater than 0.5between two measurements can beattributed to real change rather thanoccurring as a result of measurementerror.

Fig 1: The cervical lateral glide technique



681Research report

The validity of the electrogoniometerwas established by comparison with auniversal goniometer (BaselineTM, UnitedKingdom). One subject was measured byone assessor, with the output of the

goniometers read by an assistant. Onemeasurement was taken with eachgoniometer at ten different angles ofelbow range. Using the analysis recom-mended by Bland and Altman (1986),the mean difference between the twomeasurement methods was found tobe 0.2 with 95% limits of agreementbetween 0.64 and 1.04. This suggeststhat measurements taken with theelectrogoniometer will be within twodegrees of measurements taken withthe universal goniometer on 95% of

occasions. Although the limitations ofusing one subject and one assessor shouldbe acknowledged, this suggests that theelectrogoniometer has some validity inthe measurement of elbow range.

ResultsThe data were not normally distributedand therefore did not satisfy the criteriafor parametric statistical analysis and thethree conditions were analysed using thenon-parametric Friedmans analysis of

variance test. The Wilcoxon signed rankprocedure was used to determine if there

was a difference between the conditions.The p value was adjusted for the per-formance of multiple comparisons by

using Bonferroni corrections at p < 0.017(Altman, 1991; Sim and Wright, 2000).Boxplot comparisons of the threeconditions are presented in figure 3overleaf.

The results of a Friedmans analysis of variance suggested that there was asignificant difference between the threeconditions (2 = 25.162; p < 0.0001).Results of the multiple comparisonanalysis using the Wilcoxon signed ranktest suggested significant differencesbetween the cervical lateral glidetechnique and the placebo (Z = --3.854,p < 0.0001), and the control techniques(Z = 3.769, p < 0.0001), and that nostatistically significant difference existedbetween the placebo and control

techniques (Z = 0.805, p < 0.421).

DiscussionThe findings of this study suggested thatthe cervical lateral glide techniqueapplied at the facet joint of the fifth andsixth cervical segments and directedtowards the arm being investigated maybe capable of significantly increasing theelbow extension component of the upperlimb neurodynamic test 1, which mayindicate greater neural extensibility.

Furthermore the results suggest that theother two conditions tested (placeboand control) did not affect the elbowextension component of the upper limbneurodynamic test 1.

Fig 2: Placebo (a) and control (b) techniques

(a) (b)



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Evidence of a change in the range ofelbow extension indicates that a clinicianmay be able to influence the peripheralnervous system. Hypotheses have beenproposed which attempt to explain the

mechanism of action of manual therapytechniques. One is that the cervical lateralglide technique affects the interface at theintervertebral foramen and thus increasesthe movement of the neural tissuespassing through this space. This isthought to result in an increase in theobserved elbow extension range (Elvey,1986; Shacklock, 1995). The suggestion isthat the dynamic roominess around thenerve roots has been increased (Penning,1992).

This hypothesis depends on the cervical

lateral glide influencing the anatomicalrelationships between the opposingsurfaces of the intervertebral joint andthe soft tissues. The ability of manualtherapy procedures to achieve changesin joint position is hypothetical andopen to conjecture (Elvey, 1986; Penning,1992; Shacklock, 1995; McGregor et al,2001).

It is also possible that spinal manualtherapy may result in a reduction ofmuscle tone (Zusman 1994, Katavich

1998). Through this mechanism thecervical lateral glide technique may havereduced the tone of the muscles suppliedby the emergent nerves, including thebiceps brachii muscles (Williams et al,

1995). The hypothetical reduction in tonemay have allowed a greater range of elbowextension. Vicenzino et al(1996) used acervical lateral glide technique thatmobilised the facet joint of the fifth and

sixth vertebrae towards the contralateralside.The findings of both the present study

and that reported by Vicenzino et al(1996) suggest that the cervical lateralglide technique is capable of improvingthe joint range by using apparentlyopposing techniques. This may supporta more neurophysiological basis forthe effect of mobilisation rather thana mechanical role. Further research isrequired before the mechanisms ofmobilisation are better understood. Open

magnetic resonance image scanning mayprovide one method of achieving agreater insight.

With a total of 125 of elbow movementrequired for activities of daily livingranging from 15 to 140 in asymptomaticsubjects (Moorey et al, 1981) an increaseof 7.1 of elbow extension from onetreatment may prove clinically significant.

There are several limitations associated with the present study. Although everyeffort was made to maintain a consistent

grade III mobilisation force, the magn-itude of the force was not controlled,

which may have influenced the findings.The study population of 20 asymptomaticsubjects provided some insight into the

20

Cervical lateral glide

N =

0

20

Placebo

20

Control

Degrees

10

20

10

Fig 3: Boxplot representing changes for the three conditions, illustrating median, 25th and 75thcentiles (boxes) and highest and lowest values (whiskers)



683Research report

effect of the technique, and the studyshould be repeated with a population ofsymptomatic subjects to enhance itsexternal validity. By definition theasymptomatic subjects had a full rangeof elbow movement, so the effects notedare relevant to tissues in the absence ofpathology. It is not possible to drawinferences about the effect that thistechnique will have on a symptomaticgroup.

Future research may aim at comparingthe effect of an ipsilateral and contra-lateral cervical lateral glide on theflexibility of the neural tissues, as well as

joint range of movement. Further studiesare needed to investigate the influence of

grade of mobilisation, and mobilisationtechnique on these variables.

ConclusionThe cervical lateral glide techniqueapplied to the facet joint of the fifth andsixth cervical segment significantlyincreased the elbow extension com-ponent of the upper limb neurodynamictest 1 in asymptomatic subjects, compared

with placebo technique and a controlgroup. The resulting increase in elbowextension indicates that clinicians may beable to influence the peripheral nervoussystem using this technique. Furtherresearch is required involving sym-ptomatic subjects and larger cohorts tosubstantiate these results and determine

whether the increases in range ofmovement observed in this study are

reflected by improvements in generalfunction.

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