Mechanical Effects of a Specific Neurodynamic Mobilization of the Superficial Fibular Nerve: A Cadaveric Study.

CONTEXT: A specific neurodynamic mobilization for the superficial fibular nerve (SFN) has been suggested in the reference literature for manual therapists to evaluate nerve mechanosensitivity in patients. However, no authors of biomechanical studies have examined the ability of this technique to produce nerve strain. Therefore, the mechanical specificity of this technique is not yet established. OBJECTIVES: To test whether this examination and treatment technique produced nerve strain in the fresh frozen cadaver and the contribution of each motion to total longitudinal strain. DESIGN: Controlled laboratory study. SETTING: Laboratory. MAIN OUTCOME MEASURE(S): A differential variable reluctance transducer was inserted in 10 SFNs from 6 fresh cadavers to measure strain during the mobilization. A specific sequence of plantar flexion, ankle inversion, straight-leg raise position, and 30° of hip adduction was applied to the lower limb. The mobilization was repeated at 0°, 30°, 60°, and 90° of the straight-leg raise position to measure the effect of hip-flexion position. RESULTS: Compared with a resting position, this neurodynamic mobilization produced a significant amount of strain in the SFN (7.93% ± 0.51%, P < .001). Plantar flexion (59.34% ± 25.82%) and ankle inversion (32.80% ± 21.41%) accounted for the biggest proportions of total strain during the mobilization. No difference was noted among different hip-flexion positions. Hip adduction did not significantly contribute to final strain (0.39% ± 10.42%, P > .05), although high variability among limbs existed. CONCLUSIONS: Ankle motion should be considered the most important factor during neurodynamic assessment of the SFN for distal entrapment. These results suggest that this technique produces sufficient strain in the SFN and could therefore be evaluated in vivo for correlation with mechanosensitivity.

A perspective on the use of the cervical flexion rotation test in the physical therapy management of cervicogenic headaches.

BACKGROUND: The Cervical Flexion-Rotation Test (CFRT) is widely used in the assessment of upper cervical spine mobility impairments and in the diagnosis of cervicogenic headache (CGH) by physiotherapist. Many studies investigated its different properties, and the results show that the CFRT has good construct validity in the measurement of C1-C2 rotation as well as good to excellent reliability. PURPOSE: In this theoretical paper, we explore the value and point out two methodological issues associated to the CFRT, one related to the procedures and another related to its diagnostic accuracy. RESULTS: Our analysis indicate that there are many confounding factors that could affect the CFRT cut-off's accuracy, which are likely to overestimate the diagnosis properties of CFRT. Potential solutions are discussed. Moreover, the gold standard (manual examination) used to examine the validity of the CFRT for the diagnosis of CGH appears to be far from perfect - we could argue that the diagnostic properties of the CFRT for CGH might be biased and the likelihood ratios are likely to be overestimated. However, it could be relevant to explore if results of the CFRT could be considered as a treatment-effect modifier. Maybe the CFRT could be more valuable as a prognostic factor? CONCLUSION: The quality of evidence supporting the validity of the CFRT is most likely biased. In the absence of a better gold standard, maybe the CFRT could be a more valuable test to establish the patient's prognosis and help the clinician to choose the most appropriate treatment options.

Effects of SNAG mobilization combined with a self-SNAG home-exercise for the treatment of cervicogenic headache: a pilot study.

INTRODUCTION: Cervicogenic headache (CGH) may originate from the C1-C2 zygapophyseal joints. CGH is often associated with loss of range of motion (ROM), specific to this segment, and measurable by the cervical flexion-rotation test (CFRT). The main purposes of the study were: 1) to investigate the immediate effect of C1-C2 rotation SNAG mobilizations plus C1-C2 self-SNAG rotation exercise for patients with CGH and 2) to explore the link between the CFRT results and treatment response. METHODS: A prospective quasi-experimental single-arm design was used where patients with CGH received eight physical therapy treatments using a C1-C2 rotational SNAG technique combined with a C1-C2 self-SNAG rotation exercise over a four-week period. Outcome measures were pain intensity/frequency and duration, active cervical ROM, CFRT, neck-related and headache-related self-perceived physical function, fear-avoidance beliefs, pain catastrophizing and kinesiophobia. RESULTS: The intervention produced strong effects on pain intensity, CFRT, physical function and pain catastrophizing. Moderate improvement was noted on active cervical ROM and on fear-avoidance beliefs and kinesiophobia. No link was found between pre-intervention CFRT ROM and treatment response. CONCLUSION: SNAG mobilization combined with a self-SNAG exercise resulted in favorable outcomes for the treatment of CGH on patient-important and biomechanical outcomes, as well as pain-related cognitive-affective factors.

Exercises for mechanical neck disorders.

BACKGROUND: Neck pain is common, disabling and costly. Exercise is one treatment approach. OBJECTIVES: To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain. SEARCH METHODS: We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors). SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity. MAIN RESULTS: Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises. AUTHORS' CONCLUSIONS: No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.