original paper Physiotherapy Quarterly (ISSN 2544-4395)

2021, 29(1), 12–16

© University School of Physical Education in Wrocław

The effectiveness of tensioning neural mobilization of brachial plexus

in patients with chronic cervical radiculopathy: a randomized clinical trial
doi: https://doi.org/10.5114/pq.2020.96419

Asmaa Omer Ibrahim1, Nadia Abdelazeem Fayaz2, Ahmed Hazim Abdelazeem3, Karima Abdelaty Hassan2
1
Ministry of Health and Population, Cairo, Egypt
2
Department of Physical Therapy for Musculoskeletal Disorders, Faculty of Physical Therapy, Cairo University, Egypt
3
Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Egypt

Abstract
Introduction. Tensioning neural mobilization (NM) is accomplished through increasing the distance between nerve bed ends
via elongation. NM techniques have different biomechanical effects on the nervous system. Evidence for their use in treating
certain upper-quarter conditions like cervicobrachial pain is limited. The study was to determine tensioning NM efficacy on
unilateral chronic cervical radiculopathy regarding mechanosensitivity of the affected nerve roots and intensity of neck and
arm pain.
Methods. Forty participants with chronic unilateral cervical radiculopathy were randomly assigned to group A (n = 20), receiving
traditional physical therapy (manual traction and infrared irradiation), and group B (n = 20), receiving traditional physical therapy
in addition to tensioning NM of brachial plexus. Mechanosensitivity of the affected brachial nerve roots and intensity of neck and
arm pain were evaluated at baseline and after a 3-week program with the upper limb tension test-1 and visual analogue scale.
The normal (Z) test, paired and unpaired t-test, Wilcoxon signed-rank test, and Wilcoxon rank-sum test (Mann-Whitney) were
used in data analysis.
Results. There were significant within-group differences in both groups regarding mechanosensitivity and pain intensity
(mechanosensitivity: p = 0.001 for group A, p = 0.001 for group B; pain: p < 0.01 for group A, p < 0.01 for group B). There was
no statistically significant between-group difference regarding mechanosensitivity (p = 0.07) or pain intensity (p = 0.838).
Conclusions. The addition of tensioning NM to traditional physical therapy had no significant benefits, although both groups
showed decreased post-treatment mechanosensitivity and pain intensity.
Key words: chronic cervical radiculopathy, neural mobilization, mechanosensitivity

Introduction nerve bed through elongation [5]. NM techniques, including

tensioning techniques, have different biomechanical effects
Cervical radiculopathy (CR) is a pain and/or sensorimotor on the nervous system [6, 7]. There is limited evidence for the
deficit syndrome caused by compression of a cervical nerve use of NM in the treatment of certain upper-quarter condi-
root. The compression may result from disc herniation, spon- tions [8]. Also, few studies focused on the effect of tensioning
dylosis, instability, trauma, or tumours. The patient may com- NM on mechanosensitivity in patients with CR. The purpose
plain of pain, numbness, and/or tingling in the upper extremity, of this study was to investigate if there were any benefits
which may develop to electrical-type pains or even weak- from adding tensioning NM to a traditional physical therapy
ness [1]. program in the treatment of patients with chronic unilateral
Symptoms of mechanically induced nervous system dis- CR regarding mechanosensitivity and pain intensity.
orders can have either local or remote causes. The local
causes include hypoxic, damaged, regenerating, or imma- Subjects and methods
ture axons, connective tissue irritation (e.g. dura mater, epi-
neurium, attachments), and mechanical interface irritation, Patients
while the remote causes are extra-segmental referral from
the dura mater and nerve root sleeves, mechanical interface Forty (male and female) patients with unilateral CR par-
referral (e.g. disc, zygapophyseal joint), and referral from the ticipated in the study and were randomly assigned to group A
autonomic nervous system. Intraneural pathology will affect (n = 20), who received traditional physical therapy in the form
the intrinsic elasticity of the nervous system and extra-neu- of manual traction and infrared irradiation, and group B (n =
ral pathology will affect the nerve/interface relationship [2]. 20), who received traditional physical therapy in addition to
Changes in the neurophysiology and mobility of the pe- tensioning NM of brachial plexus. All patients were informed
ripheral nerves usually cause neural dysfunction [3]. These about the study procedures and all patients were referred
changes can lead to mechanosensitivity, which is the sensi- by physicians for physiotherapy. The study was conducted
tivity of a nerve to movement and palpation, resulting in pain at the physiotherapy outpatient clinic in Al-Nozha hospital.
during movement and/or sustained postures [4]. Patients were included if they were 20–40 years of age,
Tensioning neural mobilization (NM) is accomplished had a history of pain for more than 3 months, had radiating
through increasing the distance between each end of the pain only in one upper limb, and met at least 3 of the Wainner

Correspondence address: Asmaa Omer Ibrahim, Physical Therapist at the Ministry of Health and Population, 5 Al-Eman St, New-Nozha 2,
Cairo, Egypt, e-mail: [email protected]

Received: 28.09.2019
Accepted: 03.02.2020

Citation: Ibrahim AO, Fayaz NA, Abdelazeem AH, Hassan KA. The effectiveness of tensioning neural mobilization of brachial plexus in pa-
tients with chronic cervical radiculopathy: a randomized clinical trial. Physiother Quart. 2021;29(1):12–16; doi: https://doi.org/10.5114/
pq.2020.96419.
Physiother Quart 2021, 29(1) A.O. Ibrahim, N.A. Fayaz, A.H. Abdelazeem, K.A. Hassan
physiotherapyquarterly.pl Tensioning neural mobilization in cervical radiculopathy

et al. [9] criteria. Those who had a history of high level spinal Treatment procedures
cord injury and malignancy or any of the medical ‘red flags’
(e.g. tumour, fracture, rheumatoid arthritis, osteoporosis, pro- Both groups received traditional physical therapy consist-
longed steroid use), circulatory disturbances of upper ex- ing of infrared radiation and manual traction. NM was addi-
tremity, traumatic injuries of upper limb and cervical spine, or tionally applied in group B. The rehabilitation program was
dizziness were excluded from the study [10]. Also, patients performed for all patients, 3 sessions per week, under the
were excluded if they had any contraindications to any of supervision of the principal investigator for 9 sessions.
the applied treatment programs.
Infrared radiation
Randomization
The application parameters were as follows: model
After baseline evaluation, the patients were randomly as- 2004/2N, power of 400 W, voltage of 203 V, and frequency
signed to 2 groups by using opaque, sealed envelopes, each of 50/60 Hz. With the patient in a sitting position and their
containing the name of one of the groups (traditional physi- head supported comfortably over a pillow on the top of
cal therapy or NM). The envelopes were picked before the a table, the neck was exposed and the infrared was adjusted
first treatment session by an investigator not participating with the centre of the emission coil directly above and behind
in the study. the spinous process of the 4th cervical vertebra. The distance
between the patient and the lamp was adjusted so that the
Sample size calculation patient reported mild comfortable warmth over the back of
their neck. The irradiation time was 20 minutes [14].
Sample size calculation was based on a previously re-
ported difference of pain and disability in a study by Anwar Manual traction of the cervical spine
et al. [11], 2-tailed alpha level of 0.05, and 80% power. A sam-
ple size of 20 patients per group was determined. With the patient in a supine position, the therapist applied
distraction force by placing the right hand on the patient’s
Assessment procedures chin and left hand on the occiput; then, the distraction force
was applied for 15 seconds for 3 sets of 10 repetitions, with
The participants’ demographic data, including name, age, 30- and 60-second rest between repetitions and sets, respec-
height, and weight, were recorded. An investigator who was tively [15].
blind to the group assignment and was not involved in the in-
tervention was responsible for the assessment before start- Neural mobilization
ing the treatment (baseline) and at 3 weeks after the inter-
vention. Group B received the same program as mentioned above,
The upper limb tension test-1 (ULTT-1) was used to as- in addition to tensioning NM of brachial plexus [16, 17]. The
sess the mechanosensitivity of brachial nerve roots. ULTT-1 patient was supine, with their arm passively positioned in
is evident to be reliable, valid, and responsive in evaluating the neurodynamic testing position, 25° of contralateral cer-
the outcome in persons with CR [12]. vical lateral flexion, followed by passive scapular depression,
The patient was supine without a pillow, and the hand of 90° combined shoulder abduction and external rotation,
the untested side rested on the abdomen. The standardized forearm supination, wrist extension, and, finally, finger exten-
sequence of upper limb movements was performed as fol- sion (Figure 1). Movements were performed to full range or
lows: shoulder girdle depression, 90° shoulder abduction, until a sense of resistance perceived by the investigator.
wrist and fingers extension, forearm supination, 90° shoulder After being in the previous neurodynamic testing position,
external rotation, and, finally, elbow extension [12]. the patient’s arm was taken into passive elbow extension for
Full range of each movement was reached unless the pa-
tient’s symptoms reproduced. Any sensation such as stretch,
tingling, or pain anywhere in the arm or neck was communi-
cated with the patient. If any of these sensations were pro-
voked, structural differentiation between neurogenic and non-
A
neurogenic sources of pain was performed by the addition
of sensitizing movements at a site distant to the pain: ipsi- and
contralateral cervical lateral flexion, shoulder girdle eleva-
tion, wrist extension, or wrist flexion. More than one of these
sensitizing movements may be used to obtain a clear pa-
tient’s response. The unaffected arm response to the test
was used as a reference for the affected arm. ULTT-1 was
B
considered positive if it reproduced the patient’s symptoms
at least partially and if the structural differentiation supported
a neurogenic source [12].
Neck and arm pain were assessed by using a visual ana-
logue scale. The subjects were instructed to mark any point
on the continuum that expressed their pain intensity along
the neck and the affected arm. The measurement of the length
was then recorded as pain intensity [13].
Figure 1. Tensioning neural mobilization of brachial plexus.
A: the starting neurodynamic testing position
B: taking patient’s elbow into extension 13
 A.O. Ibrahim, N.A. Fayaz, A.H. Abdelazeem, K.A. Hassan Physiother Quart 2021, 29(1)
Tensioning neural mobilization in cervical radiculopathy physiotherapyquarterly.pl

10 cycles of elbow extension and flexion for 6 seconds (3 sec- followed the tenets of the Declaration of Helsinki, and has
onds into extension and 3 seconds into flexion). The initial been approved by the Research Ethical Committee of Faculty
sense of resistance perceived by the investigator was used as of Physical Therapy, Cairo University, Egypt (No.: P.T.REC/
a sign to alternate directions when moving from elbow flexion 012/001656).
to extension. Finally, at the 10th cycle, static hold was main-
tained while in elbow extension for 10 seconds [16, 17]. Informed consent
Informed consent has been obtained from all individuals
Statistical analysis included in this study.

Data were analysed with the Shapiro-Wilk W test and by Results

using the SPSS software, version 22.0 (SPSS Inc., Chicago,
USA), in accordance with the statistical distribution. Descrip- Overall, 76 patients were screened for inclusion criteria,
tive statistics were obtained for variables (age, height, weight) 10 refused to participate in the study, 26 did not meet the
as means and standard deviations, unpaired t-test was ap- inclusion criteria, and 40 patients were allocated into 2 groups
plied for within- and between-group data analysis of sample (Figure 2).
background (age, height, and weight), normal (Z) test served There was no statistically significant difference (p > 0.05)
for mechanosensitivity data analysis. The Mann-Whitney test in age, height, or weight for patients in the A and B groups,
and Wilcoxon signed-rank test were used for within- and be- with the p value equal 0.455, 0.343, and 0.752 for the respec-
tween-group data analysis of pain intensity. The alpha level tive parameters.
was set at 0.05. Regarding mechanosensitivity, there was no statistically
significant difference between groups A and B (p = 0.07), but
Ethical approval for within-group data; there was a statistically significant
The research related to human use has complied with all difference between treatments (before and after treatment)
the relevant national regulations and institutional policies, has for group A and group B, as shown in Table 1.

Figure 2. The study flow diagram

Table 1. Within- and between-group differences for mechanosensitivity

Before treatment After treatment Within groups
ULTT-1
n x % n x % Z p

Group A Positive 20 18 90 20 9 45 3.464 0.001*

(n = 20) Negative 20 2 10 20 11 55 3.464 0.001*

Group B Positive 20 16 80 20 2 10 5.534 0.001*

(n = 20) Negative 20 4 20 20 18 90 5.534 0.001*

Between Z 0.791 1.752

groups p 0.125 0.07
ULTT-1 – upper limb tension test-1, n – sample size, x – number of patients
* significant at the level of p < 0.01
14
Physiother Quart 2021, 29(1) A.O. Ibrahim, N.A. Fayaz, A.H. Abdelazeem, K.A. Hassan
physiotherapyquarterly.pl Tensioning neural mobilization in cervical radiculopathy

Table 2. Within- and between-group differences for VAS using Mann-Whitney test and Wilcoxon signed-rank test (n = 20)
Before treatment After treatment Within groups
VAS
Median Range Median Range Z p Indication

Group A 7.50 7 3.75 7 4.36 0.001* S

Group B 7.50 6 3.75 7 4.60 0.001* S

Z 0.150 0.204
Between
p 0.881 0.838
groups
Indication NS NS
VAS – visual analogue scale, S – significant, NS – not significant
* significant at the level of p < 0.01

With reference to pain intensity, there was no statistically ducted by Anwar et al. [11] concluded that the addition of
significant difference between groups A and B (p = 0.838), neurodynamics to moist heat, mobilization, and isometric
but for within-group data; there was a statistically significant exercises resulted in a significant improvement in the dis-
difference between treatments (before and after treatment) ability. Although both the NM technique and treatment du-
for group A and group B, as shown in Table 2. ration were not identified, this study may indicate the benefit
of adding NM to a multimodal program.
Discussion Gupta and Sharma [21] compared NM in the form of me-
dian slider applied 3 sets of 10 repetitions with isometric exer-
The results of this study revealed that there was a de- cise, posture, and advice to move regularly, and concluded
crease in mechanosensitivity of the affected brachial nerve that there was a better improvement in the NM group re-
roots and a decrease in pain intensity in both groups. Adding garding neck disability index, visual analogue scale, and pain-
tensioning NM to a traditional physical therapy program did free elbow extension. However, these results are not conclu-
not significantly decrease mechanosensitivity or pain inten- sive as the research compared NM with minimal intervention
sity in comparison with the control group, who received only (only isometric exercise and advice), which may have con-
a traditional program. tributed to the outcome.
Despite the lack of a significant difference in reducing The current study showed no significant effect of tension-
mechanosensitivity of brachial nerve roots between the ing NM in spite of its proven impact on decreasing pain and
2 groups, the analysis of data suggests greater clinical ben- sensory descriptors (stinging, tingling, tightness, sharpness,
efits for the study group. and numbness) induced by neurodynamic testing in the as-
In a systematic review with a meta-analysis, the effect of ymptomatic population [17]. This might be due to the rela-
NM on nerve-related chronic musculoskeletal pain condi- tively short duration, which may have limited our capacity to
tions was reviewed and it was concluded that NM was not demonstrate a significant between-group difference, as well
superior to other interventions in decreasing pain or disability as to the absence of follow-up, which might have shown
but it might be superior to minimal intervention in these re- a significant difference in the long term.
gards [18]. These results are in accordance with the present Also, it might be more suitable to apply another NM tech-
study with reference to the benefit of adding NM to a multi- nique in symptomatic patients (i.e. sliding NM) and to conduct
modal program. separate NM on each peripheral nerve instead of mobiliz-
Also, the results of the current study agree with those ob- ing the entire brachial plexus.
tained by Langevin et al. [19], who reported that only manual All diagnoses of CR were included in the study and it
therapy and exercises were effective in reducing pain and might be more appropriate to include patients who most likely
functional limitations caused by CR, and NM led to no signifi- would benefit from NM. Finally, the absence of a real control
cant additional benefits. This study is comparable with the group or no-treatment group might have affected our capac-
present one in the multimodal approach adopted and in in- ity to show a significant difference of NM.
cluding manual therapy in both groups.
Furthermore, Marks et al. [20] reported a significant dif- Limitations
ference between the NM group (nerve tensioner depending
on the most painful test) and the cervical spine mobilization The results might have been affected by different causes
group (control group) in patients with cervicobrachial pain, of CR with variable symptom durations, as well as by life
favouring the control group regarding the improvement of stresses, emotional status, and culture, which are known to
cervical range of motion and decrease in neck pain. This influence pain coping strategy.
study is comparable with the present one in one of the out- Further studies are recommended on specific groups of
come measures (ULTT-1) and in using the neural tensioning radiculopathy, with similar or at least comparable symptom
technique; although it indicated the superiority of cervical mo- durations. Also, a third group of no treatment as a real control
bilization on NM, it supports the effectiveness of NM in de- group would be advised, and a long-term follow-up. More-
creasing pain and mechanosensitivity. This superiority may over, further studies could be conducted on other types of
have been caused by the way of NM application, as it con- NM exercises or in comparison with mechanical traction.
tinued for 15 minutes on one session while in the present
study it was intermittent and lasted over 3 weeks. Conclusions
In contrast to the current results, some papers [11, 21]
demonstrated that the addition of NM to a multimodal pro- In accordance with the current results, the addition of ten-
gram was more effective in CR management; a study con- sioning NM to traditional physical therapy yielded no signifi-
15
 A.O. Ibrahim, N.A. Fayaz, A.H. Abdelazeem, K.A. Hassan Physiother Quart 2021, 29(1)
Tensioning neural mobilization in cervical radiculopathy physiotherapyquarterly.pl

cant additional benefits, although both groups showed re- 11. Anwar S, Malik AN, Amjad I. Effectiveness of neuromo-
duced pain intensity and decreased mechanosensitivity after bilization in patients with cervical radiculopathy. Rawal
treatment. Med J. 2015;40(1):34–36.
12. Schmid AB, Brunner F, Luomajoki H, Held U, Bach-
Clinical implications mann LM, Künzer S, et al. Reliability of clinical tests to
evaluate nerve function and mechanosensitivity of the
Traditional physical therapy alone is effective in the man- upper limb peripheral nervous system. BMC Musculo-
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for brachial neuralgia among cellulo-teno periosteo myal-
Acknowledgments gic syndrome (CTPMS) patients. MOJ Orthop Rheu-
We would like to thank all individuals who contributed to matol. 2015;2(1):00033; doi: 10.15406/mojor.2015.02.
the completion of this work, especially the study participants. 00033.
14. Chiu TTW, Lam T-H, Hedley AJ. A randomized controlled
Disclosure statement trial on the efficacy of exercise for patients with chronic
No author has any financial interest or received any finan- neck pain. Spine. 2005;30(1):E1–E7; doi: 10.1097/01.
cial benefit from this research. brs.0000149082.68262.b1.
15. Goyal M, Kumar A, Sethi R. Functional disability and grip
Conflict of interest strength of cervical radiculopathy patients before and
The authors state no conflict of interest. after cervical collar use and traditional physiotherapy
treatment. J Exerc Sci Physiother. 2012;8(2):119–122.
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