Impact of Order of Movement on Nerve Root Function

Study Overview
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Brief Summary
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the main objective of this study is to investigate if different neurodynamic test sequencing of the median nerve has a different impact on median nerve root function. We hypothesized that the order of median nerve neurodynamic movements would influence peak-to-peak amplitude and latency.

Detailed Description
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Neurodynamic concept is used clinically to normalize nerve mobility. It has been manifested in previous studies that neurodynamics have increased mobility by floss like movement of the nerve. Whereas in other studies it has been concluded that neurodynamic techniques has an effect in decreasing fibrous and adhesions between neural tissues and the surrounding tissues therefore giving an outcome of improved infrafasicular gliding. The upper limb neurodynamic test has an effect to alter the mechanical loads on the nerve by changing its dimensions. For neurodynamic to be more effective, it requires a certain sequence. The different order of movements will induce different duration of tension in which it will influence the nerve root function, which is needed to be investigated to check for the effectiveness. A previous study has found that the difference of sequence on median nerve, had caused a change on the distribution of the sensory response on the asymptomatic participants. The sensory responses were more prevalent during the neurodynamic of the median nerve when it was applied from a distal to proximal sequence . One of the main purposes of the order of sequences is to add more strain to the nerve segment to increase the sensitivity of the test. Clinically it has been assumed that the different order of movements could possibly influence the level of strain on a certain nerve segment. When the standard sequence was compared with the distal-to-proximal sequence for the median nerve, there was no physiological difference obtained at the end of the test. In comparison, there was a larger strain in the distal-to-proximal sequence in comparison to the proximal-to-distal sequence observed. However, the longitudinal excursion collected data indicated that the start and end positions for all the three sequences were alike. In terms of neurophysiological outcomes, in this study we will use the dermatomal somatosensory evoked potential as a primary outcome due to its reliability in comparison with other physiological outcomes. There is a literature gap in regard to the effect of the order of sequence on the median nerve on the nerve root function and this is what the study will focus on. We hypothesized that the order of movements of the median nerve neurodynamic will influence the peak-to-peak amplitude and the latency.

Official Title
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Impact of Order of Movement on Nerve Root Function: A Neurophysiological Study With Implications for Neurodynamic Test Sequencing

Conditions
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Physical and Rehabilitation Medicine

Intervention / Treatment
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* Other: standard neural mobilization
* Other: Distal to proximal neural mobilization
* Other: proximal to distal neural mobilization


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: not currently experiencing any neck or dominant upper extremity symptoms. do not have a history significant for a chronic painful condition. do not using pain relievers. Exclusion Criteria: inflammatory joint disease or other systemic pathologies. prior history of overt injury and surgery relating to the musculoskeletal system. disorder related to the spine and extremities. musculoskeletal pain in the last three months

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: A prospective, parallel-group, randomized clinical trial participants will be randomly assigned to one of three different groups. One group will receive the standard neural mobilization, the second group will receive Distal-Proximal neural mobilization, and the third group will receive Proximal-Distal neural mobilization, all targeting the median nerve.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: standard neurodynamic sequence<br>Participants in the first group will receive the standard neurodynamic sequence. The starting position for this sequence will be shoulder in extension with lateral rotation, elbow in full flexion and wrist in neutral position. Passively the shoulder is abducted till 90 degrees followed by wrist extension then ended by elbow extension. Ipsilateral movement of the head bending till 45 degrees with movement of the wrist towards the body for 10 repetitions | Other: standard neural mobilization<br>* is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system.<br>|
| Active Comparator: Distal to proximal neurodynamic sequence<br>The second group participants will receive the distal to proximal neurodynamic sequence. For this sequence the starting position will be shoulder in full extension with lateral rotation, elbow fully extended and wrist in neutral position. the sequence will start with wrist extension, going to elbow extension, and ending with shoulder abduction. Ipsilateral movement of the head bending till 45 degrees with movement of the wrist towards the body for 10 repetitions | Other: Distal to proximal neural mobilization<br>* is a distal to proximal movement-based intervention aimed at restoring the homeostasis in and around the nervous system.<br>|
| Active Comparator: proximal to distal neurodynamic sequence<br>The participants in the third experimental group will receive the proximal to distal sequence which will start with shoulder abduction, elbow extension and then wrist extension. The starting position is shoulder in extension and laterally rotated, elbow in full flexion, and wrist in neutral position. The shoulder will be passively mobilized to 90 degrees of abduction, elbow into full extension and wrist in full extension. Ipsilateral movement of the head bending till 45 degrees with movement of the wrist towards the body for 10 repetitions | Other: proximal to distal neural mobilization<br>* is a proximal to distal movement-based intervention aimed at restoring the homeostasis in and around the nervous system.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in dermatomal somatosensory evoked potentials. | In all dermatomes, 2 complete recording runs will be undertaken during each session with averages of 250 to 1200 cortical responses from scalp surface recording electrodes (C3'-C4' in a 10-20 electrode configuration) of the contralateral scalp to the stimulated dermatomes being stimulated. The impedance of ground and scalp electrodes will be maintained at < 5 k Cutaneous areas of C5,C6,C7 sensory roots will be stimulated in lower limb with the electrical impulses of 0.2 ms duration, frequency of 3.3 Hz and intensity 3 times higher than the sensory threshold will be determined individually for each subject. | baseline (pre-treatment) and immediately after the treatment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Randomized controlled trial, Neurodynamics, Evoked potential, Somatosensory