Oskay D, Meriç A, Kirdi N, Firat T, Ayhan C, Leblebicioglu G.
Faculty of Health Science, Department of Physical Therapy and Rehabilitation,
Gazi University, Ankara, Turkey. email@example.com
OBJECTIVE: The aim of this case series is to describe the effect of nerve mobilization techniques in the standard conservative management of cubital tunnel syndrome (CTS).
METHODS: Seven patients with CTS participated in this study. Inclusion criteria were having grade 1 and grade 2 entrapment neuropathy according to the McGowan grading system and no other neuropathies. In the evaluation, gripping with grip dynamometer; palmar gripping with a pinchmeter; pain level and Tinel sign with visual analog scale; sensibility with Semmes-Weinstein monofilaments; and functional status of the patients with the Turkish version of the Disability of Arm, Shoulder, and Hand Index were performed before starting a rehabilitation program, at the end of the 8-week rehabilitation program, and at 12-month follow-up. The physiotherapy program consisted of cold application, pulsed ultrasound, nerve mobilization techniques, strengthening exercises, postural adaptations, patient education, and ergonomic modifications.
RESULTS: Pain; Tinel sign; and Disability of Arm, Shoulder, and Hand Index scores were decreased, whereas grip and pinch strength increased in the observation period for these 7 patients.
CONCLUSION: This case series demonstrated that conservative treatment of CTS may be beneficial for selected patients with mild to moderate symptoms. The treatment included neurodynamic mobilizations, including sliding techniques and tensioning techniques, which are thought to enhance ulnar nerve gliding and restore neural tissue mobility. Conservative treatment using neurodynamic mobilization with patient education and activity modification demonstrated some long-term positive results.
From the FULL TEXT Article:
In this study, compression was regarded as grade 1 for 3 patients and grade 2 for 4 patients, according to the McGowan grading system. For this reason, these patients’ grades were appropriate for conservative treatment to alleviate the symptoms. All of the patients’ symptoms were alleviated by the end of the treatment program.
After nerve damage, there are several healing phases, including inflammatory (4-7 days), fibroblastic (3 weeks-3 months), remodeling, and maturation (3-12 months). The specific tissue structure is established in the remodeling and maturation phase.  In the early phase of nerve damage, inflammation and edema limit nerve gliding; and intraneural edema increases intraneural pressure, which blocks intraneural blood circulation and axoplasmic transport. These result in neuroischemia, which may cause pain and paresthesia. [16, 17] In the early phase of nerve tissue healing, reduction of overload, pain, and inflammation is important. Ice, pulsed US, and resting splints are the modalities for reduction of these symptoms. [3, 6] We did not use resting splints because the patients’ duration of complaints were not earlier than 4 weeks and this was also the subacute phase of the healing.
In the patients in this study, the mean duration of the complaints was 4 to 6 weeks. This was the fibroblastic phase of the healing. Endoneural edema cannot be evacuated in the lack of lymphatic vessel in endoneurium. In this condition, the endoneurium becomes an ideal environment for excessive fibroblastic activities. [3, 7] Vascular systems may be compromised by external compression or adverse tension. Adverse tension may be the result of adaptive shortening of the peripheral nerve from positioning or external scarring of the nerve.
Compromising the vascularity of a nerve can lead to release of mediators such as histamine and bradykinin, potentially creating a new inflammatory reaction in or around the connective tissue of the nerve.  This causes intraneural and perineural fibrosis; increases intraneural pressure; leads to pain and paresthesia; and decreases neural elasticity, neural extensibility, and mobility of the nerve alongside the adjacent tissue in the fibroblastic phase of healing.  Because of these issues, we aimed to reduce pain and inflammation, to restore tissue mobility, to improve tissue healing, and to prevent postural and environmental problems.
The concept of nerve tension and gliding plays a major role in formulating a treatment plan for nerve mobilization. Tension creates strain within the nerve by pulling on both ends of the nerve. This effect reduces vascular and axoplasmic flow. Gliding refers to placing tension on the nerve at one point while releasing it at another. Gliding can occur within the nerve itself as well as between the nerve and its interfacing tissue. [19-22] Adventitia that surrounds the nerve trunk permits excursion of the nerve trunk. This extraneural gliding surface, together with the normally occurring sliding of fascicules against each other in the deeper layers (intraneural gliding surfaces), makes the normal gliding of a nerve during joint motion possible.  The median and ulnar nerve may glide 7.3 and 9.8 mm, respectively, during full flexion and extension of the elbow. Gliding of the nerve accumulates intraneural and extraneural fluids that may regulate the increased pressure caused by intraneural edema and fibroblastic activity. Blood circulation and axonal transport, which are necessary for the functional and structural integrity of a neuron, will recover after the removal of the pressure.  In this study, neurodynamic mobilization was performed for all of the patients during 8 weeks for reducing pressure caused by intraneural and extraneural fibrosis, increasing vascular and axoplasmic flow, and restoring tissue mobility.
Ultrasound has shown effectiveness in chronic overuse syndromes due to its nonthermal effects, which include cavitations and microstreaming. [24, 25] Furthermore, it has been suggested that US can affect nerve conduction in normal nervous tissue and healing in damaged nerves. [24, 26] In the literature, US has been studied in the area of peripheral nerve injury, showing reduced pain and improved function with entrapment neuropathies; and it can facilitate regeneration.  A continuous beam of US can increase the sensory and motor conduction rate of the nerve provided that the treatment took place under a low-intensity and appropriate frequency. [26, 28] In a study by Tanuguchi et al,  patients with mild to moderate carpal tunnel syndrome for an average of 8 months’ duration who were treated with pulsed US at 1.0 W/cm2 had greater relief of symptoms and greater improvements in median nerve conduction velocity than those who were treated with continuous US. In our study, we applied 25% pulse ratio at 1 W/cm2 pulsed US to improve nerve tissue healing and to reduce pain and inflammation.
Initial changes of nerve compression will include aching, followed by weakness and finally muscle atrophy. Although weakness may not be evident until the nerve has undergone considerable degeneration from chronic nerve compression,  we found mild weakness in palmar gripping and grasping functions on the effected side. Weakness of intrinsic muscles reduced gradually at the end of long-term follow-up. In addition, a resistance exercises program was planned in the first and second stage of the rehabilitation program for the musculature surrounding multiple joints that affect ulnar nerve gliding. In the second stage, closed chain exercises were added to the program to cause co-contraction of these musculatures. The goals of the rehabilitation in this stage were facilitating soft tissue healing by providing vascular response, reintegrating neuromotor control of the ulnar nerve, promoting local muscle endurance, and improving resistance to repetitive stress.
Patient education may also be important and critical in the beginning of conservative treatment for avoiding the provocative effects of the working conditions of the patients with entrapment neuropathies. Lund and Amado6 reported that ergonomic evaluation and modifications can play an important role in alleviating symptoms. Robertson and Saratsiotis  suggest to educate patients on how they develop pain and paresthesia and how they contribute to them via their daily activities. Unfortunately, activities of daily living may cause reinjury. In this study, we started this education by explaining the anatomy of ulnar nerve to patients and how to analyze their daily tasks for these joint movements on posture, along with minimizing the impact of repetition, prolonged holding, and resistance. We feel that this can greatly improve their ability to identify behaviors that aggravate their symptoms and allow them to take ownership of their rehabilitation program.
This study gives 2 different results according to follow-up time. In the short term, grip, pinch, and pain values showed improvements, although functional status did not. Function and sensation began to improve after the eighth week and until the 12th month. If there were targets according to obvious time lines in the treatment, the short-term target does not have to be improvement in function.
There were several limitations of our study. This was only a case series of 7 patients and therefore should not be interpreted as a clinical trial. Interpretation of statistical significance should be done with caution because there were only 7 subjects in this study and statistical significance does not necessarily imply clinical significance. As well, this study emphasizes a basic rehabilitation program of a peripheral nerve entrapment based on nerve gliding techniques. However, we also used US therapy that gives effective results in entrapment neuropathies with nerve gliding techniques. Thus, it is difficult to state that the major benefit was from nerve gliding exercises. Therefore, we would recommend a clinical trial that would include another study group excluding peripheral nerve gliding and/or also including a control group. It is also possible that the therapeutic benefits were due to something other than the treatments offered. Another limitation of the study is the wide range of ages and the older age of some of the patients. One reason we saw less-than-desirable results in older patients may have been due to less capability of tissue healing. A further limitation is that the number of patients was not sufficient to perform a parametric statistical analysis. Further studies using prospective clinical trials are necessary.
This study demonstrated that conservative treatment of CTS may be beneficial for selected patients with mild to moderate symptoms. This study used neurodynamic mobilizations, including sliding techniques and tensioning techniques, which are thought to enhance ulnar nerve gliding and restore neural tissue mobility. Conservative treatment using neurodynamic mobilization with patient education and activity modification demonstrated some long-term positive results.
Conservative treatment of CTS may be beneficial for patients with mild to moderate symptoms.
Neurodynamic mobilizations, including sliding techniques and tensioning techniques, are thought to enhance ulnar nerve gliding and restore neural tissue mobility.
Conservative treatment using neurodynamic mobilization with patient education and activity modification demonstrated some long-term positive results.