678
Mobilisation, cervical spine,
Effect of a Cervical Lateral
Glide on the Upper Limb
Neurodynamic Test 1
A 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 limb
neurodynamic test 1.
Methods Twenty asymptomatic subjects, naïve 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 Friedman’s 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 7º (p < 0.001) where minimal change
occurred in the placebo and control conditions.
Conclusions The cervical lateral glide technique applied to
the 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.
Saranga, J, Green, A, Lewis, J and Worsfold, C (2003). ‘Effect of a
cervical lateral glide on the upper limb neurodynamic test 1: A blinded
placebo-controlled investigation’, Physiotherapy, 89, 11, 678-684.
Physiotherapy November 2003/vol 89/no 11
Key Words
elbow extension,
neural tissue.
by Jacob Saranga
Ann Green
Jeremy Lewis
Chris Worsfold
Introduction
Examination of the ner vous system
through assessment of reflexes, muscle
power and sensation has been common
practice in the neuromusculoskeletal
discipline for many years. More recently
there has been a trend, particularly within
the physiotherapy profession, also to
include palpation of peripheral nerves,
as well as ‘neurodynamic’ tests as part
of this assessment (Elvey, 1986; Butler,
1991, 2000; Selvaratnam, 1995; Fidel et al,
1996; Vicenzino et al, 1996, 1998; Wainner
et al, 2003).
In the upper limb, four tests have been
proposed, collectively called the upper
limb tension tests (Butler, 1991), more
recently the upper limb neurodynamic
test in order to encourage a shift away
from a purely mechanical (tension,
provocation) view of these tests (Butler,
2000).
Over the past decade various treatment
approaches have been advocated once the
presence of restricted neural tissue has
been identified. These techniques have
included neural stretches and neural
mobilisation techniques (Butler, 1991;
Butler and Slater, 1995; Selvaratnam,
1995), as well as treatment directed at the
adjacent structures that might impede on
neural tissue mobility (Elvey, 1986; Butler,
1991; Selvaratnam, 1995; Vicenzino et al,
1996, 1998). The cervical intervertebral
foramen is one such structure, and Elvey
(1986 page 229) recommended that a
cervical lateral gliding technique would
allow movement of structures within the
intervertebral foramen without undue
tension being applied to the neural
tissues. Since its description the cervical
lateral glide has been used extensively as a
technique to improve neural mobility
(Vicenzino et al, 1994, 1996, 1998;
Coppieters and Stappaerts, 2000).
In a study on the effect of the cervical
Research report
lateral glide technique on 34 asympt-
omatic subjects Vicenzino et al (1994)
reported that the technique produced
significantly greater increases in skin
conductance, but not on skin temp-
erature, than did placebo or control in
two different positions of neural tension
testing (upper limb neuro-dynamic test 1
and 2b). Vicenzino et al (1996) examined
the effect of the cervical lateral glide
technique applied to the motion segment
consisting of the fifth and sixth cervical
vertebrae on 15 patients suffering from
lateral epicondylalgia. A number of
variables were measured including the
effect of the technique on the flexibility
of the upper limb neurodynamic test 2b
(Butler, 1991), reflected as a change in
glenohumeral abduction range. Their
results suggested that the cervical lateral
glide produced significant increases in
abduction range (measured using an
electrogoniometer) and concluded that
the technique had an influence on the
flexibility of the upper limb neuro-
dynamic test 2b.
More recently, Vicenzino et al (1998)
investigated the effect of a cervical lateral
glide, directed contralaterally to the
affected upper limb at the fith and sixth
cervical vertebrae on the flexibility of the
upper limb neurodynamic test 2b in 24
subjects with lateral epicondylalgia. The
results suggested that the technique
significantly increased the flexibility of the
neural tissues when compared to a control
procedure and placebo technique.
The upper limb neurodynamic test
assesses the mobility of the upper
quadrant neural tissues by applying a
sequence of movements that mechanically
elongate 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 limb
neurodynamic test also produces move-
ment of the nervous system in relation to
inter facing structures. These are the
structures that are anatomically related to
the neural tissue and have the potential to
restrict 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 and
external rotation, forearm supination,
wrist and finger extension and elbow
extension. Selvaratnam (1995) recom-
679
mends elbow extension as the final Authors
manoeuvre of the test due to the relative Jacob Saranga BPT
clinical ease of measuring elbow MCSP MMACP
extension range. MSc(Manipulative
The results of the upper limb neuro- Therapy) is a senior
dynamic test 1 determine whether sub- lecturer and Ann
sequent tests should be per formed Green MSc MCSP
(Butler, 2000). Furthermore the test has ILTM is associate
head of physiotherapy
been found to be positive in the presence
and dietetics in the
of minor peripheral neuropathies and School of Health and
cervical radiculopathies (Greening and Social Sciences,
Lynn, 2000; Wainner et al, 2003). The Coventry University.
purpose of this study was to investigate
Jeremy Lewis PhD
the effect of the cervical lateral glide
MCSP MAPA MMPA
technique on elbow extension in the MMACP
upper limb neurodynamic test 1. MSc(Manipulative
The experimental hypothesis for this Physiotherapy) is a
study was that the cervical lateral glide research co-ordinator
technique applied to the facet joint and Chris Worsfold
between the fifth and sixth cer vical MSc MCSP
vertebrae would increase the flexibility PGDip(Manipulative
of the structures tested by the upper Physiotherapy) is a
limb neurodynamic test 1. senior physiotherapist
in Chelsea and
Westminster
Methods
Healthcare NHS
Design Trust.
A single-blind study was designed which
included an experimental condition, a
placebo and a control condition. Address for
Participants were subjected to all three Correspondence
conditions in a randomised order. The Jacob Saranga MSc,
upper limb neurodynamic test 1, assessed Senior Lecturer,
by measuring range of elbow extension, Physiotherapy
was the selected outcome measure and Dietetics
(Butler, 2000). The experimental subject group,
condition was the cervical lateral glide School of Health and
Social Sciences,
described by Maitland (1986).
Coventry University,
Priory Street,
Ethical Approval and Patient Consent Coventry CV1 5FB.
Ethical approval for this study was granted
E-mail
by Coventry University Ethics Committee.
j.saranga@coventry.ac.
Each subject was provided with an
uk
information document and signed an
informed consent sheet before taking
part. All subjects were able to withdraw at
any stage of the investigation.
Subjects
Twenty asymptomatic subjects (12 women
and 8 men) with a mean age of 32 years
(SD 8.6), a mean height of 167 cm (SD
8.2), and a mean weight of 67 kg (SD
14.2) participated in the investigation.
Subjects were naïve to the effects of
manual therapy, therefore anyone with
previous experience of manual therapy
was excluded as well as subjects with
current cervical and upper quadrant
symptoms.
Physiotherapy November 2003/vol 89/no 11
 680
Procedure
Each subject was randomly allocated to a
presentation order of the three
procedures. The investigator was unaware
of the treatment allocation as she did not
observe the procedure and collected the
elbow extension measures independently.
A physiotherapist with a postgraduate
degree in manipulative physiotherapy
performed each of the techniques on all
the subjects and was blinded to the
measured elbow extension range.
Subjects were investigated in the supine
position on the same treatment plinth. An
electrogoniometer (Penny and Giles,
Biometrics Ltd, UK) was attached to the
subject’s dominant arm and was used to
measure elbow extension range. Shoulder
girdle depression was maintained at
60 mm Hg using a pressure biofeed-
back device (Chattanooga, Australia).
This method of maintaining a constant
shoulder position has been reported
(Edgar et al, 1994; Lewis et al, 1998). The
subject’s glenohumeral joint was passively
positioned at 110° abduction and this
angle was maintained using a universal
goniometer (Baseline™, UK) with one
arm of the device held along the lateral
border of the trunk and the other along
the humerus. The subject’s forearm was
then passively taken to the end range of
available supination, wrist and finger
extension, and glenohumeral external
rotation. The final movement was passive
elbow extension taken to the point of
Fig 1: The cervical lateral glide technique
Physiotherapy November 2003/vol 89/no 11
maximum resistance confirmed by the
subject (Maitland, 1986). Following a
pilot study before the main investigation,
the procedure was repeated five times and
elbow extension range was measured on
the sixth occasion.
The second measurement of elbow
extension was made after application
of the cervical lateral glide (fig 1), the
placebo technique and the control
technique. The cervical lateral glide tech-
nique (Maitland, 1986) was performed on
the facet joint between the fifth and
sixth cervical vertebral segment on the
contralateral side and directed towards
the side of the arm being investigated for
three repetitions, each of 60 seconds. The
technique, a grade III mobilisation
(Maitland, 1986), was repeated three
times, each set of mobilisations lasting for
60 seconds. There was an interval of one
minute between each repetition. The
head and cervical spine were kept in a
neutral position. The facet joint was
identified by palpation (Elvey, 1986;
Maitland, 1986).
The placebo technique (fig 2a) was
designed to imitate the experimental
technique and involved placing the
investigator’s hands lightly over the
subject’s neck in the same position as the
cer vical lateral glide without any
movement being elicited. The control
technique (fig 2b) involved the same
subject position with the investigator
standing motionless at the end of the bed
without having any physical contact with
the subject, similar to a technique
reported by Vicenzino et al (1996).
Pilot Study
To give some indication of the error
measurement using the electrogonimeter,
ten measurements of elbow extension
range were made on each of three
consecutive days, on one subject, by one
assessor. The intraclass correlation
coefficient of these measurements was
0.92 with a 95% confidence interval of
0.77-0.98 (although the limitations of
the intraclass correlation coefficient as
an indication of reliability should be
acknowledged) and the standard error of
measurement (SEM) was 0.5˚. This
suggests that a change of greater than 0.5˚
between two measurements can be
attributed to real change rather than
occurring as a result of measurement
error.
Research report
(a)
Fig 2: Placebo (a) and control (b) techniques
The validity of the electrogoniometer
was established by comparison with a
universal goniometer (BaselineTM, United
Kingdom). One subject was measured by
one assessor, with the output of the
goniometers read by an assistant. One
measurement was taken with each
goniometer at ten different angles of
elbow range. Using the analysis recom-
mended by Bland and Altman (1986),
the mean difference between the two
measurement methods was found to
be 0.2˚ with 95% limits of agreement
between –0.64˚ and 1.04˚. This suggests
that measurements taken with the
electrogoniometer will be within two
degrees of measurements taken with
the universal goniometer on 95% of
occasions. Although the limitations of
using one subject and one assessor should
be acknowledged, this suggests that the
electrogoniometer has some validity in
the measurement of elbow range.
Results
The data were not normally distributed
and therefore did not satisfy the criteria
for parametric statistical analysis and the
three conditions were analysed using the
non-parametric Friedman’s analysis of
variance test. The Wilcoxon signed rank
procedure 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
681
(b)
using Bonferroni corrections at p < 0.017
(Altman, 1991; Sim and Wright, 2000).
Boxplot comparisons of the three
conditions are presented in figure 3
overleaf.
The results of a Friedman’s analysis of
variance suggested that there was a
significant difference between the three
conditions (χ2 = 25.162; p < 0.0001).
Results of the multiple comparison
analysis using the Wilcoxon signed rank
test suggested significant differences
between the cer vical lateral glide
technique and the placebo (Z = --3.854,
p < 0.0001), and the control techniques
(Z = –3.769, p < 0.0001), and that no
statistically significant difference existed
between the placebo and control
techniques (Z = –0.805, p < 0.421).
Discussion
The findings of this study suggested that
the cer vical lateral glide technique
applied at the facet joint of the fifth and
sixth cervical segments and directed
towards the arm being investigated may
be capable of significantly increasing the
elbow extension component of the upper
limb neurodynamic test 1, which may
indicate greater neural extensibility.
Furthermore the results suggest that the
other two conditions tested (placebo
and control) did not affect the elbow
extension component of the upper limb
neurodynamic test 1.
Physiotherapy November 2003/vol 89/no 11
 682
20
10
Degrees
–10
N= 20
Cervical lateral glide
Fig 3: Boxplot representing changes for the three conditions, illustrating median, 25th and 75th
centiles (boxes) and highest and lowest values (whiskers)
Evidence of a change in the range of
elbow extension indicates that a clinician
may be able to influence the peripheral
nervous system. Hypotheses have been
proposed which attempt to explain the
mechanism of action of manual therapy
techniques. One is that the cervical lateral
glide technique affects the interface at the
intervertebral foramen and thus increases
the movement of the neural tissues
passing through this space. This is
thought to result in an increase in the
observed elbow extension range (Elvey,
1986; Shacklock, 1995). The suggestion is
that the ‘dynamic roominess’ around the
nerve roots has been increased (Penning,
1992).
This hypothesis depends on the cervical
lateral glide influencing the anatomical
relationships between the opposing
surfaces of the intervertebral joint and
the soft tissues. The ability of manual
therapy procedures to achieve changes
in joint position is hypothetical and
open to conjecture (Elvey, 1986; Penning,
1992; Shacklock, 1995; McGregor et al,
2001).
It is also possible that spinal manual
therapy may result in a reduction of
muscle tone (Zusman 1994, Katavich
1998). Through this mechanism the
cervical lateral glide technique may have
reduced the tone of the muscles supplied
by the emergent nerves, including the
biceps brachii muscles (Williams et al,
Physiotherapy November 2003/vol 89/no 11
20 20
Placebo Control
1995). The hypothetical reduction in tone
may have allowed a greater range of elbow
extension. Vicenzino et al (1996) used a
cer vical lateral glide technique that
mobilised the facet joint of the fifth and
sixth vertebrae towards the contralateral
side.
The findings of both the present study
and that reported by Vicenzino et al
(1996) suggest that the cervical lateral
glide technique is capable of improving
the joint range by using apparently
opposing techniques. This may support
a more neurophysiological basis for
the effect of mobilisation rather than
a mechanical role. Further research is
required before the mechanisms of
mobilisation are better understood. Open
magnetic resonance image scanning may
provide one method of achieving a
greater insight.
With a total of 125˚ of elbow movement
required for activities of daily living
ranging from 15˚ to 140˚ in asymptomatic
subjects (Moorey et al, 1981) an increase
of 7.1˚ of elbow extension from one
treatment may prove clinically significant.
There are several limitations associated
with the present study. Although every
effort 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 asymptomatic
subjects provided some insight into the
Research report
effect of the technique, and the study
should be repeated with a population of
symptomatic subjects to enhance its
external validity. By definition the
asymptomatic subjects had a full range
of elbow movement, so the effects noted
are relevant to tissues in the absence of
pathology. It is not possible to draw
inferences about the effect that this
technique will have on a symptomatic
group.
Future research may aim at comparing
the effect of an ipsilateral and contra-
lateral cer vical lateral glide on the
flexibility of the neural tissues, as well as
joint range of movement. Further studies
are needed to investigate the influence of
grade of mobilisation, and mobilisation
technique on these variables.
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683
Conclusion
The cer vical lateral glide technique
applied to the facet joint of the fifth and
sixth cer vical segment significantly
increased the elbow extension com-
ponent of the upper limb neurodynamic
test 1 in asymptomatic subjects, compared
with placebo technique and a control
group. The resulting increase in elbow
extension indicates that clinicians may be
able to influence the peripheral nervous
system using this technique. Further
research is required involving sym-
ptomatic subjects and larger cohorts to
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movement observed in this study are
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Key Messages
■ Neurodynamic tests form part of the
examination of the nervous system.
■ The cervical lateral glide is a
mobilisation technique that has been
used to treat pathology associated
with neural tissue.
Physiotherapy November 2003/vol 89/no 11
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■ The results of a number of studies
have suggested that this mobilisation
technique may lead to an
improvement in symptoms in
symptomatic subjects and range of
movement in symptomatic and
asymptomatic subjects.