original paper Physiotherapy Quarterly (ISSN 2544-4395)

2023, 31(3), 53–56

© Wroclaw University of Health and Sport Sciences

Effects of neurodynamic exercises on the management of diabetic peripheral

neuropathy of the upper limb: a case series
doi: https://doi.org/10.5114/pq.2021.111834

Misbah Amanat Ali1 , Sahreen Anwar2 , Wajida Perveen3 , Muhammad Akhtar2 , Riaz Hashmi4 , Zahra Jabeen5
1
Sialkot College of Physical Therapy (affiliated with University of Sargodha), Sialkot, Pakistan
2
University Institute of Physical Therapy, University of Lahore, Lahore, Pakistan
3
Physical Therapy Department, School of Allied Health Sciences, CMH Lahore Medical College and Institute of Dentistry,
National University of Medical Sciences, Rawalpindi, Pakistan
4
Physical Therapy Department, Syed Medical Complex, Sialkot, Pakistan
5
Physical Therapy Department, DHQ Hospital Pakpattan, Pakpattan, Pakistan

Abstract
Introduction. This study was designed to find out the effectiveness of neurodynamic exercises in patients with diabetes mel-
litus having peripheral neuropathy in the upper limb.
Methods. This was a case series. A total of 40 patients were selected in this study who had diabetes mellitus type 2 with periph-
eral neuropathy pain. The consecutive sampling technique was used. Standard neurodynamic sliders techniques were applied
for radial, ulnar, and median nerves in appropriate positions by a qualified physical therapist for 10 s with a 2-s rest and 10 rep-
etitions. Transcutaneous electrical nerve stimulation (80 Hz and 150 µs) was applied for 20 minutes. The neuropathic pain
questionnaire DN4 served to collect the data. Pre-test and post-test values were calculated on the basis of the questionnaire.
The paired sample t-test was used to compare the pre-test and post-test values.
Results. Finally, 31 females and 8 males with peripheral neuropathy were involved in this study. The mean age of the patients was
51.22 ± 6.712 years. The mean total pre-test value was 6.42 ± 1.152 and the mean total post-test value equalled 3.68 ± 1.095.
Conclusions. Neurodynamic exercises were effective in managing diabetic peripheral neuropathy pain. Neurodynamic tech-
niques for peripheral nerves can reduce diabetes-associated peripheral neuropathy symptoms in the upper limb.
Key words: diabetic complication, neurodynamic techniques, diabetic peripheral neuropathy, numbness

Introduction to straight leg raise neurodynamic testing [8]. These changes

further increase the likelihood of injuries, burns, and infec-
Type 1 diabetes is insulin-dependent diabetes; only tions. Some patients report sleep disturbance and restless-
5–10% of diabetic patients suffer from it. Type 2 diabetes is ness at night due to pain in hands and feet [9]. Foot infections
also known as non-insulin-dependent diabetes and is mainly are the most common impairments caused by diabetic pe-
due to insulin resistance. This type is more common than ripheral neuropathy. Peripheral neuropathy is, in turn, the
type 1 and affects 90–95% of diabetic patients [1]. Diabetic most common reason for foot ulcers in diabetic patients,
peripheral neuropathy, a common complication of diabetes, responsible for more than 80% of these ulcers [10, 11].
is present in almost 50% of people suffering from diabetes There is no specific treatment guideline for neuropathic
mellitus [2]. In 26.4% of diabetic patients, it has a consider- pain and a small number of studies describe the effect of ex-
able negative impact on the quality of life [3]. In the United ercise training and lifestyle modification on diabetic periph-
States, the total calculated annual cost associated with dia- eral neuropathic pain. According to a study, a conservative
betic individuals is between $4.6 and $13.7 billion, and 27% treatment program had a positive and long-lasting effect on
of the medical cost of diabetes is ascribed to diabetic neu- pain [12]. Another research showed that aerobic exercise
ropathy and the resultant impairments [4]. training applied for a long time could save patients from
Diabetic peripheral neuropathy is caused by hypergly- neuropathic pain or change the pattern of neuropathic pain
caemia and diminished blood supply to the peripheral nerves. by decreasing its extent and severity [13]. Conservative
It more commonly affects the lower limb [5]. According to management including non-neural tissue interventions and
a survey, symptoms of diabetic peripheral neuropathy were neurodynamic mobilization techniques can be effective in ad-
dominant among diabetes patients aged less than 40 years dressing musculoskeletal presentations of peripheral neu-
in the United States [6]. ropathic pain [14].
The clinical changes which occur owing to peripheral neu- Neuromobilization is one of the conservative methods
ropathy are altered sensations in the form of tingling, numb- used in physical therapy [7]. It is an innovative management
ness, and severe pain, while some patients experience a feel- tool which involves conservative decompression of nerves,
ing of electric shock [7]. A cross-sectional survey reported the applying different neural mobilizing techniques and patient
relationship between diabetes type 2 and lower limb mech- education techniques. These techniques, implemented along
anism of sensitivity, where diabetic patients had little response with routine physiotherapy, are effective in treating shoulder

Correspondence address: Wajida Perveen, Physical Therapy Department, School of Allied Health Sciences, CMH Lahore Medical
College and Institute of Dentistry, Abdul Rahman Road, Lahore Cantt, Punjab, 54800, Pakistan, e-mail: [email protected];
https://orcid.org/0000-0002-4833-0928

Received: 29.03.2021
Accepted: 19.10.2021

Citation: Ali MA, Anwar S, Perveen W, Akhtar M, Hashmi R, Jabeen Z. Effects of neurodynamic exercises on the management of diabetic
peripheral neuropathy of the upper limb: a case series. Physiother Quart. 2023;31(3):53–56; doi: https://doi.org/10.5114/pq.2021.111834.
 M.A. Ali, S. Anwar, W. Perveen, M. Akhtar, R. Hashmi, Z. Jabeen
Neurodynamic exercises in diabetic peripheral neuropathy Physiother Quart 2023, 31(3)

impingement syndrome [15]. This is a concept devised by Median nerve

Michael Shacklock and David Butler [16]. Over the past 20
years, further researchers, such as Dr. Michel Coppieters and In the median nerve, a slider technique in appropriate po-
Dr. Alf Brief, have added a great volume of research on this sitions was applied. The patient lay in supine position; se-
topic. According to Michael Shacklock, there are 3 main com- quentially, shoulder girdle depression was employed, then
ponents indispensable to understand neurodynamics: the slight abduction of the shoulder, extending the elbow, laterally
mechanical interface, the neural structures, and the inner- rotating the arm, and supinating the forearm. Wrist, finger, and
vated tissues [16]. thumb extensions were then added; finally, the shoulder was
If employed at an early stage, peripheral nerve mobiliza- taken into further abduction. The full stretch position included
tion can reduce diabetes-associated peripheral neuropathy contralateral cervical side flexion [24] (Figure 1).
[17]. Neuromobilization of the sciatic and peroneal nerves re-
sulted in restoration of full function of the lower leg in a 24-year-
old male with severe compression of the peroneal nerve [18].
In a quasi-experimental study to investigate the effect of the
neurodynamic technique on neuropathic pain, no increase
in pain was observed [19]. According to a systematic review,
addition of neurodynamic exercises to a treatment protocol
for diabetic patients with peripheral neuropathy brought
about positive results in modulating pain and functional dis-
ability [20]. Studies revealed that exercise of low-level me-
chanical stimuli, such as ‘slide’/’glide’ and stretch ‘tension,’
decreased clinical symptoms and acted directly on the
Schwann cells [21]. A case report suggested the use of neu-
rodynamics along with electrical stimulation and dry nee-
dling for the treatment of peripheral neuropathy [22].
Many studies were conducted which showed the preva-
lence of diabetic peripheral neuropathy and the role of neuro- Figure 1. Median nerve neurodynamics
dynamic exercises in lower limb neuropathy management.
Not a single study was found to support the impact of neu- Ulnar nerve
rodynamic exercises in the upper limb.
The patient lay in supine position. Sequentially, wrist ex-
Subjects and methods tension, forearm supination, followed by elbow flexion (full
range) were applied; then, shoulder girdle depression was
Study design and patients added. While maintaining this position, shoulder lateral rota-
tion and abduction were practised. In the final position, the
A case series was presented. The non-probability con- patient’s hand was near their ear, with fingers pointing pos-
venient consecutive sampling technique was used. Data were teriorly. In the full stretch position, contralateral side flexion
collected from Allama Iqbal Memorial Teaching Hospital of the cervical spine was added [24] (Figure 2).
Sialkot.
Successive diabetic patients with neuropathy who vis-
ited the Allama Iqbal Memorial Teaching Hospital Sialkot in
the previous 3 months were selected; the sample size was
determined with the use of the online Google calculator. Con-
fidence interval was 95% and the margin of error equalled
0.5%. A total of 40 diabetic patients were selected for this
study. Males and females were included aged over 40 years,
with type 2 diabetes mellitus for at least 2 years and periph-
eral neuropathy in an upper limb. Diabetic patients having
frozen shoulder, history of altered mental health status, or
history of particular shoulder injury surgery were excluded.
The neuropathic pain questionnaire Douleur Neuro­
pathique 4 (DN4) was used to collect data. The test is char-
acterized by 80% sensitivity and 90% specificity [23]. The
questionnaire consisted of 2 parts: one part was subjective
(patient interview) and the other part was objective (examina- Figure 2. Ulnar nerve neurodynamics
tion part). DN4 was applied twice: once before the treatment
and once after the treatment. Pre-test and post-test values Radial nerve
of peripheral neuropathy pain were calculated on the basis
of the questionnaire. Neurodynamic (tension) techniques The patient lay in supine position; sequentially, shoulder
were applied in the patients with type 2 diabetes and pe- abduction, elbow extension, medial rotation of the arm, and
ripheral neuropathy in the upper limb by a qualified physical pronation of the forearm were applied. While keeping the
therapist with 2 years of experience in practising neurody- elbow in extension, wrist, finger, and thumb flexion, and fi-
namic techniques. nally ulnar deviation of the wrist were added. The full stretch
Data were analysed by using the SPSS 21 software. The position included contralateral side flexion of the cervical
paired sample t-test served to compare the pre-test and spine [24] (Figure 3).
post-test values.
54
 M.A. Ali, S. Anwar, W. Perveen, M. Akhtar, R. Hashmi, Z. Jabeen
Physiother Quart 2023, 31(3) Neurodynamic exercises in diabetic peripheral neuropathy

Discussion

A cross-sectional study was conducted in the United

Kingdom according to which the commonest problem related
to diabetes was diabetic peripheral neuropathy. It is present
in more than 50% of type 2 diabetic patients aged over 60
years and the incidence increases with both age and dura-
tion of diabetes [26]. The majority of patients with diabetic
peripheral neuropathy do not experience any pain. Almost
11% suffer from pain, and the consequences of pain include
sleep disturbances, which affect the activities of daily life and
patient progress to depression [2].
The neurodynamic exercises were effective in diabetic
Figure 3. Radial nerve neurodynamics peripheral neuropathy. Peripheral nerve mobilization can re-
duce the diabetes-associated peripheral neuropathy. In this
General characteristics of the intervention study, the DN4 pain questionnaire was used before and after
the treatment. The mean value of the pre-test was 6.42 and
Tension techniques were applied for 10 s with a 2-s rest the mean post-test value was 3.68. The values of painful cold,
and 10 repetitions in each session, along with traditional ther- burning, hypoesthesia to touch, itching and tingling were
apy consisting of transcutaneous electrical nerve stimulation decreased. Hypoesthesia to pinprick was also reduced after
of 80 Hz and 150 µs for 20 minutes on the cervical area [25]. the treatment. Numbness was the most affected component
as its value decreased more than that of other components
Ethical approval of the DN4 questionnaire. This shows that the neurodynamic
The research related to human use has complied with all exercises were effective in diabetic peripheral neuropathy.
the relevant national regulations and institutional policies, has According to a quasi-experimental study among 20 dia-
followed the tenets of the Declaration of Helsinki, and has been betic patients, there was no increase in the severity or irrita-
approved by the Sialkot College of Physical Therapy Institu- bility of symptoms, which suggests the manoeuvre to be safe
tional Review Board (approval No.: SCPT-IRB/2018/410). in diabetic neuropathy [19]. Moreover, the limb to which the
tensioner technique was applied presented a bigger straight
Informed consent leg raise range as compared with the other limb, mainly owing
Informed consent has been obtained from all individuals to a decrease in sensitivity to painful stimuli [19].
included in this study. A systematic review demonstrated the effectiveness of
adding neurodynamic mobilization to the treatment protocol
Results for patients with lower limb symptoms. Neural mobilization
appeared to modulate the pain, flexibility, and range of mo-
For this case series, a total of 40 patients were selected. tion [20]. Another systematic review reported that the use of
Of them, 31 female subjects and 8 male diabetic patients with transcutaneous electrical nerve stimulation helped alleviate
peripheral neuropathy were finally included in the research. pain in patients with diabetic neuropathy, in contrast to elec-
The mean and standard deviation of age were 51.22 ± 6.712 tromagnetic field treatment [27].
years. The mean value of painful cold was 1.54 before the
treatment and 1.18 after the treatment. The mean and stand- Limitations
ard deviation of pre-test value of burning sensation were
1.78 ± 0.505; after applying the neurodynamic exercises, the Diabetic peripheral neuropathy is more common in the
post-test value decreased to 1.15 ± 0.389. Numbness was lower limb. As a result, fewer patients were available for the
also present along with neuropathic pain; its mean and stand- study investigating upper limb neuropathy.
ard deviation value before the treatment equalled 1.79 ± 0.409 This study suggests that further research may be con-
and after the treatment, the value was reduced to 1.10 ± 0.307. ducted to explore the effectiveness and safety of these neu-
Numbness was the component most affected by the rodynamic exercises performed in more than one session.
neurodynamic techniques. Similarly, the pre-test mean and These exercises may be used for the management of upper
standard deviation values of itching were 1.18 ± 0.385 and limb type 2 diabetic peripheral neuropathy.
the post-test values were 1.05 ± 221. The patients with dia-
betic peripheral neuropathic pain also complained that they Conclusions
felt pins and needles. Before the neurodynamic exercises,
the mean value of pins and needles was 1.72 ± 0.452 and The neurodynamic exercises were useful in reducing
after the treatment, the value decreased to 1.12 ± 0.335. type 2 diabetic peripheral neuropathic pain. They can help to
The results showed that 60% of the patients had hypoes- decrease diabetes-associated peripheral neuropathy symp-
thesia to touch. The pre-test value of hypoesthesia to touch toms. All participants of this study completed their neurody-
equalled 1.62 ± 0.493 and the post-test outcome was 1.15 ± namic exercise intervention but their pain and other neuro-
0.366. Tingling sensation was also present in those patients, pathic symptoms did not aggravate. Painful cold and the
with the value of 1.45 ± 0.504 before the treatment and sensation of pins and needles were reduced. Numbness was
1.12 ± 0.335 after the treatment. The mean value of pain with significantly decreased. All participants felt comfortable dur-
brushing before the treatment equalled 1.23 ± 0.427; after ing the process of applying the neurodynamic exercises.
the treatment, it was reduced to 1.08 ± 270.
The total pre-test mean and standard deviation of all vari- Disclosure statement
ables were 6.42 ± 1.152. The total post-test mean and stand- No author has any financial interest or received any finan-
ard deviation of all variables were 3.68 ± 1.095. cial benefit from this research. The abstract of the study was
55
 M.A. Ali, S. Anwar, W. Perveen, M. Akhtar, R. Hashmi, Z. Jabeen
Neurodynamic exercises in diabetic peripheral neuropathy Physiother Quart 2023, 31(3)

presented as a poster at the World Physiotherapy virtual 14. Anwar S, Malik AN, Amjad I. Effectiveness of neuromo-
congress 2021. bilization in patients with cervical radiculopathy. Rawal
Med J. 2015;40(1):34–36.
Conflict of interest 15. Akhtar M, Karimi H, Gilani SA, Ahmad A. Effects of rou-
The authors state no conflict of interest. tine physiotherapy with and without neuromobilization in
the management of internal shoulder impingement syn-
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