3 Simple Nerve Flossing Exercises to Help Resolve Arm Pain

Recent months have produced multiple studies on the utility of nerve tensioning and nerve flossing for various upper extremity musculoskeletal conditions:

• A December 2020 BMC Musculoskeletal Disorders study found that patients receiving nerve mobilization had a nearly two-point greater VAS improvement. (1)

• A July 2020 Journal of Hand Therapy study on the long-term effect of neurodynamic technique vs. exercise found: “neurodynamics therapy was superior in improving function and strength and in decreasing pain.” (2)

• A November 2020 study of 120 carpal tunnel patients found that: “desensitization maneuvers of the central nervous system resulted in similar outcomes to surgery.” (3)

• A recent JOSPT systematic review found that, in addition to improving outcomes for neck and back pain, neuromobilization may have merit for lateral epicondylalgia via “significant improvements in pressure pain threshold, pain-free grip strength, neurodynamic test ROM, and pain scores.” (4) 

In response to requests for additional neurodynamic tutorials, this week’s blog is an updated review of the three most useful upper extremity neurodynamic assessment and management techniques.

Nerves are dynamic structures that need the ability to glide and stretch. (5) Edema and fibrosis can impair this normal nerve movement and often translate into neurogenic complaints. “Nerve flossing” aims to restore normal neurodynamics and may help to resolve the associated symptoms. Check out the following video demonstration of three simple nerve flossing exercises to help you manage upper extremity complaints.

The Presentation 

“According to the double-crush syndrome hypothesis, the peripheral nerves arising from irritated nerve roots are more sensitive to pressure.”(6) This cumulative nerve irritation is well recognized in neuropathies like carpal tunnel syndrome but is also thought to contribute to other musculoskeletal complaints like tennis elbow or shoulder impingement – as evidenced by the (remarkably reliable) arm squeeze test. (7)

The Diagnosis

How do we confirm that a nerve is irritated? In the lower extremity, it is relatively uncomplicated - straight leg raise for the sciatic nerve and Yeoman (aka Femoral nerve stretch test) for the femoral nerve. However, the upper extremity has more potential candidates, and the associated nerve tension tests are not generally as familiar. For a refresher, check out this ChiroUp tutorial video of three simple nerve tension tests to help you differentiate upper extremity neurogenic complaints.

The Solution

Nerve tension tests place a nerve under maximum stretch in order to elicit irritation; however, these maneuvers should not be confused with nerve flossing treatments. Flossing entails tensioning one end of the nerve while simultaneously releasing tension on the other end. This repetitive motion glides the nerve back and forth through its path and aims to release adhesions that have developed along the way. Nerve flossing can be performed in-office by the clinician, or as part of a home-based program.

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• References

  1. Akhtar M, Karimi H, Gilani SA, Ahmad A, Raza A. The effectiveness of routine physiotherapy with and without neuromobilization on pain and functional disability in patients with shoulder impingement syndrome; a randomized control clinical trial. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-9. Link

  2. Hamzeh H, Madi M, Alghwiri AA, Hawamdeh Z. The long-term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Journal of Hand Therapy. 2020 Jul 30. Link

  3. Fernández-de-Las-Peñas C, Arias-Buría JL, Cleland JA, Pareja JA, Plaza-Manzano G, Ortega-Santiago R. Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial. Physical Therapy. 2020 Nov;100(11):1987-96. Link

  4. Basson A, Olivier B, Ellis R, Coppieters M, Stewart A, Mudzi W. The effectiveness of neural mobilization for neuromusculoskeletal conditions: a systematic review and meta-analysis. Journal of orthopaedic & sports physical therapy. 2017 Sep;47(9):593-615. Link

  5. Wilgis EF, Murphy R. The significance of longitudinal excursion in peripheral nerves. Hand Clin. Nov 1986;2(4):761-6. Link

  6. Okmen BM. et al. Investigation of the Effect of Cervical Radiculopathy on Peripheral Nerves of the Upper Extremity With High-Resolution Ultrasonography. SPINE. 43(14):E798–E803, JUL 2018 Link

  7. Gumina S, Carbone S, Albino P et al. Arm squeeze test: a new clinical test to distinguish neck from shoulder pain. European Spine Journal 2013; 22: 1558-63. Link