Neural mobilization
Gayathri R
MPT 1st Year
PATHOPHYSIOLOGY
• Altered vascular supply
– Ischaemia
• Inflammatory response
• Altered axonal plasma flow
• Activity specific mechano sensitivity
• Double crush injury
Double crush injury
• Development of symptoms elsewhere in the body or along
the nervous system distinct from the original nerve
entrapment
• Upton and Mc Comas [1973] examined 115 patients with
carpal tunnel syndrome and found that 81 had
electrophysiological and clinical evidence of neural lesions
in the neck.
PATHOMECHANICS
• Mechanical interface
– Attachment
– Branches
– Unyielding interface
– Tunneling
– Cutaneous
• Shortening of the connective tissue
PATHODYNAMICS
• Tension on the peripheral nervous system decreases
circulation
• Mechanical interfaces can alter axoplasmic flow
• Axoplasmic flow is regulated by ATP transport in the
microtubules.
• “DOUBLE CRUSH”
– A lesion at one site predisposes development of another
lesion
– According to Osterman (1998), multiple lesion can occur
along a peripheral nerve .
Major forms of neurogenic pain
NEUROGENIC V/S NEUROPATHIC PAIN
• Radiating, shooting pain- nerve root
• Parasthesia, pins & needles- nerve trunk
• Tingling & numbness- nerve fibre
• Pathoneurodynamics- pulling
• Neurophysiological- sensation, weakness
• Neural claudication- cramping, squeezing
• Neuropathic- burning, lancinating, excruciating
BASE TESTS
• Passive neck flexion (PNF).
• Straight leg raise (SLR).
• Slump test.
• Prone knee bends (PKB).
• Upper limb tension tests
(ULTT).
PASSIVE NECK FLEXION (PNF)
History
o connell 1946 lists PNF sign of Brudzinski 1909 –
sign of meningitis
Troup in 1986 described PNF in sitting and in
combination with SLR
Indications:
• For all possible spinal disorders, headache symptoms,
and for arm and leg pain of possible spinal origin.
Method:
The patient lies supine, arms are by the sides, and legs together.
The therapist takes the head into passive flexion in a chin on chest direction.
Normal response :
PNF is a painless test.
May add SLR as sensitizing addition
Passive neck flexion
STRAIGHT LEG RAISING (SLR)
History unclear and disrupted
according to dyck 1984 – 1st person to recognize
that pain produced on SLR was due to sciatic
nerve – serabin lazerenic 1980
Initiator of the test as lesegue 1864 referred to pain
from slr as coming from compression of sciatic
nerve by hamstrings, dorsiflexors of foot
intensified patients sciatica
Lesegues test described and named by forst
Indications:
• Assess a low lu mbar discogenic problem, routine
examination with back, and lower limb disorders.
Originally designed to test sciatic nerve.
Method:
• The patient lies supine, trunk and hips in
neutral position. The therapist place one hand
under the Achilles tendon and the other hand
above the knee preventing knee flexion.
• The limb is lifted straight. Notice the range
that is recorded before pain or symptoms are
provoked.
Normal response:
• The normal range for SLR range between 50-
120 degree.
Sensitizing additions
• Ankle dorsiflexion stress tibial nerve.
• Ankle planter flexion and inversion stress
common peroneal nerve.
• Hip adduction further sensitize sciatic
nerve.
• Hip medial rotation further sensitize sciatic
nerve.
PRONE KNEE BEND (PKB)
History
Credit can be given to wasserman in 1919 ,
according to estride et al, 1982
First suggesting the manoeuvre as tension test
which match the complaints of thigh and shin
pain
To increase tension in PKB , O Connell 1946
recommended the inclusion of hip extension
Indications:
• Routine test for patients with knee, anterior
thigh, hip and upper lumbar symptoms.
Assessment of femoral nerve and its branches.
Method:
• The patient lies prone, the therapist grasps the
lower leg and flexes the knee to a
predetermined symptoms response.
• The response should be compared to the other
side.
Normal response :
• Asymptomatic, and in some normal there is
sensation of pulling or pain in the area of the
quadriceps
Sensitizing additions
• Cervical flexion
• Slump in side lying.
Prone knee bend test
SLUMP TEST
Slump test
• History
According to woodhall &hayes 1950 , petern 1909 was
1st to employ Knee Extension in sitting as Tension tesT
IN 1942 cyriax combination Knee Extension IN
SITTING WITH Cervical Flexion to diagnose sciatic
perineuritis
Inman and sounders 1942 suggested spinal flexion and
SLR to try and localise the source of lumbar spine
Indication
Spinal symptoms
Patient may complaint that symptoms are
worse while getting into a car
• Normal response
Stage 2 : on slump- nill
Stage 3 : on slump / CF – pain in area of T8 & T9
Stage 4 : on slump / CF /KE- pain behind the extended
Knee & hams
Stage 5 : on slump / CF / KE / ADF – some restriction of
ankle dorsiflexion
Stage 6 : on release of CF – decrease symptom in all areas
& an increase in ROM of knee extension and ankle
dorsiflexion
Variation
• To examine the nervous system in hyper
mobile patients, the slump test will need to be
taken further
• Greater hip flexion , adduction and medial
rotation
• Some lateral flexion of spinemay be required
to get desired response .
• Obturator nerve – (position )
• If the patient were abduct the leg during onset
of symptoms , then the trunk could be flexed
and neck position altered .
• Where neck flexion alters the groin pain
response there is slightly to be a neurogenic
component disorder
Slump test in long sitting
• Both assessment and treatment technique
restriction is not necessarily nervous system
• Slum from other end
• Tension from the nervous system from leg and
lower trunk has been taken up 1st
• Clinically the response are different from slum
test in sitting position
• Indication
• Slum LS ted especially is indicated for the
patient complaints of symptoms in slum long
sitting position
• Eg
UPPER LIMB TENSION TEST (ULTT)
Indications:
Method:
• The patient is positioned in neutral supine
• A constant depression of shoulder girdle is ensured
during movement.
• The shoulder is abducted to 110 degree.
• With this position is maintained,
• The forearm is supplicated and the wrist and fingers
extended.
• The shoulder is laterally rotated.
• The elbow is extended.
ULTT 1
History
• Developed by elvey in 1979, kenneley et el in
1988 called ULTT as Straight Leg Raise of arm
Indication
• ULTT is recommended test for all patients with
symptoms in the arm, head, neck and thoracic
spine. Different test is provided to test each nerve
(for example median nerve test, radial nerve test).
Normal response
• A deep stretch or ache in the cubital fossa
extending down the anterior and radial aspects
of forearm
• Tingling sensation the thumb and 1st third fingers
• Cervical lateral flexion away from side test
increas response
• Cervical lateral flexion towards the tested side
reduces the response
• Sensitinzing addition and variation
• A small movement which acts to sensitize one
nerve will rapidly take tension of another
• Ultt can be performed from the other end ie.,
From the hand first , ultt of the contralateral arm
and the SLR
LANDER 1987 – SHOULDER ABDUCTION range
70,110,130,150
ULTT 2
ULTT2A
ULTT2B
HISTORY
Smith 1956 revolved the significant effect that the
depression of the brachial plexus and the cervical cord
Elvey 1986 suggested using shoulder depression as a part
of mobilisation treatment for cranial nerve root
Butler include 2base tension test , with depression as key
position one is biased towards median and another radial
Normal response
• Symptoms could expeccted in the respective
innervation fields
Variations
• During shoulder gridle depression can add retraction
/protraction
• Lateral flexion and some abduction,or extension of
shoulder
• Elbow flexion combination with supination or pronation
ULTT 3
• HISTORY
• Peelian 1973 to devise a test to ulnar nerve
Indication
Nerve root lesion at c8and t1
Golfers elbow
Normal response
Tingling sensation, burning in the hand or
medial aspect of elbow
• ULTT 1 -- MEDIAN NERVE BIAS
• ULTT 2a -- MEDIAN NERVE BIAS
• ULTT 2b -- RADIAL NERVE
• ULTT 3 -- ULNAR NERVE
ULTT 1
ULTT 2A
ULTT 2B
ULTT 3
KEY TO SUCCESSFUL TREATMENT
• Nervous tissue mobilization fits perfectly into the
Maitland concept. That is, the treatment of signs
and symptoms based on the severity, irritability
and nature of the disorder.
• Treatment via neural mobilization is not a quickly
acquired skill, nor is it an easy skill to learn.
GUIDELINES TO THE STARTING TECHNIQUE
• Whatever the starting point used, the following should
apply during the first technique application
• The technique should be well away from the symptom
area
• Treatment should be non-provoking initially.
• A large amplitude technique (grade II) should be used if
possible with irritable disorders, while (grade III and IV)
with non-irritable disorders.
• Maximal relaxation of the patient, and the painful areas
will allow better nerve movement
• If the technique starts to irritate the pain, either reduce
the amplitude/range/speed of the technique.
• After the initial mobilization, the symptoms must be
reassessed.
GRADING THE TECHNIQUE
• The grading of the technique is dependent on
- Degree of irritability of the tissue
- The relationship between resistance to the
movement and the symptoms received
• Grade II: large amplitude rhythmic oscillations are
performed within the range not reaching the limit
• Grade III: large amplitude, rhythmic oscillations are
performed up to the limit of the available motion and
are stressed into the tissue resistance
• Grade IV: small amplitude rhythmic oscillations are
performed at the limit of the available motion and
stressed into the tissue resistance
PROGRESSION
• The number of repetition of the technique may be as
few as five or ten initially but can increase to many
repetitions for several minutes. It is preferred to
perform a sequence of gentle oscillations, for 20
seconds and then repeated again.
• Increasing the amplitude and taking the technique
further into resistance.
• Repeat the technique but alter to increase degree of
tension by addition of the sensitizing components.
SELF NEURAL MOBILIZATION TECHNIQUES
SELF NEURAL MOBILIZATION TECHNIQUES (COND)
