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W it ht hanksto ...
NOI Faculty members Translators - Ruggero Strobbe(Italian),Stefan Schiller and MargotBauer-Mitterlehner (German), HenryTsaoand Mei-Chun Kuo Tsao(Chinese M andar in)B enit oC a o(S p a n i s h ). , Models - Claire,Davidand Rookie Design - ArianeAllchurch, DinahEdwards Production manager - JulietGore Anatomy artwork - Copyright (2005), Icon Learning Systems,LLC,A subsidiary MediMedia, of USA,Inc. All rights reserved. DVD authoring - AnthonyJames Spectra Videographics, spectravideogfx@ hotmail.com Reproduction - MicroviewSolutions ChatswoodNSW,AustraIia, www.microview. com.au Printing - van GastelPrinting,Adelaide,Australia Husic - Naria by MiguelEspinoza

Our international faculty

NOI instructors hand selected the basisof are on their existingskillsand expeftise and undergo progressive peer and experttraining.All instructors have postgraduate manualtherapyeducations ano are membersof nationalassociations of the and International Association the Studyof pain. for Our courses taught in languages other than English are predominantly delivered nativespeaking by membersof the faculty. , NOI'sfacultymembersall travel widelyto meet their teachingcommitments. Australia DavidButler,PeterBarrett,CarolynBerryman, MichelCoppieters and MeganDalton. Europe - German speaking Gerti Bucher-Dollenz, MartinaEgan-Moog, HannuLuomajoki, Harryvon piekartz, HugoStam and Irene Wicki. Europe - Italian speaking SergioParazza, ErikaSchiffereger, Ruggero Strobbe, Susanne Wahrlich and Irene Wicki. USA Bob Johnson, AdriaanLouw,Bob Nee, S tephen chmi dt S and l ohn Tomberl i n. Canada Sam Steinfeld and Launie Urban.

Introduction
This neurodynamics techniques DVD and book has been produced the by Neuro Orthopaedic Institute Australasia,with contributions from our international faculty.It is expected that userswill be health professionals, thus will have an and existingknowledge neuroanatomy of and neuroorthopaedic assessment plus knowledge relevantpathology, of precautions and contraindications. For optimaland safe clinical integration, is highlyrecommended it that this DVDand book be usedin association with NOI education seminars (www.noigroup.com) and/or used with the textbooks Mobilisation of the Nervous System or preferably, The Sensitive Nenrous System. This DVDand book shouldnot be taken as just a list of exercises, but more a seriesof ideas,For example, techniques may be demonstrated to illustratea particularprinciple one for nerve,but similartechniques could be usedfor other neuralstructures.

Nine key points

1 > wfr"t is a neurodynamic test? Neurodynamics the science the relationships is of betweenmechanics ano physiology the nervous of system.simply put - it is the assessment ano treatmentof the physical healthof the nervoussystem,Just as a joint moves and a musclestretches, the nervoussystemalso has physical properties you can examinethese properties that are essential movement. for via nerve palpation and neurodynamic tests. Z >The nervous system is a continuum A mechanical, electrical and chemical continuum existsin the nervous system.This is the basisof tests suchas the slumptest, wherefor example, the position the neckwill influence of neuralresponses the lec. in 3 > Structural differentiation The neuralcontinuum allowsa differentiation betweenneuraland nonneuraltissues.For example,in the caseof the slumptest (see below), if neck extension whichtakes load off the nervoussystemeasesevoked symptomsin the leg, then this provides some clinical data to suggestthat there is a physical healthissue in the nervous system.

4 > Neural relations to joint axes dictates load The nervoussystemis usually behind,in front, or to the side of joint axesof movement. This meansthat the physical loading on the nervoussystemwill be dictatedby joint position. In the exampleshownof the UpperLimb Neurodynamic Test(ULNT), wrist extension, elbowextension, and shoulder abduction would be examples of movements which challenge mediannerveand the the plexus.If you know your anatomy,you couldmake brachial up neurodynamic tests yourself. 5 > Pin"t and tension - the key role of neighbouring structures Mostneurodynamic tests are tests of the abilityof the neryoussystemto elongate. The neighbouring structures (e .9 .j o i n t a n d mu scl e) hi ch w 'contain'the nervoussystem pinch it. Wrist can sometimes flexionis a test of the neural container aroundthe median nerve at the carpaltunnel, and the Spurlingt test (illustrated here) is an example o'a pinchtest for lower ceruica nen*eroots.

6 t o.d", of Movement The strainand movementof the nervoussystem will be affectedby the order in whichthe movement is taken up. For example,as iilustrated, you add if ankledorsiflexion and eversion and then performa problemin StraightLeg Raise(SLR), a neurogenic the tibial nerveat the ankle is more likelyto be exposed than with other combinations. Thereare probably two reasons this: a more for mechanical reasonwherethe neuraltissuesare 'borrowed'fromother areasand thus given more of a chanceto be challenged, perhaps or the first movementis the one which takes priorityin the patient's consciousness.

7 t Slid.r" and tensioners (1) A tensioner can be a vigorous technique which'pullsfrom both ends'of the nervous system.A slider(2) is a 'flossing' movement wheretensionis placedat one end of the systemand slackat the other.Sliders providea largeamountof neuralmovement and are a neurallynonaggressive movement for anxiouspatients.

() > Recording Abbreviations such as PFlIN/SLR inform the order and kind of movement. thus ankle plantarflexionfirst, then inversion and then StraightLeg Raise,Eachcomponent can also be quantified terms of rangeof in movementor qualified terms of in symptomsevoked, The' In:D i d' system i s al soused.For In: H Fl LR D i d: K E meansthat i n exampl e, the hip flexionand lateralrotationposition, knee extension was performed. Y > Don't forget the brain Remember that responses thesetests to may not alwaysbe due to physical health issues the nervous in system.In some patients the sensitivity evokedduringtesting may be due to changes the central in nervoussystem.There is much more on this impotant part of assessment The Sensitive in Nervous System.

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Glossary
C IT . . . Cer v ic o -th o ra c i c D F. . . . Dor s if lex io n FV . . . . E v er s ion GH. . . . G lenohum e ra l H A b. . . Hipabduc ti o n H A d. . . Hipadduc ti o n H E . . . . Hipex t ens i o n HF . . . . Hipf lex ion IMT . . . Intermetatarsal IN . . . . I nv er s ion KE . . . . K neeex t e n s i o n KF . . . . K neef lex i o n Lat flex . Lateralflexion LR . . . . Lateralrotation L S. . . . . Longs it t in g NF . . . , . Nec k f le x i o n PF . . . . Plantar.flexion PK B . . . P r oneK ne e Be n d NeckFlexion PNF ., . Passive Rad . . . Radial SK B . . . S lum pK ne e B e n d sl i . . . . . s lider SLR . . . Straight Leg Raise SL S . . . . S lum pLon g Si t SL Y . . , . S lum psi d e l y i n g SP . . . . S pinal tibiofibular Sup TF . Superior te n . . . . t ens ioner Thx . . . . T hor ax Test ULNT . . Upper Limb Neurodynamic e Ho[

References
Butler DS (2000) The SensitiveNervous System,ISBN 0-646-40251-X, Adelaide. NOI Publications, of Butler DS (1991) Mobitisation the System,ISBN 0-443-04400-7, Neruous Melbourne. Livingstone, Churchill
(Also in German, Italian, Spanish and Japanese.)

Supportmateirial
is and brain products literature NOI'slist of self published for Visit noigroup'com updatedand expanded. continually and detaileddescriptions secureonlineordering'

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nerve Peroneal
An at om y andpalp a ti o n .... Therapist's assessment PFI I N/ S LR PFlI N/ S LRv ia ho u l d e r s Passive techniques In :S LR/ HA d/ HMR /SP fl e x ... > D In : HF / P F I I N DF IEV i d : K E .... ..3 .....4 ........2 ....2 ....1 Passive techniques ... 11 In: S LV D F/E V D i d: IMTmob.. . .. . .. 11 In: S l umpLS /D FIE V i d: IMT mob .. D D In: H F/D F/E V i d: K E w i th neruemassage... . ... . t 2 D ti In: K FID F/IN i d: K E /S LR ' U l ti matebi almob' . . . . . 13 Self management > gentler movements . . . . t4 D In: H F/D F/E V i d: K E ' H eelto the sky' ... ..... L4 sw i ngheelto fl oor. . Leg Self management > stronger movements .,...15 S In: S tand/D F/E V D i d: P fl ex l K In: H F/D FIE V D i d: E + strap' W al w ork' .,......15 ... . . 16 D In: S l umpLS /D FIE V i d: K E (sl i /ten) Did: IMT mob In: Slump LS/DFIEV/NF ....16 Toew ri ggl eri nsl ump.

D In : S lum pLS / P F IIN i d : Su p T F mo b + KE .. . ' .. ' ' 4 Self management > gentler movements .. ...5 In : HF I P F I I NDidK E : ....' .5 Leg swingtoes curledunder, Self management > stronger movements ..,... D In : S lum pLS / P F IIN i d : K E(s l i /te n ) ' .6 .. .. ' 7 m Standing obilis a ti o n ,... ..8 Wallm obilis at ion .., peroneal nerve. . . . .' . 8 'Hamstrings on stretch'Focus

Suralndrve
A natomyand pal pati on..... Therapist's assessment D Fl rN l S LR Passive techniques K In: H F/D F/IN D i d: E In: DF/INDid: nerve massage Self management D In: H FID F/IN i d: K E (sl i /ten) ...17 .....,1 8 ,...1 9 . . . . 19 . . . . 2O

Tibial nerve
Anat om y andpal p a ti o n ..,. Therapist's assessment D F I E V / S LR Rev er s alS LR/ D F IIN
ONor

." ' 9 ..... .10 ...,..10

Femoral nerve
An at om y and pal p a ti o n ..... Therapist's assessment ProneK neeB end(P KB ) Sl um pK neeB end(S KB ). In : S lum pS LY / K FIH E i d : H Ab D Obt ur at or t es t . . . In : S lum pS LY / K FIH E i d : H Ad D Me r algiaes t . . . t ...2I . . .22 ........22 .......23

Median nerve
A natomyand pal pati on..... ... 33 A cti ve qui cktest. ......34 Therapist's assessment U LN T1 ....,.35-3 6 U LN T1A l ternati veposi ti on ..,....36 U LN T1R eversed... .....37 ULNT1 Reversed: indexfingerfirst . . . . . . . 38 U LN T2..;.... ........39 posi ti on U LN T2S eated ....40 Passavetechniques U LN T2S Ii /ten ....4 t U LN Tl S l i /ten ....4 t ' N annaarmw obbl e' .,,,,.42 In: U LN T1 i d: GH mob.. D .......43 Self management > gentler movements patti ng,' W atch B al l oon thew atch' . .... ... 44 Y oyo,Juggl i ng.... ......44 ' N o moredi shes'B al lthrow i ngprogressi on , .......45 Self management > stronger movements 'Busy bee','Finger stretch',Wrist stretch . . . 46 ' R ockaroundthe cl ock' . . . 46 'Sawatdika',Crawling,'Zorro', Balancing acts. . . . . . 47 Lookat your hands,Wallstretch . . . 48 ' Freethebi rd' .. ........48

........2 4 Self management H alfP us hup, HalfP u s h u p n e c ks l i /te n . + . . .25 'Thom as t es t ex e rc i s e .... .26 'Hur dler s t r et c h' ........27

Saphenous nerve
An at om y and pal p a ti o n ..... Therapist's assessment Prone/H E/HAb KE/MR/DF EV / / Thes aphenous t e s t Passive technique In : P r one/ HE lHA b /M R /D F l E VD i d : KE ,.... Self management Th e s aphenous stre tc h ....32 31 ...29

......30

Ulnarnerve
Anat om y and pal p a ti o n ..... Ac t iv equic k t es t . Therapist's assessment ULNT 3 r om wr is t fi rs t F F ULNT 3 r om s hou l d e rfi rs t.. Passive techniques tu c In l ULNT 3 Did: m a s s a g e u b i ta l n n e l . ...49 .,....50 .. ..51 ... ' ' 52 , . . 53 Passive techniques ' Gentl eradi al i di ng' sl .....6 4 ......64 ' W hol earmrotati ons (radi al ) i d: R adheadsoftti ssuemob...65 D In: U LN T2 Self management > gentler movements ' P ouri ngw ater' . ' Fi guresofei ght' ' P umpw ater Lookat your hand behi ndyour el bow Self management > stronger movements ' B ackmassage' .... ' Ti ppl ease' ' Tabl estretch ...,.6 8 ......68 .....6 8 ........66 ...,.,,.66 ......67 . . . . . 67

..,53 In :ULNT 3Did: pi s i fo rmmo b ,. . . . .54 Did: S l i /te n In : ULNT 3 Self management > gentler movements . . . . . . .. 55 'Don' t lis t en' , ' F acm a s s a g e s '.. . e . . .' . . . 55 'M ak ea halo' , ' s mo k i n g ' ,' Y a h o o l ' , Self management > stronger movements ,... ' 56 'Pl at eex er c is e' . ... 'Crawlto the pits' . . . . . 57 'Dry the back','Sunglasses',

nerve Musculocutaneous
nni tomyand pal pati on..... Active quick test. ... 69 . . . . . .7O .......7t ... 72 ... 72 Therapist's assessment U LN T(muscul ocutaneous) Self Management R unni ngonthespot.. ' Throw i taw ay'

Radialnerve
Anat om y andpal p a ti o n ..... Ac t iv equic k t es t. Therapist's assessment ( ULNT 2 r adial) . , ... (radial)Seatedvariation ULNT2 (radial)Fromwrist first ULNT2
(c) NoI

,..59 .,....60 .....61 . . . 62 . . . ' 63

S pine, dan d me nin ge s cor

An at om y Ac t iv equic k t es t. ...... .73 ......74 Therapist's assessment Pa s s iv e Nec kF lex i o n N F ).. (p ... ..75 StraightLeg Raise(SLR)Sensitising movements. . , 76 . Bi lat er al LR. . . S Sl um pt es t ac t iv e . Sl um pt es t pas s iv e Sl um pLongS it ( S L S ). Passive techniques SlS/Structural differentiation . . In : leg dis t r ac t io n i d : n e c k s l i /te n . D In: SLSDid: Thx Lat flex techniques In : S LSDid: A , t P m o v e me n ts Notalgia paraesthetica techniques . . . . . . . . 81 . . .. ..a2 . . . . . . g3 ........77 ..... .7g ..... .7g ....B O Self management > stronger techniques ' W ri ng' techni que. .......g9 S LS /S houl dershrug .....9 0 ' K i ckyourheadoff, ...,..91 'Kick your head off, Focus peroneal on nerye . . . . . . 91 ' W al lw al ki ng 'Totalslump.'Bob Johnson technique ' R ol lover' .....g 2 . . . . . . 93 ......,93

Other Nerves
Accessorynerve (cranialnerve XI) Axillarynerve Suprascapular nerve Trigeminal nerve Occipital nerve .....9 5 ....97 ....98

.....84 . . . . ., . . 85 Wedgemobilisation techniques/Thorax spine ., . . . . g6 Wedgemobilisation techniques/Cervico-thoracic . . 87 area Self management > gentler techniques Pe lv ic t ilt / nec k S l i /te n .... B B SL R/ nec k S li/ t en . ....... 88

Peroneal nerve > anatomyand palpation

Palpable areas A Medialto BicepsFemoris B At the head of the fibula C Dorsum of the foot (both superficialand deep peronealnerves) Common entrapments / syndromes Lowerlumbarspine Piriformisarea Superior tibiofi bularjoint Lower limb compartments Ankle extensor retinaculum The Sensitive Neruous System Chapters 11 and 15 B,

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pist'sassessment Peroneal nerve > thera

PFlIN/SL R

p2

Foot held in plantar flexion/inversion

As the hip is flexedthe therapist's arm maintains kneeextension

PFlIN/SLR via shoulder Moremobilesubjects require the technique variationshown.The leg is placedon the ther apis t ' s houl d e a n d th e n ' w a l k e d u p . r '

Peroneal nerve > passivetechniques

In: SLR/HAd/HMR/SP flex Thesefour imagesshow increasing tensionbeingplacedupon the peroneal may be and the neuromeningeal system.Exploring these movements nerve (add PFIIN) necessary minor physical for healthissuesof the peroneal or tibial (add DFlEV)or situations wherethere is a spinalas well as peripheral component. Any of these movements could be usedas therapy.

p3

H i p a d d u c ti o n

Hip medial rotation

Soinal lateral flexion

ONor

Peroneal nerve> passive techniques

In= HF/PF/IN > DFI EV Did: KE

p4

K neeextensi onn hi p fl exi onand.ankle i plantarflexion/inversion a gentleway to is mobilise the peroneal nervefor physical healthissues anywhere alongthe nerve. In the techni que exampl e here,w hi l et he knee is beingextended, the ankle is taken from plantarflexion/inversion to dorsiflexion and eversion additional for nervemobi l i sati on.

In : S lum p LS / P F IIN D i d : S u p T F m o b + KE The slump basedtechnique illustrated is joint a combi nati on superi or bi ofi bul ar of ti pl mobi l i sati on, uskneeextensi on, u s pl spi nalfl exi onand note al sothat the patient'sright foot is held into plantar flexionand inversion her left foot. All by these movements togetherwould compri se vi gorous a tensi oner technique. N eckextensi on the sameti me as knee at extensi on oul dbe a sl i der. w

Peroneal nerve > self management> gentler movements

Thesetechniques examples are the of gentleways to mobilise peroneal nervesand roots. If a more gentledistracting movementis required, the patient couldextendher neck duringthe knee extension the 'swing or through'in the leg swingtechnique.
I'nt HFIPFIIN Did: KE

p5

Leg swing toes curled under

ONor

Peroneal nerve> self management stronger > movements

Thesetechniques more vigorous are than the oneson pageand may be applicable mobile the previous for patientsand patientswith sportsinjuriesinvolving the peroneal nervesuch as a settlingsprained ankle.

p6

In: Slump LS/PFIIN Did: KE (sli/ten)

With the foot held in plantar flexion/inversion, knee extension and neckflexionmakes a te n s i oner techni oue.

With neck extension, slider a technique performed. is

Peroneal nerve > self management> strongermovements

Standing mobilisation Note how all the movement components which place load on the peroneal nerves and roots are used here. The right hip is adducted and medially rotated and the knee is held extended by the patient's left leg. With foot in plantar flexion and inversion, spinal flexion including neck flexion allows a strong self mobilisation of the peroneal nerve and associated roots.

p7

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> Peroneal nerve> self management stronger movements

Illustrated here are two vigorous peroneal nerve based techniques. W all mob ilisa tion The key with the wall technique, where the patient lies in a doorway, is to make sure that the foo t is maint ained in plant ar f lex ion and inversion via a towel or a straD.

pB

'Hamstrings stretch' Focus on peroneal nerve The 'hamstrings stretch' is a reminder that any muscle stretch will be likely to be a nerve mo bilisatio n,par t ic ular ly if t he movements that place more load onto the nerve are in clu de d. In th is examp le, no t e in im age 2 t he add ition of h ip flex ion, adduc t ion and med ial rota tion , an k le plant ar f lex ion and inversion a nd soin al f lex ion.

Tibial nerve > anatomyand palpation

Palpable areas A Posterior the knee to B M edial ank le( p l a n ta rn e rv e s ) Common entrapments / syndromes Plantar fasciitis Heels pur Recurrent hamstringinjury Piriformis area The Sensitive Nervous System Chapt er s , 11 an d 1 5 B

p9

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ONor

Tibialnerve > thera pist'sassessment

DFlEVlSLR

p10

The foot is held in dorsiflexion, eversion and pronation. Straight Leg Raise is then performed with the therapist,s arm on the shaft of the Ubia. The rlght leg can be flexed for a more sensitive problem. In the reversal technique, the therapistt shoulder can be used.

Reversal SLR/DFlIN

Tibial nerye > passivetechniques

Thesetechniquesmay be useful for Morton,s metatarsalgia. More comfort may be achievedwith the therapist seatedand the pauentin a SLs position. Try intermetatarsal splaying and antero_posterior movements (inset)and include extension the toes. of In: SLR/DFlEV Did: IMT Mobilisation fn: S l ump LS /D F/E V Did: fMT Mobilisation

p1 1

O Nor

Tibialnerve> passive techniques

ln HF/DFIEV Did: KE with nerve massage This technique may be appropriate neurogenic for foot problems particularly such as plantarfasciitis, wherethere is swelling a roundt he ner v ea t th e me d i a la n k l e . Mostnervescan be massaged there is no direct nerve injury if and the nerve is not too sensitive.

pL2

Tibial nerve > passive techniques

lnt KFIDFIIN Did: KEISLR 'Ultimate tibial mobilisation' This technique usesorder of movementprinciples take to up the nerveslackfrom the foot first.

p13

It is important staft with the to kneeflexed

Ankle dorsiflexion, eversion, pronation

SLR. In the final position,any of the components could be mobilised.

> Tibial nerve > se lf man ag em ent gent ler ov em ent s m

lnt HF/DF/EV Di d: KE 'Heel to the sky'

p t4

l"

'i,ft*

Leg swing heel to floor

T h e s e a r e g e n t l e m o v e m e n t s, appropriate for a more acute or s e n s i t i v e s t a t e i n v o l v i n g t h e ti b i a l nerve. If the patient focuses on. pushing the heel to the sky it will e n c o u r a g e m o b i l i s a t i o no f t h e t i b i a l n e r v e a n d p e r h a p s p r o vi d e a distracting metaphor. In the leg swing technique, poking the heel at the floor will create a similar nerve challenoe.

Tibial nerve > self management> strongermovements

In: Stan d/DFlEV Did: SP f lex

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YLJ

These are examples of more a9gressrve m o b i l i s a t i o nt e c h n i q u e s. S o m e o f t h e p e r o n e al n e r v e m o b i l i s a t i o n sco u l d also be adapted for the tibial nerve. N o t e t h e t e n s i o n e r a nd t h e s l i d e r i n t h e s p i n al flexion technique.

In: HFIDFIEV 'Wall work'

Did: KE + s t r ap

I n th e wall mob ilis at iont ec hnique, t he key is to use the strap or towel to make sure that the foot is securelv held in dorsiflexion ,e ve rs ion and pr onat ion.

ONor

Tibialnerve> self management stronger > movements

In r S lum p LS / DF/EV D i d : KE (sli/ten)

p16

Tensioner In: Slump LS/DFIEVINF Did: IMT mobilisation Toe wriggler in slump

Slider

Suralnerve> anatomy and palpation

Palpable areas A Lateral the Achilles to tendon B Distalto the fibula Common entrapments / syndromes Recurrent ankle problems A component Achilles of tendonitis The Sensitive Nervous System Chapters and 11 B

p17

pist'sassessment Suralnerve> thera

DFlIN/SL R

p1B

dorsiflexed and inverted and

Therapist's forearm is on the shaft of the patient's kneeextension tibia, maintaining duringthe SLR.

Suralnerve> passive techniques

In : HF |DF |I N Di d : KE With the patient'ship in flexion a n d ank lein dor s i fl e x i oa n d n inversion, knee extension can be usedto mobilise the nerve.

p1 9

In: DFIIN Did: nerve massage Massage techniques may be useful here, particularly swelling for a roundt he lat er al c h i l l e s n d o n . A te If appropriate, nerveand its the surrounding tissuescan be massaged with the nervein tension as in the SLS position depicted,

O No r

Suralnerve> self management

ln=HFIDFII.N Did: KE (sli/ten)

p20

the sural The easiest way to self mobilise nerve is to reolicate the passive that the Spendtime ensuring technique. foot is in dorsiflexion and inversion.

a Addingneckflexion(3) provides more movement and neckextension aggressive (4) allowsa lessaggressive and distracted large rangemovement.

Femoral nerve> anatomy and palpation

Palpable areas A M ay be palpab l e ro u g hti s s u ea t th e i n g u i n al i gament th Common entrapments / syndromes Pinchor hyperextension the inguinalligament at L2-3 root syndromes The Sensitive Nervous System Chapt er s and 1 1 8

p21

ONor

Femoral nerve> therapist's assessment

Prone Knee Bend (PKB) The PKBis a crudetest, as many (including femoral structures the nerve)are tested.

p22

Slump Knee Bend (SKB) The SKBallowsa more refined testing than the PKB.Forthe left SKB,the patient'sleft knee shouldbe around 90 degrees. Get the patientto hold her right kneein some,but not full, hip flexionand then extendthe hip. Use neckflexion/extension for structu I differentiation. ra For heavylegs,try performing the SKBwith the test leg downside. Hip lateraland medialrotationcan be addedto test groin nervessuch as the ilioinguinal iliohypogastric and nerves.

! [[l
Femoralnerve > therapist'sassessment
In: Slump SLY/KFIHE Did: HAb Obturator test

p23

To test the obturatornerve,use the Slump Knee Bendposition and then abductthe hip (2). This could be an assessment treatmenttechnioue and for neurogenic components groin and medial to kn eepain. The neck could be usedfor structuraldifferentiation.

Femoral nerve> therapist's assessment

In : S lum p S LY / K F IH E D i d : H Ad Meralgia test

p24

To test the lateralfemoralcutaneous nerve,which may be involvedin the syndromemeralgia paraesthetica, Slump KneeBendpositionis the u s edand t hen t he h i p a d d u c te d . Any of these components could be usedas therapeutic movements and/or if appropriate, structures aroundthe nervessuch as the L2-3 j o int s ,t he inguina l i g a me n a n d th e a n te ri o r i g h t th fa sc iac ouldbe m o b i l i s e d .

e lroi

Femoralnerve > self management

Half Pushup H alfpus hups e w i d e l yu s e di n ar rehabilitation. manoeuvre The mobilises anteriorhip structures all including femoralnerve. the

p25

Half Pushup + neck sli/ten

If the patient lies propped up on her elbows and flexes her he ad a nd th e k nee at t he s am e t im e. t his is a tensioner along the femoral tract even though the lumbar extension may slacken the system a little. ONor

Neckextension and knee flexionwouldcomprise slider. a

Femoralnerve > se lf mana gem ent

'Thomas test exercise'

p26

A n e xa mple of mor e aggr es s iv es elf m obilis at ionfo r t h e femoral nerve complex. In the 'Thomas test exercise', ante rior hip muscl es will m os t lik ely lim it t he hip e x t e n s i o n and kne e flexion . I f t her e is a neur ogenic c om pon e n t , t h e add ition of n eck flex ion m ay inf luenc e r es pons es .

Femoralnerve > self management

'Hur dler s t r et c h'

p27

Another example of more aggressive self mobilisation for the femo ral ne rve c om olex . I n t he ' Hur dler s t r et ch ' position, neck flexion, left knee flexion and right knee extension can be used simultaneously for an aggressive so ft tissu e a nd n eur al m obilis at ion.

ONor

Saphenous nerve > anatomyand palpation

Palpable areas A Infrapatellarbrancheson the head of the tibia B Mainsaphenous nerve betweengracilis and ' sartorius the kneejoint at Common entrapments / syndromes Postarthroscopy medialknee pain May be involved knee medialcollateral in ligamentinjuries The Sensitive Neruous System Chapters and 11 B

p29

ONor

pist'sassessment Saphenouserve> thera n

Prone/ HE/ HAb / KE/ MRI DFI Ev The saphenous test

p30
Alternative position Patientin supine,therapistseated

Hip ex t ens ion and a b d u c ti o n

Kneeextension

Hip lateral rotation

Ankle dorsiflexion eversion

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Saphenous nerye > passivetechnique
In: Prone/HE/HAblMR/DFlEV Did: KE In the saphenous test position, knee extension a usefulway to is mo bilis ehe ner v ec o m p l e x . a s s a g te c h n i q u e ( 3) coul dal sobe useo. t M e s

p3 1

S aphenous rve> se lf man agem ent ne

The saphenous stretch

p32

The patient stands with feet apart. To mobilise the left saph en ou s ne rve , p lac e r ight leg in front of the left. The left foot is in dorsiflexion and e ve rsro n.

By flexingthe right knee th e l e ft s a p h e n o us nervei s s e l fm o b i l i s e d .

Mediannerve > anatomyand palpation

P alp ab le are as A Up pe r arm B Me dia l to the bic eps t endon C Ind irectly at th e c ar pal t unnel

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Common entrapments / syndromes Car pal unnels v n d ro me t PostColles' fracturesymptoms C5-6 nerve root The Sensitive Nervous System Chapt er s , 12 an d 1 5 B

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Mediannerve > active quick test

This active quick test is an example of structural differentiation. If there are symptoms on shoulder elevation that are made worse by either neck lateral flexion away from the test side and/or wrist extension, then the clinical inference is that those symptoms are from a neurogenic source, perhaps the median nerve and/or its roots. If the therapist stabilisesthe shoulder, more refined testing is possible.

p34

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assessment Mediannerve > therapist's

U LNT1 (Se e sta ge by s t age des c r ipt ion on nex t p a g e )

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Median nerve> therapist's assessment

ULNT 1 1. Startingposition. Note patient's thumb plus some of and fingertips supported, the weight of the arm taken on the therapist's thigh. 2 . S houlder abducti o n s y m p to mo n s e t/o r to tissuetightness, approximately or 100 oegrees. 3. Wristextension. Makesure the shoulder positionis kept stable. 4 . W r is ts upinat io na g a i nm a k i n gs u reth a t , the shoulderpositionis kept stable. 5. Shoulder lateralrotation,to symptom onsetor wherethe tissuestighten a little. 6. Elbowextension symptomonset. to 7. Necklateralflexionaway,makingsure it is wholenec ka n d n o t j u s t th e u p p e r cervical spine. B. Necklateralflexiontowards.This should easeevokedsymptoms. position The alternative shownusesthe theraoist's shoulderratherthan their fist. Fromthe stafting positionshown,the entire test can be performed. It is a comfortable position and very supportive for anxiouspatients.It is also a usefulway to provide passive movementtechniques patients. to ULNTI Alternative position

p36

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Mediannerve > therapist's assessment
ULNT1 Reversed This reversal of the ULNTl is an example of using the order of movement principles. Such a technique may be appropriate for a median nerve based problem such as carpal tunnel syndrome.

p37

Stafting position

Wrist extension

W ri stsupi nati on

Elbow extension, hold wrist position securely

Wholearm lateralrotation

Bloc k t he s houlder g i r d l e from elevatino

Careful shoulder abduction u s i n g t h e t h e r a p i s t 's t h i g h

Add cervical flexion or lateral flexion

Median nerve> therapist's assessment

ULNT1 Reversed: index finger first The reversed ULNT1 can also be performed startingwith one digit and by th e n addingt he ot h e r c o m p o n e n ts . c h Su a n as s es s m ent tre a tm e n t c h n i o u e and te may be appropriate a patientwith a for p e r s is t ent digit aln e rv ep ro b l e m .

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pist'sas s es s m ent Median nerve > the ra

ULNT 2

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P a tie nt h as he r sho ulder gir dle just over the side o f t he bed

(via girdledepression the Shoulder therapist's thigh) to symptoms or wherethe tissues tightena little

Elbowextension

Whole arm lateral rotation, keep ing sho uld er g ir dle depr es s ed @r.ror

W ri s ta n d fi ngerextensi on (note suggested grip in the inset)

Structu differentiation ral can be preformed by elevating shoulder the girdlea little,or if there are shoul der/neck symptoms, the wrist flexioncan be released.

Median nerve> therapist's assessment

ULNT2 Seated position The ULNT2 can be performed with the therapist sitting.Manypatients preferthis as and therapists the arm can be very well supported and it is easier to see the patient'sface. In image2, structural differentiation performed is via wrist flexionto differentiate originof the sh oulder eas y m p to ms . ar

p40

techniques Mediannerve > passive

Here are two examples of the slide r a nd ten sio ne r m ov em ent s for the me dia n n er v e.

p47

U LNT2 Sli/ten In the seated position, if the wrist is fle xe d an d the s houlder gir dle dep resse d,a s in the im age, t his com p rise s a slid er m ov em ent .

ULNTl Sli/ten Whe n th ere is ne ur ogenic pr oblem , during the ULNTl test, the patient's shoulder girdle will often protract, thus avoiding some of the tension on the nervous svstem. At the moment of protraction, if wrist flexion is add ed , th en a slid er will be performed. This allows a gentle mob ilisa tionas well as a way of unlearning unuseful motor patterns.

Median nerve> passive techniques

'Nanna arm wobble'

p42

'Nannaarms' are the floppy bits many peopleget u n dert heir uppera rm , e s p e c i a l la s w e g e t a b i t y older.The aim of this passive technique to make is the arm 'flop'.If the patientis relaxed,whilethe wrist goes into flexionthe shoulder adducts.

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Mediannerve > passive techniques
In: ULNT1 Did: GH mobilisation

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p43

This is an exampleof performing a j o int m obilis at ion h i l eth e n e rv ei s w in some tension.Theremay be a stiff joint accessory movementwhich can be mobilised while the nerve is i n s om et ens ion. u c ha p a ti e n t S wouldhav ejoint a n d n e u ra lti s s u e physical healthissues.

T e c h n i o ue more shoul der in a b d u c ti on.

Note how further tensionis olaced on the nerve,by askingthe patient to extendher wrist.

Median nerve> self ma na qem ent gent lerm ov em ent s >

T his serie s of g en tle s elf m obilis at ion tec hn iqu es uses fu nc t ional and f un mo ve men ts an d met aphor s . ' Balloon patting', 'watch the watch' (place watch on ventral side of wrist) and using a yoyo en co ura ge th e s upinat ion and elbo w exten sio n pa r t s of t he ULNTl. A t te mpts at jug glin g pr ov ide a s im ilar nerve mob ilisa tion .

p44

Balloon patting

'Watch the watch'

Yoyo

J ugg l i n g
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Mediannerve > gentler movements

' N o more d ish es'and t he ball t hr owing prog ressio nare mor e aggr es s iv e mo bilisers, bu t still f unc t ional and f un. Ball throwing can be progressed from unde rha nd to over hand t hr owing.

p45

'No more dishes' (after Barb Beatty)

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Ball throwing Progression

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Median nerve> stronger movements

W ith imag ina tion , k nowledge of neur oanat om y ,an d use of metaphors, a series of functional mobilisation techniques for the median nerve can be constructed. Get the patient to'buzz'during 'busy bee', note that the finger and wrist stretches are quite vigorous for neu ral tissue in the hand and wr is t . C r a wling is a stro ng f unc t ional m edian ner v e m ob i l i s e r and n ote ho w ba lanc ing c r eat es lar ge r ange s lider moveme nts simila r t o a ULNT2 f or t he m edian ner v e . F o r'free the b ird'g et t he pat ient t o im agine t hey a r e hold ing a sma ll bir d and t hen t o let it go. Now wh e r e i s that frisbee? 'Finger stretch'

p46

'Busy bee'

Wrist stretch

Mediannerve > strongermovements

' S awa tdika' Crawling

p47

'Zorro'

Balancing acts

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Mediannerve > stronger movements

L o o k a t y our hands

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Wall stretch

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Ulnarnerve> activequ ickt es t

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A sk the pati entto put her handon her ear and th en, keepi ng handon the the ear, lift the elbowup. For most patientswith ulnar nerveor root based probl ems s movem ent , thi or part of the movement, w i l l be sensi ti ven the i ul nardi stri buti on.

ass U lnarnerve> the rap ist's es s m ent

ULNT3 From wrist first

p51

Starting position - the oatient's elbow rests on the therap ist's h ip

Wrist and finger extension, P r o n a t i o n ensure4th and 5th fingers are extended

lateralrotation, Shoulder wrist positionis ensuring mai ntai ned

Elbow flexion

Bl o c ks h o u l d e g i rdl e r fist elevation pushing into by th e b e d

Shouldergirdle depression if required

S h o u l d e r a b d u c t i o n ; n e ck lateral flexions can be added if reouired

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Ulnarnerve> therapist's assessment

ULNT3 From shoulder first

p52

Startingposition. With hand under patient's scapula g d epr es s houlder i rd l e s

S h o u l d ea b d u c ti o n r

Lateralrotationof shoulder

W ri s ta n d fi n g e re x t ensi on

pronation Forearm

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Ulnar nerve > passive techniques
In: ULNT3 Did: massage cubital tunnel Theseare examples massage of te c hniques neura l o a dp o s i ti o n s . in Note how the ulnar nerve in the cubital tu n nelis m as s ag e d o re a g g re s s i v e l y m (1 wi th t he wr is t in e x te n s i o n ) a n d th e n more gentlywith the wrist in flexion(2). The massage and the wrist movements couldbe c om bine d .

p53

In: ULNT3 Did: pisiform mobilisation The pis if or m obi l i s a ti oin u l n a rn e rv e m n load is an aggressive technique. may be It relevantfor a patientwith persistent little finger problems after a wrist injury.

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U lnarnerv e> pa ssive techn iques

In: ULNT3 Did : S li/ t en

p54

In 1, a t ens ioner p e rfo rme d s th e is a gir sh oulder dleis d e p re s s e w h i l e d th e ulnarner v eis l o a d e d .

The patientt neck is extendedas the maki ng s h o u l d e g i rdl ei s depressed, r a s l i d e rte chni que.

Wi t h n e c k f l e x i o n , t h i s i s a m o r e a g g r e s s i v et e n s i o n e r t e c h n i q u e .

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Ulnar nerve > self management> gentler movements
' D on 't liste n' ' Fac e m as s a g e s ' 'M a k e a h a l o '
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'Smoking' T h e s e a r e e x a m p l e s o f g e n t l e f u n c t i o na l movement for the ulnar nerve and its brain representations.The metaphors orovide a distraction. Be creative.

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Ulnarnerve> self ma na ge m ent stronger > movements

'Plate exercise,

p56

Ask your patientto imaginethey have a glassof wine on the plate and then do the exercise shownin the images. as

ulnar nerye> serfmanagement stronger > movements

some examples stronqer of -nobilisation exercises tfre fol utnarnerve. 'Sunglasses,

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p57

'Crawl to the pits'

Radial nerve > anatomyand palpation

Palpable areas A Mid humerus B Radialsensorynerve on the lateral aspectof the forearm Common entrapments / syndromes De Quervain's tenosynovitis Supinator muscle(tenniselbow) Post humeralfracture pain C5-6 root syndromes

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Radialnerve > activequick test

p60

Ask th e p atie nt to let t heir ar m hang by t heir s id e , t h e n make a fist ho ldi ng t heir t hum b, t hen ex t end t he e l b o w ' then point the thumb away from the body (internal rotation) a n d de pre ss th e shoulder .A f ew degr ees of s hou l d e r extension may sensitise the test, Elevation of the shoulder girdle provides an easy way to structurally differentiate.

Radialnerve > therapist's assessment

U LNT2 (rad ial)

p61

T h e pa tien t lie s wi t h t heir s houlder just over the side of the bed, the t hera pist uses h is t high t o c ar ef ully dep ress th e sh ou lder gir dle

Elbowextension

Notice how the therapist has brought h i s l e f t a r m 'a r o u n d ' t o g r a s p t h e patient's wrist in order to medially rotate the whole arm

W ho le arm med ial ( int er nal) r ot at ion

W ri s ta n d thumb fl exi oncan be added.Leavethe fingersout as the will be too tight extensors

A d d i n g a f e w d e g r e e s o f s h o u l d er a b d u c t i o n w i l l s e n s i t i s et h e t e s t a n d elevationof shoulder girdle will provide structural differentiation

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Radial nerve> therapist's assessment

ULNT2 (radial) Seated variation preferto assess the Sometherapists radialnerve in sitting,particularly if th e pat ientis anx i o u s n d s e n s i ti v e . a The oatient's arm can be well cradled and suppofted. This is also a good position performpassive to techniques. 1 . T he ar m is wel l s u p p o rte d in the startingposition gir 2 . S houlder dled e p re s s i o n 3 . W holear m m ed i a lro ta ti o n 4. Wristflexion

p62

assessment Radialnerve > therapist's

ULNT2 (radial) From wrist first problems the on for This may be appropriate persistent wrist. Usingorder of movement lateralaspectof the (1), p rinc iples , is t an d fi n g e rfl e x i o np l u su l n a rd e v i ati on wr (2), arm medialrotation(3) loads then elbowextension the radialnervefrom the wrist first.

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techniques nerve> passive Radial

for there are plentyof opportunities In the seatedposition If gentlepassive techniques. you get the patientto point girdle, the shoulder to their nosewhile you gently depress this forms a gentleslider.Be creative.
'Gentle radial sliding'

p64

'Whole arm rotations'

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Radialnerve > passivetechniques
In: ULNT2 (radial) Did: Rad head and soft tissue mobilisation Once the ULNT2 radial nerve position is maintained, a variety of t e c h n i o u e s a r e a v a i l a b l e ,T h e r adi a l h e a d c o u l d b e m o b i l i s e d o r soft tissue stretches performed. Some of these may be useful for tennis elbow which has strong local tissue components.

p65

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Radialnerve > self management> gentler movements

'Pouring water' 'Figures of eight'

' P ou ring wa ter' an d big s winging ' f igur es of eight , are g en tle wa ys to m obilis e t he r adial ner v e and it s repre se nta tion sin t he br ain. M ak e s ur e wit h t he swin gin g techn iqu e t hat t he s houlder int er nallv an o then e xte rna lly rotat es .

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' P ump w ater' P umpi ng ater al l ow s w the non-pai nful arm to hel p gui demobi l i sati on the of pai nful /i nj ured arm. The startingposition encourages internalrotation.

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p67

Radialnerve > self management> gentler movements

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Look at your hand behind your elbow If the patient attempts to see their hand behind their elbow and to see their fingers and their thumb, this providesa vigorous sliding self m o b i l i s a t i o n .T r y i t b i l a t e r a l l y- i t 's a l m o st a dance move.

> movements Radial nerve> self ma na ge m ent stronger

yet self Theseare examples strongeri functional of In movements. the table stretch,the patient mobilisation keepsthe backof their hand flat on the table and then rotatestheir wholebody away. 'Back massage' 'Tip please' 'Table stretch'

p6B

Musculocutaneous nerve> anatomyand palpation

Palpable areas Difficult palpate to Common entrapments/ syndromes De Quervain's tenosynovitis Tennis elbow' abo v e ' th ee l b o w Postintravenous drip pain syndromes The Sensitive Neruous System Chapter12

p69

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nerve> activequicktest Musculocutaneous

p70

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Make a fist, ulnar deviate the wrist, extend the elb ow an d exten d t he s houlder as t hough m ar c hi n g .

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Musculocu tan eo usrve> th er apis t 'as s es s m ent ne s
ULNT ( m us c uloc u ta n e o u s )T h i sposition can also be used for passive mobilisation.
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Starting position (same as the ULNT2 test for the radial nerve)

S h o u l d e g i r dl edepressi on r

E l bowextensi on

Sh oulder t ens io n ar ef ully ex c

W r is t ulnar de v i a t i o na n d t h u m b f l e x i o n . Either medial or lateral rotation could sensitisethe nerve further.

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Muscu locuta neousne rve> self m anagem ent

Running on t he s p o t

p72

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'Throw it away'

Spine,cord and meninges> anatomY

T h e spin al a nd cr anial m eninges ( dur a, pia and a r a c h n o i d mate r) su rrou nd t he s pinal c or d and f or m a c onti n u o u s structure allowing force transmission from the peripheral to the central nervous system and vice versa. The spinal ca na l is be twee n 7- 11 c ent im et r es longer in f lex i o n t h a n in e xte nsion , thu s t he m eninges and s pinal c or d w i l l b e physicallych alle ngedin pos it ions s uc h as s it t ing, f o r w a r d ben din g an d e sp ec iallyt he Slum p t es t s dem ons t r a t e d i n this se ctio n. The Sensitive Nervous System Cha pte rs 5, 1 1 a nd 15

p73

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> cordan d men ing es ac t iv equic kt es t S pine,

In sp ina l flexion th e m eninges and s pinal c or d wil l b e p h y s i c a l l yc h a l l e n g e d .I f l o w back symptoms evoked by spinal flexion are made worse by the addition of neck flexion this infers that there is a physical health problem of the nervous system. Neck extension should relieve symptoms,

p74

assessment Spine,cord and meninges> therapist's

Passive Neck Flexion (PNF) PNF can be performed in two ways. Upper cervical flexion (2), places load on the cervical and cranial meninges and if this is combined with lower cervical flexion (3), a considerable load is placed right through the entire neuromeningeal system. PNF will frequently reproduce back pain, suggesting nervous system involvement is a frequent component of back disorders'

p75

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> s Spine, corda nd me nin ge s t her apis t 'as s es s m ent

Straight Leg Raise (SLR) Sensitising movements The nervous system sensitising movements which are fre q ue ntly u se d for lower lim b dis or der s c an als o b e u s e d for the n eu rome ni ngealt is s ues .

p76

Hip adduction (2), hip medial rotation (3), spinal lateral flexion (4) and upper cervicalflexion (5) are shown. These movements may be required to identify minor disorders of the nervous svstem and any of these movements c o u l d b e u s e d t o m o b i l i s et h e nervous system.

Spine,cord and meninges> therapist's assessment

B ila tera l SLR

p77

Bilateral Straight Leg Raise (BSLR) techniques are useful and can be easily converted into self mobilisation techniques. BSLR provide s a d iffere nt biom ec hanic alc hallenget o ne u r o m e n i n g e a l tissu es tha n a sin gle SLR. I n t he ex am ple s hown, a n k l e dorsiflexionis used as a t ec hnique. The technique may be appropriate in patients with positive S lu mp L on g Sit test s . O f c our s e, nec k and s houlde r g i r d l e moveme nts co uld a ls o be int r oduc ed as par t of t en s i o n e r a n d slide r techn iqu es. B e c r eat iv e.

O No r

> s S pine, cordan d me nin ge s t her apis t 'as s es s m ent

Slump test active It is best to performtests activelyfirst so the therapistand patientthen know what to expect. C hec k y m pt om s n d s a sym pt omc hange t a
Ed Lr r > LqgE.

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1. Startin g po sitio n, k nees tog eth er a nd thighs well supported 2. Spin al slu mp, ens ur ing patient doesn't forward tilt h er pe lvis 3. Neck fle xio n 4. Knee extension 5. Re lea sene ck fle x ion. The knee can usually be extended further and the ankle dorsiflexed. 6. Bilateral knee extension

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Spine,cord and meninges> therapist's assessment

Slump test passive 1 . S pinals lum p,m a k i n g
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forwa rd tilt he r pelv is 2. Neck flexion wit h gent le overpressure 3. Knee extension 4. Add dorsiflexion if required 5. Releaseneck flexion. The neck is extended in stages checking the response to evoked leg an d b ack symptom s 6. Bilateral knee extension if req uire d

O No r

> assessment S pine, da nd meninges therapist's cor

Slump Long Sit (SLS) This test positionprovides a very stableassessment olatformfor neural p ro blem s t he s p i n ea n d in h e ad. to Remember checkfor symptomsat eachstage of the test. The test will needto be o a d apt ed dependin g n th e patient.For those who are tight, pillowsunderthe kneesmay be required and more hip flexionmay for be necessary those who are more flexible.

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the Startingposition, useshis kneeto therapist the stabilise sacrum

Thorax and lumbar spine slump

Neck flexion

Extend left knee

Release neckflexionto orovidestructural differentiation any lower body evokedsymptoms. of further Note how the anklecan be dorsiflexed

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Spine,cord and meninges> passive techniques
Slump Long Sit / Structural differentiation Duringthe SLStest, a more refinedstructural can differentiation be performed.

p 81

The pat ientis in a S L S p os it ion. his c oul db e T adaptedas necessary, for e xam plepillows d e rth e un kn eesor m or e s pi n a l fl e x ion.

The therapiststabilises the Lateral flexion of the entire sDineat the cervicothoracic cervical spine has been j u n c ti o n . performed allowing a test of
the physical health of upper thoracic neural structures. This will frequently produce relevant thoracic and lumbar symptoms on the convex side.

Structu d ifferentiation ral can be performedby fl exi nothe knee.

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> t S pine, da nd men ing es pas s iv eec hniques cor

In: leg distraction Did: neck sli/ten This is an example of a very gentle challenge to the spinal canal and its contained structures. First, gentle leg distraction is performed rhythmically. If the patlent puts her head back at the same time this is a slider technique. The technique can be progressedby performing the same distraction in SLR.

p8 2

Spine,cord and meninges> passive techniques

In : SLS Did : Th x Lat er al f lex ion t ec hniques

p83

On th is a nd th e following page ar e ex am ples of s o m e vigorous passive techniques for the thorax. Note the late ral flexion te ch niques abov e, inc luding t he t hir d i m a g e where lateral flexion is localisedto a specific and relevant level. Thoracic lateral flexion can be achieved by the therapist's body. If the patient extended her knee at the sa me time as th e lat er al f lex ion was applied, t his w o u l d be a ten sio ne r.

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t > cordan d me nin ge s pas s iv eec hniques S pine,

In: SLS Did: A/P movements

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movementcan be appliedin An anteroDosterior left the Slump LongSit. The therapist's carpal a tu n nelis jus t unde rth e l e v e lto b e m o b i l i s e d n d sternum,softened right hand in on the patient's his by a towel or pillow.This may be usefulfor a flat upperthoracicspinerelevantto a particular thoracicsoinedisorder.

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techniques Spine,cord and meninges> passive
Notalgia paraesthetica techniques

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of for technique entrapment of This is an example a refined primary of branches the thoracicposterior the cutaneous rami. The syndromeis callednotalgiaparaesthetica' wherethese may be palpated Tenderspots,even nodules, and fasciato becomecutaneous. nervesexit the muscles Thesewill be more tender in the SlumpLongSit position, the Frequently nervewill lessso if the neck is extended. laterally alongthe lateral be more reactiveif massaged This may be an appropriate branch,ratherthan medially. for technique some patients.

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> t Spine, da nd men ing es pas s iv eec hniques cor

Wedges can be a useful adjunct to passive and self mobilisation. In the e xa mple sh own, t he wedge is being us ed to f a c i l i t a t e a thoracic (predetermined level) mobilisation. The spinous processes lie in the gro ove of t he wedge and t he m obilis at i o n i s g e n t l y perfo rmed u sin g t he r ibs . A t owel or s m all pillow f o r p a d d i n g makes it more comfortable. Becausethis allows a superior joint mob ilisa tion it can als o be us ed t o m obilis e as s o c i a t e dn e u r a l tis su e, fo r e xa mple, if t he s am e t ec hnique was pe r f o r m e d i n Straight Leg Raise or Bilateral Straight Leg Raise.

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Wedge mobilisation techniques / Thorax spine

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assessment and meninges> therapist's Spine,cor-d
Wedge mobilisation techniques / Cervico thoracic area Wedge techniques can be useful for the cervico-thoracicarea. The force is th rou gh the clavic lesnot t he jaw, and t he t her a p i s t 's l e f t h a n d i s o n l y assessingthe intervertebral movement while cradling the patient's head.

p87

More tension can be placedon the nervous system during the mobilisation by adding an Upper Limb Neurodynamic Test (3 and 4) or Straight Leg Raise (5).

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Spine,cord and meninges> s elf m anagem ent

gent ler ec hniques t

Pelvic tilt/neck Sli/ten (1 Exam ples gent les l i d e rs ) of ( a n d t ens ioner s2) fo r th e me ninges and s pin a lc o rd .

PBB

SLR/neck Sli/ten

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Spine,cord and meninges> self nnanagennent > strongertechniques
' W ring ' te ch niq ue T his te ch niq ue is n am ed af t er t he ac t lon of wr ingin g o u t a w e t t o w e l . Wi t h t h e k n e e s f l e x e d a n d r o l l i n g f r o m s i d e to side (2), a g en tle w r inging ef f ec t is plac ed on t he s p i n a l c o r d . I f t h e p a t i e n t t u r n s t h e i r n e c k a w a y a t t h e s a m e t i me (3) , a more ag gre s s iv ewr inging is pr ov ided, and i f t h e c h i n i s t u c k e d i n ( 4 ) , e v e n m o r e l o a d c a n b e a p p l i e d . B y u si n g the arms an d de pr es s ingt he s houlder gir dle ( 5) , e v e n m o r e l o a d c a n b e p l a c e d o n t h e n e r v o u s s y s t e m .

Oror

:89

> Spine,cord an d men ing es s elf m anagem ent techniques stronger

SLS / Shoulder shrug

for The SLSposition offersa safe and supported startingposition self mobilisation. In the images, slideris beingperformed. the patientextendsher knee,she shrugs As a there her shoulders. This may be a usefulsliderwhenthe neckis sore.In this position if and tensioners. example, the kneeis extended For are many combinations sliders of a this creates slidermovement. at the sametime as the neckis extended,

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Spine,cord and meninges> self management > strongertechnlques
'Kick your head off' Theseare stronger sliders and tensioners the for l o w erlim b and m e n i n g e s . They can be adaptedto focus more on the peroneal tibial nerves. or This not only m ob i l i s e s neuraltissuesbut movementin a orovides noveland safeway.

p 91

Spine,cord and meninges> self management > strongertechniques

' W all wa lkin g' Images 4, 5 and 6: Notice how the patient moves closer to the wall to achieve more Straight Leg Raise.

p92

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Spine,cord and meninges> self management strongertechniques

'Total slump' B ob Jo hn so n technique T wo vig oro us mo bi lis at ions are sh own he re. No tice ho w th e standing total slu mp uses o r der of moveme nt prin cip lest o loa d ce rvical an d c r anial men ing es first.

n Q?

'Roll over' I n the ro ll over po s it ion for the appropriate pa tien t an d p rob lem , fur the r mob ilisa tionc an be performed by leg move men ts.

ONor

nerve(cranialnerveXI) Other nerves> Accessory

1. The pati entl i esi n si del yi ng 2. Lateral flexionand protraction the neck of 3. Retraction the shoulder of girdle,makingsure there is enoughsl acki n the ski n 4. Uppercervical flexionwill add more load

p94

I E.E E E E E E E E E E E E ET E E E E E ET E
Other nerves > Axillary nerve
A neurodynamictest can be placed on any nerve, simply by observingwhere the nerve is in relationto joint axes of movement.A test for the axillary nerve will be a combinationof neck lateralflexion, shouldergirdle depression and intemal rotation. Any of these movementscould be used for mobilisation. The axillary nerve may be injured post shoulderdislocation.

p95

ONor

Othernerves> Suprascapular nerve

The s upr as c apul a r rv ei s c h a l l e n g e id a c o m b i nati on ne n o f nec klat er al lex i o na n d s h o u l d e g i rd l ed e p re ssi on. f r A forcedown the humeralshaft takesthe nervefurther from its roots and finallythe scapula can be rotatedas a m obilis at ion t ech n i o u e .

p96

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nerve Other nerves > Tnfrgemlnal p97
TrlEerninalnei-ve

flexion Uppercervical

Upper cervical lateral flexion

Total cervical flexion

Open mouth and move jaw to the right

ONor

nerve Other nerves > Occipital

T h e gre ate r an d les s er oc c ipit al ner v es c an be c ha l l e n g e d in up pe r ce rvical flex ion and lat er al f lex ion of t he n e c k away from the side to be tested.

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