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NEURAL MOBILIZATION

OBJECTIVES
Nerve anatomy and physiology
Clinical biomechanics of nerve
Pathomechanics(pathophysiological and
pathomechanical)
Principles of neural mobilization
Demo
Evidence on all NTT

Introduction
Concept of continuous tissue tract
1. Both CNS and PNS need to be considered as one s
ince they form a continuous tissue tract
2. This system is continuous in three ways
. The connective tissue is continuous although diffe
rent in format (epineurium , duramater). A single a
xon is associated with number of connective tissu
es.
. Neurones are interconnected both electrically and
chemically.

Introduction cont
The Nervous system
Includes all the neural tissue in the body
Neural tissue
Neurons
-- cells that send and receive signals
Neuroglia (glial cells)
-- cells that support and protect neurons

Central Nervous System


Nerve roots are considered to be more a part of ce
ntral than peripheral nervous system which include
meninges , lack schwann cells & receive nutrition fr
om CSF.
The connective tissue of the nerve trunks are very d
iff from those of the roots even though the same ax
on is present in the ventral roots.
Many authors have drawn attention to the fact that
the connective tissue coverings in nerve roots are
much weaker, or not present at all(Murphy 1977).

CNS cont.
Gamble(1964) conducted an electron microscopy st
udy & found the connective tissue of the nerve root
s were more like leptomeninges(arachnoid &Piamat
ter) than that of peripheral trunk.
Watanabe (1985) using an electron microscope fou
nd that each rootlet has a pial layer and it resemble
d a wispy sheet of gauge.
There are a no. features at the nerve root level for t
ransmission

CNS cont..
The fourth, fifth, sixth cervical spinal nerves has a st
rong attachment to the gutter of respective transve
rse process.
At segmental level dural & epidural tissues form a
connective tissue sheath which include epidural sh
eath(Dommisse & Hause et al ).
Beyond the dorsal root ganglion this sheat
h forms the epineurium & perineurium. These attac
hments are not immediate as there is no mechanic
al equivalent to perineurium in nerve rots.

CNS cont
The epidural tissues and the dura combine to fo
rm epineuriuma and the outer layer of perineurium
where as the endoneurium is the continuation of th
e pia(Sunderland 1974, Hanse et al 1985)
The dural sleeve forms a plugging mechanism whic
h helps in preventing the nerve root being pulled a
way from foramina but also distributes force.
Nerve roots have their own inbuilt mechanism for n
utrition and protection. CSF does both the activities
(Rydevik et al).

The Neuraxis
The neuraxis (spinal cord ) is the continuation of m
edulla oblangata and extends app to L2 vertebral le
vel and it tapers to form conus medullaris.
Breig(1978) notes two methods of neuraxial adapta
tion to stretch
Unfolding and untwisting as axons straighten
Movements in relation to neighbouring vertebral se
gments.

The Meninges
o Pia & Arachnoid mater :
These are very delicate membranes far more than d
uramater. A mesh or lattice of collagen fibres make
up the pia and arachnoid maters.
This allows stretch & some compression without ki
nking (Breig 1978) and they protect the neural elem
ents and allowing the movements at the same time.
o CSF, Sub arachnoid &Subdural spaces :
The subarachnoid space contain CSF .

It acts as a hydraulic cushion surrounding the cord


and nerve roots.
o Dura mater
Outermost layer meningeal layer & by far the tough
est and the strongest which contains collagen and s
ome elastin fibres arranged longitudinally (Tinturi).
This gives the dural theca greater axial strength (Ha
upt &Stofft ).

Neurodynamics
Definition : Clinical neurodynamics is essentially th
e clinical application of mechanics and physiology o
f the nervous system as they relate to each other a
nd are integrated with musculoskeletal system.
General layout of the system :
Mechanical interface : It is defined as that tissue or
material adjacent to the nervous system that can m
ove independently to the system.

Neural structures
Innervated tissues
The first is that they provide the basis for some c
ausal mechanisms that therapists should pay partic
ular attention.
The second reason is for making specific refere
nce to the innervated tissues is that they provide th
e therapists with the opportunity to move nerves.
The third reason is for the treatment basis(Laba
n et al 1989).

Mechanical functions
Tension :
The first primary mechanical events in the nervou
s system is generation of tension.
Since the nervous system is attached to each end
of the neural container the nerves are lengthened b
y elongation.
Perineurium : This is the primary guardian against exc
essive tension and is effectively cabling in the perip
heral nerve(Sunderland 1991).

Dense packed connective tissue and forming each f


ascicle this possess considerable longitudinal and el
asticity.
It allows peripheral nerve to withstand approx. 18-2
2 % strain before failure(Sunderland 1991).
Sliding of nerves : The second event is movement of n
ervous system relative to their adjacent tissues.This
is called excursion or sliding(Wilgis &Murphy 1986).
It is of longitudinal and transverse .

Longitudinal sliding :The sliding of nerves down the


tension gradient enables them to lend their tissue t
oward the part at which elongation is initiated.
This way tension is distributed along the nervous sy
stem.
For eg. Median nerve at elbow

Transverse sliding: It occurs in two ways


The first is to enable the nerve to take the sh
ortest course between two points when tension is a
pplied.
The second means by side way pressure by
neighbouring structures such as muscle and tendo
ns.
Sliding of peripheral nerve in the nerve bed
is provided by mesoneurium and internal sliding of
the fascicles.

Compression : Neural structures can change their s


hape when pressure is exerted on them.
A clinical example ulnar nerve in elbow flexion .
The epineurium is the padding of the nerve and it p
rotects the axons from excessive compression.
It contains finer and less densely packed connectiv
e which gives them spongy qualities and enables th
e nerve to spring back when pressure is removed.

How nerves move


Movement of joints :
Convergence The nerves move in the direction of the j
oint because that is where elongation is initiated. The
effects of the two ends produce little or no movemen
t of the nerves relative to joint roughly at the midpoi
nt.
convergence ocurs in limbs (Smith&Swa
sh 1976) and spine at most mobile segments(C5-6,C
4-5) during sagittal movements(Adams&Logue1982).

Nerve bending:
The bending of the nerural structure aro
und the interface is a good example of the combini
ng of fundamental events to produce a more compl
ex action.
Ex: Ulnar nerve at elbow

Movement of innervated tissues:


In addition to longitudinal forces being applie
d to the nervous system from the adjacent to the n
erve, the innervated tissues can be used to produce
such events.
For instance Dorsiflexion of foot and toes used to app
ly tension on sciatic nerve.

Movement of interface

Nervous system responses to movement.

Physiological evenets
Intraneural blood flow:
Blood flow of the peripheral nerves is a
ctually maintained by nerves(nervi vasa nervorum)
(Bove&Light 1995).
Nocioceptors and sympathetic fibres ar
e relevant because in addition to potentially causin
g pain they release substance P and calcium gene r
elated peptide from their terminals into the walls of
the blood vessels(Zochodne & Ho 1991).

Maintanence of blood flow during movem


ent:
During normal movement, nerve blo
od flow is preserved through an intricate system of
vessels that distort the nerve.
At rest, vessels are coiled and during
movement they become uncoiled rather than stretc
hed(Sunderland & Lundborg 1998).

Neurodynamic sliders

Neurodynamic tensioners

Spine
Mechanical interface
Neural
Innervated tissue

Flexion and extension


Mechanical interface- Spinal canal
Flexion of the whole spine causes elongation of th
e spinal neural structures because they, and their canal are
located behind the axis of rotation of the spinal segments.
Neural tissues
Tension and strain are the two responses for flexi
on. The amount of tension is not clearly known but strain fr
om lumbar extension to flexion in lumbar dura can reach 3
0%, sacral nerve roots 16%(Adams&Logue; Yuan et al 1988)
.

Sliding and convergence


Sliding of neural structures is complex in
spine and specific sequences of movements their o
wn sliding.
for eg. Neck flexion produces cephalad sl
iding of neural structures in lumbar region(Breig 19
78). However SLR produces caudad sliding of the ne
rve roots in the lumbasacral foraminae(Goddard &
Reid; Breig 1978).

Lateral flexion and lateral glide


Mechanical interface
The key event with lateral flexion in relatio
n to mechanical interface is that the intervertebral f
oraminae close down ipsilateral side and open on t
he contralateral side(Fujiwara et al 2001).
Neural effects
Lateral flexion produces increased tensio
n in the neural structures on the convex side of the
spine and reduce tension on the concave side(Selva
ratnam et al 1988).

Increase in tension occurs in two ways :


The first is that lateral flexion itself prod
uces elongation of the interface and neural tissues
on the convex side.
The second is by causing an increase in
distance between the spine and the periphery by si
deway translation of the vertebrae(Louis 1981).
Uses :
1. Structural differentiation.
2. Sensitization.

Others
Contralateral neurodynamics.
Bilateral neurodynamic techniques.

General Neuropathodynamics
Mechanical interface dysfunctions

Mechanical interface dysfunctio


ns
Closing dysfunctions

Pathoanatomical

Closing dysfunctions
Reduced closing
Symptoms :
Key behavioural aspect is symptoms increase with closing
movements.
Physical findings:
1. Posture :
In acute and severe dysfunctions a protective deformity i
s frequently apparent. This deformity is always in the openin
g direction so as to reduce pressure on the adjacent neural st
ructure

Excessive closing
Symptoms :
Provoked by closing mechanism.
Hypermobility, instability or habitual closing exist.
Eg. Hyperlordotic lumbar spine.
History :
Habitual posture or posture imperfection is common.
Sometimes a history of trauma and features of instability als
o
instability

Opening dysfunctions
Reduced opening
Symptoms :
Usually aches and pains in the localized area with or without ref
erred pain.
Opening movements provoke pain and are usually restricted.
History :
Usually history of trauma exists in which patient has been force
d into opening positions.
The body then compensated during healing process to produce
inflammation and muscular bracing such that opening moveme
nts are reduced to avoid further provocation.
Eg. Spine

Physical findings:
The reduced opening dysfunction produce a protective
deformity on the ipsilateral side unlike closing type has on co
ntralateral side.
This deformity is specially designed to reduce tension i
n the interfacing and neural tissues.
Palpation :
Tenderness, muscle tightness and thickening.
Eg. L4-S1 segments may be accompanied by tenderness an
d tightness of ipsilateral erector spinae as they limit contralat
eral flexion.

Excessive opening
Symptoms :
Aches and pains and can produce referred pain.
Pins and needles ,numbness can occur in this dysfuction.
Symptoms are intermittent and they are produces when prov
oking movements are done .
Physical findings
No deformity occurs in this type.
Opening movements are increased and that leads to this diso
rder.
Ex. Cervical region contralateral flexion and rotation.

Palpation :
Tenderness over specific sites is often presen
t.
Hypermobilty produces mechanical irritatio
n of the relevant structures.

Neural dysfunctions

Neurodynamis tests
What to observe changes in movement, movemen
t diagram.
Planning the examination.
Levels.

Level 0 neurodynamic testing contraindicated.


Any contraindication for manual therapy generally exis
ts for neurodynamic testing.
Level 1 limited examination
Indications :
1.When symptoms are easily provoked and takes long time to s
ettle after movement.
2. In cases of severe pain.
3. Presence of any neurological deficit.
4.When problems shows a progressive worsening after physical
examinantion

Level 2- Standard examination


Indications and contraindications:
The problem is not especially easily provoked and symptoms
are not severe.
Neurological symptoms are absent.
When pain is not severe at the time of examination.
It is contraindicated when problem is unstable, hypersensitiv
e, irritable or when pathology is present

Higher level of examination:


Indications and contraindications:
1. The level 2 testing is normal and didn't reveal sufficient info
rmation.
2. Symptoms are stable and not easily provoked.
3. When there is no pathology that might adversely affect the
nervous system.
4. Contraindications same as level 2.

General points on technique:

Explanation to patient
Bilateral comparison
Test the unaffected side first
Maintain each movement precisely
Be gentle and donot hurry
Evoke versus Provoke
Short duration of testing.

Standard neurodynamic testing


Slump test
Straight leg raise
Prone knee bend

Slump test
Introduction:
This is used to evaluate the dynamics of neural s
tructures of the central and peripheral nervous system from
the head, along the spinal cord, sciatic nerve tract and its ext
ensions.
Indications :
Headache, pain anywhere in the spine,pelvis and th
e lower limb.
Preparation:
Pt sits with posterior aspect of their against the couch
with their thighs lying parallel. The parallel placement of thig
hs is for internal consistency(differences in pelvic size of mal
e and female)

Steps in slump

Level 1: Neurodynamic sequencing


Stage 1: If the patient sits without provocation of symp
toms, they adapt the starting position of the slump. However
if they cannot sit altering the position is necessary.
In this level thoracic and lumbar flexion is av
oided. Instead neck passive flexion and straight leg raise is us
ed.
Stage 2 :
neck flexion is performed by the patient whi
le the therapist supports patient forehead to prevent rapid d
escent of head.
Stage 3 : Dorsiflexion may be performed passively an
d is followed by passive knee extension.

Level 3a(neurodynamically sensitized)


The level 3a position of the slump test incorporate
s additional sensitizing manoeuvres of medial rotation and a
dduction of hip, dorsiflexion of ankle and contralateral flexio
n of spine.

SLR
Introduction:
The SLR is used to test the movement and mechanical
sensitivity of the lumbosacral neural structures and their dist
al extensions.
Indications:
It is generally applied in cases of pain and other sympt
oms in the posterior and lateral aspect of the lower quarter b
ut its use can be warranted in examination of the thoracic spi
ne.
Preparation :
Pt in supine lying with the body aligned symmetrically
.In it purest form the test is performed without a pillow.

Method
Structural differentiation
proximal symptoms : use dorsiflexion
Distal symptoms:
hip flexion produces distal sy
mptoms so further differentiation is required.
Active cervical flexion : not required

Normal response:
The normal response to the SLR is pulli
ng and stretching in the posterior thigh that spread
s into the posterior knee and sometimes upper thir
d of calf(Lew& Slater 1988).

Level 1 :
Technique: Pt is in supine lying with straight knee if
possible .Passive dorsiflexion is performed and the
limb is raised slowly to the first onset of symptoms.
Level 3a
Technique : the straight leg is raised to the first poi
nt of symptoms, then internal rotation and adducti
on are performed and dorsiflexion is added at the e
nd.

Treatment giudelines
Mechanical interface
Not to provoke symptoms.
Initially performed as atrail for 3
0-60 seconds.
Neural components
sliders : One ended
Two ended

Tensioners : One ended


two ended

Lumbar spine and radiculopath


y
Mechanical interface
Reduced closing dysfunction : level 1
Position -- contralateral side lying with hip
and knee flexed to 90 degree.

Static openers

Dynamic closures

Neural dysfunctions-cephalad