Neural Mobilization

MUST READINGS Shacklock. 2005. Clinical Neurodynamics (2-29, 98-104, 118-152, 154-158, 160-216) Butler. 2002. Mobilisation of the Nervous System (55-90, 203-210)

Briefly: Neural Testing & Mobilization Neural testing and mobilization has to be used with care and precision By using neural testing or mobilization too forceful you may cause more harm than benefit! Houglum 2010, 185, 191-192

Length change in the spinal canal

SPINAL CORD MOVEMENT During Flexion

Neural Mobilization Mobilisation of the nervous system is an approach to physical treatment of pain. The method relies on influencing pain physiology via mechanical treatment of neural tissues (direct method) and the non-neural structures surrounding the nervous system (indirect method). Shackloc 1995

Neural Testing and Mobilization GOAL: differentiate symptomatic tissue Testing: Does provocation testing reveal/increase the type of symptoms customer has had, compare to the uneffected side Treatment: Does treatment decrease symptoms the customer has had PHYSIOLOGY: Compression or tension or both > effects to nerve’s conduction and metabolism and itraneural blood flow Refresh your memory: How and which direction nerve move/slide in the joint Shackloc 2005

Physiological effects of Neural Mobilization Restore the dynamic balance between the relative movement of neural tissues and surrounding mechanical interfaces Facilitation of nerve gliding Reduction of nerve adherence (viscoelastic properties), Dispersion of noxious fluids, Increased neural vascularity (intraneural bloodflow), and Improvement of axoplasmic flow Ellis et al. 2008

Indications Use in non-irritable conditions (neurpathic/neurogenic) For pathomecanical causes: Fibrosis Connective tissue adhesions Restriction of normal tissue mobility Houglum 2010, 192

CONTRAINDICATIONS Malignancies of the nervous system or vertebral column (selkäranka) Acute inflammatory infections Areas of instability Spinal Cord Injuries Suspected disc lesions Cauda equina lesions Dizziness related to vertebral artery insufficiencies Any central nervous system disorders (e.g. spina bifida, MS) Worsening neurological signs Houglum 2010, 104

Concepts of Nerve Testing and Mobilization CLOSING: Closing mechanisms are those that produce increased pressure on a neural structure by way of reducing the space around it (Phalen) OPENING: Opening mechanism are those that procude reduced pressure on a neural structure. The reduced pressure occurs when the space around the neural structure is increased by a particular manouvere (Spinal flexion) Combining to muscle and tendon testing improves sensitivity. Validity and reliability in testing is correlated with performance (repeats, repeats, repeats in exercising techniques) Shackloc 2005

OPENING and CLOSING in the SPINE Shackloc 2005

Concepts of Nerve Testing and Mobilization Slider – goal is to produce gliding movement in relation to surrounding tissues Tension – goal is to produce tension in the certain part of peripheral nerve. Activity in ”normal area” - do not exceed the limits of elasticity (no lesions, is not a ”strech”) > may improve viscoelastic properties and physiological function of nerve) In testing (ant treatment) directly to nerve tissue 1. SLIDER, 2. TENSIONER (observe symptoms, decreased ROM or change in muscle activity) Shackloc 2005

Testing Neural Tissue THE IDEA is to determine can we provoce the symptoms of the customer has and compare the uneffected side to the symptomatic side. Tension Test 1. stop – First sensation of resistance Final stop – Symptoms or pain (scale 1-10) Useful tool is a mental movement diagram > is the condition Pain Dominant (pathofhysiologic) Limitation Dominant (Pathomechanical) Shackloc 2005

Testing Neural Tissue Start from the uneffected side > effects to the symptomatic side (e.g. SLUMP and SLR) Upper extrimities: Tension increases when Lateral flexion of cervical spine (plexus prachialis, > n.med. ja n.rad.) Depression of Shoulder girdle/scapula (all the nerves of upper extremity) Shoulder abduction (90-100°) > plexus prachialis and pheripheral parts, LR especially n. medianus, MR n. radialis Elbow extension > n. medialis, Flexion > n. ulnaris, Supination > n. medianus, Pronation > n. radialis, n. interosseus Wrist extension > n. medianus Finger extension > n. medianus

Medianus – ULTT1

Medianus – ULTT 1

Testing N. medianus (ULTT 1) Shoulder depression GH 110 abduction (support with thigh) Elbow in flexion Wrist dorsiflexion, Finger extension Arm supination GH Lateral rotation Elbow extension Cervical lateral flexion

Medianus - ULTT 2a

Testing N. medianus (ULTT 2a) 1. Shoulder depression 2. Elbow extension 3. GH lateral rotation + supination 4. Wrist extension abduction of the thumb 5. Shoulder abduction 6. If distal symptoms > release scapula, If proximal symptoms > release fingers/wrist

Radial – ULTT 2b

Ulnar – ULTT3

Lumbar area - Ichias

SLUMP

SLR = Straght Leg Raise Shacklock 2005, 138

Tibial Neurodynamic Test Shacklock 2005, 138

Peroneal Neurodynamic Test

PKB = Prone Knee Bent – Mid lumbar & Femoralis

Neural Mobilization Tell the customer what you are doing Test or mobilize uneffected side first (compare sides in testing) Use sliders, spine slider (neck) may be beneficial to use before peripheral slider Stop in the first sign Be gentle – with inappropriate testing and mobilization may cause more harm than benefit Throughout the treatment, the customer’s symptoms havs to be monitored > treatment should NOT cause pain A sequence of of slow oscillations can last 20-30 sec > reassess customer’s condition Don’t give nerve mobilization home exercises at the first meeting (because you don’t know the response, may occur after several hours) Houglum 2010, 191-193

Neural Mobilization Start locally Analyze provocing position or movement accurately and then choose test movement Refresh your memory: Spine movement in flexion extension increase the length of spine approximately 9cm the status of tissues and tension Spinal cord and membranes and nerve roots glide cranially/caudally Flexion: opener, flexion closer, notice ”tension points” (picture) how spinal cord and membranes glide

References Butler. 2002. Mobilisation of the Nervous System (55-90, 203-210) Ellis et al. 2008. Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy. J Man Manip Ther. 2008; 16(1): 8–22. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565076/?_escaped_fragment_=po=25.0000 Houglum 2010. Therapeutic Exercise for Musculoskeletal Injuries: Chapter 6: Manual Therapy Techniques (p. 153-198) Huijbregts. 2010. Orthopaedic Manual Physical Therapy- History, Development and Future Opportunities. Journal of Physical Therapy 1, 11-24. Kaltenborn. 2012. 6th Edition. Manual Mobilization of the Joints. Joint Examination and Basic Treatment. Volume II. The Spine. Pickar. 2002. Neurophysiological effects of spinal manipulation. The Spine Journal 2, 357–371. http://www.wellwave.net/resources/Grundlagen/Pickar_-02_review_SpinalMan.pdf Shacklock. 2005. Clinical Neurodynamics (2-29, 98-104, 118-152, 154-158, 160-216) Shackloc. 1995. Neurodynamics. Pysiotherapy. 81(1), 9-15. http://www.hzf.hr/text/Physio%20Shacklock%2095.pdf