Neural Mobilization
MUST READINGS
• Shacklock. 2005. Clinical Neurodynamics (229, 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)
1.
2.
3.
4.
5.
6.
7.
8.
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
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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_=p
o=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, 160216)
Shackloc. 1995. Neurodynamics. Pysiotherapy. 81(1), 9-15.
http://www.hzf.hr/text/Physio%20Shacklock%2095.pdf