NEURAL TENSION TEST AND MOBILIZATION PRESENTED BY JOJI SAM PHYSIOTHERAPIST AL JAHRA HOSPITAL
INTRODUCTION ďƒ˜ Neural
mobilization is a treatment technique used in relation to pathologies of the nervous system.
PHYSIOLOGY Nervous system adapts to mechanical load by – - elongation - sliding - cross sectional changes, - angulation and - compression. Failure of these dynamic protective mechanism leads to altered neuro dynamics. Neural glides restore the dynamic balance between neural tissue movement and surrounding mechanical interface. This reduces intrinsic pressure on neural tissue. Thus promoting optimum physiological function.
TENSION IS APPLIED REDUSES CROSS SECTIONAL AREA INCREASE IN INTRANEURAL PRESSURE REDUSES BLOOD SUPPLY TO NERVES AFFECTS AXONAL TRANSPORT SYSTEM
Neurodynamics – David Butler ďƒ˜ Use of body movement to produce
mechanical effects on the peripheral nervous system with central influence
BENEFITS OF NEURAL MOBILIZATION Circulation and nutrition occur optimally
through movement
MS tissue changes dimension and exert mechanical forces on neural structures ∆ management of injured neural tissues should ensure that MS structures operate optimally • Minimize forces on adjacent neural structures
Movement of the nerve bed Should elongate and shorten the nerve Increase nerve tension and intraneural pressure Facilitate venous return Disperse edema Reduce pressure inside the perineurium Should limit fibroblastic activity Which may minimize scar formation Physical loading (tension or compression) of the nervous system can be produced by adjusting joint position
Continuous strain recordings in the median nerve related to angles at the elbow and wrist for two consecutive recordings for each movement technique.
ASSESMENT Determine
if the test is positive Determine structure at fault Determine if it is irritable or nonirritable Apply appropriate grades of mobilization Patient education Document Continually re-evaluate
DEFINITION ďƒ˜
Neural tension test is an established component of neuro – orthopaedic examination in which the tension in the nerves is increased thus reproducing the signs and symptoms proving neural involvement.
Classification Neural Tension Test
Upper limb ULTT 1 ULTT 2 a b ULTT 3
Spinal Slump test PNF
Lower limb SLR
PKB
Upper Limb Tension Test .Also k/a Elvey’ s Test or Brachial Plexus Tension Test .ULTT1- Median Nerve dominant utilising shoulder abduction . .ULTT2a-Median Nerve dominant utilising shoulder girdle depression and external rotation .ULTT2b- Radial Nerve dominant utilising shoulder girdle depression and internal rotation .ULTT3- Ulnar Nerve dominant utilizing shoulder abduction and elbow flexion.
ULTT1 - Median Nerve
Performed in a non irritable disorder where full range of motion of fingers ,wrist, elbow, shoulder and neck movements are present Position Subject - neutral supine Pillow is not normally required but if used it should become a standard feature of later testing. Therapist -stride standing holding subject’s test hand Subject’s arm on therapists thigh
Steps Shoulder depression maintained by PT’s fist being pushed vertically into the bed Lateral flexion of the neck Arm is abducted to 110 degrees Forearm supination External rotation of the arm Wrist and finger extension Elbow extention
Note- once part of the test is done , it
should be firmly maintained before addition of the next component Symptoms and symptom changes must be identified and interpreted after each step. Elbow extension is prefered as the last component as the nerves are stronger at the elbow than at the wrist . Precautions On performing this test ;it should be done to prevent further irritation or inflammation of the nervous system.
Indications Symptoms of arm , neck or thoracic spine . Normal response Deep stretch or pain in the cubital fossa ,
radial aspect of the forearm and radial hand Definite tingling sensation in the thumb and the first three fingers. Stretch in the anterior shoulder area.
ULTT2 Position Subject lies diagonally with the scapula free of the bed. ULTT2b – Radial Nerve
ULTT2a-Median ULTT2b – Radial Nerve nerve
METHOD Therapist’s thigh depresses the subject’s shoulder . Abduct shoulder to 10 degrees Cervical lateral flexion . Elbow extension Lateral rotation of arm Forearm supination . Wrist and finger extension Most sensitizing addition is shoulder abduction .
METHOD
Shoulder depression 10 degrees of shoulder abduction . Cervical lateral flexion . Elbow extension Medial rotation of arm Forearm pronation wrist and finger flexion Ulnar deviation will further sensitise the radial nerve.
ULTT 2a
ULTT 2b
Indications of ULTT2 Cervical , thoracic and upper limb symptoms. Tennis elbow De Queruain’s disease. Normal response Compare with the other arm Symptoms should be expected in the innervation fields of either radial or median nerve.
ULTT 3 ULNAR NERVE
Position Subject in neutral supine Therapist stride standing holding subject’s test hand Method Shoulder depression by the PT’s arm pushing into the bed Cervical lateral flexion Wrist extension Forearm supination Elbow fully flexed Shoulder abduction is added though it were a matter of placing the subject’s hand over his/her ear
Indications Cervical , thoracic or upper limb symptoms Normal response Compare with the other arm In asymptomatic young people a common response is a degree of burning and tingling in the ulnar nerve distribution in the hand or medial aspect of the elbow .
Prone Knee Bending Position Subject is prone with his head turned towards the therapist . Method Therapist grasp the lower leg and flexes the knee to a pre determined symptom response . Range , symptom responses and resistance through the movement are noted.
Normal response Compare to the contralateral leg . Pulling or pain in the quadriceps area
Indications Knee , anterior thigh , hip or upper lumbar
symptoms .
Straight Leg Raise (SLR) Position
Supine with trunk and hip in neutral position .
Method
Therapist places one hand under the calcaneum and the other proximal to the knee. The leg is lifted perpendicular to the bed as a solid lever moving at a fixed point in the hip joint. The hand above the knee prevents knee flexion
Indications Posterior thigh pain Radiating pain Lower lumbar pain Response Range of motion , symptom response and restriction encountered through the movement are noted . Response are compared to the other leg.
Variations SLR /Dorsiflexion Dorsiflexion /SLR Tibial tract . SLR/dorsiflexon/inversion – Sural nerve. SLR/ PF/inversion Common peroneal PF/inversion/SLR nerve . SLR /Add/medial rotation – Sciatic tract. Bilateral SLR. SLR in spinal extension.
SLR/DF----TIBIAL NERVE
SLR/INV/DF----SURAL NERVE
SLR/INV/PF---COMMON PERONEAL NERVE
Passive Neck Flexion Position Supine lying preferable without a pillow . Method Therapist passively flex the neck in a chin to chest direction . Symptom responses , range of motion and restrictions encountered through the movement are noted and analyzed .
Normal response Asymptomatic person may feel a pulling at the cervico thoracic junction . Indications Spinal disorders Headache symptoms Arm and leg pain of spinal origin Lumbar pain Sciatic pain
Note In supine , other spinal components are neutralized , thus allowing better interpretation of test result . Here the neuraxis and meninges of the lumbar spine and a part of sciatic tract is moved and tensioned . Variations Passive neck flexion / upper thoracic flexion Passive cervical extension .
Slump Test Method Patient sits with thighs fully supported and knees together . Patients hand is linked gently behind his back . Patient is asked to ‘slump or sag Over pressure is applied to the lumbar and thoracic in attempt to bow the spine rather than hip flexion . Ask the patient to bend the chin to chest . Over pressure in the same direction is added . Extend the knee actively . Dorsiflex the ankle actively .
Normal response On slump – nil Slump / neck flexion – pain in T8- T9 area in 50% of cases. Slump / neck flexion / knee extension –pain in the hamstrings and restriction of knee extension which should be symmetrical . Pain is also felt behind the knee. Slump / neck flexion / knee extension / ankle DF -Some restrictions of ankle DF On release of neck flexion, symptoms reduces in all areas . Increase in range of knee extension and ankle DF
Indications Spinal
symptoms Symptoms seen in positions of slump test such as while getting into a car or kicking a foot ball.
TREATMENT
IRRITABLE
Non-provoking initially Grades I & II (Maitland) “anti-tension” postures Avoiding activities that provoke the symptoms Rest
NON-IRRITABLE
Non-provoking initially Grades I & II Grades III & IV (Maitland) Rest
TREATMENT PROGRESSION
IRRITABLE Increase # of oscillations Increase amplitude Increase the mobilization of the nervous system Point of application of the technique moved closer to the involved area Treat as non-irritable
NON-IRRITABLE
Increase length of time Increase # of oscillations Increase amplitude Increase mobilization of the nervous system Point of application of the technique moved closer to the involved area Treat non-neural structures
SELF TREATMENT Has two main aspects
-self mobilization technique -postural adaptation. Therapist and the subject must be aware of affects of mobilization. Technique must fit the subject. Can be adapted for irritable as well as non irritable disorders. Mechanical pain is best for mobilization. How much , How many and When to perform must be based on clinical reasoning .
SELF TREATMENT
PRECAUTIONS
Age of presentation less than 20 yrs or more than 55yrs Unrelenting, progressive non mechanical pain Night pain Recent weight loss Violent trauma Thoracic pain Drug abuse, HIV Morning stiffness Peripheral and spinal joint stiffness in all directions Inflammatory, systemic, and ineffective disorders that affect the nervous system Family history of spondyloarthropathy
CONTRAINDICATIONS Rheumatoid Arthritis. OsteoArthritis. Suspicion of metastasis. Current back or neck pain. Bladder/bowel incontinence.
Neurological changes are worsening - Acute compartment syndrome - Injury likely to cause neurological deficit.
Any other neurological signs and
symptoms elsewhere in the body.
CONCLUSION
Treatment is based on the severity, irritability and nature of the disorder. Should be non provoking initially. Large Grade II glides performed slowly and rhythmically. Oscillations for 20 sec to several min can be given. Amplitude of the technique can be progressed till some symptoms are reproduced or where some resistance to the movt is encountered.
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