Neurodynamics

In-service nerve glide education

1. Neurodynamic Mobilization Gabriel Turner, SPTA Concorde Career College

2. Objectives 2 Neurodynamics Principles of Neural Mobilization Test for Provocation Technique Upper limb neurodynamic test (ULNT) Straight leg raise (SLR) Slump-Sitting Maneuver (SSM) Femoral Nerve: Prone Knee Bend (PKB) Carpal Tunnel Syndrome

3. Neurodynamics Is a concept of changes in the plasticity of the nervous system. Neurodynamic test maneuvers Are preformed to detect tension or compression in the neural tissue. Nerve flossing A gentle way to soothe compressed nerves and regain range of motion, when combined with physical therapy. 3

4. Principles of Neural Mobilization Based on anatomic and biomechanical properties of peripheral nerves and their response to stress and strain. The goal is to increase the excursion of the nerve while reducing the strain. Important to note that clinicians often make the error of being to aggressive with the techniques. Intensity of the technique should be related to the irritability of the tissue and patient’s response and changes in symptoms The greater the irritability the gentler the technique When applied properly – technique should be symptom free, with slow and rhythmic oscillatory motion 4 ( Manvell , Manvell , Snodgrass, & Reid, 2015)

5. Precautions / Contradictions Precautions : Vascular compromise or insufficiency Inflammation Edema Contraindications Cauda equina symptoms Changes in bowel and bladder control and perineal sensation Spinal cord injury Neoplasm Infection 5

6. Test for Provocation Test positions elongate the nerves across multiple joints, every joint in the chain must be examined separately for limitations in ROM, mobility, and symptoms of provocation so that any restrictions that occurs during the test is not a result of joint prearticular tissue limitations General testing procedure Slowly and carefully elongated the nerve across each joint in succession until there is an onset of symptoms or tissue restriction is felt Symptoms are the result of tension being placed of some component of the nervous system. 6

7. Positive test For the test to be considered positive it must reproduce the patient symptoms pain or paresthesia Must demonstrate differences from side to side, with a known normal response Support findings full examination to include symptoms pattern, location, strength, ROM and joint mobility. Sensitizing maneuvers alters patient’s symptoms 7 Sensitizing maneuvers Produce pain or paresthesia when neurological system is elongated across multiple joints or is relieved when one joint is moved into a slackened position

8. Technique Neural sliding flossing Position the patient at the point of tissue resistance or the onset of symptoms then move joints in the chain simultaneously so that the neural tissue glides proximally or distally Example: to glide the median nerve proximally once at the position of tissue resistance or onset of symptoms, perform elbow flexion simultaneously with contralateral cervical flexion or wrist flexion simultaneously with elbow flexion. 8

9. Technique Neural Glide Patient position the same as in neural sliding. Offload the nerve by placing the neural tissue on slack by laterally flexing the proximal segment toward the involved side or by releasing the position of the distal segment. Then slowly oscillate using large movements, gently move one segment in and out of the point of tissue resistance. 9

10. Upper Limb Neurodynamic Test (ULNT) 10 The ulnar, median, and radial nerve upper limb neuro-dynamic test is used to detect peripheral neuropathic pain. By assessing the interaction between the mechanics and physiology of the three major nerves of the arm. ( Manvell , Manvell , Snodgrass, & Reid, 2015)

11. Median Nerve ULNT1 11 Maneuver used when examining and treating symptoms related to median nerve distribution, including carpal tunnel syndrome ( Kisner , Colby, & Borstad , 2018)

12. Median Nerve ULNT1 Begin with patient in supine, place your fist at the superior aspect of the patient’s shoulder, pushing fist into the table to control elevation of the shoulder during abduction Abduct the arm to 110 ° while keeping the elbow flexed at 90°. Maintain the elbows position ext. wrist & fingers Supinate the forearm followed by lateral rotation Slowly extend the elbow, while keeping wrist & shoulder position constant, stop the movement if the patient reports symptoms or you feel tension in the tissue. To sensitize the maneuver as the patient to lat. flex the cervical spine away from test side and then towards test side and ask if movements increase or decrease symptoms 12 ULNT 1

13. Radial Nerve ULNT 2 13 This maneuver is used when examining and treating symptoms related to shoulder girdle depression, radial nerve distribution, differentiating between tennis elbow, radial tunnel syndrome. ( Kisner , Colby, & Borstad , 2018)

14. Radial Nerve ULNT 2 Begin with the patient in supine, apply gentle shoulder girdle depression then slightly abduct shoulder 10 °, Extend the elbow, and medially rotate the whole arm. With elbow in extension add wrist, finger and thumb flexion then add ulnar deviation. Maintaining this position, slowly abduct the shoulder until reproduction of symptoms or tension is felt in tissue. To sensitize the maneuver as the patient to lat. flex the cervical spine away from test side and then towards test side and ask if movements increase or decrease symptoms 14 ULNT 2

15. Ulnar Nerve – ULNT 3 15 This maneuver is used when symptoms are related to lower brachial plexus or ulnar nerve distribution and differentiating between medial epicondylosis and pronator syndrome. ( Kisner , Colby, & Borstad , 2018)

16. Ulnar Nerve – ULNT 3 Begin with the patient in supine. Extend the wrist and fingers, pronate the forearm and flex the elbow. While maintaining this position laterally rotate the shoulder and depress the shoulder girdle. Finally abduct the shoulder 110 ° or until symptoms are felt. To sensitize the maneuver as the patient to lat. flex the cervical spine away from test side and then towards test side and ask if movements increase or decrease symptoms 16 ULNT 3

17. Sciatic Nerve – Straight Leg Raising SLR This maneuver is used as the main test to diagnosis lumbar disc herniations. SLR can also distinguish tight or strained hamstrings caused by possible restriction in the lumbosacral plexus and sciatic nerve. Changes in position of the ankle in combination with various hip and knee positions are used to differentiate foot impairments such as plantar fasciitis and tarsal tunnel syndrome. Research has found that with hamstring tears, that neural glides with an emphasis on sciatic nerve glides as part of a treatment program could have a prophylactic effect of preventing scar tissue from developing and entrapping nerve structures which lie near hamstring muscle bellies. 17 ( Aggen , PT & Reuteman , PT, 2010)

18. Place the patient in supine, lift the lower extremity into SLR position and add ankle DF. Serval variations may be done to assist in differentiating the neural load. Ankle DF w/ eversion places tension on the tibial tract Ankle DF w/ inversion places tension on the sural nerve Ankle PF w/ inversion places tension on the common peroneal tract Hip Adduction while in SLR places further tension on Sciatic nerve - same as medial rotation increases tension on Sciatic Passive neck flexion while in SLR pulls the spinal cord cranially, placing the entire nervous system on a stretch. Ankle DF with toe extension increases tension on medial and lateral plantar nerves 18 ( Kisner , Colby, & Borstad , 2018)

19. Slump-Sitting Maneuver The Slump is a more sensitive test, used identify herniations in which the SLR is negative. Like the SLR test the slump is used as the primary test to diagnosis lumbar disc herniations and found to have high correlation with findings on operation since its sensitivity is high in only disc herniations leading to root compression that may eventually need surgery. The Slump test applies traction to the nerve roots by incorporating spinal and hip joint flexion into the leg raising and would warn the therapist of the presence of nerve root compression when there is a negative SLR test. 19 ( Kisner , Colby, & Borstad , 2018)

20. Begin with the patient sitting upright. Have the patient slump by flexing the spine and neck. Apply gentle over pressure to cervical spine flexion To sensitize the maneuver, dorsiflex the ankle and then extend the knee to the point of resistance and reproduction of symptoms. Release the over pressure of the spine and have patient actively extend the neck to see if symptoms subside. Increase and release the stretch force by moving one joint in the chain a few degrees Knee Flex/Ext Ankle DF/PF Note Response 20

21. Femoral Nerve: Prone Knee Bend 21 This maneuver is used when symptoms are related to pain in the low back or neurological signs of sensation in the anterior thigh are considered a positive sign for upper lumbar nerve roots and femoral nerve tension. Thigh pain could indicate rectus femoris tightness. ( Kisner , Colby, & Borstad , 2018)

22. 22 With the patient in prone position spine neutral and the hips to 0 ° of extension. Flex the knee to the point of resistance and reproduction of symptoms. An alternative position can be done in side-lying With the involved leg in the uppermost position. Stabilize the pelvis and extend the hip with the knee flexed until symptoms are reproduced. Maintain knee flexion, release and apply tension across the hip by moving it a few degrees at a time. Femoral Nerve: Prone Knee Bend

23. Carpal Tunnel Syndrome -CTS 23 Is the result of irritation and compression or stretching the median nerve as it passes through the carpal tunnel in the wrist along with extrinsic finger flexor tendons on it way to the hand. Symptoms include tendonitis, pain, paresthesia, inflammation and tendinosis ( scarring of the tendon sheaths). CTS is classified as a cumulative trauma or overuse syndrome .

24. 24 Begin with position A and slowly progress to each following position until the median nerve symptoms are provoked. That is the maximum position to use, then shift through each proceeding position before the point of provocation. Once patient can move into the maximum position without pain then patient can proceed to the next position. Nerve gliding with standard care, such as splint or tendon/carpal mobilization, found that all participants improved independently with nerve gliding application. Research found that almost all the participants receiving nerve gliding avoided the surgical intervention. Median Nerve Mobilization ( Ballestero -Perez, PhD, et al., 2016)

25. Video Demonstration https://youtu.be/Fv_EJV8q2E0 25

26. Questions Gabriel Turner [phone] [email protected]

27. References 27 Aggen , P. D., & Reuteman , P. (2010). Conservative Rehabilitation of Sciatic Nerve Injury Following Hamstring Tear. North American Journal of Sports Physical Therapy, 5 (3), 143+. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971645/ Ballestero -Perez, R., Plaza-Manzano, G., Urraca-Gesto , A., Romo-Romo, F., Atin - Arratibel , M. D., Pecos-Martin, D., Romero-Franco, N. (2016, Nov 11). Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review. Journal of Manipulative & Physiological Therapeutics, 40 (1), 50-59. doi : https ://doi.org/10.1016/j.jmpt.2016.10.004 Kisner , C., Colby, L. A., & Borstad , J. (2018). Therapeutic Exercise Foundations and Techniques (Seventh ed.). Philadelphia: F.A. Davis Company. Manvell , N., Manvell , J. J., Snodgrass, S. J., & Reid, S. A. (2015). Tension of the Ulnar, Median, and Radial Nerves During Ulnar Nerve Neurodynamic Testing: Observational Cadaveric Study. Physical Therapy, 95 (6), 891+. doi: http ://dx.doi.org/10.2522/ptj.20130536