neural mobilization

NEURAL MOBILIZATION

Prepared by

Associate Professor

S.Dineshkumar

Madha college of physiotherapy

1.Functional anatomy2.Clinical neurobiomechanics3.Pathological processes4.The clinical consequences of injury to

the nervous system5.Examination6.Tension testing7.Treatment

1.FUNCTIONAL ANATOMY CONCEPT OF CONTINUOUS TISSUE

TRACTConnective tissues are continuousNeurons are interconnected Continuous chemically

The neuronConsist of a cell body,some dendrites and

usually one AxonAxons are either myelinated or non

myelinatedAxon grouped together in to bundles or

fasciclesAxons –Nerve fibersCytoplasm of neuron-Axoplasm

Nerve fibers three kindmotor(AHC-NMJ)sensory(DRG-RECEPTORS)Autonomic(ventral horn SC,PGF)

ENDONEURIUM A distensible ,elastic structure made up

of matrix of closely packed collagenous tissue surrounding the basement membrane is the endoneurial tube.Protects axons from tensile forceMaintains the endoneurial space and fluid

pressure,A slight positive pressure .

PERINEURIUM Each fascicle is surrounded by a thin

lamellated sheath known as PerineuriumProtecting the content of endoneurial tubesActing as mechanical barrier to External

forcesServing as a diffusion barrierMost resistant to tensile forces

EPINEURIUM The outermost connective tissue

investment surrounds ,protects and cushions the Fascicles.Keep the fascicles apart(internal

epineurium)Definite sheath around the fascicles

(external epineurium)Facilitate gliding between the fascicles

MESONEURIUM Mesoneurium is a loose areolar tissue

peripheral nerve trunks .Blood vessels enter the nerve via

mesoneuriumAllows the nerve to glide along the adjacent

tissue.

FASCICULAR ARRANGEMENT Nerves are not uniform Run in wavy course throught the nerve

course Constantly changing the plexus within

the trunk Inverse relation between size and

number of fascicle More number –more protection from

compressive forces.

CENTRAL NERVOUS SYSTEM THE NERVE ROOT Each roolet emerged was ensheathed by

a pial layer the outer most covering which formed a covering around individualfascicle.

Injuries to nerveroot –not commonly from traction but directly from neighing structure such as discs and zygopophyseal joints.

SAFETY MECHANISM AT ROOT LEVEL 4th ,5th,6th cervicalsipnal nerve have a strong

attachment to the gutter of the respective transverse process.

Open endedness of perineurium continuos with the dura /arachnoid and the inner layer forms pial sheeth.best for force distribution.

Duralsleeve forms a plugging mechanism(traction force transmitted to cord via the denticulate lig –ease the tension on NR)

Angulated nerve roots being proteted from tethered

NERVOUS SYSTEM RELATIONS –SPACE AND ATTACHMENT

BASIS OF SYMPTOMS The supply of blood to the nervous

system The axonal transport nervous system The innervations of the connective

tissues of nervous system

Lattice collagen arrangementWhen cord is elongaed the vessels running

longitudinally are streched while those runing transversly are folded.

Veins in the spinal canal are valveless and allows flow reversibility .

Critical vascular zone fromT4 to T9

Arrest of blood at 8%elongation Complete arrest at 15% elongation Two barriers maintain endoneurial

environment:The perineurial diffusion barrier(resistant to

trauma even after surgery to epineurium)-Blood nerve barrier(at endoneurial

microvessels)

AXONAL TRANSPORT SYSTEM Three flow identified:

Axo plasm flow from cell body to target tissue(Antegrade flow)

From target tissue to cell body(retrograde flow)

Bidirectional flow.Flow interruption induces cell body reactionConsriction,loss blood supply, viruses may

impede the flow.

INNERVATION OF NERVOUS SYSTEM Innervation of nervous system means

innervation connective tissues of nervous system.

Dura matter innervated by segmental ,bilateral,sinuvertebral nerves

Sinuvertebralnerve innervates directly or via PLL

Innervation density varies deppending on spinal segment

Rich in superficial than in deeper Innervation aracchnoid and pia less

experimental attention.

Ventral nerve root innervation from DRG Anterior nerve roots from branches from

sinu vertebralnerves. The connective tisues of PNS,ANS, have

an intrinsic innervation :the nervi nervorum from localaxonal branching

Also extrinsic innervation from fibers entering the nerve from the perivascular plexuses.

2.CLNICAL NEURO BIOMECHANICS MECHANICAL INTERFACE

Defined as that tissue or material adjacent to the nervous system that can move independently to the system.

Pathological interfaceA tight plaster or bandageEdemaBloodOsteophyttesLigamentous swellingFascial scarring

NERVOUS SYSTEM ADAPTATIONS TO MOVEMENT1.the development of tension or increased

pressure within the tissues2.gross movement or intraneuralmovement

Grossmt example:median nerve movement in caarpal tunnel.

Intraneural mt:Spinalcord mt in relation to duramatter.

RELATIONSHIP BETWEEEN MOVEMENT AND TENSION If a body part is moved with other body part

is in neutral position –less tension more movement

Conversly if the same movement performed with body parts in tension,there will be a great increase in intraneural tension but little mt of the nervous system.

EX:ULTT1 with neck in neutral ULTT1 with neck laterally flexed to opposite

side.

Neuraxialand meningeal adaptive mechanism:Ex:the slump test and passive neck flexion

testBoth employ spinal flexion test In flexion –moves anteriorly In extension –moves posteriorly In rotation stays constantC6,T6,L4 vertebral levels –no nervous

system movement in relation to interfaces.From spinal extension to flexion the cord

converge towards C4,C5 disc.

SLR Sciatic and tibial nerve superior to knee moves

caudal in direction Tibial nerve below the knee moves cephalad in

direction. Posterior to knee joint –no movement of nerve

occurs in relation to interface. When tension applied to the nerve, the intraneural

pressure will increase as the cross sectional area decreases.ex:siting to standing.

Blood supply will diminish at around 8 % elongation, and stop around 15 % elongation.

The biomechanic of additional movements which further sensitises the test such as ankle DF,hip adduction,medialrotation and cervical flexon etc.

UPPERLIMB ADAPTIVE MECHANISM I.MOVEMENT MEDIAN NERVE

Finger extension-pulled the nerve downward of 7.4 cm

Flexion of elbow allowed upward movement of 4.3 cm

Arm movement allowed 2-3 cmULNAR NERVEMigrated proximally during flexion of elbow.

II.DEVELOPMENT OF PRESSURE OR TENSION IN THE SYSTEM.The two adaptive mechanism of tension and

movement must occur simultaneously in some situation one will predominate..

Pathological processes or injury may affect one or both of these adaptive mechanisms.

3.PATHOLOGICAL PROCESSES Site of injury

Soft tissues ,osseus or fibro- osseus tunnels.Where the nervous system branchesWhere the system is relatively fixedUnyielding interfaces.Tension points.

Kind of injuryMechanical and physiological consequences

of friction ,compression, stretch and occasionally disease.

Unphysiological movements, body postures, and repetitive muscle contraction.

Secondary injury to nervous system such as blood and edema from damaged interface.

Change in shape of interface.

Intraneural and extra neural pathology1.intra neural pathology

Conducting tissue connective tissue Demyelination scarred

epineurium Neuroma formation arachnoiditis Hypoxic nerve fibers irritated duramatter

Extra neural pathologyNerve bed

Blood in nerve bed or epidural spaceMechanical inetrface

`swelling of bone and muscle adjacent to a nerve trunk.

PATHOLOGICAL PROCESSVASCULAR FACTORS IN JNIURYHypoxiaEdemaFibrosisMEHANICAL FACTORSThe myelin on one side of the node

becomes strechedThe myelin on the other side becomes

invagenatedDisplacement of node of Ranvier

Injury and axoplasmic flowTrophic changes in target

tissue(skin,muscle)Damage to cell body and axonBlood supply compromise affect the axonal

flowMild compression of 30-50 mmhg interrupt

both antegrade and retrograde flow. an axoplsmic transport block by a 50

mmhgFor 2 hours was reversible in 24 hours.

2 hours of compression at 200 mmhg was reversible within 3 days.

Nucleus looses its information gathering mechanism about the state of target tissue and the neuronal environment.

Ability to produce neurotransmitters diminished

Cytoskeletal elements for the neuron diminished.

Further consequences of nerve injuryFibrosisDouble crush syndromeTriple and multiple crush syndromesAbnormal impulse generating mechanism

4.CLINICAL CONSEQUENCES OF INJURY TO THE NERVOUS SYSTEM SIGNS AND SYMPTOMS FOLLOWING

INJURY AREA OF SYMPTOMS KINDS OF SYMPTOMS HISTORY POSTURAL AND MOVEMENT PATTERNS

SIGNS AND SYMPTOMSLevel of

involvement(UMN,LMN,SEGMENTAL)Severity of involvementThe tissue components involved(neural

tissue or connective tissue)From local or remote sources.Whether an intraneural or extraneural

process is evedentThe sstage of the disorder(acute or chronic)The progression of the disorder

AREA OF THE SYMPTOMSVulnerable areas ex:carpaltunnel,head of

fibulaSymptoms donot fit to the familiar patterns

such as a dermatomal or myotomal.(cyriax-extrasegmental patterns from dura matter)

symptoms fit nerve anatomy significant(conducting tissue injury)

Symptoms may link up(double crush syndrome such as co existent tennis elbow and carpal tunnel syndrome)

Lines and clumps of pain can occur(around the joints or tension points)

KIND OF SYMPTOMS Constant or intermittent Sensation of swelling(ans) Paraesthesia or anaesthesia(with or with

out pain) Weakness(impairment in efferent

impulses,pain inhibited weakness) Symptoms worse at night(peripheral

nerve entrapment) Worse at the end of the day(chronic

nerve root iritaion)

HISTORYMECHANISM OF INJURYPREVIOUS INJURYPREVIOUS TREATMENTOTHER CONTRIBUTING FACTORS

POSTURAL AND MOVEMENT PATTERNS ANTALGIC TENSION POSTURE POKED CHIN POSTURE SCOLIOSIS THORACIC KHYPHOSIS READING IN LONG SITTING IN BED(SLR) GETTING IN TO A CAR(SLUMP,SLR) REACHING UP TO A CLOTH LINE SHOULDER GIRDLE DEPRESSION SMALL REPETITIVE

MOVEMENTS(KEYBOARD,PLAYING MUSICAL INSTRUMENT)

IRREGULAR PATTERNS ON MOVEMENT PROVOKING SYMPTOMS –OTHER THAN JOINT.

5.EXAMINATION SUBJECTIVE NEUROLOGICAL EXAMINATION

DIZZNESS( VBI,dural attachment,) INVOLVEMENT OF CAUDA EQUINA (functions of

bladder,bowel,perianal,genital sensation) CORD SYMPTOMS(spasticity,gross

alteredmovement patttern,paralysis,bilateral pins and needles,broad based jerky gait,diffuse non specific weakness,Tethered cord syndrome -complete numbness ,hair tufts,dermal sinuses,tight calves and hamstring)

GENERAL HEALTH(diabetes,AIDS,Multiple sclerosis,poly neuropathies)

PHYSICAL EXAMINATION OF SENSATIONLIGHT TOUCHPIN PRICKVIBRATIONPROPRIOCEPTIONTWO POINT DISCRIMINATION

EXAMINATION OF MOTOR FUNCTIONWASTINGREFLEX TESTINGMUSCLE POWER TESTINGTEST FOR SEGMENTALLEVEL

C4-SCAPULAR ELEVATORS C5-DELTOID C6-BICEPS C7-TRICEPS C8-LONG FINGER FLEXORS T1-INTERROSSEI AND LUMBRICALS

TEST FOR INDIVIDUAL NERVE TRUNK RADIAL NERVE-RESIST THE WRIST EXTENSION MEDIAN NERVE-RESIST THE DISTAL IP JOINT OF

INDEX FINGER ULNAR NERVE-RESIST ABDUCTION OF INDEX

FINGER. DORSAL SCAPULAR NERVE-THE RHOMBOIDS LONG THORACIC NERVE-SERRATUS ANTERIOR

MUSCLE TESTING LOWER LIMB L2-HIP FLEXORS L3-KNEE EXTENSORS L4-ANKLE DORSIFLEXORS L5,S1-EXTENSORS OF THE DISTAL PHALANX OF

THE GREAT TOE S1-EVERTORS OF ANKLE S1,S2-ANKLE PLANTOR FLEXORS S2-TOE FLEXORS

Cord function testAnkle clonusBabinski testELECTRO DIAGNOSIS

NEUROPATHY IS FROM PERIPHERALNERVE OR MYOPATHY

SYSTEMIC CONDITIONS(alcoholic,diabettic neuropahy)

ASSISTING FOR SURGICAL INTERVENTION OBJECTIVE MEASUREMENT FOR TREATMENT IDENTIFICATION OF ANAMALIES.

6.TENSION TESTING UPPER LIMB TENSION TEST 1-median

nerve dominant utilizing shoulder abduction

UPPERLIMB TENSION TEST 2-radial nerve dominant utilising shoulder girdle depression plus internal rotation of the shoulder

UPPERLIMB TENSION TEST 3-ulnar nerve dominant utilising shoulder abduction and elbow flexion.

ULTT1:METHOD:Patient positioned in supineA constant depression force placed on

shoulder girdleForearm supiated ,wrist and fingers

extended.The shoulder is laterally rotatedThe elbow is extended.earlier component

positions must be maintainedWith this position ,cervical lateral flexion to

the left then to the right are added.

NORMAL RESPONSESA deep stretch or ache in the cubital fossaA definite tingling sensation in the thumb

and first three fingersA small percentage of subjects may feel

stretch in the anterior shoulder area. Cervical lateralflexion away from tested

side increases the response in approximatelyn90 % of individuals.

Upper limb tension test 2Supine lyingShoulder depression maintainedShoulder medially rotatedForearm pronated ad wrist flexion Flexion of thumb joints and ulnar deviation

further sensitises the radial nerve.NO STUDIES HAVE BEEN UNDERTAKEN

REGARDING NORMAL RESPPONSE OF ULLT2

UPPERLIMB TENSION TEST 3Starting position same as ULTT1wrist exended and fore armsupinated Elbow fully flexedWith maintaining Shoulder

depression ,abduction addedNORMAL RESPONSE

In asymptomatic people ,a commo response is burning and tingling in the ulnar nerve distribution in the hand or medial aspect of elbow.

PASSIVE NECK FLEXION TEST(PNF) STRAIGHT LEG RAISE TEST(SLR) SLUMP TEST PRONE KNEE BEND(PKB)

PASSIVE NECK FLEXION TESTPATIENT LIES SUPINELIFT HEAD OFF THE BED A LITTLEPASSIVELY FLEXING THE NECK TOWARDS

CHIN ON CHEST DIRE CTIONDuring the movement symptom

responses ,ROM,resistance encountered through the movement are noted and analysed.

STRAIGHT LEG RISE TESTSupine lyingHip and trunk neutralThe leg is lifted perpendicular to the

bed,hand above knee joint prevents knee flexion.

The responses must compared with the responses of other leg.

SENSITISINGAnkle dorsiflexion(tibial tract)Ankle plantar flexion(common peroneal

nerve)

PRONE KNEE BENDPatient lies proneGrasp the lower leg and flexes the kneeCheck for symptom response Compare to contralateral leg

THE SLUMP TEST High sitting at the end of the plinth thighs fully

supported and knees together. Patient asked to slump or sag with Cervical spine in

neutral With spinal flexion position patient asked to bend chin

to chest and then over pressure in the same direction. The patient is asked to extend the knee actively and

the response assesed Then dorsiflexion added Neck flexion slowly released and the response

carefully assessed The same procedure repeated for the other leg If there is any change in symptom in hamsring area

after releasing the neck flexion –neurogenic in origin.

Analysis of tesion testThe range of movement at which symptom

first start.Whether the disorder is non irrritableThe type and area of symptomsThe resistance encountered during the testThe above findings must be compared to

the testof the contralateral limb.

POSITIVE TENSION TEST It reproduces the patients symptoms The test responses can be altered by

the movement of the body parts. There are differences in the test from

the left side to the right sideRange of movementResistance encountered duringthe

movementSymptom response during the movement.

INDICATIONS Nerve root injuries Thoracic nerve root syndrome Whiplash injuries Coccydynia Spondylolishesis Post lumbar spine injuries Epidural haematoma Head ache. T4 syndrome.

CONTRAINDICATIONS Recent onset of,or worsening

neurological signs Cauda eqina leision Injurt spinal cord.

PRECAUTIONS Irritability the nervous systemPresenceof meurological signsGeneral health problemssDizznessCirculatory distubances

References MOBILISATION OF THE NERVOUS

SYSTEM ByDavid s.butlerMark A jones.

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