NEURAL MOBILIZATION

1. NEURAL MOBILIZATION By Prof.Dr. Samy A. Nasef

3. Definition Neural mobilization is a manipulative technique by which neural tissues are moved, and stretched, either by movement relative to their surroundings (mechanical interface) or by tension development

4. Mechanical interface: are the tissues most anatomically adjacent to the nervous tissue that can move independently of the nervous system. As supinator muscle is mechanical interface to the radial nerve as it pass through the radial tunnel

5. Rational for Use The brain, spinal cord and nerves are continuous and are surrounded by connective tissue which can develop tension or tightness, often contributing to nerve symptoms experienced as radiating pain, numbness, tingling or weakness. Neural mobilization is a gentle nerve stretching technique to relieve this tension and its associated symptoms.

6. Neural tension techniques are used to decrease adverse mechanical tension on the nerves. Peripheral nerves can often become trapped within the tissues, where there can be a pull on the nerve with movement. This technique frees up the nerve so it can slide in its sheath. .

7. Site of Pathology  It is very important to determine the tissues responsible for the symptoms ( site of pathology). This may be intraneural or extraneural

8. Extra-neural Pathology at the mechanical interface any where along the length of a nerve can give rise to abnormalities in the nerve movements. For example, in carpal tunnel syndrome, entrapment of the median nerve at the carpal tunnel could occur due to lesion within the tunnel which induce compression on the nerve and giving rise to symptoms of nervous tissue pathology.

9. Intraneural Inflammatory changes occurring around a nerve can lead to changes in the connective tissues within the nerve leading to intraneural fibrosis. Intraneural fibrosis decrease nerve extensibility.

10. Effect of neural mobilization Mobilization of the neural tissue has a mechanical effect that affect the vascular dynamic, axonal transport system and connective tissue as well resulting in the followings: Improving neural axonal transport Improving blood flow to the neural tissue

11. Restoration of normal mechanics of the connective tissues thus lessening the possibility of the nerve being entrapped in their surrounding connective tissue Enhancing the intraneural process by alteration of the pressure in the nervous system and dispersion of intraneural edema.

12. Neural Tension Tests Tension tests: are technique using body movement and designed to increase tension within the nerve and move the nerve in relation to its surrounding tissues.

13. Nervous tissue adaptation to movement The nervous tissue respond to movements of body by producing movements at different levels Gross movements of the nerves in relation to the mechanical interface. .

14. As sliding movement of the median nerve in relation to the carpal tunnel with movements of upper limb. Intraneural movement, in which the nervous tissue elements move in relation to the connective tissue surrounding it.

15. The Base Tests Passive neck flexion (PNF). Straight leg raise (SLR). Prone knee bens (PKB). Upper limb tension tests (ULTT).

16. Basic principles of tension testing A positive tension test does not constitute a definite indication to neural mobilization. Tension tests affect a lot of other structure as well as nerves. Normal neural tissue which is being moved by testing may come into contact with sensitive interface structure and elicit pain.

17. Differential Diagnosis To distinguish between origin of the symptoms the following should be considered: Be aware of the expected normal response. Know all details of all the symptoms. Know the symptoms in the starting position.

18. Monitor symptoms throughout the procedures. Notice when pain starts. The effect of sensitizing additions/subtractions on the symptoms. This is considered an important factor to distinguish that the positive test is due to neural tissue affection.

19. Positive tension test A tension test can be considered positive if It reproduces the patient�s symptoms The test response can be altered by movement of distant body parts There are differences in the test from the left side to the right side.

20. Passive neck flexion (PNF) Indications: For all possible spinal disorders, headache symptoms, and for arm and leg pain of possible spinal origin. Method: The patient lies supine, arms are by the sides, and legs together. The therapist takes the head into passive flexion in a chin on chest direction. Normal response : PNF is a painless test.

21. If patient felt pulling at the cervico-thoracic junction, this is related to muscle and joint rather than neuroaxis. Sensitizing addition For differentiation maintain PNF and adding SLR. If symptoms increase so it is neural if not so it is muscle or joint origin.

22. Straight leg raising Indications: Assess a low lumber discogenic problem, routine examination with back, and lower limb disorders. Originally designed to test sciatic nerve. Method: The patient lies supine, trunk and hips in neutral position. The therapist place one hand under the Achilles tendon and the other hand above the knee preventing knee flexion. The limb is lifted straight. Notice the range that is recorded before pain or symptoms are provoked. Normal response: The normal range for SLR rang between 50-120 degree.

23. Sensitizing additions - Ankle dorsiflexion stress tibial nerve. - Ankle planter flexion and inversion stress common peroneal nerve. - Hip adduction further sensitize sciatic nerve. - Hip medial rotation further sensitize sciatic nerve.

24. Prone knee bend Indications: Routine test for patients with knee, anterior thigh, hip and upper lumbar symptoms. Assessment of femoral nerve and its branches. Method: The patient lies prone, the therapist grasps the lower leg and flexes the knee to a predetermined symptoms response. The response should be compared to the other side.

25. Normal response : Asymptomatic, and in some normal there is sensation of pulling or pain in the area of the quadriceps Sensitizing additions - Cervical flexion - Slump in side lying.

26. Upper limb tension test Indications: ULTT is recommended test for all patients with symptoms in the arm, head, neck and thoracic spine. Different test is provided to test each nerve (for example median nerve test, radial nerve test). Method: The patient is positioned in neutral supine A constant depression of shoulder girdle is ensured during movement. The shoulder is abducted to 110 degree. With this position is maintained, - The forearm is supinated and the wrist and fingers extended. - The shoulder is laterally rotated. - The elbow is extended.

27. Normal response : Deep stretch or ach in the cubital fossa, tingling sensation on the fingers Sensitizing additions With this position held, cervical lateral flexion to the left and then to the right is added

28. Treatment  After examination of the patient, if the therapist decides there is a relevant tension of the neural tissue, which need treatment. One approach to that is the use of direct mobilization of the nervous system usually via tension tests and their derivatives.

29. Key to successful treatment Nervous tissue mobilization fits perfectly into the Maitland concept. That is, the treatment of signs and symptoms based on the severity, irritability and nature of the disorder. Treatment via neural mobilization is not a quickly acquired skill, nor is it an easy skill to learn.

30. Guidelines to the starting technique Whatever the starting point used, the following should apply during the first technique application The technique should be well away from the symptom area Treatment should be non-provoking initially. A large amplitude technique (grade II) should be used if possible with irritable disorders, while (grade III and IV) with non-irritable disorders. Maximal relaxation of the patient, and the painful areas will allow better nerve movement If the technique starts to irritate the pain, either reduce the amplitude/range/speed of the technique. After the initial mobilization, the symptoms must be reassessed.

31. Grading the technique The grading of the technique is dependent on - Degree of irritability of the tissue - The relationship between resistance to the movement and the symptoms received Grade II: large amplitude rhythmic oscillations are performed within the range not reaching the limit Grade III: large amplitude, rhythmic oscillations are performed up to the limit of the available motion and are stresses\d into the tissue resistance Grade IV: small amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance

32. Progression The number of repetition of the technique may be as few as five or ten initially but can increase to many repetitions for several minutes. It is preferred to perform a sequence of gentle oscillations, for 20 seconds and then repeated again. Increasing the amplitude and taking the technique further into resistance. Repeat the technique but alter to increase degree of tension by addition of the sensitizing components.

33. Contraindications Recent onset of, or worsening neurological signs. Cauda equine lesions Cord signs. Recent surgery Dizziness in cervical spine problem