neural mobilization
DESCRIPTION
Neural mobilization one of the advanced tecnique in treating neural stiffness and movement restriction.TRANSCRIPT
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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