NEURAL STRUCTURES

Outcomes Be familiar with the anatomy and function of the neural structures. Be familiar with the aim of neural dynamic tests. Be familiar with the neural dynamic evaluation tests. Be familiar with the clinical presentation of a patient with neural symptoms. Be familiar with the general principles of treatment of neural symptoms. Be familiar with the contra-indications of neural mobilisations.

Introduction Neural pain sensitive structures should always be kept in mind

Especially in patients who were subjected to trauma

The possibility exists that the resultant inflammatory process could also affect the nerve-root and nerve-root sheaths

Introduction This could lead to abnormalities in terms of mobility

Meningeal nerve-root sheaths have a well developed pain receptor system which is responsible for the strange pain distribution

Adhesions are generally prevalent as a result of the weak lymphatic drainage in the area

Introduction The nerve-root which is an extension of the dura mater, can therefore also be responsible for symptoms in another area – continuity of the system

The most common cause is reduced mobility of the neural structures

Introduction During the normal flexion and extension movements, the spinal cord moves approximately 7 – 10 cm and therefore the surrounding neural structures must be relatively mobile

Mechanical stimuli of a non-injured nerve is pain free, but excessive lengthening or pressure stimulates the nervi nervorum which results in a pain response and ischemia

Ischemia leads to pins and needles, pain and muscle spasm

Clinical presentation

Rare patterns of referred pain

Strips of pain

Pain at pressure points

Block of pain around a joint

Burning sensation or swelling

Symptoms mostly set in after assuming certain positions or carrying out actions which could cause stretching

Aim A neurodynamic test evaluate/tests the pain sensitivity/ provocation of the mechano-sensitive neural structures and the reaction of the protective muscles to lengthen around the neural tissue

Evaluation techniques

Passive neck flexion (PNF) Straight leg raise (SLR) Mid-slump test Slump test Upper limb tension test (ULTT)

General principles Explain to the patient what you are going to do and what they must do

Do one component of the test at a time

Take into account barriers to movement (onset of resistance, pain or other symptoms)

Note the quality of movement

General principles Consider irritability

Be consistent with starting position (e.g. pillows)

Note pain response (area and nature)

Do not necessarily reproduce the pain

Watch for and correct antalgic posture/movement

General principles

Test for symmetry – compare both sides

Sensitising and desensitising components can be added

Handle well or don’t bother

Positive test The test is considered positive if:

the patient’s symptoms are elicited

pain is reproduced

if there is more muscle reaction than on the other side

if there is any limitation in the mobility

if it is different from the normal

Treatment Both non-neural and neural structures must be treated

Soft tissue must be prepared before the neural structures are mobilised

First mobilises non-neural structures, soft tissue and then neural structures

Be aware of signs and symptoms in respect to irritability and intensity

Treatment Always start distal e.g. DF

Gr II short of pain and resistance, slow

Dull, constant pain must be avoided during treatment

Joint or muscle must be in mid-range since the separation level is more open in this position

Treatment Work in 20 sec or 20 movements and increase the treatment by 20 each time

Re-evaluation signs and symptoms

Neurological evaluation is very important

Home exercises may be given after the second day of treatment

Neural structures must not be rested in stretched positions

Treatment Less movement and more adhesions

Pins and needles may be experienced during treatment – should disappear immediately after treatment

Place nerve in stretched position and then add the other components

Through range of movement Grade III and IV

All components must be evaluated

Treatment Treat in close proximity of the origin of the symptoms

Can also perform an AP on the radius while the arm is placed in the ULTT

Get full tension before strong techniques are carried out e.g. SLR with rotation

Ensure at all times that the joints are able to withstand strong neural techniques

Patients react well to treatment, but can flare-up easily – be very careful!

Contra-indications Acute nerve-root pressure

Worsening of neurological symptoms

Pathological conditions that affect the structures e.g. diabetes

Cord and cauda equina

Malignancies

Acute inflammation

Contra-indications The slump test must not be carried out during a possible disc herniation or instability

Take care with irritable conditions

Always test neurological signs before and after neural mobilisations

Adhesive spinal cord