neural tension test

NEURAL TENSION TESTNEURAL TENSION TESTANDAND

MOBILIZATIONMOBILIZATION

PRESENTED BYPRESENTED BY

JOJI SAMJOJI SAM

PHYSIOTHERAPISTPHYSIOTHERAPISTAL JAHRA HOSPITALAL JAHRA HOSPITAL

INTRODUCTIONINTRODUCTION

NeuralNeuralmobilization is amobilization is atreatmenttreatmenttechnique usedtechnique usedin relation toin relation topathologies ofpathologies ofthe nervousthe nervoussystemsystem..

PHYSIOLOGYPHYSIOLOGYNervous system adapts to mechanical load byNervous system adapts to mechanical load by ––

-- elongationelongation-- slidingsliding-- cross sectional changes,cross sectional changes,-- angulationangulation andand-- compression.compression.

Failure of these dynamic protective mechanismFailure of these dynamic protective mechanismleads to alteredleads to altered neuroneuro dynamics.dynamics.

Neural glides restore the dynamic balanceNeural glides restore the dynamic balancebetween neural tissue movement andbetween neural tissue movement andsurrounding mechanical interface.surrounding mechanical interface.

This reduces intrinsic pressure on neural tissue.This reduces intrinsic pressure on neural tissue. Thus promoting optimum physiological function.Thus promoting optimum physiological function.

TENSION IS APPLIEDTENSION IS APPLIED

REDUSES CROSS SECTIONAL AREAREDUSES CROSS SECTIONAL AREA

INCREASE IN INTRANEURAL PRESSUREINCREASE IN INTRANEURAL PRESSURE

REDUSES BLOOD SUPPLY TO NERVESREDUSES BLOOD SUPPLY TO NERVES

AFFECTS AXONAL TRANSPORT SYSTEMAFFECTS AXONAL TRANSPORT SYSTEM

NeurodynamicsNeurodynamics –– David ButlerDavid Butler

Use of body movement to produceUse of body movement to producemechanical effects on the peripheralmechanical effects on the peripheralnervous systemnervous system with central influencewith central influence

BENEFITS OF NEURALBENEFITS OF NEURALMOBILIZATIONMOBILIZATION

Circulation and nutrition occur optimallyCirculation and nutrition occur optimallythrough movementthrough movement

MS tissue changes dimension and exertMS tissue changes dimension and exertmechanical forces on neural structuresmechanical forces on neural structures

∆∆ management of injured neural tissuesmanagement of injured neural tissuesshould ensure that MS structures operateshould ensure that MS structures operateoptimallyoptimally

•• Minimize forces on adjacent neural structuresMinimize forces on adjacent neural structures

Movement of the nerve bedMovement of the nerve bed

Should elongate and shorten the nerveShould elongate and shorten the nerve

Increase nerve tension andIncrease nerve tension and intraneuralintraneuralpressurepressure

Facilitate venous returnFacilitate venous return

Disperse edemaDisperse edema

Reduce pressure inside theReduce pressure inside the perineuriumperineurium

Should limit fibroblastic activityShould limit fibroblastic activity

Which may minimize scar formationWhich may minimize scar formation

Physical loading (tension or compression) ofPhysical loading (tension or compression) ofthe nervous system can be produced bythe nervous system can be produced byadjusting joint positionadjusting joint position

Continuous strainrecordings in themedian nerverelated to angles atthe elbow and wristfor two consecutiverecordings for eachmovementtechnique.

ASSESMENTASSESMENTDetermine if the test is positive

Determine structure at fault

Determine if it is irritable or non-irritable

Apply appropriate grades ofmobilization

Patient education

DocumentContinually re-evaluate

DEFINITIONDEFINITION

Neural tension test is an establishedNeural tension test is an establishedcomponent ofcomponent of neuroneuro –– orthopaedicorthopaedicexamination in which the tension inexamination in which the tension inthe nerves is increased thusthe nerves is increased thusreproducing the signs andreproducing the signs andsymptoms proving neuralsymptoms proving neuralinvolvement.involvement.

ClassificationClassification

Neural Tension Test

Upper limbULTT 1ULTT 2 a

bULTT 3

Spinal

Slump testPNF

Lower limb

SLR PKB

Upper Limb Tension TestUpper Limb Tension Test..Also k/aAlso k/a ElveyElvey’’ s Test or Brachial Plexuss Test or Brachial Plexus

Tension TestTension Test

..ULTT1ULTT1-- Median Nerve dominantMedian Nerve dominant utilisingutilisingshoulder abduction .shoulder abduction .

..ULTT2aULTT2a--Median Nerve dominantMedian Nerve dominant utilisingutilisingshoulder girdle depression and externalshoulder girdle depression and externalrotationrotation

..ULTT2bULTT2b-- Radial Nerve dominantRadial Nerve dominant utilisingutilisingshoulder girdle depression and internalshoulder girdle depression and internalrotationrotation

..ULTT3ULTT3-- UlnarUlnar Nerve dominant utilizingNerve dominant utilizingshoulder abduction and elbow flexion.shoulder abduction and elbow flexion.

ULTT1ULTT1 -- Median NerveMedian Nerve

Performed in a non irritable disorder wherePerformed in a non irritable disorder wherefull range of motion of fingers ,wrist, elbow,full range of motion of fingers ,wrist, elbow,shoulder and neck movements are presentshoulder and neck movements are present

PositionPosition

SubjectSubject -- neutral supineneutral supine

Pillow is not normally required but if usedPillow is not normally required but if usedit should become a standard feature ofit should become a standard feature oflater testing.later testing.

TherapistTherapist --stride standing holding subjectstride standing holding subject’’sstest handtest hand

SubjectSubject’’s arm on therapists thighs arm on therapists thigh

StepsSteps

Shoulder depression maintained by PTShoulder depression maintained by PT’’ssfist being pushed vertically into the bedfist being pushed vertically into the bed

Lateral flexion of the neckLateral flexion of the neck

Arm is abducted to 110 degreesArm is abducted to 110 degrees

ForearmForearm supinationsupination

External rotation of the armExternal rotation of the arm

Wrist and finger extensionWrist and finger extension

ElbowElbow extentionextention

NoteNote-- once part of the test is done , itonce part of the test is done , itshould be firmly maintained before additionshould be firmly maintained before additionof the next componentof the next component

Symptoms and symptom changes must beSymptoms and symptom changes must beidentified and interpreted after each step.identified and interpreted after each step.

Elbow extension isElbow extension is preferedprefered as the lastas the lastcomponent as the nerves are stronger atcomponent as the nerves are stronger atthe elbow than at the wrist .the elbow than at the wrist .

PrecautionsPrecautions

On performing this test ;it should be doneOn performing this test ;it should be doneto prevent further irritation or inflammationto prevent further irritation or inflammationof the nervous system.of the nervous system.

IndicationsIndications

Symptoms of arm , neck or thoracic spine .Symptoms of arm , neck or thoracic spine .

Normal responseNormal response

Deep stretch or pain in theDeep stretch or pain in the cubitalcubital fossafossa ,,radial aspect of the forearm and radialradial aspect of the forearm and radialhandhand

Definite tingling sensation in the thumbDefinite tingling sensation in the thumband the first three fingers.and the first three fingers.

Stretch in the anterior shoulder area.Stretch in the anterior shoulder area.

ULTT2ULTT2PositionPosition Subject lies diagonally with the scapula freeSubject lies diagonally with the scapula free

of the bed.of the bed.ULTT2bULTT2b –– Radial NerveRadial Nerve

ULTT2aULTT2a--MedianMediannervenerve

METHODMETHOD TherapistTherapist’’s thighs thigh

depresses the subjectdepresses the subject’’ssshoulder .shoulder .

Abduct shoulder to 10Abduct shoulder to 10degreesdegrees

Cervical lateral flexion .Cervical lateral flexion . Elbow extensionElbow extension Lateral rotation of armLateral rotation of arm ForearmForearm supinationsupination .. Wrist and fingerWrist and finger

extensionextension Most sensitizingMost sensitizing

addition is shoulderaddition is shoulderabduction .abduction .

METHODMETHOD

Shoulder depressionShoulder depression 10 degrees of shoulder10 degrees of shoulder

abduction .abduction . Cervical lateral flexion .Cervical lateral flexion . Elbow extensionElbow extension Medial rotation of armMedial rotation of arm ForearmForearm pronationpronation wristwrist

and finger flexionand finger flexion UlnarUlnar deviation will furtherdeviation will further

sensitisesensitise the radial nerve.the radial nerve.

ULTT2bULTT2b –– RadialRadialNerveNerve

ULTT 2aULTT 2a

ULTT 2bULTT 2b

Indications of ULTT2Indications of ULTT2

Cervical , thoracic and upper limbCervical , thoracic and upper limbsymptoms.symptoms.

Tennis elbowTennis elbow

DeDe QueruainQueruain’’ss disease.disease.


Compare with the other armCompare with the other arm

Symptoms should be expected in theSymptoms should be expected in theinnervationinnervation fields of either radial or medianfields of either radial or mediannerve.nerve.

ULTT 3 ULNAR NERVEULTT 3 ULNAR NERVE

PositionPosition Subject in neutral supineSubject in neutral supine Therapist stride standing holding subjectTherapist stride standing holding subject’’s tests test

handhandMethodMethod Shoulder depression by the PTShoulder depression by the PT’’s arm pushings arm pushing

into the bedinto the bed Cervical lateral flexionCervical lateral flexion Wrist extensionWrist extension ForearmForearm supinationsupination Elbow fully flexedElbow fully flexed Shoulder abduction is added though it were aShoulder abduction is added though it were a

matter of placing the subjectmatter of placing the subject’’s hand over his/hers hand over his/herearear

IndicationsIndicationsCervical , thoracic or upper limbCervical , thoracic or upper limb

symptomssymptoms

Normal responseNormal responseCompare with the other armCompare with the other arm In asymptomatic young people aIn asymptomatic young people a

common response is a degree ofcommon response is a degree ofburning and tingling in theburning and tingling in the ulnarulnar nervenervedistribution in the hand or medialdistribution in the hand or medialaspect of the elbow .aspect of the elbow .

Prone Knee BendingProne Knee BendingPositionPosition

Subject is prone with his headSubject is prone with his headturned towards the therapist .turned towards the therapist .

MethodMethod

Therapist grasp the lower legTherapist grasp the lower legand flexes the knee to a preand flexes the knee to a predetermined symptomdetermined symptomresponse .response .

Range , symptom responsesRange , symptom responsesand resistance through theand resistance through themovement are noted.movement are noted.


Compare to theCompare to the contralateralcontralateral leg .leg .

Pulling or pain in the quadriceps areaPulling or pain in the quadriceps area


Knee , anterior thigh , hip or upper lumbarKnee , anterior thigh , hip or upper lumbarsymptoms .symptoms .

Straight Leg Raise (SLR)Straight Leg Raise (SLR)PositionPosition

Supine with trunk and hip inSupine with trunk and hip inneutral positionneutral position ..

MethodMethod

Therapist places one handTherapist places one handunder theunder the calcaneumcalcaneum and theand theother proximal to the knee.other proximal to the knee.

The leg is lifted perpendicular toThe leg is lifted perpendicular tothe bed as a solid lever movingthe bed as a solid lever movingat a fixed point in the hip joint.at a fixed point in the hip joint.

The hand above the kneeThe hand above the kneeprevents knee flexionprevents knee flexion


Posterior thigh painPosterior thigh pain

Radiating painRadiating pain

Lower lumbar painLower lumbar pain

ResponseResponse

Range of motion , symptom response andRange of motion , symptom response andrestriction encountered through therestriction encountered through themovement are noted .movement are noted .

Response are compared to the other leg.Response are compared to the other leg.

VariationsVariations

SLR /SLR /DorsiflexionDorsiflexion

DorsiflexionDorsiflexion /SLR/SLR TibialTibial tract .tract .

SLR/SLR/dorsiflexondorsiflexon/inversion/inversion –– SuralSural nerve.nerve.

SLR/ PF/inversion CommonSLR/ PF/inversion Common peronealperoneal

PF/inversion/SLR nerve .PF/inversion/SLR nerve .

SLR /Add/medial rotationSLR /Add/medial rotation –– Sciatic tract.Sciatic tract.

Bilateral SLR.Bilateral SLR.

SLR in spinal extension.SLR in spinal extension.

SLR/DFSLR/DF--------TIBIAL NERVETIBIAL NERVE

SLR/INV/DFSLR/INV/DF--------SURAL NERVESURAL NERVE

SLR/INV/PFSLR/INV/PF------COMMONCOMMONPERONEAL NERVEPERONEAL NERVE

Passive Neck FlexionPassive Neck Flexion

PositionPosition

Supine lying preferable without a pillow .Supine lying preferable without a pillow .

MethodMethod

Therapist passively flex the neck in a chinTherapist passively flex the neck in a chin

to chest direction .to chest direction .

Symptom responses , range of motion andSymptom responses , range of motion andrestrictions encountered through therestrictions encountered through themovement are noted and analyzed .movement are noted and analyzed .


Asymptomatic person may feel a pulling atAsymptomatic person may feel a pulling atthethe cervicocervico thoracic junction .thoracic junction .


Spinal disordersSpinal disorders

Headache symptomsHeadache symptoms

Arm and leg pain of spinal originArm and leg pain of spinal origin

Lumbar painLumbar pain

Sciatic painSciatic pain

NoteNote

In supine , other spinal components areIn supine , other spinal components areneutralized , thus allowing betterneutralized , thus allowing betterinterpretation of test result .interpretation of test result .

Here theHere the neuraxisneuraxis andand meningesmeninges of theof thelumbar spine and a part of sciatic tract islumbar spine and a part of sciatic tract ismoved and tensioned .moved and tensioned .

VariationsVariations

Passive neck flexion / upper thoracicPassive neck flexion / upper thoracicflexionflexion

Passive cervical extension .Passive cervical extension .

Slump TestSlump TestMethodMethod Patient sits with thighs fully supported and kneesPatient sits with thighs fully supported and knees

together .together . Patients hand is linked gently behind his back .Patients hand is linked gently behind his back . Patient is asked toPatient is asked to ‘‘slump or sagslump or sag Over pressure is applied to the lumbar andOver pressure is applied to the lumbar and

thoracic in attempt to bow the spine rather thanthoracic in attempt to bow the spine rather thanhip flexion .hip flexion .

Ask the patient to bend the chin to chest .Ask the patient to bend the chin to chest . Over pressure in the same direction is added .Over pressure in the same direction is added . Extend the knee actively .Extend the knee actively . DorsiflexDorsiflex the ankle actively .the ankle actively .


On slumpOn slump –– nilnil

Slump / neck flexionSlump / neck flexion –– pain in T8pain in T8-- T9 area inT9 area in50% of cases.50% of cases.

Slump / neck flexion / knee extensionSlump / neck flexion / knee extension ––pain inpain inthe hamstrings and restriction of knee extensionthe hamstrings and restriction of knee extensionwhich should be symmetrical . Pain is also feltwhich should be symmetrical . Pain is also feltbehind the knee.behind the knee.

Slump / neck flexion / knee extension / ankle DFSlump / neck flexion / knee extension / ankle DF--Some restrictions of ankle DFSome restrictions of ankle DF

On release of neck flexion, symptoms reduces inOn release of neck flexion, symptoms reduces inall areas .all areas .

Increase in range of knee extension and ankleIncrease in range of knee extension and ankleDFDF


Spinal symptomsSpinal symptoms

Symptoms seen in positions ofSymptoms seen in positions ofslump test such as while gettingslump test such as while gettinginto a car or kicking a foot ball.into a car or kicking a foot ball.

TREATMENT IRRITABLE

Non-provoking initially

Grades I & II(Maitland)

“anti-tension”postures

Avoiding activitiesthat provoke thesymptoms

Rest

NON-IRRITABLE

Non-provokinginitially

Grades I & II

Grades III & IV(Maitland)

Rest

TREATMENT PROGRESSION

IRRITABLE Increase # of

oscillations Increase amplitude Increase the

mobilization of thenervous system

Point of application ofthe technique movedcloser to the involvedarea

Treat as non-irritable

NON-IRRITABLE Increase length of

time Increase # of

oscillations Increase amplitude Increase mobilization

of the nervous system Point of application of

the technique movedcloser to the involvedarea

Treat non-neuralstructures

SELF TREATMENTSELF TREATMENT Has two main aspectsHas two main aspects

--self mobilization techniqueself mobilization technique--postural adaptation.postural adaptation.

Therapist and the subject must be awareTherapist and the subject must be awareof affects of mobilization.of affects of mobilization.

Technique must fit the subject.Technique must fit the subject. Can be adapted for irritable as well as nonCan be adapted for irritable as well as non

irritable disorders.irritable disorders.Mechanical pain is best for mobilization.Mechanical pain is best for mobilization. How much , How many and When toHow much , How many and When to

perform must be based on clinicalperform must be based on clinicalreasoning .reasoning .

SELF TREATMENTSELF TREATMENT

PRECAUTIONS Age of presentation less than 20 yrs or moreAge of presentation less than 20 yrs or more

than 55yrsthan 55yrs Unrelenting, progressive non mechanical painUnrelenting, progressive non mechanical pain Night painNight pain Recent weight lossRecent weight loss Violent traumaViolent trauma Thoracic painThoracic pain Drug abuse, HIVDrug abuse, HIV Morning stiffnessMorning stiffness Peripheral and spinal joint stiffness in allPeripheral and spinal joint stiffness in all

directionsdirections Inflammatory, systemic, and ineffective disorders

that affect the nervous systemFamily history ofFamily history of spondyloarthropathyspondyloarthropathy

CONTRAINDICATIONS

Rheumatoid Arthritis.Rheumatoid Arthritis.

OsteoArthritisOsteoArthritis..

Suspicion of metastasis.Suspicion of metastasis.

Current back or neck pain.Current back or neck pain.

Bladder/bowel incontinence.Bladder/bowel incontinence. Neurological changes are worsening

- Acute compartment syndrome

- Injury likely to cause neurological deficit.

Any other neurological signs andAny other neurological signs andsymptoms elsewhere in the body.symptoms elsewhere in the body.

CONCLUSIONCONCLUSION

Treatment is based on the severity, irritabilityTreatment is based on the severity, irritabilityand nature of the disorder.and nature of the disorder.

Should be non provoking initially.Should be non provoking initially.

Large Grade II glides performed slowly andLarge Grade II glides performed slowly andrhythmically.rhythmically.

Oscillations for 20 sec to several min can beOscillations for 20 sec to several min can begiven.given.

Amplitude of the technique can be progressedAmplitude of the technique can be progressedtill some symptoms are reproduced or wheretill some symptoms are reproduced or wheresome resistance to thesome resistance to the movtmovt is encountered.is encountered.

THANK YOUTHANK YOU

neural tension test

Documents

Transcript of neural tension test