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

1. Prepared by
Associate Professor
S.Dineshkumar
Madha college of physiotherapy

2. 1.Functional anatomy
2.Clinical neurobiomechanics
3.Pathological processes
4.The clinical consequences of injury to the
nervous system
5.Examination
6.Tension testing
7.Treatment

3.  CONCEPT OF CONTINUOUS TISSUE TRACT
 Connective tissues are continuous
 Neurons are interconnected
 Continuous chemically

4.  The neuron
 Consist of a cell body,some dendrites and usually
one Axon
 Axons are either myelinated or non myelinated
 Axon grouped together in to bundles or fascicles
 Axons –Nerve fibers
 Cytoplasm of neuron-Axoplasm

5.  Nerve fibers three kind
motor(AHC-NMJ)
sensory(DRG-RECEPTORS)
Autonomic(ventral horn SC,PGF)

6.  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 force
 Maintains the endoneurial space and fluid
pressure,A slight positive pressure .

8.  Each fascicle is surrounded by a thin
lamellated sheath known as Perineurium
 Protecting the content of endoneurial tubes
 Acting as mechanical barrier to External forces
 Serving as a diffusion barrier
 Most resistant to tensile forces

9.  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

10.  Mesoneurium is a loose areolar tissue
peripheral nerve trunks .
 Blood vessels enter the nerve via mesoneurium
 Allows the nerve to glide along the adjacent
tissue.

11.  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.

13.  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.

15.  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

17.  The supply of blood to the nervous system
 The axonal transport nervous system
 The innervations of the connective tissues of
nervous system

18.  Lattice collagen arrangement
 When 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

20.  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)

21.  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 reaction
 Consriction,loss blood supply, viruses may impede
the flow.

23.  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.

24.  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.

25.  MECHANICAL INTERFACE
 Defined as that tissue or material adjacent to the
nervous system that can move independently to
the system.

27.  Pathological interface
 A tight plaster or bandage
 Edema
 Blood
 Osteophyttes
 Ligamentous swelling
 Fascial scarring

28.  NERVOUS SYSTEM ADAPTATIONS TO
MOVEMENT
 1.the development of tension or increased
pressure within the tissues
 2.gross movement or intraneuralmovement
 Grossmt example:median nerve movement in caarpal
tunnel.
 Intraneural mt:Spinalcord mt in relation to duramatter.

29.  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.

30.  Neuraxialand meningeal adaptive
mechanism:
 Ex:the slump test and passive neck flexion test
 Both employ spinal flexion test
 In flexion –moves anteriorly
 In extension –moves posteriorly
 In rotation stays constant
 C6,T6,L4 vertebral levels –no nervous system
movement in relation to interfaces.
 From spinal extension to flexion the cord
converge towards C4,C5 disc.

31.  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.

32.  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 cm
ULNAR NERVE
Migrated proximally during flexion of elbow.

33.  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.

34.  Site of injury
 Soft tissues ,osseus or fibro- osseus tunnels.
 Where the nervous system branches
 Where the system is relatively fixed
 Unyielding interfaces.
 Tension points.

35.  Kind of injury
 Mechanical 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.

36.  Intraneural and extra neural pathology
 1.intra neural pathology
 Conducting tissue connective tissue
 Demyelination scarred epineurium
 Neuroma formation arachnoiditis
 Hypoxic nerve fibers irritated duramatter

37.  Extra neural pathology
 Nerve bed
 Blood in nerve bed or epidural space
 Mechanical inetrface
 `swelling of bone and muscle adjacent to a nerve
trunk.

38.  PATHOLOGICAL PROCESS
 VASCULAR FACTORS IN JNIURY
 Hypoxia
 Edema
 Fibrosis
 MEHANICAL FACTORS
 The myelin on one side of the node becomes
streched
 The myelin on the other side becomes
invagenated
 Displacement of node of Ranvier

39.  Injury and axoplasmic flow
 Trophic changes in target tissue(skin,muscle)
 Damage to cell body and axon
 Blood supply compromise affect the axonal flow
 Mild compression of 30-50 mmhg interrupt both
antegrade and retrograde flow.
 an axoplsmic transport block by a 50 mmhg
For 2 hours was reversible in 24 hours.
2 hours of compression at 200 mmhg was reversible
within 3 days.

41.  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.

42.  Further consequences of nerve injury
 Fibrosis
 Double crush syndrome
 Triple and multiple crush syndromes
 Abnormal impulse generating mechanism

43.  SIGNS AND SYMPTOMS FOLLOWING INJURY
 AREA OF SYMPTOMS
 KINDS OF SYMPTOMS
 HISTORY
 POSTURAL AND MOVEMENT PATTERNS

44.  SIGNS AND SYMPTOMS
 Level of involvement(UMN,LMN,SEGMENTAL)
 Severity of involvement
 The tissue components involved(neural tissue or
connective tissue)
 From local or remote sources.
 Whether an intraneural or extraneural process is
evedent
 The sstage of the disorder(acute or chronic)
 The progression of the disorder

45.  AREA OF THE SYMPTOMS
 Vulnerable areas ex:carpaltunnel,head of fibula
 Symptoms 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)

46.  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)

47.  HISTORY
 MECHANISM OF INJURY
 PREVIOUS INJURY
 PREVIOUS TREATMENT
 OTHER CONTRIBUTING FACTORS

48.  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.

49.  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)

50.  PHYSICAL EXAMINATION OF SENSATION
 LIGHT TOUCH
 PIN PRICK
 VIBRATION
 PROPRIOCEPTION
 TWO POINT DISCRIMINATION

51.  EXAMINATION OF MOTOR FUNCTION
 WASTING
 REFLEX TESTING
 MUSCLE POWER TESTING
 TEST FOR SEGMENTALLEVEL
 C4-SCAPULAR ELEVATORS
 C5-DELTOID
 C6-BICEPS
 C7-TRICEPS
 C8-LONG FINGER FLEXORS
 T1-INTERROSSEI AND LUMBRICALS

52.  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

53.  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

54.  Cord function test
 Ankle clonus
 Babinski test
 ELECTRO DIAGNOSIS
 NEUROPATHY IS FROM PERIPHERALNERVE OR MYOPATHY
 SYSTEMIC CONDITIONS(alcoholic,diabettic neuropahy)
 ASSISTING FOR SURGICAL INTERVENTION
 OBJECTIVE MEASUREMENT FOR TREATMENT
 IDENTIFICATION OF ANAMALIES.

55.  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.

56.  ULTT1:
 METHOD:
 Patient positioned in supine
 A constant depression force placed on shoulder
girdle
 Forearm supiated ,wrist and fingers extended.
 The shoulder is laterally rotated
 The elbow is extended.earlier component
positions must be maintained
 With this position ,cervical lateral flexion to the
left then to the right are added.

58.  NORMAL RESPONSES
 A deep stretch or ache in the cubital fossa
 A definite tingling sensation in the thumb and
first three fingers
 A 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.

59.  Upper limb tension test 2
 Supine lying
 Shoulder depression maintained
 Shoulder medially rotated
 Forearm 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

61.  UPPERLIMB TENSION TEST 3
 Starting position same as ULTT1
 wrist exended and fore armsupinated
 Elbow fully flexed
 With maintaining Shoulder depression ,abduction
added
 NORMAL RESPONSE
 In asymptomatic people ,a commo response is burning
and tingling in the ulnar nerve distribution in the hand
or medial aspect of elbow.

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

64.  PASSIVE NECK FLEXION TEST
 PATIENT LIES SUPINE
 LIFT HEAD OFF THE BED A LITTLE
 PASSIVELY FLEXING THE NECK TOWARDS CHIN ON
CHEST DIRE CTION
 During the movement symptom responses
,ROM,resistance encountered through the
movement are noted and analysed.

65.  STRAIGHT LEG RISE TEST
 Supine lying
 Hip and trunk neutral
 The leg is lifted perpendicular to the bed,hand
above knee joint prevents knee flexion.
 The responses must compared with the responses
of other leg.
 SENSITISING
 Ankle dorsiflexion(tibial tract)
 Ankle plantar flexion(common peroneal nerve)

66.  PRONE KNEE BEND
 Patient lies prone
 Grasp the lower leg and flexes the knee
 Check for symptom response
 Compare to contralateral leg

67.  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.

69.  Analysis of tesion test
 The range of movement at which symptom first
start.
 Whether the disorder is non irrritable
 The type and area of symptoms
 The resistance encountered during the test
 The above findings must be compared to the
testof the contralateral limb.

70.  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 side
 Range of movement
 Resistance encountered duringthe movement
 Symptom response during the movement.

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

72.  CONTRAINDICATIONS
 Recent onset of,or worsening neurological
signs
 Cauda eqina leision
 Injurt spinal cord.

73.  PRECAUTIONS
 Irritability the nervous system
 Presenceof meurological signs
 General health problemss
 Dizzness
 Circulatory distubances

74.  References
 MOBILISATION OF THE NERVOUS SYSTEM
 By
 David s.butler
 Mark A jones.

75. THANK YOU