13 - Neural Mobilization

Neurodynamics &
Neural Mobilization
Tec hniques
BY DR/ KHALED ALSAYANI
Introduction
Neurodynamics refers to the communication between different parts

of the nervous system and to the nervous systems relationship to the
musculoskeletal system. It has been shown that the nerves move
independently from other tissues. The term Neurodynamics first made
an appearance in 1989 and has since been further developed over
the last 30 years. Neurodynamics is now seen as an important part of
injury assessment and treatment.
 Neurodynamics in the sense implied here is the mobilization of the nervous system as an
approach to physical treatment of pain. The treatment and/or assessment relies on influencing
pain physiology via the mechanical treatment of neural tissues and non-neural structures
surrounding the nervous system. This mobilization activates a rang of mechanical and
physiological responses in nervous tissues .Eg neural sliding, elongation, tension and changes
in intraneural microcirculation, axonal transport and nervous impulse movements.
•Definition:
Neural mobilization is a manipulative technique by which neural
tissues are moved & stretched either by movement relative to their
surroundings or by tension development.
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
•Rational for Use
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.
•Site of Pathology
It is very important to determine the tissues responsible for
the symptoms ) site of pathology( this may be intraneural
or extraneural.
Extra-neural Pathology: at the mechanical interface

anywhere 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.
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
•Effect of neural mobilization:
1. Improving neural axonal transport
2. Improving blood flow to the neural tissue.
3. Restoration of normal mechanics of the connective tissues

thus lessening the possibility of the
nerve being entrapped in their surrounding
connective tissue.
4. Enhancing the intraneural process by alteration of the

pressure in the nervous system and dispersion of
intraneural edema.
• Neural Tension Tests
1. 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)
2. Nervous tissue adaptation to movement the nervous tissue responed
to movement of the body by producing movement at
different levels Gross movement of the nerves in relati on to the
mechanical interface .g.e Sliding movement of the median nerve in
relation to the carpal tunnel with movements of upper limb
3. The Base Tests Passive neck flexion (PNF)
4. Straight leg raise(SLR)
5. Prone knee Bens( PKB)
6. Upper Limb tension tests (ULTT)

•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.
-Be aware of the expected normal response .
-Know all details of all the symptoms.
-Know the symptoms in the starting position.
-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.
•Positive tension test:
A tension test can be considered positive if It reproduces the patients
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.
• 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.
N.B 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.
SLR - Straight Leg Raise
• Test
The Straight Leg Raise (SLR) test is commonly used to identify disc pathology
or nerve root irritation, as it mechanically stresses lumbosacral nerve
roots.
• It also has specific importance in detecting disc herniation and
neural compression.
• It is also classified as a neurodynamic evaluation test as it can detect
excessive nerve root tension or compression.
Technique:
- The classic straight leg raise is performed passively.
- Each leg is tested individually with the unaffected leg being tested first.
- When performing the SLR test, the patient is positioned in supine without a pillow under their head, the clinician stands at the tested
side with their distal hand around the patient's heel and proximal hand on patient's distal thigh(anterior) to maintain knee extension.
- The clinician lifts the patient's leg by the posterior ankle while keeping the knee in a fully extended position.
- The clinician continues to lift the patient's leg slowly through flexing at the hip, until the patient's symptoms are replicated, or they
experience tightness in the back or posterior thigh.
- If pain is primarily in the leg, it is more likely that the pathology causing the pressure on neurological tissue(s) is more lateral.
Special
Tests
For
neurologica
l
dysfunction
SLR showed high sensitivity of 91 % varying specificity

of 26 %
Prone knee bend test or variant – Femoral Nerve
• The prone knee bending test is a neural tension test used to stress the femoral nerve and the mid lumbar (L2-L4) nerve roots.
• The femoral nerve tension test is used to screen for sensitivity to stretch soft tissue at the dorsal aspect of the leg,
possibly related to root impingements.
Special
Tests For
neurological
dysfunction
Technique:
- The patient lies prone, and the therapist stands on the affected side and stabilizes the pelvis to prevent anterior
rotation with one hand. With the other hand, the therapist then maximally flexes the knee to end range.
- If no positive signs are noted in this position, the therapist proceeds to extend the hip while maintaining knee
flexion.
- Normal response: Knee flexion allowing the heel to touch the buttocks. A pull or a stretch is
felt in the quadriceps.
- If unilateral pain is produced in the lumbar region, buttocks, posterior thigh, between the ranges of 80-100
degrees of knee flexion in a combination of these regions, the test is considered positive.
- If pain is produced before 80 degrees of knee flexion, quadricep tightness and/or injury may be the cause.
Evidence
The specificity and sensitivity of the test is unknown.
• Upper limb tension test (ULTT(
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.
Normal response Deep stretch or ache 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
•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
•Key to successful treatment:

Neural 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.
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.
Contraindications:
• Recent onset, or worsening neurological signs
• Cauda equine lesions
• Cord signs
• Recent surgery
• dizziness.

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Neurodynamics &

Neurodynamics refers to the communication between different parts

Neural tension techniques are used to decrease adverse mechanical

Extra-neural Pathology: at the mechanical interface

2. Improving blood flow to the neural tissue.

3. Restoration of normal mechanics of the connective tissues

4. Enhancing the intraneural process by alteration of the

3. The Base Tests Passive neck flexion (PNF)

4. Straight leg raise(SLR)

5. Prone knee Bens( PKB)

6. Upper Limb tension tests (ULTT)

-Be aware of the expected normal response .

-Know all details of all the symptoms.

-Know the symptoms in the starting position.

-Monitor symptoms throughout the procedures.

-Notice when pain starts .

The effect of sensitizing additions/subtractions on the symptoms, this is

The test response can be altered by movement of distant body parts.

Normal response: PNF is a painless test.

N.B If patient felt pulling at the cervico-thoracic junction, this is related to

SLR showed high sensitivity of 91 % varying specificity

After examination of the patient, if the therapist decides there is a

•Key to successful treatment:

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