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- 1. Neurodynamic Testing andNeural Mobilization Tyler A Wood PhD, ATC* & Nicholas E Grahovec, PhD, LAT, ATC, CSCS Northern Illinois University Department of Kinesiology and Physical Education, DeKalb IL. email: [email protected]
- 2. • The authorshave no conflicts of interest to report Disclosures
- 3. • Determine whenneurodynamic restrictions may be present. • Evaluate neurodynamics through neurodynamic testing and peripheral nerve tension testing. • Select neural mobilizations based on findings from neurodynamic testing and peripheral nerve tension testing. Objectives
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- 5. • Nervous systemdivided into central nervous system (CNS) and peripheral nervous system (PNS) • PNS pathways – Afferent – Efferent – Autonomic Neural Anatomy https://www.apa.org/helpcenter/stress/ef fects-nervous
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- 7. Upper Extremity NeuralAnatomy https://en.wikipedia.org/wiki/M edian_nerve#/media/File:Nerves _of_the_left_upper_extremity.gi f
- 8. Upper Extremity NeuralAnatomy https://en.wikipedia.org/wiki/Nerve_sup ply_of_the_human_arm#/media/File:Gra y812and814.svg
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- 13. • With motor movement,such as athletic participation, the nerves and surrounding connective tissues glide with the movement (Shacklock 2005) Neurodynamics http://eznetpublish.ihealthspot.com/
- 14. Median Nerve Excursion MTWalsh. Upper limb neural tension testing and mobilization: fact, fiction, and practical approach. J Hand Ther. 2005;18(2):241-258
- 15. Median Nerve Excursion MTWalsh. Upper limb neural tension testing and mobilization: fact, fiction, and practical approach. J Hand Ther. 2005;18(2):241-258
- 16. • Nerve fibersand the surrounding connective tissue are susceptible to injury • How the nerve responses to injury (Carp 2015) – Neuropraxia – axon conduction is blocked due to a physiologic process without a histological change – Axonotmesis – loss of continuity of the nerve with continuity of the connective sheaths – Neurotmesis – loss of axon including the connective tissue Neural Injury
- 17. • Injury ofthe neural tissue and surrounding areas may result in scaring and neurodynamics restrictions (Shacklock 2005; Carp 2015) • Symptoms of neurodynamic restrictions include numbness or tingling with movement and/or a deep uncomfortable sensation which has never been felt before (Shacklock 2005; Carp 2015) Neural Injury
- 18. • With motor movement,such as athletic participation, the nerves and surrounding connective tissues glide with the movement (Shacklock 2005) Neurodynamics (Restrictions) http://eznetpublish.ihealthspot.com/
- 19. Video Demonstrations withDr. Grahovec
- 20. • Straight LegRaise Test • Prone Knee Bend • Median Nerve Traction Test • Radial Nerve Traction Test • Ulnar Nerve Traction Test Neurodynamic Testing
- 21. • Examination ofmotor function • Sensory examination • Integumentary and vascular examination • Deep tendon reflexes (DTR) • Abdominal reflex • Babinski reflex • Tinel sign • Functional examination Additional Neural Diagnostic Tests
- 22. Neural vs Non-Neural10 Sign/SymptomNeural Tissue Non-Neural Tissue Tissue example Median nerve Biceps tendon Description of pain “Unusual, never felt anything like this, deep, uncomfortable, toothache like, numbness, pins and needles” “A pulled muscle, like I worked out too much, a sharp pain” Constancy of pain Prolonged perception after stretch; does not immediately decrease Once tension removed, symptoms decrease rapidly Palpation symptoms Causes radicular symptoms in specific innervation pattern Local pain and tenderness occasionally with myotomal or dermatomal reference Visualization Therapist may see muscle fasciculations Occasional muscle spasms
- 23. • Neural Gliding –Fixation of proximal portion of the nerve – Distal portion of nerve in controlled stretch – Symptoms typically occur distal aspect of nerve Neural Gliding vs Neural Sliding
- 24. • Neural Sliding(“Flossing”) – Movement of proximal end toward distal end with simultaneous elongating of distal end – Movement of distal end toward proximal end with simultaneous elongating of proximal end Neural Gliding vs Neural Sliding Santana HHS, Fernandes de Oliveira IAV, Medrado AP, Nunes Sá K, et al., (2015) Neurodynamic Mobilizatio and Peripheral NerveRegeneration: A Narrative Review. Int J Neurorehabilitation 2: 1000163.
- 25. A :Sliding technique B: Tensioning technique C-F : Gliding Techniques Neural Gliding vs Neural Sliding Coppieters MW, Alshami, AM. Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. J Ortho Res. 2007; 25:972-980.
- 26. • Combine neuralmobilization with other interventions. • Minimize the effects of inflammation and avoid any additive inflammation through undue stresses. • Be cognizant that physiologic responses to nerve mobilization are typically much greater than with contractile and other noncontractile tissues • Ensure only the exact prescribed mobilization is being performed and that all extraneous joint movement is controlled. • Instruct the patient in the prescribed frequency, repetition, duration, and intensity of the prescribed self-management techniques. Neural Mobilization Guidelines3
- 27. • Limit excursionto the onset of symptoms, hold for short period of time, and then release. • Daily reexamination pre- and post-intervention is required in order to identify the stage of healing. • Home self-management is often delayed until similar technigues are tolerated during formal therapy sessions and the patient’s ability to handle such stresses is established. • Examination procedures become the intervention. Neural Mobilization Guidelines3
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- 31. Neurodynamic Evidence • Neuralmobilization was effective for nerve-related low back pain, nerve-related neck and arm pain, and plantar heel pain and tarsal tunnel syndrome • Neural mobilization was not effective in the management of carpal tunnel syndrome
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- 33. Neurodynamic Evidence • Neuralmobilization increased knee extension range of motion of contralateral limb • May have occurred through displacement of the sciatic nerve of the ipsilateral nerve root
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- 36. • Passive straight-legraise and prone knee bend displayed significant improvements of 5 deg – 9 deg of increased motion bilaterally • Significantly increased stretch tolerance of the participants before and after treatment Neurodynamic Evidence
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- 38. Neurodynamic Evidence • Neurodynamicmobilization showed a medium effect (0.7) on knee extension range of motion when compared to manual therapy • Neurodynamic mobilization showed a large effect (1.2 5) on tissue extensibility when compared to other manual therapy
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- 41. • Neural mobilizationhas been shown to be effective in: – reducing pain perception related to delayed onset muscle soreness – decreasing neck and back pain – improving lower flexibility and range of motion – improving stretch tolerance – improving vertical jumping performance • Still yet, more research is needed to fully understand neurodynamic and treatment of neurodynamic restriction Bottom Line
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- 43. 1. Aksoy CC,Kurt V, Okur İ, Taspınar F, Taspinar B. The immediate effect of neurodynamic techniques on jumping performance: A randomised double-blind study. J Back Musculoskelet Rehabil. 2019;(Preprint):1–6. 2. Basson A, Olivier B, Ellis R, Coppieters M, Stewart A, Mudzi W. The effectiveness of neural mobilization for neuromusculoskeletal conditions: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017;47(9):593–615. 3. Carp, SJ. The theory and practice of neural dynamics and mobilizations. In: Orthopaedic Manual Physical Therapy: From Art to Evidence. FA Davis. 4. Leonardo P, Matteo P, Tommaso G, Daniele P, Marco B. Mobilization of the contralateral limb in Slump position: effects on knee extension in healthy adult subjects. Acta Bio Medica Atenei Parm. 2020;90(3):245. 5. López LL, Torres JR, Rubio AO, Sánchez IT, Martos IC, Valenza MC. Effects of neurodynamic treatment on hamstrings flexibility: A systematic review and meta-analysis. Phys Ther Sport. 2019;40:244–250. 6. Pietrzak M, Vollaard NB. Effects of a novel neurodynamic tension technique on muscle extensibility and stretch tolerance: A counterbalanced crossover study. J Sport Rehabil. 2018;27(1):55–65. 7. Romero-Moraleda B, La Touche R, Lerma-Lara S, et al. Neurodynamic mobilization and foam rolling improved delayed-onset muscle soreness in a healthy adult population: a randomized controlled clinical trial. PeerJ. 2017;5:e3908. 8. Shacklock M. Improving application of neurodynamic (neural tension) testing and treatments: a message to researchers and clinicians. Man Ther. 2005;3(10):175–179. 9. Walsh MT. Upper limb neural tension testing and mobilization: fact, fiction, and a practical approach. J Hand Ther. 2005;18(2):241–258. References
- 44. 10. Santana HHS,Fernandes de Oliveira IAV, Medrado AP, Nunes Sá K, et al. Neurodynamic Mobilization and Peripheral NerveRegeneration: A Narrative Review. Int J Neurorehabilitation. 2015; 2: 1000163. 11. Coppieters MW, Alshami, AM. Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. J Ortho Res. 2007; 25:972-980. References