Nerve Mobilization PDF

NERVE MOBILIZATION Definitions Injuries with a neural component – Disc – Sciatica – Carpal Tunnel – Brachial plexus Low compressive forces causes a temporary compromise of intraneural tissue (Lundberg, 1988 as in Slater, Butler & Shacklock, 1994) Continued load caus...

NERVE MOBILIZATION Definitions Injuries with a neural component – Disc – Sciatica – Carpal Tunnel – Brachial plexus Low compressive forces causes a temporary compromise of intraneural tissue (Lundberg, 1988 as in Slater, Butler & Shacklock, 1994) Continued load causes the neuron and supporting structures to become more susceptible to compression (Dahlin et al, 1986, as in Slater et al., 1994) Nerve pathology affects innervated structures  Nerve Mobilization – Overall Principles (Butler, Shacklock & Slater, 1994) Assess neural tension tests to determine problem Assess interfaces (muscle, joint, fascia) – Treat interfaces first if they have the most restriction Treat NS when these structures have been addressed – Treat NS first when nerve = most comparable structure in assessment (no interfaces indicated) Amount and intensity of treatment based on reaction to treatment – Passive techniques allow muscle interfaces to relax – Active techniques needed for home programs If progress plateaus, assess whether all components been addressed Principles of Tension Testing (Slater et al., 1994) Tension tests affect neural and non-neural tissue Components Concept – Consider all possible sources of signs and symptoms – Establish whether sources present physical signs – Demonstrate physical signs that are related to disorder Be able to retest following treatment of a specific component Principles of Tension Testing (Slater et al., 1994) Sensitizing Tests – Use structural differentiation to alter component movements remote from the site of symptoms Upper Limb Tension (Neurodynamic) Tests SLR Slump Principles of Tension Testing (Slater et al., 1994) Interpretation of tests – Response of contralateral limb – Range of tension test – Behaviour of symptoms through range – Area of response – Sequence of area response – Affect of sensitizing manoeuvres – Abnormal responses (e.g. dizziness)  SLR Sensitizing Tests (Slater et al., 1994) SLR traditionally used to assess L/S and LE disorders, but can also help assess lower limb overuse syndromes, recurrent ankle sprains, plantar fasciatus, achilles tendonitis Ankle DF – increases tension in tibial branch of sciatic N. Ankle DF/INV – increases tension in sural branch of sciatic nerve Hip adduction – increases tension b/c sciatic nerve lateral to ischial tuberosity Hip medial rotation – increases tension in sciatic nerve and common peroneal branch Cervical flexion, extension, side flexion – increase tension in dural structures  Other Neural Tests Slump Test Differs from SLR in inclusion of meninges/dural component C6, T6, L4 = areas where dura relatively tethered (Louis, 1981 as in Slater, Butler & Shacklock, 1994) Upper Limb Tension (Neurodynamic) Tests If symptoms are distal, taking up the distal components first will be more sensitive, and visa versa (Slater et al., 1994)  Treatment (Butler, Shacklock & Slater, 1994) Goal = restore range of movement of nervous system and normalize sensitivity of the system Determine whether nervous system involved through SLR, PKB, Slump, ULTTs Mobilize, not stretch – Gentle and strong techniques – Through range and at end range – With respect to symptoms – Reassessment  Treatment (Butler, Shacklock & Slater, 1994) Suitable disorders for treatment – Inflammatory reaction (pathophysiology) = irritable – Biomechanical compromise (pathomechanics) = non-irritable Sliders more likely to be used in irritable conditions Tensioners more likely to be used in non-irritable conditions Treatment of Irritable Disorders (Butler, Shacklock & Slater, 1994) Treat relevant interfacing structures distal to the injury site NS mobilization distant to symptom area Non-provoking initially (no change in symptoms) – Under-treat initially until the sensitivity of the system becomes clear – Gr. II (amplitude) slowly and rhythmically through non-provoking range – 3-5 sec oscillations (vs. 2-3 oscillations/sec with joint mobilization) Treatment Progression of Irritable Disorders (Butler, Shacklock & Slater, 1994) Treatment progression based on reassessment of symptoms Change one of the following at a time Increase # reps – Start with 20 sec total – Increase to several minutes Increase amplitude of techniques Repeat with NS in tension Move technique closer to symptom area Move from passive treatment to active self- treatment  Treatment of Non -Irritable Disorders (Butler, Shacklock & Slater, 1994) Treat relevant interfacing structures Gr. III or Gr. IV (amplitude) through range If concerned about irritability, technique should stop just prior to provoking symptom Can direct treatment at area of symptoms Treat 20-30 sec of oscillations – 3-5 sec oscillations (vs. 2-3 oscillations/sec with joint mobilization) Treatment will involve some discomfort, but symptoms should resolve within seconds of stopping technique  Treatment Progression of Non- Irritable Disorders (Butler, Shacklock & Slater, 1994) Treatment progression based on reassessment of symptoms Change one of the following at a time – Increase time of technique – Go further into resistance – Add components that increase tension to original technique – Use technique closer to the source of symptoms – Treat involved non-neural structures in tension position – Move from oscillatory technique to sustained technique  Nerve Mobilization – Precautions & Contraindications (Butler, Shacklock & Slater, 1994) Precautions – Maitland, 1986 – Discontinue if symptoms worsening – Cord signs Contraindications – Inflammatory, systemic, infectious disorders of the nervous system e.g. AIDS, diabetes, multiple sclerosis  Nerve Mobilization – Overall Principles (Butler, Shacklock & Slater, 1994) Assess neural tension tests to determine problem Assess interfaces (muscle, joint, fascia) – Treat interfaces first if they have the most restriction Treat NS when these structures have been addressed – Treat NS first when nerve = most comparable structure in assessment (no interfaces indicated) Amount and intensity of treatment based on reaction to treatment – Passive techniques allow muscle interfaces to relax – Active techniques needed for home programs If progress plateaus, assess whether all components been addressed