Neurodynamic Techniques EN
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Transcript of Neurodynamic Techniques EN
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A DEFTfiIITIVE GUIMT
D\ID AIVN HANSBOOK
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Published by Noigroup Publications
for NOI Australasia PtY Ltd
DVD reproduction by Microview Solutions
Printed and bound by van Gastel Printing
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All rights reserved' No part of this publication may be
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orofessional standards set for the circumstances that
apply in each situation. Every effort has been made to
confirm accuracy of the information presented and to
correctly relate generally accepted practises'
The authors, editor and publisher cannot accept
responsibility for errors or exclusions or for the outcome
of the application of the material presented hereln'
There is no expressed or implied warranty of this book
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NoigrouP PublicationsNOI Australasia PtY Ltd
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South Australia 5000www. noigrouP.comTelephone +61 (0)B 8211 6388
Facsimile +61 (0)B 8211 8909
Butler, David S.
First edition 2005
ISBN 0-9750910-1-B
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With thanks to... Our international faculty I
NOI Faculty members NOI instructors are hand selected on the basis of ITranslators - Ruggero strobbe (Italian), stefan their existing skills and expertise and undergo Ischiller and Margot Bauer-Mitterlehner (German), progressive peer and expert training' All instructors IHenry Tsao and Mei-chun Kuo Tsao (chinese have postgraduate manual therapy educations and I
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Desisn - Ariane Ailchurch, Dinah Edwards n'J,""ffi:i:ffiit;: iT::'ff'.:ill"JiiSio=#"'n IProduction manager - Juliet Gore members of the faculty IAnatomy artwork - copyright (2005), Icon NOI's faculty members all travel widely to meet their ILearning Systems, LLC. A subsidiary of MediMedia, teaching commitments IUSA, Inc. All rights reserved. Australia IDvD authoring - Anthony James David Butler, Peter Barrett, carolyn Berryman, Ispectra Videographics, [email protected] Michel coppieters and Megan Dalton IReproduction - Microview solutions Europe - German speaking IChatswood NSW Australia, www.microview.com.au Gerti Bucher-Dollenz, Martina Egan-Moog, Iprintins - van Gastet printins, Adetaide, Austratia :ili:"::"#:].:ki'
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Music - Maria by Miguel Espinoza Europe _ rtalian speaking ISergio Parazza, Erika Schiffereger, Ruggero Strobbe, ISusanne Wahrlich and Irene Wicki. IUSA
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IIIntroduction Nine key points III
This neurodynamics techniques DVD 1 , wn"t is a neurodynamic test? |and book has been produced by the Neurodynamics is the science of the relationships between mechanics and INeuro orthopaedic Institute physiology of the nervous system. simply put - it is the assessment and I
Australasia' with contributions from treatment of the physical health of the nervous system. Just as a joint morour international faculty' It is and a muscle stretches, the nervous system arso has physicar prop".,i"Jut Iexpected that users will be health that are essential for movement. you can examine these properties via I
::",ff:;?H #"t:nJJi"::::#, nerve parpation and neurodvnamic rests. 's Lrrese Properures vra I
and neuro orthopaedic assessment 2 > tn" nervous system is a continuum Iplus knowledge of relevant pathology, A mechanical, electrical and chemical continuum exlsts in the nervous Iprecautions and contraindications. system. This is the basis of tests such as the slump test, where for I
For optimal and safe clinical example, the position of the neck will influence neurar responses in the leq. I
integration/ it is highly recommended 3 > Structural differentiationthat this DVD and book be used in The neural continuum arrows a differentiation between neurar and non-association with NoI education neural tissues. For exampre, in the case of the srump test (see below),seminars (www'noigroup'com) and/or if neck extension which takes load off the nervous sysrem eases evokedused with the textbooks Mobilisation symptoms in the leg,of the Nervous System or preferably, th"n this provides
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4 > Neural relations tojoint axes dictates load
The nervous system is usuallybehind, in front, or to the side
of joint axes of movement. Thismeans that the physical loadingon the nervous svstem will be
dictated by joint position. Inthe example shown of the
Upper Limb Neurodynamic Test (ULNT), wrist extension,elbow extension, and shoulder abduction would be examplesof movements which challenge the median nerve and the
brachial plexus. If you know your anatomy, you could make
up neurodynamic tests yourself.
5 > Pincn and tension - the key roleof neighbouring structures
Most neurodynamic tests are tests of the ability of thenervous system to elongate. The neighbouring structures
(e.9. joint and muscle) which'contain' the nervous systemcan sometimes pinch it. Wristflexion is a test of the neuralcontainer around the mediannerve at the carpal tunnel,and the Spurling's test(illustrated here) is an exampleof a pinch test for lowercervical nerve roots.
6 t o.d.. of Movement
The strain and movement of the nervous systemwill be affected bv the order in which the movementis taken up. For example, as illustrated, if you add
ankle dorsiflexion and eversion and then perform a
Straight Leg Raise (SLR) , a neurogenic problem in
the tibial nerve at the ankle is more likely to be
exposed than with other combinations.
There are probably two reasons for this: a moremechanical reason where the neural tissues are'borrowed' from other areas and thus given moreof a chance to be challenged, or perhaps the firstmovement is the one which takes priority in theoatient's consciousness.
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B > necordingAbbreviations such as PFIIN/SLR informthe order and kind of lnovement, thus ankleplantar flexion first, then inversion and thenStraight Leg Raise. Each component canalso be quantified in terms of range ofmovement or qualified in terms ofsymptoms evoked.
The 'In:Did' svstem is also used. Forexample, In: HFlLR Did: KE means that inthe hip flexion and lateral rotation position,knee extension was performed.
Y > Don't forget the brainRemember that responses to these testsmay not always be due to physical healthissues in the nervous system. In somepatients the sensitivity evoked during testingmay be due to changes in the centralneryous svstem. There is much more on thisimportant part of assessment in The SensitiveNervous System.
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7 t Slid.." and tensionersA tensioner (1) can be a vigorous techniquewhich 'oulls from both ends' of the nervoussystem. A slider (2) is a 'flossing' movementwhere tension is placed at one end of thesystem and siack at the other, Slidersprovide a large amount of neural movementand are a neurally nonaggressive movementfor anxious patients.
Gf ossaryC/T . ., Cervico-thoracicDF....DorsiflexionEV ,...Eversion
SLR
ReferencesButler DS (2000) The Sensitive NervousSystem, ISBN 0-646-40251-X,NOI Publications, Adelaide.
Butler DS (1991) Mobilisation of theNervous System, ISBN 0-443-04400-7,Churchill Livingstone, Melbourne.(Also in German, Italian, Spanish and Japanese.)
Support materialNOI's list of self published literature and brain products iscontinually updated and expanded. Visit noigroup'com fordetailed descriptions and secure online ordering.
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GHHAb
GlenohumeralHip abduction
HAd...HipadductionHE....HipextensionHF....HipflexionIMT . . . IntermetatarsalIN ....InversionKE....KneeextensionKF....KneeflexionLat flex . Lateral flexionLR . . . . Lateral rotationLS.....LongsittingNF..... NeckflexionPF .... PlantarflexionPKB...ProneKneeBendPNF . . . Passive Neck FlexionRad ...RadialSKB...SlumpKneeBend
Straight Leg RaiseSLS....SlumpLongSitSLY . . . . Slump sidelyingSP ....SpinalSup TF . Superior tibiofibularten....tensionerThx....ThoraxULNT . . Upper Limb Neurodynamic Test
Passive techniquesIn: SLR/DFIEV Did: IMT mob . .
In: Slump LS/DF/EV Did: IMT mob
In: HF/DF/EV Did: KE with nerve massage
In: KF/DF/IN Did: KEISLR'Ultimate tibial mob'. . . . .
Self management > gentler movements
In: HF/DFIEV Did: KE 'Heel to the skY'
Leg swing heel to floor. .
Self management > stronger movements
In: Stand/DFlEVDid: SPflex '. '..15In: HF/DFIEVDid: KE+ strap'Wall work' ... '.. '.15In: Slump LS/DFIEV Did: KE (sli/ten) .. '. ' 16
In: Slump LS/DFIEV/NF Did: IMT mobToewrigglerinslump '....16
Sural nerveAnatomy and palPation.
Thera pist's assessmentDFlIN/SLR
Passive techniquesIn: HFIDFIIN Did: KE
11
11
I213
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1A
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In: DF/IN Did: nerve massage
Self managementIn: HF/DFIIN Did: KE (sli/ten)
1B
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19
20
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$EE EE E E E E E E E E E E E EEUEETlTPeroneal nerveAnatomyandpalpation ....1Thera pist's assessment
PFIIN/SLR ... "..2PFIIN/SLRviashoulder ..' 2
Passive techniquesIn: SLR/HAd/HMR/SPflex... .... "3In: HFIPF/IN > DFIEVDid: KE '....4In: Slump LS/PFIIN Did: SupTF mob + KE' . ".. " 4
Self management > gentler movements
In: HF/PFIIN Did: KE .. '..5Leg swing toes curled under. . . . . . . 5
Self management > stronger movements
In: Slump LS/PFIIN Did: KE (sli/ten) ....... ' 6
Standing mobilisation '. ' ' '7Wall mobilisation... .. '...8'Hamstringsstretch'Focuson peroneal nerve. .... ' B
Tibia I nerveAnatomyandpalPation '...9Therapist's assessment
DFIEVISLR ......10ReversalSLR/DFIIN .... '.10
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Femora I nerveAnatomy and palpation. . . .2ITherapist's assessment
Prone Knee Bend (PKB) . . .22
Slump Knee Bend (SKB). ........22In: Slump SLY/KFIHE Did: HAbObturatortest.,. .......23In: Slump SLY/KFIHE Did: HAd
Meralgiatest... ........24Self managementHalf Pushup, Half Pushup + neck sli/ten. . . .25'Thomastestexercise .....26'Hurdlerstretch' ........27
Saphenous nerveAnatomy and palpation. . . .29Therapist's assessment
Pro n e/H E/ HAb / KE/ MR/ DF / EvThesaphenoustest ......30Passive techniqueIn: Prone/HE/HA5/MR/DF/EV Did: KE . . . . ., . . . . . 31
Self managementThesaohenousstretch ....32
Median nerveAnatomyandpalpation. ...33Activequicktest. ....,.34Thera pist's assessmentULNT1 ......35-36ULNT1Alternativeoosition .......36ULNT1Reversed.. ......37ULNT1 Reversed: indexfingerfirst . . . . . . . 38
ULNT2. ........39ULNT2Seated oosition ....40Passive techniquesULNT2SIi/ten ....4IULNTlSli/ten ....4I'Nannaarm wobble' ......42In: ULNT1Did: GHmob.. .,.....43Self management > gentler movementsBalloon patting,'Watch the watch'. . . . . . . . 44
Yoyo, Juggling..... .....44'No moredishes', Ball throwing progression .......45Self management > stronger movements'Busy bee', 'Finger stretch', Wrist stretch . . . 46
'Rock around the clock' . . .46'Sawatdika', Crawling,'Zorro', Balancing acts. . . . . . 47
Look atyourhands, Wall stretch . .. . . . . . . 48
'Freethe bird'.. ........48
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Ulnar nerveAnatomy and PalPation. " ' 49
Activequicktest. ' ' " " 50
Therapist's assessment
ULNT3 From wrist first " " 51
ULNT3Fromshoulderfirst.' ""'52Passive techniquesIn: ULNT3 Did: massage cubital tunnel ' ' ' ' 53
In: ULNT3 Did: Pisiform mob . ' " ' 53
In: ULNT3 Did: Sli/ten ' " ' 54
Self management > gentler movements
'Don't listen;'Face massages'' ' ' ' ' ' ' ' ' 55
'Makea halo','smoking','Yahool' " " " ' ' 55
Self management > stronger movements
'Plateexercise' "'"56'Dry the back', 'sunglasses', 'Crawl to the pits' ' ' ' ' ' 57
nerveAnatomy and PalPation. " ' 59
Active quick test. . ' .
Thera pist's assessment
ULNT2 (radial)' ' '
Passive techniques'Gentle radial sliding' " ' "64'Wholearm rotations " " ' '64
In: ULNT2 (radial) Did: Rad head soft tissue mob ' ' ' 65
Self management > gentler movements
'Pouringwater'. """"66'Figuresof eight' " " " " 66
'Pumpwater' "" 67
Look at vour hand behind your elbow ' ' ' ' ' 67
Self management > stronger movements
'Backmassage'. ""'68'Tipplease' """68'Tablestretch ""'68
M uscu locuta neous nerveAnatomyandPalPation. '. "'69Activequicktest ' " ' " '70Therapist's assessment
ULNT(musculocutaneous) " " ' ' '71
Self Management
Running on the sPot " ' ' '72o-t
ULNT2 (radial) Seated variation
ULNT2 (radial) From wrist first
OruoI
'ThrowitawaY''.... 72
Spine, cord and meningesAnatomy .......73Active quicktest. . . . . .
Therapist's assessmentPassive Neck Flexion (PNF). . .. ...75Straight Leg Raise (SLR) Sensitising movements. . . . 76Bilateral SLR. , . ..... ...77Slumptestactive. ......78Slumptestpassive ......7gSlumpLongSit(SLS). ....80Passive techniquesSLS/ Structural differentiation . . . . . . . . . . 81In: leg distraction Did: necksli/ten. ......82In: SLS Did: Thx Lat flex techniques . . . . . . 83In: SLS Did: A/P movements . . . . .84Notalgia paraesthetica techniques . . . . . . . . 85Wedge mobilisation techniques/Thorax spine . . . . . . 86Wedge mobilisation techniques/Cervico-thoracic area . . 87Self management > genUer techniquesPelvictilt/neckSli/ten .... BB
SlR/neckSli/ten. .......88
Self management > stronger techniques'Wring'technique. .......89SLS/Shouldershrug .....90'Kickyourhead off' ......91'Kick your head off'Focus on peroneal nerve . . . . . 91'Wall walking .....92'Total slump' Bob Johnson technique . . .. . . 93'Roll over' ...,...93
Other NervesAccessory nerve (cranial nerveXl) . . . ....g4Axillarynerve ...95Suprascapularnerve .....96Trigeminal nerve. .......g7Occipital nerve ........98
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$f TEEE E E E E E E E E E EPeroneal nerve > anatomy and palpation
Palpable areasA Medial to Biceps Femoris
B At the head of the fibula
C Dorsum of the foot(both superficial and deep peroneal nerves)
Common entrapments / syndromesLower lumbar spine
Piriformis area
Superior tibiofibular jointLower limb compartments
Ankle extensor retinacurum
The Sensitive Nervous SystemChapters B, 11 and 15
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Peroneal nerve > therapist's assessment
PFlIN/SLR
PFlIN/SLR via shoulderMore mobile subjects require the techniquevariation shown. The leg is placed on thetherapist's shoulder and then'walked' up.
Peroneal nerve > passive techniques
In: SLR/HAd/HMR/SP flexThese four images show increasing tension being placed upon the peroneal
and the neuromeningeal system' Exploring these movements may be
necessary for minor physical health issues of the peroneal nerve (add PFlIN)
or tibial (add DFlEV) or situations where there is a spinal as well as peripheral
comoonent. Anv of these movements could be used as therapy'
p2
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Foot held in plantar flexion/inversion As the hip is flexed the therapist's armmaintains knee extension
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Hip adduction Hip medial rotation Spinal lateral flexion
Peroneal nerve > passive techniques
In: HF/PF/IN > DFIEV Did: KE
In: Slump LS/PFIIN Did: Sup TF mob + KE
Knee extension in hip flexion and ankleplantar flexion/inversion is a gentle way tomobilise the peroneal nerve for physicalhealth issues anywhere along the nerve.In the technique example here, while theknee is being extended, the ankle is takenfrom plantar flexlon/inversion todorsiflexion and eversion for additionalnerve mobilisation.
The slump based technique illustrated is
a combination of superior tibiofibular jointmobilisation, plus knee extension, plusspinal flexion and note also that thepatient's right foot is held into plantarflexion and inversron by her left foot. Allthese movements together wouldcomprise a vigorous tensioner technique.
Neck extension at the same time as kneeextension would be a slider.
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Peronea|nerve>Selfmanagement>gent|ermovementsp5
These techniques are examPles
of gentle ways to mobilise the
peroneal nerves and roots'
If a more gentle distractingmovement is required, the Patient
could extend her neck during the
knee extension or the 'swing
through'in the leg swing technique'
I,n;HFIPF/rN Did: KE
Leg swing toes curled under
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$d EEEE E E E E E E E E E E ! E E ET!!TPeroneal nerve > self management > stronger movements
Standing mobilisationNote how all the movement components which placeload on the peroneal nerves and roots are used here.
The right hip is adducted and medially rotated and theknee is held extended by the patient's left leg.
With foot in plantar flexion and inversion, spinal flexionincluding neck flexion allows a strong self mobilisationof the peroneal nerve and associated roots.
p6Peroneaf nerve > self management > stronger movements
These techniques are more vigorous than the ones onthe previous page and may be applicable for mobilepatients and patients with sports injuries involving theperoneal nerve such as a settlrnq sprained ankle.
In: Slump LS/PFIIN Did: KE (sti/ten)
With the foot held in plantarflexion/inversion, knee extensionand neck flexion makesa tensioner technique.
With neck extension, a slidertechnique is performed.
p7
Peroneal nerve > self management > stronger movements pB
Illustrated here are two vigorousperoneal nerve based techniques.
Wall mobilisationThe key with the wall technique, where thepatient lies in a doorway, is to make surethat the foot is maintained in olantar flexionand inversion via a towel or a strao.
'Hamstrings stretch'Focus on peroneal nerveThe 'hamstrings stretch' is a reminder thatany muscle stretch will be likely to be a
nerve mobilisation, particularly if themovements that place more load onto thenerve are included,
In this example, note in image 2 theaddition of hip flexion, adduction andmedial rotation, ankle olantar flexion andinversion and spinal flexion.
p9
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Palpable areas
A Posterior to the knee
B Medial ankle (plantar nerves)
Common entrapments / syndromesPlantar fasciitis
Heel spur
Recurrent hamstring injury
Piriformis area
The Sensitive Nervous System
Chapters B, 11 and 15
ltDtal nerve
DFlEVlSLR
> therapist's assessment p10
p11
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The foot is held in dorsiflexion, eversionand pronation. Straight Leg Raise isthen performed with the therapist's armon the shaft of the tibia
The right leg can be flexed for a more<enciii\/e nrnhlem
In the reversal technique, thetherapist's shoulder can be used.
Reversal SLR/DFlIN
Tibial nerve > passive techniques
These techniques may be useful for Morton's metatarsalgia'
More comfoft may be achieved with the therapist seated and thepatient in a SLS position.
Trv intermetatarsal splaying and antero-posterior movements(inset) and include extension of the toes.
In: SLR/DFlEV Did: IMT Mobilisation
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Slump LS/DF/EV: IMT Mobilisation
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Tibial nerve > passive techniques
Inz HF/DF/EV Did: KE with nerve massage
This technique may be appropriate for neurogenic foot problems
such as plantar fasciitis, particularly where there is swelling
around the nerve at the medial ankle.
Most nerves can be massaged if there is no direct nerve injuryand the nerve is not too sensitlve.
Tibial nerve > passive techniques
ln:, KF/DF/IN Did: KEISLR
'Ultimate tibial mobilisation'This technique uses order ofmovement principles to takeup the nerve slack from thefoot first.
knee flexed
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Ankle dorsiflexion, eversion,pronatlon
SLR. In the final position, any of thecomDonents could be mobilised.
Knee extension
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Tibial nerve > self
In: HF/DF/EV Did: KE
'Heel to the sky'
Leg swing heelto floor
ma nagement > gentler movements pr4
These are gentle movements,appropriate for a more acute orsensitive state involving the tibialnerve. If the patient focuses on
pushing the heel to the sky it willencourage mobilisation of thetibial nerve and perhaPs Provide a
distracting metaphor,
In the leg swing technique,poking the heel at the floor willcreate a similar nerve challenge.
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Tibial nerve > self management
In: Stand/DFlEV Did: SP flex
In: HFIDFIEV Did: KE + strap'Wall work'In the wall mobilisation technique, the
kev is to use the strap or towel to make
sure that the foot is securely held indorsiflexion, eversion and pronation.
> stronger movements p15
These are examPles ofmore ag9resslvemobilisation techniques'Some of the peronealnerve mobilisations could
also be adapted for thetibial nerve.
Note the tensioner and
the slider in the sPinal
flexion technique.
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p17
self management
Did: KE (sli/ten)
Did: IMT mobilisation
and pa
> stronger movements p16
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Tibial nerve >
In: Slump LS/DF/EV
In: Slump LS/DFlEVlNFToe wriggler in slumP
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Palpable areas
A Lateral to the Achilles tendon
B Distal to the fibula
Common entraPments y' sYndromes
Recurrent ankle Problems
A component of Achilles tendonitis
The Sensitive Nervous SYstem
Chapters B and 11
Tensioner
Sural nerve
DFlIN/SLR
> therapist's assessment p1B
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The ankle is dorsiflexed and inverted and
held firmly.Therapist's forearm is on the shaft of the patient's
tibia, maintaining knee extension during the SLR.
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Sural nerve > passive techniques
Inl. HF/DF/lN Did: KE
With the Datient's hio in flexionand ankle in dorsiflexion andinversion, knee extension can be
used to mobilise the nerve.
In: DFIIN Did: nerve massage
Massage techniques may be usefulhere, particularly for swellingaround the lateral Achilles tendon.If appropriate, the nerve and itssurrounding tissues can be
massaged with the nerve in tensionas in the SLS position depicted.
p19
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Sural nerve > self management
ln: HF/DF/lN Did: KE (sli/ten)
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p20
The easiest way to self mobilise the sural
nerve is to replicate the passive
technique. Spend time ensuring that thefoot is in dorsiflexion and inversion.
Adding neck flexion (3) provides a moreaggressive movement and neck extension(4) allows a less aggressive and distractedlarge range movement.
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Femoral nerve > anatomy and palpation
Palpable areas
A May be palpable through tissue at the inguinal ligament
Common entrapments / sYndromes
Pinch or hvperextension at the inguinal ligament
L2-3 root syndromes
The Sensitive Nervous SYstem
ChaDters B and 11
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Tensioner
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Femoral nerve > therapist's assessment
Prone Knee Bend (PKB)The Dl.iR i< > rrr r.lo facf-,--l a5 manystructures (including the femoral^^-.,^\ ^-^ r^^!^f,I tEt vE,/ dt E LE>LEU.
Slump Knee Bend (SKB)
The SKB allows a more refined testingthan the PKB. For the left SKB, thepatient's left knee should be around90 decrees. Get fhe natient to holdher right knee in some, but not full,hip flexion and then extend the hip.
Use neck flexion/extension forstructural differentiation.
For heavy legs, try performing theSKB with the test leg downside.
Hip lateral and medial rotation can be
added to test groin nerves such as theilioinguinal and iliohypogastric nerves.
Femoral nerve > therapist's assessment
In: Sfump SLY/KF/HE Did: HAbObturator test
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To test the obturator nerve/ use the Slump Knee
Bend oosition and then abduct the hip (2). This
could be an assessment and treatment technique
for neurogenic components to groin and medial
knee patn.
The neck could be used for structural differentiation'
p22
p23
Femoral nerve > therapist's assessment
In: Sfump SLY/KF/HE Did: HAdMeralgia test
To test the lateral femoral cutaneous nerve, whichmay be involved in the syndrome meralgiaparaesthetica, the Slump Knee Bend position is
used and then the hio adducted.
Any of these components could be used as
therapeutic movements and/or if appropriate,structures around the nerves such as the L2-3joints, the inguinal ligament and the anterior thighfascia could be mobilised.
p24
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n'fr Dttttr t t t il t;;;gggusHsu ilttttttttrHtlHtTus!!!uuHH#gIFemoral nerve > self management
Half Pushup
Half pushups are widely used inrehabilitation. The manoeuvremobilises all anterior hip structuresincluding the femoral nerve.
Half Pushup + neck sli/ten
If the patient lies propped up on her elbows and flexesher head and the knee at the same time, thisis a tensioner along the femoral tract even though thelumbar extension may slacken the system a Iittle,
ac) Nor
p25
Neck extension and knee flexion would comprise a slider,
Femoral nerve >
'Thomas test exercise'
self ma nagement p26
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An example of more aggressive self mobilisation for thefemoral nerve complex. in the'Thomas test exercise',anterior hip muscles will most likely limit the hip extensionand knee flexion. If there is a neurogenic component, theaddition of neck flexion mav influence responses.
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Femoral nerve > self management
'Hurdler stretch'
Another example of more aggressive self mobilisation forthe femoral nerve complex. In the'Hurdler stretch'position, neck flexion, left knee flexion and right kneeextension can be used simultaneously for an aggressivesoft tissue and neural mobilisation,
p27
T!E T,E E [ [ E I E [ ! ! ! E I E N !II IISaphenous nerve > anatomy and palpation
Palpable areas
A Infraoatellar branches on the head of the tibia
B Main saphenous nerve between gracilis andsartorius at the knee ioint
Common entrapments / syndromesPost arthroscopy medial knee pain
May be involved in knee medial collateralligament injuries
The Sensitive Nervous System/-h:nfcrqRand11
p29
I
i,4i.:',p
Saphenous nerve >
Prone / HE / HAb / KE / MR/ DF / EvThe saphenous test
thera pist's assessment p30
Alternative positionPatient in supine, therapist seated
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Saphenous nerve > passive technique
In: Prone/HE/HAb/MR/DF/EV Did: KE
In the saphenous test position, knee extension is a useful way tomobilise the nerve complex, Massage techniques (3) could also be used.
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Hlp extension and abduction
Hip lateral rotation Ankle dorsiflexion eversion
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Saphenous nerve > self management
The saphenous stretch
p32
p33
The patient stands with feetapart. To mobilise the leftsaphenous nerve, place rightleg in front of the left. Theleft foot is in dorsiflexionand eversion.
By flexing the right kneethe left saphenous nerve isself mobilised.
I NOr
E E E E E E E E E E E E ! E E ! ! E E ! ! ! [Median nerve > anatomy and
Palpable areasA Upper arm
B Medial to the biceps tendon
C Indirectly at the carpal tunnel
Common entrapments / syndromesCarpal tunnel syndrome
Post Colles' fracture symptoms
C5-6 nerve root
The Sensitive Nervous System
Chapters B, 12 and 15
palpation
p34tMedian nerve > active quick test
This active quick test is an example of structural differentiation. If there are symptoms
on shoulder elevation that are made worse by either neck lateral flexion away from the
iest side and/or wrlst extension, then the clinical inference is that those symptoms are
from a neurogenic source, perhaps the median nerve and/or its roots. If the therapist
stabilises the shoulder, more refined testing is possible.
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Median nerve > therapist's assessment
ULNT1 (See stage by stage description on next page)
p35
ONor
Median nerve > therapist's assessment p36
ULNT 1
1. Starting position. Note patient's thumband finger tips supported, plus some ofthe weight of the arm taken on thefhorenicf'c fhinh
2. Shoulder abduction to symptom onset, ortissue tightness, or approximately 100
deg rees.
3. Wrist extension. Make sure the shoulderposition is kept stable.
4. Wrist supination, again making sure thatthe shoulder position is kept stable.
5. Shoulder lateral rotation, to symptomonset or where the tissues tighten a little.
6. Elbow extension to symptom onset.
7. Neck lateral flexion away, making sure itis whole neck and not just the uppercervical spine.
B. Neck lateral flexion towards. This shouldease evoked symptoms.
ULNTl Alternative position
:]f:r
The alternative position shown uses the therapist'sshoulder rather than their fist. From the startingposition shown, the entire test can be performed.It is a comfortable and very supportive position foranxious patients. It is also a useful way to providepassive movement techniques to patients.
q) Noi
IEE AEEEE E E E E E ! ! ! ! ! ! ! $ $Median nerve > therapist's assessment p37
ULNT1 Reversed This reversal of the ULNT1 is an example of using the order of movement principles.Such a technique may be appropriate for a median nerve based problem such as carpal tunnel syndrome.
ilffU#
Block the shoulder girdlefrom elevating
Careful shoulder abductionusing the therapist's thigh
Elbow extension, holdwrist position securely
Add cervical flexion orlateral flexion
Starting position Wrist extension Wrist supination
Whole
NOI
arm lateral rotation
Median nerve > therapist's assessment
ULNT1 Reversed: index finger firstThe reversed ULNT1 can also be
performed by starting wlth one digit and
then adding the other components. Such
an assessment and treatment technique
may be appropriate for a patient with a
persistent digital nerve problem.
DT;;& E T H
Median nerve > therapist's assessment
ULNT2
p3B
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Patient has her shoulder girdlejust over the side of the bed
Whole arm lateral rotation,keeping shoulder girdle depressed
acJ Nor
Shoulder girdle depression (via thetherapist's thigh) to sYmPtoms orwhere the tissues tighten a little
Wrist and finger extension(note suggested griP in the inset)
p39
Structu ral differentiationcan be preformed bY
elevating the shouldergirdle a little, or if thereare shoulder/necksymptoms, the wristflexion can be released.
Elbow extension
Median nerve > therapist's assessment
ULNT2 Seated position
The ULNT2 can be performed with the therapistsitting. Many patients and therapists prefer this as
the arm can be very well supported and it is easier
to see the patient's face.
In image 2, structural differentiation is performed
via wrist flexion to differentiate the origin ofshoulder area symptoms.
n;rsMedian nerve > passive techniques
Here are two examples of theslider and tensioner movementsfor the median nerve.
ULNT2 Sli/tenIn the seated position, if the wristis flexed and the shoulder girdle
depressed, as in the image, thiscomorises a slider movement.
ULNTl Sli/tenWhen there is neurogenic Problem,during the ULNTl test, the patient'sshoulder girdle will often protract,thus avoiding some of the tension on
the nervous system. At the momentof protraction, if wrist flexion is
added, then a slider will be
performed. This allows a gentle
mobilisation as well as a waY ofunlearning unuseful motor patterns.
Oruor
p40
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Median nerve > passive techniques
'Nanna arm wobble'
'Nanna arms'are the floppy bits many people getunder their upper arm/ especially as we get a bitolder. The aim of this passive technique is to makethe arm'flop'. If the patient is relaxed, while the wristgoes into flexion the shoulder adducts.
p42
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p43Median nerve > passive techniques
In: ULNT1 Did: GH mobilisation
This is an example of Performing a
joint mobilisation while the nerve is
in some tension. There maY be a
stiff joint accessory movement whichcan be mobilised while the nerve is
in some tension. Such a Patientwould have joint and neural tlssuephysical health issues.
Technique in more shoulderabduction.
Note how further tension is Placedon the nerve, by asking the Patientto extend her wrist.
Median nerve > self management > gentler movements p44
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This series of genlle self mobilisationtechnicues uses functional and funmovements and metaphors. 'Balloonpatting', 'watch the watch' (place watchon ventral side of wrist) and using a
yoyo encourage the supination andelbow extension Darts of the ULNT1.Attempts at juggling provide a similarnerve mobilisation.
Balloon patting
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'Watch the watch'
Juggling
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p45
'No more dishes' and the ball throwingprogression are more aggressivemobilisers, but still functional and fun,
Ball throwing can be progressed fromunderhand to overhand throwing'
Ball throwing progression
'No more dishes' (after Barb Beatty)
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Median nerve > stronger movements
With imagination, knowledge of neuroanatomy, anduse of metaphors, a series of functional mobilisationtechniques for the median nerve can be constructed.Get the patient to'buzz' during 'busy bee', note thatthe finger and wrist stretches are quite vigorous forneural tissue in the hand and wrist.
Crawling is a strong functional median nerve mobiliserand note how balancing creates large range slidermovements similar to a ULNT2 for the median nerve.
For'free the bird'get the patient to imagine they areholding a small bird and then to let it go. Now where isthat frisbee?
'Finger stretch'
'Busy bee'
p46
'Rock around the clock'
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aO NoItDnilfitt Dttt;I g g g sMedian nerve > stronger movements p47
Crawling
Balancing acts
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p4BMedian nerve > stronger movements
Look at your hands
A Pisiform area at the wrist
B At the elbow and in the uoper arm
Common entrapments / syndromes
The Sensitive Nervous System
Chapters 5, B and 12
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p49
NEEI,EEEEEEEEE!Ulnar nerve > anatomy and palpation
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Ulnar nerve > active quick test ps0
Ask the patient to put herhand on her ear and then,keeping the hand on theear, lift the elbow up.
For most patients withulnar nerve or root basedproblems this movement,or part of the movement,will be sensitive in theulnar distribution.
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Ulnar nerve > therapist's assessment p51
ULNT3 From wrist first
Starting position - thepatient's elbow rests on thetherapist's hip
Wrist and finger extension,ensure 4th and 5th fingersare extended
Block shoulder girdleelevation by pushing fist intothe bed
Shoulder girdle dePressionif required
Shoulder lateral rotation,ensuring wrist position ismaintained
Shoulder abduction; necklateral flexions can be=AAaA if ranrrirod
' vYe'r vv
Pronation
Elbow flexion
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Ulnar nerve > Passive techniquesp53
In: ULNT3 Did: pisiform mobilisation
The pisiform mobilisation in ulnar nerve
load is an aggressive technique' It may De
relevant for a patient with persistent little
finger problems after a wrist injury'
Ulnar nerve > therapist's assessment
ULNT3 From shoulder first
f
Starting position. With handunder patient's scaPuladepress shoulder girdle
p52
In: ULNT3 Did: massage cubital tunnel
These are examPles of massage
techniques in neural load positions'
Note how the ulnar nerve in the cubital
tunnel is massaged more aggressively
with the wrist in extension (1) and then
more gently with the wrist ln flexion (2)'
The massage and the wrist movements
could be combined'
Shoulder abduction Lateral rotation of shoulder
Wrist and finger extension Forearm pronation
,b;
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Ulnar nerve > Passive techniques
In: ULNT3 Did: Sli/ten
p54
In 1, a tensioner is Performed as the
shoulder girdle is depressed while
the ulnar nerve is loaded.
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The patient's neck is extended as theshoulder girdle is depressed, making
a siider technique.
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'Don't listen'
self management
'Face massages'
> gentler movements
'Make a halo'
ps5
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With neck flexion, this rs a moreaggressive tensioner technique'
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tt\LTThese are examples of gentle functional
movement for the ulnar nerve and its
brain representations. The metaphors
orovide a distraction. Be creative.
iO NoriltDilttll
'Yahoo!''Smoking'
Ufnar nerve > self management > stronger movements
'Plate exercise'
Ask your patient to imagine they have a
glass of wine on the plate and then dothe exercise as shown in the imaqes.
Some examples of strongermobilisation exercises for theulnar nerve.
'Dry the back'
p56
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p57
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'Crawl to the pits'
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Radial nerve > anatomy and palpation
Palpable areas
A Mid humerus
B Radial sensory nerve on the lateral
aspect of the forearm
Common entrapments / sYndromes
De Querva in's tenosynovitis
Supinator muscle (tennis elbow)
Post humeral fracture Pain
C5-6 root syndromes
p59
Radial nerve > active quick test
Ask the patient to let their arm hang by their side, thenmake a fist holding their thumb, then extend the elbow,then point the thumb away from the body (internal rotation)and depress the shoulder. A few degrees of shoulderextension may sensitise the test. Elevation of the shouldergirdle provides an easy way to structurally differentiate.
p60
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The patient lies with their shoulderjust over the side of the bed, thetherapist uses his thigh to carefullydepress the shoulder girdle
nerve > therapist's assessment p61
Notice how the therapist has broughthis left arm'around'to grasp thepatient's wrist in order to mediallyrotate the whole arm
Adding a few degrees of shoulderabduction will sensitise the test andelevation of shoulder girdle willprovide structural differentiation
Wrist and thumb flexion can beadded. Leave the fingers out as theextensors will be too tight
ULNT2 (radial)
Elbow extension
Whole arm medial (internal) rotation
Radial nerve > therapist's assessment
ULNT2 (radial) Seated variationSome therapists prefer to assess theradial nerve in sitting, particularly ifthe patient is anxious and sensitive.The patient's arm can be well cradledand supported. This is also a goodposition to perform passive techniques.
1. The arm is well supportedin the starting position
2. Shoulder girdle depression
3. Whole arm medial rotation
4. Wrist flexion
Radial nerve > therapist's assessment
ULNT2 (radial) From wrist firstThis may be appropriate for persistent problems on thelateral aspect of the wrist. Using order of movementprinciples, wrist and finger flexion plus ulnar deviation (1),then elbow extension (2), arm medial rotation (3) loads
the radial nerve from the wrist first,
p62
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p63
Radial nerve > passive techniques
In the seated position there are plenty of opportunities forgentle passive techniques, If you get the patient to point
to their nose while you gently depress the shoulder girdle,
this forms a gentle slider. Be creative.
'Gentle radial sliding' 'Whole arm rotations'
Radial nerve > passive techniques
In: ULNT2 (radial) Did: Rad head and soft tissue mobilisation
p64
5 EE 4EE E E E E ! E ! ! ! ! ! ! !!!!IIp65
Once the ULNT2 radial nerveposition is maintained, a varietyof techniques are available. The
radial head could be mobilised orsoft tissue stretches performed.Some of these may be useful fortennis elbow which has stronglocal tissue components
Radial nerve > self
'Pouring water'
ma nagement
'Pouring water' and big swinging 'figures of eight'are gentle ways to mobilise the radial nerve and itsrepresentations in the brain. Make sure with theswinging technique that the shoulder internally andthen externallv rotates.
Radial nerve > self ma nagement
> gentler movements
'Figures of eight'
p66
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> gentler movements p67
'Pump water'Pumping water allows thenon-painful arm to helpguide mobilisation of thepainful/injured arm. Thestarting position encouragesinternal rotation.
Look at your handbehind your elbowIf the patient attempts tosee their hand behindtheir elbow and to see
their fingers and theirthumb, this provides a
vigorous sliding selfmobilisation. Try itbilaterally - it's almost a
dance move.
T
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Radial nerve > self management
These are examples of stronger, yet functional selfmobilisation movements, In the table stretch, the patientkeeps the back of their hand flat on the table and thenrotates their whole bodv awav.
'Back massage' 'Tip please'
Musculocutaneous
Palpable areas
Difficult to palpate
Common entrapments/ syndromesDe Quervain's tenosynovitis
Tennis elbow 'above' the elbow
Post intravenous drip pain syndromes
The Sensitive Nervous System
Chaoter 12
> stronger movements p6B
'Table stretch'
nerve > anatomy and palpation p69
s"*;:
I p70Musculocutaneous nerve > active quick test
Make a fist, ulnar deviate the wrist, extend theelbow and extend the shoulder as though marching.
Musculocutaneous nerve > therapist's assessment
ULNT (musculocutaneous) This position can also be used for passive mobilisation.
Starting position (same as theULNT2 test for the radial nerve)
p77
Wrist ulnar deviation and thumb flexion.Either medial or lateral rotation could sensitise the nerve further.
Shoulder girdle depression Elbow extension
Shoulder extension carefullv
Musculocutaneous
Running on the spot
nerve > self management p72
p73
'Throw it away'
Spine, cord and meninges > anatomy
The spinal and craniai meninges (dura, pia and arachnoidmater) surround the spinal cord and form a continuousstructure allowing force transmission from the peripheralto the central nervous system and vice versa. The spinalcanal is between 7-11 centimetres longer in flexion thanin extension, thus the meninges and spinal cord will bephysically challenged in positions such as sitting, forwardbending and especially the Slump tests demonstrated in
this section.
The Sensitive Nervous System
ChaDters 5. 11 and 15
A{tr"'' olEN:1^.'',. t:
Spine, cord and meninges > active quick test
In spinal flexion the meninges and spinal cord will be physically challenged. If low
back symptoms evoked by spinal flexion are made worse by the addition of neckflexion this infers that there is a physical health problem of the nervous system.Neck extension should relieve symptoms.
Spine, cord and meninges > therapist's assessment
Passive Neck Flexion (PNF)
PNF can be performed rn two ways. Upper cervical flexion (2),places load on the cervical and cranial meninges and if this iscombined with lower cervical flexion (3), a considerable load isplaced right through the entire neuromeningeal system.
PNF will frequently reproduce back pain, suggesting nervoussystem involvement is a frequent component of back disorders.
p74
p75
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Spine, cord and meninges > therapist's
Straight Leg Raise (SLR) Sensitising movements
The nervous system sensitising movements which are
frequently used for lower limb disorders can also be used
for the neuromeningeal tissues.
Spine, cord and meninges > therapist's
Bilateral SLR
ASSCSSMCNT
Hip adduction (2), hiP medialrotation (3), spinal lateral flexion(4) and upper cervical flexion (5)are shown. These movementsmay be required to identifY minordisorders of the nervous systemand any of these movementscould be used to mobilise thenervous system.
p76
!!!!!!!!EUslASSCSSMCNT p77
ii
Bilateral Straight Leg Raise (BSLR) techniques are useful and
can be easily converted into self mobilisation techniques. BSLR
provides a different biomechanical challenge to neuromeningealtissues than a single SLR. In the example shown, ankledorsiflexion is used as a technique.
The technique may be appropriate in patients with positive
Slump Long Sit tests. Of course, neck and shoulder girdlemovements could also be introduced as part of tensioner and
slider techniques. Be creative.
Spine, cord and meninges > therapist's assessment p7B
p79
'i:,ffi
Slump test activeIt is best to perform tests:dirrelrr firct cn fhc
therapist and patient thenknow what to expect.
Check symptoms andsymptom change ateach stage.
1. Starting position, kneestogether and thighs wellsu pported
2, Spinal slump, ensuringpatient doesn't forwardtilt her pelvis
3. Neck flexion
4. Knee extension
5. Release neck flexion.The knee can usually beextended further andthe ankle dorsiflexed.
6. Bilateral knee extension
Spine, cord and
Slump test passive
1. Spinal slump, makingsure the patient doesn'tforward tilt her pelvis
2. Neck flexion with gentleoverpressu re
3. Knee extension
4. Add dorsiflexion ifreq u i red
5. Release neck flexion.The neck is extended instages checking theresponse to evoked legand back symptoms
6. Bilateral knee extensionif required
i'ttr'
meninges > therapist's assessment
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Spine, cord and meninges > therapist's assessment
Lateral flexion of the entirecervical spine has beenper-formed allowing a test ofthe physical health of upperthoracic neural structures,This will frequentlyproduce relevant thoracicand lumbar symptoms on
the convex side.
pB0
Structural d ifferentiationcan be performed byflexing the knee.
Slump Long Sit (SLS)
This test position providesa very stable assessmentplatform for neuralproblems in the spine andneao.
Remember to check forsymptoms at each stageof the test.
The test will need to be
adapted depending on thepatient. For those who aretight, pillows under theknees may be requiredand more hip flexion maybe necessary for thosewho are more flexible.
The patient is in a SLSposition, This could beadapted as necessary, forexample pillows under theknees or more spinalflexion.
*."3
Starting position, thetherapist uses his knee tostabilise the sacrum
The therapist stabilises thespine at the cervicothoracicj u nction ,
differentiation of any lower body evoked symptoms.Note how the ankle can be dorsiflexed further
Thorax andsrump
FTHHHilFTillIlllllllrJSpine, cord and meninges > passive techniques
Slump Long Sit / Structural differentiationDurinq the SLS test, a more refined structural differentiation can be performed,
lumbar spine
Extend left knee Release neck flexion to provide structural
q.
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Spine, cord and meninges > passive techniques
fn: leg distraction Did: neck sli/tenThis is an example of a very gentle challenge to the spinal canal and its contained structures. First,gentle leg distraction is performed rhythmically. If the patient puts her head back at the same timethis is a slider technique. The technique can be progressed by performing the same distraction in SLR.
Spine, cord and meninges > passive techniques
fn: SLS Did: Thx Lateral flexion techniques
On this and the following page are examples of some
vigorous passive techniques for the thorax. Note the
lateral flexion techniques above, including the third image
where lateral flexion is localised to a specific and relevant
level. Thoracic lateral flexion can be achieved by the
therapist's body. If the patient extended her knee at the
same time as the lateral flexion was applied, this would
be a tensioner.
pB2
pB3
x
ONOIilnnF-STEE
Spine, cord and meninges
In: SLS Did: AlP movements
An anteroposterior movement can be applied in
the Slump Long Sit. The therapist's left carpaltunnel is just under the level to be mobilised and
his right hand in on the patient's sternum, softenedby a towel or pillow. This may be useful for a flatupper thoracic spine relevant to a particularthoracic spine disorder.
> passive techniques
> passive techniques
rrrFFH;ttiltTgEHHHHUUHU
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pB4
tfrilupB5
tttuuuSpine, cord and meninges
Notalgia paraesthetica techniques
This is an example of a refined technique for entrapment of
the cutaneous branches of the thoracic postertor prlmary
rami. The syndrome is called notalgia paraesthetica'
Tender spots, even nodules, may be palpated where these
nerves exit the muscles and fascia to become cutaneous'
These will be more tender in the Slump Long Sit position'
less so if the neck is extended. Frequently the nerve will
be more reactive if massaged laterally along the lateral
branch, rather than medially. This may be an appropriate
technique for some Patients.
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Spine, cord and meninges > passive techniques
Wedges can be a useful adjunct to passive and self mobilisation.In the example shown, the wedge is being used to facilitate a
thoracic (predetermined level) mobilisation. The spinous processes
lie in the groove of the wedge and the mobilisation is gentlyperformed using the ribs, A towel or small pillow for paddingmakes it more comfortable. Because this allows a superior jointmobilisation it can also be used to mobilise associated neuraltissue, for example, if the same technique was performed in
Straight Leg Raise or Bilateral Straight Leg Raise.
Wedge mobilisation techniques / Thorax spine
Spine, cord and meninges > therapist's assessment
Wedge mobilisation techniques / Cervico thoracic area
wedge technlques can be useful for the cervico-thoracic area. The force
is through the clavicles not the jaw, and the therapist's left hand is only
assessing the intervertebral movement while cradling the patient's head.
pB6
p87
More tension can be Placed on thenervous system during the mobilisation
by adding an Upper Limb NeurodynamicTest (3 and 4) or Straight Leg Raise (5).
Spine, cord and meninges > self managementgentler techniques
PBB
pB9
Pelvic tilt/neck Sli/tenExamples of gentle sliders (1)and tensioners (2) for themeninoes and soinal cord.
SLR/neck SIi/ten
Spine, cord and meninges > self management> stronger techniques
'Wring' techniqueThis technique is named after the action of wringing out a wet towel. With the knees flexed and rolling from side to
side (2), a gentle wringing effect is placed on the spinal cord. lf the patient turns their neck away at the same time(3), a more aggressive wringing is provided, and if the chin is tucked in (4), even more load can be applied. By using
the arms and depressing the shoulder girdle (5), even more load can be placed on the nervous system.
Spine, cord and meninges > self ma nagementstronger techniques
p90
p91
SLS / Shoulder shrug
The SLS position offers a safe and supported starting position for self mobilisation.
In the images, a slider is being performed. As the patient extends her knee, she shrugs
her shoulders. This may be a useful slider when the neck is sore. In this positlon there
are many combinations of sliders and tensioners. For example, if the knee is extended
at the same time as the neck is extended, this creates a slider movement.
Spine, cord and meninges > self managementstronger techniques
'Kick your head off'These are stronger slidersand tensioners for thelower limb and meninges.
They can be adapted tofocus more on theperoneal or tibial nerves.This not only mobilisesneural tissues butprovides movement in a
novel and safe way.
'Kick your head off' Focus on peroneal nerve
1-
Oruor
Spine, cord and meninges > self management> stronger techniques
'Wall walking'Images 4,5 and 6: Notice how the patient moves closer to the wall to achieve more Straight Leg Raise.
p92
tHttttrttrrllllJlJlllllltp93Spine, cord and meninges > self management
stronger techniques
'Total slump'Bob Johnson techniqueTwo vigorous mobilisationsare snown nere.
Notice how the standingtotal slump uses order ofmovement principles toload cervical and cranialmeninges first.
'Roll over'In the roll over Positionfor the appropriatepatient and problem,further mobilisation can
be performed by leg
movements.
O Nor
Other nerves > Accessory nerve (cranial nerve XI) p94
p95
1. The patient lies in sidelying
2. Lateral flexion andprotraction of the neck
3. Retraction of the shouldergirdle, making sure there is
enough slack in the skln
4. Upper cervical flexion willadd more load
Other nerves > Axillary nerve
A neurodynamic test can be placed on any nerve, simplyby observing where the nerve is in relation to joint axesof movement, A test for the axillary nerve will be a
combination of neck lateral flexion, shoulder girdledepression and internal rotation. Any of thesemovements could be used for mobilisation. The axillarvnerve may be injured post shoulder dislocation.
p97
p96Other nerves > Suprascapular nerve
The suprascapular nerve is challenged in a combinationof neck lateral flexion and shoulder girdle depression.A force down the humeral shaft takes the nerve furtherfrom its roots and finally the scapula can be rotated as
a mobilisation technique.
Other nerves > Trigeminal nerve
Open mouth and move Jawto the right
Trigeminal nerve
Upper cervical lateral flexionUpper cervicai flexion
Total cervical flexion
4{#_
p9BOther nerves > Ocei*ita! nerve
The greater and lesser occipital nerves can be challengedin uooer cervical flexion and lateral flexion of the neckaway from the side to be tested.
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