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NEURAL STRUCTURES
Outcomes Be familiar with the anatomy and function of the neural structures. Be familiar with the aim of neural dynamic tests. Be familiar with the neural dynamic evaluation tests. Be familiar with the clinical presentation of a patient with neural symptoms. Be familiar with the general principles of treatment of neural symptoms. Be familiar with the contra-indications of neural mobilisations.
Introduction Neural pain sensitive structures should always be kept in mind
Especially in patients who were subjected to trauma
The possibility exists that the resultant inflammatory process could also affect the nerve-root and nerve-root sheaths
Introduction This could lead to abnormalities in terms of mobility
Meningeal nerve-root sheaths have a well developed pain receptor system which is responsible for the strange pain distribution
Adhesions are generally prevalent as a result of the weak lymphatic drainage in the area
Introduction The nerve-root which is an extension of the dura mater, can therefore also be responsible for symptoms in another area – continuity of the system
The most common cause is reduced mobility of the neural structures
Introduction During the normal flexion and extension movements, the spinal cord moves approximately 7 – 10 cm and therefore the surrounding neural structures must be relatively mobile
Mechanical stimuli of a non-injured nerve is pain free, but excessive lengthening or pressure stimulates the nervi nervorum which results in a pain response and ischemia
Ischemia leads to pins and needles, pain and muscle spasm
Clinical presentation
Rare patterns of referred pain
Strips of pain
Pain at pressure points
Block of pain around a joint
Burning sensation or swelling
Symptoms mostly set in after assuming certain positions or carrying out actions which could cause stretching
Aim A neurodynamic test evaluate/tests the pain sensitivity/ provocation of the mechano-sensitive neural structures and the reaction of the protective muscles to lengthen around the neural tissue
Evaluation techniques
Passive neck flexion (PNF) Straight leg raise (SLR) Mid-slump test Slump test Upper limb tension test (ULTT)
General principles Explain to the patient what you are going to do and what they must do
Do one component of the test at a time
Take into account barriers to movement (onset of resistance, pain or other symptoms)
Note the quality of movement
General principles Consider irritability
Be consistent with starting position (e.g. pillows)
Note pain response (area and nature)
Do not necessarily reproduce the pain
Watch for and correct antalgic posture/movement
General principles
Test for symmetry – compare both sides
Sensitising and desensitising components can be added
Handle well or don’t bother
Positive test The test is considered positive if:
the patient’s symptoms are elicited
pain is reproduced
if there is more muscle reaction than on the other side
if there is any limitation in the mobility
if it is different from the normal
Treatment Both non-neural and neural structures must be treated
Soft tissue must be prepared before the neural structures are mobilised
First mobilises non-neural structures, soft tissue and then neural structures
Be aware of signs and symptoms in respect to irritability and intensity
Treatment Always start distal e.g. DF
Gr II short of pain and resistance, slow
Dull, constant pain must be avoided during treatment
Joint or muscle must be in mid-range since the separation level is more open in this position
Treatment Work in 20 sec or 20 movements and increase the treatment by 20 each time
Re-evaluation signs and symptoms
Neurological evaluation is very important
Home exercises may be given after the second day of treatment
Neural structures must not be rested in stretched positions
Treatment Less movement and more adhesions
Pins and needles may be experienced during treatment – should disappear immediately after treatment
Place nerve in stretched position and then add the other components
Through range of movement Grade III and IV
All components must be evaluated
Treatment Treat in close proximity of the origin of the symptoms
Can also perform an AP on the radius while the arm is placed in the ULTT
Get full tension before strong techniques are carried out e.g. SLR with rotation
Ensure at all times that the joints are able to withstand strong neural techniques
Patients react well to treatment, but can flare-up easily – be very careful!
Contra-indications Acute nerve-root pressure
Worsening of neurological symptoms
Pathological conditions that affect the structures e.g. diabetes
Cord and cauda equina
Malignancies
Acute inflammation
Contra-indications The slump test must not be carried out during a possible disc herniation or instability
Take care with irritable conditions
Always test neurological signs before and after neural mobilisations
Adhesive spinal cord
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