ADVERSE MECHANICAL NEURAL TENSION to NEURODYNAMICS

(Shacklock, 1995)
by Vince Lepak, PT, MPH, CWS Tiny bubbles in my wine, makes me happy, makes me feel fine. Don Ho

History
40 year old person Left lateral elbow pain for 7 months Lumbar laminectomy 4 years ago Minor whiplash 18 months ago Pain increases at the computer Pain is greater after activity, although stiff in the morning Decrease in physical activity stopped jogging, playing tennis, and nightly push-ups Divorced

Physical Exam
Palpation reveals tenderness of the common origin of the extensors and over the head of the radius Resistive testing of the extensor muscle group was weak and painful The end-feel of elbow extension is empty Overpressures are painless at the shoulder Rotation and lateral flexion of the cervical spine to the opposite side of the involved limb is limited secondary to pain Thoracic extension appears limited ULTT2b (radial bias) demonstrates a comparable sign

Tennis Elbow
(Neuro Orthopaedic Institute, 1996)
Sources of Pain
Nociceptive Peripheral Neurogenic Central Sympathetic/Motor Affective

Neural Tension Tests

Kernigs Slump SLR
dorsiflexion

Leseagues Well leg test (contralateral limb test) Elys

UE - Neural Tension Tests

ULTT1 (Median) ULTT2a (Median) ULTT2b (Radial) ULTT3 (Ulnar)

(Butler, 1991)

Validity, Reliability, Sensitivity, Specificity

ULTT1 (Median)
It was sensitive and specific for producing tension in the median nerve with minimal tension in the ulnar and radial nerve. Ekstrom and Holden (2002) reported that Kleinrensink, et al (2000) concluded that it was a valid test, based on the sensitivity and specificity. No measures for reliability were reported.

(Butler, 1991)

(Ekstrom & Holden, 2002)

Validity, Reliability, Sensitivity, Specificity

ULTT2a (Median) no information ULTT2b (Radial)
Ekstrom and Holden (2002) reported that Kleinrensink et al (2000) concluded that it was not sensitive or specific to the radial nerve. It did produce tension in the radial nerve however it produced more tension in the median nerve.

Validity, Reliability, Sensitivity, Specificity

ULTT3 (Ulnar)
An abstract by Garmer, Jones, & McHorse (2002) describes a descriptive study that appears to show that the Ulnar nerve tension test is specific and sensitive to the ulnar nerve in 55 asymptomatic volunteers. 99% of the subjects reported sensation disturbances along the appropriate anatomical or sensory route. Symptoms that were most often described during the test included; stretch (69%), burning (56%), tingling (39%), and numbness (26%)

Neurodynamics
Mechanics Pathomechanics Physiology Pathophysiology

Mechanics
Continuum Designed for movement Connective tissue Mechanical interfaces

Pathodynamics
(Neuro Orthopedic Institute, 1996, p.33)

Physiology
Circulation Axoplasmic flow

Yes, I know it should be referenced. I am looking for the website that I retrieved this picture from without permission.

Pathomechanics
Mechanosensitivity Mechanical interface
Attachment Branches Unyielding interface Tunneling Cutaneous

Shortening of the connective tissue

(Copeland, et al., 2000)

Pathophysiology
Altered vascular supply
ischaemia

Inflammatory response Altered axonal plasma flow

(Rydevik, Lundborg, Skalak, 1989, p.81)

(I believe this is from Butler, 1991)

PATHODYNAMICS
Tension on the peripheral nervous system decreases circulation Mechanical interfaces can alter axoplasmic flow
Thixotrophic Axoplasmic flow is regulated by ATP transport in the microtubules not thixotrophic properties (Reference?)

POSITIVE FINDINGS
Does it reproduce the Signs & Symptoms? Are the test responses altered by distal movements? Are there differences from right to left?
Beware that the good side may be affected too.

DOUBLE CRUSH
A lesion at one site predisposes development of another lesion According to Osterman (1998), multiple lesion can occur along a peripheral nerve .

Signs of adverse neural tissue tension, when present, must be complementary to some condition determined by the overall examination before their meaning can be discerned.(Elvey, 1994, p.584)

TREATMENT
Determine if the test is positive Determine structure(s) @ fault Determine if it is irritable or non-irritable Apply appropriate grades of mobilisation Patient education Document Continually re-evaluate

To Be or Not To Be IRRITABLE
Severity? Irritability?
IRRITABLE Treatment Non-provoking initially Grades I & II (Maitland) MOVEMENT IS LIFE anti-tension postures *Avoiding activities that provoke the symptoms (Hall & Elvey, 2001, p.635) Rest NON-IRRITABLE Treatment Non-provoking initially (Grades I & II) Grades III & IV (Maitland) MOVEMENT IS LIFE HEP Rest
(Butler, Shacklock, & Slater, 1994)

TREATMENT PROGRESSION
IRRITABLE Increase # of oscillations Increase amplitude Increase the mobilisation of the nervous system Point of application of the technique moved closer to the involved area Treat as non-irritable NON-IRRITABLE Increase length of time # of oscillations Increase amplitude Increase mobilisation of the nervous system Point of application of the technique moved closer to the involved area Treat non-neural structures (this can be done at anytime during the treatment)

PRECAUTIONS & CONTRAINDICATIONS

Irritable disorders or Severe pain Neurological changes are worsening
acute compartment syndrome injury likely to cause neurological deficit

Inflammatory, systemic, and ineffective disorders that affect the nervous system
abscess Guillian barre

(Butler, Shacklock, & Slater, 1994)

Tethered spinal cord Marked injury or abnormality

REFERENCES
Butler, D.S. (1991). Mobilisation of the nervous system. Edinburgh: Churchill Livingstone. Butler, D. S., Shacklock, M. O., & Slater, H. (1994). Treatment of altered nervous system mechanics. In J. D. Boyling & N. Palastanga (Eds.), Grieves modern manual therapy, the vertebral column (2nd ed., pp.693-703). Edinburgh: Churchill Livingstone. Copeland, S., Bigliani, L.U., Emery, R., Amis, A., Chippindale, A., & Stoller, D.W. (2000). Interactive Shoulder [Computer software]. London, UK. Primal Pictures. Dommisse, G. F. (1994). The blood supply of the spinal cord and the consequences of failure. In J. D. Boyling & N. Palastanga (Eds.), Grieves modern manual therapy, the vertebral column (2nd ed., pp.3-20). Edinburgh: Churchill Livingstone. Ekstrom, R. A., & Holden, K. (2002). Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Physical Therapy, 82, 1077-1086. Elvey, R. L. (1994). The investigation of arm pain: signs of adverse responses to the physical examination of the brachial plexus and related tissues. In J. D. Boyling & N. Palastanga (Eds.), Grieves modern manual therapy, the vertebral column (2nd ed., pp.577-585). Edinburgh: Churchill Livingstone.

References
Garmer, D. A., Jones, M. A., & McHorse, K. J. (2002). The ulnar nerve bias upper limb neurodynamic tension test: An investigation of responses in asymptomatic subjects [Abstract]. Abstract presented the annual meeting of the American Physical Therapy Association, Cincinnati, OH. Retrieved February 25, 2003 from http://www.ptjournal.org/abstracts/pt2002/abstractsPt2002.cfm?pubNo=PL-RR-176-F Hall, T. M., & Elvey, R. L. (2001). Evaluation and treatment of neural tissue pain disorders. In R. A. Donatelli & M. J. Wooden (Eds.), Orthopaedic physical therapy (3rd ed., pp. 618-639). Philadelphia: Churchill Livingstone. Kleinrensink, G.J., Stoeckart, R., Mulder, P. G., Hoek, G., Broek, T., Vleeming, A., & Snijders, C. J. (2000). Upper limb tension test as tools in the diagnosis of nerve and plexus lesions. Anatomical and biomechanical aspects [Abstract]. Clinical Biomechanics, 15 (1), 9-14. Retrieved February 25, 2003 from OVID database. Neuro Orthopaedic Institute. (1996). Mobilization of the nervous system (5th ed.). Marina del Ray, CA: Neuro Orthopaedic Institute International and Longmans PTY. Oliver, J., & Middleditch, A. (1991). Functional anatomy of the spine. London: Butterworth-Heinemann. Osterman, A. L. (1998). The double crush syndrome. Orthopedic Clinics of North America, 19 (1), 147-155.

References
Rydevik, B., Lundborg, G., & Skalak, R. (1989). Biomechanics of peripheral nerves. In M. Nordin & V. H. Frankel (Eds.), Basic biomechanics of the musculoskeletal system (2nd ed., pp.75-87). Malvern, PA: Lea & Febiger. Shacklock, M. (1995).Clinical application of neurodynamics. In M. Shacklock (Eds.), Moving in on pain (pp.123-131). Sydney: Butterworth-Heinemann. Shacklock, M. O., Butler, D. S., & Slater, H. (1994). The dynamic central nervous system: structure and clinical neurobiomechanics. In J. D. Boyling & N. Palastanga (Eds.), Grieves modern manual therapy, the vertebral column (2nd ed., pp.21-38). Edinburgh: Churchill Livingstone.