Chapter 12 Neurodynamic Mobility. Overview Neurodynamic mobility testing is designed to examine the neurological structures for adaptive shortening and.

Chapter 12Chapter 12

Neurodynamic MobilityNeurodynamic Mobility

OverviewOverview

Neurodynamic mobility testing is Neurodynamic mobility testing is designed to examine the designed to examine the neurological structures for neurological structures for adaptive shortening and adaptive shortening and inflammation of the neural inflammation of the neural structuresstructures

Neurodynamic Neurodynamic DysfunctionDysfunction Proposed mechanisms:Proposed mechanisms:

– Theoretically, increased dural tension may Theoretically, increased dural tension may be felt throughout the neuromeningeal be felt throughout the neuromeningeal system, and can potentially affect the system, and can potentially affect the range of motion available to the trunk and range of motion available to the trunk and to an extremityto an extremity

– Neural tissue responds in the same way to Neural tissue responds in the same way to trauma that a ligament or tendon does by trauma that a ligament or tendon does by evoking the cascade of the inflammatory evoking the cascade of the inflammatory process, resulting in pain when stressed process, resulting in pain when stressed

Mechanisms of injuryMechanisms of injury

Adverse postureAdverse posture Direct traumaDirect trauma Extremes of motionExtremes of motion Electrical injuryElectrical injury Compression/ischemiaCompression/ischemia

Double Crush InjuriesDouble Crush Injuries

Theoretically, if the axoplasmic Theoretically, if the axoplasmic flow is partially reduced at a flow is partially reduced at a proximal site of injury, further proximal site of injury, further reduction can occur at a distal reduction can occur at a distal compression sitecompression site

Evidence is inconclusive Evidence is inconclusive

Neurodynamic Mobility Neurodynamic Mobility ExaminationExamination Consist of a series of tension testsConsist of a series of tension tests

– The tension tests are designed to The tension tests are designed to apply controlled mechanical and apply controlled mechanical and compressive stresses to the dura compressive stresses to the dura and other neurological tissues, both and other neurological tissues, both centrally and peripherallycentrally and peripherally

– Employ a sequential and progressive Employ a sequential and progressive stretch to the dura until the patient’s stretch to the dura until the patient’s symptoms are reproducedsymptoms are reproduced

Neurodynamic Mobility Neurodynamic Mobility ExaminationExamination Positive symptoms for the Positive symptoms for the

presence of neuropathic presence of neuropathic dysfunction include pain, dysfunction include pain, paresthesia, and spasmparesthesia, and spasm

Straight Leg Raise testStraight Leg Raise test

The SLR test places a tensile stress on The SLR test places a tensile stress on the sciatic nerve, and exerts a caudal the sciatic nerve, and exerts a caudal traction on the lumbosacral nerve roots traction on the lumbosacral nerve roots from L4 to S2from L4 to S2

The evaluation of the findings from the The evaluation of the findings from the SLR test requires that the range of SLR test requires that the range of motion measured, and the symptoms motion measured, and the symptoms produced, are compared with the produced, are compared with the contralateral side and with expected contralateral side and with expected normsnorms

Straight Leg Raise testStraight Leg Raise test

It is generally agreed that the first 30º It is generally agreed that the first 30º of the straight leg raise serve to take of the straight leg raise serve to take up the slack or crimp in the sciatic up the slack or crimp in the sciatic nerve and its continuationsnerve and its continuations

Between 30-70º, the spinal nerves, Between 30-70º, the spinal nerves, their dural sleeves, and the roots of their dural sleeves, and the roots of the L4, L5, S1 and S2 segments are the L4, L5, S1 and S2 segments are stretched with an excursion of 2-6 stretched with an excursion of 2-6 mm mm

Straight Leg Raise testStraight Leg Raise test

After 70°, while these structures After 70°, while these structures undergo further tension, other undergo further tension, other structures also become involved:structures also become involved:– The hamstringsThe hamstrings– The gluteus maximusThe gluteus maximus– The hip, lumbar and sacroiliac joints The hip, lumbar and sacroiliac joints

SensitizersSensitizers

The The following following sensitizerssensitizers can be can be used:used:– Dorsiflexion of the ankleDorsiflexion of the ankle– Cervical flexion Cervical flexion – Internal rotation of the hipInternal rotation of the hip

Crossed Straight Leg Crossed Straight Leg SignSign Three recognized typesThree recognized types::

– A SLR that produces pain in the contralateral A SLR that produces pain in the contralateral leg, but not when the contralateral leg is leg, but not when the contralateral leg is raisedraised

– A SLR that produces pain in both legsA SLR that produces pain in both legs– A SLR of either leg that produces pain in the A SLR of either leg that produces pain in the

contralateral limb contralateral limb The crossover sign is thought to be more The crossover sign is thought to be more

significant than the SLR test in terms of significant than the SLR test in terms of its diagnostic powers to indicate the its diagnostic powers to indicate the presence of a large disc protrusion presence of a large disc protrusion

Bilateral Straight Leg Bilateral Straight Leg RaiseRaise By performing a bilateral straight By performing a bilateral straight

leg raise and incorporating both leg raise and incorporating both neck flexion and dorsiflexion, neck flexion and dorsiflexion, central protrusions may be central protrusions may be detecteddetected

Bowstring testsBowstring tests

The Bowstring tests do not impart a The Bowstring tests do not impart a sufficient stretch of the dura to detect sufficient stretch of the dura to detect chronic adhesionschronic adhesions

However, they can be used to make a However, they can be used to make a prognosis about acute disc herniationsprognosis about acute disc herniations

A positive bowstring test is a strong A positive bowstring test is a strong indicator for surgery, but it need only indicator for surgery, but it need only be performed if the straight leg raise is be performed if the straight leg raise is positive with the addition of dorsiflexionpositive with the addition of dorsiflexion

Bowstring testsBowstring tests

Two types:Two types:– Cram’s Tibial Nerve TestCram’s Tibial Nerve Test – Common Peroneal TestCommon Peroneal Test

The Slump TestThe Slump Test

The slump test, popularized by Maitland, The slump test, popularized by Maitland, is a combination of other neuromeningeal is a combination of other neuromeningeal tests; namely the seated SLR, neck tests; namely the seated SLR, neck flexion, and lumbar slumpingflexion, and lumbar slumping

Maitland asserted that the slump test Maitland asserted that the slump test enables the tester to detect adverse enables the tester to detect adverse nerve root tension caused by spinal nerve root tension caused by spinal stenosis, extraforaminal lateral disc stenosis, extraforaminal lateral disc herniation, disc sequestration, nerve root herniation, disc sequestration, nerve root adhesions, and vertebral impingementadhesions, and vertebral impingement

Prone Knee Bending Prone Knee Bending TestTest The prone knee bending (PKB) test The prone knee bending (PKB) test

stretches the femoral nerve using hip stretches the femoral nerve using hip extension and knee flexion to stretch extension and knee flexion to stretch the nerve termination in the the nerve termination in the quadriceps muscle, and has been quadriceps muscle, and has been used to indicate the presence of used to indicate the presence of upper lumbar disc herniations, upper lumbar disc herniations, particularly when hip extension is particularly when hip extension is addedadded

Upper Limb Tension Upper Limb Tension Tests Tests The upper limb tension tests (ULTT), or The upper limb tension tests (ULTT), or

brachial plexus tension tests, involve an brachial plexus tension tests, involve an ordered sequence of movement of the ordered sequence of movement of the shoulder girdle, arm, elbow, forearm, shoulder girdle, arm, elbow, forearm, wrist and handwrist and hand

Because there are a number of tissues Because there are a number of tissues in the cervicobrachial region that could in the cervicobrachial region that could be stressed by these maneuvers, be stressed by these maneuvers, cervical side bending, or cervical flexion cervical side bending, or cervical flexion is addedis added

ULTT 1 (Median nerve ULTT 1 (Median nerve dominant)dominant) Components include:Components include:

– Shoulder girdle depressionShoulder girdle depression– Humeral abduction to approximately Humeral abduction to approximately

110°110°– Forearm supinationForearm supination– Elbow, wrist and finger extensionElbow, wrist and finger extension

ULTT 2 (Radial nerve ULTT 2 (Radial nerve dominant)dominant) Components include:Components include:

– Shoulder girdle depressionShoulder girdle depression– Humeral abduction and external Humeral abduction and external

rotationrotation– Forearm pronationForearm pronation– Elbow extensionElbow extension– Wrist and finger/thumb flexionWrist and finger/thumb flexion

ULTT 3 (Ulnar nerve ULTT 3 (Ulnar nerve dominant)dominant) Components include:Components include:

– Shoulder girdle depressionShoulder girdle depression– Humeral abductionHumeral abduction– Forearm supinationForearm supination– Elbow flexionElbow flexion– Wrist extensionWrist extension