1. Neural Mobilization

2. MUST READINGS
Shacklock Clinical Neurodynamics (2-29, , , , )
Butler Mobilisation of the Nervous System (55-90, )

3. Briefly: Neural Testing & Mobilization
Neural testing and mobilization has to be used with care and precision
By using neural testing or mobilization too forceful you may cause more harm than benefit!
Houglum 2010, 185,

4. Length change in the spinal canal

5. SPINAL CORD MOVEMENT During Flexion

6. Neural Mobilization
Mobilisation of the nervous system is an approach to physical treatment of pain.
The method relies on influencing pain physiology via mechanical treatment of neural tissues (direct method) and the non-neural structures surrounding the nervous system (indirect method).
Shackloc 1995

7. Neural Testing and Mobilization
GOAL: differentiate symptomatic tissue
Testing: Does provocation testing reveal/increase the type of symptoms customer has had, compare to the uneffected side
Treatment: Does treatment decrease symptoms the customer has had
PHYSIOLOGY: Compression or tension or both > effects to nerve’s conduction and metabolism and itraneural blood flow
Refresh your memory: How and which direction nerve move/slide in the joint
Shackloc 2005

8. Physiological effects of Neural Mobilization
Restore the dynamic balance between the relative movement of neural tissues and surrounding mechanical interfaces
Facilitation of nerve gliding
Reduction of nerve adherence (viscoelastic properties),
Dispersion of noxious fluids,
Increased neural vascularity (intraneural bloodflow), and
Improvement of axoplasmic flow
Ellis et al. 2008

9. Indications Use in non-irritable conditions (neurpathic/neurogenic)
For pathomecanical causes:
Fibrosis
Connective tissue adhesions
Restriction of normal tissue mobility
Houglum 2010, 192

10. CONTRAINDICATIONS
Malignancies of the nervous system or vertebral column (selkäranka)
Acute inflammatory infections
Areas of instability
Spinal Cord Injuries
Suspected disc lesions
Cauda equina lesions
Dizziness related to vertebral artery insufficiencies
Any central nervous system disorders (e.g. spina bifida, MS)
Worsening neurological signs
Houglum 2010, 104

11. Concepts of Nerve Testing and Mobilization
CLOSING: Closing mechanisms are those that produce increased pressure on a neural structure by way of reducing the space around it (Phalen)
OPENING: Opening mechanism are those that procude reduced pressure on a neural structure. The reduced pressure occurs when the space around the neural structure is increased by a particular manouvere (Spinal flexion)
Combining to muscle and tendon testing improves sensitivity.
Validity and reliability in testing is correlated with performance (repeats, repeats, repeats in exercising techniques)
Shackloc 2005

12. OPENING and CLOSING in the SPINE
Shackloc 2005

13. Concepts of Nerve Testing and Mobilization
Slider – goal is to produce gliding movement in relation to surrounding tissues
Tension – goal is to produce tension in the certain part of peripheral nerve.
Activity in ”normal area” - do not exceed the limits of elasticity (no lesions, is not a ”strech”) > may improve viscoelastic properties and physiological function of nerve)
In testing (ant treatment) directly to nerve tissue
1. SLIDER, 2. TENSIONER (observe symptoms, decreased ROM or change in muscle activity)
Shackloc 2005

14. Testing Neural Tissue
THE IDEA is to determine can we provoce the symptoms of the customer has and compare the uneffected side to the symptomatic side.
Tension Test
1. stop – First sensation of resistance
Final stop – Symptoms or pain (scale 1-10)
Useful tool is a mental movement diagram > is the condition
Pain Dominant (pathofhysiologic)
Limitation Dominant (Pathomechanical)
Shackloc 2005

15. Testing Neural Tissue
Start from the uneffected side > effects to the symptomatic side (e.g. SLUMP and SLR)
Upper extrimities: Tension increases when
Lateral flexion of cervical spine (plexus prachialis, > n.med. ja n.rad.)
Depression of Shoulder girdle/scapula (all the nerves of upper extremity)
Shoulder abduction (90-100°) > plexus prachialis and pheripheral parts, LR especially n. medianus, MR n. radialis
Elbow extension > n. medialis, Flexion > n. ulnaris, Supination > n. medianus, Pronation > n. radialis, n. interosseus
Wrist extension > n. medianus
Finger extension > n. medianus

16. Medianus – ULTT1

17. Medianus – ULTT 1

18. Testing N. medianus (ULTT 1)
Shoulder depression
GH 110 abduction (support with thigh)
Elbow in flexion
Wrist dorsiflexion, Finger extension
Arm supination
GH Lateral rotation
Elbow extension
Cervical lateral flexion

19. Medianus - ULTT 2a

20. Testing N. medianus (ULTT 2a)
1. Shoulder depression
2. Elbow extension
3. GH lateral rotation + supination
4. Wrist extension abduction of the thumb
5. Shoulder abduction
6. If distal symptoms > release scapula, If proximal symptoms > release fingers/wrist

21. Radial – ULTT 2b

22. Ulnar – ULTT3

23. Lumbar area - Ichias

24. SLUMP

25. SLR = Straght Leg Raise
Shacklock 2005, 138

26. Tibial Neurodynamic Test
Shacklock 2005, 138

27. Peroneal Neurodynamic Test

28. PKB = Prone Knee Bent – Mid lumbar & Femoralis

29. Neural Mobilization Tell the customer what you are doing
Test or mobilize uneffected side first (compare sides in testing)
Use sliders, spine slider (neck) may be beneficial to use before peripheral slider
Stop in the first sign
Be gentle – with inappropriate testing and mobilization may cause more harm than benefit
Throughout the treatment, the customer’s symptoms havs to be monitored > treatment should NOT cause pain
A sequence of of slow oscillations can last sec > reassess customer’s condition
Don’t give nerve mobilization home exercises at the first meeting (because you don’t know the response, may occur after several hours)
Houglum 2010,

30. Neural Mobilization Start locally
Analyze provocing position or movement accurately and then choose test movement
Refresh your memory: Spine movement in flexion extension increase the length of spine approximately 9cm
the status of tissues and tension
Spinal cord and membranes and nerve roots glide cranially/caudally
Flexion: opener, flexion closer, notice ”tension points” (picture) how spinal cord and membranes glide

31. References
Butler Mobilisation of the Nervous System (55-90, )
Ellis et al Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy. J Man Manip Ther. 2008; 16(1): 8–22.
Houglum Therapeutic Exercise for Musculoskeletal Injuries: Chapter 6: Manual Therapy Techniques (p )
Huijbregts Orthopaedic Manual Physical Therapy- History, Development and Future Opportunities. Journal of Physical Therapy 1,
Kaltenborn th Edition. Manual Mobilization of the Joints. Joint Examination and Basic Treatment. Volume II. The Spine.
Pickar Neurophysiological effects of spinal manipulation. The Spine Journal 2, 357–371.
Shacklock Clinical Neurodynamics (2-29, , , , )
Shackloc Neurodynamics. Pysiotherapy. 81(1),