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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 themorning

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 anpainful

The end-feel of elbow extension is empty

Overpressures are painless at the shoulder

Rotation and lateral flexion of the cervical spine to theopposite side of the involved limb is limited secondary topain

Thoracic extension appears limited

ULTT2b (radial bias) demonstrates a comparable sign

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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

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UE - Neural Tension Tests

ULTT1 (Median)

ULTT2a (Median) ULTT2b (Radial)

ULTT3 (Ulnar)

(Butler, (Butler,

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(Butler, 1991)

Validity, Reliability, Sensitivity,

Specificity

ULTT1 (Median)

It was sensitive and specific for producing tension inthe 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.

(Ekstrom & Holden, 20


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 inthe median nerve.


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%)

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Neurodynamics

Mechanics

Pathomechanics

Physiology

Pathophysiology

Pathodynamics

(Neuro Orthopedic Institute, 1996, p.33)

Mechanics

Continuum

Designed for movement Connective tissue

Mechanical interfaces

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

Physiology

Circulation

Axoplasmic flow

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Pathomechanics

Mechanosensitivity

Mechanical interface Attachment

Branches

Unyielding interface

Tunneling

Cutaneous

Shortening of the connective tissue

(Copeland, et

Pathophysiology

Altered vascular supply

ischaemia

Inflammatory response

Altered axonal plasma flow

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(Rydevik, Lundborg, Skalak, 1989, p.81)(I believe this is from Butler

PATHODYNAMICS

Tension on the peripheral nervous system decreasescirculation

Mechanical interfaces can alter axoplasmic flow

Thixotrophic

Axoplasmic flow is regulated by ATP transport in themicrotubules not thixotrophic properties (Reference?)

DOUBLE CRUSH A lesion at one site predisposes development of another lesion

According to Osterman (1998), multiple lesion can occur alonga peripheral nerve .

POSITIVE FINDINGS

Does it reproduce the Signs & Symptoms?

Are the test responses altered by distalmovements?

Are there differences from right to left?

Beware that the good side may be affected too.

Signs of adverse neural tissue tension, whenpresent, must be complementary to some

condition determined by the overall examinationbefore their meaning can be discerned.(Elvey,1994, p.584)

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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

IRRITABLE

Treatment Non-provoking initially

Grades I & II (Maitland)

MOVEMENT ISLIFE

anti-tension postures

*Avoiding activities

that provoke thesymptoms (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, 19

Severity?

Irritability?

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)

(Butler, Shacklock, & Slater, 1994)

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 affethe nervous system

abscess

Guillian barre

Tethered spinal cord

Marked injury or abnormality

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