Neural Mobilization

1. Concept of Clinical Neurodynamic

2. Functional Anatomy and Physiology of Nervous System
3. General Layout of The System
4. Primary Mechanical Functions of the nervous system

5.

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 Concept of Clinical neurodynamic

 Clinical Neurodynamic is essentially the clinical application of mechanics & physiology of

the nervous system (NS) as they relate to each other & are integrated with
musculoskeletal function.

 Concept of 'Neural Tension' emerged, many physios mistook “Tension” for “Stretch”.

 Stretching of nerve may irritate & provoke pain, thus they gave up on neural
mobilization.

 Functions of Nervous system, such as movement, pressure, viscoelasticity & physiology

were equally important but many a times, ignored from analysis.

 So, the concept evolved with integration of mechanical & physiological mechanisms
making it easier and safer to apply.

 Clinical Neurodynamic is divided into

 General Neurodynamic is concerned with fundamental mechanisms that apply to

the whole body, no matter what region.
 Specific neurodynamic applies to regions of the body to cater for local anatomical
and biomechanical idiosyncrasies that the therapist must consider making
examination and treatment more specific to the patient's needs.

Clinical
Neurodynamics

General Specific

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 Functional Anatomy and Physiology of Nerves

Nerve: Structure and its function

 Neuron or nerve cell is defined as the structural and functional unit of nervous

system. Neuron is like any other cell in the body, having nucleus and all the

organelles in cytoplasm.

 A nerve is an enclosed, cable-like bundle of nerve fibers called dendrites and axons,

in the peripheral nervous system. They form the processes of neuron; dendrites are

short processes and the axons are long processes.

 A nerve transmits electrical impulses by providing a common pathway for the

electrochemical nerve impulses called action potentials that are transmitted along

each of the axons to peripheral organs or, in the case of sensory nerves, from the

periphery back to the central nervous system.

 The nerves are solid white cords composed of bundles (fasciculi) of nerve fibers.

 Each nerve fiber is an axon with its coverings, along with other supportive cells

such as some Schwann cells that coat the axons in myelin.

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Coverings of nerve
 The nerve fibers are supported and bound together by connective tissue sheaths at
different levels of organization of the nerve.
 Connective tissue surrounds each axon (endoneurium) as well as fascicles
(perineurium) and entire nerve fibers (epineurium).
 The axolemma is the surface membrane of axon. Schwann cells lie between the
axolemma and endoneurium; they form myelin, which functions to insulate the axon
as well as speed the conduction of action potentials along the nerve fiber.
 The exceptions are very small fibers that are unmyelinated.
 A peripheral nerve may consist of a single fascicle or consist of several fascicles,
each fasciculus is covered by perineurium, and each nerve fiber by a delicate
endoneurium.
 The toughness of a nerve is due to its fibrous sheaths, otherwise the nerve tissue itself
is very delicate and friable.

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 GENERAL LAYOUT OF THE SYSTEM
3-part system –
 Mechanical interface

 Neural structures

 Innervated tissues

 Use to categorize body tissues with

respect to Nervous system.

 Diagnosis and treatment can be

derived from causal mechanisms.

Mechanical interface

 The body is container of Nervous system in which musculoskeletal system presents a

mechanical interface to NS.

 Mechanical interface can consist of anything that resides next to Nervous system.

 Such as – tendon, muscle, bone, intervertebral discs, ligaments, fascia & blood
vessels.

 Nervous system must follow the movement of flexible interface.

 During daily movements like elongates, shortens, bends, twists & turns, resulting in
simultaneous changes in the neural structures.
 In doing so, the complexity of interactions between the Nervous system &
Musculoskeletal system systems is natural part of body movement.
 A good knowledge of these events is a key part of clinical practice, so that assessment &
treatment can be directed specifically toward them.

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Neural structures

 Neural structures are those that constitute Nervous

system which includes –
 Brain, cranial nerves, spinal cord, nerve
rootlets, nerve roots, peripheral nerves
(including sympathetic trunks) & all their
related connective tissues.
 The connective tissues of Nervous system are
formed in –
 CNS by meninges (pia, arachnoid & dura maters)
 PNS by mesomerism, epineurium, perineurium endoneurium.
 Functions-
 Mechanical Functions are –
Tension, movement & compression
 Physiological Functions are –
Intra-neural blood flow, impulse conduction, axonal transport,
inflammation & mechanosensitivity.

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Innervated tissues

1. Any tissues that are innervated by NS.

2. Virtually all tissues are innervated directly by nerve endings or psychoneuro-immune

connection.

3. Direct neural connections are concern for 3 reasons –

1. They provide the basis for some causal mechanisms.

2. They provide the opportunity to move nerves.

3. Sometimes, treatment of the innervated tissues is the best way to treat what
seems to be a neural problem.

1. Causal mechanisms example-

 Over straining injury to the innervated tissues.

 It could produce excessive stretching of a peripheral nerve or nerve root &
clinical sequel.
 In terms of physiology, the Nervous system interacts in both afferent & efferent
directions with the innervated tissues which is clinically important actions.
2. Opportunity to move nerves example-

 To test the femoral nerve & its associated nerve roots is by movement of the
quadriceps muscle.
 Stretching the muscle applies tension to nerve & therefore yields techniques for
testing & Rx.
3. Treatment of innervated tissue example-

 A nerve root disorder may produce trigger points in the muscles innervated by the
related nerve root.
 In the absence of a thorough examination of the innervated tissues, muscle pain
would typically be termed “referred pain” & the muscles would often be ignored.

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 Primary Mechanical Functions of the Nervous System

 The Nervous system has natural ability to move & withstand mechanical forces that are
generated by daily movements.
 This capacity is essential in prevention of injury & malfunction.
 Primary mechanical functions:
 Withstand Tension
 Slide in its Container
 Be Compressible
 These events occur in both peripheral & central nervous systems.
 However, achieved in different ways because of regional differences in anatomy and
biomechanics.

Tension of nerve

 Nerves are lengthened by elongation of

container. Joints are the key site at which nerves are elongated.

 Stronger parts of Nervous system, e.g. sciatic nerve, can withstand 50

kg of tension.

 Perineurium plays the key role in tension

of nerves.

 It is a primary guardian against excessive tension & is

effectively the cabling in Peripheral nerves.

 Densely packed connective tissue & forming each fascicle, the perineurium has
considerable longitudinal strength & elasticity.

 It allows peripheral nerves to withstand approximately 18-22% strain before

failure.

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Sliding of nerves

 The movement of neural structures relative to their adjacent tissues is referred as

excursion or sliding which occurs longitudinally & transversely.

 It is an essential aspect of neural function because it serves to dissipate tension in NS.

 Nerves slide down the tension gradient by displacing toward the point of highest tension

to produce an equalization of tension throughout the neural tract.

 Sliding can be either-

 Longitudinal sliding

 Transverse sliding

Longitudinal sliding

 Sliding of nerves down the tension gradient enables them to lengthen their tissue toward
the part at which elongation is initiated.

 This way, tension is distributed along the Nervous system more evenly, rather than it is
building up too much at one location.

 Protective effect of neural Sliding– e.g. – 1

 Blood flow in PN is blocked at 8-15%

elongation, however, the median nerve
elongates by 20% between full elbow
flexion & extension.
 If longitudinal sliding did not occur,
neural ischaemia would result in medial nerve, but it
continues to function normally.
 Because the actual strain in the medial nerve is
probably only 4 - 6% due to nerve sliding toward the elbow from wrist & shoulder.

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  Protective effect of neural Sliding– e.g. – 2

 During SLR, the sciatic/tibial nerve elongates by up to 124mm.

 Calculated in a person 1.75 m tall, this would amount to approximately 14%
elongation of the nerve.
 But nerve failure did not occur with SLR because it is protected from excessive
elongation by an intrinsic mechanism that is, sliding.

 In contrast, nerves are more likely to malfunction if additional movements are performed
that prevent sliding by simultaneous increase in neural tension from both ends.

 Examples of median nerve – Contralateral side flexion of neck, shoulder abduction, wrist
& finger extension.

 The addition of neck side flexion would now produce neural symptoms even in normal
subject. This introduces the phenomenon.

Transverse sliding

 Like longitudinal movement, transverse sliding is

also helping in dissipating tension & pressure in the
nerves.

 Transverse excursion occurs in 2 ways.

 Specific combinations of UL & spinal movements

can be used to deliberately produce transverse
sliding of nerves.

 Examples-

1. To enable the nerves to take the shortest

course between two points when tension is applied.
This is particularly important in locations where transverse movement is a key part of
the nerve's local biomechanics, Example, the superficial peroneal nerve over the
ankle.

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 2. The transverse movement occurs when nerves are subjected to sideways pressure by
neighbouring structures, such as tendons & muscles. Sideways pressure induced by
movement of flexor tendons causes median nerve at wrist to slide transversely out of
its resting position.

 Sliding of peripheral nerves is provided by specific connective tissues.

 At surgery & in cadavers, mesomerism has been observed to be a thin multi layered
membrane made of loose connective tissue that has distinct boundaries & behaves like
synovial membrane around tendons.

 Another dimension of neural sliding is the movement of fascicles on their neighbouring

bundles.

 This inter-fascicular sliding is permitted by inter-fascicular epineurium which also

consists of soft & loose connective tissues.

Compression
 Neural structures can distort in many ways,
including the changing of shape according to
pressure exerted on them.
 Clinical example of PN –
 Compression of median nerve at the
wrist in Phalen's sign by mechanical
interface of wrist flexion.
 Elbow flexion applying pressure on
ulnar nerve at elbow. Here, bone &
tendon combined with muscle & fascia
are what press on nerve.
 Clinical example of Spine –

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 Extension + lateral flexion of spine closes the spinal canal inter-vertebral foramina
around the nerve roots.
 In this way, mechanical interface transmits forces to Nervous system which then
responds to these demands by altering its own dimensions and position.
 The Nervous system effectively moves down the pressure gradient.
 Epineurium:
 The epineurium is the padding of nerve & is what protects the axons from
excessive compression.
 It consists of finer & less densely packed connective tissue than the perineurium
(a feature that gives the nerve spongy qualities & enables the nerve to spring
back when pressure is removed).

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