BY DAVID BUTLER

 This is primarily built to treat adverse neural tensions.

 The neuropathic symptoms explained by the patient in terms of a vague
pain,deep,burning pain, heaviness of limb.
 Pain may be constant or intermittent with paraesthesia & anaesthesia, worst at
night time in peripheral entrapment neuropathies.
 Worst at the end of the day in chronic nerve root irritation,weakness,overuse.

 C1 Upper cervical flexn

 C2 Upper cervical extn
 C3 cervical lateral rotatn
 C4 Shoulder girdle elevation
 C5 Shoulder abduction
 C6 Elbow flexn
 C7 Elbow extn
 C8 Thumb extn,finger flexion.
 T1 Finger abdn/addn
 L2 Hip flexn
 L3 Knee extn
 L4 Dorsiflexn
 L5 Great toe extn
 S1 Eversion,knee flexn
 S2 Knee flexion,toe standing.

 The concept of the continuous tissue tract:

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  The peripheral & CNS are considered as one as they form a continuous tissue
tract.
 The system is continuous in 3 ways
 1) the connective tissues are continuous, although in different forms, such as
epineurium & duramatter.
 Ex: a single axon can be associated with a number of these connective tissues.
2) The neurons are interconnected electrically
Ex: an impulse generated at the foot may be received at the brain.
3) The nervous system is continuous chemically
Ex: neurotransmitters
 The spinal canal is from 5cm to 9cm longer in flexion than extension.
 The peripheral nervous system requires more adaptive mechanism than the CNS.


 The spinal canal undergoes length changes during movement.
 From spinal extension to spinal flexion, it elongates by 5-9cm.
 In early ranges of flexion, the cross sectional area of sp.canal increases, where as
in extension it decreases.
 The walls of sp.canal do not move as one. posterior wall of the canal elongates
more than the anterior wall during flexion movts.

 Both movt & elongation occur in the sciatic tract during the SLR.
 During the SLR the lumbosacral nerve roots move caudal in relation to their
respective intervertebral foramen & in a caudal direction with in the pelvis.
 Sciatic & tibial nerves superior to the knee move caudal in relation to interfaces,
this relationship is reversed inferior to the knee i.e., the tibial nerve below the
knee moves cephalad in relation to surrounding tissue.

 The points along the nervous system which apparently do not move or have
minimal movt in relation to surrounding structures are defined as tension points.
 Ex: at the limit of SLR test, patients complain of pain in varying areas. A
common complaint is pain or stretch posterior to the knee or higher in the bulk of
hamstrings. this pain is tension point pain.

 ULTT1 –Median nerve

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  ULTT2 a)Median nerve
b) Radial nerve
 ULTT3- Ulnar nerve
 Other ULTT-Axillary nerve
 Musculocutaneous nerve
 Passive neck flexion.
 SLR
 SLUMP TEST
 Bent knee test
 Self technique

 Examination is based on subjective, physiological & physical observation & by

electrodiagnostic tests.
 Movt & elasticity of neurons, nervous system can be examined.

 TESTING OF UPPER LIMB:

 ULTT 1:
 Median nerve dominant utilizing shoulder abduction.

 Brachial plexus tension test or ELVEYS test,SLR of arm.

 Median nerve dominant using shoulder abduction.
 Clinical: UL

 neck disorder.
cervical lesions.
spinal disorders.
(symptoms any where in the arm,head,neck,thoracic spine)

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METHOD:
Non irritable.(W/F/E/S/ Neck full range normal)
SUPINE:
Left hand side of couch.
Upper arm rest on examiners thigh.
Wrist finger to hold.
Depression of shoulder.
110 degrees of abduction.
Fore arm supination,wrist finger extension, shoulder lateral rotation, elbow extension.
Cervical lateral flexion to left and right added.
Take ear to shoulder

 ULTT 2a): Median nerve dominant

utilizing shoulder girdle depression &
external rotation.
 Same as before.
 10 degrees of shoulder abduction- arm
clear & parallel to bed.
 Shoulder depression/elbow
extension/lateral rotation.
 Forearm pronation:thus between patient

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 thumb & index finger.
 Extend wrist fingers & thumb(if symptoms reproduced/shoulder depression
released & assessed.)

 ULTT 2 b): Radial nerve dominant utilizing shoulder girdle depression & internal
rotation.
 Same as before.
 Shoulder/elbow etension
 Shoulder medial rotation.
 Forearm pronation.(left elbow lock left elbow)
 Wrist flexion/extension.
 Thumb flexion,ulnar deviation, finger flexion.
 Normal response:
 compare with other arm.
 Symptom over radial& median nerve
 Add up lateral flexion of neck

 Left hand side, supine lying without pillow.

 Hand side of the couch.
 Upper arm rests on examiners thigh.
 Hold wrist & fingers.
 110 degrees of abduction, forearm supinated,wrist fingers extended, shoulder
laterally rotated, elbow extended.
 Cervical lateral flexion to right or left can be added

 Degree of burning & tingling in ulnar nerve & medial aspect of elbow.
 No pain with resistance & no range of movt restriction.

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  Long thoracic nerve,subscapular nerve,cutaneous,axillary nerve: all these nerves
can be tested with more stress placed in tension testing.
 Long thoracic nerve: shoulder depression & lateral flexion of cervical & thoracic
spine.
 Subscapular nerve tension can be tested by placing more stress on protraction.

 Cutaneous nerve :shoulder girdle depression, elbow extension & lateral rotation.
 Axillary: abduction & lateral rotation of shoulder.
 All the above test will be positive if decreased range of motion, relevant
symptoms, referred pains,dermatomes,myotomes signs to total area of nerve cord.

 TECHNIQUE 1:
 Passive neck flexion
 SLR
 SLUMP test
 Prone knee bending test

 INDICATIONS:
 For all spinal disorders to find adverse neural tension.
 METHOD:
 Supine lying.
 Lift head off bed, passively flex neck, chin to chest & symptoms , range noted.
 To sensitize this test, add neck lateral rotation, flexion.
 to further sensitize this test do SLR & ULTT
 NORMAL RESPONSE:
 Pain loss test.
 Pulling effect at cervico thoracic junction

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  INDICATIONS:

 All lumbar disc genic problems.

 METHOD:
 Supine lying
 Trunk & hip in neutral position. lift the leg perpendicular to bed.
 Check for range, symptoms, resistance & movt encountered.
 Normal response will be 50-120 degrees.
 Interpret by checking the other leg.
 Symptoms mostly over posterior thigh,knee,calf.

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  Add ankle dorsiflexion & check neuropathic signs.
 Add ankle plantar flexion with inversion.
 Add hip adduction with SLR.
 Add hip medial rotation.
 Add passive neck flexion/lateral neck flexion & elicit the response.
 Use 2 pillows under cervical & thoracic spine.

 Use dorsiflexion & inversion with SLR.

 Ankle plantar flexion & inversion used for shin splints, chronic ankle sprains.
 OTHER SLR TESTS:
 Knee on couch both sides, ask him to raise leg, both legs on therapists shoulder.
 WELL LEG RAISING TEST:(unilateral neck pain)
 If opposite leg pains, test is +ve & this is best test for disc prolapse.
 Many structures moved when SLR is performed.hamstrings,lumbar
spine,hip,fascia are moved but we concentrate on nervous system.

 INDICATIONS
 Lumbar radiculopathy.
 Anterior thigh pain
 Upper lumbar symptoms.
 METHOD
 PRONE LYING
 Head turned towards therapist, flex the knee heel touch to buttocks.
 Now test range,symptoms,response,resistance.
 Normal response: pulling pain over quadriceps area, check over contralateral area.

VARIATIONS TO SENSITISE THE TEST

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Prone lying
Extension of hip,abduction,knee extension & now again extend the hip & laterally rotated
with eversion & dorsiflexion

With hip extension, adduction.One pillow under the thigh

 For lower lumbar pathology, upper lumbar pathology.

 METHOD:
 Patient sit back on plinth, thighs fully supported, knee together.
 Knee crease out of bed, hands locked behind back.
 Therapists hand behind the patients back.

 1. patient is asked to sag without bending the sacrum & neck.

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  2.over pressure over lumbar & thoracic flexion. Pressure should be given from the
axilla or ribs of therapist.
 3.chin to chest. ask to bend the neck to chest & apply over pressure.
 4.ask to extend knee.
 5.patient is asked to do dorsiflexion of ankle.
 6.neck flexion slowly released.
 7.repeat on other leg.
 If neck flexion, knee extension restricted by pain, slowly release neck flexion.
 If pain changes then pain is neurogenic.


 Some discomfort only pain may be there.
 STAGE 3: Knee flexion.
 STAGE 4: Knee extension ,behind knee.
 STAGE 5: Some restriction of dorsiflexion.
 STAGE 6: All the symptoms should be released.
 TREATMENT:
 For slump test +ve is SLR & PKB.

 TREATMENT: Long sitting, foot supporting on the wall, maintaining

dorsiflexion.
 With one flexion & rhythmic oscillation.
 SELF TREATMENT FOR NEURAL MOBILISATION:
 For moderately irritable lumbar spine.
 Hip flexion, active knee extension

 Use powder on heels for sliding.

 PKB: Quadriceps stretch in standing.
 Slightly bend forward to stretch femoral nerve.
 Standing SLUMP with foot in plantarflexion,inversion & knee held extended:
 HURDLERS STRETCH: PKB & SLR
 SARVANGASANAM
 Self stretch for ULTT
 ULTT1:
 Place hand on wall with shoulder depression.
 ULTT2:
 Maintain wrist extension & clasp hands back.
 ULTT3:
 Touch the palm to the ear lobe or leaning position in sidelying.

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