Therapeutic exercise and related manual therapy techniques would not be possible without the

nervous system and all its components activating, controlling, and modifying motor responses as
well as receiving and interpreting feedback from the variety of sensory receptors throughout the
body. Because of their intimate proximity to all the structures in the trunk and extremities,
nerves may become stressed or injured with various musculoskeletal conditions, postures, and
repetitive microtraumas resulting in neurological symptoms, structural and functional
impairments, activity limitations, and participation restrictions.
Content of Peripheral Nerves
Peripheral nerves contain a mix of motor, sensory, and sympathetic neurons.
Alpha motor neurons (somatic efferent fibers): cell bodies located in anterior column of spinal cord;
innervate skeletal muscles
Gamma motor neurons (efferent fibers): cell bodies located in lateral columns of spinal cord;
innervate intrafusal muscle fibers of the muscle spindle
Sensory neurons (somatic afferent fibers): cell bodies located in the dorsal root ganglia; innervate
sensory receptors
Sympathetic neurons (visceral afferent fibers): cell bodies located in sympathetic ganglia; innervate
sweat glands, blood vessels, viscera, and glands
Mobility Characteristics of the Nervous System
When a joint moves and tension is placed on a nerve bed, nerve gliding is toward the moving joint
(convergence); and when tension is relieved, nerve gliding is away from the moving joint (divergence).
Initially, excursion of the nerve occurs adjacent to the moving joint, but excursion of the nerve
progresses more distant from the moving joint as limb movement continues.Substantial mobility in the
nervous system is needed for an individual to move during functional activities. With movement of an
extremity, before there is increased tension in the nerve itself, the whole peripheral nerve moves, and
there is movement between connective tissues and neural tissues. The mobility is allowed without
undue stress on the nerve tissue because:
The arrangement of the spinal cord, nerve roots, and plexes allows mobility. If any part of the H is
placed under tension, the force can be dissipated throughout the system.
The nerves themselves are wavy and can straighten when tension is applied.
The connective tissue around the individual nerves and bundles of nerves (epineurium, perineurium,
endoneurium) absorb tensile forces before the nerve itself stretches.
Common Sites of Injury to Peripheral Nerves
Injury to the nerves of the peripheral nervous system can occur anywhere along the pathway from the
nerve roots to their termination in the tissues of the trunk and extremities. As each nerve courses from
the intervertebral foramina to its peripheral destination, there are sites that increase its susceptibility to
either tension or compression. Symptoms and signs of nerve impairments are sensory changes or loss
and motor weakness in the distribution of the involved nerve fibers. Because nerves are composed of
innervated connective tissue and blood vessels surround the axons, ischemic pain or tension pain may
also occur when these tissues are stressed. Also, because peripheral nerves include sympathetic fibers,
autonomic responses might occur. Whenever neurological symptoms and signs are present, the entire
nerve should be tested for mobility and signs of compression at key points along its pathway.

Nerve Roots
Nerve roots emerge from the spinal canal and traverse the foramina of the spine, where they can
become impinged as a result of various pathologies of the spine that reduce the space in the foramina,
such as degenerative disc disease (DDD), degenerative joint disease (DJD), disc lesions, and
spondylolisthesis. With reduced spinal canal or foraminal space (stenosis), extension, side bending, or
rotation to the side of the stenosis further decreases the space where the nerve root courses and may
cause or perpetuate symptoms.
Brachial Plexus
After emerging from the foramina, the nerve fibers divide into anterior and posterior primary rami.
Vasomotor fibers from the sympathetic trunk join the anterior primary rami to course within the
brachial plexus and peripheral nerves to the extremities. The brachial plexus is formed by the anterior
primary divisions of the C5T1 nerve roots. The plexus functions as the distribution center for
organizing the contents of each peripheral nerve. In addition, Butler11 suggested that the weave pattern
in the brachial plexus contributes to the mobility of the nerves such that when tension is placed on any
one peripheral nerve, the tension is transmitted to several cervical nerve roots rather than just one nerve
root.
Lumbosacral Plexus
The lumbar plexus is formed by the anterior primary divisions of the nerve roots L1, L2, L3, and part
of L4; the sacral plexus is formed from L4, L5, S1, and parts of S2 and S3. As with the brachial plexus,
the branches and divisions of the LS plexus organize the content of each of the peripheral nerves
coursing into the lower extremity. In addition, the anterior primary rami of the plexus receive
postganglionic sympathetic fibers from the sympathetic chain that innervate blood vessels, sweat
glands, and piloerector muscles in the lower extremity. Isolated injuries to the lumbar plexus or sacral
plexus are not common; symptoms more commonly arise from disc lesions or spondylitic deformities
that affect one or more nerve roots or from tension or compression of specific peripheral nerves.
Impaired Nerve Function
Nerve Injury and Recovery
Peripheral nerve injury may result in motor, sensory, and/or sympathetic impairments. In addition, pain
may be a symptom of nerve tension or compression, because the connective tissue and vascular
structures surrounding and in the transport,thus blocking nerve impulses; if sustained, the compression
can cause nerve damage. The endoneurium helps maintain fluid pressure and may provide cushioning
for nerves, especially when the nerves are close to the surface and subject to greater pressure. The
insult can be acute from trauma or chronic from repetitive trauma or entrapment. Sites where a
peripheral nerve is more vulnerable to compression, friction, or tension include tunnels (soft tissue,
boney, fibro-osseus), branches of the nervous system (especially if the nerve has an abrupt angle),
points at which a nerve is relatively fixed when passing close to rigid structures (across a boney
prominence), and at specific tension points. Results may be intraneural and/or extraneural.
Intraneural. Pathology that affects the conducting tissues (e.g., hypoxia or demyelination) or
connective tissues of the nerve (e.g., scarring of epineurium or irritation of dura mater) may restrict the
elasticity of the nervous system itself.
Extraneural.Pathology that affects the nerve bed (e.g., blood), adhesions of epineurium to another
tissue (e.g., a ligament), and swelling of tissue adjacent to a nerve (e.g., foraminal stenosis) may restrict
the gross movement of the nervous system in relation to surrounding tissues.

Mechanisms of Nerve Injury

Nerves are mobile and capable of considerable torsion and lengthening owing to their arrangement.
Yet, they are susceptible to various types of injury including:
Compression (sustained pressure applied externally, such as tourniquet, or internally, such as from
bone, tumor, or soft tissue impingement resulting in mechanical or ischemic injury).
Laceration (knife, gunshot, surgical complication, injection injury).
Stretch (excessive tension, tearing from traction forces).
Radiation.
Electricity (lightening strike, electrical malfunction). Injury may be complete or partial and produces
symptoms based on the location of the insult.
Classification of Nerve Injuries
Seddons Classification and Characteristics of Nerve Injury
Neuropraxia
Segmental demyelination
Action potential slowed or blocked at point of demyelination; normal above and below point of
compression
Muscle does not atrophy; temporary sensory symptoms
The result of mild ischemia from nerve compression or traction
Recovery is usually complete
Axonotmesis
Loss of axonal continuity but connective tissue coverings remain intact
Wallerian degeneration distal to lesion
Muscle fiber atrophy and sensory loss
The result of prolonged compression or stretch causing infarction and necrosis
Recovery is incompletesurgical intervention may be required
Neurotmesis
Complete severance of nerve fiber with disruption of connective tissue coverings
Wallerian degeneration distal to lesion
Muscle fiber atrophy and sensory loss
The result of gunshot or stab wounds, avulsion, rupture
No recovery without surgeryrecovery depends on surgical intervention and correct regrowth of
individual nerve fibers in endoneural tubes
Recovery from Nerve Injuries
Nerve tissue that has become irritated from tension, compression, or hypoxia may not have permanent
damage and shows signs of recovery when the irritating factors are eliminated. When the nerve has
been injured, recovery is dependent on several factors including the extent of injury to the axon and its
surrounding connective tissue sheath, the nature and level of the injury, the timing and technique of the
repair (if necessary), and the age and motivation of the person.
Nature and level of injury.
The more damage to the nerve and tissues, the more tissue reaction and scarring occur. Also, the
proximal aspect of a nerve has greater combinations of motor, sensory, and sympathetic fibers

 Timing and technique of repair.

Laceration or crush injuries that disrupt the integrity of the entire nerve require surgical repair. For
optimal nerve regeneration, timing of the repair is critical, as are the skill of the surgeon and the
technique used to align the segments accurately and avoid tension at the suture line. Different
regenerative potential outcomes following nerve repair have also been reported based on groupings of
specic nerves.
-Excellent regenerative potential: radial, musculocutaneous, and femoral nerves
-Moderate regenerative potential: median, ulnar, and tibial nerves
-Poor regenerative potential: peroneal nerve
Age and motivation of the patient.
The nervous system must adapt and relearn use of the pathways once regeneration occurs. Motivation
and age play a role in this, especially in the very young and the elderly

Management Guidelines: Recovery from Nerve Injury

In general, recovery from nerve injury can be viewed as occurring in three phases.
Acute phase. This is early after injury or surgery when the emphasis is on healing and prevention of
complications.
Recovery phase. This is when reinnervation occurs. Emphasis is on retraining and re-education.
Chronic phase. This occurs when the potential for reinnervation has peaked, and there are signicant
residual decits. The emphasis is training compensatory function. Effective management must consider
not only nerve healing but connective tissue healing in general
Neural Tension Disorders
Normally, the nervous system has considerable mobility to adapt to the wide range of movements
imposed on it by daily activities. Still, there are sites where nerves are vulnerable to increased pressure
or tension, especially when excessive or repetitive stresses or strains are imposed on the tissues
surrounding the nerves or on the nerves themselves. If a nerve is compressed as it passes near a boney
structure or through a confined space, undue tension may be placed on it as movement occurs proximal
or distal to that site. This may be magnified if there is adhesive scar tissue or swelling that restricts
mobility. When examining a patient, the therapist needs to be alert to symptoms described by the
patient and able to understand and interpret positive signs detected with testing maneuvers.
Symptoms and Signs of Impaired Nerve Mobility
History
Vascular and mechanical factors can lead to nerve pathology. Pain is the most common symptom.
Sensory responses, reported as stretch pain or paresthesia, occur when tissues are in the neural stretch
position.Clinical reasoning is used to understand the possible mechanism of injury, such as pathological
insult to the nervous tissue or surrounding tissues or symptoms from movement patterns that place
tension on the neural tissues and reproduce symptoms.

Tests of Provocation
Neurodynamic test maneuvers are performed to detect tension signs in the neural tissue. The upper
limb tension test (ULTT), upper limb neurodynamic test (ULNT), straight leg raise (SLR), and slump
test are familiar terms that describe various tests and procedures. The reader is referred to textbooks by
Butler for greater details and variations of these tests.10,11 Points regarding the tests:
Because the test positions place stress across multiple joints, every joint in the chain must be tested
separately for range, mobility, and symptom provocation prior to nerve tension testing so any
restriction that occurs during the test is not the result of joint or periarticular tissue limitations.
Coppieters and associates14 demonstrated that the stretch position altered the available ROM and
sensory responses in 35 normal male subjects during neurodynamic testing and reiterated the
importance of looking at other influences prior to neural-tension testing.
Additional tests include nerve palpation, sensation testing, reex testing, and muscle testing.
The test positions and maneuvers used to detect nerve tension and mobility are the same as the
treatment positions and maneuvers.
Tension signs are stretch pain or paresthesias that occur when the neurological system is stretched
across multiple joints and is relieved when one of the joints in the chain is moved out of the stretch
position.
General testing procedure: Carefully elongate the nerve across each joint in succession until there is
symptom provocation (this is described in detail in the techniques section). When symptoms occur,
note the final position. It is important to recognize that in highly irritable or restrictive conditions full
range is not possible. Once symptoms are provoked,
move one of the joints in the chain out of the stretch position to see if the symptoms are relieved.
Repeat with each of the joints in the chain until the mobility pattern of the nerve is understood.
Causes of Symptoms
Symptoms are the result of tension being placed on some component of the nervous system. If
compression is preventing normal mobility, tension signs occur when the nerve is stressed either
proximal or distal to the site of compression. Restriction of movement can be from inflammation and
scarring between the nerve and the tissue through which it runs or from actual changes in the nerve
itself.
Principles of Management
The principles of treatment are similar to those of any mobilization technique.
The intensity of the maneuver should be related to irritability of the tissue, patient response, and
change in symptoms. The greater the irritability, the gentler the technique.
Neurological symptoms of tingling or increased numbness should not last when the stretch is
released.
Neural tension technique. Application of the techniques requires positioning the trunk and extremity
at the point of
tension (symptoms just begin), then either passively or having the patient actively moving one joint in
the pattern in such a way as to stretch and then release the tension. Moving different joints in the
pattern while maintaining the elongated position on the other joints changes the forces on the nerves.
Neural glide technique. Positioning the individual is the same as with the tension technique (at point
of tension), but the movement involves moving two joints in the chain, so the tension remains the same
but the neural tissue glides proximally or distally. For example, once at the position of tension, perform

elbow exion simultaneously with cervical contralateral exion, or wrist exion simultaneously with
elbow exion to glide the median nerve proximally.
The stretch force for both techniques is held for 15 to 20 seconds, released, and then repeated several
times.
After the therapist has performed several treatments and learned the tissue response, the patient is
taught selfstretching.
Precautions and Contraindications to Neural Tension Testing and Treatment
There is incomplete scientific understanding of the pathology and mechanisms that occur when
mobilizing the nervous system.Use caution with the stretch force; neurological symptoms of tingling or
increased numbness should not last when the stretch is released. The clinician should always use
caution and perform a thorough systems review and screening examination to rule out red flag
conditions prior to neural tension testing and treatment.
PRECAUTIONS:
Know what other tissues are affected by the positions and maneuvers.
Recognize the irritability of the tissues involved and do not aggravate the symptoms with excessive
stress or repeated movements.
Identify whether the condition is worsening and the rate of worsening. A rapidly worsening condition
requires greater care than a slowly progressing condition.
Use care if there is an active disease or other pathology affecting the nervous system.
Watch for signs of vascular compromise. The vascular system is in close proximity to the nervous
system and at no time should show signs of compromise when mobilizing the nervous system.
CONTRAINDICATIONS:
Acute or unstable neurological signs
Cauda equina symptoms related to the spine including changes in bowel or bladder control and
perineal sensation
Spinal cord injury or symptoms
Neoplasm and infection
Neural Testing and Mobilization Techniques for the Upper Quadrant
Median Nerve
This maneuver is used when examining and treating symptoms related to median nerve distribution,
problems with shoulder girdle depression (e.g., thoracic outlet syndrome), and carpal tunnel
syndrome.10 Patient position and procedure: Begin with the patient supine; sequentially apply shoulder
girdle depression, then slightly abduct the shoulder, extend the elbow, laterally rotate the arm, and
supinate the forearm. Wrist, finger, and thumb extensions are then added; finally, the shoulder is taken
into greater abduction. The full stretch position includes contralateral cervical side flexion. While
maintaining the stretch position, move one joint at a time a few degrees in and out of the stretch
position, using wrist extension and flexion or elbow flexion and extension, or perform the sliding
technique by moving two joints simultaneously in the same direction.
Radial Nerve
This maneuver is important when examining and treating symptoms that are related to shoulder girdle
depression, radial nerve distribution, and disorders such as tennis elbow and de Quervains syndrome.
Patient position and procedure: Begin with the patient supine; sequentially apply shoulder girdle
depression, then slightly abduct the shoulder, extend the elbow, then medially rotate the arm and

pronate the forearm. Keep the elbow in extension and add wrist, finger, and thumb flexion, and finally
ulnar deviation of the wrist. The full stretch position includes contralateral side flexion of the cervical
spine. While maintaining the stretch position, move one joint at a time a few degrees in and out of the
stretch position, using wrist extension and flexion.

Ulnar Nerve
This maneuver is used when symptoms are related to the C8 and T-1 nerve roots, lower brachial plexus,
ulnar nerve, and disorders such as medial epicondylitis.
Patient position and procedure: Begin with the patient supine. Sequentially apply wrist extension and
forearm supination followed by elbow flexion (full range); then add shoulder girdle depression.
Maintain this position and add shoulder lateral rotation and abduction. In the final position the patients
hand is near his or her ear with fingers pointing posteriorly. In the full stretch position, contralateral
side flexion of the cervical spine is added. While maintaining the overall stretch position, move one
joint at a time a few degrees in and out of the stretch position, such as elbow extension and flexion.
Neural Testing and Mobilization Techniques for the Lower Quadrant
Sciatic Nerve: Straight-Leg Raising with Ankle Dorsiflexion
Patient position and procedure: The patient is supine. Lift the lower extremity in the straight-leg raise
(SLR) position and add ankle dorsiflexion. Several variations may be done; ankle dorsiflexion, ankle
plantar flexion with inversion, hip adduction, hip medial rotation, and passive neck flexion.10 The
maneuver may also be performed long-sitting (slumpsitting positionsee below) and side-lying. These
various positions of the lower extremity and neck are used to differentiate tight or strained hamstrings
from possible sites of restriction or nerve mobility in the lumbosacral plexus and sciatic nerve.8,27,70
Changing positions of the ankle in conjunction with variations in the hip and knee positions are used to
differentiate foot impairments, such as plantar fasciitis and tarsal tunnel syndrome. Once the position
that places tension on the involved neurological tissue is found, maintain the stretch position and then
move one of the joints a few degrees in and out of the stretch position, such as ankle plantarflexion and
dorsiflexion or knee flexion and extension.
Slump-Sitting
Patient position and procedure: Begin with the patient sitting upright. Have the patient slump by flexing
the neck, thorax, and low back. Apply overpressure to cervical spine. Dorsiflex the ankle and then
extend the knee as much as possible to the point of tissue resistance and symptom reproduction.
Release the overpressure on the spine and have the patient actively extend the neck to see if symptoms
decrease. Increase and release the stretch force by moving one joint in the chain a few degrees, such as
knee flexion and extension or ankle dorsiflexion and plantarflexion

Femoral Nerve: Prone Knee Bend

Patient position and procedure: Prone with the spine neutral (not extended) and the hips extended to 0.
Flex the knee to the point of resistance and symptom reproduction. Pain in the low back or neurological
signs (change in sensation in the anterior thigh) are considered positive for upper lumbar nerve roots

and femoral nerve tension. Thigh pain could be rectus femoris tightness. It is important not to
hyperextend the spine to avoid confusion with nerve root pressure from decreased foraminal space or
facet pain from spinal movement. Flex and extend the knee a few degrees to apply and release tension.
Alternate position and procedure: Side-lying with the involved leg uppermost. Stabilize the pelvis and
extend the hip with the knee flexed until symptoms are reproduced. Maintain knee flexion, release, and
apply tension across the hip by moving it a few degrees at a time.