m Dynamic function of nervous system is adaptive

and protective and prevents concentration of

abnormal stress and allowing normal physiological
function.
m CNS is a dynamic organ like muscle, joint or any
other involved in movement. CNS possesses
elastic and plastic properties and have major role
in dynamic response to forces and impulse
transmission.
m Nervous system is mechanically and
physiologically a continuous structure from brain
to end terminals in periphery.
m Mechanical and physiological changes anywhere
in the system can implicate whole nervous
system.
ltered nervous system function part of many
common clinical syndromes ±
m WHIPLSH
m Discogenic LBP
m Dequervain's syndrome
m Lateral epidondylalgia
m There is a link between altered nervous system
function and signs of these syndromes.
m rterial pressure in vasa nervosum is more
compare to capillary and venous pressure for
optimal neuronal nutrition.
m Slight alteration in pressure gradients changes
blood flow and axonal transport.
m ltered axoplasmic flow cause for double crush,
spread of symptoms.
m Intraneural ± pathology affects elasticity of Nervous system
e.g. fibrosed nerve
m Extraneural ± osteophytes
m The three pathobiological processes that occur when a
nerve is injured relate to
m ltered blood flow to the nerve,
m ltered axoplasm flow in the nerve,
m The development of abnormal impulse-generating sites.
m ll three of these can be effectively treated with active
rehabilitation.
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m Nervous system as a whole ± interface (muscle,
bone, ligaments)
m Neurones of the conducting elements -
m Connective tissue components -
m Neural blood vessels -
m Tissue or material adjacent to the nervous system
that can move independently of the system.
m ctivity specific mechanosensitivity- repetitive
movements or overuse
m mPeripheral neuropathic pain' has been suggested
to embrace the combination of positive and
negative symptoms
m Positive symptoms include pain, paraesthesia and
spasm.
m naesthesia and weakness are negative sensory
and motor symptoms.
m Pain results from volleys of impulses arising in
damaged or regenerating nociceptive afferent
fibres.
m Pain is felt in the peripheral sensory distribution
of a sensory or mixed nerve
m Pain description includes abnormal or unfamiliar
sensations, frequently having a burning or
electrical quality; pain felt in the region of the
sensory deficit; pain with a paroxysmal brief
shooting or stabbing component; and the
presence of allodynia .
m Nerve trunk pain has been attributed to
increased activity in mechanically or chemically
sensitized nociceptors within the nerve sheaths.
m Pain is said to follow the course of the nerve
trunk commonly described as deep and aching,
similar to a mtoothache' and made worse with
movement, nerve stretch or palpation.
m rea and nature of symptoms±
m Bizarre descriptive terms: Crawling, ant like,
pulling like, string, dry, woody, dragging
m Report sensations or areas of swelling
m ltered sweating patterns
m Symptoms may be aggravated by recognized
positions that load the nervous system.
m Symptoms vary at night due to reduced blood
pressure, altered tissue pressure gradients
m Inflammatory reaction, compromised
microcirculation slow axonal transport
(pathophysiology)].
m ntalgic posture ± forward head, sciatic scoliosis
m
m Physiological ± normal
m Clinical physiological ± symptoms are different but
related area
m Neurogenic ± symptoms arise from CNS, NS and
PNS
m Interface problems ± muscle, joint, and ligament
m Response to contralateral limb
m Range of NTPT
m BOS through range of NTPT
m rea of response
m Sequence of area of response
m Effect of sensitivity maneuvers
m ctivity specific mechanosensitivity (combination of
tension test with varying speed in conjuction with
varying joint or muscle positions)
m Distal component first if the symptom is predominantly
distal
m High velocity trauma
m Old fracture of soft tissue injury
m Chronicity ± no treatment in the acute stage,
surgery
m Rapid growth spurt ± nervous system lags behind
bone, muscle
m Diabetes, PVD
m Neural tissue provocation test
m Examination of conduction
m Palpation of the spinal and peripheral structures
m Muscle power
m ltered reflexes
m Interface structures
m Consider symptoms of nervous system
m Consider nervous system and muscloskeletal
anomalies
m NTPT RE NOT SPECIFIC TO NERVOUS TISSE
LONE THEY FFECT NON ± NEURL
STRUCTURES S WELL.
m STRUCTURL DIFFERNTITION
m
m Precautions and contraindications
m Familiar with normal responses
m BOS during rest and NTPT should be recorded.
m Patient should be completely relaxed CREFUL
handling
m Small and subtle movement changes can effect a
symptomatic change
m NEUTRL
m Midway between flexion and extension.
m Nervous system is relaxed
m Blood vessel and perivascular space quite patent
and permit blood, lymph and CSF flow.
m Full flexion spinal canal
elongates around 98mm
inCx, 28mm in Lx and 3mm
in Tx region
m Strain high in cervical C5,6
and lower lumbar L5-S1
m Stretching of peripheral
nerves decreases intra
neural micro circulation.
m Conrgence at low lumbar
and cervical , divergence at
thoracic level
m Neutral to hyper extension spinal canal shortens
around 38 mm.
m Nervous system loose in extension.
m Intraneural circulation is better in extension than in
flexion.
m Extension in lumbar region narrows at interspaces
± inward bulging of IVD, ligament flavum and
crowding of facets.
m IVF size decreases and also it increases CSF
pressure.
m Right side lying ± concave right side loosen and
convex side tighten (L).
m Tension ± NRC on the convex side drawn into
contact with adjacent pedicles ± transmitted to
ipsilateral sciatic nerve.
m Contralateral side flexion sensitizes SLR.
m ntalgic listing ± ipsilateral side less tension.
m Regular and appropriate movement of the
neuraxis is necessary for optimum physiological
function. Regular stress improves nutrition and
removes metabolic waste products.
Irritable disorder:
s Treat interface structure away from injury site
s Treat structures away from symptom area
s Treatment should start from non provoking
position and progress to short of symptoms
s Grade 2 and 3
s Enquire about latent response
s Constant verbal and non-verbal communication
s nti-tension postures and patient relaxation
s mplitude- some symptom reproduction, some
resistance encountered
s Nervous system in tension position
s Reassessment- joint, muscle and NS

s If symptoms are provoked ±give technique gently

s Teach some self mobilization techniques
m Non-irritable disorder:
m Grade 3 or 4
m Treatment short of symptom reproduction and
short of resistance
m Treatment at the site of involvement
m Starting technique longer period
m Starting technique in nervous system in a loaded
position
m Treatment closer to source of symptoms
m Biomechanics:

m SLR affects not just the sciatic

nerve but other structures
including hamstrings,
vertebral, hip and SI joints.

m SLR pulls caudally on sciatic

nerve, force transmitted from
low lumbar to sacral NRCs
which move caudolaterally.
m Normal response:
m Deep, moderate
stretch sensation in the
posterior thigh,
posterior knee,
extending to calf and
plantar aspect of foot.
m nkle dorsiflexion ± increase tension tibial branch
(S1)
m SLR + DF + Inversion ± sural branch
m nkle PF + inversion ± common peroneal branch
(L5) ± (useful in ankle sprain, shin splint,
compartmental syndrome)
m Hip adduction ± sciatic nerve
m Hip medial rotation ± common peroneal than tibial
m Cervical flexion and extension ±
m Normal response ± pulling sensation in the cervico
thoracic region.
m Sensitizing maneuvers ± upper and lower cervical
flexion
m lateral flexion and rotation
m thoracic flexion and extension
m PKB moves and tensions the nervous system via
the L2 L3 L4 nerve roots particularly femoral
nerve.
m Tension the lateral cutaneous nerve than
saphenous nerve.
m C6, T6, L4 ± mechanical interface relationship
remains constant during movement of spinal
canal. Important to examine these and adjacent
areas for early signs of altered nervous system
changes.
m If extra neural causes ± no slump symptoms
m Cervical flexion ± pain felt T8 T9 region
m Knee extension ± pain or stretch post thigh
m Release of cervical flexion ± decrease symptoms
m Shoulder girdle depression:
m Neurovascular bundle taut at shoulder
m Movement occurs from C4-T1
m Tension imparted from c spine to shoulder
m Tension at subclavian artery and vein
m Cervical spine contralateral flexion
m Movement occurs from C4-C8
m Most movement at C4-C7
m Little movement at C8,T1
m No tension in subclavian artery or vein
m rm abduction:
m Movement occurs at C5-T1
m Most movement C4-C7
m Little movement at C8,T1
m Less tension in suclavian artery and vein
m Further tension in the neurovascular bundle
mainly in the median nerve.
m Tensioner- the neural tissue and its connective tissue are stretched at
the same time in opposite directions, such as neck flexion while
dorsiflexing the ankle.
m Sliders move the nerve towards one end (dorsiflexion) while putting the
other side on slack (neck extension).
m Tensioners may be performed in a neurally loaded position, where the
position already challenges the neurodynamics.
m In a slider, the patient should be in a comfortable, neurally unloaded
position to avoid unwanted stress on the nervous system.
m During tensioners, the end-position may be kept for one to two
seconds, but during the slider, an end-ROM stretch should be avoided
by using gentle, easy movements.
m Sliders will be more advantageous in the acute phase. s the injury
heals, more and more tensioners should be added.