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Prepared by

Associate Professor
S.Dineshkumar
Madha college of physiotherapy
1.Functional anatomy
2.Clinical neurobiomechanics
3.Pathological processes
4.The clinical consequences of injury to the
nervous system
5.Examination
6.Tension testing
7.Treatment
CONCEPT OF CONTINUOUS TISSUE TRACT
Connective tissues are continuous
Neurons are interconnected
Continuous chemically
The neuron
Consist of a cell body,some dendrites and usually
one Axon
Axons are either myelinated or non myelinated
Axon grouped together in to bundles or fascicles
Axons Nerve fibers
Cytoplasm of neuron-Axoplasm
Nervefibers three kind
motor(AHC-NMJ)
sensory(DRG-RECEPTORS)
Autonomic(ventral horn SC,PGF)
A distensible ,elastic structure made up of
matrix of closely packed collagenous tissue
surrounding the basement membrane is the
endoneurial tube.
Protects axons from tensile force
Maintains the endoneurial space and fluid
pressure,A slight positive pressure .
Eachfascicle is surrounded by a thin
lamellated sheath known as Perineurium
Protecting the content of endoneurial tubes
Acting as mechanical barrier to External forces
Serving as a diffusion barrier
Most resistant to tensile forces
Theoutermost connective tissue investment
surrounds ,protects and cushions the
Fascicles.
Keep the fascicles apart(internal epineurium)
Definite sheath around the fascicles (external
epineurium)
Facilitate gliding between the fascicles
Mesoneurium is a loose areolar tissue
peripheral nerve trunks .
Blood vessels enter the nerve via mesoneurium
Allows the nerve to glide along the adjacent
tissue.
Nerves are not uniform
Run in wavy course throught the nerve
course
Constantly changing the plexus within the
trunk
Inverse relation between size and number of
fascicle
More number more protection from
compressive forces.
THE NERVE ROOT
Each roolet emerged was ensheathed by a
pial layer the outer most covering which
formed a covering around individualfascicle.
Injuries to nerveroot not commonly from
traction but directly from neighing structure
such as discs and zygopophyseal joints.
4th,5th,6th cervicalsipnal nerve have a strong
attachment to the gutter of the respective
transverse process.
Open endedness of perineurium continuos
with the dura /arachnoid and the inner layer
forms pial sheeth.best for force distribution.
Duralsleeve forms a plugging
mechanism(traction force transmitted to
cord via the denticulate lig ease the tension
on NR)
Angulated nerve roots being proteted from
tethered
The supply of blood to the nervous system
The axonal transport nervous system
The innervations of the connective tissues of
nervous system
Lattice collagen arrangement
When cord is elongaed the vessels running
longitudinally are streched while those runing
transversly are folded.
Veins in the spinal canal are valveless and allows
flow reversibility .
Critical vascular zone fromT4 to T9
Arrestof blood at 8%elongation
Complete arrest at 15% elongation
Two barriers maintain endoneurial
environment:
The perineurial diffusion barrier(resistant to
trauma even after surgery to epineurium)
-Blood nerve barrier(at endoneurial microvessels)
Three flow identified:
Axo plasm flow from cell body to target
tissue(Antegrade flow)
From target tissue to cell body(retrograde flow)
Bidirectional flow.
Flow interruption induces cell body reaction
Consriction,loss blood supply, viruses may impede
the flow.
Innervation of nervous system means
innervation connective tissues of nervous
system.
Dura matter innervated by segmental
,bilateral,sinuvertebral nerves
Sinuvertebralnerve innervates directly or via
PLL
Innervation density varies deppending on
spinal segment
Rich in superficial than in deeper
Innervation aracchnoid and pia less
experimental attention.
Ventral nerve root innervation from DRG
Anterior nerve roots from branches from sinu
vertebralnerves.
The connective tisues of PNS,ANS, have an
intrinsic innervation :the nervi nervorum
from localaxonal branching
Also extrinsic innervation from fibers
entering the nerve from the perivascular
plexuses.
MECHANICAL INTERFACE
Defined as that tissue or material adjacent to the
nervous system that can move independently to
the system.
Pathological interface
A tight plaster or bandage
Edema
Blood
Osteophyttes
Ligamentous swelling
Fascial scarring
NERVOUS
SYSTEM ADAPTATIONS TO
MOVEMENT
1.the development of tension or increased
pressure within the tissues
2.gross movement or intraneuralmovement
Grossmt example:median nerve movement in caarpal
tunnel.
Intraneural mt:Spinalcord mt in relation to duramatter.
RELATIONSHIP BETWEEEN MOVEMENT AND
TENSION
If a body part is moved with other body part is in
neutral position less tension more movement
Conversly if the same movement performed with
body parts in tension,there will be a great
increase in intraneural tension but little mt of
the nervous system.
EX:ULTT1 with neck in neutral
ULTT1 with neck laterally flexed to opposite side.
Neuraxialand meningeal adaptive
mechanism:
Ex:the slump test and passive neck flexion test
Both employ spinal flexion test
In flexion moves anteriorly
In extension moves posteriorly
In rotation stays constant
C6,T6,L4 vertebral levels no nervous system
movement in relation to interfaces.
From spinal extension to flexion the cord
converge towards C4,C5 disc.
Sciatic and tibial nerve superior to knee moves
caudal in direction
Tibial nerve below the knee moves cephalad in
direction.
Posterior to knee joint no movement of nerve occurs
in relation to interface.
When tension applied to the nerve, the intraneural
pressure will increase as the cross sectional area
decreases.ex:siting to standing.
Blood supply will diminish at around 8 % elongation,
and stop around 15 % elongation.
The biomechanic of additional movements which
further sensitises the test such as ankle DF,hip
adduction,medialrotation and cervical flexon etc.
I.MOVEMENT
MEDIAN NERVE
Finger extension-pulled the nerve downward of
7.4 cm
Flexion of elbow allowed upward movement of
4.3 cm
Arm movement allowed 2-3 cm
ULNAR NERVE
Migrated proximally during flexion of elbow.
II.DEVELOPMENT OF PRESSURE OR TENSION IN
THE SYSTEM.
The two adaptive mechanism of tension and
movement must occur simultaneously in some
situation one will predominate..
Pathological processes or injury may affect one
or both of these adaptive mechanisms.
Site of injury
Soft tissues ,osseus or fibro- osseus tunnels.
Where the nervous system branches
Where the system is relatively fixed
Unyielding interfaces.
Tension points.
Kind of injury
Mechanical and physiological consequences of
friction ,compression, stretch and occasionally
disease.
Unphysiological movements, body postures, and
repetitive muscle contraction.
Secondary injury to nervous system such as blood
and edema from damaged interface.
Change in shape of interface.
Intraneural and extra neural pathology
1.intra neural pathology

Conducting tissue connective tissue


Demyelination scarred epineurium
Neuroma formation arachnoiditis
Hypoxic nerve fibers irritated duramatter
Extra neural pathology
Nerve bed
Blood in nerve bed or epidural space
Mechanical inetrface
`swelling of bone and muscle adjacent to a nerve
trunk.
PATHOLOGICAL PROCESS
VASCULAR FACTORS IN JNIURY
Hypoxia
Edema
Fibrosis
MEHANICAL FACTORS
The myelin on one side of the node becomes
streched
The myelin on the other side becomes
invagenated
Displacement of node of Ranvier
Injury and axoplasmic flow
Trophic changes in target tissue(skin,muscle)
Damage to cell body and axon
Blood supply compromise affect the axonal flow
Mild compression of 30-50 mmhg interrupt both
antegrade and retrograde flow.
an axoplsmic transport block by a 50 mmhg
For 2 hours was reversible in 24 hours.
2 hours of compression at 200 mmhg was reversible
within 3 days.
Nucleus looses its information gathering
mechanism about the state of target tissue
and the neuronal environment.
Ability to produce neurotransmitters
diminished
Cytoskeletal elements for the neuron
diminished.
Further consequences of nerve injury
Fibrosis
Double crush syndrome
Triple and multiple crush syndromes
Abnormal impulse generating mechanism
SIGNS AND SYMPTOMS FOLLOWING INJURY
AREA OF SYMPTOMS
KINDS OF SYMPTOMS
HISTORY
POSTURAL AND MOVEMENT PATTERNS
SIGNS AND SYMPTOMS
Level of involvement(UMN,LMN,SEGMENTAL)
Severity of involvement
The tissue components involved(neural tissue or
connective tissue)
From local or remote sources.
Whether an intraneural or extraneural process is
evedent
The sstage of the disorder(acute or chronic)
The progression of the disorder
AREA OF THE SYMPTOMS
Vulnerable areas ex:carpaltunnel,head of fibula
Symptoms donot fit to the familiar patterns such
as a dermatomal or myotomal.(cyriax-
extrasegmental patterns from dura matter)
symptoms fit nerve anatomy
significant(conducting tissue injury)
Symptoms may link up(double crush syndrome
such as co existent tennis elbow and carpal
tunnel syndrome)
Lines and clumps of pain can occur(around the
joints or tension points)
KIND OF SYMPTOMS
Constant or intermittent
Sensation of swelling(ans)
Paraesthesia or anaesthesia(with or with out
pain)
Weakness(impairment in efferent
impulses,pain inhibited weakness)
Symptoms worse at night(peripheral nerve
entrapment)
Worse at the end of the day(chronic nerve
root iritaion)
HISTORY
MECHANISM OF INJURY
PREVIOUS INJURY
PREVIOUS TREATMENT
OTHER CONTRIBUTING FACTORS
POSTURAL AND MOVEMENT PATTERNS
ANTALGIC TENSION POSTURE
POKED CHIN POSTURE
SCOLIOSIS
THORACIC KHYPHOSIS
READING IN LONG SITTING IN BED(SLR)
GETTING IN TO A CAR(SLUMP,SLR)
REACHING UP TO A CLOTH LINE
SHOULDER GIRDLE DEPRESSION
SMALL REPETITIVE MOVEMENTS(KEYBOARD,PLAYING
MUSICAL INSTRUMENT)
IRREGULAR PATTERNS ON MOVEMENT PROVOKING
SYMPTOMS OTHER THAN JOINT.
SUBJECTIVE NEUROLOGICAL EXAMINATION
DIZZNESS( VBI,dural attachment,)
INVOLVEMENT OF CAUDA EQUINA (functions of
bladder,bowel,perianal,genital sensation)
CORD SYMPTOMS(spasticity,gross
alteredmovement patttern,paralysis,bilateral
pins and needles,broad based jerky gait,diffuse
non specific weakness,Tethered cord syndrome -
complete numbness ,hair tufts,dermal
sinuses,tight calves and hamstring)
GENERAL HEALTH(diabetes,AIDS,Multiple
sclerosis,poly neuropathies)
PHYSICAL EXAMINATION OF SENSATION
LIGHT TOUCH
PIN PRICK
VIBRATION
PROPRIOCEPTION
TWO POINT DISCRIMINATION
EXAMINATION OF MOTOR FUNCTION
WASTING
REFLEX TESTING
MUSCLE POWER TESTING
TEST FOR SEGMENTALLEVEL
C4-SCAPULAR ELEVATORS
C5-DELTOID
C6-BICEPS
C7-TRICEPS
C8-LONG FINGER FLEXORS
T1-INTERROSSEI AND LUMBRICALS
TEST FOR INDIVIDUAL NERVE TRUNK
RADIAL NERVE-RESIST THE WRIST EXTENSION
MEDIAN NERVE-RESIST THE DISTAL IP JOINT OF INDEX
FINGER
ULNAR NERVE-RESIST ABDUCTION OF INDEX FINGER.
DORSAL SCAPULAR NERVE-THE RHOMBOIDS
LONG THORACIC NERVE-SERRATUS ANTERIOR
MUSCLE TESTING LOWER LIMB
L2-HIP FLEXORS
L3-KNEE EXTENSORS
L4-ANKLE DORSIFLEXORS
L5,S1-EXTENSORS OF THE DISTAL PHALANX OF THE
GREAT TOE
S1-EVERTORS OF ANKLE
S1,S2-ANKLE PLANTOR FLEXORS
S2-TOE FLEXORS
Cord function test
Ankle clonus
Babinski test
ELECTRO DIAGNOSIS
NEUROPATHY IS FROM PERIPHERALNERVE OR MYOPATHY
SYSTEMIC CONDITIONS(alcoholic,diabettic neuropahy)
ASSISTING FOR SURGICAL INTERVENTION
OBJECTIVE MEASUREMENT FOR TREATMENT
IDENTIFICATION OF ANAMALIES.
UPPER LIMB TENSION TEST 1-median nerve
dominant utilizing shoulder abduction
UPPERLIMB TENSION TEST 2-radial nerve
dominant utilising shoulder girdle depression
plus internal rotation of the shoulder
UPPERLIMB TENSION TEST 3-ulnar nerve
dominant utilising shoulder abduction and
elbow flexion.
ULTT1:
METHOD:
Patient positioned in supine
A constant depression force placed on shoulder
girdle
Forearm supiated ,wrist and fingers extended.
The shoulder is laterally rotated
The elbow is extended.earlier component
positions must be maintained
With this position ,cervical lateral flexion to the
left then to the right are added.
NORMAL RESPONSES
A deep stretch or ache in the cubital fossa
A definite tingling sensation in the thumb and
first three fingers
A small percentage of subjects may feel stretch
in the anterior shoulder area.
Cervical lateralflexion away from tested side
increases the response in approximatelyn90 % of
individuals.
Upper limb tension test 2
Supine lying
Shoulder depression maintained
Shoulder medially rotated
Forearm pronated ad wrist flexion
Flexion of thumb joints and ulnar deviation
further sensitises the radial nerve.
NO STUDIES HAVE BEEN UNDERTAKEN REGARDING
NORMAL RESPPONSE OF ULLT2
UPPERLIMB TENSION TEST 3
Starting position same as ULTT1
wrist exended and fore armsupinated
Elbow fully flexed
With maintaining Shoulder depression ,abduction
added
NORMAL RESPONSE
In asymptomatic people ,a commo response is burning
and tingling in the ulnar nerve distribution in the hand
or medial aspect of elbow.
PASSIVENECK FLEXION TEST(PNF)
STRAIGHT LEG RAISE TEST(SLR)
SLUMP TEST
PRONE KNEE BEND(PKB)
PASSIVE NECK FLEXION TEST
PATIENT LIES SUPINE
LIFT HEAD OFF THE BED A LITTLE
PASSIVELY FLEXING THE NECK TOWARDS CHIN ON
CHEST DIRE CTION
During the movement symptom responses
,ROM,resistance encountered through the
movement are noted and analysed.
STRAIGHT LEG RISE TEST
Supine lying
Hip and trunk neutral
The leg is lifted perpendicular to the bed,hand
above knee joint prevents knee flexion.
The responses must compared with the responses
of other leg.
SENSITISING
Ankle dorsiflexion(tibial tract)
Ankle plantar flexion(common peroneal nerve)
PRONE KNEE BEND
Patient lies prone
Grasp the lower leg and flexes the knee
Check for symptom response
Compare to contralateral leg
THE SLUMP TEST
High sitting at the end of the plinth thighs fully
supported and knees together.
Patient asked to slump or sag with Cervical spine in
neutral
With spinal flexion position patient asked to bend
chin to chest and then over pressure in the same
direction.
The patient is asked to extend the knee actively and
the response assesed
Then dorsiflexion added
Neck flexion slowly released and the response
carefully assessed
The same procedure repeated for the other leg
If there is any change in symptom in hamsring area
after releasing the neck flexion neurogenic in origin.
Analysis of tesion test
The range of movement at which symptom first
start.
Whether the disorder is non irrritable
The type and area of symptoms
The resistance encountered during the test
The above findings must be compared to the
testof the contralateral limb.
POSITIVE TENSION TEST
It reproduces the patients symptoms
The test responses can be altered by the
movement of the body parts.
There are differences in the test from the
left side to the right side
Range of movement
Resistance encountered duringthe movement
Symptom response during the movement.
INDICATIONS
Nerve root injuries
Thoracic nerve root syndrome
Whiplash injuries
Coccydynia
Spondylolishesis
Post lumbar spine injuries
Epidural haematoma
Head ache.
T4 syndrome.
CONTRAINDICATIONS
Recent onset of,or worsening neurological
signs
Cauda eqina leision
Injurt spinal cord.
PRECAUTIONS
Irritability the nervous system
Presenceof meurological signs
General health problemss
Dizzness
Circulatory distubances
References
MOBILISATION OF THE NERVOUS SYSTEM
By
David s.butler
Mark A jones.
THANK YOU