Dynamic function of nervous system is adaptive and protective and prevents concentration of abnormal stress and allowing normal physiological function.

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.

Nervous system is mechanically and physiologically a continuous structure from brain to end terminals in periphery.

Mechanical and physiological changes anywhere in the system can implicate whole nervous system.

Altered nervous system function part of many common clinical syndromes –

WHIPLASH Discogenic LBP Dequervain's syndrome Lateral epidondylalgia There is a link between altered nervous

system function and signs of these syndromes.

Arterial pressure in vasa nervosum is more compare to capillary and venous pressure for optimal neuronal nutrition.

Slight alteration in pressure gradients changes blood flow and axonal transport.

Altered axoplasmic flow cause for double crush, spread of symptoms.

  Intraneural – pathology affects elasticity of Nervous

system e.g. fibrosed nerve Extraneural – osteophytes The three pathobiological processes that occur

when a nerve is injured relate to Altered blood flow to the nerve, Altered axoplasm flow in the nerve, The development of abnormal impulse-generating

sites. All three of these can be effectively treated with

active rehabilitation.

 

Repetitive mechanical stimuli Chemical stimuli from non neural tissue injury IVDP Venous congestion Reduced axoplasmic flow Inflammatory response form nerve trunks and roots Intraneural oedema Further congestion, impaired axo flow Progressive fibrosis, Demyelination

Sensitization of nociceptors in neural tissues AIGS formation Impairement of impulse conduction Increased nociceptive input in response to mechanical and Chemical stimuli CNS Sensitized Neural tissue symptoms

Nervous system as a whole – interface (muscle, bone, ligaments)

Neurones of the conducting elements - Connective tissue components - Neural blood vessels - 

Tissue or material adjacent to the nervous system that can move independently of the system.

Activity specific mechanosensitivity- repetitive movements or overuse

`Peripheral neuropathic pain' has been suggested to embrace the combination of positive and negative symptoms

Positive symptoms include pain, paraesthesia and spasm.

Anaesthesia and weakness are negative sensory and motor symptoms.

Pain results from volleys of impulses arising in damaged or regenerating nociceptive afferent fibres.

Pain is felt in the peripheral sensory distribution of a sensory or mixed nerve

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 .

Nerve trunk pain has been attributed to increased activity in mechanically or chemically sensitized nociceptors within the nerve sheaths.

Pain is said to follow the course of the nerve trunk commonly described as deep and aching, similar to a `toothache' and made worse with movement, nerve stretch or palpation.

Area and nature of symptoms– Bizarre descriptive terms: Crawling, ant like,

pulling like, string, dry, woody, dragging Report sensations or areas of swelling Altered sweating patterns

Symptoms may be aggravated by recognized positions that load the nervous system.

Symptoms vary at night due to reduced blood pressure, altered tissue pressure gradients

Inflammatory reaction, compromised microcirculation slow axonal transport (pathophysiology)].

Antalgic posture – forward head, sciatic scoliosis

 

Physiological – normal Clinical physiological – symptoms are

different but related area Neurogenic – symptoms arise from CNS,

ANS and PNS Interface problems – muscle, joint, and

ligament

Response to contralateral limb Range of NTPT BOS through range of NTPT Area of response Sequence of area of response Effect of sensitivity maneuvers Activity specific mechanosensitivity

(combination of tension test with varying speed in conjuction with varying joint or muscle positions)

Distal component first if the symptom is predominantly distal

High velocity trauma Old fracture of soft tissue injury Chronicity – no treatment in the acute

stage, surgery Rapid growth spurt – nervous system lags

behind bone, muscle Diabetes, PVD

Neural tissue provocation test Examination of conduction Palpation of the spinal and peripheral

structures Muscle power Altered reflexes Interface structures Consider symptoms of nervous system Consider nervous system and

muscloskeletal anomalies

NTPT ARE NOT SPECIFIC TO NERVOUS TISSE ALONE THEY AFFECT NON – NEURAL STRUCTURES AS WELL.

STRUCTURAL DIFFERNTIATION  

Precautions and contraindications Familiar with normal responses BOS during rest and NTPT should be

recorded. Patient should be completely relaxed

CAREFUL handling Small and subtle movement changes can

effect a symptomatic change

NEUTRAL   Midway between flexion and extension. Nervous system is relaxed Blood vessel and perivascular space quite

patent and permit blood, lymph and CSF flow.

Full flexion spinal canal elongates around 98mm inCx, 28mm in Lx and 3mm in Tx region

Strain high in cervical C5,6 and lower lumbar L5-S1

Stretching of peripheral nerves decreases intra neural micro circulation.

Conrgence at low lumbar and cervical , divergence at thoracic level

Neutral to hyper extension spinal canal shortens around 38 mm.

Nervous system loose in extension. Intraneural circulation is better in extension

than in flexion. Extension in lumbar region narrows at

interspaces – inward bulging of IVD, ligament flavum and crowding of facets.

IVF size decreases and also it increases CSF pressure.

 

Right side lying – concave right side loosen and convex side tighten (L).

Tension – NRC on the convex side drawn into contact with adjacent pedicles – transmitted to ipsilateral sciatic nerve.

Contralateral side flexion sensitizes SLR. Antalgic listing – ipsilateral side less

tension. 

Regular and appropriate movement of the neuraxis is necessary for optimum physiological function. Regular stress improves nutrition and removes metabolic waste products.

Irritable disorder: Treat interface structure away from injury

site Treat structures away from symptom area Treatment should start from non provoking

position and progress to short of symptoms Grade 2 and 3 Enquire about latent response Constant verbal and non-verbal

communication Anti-tension postures and patient relaxation

Amplitude- some symptom reproduction, some resistance encountered

Nervous system in tension position Reassessment- joint, muscle and NS If symptoms are provoked –give technique

gently Teach some self mobilization techniques

Non-irritable disorder: Grade 3 or 4 Treatment short of symptom reproduction

and short of resistance Treatment at the site of involvement Starting technique longer period Starting technique in nervous system in a

loaded position Treatment closer to source of symptoms

Biomechanics:

SLR affects not just the sciatic nerve but other structures including hamstrings, vertebral, hip and SI joints.

SLR pulls caudally on sciatic nerve, force transmitted from low lumbar to sacral NRCs which move caudolaterally.

Normal response: Deep, moderate

stretch sensation in the posterior thigh, posterior knee, extending to calf and plantar aspect of foot.

 

Ankle dorsiflexion – increase tension tibial branch (S1)

SLR + DF + Inversion – sural branch Ankle PF + inversion – common peroneal

branch (L5) – (useful in ankle sprain, shin splint, compartmental syndrome)

Hip adduction – sciatic nerve Hip medial rotation – common peroneal

than tibial Cervical flexion and extension –

Normal response – pulling sensation in the cervico thoracic region.

Sensitizing maneuvers – upper and lower cervical flexion

lateral flexion and rotation thoracic flexion and extension 

PKB moves and tensions the nervous system via the L2 L3 L4 nerve roots particularly femoral nerve.

Tension the lateral cutaneous nerve than saphenous nerve.

 

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.

If extra neural causes – no slump symptoms 

Cervical flexion – pain felt T8 T9 region Knee extension – pain or stretch post thigh Release of cervical flexion – decrease

symptoms

Shoulder girdle depression: Neurovascular bundle taut at shoulder Movement occurs from C4-T1 Tension imparted from c spine to shoulder Tension at subclavian artery and vein

Cervical spine contralateral flexion Movement occurs from C4-C8 Most movement at C4-C7 Little movement at C8,T1 No tension in subclavian artery or vein

Arm abduction: Movement occurs at C5-T1 Most movement C4-C7 Little movement at C8,T1 Less tension in suclavian artery and vein

Further tension in the neurovascular bundle mainly in the median nerve.

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.

Sliders move the nerve towards one end (dorsiflexion) while putting the other side on slack (neck extension).

Tensioners may be performed in a neurally loaded position, where the position already challenges the neurodynamics.

In a slider, the patient should be in a comfortable, neurally unloaded position to avoid unwanted stress on the nervous system.

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.

Sliders will be more advantageous in the acute phase. As the injury heals, more and more tensioners should be added.