Clinical Reasoning and Neurodynamic Testing and Treatment-Shacklock

NEURODYNAMIC SOLUTIONS (NDS)
AAOMPT One Day Workshop

Providing practical solutions
for clinical therapists
www.neurodynamicsolutions.com
2
Contents
Section 1 - Introduction to NDS and aims

Section 2 - General and specific neurodynamics
Section 3 - Technique selection
Section 4 - Diagnosis with neurodynamic tests
Section 5 - Neuropathodynamics - functional disorders

Section 6 - Physical examination and hypothesis testing
Section 7 - Treatment method
Section 8 - Lumbar and radicular pain
Section 9 - References
© 2014 NDS Neurodynamic Solutions

3
About Neurodynamic Solutions (NDS)

Background
Neurodynamic Solutions (NDS) is the teaching entity founded by Michael Shacklock. It
was started with the express purpose of offering practical clinical solutions for therapists
with an interest in neuromusculoskeletal problems. The emphasis is on clinical
neurodynamics for neuromusculoskeletal problems in a way which clarifies and
demystifies neurodynamics and makes the subject as clinically applied as possible.
Objectives
Offer practical clinical solutions for therapists who treat patients with musculoskeletal
problems with a neural component
Include the most up-to-date research and clinical information
Offer a systematic method of application of neurodynamics
Foster further development in clinical neurodynamics
Resources
Free registration
Web site - neurodynamicsolutions.com
Courses - upper and lower quarters
Newsletters - clinical solutions, new updates in research, conferences announcements,
books and other resources, web links - other physiotherapy/physical therapy and
educational groups, search engines and physical therapy data bases
AAOMPT Course Manual

© 2014 Michael Shacklock, Neurodynamic Solutions (NDS). All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or

transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission of the author. Copyright permission
may be obtained from NEURODYNAMIC SOLUTIONS (NDS), or in specific cases,
Elsevier Health, UK. For information on reproduction, please contact Neurodynamic
Solutions (NDS).
All illustrations, except where acknowledged otherwise, are copyrighted to Elsevier

Health, Oxford, United Kingdom.
NEURODYNAMIC SOLUTIONS (NDS) COURSES
Courses in clinical neurodynamics as

presented in Michael Shacklockʼs book are
available worldwide. If you are interested in
hosting or attending a workshop, seminar or
conference event in neurodynamics do contact
Neurodynamic Solutions (NDS).
CONTACT:
admin@neurodynamicsolutions.com www.neurodynamicsolutions.com

4
About Michael Shacklock

Michael Shacklock graduated as a physiotherapist from the Auckland School of Health
Sciences in 1980. During his undergraduate training, he quickly developed an interest
in manual therapy and has pursued this interest throughout his career. He worked in
public hospitals and private practices for several years in New Zealand before traveling
to Adelaide, South Australia in 1985, to take part in post-graduate study. In 1989, he
completed a Graduate Diploma in Advanced Manipulative Therapy at the University of
South Australia and converted this to a Master of Applied Science in 1993. He has
taught internationally for over 20 years and has given numerous keynote and invited
presentations around the world. His Masters thesis was on the effect of order of
movement on the peroneal neurodynamic test, in which he discovered the concept of
neurodynamic sequencing. He proposed the concept of neurodynamics in 1995 in the
journal Physiotherapy. Since then he has studied neural mechanics and pain
physiology, performing research and writing a number of publications on the subject.
Michael edited the book Moving in on Pain and has featured as an invited contributor for various journals such
as Manual Therapy, New Zealand Journal of Physiotherapy and the Australian Journal of Physiotherapy.
Michael’s most recent publications consist of his new book Clinical Neurodynamics, which became an
international best-seller and for which he received a Fellow of the Australian College of Physiotherapists by
original contribution by monograph. His most recent publication is the book, Biomechanics of the Nervous
System: Breig revisited.
Michael’s recent area of investigation has been the in vivo imaging of mechanical function of the nervous system
and cadaver observations of lumbosacral nerve root movement. He is a multi-award winning researcher, his
most recent being a collaborator and mentor in the Young Investigator of the Year awards, won by Marinko
Rade, for the Finnish Spine Society (2013) and the International Society for the Study of the Lumbar Spine 2014
for validating Michael Shacklock’s proposal of spinal cord movement with the unilateral and bilateral straight leg
raise.
MIchael Shacklock teaches Clinical Neurodynamics internationally. His current positions are founding director of
Neurodynamic Solutions (NDS) and he is a member of the International Advisory Board and a reviewer for
Manual Therapy.
Some Publications
Shacklock M 1989 The plantarflexion/inversion straight leg raise, Master of Applied Science thesis, University of
South Australia
Shacklock M 1995 Neurodynamics. Physiotherapy 81: 9-16
Shacklock M 1995 Moving in on Pain, Butterworth-Heinemann, Sydney
Shacklock M 1996 Positive upper limb tension test is a case of surgically proven neuropathy: analysis and
validity. Manual Therapy 1: 154-161
Shacklock M 1999a Central pain mechanisms; a new horizon in manual therapy. Australian Journal of
Physiotherapy 45: 83-92
Shacklock M 1999b The clinical application of central pain mechanisms in manual therapy. Australian Journal of
Shacklock M 2000 Balanced on a tight rope between low back pain and evidence-based practice. New
Zealand Journal of Physiotherapy 28 (3): 22-27
Shacklock M 2005a Clinical Neurodynamics: a new system of musculoskeletal treatment, Elsevier, Oxford
Shacklock M 2007 Biomechanics of the Nervous System: Breig revisited. Neurodynamic Solutions, Adelaide
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 young
investigator award winner: In vivo magnetic resonance imaging measurement of spinal cord displacement
in the thoracolumbar region of asymptomatic subjects: part 1: straight leg raise test. Spine 2014 39 (16):
1288-1293
2014 Young Investigator Award Winner: In vivo magnetic resonance imaging measurement of spinal cord
displacement in the thoracolumbar region of asymptomatic subjects: part 2: comparison between
unilateral and bilateral straight leg raise tests. Spine 2014 39 (16): 1294-1300

5
Clinical Neurodynamics - the book

After much study and investigation over the last 10
years, Michael Shacklock's book is about a new
system of musculoskeletal treatment for patients
whose musculoskeletal problem has a neural
component. The book takes the therapist from
neural tension to neurodynamics. Key problems with
neural tension treatments in the past have been the
risk of provocation of symptoms, the method of
diagnosis and treatment has been unclear and there
has not been a systematic and methodical approach
to diagnosis and selection and progression of
treatment techniques.
In this internatioal best-seller, Michael demystifies

how the nervous system moves and can cause
problems, provides a new systematic approach to
prevent provocation of symptoms yet still provide a
beneficial effect and how to select advanced
techniques ranging from those for the very restricted
patient to the athlete.
Key Features
• new diagnostic and treatment techniques
• over 200 diagrams and illustrations of techniques
• new movement diagram to help the clinician link musculoskeletal and neural
functions
• new system for technique progression from restricted to highly mobile patients
• a method of integrating neural and musculoskeletal techniques in diagnosis and
treatment
• CD-ROM of nerves and musculoskeletal tissues moving in real time to illustrate
normal and abnormal situations and the importance of the interdependence of
the musculoskeletal and neural systems
Web: neurodynamicsolutions.com
Purchase on Click: books
the internet Click: clinical neurodynamics

6
AAOMPT NDS One Day Workshop Aims
Improve/develop:
• manual and clinical reasoning skills, specifically related to neurodynamics
• abilities in diagnosis and interpretation of neurodynamic testing and

musculoskeletal relationships
• technique selection and performance
Please Note
Participants are responsible for their own well being on this course. It is
recommended that participants decline to have any manoeuvres performed on
them if the participant may react with undue pain or suffering, have a condition
which might influence their ability to tolerate any manoeuvres or predispose to
the development of subsequent pain or suffering.
Participants are under no obligation to have a manoeuvre performed on them

and may freely decline.

Section 2
Neurodynamics
Audiovisual Presentation
NDS
Neurodynamic Solutions
Providing practical solutions for clinical therapists
NO RECORDING!
OK!!
AAOMPT One Day CR Neurodynamics

Workshop
Improve/develop:
manual and clinical reasoning skills,
specifically related to neurodynamics
abilities in diagnosis and interpretation of
neurodynamic testing and musculoskeletal
relationships
technique selection and performance
Problems with ‘Tension’
Makes us think of tightness in nervous system

Corollary is ‘stretch’
Stretch:
can cause injury
can increase pain
often ineffective
caused therapists to abandon the approach
Concept of Neurodynamics
Many other aspects were being omitted:

sliding, pressure
physiology
intraneural blood flow
mechanosensitivity
inflammation in neural tissues
Challenge the word ‘tension’
6
7
Concept of Neurodynamics (cont.)
Must link mechanics and physiology and function

of the musculoskeletal system
Shacklock 1995 Physiotherapy
Clinical Neurodynamics Definition - clinical

application of mechanics and physiology of the
nervous system as they relate to each other and
are integrated with musculoskeletal function
Benefits of Clinical Neurodynamics
Safer - less stretching of nerves
Links diagnosis and treatment to causal

mechanisms
Integrates neural aspects with the musculoskeletal

system
Systematic
General Neurodynamics
Definition
Principles of clinical neurodynamics that apply to
the whole body no matter what region. They are
therefore general or universal principles.
10
Concept of Neurodynamics (cont.)
11
Three Part System

3
2
1
12
Nervous System Primary Functions
Withstand tension
- 18%-22 elongation
before failure
- varies between
individuals and between
specific nerves
13
Sliding - longitudinal
14
Longitudinal sliding
prevents
excessive tension.
15
Sliding - transverse Transverse

movement of the
median nerve at
the wrist
1-5 mm
Nakamichi and
Takibana 1995
Greening et al
1999
16
Transverse sliding prevents
excessive compression.
17

Compression
Compression of nerve
during daily movement
Similar events occur with

joints and fascia
18
Three Ways to Move Nerves
1. Move the joint

Force direction is away
from the joint.

DIFFERENT FROM
direction of movement.
19
How Nerves Move
2. Move the Innervated tissues
Other nerves:
- ulnar
- median
- motor branch (median)
- digital
- axillary
- musculocutaneous
20
Ways to Load the Nervous System
3. Move the interfacing

soft tissues
- muscle
- fascia
21
The Nervous System is a Continuum
Breig 1978
NF
NE
© Neurodynamic Solutions (NDS)

22
Structural Differentiation
Definition
When the therapist moves the relevant neural

structures (remotely) without moving the adjacent
musculoskeletal structures.
The nervous system is emphasized.
23
Structural Differentiation (UQ)
Wrist symptoms - contralateral lateral flexion
24
Structural differentiation is
used in
ALL
neurodynamic tests in
diagnosis
25
Transmission of forces along the system
Type of neural effects during neurodynamic

technique:
early in movement - taking up slack
mid range - sliding effects
end range - tension effects
Charnley (1951), McLellan and Swash (1976), Wright
et al (1996)
26
Gives Us Progressions
Early in movement - just apply small force to

nerve without producing significant movement
Mid range - produce sliding
End range - apply tension
27
Convergence
Shacklock
2005
Elsevier
28
Nerves move toward the
joint at which tension is
being applied.
29
Neurodynamic Sequencing
Summary
The sequence of movements influences the
location of symptoms.
more symptoms at the region that is moved

first and most strongly (distal)
eg. foot - peroneal nerve (Shacklock 1989)
upper limb (Zorn, Shacklock & Trott 1995)
30
Tsai 1995
- almost
20% more
strain in
nerve with
local
sequence
31
Tsai 1995 - cadaver study on ulnar nerve

proximal-to-distal sequence
distal-to-proximal sequence
elbow first sequence
Greater strain in the ulnar nerve at the elbow with

the elbow first sequence (approx. 20%)
Intraneural tension reflected this change.
32
General principles
Sequence of movements influences local
tension and strain in the neural tissues.
Greater strain in nerves occurs where the force

is applied first and most strongly.
This translates into changes in symptom

responses with human subjects.
33
TECHNIQUE
IS
IMPORTANT!
34
quence Neurodynamic Sequencing -

progressions
Focused
Sequence
Tensioners HIGH
Sliders
MEDIUM
Protective
Progression
LOW
© Neurodynamic Solutions
35
1. Protective - remote sequence
CLF ShAb
Note:
No hand or
finger
movement
Release Differentiation
ElbExt CLF is the ‘off
switch’.
36
2. Sliders
The nerves slide toward the site where force

(elongation) is initiated - ‘down the tension gradient’
Distal slider Proximal slider
37
3. Tensioners
Shacklock 2005 Elsevier

38
4. Focused Sequence - more Specific/

localised
Start at the relevant

location
Wrist:
Wrist extension
elbow extension
shoulder abduction
lateral flexion
39
4. Focused Sequence
Neck:
Lateral flexion
Shoulder abduction
Elbow extension
Wrist/finger extension
40
Physiology and Movement
Elongation
elongation produces changes in blood vessel

function
8% - intraneural veins start getting blocked
15% - all blood flow through nerve is blocked
Lundborg and Rydevik (1973)
41
Physiology and Movement (cont.)
Compression
30-50 mmHg reduces venous flow from
nerve
Over one hour and the nerve fails
(Gelberman et al 1983)
Clinical pressures can reach 240 mmHg
(Werner et al 1985)
42
Physiology and Movement (cont.)
Normal nerve Pressurized nerve
43
Force
Time
44
Mechanosensitivity
How easily nerves are activated when

subjected to mechanical force.
45
Mechanosensitivity (cont.)
Is tested (evaluated) with:

neurodynamic tests
palpation
passive movements
active movements
46
NEURODYNAMIC TESTS
Tension
Mechanics Sliding
Pressure
Neurodynamic
Tests
Blood flow
Physiology Inflammation
Sensitivity
47
Neuropathodynamics
* Tension
* Sliding
Abnormal
* Pressure Neurodynamic
Tests
* Blood flow
* Inflammation Pathodynamics
* Sensitivity
48
Neurodynamic Test
Definition
A series of body movements that

produces mechanical and
physiological events in the nervous
system according to the movements
of the test.
49
Specific Neurodynamics
50
Specific Neurodynamics
Definition
Local effects of body movement on the nervous
system in a way that is specific to each region
Eg. differences between dynamics of the median,

ulnar and radial nerves
51
Mechanical interface - spinal canal
52
Intervertebral Foramen
53
Neural Tissues
a. Extension
- shorter and
compressed
b. Flexion
- tissues longer
and slide
© Neurodynamic Solutions (NDS) (Breig 1978)
54
Clinical Uses of Flexion/Extension
Diagnosis of mechanical interface component

reduced flexion - reduced opening dysfunction
reduced extension - reduced closing
dysfunction
Treatment is directed at the specific dysfunction:

improve opening or closing, depending the
problem
55
Lateral Flexion
Neural tissues on
the convex side
are tightened
Breig
1978
© 2007
56
Application of Lateral Movements
Sensitizing movements
contralateral lateral flexion
contralateral lateral glide
Desensitizing (off-loading) movements

ipsilateral lateral flexion
ipsilateral lateral glide
57
Contralateral Neurodynamic Tests
Shacklock 2005 Elsevier

58
Contralateral MNT1 (CMNT1)
95-97% of young asymptomatic subjects show a

change in symptoms with the MNT1 with the
CMNT1:
62% show a decrease
33% show no change
approx. 5% show increase
Elvey 1979, Rubenach 1985
59
CMNT1 (cont.)
The CMNT1 often reduces tension in the

nerve roots:
can be used to off-load the nerve roots in
the cervical spine
Technique is important:
maintain scapular position and pressure
constant
body and limb positions must be accurate
60
CMNT1 (cont.)
Can:
be used to reduce the power of a
technique
itself be progressed to higher or lower
levels
forms part of the progressional system of
clinical neurodynamics
61
NDS
Providing practical solutions for clinical therapists
62
Section 3
Planning Examination and Treatment
Lecture
System of technique selection

Should I do a neurological examination?
Section 3 Technique Selection 2
Planning Examination and Treatment

How extensive should it be?
General Points
Confusion exists about how to select examination and treatment techniques

‣ how strongly should a neurodynamic test be performed?
‣ how far into a provoking movement should a test be taken?
There is a spectrum of patient problems ranging from the very sensitive to the
athletic which systematic treatment can take into account
‣ which neurodynamic sequence should be used?
‣ sliding versus tension treatments
‣ interface versus neural treatments
‣ standard tests in evaluation/treatment or limited or extensive/sensitised
techniques
Decisions on the extent and type of examination are influenced by many clinical
factors that need clarification.
Below is a three tier system of deciding on the extent of the examination in the
planning of neurodynamic testing. Naturally, not all criteria will occur
simultaneously in the same patient and it is the role of the practitioner to choose
the most appropriate elements in deciding on the extent of the examination.

Level Zero – Neurodynamic Testing Contraindicated

Severe pain
Psychological influences
Legal problems
Highly unstable condition, worsening rapidly and other priorities take precedence
Level 1 - Limited
Description
This level of examination is designed to open new and safer avenues for
assessment and treatment in the patient with irritable symptoms or a pathology
through refined testing.
Previously this has not been the case because, in the presence of risk factors,
therapists have generally neglected the neural component.
Safety is the primary concern.
Indications
When pain that is easily provoked and takes a long time to settle after movement.
This relates to Maitland’s concept of irritability in which irritable problems are
treated more gently and with greater caution than non-irritable problems (Maitland
1986).
Severe pain is present, a complete neurodynamic assessment may not be

appropriate for ethical and safety reasons.
Latent pain – when the patient’s pain develops a long time after physical testing.
Latency carries risk because adequate warning of an imminent increase in
symptoms does not occur at the time of testing.
Pathology is present either in the nervous system or the mechanical interface eg.
a severe disc bulge or stenosed lateral recess in which pressure on the nerve root
might be elevated and the excursion of the nerve root may be limited.
Neurological deficit may necessitate a level 1 examination so as not to provoke

neural irritation or damage.
When a lasting increase in neurological symptoms is possible with neurodynamic

testing.
Progressive worsening prior to physical examination.
Uncertain that the nervous system will tolerate standard testing (level 2
examination). If performance of a level 1 examination is found to be safe and
does not reveal sufficient information, then the therapist may progress carefully
toward a level 2 examination by gradually including more features of a level 2
technique.

Method (General Points)

Some of the components of a neurodynamic test may be omitted so that only
minimal forces are applied to the nervous system.
It will also be necessary to modify the sequence of movements (eg. remote).
The therapist performs the usual neurodynamic tests and other mechanical tests
for the musculoskeletal structures separately ie. simultaneous testing of the
nervous system, interface and innervated tissues is avoided.
Restricted to evoking first onset of symptoms once only, if possible
Full range of motion is often not be achieved
The level 1 examination can provide sufficient information about the problem,
particularly whether a neural component exists.
Structural differentiation is still performed, however, it takes a modified form.
Modified Structural Differentiation

Differentiating tension movement is performed prior to the application of any
other test movements. The rest of the level 1 test is performed so that, at the
first onset of symptoms, the differentiating movement can be released to produce
a reduction in symptoms. This is instead of performing a differentiating
movement that increases tension at the end of the neurodynamic test and so
prevents further provocation of symptoms.
Structural differentiation becomes the ‘off switch’.
Clinical Example: irritable wrist problem
‣ contralateral lateral flexion

‣ shoulder abduction
‣ elbow extension
‣ structural differentiation (off-switch) - neck back to neutral position

Level 2 - Standard
Description
Standard tests are used
Interface, neural and innervated tissues are tested/treated separately
Neurodynamic tests are performed to a comfortable production of symptoms
only.
May be, but not necessarily, taken to end range.
Indications
The problem is not particularly irritable
Neurological symptoms are absent, or are only a minor part of the condition, and
these neurological symptoms are not easily provoked
The problem is reasonably stable and is certainly not deteriorating rapidly
The pain is not severe at the time of examination, neither is there severe latency in
terms of symptom provocation.
Method
The nervous system is effectively put through all its normal paces, but without
combining neural tests with musculoskeletal ones. The test movements should
not evoke excessive pain, neurological symptoms or go into a great deal of
resistance.
Standard neurodynamic tests are used
Neural and musculoskeletal structures are examined separately
Movement into some symptoms is acceptable, as long as they are not severe
and settle down immediately after the test
A degree of resistance may be encountered, however, it should not be strong
Full range of movement may be reached but this is not essential.
Level 3 – Advanced
General Description
Testing of the nervous system is more extensive than the previous levels.
Specificity and sensitivity are the focus and this is based heavily on the
neuropathodynamic mechanisms.
Neural structures can be tested in relation to the musculoskeletal tissues - more

sensitive.
Indications
Level 2 (standard) examination tests are normal, or do not reveal sufficient useful
information, and the clinician wishes to investigate the problem more extensively
The problem is stable
When the patient’s clinical pain is difficult to evoke
When there is no evidence of pathology that might adversely affect the nervous
system
No neurological abnormalities eg. loss of conduction are present
High expectations in physical function.
In any patient from whom sufficient information has been gained by the execution
of a level 1 or 2 examination, the level 3 examination is unnecessary and
contraindicated.
Level/type 3a. Neurodynamically Sensitised

Definition
More neural tension is added to the standard neurodynamic test through the
addition of sensitising movements.
Standard test but “more-of-the-same’ technique”
‣ contralateral lateral flexion

‣ scapular depression
‣ shoulder horizontal extension
Method
The level 2 examination is performed prior to executing one at level 3. This is to

be sure that the nervous system can cope with such testing.
Only the sensitizing movements of the standard neurodynamic test are added to
the standard test.
Level/type 3b. Neurodynamic Sequencing (Localised)

Description
Local sequence - movements start locally and become progressively more

remote.
A particular part of the nervous system is emphasized

Level/type 3c. Multistructural

Description
Neural structures are tested in combination with tests for musculoskeletal

structures.
Generally used in the person with high expectations in terms of human function in
which minor mechanical problems will provoke symptoms more easily than in
patients whose needs are less extensive.
Often athletes, sports people and persons who work in occupational settings
where high demands are a feature of their activities.
Method
Many movements and structures can be used.
Interface, neural and innervated tissues can be moved at the same time eg.
opener and neural, with some innervated tissues testing also.
Neurodynamic sequencing is modified to suit the patient’s specific

pathodynamics.
Level/type 3d. Symptomatic Position or Movement

Description
Neural structures are tested in the position or movement that reproduces the
patient’s symptoms. This makes the manoeuvre relevant to the patient and offers
an infinite number of opportunities to test the neural and musculoskeletal systems
together.
Also may be performed after or during a symptomatic activity eg. throwing,

writing or working at a factory.
Method
The patient nominates their provoking symptomatic position/movement and

performs that particular manoeuvre.
Symptoms are then differentiated with remote movements.
Neurodynamic sequencing can be modified to suit the patient’s needs eg. they
might need to move into the relevant position in a certain way.
Differentiation of shoulder pain during a throwing action (eg. wrist movements)

Practical Exercises
Perform the following examination for:
‣ irritable wrist problem - proximal-to-distal sequence (level 1)
‣ minor wrist problem - distal-to-proximal sequence (level/type 3b
‣ irritable neck problem - distal-to-proximal sequence (level 1)
‣ minor neck problem - proximal-to-distal sequence (level/type 3b)
Should I Do a Neurological Examination?

A neurological examination should be performed:
‣ when a neural component is suspected
‣ before and after significant neurodynamic techniques in treatment eg.
level 3a
‣ making sure that a neurological deficit has not developed at the end of a
course of treatment
‣ neurological deficit that was present in the first instance is changing for
better or worse
‣ reassess progress when neurological problem is detected
‣ when performing contralateral neurodynamic movements - m ay have to
do assess the effect of these movements to be assured that the
contralateral technique has not produced any problems
‣ may be indicated when starting closer techniques for the first time after
doing openers
‣ if in doubt, a neurological examination should always be performed.

Section 4
Diagnosis with Neurodynamic Tests
Lecture and practical/lab session
Classification of responses
Interpretation of neurodynamic tests
Practise testing
Section 4 Diagnosis with Neurodynamic Tests 2
Diagnosis with Neurodynamic Tests

Interpretation of Neurodynamic Tests
Potential Sources of symptoms
• Axons in the nerve
• Connective tissues in the nerve (nervi nervorum)
• Blood vessels in or around the nerve
• Muscles
• Joints
• Fascia
Therefore structural differentiation manoeuvres are essential
Structural Differentiation
The first distinction to make is whether the nervous system is involved because
it affects the next chain of events with the way we reason through the
examination and treatment.
Structural differentiation is used to make a distinction between neural and non-
neural structures and is an essential part of neurodynamic testing. As a
reminder, it is when the nerves in the problem area are moved without moving
the musculoskeletal tissues. Therefore, if the symptoms change with the
differentiating manoeuvre, the symptoms are inferred to be neurogenic. In the
non-neural response, the symptoms do not change with the differentiating
movement. The validity of structural differentiation has not been definitively
proven but there is good evidence that, in some cases, it is a valid way of
testing nerves.
Here is an example of structural differentiation:
eg. Forearm symptoms with the MNT1. Neural or musculoskeletal?
Change the tension in the nerves with side bending of the neck and, if the
symptoms also change, the symptoms are likely to be neural. If they do not,
then they are likely to be non-neural (ie. from muscles, joint or fascia). To
differentiate symptoms in the neck or shoulder, you would use wrist
movements.
The next section on classification of responses challenges some of our old
concepts of positivity.
Classification of Responses
Problems exist with the classification of symptoms responses with
neurodynamic tests because of the many possible types of responses that can

occur and what each means. Here is a suggested classification of responses

and a distinction between them must be made for clinical interventions to be
well-founded.
Diagnostic/Clinical Pathway


Musculoskeletal Response
A musculoskeletal response does not change when a differentiating movement
is performed. Neurodynamic tests can produce this kind of response. In which
case the neural tissues are not likely to be the source of symptoms.
Normal Neural Responses

The ULNTs are very sensitive tests because the are neurogenic in normal
subjects (Kenneally et al 1988). So here are some crucial questions.
Q: What does a positive test mean if they are positive in normals?
A: It is normal for test to produce a neurogenic response. Therefore, we must
now distinguish between normal neurogenic and abnormal neurogenic
responses in our patients.
Are differentiated to be neural
Are similar in location and range of movement and quality of symptoms to those
in normal subjects
Reasonably symmetrical in site and quality of symptoms
Reasonably symmetrical in range of motion and behaviour of resistance
Does not reproduce the clinical symptoms
Abnormal Neurogenic Responses (neuropathic)

Are differentiated to be neural with structural differentiation
Are different from those in normal subjects
Show reduced range of movement compared with the unaffected side
Show increased resistance compared with the unaffected side
The location or quality of symptoms can be different from normal or unaffected
side
A. Overt Abnormal Response

Structural differentiation gives a neural result.
The test reproduces the patient’s symptoms
The range of motion may be reduced.

B. Covert Abnormal Response

Is differentiated to be neural
Evokes abnormal symptoms but it:
Does not reproduce the patient’s clinical pain
May be asymmetrical in range, resistance pattern or distribution of symptoms
May be a “comparable sign” worth treating.
The most important thing is to determine the relevance of the response. In the
symptomatic patient, it could be a subtle problem that needs treatment.
Or, in the asymptomatic person, the response could be a hidden subclinical

abnormality, or even a variation on normal for that individual. Matching this
response with the patient problem is a key aspect of interpreting responses to
neurodynamic tests.
eg. a patient complains of forearm pain when working with computers. A

cramping ache is evoked by the MNT1 in the region of the problem but it is not
the sharp pain like it is with using a computer. The clinical pain is not
reproduced but something abnormal is evoked. It is differentiated to be neural
with neck contralateral lateral flexion and the range of elbow extension is
reduced by several degrees compared with the normal side. The supination
component of the test is tight compared with the other side, and this loosens
with releasing neck contralateral lateral flexion. These physical signs could be
relevant and to miss them would leave the patient without the option of
potentially effective treatment.
What Is a Positive Test and What Does It Mean?
Get away from using the term positive because tests are neurogenic (positive) in
normal subjects. The NDTs are sometimes so sensitive that an ordinary
neurogenic response does not necessarily indicate an abnormality. So I suggest
that you do not use the term “positive”.
Use the terms - “normal neurogenic” or “abnormal neurogenic” (neuropathic)

and then categorise what type of abnormal neurogenic response it is.
An abnormal neurogenic test does not tell you what exactly is wrong. For more
discussion see (Shacklock 1996).
Practical Application - exercises in diagnosis

Tasks:
Classify the category of response in your partner(s) for the MNT1, RNT and/or
MNT2 and UNT.
Remember all the details with physical examination that you practised earlier.
eg. patient position, hand holds, land marks, slow and gentle, feel for resistance
to movement, communicate about where the symptoms are, do structural
differentiation etc.
Please do NOT obtain a history from your colleague prior to testing. However,
naturally, they are free to decline from being a subject for testing for any reason.
Do the test slowly and gently.
AIM: see if you can identify a neurodynamic abnormality without prior
knowledge of your colleague’s history.
In the event that you find an abnormality, you may be interested in taking a brief
history to understand the significance of the subject’s response.
Analysis of Test Responses

Once you have decided that the testis positive (to structural differentiation), do
the following:
Are those the symptoms you have had before (or partly)?
“YES” - overt abnormal response
“NO” perform stage 2.
Is the response similar to the known normal response?

Are the:
- ranges of motion and tissue resistance normal?
- location and distribution, type of symptoms (stretch etc) normal?
“YES” - normal positive test
“NO” - covert abnormal response (tighter than normal, range of motion
reduced, symptoms spread outside the normal area).
1. Not sure - compare with contralateral side.
NOTE: Any variable used in classifying the response must be positive to

structural differentiation.
2. Is it Relevant?
You can have any type of response (overt, covert, normal) being relevant or
irrelevant and this depends on how it relates to the patient’s current
problem.
Relevant
- reproduces the patient’s current clinical pain - overt abnormal
- is tighter r than normal
- the symptoms spread further than normal
- this is different from the asymptomatic side
- the difference is in the right location for the patient problem
Irrelevant
- relates to an old problem that is no longer symptomatic
- anomalous response that is symmetrical eg. bilateral tightness
- normally tight for that person and is symmetrical
- may have an anatomical anomaly that is not relevant
It is possible that not all nerve problems hurt (Neary et al 1975).
Relationship of NDTs to the Cause

An abnormal neurodynamic test does not establish the cause. This is
ascertained in the entirety of the evaluation process and involves subjective and
physical examinations, medical and radiological tests etc.
Therefore, the main thing that an abnormal neurodynamic test offers is that fact
that something in the nervous system is wrong and the cause must be
established.
Possible causes of an abnormal neurodynamic test:

- Pancoast tumour and malignancies
- osteophytes
- disc bulges
- swollen joints and tendon sheaths
- ganglia
- myotendinous and nervous system anomalies
- neuritis
- nerve compression
- joint movement dysfunctions.
Therefore it is imperative that NDTs are only used as an indicator that something
is wrong.
An abnormal neurodynamic test means that the neural tissues may be

mechanosensitive or contain movement impairment for which the cause must
be established.

MNT1 - Median Neurodynamic

Test 1
Patient position - supine, shoulder flush with the edge of the couch, as little
abduction as possible, no pillow
Explanation to the patient
Practise lateral flexion
Hand holds - close hand sits on bed above the shoulder, using knuckles as a
fulcrum. Lean on that hand with a straight elbow. Other hand holds patient’s
hand with a pistol grip
1. Starting position - arm down by side, elbow at 90˚, neutral wrist position
Make your move: be slow and gentle

2. Glenohumeral abduction/external rotation - up to approx. 90-110˚ (in

frontal plane, stop shoulder from elevating). DO NOT DEPRESS THE
SCAPULA.
3. Supination of forearm/wrist and finger extension
4. Elbow extension - to point decided on prior to testing - assess the symptom

response and physical behaviour through the movement

5. Structural differentiation - decided by where the symptoms occur

• Proximal symptoms - use the wrist
• Distal symptoms - use the neck
Notes on Structural Differentiation

‣ Only ask about WHERE the symptoms are
‣ Use this information to decide on and perform the structural
differentiation manoeuvre
- proximal symptoms - use distal movement
- distal symptoms - use proximal movement
‣ Was the test positive? Remember this does NOT determine whether
it is abnormal yet. It could be a normal positive test!
‣ Return to the rest position
‣ Do NOT ask about quality of the symptoms and other features
during the manoeuvre. Wait until later.
‣ This helps to shorten the test
‣ When we do diagnosis later, we will analyse the symptoms in relation
to the diagnostic categories
‣ You still make observations on range of motion, tissue resistance
and adaptive movements etc.
Normal Response
Symptoms - pulling in the front of the elbow extending to the first three
digits. Sometimes P+N in the hand in median nerve distribution. These
change with neck side bending (Kenneally et al 1988).
Range of movement - anything between - 60˚- full elbow extension

(Pullos 1986, for review see Shacklock 2005).

Section 5
Neuropathodynamics
FUNCTIONAL DISORDERS
Audiovisual presentation
Diagnostic categories
Clinical features
Neuropathodynamics
Functional Disturbances
Aims
Present some functional disturbances for

diagnosis and treatment
Link neural system to the musculoskeletal

system
Base the classifications on causal

mechanisms
Mechanisms will interact and coexist
Types of Dysfunction
1. Mechanical interface
1
2. Neural
2
3. Innervated tissue
Mechanical Interface
Reduced Closing Dysfunction - Definition
When the mechanical interface lacks appropriate

movement in the closing direction
Increased pressure on the nervous system
Space-occupying element eg. disc bulge, swollen

joint, tendons etc.
Always suspect pathology.
Reduced Closing Dysfunction (cont.)
Severe cases - contralateral shift

Less severe - reduced closing eg. extension or
ipsilateral lateral flexion
Symptom production or reproduction on closing
Opening movements ease eg. flexion or
contralateral lateral flexion, rotation
Often co-exists with pathology eg. disc bulge,
stenosis, swollen structure.
Reduced Opening Dysfunction
Hypomobile/stiff in opening eg. contralateral

lateral flexion and/or sometimes flexion
Severe cases - ipsilateral shift
Production or reproduction of symptoms
with opening movement eg. contralateral
lateral flexion
Neural tension signs common because
opening movements pull on sensitive nerves.
6
Neural Tension Dysfunction
Mechanisms
MECHANICAL PATHOPHYSIOLOGY
DYSFUNCTION
Inflammation/hypoxia
Tension movements Mechanosensitivity
Lower threshold
Viscoelastic Increased response
changes
Neural Tension Dysfunction

Clinical Features
TENSION
MOVEMENTS
Increase
ABNORMAL symptoms
TEST
RESPONSE
Overt TENSION
Covert
RELEASE
Decreases
symptoms
Neural Sliding Dysfunction

Mechanisms
MECHANICAL
DYSFUNCTION
PATHOPHYSIOLOGY
Sliding movements
Inflammation/hypoxia
Contact with Mechanosensitivity
interface or Lower threshold
impairment in sliding Increased response
(adhesion)
Neural Sliding Dysfunction

Clinical Features
ABNORMAL SLIDING
TEST MOVEMENTS
RESPONSE Increase
symptoms
Overt
Covert
10
Sliding Patterns
Distal Proximal
11
Context for Sliding Dysfunctions
Sliding dysfunctions are rare but they do happen

Consistent responses to physical testing
Localising signs
History of pathological process in the region
trauma, inflammation, degeneration
Radiological evidence of pathology in the interface
Not as likely in patients with erratic physical signs and
central and psychosocial mechanisms.
12
Pathophysiology Pressure -
tourniquet effect
13
Mechanical Irritation
Mechanical Nociceptor Activation of nervi

Irritation Activation vasa nervorum
Release of neuropeptides (SP,

Blood vessel dilation
CGRP)
Neuritis + Mechanosensitivity
14
Mechanosensitivity
Overview
Mechanosensitivity is how nerves hurt with
movement.
Definition
How easily impulses are activated from a site in
the nervous system where mechanical force is
applied.
15
Mechanosensitive Axons
Sympathetic
Motor
Proprioceptive
Nociceptive
16
Nerves are
mechanosensitive when
given enough force
17
Normal nerves hurt if you
pull or push hard enough
on them
18
Full neurodynamic tests pull
hard enough to produce a
symptom response.
Mechanism?
- ischaemia
- stretch/nociceptive receptors
19
STRUCTURAL KIND OF KIND OF RELEVANT? CAUSE?

DIFFERENTIATION? RESPONSE? ABNORMAL
RESPONSE?
Musculoskeletal Normal
no change in
symptoms Whole
evaluation
Neurodynamic Normal NO
- sinister
symptoms change Does not - muscle
match - disc
ABNORMAL OVERT problem - joint
Reprod.
-
neuropathy
COVERT - neuritis
No reprod. YES
- interface
Matches
- tension
problem
- sliding
20
Section 6
Physical Examination and

Hypothesis Testing
Practical/lab session
Observation
Hypothesis creation and testing
Physical examination targeted to neurodynamics
Section 6 Physical Examination and Hypothesis Testing 2
Observation
Purposes of Observation
Detect possible abnormalities in:
‣ body alignment
‣ pathology (biomedical) - tumours, medical conditions etc.
‣ pathological processes - inflammation, vascular changes
‣ routine part of the neuromusculoskeletal examination
‣ detect abnormal patterns with respect to NEURODYNAMICS
- opening
- closing
- muscle dysfunction
- neural tension
What to Look For
Body contours and postures that might suggest:
‣ closing and opening

‣ tension, compression
Frontal plane
- symmetry, midline
- rotated
- lateral flexion
- muscle activity
- contours
- hypertrophy
- wasting
The objective is to observe what changes that you can see are related to
neurodynamics eg. closing or opening posture, tension/protective postures.
This part of the physical examination guides the therapist to what physical tests
to do.

Sagittal Plane
‣ flexion/extension
‣ lordosis
‣ hyperextension
‣ upper and lower cervical spine
‣ muscle contours - hyperactive, hypoactive
A common necessity in testing for a hidden neurodynamic component is to apply

neurodynamic differentiation to see if it changes:
Yes - may be neurodynamic aspect
No - neurodynamics are not contributing therefore - eliminated.
This applies to almost any musculoskeletal dysfunction:
‣ opening, closing
‣ muscle and nerve
‣ specific movement and nerve - eg. postural change, shift, list, muscle
tightness.

Planning the Physical Examination
Define your observations and develop hypotheses in relation to neurodynamics.
Upper cervical spine
Lower cervical spine

In order of priority, write down what physical tests you might do for the above patient
and why.
Interface
Neural

Common Patterns in Muscle and Nerve

Upper Trapezius
With wrist extension
Levator Scapulae

Anterior and Middle Scalenes

Retraction Ipsilateral rotation
Lateral translation Lateral flexion
These are only the specific movement and it will be necessary to adjust hand positions at
different stages of the technique.
Final position
Picture at left - hand positions for the technique.

Section 7
Treatment Method
Lecture
Working through a system of techniques

Section 7 Treatment Method 2
Treatment - working through a system

of techniques
Note that the system of levels and types of examination applies to treatment in
the same way that it does to examination.
SUMMARY OF TECHNIQUE SELECTION
General Principles
Observe symptoms at all times - before, during and after treatment
Reassess symptoms and physical signs - particularly neurodynamic status
immediately after treatment, unless there is reason not to, such as to avoid
provocation or undue focus on the problem. This includes neurological
examination when appropriate.
Classify the dysfunction
Base treatment on the dysfunction category and level/type of examination
Avoid the words ‘stretch’ and ‘tension’ - I say ”this technique is designed to
improve the function of the nerve”
Respect resistance - low, medium or high
Be extremely sensitive - because this forms the basis for close analysis between
you and the patient so that treatment can be responsive and derived from the
patient’s response.
Speed - slow and gentle
Amplitude - generally the movement should come back to the inner range each
time so the mobilisations are usually medium to large in amplitude

Section 7 Treatment Method 3
Dosage/Repetitions - perform several movements then reassess symptoms at

rest or some physical sign that is not irritated with reassessment. this may be
performed up to several times in one treatment session, as long as there is some
value in the technique.
Sometimes, at higher levels (2 and 3) treatment can evoke (or elicit) symptoms
- but it should not provoke them. There is a difference. I use provoke to
designate a more severe and long lasting response. Evoke suggests that
symptoms have been triggered but more on an instantaneous basis rather than
the response being long lasting.
Slider Techniques
Are particularly good for pain
Produce a lot of neural movement without producing much tension
Can be used reduce possibility of treatment soreness and settle symptoms down
with advanced treatments

Section 8
Treatment
Practical/lab session
Low back and radicular pain

Section 8 Treatment -low back and radicular pain 2
Low Back and Radicular Pain

Treatment progressions
Mechanical interface - reduced closing dysfunction
The techniques below are particularly suited to patients with significant distal
symptoms that involve pain, pins and needles or loss of sensation.
Indications
Predominantly distal symptoms - particularly pins and needles, numbness and
weakness, neurological signs
Persistent/ continuous distal symptoms
Not as common to use these techniques with acute /severe low back pain
without referral of symptoms into the lower limb
Distal symptoms provoked by closing movements - extension, ipsilateral lateral

flexion
Reduced ROM of closing movements
Key aspect - MUST do a neurological examination before and after each

treatment.
Treatment is directed at reducing the pathophysiology in the nerve root rather

than the mechanical dysfunction. this is because to treat the mechanical
dysfunction (ie. closing) would be to risk provoking the nerve root.

Level 1 - Limited
1. Static Opener
Position - painful side uppermost with a bolster under the lower side.
Progression 1a. Towel between ilium and trochanter
Progression 1b - One leg over the side

Place in open position - painful side up, legs flexed to 90°, one foot placed over
the side of the couch.
If this increases symptoms return foot to couch and place a bolster under waist
instead.
Do not mobilise.
Degree of opening - depends on response to positioning
Duration - 30-60 seconds at first. If better, repeat several times. If the same, still
repeat once more and reassess at the next session.
Monitor symptoms at rest and, if they improve, offer this position as a pain relief
strategy.
Either leg can be lowered, depending which is

more effective in achieving lateral flexion and
what is more comfortable for the patient.
Progression 1c - Static Opener

Position - as above, two feet placed over the
side of the couch. Dosage same as in
progression 1.
Dosage - up to several minutes at a time, hourly.
Good gains can be achieved by doing this
manoeuvre several times per day.
Progression 1d - manual opening to maximize.

2. Dynamic Opener/mobilisation (Level 1 continued)
Passive opener - contralateral lateral flexion
Can be done as small or large amplitude, in the

inner or outer range.
Can be performed as a home also
Level 2 - Standard
Indications/clinical features
At this point, there is little to be found on neurological examination.
The distal symptoms are not easily provoked and are now intermittent or absent.
Neurodynamic testing shows minor signs (overt abnormal response (OAR) and
covert abnormal response (CAR) late in range).
The interface dysfunctions are still present (reduced closing).
Now the treatment changes from treating pathophysiology in the nerve root to
treating the mechanical dysfunction in the interface.
Dynamic Closer
Closer mobilisation – inner, middle and outer range
Position - start mobilisation in open position and

gently move toward closed position
Mobilisation - in the direction of closing but only

to the neutral position.
Perform slowly and carefully and with respect to

the patient’s symptoms and physical responses,
especially resistance and protective responses.

Dosage - 5-6 gentle movements then reassess.

if there is an improvement, repeat several more
movements. If the same after mobilisations,
repeat sets of mobilisations, stop and reassess
at next session.
This can be progressed by positioning the patient into ipsilateral rotation, less hip/
lumbopelvic flexion and even into some extension but care must be exercised.
Neural Dysfunctions
Clinical Features
Symptoms reproduced by movements that produce sliding in one particular
direction.
Neural Tension dysfunction
‣ SLR painful +/- PNF painful in severe cases
‣ Slump - NF painful - KE painful

Moving Through the Progressions

It may not always be necessary to pass through each progression because they
provide small increments. It is therefore possible in many patients to jump a
progression or two. However, this should always be done carefully with respect
to the patient’s signs and symptoms and sufficient time should be allowed
between treatments so that accurate observation of patient responses can be
achieved.
Progression 1 Position OUT - Position OUT

(ipsilateral) (contralateral)
Position – generic off-loaded position for the sciatic nerve,
- contralateral hip flexed approximately 90˚ if possible
- contralateral knee extension
- hold for approx. 15 secs, longer if comfortable and safe (no problems in the
contralateral limb - pins and needles or other symptoms)
Ipsilateral limb Contralateral limb
Progression 2 - position OUT-move OUT (of tension)

As above (1) except the knee is extended and flexed

Perform approx. 5-10 times. This set can be repeated up to 3-5 more times
Progression 3 - position IN-move OUT (of tension)

Ipsilateral lower limb in neutral Ipsilateral dorsiflexion

Add ipsilateral SLR Move OUT - contralateral knee
More SLR Move OUT - contralateral knee
Progression 4 - position OUT-move IN (to tension)

(contralateral) (ipsilateral)
Sitting
Position OUT Move IN
- contralateral knee extension - ipsilateral knee extension
- protects nerve root - dorsiflexion optional
- dorsiflexion optional
OPTIONS:
‣ ipsilateral dorsiflexion
‣ neck flexion

Progression 5 - position IN-move IN (to tension)

(contralateral) (ipsilateral)
From this
This was the progression 4 starting position.
Now the protection from the contralateral knee

is removed (remove the contralateral knee
extension).
To this:
Position IN Move IN - ipsilateral knee extension
Add cervical flexion Move IN - ipsilateral knee extension
WHAT IS THIS?
Option - add dorsiflexion
This is now level 2, the standard slump test.
You now have a wide variety of techniques below level two that are not likely to
provoke symptoms.

Level/type 3a - Position IN - move IN (to tension)

Contralateral lateral flexion Ipsilateral knee extension
HERE IS THE PROCEDURE FOR SAFER MORE ADVANCED TECHNIQUE

1. Test neurological function. If abnormal, this technique at level 3a is not
recommended.
2. Position the patient comfortably.
3. Ask if the patient has any symptoms at rest. If “Yes”, do NOT proceed. The
problem may not be at level 3.
4. Explain that symptoms may occur and, if they do, they must only be mild at
most. Generally reproduction of the patient’s clinical symptoms is to be avoided.
Stretching sensations are common.
5. Perform a test movement to the first onset of symptoms.
5.1. make sure the patient moves slowly and carefully and that they learn to
stop at the right place.
5.2. return to the starting position and check that any symptoms disappear
instantly. If not, wait until they do. If they take more than a few seconds,
it may be better to do something more gentle.
6. If this goes according to plan:
6.1. perform 3-5 movements the same way, making sure that the symptoms
stop between movements.
6.2. return to the start position for at least a second or two each time a
movement is performed.
7. Do NOT stay in the end range position for more than about one second.
8. Test the neurological status to be sure that it has not deteriorated. If a

deterioration occurs, the technique is contraindicated.

Position - as for slump test
Movement - cervical, thoracic, lumbar flexion, contralateral lateral flexion, knee

extension,, dorsiflexion.
Make sure the amplitude is large so you retreat from the symptomatic position
each time.
Level/type 3c. Advanced - reduced closing with neural tension dysfunction
Patient position - painful side up
Mobilisation - closing (ipsilateral lateral flexion) + neck flexion and knee extension
(ie. two-ended tensioner)
This one often needs practice so the patients gets the movements right.

Starting position Closer with knee extension/neck flexion

Section 9 References 1
References
Abe Y, Doi K, Kawai S 2005 An experimental model of peripheral nerve adhesion in rabbits. British Journal of
Plastic Surgery 58: 533-540
Beith I, Robins E, Richards P 1995 An assessment of the adaptive mechanisms within and surrounding the
peripheral nervous system, during changes in nerve bed length resulting from underlying joint movement. In:
Shacklock M (ed), Moving in on Pain, Butterworth-Heinemann: 194-203
Bove, G, Ransil B, Lin H-C, Leem J-G 2003 Inflammation induces ectopic mechanical sensitivity in axons of
nociceptors innervating deep tissues. Journal of Neurophysiology 90: 1949–1955
Breig A 1978 Adverse mechanical tension in the central nervous system. Almqvist and Wiksell, Stockholm
Butler D, Gifford L 1989 The concept of adverse mechanical tension in the nervous system. Physiotherapy 75 (11):
622-636
Butler D 1991 Mobilisation of the Nervous System. Churchill Livingstone, Edinburgh
Byrod G, Olmarker K, Konno S, Larsson K, Takahashi K, Rydevik B 1995 A rapid transport route between the
epidural space and the intraneural capillaries of the nerve roots. Spine 20 (2): 138-143
Byrod G, Rydevik B, Nordborg C, Olmarker K. 1998 Early effects of nucleus pulposus application on spinal nerve
root morphology and function. European Spine Journal 7(6): 445-449
Charnley J 1951 Orthopaedic signs in the diagnosis of disc protrusion. Lancet 1: 186-192
Cleland J, Childs J, Palmer J, Eberhart S 2006 Slump stretching in the management of non-radicular low back pain:
a pilot clinical trial. Manual Therapy 11 (4): 279-286
Coppieters M, Alshami A, Babri A, Souvlis T, Kippers V, Hodges P 2006 Strain and excursion of the sciatic, tibial,
and plantar nerves during a modified straight leg raising test. Journal Orthopaedic Research 24 (9):
1883-1889
Coppieters M, Butler D 2008 Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques
and considerations regarding their application, Manual Therapy 13: 213–221
Coppieters M, Kurz K, Mortenson T, Richards N, Skaret I, McLaughlin L, Hodges P 2005 The impact of
neurodynamic testing on the perception of experimentally induced muscle pain. Manual Therapy 10 (1):
52-60
Coppieters M, Stappaerts K, Janssens K 2002 Reliability of detecting ‘onset of pain’ and ‘submaximal pain’ during
neural provocation testing of the upper quadrant Physiotherapy Research International 7(3): 146–156
Coppieters M, Stappaerts K, Wouters L, Janssens K 2003 Aberrant protective force generation during neural
provocation testing and the effect of treatment in patients with neurogenic cervicobrachial pain. Journal of
Manipulative and Physiological Therapeutics 26 (2): 99-106
Coppieters M, Alshami A, Babri A, Souvlis T, Kippers V, Hodges P 2006 Strain and excursion of the sciatic, tibial,
and plantar nerves during a modified straight leg raising test. Journal of Orthopaedic Research 2006;24 (9):
1883-1889
Coveney B, Trott P, Grimmer K, Bell A, Hall R, Shacklock M 1997 The upper limb tension test in a group of subjects
with a clinical presentation of carpal tunnel syndrome. In: Proceedings of the Manipulative Physiotherapists’
Association of Australia, Melbourne: 31-33
Daniels T, Lau J, Hearn T 1998 The effects of foot position and load on tibial nerve tension. Foot and Ankle
International 19 (2): 73-78
Dilley A, Lynn B, Pang S 2005 Pressure and stretch mechanosensitivity of peripheral nerve fibres following local
inflammation of the nerve trunk. Pain 117 (3):462-472
Eliav E,Benoliel R, Tal M 2001 Inflammation with no axonal damage of the rat saphenous nerve trunk induces
ectopic discharge and mechanosensitivity in myelinated axons. Neuroscience Letters 311: 49-52
Elvey 1979 Brachial plexus tension tests and the pathoanatomical origin of arm pain. In: Idczak R (ed.) Aspects of
Manipulative Therapy. Lincoln Institute of Health Sciences, Melbourne: 105-110
Erel E, Dilley A, Greening J, Morris V, Cohen B, Lynn B 2003 Longitudinal sliding of the median nerve in patients with
carpal tunnel syndrome. Journal of Hand Surgery 28B (5): 439-443
Greening J, Leary R 2007 Manual Therapy 2007 Jun 16 Letter to the Editor. Re: Improving application of
neurodynamic (neural tension) and treatments: A message to researchers and clinicians M. Shacklock, 10 (3)
(August 2005) 175-179

Farmer J, Wisneski R 1994 Cervical spine nerve root compression. An analysis of neuroforaminal pressures with
varying head and arm positions. Spine 19(16): 1850-1855
Fazey PJ, Song S, Mønsås S, Johansson L, Haukalid T, Price RI, Singer KP 2006 An MRI investigation of
intervertebral disc deformation in response to torsion. Clinical Biomechanics 21(5): 538-542
Flanagan M 1993 The normal response to the ulnar nerve bias upper limb tension. Master of Applied Science
Thesis, University of South Australia
Fujiwara A, An HS, Lim TH, Haughton V 2001 Morphologic changes in the lumbar intervertebral foramen due to
flexion-extension, lateral bending, and axial rotation: an in vitro anatxomic and biomechanical study. Spine 26
(8): 876-882
Gelberman R, Szabo R, Williamson R, Hargens A, Yaru N, Minteer-Convery M 1983 Tissue pressure threshold for
peripheral nerve viability. Clinical Orthopaedics and Related Research 187: 285-291
Ginn K 1988 An investigation of tension development in upper limb soft tissues during the upper limb tension test.
In: Proceedings of the International Federation of Orthopaedic Manual Therapists: 25-26
Greening J, Smart S, Leary R, Hall-Craggs M, O'Higgins P, Lynn B. Reduced movement of median nerve in carpal
tunnel during wrist flexion in patients with non-specific arm pain. Lancet 1999; 354:217-218.
Grewal R, Varitimidis S, Vardakas D, Fu F, Sotereanos D 2000 Ulnar nerve elongation and excursion in the cubital
tunnel after decompression and anterior transposition. Journal of Hand Surgery 25B (5): 457-460
Hall T, Zusman M, Elvey R 1998 Adverse mechanical tension in the nervous system? Analysis of the straight leg
raise. Manual Therapy 3 (3): 140-146
Hough A, Moore A, Jones. M. Restricted excursion of the median nerve in carpal tunnel syndrome. Poster
presentation, Manipulation Association of Chartered Physiotherapists conference, Edinburgh; 2005
Inufusa A, An HS, Lim TH, Hasegawa T, Haughton VM, Nowicki BH 1996 Anatomic changes of the spinal canal and
intervertebral foramen associated with flexion-extension movement. Spine 21:2412-2420
Kenneally M, Rubenach H, Elvey R 1988 The upper limb tension test: the SLR of the arm. In: Grant R (ed), Physical
Therapy of the Cervical and Thoracic Spine, Churchill Livingstone, New York
Kingery W, Park K, Wu P, Date E 1995 Electromyographic motor Tinel's sign in ulnar mononeuropathies at the
elbow. American Journal of Physical Medicine and Rehabilitation 74 (6): 419-426
Kobayashi S, Shizu N, Suzuki Y, Asai T, Yoshizawa H 2003 Changes in nerve root motion and intraradicular blood
flow during an intraoperative straight-leg-raising test. Spine. 28 (13):1427-34
Laban M, MacKenzie J, Zemenick G 1989 Anatomic observations in carpal tunnel syndrome as they relate to the
tethered median nerve stress test. Archives of Physical Medicine and Rehabilitation 70: 44-46
Lai W-H, Shih Y-F, Lin P-L, Chen W-Y Ma H-L 2012 Normal neurodynamic responses of the femoral slump test.
Manual Therapy 17 (2):126-132
Lewis J, Ramot R, Green A 1998 Changes in mechanical tension in the median nerve: possible implications for the
upper limb tension test. Physiotherapy 84 (6): 254-261
Levy L 1999 MR imaging of cerebrospinal fluid flow and spinal cord motion in neurologic disorders of the spine.
Magnetic Resonance Imaging Clinics of North America 7 (3): 573-587
Lindquist B, Nilsson B, Skoglund C 1973 Observations on the mechanical sensitivity of sympathetic and other types
of small-diameter nerve fibres. Brain Research 49: 432-435
Luchetti R, Schoenhuber R, Nathan P 1998 Correlation of segmental carpal tunnel pressures with changes in hand
and wrist positions in patients with carpal tunnel syndrome and controls. Journal of Hand Surgery 23B (5):
598-602
Lundborg G, Rydevik B 1973 Effects of stretching the tibial nerve of the rabbit: a preliminary study of the intraneural
circulation and barrier function of the perineurium. Journal of Bone and Joint Surgery 55B: 390-401
McLellan D, Swash M 1976 Longitudinal sliding of the median nerve during movements of the upper limb. Journal
of Neurology, Neurosurgery and Psychiatry 39: 556-570
Maitland G 1986 Vertebral Manipulation, 5th edition. Butterworth Heinemann, London
Majlesi J, Togay H, Ünalan H, Toprak S 2008 The sensitivity and specificity of the slump and the straight leg raising
tests in patients with lumbar disc herniation. Journal of Clinical Rheumatology (2): 87-91
Marshall J Nerve stretching for the relief or cure of pain. British Medical Journal 1883; 1173-1179
Mauhart D 1989 The effect of chronic ankle inversion sprain on the plantarflexion/inversion straight leg raise test.
Unpublished Graduate Diploma Thesis, University of South Australia
Miller A 1986 The straight leg raise. Unpublished Graduate Diploma in Advanced Manipulative Therapy thesis,
University of South Australia

Morishita Y, Hida S, Naito M, Arimizu J, Matsushima U, Nakamura A 2006 Measurement of the local pressure of the
intervertebral foramen and the electrophysiologic values of the spinal nerve roots in the vertebral foramen.
Spine 31 (26): 3076 –3080
Millesi H 1986 The nerve gap: theory and clinical practice. Hand Clinics 4: 651-663
Nakamichi K, Tachibana S 1995 Restricted motion of the median nerve in carpal tunnel syndrome. Journal of Hand
Surgery 20B: 460-464
Neary D, Ochoa J, Gilliatt R 1975 Sub-clinical entrapment neuropathy in man. Journal of the Neurological Sciences
24: 283-298
Olmarker K, Nordborg C, Larsson K, Rydevik B 1996 Ultrastructural changes in spinal nerve roots induced by
autologous nucleus pulposus. Spine 21(4): 411-414
Olmarker K, Rydevik B, Nordborg C 1994 Autologous nucleus pulposus induces neurophysiologic and histologic
changes in porcine cauda equina nerve roots. Spine 19 (20): 2369-2370
Pechan J, Julis I 1975 The pressure measurement in the ulnar nerve. A contribution to the pathophysiology of
cubital tunnel syndrome. Journal of Biomechanics 8: 75-79
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In Vivo MRI
measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 2 -
Comparison Between Unilateral and Bilateral Straight Leg Raise Tests.Rade M, Könönen M, Vanninen R,
Marttila J, Shacklock M, Kankaanpää M, Airaksinen O. Spine Feb 5. [Epub ahead of print]PMID: 24503694
[PubMed - as supplied by publisher]
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In vivo MRI
Measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 1 -
Straight Leg Raise Test. Spine Feb 5. [Epub ahead of print]PMID: 24503694 [PubMed - as supplied by
publisher]
Rosenblueth A, Buylla A, Ramos G 1953 The responses of axons to mechanical stimuli. Acta Physiologica
Latinoamericana 3 (2): 204-215
Rozmaryn L, Dovelle S, Rothman E, Gorman K, Olvey K, Bartko J 1998 Nerve and tendon gliding exercises and the
conservative management of carpal tunnel syndrome. Journal of Hand Therapy 11: 171-179
Rubenach H 1985 The upper limb tension test – the effect of the position and movement of the contralateral arm.
In: Proceedings of the 4th biennial conference of the Manipulative Therapists’ Association of Australia:
274-283
Rydevik B 1993 Neurophysiology of cauda equina compression. Acta Orthopaedica Scandinavica Supplement
251: 52-55
Saijilafu Nishiura Y, Yamada Y, Hara Y, Ichimura H, Yoshii Y, Ochiai N 2006 Repair of peripheral nerve defect with
direct gradual lengthening of the proximal nerve stump in rats. Journal of Orthopaedic Research 24 (12):
2246-2253
Saranga, J, Green, A, Lewis, J, Worsfold, C 2003 Effect of a cervical lateral glide on the upper limb neurodynamic
test 1: A blinded placebo-controlled investigation. Physiotherapy 89 (11): 678-684
Schuind F, Goldschmidt D, Bastin C, Burny F 1995 A biomechanical study of the ulnar nerve at the elbow. Journal
of Hand Surgery 20B (5): 623-627
Selvaratnam P, Cook S, Matyas T 1997 Transmission of mechanical stimulation to the median nerve at the wrist
during the upper limb tension test. In: Proceedings of the Manipulative Physiotherapists’ Association of
Australia, Melbourne: 182-188
Selvaratnam P, Glasgow E, Matyas T 1988 Strain effects on the nerve roots of brachial plexus. Journal of Anatomy
161: 260-264
Shacklock M 1989 The plantarflexion inversion straight leg raise. Master of applied science thesis. University of
South Australia, Adelaide
Shacklock M 1995a Neurodynamics. Physiotherapy 81: 9-16
Shacklock M 1995b Clinical application of neurodynamics. In: Shacklock M (ed.) Moving in on Pain. Butterworth-
Heinemann, Sydney: 123-131
Shacklock M 1996 Positive upper limb tension test is a case of surgically proven neuropathy: analysis and validity.
Manual Therapy 1: 154-161
Shacklock M 1999a Central pain mechanisms; a new horizon in manual therapy. Australian Journal of
Shacklock M 1999b The clinical application of central pain mechanisms in manual therapy. Australian Journal of
Shacklock M 2005a Clinical Neurodynamics: a new system of musculoskeletal treatment. Elsevier, Oxford
Shacklock M 2005b Editorial: Improving application of neurodynamic (neural tension) testing and treatments: a
message to researchers and clinicians. Manual Therapy 10 (3): 175-179
Shacklock M. Manual Therapy 2007 letter to the Editor, reply to Greening J, Leary R 2007
Shacklock M, Wilkinson M 2000 Dynamics of the median nerve in the wrist and forearm with specific active and
passive movements of the upper limb and neck in the conscious human. Unpublished recordings, School of
Medical Radiation, University of South Australia
Shacklock, M, Wilkinson M 2001 Can nerves be moved specifically? In: Proceedings of the 11th Biennial
Conference of the Musculoskeletal Physiotherapists’ Association of Australia, Adelaide, Australia
Shacklock, M, Wilkinson M, Scutter S 2002 Dynamics of the median nerve at the elbow and posterior interosseous
nerve during pronation and supination movements of the forearm. Unpublished recordings, School of
Medical Radiation, University of South Australia
Shacklock M 2006 Van neuraler Spannung zu klinischer Neurodynamik - Neues System zur Anwendung neuraler
Test - und Behandlungstechniken. Manuelle Therapie 10: 22-30
Slater H 1988 The effect of foot and ankle position on the ‘normal’ response to the SLR test, in young,
asymptomatic subjects. Unpublished Master of Applied Science Thesis, University of South Australia
Takahashi K, Shima I, Porter R 1999 Nerve root pressure in lumbar disc herniation. Spine 24(19): 2003-2006
Tsai Y-Y 1995 Tension change in the ulnar nerve by different order of upper limb tension test. Master of Science
Thesis, Northwestern University, Chicago
Trainor K, Pinnington M 2011 Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/
mid lumbar nerve root compression: a pilot study. Physiotherapy 97: 59-64
Valls-Sollé J, Alvarez R, Nuñez M 1995 Limited longitudinal sliding of the median nerve in patients with carpal tunnel
syndrome. Muscle and Nerve 18: 761-767
Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S 2003 Reliability and diagnostic accuracy of the clinical
examination and patient self-report measures for cervical radiculopathy. Spine 28 (1): 52–62
Werner C, Haeffner F, Rosén 1980 Direct recording of local pressure in the radial tunnel during passive stretch and
active contraction of the supinator muscle. Archives of Orthopaedic and Traumatic Surgery 96: 299-301
Werner C, Ohlin P, Elmqvist D 1985 Pressures recorded in ulnar neuropathy. Acta Orthopaedica Scandinavica 56
(5): 404-406
Wright T, Glowczewskie F, Wheeler D, Miller G, Cowin D. 1996 Excursion and strain of the median nerve. Journal of
Bone and Joint Surgery 78A (12): 1897-1903
Yaxley G, Jull G 1991 A modified upper limb tension test: an investigation of responses in normal subjects.
Australian Journal of Physiotherapy 37 (3): 143-152
Yokota A, Doi M, Ohtsuka H, Abe M 2003 Nerve conduction and microanatomy in the rabbit sciatic nerve after
gradual limb lengthening-distraction neurogenesis. Journal of Orthopaedic Research 21(1): 36-43
Zochodne D, Allison J, Ho W, Ho L, Hargreaves K, Sharkey K 1995 Evidence for CGRP accumulation and activity in
experimental neuromas. American Journal of Physiology 268 (2/2): 584-90
Zochodne D, Ho L 1991a Influence of perivascular peptides on endoneurial blood flow and microvascular resistance
in the sciatic nerve of the rat. Journal of Physiology 444: 615-630
Zochodne D, Ho L 1991b Stimulation-induced peripheral nerve hyperemia: mediation by fibers innervating vasa
nervorum? Brain Research 12, 546 (1): 113-118
Zochodne D, Ho L 1993 Vasa nervorum constriction from substance P and calcitonin gene-related peptide
antagonists: sensitivity to phentolamine and nimodipine. Regulatory Peptides 47 (3):285-90
Zochodne D, Huang Z, Ward K, Low P 1990 Guanethidine-induced adrenergic sympathectomy augments
endoneurial perfusion and lowers endoneurial microvascular resistance. Brain Research 519 (1-2): 112-117
Zoech G, Reihsner R, Beer R, Millesi H 1991 Stress and strain in peripheral nerves. Neuro-Orthopaedics 10:
371-382
Zorn P, Shacklock M, Trott P, Hall R 1995 The effect of sequencing the movements of the upper limb tension test on
the area of symptom production. Proceedings of the 9th biennial conference of the Manipulative
Physiotherapists’ Association of Australia: 166-167

Clinical Reasoning and Neurodynamic Testing and Treatment-Shacklock

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Clinical Reasoning and Neurodynamic Testing and Treatment-Shacklock

Încărcat de

Drepturi de autor:

Formate disponibile

NEURODYNAMIC SOLUTIONS (NDS)

AAOMPT One Day Workshop

Section 1 - Introduction to NDS and aims

Section 3 - Technique selection

Section 4 - Diagnosis with neurodynamic tests

Section 5 - Neuropathodynamics - functional disorders

Section 7 - Treatment method

Section 8 - Lumbar and radicular pain

© 2014 NDS Neurodynamic Solutions

About Neurodynamic Solutions (NDS)

AAOMPT Course Manual

No part of this publication may be reproduced, stored in a retrieval system, or

All illustrations, except where acknowledged otherwise, are copyrighted to Elsevier

NEURODYNAMIC SOLUTIONS (NDS) COURSES

Courses in clinical neurodynamics as

© 2014 NDS Neurodynamic Solutions

About Michael Shacklock

© 2014 NDS Neurodynamic Solutions

Clinical Neurodynamics - the book

In this internatioal best-seller, Michael demystifies

the internet Click: clinical neurodynamics

© 2014 NDS Neurodynamic Solutions

AAOMPT NDS One Day Workshop Aims

• manual and clinical reasoning skills, specifically related to neurodynamics

• abilities in diagnosis and interpretation of neurodynamic testing and

• technique selection and performance

Participants are under no obligation to have a manoeuvre performed on them

© 2014 NDS Neurodynamic Solutions

Providing practical solutions for clinical therapists

AAOMPT One Day CR Neurodynamics

Problems with ‘Tension’

Makes us think of tightness in nervous system

Many other aspects were being omitted:

Challenge the word ‘tension’

Concept of Neurodynamics (cont.)

Must link mechanics and physiology and function

Clinical Neurodynamics Definition - clinical

Benefits of Clinical Neurodynamics

Safer - less stretching of nerves

Links diagnosis and treatment to causal

Integrates neural aspects with the musculoskeletal

Principles of clinical neurodynamics that apply to

the whole body no matter what region. They are

therefore general or universal principles.

Concept of Neurodynamics (cont.)

Three Part System

Nervous System Primary Functions

Nervous System Primary Functions

Sliding - transverse Transverse

Transverse sliding prevents

Nervous System Primary Functions

Similar events occur with

1. Move the joint

from the joint.

How Nerves Move

2. Move the Innervated tissues

Ways to Load the Nervous System

3. Move the interfacing

The Nervous System is a Continuum

© Neurodynamic Solutions (NDS)

When the therapist moves the relevant neural

The nervous system is emphasized.

Structural Differentiation (UQ)

Wrist symptoms - contralateral lateral flexion