Neural tension disorder; causes and treatment

NEURAL TENSION DISORDERS

Normally, the nervous system has considerable mobility to adapt to the wide range of movements imposed on it by daily activities. Still, there are sites where nerves are vulnerable to increased pressure or tension, especially when excessive or repetitive stresses or strains are imposed on the tissues surrounding the nerves or on the nerves themselves. If a nerve is compressed as it passes near a bony structure or through a confined space, undue tension may be placed on it as movement occurs proximal or distal to that site. This may be magnified if there is adhesive scar tissue or swelling that restricts mobility. When examining a patient, the therapist needs to be alert to symptoms described by the patient and be able to understand and interpret positive signs that are detected with testing maneuvers.

Neural tension disorder


Symptoms and Signs of Nerve

Mobility Impairment

History

Vascular and mechanical factors can lead to nerve pathology. Pain is the most common symptom. Sensory responses, reported as stretch pain or paresthesia, occur when tissues are in the neural stretch position. Clinical reasoning is used to understand the possible mechanism of injury, such as pathological insult to the nervous tissue or surrounding tissues or symptoms from movement patterns that place tension on the neural tissues and reproduce symptoms.

Tests of Provocation

Neurodynamic test maneuvers are performed to detect tension signs in the neural tissue. The upper limb tension test (ULTT), upper limb neurodynamic test (ULNT), straight leg raise (SLR), and slump test are familiar terms that describe various tests and procedures.  Because the test positions place stress across multiple joints, every joint in the chain must be tested separately for range, mobility, and symptom provocation prior to nerve tension testing so any restriction that occurs during the test is not the result of joint or periarticular tissue limitations. Additional tests include nerve palpation, sensation testing, reflex testing, and muscle testing. The test positions and maneuvers used to detect nerve tension and mobility are the same as the treatment positions and maneuvers. Tension signs are stretch pain or paresthesias that occur when the neurological system is stretched across multiple joints and is relieved when one of the joints in the chain is moved out of the stretch position. Therefore, the examiner carefully elongates the nerve across each joint in succession until there is symptom provocation. When symptoms occur, the final position is noted. It is important to recognize that in highly irritable or restrictive conditions full range is not possible. Once symptoms are provoked, the examiner moves one of the joints in the chain out of the stretch position to see if the symptoms are relieved. This may then be repeated with each of the joints in the chain until the examiner understands the mobility pattern of the nerve.

Causes of Symptoms

Butler proposed that symptoms are the result of tension being placed on some component of the nervous system. If compression is preventing normal mobility, tension signs occur when the nerve is stressed either proximal or distal to the site of compression. Restriction of movement can be from inflammation and scarring between the nerve and the tissue through which it runs or from actual changes in the nerve itself.

Neural tension disorder


Principles of Management

The principles of treatment are similar to those of any mobilization technique. The intensity of the maneuver should be related to irritability of the tissue, patient response, and change in symptoms. The greater the irritability, the more gentle the technique. If the restriction is primarily tension, the stretch force is applied into the tissue resistance, held for 15 to 20 seconds, released, and then repeated several times. Neurological symptoms of tingling or increased numbness should not last when the stretch is released. Application of the techniques requires positioning the individual at the point of tension (symptoms just begin), then either passively or having the patient actively move one joint in the pattern in such a way as to stretch and  then release the tension. Moving different joints in the pattern while maintaining the elongated position on the other joints changes the forces on the nerves. After several treatments and the tissue response is known, the patient is taught self-stretching.

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