1. Neural tissue mobilization (NTM) is a clinical technique that applies the mechanics and physiology of the nervous system and how it relates to and integrates with the musculoskeletal system. 2. NTM uses specific movements and positions to assess nerve mobility and elicit symptoms in order to determine the source of a patient's pain. Common tests include the median, ulnar, and radial nerve tests. 3. A positive NTM test is indicated by reproduction of the patient's clinical symptoms that change with structural differentiation. NTM can help diagnose neurogenic causes of pain and guide effective treatment.

1. NEURAL TISSUE MOBILIZATION
(ASSESSMENT-UPPER LIMB)
- NITHIN NAIR (MPT-1)

2. WHAT IS NEURODYNAMICS
Eg : Excessive pronation at ankle (mechanical); Diabetic neuropathy (physiological)
INTERLINKED

3. BENEFITS OF CLINICAL NEURODYNAMICS
Safer
More effective
Link diagnosis and treatment to causal mechanisms
Integrates neural aspects with the musculoskeletal system
Systematic

4. CLINICAL NEURODYNAMIC DEFINITION
• Clinical application of mechanics and physiology of nervous system as
they relate to each other and are integrated with musculoskeletal function
MECHANICS
PHYSIOLOGY

5. INTEGRATIVE FUNCTION – NERVOUS SYSTEM &
MUSCULOSKELETAL SYSTEM
Mechanical Interface: Tissues most anatomically adjacent to the nervous system that
can move the nervous system. Eg: Supinator muscle (Radial nerve)

6. TERMINOLOGIES
• Convergence: Nerve move toward the part where tension is applied.
• Sliders: movement of nerve without stretching (stretch at one joint
and relax at other joint) – goal is to produce gliding movement in
relation to surrounding tissues
• Tensioners: It produces an increase in tension in neural structures. -
goal is to produce tension in the certain part of peripheral nerve.

7. TERMINOLOGIES
• Structural Differentiation : When the therapist moves the relevant neural
structures without moving the adjacent musculoskeletal structures
Structural differentiation is
used in
ALL
Neurodynamic tests in

8. INDICATIONS
• Use in non-irritable conditions (neuropathic/neurogenic)
• For pathomecanical causes:
- Fibrosis
- Connective tissue adhesions
- Restriction of normal tissue mobility

9. CONTRAINDICATIONS
• Malignancies of the nervous system or vertebral column
• Acute inflammatory infections
• Areas of instability
• Spinal Cord Injuries
• Suspected disc lesions
• Cauda equina lesions
• Dizziness related to vertebral artery insufficiencies
• Any central nervous system disorders (e.g. spina bifida, MS)
• Worsening neurological signs

10. TECHNIQUE SELECTION
• Based on categorization of patient’s severity.
• Divided into levels – 0, 1, 2, 3a, 3b, 3c & 3d
• Level 0 – Patients who are contraindicated, Severe pain, Severe
psychological influence, highly unstable condition, worsening rapidly.
• Level 1: Acute/ Limited examination, Highly irritable symptoms,
symptoms easily provoked, take long time to settle.
• Level 2: Standard/ Subacute, Not particularly irritable, stable conditions
are present, no significant neurological symptoms are present.
• Level 3: Chronic / Advanced, Pain is difficult to evoke, need for more
specificity & sensitivity testing.
• 3a – Neurodynamic sensitization, 3b - Neurodynamic sequencing, 3c –
Multistructural examination, 3d – Symptomatic position / movement.

11. TECHNIQUE
IS
IMPORTANT

12. 1. Explanation to the patient :
If it is alright with you, I’d like to perform some movements on your arm. This helps
me evaluate the problem and may or may not produce some mild symptoms. It doesn’t
matter either way, but I need to know precisely what happens, as it happens. So,
without moving your body part, please tell me verbally what happens. Do you
understand? Now, are you comfortable and relaxed?
2. Test the unaffected side first
3. Maintain each movement precisely
4. Be gentle, Do Not hurry
5. Evoke vs Provoke
6. Short duration of testing : < 10 secs
7. Observe the site & quality of symptoms
8. Perform structural differentiation
9. Watch for antalgic movements

13. DIFFERENTIAL DIAGNOSIS
To distinguish between origin of the symptoms the following should be
considered
• Be aware of the expected normal response
• Know all details of all the symptoms
• Know the symptoms in the starting position
• Monitor symptoms throughout the procedures
• Notice when pain starts
• The effect of sensitizing additions / subtractions on the symptoms. This is
considered an important factor to distinguish that the positive test is due
to neural tissue affection.

14. CLASSIFICATION OF NEURODYNAMIC TEST RESPONSE
NEGATIVE
POSITIVE
DOESNOT REPRODUCE
PATIENT’S CLINICAL
SYMPTOMS
REPRODUCES PATIENT’S
CLINICAL SYMPTOMS
NORMAL
ABNORMAL

16. MEDIAN NERVE (ACTIVE QUICK TEST)
EXAMPLE OF SD
IF THERE ARE SYMPTOMS ON SHOULDER ELEVATION THAT
ARE MADE WORSE BY EITHER NECK LATERAL FLEXION
AWAY FROM THE TEST SIDE AND / OR WRIST EXTENSION

17. MEDIAN NEURODYNAMIC TEST 1
INDICATIONS
 UPPER QUARTER PAIN
SYMPTOMS LOCALISED TO MEDIAN NERVE
PREPARATION
PATIENT: SUPINE, ARMS BY SIDE, SHOULDER AT THE EDGE OF THE
PLINTH, NO PILLOW
THERAPIST: STRIDE STANDING, FACING CEPHALAD, PARALLEL TO
PATIENT, HIP APPROXIMATING THE PLINTH. USES PISTOL GRIP.

18. MEDIAN NEURODYNAMIC TEST 1
SHOULDER DEPRESSION
PISTOL GRIP

19. MEDIAN NEURODYNAMIC TEST 1
ELBOW FLEXED 90°
SHOULDER ABDUCTION 90 -110°
EXTERNAL ROTATION (FULL AVAILABLE RANGE)

20. MEDIAN NEURODYNAMIC TEST 1
FOREARM SUPINATION
WRIST & FINGER EXTENSION
ELBOW EXTENSION

21. MEDIAN NEURODYNAMIC TEST 1
KEEP DOING TILL P1 (START OF PAIN). ASK FOR THE AREA OF SYMPTOMS
DO STRUCTURAL DIFFERENTIATION – SWITCH ON / SWITCH OFF
PROXIMAL SYMPTOMS (ABOVE ELBOW) – USE THE WRIST
DISTAL SYMPTOMS (AT OR BELOW ELBOW) – USE THE NECK

22. NORMAL RESPONSE OF MNT 1
• PULLING IN FRONT OF THE ELBOW EXTENDING TO FIRST THREE
DIGITS.
• SOMETIMES PINS AND NEEDLES OCCUR IN THE MEDIAN NERVE
DISTRIBUTION
• SYMPTOMS CHANGE WITH LATERAL FLEXION OF CERVICAL SPINE
• ROM: BETWEEN 60° - FULL ELBOW EXTENSION

23. MEDIAN NEURODYNAMIC TEST 2
INDICATIONS
 PATIENT SYMPTOMS PROVOKED BY DEPRESSION MOVEMENTS OF THE
SCAPULA
SYMPTOMS OCCUR IN THE DISTRIBUTION OF THE MEDIAN NERVE
PROTECT SHOULDER JOINT BY REDUCING AMOUNT OF ABDUCTION
(ARTHROPLASTY, MASTECTOMY, RECENT DISLOCATION, CAPSULITIS)
PREPARATION
PATIENT: SUPINE, LIE DIAGONALLY, SHOULDER AT THE EDGE OF THE
PLINTH, NO PILLOW
THERAPIST: STRIDE STANDING WITH NEAR LEG FORWARD, FACING
FOOT (CAUDAD), USES PISTOL GRIP.

24. MEDIAN NEURODYNAMIC TEST 2
THERAPIST’S THUMB PASSES BEHIND THE
PATIENT’S MCP JOINTS

25. MEDIAN NEURODYNAMIC TEST 2
SHOULDER DEPRESSION
ELBOW EXTENSION

26. MEDIAN NEURODYNAMIC TEST 2
EXTERNAL ROTATION / SUPINATION
WRIST AND FINGER EXTENSION

27. MEDIAN NEURODYNAMIC TEST 2
SHOULDER ABDUCTION – TILL MAX 45°
STRUCTURAL DIFFERENTIATION: RELEASE SMALL AMOUNT OF
PRESSURE FROM THE SCAPULA DEPRESSION.
PROXIMAL SYMPT – USE THE WRIST
DISTAL SYMPTOM – USE THE SCAPULA

28. NORMAL RESPONSE TO MNT 2
• PULLING IN FRONT OF THE ELBOW EXTENDING TO FIRST THREE
DIGITS.
• SOMETIMES PINS AND NEEDLES OCCUR IN THE MEDIAN NERVE
DISTRIBUTION
• SYMPTOMS CHANGE WITH LATERAL FLEXION OF CERVICAL SPINE
OR RELEASE OF SCAPULAR DEPRESSION
• ROM – FULL ELBOW EXTENSION AND ANYTHING BETWEEN 0 -45°

29. ULNAR NERVE (ACTIVE QUICK TEST)
ASK THE PATIENT TO PUT HER HAND ON HER EAR AND
THEN, KEEPING THE HAND ON THE EAR, LIFT THE
ELBOW UP

30. ULNAR NEURODYNAMIC TEST
INDICATIONS
SYMPTOMS OCCUR IN THE DISTRIBUTION OF THE ULNAR NERVE,
LOWER TRUNK OF BRACHIAL PLEXUS, C8 – T1
C8 RADICULOPATHY, TOS, CUBITAL TUNNEL SYNDROME, ULNAR
NEUROPATHY AT GUYON’S CANAL.
PREPARATION
PATIENT: SUPINE, LIE DIAGONALLY, SHOULDER AT THE EDGE OF THE
PLINTH, NO PILLOW
THERAPIST: STRIDE STANDING WITH NEAR FOOT FORWARD, FACING
CEPHALAD, THERAPISTS FINGERS SPREADS OVER PATIENTS FINGERS

31. ULNAR NEURODYNAMIC TEST
ARM EXTENDED WITH PALM FACING DOWN
SHOULDER DEPRESSION
WRIST AND FINGER EXTENSION
FOREARM PRONATION
ELBOW FLEXED – TRY TO TOUCH SHOULDER

32. ULNAR NEURODYNAMIC TEST
GLENOHUMERAL EXTERNAL ROTATION
USE THIGH (Therapist) TO SUPPORT ARM
GLENOHUMERAL ABDUCTION 55 - 60°
SD: DISTAL SYMPTOMS – RELEASE SCAPULAR DEPRESSION
PROXIMAL SYMPTOMS – WRIST FLEXION (SMALL AMOUNT)

33. NORMAL RESPONSE OF UNT
• PULLING IN MEDIAL ELBOW, SOMETIMES EXTENDING INTO
FOREARM
• STRETCHING IN ULNAR BORDER OF WRIST AND/OR
HYPOTHENAR EMINENCE
• SYMPTOMS USUALLY CHANGE WITH RELEASING SCAPULAR
DEPRESSION

34. RADIAL NERVE (ACTIVE QUICK TEST)
ASK THE PATIENT TO LET THEIR ARM BY THE SIDE, THEN
MAKE A FIST HOLDING THEIR THUMB, THEN EXTEND THE
ELBOW AND POINT THE THUMB AWAY FROM THE BODY (IR)
AND DEPRESS THE SHOULDER.

35. RADIAL NEURODYNAMIC TEST
INDICATIONS
SYMPTOMS OCCUR IN THE DISTRIBUTION OF THE RADIAL NERVE OR
C6 NERVE ROOT
POSTERIOR SHOULDER PAIN, LATERAL ELBOW PAIN, DORSAL
FOREARM PAIN, SUPINATOR TUNNEL SYNDROME, DE QUERVAIN’S
DISEASE
PREPARATION
PATIENT: SUPINE, LIE DIAGONALLY, SHOULDER AT THE EDGE OF THE
PLINTH, NO PILLOW
THERAPIST: STRIDE STANDING WITH NEAR LEG FORWARD, FACING
FOOT (CAUDAD), USES PISTOL GRIP. PROXIMAL HAND SUPPORTS
PATIENTS ELBOW AND DISTAL HAND COVERS BACK OF THE PATIENTS
HAND AND FINGERS.

36. RADIAL NEURODYNAMIC TEST
SHOULDER DEPRESSION
ELBOW EXTENSION

37. RADIAL NEURODYNAMIC TEST
INTERNAL ROTATION
PRONATION
WRIST AND FINGER FLEXION

38. RADIAL NEURODYNAMIC TEST
SHOULDER ABDUCTION
SD: DISTAL SYMPTOMS – RELEASE SCAPULAR DEPRESSION (SMALL PRESSURE)
PROXIMAL SYMPTOMS – RELEASE WRIST FLEXION (SMALL AMOUNT)

39. NORMAL RESPONSE OF RNT
• PULLING IN THE LATERAL ELBOW EXTENDING INTO FOREARM.
• STRETCH IN THE BACK OF WRIST
• SYMPTOMS CHANGE WITH RELEASING SCAPULAR DEPRESSION
• ROM – ANYTHING BETWEEN 40 -45°

41. REFERENCES
• CLINICAL NEURODYNAMICS – MICHAEL SHACKLOCK
• MOBILISATION OF NERVOUS SYSTEM – DAVID BUTLER
• THE NEURODYNAMIC TECHNIQUES – DAVID BUTLER