Addressing Spinal and Neural Restrictions

One of the goals of clinical development as a physical therapist is recognizing the source of the problem and not just treating the symptoms. For example, if a shoulder hurts but the thoracic spine is not moving sufficiently, we want to include the thoracic spine in our management. If a knee is hurting during walking because of poor dorsiflexion mobility, we want to treat the dorsiflexion restriction. If a person cannot touch their toes because of poor lumbar flexion, it may be that proper motor control is lacking. Whatever the issue, we must be thorough with our examination to identify all contributing factors and the primary driving force.

One variation of this I regularly see is spinal mobility restrictions and neural tension. I typically will address both in the same treatment session, but often I will notice that neural tension will be eliminated or significantly decreased following treatment to the spine. This may include a manipulation, IASTM or repeated motions. Because of this, I rarely give nerve glides as an exercise for home. That doesn't mean nerve glides aren't effective. Even after treatment to the spine, some nerve tension can remain and be improved upon by addressing the neural tubes. In fact, I have come across patients that have greater responses to nerve glides than spinal treatment. This may be the case in your patients who inappropriately try "stretching their hamstrings" when neural tension is the issue. The nerve glides may be a novel movement to the peripheral nervous system, especially if there are greater restrictions peripherally. Because of this, your patients may express significant relief of pain and improvements in mobility following treatment.

As far as specific treatment goes, I recommend IASTM to the paraspinals of the innervating segments and anywhere along the path of the peripheral nerves. The joints that are crossed by the nerves and from which the nerve originate can be manipulated if restricted (or use other techniques like repeated motions). Additionally, think about addressing any tension points. I often will manipulate T6 for both upper and lower quarter patients and the TL junction for lower quarter patients. When addressing nerve mobility, glides and tensioners are often used. Both are effective, but glides have been shown to have greater nerve excursion (Coppieters and Butler, 2008). While I prefer to use nerve glides myself, I will use tensioners if performing a glide is difficult.

I should note that occasionally you will come across a patient that has adverse reactions to nerve tensioning. Aside from cauda equina syndrome and tethered cord syndrome, you should be careful with patients that are significantly centrally sensitized. You'll notice your patient feels worse following the treatment. I have found these patients have a high fear avoidance behavior, anxiety, or significant neural tension. In these cases, use your other methods to address nerve mobility restrictions.

-Chris

Reference:
Coppieters MW1, Butler DS. (2008). Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008 Jun;13(3):213-21.

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You may have seen some posts earlier on our site about OPTIM Physical Therapy. Several months ago, Chris and Jim joined OPTIM Physical Therapy to create a COMT program based out of Scottsdale, AZ. The mission of the program is to create a residency-like experience for those who are unable to make the financial and location commitment. The program consists of 6 weekend-long courses on-site, in addition to Medbridge courses and online mentoring between classes. Throughout the year, the class as a whole will improve their clinical skills and reasoning while working as a team. Check out www.optimfellowship.com for more information. Only a few spots remain for the year's cohort!

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