A similar technique often confused with nerve gliding is nerve sliding. Nerve sliding works by elongating the nerve bed at one joint, while simultaneously shortening it at another (Coppieters & Butler, 2008). The reasoning is that the nerve can move without increasing strain. It was found that nerve sliding creates the largest nerve excursions with the least amount of strain. Nerve gliding can potentially create even larger nerve excursions at proximal joints but it creates significant strain. Due to the chance for symptom provocation, nerve gliding should only be considered in non-acute and non-surgical conditions. It is here that nerve sliding is the preferred intervention.

A recent study found that the sequencing of nerve tensioning/gliding at each joint was irrelevant when looking at net strain on the nerve (Boyd et al, 2013). However, it was also shown that variation in sequencing of joint movements altered where the nerve strain occurred first. This has potential clinical implications as we may be able to target specific locations if we know where the restrictions lie. The real-world applicability is unknown at this point as there have not been any studies performed in this area.

When comparing education to education + neural tissue management (both nerve sliding/gliding were used with cervical manual therapy), it was found that the intervention group had superior results compared to the control with no significant increased risk of exacerbations (Nee et al, 2012). Not only is it important to note the benefit of these nerve gliding/sliding exercises, but it brings up the point that we should also be looking at the spine. Other than some form of direct trauma, another source of nerve irritation can come from poor spinal mechanics that lead to neural irritation. Treating just the nerve may mean treating just the symptoms in some cases. It is essential to look at the spinal and restore normal mechanics if any abnormalities are found, especially because a manipulation may immediately show symptom relief as well.

There are two additional treatment techniques we wanted to mention. A case study we looked at utilized Active-Release Therapy (ART) for saphenous nerve entrapment (Settergren, 2012). In general, ART involves a technique where the clinician applies a force to the restricted area while the patient actively moves to "release" the adhesion. The technique often causes significant pain during the maneuver but is followed by increased mobility and decreased pain. This method may not be as useful to most clinicians as it involves extensive training to correctly perform and the research is limited in the area. Another technique that we often perform and have had success with is Instrument-Assisted Soft Tissue Mobilization (IASTM). While we have personally seen immediate effects on pain and neural symptoms with this, again the research is limited in the area.

References:
Boyd BS, Topp KS, & Coppieters MW. (2013). Impact of Movement Sequencing on Sciatic and Tibial Nerve Strain and Excursion During the Straight Leg Raise Test in Embalmed Cadavers. JOSPT 2013 43(6):398-403.

Coppieters MW & Butler D. (2008). Do "sliders" slide and "tensioners" tension? An Analysis of Neurodynamic Techniques and Considerations Regarding Their Application. Manual Therapy 2008 13(3): 213-221. Web. 26 October 2013.

Nee RJ, Vicenzino B, Jull GA, Cleland JA, and Coppieters MW. (2012). Neural Tissue Management Provides Immediate Clinically Relevant Benefits Without Harmful Effects For Patients With Nerve-Related Neck and Arm Pain: A Randomised Trial. Journal of Physiotherapy 58 2012. Web. 26 October 2013.

Settergren R. (2012). Conservative Management of a Saphenous Nerve Entrapment in a Female Ulra-Marathon Runner. J Bodyw Mov Ther. 2013 Jul;17(3):297-301. Web. 26 October 2013.

Subacromial Impingement Syndrome (SAIS) is reported to be the most frequent cause of shoulder pain in an OP physical therapy clinic. Despite the high prevalence, physical therapists still struggle to appropriately diagnose the syndrome. The gold standard for diagnosing SAIS in arthroscopic surgery. Since we do not have access to this tool everyday, we must reply on our patient examination skills. A study by Michener et al, Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement, assessed 5 special tests commonly used to help rule-in SAIS. The 5 tests were Neers, Hawkins-Kennedy, Painful Arc, Empty Can (Jobe), and External Rotation Resistance Test. Specifically this article wanted to assess the interrator reliability of the tests, diagnostic accuracy of each test, and finally if clustering the tests would confirm or rule-out SAIS.


     The results of the study were surprising. Moderate to Substantial strength of agreement between raters was found for the empty can test, the painful arc sign, and external rotation resistance test. Surprisingly Hawkins Kennedy had the lowest kappa value at .39. We found this surprising because Hawkins-Kennedy is graded as painful or not painful. There seems to be little room for subjectivity, yet it received the lowest reliability among raters of all the tests. The difference likely lies in how the test is performed and thus perceived. It is easy to forget to not horizontally adduct the shoulder sufficiently or to ignore the patient's compensation of elevating the tested shoulder during IR as a means of avoiding/minimizing the pain provocation. Something we must always be wary of in studies of manual techniques is accepting the fact that all examiners perform/analyze movements the same.


     When looking at the diagnostic accuracy of each test individually, the External rotation resistance test had the highest positive likelihood ratio (LR) of 4.39, empty can had the second highest with 3.9, and the painful arc sign came in third at positive LR 2.25. Finally, the article found that when clustering the tests a "combination of any 3 positive tests out of the 5 have the best ability to confirm SAIS, with small to moderate shifts in the pretest to posttest probability."    

      While this article provides interesting and useful clinical information, the results are different from other studies in the literature. A separate article on SAIS by Park et al found that the clustering Hawkins-Kennedy, Infraspinatus Muscle Test, and the Painful Arc Sign yielded a high +LR (10.56) for ruling-in SAIS. So what cluster should you use? Personally, we would use both. The etiology of SAIS is multifactorial. Several structures have the potential to be pain generators and the presentation of SAIS will vary based on posture, scapulohumeral rhythm, accessory joint mechanics, and more. The Michener article was quick to point out the importance of a thorough subjective history to help aide in the diagnostic process.  

We are once again back on the topic of SIJ Dysfunction. A couple months ago, we had a pretty controversial post about non-painful sacroiliac joint dysfunction. A large part of our discussion was on the basis of how limitations in SIJ mobility could alter the normal stresses in adjacent joints. While we still believe this is an important aspect, in the past few weeks we have become aware of yet another reason for regularly assessing the sacroiliac joint.

Something that is often lost in the effects of SIJ dysfunction is impact on muscle alignment. Any time there is a deficiency in the alignment of the joint surfaces, the origin or insertion of the muscles are altered, thus changing the moment arm of the muscle as it crosses its respective joint. These changes may seem small and insignificant, but they can result in both muscle pain and weakness. The significance of a muscle alignment issue is that these patients will likely not have many positive pain provocation tests, because it is not the joint that is painful - it is the muscle (or structures near the muscle). Therefore, when assessing the sacroiliac joint, be sure to assess the symmetry and depth of SIJ structures such as the PSIS, sacral sulci, sacral ILAs, ischial tuberosities, and more. In the past few weeks, we have had multiple patients with pain or weakness that was eliminated or minimized simply by doing a sacral mobilization or other manual technique to correct the asymmetry. These patient's had negative pain provocation testing but noticeable bony landmark asymmetries. We are aware of the fact that SI mobility tests are unreliable according to several research studies, but we again argue that they should not be forgotten. This brings up the importance of testing and re-testing after a treatment. A muscle that appeared weak initially in your eval may be normal after correction. If you can show immediate changes in pain and strength from a treatment directed at the SIJ, not only will it potentially alter your plan of care, but it also builds your patients' confidence in you as a clinician! 

Neurodynamics, Neural flossing, Nerve glides...what do these terms mean exactly? The concept of placing a mechanical stress on the nervous system is abstract for many students. While many people learn the common "tensioning tests" in a school lab or at a con-ed course, the knowledge of when to perform these tests AND how to interpret the tests is lost by many individuals. 
    
Clinicians often use neural tensioning tests to determine if a patient has adverse neural tension. If a part of the nervous system becomes inflamed, entrapped, or damaged, the patient will present with signs and symptoms of neural origin. Examples of diagnoses seen with adverse neural tension include carpal tunnel syndrome, cervical radiculopathy, and cubital tunnel syndrome.  By performing tensioning tests, the clinician can determine if the origin (or a component) of pain (or other symptoms) is neural or non-neural. Pain is not your only "positive" finding in the test. Pulling and stretching are just as significant. Basically, if you develop pain/pulling/stretching in an area when tensioning the nerve and it is modified by cervical movement, you need to consider nerve components. A study published in JOSPT in 2012 by Nee et al gives "probable" criteria in regards to diagnosing peripheral neuropathic pain: 1. symptoms fit a nerve related pattern 2. history of symptoms correlates with a nerve related problem. 3. a clinical neuro examination or imaging rule-in or confirm a neurological injury. 

If you suspect adverse neural tension to be contributing to your patient's symptoms, perform a neurodynamic test to help confirm your hypothesis. For example, if you suspect a patient has carpal tunnel syndrome, perform the Median Nerve ULTT first and foremost because that is the nerve most directly involved. When performing the tests, be cautious of false positive results. Many asymptomatic individuals will have adverse neural tension so you must ask yourself if the symptom response is relevant. A general 3-part rule I follow is A. does the + test reproduce the symptoms the patient came to see you for, B. is there a side to side difference, and c. Does the neural response change by moving a distant component. If these 3 components are true, adverse neural tension is likely contributing to your patient's pain. Now this is a controversial topic. Some people follow this 3-step rule. Others look for any findings of neural tension at all (not just pain and not just at the location of chief complaint) as a possible component to the pathology. Why? Because it is not normal.

There are neural tension for both the upper and lower extremities. Many people have heard of the SLUMP, Straight Leg Raise Tests, and ULTTs. You can check out how to perform the ULTT tests below:
1) Median Nerve ULTT
2) Radial Nerve ULTT
3) Ulnar Nerve ULTT

Why is it that we have neural tension and what do we do about the positive findings? Remember, neural tension is not normal, just like hypertonicity is not normal. Trauma (micro or macro) often is culprit. That trauma can be local to the nerve or as a result of abnormal spinal motion. For example, if you have excessive lumbar mobility on one side compared to another, eventually this stress can damage the nerves, leading to pain down the chain. Sound ridiculous? We have seen where a patient had greater lumbar extension R compared to L and had positive SLUMP testing with calf pain. Following a manipulation to the hypomobile side of the lumbar spine, the pain was significantly reduced. Nerve flossing is important for improving the mobility of neural tissue, but we must not forget to correct the original factor that led to the neural tension. In an upcoming post, we will review various methods of how to treat neural tensioning in general along with some other information.

The tests above with help you determine if adverse neural tension is present. The videos below by Chris Johnson will guide your intervention selection.
Commonly used Neurodynamic Interventions by Chris Johnson


As stated early, there are many false positive with neural tensioning tests. It is important that you be consistent and precise with your tension tests to get accurate results. Also, be sure to clarify your patient's responses and watch for compensations in the test positions. A slight variation can completely lose the pathological nerve tension.

Have you ever found yourself talking with Medical students or even doctors and wanted to give them some advice regarding referrals, treatments, or pathology in general. Well we definitely have been in this situation. Many medical school programs receive no formal education in Kinesiology or Biomechanics. As therapists, our scope on knowledge on regional interdependence in much greater. Specialists in Sports and Ortho Rehab (SSOR) recently came out with a post regarding 10 tips on how to educate primary care students/ residents/ fellows. 
The 10 tips are listed below, but check out the full post for in depth reading on the topic. 

1. Shoulder pain can be disguised as neck pain (and vice versa).
2a. Not all tendinopathies are the same.
2b. Eccentric exercises can be a promising intervention for certain tendinopathies.
3. Signs and symptoms of mensical tears. How to spot them during your physical exam!  
4. For people with general knee pain, address the hip abductors and external rotators.
5. Headaches can be treated by physical therapists.
6. Sciatica can be managed by postural education, core strengthening, nerve glides, and hip strengthening.
7. Carpal Tunnel isn't always just in the wrist.
8. In acute ankle sprains, give your patients an assistive device before having them walk around with a limp. 
9. In patients with low back pain or SI pain, the problem may not be in the back.
10. Modalities are misused and abused, and frankly, there is little evidence supporting them. 

These points may all seem very obvious to physical therapists, but they may not be so clear to everyone else. For example, how many times have you had a referral for low back pain when the cause of the dysfunction was not the low back at all. This is a good top 10 list, but it is not a complete list. Can you think of other beneficial tips on how to educate medical students/residents?