How to Treat Neural Tension

A couple weeks ago we reviewed the topic of Neurodynamics and along with how, when, and why we should test for neural tension. Due to the impact nerve irritation can have on your patient's symptoms, we thought we would review how to treat neural tension as well. Some of the techniques we will review include: nerve gliding/tensioning, nerve sliding, Active Release Therapy, and IASTM.

Often thought to be synonymous, in the next two paragraphs we will address the distinct differences between nerve gliding and nerve sliding exercises. 

Nerve gliding exercises try to separate the nerve from the surrounding structures by sliding the nerve via joint movements that lengthen the nerve bed (Coppieters & Butler, 2008). Lengthening the nerve bed also stretches the nerve. This can lead to increased neural tension and intraneural pressure. If this stretch is held statically, it can decrease blood flow to the nerves, thus leading to cell death. On the other hand, dynamic movements can assist in pumping out some of the edematous fluid that compresses the nerve. That being said, any time the nerve bed is elongated there is a chance for increasing symptoms. Due to the risk of increasing symptoms, these exercises are not as common as they once were.

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.