Assessment - Neural Provocation Testing

• (Lower limb) Neural Provocation Testing:

  • Tests the mobility of the nervous system, including surrounding vascular tissue and connective tissues
  • Establish a baseline of symptoms prior to test and throughout
  • Ensure to clarify symptoms prior to test and throughout the test to determine if leads to reproduction of patients symptoms
  • Important to maintain each movement during the testing process
  • Add cervical spine flexion as a sensitising manoeuvre to (increase) load/unload - useful way to determine if symptoms are neural in origin or from something else
• (Lower limb) Neural Provocation Testing:

  • these tests are indicated when we suspect a patient may have symptoms that are neural in origin - but pts may not have typical nerve related symptoms such as anaesthesia and paraesthesia, but may report symptoms such as nerves restricting movement that mimics the pathway of the nerve
• Neural Provocation Testing - Monitoring for:

  • Symptom reproduction
  • Differences in range of motion between sides
  • Associated resistance to movement (stiffness) and muscle spasms - as nerve may not want to be placed in a lengthened position
• Neural Provocation Testing - Tests are positive if:

  • You reproduce patients’ symptoms, and you can structurally differentiate by moving a joint at least two joints away from the area of pain
  • There is a different response to the unaffected side
• Neural Provocation Testing - Passive Neck Flexion:

  • Patient position: Performed in any position. Used to help differentiate neural tissue from non-neural tissue
  • Handling: Patient interlocks hands and place behind head, keeping their neck relaxed they bring their chin to their chest with the upper body
• Neural Provocation Testing - Slump:

  • Patient position: Patient sitting
  • Handling: have patient place their hands behind back, and slump through their spine into flexion.
  • Positive: Reproduction of symptoms
• Neural Provocation Testing - Slump:

  • To progress further:
  • Patient to extend one knee or both knees
  • Add further load by biasing the Sural nerve add DF + INV
  • Add further load by biasing the peroneal nerve add PF + INV
  • Add further load by biasing the Tibial nerve add DF + EV
  • Add overpressure at the shoulders to increase flexion of the spine
  • Over press knee extension one or both legs +/- nerve bias positioning
  • if symptoms are reproduced – can help differentiate if neural tissue or non-neural tissue with cervical spine movement into flexion/extension or movement at least two joints away
• Neural Provocation Testing - Slump:

  • a non specific neural provocation test that puts a strain, stretch or load onto the nervous system
  • can be highly irritable and is subjectively presented with neurological symptoms
  • good test to rule out neurological tissue as a cause of pts symptoms
  • can be done actively or passively:
  • slump - can add cervical flexion to increase load onto central nervous system
  • ????? (RELISTEN THE LECTURE SLIDE) for someone with neural tissue sensitivity - pain is less when the look up, pain is more when they look down
• Neural Provocation Testing - Straight Leg Raise (Sciatic Nerve):

  • Patient position: Supine
  • Handling:
  • Passive technique, patient must be relaxed
  • Stabilise the knee anteriorly and other hand at the foot/ankle
  • Begin with the knee in extension, bring the leg into hip flexion
  • Continue until symptoms are reproduced or due to posterior thigh tightness/discomfort
  • Compare between sides looking at symptom reproduction and range of motion
• Neural Provocation Testing - Straight Leg Raise (Sciatic Nerve):

  • Can bias specific neural tissue
  • Sural nerve: add Dorsiflexion & inversion
  • Peroneal nerve: add Plantarflexion & Inversion
  • Tibial Nerve: add Dorsiflexion & eversion
  • if symptoms are reproduced – can help differentiate if neural tissue or non-neural tissue with cervical spine movement into flexion/extension or movement at least two joints away
• Neural Provocation Testing - Passive Knee Bend (Femoral Nerve):

  • Patient position: Sidelying, bottom leg hugged towards the chest. Ensure spine is neutral
  • Handling:
  • 1 hand above the knee cradling the leg
  • Take weight of leg to ensure movement is passive
  • Block pelvis with other hand, move into hip extension
  • Ensure no movement through lumbar spine
  • Stop when tightness or symptoms restrict movement
  • Positive: reproduction of symptoms +/- significant reduction in movement compared to opposite side
• Neural Provocation Testing - Passive Knee Bend (Femoral Nerve):

  • if symptoms are reproduced – can help differentiate if neural tissue or non-neural tissue with cervical spine movement into flexion/extension or movement at least two joints away
• Additional Nerve Tests - Tinel’s Test (Foot & Ankle):

  • Helps differentiating Peripheral nerve vs Nerve root
  • Tinel’s Test – Foot & Ankle:
  • Common Peroneal Nerve (superficial branch)
  • Sural Nerve
  • Tibial Nerve
  • Patient position: Sidelying or supine
  • Handling: Apply a taping force with your index and middle finger over the target peripheral nerve
  • Positive: Reproduction of symptoms, maybe paraesthesia as well