Nds Lower Quarter Course Manual PDF

NEURODYNAMIC SOLUTIONS (NDS)
lower quarter course 2017-18

Providing practical solutions
for clinical therapists
www.neurodynamicsolutions.com
!2
Contents
Section 1 - Introduction to NDS and aims

Section 2 - General neurodynamics
Section 3 - Nerve palpation
Section 4 - Standard neurodynamic tests
Section 5 - Diagnosis with neurodynamic tests

Section 6 - Planning examination and treatment
Section 7 - Diagnostic categories - neuropathodynamics

Section 8 - Treatment method
Section 9 - Clinical application - treatment progressions

Section 10 - References
© 2017-18 NDS Neurodynamic Solutions !

!3
About Neurodynamic Solutions (NDS)
Background
Neurodynamic Solutions (NDS) is the teaching entity founded by Michael Shacklock. It
was started with the express purpose of offering practical clinical solutions for therapists
with an interest in neuromusculoskeletal problems. The emphasis is on clinical
neurodynamics for neuromusculoskeletal problems in a way which clarifies and
demystifies neurodynamics and makes the subject as clinically applied as possible.
Objectives
Offer practical clinical solutions for therapists who treat patients with musculoskeletal
problems with a neural component
Include the most up-to-date research and clinical information
Offer a systematic method of application of neurodynamics
Foster further development in clinical neurodynamics
Resources
Free registration
Web site - neurodynamicsolutions.com
Courses - upper and lower quarters
Newsletters - clinical solutions, new updates in research, conferences announcements,
books and other resources, web links - other physiotherapy/physical therapy and
educational groups, search engines and physical therapy data bases
Course Manual (8th edition)

© 2017-18 Michael Shacklock, Neurodynamic Solutions (NDS). All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted

in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the author. Copyright permission may be
obtained from NEURODYNAMIC SOLUTIONS (NDS), or in specific cases, Elsevier Health,
UK. For information on reproduction, please contact Neurodynamic Solutions (NDS).
All illustrations, except where acknowledged otherwise, are copyrighted to Elsevier

Health, Oxford, United Kingdom.
NEURODYNAMIC SOLUTIONS (NDS) COURSES
Courses in clinical neurodynamics as

presented in Michael Shacklock’s book are
available worldwide. If you are interested in
hosting or attending a workshop, seminar or
conference event in neurodynamics do contact
Neurodynamic Solutions (NDS).
CONTACT:
admin@neurodynamicsolutions.com www.neurodynamicsolutions.com

!4
About Michael Shacklock
Michael Shacklock graduated as a physiotherapist from the Auckland School of Health

Sciences in 1980. During his undergraduate training, he quickly developed an interest in
manual therapy and has pursued this interest throughout his career. He worked in public
hospitals and private practices for several years in New Zealand before traveling to
Adelaide, South Australia in 1985, to take part in post-graduate study. In 1989, he
completed a Graduate Diploma in Advanced Manipulative Therapy at the University of
South Australia and converted this to a Master of Applied Science in 1993. He has
taught internationally for over 20 years and has given numerous keynote and invited
presentations throughout the western world. His Masters thesis was on the effect of
order of movement on the peroneal neurodynamic test, in which he discovered the
concept of neurodynamic sequencing. Since then he has studied mechanics and
physiology of the nervous system, performing research and writing a number of
publications on the subject. Michael edited the extremely successful book Moving in on
Pain and has published in Physiotherapy and Manual Therapy and written leading and invited articles for the
Australian Journal of Physiotherapy and New Zealand Journal of Physiotherapy. Michael’s most recent
publications consist of his new book on clinical neurodynamics, for which he received a Fellow of the Australian
College of Physiotherapists by original contribution by monograph. He has been a featured author in Manual
Therapy, Australian Journal of Physiotherapy and the New Zealand Journal of Physiotherapy on critical issues in
research and clinical application of neurodynamics. His most recent publication is the book, Biomechanics of the
Nervous System: Breig revisited.
Michael’s recent area of investigation has been the in vivo imaging of mechanical function of the nervous system.
He teaches Clinical Neurodynamics internationally. Michael Shacklock’s current positions are founding director of
Neurodynamic Solutions (NDS). He is a member of the International Advisory Board for Manual Therapy. He is
also a reviewer for the international peer-reviewed journals Manual Therapy.
Some Publications
Butler D, Slater S, Shacklock 1994 Treatment of altered nervous system mechanics. In: Palastanga N, Boyling J (eds) Grieve’s Modern Manual
Therapy of the Vertebral Column (2nd edn), chapter 50. Churchill Livingstone, Edinburgh
Coveney B, Trott P, Grimmer K, Bell A, Hall R, Shacklock M 1997 The response to the upper limb tension test in carpal tunnel sufferers. In:
Proceedings of the Tenth Biennial Conference of the Manipulative Physiotherapists’ Association of Australia, Melbourne: 31-33. Awarded best
scientific paper at conference.
Rade M, Shacklock M, Peharec S, Bacic P, Candian C, Kankaanpäa M, Airaksinen O 2012 Effect of cervical spine position on upper limb
myoelectric activity during pre-manipulative stretch for Mills manipulation: A new model, relations to peripheral nerve biomechanics and
specificity of Mills manipulation. Journal of Electromyography and Kinesiology 22: 363–369
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In vivo MRI Measurement of Spinal Cord
Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 1 - Straight Leg Raise Test. Spine 39 (16): 1288-1293
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In Vivo MRI measurement of Spinal Cord
Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 2 - Comparison Between Unilateral and Bilateral Straight Leg
Raise Tests.Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O. Spine 39 (16): 1294-1300
Shacklock M 1995 Moving in on Pain, Butterworth-Heinemann, Sydney
Shacklock M 1989 The plantarflexion/inversion straight leg raise, Master of Applied Science thesis, University of South Australia. Master of Applied
Science dissertation.
Shacklock M, Butler D, Slater H 1994 The dynamic central nervous system: structure and clinical neurobiomechanics. In: Boyling G, Palastanga N
(eds), Modern Manual Therapy of the Vertebral Column, Churchill Livingstone, Edinburgh: 21-38
Shacklock M 1995a Moving in on Pain, Butterworth-Heinemann, Sydney
Shacklock M 1995b Neurodynamics. Physiotherapy 81: 9-16
Shacklock M 1995c Clinical applications of neurodynamics. Moving in on Pain. Butterworth Heinemann, Sydney: 123-131
Shacklock M 1996 Positive upper limb tension test is a case of surgically proven neuropathy: analysis and validity. Manual Therapy 1: 154-161
Shacklock M 1997 Dorsal horn injury as a cause of pain in cervical trauma. In: Proceedings of the Tenth Biennial Conference of the Manipulative
Physiotherapists’ Association of Australia, Melbourne: 189-195.
Shacklock M 1998 The endorphin response and its relation to the treatment of pain. In: Proceedings of the Australian Conference of Science and
Medicine in Sport, Adelaide: 44.
Shacklock M 1999a Central pain mechanisms; a new horizon in manual therapy. Australian Journal of Physiotherapy 45: 83-92
Shacklock M 1999b The clinical application of central pain mechanisms in manual therapy. Australian Journal of Physiotherapy 45: 215-221
Shacklock M, Wilkinson M 2001 Can nerves be moved specifically? In: Proceedings of the Biennial Conference of the Musculoskeletal
Physiotherapists’ Association of Australia, Adelaide, November 2001: 47.
Shacklock M 2000 Balanced on a tight rope between low back pain and evidence-based practice. New Zealand Journal of Physiotherapy 28 (3):
22-27
Shacklock M 2005a Clinical Neurodynamics: a new system of musculoskeletal treatment, Elsevier, Oxford
Shacklock M 2005b Editorial: Improving application of neurodynamic (neural tension) testing and treatments: a message to researchers and
clinicians. Manual Therapy 10: 175-179
Slater S, Butler D, Shacklock M 1994 The dynamic central nervous system: examination and assessment using tension tests. In: Palastanga N,
Boyling J (eds) Grieve’s Modern Manual Therapy of the Vertebral Column (2nd edn), chapter 44. Churchill Livingstone, Edinburgh
Zorn P, Shacklock M, Trott P 1995 The effect of sequencing the movements of the upper limb tension test on the area of symptom production. In:
Proceedings of the Ninth Biennial Conference of the Manipulative Physiotherapists’ Association of Australia, Gold Coast: 166-167

!5
Collaboration Between Michael Shacklock and University of Eastern

Finland Wins Prestigious Research Awards for NDS Instructor,
Marinko Rade, for Investigation of Shacklock’s Proposal on Spinal
Cord Movement
Under the support and supervision of Professor Olavi Airaksinen at the University of Eastern Finland, NDS
researcher with Michael Shacklock and PhD candidate, Marinko Rade, has won the prestigious Young Investigator
of the Year awards with both the International Society for the Study of the Lumbar Spine (2014) and Finnish Spine
Society (2013) for research into a new model for non-invasive measurement of spinal cord movement.
So we now have a new model for measurement of neurodynamics with five innovations:
A. measurement of spinal cord longitudinal movement is now possible
B. conscious healthy humans
C. non-invasive
D. emulates clinical testing
E. establishes the effect of unilateral and bilateral
testing on cord dynamics.
This opens the door for more research on lumbar

spine neurodynamics and may assist in the
physical treatment of low back pain and sciatica.
See: www.neurodynamicsolutions.com
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In vivo MRI Measurement of Spinal Cord
Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 1 - Straight Leg Raise Test. Spine 39 (16): 1288-1293
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In Vivo MRI measurement of Spinal Cord
Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 2 - Comparison Between Unilateral and Bilateral Straight Leg
Raise Tests.Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O. Spine 39 (16): 1294-1300
Clinical Neurodynamics Book
In this internatioal best-seller, Michael demystifies how

the nervous system moves and can cause problems,
provides a new systematic approach to prevent
provocation of symptoms yet still provide a beneficial
effect and how to select advanced techniques ranging
from those for the very restricted patient to the athlete.

!6
NDS Lower Quarter Course Aims
Improve/develop:
• manual skills, specifically the ability to feel abnormalities in movement related
to the nervous system in the lower quarter
• abilities in diagnosis and interpretation of lower quarter neurodynamic testing

and musculoskeletal relationships
• clinician’s repertoire of diagnosis and treatment of techniques
• safety in relation to clinical neurodynamics
Please Note
Participants are responsible for their own well being on this course. It is
recommended that participants decline to have any manoeuvres performed on
them if the participant may react with undue pain or suffering, have a condition
which might influence their ability to tolerate any manoeuvres or predispose to the
development of subsequent pain or suffering.
Participants are under no obligation to have a manoeuvre performed on them and

may freely decline.

Section 2
General Neurodynamics
Audiovisual Presentation
1
NDS
Neurodynamic Solutions
Michael Shacklock 
FACP, MAppSc, DipPhysio
Providing practical solutions for clinical therapists
2
NDS Lower Quarter Course Aims
Improve/develop:
manual skills, specifically the ability to feel
abnormalities in movement related to the nervous
system in the lower quarter
abilities in diagnosis and interpretation of lower quarter
neurodynamic testing and musculoskeletal relationships
clinician’s repertoire of diagnosis and treatment of
techniques
safety in relation to clinical neurodynamics
3
Problems with ‘Tension’
Makes us think of tightness in nervous system

Corollary is ‘stretch’
Stretch:
can cause injury
can increase pain
often ineffective
caused therapists to abandon the approach
4
Proposal 1995 - ‘Neurodynamics’
Many other aspects were being omitted:

sliding, pressure
physiology
intraneural blood flow
mechanosensitivity
inflammation in neural tissues
Challenge the word ‘tension’

5
8
9
Concept of Neurodynamics (cont.)
Must link mechanics and physiology and function

of the musculoskeletal system
Shacklock 1995 Physiotherapy
Clinical Neurodynamics Definition - clinical

application of mechanics and physiology of the
nervous system as they relate to each other and
are integrated with musculoskeletal function
10
Benefits of Clinical Neurodynamics
Safer - less stretching of nerves
Links diagnosis and treatment to causal

mechanisms
Integrates neural aspects with the musculoskeletal

system
Systematic
11
General Neurodynamics
Definition
Principles of clinical neurodynamics that apply to
the whole body no matter what region. They are
therefore general or universal principles.
12
Concept of Neurodynamics (cont.)
13
Three Part System
2
1
14
Nervous System Primary Functions
Withstand tension
- 18%-22 elongation
before failure
- varies between
individuals and between
specific nerves
15
Sliding - longitudinal
16
Longitudinal sliding
prevents
excessive tension.
17
Sliding - transverse Transverse

movement of the
median nerve at
the wrist
1-5 mm
Nakamichi and
Takibana 1995
Greening et al
1999
18
Transverse sliding prevents
excessive compression.
19
Compression
Compression of nerve
during daily movement
Similar events occur with

joints and fascia
20
Three Ways to Move Nerves
1. Move the joint
Force direction is
away from the
joint. DIFFERENT
FROM direction of
movement.
21
© Neurodynamic Solutions
22
Three Ways to Move Nerves (cont.)
2. Move the Innervated tissues
Other nerves:
- femoral
- peroneal
- sural
- tibial
- medial calcaneal
- lateral femoral cutan.
23
Innervated Tissue Technique
Superficial
fibular
and sural nerves
anastomosing
24
Ways to Load the Nervous System
3. Move the
interfacing soft
tissues
- muscle
- fascia
25
The Nervous System is a Continuum
Breig 1978
NF
NE
© Neurodynamic Solutions (NDS)
26
Structural Differentiation
Definition
When the therapist moves the neural structures in

question (remotely) without moving the
musculoskeletal structures.
The nervous system is emphasized.
27
The Nervous System is a Continuum
(cont.)
Offers us structural differentiation
* *
Stable
28
Structural Differentiation (Lumbar)
Release neck flexion (RNF) for lumbar symptoms
* *
* *
Full slump Release neck flexion
29
Structural differentiation is
used in
ALL
neurodynamic tests in
diagnosis
30
Transmission of forces along the system
Type of neural effects during neurodynamic

technique:
early in movement - taking up slack
mid range - sliding effects
end range - tension effects
universal finding
Charnley (1951), McLellan and Swash (1976), Wright et
al (1996)
31
Gives Us Progressions
Early in movement - just apply small force to

nerve without producing significant movement
Mid range - produce sliding
End range - apply tension
32
Convergence
Shacklock
2005
Elsevier
33
Nerves slide
to the point where tension
is applied.
34
Sliding of Nerves
The nerves slide toward the site where force

(elongation) is initiated - ‘down the tension gradient’
35
Neurodynamic Sequencing
Summary
The sequence of movements influences the
location of symptoms.
more symptoms at the region that is moved

first and most strongly (distal)
eg. foot - peroneal nerve (Shacklock 1989)
upper limb (Zorn, Shacklock & Trott 1995)
36
Tsai 1995 - cadaver study on ulnar nerve

proximal to distal sequence
distal to proximal sequence
elbow first sequence
Greater strain in the ulnar nerve at the elbow with

the elbow first sequence (approx. 20%)
Intraneural tension reflected this change.

37
Tsai 1995
- almost
20% more
strain in
nerve with
local
sequence
38
General principles
Sequence of movements influences local
tension and strain in the neural tissues.
Greater strain in nerves occurs where the force

is applied first and most strongly.
This translates into changes in symptom

responses with human subjects.
39
Implications
Consistency in neurodynamic testing is
important
Change the technique and you change
the test
Small changes in technique can
produce BIG changes in the response
40
TECHNIQUE
IS
IMPORTANT!
41
Neurodynamic Sequencing -
progressions
Focused
sequence
Tensioners HIGH
Sliders
MEDIUM
Protection
LOW
42
1. Protective - remote sequence (LBP)
Example: - low back pain

Dorsiflexion
SLR to first onset of pain
Release dorsiflexion - back pain reduces
Differentiation is the OFF SWITCH
43
1. Protective - remote sequence (foot)
Example: - heel pain

SLR first
dorsiflexion to first onset of pain
Release SLR - foot pain reduces
Differentiation is the OFF SWITCH
44
2. Sliders 
Proximal/cephalad Distal/caudad
45
3. Tensioners
Neutral Tension
46
4. Focused Sequence
Start at the relevant location
Ankle:
dorsiflexion then SLR
differentiate with SLR
47
Physiology and Movement (cont.)
Peripheral Nerve Compression

30-50 mmHg reduces venous flow from nerve
peripheral nerve
Over one hour and the nerve fails (Gelberman
et al 1983)
Clinical pressures can reach 240 mmHg (Werner
et al 1985)
48
Compression (cont)
Nerve Root
10 mmHg - acute ischaemia
50 mmHg, 2 minutes - oedema
120 mmHg - total ischaemia
Patients with radiculopathy - 7 mmHg - 256

(mean 53.2)
Takahashi, Shima, Porter 1999 Spine 24 (19): 2003-2006
49
Physiology and Movement
Elongation
elongation produces changes in blood vessel

function
8% - intraneural veins start getting blocked
15% - all blood flow through nerve is blocked
Lundborg and Rydevik (1973)
50
Physiology and Movement (cont.)
Normal nerve Pressurized nerve
51
Force
Time
52
Mechanosensitivity
How easily nerves are activated when

subjected to mechanical force.
53
Mechanosensitivity (cont.)
Is tested (evaluated) with:

neurodynamic tests
palpation
passive movements
active movements
54
NEURODYNAMIC TESTS
Tension
Mechanics Sliding
Pressure
Neurodynamic
Tests
Blood flow
Physiology Inflammation
Sensitivity
55
Neuropathodynamics
* Tension
* Sliding
Abnormal
* Pressure Neurodynamic
Tests
* Blood flow
Pathodynamics
* Inflammation
* Sensitivity
56
Neurodynamic Test
Definition
A series of body movements that

produces mechanical and
physiological events in the nervous
system according to the movements
of the test.
57
Specific Neurodynamics
58
Specific Neurodynamics
Definition
Local effects of body movement on the
nervous system in a way that is specific to
each region
59
Mechanical interface - spinal canal
60
Intervertebral Foramen - interface
61
Lateral Flexion
Neural tissues on
the convex side
are tightened
Contralateral lateral
flexion can be
used to sensitise
neurodynamic
tests
Breig 1978 © 2007 Neurodynamic Solutions
62
Contralateral Neurodynamic Tests
Shacklock 2005 Elsevier
63
Cervical Cord
60˚
© Neurodynamic Solutions
Breig 1960, 1978
64
"! #$%&'(!)*+,!,%#$(')-.-&/!0&%('/-+'(!'&,!1%('/-+'(!#(+2!
!
65
"! #$%&'(!)*+,!,%#$(')-.-&/!0&%('/-+'(!'&,!1%('/-+'(!#(+2! Straight Leg Raise
!
60˚
A B C
!
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Reference Unilateral Bilateral SLR
:84B7!#(+=!/B6!3G6H!<A!7B6!9<5C;!D6FC@@3:8;!35F!87;!F8;73596!A:<D!7B6!CGG6:!65FG@376!<A!7B6!3FI39657!
J6:76E:3@!E<FK!3:6!D3:L6F=!)>!,?!.3458A89378<5!<A!'!35F!1=!,8AA6:657!D63;C:6D657;!A:<D!E<7B!
Rade M, Shacklock M, Könönen<E;6:J6:;!3:6!G:6;6576F=!
M, Marttila J, Vanninen R, Kankaanpää M, Airaksinen O
2015 Spine 40 (12): 935-941
!
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! !
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66
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A B C
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Control 30s 30s + Sham 30s + Knee Ext
!
!
67
Effect of Contralateral Slump Test
4
P<0.001  3.80 
3
NPRS 2
1 P≤.996
0.65  0.62 
0
Control Sham Contralateral
0.65 
68
Contralateral Neurodynamic
Movements - cadaver study
69
* *
*
A B
70
SPINE Volume 41, Number 4, pp E205–E210
! 2016 Wolters Kluwer Health, Inc. All rights reserved
DIAGNOSTICS
Slump Test: Effect of Contralateral Knee Extension

on Response Sensations in Asymptomatic Subjects
and Cadaver Study
Michael Shacklock, MPT, FACP,!,!! Brian Yee, MPhty, FAAOMPT,y Tom Van Hoof, MSc, PhD,z
Russ Foley, PT, MSc,y Keith Boddie, DPT,§ Erin Lacey, DPT,{ J. Bryan Poley, DPT,jj
Marinko Rade, MSc (Orthop Med),yy,! Markku Kankaanpää, MD, PhD,zz
Heikki Kröger, MD, PhD,§§ and Olavi Airaksinen, MD, PhD !
Results. Part 1: Reduction of stretch sensations occurred in the

Study Design. Part 1: A randomized, single-blind study on the
intervention group but not in control and sham groups
effect of contralateral knee extension on sensations produced by
(P " 0.001).
the slump test (ST) in asymptomatic subjects. Part 2: A cadaver
Part 2: Tension in the contralateral lumbar nerve roots and dura
study simulating the nerve root behavior of part 1.
reduced in a manner consistent with the responses in the
Objective. Part 1: Test if contralateral knee extension consist-
intervention (contralateral ST) group.
ently reduces normal stretch sensations with the ST.
Conclusion. Part 1: In asymptomatic subjects, normal thigh
Part 2: Ascertain in cadavers an explanation for the results.
stretch sensations with the ST reduced consistently with the
Summary of Background Data. In asymptomatic subjects,
contralateral ST, showing that this is normal and may now be
contralateral knee extension reduces stretch sensations with the
compared with patients with sciatica.
ST. In sciatica patients, contralateral SLR also can temporarily
Part 2: Contralateral reduction in lumbar neural tension with
reduce sciatica. We studied this methodically in asymptomatic
unilateral application of tension-producing movements also
subjects before considering a clinical population.
occurred in cadavers, supporting the proposed explanatory
Methods. Part 1: Sixty-one asymptomatic subjects were tested
hypothesis.
in control (ST), sham, or intervention (contralateral ST) groups
Key words: contralateral, dura, low back pain, lumbar nerve
and their sensation response intensity compared.
roots, neurobiomechanics, neurodynamic tests, neurodynamics,
Part 2: Caudal tension was applied to the L5 nerve root of 3 sciatica, slump test.
cadavers and tension behavior of the contralateral neural tissue Spine 2016;41:E205–E210
recorded visually.
D
iagnosis of low back pain and sciatica is a key issue
From the !Department of Physical and Rehabilitation Medicine, Kuopio in which physical tests for nerve root tension signs,
University Hospital, Kuopio, Finland; yMercer University Physical Therapy such as the straight leg raise (SLR) and slump test
Program, Atlanta, Georgia; zGhent University, Ghent, Belgium; §Amedisys (ST), are commonly performed clinically. Here, we focus on
Home Healthcare, Duluth, Georgia; {Gentiva Health Services, Seattle,
Washington; jjRestore Health Group, Rosewell, Georgia; !!Neurodynamic the ST, which is inexpensive and has been shown to be
Neurodynamic Solutions, Adelaide, South Australia, Australia; yyJosip Juraj reliable1–6 and has good diagnostic efficacy ratings for disc
Strossmayer University of Osijek, Faculty of Medicine, Orthopaedic and protrusion.7
Rehabilitation Hospital ‘‘Prim. dr.Martin Horvat’’, Rovinj, Croatia;
zz
Department of Physical and Rehabilitation Medicine, Tampere University The clinically applied ST utilizes spinal flexion and lower
Hospital, Tampere, Finland; §§Department of Orthopaedic, Traumatology limb movements to apply tension to the neural tissue of the
and Hand Surgery, Kuopio University Hospital, Kuopio, Finland.
Acknowledgment date: January 20, 2015. First revision date: April 3, 2015.
Second revision date: July 2, 2015. Acceptance date: August 29, 2015.
lumbar spine.8–21 The recipient is seated whilst the spine is
flexed and the knee extended.22–28 Cervical flexion is 71
Contralateral Effects in the Lumbar
released to ascertain whether any responses produced by
The manuscript submitted does not contain information about medical
device(s)/drug(s). No funds were received in support of this work. No the test change, whether they be a normal stretch sensation
relevant financial activities outside the submitted work. (eg, posterior thigh), or symptoms such as back pain and
sciatica. At its end position in asymptomatic subjects, the
Spine
Address correspondence and reprint requests to Michael Shacklock, FACP,
MPT, 26 Erskine Street, Adelaide, SA 5034, Australia; E-mail: michael@ test typically produces sensory responses and here we use the
neurodynamicsolutions.com
term ‘‘evoked sensations’’ to denote what asymptomatic
DOI: 10.1097/BRS.0000000000001218 subjects report.
Spine www.spinejournal.com E205
Reduction in symptoms with contralateral

SLR is typical
Observations in clinical and normal subjects
suggest that the effects are MORE
SIGNIFICANT than in cervical
5 spine
on Between Michael Shacklock and University of Eastern
Possibly because the intradural nerve roots
ns Prestigious Research Awards for NDS Instructor,
are more
ade, for Investigation of Shacklock’s parallel and in a better position to
Proposal on Spinal
ement assist one another.
t and supervision of Professor Olavi Airaksinen at the University of Eastern Finland, NDS
ichael Shacklock and PhD candidate, Marinko Rade, has won the prestigious Young Investigator
s with both the International Society for the Study of the Lumbar Spine (2014) and Finnish Spine
research into a new model for non-invasive measurement of spinal cord movement.
t and supervision of Professor Olavi Airaksinen at the University of Eastern Finland, NDS

ichael Shacklock and PhD candidate, Marinko Rade, has won the prestigious Young Investigator
s with both the International Society for the Study of the Lumbar Spine (2014) and Finnish Spine
research into a new model for non-invasive measurement of spinal cord movement.
72
Thanks to My Collaborators
a new model for measurement of neurodynamics with five innovations:
of spinal cord longitudinal movement is now possible
thy humans
al testing Olavi Airaksinen

effect of unilateral and bilateral
namics.
PT, MSc,PhD
or for more research on lumbar

mics and may assist in the
t of low back pain and sciatica.
ynamicsolutions.com Marinko Rade

MSc,PhD Brian Yee
PT, DPT
Neurodynamics - the book

Tom Van Hoof
MSc, PhD
In this internatioal best-seller, Michael demystifies how

the nervous system moves and can cause problems,
provides a new systematic approach to prevent
provocation of symptoms yet still provide a beneficial
effect and how to select advanced techniques ranging
from those for the very restricted patient to the athlete.
73
ResearchGate
Free research updates
www.researchgate.net/profile/Michael_Shacklock
74
NDS
Providing practical solutions for clinical therapists
Section 3
Nerve Palpation
Practical/lab session
Sciatic
Tibial - tarsal tunnel, medial calcaneal
Fibular (peroneal) - common, superficial, deep
Sural
Section 3 Nerve Palpation "2
Nerve Palpation
General Points
Reasons for Use
Detect site of pathology or abnormal response
Establish whether anatomical changes are present in or around the nerve. This
means:
What Does Palpation Tell Us?
Where the problem is and how sensitive it is.
Whether the nerve or neighbouring tissues are inflamed or swollen or whether a

pathology might exist.
Normal Response
Nerves are normally mechanosensitive, given an adequate stimulus such as

strong force. So palpation will elicit symptoms in some people and not others,
depending on how sensitive that person’s nerves are.
Possibilities:
‣ no symptoms
‣ local discomfort
‣ sometimes referred symptoms but not usually for normal people
‣ this could be a subclinical abnormal response
Abnormal Response
Reproduction of symptoms, local or referred.
Different from other (asymptomatic) side or in a fashion that reflects the patient’s
problem
‣ asymmetrical response - more tender on the symptomatic side

‣ thickening or swelling in or around the nerve
Technique
Large deep nerves - use either the pad of the thumb or index finger
Small superficial nerves - the back of the thumb nail or finger nail
© 2017-18 NDS Neurodynamic Solutions "

Perform a ‘catch-it-then-roll-of-it’ action,like a guitar string.
Or: just apply pressure to the nerve and feel the tissues around also.
Deeper nerves - burrow to displace the overlying structures - GENTLY don’t

scrape around.
Test along the length of the nerve.
What To Do
Palpate the following nerves and write down the following variables:
‣ Size, shape and texture of the nerve (thickening?)

‣ Swelling in or around the nerve
‣ Flat nerve, round nerve?
‣ Where the tunnel structures are
‣ Can you feel the fascicles?
‣ Depth of the sulcus or surrounding tissues
‣ Sensitivity of the nerve – how hard to you have to push before
symptoms develop
‣ Location of the symptoms – local or remote
‣ Extent of the physical signs ie. how far do they spread
‣ Kind of symptoms – ie. what do they feel like, pins and needles,
numbness, aching or tenderness.
‣ Do a bilateral comparison
You may have to palpate a great distance along the nerve
Sciatic nerve in the buttock
Posterior aspect of greater trochanter
Lateral aspect of ischial tuberosity.
In between these two structures, find the groove.
Follow the nerve into the thigh.
Sciatic nerve with the hamstrings
Following the nerve into the thigh, you can add knee extension, dorsiflexion or
spinal flexion.
Tibial nerve behind the knee
De-rotate the limb to the neutral

position to place the access point for
the nerve in the centre of the limb
Nerve is in the middle between the two

dimples behind the knee.
Peroneal nerve at the knee
Place knee in 90 flexion.
Find head of fibula.
Nerve runs horizontally along the neck

of the fibula.
Follow it around the neck of the fibula

and move your finger up and down.
Tunnel for the superficial peroneal

nerve
If necessary, position ankle in a small

amount of plantarflexion/inversion to
take the slack out of the nerve.
Follow the nerve up to its tunnel, where

there is a soft spot which indicates the
tunnel.
The nerve often has medial and lateral branches and can anastomose with the
sural nerve.
Superficial peroneal nerve over the ankle
You can ‘twang’ the nerve like a guitar string and palpate along its course.

Sensory nerve that supplies most of the dorsum

of the foot, but NOT the skin between the first
and second toes.
Deep peroneal nerve at the ankle to its

terminal in between the first and
second toes
Between extensor hallucis and

digitorum tendons over the dorsum of
the ankle.
Follow it along the dorsum of the foot

to the lateral aspect of the first
metatarsal.
Sural nerve at the ankle
With your fingers, provide counter

pressure on the medial aspect of the
Achilles tendon.
Gently roll your thumb over the nerve.
If you can’t feel it you can add some

dorsiflexion/inversion and/or straight leg
raise.
Tibial nerve at the ankle
Located medially between the medial

malleolus and the calcaneum.
Look for swelling in medial aspect of

both ankles over the tarsal tunnel.

Section 4
Standard Neurodynamic Tests

Straight leg raise

Slump test (unilateral and bilateral)
Tibial nerve
Peroneal nerve
Sural nerve
Section 4 Standard Neurodynamic Tests "2
Standard Neurodynamic Tests
Standard Explanation Before All Neurodynamic Tests

To be done prior to the first neurodynamic test and repeated in short form with
subsequent tests.
Aims
‣ Reassure and relax the patient, reduce expectations
‣ Inform the patient about the manoeuvre
‣ Get the patient’s permission
‣ Make the patient communicate effectively about their response
‣ Prevent them from compromising the technique
Example
1. “If it’s alright with you, I’d like to perform some movements on your leg.
1. This helps me evaluate the problem and may or may not produce some
symptoms.
2. If you do feel anything, make sure that it does not go above mild to moderate
(3-4/10).
3. It doesn’t matter if you experience symptoms or not, but I need to know
precisely what happens, as it happens.
4. So, without moving your body, please tell me verbally what happens.
5. Do you understand?
6. Now, are you comfortable and relaxed?”
Short Explanation for Subsequent Tests

“I’m going to do another test like the other one on your leg/arm/back, OK?”. Just
remember to ..... (discuss any previous problems only). OK?”

Neurodynamic Testing Procedure

Mental Movement Diagram:
1. Symptoms at rest
2. Change in symptoms during test
3. Change in resistance to movement during test
4. Adaptive movements - these can show abnormalities
5. End range of motion and reason for ceasing the movement
6. Location of symptoms
7. Effect of structural differentiation
8. After completion of the manoeuvre, the characteristics of the symptoms are

discussed
9. Full details of the symptoms is obtained so as to determine the response

category.
Aims
‣ Streamline diagnosis
‣ Prevent provocation of symptoms by reducing the duration of the test 
Procedure
1. Is it permissible to perform the NDT on the SYMPTOMATIC SIDE FIRST. This
can help reduce the patient’s expectations and concerns that might be
evoked by moving the less affected side first. Perform neurodynamic test to
point of onset of symptoms (P1) or resistance (somewhere between R1 and
R2) or both. It is permissible to go further but this should be judged carefully
and must be of value.
2. Ask “Where are your symptoms”
3. Based on the location of symptoms, decide which end of the test to move for
structural differentiation (proximal or distal).
4. Perform structural differentiation to ascertain if the test is positive. Note that

this does not describe whether it is abnormal at this stage.
5. Return to the neutral position.
6. Analyse the response (symptoms and physical behaviour) 

Adaptive Movements
‣ If not enough information gained in the test used and an adaptive movement
is observed, correction of the movement can be performed and the NDT is
repeated
‣ The effect of structural differentiation on the adaptive movement is
assessed. If a change in the adaptive movement occurs, there is a positive
link and this may later be considered relevant, depending on the relationship
of these events to the patient’s current clinical problem.
‣ A positive effect of structural differentiation on the adaptive movement may
indicate that the adaptive movement holds a neurodynamic component.
‣ Bilateral comparison is performed in a similar fashion to the ipsilateral side
‣ The adaptive movement can be used for reassessment
‣ It can also be used in treatment in certain circumstances
Straight Leg Raise

Introduction
The straight leg raise is used to test the movement and mechanical sensitivity of
the lumbosacral neural structures and their distal extensions which consist of the
lumbosacral trunk and plexus in the pelvis, sciatic and tibial nerves and their
distal extensions in the leg and foot.
Indications
Lower quarter problems - pathology, dysfunction, pain
Thoracic spine problems
Occasionally cervical disorders and headache
Preparation
Patient position - supine, aligned symmetrically, in purest form - no pillow under
the patient’s head for reasons of consistency.
Therapist position - stride standing so that the therapist can alter their position
and maintain good technique at the same time. 

Movements
Hip flexion with a straight knee.
Prevent any variation of movements in the frontal and transverse planes, namely
adduction/abduction and internal and external rotation of the hip. This is
because all these movements sensitise the test
Technique
The therapist’s distal hand gently clasps the posterior aspect of the leg,
immediately proximal to the ankle. The reason for choosing this position is that
patients often experience ankle discomfort if the calcaneum is used at the
contact point. This is because, as the limb is raised, its weight pushes the tibia
posteriorly on the talus which turns the test into an anterior draw for talocrucal
instability and can be uncomfortable in even normal subjects, especially if the
ankle is relaxed and hypermobile.
The therapist’s proximal hand is then placed over the anterior aspect of the knee,
either immediately distal to the patella over the tibial plateau, or immediately
proximal to the patella over the distal insertion of the quadriceps tendon. These
hand positions are chosen to avoid patellofemoral compression and subsequent
discomfort.
The limb is gently raised and the symptoms and physical responses are
monitored closely. During the actual movement, it is crucial that the therapist
prevent any knee flexion because small changes in knee position will produce
significant changes in the response and range of motion. Movements of the hip
in the transverse and frontal planes are also controlled precisely.
Starting position Leg raise - hip flexion in sagittal plane
" "
Differentiation with dorsiflexion

Note the changes in position with each phase.
Apply counter pressure distally with proximal

hand so as to avoid compression up the limb.
Use your thumb to assist with the DF.

Sensitising Movements (level 3A)

Internal rotation and adduction of the hip

Internal rotation/adduction of the hip
Contralateral lateral flexion of the spine can be added.
Structural Differentiation
Proximal symptoms – use dorsiflexion, a change in grip and body position are
necessary.
Distal symptoms – they are probably already differentiated hip flexion producing
distal symptoms.
ACTIVE CERVICAL FLEXION

Structural differentiation of the straight leg raise is often attempted by the
therapist asking the patient to perform active neck flexion. Unfortunately, this is
entirely flawed and can produce a wide variety of false results. The inadequacy of
this method is by virtue of the abdominal muscles contracting during the head
raise, causing the pelvis to rotate posteriorly. This reduces the hip flexion angle
and often reduces the symptoms because of a lowering of the straight leg raise
by the mechanism of reversed origin. Conversely, some patients activate their hip
flexors which produces an increase in straight leg raise angle by rotating the
pelvis anteriorly. On account of the above, active neck flexion in the differentiation
of the straight leg raise test is not recommended.
Common Problems with Technique

Not holding the knee in full extension - note that the technique of holding the
knee does not force the knee into extension.

Not controlling movements of the hip in the transverse and frontal planes – this
produces alterations in sensitization of the test.
Not being able to make the transition from the beginning of the straight leg raise
to the end in which the therapist’s standing position changes at the middle part of
the test. This will necessitate the therapist paying particular attention to altering
the weight on their feet and direction of their own body smoothly. Practising this
aspect of the technique on people of different sizes and shapes solves this
problem.
Stopping hip flexion at the first movement of the pelvis – this has been a popular
technique in structural differentiation. The idea is that if the pelvis has not moved,
neither has the lumbar spine. Therefore, if low back pain is reproduced, the
problem must have a neural aspect to it. Even though the logic for the use of this
approach is reasonable, it houses problems. Since the hip flexion angle never
reaches full range, the neural structures are also not moved through their full
range. This procedure will therefore be prone to producing false negatives.
Normal response
Pulling and stretching in the posterior thigh that spreads into the posterior knee
and sometimes into the upper third of the calf. The range of motion varies
between approximately 50˚-100˚°.
Tibial Neurodynamic Test (TNT)

Indications
When symptoms are located in the distribution of the tibial nerve and its
extensions ie. posterior tibial nerve, medial calcaneal nerve, and the plantar and
digital nerves.
Calf pain, heel pain (including plantar fasciitis) and pain in the plantar aspect of
the foot,
Preparation
Step 1 - starting position Step 2- dorsiflexion/eversion (both hands)

Step 3 - stabilise tibia (triceps) Step 4 - raise leg with straight knee
Common Problems With Technique

Not starting in the right position of kneeling relative to the patient.
Not holding the patient’s foot correctly – must be full comfortable dorsiflexion/
inversion. Remember that, because not much of these movements occurs, the
test is not particularly sensitive, except in cases that are easily provoked.
Not holding the knee in extension properly with your triceps. Use your triceps
because it is uncomfortable for the patient if you use your elbow.
Normal Response
Stretching in the calf region (sometimes medial calf) and this

often extends into the medial aspect of the ankle and plantar
surface of the foot.
ROM - straight leg raise is usually between 30° and 70°. When
performed effectively, the leg can not be raised as far as the
standard straight leg raise test in the same individual.

Fibular (Peroneal) Neurodynamic Test (FNT)

Indications
Conditions that affect the anterolateral leg and ankle and dorsal foot areas.
The therapist should also be willing to test use this test in the presence of L4-5
radicular pain because, occasionally, it can be more sensitive for this problem
than the standard straight leg raise with dorsiflexion.
Preparation
Therapist position - stride standing, facing and leaning caudad.
The therapist’s far hand passes under the plantar aspect of the foot so that, by
the time plantarflexion/inversion has occurred, the fingers can come over the top
of the toes, after passing distally and wrapping back over their dorsal surface.
This is important because movement of the toes (target tissue) is an important
part of the test and is often omitted. Executing this part of the technique properly
will give the therapist the opportunity to take the nerve to its end range of motion
and will necessitate that the therapist cradles the patient’s achilles tendon and
ankle regions on the therapist’s forearm.
Place the near (proximal) hand over the anterior aspect of the proximal end of the
tibial plateau and grasp it firmly but comfortably. The job of this hand is to
maintain the knee in extension
Prevent internal rotation of the tibia during the plantarflexion/inversion movement
so that the patient’s hip does not rotate extraneously.
Starting position for the peroneal neurodynamic test (PNT).
Movements
Plantarflexion/inversion of the ankle foot, and

toes, followed by the straight leg raise.
Technique
The leg raise component movement is

performed by the therapist’s distal arm, such that
the main weight-bearing surface is the therapist’s distal forearm. This means that
the therapist will have to transfer their weight from their front (distal) foot toward
their back (proximal) foot so that the movement hinges around the patient’s hip
joint during the straight leg raise movement.

Section 4 Standard Neurodynamic Tests " 10

Not holding the foot correctly – in this case, the movements of the foot will be
insufficient in amplitude or they may deviate into either too much plantarflexion
relative to the inversion.
Not using the distal forearm to produce the straight leg raise (hip flexion)
component – this will make it difficult to raise the leg without losing control of the
foot movements.
Not fixating the tibia on the femur – this results in internal rotation of the entire
lower limb, which, although may be used to sensitize the test, is an extraneous
movement in relation to the standard one.
Normal Response
Stretching/pulling in the anterolateral leg, ankle and foot. When

it does not extend the whole length of this area, it can occupy
patches that are within the distribution of the peroneal nerve.
Sensitising Movements
‣ contralateral lateral flexion

‣ slump test
‣ internal rotation and adduction of the hip joint
Sural Neurodynamic Test (SNT)

Indications
When symptoms appear in the posterolateral leg, ankle and foot eg. sprained
ankle, S1 radiculopathy, cuboid syndrome and peroneal tendonitis.
Preparation
The hand hold is the opposite to the peroneal

neurodynamic test
Distal hand passes medially around the foot.
Proximal hand passes medially around tibia and

knee.

Dorsiflexion/inversion + straight leg raise

Not holding the knee properly – this enables the knee to straighten slightly, which
compromises the sequence of movements and reduces the effectiveness of the
test.
Not moving around the patient’s hip joint – this means that the limb will tend to
abduct and, again, the effectiveness of the test is reduced. To correct this, it is
essential to start from the point of standing with the legs wide apart, leaning
around the patient and being prepared to transfer weight from foot to foot.
Normal Response
Pulling/stretch in the lateral ankle region and sometimes this

spreads into the posterolateral aspect of the calf.
SLR ROM - 30°-60°

Sensitising Movements
‣ contralateral lateral flexion of the lumbar spine
‣ slump test
‣ internal rotation and adduction of the hip joint
‣
‣
Slump Test
Introduction
The Slump test is used to evaluate the dynamics of the neural structures of the
central and peripheral nervous systems from the head, along the spinal cord and
sciatic nerve tract and its extensions, in the foot. It is a complex test and is often
misunderstood and misinterpreted. In the past, the general technique has been
to lower the head and straighten the leg whilst the patient is in the sitting position.
If the patient’s pain is reproduce, the test is abnormal. The problem with this is
that it does not take into account subtleties that should be applied in order to
gain the most from the test and offer the patient an accurate diagnosis. By this, it
is meant that sensitive with attention to detail in both technique and interpretation
is crucial in effective application of the test.
Indications
Technically, any symptom from the head to the foot that lies in the distribution of
the brain and spinal cord could warrant evaluation with the slump test.
Common conditions - headache, pain anywhere in the spine or shoulder girdle,

pelvic problems
Lower limb problems in which the pain is located in the distribution of the sciatic
nerve and its extensions.
Preparation
Patient position
• sitting with the posterior aspect of their knees against the edge of the treatment
couch with their thighs parallel.
• patient’s knees against the edge of the couch
Therapist position
Both feet on the ground, leaning toward the patient’s shoulders, proximal arm
over the patient’s shoulders ready to guide the patient’s upper body and neck
movements

Movements
1. Thoracic and lumbar flexion (slump component)
This is the bow string effect between C7 and hip joints. It is not compression,
even though some occurs.
Check that the sacrum is vertical at the end of this manoeuvre for consistency
reasons.
Apply over pressure - if appropriate
2. Cervical Flexion
The patient slowly lowers their head toward their chest. So that provocation of
symptoms is avoided, the therapist places their far hand on the patient’s forehead
and controls the speed and amplitude of neck flexion.
The range of motion (determined by prior clinical reasoning) is maintained by the

therapist changing their hand position so that the palm of the near hand rests
gently on the patient’s occiput.
The hand that controlled the cervical flexion (far hand) is freed to deal with the
lower limbs.
The action of the hand that lies over the patient’s occiput is one of preventing
release of cervical flexion rather than applying overpressure into flexion.
Usually, sufficient information can be obtained without performing overpressure.

For this reason, overpressure to cervical flexion should not be part of the
standard slump test.
However, gentle overpressure into cervical flexion can be a very useful addition to
standard testing, as in more extensive examination. Its benefit is in the detection
of subtle abnormalities and is a key part in diagnosis of the covert abnormal
response. In patient’s who have such an abnormality, the neck shows greater
tightness than usual or the therapist can feel the head trying to elevate in an
attempt to release cervical flexion.
3. Knee extension
Active or passive - at the therapist’s discretion and will vary between patients.
I suggest a combination of both. In the end, the imperative is for the therapist to
have a good understanding of the relationships between each dimension.
In the performance of knee extension, the therapist holds the patient’s ankle,
which is the easy part. The difficult part of this manoeuvre is to hold the rest of
the patient’s body still so that extraneous movements do not occur. This
necessitates the therapist holding their near hand and medial forearm on the
patient’s occiput and C7 spinous process precisely in the same position
throughout the latter stages of the test

4. Dorsiflexion
Uses - finalize the slump test, differentiate lumbar symptoms
Method - hold the foot with the whole of the therapist’s distal hand and make the
movement.
Thoracic and lumbar flexion Neck flexion
" "
Knee extension Dorsiflexion
" "
5. Release Neck Flexion
"
The patient can also have their hands behind their back, resting on the bed.
NORMAL RESPONSE
Cervical flexion - stretching in thoracic region
Knee extension- stretching in posterior thigh
Symptoms differentiate with dorsiflexion and release of cervical flexion
Release of cervical flexion also produces increase ROM of knee extension and
dorsiflexion
Level 3a - Neurodynamically Sensitized Slump Test

The complete level 3 (sensitized) slump test consists of the standard slump test
and the additional sensitising movements which are as follows.
" "

Section 5
Diagnosis with Neurodynamic Tests

Lecture and practical/lab session
Classification of responses
Interpretation of neurodynamic tests
Practise testing
Section 5 Diagnosis with Neurodynamic Tests !2
Diagnosis with Neurodynamic Tests
Interpretation of Neurodynamic Tests

Potential Sources of symptoms
• axons in the nerve
• connective tissues in the nerve (nervi nervorum)
• blood vessels in or around the nerve
• muscles
• joints
• fascia
Therefore structural differentiation manoeuvres are essential.
Structural Differentiation
The first distinction to make is whether the nervous system is involved because
it affects the next chain of events with the way we reason through the
examination and treatment.
Structural differentiation is used to make a distinction between neural and non-
neural structures and is an essential part of neurodynamic testing. As a
reminder, it is when the nerves in the problem area are moved without moving
the musculoskeletal tissues. Therefore, if the symptoms change with the
differentiating manoeuvre, the symptoms are inferred to be neurogenic. In the
non-neural response, the symptoms do not change with the differentiating
movement. The validity of structural differentiation has not been definitively
proven but there is good evidence that, in some cases, it is a valid way of
testing nerves.
Here is an example of structural differentiation:
eg. Forearm symptoms with the MNT1. Neural or musculoskeletal?
Change the tension in the nerves with side bending of the neck and, if the
symptoms also change, the symptoms are likely to be neural. If they do not,
then they are likely to be non-neural (ie. from muscles, joint or fascia). To
differentiate symptoms in the neck or shoulder, you would use wrist
movements.
The next section on classification of responses challenges some of our old
concepts of positivity.

Classification of Responses
Problems exist with the classification of symptoms responses with
neurodynamic tests because of the many possible types of responses that can
occur and what each means. Here is a suggested classification of responses
and a distinction between them must be made for clinical interventions to be
well-founded.
Diagnostic/Clinical Pathway
Step 1
Step 2

Musculoskeletal Response
A musculoskeletal response does not change when a differentiating movement
is performed. Neurodynamic tests can produce this kind of response. In which
case the neural tissues are not likely to be the source of symptoms.
Normal Neural Responses

The ULNTs are very sensitive tests because the are neurogenic in normal
subjects (Kenneally et al 1988). So here are some crucial questions.
Q: What does a positive test mean if they are positive in normals?
A: It is normal for test to produce a neurogenic response. Therefore, we must
now distinguish between normal neurogenic and abnormal neurogenic
responses in our patients.
Are differentiated to be neural
Are similar in location and range of movement and quality of symptoms to those
in normal subjects
Reasonably symmetrical in site and quality of symptoms
Reasonably symmetrical in range of motion and behaviour of resistance
Does not reproduce the clinical symptoms
Abnormal Neurogenic Responses (neuropathic)

Are differentiated to be neural with structural differentiation
Are different from those in normal subjects
Show reduced range of movement compared with the unaffected side
Show increased resistance compared with the unaffected side
The location or quality of symptoms can be different from normal or unaffected
side.
A. Overt Abnormal Response

Structural differentiation gives a neural result
The test reproduces the patient’s symptoms
The range of motion may be reduced.
B. Covert Abnormal Response

Is differentiated to be neural
Evokes abnormal symptoms but it:
Does not reproduce the patient’s clinical pain
May be asymmetrical in range, resistance pattern or distribution of symptoms
May be a “comparable sign” worth treating.
The most important thing is to determine the relevance of the response. In the
symptomatic patient, it could be a subtle problem that needs treatment.

Or, in the asymptomatic person, the response could be a hidden subclinical

abnormality, or even a variation on normal for that individual. Matching this
response with the patient problem is a key aspect of interpreting responses to
neurodynamic tests.
eg. a patient complains of forearm pain when working with computers. A

cramping ache is evoked by the MNT1 in the region of the problem but it is not
the sharp pain like it is with using a computer. The clinical pain is not
reproduced but something abnormal is evoked. It is differentiated to be neural
with neck contralateral lateral flexion and the range of elbow extension is
reduced by several degrees compared with the normal side. The supination
component of the test is tight compared with the other side, and this loosens
with releasing neck contralateral lateral flexion. These physical signs could be
relevant and to miss them would leave the patient without the option of
potentially effective treatment.
What Is a Positive Test and What Does It Mean?

Get away from using the term positive because tests are neurogenic (positive) in
normal subjects. The NDTs are sometimes so sensitive that an ordinary
neurogenic response does not necessarily indicate an abnormality. So it is
suggested that you do NOT use the term “positive”.
Use the terms - “normal neurogenic” or “abnormal neurogenic” (neuropathic)

and then categorise what type of abnormal neurogenic response it is.
An abnormal neurodynamic response does not indicate the cause. For more
discussion see (Shacklock 1996).
Step 3

Relevant 
- reproduces the patient’s current clinical pain - overt abnormal 
- is tighter than normal 
- the symptoms spread further than normal 
- this is different from the asymptomatic side 
- the difference is in the right location for the patient problem. 
 
Irrelevant 
- relates to an old problem that is no longer symptomatic 
- anomalous response that is symmetrical eg. bilateral tightness 
- normally tight for that person and is symmetrical 
- may have an anatomical anomaly that is not relevant.
It is possible that not all nerve problems are painful (Neary et al 1975).
Relationship of NDTs to the Cause

An abnormal neurodynamic test does not establish the cause. This is
ascertained in the entirety of the evaluation process and involves subjective and
physical examinations, medical and radiological tests etc.
Therefore, the main thing that an abnormal neurodynamic test offers is that fact
that something in the nervous system is wrong and the cause must be
established.Possible causes of an abnormal neurodynamic test: 
- Pancoast tumour and malignancies 
- osteophytes 
- disc bulges 
- swollen joints and tendon sheaths 
- ganglia 
- myotendinous and nervous system anomalies 
- neuritis 
- nerve compression 
- joint movement dysfunctions.
Therefore it is imperative that NDTs are only used as an indicator that something
is wrong.
An abnormal neurodynamic test means that the neural tissues may be

mechanosensitive or contain movement impairment for which the cause must
be established.

Step 4 - what is the cause and how should it be treated or managed?
What is the best treatment?
Treatment is very much dependent on what the problem is (diagnostic category) and
what level (progression) it occupies.
Practical Application - exercises in diagnosis. Practise the three steps on your

colleague(s
Steps summarized again
Step 1
!  

Step 2
Step 3
If you find something wrong, you may be able to relate it to your colleague’s clinical
situation

Section 6
Planning Examination and Treatment

Lecture
Section 6 Planning Examination and Treatment "2
Planning Examination and Treatment
How extensive should it be?

General Points
Confusion exists about how to select examination and treatment techniques

‣ how strongly should a neurodynamic test be performed?
‣ how far into a provoking movement should a test be taken?
There is a spectrum of patient problems ranging from the very sensitive to the
athletic which systematic treatment can take into account
‣ which neurodynamic sequence should be used?
‣ sliding versus tension treatments
‣ interface versus neural treatments
‣ standard tests in evaluation/treatment or limited or extensive/sensitised
techniques
Decisions on the extent and type of examination are influenced by many clinical
factors that need clarification.
Below is a three tier system of deciding on the extent of the examination in the
planning of neurodynamic testing. Naturally, not all criteria will occur
simultaneously in the same patient and it is the role of the practitioner to choose
the most appropriate elements in deciding on the extent of the examination.

Level Zero – Neurodynamic Testing Contraindicated

Severe pain
Psychological influences
Legal problems
Highly unstable condition, worsening rapidly and other priorities take precedence
Obvious severe pathology with neurological impairment eg. syrinx, CVA etc,
acute foot drop etc.
Level 1 - Limited
Description
This level of examination is designed to open new and safer avenues for
assessment and treatment in the patient with irritable symptoms or a pathology
through refined testing.
Previously this has not been the case because, in the presence of risk factors,
therapists have generally neglected the neural component.
Safety is the primary concern.
Indications
When pain that is easily provoked and takes a long time to settle after movement.
This relates to Maitland’s concept of irritability in which irritable problems are
treated more gently and with greater caution than non-irritable problems (Maitland
1986).
Severe pain is present, a complete neurodynamic assessment may not be

appropriate for ethical and safety reasons.
Latent pain – when the patient’s pain develops a long time after physical testing.
Latency carries risk because adequate warning of an imminent increase in
symptoms does not occur at the time of testing.
Pathology is present either in the nervous system or the mechanical interface eg.
a severe disc bulge or stenosed lateral recess in which pressure on the nerve root
might be elevated and the excursion of the nerve root may be limited.
Neurological deficit may necessitate a level 1 examination so as not to provoke

neural irritation or damage.
When a lasting increase in neurological symptoms is possible with neurodynamic

testing.
Progressive worsening prior to physical examination.

Uncertain that the nervous system will tolerate standard testing (level 2
examination). If performance of a level 1 examination is found to be safe and
does not reveal sufficient information, then the therapist may progress carefully
toward a level 2 examination by gradually including more features of a level 2
technique.

Method (General Points)

Some of the components of a neurodynamic test may be omitted so that only
minimal forces are applied to the nervous system.
It will also be necessary to modify the sequence of movements (eg. remote).
The therapist performs the usual neurodynamic tests and other mechanical tests
for the musculoskeletal structures separately ie. simultaneous testing of the
nervous system, interface and innervated tissues is avoided.
Restricted to evoking first onset of symptoms once only, if possible
Full range of motion is often not be achieved
The level 1 examination can provide sufficient information about the problem,
particularly whether a neural component exists.
Structural differentiation is still performed, however, it takes a modified form.
Modified Structural Differentiation

Differentiating tension movement is performed prior to the application of any
other test movements. The rest of the level 1 test is performed so that, at the
first onset of symptoms, the differentiating movement can be released to produce
a reduction in symptoms. This is instead of performing a differentiating
movement that increases tension at the end of the neurodynamic test and so
prevents further provocation of symptoms.
Structural differentiation becomes the ‘off switch’.

"
Clinical Example: irritable lumbar nerve root
‣ ankle dorsiflexion first

‣ slow and gentle SLR to first onset of mild symptoms
‣ release dorsiflexion to differentiate
‣ structural differentiation (dorsiflexion becomes the off-switch 

Level 2 - Standard
Description
Standard tests are used
Interface, neural and innervated tissues are tested/treated separately
Neurodynamic tests are performed to a comfortable production of symptoms
only.
May be, but not necessarily, taken to end range.
Indications
The problem is not particularly irritable
Neurological symptoms are absent, or are only a minor part of the condition, and
these neurological symptoms are not easily provoked
The problem is reasonably stable and is certainly not deteriorating rapidly
The pain is not severe at the time of examination, neither is there severe latency in
terms of symptom provocation.
Method
The nervous system is effectively put through all its normal paces, but without
combining neural tests with musculoskeletal ones. The test movements should
not evoke excessive pain, neurological symptoms or go into a great deal of
resistance.
Standard neurodynamic tests are used
Neural and musculoskeletal structures are examined separately
Movement into some symptoms is acceptable, as long as they are not severe
and settle down immediately after the test
A degree of resistance may be encountered, however, it should not be strong
Full range of movement may be reached but this is not essential.

Level 3 – Advanced
General Description
Testing of the nervous system is more extensive than the previous levels.
Specificity and sensitivity are the focus and this is based heavily on the
neuropathodynamic mechanisms.
Neural structures can be tested in relation to the musculoskeletal tissues - more
sensitive.
Indications
Level 2 (standard) examination tests are normal, or do not reveal sufficient useful
information, and the clinician wishes to investigate the problem more extensively
The problem is stable
When the patient’s clinical pain is difficult to evoke
When there is no evidence of pathology that might adversely affect the nervous
system
No neurological abnormalities eg. loss of conduction are present
High expectations in physical function.
In any patient from whom sufficient information has been gained by the execution
of a level 1 or 2 examination, the level 3 examination is unnecessary and
contraindicated.
Level/type 3a. Neurodynamically Sensitised
Definition
More neural tension is added to the standard neurodynamic test through the
addition of sensitising movements.
Standard test but “more-of-the-same’ technique”
‣ lumbar contralateral lateral flexion

‣ hip internal rotation/adduction
Method
The level 2 examination is performed prior to executing one at level 3. This is to
be sure that the nervous system can cope with such testing.
Only the sensitizing movements of the standard neurodynamic test are added to
the standard test.

Level/type 3b. Neurodynamic Sequencing (Localised)
Description
Local sequence - movements start locally and become progressively more
remote.
A particular part of the nervous system is emphasized.
Level/type 3c. Multistructural
Description
Neural structures are tested in combination with tests for musculoskeletal
structures.
Generally used in the person with high expectations in terms of human function in
which minor mechanical problems will provoke symptoms more easily than in
patients whose needs are less extensive.
Often athletes, sports people and persons who work in occupational settings
where high demands are a feature of their activities.
Method
Many movements and structures can be used.
Interface, neural and innervated tissues can be moved at the same time eg.
opener and neural, with some innervated tissues testing also.
Neurodynamic sequencing is modified to suit the patient’s specific

pathodynamics.

Section 7
Neuropathodynamics
DIAGNOSTIC CATEGORIES
Audiovisual presentation
Opening and closing dysfunctions

Neural tension dysfunction
Combined dysfunctions - level/type 3c
1
Neuropathodynamics
DIAGNOSTIC CATEGORIES
2
Aims
Present some new diagnostic categories for

mechanical diagnosis and treatment
Link neural system to the musculoskeletal

system
Base the classifications on causal

mechanisms
Mechanisms will interact and coexist
3
Types of Dysfunction
1. Mechanical interface
1
2. Neural
2
3. Innervated tissue
4
Mechanical Interface
Reduced Closing Dysfunction Definition
When the mechanical interface lacks appropriate

movement in the closing direction
Often due to increased pressure on the nervous

system and often houses a space-occupying
element eg. disc bulge, swollen joint, tendons
etc.
Always suspect pathology.

5
Reduced Closing Dysfunction
Clinical Features
Severe cases - contralateral shift

reduced closing eg. extension or ipsilateral
lateral flexion
symptom production or reproduction on
closing
opening movements ease eg. flexion or
contralateral lateral flexion
6
Reduced Opening Dysfunction
Hypomobile/stiff in opening eg. contralateral

lateral flexion
Severe cases - ipsilateral shift
Production or reproduction of symptoms
with opening movement eg. contralateral
lateral flexion
Neural tension signs common (ie. often
coexists with neural tension dysfunction).
7
Neural Tension Dysfunction
Clinical Features
TENSION
MOVEMENTS
Increase
ABNORMAL symptoms
TEST
RESPONSE
Overt TENSION
Covert RELEASE
Decreases
symptoms
8
Neural Tension Dysfunction (cont.)
9
Neural Sliding Dysfunction
Clinical Features
ABNORMAL SLIDING
TEST MOVEMENTS
RESPONSE Increase
symptoms
Overt
Covert
10
Key Features
Tension movement sometimes relieve the

pain
neck flexion in slump produces back pain
knee extension decreases the pain
11
Cephalad (upward) Sliding
Dysfunction
Neck flexion
increases
symptoms
Knee flexion
increases
symptoms
12
Caudad (downward) Sliding
Dysfunction
Neck extension
Knee extension
13
Context for Sliding Dysfunctions
Sliding dysfunctions are rare but they do happen

1. Consistent responses to physical testing
2. Localising signs
3. History of pathological process in the region
trauma, inflammation, degeneration
4. Radiological evidence of pathology in the interface
Not as likely in patients with erratic physical signs and
central and psychosocial mechanisms.
14
Pathoanatomical Dysfunction
Definition
When disturbance of nervous system function is
caused by pathology in the nervous system
Examples:
Neurapraxia, axonotmesis, neurotmesis
(Seddon, Sunderland)
Arachnoiditis, tumours (Schwannoma),

neuromas, amyotrophy
15
16
Pathophysiological Dysfunction
Definition
When an aspect of the physiology of

the nervous system is abnormal
Intraneural blood flow - elevated

pressure and the tourniquet effect
17
Pressure - tourniquet effect
18
Impaired Pressure Gradients
P artery > p capillaries > P veins > P fascicle > P TUNNEL

OR FORAMEN
Blood can get in but it can’t get out.

Congestion with venous blood
Swelling/oedema in the nerve
Hypoxia
Scar tissue
Further mechanical dysfunction
Pain, pins and needles, numbness, weakness
19
Links Between Pathomechanics and
Pathophysiology
Reduced movement of lumbar nerve roots

correlates with:
Reduced intraradicular blood flow
Scar tissue
Symptom production at the same ROM as the
reduction in blood flow occurred
Sciatica patients
Correction reversed all these changes
Kobayashi et al (see NDS web site/resources/
scientific)
20
Mechanical Irritation
Mechanical Nociceptor Activation of nervi

Irritation Activation vasa nervorum
Release of neuropeptides (SP,

Blood vessel dilation
CGRP)
Neuritis + Mechanosensitivity
21
Mechanosensitivity
Overview
Mechanosensitivity is how nerves hurt with
movement.
Definition
How easily impulses are activated from a site in
the nervous system where mechanical force is
applied.
22
23
24
Mechanosensitive Axons
Sympathetic
Motor
Proprioceptive
Nociceptive
25
Nerves are
mechanosensitive when
given enough force
26
Normal nerves hurt if you
pull or push hard enough
on them
27
Full neurodynamic tests pull
hard enough to produce a
symptom response.
Mechanism?
- ischaemia
- stretch/nociceptive receptors
28
STRUCTURAL KIND OF KIND OF RELEVANT? CAUSE? 
DIFFERENTIATION? RESPONSE? ABNORMAL
RESPONSE?
Musculoskeletal Normal
no change in
symptoms Whole
evaluation
Neurodynamic Normal NO - sinister
symptoms change Does not - muscle
match - disc
ABNORMAL OVERT problem
Reprod. - joint
-
neuropathy
COVERT  - neuritis
No reprod. YES
Matches - interface
problem - tension
- sliding
Section 8
Treatment Method
Lecture
Working through a system of techniques

Section 8 Treatment Method "2
Treatment - working through a system

of techniques
Note that the system of levels and types of examination applies to treatment in
the same way that it does to examination.
SUMMARY OF TECHNIQUE PROGRESSION
Disc Function
- behaviour of the nucleus, annulus and foramen are different. This has
implications for the nerve root.
As the segment extends, the nucleus

moves forward but the annulus moves
backward. This is because
compression at the back of the disc
displaces annulus out of the area.
Also, the approximation of the
posterior vertebral surface loosens the
annlus which bulges backward.
The opposite occurs in flexion.
This is in the case of normal,

degnerated and protruding discs.

Lumbar disc protrusion in standing, flexion/extension - annulus bulges more in

extension and less in flexion. RivistuIi Net!ft)ruIit
lognr 15:3.3.3-356.2002
78 J.R. Jinkitt.rturd J. Dlnl'rtrkit
Figure5 C) U priSht-exlension -f2

midlincsagittal wcighledIas(spincchoMR | (kMRI)rcvcalssevereworseningofthecenlrtlspinal
c a n a l s t e n o si ni st h e l o w e rl u m b a ra r e a( a r r o w sL: ' l - L 5 . L 5 S l ) . T h i s r e s u l l s f r o m a c o m b i n { l i o n o f f a c l o r s . i n c l u d i ; e r e d u n d a n c v o f t h e
I h e c asl a ca n d s p i n alli g a m c n las n d i n c r e a s i rpuo s t e r i opr r o l f u s i o nosf t h c i n t e r \ c r t . b r i ldl i \ c \ . r tL l - i i | n L i L 5 S l . D ) U p r i g h t - f l e x i o n
midlinesag.illalf2-weightedfitstspinccho MRI (kMRI) demonstrates completereduclionof lhc posrcriordiscprotrusiiniar the L.l-
5 and L5_Sllcvels.lnd resolutionof the ccnlralspinalcanalslcnosisa1thcselurnbarscqnrcnts (c;parc with Cj. Also note that there
is nlinor anierolislhesis at Ihe L2-3and L:l 5 levelsascomparedto the neutralcxaminali()ns (A.B). indicatingrssociatcdmild transla-
tional interscqmcnlal hypertnobileinstabilityal thcscIcvels.
tive (i.e..hypermobility)or negative(i.e..hypomo- Tablc tl Tvpesof upright postural spinal curvature

bility) effectsupon intersegmentalmotion^.o..
. Normal curvature
Also noted at levelsof disc degenerationwas a Cervical:lordotic
sagittalplane hypermobile"rocking" of the verte- - l horacic:kyphotic
brae in relationshipto each other (figurcs 4.6),'". - Lumbar: lordotic
Observation of the opposed adjacent vertebral
endplatesin such casesshowed them to move in Exaggeratedcurvature
relationshipto each other to a much greatcr de- - Hvperlordosis
- Hyperkyphosis
'l'able
7 Translationalhvpelmobile instabilit.l of the spinal cot-
. Lossof sagittalspinalcurvature
(straightspine)
L i ganten top ath i c alter ations'. - Hl,polordosis
ligamentousstretching/rupture - Hvpokvphosis
Mobile translationalantero-and retrolisthesis

. Coronal plane scoliosis
(X-plane)
(directionof convexcurve)
- Mobilc latero- and roblisthesis(Z and Y-planes) - Leftward:levoscoliosis
- Rightward:dextroscoliosis
Dynamic overextensionof spinalrange(s)ofmotion
(X. Y. Z planes) - Serpentine:serpentinescoliosis
Figure4. Worsening-reducing spinal stenosis.(a) Recumbenrmidline sagirtalT2-weighredfasrspin echo MRI (rMRI) showsmild.
generalizedspondylosisand minor narrowingof the centralspinalcanal inferiorly.(b) Uprightneulral midline sagillalT2-weighted
Jinkins et al (2002a, 2002b), Alexander et al 2007

laslspin echo MRI (pMRl) showsmild worseningof the centralspinalcanalstenosisinferiorly.Note the assumptionby the patientof
the true postufalsagitlalcurvNture 343
of the lumbosacralspineas comparedro the recumbentexamination.(c) Uprighl extensionmidline
sasiltalT2_weighted last_spinechoMRI (kMRI) revealssevereworseningof the centralspinalcanalin thc lower lumbararea(L4-L5.
L5lSl) (d) UpriSht-flexionnridlinesagittalT2-weighledfasGspinecho MRI (kMRI) demonsrrares complerereduqion of lhe cenrrat
Annulus compresses nerve root during extension.

spinalcanalslenosisat evervlumbarlevel.
4. DISCUSSION well as complex kinetic maneuvers.or kMRI. The

presentMRI unit was intendedto addressthesecon-
ConyentionalrecumbentMRI, or rMRI, is obviously siderations,Both occult weight-bearingdisease(e.g.
inadequatetheoretically tbr a complete evaluationof fbcal intervertebral
disc herniations.spinalstenosis),
the spinal column. The human condition includes and kinetic-dependentdisease(e.g.disc herniations,
both weight-bearing body positioning, or pMRI, as spinalstenosis.hypermobileinstability)of a degen-
Foramen dynamics
with opening and
closing.
Schmid et al 1999 

"
General Principles
Observe symptoms at all times - before, during and after treatment
Reassess symptoms and physical signs - particularly neurodynamic status
immediately after treatment, unless there is reason not to, such as to avoid
provocation or undue focus on the problem. This includes neurological
examination when appropriate.
Classify the dysfunction

Base treatment on the dysfunction category and level/type of examination
Avoid the words ‘stretch’ and ‘tension’ - I say ”this technique is designed to
improve the function of the nerve”
Respect resistance - low, medium or high
Be extremely sensitive - because this forms the basis for close analysis between
you and the patient so that treatment can be responsive and derived from the
patient’s response.
Speed - slow and gentle
Amplitude - generally the movement should come back to the inner range each
time so the mobilisations are usually medium to large in amplitude
Dosage/Repetitions - perform several movements then reassess symptoms at
rest or some physical sign that is not irritated with reassessment. this may be
performed up to several times in one treatment session, as long as there is some
value in the technique.

Sometimes, at higher levels (2 and 3) treatment can evoke (or elicit) symptoms
- but it should not provoke them. There is a difference. I use provoke to
designate a more severe and long lasting response. Evoke suggests that
symptoms have been triggered but more on an instantaneous basis rather than
the response being long lasting.
Slider Techniques
Produce:
‣ a lot of neural movement without producing much tension
‣ hypoalgesic effects (more than tensioners)
Can be used:
‣ level 1 tension dysfunction
‣ to reduce possibility of treatment soreness and settle symptoms down with
advanced treatments

Section 9
Clinical Application
Low back and radicular pain - specific dysfunctions
Piriformis syndrome
Hamstrings
Heel pain and tibial nerve

Section 9 Clinical Application - low back and radicular pain "2
Low Back and Radicular Pain
Treatment progressions
Mechanical interface - reduced closing dysfunction

The techniques below are particularly suited to patients with significant distal
symptoms that involve pain, pins and needles or loss of sensation.
Indications
Predominantly distal symptoms - particularly pins and needles, numbness and
weakness, neurological signs
Persistent/ continuous distal symptoms
Not as common to use these techniques with acute /severe low back pain
without referral of symptoms into the lower limb
Distal symptoms provoked by closing movements - extension, ipsilateral lateral
flexion
Reduced ROM of closing movements
Key aspect - MUST do a neurological examination before and after each
treatment.
Treatment is directed at reducing the pathophysiology in the nerve root rather
than the mechanical dysfunction. this is because to treat the mechanical
dysfunction (ie. closing) would be to risk provoking the nerve root.
"

Level 1 - Limited
1. Static Opener
Position - painful side uppermost with a bolster under the lower side.
Progression 1a. Towel between ilium and trochanter
Progression 1b - One leg over the side
Place in open position - painful side up, legs flexed to 90°, one foot placed over
the side of the couch.
If this increases symptoms return foot to couch and place a bolster under waist
instead.
Do not mobilise.
Degree of opening - depends on response to positioning
Duration - 30-60 seconds at first. If better, repeat several times. If the same, still
repeat once more and reassess at the next session.
Monitor symptoms at rest and, if they improve, offer this position as a pain relief
strategy.
Either leg can be lowered, depending which is

more effective in achieving lateral flexion and
what is more comfortable for the patient.
Progression 1c - both legs over the side
Position - as above, two feet placed over the

side of the couch. Dosage same as in
progression 1.
Dosage - up to several minutes at a time, hourly.
Good gains can be achieved by doing this
manoeuvre several times per day.

Progression 1d - manual opening to maximize.
2. Dynamic Opener/mobilisation (Level 1 continued)
Passive opener - contralateral lateral flexion
Can be done as small or large amplitude, in the

inner or outer range.
Can be performed as a home also
Level 2 - Standard
Indications and Clinical Features
At this point, there is little to be found on neurological examination.
The distal symptoms are not easily provoked and are now intermittent or absent.
Neurodynamic testing shows minor signs (overt abnormal response (OAR) and
covert abnormal response (CAR) late in range).
The interface dysfunctions are still present (reduced closing).
Now the treatment changes from treating pathophysiology in the nerve root to
treating the mechanical dysfunction in the interface.
Dynamic Closer
Closer mobilisation – inner, middle and outer range
Position - start mobilisation in open position and

gently move toward closed position
Mobilisation - in the direction of closing but only

to the point of first symptoms and the
mobilisation is less than this range.
Perform slowly and carefully and with respect to

the patient’s symptoms and physical responses, especially resistance and
protective responses. 

Dosage - 5-6 gentle movements then reassess.

if there is an improvement, repeat several more
movements. If the same after mobilisations,
repeat sets of mobilisations, stop and reassess
at next session.
This can be progressed by positioning the patient into ipsilateral rotation, less hip/
lumbopelvic flexion and even into some extension but care must be exercised.
Neural Tension Dysfunction
Clinical Features
‣ SLR painful +/- PNF painful in severe cases

‣ Slump - NF painful - knee extension +/- dorsiflexion painful

The MORE and LESS are with respect to TENSION in the treated nerve
root.
Contralateral and ipsilateral - THE LIMB that is used to produce the

tension changes.
The following are pictures of the movement progressions but they are performed
manually by the therapis
Moving Through the Progressions

It may not always be necessary to pass through each progression because they
provide small increments. It is therefore possible in many patients to jump a
progression or two. However, this should always be done carefully with respect
to the patient’s signs and symptoms and sufficient time should be allowed
between treatments so that accurate observation of patient responses can be
achieved.
LEVEL 1 - Progression 1 - Position LESS - Position LESS (tension)

ipsilateral limb - contralateral limb
Generic off-loader for the median nerve (applies to whole upper quarter
Contralateral limb - hip flexed approximately 90˚ if possible 

- contralateral knee extension 
- hold for approx. 15 secs, longer if comfortable and safe (no problems in the
contralateral limb - pins and needles or other symptoms)
Ipsilateral limb Contralateral limb
"
R
* " *

Progression 2 - Position LESS - Move LESS (tension)

ipsilateral limb * - contralateral limb
As above (1) except the knee is extended and flexed

Perform approx. 5-10 times. This set can be repeated up to 3-5 more times.
Progression 3 - Position MORE - move LESS (tension) - knee flexion/ext.

ipsilateral limb * - contralateral limb
Ipsilateral lower limb in neutral Ipsilateral dorsiflexion
L L
R
R
"
* "
*
Add ipsilateral SLR Move LESS - contralateral knee
*
* *
"
More SLR Move LESS - contralateral knee
* *
"

Progression 4 - Position LESS - move MORE (tension)

contralateral limb - ipsilateral limb *
Sitting
* *
" "
Position LESS Move MORE

- contralateral knee extension - ipsilateral knee extension
- protects nerve root - dorsiflexion optional
" - dorsiflexion optional "

OPTIONS:
‣ ipsilateral dorsiflexion
‣ neck flexion
Progression 5 - Position MORE - Move MORE (tension)

contralateral limb - ipsilateral limb *
From this:
This was the progression 4 starting position.
Now the protection from the contralateral knee

is removed (remove the contralateral knee
* extension).

To this:
Position MORE Move MORE - ipsilateral knee extension
* *
" "
Add cervical flexion Move MORE - ipsilateral knee extension
* *
" "
WHAT IS THIS?
Option - add dorsiflexion
This is now level 2, the standard slump test.
You now have a wide variety of techniques below level two that are not likely to
provoke symptoms.
Level/type 3a - Position MORE - move MORE (to tension)

Contralateral lateral flexion Ipsilateral knee extension
* *
" "

HERE IS THE PROCEDURE FOR SAFER MORE ADVANCED TECHNIQUE
1. Test neurological function. If abnormal, this technique at level 3a is not

recommended.
2. Position the patient comfortably.
3. Ask if the patient has any symptoms at rest. If “Yes”, do NOT proceed. The
problem may not be at level 3.
4. Explain that symptoms may occur and, if they do, they must only be mild at
most. Generally reproduction of the patient’s clinical symptoms is to be avoided.
Stretching sensations are common.
5. Perform a test movement to the first onset of symptoms.
5.1. make sure the patient moves slowly and carefully and that they learn to
stop at the right place.
5.2. return to the starting position and check that any symptoms disappear
instantly. If not, wait until they do. If they take more than a few seconds,
it may be better to do something more gentle.
6. If this goes according to plan:
6.1. perform 3-5 movements the same way, making sure that the symptoms
stop between movements.
6.2. return to the start position for at least a second or two each time a
movement is performed.
7. Do NOT stay in the end range position for more than about one second.
8. Test the neurological status to be sure that it has not deteriorated. If a

deterioration occurs, the technique is contraindicated.
Position - as for slump test
" "
Movement - cervical, thoracic, lumbar flexion, contralateral lateral flexion, knee

extension,, dorsiflexion.
Make sure the amplitude is large so you retreat from the symptomatic position
each time.

Level/type 3c. Advanced - reduced closing with neural tension dysfunction
"
Patient position - painful side up
Mobilisation - closing (ipsilateral lateral flexion) + neck flexion and knee extension
(ie. two-ended tensioner)
This one often needs practice so the patients gets the movements right.
Starting position Closer with knee extension/neck flexion
" "

Mechanical Interface - reduced opening dysfunction

Level 1 to Level 2
Position - leaning over the patient with both hands around the pelvis.
Mobilisation - as an opener from the slightly closed position to the slightly
opened position.
Should not provoke pain.
"
This is effectively the opening mobilisation shown earlier except that a sustained
opener is not performed for reasons of provocation.
The same as the dynamic opener for the closing dysfunction, but for different
reasons.

Level 3c. Multistructural - reduced opening with

neural tension dysfunction - dynamic opener
"
Dynamic opener + one-ended or two ended tensioner

Optional - neck flexion or not, depending on the desired progression.
It is normally positioned. Active neck flexion makes the patients stabilize their
pelvis which reduces the opening, not desirable.
This is used when there is:
‣ less risk of provocation

‣ a tension dysfunction with reduced opening - quite common 

! !
! !
Distal/Caudal (downward) Sliding Dysfunction
Clinical Features
‣ SLR painful - neck flexion OK or eases

‣ Slump - release neck flexion painful

Progression 1 position LESS (up/cephalic) - position LESS (up/cephalic)

Same as in progression 2 except the neck is positioned in the flexion for a rest
position to ease pain.
Progression 2 - position LESS (up/cephalic) - move LESS (up/cephalic)

Aim - to move the neural tissues away from the provoking direction and to do so
with little neural tension.
Position - reduced tension (off-loaded) position
• painful side up, neutral spinal position in the sagittal and frontal planes
• approximately 45° of bilateral hip flexion, 45° of bilateral knee flexion
Movement - gentle passive neck flexion
Symptoms are not evoked
Observe symptoms as you would in all other

progressions.

Progression 3 - position MORE (down/caudal) -move LESS (up/cephalic)
Position - same as above, add a small amount of ipsilateral knee extension prior
to the mobilisation. This position should not evoke or reproduce any symptoms.
Movement - passive neck flexion again (position
This does not take the system to its end point of

sliding, nor does it produce symptoms.
Progression 4 - position LESS (up/cephalic) - move MORE (down/caudal)

Position - painful side up, neck in flexion (to bring the neural tissues into a
cephalad position in the canal - position away).
Movement - straight leg raise (move IN to dysfunction - down/caudad).
Some symptoms may be evoked but they

should be mild and should cease immediately
after the technique. However, if this mobilisation
is provocative, it may be modified, as in the
following:
You can then go further into SLR as a

progression or add dorsiflexion if you wish.
Progression 5
This progression permits more caudal (downward) positioning (position IN - move
IN = position down/caudal - move down /caudal).
5.1 As progression 4 position cervical spine in neutral then extension (down/

caudad). Move the SLR for (downward/caudad) movement of the nerve roots.

5.2 Position - sitting across the plinth as if for

the slump test, neck and thoracic spine straight
Movements - cervical and thoracic extension

with knee extension.
To progress - add dorsiflexion.
Ipsilateral lateral flexion can be added for more effect
Understanding Sliders
Uses
‣ easing pain in the low level tension dysfunction
‣ easing pain or soreness from treatment
‣ promote movement
‣ muscle relaxation.
Mechanical Effects
‣ maximal sliding with minimal tensile forces inside the nerves
‣ may maintain or improve sliding mechanism, eg. prevention of adhesion or loss
of movement in the case of surgery, trauma with bruising or bleeding from
adjacent structures.
Physiological Effects
‣ may improve blood flow of nerve
‣ sliders produce greater hypoalgesic effects than tensioners.
Care with Sliders

‣ general slider for the tension dysfunction is a high progression for the siding
dysfunction so:
‣ if there is a sliding dysfunction, use the slider progressions provided
above.
‣ If sliders increase pain, you may be treating an actual sliding
dysfunction at a high progression for what you though was a tension
dysfunction.

Section 9 Clinical Application - piriformis " 18
Piriformis Syndrome
You can use plantarflexion/inversion or dorsiflexion with these techniques
because of the relationship the peroneal nerve has with the sciatic nerve in the
pelvis and with piriformis. Sometimes the peroneal component can feature in the
patient’s symptomatology.
Level 1
Progression 1 - Static opener
Hip position - slight flexion, abduction, external rotation
Knee position - slight flexion

Ankle position - neutral
Can do this in side lying or supine lying
Progression 2- Dynamic opener
Passive external rotation - slow speed and large amplitude

This is for pain relief and can be performed as a home exercise
Level 2
Progression 1 - interface (muscle) release technique
Passive stretch of piriformis to be performed by therapist then as a home

exercise by the patient. Even though this will produce closing during the
technique, it will subsequently produce an opening effect as the muscle releases.
This can be combined with contract/relax techniques.
Piriformis stretch - external rotation is IMPORTANT!
"

Neural
Level 1
1. Off-loader for Sciatic Nerve and Piriformis
‣ hip flexion below 70,˚abduction/

external rotation
‣ knee flexion
‣ foot comfortable
‣ can do this in supine also
General Point About Peroneal and Tibial Components
With all these following techniques, you can emphasize one part of the nerve in
some people by using:
‣ plantarflexion/inversion -peroneal (fibular) nerve
"
‣ dorsiflexion - tibial nerve
"

2. Taking up the slack in the nerve - expected. ROM
"
3. Slider for the nerve (one-ended) - expected ROM
" "
Option - place neck in extension to facilitate distal movement
"
Level 2
4. Tensioner for the nerve (one-ended) - expected ROM
" "

Option - add neck flexion to increase tension
Then you could progress to the standard slump test as the treatment with knee
extension as the mobilisation.
Level/type 3c
Piriformis Slump Test

In the slump position, perform the following movements in the following order:
‣ hip adduction
‣ passive external rotation (stretches piriformis onto the sciatic nerve)
‣ knee extension
‣ check response - reproduction of symptoms etc
‣ differentiate if need to with foot (PFI or DF) and neck movements
‣ sometimes the neural and interface components can be distinguished
‣ release external rotation
- increase pain -> neural, decrease pain -> muscle
Piriformis slump test.
You can use dorsiflexion or

plantarflexion/inversion to differentiate
the two components of the sciatic
nerve - tibial and fibular (peroneal).

Hamstrings and the Sciatic Nerve

Turl and George (1998) found that 57% of repetitive hamstring patients had an
abnormal slump test between episodes (Rugby players).
Kornberg and Lew (1989) found that, during an episode, 76% had abnormal slump
test. Both used the overt abnormal response category.
Level 1
Two-ended Sliders
Patients often can’t stretch their hamstrings
Distal Slider
Pillow under knee
So the hamstrings and ischial tuberosity stay

stable, be careful NOT to move the hips
Movements - ipsilateral lateral flexion/dorsiflexion
Proximal Slider
Contralateral lateral flexion/plantarflexion.
This produces very little movement of the

hamstrings.

Next: In long sitting with the knee remaining stable, you can do the following:
Hip flexion - plantarflexion
Hip extension - dorsiflexion
This will start to produce movement in the hamstrings.
Level 2
Progress to the standard slump test using knee extension and neck flexion.
Level 3
Muscle and Nerve
In: slump test position
Do: contract relax technique to the hamstrings and as they relax you can release
the muscle.
Dorsiflexion is an option.
Manual Treatment of the Hamstrings and Sciatic Nerve

Combined Techniques
Manual techniques eg. connective tissue

massage, deep frictions
Neural mobilisation - active dorsiflexion

Section 9 Clinical Application - foot " 23
Heel Pain
Alias - plantar fasci-itis/opathy, posterior tarsal tunnel syndrome
Level 1
Progression 1 - static opener
Ankle position - plantar flexion/inversion, adduction and pronation of the forefoot

on the hindfoot.
Nerve component - use generic off-loading positions as for releasing tension
along the whole tract.
Progression 2- dynamic opener
‣ Passive plantarflexion/inversion of ankle

‣ Adduction/pronation of forefoot on hindfoot
‣ Technique is important here.
‣ Do it in a plane that both opens the interface and reduces tension in the
tibial nerve
Palpatory techniques for the interface and nerve - you can use your hands to
massage the tunnel and nerve proximally to reduce local congestion.
Level 2
Progression 1 - closers
Dorsiflexion/eversion/abduction/supination - gentle because it is a closer -

monitor symptoms afterwards, as usual.
Neural - tibial nerve at the ankle

Level 1
Progression 1 - off-loader as a position
Sciatic nerve generic off-loader - rest foot in neutral or open position

Section 9 Clinical Application - foot " 24
Progression 2 - two-ended slider
Toe flexion + SLR, hold the ankle still, you can do this in sitting with the patient
leaning forward of backwards or passively as an SLR.
Starting position
PROXIMAL SLIDER – knee extension/toe flexion
DISTAL SLIDER
Hip and knee flexion/toe dorsiflexion
Level 2 - tensioner
Progression 1 - tensioner/slider relative to the tendons
Ankle/toe dorsiflexion with SLR/knee extension
Level/type 3c. Multistructural (interface + neural)

Closer moving the heel into abduction/eversion during a slider or tensioner.

Section 10 References 1"
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NEURODYNAMIC SOLUTIONS (NDS)

lower quarter course 2017-18

Section 1 - Introduction to NDS and aims

Section 3 - Nerve palpation

Section 4 - Standard neurodynamic tests

Section 5 - Diagnosis with neurodynamic tests

Section 7 - Diagnostic categories - neuropathodynamics

Section 9 - Clinical application - treatment progressions

© 2017-18 NDS Neurodynamic Solutions !

About Neurodynamic Solutions (NDS)

Course Manual (8th edition)

No part of this publication may be reproduced, stored in a retrieval system, or transmitted

All illustrations, except where acknowledged otherwise, are copyrighted to Elsevier

NEURODYNAMIC SOLUTIONS (NDS) COURSES

Courses in clinical neurodynamics as

© 2017-18 NDS Neurodynamic Solutions !

About Michael Shacklock

Michael Shacklock graduated as a physiotherapist from the Auckland School of Health

© 2017-18 NDS Neurodynamic Solutions !

Collaboration Between Michael Shacklock and University of Eastern

This opens the door for more research on lumbar

Clinical Neurodynamics Book

In this internatioal best-seller, Michael demystifies how

© 2017-18 NDS Neurodynamic Solutions !

NDS Lower Quarter Course Aims

to the nervous system in the lower quarter

• abilities in diagnosis and interpretation of lower quarter neurodynamic testing

• clinician’s repertoire of diagnosis and treatment of techniques

• safety in relation to clinical neurodynamics

Participants are under no obligation to have a manoeuvre performed on them and

© 2017-18 NDS Neurodynamic Solutions !

Providing practical solutions for clinical therapists

Makes us think of tightness in nervous system

Many other aspects were being omitted:

Challenge the word ‘tension’

Must link mechanics and physiology and function

Clinical Neurodynamics Definition - clinical

Safer - less stretching of nerves

Links diagnosis and treatment to causal

Integrates neural aspects with the musculoskeletal

Principles of clinical neurodynamics that apply to

the whole body no matter what region. They are

therefore general or universal principles.

Sliding - transverse Transverse

Transverse sliding prevents

Similar events occur with

1. Move the joint

away from the

2. Move the Innervated tissues

© Neurodynamic Solutions (NDS)

When the therapist moves the neural structures in

The nervous system is emphasized.

Offers us structural diﬀerentiation

Release neck flexion (RNF) for lumbar symptoms

Type of neural effects during neurodynamic

Early in movement - just apply small force to

Mid range - produce sliding

End range - apply tension

to the point where tension

The nerves slide toward the site where force

more symptoms at the region that is moved

eg. foot - peroneal nerve (Shacklock 1989)

upper limb (Zorn, Shacklock & Trott 1995)