Feature Article - The Sporting Nerve
(Part Two - Lower Quarter)

Introduction: One of the more important aspects of management of patients at a high level of function is to increase the sensitivity of the manual treatment technique so that small or hidden problems do not pass untreated. In this capacity, neurodynamic testing is no exception. A key objective therefore is to modify the technique so that it becomes as specific as possible to the patient's problem.

1. Increasing the intensity of the force on the nervous system (not always recommended)
2. Increasing the specificity with which forces are applied, ie. the focus of forces. A key benefit of this is that it helps to reduce extraneous and potentially harmful effects.
3. Deliberately reproducing the causal mechanisms in the patient, which naturally 'taps into' the effects that produce the patient's problem. For instance, if two dysfunctions exist, interface and neural, it may be ineffective to merely treat each dysfunction as a separate entity, whilst only observing the effect of treatment on the other components. Instead it may be more effective to produce movements or forces that produce changes in both dysfunctions simultaneously (eg. interface and neural).

A means of achieving the above goals is to apply the system of technique selection and performance created by Shacklock (2005). Built into this system is a way of linking the mechanisms that are established to occur in basic and clinical science research to clinical observations, thus forming part of a clinicoscientific approach to neurodynamics.

Indications for Sensitisation

1. The patient has a level 3 problem. For classification/stratification of patient problems, see Shacklock (2005, pp 104-116, see categorization system in figure below). However, briefly, the level 3 patient is one in whom there is little danger of provocation of symptoms, has little or no major pathology, no persistent or severe neurological symptoms or signs and moves well. These people are often dancers, athletes, sports people or persons in an occupational overuse setting. The KEY FEATURES are that the symptoms are intermittent, only occur with extensive activity or a highly specific movement pattern and are not at any stage severe.
2. For the level/type 3 technique to be justified, the following inclusion criteria are essential:
   1. neurodynamic testing at standard tests (level 2), does not reveal sufficient information
   2. it is safe to perform more extensive testing
   3. it is necessary to perform more extensive testing.

The reason that these three inclusion criteria are essential is that the level 3/type evaluation/treatment techniques apply significant force to the nervous system and are often a source of provocation.

In any patient from whom sufficient information has been obtained from a level 2 (standard tests) or level 1 (limited) evaluation, level 3 techniques are CONTRAINDICATED.

Evaluation / Treatment of the Level 3c Technique
Dysfunction Category.

Example — Reduced Closing and Neural Tension Dysfunction.

Technique for the right lumbar reduced closing dysfunction with distal sliding dysfunction. Closing technique (ipsilateral lateral flexion) with neural tensioner (neck flexion and SLR), performed with care and without an increase in symptoms.

1. Test each component separately ,eg. contralateral lateral flexion and slump and/or SLR. Try to detect small changes in each. If not enough information is obtained, it may be justifiable to proceed to level 3 testing.
2. Test/treat them together (eg. interface and nerve).
   1. Place in neurodynamic position
   2. Perform opening technique feel for stiffness, observe range of motion and symptom responses, classify as overt, covert or normal
   3. Perform the same test in more neural tension, including structural differentiation to establish whether the response is neurodynamic or musculoskeletal. No change in response may indicate musculoskeletal response. A change in response may indicate a neurodynamic mechanism. Does the impairment in opening change with the differentiation movement? No — possibly musculoskeletal, Yes — possibly neural relationship.
   4. Comparison with same technique on the other side. Significant differences may indicate abnormality. Remembering that it can be quite normal for the neural technique to affect the interface function. Therefore, again, significant asymmetry is a key aspect in diagnosis (see Figure above).

Treatment Techniques at Level/type 3c - Multistructural

Technique for simultaneous treatment of the neural tension and innervated tissue dysfunctions (eg. calf muscle). Clearly, the patient must perform some of the treatment but this is usually no problem because often these people are kinaesthetically aware and move well. Contraction is performed immediately prior to gastrocnemius stretch. The patient leans forward to execute the neural component of the treatment. Interface and Neural

Treatment at lower levels than level 3 often does not involve direct treatment of the neurodynamic signs, ie. with neural mobilisation. For instance, if there is a neural dysfunction, it is common to treat the interface an use the neurodynamics to assess progress. Hence treatment is indirect.

However, at level 3, direct treatment of the exact dysfunction in the same situation in which it manifests is common and is often recommended. This is due to the reduced likelihood of provocation and increased need to reproduce the patient's specific causal mechanisms.

Therefore, for a dysfunction at level 3 that involves both interface and neural dysfunctions, treatment to both components in the same technique is often performed.

In this situation, the technique is predominantly determined by the diagnostic category. So unlike in the picture above (reduced closing and tension dysfunctions), the reduced opening dysfunction with neural tension dysfunction would be treated with the opening technique and neural tensioner are performed simultaneously.

Neural and Innervated Tissue

An additional technique for a patient with calf pain who also has a mildly abnormal slump test and a reduced opening dysfunction would be to perform the opener for the spine, neural tensioner for the nerve root/sciatic nerve and stretch the calf in the same technique. By definition, this technique is again a level/type 3c and involves the interface, neural and innervated tissues. It is particularly useful for people with high levels of function and subtle muscle dysfunctions.