Chapter 16: Manual Therapy Techniques for Peripheral Nerve Injuries

Objectives

On completion of this chapter, the student/practitioner will be able to:

• Verbalize the concepts of manual therapy.

• Understand the basic techniques of neural mobilization.

• Describe key manual therapy techniques.

Key Words

• Manual therapy

• Neurodynamic tests

• Passive movement

Introduction

Manual therapy encompasses treatment interventions involving the application of skilled passive movement techniques. Several types of clinicians are trained in and apply manual therapy, including chiropractors, osteopaths, and physical therapists. There is moderate evidence that manual therapy, when included as part of a multimodal rehabilitation program, is effective in the management of many common musculoskeletal disorders.¹ In the past, manual therapy had mostly focused on interventions targeting joint articulations or soft tissue. Over the past 25 years, manual therapy techniques and systems have emerged that purport to assess and mobilize neural tissue directly.² Research in the form of high-quality clinical trials and observational studies investigating the effectiveness of manual therapy for peripheral nerve injuries has also emerged. As a result, clinicians frequently use manual therapy in the management of peripheral nerve injuries. This chapter begins with an overview of concepts related to manual therapy assessment and management directed toward neural tissue and peripheral nerve injuries. For each region, we focus on key manual therapy techniques, especially techniques supported by evidence from the peer-reviewed literature, for common peripheral nerve injuries. Several excellent texts written by experts and pioneers in the field of manual therapy related to neural tissue are available.^2–5 The reader is directed to these texts for further information and more detailed coverage of this topic.

Manual therapy for peripheral nerve injuries begins with the assessment and clinical examination of the patient. For patients with peripheral nerve injuries, the clinician should first perform standard orthopedic and neurological testing to assist with making the diagnosis. Specific to manual therapy, clinicians can examine the joint articulations and soft tissue structures surrounding the injured nerve, also known as the neural tissue interface or neural container. Manual therapy interventions can be directed to impairments of these interfacing tissues as one method of treatment for peripheral nerve injuries. Manual therapists can also attempt to palpate the nerve in question directly, when possible.^6,7 Nerves are not normally sensitive to mechanical pressure, and increased sensitivity can alert the clinician to an underlying disorder.

To help with the examination and diagnosis of peripheral nerve injuries, clinicians can use tests and positions that selectively apply tension to particular peripheral nerves based on anatomical and biomechanical principles. These tests have been referred to as neural tension tests and more recently as neurodynamic tests.² The term “neurodynamic” has been used to reflect that these tests are ...