STATION

1
Nerve Tension Tests
1. Passive Neck Flexion
Indication Pain suspected to be of spinal origin

Method 1. Supine without pillow

2. Standard position – arms by sides and legs together
3. Patient lifts head a little and then clinician takes over, passively flexing the neck in a ‘chin
on chest’ direction
4. Note symptom responses, ROM, resistance encountered through the movement

Normal Painless – just perhaps a pulling ay CT junction (joint/muscle)

response ** FPs: CT junction tightness (traps, levscap), cervical joint restrictions

Biomechanics • The effects are not limited to the cervical/upper thoracic area
• Cadaver experiments have shown tensions the lumbar area and part of the sciatic tract

Sensitizing If performed with the legs in the SLR position, more tension is developed

2. SLR (including ALL nerve bias)

Indication Not just to test low lumbar dis-cogenic problems or sciatica

Routine for all spinal and leg symptoms as it tests nervous system mechanics from the toes to
the brain

Method 1. Patient supine

2. Place one hand under the Achilles tendon and the other above the knee
3. Lift the leg perpendicular to the bed, slightly adducted and internally rotated, knee fully
extended
4. Note range, symptom response and encountered resistance
5. Compare limbs

Normal The normal range is between 80°-90°

response
o Initial 30°: straightening of internal neural sack (P = axonal damage)
o 30°-70°: dural sleeves and L4-S2 roots (sciatic nerve) are mechanically loaded
o After 70°: while the above structures undergo further tension, other structures also
become loaded; hamstrings, gluteus max, hip, lumbar and SI joints

Symptom areas in normal people are posterior thigh, posterior knee and posterior calf
(sciatic nerve distribution)

Biomechanics ∗ When a SLR test is done, the hamstring, lumbar spine, hip and SI joint, fascia and
nervous system move
∗ Pathology affecting any of these structures can lead to symptoms in this test

Sensitizing • Active neck flexion: make symptoms worse, decrease ROM

• Ankle dorsiflexion: biases to the tibial nerve / sural nerve
• Ankle plantar flexion/inversion: biases to the common peroneal/fibular nerve
3. Slump Test
Indication • Spinal symptoms
• History of symptoms that become worse getting into a car or kicking a ball

Method 1. Patient sits, knees together at table edge – patient’s hands are linked behind his back
2. Patient is asked to slump while the examiner holds the cervical spine in a neutral position
3. Patient bends chin to chest – Pressure applied here
4. Patient extends knee – Response assessed (then do other side)
5. Patient extends and dorsi-flex ankle – Response assessed
6. Neck flexion is eased – Response assessed

Normal • Almost always causes discomfort or even pain

response • Pain is often at: T8/9
• During knee extension: Pain behind the knee and hamstring area is common, restricting
full extension (Further ankle dorsiflexion is often restricted)

NOTES *If the tissues seem irritable, only parts of the slump test can be done
*The flexion component could place an unstable disc at risk

4. Prone knee bend (femoral, lateral femoral cutaneous, saphenous)

Indication • Knee, anterior thigh, hip and lumbar symptoms
• If the patient gives the clue that a similar position has been responsible for their symptoms
(eg. Kneeling in their job)

Method 1. Patient Prone, headpiece down (allows neck flexion)

2. Grasp patients lower leg: Plantar-flex the foot and flex the knee as far as possible toward
the gluts, then extend the hip
3. Hold the position for ~15sec (differentiates discomfort due to muscle stretch)

Sen: Extend Neck – assess if this relieves the discomfort in the anterior thigh

ROM, symptom response and resistance to movement noted (eg. Buttocks may lift or the
patient may try to rotate the hips – this could be due to problems in the muscle, fascia,
nervous system or due to the extension forced on the lumbar spine)

Normal Quadriceps pain or stretch (anterior thigh)

response

Positive test • U/L pain in the lumbar area, buttock or posterior thigh may indicate L2-3 nerve root lesion
• Pain in the anterior thigh indicated thigh quadriceps or sensitivity around the femoral nerve
(L2-4)

…….
BIASES ………

Femoral nerve 1. Side-lying (start with unaffected side up first) – Dr stabilize Pt
2. The patient’s bottom leg, trunk and neck held in slight flexion
3. The superior leg lifted, extended at the hip 15°, then flex knee
slowly until tension

Pain radiating down the anterior thigh indicates likely spinal and
femoral nerve involvement

Lateral femoral 1. Side-lying – same set up as femoral nerve bias

cutaneous nerve 2. Addition: Adduction of hip (mechanoloads lateral femoral more)

Test for meralgia paresthetica – compression of this nerve usually

occurs as it passes under the inguinal ligament

Presenting/indicating symptoms: Pain + paraesthesia anterior thigh

Associated with: Obesity, Pregnancy, tight clothes, scar tissue

Saphenous nerve Saphenous is a sensory cutaneous branch off the femoral nerve
(L3L4)
Entrapment can occur at the Adductor/Hunter’s canal (aponeurotic
canal in middle third of thigh), causing medial knee and leg pain after
prolonged walking or standing, and burning pain along the distribution
of the saphenous nerve

Method:
1. Prone
2. Hip Extension + Abduction
3. Knee Extension
4. Hip External Rotation
5. Ankle Dorsiflex + Evert

5. Upper Limb tension test – median, radial and ulnar biases

NOTE:
² Previous positions are maintained to apply the load
² Look for presence of the encountered resistance (reflexive muscle contraction)
² Look for the level of irritability (patient response)
² Avoid progressing beyond the end point of resistance which will exacerbate the symptoms

Median nerve bias *non-irritable disorder with full ROM

(ULNTT1)
Motor function: lateral flexors of wrist in the forearm, 2 lateral lumbricals in the
hand (flex MCP joints) + thenar eminence
Sensory function: lateral 3.5 fingers, lateral palmar surface, dorsum fingertips

Method
∗ Patient supine – Dr faces cephalad
∗ Hold patient’s hand in a pistol grip – forefinger across thumb to extend it
∗ A depression force is applied to the shoulder girdle, preventing elevation during
abduction

1. Arm Abducted 90°-110°

2. Shoulder Externally rotated
3. Forearm Supinated + Wrist and fingers extended
4. Elbow Extended slowly

Sensitising: Cervical lateral flexion to the C/L side

Mobilisation:
Head turn in lateral flexion without wrist extension à head turn to neutral with wrist
extension
 Indication:
• All symptoms in arm, head, neck and thoracic spine
• Should not be done in severe and irritable disorders

Normal response:
• A deep stretch or ache in the cubital fossa extending down the anterior and radial
aspects of the forearm and into the radial side of the hand
• Tingling in the first 3 fingers

Biomechanics:

• Every structure in the arm and may in the neck are moved
• The median nerve in particular is maximally tested
• All cords of the brachial plexus are loaded
• Elbow extension loads the radial and median nerves and slackens the ulnar

Radial nerve bias Motor function: Wrist and finger extension

(ULNTT2) Sensory function: superficial sensory branch to hand/fingers

Method:

∗ Patient slightly diagonally with scapula free of bed – Dr face caudally

∗ Depress shoulder (use leg to do this)

1. Abduct arm 10° so the arm is clear of the bed

2. Extend elbow and support with outer hand
3. Wrap fingers of your inner hand around patient’s hand
4. Internally rotate shoulder + pronate arm
5. Flex wrist and thumb, and ulnar deviate wrist (can abduct the arm more to
increase the effect on the radial nerve)

Sensitising: Cervical C/L lateral flexion

Mobilisation:

Wrist is flexed with head in neutral position à head C/L lateral flexed without wrist
flexion

Ulnar nerve bias Motor function: medial flexors of the wrist, hypothenar eminence, 3 and 4
(ULNTT3) lumbricals, interosseous muscles
Sensory function: medial forearm and the dorsal + anterior aspects of medial 1.5
fingers and associated palm

Method:

∗ Hold hand of patient palm to palm and wrap hand around 5th finger (pinky)
∗ Abduct patient shoulder (90˚)
∗ Keep patient’s shoulder down and put leg under arm for support

1. Pronate arm first

2. Extend wrist and 5th finger
3. Flex elbow (slowly) – ulna nerve is only one that runs posteriorly
4. Abduct and externally rotate shoulder – walk up table to abduct
5. Bring hand to head

Sensitising: cervical contralateral and lateral flexion

Mobilization:
Head C/L lateral flexed and release the pressure of the hand
6. Mobilizations (Upper and Lower limb)

Gliding Techniques (sliders): produce sliding movements

Tensile Loading Techniques: not stretches, and more aggressive than the slider techniques

Sliders Tensioners
• Tension at one end, none at the • Tether at both ends
other • Not a stretch
• Flossing • Small oscillations
• A lot of movement involved • Gentle engagement of resistance to
• Low force/aggression movement
• Acute injuries, post surgery • More aggressive
• Can evoke symptoms
Mental status
1. Level of Qualitative Test for Consciousness
consciousness Level Technique
Alertness ∗ Speak to the patient in a
normal tone of voice
∗ Alert patient will open eyes,
look at you and responds
fully and appropriately to
stimuli (arousal intact)
Lethargy Speak to patient in loud voice
e.g. call patients name loudly
Obtundation Shake patient gently till they
wake
Stupor Apply painful stimulus – pinch
tendon, roll pencil on nail bed
Coma Apply repeated painful stimuli
Quantitative Test for Consciousness (GLASGOW COMA SCALE (GCS)
Abnormal responses
Appears drowsy but opens eyes
and looks at you, responds to
questions then falls asleep
∗ Opens eyes and look at you,
responds slowly and
confused
∗ Alertness and interest in the
environment are decreased
∗ Wakes from sleep only after
painful stimuli
∗ Verbal response
slow/absent
∗ Lapses into unresponsive
state when painful stimuli
gone
∗ Minimal awareness of self or
the environment
∗ Remains un-aroused with
eyes closed
∗ No evident response to inner
need or external stimuli
 The GCS Quantifies the level of consciousness typically following a traumatic
injury to the brain – most frequently used to assess head injuries. Score ranges
from 15-3 è Score of >8 = unconscious patient, needs to be intubated

De-corticate posture Lesion to the cerebral hemisphere, internal capsule

or thalamus

De-cerebrate posture All limbs are extended and head with neck are
arched (serious damage to CNS)
è Lesion in the brainstem

If level of alertness is very impaired = brainstem damage (reticular formation)

and bilateral lesions of cerebral hemisphere and thalamus – Toxic or metabolic
factors can also impair arousal level

2. Attention and Attention Ask patient to spell “WORLD” then spell it backwards OR ask them
orientation to list all the months of the year backwards
• Testing for focal brain damage lesion in dementia and
encephalitis, and behavioural or mood disorders

Orientation Ask patient’s name, address, date and time

• Requires memory, cognition and attention

3. Memory Recent • Ask patient to recall 3 items or a brief story after a 5min delay
• Make sure the patient has understood the info by asking her
to repeat it immediately first

Remote • Ask patient about past events – that can be verified by

someone that knows about it too
• Difficulty in recalling information after ~5mins è damage to
the limbic system
à Usually have anterograde and retrograde amnesia
 Declarative Conscious recollection of facts and dates
(Retained in the bilateral medial temporal lobes and
diencephalon)

Non- Recollection of unconscious skills or habits

declarative
(implicit memory)

4. Language Spontaneous Ask a question to patient and check for their fluency, rate,
abundance and note any errors or invented words

Comprehension • Point to things and ask them to name it

• Ask the patient to point to a named object
• Give the patient a sentence and ask them to repeated it

Need to observe for:

1. Hesitancies in speech – e.g. Patient has aphasia from strokes
2. Monotone inflections – e.g. Depression, schizophrenia
3. Circumlocutions –Unable to identify an object, so they keep describing it
4. Paraphasia – Malformed words

∗ Broca’s Aphasia – Patient has difficulty expressing themselves but understands

speech from others
∗ Wernike’s Aphasia – Patient speaks in long sentences that make little sense and
include invented words

5. Gertsmann’s Acalculia (calculations) Simple addition, subtraction

syndrome
Right/Left confusion Identification of the right and left body parts

Finger Agnosia Name and identify each digit – Touch your right ear with
your left thumb
Agraphia Write name or a sentence

If all four are impaired in an otherwise intact person, this is called ‘Gertsmann’s
Syndrome’ – due to lesions in the dominant parietal lobe, in the angular gyrus

If all four are strongly out of proportion to other cognitive functions, it usually indicates
damage of the left (dominant) parietal lobe – but may indicate problems in the languae,
praxis, construction, logic, and abstraction functions