Skip to main content
Medicine LibreTexts

2.3: Neural Mobilization

  1. Last updated
  2. Save as PDF
  • Page ID
    59115

    • \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash {#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\)\(\newcommand{\AA}{\unicode[.8,0]{x212B}}\)

    Neural Mobilization: A Conceptual Framework

    Neural mobilization is a multidimensional treatment approach that has gained popularity because it is effective, and easy to implement. These maneuvers can be performed in a passive manner where a therapist guides the client through a movement pattern, it can also be carried out as part of a self-care program that clients perform on their own. Clinicians may be familiar with terms such as nerve gliding, nerve flossing, sliders and tensioners. These names describe similar approaches, and all these techniques fall under the umbrella of neural mobilization – a gentle form of manual therapy that aims to assess and address irritated peripheral nerves.

    Pathophysiology: Sensitivities of Axons Exposed to a Pathological Environment

    As peripheral nerves pass through the body they may be exposed to mechanical or chemical irritation at different anatomical points. Prolonged compression or fixation of a nerve may result in a reduction of intraneural blood flow (Bove et al., 2019). This then triggers the release of pro-inflammatory substances (calcitonin gene-related peptide and substance P) from the nerve. This by product is referred to as neurogenic inflammation and it can disrupt the normal function of nerves even without overt nerve damage, it can also contribute to the initiation and propagation of chronic pain (Matsuda et al., 2019).

    clipboard_e7f5625d9187f7c1a567024815040c939.png

    Prolonged compression or fixation of a nerve may result in a reduction of intraneural blood flow.

    Examination: Clinical Sensory Testing Can Be Used to Assess for Increased Sensitivity of the Nervous System

    If there is an irritated peripheral nerve, clinical sensory testing can be used to assess for areas of hypersensitivity. In addition to orthopedic testing this could involve palpation (neural and non-neural structures). If a hypersensitive peripheral nerve has been identified, a treatment plan is then implemented based on patient-specific assessment findings and patient tolerance.

    FXNL: How Do Nerves Become Hypersensitive?

    Treatment Considerations

    Manual Therapy

    The responses to neural mobilization are complex and multifactorial – physiological and psychological factors interplay in a complex manner. Systematic reviews have shown that neural mobilization combined with multimodal care can improve symptoms, decrease disability and improve function for patients who suffer from peripheral nerve entrapment (Basson et al., 2017).

    The biopsychosocial model provides a practical framework for investigating the complex interplay between manual therapy and clinical outcomes. Based on this, the investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation (Bialosky et al., 2018).

    Central Response
    Neural mobilization has a modulatory effect on peripheral and central processes via input from large sensory neurons that prevents the spinal cord from amplifying the nociceptive signal. This anti-nociceptive effect of massage therapy can help ease discomfort in patients who suffer from peripheral nerve entrapments.

    Peripheral Response
    Neural mobilization may also involve specific soft tissue treatment to optimize the ability of mechanical interfaces to glide relative to the neural structure. The application of appropriate shear force and pressure impart a mechanical stimulus that may attenuate tissue levels of fibrosis and TGF-β1 (Bove et al., 2016; Bove et al., 2019). Furthermore, passive stretching may help diminish intraneural edema and/or pressure by mobilizing the peripheral nerve as well as associated vascular structures (Boudier-Revéret et al., 2017; Gilbert et al., 2015).

    Nerves, Knowledge and Theratube With David Butler

    Prognosis

    In terms of research evidence neural mobilization has been shown to be particularly helpful for common forms of back, neck, leg and foot pain (Basson et al., 2017). An observed favorable outcome may be explained by overlapping mechanisms in the periphery, spinal cord, and brain, including but not limited to affective touch, contextual factors, neurological factors, and mechanical factors.

    Key Takeaways

    Nerves can be exposed to mechanical or chemical irritants at different anatomical points. Gently stretching the muscles, neurovascular structures, and investing fascia activates endogenous pain modulating systems that help to mitigate the transition, amplification and development of peripheral neuropathies and chronic pain.

    References and Sources

    Andrade, R. J., Freitas, S. R., Hug, F., Le Sant, G., Lacourpaille, L., Gross, R., … Nordez, A. (2018). The potential role of sciatic nerve stiffness in the limitation of maximal ankle range of motion. Scientific reports, 8(1), 14532. doi:10.1038/s41598-018-32873-6

    Andrade, R. J., Freitas, S. R., Hug, F., Le Sant, G., Lacourpaille, L., Gross, R., Quillard, J. B., McNair, P. J., & Nordez, A. (2020). Chronic effects of muscle and nerve-directed stretching on tissue mechanics. Journal of applied physiology (Bethesda, Md.: 1985), 129(5), 1011–1023. https://doi.org/10.1152/japplphysiol.00239.2019

    Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 47(9), 593–615. doi:10.2519/jospt.2017.7117

    Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. The Journal of orthopaedic and sports physical therapy, 48(1), 8–18. doi:10.2519/jospt.2018.7476

    Boudier-Revéret, M., Gilbert, K. K., Allégue, D. R., Moussadyk, M., Brismée, J. M., Sizer, P. S., Jr, … Sobczak, S. (2017). Effect of neurodynamic mobilization on fluid dispersion in median nerve at the level of the carpal tunnel: A cadaveric study. Musculoskeletal science & practice, 31, 45–51. doi:10.1016/j.msksp.2017.07.004

    Bove, G. M., Harris, M. Y., Zhao, H., & Barbe, M. F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the neurological sciences, 361, 168–180. doi:10.1016/j.jns.2015.12.029

    Bove, G. M., Delany, S. P., Hobson, L., Cruz, G. E., Harris, M. Y., Amin, M., … Barbe, M. F. (2019). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain, 160(3), 632–644. doi:10.1097/j.pain.0000000000001443

    Butler, D. S. (1989). Adverse mechanical tension in the nervous system: a model for assessment and treatment. The Australian journal of physiotherapy, 35(4), 227–238. https://doi.org/10.1016/S0004-9514(14)60511-0

    Donnelly, C. R., Chen, O., & Ji, R. R. (2020). How Do Sensory Neurons Sense Danger Signals?. Trends in neurosciences, 43(10), 822–838. https://doi.org/10.1016/j.tins.2020.07.008

    Elvey, R. L. (1986). Treatment of arm pain associated with abnormal brachial plexus tension. The Australian journal of physiotherapy, 32(4), 225–230. https://doi.org/10.1016/S0004-9514(14)60655-3

    Gilbert, K. K., Smith, M. P., Sobczak, S., James, C. R., Sizer, P. S., & Brismée, J. M. (2015). Effects of lower limb neurodynamic mobilization on intraneural fluid dispersion of the fourth lumbar nerve root: an unembalmed cadaveric investigation. The Journal of manual & manipulative therapy, 23(5), 239–245. doi:10.1179/2042618615Y.0000000009

    Gilbert, K. K., Roger James, C., Apte, G., Brown, C., Sizer, P. S., Brismée, J. M., & Smith, M. P. (2015). Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: implications for the treatment of neuropathic pain and dysfunction. The Journal of manual & manipulative therapy, 23(4), 219–225. doi:10.1179/2042618614Y.0000000094

    Goodwin, G., Bove, G. M., Dayment, B., & Dilley, A. (2020). Characterizing the Mechanical Properties of Ectopic Axonal Receptive Fields in Inflamed Nerves and Following Axonal Transport Disruption. Neuroscience, 429, 10–22. https://doi.org/10.1016/j.neuroscience.2019.11.042

    Holmes, S. A., Barakat, N., Bhasin, M., Lopez, N. I., Lebel, A., Zurakowski, D., … Borsook, D. (2019). Biological and behavioral markers of pain following nerve injury in humans. Neurobiology of pain (Cambridge, Mass.), 7, 100038. doi:10.1016/j.ynpai.2019.100038

    Jacobson, L., Dengler, J., & Moore, A. M. (2020). Nerve Entrapments. Clinics in plastic surgery, 47(2), 267–278. https://doi.org/10.1016/j.cps.2019.12.006

    Jain, A., Hakim, S., & Woolf, C. J. (2020). Unraveling the Plastic Peripheral Neuroimmune Interactome. Journal of immunology (Baltimore, Md. : 1950), 204(2), 257–263. doi:10.4049/jimmunol.1900818

    Matsuda, M., Huh, Y., & Ji, R. R. (2019). Roles of inflammation, neurogenic inflammation, and neuroinflammation in pain. Journal of anesthesia, 33(1), 131–139. doi:10.1007/s00540-018-2579-4

    Nee, R. J., Jull, G. A., Vicenzino, B., & Coppieters, M. W. (2012). The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain. The Journal of orthopaedic and sports physical therapy, 42(5), 413–424. doi:10.2519/jospt.2012.3988

    Neto, T., Freitas, S. R., Andrade, R. J., Vaz, J. R., Mendes, B., Firmino, T., Bruno, P. M., Nordez, A., & Oliveira, R. (2020). Shear Wave Elastographic Investigation of the Immediate Effects of Slump Neurodynamics in People With Sciatica. Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine, 39(4), 675–681. https://doi.org/10.1002/jum.15144

    Plaza-Manzano, G., Ríos-León, M., Martín-Casas, P., Arendt-Nielsen, L., Fernández-de-Las-Peñas, C., & Ortega-Santiago, R. (2019). Widespread Pressure Pain Hypersensitivity in Musculoskeletal and Nerve Trunk Areas as a Sign of Altered Nociceptive Processing in Unilateral Plantar Heel Pain. The journal of pain: official journal of the American Pain Society, 20(1), 60–67. doi:10.1016/j.jpain.2018.08.001

    Satkeviciute, I., Goodwin, G., Bove, G. M., & Dilley, A. (2018). Time course of ongoing activity during neuritis and following axonal transport disruption. Journal of neurophysiology, 119(5), 1993–2000. https://doi.org/10.1152/jn.00882.2017

    Schmid, A. B., Brunner, F., Luomajoki, H., Held, U., Bachmann, L. M., Künzer, S., & Coppieters, M. W. (2009). Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC musculoskeletal disorders, 10, 11. doi:10.1186/1471-2474-10-11

    Schmid, A. B., Nee, R. J., & Coppieters, M. W. (2013). Reappraising entrapment neuropathies–mechanisms, diagnosis and management. Manual therapy, 18(6), 449–457. doi:10.1016/j.math.2013.07.006

    Schmid, A. B., Hailey, L., & Tampin, B. (2018). Entrapment Neuropathies: Challenging Common Beliefs With Novel Evidence. The Journal of orthopaedic and sports physical therapy, 48(2), 58–62. doi:10.2519/jospt.2018.0603

    Schmid, A. B., Fundaun, J., & Tampin, B. (2020). Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain reports, 5(4), e829. https://doi.org/10.1097/PR9.0000000000000829

    Stecco, A., Pirri, C., & Stecco, C. (2019). Fascial entrapment neuropathy. Clinical anatomy (New York, N.Y.), 32(7), 883–890. doi:10.1002/ca.23388

    Stonner, M. M., Mackinnon, S. E., & Kaskutas, V. (2020). Predictors of functional outcome after peripheral nerve injury and compression. Journal of hand therapy: official journal of the American Society of Hand Therapists, S0894-1130(20)30039-9. Advance online publication. https://doi.org/10.1016/j.jht.2020.03.008

    This page titled 2.3: Neural Mobilization is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Richard Lebert (eCampus Ontario) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request.