Upper Limb Neurodynamic Considerations

Here are a few hints when using neurodynamic tensioners as a manual treatment.

End range is important in neurodynamics too, especially when performing tensioners.

1) Patients will find a way to cheat or take the path of least resistance

tsk tsk!

I've seen it one too many times when students and even experienced therapists are using upper limb neurodynamics as treatments. The patient flexes their DIPs or PIPs around the therapist's hand. If they are still getting a stretch, and improvements in pain, function, and ROM, great. However, if the improvements do not seem to hold, perhaps you are not getting to end range. Make sure you are extending the patient's fingers at the DIPs as well.

now that's better!

2) The therapist does not supinate or pronate fully

One thing David Butler did at the neurodynamics courses I went to with him was go around and take up all the slack in the forearms when practicing tensioners. I was surprised to find out I was not either supinating fully for median and ulnar nerves or pronating fully for radial nerve. It was common with almost every practitioner in the clinic.

To make sure I'm getting to end range, I take my stabilizing hand off of the scapula once it is depressed and fully rotate the forearm into either supination or pronation then take up distal slack at the wrist and fingers. If you maintain a slight long axis distraction, the scapula stays stable.

An example of this is a former patient who had ulnar distribution complaints. She was a violinist for the Buffalo Philharmonic. Soft tissue work to her forearm and cervical MDT helped centralize her complaints except the most distal in her hand. After about 3-4 Tx, she told me she had a congenitally small fifth digit on her involved side. This required her to supinate excessively to reach the stings on her violin (not her bow hand). As a component, her supination was at least 120 degrees! After taking up this slack, and translating that to her HEP, her Sx centralized and stayed reduced.