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Butler’s Neurodynamics
Concept
Saurab Sharma, MPT
Lecturer, KUSMS
History
• The concept of the
continuum of the nervous
system
• ALF BREIG
– founder of Neurodynamics
2
Neurodynamics
• Encompasses the interactions between
mechanics and physiology of the
nervous system.
M. Shacklock, Physiotherapy, 1995
3
Functional Anatomy
and Physiology
4
The dynamic nervous system
• The central nervous system is a dynamic
organ like muscle, joint or any other
involved in movement.
• Possesses plastic and elastic
properties
• Mechanically and physiologically
continuous
5
Transection of a nerve
6
mesoneurium
Blood supply of a nerve
7
Cross section of nerves
8
Sites of peripheral nerve vulnerability
1. Tunnels: Carpal tunnel, tarsal tunnel
2. Branches: medial and lateral plantar nerves
3. Hard Interface: radial nerve in spiral groove
4. Proximity to surface
5. Where nerves are fixed to interfacing
surface: common peroneal nerve at fibular
head
9
Stages of nerve injury
• Hypoxia
• Edema
• Fibrosis
10
What happens after nerve injury?
Sequel
• Intraneural fibrosis’
• Alterations in the conduction
Sunderland, 1976
• Loss of elasticity
• Mechanosensitivity
(Shacklock, 2005)
11
Mechanical interface (MI)
• Tissue most anatomically adjacent to the
nervous system that can move
independently to the system
Butler , 1987
• Pathology at the MI can give rise to
abnormalities in the nerve movement &
cause increases in tension within the nerve
Butler, Gifford , Physiotherapy, 1989
12
Neurodynamics
• Encompasses the interactions between
mechanics and physiology of the
nervous system.
M. Shacklock, Physiotherapy, 1995
13
Neurodynamics
15
• Median nerve can withstand 20-30% of tensile
force before failure (70-220N).
Mechanical responses
1. Neural movement
2. Tension
3. Intraneural pressure changes
4. Alterations in cross sectional shape
16
Physiological responses to movement
• Viscoelasticity- improves
• Thixotropy- axoplasm viscosity reduces
• Intraneural blood flow – improves
• Axonal transport- increases
• Sympathetic response
17
Examination
18
Examination
1. Assessment and Clinical reasoning
2. Examination of nerve conduction
3. Nerve palpation
4. Neurological examination- Subjective and
objective
19
Neurodynamic tests
24
Indications
• Disorders suitable for mobilization can be
classified into those whose origins may result
from:
1. Any inflammatory reaction i.e. irritable
disorders (with patho-physiological
dominance)
2. Biomechanical compromise i.e. non-
irritable disorders (with patho-mechanical
dominance)
25
Precautions
1. Other structures involved in testing like discs
2. Irritability related to nervous system
3. Worsening disorder
4. Presence of neurological signs
5. General health problems
6. Dizziness due to cervical spine pathology
7. Circulatory disturbances
26
Contraindications
1. Recent infection, malignancy of nervous system
2. Recent onset of, or worsening neurological signs
3. Cauda equina lesions
4. Injury to the spinal cord
27
Neurodynamic testing
• Straight leg raise test (SLRT)
• Slump test
• Upperlimb neurodynamic tests (ULNT)
• Passive neck flexion test
• Prone Knee bend test (PKBT)
28
Neurodynamic testing
• Used for non-irritable condition
1. Symptom response: P1= range at which symptom
starts; P2= symptom at limit of range
2. Resistance encountered: R1= Resistance first
encountered; R2= resistance stops any further
movement
29
Neurodynamic testing
30
Analysis of Neurodynamic testing
• Normal response
– Resistance/ pain or both bilaterally
– Is it relevant to patient’s problem?
• Positive test
– If test reproduces patient’s symptom
– If response is altered by movement of distant
body part
31
Further testing
• Nerve Palpation: direct/ indirect
– Median nerve
– Ulnar nerve
– Radial nerve
– Sciatic nerve
– Common peroneal nerve
– Posterior tibial nerve
33
Treatment
34
General consideration
• Nervous system cannot avoid being mobilized
• Analytical assessment (Maitland, 1986) is
cornerstone of the concept
• No recipe treatments- treatment based on
clinical reasoning
35
Treatment approach
Q. How can we treat a problem related to
neural mobility?
1. Direct mobilization of nervous system by
neurodynamic exercises (sliders & tensioners).
2. Treatment of the interface and related tissues.
3. Indirect treatment by postural advice and
ergonomic design.
36
Basic principles of mobilization
1. Maitland Concept: treatment based on
severity, irritability and nature of disorder.
2. Maitland’s Grades of Mobilization
3. Movement diagram may be used
37
Movement diagram for SLR
38
Butler D. Mobilization of nervous system, 1991
Irritable disorder: Guidelines
• Start with remote (distant) technique
• Non-provoking
• Under-treat
• Large amplitude grade II- slow and
rhythmic
• Progress to grade IV to P1
42
Non-irritable disorder
Pathomechanical dominance
• Chronic problem
• Into the resistance:
– Grade III: for extraneural disorder
– Grade IV : for intraneural disorder
• Start by technique not provoking pain
45
Recent advance
• Addition of sciatic nerve mobilization in slump
position (both by tensioner and sliders) can
improve hamstring flexibility than static
stretching alone to hamstrings.
47
Sharma et al. Physical Therapy in Sport. 2015
Summary
• Nervous system – a continuum
• Neurodynamics – mechanical and physiological
benefits
• Management principles
48
References
• Butler DS. Mobilization of the nervous system. 1991
• Butler DS, Tromberlin JS. Structure, function, and
physiology of the nervous system. Chapter 8; page 175-
189
• Shacklock M. Clinical neurodynamics 2005
49

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Neurodynamics, mobilization of nervous system, neural mobilization

  • 2. History • The concept of the continuum of the nervous system • ALF BREIG – founder of Neurodynamics 2
  • 3. Neurodynamics • Encompasses the interactions between mechanics and physiology of the nervous system. M. Shacklock, Physiotherapy, 1995 3
  • 5. The dynamic nervous system • The central nervous system is a dynamic organ like muscle, joint or any other involved in movement. • Possesses plastic and elastic properties • Mechanically and physiologically continuous 5
  • 6. Transection of a nerve 6 mesoneurium
  • 7. Blood supply of a nerve 7
  • 8. Cross section of nerves 8
  • 9. Sites of peripheral nerve vulnerability 1. Tunnels: Carpal tunnel, tarsal tunnel 2. Branches: medial and lateral plantar nerves 3. Hard Interface: radial nerve in spiral groove 4. Proximity to surface 5. Where nerves are fixed to interfacing surface: common peroneal nerve at fibular head 9
  • 10. Stages of nerve injury • Hypoxia • Edema • Fibrosis 10
  • 11. What happens after nerve injury? Sequel • Intraneural fibrosis’ • Alterations in the conduction Sunderland, 1976 • Loss of elasticity • Mechanosensitivity (Shacklock, 2005) 11
  • 12. Mechanical interface (MI) • Tissue most anatomically adjacent to the nervous system that can move independently to the system Butler , 1987 • Pathology at the MI can give rise to abnormalities in the nerve movement & cause increases in tension within the nerve Butler, Gifford , Physiotherapy, 1989 12
  • 13. Neurodynamics • Encompasses the interactions between mechanics and physiology of the nervous system. M. Shacklock, Physiotherapy, 1995 13
  • 14. Neurodynamics 15 • Median nerve can withstand 20-30% of tensile force before failure (70-220N).
  • 15. Mechanical responses 1. Neural movement 2. Tension 3. Intraneural pressure changes 4. Alterations in cross sectional shape 16
  • 16. Physiological responses to movement • Viscoelasticity- improves • Thixotropy- axoplasm viscosity reduces • Intraneural blood flow – improves • Axonal transport- increases • Sympathetic response 17
  • 18. Examination 1. Assessment and Clinical reasoning 2. Examination of nerve conduction 3. Nerve palpation 4. Neurological examination- Subjective and objective 19
  • 20. Indications • Disorders suitable for mobilization can be classified into those whose origins may result from: 1. Any inflammatory reaction i.e. irritable disorders (with patho-physiological dominance) 2. Biomechanical compromise i.e. non- irritable disorders (with patho-mechanical dominance) 25
  • 21. Precautions 1. Other structures involved in testing like discs 2. Irritability related to nervous system 3. Worsening disorder 4. Presence of neurological signs 5. General health problems 6. Dizziness due to cervical spine pathology 7. Circulatory disturbances 26
  • 22. Contraindications 1. Recent infection, malignancy of nervous system 2. Recent onset of, or worsening neurological signs 3. Cauda equina lesions 4. Injury to the spinal cord 27
  • 23. Neurodynamic testing • Straight leg raise test (SLRT) • Slump test • Upperlimb neurodynamic tests (ULNT) • Passive neck flexion test • Prone Knee bend test (PKBT) 28
  • 24. Neurodynamic testing • Used for non-irritable condition 1. Symptom response: P1= range at which symptom starts; P2= symptom at limit of range 2. Resistance encountered: R1= Resistance first encountered; R2= resistance stops any further movement 29
  • 26. Analysis of Neurodynamic testing • Normal response – Resistance/ pain or both bilaterally – Is it relevant to patient’s problem? • Positive test – If test reproduces patient’s symptom – If response is altered by movement of distant body part 31
  • 27. Further testing • Nerve Palpation: direct/ indirect – Median nerve – Ulnar nerve – Radial nerve – Sciatic nerve – Common peroneal nerve – Posterior tibial nerve 33
  • 29. General consideration • Nervous system cannot avoid being mobilized • Analytical assessment (Maitland, 1986) is cornerstone of the concept • No recipe treatments- treatment based on clinical reasoning 35
  • 30. Treatment approach Q. How can we treat a problem related to neural mobility? 1. Direct mobilization of nervous system by neurodynamic exercises (sliders & tensioners). 2. Treatment of the interface and related tissues. 3. Indirect treatment by postural advice and ergonomic design. 36
  • 31. Basic principles of mobilization 1. Maitland Concept: treatment based on severity, irritability and nature of disorder. 2. Maitland’s Grades of Mobilization 3. Movement diagram may be used 37
  • 32. Movement diagram for SLR 38 Butler D. Mobilization of nervous system, 1991
  • 33. Irritable disorder: Guidelines • Start with remote (distant) technique • Non-provoking • Under-treat • Large amplitude grade II- slow and rhythmic • Progress to grade IV to P1 42
  • 34. Non-irritable disorder Pathomechanical dominance • Chronic problem • Into the resistance: – Grade III: for extraneural disorder – Grade IV : for intraneural disorder • Start by technique not provoking pain 45
  • 35. Recent advance • Addition of sciatic nerve mobilization in slump position (both by tensioner and sliders) can improve hamstring flexibility than static stretching alone to hamstrings. 47 Sharma et al. Physical Therapy in Sport. 2015
  • 36. Summary • Nervous system – a continuum • Neurodynamics – mechanical and physiological benefits • Management principles 48
  • 37. References • Butler DS. Mobilization of the nervous system. 1991 • Butler DS, Tromberlin JS. Structure, function, and physiology of the nervous system. Chapter 8; page 175- 189 • Shacklock M. Clinical neurodynamics 2005 49

Editor's Notes

  1. first book, Biomechanics of the Central Nervous System was published in 1960 1978 (Adverse Mechanical Tension in the Central Nervous System) 
  2. Endoneurium, perineurium (fasciculus), epineurium (inner and outer), mesoneurium (thin connective tissue membrane) Collagen and few elastin interlace to form a lattice.
  3. Perineurium is layered with specialized cells. Form blood nerve barrier.
  4. Implication - ischemia due to nerve pressure or compression or stretch
  5. Circulation reverses in few hours if compression is released.
  6. Always be careful when the pathology is uncertain spondylosis, spinal stenosis as response is seen earlier during the testing. Facet- care during cervical maneuver, lumbar disc problem during slump 2. May be due to mechano or chemosensitivity of nervous system. May also be due to interface problem or repeated movements 4. No passive movement if neurological signs. As long as the disorder is chronic and neuro signs are stable and not indicative or active disease process. 5. Diabetes, leprosy, AIDS, multiple sclerosis- weaken the nervous system 6. Cervical flexion, slump and shoulder depression tenses the vessels
  7. 3. Alteration in the bladder and bowel function, perineal sensation , 4. Tethered spinal cord- no benefit as requires surgical intervention. Stress on cord- anoxic cord.
  8. Generally sliders as treatment for if pain appears before resistance (no tensioner). And relieving maneuver should be done during structural differentiation
  9. brachial plexus being moved while breathing
  10. 4. Use of “nature”= pathology (Maitland, 1986) Site of altered mechanics