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

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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

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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

38Butler 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.

47Sharma 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