Uploaded bySaurab Sharma
Neurodynamics, mobilization of nervous system, neural mobilization
The document discusses the concept of neurodynamics, which examines the interactions between the mechanics and physiology of the nervous system, emphasizing its continuity and plastic properties. It outlines stages of nerve injury, examination and testing techniques, and treatment approaches for addressing neural mobility issues. The principles of treatment are guided by the nature of the disorder and incorporate both direct and indirect mobilization methods.
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Neurodynamics, mobilization of nervous system, neural mobilization
- 1. Butler’s Neurodynamics Concept Saurab Sharma,MPT Lecturer, KUSMS
- 2. History • The conceptof the continuum of the nervous system • ALF BREIG – founder of Neurodynamics 2
- 3. Neurodynamics • Encompasses theinteractions between mechanics and physiology of the nervous system. M. Shacklock, Physiotherapy, 1995 3
- 4.
- 5. The dynamic nervoussystem • 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 anerve 6 mesoneurium
- 7. Blood supply ofa nerve 7
- 8. Cross section ofnerves 8
- 9. Sites of peripheralnerve 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 nerveinjury • Hypoxia • Edema • Fibrosis 10
- 11. What happens afternerve 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 theinteractions between mechanics and physiology of the nervous system. M. Shacklock, Physiotherapy, 1995 13
- 14. Neurodynamics 15 • Median nervecan withstand 20-30% of tensile force before failure (70-220N).
- 15. Mechanical responses 1. Neuralmovement 2. Tension 3. Intraneural pressure changes 4. Alterations in cross sectional shape 16
- 16. Physiological responses tomovement • Viscoelasticity- improves • Thixotropy- axoplasm viscosity reduces • Intraneural blood flow – improves • Axonal transport- increases • Sympathetic response 17
- 17.
- 18. Examination 1. Assessment andClinical reasoning 2. Examination of nerve conduction 3. Nerve palpation 4. Neurological examination- Subjective and objective 19
- 19.
- 20. Indications • Disorders suitablefor 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 structuresinvolved 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 • Straightleg raise test (SLRT) • Slump test • Upperlimb neurodynamic tests (ULNT) • Passive neck flexion test • Prone Knee bend test (PKBT) 28
- 24. Neurodynamic testing • Usedfor 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
- 25.
- 26. Analysis of Neurodynamictesting • 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 • NervePalpation: direct/ indirect – Median nerve – Ulnar nerve – Radial nerve – Sciatic nerve – Common peroneal nerve – Posterior tibial nerve 33
- 28.
- 29. General consideration • Nervoussystem 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. Howcan 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 ofmobilization 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 forSLR 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 • Additionof 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
- #3 first book, Biomechanics of the Central Nervous System was published in 1960 1978 (Adverse Mechanical Tension in the Central Nervous System)
- #7 Endoneurium, perineurium (fasciculus), epineurium (inner and outer), mesoneurium (thin connective tissue membrane) Collagen and few elastin interlace to form a lattice.
- #8 Perineurium is layered with specialized cells. Form blood nerve barrier.
- #9 Implication - ischemia due to nerve pressure or compression or stretch
- #16 Circulation reverses in few hours if compression is released.
- #27 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
- #28 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.
- #30 Generally sliders as treatment for if pain appears before resistance (no tensioner). And relieving maneuver should be done during structural differentiation
- #36 brachial plexus being moved while breathing
- #38 4. Use of “nature”= pathology (Maitland, 1986) Site of altered mechanics