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Neurodynamics, mobilization of nervous system, neural mobilization

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This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.

Veröffentlicht in: Gesundheit & Medizin
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Neurodynamics, mobilization of nervous system, neural mobilization

  1. 1. Butler’s Neurodynamics Concept Saurab Sharma, MPT Lecturer, KUSMS
  2. 2. History • The concept of the continuum of the nervous system • ALF BREIG – founder of Neurodynamics 2
  3. 3. Neurodynamics • Encompasses the interactions between mechanics and physiology of the nervous system. M. Shacklock, Physiotherapy, 1995 3
  4. 4. Functional Anatomy and Physiology 4
  5. 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. 6. Transection of a nerve 6 mesoneurium
  7. 7. Blood supply of a nerve 7
  8. 8. Cross section of nerves 8
  9. 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. 10. Stages of nerve injury • Hypoxia • Edema • Fibrosis 10
  11. 11. What happens after nerve injury? Sequel • Intraneural fibrosis’ • Alterations in the conduction Sunderland, 1976 • Loss of elasticity • Mechanosensitivity (Shacklock, 2005) 11
  12. 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. 13. Neurodynamics • Encompasses the interactions between mechanics and physiology of the nervous system. M. Shacklock, Physiotherapy, 1995 13
  14. 14. Neurodynamics 15 • Median nerve can withstand 20-30% of tensile force before failure (70-220N).
  15. 15. Mechanical responses 1. Neural movement 2. Tension 3. Intraneural pressure changes 4. Alterations in cross sectional shape 16
  16. 16. Physiological responses to movement • Viscoelasticity- improves • Thixotropy- axoplasm viscosity reduces • Intraneural blood flow – improves • Axonal transport- increases • Sympathetic response 17
  17. 17. Examination 18
  18. 18. Examination 1. Assessment and Clinical reasoning 2. Examination of nerve conduction 3. Nerve palpation 4. Neurological examination- Subjective and objective 19
  19. 19. Neurodynamic tests 24
  20. 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. 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. 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. 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. 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
  25. 25. Neurodynamic testing 30
  26. 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. 27. Further testing • Nerve Palpation: direct/ indirect – Median nerve – Ulnar nerve – Radial nerve – Sciatic nerve – Common peroneal nerve – Posterior tibial nerve 33
  28. 28. Treatment 34
  29. 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. 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. 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. 32. Movement diagram for SLR 38 Butler D. Mobilization of nervous system, 1991
  33. 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. 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. 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. 36. Summary • Nervous system – a continuum • Neurodynamics – mechanical and physiological benefits • Management principles 48
  37. 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

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