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.

1. Butler’s Neurodynamics
Concept
Saurab Sharma, MPT
Lecturer, KUSMS

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

4. Functional Anatomy
and Physiology
4

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
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mesoneurium

7. Blood supply of a nerve
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8. Cross section of nerves
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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
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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)
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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
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17. Examination
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18. Examination
1. Assessment and Clinical reasoning
2. Examination of nerve conduction
3. Nerve palpation
4. Neurological examination- Subjective and
objective
19

19. Neurodynamic tests
24

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)
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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
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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)
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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
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25. Neurodynamic testing
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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
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27. Further testing
• Nerve Palpation: direct/ indirect
– Median nerve
– Ulnar nerve
– Radial nerve
– Sciatic nerve
– Common peroneal nerve
– Posterior tibial nerve
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28. Treatment
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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
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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.
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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
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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.
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Sharma et al. Physical Therapy in Sport. 2015

36. Summary
• Nervous system – a continuum
• Neurodynamics – mechanical and physiological
benefits
• Management principles
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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
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