The Neurodynamic Techniques

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A DEFTfiIITIVE GUIMT

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Published by Noigroup Publications

for NOI Australasia PtY Ltd

DVD reproduction by Microview Solutions

Printed and bound by van Gastel Printing

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All rights reserved' No part of this publication may be

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The procedures ano practises described in this book and

DVD should be implemented in a manner consistent with

orofessional standards set for the circumstances that

apply in each situation. Every effort has been made to

confirm accuracy of the information presented and to

correctly relate generally accepted practises'

The authors, editor and publisher cannot accept

responsibility for errors or exclusions or for the outcome

of the application of the material presented hereln'

There is no expressed or implied warranty of this book

and DVD or information imparted by it'

NoigrouP PublicationsNOI Australasia PtY Ltd

19 North Street, Adelaide City West'

South Australia 5000www. noigrouP.comTelephone +61 (0)B 8211 6388

Facsimile +61 (0)B 8211 8909

Butler, David S.

First edition 2005

ISBN 0-9750910-1-B

National LibrarY of AustraliaA catalogue record for this book is available

from the National Library of Australia '

State LibrarY of South Australia

A catalogue record for this book is available

from the State Library of South Australia'

With thanks to... Our international faculty I

NOI Faculty members NOI instructors are hand selected on the basis of ITranslators - Ruggero strobbe (Italian), stefan their existing skills and expertise and undergo Ischiller and Margot Bauer-Mitterlehner (German), progressive peer and expert training' All instructors IHenry Tsao and Mei-chun Kuo Tsao (chinese have postgraduate manual therapy educations and I

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Desisn - Ariane Ailchurch, Dinah Edwards n'J,""ffi:i:ffiit;: iT::'ff'.:ill"JiiSio=#"'n IProduction manager - Juliet Gore members of the faculty IAnatomy artwork - copyright (2005), Icon NOI's faculty members all travel widely to meet their ILearning Systems, LLC. A subsidiary of MediMedia, teaching commitments IUSA, Inc. All rights reserved. Australia IDvD authoring - Anthony James David Butler, Peter Barrett, carolyn Berryman, Ispectra Videographics, [email protected] Michel coppieters and Megan Dalton IReproduction - Microview solutions Europe - German speaking IChatswood NSW Australia, www.microview.com.au Gerti Bucher-Dollenz, Martina Egan-Moog, Iprintins - van Gastet printins, Adetaide, Austratia :ili:"::"#:].:ki'

Harrv von Piekartz' Huso stam II

Music - Maria by Miguel Espinoza Europe _ rtalian speaking ISergio Parazza, Erika Schiffereger, Ruggero Strobbe, ISusanne Wahrlich and Irene Wicki. IUSA

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IIIntroduction Nine key points III

This neurodynamics techniques DVD 1 , wn"t is a neurodynamic test? |and book has been produced by the Neurodynamics is the science of the relationships between mechanics and INeuro orthopaedic Institute physiology of the nervous system. simply put - it is the assessment and I

Australasia' with contributions from treatment of the physical health of the nervous system. Just as a joint morour international faculty' It is and a muscle stretches, the nervous system arso has physicar prop".,i"Jut Iexpected that users will be health that are essential for movement. you can examine these properties via I

::",ff:;?H #"t:nJJi"::::#, nerve parpation and neurodvnamic rests. 's Lrrese Properures vra I

and neuro orthopaedic assessment 2 > tn" nervous system is a continuum Iplus knowledge of relevant pathology, A mechanical, electrical and chemical continuum exlsts in the nervous Iprecautions and contraindications. system. This is the basis of tests such as the slump test, where for I

For optimal and safe clinical example, the position of the neck will influence neurar responses in the leq. I

integration/ it is highly recommended 3 > Structural differentiationthat this DVD and book be used in The neural continuum arrows a differentiation between neurar and non-association with NoI education neural tissues. For exampre, in the case of the srump test (see below),seminars (www'noigroup'com) and/or if neck extension which takes load off the nervous sysrem eases evokedused with the textbooks Mobilisation symptoms in the leg,of the Nervous System or preferably, th"n this provides

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4 > Neural relations tojoint axes dictates load

The nervous system is usuallybehind, in front, or to the side

of joint axes of movement. Thismeans that the physical loadingon the nervous svstem will be

dictated by joint position. Inthe example shown of the

Upper Limb Neurodynamic Test (ULNT), wrist extension,elbow extension, and shoulder abduction would be examplesof movements which challenge the median nerve and the

brachial plexus. If you know your anatomy, you could make

up neurodynamic tests yourself.

5 > Pincn and tension - the key roleof neighbouring structures

Most neurodynamic tests are tests of the ability of thenervous system to elongate. The neighbouring structures

(e.9. joint and muscle) which'contain' the nervous systemcan sometimes pinch it. Wristflexion is a test of the neuralcontainer around the mediannerve at the carpal tunnel,and the Spurling's test(illustrated here) is an exampleof a pinch test for lowercervical nerve roots.

6 t o.d.. of Movement

The strain and movement of the nervous systemwill be affected bv the order in which the movementis taken up. For example, as illustrated, if you add

ankle dorsiflexion and eversion and then perform a

Straight Leg Raise (SLR) , a neurogenic problem in

the tibial nerve at the ankle is more likely to be

exposed than with other combinations.

There are probably two reasons for this: a moremechanical reason where the neural tissues are'borrowed' from other areas and thus given moreof a chance to be challenged, or perhaps the firstmovement is the one which takes priority in theoatient's consciousness.

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B > necordingAbbreviations such as PFIIN/SLR informthe order and kind of lnovement, thus ankleplantar flexion first, then inversion and thenStraight Leg Raise. Each component canalso be quantified in terms of range ofmovement or qualified in terms ofsymptoms evoked.

The 'In:Did' svstem is also used. Forexample, In: HFlLR Did: KE means that inthe hip flexion and lateral rotation position,knee extension was performed.

Y > Don't forget the brainRemember that responses to these testsmay not always be due to physical healthissues in the nervous system. In somepatients the sensitivity evoked during testingmay be due to changes in the centralneryous svstem. There is much more on thisimportant part of assessment in The SensitiveNervous System.

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7 t Slid.." and tensionersA tensioner (1) can be a vigorous techniquewhich 'oulls from both ends' of the nervoussystem. A slider (2) is a 'flossing' movementwhere tension is placed at one end of thesystem and siack at the other, Slidersprovide a large amount of neural movementand are a neurally nonaggressive movementfor anxious patients.

Gf ossaryC/T . ., Cervico-thoracicDF....DorsiflexionEV ,...Eversion

SLR

ReferencesButler DS (2000) The Sensitive NervousSystem, ISBN 0-646-40251-X,NOI Publications, Adelaide.

Butler DS (1991) Mobilisation of theNervous System, ISBN 0-443-04400-7,Churchill Livingstone, Melbourne.(Also in German, Italian, Spanish and Japanese.)

Support materialNOI's list of self published literature and brain products iscontinually updated and expanded. Visit noigroup'com fordetailed descriptions and secure online ordering.

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details to noi @ noig roup.com.

GHHAb

GlenohumeralHip abduction

HAd...HipadductionHE....HipextensionHF....HipflexionIMT . . . IntermetatarsalIN ....InversionKE....KneeextensionKF....KneeflexionLat flex . Lateral flexionLR . . . . Lateral rotationLS.....LongsittingNF..... NeckflexionPF .... PlantarflexionPKB...ProneKneeBendPNF . . . Passive Neck FlexionRad ...RadialSKB...SlumpKneeBend

Straight Leg RaiseSLS....SlumpLongSitSLY . . . . Slump sidelyingSP ....SpinalSup TF . Superior tibiofibularten....tensionerThx....ThoraxULNT . . Upper Limb Neurodynamic Test

Passive techniquesIn: SLR/DFIEV Did: IMT mob . .

In: Slump LS/DF/EV Did: IMT mob

In: HF/DF/EV Did: KE with nerve massage

In: KF/DF/IN Did: KEISLR'Ultimate tibial mob'. . . . .

Self management > gentler movements

In: HF/DFIEV Did: KE 'Heel to the skY'

Leg swing heel to floor. .

Self management > stronger movements

In: Stand/DFlEVDid: SPflex '. '..15In: HF/DFIEVDid: KE+ strap'Wall work' ... '.. '.15In: Slump LS/DFIEV Did: KE (sli/ten) .. '. ' 16

In: Slump LS/DFIEV/NF Did: IMT mobToewrigglerinslump '....16

Sural nerveAnatomy and palPation.

Thera pist's assessmentDFlIN/SLR

Passive techniquesIn: HFIDFIIN Did: KE

11

11

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1A

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In: DF/IN Did: nerve massage

Self managementIn: HF/DFIIN Did: KE (sli/ten)

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$EE EE E E E E E E E E E E E EEUEETlTPeroneal nerveAnatomyandpalpation ....1Thera pist's assessment

PFIIN/SLR ... "..2PFIIN/SLRviashoulder ..' 2

Passive techniquesIn: SLR/HAd/HMR/SPflex... .... "3In: HFIPF/IN > DFIEVDid: KE '....4In: Slump LS/PFIIN Did: SupTF mob + KE' . ".. " 4


In: HF/PFIIN Did: KE .. '..5Leg swing toes curled under. . . . . . . 5


In: Slump LS/PFIIN Did: KE (sli/ten) ....... ' 6

Standing mobilisation '. ' ' '7Wall mobilisation... .. '...8'Hamstringsstretch'Focuson peroneal nerve. .... ' B

Tibia I nerveAnatomyandpalPation '...9Therapist's assessment

DFIEVISLR ......10ReversalSLR/DFIIN .... '.10

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Femora I nerveAnatomy and palpation. . . .2ITherapist's assessment

Prone Knee Bend (PKB) . . .22

Slump Knee Bend (SKB). ........22In: Slump SLY/KFIHE Did: HAbObturatortest.,. .......23In: Slump SLY/KFIHE Did: HAd

Meralgiatest... ........24Self managementHalf Pushup, Half Pushup + neck sli/ten. . . .25'Thomastestexercise .....26'Hurdlerstretch' ........27

Saphenous nerveAnatomy and palpation. . . .29Therapist's assessment

Pro n e/H E/ HAb / KE/ MR/ DF / EvThesaphenoustest ......30Passive techniqueIn: Prone/HE/HA5/MR/DF/EV Did: KE . . . . ., . . . . . 31

Self managementThesaohenousstretch ....32

Median nerveAnatomyandpalpation. ...33Activequicktest. ....,.34Thera pist's assessmentULNT1 ......35-36ULNT1Alternativeoosition .......36ULNT1Reversed.. ......37ULNT1 Reversed: indexfingerfirst . . . . . . . 38

ULNT2. ........39ULNT2Seated oosition ....40Passive techniquesULNT2SIi/ten ....4IULNTlSli/ten ....4I'Nannaarm wobble' ......42In: ULNT1Did: GHmob.. .,.....43Self management > gentler movementsBalloon patting,'Watch the watch'. . . . . . . . 44

Yoyo, Juggling..... .....44'No moredishes', Ball throwing progression .......45Self management > stronger movements'Busy bee', 'Finger stretch', Wrist stretch . . . 46

'Rock around the clock' . . .46'Sawatdika', Crawling,'Zorro', Balancing acts. . . . . . 47

Look atyourhands, Wall stretch . .. . . . . . . 48

'Freethe bird'.. ........48

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Ulnar nerveAnatomy and PalPation. " ' 49

Activequicktest. ' ' " " 50

Therapist's assessment

ULNT3 From wrist first " " 51

ULNT3Fromshoulderfirst.' ""'52Passive techniquesIn: ULNT3 Did: massage cubital tunnel ' ' ' ' 53

In: ULNT3 Did: Pisiform mob . ' " ' 53

In: ULNT3 Did: Sli/ten ' " ' 54


'Don't listen;'Face massages'' ' ' ' ' ' ' ' ' 55

'Makea halo','smoking','Yahool' " " " ' ' 55


'Plateexercise' "'"56'Dry the back', 'sunglasses', 'Crawl to the pits' ' ' ' ' ' 57

nerveAnatomy and PalPation. " ' 59

Active quick test. . ' .

Thera pist's assessment

ULNT2 (radial)' ' '

Passive techniques'Gentle radial sliding' " ' "64'Wholearm rotations " " ' '64

In: ULNT2 (radial) Did: Rad head soft tissue mob ' ' ' 65


'Pouringwater'. """"66'Figuresof eight' " " " " 66

'Pumpwater' "" 67

Look at vour hand behind your elbow ' ' ' ' ' 67


'Backmassage'. ""'68'Tipplease' """68'Tablestretch ""'68

M uscu locuta neous nerveAnatomyandPalPation. '. "'69Activequicktest ' " ' " '70Therapist's assessment

ULNT(musculocutaneous) " " ' ' '71

Self Management

Running on the sPot " ' ' '72o-t

ULNT2 (radial) Seated variation

ULNT2 (radial) From wrist first

OruoI

'ThrowitawaY''.... 72

Spine, cord and meningesAnatomy .......73Active quicktest. . . . . .

Therapist's assessmentPassive Neck Flexion (PNF). . .. ...75Straight Leg Raise (SLR) Sensitising movements. . . . 76Bilateral SLR. , . ..... ...77Slumptestactive. ......78Slumptestpassive ......7gSlumpLongSit(SLS). ....80Passive techniquesSLS/ Structural differentiation . . . . . . . . . . 81In: leg distraction Did: necksli/ten. ......82In: SLS Did: Thx Lat flex techniques . . . . . . 83In: SLS Did: A/P movements . . . . .84Notalgia paraesthetica techniques . . . . . . . . 85Wedge mobilisation techniques/Thorax spine . . . . . . 86Wedge mobilisation techniques/Cervico-thoracic area . . 87Self management > genUer techniquesPelvictilt/neckSli/ten .... BB

SlR/neckSli/ten. .......88

Self management > stronger techniques'Wring'technique. .......89SLS/Shouldershrug .....90'Kickyourhead off' ......91'Kick your head off'Focus on peroneal nerve . . . . . 91'Wall walking .....92'Total slump' Bob Johnson technique . . .. . . 93'Roll over' ...,...93

Other NervesAccessory nerve (cranial nerveXl) . . . ....g4Axillarynerve ...95Suprascapularnerve .....96Trigeminal nerve. .......g7Occipital nerve ........98

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$f TEEE E E E E E E E E E EPeroneal nerve > anatomy and palpation

Palpable areasA Medial to Biceps Femoris

B At the head of the fibula

C Dorsum of the foot(both superficial and deep peroneal nerves)

Common entrapments / syndromesLower lumbar spine

Piriformis area

Superior tibiofibular jointLower limb compartments

Ankle extensor retinacurum

The Sensitive Nervous SystemChapters B, 11 and 15

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Peroneal nerve > therapist's assessment

PFlIN/SLR

PFlIN/SLR via shoulderMore mobile subjects require the techniquevariation shown. The leg is placed on thetherapist's shoulder and then'walked' up.

Peroneal nerve > passive techniques

In: SLR/HAd/HMR/SP flexThese four images show increasing tension being placed upon the peroneal

and the neuromeningeal system' Exploring these movements may be

necessary for minor physical health issues of the peroneal nerve (add PFlIN)

or tibial (add DFlEV) or situations where there is a spinal as well as peripheral

comoonent. Anv of these movements could be used as therapy'

p2

p3

Foot held in plantar flexion/inversion As the hip is flexed the therapist's armmaintains knee extension

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Hip adduction Hip medial rotation Spinal lateral flexion

Peroneal nerve > passive techniques

In: HF/PF/IN > DFIEV Did: KE

In: Slump LS/PFIIN Did: Sup TF mob + KE

Knee extension in hip flexion and ankleplantar flexion/inversion is a gentle way tomobilise the peroneal nerve for physicalhealth issues anywhere along the nerve.In the technique example here, while theknee is being extended, the ankle is takenfrom plantar flexlon/inversion todorsiflexion and eversion for additionalnerve mobilisation.

The slump based technique illustrated is

a combination of superior tibiofibular jointmobilisation, plus knee extension, plusspinal flexion and note also that thepatient's right foot is held into plantarflexion and inversron by her left foot. Allthese movements together wouldcomprise a vigorous tensioner technique.

Neck extension at the same time as kneeextension would be a slider.

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Peronea|nerve>Selfmanagement>gent|ermovementsp5

These techniques are examPles

of gentle ways to mobilise the

peroneal nerves and roots'

If a more gentle distractingmovement is required, the Patient

could extend her neck during the

knee extension or the 'swing

through'in the leg swing technique'

I,n;HFIPF/rN Did: KE

Leg swing toes curled under

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$d EEEE E E E E E E E E E E ! E E ET!!TPeroneal nerve > self management > stronger movements

Standing mobilisationNote how all the movement components which placeload on the peroneal nerves and roots are used here.

The right hip is adducted and medially rotated and theknee is held extended by the patient's left leg.

With foot in plantar flexion and inversion, spinal flexionincluding neck flexion allows a strong self mobilisationof the peroneal nerve and associated roots.

p6Peroneaf nerve > self management > stronger movements

These techniques are more vigorous than the ones onthe previous page and may be applicable for mobilepatients and patients with sports injuries involving theperoneal nerve such as a settlrnq sprained ankle.

In: Slump LS/PFIIN Did: KE (sti/ten)

With the foot held in plantarflexion/inversion, knee extensionand neck flexion makesa tensioner technique.

With neck extension, a slidertechnique is performed.

p7

Peroneal nerve > self management > stronger movements pB

Illustrated here are two vigorousperoneal nerve based techniques.

Wall mobilisationThe key with the wall technique, where thepatient lies in a doorway, is to make surethat the foot is maintained in olantar flexionand inversion via a towel or a strao.

'Hamstrings stretch'Focus on peroneal nerveThe 'hamstrings stretch' is a reminder thatany muscle stretch will be likely to be a

nerve mobilisation, particularly if themovements that place more load onto thenerve are included,

In this example, note in image 2 theaddition of hip flexion, adduction andmedial rotation, ankle olantar flexion andinversion and spinal flexion.

p9

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FTDilffr EEEEEEEE!!!E!!!ET!T!nerve > anatomy and palpation

Palpable areas

A Posterior to the knee

B Medial ankle (plantar nerves)

Common entrapments / syndromesPlantar fasciitis

Heel spur

Recurrent hamstring injury

Piriformis area

The Sensitive Nervous System

Chapters B, 11 and 15

ltDtal nerve

DFlEVlSLR

> therapist's assessment p10

p11

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The foot is held in dorsiflexion, eversionand pronation. Straight Leg Raise isthen performed with the therapist's armon the shaft of the tibia

The right leg can be flexed for a more<enciii\/e nrnhlem

In the reversal technique, thetherapist's shoulder can be used.

Reversal SLR/DFlIN

Tibial nerve > passive techniques

These techniques may be useful for Morton's metatarsalgia'

More comfoft may be achieved with the therapist seated and thepatient in a SLS position.

Trv intermetatarsal splaying and antero-posterior movements(inset) and include extension of the toes.

In: SLR/DFlEV Did: IMT Mobilisation

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Slump LS/DF/EV: IMT Mobilisation

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Inz HF/DF/EV Did: KE with nerve massage

This technique may be appropriate for neurogenic foot problems

such as plantar fasciitis, particularly where there is swelling

around the nerve at the medial ankle.

Most nerves can be massaged if there is no direct nerve injuryand the nerve is not too sensitlve.


ln:, KF/DF/IN Did: KEISLR

'Ultimate tibial mobilisation'This technique uses order ofmovement principles to takeup the nerve slack from thefoot first.

knee flexed

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Ankle dorsiflexion, eversion,pronatlon

SLR. In the final position, any of thecomDonents could be mobilised.

Knee extension

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Tibial nerve > self

In: HF/DF/EV Did: KE

'Heel to the sky'

Leg swing heelto floor

ma nagement > gentler movements pr4

These are gentle movements,appropriate for a more acute orsensitive state involving the tibialnerve. If the patient focuses on

pushing the heel to the sky it willencourage mobilisation of thetibial nerve and perhaPs Provide a

distracting metaphor,

In the leg swing technique,poking the heel at the floor willcreate a similar nerve challenge.

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Tibial nerve > self management

In: Stand/DFlEV Did: SP flex

In: HFIDFIEV Did: KE + strap'Wall work'In the wall mobilisation technique, the

kev is to use the strap or towel to make

sure that the foot is securely held indorsiflexion, eversion and pronation.

> stronger movements p15

These are examPles ofmore ag9resslvemobilisation techniques'Some of the peronealnerve mobilisations could

also be adapted for thetibial nerve.

Note the tensioner and

the slider in the sPinal

flexion technique.

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self management

Did: KE (sli/ten)

Did: IMT mobilisation

and pa

> stronger movements p16

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Tibial nerve >

In: Slump LS/DF/EV

In: Slump LS/DFlEVlNFToe wriggler in slumP

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Palpable areas

A Lateral to the Achilles tendon

B Distal to the fibula

Common entraPments y' sYndromes

Recurrent ankle Problems

A component of Achilles tendonitis

The Sensitive Nervous SYstem

Chapters B and 11

Tensioner

Sural nerve

DFlIN/SLR

> therapist's assessment p1B

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The ankle is dorsiflexed and inverted and

held firmly.Therapist's forearm is on the shaft of the patient's

tibia, maintaining knee extension during the SLR.

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Sural nerve > passive techniques

Inl. HF/DF/lN Did: KE

With the Datient's hio in flexionand ankle in dorsiflexion andinversion, knee extension can be

used to mobilise the nerve.

In: DFIIN Did: nerve massage

Massage techniques may be usefulhere, particularly for swellingaround the lateral Achilles tendon.If appropriate, the nerve and itssurrounding tissues can be

massaged with the nerve in tensionas in the SLS position depicted.

p19

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Sural nerve > self management

ln: HF/DF/lN Did: KE (sli/ten)

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p20

The easiest way to self mobilise the sural

nerve is to replicate the passive

technique. Spend time ensuring that thefoot is in dorsiflexion and inversion.

Adding neck flexion (3) provides a moreaggressive movement and neck extension(4) allows a less aggressive and distractedlarge range movement.

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Femoral nerve > anatomy and palpation

Palpable areas

A May be palpable through tissue at the inguinal ligament

Common entrapments / sYndromes

Pinch or hvperextension at the inguinal ligament

L2-3 root syndromes

The Sensitive Nervous SYstem

ChaDters B and 11

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Tensioner

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Femoral nerve > therapist's assessment

Prone Knee Bend (PKB)The Dl.iR i< > rrr r.lo facf-,--l a5 manystructures (including the femoral^^-.,^\ ^-^ r^^!^f,I tEt vE,/ dt E LE>LEU.

Slump Knee Bend (SKB)

The SKB allows a more refined testingthan the PKB. For the left SKB, thepatient's left knee should be around90 decrees. Get fhe natient to holdher right knee in some, but not full,hip flexion and then extend the hip.

Use neck flexion/extension forstructural differentiation.

For heavy legs, try performing theSKB with the test leg downside.

Hip lateral and medial rotation can be

added to test groin nerves such as theilioinguinal and iliohypogastric nerves.


In: Sfump SLY/KF/HE Did: HAbObturator test

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To test the obturator nerve/ use the Slump Knee

Bend oosition and then abduct the hip (2). This

could be an assessment and treatment technique

for neurogenic components to groin and medial

knee patn.

The neck could be used for structural differentiation'

p22

p23


In: Sfump SLY/KF/HE Did: HAdMeralgia test

To test the lateral femoral cutaneous nerve, whichmay be involved in the syndrome meralgiaparaesthetica, the Slump Knee Bend position is

used and then the hio adducted.

Any of these components could be used as

therapeutic movements and/or if appropriate,structures around the nerves such as the L2-3joints, the inguinal ligament and the anterior thighfascia could be mobilised.

p24

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n'fr Dttttr t t t il t;;;gggusHsu ilttttttttrHtlHtTus!!!uuHH#gIFemoral nerve > self management

Half Pushup

Half pushups are widely used inrehabilitation. The manoeuvremobilises all anterior hip structuresincluding the femoral nerve.

Half Pushup + neck sli/ten

If the patient lies propped up on her elbows and flexesher head and the knee at the same time, thisis a tensioner along the femoral tract even though thelumbar extension may slacken the system a Iittle,

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p25

Neck extension and knee flexion would comprise a slider,

Femoral nerve >

'Thomas test exercise'

self ma nagement p26

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An example of more aggressive self mobilisation for thefemoral nerve complex. in the'Thomas test exercise',anterior hip muscles will most likely limit the hip extensionand knee flexion. If there is a neurogenic component, theaddition of neck flexion mav influence responses.

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Femoral nerve > self management

'Hurdler stretch'

Another example of more aggressive self mobilisation forthe femoral nerve complex. In the'Hurdler stretch'position, neck flexion, left knee flexion and right kneeextension can be used simultaneously for an aggressivesoft tissue and neural mobilisation,

p27

T!E T,E E [ [ E I E [ ! ! ! E I E N !II IISaphenous nerve > anatomy and palpation

Palpable areas

A Infraoatellar branches on the head of the tibia

B Main saphenous nerve between gracilis andsartorius at the knee ioint

Common entrapments / syndromesPost arthroscopy medial knee pain

May be involved in knee medial collateralligament injuries

The Sensitive Nervous System/-h:nfcrqRand11

p29

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Saphenous nerve >

Prone / HE / HAb / KE / MR/ DF / EvThe saphenous test

thera pist's assessment p30

Alternative positionPatient in supine, therapist seated

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Saphenous nerve > passive technique

In: Prone/HE/HAb/MR/DF/EV Did: KE

In the saphenous test position, knee extension is a useful way tomobilise the nerve complex, Massage techniques (3) could also be used.

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Hlp extension and abduction

Hip lateral rotation Ankle dorsiflexion eversion

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Saphenous nerve > self management

The saphenous stretch

p32

p33

The patient stands with feetapart. To mobilise the leftsaphenous nerve, place rightleg in front of the left. Theleft foot is in dorsiflexionand eversion.

By flexing the right kneethe left saphenous nerve isself mobilised.

I NOr

E E E E E E E E E E E E ! E E ! ! E E ! ! ! [Median nerve > anatomy and

Palpable areasA Upper arm

B Medial to the biceps tendon

C Indirectly at the carpal tunnel

Common entrapments / syndromesCarpal tunnel syndrome

Post Colles' fracture symptoms

C5-6 nerve root


Chapters B, 12 and 15

palpation

p34tMedian nerve > active quick test

This active quick test is an example of structural differentiation. If there are symptoms

on shoulder elevation that are made worse by either neck lateral flexion away from the

iest side and/or wrlst extension, then the clinical inference is that those symptoms are

from a neurogenic source, perhaps the median nerve and/or its roots. If the therapist

stabilises the shoulder, more refined testing is possible.

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Median nerve > therapist's assessment

ULNT1 (See stage by stage description on next page)

p35

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Median nerve > therapist's assessment p36

ULNT 1

1. Starting position. Note patient's thumband finger tips supported, plus some ofthe weight of the arm taken on thefhorenicf'c fhinh

2. Shoulder abduction to symptom onset, ortissue tightness, or approximately 100

deg rees.

3. Wrist extension. Make sure the shoulderposition is kept stable.

4. Wrist supination, again making sure thatthe shoulder position is kept stable.

5. Shoulder lateral rotation, to symptomonset or where the tissues tighten a little.

6. Elbow extension to symptom onset.

7. Neck lateral flexion away, making sure itis whole neck and not just the uppercervical spine.

B. Neck lateral flexion towards. This shouldease evoked symptoms.

ULNTl Alternative position

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The alternative position shown uses the therapist'sshoulder rather than their fist. From the startingposition shown, the entire test can be performed.It is a comfortable and very supportive position foranxious patients. It is also a useful way to providepassive movement techniques to patients.

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IEE AEEEE E E E E E ! ! ! ! ! ! ! $ $Median nerve > therapist's assessment p37

ULNT1 Reversed This reversal of the ULNT1 is an example of using the order of movement principles.Such a technique may be appropriate for a median nerve based problem such as carpal tunnel syndrome.

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Block the shoulder girdlefrom elevating

Careful shoulder abductionusing the therapist's thigh

Elbow extension, holdwrist position securely

Add cervical flexion orlateral flexion

Starting position Wrist extension Wrist supination

Whole

NOI

arm lateral rotation


ULNT1 Reversed: index finger firstThe reversed ULNT1 can also be

performed by starting wlth one digit and

then adding the other components. Such

an assessment and treatment technique

may be appropriate for a patient with a

persistent digital nerve problem.

DT;;& E T H


ULNT2

p3B

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Patient has her shoulder girdlejust over the side of the bed

Whole arm lateral rotation,keeping shoulder girdle depressed

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Shoulder girdle depression (via thetherapist's thigh) to sYmPtoms orwhere the tissues tighten a little

Wrist and finger extension(note suggested griP in the inset)

p39

Structu ral differentiationcan be preformed bY

elevating the shouldergirdle a little, or if thereare shoulder/necksymptoms, the wristflexion can be released.

Elbow extension


ULNT2 Seated position

The ULNT2 can be performed with the therapistsitting. Many patients and therapists prefer this as

the arm can be very well supported and it is easier

to see the patient's face.

In image 2, structural differentiation is performed

via wrist flexion to differentiate the origin ofshoulder area symptoms.

n;rsMedian nerve > passive techniques

Here are two examples of theslider and tensioner movementsfor the median nerve.

ULNT2 Sli/tenIn the seated position, if the wristis flexed and the shoulder girdle

depressed, as in the image, thiscomorises a slider movement.

ULNTl Sli/tenWhen there is neurogenic Problem,during the ULNTl test, the patient'sshoulder girdle will often protract,thus avoiding some of the tension on

the nervous system. At the momentof protraction, if wrist flexion is

added, then a slider will be

performed. This allows a gentle

mobilisation as well as a waY ofunlearning unuseful motor patterns.

Oruor

p40

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Median nerve > passive techniques

'Nanna arm wobble'

'Nanna arms'are the floppy bits many people getunder their upper arm/ especially as we get a bitolder. The aim of this passive technique is to makethe arm'flop'. If the patient is relaxed, while the wristgoes into flexion the shoulder adducts.

p42

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p43Median nerve > passive techniques

In: ULNT1 Did: GH mobilisation

This is an example of Performing a

joint mobilisation while the nerve is

in some tension. There maY be a

stiff joint accessory movement whichcan be mobilised while the nerve is

in some tension. Such a Patientwould have joint and neural tlssuephysical health issues.

Technique in more shoulderabduction.

Note how further tension is Placedon the nerve, by asking the Patientto extend her wrist.

Median nerve > self management > gentler movements p44

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This series of genlle self mobilisationtechnicues uses functional and funmovements and metaphors. 'Balloonpatting', 'watch the watch' (place watchon ventral side of wrist) and using a

yoyo encourage the supination andelbow extension Darts of the ULNT1.Attempts at juggling provide a similarnerve mobilisation.

Balloon patting

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'Watch the watch'

Juggling

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p45

'No more dishes' and the ball throwingprogression are more aggressivemobilisers, but still functional and fun,

Ball throwing can be progressed fromunderhand to overhand throwing'

Ball throwing progression

'No more dishes' (after Barb Beatty)

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Median nerve > stronger movements

With imagination, knowledge of neuroanatomy, anduse of metaphors, a series of functional mobilisationtechniques for the median nerve can be constructed.Get the patient to'buzz' during 'busy bee', note thatthe finger and wrist stretches are quite vigorous forneural tissue in the hand and wrist.

Crawling is a strong functional median nerve mobiliserand note how balancing creates large range slidermovements similar to a ULNT2 for the median nerve.

For'free the bird'get the patient to imagine they areholding a small bird and then to let it go. Now where isthat frisbee?

'Finger stretch'

'Busy bee'

p46

'Rock around the clock'

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aO NoItDnilfitt Dttt;I g g g sMedian nerve > stronger movements p47

Crawling

Balancing acts

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p4BMedian nerve > stronger movements

Look at your hands

A Pisiform area at the wrist

B At the elbow and in the uoper arm

Common entrapments / syndromes


Chapters 5, B and 12

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p49

NEEI,EEEEEEEEE!Ulnar nerve > anatomy and palpation

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Ulnar nerve > active quick test ps0

Ask the patient to put herhand on her ear and then,keeping the hand on theear, lift the elbow up.

For most patients withulnar nerve or root basedproblems this movement,or part of the movement,will be sensitive in theulnar distribution.

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Ulnar nerve > therapist's assessment p51

ULNT3 From wrist first

Starting position - thepatient's elbow rests on thetherapist's hip

Wrist and finger extension,ensure 4th and 5th fingersare extended

Block shoulder girdleelevation by pushing fist intothe bed

Shoulder girdle dePressionif required

Shoulder lateral rotation,ensuring wrist position ismaintained

Shoulder abduction; necklateral flexions can be=AAaA if ranrrirod

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Pronation

Elbow flexion

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Ulnar nerve > Passive techniquesp53

In: ULNT3 Did: pisiform mobilisation

The pisiform mobilisation in ulnar nerve

load is an aggressive technique' It may De

relevant for a patient with persistent little

finger problems after a wrist injury'

Ulnar nerve > therapist's assessment

ULNT3 From shoulder first

f

Starting position. With handunder patient's scaPuladepress shoulder girdle

p52

In: ULNT3 Did: massage cubital tunnel

These are examPles of massage

techniques in neural load positions'

Note how the ulnar nerve in the cubital

tunnel is massaged more aggressively

with the wrist in extension (1) and then

more gently with the wrist ln flexion (2)'

The massage and the wrist movements

could be combined'

Shoulder abduction Lateral rotation of shoulder

Wrist and finger extension Forearm pronation

,b;

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Ulnar nerve > Passive techniques

In: ULNT3 Did: Sli/ten

p54

In 1, a tensioner is Performed as the

shoulder girdle is depressed while

the ulnar nerve is loaded.

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The patient's neck is extended as theshoulder girdle is depressed, making

a siider technique.

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'Don't listen'

self management

'Face massages'

> gentler movements

'Make a halo'

ps5

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With neck flexion, this rs a moreaggressive tensioner technique'

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tt\LTThese are examples of gentle functional

movement for the ulnar nerve and its

brain representations. The metaphors

orovide a distraction. Be creative.

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'Yahoo!''Smoking'

Ufnar nerve > self management > stronger movements

'Plate exercise'

Ask your patient to imagine they have a

glass of wine on the plate and then dothe exercise as shown in the imaqes.

Some examples of strongermobilisation exercises for theulnar nerve.

'Dry the back'

p56

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'Crawl to the pits'

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Radial nerve > anatomy and palpation

Palpable areas

A Mid humerus

B Radial sensory nerve on the lateral

aspect of the forearm

Common entrapments / sYndromes

De Querva in's tenosynovitis

Supinator muscle (tennis elbow)

Post humeral fracture Pain

C5-6 root syndromes

p59

Radial nerve > active quick test

Ask the patient to let their arm hang by their side, thenmake a fist holding their thumb, then extend the elbow,then point the thumb away from the body (internal rotation)and depress the shoulder. A few degrees of shoulderextension may sensitise the test. Elevation of the shouldergirdle provides an easy way to structurally differentiate.

p60

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The patient lies with their shoulderjust over the side of the bed, thetherapist uses his thigh to carefullydepress the shoulder girdle

nerve > therapist's assessment p61

Notice how the therapist has broughthis left arm'around'to grasp thepatient's wrist in order to mediallyrotate the whole arm

Adding a few degrees of shoulderabduction will sensitise the test andelevation of shoulder girdle willprovide structural differentiation

Wrist and thumb flexion can beadded. Leave the fingers out as theextensors will be too tight

ULNT2 (radial)

Elbow extension

Whole arm medial (internal) rotation

Radial nerve > therapist's assessment

ULNT2 (radial) Seated variationSome therapists prefer to assess theradial nerve in sitting, particularly ifthe patient is anxious and sensitive.The patient's arm can be well cradledand supported. This is also a goodposition to perform passive techniques.

1. The arm is well supportedin the starting position

2. Shoulder girdle depression

3. Whole arm medial rotation

4. Wrist flexion

Radial nerve > therapist's assessment

ULNT2 (radial) From wrist firstThis may be appropriate for persistent problems on thelateral aspect of the wrist. Using order of movementprinciples, wrist and finger flexion plus ulnar deviation (1),then elbow extension (2), arm medial rotation (3) loads

the radial nerve from the wrist first,

p62

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p63

Radial nerve > passive techniques

In the seated position there are plenty of opportunities forgentle passive techniques, If you get the patient to point

to their nose while you gently depress the shoulder girdle,

this forms a gentle slider. Be creative.

'Gentle radial sliding' 'Whole arm rotations'

Radial nerve > passive techniques

In: ULNT2 (radial) Did: Rad head and soft tissue mobilisation

p64

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Once the ULNT2 radial nerveposition is maintained, a varietyof techniques are available. The

radial head could be mobilised orsoft tissue stretches performed.Some of these may be useful fortennis elbow which has stronglocal tissue components

Radial nerve > self

'Pouring water'

ma nagement

'Pouring water' and big swinging 'figures of eight'are gentle ways to mobilise the radial nerve and itsrepresentations in the brain. Make sure with theswinging technique that the shoulder internally andthen externallv rotates.

Radial nerve > self ma nagement

> gentler movements

'Figures of eight'

p66

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> gentler movements p67

'Pump water'Pumping water allows thenon-painful arm to helpguide mobilisation of thepainful/injured arm. Thestarting position encouragesinternal rotation.

Look at your handbehind your elbowIf the patient attempts tosee their hand behindtheir elbow and to see

their fingers and theirthumb, this provides a

vigorous sliding selfmobilisation. Try itbilaterally - it's almost a

dance move.

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Radial nerve > self management

These are examples of stronger, yet functional selfmobilisation movements, In the table stretch, the patientkeeps the back of their hand flat on the table and thenrotates their whole bodv awav.

'Back massage' 'Tip please'

Musculocutaneous

Palpable areas

Difficult to palpate

Common entrapments/ syndromesDe Quervain's tenosynovitis

Tennis elbow 'above' the elbow

Post intravenous drip pain syndromes


Chaoter 12

> stronger movements p6B

'Table stretch'

nerve > anatomy and palpation p69

s"*;:

I p70Musculocutaneous nerve > active quick test

Make a fist, ulnar deviate the wrist, extend theelbow and extend the shoulder as though marching.

Musculocutaneous nerve > therapist's assessment

ULNT (musculocutaneous) This position can also be used for passive mobilisation.

Starting position (same as theULNT2 test for the radial nerve)

p77

Wrist ulnar deviation and thumb flexion.Either medial or lateral rotation could sensitise the nerve further.

Shoulder girdle depression Elbow extension

Shoulder extension carefullv

Musculocutaneous

Running on the spot

nerve > self management p72

p73

'Throw it away'

Spine, cord and meninges > anatomy

The spinal and craniai meninges (dura, pia and arachnoidmater) surround the spinal cord and form a continuousstructure allowing force transmission from the peripheralto the central nervous system and vice versa. The spinalcanal is between 7-11 centimetres longer in flexion thanin extension, thus the meninges and spinal cord will bephysically challenged in positions such as sitting, forwardbending and especially the Slump tests demonstrated in

this section.


ChaDters 5. 11 and 15

A{tr"'' olEN:1^.'',. t:

Spine, cord and meninges > active quick test

In spinal flexion the meninges and spinal cord will be physically challenged. If low

back symptoms evoked by spinal flexion are made worse by the addition of neckflexion this infers that there is a physical health problem of the nervous system.Neck extension should relieve symptoms.

Spine, cord and meninges > therapist's assessment

Passive Neck Flexion (PNF)

PNF can be performed rn two ways. Upper cervical flexion (2),places load on the cervical and cranial meninges and if this iscombined with lower cervical flexion (3), a considerable load isplaced right through the entire neuromeningeal system.

PNF will frequently reproduce back pain, suggesting nervoussystem involvement is a frequent component of back disorders.

p74

p75

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Spine, cord and meninges > therapist's

Straight Leg Raise (SLR) Sensitising movements

The nervous system sensitising movements which are

frequently used for lower limb disorders can also be used

for the neuromeningeal tissues.

Spine, cord and meninges > therapist's

Bilateral SLR

ASSCSSMCNT

Hip adduction (2), hiP medialrotation (3), spinal lateral flexion(4) and upper cervical flexion (5)are shown. These movementsmay be required to identifY minordisorders of the nervous systemand any of these movementscould be used to mobilise thenervous system.

p76

!!!!!!!!EUslASSCSSMCNT p77

ii

Bilateral Straight Leg Raise (BSLR) techniques are useful and

can be easily converted into self mobilisation techniques. BSLR

provides a different biomechanical challenge to neuromeningealtissues than a single SLR. In the example shown, ankledorsiflexion is used as a technique.

The technique may be appropriate in patients with positive

Slump Long Sit tests. Of course, neck and shoulder girdlemovements could also be introduced as part of tensioner and

slider techniques. Be creative.

Spine, cord and meninges > therapist's assessment p7B

p79

'i:,ffi

Slump test activeIt is best to perform tests:dirrelrr firct cn fhc

therapist and patient thenknow what to expect.

Check symptoms andsymptom change ateach stage.

1. Starting position, kneestogether and thighs wellsu pported

2, Spinal slump, ensuringpatient doesn't forwardtilt her pelvis

3. Neck flexion

4. Knee extension

5. Release neck flexion.The knee can usually beextended further andthe ankle dorsiflexed.

6. Bilateral knee extension

Spine, cord and

Slump test passive

1. Spinal slump, makingsure the patient doesn'tforward tilt her pelvis

2. Neck flexion with gentleoverpressu re

3. Knee extension

4. Add dorsiflexion ifreq u i red

5. Release neck flexion.The neck is extended instages checking theresponse to evoked legand back symptoms

6. Bilateral knee extensionif required

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meninges > therapist's assessment

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Lateral flexion of the entirecervical spine has beenper-formed allowing a test ofthe physical health of upperthoracic neural structures,This will frequentlyproduce relevant thoracicand lumbar symptoms on

the convex side.

pB0

Structural d ifferentiationcan be performed byflexing the knee.

Slump Long Sit (SLS)

This test position providesa very stable assessmentplatform for neuralproblems in the spine andneao.

Remember to check forsymptoms at each stageof the test.

The test will need to be

adapted depending on thepatient. For those who aretight, pillows under theknees may be requiredand more hip flexion maybe necessary for thosewho are more flexible.

The patient is in a SLSposition, This could beadapted as necessary, forexample pillows under theknees or more spinalflexion.

*."3

Starting position, thetherapist uses his knee tostabilise the sacrum

The therapist stabilises thespine at the cervicothoracicj u nction ,

differentiation of any lower body evoked symptoms.Note how the ankle can be dorsiflexed further

Thorax andsrump

FTHHHilFTillIlllllllrJSpine, cord and meninges > passive techniques

Slump Long Sit / Structural differentiationDurinq the SLS test, a more refined structural differentiation can be performed,

lumbar spine

Extend left knee Release neck flexion to provide structural

q.

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Spine, cord and meninges > passive techniques

fn: leg distraction Did: neck sli/tenThis is an example of a very gentle challenge to the spinal canal and its contained structures. First,gentle leg distraction is performed rhythmically. If the patient puts her head back at the same timethis is a slider technique. The technique can be progressed by performing the same distraction in SLR.


fn: SLS Did: Thx Lateral flexion techniques

On this and the following page are examples of some

vigorous passive techniques for the thorax. Note the

lateral flexion techniques above, including the third image

where lateral flexion is localised to a specific and relevant

level. Thoracic lateral flexion can be achieved by the

therapist's body. If the patient extended her knee at the

same time as the lateral flexion was applied, this would

be a tensioner.

pB2

pB3

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Spine, cord and meninges

In: SLS Did: AlP movements

An anteroposterior movement can be applied in

the Slump Long Sit. The therapist's left carpaltunnel is just under the level to be mobilised and

his right hand in on the patient's sternum, softenedby a towel or pillow. This may be useful for a flatupper thoracic spine relevant to a particularthoracic spine disorder.

> passive techniques

> passive techniques

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pB4

tfrilupB5

tttuuuSpine, cord and meninges

Notalgia paraesthetica techniques

This is an example of a refined technique for entrapment of

the cutaneous branches of the thoracic postertor prlmary

rami. The syndrome is called notalgia paraesthetica'

Tender spots, even nodules, may be palpated where these

nerves exit the muscles and fascia to become cutaneous'

These will be more tender in the Slump Long Sit position'

less so if the neck is extended. Frequently the nerve will

be more reactive if massaged laterally along the lateral

branch, rather than medially. This may be an appropriate

technique for some Patients.

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Wedges can be a useful adjunct to passive and self mobilisation.In the example shown, the wedge is being used to facilitate a

thoracic (predetermined level) mobilisation. The spinous processes

lie in the groove of the wedge and the mobilisation is gentlyperformed using the ribs, A towel or small pillow for paddingmakes it more comfortable. Because this allows a superior jointmobilisation it can also be used to mobilise associated neuraltissue, for example, if the same technique was performed in

Straight Leg Raise or Bilateral Straight Leg Raise.

Wedge mobilisation techniques / Thorax spine


Wedge mobilisation techniques / Cervico thoracic area

wedge technlques can be useful for the cervico-thoracic area. The force

is through the clavicles not the jaw, and the therapist's left hand is only

assessing the intervertebral movement while cradling the patient's head.

pB6

p87

More tension can be Placed on thenervous system during the mobilisation

by adding an Upper Limb NeurodynamicTest (3 and 4) or Straight Leg Raise (5).

Spine, cord and meninges > self managementgentler techniques

PBB

pB9

Pelvic tilt/neck Sli/tenExamples of gentle sliders (1)and tensioners (2) for themeninoes and soinal cord.

SLR/neck SIi/ten

Spine, cord and meninges > self management> stronger techniques

'Wring' techniqueThis technique is named after the action of wringing out a wet towel. With the knees flexed and rolling from side to

side (2), a gentle wringing effect is placed on the spinal cord. lf the patient turns their neck away at the same time(3), a more aggressive wringing is provided, and if the chin is tucked in (4), even more load can be applied. By using

the arms and depressing the shoulder girdle (5), even more load can be placed on the nervous system.

Spine, cord and meninges > self ma nagementstronger techniques

p90

p91

SLS / Shoulder shrug

The SLS position offers a safe and supported starting position for self mobilisation.

In the images, a slider is being performed. As the patient extends her knee, she shrugs

her shoulders. This may be a useful slider when the neck is sore. In this positlon there

are many combinations of sliders and tensioners. For example, if the knee is extended

at the same time as the neck is extended, this creates a slider movement.

Spine, cord and meninges > self managementstronger techniques

'Kick your head off'These are stronger slidersand tensioners for thelower limb and meninges.

They can be adapted tofocus more on theperoneal or tibial nerves.This not only mobilisesneural tissues butprovides movement in a

novel and safe way.

'Kick your head off' Focus on peroneal nerve

1-

Oruor

Spine, cord and meninges > self management> stronger techniques

'Wall walking'Images 4,5 and 6: Notice how the patient moves closer to the wall to achieve more Straight Leg Raise.

p92

tHttttrttrrllllJlJlllllltp93Spine, cord and meninges > self management

stronger techniques

'Total slump'Bob Johnson techniqueTwo vigorous mobilisationsare snown nere.

Notice how the standingtotal slump uses order ofmovement principles toload cervical and cranialmeninges first.

'Roll over'In the roll over Positionfor the appropriatepatient and problem,further mobilisation can

be performed by leg

movements.

O Nor

Other nerves > Accessory nerve (cranial nerve XI) p94

p95

1. The patient lies in sidelying

2. Lateral flexion andprotraction of the neck

3. Retraction of the shouldergirdle, making sure there is

enough slack in the skln

4. Upper cervical flexion willadd more load

Other nerves > Axillary nerve

A neurodynamic test can be placed on any nerve, simplyby observing where the nerve is in relation to joint axesof movement, A test for the axillary nerve will be a

combination of neck lateral flexion, shoulder girdledepression and internal rotation. Any of thesemovements could be used for mobilisation. The axillarvnerve may be injured post shoulder dislocation.

p97

p96Other nerves > Suprascapular nerve

The suprascapular nerve is challenged in a combinationof neck lateral flexion and shoulder girdle depression.A force down the humeral shaft takes the nerve furtherfrom its roots and finally the scapula can be rotated as

a mobilisation technique.

Other nerves > Trigeminal nerve

Open mouth and move Jawto the right

Trigeminal nerve

Upper cervical lateral flexionUpper cervicai flexion

Total cervical flexion

4{#_

p9BOther nerves > Ocei*ita! nerve

The greater and lesser occipital nerves can be challengedin uooer cervical flexion and lateral flexion of the neckaway from the side to be tested.

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Documents

The Neurodynamic Techniques