With thanks to ... Our international faculty NOI Faculty members NOI instructors are hand selected on the basis of Translators - Ruggero Strobbe (Italian), Stefan their existing skills and expertise and undergo Schiller and Margot Bauer-Mitterlehner (German), progressive peer and expert training. All instructors Henry Tsao and Mei-Chun Kuo Tsao (Chinese have postgraduate manual therapy educations and Mandarin), Benito Cao (Spanish). are members of national associations and of the Models - Claire, David and Rookie International Association for the Study of Pain. Design - Anane Allchurch, Dinah Edwards Production manager - Juliet Gore Our courses taught in languages other than English Anatomy artwor - CopYright (2005), Icon are predominantly delivered by native speaking members of the faculty. _=. ._E3IT r _ 5 \"tems, LLC A subsidiary of 1Y1ediMedia, _,..,z. r ts reserved. NOI's faculty members all travel widely to meet their o 0 autho jng - nthony ~ames teaching commitments. :;re.ra eographics, [email protected] Australia David Butler, Peter BalTett, Carolyn Berryman, Reproduction - rvlicroview Solutions Michel Coppieters and Megan Dalton. Chars wood NSW, Australia, www.microview.com.au Europe - German speaking Printing - van Gastel Printing, Adelaide, Australia Gerti Bucher-Dollenz, Martina Egan-Moog, Music· Maria by Miguel Espinoza Hannu Luomajoki, Harry von Piekartz, Hugo Stam and Irene Wicki. Europe - Italian speaking Sergio Parazza, Erika Schiffereger, Ruggero Strobbe. Susanne Wahrlich and Irelle Wicki. USA Bob Johnson, Adriaan Lou I Stephen chfTlidt and .' Canada Sa\"'\" - Introduction Nine key points This neurodynamics techniques DVD 1 > What is a neurodynamic test? and book has been produced by the Neuro Orthopaedic Institute Neurodynamics is the science of the relationships between mechanics and Australasia, with contributions from physiology of the nervous system. Simply put - it is the assessment and our international faculty. It is treatment of the physical health of the nervous system. Just as a joint moves expected that users will be health and a muscle stretches, the nervous system also has physical properties professionals, and thus will have an that are essential for movement. You can examine these properties via existing knowledge of neuroanatomy nerve palpation and neurodynamic tests. and neuro orthopaedic assessment plus knowledge of relevant pathology, 2 > The nervous system is a continuum precautions and contraindications. A mechanical, electrical and chemical continuum exists in the nervous For optimal and safe clinical system. ThitS is the basis of tests such as the slump test, where for integration, it is highly recommended example, the position of the neck will influence neural responses in the leg. that this DVD and book be used ·in association with Nor education 3 > Structural differentiation seminars (www.noigroup.com) and/or used with the textbooks Mobilisation The neural continuum allows a differentiation between neural and non of the Nervous System or preferabl,y, neural tissues. For example, in the case of the slump test (see below), The Sensitive Nervous System. if neck extension which takes load off the nervous system eases evoked symptoms In the leg, This DVD and book should not be then this provides taken as just a list of exercises, but some clinical data to more a series of ideas. For example, suggest that there is techniques may be demonstrated to a physical health issue illustrate a particular principle for one in the nervous system. nerve, but similar techniques could be used for other neural structures.
4 > Neural relations to 6 > Order of Movement joint axes dictates load The strain and movement of the nervous system will be affected by the order in which the movement The nervous system is usually is taken up. For example, as illustrated, if you add behind, in front, or to the side ankle dorsiflexion and eversion and then perform a of joint axes of movement. This Straight Leg Raise (SLR) , a neurogenic problem in means that the physical loading the tibial nerve at the ankle is more likely to be on the nervous system will be exposed than with other combinations. dictated by joint position. In the example shown of the There are probably two reasons for this: a more Upper Limb Neurodynamic Test (ULNT), wrist extension, mechanical reason where the neural tissues are elbow extension, and shoulder abduction would be examples 'borrowed' from other areas and thus given more of movements which challenge the median nerve and the of a chance to be challenged, or perhaps the first brachial plexus. If you know your anatomy, you could make movement is the one which takes priority in the up neurodynamic tests yourself. patient's consciousness. 5 > Pinch and tension - the key role of neighbouring structures Most ne,Jrodynamic tests are tests of the ability of the nervous system to elongate. The neighbouring structures (e.g. joint and muscle) which 'contain' the nervous system can sometimes pinch it. Wrist flexion is a test of the neural container around the median nerve at the carpal tunnel, and the Spurling's test (illustrated here) is an example of a pinch test for lower cervical ne e roots. 7 > Sliders and tensioners 8 > Recording A tensloner ( ) can _~ a 9 steen qc.E borevla 'ons such as PF/IN/SLR inform which 'pulls from both ends of t \" \"leJVo_s the or er and kind of movement, thus ankle system. A slider (2) is a 'flossing' movement olanta flexion first, then inversion and then where tension is placed at one end of the Straight Leg Raise. Each component can system and slack at the other. Sliders also be quantified in terms of range of provide a large amount of neural movement movement or qualified in terms of and are a neurally nonaggressive movement symptoms evoked. for anxious patient$. The 'In:Did' system is also used. For example, In: HF/LR Did: KE means that in the hip flexion and lateral rotation position, knee extension was performed. 9 > Don't forget the brain Remember that responses to these tests may not always be due to physical health issues in the nervous system. In some patients the sensitivity evoked during testing may be due to changes in the central nervous system. There is mucn more on this important part of assessment in The Sensitive Nervous System.
Glossary References CIT '\" Cervico-thoracic Butler DS (2000) The Sensitive Nervous System, ISBN 0-646-40251-X, OF Dorsiflexion NO! Publications, Adelaide. EV Eversion Butler DS (1991) Mobilisation of the Nervous System, ISBN 0-443-04400-7, GH Glenohumeral Churchill Livingstone, Melbourne. (Also in German, Italian, Spanish and Japanese,) HAb '\" Hip abduction Support nlaterial HAd Hip adduction NO!'s list of self published literature and brain products is HE Hip extension continually updated and expanded'. Visit noigroup.com for detailed descriptions and secure online ordering. HF Hip flexion noigroup,conl IMT '\" Intermetatarsal An acti,ve network for reviews, case studies, relevant research IN Inversion data, reference lists, international course schedules in English and other languages, discussion forum and' feedback page, KE Knee extension resources, product sales, booklist with links to booksellers. Become a member of the NO! network by completing the KF Knee flexion membership form at www.noigroup.com or by emailing your details to [email protected]. lat flex. Lateral flexion lR Lateral rotation lS Longsitting NF Neck flexion PF Plantar flexion PKB '\" Prone Knee Bend PNF Passive Neck Flexion Rad Radial SKB Slump Knee Bend sli slider SlR Straight Leg Raise SlS Slump Long Sit SLY Slump sidelying SP Spinal Sup TF . Superior tibiofibular ten .... tensioner Thx . , .. Thorax UlNT .. Upper Limb Neurodynamic est al erve a omy and palpation .1 Passive techniques erapist's assessment :n: SLR/DF/EV Did: IMT rrob .... , . . • . . . . . . 11 c =- ' . . . . . . . 2 In: Slur:lp LS/DF/EV Did: IMT mob 11 as ou de- . .2 In: HF/DF/EV Did: KE with nerve massage. , , 12 Passive techniques In: KF/DF/IN Did: KE/SLR 'Ultimate tibial mob' 13 In: SLR/HAd/HMR/SP flex ,3 Self management> gentler movements In: HF/PF/IN > DF/EV Did: KE 4 In: HF/DF/EV Did: KE 'Heel to the sky' . . . . . . . • . . 14 4 In: Slump LS/PF/IN Did: Sup TF mob + KE Leg swing heel to floor 14 Self management> gentler movements Self management> stronger movements In: HF/PF/IN Did: KE 5 In: Stand/DF/EV Did: SP flex 15 15 Leg swing toes curled under 5 In: HF/DF/EV Did: KE + strap 'Wall work' In: Slump LS/DF/EV Did: KE (slijten) 16 Self management> stronger movements In: Slump LS/DF/EV/NF Did: IMT mob Toe wriggler in slump In: Slump LS/PF/IN Did: KE (slijten) 6 16 Standing mobilisation 7 Wall mobilisation 8 Sural nerve 'Hamstrings stretch' Focus on peroneal nerve 8 Anatomy and palpation 17 Therapist's assessment Tibial nerve DF/IN/SLR . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . 18 Anatomy and palpation Passive techniques Therapist's assessment DF/EV/SLR 9 In: HF/DF/IN Did: KE , 19 Reversal SLR/DF/IN 10 In: DF/IN Did: nerve massage 19 10 Self management In: HF/DF/IN Did: KE (slijten) 20
Sa..,..... '''' ... \". > a o y and palpation p29 Palpable areas A Infrapatella- b-ancnes on t e ead 0 - the tibia B Main saphenous nerve between gracilis and sartorius at the knee joint Common entrapments / syndromes Post arthroscopy medial knee pain May be involved in knee medial collateral ligament injuries The Sensitive Nervous System Chapters 8 and 11
Saphenous nerve> therapist's assessment p30 Prone/HE/H b/KE/MR/DF/EV Alt rnatlve position The saphenous test Patient in supine, therapist seated Hip extension and abduction Knee extension Saphenous nerve> pa sive tech . p31 In: Prone/HE/HAb/MR/DF/EV Old: KE In the saphenous test position, knee extension is a useful way to mobilise the nerve complex. Massage techniques (3) could also be sec
Saphenous nerve> self management p32 The saphenous stretch The patient stands with feet By flexing the right knee apart. To mobilise the left the left saphenous nerve is saphenous nerve, place right self mobilised. leg in front of the left. The left foot is in dorsiflexion and eversion. Me ia nerve> a atomy and p33 Palpable areas A Upper arm B Medial to the biceps tendon C Indirectly at the carpal tunnel Common entrapments / syndromes Carpal tunnel syndrome Post Colles' fracture symptoms C5-6 nerve root The Sensitive Nervous System Chapters 8, 12 and 15
Median nerve> active qUick test p34 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 test side and/or wrist 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. ~, I M ian nerve> t e r p35
Median n rve > therapist's assessment p36 ULNT 1 ULNTI Alternative position 1. Starting position. Note patient's thumb The alternative position shown uses the therapist's and finger tips supported, plus some of shoulder rather than their fist. From the starting the weight of the arm taken on the position shown, the entire test can be performed. therapist's thigh. It is a comfortable and very supportive position for anxious patients. It is also a useful way to provide 2. Shoulder abduction to symptom onset, or passive movement techniques to patients. tissue tightness, or approximately 100 degrees. 3. W,ist extension. Make sure the shoulder position is kept stable. 4. Wrist supination, again making sure that the shoulder position is kept stable. 5. Shoulder lateral rotation, to symptom onset or where the tissues tighten a little. 6. IClbow extension to symptom onset. 7. Neck lateral flexion away, making sure it is whole neck and not jlust the upper cervical spine. 8. Neck lateral flexion towards. This should ease evoked symptoms. Media nerve > thera 5 5 p3 Starti1g position Wrist extension Wrist supination Elbow extension, hold wrist position securely Whole arm lateral rotation =- cec srJoulder abduction Add cervical flexion or lateral flexion ., r = _ '= therapist's thigh
Radial nerve> self management> gentler movements p66 'Pouring water' 'Figures of eight' 'Pouring water' and big swinging 'figures of eight' are gentle ways to mobilise the radial nerve and its representations in the brain. fv1ake sure with the swinging technique that the shoulder in' emally and then exterrally rotates. a 2 e s P ter S ;:re -~--:a '_ a to eJ] : Of: ') lilsa on of t' e pa nful J , Jured arm The starting pas tion e.ncourages internal rotation. Look at your hand behind your elbow If the patient attempts to see their hand behind their elbow and to see their fingers and their thumb, this provides a vigorous sliding self mobilisation. Try it bilaterallv - it's almost a dance move.
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