Neurodynamics, History and Biases
Recently I ran a workshop for my workers and the local therapists to explore neurodynamics and their application in the clinic. At the start of the workshop I thought it was important to outline my Biases to the group. Why you ask? because my Biases will influence and guide my assessment, clinical reasoning and how I apply the technique. Knowing my biases allows me to stand back and apply more critical thinking to my clinical reasoning. My strong biases are the Biopsychosocial model of care, Neuro matrix/ Neurotag Theory and the Mature Organism Model. I have included a link below to the first part of my presentation to my workers outlining my biases. I have been guided by resources from Butler, Moseley, Coppieters and Gifford and they are great examples of clinicians that have evolve with the science and occasionally loose clinical mileage along the way. Unfortunately, I haven’t got around to reading the work of Michael Shacklock yet, who is another big name in this field of neurodynamics. This blog is a quick birds eye view of the history of neurodynamics and how theories and biases can alter our clinical reasoning of this technique.
The more modern application of the Neurodynamic technique occurred in the 1970’s-80’s with Maitland exploring variations in the slump test and Elvey with the Upper Limb Tension Tests. Coming from a Pathoanatomical/ Biomedical approach, they were searching for the source of the pain or the restriction in the nervous system. This thinking drove the notion of adverse neural tension where there was restriction along the pathways played a large role with pain and dysfunction and aggressive neural tension tests and exercises were created to try and stretch out and mobilize the tissues.
In the 80’s and early 90’s Butler further explored the role of adverse neural tension and in 1991 Butler released the book Mobilisation of the Nervous System. This was the first book I read of David Butler’s back when I was a t University 20 years ago and it stroked my biases, as I was more biomedically oriented back then. Butler wrote about the nervous system as a continuum and altering tension at one point would alter tension throughout the nervous system. Along the continuum there were points were the nervous system would become entrapped or what was called “crush” and “double crush” sites that would create adverse neural tension. The words crush could now be seen as a DIM or Nocebic language due to it creating a powerful metaphor about entrapment. David himself was not fully happy with the book as there was starting to be a shift around the world in our understanding of pain and health.
“My publisher had to wrench Mobilisation of the Nervous System away from me. I knew it wasn’t complete and I knew the pressures and forces for change in manual therapy practice were growing and uniting” (Butler, 2000)
This quote was in opening of Butler’s next book The Sensitive Nervous System, published in 2000 by Noigroup Publications. At this time there was a shift away from the biomedical model and moving to a more Biopsychosocial model of health. The two headings of Butler’s books show the shift in understanding from “Mobilisation” to one of the “Sensitive Nervous System”. The neurodynamic testing moved to explore more the sensitivity and tolerance of the organism in a particular context. In 2003 Butler and Moseley released the amazing Explain Pain. This book triggered a change in thinking for many clinicians around the world around pain and health. Explain Pain explored the emergent and contextual nature of pain and how tissue damage and pain relate poorly, and that pain was more about protection rather than indication of the state of the tissues (Butler & Moseley, 2003).
Butler teamed up with Coppieters in 2008 and explored Do Sliders slide and tensioners tension. With this shift our understanding of pain and the sensitive nervous system, it was still important to explore the mechanical effects on the peripheral nervous system and the surrounding tissues when mobilized. This is what they found:
tensioning- nervous tissue will see a lengthen effects on the peripheral nervous system of the nerve bed and change the intra neural pressures and creating a proposed pumping effect on “enhancing the dispersal of local inflammatory products in and around the nerves” (Coppieters & Butler, 2008)
longitudinal excursion- the nerve would move and glide in respects to the adjacent tissues. Example: during wrist extension the median nerve distally glide approximately 9mm.
For a lot of our patients pain is their primary concern, but it is important to educate them on the importance of movement in maintaining the health of our tissues, particularly post-surgery, immobility and when there is lots of pain related fear and disability.
The neurodynamics test are not specific to one particular tissue but are testing the sensitivity of a wide array of tissues through motion, blood vessels, fascia, lymphatic and the list goes on. The information being feed into body is just that, information. Our body will “sample, scrutinize and respond from both a cellular and an organism level” (Gifford Mature Organism Model, 2014). As clinician’s this now gives us a huge array of ways to change the relationship and context when is client is preforming neurodynamics and thus may alter their pain experience. When I am preforming these techniques with clients, I use a lot of experiential learning to show them how changing the context can alter the pain and the body can learn that is no longer as dangerous as what it once thought. Using the clients experience of a change in their pain during these techniques can be a great time to bring in some good quality education about pain. Then through graded exposure “start easy, build slowly” (Gifford 2014) you can slowly challenge the client’s relationship to pain from gentle to more aggressive contexts (movement, environmental and psychological). This graded exposure can be where you use sliders and tensioners, that can be perceived as being less aggressive to more aggressive techniques and you can alter the environment to bring in more or less danger or safety cues to the patient.
Click here for the link to the first part of the presentation on biases
Cick here to see Butler preforming a neurodynamic technique, in particular watch the safety cues he sues when preforming the techniques and watch how he guides a change in relationship to the pain through the motion.
Butler, Mobilsation of the Nervous System, Churchill Livingston, 1991
Butler, The Sensitive Nervous System, Noigroup Publications, 2000
Butler & Moseley, Explain Pain, Noigroup Publications, 2003
Butler, The neurodynamic Technique, Noigroup Publications, 2011
Coppieters & Butler, Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and consideration in regarding their applications, Elsevier, 2008
Gifford, Aches and pains, CNS Press, 2014