Athletic Training and Sports Health Care

Clinical Roundtable 

Neurodynamics

Elizabeth Ballard, DPT, PT, LAT, ATC; Marty Fontenot, DPT, PT, OCS, SCS; James May, DAT, LAT, ATC; James R. Scifers, DScPT, PT, SCS, LAT, ATC

Abstract

Neurodynamics involves the assessment of nerve length and mobility as a component of the overall joint and soft tissue mobility assessment. Nerve mobility issues are identified through the use of neural tension testing. When positive mobility issues related to the nervous system are identified, nerve mobilization, nerve gliding, or nerve flossing are used as treatment interventions to normalize nerve mobility. Neurodynamics are an essential part of assessing and treating limited mobility in many patients suffering from orthopedic dysfunction.

Scifers: What are the primary treatment goals associated with neurodynamics?

Ballard: Neurodynamics are typically assessed for two reasons: the clinician either suspects a neurologic pathology or believes decreased nerve mobility may be limiting mobility of a joint. The primary treatment goals with an acute neural pathology are to decrease neurologic symptoms or pain while also improving range of motion.

Fontenot: Treatment goals when using neurodynamics include normalizing or improving neural mobility in an effort to decrease neural irritation, improve joint mobility, or promote improved upper and lower extremity movement patterns.

May: Treatment goals associated with neurodynamics are focused on normalizing the neuromusculoskeletal system associated with the assessment findings and patient-reported impairments. Normalizing is described as a progression to an ideal state of neurological tissue movement as related to the dynamic and functional demands of human movements over time. Treatment goals may also include: reduced radicular symptoms associated with neural tension testing, normalization of neural tension tests, improvement and/or normalization of symmetrical pain-free motion, or improvement and/or resolution of patient-reported impairment measures.

Scifers: How do neural mobilization techniques differ from neural tension testing?

Ballard: Neural mobilization techniques often mirror the neural tension test for each specific nerve. For example, when evaluating a limitation in sciatic nerve mobility, the clinician should perform a straight leg raise test. If there is a noted limitation in sciatic nerve mobility, treatment should begin with a passive technique of gliding the sciatic nerve in the same position as testing. However, the main difference between testing and treatment is that the test is a single glide assessment to the point of the patient's restriction, whereas treatment or “neural mobilization” is multiple glides or mobilizations of the nerve within the patient's comfort zone.

Fontenot: Neural tension testing is an assessment tool used to determine whether a nerve has restricted mobility and/or is a pain generator. Clinicians should think of testing as a “static” assessment of limited nerve mobility with the goal of symptom reproduction. With neural mobilization, as Dr. Ballard discussed, “assessment becomes treatment” by using the neural tensioning position as the position to address restricted nerve mobility. These mobilization techniques are “dynamic” in an effort to normalize neural mobility across single or multiple joints with the use of a single joint (gliding) or multiple joints (flossing).

May: Neural tension testing, which includes maneuvers of provocation directed at specific neural segments, is used to identify dysfunction and/or abnormal radicular symptomology that may warrant intervention. Although neural tension testing is first used to help determine intervention, the clinician will also use the same assessment techniques to track patient progress and assist in both return to play protocols and discharge criteria.Generally, neuro-mobilization techniques are applied with the intent of providing an intervention to a segment of the neurological system that has been assessed and is indicated for treatment. The treatment intervention can encompass many techniques, such as sliders and tensioners, that create movement of specific neurological tissue. Clinicians should follow a pain-free and radicular symptom-free philosophy during treatment. Accordingly, neurodynamics sliders are recommended to best create more ideal or normalized movement of specific neurological tissue that is void of pain or radicular…

Neurodynamics involves the assessment of nerve length and mobility as a component of the overall joint and soft tissue mobility assessment. Nerve mobility issues are identified through the use of neural tension testing. When positive mobility issues related to the nervous system are identified, nerve mobilization, nerve gliding, or nerve flossing are used as treatment interventions to normalize nerve mobility. Neurodynamics are an essential part of assessing and treating limited mobility in many patients suffering from orthopedic dysfunction.

Scifers: What are the primary treatment goals associated with neurodynamics?

Ballard: Neurodynamics are typically assessed for two reasons: the clinician either suspects a neurologic pathology or believes decreased nerve mobility may be limiting mobility of a joint. The primary treatment goals with an acute neural pathology are to decrease neurologic symptoms or pain while also improving range of motion.

Fontenot: Treatment goals when using neurodynamics include normalizing or improving neural mobility in an effort to decrease neural irritation, improve joint mobility, or promote improved upper and lower extremity movement patterns.

May: Treatment goals associated with neurodynamics are focused on normalizing the neuromusculoskeletal system associated with the assessment findings and patient-reported impairments. Normalizing is described as a progression to an ideal state of neurological tissue movement as related to the dynamic and functional demands of human movements over time. Treatment goals may also include: reduced radicular symptoms associated with neural tension testing, normalization of neural tension tests, improvement and/or normalization of symmetrical pain-free motion, or improvement and/or resolution of patient-reported impairment measures.

Scifers: How do neural mobilization techniques differ from neural tension testing?

Ballard: Neural mobilization techniques often mirror the neural tension test for each specific nerve. For example, when evaluating a limitation in sciatic nerve mobility, the clinician should perform a straight leg raise test. If there is a noted limitation in sciatic nerve mobility, treatment should begin with a passive technique of gliding the sciatic nerve in the same position as testing. However, the main difference between testing and treatment is that the test is a single glide assessment to the point of the patient's restriction, whereas treatment or “neural mobilization” is multiple glides or mobilizations of the nerve within the patient's comfort zone.

Fontenot: Neural tension testing is an assessment tool used to determine whether a nerve has restricted mobility and/or is a pain generator. Clinicians should think of testing as a “static” assessment of limited nerve mobility with the goal of symptom reproduction. With neural mobilization, as Dr. Ballard discussed, “assessment becomes treatment” by using the neural tensioning position as the position to address restricted nerve mobility. These mobilization techniques are “dynamic” in an effort to normalize neural mobility across single or multiple joints with the use of a single joint (gliding) or multiple joints (flossing).

May: Neural tension testing, which includes maneuvers of provocation directed at specific neural segments, is used to identify dysfunction and/or abnormal radicular symptomology that may warrant intervention. Although neural tension testing is first used to help determine intervention, the clinician will also use the same assessment techniques to track patient progress and assist in both return to play protocols and discharge criteria.Generally, neuro-mobilization techniques are applied with the intent of providing an intervention to a segment of the neurological system that has been assessed and is indicated for treatment. The treatment intervention can encompass many techniques, such as sliders and tensioners, that create movement of specific neurological tissue. Clinicians should follow a pain-free and radicular symptom-free philosophy during treatment. Accordingly, neurodynamics sliders are recommended to best create more ideal or normalized movement of specific neurological tissue that is void of pain or radicular symptoms.

Scifers: What conditions or diagnoses have you found to benefit the most from neurodynamics?

Ballard: In my practice, I have seen the greatest improvements in range of motion, subjective reports of tightness, and pain following neurodynamic interventions for chronic overuse injuries, specifically those patients with chronic strains. It seems inherent to clinicians that, following a strain, a multitude of treatments could be applied, including, but not limited to, modalities to decrease pain, stretching, eccentric strengthening, and myofascial work to decrease adhesions in the soft tissue. However, it is easy to forget about the nerve that runs through the same myofascial network and the role adhesions play in the mobility of the nerve.In terms of chronic overuse injuries, the nerve is, again, only one piece of the puzzle. An example is medial epicondylitis. Once the inflammation process begins at the musculotendinous junction, it continues to spread further into the muscle belly. If this goes untreated, it is likely that the radial nerve also becomes inflamed. This is another classic example where the clinician has to assess both the nerve and the muscle that cross a given joint.One other common condition I have seen improve with neurodynamics is impingement syndrome, primarily shoulder and hip impingement. Impingement of any joint usually requires a multi-factorial approach to treatment, including: improving joint mobility, decreasing myofascial restrictions, stretching, and strengthening. I have seen many chronic impingement cases where the last piece of the puzzle was adding nerve glides to the treatment once joint mobility and proper postural alignment was restored.

Fontenot: In my practice, I have seen excellent outcomes associated with neurodynamic intervention for cervical and lumbar radiculopathy, thoracic outlet syndrome, and peripheral neuropathies, such as radial tunnel syndrome, carpal tunnel syndrome, and tarsal tunnel syndrome. Neurodynamics can also be useful in the treatment of patients following prolonged immobilization in a cast or walking boot that results in limited soft tissue and nerve mobility. Finally, I have had success treating lateral epicondylagia, persistent hamstring and gastrocnemius strains, and adhesive capsulitis.

May: Clinical experience and reflection of patient outcomes highlight clinical use with patients most commonly classified or diagnosed as having pathology such as apparent tendinopathies, muscle strains, and postoperative cases. Beyond classification and patient complaints of radicular symptoms, high functioning patients who complain of symptoms that are chronic in nature, vague, and/or intermittent often have a positive neural tension test result and will respond well to neurodynamic intervention.High functioning patients often train and compete in high volume repetitive activities (eg, runners who report tightness in a lower extremity or throwers and unilateral specialists who complain of unusual tightness, fatigue, or weakness). Any suspected neural or dural complaint may benefit from a neurodynamic intervention.

Scifers: How do you incorporate neurodynamics into the overall treatment plan for your patients?

Ballard: It depends on the patient. Every case is different, but I think there is a theme that is beginning to emerge from listening to the other panelists' answers. There is rarely a single treatment that a patient can benefit from. For example, if a patient has both a joint mobility restriction and neural restriction, I will likely begin with joint mobilization to increase the space for a nerve to glide through before implementing neurodynamics. For example, for a classic facet dysfunction in the spine, a clinician will only further tension the nerve and create inflammation if the underlying cause of joint restriction is not treated first. The same principle can be used when a tight muscle is restricting a nerve.

Fontenot: Just as with a joint or muscle, if the nerve appears to be the culprit affecting joint mobility, then neurodynamics should be applied, along with stretching, soft tissue mobilization, and joint mobilization to address any other tissue restrictions. Having said that, nerve restrictions are usually the last part I address clinically, after addressing joint and muscle restrictions first. As Dr. May stated earlier, neurodynamics should be used for any and all radiculopathies within a pain-free treatment range.

May: Like the other panelists, my initial interventions are used with the intent to clear as many neuromusculoskeletal symptoms and patient-reported complaints as possible prior to intervening with neurodynamics. Accordingly, and while fostering a treatment-based model, I will treat with more robust interventions such as primal reflex release technique and/or a Mulligan concept to treat neurogenic complaints. Both interventions are indirect manual therapy techniques and will often provide an instantaneous neural “reboot” that is intended to best normalize the neural system. The patient will commonly report immediate and meaningful changes in symptoms. After the initial treatment, the patient's neural symptoms will be reassessed and if the initial intervention does not fully resolve the patient's neural complaints, I would then attempt the appropriate neurodynamic maneuvers. If resolution of symptoms is reported, the neural system is considered to be more normalized and the patient will be reassessed for other impairments and continue care to return to play or discharge.

Scifers: How have you seen neurodynamics benefit your patients in terms of clinically measurable outcomes, such as decreasing pain and improving range of motion and function?

Fontenot: In relation to neurodynamics, I have seen improved outcomes such as range of motion, pain, and function when I have added the techniques to more traditional joint and muscle interventions. This is specifically true in cases of radiculopathies and neuropathies, where patients have demonstrated improved range of motion and reported decreased pain and discomfort after performing neurodynamics. This was certainly enhanced with improved carry-over once the underlying cause of the nerve restriction was addressed. Clinically, the addition of neurodynamics for patients who have plateaued has allowed the achievement of the last 10% to 20% improvement that often escapes patients and clinicians.

May: While delivering patient-centered care, clinically measurable outcomes are vital and a constant component of using neurodynamics in isolation or in conjunction with other manual therapy paradigms and clinical decision-making. Outcome measures that may be useful during care are one or two functional tasks assessed via the Patient Specific Functional Scale, a current resting Numeric Pain Rating Scale, and an active range of motion impairment measure to assess the effects of intervention. Clinicians should expect trends of improvement in all measures as the patient progresses through care.Additionally, the clinician should see immediate changes if neurodynamics are the solution. Examples of improved outcomes may include increased motion prior to radicular symptom onset, progress on patient-reported functional task, improvements on the Patient Specific Functional Scale that may be assessed by minimal clinically important differences, improved changes on the Numeric Pain Rating Scale that may be assessed by minimal clinically important differences, and improved range of motion and function.Assessing lasting effects of intervention, day to day and week to week, clinicians can expect consistent improvement, and further assessment of intervention, diagnosis, and external variables is warranted if trends plateau or become negative. Importantly, if the clinician is using outcome measures properly, the clinical decision-making process will be made easier.

Scifers: When performing neurodynamics, are there best practice guidelines in terms of sets, repetition, and time for treatment?

Ballard: To my knowledge, there are no best practices regarding specific treatment parameters when applying neurodynamics. The literature supports gliding techniques over tensioning techniques, but fails to define a standard of practice for sets, repetitions, or duration. When treating patients, I often apply treatment parameters that have been shown to work for other soft tissue restrictions. In a recent study, I used three sets of 1-minute duration of neural glides. This design was based on the classic Bandy and Irion study that recommended a 60-second stretching duration for soft tissue elongation. In that study, comparing neurodynamics to traditional stretching, a 60-second neurodynamic intervention proved effective. However, muscle elasticity is not generalizable to neural mobility because nerves are inelastic. I think this is an area that requires more research. Hopefully, one day a clinical guideline will exist for neurodynamics application.

Fontenot: I believe the key here is to make sure we always abide by the “assess, treat, reassess” paradigm to determine whether our intervention is successful. Although the evidence does not provide specific “best-practices,” I tend to apply three to five sets of 10 to 30 repetitions or three to five sets of 30 to 60 seconds when using neurodynamics. Just like any other manual therapy technique, it is always important to start with low volume and progress based on patient tolerance and improvement. As mentioned previously, a key best practice is to ensure the treatment is provided in a pain-free, symptom-free manner.

May: When specifically targeting the neurological system, one must be aware of the potential to irritate the nervous system. Many times this depends on the sensitivity or hypersensitivity of the patient participating in the treatment. Explaining the anatomy and purpose of the intervention is often easy for the patient to interpret, but emphasizing the importance of maintaining pain-free movements without radicular symptoms is most important for the patient to embrace and understand.All decisions regarding sets, repetitions, and duration are based on the patient's level of function and level of irritability, or potential for irritability, which are commonly inversely correlated. If a patient is participating in normal activities of daily living and normal work or sport activity, this patient is considered high functioning and the level of irritability is low, whereas a patient who is restricted to only activities of daily living is considered lower functioning and, as such, the level of irritability is likely higher.To best decrease risk of irritability, I begin treatment with commonly accepted standards of two to four sets and 8 to 20 repetitions. To remain cautious, clinicians can pause for 5 or 10 minutes between the first and second sets to ensure the patient is responding appropriately. Once the clinician is comfortable with the appropriateness of the patient-performed movements and the mitigation of the initial risk of irritability, progressions and modification can ensue. Commonly, patients who are high functioning do well with time intervals and lower functioning patients are safer maintaining progressions of sets and repetitions.

Scifers: How do you incorporate neurodynamics into a patient's home exercise programs?

Ballard: First, I only incorporate neurodynamics into a home exercise program once I am confident that a patient can perform the technique correctly in the clinic without cueing. If performed incorrectly, neurodynamics can cause further inflammation and potentially damage a nerve. Once I am confident in the patient's ability to perform a technique correctly, I prescribe an active technique such as self-glides.

Fontenot: To be honest, I only include neurodynamics in the home exercise program of patients I trust. I have found that being overly aggressive in treating mobility limitations involving nerves results in longer-lasting and more severe symptoms than are seen with aggressively treating soft tissue limitations associated with muscle or capsular tightness. When I do include neurodynamics as part of the home exercise program, patients must really understand the “what, how, and why” behind the intervention because the negative consequences associated with performing these exercises incorrectly can delay or even regress outcomes. Clinicians should be sure to assess patient independence in performing these techniques safely and effectively before the patient leaves the clinic. I have found more success in incorporating lower extremity neurodynamics into the home exercise program than upper extremity neurodynamics. I surmise this is because self-glides are easier to do in the lower extremity.

May: Patient education and creating patient ownership of healing is important to patient care and matches well with neurodynamics. Educating patients on the anatomy and theory of mobilizing nerves often resonates with patient self-care because it is relatively easy to visualize a nerve successfully moving by shortening one end of the nerve and then lengthening the opposite end.The emphasis on the home neurodynamic program for sliders is on slacking one end first and then lengthening the opposite end. It is important to take extreme care in ensuring the patient understands the concepts and procedures before prescribing home care. Educating the patient allows the clinician to clearly highlight and emphasize the importance of pain-free movements and avoid any radicular symptoms. Maintaining the commonly accepted athletic mindset of “no pain, no gain” will result in poor outcomes. Of note, if a clinician is considering applying a manual therapy treatment as a home intervention, the patient must be taught in the clinic while he or she currently has symptoms. Too many times, the home manual therapy exercises are taught after the patient is already pain-free in the clinic and the patient never becomes aware of the subtleties of applying the intervention on oneself.Time intervals are often prescribed in conjunction with home exercise programs. Again, based on the level of functioning and irritability, beginning with 3 minutes of each neurodynamics technique three times a day (morning, afternoon, and evening) and then adding or subtracting based on the patient response is a good starting point for higher functioning patients. As the patient progresses through treatment toward increased activity and ultimately unrestricted activity, the techniques can transition from intervention to a component of warm-up used prior to or after dynamic warm-ups based on patient desires.

Scifers: For a clinician who has not used neurodynamics previously, what advice would you offer for getting started with this treatment intervention?

Ballard: I would begin with a continuing education course on neurodynamics if he or she is not comfortable with testing or performing specific techniques. Basic techniques can be developed from the position in which nerve mobility is tested. Once the clinician understands how to tension a nerve for testing, then he or she knows at least one position that can be used for treatment. Like any other treatment technique, interventions must be tailored to the patient in front of you. I am constantly adapting patient positioning and application techniques based on individual patient response to the treatment.

Fontenot: I would encourage clinicians to include neural tension assessment in every orthopedic evaluation. Just like joint mobility, muscle length, and muscle strength assessments, nerve mobility should be a fundamental part of every patient evaluation. When applying the technique, it is important to remember that, like all manual therapy interventions, not all patients will benefit from neurodynamics.

May: Neurodynamics is a great paradigm to embrace because the philosophy is clearly based on anatomical structure that a clinician can easily visualize, clinically decipher, and use to educate the patient. As Dr. Fontenot recommended, assessing for neurological dysfunction should be part of every patient evaluation.For clinicians who work in busy clinics, the neurodynamics paradigm provides an avenue for patient ownership of healing and may create more time for the clinician. I would encourage novice clinicians to create a “cheat sheet,” a document readily available in the clinic that can be a useful reminder for assessment and intervention progression. This document can also be used for patient education.

This Clinical Roundtable was conducted on May 28, 2018.

Suggested Reading

  1. Basson A, Olivier B, Ellis R, Coppieters M, Stewart A, Mudzi W. The effectiveness of neural mobilization for neuromusculoskeletal conditions: a systematic review and meta-analysis. J Orth Sports Phys Ther. 2017;47:593–615. doi:10.2519/jospt.2017.7117 [CrossRef]
  2. Coppieters MW, Butler DS. Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13:213–221. doi:10.1016/j.math.2006.12.008 [CrossRef]
  3. Ellis RF, Hing WA. Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther. 2008;16:8–22. doi:10.1179/106698108790818594 [CrossRef]
Authors

Elizabeth Ballard, DPT, PT, LAT, ATC, is from St. Luke's University Health Network, Bethlehem, Pennsylvania.

Marty Fontenot, DPT, PT, OCS, SCS, is from the Murphy Deming College of Health Sciences at Mary Baldwin University, Staunton, Virginia.

James May, DAT, LAT, ATC, is from the University of Idaho, Moscow, Idaho.

Moderator: James R. Scifers, DScPT, PT, SCS, LAT, ATC

The authors have no financial or proprietary interest in the materials presented herein.

10.3928/19425864-20180612-01

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