· butler, 1991. management patient education non-neural tissue joint mobilization, soft-tissue...
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NeurodynamicsNeurodynamics
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Peripheral Peripheral NeuropathicNeuropathic PainPainPositive Positive sxsx
Abnormal excitability (pain, Abnormal excitability (pain, paresthesiaparesthesia, , dysesthesiadysesthesia, and spasm), and spasm)
Negative Negative sxsxReduced impulse production (hypoesthesia or Reduced impulse production (hypoesthesia or anesthesia and weakness)anesthesia and weakness)
Harden 2005; Woolf 2004; Baron 2000; Hall & Elvey 1999
Peripheral Peripheral NeuropathicNeuropathic PainPainDysestheticDysesthetic pain shows a variety of clinical pain shows a variety of clinical behaviorsbehaviors
Burst of pain at onset of a stimulus but subsides before the Burst of pain at onset of a stimulus but subsides before the stimulus is removedstimulus is removedSxSx provoked by movement may persist well afterprovoked by movement may persist well afterthe stimulus has been removedthe stimulus has been removedResponse to the cumulative effect of several stimuliResponse to the cumulative effect of several stimuliParoxysmal stimulusParoxysmal stimulus--independent or spontaneous painindependent or spontaneous painPain worse during increased life stressPain worse during increased life stress
Harden 2005 - Hyperexcitablenervous system with increased afferent discharge AIGS
Burning, tingling, electric, searing, drawing, crawling, shooting
AIGS – adverse impulse generating site
Not produced by A-δ or C fiber stimulus
Physical AssessmentPhysical AssessmentUse Use multijointmultijoint movements to challenge movements to challenge (inc (inc mechanosensitivitymechanosensitivity) the nervous ) the nervous systemsystem
Testing reproduces Testing reproduces sxsxMovement of a segment remote from the Movement of a segment remote from the sxsx location location alters the response; changes in sequence may alter alters the response; changes in sequence may alter the responsethe responseReliability and Differences from Reliability and Differences from contralateralcontralateral sideside
Sensory, ROM, or resistanceSensory, ROM, or resistance
Butler, 1991
ManagementManagementPatient educationPatient educationNonNon--neural tissueneural tissue
Joint mobilization, softJoint mobilization, soft--tissue work, taping, tissue work, taping, neuromuscular controlneuromuscular control
Neural mobilizationNeural mobilizationPassive or active, focusing on tolerating Passive or active, focusing on tolerating normal compressive, friction, and tensile normal compressive, friction, and tensile forcesforces
Neural MobilizationNeural Mobilization
NeurodynamicsNeurodynamics –– David ButlerDavid ButlerUse of body movement to produce Use of body movement to produce mechanical effects on the peripheral mechanical effects on the peripheral nervous system with central influencenervous system with central influence
Science of the relationships between mechanics and physiology of the nervous system
Volleyball & Shoulder PainVolleyball & Shoulder Pain17 case series17 case series
7 rotator cuff impingement7 rotator cuff impingement2 possible SLAP/biceps/post labrum2 possible SLAP/biceps/post labrum5 anterior 5 anterior coracoacromialcoracoacromial impingementimpingement3 rotator cuff strain3 rotator cuff strain
5 recurrent w/ minimal 5 recurrent w/ minimal sxsx
2005-2008
1 lost time injury following surgery
Routine PreventionRoutine PreventionDaily tubing programDaily tubing programDynamic, graduated warm up with Dynamic, graduated warm up with stretchingstretching
Any shoulder pain, automatic active Any shoulder pain, automatic active neurodynamicneurodynamic techniquestechniques
NeurodynamicsNeurodynamics TechniqueTechniqueMoses prayerMoses prayer
Shoulder depression & Scapular retractionShoulder depression & Scapular retractionPush awayPush away
Median nerve, protractionMedian nerve, protractionCover earsCover ears
UlnarUlnar nervenerveTrack batonTrack baton
Radial nerve, shoulder depression, IRRadial nerve, shoulder depression, IRThrow behindThrow behind
MusculocutaneousMusculocutaneous nerve, shoulder depressionnerve, shoulder depression
Moses PrayerMoses Prayer--ShoulderShoulder
Push Away Push Away –– Median NerveMedian Nerve
Cover Ears Cover Ears –– UlnarUlnar NerveNerve
Track Baton Track Baton –– Radial NerveRadial Nerve
Throw BehindThrow Behind--MusculocutaneousMusculocutaneous NerveNerve
NeurodynamicNeurodynamic RoutineRoutine
Summary of CasesSummary of CasesInconsistent applicationInconsistent applicationCases have been variedCases have been variedSimple easy to remember maneuversSimple easy to remember maneuversWho knows what is helping?Who knows what is helping?
Neural flossing or movement or nutritionNeural flossing or movement or nutritionMS stretchingMS stretchingMechanical space improvementMechanical space improvementNeural control feedbackNeural control feedback
NeurodynamicsNeurodynamics –– David ButlerDavid ButlerUse of body movement to produce Use of body movement to produce mechanical effects on the peripheral mechanical effects on the peripheral nervous system with central influencenervous system with central influence
ItIt’’s just your body reporting ins just your body reporting in
Danger(nociception)
+ ThreatsPain
Muscle activity occurs at the onset of Muscle activity occurs at the onset of danger, normally it occurs at some level of danger, normally it occurs at some level of pain tolerancepain tolerance
Muscle
Hall & Elvey, 2005
DevorDevor & Seltzer. & Seltzer. Textbook of PainTextbook of Pain. 1999 . 1999 ––after peripheral nerve injury, many primary after peripheral nerve injury, many primary afferent neurons start to generate ongoing afferent neurons start to generate ongoing discharges of discharges of ectopicectopic originorigin
Can evoke ongoing Can evoke ongoing paresthesiasparesthesias and painand painCan trigger and maintain central sensitizationCan trigger and maintain central sensitization
Michaels et al. J Neurscience. 2000 –muscle afferent discharges in DRG
Movement is OptimalMovement is OptimalCirculation and nutrition occur optimally Circulation and nutrition occur optimally through movementthrough movement
MS tissues change dimensions and exert MS tissues change dimensions and exert mechanical forces on neural structuresmechanical forces on neural structures∆∆ management of injured neural tissues management of injured neural tissues should ensure that MS structures operate should ensure that MS structures operate optimallyoptimally
Minimize forces on adjacent neural structuresMinimize forces on adjacent neural structures
Shacklock, 1995
Butler 2000; Hall & Elvy 1999
Movement of the nerve bed Movement of the nerve bed Should elongate and shorten the nerve Should elongate and shorten the nerve
Increase nerve tension and Increase nerve tension and intraneuralintraneural pressurepressureFacilitate venous returnFacilitate venous returnDisperse edemaDisperse edemaReduce pressure inside the Reduce pressure inside the perineuriumperineurium
Should limit fibroblastic activityShould limit fibroblastic activityWhich may minimize scar formationWhich may minimize scar formation
Should reduce neural sensitivityShould reduce neural sensitivityMinimizing ion channel Minimizing ion channel upregulationupregulation
Nerve MovementNerve MovementPhysical loading (tension or compression) Physical loading (tension or compression) of the nervous system can be produced by of the nervous system can be produced by adjusting joint positionadjusting joint position
Coppieters, Butler. Manual Therapy. 2008; 13;213-221
Continuous strain recordings in the median nerve related to angles at the elbow and wrist for two consecutive recordings for each movement technique.
Comparison between embalmed and unembalmedhuman peripheral nerves (tensile force data)Kleinrensink et al. Clin Biomech. 1995; 10:235-239.
Ogata & Naito. Ogata & Naito. J Hand J Hand SurgSurg. 1986; . 1986; RempelRempel et al. et al. JBJSJBJS. 1999 . 1999 –– Showed a Showed a clear relationship between clear relationship between extraneuralextraneuralpressures, pressures, intraneuralintraneural pressure and pressure and subsequent inhibition of circulation and subsequent inhibition of circulation and axonal transportaxonal transport
2020--30 mmHg pressure can limit blood flow and 30 mmHg pressure can limit blood flow and axonal transport, and cause axonal transport, and cause endoneurialendoneurial edemaedema50 mmHg alters structure or myelin50 mmHg alters structure or myelin 6-8%
strain
Sliding TechniqueSliding TechniqueLow strain, appropriate for acute injuries, Low strain, appropriate for acute injuries, postpost--op management, or bleeding and op management, or bleeding and inflammationinflammation
Enhance dispersal of local inflammatory Enhance dispersal of local inflammatory productsproductsLimit fibroblastic activity (unknown)Limit fibroblastic activity (unknown)
MesoneurialMesoneurial glidinggliding
Lundborg 1988
Tensioning TechniqueTensioning TechniqueAppropriate for chronic or postAppropriate for chronic or post--acute acute stagesstages
May help to reduce May help to reduce intraneuralintraneural swellingswellingStimulate circulationStimulate circulationBy varying effects on By varying effects on intraneuralintraneural pressurepressure
Dynamic pumping action or Dynamic pumping action or ““milking effectmilking effect””Improving nerve hydrationImproving nerve hydrationDisperse local inflammatory effects venous returnDisperse local inflammatory effects venous return
Reducing acidic environmentReducing acidic environment
Rempel 1999
Ogata 1986
Sliding & TensioningSliding & TensioningLarge amplitude movements, passive or Large amplitude movements, passive or active, and can be integrated into postures active, and can be integrated into postures or dance or dance -- distractdistract
Reduces sensitivity and restores functionReduces sensitivity and restores functionEases the threat value of the injuryEases the threat value of the injury
Minimizes potential for ion channel Minimizes potential for ion channel upregulationupregulation in in DRG and CNSDRG and CNSNovel ways to uncouple learned expectations of Novel ways to uncouple learned expectations of pain pain –– decdec fear of movementfear of movement
SummarySummaryWe used dynamic tensioning exclusively We used dynamic tensioning exclusively with shoulder caseswith shoulder casesPlan more sliding maneuvers and Plan more sliding maneuvers and incorporate cervical spine and shoulder incorporate cervical spine and shoulder moremoreReport back in a few years with an updateReport back in a few years with an update