Neurodynamics
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Neurodynamics. Dan Foster , PhD, ATC Sports Medicine Conference August 7, 2008. Peripheral Neuropathic Pain. Positive sx Abnormal excitability (pain, paresthesia , dysesthesia , and spasm) Negative sx Reduced impulse production (hypoesthesia or anesthesia and weakness).

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Neurodynamics

Neurodynamics

Dan Foster, PhD, ATC

Sports Medicine Conference

August 7, 2008


Peripheral neuropathic pain

Peripheral Neuropathic Pain

  • Positive sx

    • Abnormal excitability (pain, paresthesia, dysesthesia, and spasm)

  • Negative sx

    • Reduced impulse production (hypoesthesia or anesthesia and weakness)

Harden 2005; Woolf 2004; Baron 2000; Hall & Elvey 1999


Peripheral neuropathic pain1

Peripheral Neuropathic Pain

  • Dysesthetic pain shows a variety of clinical behaviors

    • Burst of pain at onset of a stimulus but subsides before the stimulus is removed

    • Sx provoked by movement may persist well after

    • the stimulus has been removed

    • Response to the cumulative effect of several stimuli

    • Paroxysmal stimulus-independent or spontaneous pain

    • Pain worse during increased life stress

Burning, tingling, electric, searing, drawing, crawling, shooting

Not produced by A-δ or C fiber stimulus

Harden 2005 - Hyperexcitable nervous system with increased afferent discharge AIGS

AIGS – adverse impulse generating site


Physical assessment

Physical Assessment

  • Use multijoint movements to challenge (inc mechanosensitivity) the nervous system

    • Testing reproduces sx

    • Movement of a segment remote from the sx location alters the response; changes in sequence may alter the response

    • Reliability and Differences from contralateral side

      • Sensory, ROM, or resistance

Butler, 1991


Management

Management

  • Patient education

  • Non-neural tissue

    • Joint mobilization, soft-tissue work, taping, neuromuscular control

  • Neural mobilization

    • Passive or active, focusing on tolerating normal compressive, friction, and tensile forces


Neural mobilization

Neural Mobilization


Neurodynamics david butler

Neurodynamics – David Butler

  • Use of body movement to produce mechanical effects on the peripheral nervous system with central influence

Science of the relationships between mechanics and physiology of the nervous system


Volleyball shoulder pain

Volleyball & Shoulder Pain

2005-2008

  • 17 case series

    • 7 rotator cuff impingement

    • 2 possible SLAP/biceps/post labrum

    • 5 anterior coracoacromial impingement

    • 3 rotator cuff strain

  • 5 recurrent w/ minimal sx

1 lost time injury following surgery


Routine prevention

Routine Prevention

  • Daily tubing program

  • Dynamic, graduated warm up with stretching

  • Any shoulder pain, automatic active neurodynamic techniques


Neurodynamics technique

Neurodynamics Technique

  • Moses prayer

    • Shoulder depression & Scapular retraction

  • Push away

    • Median nerve, protraction

  • Cover ears

    • Ulnar nerve

  • Track baton

    • Radial nerve, shoulder depression, IR

  • Throw behind

    • Musculocutaneous nerve, shoulder depression


Moses prayer shoulder

Moses Prayer-Shoulder


Push away median nerve

Push Away – Median Nerve


Cover ears ulnar nerve

Cover Ears – Ulnar Nerve


Track baton radial nerve

Track Baton – Radial Nerve


Throw behind musculocutaneous nerve

Throw Behind-Musculocutaneous Nerve


Neurodynamic routine

Neurodynamic Routine


Summary of cases

Summary of Cases

  • Inconsistent application

  • Cases have been varied

  • Simple easy to remember maneuvers

  • Who knows what is helping?

    • Neural flossing or movement or nutrition

    • MS stretching

    • Mechanical space improvement

    • Neural control feedback


Neurodynamics david butler1

Neurodynamics – David Butler

  • Use of body movement to produce mechanical effects on the peripheral nervous system with central influence


It s just your body reporting in

It’s just your body reporting in

Muscle activity occurs at the onset of danger, normally it occurs at some level of pain tolerance

Muscle

Pain

+ Threats

Danger

(nociception)

Hall & Elvey, 2005


Neurodynamics

  • Devor & Seltzer. Textbook of Pain. 1999 – after peripheral nerve injury, many primary afferent neurons start to generate ongoing discharges of ectopic origin

    • Can evoke ongoing paresthesias and pain

    • Can trigger and maintain central sensitization

Michaels et al. J Neurscience. 2000 – muscle afferent discharges in DRG


Movement is optimal

Movement is Optimal

Shacklock, 1995

  • Circulation and nutrition occur optimally through movement

    • MS tissues change dimensions and exert mechanical forces on neural structures

    • ∆ management of injured neural tissues should ensure that MS structures operate optimally

      • Minimize forces on adjacent neural structures

Butler 2000; Hall & Elvy 1999


Neurodynamics

  • Movement of the nerve bed

    • Should elongate and shorten the nerve

      • Increase nerve tension and intraneural pressure

      • Facilitate venous return

      • Disperse edema

      • Reduce pressure inside the perineurium

    • Should limit fibroblastic activity

      • Which may minimize scar formation

    • Should reduce neural sensitivity

      • Minimizing ion channel upregulation


Nerve movement

Nerve Movement

  • Physical loading (tension or compression) of the nervous system can be produced by adjusting joint position

Coppieters, Butler. Manual Therapy. 2008; 13;213-221


Neurodynamics

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 unembalmed human peripheral nerves (tensile force data)

Kleinrensink et al. Clin Biomech. 1995; 10:235-239.


Neurodynamics

6-8% strain

  • Ogata & Naito. J Hand Surg. 1986; Rempel et al. JBJS. 1999 – Showed a clear relationship between extraneural pressures, intraneural pressure and subsequent inhibition of circulation and axonal transport

    • 20-30 mmHg pressure can limit blood flow and axonal transport, and cause endoneurial edema

    • 50 mmHg alters structure or myelin


Sliding technique

Sliding Technique

  • Low strain, appropriate for acute injuries, post-op management, or bleeding and inflammation

    • Enhance dispersal of local inflammatory products

    • Limit fibroblastic activity (unknown)

      • Mesoneurial gliding

Lundborg 1988


Tensioning technique

Tensioning Technique

  • Appropriate for chronic or post-acute stages

    • May help to reduce intraneural swelling

    • Stimulate circulation

    • By varying effects on intraneural pressure

      • Dynamic pumping action or “milking effect”

      • Improving nerve hydration

      • Disperse local inflammatory effects venous return

        • Reducing acidic environment

Rempel 1999

Ogata 1986


Sliding tensioning

Sliding & Tensioning

  • Large amplitude movements, passive or active, and can be integrated into postures or dance - distract

    • Reduces sensitivity and restores function

    • Eases the threat value of the injury

      • Minimizes potential for ion channel upregulation in DRG and CNS

      • Novel ways to uncouple learned expectations of pain – dec fear of movement


Summary

Summary

  • We used dynamic tensioning exclusively with shoulder cases

  • Plan more sliding maneuvers and incorporate cervical spine and shoulder more

  • Report back in a few years with an update


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