Shacklock's course

[Diane]

What a weekend this is turning into. I'm about to head out soon for day two. So far, so good. :thumbs_up

Michael has a very complete package here, with his well designed lecture followed by two days of workshop. Did you know the very first ever slump testing was done (Imhotep) 2800 BC? I didn't..

Michael teaches the hands-on portion very well, very carefully. He freely admits that the techniques are potent and in the wrong hands taught the wrong way, could be hurtful. Far from peripheralist, he is very cognizant of pain science, suggests ways to "neutralize" the experience for the patient by taking care to instruct them properly in side bend of neck, choosing words carefully prior and during, going very slowly, checking for symptoms after each large joint is positioned, stopping with the very first positive symptom, examining that symptom further, deciding after a single further move, (side bend of head if the symptom is distal, or a wrist bend if the symptom is proximal) whether the problem is neural or interface, overt or covert. What happens when sequencing is altered, what to expect, what the symptoms mean, with every variation. Very finely tuned testing, much more sensitive and yielding much more voluminous info. Very close verbal contact with patient throughout. Lots of discussion on who to not test in these ways.

I'd say by comparison with Butler's course, Butler emphasizes the research part, and not so much the handling. Michael is big on the minutia of the handling, and presents the research but doesn't dwell on it for very long. Instead the class is mostly practical lab. He personally inspects hand placement, 'pistol grip', 'hand like a paddle' over the examiner's thumb (so as not to introduce pressure up into the shoulder), even how not to pull patients' hair; many many safe handling tips. He says technique and proper sequencing are everything. It makes him shake his head to see outcome studies that suggest that neurodynamics "don't work" when poor technique was used, or the method isn't even described.

I think he's managing to make a convert out of me. Certainly I warm to those who are able to show me (personally) ways to get around my own physical limitations, like small stature and hands, and feel confident I'm picking up the info at an adequate pace.

When I asked him, what about all the fine branches that are coming off the main neural trunks, he said he doesn't know about those yet. He said he thought it might take him another 8-10 years to work through all those (in his own unique, meticulous way).

:lightbulb Bernard, any chance we could get a copy of Bob Elvey's original papers here in Sounds of Silence? :lightbulb (Not sure if it's "Elvey" or "Elvy".. first name Robert.) They date back to late 70s - early 80s, and are about treating the nerves as physical structures/ neurodynamics. Elvey's name crops up everywhere; it was Elvey who lit the fire apparently and inspired people as diverse as Butler, Shacklock, and Dorko. Might be good to read those papers if they are available.

[nari]

Diane

An interesting report on the course; and I had gathered that Michael pays good attention to practical neurodynamics, which is absolutely critical. The problem with many PTs who try the tests, is they still think of the old "adverse neural tension" and if something is tense, you stretch it, like a muscle. No wonder so many do not bother with neurodynamics as a treatment; and they miss out on a wonderful aspect of pain management.
Handling is critical, and along with it, speed of movement (very slow), gradation of placement and decisions on repetitions. I would be very interested in how many times Michael recommends a movement be repeated in a Rx session. I know the ideal number of reps is not known, and it is really only a safe guesstimate.

I certainly agree that the patient needs close conversation during a test or Rx, and the face needs to be observed consistently. Anyway, that is my take on it over the last 2-3 years.

I hope you do become a convert;it can be a spectacular way to treat someone even with global pain. With your imagination and knowledge of those durn nerves' behaviour, I think you will need very little practice to go flying with neurodynamics.

The advantage of SC over neurodynamics as a Rx is the 'risk' factor - SC will not "flare" up patients (well, I don't think so), the latter can.

It's Robert Elvey.

He did light the fire, along with Breig and others, just as Maitland did for jumping about on joints. He was the originator of the term 'adverse neural tension' as far as I know, which was later shown to be incorrect, and Butler took up the slack in the early 90s, after lecturing through the 80s on 'stretching' nerves. It has never become "popular" because it 'made the pain worse'.
Nothing is further from the truth...


Nari

[Diane]

Michael pays good attention to practical neurodynamics, which is absolutely critical. The problem with many PTs who try the tests, is they still think of the old "adverse neural tension" and if something is tense, you stretch it, like a muscle. No wonder so many do not bother with neurodynamics as a treatment; and they miss out on a wonderful aspect of pain management.
Handling is critical, and along with it, speed of movement (very slow), gradation of placement and decisions on repetitions.
Michael mentioned this several times throughout the weekend. He said he went back to square one with the entire school of thought and redid it the way he thought it should have been done right from the start (because it had gone a bit into in the ditch instead, as you pointed out Nari). He really does teach it as carefully as he would like others to practice it. And he has plans for the future of neurodynamics.

I think it must take a great deal of self reevaluation for most individuals who are bone&joint thinkers, orthopaedic manipulative types, to really slow down and consider soft tissue in any serious way. I am so glad that I've crossed paths with those who have shifted gears.

I don't know how many times Michael would repeat a technique, he didn't say... I think he sort of intuits that as he goes. He never seems to do anything any more than absolutely necessary, and is a minimalist when it comes to provoking anything, preferring to give control over to the patient (report symptoms in the moment), and lets that be his guide.

There were some techniques I truly would never practice, like the one for the first rib/scalenes (the osteopathic ones are so much kinder and less provocative of nocioception..). But what I absolutely gained and took away was a much better understanding of what's going on in those tunnels, relative motion between nerve and interface, of differentiable introducible movement from distal to proximal parts and vice versa, a slider versus a tensioner, how important it is to never use the word tensioner, ever, lots and lots of tips on handling of the hand, clearer understanding of the basics, a good grasp I think of how to move the nerve relative to the interface and how to move the interface relative to the nerve.

I would definitely attend a lower extremity class.

I would also look forward to a class on the ribs and segmental nerves of the trunk, including those long thoracic and lumbar nerves that spiral down around the trunk and exit in front of the hip. :) I think I already treat those pretty routinely and effectively.. I am curious though how an orthopaedic/neurodynamic trained mind would go about sliding those... and pushing the vertebrae around wouldn't be allowed. (Haha!)

[nari]

Diane, when you have used the techniques on a few patients, post a case presentation. I would be most interested in his way of handling the arm/shoulder/etc as there are quite a few variations around.

So he does a little passive testing first, and then hands over to the patient for active movement? Is that right?

I used the phrase 'moving in oil' with patients who were to do it themselves at home. It seemed to help them to SLOW down. Just a suggestion....

Nari

[Diane]

I'll play around with the new stuff and see. I've never been much of a purist with anything though.. I'll probably end up doing something that would be completely unrecognizable by Shacklock or you, or Cory who I met there, and partnered with for some labs. :)

[nari]

That's quite OK!!
New things are plastic - one makes the most of what one wants to do with the skills - that prevents the rigid guruism we see with other techniques.

Nari

[Diane]

Hi Nari,
From your earlier post:
"So he does a little passive testing first, and then hands over to the patient for active movement? Is that right?"
Sometimes, but not always. I think he never does anything just because. He showed us gapping techniques to do with opening neck foramina, that are done while the patient (who has been very carefully instructed) does either sliders or tensioners. Sometimes with the contralateral arm, or leg. He tries to pull that cord around however he can, away from the nerve root he perceives as not gliding in and or out properly..
He specifically said he doesn't give homework day one of seeing someone. He mentioned the same mentality I've seen in people, especially athetes, who
a) think if something is good, then a hundred fold of the same thing will be a hundred fold better
b) think pain is something to compete with rather than understand and carefully corrall with the intent of eventually downregulating it. If asked to stop at a one or two on a pain scale of ten, they'll immediately think they should be able to tolerate a fifteen.

No guruism here. I like your "moving in oil" idea. I used another one of yours today in a lab Nari, the thing about parking in a tight spot by going slow/ touching the car in front and behind, not crashing into them (moving too suddenly into pain).

[nari]

Over-enthusiastic patients who 'do their own thing' with neurodynamical homework are a real problem. I can really appreciate Michael's ideas on that.Pardon my ignorance - what is a "lab"? ...apart from a room full of test tubes and things that go bang with chemical alterations. :confused:

Nari

[Diane]

A lab is just a practical session Nari, where you and a partner practice a new technique. Don't you call them labs in Aus?

[flaviovitor]

Hi Diane and Nari,


as I have already told you, I went to this course too in 2005, but in Brazil, Rio de Janeiro. It was a refreshing to some of my thoughts in Neurodynamics. It was really good.

Michael is a good man and clinician and I agree with everything Diane has said in this thread. Even, I do not use scalene / first rib technique teached by Michael, because lots of many other things, including pain perhaps.

Kind regards,


Flávio.

[Diane]

Wow! South America too! The guy is inexhaustible. In fact I see from his page Neurodynamics Solutions (http://www.neurodynamicsolutions.com/) that he has a Spanish version, a German one, English one and ...not one but TWO Brazilian versions. How cool is that? :shade:

[BB]

Hello all,

I really thought this was a good course. In the same way that low back pain as a diagnosis is a grouping of many different problems, neurodynamic problems is a broad description for many different problems. What Michael has done, is describe some of these separate presentations...for example, a median nerve that has dysfunction with sliding proximally, versus a median nerve that shows dysfunction when tension is introduced. Also, he has described how other areas may be an influence, for example a foramen that closes excessively onto the nerve. He then describes a systematic progression of treatment that is based on their test findings. I liken this to the pacing model of L. Gifford. I think that he has done a great job of finding a way to introduce all of these concepts in a fairly simple way. Great course.

Also, I got my wish of seeing Diane work.....on me! Thanks for working on my Omohyoid. The jaw is still pain-free, and I have to go to the dentist today, so that is VERY helpful (although I may have all new pains when he is done with me!) It was great to meet you Diane, and thanks for showing me some of your micro-neurodynamics!

Cory

[Diane]

Cory, you couldn't be more welcome. And ditto your thoughts on Shacklock's vision.
Diane

[nari]

As far as I know, the word 'lab" is new to me - we used to call them practicals - but maybe things have changed recently..one never knows.

At my first Butler course in 1990, I was inspired in just the same way as you guys were, with the paradigm of a neural focus. It is a real shift for me, from thinking that nothing really works too well in physiotherapy long term..to "hey we can actually DO something useful with a 1:1 session....." AND throw out all that EPA stuff along the way...

Cory, Diane also fixed up my problem of residual hip restriction while in Nanaimo for Barrett's course - and it has not returned. My CNS did like the way she 'talked' to it!
Nari

[Diane]

(Glad your hip is happy Nari.:))

[Diane]

Ok, a mini and casual and anecdotal case study coming up:
Librarian assistant, WCB, middle age, I've seen her over the years for this and that, usually work related pain, usually arms. She has major head forward posture, with tightened anterior neck structures. I can loosen those and hound her about head posture but I'm not optimistic that I'll be able to change her "approach" to life, after trying many times. I've been seeing her for a few weeks now; she's off work again with a "frozen shoulder" dominant arm. She's in a dance with her work place, a bit too soon to retire but can't really work full bore.. is on "modified duties" (i.e., shelving fewer books, longer rest breaks in between.) Except for.. the library collapsed a few jobs into each other and they wanted her to handle the extras. She tried, but couldn't tolerate the extra work, from 250 books a day to about 400 books a day, something like that.

Her shoulder is painful for her to elevate. Her main complaint: an achy pain in the front of the shoulder that kicks in and stops her going any higher. Today I tried neurodynamics, just the first position, and after a "static opener" directed at the lower neck. We flossed a few times. Voil-A! Achy pain disappeared, most mysteriously. She could elevate both arms the same amount after. Good stuff. :rolleyes: I will see her in a week for review.

[nari]

It's a wonderful world, the world of neurodynamics....I would bet (probably wrongly) that the same result would not be achieved so rapidly by jumping on the cervical joints.

I've had similar resolution of pain in the anterior shoulder with similar histories and never had to go near the shoulder - even in the initial visit. Which is why I don't know anything about direct shoulder management; have not found the need for it.


Nari

[bernard]

Hi all,

I added direct link to the courses page of Neurodynamics Solutions in this forum.

[bernard]

Diane,

I forgot to say that I didn't found anything new about Elvey Robert on Pubmed, only six citations on Elvey and 3 about the searched Robert. (only title without text).

[bernard]

But Google Scolar give many things => (have to dig!).

Elvey R (http://scholar.google.com/scholar?q=ELVEY+R&ie=UTF-8&oe=UTF-8&hl=en&btnG=Search)

[Diane]

I've used ND concepts and applications briefly and sparingly on three tough shoulder problems, the one I mentioned above and two more, all of whom had a sickening achey pain in the front of the shoulder, which was their worst symptom and which they made a priority of contorting themselves into avoiding. All were female. All improved dramatically, immediately, aching pain gone, with ND. All were taught to do gliding as a home plan. The rest of my job has been easier with the pain factor managed, just help them get back all the lost range and open up the whole upper quadrant, most of which they seemed to have lost complete connection to.

So ND is definitely a keeper. It is like a little fire extiguisher, very handy to have in appropriate moments.

[Barrett Dorko]

Diane,

I woke up in the middle of the night, sat down and finally read of your experience with Shacklock. This must mean something, so I'm posting first thing this morning before patients. Several things come to mind.

I've never met Michael but as you know we've corresponded a bit and I worked hard at reviewing his book-very favorably-this past year.

I'm not surprised that you describe his thinking and consequent handling as so meticulous. His writing reflects that. Did you end up feeling that this sort of attention to detail was necessary given the vast fractal nature of the thing he's trying to control with movement? As he turns his attention from the major nerve trunks and roots does his comment about years of subsequent study lead you to believe this is actually possible?

Does he have any sense whatsoever of ideomotion?

Are we treating the same condition?

I like the fire extinguisher analogy. I'm reminded of something Sebastian Asselbergs in Canada wrote earlier this year when discussing neurogenic pain. I think he pointed out that this "fire within" was not of the usual sort. It needed a retardant but, being akin to a grease fire, the usual ones like water would only make it worse. As you know, I recommend movement of an unconscious sort for this fire having been burned too many times in the past while passively moving my patients or trying to choreograph correction.

Is Shacklock just teaching us how to manipulate the extinguisher with greater care? Is there more to it than that?

[Diane]

Hey Barrett, good morning.
Hmmnn, lots of questions:
I'm not surprised that you describe his thinking and consequent handling as so meticulous. His writing reflects that. Did you end up feeling that this sort of attention to detail was necessary given the vast fractal nature of the thing he's trying to control with movement?

I did, Barrett, in that he's trying to control it with externally applied movement..
Neurodynamics can backfire bigtime if people are crude with it (no surprise to you I'm sure). It seems to work fine when done gently, the way Michael teaches it and the way I think Nari has been describing for years.

As he turns his attention from the major nerve trunks and roots does his comment about years of subsequent study lead you to believe this is actually possible?

Do I think it's possible he will keep going for years or do I think it's possible he'll ever finish?
I can see him going deeper into his own mind, in his chosen direction until death does he part from it.. he is already cognizant that the whole exists, but seeks to find a way to objectify it one level at a time. I don't think he'll get to that goal in his own lifetime.

What he is most big on is is leaving the PT world some tool to test with, and he considers "tool" to be a "way of handling" that is simplified and repeatable. It is still mobilipulative, of course, but a far cry from pushing bone around (the ground from which he sprang) and a lot closer to actually meeting the patient where the patient is. The body is still the "object" in this situation, and is still handled by the therapist. The body operating nonconsciously is still not given credence or allowed/encouraged to be the third "actor" in the room the way you have/do.

Does he have any sense whatsoever of ideomotion?
None at all other than watch the face and stay in close verbal contact and close palpatory contact so as to stop at the first tiny tug, the first whiff of a resistance.

Are we treating the same condition?
Probably.

Is Shacklock just teaching us how to manipulate the extinguisher with greater care?
Yes. With exquisite care.

Is there more to it than that?
What there is, that's "more", is that the guy is a research bean. Being a research bean is what presses PTs like him to develop a controllable set of variables, married to a firmly reasoned set of concepts, that keep the body/nonconscious forever manipulated from outside the patient's conscious brain, so that the handling can be third person and more "objective/measurable" somehow (I suppose it's never really been considered that the body/nonconscious can operate autonomously and that that phenomenon might provide all sorts of interesting food for thought and research in PT. In a different field, Eric Schneider (http://www.press.uchicago.edu/Misc/Chicago/739368.html) seems to not only have conceptualized the barrenness of reductionist research but seems to have overcome it in ecosystems research and in his mind-bending book with Dorion Sagan. Is the human organism not just another ecosystem to be considered as a whole?)

Michael had a bit to say about research culture in different countries. He talked about how incredibly easy it was in Aus to simply ring up the head of whatever department and ask if it might be possible to get together to discuss a project that was underway, over at the blah blah department, and say that it had suddenly occurred to him that it would be great if such and such could be added; was there a way to do this? And the head of the whatever department says, we should go over it in more detail, but yes I think we could work something out. All of this on first name bases. Everyone is interested in supporting everyone elses' efforts at getting science done, getting it produced. There is no rat race to win, funding is relatively easy to get, there are many universities. (Luke mentioned that there are 30 at least in a thinly populated country.) It's as if the founding mothers and fathers of Australia decided they wanted to nurture the brains of subsequent generations and made it a priority that Aus would be a science/technology leader in the world. Different story than in the US I think, or Canada for that matter, where PT research gets some public money but needs private/bequeathed/donated funding to be able to build any steam.

[nari]

Diane, I am not so sure about the founding fathers' vision for tertiary learning, but at one stage our own (Canberra-sited) Australian National University was sitting easily in the top ten in the world. It has now slid into the bottom of the top 25. Funding is a major problem nationally, from what I hear, but it is very dependent on what one is trying to prove or disprove. A lot of money seems to be wasted on little stuff - but that is another story.

Re neurodynamics. I think in many cases, it serves as a fire extinguisher and the potential for flare-up is always there. So the extinguisher, plus education, so the person hopefully realises the circumstances where the movements might be applied.

It is a fractal process, and the door knocking metaphor of long ago comes in here. During the start of the action, the resistance is palpable. I used to think it was consciously applied - am not so sure now.
Then, as it progresses, like a snake in molasses, the resistance vanishes, and previously restricted movement just appears. Pain just vanishes in seconds. Then, under slightly different circumstances, it will come charging back - but if the patient has listened and absorbed, he/she should be able to manage it more effectively. I think that once they know that the pain can be switched on and off is a positive thing for them, it implies the pain is a visitor, albeit a most unwelcome one.
I don't think neurodynamic movement could ever elicit ideomotion - it is too conscious a level of operation and too dependent on external control; but the effects are similar.

I went on and developed my own plan of "action" a couple of years ago after being inspired by David's Level 3 course. There are many nice oily movements to do, most very similar to Tai Chi, as ChrisB might agree.


Nari