Neural mobilization

[BB]

Hello all,

I have another question for you....

This one is regarding the neural mobilization techniques.

I have always had issues with these treatments. When I treat, I feel that I should be able to see the change that I am looking for quickly. If you change something and it makes a difference, that becomes your treatment as one of my teachers used to say. I'm sure that it is my use of the treatment, but I do not often see this change when I use neural mobs.

Is this an unreal expectation for this type of treatment?

I'm also curious how you all incorporate this into functional movements?

Hoping you can give me some things to absorb and use before I take the first Butler course in July.

Cory

[nari]

Hi Cory

Am very glad you are doing a Butler course; you will find it enlightening and challenging.
Re the mobilisations:

As a brief (hopefully) synopsis to your course, I might suggest that if you are doing these movements with unreliable positive results, there might be two reasons for this.
One, is choosing to do the movement/s as a result of assessment. If you have found that pain is reproduced by ULNT1, you would proceed to at least clear that sign. How that is done, depends on the severity and locus of that pain. If ROM is limited and the pain produces intense response from the patient, start as distal as possible. eg, if the primary pain output is in the anterior shoulder and you can't get beyond 40 degrees abd, work in that range, and start with extremely slow wrist extension. if you cannot get full elbow extension, work with what you have got. Sit on the edge of the pain, never beyond.

Secondly,the movement MUST be slow. Give that plasticity time to organise itself or the brain just slams on the brakes. It must be low amplitude movement, and only 3-4 reps.

When it works, the results are immediate. I have taken a chronically painful upper limb from barely functioning to full range, painfree in 1 session. But that does not happen often. Education is vital. if the patient cannot perform the action correctly, ie along the path of the nerve from proximal to distal, it will not work.

Turning neural into functional stuff is not hard. Think of your pathways, memorise their tracts and make it up. For instance, for ULNT2, start in a slalom position, bend zee knees and sweep forwards and backwards with both arms (as in skiing), keeping wrist and fingers fully flexed.
For ULNT3, ask the patient to recline on their affected side, and rest the head on the extended wrist and fingers (Reclining Roman, grapes and wine optional), for a few minutes. Then you might ask them to do a gentle neck stretch - place one or both hands upside down so their extended wrist and fingers are cuddling the occiput/cervical spine, and move the elbows forwards or backwards, SLOWLY. I don't know what it does to the neck, but it will target the ulnar n.

Shrug shoulders, as if moving through molasses. (Great for relieving proximal median and radial tension)
If your pt plays golf, ask him to try an extremely slow tee-off swing. (no club necessary). Ask him to time it so that it takes around 5-6 seconds to complete.

Reach slowly to a cup in a cupboard, but stand side on.

Look at pictures/videos of Thai dancing, ancient Egyptian dancing.

Look at Tai Chi movements, yoga.

The possibilities are endless, the challenge comes with not pushing into pain, just nudging softly. The other challenge is convincing the patient these are NOT exercises. more is NOT better. Ten repetitions four times a day will plunge them into strong pain for days. Then your credibility goes off down the drain.

It also makes you remember that all these 'orthopaedic' exercises we used to 'force' patients to do - theraband, crawling up walls with fingers (horrors), arm circle with weights- will be looked at in a new light. They start to look positively scary. Eliminate neural components (and they are nearly always there to some degree) and maybe a focus on strength is useful.


Hope this helps - it is a BIG topic and hard to precis - for me, anyway.

Nari

[Diane]

Nari, you are brilliant. I hope you write a PT manual some day soon. I'll write a hands-on one (the laziest possible way to do hands on) and we'll be set. Maybe we could do it as a joint project from a couple of seasoned PTs.
Cheers,
Diane

[BB]

Nari,
Thank you so much! That is very helpful. If you don't mind I might continue to pick your brain on this matter as I am learning.

Cory

[BB]

Nari,

Start distal and work proximal- If as I have the person move the distal segment the movement improves quickly, do you then move to slow elbow movements and on to shoulder movements? Would you progress this far in one session or would that be too much, typically?

If you want to be careful not to mobilize too much, do you teach the functional incorporation right away? Would these functional self mobs cause a flare up as they might be done several times throughout the day? How do you educate on activity level following your treatment?

Cory

[emad]

Hi all :

i hoped to share this discussion , but you know what i was concerned :? :? .

Nari:
Regarding neural mobilisation .

i usually teach the patient , spend time speak about this approach , asking the patient at the first session to perform only 3-4 times /repitations.

Today .
one of the consumer asked me ,
why you insist to do this few repitations , however i am doing a lot through all my ADL daily activities , even when i say hello to my friend in the street i do actions like this, so do you think my daily activities in such manner detiroriate my pain.


cheers

emad

[nari]

Cory -

I probably would not include all segments in one session - too likely to flare. People's sensitivity varies so much I am continually surprised by the unpredictability of causing a flare-up.

Whether I start them on functional movements depends on how much I feel they have taken in about the nature of their pain. If they do not really understand what they are doing and how it needs to be accurate, and just waggle the arm around as an 'exercise', they will not change- except possibly for the worse. After 4 sessions, a man in his 70s still figured that a neural movement was a as good as lugging a wheelbarrow around or climbing up a ladder. I had not got the message through; it does take a long time. Someone who appreciates the difference between a neural movement and a 'strengthening' 'exercise', I would recommend they incorporate their ULNM into functional actions.


emad-

Am not sure what sort of activities would be too much - waving to a friend in the street is not like a 'neural movement' which you would have taught him (unless it is a very unusual wave!)

The more activity the better - but when the nerve is specifically targeted, it should be controlled!

Try doing a FULL ULNT1 on yourself with neck lat flex, etc, more than 5 reps. I think you would be quite painful for a while.

After the first Butler course (in 1990) 2 days, six hours a day, I was in moderate pain for three days after. After the second one 13 years later, barely a twinge.
Now that is awareness - my tissues were 13 years older and NT had lessened quite nicely!


Nari

[emad]

Hi Nari:

First , here the action they do to salut another person is composed of shoulder abduction ,external rotation ,elbow may be flexed/extended.

Ok. let us take what we concen more.

so i think you belive that ;

tensioners :arrow: could flare up

sliders :arrow: not likely to flare up .

slected movements :arrow: could not flare up .
But i think Flare up could occur particularly if there is perpherial/central senstisation.

In General when i find for example ULTT1 + , usually i prefer to begin with sliders , few repitations , no more than 3-4 times .

i begin with elbow flex(of one side )+elbow exte(of the opposite side)
even the range i begin with small ranges.

cheers
emad

[Green Hornet]

Cory and all,
I would like to add my comment:
"Zoom-out" from, for example, an arm (if you are mobilizing the arm). You will need to restore organic movement in the neck/trunk, scapulae, and/or legs to positively induce a change in the arm.
If you don't get a result you want, you will need to see how the rest of the body affects the arm.

A lesson I just learned recently by Servaas: To get a positive response/avoid a latent flare-up, meet where the patients are.

After observing Servaas' somatic conditioning demonstrations: Functional movements are limitless. There are countless number of ways to enjoy our body in motion. We could create functional motions undiscovered to our clients for enhanced human potential.

[nari]

takao, you sound very inspired by the course.

I guess I did not stress the need to be holistic as well, Cory, but I figured you were aware of that anyway.

I have had patients where moving their left great toe hurts the (R) T3-6 - the body is intimately connected where persistent pain is concerned.
After a little zoom-in, it is time for zoom-out. Patient needs to understand that, of course...

Nari

[Green Hornet]

One of the best things of somtic work is that it allows patiens to become aware of how the whole relates to a part. They can experience the connection and difference.

Does your client have an ability to fully arch and curl the entire spine without glitches? Does your client have an ability to full exhale and inhale?
After accomplishing these, try neurodynamic test to see if there is any change.

[nari]

Takao

I am sure that free movement, being allowed to move with awareness, would result in changed ULNTs.

I am interested in how one achieves 'normal movement' by just telling the client to move, with or without instruction/guide??


Nari

[Diane]

Hi Nari,
This might provide a few clues.
I've copied and pasted a little description of Servaas' workshop that I wrote for rehabedge.

1. It's all about teaching 'first person' production of and experiencing of movement, by the patient. Not a 'third person' production of movement by the therapist. The patient has to learn to deliberately contract through the whole muscle and deliberately relax or lengthen through the full length of a (slightly loaded) muscle.

2. Nothing is done 'to' 'tissue'. It is allowed to be in its natural state, painful or not. Clothing is allowed to be on. Patient lies supine with feet flat/knees up. Practitioner's hands lie under or on top of a large joint or under the scap.

3. Movement is requested by the practitioner.
E.g.: Absolutely basic: arch of low back on full belly inhale (TrA stretches out with the breath in..); reverse arch on exhale, with active contraction of TrA. No pelvic floor or leg adductor co-contraction is permitted.

4. Movement is practiced by patient until it is done properly, essentially, fully, painlessly, minimalistically and easily by patient, with no other muscles kicking in. No stress. No "correction", no interference by practitioner. Just positive feedback, encouragement, request for repetition and suggestions for another way they might try to do it with less effort from compensatory co-contractions, until they "get it".

RE: PAIN: If someone says, for example, "that hurts me, here in the shoulder" Servaas says, "Isn't that interesting! Now see if you can do the same thing, without pain."

5. Hands-on example: practitioner shows patient where to feel their TrA, and how to know that they are using it and not, for example, obliques.

6. Once the breathing and back movement and TrA are all synched, patient and practitioner move on to the next piece, which often will be traps/lats. Patient learns to relax these large sheet muscles which function as agonist/antagonist, both vertically and in crosspattern.
E.g: Latissimus: With hand placed behind scapula, fingers around bottom edge, slight traction on blade, practitioner asks patient to pull their shoulder blade "down" toward waist at the back (concentric voluntary contraction against slight resistance.) They are asked to arch the low back and breathe in at the same time. Then practitioner asks for patient to "relax slowly" (i.e. controlled conscious eccentric contraction of lat) while practitioner's is still pulling in cephalad direction. Very important that patient doesn't just "let go"... they MUST learn to relax their lat s-l-o-w-l-y and make their eccentric contraction conscious and felt by their own brain. The hand adds just enough stress to the lat system that the antagonist (trap in this case) won't take over and completely inhibit the lat. The whole point of the exercise is to help the patient learn to turn the tightness in the lat 'down' by themselves, using lat only and not switching it 'off' by contracting something else instead. (Ultimately, one is trying to turn down the level of muscle contraction in all the contractors, in the whole body, and learn to control the 'knob' better, more like a rheostat and less like an on-off switch. In somatics this is referred to as completing the motor sensory feedback loop to combat "sensorymotor amnesia.")

7. Once they have this piece, and the experience of being able to perceive movement/to move each vertebrae separately has reached the conscious part of the brain, new movements can be stacked in and learned.

8. A practitioner, while nice, isn't absolutely necessary for everyone to 'get' this work. But the teacher of it, whether it's in a class or one-on-one, must have the experience of their own brain coming awake through movement in order to be able to convey to someone how to do it. Its basic experential nature makes it very hard to describe in 'third person' terms.

9. All I can tell you is, it was great to feel my own spine turn into an elongatable snaky-feeling python-esque twisty version of its usual somewhat tightish somewhat shortened self. I'll be doing my little somatic exercises everyday from now on. And six of us locals decided to form a little study group.

Diane
* www.somatichealthcenter.com
Servaas Mes has been invited to conduct a workshop at the upcoming Melbourne lowback and pelvis conference in November.

[nari]

Thanks, Diane

A very nice summary; and interestingly, a few parallels with my ideas.

I like the sound of it all; it sounds magical without the hype.

I rarely if ever undress patients. (Chiros tend not to either.) To me it means I am looking for signs of pain in their torso and this becomes a focus. It also unmedicalises the environment.

I now teach pelvic arch and flatten by hand contact - much more effective.

I use a whole range of 'movements' for homework - based on imagination and a lot of Butler's patterns (he has hundreds)

Servaas's work sounds very simple and effective - as he intended.



Nari

[BB]

Nari and others,
I have been thinking on the neurodynamic treatments and have some thoughts/questions.

It seems that the nerve would follow the same mechanical tendencies of other tissues. If the nerve is not gliding adequately at one area, it is likely being forced to move more, or at least is recieving excessive stress at another site. If this adjacent segment is moving more, it would have to be in the form of a stretch it seems.

Also it seems, that if a nerve does not tolerate a tension, or stretch well, similar issues will be at play. It is likely that the nerve stretches too little in some segments and too much in the adjacent segments.

My concern is that, by appying a slider we may likely be mobilizing the segment of the nerve that is already too mobile, and when we tension a nerve we may be tensioning the segment that already stretches too much. It seems that these, as similar to passive joint mobilizations, would actually mobilize the already too mobile segment?

Now, I'm not saying that I don't buy the concept, because I do, and I am seeing some results already since my course. I am only trying to organize my thoughts on how to logically incorporate this intervention into practice, so that before I use it on a particular patient I have a good idea of what the results will be.

Cory

[bernard]

Hello Cory,

Good point. I think that there is, here, a lack in the training? If I could understand easily that some nerves need to be mobilized, what are the best conditions to do it?

Suppose you have a woman with a common CTS. Neurodynamics will certainly help this woman but if she had got tight trapezius, how would be the results?

Is it not necessary to firstly relax all the areas that may prevent a normal gliding?

[emad]

Hi Cory & Bernard:

This is not Absolute right , i mean your thought/thinking of one area more be tensioned than other area which is free/mobilised .

I think i can proveide you with lots/heaps of evidences which i have printed and read before , i will pull all stops to provide you with the evidence .

But Cory ;

The main idea is , the Nervous system is one entity /system, i mean when you compress one site all the nervous system follwoing that site is more liable to compression and more neural symptoms . AND
may lead to DCS(double crush syndrome) or/(mutiple crush syndrome).


So It is the main idea when you mobilse the nervous system at one area the other areas will be slided/mobilised , i think so ....

I think you attended the course , so you might be more better than me .

i will try to provide evidences.

cheers
emad

[bernard]

Emad,

The concept of neuro mobilization or nerve gliding is based upon the fact that nerves are like elastic ropes. A nerve can be stretched on 3/5%. This gives us already a great ability to move freely without problem and nerve tension. If this rope is slowed down by an upper muscle constant and irrelevant tension, something could happen in the periphery.

My example about CTS is simple. Actually, I treat always neck and often the CTS symptoms fade away before I tried to treat them!

[nari]

emad

You mentioned a tricky point re mobilising in one area and affecting another quite remote. I don't know if anyone knows that flexing and extending the wrist on a straight elbow with the shoulder at 90 degress flexion is actually moving anything outside the distal ends of the median nerve...
BUT it certainly affects other structures - pain can be reproduced in the contralteral shoulder, face, great toe - anywhere.

Bernard:
One would always assess the neck and the integrity of the three UL nerves in a CTS? It is a syndrome, and is only a diagnosis....n'est-ce pas?


Nari

[bernard]

My neuronut skill will say yes but I know many PTs that will focus on whrist! :oops:

Assess is the thing and relax shoulders and traps is a different thing? isn't it?

[BB]

Hello all,
I appreciate your replies. Bernard, I agree with your thoughts on creating the best environment for the nerves to slide.

I am going to make a comparison here, and it may be a bit of a reach, but this is how I am currently organizing myself....

The patella is a passive structure in that it goes where the quads and jt. surfaces (and of course brain) guide it to go. If the leg is turned, the quad becomes tight laterally and loose medially (along with many other happenings) and the patella becomes arranged laterally. It goes where it is lead.

This is how I am thinking about neural structures. They are passive structures movement wise. They move how the surrounding structures move them.

So....To this point, I am organizing myself with neural mobilization much as I would patellar mobilizations. I address first the tissues that dictate its placement. I am using the neural mobs to help once this is established.

I am out of time here, but that is my thoughts quickly.

Cory

[emad]

Hi all;

Cory , the example you gave to make it clear how you think about neural mobils ,using the patella example :arrow: ok

What i know , you are true when you move /mobilise enviornment /surrounds of the nerve you are alerady mobilise the nerve .

Nari ;

sometimes when i want to apply neral mobils in the form of sliders , i think of just moving the non-affected side could give me what i want to apply in a very simple,genle manner.

Bernard:

Why not considering this tight muscle in the neck is a part of compression on the main Nerve passways of the whole plexus .

cheers
emad

[bernard]

Emad,

I think that my approximate English words are not actually well understood by you.
I understood that tight muscles could be a part of the neural process or induced as a consequence of a nerve problem.
It is why I said that it was important to permit a discarding of these barriers which prevent a normal gliding of nerves?

[nari]

Hi Cory

It took a while but I finally worked up a visual analogy between a nerve and a patella...I know exactly what you mean.
But I would err on the cautious side - muscle and nerve function very differently, of course, and overdoing the nerve glide/s could set the sensitising fires off under certain conditions.

Bernard

Perhaps another way of loking at our debate is this:
Chook (Oz for hen/chicken) and....
Egg.

Who knows which came first, so give both a hands-on Rx.

emad - you can have very good results treating the normal, comfortable side and not touching the affected side

Except the patients can think you are nutty or lost the plot....


nari

[emad]

Hi Bernard:

Ok ,thank you for clarifying


cheers
emad

[bernard]

Hi Somasimplers,

I must clarify for Nari, too. :wink:
In my view there is no such question about egg/chook, here?
Simply temporal priorities.
I considered that treating the proximal site, firstly (chook), will prevent to smash my nervous eggs a bit more?

[nari]

Bernard

I think you have all your eggs in one basket.
Why is a sensitive nerve seen as distal? You said treat the chook proximally (muscle?)-what about the nerve roots?

I know we agree to disagree - no prizes for the winner and no winners!

:wink: 8)

Nari (claws retracted!)

[bernard]

:wink:
Proximal sites are close to the roots and relaxing these areas help to make room for them?

I agree anyway!

[BB]

Hello again,
Obviously the patella analogy I made earlier only approaches the passive characteristics of a peripheral nerve. However, these nerves are a very active structure, just not with movement.

In the course it was discussed how the nerve actually creates an inflammatory response at its ending. It seems that if the imflammation became chronic, that this would eventually become an issue of developing fibrosis. This would affect the ability of the nerve to move passively.


Cory

[bernard]

In the course it was discussed how the nerve actually creates an inflammatory response at its ending.

Could you elaborate?

[BB]

A distinction was made between neurogenic and non-neurogenic contributions to inflammation.

The C-fiber releases peptides into the synaptic space. Peptides stimulate capillary membrane leakage, mast cell degranulation, and enhanced enzyme activity.

Therefore, the target tissue becomes inflamed as a result of the neurogenic contribution. (It was also said that NSAIDs do not affect neurogenic inflammation)

My point was that chronic inflammation can lead to fibrotic tissue which can significantly alter the way that tissue moves. It also makes sense that this would contribute to positive neurodynamic testing.

Cory

[nari]

Cory

No-one responded to your points made re C fibres and inflammation -especially the difference between chronic and acute, so I will.
Several good points: re NSAIDS being ineffective for neurogenic pain (which I always suspected from talking to patients) and target tissue develops secondary inflammation, (I recently had a woman with bilateral Achilles tendonitis - obviously not from any activity, as she was inactive- and she was as puzzled by the dense, non-warm swelling as I was).

David talked about not forgetting the periphery even if healing has clearly taken place, and I think he was referring to this secondary inflammation process.
Thanks for the info.


Nari

[bernard]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14984413

Eur J Neurosci. 2004 Feb;19(3):634-42. Related Articles, Links


Integrin signaling in inflammatory and neuropathic pain in the rat.

Dina OA, Parada CA, Yeh J, Chen X, McCarter GC, Levine JD.

Departments of Medicine and Oral and Maxillofacial Surgery, Division of Neuroscience and Biomedical Sciences Program, NIH Pain Center (UCSF), CA 94143-0440, USA.

Many painful conditions are associated with alterations in the extracellular matrix (ECM) of affected tissues. While several integrins, the receptors for ECM proteins, are present on sensory neurons that mediate pain, the possible role of these cell adhesion molecules in inflammatory or neuropathic pain has not been explored. We found that the intradermal injection of peptide fragments of domains of laminin and fibronectin important for adhesive signaling selectively inhibited the hyperalgesia caused by prostaglandin E2 (PGE2) and epinephrine (EPI), respectively. The block of EPI hyperalgesia was mimicked by other peptides containing the RGD integrin-binding sequence. Monoclonal antibodies (mAbs) against the alpha1 or alpha3 integrin subunits, which participate in laminin binding, selectively blocked PGE2 hyperalgesia, while a mAb against the alpha5 subunit, which participates in fibronectin binding, blocked only EPI-induced hyperalgesia. A mAb against the beta1 integrin subunit, common to receptors for both laminin and fibronectin, inhibited hyperalgesia caused by both agents, as did the knockdown of beta1 integrin expression by intrathecal injection of antisense oligodeoxynucleotides. The laminin peptide, but not the fibronectin peptides, also reversibly abolished the longer lasting inflammatory hyperalgesia induced by carrageenan. Finally, the neuropathic hyperalgesia caused by systemic administration of the cancer chemotherapy agent taxol was reversibly inhibited by antisense knockdown of beta1 integrin. These results strongly implicate specific integrins in the maintenance of inflammatory and neuropathic hyperalgesia.

PMID: 14984413 [PubMed - indexed for MEDLINE]