In your assessment.......

[nari]

When you are assessing a patient with pain, and the complaint is less than 3 months (or so) old, do you always include neural tension testing?

If your patient has had a knee replacement and 4 weeks later still has pain and lack of optimal ROM.....do you include routine neural testing?

If there is pain across the metatarsal arch on standing and walking and very occasionally on sitting.........?

If there is pain down the lateral and ventral aspect of the thigh and loss of ROM in the hip of a 60 year old overweight woman and the XR shows "mild arthritis"............?

If there is functionl ROM in a painful shoulder and cervical spine is painfree and within normal ROM.............???

I am interested in what leaps out of your brain after you have taken initial history and assessment, and are about to start a treatment....


Nari

[nari]

Great answer, Bernard

But I have to add that understanding and proof of the nociceptive impulse and central sensitisation of pain is also well researched and consolidated by Gifford, Moseley, Linda Watkins and many others.
Damasio, with his skills of writing, and his deep interest, has been vindicated by later researchers; he must have felt, years ago, that nobody would accept his hypotheses. I hope he will continue to write up his work. As with Patricia Churchland and Susan Carter and lot of others whose interests lie with the brain.

I must also add that Australia has finally seen the light - well behind the UK and Europe - and now physio associations are running courses in cognitive-behaviour therapy for physiotherapists.

About time!!!


Nari

[Diane]

Sounds like neural consideration in a pain patient is a phenomenon that is travelling west to east, against the edge of the sunrise. I'm ready for when it comes to the west shore of Canada.

When you are assessing a patient with pain, and the complaint is less than 3 months (or so) old, do you always include neural tension testing?

I always palpate over the superficial nerves (which are just continuations of the deeper ones) where they exit the fascial layers, to see if they are tender. If they are I treat them.

If your patient has had a knee replacement and 4 weeks later still has pain and lack of optimal ROM.....do you include routine neural testing?

See above. I would focus on the big neural tracks that run behind the knee, the little horizontal plexus around the knee on both sides, see to it that all that was mobile. I'd check and clear any palpable neural tightness along the fibula. The myotendonous junction of gastroc holds a neurovascular plexus that is twisted. I'd see to handling that to persuade the neuromatrix to permit lengthening of gastroc. All about the ankle. Check and clear anterior hip if necessary. Ditto posterior cutaneous nerve of thigh. Obturator that winds through adductors. Anywhere in the limb that nerves live.

If there is pain across the metatarsal arch on standing and walking and very occasionally on sitting.........?

The bottom of the foot is nerve city.

If there is pain down the lateral and ventral aspect of the thigh and loss of ROM in the hip of a 60 year old overweight woman and the XR shows "mild arthritis"............?

I'd show her a picture of the nerves in the pelvic floor that pass near the sacrotuberous ligament, (I have a 'picture book' of all the superficially accessible nerves at work for this purpose) and would propose we treat the pelvic floor. One ten minute session produced internal rotation in a hip of about 30 degrees, in a woman who had had next to none for months.

If there is functionl ROM in a painful shoulder and cervical spine is painfree and within normal ROM.............???

It's gotta be the nerves.

I am interested in what leaps out of your brain after you have taken initial history and assessment, and are about to start a treatment....

Now you know. I take the initial history and assessment, highlight which nerves are stuck where, and begin to plot ways I can get my paws on their neural tunnels. Then I show patients how to keep them slidey.
:),
Diane

[emad]

Hi Nari , Bernard & Diane:

Before , i know NOi , i did not know an.
ything about neurodynamics .

But now ,
yes , i put it as a priority
After i take the intial history , yes , now i am so interetsed to test /apply neurodynamics to improve my experience through thus new concept , at least for me

Even , i could say to you , i meet lots (heaps) of orthopedic cases which are mainly bone and soft tissue , and i try to test neural tests , as i read before an evidence that in cases of lateral ligaments injury of the ankle (sprain) , the perioneal neve is affected , so i apply all those tests , i think very fast ,
Even
i criticize my self , i say to my self , i apply those knowledge very early through my managenet process , i have to be more slowly in applying those tests , i find myslef automaticaaly attracted toward that area , i am afraid , i have to take more accuracy through my work , i have to put all hypothses
neural hypothesis
ST hypothesis
other hypotheses

yes , Nari
you are right
i find myself more attracted to put the neural hypthesis .

But
The issue sounds/seems the neural hypthsis is actually existed , which i try to postpone , or put it aside .

cheers
emad

[emad]

HI Nari:

i want to say , one of the errors in clincal reasoning is overemphasising certain hypothesis , so when i go on through the assessment , i put that in my mind .

cheers
emad

[nari]

emad

Yes, you are right with your posts - overemphasising one hypothesis tends to lead a PT into a tunnel.
Epicondylopathy is one such tunnel!



Nari

[Servaas]

Bernard,

I see that all the time. Good story, you gotta love it!

Maybe the truth is inhibited human reasoning ?

Which was taught to us by our teachers...

Servaas Mes
www.somatichealthcenter.com

[BB]

Hi Nari,

I use the neural tests in the upper quarter most consistently when I have a patient with neural type complaints when I don't see any stand out strange movements of the scapula or c-spine. I'll guess that I use them around 50% in the upper quarter. I use the specific neural exercises even less. I use the tests more often to gage thier level of sensitivity. If however, movement is improving, function is improving, but the pain is still lingering, I do go back to the neural dynamics and that is usually the missing peice.

Same is true in the lower quarter. I test SLR on everybody, but rarely use it as a treatment.

I will say that I use the neural dynamics more often since you helped me figure out how to better use them. I go to the Butler course in 1 month, then hopefully I will be able to gain more consistency in thier use.

Cory

[BB]

Bernard and Servaas,

It seems that with advances in imaging technologies comes even more dependence of our patients on "the system". What an unfortunate trend.

Cory

[bernard]

Cory,

I think that we zoom-out the problem!

If you get a positive SLR test, with a positive RX signs, you can stay there (zoom-in) or you can change the whole functioning and then the positive signs may have disapeared? What does it tell us?

[emad]

Hi Servaas:

Really i find difficult to see what do yuo mean through your question ;

Maybe the truth is inhibited human reasoning ?

i hope you find time to clarify , ////or Bernard &Nari clarify the meaning of that question if you see the meanung well.


cheers
emad

[Servaas]

Hi Emad,

Nothing spectacular.

I am just referring to the fact that many people are inhibited thinking outside of the box, that many people have difficulties to be open to exploring new ways.

Which is the way we are often taught, because how many times do we have to learn a protocol and perform the protocol and stick to the protocol ??

And to change the protocol, hmmm, we'll have to have a meeting about that !

I hope that clarifies.

Servaas Mes
www.somatichealthcenter.com

[emad]

Hi Servaas ;

Thank you for clarifing ,you are right , we are not given the chance to think, to use our reasoning .

particularly those called protcols, guidelines, and pathways, yes restrict our abilities to think.


Nari :

I think i have read before about one of the errors in clinical reasoning , after attending a course (e.g. neurodynamics) the prationner sees all cases need neural mobilisation , means the person who holds a hammer sees all things as nail.

cheers
emad

[nari]

Hi emad

It is true that if anyone attends a course on anything, their clinical reasoning is altered by that course, so that they might forget other aspects that should be considered....

Quite right, and we all fall into that trap.

Sooner or later, we crawl out again and take note of other aspects of the big picture...but some do not, and continue zipping along the tunnel of their choice.

The one advantage of neurodynamics and its psychosocial aspects is that it belongs with the big picture of the brain-body; other anatomical systems are not so big-pictured, but still need attention.

Does that make sense?


Nari

[emad]

Hi Nari:

yes, you are absoultely right .

I think practionners who are working on the concsious level , only those who can go out of the trap(tunnel), those being fully attentitive (reflective practionners , particularly those use reflect -IN-action ) during their work.

Regarding , neurodynamics being belong to the big-picture :arrow: Neurodynamics are so fine in the manner applied :arrow: :arrow: :arrow: I think all peoples have the sense /thinking that as they do more vigrous excercise the pain decreses , however thus may detiororate the case , so in neural mobilis all therapists advise patients to perform more gentle/fine /slow/simple exercise, may be thus the background of relaxation feeeling fallowing neural mobilis , of course i believe nerve moving /mobilis/stretch could be of benifit, but clear the manner of what we are applying is more important than what we are applying in our approachs.

cheers
emad :?

[Diane]

I did it! (Split a topic that is.. I might have split it a bit too far up in the thread, by one post...) Look for Brains Versus Muscles in the Rubbish Cube forum. Nari, I hope you don't mind my little foray into the adventure of splitting a topic, your topic, on your forum... hope you are OK with that..
Here is your last post:
emad

Yes, you are right in what you are saying - when neural movements are slow, thoughtful and simple, they work better and faster.
So does any exercise, really. How many times do we review what exs we have asked the patient to do, and often, he/she does them too quickly, or just in middle range, or not anything to do with what was shown?
The nice aspect of neurodynamics is their simplicity - often nothing more than elbow flexion/extension in shoulder abduction, or wrist flexion/extension and shoulder elevation.
And neurodynamics can sneak into basic "muscle stretches'. If you ask your patient who is a bit stiff all round, but has a painful neck/shoulder and cervico-thoracic joint (common in women) and is ULNT1 positive, to do a wall push-up, the calves are stretched lightly, the neck is controlled, the median nerve gets to glide, and the scapula retract. They learn the feeling of tension/muscle contraction around the CTjoint and realise they slouch the shoulders and poke their chin forward in normal posturing.
Middle ground can be easier to find when stretching tension and active contraction of muscles are recognised.

Yes, Bernard - I am talking muscles; I don't ignore them entirely, but I want my patients to know what they are stretching/mobilising/contracting and it is not just muscle, it is a whole bunch of tissue. Combination movements can work well.
And, of course, the neurodynamic tests, when done as a treatment, mobilise nerve, joint, fascia, muscle and whatever else is lurking in the region/s. Tai Chi is a good example of composite activity.


Nari
Learning how to manouver a board,
Over and out,
Diane

[nari]

Diane

That's fine!! You are much more competent with fiddling around with such things....



Nari