Getting my feet wet

[luca m]

So, I'm very new to this forum but I have been absorbing some things. I've tried to use some of it in practice and, low and behold, positive results! I have to admit, though, it was more a change in thinking than a change in technique. Definitely easier to rationalize an outcome after a treament when looking at it from a neurodynamic perspective.

Thanks (probably the first of many).

[luca m]

not sure if this was the right area to post this ????

[Diane]

This is a perfect area to post in, start a thread. Don't worry, if it seems the thread would suit another place better we could always move it. So no worries.

[Jason Silvernail]

Welcome luca.
Tell us, how is what you tried different?

[nari]

Hello Luca

You are so right - the technique is less important than thinking things through to arrive at a logical conclusion, plus a decent knowledge of neural anatomy.
Techniques come and go, but understanding what is happening with pain doesn't change - unless of course something massively different occurs in the pain research area. It is soooo much easier than trying to slot patients into neat pigeonhole categories of techniques, be it McKenzie, Sahrmann, Maitland or whoever.
I've never got over the fact that pain can vanish so quickly if one remembers the nervous system is the primary player.


Nari

[luca m]

Hi Jason,

Changed gears from thinking of the pain generators as muscle and joint to the pain generator being nerve is the main difference. Most prominant example; Man with right lateral leg pain, mid to distal 1/3. Was treated for 7 weeks in a nearby physio clinic. They treated his lower back because MD found DJD/DDD on films. No change in his condition. He had no back pain and no motor/sensory findings, only pain in lateral leg. My findings included tib-fib. joint restriction and multiple trigger points in peronei. I typically would dive in and mob/manip the tib-fib. jt., dig into those trigger points, stretch out peronei mm.(that's actually what i did for the first 4 sessions with short-lived reduction in pain).
Tried nerve mobs trying to bias common peroneal n. and some "skin traction" (for lack of a better term) in lower 3rd of lat. leg (around superficial peroneal n. region) and sent him home with a couple of exercises.
2 sessions later he had no trigger points and sustained pain reduction. Joint restriction was still present but non-painful.

Admittedly, I'm not in the least bit confident in my skill with these techniques, but I'm playing with it.

I would like to purchase a text. Either Butler or Micheal Shacklock. Is one better as a starter than the other?

[Bas]

I would go for broke and get both....Really. They are not "either/or"....

Nice case description Luca! I hope it raises your confidence: 7 weeks in one clinic= no change, and you in 3 sessions=better. Yes, it's only a single case, but indicative of what your change of 'style" can bring to both you and your patients.

[nari]

I agree that both are needed because each is different in its own way; just as any two books on science by different writers can give similar perspectives but travel separate roads.

Luca, changing gears in what may seem midstream can be a challenge. For many PTs I know, the effort is well worthwhile; for some it may mean largely forgetting about what was taught in PT school, and even post-grad education needs a change in approaches. There is nothing absolutely certain in science, and that applies to physiotherapy; but working from basic constructs of neurophysiology makes more sense than battling with muscle and joint anatomy malfunctions.

Go for it! Enjoy the water.

Nari

[Jason Silvernail]

Great example, luca.
I think that was the biggest shift for me, too. I mean the realization that muscles and joints don't hurt, only nerves hurt. The fact that those relevant nerves might be somewhere other than muscle, tendon, and the joint capsule and surfaces itself just never seemed to occur to me. Or many others in our respective professions.

Seeing the body this way is so much more solid of a scientific construct, don't you think?

[Randy Dixon]

I think Jason is right, but I also think there is a danger in becoming overenthusiastic and becoming antagonistic towards the understanding you had before. Looking at the structure and biomechanics without understanding the influence the nervous system plays in human function is a mistake, but considering only the nervous system without regard to structure and biomechanics is also a mistake. The mistake is believing that either can be understood in the actual human condition without considering both simultaneously as an integrated whole.

[nari]

Randy,

You are right; they are integrated, but in the case of the abnormal neurodynamic, the nervous system comes first.
If I had a person with tendon repair of an extensor tendon of IF, gaining ROM and preservation of the repair site is paramount. But there is no pain associated with these repairs, if the surgeon has been accurate; and the same would be for a knee reconstruction, but in the latter, there is pain, usually. Attending to this improves rehabilitation prospects.
I don't think we are throwing away orthopaedic principles, where there is surgical intervention. The aim is to get the patient over the effects of surgery, just as with cardiac rehab. It can be a combination, and should be.

But with the chronic pain patient, biomechanical approaches do not work so well, without close attention to the neurodynamics. The nervous system comes into the fore with these folk.

If pain is reduced, increased function follows. The method of pain reduction is where some PTs might part company. But a focus on the nervous system should greatly increase the positive outcome of a traditional "gym/exercise" concept.

The baby is preserved; some bath water, if not a lot, can be thrown out; the state of the patient (critical, subcritical) is what counts, and whether this state is due entirely to an abnormal neurodynamic, as spelt out by Barrett.

Nari

[luca m]

I agree that we can't disregard the biomechanical aspects, but too many only view it from that perspective. I know I did. If a patient didn't respond, I would chaulk it up to a yellow flag or central sensitization or non-compliance. Looking at it from a neurodynamic view has now given me a solid rational for the non-responder to the biomechanically-based treatments that are, or should I say were, engrained in me.

[Diane]

luca, do you realize how advanced you were to even know about let alone consider items such as "yellow flags" and "central sensitization" in your repertoire? I think the vast majority of HPSGs (human primate social groomers) are still at the level of just thinking about misbehaving mesoderm (joints/bones/muscles).

Here is a link to the "father" of central sensitization, Clifford Wolfe (http://www.asahq.org/Newsletters/2004/08_04/zapol.html). I'm about to put him into the Pharos section (http://www.somasimple.com/forums/forumdisplay.php?f=23) here. :thumbs_up

[Jason Silvernail]

I agree with Randy also in that it isn't an either/or situation. I find many patients still in my practice who have biomechanical problems who do very well with biomechanical solutions. However, there are a percentage of patients (and this varies depending on your practice pattern and winds of change) who essentially stop having a musculoskeletal problem and start having a neurological problem. Being able to recognize that and change gears is I think very important.