neurodynamic question/help

[mrupe82]

Since becoming a member here at SS I tend to look at patients as Jason S. mentioned in a thread (somewhere??). I can't help but see nerves move more so than muscles/tendons/bones etc (peel the skin back if you will....but still acknowledging/accepting it Diane:teeth:).

I have had 4 pts. with a dx of adhesive capsulitis and watch the 'defense' of upper trap compensation with shoulder and even elbow motions. I have also seen a pt. with dx of 'hip pain' with recreation of symptoms via SLR, initiation of slump stretch in the piriformis region. Relief only results with exercise and piriformis stretching. I have had a handful of pts. with cervical radiculopathy with ULNTs always + on symptomatic side and nothing on the contralateral side.

I see neurodynamic issues (?) everyday and (I am continuing to learn/read about) is present in many patients I've seen. Could anyone point me to the threads/sources/etc that show how to treat this. We learned NOTHING on neurodynamics for diagnosis or treatment in school so I'm looking for some help. I see this almost everyday and I looking to figure how to address it on a treatment, dosage level.

P.S.
I don't have the luxury of buying Shacklock's book so options that don't require dropping too much change would be best...

Thanks so much...

[Joe Haverkamp]

Matt, I have a (very) limited knowledge of the complexities of treatments, but as a new graduate I have found some benefit to treating with a couple basic techniques.

I believe the traditional approach involves "sliders" or "tensioners" (although I have heard also to steer clear of tensioners, as the neural issue is more of an impaired neural dynamic rather than a true tension?). A slider involves giving slack to one aspect of the nerual structure and taking up the slack with the other - i.e dorsiflexion coupled with cervical extension in the slump position. This would obviously depend on the neural structure and where it lies in relation to the joints you are moving.

Another option would be treating the neural interface - one example would be performing a side glide in the cervical spine at the segment you propsed to be affected, instead of performing a slider through upper extremity movements.

Forgive me if this is elementary - I'm also a new graduate and would be very interested in learning other treatments....

[BB]

Hey Matt,

Have you had a chance to read the Shacklock interview (http://www.somasimple.com/forums/showthread.php?t=2629) and follow up discussion (http://www.somasimple.com/forums/showthread.php?t=2734) in the Choices forum? He offered up quite a bit of detail on his approach.

[Frédéric]

Hello Matt,

I would simply like to say that I routinely see what we could call positive ULNT or SLR/PKB or others. I don't think there is always an «issue» with a nerve per se because a neurodynamic tests has less amplitude on the affected side. It could simply reflect an increased central/peripheral sensitivity to mechanical stress on nerve tissue and by extension to any innervated tissu in the vicinity. That means that we might not have to address specifically the affected neurodynamic tests. In treatment, I have the habit (good or bad ?) to address specifically a nerve or a neurodynamic issu if it is really standing out from the other tests in the exam. Or, if the symptoms are pointing to a specific root or nerve in particular. I tend to leave specific treatment of nerves alone when many/all neurodynamic tests are positive. To me this means increased central or peripheral sensitivity. In such cases I tend to do more gentle stuff and include more non-specific mvts that will simply introduce general nerve gliding to basicaly re-introduce painfree mobiltity in a graded fashion.

Then, there is also the cases where the ULNT or other neurodynamic tests are negative but there really seem to be a nerve involved. Then I might still do some gliding and even tensionners depending on the patients response to mvts.

I am sure others have some insights on this

[Jason Silvernail]

I see this similarly to Frederic. In most patients with problems like this, you are well advised to treat their spine first and just check the NT periodically to monitor progress. The existing data as far as outcomes goes for these common problems doesn't specifically include neurodynamic treatment, there is some good evidence for PT intervention in those areas, and I've found these issues calm down when other things are treated. As Frederic said, perhaps often it's a case of sensitization and not a primary nerve disorder. I think dosing this sort of neurodynamic treatment is very very difficult and I struggle with a sensible way to do this so as not to flare symptoms.

Cleland's slump stretching trial for LE pain was a bit of a surprise to me in that they used much more long duration "tensioners" than I would consider prudent yet the people in that trial did very well. Which is a great addition to the evidence but does clash to some degree with my (lower level of evidence of course) experience and it makes it hard to understand dosing these things, in my view.

Tread carefully.

[smikolic]

In patients with high response to mechanical load, hyperalgesia/allodynia, n. glides are not usually where I start. I agree with Frederic on that.

Always education first. Tell the pt what their system is doing and why they are responding with pain, get them to realize that pain does not = damage. Jason Silvernail's handouts are helpful (under the Persistant Pain section, Jason's Handout's thread..sorry don't know how to get that to come on here so you can just click and go). Educate them on how movement, and relearning use of the affected part in a painfree way is critical to return to full function, and use their reports of pain at rest to bolster the arguement that rest doesn't work, and illucidate what rest/compression are not doing for the nerves that are irritable (providing them circulation/oxygen). Also helpful to include some education on motor learning vs. telling them we are simply working on increasing ROM/strength so that they start to "get" that their body "learned" to be in pain, and they can unlearn it too, and that the body is stuck in option 1 = pain w/_______). Helps a lot in people with previous experience (bad previous experience) w/therapies to open them to the possibility that there is another way, and that they have permission to feel and can respond to it and learn other responses too. Fun to hear pt's insights when you go this way w/education.

Diaphram breathing and awareness training, education on stimulating vagus n. vs. not is sometimes helpful to get them to see the "physical" benefit of diaphram breathing and to realize that warming in the area of complaint is not a bad sign (lots of pt's tend to see that response as indicative of increased inflammatory response, despite decreased pain and improved motor function as measured by balance/control/ROM, etc.)

You can introduce neurodynamic mobilizations indirectly by pulling skin in a related area in a direction that emphasizes elongation of the affected/sensitized tissue (think of the skin as a t-shirt and the affected dermatomal area/s as simply a part of that t-shirt. If you pull on the sleeve on one side, you end up pulling/mobilizing the entire shirt right?).

Introduction of dissiciative movements (hand's off, getting the pt to "turn in") approach works as it improves proprioception, and I have had a lot of good response (warming, softening, increased ease of movement and range, decreased pain quickly with this approach). But be gentle, don't make it about the motion and keep the effort low, pain minimal (within a 2 point range of change or less), and keep them breathing....basically if it doesn't look like it's working, try a different way, give them a rest, gently hands on facilitate to promote proprioception and improve confidence/reduce fear-avoidance.

Have them move some part, for example, in sidelying have the pt tilt their pelvis anterior/posterior, and have them tell you what's happening to shoulder/knee/head/breath and then try to somehow facilitate them doing it "different" (ie. if head goes with pelvis, have them turn it opposite, etc.).
Always love ideomotion, but it's so hard to get a pt to learn how to do it on their own for me. I need to keep working on that.

I have had a lot of success, and very quickly, with simply having pt do wall glides (put the hand at shoulder level on the wall and turn body away (to elongate through brachial plexus), or SLR's w/slump mobilization (dorsiflexion, knee EXT, hip flexion, reach through trunk toward toe, chin tuck). Be CAREFUL w/introduction of the patterns though, sometimes fingertips w/elbow flexion and body turned completely toward wall is the ONLY way to reduce irritability enough to introduce (probably not appropriate to add if that's all they can handle), so add slowly, educate on what to expect and limitations to progression. I typically educate that sensations are OK, but increase pain on release is NOT, and to be gentle with the glides, it's NOT a stretch...some pt's want to hold it, so I roll up a towel/pillowcase, explain the anatomy of n. and it's winding blood vessles and pull on it and say, now if this towel was wet, and I just did this (w/it all twisted), what would happen to the water/blood? Do you think that an irritable n. is going to appreciate you doing that to it?

Hmm....I tend to progress from improving active assistive ROM and tolerance to the patterns, and manual work toward progressive compressive (weighted/resisted) activities that are functional toward graded exposure toward their specific deficits, to increase the tolerance of the n. pathways and innervated tissues to mechanical load. Again, setting strict limitations for progression and educating on what's OK, and on what to do when pain increases (glides, breathing, skin stretching etc. as per what works for that pt and fits into their lives).

Hope it helps!

Steph

[smikolic]

let me try this for Jason's Pain Handouts (http://www.somasimple.com/forums/showthread.php?t=5332&highlight=jason%27s+pain+handouts). See if it works.

Steph

[smikolic]

Yeah! it worked!

Also, Jason's Handouts got me thinking about analogies to illucidate "what is going on" in pt's w/pain. I came up with the analogy of the worm:

If you threaten a worm, what does it do? Threat creates a pulling back response by the worm in an effort to protect itself. The worm will even respond to the shadow of the bird (the idea he will be a tasty treat) just as easily as to the actual act of the birdy grabbing him, because he learns very quickly the stimuli that threaten his survival with damage to his body, whether that worm is being actually pulled on, or thinks he could be in the presence of some stimuli perceived by him as threatening. The reason our "pulling in" in response to percieved threat is not as dramatic as that worm is that we have a skeleton to disallow a lot of movement "in" so-to-speak. Is very useful for all the fisherpeople up here. It really helps explain "why" the muscles feel stiff/tight, why they are or feel "shorter" on one side, and why it doesn't help to pull on them, strengthen them, and push into them....duh, right?

I don't see a responding worm as weak or think that digging into him will serve to "relax" him or pulling on him as a good way to encourage him to come out of his hole, any more than I would see doing those things to a person as helpful to get them out of their "hole."

Let me know if you come up with any others for your patients.

Steph