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  • The Case Against Neural Tension

    Posted by Barrett<script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,13,20,7,0), dfrm, tfrm, 0, 0, 0, 0)); </script> (Member # 67) on 14-12-2005 03:07<noscript>December 13, 2005 08:07 PM</noscript>:

    There’s a “nerve lengthening” thread over on NOI that I’ve found very interesting and I’d like to see if we can’t do something more with it here. Both Diane and Nari have participated and I’d recommend others looking in. What interests me most about the discussion is the lack of consensus regarding what happens to the length of the involved neural tissue both when it is challenged with a test and when its problems are resolved with some sort of movement. Apparently, a “longer” nerve can’t be said to exist when all is said and done, so you can’t make the case very easily that it was shortened or “tensioned” beforehand, though this kind of biomechanical problem needn’t be ruled out either. So what’s going on here?

    One of what I call “the four corners” of Simple Contact is the concept of adaptive potential; a way of describing a person’s tolerance for mechanical deformation without pain that is primarily a function of their autonomic state. Moving this toward parasympathetic dominance with diaphragmatic breathing, ideomotion and a non-judgmental presence is important for profound recovery, I feel. Maybe this physiologic shift outstrips the alteration in neural mobility. If this is true, it would account for the many patients I’ve treated successfully without ever seeing much movement emerge from them.

    Consider this from Michael Shacklock in Moving In On Pain (1995): “Physiology is the avenue through which nerves cause pain and much of what is observed in the patient is an expression of the pathophysiological changes. Practitioners who wish to mobilise neural tissues must routinely embrace physiology in their reasoning.”

    Given the paucity of evidence for a lengthening of the nerve with manual care or prescribed exercise, maybe we need at this point to consider the physiologic shift necessary for recovery with a little more care.

    I’ve some more to say about what history and testing might reveal, but let’s see where this goes.
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,13,21,25,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 14-12-2005 04:25<noscript>December 13, 2005 09:25 PM</noscript>:

    Maybe it is just a matter of taking up or not taking up the slack at the nerve roots. If there is little 'slack' due to some sort of inhibitory effect, say in the median when abd/ER/wrist ext begins, then it's going to screech by the time it gets to 90 degrees or so.
    An 'anormal'(sic) ULNT1 and 2 can occur in perfectly healthy and functioning young people; eg anormal tension 2/3 of the way through the test they are jumping about. However, no pain, no loss of function. So the 'normal' for these tests is a pretty large parameter.

    The other, more likely explanation, is the 'shortening' or 'lengthening' of a nerve, is purely perception. If a test is done strongly - and many, many are done with force - there will be pain well short of full 'normal' range. Ahh, tight muscles, tight nerves, etc. Stretch 'em out...tick off positive in the boxes.
    Yet the same test, done once again with feeling (was that a movie??)and snail's pace, is uneventful. Tick off negative in the boxes.

    The same applies to movements / exercises.

    Anyone take on the nociceptive idea of a passive test (or active, maybe) done with some speed and lack of thought about what the patient's brain is going to think of a therapist's zooming in to test 'tension'...? or saying to the patient: "..further, try and go as far as you can"....is a matter of brain perceiving a threat?

    (Excluding those unfortunates who have been tied up in plaster or some such restraint and have developed severe deficiencies in lengthening)


    Nari
    <hr> Posted by FunctionbyDesign (Member # 6097) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,13,21,53,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 14-12-2005 04:53<noscript>December 13, 2005 09:53 PM</noscript>:

    This is definitely the clearest description of what "Simple Contact" tries to accomplish thus far. Still a novice and tool happy, but I look forward to learning more about it's application and relinquishing my toolbelt....it's starting to get heavy....and expensive. [IMG]smile.gif[/IMG]
    <hr> Posted by Barrett (Member # 67) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,14,6,13,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 14-12-2005 13:13<noscript>December 14, 2005 06:13 AM</noscript>:

    I’d agree with Nari that passive testing presents us with problems that are difficult if not impossible to overcome. I’ve concluded after all these years that I’m better off just asking people about their symptoms and whether or not they can be altered with movement of any sort. To me, the geometry and complexity of the nervous system makes it impossible to know much of anything about a specific nerve for sure. As my students know, I place great store in hip position and its relation to discomfort. Breig and my patients taught me this.

    I think many, many people have what Shacklock calls a “covert” abnormal neurodynamic. He says in Clinical Neurodynamics “A covert abnormal response does not reproduce the patient’s clinical pain but it does show covert or hidden neuropathodynamics that later might be deemed relevant.”

    Chronic cooling is important to note here along with a general increase in muscular activity in related and unrelated areas, difficulty falling asleep and worsening upon waking. For all or some combination of these bits of history I begin with Simple Contact and see what it might reveal as ideomotion ensues.

    This seems to have the desired effect, but the question remains: Is this because the nerve has now lengthened and thus less tension is present?
    <hr> Posted by avalon (Member # 4679) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,14,7,42,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 14-12-2005 14:42<noscript>December 14, 2005 07:42 AM</noscript>:

    Hi All,

    Mechanisms of axon ensheathment and myelin growth.
    Sherman DL, Brophy PJ.
    Centre for Neuroscience Research, University of Edinburgh, Summerhall, Edinburgh EH9 1QH, UK.

    The evolution of complex nervous systems in vertebrates has been accompanied by, and probably dependent on, the acquisition of the myelin sheath. Although there has been substantial progress in our understanding of the factors that determine glial cell fate, much less is known about the cellular mechanisms that determine how the myelin sheath is extended and stabilized around axons. This review highlights four crucial stages of myelination, namely, the selection of axons and initiation of cell-cell interactions between them and glial cells, the establishment of stable intercellular contact and assembly of the nodes of Ranvier, regulation of myelin thickness and, finally, longitudinal extension of myelin segments in response to the lengthening of axons during postnatal growth.

    Publication Types:
    * Review
    PMID: 16136172 [PubMed - indexed for MEDLINE]

    I'm a bit lost with this lengthening problem. M Schacklock brings strong evidences that show nerves motion and lengthening.

    It is known that when a nerve grows after a paralysis, it hurts.
    We have heard and seen that children have painful events when they grow. (What's hurt?)

    Is it illogical to suppose that nerve lengthening made during nerve tensioning may solve some abnormal neurodynamics?
    <hr> Posted by Barrett (Member # 67) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,14,20,57,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 15-12-2005 03:57<noscript>December 14, 2005 08:57 PM</noscript>:

    Henry,

    I appreciate your contribution here but think it may not be relevant to the type of very rapid changes I see clinically. Perhaps I'm wrong.

    Something told me to search into the old threads in the Bullypit and I came across "Sympathetic Vibrations" which began on March 22, 2001. It begins with my saying: "I will be the first to admit that I focus on the autonomic state of every patient I see in pain, and that I am convinced sympathetic increase contributes persistently to both chronic and acute conditions. The first thing I remember reading about this (though it was certainly not the first thing published) was Irvin Korr’s commentary in a book he edited in 1978 entitled “Neuurobiologic Mechanisms in Manipulative Therapy” (Plenum Press). Korr was the physiologist that worked out the research done on manipulative technique and examination procedures at Kirksville Osteopathic College in the ‘50s and went on to do a great deal more work at Michigan State.

    He says in his article, “Sustained Sympathicitonia,” “The most critical effect, clinically, (of manipulation) is the subsidence of sympathetic hyperactivity and its pathogenic, pain-producing influences.” I’ve spoken to Korr personally, and he made it clear that he meant not only the local manifestation of sympathetic increase that he had proven reliably palpable by a trained practitioner, but also the general picture of a patient reacting as if under attack, which is fairly easy for anyone to see."

    What follows is a long and intricate discussion including several comments from Butler that certainly fit here. I'd suggest we look back there and see if the information might help us.

    Oh yes, the thread contains one of the repetitive and senseless conflicts seen on these pages, always beginning in the same way, just in case anybody thinks this is something new.
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,15,1,3,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 15-12-2005 08:03<noscript>December 15, 2005 01:03 AM</noscript>:

    I have wandered through the threads of the Bullypit since its inception - which I had not done before - and wondered how many others have done the same.
    The thing that struck me most is the progression in knowledge of the brain/body thing since 2001; from 'not sure'; 'don't know'; to far more certainty. That can only be good, and the Bullypit is a bit of a time capsule.

    But, as Barrett points out, history tends to repeat itself in some ways. Which implies, whether in politics or health..some do not learn from history too well.

    Nari
    <hr> Posted by Luke R (Member # 3561) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,15,3,31,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 15-12-2005 10:31<noscript>December 15, 2005 03:31 AM</noscript>:

    I remember some discussion from Nic Lucas at uni that the concept of 'neural tension' has several problems in terms of validity and is therefore misleading. Similarly to Barrett's quote from Shacklock, he preferred 'neural mechanosensitivity' as a more accurate description of the tissue state and the clinical findings. This physiological term also lends itself more easily to the interrelation with other aspects of physiology involved in pain such as central processing and the autonomic state. Barrett, I think it would also explain why a "physiologic shift outstrips the alteration in neural mobility..., account[ing] for the many patients I’ve treated successfully without ever seeing much movement emerge from them."

    There is something David wrote in another of the early threads that I think is relevant here and I love to remind myself of and quote to people - "Anatomy will (almost) never change with our treatment. What can and will change significantly is pathobiological processes”

    Luke
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,15,4,8,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 15-12-2005 11:08<noscript>December 15, 2005 04:08 AM</noscript>:

    About 10 or 11 years ago, I understood that the phrase 'neural tension' and 'adverse mechanical tension' were declared misnomers and inaccurate; which is why David moved on to using 'sensitivity' as a suffix and stand-alone word. To my way of thinking, 'tension' has the undertones of physical tightness-therefore-stretch implication. Tension headache bears the same inaccuracy.
    Have I missed something in thinking that neural tension does not really exist??

    That is a good quote, Luke. PTs have been taught for years about correcting posture and strengthening as 'changing anatomy'. I think that is fading away quite a bit in Australia; I don't know about elsewhere.

    Very rapid changes, talking about mere seconds, has intrigued me for a long time. Doesn't matter if the "Rx" is verbal or tactile; the fact that pain can vanish so rapidly is quite amazing, whether it is through neurodynamic movements or SC. The fact that it can return is another matter...

    Nari
    <hr> Posted by Gil Haight (Member # 691) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,15,9,27,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 15-12-2005 16:27<noscript>December 15, 2005 09:27 AM</noscript>:

    So, aren’t we back to the same dilemma/discussion? The recent thread on expectations seems to fit in nicely here. Pts. and MDs use PT to help identify and change things we can see. Everything else is thought to be psychological or at least a function of the will. I think tied to the anatomical model is the perception that changes there are more permanent. Nari’s point about the return of sxs. is very relevant. What of course we need is to establish a middle ground between anatomy and psychology. The field of physiological psychology is real close, but beyond biofeedback is there any of this in PT school?
    Gil
    <hr> Posted by Shill (Member # 2325) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,15,10,5,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 15-12-2005 17:05<noscript>December 15, 2005 10:05 AM</noscript>:

    Is it plausible that another type of tissue is tethered to the nerve, and the mobilizing exerts an effect on this tissue that results in the changes reported by the nerve itself, thus not changing the end length of anything but the tether? I believe Barrett feels that the movement brings about circulatory changes to the nerve due to reduction in the mechanical deformation of the nervous tissues, and that certainly makes sense too. Eventually as a result of stressing and unstressing, could the tether remodel to become a tissue that does not apply a mechanical deformation stress to the nerve itself? Just a thought.

    Steve
    <hr> Posted by Diane (Member # 1064) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,16,10,46,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 16-12-2005 17:46<noscript>December 16, 2005 10:46 AM</noscript>:

    quote: <hr> Is it plausible that another type of tissue is tethered to the nerve, and the mobilizing exerts an effect on this tissue that results in the changes reported by the nerve itself, thus not changing the end length of anything but the tether? <hr>
    Yes. In fact there are fine tethers at intervals on everything in the body: It holds itself together after all, and the tethers are innervated so that the brain can read where everything is at, in a thinslice. Specifically the nerves are indeed tethered. If you read Butler's first book, he discusses the microanatomy in exquisite detail. The nerves receive their own blood supply and innervation (vasa nervorum and nervi nervorum) through these tethers. The nerves are not just inert cords sliding through tunnels, as the simplistic idea would have us believe. They are living tissue and are connected to a supply system. All supply tubing is surrounded/strengthened by protective connective tissue, no matter how microscopic you go.. At a certain point, it's hard to know just by looking what the difference is between cell families. The finest arterioles that can still be considered arterioles and not capillaries exhibit some pretty funky local autonomous behavior (Roget cells).

    quote: <hr> could the tether remodel to become a tissue that does not apply a mechanical deformation stress to the nerve itself? Just a thought. <hr>
    I think so. I think that's what Butler means by "treating physiology, not anatomy." You can't do that directly, you have to "induce" changes (Barrett's department) that are preferable to business as usual. I doubt you can get your hands on a vasa nervorum to manipulate it.. it has to be done reflexively through the N. system itself.
    <hr> Posted by Shill (Member # 2325) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,16,10,52,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 16-12-2005 17:52<noscript>December 16, 2005 10:52 AM</noscript>:

    Thanks Diane, thats what I figured.
    <hr> Posted by Mike T. (Member # 4226) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,16,13,2,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 16-12-2005 20:02<noscript>December 16, 2005 01:02 PM</noscript>:

    Scenario:

    A pt. has a SLR (standardly performed) which cannot go beyond 30 degrees without significant posterior thigh/hip/LB pain, pain which is not present when the SLR is performed on the contralateral limb.

    1) If this pt. is successfully treated and progresses to having a SLR test equivalent in all respects to his contralateral side, what accounts for this success?

    2) Can a change in global autonomic state and local physiology account for the change?

    3) Is it logical to assume that there must be a mechanical component to the problem?

    4) If the pt. mentioned above is a professional ballerina with a contralateral SLR in the area of 120-140 degrees, what does length or tension have to do with the pain?

    These are questions that have been floating through my skull for quite some time.

    mike t
    <hr> Posted by Sarah C. (Member # 4115) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,16,14,17,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 16-12-2005 21:17<noscript>December 16, 2005 02:17 PM</noscript>:

    Mike T.
    I will attempt to answer your questions with my meager understanding of Barrett's work:
    1) an improved adaptive potential
    2) yes
    3) yes
    4) not much
    Barrett, interesting history lesson going back to 2001. I was wondering whatever happened to David Butler and why doesn't he participate here anymore?? The Bullypit was founded when I was still in PT school, and I agree with Nari that it is very interesting to look back and see where we've been.....I'll be peeking back a little more often now I suspect (as time permits). I'm still trying to get through Shacklock's book. And I will be checking out Diane's embryology studies. I am also excited as I have a vague notion of an area to research when I do back for my doctorate next Fall......well an "embryo" of an idea right now, it's still forming.
    Sarah
    <hr> Posted by Alex Brenner1 (Member # 2976) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,17,5,46,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-12-2005 12:46<noscript>December 17, 2005 05:46 AM</noscript>:

    Interestingly I was given this article about a week before Barrett started this thread. I have not had a chance to read the thread over on NOI so forgive me if it has already been referenced. This article has some insight into the basic science and theory behind neural tension and it is a recently published article.

    Upper Limb Neural Tension Testing and Mobilization. Fact, Fiction, and Practical Approach. Mike Walsh. Journal of Hand Therapy; Apr-Jun 2005; 18, 2.
    <hr> Posted by freetomove (Member # 2735) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,18,10,2,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 18-12-2005 17:02<noscript>December 18, 2005 10:02 AM</noscript>:

    Barrett,

    Just for review, what are the other three corners of Simple Contact?

    Nick
    <hr> Posted by Christophb (Member # 3884) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,19,11,15,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 19-12-2005 18:15<noscript>December 19, 2005 11:15 AM</noscript>:

    I found this to be an interesting article, again making me wonder why I used to focus exclusively on strengthening.

    "Muscular activity did not explain the pain which developed during the stressful task for either group"

    low grade stress and pain

    Chris
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,19,13,26,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 19-12-2005 20:26<noscript>December 19, 2005 01:26 PM</noscript>:

    Certainly the article goes some way towards recognising the phenomenon of sensitisation.
    Perhaps, one needs to identify the difference between strengthening movements and just natural movements. One will tend to aggravate sensitive structures and the other perhaps restore what the brain reckons it needs for resolution....but with no connection between muscular activity (which could mean anything like blinking, etc) and pain levels, one is simply left with stress as the origin of the pain, plus anticipation, negative thoughts, fear, expectations and so on...

    I wonder what would have happened in a study where the subjects were told that the particular activity would definitely decrease their pain.
    Isn't that how US and countless other gadgets work>

    Nari
    Last edited by bernard; 29-12-2005, 06:04 PM.
    Simplicity is the ultimate sophistication. L VINCI
    We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

    Everything should be made as simple as possible, but not a bit simpler.
    If you can't explain it simply, you don't understand it well enough. Albert Einstein
    bernard
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