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Skin stretch (DNM), Neurodynamics case studies thread

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  • Skin stretch (DNM), Neurodynamics case studies thread

    Hi all!

    I'm currently in the process of trying to grasp the different aspects of applying skin stretching (DNM) and neurodynamics (sliders and tensioners) to help resolve pain in the patients I'm seeing (being freed from muscles, joints and all that :-)). I'm digesting Butlers and Shacklocks books at the same time. I'm sure there are plenty of both active and passive members here having the same goals as myself.

    Trying out new things with patients, succeeding and failing is all part of learning new concepts and improving onces practice.

    I know that having a good basic understanding of neuroanatomy and physiology is key to succesfully applying these concepts. Having said that, I for one, often get an "aha!!" moment when reading the experiences and reasoning of others.

    I would like to present an idea for a thread containing short, simple case studies/reports describing treatments of patients in pain, where the clinician has reasoned that mainly interventions with DNM and neurodynamics helped to resolve the complaint of pain.

    The aim of this thread would not be to "increase the tool box", or forming some "recipe treatment" for different conditions, but help with creating a deeper understanding of these concepts/methods and how they could help our patients.

    What do you think?

    "There is nothing so practical as a good theory." -Kurt Lewin

  • #2
    Anders, a column such as this would be a very welcome addition on here. Go for it!
    HumanAntiGravitySuit blog
    Neurotonics PT Teamblog
    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
    Canadian Physiotherapy Association Pain Science Division Facebook page
    WCPT PhysiotherapyPainNetwork on Facebook
    Neuroscience and Pain Science for Manual PTs Facebook page

    SomaSimple on Facebook

    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire


    • #3
      Go for it, Anders.



      • #4
        Cory Blickenstaff, PT, OCS

        Pain Science and Sensibility Podcast
        Leaps and Bounds Blog
        My youtube channel


        • #5
          I think is a great idea.
          Javier González Iglesias


          • #6
            First case:

            20 year old female complaining of low back pain during sitting in a car and sitting in a lecture. Hypothesis: Smells like "slump". First I checked the PAIVMs and found nothing. That means IV+++ and no complains from the patient. Next I checkes the slump and BINGO.
            All I did was teaching her to do the slump slider and how to change her posture when sitting in a car and/or a lecture. That was it! I saw her 4 times over all and every time we worked on the slump only. She then was free of comlpains.

            For me that is a typical case for neurodynamics-only-treatment. What should be wrong with the back (bones, ligaments, etc.) of a 20yo?
            There are some more cases in my files at work but now it is too late for me - have to go to bed. But more is to be come...

            "Use only that which works, and take it from any place you can find it." Bruce Lee


            • #7
              Anders, a good example.

              If the woman had been 50 years old, what difference do you think that would have made, if any?



              • #8
                A young case of mines:
                A 15 yo sportive (Tai boxe) boy "stretched" his knee over the limit. The surgeon diagnose was a "definite" ACL problem but I found the other side flexible as the R painful one.
                MRI negative and walking hurts and running is made impossible.
                No neurodynamic signs: Only a slight IR problem. Pain was located on the interior side of the knee.
                The boy was sent 3 months after the initial injury.

                I tried "normal" neurodynamics but failed to improve the condition until I suspected it was a small but superficial nerve problem => Stretched and a session later, nothing.

                I was fooled by the initial diagnose and the injury condition. :embarasse
                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


                • #9
                  Hi all!

                  Thanks for presenting some cases! Interesting reads..

                  Sorry for not kicking off this thread myself, but I think the following case is interesting and I sure do remember it well

                  A middle aged woman came to see me for anterior right shoulder pain, with occasionally radiating pain to the lower arm and fingers. She had difficulty determining which fingers. Almost all her shoulder movements was painful and restricted by pain. She also complained of weakness. Symptoms had gradually developed over the previous week, and was now severly limiting her function. The shoulder was also aching at night. No complaint of neck pain/restriction. No history of truma.

                  Proceeded with standard orto tests for the shoulder, but very quickly realised this was not going to lead anywhere. Upper limb tension tests were difficult to interpret because of pain.

                  Layed her down in prone, and palpated the neck. Pressure over the facet joints of c5-c6-c7 on the right side reproduced her anterior shoulder pain. She was overweight and had quite a "thick" neck, so accurate palpation was very difficult. I proceeded to mobilise the segments with postero-anterior pressure, which reproduced her pain, but it did not change.

                  Explained my findings and that I thought that her pain was coming from the nerves themselves etc.. Scheduled an appointment in 2 days, but it left me with the feeling of not having accomplished that much.

                  Saw her 2 days later, she was amazed and reported a dramatic reduction in pain and improvement in movement the morning after our previous treatment. She had a very minor "feeling of ache" remaining in the shoulder. I repeated the treatment and told her to get back to me if the symptoms did not completely resolve. This was 2 months ago.

                  Neurodynamics at the nerve root (ginger style)? DNM?
                  "There is nothing so practical as a good theory." -Kurt Lewin


                  • #10

                    For me and my clinical reasoning there is a difference between a 20yo and 50yo indeed. I assume that the 20yo has young healthy joints in mint condition and the 50yo does not. Over the last two years I often saw young people - mostly female - in the age between 12 to 23 with referred pain and/or a headache as well. The P/E of that kind of patients often lead me to the conclusion that there is nothing wrong with their muskulo-skeletal system. That is why I started to put neurodynamics on these patients. Now, for me this is a typical clinical pattern. There is another case which may explain my clinical reasoning:

                    12yo female, very sporty, quite tall for her age. She complains of a headache that often forces her to take a nap right after school. My thoughts: young tall female - biologic growth goes in episodes not linear - let us do a slump test. And that was it. She performed a cervical slider for homework and after a couple of weeks she was just fine.
                    By the way: There may be some physios which may go directly to the muskulo-skeletal structures of a 12yo girl, but not me. That is what clinical reasoning and life long learning told me.

                    "Use only that which works, and take it from any place you can find it." Bruce Lee


                    • #11

                      I would still look at the neurodynamics of a 50 yr old first. A joint not in mint condition can still be blameless for pain!

                      Mobilisations do work; but it is tough on the PT and I suspect CMs ginger-style could be tough on the patient as well. But I have no doubts that they work - I have resolved persistent headaches on pts with 5 minutes of post/ant cervical movement at C1C2. I suspect it has absolutely nothing to do with the 'joint' or whatever else is hanging around subdermally.

                      58 yo woman with increasing loss of internal and external rotation in the (R) shoulder; night pain; pain and stiffness present for about 4 weeks. Abduction about 60 degrees. Scapulohumeral rhythm decreased. Intermittent back pain, since about 8 weeks ago. No history worth looking into.

                      ULNTTs all positive but unable to be completed - proximal movements only.
                      Proceeded with distal work, and crept up from there. After about three weeks, one session a week, ROM improved, pain slightly less at night.
                      After 6 weeks, pain gone and ROM rapidly resolving.
                      All I did was education on pain and movement based on ULNTT1 and 3. No ROM exercises; no gadgets; no pressure to perform.
                      Shoulder pain and back pain resolved after another week or so. Patient became fully functional in her job as a fulltime carer for her disabled husband.



                      • #12
                        Being new to the site. I want to thank you for the case studies. Just wanted a bit of clarification on what a cervical slider and slump sliders are.

                        Thanks again.
                        Alice Burton, P.T.


                        • #13

                          In your case, did you give the woman any homework? Or did you only work on her neurodynamics in the clinic?

                          "There is nothing so practical as a good theory." -Kurt Lewin


                          • #14
                            Welcome Alice,

                            here is my "slump slider" for you

                            "Use only that which works, and take it from any place you can find it." Bruce Lee


                            • #15

                              Doing 'homework' is fairly important, but with neurodynamics, one has to be soooo cautious because patients get carried away and think more is better.
                              From memory, 5 repetitions of proximal contralateral neck flexion; no holds even for a second; then, after a pause, some distal work: wrist, fingers.

                              Altogether about 40 seconds of "work"; then an hour later, or thereabouts, another 40 seconds or so. She was to visualise what the nerves were doing, and forget about muscles and joints and things. This adds to the care and softness that must be taken with neurodynamics, especially in the upper trunk.

                              Everybody, of course, is different, so no one patient ever had the same program as another.