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Neurodynamics

Neurodynamics. Dan Foster , PhD, ATC Sports Medicine Conference August 7, 2008. Peripheral Neuropathic Pain. Positive sx Abnormal excitability (pain, paresthesia , dysesthesia , and spasm) Negative sx Reduced impulse production (hypoesthesia or anesthesia and weakness).

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Neurodynamics

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  1. Neurodynamics Dan Foster, PhD, ATC Sports Medicine Conference August 7, 2008

  2. Peripheral Neuropathic Pain • Positive sx • Abnormal excitability (pain, paresthesia, dysesthesia, and spasm) • Negative sx • Reduced impulse production (hypoesthesia or anesthesia and weakness) Harden 2005; Woolf 2004; Baron 2000; Hall & Elvey 1999

  3. Peripheral Neuropathic Pain • Dysesthetic pain shows a variety of clinical behaviors • Burst of pain at onset of a stimulus but subsides before the stimulus is removed • Sx provoked by movement may persist well after • the stimulus has been removed • Response to the cumulative effect of several stimuli • Paroxysmal stimulus-independent or spontaneous pain • Pain worse during increased life stress Burning, tingling, electric, searing, drawing, crawling, shooting Not produced by A-δ or C fiber stimulus Harden 2005 - Hyperexcitable nervous system with increased afferent discharge AIGS AIGS – adverse impulse generating site

  4. Physical Assessment • Use multijoint movements to challenge (inc mechanosensitivity) the nervous system • Testing reproduces sx • Movement of a segment remote from the sx location alters the response; changes in sequence may alter the response • Reliability and Differences from contralateral side • Sensory, ROM, or resistance Butler, 1991

  5. Management • Patient education • Non-neural tissue • Joint mobilization, soft-tissue work, taping, neuromuscular control • Neural mobilization • Passive or active, focusing on tolerating normal compressive, friction, and tensile forces

  6. Neural Mobilization

  7. Neurodynamics – David Butler • Use of body movement to produce mechanical effects on the peripheral nervous system with central influence Science of the relationships between mechanics and physiology of the nervous system

  8. Volleyball & Shoulder Pain 2005-2008 • 17 case series • 7 rotator cuff impingement • 2 possible SLAP/biceps/post labrum • 5 anterior coracoacromial impingement • 3 rotator cuff strain • 5 recurrent w/ minimal sx 1 lost time injury following surgery

  9. Routine Prevention • Daily tubing program • Dynamic, graduated warm up with stretching • Any shoulder pain, automatic active neurodynamic techniques

  10. Neurodynamics Technique • Moses prayer • Shoulder depression & Scapular retraction • Push away • Median nerve, protraction • Cover ears • Ulnar nerve • Track baton • Radial nerve, shoulder depression, IR • Throw behind • Musculocutaneous nerve, shoulder depression

  11. Moses Prayer-Shoulder

  12. Push Away – Median Nerve

  13. Cover Ears – Ulnar Nerve

  14. Track Baton – Radial Nerve

  15. Throw Behind-Musculocutaneous Nerve

  16. Neurodynamic Routine

  17. Summary of Cases • Inconsistent application • Cases have been varied • Simple easy to remember maneuvers • Who knows what is helping? • Neural flossing or movement or nutrition • MS stretching • Mechanical space improvement • Neural control feedback

  18. Neurodynamics – David Butler • Use of body movement to produce mechanical effects on the peripheral nervous system with central influence

  19. It’s just your body reporting in Muscle activity occurs at the onset of danger, normally it occurs at some level of pain tolerance Muscle Pain + Threats Danger (nociception) Hall & Elvey, 2005

  20. Devor & Seltzer. Textbook of Pain. 1999 – after peripheral nerve injury, many primary afferent neurons start to generate ongoing discharges of ectopic origin • Can evoke ongoing paresthesias and pain • Can trigger and maintain central sensitization Michaels et al. J Neurscience. 2000 – muscle afferent discharges in DRG

  21. Movement is Optimal Shacklock, 1995 • Circulation and nutrition occur optimally through movement • MS tissues change dimensions and exert mechanical forces on neural structures • ∆ management of injured neural tissues should ensure that MS structures operate optimally • Minimize forces on adjacent neural structures Butler 2000; Hall & Elvy 1999

  22. Movement of the nerve bed • Should elongate and shorten the nerve • Increase nerve tension and intraneural pressure • Facilitate venous return • Disperse edema • Reduce pressure inside the perineurium • Should limit fibroblastic activity • Which may minimize scar formation • Should reduce neural sensitivity • Minimizing ion channel upregulation

  23. Nerve Movement • Physical loading (tension or compression) of the nervous system can be produced by adjusting joint position Coppieters, Butler. Manual Therapy. 2008; 13;213-221

  24. Continuous strain recordings in the median nerve related to angles at the elbow and wrist for two consecutive recordings for each movement technique. Comparison between embalmed and unembalmed human peripheral nerves (tensile force data) Kleinrensink et al. Clin Biomech. 1995; 10:235-239.

  25. 6-8% strain • Ogata & Naito. J Hand Surg. 1986; Rempel et al. JBJS. 1999 – Showed a clear relationship between extraneural pressures, intraneural pressure and subsequent inhibition of circulation and axonal transport • 20-30 mmHg pressure can limit blood flow and axonal transport, and cause endoneurial edema • 50 mmHg alters structure or myelin

  26. Sliding Technique • Low strain, appropriate for acute injuries, post-op management, or bleeding and inflammation • Enhance dispersal of local inflammatory products • Limit fibroblastic activity (unknown) • Mesoneurial gliding Lundborg 1988

  27. Tensioning Technique • Appropriate for chronic or post-acute stages • May help to reduce intraneural swelling • Stimulate circulation • By varying effects on intraneural pressure • Dynamic pumping action or “milking effect” • Improving nerve hydration • Disperse local inflammatory effects venous return • Reducing acidic environment Rempel 1999 Ogata 1986

  28. Sliding & Tensioning • Large amplitude movements, passive or active, and can be integrated into postures or dance - distract • Reduces sensitivity and restores function • Eases the threat value of the injury • Minimizes potential for ion channel upregulation in DRG and CNS • Novel ways to uncouple learned expectations of pain – dec fear of movement

  29. Summary • We used dynamic tensioning exclusively with shoulder cases • Plan more sliding maneuvers and incorporate cervical spine and shoulder more • Report back in a few years with an update

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