NeurodynamicsNeurodynamics

Dan Foster, PhD, ATCDan Foster, PhD, ATC

Sports Medicine ConferenceSports Medicine Conference

August 7, 2008August 7, 2008

Peripheral Neuropathic PainPeripheral Neuropathic Pain

Positive sxPositive sx– Abnormal excitability (pain, paresthesia, Abnormal excitability (pain, paresthesia,

dysesthesia, and spasm)dysesthesia, and spasm)

Negative sxNegative sx– Reduced impulse production Reduced impulse production

(hypoesthesia or anesthesia and (hypoesthesia or anesthesia and weakness)weakness)

Harden 2005; Woolf 2004; Baron 2000; Hall & Elvey 1999

Peripheral Neuropathic PainPeripheral Neuropathic PainDysesthetic pain shows a variety of clinical Dysesthetic pain shows a variety of clinical behaviorsbehaviors– Burst of pain at onset of a stimulus but subsides before Burst of pain at onset of a stimulus but subsides before

the stimulus is removedthe stimulus is removed– Sx provoked by movement may persist well afterSx provoked by movement may persist well after– the stimulus has been removedthe stimulus has been removed– Response to the cumulative effect of several stimuliResponse to the cumulative effect of several stimuli– Paroxysmal stimulus-independent or spontaneous painParoxysmal stimulus-independent or spontaneous pain– Pain worse during increased life stressPain worse during increased life stress

Harden 2005 - Hyperexcitable nervous system with increased afferent discharge AIGS

Burning, tingling, electric, searing, drawing, crawling, shooting

AIGS – adverse impulse generating site

Not produced by A-δ or C fiber stimulus

Physical AssessmentPhysical Assessment

Use multijoint movements to Use multijoint movements to challenge (inc mechanosensitivity) challenge (inc mechanosensitivity) the nervous systemthe nervous system– Testing reproduces sxTesting reproduces sx– Movement of a segment remote from the sx Movement of a segment remote from the sx

location alters the response; changes in location alters the response; changes in sequence may alter the responsesequence may alter the response

– Reliability and Differences from contralateral Reliability and Differences from contralateral sideside

Sensory, ROM, or resistanceSensory, ROM, or resistanceButler, 1991

ManagementManagement

Patient educationPatient education

Non-neural tissueNon-neural tissue– Joint mobilization, soft-tissue work, Joint mobilization, soft-tissue work,

taping, neuromuscular controltaping, neuromuscular control

Neural mobilizationNeural mobilization– Passive or active, focusing on tolerating Passive or active, focusing on tolerating

normal compressive, friction, and tensile normal compressive, friction, and tensile forcesforces

Neural MobilizationNeural Mobilization

Neurodynamics – David ButlerNeurodynamics – David Butler

Use of body movement to produce Use of body movement to produce mechanical effects on the peripheral mechanical effects on the peripheral nervous system with central nervous system with central influenceinfluence

Science of the relationships between mechanics and physiology of the nervous system

Volleyball & Shoulder PainVolleyball & Shoulder Pain

17 case series17 case series 7 rotator cuff impingement7 rotator cuff impingement 2 possible SLAP/biceps/post labrum2 possible SLAP/biceps/post labrum 5 anterior coracoacromial 5 anterior coracoacromial

impingementimpingement 3 rotator cuff strain3 rotator cuff strain

5 recurrent w/ minimal sx5 recurrent w/ minimal sx

2005-2008

1 lost time injury following surgery

Routine PreventionRoutine Prevention

Daily tubing programDaily tubing program

Dynamic, graduated warm up with Dynamic, graduated warm up with stretchingstretching

Any shoulder pain, automatic active Any shoulder pain, automatic active neurodynamic techniquesneurodynamic techniques

Neurodynamics TechniqueNeurodynamics TechniqueMoses prayerMoses prayer– Shoulder depression & Scapular retractionShoulder depression & Scapular retraction

Push awayPush away– Median nerve, protractionMedian nerve, protraction

Cover earsCover ears– Ulnar nerveUlnar nerve

Track batonTrack baton– Radial nerve, shoulder depression, IRRadial nerve, shoulder depression, IR

Throw behindThrow behind– Musculocutaneous nerve, shoulder depressionMusculocutaneous nerve, shoulder depression

Moses Prayer-ShoulderMoses Prayer-Shoulder

Push Away – Median NervePush Away – Median Nerve

Cover Ears – Ulnar NerveCover Ears – Ulnar Nerve

Track Baton – Radial NerveTrack Baton – Radial Nerve

Throw Behind-Musculocutaneous NerveThrow Behind-Musculocutaneous Nerve

Neurodynamic Routine

Summary of CasesSummary of CasesInconsistent applicationInconsistent applicationCases have been variedCases have been variedSimple easy to remember maneuversSimple easy to remember maneuversWho knows what is helping?Who knows what is helping?– Neural flossing or movement or nutritionNeural flossing or movement or nutrition– MS stretchingMS stretching– Mechanical space improvementMechanical space improvement– Neural control feedbackNeural control feedback

Neurodynamics – David ButlerNeurodynamics – David Butler

Use of body movement to produce Use of body movement to produce mechanical effects on the peripheral mechanical effects on the peripheral nervous system with central nervous system with central influenceinfluence

It’s just your body reporting inIt’s just your body reporting in

Danger(nociception)

+ ThreatsPain

Muscle activity occurs at the onset of Muscle activity occurs at the onset of danger, normally it occurs at some level of danger, normally it occurs at some level of pain tolerancepain tolerance

Muscle

Hall & Elvey, 2005

Devor & Seltzer. Devor & Seltzer. Textbook of PainTextbook of Pain. . 1999 – after peripheral nerve injury, 1999 – after peripheral nerve injury, many primary afferent neurons start many primary afferent neurons start to generate ongoing discharges of to generate ongoing discharges of ectopic originectopic origin– Can evoke ongoing paresthesias and Can evoke ongoing paresthesias and

painpain– Can trigger and maintain central Can trigger and maintain central

sensitizationsensitizationMichaels et al. J Neurscience. 2000 – muscle afferent discharges in DRG

Movement is OptimalMovement is Optimal

Circulation and nutrition occur Circulation and nutrition occur optimally through movementoptimally through movement– MS tissues change dimensions and exert MS tissues change dimensions and exert

mechanical forces on neural structuresmechanical forces on neural structures– ∆ ∆ management of injured neural tissues management of injured neural tissues

should ensure that MS structures should ensure that MS structures operate optimallyoperate optimally

Minimize forces on adjacent neural Minimize forces on adjacent neural structuresstructures

Shacklock, 1995

Butler 2000; Hall & Elvy 1999

Movement of the nerve bed Movement of the nerve bed Should elongate and shorten the nerve Should elongate and shorten the nerve

Increase nerve tension and intraneural pressureIncrease nerve tension and intraneural pressure

Facilitate venous returnFacilitate venous return

Disperse edemaDisperse edema

Reduce pressure inside the perineuriumReduce pressure inside the perineurium

Should limit fibroblastic activityShould limit fibroblastic activityWhich may minimize scar formationWhich may minimize scar formation

Should reduce neural sensitivityShould reduce neural sensitivityMinimizing ion channel upregulationMinimizing ion channel upregulation

Nerve MovementNerve Movement

Physical loading (tension or Physical loading (tension or compression) of the nervous system compression) of the nervous system can be produced by adjusting joint can be produced by adjusting joint positionposition

Coppieters, Butler. Manual Therapy. 2008; 13;213-221

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.

Ogata & Naito. Ogata & Naito. J Hand SurgJ Hand Surg. 1986; . 1986; Rempel et al. Rempel et al. JBJSJBJS. 1999 – Showed . 1999 – Showed a clear relationship between a clear relationship between extraneural pressures, intraneural extraneural pressures, intraneural pressure and subsequent inhibition pressure and subsequent inhibition of circulation and axonal transportof circulation and axonal transport– 20-30 mmHg pressure can limit blood flow 20-30 mmHg pressure can limit blood flow

and axonal transport, and cause and axonal transport, and cause endoneurial edemaendoneurial edema

– 50 mmHg alters structure or myelin50 mmHg alters structure or myelin6-8% strain

Sliding TechniqueSliding Technique

Low strain, appropriate for acute Low strain, appropriate for acute injuries, post-op management, or injuries, post-op management, or bleeding and inflammationbleeding and inflammation– Enhance dispersal of local inflammatory Enhance dispersal of local inflammatory

productsproducts– Limit fibroblastic activity (unknown)Limit fibroblastic activity (unknown)

Mesoneurial glidingMesoneurial gliding

Lundborg 1988

Tensioning TechniqueTensioning Technique

Appropriate for chronic or post-acute Appropriate for chronic or post-acute stagesstages– May help to reduce intraneural swellingMay help to reduce intraneural swelling– Stimulate circulationStimulate circulation– By varying effects on intraneural By varying effects on intraneural

pressurepressureDynamic pumping action or “milking effect”Dynamic pumping action or “milking effect”

Improving nerve hydrationImproving nerve hydration

Disperse local inflammatory effects venous returnDisperse local inflammatory effects venous return– Reducing acidic environmentReducing acidic environment

Rempel 1999

Ogata 1986

Sliding & TensioningSliding & Tensioning

Large amplitude movements, passive Large amplitude movements, passive or active, and can be integrated into or active, and can be integrated into postures or dance - distractpostures or dance - distract– Reduces sensitivity and restores Reduces sensitivity and restores

functionfunction– Eases the threat value of the injuryEases the threat value of the injury

Minimizes potential for ion channel Minimizes potential for ion channel upregulation in DRG and CNSupregulation in DRG and CNS

Novel ways to uncouple learned Novel ways to uncouple learned expectations of pain – dec fear of movementexpectations of pain – dec fear of movement

SummarySummary

We used dynamic tensioning We used dynamic tensioning exclusively with shoulder casesexclusively with shoulder cases

Plan more sliding maneuvers and Plan more sliding maneuvers and incorporate cervical spine and incorporate cervical spine and shoulder moreshoulder more

Report back in a few years with an Report back in a few years with an updateupdate