Times are a Changing. Disclosures. I have nothing to disclose. Pop Quiz. Passive Neurodynamic Test

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Nicholas Palmer
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Disclosures Moving Beyond Nerve Mobilization and into Neurodynamics: Its not just a Nomenclature Change I have nothing to disclose. Mark T.

What causes the increase in sensitivity of the PNS? Which is the best way to move the nervous system? What is the purpose of structural tissue differentiation?

What are the proper Dosage, Duration, Frequency to Tx? Can applying neural techniques lead to disatreous? results?

Passive Neurodynamic Test Limb Tensile Loading Test is Beyond Its Time? Neurodynamic Test Identified by the Nerve being examined.

1 Disclosures Moving Beyond Nerve Mobilization and into Neurodynamics: Its not just a Nomenclature Change I have nothing to disclose. Mark T. Walsh PT, DPT, MS, CHT Lauren DeTullio MS, OTR/L, CHT Ann Lucado PT, PhD. CHT Pop Quiz Define Mobilization in clinical terms? Define Neurodynamics? What causes the increase in sensitivity of the PNS? Which is the best way to move the nervous system? What is the purpose of structural tissue differentiation? What are the components of the Neurodynamic Exam? What is ULTT 1? Theoretically how much strain is safe to use? What are the proper Dosage, Duration, Frequency to Tx? Can applying neural techniques lead to disatreous? results? Times are a Changing It is time to Rethink Upper Limb Tension Testing and Neural Mobilization Neurodynamic Examination and Evaluation and Neurodynamic Intervention. Passive Neurodynamic Test Limb Tensile Loading Test is Beyond Its Time? Neurodynamic Test Identified by the Nerve being examined. Same components to each exam allow patient escape. The difference? Examine is meant to reduce the symptoms. Sensitizing components Only If Necessary Cervical Contralateral Movement/Scapular Depression Standardized Base Exam followed by Sequencing and Structural Tissue Differentiation to help localize the lesion. Shacklock 2005 Top Down Bottom Up 1

RED FLAG Features: Constant Non-Mechanical Sleep Disturbance Sharp Diffuse

PT2007 Cervical Neurogenic Screen Hard Neurological Signs Potential RED FLAGS

the importance of the related biomechanical principles of the peripheral

Achieve a basic understanding in interpreting the results of the examination.

There is no one size fits all! www necksolutions.

2 RED FLAG Features: Constant Non-Mechanical Sleep Disturbance Sharp Diffuse Visceral Pain Patterns Four Signs Cervical Radiculopathy Cleland J et al PT2007 Cervical Neurogenic Screen Hard Neurological Signs Potential RED FLAGS Motor Weakness Sensory Loss Absent Reflex Key Learning Objectives Appreciate the importance of the related biomechanical principles of the peripheral nerve. Understand the 5 components of a neurodynamic examination. Achieve a basic understanding in interpreting the results of the examination. Begin to apply concepts of neural mobilization as a treatment strategy. There is no one size fits all! www necksolutions.com Nervous System Continuum The demands on the Nervous System are no different than on any other tissues. Nerve Stretching for the Relief or Cure of Pain John Marshall Lancet 1883 Nervi Nevorum, SLR as Mobilization Nervous System Continuum (CNS, PNS, ANS) Mechanical Electrical Chemical 2

The Peripheral Nerve Three Connective Tissue Layers and Vascular

Bidirectional Barrier Tension Resistor Endoneurium Tension

Neural Mechanics Neural Physiology Pathodynamics Neurodynamics

Dysfunction Strong or sustained neurodynamic tests typically

contraindicated Shacklock 2005 Nerve Movements Tension Compression

Interfacing Tissue Bed Inflammation Mechanosensitivity Shacklock

3 The Peripheral Nerve Three Connective Tissue Layers and Vascular Plexus Epineurium Vascular Highway Compression Perineurium Bidirectional Barrier Tension Resistor Endoneurium Tension Resistor for Axon Yu et al. Neural Mechanics Neural Physiology Pathodynamics Neurodynamics Alteration in Mechanics and/or Physiology = Neural Tension Dysfunction Strong or sustained neurodynamic tests typically constitute highly sensitized techniques and are often contraindicated Shacklock 2005 Nerve Movements Tension Compression Translation Excursion (Glide) Intraneural Extraneural Vascularity Interfacing Tissue Bed Inflammation Mechanosensitivity Shacklock 05 Neural Strain in Vitro Kleinrensink et al, 2000 Neural Excursion in Vitro Neural Excursions In Vivo Wright et al. 1996, 2001, 2005 Coppieters et.al. 09 3

Neural Excursions In Vivo Neural Excursions In Vivo Coppieters, Alshami 07 Coppieters, Butler 08 Rate of Elongation General Principles of the Nervous System Rate: 0.

5% Tolerance to Tensile Loading (Elongation) Vascular Flow 5-10% = 50% Venule Flow 11-18% = Complete Occlusion (Lundborg 73) 15% Complete Occlusion (Ogata 86) Yu et

Gross Changes In Situ Entire Nerve Stiffer than Segment Neural Fibrosis results in a significant change in the load deformation curve!

4 Neural Excursions In Vivo Neural Excursions In Vivo Coppieters, Alshami 07 Coppieters, Butler 08 Rate of Elongation General Principles of the Nervous System Rate: 0.05mm/min Haftek 1970 Ultimate Elongation 55.7% 1cm/min Kwan 1992 Ultimate Elongation 38.5% Tolerance to Tensile Loading (Elongation) Vascular Flow 5-10% = 50% Venule Flow 11-18% = Complete Occlusion (Lundborg 73) 15% Complete Occlusion (Ogata 86) Yu et al. Lundborg 73 Load Deformation of the Peripheral Nerve In Vitro Rabbit Tibial Nerve Strain to 15% = Low Stiffness Strain 15-20% = Increased Stiffness Failure No Gross Changes In Situ Entire Nerve Stiffer than Segment Neural Fibrosis results in a significant change in the load deformation curve! Neuropathic Pain IASP: Pain caused by a lesion or disease of the somatosensory system Neuropathic Pain Scale Sensitive to changes in treatment (Galer) Neuropathic Pain Symptom Inventory Discriminates and Quantifies 5 distinct dimensions sensitive to treatment (Bouhassira) 4

Neuropathology Neuropathic Pain Vascular Compression Fibrosis Inflammation C and Aδ fibers Mechanical Allodynia (Bove et al) Axoplasmic Flow Immune Mediated

Tension Dysfunction Intraneural Inherent Elongation/Tension Potential is Compromised Extraneural Nervous System's Mobility limited within the Nerve Bed

Pain: Various Measurement Tools Objective Findings Passive Dysfunction Nerve Trunk Hyperalgesia Local Tender Spots Local Dysfunction Elvey JHT 101 122, 1997

DO NOT! Offer up any extremity for testing during the workshop if you have any pathology. Remember to examine your partner as if they are a patient.

5 Neuropathology Neuropathic Pain Vascular Compression Fibrosis Inflammation C and Aδ fibers Mechanical Allodynia (Bove et al) Axoplasmic Flow Immune Mediated Inflamation = Wide Spread Inflamed Fibers Fire at 3% Strain (Dilley) Intra/extra Neural Gliding Reduced-Fibrosis Pathological Consequences Fibrosis = Neural Tension Dysfunction Intraneural Inherent Elongation/Tension Potential is Compromised Extraneural Nervous System's Mobility limited within the Nerve Bed Clinical Response Symptoms response Provocation Range of movement Limitation Resistance encountered Reflex Muscle Contraction Pathological Consequences Pain: Various Measurement Tools Objective Findings Passive Dysfunction Nerve Trunk Hyperalgesia Local Tender Spots Local Dysfunction Elvey JHT , 1997 Assumptions/Precautions It is ASSUMED that you have completed and upper quarter screening exam before incorporating Neurodynamic Testing and Treatment. DO NOT! Offer up any extremity for testing during the workshop if you have any pathology. Remember to examine your partner as if they are a patient. Treat this workshop as if you are in the clinic. The rate of application is crucial. Nerve is a highly vascularized viscoelastic tissue. Observation Adverse Neural Tension 5

6 Active Elevation Contra-lateral ABD Ipsi-lateral ABD Contra-lateral ABD + Tension Ipsi-lateral ABD + Tension Active Dysfunction 6

7 Active Dysfunction Active Neural Dysfunction Passive Dysfunction Neurodynamic Testing Tension Compression Excursion Vascularity Inflammation Mechanosensitivity Shacklock 05 Passive Dysfunction Neurodynamic Testing: Median Nerve Passive Dysfunction Neurodynamic Testing: Ulnar Nerve 7

Passive Dysfunction Neurodynamic Testing: Radial Nerve Nerve Mobilization (Neurodynamic Intervention) as a treatment rarely stands alone Intervention Basic Science Animal Model Dispersion of fluid

8 Passive Dysfunction Neurodynamic Testing: Radial Nerve Nerve Mobilization (Neurodynamic Intervention) as a treatment rarely stands alone Intervention Basic Science Animal Model Dispersion of fluid with gliding = decrease in edema Reduced Pain and increase in NGF (Santos) Increase in endogenous modulation (Santos) Increase in NGF and MPZ, Increase Myelin Sheath and Decrease Axonal Fibrosis (desilva) Evidence to Support Neural Intervention Pinar et.al CTS Splints and Splints + NG Improved post treatment NG - Rate of Pain, > Functional Improvement Akalin et.al CTS Splints and Splints + NG&TG Significant Improvement Both Groups NG > Improvement Nonsignificant Tal-Akabi & Rushton 2000 Carpal Bone Mob & Neurodynamic Mobilization Significant Pain Relief, Nonsignificant Between Groups Evidence to Support Neural Intervention Oskouei et.al RCT CTS Patients Control: Wrist Orthosis 0, Wrist Mob., TENS, US Experimental: Neuromobilization (Tension) + Control Results: Sig. Imp., VAS, SSS,MNTT, Phalens both groups. Experimental: Sig. Imp FSS and EDS-DML Basson et.al Systematic Review/Meta-analysis Chronic neck-arm pain sig. decrease in pain intensity CTS: No sig. improvement in outcomes however improve Neurophysiological effects of MN Ballestero-Perez et. al Nerve Gliding CTS Systematic Review Limited evidence of neural gliding compare to standard care. Neural Gliding did accelerate recovery 8

Neuropathic Pain No Strong Sustained Tensile Loading (Shaclok) Education, Stuctural Differenciation, Gliding, Tensile Loading with Caution (Nee/Butler) Systemic Review: Musculoskeletal Pain NM no

(Day) Evidence Problems Different Techniques used Tension vs Glide Degree of Compression (mild, moderate, severe) No Standardization of: Dosage, Duration, Frequency No Standardization Rate of

9 Neuropathic Pain No Strong Sustained Tensile Loading (Shaclok) Education, Stuctural Differenciation, Gliding, Tensile Loading with Caution (Nee/Butler) Systemic Review: Musculoskeletal Pain NM no more effective other forms of treatment (Su) Effective in Cervical and Lumbar Pain (Basson) Neck and Arm Pain: NM Clinically Relevant (RCT) Benefits (Nee) NM Reduces Disability QDASH, and Pain NPRS (Day) Evidence Problems Different Techniques used Tension vs Glide Degree of Compression (mild, moderate, severe) No Standardization of: Dosage, Duration, Frequency No Standardization Rate of Application Determining Irritability High Irritability (Irritable) (+) Sleep Disturbance Neuropathic Pain 1 Prolonged Recovery Symptoms Easily Provoked Latency Significant Limitation of Motion Low Irritability (Non-irritability) (-) Pain at Rest (Paresthesia 1 Complaint) Rapid Recovery Symptoms End Range Provoked Latency? Limitation of End Range Motion Treatment Guidelines Tension vs. Glide (Excursion) Tension Lengthens the Nerve - Stressing Vascular Supply Intervention Progression High Irritability Low Irritability Phase 1 Phase 2 Phase 3 Glide Tension in One Location - Release in Another Lying Lying/Sitting Sitting/standing 9

10 Treatment Guidelines Intraneural vs. Extraneural Fibrosis Intraneural Increase Mobility Away from Site Extraneural Treat Interfacing Tissue Glide/Tension Dosage Duration Treatment Frequency Guided by Clinical/Physiological Response No Studies to Support Clear Guidelines Oscillatory vs Sustained Movement Maitland, Butler, Elvey 10s hold 10s rest 10 reps O.D. - Sweeney 7s hold 5reps 3-5x/day - Rozmaryn 3m 10s O.D. - Seradge Precaution Irritable Conditions Spinal Cord Signs Nerve Root Signs Severe Unremitting Night Pain Lacking a Diagnosis Recent Paresthesia/Anesthesia CRPS Type I/II Mechanical Spine Pain with Peripheralization Pregnancy Contraindication Recently Repaired Peripheral Nerve Malignancy (Local) Active Inflammatory Condition Neurological Acute Inflammatory Demyelinating Diseases SUMMARY Appreciate Nervous System Principles Understand Pathological Process/Manifestations Knowledge Neural Tissue Assessment Guidelines Tension vs. Glide Irritable vs. Non-Irritable Neural vs. Non-Neural Intraneural vs. Extraneural SUMMARY Recognize Contraindication/Precautions Hypothesis Driven No Protocol Gentle Technique Treatment Limited Only by Therapist Imagination 10

11 Summary What it does not do! Relieve external compression? Alter Nerve CT Viscoelastic Properties (Intraneural Fibrosis)? What it may do! Restore Normal Physiologic Tension Potential to Increase Excursion Potential to Decrease Mini Compartment Syndrome Maintain Post Op Excursion Stop and Smell the Flowers 11

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Downloaded from umj.umsu.ac.ir at 22: on Friday March 22nd 2019 * 91/06/07 : 91/04/02 : :.. -. :. ICC. ICC.. :. // // :. : - - : :.(-) - (SLR) Email: eterafoskouei@tbzmed.ac.ir.(). (ULTT).().. ( ) Straight Leg Raise Upper Limb Tension Tests .().(-) Hough.().() ULTT1.()