Neurodynamics

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Neurodynamics

• Dan Foster, PhD, ATC
• Sports Medicine Conference
• August 7, 2008

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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
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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-d or C fiber stimulus
Harden 2005 - Hyperexcitable nervous system with
increased afferent discharge AIGS
AIGS adverse impulse generating site
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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
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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

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Neural Mobilization
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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
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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
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Routine Prevention

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

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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

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Moses Prayer-Shoulder
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Push Away Median Nerve
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Cover Ears Ulnar Nerve
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Track Baton Radial Nerve
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Throw Behind-Musculocutaneous Nerve
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Neurodynamic Routine
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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

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Neurodynamics David Butler

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

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Its 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
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• 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
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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
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• 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

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Nerve Movement

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

Coppieters, Butler. Manual Therapy. 2008
13213-221
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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
10235-239.
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• 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

6-8 strain
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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
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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
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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

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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