Transcript Thermal Stress - Athletic Training at Iowa

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)
Harden 2005; Woolf 2004; Baron
2000; Hall & Elvey 1999
Peripheral Neuropathic Pain
Dysesthetic pain shows a variety of clinical
Burning, tingling, electric, searing,
behaviors
drawing, crawling, shooting
– Burst of pain at onset of a stimulus but subsides before
the stimulus is removed Not produced by A-δ or C fiber stimulus
– 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
Harden 2005 - Hyperexcitable
nervous system with increased
afferent discharge AIGS
AIGS – adverse impulse generating site
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
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
Neural Mobilization
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
2005-2008
Volleyball & Shoulder Pain
17 case series
 7 rotator cuff impingement
 2 possible SLAP/biceps/post
1 lost time injury
labrum
following surgery
 5 anterior coracoacromial
impingement
 3 rotator cuff strain
5 recurrent w/ minimal sx
Routine Prevention
Daily tubing program
Dynamic, graduated warm up with
stretching
Any shoulder pain, automatic active
neurodynamic techniques
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
Moses Prayer-Shoulder
Push Away – Median Nerve
Cover Ears – Ulnar Nerve
Track Baton – Radial Nerve
Throw Behind-Musculocutaneous Nerve
Neurodynamic Routine
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
Neurodynamics – David Butler
Use of body movement to produce
mechanical effects on the peripheral
nervous system with central
influence
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
Danger
(nociception)
+ Threats
Hall & Elvey, 2005
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
Movement is Optimal
Circulation and nutrition occur
optimally through movement
Shacklock,
1995
– 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
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
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
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. 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
6-8%
strain
endoneurial edema
– 50 mmHg alters structure or myelin
Sliding Technique
Low strain, appropriate for acute
injuries, post-op management, or
bleeding and inflammation
– Enhance dispersal of local inflammatory
Lundborg 1988
products
– Limit fibroblastic activity (unknown)
Mesoneurial gliding
Tensioning Technique
Appropriate for chronic or post-acute
stages
– May help to reduce intraneural swelling
– Stimulate circulation Rempel 1999
– By varying effects on intraneural
Ogata 1986
pressure
Dynamic pumping action or “milking effect”
Improving nerve hydration
Disperse local inflammatory effects venous return
– Reducing acidic environment
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
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