NeurodynamicsNeurodynamics

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Peripheral Peripheral NeuropathicNeuropathic PainPainPositive Positive sxsx

Abnormal excitability (pain, Abnormal excitability (pain, paresthesiaparesthesia, , dysesthesiadysesthesia, and spasm), and spasm)

Negative Negative sxsxReduced impulse production (hypoesthesia or Reduced impulse production (hypoesthesia or anesthesia and weakness)anesthesia and weakness)

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

Peripheral Peripheral NeuropathicNeuropathic PainPainDysestheticDysesthetic pain shows a variety of clinical pain shows a variety of clinical behaviorsbehaviors

Burst of pain at onset of a stimulus but subsides before the Burst of pain at onset of a stimulus but subsides before the stimulus is removedstimulus is removedSxSx provoked by movement may persist well afterprovoked by movement may persist well afterthe stimulus has been removedthe stimulus has been removedResponse to the cumulative effect of several stimuliResponse to the cumulative effect of several stimuliParoxysmal stimulusParoxysmal stimulus--independent or spontaneous painindependent or spontaneous painPain worse during increased life stressPain worse during increased life stress

Harden 2005 - Hyperexcitablenervous 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 AssessmentUse Use multijointmultijoint movements to challenge movements to challenge (inc (inc mechanosensitivitymechanosensitivity) the nervous ) the nervous systemsystem

Testing reproduces Testing reproduces sxsxMovement of a segment remote from the Movement of a segment remote from the sxsx location location alters the response; changes in sequence may alter alters the response; changes in sequence may alter the responsethe responseReliability and Differences from Reliability and Differences from contralateralcontralateral sideside

Sensory, ROM, or resistanceSensory, ROM, or resistance

Butler, 1991

ManagementManagementPatient educationPatient educationNonNon--neural tissueneural tissue

Joint mobilization, softJoint mobilization, soft--tissue work, taping, tissue work, taping, neuromuscular controlneuromuscular control

Neural mobilizationNeural mobilizationPassive 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

NeurodynamicsNeurodynamics –– David ButlerDavid ButlerUse 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 influencenervous system with central influence

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

Volleyball & Shoulder PainVolleyball & Shoulder Pain17 case series17 case series

7 rotator cuff impingement7 rotator cuff impingement2 possible SLAP/biceps/post labrum2 possible SLAP/biceps/post labrum5 anterior 5 anterior coracoacromialcoracoacromial impingementimpingement3 rotator cuff strain3 rotator cuff strain

5 recurrent w/ minimal 5 recurrent w/ minimal sxsx

2005-2008

1 lost time injury following surgery

Routine PreventionRoutine PreventionDaily tubing programDaily tubing programDynamic, graduated warm up with Dynamic, graduated warm up with stretchingstretching

Any shoulder pain, automatic active Any shoulder pain, automatic active neurodynamicneurodynamic techniquestechniques

NeurodynamicsNeurodynamics TechniqueTechniqueMoses prayerMoses prayer

Shoulder depression & Scapular retractionShoulder depression & Scapular retractionPush awayPush away

Median nerve, protractionMedian nerve, protractionCover earsCover ears

UlnarUlnar nervenerveTrack batonTrack baton

Radial nerve, shoulder depression, IRRadial nerve, shoulder depression, IRThrow behindThrow behind

MusculocutaneousMusculocutaneous nerve, shoulder depressionnerve, shoulder depression

Moses PrayerMoses Prayer--ShoulderShoulder

Push Away Push Away –– Median NerveMedian Nerve

Cover Ears Cover Ears –– UlnarUlnar NerveNerve

Track Baton Track Baton –– Radial NerveRadial Nerve

Throw BehindThrow Behind--MusculocutaneousMusculocutaneous NerveNerve

NeurodynamicNeurodynamic RoutineRoutine

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 nutritionMS stretchingMS stretchingMechanical space improvementMechanical space improvementNeural control feedbackNeural control feedback

NeurodynamicsNeurodynamics –– David ButlerDavid ButlerUse 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 influencenervous system with central influence

ItIt’’s just your body reporting ins 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

DevorDevor & Seltzer. & Seltzer. Textbook of PainTextbook of Pain. 1999 . 1999 ––after peripheral nerve injury, many primary after peripheral nerve injury, many primary afferent neurons start to generate ongoing afferent neurons start to generate ongoing discharges of discharges of ectopicectopic originorigin

Can evoke ongoing Can evoke ongoing paresthesiasparesthesias and painand painCan trigger and maintain central sensitizationCan trigger and maintain central sensitization

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

Movement is OptimalMovement is OptimalCirculation and nutrition occur optimally Circulation and nutrition occur optimally through movementthrough 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 operate should ensure that MS structures operate optimallyoptimally

Minimize forces on adjacent neural structuresMinimize forces on adjacent neural structures

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 Increase nerve tension and intraneuralintraneural pressurepressureFacilitate venous returnFacilitate venous returnDisperse edemaDisperse edemaReduce pressure inside the Reduce pressure inside the perineuriumperineurium

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

Should reduce neural sensitivityShould reduce neural sensitivityMinimizing ion channel Minimizing ion channel upregulationupregulation

Nerve MovementNerve MovementPhysical loading (tension or compression) Physical loading (tension or compression) of the nervous system can be produced by of the nervous system can be produced by adjusting joint positionadjusting 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 unembalmedhuman peripheral nerves (tensile force data)Kleinrensink et al. Clin Biomech. 1995; 10:235-239.

Ogata & Naito. Ogata & Naito. J Hand J Hand SurgSurg. 1986; . 1986; RempelRempel et al. et al. JBJSJBJS. 1999 . 1999 –– Showed a Showed a clear relationship between clear relationship between extraneuralextraneuralpressures, pressures, intraneuralintraneural pressure and pressure and subsequent inhibition of circulation and subsequent inhibition of circulation and axonal transportaxonal transport

2020--30 mmHg pressure can limit blood flow and 30 mmHg pressure can limit blood flow and axonal transport, and cause axonal transport, and cause endoneurialendoneurial edemaedema50 mmHg alters structure or myelin50 mmHg alters structure or myelin 6-8%

strain

Sliding TechniqueSliding TechniqueLow strain, appropriate for acute injuries, Low strain, appropriate for acute injuries, postpost--op management, or bleeding and op management, or bleeding and inflammationinflammation

Enhance dispersal of local inflammatory Enhance dispersal of local inflammatory productsproductsLimit fibroblastic activity (unknown)Limit fibroblastic activity (unknown)

MesoneurialMesoneurial glidinggliding

Lundborg 1988

Tensioning TechniqueTensioning TechniqueAppropriate for chronic or postAppropriate for chronic or post--acute acute stagesstages

May help to reduce May help to reduce intraneuralintraneural swellingswellingStimulate circulationStimulate circulationBy varying effects on By varying effects on intraneuralintraneural pressurepressure

Dynamic pumping action or Dynamic pumping action or ““milking effectmilking effect””Improving nerve hydrationImproving nerve hydrationDisperse local inflammatory effects venous returnDisperse local inflammatory effects venous return

Reducing acidic environmentReducing acidic environment

Rempel 1999

Ogata 1986

Sliding & TensioningSliding & TensioningLarge amplitude movements, passive or Large amplitude movements, passive or active, and can be integrated into postures active, and can be integrated into postures or dance or dance -- distractdistract

Reduces sensitivity and restores functionReduces sensitivity and restores functionEases the threat value of the injuryEases the threat value of the injury

Minimizes potential for ion channel Minimizes potential for ion channel upregulationupregulation in in DRG and CNSDRG and CNSNovel ways to uncouple learned expectations of Novel ways to uncouple learned expectations of pain pain –– decdec fear of movementfear of movement

SummarySummaryWe used dynamic tensioning exclusively We used dynamic tensioning exclusively with shoulder caseswith shoulder casesPlan more sliding maneuvers and Plan more sliding maneuvers and incorporate cervical spine and shoulder incorporate cervical spine and shoulder moremoreReport back in a few years with an updateReport back in a few years with an update