1. Dan Foster, PhD, ATC Sports Medicine Conference August 7, 2008
Neurodynamics
Dan Foster, PhD, ATC
Sports Medicine Conference
August 7, 2008

2. 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

3. 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-δ or C fiber stimulus
Harden Hyperexcitable nervous system with increased afferent discharge AIGS
AIGS – adverse impulse generating site

4. 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

5. Management Patient education Non-neural tissue Neural mobilization
Joint mobilization, soft-tissue work, taping, neuromuscular control
Neural mobilization
Passive or active, focusing on tolerating normal compressive, friction, and tensile forces

6. Neural Mobilization

7. 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

8. Volleyball & Shoulder Pain
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

9. Routine Prevention Daily tubing program
Dynamic, graduated warm up with stretching
Any shoulder pain, automatic active neurodynamic techniques

11. 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

12. Moses Prayer-Shoulder

13. Push Away – Median Nerve

14. Cover Ears – Ulnar Nerve

15. Track Baton – Radial Nerve

16. Throw Behind-Musculocutaneous Nerve

17. Neurodynamic Routine

18. 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

19. Neurodynamics – David Butler
Use of body movement to produce mechanical effects on the peripheral nervous system with central influence

20. 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
+ Threats
Danger
(nociception)
Hall & Elvey, 2005

21. Devor & Seltzer. Textbook of Pain
Devor & Seltzer. Textbook of Pain – 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 – muscle afferent discharges in DRG

22. 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

23. 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

24. Nerve Movement
Physical loading (tension or compression) of the nervous system can be produced by adjusting joint position
Coppieters, Butler. Manual Therapy ; 13;

25. 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 ; 10:

26. Ogata & Naito. J Hand Surg. 1986; Rempel et al. JBJS
Ogata & Naito. J Hand Surg. 1986; Rempel et al. JBJS – 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

27. 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

28. 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

29. 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

30. 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