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 behaviors Burning, tingling, electric, searing, 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 labrum 1 lost time injury 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 + Threats (nociception)
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 Shacklock, Circulation and nutrition occur 1995
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 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 endoneurial edema 6-8% – 50 mmHg alters structure or myelin strain Sliding Technique Low strain, appropriate for acute injuries, post-op management, or bleeding and inflammation – Enhance dispersal of local inflammatory products Lundborg 1988
– 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 pressure Ogata 1986 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