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4/7/17	
1	
Title
Name	
Neurodynamics: Anatomy, Biomechanics,
and Physiology
Kerry K. Gilbert, PT, ScD
Professor/Program Di...
4/7/17	
2	
Anatomy/
Biomechanics	
Neurodynamic	
Treatment	
Neurodynamic	
Tes8ng 		
•  History	of	ND	
•  Macro	Anatomy	
•  ...
4/7/17	
3	
Clinical	Applica8on:	Pathoanatomy	
•  Upper	Limb	Neural	Pathoanatomy	
–  Axillary	Arch	
•  Anomalous	bands	of	t...
4/7/17	
4	
Clinical	Applica8on:	Pathoanatomy	Radial	Nerve	
•  Upper	Limb	Neural	Pathoanatomy	
–  Fracture	of	humeral	shal-...
4/7/17	
5	
Moore	&	Dalley:.Ch	5;		
NeLer:	plate	529	
Gilroy:	Fig	29.1-29.28	
19	
Summary:	Lower	
Limb	Innerva8on	
Distribu...
4/7/17	
6	
The	micro	Anatomy	of	a	Nerve	
•  Endoneurium	
–  Surrounds	axons	
•  Perineurium	
–  Surrounds	fasicles	
•  Epi...
4/7/17	
7	
ULNT	Tension	(Strain)	
Kleinrensink	GJ,	et	al.	 	Upper	limb	tension	tests	as	tools	in	the	diagnosis	of	nerve	an...
4/7/17	
8	
Physiology	of	Nerve	Tissue	
•  Mechanics	and	physiology	of	the	nervous	system	have	been	
described	as	“interdep...
4/7/17	
9	
Mechanical	Stress	on	Intraneural	Blood	Flow-Physiology	
•  Inflamma>on	à	intraneural	edemaàê	func>on,	blood	supp...
4/7/17	
10	
Theory	of	Neurodynamic		
Summary	Tes8ng	and	Treatment	
Review	of	Neurodynamic	Tes8ng:	
•  Aler	the	systems	rev...
4/7/17	
11	
Fluid	Dynamics-	Peripheral	Nerve	Tissue-	
Scia8c	(in	vitro)-JMMT	2015	
Fluid	Dynamics-	Tibial	Nerve	
(in	situ)...
4/7/17	
12	
Nerve	Tissue	Fluid	Dynamics	(Pressure)		
Study	Pedigree:	
•  Displacement	not	as	large	as	originally	thought…
...
4/7/17	
13	
Selected	References	
•  Butler,	David	S.	(1989).	Adverse	mechanical	tension	in	the	nervous	system:	a	model	for...
4/7/17	
14	
•  Nowicki,	B.	H.,	&	Haughton,	V.	M.	(1992).	Neural	foraminal	ligaments	of	the	lumbar	spine:	appearance	at	CT	...
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‘Clinical Neurodynamics: clinical application from an anatomical perspective’

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Kerry Gilbert

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‘Clinical Neurodynamics: clinical application from an anatomical perspective’

  1. 1. 4/7/17 1 Title Name Neurodynamics: Anatomy, Biomechanics, and Physiology Kerry K. Gilbert, PT, ScD Professor/Program Director- Doctor of Physical Therapy Program Director- Anatomy Research and Education Director- Clinical Anatomy Research Laboratory Department of Rehabilitation Sciences School of Health Professions Texas Tech University Health Sciences Center Lubbock, Texas, USA Butler’s Seven Points for Consideration NVMT (2017): 1.  Aim to make neurodynamics central and essen8al to Neurology -Goal: to provide mechanically permissible movement 2.  Biopsychosocial considera8ons -all parts are important to treatment 3.  Confident Clinicians are cri8cal -Pa8ents respond to confident clinicians 4.  Educa8on is therapy- Neurodynamics enriches therapy -educa8on is especially important with pain pa8ents; explain the con8nuum of the nervous system; odd symptom paLerns are not surprising; “Nothing about your condi8on surprises me.” 5.  Recognize the Neuroimmune cascade -not just neuro, but neuroimmune; ac8vated inflamma8on 6.  Consider CNS mobiliza8on -cord movement; meninges movement; CSF flow 7.  Consider Neurodynamics with reasoned judgment (in context of clinical exam) -s8ff, s8cky, stuck – mobilize the nervous system; There is an “awakening to Neurodynamics” -David Butler, NVMT 2017 Pa#ent Social Screening Examina#on Clinical Examina#on Educa#on Imaging History/ Observa#on Bio/Patho/ Physiological Psychological Assessment Treatment Plan Re-Examina#on Special Tes#ng (Neurodynamics) Clinical Examina8on Take Home Message: Neurodynamic tes#ng is a small (but vital) part of the overall clinical examina#on picture. Research: Reliability/Validity Outcomes
  2. 2. 4/7/17 2 Anatomy/ Biomechanics Neurodynamic Treatment Neurodynamic Tes8ng •  History of ND •  Macro Anatomy •  Micro Anatomy •  Biomechanics •  Rela8on to Tes8ng and Treatment •  Recent Findings NVMT 2017 1929- Nerve Extension upper lim b- Bragard 1959- Upper Lim b- Von Laniz & W achsm uth 1960-1980- Adverse M echanical Tension- Breig 1970’s-sensi8vity of NS- Grieve; Slum p- Cyriax/M aitland 1980’s- Adverse NT- Butler; M aitland; Elvey; 8 History of Neurodynamics 2800 BC? –Im hotep 1982- Pain- M elzack and W all 1991- M obiliza#on of the NS- Butler 1880’s- Nerve Stretching- Cavafy,; Sym ington; M arshall 1979- Brachial Plexus Tension Test (ULNT)- Elvey 1960-1980- Nerve Com pression/Tension- Rydevik, Sunderland, Olm arker, Lundborg 1993- LNR Disp.- Sm ith and M assey 2005- Clinical Neurodynam ics- Sequencing- Shacklock 2012- ND Validity-Nee, Coppieters, Schm id 2011- Tibial Nerve Fluid Dynam ics- Brown, Gilbert 2007- LNR-SLR Displacem ent and Strain- Gilbert 9 History of Neurodynamics 2017– Neuroim m une; Rx- Coppieters, Schm id 2017-Beyond- “ND Aw akening”-Butler 2008- Treatm ent Effi cacy- Ellis; In Vivo US- Dilley 2000- Sensi#ve NS- Butler 2013- Entrapm ent Neuropath-Schm id and Coppieters 2015- CNR Displ/Strn-Foram inal Ligs- Lohm an and Gilbert 2015-Fluid Disp- Gilbert, Sobczak 2000- ND Tes8ng Reliability- Coppieters Macro (Gross) Anatomy: Median and Ulnar Nerves
  3. 3. 4/7/17 3 Clinical Applica8on: Pathoanatomy •  Upper Limb Neural Pathoanatomy –  Axillary Arch •  Anomalous bands of the la8ssimus dorsi muscle •  Bands compressed the underlying neurovascular structures during ABD/ER including the axillary vessels, musculocutaneous, median, and ulnar nerves. •  Similar reports have shown this type of 8ssue to aLach to coracoid process, pectoralis major, and coracobrachialis muscle. •  Authors suggest clinical manifesta8on similar to TOS symptoms and suggest a clinical test using ABD/ER and palpa8on. 11 Smith AR, Cummings JP. The Axillary Arch: Anatomy and Suggested Clinical Manifesta#ons. JOSPT, 2006; 36(6):425-429. Clinical Applica8on: Pathoanatomy Ulnar Nerve •  Upper Limb Neural Pathoanatomy –  Archade of Struthers 12 Macro (Gross) Anatomy: Radial Nerve Clinical Applica8on: Pathoanatomy Median Nerve •  Upper Limb Neural Pathoanatomy –  Ligament of Struthers –  Pronator Syndrome –  Carpal Tunnel Syndrome 14
  4. 4. 4/7/17 4 Clinical Applica8on: Pathoanatomy Radial Nerve •  Upper Limb Neural Pathoanatomy –  Fracture of humeral shal- radial nerve injury –  Radial Tunnel Syndrome- Archade of Frosche 15 Clinical Applica8on: Pathoanatomy Radial Nerve •  Upper Limb Neural Pathoanatomy –  Fracture of humeral shal- radial nerve injury –  Radial Tunnel Syndrome- Archade of Frosche (Calavert, 2009) 16 Macro (Gross) Anatomy: Radial Nerve Macro (Gross) Anatomy: Tibial and Common Fibular Nerves Moore & Dalley:.Ch 5; NeLer: plate 528 Gilroy: Fig 29.1-29.28 18 Summary: Lower Limb Innerva8on Distribu8on: Scia8c and Posterior Cut. Nerve of the Thigh
  5. 5. 4/7/17 5 Moore & Dalley:.Ch 5; NeLer: plate 529 Gilroy: Fig 29.1-29.28 19 Summary: Lower Limb Innerva8on Distribu8on: Tibial Nerve Moore & Dalley:.Ch 5; NeLer: plate 530 Gilroy: Fig 29.1-29.28 20 Summary: Lower Limb Innerva8on Distribu8on: Common Fibular (Peroneal) Nerve Dermatomes vs. Cutaneous Innerva8on Moore & Dalley:.Ch 5; NeLer: plate 470; 530 Gilroy: Fig 29.27-29.28 21 The Anatomy of the PNS •  Peripheral Nervous System (PNS) Layout: –  Mechanical interface •  “con8nuum”– Butler, 1989 •  “container” – Shacklock 1995 •  “nerve bed” consists of anything that lies next to the nervous system (tendon, muscle, bone, IV disc, ligaments, fascia, blood vessels) –  Neural structures •  Actual nerve 8ssue –  Innervated 8ssues •  The actual 8ssue innervated by the neural structures Butler, 1988; Shacklock, 1995; 2005 22
  6. 6. 4/7/17 6 The micro Anatomy of a Nerve •  Endoneurium –  Surrounds axons •  Perineurium –  Surrounds fasicles •  Epineurium –  Surrounds nerve •  Mesoneurium –  Outside the epineurium Butler 1991 23 The Anatomy of a Nerve •  Blood Flow 1.  Extrinsic 2.  Intrinsic •  2a-superficial intrinsic arterioles •  2b-interfascicular arterioles •  2c-endoneurial capillary networks 3.  Vascular “coils” 4.  Spinal dura 5.  Root sheath Nordin & Frankel, Fig 5.5; Olmarker 1991 24 Biomechanics- Movement of Nerves •  Mechanical func8ons of all nerves: –  Tension •  Perineurium – 18-22% strain before failure (Sunderland & Bradley, 1961; Sunderland 1991) •  Leads to decrease of cross-sec8onal area and “transverse compression” –  Sliding •  Movement of neural structures within the container or nerve bed (McLellan & Swash 1976; Wilgis & Murphy 1986) •  AKA- “excursion,” “displacement,” or “gliding” •  Longitudinal or transverse movement; dissipates strain •  Mesoneurium-sliding in the nerve bed; •  Interfascicular epineurium- interfascicular gliding; (Millesi 1990) –  Compression •  Bone, tendon, muscle, fascia, etc., pressing on the nerve Shacklock 2005 25 Movement of Nerves •  Movement of joints –  Related to the posi8on of the nerve to the joint axis –  “convergence”- movement of the nerve 8ssue toward the joint that is moved/moved most. (Smith 1956; McLellan & Swash 1976) –  Bending of a joint à tension and compression of nerve •  Movement of the innervated 8ssues –  Causes elonga8on; “sensi8zing maneuvers” •  Movement of the mechanical interface –  Opening (ê pressure) vs. Closing mechanisms (épressure) •  These concepts are important for clinical diagnosis Shacklock 2005 26
  7. 7. 4/7/17 7 ULNT Tension (Strain) Kleinrensink GJ, et al. Upper limb tension tests as tools in the diagnosis of nerve and plexus lesions. Anatomical and biomechanical aspects. Clin Biomech (Bristol, Avon). 2000; 15(1):9-14. •  Median nerve bias caused the most ten>on (strain) •  ‘it is unlikely that any of the six tests studied will selec>vely stress specific cervical nerve roots’ •  ‘So, based on tensile force distribu>on and considering both sensi>vity and specificity, exclusively the median nerve ULTT and ULTT+ can be seen as specific nerve tension tests’ Upper Limb NDM Displacement and Strain Coppieters MW, Alshami AM. Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. J Ortho Rsch. 2007; 25(7):972-80. •  Sliding technique elicited the most displacement and the least strain in the median nerve at the carpal tunnel. •  Allowing movement of other joints during NDM leads to less strain. •  This sliding strategy is recommended for use in order to maximize displacement but minimize strain to the nerve >ssue. The Nerve “Con8nuum” •  The nervous system is a long organ –  Movement (gentle or aggressive) has an effect on the nervous system/ path. Important for clinical tes8ng and sequencing. •  Structural differen8a8on –  Performed during all neurodynamic tests to determine whether the nervous 8ssue is involved in the pathology (i.e., a pain generator). –  Differen8a8on occurs when nerve 8ssue is moved in a region of interest without moving the musculoskeletal 8ssues in the same region. –  **Change in symptoms with the differen8a8ng maneuver may indicate a neural mechanism. Butler, 1989, 1991; Shacklock 2005 29 Nerve Movement PaLerns •  Joint movement leads to movement of the nerves closest to the movement (force) first and then…tension passes to the more remote nerve path in a delayed fashion as the movement takes up the slack. •  Mid-range, slack is taken up and sliding occurs of the nerve within its nerve bed or container. •  End range, tension ensues to the en8re system. •  Applica8on to treatment –  If the desired mechanical input is sliding- apply large amplitude movement in mid-range. –  If the desired mechanical input is tension- apply smaller amplitude movement at the end range. –  Or, combine the techniques- large range amplitude up to the end-range of mo8on. –  Or, incorporate minimal amplitude movement to simply take up the slack in the nerve… early-range. –  Olen the pa8ent’s symptoms will indicate which mobiliza8on approach is most appropriate…don’t work into the painful movement. Shacklock 2005 30
  8. 8. 4/7/17 8 Physiology of Nerve Tissue •  Mechanics and physiology of the nervous system have been described as “interdependent.” This concept forms the basis for neurodynamics according to Shacklock. While not described this specific manner, Butler discussed nerve physiology as well (1989 and 2000). •  This is an important considera8on in that we can not consider only mechanical or only physiological aspects of neural 8ssue in clinical prac8ce. We must consider both. Shacklock 2005 31 Physiology of Nerve Tissue •  “Improving physiology through treatment of mechanical func>on is also an integral part of the concept of neurodynamics and can be highly effec>ve in both diagnosis and treatment. Releasing pressure or tension in a nerve could improve its physiology and clinical correlates.” – Shacklock, 2005 –  Note the mechanical focus to the physiological benefit. Is it possible the physiological benefit by itself may be sufficient to lead to posi>ve clinical outcomes? Shacklock 2005 32 Intraneural Blood Flow •  Blood flow is redundant and designed to maintain flow in light of mechanical influence/stress. •  Changes in blood flow, especially secondary to inflamma8on, may contribute to painful response to neurodynamic tes8ng without the objec8ve findings of changes in conduc8on velocity. •  Vasodila8on-nocicep8ve (C fibers)àincrease of intraneural blood flowàinflamma8on and edemaàmay lead to fibrosis •  Vasoconstric8on- sympathe8c NSà reduc8on of intraneural blood flowàoverac8vity of sympathe8cs may lead to decreased blood flow to nerve Shacklock 2005 33 Mechanical Stress on Intraneural Blood Flow •  Movement has an effect on intraneural fluid movement (Browne, Gilbert, et al 2011; Gilbert et al 2015a; Gilbert et al 2015b; Gilbert et al 2017 (unpublished); Sobczak et al, 2015 (submiLed) •  Movement is expected to have an effect on intraneural blood flow. •  Tension- reduces intraneural blood flow –  8% elonga8on- diminished venular flow (Lundborg & Rydevik 1973) –  15% elonga8on- cessa8on of arterial and venular flow (Lundborg & Rydevik 1973) –  Time dependent- 6% strain for 1 hour decreases conduc8on by 70%; longer dura8on = longer recovery 8me necessary (Lundborg & Rydevik 1973) •  Movement has an effect on neural blood flow. •  Compression- 30-50mmHg leads to hypoxia, decreased flow, conduc8on, and axonal transport (Gelberman et al 1983; Ogata & Naito 1986, Remel et al 1999) •  Same occurs in nerve roots (Olmarker et al 1991; Rydevik 1993) •  Tension and compression can be cumula8ve in effect- “double crush” (Lundborg & Rydevik 1973) 34
  9. 9. 4/7/17 9 Mechanical Stress on Intraneural Blood Flow-Physiology •  Inflamma>on à intraneural edemaàê func>on, blood supply and venous drainage. (Butler 1989; Butler 2001) •  “physiology must be included in management of mechanical problems in the nervous system.”- (Shacklock 2005; Shacklock 1995a) •  Clinical applica8on note: these were big steps to recognize the role of physiology in the recovery of nerve pathology. However, this is s8ll in the context of there being a “mechanical problem” to manage. Is it possible that the problem is chemical, fluid, pressure, neuroimmune related instead of mechanical alone? Or that a nerve could adapt to the mechanical challenge if the chemical/pressure issues were resolved? Shacklock 2005 35 Inflamma8on and PNS Shacklock 2005 36 Lundborg G, Myers R, Powell H. Nerve compression injury and increased endoneurial fluid pressure: a ‘‘miniature compartment syndrome’’. J Neurol Neurosurg Psychiatry 1983;46:1119–24. Brown C, Gilbert KK, Brismee JM, James CR, Smith, MP, Sizer PS. The effects of neurodynamic mobiliza8on on fluid dynamics within the 8bial nerve at the ankle: An unembalmed cadaveric study. Journal of Manual & Manipula>ve Therapy, 2011; 19:26-34. •  Serial Neurodynamic sequences –  Shacklock suggests that if the sequencing is different, then the test is completely different. –  Topp et al, 2013 suggests no difference in excursion or strain (scia8c or 8bial nerves) at the end posi8on regardless of the sequencing of the test. –  Nee et al, 2010 suggests no difference in strain and rela8ve posi8on between different sequences of ND tes8ng. However, the paLern of mo8on and loading may change with varying sequences. •  Considera8on: What’s the goal of tes8ng? –  To determine whether the peripheral nervous system 8ssue is involved in the pathological problem at some level. –  Is it possible for some people to respond differently and therefore, is it helpful (in light of a history that might lead us to think of neurogenic involvement) to approach the clinical tes8ng from a variety of direc8ons…to “sneak up” on it? Proximal vs. Distal ini8a8on? Shacklock, 2005; Topp et al, 2013; 37 Nee RJ1, Yang CH, Liang CC, Tseng GF, Coppieters MW. Impact of order of movement on nerve strain and longitudinal excursion: a biomechanical study with implica8ons for neurodynamic test sequencing. Man Ther. 2010 Aug;15(4):376-81. doi: 10.1016/j.math.2010.03.001. Epub 2010 Mar 31. Rela8on to Neurodynamic Tes8ng Rela8on to Neurodynamic Treatment Summary of Treatment Recommenda8ons: •  First, do no harm (nonmaleficence); Be gentle and get the pa8ent moving •  Treat the primary problem (e.g., disc, muscle, tendon) that is affec8ng the nerve •  If the nerve is the primary problem, then treat the nerve. •  If irritable, consider sliding; work away from painful segment •  If less irritable, consider tensioning; work closer to painful segment •  Play with posi8oning using one and two-ended approaches to get the desired input into the system •  Manage reps, sets, dura8on, etc. based on pt. response and desired outcomes. •  Consider external sol 8ssue mobiliza8on as adjunct Rx •  Nee et al 2013a and 2013b-Baseline indica8ons may help predict efficacy, (absence of NP pain, older age, small ROM deficits); and RCT supports use of ND Mobiliza8on with no adverse effects Butler, 1991; Butler, 2000; Shacklock, 2005 38
  10. 10. 4/7/17 10 Theory of Neurodynamic Summary Tes8ng and Treatment Review of Neurodynamic Tes8ng: •  Aler the systems review (CP, NM, Msk, Integ, etc.) screening. •  Aler the Basic Clinical Exam (AROM/PROM/RROM) •  Special Tes8ng to rule in or out (ND tes8ng)-Sequencing •  Tissue specific diagnosis Review of Clinical Treatment: •  Treatment aimed at the problem (e.g., disc, nerve, etc.) •  Tissue specific- slide/tension, etc. •  Restore func8onal ability- (posture, strength, stretch) •  Educa8on and daily management 39 •  1994- SLR; Slump; ULTT; TOS; Carpal Tunnel (Phil Sizer, PT, PhD and Omer Mattijs, PT, ScD) •  1997- Frustration as a clinicianà IAOM-US (Valerie Phelps, PT, ScD) (“Diagnosis Specific Orthopaedic Management”- Maitland History, Cyriax Examination, Butler ND, Kaltenborn mobilization •  2000/2002- COMT IAOM-US- Spine and Extremities •  2003- Elbow Study- Soft Tissue Mobilization dorsal forearm (posterior interosseous nerve) •  2004- ScD Dissertation- L4, L5, S1 root movement during SLR •  2007- K. Gilbert-Lumbosacral NR Displacement Strain Parts 1 and 2- SPINE Young Investigator Award 2006; •  Dilemma- if < 1mm movement at the root level, how is NDM helping…won’t break scar tissue...must be physiological health of the nerve tissue...but how. (Butler 1989; Shacklock 2005) •  Breig- extension of spine = slack to lumbar roots—relation to Mackenzie Ext Protocol…maybe it’s not the Disc afterall... •  2009-Intraneural Fluid Dispersion- •  2011- C. Brown- Tibial Nerve; 2015- K. Gilbert- Simulated Sciatic Nerve; 2015- K. Gilbert- L4 Root; 2016- S. Sobczak- Median Nerve; 2018- N. Burgess- Cervical NR •  2015-C. Lohman- Cervical NR Displacement and Strain Parts 1 and 2- Spine Young Investigator Award 2015 •  2016- R. Ellis; S. Sobczak; P. Sizer; S. Pol; A. Ali—continuing to seek ways to evaluate nerve tissue…stay tuned. •  In vitro à In situ à In vivo (desire to progress from passive system to active system in order to build on physiological nerve health). Recent Findings and My Neurodynamic Story •  Novel method for neural marking (lumbar roots) that spared foraminal ligaments •  Computer digitization and analysis: --L4, L5, S1 move less than previously reported (Smith & Massie, 1993) --Relatively large SLR ROM needed to provide lumbar root displacement --SLR NPP moved more than SLR DF --distal initiation (DF) may increase strain •  SLR NPP and SLR DF are useful clinical tools that provide displacement and strain to the lumbar roots. •  Clinical applica8on of ULNTT is not limited to the brachial plexus or within upper extremity. •  Provides mechanical founda8on for provoca8ve neurodynamic tes8ng of the roots. Kleinrensink, 2000 could not measure roots –  Bolsters the exis8ng clinical research that has validated ULNTT for symptom reproduc8on in pa8ents with neck pain and radiculopathies (Sandmark & Nisell, 1995; Wainner et al., 2003) •  May be useful in the examina8on of pathology of the cervical nerve roots •  Clinical implica8ons of foraminal ligaments are unclear –  Hypothesized they paly a role in compression pathologies (Nowicki & Haughton, 1992; Park et al., 2001) –  Foraminal ligaments appear to protect cervical nerve roots by limi8ng transfer of strain to prox root
  11. 11. 4/7/17 11 Fluid Dynamics- Peripheral Nerve Tissue- Scia8c (in vitro)-JMMT 2015 Fluid Dynamics- Tibial Nerve (in situ)- JMMT 2011 Fluid Dispersion with Neurodynamic Mobilization 20.65 20.84 21.77**# 20 20.2 20.4 20.6 20.8 21 21.2 21.4 21.6 21.8 22 Pre-mobilization Post-mobilization Time LongitudinalDye Spread(mm) Control Experimental 15.3 16.3 15 15.2 15.4 15.6 15.8 16 16.2 16.4 16.6 16.8 17 Pre Post Distance (mm) Time (premobiliza#on to post mobiliza#on) Rela#ve Fluid Movement Compared to Baseline Experimental Fluid Dynamics- Lumbar Nerve Root- (in situ) JMMT 2015 Nerve Tissue Fluid Dynamics Series of studies examining the dynamics of intraneural fluid: •  Scia8c Nerve – in vitro •  Tibial Nerve – in situ •  Lumbar (L4) Root– in situ •  Median Nerve- in situ (In prepara>on; emphasize tension vs. slide) •  Boudier-Revéret M., Gilbert K.K., Allégue D.R., Moussadyk M., Brismée J-M., Feipel V., Sizer P.S., Dugailly P- M., Sobczak S., Carpal Tunnel Syndrome: Effect of Specific Neural Mobiliza8on on Median Nerve Edema Dispersion: A Cadaveric Inves8ga8on. Best Scien>fic Poster, Texas Society for Hand Therapy 22nd Annual Educa8on Conference San Antonio, March 24-26, 2017.-Poster Presenta8on. •  Cervical Roots– in situ (data collec>on) Neurodynamic (mechanical) input moves intraneural fluid aler it has stabilized over 8me.
  12. 12. 4/7/17 12 Nerve Tissue Fluid Dynamics (Pressure) Study Pedigree: •  Displacement not as large as originally thought… (Gilbert et al, 2007a; Gilbert et al, 2007b); perhaps another mechanism dealing with intraneural fluid mechanics; flushing/pumping •  NDM causes intraneural fluid to move: scia8c nerve sec8on; 8bial nerve, lumbar root, (Median), (Cervical root). •  Next line of direc8on will deal with intraneural pressure changes associated with neural mobiliza8on. •  Pilot Study- N=1: Intraneural pressure of CNR during ULNT incorpora8ng Median Bias •  Significant at C5 and C6 •  SB increased intraneural pressure at C5 but not C6. •  Poster submission Theory of Neurodynamics Summary- Current Literature So, what do we take away from these areas of study? 1.  Anatomy/Biomechanics- structure and func8on**** –  Nerves are meant to move but do not tolerate tension and compression as well as other 8ssues 2.  Pathophysiology- blood flow and chemical response*** –  Tension/compression can alter blood flow, axoplasmic flow, and lead to pain, inflamma8on, and intraneural edema 3.  Tes8ng** –  Tes8ng has been shown to be valid and reliable as long as clinicians fully examine pa8ent; 1) reproduc8on of pa8ent symptoms; 2) change in response resul8ng from differen8a8ng maneuvers; 3) asymmetrical presenta8on? 4.  Treatment* –  Seems to work; not really sure why; may have something to do with mechanical input, but evidence is moun8ng to suggest that the physiological component of treatment is beneficial and may work to “pump” out inflamma8on and restore appropriate blood flow. 48 Nerve Related Pain Research Model Mechanical Anatomical/ Physiological Clinical Engineering (CARL/TTU-ME) Cadaveric / Animal / Normals (CARL) / (LARC) / (Msk/Bm/PC) Clinical Research (UMC/TTUHSC/Grace) •  Theore8cal Modeling •  Valida8on Modeling •  Clinical Tes8ng •  Interven8on •  Outcomes Ques#ons: 1.  Can we improve pain/func8on in pa8ents with nerve related pain? 2.  Is improvement in pain/func8on correlated with nerve movement or fluid dispersion/ change in pressure? 3.  What parameters of interven8on provide the best clinical outcomes? Grant Progression: 1.  SPFàSHP 2012 2.  SHP 2012àCH Found 3.  SHP 2014àNSF 4.  SHP NicheàR15 5.  R15àR01 Copyright: Gilbert, Sizer, Brismee, Sobczak, Pol, 2013 Byorn Rydevik-ISSLS Hong Kong TTUHSC/TTU/AUT/UQ Research Team: Lel to Right: Suhas Pol, PhD; Richard Ellis, PT, PhD; Kerry Gilbert, PT, ScD; Stephane Sobczak, PT, PhD; Not pictured: Jean-Michel Brismee, PT, ScD; Phil Sizer, PT, PhD
  13. 13. 4/7/17 13 Selected References •  Butler, David S. (1989). Adverse mechanical tension in the nervous system: a model for assessment and treatment. The Australian Journal of Physiotherapy, 35(4), 227–238. •  Butler, David Sheridan, & Jones, M. A. (1991). Mobiliza>on of the nervous system: CIP >tle. Elsevier Health Sciences. •  Brown C, Gilbert KK, Brismee JM, James CR, Smith, MP, Sizer PS. The effects of neurodynamic mobiliza8on on fluid dynamics within the 8bial nerve at the ankle: An unembalmed cadaveric study. Journal of Manual & Manipula>ve Therapy, 2011; 19:26-34. •  Boyd BS1, Topp KS, Coppieters MW. Impact of movement sequencing on scia8c and 8bial nerve strain and excursion during the straight leg raise test in embalmed cadavers. J Orthop Sports Phys Ther. 2013 Jun;43(6):398-403. doi: 10.2519/jospt.2013.4413. Epub 2013 Apr 30. •  Coppieters MW1, Hough AD, Dilley A. Different nerve-gliding exercises induce different magnitudes of median nerve longitudinal excursion: an in vivo study using dynamic ultrasound imaging. J Orthop Sports Phys Ther. 2009 Mar;39(3):164-71. doi: 10.2519/jospt.2009.2913. •  Coppieters MW, Alshami AM. Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. J Ortho Rsch. 2007; 25(7):972-80. •  Côté, P., Cassidy, J. D., & Carroll, L. (1998). The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine, 23(15), 1689–1698. •  Elvey, R. (1979). Brachial plexus tension tests and the pathoanatomical origin of arm pain. In Aspects of Manipula>ve Therapy. Melbourne, Australia. •  Elvey, R. L. (1986). Treatment of arm pain associated with abnormal brachial plexus tension. Australian Journal of Physiotherapy, 32(4), 225–230. •  Gilbert, K. K., Brismée, J.-M., Collins, D. L., James, C. R., Shah, R. V., Sawyer, S. F., & Sizer, P. S., Jr. (2007a). 2006 Young Inves8gator Award Winner: lumbosacral nerve root displacement and strain: part 1. A novel measurement technique during straight leg raise in unembalmed cadavers. Spine, 32(14), 1513–1520. doi:10.1097/BRS.0b013e318067dd55 •  Gilbert, K. K., Brismée, J.-M., Collins, D. L., James, C. R., Shah, R. V., Sawyer, S. F., & Sizer, P. S., Jr. (2007b). 2006 Young Inves8gator Award Winner: lumbosacral nerve root displacement and strain: part 2. A comparison of 2 straight leg raise condi8ons in unembalmed cadavers. Spine, 32(14), 1521–1525. doi:10.1097/BRS.0b013e318067dd72 Selected References •  Gilbert KK, James CR, Apte G, Brown C, Sizer PS, Brismee JM, Smith MP. Effects of Simulated Neural Mobiliza8on on Fluid Movement in Cadaveric Peripheral Nerve Sec8ons: Implica8ons for the Treatment of Neuropathic Pain and Dysfunc8on. Journal of Manual & Manipula>ve Therapy, 2015; 23:219-225. •  Gilbert KK, Brismee JM, Sobczak S, James CR, Smith M. Effects of Lower Limb Neurodynamic Mobiliza8on on Intraneural Fluid Dispersion of the Fourth Lumbar Nerve Root: An Unembalmed Cadaveric Inves8ga8on. Journal of Manual & Manipula>ve Therapy, 2015; 23:239-243. •  Goddard, M. D., & Reid, J. D. (1965). Movements induced by straight leg raising in the lumbo-sacral roots, nerves and plexus, and in the intrapelvic sec8on of the scia8c nerve. Journal of Neurology, Neurosurgery, and Psychiatry, 28(1), 12–18. •  Graham, G. (1981). Intraopera8ve straight-leg raising during laminectomy and disk excision for scia8ca. Clin Orthop, 154, 343–344. •  Gray, H. (2008). Gray’s Anatomy (S. Standring, Ed.) (40th ed.). Churchill Livingstone. •  Grimes, P. F., Massie, J. B., & Garfin, S. R. (2000). Anatomic and biomechanical analysis of the lower lumbar foraminal ligaments. Spine, 25(16), 2009–2014. •  Hasue, M., Kikuchi, S., Sakuyama, Y., & Ito, T. (1983). Anatomic study of the interrela8on between lumbosacral nerve roots and their surrounding 8ssues. Spine, 8, 50–58. •  Kenneally, M. (1983). The upper limb tension test. Presented at the Fourth Biennial Conference of the Manipula8ve Therapists Associa8on of Australia, Melbourne, Australia. •  Kleinrensink, G. J., Stoeckart, R., Mulder, P. G., Hoek, G., Broek, T., Vleeming, A., & Snijders, C. J. (2000). Upper limb tension tests as tools in the diagnosis of nerve and plexus lesions. Anatomical and biomechanical aspects. Clinical Biomechanics (Bristol, Avon), 15(1), 9–14. •  Kleinrensink, G. J., Stoeckart, R., Vleeming, A., Snijders, C. J., Mulder, P. G. H., & van Wingerden, J. P. (1995). Peripheral nerve tension due to joint mo8on. A comparison between embalmed and unembalmed human bodies. Clinical Biomechanics (Bristol, Avon), 10(5), 235–239. •  Kleinrensink, G., Stoeckart, R., Vleeming, A., Snijders, C., & Mulder, P. (1995). Mechanical tension in the median nerve. The effects of joint posi8ons. Clinical Biomechanics, 10(5), 240–244. doi:10.1016/0268-0033(95)99801-8 •  Kleinrensink, G., Stoeckart, R., Vleeming, A., Snijders, C., Mulder, P., & van Wingerden, J. (1995). Peripheral nerve tension due to joint mo8on. A comparison between embalmed and unembalmed human bodies. Clinical Biomechanics, 10(5), 235–239. doi:10.1016/0268-0033(95)99800-H Selected References •  Kosteljanetz, M., Bang, F., & Schmidt-Olsen, S. (1988). The clinical significance of straight-leg raising (Lasègue’s sign) in the diagnosis of prolapsed lumbar disc. Interobserver varia8on and correla8on with surgical finding. Spine, 13(4), 393–395. •  Kraan, G A, Hoogland, P. V. J. M., & Wuisman, P. I. J. M. (2009). Extraforaminal ligament aLachments of the thoracic spinal nerves in humans. European Spine Journal: Official Publica>on of the European Spine Society, the European Spinal Deformity Society, and the European Sec>on of the Cervical Spine Research Society, 18(4), 490–498. doi:10.1007/s00586-009-0881-4 •  Kraan, G A, Smit, T. H., Hoogland, P. V. J. M., & Snijders, C. J. (2010). Lumbar extraforaminal ligaments act as a trac8on relief and prevent spinal nerve compression. Clinical Biomechanics (Bristol, Avon), 25(1), 10–15. doi:10.1016/j.clinbiomech.2009.09.001 •  Kraan, G A., Delwel, E. J., Hoogland, P. V. J. M., van der Veen, M. R., Wuisman, P. I. J. M., Stoeckart, R., … Snijders, C. J. (2005). Extraforaminal Ligament ALachments of Human Lumbar Nerves. Spine, 30(6), 601–605. doi:10.1097/01.brs.0000155403.85582.39 •  Kraan, Gerald A, Smit, T. H., & Hoogland, P. V. J. M. (2011). Extraforaminal ligaments of the cervical spinal nerves in humans. The Spine Journal: Official Journal of the North American Spine Society, 11(12), 1128–1134. doi:10.1016/j.spinee.2011.10.025 •  Lasègue, C. (1864). Considèra8ons sur la scia8que. Arch Gen Med (Paris), 2, 558–80. •  Lew, P. C., Morrow, C. J., & Lew, A. M. (1994). The effect of neck and leg flexion and their sequence on the lumbar spinal cord. Implica8ons in low back pain and scia8ca. Spine, 19(21), 2421–2424; discussion 2425. •  Lewis, J., Ramot, R., & Green, A. (1998). Changes in Mechanical Tension in the Median Nerve: Possible implica8ons for the upper limb tension test. Physiotherapy, 84(6), 254–261. doi:10.1016/S0031-9406(05)65524-1 •  Lohman C, Gilbert KK, Sobczak S, Brismée JM, James CR, Day M, Smith MP, Taylor L, Dugailly PM, Pendergrass TP, Sizer PS. 2015 Young Inves8gator Award Winner: Cervical nerve root displacement and strain during upper limb neural tension tes8ng: Part 1. A minimally invasive assessment in unembalmed cadavers. Spine, 2015; 40(11); 793-800. •  Lohman C, Gilbert KK, Sobczak S, Brismée JM, James CR, Day M, Smith MP, Taylor L, Dugailly PM, Pendergrass TP, Sizer PS. 2015 Young Inves8gator Award Winner: Cervical nerve root displacement and strain during upper limb neural tension tes8ng: Part 2. Role of foraminal ligaments in the cervical spine. Spine, 2015; 40(11); 801-808. •  Loyd L, Gilbert KK, Sizer PS, Atkins L, Sobczak S, Brismee JM, Pendergrass TJ. The rela8onship between various anatomical landmarks used for localizing the first rib during surface palpa8on. J Man Manip Ther. 2014 Aug;22(3):129-33 •  Lundborg G, Myers R, Powell H. Nerve compression injury and increased endoneurial fluid pressure: a ‘‘miniature compartment syndrome’’. J Neurol Neurosurg Psychiatry. 1983;46:1119–24. •  Manvell JJManvell N, Snodgrass SJ*, SA Reid. Improving the radial nerve neurodynamic test: An observa8on of tension of the radial, median and ulnar nerves during upper limb Posi8oning. 2015; Manual Therapy 20 (2015) 790-796. •  McGillicuddy, J. (2004). Cervical radiculopathy, entrapment neuropathy, and thoracic outlet syndrome: how to differen8ate? J Neurosurg, 1(2), 179–187. •  Molinari, W. J., 3rd, & Elfar, J. C. (2013). The double crush syndrome. The Journal of Hand Surgery, 38(4), 799–801; quiz 801. doi:10.1016/j.jhsa. 2012.12.038 •  Nee RJ1, Jull GA, Vicenzino B, Coppieters MW. The validity of upper-limb neurodynamic tests for detec8ng peripheral neuropathic pain. J Orthop Sports Phys Ther. 2012 May;42(5):413-24. doi: 10.2519/jospt.2012.3988. Epub 2012 Mar 8. •  Nee RJ1, Vicenzino B, Jull GA, Cleland JA, Coppieters MW. Neural 8ssue management provides immediate clinically relevant benefits without harmful effects for pa8ents with nerve-related neck and arm pain: a randomised trial. J Physiother. 2012;58(1):23-31. doi: 10.1016/ S1836-9553(12)70069-3. •  Nee RJ1, Vicenzino B, Jull GA, Cleland JA, Coppieters MW. Baseline characteris8cs of pa8ents with nerve-related neck and arm pain predict the likely response to neural 8ssue management. J Orthop Sports Phys Ther. 2013 Jun;43(6):379-91. doi: 10.2519/jospt.2013.4490. Epub 2013 Apr 30. •  Nee RJ1, Yang CH, Liang CC, Tseng GF, Coppieters MW. Impact of order of movement on nerve strain and longitudinal excursion: a biomechanical study with implica8ons for neurodynamic test sequencing. Man Ther. 2010 Aug;15(4):376-81. doi: 10.1016/j.math.2010.03.001. Epub 2010 Mar 31. •  Nee RJ1, Vicenzino B, Jull GA, Cleland JA, Coppieters MW. A novel protocol to develop a predic8on model that iden8fies pa8ents with nerve- related neck and arm pain who benefit from the early introduc8on of neural 8ssue management. Contemp Clin Trials. 2011 Sep;32(5):760-70. doi: 10.1016/j.cct.2011.05.018. Epub 2011 Jun 22. Selected References
  14. 14. 4/7/17 14 •  Nowicki, B. H., & Haughton, V. M. (1992). Neural foraminal ligaments of the lumbar spine: appearance at CT and MR imaging. Radiology, 183(1), 257–264. doi:10.1148/radiology.183.1.1549683 •  Park, H. K., Rudrappa, S., Dujovny, M., & Diaz, F. G. (2001). Intervertebral foraminal ligaments of the lumbar spine: anatomy and biomechanics. Child’s Nervous System: ChNS: Official Journal of the Interna>onal Society for Pediatric Neurosurgery, 17(4-5), 275–282. •  Radhakrishnan, K., Litchy, W. J., O’Fallon, W. M., & Kurland, L. T. (1994). Epidemiology of cervical radiculopathy. A popula8on-based study from Rochester, Minnesota, 1976 through 1990. Brain: a Journal of Neurology, 117 ( Pt 2), 325–335. •  Rydevik, B., Lundborg, G., Olmarker, K., & Myers, R. (2001). Biomechanics of Peripheral Nerves and Spinal Nerve Roots. In Basic Biomechanics of the Musculoskeletal System. (pp. 128–149). LippincoL Williams & Wilkins. •  Sandmark, H., & Nisell, R. (1995). Validity of five common manual neck pain provoking tests. Scand J Rehabil Med, 27, 131–136. •  Shacklock, M. (1995). Neurodynamics. Physiotherapy, 81(1), 9–16. doi:10.1016/S0031-9406(05)67024-1 •  Shacklock, M. (2005). Clinical Neurodynamics (1st ed.). Elsevier. •  Smith AR, Cummings JP. The Axillary Arch: Anatomy and Suggested Clinical Manifesta8ons. JOSPT, 2006; 36(6):425-429. •  Rade M1, Könönen M, Vanninen R, Mar|la J, Shacklock M, Kankaanpää M, Airaksinen O. 2014 young inves8gator award winner: In vivo magne8c resonance imaging measurement of spinal cord displacement in the thoracolumbar region of asymptoma8c subjects: part 1: straight leg raise test. Spine (Phila Pa 1976). 2014 Jul 15;39(16):1288-93. •  Rade M1, Könönen M, Vanninen R, Mar|la J, Shacklock M, Kankaanpää M, Airaksinen O. 2014 young inves8gator award winner: In vivo magne8c resonance imaging measurement of spinal cord displacement in the thoracolumbar region of asymptoma8c subjects: part 2: comparison between unilateral and bilateral straight leg raise tests. Spine (Phila Pa 1976). 2014 Jul 15;39(16):1294-300. •  Schmid AB1, Nee RJ, Coppieters MW. Reappraising entrapment neuropathies--mechanisms, diagnosis and management. Man Ther. 2013 Dec; 18(6):449-57. doi: 10.1016/j.math.2013.07.006. Epub 2013 Sep 2. •  Schmid AB1, EllioL JM, Strudwick MW, LiLle M, Coppieters MW. Effect of splin8ng and exercise on intraneural edema of the median nerve in carpal tunnel syndrome--an MRI study to reveal therapeu8c mechanisms. J Orthop Res. 2012 Aug;30(8):1343-50. doi: 10.1002/jor.22064. Epub 2012 Jan 9. Selected References •  Schmid AB1, Coppieters MW. The double crush syndrome revisited--a Delphi study to reveal current expert views on mechanisms underlying dual nerve disorders. Man Ther. 2011 Dec;16(6):557-62. doi: 10.1016/j.math.2011.05.005. Epub 2011 Jun 8. •  Sobczak S, Dugailly PM, Gilbert KK, Hooper TL, Sizer PS Jr, James CR, Poortmans B, MaLhijs OC, Brismée JM. Reliability and valida8on of in vitro lumbar spine height measurements using musculoskeletal ultrasound: A preliminary inves8ga8on. J Back Musculoskelet Rehabil. 2016 Jan 25;29(1):171-82. •  Wainner, R. S., Fritz, J. M., Irrgang, J. J., Boninger, M. L., DeliLo, A., & Allison, S. (2003). Reliability and diagnos8c accuracy of the clinical examina8on and pa8ent self-report measures for cervical radiculopathy. Spine, 28(1), 52–62. doi:10.1097/01.BRS.0000038873.01855.50 •  Wilbourn, A. J. (1988). Thoracic outlet syndrome surgery causing severe brachial plexopathy. Muscle & Nerve, 11(1), 66–74. doi:10.1002/mus. 880110111 •  Wiltse, L., Fonseca, A., Amster, J., Dimar8no, P., & Ravessoud, F. (1993). Rela8onship of the dura, Hoffmann’s ligaments, Batson’s plexus, and a fibrovascular membrane lying on the posterior surface of the vertebral bodies and aLaching to the deep layer of the posterior longitudinal ligament: an anatomical, radiologica, and clinical study. Spine, 8, 1030–1043. Selected References Dank Je!/Thank You!
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