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Lateral Elbow Pain – supinator tunnel syndrome
Mechanical Interface
Level 1
Progression 1 - static opener
Position - elbow flexion (approx. 35-50° from full extension), passive supination, wrist and fingers in neutral, shoulder elevated if necessary
Offer this as a rest position for pain relief.
Progression 2 - dynamic opener
Passive supination
Can be given as a home exercise
Level 2
Progression 2 - closing technique
Position - ,elbow extension passively
Mobilise/stretch - passive pronation, wrist and fingers in neutral
Progression 3- closing technique
Position - for RNT, obtain elbow extension passively
Mobilise/stretch - passive pronation, wrist and fingers in neutral
Include wrist and finger flexion and resist them actively and perform hold/relax techniques.
Interface release technique
Place elbow in 20-30˚ flexion, find medial border with thumbs and release across the muscle with thumbs. Be careful, it can dig in and be uncomfortable.
This is designed to release supinator as you perform an additional lifting action.
Section 12 Treatment - elbow pain 19
© 2014-15 NDS Neurodynamic Solutions
Neural
Level 1
Progression 1 - off-loader
Use the usual generic off-loaded position for the upper quarter but it can be biased to the posterior interosseous nerve with:
• a degree of supination and wrist and finger extension if so desired
Progression 2 - sliders
Starting position- elbow straight- wrist and fingers in neutral- scapula elevated- shoulder external rotation
Proximal slider - scapular depression/internal rotation
Back to original position - scapular elevation/shoulder external rotation
Wrist and fingers remain in neutral
Section 12 Treatment - elbow pain 20
© 2014-15 NDS Neurodynamic Solutions
Progression 3 - sliders
Starting position - elbow almost straight, wrist and fingers in neutral, scapula elevated. Positioning in internal rotation can be used as a progression.
Distal slider - scapular elevation/wrist and finger flexion
Proximal slider - scapular depression/wrist and finger extension
Level/type 3a - Neurodynamically Sensitised
Add CLF.
Level/type 3b - Neurodynamic Sequencing
Position – as for RNT
Movements
• EE/Pron
• wrist and finger flexion
• shoulder internal rotation
• shoulder abduction
• scapular depression
• CLF
The sequence can naturally be varied according to the patient’s needs or what is more practical to peform.
Section 12 Treatment - elbow pain 21
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Level/type 3 (C) - Multistructural
Progression 1 - neural massager (slider under thumb)
Performed as a slider at level 2 except you place pressure over the nerve and/or neighbouring structures, eg. supinator, whilst sliding the nerve underneath.
Progression 2 - interface and neural
Contract supinator then, when it relaxes, perform tensioner for the posterior interosseous nerve as per level 2.
Section 12 Treatment - elbow pain 22
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Section 13
Clinical ApplicationPractical/lab session
Low back and radicular pain - specific dysfunctions
Piriformis syndrome and the sciatic nerve
Foot/heel pain and the tibial nerve
Low Back and Radicular PainTreatment progressions
Mechanical interface - reduced closing dysfunctionThe techniques below are particularly suited to patients with significant distal symptoms that involve pain, pins and needles or loss of sensation.
IndicationsPredominantly distal symptoms - particularly pins and needles, numbness and weakness, neurological signs
Persistent/ continuous distal symptoms
Not as common to use these techniques with acute /severe low back pain without referral of symptoms into the lower limb
Distal symptoms provoked by closing movements - extension, ipsilateral lateral flexion
Reduced ROM of closing movements
Key aspect - MUST do a neurological examination before and after each treatment.
Treatment is directed at reducing the pathophysiology in the nerve root rather than the mechanical dysfunction. this is because to treat the mechanical dysfunction (ie. closing) would be to risk provoking the nerve root.
Section 13 - low back and radicular pain, piriformis syndrome, foot/heel pain 2
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Level 1 - Limited
1. Static Opener
Position - painful side uppermost with a bolster under the lower side.
Progression 1a. Towel between ilium and trochanter
Progression 1b - One leg over the side
Place in open position - painful side up, legs flexed to 90°, one foot placed over the side of the couch.
If this increases symptoms return foot to couch and place a bolster under waist instead.
Do not mobilise.
Degree of opening - depends on response to positioning
Duration - 30-60 seconds at first. If better, repeat several times. If the same, still repeat once more and reassess at the next session.
Monitor symptoms at rest and, if they improve, offer this position as a pain relief strategy.
Either leg can be lowered, depending which is
more effective in achieving lateral flexion and
what is more comfortable for the patient.
Progression 1c - Static Opener
Position - as above, two feet placed over the side of the couch. Dosage same as in progression 1.
Dosage - up to several minutes at a time, hourly. Good gains can be achieved by doing this manoeuvre several times per day.
Progression 1d - manual opening to maximize.
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2. Dynamic Opener/mobilisation (Level 1 continued)
Passive opener - contralateral lateral flexion
Can be done as small or large amplitude, in the inner or outer range.
Can be performed as a home also
Level 2 - Standard
Indications/clinical features
At this point, there is little to be found on neurological examination.
The distal symptoms are not easily provoked and are now intermittent or absent.
Neurodynamic testing shows minor signs (overt abnormal response (OAR) and covert abnormal response (CAR) late in range).
The interface dysfunctions are still present (reduced closing).
Now the treatment changes from treating pathophysiology in the nerve root to treating the mechanical dysfunction in the interface.
Dynamic Closer
Closer mobilisation – inner, middle and outer range
Position - start mobilisation in open position and gently move toward closed position
Mobilisation - in the direction of closing but only to the neutral position.
Perform slowly and carefully and with respect to the patient’s symptoms and physical responses,
especially resistance and protective responses.
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Dosage - 5-6 gentle movements then reassess. if there is an improvement, repeat several more movements. If the same after mobilisations, repeat sets of mobilisations, stop and reassess at next session.
This can be progressed by positioning the patient into ipsilateral rotation, less hip/lumbopelvic flexion and even into some extension but care must be exercised.
Neural DysfunctionsClinical Features
Symptoms reproduced by movements that produce sliding in one particular direction.
Neural Tension dysfunction‣ SLR painful +/- PNF painful in severe cases‣ Slump - NF painful - KE painful
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Moving Through the Progressions
It may not always be necessary to pass through each progression because they provide small increments. It is therefore possible in many patients to jump a progression or two. However, this should always be done carefully with respect to the patient’s signs and symptoms and sufficient time should be allowed between treatments so that accurate observation of patient responses can be achieved.
Progression 1 Position OUT - Position OUT(ipsilateral) (contralateral)
Position – generic off-loaded position for the sciatic nerve, - contralateral hip flexed approximately 90˚ if possible
- contralateral knee extension- hold for approx. 15 secs, longer if comfortable and safe (no problems in the contralateral limb - pins and needles or other symptoms)
Ipsilateral limb Contralateral limb
Progression 2 - position OUT-move OUT (of tension)(ipsilateral) (contralateral)
As above (1) except the knee is extended and flexedPerform approx. 5-10 times. This set can be repeated up to 3-5 more times
Progression 3 - position IN-move OUT (of tension)(ipsilateral) (contralateral)
Ipsilateral lower limb in neutral Ipsilateral dorsiflexion
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Add ipsilateral SLR Move OUT - contralateral knee
More SLR Move OUT - contralateral knee
Progression 4 - position OUT-move IN (to tension)(contralateral) (ipsilateral)
Sitting
Position OUT- contralateral knee extension- protects nerve root- dorsiflexion optional
Move IN- contralateral knee extension- dorsiflexion optional
OPTIONS:
‣ ipsilateral dorsiflexion
‣ neck flexion
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Progression 5 - position IN-move IN (to tension)
(contralateral) (ipsilateral)
From thisThis was the progression 4 starting position.
Now the protection from the contralateral knee is removed (remove the contralateral knee extension).
To this:
Position IN Move IN - ipsilateral knee extension
Add cervical flexion Move IN - ipsilateral knee extension
WHAT IS THIS?
Option - add dorsiflexion
This is now level 2, the standard slump test.
You now have a wide variety of techniques below level two that are not likely to provoke symptoms.
Section 13 - low back and radicular pain, piriformis syndrome, foot/heel pain 8
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Level/type 3a - Position IN - move IN (to tension)
Contralateral lateral flexion Ipsilateral knee extension
HERE IS THE PROCEDURE FOR SAFER MORE ADVANCED TECHNIQUE
1. Test neurological function. If abnormal, this technique at level 3a is not recommended.
2. Position the patient comfortably.
3. Ask if the patient has any symptoms at rest. If “Yes”, do NOT proceed. The problem may not be at level 3.
4. Explain that symptoms may occur and, if they do, they must only be mild at most. Generally reproduction of the patient’s clinical symptoms is to be avoided. Stretching sensations are common.
5. Perform a test movement to the first onset of symptoms.
5.1. make sure the patient moves slowly and carefully and that they learn to stop at the right place.
5.2. return to the starting position and check that any symptoms disappear instantly. If not, wait until they do. If they take more than a few seconds, it may be better to do something more gentle.
6. If this goes according to plan:
6.1. perform 3-5 movements the same way, making sure that the symptoms stop between movements.
6.2. return to the start position for at least a second or two each time a movement is performed.
7. Do NOT stay in the end range position for more than about one second.
8. Test the neurological status to be sure that it has not deteriorated. If a deterioration occurs, the technique is contraindicated.
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Position - as for slump test
Movement - cervical, thoracic, lumbar flexion, contralateral lateral flexion, knee extension,, dorsiflexion.
Make sure the amplitude is large so you retreat from the symptomatic position each time.
Level/type 3c. Advanced - reduced closing with neural tension dysfunction
Patient position - painful side up
Mobilisation - closing (ipsilateral lateral flexion) + neck flexion and knee extension (ie. two-ended tensioner)
This one often needs practice so the patients gets the movements right.
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Starting position Closer with knee extension/neck flexion
Mechanical Interface - reduced opening dysfunctionLevel 1 to Level 2
Position - leaning over the patient with both hands around the pelvis.
Mobilisation - as an opener from the slightly closed position to the slightly opened position.
Should not provoke pain.
This is effectively the opening mobilisation shown earlier except that a sustained opener is not performed for reasons of provocation.
The same as the dynamic opener for the closing dysfunction, but for different reasons.
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Level 3c. Multistructural - reduced opening with neural tension dysfunction - dynamic opener
Dynamic opener + one-ended or two ended tensioner
Optional - neck flexion or not, depending on the desired progression.
It is normally positioned. Active neck flexion makes the patients stabilize their pelvis which reduces the opening, not desirable.
This is used when there is:
‣ less risk of provocation
‣ a tension dysfunction with reduced opening - quite common
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Distal/Caudad (downward) Sliding Dysfunction
Clinical Features
‣ SLR painful-neck flexion OK or eases
‣ Slump - release neck flexion painful
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Progression 1 position OUT (up/cephalad) - position OUT (up/cephalad)
Same as in progression 2 except the neck is positioned in the flexion for a rest position to ease pain.
Progression 2 - position OUT (up/cephalad) - move OUT (up/cephalad)
Aim - to move the neural tissues away from the provoking direction and to do so with little neural tension.
Position - reduced tension (off-loaded) position
• painful side up, neutral spinal position in the sagittal and frontal planes• approximately 45° of bilateral hip flexion, 45° of bilateral knee flexion
Movement - gentle passive neck flexion
Symptoms are not evoked
Observe symptoms as you would in all other progressions.
Progression 3 - position IN (down/caudad) -move OUT (up/cephalad)
Position - same as above, add a small amount of ipsilateral knee extension prior to the mobilisation. This position should not evoke or reproduce any symptoms.
Movement - passive neck flexion again (position
This does not take the system to its end point of sliding, nor does it produce symptoms.
If this is provocative, the patient can be positioned in bilateral knee extension and the mobilisation repeated (PNF).
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Progression 4 - position OUT (up/cephalad) - move IN (down/caudad)
Position - painful side up, neck in flexion (to bring the neural tissues into a cephalad position in the canal - position away).
Movement - straight leg raise (move IN to dysfunction - down/cephalad).
Some symptoms may be evoked but they should be mild and should cease immediately after the technique. However, if this mobilisation is provocative, it may be modified, as in the following:
You can then go further into SLR as a progression or add dorsiflexion if you wish.
Progression 5
This progression permits more caudal (downward) positioning (position IN - move IN = position down/caudad - move down /caudad).
5.1 As progression 4 position cervical spine in neutral then extension (down/caudad). Move the SLR for (downward/caudad) movement of the nerve roots.
5.2 Position - sitting across the plinth as if for the slump test, neck and thoracic spine straight
Movements - cervical and thoracic extension with knee extension.
To progress - add dorsiflexion.
Ipsilateral lateral flexion can be added for more effect.
Section 13 - low back and radicular pain, piriformis syndrome, foot/heel pain 15
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Progression 5.3
Position - ipsilateral long sitting, neck and thoracic flexion
Movement - neck and thoracic extension whilst the patient leans forward to apply distal movement to the neural elements.
Understanding Sliders
Mechanical Effects
‣ maximal sliding with minimal tensile forces inside the nerves
‣ may maintain or improve sliding mechanism, eg. prevention of adhesion or loss of movement in the case of surgery, trauma with bruising or bleeding from adjacent structures.
Physiological Effects
‣ may improve blood flow of nerve
‣ sliders produce greater hypoalgesic effects than tensioners
Behavioural Effects
‣ promote movement
‣ muscle relaxation
‣ reduce pain
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Applications
A. Tension dysfunction and pain
‣ useful for patients with a lot of pain who need movement rather than tension
B. Sliding dysfunction
‣ The sliding progressions must be applied so the technique relates directly to the causal mechanisms and progressions
‣ the general sliders above may not follow the progressions for the slider dysfunction therefore may be contraindicated.
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Piriformis Syndrome
Mechanical Interface
You can use plantarflexion/inversion or dorsiflexion with these techniques because of the relationship the peroneal nerve has with the sciatic nerve in the pelvis and with piriformis. Sometimes the peroneal component can feature in the patient’s symptomatology.
Level 1
Progression 1 - Static opener
Hip position - slight flexion, abduction, external rotation
Knee position - slight flexion
Ankle position - neutral
Can do this in side lying or supine lying
Progression 2- Dynamic opener
Passive external rotation - slow speed and large amplitude
This is for pain relief and can be performed as a home exercise
Level 2
Progression 1 - interface (muscle) release technique
Passive stretch of piriformis to be performed by therapist then as a home exercise by the patient. Even though this will produce closing during the technique, it will subsequently produce an opening effect as the muscle releases. This can be combined with contract/relax techniques.
Neural
Level 1
Off-loader for Sciatic Nerve and Piriformis
‣hip flexion below 70,˚abduction/external rotation
‣knee flexion
‣foot comfortable
‣can do this in supine also
Section 13 piriformis syndrome 18
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One ended slider (distal)
Movements - knee extension and/or plantarflexion/inversion
Two ended slider:
Movements
Distal slider - neck extension/knee extension
Proximal slider - neck flexion/knee flexion
Level 2
Tensioners
As above - neck flexion/knee extension with or without foot movements.
Level/type 3c - Multistructural (interface + neural)
Piriformis SLR Test
Remember that the interface function changes with range of motion of hip flexion, ie. above and below 70°.
Below 70°, the piriformis is an external rotator.
1. Starting position 2. Knee extension
3. Internal rotation 4. Plantarflexion/inversion
Section 13 piriformis syndrome 19
© 2014-15 NDS Neurodynamic Solutions
Above 70°, piriformis is an internal rotator.
5. Substitute internal rotation with external rotation
Repeat with dorsiflexion instead of plantarflexion/inversion.
Piriformis Slump Test
In the slump position, perform the following movements in the following order:
‣ knee extension
‣ passive external rotation (stretches piriformis onto the sciatic nerve)
‣ check response - reproduction of symptoms etc
‣ differentiate if need to with foot (PFI or DF) and neck movements
‣ sometimes the neural and interface components can be distinguished
‣ release external rotation
- increase pain -> neural, decrease pain -> muscle
Piriformis slump test.
Section 13 piriformis syndrome 20
© 2014-15 NDS Neurodynamic Solutions
Heel PainAlias - plantar fasciitis, posterior tarsal tunnel syndromeMechanical Interface
Level 1
Progression 1 - static opener
Ankle position - plantar flexion/inversion, adduction and pronation of the forefoot on the hindfoot.
Nerve component - use generic off-loading positions as for releasing tension along the whole tract.
Progression 2- dynamic opener
‣ Passive plantarflexion/inversion of ankle
‣ Adduction/pronation of forefoot on hindfoot
‣ Technique is important here.
‣ Do it in a plane that both opens the interface and reduces tension in the tibial nerve
Palpatory Techniques for the interface and nerve
DemonstrationLevel 2
Progression 1 - closers
Dorsiflexion/eversion/abduction/supination - gentle because it is a closer - monitor symptoms afterwards, as usual.
Neural - tibial nerve at the ankle
Level 1
Progression 1 - off-loader as a position
Sciatic nerve generic off-loader - rest foot in neutral or open position
Progression 2 - two-ended slider
Toe flexion + SLR, hold the ankle still, you can do this in sitting with the patient leaning forward of backwards or passively as an SLR.
Section 13 - foot/heel pain 21
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Starting position
Hold the calcaneum so you can fixate the ankle joint.
Ankle joint should not move during the mobilsation
Do not press on the tibial nerve
PROXIMAL SLIDER – knee extension/toe flexion
DISTAL SLIDER
Hip and knee flexion/toe dorsiflexion
Level 2 - tensioner
Progression 1 - tensioner/slider relative to the tendons
Ankle/toe dorsiflexion with SLR/knee extension
Level/type 3c. Multistructural (interface + neural)
Closer moving the heel into abduction/eversion during a slider or tensioner.
Neural mobilisation and calf stretch- in long sitting slump, test length of gastrocs in/out of neck flexion, see the difference and compare with other side.
‣ do contract/relax in neural position
Section 13 - foot/heel pain 22
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Neary D, Ochoa J, Gilliatt R 1975 Sub-clinical entrapment neuropathy in man. Journal of the Neurological Sciences 24: 283-298
Nee R, Yang C, Liang C-C, Tseng G-F, Coppieters M 2010 Impact of order of movement on nerve strain and longitudinal excursion: A biomechanical study with implications for neurodynamic test sequencing. Manual Therapy 15: 376-381
Olmarker K, Nordborg C, Larsson K, Rydevik B 1996 Ultrastructural changes in spinal nerve roots induced by autologous nucleus pulposus. Spine 21(4): 411-414
Olmarker K, Rydevik B, Nordborg C 1994 Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots. Spine 19 (20): 2369-2370
Pechan J, Julis I 1975 The pressure measurement in the ulnar nerve. A contribution to the pathophysiology of cubital tunnel syndrome. Journal of Biomechanics 8: 75-79
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In Vivo MRI measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 2 - Comparison Between Unilateral and Bilateral Straight Leg Raise Tests.Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O. Spine Feb 5. [Epub ahead of print]PMID: 24503694 [PubMed - as supplied by publisher]
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In vivo MRI Measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 1 - Straight Leg Raise Test. Spine Feb 5. [Epub ahead of print]PMID: 24503694 [PubMed - as supplied by publisher]
Read R 1991 Stress testing in nerve compression. Hand Clinics: Frontiers in hand rehabilitation. 7 (3): 521-526Rosenblueth A, Buylla A, Ramos G 1953 The responses of axons to mechanical stimuli. Acta Physiologica
Latinoamericana 3 (2): 204-215Rozmaryn L, Dovelle S, Rothman E, Gorman K, Olvey K, Bartko J 1998 Nerve and tendon gliding exercises and the
conservative management of carpal tunnel syndrome. Journal of Hand Therapy 11: 171-179 Rubenach H 1985 The upper limb tension test – the effect of the position and movement of the contralateral arm.
In: Proceedings of the 4th biennial conference of the Manipulative Therapists’ Association of Australia: 274-283
Rydevik B 1993 Neurophysiology of cauda equina compression. Acta Orthopaedica Scandinavica Supplement 251: 52-55
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Selvaratnam P, Glasgow E, Matyas T 1988 Strain effects on the nerve roots of brachial plexus. Journal of Anatomy 161: 260-264
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Shacklock, M, Wilkinson M, Scutter S 2002 Dynamics of the median nerve at the elbow and posterior interosseous nerve during pronation and supination movements of the forearm. Unpublished recordings, School of Medical Radiation, University of South Australia
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Slater H 1988 The effect of foot and ankle position on the ‘normal’ response to the SLR test, in young, asymptomatic subjects. Unpublished Master of Applied Science Thesis, University of South Australia
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in patients with lumbar spinal stenosis. Spine 20 (24): 2746-2749Tsai Y-Y 1995 Tension change in the ulnar nerve by different order of upper limb tension test. Master of Science
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examination and patient self-report measures for cervical radiculopathy. Spine 28 (1): 52–62 Werner C, Haeffner F, Rosén 1980 Direct recording of local pressure in the radial tunnel during passive stretch and
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(5): 404-406Wright T, Glowczewskie F, Wheeler D, Miller G, Cowin D. 1996 Excursion and strain of the median nerve. Journal of
Bone and Joint Surgery 78A (12): 1897-1903Yaxley G, Jull G 1991 A modified upper limb tension test: an investigation of responses in normal subjects.
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Zochodne D, Huang Z, Ward K, Low P 1990 Guanethidine-induced adrenergic sympathectomy augments endoneurial perfusion and lowers endoneurial microvascular resistance. Brain Research 519 (1-2): 112-117
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Section 11
Treatment MethodLecture
Working through a system of techniques
Treatment - working through a system of techniques
Note that the system of levels and types of examination applies to treatment in the same way that it does to examination.
SUMMARY OF TECHNIQUE SELECTION
General Principles
Observe symptoms at all times - before, during and after treatment
Reassess symptoms and physical signs - particularly neurodynamic status immediately after treatment, unless there is reason not to, such as to avoid provocation or undue focus on the problem. This includes neurological examination when appropriate.
Classify the dysfunction
Base treatment on the dysfunction category and level/type of examination
Avoid the words ‘stretch’ and ‘tension’ - I say ”this technique is designed to improve the function of the nerve”
Respect resistance - low, medium or high
Be extremely sensitive - because this forms the basis for close analysis between you and the patient so that treatment can be responsive and derived from the patient’s response.
Speed - slow and gentle
Amplitude - generally the movement should come back to the inner range each time so the mobilisations are usually medium to large in amplitude
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Dosage/Repetitions - perform several movements then reassess symptoms at rest or some physical sign that is not irritated with reassessment. this may be performed up to several times in one treatment session, as long as there is some value in the technique.
Sometimes, at higher levels (2 and 3) treatment can evoke (or elicit) symptoms - but it should not provoke them. There is a difference. I use provoke to designate a more severe and long lasting response. Evoke suggests that symptoms have been triggered but more on an instantaneous basis rather than the response being long lasting.
Slider Techniques
Are particularly good for pain
Produce a lot of neural movement without producing much tension
Can be used reduce possibility of treatment soreness and settle symptoms down with advanced treatments
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Section 12
TreatmentPractical/lab session
Neck and radicular pain
Brachialgia
Elbow pain
Neck and Radicular PainTreatment Progressions
Mechanical interface - reduced closing dysfunction
Level 1 (Limited) - Progression 1
Static opener
Indications:
• mainly distal symptoms• continuous distal symptoms• neurological changes• openers relieve the symptoms
Method
Place in open position - segmental localisation is preferable because it places less stress on neural and other structures than a generalised technique. Do not mobilise.
Degree of opening - depends on response to positioning
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Duration - 30-60 seconds at first. If better, repeat several times. If the same, still repeat once several and reassess at the next session. Can increase duration up to 15 mins as a home exercise after good effect is established, usually after a couple of sessions.
Lower cervical - more neck flexion, then contralateral lateral flexion and rotation
Upper cervical - less neck flexion, then contralateral lateral flexion
Range of motion and time are the key ingredients:
Level 1 - Progression 2
Dynamic opener
Monitor symptoms at rest and, if they improve, offer this position as a pain relief strategy.
Naturally, other treatments may be administered.
Dynamic opener for right side - contralateral lateral flexion
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Level 2 - Standard
The main reason for the change in direction of the mobilisation (from opening to closing) is because the physiology in the nerve root has improved by now and we begin to treat the mechanical dysfunction (reduced closing). The nerve root should now be able to tolerate closing.
Dynamic closer
Is simply the reverse of the dynamic opener (closer for the ipsilateral side), except that the foramen is not specifically opened on the contralateral side.
Is gentle and monitored very closely. It is simply a similar technique as the opener but applied in the direction of ipsilateral lateral flexion.
Neural Tension Dysfunction
The IN and OUT are with respect to TENSION in the treated nerve root.
Contralateral and ipsilateral - which limb is used to produce the tension changes.
The following are pictures of the movement progressions but they are performed manually by the therapist
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LEVEL 1
Progression 1 - Position OUT (ipsilateral)- Position OUT (contralateral)
Generic off-loader for the median nerve (applies to whole upper quarter)
Ipsilateral Contralateral
To reduce tension in the ipsilateral nerve root force must be applied to the contralateral.
Ipsilateral Limb:
‣ ipsilateral lateral flexion, if the closing will allow this‣ scapular elevation‣ shoulder adduction/internal rotation‣ elbow flexion, wrist and fingers comfortable
Contralateral Limb
‣ glenohumeral abduction/external rotation
‣ elbow extension
‣ wrist/finger extension if this is comfortable but these movements are often not necessary
‣ the contralateral test is performed as a TEST to ascertain if it will work. If so, proceed.
‣ hold for up to 10-15 seconds
‣ may need to do a neurological evaluation on the CONTRALATERAL side before and after performing the contralateral manoeuvre. This is to ensure that no neurological changes have developed in this limb.
‣ perform the test as a local sequence, ie. use the following sequence to focus the forces on the contralateral nerve root as opposed to the more distal part of the neural tract. This proximal sequence may be more likely to transmit forces to the ipsilateral nerve root
‣ contralateral scapular depression - gentle and small movement- glenohumeral abduction/external rotation
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- elbow extension- wrist extension but this is often not necessary)
‣ may produce stretching in the contralateral limb but it should not produce pins and needles or other neurological symptoms
Progression 2 - Position OUT (ipsilateral)- Move OUT (contralateral)
Progression 3 - Position IN (ipsilateral) - Move OUT (contralateral)
Add some tension to the ipsilateral nerve root but move it out of tension. This effectively places the nerves in a slightly more loaded position before they are moved out of tension.
Ipsilateral abduction Contralateral movements
More ipsilateral abduction Contralateral elbow extension
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Ipsilateral elbow extension Contralateral elbow extension
Add wrist extension Contralateral elbow extension
Progression 4 - Position OUT (contralateral) - move IN (ipsilateral)
Contralateral MNT1 Move ipsilateral MNT1
Add wrist extension
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Progression 5 - Position IN (contralateral) - move IN (ipsilateral)
Move MNT1 Reduce protection - flex elbow
Add wrist extension
FINISH
LEVEL 2 - Standard Test
No assistance is provided by contralateral side now.
Ipsilateral side is moved INTO tension.
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This is now level 2, standard testing
You now have a wide variety of techniques below level two that are not likely to
provoke symptoms.
LEVEL 3a - two-ended tensioner
Two-ended MNT1 tensioner - Contralateral lateral flexion, stabilize the scapula or depress it, elbow extension and wrist extension optional. Be sure to return the limb and neck to ipsilateral lateral flexion and elbow flexion between each mobilisation so as to reduce tension fully each time.
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HERE IS THE PROCEDURE FOR SAFE TECHNIQUE
1. Test neurological function. If abnormal, this technique at level 3a is not recommended.
2. Position the patient comfortably.
3. Ask if the patient has any symptoms at rest. If “yes”, do NOT proceed. The problem may not be at level 3.
4. Explain that symptoms may occur and, if they do, they must only be mild at most. Generally reproduction of the patient’s clinical symptoms is to be avoided. Stretching sensations are common.
5.Perform a test movement to the first onset of symptoms.
5.1. make sure the patient moves slowly and carefully and that they learn to stop at the right place.
5.2. return to the starting position and check that any symptoms disappear instantly. If not, wait until they do. If they take more than a few seconds, it may be better to do something more gentle.
6. If this goes according to plan:
6.1. perform 3-5 movements the same way, making sure that the symptoms stop between movements.
6.2. return to the start position for at least a second or two each time a movement is performed.
7.Do NOT stay in the end range position for more than about one second.
8.Test the neurological status to be sure that it has not deteriorated. If a deterioration occurs, the technique is contraindicated.
Up to this point, the reduced closing dysfunction (interface) and neural tension dysfunction would have been treated separately, even though in the same session. Next, they can be combined (multistructural, level/type 3c).
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Level/type 3b – Sensitised with Neurodynamic Sequencing (focused sequence)
Proximal-to-distal (local) sequence for the MNT1
Scapular stabilisation Contralateral lateral flexion
Abduction/external rotation - 90˚ Elbow extension/supination
Wrist and finger extension but t his is usually not necessary.
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3c. Multistructural - Reduced Closing with Neural Tension Dysfunction
Localised closing at appropriate level
Add MNT1
Perform ILF and/or glide the neck contralaterally whilst performing a closing movement and the patient performs, elbow, wrist and finger extension.
A localised closing manoeuvre is (ILF) applied to the appropriate spinal segment and the MNT1 is executed by the patient.
Mechanical Interface - reduced opening dysfunction
General principles
The techniques for the reduced opening dysfunction actually are similar in some respects to the closing techniques. They start with dynamic openers, since static openers are likely to provoke symptoms. They commence early in the range and progress to the outer range. Generally, lateral flexion is the movement of choice but rotation can also be used.
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Level 3c - Multistructural - Reduced Opening with Neural Tension Dysfunction
Emphasis can be placed on:
Neural Tension Dysfunction and Cervical Joints
The cervical joints are mobilized by using the contralateral hand whilst the scapula is stabilized by the other. The patient performs or holds the MNT1,. Here the force is directed through the contralateral spinal segment toward the correct level. This opens the ipsilateral segment.
Neural Tension Dysfunction and Neck Muscles HyperactivityUpper trapezius and levator scapulae
Here the scapula is stabilised and an upper trapezius stretch is performed whilst the patient maintains extension in the MNT1 position.
Levator scapulae
-flexion
- contralateral lateral flexion
- contralateral rotation
- contract/hold relax, then move nerve when muscle relaxes
Upper trapezius
- flexion
- contralateral lateral flexion
- ipsilateral rotation
- contract/hold relax, then move nerve when muscle relaxes
Sliders -for many types of problemsSliders can be used to relieve pain and improve dynamics in the nervous system at all levels of problem:
• reduce pain at level 1
• reduce treatment soreness between or after treatment at higher level (2, 3)
• do not produce much tension in the nervous system so they are particularly safe
Level 1 - Progression through the levels (continued) - sliders as an option
SlidersThere are two ways of performing the slider, with a. lateral flexion and b. lateral translation.
NEURAL SLIDERS WITH LATERAL TRANSLATION OF CERVICAL SPINE
Proximal- contralateral translation- elbow flexion- wrist flexion
Distal- ipsilateral translation- elbow extension- wrist extension
SLIDERS WITH LATERAL FLEXION
Proximal- contralateral lateral flexion- elbow flexion- wrist flexion
Distal- ipsilateral lateral flexion- elbow extension- wrist extension
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Brachialgia/brachial plexusTreatment progressions
Mechanical Interface
Classify the disorder in terms of opening or closing dysfunctions (reduced or excessive).
Level 1
Progression 1 - static opener
Position – painful side up, scapular elevation/protraction to increase the distance between the clavicle and first rib.
Progression 2 - dynamic opener
As above as mobilisation
Small amplitude and within symptoms
Can emphasize different components - elevation or protraction
The patient can perform this as a home exercise.
Level 2 - dynamic closers
Position - as for opener
Mobilisation - scapular depression/retraction/posterior rotation.
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Opener (costoclavicular space) with Rib Mobilisation and Neural Slider
Breathing (opening and closing) is coordinated with neural sliders
Aim – to improve the dynamics and muscle control around the thoracic outlet in the presence of neurodynamic movements.
Starting position - caudad mobilisation for the first rib is performed with the patient performing components of the MNT1.
Opener + distal slider
Using MNT1 – exhale and depress first rib, elbow extension, ipsilateral lateral flexion.
NeuralLevel 1
Progression 1 - static off-loader
Position as for interface progression 1 and generic off-loader for the brachial plexus.
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Progression 2 - two-ended slider
A) Median nerve
Position - 45° shoulder abduction, scapula stabilized,
Proximal Slider
- contralat. lat. flex./Elb. flex Distal slider – ipsilat. lat. flex./Elb. ext.
‣ perform as a wide amplitude without provocation‣ no scapular depression‣ short of symptoms or minimal symptoms
B) Ulnar nerve
As above except use:
Proximal slider – Elbow extension/contralateral lateral flexion
Distal slider - Elbow flexion/ipsilateral lateral flexion
Level 2
A. Median Nerve – two-ended tensioners
Progression 1
Position
• neck in neutral• arm in approx. 45° abduction or whatever is comfortable for the patient• elbow flexion 90˚• wrist in neutral
Movement
• Elb. ext./contralat. lat. flex.. Make the movement large in amplitude and return to the off-loaded position
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Progression 2
Position‣ neck in neutral, stabilise scapula‣ 90° abduction or whatever is comfortable for the patient‣ elbow flexion 90˚‣ wrist in neutral
Movement – Elbow extension, contralateral lateral flexion.
Make the movement large in amplitude and return to the off-loaded position. Go into a reasonable range without provoking symptoms.
B) Ulnar Nerve – tensioners
Same as the MNT1 neurodynamic techniques except the elbow extension is swapped for elbow flexion.
Progression 1
Position‣ neck in neutral‣ arm in approx. 45° abduction or whatever is comfortable for the patient‣ elbow flexion 90˚, forearm comfortably pronated‣ wrist in neutral
Movement – Elb. flex/contralat. lat. flex. Make the movement large in amplitude and return to the off-loaded position
Progression 2
Position‣ neck in neutral‣ arm in approx. 90° abduction or whatever is comfortable for the patient‣ elbow flexion 90˚, forearm comfortably pronated‣ wrist in neutral
Movement – Elb. flex/contralat. lat. flex.. Make the movement large in amplitude and return to the off-loaded position
Level/type 3a - Neurodynamically Sensitised
A. Median Nerve
Position‣ neck in neutral‣ gentle scapular depression if so desired‣ 90° shoulder abduction‣ elbow extension 90˚ (with supination)‣ wrist and finger extension
Movement - Elb. ext./contralat. lat. flex.
B) Ulnar Nerve
Use elbow flexion, pronation and wrist and finger extension and contralateral lateral flexion
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