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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. Aimtomakeneurodynamicscentralandessen8altoNeurology
-Goal:toprovidemechanicallypermissiblemovement2. Biopsychosocialconsidera8ons
-allpartsareimportanttotreatment3. ConfidentCliniciansarecri8cal
-Pa8entsrespondtoconfidentclinicians4. Educa8onistherapy-Neurodynamicsenrichestherapy
-educa8onisespeciallyimportantwithpainpa8ents;explainthecon8nuumofthenervoussystem;oddsymptompaLernsarenotsurprising;“Nothingaboutyourcondi8onsurprisesme.”
5. RecognizetheNeuroimmunecascade-notjustneuro,butneuroimmune;ac8vatedinflamma8on
6. ConsiderCNSmobiliza8on-cordmovement;meningesmovement;CSFflow
7. ConsiderNeurodynamicswithreasonedjudgment(incontextofclinicalexam)-s8ff,s8cky,stuck–mobilizethenervoussystem;
Thereisan“awakeningtoNeurodynamics”-DavidButler,NVMT2017
Pa#ent
Social
ScreeningExamina#on
ClinicalExamina#on
Educa#onImaging
History/Observa#on
Bio/Patho/Physiological
Psychological
Assessment
TreatmentPlan
Re-Examina#on
SpecialTes#ng(Neurodynamics)
ClinicalExamina8on
TakeHomeMessage:Neurodynamictes#ngisasmall(butvital)partoftheoverallclinicalexamina#onpicture.
Research:Reliability/Validity
Outcomes
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Anatomy/Biomechanics
NeurodynamicTreatment
NeurodynamicTes8ng
• HistoryofND• MacroAnatomy• MicroAnatomy• Biomechanics• Rela8ontoTes8ngand
Treatment• RecentFindings
NVMT2017
1929-NerveExtensionupperlimb-Bragard
1959-UpperLimb-VonLaniz&Wachsmuth
1960-1980-AdverseMechanicalTension-Breig
1970’s-sensi8vityofNS-Grieve;Slump-Cyriax/Maitland
1980’s-AdverseNT-Butler;Maitland;Elvey;
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HistoryofNeurodynamics
2800BC?–Imhotep
1982-Pain-MelzackandWall
1991-Mobiliza#onoftheNS-Butler
1880’s-NerveStretching-Cavafy,;Symington;Marshall
1979-BrachialPlexusTensionTest(ULNT)-Elvey
1960-1980-NerveCompression/Tension-Rydevik,
Sunderland,Olmarker,Lundborg
1993-LNRDisp.-SmithandMassey
2005-ClinicalNeurodynamics-Sequencing-Shacklock
2012-NDValidity-Nee,Coppieters,Schmid
2011-TibialNerveFluidDynamics-Brown,Gilbert
2007-LNR-SLRDisplacementandStrain-Gilbert
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HistoryofNeurodynamics
2017–Neuroimmune;Rx-Coppieters,Schmid
2017-Beyond-
“NDAwakening”-Butler
2008-TreatmentEfficacy-Ellis;InVivoUS-Dilley
2000-Sensi#veNS-Butler
2013-EntrapmentNeuropath-SchmidandCoppieters
2015-CNRDispl/Strn-ForaminalLigs-LohmanandGilbert
2015-FluidDisp-Gilbert,Sobczak
2000-NDTes8ngReliability-Coppieters
Macro (Gross)
Anatomy: Median and
Ulnar Nerves
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ClinicalApplica8on:Pathoanatomy• UpperLimbNeuralPathoanatomy
– AxillaryArch• Anomalousbandsofthela8ssimusdorsimuscle• BandscompressedtheunderlyingneurovascularstructuresduringABD/ERincludingtheaxillaryvessels,musculocutaneous,
median,andulnarnerves.• Similarreportshaveshownthistypeof8ssuetoaLachtocoracoidprocess,pectoralismajor,andcoracobrachialismuscle.• Authorssuggestclinicalmanifesta8onsimilartoTOSsymptomsandsuggestaclinicaltestusingABD/ERandpalpa8on.
11SmithAR,CummingsJP.TheAxillaryArch:AnatomyandSuggestedClinicalManifesta#ons.JOSPT,2006;36(6):425-429.
ClinicalApplica8on:PathoanatomyUlnarNerve• UpperLimbNeuralPathoanatomy
– ArchadeofStruthers
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Macro (Gross) Anatomy:
Radial Nerve
ClinicalApplica8on:PathoanatomyMedianNerve• UpperLimbNeuralPathoanatomy
– LigamentofStruthers– PronatorSyndrome– CarpalTunnelSyndrome
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ClinicalApplica8on:PathoanatomyRadialNerve• UpperLimbNeuralPathoanatomy
– Fractureofhumeralshal-radialnerveinjury– RadialTunnelSyndrome-ArchadeofFrosche
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ClinicalApplica8on:PathoanatomyRadialNerve• UpperLimbNeuralPathoanatomy
– Fractureofhumeralshal-radialnerveinjury– RadialTunnelSyndrome-ArchadeofFrosche(Calavert,2009)
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Macro (Gross) Anatomy:
Radial Nerve
Macro (Gross) Anatomy:
Tibial and Common Fibular Nerves
Moore&Dalley:.Ch5;NeLer:plate528
Gilroy:Fig29.1-29.28
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Summary:LowerLimbInnerva8onDistribu8on:Scia8cand
PosteriorCut.Nerveofthe
Thigh
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Moore&Dalley:.Ch5;NeLer:plate529
Gilroy:Fig29.1-29.28
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Summary:LowerLimbInnerva8onDistribu8on:TibialNerve
Moore&Dalley:.Ch5;NeLer:plate530
Gilroy:Fig29.1-29.28
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Summary:LowerLimbInnerva8onDistribu8on:
CommonFibular(Peroneal)Nerve
Dermatomesvs.CutaneousInnerva8on
Moore&Dalley:.Ch5;NeLer:plate470;530Gilroy:Fig29.27-29.28
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TheAnatomyofthePNS
• PeripheralNervousSystem(PNS)Layout:– Mechanicalinterface
• “con8nuum”–Butler,1989• “container”–Shacklock1995• “nervebed”consistsofanythingthatliesnexttothenervoussystem(tendon,muscle,bone,IVdisc,ligaments,fascia,bloodvessels)
– Neuralstructures• Actualnerve8ssue
– Innervated8ssues• Theactual8ssueinnervatedbytheneuralstructures
Butler,1988;Shacklock,1995;200522
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ThemicroAnatomyofaNerve
• Endoneurium– Surroundsaxons
• Perineurium– Surroundsfasicles
• Epineurium– Surroundsnerve
• Mesoneurium– Outsidetheepineurium
Butler199123
TheAnatomyofaNerve• BloodFlow
1. Extrinsic2. Intrinsic
• 2a-superficialintrinsicarterioles
• 2b-interfasciculararterioles
• 2c-endoneurialcapillarynetworks
3. Vascular“coils”4. Spinaldura5. Rootsheath
Nordin&Frankel,Fig5.5;Olmarker199124
Biomechanics-MovementofNerves• Mechanicalfunc8onsofallnerves:
– Tension• Perineurium–18-22%strainbeforefailure(Sunderland&Bradley,1961;Sunderland1991)
• Leadstodecreaseofcross-sec8onalareaand“transversecompression”– Sliding
• Movementofneuralstructureswithinthecontainerornervebed(McLellan&Swash1976;Wilgis&Murphy1986)
• AKA-“excursion,”“displacement,”or“gliding”• Longitudinalortransversemovement;dissipatesstrain• Mesoneurium-slidinginthenervebed;• Interfascicularepineurium-interfasciculargliding;(Millesi1990)
– Compression• Bone,tendon,muscle,fascia,etc.,pressingonthenerve
Shacklock200525
MovementofNerves• Movementofjoints
– Relatedtotheposi8onofthenervetothejointaxis
– “convergence”-movementofthenerve8ssuetowardthejointthatismoved/movedmost.(Smith1956;McLellan&Swash1976)
– Bendingofajointàtensionandcompressionofnerve
• Movementoftheinnervated8ssues– Causeselonga8on;“sensi8zingmaneuvers”
• Movementofthemechanicalinterface– Opening(êpressure)vs.Closingmechanisms
(épressure)• Theseconceptsareimportantforclinicaldiagnosis
Shacklock200526
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ULNTTension(Strain)
KleinrensinkGJ, et al. Upper limb tension tests as tools in thediagnosis of nerve andplexuslesions.Anatomicalandbiomechanicalaspects.ClinBiomech(Bristol,Avon).2000;15(1):9-14.
• Mediannervebiascausedthemostten>on(strain)
• ‘itisunlikelythatanyofthesixtestsstudiedwillselec>velystressspecificcervicalnerveroots’
• ‘So,basedontensileforcedistribu>onandconsideringbothsensi>vityandspecificity,exclusivelythemediannerveULTTandULTT+canbeseenasspecificnervetensiontests’
UpperLimbNDMDisplacementandStrain
CoppietersMW, Alshami AM. Longitudinal excursion and strain in themedian nerve duringnovelnerveglidingexercisesforcarpaltunnelsyndrome.JOrthoRsch.2007;25(7):972-80.
• Slidingtechniqueelicitedthemostdisplacementandtheleaststraininthemediannerveatthecarpaltunnel.
• AllowingmovementofotherjointsduringNDMleadstolessstrain.
• Thisslidingstrategyisrecommendedforuseinordertomaximizedisplacementbutminimizestraintothenerve>ssue.
TheNerve“Con8nuum”• Thenervoussystemisalongorgan
– Movement(gentleoraggressive)hasaneffectonthenervoussystem/path.Importantforclinicaltes8ngandsequencing.
• Structuraldifferen8a8on– Performedduringallneurodynamicteststodeterminewhetherthenervous8ssueisinvolvedinthepathology(i.e.,apaingenerator).
– Differen8a8onoccurswhennerve8ssueismovedinaregionofinterestwithoutmovingthemusculoskeletal8ssuesinthesameregion.
– **Changeinsymptomswiththedifferen8a8ngmaneuvermayindicateaneuralmechanism.
Butler,1989,1991;Shacklock200529
NerveMovementPaLerns• Jointmovementleadstomovementofthenervesclosesttothemovement
(force)firstandthen…tensionpassestothemoreremotenervepathinadelayedfashionasthemovementtakesuptheslack.
• Mid-range,slackistakenupandslidingoccursofthenervewithinitsnervebedorcontainer.
• Endrange,tensionensuestotheen8resystem.• Applica8ontotreatment
– Ifthedesiredmechanicalinputissliding-applylargeamplitudemovementinmid-range.– Ifthedesiredmechanicalinputistension-applysmalleramplitudemovementattheend
range.– Or,combinethetechniques-largerangeamplitudeuptotheend-rangeofmo8on.– Or,incorporateminimalamplitudemovementtosimplytakeuptheslackinthenerve…
early-range.– Olenthepa8ent’ssymptomswillindicatewhichmobiliza8onapproachismost
appropriate…don’tworkintothepainfulmovement.
Shacklock200530
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PhysiologyofNerveTissue• Mechanicsandphysiologyofthenervoussystemhavebeendescribedas“interdependent.”ThisconceptformsthebasisforneurodynamicsaccordingtoShacklock.Whilenotdescribedthisspecificmanner,Butlerdiscussednervephysiologyaswell(1989and2000).
• Thisisanimportantconsidera8oninthatwecannotconsideronlymechanicaloronlyphysiologicalaspectsofneural8ssueinclinicalprac8ce.Wemustconsiderboth.
Shacklock200531
PhysiologyofNerveTissue• “Improvingphysiologythroughtreatmentofmechanicalfunc>onisalsoanintegralpartoftheconceptofneurodynamicsandcanbehighlyeffec>veinbothdiagnosisandtreatment.Releasingpressureortensioninanervecouldimproveitsphysiologyandclinicalcorrelates.”–Shacklock,2005– Notethemechanicalfocustothephysiologicalbenefit.Isitpossiblethephysiologicalbenefitbyitselfmaybesufficienttoleadtoposi>veclinicaloutcomes?
Shacklock200532
IntraneuralBloodFlow• Bloodflowisredundantanddesignedtomaintainflowinlightofmechanicalinfluence/stress.
• Changesinbloodflow,especiallysecondarytoinflamma8on,maycontributetopainfulresponsetoneurodynamictes8ngwithouttheobjec8vefindingsofchangesinconduc8onvelocity.
• Vasodila8on-nocicep8ve(Cfibers)àincreaseofintraneuralbloodflowàinflamma8onandedemaàmayleadtofibrosis
• Vasoconstric8on-sympathe8cNSàreduc8onofintraneuralbloodflowàoverac8vityofsympathe8csmayleadtodecreasedbloodflowtonerve
Shacklock200533
MechanicalStressonIntraneuralBloodFlow• Movementhasaneffectonintraneuralfluidmovement(Browne,Gilbert,etal2011;
Gilbertetal2015a;Gilbertetal2015b;Gilbertetal2017(unpublished);Sobczaketal,2015(submiLed)
• Movementisexpectedtohaveaneffectonintraneuralbloodflow.• Tension-reducesintraneuralbloodflow
– 8%elonga8on-diminishedvenularflow(Lundborg&Rydevik1973)– 15%elonga8on-cessa8onofarterialandvenularflow(Lundborg&Rydevik1973)– Timedependent-6%strainfor1hourdecreasesconduc8onby70%;longerdura8on=
longerrecovery8menecessary(Lundborg&Rydevik1973)• Movementhasaneffectonneuralbloodflow.• Compression-30-50mmHgleadstohypoxia,decreasedflow,conduc8on,and
axonaltransport(Gelbermanetal1983;Ogata&Naito1986,Remeletal1999)
• Sameoccursinnerveroots(Olmarkeretal1991;Rydevik1993)• Tensionandcompressioncanbecumula8veineffect-“doublecrush” (Lundborg&Rydevik1973)
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MechanicalStressonIntraneuralBloodFlow-Physiology• Inflamma>onàintraneuraledemaàêfunc>on,bloodsupplyand
venousdrainage.(Butler1989;Butler2001)• “physiologymustbeincludedinmanagementofmechanicalproblemsin
thenervoussystem.”-(Shacklock2005;Shacklock1995a)
• Clinicalapplica8onnote:thesewerebigstepstorecognizetheroleofphysiologyintherecoveryofnervepathology.However,thisiss8llinthecontextoftherebeinga“mechanicalproblem”tomanage.Isitpossiblethattheproblemischemical,fluid,pressure,neuroimmunerelatedinsteadofmechanicalalone?Orthatanervecouldadapttothemechanicalchallengeifthechemical/pressureissueswereresolved?
Shacklock200535
Inflamma8onandPNS
Shacklock200536
LundborgG,MyersR,PowellH.Nervecompressioninjuryandincreasedendoneurialfluidpressure:a‘‘miniaturecompartmentsyndrome’’.JNeurolNeurosurgPsychiatry1983;46:1119–24.BrownC,GilbertKK,BrismeeJM,JamesCR,Smith,MP,SizerPS.Theeffectsofneurodynamicmobiliza8ononfluiddynamicswithinthe8bialnerveattheankle:Anunembalmedcadavericstudy.JournalofManual&Manipula>veTherapy,2011;19:26-34.
• SerialNeurodynamicsequences– Shacklocksuggeststhatifthesequencingisdifferent,thenthetestiscompletely
different.– Toppetal,2013suggestsnodifferenceinexcursionorstrain(scia8cor8bialnerves)at
theendposi8onregardlessofthesequencingofthetest.– Neeetal,2010suggestsnodifferenceinstrainandrela8veposi8onbetweendifferent
sequencesofNDtes8ng.However,thepaLernofmo8onandloadingmaychangewithvaryingsequences.
• Considera8on:What’sthegoaloftes8ng?– Todeterminewhethertheperipheralnervoussystem8ssueisinvolvedinthe
pathologicalproblematsomelevel.– Isitpossibleforsomepeopletoresponddifferentlyandtherefore,isithelpful(inlight
ofahistorythatmightleadustothinkofneurogenicinvolvement)toapproachtheclinicaltes8ngfromavarietyofdirec8ons…to“sneakup”onit?Proximalvs.Distalini8a8on?
Shacklock,2005;Toppetal,2013;
37NeeRJ1,YangCH,LiangCC,TsengGF,CoppietersMW.Impactoforderofmovementonnervestrainandlongitudinalexcursion:abiomechanicalstudywithimplica8onsforneurodynamictestsequencing.ManTher.2010Aug;15(4):376-81.doi:10.1016/j.math.2010.03.001.Epub2010Mar31.
Rela8ontoNeurodynamicTes8ng Rela8ontoNeurodynamicTreatmentSummaryofTreatmentRecommenda8ons:• First,donoharm(nonmaleficence);Begentleandgetthepa8entmoving• Treattheprimaryproblem(e.g.,disc,muscle,tendon)thatisaffec8ngthe
nerve• Ifthenerveistheprimaryproblem,thentreatthenerve.• Ifirritable,considersliding;workawayfrompainfulsegment• Iflessirritable,considertensioning;workclosertopainfulsegment• Playwithposi8oningusingoneandtwo-endedapproachestogetthedesired
inputintothesystem• Managereps,sets,dura8on,etc.basedonpt.responseanddesiredoutcomes.• Considerexternalsol8ssuemobiliza8onasadjunctRx• Neeetal2013aand2013b-Baselineindica8onsmayhelppredictefficacy,
(absenceofNPpain,olderage,smallROMdeficits);andRCTsupportsuseofNDMobiliza8onwithnoadverseeffects
Butler,1991;Butler,2000;Shacklock,200538
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TheoryofNeurodynamicSummaryTes8ngandTreatment
ReviewofNeurodynamicTes8ng:• Alerthesystemsreview(CP,NM,Msk,Integ,etc.)screening.• AlertheBasicClinicalExam(AROM/PROM/RROM)• SpecialTes8ngtoruleinorout(NDtes8ng)-Sequencing• TissuespecificdiagnosisReviewofClinicalTreatment:• Treatmentaimedattheproblem(e.g.,disc,nerve,etc.)• Tissuespecific-slide/tension,etc.• Restorefunc8onalability-(posture,strength,stretch)• Educa8onanddailymanagement
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• 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).
RecentFindingsandMyNeurodynamicStory
• 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.
• Clinicalapplica8onofULNTTisnotlimitedtothebrachialplexusorwithinupperextremity.
• Providesmechanicalfounda8onforprovoca8veneurodynamictes8ngoftheroots.Kleinrensink,2000couldnotmeasureroots
– Bolsterstheexis8ngclinicalresearchthathasvalidatedULNTTforsymptomreproduc8oninpa8entswithneckpainandradiculopathies(Sandmark&Nisell,1995;Wainneretal.,2003)
• Maybeusefulintheexamina8onofpathologyofthecervicalnerveroots
• Clinicalimplica8onsofforaminalligamentsareunclear
– Hypothesizedtheypalyaroleincompressionpathologies(Nowicki&Haughton,1992;Parketal.,2001)
– Foraminalligamentsappeartoprotectcervicalnerverootsbylimi8ngtransferofstraintoproxroot
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FluidDynamics-PeripheralNerveTissue-Scia8c(invitro)-JMMT2015
FluidDynamics-TibialNerve(insitu)-JMMT2011
Fluid Dispersion with Neurodynamic Mobilization
20.6520.84
21.77**#
2020.220.420.620.8
2121.221.421.621.8
22
Pre-mobilization Post-mobilization
Time
Long
itudin
al Dy
e Sp
read
(mm)
Control
Experimental
15.3
16.3
1515.215.415.615.816
16.216.416.616.817
Pre Post
Distan
ce(m
m)
Time(premobiliza#ontopostmobiliza#on)
Rela#veFluidMovementComparedtoBaseline
Experimental
FluidDynamics-LumbarNerveRoot-(insitu)JMMT2015 NerveTissueFluidDynamics
Seriesofstudiesexaminingthedynamicsofintraneuralfluid:• Scia8cNerve–invitro• TibialNerve–insitu• Lumbar(L4)Root–insitu• MedianNerve-insitu(Inprepara>on;emphasizetensionvs.slide)
• Boudier-RevéretM.,GilbertK.K.,AllégueD.R.,MoussadykM.,BrisméeJ-M.,FeipelV.,SizerP.S.,DugaillyP-M.,SobczakS.,CarpalTunnelSyndrome:EffectofSpecificNeuralMobiliza8ononMedianNerveEdemaDispersion:ACadavericInves8ga8on.BestScien>ficPoster,TexasSocietyforHandTherapy22ndAnnualEduca8onConferenceSanAntonio,March24-26,2017.-PosterPresenta8on.
• CervicalRoots–insitu(datacollec>on)Neurodynamic(mechanical)inputmovesintraneuralfluidalerithasstabilizedover8me.
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NerveTissueFluidDynamics(Pressure)StudyPedigree:• Displacementnotaslargeasoriginallythought…
(Gilbertetal,2007a;Gilbertetal,2007b);perhapsanothermechanismdealingwithintraneuralfluidmechanics;flushing/pumping
• NDMcausesintraneuralfluidtomove:scia8cnervesec8on;8bialnerve,lumbarroot,(Median),(Cervicalroot).
• Nextlineofdirec8onwilldealwithintraneuralpressurechangesassociatedwithneuralmobiliza8on.
• PilotStudy-N=1:IntraneuralpressureofCNRduringULNTincorpora8ngMedianBias
• SignificantatC5andC6• SBincreasedintraneuralpressureatC5butnotC6.• Postersubmission
TheoryofNeurodynamicsSummary-CurrentLiterature
So,whatdowetakeawayfromtheseareasofstudy?1. Anatomy/Biomechanics-structureandfunc8on****
– Nervesaremeanttomovebutdonottoleratetensionandcompressionaswellasother8ssues
2. Pathophysiology-bloodflowandchemicalresponse***– Tension/compressioncanalterbloodflow,axoplasmicflow,andleadtopain,
inflamma8on,andintraneuraledema3. Tes8ng**
– Tes8nghasbeenshowntobevalidandreliableaslongascliniciansfullyexaminepa8ent;1)reproduc8onofpa8entsymptoms;2)changeinresponseresul8ngfromdifferen8a8ngmaneuvers;3)asymmetricalpresenta8on?
4. Treatment*– Seemstowork;notreallysurewhy;mayhavesomethingtodowithmechanicalinput,
butevidenceismoun8ngtosuggestthatthephysiologicalcomponentoftreatmentisbeneficialandmayworkto“pump”outinflamma8onandrestoreappropriatebloodflow.
48
NerveRelatedPainResearchModelMechanical Anatomical/
Physiological Clinical
Engineering(CARL/TTU-ME)
Cadaveric/Animal/Normals(CARL)/(LARC)/(Msk/Bm/PC)
ClinicalResearch(UMC/TTUHSC/Grace)
• Theore8calModeling• Valida8onModeling
• ClinicalTes8ng• Interven8on• Outcomes
Ques#ons:1. Canweimprovepain/func8oninpa8entswithnerverelatedpain?2. Isimprovementinpain/func8oncorrelatedwithnervemovementorfluiddispersion/
changeinpressure?3. Whatparametersofinterven8onprovidethebestclinicaloutcomes?
GrantProgression:1. SPFàSHP20122. SHP2012àCHFound3. SHP2014àNSF4. SHPNicheàR155. R15àR01
Copyright:Gilbert,Sizer,Brismee,Sobczak,Pol,2013
ByornRydevik-ISSLSHongKong TTUHSC/TTU/AUT/UQResearchTeam:
LeltoRight:SuhasPol,PhD;RichardEllis,PT,PhD;KerryGilbert,PT,ScD;StephaneSobczak,PT,PhD;Notpictured:Jean-MichelBrismee,PT,ScD;Phil
Sizer,PT,PhD
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SelectedReferences• Butler,DavidS.(1989).Adversemechanicaltensioninthenervoussystem:amodelforassessmentandtreatment.TheAustralianJournalof
Physiotherapy,35(4),227–238.• Butler,DavidSheridan,&Jones,M.A.(1991).Mobiliza>onofthenervoussystem:CIP>tle.ElsevierHealthSciences.• BrownC,GilbertKK,BrismeeJM,JamesCR,Smith,MP,SizerPS.Theeffectsofneurodynamicmobiliza8ononfluiddynamicswithinthe8bial
nerveattheankle:Anunembalmedcadavericstudy.JournalofManual&Manipula>veTherapy,2011;19:26-34.• BoydBS1,ToppKS,CoppietersMW.Impactofmovementsequencingonscia8cand8bialnervestrainandexcursionduringthestraightlegraise
testinembalmedcadavers.JOrthopSportsPhysTher.2013Jun;43(6):398-403.doi:10.2519/jospt.2013.4413.Epub2013Apr30.• CoppietersMW1,HoughAD,DilleyA.Differentnerve-glidingexercisesinducedifferentmagnitudesofmediannervelongitudinalexcursion:anin
vivostudyusingdynamicultrasoundimaging.JOrthopSportsPhysTher.2009Mar;39(3):164-71.doi:10.2519/jospt.2009.2913.• CoppietersMW,AlshamiAM.Longitudinalexcursionandstraininthemediannerveduringnovelnerveglidingexercisesforcarpaltunnel
syndrome.JOrthoRsch.2007;25(7):972-80.• Côté,P.,Cassidy,J.D.,&Carroll,L.(1998).TheSaskatchewanHealthandBackPainSurvey.Theprevalenceofneckpainandrelateddisabilityin
Saskatchewanadults.Spine,23(15),1689–1698.• Elvey,R.(1979).Brachialplexustensiontestsandthepathoanatomicaloriginofarmpain.InAspectsofManipula>veTherapy.Melbourne,
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