Neurodynamic myths

Neurodynamic myths

Shacklock in 2005 very well said that the nervous system is a mechanically and physiologically continuous strusture from the brain till the end terminals in the periphery. 👈

You might have been practicing with ''neurodynamic glides'' or ''neuroglide treatment'' or ''neurodynamic treatment'' but what is neurodynamics really ?

According to Basson et al.2017, ''Neurodynamics is an intervention aimed at restoring the homeostasis in and around the nervous system by mobilisation of the nervous system it self or the structures that surround it''. 👈

Specifically Basson et al.2017 mentioned that NDT (Neurodynamic Treatment) might reduce intraneural pressure, thermal and mechanical hyperalgesia and to reverse increased immune responses after a neeve injury.

What NDT can't do is:

• To test the length and flexibility of nerve tissue
• To test the tension or ''stiffness'' of a nerve
• To tell you whether a nerve is ''trapped''
• Or to be used as standalone tests during a physiotherapy examination

What NDT might be able to do is:

• To test the mechanical sensitivity of nerve tissue

However when therapists use the NDT for their patients they need to consider few things

• All NDT tests might be positive in patients with altered pain state
• NDT tests might provoke all spinals nerve roots or more than one peripheral nerve
• NDT tests could be positive on both side or one side

With that being said Neurodynamics test both the mechanics and physiology of the nervous system.

As David Butler mentioned here 😋, peripheral nerves are long, living and responsive tissues which have encoding, relay and processing functions and can withstand mechanical forces induced by human movement. Information is transmitted along the axons and the dorsal root ganglion acts as the ''brain'' of the nerve through processing and transmitting information from the periphery to the spinal cord.

Once again thanks for reading 👌

Arty

Anatomy Review - The Thoracic and Lumbar Spine (video)

Lets start the day by reviewing some of the basics around Thoracic and Lumbar Spine anatomy structures. This is video is created by Kenhub

A recap of Low back Pain (video)

As World Spine Day approaches ( 16th Oct. 18 ) ... let's have a recap on Low Back Pain via this useful video by Mike Evans.

Midsubstance Tendinopathy Infograph

(from link)

Smart infograph and things to look out, from Clinical Edge's David Pope, when possible midsubstance tendinopathy occurs.

How do nerves work ?

Source from https://www.youtube.com/watch?v=uU_4uA6-zcE

Sports hernia and pelvic rehab

(picture)

Hi guys !

It's that time where we do a quick exploration of another MSK topic and its management from a physio-point of view. It has been long since my previous blog but this has been due to a good cause as I am currently undergoing an OMT diploma in the University of Birmingham. Sooo more great stuff to come through !

Recently, I have had the chance to treat a post-op inguinal hernia patient.  The inguinal hernia is known with multiple nomenclature such as Sports Hernia (SH) or Gillmore's groin. However they all share common clinical characteristics. I am not going to discuss about the relevant anatomy or pathophysiology, though you can find further information by pressing this link !

I will mainly touch on some key study findings which I think  are important when focussing on the pelvic rehabilitation of such cases.

Core stabilisation exercises are important to increase motor recruitment of the Transverse Abdominis (TrA) and Internal Obliques. These two muscles attach at the anterior iliac spine and inguinal ligament providing anterior and superior pelvic stability though, decreasing  inferior pubical control through distraction. Thus, pelvic muscle activation seems to be a logical theory where the pelvic floor muscles provide compressive forces to the inferior pubic symphisis (PS) and thus forming a stable pelvic ring. This theory seems to be achievable via pelvic floor strengthening which can allow stability during the shear forces at kicking, landing and twisting, especially during sport (increased forces !).

(picture from Yuill et al. 2012)

The study by Cowan et al. (2004) depicted a significant decrease in the activation of TrA (via EMG) during an Active Straight Leg Raise (ASLR), in patients with long standing groin pain compared to a control group. They found no significant difference in the activation of Internal / External Oblique (IO/EO), Rectus Abdominis (RA) and Rectus Femoris (RF). Thus once could speculate that TrA strengthening could actually improve TrA motor recruitment during ASLR and potentially during multidirectional tasks as in sport.

However, there were some major limitations of this study making it hard to generalise its findings to post-operative inguinal patients.

Firstly, they excluded any lower abdominal surgery or inguinal hernia patients. Nevertheless, further studies could include such cases or focus only in these cases since a SH may affect the oblique core activation and hip isokinetic strength (link).

Secondly, the authors tested the subjects only during ASLR which is a non functional test. Lumbar pertubations can occur as well apart from pelvic rotations. Thus, TrA activation could not be directly attributed to the pelvic movement.

Furthermore, the researchers examined only the symptomatic side, though the decreased TrA recruitment could be bilateral. Lastly there was a variable sample selection and placement of fine electrodes which could be the reason for the variable temporal responce in this study.

Another study by Yuill et al. (2012) showed good results after a conservative 8wk treatment of 3 sports related hernia cases. It consisted of manual / physical therapy and exercise which included pelvic stabilisations. Despite the clear treatment protocol and the improved pain outcomes it is very hard to generalise these findings due to methodological flaws and the variation in the treatment modalities that were used.

To conclude, pelvic stabilisation exercises might prove fruitful in decreasing pain and improving overall function and return to previous activities or sport via correction of stability and biomechanics of the pelvic ring.

As always, thanks for reading !

Art.

Happy New Year 2018 !

Created with Klex

Chronic pelvic pain and physical therapy

                                                                       (picture source)

As 2018 is approaching, new challenges, opportunities, ambitions, connections and dreams begin to take form ! New Year means new things in life either good or bad. We reflect from the past and we plan for the future. Anything new is welcome ! I hope that everyone finds true meaning for the new year as we leave 2017 behind us.

This last blog is based on Male Pelvic Pain.

Few months ago I completed a very informative course on Mens Health and Pelvic Pain. It was  instructed by Ruth Jones and introduced by Gerard Greene.

Chronic Idiopathic Pelvic pain in men is very common and if left untreated can cause serious issues in their life quality. Likely physiotherapy can help to treat pelvic related symptoms and encourage this population to take in charge of their situation through certain exercise and pain relieving techniques.

Physiotherapy including manual therapy, stretching and strengthening exercise, biofeedback and neuromodulation can help at alleviating chronic pelvic pain in male population. According to Masterson et al. 2017, the above modalities leave promising results for further facilitation of idiopathic pelvic pain for men experiencing it more than 3 months.

Specifically they have included 10 men with no history of prostatitis, trauma, infection, epididymitis or post urinary incontinence and prostatectomy. From these 50% showed statistically significant improvements with the above interventions based on GUPI ( Genitourinary pain index ) which is the modified NIH - CPSI ( National Institude of Health - Chronic Prostatitis Symptom Index ).

Despite the above results, further research is needed to identify which subgroup of men with CPPS can benefit the most from the above type of treatment.

Many thanks for reading, ✊

And...

Happy Christmas and New Year people 🙏!

Art.

Reducing knee loading after ACL injury

The study by Pollard et. al (2017) has investigated the kinematics and kinetics during the drop-landing test. They might have confirmed that through introducing the PEP ( Prevent Injury and Enhance Performance) program can reduce the incidence of ACL injury. This was reasoned by the fact that the person is using a hip strategy to prevent the increase in knee loading. 

The study included 30 female soccer players. Pre and posttraining measurements were taken via a biomechanical assessment of knee joint kinematics and kinetics before and after a 12 week ACL injury prevention program. Each measurement took place 2 weeks before and after the pogram.

Subjects were found to be enough to show statistical significance and clear exclusion criteria were met (1) no history previous ACL injury (2) previous injury which could result in ligamentous injury in the ankle, hip and knee (3) other medical / neurological condition that could impair proper landing (4) previous participation in ACL injury prevention program.

Clear information was given with regards to their biomechanical analysis of kinematics and kinetics where they used an 8 camera, 3D motion system and 2 separate force plates.

Results depicted a decreased knee extensor moment but no significant change in hip extensor moment. Despite an increased hip extensor energy absorption a statistical change was not measured in the knee extensor energy absorption. Knee/hip extensor moment and energy absorption ratios were decreased post-training.

They have concluded that the reduction of ACL injury can be attributed to above biomechanical mechanism ( decreased knee/hip extensor moment and energy absorption ratio can ). Introducing, a hip strategy through a PEP program can prevent occurence of such knee injury.

Movement Control and Pain

Pain has always been the focus of attention when it comes to treatment. Soft tissue massage, Spinal manipulation , joint mobilisations,  acupuncture, foam rolling and other techniques have been used to heal muscles, joints and tendons.

All the above work, in their own way, as novel impulses to our bodies making us focus the attention on the problem and feel better. Although they all work well, in some cases the problem with the above interventions is that they don't last.

Creating distractions via movement can produce new body pathways to feel and move better in the long term. This is not enough though. It is important that this movement is based on focussed attention, graded exposure, relevancy, motivation and play !

This can promote plasticity necessary for remembering old movement habits and creating new ways to move. Movement is a habit , skill that can be forgotten and sometimes a threat. If you move only through a certain pattern then all other are forgotten ( but not erased ! ). This is directly related to improving pain , disability and performance ( link ).

Sooo ... what is the difference between you and Lebron James ?
Tons of motrol control my friend , except if you've reached his skill and ability !

Lebron's workouts have been focussed on attention , coaching , motivation , challenge and fun.

Thanks for reading.

Art.

References

1. Todd Hargrove (2014), A Guide to Better Movement ''The Science and Practice of Moving with More Skill and Less Pain''.

The TFCC injury

The Triangular fibrocartilage complex (TFCC) is a group of soft tissues that provides support , load transmission and absorption between the carpal bones and the ulna. Also it stabilises the distal forearm (radius & ulna) during a gripping or rotational movement of the forearm. 

(picture link)

Anatomy

The origin involves the dorsal and volar radioulnar ligaments at the sigmoid notch of the radius. The insertion consists of the dorsal and volar radioulnar ligaments which converge at the base of the ulnar styloid process.

The Triangular fibrocartilage complex is formed by the soft tissues below

• The Dorsal and Volar Radioulnar ligaments (RULs)
• the Central Disc (CD)
• the Meniscus Homolog (MH)
• the Ulnolunate and Ulnotriquetral ligaments (UL & UT)
• the Extensor Carpi Ulnaris subsheath (ECU)

                                                                                                       (picture link)

The Blood supply

The periphery is vascularised by 10-40%

The central portion is avascular

It is very important to mention that the RULs are the main stabilisers of the DRUJ (distal radioulnar joint). There are superficial and deep fibers providing support during rotational movements with current dispute over which of them tighten during pron/supination

( superficial and deep fibers , picture link )

Common Signs

• Pain at the ulnar aspect of the wrist (just above the flexor carpi ulnaris)
• Pain with side to side movement of the wrist
• Painful gripping
• Swelling in the area
• Painful clicking

Causes

The injury of the TFCC can be traumatic (Type I) or degenerative (Type II)

Most common traumatic cause of injury is with the hand outstreched or during excessive rotation of the wrist. However, a traction force to the ulnar wrist might cause this type of injury. It affects mostly athletes in racquet or bat sports as well as gymnasts.

The degenerative injury occurs with time and age, mostly in people over 50 hovewer, it has been found that people can acquire such injury when in their 30s. This injury is associated with a positive ulnar variance or ulnocarpal impaction. Type II TFCC tears can also be caused in people with inflammatory diseases such as rheumatoid arthritis or gout.

Diagnosis

Diagnosing should start with careful examination of the wrist. It should be followed by an X ray to excluded any possible wrist fracture. The MRI provides the most reliable imaging to observe the extent of the TFCC tear as there are mildly useful provocative tests for diagnosing such an injury (link)

Management Non surgical options These can include the use of NSAIDs , CS injections and immobilisation. Immobilisation can take place via a splint, cast or wrap (favourable). There are few techniques that might help however I ve found that gently taping round the wrist  (check for P+Ns, hand / finger colour change after the application in case of nerve and/or blood vessel compression) might prove effective in the acute type I injury (link).Anecdotal Weight bearing on a scale might be a pain assessment tool for people who are doing a lot of hand bearing activities. There is no evidence on the effectiveness of manual therapy in such injuries apart from a case study of wrist bracing (link). Surgical options These include different methods depending on the extent of the TFCC tear (the classification of TFCC tears can be found here, link). Arthroscopic debridement Arthroscopic repain Open surgical repair If you' re interested in learning the literature behind the above then you could check this link. As always, thanks for reading. Art.

Conservative management over knee arthroscopy

Pic: http://thevanguardclinic.com/knee-pain/

Its been a long time again I know 😅 

Yet this recent paper supports once again that conservative methods 🙌 ( exercise therapy and more ) might be more beneficial in the long term ( after 3 months ) management of degenerative knee disease ( joint line / menisci) over knee arthroscopy . There has been an increasing evidence of no actual benefit from other invasive methods as well ( shoulder decompression, spinal surgery and knee osteoarthritis ) in overall function and pain.

Although, the patient mean age was between 42-62 and 39-64% women ,the above strong evidence by Petersen et. al  could encourage the use of movement over invasive treatments. 

If we could look improvement as a long journey rather than a short term relief then why physiotherapy can't impact for a better function and QUALITY of life ?

Spread the knowledge.

Thanks

Art.

Do you stretch the plantar fascia ?

Recent post from clinical edge (here) inspires thought when it comes to treatment of plantar fasciopathy. Specifically stretching and loading of the plantar fascia should be performed within the tolerance level of the tissue. It also needs to be specialised according to each patient's needs, whether thats the athlete, moderately active or elder person that we talk about.

Interestingly, a 2016 single-blinded trial by Kamonseki et al. (link) shows that either stretching and strengthething or stretching alone might have no difference at all when it comes to pain and overall function.

So .. do you stretch the PLANTAR FASCIA ?

Sex related asymmetries after ACL reconstruction

The study of Di Stasi et al 2015 compared the lower limb mechanics of men and women athletes before and up to six months after an ACL reconstruction (ACLR).

Sample

39 non top athletes were appropriatelly screened as non coping individuals and underwent an ACLR (orthopaedic surgeon used a hamstring autograft or soft tisse allograft).

Intervention

Prior to the operation all participants received a 10 session programme which involved progressive quadriceps strengthening (consisted of a weight-bearing, functional training, neuro-muscular electric stimulation and an isokinetic protocol). 18 from the 39 athletes received also a pertubation training (PERT) as part of another randomised controlled trial. Postop, a physical therapy programme was utilised for the decrease in effusion, strength,range of motion deficits and functional impairments.

Outcomes and measures

Hip / knee joint excursions and knee joint moments were examined.
A 3D camera and a 6 component force plate were used to gather walking gait mechanics

Results

The stydy showed sex related differences in kinematics before and after ACLR. Neither women nor men athletes did not demonstrate statistically significant gait kinematics in the affected limb before their operation. However, women athletes showed better results with the pre operative regime but increased asymmetries after the ACLR. Moreover, both female and male athletes did not continue to demonstrate improved mechanics in the post op period compared to the pre operative programme and adaptations to gait mechanics occured in both limbs.

Conclusion

Rehabilitation efforts should be unique and focus differently in men and women athletes. The effects of current neuromuscular training post ACLR are still under investigation since athletes are still on high risk of a second ACL injury (same or contralateral limb).

Choose to move

Move for a better life.

Physiotherapy Association of British Columbia

Source:https://www.youtube.com/watch?v=e86mDnK1Rgk

Kinesiological Taping and shoulder impingement

Hi Guys !

I know it has been a while since my first post but better be late than never. Recently, I was very eager to find out the results of Taping (...and YES I am one of those that love some bits of Taping, specially Dynamic) in patients with shoulder impingement problems.

The reason behind my search was ''Ms A's'' shoulder impingement (SI) problem. She's been experiecing moderate to severe shoulder pain, mainly at overhead activities. Soft tissue / Joint mobilisations, Exercise, hot and cold therapy have provide her minimal benefits for her. Due to the above I started using my Tape to provide some proprioceptive feedback and positional correction of her shoulder joint. In terms of pain during movement this intervention was beneficial immediatelly and for 2-3 days after as she mentioned. So what are the results of Taping in SI syndrome ?

A paper by Shakeri et al. (2013) http://www.ncbi.nlm.nih.gov/pubmed/24377066 investigated the effectiveness of Kinesio Tape on pain and pain free shoulder ROM (range of motion) in patients with SI syndrome.

The above trial had a clearly focused issue which was addressed for the first time. It was a randomised (block randomisation), double blinded (assessor, patients) and placebo controlled study ! Although concealled allocation was not mentioned, the authors had clearly stated their Inclusion / Exclusion criteria. Both groups were similar at the start of the trial and equally treated since both groups received a K. Tape treatment although the control group with a non effective technique (for more information regarding the particular application see the above link please). Despite the small number of patients there was no drop out at its conclusion (good for result bias !).

Nevertheless, there was no statistically significant difference between the groups when measured for improved pain  ( VAS ) during movement / night , ROM (goniometer) either immediatelly or one week after its application (researchers reassessed /  re-applied K.Tape after 3 days). However significant results for the experimental compared to the control group were measured after an immediate application in pain during movement / night.

Why ''A'' found it beneficial only for 3 days after ? Would a different technique provide longer / better results ?

Cheers

Arty

Treating peripheral in chronic msk conditions ? Rethink...

Mskspot is purely created for reflection in various issues of current MSK physiotherapy management. However, it will be an open space for discussion, new ideas as well as a place where practitioners can read about multiple hot topics related to msk practice and research.

Mskspot is hungry for exploring the latest research and its starting with a post where I think most therapists are troubled with...CHRONIC PAIN

A recent research paper by Pelletier et al. (2015) [1] discussed the issue of neuroplasticity in the CNS and how this might correlate into the rehabilitation of chronic MSK conditions.

We know that traditional intervetions are lacking the ability to successivelly address chronic MSD  symptoms [2]. Effects of the above treatment type are only valuable in the short term. Consequently they cannot target the above population, resulting in perpetuation of their problems and lower life quality.

Chronic MSD might be related with hyperalgesic, allodynic and other altered sensations. However, hyperalgesia is a normal responce of the injured tissue where it protects itself from further damage [3]. According to Woolf, JC. this is a responce related to the structural-pathology paradigm and where traditional interventions are more valuable. Consequently, we need better interventions to improve chronic symptoms.

Cortical reorganisation in the S1 is reported in patients with Phantom Limb pain (PLP), Chronic Lower Back pain (CLBP), Complex Regional Pain Syndrome (CRPS) and many more [4-7]. Distortions of body image and perceptual changes have also been reported in the above studies in which the changes involved abnormal size, shape, swelling and position. Nevertheless, perceptual changes may arise not only from an abnormal sensory modulation but from conflicting  motor and sensory inputs as well [8]. Perceptual changes might have functional implications. That might occur when there is not an agreement between sensory and motor input which might lead to increased pain responces and sensory disruptions [9].

It is important to mention that modulation of the shape / size of a limb (Visual distortion) might produce better results in tactile acuity and pain [10,11].

What is also very interesting to mention is that motor skill learning exercises and not traditional exercise programmes might generate better results.  That is evident in a study in where there was a reinstatement within the cortical representation of the M1 as well as an improved EMG activation pattern (multifidus, transverse abdominis, iliocostalis lumborum) in individuals with Chronic Low Back Pain. [12-14]. However, repetition should occur in skilled movement patterns since repetitions in any un-skilled movement does not lead to neuroplastic alterations in the M1 [15].

We also know that nociceptive / neuropathic stimuli, altered cutaneous and proprioceptive input can affect sensorimotor organisation in the CNS which in turn affect perception, pain, and motor control. However if the above changes remain for too long then they can lead to permanent adaptations to the peripheral msk structures [16].

Prolonged use of the affected area might lead to a vicious cycle where immobility, cortical representation and atrophic changes strengthen each other [1].

Can't we deal better with chronic pain ? Which intervention  and how can we use it best to improve overall function ? Does it work for all chronic conditions ?

Food for thought...




 [1] Pelletier,R., Higgins.J., and Bourbonnais, D. (2015) Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders (2015) 16:25

[2] Wand BM, Parkitny L, O’Connell NE, Luomajoki H, McAuley JH, Thacker M, et al. Cortical changes in chronic low back pain: current state of the art and implications for clinical practice. Man Ther. 2011;16:15–20.

[3] Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152:S2–15.

[4] Moseley GL, Parsons TJ, Spence C. Visual distortion of a limb modulates the
pain and swelling evoked by movement. Curr Biol. 2008;18:R1047–8.

[5] Mancini F, Longo MR, Kammers MP, Haggard P. Visual distortion of body size modulates pain perception. Psychol Sci. 2011;22:325–30.

[6] Bray H, Moseley GL. Disrupted working body schema of the trunk in people with back pain. Br J Sports Med. 2011;45:168–73.

[7] Moseley GL, Flor H. Targeting cortical representations in the treatment of chronic pain a review. Neurorehabil Neural Repair. 2012;26:646–52.

[8] Bailey J, Nelson S, Lewis J, McCabe CS. Imaging and clinical evidence of sensorimotor problems in CRPS: utilizing novel treatment approaches. Journal of Neuroimmune Pharmacology. 2012;8:564–75.

[9] McCabe C, Haigh R, Halligan P, Blake D. Simulating sensory–motor incongruence in healthy volunteers: implications for a cortical model of pain. Rheumatology. 2005;44:509–16.

[10] Preston C, Newport R. Analgesic effects of multisensory illusions in osteoarthritis. Rheumatology. 2011;50:2314–5.

[11] Osumi M, Imai R, Ueta K, Nakano H, Nobusako S, Morioka S. Factors associated with the modulation of pain by visual distortion of body size. Front Hum Neurosci. 2014;8:1–9.

[12] Danneels L, Coorevits P, Cools A, Vanderstaeten G, Cambier D, Witvrouw E, et al. Differences in electromyographic activity in the multifidus muscle and the iliocostalis lumborum between healthy subjects and patients with sub-acute and chronic low back pain. Eur Spine J. 2002;11:13–9.

[13] Sihvonen T, Lindgren K, Airaksinen O, Manninen H. Movement disturbances of the lumbar spine and abnormal muscle electromyographic findings in recurrent low back pain. Spine. 1997;22:289–95.

[14] Tsao H, Druitt TR, Schollum TM, Hodges PW. Motor training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain. J Pain. 2010;11:1120–8.

[15] Remple M, Bruneau R, VandenBerg P, Goertzen C, Kleim J. Sensitivity of cortical movement representations to motor experience: evidence that skilled learning but not strength training induces cortical reorganisation. Behav Brain Res. 2001;123:133–41.

[16] Mansour A, Farmer M, Baliki M, Apkarian AV. Chronic pain: the role of learning and brain plasticity. Restor Neurol Neurosci. 2014;32:129–39.