The Sensitive Nervous System Chapter X: Neurodynamic Tests in the Clinic

 This is a summary of Chapter X of “The Sensitive Nervous System” by David Butler. The Tests When assessing neurodynamics, there is a general system that is used including the following tests: Passive neck flexion (PNF). Straight leg raise (SLR). Prone knee bend (PKB). Slump. 4 different upper limb neurodynamic tests (ULNT). I will demonstrate these tests for you in later chapters. Many clinicians when discussing the lower extremity-biased tests deem that maybe only one or two of the tests need to be performed, however this assertion is erroneous. Slump, SLR, and PNF all need to be tested as a cluster. The reason being is that the clinical responses may often differ. This difference is especially noticeable when comparing the SLR and the slump. These two are not equal tests for the following reasons: Components are performed in a different order. Spine position is different. Patients may be more familiar with the SLR, therefore give more familiar responses. The patient is in control during the slump, not in the SLR. The slump is more provocative. Rules of Thumb When testing neurodynamics, here are the following guidelines: 1)      Active before passive. 2)      Differentiate structures – add/subtract other movements to see if symptoms can change. 3)      Document the test order. Positive Test The positive testing here is a little dated based on what Butler’s group and the research says as of right now. Based on what I have learned from Adriaan Louw, having any of the following is what constitutes a positive

Read More

The Sensitive Nervous System Chapter IX: Manual Assessment of Nerve Conduction

This is a summary of Chapter IX of “The Sensitive Nervous System” by David Butler. The Value The neurological exam is an excellent way to sample the patient’s nervous system. When looking at the neurological system, we must realize that testing does not reflect a tissue injury alone. It demonstrates the neurological pathway’s response. There is no such thing as a focal lesion in the nervous system. We must also understand that the exam is a very small component of a further comprehensive assessment, providing moderate diagnostic value at best. Sensitivity for a screen like this is inherently poor, meaning this examination cannot rule out nervous system pathology or involvement. Sensory Examination If we are going to walk the neurological walk, we first need to talk the neurological talk. Here are some important definitions. Allodynia: Pain from a non-painful stimulus. Hyperalgesia: Increased response to a painful stimulus. Analgesia: No pain from a painful stimulus. Hyperpathia: Abnormal pain reaction to a repetitive stimulus. Hypoalgesia: Decreased response to a painful stimulus. Hypoesthesia: Decreased sensitivity to a stimulus. Hyperesthesia: Increased sensitivity to a stimulus. Dysesthesia: Unpleasant, but not painful response to a stimulus. First, we will take a look at dermatomes. Now depending on who you talk to, dermatomal levels will be different. Moreover, many people have anatomically variant dermatomes, and often times these can fluctuate throughout the day. There are however, some signature zones that are fairly consistent throughout the literature. There are several different sensations that need to be tested. Make

Read More

The Sensitive Nervous System Chapter VIII: Palpation and Orientation of Peripheral Nervous System

This is a summary of Chapter VIII of  “The Sensitive Nervous System” by David Butler. Intro Palpation is a major component to therapeutic touch, and gives us a way to build rapport and interact with our patients. When palpating the nervous system, it is important to palpate in sensitive positions so the nervous system is placed on load. Here are some general nerve anatomical rules. Where a nerve has fewer fascicles and less connective tissue, palpation will be more sensitive (ulnar nerve). Where there is a lot of connective tissue, there will be a more localized and less “nervy” response. Where there is increased sensitivity does not mean there is damage locally. Damage could have occurred more proximally (that whole nerves fire in both directions thing). You must also be mindful that anatomical variations are common, especially if symptoms seem anatomically weird. Here are some of the more common ones: Martin-Gruber anastomosis: Median and ulnar communicate distally. Rieche-Cannieu anastomosis: Deep branch of ulnar and recurrent branch of median nerve. Absent musculocutaneous nerve. Palpation 101 Here are some basic nervous system palpation guidelines. Nerves feel hard and slippery. Palpate with your finger tip or thumb, and follow it proximally or distally. Use sustained pressure up to 30 seconds. Twang if easily accessible. If using a Tinel’s, tap the nerve 4-6 times. Spinal Nerve Palpation Here are the craniocervical nerves. The Trunk Upper Extremity Nerve Palpation Brachial plexus The median nerve The Ulnar nerve The Radial Nerve The Musculocutaneous Nerve Lower Extremity

Read More

Explain Pain Section 1: Intro to Pain

This is a summary of the first section of the book “Explain Pain” by David Butler and Lorimer Moseley. Intro The major premise of this book is that pain is normal. It is the way that your brain judges a situation as threatening. Even if there are problems in the body, pain will not occur if your brain thinks you are not in danger. Explaining pain can reduce the threat value and improve pain management. And the good thing about explaining pain? Research shows that it can be an easily understood concept. Pain is Normal Pain from bites, postures, sprains, and other everyday activities are more often than not changes in the tissues that the brain perceives as threatening. This system is very handy, as often it keeps us from making the same mistake twice. I personally akin this to patients as recognizing a certain smell and that smell reminding you of something. Pain is often the reminder of previous injuries. Pain becomes problematic when it becomes chronic. This pain is often the result of the brain concluding that for some reason, often a subconscious one, that the person is threatened and in danger. The trick is finding out why. Pain Stories Stories are some of the best ways to relate pain to patients. There are many cases when you hear soldiers sustaining major injuries yet charging further into battle. On the flipside, take a look at paper cuts. The damage is very miniscule; however, the pain levels are huge.

Read More

Course Notes: The Eclectic Approach to Upper Quarter Evaluation and Treatment

I recently attended this course with my man Erson Religioso III. It was great connecting with him and learning his approach. Check out his stuff on www.themanualtherapist.com Overall, I thought it was an excellent course and definitely opened my mind to an approach (i.e. McKenzie) that I was not a huge fan of. I highly recommend taking one of his courses. Here were some of the pearls I got from his course. My thoughts will be italicized. On Assessments “If you don’t have a system, you are lost in an evaluation.” The SFMA reasons why people get hurt. #1 cause – previous injury. Asymmetry of quality and quantity. Motor control. Stupidity. Just because you clear something once doesn’t mean it has been cleared forever. If one has knee pain and decreased ankle dorsiflexion, check tibial internal rotation. On Education “Never tell people they are train wrecks.” This goes back to reducing the threat response and explaining pain. We want to maximize the placebo effect. On Neuroscience Nerves move like an arm in a sleeve. A tight sleeve wears down myelin which is replaced with ion channels. This is why nerves become sensitive. Also why you must treat the entire nerve container. Abnormal impulse generating site (AIGS) These fire both ways. Not normally at the sight of symptoms. If symptoms are episodic, then it is not centrally maintained. If you skin your knee 10 times in 10 years, you don’t say I have a chronic skinned-knee problem. On Surgery “Less than 1%

Read More