Chapter 11: Lumbar Spine

This is a Chapter 11 summary of “Clinical Neurodynamics” by Michael Shacklock. Physical Exam The slump is the big dog for assessing lumbar spine complaints. Deciphering which movements evoke the patient’s symptoms can tell you a lot about the nervous system’s dysfunction: Neck flexion increases symptoms – Cephalid sliding dysfunction. Knee extension/dorsiflexion increases symptoms – Cauded sliding dysfunction. Both neck flexion and knee extension increase symptoms – Tension dysfunction. The straight leg raise is another important test that can help determine the nervous system’s state. Treatment The treatment parallels similar tactics as previous body areas. For reduced closing dysfunctions We start level 1 with static openers, progress to dynamic openers, then work to close. For opening dysfunctions, we progress toward further opening/contralateral lateral flexion. Neural Dysfunctions We treat these mechanisms based on which dysfunction is present. For cephalid sliding dysfunctions, we approach with distal to proximal progressions; and for caudad sliding dysfunction, we work proximal to distal Tension dysfunctions are started with off-loading mvoements towards tensioners Complex Dysfunctions Sometimes you can have interface dysfunctions that simultaneously have contradictory neurodynamic dysfunction. There are several instances of the case. Reduced closing with distal sliding dysfunction – Treat by combining closing maneuvers while perform active knee extension. Reduced closing with proximal sliding dysfunction – Address by closing maneuver with neck flexion. Reduced closing with tension dysfunction – This is treated with adding closing components to tensioners Reduced opening with distal sliding dysfunction – Here we add a dynamic opener along with leg movements. Reduced

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Course Notes: PRI Myokinematic Restoration

What a Class Wow. That’s all that really needs to be said.  I have had a great deal of exposure to PRI in the past, but I have only had one formal class under my belt. Needless to say, I was looking forward to learning more. James Anderson and the PRI folks did not disappoint. Myokinematic Restoration was easily the best class I have taken all year. It also helped having another like-minded group attending. You learn so much more when you are surrounded by friends. Here is the course low-down. Disclaimer for the Uninitiated I know there are a lot of misconceptions about PRI on the interwebz. Even though posture is in the name, PRI has little to do with posture in the traditional sense. We know posture does not cause pain, and PRI agrees with this notion. But it’s not like they can change the name of the organization now. What? Do you think Ron Hruska is Diddy or something? After discussions with James and his mentioning this aloud in class, the target of PRI is the autonomic nervous system. Not posture, not pain, not pathoanatomy, but the brain. Essentially, they have figured out a window into the autonomic nervous system via peripheral assessment. Moreover, PRI is not in the pain business, though many think this is the case. Hell, even in the home studies they mention pain quite a bit. But realize those were done in 2005. Would you like me to hold you to things you have

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Chapter 10: Upper Limb

This is a Chapter 10 summary of “Clinical Neurodynamics” by Michael Shacklock. Thoracic Outlet Syndrome (TOS) When discussing TOS pathoneurodynamics, you must talk about breathing. The brachial plexus passes inferolaterally between the first rib and clavicle. When inhalation occurs, the plexus bowstrings over the first rib cephalidly. So breathing dysfunctions can contribute to one’s symptoms. Excessive scapular depression can also contribute because the clavicle approximates the plexus from above. Clinically, TOS often presents as anteroinferior shoulder pain, with some cases passing distally along the course of the ulnar nerve.  A resultant upper trapezius/levator scapula hyper or hypoactivity can occur that may affect the neural elements. Treating the Interface Level 1 – Static Opener with breathing Level 2 – Static opener with rib mob during exhalation; progressing with scapular depression. Level 3 – Rib depression with sliders and tensioners. Pronator Tunnel Syndrome This syndrome consists of pain in the anteromedial forearm region with or without pins and needles. Symptoms are usually provoked by repetitive activities such as squeezing, pulling through the elbow, and pronation movements. From an interface perspective, pronator syndrome deals with excessive closing. So we will use openers to treat. Level 1 – Static opener combining 60-90 degrees of elbow flexion with forearm pronation Level 2 – Dynamic opener Treating neural components depends on the present dysfunction. There are the following possible dysfunctions: Distal sliding dysfunction – symptoms decrease with contralateral cervical flexion. Proximal sliding dysfunction – Symptoms increase with contralateral cervical sidebend and finger flexion. Tension dysfunction –

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Chapter 9: Cervical Spine

This is a Chapter 9 summary of “Clinical Neurodynamics” by Michael Shacklock. Physical Exam The key tests you will want to perform include: Slump test. MNT 1. You can tier your testing based on one’s dysfunctions, such as opening or closing, as well as using sensitizers for less severe problems. Reduced Closing Dysfunction Level 1a – Static opener to increase space and decrease pressure in the intervertebral foramen. In the picture below, we would open the right side by combining flexion, contralateral sidebend, and contralateral rotation. Level 1b to 2b Reduced Opening Dysfunctions For these impairments, they are treated just the same as closing dysfunctions. The major difference is rationale. In closing dysfunction, the goal is to reduce stress on the nervous system. With opening dysfunctions, however, we are trying to improve the opening pattern. Static openers will generally not be used because these treatments could potentially provoke symptoms. Neural Dysfunction The gentlest technique is the two-ended slider, in which an ipsilateral lateral glide and elbow extension are performed. For tension dysfunctions, we go through the following progression:

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Chapter 8: Method of Treatment: Systematic Progression

This is a Chapter 8 summary of “Clinical Neurodynamics” by Michael Shacklock. Let’s Treat the Interfaces The two main ways to treat interfaces involve opening and closing techniques. These treatments involve either sustained or dynamic components. We will discuss which techniques work best in terms of dysfunction classification. – Reduced Closing Dysfunction – Given static openers early in this progression, continuing to increase frequency and duration. Eventually you move to more aggressive opening techniques, while finishing with closing maneuvers. – Reduced Opening Dysfunction – Start with gentle opening techniques working to further increasing the range. – Excessive Closing and Opening Dysfunctions – Work on improving motor control and stability. How About Neural Dysfunctions The main treatments are sliders and tensioners; each can be performed as one or two-ended. Sliders ought to be applied when pain is the key symptom. Sliding may milk the nerves of inflammation and increase blood flow. These techniques could also be used to treat a specific sliding dysfunction. Sliders can be performed for 5 to 30 reps with 10 seconds to several minute breaks between sets. Increased symptoms such as heaviness, stretching, and tightness is okay, but pain should not occur afterwards. Typically sliders are performed in early stages, and in acute situations should occur away from the offending site. Tensioners are reserved for higher level tension dysfunctions. The goal is to improve nerve viscoelasticity. Some symptoms are likely to be evoked, but this occurrence is okay as long as symptoms do not last.  Tensioners are

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Chapter 7: Standard Neurodynamic Testing

This is a Chapter 7 summary of “Clinical Neurodynamics” by Michael Shacklock. Passive Neck Flexion With this test, the upper cervical tissues slide caudad, and the lower cephalid. The thoracic spine moves in a cephalid direction as well. Normal responses ought to be upper thoracic pulling at end-range. Abnormal symptoms would include low back pain, headache, or lower limb symptoms. Median Neurodynamic Test 1 (MNT1) This test, also known as the base test, moves almost all nerves between the neck and hand. Normal responses include symptoms distributed along the median nerve; to include anterior elbow pulling that extends to the first three digits. These symptoms change with contralateral lateral flexion and less often ipsilateral lateral flexion. Anterior shoulder stretching can also occur. Ulnar Neurodynamic Test (UNT) This test biases the ulnar nerve, brachial plexus, and potentially the lower cervical nerve roots. Normal responses include stretching sensations along the entire limb, but most often in the ulnar nerve’s field. Median Neurodynamic Test 2 (MNT2) This version biases the lower cervical nerve roots, spinal nerves, brachial plexus, and median nerve. Normal responses would be similar to MNT1. Radial Neurodynamic Test (RNT) This test looks predominately at radial nerve, as well as the nerve roots. It is uncertain if this test biases any particular nerve root. Normal responses include lateral elbow/forearm pulling, stretch in the dorsal wrist. Axillary Neurodynamic Test (ANT) This test tenses the axillary nerve, though may not be specific. Normal responses include posterolateral shoulder pulling with about 45-90 degrees of

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Online Consult with The Manual Therapist

The Rundown My good friend Erson Religioso of The Manual Therapist fame recently contacted me to do a consult for some back/leg trouble he has been having. It was a very interesting eval for many reasons. Online consults are a completely different animal, as you cannot do any hands-on testing. Moreover, when you have a therapist who is initiated into pain neuroscience, you don’t have to go so much the Explain Pain route 🙂 So with this eval, we looked at things a lot through a PRI lens, and were able to get him strategies to modulate his pain experience. The eval runs a smidge over 1 hour, so here are some vids with a quick rundown. Subjective – Getting paresthesia down the R LE that began 2 weeks ago after a car ride…has peripheralized since initial event. – Symptoms are aggravated with static sitting or standing…onset ranging from seconds to minutes. – Has tried loading/unloading MDT strategies, neurodynamics, Mulligan techniques, IASTM, compression wrapping, etc…all to no avail. Objective (major findings) – Limited B Apley’s scratch (1 per FMS scoring) – Negative slump and ASLR – Painful lumbar motions of extension, right rotation and sidebend. R sidebend was limited. – Negative thomas test on left, positive on right – Slight limitations in active seated hip IR B, R>L. – Adduction lift scores 1/5 B. My Impression If I were to classify Erson, it seems his symptoms would seems to be more dominant as peripheral nociceptive ischemic and central sensitivity (he stated he has

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Course Notes: Pain by Lorimer Moseley

I just ran through my second watching of a lecture that Lorimer Moseley did on Pain in LA. It was an excellent presentation that was put together by Laree Draper over at movementlectures.com.  Please purchase this product here and help her continue to put out great content. There were so many valuable examples Lorimer gave that there is no way I could account for all of them. Here are the highlights. Nociception and Pain Pain is all about meaning. Pain relies on credible evidence to be active. Pain experiments are really nociceptive experiments. Visual experience depends on the evaluation of sensory input. The brain has to figure out how dangerous “x” really is. Pain emerges from the human. Nociception doesn’t make us do anything, but pain will. You can differentiate peripheral and central sensitivity by applying heat to the painful area. Heat ought to increase the symptoms in peripheral nociceptive problems. Pain Modulators Nociception Anything that modulates the evaluation of danger and protection of body tissue. Neurotags Small changes in the neurotag can lead to major changes in the output. Any belief you have regarding your pain is linked to the pain neurotag. Cortical Body Matrix (CBM) The CBM is a network of neural loops that protect and regulate the body physiologically and psychologically. When the pain neurotag becomes facilitated, less and less input needs to occur for it to activate. When pain persists, oftentimes the pain neurotags becomes imprecise; leading to noninvolved neurons firing. This is how pain spreading

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Chapter 6: Planning the Physical Examination

This is a Chapter 6 summary of “Clinical Neurodynamics” by Michael Shacklock. Observe When assessing the patient, you must look at the following information: Symptom location, extent, quality, and behavior. Movement resistance. Range of motion. Compensatory patterns. Breathing quality. Tone of voice. Facial expression Protective muscle tone. Avoidance. When planning the exam, you can tier to what extent you ought to assess someone. Level 0: neurodynamics are contraindicated for physical or psychosocial reasons. Level 1: Limited exam where symptoms are minimally provoked. Full neurodynamic tests are not performed, and are tested separately from musculoskeletal structures. The neurodynamic tests are performed with relieving-based structural differentiation. Level 1 is indicated when… Symptoms are easily provoked and take a long time to settle after movement. Severe or latent pain is present. Potential pathology. Neurological deficit. Progressive worsening prior to exam. Level 2: Standard examination in which neurodynamics, interfaces, and innervated tissue are tested separately. Standard neurodynamic sequences are used and symptoms can more readily be brought on. Level 2 is indicated when… Less severe, latent, or easily provoked symptoms. Absent/minor neurological symptoms. Stable problem that is not rapidly deteriorating. Level 3: It’s gettin’ real. Here we see greater force localization and sequences that start at the problem. Sensitizers are often used as well. Level 3 is indicated when… Level 2 exam is normal or provides insufficient information. Symptoms are not severe or easily provoked. Problem is stable. No evidence of pathology. There are four examination types here: 3a) sensitizers are added. 3b) Begin

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Chapter 5: Diagnosis with Neurodynamic Tests

This is a Chapter 5 summary of “Clinical Neurodynamics” by Michael Shacklock. Neurodynamic Tests In neurodynamic tests, there are two movement types: 1)      Sensitizing: Increase force on neural structures. 2)      Differentiating: Emphasizing nervous system by moving the neural structure as opposed to musculoskeletal tissue. The reason why sensitizers are not considered differentiating structures is because they also move musculoskeletal structures. Examples of sensitizing movements include: Cervical or lumbar spine contralateral lateral flexion. Scapular depression Humeroglenoid (HG) horizontal extension HG external rotation Hip internal rotation Hip adduction Interpreting The ability to interpret neurodynamic findings is crucial when determining the nervous system’s involvement.  Findings such as asymmetry, symptoms, and increased sensitivity are all important. But to implicate neurodynamics, structural differentiation ought to be performed. Just because there is a positive test does not mean that it is relevant to the patient’s complaints. There are several ways to classify findings: Negative structural differentiation: Implicates musculoskeletal response. Positive structural differentiation: Implicates neurodynamic response. Neurodynamic responses can have different interpretations: Normal: Fits normal responses per literature. Abnormal: Differ from normal responses. Can be broken down further into… Overt abnormal responses: Symptoms reproduction. Covert abnormal response: No symptoms, but may have other subtle findings such as asymmetry, abnormal location, and/or different resistance. From here, one must determine if the findings are relevant or irrelevant to the condition in question. You may also come across subclinical findings, in which the neurodynamic test is related to a minor problem that may become major at some point.

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My 50th Post: Motivation to Learn

A Little Personal It is hard to believe that I have already written my 50th post after starting this blog in February as a way to enhance both my learning and the learning of others. This blog has allowed me to interact with a variety of different individuals that I otherwise would not have. And when people who I deeply respect say they admire what I have to say (or at least my version of what other people say), I am deeply humbled. But I have had several cases in which people wondered if I do anything other than physical therapy and personal training (I do). One of my former mentors came up to me saying that she was worried about me because of how much I am into this. These interactions have made me reflect on why I am reading, working, writing, and learning as much as I can. Thus, I have come to some conclusions as to what drives me to help others. And this drive, while not the norm that some of my peers are accustomed to, is far from wrong. Others are Depending on You When you work as a health professional, some people neglect the fact that your patients and clients trust their bodies with you.  They put their confidence in your knowledge and skills to show them the path to bettering themselves. When someone puts this amount of trust into me, the last thing I want to do is let them down. So I

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Course Notes: Mobilisation of the Nervous System

I Have an Addiction It seems the more and more that I read the more and more and read the more and more addicted I become to appreciating the nervous system and all its glory. To satisfy this addiction, I took Mobilisation of the Nervous System with my good friend Bob Johnson of the NOI Group. This was the second time I have taken this course in a year’s span and got so much more value this time around. I think the reason for this enrichment has been the fact that I have taken many of their courses prior and that I prepared by reading all the NOI Group’s books. A course is meant to clarify and expand on what you have already read. So if you are not reading the coursework prior, you are not maximizing your learning experience. What made this course so much more meaningful was being surrounded by a group of like-minded and intelligent individuals. As many of you know, I learned much of my training through Bill Hartman. Myself, Bill, the brilliant Eric Oetter and Matt Nickerson, my good friend Scott, and my current intern Stephanie, all attended. When you surround yourself with folks smarter than you, the course understanding becomes much greater. This course was so much more with the above individuals, so thank you. Try to attend courses with like-minded folks. Here are the highlights of what I learned. If you would like a more in-depth explanation of these concepts, check out my

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