You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.
I had a problem.
Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.
The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.
It’s a tough business.
The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹. Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.
Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.
To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):
Nonmanual (including exercise and education) = 80%
Manual = 20%
Modalities = 0%!!!!!!!!!!!!
Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:
PRI manual = 14%
Other manual = 6%
As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.
There’s a reason for the shift
I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.
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 blogs on “The Sensitive Nervous System.”
Neurodynamics, Clinical Reasoning, and Neuroscience
When discussing clinical reasoning and neuroscience, we have to discuss processing. The pain processes are what we end up treating in rehabilitation, so we have to know where our patient’s problem occurs along the process:
Input – Issues in the tissues; typical therapeutic approaches.
Processessing – How the brain interprets inputs.
Output – The experiences and emotions we feel.
Processes, as opposed to structures, are what we really treat. We can define processes as changes in the physiology. These changes can include degeneration, ischemia, stiffness, inflammation, etc.
In terms of inputs, the two types of input processes that may lead to a pain mechanism include nociception (the firing of A delta and C fibers from tissues) and peripheral neuropathic (involving the neural tissues outside the dorsal horn). The above mechanisms have predictable stimulation responses.
Understand that all injuries to structures are the same, but the context and environment affect processing and output. We have all experienced this phenomenon. A paper cut can hurt like hell, but a cut from a branch while hiking in the forest may not even be noticed. Context makes all the difference.
The pain mechanism related to processing occurs in the central nervous system. With processing problems, the stimulation-response relationship is unpredictable. Thoughts, feelings, past experiences, knowledge, and other states can affect responses here. These components are designed to help us survive our environment.
Lastly, there are several outputs related to pain mechanisms. These outputs involve all our body systems, with the central nervous system acting as the driver.
All these pain mechanisms–input, processing, and output—are involved in some way during a pain state or sensory alteration. One can be more dominant than the others, but all areas are active. It is similar to energy systems. The aerobic, lactic, and alactic energy systems are always active with one often as the primary driver. So too are the involved pain mechanisms.
Often, genetics is the biggest contributing factor to chronic pain development. It is strongly hereditary, like having blue eyes. Here were some values given in the course as to what percentage of pain is genetic:
50% of migraines.
55% of menstrual pain.
35-68% of lower back or neck pain.
50% of shoulder and elbow pain.
40% of pain with carpal tunnel syndrome.
The Nervous System is a Continuum
The nervous system is one of three continuous systems, the other being vascular and fascial. If you move the nervous system at any one place, the entire system moves. It is like moving a tree branch and creating motion throughout the whole tree. Continuum concepts cannot be enhanced by tissue dominant approaches.
There are four ways in which the nervous system is continuous:
Discussing nerves often puts people at unease. However, this feeling should not be the case. Nerves are like any other tissue. Therefore, they live under the same rules as all other tissues. They can bend, twist, and slide transversely. Nerves can also take on increased pressure by loading.
This interconnected quality often confounds traditional segmental-based testing such as myotomes and dermatomes. The nervous system ought to be thought of instead as a continuous piece with multiple reference points.
Moreover, everyone has a different nervous system. Therefore, each person may require a different sequence when performing neurodynamic tests.
Ion channels are the molecular targets for manual therapy. These channels go where no myelin is present:
Dorsal root ganglion
Nodes of Ranvier
There are six points to describe these ion channels:
1) They are proteins with holes in the middle.
2) They have holes that open or close.
3) Some stay open for longer.
4) There are different kinds of channels.
5) They have a half-life of 2-7 days.
6) They represent needs and perceived needs.
I will not go over all the neurodynamic tests in this post, but there were some different variations that I liked in this course compared to what I was doing. The biggest thing when performing these tests is to have a consistent starting position every time. And if you are doing a straight leg raise, pay attention to potential responses on the contralateral leg.
Here is a radial neurodynamic test…proximal to distal style.
The biggest thing that I got out of the nociception section involved inflammation. First off there are two types of inflammation:
1) Non-neurogenic – occurs with tissue damage; creating bleeding and fluid buildup. NSAIDs work well on non-neurogenic inflammation.
2) Neurogenic – Created via C-fibers, which is driven by changes in peripheral tissues and threat perception. It can occur even if the nervous system was not fully involved in the injury. Pregabalin,Gabapentin, Cymbalta, and other similar drugs work well with these.
Peripheral Neuropathic Highlights
Injury to peripheral nerves involves blood flow, axoplasmic flow, and development of abnormal impulse generating sites (AIGS) along the nerve. There are also three different issues that can occur in the nervous system:
Physiologic conduction blocks – local circulatory changes
Neuropraxia – Local conduction block where axon is okay and conduction returns in weeks to months.
Axonotmesis – Axon continuity loss with intact endoneurial tubes; Wallerian degeneration occurs.
Central Sensitivity Highlights
It is important to understand with central sensitization is that it occurs with all injuries. The difference between those with and without chronic pain is that the sensitivity stays turned on.
The CNS utilizes opiate components to combat nociception. There are three major endogenous opioids produced in the central nervous system to create an anti-nociceptive response:
Endorphins – produced in the periaqueductal gray matter
Enkephalins – Produced in the Nucleus raphe magnus
Dynorphins – produced in the spinal cord.
There are also exogenous opioids, which include epidurals, TENS units, and counter-irritants. However, if the endogenous piece is not present first, these opioids will not work.
Arguably the most important part of the entire course was Bob’s talk on the immune system and glia. Research is starting to show that glia runs the central nervous system. They are the gate and clean up synapses. Inflammation can activate glial activity via the vagus nerve, and when glia activates are opioid systems become much less effective. Nitric oxide is also released, which can sensitize receptive fields in the periphery.
A Side Note
One area that I struggle with in pain education is patients who either dislike pain or have huge functional changes but still have some pain. Bob suggested with these folks that this problem deals with the patient’s beliefs. The best thing to do is to talk around the beliefs or find methods to get them to detach from the pain. This could involve meditation or other similar outlets.
Great Bob Johnson Quotes
“Pain is your brain loving you too much!”
“Spreading pain is connecting the dots in the nervous system.”
“We are good at gathering data, but we are not good at determining what is relevant. Gather the data and make it tell a story.”
“Ask the patient what they think the issue is.”
“Showing the patient how they are better is a central component.”
“All we do is move people.”
“We want pain freedom, not pain control.”
“If I save a patient a day, I did something good.”
“When you treat the container, you treat the nervous system.”
“Sensitivity is plastic.”
“A 30-35 degree SLR is needed for normal gait.”
“We rarely see true nerve root compression.”
“Sliders are like grade I & II mobilizations.”
“Nerves love space, movement, and bloodflow.”
“Cardiovascular health has everything to do with nervous system health.”
“The better cardiovascular fitness, the less pain people with chronic pain have.”
“Most patients have a spinal component to a peripheral piece.”
“Beliefs are a big deal.”
“A biochemical memory is left in the tissues…An immune marker.”
“Movement is Wolff’s law for the nervous system.”
“The pattern of central sensitivity is no pattern.”