This is a summary of chapter XIV of “The Sensitive Nervous System” by David Butler.
The Big Picture Evidence Based Approach
Here is the step by step patient care process that Butler advocates.
1) Identify red flags and manage accordingly.
2) Educate on the whole problem to include tissue health status, the nervous system’s role, and test results.
3) Provide prognosis and make realistic goals.
4) Promote self-care, control, and motivation.
5) Decrease unnecessary fear and manage catastrophization.
6) Get patients moving as early as possible.
7) Help patients identify success and sense of mastery of a problem.
8) Perform a skilled exam.
9) Acknowledge that biopsychosocial inputs combine with the nervous system to produce pain and disability.
10) Use any measures possible to reduce pain.
11) Minimize number of treatments and contacts with all medical personnel.
12) Chronic pain may need a multidisciplinary approach.
13) Manage physical function and dysfunction.
14) Assess and assist in improving general fitness.
15) Assess how injury affects creative outlets and assist the patient with regaining creativity and discovering new creative outlets.
There are several ways to incorporate neurodynamics into the patient’s plan of care which will be outlined below.
- Passive mobilization.
- Active mobilization.
- Posture and ergonomics.
There are many evaluation protocols that warrant constant reassessment after applying an intervention. Be it a comparable sign or audit, neurodynamic tests can be utilized well within these systems.
A word of caution with instant reassessment, as quick changes could merely be playing with impulses in a healing environment. The real sense of improvement is through improved function.
When working with Peripheral neuropathic pain (PNP), it is important to educate patients on normal responses. Many may find it weird that neck movements can change sensations at the wrist, but patients must realize that the nervous system is a continuous structure. Providing stimulus at one point of the structure can lead to responses at other ends of the same structure.
In central sensitization, the language provided must be spoken tactfully. The following points are important to hit home:
1) Acknowledge the specific dysfunction, but say it has had time to heal.
2) Real processes within the central nervous system occur that magnify inputs.
3) There are several reasons why this increased sensitivity occurs, including biopsychosocial inputs.
4) The nervous system produces chemicals that keep it sensitive.
Regardless of how we communicate with patients, the most important thing is to not be frightened by pain. If we are frightened of pain and do not understand it, this will be carried to the patient.
First some ground rule concepts.
1) Reject the notion of neural stretches and crude assessments.
2) Passive is only a part.
3) Your patient interaction could affect the response.
4) Passive could educate a patient on what they are capable of.
5) Judgments about technique efficacy should consider the evidence.
6) Early mobilization is best after nerve injury.
7) If there are many sensitive tests, mobilize the least sensitive first.
Here are some potential mobilization techniques.
- Tissue mobilization with the nervous system positioned.
- Nervous system mobilization with the tissues positioned.
- Neurogenic massage
Here are some examples of the above.
Several options can be used.
- Movement breakdowns.
- Change movement order.
- Trick movements: Changing positions or using eye movements.
- Relate to a meaningful activity.
- Pacing – Working into painful activity with a gradual progression into further activity.
Here are some examples of sliders and tensioners
Here is an example a movement breakdown I have been using a lot.
Posture & Ergonomics
Here we present a table of potential movements that can affect sensitivity of specific nerves.
|Sciatic||Sitting long periods or on a hard edge.|
|Common fibular||Ankle sprains, squatting, repeated leg crossing, tight splints|
|Deep fibular||Tight shoes, high heels, sitting on ankles.|
|Superficial fibular||Repeat ankle sprains, tight shoes, metal capped boots.|
|Tibial||Excessive exercise, running in shoes without arch support.|
|Sural||Tight ankle bracelet or sustained compression.|
|Femoral||Repeated lumbar extension and hip flexion; prolonged FABER.|
|Lateral femoral cutaneous||Tight jeans; weight gain.|
|Saphenous||Straddling a surfboard.|
|Pudendal||Long bike ride.|
|Brachial plexus||Contralateral cervical sidebend + shoulder depression (football tackle).|
|Ulnar at the wrist||Cylcing, wrist used as hammer, prolonged video gaming.|
|Ulnar at the elbow||Elbow flexion + compression, taxi driver, being chair-bound.|
|Radial at the upper arm||Crutches or Saturday Night Palsy.|
|Radial at the elbow||Repeated pronation/supination.|
|Radial Sensory||Tight handcuffs or bracelets; repeated pronation/supination.|
|Median at the upper arm||Saturday Night Palsy|
|Median||Repeated wrist flexion/extension; vibration.|
|Musculocutaneous||Heavy bicep exercise; strap heavy bag at the elbow.|
|Axillary||Anterior-inferior shoulder dislocation; sleep with arm overhead.|
|Suprascapular||Repeated overhead movement; volleyball/swimming.|
|Spinal accessory||Comatose surgical patient head down with shoulder support; “Love bite.”|
|Long thoracic||Tight bandages; forceful shoulder motion; overuse|