January 15, 2018

Parts of my presentation from AAHS meeting on Neuropathic Pain

Neuropathic pain is associated with CRPS and painful peripheral neuropathies

Peripheral Neuropathies are assessed via Upper Limb Tension Test, specific nerve testing via tinels / phalens and Scratch collapse test

Nerve gliding in painful neuropathies area done as a routine treatment to manage adverse Neurodynamics, •Restore dynamic balance between the relative motion of neural tissues and the surrounding mechanical interfaces, •Allow reduced intrinsic pressure on neural tissue, •Optimize physiological function, •Reduce nerve adherence, •Dispersion of noxious fluids, •Increase vascularity, •Improve axoplasmic flow, •Ellis et al 2008. Jour of manual therapy

•Our hypothesis in neural gliding was “If intra-neural tissue is fibrotic, is the nerve really gliding and the treatment we are prescribing is it actually therapeutic ? “In painful neuropathies when we give nerve gliding exercises is it truly gliding or is it stretching if the nerve is adhered to the surrounding structures how do we assess if our treatment is actually therapeutic.”

So we used scratch collapse test to test our assumption

We performed the baseline scratch collapse test, then performed median nerve glide and re-tested the patient. The patient seemed to collapse more after the glide

Then we wanted to test our assumption, if we improved the excursion of the nerve (Movement of the neural tissue relative to the surrounding structures) by providing Myofascial manipulation with Neural mobilization would that improve the response and improve gliding of the nerve.

•Nerve functions in continuity, assessment and treatment of a nerve MUST be done as a whole and not segmental. So we provided myofascial release to all the structures from the neck to the finger tip and then performed nerve glide with myofasical release

Principals of nerve gliding was followed – Neural mobilization best achieved by “tensioning” of the nerve at either end sequentially and not simultaneously, Slow  rhythmic movements – 1-2 second holds, avoiding symptom provocation and patient reporting imperative.

The physiological component to maintain blood flow and restrict inflammation can be done by providing myofascial release to release the structures through which the nerve passes. This in turn would provide the nerves the mechanical interface to move freely in relation to and with the surrounding tissues to help restore dynamic balance between the relative motion of neural tissues and the surrounding mechanical interfaces. 

When we retested the patient with scratch collapse after the myofascial release the patient was able to hold the position, indicating that the treatment worked

Then we designed the program based on the restriction noticed with the ULTT to allow just enough gliding of the nerve there by preventing stretching of the nerve from its entrapment site.

This was combined with adjunct treatment like leuko taping for posture or kinesio taping for lymphatic flow, modalities, exercises maintaining the balance between tonic and phasic muscles and including ergonomics to prevent return to provocative occupations.

Our hope is more therapist will perform the assessment to perform effective treatment and accurate prescription of exercise to help patients with these disabling neuropathic pains.

We teach these hands on techniques in our courses through Advanced Rehab Seminars

For more information please log in to www.AdvancedRehabSeminars.com