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Neuro? Logical! Forum for all neuro-things => from neuron to brain...

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Old 19-06-2005, 02:48 PM   #101
Michael Shacklock
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Default Shoulder Pain

Thanks Nari,

There is a study in which the motor axons of the median nerve at the wrist were stimulated electrically. It was used as an experimental model for central pain mechanisms to see what pain referral occurred. The subjects (asymptomatic) experienced shoulder pain from the median nerve at the wrist. It is possible that the motor branch of the nerve at the wrist is being moved by the thumb movements you discuss and it might be mechanosensitive. It is tensioned by extension of the thumb. Also, go into the past history about a wrist injury or overuse. In the patient with carpal tunnel syndrome on the CD of my book, we imaged her motor branch about 6 weeks ago and we could track it right into the thenar eminence muscles. It's only about 0.8 mm in diameter but it can still be imaged. Anyway, IF the problem is in the median nerve at the wrist area, this could be relevant. The nerve can be palpated just between the carpal tunnel and the nerve's entrance to the thenar muscles, near the ventral surface of the trapezium. So you might want to try this for pain reproduction or tissue changes. The shoulder postural changes might not produce a change in the symptoms if the movements are performed without the MNT1 because not enough tension is generated in the nerve in the wrist. You might need to sensitize testing to level/type 3a, 3b, or 3c (chapters 6 and pp 187-194). Also, the surgical picture (Fig. 10.16) is the very motor branch of the median nerve that I'm talking about! Remember also that level/type 3c assessment/treatment can involve simultaneous testing of the INNERVATED tissues as well as the nerve. So you could resist thumb flexion/adduction whilst in the MNT1 position.

For those who have not come across the reference here:
Shacklock M 2005 Clinical neurodynamics: a new system of musculoskeletal treatment. Elsevier, Oxford

Hope this helps

Regards,
Michael
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Old 19-06-2005, 03:03 PM   #102
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Thanks, Michael..I did not expect an answer tonight; maybe you should be getting some beauty sleep!

I did not expect the result I got because her wrist seems quite OK, and the response was so isolated. But I will follow this further as you suggested - it gets a bit tricky as she is an elderly Polish lady and her English is not good.
I will look more closely at her wrist/shoulder action too.

Have a good week


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Old 20-06-2005, 10:06 PM   #103
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Hi Micheal & Nari :

Good Thread .

Thank you for writing .


Micheal , I have a logical question ( attacking me contuinually ) regarding neurodynamics .

Briefly , I believe in Physical , bilogical , scienitific rule ( as i assume ) which is any :

"Any materinal could suffer from overusing "


The question :

Does the nerve comply with this rule ?? I mean over conducting of signals in the forum of affrent and efferent signals could affect the nerve negatively ?? of course , considering the surrounding environment of the nerve :idea:


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Old 22-06-2005, 12:29 PM   #104
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Hi Craig, welcome to the forum. I'm in the UK right now (arrived this morning) so we're practically neighbours!

The idea of neural tissues being related to inflammation in the musculoskeletal tissues really has not gone far enough in my opinion. There are many possible links but I've reviewed some of the evidence in my book in chapter 3 on neuropathodynamcs. There is some good evidence in patients whose skin was tested for inflammatory reactions and in the biological research, stimulation of nerves electrically has been shown to produce inflammation in the joint innervated by the nerve. I feel that some patients do have a link between neural problems and others don't. The trick is to do a really good evaluation.

Also, if the adjacent musculoskeletal tissues don't move well, there is the possibility that the forces on the neural tissues will also be imperfect. The neural tissues may adapt by shortening and may not maintain a normal tolerance to movement, rendering them more sensitive to normal movement. A good example of this clinically is the stiff shoulder after or during capsulitis. I'm not saying that neurogenic inflammation causes the capsulitis but the lack of movement mayproduce resultant neurodynamic impairments which then may impact on the clinical picture. Consider doing an MNT1 on a patient with reduced shoulder movement. Get the shoulder to the end of available and tolerable range, then add the neurodynamic components to differentiate the responses. Frequently a covert or even overt abnormal response will occur (described in chapter 5). This suggests that the neurodynamics might need addressing.

Many thanks for your positive feedback about the book. I'm so pleased that it is useful and produces Neurodynamic Solutions!

Kind regards,
Michael
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Old 22-06-2005, 12:39 PM   #105
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Hi Emad, The idea that neural tissues could become a problem with over use has some evidence support.
1. Neural tissues need release of substance p and calcitonin gene related peptide for normal nutrition. This is shown by capcaicinizing a nerve and its blood flow decreases and indicates that normal nutrition is mediated tonically by this release mechanism.
2. Stimulate the nerve and more vasodilation occurs and this is related to release of SP and CGRP.
3. Too much stimulation produces inflammation in the nerve and this is mediated also by SP and CGRP.

Long term repetitive actions have been correlated with nerve scarring and impaired sliding (found at surgery, Laban et al). Goddard and Reid 1965 also showed in cadavers that older cadavers had more connective tissues between the lumbosacral plexus and the neighbouring musculoskeletal tissues.

So there is at least fragmental support for what you say.

In summary:
1. Nerves possibly need normal forces to produce normal nutrition.
2. Too much stimulation leads to inflammation and possible scarring.
3. This may lead to neurodynamic impairment.

This is identical to musculoskeletal tissues - funny that!

Regards,
Michael
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Old 22-06-2005, 02:04 PM   #106
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Michael

Re adhesive capsulitis / frozen shoulder - I find this to be something of a misnomer, and I see quite a few patients with limited ROM, particularly abduction, ER and scapulohumeral dysrythmia, who have been told it will all go away in two years. In the early stages of acute pain and restricted movement without the dead end feel of the capsulitis phase (in the first three months or so) these folk seem to respond very well just with neurodynamic movements. I find the whole condition a peculiar one - especially when the histology is comparable with Dupuytren's contracture.

I would have thought ULNTTs were standard for every shoulder with pain and inhibited movement; is this not the case? The standard exercises seem only to aggravate the condition, and I dropped them some years ago.

I'm interested in more of your comments on and around the nuances of the 'frozen shoulder' syndrome....

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Old 22-06-2005, 04:39 PM   #107
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Hi Micheal :

Thank you for your views , regarding nerve overuse problems and evidences , very good explanation .


By the way , I liked very much the idea that of the invlovement of neural factor in joints restrication , of course this is true .


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Old 22-06-2005, 06:41 PM   #108
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Yes Nari, I agree that neurodynamics should be routine for all shoulder problems. But those who do the educating have often say that NDTs are only indicated when there are symptoms that suggest neural involvement such as pins and needles, numbess, weakness, symptoms distal to the shoulder and dermatomal symptoms etc.

We should look at neurodynamics because they have the potential to contribute to any musculoskeletal problem.

I also haven't found much success with the standard exercises but, having spoken to an upper limb surgeon friend of mine who has operated on some of them, he said that the only histopathology they find is a severe synovitis related to the capsule. They have also done extensive work on the causes of capsulitis and still can't pin it down to anything specific or singular.

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Michael
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Old 22-06-2005, 09:45 PM   #109
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Hi Nari & Michael :

At least , when we ,as practationers, think of the nervous system in cases of joint restrication ( stiffness ) , we avoid its adverse effects and more detrioration , putting the nervous system aside in those cases is more better , however it will be more advanced if we could use the nervous system postively in those cases .But how ?? i do not know !

Just ideas :idea:

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Old 23-06-2005, 01:17 AM   #110
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Thanks, Michael.

Interesting that so many PTs think neurodynamics is only for neuro exams in the presence of neuro 'signs' - I have found that almost universal, and trying to change that perspective is quite difficult....


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Old 23-06-2005, 12:41 PM   #111
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Yes Nari, it 's very difficult but nevertheless things are improving I feel. Rome wasn't built in a day, neither was clinical neurodynamics!

Emad, many neurodynamic solutions exist for these patients. ND exercises, interface release techniques, ND off-loaders, tensioners. sliders - it all depends on what the patient presents with and how to progress the patient. I use a system that does the following:

1. classifies the patient's neurodynamic and musculoskeletal changes
2. when appropriate, treats each component in an integrated way
3. starts the patient at the correct progression to a. avoid provocation of symptoms and b. offer them solutions for their level of problem
4. progresses them through the levels from low to high. It's all outlined in my book. But if you have any questions, feel free to ask.

I hope this helps.

Regards,
Michael
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Old 23-06-2005, 04:17 PM   #112
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Hi Michael ;

Of course , this is helpful. Thank you very much .


you are so kind .

Regards

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Old 02-11-2007, 06:29 AM   #113
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Rolf
I wonder if atmospheric pressure changes might be making things worse for your patients. I have CRPS. In the areas where I have arthritic changes I'm affected by pressure changes, including ascending and descending in a plane.
When it's cold I need to artificially make myself warm (eg hot bath, heater, heat pack) and then wear suitable clothing to retain the warmth. If I fail to get warm then I am in more pain.

I can be in the snow but warm and no added pain, or in a cool breeze in summer and have blue extremities.
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