02. Post-operative Lumbar Decompression: Pathoneurodynamics

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Nov 16, 2013 (4 years and 1 month ago)

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September 5
th



8
th

2013

Nottingham Conference Centre, United Kingdom


www.nspine.co.uk

Post
-
operative Lumbar
Decompression:
Pathoneurodynamics

Ellen Hobbs

Physiotherapist

September 2013

Introduction

Low Back Related Leg
Pain

Influence of
neurodynamics

Pain and
Pathoneurodynamics

Clinical Manifestation
and Patient
Presentation

Case Study

Summary

Low Back Related Leg Pain


Leg pain frequently accompanies low back pain
.
(Schafer et al 2009)



Decompression / Discectomy performed for leg
pain.



Present in approximately 25
-
57% of all low back pain cases
(Heliovarra et al 1987;
Cavanaugh and Weinstein 1994; Selim et al; cited in Schafer et al 2009
)



Accompanying leg pain is an important predictor for LBP chronicity
(Selim et al cited
in Schafer et al 2009
)



Primary pathology causing referred leg pain can be indistinct. Many structures
can evoke similar patterns of pain
(Adams et al 2002; Bogduk and McGuirk 2002 cited in Schafer et
al 2009
)



Patients may be left with residual post operative
leg pain; Necessary
to
understand the possible
causes
to optimise treatment.


Neurodynamics

“The science of the relationships between
mechanics and physiology

of the nervous system.”
(Butler 2005)








Mechanical and physiological events of the nervous system are
dynamically interdependent
(Shacklock 1995)



Mechanical stresses applied to nerves evoke physiological
responses e.g. alterations in intraneural blood flow; impulse traffic
and axonal transport
(Shacklock 1995)


Physiological

Impulse generation and conduction.

Mechanical

movement of the nervous system to

slide, move and elongate in relation

to surrounding tissue.

Pathoneurodynamics


Changes in neural
dynamics or physiology
may lead to
pathoneurodynamics.

(Shacklock 1995)



High likelihood in
postoperative
decompression patient


Neurodynamics



Mechanics



Physiology




Pathomechanics


Pathophysiology




Pathoneurodynamics

(Shacklock 1995)

Peripheral Neuropathic Pain


Situations where nerve roots or peripheral nerve trunks have
been injured by mechanical or chemical stimuli that exceed
the capabilities of the nervous system.



Neural connective tissue nociceptor sensitisation


Abnormal impulse generating site (AIGS) formation


Impules conduction impairment

(Nee and Butler
2006; Ellis et al 2012)



Neurodynamic tests assess the mechanosensitivity of the
nervous system through sequential limb movements.
(Boyd et al
2010)



Peripheral Neuropathic Pain

AIGS formation / Impulse conduction impairment

(Nee and Butler 2006)

Clinical Manifestation

Positive
(Abnormal
levels of excitability)



Pain


Paraesthesia


Dysesthesia


Spasm

Negative
(Reduced
impulse conduction
in neural tissue)



Hypoesthesia


Anaesthesia


Weakness

(Nee and Butler 2006)

Objective Findings


Neural unloading antalgic posture



Reduced active / passive movement



Provocative neurodynamic testing (correlating the
reduced active / passive ROM)



Lines / clumps of pain over neural interface



Nocturnal pain (due to reduced O2 perfusion)

(Nee and Butler 2006; Welch 2011)

Treatment Techniques

What can we do for residual post operative leg
pain?



Mechanical Interface



Nervous System



Both

(Welch 2011)

Case Study Example

Subjective Assessment


68 year old lady


Left posterior LL pain to calf (burning /
restless) (mild improvement) (p1)


Localised central LBP sharp/catching (p2)


23.05.2013 bilateral S1 lateral recess
decompression. Revision L5 root
decompression. Degenerative scoliosis


2x previous decompressions


Right L3/L4 2002


Bilateral L5 (L4/5 L5/S1) 2010


Improved


Subtotal colectomy / permanent
ileostomy 2002


Angina


Gabapentin / Tramadol / Aspirin /
Paracetamol /
Olmetec

/ Atorvastatin

Objective Assessment


Lx scoliosis concave to left


Limited painful (p2) extension / side
flexion.


Reduced left hip active / passive ROM IR
20 (p1 to mid thigh)


Normal power / sensation


Positive (p2) left SLR 30 / Slump
-
60
extension


+ TrP HS / piriformis / mid calf


UMN NAD


Treatment


Arthrogenic (closing dysfunction)


Rotational PPIVMS right SL GII. 30 sec x 3


Lx SF right SL


Work into neurodynamic range


Mechanical interface


Inhibitory taping to differentiate / ? sciatic bifurcation ? piriformis


TrP acupuncture piriformis


HEP


Slump slider (started with right) one ended / function


Cat / posterior pelvic tilt 4 point


Piriformis stretch



Possible progressions / relate to function


Consideration of SIN factor / objective markers




Summary


Leg pain frequently accompanies low back pain. Post
-
operative decompression
patients may have residual leg pain.



For effective treatment we need to consider neurodynamics /
pathoneurodynamics.



To optimise treatment we need to understand the neurobiological process
involved that may contribute to pathoneurodynamics.



Neurodynamic testing and differentiation can indicate potential structures /
contributors involved in pathoneurodynamics.



Treatment techniques aim to offload / open / close / facilitate gliding / reduce
neural sensitivity.


Appendix


Physiological


Peripheral nerve structure and
movement


Blood supply to the nerve


Epineurium


Outer vascular layer


Inner layer facilitates gliding


Allows bending


Perineurium


Connective tissue


Diffusion barrier controlling fluids


Endoneurium


Provides optimal nerve nerve fibre
environment

(Welch 2011)


Mechanical


The Musculoskeletal system is the mechanical interface to the nervous
system
i.e.
anything lying next to the nervous system:



Central and Peripheral components:



Peripheral

Muscles

Tendons

Bone

Discs

Ligaments

Fascia

Blood
Vessels

Central

Cranium

Neuraxia

Cranial
Nerves

Meninges

Nerve
Roots

(Nee and Butler 2011)

Injury / Degenerative Cycle

Injury


Degeneration








MALAISE

Inflammation








Activity

Pain

Biochemical







Mechanical
Imbalance







stresses to injury



CHEMORECEPTORS



MECHANORECEPTORS






Spasm


Blood Flow







Muscle action









(protective guarding)



Protective




Early onset fatigue


guarding





Fluid congestion


(
Reid 2011)


NEURAL
HYPER
-
SENSITIVITY

Where is the pain evoked?

Peripherally evoked

Centrally evoked

Stimulus / response fairly constant

on
testing

May not get positive / clear signs on
testing

Neuroanatomical pattern

May have summation, latency of high
sin

Symptom linkage

Allodynia / hyperalgesia

Often related to severe or prolonged
injury


Also consider autonomic effect: Sweating swelling skin
changes.

Look for symptom reproduction / resistance to movement.

Must use neural sensitizers to differentiate other structures

(Nee and Butler 2006; Welch
2011)

Lower Limb Nerve Anatomy


Sciatic Nerve



Femoral Nerve

LL Neurodynamic Testing

SLR


Supine (note pillows)


Passive straight leg raise (knee extended)


Add PNF, DF or hip internal rotation / adduction


Normal response: Posterior thigh, posterior knee and calf


Indications: All spinal and leg symptoms


Variations


DF and inversion (sural)


DF and eversion (tibial)


PF and inversion


Consider sequencing: Greater strain at the site moved first ? Response
localised to this site.

Direction of neural sliding influenced by order that body movements are added.

LL Neurodynamic Testing

Slump


Sitting with thighs supported and hands behind back


Flexion of spine


Cervical flexion


Active DF on asymptomatic side


Active DF on symptomatic side


Active knee extension on symptomatic side


Release of cervical flexion if symptoms reduced


NORMAL: Pain / pull mid Tx; Pain pull hamstrings / calf on DF and
knee extension; symptom decrease on release neck flexion / ankle PF.


Indications: Spinal symptoms, upper and lower limb symptoms

LL Neurodynamic Testing

Femoral Slump


Side lying head on pillow slumped. Lowermost knee hugged to
chest. Therapist stands behind


Uppermost knee flexion and hip extension.


Extend head and monitor response


NORMAL: Anterior thigh tension


Indications: Spinal and anterior leg symptoms



A positive test only indicates mechanosensitivity to elongation / compression
or lateral sliding.



It does not tell us the exact nervous system dysfunction.


Intraneural: Hypersensitivity of the nerve, AIGS development


Extraneural: Mechanical interface friction

Mechanical Interface Treatment


Opening dysfunctions:
tension / elongation: Close to start then progress into the opening
dysfunction and into neural provocation positions


Closing dysfunctions:
compression: Open to start then progress into closing positions
and into neural provocation positions


Can be:



Arthrogenic


Example: Lx rotation PPIVMS
= rotate away from side of pain opening IV foramen


AP glide fibular head


Myogenic


Trigger point / acupuncture


Taping to
offload: Inhibitory across muscle fibres. Neural offloading: reduces nociceptor
impulses


Example



Neural Massage


Intrinsic blood supply to nerve has multidirectional flow


Massaging up and down along the line of the nerve can reduce venous



stasis and improve neural circulation

(Welch 2011)

Nervous System


Aim to perform joint movements that elongate the nerve bed.


This increase nerve elongation / nerve tension and intraneural
pressure.


Sustained intraneural fluid pressure reduces blood flow =
ischemic changes.
(Myers et al 1986 cited in Coppieters and Butler 2007)


HOWEVER: Correct application of a dynamic version in
intraneural pressure may facilitate evacuation of intradural
oedema and reduce symptoms.
(Burke et al 2003 cited in Coppieters and Butler
2007).


GLIDING: Tensioning or Sliding technique??

Sliding and Tensioning

Sliding

Tensioning

Alternating

combined movements of at least
two joints.


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r敤畣敳u瑨攠t敲v攠扥搠汥湧瑨t畮l潡摩湧
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Movement

of one or several joints causing
nerve bed elongation in relation to
surrounding tissue.

Aim to mobilise the nerve with a minimal
tension increase

Result in larger longitudinal excursion than
tensioning

One ended: with the body: most neural
movement occurs mid joint range

One ended: tension occurs in outer range

Two ended: applying tension in one end and
letting go at another.

Two ended:

Elongation from both ends

Useful for pain

Useful

for the nerve to adapt to elongation

(Coppieters and Butler 2007; Welch 2011; Ellis et al 2012)

Physiological Effects

Sliders

Tensioners

Reduces sensitivity and restores

function,
thus easing the threat value of the injury.


THIS IS LIKELY TO; minimise the potential for
ion channel up regulation in dorsal root
ganglia and the CNS and limit the potential
for dorsal horn and brain changes

Reduce intraneural swelling and circulatory
compromise via fluctuating effects on
intraneural pressure.

Dynamic alteration of intraneural pressure
results in ‘pumping’ or ‘milking’ action.

Thought to enhance hydration and dispersal
of local inflammatory products.


Involve large amplitudes,

can be performed
actively and passively and can be integrated
into metamorphical movements thus
distracting the patient from the condition.

Limit fibroblastic activity and minimise scar /
adhesion formation.


Large range neutrally non
-
aggressive
movements allows movement to be
presented in novel ways the

brain. This
reduces fear avoidance and assists
remapping.





(Coppieters and Butler 2007)

References

Boyd BS, Wanek L, Gray AT, Topp KS. Mechanosensitivity during lower
extremity neurodynamic testing is diminished in individuals with Type 2
Diabeted Mellitus and peripheral neuropathy: a cross sectional study.
BMC
Neurology 2010, 10:75


Coppieters MW, Butler DS. Do
‘sliders’
slide and
‘tensioners’
tension. An
alalysis of neurodynamic techniques and considerations regarding their
application.
Manual Therapy 2007, doi10.1016 pp 1
-
9.


Coppieters MW, Stappaerts KH, Wouters, LL, Janssens K. The Immediate
Effects of a Cervical Lateral Glide Technique in Patients With Neurogenic
Cervicobrachial Pain.
Journal of Orthopaedic & Sports Physical Therapy 2003,
Vol 33: No 7 pp 369


378.


References

Ellis RF, Hing WA, McNair PJ. Comparrison of Longitudinal Nerve Movement
With Different Mobilization Exercises: An In Vivo Study Utilizing Ultrasound
Imaging.
Journal of Orthopaedic & Sports Physical Therapy 2012; Vol 42: No
8: pp 667
-
675


Hagert CG, Larsen AI, Jepsen JR, Kreiner S, Laursen LH. Editorial: Improving
application of neurodynamic (neural tension) testing and treatments: A
message to researchers and clinicians.
Manual Therapy 2005, 10, pp175
-
179.


Herrington L, Bendix K, Cornwell C, Fielden N, Hankey K. What is the normal
response to structural differentiation within the slump and straight leg raise
test?
Manual Therapy 13 2008 pp289


294.


Nee RJ and Butler D: Management of peripheral neuropathic pain:
Integrating neurobiology, neurodynamics, and clinical

evidence.
Physical Therapy in Sport 2006, 7 pp 36


49.




References

Reid. An Introduction to PathoNeurodynamics Handbook. 2011


Saranga J Green A, Lewis J, Worsfold C. Effect of a Cervical Lateral Glide on
the Upper Limb Neurodynamic Test 1: A blinded placebo
-
controlled
investigation.
Physiotherapy, 89, 11 pp678


684.



Shafer A, Hall T, Briffa K. Classification of low
-
back related leg pain
-
A
proposed patho
-
mechanism based approach.
Manual Therapy 14, 2009: pp
222


230.


Shacklock M: Neurodynamics.
Physiotherapy; January 1995, vol 1, no 1.


Welch H. Neurodynamics Masterclass handbook. 2011