709 1.8-1.9 Neurodynamic Assessment and Treatment in Physiotherapy

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Questions and Answers

What is the first and most common way the nervous system is involved in musculoskeletal conditions?

Transmission of messages by intact nerves (correct)

Altered reflexes in the nervous system

Increased sensitivity of the receptors

Irritation of the nerve roots

Which type of testing assesses altered transmission by the nervous system?

Neurological testing (correct)

Reflex testing

Sensory testing

Neurodynamic testing

What results from irritation of nerve roots according to the text?

Carpal tunnel syndrome

Radicular symptoms (correct)

Piriformis syndrome

Increased sensitivity of nerve receptors

What distinguishes neurodynamic testing from neurological testing?

The intention behind the test Signup and view all the answers

How is increased nerve sensitivity assessed?

By using neurodynamic testing Signup and view all the answers

What can remain even after removing the source of irritation according to the text?

Increased sensitivity and pain from the nerve itself Signup and view all the answers

What is the primary consideration for deciding if neural mobilisation should be part of the treatment strategy?

Symptoms produced during the test Signup and view all the answers

Which of the following is true about neurodynamic treatment techniques?

They can be adjusted to maximize the change in targeted movement. Signup and view all the answers

What is the purpose of neurodynamic treatment techniques?

To decrease sensitivity of nerve movement Signup and view all the answers

How are sliders and tensioners classified in neurodynamic treatments?

Similar to Grades III and IV techniques Signup and view all the answers

What does a positive neurodynamic test indicate?

That a nerve is more sensitive Signup and view all the answers

When using manual therapy to target articular structures, why is it important to reassess active and/or functional movements?

To ensure changes made are relevant to patient's symptoms Signup and view all the answers

What is the primary focus when using neurodynamic techniques?

Affecting the nerve interface with articular structures Signup and view all the answers

Which factor determines whether targeted neurodynamic movement has improved?

Symptom improvement after treatment Signup and view all the answers

What do sliders and tensioners represent in neurodynamic treatments?

Different grades of treatment intensity Signup and view all the answers

What does a positive neurodynamic test signify?

The nerve exhibits increased sensitivity Signup and view all the answers

What is the trigger for performing an upper limb neurological assessment in a patient with a musculoskeletal condition?

Presence of neurological symptoms or symptoms below the shoulder Signup and view all the answers

When are muscles most commonly painful?

As a result of direct trauma or sustained contraction Signup and view all the answers

How is stability defined according to Richard Bellman in the text?

As a term with an unstable definition Signup and view all the answers

What are the components that determine stability in the spine?

A combination of non-contractile and contractile components Signup and view all the answers

When muscles are tender in tension and compression, what makes determining if the muscle is injured challenging?

Referred pain to the area Signup and view all the answers

What is the common source of nociception in back pain according to the text?

Muscles Signup and view all the answers

In what situations can muscles be painful?

As a result of direct trauma or sustained contraction Signup and view all the answers

'Force and control' are important aspects of muscle function when performing what kind of activity?

'Force and control' work together when performing any functional activity. Signup and view all the answers

'Core strength' is related to the concepts of stability and instability in which part of the body according to the text?

'Core strength' is related to the lumbar spine. Signup and view all the answers

'MSK Neurological Screening' provides guidance on how to perform what kind of screening?

'MSK Neurological Screening' provides guidance on how to perform neurological screening. Signup and view all the answers

What is the primary function of neurological testing?

Assessing the ability of nerves to conduct messages Signup and view all the answers

Which assessment evaluates the sensitivity of nerve structures?

Neurodynamic testing Signup and view all the answers

Why is it important to perform neurodynamic testing selectively?

Only when it provides useful information for management Signup and view all the answers

How can sensitising maneuverers help in neurodynamic testing?

By increasing or decreasing tension on neural structures without affecting shorter structures Signup and view all the answers

What is a possible limiting factor in straight leg raise (SLR) if ankle dorsiflexion increases pain?

Sciatic nerve tension Signup and view all the answers

Why are neurodynamic tests expected to be painful to some extent?

As a sign of neural dysfunction Signup and view all the answers

What is the purpose of comparing with the opposite side in neurodynamic testing?

To determine if neural movements are normal for the individual Signup and view all the answers

When should neurodynamic testing be avoided?

When a client has a radiculopathy Signup and view all the answers

Which technique can help determine if hip joint tension is limiting straight leg raise (SLR)?

Bending the knee during SLR Signup and view all the answers

What is an important consideration when assessing positive neural tests?

Positive test does not necessarily mean neural dysfunction Signup and view all the answers

Why does the central nervous system closely monitor threats to spine stability according to Reeves et al. (2019)?

To prevent segmental instability caused by erroneous motor control Signup and view all the answers

What can a habitual pattern of movement that holds the lumbar spine at the limit of extension predispose an individual to?

Developing low back pain Signup and view all the answers

Why might a person continue a movement pattern that exacerbates their low back pain?

It is the only strategy they know for comfort Signup and view all the answers

What can altered muscle activation strategies in response to pain lead to?

Increased muscle activity as pain resolves Signup and view all the answers

How might a person's maladaptive response to low back pain be described?

Counterintuitive and making symptoms worse Signup and view all the answers

What does Reeves et al. (2019) suggest about the protecting mechanisms for the spine?

They may be problematic in an injured spine Signup and view all the answers

In what conditions might people have altered patterns of muscle recruitment in response to pain?

'Low back pain with movement coordination impairments' Signup and view all the answers

What are some possible outcomes when people develop mal-adaptive motor recruitment strategies?

'Unknown contribution to pain episode' Signup and view all the answers

'Active extender' is used to describe individuals who:

'Hold their lumbar spine at the limit of extension' Signup and view all the answers

In what way might altered muscle activation strategies affect individuals as their symptoms resolve?

Increased or decreased levels of muscle activity Signup and view all the answers

What is a predominant impairment seen in a subgroup of LBP and SIJ dysfunction population?

Altered movement patterns Signup and view all the answers

What is a natural response to experiencing low back pain?

Increasing co-contraction of global muscles Signup and view all the answers

What could persisting protective movement patterns in response to low back pain potentially lead to?

Increased strain on damaged tissues Signup and view all the answers

What is an important step before progressing to core muscle strength training in clients with movement coordination impairments?

Assessing and recovering individual muscle activation patterns Signup and view all the answers

Which approach is recommended for muscle re-education to address presenting impairments?

Motor learning approach Signup and view all the answers

Which muscle can show an overflow of contraction from isometric gluteus maximus contraction?

Lumbar multifidus Signup and view all the answers

What are the four stages into which muscle re-education can be divided according to the text?

Attention, Intention, Action, Reflection on action Signup and view all the answers

What is the primary focus of Stage 3 in the exercise prescription framework?

Increasing the level of challenge in more functional positions Signup and view all the answers

Why is the exercise in Stage 3 done on an unstable surface?

To challenge trunk muscles for dynamic stabilisation Signup and view all the answers

In which stage of healing would a client with ongoing pain benefit from more dynamic stabilisation?

Stage 3 Signup and view all the answers

What is one of the validated functional assessments for strength in the lumbar spine?

Maximal capacity to keep upper body horizontal in prone position Signup and view all the answers

How long is the client instructed to hold the upper body in a horizontal position during the Biering-Sorensen test?

240 seconds Signup and view all the answers

What is associated with chronic low back pain according to the text?

Excess fatigability of lumbar extensor muscles Signup and view all the answers

When should the Biering-Sorensen test be terminated?

If the client or tester deems it necessary Signup and view all the answers

Which muscle activation mechanism improves lumbar stability by applying tension to the thoracolumbar fascia?

Increasing intra abdominal pressure Signup and view all the answers

In the framework for core stability training, what is the focus of Stage 1?

Pain control Signup and view all the answers

Which muscle group is preferentially activated during supine exercises in the early stages of rehabilitation?

Transversus abdominis and internal oblique abdominis Signup and view all the answers

What is the aim of Stage 2 in the core stability training framework?

Restore movement in the affected area Signup and view all the answers

What can instability at one level be accompanied by according to the text?

Hypomobility at an adjacent level Signup and view all the answers

Which factor might instability at one level be due to according to the text?

Mechanical joint restriction Signup and view all the answers

What type of exercises are appropriate for clients in Stage 2 of rehabilitation according to the text?

'Rotation-aggravated' movements only Signup and view all the answers

What should clients focus on when their symptoms reduce with repeated movement in one direction?

'Smooth coordinated movement with control' in that direction Signup and view all the answers

What does paying attention to movement help clients retrain according to the text?

'Proprioceptive-rich stabilising muscles' Signup and view all the answers

What allows practitioners to provide verbal and tactile cues for quality and efficient movement?

'Observation of the quality of movement' Signup and view all the answers

Study Notes

Neurological Testing vs Neurodynamic Assessment

Neurological testing assesses the ability of nerves to conduct messages by evaluating afferent (sensory), efferent (motor), or combined (deep tendon reflexes) functioning of the nervous system.
Neurodynamic assessment assesses the sensitivity of nerve structures, particularly when they are put on tension.

Principles of Neurodynamic Assessment

Neurodynamic testing determines whether there is increased sensitivity of the nerve itself or whether there is a loss of conduction.
Neurodynamic testing can be quite provocative, so it should only be performed when it will provide useful information that has the potential to change one's thinking or management plan.
The neural structures being assessed are longer than either the articular or muscular structures.

Neurodynamic Testing Procedures

Neurodynamic testing procedures progressively tension the neural structures.
Sensitising maneuverers are used to either increase or decrease tension on the neural structures without affecting the other, shorter structures.
Examples of sensitising maneuverers include:
- Flexing the hip with the leg straight to test for tension on the sciatic nerve.
- Dorsiflexing the ankle to increase tension on the sciatic nerve.

Interpreting Neurodynamic Test Results

A response to the sensitising manoeuvres indicates that neural structures are being assessed by the movements.
The response to the sensitising manoeuvres must be compared to the opposite side or clinical judgement to determine if the range of movement in the test is normal for the individual.
A positive test does not necessarily mean treatment should target neural sensitivity.

Lumbar Spine Instability

The way someone moves can predispose them to developing low back pain.
Habitual patterns of movement can predispose individuals to developing LBP.
Maladaptive responses to pain can lead to further injury.

Muscle Activation and Movement Coordination

Muscle activation and movement coordination are important for spine stability and movement.
Altered muscle activation strategies in response to pain can lead to maladaptive movement patterns.
Assessment of lumbar spine clinical and structural instability is important for developing effective treatment plans.

Neurodynamic Treatment Techniques

Neurodynamic treatment techniques are intended to reduce the sensitivity of movement of the nerves.
Treatment techniques can be adjusted to maximise the change in the targeted movement.
Reassessment is critical to ensuring the relevance of the treatment.

Slider and Tensioner Techniques

Slider techniques are analogous to Grade I or II treatment techniques.
Tensioner techniques are similar to Grades III and IV treatment techniques.

Summary of Neurodynamic Testing and Treatment

Neurodynamic testing will be positive when a nerve is irritated by an interface or has increased sensitivity of the nerve itself.
The tests put tension on the entire length of the structure from the nerve roots to the peripheral receptors.
Treatment will target the nerve structures when either the interface cannot be altered directly or the irritation has been present for a period of time such that the nerve itself has become sensitised.### Pain-Related Adaptive Inhibition and Impairments
Pain-related adaptive inhibition can occur in the deep stabiliser muscles of the lumbar spine (TrA, Internal Oblique, Diaphragm, and Pelvic floor muscles) in individuals with LBP and SIJ dysfunction.
This inhibition can lead to impaired movement control and coordination in the lumbopelvic region, with or without associated mobility deficits and referred pain to the leg.

Protective Response and Adaptive Co-Contraction

When people experience low back pain, they naturally respond by protecting the affected area, which often involves increasing co-contraction of the 'global' muscles that span the entire spinal region.
This increased stiffness and altered movement patterns are an adaptive response in the short term, allowing for the healing process to proceed without ongoing injury.
However, if this protective movement pattern persists, it can reduce the necessary movement for normal spinal nutrition and remodelling of damaged tissues, potentially placing greater strain on previously damaged tissues.

Assessing and Recovering Muscle Activation Patterns

Assessing and recovering individual muscle activation patterns of deep stabilisers can help reduce the adaptive co-contraction of global (superficial) mobilisers, reducing the load and pain irritability, and regaining segment control during functional activity.
Addressing muscle activation impairments plays a crucial role before progressing with core muscle strength training programs in clients with movement control or coordination impairments due to neuro-musculoskeletal pain conditions of the lumbopelvic region.

Muscle Re-Education and Motor Learning Approach

Muscle re-education can be an effective strategy to address presenting ongoing impairments, regardless of the type of altered motor or muscle recruitment strategy.
Enhancing neuromuscular performance can improve the ability of the muscle to resist deformation and react by generating the desired amount of force to carry out the planned movement.
Muscle re-education involves four stages: Attention, Intention, Action, and Reflection on Action.

Strategies for Assisting Clients in Activating Lumbar Spine Stabilising Muscles

Several strategies can be used to assist clients in activating their lumbar spine stabilising muscles, including:
- Conscious activation of TrA and IO using exhalation
- Activating pelvic floor muscles
- Body position changes (gravity on abdominal wall)
- Lumbar multifidus activation using overflow of muscle contraction from isometric gluteus maximus contraction

Dynamic Control and Functional Re-Education

Stage 3 of muscle re-education involves dynamic control and functional re-education, which includes:
- Increasing the level of challenge in more functional and gravity-dependent positions
- Less assistance
- Targeted toward the goals of clients
- Task-specific focus for neuro-musculature re-education
- Moving from foreign to familiar environments
- Adding endurance

Framework for Core Stability Training

The framework for core stability training involves three stages:
- Stage 1: Pain control (stabilisation, short-term)
- Stage 2: Begin controlled loading (commence usage that has a positive effect on the affected area through mobilisation exercises)
- Stage 3: Dynamic control and functional re-education

Applying the Framework for Core Stability Training

The framework can be applied in a non-linear fashion for clients with re-injury or chronic low back pain, with force moderation for presentations at different stages of healing.
Clients with ongoing or recurring episodes of pain require an approach that includes more dynamic stabilisation to assist in resolving impairments.
Pain control and biomechanical counselling are essential elements for all clients, regardless of the stage of healing.

Exercise Prescription and Assessment

Exercise assessment involves observing movement and using objective measures of strength, such as the Biering-Sorensen test and lateral stability using the side plank.
Measuring strength isometrically can provide valuable information, and exercises can be progressed to more functional and dynamic activities.

Deep Trunk Stabiliser Muscle Activation

The deep trunk stabiliser muscle activation helps to improve lumbar stability through three mechanisms:
- Applying tension to the thoracolumbar fascia (mechanical stiffness)
- Increasing intra-abdominal pressure (in coordination with the diaphragm and pelvic floor muscles)
- Providing a small amount of flexion torque

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Description

Learn about how physiotherapists assess and treat conditions related to the nervous system in musculoskeletal practice, including pain from stimulation of peripheral nociceptors and nerve-related issues. Explore the importance of neurodynamic assessment and treatment techniques.