Mobilization of the Neural Tissue 2020 PDF

MOBILIZATION OF THE NEURAL TISSUE UNIT 2. Pathological processes in the NS Manual Therapy I Arturo Pérez Gosálvez CEU-Universidad San Pablo PATHOLOGICAL PROCESSES • PLACES OF INJURY. • TYPES OF INJURY. • PATHOLOGICAL PROCESSES. • OTHER FACTORS TO CONSIDER. • ADVERSE NEURAL TENSION. 2 PLACES...

MOBILIZATION OF THE NEURAL TISSUE UNIT 2. Pathological processes in the NS Manual Therapy I Arturo Pérez Gosálvez CEU-Universidad San Pablo PATHOLOGICAL PROCESSES • PLACES OF INJURY. • TYPES OF INJURY. • PATHOLOGICAL PROCESSES. • OTHER FACTORS TO CONSIDER. • ADVERSE NEURAL TENSION. 2 PLACES OF INJURY 3 PLACES OF INJURY • 1. Bone tunnels, fibro- osseous or soft tissue: • 2. Places where the NS is more fixed: – They act as no flexible walls! – Decreased ability sliding. – Possible friction. – Example: Head of fibula (peroneal nerve). – Example: Carpal tunnel. PLACES OF INJURY • 3. NS branch locations (ramification): – Decreased ability of sliding. – Example: Braquial plexus • 4. Places where the NS is near to rigid interfaces: – Friction is favored – Example: Guyon´s canal. • 5. Stress/tensión points: – The combination of movements can generate them… PLACES OF INJURY • There is a greater susceptibility to suffer affectations in previously damaged areas. • Also injuries in a relatively vulnerable segment may have implications in more vulnerable areas. TYPES OF INJURY. 7 TYPES OF INJURY • Mechanical and physiological consequences. • ¡Remember neurophysiology!: It is not necessary that exist very serious trauma. • It is not necessary a direct injury to the NS : changes in the mechanical interface. TYPES OF INJURY 1. According to the form of appearance and time of evolution: • CHRONIC INJURIES: – Allow some degree of adaptation to NS. – Insidious alterations. • ACUTE INJURIES: – They can generate more serious consequences. – Sudden alteration in blood flow and axonal transport and mechanical deformation of the nerve fiber. TYPES OF INJURY 2. According to injury location: • INTRANEURAL PATHOLOGY: • EXTRANEURAL PATHOLOGY: – Affect the conducting or connective tissues. – It involves the mechanical interface. – Although the NS can move, decrease its elasticity. – Affectation nerve movement on the interface. – Example: Arachnoiditis – Example: Lumbar spinal stenosis. PATHOLOGICAL PROCESSES 11 PATHOLOGICAL PROCESSES • 1. Vascular Factors . • 2. Mechanical Factors. • In the early stages vascular factors tend to predominate PATHOLOGICAL PROCESSES • 1. VASCULAR FACTORS: – Need for blood supply. – Intraneural circulation needs a proper pressure gradient. – Any alteration in the container may alter the pressure gradient. PATHOLOGICAL PROCESSES • 1. VASCULAR FACTORS : – If a pressure rise occurs => drainage weakens (20-30 mmHg). – Hypoxia as initial state. – If continuous hypoxia, endothelial damage and capillary occurs, presenting a rich protein edema. – Then fibroblast proliferation occurs, leading to intraneural fibrosis. • Vicious circle => fibrosis increases pressure. INJURY PRESSURE RISE VICIOUS CIRCLE VASCULAR DRAINAGE WEAKENS INTRANEURAL FIBROSIS HYPOXIA (initial state) RICH PROTEIN EDEMA ENDOTHELIAL AND CAPILLARY DAMAGE 15 PATHOLOGICAL PROCESSES • 2. MECHANICAL FACTORS : – These factors can injure connective and neural tissue. – Epineurium: reactive tissue to mechanical factor: • Possible tear and edema (ex: ankle sprain). • It does not usually affect nerve conduction. PATHOLOGICAL PROCESSES • 2. MECHANICAL FACTORS: – Stretching is more harmful than compression. – Be careful!!, mechanical forces also produce injuries through rupture of blood vessels. – It would be possible that coexist in the lesion mechanical and vascular factors. PATHOLOGICAL PROCESSES • 3. INJURY AND AXONAL FLOW: – The axonal flow requires energy: blood supply. – Alteration in axonal flow if there is reduction of this contribution. – Changes in the cell body, axon and synapses… PATHOLOGICAL PROCESSES • 3. INJURY AND AXONAL FLOW – ¿ What pressure causes alterations in it? • 20 mmHg during 8 hours. • 30 mm Hg during 2 hours. – Reversible alterations. • 50 mm Hg during 2 hours produce reversible symptoms in 24 hours. • 200 mm Hg during 2 hours: reversible in 3 days. • 400 mm Hg during 4 hours: reversible in 1 week. PATHOLOGICAL PROCESSES • 4. FIBROSIS – Final state of any injury of the NS. – The changes produced locally can encourage the emergence of further injury : • Changes in a zone alterate all the NS. • Axoplasmatic flow alteration, affects the entire/ whole neuron. • Coexistence of mechanical and vascular factors. PATHOLOGICAL PROCESSES • “DOUBLE CRUSH SYNDROME”: – Small grips on the nerve may have an added effect, causing distal neuropathy by entrapment. – May be distal or proximal. – By altering the axoplasmatic flow. • Predisposes to mechanical deformation of the nerve. PATHOLOGICAL PROCESSES • 5. PAIN IN NERVOUS SYSTEM: – Conective tissues: • Nociceptive origin. • Special importance of the dura- mater. – Peripheral nervous trunk: Dysestesic • Pain through nervi- nervorum. “Trunk pain” PATHOLOGICAL PROCESSES – Neural tissues: • Ectopic pulses by compression, stretching or vascular injury/lesion. • Downloads by formation of neuromas. • Overactivity of C fibers. • Abnormal synapse by myelin injury. 23 OTHER FACTORS TO CONSIDER 24 OTHER FACTORS TO CONSIDER • ATYPICAL ANATOMY OF THE NS: – Changes in normal morphology produce greater chance by nerve entrapment. – Frequent changes: 10% -15% of the population. OTHER FACTORS TO CONSIDER • TIMEOUT AFTER INJURY : – The nervous system adapts well to a tension or pressure during time. – More damaging the sudden injuries. • The slow processes allows some protection, but also increases the irreversibility of the same. ADVERSE NEURAL TENSION 27 ADVERSE NEURAL TENSION • “It is the set of abnormal/atypical, physiological and mechanical, responses from NS structures when their normal motion amplitude and stretchability are tested.” • The presence of alterations in the normal mechanics of NS can produce signs and symptoms of various kinds. • These alterations in the normal mechanics may be due to different pathologies.