Transcript Spinal Stenosis

September 5th – 8th 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
Summary
Influence of
neurodynamics
Case Study
Pain and
Pathoneurodynamics
Clinical Manifestation
and Patient
Presentation
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
movement of the nervous system to
slide, move and elongate in relation
to surrounding tissue.
Physiological
Impulse generation and conduction.
• 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)
Pathoneurodynamics
• Changes in neural
dynamics or physiology
may lead to
pathoneurodynamics.
Neurodynamics
Mechanics
Physiology
(Shacklock 1995)
• High likelihood in
postoperative
decompression patient
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:
Cranium
Muscles
Blood
Vessels
Nerve
Roots
Tendons
Neuraxia
Central
Peripheral
Fascia
Bone
Meninges
Ligaments
Discs
(Nee and Butler 2011)
Cranial
Nerves
Injury / Degenerative Cycle
Injury
Degeneration
MALAISE
Inflammation
Activity
Pain
Biochemical
Imbalance
Mechanical
stresses to injury
MECHANORECEPTORS
CHEMORECEPTORS
Spasm
Blood Flow
Protective
guarding
Fluid congestion
(Reid 2011)
NEURAL
HYPERSENSITIVITY
Muscle action
(protective guarding)
Early onset fatigue
Where is the pain evoked?
Look for symptom reproduction / resistance to movement.
Must use neural sensitizers to differentiate other structures
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
(Nee and Butler 2006; Welch
2011)
• Also consider autonomic effect: Sweating swelling skin
changes.
Lower Limb Nerve Anatomy
Sciatic Nerve
Femoral Nerve
LL Neurodynamic Testing
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.
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
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.
• One movement lengthens the nerve bed.
• The other movement simultaneously
reduces the nerve bed length unloading
the nerve
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.
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.
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
Involve large amplitudes, can be performed
actively and passively and can be integrated
into metamorphical movements thus
distracting the patient from the condition.
Large range neutrally non-aggressive
movements allows movement to be
presented in novel ways the brain. This
reduces fear avoidance and assists
remapping.
Limit fibroblastic activity and minimise scar /
adhesion formation.
(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