Since 1991 when David Butler published his groundbreaking book “Mobilization of the Nervous System” there has occurred a fundamental change in the way SP.OR.T.S physical therapists evaluate and treat upper and lower quarter pain presentations. Mr. Butler was instrumental in taking the work of Alf Breig, M.D., and others who had studied the nervous system and its connective tissue coverings and making it useful in the assessment of the extensibility of the nervous system. Years ago it was considered inappropriate to place tension on the nervous system. Since this time it has become common for our Silver Spring physical therapists to evaluate and treat patients who demonstrate objective findings indicative of restricted neurodynamics.
The nervous system and its connective tissue coverings are innervated and subsequently, are capable of being a symptom source. As with other connective tissues in the body, the nervous system may respond to hypoxia from compression by developing fibrosis or through injury and inflammatory exudate by developing scar (Cantu and Grodin). The mobility of the nervous system is dependent on itself and upon the soft and hard tissue structures it spans.
Mechanical interfaces adjacent to the nerve such as bony foramina, osseous tunnels, or fibrous tunnels, etc. may affect its mobility. The goal of treatment in manual therapy is to restore pain-free and friction free mobility from restricted tissues and movement restriction can exist either in the mechanical interface related to the nerve, the somatic structures of the nerve, or the axon itself. Neuro-biomechanics are affected by structures which are adjacent to it: the mechanical interface. The mechanical interface moves independently of the nervous system (Shacklock). Because symptoms of somatic dysfunction may emanate from the connective tissues of the nerve a thorough examination is required to differentiate intraneural from extraneural dysfunction.
Because the nervous system which conducts both sensory (pain/proprioceptive) and motor signals to and from the central nervous system, problems related to either compression or limited excursion will affect the mechanical and/or chemical function (conduction of signals) of the affected nerve or nerves coursing through a region of the body. Symptoms may be either somatic (arising from the connective tissue elements-extraneural) which typically are of a familiar sensation like achy pain, or neurogenic (arising from the axon-intraneural) which may be unfamiliar such as burning, tingling, electric, hard to ease. In order to restore function to the affected nerve, it is incumbent on a physical therapist to understand the anatomy of the nerve pathway, the nerves motor innervation, and the peripheral distribution of sensory innervation. Understanding that a peripheral nerve distributes to a specific skin region and that from a segmental spinal nerve will distribute to a more diffuse area help in determining where the likely region of entrapment exists. The treatment of these problems which are surprisingly frequent are also frequently not assessed adequately by most physical therapists, but at Sports & Orthopaedic Therapy Services they are always a component of a typical examination for problems that may look like orthopedic problems such as tennis elbow, plantar fasciitis, etc.
Mr. Grossman has been teaching courses on the Assessment and Treatment of Altered Neurodynamics for years and has assisted David Butler to instruct in the Maryland area.
For more information, Contact us at Silver Spring, MD center.