One of the goals of clinical development as a physical therapist is recognizing the source of the problem and not just treating the symptoms. For example, if a shoulder hurts but the thoracic spine is not moving sufficiently, we want to include the thoracic spine in our management. If a knee is hurting during walking because of poor dorsiflexion mobility, we want to treat the dorsiflexion restriction. If a person cannot touch their toes because of poor lumbar flexion, it may be that proper motor control is lacking. Whatever the issue, we must be thorough with our examination to identify all contributing factors and the primary driving force.
One variation of this I regularly see is spinal mobility restrictions and neural tension. I typically will address both in the same treatment session, but often I will notice that neural tension will be eliminated or significantly decreased following treatment to the spine. This may include a manipulation, IASTM or repeated motions. Because of this, I rarely give nerve glides as an exercise for home. That doesn't mean nerve glides aren't effective. Even after treatment to the spine, some nerve tension can remain and be improved upon by addressing the neural tubes. In fact, I have come across patients that have greater responses to nerve glides than spinal treatment. This may be the case in your patients who inappropriately try "stretching their hamstrings" when neural tension is the issue. The nerve glides may be a novel movement to the peripheral nervous system, especially if there are greater restrictions peripherally. Because of this, your patients may express significant relief of pain and improvements in mobility following treatment.
As far as specific treatment goes, I recommend IASTM to the paraspinals of the innervating segments and anywhere along the path of the peripheral nerves. The joints that are crossed by the nerves and from which the nerve originate can be manipulated if restricted (or use other techniques like repeated motions). Additionally, think about addressing any tension points. I often will manipulate T6 for both upper and lower quarter patients and the TL junction for lower quarter patients. When addressing nerve mobility, glides and tensioners are often used. Both are effective, but glides have been shown to have greater nerve excursion (Coppieters and Butler, 2008). While I prefer to use nerve glides myself, I will use tensioners if performing a glide is difficult.
I should note that occasionally you will come across a patient that has adverse reactions to nerve tensioning. Aside from cauda equina syndrome and tethered cord syndrome, you should be careful with patients that are significantly centrally sensitized. You'll notice your patient feels worse following the treatment. I have found these patients have a high fear avoidance behavior, anxiety, or significant neural tension. In these cases, use your other methods to address nerve mobility restrictions.
Coppieters MW1, Butler DS. (2008). Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008 Jun;13(3):213-21.
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James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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