RSSNeurodynamic Testing – Coming of Age?
June 16, 2010 by David Fitzgerald
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Filed under Pain Mechanisms, Physiotherapy Blog
Neurodynamic or adverse neural tension assessment as a concept of examination and treatment became popular in the 1980’s. I had recently cause to reflect on how far things have come when I received a letter from my local Consultant Rheumatologist indicating that a patient he had assessed demonstrated a mild positive “Slump test”. What was most satisfying from my perspective was that the slump test (pioneered by a Physiotherapist) and utilised in routine musculoskeletal clinical practice has now transcended inter-disciplinary boundaries.
You may recall that Jeff Maitland was the first to describe the concept of a slump when he observed that patients reported an increase in their low back pain when flexing their head to get into a car seat. This coincided with a body of anatomical work from a Swedish Orthopaedic Surgeon Alf Nachemson, who performed much of the basic science research looking at neural tissue movement, its relationship to the interface and the mechanisms of pathophysiology.
Other pioneer’s in the field of peripheral neuropathic physiology were Sir Sidney Sunderland and Goran Lunborg. Both of these researchers contributed vastly to the understanding of peripheral nerve physiology and most importantly the nerve pressure gradient, which is the mechanism for understanding normal homeostasis across a peripheral nerve. In the early 1980’s two Australian Physiotherapists Bob Elvey and David Butler simultaneously described nerve sensitivity tests for the upper limb, which became known as the Brachial Plexus Tension Tests and have more recently been defined as the Upper Limb Neurodynamic Tests. These have become so widespread in Undergraduate Physiotherapy Curriculum’s that testing for neural sensitivity either in the axial skeleton or the peripheries is now considered a mandatory component of any physical examination performed by competent Manual Therapist’s.
My colleagues in Occupational Medicine tell me that it is becoming more prevalent to see Occupational Physicians describing normal or positive upper limb tension test responses in patients they examine. Over the years I have spent some considerable time training, studying and teaching with some of the above-mentioned experts and trying to impart some of this knowledge on the G.P. training schemes for which I have input. I must sadly acknowledge that I have never received a letter from a G.P. describing altered neurodynamics and do wonder whether these concepts have reached the broader aspects of application in musculoskeletal primary care.
Do any of you have evidence of neurodynamic evaluation by your referring physicians?
Perhaps this is a secret which should be kept amongst Physiotherapists and used as a silver bullet to resolve challenging pain problems where altered neurodynamics form part of the symptom pathology?
Let us know your thoughts.
PS The positive Slump test reported was actually localised dorsal sacroiliac ligament pain with pseudo sciatica from Piriformis syndrome but that’s a discussion for another day!!
Enjoy the clinical challenge.
David
Your term “extremes” fits nicely … or not so nicely depending on the point of view. But it is little to judge from the medical side, I am not good at it ! Thanks for sharing