Workshop 2

1. 10.03.2019
1
Mekanosensitivitet Hva er egentlig nevral mekanosensitivitet?
Mecahnosensitivity is thought to be a normal
protective mechanism that allows the nerves to
respond to the mechanical stresses imposed
upon them during movement
Bread & Butter - Neurodynamics
Nevrodynamiske tester
Er det i det hele tatt biologisk plausibelt ?
Mekanosensitivitet Nervepatologi BPS Modell
Nervepatologi
BPS Modell
Mekanosensitivitet Validitet av de nevrodynamiske testene
NTPT Overeks Medianus Radialis Ulnaris
Nee 2012 Cx radikulopati (svak evidens) Cx radikulopati (ingen evidens) Case study på cubital syndrom
Ingen hjelp ved CTS
Appelby – Albrecht 2016 Cx radikulopati (sterk evidens)
både for +ve og -ve
Cx radikulopati (svak evidens)
både for +ve og -ve
Cx radikulopati (sterk evidens)
både for +ve og -ve
Koulidis 2019 Systematic
Review
Validitet Testen
Gull
Standard
- Reproduksjon av symptomer
- Strukturell differensiering
- Falske positive hos normale

2. 10.03.2019
2
Nevrodynamikk i praksis
• NTPT
• Utgangsstilling ?
• Nakkeposisjon ?
• Hva er en positiv test ?
• Hva tester man egentlig?
- tensjon? strekk? lengde? smerte? CNS?
Butler DS (2001) The Sensitive Nervous System, Melbourne, Aus
Grunnleggende prinsipper
• Fortell pasienten akkurat hva du skal gjøre og hva de skal gjøre
• Du må ha resonnert deg frem til at du ønsker å gjøre testen før du
tester – ingen kliniske tester må gjøres på autopilot
• Når du kan, test aktivt først (anamesen?)
• Føl for motstand, smerte eller spenning
• Start posisjon må være konstant
• Smerterespons må defineres
• Do it well and properly, if not, dont fucking bother, do something else
(Helen Slater, personlig kommunikasjon 2006)
Quick test – screening – aktive prøver
Medial biasRadial bias
NTPT 1 - brachial plexus / medianus
Test for hele plexus C5- T1, med bias for medianus
NTPT 3 ulnaris NTPT 2 radialis

3. 10.03.2019
3
Straight Leg Raise L3-S2 SLUMP Test..L4-S2
Alternativ SLUMP Femoralis nerven L2-L4
Nerve palpasjon et forglemt verktøy for vurdering av
mekanosensitivitet i nervesystemet
This study provides support for
the use of nerve palpation in
clinical examination, with
evidence of excellent reliability
and diagnostic accuracy as well
as validity of manual palpation
for three lower limb nerve sites.
Palpasjon av nerverøttene ”Door bell”
• Palper anteriore (C4),C5,C6,(C7)
• Landmark: C6 bredest / enklest
• C8 og Th1 ikke mulig å palpere,
men komplett plexus er mulig

4. 10.03.2019
4
Nervepalpasjon medianus C6-T1 Nervepalpasjon ulnaris C8-T1
Nervepalpasjon radialis C5-T1 Nervepalpasjon
• Peroneus nerven (PF, PF & Inv)
1. Common peroneus nerve
2. Superfisiale peroneus nerve
Nervepalpasjon
• Tibialis nerven
Ischias
Tibial
CPN
Nervepalpasjon
• Suralis nerven (DF, Inv)

5. 10.03.2019
5
Nervepalpasjon
• Fibularis nerven
Nervepalpasjon
• Ischias / Sciatic nerven
Nervepalpasjon
• Femoralis nerven L1 – L3
Perifere Nerver verdt å tenke over #triggerpunkter
Hvor ofte opplever du dette i klinikken?
Hyperalgesi
Sekundær
hyperalgesi
Allodynia Wind up

6. 10.03.2019
6
Og hva betyr det egentlig ?
Hyperalgesi
Hyperalgesia (/ˌhaɪpərælˈdʒiːziə/ or /-siə/;
'hyper' from Greek ὑπέρ (huper, “over”), '-
algesia' from Greek algos, ἄλγος (pain)) is an
increased sensitivity to pain, which may be
caused by damage to nociceptors or peripheral
nerves and can cause hypersensitivity to
stimulus, stimuli which would normally not be
cause for a pain reaction
Og hva betyr det egentlig ?
Sekundær
hyperalgesi
Secondary hyperalgesia is a centrally-mediated
condition that may occur due to injury or disease in
an area of the body. Secondary hyperalgesia is
defined as an increase in pain sensitivity when a
noxious stimulus is delivered to a region
surrounding, but not including, the zone of injury
(increased pain sensitivity outside of the area of
injury or inflammation). Secondary hyperalgesia is
due to central neuron sensitization and requires
continuous nociceptor input from the zone of
primary hyperalgesia for its maintenance.
Og hva betyr det egentlig ?
Allodynia
Allodynia means pain due to a stimulus that does not
normally provoke pain and is mostly used as a synonym
for “Touch evoked hyperalgesia” (e.g., pain evoked by
stroking the skin with a wisp of cotton wool). This kind of
stimulation does not excite nociceptors – even in their
sensitized state. It excites sensitive mechanoreceptor
units belonging to “another sensory modality.” It typically
occurs in an inflamed area, but also in a surrounding
secondary zone, and therefore has been attributed to
altered central synaptic processes.
Og hva betyr det egentlig ?
Wind
up
Abnormal Temporal Summation (“wind-up”):
Repeated stimuli (e.g., touch) delivered in rapid
succession to the skin are normally felt
individually, or as vibration. Patients with
neuropathic pain sometimes report that light
touch stimuli repeated about once per second
cause a sensation that builds up abnormally into
an intensely painful crescendo.
Kvantitativ Sensorisk Testing
SENSORISK PROFILERING

7. 10.03.2019
7
Hvordan kan vi gjøre det i klinikken?
Berøring Vibrasjon Skarp Trykk
Hvorfor bruke tid på dette ?
• Currently pain diagnosis is
primarily based on signs and
symptoms, sometimes in
combination with clinical evi-
dence of structural/tissue damage.
However, this diagnosis provides
limited information regarding the
mechanisms underlying the pain
experience of the individual
patient. It has been suggested that
pain diagnosis and management
should be mechanism-based [49].
Hvordan formidle funn til pasienter?
• Historien – the narrative
• Kommunikasjon – pitching
• Metaforer – linken
• Beliefs – for å kunne utfordre
• Mening – gi mening til plagene
• Refleksjon – gi mening for oss
• Dialog – på samme nivå
• Compliance ??
Nevrodynamiske tester & sensorisk profilering
Diagnostikk
Mening
Beliefs
THIS IS
PHYSIO
Smerte
mekanismer