Median Nerve Neurodynamics

Hi everyone,

This blog post will be a quick one. I often utilize the upper limb tension tests (ULTT) to assess patients with pain and other radicular symptoms going down the arm. I check first the unaffected side and then the affected side to compare asymmetries and also use it for mobilization of nerve roots. However, as a reoccuring theme I have been aggressive with my tension tests in the past just like so many  other techniques and have had less than favourable results. So in accordance with my ‘less is more’  thought process (in terms of pressure/force/aggressivness) I have made some tweaks in how I perform my nerve mobilizations. This is especially true for ULTT and LLTT tests and mobs because these are provocative manuvers and ‘I like lightning bolts running down my arms and legs’ said NO ONE EVER. Today we will discuss Median Nerve Neurodynamics.

Components of Median nerve neurodynamics involve-

  1. Shoulder abducted to about 60 degree. (Initially, I’d abduct to around 90-110. However, Butler and his colleagues at the NOI group have suggested that shoulder abduction at 60 degrees puts the most tension on the Median nerve root and my patients also seem to tolerate this a little better so I now do it at around 60).
  2. Shoulder depression (I have stopped pushing down on it too much as it can be very aggressive and threatening to some patients. I just try to avoid shoulder hiking).
  3. Full external rotation of shoulder.
  4. Full elbow extension.
  5. Full forearm supination. (In the past, I would often leave some slack here due to focusing on shoulder depression. Try to get end range supination).
  6. Full wrist extension.
  7. Full finger extension. (Important to make sure that the PIP and DIP do not flex).

Here is a video demonstration of the test with some variations.

 

Please note that in one of the mob variation with elbow movements, I do not press the wrist down into complete extension. That is because prior testing of this variation of nerve mobilization was very threat inducing and provocative and I didn’t want to be very aggressive.

What are your thoughts? Do you have some tweaks on hand placement, body positioning, force applied or different variations?  I’d love to hear it.

In the next blog post we will discuss some home exercise programs (HEP) for self mobilization. Happy flossing (but go a little easy maybe). Until next time.

Pursue excellence.

Abhijit Minhas

(BPT, MS, CMP, FMT)

 

My Course Review 2- The Certified Mulligan Practitioner Exam

Greetings

Part deux of this blog is not really a course review but my thought on taking the Certified Mulligan Practitioner exam. To begin, I’ll say this, you don’t need to be a Certified Mulligan Practitioner (CMP) to be a good therapist. I know many physios who are great clinicians but haven’t taken the CMP exam. The Certified Mulligan Practitioner exam is a test to check your competency in Mulligan concept principles and application of  techniques passing which you get the title CMP. Like I mentioned in the last blog, the Mulligan concept does not cover a whole lot on assessment/diagnosis. So the testing skips that part too.

What to expect in the test-

I gave the test back in 2010 and back then the test had two components. I have heard that the format has not changed a whole lot but don’t quote me on this.

Written Component- consisted of 50 MCQ’s.   The Multiple choice questions which seemed tricky and often felt like they had more than one correct answer (they did not) was the easier part of the exam in my opinion.

The practical component- I believe was demonstration of 10-15 techniques (approx).  Successfully passing the exam requires the test taker to be competent in each and every technique of the book and one would be asked to demonstrate any random 10-15 techniques covering all bases. This included everything- NAG’S, SNAG’S, MWM’S, SMWAM, SMWLM, headache SNAG’S, belt techniques, BLR, taping techniques etc. The practical component was conducted by two Mulligan Concept Teachers Association (MCTA) members; in our case one local from India and one from Australia.

Passing requires around 80% scores (approx) and attention to detail is important making sure one applies all the 7 principles of the concept when performing the techniques.

Is it worth it?

I can see why this question would cross someone’s mind. After all, one doesn’t need the title to practice in  the profession or even to apply these techniques. You could just do the workshop/seminar course and still apply the concepts in your clinical practice. However, in my opinion it is worth it. Going through the extra grind has its advantages. I’ll give you not one but…. two!!

  • Early on in my career as a new grad, I always used my CMP credentials to bag better than average job opportunities and a little higher than average salary  that a new physio would expect. To the new graduates starting their career in physiotherapy I’d say this, physio school will teach you the basics and how not to harm a patient but some of the curriculum is not up to date with the latest in the field and taking certifications will improve your overall clinical skills. It will also make you a more desirable candidate in the job market. Good physiotherapy offices value continuing education certifications and titles. CMP is a good title to have.
  •  On becoming a CMP, you become part of the network of Certified Mulligan Practitioners. The database for a full list of CMP’s across the world can be found on the Mulligan website here.. This directory can sometimes be a good source of referrals for new patients/clients. I have had other mulligan practitioners refer patients who were around my practice and I have also had patients use this directory to find me directly. It can be quite a useful tool.
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It is worth it!

Hope this information helps. More course reviews to follow in some upcoming blogs. Lets keep the dialogue going. Until next time.

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

My Course Review 1- The Mulligan Concept

This is my first blog post review on a workshop/course so it only makes sense that I write about one of the most pivotal workshops early on in my career. Drum roll, ‘The Mulligan Concept’.

Before we begin, I would like to take you’ll on a little flash back in history back to 2009. I was in my 4th and final year and was about to graduate with my bachelors in physiotherapy degree. Needless to say, I was still trying to put all the pieces of the puzzle together (almost a decade later and I still am!) and quite frankly struggling at it. By now I was expected to be able to figure out what was going on with my patients. I could follow the SOAP procedure to get all the information like I was taught but was unable to put it all together. To make matters worse, the few things that I had truly mastered at the end of my 4 years was how to make near perfect loopy circles on the body while giving  ultrasound and mastered not to electrocute patients on  modalities (that’s right, a slight exaggeration). Modalities were the biggest arsenal in my ‘physio toolkit’ along with some very basic home exercises and frankly it did barely something if anything to my patients pain scores or any other outcomes. It didn’t matter if the machines now had digital panels instead of the knobs, they were all a let down. Maybe I relied on modalities too much (In fact now I know that really was the case). But what else was out there? I had not even started my internship and the future didn’t look so promising. I was looking for a way out. And then…

Enter the Mulligan Concept

This 8 day workshop was everything I need at that time (almost everything). It was a real game changer. Taught by a dynamic and engaging teacher who was also a great role model for a young physio student, the concepts looked pretty straightforward and gave me new hope. I began using the techniques right away and as many physios have reported alike, the results were just like how Brian Mulligan would describe it instantaneous and almost miraculous.

Before we proceed, full disclosure, I am a Certified Mulligan Practitioner and I am biased to this approach in physiotherapy. But I’m even more biased at presenting accurate information through my experience in this blog. So here is my take on what I liked and disliked in this concept-

The Good

  • The 7 general principles of the Mulligan concept apply to every technique on every joint in the body. Now there are many techniques (NAG’s,Reverse NAG’S, SNAGS, MWM’s, SMWAM’s, SMWLM’s, belt assisted MWM’s etc) and even more joints in the body. However, there are no exceptions to the rule.
  • When a particular glide is applied correctly and it works good to reduce pain with a certain movement, it works just great.
  • If you follow the general rules of the concept, chances of aggravating patients symptoms are slim. All movements must be pain free or should reduce pain with every repetetion.
  • The concept focuses on function and I’m a big fan of that. If squatting hurts, your glides will preferably be in squatting, if its walking that gives your patients some grief, the glide is applied in walking (a little difficult) and so on. I’m not a big fan of prolonged passive treatments on a bed if the chief complain is doing some activities. Weight bearing and movement is not just encouraged, its a principle.
  • Results are generally quick and instantenous.

The Bad-

  • Most of the techniques are joint biased. It does not address soft tissue work that might be needed on up-regulated, knotted muscles etc. (Brian Mulligan does mention that his techniques should be applied with other interventions). So this course will not address too much of your ‘manual therapy for soft tissue’ needs.
  • In my mind the biggest short coming in the concept is the lack of understanding of why it works so well when it does. It is based upon the older mal alignment, ‘positional fault’ leading to pain model of explanation which we now know is not the best model to explain something as complex as pain. We have better understanding of these concepts now. I’m not sure if the Mulligan Concept Teachers Association (MCTA) has now changed their explanation/narrative in light of the new pain science research coming out. There is still some ambiguity there.
  • Unlike some other concepts like the MDT, Maitland etc that focus on the assessment part as well as intervention the Mulligan Concept is more of a treatment system. It won’t do a whole lot in terms of adding to your diagnosis or assessment skills.
  • Some techniques are too specific and in my humble opinion too subjective from physio to physio. Here’s an example, some glides like the rotational MWM’s require the practitioner to isolate say the L/R transverse process of the C6 vertebral body. This gets even harder by the time we get to the lumbar spine as now we cannot use our digits but gotta use the ulnar border of the hand on specific spinal and transverse processes. Try this with a bunch of your physio friends and see if you can agree upon your palpation skills every time on every segment of the spine. I struggle with some of these palpatory methods that need us to be highly specific and have such subjectivity. Another example is the PA mobilization (sorry not Mulligan but I had to throw it in there). I have found  movement based observatory method more quantifiable.
  • I am not the biggest fan of the Mulligan Taping techniques. Some of the taping techniques are supposed to ‘hold’ the joint in the correct position. I don’t think a tape on the skin can keep for example a shoulder in a postero-lateral position and keep it from falling back in a ‘mal-position’. There are other examples too and I can state a few but I wont. You get the point. There are better taping courses out there with better explanation of why we belief taping works. Also, baring a few conditions, I like tape that permits motion not restrict it.

There is no ugly.

To sum it all up I think the Mulligan Concept has some shortcomings but is all in all a great concept. It definetly changed the trajectory of my professional career and taught me a lot. I will endorse it to anyone who cares to hear my opinion. Its a good concept to be familiar with.

Now would you want  to go the extra distance to get recoganised in the system as a Certified Mulligan Practitioner (CMP), go through the pains of going through a written and practical exams like I did? More on that in part two of the blog post series. Until then

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

My thought process on improving hamstrings flexibility

To say that I wanted to write a blog post on hamstring flexibility would be incorrect. In fact, this is a issue I avoid like the plague. Why? I’ll tell you. I have pretty tight hamstrings. And since I make all the videos on this blog myself with my friends and not just throw in some you tube video of someone else doing these exercises, I’m nervous to look bad. And my hamstring flexibility makes me look bad, at least in my head. But then again, there’s also frustration. The frustration of doing repeated static stretching and not really getting much outta it. Not to forget, I have tried to be aggressive thinking if I yank on that muscle, maybe it will finally give. What it has often given me is pain instead of flexibility,  and soreness. I’m sure many of you will agree with me, that for the subset of people who are on level 0 on path to becoming a yogi, this process is discouraging. So we avoid it. I can’t argue with the fact that if we keep up this torture, we might get better, but I know many people who have not made significant strides with this approach, myself included.

The reason I wrote this blog is because I had a few of my readers respond to my previous blog post reporting that one of the major reasons they were unable to hip hinge was due to those disobedient, stubborn hamstrings that were preventing people from hip hinging. So essentially this blog came from a need to hinge better. It would be great if one could touch their toes but that’s not up in the front on the priority list. The point is to hinge from your hips to learn correct lifting form so you don’t throw your back out.

If you have been part of my writing journey so far, you know that I don’t like interventions that are too painful. After all, a lot of ‘hands on’ intervention that we do is desensitizing the nervous system. Why cause deliberate discomfort (with good intentions of course) to ‘release things’ only to set the warning alarms off on the CNS. I’m not saying this is the only way, I’m saying its an easier, non/less threatening option. Hence I tread the path of lesser resistance.

So without much more blabber, here are some lesser threatening, novel approaches to improving hamstring flexibility. I like to wrap the mobility band on the hamstrings and do my neural glides, SLR’s, some hold relax etc. I will let you be the judge, practice these strategies and retest your hinge,dead lift, possibly toe touch etc.

Here’s the first one-

 

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Here’s another strategy-

Right side-

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Left-image3

Worth a try?

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

My ever evolving thought process on headaches Part deux

Sometime last year, I wrote a blog post on how I managed cervical headaches which you can find Here. Having often been at the receiving end of this mostly bad and sometimes extremely painful condition, I have played around with the position I suggested in my last blog post and I have realized that there may be an even better way to manage a painful acute flair up.

Before I proceed to discuss this position, I want to give full credit to my father for this light bulb moment. Here’s how it happened. He was suffering from some dull 2-3/10 pain at his right shoulder for a few years now which of course was intermittent. He would often also complain of tingling and numbness along the median nerve root on his right hand but only around the fingers and palm. So after some assessment I put him on a textbook McKenzie chin retraction and side bending program which did provide him relief but not completely. I noticed that as he wore a turban, the extra weight on the head along with the way it was tied, prevented him from getting into a retracted neck position. Now this, along with sitting at work for 8+ hours for six days a week (ya, that’s right, 6 days, maybe we should stop complaining about our long work weeks, maybe. Lol) was putting him in the dreaded rounded shoulders, blah blah blah … upper crossed posture. So apart from the exercise and manual therapy, I put him in my headache posture in supine hoping for the positive results that I was getting for me and some of my patients.

 

Alas, to my great dismay, this was only minimally helping him. He still complained of shoulder pain and in fact didn’t like to lie in that position for too long (he didn’t want to tell me it wasn’t helping so instead he just asked for a little break. He’s a solid dad). Now, I often saw him place both his hands over/behind his head on numerous occasions and when I inquired about it, he said this was the only position that made him feel better. This got my neurons firing; how could this simple position make him feel better when other advanced physiotherapy techniques had fallen short? This warrantied some investigation and the answer wasn’t too hard to figure out.

 

 

So lets try and break it down- what are some of the conmon postural dysfunctions that we suspect causes headaches, neck pain, shoulder pain and symptoms down the arm?

  1. Forward head and upper cervical extension
  2. Protracted rounded shoulders
  3. Rounded kyphotic upper and middle back region
  4. Downward rotated scapula
  5. Internally rotated shoulders.

On careful observation of  his favorite ‘shoulder pain relieving position’ (For the sake of simplicity, I will use the term-Dad’s position) I realized that this position was putting his body in the exact opposite of some of the above mentioned shoulder dysfunction.

  1. Minimum benefit in correcting forward head position.
  2. Dad’s position forces the shoulders into retraction
  3. Forces some extension at the thoracic spine.
  4. Arm elevation causes scapular upward rotation.
  5. Shoulders comfortably in an externally rotated position.

All of the above seem like thing we recommend to our patients all the time, no wonder his shoulders and arm were happy in this position. However, there were still a few things that had to be tweaked. I asked him to tuck his chin in and to avoid shrugging his shoulders so that the upper traps didn’t tense up. Even better, he reported after trying it a few times!!

Now if you have been following my blog posts from before, you’d know that I almost always consider a shoulder problem as a neck problem and vice-versa. They generally go hand in hand and are my ‘usual suspects’. So given this logic, I applied this on myself and some of my patients for neck related issues , headaches and got some extremely encouraging results. After all what better position to get the neck into retraction then in supine and gently force the thoracic spine into extension with a small pillow under it?? Adding heating packs could be the cherry on top if your a cherry person.

So with the explanation out of the way, I would like to present to you my modified position for cervicogenic headaches (also for neck and shoulder pain).

 

 

 

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My new preferred position for Cervicogenic headaches
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Watch out for excessive cervical extension which may look something like this!
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Tuck that chin in ‘gently’. Do not retract too hard
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Check for elevated shoulders like in the picture. Avoid this.
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Push down the shoulders gently.

 

So after a through assessment, if your patients fit the bill, I recommend you try it out and please let me know your thought on this subject.  As always,

 

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

In the spotlight- Mobility Bands

Having been on a hiatus for a while it only seems natural that my next blog post be on a subject that has helped me a lot not just during my practice but also has great clinical applications for manual therapists, patients, personal trainers etc. The edge mobility bands/ voodoo floss bands are great elastic compression bands to use as an adjunct to IASTM/ kinesiology taping etc to decrease pain, improve ROM and improve overall function and quality of movement. Good enough reasons to use them? I would think so.

To begin with, they are about 7′ in length and 2′ wide made of rubber. The voodoo floss bands and the edge mobility bands serve the same purpose just different manufactures. However, the distinguishing factor for me is the application technique. The voodoo floss bands, made famous by the rock star physical therapist ‘K-star’ is now a gym essential for crossfitters worldwide( FYI it’s ‘box’ and not ‘gym’ in crossfit lingo). The biggest advantage of this in my opinion is that people can now tackle ‘some’ of their own mobility issues without waiting to see a PT. I’m all for that, more power to the patients. However,  very tight compression can cause some discomfort and pain ( which sometimes is seen as a batch of honor by some in crossfit). Moreover, wrapping it too tight can hinder blood circulation to a body part limiting its duration of application.  The edge mobility band application by Dr. E resonates well with my principles. Very light compression of about 20-30 % stretch on the band ensures  minimum to no pain/discomfort. As mentioned in my previous blog posts, I prefer intervention that cause minimum pain and discomfort (I really follow the mantra ‘less is more’). Gone are my days of digging my elbows into sore tissues and trying to ‘release’ tight muscles. We now know that it is impossible to really release tissue in the body with our hands. If you stand behind the idea that one can cause true facial deformation or release with one’s hands, here’s  some food for thought.

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So how does it really work? Well, we honestly don’t know as there isn’t enough research evidence. But I will refrain from trying to convince the ‘EVIDENCE BASED POLICE’. To explain in the simplest possible way,  through the work of Butler and Lorimer Mosely we know that pain, muscle tightness etc are controlled by the central nervous system which locks the body down when it detects threat following an injury/trauma etc. This is the body’s own defense mechanism trying to protect the body from further harm. This threat perception could persist long after the injury has healed and cause the brain to put the body part on a ‘lock down’ manifesting itself as tightness/pain/dysfunction. With the band we try to modulate the pain perception to the brain at a neuro-physiological level. With the help of the intervention, as the brain detects no threat, it slowly ‘lets go’. At this point we see some of the almost magical effects of the mobility bands. Very similar to the modern concept of manual therapy and kinesiology tape (Rocktape is my brand!!). It is believed that the mobility band/floss band also helps with better skin gliding by stimulating mechanorecptors which helps with range of motion.

Here are three quick video of my hip internal rotation pre and post using the floss band. And yes, I am pretty restricted in my hip IR.

The few negatives of using the band are sometimes it could pull on patient’s skin or hair if used too aggressively (you know how I feel about that) and cause some discomfort. Also, rolling it back up after using it on a patients seems like a humongous task for lazy therapists like myself. It should also not be considered a panacea for all conditions. My favorite part about using the band is you could play around with it; with your patient laying down doing single joint passive movements, to performing functional exercises or during mobilizations etc.

In my limited imagination, the analogy that comes to my mind is that of an artist drawing on a canvas. You are the artist, if you will, your patient is the canvas and armed with your band that doesn’t come remotely close to resembling a brush, the possibilities are limitless.

Feedback is always appreciated.

Pursue excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)