Median Nerve Neurodynamics Part 2- Home Exercises

Hello

Following up on my blog post last week (which you could find Here), in this blog post I put forth some Median nerve Neurodynamics home exercises. The general principle remains the same for me. Start slow, try to keep the exercises pain free/threat free if possible or at least to a minimum with head bend to the same side slowing progressing to head neutral and eventually away from the side that is being stretched. I start with sliders and then progress to tensioners.

If any of the exercises increase pain levels, I instruct my patients to either go gentler and if that does not help, I ask them to stop.

Enough said, here are some videos-

1. Unilateral exercises with nerve mobilization @ the wrist level-

2. Unilateral exercises with nerve mobilization @ the shoulder and the fingers-

3. Unilateral exercises with nerve mobilization @ the elbow with head neutral and slowly progressing to sliders.

(Starting position is shoulder abduction not flexion as mentioned in the video, sorry for the error but you knew that).

4. Unilateral exercises with nerve mobilization @ the elbow level with sliders and tensioners –

 

 

5. Bilateral exercises like the prayer stretch, butler’s busy bee-

 

 

I would love to know some of your favorite exercises, tweaks and variations. That’s all I got for this post. Keep fighting the good fight. Until next time.

Pursue excellence.

Abhijit Minhas

(BPT, MS, CMP, FMT)

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)

 

Thoracic Spine Mobility Drills

The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These  modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc.  However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.

  1. Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
  2.  Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
  3. Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
  4. Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.

Furthermore,  if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.

So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-

  1. Bench/chair thoracic spine extension with stick-
  2. T-Spine extension on foam roller
  3. T-Spine windmill rotation
  4. Cat Cow
  5. Four point T-Spine rotation
  6. Threading the needle

 

Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.

Keep limber

Pursue excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)

In The Spotlight- ‘Hip Extension’

Welcome back

As we already know, the problem of glutes amnesia has reached epidemic proportions. Our lifestyle is not like what it used to be. More work gets done sitting on our behinds all day than ever before. Spend too long in sitting  and we slowly start to lose the important movement of hip extension. In this blog post I would like to discuss two conditions that I have often seen in the past which can be directly or indirectly related to loss of hip extension (both lack of active control and loss of ROM). Seen in the general population and often perpetuated in runners. Lets begin-

  1. Low back pain– while the causes for LBP could be endless, we will discuss the role of inhibited glutes and lack of proper hip extension in LBP. If we spend  8+ hours a day sitting on a chair (hip flexion), the glutes will be in an overstretched position and often inhibited. To add to those woes, the hip also gets stuck in a flexion position with classic ilicaus and psoas tightness. Now to maintain a upright posture and to compensate for tightness caused by excessive prolonged hip flexion which would put our trunk in a forward lean,  the back extensors have to work harder to keep us upright. This often manifests as an increased lumbar lordosis (low back curvature). Prolonged time in this position can cause increase in tone of the lumbar erectors and could potentially cause low back pain. I see this often with recreational runners or those who are new to running. During running, if your hip do not go in to enough extension, the back begins to arch and the erectors being part of the posterior chain have to work extra hard. Remember the body is a great compensator but over time this catches up. This, I believe is often one of the common reasons why recreational runners come to see us for low back pain with running.  If you are an athlete or a runner, this is not the best situation for running.  Your glutes have lost their VIP status.  No one likes weak glutes, unacceptable.
  2. Plantar fascitis– I often find people with plantar fascitis have well developed calf muscles. It appears like its ‘calf raises’ day everyday for these folks however on further questioning you may find that they might not have been doing any calf strengthening exercises. If such is the case, I implore you to  check for their active hip extension in walking or running especially during the midstance, heel off and toe off of the stance phase. This is the time when the leg should start to cross back behind the body due to hip extension. This is the primary movement that propels us forward. Now if the body lacks this crucial movement, due to weakness of the glutes max or tightness of the ilio-psoas etc the calf seems to become a more significant driver to push the body forward. Now multiply this a few thousand times a day (even more if you are a runner) over a few weeks, months or years and we have a overworked calf complex. As we all know, the calf exerts a pull on the plantar fascia (remember its a two joint muscle) and that irretates the PF blah blah, we all know this. So improving active hip extension and utilizing the full potential of the glutes is crucial to give the calf a break and in turn might relieve some stress of the PF.

The take home message is simple-  Hip extension is a crucial movement for many daily activities and a lack of which might cause LBP or PF. When treating these conditions, don’t make the mistake of running after the symptoms like I have so often in the past. Here’s a little video to give you an idea of my thought process when analyzing hip extension in running.

 

(PS- this is not the only thing I look for, I’m only focusing on Hip extension here).

You know the drill.

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

#TechniqueTuesday 1- Quad & Hip Flexors Stretch

The intention of #techniquetuesday is to highlight mistakes and demonstrate corrections for common exercises that I see often. For the very first one, we will discuss everyone’s favourite, the quadriceps stretch and the hip flexor stretch. Here goes-

Do it right and do it often.

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-

 

image1

Here’s another strategy-

Right side-

image2

Left-image3

Worth a try?

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

Drive your woes away

Ladies and gentlemen

Got a long drive ahead of you that you are dreading? Feel stiff and achy sitting all day. Below I present to you some simple exercises, stretches and strategies that you should try and incorporate if you know you would be behind the wheel for a few hours. Make them a non negotiable part of your drive (safety permitting) and more likely than not, your body will thank you for it.

Here you go-

1. While driving

(Disclaimer- do not take your hands of the wheel for more then 2-3 seconds and never both together, driving safety comes first. Do not let these exercises distract you from the primary activity of driving, I do these often and they are like second nature to me. Only perform them if you feel comfortable to do so safely depending upon your traffic conditions. Practice them at home or work first and then incorporate them carefully while driving. If you still feel unforgettable, avoid this and try the strategies in step two).

2. Take breaks often and move

Try holding the stretches in the above videos for about 30 seconds and repeat 2-3 times. For neck, wrist, back exercises that are not stretches, try about 10 repetitions. Although you ‘might’ feel some discomfort due to staying in one place for some a few hours, none of these exercises should cause pain. If they progressively increase pain and/or discomfort every time you do it, STOP. DO WHAT YOU CAN.

Always remember, the body is not meant to sit in one position all day and ‘motion is lotion’ for your body. Consult your physio if you have pre existing conditions as some of these exercises might not be right for you.

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.

image

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)