Clinical Edge - 107. Treatment of peripheral nerve sensitisation with Dr Toby Hall Clinical Edge - 107. Treatment of peripheral nerve sensitisation with Dr Toby Hall

107. Treatment of peripheral nerve sensitisation with Dr Toby Hall

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David: Why don't we just give a quick recap of what we talked about last week. I think, if people haven't listened to it, that's definitely a precursor. It'll make what we're going to talk about today a lot clearer. If we just recap, last week we had a chat about identifying categories that patients fit into, and talked about three main categories that you classify people with neural tissue involvement, and you mentioned the serious…like the CRPS type category, and what would you name that one? What category is that?

Toby: Well, we call that a neuropathic pain with sensory hypersensitivity. That's the truly neuropathic disorder where they've got really severe pain, severe levels of disability, unusual features like burning, tingling and allodynia with spontaneous pain, those kinds of things. The patient that you see with CRPS is one example, but there are other types that are not related to CRPS.

David: So that's our first category. Then we had neural compromise. So, what sort of conditions are involved in that category?

Toby: For a compressive neuropathy, you think about the classic one is carpal tunnel syndrome, but not all patients with carpal tunnel have altered conduction. So, the gold standard is reduced conduction of the nerve. So, you've got some sort of compressive disorder, which is reducing nerve conduction, so you're getting reduced muscle power, reduced sensation, anaesthesia, those kinds of things. It could be nerve root, so you're getting a myotomal dermatomal pattern of conduction loss.

So, it could be a peripheral nerve compression, or it could be a nerve root compression, or it could even be the spinal cord that's being compressed. So, this is a compressive disorder, but it's compressive, but there are other types where the nerve is damaged and doesn't conduct normally, so we would lump them all together within that, but we've decided to call it a compressive neuropathy.

David: Okay. And, final category is sensitisation?

Toby: Yes. That's what I have called peripheral nerve sensitisation. It's just a name to indicate that the nerve is mechanosensitive, and it's painful to either compress, touch, or to stretch, and even at low levels of stretch. And some studies have shown that perhaps even only 3% elongation of an inflamed nerve can cause pain.

David: Okay. And that's the final category that we're going to really focus on here today. We talked last week about how the signs and symptoms that people have when they have these conditions or categories, and then we talked about how you can go about testing it clinically. So, really looking forward to having a chat to you now about where you take that, your objective findings into your treatment, how you can go about treating it.

Toby: Yes. That's the basis of this classification system. It's based on the work of Bob Elvey originally. In his clinic, he had patients, and he would try to show how you could treat some patients with neural mobilisation, but other patients with the neural disorder were not appropriate, but at that time, he didn't really have the evidence to explain why that is, but as research has evolved, we've gathered new information, which enabled us to put into a little bit more of a firm context, this treatment based classification system. So we think these three different types of nerve problems, each of them requiring a different treatment, and there is some evidence to support that, that each of the categories respond to different forms of treatment.

David: Right. Before we move onto the treatment phase, you'd mentioned there before about identifying whether with the sensitisation, you're looking most at peripheral nerves. Can we identify clinically where the location of someone's mechanosensitivity?

Toby: Yes, that's a good question. Classic case is a patient presents with arm symptoms that may be down into the forearm and hand, and some middle-aged patient who has developed this condition gradually over time. They've got typical features of cervical problems, they've got typical features of carpal tunnel disorder, and maybe even other disorders in the arm. So, it's sometimes difficult to identify the origin of the patient's problem, and in fact, there is some studies to show that if you treat the whole length of the nerve, you'll get a better outcome. If you just focus on one little part of the nerve problem, perhaps you're not dealing with all the complexity of it.

But to identify where the problem originates, I think you've got to look at a number of different factors. In terms of nerve mechanosensitivity, just doing a median neurodynamic tests, doesn't tell you where the nerve is going to be a problem. The test may be positive for a patient with a cervical radiculopathy, but it may be also be positive for a carpal tunnel syndrome. So, the test is very good at identifying the nerve mechanosensitivity, but it doesn't tell you where the problem is. To do that, I think, I personally would look at the nerve palpation and expect to find more sensitivity at the point of where the nerve is affected. And if you think about the classic Tinel's sign, then that's a very good at picking up sites of regenerating sprouting axons at the site of nerve damage. And that's a form of palpation.

So we need to specifically palpate the point of the nerve damage to get a positive Tinel's sign, but I would look at a gentle form of palpation looking for mechanosensitivity, and the point of the maximum mechanosensitivity is most likely to be closest to where the nerve is being affected.

Not that that's always the case, but in general, if you were to use that together with the rest of your examination, I think you can have an idea about where the problem may originate.

David: So, clinically the palpation seems to be the way you identify the most likely source of it, or the most likely area of mechanosensitivity. Will nerve conduction studies help you at all with that, or do they only pick up if there's a conduction loss?

Toby: The problem with nerve conduction studies, they're only testing the large diameter with the fibres. So, if you have an EMG, for example, you're only testing a small proportion of the nerve fibres. Of majority, 80% of a nerve is made up of small fibres like a C fibres. So, when you do electro-diagnostic tests like EMG, you're only testing for a very specific dysfunction, and it's not telling you about the whole picture. And in fact, neurodynamic tests themselves can be negative in the presence of severe nerve damage. And, there's a nice study again by Annina Schmid and her group, which found that there was reduced positive tests on neurodynamic testing in patients with more severe forms of carpal tunnel syndrome. So, the more severe they were, the more compressed they were, the more they had, or the less likely they had a positive test to neurodynamic testing.

So neurodynamic tests don't tell us so much about whether a nerve is compressed, they don't tell us where the nerve is being a problem, they tell us if the nerve is mechanosensitive; if it's inflamed and mechanosensitive. It doesn't tell us about nerve compression per se.

David: Interesting. You'd think it'd be the opposite, wouldn't you? But that's pretty interesting finding.

Toby: Well, it could be that if a nerve is severely inflamed, and severely compressed at the same time, then you would have a positive neurodynamic test, but you can think about spinal stenosis. If you see patients with spinal stenosis, often it's a very gradual process that occurs over time.

And this doesn't lead to much mechanosensitivity of the nerve. And if you look at slump test, straight leg raise test in patients with stenosis, it's often not very valuable. It's not very often positive. Whereas, if you have a disc prolapse, which is involving some significant inflammatory products sensitising the nerve root, then the nerve root is exquisitely mechanosensitive. It's very painful to do a straight leg raise. So, there's a difference between a very gradual compressive disorder and an inflammatory compressive disorder, I think.

David: As far as being able to nail down the exact location of mechanosensitivity, I guess the first thing is, can we do it? And, we said that, potentially, with palpation, we can identify sites that may be mechanosensitive, and nerve conduction tests are only going to pick it up if we put that conduction loss, which may not relate to that mechanosensitivity. So, I guess, is it important when we come to the treatment, if we identify the exact location of that?

Toby: Yes, that's a good question. Probably, in many cases, it's not so important. If you look at neural mobilisation, I'm thinking about techniques in the neck, there's a technique called a lateral glide, also was developed by Bob Elvey. And, it's been shown that when you do a lateral glide technique, you can measure the movement of the median nerve in the arm using ultrasound imaging, and it shows movement all the way along the course of the nerve, well into the arm. So just trying to be specific with treatment techniques, it's questionable whether it has to be done in that way.

David: The other thing that I was thinking about after our chat last time too was, you mentioned before that oftentimes with nerves, when you're treating these, or when patients experience nerve related issues, that exercise in general can help to improve the function, or improve pain over a period of a few weeks. When it comes to, you mentioned there with rats, that three weeks of exercise on a treadmill could help to improve their ... Was it nerve regeneration will actually improve with exercise there?

Toby: There's a number of things that's being measured. With different studies, they've looked at very highly rigorous studies to measure cytokine productions in the dorsal horn, and shown that pro-inflammatory cytokines are reduced, and anti-inflammatory cytokines are increased. So, we're reducing inflammation at the source of the problem with exercise. We're also having effects on histology, on immunohistochemical changes, all sorts of changes have been shown with movement, with exercise, whether it's passive movements, whether it's neural mobilisation in these rat studies, or whether it's just simply forcing the rat to be on a treadmill or to swim. Movement is the key, and it's movement regularly, and it's move early, and the more you do, the better.

David: So, we're looking at movement, and within exercises versus neural mobilisation, you've done this in rats obviously, but if we notice that we've got a positive effect with exercise in those cytokines, the information and the immunohistochemical reactions and processes, do we need to do anything specific when it comes to mechanosensitivity, or are we just getting patients to exercise generally? What's the ...

Toby: Well, that's a good point, isn't it? Should we really have to do this? I don't think we should. I mean, if the general public were educated to the value of exercise, how much benefit it has for so many different conditions, there are so many ways that exercise help us, that maybe there wouldn't be a need to mobilise these patients. But unfortunately, patients don't do exercise. There's a nice study, I think it is that the number needed to treat to get people to be more active is 12. You tell 12 people to be active, and to exercise, but only one person takes up that message and does something about it. It's crazy when the evidence is so overwhelming, that exercise has such positive benefits for human health.

So, the problem is, people don't do exercise. They don't do activity. You can tell them, but they need to be guided through it, and they need to be encouraged.

And I can understand why they don't do it, for one thing. When you've got severe pain, I experienced that myself, it's extremely difficult to force yourself to do something that's extremely painful. And in those rats studies we mentioned, I'm sure it was very painful for the rats to exercise, but they forced the rats to do it, and there was a positive benefit as a result. So, it's difficult for people to understand why you should do something that's so painful, and to believe that it will ultimately help you over time. The other issue is that people are fearful about movement, and they can't do these exercises for various reasons. So my feeling is that, if you can encourage people to start to move by showing them the benefits of movement, then I think it can help them, and I think we need to encourage more activity as much as possible in people. And one way of doing that is by doing manual therapy for the patient, so long as it's in a framework that encourages them to be more active.

David: Okay. So we can have positive benefits with our exercise, but the patients might not work with themselves through a whole lot of pain. So, potentially, we can help to involve some sort of neuromodulatory effects with our manual therapy or with our other techniques that might enable them to exercise for that exercise is a key component within that.

Toby: Exactly. If we've got to get the message across to people, the importance of exercise, I just don't think people understand how positive benefits the effects that exercise has on things like neural disorders, in acute neural disorders. It's different, I think, when you get to chronic neuropathic pain, and that's why we have that classification system, because it seems that exercise doesn't seem to work so well when you've got a positive LANSS, when you've got those features of CRPS, for example. Exercise doesn't seem to work so well, because the brain has changed, and the effects that exercise have on the brain are different in people with these more severe neuropathic disorders. They don't have the same pain modulatory systems, because those systems have become altered by the presence of this neuropathic disorder. So when they exercise, they get more pain, more dysfunction, and they don't have the same positive benefits that people have who don't have those problems.

And what we saw in the rats was that they had positive benefits, but I think it's different in some people with chronic neuropathic pain. That's why I've got to be a little bit careful trying to extrapolate what we see in a rat after three weeks of exercise, to humans who've had chronic pain for six months. It's a little bit different.

David: For sure. Definitely. We sometimes behave like rats, but we're not always exactly the same. So we want to encourage our patients to exercise, that's an important part of their rehab, but it can be painful, and so, with that reassurance, is obviously going to play a big part. Is there treatment that we can do that helps to either accelerate it, or make the transition to a less mechanosensitivity, more enjoyable process, or a less un enjoyable process as the case may be? Can we improve their outcomes and the speed that it happens with some of our other techniques, do you think?

Toby: Yes, I think we can. That was one of the important messages that we give to people, is that, treatment doesn't have to be painful. You don't have to have the same feeling of pain that you would going for exercise like the rats did. You can have the same benefits by doing a non-painful procedure. I think that's why it's useful to encourage people to become more active, because you can do non-painful mobilisations. For example, in the Mulligan concept, we have mobilisation with movement as a way of helping people to increase their function without pain. And neural mobilisation itself as described by Bob Elvey was always painless mobilisation, different schools of thought.

I can remember when I first started using neural mobilisation in 1985, I used to assist people to do very strong, aggressive stretching techniques on people. And it was extremely painful for those people.

I realised that it wasn't particularly helpful to help people in that way, and then I learned from Bob Elvey that you could have very positive effects in that painless way, and it's a much nicer way to treat people, I think.

David: The patients seem to enjoy a bit more too.

Toby: They do. Some patients like to feel pain, but they're a different group.

David: But not all of them. And so, if you had to sum up the categories of things that you find helpful when we're treating mechanosensitivity, how would you sum it up? It sounds like manual therapy is one area, and then, what are some of the other things that we can incorporate into our toolkit to help retrieve this?

Toby: Education is the first thing, and trying to get people to understand what the condition is that they have. So, just as if you've got low back pain or neck pain, education is an important component to help them to understand why they feel pain, and how they can help themselves. That's very powerful, but it needs a lot of repetition, because I find that people just need that encouragement and education repeated before they can understand that things will get better, and why they feel pain.

David: Great. So, you got that education, you got exercise, what else do you think is some of the other categories of things? And we'll dive into these in more detail, but just to get an overview of some of the areas.

Toby: Well, drugs are often something that get prescribed to people in this situation, because they're typically in severe pain, but I think understanding about drugs for neural disorders is becoming a bit clearer, to show that perhaps it's not so helpful for many of the disorders we're talking about. In fact, there is evidence that perhaps may be counter-intuitive that you take strong opioids, for example.

Because you're in a lot of pain, and you can understand why people get prescribed those when you've got severe symptoms, but in fact, those opioid medications may well be enhancing the central sensitisation, and maybe enhancing the changes that we see involving neural sensitivity.

I think we mentioned it last time, but the study when rats where they gave them morphine for five days after a significant nerve injury, and they found that it took twice as long for the rats to recover compared to a control group who weren't given that medication. So, often you see people, they have an injury, they go to their doctor, and then the doctor is trying to do the right thing and give them some pain relief, but in fact, that medication's enhancing the problem, causing them to take much longer to get better, perhaps. The evidence about that is unclear. I mean, this is, again, talking about rats, but it's very clear that once you start taking opioids, you're often become dependent on them. And I think the evidence is that, perhaps 30% of people who start taking opioids were still taking them one year later.

So, you've got to be really careful about drugs. There is evidence that things like Lyrica are not effective for neuropathic pain for ... When we're talking about radiculopathy, for example, in the lumbar spine, there's evidence that anti-inflammatories don't work particularly well for most people, and there's just a few people who do get positive benefits. And all these drugs have significant harms. So, if you can treat people without that, then I think it's going to be much better for people, but trying to encourage people not to get onto opioids, I think, is quite difficult. There is a understanding that, for severe pain, you need some strong drug, but unfortunately, the evidence that those opioids have a stronger effect than simple analgesics is not that great.

With medication, with surgery, there are options for surgery, but from a physiotherapy perspective, I think the main things that we can contribute to people are some manual therapy, some education, some advice, some exercise. These would be the main things.

David: Where would you fit in neural mobilisation? Does that tend to fit in your categories into a manual therapy approach, or an exercise, or where do you think about that?

Toby: Well, that's a good thing, isn't it? Because it's both an exercise, and it's manual therapy. I mean, you can give a patient a neural sliding exercise to do at home, which is just another form of exercise, and you can do sliding exercises with the patient in the clinic, but I think, sometimes, it's helpful to give them hands-on manual techniques to do some neural mobilisation in the clinic. So that's a passive form of treatment, but it can be combined also with exercise. So, you have the merging of the two, which is the Mulligan concept, where you apply some manual force to the patient's lumbar spine, for example, where we do a transverse pressure on one of the spinous processes, and at the same time, get the patient to do a neurodynamic movement. We call this a spinal mobilisation with leg movement, described by Brian Mulligan quite a few years ago.

But, there is a nice study that Keiran Sandberg did. He had 60 patients with radiculopathy in the lumbar spine, and half the group were given standard treatments, and the other half had the same treatment, but also this small additional mobilisation with movement. And, the patients were followed up for six months, and there was a good outcome in both groups. There was an improvement in both groups, but the group who received the additional Mulligan technique had greater improvement in pain, and disability in leg symptoms, in range of straight leg raise, just with a simple manual technique applied on six treatment sessions over two weeks. It's a useful technique. There are other studies as well showing positive benefits for this, but something we need to look into a little bit more; encouraging people to move actively, while at the same time combining that with some manual force, some mobilisation in a non-painful way, again, encouraging the patient to move without pain.

David: So it sounds like with your manual therapy, there is that mobilisation with moving type approach, or spinal mobilisation with movement. Is that one of your favorite types of approaches when it comes to manual therapy in this mechanosensitive population?

Toby: I think so, because anything you can do to encourage people to move without feeling pain, particularly when you're really sensitive and in a lot of distress or feeling a lot of pain, I think it can be very helpful to use non-painful techniques. Some conditions, I think it doesn't matter so much that the patients can feel pain during exercise. For example, if you've got an Achilles tendinopathy patient and you give them loading exercise, how much pain can they tolerate, that could be questionable, but for some neural disorders, I think you have to be a little bit more careful. It's okay for the rats to be forced to exercise with pain, but I think some humans just don't respond so well to that.

David: When you're looking at using one of these mobilisation techniques, for instance ... Let's dive into it a little bit with that to start with, then we can go into some of the other things that we use as well. So, if we're having to think about these manual techniques that we might use in someone that is mechanosensitive, how do you go about identifying the technique that you're going to use, and the level that you're going to work on and that type of thing?

Toby: Yes. Well, first of all, you've got to identify, is it an L5 nerve root disorder? If you're not sure, the technique itself becomes the assessment. So, if you apply some force on the L5 spinous process, and get the patient to do the positive neurodynamic test, in this case, it's likely to be straight leg raise, patients got some legs symptoms, they've got a positive straight leg raise test. We talked about the features of mechanosensitivity last time, and the features there are some sort of active mood dysfunction. So, in this case, the patient usually would have pain with forward bending, lumbar flexion. They've got a positive straight leg raise or slump test, and they've got pain on palpation of the sciatic nerve. So that tells me that they've got features of peripheral nerve sensitisation, and I'm thinking that they've got an L5 problem because of the rest of my examination.

So, I apply some pressure on the spinous process of L5, and see if the patient can gain greater improvement in the range of straight leg raise. And, normally, if you do this technique, you can get a significant improvement in the neurodynamic movement, straight leg raise increases in range. And this is exactly what Keiran Sandberg found in his study.

David: When identifying an L5 issue, what are you basing that on? Palpation with a passive assessment test with your PAIVMs or PPIVMs, or were you basing it on the fact that they had a straight leg raise or slump that was restricted? Can you help clarify that?

Toby: When you have somebody with leg pain, and if they got a positive straight leg raise, I think that's pointing most likely to an L5 or S1 nerve root problem. It could be helpful, but it's less common. If you test the femoral nerve, and the femoral nerve is negative, femoral nerve is L2, three and four, so that can eliminate the L4 typically. So then you're thinking that it's most likely to be an L5 or S1 root problem. If you assess the spine with your PAIVMs and your PPIVMs as I would do, then I would expect to find some dysfunction at the level that is affected. So, if I apply some pressure with my MWM to the L5, and it doesn't change the patient's presentation, maybe I've misjudged or misinterpreted the problem, maybe I didn't assess them correctly.

So then I'd move up to L4, if there's no change, move up to L3. So, it's possible to use the MWM as the assessment. I mean, if you don't think that you can identify the origin of the patient's problem, or you don't think it's necessary, try the MWM as a technique. There's no harm to try it, so long as you only ask the patient to move in a pain-free way.

David: And, do you ever use the PAIVM or PPIVM even before you go straight into this MWM approach, or do you mostly go straight to that?

Toby: No, normally I assess the patient I want to find out which level in the lumbar spine is the most sensitive, so that I can be a little bit more targeted in my treatment from the beginning. If you have an idea, from the beginning, that it's L5, then I think you can help the patient without the likelihood of flaring them up so much. So, it's a nice way to get into the treatment more quickly.

David: So, you've tied to gather the fact that they had restricted straight leg raise, which has given you an idea that lumbar spine was potentially involved. You check their prone knee bend, and that was clear in this case, and so you're thinking that most likely cleared the L2, 3 & 4. So you're thinking that's an L5-S1 issue, and then you perform the PAIVM and PPIVM assessment, and you've found that there's some restriction or pain reproduction with it at around that L5 level. And so you're going, "This is most likely the level we're going to target with our MWMs." Am I following you so far?

Toby: Exactly. That's my clinical reasoning. Some people would argue that those assessments are not accurate, they're not reliable. We can argue about that, but I personally find them to be useful in my clinical evaluation to help me to identify where I should treat the patient. And, definitely for an MWM, if you do the MWM at the wrong place, it's painful. It doesn't make any difference. If you find the appropriate place, then it does have a good outcome.

David: So, you hit upon this L5, we're thinking the L5's the area that we need to treat with MWM. So, we've got them in sidelie, is that right?

Toby: Yes, basic sidelie, although you can do it in other positions. It's just easier to manage the patient's sidelie. So, in that position, you ask the patient to do an active neurodynamic movement of straight leg raise, or they can do an active knee extension with a hip in 90 degrees flexion. So they're actively doing this mobilisation. At the same time, I'm applying a transverse pressure on the L5 spinous process, to see if that has any impact on the patient's active neurodynamic movement. Can be done passively, completely, if you have an assistant to help the neurodynamic movement, but not so many people have the luxury of an assistant in their clinic. So, I would just go for the active neurodynamic movement from the patient.

Being careful to instruct them what to do, some patients feel they've got to force themselves. The therapist asking me to move, "I'm going to force myself," but we want the patient to move in a pain-free way. So, we measure their pain-free range of straight leg raise in sideline, 30 degrees. I apply the transverse pressure, then I ask the patient to move to that same point where they start to feel symptoms, and now they're moving to 50 degrees. So, it's 20 degree increase. So, I ask the patient to repeatedly move through that range that's pain-free, and then, at the end of six repetitions, I might reevaluate the patient and see if there's been any sustained benefit. And if it has, then I'll do repeated sets. Then I'd advise the patient to do some slider mobilisations at home, to try to maintain these positive benefits.

I'd encourage the patient to be more active, and give them some education. And we know that if they just do some simple walking, just like in those rats, it's going to be beneficial for them. So there's mixture of manual technique, exercise at home, and general movement can have a positive outcome.

David: Normally, are you doing a transverse glide ... Just say they've got it in their left leg, and you've got them lying sidelie with their left side upper most, is that right?

Toby: That's right.

David: And normally you do a transverse glide from left to right, is that right?

Toby: Exactly.

David: Okay. And you're looking to reassess while they're doing it to see if you get a change in their pain and their range of movement, to give you an idea that that's the right treatment direction for it.

Toby: That's it. You want a substantial change. if you've got, it's gone from 30 to 35, then probably that's not significant. We need to be more than that. You've also got to be mindful of any adverse events. So, we're talking about people with significant problems, and if they've got an evidence of altered conduction, we've got to keep checking that there's no deterioration in their conduction after the technique. Some people get less leg pain, because their nerve root is more compressed. So, they think, "This is getting better," but it's not. It's actually getting worse. So, deterioration of conduction is an important thing to look for, but in this study that we did with 60 patients with radiculopathy, there was no evidence of adverse events with deteriorating neurology.

David: So if they had some sort of conduction loss, for instance, they had an area of decreased sensation, you'd reassess that afterwards, is that right?

Toby: Exactly. Or maybe reassessing their calf strength. Before the technique, they could do six heel lifts on one leg, but now they can't even lift their heel. That would be a serious worsening of the patient's neurological conduction. We need to be very careful about that. But that's not something that you would do typically find, but we always got to be mindful of worsening neurology.

David: How do you go about supporting that leg when they're in side-lying to make sure they're not just dropping into hip reduction, because sometimes that can be a bit of a irritable position for them too, can’t it?

Toby: Yes it can be, particularly for patients with more severe symptoms, then I put a couple of pillows between the thighs, so they're just supported; some firm pillows just to give some support. That's why it's difficult sometimes to do an active straight leg raise, because they've got to hold their leg up, but if you do a knee extension with the hip at 90 degrees flexion, it's usually a little bit easier for the patient, and you can support them then, or if you have a bolster, or if you've got a thick sponge pad you can put between the patient's thighs there, just to support them, so they're free to do some knee extension with the foot movement as well if you want.

David: And what sort of instructions do you give them to make sure they're not getting irritated throughout the set?

Toby: Well, that's it. Just be careful to test the patient only moves to the onset of symptoms. Sometimes it's even feeling of pulling, or tingling, or some other strange sensation that the patient has when they do the neurodynamic movement. So, it's not always pain, but just being very clear to the patient that you just want them to move to their onset of their symptoms, so that we can have pain-free movement.

David: And how many sets do you normally do? You said to do the set of six, and then recheck them if you've got an improvement in their pain and their range of movement. How many sets do you normally do?

Toby: Yes. I think you got to be a little bit careful in some people. In some people, if you've just assessed them on the first occasion, and you've done a lot of examination, there's a likelihood that you could aggravate them by that. If you just go into a whole lot of manual therapy on top of that, you're probably going to stir them up. So, on the first occasion, you might even just do three sets of six repetitions, and then, if they come back and they've had some improvement, then we can increase that, gradually ramp it up. Just like any form of mechanical input, you need to increase it. You need to increase the repetitions, you need to increase the load, you need to increase the range.

You need to do more home exercise, and needs to do more activity, just gradually increasing that as their improvement shows.

David: So you've got an improvement with your three sets of six, and then you've left it there to see how they go and you get them back for a followup assessment, and you check them out then. In the meantime, you said you're giving them often some sort of sliders, and they ... Most of them have done this, want to know, "Oh where can I press to try and achieve the same thing?" That's the normal question, right?

Toby: Yes, that's it. People think that they should feel pain when they do exercise. They poke and prod around to try to find the sore spot, but I think we have to try to encourage people to move away from that kind of thing. So, try and educate them about the benefits of movement.

David: And how many sliders or whatever do you tend to give them, get them to do at home, and what instructions do you give them there?

Toby: I think sliders is ... I think we used to be a lot more conservative, but after looking at these rat studies, and that being a rat myself, I was talking about my own experience of having a radiculopathy, then I've found that by doing more, it actually gave me more relief. So, I would gradually ramp up those repetitions for the sliders, and maybe at home, to begin with, to get into 10 repetitions, is a good starting point, and just three times in that first day. How did they feel? If they feel okay, then the next day they can go to five times 10, then the next day can go to five times 15, then the next day they can go to five times 20, quickly ramp them up as they get used to them, but sometimes you can do too much, and if they go too fast too soon, then they're back in a heap, and they're really in trouble.

And I think particularly patients with peripheral nerve sensitisation, they can easily be aggravated, they can easily be flared up.

And they often have that boom-bust kind of problem where they do too much, they fall in a heap, takes them days and days to recover, then they do the same thing again. So we've got to try to modify their activity, and try and get them back into activity in a graduated way.

David: And when you're giving them instructions, what do you tell them to do as far as performing their sliders? And so, you've mentioned there about reps and how many to do, what other instructions do you give them?

Toby: I just make sure that the movement that they're doing is pain-free. I try and encourage that. We're talking about patients with severe sensitisation disorders. Now, for this patient. If you have a patient who's got some minor neural problem, they've got some ... It's an athlete who has got some residual posterior thigh pain as a result of some sort of musculoskeletal disorder with a positive neurodynamic test, then I think you can be a lot more aggressive. So, there's a big difference between that patient and the patient who comes in with an acute radiculopathy, who's highly sensitised, or a patient with acute radicular pain disorder that's highly sensitised. So, I think we've got to be a lot more careful for those patients.

So, I would encourage them just to move in a pain-free way. They can do the same thing as they were doing in the clinic; so they're lying aside with a painful leg upper most, and they do a hip flexion with knee flexion movements as far as they can go, pull their knee towards their chest, because it's usually not painful when the knee is maximally flexed. And then they bring the hip into extension with the knee in extension.

So they're bringing their whole legs through a large amplitude movement. They can do it standing up, they can do it in different positions, but a side-lying seems to be the easiest one. So they're getting a maximum movement of the lower leg to try to achieve some kind of sliding movement.

I wouldn't worry about the foot too much, just don't get them to think about the foot position, but just start off with that, and gradually ramp them up. You can do more aggressive sliding exercises as the patient gets better in different positions. Sliders can be modified to put more load onto the nerve tissue. We're looking at trying to move the nerve with minimal load to begin with, but as they get better, then we have to modify the exercise to get them comfortable with load.

David: Awesome. Tell us a little about some of those progressions then.

Toby: A nice progression would be to have the patient sitting. So the patient's sitting so that their knee is in 90 degrees flexion, hip is in 90 degree flexion, and as they extend their knee, if they then go into an anterior pelvic tilt, so they're doing two movements at the same time. A slider, by definition, is two movements of two joints to put some movement through the nerve tissue without putting significant tension. So, if you put the patients into anterior pelvic tilt and knee extension, then it's getting some movement of the nerve tissue in a more aggressive way, compared to the one we just talked about. If they're sitting, they're doing it at the same time, anterior pelvic tilt and the extension, and then coming back into posterior tilt and knee flexion.

It's a fluid movement of the leg, of areas moving at the same time, but not putting maximum tension through the system. If they then gradually progress, they can change their foot position, and so they can add in ankle movements at the same time, or have their foot in more dorsiflexion to put more stress through the sciatic nerve. Once you've gone through that, then the patient's symptoms by now should be starting to resolve quite well. This is down the track. Then we could go to more of a tension technique, if it's necessary. Once the patients mechanosensitivity has subsided to a point where they can tolerate the tension technique, if it's necessary, then you can do tension techniques.

David: Tell us a little bit about those then.

Toby: So, a patient sitting, just do knee extension with the foot in plantar flexion. So the foot is maintained in one position, their active movement is just knee extension. That will be to some degree tensioning the sciatic nerve. If you then add gradually more and more dorsiflexion, it's going to put more tension on the nerve. If you then go into a slump position, it's going to put more tension on the nerve. If you go into cervical flexion with slump, it's going to put even more tension. Now, I'm not suggesting that we need to do that for most patients, but occasionally, you might find for some people with residual symptoms that don't seem to go away, they need stronger techniques to more load the neural system, to get it accustomed to movement and to desensitise it.

David: So, within your session, let's imagine you're back at that first session, and you've gone through a lot of really nice progressions there, and obviously these are with subsequent treatment sessions. You've looked at starting with that. And that was a really nice one, you're in side-lying, they've come into some hip flexion, and then as they're performing their extension, they're also performing hip extension. So they're taking off the tension at the hip while they increase the tension at the knee. So, that's a really nice one. I like that one.

And so, how do you monitor that as they're performing that, because you're going to get them to do that in the clinic with you, I'm sure, before they go home. So, what sort of things are you monitoring throughout the treatment?

Toby: I think you've just going to make sure that the patient's getting the movement where you want them to move, and they're getting good control over the body. They're not falling all over the place, they're not rolling back onto their back, they're not doing some uncontrolled movement. So, just try to give them some awareness of how to move, and maybe we do it passively, or active assisted with the patient to begin with, to give them the idea of that, you can do a purely passive slider, which is, again, it's a manual therapy technique.

But then encouraging the patient to be more active as they take over and do the movement by themselves. I think then they get the idea of the movement quite well. It's a very simple thing, so I think, usually, they get the idea pretty well.

David: When you're trying to monitor that treatment success within the treatment session or afterwards, what are you generally looking for? Are you looking for an immediate change in their symptoms, whether it aggravates it or irritates it or ...

Toby: Yes. We always in the past, we used to be very focused on immediate effects to have some sort of pointer that their patient is going to have a good long-term outcome. And it's something I've always looked at, but I think the evidence for that, there's not great evidence. There's not a lot of studies that looked at it in terms of neural mobilisation. I'm not aware of any studies that have looked at the consequences of immediate change on neural mobility in the initial session, for the outcome for the long-term, but to me, I think it's important to show the patient that they can change. And I show to the patient, said, "Look, when you came in, you could bend down, and you could only get as far as your knee, but as a result of what we've been doing today, now you're getting halfway down the shin." So, there's a good change.

And sometimes to point this out to the patient, it gives them positive feedback and less fearful that they show that they can change. And if they can do, and if they can improve after doing an active slider exercise, then I think it increases self-efficacy. So, it's all positive feedback for the patient. I think it's showing to the patient that you know what you're doing, that they can change, it's not going to be permanent, and there will have a good outcome. These are all important things that we need to show the patient.

David: So you can have a nice change by the sounds of it within the session. Is that your main guideline to know that you're on the right treatment pathway, or you're looking at 24-hour response? What's the most important things for you?

Toby: I'd expect to see some objective change, so I'd measure forward bending and standing, and I'd also measure straight leg raise. So, I would expect to see some significant change. If the patient's had leg pain for two years and they're very severe, then that might be a relatively small change. If they've got more acute pain, then I think we could expect to see a more rapid resolution in the session in the clinic. So, it depends a little bit on the patient, but I would expect to see some objective change. To the patient themselves, they may not feel much different in the first session, and I would explain that to the patient, and it's pretty much the same as with the rats. They didn't show positive benefits for about three weeks, but I would expect to see some objective change within the sessions during the progress.

David: And do you have any sort of discussion with the patient about what's likely to happen with their symptoms over the next day, week, that sort of thing?

Toby: Yes, I think that's so important to tell the patient what to expect. They want to know what's going to happen to them. They want some guidance on what's going to happen. With these neural disorders, I find that they're often very cyclical, and they're two steps forward, one step back kind of thing. It's never a straight linear improvement in the patient's condition. They go home and they feel a little bit better, so they decide they're going to do a little bit of extra activity at home. They might do something they've not been doing for a long time, and then they come back and say, "Oh, I'm much worse after that treatment." And you ask them what they were doing, "Oh, well, I went home and cleaned all the house," but you've gotta be very careful to educate them not to do those things, just like an athlete.

If they've not been running for 12 weeks, and you get the patient to go home and do some exercise, they don't go for a 10K run in that first session. You've got to get the patient to gradually return to activity. But explain to them that there will be ups and downs that may not be explained by what they've been doing.

It's in the nature of nerve problems, and it does take time to recover, give it time, and we've seen a bell curve for recovery for neural disorders. Some people, it's much quicker, some people, it's much longer. If you do the right things, then I think generally, you would expect to see a good outcome in four weeks.

David: What about when you come to see other parts of your treatment you wanted to include? So, it sounds like you've got them up to a nice start ... Let's just imagine you've got this patient's got a radiculopathy, and you've identified that L5, and then you've gone ahead and treated with spinal mobilisation with the leg movement, and that's improved their range and their pain as well, and in their straight leg raise, and also their forward bending. So now, you're going, "All right, we're off to a good start." And then you've given them some sliders to start with at home as well, check them in the clinic and then that's going okay. And they've gone off to do those, and you've given them some of that education and advice you mentioned there before. If you then wanted to ... Does strengthening have a role, and if so, how do you tend to tie that in with this type of thing?

Toby: Yes, I think there's definitely a role for a progressive loading exercise as the patient gets better. It depends, I think, on the type of patient that you see. If you're talking about the patient who comes to a pain clinic with severe neural symptoms, then it's going to be a long way down the track before you look at something like that, but if you've got an athlete who's had some injury, and they've got some residual symptoms, then I think that it's going to be coming in much earlier, and probably quite quickly into the beginning part of the treatment. So, I think it depends a little bit on the individual, and the type of patients you see. Maybe in some patients, you might never look at that, because they're expected in improvement. If you've got some patients with severe neural disorders, the expected improvement is not going to be so substantial.

David: Is that normally something you'd tie in together? Let's just say you got that athlete or someone that's got a fairly high load job, or that type of thing, and you're thinking that, potentially there's some ... You want to address that and progressively load them. How do you tend to incorporate that at the same time, or when would you start to incorporate that strengthening or progressive loading component to it?

Toby: When I think about the shoulder, for example, I think about patients who have had severe neck, shoulder, arm pain for six months. You see those patients and they come to the clinic, they're holding their arm, they're supporting it because it's been so painful. Their arms' in internal rotation, their shoulder girdle's in elevation, and they don't want to go into abduction. And if you put them into a neural provocative position, it's extremely painful into abduction. So their medial rotators are facilitated, so they're very weak in their external rotators and abductors, because of the antalgic position that they've been adopting for however long they've had this condition.

And always remember that Bob Elvey, an important part of his treatment was to strengthen the patient. They used to use PNF as a way of strengthening people, because it was a nice way to facilitate the muscles in the shoulder after they've had this internal rotation, adduction of the shoulder. So I think it's a nice way to treat them, but we don't have to use PNF, we can use some simple loading strategies that you would for any kind of musculoskeletal condition. I think you'd have to be a bit careful about introducing it too soon. So, he would introduce it probably after about six treatment sessions in a patient who's got this severe shoulder pain. So, something that you could look towards doing as the patient gets a little bit of improvement.

Once you're happy that they're getting progress, then I think you can add a gradual progressive load.

David: What about when it comes to performing your neurodynamic treatment, for instance, your sliders without the manual therapy, have you ever compared the two?

Toby: Yes. Well, some people. You get patients who are just not able to come in for treatment. I remember patients where you just have to give them an exercise program to see if they can follow that home. Some people will do that, some people are very strict with themselves, and they do what you tell them to do. Other people don't, but you're sometimes forced to just give people an exercise program over time, and then, maybe they can't come in for regular treatment, whatever it might be. For the right patient, I don't think you really need do a lot of hands-on treatment. Just getting them to understand that the condition is normally self-limiting. If they keep active, and if they try to resume normal activity in a graduated way, I think you should have a positive outcome.

David: What sort of patients do you think overall? If you had to look at different types of patients you've treated, and how they respond, or what the studies tell us, when you're looking at the types of patients that are likely to respond to any of their tissue based treatments like sliders or manual therapy, which sort of patients tend to go the best then would you tend to incorporate this type of treatment with?

Toby: I think the patient with peripheral nerve sensitisation. As a patient, I would like to see to treat, and I would expect to show some improvement if the patient was able to follow my advice and to understand. Now, some people don't do that, they don't follow what you tell them. We all have people that don't do the right thing. So, if you can do the right thing, they're likely to improve. So, I think any level of sensitisation ... I remember we did a study many years ago, and then it was published. It was a pilot study of the use of neural mobilisation for people with cervicobrachial pain, and we had a control group. We had a group who received some joint mobilisation, and we had a group who received neural mobilisation. And I remember one of the patients in the study, she came in with a 20-year history of shoulder pain that she'd been told by a doctor that she got a frozen shoulder and that she had to live with it. So she did.

She lived for 20 years with this frozen shoulder, and it's wasn't self-limiting. And she had that typical pattern of restricted movement that you would expect from a frozen shoulder, and she also had positive signs of neural sensitisation. So, she was included in the study. And when I started to treat her, I thought, "Is this patient going to improve? She's just so severe. She's had it for 20 years. What's the point of doing this?" So, she had a course of treatment, and she had complete recovery. She had full movement in her shoulder. I was totally blown away that she could make such a complete recovery with some simple manual therapy. This was quite a few years ago. It was simple manual therapy of neural mobilisation, simple exercise, and some graduated loading as we've been talking about, and she had a full recovery in her movement.

So, I don't think you can ever tell who's going to respond and who's not just by looking at the patient's history. I think you have to give everybody a go if you can, if it's appropriate.

David: Okay. And what about when you've got patients that have that radiculopathy, or that you think they've got some sort of a disc involvement or something like that or raging disc signs and neuro signs, are you still happy to trial this type of treatment with them?

Toby: Definitely. I think they'll also do well. And we know that most patients should recover if they're given the appropriate treatment, and they should recover without treatment. If they keep active, if they don't take the wrong drugs, if they keep moving, then there's research to show that 83% in the UK, 83% of discs will spontaneously resolve by themselves. So, if they can resolve by itself, you don't need to have surgery, you don't need to have other forms of intervention. There's a high likelihood that they will get better, but we can also encourage them to get better a little quicker, I think, if we give them some simple physiotherapy.

David: And so, when you're looking at the education side of things as well, so, anyone that's got those neuro signs where you've identified from your subjective and your objective that they've got this peripheral nerve sensitisation, then you're going to trial this treatment with them and see if you can get those objective changes and subjective changes, and that gives you a good idea about this is a good treatment approach for them particularly, is that right?

Toby: Yes. Yes. I think, not everybody responds, but I think in the main, people should have a positive outcome from treatment.

David: When they don't respond, what do you do? Just imagine that those patients, and they've got those sort of signs. You've trialed the spinal mobilisation with leg movement, and you've trialed your sliders, and you're not getting that response. What's your next go-to there?

Toby: Well, I think you have to look at what are the drivers for the patient's problem. I mean, there are other factors as well. I mean, we haven't really talked about psychosocial issues, so we have to look at all the potential issues for the patient. So, the Curtin University have a nice clinical framework for assessment of patients, and there are many drivers for patients' persistent pain. So, I think we've touched on the one aspect, but there are many other aspects that we need to consider. So I'm not saying that a patient doesn't get better because they've got psychosocial issues, but it could explain why some people don't respond in the way that we expect. So, we have to look at all the different potential contributing factors, and not just the biological aspects.

David: When we're looking at that education that you're providing, you mentioned a few of the factors as well, about making sure they don't go home and don't just go cleaning the whole house from top to bottom after they're feeling a little bit better, but that education and advice you really emphasised before, and is a massive component and really important to what we do.

So, tell us a little bit about some of those specifics when you, maybe it's with some ... Could be upper limb or lower limb, whatever you choose. What are some of the important aspects when we are educating and give a patient some advice if we want to provide to them?

Toby: Yes, I think it's so important that, if you think about the upper limbs, if you think about a patient who's got neck and shoulder pain, and this patient's very sensitised, they've got features of peripheral nerve sensitisation, they've got limitation of shoulder abduction, elevation, they've got positive neurodynamic tests, they've got pain on palpation around the brachial plexus, so they're the classic features for that patient. Now, the patient goes home, does the shopping, carries the shopping bag in their arm, and by the time they got home, the shoulder depression has put so much stress onto the sensitised plexus that they're flared up for a week. So, just telling people, giving them some advice about how they might reduce the stress on the mechanosensitive tissues, let the tissues recover, unload those tissues, and then gradually let them build up with loading capability.

So, I think just advising them about carrying things. A lot of ladies like to have that heavy handbag on their shoulder, and they don't realise that they're carrying five kilos on that shoulder, which is causing them some stress. A lot of people don't understand the importance of sleep, and sleep is such a powerful thing. In fact, sleep is the number one factor associated with recovery for patients with neck disorders. So, if you can explain to the patient that the amount of sleep that they get is also having an effect on the sensitivity of the neural system, it's having an effect on inflammatory markers, all sorts of different things, not only the amount of sleep that they get, but the position that they sleep in can also be affected. Patients often that don't understand the position of their neck when they lie on their side, could have an impact on the sensitivity of the neural system.

If you have one thin pillow and you sleep on your good side, you're likely to put some stress through the brachial plexus to sensitise it more. If it's already mechanosensitive, it's just going to aggravate you. You're going to have less sleep, and you're going to wake up in the morning and feel more pain, and you're going to have a vicious cycle of no sleep, more pain, and so on. So, I think we can give some people advice about simple unloading positions for the neural system. I try to explain to people, it's probably best if they can, to lie supine with a thin pillow if you have PNS, peripheral nerve sensitisation. If you have a very fat pillow or two pillows, you're likely to flex your neck and put more stress onto the system.

So, a thin pillow, put your arms into a non-provocative position, so let your elbows be a little bit flexed, support your hands on your thighs. It's a very comfortable resting position for people. If they want, they can have a pillow under their arm just to support it, just to allow them to find a nice pain-relieving position. So, I think sleep is very important. We can give some people a lot of help from that regard, and most people just don't understand the association between the amount of sleep you get and their musculoskeletal disorder, and particularly sensitisation disorder. So, I think that's something we can spend quite a bit of time on, and also looking at trying to unload the neural system with simple everyday activities. So, that's takes quite a bit of time. And the education about their problem itself, how it becomes mechanosensitised, I think is important.

David: When you're looking at, you said, unloading the nervous system with everyday activities, talk about some of those.

Toby: Well, that's like you carrying the shopping bag, sitting in a slump position if you've got low back pain, then looking at trying to, if you got a sensitised neural system in your lumbar spine with a sensitised straight leg raise, for example, you don't really want to be putting yourself into an end-range lumbar flexion position all the time. It's likely to aggravate the patient.

The patient probably wouldn't tolerate it anyway, and they'll tell you, they can't sit for very long, so, when we have to give them some advice about trying to minimise the stress through the neuro system.

David: That was some good advice about sleeping too. You find a position that's non-provocative, for instance, getting them to lie on their back on a thin pillow and supporting those arms on their thighs, and you're looking to find those positions that aren't likely to put the nervous system under stretch, or an end range position.

Toby: Exactly. And I think prone is a bad sleeping position for most people, because you end up being in a rotated cervical position, which can also put stress on to the neural system. If you rotate your neck, you're going to put some contralateral stress through the brachial plexus.

So, prone position is not so great. Side-lying also is difficult too, unless you can really optimise the thickness of your pillows. It's difficult to position the neck in a neutral position.

David: Any other sort of aggravating activities you tend to advise patients to avoid in that early or acute stages while you're allowing recovery to occur?

Toby: I think any repeated movement in the direction of provocation. So, for the patient with neck and shoulder pain, reaching into abduction and to elevation for repeated activity, maybe at work, maybe the reaching for a mouse or something to do some repetitive movement during the everyday office activity, or they're working in a factory where they have to do some repeated movements involving abduction.

I think you've got to be thinking about trying to modify those to begin with, to try to allow the patient to settle. And then, as they get better, we can just gradually return them to their normal activity.

David: And about educating them about these things, we're all keeping in mind that you want them to return to these, and you're trying to avoid making them fearful about these activities. Tell us a little bit about that.

Toby: That's a fine line, and this is between making somebody fearful by telling them that something's bad for them, we don't want to be doing that, but we also have to try to bring them down to a level that's going to allow them to recover. So, we have to modify the load just like you do for a tendon problem, modify the load on the neural system. It's really no different. And that, in fact, they're just probably a little bit more sensitive to that kind of load, so we just have to minimise that as much as we can, explain to the patient that it's a temporary reduction in load that we can then gradually increase over time as they get better.

David: Any other sort of advice or educational things that are important to include there?

Toby: Not that I can think of off the top of my head at the moment.

David: I'm going to just take a couple steps back, because as I was thinking about this, you gave some really nice clues about that, especially with that lower limb when it came to identifying your spinal mobilisation with leg movement and incorporating those. And there you've brought up some nice points about the upper limb. So, do you mind if we just step back a little bit and go to some of those upper limb movements, if we've got ... How you might address some of the peripheral nerve sensitisation in the upper limbs with some of your manual techniques?

Toby: Yes. So, in the upper limb, we have a similar technique, it's called a spinal mobilisation with arm movement, where we apply a similar technique to the neck. Just like in lumbar spine, we apply that specific force of transverse pressure to the spinous process. You can do the same in the neck, while the patient does a median or radial or an ulnar neurodynamic movement, so that they're moving with the mobilisation. So, it's again, a pain-free mobilisation.

You've have to identify which neurodynamic test is the most important for the patient. So maybe it's a median nerve, which is giving them some shoulder symptoms radiating into the arm, and that reproduces the patient's symptoms. So, you apply a transverse pressure while the patient does the median neurodynamic move.

Now, sometimes it's difficult to do that, so you might do a mobilisation in a slightly different direction. There is a way of applying a flexion mobilisation at the segment using a manual therapy belt, so the patient's lying down with the head resting on a pillow, and we have a therapist standing at the head of the patient with a manual therapy belt looped under the patient's neck to apply a little bit of flexion force at the segment, while the patient does the neurodynamic movement. So, the patient is at 90 degrees of abduction with the elbow flexed, and they're just doing an elbow extension movement from that position. And you measure their onset of pain. At the same time, while the patient is doing that movement, you apply this little flexion mobilisation force using the belt, or with a transverse pressure, as we talked about before, so one or the other, to see the immediate effects on the patient's neurodynamic movement.

If the neurodynamic movement improves, then that's the treatment that we apply for the patient with the same principles.

David: You got to be lying prone when you're doing that median nerve test, you can use the belt, or if you can't get at it with your thumbs, do you ever do it in sitting or standing or any of that, checking out your spinal mobilisation with arm movements while they're doing some sort of ...

Toby: Yes, you can do it in an active, functional way. So, if you have the patient just to do an active elevation of the arm, shoulder abduction elevation, or you can get the patient to do a horizontal extension. So, while they're doing that movement, we can also apply the mobilisation at the level we think is the patient's problem, to see if we can impact on the patients active functional movement. And if it does, then it becomes the treatment.

Now, some patients are not so easy to manage in that way. So, I think for the patient with more severe symptoms, with more major limitation of movement, I would treat them in a supine position, and I would do the lateral glide technique, which is of more passive technique. It is a passive technique where you do a lateral glide away from the painful side, starting with the arm in a non-provocative position.

So the patient starts, they're coming in, they're very severe, they're the most severe patient you can imagine. So we want to start in the least provocative position. They've got right symptoms, right arm pain. So the right arm is positioned with a neural system in a maximally unloaded position. So they have elbow flexion to 90 degrees, they have the arm close by the body. The shoulder girdle is elevated in a position that takes away the stress completely as much as possible on the neural system. In that position, we do a lateral glide technique to the contralateral side, mobilising for approximately one minute, and then giving the patient rests. And then repeating that for maybe five sets. That's what we would think of for a patient with a more severe neural disorder, until they may be able to then tolerate those more active techniques that we just talked about.

And as the patient gets better with that passive mobilisation, it's so important to gradually progress the load onto the neural system. You've started from the least provocative position, but as they get better, you need to progress the neurodynamic position. So, you gradually add more abduction of the shoulder, you gradually add elbow extension, you gradually add some, maybe, depression, till you get to the point where the patient over several treatment sessions, they're much improved, and now they're at 90 degrees abduction, and full elbow extension, maybe even wrist extension, which is a strong stress on the median nerve, and they're able to tolerate that, because we're gradually worked up to that position over time.

And unless we do that, we're not putting them through a natural progression and a natural loading process. I think that's what people fail to do when they use manual therapy, they fail to progress the patient. They start with a simple technique, but they keep using that same simple technique and the patient fails to progress. It's just like anything. If you go to the gym and pick the smallest weight in the gym and say, "I'm going to do some strengthening on my biceps," and use that same pink weight, half kilo, that nice little pink one, and you use that same one every session for six weeks, and you're disappointed at the end of six weeks because you're not any better. I mean, that would be crazy, wouldn't it? It was just the same with manual therapy. We need to progress the load in many patients.

David: Indeed. That makes sense. And so, you mentioned there some really good points. And so, just coming back to it again for a second way, you were talking about identifying the levels that you want to perform your spinal mobilisation with arm movement. In the lumbar spine, you used your tests with your straight leg raise, and also your prone knee bend to identify which levels were potentially affected, and you confirmed it with your PAIVMs and your PPIVMs, and then you then went further to identify that they had that improvement in their range when you performed that lateral glide. So, talk to us a little bit about, in the cervical spine, what are some of your tests to help identify which level? So we've got a whole bunch of levels there that we could perform a spinal mobilisation with arm movement, so how do you go about identifying that there?

Toby: I think we use a similar process. For one thing, if you're talking about a patient with arm symptoms, then the possibility of an upper cervical problem is pretty remote. We're not going to deal with C1, C2, C3, C4 roots as possible contributors to arm pain. I think it's highly unlikely. So we're mainly thinking about C5, and even C5 is probably less likely, but it's possible; C5, C6, C7, C8, maybe even T1. So, if you test the ulnar nerve, then pretty quickly you can eliminate C8 and T1, because if that's negative, then you know that it's not likely to be that. So you have down to a C5, C6, C7. So we can be a little bit more confident.

The median nerve doesn't have much contribution from C5. It mainly comes from C6, C7, C8 and T1, so, if you've got a positive median nerve, you know that you're most likely to be dealing with six or seven. I would then look at the nerve palpation in the anterior aspect of the neck.

I think you, with careful practice, you can try to palpate the different routes in the neck as they emerge from the gutters of the transverse process. Some people might argue with that, but I think with very careful palpation, you should be able to identify the most sensitised level, but even without using palpation, you've got a much stronger idea of the probable origin, based on what we just talked about. If you use palpation of the spinous process, I would expect to find some greater sensitivity. So, my PAIVMs might give me some identification as to the level as well. So, if I combine information from the PAIVMs, the PPIVMs, as we've talked about before, the neurodynamic tests, the nerve palpation, I think we get an idea about the most sensitive point, and that's where I'm going to apply this lateral glide technique.

David: With your PAIVMs, do you tend to find that you can get some sort of symptom reproduction with those?

Toby: I think it would be unlikely to reproduce the patient's arm symptoms. You're more likely to get local neck pain. Sometimes it is possible to reproduce arm pain, particularly if you've got to be a little bit rougher, so you've got to be a bit careful there. It's not usually the goal to identify their arm symptoms. So, I think we're a little bit careful about that.

David: So you use the ulnar nerve there, if they had that negative, you were tending to try and use that to exclude C8, T1, you would end looking and going to less likely to be the upper cervical spine down to C4. And so, you're looking at around that C5, C6, C7, and then your potentially using palpation, but you've narrowed it down to a few levels that you can then use to perform your spinal mobilisation with arm movement on and see if you can improve that now, that pain.

Toby: Yes. Or to do the lateral glide technique. And the actual glide technique, it's not really such a specific segmental technique. It's moving the whole neck with some emphasis on the positioning of your hand to apply additional stress through that part, but it's going to move most of the neck to some degree. So you will be getting some movement of multiple levels. So, the idea that you have to be specific at one specific level, maybe is not so important for that technique.

David: So, you can perform those lateral glides where you're getting movements at a few different levels. And you mentioned there before, if they're quite irritable, you've got them down into a position that's less likely to be provocative, like no shoulder abduction, you've got an arm by their side with the elbow bent to 90 degrees, and their shoulder elevated a bit, so they're in a non-provocative position, and then progressing that, is that right?

Toby: Exactly. If you had started that position, for a patient whose only got minor symptoms in their arm with minor limitation of neurodynamic tests, you probably wouldn't have any impact on them at all. And you'd think, "Oh, that didn't work." But because you didn't start in a strong enough position, as it were, to put some stress onto the system, we're trying to stress the system to try to desensitise it. You're putting some mechanical force through the neural system to gradually desensitise it over time, and that's how it works, I think. So if you choose a too strong position, you're going to flare them up and they're going to be worse, if it's not strong enough, it's not going to have any impact, if you don't progress it over time, it's not going to gradually get better; it's not going to progressively get better.

David: So how do you find that initial position? You mentioned that you go too strong, you can go not strong enough. How do you find that goldilocks zone?

Toby: A couple of things; first of all, if you're doing the technique and they can feel the pain in their arm, that's too strong, usually.

So I would back off the position until you can do the technique without reproduction of symptoms into the arm. The other thing is the amount of movement. And you'll notice that, when they’re in a provocative position, the muscles will guard and prevent any movement of the neck, and it'll feel like nothing is moving, whereas if they're in a comfortable position, the muscles relax a little bit more, and they will be able to move their arm. We've measured EMG activity during neuro provocation tests, and we found that there is a degree of reactive muscle activity, and we try to minimise that during the technique. So, if you're in too strong a position, you'll get strong muscle reactivity, and you won't be able to move very much.

If you're also reproducing the patient's pain, then it's telling you it's too strong, so back off quite a lot, try again, which is still the same, back off more. If you can't do it at all without reproducing the symptoms, and we can't get any movement at all, even in the most easy position, it's probably telling you that their condition is too sensitised. Perhaps they've got the more severe problem with the positive LANSS, and the neuropathic pain with sensory hypersensitivity, maybe we should have a hands-off approach for that patient, but that's not many patients in my experience. I've rarely come across that. If you've gone through the examination process, usually you should be able to position the patient well and get a good treatment outcome in that treatment session.

A positive outcome would be some improvement in their neurodynamic test or an improvement in the active shoulder movement abduction, for example, if I'm talking about the upper limb.

David: That gives us some really nice guidelines about where to start and have progress, and that's fantastic. And what about, if a patient brings up the next day and they said they've had an increase in their pain, what does it tell you and what do you do then?

Toby: Well, I think it's sometimes okay to feel pain after treatment sessions, as long as it's tolerable for the patient, and you asked the patient how much they can tolerate. So the patient will tell you what's acceptable. If you warn the patient that after an examination, you've tried to find out exactly what the treatments is required, and that sometimes can aggravate the patient's condition, and it may take 24 hours for that to settle. It's not something I would want from the patient, but as long as it's settled within 24 hours, I think it's okay. And as long as you've warned the patient that that's can occur, usually most patients are accepting of that kind of situation. if you don't warn them, they do get a bit disturbed, and that's maybe why they've called that up, and you need to just calm them to reassure them that that's not going to be something that's to expect every treatment session.

If you've had that flare up 24 hours, then the next session, you know what you've done has had some impact, so you just back off a little bit and repeat, and explain to the patient why you're doing that. So, an increase in symptoms can be quite valuable sometimes. The worst thing of all is if you treat somebody and there's no change, that's the worst thing of all, because it means you're either in the wrong place, you've misread the patient's problem, or what you're doing is not sufficient.

David: And then, when you're thinking about explaining to patients how our treatments work, so we're looking at your manual therapy, looking at your neuro mobilisation techniques to improve pain in these patients that have the mechanosensitivity, how do you think they work, and how do you explain it to patients?

Toby: Well, there's two separate things there; how they actually work, whether it's a great shopping list of what these techniques have. They have physiological effects where they have shown in studies to change edema within a nerve, that's been shown to change axoplasmic flow within the nerve. So there are these physiological effects on the circulation itself, which can alter the patient's symptoms.

If you improve the blood supply to that nerve root, or that nerve that's not been moving, then if you can get some movement around that tissue, it's going to help improve the circulation, it's going to help get rid of those nasty chemicals that are sensitising the nerve tissue.

So that's one aspect, probably the least important, I think. The most important are the effects of movement on the nervous system, and they're very complex changes with changes to the central nervous system to cause inhibition, changes to pro and anti-inflammatory cytokine production, all sorts of changes on the immune system with their glial cells in the dorsal horn. So, many, many complex changes associated with the central nervous system that, how can we tell them which of these is having the impact on the patient, but we know that they do have an effect? So sometimes people criticise when we say that there is a neurophysiological effect, but there are many broad changes to the nervous system that occur, and it's difficult to know in an individual patient, which of those mechanisms is actually occurring. So, we don't really explain that in such depth to the patient. Well, there's, some people would argue that that's important to explain pure effects in very, in-depth way. I would explain to them the neurophysiology in a simple way, that nerve tissue is sensitised, that if we're to move it, we can desensitise it. So, just by repeated movement, you can desensitise the nerve tissue to allow more normal moving to occur, and if a patient does that themselves, they can maintain that desensitising effect and have long-term improvement in the patient's condition. So, I like to talk about it as a desensitisation of the nervous system.

David: Beautiful. And I think that's a really nice place to wrap up this podcast, and you've shared an absolute ton of information there. We've been able to really dive into the overview of how people can understand neural tissue disorders, and then categorising them, understanding the symptoms and how to assess them, and then diving into the treatment and practical strategies that people can use there. So, you've shared a ton of information, and it's been absolutely fantastic and very enjoyable to have a chat about.

Toby: Thanks, Dave, I really appreciate that. You've asked some very in-depth questions, who made me maybe think about what we do in terms of assessments and treatment. So, there's a lot more that we can go into, and I'm sure that if anybody's interested, there's a lot more information. We can point people in that direction with further reading, if you're interested about that.

David: Absolutely. So, tell people where can they find out about yourself, and then your courses and those sort of things, things you've got going on, Toby.

Toby: Yes. Well, if you'd like to follow up and attend one of our courses, have a look at our website,, or you can email me for information,, or you can follow me on Twitter, @DrTobyHall, D-R-T-O-B-Y H-A-L-L. So, that's some of the places you can contact me. I'm happy to send you further information if you've got some interests, but thanks for listening, and really appreciate you inviting me, Dave. It's been a pleasure to talk with you.

David: It has been an absolute pleasure. And obviously you've got a lot to share there, Toby, and lots of practical ways that people can incorporate this into their practice, and obviously a lot more to share. So, if you're wondering whether you should be jumping on to one of Toby's courses, it seems like it's going to be a great idea to go and get on one of those as soon as this whole lockdown eases a bit and the courses are back up and running, but we've given people a lot to think about, and we do really appreciate it, Toby. So thanks.

Toby: Thank you.

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