- Email: [email protected]
The state of the art of neurodynamics – Assessment and management
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Abstracts / Manual Therapy 25 (2016) e5ee32
the European College for Decongestive Lymphatic Therapy. He is the Scientific Chair of the executive committee of the Pain, Mind and Movement Special Interest Group of the International Association for the Study of Pain (IASP). Jo runs the Pain in Motion international research group (www. paininmotion.be) and a physiotherapy-based treatment program for patients with chronic pain in the University Hospital Brussels. His research and clinical interests are patients with chronic ‘unexplained’ pain / fatigue and pain-movement interactions, with special emphasis on the central nervous system. The primary aim of his research is improving care for patients with chronic pain. At the age of 39, he has (co-)authored more than 150 peer reviewed publications, has obtained over V4.7 million of grant income, served more than 150 times as an invited or keynote speaker at national and international meetings in 17 different countries, and supervised 6 PhD projects to completion. His work has been cited >1700 times (h-index: 25; ISI Web of Knowledge). 4. Dr Trudy Rebbeck PhD FACP MAppSc(ManipPHty) BAppSc(Phty) Specialist Musculoskeletal Physiotherapist ; NHMRC Research Fellow University of Sydney Dr Trudy Rebbeck is a NHMRC Research Fellow at the University of Sydney with appointments at the Faculty of Health Sciences and John Walsh Centre for Rehabilitation Research, Sydney Medical School. Dr Rebbeck's area of research and clinical expertise is in the development and implementation of best practice for the management of whiplash. She has 25 peer reviewed publications and over $4m in research grants. She has coauthored several clinical guidelines for whiplash and several implementation / translations trials which have resulted in a successful change of practise in primary care settings. Dr Rebbeck's current research fellowship focuses on improving recovery for cervical spine disorders including people with whiplash, headache and neck pain. Her international profile results in her being frequently invited to present workshop and courses nationally and internationally in the area of cervical spine disorders. Funding acknowledgements: Funding Acknowledgements as per bio and affiliations Disclosure of interest: None declared Keywords: whiplash, new directions, FOCSYM-292 THE STATE OF THE ART OF NEURODYNAMICS e ASSESSMENT AND MANAGEMENT H. Luomajoki 1, *, R. Ellis 2, M.W. Coppieters 3, A. Schmid 4, R. Nee 5. 1 Institute for Physiotherapy, Zürich University of Applied Sciences ZHAW, Winterthur, Switzerland; 2 Institute for Physiotherapy, Auckland University of Technology, Auckland, New Zealand; 3 MOVE Research Institute Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; 4 Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; 5 School of Physical Therapy, Pacific University, Hillsboro, United States * Corresponding author.
Relevance to IFOMPT and expected audience: Neurodynamic tests and mobilization techniques have been used in musculoskeletal physiotherapy for more than 35 years. However, treatment modalities and insights in possible working mechanisms have evolved substantially in recent years thanks to new insights in nerve biomechanics and the pathophysiology of nerve compression. In this symposium, the latest insights in the domain of neurodynamics will be presented which will assist the audience in the diagnosis, management and clinical reasoning process for people with entrapment neuropathies. Summary of session format: 5 minutes: Convenor Hannu Luomajoki gives an overview of the contents and learning objectives of the workshop. 15 minutes: Richard Ellis reviews neurodynamic assessment and treatment from a biomechanical perspective, providing insight in cadaveric and ultrasound studies. 15 minutes: Michel Coppieters reviews the validity of the neurodynamic testing and the evidence for different treatment options.
10 minutes: Robert Nee reviews the evidence on clinical outcomes related to neurodynamic treatment. 15 minutes: Annina Schmid explores the evidence for neurophysiological mechanisms of action of neurodynamic exercises. 10 Minutes: Hannu Luomajoki presents some cases studies and practical techniques through videos. 15-20 Panel discussion Information concerning any presentations or publications: The contributors will present previously published key papers from their own research and from other research groups, and will blend this with the latest unpublished data and their own clinical experience. Description: The participants will have an evidence based overview of: - $ Latest insight in the pathophysiology of entrapment neuropathies - $ Validity of neurodynamic testing; Rationale of neurodynamic mobilization, integrating biomechanical, physiological and neuro-immune aspects - $ Practical and neurophysiological explanation models for neurodynamic management Description At the beginning of the session, Hannu Luomajoki will review the rationale of neurodynamic testing and management. He will give an overview of the following presentations and also introduce the symposium members. Richard Ellis will explore biomechanical concepts of neurodynamics and relate these back to sound clinical reasoning for the selection of neurodynamic testing and neural mobilisation. The biomechanical features of the peripheral nervous system (PNS) which are necessary to appreciate, for all clinicians, is the fact that it is a continuous system (along with the CNS), it moves in relation to its mechanical interface, movement will be influenced by proximity of moving joints/limbs and postures and the influence of strain/tension upon the PNS. The selection of neurodynamic testing and neural mobilisation exercises must not be ad hoc. The choice of clinicians to utilise specific techniques must be based upon sound clinical reasoning and take into account relevant nerve biomechanics. This presentation will draw upon cadaver models and the use of medical imaging (including ultrasound imaging) to highlight and explain the relevant neurodynamic features of the PNS. Michel Coppieters will present on the meaning and clinical applicability of neurodynamic tests. The current literature raises many questions, which can be confusing for clinicians and researchers. Some studies recommend neurodynamic tests to rule out a neuropathy, others state the tests are useful to rule the pathology in. There are no universally accepted criteria to diagnose a neuropathy, but the impact on diagnostic accuracy studies is rarely considered. Occurrence of false positive test results is described in healthy populations, but according to which criteria? The aim of the first part of his presentation is to clarify the divergent conclusions that are reported in the literature about the diagnostic accuracy of neurodynamic tests. In the second part of the presentation, Michel will focus on psychosocial aspects that need to be considered in neurodynamic testing and the biomechanical evidence for different types of neurodynamic treatment techniques. The clinical efficacy of these techniques will be addressed in the next presentation. Robert Nee will present an overview of the available evidence on potential benefits and harms of neurodynamic treatment for nerve-related conditions. The variable results from clinical trials suggest that certain nerverelated conditions may be more suitable for neurodynamic treatment. Evidence-based patient characteristics that may help identify patients who are and are not likely to improve with neurodynamic treatment will be discussed for those nerve-related conditions where neurodynamic treatment appears to be beneficial. By integrating these patient-centered outcome data with biomechanical evidence and potential neurophysiological mechanisms addressed in accompanying presentations, clinicians can make more informed decisions about using neurodynamic treatment techniques in daily practice. Annina Schmid will summarise the available evidence for mechanisms of action of neurodynamic treatments with a focus on neurophysiological aspects. The first part of her talk will give an overview of different pathophysiological mechanisms at play in patients with entrapment neuropathies. This will include the most recent evidence from both experimental models as well as patient populations. Pathophysiological mechanisms including ischaemia, demyelination, axon degeneration and neuroinflammation will be explained. The second part of this talk will highlight
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recent scientific advances on how neurodynamic treatment may exert its effect on these pathophysiological mechanisms. Focus will thereby be placed on neurophysiological mechanisms including remyelination, axon regeneration and the reduction of focal intra- and extraneural oedema. We will also discuss potential effects of neurodynamic exercises that extend beyond the focal lesion site. Hannu Luomajoki will display some video examples of possible treatment techniques and patient cases In following discussion the presenters together answer questions from the audience in a panel discussion format. Implications/conclusions Neurodynamic testing and mobilization have been used in physiotherapy for more than 35 years. However, we still do not know the exact working mechanisms of this method. In this focused symposium the leading experts of the field will critically review the evidence based on their own research, and that of other groups working in this field.. The presentations will be followed by clinical and practical examples and ideas of treatment possibilities. The symposium will be wrapped up with a panel discussion during which the presenters will discuss together and with the audience the current concepts and their meaning to practice. Learning objectives: Latest insight in the pathophysiology of entrapment neuropathies $ Validity of neurodynamic testing; Rationale of neurodynamic mobilization, integrating biomechanical, physiological and neuro-immune aspects $ Practical and neurophysiological explanation models for neurodynamic management Implication/Conclusions: Neurodynamic testing and mobilization have been used in physiotherapy for more than 35 years. However, we still do not know the exact working mechanisms of this method. In this focused symposium the leading experts of the field will critically review the evidence based on their own research, and that of other groups working in this field.. The presentations will be followed by clinical and practical examples and ideas of treatment possibilities. The symposium will be wrapped up with a panel discussion during which the presenters will discuss together and with the audience the current concepts and their meaning to practice. Biography: Prof. Hannu Luomajoki is the head of master program for musculoskeletal physiotherapy in Zürich University of applied sciences (ZHAW) in Winterthur, Switzerland. He has been working 30 years as a physiotherapist. He finished his graduate training in Finland 1986 and Masters degree in manipulative Physiotherapy in Adelaide 1999. His PhD was given in 2010 through the university of East- Finland on the topic movement control impairment of lumbar spine. Since 2011 he is professor for musculoskeletal physiotherapy in ZHAW. He has published over 20 peer reviewed research papers, over 40 further articles and has presented in over 50 national and international congresses and he is co-author of several books. Hannu is also reviewer of many scientific journals. He has gained research grants for over 200 000.- CHF. In 2008 he won the price physiotherapy researcher of the year in Switzerland and in 2014 he was named physiotherapist of the year in Finland. Hannu has been involved and currently supervising several PhD projects. Currently he works in his own practice part time as well as teaches and does research in the university. His main areas of interest are Low Back Pain, clinical reasoning and pain physiology. He has been NOI instructor since 2001. He is giving courses for physiotherapists and doctors around Europe in topics LBP, pain education, neurodynamics and evidence based practice. He has been coorganisator of many national physiotherapy congresses. Dr. Richard Ellis is the Associate Head of Research within the School of Clinical Sciences at Auckland University of Technology (AUT) in New Zealand. Richard is also a Senior Lecturer within the Department of Physiotherapy. He teaches on both the undergraduate and postgraduate musculoskeletal physiotherapy programmes. Richard completed his PhD in 2011 using ultrasound imaging (USI) to assess movement of the sciatic nerve in response to neural mobilisation. Richard's ongoing areas of research interests include the assessment and management of peripheral nervous system dysfunction; neurodynamics; peripheral nervous system biomechanics; manual therapy and musculoskeletal physiotherapy; USI and the use of USI by physiotherapists. He has 20 peer-reviewed publications and has presented his research both nationally and internationally. Richard has attracted over $80,000NZD in research funding. He has international research collaborations with groups from Australia, USA,
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United Kingdom, The Netherlands and South Africa. External to AUT, Richard is the President of the New Zealand Manipulative Physiotherapists Association (NZMPA), which is the Member Organization for New Zealand within IFOMPT. He is also an Associate Editor for the New Zealand Journal of Physiotherapy. Richard remains clinically active and practices as a specialist musculoskeletal physiotherapist. Prof Michel Coppieters is a musculoskeletal physiotherapist with a special interest in nerve disorders and pain. Since 2014, he is Professor in Musculoskeletal Physiotherapy at VU University Amsterdam in The Netherlands. He is Program Director of the Master of Science in Musculoskeletal Physiotherapy at VU University Amsterdam, where he also directs the research lines in musculoskeletal physiotherapy. Previously, he was Associate Professor at The University of Queensland in Brisbane, Australia, where he was the inaugural director of the Neuropathic Pain Research Group in the Centre for Clinical Research Excellence in Spinal Pain, Injury and Health at the School of Health and Rehabilitation Sciences. He has published more than 40 peer-reviewed papers and several book chapters in the field of neurodynamics and multiple other papers in other areas of Musculoskeletal, Orthopaedic and Sports Physiotherapy. With respect to neurodynamics, his research aims to obtain a better understanding of the pathophysiology of nerve injuries, to develop novel treatment approaches for patients with neuropathic pain and to test the clinical efficacy of these programs. He has received competitive grants and fellowships (in excess of 1.5 million euro) and several prestigious awards for his research achievements and conference presentations. He frequently delivers neurodynamic and pain workshops internationally and has delivered multiple invited and keynote lectures at national and international conferences. Dr Annina Schmid is a researcher affiliated with the Nuffield Department of Clinical Neurosciences at The University of Oxford in the UK. She qualified as a Physiotherapist in Switzerland before obtaining a Master in Manipulative Physiotherapy from Curtin University of Technology in Perth, Australia. Annina has worked clinically for several years as a specialised musculoskeletal Physiotherapist in Switzerland before completing a PhD in Neuroscience at The University of Queensland in Australia. Annina's research is an exciting and unique combination of basic and clinical science which is aimed to improve our understanding of the pathomechanisms of neuropathic pain and entrapment neuropathies to ultimately improve management of these patients. Since the completion of her PhD and postdoc at The University of Queensland, she is continuing her research into the pathomechanisms of entrapment neuropathies at Oxford University under the guidance of world leading experts in the field of neuropathic pain. Annina presented her work at many national and international conferences related to both Physiotherapy as well as Neuroscience and has published her work widely. Her research contribution is recognised by the award of several grants, awards and competitive fellowships including the prestigious Neil Hamilton Fairley Fellowship from the NHMRC Australia and the early career research grant from the International Association for the Study of Pain. Annina shares her knowledge by teaching postgraduate courses related to pain and neuroscience internationally. She also maintains a small weekly caseload as a musculoskeletal Physiotherapist. Further information can be found at www.neuroresearch.ch. A/Prof. Robert Nee is the primary instructor for the musculoskeletal curriculum in the entry-level Doctor of Physical Therapy program within the School of Physical Therapy at Pacific University in Hillsboro, Oregon. He completed his Bachelor of Science in physical therapy at Boston University in 1985, a Master of Applied Science in manipulative physiotherapy at the University of South Australia in 1993, and a PhD in physiotherapy at The University of Queensland in 2012. His research has investigated the value of neurodynamic techniques in the diagnosis and treatment of nerverelated neck and upper limb pain and the use of prediction models to assist in clinical decision-making. He has 10 peer-reviewed publications and 3 book chapters related to neurodynamics. He was the lead author of a clinical trial on neurodynamic treatment of nerve-related neck and upper limb pain that won the 2012 Paper of the Year Award for the Journal of Physiotherapy. Bob has 30 years of clinical practice experience in musculoskeletal manual therapy and over 15 years of experience in entry-level and post-professional physiotherapy education. Funding acknowledgements: Michel Coppieters' research has been predominantly funded by the National Health and Medical Research Council
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of Australia, the Australian Research Council, the Manual Therapy Association and the Musculoskeletal Group of The Netherlands, and internal grants from The University of Queensland and VU University Amsterdam. Annina Schmid's research is mainly funded by the Swiss National Science Foundation, The National Health and Medical Research Council of Australia and the International Association for the Study of Pain. Robert Nee's research that will be presented was supported by an Endeavour International Postgraduate Research Scholarship from the Australian Government and a Research Scholarship from The University of Queensland. Hannu Luomajoki and Richard Ellis are funded partly by their universities and their national associations. Disclosure of interest: H. Luomajoki: None Declared, R. Ellis: None Declared, M. W. Coppieters Conflict with: National Health and Medical Research Council of Australia, A. Schmid Conflict with: Swiss National Science Foundation, R. Nee: None Declared Keywords: Neuroscience, Assessment, Working mechanisms FOCSYM-293 GROIN INJURY e TIME TO MOVE FORWARDS C. Small 1, 2, *, A. Grimaldi 1, J. Whittaker 2. 1 Physiotherapy Department, University of Qld, Brisbane, Australia; 2 Physical Therapy, University of Alberta, Edmonton, Canada * Corresponding author.
Relevance to IFOMPT and expected audience: Groin injury presents a significant and ongoing challenge for the sporting community. Most common in field sports involving rapid change of direction such as the football codes and hockey, costs are high due to often extended rehabilitation periods, high recurrence rates and time lost from sports participation. Physical therapists play a key role in pushing forward the development of more effective screening, prevention and rehabilitation strategies. Summary of session format: The session will open with a live survey via mobile devices to highlight where current beliefs around groin injury stand. Three highly experienced clinicians and researchers from The United Kingdom, Canada and Australia will then bring to the IFOMPT audience an update regarding current evidence available on risk factors for groin injury in sport and interventions for groin injury and an examination of contemporary clinical approaches including the role that real time ultrasound plays. Information concerning any presentations or publications: All authors have a special interest in groin/hip/pelvic pathologies having presented regularly on topics in this region. Publications include recent systematic reviews on groin injury risk factors and neuromuscular prevention strategies, EMG studies assessing muscle function in groin injury, book chapters and a clinical text book on sports injuries. Description: An understanding of the risk factors for groin injury in sport is an important first step in the injury prevention continuum. It is recognized that a sporting injury is unlikely to result from a single risk factor but rather as a consequence of complex interactions of multiple risk factors and inciting events. Recently a systematic review aimed at identifying and evaluating the evidence regarding risk factors for groin injury in sport showed that, despite a large volume of research papers and many millions of pounds in funding, little had been added to the knowledge base in the seven years since the last review. The majority of studies represented level two evidence (cohort studies) however few considered the interrelationships between risk factors. There is level one and two evidence that previous groin injury, higher-level of play, reduced hip adductor (absolute and relative to the hip abductors) strength and lower levels of sport-specific training are associated with increased risk of groin injury in sport. Despite this, interventions aimed at reducing incidence of groin injury by targeting the potentially modifiable risk factors identified have had limited impact. Similarly, rates of recurrence remain high reflecting a lack of forward progress in outcomes of conservative management of groin injury. Most scientific evidence for management is level four, with a recent review identifying only two high quality randomized controlled trials assessing conservative intervention for groin pain. Both studies use a very similar
exercise programme leaving clinicians with high quality evidence for only one intervention developed in the 1990's. A large focus in this exercise programme is high load adductor strengthening, based on the identification of adductor weakness in those with groin pain. The testing of adductor strength however, does not simply test the ability of that muscle group to develop force across that isolated musculotendinous unit. Most methods of adductor strength testing require high levels of force transference across the lumbopelvic region, suggesting that adductor weakness may often be a more global sign of failure of load transference across the pelvis rather than weakness in an isolated muscle group. Early evidence is emerging that control of pelvic position and displacement of the centre of mass of the trunk during change of direction may be integral to controlling loads across the anterior pelvis and adductor-abdominal complex. Learning objectives: By the completion of this session, participants will have updated knowledge regarding: 1. Risk factors for groin injury 2. Current prevention strategies including the role of neuromuscular training injury prevention strategies in sports 3. Current rehabilitation strategies Implication/Conclusions: Prevention and management of groin injury remains a substantial issue in the football codes and in hockey. Despite much research and funding our understanding of risk factors and evidence for optimal interventions remains relatively poor. A recent world summit on groin pain has established common terminology and minimum reporting standards which should be helpful in raising the quality of future research. Researchers may also need to broaden the search for risk factors and optimal interventions by considering the complex interactions of forces across the groin imposed by body, pelvic and femoral position and muscle recruitment strategies. Biography: Claire Small BPhty, MPhty(Musc), Convenor Claire Small is the Clinical Director of Pure Sports Medicine, a multidisciplinary sports and musculoskeletal organization with four clinics in London. She also holds an honorary senior lecturer position within the Sports and Exercise Medicine department at Queen Mary, University of London, where she has been involved in research into the mechanisms of groin pain, specifically examining altered motor control in subjects with long standing groin pain. She teaches on several post-graduate advanced musculoskeletal physiotherapy courses covering topics that include the assessment and management of low back, pelvic and hip pain and dysfunction. She has presented at both National and International physiotherapy and medical conferences and is the author of Managing the Injured Athlete, published by Elsevier. Dr Jackie L. Whittaker PT, PhD Dr. Whittaker is an Assistant Professor in the Department of Physical Therapy, Faculty of Rehabilitation Medicine, and Research Director of the Glen Sather Sports Medicine Clinic at the University of Alberta, Canada. Jackie is a US Bone and Joint Initiative / Bone & Joint Canada Young Investigator, recognized as a clinical specialist in musculoskeletal (MSK) physiotherapy by the Canadian Physiotherapy Association and is a Fellow of the Canadian Academy of Manipulative Physical Therapists. She is well known for her work using ultrasound imaging as it pertains to understanding muscle composition, structure and function in low back pain and pelvic girdle pain, and more recently in sport injury and post-traumatic osteoarthritis (OA) prevention models. Her interests lie in scientific inquiry that will substantially influence a shift in the approach taken to manage chronic MSK disorders from treatment of chronic disease (tertiary prevention) towards prevention and delaying/halting disease onset (primary and secondary prevention). Jackie's background combines knowledge gained through 20 years of clinical practice and academic work, having completed her PhD at the University of Southampton, UK 2012. Dr Alison Grimaldi, BPhty, MPhty(Sports), PhD Dr Grimaldi is an Australian Sports Physiotherapist and principal of Physiotec Physiotherapy, with 25 years of clinical experience and a special interest in the management of hip, groin and pelvic pathologies. She has a Bachelor of Physiotherapy, Masters of Sports Physiotherapy and a PhD (University of Queensland). Her PhD involved investigations into the lateral stability mechanism of the hip and pelvis. Alison is involved in ongoing research through the University of Queensland and has co-supervised a number of PhD students on topics around hip and groin pain. Alison has presented widely nationally and internationally, presenting
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the European College for Decongestive Lymphatic Therapy. He is the Scientific Chair of the executive committee of the Pain, Mind and Movement Special Interest Group of the International Association for the Study of Pain (IASP). Jo runs the Pain in Motion international research group (www. paininmotion.be) and a physiotherapy-based treatment program for patients with chronic pain in the University Hospital Brussels. His research and clinical interests are patients with chronic ‘unexplained’ pain / fatigue and pain-movement interactions, with special emphasis on the central nervous system. The primary aim of his research is improving care for patients with chronic pain. At the age of 39, he has (co-)authored more than 150 peer reviewed publications, has obtained over V4.7 million of grant income, served more than 150 times as an invited or keynote speaker at national and international meetings in 17 different countries, and supervised 6 PhD projects to completion. His work has been cited >1700 times (h-index: 25; ISI Web of Knowledge). 4. Dr Trudy Rebbeck PhD FACP MAppSc(ManipPHty) BAppSc(Phty) Specialist Musculoskeletal Physiotherapist ; NHMRC Research Fellow University of Sydney Dr Trudy Rebbeck is a NHMRC Research Fellow at the University of Sydney with appointments at the Faculty of Health Sciences and John Walsh Centre for Rehabilitation Research, Sydney Medical School. Dr Rebbeck's area of research and clinical expertise is in the development and implementation of best practice for the management of whiplash. She has 25 peer reviewed publications and over $4m in research grants. She has coauthored several clinical guidelines for whiplash and several implementation / translations trials which have resulted in a successful change of practise in primary care settings. Dr Rebbeck's current research fellowship focuses on improving recovery for cervical spine disorders including people with whiplash, headache and neck pain. Her international profile results in her being frequently invited to present workshop and courses nationally and internationally in the area of cervical spine disorders. Funding acknowledgements: Funding Acknowledgements as per bio and affiliations Disclosure of interest: None declared Keywords: whiplash, new directions, FOCSYM-292 THE STATE OF THE ART OF NEURODYNAMICS e ASSESSMENT AND MANAGEMENT H. Luomajoki 1, *, R. Ellis 2, M.W. Coppieters 3, A. Schmid 4, R. Nee 5. 1 Institute for Physiotherapy, Zürich University of Applied Sciences ZHAW, Winterthur, Switzerland; 2 Institute for Physiotherapy, Auckland University of Technology, Auckland, New Zealand; 3 MOVE Research Institute Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; 4 Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; 5 School of Physical Therapy, Pacific University, Hillsboro, United States * Corresponding author.
Relevance to IFOMPT and expected audience: Neurodynamic tests and mobilization techniques have been used in musculoskeletal physiotherapy for more than 35 years. However, treatment modalities and insights in possible working mechanisms have evolved substantially in recent years thanks to new insights in nerve biomechanics and the pathophysiology of nerve compression. In this symposium, the latest insights in the domain of neurodynamics will be presented which will assist the audience in the diagnosis, management and clinical reasoning process for people with entrapment neuropathies. Summary of session format: 5 minutes: Convenor Hannu Luomajoki gives an overview of the contents and learning objectives of the workshop. 15 minutes: Richard Ellis reviews neurodynamic assessment and treatment from a biomechanical perspective, providing insight in cadaveric and ultrasound studies. 15 minutes: Michel Coppieters reviews the validity of the neurodynamic testing and the evidence for different treatment options.
10 minutes: Robert Nee reviews the evidence on clinical outcomes related to neurodynamic treatment. 15 minutes: Annina Schmid explores the evidence for neurophysiological mechanisms of action of neurodynamic exercises. 10 Minutes: Hannu Luomajoki presents some cases studies and practical techniques through videos. 15-20 Panel discussion Information concerning any presentations or publications: The contributors will present previously published key papers from their own research and from other research groups, and will blend this with the latest unpublished data and their own clinical experience. Description: The participants will have an evidence based overview of: - $ Latest insight in the pathophysiology of entrapment neuropathies - $ Validity of neurodynamic testing; Rationale of neurodynamic mobilization, integrating biomechanical, physiological and neuro-immune aspects - $ Practical and neurophysiological explanation models for neurodynamic management Description At the beginning of the session, Hannu Luomajoki will review the rationale of neurodynamic testing and management. He will give an overview of the following presentations and also introduce the symposium members. Richard Ellis will explore biomechanical concepts of neurodynamics and relate these back to sound clinical reasoning for the selection of neurodynamic testing and neural mobilisation. The biomechanical features of the peripheral nervous system (PNS) which are necessary to appreciate, for all clinicians, is the fact that it is a continuous system (along with the CNS), it moves in relation to its mechanical interface, movement will be influenced by proximity of moving joints/limbs and postures and the influence of strain/tension upon the PNS. The selection of neurodynamic testing and neural mobilisation exercises must not be ad hoc. The choice of clinicians to utilise specific techniques must be based upon sound clinical reasoning and take into account relevant nerve biomechanics. This presentation will draw upon cadaver models and the use of medical imaging (including ultrasound imaging) to highlight and explain the relevant neurodynamic features of the PNS. Michel Coppieters will present on the meaning and clinical applicability of neurodynamic tests. The current literature raises many questions, which can be confusing for clinicians and researchers. Some studies recommend neurodynamic tests to rule out a neuropathy, others state the tests are useful to rule the pathology in. There are no universally accepted criteria to diagnose a neuropathy, but the impact on diagnostic accuracy studies is rarely considered. Occurrence of false positive test results is described in healthy populations, but according to which criteria? The aim of the first part of his presentation is to clarify the divergent conclusions that are reported in the literature about the diagnostic accuracy of neurodynamic tests. In the second part of the presentation, Michel will focus on psychosocial aspects that need to be considered in neurodynamic testing and the biomechanical evidence for different types of neurodynamic treatment techniques. The clinical efficacy of these techniques will be addressed in the next presentation. Robert Nee will present an overview of the available evidence on potential benefits and harms of neurodynamic treatment for nerve-related conditions. The variable results from clinical trials suggest that certain nerverelated conditions may be more suitable for neurodynamic treatment. Evidence-based patient characteristics that may help identify patients who are and are not likely to improve with neurodynamic treatment will be discussed for those nerve-related conditions where neurodynamic treatment appears to be beneficial. By integrating these patient-centered outcome data with biomechanical evidence and potential neurophysiological mechanisms addressed in accompanying presentations, clinicians can make more informed decisions about using neurodynamic treatment techniques in daily practice. Annina Schmid will summarise the available evidence for mechanisms of action of neurodynamic treatments with a focus on neurophysiological aspects. The first part of her talk will give an overview of different pathophysiological mechanisms at play in patients with entrapment neuropathies. This will include the most recent evidence from both experimental models as well as patient populations. Pathophysiological mechanisms including ischaemia, demyelination, axon degeneration and neuroinflammation will be explained. The second part of this talk will highlight
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recent scientific advances on how neurodynamic treatment may exert its effect on these pathophysiological mechanisms. Focus will thereby be placed on neurophysiological mechanisms including remyelination, axon regeneration and the reduction of focal intra- and extraneural oedema. We will also discuss potential effects of neurodynamic exercises that extend beyond the focal lesion site. Hannu Luomajoki will display some video examples of possible treatment techniques and patient cases In following discussion the presenters together answer questions from the audience in a panel discussion format. Implications/conclusions Neurodynamic testing and mobilization have been used in physiotherapy for more than 35 years. However, we still do not know the exact working mechanisms of this method. In this focused symposium the leading experts of the field will critically review the evidence based on their own research, and that of other groups working in this field.. The presentations will be followed by clinical and practical examples and ideas of treatment possibilities. The symposium will be wrapped up with a panel discussion during which the presenters will discuss together and with the audience the current concepts and their meaning to practice. Learning objectives: Latest insight in the pathophysiology of entrapment neuropathies $ Validity of neurodynamic testing; Rationale of neurodynamic mobilization, integrating biomechanical, physiological and neuro-immune aspects $ Practical and neurophysiological explanation models for neurodynamic management Implication/Conclusions: Neurodynamic testing and mobilization have been used in physiotherapy for more than 35 years. However, we still do not know the exact working mechanisms of this method. In this focused symposium the leading experts of the field will critically review the evidence based on their own research, and that of other groups working in this field.. The presentations will be followed by clinical and practical examples and ideas of treatment possibilities. The symposium will be wrapped up with a panel discussion during which the presenters will discuss together and with the audience the current concepts and their meaning to practice. Biography: Prof. Hannu Luomajoki is the head of master program for musculoskeletal physiotherapy in Zürich University of applied sciences (ZHAW) in Winterthur, Switzerland. He has been working 30 years as a physiotherapist. He finished his graduate training in Finland 1986 and Masters degree in manipulative Physiotherapy in Adelaide 1999. His PhD was given in 2010 through the university of East- Finland on the topic movement control impairment of lumbar spine. Since 2011 he is professor for musculoskeletal physiotherapy in ZHAW. He has published over 20 peer reviewed research papers, over 40 further articles and has presented in over 50 national and international congresses and he is co-author of several books. Hannu is also reviewer of many scientific journals. He has gained research grants for over 200 000.- CHF. In 2008 he won the price physiotherapy researcher of the year in Switzerland and in 2014 he was named physiotherapist of the year in Finland. Hannu has been involved and currently supervising several PhD projects. Currently he works in his own practice part time as well as teaches and does research in the university. His main areas of interest are Low Back Pain, clinical reasoning and pain physiology. He has been NOI instructor since 2001. He is giving courses for physiotherapists and doctors around Europe in topics LBP, pain education, neurodynamics and evidence based practice. He has been coorganisator of many national physiotherapy congresses. Dr. Richard Ellis is the Associate Head of Research within the School of Clinical Sciences at Auckland University of Technology (AUT) in New Zealand. Richard is also a Senior Lecturer within the Department of Physiotherapy. He teaches on both the undergraduate and postgraduate musculoskeletal physiotherapy programmes. Richard completed his PhD in 2011 using ultrasound imaging (USI) to assess movement of the sciatic nerve in response to neural mobilisation. Richard's ongoing areas of research interests include the assessment and management of peripheral nervous system dysfunction; neurodynamics; peripheral nervous system biomechanics; manual therapy and musculoskeletal physiotherapy; USI and the use of USI by physiotherapists. He has 20 peer-reviewed publications and has presented his research both nationally and internationally. Richard has attracted over $80,000NZD in research funding. He has international research collaborations with groups from Australia, USA,
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United Kingdom, The Netherlands and South Africa. External to AUT, Richard is the President of the New Zealand Manipulative Physiotherapists Association (NZMPA), which is the Member Organization for New Zealand within IFOMPT. He is also an Associate Editor for the New Zealand Journal of Physiotherapy. Richard remains clinically active and practices as a specialist musculoskeletal physiotherapist. Prof Michel Coppieters is a musculoskeletal physiotherapist with a special interest in nerve disorders and pain. Since 2014, he is Professor in Musculoskeletal Physiotherapy at VU University Amsterdam in The Netherlands. He is Program Director of the Master of Science in Musculoskeletal Physiotherapy at VU University Amsterdam, where he also directs the research lines in musculoskeletal physiotherapy. Previously, he was Associate Professor at The University of Queensland in Brisbane, Australia, where he was the inaugural director of the Neuropathic Pain Research Group in the Centre for Clinical Research Excellence in Spinal Pain, Injury and Health at the School of Health and Rehabilitation Sciences. He has published more than 40 peer-reviewed papers and several book chapters in the field of neurodynamics and multiple other papers in other areas of Musculoskeletal, Orthopaedic and Sports Physiotherapy. With respect to neurodynamics, his research aims to obtain a better understanding of the pathophysiology of nerve injuries, to develop novel treatment approaches for patients with neuropathic pain and to test the clinical efficacy of these programs. He has received competitive grants and fellowships (in excess of 1.5 million euro) and several prestigious awards for his research achievements and conference presentations. He frequently delivers neurodynamic and pain workshops internationally and has delivered multiple invited and keynote lectures at national and international conferences. Dr Annina Schmid is a researcher affiliated with the Nuffield Department of Clinical Neurosciences at The University of Oxford in the UK. She qualified as a Physiotherapist in Switzerland before obtaining a Master in Manipulative Physiotherapy from Curtin University of Technology in Perth, Australia. Annina has worked clinically for several years as a specialised musculoskeletal Physiotherapist in Switzerland before completing a PhD in Neuroscience at The University of Queensland in Australia. Annina's research is an exciting and unique combination of basic and clinical science which is aimed to improve our understanding of the pathomechanisms of neuropathic pain and entrapment neuropathies to ultimately improve management of these patients. Since the completion of her PhD and postdoc at The University of Queensland, she is continuing her research into the pathomechanisms of entrapment neuropathies at Oxford University under the guidance of world leading experts in the field of neuropathic pain. Annina presented her work at many national and international conferences related to both Physiotherapy as well as Neuroscience and has published her work widely. Her research contribution is recognised by the award of several grants, awards and competitive fellowships including the prestigious Neil Hamilton Fairley Fellowship from the NHMRC Australia and the early career research grant from the International Association for the Study of Pain. Annina shares her knowledge by teaching postgraduate courses related to pain and neuroscience internationally. She also maintains a small weekly caseload as a musculoskeletal Physiotherapist. Further information can be found at www.neuroresearch.ch. A/Prof. Robert Nee is the primary instructor for the musculoskeletal curriculum in the entry-level Doctor of Physical Therapy program within the School of Physical Therapy at Pacific University in Hillsboro, Oregon. He completed his Bachelor of Science in physical therapy at Boston University in 1985, a Master of Applied Science in manipulative physiotherapy at the University of South Australia in 1993, and a PhD in physiotherapy at The University of Queensland in 2012. His research has investigated the value of neurodynamic techniques in the diagnosis and treatment of nerverelated neck and upper limb pain and the use of prediction models to assist in clinical decision-making. He has 10 peer-reviewed publications and 3 book chapters related to neurodynamics. He was the lead author of a clinical trial on neurodynamic treatment of nerve-related neck and upper limb pain that won the 2012 Paper of the Year Award for the Journal of Physiotherapy. Bob has 30 years of clinical practice experience in musculoskeletal manual therapy and over 15 years of experience in entry-level and post-professional physiotherapy education. Funding acknowledgements: Michel Coppieters' research has been predominantly funded by the National Health and Medical Research Council
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Abstracts / Manual Therapy 25 (2016) e5ee32
of Australia, the Australian Research Council, the Manual Therapy Association and the Musculoskeletal Group of The Netherlands, and internal grants from The University of Queensland and VU University Amsterdam. Annina Schmid's research is mainly funded by the Swiss National Science Foundation, The National Health and Medical Research Council of Australia and the International Association for the Study of Pain. Robert Nee's research that will be presented was supported by an Endeavour International Postgraduate Research Scholarship from the Australian Government and a Research Scholarship from The University of Queensland. Hannu Luomajoki and Richard Ellis are funded partly by their universities and their national associations. Disclosure of interest: H. Luomajoki: None Declared, R. Ellis: None Declared, M. W. Coppieters Conflict with: National Health and Medical Research Council of Australia, A. Schmid Conflict with: Swiss National Science Foundation, R. Nee: None Declared Keywords: Neuroscience, Assessment, Working mechanisms FOCSYM-293 GROIN INJURY e TIME TO MOVE FORWARDS C. Small 1, 2, *, A. Grimaldi 1, J. Whittaker 2. 1 Physiotherapy Department, University of Qld, Brisbane, Australia; 2 Physical Therapy, University of Alberta, Edmonton, Canada * Corresponding author.
Relevance to IFOMPT and expected audience: Groin injury presents a significant and ongoing challenge for the sporting community. Most common in field sports involving rapid change of direction such as the football codes and hockey, costs are high due to often extended rehabilitation periods, high recurrence rates and time lost from sports participation. Physical therapists play a key role in pushing forward the development of more effective screening, prevention and rehabilitation strategies. Summary of session format: The session will open with a live survey via mobile devices to highlight where current beliefs around groin injury stand. Three highly experienced clinicians and researchers from The United Kingdom, Canada and Australia will then bring to the IFOMPT audience an update regarding current evidence available on risk factors for groin injury in sport and interventions for groin injury and an examination of contemporary clinical approaches including the role that real time ultrasound plays. Information concerning any presentations or publications: All authors have a special interest in groin/hip/pelvic pathologies having presented regularly on topics in this region. Publications include recent systematic reviews on groin injury risk factors and neuromuscular prevention strategies, EMG studies assessing muscle function in groin injury, book chapters and a clinical text book on sports injuries. Description: An understanding of the risk factors for groin injury in sport is an important first step in the injury prevention continuum. It is recognized that a sporting injury is unlikely to result from a single risk factor but rather as a consequence of complex interactions of multiple risk factors and inciting events. Recently a systematic review aimed at identifying and evaluating the evidence regarding risk factors for groin injury in sport showed that, despite a large volume of research papers and many millions of pounds in funding, little had been added to the knowledge base in the seven years since the last review. The majority of studies represented level two evidence (cohort studies) however few considered the interrelationships between risk factors. There is level one and two evidence that previous groin injury, higher-level of play, reduced hip adductor (absolute and relative to the hip abductors) strength and lower levels of sport-specific training are associated with increased risk of groin injury in sport. Despite this, interventions aimed at reducing incidence of groin injury by targeting the potentially modifiable risk factors identified have had limited impact. Similarly, rates of recurrence remain high reflecting a lack of forward progress in outcomes of conservative management of groin injury. Most scientific evidence for management is level four, with a recent review identifying only two high quality randomized controlled trials assessing conservative intervention for groin pain. Both studies use a very similar
exercise programme leaving clinicians with high quality evidence for only one intervention developed in the 1990's. A large focus in this exercise programme is high load adductor strengthening, based on the identification of adductor weakness in those with groin pain. The testing of adductor strength however, does not simply test the ability of that muscle group to develop force across that isolated musculotendinous unit. Most methods of adductor strength testing require high levels of force transference across the lumbopelvic region, suggesting that adductor weakness may often be a more global sign of failure of load transference across the pelvis rather than weakness in an isolated muscle group. Early evidence is emerging that control of pelvic position and displacement of the centre of mass of the trunk during change of direction may be integral to controlling loads across the anterior pelvis and adductor-abdominal complex. Learning objectives: By the completion of this session, participants will have updated knowledge regarding: 1. Risk factors for groin injury 2. Current prevention strategies including the role of neuromuscular training injury prevention strategies in sports 3. Current rehabilitation strategies Implication/Conclusions: Prevention and management of groin injury remains a substantial issue in the football codes and in hockey. Despite much research and funding our understanding of risk factors and evidence for optimal interventions remains relatively poor. A recent world summit on groin pain has established common terminology and minimum reporting standards which should be helpful in raising the quality of future research. Researchers may also need to broaden the search for risk factors and optimal interventions by considering the complex interactions of forces across the groin imposed by body, pelvic and femoral position and muscle recruitment strategies. Biography: Claire Small BPhty, MPhty(Musc), Convenor Claire Small is the Clinical Director of Pure Sports Medicine, a multidisciplinary sports and musculoskeletal organization with four clinics in London. She also holds an honorary senior lecturer position within the Sports and Exercise Medicine department at Queen Mary, University of London, where she has been involved in research into the mechanisms of groin pain, specifically examining altered motor control in subjects with long standing groin pain. She teaches on several post-graduate advanced musculoskeletal physiotherapy courses covering topics that include the assessment and management of low back, pelvic and hip pain and dysfunction. She has presented at both National and International physiotherapy and medical conferences and is the author of Managing the Injured Athlete, published by Elsevier. Dr Jackie L. Whittaker PT, PhD Dr. Whittaker is an Assistant Professor in the Department of Physical Therapy, Faculty of Rehabilitation Medicine, and Research Director of the Glen Sather Sports Medicine Clinic at the University of Alberta, Canada. Jackie is a US Bone and Joint Initiative / Bone & Joint Canada Young Investigator, recognized as a clinical specialist in musculoskeletal (MSK) physiotherapy by the Canadian Physiotherapy Association and is a Fellow of the Canadian Academy of Manipulative Physical Therapists. She is well known for her work using ultrasound imaging as it pertains to understanding muscle composition, structure and function in low back pain and pelvic girdle pain, and more recently in sport injury and post-traumatic osteoarthritis (OA) prevention models. Her interests lie in scientific inquiry that will substantially influence a shift in the approach taken to manage chronic MSK disorders from treatment of chronic disease (tertiary prevention) towards prevention and delaying/halting disease onset (primary and secondary prevention). Jackie's background combines knowledge gained through 20 years of clinical practice and academic work, having completed her PhD at the University of Southampton, UK 2012. Dr Alison Grimaldi, BPhty, MPhty(Sports), PhD Dr Grimaldi is an Australian Sports Physiotherapist and principal of Physiotec Physiotherapy, with 25 years of clinical experience and a special interest in the management of hip, groin and pelvic pathologies. She has a Bachelor of Physiotherapy, Masters of Sports Physiotherapy and a PhD (University of Queensland). Her PhD involved investigations into the lateral stability mechanism of the hip and pelvis. Alison is involved in ongoing research through the University of Queensland and has co-supervised a number of PhD students on topics around hip and groin pain. Alison has presented widely nationally and internationally, presenting