Have you ever had tingling in your hands or feet, or burning, shooting sensation down your arm? If so, you may be dealing with nerve related pain, which can be quite discomforting. When we think of enhancing our mobility, we often think of “tight muscles” or “stiff joints”, right? Ah, I gotta loosen up my low back, or I need to release my hip flexors. Yes these are all great examples of how we attack mobility deficits; however, we need to ensure that with any mobility program we do not miss an often forgotten integral piece: The Nervous System! Both our central nervous system (CNS), which consists of our brain and spinal cord, as well as our peripheral nervous system (PNS), the nerves that lie outside the CNS, each are intimately associated with our body movements and function. In this article, we are going to explain the basics behind nerve pain, and how to relieve it with neurodynamics!

 

What is Neurodynamics?

An article by Ellis and Hing in the Journal of Manual Therapy,  neurodynamics was defined as, “An integrated biomechanical, physiological, and morphological function of the nervous system”. Moreover, it is discussed that our nervous system is able to adapt to various loads, such as elongation, angulation, compression, and sliding movements. If any of these load tolerant movements fail, that is when our nervous system may become susceptible to injuries, such as neural edema or nerve root compressions.

 

Dealing With Lingering Sciatica From Low Back Pain?

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Neurodynamics was first described in the late 1980s and has continued to be a significant component in treatment plans for common injuries such as sciatica, brachial plexus injuries, carpal tunnel syndrome, cervical radiculopathy, and double crush syndrome. The evidence in regards to its effectiveness is continuing to be investigated; however, there has been success rates within a variety of populations who have nerve pain.

Healthcare practitioners frequently receive questions in regards to how to deal with pain by using heat or ice. “Should I ice my shoulder?” or “Should I put heat on it?” Does this matter? Listen to our [P]Rehab Audio Experience Podcast episode as Dillon discusses the topic of icing injuries!

LISTEN: SHOULD WE USE ICE FOR INJURIES?

 

Understanding The Nervous System

An easy way to conceptualize the nervous system is thinking about it as ‘the body’s hardwiring system’. It is composed of specific cells known as neurons, which help transport various messages to different body regions. The two main systems within it are the central nervous system (CNS) and peripheral nervous system (PNS). This system is complex and powerful. Many of the day-to-day actions we perform without even thinking about it are built within our nervous system. In order to optimize human movement, we need to take into consideration all systems of our body, including our nervous system!

The central nervous system is composed of the brain and spinal cord. These body structures work together as a team to control the functions of both the body and the mind! It is intimately associated with our peripheral nervous system, which is described next.

 

 

The peripheral nervous system is composed of two parts: the somatic nervous system and the autonomic nervous system.

Somatic Nervous System

This system contains peripheral nerves that take various sensations from our body up to our brain, as well as messages from our brain back down to the body! An example of how this nervous system operates is what happens when accidentally placing your hand on a hot stove. This cascade of events is what occurs in our nervous system:

• The receptors on your hand are going to feel the hot sensation from the stove, which sends a signal to your spinal cord, and up to the brain.

 

• From there, the brain is going to interpret that hot sensation as painful.

 

• A signal is then sent back down to your hand telling you to quickly move it away.

 

It is amazing how fast this cascade of events happens in our nervous system. Think about it, if you touch something hot, you move your hand in a split second! 

Understanding Specificity of Our Nervous System

To learn more about pain and how we interpret it, read this article!

 

Autonomic Nervous System

This system works ‘automatically’, without conscious efforts from human beings. Examples include regulating your heart rate and respiratory rate. It consists of two divisions: the sympathetic nervous system (fight or flight) and the parasympathetic nervous system (rest and digest).

 

Nerve Pain: What Does It Feel Like?

In order to understand where pain may be coming from in the body, practitioners often ask ‘descriptor questions’, to help gain more specific information. For example, a dull, boring pain often describes pain arising from a bone, whereas a spasming/tightening sensation may be arising from a muscular origin. Oftentimes, it may be difficult for someone to truly describe their pain; however, any information that can be collected is useful in helping determine an optimal diagnosis and treatment plan.

In regards to nerve pain, individuals typically will describe one or more of the following sensations:

• Burning

 

• Numbness and/or tingling

 

• Potential heaviness in an arm or leg

 

• A feeling of having to shake out an arm or leg

 

• Stabbing type of pain that is unpredictable

 

Pinched Nerve In Your Neck? Treat Your Cervical Radiculopathy

 

How Does Nerve Pain Occur?

There is a multitude of reasons that nerve pain may occur. Some of the more common etiologies include:

• Nerve Entrapment: A common example of nerve entrapment is Carpal Tunnel Syndrome (CTS).

 

• Poor blood supply to our nervous system

 

• Phantom limb pain: This pain is residual after an amputation

 

• Peripheral neuropathy: A type of pain common in individuals who are chronic alcoholics or have diabetes, often found in the hands and feet

 

• Injury to our nervous system: Examples include a head injury, traction injury, or gun shot wound

 

• Vitamin Deficiencies: Specifically B12 or B1

 

The Severity of Nerve Injuries

Based on the severity of nerve injuries, recovery times will differ. For example, if you fall asleep with your arm in a weird position, wake up, and your arm feels heavy with numbness and tingling, you usually can shake it out and that sensation goes away in a minute or two. However, on the other side of the spectrum, if you suffer a severe traction injury, the nerves involved may need several months to fully recover! Nerve regeneration is much slower in comparison to healing properties of other tissues, therefore, it is important to explain this to individuals with nerve pain as soon as they have an injury to ensure they have the proper expectations regarding prognosis.

READ: WHAT YOU NEED TO KNOW ABOUT TISSUE HEALING

 

Nerve Injury Classification

In an article by Chhabra et al on peripheral nerve injuries, they examined a grading system for nerve injuries by utilizing MR neurography. Two of the more accepted classifications for nerve injuries are the Seddon and Sunderland classifications.

Nerve Injury Classification System

What you can notice from looking at this chart is that the more severe the degree of nerve injury, the lower the recovery potential, the longer the recovery rate, and the increased likelihood of surgery. In addition, you can appreciate that some nerve injuries regenerate up to 1 millimeter per day! Quite slow! Now, keep in mind that this is really only the case for more severe injuries, and for the scope of this article, we are discussing nerve related pain that is lower on the spectrum of severity. Nonetheless, it is always beneficial to have a perspective as to how various tissues heal depending on biological make-up as well as the degree of injury, etc.

 

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So…How Do I Relieve Nerve Pain?

Our nerves like 3 things: blood, movement, and space. If we deprive our nerves of one or more of these, they become angry! Therefore, we need to ensure that our nerves are moving consistently to give them what they want. A great way to do this is by performing neurodynamics. Numbness and tingling results from irritation to a nerve, that is often due to poor blood supply or pinching on a particular nerve. Mobilizing the nervous system makes your body more comfortable with nerve movements, and also provides nutrition to our nervous system. One aspect of nerve movements is that there may be delayed effects of discomfort after first working on nerve movements. You may not feel a sensation of discomfort or a reproduction of your nerve related symptoms immediately after exercise, but it could happen later on, such as a day or two later.

In addition to performing nerve movement exercises, it is also important to mobilize other areas of the body that nerves intimately travel through! This includes our muscles, joints, and other soft tissues.

 

The Do’s and Don’ts of Neurodynamics

When a nerve is hot and irritated, the last thing you want to do is aggravate it more! Therefore, when first starting with neurodynamics, you want to promote movements that do not put the specific nerve you are moving on full tension. A concept that is commonly applied with neurodynamics is nerve sliders and nerve tensioners.

Sliders Versus Tensioners

 

• Sliders: During a slider technique, 2 joints are moving, one is creating tension on a nerve, while the other joint is relieving that nerve of tension. This sliding technique is great to use in acute cases, when a nerve is still irritated, yet you still want to provide it with mobility, space, and blood flow!

 

• Tensioners: With a tensioner, 2 joints are moving, and both joints are creating tension on that nerve, putting it on full stretch. This is better in situations where the nerve has calmed down and you are attempting to improve mobility.

 

As you can see, one part of our body will remain fixed, as the other part of our body moves! The median nerve in this case can be slackened in one position, and stretched in another!

 

Difference Between Stretching Muscles Versus Stretching Nerves

This is often a mistake seen when individuals are trying to stretch their hamstrings. Whenever we stretch our muscles, we want to ensure we are not putting additional tension on our nervous system, if our intent is to only stretch our muscles.

Yes, in some situations, we may want to provide mobility to our nervous system; however, we need to know the difference between how we stretch each, intention matters!

Limited hamstring flexibility is a common cause for hamstring strains, in addition to strength deficits, especially eccentrically. However, Goldman et al. in 2010 performed a review which corroborated that stretching as the only intervention to prevent hamstring strains was not supported by evidence. To learn more about how to overcome a hamstring strain, read this article!

A Better Way To Stretch Your Hamstrings

Multiple studies have looked at range of motion and its relationship to both neural tissues and non-neural tissues. A study by Barker and Briggs in 1999 discussed the continuity of our fascial system throughout our body, and how that may change perceptions of pain as well as knee range of motion with neurodynamic movement testing.

 

Upper Body Neurodynamics

Below we take you through some examples of upper body nerve movements to relieve nerve pain!

Radial Nerve Slider

• HOW: Get set-up seated and perform a radial nerve glide – make a fist with your thumb inside your fingers, flex your wrist, pronate your forearm, extend your elbow, depress your shoulder blade, and abduct your arm. Simultaneously, laterally flex your neck towards your arm. Perform the opposite motion of all moving parts, then repeat. See the video for additional tips and instructions as well as a visual of the exercise. Be sure to keep this symptom-free unless directed otherwise by your healthcare professional.

 

• FEEL: You should feel a stretching sensation on the top of your forearm at the end of the stretch.

 

• COMPENSATION: Perform slowly, do not lose position or perform a different motion at any moving segment described above.

 

Median Nerve Tensioner

This is another way to provide movement to the median nerve. Watch as Mike blocks his shoulder from movement with this tensioner.

 

Relieve Nerve Pain With Lower Body Neurodyamics

Now we will give examples of lower body nerve movements!

Proximal Lower Extremity Neurodynamics

This example of neurodynamics is showing how to mobilize the femoral nerve, with examples of both sliders and tensioners. The femoral nerve gives its distribution to the front of our thigh. In order to add tension to this nerve, you will extend the hip and flex the knee, as shown.

 

Distal Lower Extremity Neurodynamics

This example is showing tensioning of the sural nerves, peroneal nerve, and tibial nerve. Each of these nerves is located within different distributions of the lower leg. What you will notice is that moving the foot/ankle complex in different directions will change the tension on one of these nerves.

• Sural Nerve Tension: Ankle Dorsiflexion and Inversion

 

• Peroneal Nerve Tension: Ankle Plantar Flexion and Inversion

 

• Tibial Nerve Tension: Ankle Dorsiflexion and Eversion

 

Supine Sciatic Nerve Slider

The sciatic nerve is a common culprit of pain and discomfort for individuals experiencing low back pain, hip pain, and/or buttock pain.

 

What Else Can I Do To Relieve Nerve Pain?

In addition to the multitude of neurodynamic exercises that were exemplified throughout this article, treatment approaches for relieving nerve pain also consist of improving the mobility of our joints that nerves travel through, increasing the stability of our body, and increasing our strength as well!

For upper body nerve pain, thoracic mobility is especially important as well as optimal neck strength and stability.

For lower body nerve pain, hip mobility plays an integral role in addition to global core stability!

 

Closing Thoughts

Nerve pain may be due to many different reasons. Similar to other aspects of our body, our nerves need to move to! When working on neurodynamics, always be sure to listen to your body. Less is more in most cases. The last thing you want to do is further irritate a hot and bothered nerve. In addition, be patient. This is often difficult for all of us, as we innately want immediate results. However, nerve pain may take time to recover from fully. Do not get frustrated if you still have lingering effects or sensations. Stick with it, stay consistent, and stay positive!

 

Take Control of Your Low Back Health!

The low back is the centerpiece of our movement foundation and is the most adaptable and resilient area of the movement system. Since it takes on so many responsibilities it can at times become overwhelmed and request a change be made. Those requests tend to say: “Can you use your hips more?” and “Can you build up more core strength for this activity?” After this program, your back will be happy to know that these requests have been attended to!

 

References

1. Ellis, R. F., & Hing, W. A. (2008). Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy. Journal of Manual and Manipulative Therapy, 16(1), 8-22.
2. Boyd, B. S., Gray, A. T., Wanek, L., & Topp, K. S. (2009). Mechanosensitivity of the Lower Extremity Nervous System During Straight-Leg Raise Neurodynamic Testing in Healthy Individuals. Journal of Orthopedics and Sports Physical Therapy, 29(11).
3. Chhabra, A., Ahlawat, S., Belzberg, A., & Andreseik, G. (2014). Peripheral nerve injury grading simplified on MR neurography: As referenced to Seddon and Sunderland classifications. Indian Journal of Radiology and Imaging, 24(3), 217-224.
4. Coppieters, M. W., Kurz, K., Mortensen, T. E., Richards, N. L., Skaret, I. A., McLaughlin, L. M., & Hidges, P. W. (2004). The impact of neurodynamic testing on the perception of experimentally induced muscle pain. Journal of Manual Therapy, 10(1).
5. Goldman, E. F., & Jones, D. E. (2010). Interventions for preventing hamstring injuries. Journal of Physiotherapy, 1.
6. Lopez, L. L., Torres, J. R., Rubio, A. O., Sanchez, I. T., Martos, I. C., & Valenza, M. C. (2019). Effects of neurodynamic treatment on hamstrings flexibility: A systematic review and meta-analysis. Journal of Physical Therapy in Sport, 40, 244-250.

 

About The Author

Sherif Elnaggar, PT, DPT, OCS

[P]Rehab Head of Content

Sherif graduated from Temple University with a Bachelor’s of Science Degree and a concentration in Kinesiology. He then received his Doctorate of Physical Therapy Degree from DeSales University, graduating with honors of the professional excellence award and research excellence award. After his graduate studies, he served as Chief Resident of the St. Luke’s Orthopedic Physical Therapy Residency Program. Sherif is a Board Certified Orthopedic Clinical Specialist. Sherif focuses on understanding how movement impairments are affecting function while also promoting lifestyle changes in order to prevent recurrences of injury. His early treatment interests include running related injuries, adolescent sports rehab, and ACL rehab in lower extremity athletes. He also has been involved in performance training for youth soccer players. Outside of working as a physical therapist, he enjoys traveling, running and cycling, following Philadelphia sports teams, and spending time with his family.

 

 

 

 

 

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.