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Ballistic dural stretching
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Ballistic dural stretching - March 28, 2006 6:43:00 PM
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ginger
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From: Melbourne Victoria
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Dural tightness is a common feature in presentaions where referred pain is evident. All peripheral nerves are sheathed in a complex tough fibrous network. This sheath can be affected by inflammatory events as with other structures with blood vessels. Tightness and poor extensibility can result, this then can be a lasting feature of an otherwise solveable referred pain event.
By stretching dura , many unresolved pain problems will be solved. Self stretch plays a usefull role, however , strong stretches that bring about quick resolution are of value.
The best of which in my view, are ballistic stretches of dura.
Muscle bellies can be seen to contract with a quick stretch, this leaves whatever is not muscle to stretch. ballistic stretches are done with a forcefull quick movement through the last part of range of a joint or combination of joints. The hold is momentary, repeated 6-8 times , with testing for length and sensitivity done frequently.
For instance , brachial dura can be stretched with patient supine, therapist at the shoulder facing patients head, patients hand held into wrist and finger extension ( full ) elbow extended and shoulder hanging off the edge of the bench into horizontal extension. By drawing the wrist and fingers downwards into further end range hor. ext. a sense of the limits of dural length can be gained. quite often there will be pain and/or a minor exacerbation of other altered upper limb altered sensation during this test.
Repeated forcefull wrist finger extension into end of range and beyond , with quick movements controlled by therapist, into a painfull range, will bring about rapid and lasting improvements to range and many referred events associated with brachial dura.
Other dural stretches will be described if asked.
Approaching dural stretches with prolonged gentle stretch will ultimately work , though much slower and less likely to provide the kind of immediate pain and symptom relief available with ballistic stretching.
These stretches are safe, when done with skill and good handling, provide permanent improvements to extensibility and often remarkable quick pain and symptom relief.
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The Grand Pediculator
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Re: Ballistic dural stretching - March 29, 2006 2:26:00 AM
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Sebastian Asselbergs
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sorry, despite your response in the other thread, you still haven't convinced me that you do anything other than affect the neurofeedback mechanisms - and roughly so -- certainly nothing you mention shows that dura: a) stretches, b) is the actual "cause" of the problem, and that c) your technique is any better than gentle handling.
If gentle handling does not work for you, don't dismiss it - you may need more practice....LOL After all, you seem to be very good at "forcing" tissue, and gentle handling requires more subtlety....
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Re: Ballistic dural stretching - March 29, 2006 6:39:00 AM
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JLS_PT_OCS
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While I certainly agree with Sebastian's post, I must also ask...why are the ballistic stretches you describe so safe and effective, when in fact you are exactly simulating a brachial plexus traction injury (burner/stinger)?
If ballistic stretching affects only "tough, fibrous" dural tissue and not mechanically sensitive neural tissue, why does the brachial plexus traction injury even exist? Why don't athletes come off the field saying "wow, my UE symptoms were relieved by that tackle!" ? Why are children born with plexus lesions from the exact mechanism you describe?
J
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"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Ballistic dural stretching - March 29, 2006 6:55:00 AM
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Diane
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:D I am so loving this thread. Please continue!
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Re: Ballistic dural stretching - March 29, 2006 7:25:00 AM
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Shill
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From: Madison WI USA
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Ginger,
It seems your claims are a bit of a stretch.
Seriously.
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Re: Ballistic dural stretching - March 29, 2006 9:48:00 AM
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nari
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Ginger, from your description of positioning, I have to agree with Sebastian...what tells you that you are stretching dura? There's heaps of tissue in that extreme position that will be altered in some way; the plexus will be taut, and maybe the dura is altered...but not exclusively.
I would agree, perhaps, that it does not quite mimic a one-off severe trauma such as Jason describes, as it is a more controlled action that you do.
Nevertheless, I am not convinced that this is a safe way to mobilise neural and other tissue. Do you remember the fuss over ballistic work in gyms in the 80s? All sorts of injuries occured, which ceased when those movements were banned.
Can you see where we're coming from?
Has Melbourne recovered from the Games hype?
Nari
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Re: Ballistic dural stretching - March 29, 2006 12:20:00 PM
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ginger
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Morning all.
If my own experiences are any guide ( well they are to me ) then I've found nothing but value in ballistic dural stretches. This method is a regular feature of my practice and is safe . The method is not new , has been taught here in Oz for as many years as I've been a physio (21). It does seem that in the litigious environment americans call home, that many very usefull methods may be dumped in favour of the lighter less effective methods. Just a thought , it may be that you just have a way to go to catch up in general terms with Oz standards.
I do have a bit of a laugh when I imagine the look of horror on your face though Dianne.
Carry on.
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The Grand Pediculator
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Re: Ballistic dural stretching - March 29, 2006 12:24:00 PM
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ginger
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Speaking of games hype Nari, the commonwealth games just finished , with the swimming a stones throw from my office , and now the park is decked out ready for the australian GP, also a cooeee from my rooms. There'll be roaring v10's zooming around the albert park track today , practice day one. Ahhh the smell of high octane , and the stands groaning under the weight of milling grid girls already.
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The Grand Pediculator
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Re: Ballistic dural stretching - March 29, 2006 1:32:00 PM
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ginger
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Femoral Dural ballistic stretches.
In many cases of PFPS where the involuntary inhibition of VMO has been relieved by appropriate attention to a hypomobile L3, some dural tension may remain. At this time femoral dural stretches may be called for, where the majority of referred events relating to PFPS are by involvement of nerves arising at the L3(femoral N. ) level.
Tight femoral dura will be quickly and permanently reduced by ballistic stretches.
Method.
Patient prone, no pillows under hips or pelvis. Bring the knee into full flexion , held there while lifting the knee from below, such that hip extension movemnts are sudden and producing pain. Sensations of stretch and pain may be felt either at the knee anteromedially or along the L3 dermatome .Maintain pelvic neutral position by one hand over the sacrum providing counterpressure to the upward movements of the knee/hip. Series of 6-8 rapid movements, with a retest for dural length between. Repeat up to patient tolerance or 5.
Test for VMO activity after this stretch will often show improvements to recruitment, pain on deep squat will also be improved. It must be remembered that a full resolution of L3 inflammatory events is necessary to fully resolve PFPS. Dural stretches play a usefull role however.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Ballistic dural stretching - March 29, 2006 2:29:00 PM
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rwillcott
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I have a question about the Femoral Dural ballistic stretches. Performing this stretch in the Prone Knee Bend position sounds more like a stretch of Rectus Femoris and not the Dura. Would it not be more effective to place the patient in side lying in order to have the patient perform neck flexion.
If you take the patient into knee flexion and hip extension in sidelying you can use neck flexion to differentiate a tight rectus femoris from a tight femoral nerve.
I'm in Canada where we don't have such a litigious environment. I'll try givin' 'er on my next PFS patient who has a positive test for tight femoral nerve. I find "flossing" techniques ala Butler too gentle and the patient never seems to perform them properly.
Thanks for the ideas!
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Re: Ballistic dural stretching - March 29, 2006 2:53:00 PM
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ginger
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The trouble with an attempt at femoral dural stretches in side lying is maintaining a neutral position of the pelvis where movements are under sufficient control. A positive sense of control of inadvertant movement is an essential feature of this type of stretch. Head/neck position will increase dural load if possible( into flexion ), but I have sacrificed this in favour of control.
While rectus femoris is felt often as the chief site of stretch sensation ,with this femoral stretch, if this method is done skillfully ,little or no actual stretching takes place in the muscle belly.
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The Grand Pediculator
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Re: Ballistic dural stretching - March 29, 2006 4:37:00 PM
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nari
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ginger
Interesting that you were taught ballistics - I always thought Victoria had a mind of its own; the Uni taught Gr5 manips as routine for all undergrads in the 50s and 60s -I don't believe anywhere else did.
I always reckoned that a 'short' RF causing pain was a bit of a misdiagnosis - have found that pain starts in the thigh long before tension is palpable in the muscle structure. I use PKB a lot to resolve LBP - it works very well in most cases- but I don't bounce the movement, simply glide. Also, adding down pressure on T8-12 at the same time reduces the pain experience and hastens the resolution; have no idea why.
There is no movement in the pelvis, so there is no chance of 'slackening' the nerve roots.
Any clues on that?
Nari
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Re: Ballistic dural stretching - March 29, 2006 4:47:00 PM
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ginger
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Not sure Nari what a "'short 'RF causing pain" is.
Could you also explain PKB . Thanks , I always get sidelined by abbreviations.
I went to Lincoln here in Melbourne during the early 80's . There was no Grade 5 stuff offered as part of the undergrad course at that time.
Looking fwd to discussing your previous post , just need to clear up my missing bits.
Ta
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Ballistic dural stretching - March 29, 2006 4:50:00 PM
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Diane
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RF= rectus femoris?
PKB= prone knee bend?
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Re: Ballistic dural stretching - March 29, 2006 5:00:00 PM
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ginger
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God I'm such a dummy with abbreviations Nari , I seem to just shut down when reading them somehow, I took a breath and realised you meant prone knee bend. Duh. and a shortened Rectus femoris etc etc. forgive me, I'm having a senior moment.
I can't help but see the experience you have with my own goggles on Nari. That is , that when "flossing " and other neural glide techniques work , that some element of physical dural entrapments may be loosened. I realise thats shacklocks story , but i rather prefer to envision a loosening of the entire neural (dural ) tube , with its connections and possible adhesions being stretched.
It may well be both neural inner tube connections loosened, dural length improvements and other desensitising effects combined. The improvements you have with Low back pain after your PKB ( I'm getting into it now )could well be the same effect I'm seeing with a stronger dural stretch.
Perhaps Dianne will offer her insight here. please go on.
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The Grand Pediculator
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Re: Ballistic dural stretching - March 29, 2006 6:07:00 PM
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nari
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ginger, I think you're too young to have senior moments. ;) Sure you didn't bump into a croc while rafting on the Amazon?
Maybe the whole shebang is lengthened...all I know is gentle stuff like PKB x 4-5 reps plus lower thoracic pressure works within a few moments. The whole flexed leg and pelvis lets go quite smoothly.
I'm sure Diane can add something useful.
Nari
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Re: Ballistic dural stretching - March 29, 2006 7:06:00 PM
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ginger
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Didn't see any crocs when I was on the amazon , a lot of huge snakes, monkeys and really scary looking drug addicts around Manaus, but that's another story.
I just had a fellow here with a hamstring pain referred from L5S1 , where a certain amount of dural tightness, and by stretching, confirmed the temporal relationship ( thanks Jason ) with my perception of the origin of this pain. 15 minutes of Mobs to L5S1 and dural stretches .Full resolution in one Rx seems likely . I wonder how your approach would go? What would you have done differently.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Ballistic dural stretching - March 30, 2006 3:15:00 AM
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Diane
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I always thought "dura" was inside the spinal canal. I don't know if [URL=http://www.noigroup.com/cgi-bin/ubbcgi/ultimatebb.cgi?ubb=get_topic;f=5;t=000552]this[/URL] is useful or not; it is a discussion on NOI at present about dura and whatnot.. Anyway, I offer it as a bit of a reality check to "dura" mobilipulators. I guess my question would be, why should it need stretched in the first place? If motor outflow could be affected instead, a far easier solution, then hamstrings etc eccentrically lengthen and "dura" along with them.
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Re: Ballistic dural stretching - March 30, 2006 3:32:00 AM
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Shill
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From: Madison WI USA
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Ginger,
I dont think that our fear of litigation is what prevents us american PTs from doing ballistic stretch. I think that rather it is the complete lack of any sort of evidence that this is helpful, combined with evidence that tissue is supposed to like LOW load long duration, as opposed to HIGH load, short duration for lengthening. Now I will admit that there isnt a great deal of research on the necessity to and/or how to lengthen and mobilize nerve or neural tissues, (other than the Butler and Shacklock ideas) or whether we are truly lengthening these tissues or the tissues that connect to the nerves. It seems to me that there isnt a any widely accepted theory outside the physio realm. (Ask your favorite doc about adverse neural tension, and see what kind of looks you get). Now dont get me wrong, it doesnt mean these things dont exist. My point is in regards to the acceptance of these theories at this current point in time.
Regardless of acceptance, these theories and techniques do not propose moving in ways that simulate the rapid speed of actual injury. Your idea does, and hence the barrage of questions.
Techniques that go against tradition and actual research cant be made safe simply because you say so.
The argument that it has been taught for years is no defense. Myofascial release has been taught for years too.
Steve
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Re: Ballistic dural stretching - March 30, 2006 11:57:00 AM
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ginger
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For those of you who feel uncomfortable with dural ballistic stretching in general My advice is just leave it alone , it may not be for you. The best teacher in the world ( and it's not me ) couldn't see you through any dilemma or skill issue without being somewhere nearby to coach and guide you. Anyone who cares to continue this discussion should do so with me privately. I wouldn't want the concerns that may arise when the unskilled attempt potentially difficult manoevres without hands on guidance. While the method is quite safe, I'm not sure that the average US PT is up to it just yet.
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The Grand Pediculator
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