MSM CH 12: Neurodynamic Mobilizations
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| The nervous system is an electrical, chemical, and mechanical structure with two subdivisions: | central nervous system (brain and spinal cord); peripheral nervous system (somatic: motor and sensory; autonomic (self regulating; not automatic: self operating) with two parts: ANS (T1 to L2) & PNS (Cranial Nerves III, VII, IX, & X).
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| Nervous tissue can withstand some mechanical stress because it's | viscoelastic which allows for the stress during trunk or limb movement.
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| The adaptation results from changes in the length of the spinal cord and peripheral nerves to adapt via | passive movement by gliding around the nerve trunk.
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| There are three mechanisms important in this adaptability: | 1. Elongation of the nerve against elastic forces.2. Longitudinal movement of the nerve trunk.3. An increase and decrease of tissue relaxation at the level of the nerve trunk.
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| The efficiency of this mechanism (Tx) depends on | elasticity of the connective tissue around the nerve (described variously as adventitia, conjunctiva nervorum, and perineurium) to allow for traction on the entire length of the nerve.
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| . Perineurium | Perineurium is the anatomical term, clinicians used the other two terms in articles)
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| If this elasticity is compromised | traction can occur on the nerve.
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| Tension on neural tissue plays a role in | pain and dysfunction. Tests have been designed to examine neural structures for adaptive shortening and inflammation.
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| The spinal dura sheathes the spinal cord span from | the foramen magnum to the 2nd sacral tubercle. It continues as the filum terminale to the coccyx.
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| The dura surrounds the exiting spinal nerve roots to the | interveterbal foramen.
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| The dura is tethered to the bony canal at | C6, T6, and L4.
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| What areas are hypothesized as possible sites for tension and are called Tension Sites | The dura is tethered to the bony canal at C6, T6, and L4.
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| Three other tension sites are | the shoulder, elbow, and knee. The neurologic tissues move in different directions depending on the direction and stress applied there.
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| Usually the tension sites are not | are not adversely affected by arm and leg movement.
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| If the dura should become adherent dural tension may be | felt through the neuromeningeal system and affect the range of motion available to the trunk, extremities, or both.
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| A decrease in nerve mobility makes the nerve more | vulnerable to injury during repetitive movements. Nerve tissue responds to injury the way other tissue does which is to evoke the inflammatory process and results in pain.
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| The nerves and their microcirculation are vulnerable to | tension, friction, and compressive forces.
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| Proposed Mechanisms for Neurodynamic Dysfunction | 1. Posture: 2. Direct Trauma: 3. Extremes of Motion: 4. Electrical Injury:5. Compression:
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| Proposed Mechanisms for Neurodynamic Dysfunction. 1. Posture: | sustained postures may produce changes in the natural curves of the spine which shorten the distance traveled by the peripheral nerve trunk. Correcting the posture may produce a stretch of the neural tissues.
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| Proposed Mechanisms for Neurodynamic Dysfunction 2. Direct Trauma: | orthopedic trauma such as fracture, dislocation, tendon rupture, injection, joint manipulation, and surgery can result in nerve injury. Two common examples are the radial nerve in humeral fractures and the sciatic nerve in fx or dislocations of the hip.
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| Proposed Mechanisms for Neurodynamic Dysfunction. 3. Extremes of Motion: | due to the course many nerve trunks, a traction force may be applied to many nerves.
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| Proposed Mechanisms for Neurodynamic Dysfunction. 4. Electrical Injury: | permanent nerve injuries were found in 22 percent of electrocuted patients. Upper limbs were most commonly involved with the symptoms varying from neuropathy to reflex sympathetic dystrophy.
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| Proposed Mechanisms for Neurodynamic Dysfunction. 5. Compression: | this may result from muscle contractions, tight fascia, osteochondromas, ganglia, lipomas, other benign neoplasms, and bony protuberances.
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| The double crush syndrome | syndrome is a general term referring to the coexistence of two neuropathies along the course of a peripheral nerve.
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| The double crush syndrome concept was proposed by | Upton and McComas in 1973 who suggested that proximal nerve compression decreases the nerve’s ability to withstand distal compression.
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| (The double crush syndrome) Impairment of neural excursion may result in | disruption of axons, impairment of axonal transport, endoneural edema, or ischemic changes in nerves.
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| Double crush is defined as | a serial compromise of axonal transport along the same nerve fiber causing a subclinical lesion at a distal site to become symptomatic.
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| Double Crush Injuries Other Mechanisms | 1.Proximal lesions renders the distal nerve vulnerable to compression due to decreased axoplasmic flow.2. Peripheral nerves are susceptible to pressure.3. Interruption of lymph and venous flow affects the distal nerve.
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| Double Crush Injuries Other Mechanisms continued.... | 4.Proximal endoneurial edema affects the distal nerve.6.Tethering of the nerve at one site causes shear forces at the other site.5.A common connective tissue abnormality is present at both sites.
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| MOre Double Crush Injuries Other Mechanisms | 7.Entrapment of the n. at one site causes decreased use of the m. pump and results in generalized edema and additional n. entrapment.8.The initial n. lesion releases a metabolite that passes through interneural circ which increases vulnerability of othe
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| The initial nerve lesion releases a metabolite that passes through interneural circulation which increases vulnerability of other parts of the nerve. | Double Crush Injuries Other Mechanisms
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| Entrapment of the nerve at one site causes decreased use of the muscle pump and results in generalized edema and additional nerve entrapment. | Double Crush Injuries Other Mechanisms
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| Tethering of the nerve at one site causes shear forces at the other site. | Double Crush Injuries Other Mechanisms
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| A common connective tissue abnormality is present at both sites. | Double Crush Injuries Other Mechanisms
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| Proximal endoneurial edema affects the distal nerve. | Double Crush Injuries Other Mechanisms
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| Interruption of lymph and venous flow affects the distal nerve. | Double Crush Injuries Other mechaisms
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| Peripheral nerves are susceptible to pressure. | Double Crush Injuries Other Mechanisms
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| Proximal lesions renders the distal nerve vulnerable to compression due to decreased axoplasmic flow. | Double Crush Injuries Other Mechanisms
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| For a double crush syndrome (DCS) to exist, | , there must be anatomic continuity of nerve fibers. If this is lacking, then the axoplasmic flow cannot occur.
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| A cervical root lesion does not always | meet the criterion to be involved in carpal tunnel syndrome.
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| Golovchinsky performed what studies? | EMG/NCV studies and concluded that cause and effect relationship between damaged proximal fibers and peripheral entrapment syndromes in the same nerves.
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| Baba et al performed studies in | rabbits and noted that dual damage exceeds the expected summation of two isolated compressions.
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| Richardson et al and Bednarik et al performed studies and determined that | that there was no evidence to support a neurophysiologic explanation for the double crush hypothesis.
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| Electroneurophysiological examination is critical in determining if there is | a single or double lesion along a nerve and determining the severity of the two lesions.
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| Neurodynamic Mobility ExaminationsThe parts to treatment include: | 1.Lower extremity tension testing.2.Upper extremity tension testing.3.Neurodynamic Mobility Interventions.4.Home exercise programs to improve adaptive shortening in the upper and lower extremity nerves.
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| The examination of neural adhesions is not an exact science, but the techniques are based on | anatomic theory.
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| Two individuals have both been credited with developing neurodynamic mobility examination techniques: | Elvey and Butler.
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| Elvey developed | what he called brachioplexus tension test and was later called Upper Limb Tension Test (ULTT).
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| Neurodynamic Mobility ExaminationsThese tests are designed to | stress the dura, and assess the contribution of the spinal nerve roots and peripheral nerves in a sequential and progressive stretch on the dura.
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| Neurodynamic Mobility Examinations, Breig proposed a | tissue borrowing phenomenon as an explanation for the neurodynamic tests.
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| Breig’s explanation was | was that tension produced in a lumbosacral nerve root results in displacement of the surrounding dura, nerve roots, and lumbosacral plexus.
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| a tissue borrowing phenomenon | suggests that the slack in meningeal tissues occurs as the neural structures are pulled toward the site of increased tension and reduces the available mobility of the peripheral nerves.
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| Symptoms of neuropathic dysfunction include | pain, parethesia, and spasm. These symptoms may be associated with other injuries.
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| Neurodynamic Mobility Examinations:Asbury and Fields hypothesized that the type of pain from a peripheral nerve injury is of two varieties: | 1. Dysesthetic pain: 2. Nerve trunk pain:The type of pain is not enough to come to a diagnosis. One must use other findings from a complete exam.
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| 1. Dysesthetic pain: | a type of pain that is felt in the peripheral sensory nerve distribution of sensory or mixed nerves (motor & sensory) and comes from nociceptive afferent fibers.
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| 2. Nerve trunk pain: | this pain results from nociceptors within the nerve sheaths and has a pain distribution along the course of the nerve.
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| Neurodynamic Mobility ExaminationsObservation: | a peripheral nerve injury may have atrophy.
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| Neurodynamic Mobility ExaminationsPalpation: | palpate along the nerve trunk where it is superficial to reproduce pain.
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| Neurodynamic Mobility ExaminationsRange of motion: | AROM & PROM may be decreased in the same direction, remember, musculotendinous lesions may produce similar symptoms.
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| Neurodynamic Mobility ExaminationsResistive testing: | look for the presence of pain. If the tested muscle is pain free, but the AROM, PROM or both are painful, this may indicate nerve pain. One study did find a positive slump test in patients with hamstring strains.
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| Neurodynamic Mobility ExaminationsThe purpose of the physical examination is | to determine what tissue is at fault. A clinician must decide what tissue may be causing the pain and stressing that tissue.
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| a positive finding for many of the techniques designed to assess the integrity of a neural structure may be the result of | a sensitive movement rather than a stretch of the dura.
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| The SLR stresses | the sciatic nerve and the nerve roots of L4 to S2.Any space occupying lesions may interfere with the dura or nerve roots.
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| Straight Leg Raise-Pain from 0 to 30 degrees may indicate: | Spondylothisthesis.Tumor of the buttock.Sign of the buttock.Gluteal abscess.Disk protrusion.Inflammation of the dura.Malingering.
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| Straight Leg RaiseBetween 30 and 70 degrees | the spinal nerves and dura are stretched further
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| Straight Leg Raiseafter 70 degrees | the joints and muscles are stressed.
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| Consider the SLR positive if: | Range is limited to less than 70 degrees by spasm.There is a reproduction of leg and back pain.The pain reproduced is neurologic in nature (radiating) and has other signs and symptoms such as pain with coughing and bending over to tie the shoes.
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| SLR can be postive and not neruodynamic.... what are the positve signs. | non-radiating back pain with testing could be joint, connective tissue, or muscle)
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| Crossed Straight Leg Raiseposterior disk protrusion | The SLR produces pain in the contralateral side, both sides, or in the contralateral side whenever one leg is raised.This may indicate a very large posteriolateral protrusion or a posterior disk protrusion.
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| Crossed Straight Leg RaiseIndications of a protrusion or of a herniated disk: | Severely limited ROM. Positive crossed SLR.Severely restricted and painful trunk movement.
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| Bilateral Straight Leg RaiseThe purpose of this test is to | To highlight a posterior protrusion of a disk. It is not always positive.One must differentiate central protrusion from intermittent claudication (vascular vs neurogenic).
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| One must differentiate central protrusion from intermittent claudication (vascular vs neurogenic). Put the patient on a bicycle:If pts tolerate a bike | Lateral spinal stenosis
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| One must differentiate central protrusion from intermittent claudication (vascular vs neurogenic). Put the patient on a bicycle:pts have increased symptoms | Vascular (PVD) claudication
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| One must differentiate central protrusion from intermittent claudication (vascular vs neurogenic). Put the patient on a bicycle:pts have pain with ext | Central canal stenosis claudication
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| One must differentiate central protrusion from intermittent claudication (vascular vs neurogenic). Put the patient on a bicycle:pts can do this if they are in extension | Herniated disk
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| Bowstring Tests | Used to test nerves.Named after the nerve under examination.These tests are done for insufficient stretch of the dura to detect chronic adhesions.
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| A positive bowstring is | a strong indicator for surgery.These tests need only be done if the SLR is positive with additional dorsiflexion.
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| Slump Test | MaitlandCombines several tests: seated SLR; neck flexion, and lumbar slumping.Test enables the tester to detect n root tension caused by spinal stenosis, extraforaminal lateral dk herniation, dk sequestration, n root adhesions, and vert impingement.
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| Slump Test directions | 1. The T & L spine are flexed with C spine in neutral.2. The C spine is added.3. The SLR is added.
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| Prone Knee Bending Test | Test stretches the femoral nerve.Used to detect upper lumbar disk herniations.Neck flexion and extension can be added with this test.
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| Prone Knee Bending Test, is said to test | the L2, 3, and 4 levels.This test may be positive with patients who have had cardiac grafting.The reliability and validity of this test is not known.Similar tests include Ely’s test, Hibb’s test, Craig’s test.
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| Upper Limb Tension Tests (ULTT) | ULTT 1 (Median Nerve Dominant).ULTT 2 (Radial Nerve Dominant).ULTT 3 (Ulnar Nerve Dominant).Musculocutaneous Nerve.Axillary Nerve.Suprascapular Nerve.
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| ULTT1 Median Nerve DominantWhat is it used to treat: | Designed to treat carpal tunnel syndrome.Reduces pressure inside the carpal tunnel.
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| What the ULTT1 Median Nerve Dominant Test does? | Broadens the area of contact between the median nerve and the transverse carpal ligament.Reduces tenosynovial edema by milking action.Improves venous return from nerve bundles.
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| ULTT1 Median Nerve DominantSix positions: | 1.Wrist neut, fing & thumb in flex2.Wrist neut, fing & thumb in \3.Wrist & fingers \, thumb in neut4.Wrist, fing, thumb \5.Wrist, fingers, thumb \, forearm sup6.Wrist, fingers, thumb \ forearm sup with other hand gently stretching the thumb.
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| ULTT2 Radial Nerve Dominant | Patient is supine.Shoulder: depressed, abducted, and internally rotated.Foreman pronated.Elbow extended.Wrist and thumb flexed.Cervical spine side flexed to each side for testing.Repeat on other side.
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| ULTT3 Ulnar Nerve Dominant | Patient is supine.Wrist extended.Forearm supinated, elbow flexed.Shoulder depressed and abducted.Side flexion of the head to and away from the hand are sensitizers.
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| Musculocutaneous Nerve | Patient supine.Patients arm in 80 degrees of elbow flexion.Shoulder in full external rotation and 10 degrees of abduction.Shoulder depression with shoulder extension (sensitizer), elbow extension, and wrist in ulnar deviation.
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| Axillary Nerve | Patient supine.Patient’s shoulder is depressed.Glenohumeral joint is externally rotated.Patient side flexes the head away from the test side.Abduct the shoulder to 40 degrees.
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| Suprascapular Nerve | Patient supine.Patients shoulder in internal rotation with scapular protraction.Move arm in horizontal adduction.Patient side bends head away.Depress the shoulder.
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| Neural tension is | the response to mechanical stimulation on nerve tissue.
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| NDM is assumed to | improve axonal transport and nerve conduction velocity.Just because a limb is mobilized, it does not follow that the neural tissue is mobilized.
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| How does Elvey recommend mobilizing joints? | recommends mobilizing the joint around the neural tissue before mobilizing the neural tissue.
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| Neurodynamic Mobility Interventions For the C spine: | shoulder depression, neck in neutral, arm by side; to shoulder depression with fixation of C spine; to shoulder depression, C spine fixation, arm traction.
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| Mettler Release Technique (MRT)is based on the | relation of the fascia, muscles, nerves, and skin.
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| What is the Mettler Release Technique (MRT) | Find the dermal-fascial restriction.One can use hands, fingers, thumb to address the mobility of the skin and fasciaGrades of end feel include mild, hard, blocked.One may hold a technique on an adhered restriction for 15 – 30 seconds.
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| Home Stretching for the Sciatic Nerve Phase 1 | Patient supine near a wall with hip/knee in 90/90. Slide the foot up the wall until a stretch is felt. Hold 1 minute.These are performed 3 – 5 times a day for 3 – 5 minutes.
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| Home Stretching for the Sciatic Nerve Phase 2 | Patient slides the foot farther up the wall until the patient can have the entire leg straight against the wall.These are performed 3 – 5 times a day for 3 – 5 minutes.
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| Home Stretching for the Sciatic Nerve Phase 3 | . Patient then puts a pillow under the head. These are performed 3 – 5 times a day for 3 – 5 minutes.
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| Home Stretching for Upper ExtremityMedian nerve has four positionsPosition #1 | Involved side close to the wall with hand against the wall and posterior and superior to shoulder, fingers extended, elbow flexed.
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| Home Stretching for Upper ExtremityMedian nerve has four positionsPosition #2 | Pt. moves away from the wall and keeps the hand flat on the wall. Hold 10 – 15 seconds.
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| Median nerve has four positionsPosition #3 | After the pt. can hold this with arm straight, rotate away from the involved side for 30 – 60 seconds.
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| Median nerve has four positionsPosition #4 | After this position can be maintained, add cervical side flexion.
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| Home Stretching for Upper ExtremityRadial nerve Position #1 | Pt stands with involved side close to the wall, back of hand on wall, fingers pointing down, shoulder abducted to 40 degrees, fingers flexed elbow flexed.
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| Home Stretching for Upper ExtremityRadial nerve Position #2 | Pt moves away from the wall, when a gentle stretch is felt, hold that position for 10 – 15 seconds.
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| Home Stretching for Upper ExtremityRadial nerve Position #3 | When pt can hold #2 for 30 – 60 seconds, add trunk rotation away from involved side.
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| Home Stretching for Upper ExtremityRadial nerve Position #4 | After full rotation is accomplished, add side flexion of cervical spine.
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| Home Stretching for Upper ExtremityUlnar Nerve #1 | Patient stands with involved side close to the wall, palm against the wall, fingers pointing toward the floor, hand posterior slightly posterior and inferior to the shoulder, fingers and wrist extended, elbow slightly flexed.
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| Home Stretching for Upper ExtremityUlnar Nerve #2 | . Pt moves toward the wall and attempts to flex the elbow. When a stretch is felt, hold for 10 – 15 seconds.
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| Home Stretching for Upper ExtremityUlnar Nerve #3 | When #2 can be held for 30 – 60 seconds, rotate away from the involved side.
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| Home Stretching for Upper ExtremityUlnar Nerve # | When full trunk extension is possible, add cervical side flexion.
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