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MUSC 206 > Lower Limb Neurological & Neurodynamic testing > Flashcards

Lower Limb Neurological & Neurodynamic testing Flashcards

1
Q

What is neurological and neurodynamic testing also a PE of?

A

the nervous system

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2
Q

What does the Neurological examination include? (3)

A
  1. Observation
  2. Neurological examination (LMNL)
  3. UMNL
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3
Q

What does the ‘observation’ of a neuro examination include?

A
  • antalgic postures (creating a posture to try and take the load off something painful)
  • muscle wasting
    Look for these initially (Hx)
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4
Q

What does the ‘neurological examination’ part of a neuro exam include? and order from least to most reactive

A
  1. Dermatome testing
  2. Reflexes
  3. Myotomes (strength)
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5
Q

What are the 2 UMNL tests? (More urgent referral)

A
  1. babinski
  2. clonus
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6
Q

What does a neurological examination test?

A

nerve conduction

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7
Q

What are the 2 components of neurodynamic examination?

A
  1. nerve palpation
  2. neurodynamic testing
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8
Q

What does neurodynamic examination test?

A

Amount of neural tissue movement and its response to movement –> nerve movement

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9
Q

Which nerves does a neurological assessment involve?

A

peripherary

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10
Q

AIMS OF NEUROLOGICAL EXAMINATION
What does it confirm/ clarify?

A

findings in history thought to be related to neurological symptoms (things you find in Hx)

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11
Q

What does a neurological examination establish?

A

baseline/ assess progress (can see if theres an progress with intervention)

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12
Q

What else can a neurological examination clarify?

A

whether peripheral signs (in arms etc) & symptoms are due to local (MSK) problem/ indicative of spinal nerve root involvement

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13
Q

What can neurological examination differentiate?

A

PNS lesion & CNS lesion

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14
Q

What can a neurological exam identify?

A

contraindications & precautions

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15
Q

Indications for Lower limb neuro examination LMNL

A
  1. spinal pain extending past hip/ buttock
  2. pins & needles and/ or numbness in leg
  3. weakness/ clumsiness in leg
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16
Q

Indications for LL neuro exam (UMNL)

A
  • bilateral symptoms in a diffuse non-dermatomal distribution)
  • disturbances of gait, balance, co-ordination
    CAUDA EQUINA
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17
Q

Indications for LL neuro exam (UMNL)
Cauda equina symptoms (SERIOUS)

A
  • disturbances of bladder/ bowel function
  • saddle anaesthesia –> loss of sensation/ numbness between leg in perineum area
  • bilateral sciatica
  • severe/ progressive bilateral neurological deficit of the legs
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18
Q

Types of neurological testing (LL)

A
  1. myotome testing (muscle strength)
  2. LL reflexes
  3. dermatome testing (sensation)
  4. tests for Cord/ CNS
    - Babinski
    - Clonus
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19
Q

How do you record the strength neuro examination?

A

Record using 0-5 scale/ comment on “weak”, very “weak” etc.

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20
Q

How do you record the reflexes neuro tests?

A

Record as 0-4+

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21
Q

RECORDING REFLEXES
What is grade 0?

A

no response
always abnormal

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22
Q

RECORDING REFLEXES
What is grade 1+?

A

slight but definitely present response
may/may not be normal

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23
Q

RECORDING REFLEXES
What is grade 2+?

A

brisk response
normal

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24
Q

RECORDING REFLEXES
What is grade 3+?

A

very brisk response
may/ may not be normal

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25
Q

RECORDING REFLEXES
What is grade 4+?

A

Clonus
Always abnormal

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26
Q

What are the different dermaotome tests?

A
  1. light touch (cotton)
  2. sharp/ blunt discrimination
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27
Q

What is the mechanical function of the NS?

A

Move and withstand forces that are generated by daily movements

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28
Q

What does a nerve have to do?

A
  • slide in its container
  • be compressible
  • withstand tension
  • continue conduction
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29
Q

Neural system anatomy –> mechanical interface (nerve bed)

A

Tissue that the NS = in contact with/ running next to
e.g. bones, cartilage, IV discs etc.

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30
Q

What is an innervated tissue?

A

What the nerve supplies
–> gives us hints about how to move the nerve

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31
Q

What is neuropathic pain?

A

Pain from injury to the nervous system

32
Q

What causes neuropathic pain?

A

Repetitive mechanical forces:
- compression
- tensile
- friction
- vibration

33
Q

What else causes neuropathic pain?

A
  • ischemia (i.e. compression)–> blood supply for nerve = compromised
  • inflammation (i.e. inflammatory mediators/ inflammatory substances from adjacent tissues) –> can cause injury to NS thus pain
34
Q

What is mechanosensitivity?

A

pain provoked by mechanical stimuli (i.e. movement, postures, palpation)

35
Q

AIMS OF NEURODYNAMIC ASSESSMENT
What does a neurodynamic assessment identify (4)?

A
  1. if patients symptoms are reproduced via palpation/ movement of the NS
  2. which nerve path is reproducing the patient’s symptoms
  3. a baseline for assessing progress
  4. contraindications & precautions
36
Q

What should you always do before neurodynamic tests?

A

Neurological tests –> test the health of the neural system first

37
Q

What are the 5 testing guidelines (indications) for a neurodynamic assessment?

A
  1. area of symptoms
  2. Quality of pain
  3. behaviour
  4. mechanism/ past history
  5. physical examination findings
38
Q

Where should the area of symptoms be?

A

neuro-anatomically logical (should follow nerve pathway)

39
Q

What shapes can the symptoms be in?

A

pain may be in lines/ clumps e.g. pain at butt&back of knee & calf

40
Q

Where can the symptoms be?

A

at vulnerable sites (e.g. head of fib for common peroneal)

41
Q

What is the quality of pain for neuro sympts?

A

burning, lancinating, shooting, cramping

42
Q

Is the pain superficial/ deep for neurodynamic pain?

A

either. depends on nerve/ area involved

43
Q

What other symptoms can be present with neurodynamic examinations?

A
  • sensory loss (paraesthsia, anaesthesia)
  • dysaesthesia (unpleasant sensations – crawling)
  • hyperalgesia vs allodynia
44
Q

INDICATIONS FOR ND AX
3. Behaviour

A
  • conventional (mechanical)/ unconvential
  • provoked/ spontaneous
  • latency (e.g. whiplash)
45
Q

INDICATIONS FOR ND AX
4. Mechanism/ past Hx
What do you have to understand?

A

the causative event (sometimes straightforward, other times not)

46
Q

Why is it important to take the history?

A

MSK injury/ event related to onset of symptoms?

47
Q

What do we differentiate with the past Hx for ND Ax?

A

differentiate from non-MSK (i.e. Red flags, diabetes, tumour, post herpetic infections)

48
Q

INDICATIONS FOR ND AX
5. Physical examination findings (look for these things)
Antalgic postures

A

tension relieving positions – protective to reduce mechanical load on sensitised nerve tissue by shortening anatomical distance nerve trunk travels (shorten nerve length)

49
Q

INDICATIONS FOR ND AX
5. Physical examination findings (look for these things)
Active and Passive movements

A

Symptoms with movements that:
- move and/or
- elongate and/or
- compress the NS in that body part

50
Q

INDICATIONS FOR ND AX
5. Physical examination findings (look for these things)
Palpation

A

If mechanosensitivity is present then patient may report array of symptoms to nerve palpation (tingling, numbness, dull ache) and you may notice protective response

51
Q

Contraindications for Neurodynamic assessment

A
  • acute nerve root injury
  • recent onset of neurological signs/ worsening neuro signs (cauda equina)
  • UMNL (cord) & Cauda Equina symptoms
  • UMNL signs
  • tethered cord syndrome
  • severe pain in which examination too intrusive and provoke symptoms unnecessarily
  • severe headaches
  • dizziness/nausea
  • presence of obvious serious pathology e.g. cancer
52
Q

How extensive should the P/E be?

A

Level 2 standard examination

53
Q

What is a level 2 standard examination?

A
  • use of the standard tests (femoral slump, sciatic etc)
  • performed to a comfortable production of symptoms (or if info can be gathered without symptoms better)
  • not necessary to take to end of range if not needed, but is permissible if clinically appropriate
  • end position held for a metter of seconds
  • structural differentiation - “on” direction
54
Q

When is the level 2 standard exam used?

A

in patients who present with:
- absent neurological symptoms/ stable
- stable condition (non prgressive)
- pain not easily provoked, not severe
- lower intensity pain and no symptom latency

55
Q

Precautions for ND Ax

A

Level 1 only
- irritable conditions (possibility of latent response)
- central sensitivity; excessive handling & repeated movement may lead to long lasting aggravation
- pathology present in NS i.e. disc bulge
- acute states where disc trauma / comptmt syndrome suggests that nerve irritation or compression could occur
- altered pathology of other structures along the neural pathway (osteoporosis)
- neurological signs
- care with disorders such as diabetes, RA, guillian barre
- altered vascular conditions

56
Q

How can nerves be palpated?

A

directly/ indirectly

57
Q

What do nerves feel like?

A

feel harder than tendons, usually rounded and have a slippery feel

58
Q

How do you palpate a nerve?

A

palpate with the tip of your finger/ thumb.
- gentle ‘twanging’

59
Q

What are nerves meant to do during movement?

A

slip and flick

60
Q

Where do you move after locating the nerve?

A

proximally and distally

61
Q

What can you also do after initial palpation in less irritable conditions?

A

Adjust the amount of tension the nerve is under & re-palpate

62
Q

What should you test?

A

unaffected vs affected
–> test the difference between other nerve trunks

63
Q

What else should you palpate?

A

adjacent tissues

64
Q

How do you alter the length and dimensions of the nerve bed (interface)?

A

use multi-joint movements of the limbs and/or trunk

65
Q

What is changing the length of the nerve meant to detect?

A

Abnormal mechanosensitivity and physiological responses produced from neural system structures being selectively stressed

66
Q

What can the innervated tissue be used for? (movement of the tissue)

A

Produce longitudinal forces

67
Q

What is a ‘joint closing’ mechanism?

A

increase pressure on neural structures by way of reducing the space around it e.g. spinal ext/ LF closes the IV forarmen and compresses those nerves

68
Q

What is a ‘joint opening’ mechanism?

A

relieve pressure on a neural structure by way of increasing the space around it

69
Q

What can joint opening & closing mechanisms help diagnose?

A

if interface is component to neural problem

70
Q

What is a sensitising movement?

A

increasing forces in the neural structures in addition to movements normally used in the test
e.g. contralateral LF of the spine, hip IR and/or adduction

71
Q

What is a differentiating movement?

A

differentiation between neural & non-neural structures (MSK)
e.g. use a movement remote from the area of symptoms that moves the NS but not the MSK

72
Q

When is it the greatest mechanical challenge during the movement order?

A

when adjacent jt pathology loaded first
(load area furthest away rather than closest)

73
Q

Where do symptoms occur most frequently?

A

in the site at which the first movement is performed

74
Q

Order of steps in a ND assessment

A
  1. explanation (during testing ‘any change of symptoms’ where)
  2. positioning (keep consistent)
  3. test unaffected side first - compare
  4. accuracy and precision
  5. be gentle & dont hurry
  6. attention to response
  7. evoke vs provoke (we wanna evoke)
  8. short duration of testing
  9. use of differentiating movements for a DD (MSK vs ND)
  10. use of sensitising movements where needed (e.g. tibial nerve SLR)
75
Q

What comprises a ‘positive response’ in an ND?

A
  1. reproduction of all/ part of the patient’s symptoms
  2. altered resistance through range
  3. decreased ROM when compared to the opposite side/ in relation to the expected normal
  4. symptoms can be altered by movement of body part remote from local area (/ use sensitising movements)
76
Q

What does a positive NDT USUALLY tell you?

A

peripheral neurological test (myo,derma,reflex) is sensitive (LMNL)

MUSC 206 (5 decks)

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