Lower Limb Neurological & Neurodynamic testing Flashcards
What is neurological and neurodynamic testing also a PE of?
the nervous system
What does the Neurological examination include? (3)
- Observation
- Neurological examination (LMNL)
- UMNL
What does the ‘observation’ of a neuro examination include?
- antalgic postures (creating a posture to try and take the load off something painful)
- muscle wasting
Look for these initially (Hx)
What does the ‘neurological examination’ part of a neuro exam include? and order from least to most reactive
- Dermatome testing
- Reflexes
- Myotomes (strength)
What are the 2 UMNL tests? (More urgent referral)
- babinski
- clonus
What does a neurological examination test?
nerve conduction
What are the 2 components of neurodynamic examination?
- nerve palpation
- neurodynamic testing
What does neurodynamic examination test?
Amount of neural tissue movement and its response to movement –> nerve movement
Which nerves does a neurological assessment involve?
peripherary
AIMS OF NEUROLOGICAL EXAMINATION
What does it confirm/ clarify?
findings in history thought to be related to neurological symptoms (things you find in Hx)
What does a neurological examination establish?
baseline/ assess progress (can see if theres an progress with intervention)
What else can a neurological examination clarify?
whether peripheral signs (in arms etc) & symptoms are due to local (MSK) problem/ indicative of spinal nerve root involvement
What can neurological examination differentiate?
PNS lesion & CNS lesion
What can a neurological exam identify?
contraindications & precautions
Indications for Lower limb neuro examination LMNL
- spinal pain extending past hip/ buttock
- pins & needles and/ or numbness in leg
- weakness/ clumsiness in leg
Indications for LL neuro exam (UMNL)
- bilateral symptoms in a diffuse non-dermatomal distribution)
- disturbances of gait, balance, co-ordination
CAUDA EQUINA
Indications for LL neuro exam (UMNL)
Cauda equina symptoms (SERIOUS)
- 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
Types of neurological testing (LL)
- myotome testing (muscle strength)
- LL reflexes
- dermatome testing (sensation)
- tests for Cord/ CNS
- Babinski
- Clonus
How do you record the strength neuro examination?
Record using 0-5 scale/ comment on “weak”, very “weak” etc.
How do you record the reflexes neuro tests?
Record as 0-4+
RECORDING REFLEXES
What is grade 0?
no response
always abnormal
RECORDING REFLEXES
What is grade 1+?
slight but definitely present response
may/may not be normal
RECORDING REFLEXES
What is grade 2+?
brisk response
normal
RECORDING REFLEXES
What is grade 3+?
very brisk response
may/ may not be normal
RECORDING REFLEXES
What is grade 4+?
Clonus
Always abnormal
What are the different dermaotome tests?
- light touch (cotton)
- sharp/ blunt discrimination
What is the mechanical function of the NS?
Move and withstand forces that are generated by daily movements
What does a nerve have to do?
- slide in its container
- be compressible
- withstand tension
- continue conduction
Neural system anatomy –> mechanical interface (nerve bed)
Tissue that the NS = in contact with/ running next to
e.g. bones, cartilage, IV discs etc.
What is an innervated tissue?
What the nerve supplies
–> gives us hints about how to move the nerve
What is neuropathic pain?
Pain from injury to the nervous system
What causes neuropathic pain?
Repetitive mechanical forces:
- compression
- tensile
- friction
- vibration
What else causes neuropathic pain?
- 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
What is mechanosensitivity?
pain provoked by mechanical stimuli (i.e. movement, postures, palpation)
AIMS OF NEURODYNAMIC ASSESSMENT
What does a neurodynamic assessment identify (4)?
- if patients symptoms are reproduced via palpation/ movement of the NS
- which nerve path is reproducing the patient’s symptoms
- a baseline for assessing progress
- contraindications & precautions
What should you always do before neurodynamic tests?
Neurological tests –> test the health of the neural system first
What are the 5 testing guidelines (indications) for a neurodynamic assessment?
- area of symptoms
- Quality of pain
- behaviour
- mechanism/ past history
- physical examination findings
Where should the area of symptoms be?
neuro-anatomically logical (should follow nerve pathway)
What shapes can the symptoms be in?
pain may be in lines/ clumps e.g. pain at butt&back of knee & calf
Where can the symptoms be?
at vulnerable sites (e.g. head of fib for common peroneal)
What is the quality of pain for neuro sympts?
burning, lancinating, shooting, cramping
Is the pain superficial/ deep for neurodynamic pain?
either. depends on nerve/ area involved
What other symptoms can be present with neurodynamic examinations?
- sensory loss (paraesthsia, anaesthesia)
- dysaesthesia (unpleasant sensations – crawling)
- hyperalgesia vs allodynia
INDICATIONS FOR ND AX
3. Behaviour
- conventional (mechanical)/ unconvential
- provoked/ spontaneous
- latency (e.g. whiplash)
INDICATIONS FOR ND AX
4. Mechanism/ past Hx
What do you have to understand?
the causative event (sometimes straightforward, other times not)
Why is it important to take the history?
MSK injury/ event related to onset of symptoms?
What do we differentiate with the past Hx for ND Ax?
differentiate from non-MSK (i.e. Red flags, diabetes, tumour, post herpetic infections)
INDICATIONS FOR ND AX
5. Physical examination findings (look for these things)
Antalgic postures
tension relieving positions – protective to reduce mechanical load on sensitised nerve tissue by shortening anatomical distance nerve trunk travels (shorten nerve length)
INDICATIONS FOR ND AX
5. Physical examination findings (look for these things)
Active and Passive movements
Symptoms with movements that:
- move and/or
- elongate and/or
- compress the NS in that body part
INDICATIONS FOR ND AX
5. Physical examination findings (look for these things)
Palpation
If mechanosensitivity is present then patient may report array of symptoms to nerve palpation (tingling, numbness, dull ache) and you may notice protective response
Contraindications for Neurodynamic assessment
- 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
How extensive should the P/E be?
Level 2 standard examination
What is a level 2 standard examination?
- 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
When is the level 2 standard exam used?
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
Precautions for ND Ax
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
How can nerves be palpated?
directly/ indirectly
What do nerves feel like?
feel harder than tendons, usually rounded and have a slippery feel
How do you palpate a nerve?
palpate with the tip of your finger/ thumb.
- gentle ‘twanging’
What are nerves meant to do during movement?
slip and flick
Where do you move after locating the nerve?
proximally and distally
What can you also do after initial palpation in less irritable conditions?
Adjust the amount of tension the nerve is under & re-palpate
What should you test?
unaffected vs affected
–> test the difference between other nerve trunks
What else should you palpate?
adjacent tissues
How do you alter the length and dimensions of the nerve bed (interface)?
use multi-joint movements of the limbs and/or trunk
What is changing the length of the nerve meant to detect?
Abnormal mechanosensitivity and physiological responses produced from neural system structures being selectively stressed
What can the innervated tissue be used for? (movement of the tissue)
Produce longitudinal forces
What is a ‘joint closing’ mechanism?
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
What is a ‘joint opening’ mechanism?
relieve pressure on a neural structure by way of increasing the space around it
What can joint opening & closing mechanisms help diagnose?
if interface is component to neural problem
What is a sensitising movement?
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
What is a differentiating movement?
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
When is it the greatest mechanical challenge during the movement order?
when adjacent jt pathology loaded first
(load area furthest away rather than closest)
Where do symptoms occur most frequently?
in the site at which the first movement is performed
Order of steps in a ND assessment
- explanation (during testing ‘any change of symptoms’ where)
- positioning (keep consistent)
- test unaffected side first - compare
- accuracy and precision
- be gentle & dont hurry
- attention to response
- evoke vs provoke (we wanna evoke)
- short duration of testing
- use of differentiating movements for a DD (MSK vs ND)
- use of sensitising movements where needed (e.g. tibial nerve SLR)
What comprises a ‘positive response’ in an ND?
- reproduction of all/ part of the patient’s symptoms
- altered resistance through range
- decreased ROM when compared to the opposite side/ in relation to the expected normal
- symptoms can be altered by movement of body part remote from local area (/ use sensitising movements)
What does a positive NDT USUALLY tell you?
peripheral neurological test (myo,derma,reflex) is sensitive (LMNL)
