Nerve compression/entrapment, peripheral nerve injuries Flashcards
What is radiculopathy
pain due to nerve root compression
Radiculopathy S&S
Pain
Tingling
Dec. nerve conduction = mm weakness, sensation changes, reduced reflexes
What causes thoracic outlet syndrome
Impingement of..
- Brachial plexus
- Vagus nerve
- Subclavian artery/vein
What are common impingement sights in thoracic outlet syndrome
o superior thoracic outlet
o scalene triangle
o btw clavicle + 1st rib
o btw pec minor + thoracic wall
TOS S&S
- Pain in arms/hands, neck, axilla, pecs, upper back
- Tingling
- Vascular - one hand colder than other
TOS Ax -
- Adson
- Allen/wrights
- Military test
- Costoclavicular test
TOS Rx:
- Postural re-education
- Functional training to restore normal muscle balances: endurance, strength, power, and coordination
- Biomechanical faults: joint restrictions
- Manipulations (typically 1st rib) to diminish pain and soft tissue guarding - treat symptoms
Ulnar nerve entrapment: Location
Cubital tunnel
Tunnel of guyon (less common)
Ulnar nerve entrapment: Cause
- Direct trauma
- Compression due to thickened retinaculum or hypertrophy of FCU
Ulnar nerve entrapment: S&S
- Medial elbow pain
- Parasthesias in ulnar distribution
Ulnar nerve entrapment: Test
Posterior Tinels sign
Median nerve entrapment: Location
Within pronator teres
Under FDS
Carpal tunnel
Median nerve entrapment in forearm: Cause
Repetitive gripping activities
Median nerve entrapment in forearm: S&S
- aching pain
- Weakness in forearm muscles
- Paraesthesias in median distribution
Median nerve entrapment in forearm: test
Tinels sign in forearm
Carpal tunnel cause
compression due to inflammation of flexor tendons and/or median nerve with repetitive wrist motions (ie. gripping), pregnancy, diabetes or rheumatoid arthritis
Carpal tunnel test:
Phalens
Tinels
Reverse phalens?
Carpal tunnel S&S
Altered sensory function in median nerve distribution
o burning, tingling, pins and needles, numbness (especially at night)
o Decreased vibration, 2-pt discrimination
Atrophy/weakness of thenar muscles (thumb to 3rd finger) + lateral 2 lumbricals
Radial nerve entrapment - which segment of nerve is typically entrapment
distal branches - poster interosseous nerve
Radial nerve entrapment - Location
Radial tunnel
Radial nerve entrapment - Cause
Overhead activities (throwing0
Radial nerve entrapment - S/S
Lateral elbow pain, pain over supinator muscle, parasthesias in radial nerve distribution
Radial nerve entrapment - test
Tinels sign
Radial nerve entrapment - RX
o rule out cervical spine dysfunction, thoracic outlet syndrome, etc.
o rest + avoid exacerbating activities in initial stages (activity modifications)
o control inflammation and/or pain with NSAID’s, modalities, soft tissue techniques
o correct muscle imbalances with exercise (strengthening, flexibility, coordination)
o protective padding and night splints (to maintain slackened position)
o address predisposing factors
o medications (acetaminophen, NSAID’s, etc)
Neuropathy def.
Any nerve disease characterized by decrease in neural function
Traumatic peripheral nerve injury - S&S
- Motor, sensory, autonomic changes
- pain
Traumatic peripheral nerve injury - Dx
MRI
Nerve conduction test used to confirm
Traumatic peripheral nerve injury - types
- Neuropraxia
- Axonotemesis
- Neurotemesis
Neuropraxia:
- Def:
- Result:
- Recovery:
- Compression of the nerve
- RESULT: segmental demyelination & transient disruption
- RECOVERY: fast, good prognosis (min - wks), as edema resolves
Axonotemesis
- Def:
- Result:
- Recovery:
• Disruption of axon, myelin sheath still intact, likely CRUSH INJURY
• RESULT: prolonged disruption, may cause paralysis of the motor, sensory, and autonomic
• RECOVERY: fair prognosis (months), Wallerian degeneration
o Axon re-growth: 1mm/day, upper arm 4-6 months (up to 2 yrs), lower arm 7-9mo, up to 4 yrs
Neurotemesis
- Def:
- Result:
- Recovery:
- Completely severed axon and sheath
* RECOVERY: only w/ surgery with variable success - may never recover
What is wallerian degeneration
Process occurs with laceration or crushing of a nerve - axon separated from cell body (axonotmesis)
o Degeneration occurs distal to site of injury (within 24-36 hours)
o Can affect PNS (Schwann cells) and/or CNS (oligodendrocytes)
How does healing occur following wallerian degeneration
o Macrophages remove debris
o Proximal part - sprouting -> grow (~1mm/day) + prune off -> myelin regrowth
What is segmental demyelination
Myelin breakdown (demyelination) for few segments, but axons are preserved o Mostly reversible because Schwann cells make new myelin -> restore function - Some axons may be permanently lost
Example of segmental demyelination
Guillain-barre Syndrome
What is Guillain-barre Syndrome
o Immune system attacks nerves - 1st s&s - weakness + tingling -> entire body paralysis
o Hospital: most recover, may have slight weakness/tingling/fatigue
What is distal axonal degeneration? What is a suspected cause? Where does it develop?
• Degeneration of axon cylinder and myelin possibly d/t inability of neuronal body to keep up w/ metabolic demands of axon
• Develops: most distal part of axon then proximal
o IF abnormality persists - axon dies ‘backwards’
distal axonal degeneration S&S
Characteristic distal sensory loss + weakness
What is myasthenia Gravis?
What may it be caused by?
• Autoimmune attack of ACh receptors at the NMJ
o signal can’t travel from nerve to muscle
• May be precipitated by stressful life events, viral infections,
pregnancy, autoimmune disorders, etc.
Myasthenia Gravis Effects:
o progressive muscle weakness
- Dec cardiorespiratory function
- atrophy
- fatigue
Myasthenia Gravis Rx
Medication: prevent ACh breakdown @ NMJ - remaining receptors will eventually activate, or plasmapheresis
PT
- Activity within tolerance
- Prevent 2° conditions
What is Charcot Marie tooth disease
Hereditary condition of PNS
What is the result of Charcot Marie tooth disease
Extensive demylination of motor & sensory nerves of the hands and feet
Charcot Marie tooth disease S&S
o Distal, symmetric muscle weakness - slow progression
Foot intrinsic atrophy
Dec. DF, EVER mm
o Dec. deep tendon reflexes
o Pes cavus (high arch, doesn’t flatten with weight bearing)
Problems controlling gait and balance with lack of sensory info from foot
o Hammer toes
o Lose wrist/finger extension (radial/ulnar nerve)
Charcot Marie tooth disease Rx
o No treatment to change disease course
o Contracture management: stretching, splinting, exercise, IMS, etc.
o Foot care education (prevent damage to skin, joint, muscle, connective tissues)
o Identify & retrain muscle imbalance
What is Bell’s Palsy?
What is it caused by?
Facial nerve palsy
Cause by latent herpes virus - Virus causes inflammatory response over facial nerve
Bell’s Palsy S&S
Unilateral facial paralysis
Weakness in muscles of facial expression
Inability to close one eye, wink, or whistle
Drooping of mouth
Tears, salivation
Bell’s Palsy Rx
- corticosteroids, e-stim?, protect eye (patch + eyedrops) until eye closure possible, massage (treat compensatory changes), PROM/AROM of facial muscles (eg. raise eyebrows, wrinkle forehead, flare nostrils, smile, practice vowel sounds, etc.)
- most recover spontaneously
What may cause TOS
Chronic compression - edema + ischemia of nerve roots - neuropraxia + Wallerian deg
ROS Risk Factors
Posture
Growth
Trauma
Body comp
TOS S&S
- Paresthesia
- UE weakness + pain, hand fatigue
- Neck pain: may radiate into face, scapula, ant chest
- Raynaud’s disease ( Dec. UE artery size) + venous compromise, coldness
- Edema
TOS Rx
Correct posture; surgery (if vasculature gets compromised)
What is Diabetic Neuropathy
Peripheral nerve disorder in diabetes - occurs w/o any other neuropathy cause
Diabetic Neuropathy Pathology
Chronic metabolic disturbance - affects nerves + schwann cells
- Results in a loss of both myelinated and unmyelinated axons
Diabetic Neuropathy S&S
- Symmetric + distal sensory loss pattern
- Painless paresthesia
- Minimal motor weakness
Diabetic Neuropathy Rx
- Control hyperglycemia
- Skin care
- Amputation
Neural Tissue dysfuntion/neurodynamic dysfunction S&S
- history of inc speed/repetition of sport or work
- pain distribution does not match myotome/dermatome
- stretching does not feel good
- aggravated in neural tension positions
- Does not describe/point to pain area well
- recurrent injury that does not change w/ rehab
What is a Keloid scar
- thick scar (hyperproliferation)
- extends beyond margins of original wound
What is a Hypertrophic scar
- Thick scar
- Does not extend beyond boundary of original wound but has excess tissue amount than what is needed to replaced damaged dermis (contraction phase did not occur)
