Neurodynamic Mobility Flashcards
Types of Peripheral Nerve Conditions
- Neuripraxia
- Axontmesis
- Neurotmesis
Neuropraxia
- Transient episode which damages myelin sheath preserving the axon and connective tissue
- Numbness/tingling
- Rapid recovery of days to weeks
- “Entrapments”
- Ex: Carpal Tunnel (Occurs in transverse carpal ligament), Sciatica (Pressure due to muscle over sciatica; Piriformis), Ulnar entrapement at elbow (“Hitting funny bone”), Nerve roots existing out of spine (Radiuculopathy; lesion takes up space and leads to pressure; Most common disc buldge; Nerve root - dermatome; peripheral - peripheral nerve map)
Axonotmesis
- Injury more severe and involves the axon but preservation of the Schwan sheath
- Motor and sensory changes (weakness of muscles, decrease sensation)
- Recovery of several months
- Prolonged entrapments, crush or traction injury OR sustained exposure to inflammatory condition
- Ex: Direct blow (ulnar nerve most common due to being superficial)
- Ex: Common Fibular Nerve by fibular head
Neurotmesis
- Nerve and sheath are disrupted
- Motor and sensory loss
- Long term deficits
- Lacerations
What is “Adverse Neurodynamic Mobility”
- Impaired nerve function: Disrupted intraneural circulation or axoplasmic flow (aka: axonal transport) occurs when nerve is compressed, stretched or sheared beyond its tolerance
- Physiological changes (ex: intraneural edema and increase of sodium channel density) leads to nerve sensitization to tension (“increased mechanosensitivity”). This may explain “spread” of symptoms along the nerve (becomes the entire nerve irritated not just the one spot it was compressed)
- This leads to greater central response to nerve tension as well. Greater activation in brain pain centers (also explaining “spread” of symptoms)
- Nerve need to move along a pathway, going on stretch and shorten
- Nerves travel to muscle and are in close proximity to joints
- Ex: Median
Common Adverse Neurodynamic Mobility Conditions
- Spinal radiculopathy (inflammation or mechanical irritation of nerve root) – most common C5 or C6 and L4 or L5 nerve root
- Peripheral nerve injury (neuropraxia or Axonotmesis) – most common is ulnar N. or sciatic N.
Axoplasmic Flow
- Flow between cell body and terminal branches of the nerve
- Constant interchanging of mitochondria, lipids, synaptic vesicles and proteins
- Creates a sensitivity
- Disrupting this flow results in issues. Most commonly tension
- Doesn’t glide as it should
Classification of Pain Condition
Nociceptive Pain
* Reaction to afferent nerves to noxious chemical, mechanical or thermal stimuli
* Pain is proportionate to the mechanism and nature of the injury
Peripheral neuropathic
* Lesion or dysfunction in the peripheral N, dorsal root ganglia or dorsal root from trauma, compression, inflammation or ischemia.
* Proportionate or disproportionate to the mechanism or nature of injury
* Radicular or Radiating Pain
. Central (or peripheral) Sensitization
* Amplification of neural signaling within the central or peripheral nervous system that elicits pain hypersensitivity
* Pain is disproportionate to the mechanism or nature of the injury
Radiating pain should be referred to as
Peripheral Neuropathic Pain
Comes from the NERVE
Referral Pain is
pain coming from muscles, organs, etc.
Peripheral Neuropathic PAIN
- Describe pain as shooting, burning or electric type. (lacinating pain)
- May have associated numbness and tingling
- Usually have a history of nerve pathology or compromise (Trauma or sustained posture)
- Commonly describe symptoms in a cutaneous or dermatomal distribution.
Clinical Presentation of Neurodynamic Mobility Deficits - Subjective
- Chronic / persistent symptoms
- Pain is deep ache
- Pain distribution MAY BE anywhere along the peripheral nerve pathway (distal symptoms)
- Commonly unilateral
- Intermittent, aggravated with sustained postures
- Lying down (unloading of spine/nerve) relieves symptoms
- Absence of TRUE neurological symptoms (reflexes, weakness, sensory) - Neuropraxia
Clinical Presentation of Neurodynamic Mobility Deficits - Objective
- AROM of lumbar or cervical: Restricted motion and/or pain esp. with flexion motions or side bending away (tensioning nerve)
- AROM of peripheral joints: Variable dependent on tension of the nerve
- PROM: Variable depending on tension on nerve. Limitation of motion during selected neurodynamic test of the UE and LE (Positioning)
- Palpation: pain and /or muscle tension along path of nerve
- Special tests: Positive on neurodynamic testing
- Neuro: Usually negative neuro screen (reflexes, myotome, sensation) USUALLY except in more acute cases.
Neurodynamic Assessement for LE
- Slump Sitting Testing (More likely to be accurate)
- Straight Leg Raise
- Can compare the two tests to assess for irritability levels; No issues with SLR but symptoms with slump is less irritability)
- Put tension through the nerve and identify how sensitive the nerve is based on the tension we place.
- If the nerve is sensitive will see a decrease in ROM
- Most common: Sciatica (Cervical Flexion, Lumbar Flexion, Straight Leg and DF)
POSITIVE for Adverse Neurodynamic Mobility if:
* Reproduces symptoms
* >10° side to side difference
* Sensitized with cervical flexion or Decreased with cervical extension
Neurodynamic Assessment for UE
Median: Shoulder
Radial: ?
Ulnar: Elbow
POSITIVE for Adverse Neurodynamic Mobility if:
* Reproduces symptoms
* >10° side to side difference
* Sensitized with cervical SB AWAY
Intervention options for Neurodynamic Mobility Deficits
- Patient education
- Joint mobilization techniques of joints in proximity to the nerve
-
Soft tissue mobilization of muscles along nerve pathway
– Ex: Scalenes, Pec Minor, Biceps, medial or lateral forearm
– Increases axoplasmic flow and decrease sensitivity of the nerve. -
Neurodynamic mobilization techniques
– GLIDING/SLIDING Techniques (aka: flossing); No tension just movement
– TENSIONING Techniques
Patient Education on NMD
- Pain caused by sensitivity of nerve (no soft tissue damage)
- Be diligent of getting out of positions that irritate distal symptoms
- Nerves need MOVEMENT AND BLOOD FLOW to function. Find movement that is not irritating nerve
- Need to be patient!! Takes time for nerve to “heal”
Gliding Techniques
- Slides neural tissues and adjacent non-neural tissues
- Simultaneously moving a proximal & distal joint together in unison
- Performed in a non-provocative fashion
- Goal: Improve intraneural circulation and ↓ sensitivity
Tensioning Techniques
- Places tension on nerve and adjacent non-neural structures
- Taking up slack in one joint and oscillating other
- DO NOT HOLD STRETCH
- Goal: Increase nerve tolerance to tension/pressure (decrease mechanosensitivity)
Irritability and NMD Tx
High Irritability: Neurodynamic GLIDING TECHNIQUES
* Sx’s easily provoked
* Noticeable limitation with neurodynamic tests and may be associated with guarding
* Sensitization with palpation to light pressure along pathway of nerve
* Long time for symptoms to resolve once irritated
Moderate Irritability: Neurodynamic GLIDING to TENSIONING TECHNIQUES
* Sx’s not as easy to provoke
* Moderate limitation with neurodynamic tests
* 1:1 ratio of time to come on and time to alleviate
Low Irritability: Neurodynamic TENSIONING TECHNIQUES
* Sx’s minimal but may have periods of increased pain
* End range limitation with neurodynamic tests
* Able to alleviate immediately with change in position
Neurodynamic Mobilization UE
Neurodynamic Mobility LE in Supine
Neurodynamic Mobility LE in Sitting
