PNS tx Flashcards
demyelination/compression injuries
neurapraxia
degeneration injuries
axonotmesis, neurotmesis
paresthesia, dysesthesia, anasthesia
..
autonomic nerve dysfunction
anhidrosis
exercise intolerance
etc.
With neurapraxia GOAL of tx is to ____
alleviate compression
informed consent for working on area with nerve compression (neurapraxia)
communicate to pt, get consent — inform that working on area might reproduce SSx
when treating and pressing on an area w/ compression (E.g. pronator teres w/ median nerve)
—> If SSx are reproduced ….
when pt says they feel familiar symptoms, then remove pressure on area and wait to see if symptoms are relieved
If however pressure is removed and symptoms PERSIST, then STOP working on area.
If symptoms are relieved within a few seconds, then can still work on that area, perhaps more conservatively, and with patient renewed consent
HEAD OF FIB
watch out for COMMON FIB nerve here —> sensitive —-> EVEN WITHOUT INJURY
attachments on head of fib
soleus, biceps fem, fibularis longus
ATROPHIED MM — what not to do
ALREADY LOW TONE
avoid tehcniques that intend to lower tone even further —> esp deep techniques
DEGENERATION INJURY — touch affected nerve?
NO
some notes about demyelination
Demyelination:
Symptoms present distal to site of compression
Compression in one area makes compression elsewhere along the same nerve more likely
Following compression, the entire nerve can become a source of pain (as opposed to paresthesia)
unopposed antagonist tone leads to ____
contracture
some notes about degeneration
Degeneration:
Symptoms present distal to site of lesion
Unopposed antagonist tone and contracture formation
Sensory function generally returns before motor function
WHICH FUNCTION OF NERVE RETURNS FIRST GENERALLY?
SENSORY FIRST
Before motor function
WHAT is a better way to think about symptoms and reducing “
FREQUENCY vs INTENSITY
Compression in one area makes compression elsewhere along the same nerve more likely
think ulnar nerve dull zingy ache @ elbow (medial head Triceps)
and then followed by dull ache @ wrist (distal ulna)
GRADE 2 MMT
remove gravity –> E.g. side lying
or AAROM (active assisted)
peripheral neve injury acute phase
Acute Phase
Early after injury or surgery - emphasis on healing & preventing complications
May be immobilized - time dictated by MD
Splinting or bracing may be needed to prevent deformities
Recovery Phase
Recovery Phase
When reinnervation occurs - emphasis on retraining & re-education
Motor retraining - eg. being able to hold muscle in shortened position
Desensitization - eg. stroking the skin with different textures for sensory stimulation
Discriminative sensory re-education - identification of objects with, then without, visual cues (stereognosis)
Chronic Phase
When the potential for recovery has peaked and there are significant physical deficits - emphasis on Training compensatory function
May continue to wear splint or brace
CHRONIC PHASE
THE FUNCTION THAT ONE HAS IN CHRONIC PHASE IS GENERALLY WHAT THEY WILL KEEP MOVING FORWARD
PRECAUTION/CI FOR DEGENERATION INJURY / REGENERATING LESION (AXONOTMESIS/NEUROTMESIS)
Do not traction a regenerating nerve
Use segmental techniques proximal to the lesion
Consider “blocking” with the ulnar border of the hand just proximal to the lesion to prevent placing drag on the healing tissue
Do not work on lesion site until regeneration has passed that site – approx. 2 weeks post trauma or 3 weeks post surgery
Flaccid/low tone/unhealthy tissue
PROM can be used to affected joints in the direction that shortens the affected tissue & nerve
NTOE ABOUT ASSESSING REGENERATING NN
NOTE: Acute injuries and tissue that is still regenerating must be handled with extreme caution.
Contact the patient’s MD or Neurologist to confirm if movement assessment & treatment is safe.
note about PROM for regenerating nn injury
PROM
Can be used with a regenerating nerve to assess contracture of the unopposed antagonistic muscles only, as long as the motion does not traction or stretch the regenerating nerve
MEDIAN NERVE STRETCHED position
abd GH
(ER GH?)
extension HU
SUPINATE RU
ext wrist/digits
EXTRA (Sensitizing?)
—-> contralateral neck flexion
RADIAL NERVE STRETCHED position
add GH
(IR GH?)
extension HU
PRONATE RU
flex wrist/digits
EXTRA (Sensitizing?)
—-> contralateral neck flexion
ULNAR NERVE STRETCHED position
abd GH
slight ER GH?
FLEX HU
PRONATE RU
EXT WRIST/DIG
(HAND ON EAR)
MAKE SURE TO PEFORM NEER PROTOCOL
name
explain
—> explain protocol/consent
—> explain rationale
execute
—> unaffected first
—> then affected
record results (chart)
—> tell patient what result means
e.g. positive pronator teres test
tell patient what results means, then explain goals/rationale of treatment for area tested positive
importance of asymmetry for positive finding
affected side needs to be different from unaffected
—> If not different, then not positive
neurodynamic ax can be turned into ____
tx modality (?)
ULTT NORMAL FINDINGS
DEEP ACHE/stretch in CUBITAL FOSSA
deep ache/strech forearm/hand
tingling to fingers (IF SYMMETRICAL)
STRETCH IN SHOULDER
INCREASED WITH CONTRALATERAL CERVICAL FLEXION
POSITIVE (PATHOLOGICAL) FINDINGS (ULTT)
production pt
BEFORE DOING ULTT
PROMPT PT TO PERFORM EACH MVMT SEPARATELY
ULTT 1
median nerve
& C5-7
EVEN AFTER SEPARATE MVMT WHEN DOING ULTT
MVMTS DONE SEGMENTALLY
DONE ONE AT A TIME AND ASK FOR PT SSX
ULTT 1 start at
start @ GH
ABD, then ER
then supinate forearm
then extend wrist/fingers
THEN EXTEND ELBOW
SENSITIZING TEST
back off last movement (EXTEND ELBOW)
—-> STOP as soon as Symptoms dissipate
—> then get pt to bend CONTRALATERALLY @ cervical sp
WHY SENSITIZING TEST?
“The sensitizing test for an upper limb tension test (ULTT) is a cervical spine side flexion that increases the likelihood of reproducing a patient’s symptoms. The test is designed to differentiate between symptoms caused by the nervous system and other soft tissues.”
NEURODYNAMIC Ax —> NEURODYNAMIC Tx
NERVE FLOSSING
nerve flossing aka
nerve sliding / nerve gliding
during nerve flossing — want to keep the nerve @ SAME LENGTH
so shorten proximally while lengthening distally
or lengthen proximally while shortening distally
ULTT 1 —> nerve flossing of median nerve
similar protocol
ULTT 1
DEPRESS SHOULDER
SEOCND WAY TO FLOSS MEDIAN NERVE
FLEX ELBOW WHILE EXTENDING WRIST
EXTEND ELBOW WHILE FLEXING WRIST
shoulder elevation & NECK FLEXION
& shoulder depression & NECK EXTENSIO
a third way to floss median nerve / brach plex
other ways to floss
ANY TWO JOINTS IN CHAIN
WHERE TO FLOSS ALSO DEPENDS ON ____
where suspecting the compression/injury (?)
CIs for nerve flossing
Low MMT (3?)
atrophy
sensory loss
shoulder injury /dislocation
NERVE root injury (?)
what to do before after nerve flossing
WARM UP SURROUNDING TISSUE OF NERVE IN QUESTION
E.g.
medial triceps for ulnar nerve
PNS tx – TOS
..
Other than Erb’s & Klumpke’s every pathology in this class will be
neuropraxia injuries
Sprengel’s deformity & TOS
Lev scap is more like a fibrous band
—> elevated shoulder
Risk factor for TOS
nTOS
aTOS
vTOS
nTOS:
pain in neck, shoudler, est, u extrem
alterned sensation u extrem
—> esp ulnar nerve distrib
weakness in upperextremity, loss of coord
aTOS:
pain in hand
claudication
pallor
cold intolerance
vTOS:
cynaosis
heaviness
paresthesia
edema
nTOS more
common
if you have aTOS/vTOS you probably also have
nTOS
TOS health hx q
new activity
when/how begin
what times/patterns? (e.g. sleep posture)
TOS ax
palpation/ROM Ax
—> point tenderness? HT? fascial restrictions?
—> temperature change? edema?
E.g.
tight pecs/tight scalenes – esp unilateral
–> pec minor
–> protracted shoulder?
breathing Ax
postural Ax
special tests Scalene triangle
Scalene Triangle:
Adson’s test
Halstead’s test
Travell’s test
Scalene Cramp test
Costoclavicular Triangle:
Costoclavicular Syndrome test
Eden test
Subpectoral Space:
Wright’s manuever
Pec minor length test
ULTT 4
Froment’s Sign
Elevated Arm Stress Test (EAST)/Roos Test
Tx goals –
reduce compression
–> reduce HT affected mm
—> inrease lenght “
—> reduce fascial adh
–> mangae edema
–> teduce TrP
incrase/maintain ROM
support posture
manage pain fid
modalities
MFR
PROM
stretch
NMT
GSM
active tehcnique (Resisted isom e.g.)
nerve mobilizxation/gliding
–
CONSIDER:
positioning
pillowing
CIs:
hydro esp vascular ssx
standard CIs
homecare
stretch shortn mm
–> e.g. pec mj.mn, scalenes, scm
strenght weak mm
–> lowe rtrap, rhomb
hydro
neural mobl (???)
ADL modificaiton:
–> canes or hand/crutch
–> reduce overhead mvmt
–> support sleeping posture
–> reduce apical breathing
apical breathing
If apical breathing
Work on diaphragm and intercostals and diaphragmatic breathing
intertester reliability
everyone in group does same test and gets same reuslts
intratester reliability
same person, different times
how to make special tests more treiable
more special tests
less special tests less reliable
