W3 Lower limb Neurological & Neurodynamic Assessment Flashcards
1
Q
Tests nerve conduction (Neurological Examination) 3 steps
A
- Observation – Antalgic postures,
muscle wasting - Neurological examination LMNL
–reflexes, myotomes,
dermatomes - UMNL-Babinski and clonus
2
Q
Tests nerve movement (Neurodynamic Examination)
A
- Nerve palpation
- Neurodynamic testing: amount of neural
tissue movement and it’s response to
movement.
3
Q
Indications for Lower Limb Neurological Examination Lower Motor Neuron (Spinal nerve/Nerve root)
A
- Spinal pain extending beyond hip/buttock
- Pins and needles and/or numbness in leg
- Weakness/clumsiness in leg
4
Q
Aims of Neurological Examination
A
confirm findings
establish baseline
* Clarify whether peripheral signs and symptoms are due to localproblem or indicative of spinal nerve root involvement
diffiriniate from CNS and PNS
* Identify contraindications and precautions to treatment
5
Q
Indications for Lower Limb Neurological Examination Upper Motor Neuron (CNS)
A
- Bilateral symptoms in a diffuse non-dermatomal distribution
- Disturbances of gait, balance, co-ordination
- Disturbances of bladder/ bowel function
- Saddle anaesthesia
- Bilateral sciatica
- Severe or progressive bilateral neurological
deficit of the legs
6
Q
Lower Limb Neurological Testing
A
- Myotome testing (muscle power)
- Lower limb reflexes
- Dermatome testing (sensation)
- Tests for Cord/CNS
- Babinski
- Clonus
7
Q
Mechanical Function of the nervous system
A
- Move and withstand forces that
are generated by daily
movements. - Nerve must:
- Slide in its container
- Be compressible
- Withstand tension
- continue conduction!
8
Q
Neural system anatomy
A
Mechanical interface (nerve bed)
Innervated tissue
9
Q
Pain from injury to the nervous system
A
Neuropathic pain
* Repetitive mechanical forces:
– Compression – Tensile – Friction – Vibration
And– Ischemia (i.e. Compression) – Inflammation
Mechanosensitivity – pain provoked by mechanical stimuli (i.e. Movement,
postures, palpation)
10
Q
Aims of Neurodynamic Assessment
A
- Identify if patient symptoms are reproduced via palpation or movement of the nervous system
- Identify which nerve path is reproducing the patient’s symptoms
- Identify a baseline for assessing progres
- Identify contraindications and precautions to treatment
11
Q
5 testing guidelines for Neurodynamic assessment
A
ALWAYS do Neurological first!!
Five testing guidelines (plus clinical signs and
symptoms):
1. Area of symptoms
2. Quality of pain
3. Behaviour
4. Mechanism/past history
5. Physical examination findings
12
Q
Area of symptoms:
A
- Neuro-anatomically logical
- Pain may be in lines or clumps
- At vulnerable sites
13
Q
Quality of pain:
A
- Burning, lancinating, shooting, cramping
- Superficial or deep depending on nerve/area involved
- Other symptoms may be present:
– Sensory loss: paraesthesia (pins and needles), anaesthesia (numbness)
– Dysaesthesia (unpleasant sensations – crawling)
– Hyperalgesia vs. allodynia
14
Q
Behaviour
A
- Conventional (mechanical) or unconventional
- Provoked or spontaneous
- Latency (e.g. whiplash)
15
Q
Mechanism/past history
A
- Understand the causative event
- History – MSK injury or event related to onset of symptoms (traumatic or insidious).
- Differentiate from non-MSK (i.e. Red flags, diabetes, tumour, post herpetic infections)
16
Q
Physical examination findings
A
- Antalgic postures (tension relieving positions
Active and passive movements - Palpation
17
Q
contraindications to nerve root testing
A
- Acute nerve root injury
- Recent onset of neurological signs or worsening neurological signs
- Cord and Cauda equina symptoms eg
- Bilateral symptoms/difficult/loss of coordination with gait
- Numbness/loss of sensation in saddle area (perineum)
- Bladder retention.
- Tethered cord syndrome (Tethered peripheral nerves)
- Severe pain in which examination too intrusive and provoke symptoms unnecessarily
- Severe headache
- Dizziness or nausea
- Presence of obvious serious pathology eg cancer
18
Q
Level 2 = Standard examination
A
- Use of the standard tests
- Performed to a comfortable production of symptoms
- Not necessary to take to end of range if not needed, but is permissible if clinically appropriate
- End position held for a matter of seconds
-Structural differentiation - “on” direction
19
Q
Precautions
A
- Irritable conditions - possibility of latent response
- Central sensitivity: excessive handling and repeated movements may lead to long lasting aggravation.
- Pathology present in nervous system i.e. severe disc bulge
- Acute states where disc trauma or compartment syndrome suggests that nerve irritation or compression could occur
- Altered pathology of other structures along neural pathway e.g. Osteoporosis
- Neurological signs
- Care with disorders such as diabetes, RA, Guillian Barre
- Altered vascular conditions
20
Q
Nerve palpation
A
- Nerves feel harder than tendons, usually rounded and have a slippery feel.
- Palpation should be performed gently
- Palpate with the tip of your finger or thumb.
21
Q
Neurodynamic assessment
A
- Use multi-joint movements of the limbs and/or
trunk to alter the length and dimensions of the
nerve bed (interface) surrounding the neural
structures of interest - Allows for assessment of the sliding and
elongating abilities of the neural structure plus the
ability of the nervous system to cater to changes
in the interfacing structures. - Designed to detect abnormal mechanical
(mechanosensitivity) and physiological responses
22
Q
Joint opening and closing:
A
- Closing mechanisms –increase pressure on neural structures by way of reducing the space around it.
- Opening mechanisms – relieve pressure on a neural structure by way of increasing the space around it.
23
Q
- Sensitising movements
A
- increase forces in the neural structures in addition to movements normally used in the test.
24
Q
Differentiating movements
A
- Differentiation between neural and non-neural (MSK)structures.
- E.g. Use a movement remote from the area of symptoms that moves the nervous system but not the musculoskeletal
system
25
Movement Order
The strain and movement of the nervous system will be affected by the order in which the movement is taken up.
26
acute injuries characteristics
* Single, identifiable traumatic event
* Forces applied are greater than tissue can
withstand = tissue failure
* Macroscopic damage
* Rapid onset of pain and loss of function
* Extrinsic (e.g. collision) or Intrinsic (rapid/forceful
contraction) or both
* Modifiable and/or non-modifiable
27
acute injuries Risk Factors modified
* Previous loading history & subsequent tissue adaptation
* Presence & degree of underlying microscopic tissue damage
* History of previous acute injury and extent of mechanical strength recovery
28
acute injuries Risk Factors non modified
* Unpredictable nature of some sports & work environments (e.g. contact sport)
* Rules (e.g. high-tackles → rule changes)
* ‘Open’ environment (e.g. outdoor sports/work & weather conditions)
* Individual anatomy
* Previous injury
29
healing times for exercise muscle soreness
0-3 days
30
healing times for muscle strain
g1- 0-2 weeks
g2- 4d-3mo
g3- 5wk- 1 yr
31
healing times for ligament sprain
g1- 0-3d
g2- 3wk-6mo
g3- 5wk-6mo
32
healing times for tendinitis
3wk-7wk
33
healing times for tendinosis
3mo-6mo
34
healing times for tendon laceration
5wk-6mo
35
healing times for bone
5wk-3mo
36
healing times for articular cartliage repair
2mo-2ys
37
healing times for ligament graft
2mo-2yrs
38
treatment planning depends on
impairments, treatment aims, functional limitations, participants restrictions, stage of injury
39
Acute phase 0-72 hours
inflammation, prolieferation, maturation
When soft tissues injured,
* blood vessels damaged also
* accumulation of blood
* compressing adjacent tissues
* secondary hypoxic injury & further tissue damage
Important to reduce/control bleeding at injury site
40
Acute phase 0-72 hours
Treatment aims:
* Minimise extent of initial damage
* Reduce associated pain & inflammation
* Promote healing of damaged tissue
while
* Maintaining flexibility, strength, proprioception
in unaffected areas and maintain overall
fitness
41
Protection and Optimal Loading is and aims
* Brief immobilisation to prevent excessive distention at injury site → reduce size of haematoma → minimise size of scar
42
(Optimal) Load
* In comparison to immobilisation
early loading demonstrates
range of beneficial effects on:
* Strength
* Morphology
* Function
* Tissue regeneration
43
Protection and Optimal loading- orthopaedic
braces
* Designed to increase passive support/restraint
* Limit range of motion
* Reduce loading
44
Protection and Optimal loading- ankle braces
* Anti-pronation brace /taping i.e. ↓Tib post &
Tib Ant activity
Reduces plantarflexion excursion during walking
Reduction of ankle sprain by 69% (Dizon 2010) among those with
previous ankle injury
*Similar in effect of taping (71
45
Protection and Optimal loading - Tape
* Pain reduction
- Plantar fasciitis
-Patellofemoral pain
-Patella fat pad
-Lateral ankle sprains
* Reduction of strain on injured tissue
* Compression for oedema
* Increased passive stability
* Injury or re-injury prevention
46
Ice (Cryotherapy)
Thought to decrease oedema formation via induced vasoconstriction and reduce secondary hypoxic damage.
* Analgesic effect thus facilitating earlier therapeutic exercise.
47
Compression
* Increase pressure gradients in venous and lymphatic systems
* Can combine with ice
* Conflicting evidence
48
Elevation
* Elevation above level of heart results → decrease in hydrostatic pressure → reduces accumulation of interstitial fluid
49
Acute phase 0-72 hours
Avoid:
* Heat
* Alcohol
* Running/exercise
* Massage
* Anti-inflammatories?
50
Acute phase 0-72 hours
Educate
* (Limited role of) passive modalities
* Electrotherapy
* Acupuncture
* Manual therapy
* Condition and load management
* Realistic goal setting
51
Day 2 – 6 weeks (sub acute)
Treatment aims:
Continue to:
* Minimise extent of initial damage
* Reduce associated pain & inflammation
* Promote healing of damaged tissue
AND
* Maintain or restore flexibility, strength,
proprioception, overall fitness
* Functionally rehabilitate
* Assess & correct any predisposing factors to
reduce recurrence
52
To address flexibility:
*Massage to address:
*Address any neural tension
➢Neurodynamic exercises
* Gentle stretching (painfree!)
*Continuous passive motion
*Passive mobilisation
*Passive exercises
*Active-assisted
exercises
*Active exercises
53
Flexibility & ROM
* Following an injury, musculotendinous flexibility is decreased due to spasm of surrounding muscles
* Additionally, inflammation + pain limits ROM & normal extensibility cannot be maintained
* Also affects adjacent joints!!
54
Muscle activation
* After injury, there is rapid atrophy due to cellular response to pain, inflammation & immobilisation
* Joint effusion will lead to reflex inhibition of surrounding muscles
* Muscle exhibits reduced strength & endurance
* Injury often associated with abnormal motor patterning
* Stability important
55
Open Chain +ves
Reduced joint compression
Can exercise NWB positions
Usually through increased ROM
Can isolate individual muscles
56
Open Chain -ves
Increased joint translation
Decreased functionality
57
Closed Chain +ves
Decreased joint translation
Increased functionality
WB stimulus for local muscles
58
Closed Chain -ves
Increased joint compression
Not able to move through ROM
Not able to isolate muscles
59
days 2 – 6 weeks (sub acute)
Neuromuscular control
* Nerve endings & nerve pathways damaged with injury → impairs segmental transmission of nerve impulse in reflex action
* Leads to impaired balance, coordination, joint position sense, reaction time
* Begins with weight bearing!
60
tape Biomechanical correction
* Patella taping produces medial translation of patella
* Anti-pronation tape increases MLA height, navicular height, reduces calcaneal
eversion & tibial internal rotation
61
tape Muscle inhibition
* Vastus lateralis inhibition with cross fibre taping
* Inconclusive whether patella taping inhibits VL
62
tape muscle facilitation
* Increased knee extensor moment with PF taping
63
Days 2 – 6 weeks (sub acute)
Cardiovascular fitness
* If unable to weight bear to maintain CV fitness
consider:
* Cycling
* Hydrotherapy
* Upper body work (boxing)
* Cross-trainer/elliptical machines great for reduced load
64
When to Refer?
* Suspect a grade III ligament injury
* Combination Injuries e.g. ACL/MCL/medial meniscus
* Mechanically locked knee
* Suspected unstable meniscal tear
* Patient not progressing as expected
* If something doesn’t add up
65
When to X-ray?
To include/exclude a fracture
66
Ottawa Knee Rules
older than 55y/o
inability to immediatly and in ED (4steps)
isolated tenderness of the patella
tenderness at head of fibula
inability to flex to 90 degrees
(2 or more)
67
Ligament Injury – Immediate management ACL
* May need crutches to assist with normal gait until adequate quads strength regained
* POLICE/ROM exercises
* Isometric quads and hamstrings (co-contractions) to minimise inhibition
- bracing if other structures involved hw not normally required
68
Ligament Injury – Immediate management PCL
* Jack/Rebound brace may counteract posterior sag
* POLICE/ROM exercises
* Isometric activation of quads
* No isolated hamstrings activation as pull on tibia
posteriorly
69
Ligament Injury – Immediate management MCL/LCL
* May need crutches to assist with normal gait
* Bracing: vital if laxity >to stop valgus movement
and allow scarring to occur in shortened position.
* Extension ROM: limited to 30 deg (0-4 weeks)
* POLICE/ROM
* Isometric activation of quads and hamstrings to minimise inhibition
* Hamstring rehab important for LCL/PLC to provide posterior pull on fibula
70
Large Meniscal Tear - Immediate Management
* POLICE
* Gentle ROM /Avoid full extension
* Avoid torsional and weight bearing activities
71
Injury Specific Management
Acute Patellofemoral Lateral Dislocation
* Reduced by patient actively straightening knee (MUST XRAY POST REDUCTION)
* Immobilisation in brace between 2 and 6 weeks → ROM 0-60° first 3 weeks, 0-90° next 3 weeks.
* VMO focused rehabilitation
* General thigh muscle strengthening
* Core and gluteal muscle control and strengthening
* Proprioceptive based exercise
* Return to sport +/- bracing/taping
72
Operative Rx When/Why?
* Conservative management unsuccessful
* More severe injury or pathology e.g.
– Large intramuscular haematoma(s)
– Complete 3rd degree strain/tear
– Second degree strain if > ½ muscle belly torn
* Function/Occupation
73
Explain the difference between the Neurological Examination and Neurodynamic Tests
Neurological examination tests nerve conduction including both Lower Motor Neuron Lesions (LMNL) and Upper Motor Neuron Lesions; whereas Neurodynamic Tests assess nerve movement and response to movement
74
Explain each of the grades of mobilisation
Grade I: small amplitude movement at beginning of the available range
Grade II: large amplitude movement within a resistance-free part of available range
Grade III: large amplitude movement performed into resistance or up to the limit of available range
Grade IV: small amplitude movement performed into resistance or up to limit of available range
Grade V: small amplitude movement at end of available range
