W6: Neurodynamics & Neural Mobilisation Techniques Flashcards
How can we assess the peripheral nerves?
Dermatomes (sensation)
Myotomes (movement)
Tendon Reflex
Neurodynamic tests
What is a dermatome
An area of skin that is mainly supplied by a single spinal nerve
What vertebrae is the exception for dermatomes?
C1
How many cervical, thoracic, lumbar and sacral nerves are there?
8 cervical nerves
12 thoracic nerves
5 lumbar nerves
5 sacral nerves
1 coccygeal nerve
What is a myotome?
A group of muscles served by a spinal nerve root
What does the C2 myotome involve?
Cervical Flexion
* Look at your shoe
What does the C3 myotome involve?
Cervical lateral flexion
*A fallen tree
What does the C4 myotome involve?
Shoulder elevation
*I am not sure
What does the C5
myotome involve?
Shoulder abduction
*Arms out wide
What does the C7 myotome involve?
Wrist flex/Elbow ext
*No zombies in heaven
What does the C6 myotome involve?
Wrist ext/elbow flex
*Smell your wrist
What does the C8 myotome involve?
Thumb ext/ulnar dev
*You’re doing great
What does the T1 myotome involve?
Finger abduction
*One and done
What are the lower-limb myotomes?
L1/L2 (lift your shoe): hip flexion
L3 (Extend your knee): knee ext
L4 (Stop the door): dorsiflexion
L5 (toes divide): Great toe ext
S1 (lift a tonne): Ankle PF/hip ext
S2 (heel to bum): Knee flex
S3/S4: Rectal tone
What is a myotome?
A muscle served by a spinal nerve root
Main peripheral nerves in upper extremity?
- Brachial plexus (above clavicle)
- Axillary nerve (near head of humerus)
- Musculocutaneous nerve (upper arm - bicep)
- Median nerve
- Radial nerve (on thumb side of forearm)
- Ulnar nerve (on pinkie side
Peripheral nerves of the lower limb (anterior)
Femoral nerve (thigh)
Obturator nerve (upper thigh)
Common/superficial peroneal nerve (shin)
- Saphenous nerve (shin)
- Sural nerve (foot)
Peripheral nerves of the lower limb (posterior)
Sciatic nerve
Tibial nerve
Common peroneal nerve (wraps around knee)
Sural nerve
Radiculopathy: Sensory, strength and reflex characteristics?
Sensory: dermatomal pattern sensory loss or irritative sign
Strength: Weakness in the muscles innervated by this nerve root
Reflex: changes related to specific nerve roots
Peripheral nerve: sensory, strength and reflex characteristics?
Sensory: symptoms in nerve distribution areas.
Strength: Muscle weakness in muscles innervated by a particular peripheral nerve eg weakness in muscles innervated by the median nerve (weakness in wrist flexion)
Reflex: changes related to the nerve (not the nerve root)
What tests are used to diagnose neuropathic conditions in the upper limb?
Upper limb tension test eg for cervical radiculopathy, carpal tunnel, cubital tunnel
What is a neurodynamic test? What was the prior perspective?
- Assessment and treatment of the physical nervous system
- Series of movements that place consecutive load on the nervous system
Previous view
- Physical tests were a reflection of the flexibility/tightness of nerves
- Clinically, we therefore sought to increase their length and mobility through ‘nerve stretching’ or ‘mobilising’ techniques.
- This is a simplistic (and incorrect) view
Contemporary studies show that neurodynamic tests examine:
- Tension
- Sliding of nerves within tissues
- Intraneural blood flow
- Mechano-sensitivity
- Compression
Note: the term neurodynamic tests replaced tension tests
For the straight leg raise what nerve trunk is involved?
L4-S3
What movement is involved in the straight leg raise
- Hip flexion (maintain knee ext)
- DF ankle
- Hip adduction/IR
- Cervical flexion
- Trunk lateral flexion
What movement will bias the tibial nerve in a straight leg raise?
- Preposition in dorsiflexion + eversion + pronation
What movement will bias the sural nerve in a straight leg raise?
Dorsiflexion + inversion
What movement will bias the peroneal nerve in a straight leg raise?
Plantarflexion and inversion
What nerve trunk is involved in the slump test?
L4-S3
What nerve trunk is involved in the prone knee bend and slump knee bend?
L2-L4
Explain the slump knee bend and how its different to the prone knee bend?
Cervical & thoracic spine is flexed. The top leg is passively brought into full hip ext and then knee flexion is added (femoral) nerve). Hip is brought into abduction (obturator nerve) and then dropped into adduction (lateral femoral cutaneous nerve
The upper limb tension test 1 for the median nerve involves what nerve trunk and what movements?
Nerve trunk C6-T1
Movements:
- Shoulder girdle fixation
- Shoulder abduction (90 deg)/ER
- Wrist ext
- Forearm supination
- Elbow extension
- Differential: cervical lateral flexion
The upper limb tension test 2a for the median nerve involves what movement and nerve trunk? When would this be used?
Nerve trunk: C6-T1
Movements:
- Shoulder girdle depression
- Elbow ext
- Shoulder ER & forearm supination
- Wrist and finger ext
- Shoulder abd
- Differential: release shoulder girdle depression
Useful for shoulder instability/adhesive capsulitis
The upper limb tension test 2b for the radial nerve involves what movements and what nerve trunk?
Nerve trunk: C5-T1
- Shoulder girdle depression
- Elbow extension
- Shoulder internal rotation & forearm pronation
- Wrist and finger flexion
- Shoulder abduction
- Differential: release shoulder girdle depression
The upper limb tension test 3 for the ulnar nerve involves what movements and what nerve trunk?
Nerve trunk: C8-T1
- Wrist and finger extension (start high 5)
- Forearm pronation
- Elbow flexion
- Shoulder external rotation
- Shoulder girdle depression –
- Shoulder abduction
- E.g. differential: cervical spine lateral flexion
What is structural differentiation?
- Allows us to differentiate between neural and non-neural structures
- If change in symptoms is based on a differentiating maneuvre – symptoms are neurogenic
What is an abnormal test ie positive?
- Reproduction of patient’s symptoms (MUST)
- Structural differentiation gives a neural result (MUST)
- Range of motion may be reduced
What is not an abnormal/positive test?
- Not relevant (often the case!) – sensitive tests
- Contralateral testing: symmetrical response eg. bilateral tightness - normally tight for that person and is symmetrical
- Does not reproduce ’patients symptoms’ = KEY
- The minimal evidence available prevents any ….. statements about the diagnostic accuracy of ULNTs
Definitive
- Evidence shows that, when using a liberal definition of a positive test, ULNT (…..), but not ULNT(…..), can help determine whether a patient has cervical radiculopathy.
- When using similar criteria, ULNT(……) does not help diagnose carpal tunnel syndrome
Median
Radial
MEDIAN
What are two treatments for neurodynamic conditions?
Sliders & tensioners
What is a slider?
- Sliders aim to induce sliding of the peripheral nerves in relation to their surrounding structures with a minimal increase in nerve strain.
What is a tensioner?
- Aim to increase nerve strain by simultaneously elongating the nerve bed at multiple joints
What is the staging technique ie the intensity increase in neurodynamic treatment?
Protect –> Slider –> Tensioners
What are two common entrapment sites of the ulnar nerve?
- Entrapment may occur between the medial epicondyle and olecranon under the cubital retinaculum (Cubital tunnel syndrome)
- Entrapment may occur in the ulnar tunnel roofed by the palmar capal ligament (ulnar tunnel or Guyon canal syndrome)
In an ulnar nerve entrapment what is preserved?
Normal sensation in the radial half of the ring finger is sparred
What are other assessment tools that can be used for radiculopathy?
Palpation
Imaging
Nerve conduction studies (how fast electrical signal impulses move through your nerve)
Will is a 49-year-old accountant and keen golfer, presents with a dull ache down the right posterior thigh and right lateral ankle pain.
He has had back pain on and off for the past 10 years and reported that he sprained his right ankle 2 months ago playing soccer. He resumed soccer last week but said that the right shin and ankle feels a bit sore afterward.
What tests you would perform to aid your diagnosis?
Palpation of lumbar spine
Central and unilateral PAVIMs
Combined movements eg extension/lateral flexion/rotation
Slump test, SLR, strength test
Related dermatomes/myotomes
Nerve palpation, neurodynamic assessment – tibial positioning.
What is the easiest way to self mobilise the sural nerve?
Foot in DF/Inversion (neck flexion provides a more aggressive movement - tensioner & neck extension allows a less aggressive and distracted large range movement ie a slider)
