Week 3 Flashcards
neurological assessment
how the nerve is conducting
- observing
- muscle strength testing
- reflexes
neurodynamic assessment
- how the nerve is moving
Indications for Lower Limb Neurological Examination - LMN
- spinal pain extending beyond hip/buttock
- pins and needles and/or numbness in leg
- weakness/clumsiness in leg
Indications for Lower Limb Neurological Examination - UMN
○ Bilateral symptoms in a diffuse non-dermatomal distribution
- Disturbances of gait, balance, co-ordination
Indications for Lower Limb Neurological Examination: If cauda equina was involved
○ Disturbances of bladder/ bowel function
○ Saddle anaesthesia
§ Loss of sensation between the leg
○ Bilateral sciatica
Severe or progressive bilateral neurological deficit of the legs
Lower limb neurological testing
- Myotome testing (muscle power)
- Lower limb reflexes
- Dermatome testing (sensation)
- Tests for Cord/CNS
○ Babinski
Clonus
Mechanical function of the nervous system
- Move and withstand forces that are generated by daily movements
- Nerve must:
○ Slide in its container
○ Be compressible
○ Withstand tension
Continue conduction
- Nerve must:
Neuropathic pain
Repetitive mechanical forces:
○ Compression
○ Tensile
○ Friction
○ Vibration
And
- Ischemia (i.e compression)
- Inflammation (i.e. inflammatory mediators/inflammatory substances from adjacent tissues)
Indications for Neurodynamic assessment - Five testing guidelines (plus clinical signs and symptoms)
- Area of symptoms
- Quality of pain
- Behaviour
- Mechanism/past history
- Physical examination findings
Area of symptoms
- Neuro-anatomically logical
- Pain may be in lines or clumps
- At vulnerable sites
Quality of pain
- 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)
○ Dysesthesia (unpleasant sensations - crawling)
Hyperalgesia vs. allodynia
Behaviour
- Conventional (mechanical) or unconventional
- Provoked or spontaneous (“mind of its own”)
- Latency (e.g. whiplash)
Mechanism/past history
- Understand the causative event (sometimes straightforward, other times not)
- 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)
Physical examination findings
- Antalgic postures (tension relieving positions – protective to reduce mechanical load on sensitised nerve tissue by shortening anatomical distance nerve trunk travels) e.g. standing with hip/knee flexed
- Active and passive movements, i.e. symptoms with movements that:
○ Move and/or
○ Elongate and/or
○ Compress the NS in that body part
Palpation If - mechanosensitivity is present then patient may report array of symptoms to nerve palpation (tingling, numbness, dull ache) and you may notice protective response.
- Active and passive movements, i.e. symptoms with movements that:
Contraindications
- acute nerve root injury
- Recent onset of neurological signs or worsening neurological signs
- Cord and Cauda equina symptoms (medical referral required)
○ Bilateral symptoms/difficult/loss of coordination with gait
○ Numbness/loss of sensation in saddle area (perineum)
○ Bladder retention. - Upper motor neuron signs (medical referral required)
○ Babinski and clonus - 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 e.g. Cancer
- Cord and Cauda equina symptoms (medical referral required)
Joint opening and closing:
- Closing mechanisms –increase pressure on neural structures by way of reducing the space around it. e.g. Spinal ext/LF closes IV foramen
- Opening mechanisms – relieve pressure on a neural structure by way of increasing the space around it.
Sensitising movements
○ increase forces in the neural structures in addition to movements normally used in the test.
e.g. Contralateral LF of the spine, hip IR and/or adduction
Differentiating movements
○ 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
○ Pain in lateral ankle- differentiation of peroneal nerve pain from ligament/muscle-add passive neck flexion
A positive response - neurodynamic test
- reproduction of patients symptoms
- altered sensation through range
- decrease range of motion
- symptoms can be altered by body part remote from local area or increased response with addition of sensitising manoeuvres
modifiable risk factors for acute injuries
- Previous loading history & subsequent tissue adaptation
- Presence & degree of underlying microscopic tissue damage
- History of previous acute injury and extent of mechanical strength recovery
non-modifiable risk factors for acute injuries
- 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 – preventable?
intervention options
- advice and education
- therapeutic exercise
- manual therapy
- physical devices
- electrophysical agents
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
- P.O.L.I.C.E
P.O.L.I.C.E
protection, optimal loading, ice, compression, elevation
acute management
First 24hrs critical period
When soft tissues injured
- Blood vessels damaged also
- Accumulation of blood
- Compressing adjacent tissues
- Secondary hypoxic injury and further tissue damage
○ Hypoxic: body tissues not receiving enough oxygen
Important to reduce/control bleeding at injury site
subacute phase
2-6 weeks
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
To address flexibility:
- Massage to address:
➢adhesions
➢TPs
➢Overall tightness
➢Swelling/oedema resolution- Address any neural tension
➢Neurodynamic exercises - gentle stretching
- hold minimum 15 seconds
- Address any neural tension
types of exercise for muscle strength/endurance
- isometric
- isotonic (concentric and eccentric)
- close chain/open chain
open chain advantages and disadvantages
advantages: reduced joint compression, can exercise NWB positons, usually though increased ROM, can isolate individual muscles
disadvantages: increased joint translation, decreased functionality
closed chain advantages and disadvantages
advantages: decreased joint translation, increased functionality, WB stimulus for local muscles
disadvantages: increased joint compression, not able to move through ROM, not able to isolate muscles
tape
biomechanical correction, muscle inhibition, muscle facilitation, enhancement of proprioception
if unable to weightbear to main CV fitness consider:
○ Cycling
○ Hydrotherapy
○ Upper body work (boxing)
- Cross trainer/elliptical machines great for reduced load
Ligament injury - immediate management - ACL
- May need crutches to assist with normal gait until adequate quads strength regained
- Bracing not usually required unless other associated ligament injury present
- POLICE/ROM exercises
Isometric quads and hamstrings (co-contractions) to minimise inhibition
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
Ligament injury - immediate management - MCL/LCL
- May need crutches to assist with normal gait
- Bracing: vital if laxity >grade II 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
Large meniscal tear - immediate management
○ P.O.L.I.C.E
○ Gentle ROM/avoid full extension
○ Avoid torsional and weight bearing activities
Acute patellofemoral lateral dislocation - injury management
- 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
sciatic nerve palpation
Indirectmpalpation at buttocks
peroneal nerve palpation
in popliteal fossa, at head of fibula, dorsum of foot: superficial peroneal nerve, deep peroneal nerve
sural nerve palpation
at achillies tendon
inferior to lateral malleoli
femoral nerve palpation
4cm distal to inguinal ligament
Spinal Nerve/Nerve Root (Lower Motor Neuron Lesion/LMNL)
- Spinal pain extending beyond hip/buttock or shoulder.
- Paraesthesia and/or anaesthesia in the limb.
- Weakness and/or clumsiness using the limb.
- Symptoms in the limb thought to be spinal in origin.
Central nervous system (Upper Motor Neuron Lesion/UMNL)
- Bilateral symptoms in arms or legs in a diffuse non-dermatomal distribution.
- Disturbances of gait, balance or co-ordination
- Disturbances (retention or incontinence) of bladder or bowel function (requires urgent medical referral)
- Saddle anaesthesia (requires urgent medical referral)
myotome (L1) L2
iliopsoas - hip flexion
L3 - myotome
quadriceps - knee extension
L4 - myotome
tibalis anterior - dorsiflexion
L5 - myotome
extensor hallicus longus - extend big toe
(L5) S1- myotome
peroneaus longus - eversion
S1 (S2) - myotome
gstrocs, soleus
- single heel raise, repeat to test fatigability
S2 - mytome
long toe flexors
lower limb reflexes - L3,4
patella tendon
lower limb reflexes - S1 (S2)
achilles tendon
babinksi
- UML
- While gently holding the foot, stroke the outer surface of the sole with a blunt object starting at the heel and moving distally toward the base of the first metatarsal. A normal response if plantar flexion of the toes. The test is positive if the big toe and to a lesser extent the remaining toes dorsiflex. - for babies
clonus
Apply a sudden dorsiflexion movement to the patient’s ankle and maintain for a brief period noting the any reflex twitches/beats into plantarflexion. The test is considered positive if clonus is present (more than five reflex twitches) (Refshauge and Gass, 2004, p. 202)
SLR
tests the sciatic nerve
slump test
scatic nerve
prone knee bend
femoral nerve
femoral nerve slump test
femoral nerve
