Week 3- Principles of manual therapy: soft tissue Neural mobilisations

Question 1

How do we assess the nervous system? What are the 2 types?

Answer 1

1. Mechanosensitivity: “hyperactivity” “positive systems”
   - Questions: are the symptoms coming from the nerve itself? Pain, parenthesis, dysesthesia, spasm
   - assessments: neurodynamic tests, nerve palpation
2. Conduction: “hypoactivity” “Negative symptoms”
   - Questions: are the symptoms because of conduction loss within the nerve? Hypothesis or anaesthesia or weakness
   - Assessments: neurological exam, electro diagnostic testing

Question 2

What is the summary of nerve injury

Answer 2

Question 3

What is the summary of nerve injury

Answer 3

Question 4

What is the clinical presentation symptoms of peripheral neuropathic pain?

Answer 4

1. Connective tissues of the nerve ‘Nervi nerorum’ as the source (nerve trunk pain)
   - release of neuro peptides —> local inflammation —> nociceptive pain
   - familiar descriptions (eg. Aching, knifelike); constant (waxes and wanes) eg spinal root compression
2. Neural tissue as the source (dysaethetic pain)
   - generation of abnormal impulse generating sites (AIGS)
   - unfamiliar and bizarre descriptions (eg burning, crawling); variable and lancinating
   - may also cause muscle fasciculations and dysesthesia eg. Post hermetic neuralgia

Note:

• both types of pain are stimulus evoked via mechanical. Chemical or thermal stimulus
• pain distribution roughly follows sensory distribution eg der atom also for nerve root pain

Question 5

Examples of peripheral neuropathic pain symptoms

Answer 5

Question 6

What are neurodynamic (neural provocation) tests (NDT or NPT)?

Answer 6

Multi-joint movements that alter length and dimensions of the nerve bed?

• lower limb: SLR, slump test, side lying slump test, PKB
• upper limb: PNF, SLR, slump test, ULNPT 1, 2a, 2b, 3

Question 7

What constitutes a ‘positive’ NDT?

Answer 7

1. Reproduces patient’s symptoms or associated symptoms
2. Movement of a body segment remote from the location of symptoms alters the response (ie. sensitisation or structural differentiation)
3. Response is different between sides or compared to ‘normal’ (ie. sensation, range of motion or resistance) and can be altered with structural differentiation

NEED TO SATISFY ALL 3

Question 8

NEURODYNAMTIC TEST: What does a positive test tell you?

Answer 8

• whether mechanical hyperalgesia/ allodynia is a feature of the presentation
• assists differential diagnosis of non-neural conditions
• assists in determining irritability, prognosis and management

Question 9

NEURODYNAMIC TESTS: What does a positive test not tell you?

Answer 9

• where along the nerve bed the injury is
• you cannot use NDT to differentiate between peripheral nerve(s) and nerve root lesions, as both conditions could/ should test positive

Question 10

What can a physio do for peripheral neuropathic pain? What are the aims?

Answer 10

1> education in nuerodynamics and neurobiology

• why movements/ treatments change symptoms
• how nerve function and pain from connective tissues are affected by mechanical loading
• aim to reduce threat value of pain experience and alter unhelpful beliefs

2. Non-neural tissue impairments (address first)
   - targeting mechanical interface
   - joint mobilisations, STM, taping to unload sensitive neural structures or retraining neuromuscular control
3. Neural tissue impairments
   - target the nerve itself using neural mobilisation
   - restore tolerance of nerve to normal forces
   - mechanical, biological and psychological effects

Aim is to reduce pain and symptoms to restore function

Question 11

What is the clinical interface and Rx options for a L5 radicuopathy due to IVD protrusion?

Answer 11

Mechanical interface: IV foramen

Rx options: Rx McKenzie E, Rotations or LF away

Question 12

What is the clinical interface and Rx options of lumbar central canal stenosis?

Answer 12

Mechanical interface: central spinal canal

Rx options: lumbar flexions PPIVMs OR exercises (eg. Cat-camel, knees to chest, cycling)

Question 13

What is the clinical interface and Rx options of posterior interosseus nerve entrapment?

Answer 13

Mechanical interface: supination muscle

Rx options: STM, contract-relax, self stretches

Question 14

What is the clinical interface and Rx options of ‘Sciatica’?

Answer 14

Mechanical interface: piriformis muscle

Rx options: STM, contract-relax, self-stretches

Question 15

What is the clinical interface and Rx options of common perineal nerve entrapment?

Answer 15

Mechanical interface: superior tib-fib joint

Rx options: PAMs if hypo or taping if hyper

Question 16

What is the clinical interface and Rx options of thoracic outlet syndrome

Answer 16

Mechanical interface: depends on where the entrapment is eg interscalene triangle , costoclavicular , subcoracoid

It’s of the brachial plexus, most common ulna nerve (c8- t1) …. Clinical presentation: low cervical and or shoulder pain, tingling numbness in whole arm or hand . Weak easily fatigued gripping. Venus engorgement

Rx options: STM scalenes (ant-mid) contract-relax, reduce agg factors eg correct posture and biomechanicial contributors , address mechanical interface- soft tissue mobs (direct) , address neural sensitivity eg ulna nerve sliders

Question 17

What is the clinical interface and Rx options of carpal tunnel syndrome

Answer 17

Mechanical interface: carpal bones

Rx options: PAMs carpal bones; US carpal space; ice etc

Question 18

What are the two neurodynamic treatment techniques

Answer 18

1. Gliding techniques ‘sliders’

2. tensile loading techniques ‘tensioers’

Question 19

Describe gliding technique ‘sliders’

Answer 19

• ON at one end and OFF at the other
• Non-provocative, large amplitude oscillations (usually short of pain/ resistance), short duration, pain relieving, irritable condition

Can be passive or active

Question 20

Describe tensile loading techniques ‘tensioers’

Answer 20

• ON at one end
• small amplitude oscillations into resistance or pain (not a stretch)
• Non-irritable, chronic
• expect increase ROM

Note: passive or active

Question 21

What is the dosage of neurodynamic treatment techniques:

Answer 21

• clinically reasoned as per joint mobilisations

- can use Maitland grading system (I-IV)

Question 22

What are vulnerable sites of peripheral nerve entrapments:

Answer 22

1. soft tissue, osseous or fibro-osseous tunnels
   - carpal tunnel, posterior tarsal tunnel, intervertebral foramen
   - superficial radial nerve on the radius
   - superficial perineal nerve on the bones of the foot
2. Branching of the nervous system
   - tibial nerve split into medial and lateral plantar nerves in the foot
   - radial nerve divides at the elbow
   - sciatic splits into perineal and tibial nerves in the posterior thigh
3. Sites of fixation, cations or previous injury
   - common perineal nerve at the head of the fibula
   - radial nerve on the radial head

Question 23

What are the lower limbs peripheral nerve entrapments and their mechanical interface?

Answer 23

> sciatic nerve:
-‘piriformis syndrom’: under/through piriformis

> lateral femoral femoral cutaneous nerve:
- ‘meralgia paraesthetica’: under inguinal ligament near ASIS

> Common perineal nerve
-between fibula head/ peroneus longus

> Tibial nerve

• behind med melleolus
• ‘tarsal tunnel syndrome’: lateral plantar nerve under AHL/ quadratics plantar fascia
• ‘tarsal tunnel syndrom’: medial plantar nerve in longitudinal arch

> 3rd interdigital nerve
-‘mortons neuroma’: between 3rd-4th metatarsal heads

Question 24

Describe piriformis syndrome:

Answer 24

• 6-7% of cases of LBP and ‘sciatica’
• Clinical diagnosis of exclusion
• Signs and symptoms
– Buttock pain +/- leg pain (posterior thigh-calf)
– Aggravation with sitting
– Tenderness over the greater sciatic notch
– Agg with increased piriformis muscle tension
– +ve SLR~45deg (~50% of cases); conduction signs uncommon (~30% of cases) and more likely suggest radiculopathy

• Treatment
– Education – sitting, hard surfaces etc.
– Mechanical interface Rx – heat, STM, stretching, Lx PPIVMs, Gmed strengthening
– Neural mobilisations – SLR → slump

Question 25

Describe Meralgia Paraesthetics

Answer 25

• Under inguinal ligament
• Symptoms in LFCN (lateral femoral cutaneous nerve) distribution
– Paraesthesia/anaesthesia/hypersensitivity
– Does not cross midline of thigh
– No motor deficit (sensory only)
• Worse standing / walking/ prone
• Eased sitting (except in pregnancy)
• Reproduce with palpation and passive hip E
• Causes
– Pregnancy, tight clothing, space occupying lesions
– More common in diabetics
– Occasionally associated with trauma
• Treatment
– Education – loose clothing, weight loss, activity mods
– Self limiting usually
– Rarely need nerve block, meds or decompression

Question 26

Describe tarsal tunnel syndrome: proximal

Answer 26

• Posterior tibial n. behind medial malleolus
• Idiopathic (50%), trauma, overuse
• Signs and symptoms
– Diffuse burning pain on the sole of the foot/toes +/- altered sensation (?S1)
– Prolonged standing and walking usually exacerbate the symptoms
– May present with night pain that is improved with massage or walking
– TOP in the tarsal tunnel and over nerve (Tinel’s sign)
• Treatment
– Education – footwear, prolonged aggs etc.
– Mechanical interface Rx – taping, orthotics, strengthening tib post
– Neural mobilisations – SLR/slump with tibial nerve bias (DF+Ev)

Question 27

Describe tarsal tunnel syndrom- distal

Answer 27

Clinically cannot distinguish between the two; lateral more common then medial

• Lateral plantar nerve (Baxter’s nerve)
– Patient’s report medial inferior heel pain with inversion/eversion
– Numbness uncommon
– Often co-exists with plantar fasciopathy
– Palpation may reveal non-specific tenderness
– Soft-soled shoes, heel cups, taping/orthotics for pronation
– CST injections may be needed

• Medial plantar nerve
– Patients report medial arch or medial toe pain
– ‘Joggers’ foot
– Associated with valgus foot and excessive external rotation

Question 28

Describe common perineal nerve:

Answer 28

• Causes - crossed legs, prolonged sitting, plasters/braces, trauma (micro/macro)
• Sensory changes (+ pain)
– Superficial – anterolateral leg
– Deep – between 1st-2nd toes
• Motor changes
– Superficial – ankle eversion
– Deep – DF + inversion
• Treatment
– Education – aggs (postures, clothing, footwear - deep)
– Mechanical interface – STFJ mobility, calf and knee strengthening
– Neural mobilisations – SLR +/- PF + Inv

Question 29

What are the upper limb peripheral nerve entrapments and their mechanical interface?

Answer 29

> Brachial plexus

• ‘thoracic outlet syndrome’ (C8-T1): scalene triangle, costoclavicular space
• traction: ‘stinger/burner’

> Suprascapular nerve
-between suprascapular notch and spinoglenoid notch

> Axillary nerve
-within quadrilateral space formed by trees minor, there’s major, long head of the triceps and the neck of humerus

> RAdial nerve
-over the spiral groove of humerus

> Posterior Interosseus nerve (PIN)

• Radial tunnel: lateral epicondyle of the humerus to the distal edge of the supination muscle
• arcade of frogs: under proximal edge of the supination

> ulnar nerve

• under cubical tunnel retinaculum: ‘cubical tunnel syndrome’ (2nd most common)
• Guyon’s canal: fibroosseous tunnel between the pisiform and the hook of the hamate

> median nerve
-carpal tunnel syndrome (most common)

Question 30

Differentiation between a C7 radiculopathy and radial nerve (C5-T1)

Answer 30