Week 3- Principles of manual therapy: soft tissue Neural mobilisations Flashcards
How do we assess the nervous system? What are the 2 types?
- Mechanosensitivity: “hyperactivity” “positive systems”
- Questions: are the symptoms coming from the nerve itself? Pain, parenthesis, dysesthesia, spasm
- assessments: neurodynamic tests, nerve palpation - 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
What is the summary of nerve injury
What is the summary of nerve injury
What is the clinical presentation symptoms of peripheral neuropathic pain?
- 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 - 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
Examples of peripheral neuropathic pain symptoms
What are neurodynamic (neural provocation) tests (NDT or NPT)?
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
What constitutes a ‘positive’ NDT?
- Reproduces patient’s symptoms or associated symptoms
- Movement of a body segment remote from the location of symptoms alters the response (ie. sensitisation or structural differentiation)
- 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
NEURODYNAMTIC TEST: What does a positive test tell you?
- whether mechanical hyperalgesia/ allodynia is a feature of the presentation
- assists differential diagnosis of non-neural conditions
- assists in determining irritability, prognosis and management
NEURODYNAMIC TESTS: What does a positive test not tell you?
- 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
What can a physio do for peripheral neuropathic pain? What are the aims?
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
- Non-neural tissue impairments (address first)
- targeting mechanical interface
- joint mobilisations, STM, taping to unload sensitive neural structures or retraining neuromuscular control - 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
What is the clinical interface and Rx options for a L5 radicuopathy due to IVD protrusion?
Mechanical interface: IV foramen
Rx options: Rx McKenzie E, Rotations or LF away
What is the clinical interface and Rx options of lumbar central canal stenosis?
Mechanical interface: central spinal canal
Rx options: lumbar flexions PPIVMs OR exercises (eg. Cat-camel, knees to chest, cycling)
What is the clinical interface and Rx options of posterior interosseus nerve entrapment?
Mechanical interface: supination muscle
Rx options: STM, contract-relax, self stretches
What is the clinical interface and Rx options of ‘Sciatica’?
Mechanical interface: piriformis muscle
Rx options: STM, contract-relax, self-stretches
What is the clinical interface and Rx options of common perineal nerve entrapment?
Mechanical interface: superior tib-fib joint
Rx options: PAMs if hypo or taping if hyper
What is the clinical interface and Rx options of thoracic outlet syndrome
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
What is the clinical interface and Rx options of carpal tunnel syndrome
Mechanical interface: carpal bones
Rx options: PAMs carpal bones; US carpal space; ice etc
What are the two neurodynamic treatment techniques
- Gliding techniques ‘sliders’
2. tensile loading techniques ‘tensioers’
Describe gliding technique ‘sliders’
- 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
Describe tensile loading techniques ‘tensioers’
- ON at one end
- small amplitude oscillations into resistance or pain (not a stretch)
- Non-irritable, chronic
- expect increase ROM
Note: passive or active
What is the dosage of neurodynamic treatment techniques:
- clinically reasoned as per joint mobilisations
- can use Maitland grading system (I-IV)
What are vulnerable sites of peripheral nerve entrapments:
- 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 - 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 - Sites of fixation, cations or previous injury
- common perineal nerve at the head of the fibula
- radial nerve on the radial head
What are the lower limbs peripheral nerve entrapments and their mechanical interface?
> 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
Describe piriformis syndrome:
• 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
Describe Meralgia Paraesthetics
• 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
Describe tarsal tunnel syndrome: proximal
• 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)
Describe tarsal tunnel syndrom- distal
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
Describe common perineal nerve:
• 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
What are the upper limb peripheral nerve entrapments and their mechanical interface?
> 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)
Differentiation between a C7 radiculopathy and radial nerve (C5-T1)
