Week 5 Neurogenic Disorders Flashcards by Michael Obi

Typical Clinical Presentation for Neurogenic Syndromes: It is primarily a (pain/loss of ROM) problem.

If you have a t1 nerve compression and you have pain, it should be in the (lateral/medial) forearm.

People who sleep with their wrists curled up can wake up with pain in their hand.

Exercise is not the best answer for these patients. Exercise as in stretching and weights. Doesn’t mean CV exercises aren’t good or certain types of exercises aren’t good.

pain; medial

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Typical Clinical Presentation for Neurogenic Syndromes- Pain: Within nerve distribution, (proximal/distal) to the nerve entrapment location, nocturnal pain associated with (arm/wrist) compression

Nocturnal pain - more common with the (proximal/distal) nerve compressions compared to (proximal/distal).

distal; wrist; proximal; distal

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Typical Clinical Presentation for Neurogenic Syndromes- Paresthesia’s: an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves.
Typically intermittent
Activity dependent
May be worse at (morning/night)

night

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Typical Clinical Presentation for Neurogenic Syndromes- Sensory loss:
Occurs (before/after) motor weakness

Sensory loss should always occur BEFORE motor weakness because the sensory component of mixed nerves is more (deep/ superficial) to the axon and the motor are (deeper/superficial). Pain nerves are interspersed between superficial and deep.

before; superficial; deeper;

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Typical Clinical Presentation for Neurogenic Syndromes- Motor weakness: Longstanding condition and
Clumsiness associated with _____ Syndrome

With muscle weakness, ask if they are clumsy or having trouble with fine motor tasks, something to look out for.

Carpal tunnel

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Typical Clinical Presentation for Neurogenic Syndromes- Regulatory changes: (typical/not typical).

Regulatory changes - Are there issues with temperature and things like the ANS.

not typical

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Typical Clinical Presentation for Neurogenic Syndromes- more common in cis (males/females).

females

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Causes and Contributing Factors in Neurogenic Syndromes

Aberrant Anatomy - things like the brachial plexus on one side looking completely different than the other side

Anomalous Flexor Tendons - potentially an extra flexor tendon or things like that
Proximal Lumbrical Muscle origin - making a fist reduces space in the carpal tunnel.
Space Occupying Lesions: Tumors, Cysts - most common in the hand is the one affecting the ulnar nerve. Think of guyans canal of the cubital tunnel.

“Anomalous - deviating from what is standard, normal, or expected.”

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Causes and Contributing Factors in Neurogenic Syndromes

Infections  
Lyme Disease
Mycobacterial Infection
Septic Arthritis
Herpes
Shingles
West Nile Virus

Inflammatory Conditions 
Connective Tissue Disease
Gout or Pseudogout
Rheumatoid Arthritis
Flexor Tenosynovitis

If you are evaluating your patient and they say they had an infection and they are complaining of paresthesia’s that follow a nerve distribution you can start seeing a cause and effect.

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Causes and Contributing Factors in Neurogenic Syndromes

Metabolic Conditions
Amyloidosis - Amyloidosis is the name for a group of rare, serious conditions caused by a build-up of an abnormal protein called amyloid in organs and tissues throughout the body. The build-up of amyloid proteins (deposits) can make it difficult for the organs and tissues to work properly.
Diabetes
Hypo/Hyperthyroidism 
Alcoholism

Increased Canal/Tunnel  Volume
Congestive Heart Failure
Edema
Obesity
Pregnancy

Increased canal/tunnel volume – anything that causes swelling (ankles, wrists, hands), severe fatigue tends to be present.
These types of issues lead to more blood volume and higher levels of compression. High fluid volume is in someone who is pregnant.

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Causes and Contributing Factors in Neurogenic Syndromes

Repetitive Motion-
Work or sports related
Wheelchair propulsion

Trauma -
Fractures: Fractures in certain areas can lead to injury of the nerve (ex - radial nerve in the spinal groove). Healing process of nerve healing around the bone can also be an issue.

Iatrogenic - When practitioners use needles they can potentially nick a nerve
Dialysis Tube
Injection

“Iatrogenic - relating to illness caused by medical examination or treatment.”

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Neurogenic Syndromes > Peripheral Nerve Injuries

Physical or Mechanical Forces - 
Friction (Repetive?)
Traction – beyond limits
Compression (Space Occupying Lesion)
Laceration

Decreased Blood Flow -
Ischemia and Hypoxia

Trophic Function -
Changes in Axoplasm Flow

Toxins -
Alcohol, Lead

When we use the term compression to refer to carpal tunnel and things like that it might not be a true compression (the nerve can be overstretched causing it to act as a compression neuropathy).

Repetition creates friction. Constantly doing the same task over again leaves friction on the nerve.

Compression – ex – ganglion cyst.

Not talking about laceration (talking about denervation and things like that).
“Ischemia is a condition in which the blood flow (and thus oxygen) is restricted or reduced in a part of the body.”
“Having low oxygen levels in your tissues is called hypoxia.”
With swelling we get decrease in blood flow (ischemia and hypoxia to the area around the nerve).

Alcoholism and lead poisoning can lead to neurogenic issues

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Peripheral Nerve Structure

(Homogeneous/Not Homogenous) Throughout Length of Nerve

Number of Fascicles and Amount of Connective Tissue (is the same/varies)

Some Areas More Susceptible to Injury

Not homogenous; varies

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Peripheral Nerve Blood Supply

Intrinsic vs. Extrinsic
Designed for (staticness/movement)
20-30% of the cardiac output
Minor compression can impede blood flow

It is important to get blood to nerves because they need oxygen, they are oxygen hungry all the time. That means a minor compression can impede blood flow which means they’ll be starving for oxygen.

movement

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Epineurium-protects against (compression/tension)

compression

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Perineurium-protects against (compression/tension).

tension

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(Epineurium/Endoneurium) - surrounds axon

Endoneurium

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Normal tunnel: For adequate nerve fibre nutrition, what order must the pressure gradient be? If this is all in line there won’t be any real compressive issue.

Arterial pressure, capillary pressure, fascicular pressure, venule pressure, and tunnel pressure

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Reverse Pressure Gradient

When there is a compressive issue you have a reversed pressure gradient. In this case the tunnel pressure is (lower/higher) than the arterial pressure. Decreased blood flow = decreased oxygen.

Tunnel is either too small (shrunk) or the contents in the tunnel are too large. Changes in the contents could be due to edema or fluid retention. Can see in inflammatory responses or women who are pregnant. A fracture ending up in the carpal tunnel can make the space smaller.

Carpal tunnel changes in size based on movement. (Smaller/Larger) in flexion and extension compared to when optimal in neutral.

When the tunnel becomes greater you have venous stasis which leads to an inflammatory response which leads to mini compartment syndrome which can lead to ischemia, hypoxia, and fibrosis.

higher; smaller;

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For nerve compression the tunnel pressure is (smaller/greater) than the arterial pressure

greater

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Axonal Transport

Axoplasmic flow -
Transport of organelles & macromolecules to and from cell body to terminal bouton
Anterograde/orthograde
Retrograde

(Slow/Fast): related to signaling components 400mm/day
(Slow/Fast): related to cell maintenance 100-200mm/day

Nerve tissue is metabolically demanding

Flow is retarded with compression

Nerve gliding is all about getting the fluid mechanics back to normal. Some call it draining the swamp.

Nerve tissue is metabolically demanding and needs a lot of oxygen. When we don’t move it, the flow becomes a sludge like response.

Fast; slow

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Differential Diagnosis

Cervical Radiculopathy - think about it as compression at anyone of the IVFs in the cervical spine. In the UE (anything between C5-T1 can lead to cervical radiculopathy).
Thoracic Outlet Syndrome
Brachial Plexopathy
Other Nerve Entrapment

Other Soft Tissue Pathology: Tendinopathy-
Maybe we have a tendinopathy and if there is inflammation maybe there’s possible fluid retention. When you have edema there is a potential for compression.

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Nerve entrapments: Ligament of struthers, bicipital aponeurosis, pronator teres, FDS bridge, and carpal tunnel. (Median nerve/ulnar nerve)?

Median nerve

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Nerve entrapment: Arcade of struthers, posterior to medial epicondyle, cubital tunnel, and Guyon’s canal.
(Median/Ulnar) nerve?

Ulnar

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Nerve entrapment: Spiral groove of the humerus, lateral intramuscular septum, supinator, arcade of froshe, and distal lateral forearm. (Ulnar/Radial) nerve.

Radial

Examination for Neurogenic Disorders Patient History Posture: UE positioning Appearance UQ Screen Cervical/Shoulder Exam Tests and Measures: Sensibility Testing Muscle Performance Provocative Tests - Adverse Neural Tension / Thoracic Outlet Tests Patient-Rated Outcome Measures EMG/NCV If sitting with neck to one side could be a tension issue that acts like a compression issue. Monofilaments are used to determine how well someone’s sensations are.

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Potential spaces of compression in neurogenic disorders - Scalene Groove: This is the idea that the brachial plexus can be compressed in the scalene groove (space between anterior and middle scalene). In the scalene groove it is going to be the (trunks/cords) that will be compressed. If someone has compression at the scalene groove which is the trunk you will see (smaller/larger) areas affected compared to just a peripheral nerve.

trunks; larger

Potential spaces of compression in neurogenic disorders - _____ interval: The (trunks/divisions) will be injured.

costoclavicular: divisions

Potential spaces of compression in neurogenic disorders - axillary interval/pectoralis minor loop: The (divisions/cords) will be injured.

cords

Incidence of Thoracic Outlet Syndrome - Typically occurs in people in their _-_ decade. It is more prevalent in cis (males/females). ``` Associated with Cervical Trauma Hand Trauma Posture Overuse Arthritis (Spondylosis) of the Cervical Spine ``` PIC - IVF of c3-c4 is smaller because it has a bony spur in it. The red nerve in the picture is C4 (spinal nerves exit above their assigned vertebra).

4th-5th; females

``` (Vascular – Arterial/Vascular - Venous) TOS (1% of all cases): Ischemic Pain/Paresthesia Fatigue Coldness, Pallor to skin Loss or Reduced Pulse + Arteriogram Distal Thrombosis or Embolization ```

Vascular- Arterial

``` (Vascular – Arterial/Vascular - Venous) TOS (5% of all cases):Cyanosis Significant Distal Edema asymmetrical Pain – Dull Ache Fatigability/Heaviness of UE Dx by Clinical Presentation ^^ ```

Vascular - Venous

Majority of people (90-95% of all cases) with TOS fall into (true/false) neurogenic.

false

False neurogenic TOS involves (specific/non-specific). What are two positive symptoms of false neurogenic TOS? Negative signs include (having a /no) cervical rib and (having/no) intrinsic wasting/atrophy.

non-specific; pain and paresthesia; no; no

(True/False) Neurogenic TOS: Pain and Sensory Changes Associated with Cervical Rib (No/There is) Intrinsic Wasting/Atrophy (Sensory/Motor) Changes (No Pain/Pain) Symptoms with Maneuvers (Easier/Harder) to diagnose with an X-ray. If the person has a cervical rib there will be compression on the brachial plexus so now you get intrinsic wasting/atrophy in the hands. Pain symptoms – put the arm in certain positions and they get their pain.

True; There is; Sensory; Pain; Easier;

Cervical Rib Cervical rib pointed out by both arrows. Cervical rib with a fibrous band that runs to rib _. Fibrous bands arising from cervical ribs may impinge upon the _____ plexus running to the (1st/2nd) rib.

1; brachial; 1st

Cervical Rib Creates compression on the ____ plexus because now it is taking up space. In the cat scan image, (left cervical rib) we know that there is a smaller space for the brachial plexus to go through which is a (true/false) neurogenic TOS.

brachial; true

Differential Diagnosis ``` Brachial Plexopathy Double/Multiple “Crush” Syndromes - Multiple levels of nerve compression Myofascial Pain Trigger Points Cervical Pathology Glenohumeral Pathology ```

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TOS - Typical presentation: (Insidious/Traumatic) Onset Postural Relationship - forward head and rounded shoulders (Long lasting/Transient) Symptoms - if they get out of those positions that compress the nerve they feel better Typically (Low/High) Irritability - 0-3 range on 0-10 scale ROM/MMT: +/- impairments Palpation: +/- muscles spasms TOS Provocation Tests- Typically more than one is (+/-); greater consistency of sensory symptoms Provocation tests – stink in what they were designed for. If you use those tests, must see multiple tests positive to reproduce symptoms. They become better if you use them that way especially for those who have sensory symptoms. Conservative treatment seems (to be effective/to not be effective). Treatment directed towards minimizing symptom reproduction. “Transient - lasting only for a short time”

Insidious; Transient; Low; +; to be effective;

Surgical Options for TOS Surgery indicated if: persisting symptoms despite conservative management vascular structures involved - if blood flow is being cut off they need to have surgery Consist of decompression With vascular involvement may require vascular reconstruction ``` 3 main options Soft tissue release Cervical rib excision Combination Soft tissue release of fibrous band, removal of the cervical ribs, or both ``` Complications <5-40% Pneumothorax Nerve injuries Wound infections Surgery appears (beneficial and is relatively safe/a waste of time and harmful)- Largest challenge remains appropriate diagnosis

beneficial and is relatively safe

Brachial Plexus Injury (Brachial Plexopathy) - Etiology: Trauma - Adult onset or Birth injury Atraumatic - Tumors, irradiation, autoimmune, congenital Incidence/Prevalence: Traumatic - 1% of multi-trauma victims. ____ accident is the most common cause, 0.15-3 per 1000 births. This (is/ is not) an insidious onset unless there is a tumor (the atraumatic section). A small % of your group of patients will be atraumatic.

Motor vehicle accident; is not

Brachial Plexopathy - Presentation: Results in intractable (it really hurts) pain and ____ (Low/High) sx irritability – may be latent response Treatment often provokes symptoms Seatbelt goes right across the brachial plexus and pulls on it when the head goes forward. Paresthesia - Descriptions of burning and tingling, spiders running across your arm

paresthesia; high;

Brachial Plexus Traction Injury (BPTI): Presence of Adverse Neural Tension (+/-)Upper Limb Neurodynamic Tests TOS Provocative Tests not consistent/reliable for sensory symptoms Traction on Plexus so patient attempts to shorten or relieve tension. Picture – trying to put slack on the system by being in this position. If you start to see that, think brachial plexus.

Distribution of Symptoms (Upper/Lower) trunk brachial plexus injury - Traps, neck, and chin. (Upper/Lower) trunk brachial plexus injury - medial arm, forearm, and hand

Upper; lower

Neurogenic Radicular Pain: Neurogenic Radicular Pain Neurogenic Pain = Root Pain = Radicular Pain Follows Nerve Root “Territory” Accompanies Other Radicular Symptoms Distinct Quality of Pain: (Shooting and Sharp/ Dull and achy) Localized to (a specific region/various regions) The nerve roots are inside the spinal canal. It becomes a spinal nerve before it exits the spinal canal. The term root pain is wrong, when talking about root pain they are talking about ventral and dorsal rami pain, or spinal nerve pain. Root pain = radicular pain.

shooting and sharp; a specific region

Double Crush Syndrome/Double or Multiple “Crush” Phenomenon - This is two areas or more of (compression/tension).

compression

Double Crush Syndrome/Double or Multiple “Crush” Phenomenon: Proximal level nerve (compression/tension) may cause distal sites to be susceptible to (compression/tension). Can also go distal to proximal as well! Axoplasmic flow leads to the nerve being more susceptible to further injury which leads to these crush phenomena. Failure to realize a double crush hurts in treating the pt appropriately. Look at rest of UE if you find a crush. Consider multiple compression sites if symptoms not explained by single/specific neuropathy If symptoms don’t go to carpal tunnel syndrome, look for something else with it.

compression; compression

Double or Multiple "Crush" Incidence: (Low/High) incidence of cervical spondylosis (degenerative changes) in patients with carpal tunnel syndrome. Metabolic conditions (increases/decreases) incidence - DM, thyroid, obesity, alcoholism, RA. High incidence of TOS in patients referred with _____ syndrome

High; increases; carpal tunnel

Initial Examination Rule in/out Tos or BP or Double Crush Posture Assessment - Forward Head, Protracted Shoulders Pain Assessment - is the pain high or low irritability. Low – (TOS/BP). High – (TOS/BP) . Trauma – (TOS/BP) . Insidious – (TOS/BP). UQ Screen- Cervical Spine Examination /Shoulder Examination TOS Provocative Tests (Special Tests) Assessment of Adverse Neural Tension (ANT) - can be used for TOS Regional Special Tests for Nerve Compression Strength Testing: Grip/Pinch, MMT Sensibility Testing- using the monofilaments (sharp, dull, cold/hot, ETC)

TOS; BP; BP; TOS

Pain Assessment Tools Spatial - (body diagram/verbal rating scale) Intensity/severity - (body diagram/visual or verbal rating scales) Quality or nature - (visual rating scale/patient interview) Temporal - (Pain Diary, repeated VAS or VRS/ body diagram) Functional impairment - (self report/outcome / body diagram)

body diagram; visual or verbal rating scales; patient interview; Pain Diary, repeated VAS or VRS; self report/outcome

Sources of Musculoskeletal Referred Pain ``` (Somatic/ Neurogenic/radicular) Muscle- supraspinatus refers pain to anterolateral arm (somatic problem). Tendon/ligament Joint Capsules Connective Tissues of Peripheral Nerves ``` ``` (Somatic/ Neurogenic/radicular) Spinal nerve Nerve Roots Peripheral Nerves Cranial Nerves ``` “Somatic - of, relating to, supplying, or involving skeletal muscles”

Somatic; Neurogenic/radicular;

Somatic referred pain patterns from the cervical spine have overlapping areas from C_-C-. The pain will be (dull/sharp), diffuse, aching, and (poorly/highly) localized. There are a lot of overlapping areas, but there are general areas where those regions of the spine (the facet joints will refer) will refer.

C2-C7; dull; poorly;

Shoulder Considerations ``` Asymmetry Range of Motion Scapulohumeral Motion Strength: Shoulder Girdle, Scapula Scapula Positioning/Dyskinesia Muscle Length: latissimus, pectorals ```

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Sensibility & Fine Motor Testing If they can’t make the OKay sign we are dealing (anterior/posterior) interosseous nerve injury.

If can’t extend wrist (anterior/posterior) interosseous nerve is an issue.

posterior;

TOS Provocative Tests What are the 4 tests we test if we think it is TOS? 4 tests If we think it is TOS (No data for likelihood ratios due to tests not being designed appropriately. Most of these were designed for vascular TOS which is a minimal amount of people. Need to look for pain and if symptoms are reproducible).

Adson’s Wright’s Costoclavicular Roos = EAST

Assessment of Adverse Neural Tension Active Motion Dysfunction Passive Motion Dysfunction Peripheral Nerve Hyperalgesia Looking at how irritated the nerves are. Pic - Patient is trying to elongate the median nerve. If head tilts the same direction, (positive/negative) sign because they are putting it on slack to even get that high. TOS tends to be more chronic and insidious Brachial plexus tends to be trauma related

positive

Adverse Neural Tension (ANT) Commonly associated with peripheral neurogenic pain Examine nervous system for movement deficits and neurogenic symptoms: Nerves were made to move-if the nerve can’t move to get through full ROM there will be problems. These issues can give limitations to full ROM. Movement enhances nerve health Level of irritability drives examination and treatment with neural mobilization - If you have a pt who is highly irritable and unwilling to relax when moving arm you can’t do much of an exam.

Got it

Assessment ``` Techniques: Active motion analysis Passive motion analysis Peripheral nerve provocation tests Palpation - will palpate the brachial plexus Clinical Reasoning ```

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Active Assessment Left arm (does/does not) have full motion of the median nerve. Cant get shoulder to 180 degrees, cant fully extend the wrist, needs head tilted towards the arm to put slack on the system. That is an active assessment that is considered (positive/negative) for median nerve tension. If we think it is the nerve we should be able to put slack on the end and affect the proximal joints. To see if it is neural tension, have to put slack somewhere (proximally or distally to see if pain goes away or they get more motion). This will tell you if it is a nerve related issue. If arm is down low when doing this and you are feeling it, you might have nerve tension. We all might have nerve tension, but it is all about if you are within normal limits. Roughly getting to 120 degrees of elevation is considered WNL.

does not; positive

For upper limb neurodynamic tests, the most common one pt's have is a (median/ulnar) nerve bias which is where the (median/ulnar) nerve has tension. An ulnar nerve bias is when the (ulnar/median) nerve has tension. A radial nerve bias is when the (ulnar/radial) nerve has tension. Depressing the scapula should be the (first/last) thing you do when doing an upper limb neurodynamic test, if do it too early you can mess up the assessment. Scapula depression is a sensitizing maneuver and the last maneuver we do. Prior to that it is blocking the scapula from elevating. Always tell patient tell me when you first feel any indication of your symptoms so you don’t hurt them

median; median; ulnar; radial; last

Muscle Imbalance Typically Associated with TOS- The muscles that will be tight include the (anterior and middle/middle and posterior) scalene, (pectoralis minor/major), and the (upper/lower) trapezius. People who suffer with TOS in many cases take on poor posture (hurts to sit up straight).

anterior and middle; pectoralis minor; upper

Muscle Imbalance Typically Associated with TOS- The muscles that will be weak include the (upper/lower) trapezius and the (pectoralis minor/serratus anterior). They are weak is because it is a chronic condition, don’t want to exercise, it is uncomfortable. With chronic conditions expect weakness.

lower; serratus anterior

Therapy Intervention for neurogenic disorders- Avoid Tension on the Injured Brachial Plexus: Teach anti-tension positioning Avoid aggravating activities Posture Retraining Stretch tight muscles and strengthen weak muscles Consider sitting, standing, sleeping, driving, occupational postures This is impairment based rehab. Promote Pain-Free Movement Minimize Neural Scarring/Restriction Prevent Joint or Soft Tissue Restrictions Modulate Pain Physical Agents, Joint Mobilization, Soft Tissue Mobilization, Massage Neuromuscular Conditioning Improve Flexibility, Endurance, Posture If we have a nerve that is on tension even in neutral positions (so they are highly irritable), need to teach anti tensioning positions. Any time you put tension on a nerve beyond what it can tolerate, it'll make it worse. This is impairment based rehab. Driving: are they resting on their ulnar nerve (arms on side of the window? Could you put a pad there to take pressure off of the ulnar nerve) Sleeping – do they sleep with their arm/hand curled up?

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Posture Home Program Scalene Stretch Cervical Spine Muscle Stretches Pectoral Stretches Shoulder Circles Strengthening of the Scapular Stabilizers - get them retracted Hand Intrinsic Strengthening - can't forget about the hand (double crush)

Got it

Strengthening Specificity PNF shoulder girdle patterns to work on scapular strengthening without elevating arm which may increase symptoms. Therapist applies manual resistance. Perfect population for PNF shoulder girdle patterns. Don’t have to elevate their arm and still working on strength

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Promote Pain-Free Movement Spinal canal length 7cm (shorter/greater) in flexion than extension More room to move in flexion than extension. Nerves like movement, they do well with movement.

greater;

Nervous System in a Continuum Electrically Chemically Mechanically Our most notable component for nerve health is the (mechanical/chemical) component. This will be our bread and butter.

mechanical

General Procedures for Upper Limb Neurodynamic Tests Consistent starting position Feel barriers to movement; appreciate onset of resistance; pain or other symptoms with movement Note pain responses (area, nature) Watch for antalgic postures or reactions Test for symmetry Tests can be performed in different order- Art to evaluation and treatment because so many joints are involved. Appreciate onset of resistance – when you feel resistance, don’t push through it. Note pain response – where it is, describe its nature, angle of the joint you are moving. Should only be moving one joint at a time. Test for symmetry – do they have a lack of motion on both sides? Maybe that is just their normal.

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Therapy Intervention Promote Pain-Free Movement Minimize Neural Scarring/Restriction Prevent Joint or Soft Tissue Restrictions Modulate Pain Physical Agents, Joint Mobilization, Soft Tissue Mobilization, Massage Neuromuscular Conditioning Improve Flexibility, Endurance, Posture Want them to move, but don’t want to inflame them more. If you have to stretch soft tissue that put the nerve on stretch, the nerve crosses more joints than the muscle so you can manipulate things to put different things on slack.

Got it

Limb Positioning: Relieve Tension Pillow on chest is most slack put on the system.

Relieve tension

Nerve Glides Expected Response Physiologic Response: Tissues respond to movement, normal response Neurogenic Response: Patient’s complaint reproduced locally or remotely Clinical Physiologic Response: Symptoms reproduced, but not patients' complaints and different from other side Expected Responses: Reflex muscle activity to protect- Relative resistance perceived by clinician Reproduction of symptoms Response altered by change in joints proximal or distal Different response when comparing left to right Typically not a bilateral problem Normal Response: May feel pain in anterior shoulder Deep stretch/ache in cubital fossa which may extend down anterolateral forearm and hand Tingling in median nerve digits Lateral neck flexion away increases response Lateral neck flexion toward decreases response When doing Limb tension tests, they are only (positive/negative) when they reproduce the patients complaints, every other symptoms are (positive/negative). Have to reproduce the patients complaints to be (positive/negative). With any and all diagnoses that you treat, if there is no change within two weeks, change it up.

positive; negative; positive

Tension Vs. Glide Tension Lengthens nerve and stresses vascular supply; used in patients with non-irritable conditions or (low/high) irritability. Tensioning – putting tension on both ends of the rope (nerve) and by doing this we are trying to elongate the nerve to its full length. Glide Allows tension in one region and release in another; use in patients with (non-irritable/irritable) conditions. Ex: if I do the median nerve active glide, you are putting tension in one place while creating slack in another area.

low; irritable

Nerve Mobilization as a treatment rarely stands alone ``` Pain modulation Range of motion Joint Mobs Soft tissue stretching or mobilization Postural education Ergonomics ```

Got it

Treatment & Progression ``` Monitor symptoms; watch for delayed response Gradual increase in reps/duration Add components to increase tension Reassessment No evidence to support clear guidelines ```

Got it

(Precautions/Contraindications) ``` Irritable conditions Spinal Cord signs Nerve root signs Severe unremitting night pain – lacking a dx Recent parasthesias/anesthesia CRPS Type I/II Mechanical spine pain with peripheralization Pregnancy ``` Don’t want to do anything if irritability is high, except active rest. Spinal cord signs – cervical myelopathy Nerve root signs – is it a true radiculopathy. Does the person have drop foot ? Have to be cautious of the hard nerve root signs. Severe unremitting night pain – cancer “CRPS (Complex Regional Pain Syndrome) - The exact cause of complex regional pain syndrome isn't well understood but may involve abnormal inflammation or nerve dysfunction. Complex regional pain is characterized by pain that is greater than would be expected from the injury that causes it.”

Precautions

(Precautions/Contraindications) ``` Recently repaired peripheral nerve Malignancy (local) Active inflammatory condition Neurological- Acute inflammatory disease: Guillian-Barre, Lyme Demyelinating diseases ```

Contraindications

Summary of Nerve Glides What it does not do Relieve external compression - ex: if there is a cervical rib, can’t relieve that, need to be done through surgery. Alter nerve connective tissue viscoelastic properties ``` What it may do Restore “normal” physiologic environment Potential to increase excursion Potential to decrease “mini compartment syndrome” Maintain post-op excursion Relieve symptoms? ```

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