Week 5 Neurogenic Disorders Flashcards
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
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
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
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;
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
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
Typical Clinical Presentation for Neurogenic Syndromes- more common in cis (males/females).
females
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.”
Got it
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.
Got it
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.”
Got it
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
Got it
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
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
Epineurium-protects against (compression/tension)
compression
Perineurium-protects against (compression/tension).
tension
(Epineurium/Endoneurium) - surrounds axon
Endoneurium
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
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;
For nerve compression the tunnel pressure is (smaller/greater) than the arterial pressure
greater
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
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.
Got it
Nerve entrapments: Ligament of struthers, bicipital aponeurosis, pronator teres, FDS bridge, and carpal tunnel. (Median nerve/ulnar nerve)?
Median nerve
Nerve entrapment: Arcade of struthers, posterior to medial epicondyle, cubital tunnel, and Guyon’s canal.
(Median/Ulnar) nerve?
Ulnar
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.
Got it
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, Pallorto 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/Heavinessof 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
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
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;
Sensibility & Fine Motor Testing
If they can’t make the OKay sign we are dealing (anterior/posterior) interosseous nerve injury.
anterior
If can’t extend wrist (anterior/posterior) interosseous nerve is an issue.
posterior;
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
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
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
Got it
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
Limb Positioning: Relieve Tension
Pillow on chest is most slack put on the system.
Relieve tension
