neural mobility: examination intervention strategies · 2018-04-01 · 10/21/2014 1 neural...
TRANSCRIPT
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Neural Mobility:Examination & Intervention
StrategiesStrategiesAn Overview
Mark W Butler, PT, DPT, OCS, Cert. MDT
Objectives
Review current state of evidence
Review neuropathic pain and neural sensitivity
Identify patients with neural sensitivity
Quantify restricted neural mobility
Understand basic treatment principles to treat patients with restricted neural dynamics
J Man Manipulative Ther. 2008;16(1):8‐22
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How Effective is Neural Mobilization?
Ten RCT’s reviewed
Different methods used for each
Different neurodynamic dysfunctions for each
No standardization for assessment or treatment
All utilized tensioning techniques
Conclusion
Limited evidence to support neural mobilization
ifi i f b dJustification for treatment based on anatomy, physiology, clinical trials, anecdotal evidence
Recommendations for Future Studies
Need to classify into homogeneous subcategories
Need to standardize treatment and assessment techniques
Then proceed with clinical research
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Ideal Conditions for Nerve Health
• Space
• Movement
• Limited sustained tension
Brief Review of Nerve Anatomy & Physiology
• Connective Tissue
V N• Vasa Nervorum
• Axonal Transport
• Nervi Nervorum
Connective Tissue Layers
• Endoneurium
• Perineurium
• Epineurium
• Mesoneurium
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Endoneurium
• Separates individual axons
• Highly elastic
Perineurium
• Surrounds fascicles
• Contributes most• Contributes most to nerve’s tensile strength
• Collagen based
Epineurium
• Internal
–Adipose
– Loose connective tissue
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Epineurium
• External
–Collagen basedbased
Mesoneurium
• Loose connective tissue
• Facilitates gliding
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Potential for Nerve Injury
• Nerve passes through several tight anatomic compartments along nerve bed
– Conflict between free space and contents• Diminished compartment aperture
• Increased volume of contents
• Result → restricted gliding between tissues in the compartment, interrupted nerve physiology & impaired blood supply
Pop QuizPop Quiz
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Video QuizThis individual is stamping his foot and moving in this manner because:
A. Of the toilet tissue stuck on his shoe
B. The edge of the toilet seat cut off the blood supply to the sciatic nerve and his leg has gone to “sleep”
C. The toilet seat interrupted the axonal transport system of the sciatic nerve and his leg has gone to “sleep”
D. All of the above
Vasa Nervorum
Axonal Transport• Uninterrupted axonal transport is
necessary for neuron health
• Activity affects intra-cellular motility
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Axonal Transport
• Antegrade flowFast
• 400 mm / day
Slow• 1 – 6 mm / day
• Retrograde flow200 mm / day
Axonal Transport Vehicle
Goldstein AYN, et al. Axonal transport and the delivery of presynaptic components. Curr Opin Neurobiol. 2008;18;495‐503
Kinesin & Dynein Motor Protein
Encalada SE, et al. Stable kinesin and dynein assemblies drive the axonal transport of mammalian prion protein vesicles. Cell. 2011;144:551‐65
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Video Quiz
This individual is stamping their foot and moving in this manner because:
A. Of the toilet tissue stuck on their shoe
B. The edge of the toilet seat cut off the blood gsupply to the sciatic nerve and their leg has gone to “sleep”
C. The toilet seat interrupted the axonal transport system of the sciatic nerve and their leg has gone to “sleep”
D. All of the above
Inflammation & Axonal Transport
Inflammation
Axonal
Transport
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Nerve’s Response to Injury
• Mild focal compression– Injury to Schwann cell– Demyelination results
Nerve’s Response to Injury
• Mild focal compression– Injury to Schwann cell– Demyelination results
• More severe trauma– Degeneration of the distal axon– Reactive changes to the nerve cell body– Wallerian degeneration– Potential for axonal death
Seddon’s Classification
• Published in 1943
• 3 stages of injury3 stages of injury
• Useful in predicting outcome and formulating treatment
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Neuropraxia
• Segmental reduction or block of conduction
• Axonal continuity preserved – no wallerian degeneration
• Nerve conduction preserved distal and proximal to the lesion
• Full recovery
Axonotmesis
• Axonal damage with preservation of endoneurium
• Distal wallerian degeneration occurs
• Endoneurial tubes guide re-growth of axon
Neurotmesis
• Most severe of nerve injuries
• Connective tissue components of nerve damaged or transecteddamaged or transected
• Recovery cannot occur through axonal regeneration alone
• Surgical intervention required
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Sunderland’s Classification
• Published in 1951
• 5 grades of nerve injury
• Neurpraxia = Grade I
• Axonotmesis = Grade II
• Neurotmesis = Grades III, IV, V
Grade III Injuries
• Damage to the nerve Endoneurial tube– Axon– Endoneurium
• Perineurium preserved
• Results in intrafascicular scarring
Grade IV Injuries
• Damage to the nerve fasciculi– Axon– Endoneurium
Perineurium– Perineurium
• Epineurium preserved
• Results in intraneural scarring
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Grade V Injuries
• Neurotmesis injury• Nerve trunk divided• Surgical repair
• The nerve to the nerve
• Consists of C and
Injury Without Axonal Degeneration
Aδ fibers
• Protective and pro‐inflammatory function
EMG and NCV Testing• Of value in detecting large diameter motor and Aβ sensory nerve injury
• Of no value in detecting small diameter nerve injuryj y– Aδ fibers
– C fibers
–Nervi Nervorum
(Greening,2006; Wilbourn, 2003)
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How do we identify these patients
?
Neural Sensitization
• Very often occurs without axonal damage (Dilley et al, 2005; Schmid et al, 2013 )
• Conduction velocities maintained
• Involves sensitization of of Aδ and C fibers of the nervi nervorum & nerve (Bove et al, 2003)
• Sensitized nerve fibers respond to pressure and stretch (Dilley et al, 2005)– Pressure responding fibers > stretch responders by 50%
– Stretch responders needed as little as 3% elongation
Mechanism of Occurrence
• Inflammation in and around the nerve (Dilley et al, 2005; Bove, 2009)
• Interruption of axonal transport (Dilley & Bove, p p ( y ,2008, Dilley et al, 2013)
• Mechanical stress of stretch and/or compression Neuropraxia
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Summary
• Vast number of nerve injuries not detected via EMG/NCV
• Neural sensitization involves injury to small diameter Aδ and C fibers of the nerve anddiameter Aδ and C fibers of the nerve and nervi nervorum
• Occurs through inflammation and interruption of axonal transport system
• Detected via palpation and stretch on clinical exam
Case Study
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Case Study• 42 y.o. hunter fell while walking in woods
• Axilla impaled by dead tree branch
• Presented to ED with branch spike in situPresented to ED with branch spike in situ
• Removed by surgeon, wound explored, closed
• Presented to PT 3 weeks later with c/o restricted elbow extension
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Motion ‐ Gliding
Coppeiters MW, et al. Different nerve‐gliding exercises induce different magnitudes of median nerve longitudinal excursion… J Orthop Sports Phys Ther. 2009;39(3):164‐71.
Tensioning
Coppeiters MW, et al. Different nerve‐gliding exercises induce different magnitudes of median nerve longitudinal excursion… J Orthop Sports Phys Ther. 2009;39(3):164‐71.
Gliding = Flossing = Sliding
Coppeiters MW, et al. Different nerve‐gliding exercises induce different magnitudes of median nerve longitudinal excursion… J Orthop Sports Phys Ther. 2009;39(3):164‐71.
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UE Neural Mobility Testing• Based on work by R.L. Elvey (1997) and D.S.
Butler (2000)
• Kleinrensink et al (2000) demonstrated stressing of the brachial plexus with the ULNT 1 test
• Technique should be standardized
• Use of grading scales recommended by M.W. Butler (2014)
• Test carried out in sequence to onset or change of patient’s symptoms
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The Brachial Plexus Biasing Neurodynamic Test
ULTT 1, ULNT 1or
BPNT
BPNT 0/5
• Shoulder in IR
• Elbow at 90°
• Arm across stomach
• Wrist and fingers in neutral
BPNT 1/5
• Shoulder ER to neutral
• Elbow at 90°
• Wrist and fingers in neutral
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BPNT 2/5
• Shoulder in ~ 100°of abduction
• Elbow at 90°
• Neutral rotation• Neutral rotation
• Wrist and fingers in neutral
• Thumb in radial abduction – align with humerus
BPNT 3/5
• Shoulder in ~ 100° of abduction, 90° ER
• Elbow at 90°
• Forearm in supination
• Fingers in neutral
• Thumb in radial abduction
BPNT 4/5
• Shoulder in ~100°of abduction, 90°ER
• Elbow at 0°
• Forearm in supination
• Fingers in neutral
• Thumb in radial abduction
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BPNT 5/5• Shoulder in ~ 100°of abduction, 90°ER
• Elbow at 0°
• Forearm supination
• Wrist extension
• Fingers in neutral
• Thumb in radial abduction
BPNT
Important points
• DO NOT DEPRESS THE SHOULDER – only block elevation
• Do not drop the shoulder into extension or bring it into flexion during testingbring it into flexion during testing
• Change to ‘gangsta’ grip at 45° shoulder position between 1/5 and 2/5
• Pause at each of the above steps to check your patient’s status before moving to the next step
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• Test data points:– S1 = onset or change of patient’s symptoms
– S2 = definite stop point in the test based on patient’s discomfort level
– Motion available between S1 & S2 = the treatment zonetreatment zone
• Add (+) if beyond a grade level, but less than halfway to the next level i.e. 3+/5
• Use the next level with a (‐) if over halfway to that level i.e. 4‐/5
Recognition Reliability BPNT
• Data collected between March to October 2104
• Collected in Austin, Chicago, Philadelphia, Atlanta, and Kansas Citya a, a d a sas C y
• Video of 7 different test positions graded
• PT’s, PTA’s, OT’s, COTA’s, ATC’s, CHT’s, PA’s; N = 223
• Intertester Reliability = 0.9007 or 90%
The Median Nerve Biasing Neurodynamic Test
ULTT 2A, ULNT2Aor
MNT
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MNT 0/5
• Stand at your patient’s head with them laying diagonally, their shoulder just off the tabletable
• Shoulder in IR
• Elbow at 90°
• Wrist & fingers neutral
MNT 1/5
• Depress the shoulder 1” with your hip
• Shoulder ER to neutral
• Shoulder abduction to 45°
• Wrist and fingers relaxed‐neutral
MNT 2/5
• Externally rotate the patient’s shoulder to 90°
• Elbow maintained at 90°
• Wrist and fingers in relaxed‐neutral
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MNT 3/5
• Elbow Extension
• Forearm neutral
• Wrist and fingers relaxed‐neutral
MNT 4/5
• Shoulder in ER
• Forearm supination
• Elbow extended
• Wrist & fingers in relaxed‐neutral
MNT 5/5
• Extend the patient’s wrist with focus on the thumb through ring fingers.
• The thumb in radial abduction
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MNT
The Radial Nerve Biasing Neurodynamic Test
ULTT 2B, ULNT 2BorRNT
RNT 0/5
• Stand at your patient’s head with them laying diagonally, their shoulder just off the tabletable
• Shoulder in IR
• Elbow at 90°
• Wrist & fingers neutral
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RNT 1/5
• Depress the shoulder 1” with your hip
• Shoulder ER to neutral
• Shoulder abduction to 45°
• Wrist and fingers relaxed‐neutral
RNT 2/5
• Internally rotate the patient’s shoulder
• Elbow maintained at 90°
• Wrist and fingers in relaxed‐neutral
RNT 3/5
• Elbow Extension
• Forearm neutral
• Wrist and fingers relaxed‐neutral
• Shoulder maintained in IR
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RNT 4/5
• Shoulder in IR
• Forearm pronated
• Elbow extended
• Wrist & fingers in relaxed‐neutral
RNT 5/5
• Wrist and finger flexion with ulnar deviation
RNT
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Important Points for MNT & RNT• Prevent patient from laterally flexing their neck away from the side being tested
• Depress your patient’s shoulder ~ 1 inch, watching their face for signs of discomfort before continuing on with the test
• Keep the patient’s arm in line with the axillary midline
• Pause at each step to check your patient’s status before continuing on with the test
• Once symptoms occur or intensify, there is no reason to continue with the test
The Ulnar Nerve Biasing Neurodynamic Test
ULTT 3, ULNT 3or
UNT
UNT 0/5
• Start standing below the patient’s shoulder
• Shoulder in IR
• Elbow at 90°
• Arm across stomach
• Wrist and fingers in neutral
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UNT 1/5
• Shoulder ER to neutral
• Shoulder abduction• Shoulder abduction to 45°
• Free hand blocks shoulder elevation
UNT 2/5
• Externally rotate the shoulder to 90°
• Maintain stabilizing ghand on shoulder to block elevation
UNT 3/5
• Prevent shoulder hiking with firm counter pressure using your shoulder stabilizing hand
• Abduct the patient’s shoulder to 110°
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UNT 4/5
• Pronate the patient’s forearm
• Extend the wrist, ring d ll fiand small finger
• Maintain firm counter pressure with you shoulder stabilizing hand
UNT 5/5
• Flex the patient’s elbow, bringing their hand to the side of their face
M i i bili i• Maintain stabilizing force on the shoulder, wrist, and fingers
UNT
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LE Neural Mobility TestingThe SLR
• Described in 1880 by a Serbian physician Laza Lazarevic to detect back pain via tension on the sciatic nerve
• Used to detect herniated lumbar discs– Cochrane Review estimated a sensitivity of 92% and a
specificity of 28% (van der Windt et al, 2010)
• Modifications allow for nerve biasing and tissue differentiation
The SLR
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SLR – Tibial Nerve Bias
SLR Fibular Nerve Bias
SLRHamstring vs. Neural Pattern
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Hamstrings Schematic
Increases origin‐insertion distance
Decreases origin‐insertion distance
Sciatic Nerve Schematic
Imparts windlass effect on the nerve around the
ischial tuberosity
Hamstring Pattern
=
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Neural Pattern
Relief Discomfort
Piriformis Syndrome
• External rotator at neutral
• By 60° SLR has become an internal rotatoran internal rotator
• Piriformis/sciatic nerve anomalies exist in ~ 10% of the population (Kosukegawa et al, 2006)
Normal vs. Piriformis Pattern
Normal Piriformis
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Treatment
Initial Treatment Objectives
• Patient education of problem
• Instruct in diaphragmatic breathing
• Establish Home Exercise Program
• Link posture to recovery
• Teach stable sleeping position
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Diaphragmatic Breathing
• Seated and supine• Hand position for
feedback
Home Exercise Program
• Posture Correction
• Proximal Glides• Proximal Glides
• Tray Nerve Glides
• Functional Box
Posture
• Most important aspect of treatment
• Patient’s inability to achieve proper posture with comfort predicts treatment failure
• Goal is to help patient achieve habitual proper resting posture
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Posture Correction with Proximal Gliding
Posture Correction with Proximal Gliding - The “D”
Lift Sternum DD
The Tray
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The Tray
Median/Ulnar Glide
Radial Glide
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The Box
Sleeping Position
Ongoing Treatment Objectives
• Maximize space along the nerve bed
• Maximize tolerance to nerve bed length changes (restore neural mobility)
• Minimize sustained adverse tension on neural tissue
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Cervical MobilizationScalene Stretch
Pectoralis Minor Doorway Stretch
Kinematics - The Scapular Clock
12:00 1:00 2:00
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Scapular Clock Shrugs
HEP Progressionthe
‘Vanna White’ or ‘Spiderman’
The Vanna White / Spiderman
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Slump Glides
Slump Glides
Plexus Glide
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Therapist Intervention
• Plexus mobilization - glides and stretches
• Scalene mobilization
• Pectoralis minor lift / mobilization
Flossing
Sciatic Ankle Pumps
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Mobilizing the Plexus‘Tensioning’
Proximal Plexus:Lateral Cervical Glides
IVF Opening with Nerve Glide
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IVF Opening with Nerve Glide
Proximal Plexus:Scalene Mobilization
Distal Plexus:Pectoralis Minor Lift + Stretch
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Distal Plexus:Pectoralis Minor Lift + Glide
StrengtheningLower / Middle / Upper Traps
StrengtheningSerratus Anterior
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Serratus Press-Ups
Advanced Scapular Stabilizaton
Important Treatment Points• Postural symmetry and awareness – reduce
sustained tension on neural tissue
• Neural mobility
B thi tt• Breathing patterns
• Symptom “quiet point” for rest and sleep
• Tolerance to exercise
• Manual Interventions to enhance mobility and create space - decompress
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Questions?
Thank You
References1. Bove GM, Focal nerve inflammation induces neuronal signs consistent with
symptoms of complex regional pain syndromes. Exp Neurol.2009;219(1):223‐7.
2. Bove GM, Ransil BJ, Lin HG, Leem JG. Inflammation induces ectopic mechanical sensitivity in axons of nociceptors innervating deep tissues. J Neurophyisol. 2003;90:1949‐55.
3. Butler MB, Common shoulder diagnoses. In Cooper C, editor: Fundamentals of hand therapy 2nd ed St Louis Mosby Elsevier 2014of hand therapy 2nd ed., St. Louis, Mosby Elsevier, 2014.
4. Butler DS, The Sensitive Nervous System. Noigroup Publications, Adelaide, Australia, 2000.
5. Coppeiters MW, Hough AD, Dilley A. Different nerve‐gliding exercises induce different magnitudes of median nerve longitudinal excursion: an in vivo study using dynamic ultrasound imaging. J Orthop Sports Phys Ther2009;39(3):164‐171.
6. Dilley A, Bove GM. Disruption of Axoplasmic transport induces mechanical sensitivity in intact rat C‐fibre nociceptor axons. J Physio. 2008;586(2):593‐604.
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7. Dilley A, Lynn B, Pang SJ. Pressure and stretch mechanosensitivity of peripheral nerve fibres following local inflammation of the nerve trunk. Pain2005;117:462‐472.
8. Dilley A, Richards N, Pulman KG, Bove GM. Disruption of fast axonal transport in the rat induces behavioral changes consistent with neuropathic pain. J Pain 2013;14(11):1437‐49.
9. Elvey R, Physical evaluation of the peripheral nervous system in disorders of pain and dysfunction, J Hand Ther 10:122, 1997.
10. Greening J. Clinical implications for clinicians treating patients with non‐specific arm pain, whiplash and carpal tunnel syndrome. Man Ther. p p , p p y2006;11:171‐2.
11. Greening J, Dilley A, Lynn B. In vivo study of nerve movement and mechanosensitivity of the median nerve in whiplash and non‐specific arm pain patients. Pain 2005;115:248‐53.
12. Goldstein AYN, Wang X, Schwartz TL. Axonal transport and the delivery of presynaptic components. Curr Opin Neurobiol. 2008;18;495‐503.
13. Kleinrensink GJ, Stoeckart R, et al, Upper limb tension tests as tools in the diagnosis of nerve and plexus lesions. Anatomical and biomechanical aspects. Clinical Biomechanics (Bristol, Avon), 15 (1): 9‐14, January, 2000.
14. Kosukegawa I, Yoshimoto M, Isogai S, et al. Piriformis syndrome resulting from a rare anatomic variation. Spine 2006;39(18):E664‐6.
15. Schmid AB, Coppieters MW, et al. Local and remote immune‐mediated inflammation after mild peripheral nerve compression in rats. J NeuropatholExp Neurol. 2013;72(7):662‐80.
16. van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low‐back pain. Cochrane Database Syst Rev. 2010;17(2):CD007431.
17. Wilbourn, A. The electordiagnostic examination with peripheral nerve , g p pinjuries. Clinics Plastic Surg. 2003;30:139‐54