Neurodynamics of the Upper Extremity

1. Neurodynamics of the Upper Extremity Brenda Boucher, PT, PhD CHT, OCS, FAAOMPT Content Credit: Paul Mintken, PT, OCS, FAAOMPT Stacy Fancher, PT, FAAOMPT

2. Definition of Neurodynamics Clinical Neurodyanimics The clinical application of mechanics and physiology of the nervous system as they relate to each other and are integrated with musculoskeletal function Shacklock, 2005 Method of assessing neural structures via the application of mechanical tension, through multi-joint movements.

3. Neural Biomechanical & Physiological Concepts • Central, peripheral and autonomic nervous systems form one unit that interact as a unit. • Achieved mechanically, electrically and chemically • Requires mechanisms for elongation, tension and glide (Sunderland and Bradley) Any stresses that are imposed on the peripheral nervous system are conveyed to the central nervous system, and the reverse holds true.

4. Dissected and Mounted Human Cerebro-Spinal Nervous System Date: 1888 Professor Rufus Benjamin Weaver Hahnemann University Hospital Drexel University, Philadelphia PA

5. Slump Test

6. Oxygen Consumption Nutritional Requirements – 20% of Oxygen consumption while only comprising 2% of total body weight

7. Nerve Innervation • The connective tissues of the peripheral nerves, nerve roots and autonomic nervous system have a source of intrinsic innervation = nervinervorum • Free nerve endings have been found in the: • Perineurium • Epineurium • Endoneurium

8. Neural Mobilization • Nerve Glide • Nerve glide tensioning technique: movement of • one or more joints to mobilize the nerve and nerve bed. • Increases nerve tension and nerve pressure • Reduces intraneural blood flow • Nerve glide sliding technique: elongate nerve at • one joint balanced by a reduction of length at an • adjacent joint. • Nerve slides relative to surrounding tissues • Longitudinal excursion of the nerve

9. Susceptible Sites • sites of nerve branching • unyielding interfaces • sites of nerve attachment • soft tissue and fibro-osseous tunnels • sites at which a nerve is cutaneous

10. Common MOI • External forces • examples: casts, belts, walking boots, ill-fitting shoes • Internal forces • examples: swelling, bone spur • Chronic repeated microtrauma • example: posture • Double crush – previous injuries proximal and/or distal to site of current pain

11. Symptoms of Altered Neurodyamics • Symptoms tend to develop gradually as a secondary result from injury • Symptoms radiate (either proximally or distally) • Pain along the nerve pathway or spot pain (hyperalgesic response to palpation) • Aggravated by positions or movements that “stretch” the nerve • Nocturnal s/s not uncommon

12. Diagnostic Considerations with Peripheral Nerve Compression • Can mimic tendonopathy and can occur concurrently with such • Concurrent with many other orthopedic injuries: • Lateral ankle sprains (sural or peroneal) • Proximal Humeral fractures (radial) • Knee scope (saphenous) • Spine hypermobility • Occur frequently after fractures

13. When to suspect Altered Neurodynamics? • When not responding as should within the expected time frame • Describes in terms consistent with altered neurodynamics - “burning”, “crawling”, “electrical”, “ants on me”, “pulling”, bizarre sounding things like “warm water” • Worsening despite objective improvement of ROM, strength, etc

14. Ulnar Neuropathy- Guyon’s Canal • Cause: carpal ganglions, hamate fractures, extrinsic trauma or compression. • May present as isolated or combined sensory and motor symptoms, depending on where the compression occurs. • Symtoms: pain, paresthesia in the ulnar nerve distribution of the hand. • Weakness may develop in the intrinsic muscles, producing decreased lateral pinch and grip strength. Patient may have problems with fine motor skills. Claw hand deformity may develop due to loss of intrinsic muscle strength.

15. Ulnar Nerve-Cubital Tunnel • Second most common entrapment neuropathy in the UE. • The cubital tunnel is formed by the medial edge of the trochlea and olecranon laterally and the medial epicondyle medially. • The ulnar collateral ligament forms the floor of the tunnel. • The cubital tunnel retinaculum (or arcuate ligament) forms the roof. • Flexion tightens the retinaculum, narrowing the tunnel

16. Ulnar Nerve-Cubital Tunnel • Cause: overhead sports, anatomical variants (valgus deformities, bony hypertrophy, extension restriction), instability of ulnar nerve • Symptoms: aching pain over the medial side of the elbow, sometimes radiating to the hand. It also produces sensory disturbances (numbness, tingling, coldness) over the ulnar side of the hand and ulnar one and one-half digits.

17. Ulnar Nerve-Cubital Tunnel • Motor involvement affects the hand intrinsic musculature, but spares the flexor carpiulnaris and flexor digitorumprofundus. • Testing: sustained elbow flexion (1-3 minutes) will reproduce symptoms. Positive ANTT ulnar nerve.

18. Differentiation C8-T1 radiculopathyvs Ulnar Nerve Entrapment • Strength of the extensor pollicislongus (EPL). The EPL is innervated by the radial nerve, level C8. • Sensation, as ulnar nerve sensory loss covers the medial hand and one and half fingers, whereas sensation loss in C8 dermatome is different.

19. Median Nerve-Struthers Ligament • rare, as this vestigial ligament is present in just 1% of the population. • Stretches between a humeral spur, 3-5 cm proximal to the elbow, and the medial epicondyle. It covers the median nerve.

20. Median Nerve- PronatorTeres Syndrome Stems from 2 sites of compression: • A thickened lacertus fibrosis where it connects to the pronatorteres muscle • Pronatorteres hypertrophy or fibrous bands within the muscle • It presents as an insidious onset of proximal anterior forearm pain

21. Median Nerve- PronatorTeres Syndrome • Repeated pronation and wrist flexion increases the pain. • Night pain is uncommon. • Resisted pronation and wrist flexion reproduces symptoms. • Sensory symptoms may involve the radial hand and 3.5 digits. • Motor involvement is less common. • There may be soft tissue changes at the pronatorteres

22. Median Nerve-anterior interosseous branch • Compression by fibrous bands from the deep head of the pronatorteres or flexor digitorumsuperficialis muscles. • Compression results from repetitive trauma, casts or contusions. • The anterior interosseous syndrome presents as proximal forearm pain that is increased with activity. • There are no sensory changes

23. Median Nerve-Carpal Tunnel Syndrome • Most common of all peripheral nerve entrapment syndromes. • May stem from any condition that decreases the size of the carpal tunnel: fluid retention, external compression, excessive callus formation or malalignment after a Colles fracture, lunate dislocation, ganglions and synovitis.

24. Median Nerve-Carpal Tunnel Syndrome • Acute or insidious onset of pain, paresthesia or anesthesia over the radial side of the pal and radial three and one half digits. • Pain may radiate proximal to the wrist and is often nocturnal. • Weakness can occur in thenar musculature and 1st and 2ndlumbricals, which hinders opposition and precision maneuvers. • Positive Phalen’s test, positive ANTT for median nerve, volar swelling and thenar atrophy.

25. High Radial Nerve Compression • Caused by trauma such as fractures, tourniquet use and “Saturday night palsy”. • Activities like wrestling, throwing, gymnastics and weightlifting can compress the radial nerve between triceps and humerus. • Produces mixed motor and sensory symptoms

26. High Radial Nerve Compression • May or may not involve the triceps, depending on level of lesion • Pain may radiate proximal or distal to the elbow. • Sensory changes occur in the posterior forearm, dorsal hand and dorsal aspect of the radial 3 and one-half digits. • Weakness may affect the supinator, wrist extensor, thumb extensor/abductor and finger MP extensor muscles.

27. Radial Tunnel (posterior interosseous) syndrome • Most common radial nerve compression 4 common sites of compression in the radial tunnel: • Fibrous bands anterior to the radial head • A vascular arcade • The tendinous margin of the extensor carpiradialisbrevis • The proximal edge of the supinator (arcade of Frohse)

28. Radial Tunnel Syndrome Symptoms: • Local tenderness and extensor weakness. • Night pain is common. • No sensory changes as the PIN is a motor nerve only

29. Radial Tunnel Syndrome • Pain associated with PIN entrapment may simulate lateral epicondylitis, but careful palpation will give you the clue needed. • The radial nerve will be tender on palpation. • ANTT is + for the radial nerve.

30. Contraindications • Contraindications to neurodynamic testing and treatment: • Demyelinating conditions such as Multiple Sclerosis • Diabetes Mellitus • Disc disease • Progressing radicular signs • Highly irritable conditions

31. Neurodynamic Test- Positive • Reproduction of s/s (know it is relevant) • Response is altered by a distant component (either a distal or proximal component) • Difference in response from side to side, or what is normal • May have to differentiate if a positive test is relevant or not….

32. ULNT1 (Median Nerve Bias) • ULNT1 (Median Nerve Bias): • Patient position close to the edge of the arm to be evaluated. • Depress the shoulder girdle. • Abduct the arm to 110 degrees. • Forearm is supinated and the wrist and fingers extended. • Shoulder is then externally rotated. • Slowly extend the elbow and monitor tension and patient symptoms. • Therapist can measure the degree of elbow flexion to objectify the test. • Normal responses to ULNT11) Stretching sensation/deep ache in the cubitalfossa which may extend down the anterior and central aspects of the forearm and hand. • 2) Tingling in thumb and first three fingers

33. ULNT2 (Radial Nerve Bias) • ULNT2 (Radial Nerve Bias): • Position patient diagonally on table with arm being tested • off the table. • Therapist imparts a depression force to the shoulder with • the thigh closest to the table. • Therapist’s inside hand holds the patient’s elbow and outside hand holds the patient’s wrist and hand. • Position shoulder in 10 degrees of abduction. • Extend the elbow. • Internally rotate the shoulder. • Passively flex the wrist and fingers and ulnarly deviate the wrist. • Fully pronate the forearm. • Slowly abduct the arm and monitor tension and patient symptoms. • Therapist can measure the degree of abduction to objectify the test. • Normal responses to ULNT2: • 1) Burning/tingling in dorsal/radial distribution of hand or lateral elbow

34. ULNT3 (Ulnar Nerve Bias) • ULNT3 (Ulnar Nerve Bias): • Patient position close to the edge of the arm • to be evaluated. • Extend wrist and pronateforearm. • Fully flex the elbow. • Depress the shoulder girdle. • Externally rotate the shoulder. • Slowly abduct the shoulder as though you were bringing the patient’s hand to their ear. • Normal responses to ULNT3: • 1) Symptoms in medial distribution of the forearm, hand and ulnar 2 digits

35. Purpose of Treating Neural Mobility • The ultimate goal is to restore range of motion and stretch capabilities to the nervous system and to normalize the sensitivity of the system (David Butler in Grieves Modern Manual Therapy 1994). • Start distal to the area of symptoms • Techniques should be non-provoking initially • It is better to undertreat initially until the sensitivity of the condition is determined

36. Principles of Management • Intensity directly related to the level of irritability present – greater the irritability the less intense the glide (ie NOT into s/s) • Neurological s/s (ie tingling, numbness) should NOT persist after gliding technique or should be improved • Choose one component motion of the testing position to utilize as the “gliding force” • Either “floss” or “glide” – either one works • Ask regarding s/s after each treatment and document changes across the course of treatment • Any worsening at all need to be immediately reported to the PT – pt. education…

37. Treatment Rule of Thumb • Irritable conditions • Treatment is initiated usually using sliders at a site distal to the symptomatic area in a non-provoking fashion (grades I & II). • Main goal is pain relief rather than increased mobility. • The soft tissue around the nerve can be mobilized instead of the nerve. This is very effective for extraneural conditions (entrapments, compressions, neurodynamic following a hamstring strain).

38. Nerve Sliding Techniques • Sliders: • Neurodynamic maneuvers performed in order to produce a sliding movement of neural structures relative to their adjacent tissues. • Sliders involve application of movement/ stress to the nervous system proximally while releasing movement/ stress distally • Sliders allow larger ranges of motion, provide a means of distraction from the painful area, and should provide multi-tissue and non-painful input into the CNS. • Research has shown that sliders actually result in greater excursion than simply stretching the nerve.

39. Treatment Rule of Thumb • Non-irritable conditions • Sliders or tensioners can be used for treatment • Begin with non-symptom provoking techniques • The nerve is placed on slack • The mobilization is initially kept within the painfree range (whether a slider or tensioner). • Initially use 10-20 seconds of large oscillations (Graded just as in joint mobilizations) 3-4 bouts. • Initially, patient’s symptoms should be monitored and should not be provoked—If provoked, the symptoms should settle quickly • Progress by placing increased tension on the neural structures with oscillations.

40. Nerve Tensioning Techniques • Tensioners: • Neurodynamic maneuvers performed in order to produce an increase in tension in neural structures. • Tensioners are the opposite of sliders in that movement/ stress is applied proximally and distally to the nervous system at the same time, and then released. • Tensioners may better challenge stiffness and more long-lasting physical dysfunction. • Elongation of the nerve bed is obtained by moving one or several joints such that the ‘tension’ within the nerve is elevated. • Tensioners are, by nature, more stressful to the neural tissue and should be used with caution as they may irritate the mechanosensitive patient.