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MSPT II > Neural Mobilization Exam + Intervention > Flashcards

Neural Mobilization Exam + Intervention Flashcards

1
Q

Current State of evidence for efficacy of neural mobilization

Ellis et al.

Basson et al.

A

see pics

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2
Q

Neural Structure

2 Main Types of Tissue:

A
  1. Impulse gen. and conduction
    1. axons, myelin, Schwann cells
  2. those assoc’d w/ support and protection of the impulse conducting tissues
    1. neuroglia, Schwann cells, connect. tissue layers
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3
Q

Connective tissue relationships exist from _____ TO _____

A

from axon TO neuraxis

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4
Q

Approx 50% of the P. nerve is connective tissue sheath

Some stats..

A
  • Ulnar N. @ elbow= 21%
  • Sciatic N. @ buttocks= 81%
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5
Q

4 Major tissue layers in and around the P. nerve

Starting from the axon (innermost) and working to exterior of the nerve

A
  • Endoneurium
  • Perineurium
  • Epineurium
  • Mesoneurium
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6
Q

Endoneurium

“Inner-most” layer

A
  • Surrounds neuron
  • HIGHLY elastic→ made of close packed collagen tissue
  • Contains endoneurial fluid under positive pressure
  • *responsible for maint. healthy environment of axon
    • Blood-Nerve Barrier***
  • Contains NO LYMPHATICS
    • if swells– cannot drain
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7
Q

Perineurium

Endoneurium→ Perineurium

A
  • Surrounds Fascicles (bundles of endoneurium)
  • Multi-layered→ most collagen fibers running parallel to nerve fiber
  • HIGHLY resistant to tensile forces
  • Acts as BOTH mechanical barrier to mech. forces and a diffusion barrier to keep substances OUT of intrafascicular environment
  • Contains NO LYMPHATICS
    • if swells→ cannot be drained
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8
Q

Epineurium

Endoneurium→ Perineurium→ Epineurium

Outer vs. Inner

A
  • Outer Epineurium
    • contains vascular comps→ lymphatics AND blood supply
  • Internal Epineurium
    • surrounds and protects fascicles from ext. trauma
    • allows for interfascicular gliding
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9
Q

Mesoneurium

Endoneurium→ Perineurium→ Epineurium→ Mesoneurium

A
  • Forms loose connect. tissue sheath around nerve
  • Facilitates nerve gliding of AND anchors nerve in the nerve bed
  • *W/ injury→ often becomes fibrotic and shrinks to constrict nerve and forms adhesions to the nerve bed
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10
Q

Nerve Root Complex

Components of this:

A
  1. Dorsal and Ventral Roots
  2. Dorsal Root Ganglion (DRG)
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11
Q

Nerve Root Complex

Dorsal and Ventral Roots

A
  • RARELY damaged from traction force 2* to protective and force distributive mechs.
    • i.e. denticulate ligs
  • receive @ least 50% nutrition from CSF
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12
Q

Nerve Root Complex

Dorsal Root Ganglion (DRG)

A
  • Normally minimally mechanosensitive
    • poke, prod== no response
  • Once irritated→ very mechanosensitive
  • MAY become edamatous
    • This cond. is hypothesized to improve via pumping action w/ mvmt
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13
Q

Connective Tissue Relationships:

P. nerves to Neuraxis

What are they continuous with?

A
  • Epineurium continuos w/ Dura Mater
  • Perineurium MOSTLY cont. w/ dura, portion cont’s as Pia mater
  • Endoneurium cont. w/ Pia mater
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14
Q

The Meninges

3: Inner→ Outermost

A
  1. Dura mater
  2. Arachnoid mater (spider-web like)
  3. Pia mater
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15
Q

The Meninges:

Dura mater

A
  • Strong longitudinally→ mostly collagen fibers in long. orientation
  • Elastic as well*→ Elastin content varies 7% ventral to 14% dorsal
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16
Q

The Meninges:

Arachnoid mater

A
  • Delicate mesh (spider-web) of collagen fibers in random orientation
  • Lines inside of dura
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17
Q

The Meninges:

Pia mater

A
  • Another collagen mesh-like structure
  • Lines outer surface of brain & SC
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18
Q

The Meninges:

Pia + Arachnoid mater TOGETHER→

A

Leptomeninges

  • Embryologically ONCE one memb.
  • Interconnections (trabeculae) b/w the two dampen CSF pressure waves from mvmt.
19
Q

The Meninges:

As a Muscle Attachment.. explain

A
  • Evidence of MYO-dural (muscle→ dura) connections b/w suboccipital mm’s
    • Rectus capitis post. minor
    • Rectus capitis post. major
    • Obliquus capitis inf.
20
Q

The Meninges:

As a Muscle Attachment.. explain

Myodural Connections

Explain further: what does it DO?

A
  • MAY assist in checking dural in-folding and impinge. during C/S Ext.
  • Feedback function→ rich in proprioceptors
  • Maint. proper dural tension to facilitate CSF dynamics
  • MAY play a role in cervicogenic HA’s
21
Q

Potential for Nerve Injury:

Space + Contents Dilemma

A
  • Nerve passes thru several tight anatomical comps along course of nerve bed
  • Conflicts arise b/w avail. space and contents
    • diminished compartment aperture
    • INCd volume of contents
  • RESULT:
    • restricted gliding b/w tissues in compartment
    • interrupted nerve physio.
    • impaired blood supply
22
Q

Circulation of the NS

Blood Supply to nerve

What is this called?

A

Vasa Nervorum

23
Q

Explain the Circulation of the NS

Vasa Nervorum

A

*Great redundancy!!!

  • Neural tissue is O2 HUNGRY!!!
    • 2-6% of body mass but utilizes 20% of avail O2
  • Redundant Design*
    • ensures uninterrupted blood flow to neurons regardless of mvmt or static pos. of NS
  • Stretch and compression CAN alter circulation
    • hypoxia, edema, then fibrous changes in the nerve can follow chronic interruption in blood flow
24
Q

Axonal Transport Systems

Explain..

A
  • Mvmt of mitochondria, lipids, synaptic vesicles, PROs, prions, organelles thru the cell’s axoplasm TO and FROM neurons Cell Body
    • Active→ HIGH energy demand process
    • Mvmt along microtubules acting as train tracks
    • Kinesin and dynein motor PROs move cargo along microtubules
25
Q

Axonal Transport Systems:

Fast and Slow Transport

A
  • FAST (50-400mm/day)
    • analogous to taking the express train
  • SLOW (.1-6mm/day)
    • analogous to taking the local train w/ lots of steps along the way
26
Q

Axonal Transport Systems:

Anterograde Transport

A

AWAY from cell body (soma)

  • FAST→ responsible to transport of neurotransmitter vesicles
    • 400mm/day
  • SLOW→ resp. for transport of cell building materials
    • microtubules and neurofilaments→ .1-1mm/day
    • Actin→ 2-3mm/day
    • ~200 other PROs @ speeds up to 6mm/day
27
Q

Axonal Transport Systems:

Anterograde Transport

AWAY from cell body

Example:

A
  • During reactivation from latency, herpes simplex virus (HSV) hitches ride on the anterograde transport mechs to migrate from DRG neurons TO the skin or mucosa affected****
28
Q

Axonal Transport Systems:

Retrograde Transport

A

TOWARDS the cell body (soma)

  • Returns used synaptic vesicles TO SOMA (cell body)
  • Informs soma of cond’s @ the axon terminals
  • Exploited by pathogens as well
    • delay b/w infection and disease expression==> travel time TO SOMA
      • HSV
      • Rabies
      • Polio
29
Q

Axonal Transport Systems:

Kinesin Motor PROs

A
  • Utilizes ATP→ ADP as energy source***
  • 125,000 steps= 1mm dist. traveled along microtubule—–WOW!!!
30
Q

Axonal Transport Systems:

Consequences of disruption of axonal transport system

A
  • Inflamm. of the nerve
  • Loss of nerve function
  • Nerve becomes “sick”
31
Q

Neural Response to Injury:

Mild, focal compression

A
  • Injury to Schwann cell
  • Demyelination results
32
Q

Neural Response to Injury:

More severe trauma

A
  • Degen. of the distal axon
  • Reactive changes to nerve cell body
  • aka Wallerian Degeneration
    • NOTE: recovery NOT possible w/out Sx
33
Q

Neural Response to Injury:

Injury w/out axonal degeneration

A
  • Inflamm in and around nerve sheath
  • Activates C and A delta fibers
  • Nervi Nervorum (nerve→nerve) involved:
    • innervates connect. tissue and blood vessels of the NS
34
Q

Neural Response to Injury:

EMG and NCV Testing

*NVC=Nerve Conduction Velocity

A
  • **ONLY valuable for detecting larger diameter A-beta sensory & motor nerve injury
    • “A-beta’s make it betta”
  • ***Of no value for detecting small diameter nerve injury
    • C and A-delta fibers, Nervi Nervorum
35
Q

How do we ID Pts w/ Nerve Injury W/OUT axonal degen?

A
  • Nerve tissue becomes mechanically sensitized (C and A delta fibers via nervi nervorum) in reaction to interruption of axonal transport and inflammation in or around nerve
  • Sensitized neural tissue responded to as little as 3% stretch→ well w/in normal mvmt parameters
  • Sensitized neural tissue now reacts to stretch and pressure

*NOTE: These principles form the physiologic basis for Neurodynamic Testing!!!

36
Q

Key Takeaways from Neurodynamic Testing:

A
  • Vast # of nerve injuries not detected via EMG/NCV
  • Neural sensitization involves injury to small diameter A-delta and C fibers of the nerve AND nervi nervorum
  • Occurs thru inflammation and interruption of axonal transport system
    • *Inflamm+Axon Neural Transport very intimately related
    • when you compress nerve→ becomes pro-inflammatory
  • In the Clinic..
    • detected via palpation and stretch on clinical exam
      • aka how to detect injured neural tissue
37
Q

Neural Mobility Testing

Indications

A
  • Pain/parasthesia of neural origin deduced via exam and hx
  • Limtd mobility of NS
  • Injury of tissue close to nerve beds
    • whiplash
    • HS injury
      • Sciatic N.
    • Lat. Epicondylalgia
      • Radial Nerve
    • Medial Epicondylalgia
      • Ulnar N.
    • Ankle sprain
      • Sural and Superficial Peroneal N branches
  • Suspected cervical radiculo.
    • part of test item cluster to ID this patho
  • Post-op spine pts
38
Q

Neural Mobility Testing

Contraindications

A
  • Acute inflammatory infection involving SC or NS
  • Acute/recent onset of hard neuro. signs
    • loss of reflexes
    • localized mm weakness
39
Q

Neural Mobility Testing

Precautions

A
  • Malignancy
  • Be aware of stress to anatomical structures during testing
    • Slump: HNP concerns, nerve root impinge signs
  • Irritability lvl of the pts NS
  • Presence of stable hard neuro signs
  • Gen health issues:
    • IDDM/NIDDM, RA, MS, etc..
  • Circulatory disorders
40
Q

Structural Differentiation w/ Neural Mobility

Key Concepts

A
  • always skip an articulation (jt complex) from where sx’s are produced or changed during baseline tests
  • Add/Subtract tension to look for corresponding change in sx’s
  • Symptoms typ worsen w/ tension add→ but not always
41
Q

Meralgia Parasthetica assoc’d w/

A

LFCN entrapment

42
Q

Meralgia Parasthetica

A

Irritation or entrapment of LFCN @ anterolateral hip

@ risk= baseball catchers, equestrians (Eng-style), obese indvs, pregnant women, ant. approach THA and hip arthroscopy pts)

43
Q

Test for Meralgia Parasthetica

A

push w/ thumb down into abdomen and up toward umbilicus @ lvl just proximal to and 1” medial to ASIS.

If this relieves pts sx’s of lat. thigh burning, pain, or parasthesia→ suggests meralgia parasthetica is problem

To treat→ apply same pressure to the nerve w/ pt in S/L, while you simultaneously passively extend hip

*push down and up on nerve as you ext hip, then move back and forth

MSPT II (20 decks)

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