W6: Neurodynamics & Neural Mobilisation Techniques Flashcards by Caitlin O'Farrell

How can we assess the peripheral nerves?

Dermatomes (sensation)
Myotomes (movement)
Tendon Reflex
Neurodynamic tests

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What is a dermatome

An area of skin that is mainly supplied by a single spinal nerve

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What vertebrae is the exception for dermatomes?

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How many cervical, thoracic, lumbar and sacral nerves are there?

8 cervical nerves
12 thoracic nerves
5 lumbar nerves
5 sacral nerves
1 coccygeal nerve

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What is a myotome?

A group of muscles served by a spinal nerve root

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What does the C2 myotome involve?

Cervical Flexion
* Look at your shoe

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What does the C3 myotome involve?

Cervical lateral flexion
*A fallen tree

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What does the C4 myotome involve?

Shoulder elevation
*I am not sure

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What does the C5
myotome involve?

Shoulder abduction
*Arms out wide

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What does the C7 myotome involve?

Wrist flex/Elbow ext
*No zombies in heaven

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What does the C6 myotome involve?

Wrist ext/elbow flex
*Smell your wrist

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What does the C8 myotome involve?

Thumb ext/ulnar dev
*You’re doing great

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What does the T1 myotome involve?

Finger abduction
*One and done

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What are the lower-limb myotomes?

L1/L2 (lift your shoe): hip flexion

L3 (Extend your knee): knee ext

L4 (Stop the door): dorsiflexion

L5 (toes divide): Great toe ext

S1 (lift a tonne): Ankle PF/hip ext

S2 (heel to bum): Knee flex

S3/S4: Rectal tone

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What is a myotome?

A muscle served by a spinal nerve root

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Main peripheral nerves in upper extremity?

Brachial plexus (above clavicle)
Axillary nerve (near head of humerus)
Musculocutaneous nerve (upper arm - bicep)
Median nerve
Radial nerve (on thumb side of forearm)
Ulnar nerve (on pinkie side

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Peripheral nerves of the lower limb (anterior)

Femoral nerve (thigh)
Obturator nerve (upper thigh)
Common/superficial peroneal nerve (shin)
- Saphenous nerve (shin)
- Sural nerve (foot)

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Peripheral nerves of the lower limb (posterior)

Sciatic nerve
Tibial nerve
Common peroneal nerve (wraps around knee)
Sural nerve

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Radiculopathy: Sensory, strength and reflex characteristics?

Sensory: dermatomal pattern sensory loss or irritative sign

Strength: Weakness in the muscles innervated by this nerve root

Reflex: changes related to specific nerve roots

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Peripheral nerve: sensory, strength and reflex characteristics?

Sensory: symptoms in nerve distribution areas.

Strength: Muscle weakness in muscles innervated by a particular peripheral nerve eg weakness in muscles innervated by the median nerve (weakness in wrist flexion)

Reflex: changes related to the nerve (not the nerve root)

What tests are used to diagnose neuropathic conditions in the upper limb?

Upper limb tension test eg for cervical radiculopathy, carpal tunnel, cubital tunnel

What is a neurodynamic test? What was the prior perspective?

Assessment and treatment of the physical nervous system
Series of movements that place consecutive load on the nervous system

Previous view
- Physical tests were a reflection of the flexibility/tightness of nerves
- Clinically, we therefore sought to increase their length and mobility through ‘nerve stretching’ or ‘mobilising’ techniques.
- This is a simplistic (and incorrect) view

Contemporary studies show that neurodynamic tests examine:

Tension
Sliding of nerves within tissues
Intraneural blood flow
Mechano-sensitivity
Compression

Note: the term neurodynamic tests replaced tension tests

For the straight leg raise what nerve trunk is involved?

L4-S3

What movement is involved in the straight leg raise

- Hip flexion (maintain knee ext) - DF ankle - Hip adduction/IR - Cervical flexion - Trunk lateral flexion

What movement will bias the tibial nerve in a straight leg raise?

* Preposition in dorsiflexion + eversion + pronation

What movement will bias the sural nerve in a straight leg raise?

Dorsiflexion + inversion

What movement will bias the peroneal nerve in a straight leg raise?

Plantarflexion and inversion

What nerve trunk is involved in the slump test?

L4-S3

What nerve trunk is involved in the prone knee bend and slump knee bend?

L2-L4

Explain the slump knee bend and how its different to the prone knee bend?

Cervical & thoracic spine is flexed. The top leg is passively brought into full hip ext and then knee flexion is added (femoral) nerve). Hip is brought into abduction (obturator nerve) and then dropped into adduction (lateral femoral cutaneous nerve

The upper limb tension test 1 for the median nerve involves what nerve trunk and what movements?

Nerve trunk C6-T1 Movements: - Shoulder girdle fixation - Shoulder abduction (90 deg)/ER - Wrist ext - Forearm supination - Elbow extension - Differential: cervical lateral flexion

The upper limb tension test 2a for the median nerve involves what movement and nerve trunk? When would this be used?

Nerve trunk: C6-T1 Movements: - Shoulder girdle depression - Elbow ext - Shoulder ER & forearm supination - Wrist and finger ext - Shoulder abd - Differential: release shoulder girdle depression Useful for shoulder instability/adhesive capsulitis

The upper limb tension test 2b for the radial nerve involves what movements and what nerve trunk?

Nerve trunk: C5-T1 - Shoulder girdle depression - Elbow extension - Shoulder internal rotation & forearm pronation - Wrist and finger flexion - Shoulder abduction - Differential: release shoulder girdle depression

The upper limb tension test 3 for the ulnar nerve involves what movements and what nerve trunk?

Nerve trunk: C8-T1 1. Wrist and finger extension (start high 5) 2. Forearm pronation 3. Elbow flexion 4. Shoulder external rotation 5. Shoulder girdle depression – 6. Shoulder abduction 7. E.g. differential: cervical spine lateral flexion

What is structural differentiation?

* Allows us to differentiate between neural and non-neural structures * If change in symptoms is based on a differentiating maneuvre – symptoms are neurogenic

What is an abnormal test ie positive?

* Reproduction of patient’s symptoms (MUST) * Structural differentiation gives a neural result (MUST) * Range of motion may be reduced

What is not an abnormal/positive test?

* Not relevant (often the case!) – sensitive tests * Contralateral testing: symmetrical response eg. bilateral tightness - normally tight for that person and is symmetrical * Does not reproduce ’patients symptoms’ = KEY

* The minimal evidence available prevents any ..... statements about the diagnostic accuracy of ULNTs

Definitive

* Evidence shows that, when using a liberal definition of a positive test, ULNT (.....), but not ULNT(.....), can help determine whether a patient has cervical radiculopathy. * When using similar criteria, ULNT(......) does not help diagnose carpal tunnel syndrome

Median Radial MEDIAN

What are two treatments for neurodynamic conditions?

Sliders & tensioners

What is a slider?

* Sliders aim to induce sliding of the peripheral nerves in relation to their surrounding structures with a minimal increase in nerve strain.

What is a tensioner?

* Aim to increase nerve strain by simultaneously elongating the nerve bed at multiple joints

What is the staging technique ie the intensity increase in neurodynamic treatment?

Protect --> Slider --> Tensioners

What are two common entrapment sites of the ulnar nerve?

1. Entrapment may occur between the medial epicondyle and olecranon under the cubital retinaculum (Cubital tunnel syndrome) 2. Entrapment may occur in the ulnar tunnel roofed by the palmar capal ligament (ulnar tunnel or Guyon canal syndrome)

In an ulnar nerve entrapment what is preserved?

Normal sensation in the radial half of the ring finger is sparred

What are other assessment tools that can be used for radiculopathy?

Palpation Imaging Nerve conduction studies (how fast electrical signal impulses move through your nerve)

Will is a 49-year-old accountant and keen golfer, presents with a dull ache down the right posterior thigh and right lateral ankle pain. He has had back pain on and off for the past 10 years and reported that he sprained his right ankle 2 months ago playing soccer. He resumed soccer last week but said that the right shin and ankle feels a bit sore afterward. What tests you would perform to aid your diagnosis?

Palpation of lumbar spine Central and unilateral PAVIMs Combined movements eg extension/lateral flexion/rotation Slump test, SLR, strength test Related dermatomes/myotomes Nerve palpation, neurodynamic assessment – tibial positioning.

What is the easiest way to self mobilise the sural nerve?

Foot in DF/Inversion (neck flexion provides a more aggressive movement - tensioner & neck extension allows a less aggressive and distracted large range movement ie a slider)