Evaluation and Treatment of Peripheral Nerve Compression And

Home , Cervical spinal nerve 4, Lumbar nerves, Myotome, Sacral spinal nerve 1, Thoracic outlet

2/18/20

Peripheral Tambra Marik, OTR/L, OTD, CHT Nerves Medical University of South Carolina South Carolina Occupational Therapy Association Marc Bartholdi, OTR/L, OTD, CHT February 29, 2020 Select Medical

South Carolina Occupational Therapy Association Annual Conference 2020

Tambra Marik, OTD, OTR/L, CHT Peripheral Assistant Professor Medical University of Nerve Injuries South Carolina

Marc Bartholdi, OTR/L, OTD, CHT Select Medical

2/28/20

Objectives

• Discuss the basic anatomy and physiology of the nervous system • Identify varying surgical techniques for common nerve compression injuries • Apply assessment tools to evaluate peripheral nerve compression • Apply evidence-based intervention to treatment of common nerve compression conditions • Identify common brachial plexus injuries • Analyze proximal nerve symptoms to guide with treatment • Demonstrate cervical screening to rule in/out spinal nerve root injury • Implement treatment strategies for cervical nerve root compression • Evaluate and implement therapeutic techniques for Thoracic Outlet (TOS)

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The Nervous System

Structurally Functionally • Somatic Nervous System • Central Nervous System • Voluntary: Sensory carries (CNS) sensations and position sense • Brain and spinal cord from skin and joints. Motor carries impulses to muscles • Peripheral Nervous System (PNS) • Autonomic Nervous System • Involuntary/visceral: walls of • Nerve fibers and cell bodies blood vessels, sweat glands, viscera (internal organs), body cavities (heart, stomach, bladder, etc)

By Own work, CC BY 3.0, https:/ /commons.wikimedia.org/w/index.php?curid=10187018 By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=301480084 4

Central Nervous Structure: Brain & Spinal Cord System (CNS) Function: Control Center & Integrative

Peripheral Structure: Cranial & Spinal Nerves Nervous System Function: Communicates between CNS and (PNS) the rest of the body

Autonomic Involuntary/Visceral Sensory Motor Structure: Somatic & visceral Structure: Motor nerve Sympathetic: Parasympathetic: fibers fiber Fight or flight Conserves Energy Function: Connects impulses Function: Conducts from receptors to the CNS impulses from CNS to muscles & glands

Spinal cord relays information to and from the brain through the spinal tracts through the thalamus and finally to the cortex.

Dorsal Horn Sensory

Ventral Horn Motor

By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, https://upload.wikimedia.org/wikipedia/commons/f/f3/Sobo_1909_615.png Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148131

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Peripheral Nerve Axon away • Peripheral nerves connect information to the central nervous system • Consist of cell body, dendrite send messages to cell body and axon send Dendrite receives messages message out https://upload.wikimedia.org/wikipedia/commons/1/10/Blausen_0657_MultipolarNeuron.png • Efferent: motor • Afferent: sensory • Interneurons: connect neurons within a specific region (sensory or motor) to the central nervous system. Play a role in Interneuron By By Ruth Lawson Otago Polytechnic - originally uploaded at en.wikibooks. original description reflexes. page is/was here[1], CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=8831185

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Spinal Nerves Mixed Fibers Part of Peripheral Nervous System

• 8 pairs of cervical nerves • 12 pairs of thoracic nerves • 5 pairs of lumbar nerves • 5 pairs of sacral nerves • 1 pair of coccygeal nerves

• Axons: receives information • Dendrite: relays information

dendrite

• All peripheral nerve fibers have a sheath cell and a soma Schwann cells. Larger nerve fibers have a fatty (myelin) sheath in addition to the Schwann cell • Presence of myelin speeds conduction Myelin sheath • Nodes of Ranvier: constrictions separating successive Node of Ranvier segments Schwann of myelin cell • Nerve impulses “leap” from node to node • Farther apart=faster conduction Axon terminal

Attribution: Quasar Jarosz 9 9

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Peripheral Nerve Communication

• Nerves have three connective tissue layers to protect • Endoneurium: inner most nerve fiber or axons; protects against transmission of substances across the membrane • Perineurium: surrounds fasicles of nerve axons controls substances bi-directionally, diffusion barrier • Epinueurium: outer most connective tissue that is highly

vascularized 10 10

Sensory Receptors

• Mechanoreceptors/Pressure, Proprioception • Meissner corpuscles: light touch • Merkel cells: light touch (abundant in fingertips) • Ruffini (Bulbous Corpuscle): skin stretch, temperature, contribute to proprioception • Pacinian corpuscle: vibrations • Free nerve endings: pain fast adapting (A delta II) slow adapting (A delta I and C fibers) http://www.bayareapainmedical.com/nerve.html

Sensory Receptors of Muscle & Tendon

• Muscle Spindles : detect changes in length, protects muscle length with the stretch reflex. • Golgi tendon reflex (inhibitory): detects muscle tension changes, protects muscle force to help maintain steady levels of tension and stable joints to counteract effects that reduce muscle force such as fatigue

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Nerve Injury Classification

Mononeuropathy Poly Neuropathy • Traumatic or non-traumatic • Metabolic • Compression syndromes • Nutritional • Can result in ischemic changes, edema injury • Hereditary to myelin • Immunologically Mediated • Can result in demyelination, axonal degeneration, or both • Infectious Disease • Nerve lacerations/compression • Neoplastic • Motor & Sensory Deficits in nerve distribution • Bilateral & Symmetrical • Weakness is dependent on the motor units • Affects large fibers distally first damaged • Sensory loss precedes motor loss • Sensory loss is distal to injury site • Sensory loss at feet followed by hands (bilateral)

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Peripheral Nerve Injury • Macrophages and phagocyte remove myelin and axonal debris. Schwann cells signal to turn on pro-growth genes. • The proximal end forms a growth cone that secretes growth hormone to be guided back to its target nerve if the cell body is intact and Schwann cells have made contact in the endoneurial tube • Schwann cells then proliferate and migrate to regenerating axon Photo from: Arslantunali, D., Dursun, T., Yucel, D., Hasirci, N., & Hasirci, V. (2014). Peripheral nerve conduits: technology update. Medical Devices (Auckland, NZ), 7, 405. 14

Nerve Injury Seddon Classification Seddon Peripheral Nerve Injury Classification (Sunderland not on chart) Axonotomesis Photo by Syedm191 - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=58517905 Seddon Axon Endoneural Peri- Epi- Wallarian Nerve conduction 1943 Tube neurium neurium Degeneration distal to injury/Prognosis Neuro- + + + + No Present/ praxia Reversable Axono- - +/- ? + + Yes Absent/ tomesis Reversable Neuro- - - - +/- ? Yes Absent/ tomesis Irreversible

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Nerve Injury Classification Sunderland

Medical Treatment

• Neurapraxia - Observation

• Axonotmesis - Surgical intervention may be required

• Neurotmesis - Loss of nerve trunk, surgical intervention necessary.

Nerve Mechano-sensitivity Proximal Injuries Referring Distally

Sensitivity of Regenerating Axon Sprouts

• Micro-neuromas (sprouting nerve cells) form around the damage nerve • New cells fire causing severe electrical burning and shooting pain

http://www.bayareapainmedical.com/nrvp ain2.html

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Nerve Mechano-sensitivity Proximal Injuries Referring Distally Nervi Nervorum (unmyelinated or poorly myelinated fibers in peripheral nerve sheaths)

• Participate in the transmission of evoked sensory information • Neuropeptide release leading to edema due to poor lymphatic drainage. Distorts the endoneurom and epineurom due to Image from: Lam, K. H. S., Hung, C. Y., Chiang, Y. P., Onishi, K., Clark, T. B., Reeves, D. K., & Daniel, S. (2020). Ultrasound-Guided Nerve Hydrodissection for Pain Management: An Updated Review of Anatomy and Techniques. pressure. • Inflammatory mediators spread distal likely related to poor lymphatic drainage • Nerve becomes more sensitive

Histopathology of Chronic Nerve Compression

Double Crush Syndrome Axioplasmatic Flow Disruption

Alterations of Axoplasmic Flow

• Possible alterations with a proximal lesion affecting distal compression sites • Possible alterations with a distal lesion affecting proximal lesion sites

• Alterations to neural transmission (axoplasmic flow), but each site in isolation may not reproduce patient symptoms when tested

(Hurst, Weissberg & Carroll, 1985)

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Double Crush Syndrome Possible Posture Contribution (cont.)

↑ Muscle ↓ Muscle Length Length Middle traps. Sternocleidomastoid Lower traps. Serratus anterior Pronator teres Scalenes ↑ Nerve Pectoralis minor Tension/Compres- sion Carpal tunnel Muscle Weakness Muscle Overuse Cubital tunnel Middle trapezius Upper trapezius Levator scapulae Median nerve Lower trapezius forearm Serratus anterior Radial sensory Novak & Mackinnon, 2005 Brachial plexus • Movement patterns and posture can be effected with a nerve compression • Muscle imbalances can occur 22

Thoracic Outlet (TOS)

Potential Compression Sites • Interscalene triangle Anterior and middle scalenes • Costoclavicular space Between clavicle and 1st rib • Thoraco-coraco-pectoral space Pectoralis minor neural, arterial and/or venous Photo from: Jones, M. R., Prabhakar, A., Viswanath, O., Urits, I., Green, J. B., Kendrick, J. B., ... & Kaye, A. D. (2019). 23 Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain and therapy, 8(1), 5-18. 23

Compartment Borders Contents of Potential Compression Interscalene Anterior: anterior scalene • Brachial triangle Posterior: middle scalene plexus Inferior: 1st rib • Subclavian artery Costoclavicular Anterior: subclavius • Brachial space Inferoposterior: 1st rib and anterior plexus scalene • Subclavian Superior: clavicle artery • Subclavian

Photo from: Jones, M. R., Prabhakar, A., vein Viswanath, O., Urits, I., Green, J. B., Kendrick, J. B., ... & Kaye, A. D. (2019). Thoracic outlet syndrome: a comprehensive Sub-coracoid Anterior: pectoralis minor • Brachial review of pathophysiology, diagnosis, and treatment. Pain and therapy, 8(1), 5-18. space Posterior: ribs 2-4 plexus Superior: coracoid • Axillary artery • Axillary vein 24

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Double Crush

“Local damage to a nerve at one site along its course may sufficiently impair the overall functioning of the nerve cells that they become more susceptible than would normally be the case to trauma at other sites.”

(Upton and McComas, 1973)

• 53 cases of ulnar nerve anterior subcutaneous transposition, 7 had TOS. 44/50 had resolved symptoms at 12-74 months post-op. 5/7 had persistent subjective symptoms and objective motor dysfunction. (Lascar & Laulan, 2000)

Neurogenic TOS Estimated 95% of Cases (Freischlag & Orion, 2014) True Disputed Compressor Releasor •Paresthesia am & • Paresthesia awaken often pm pm • Releasers pm pain > day •Compressors day pain • No confirmation with pain > night pain neurophysiological test •Confirmation with • Estimated to be 95-99% of neurophysiological all neurogenic types and is tests bilateral (Stewman, Vitanzo & Harwood, 2014) 26

Test Sensitivity Specificity LR+ LR- NT 85-98 NA NA Supraclavicular Pressure (Nord et al 2008) Cervical Rotation Lateral 0.42-1.0 100 NT NA

Flexion (Gilbert et al 2004) NT 77-97 NA NA Cyriax Release (Brisme et al 2004)

90 38 1.5 0.3 Upper limb tension (Bertilson, Grunnesio & Strender, 2003)

52-84 30-100 1.2 0.4-0.53 Roos Elevated Arm Stress (Rayan & Jensen 1995)

NT 53-100 NA NA Costoclavicular Maneuver (Nord et al 2008)

70-90 29-53 1.27-1.49 0.34-0.57 Wright’s (Gillard et al 2001) 27 27

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Clinical Tests: Cervical Rotation Lateral Flexion Client must have at least 20% of lateral flexion to perform test

Lindgren, Leino & Testing right side Manninen, 1992) Patient is seated and the examiner is behind the patient. The examiner blocks the side being tested with their forearm. The examiner rotates the head away from the tested side and gently flexes the neck. Is lateral flexion limited? Bony end block? Positive Test: Notably decreased forward flexion and a hard end feel. Compare

sides. 28 28

Clinical Tests: Upper Limb Tension Test (ULLT) or Elvey Test Suspected positive test for Neurogenic TOS Position 1 • #1: Arms abduction to 90°

• #2: Extend wrists

Position 2

• #3: Tilt head to side

Position 3 Positive Test: pain and/or paresthesia in the hand or around the elbow

29 + test which position provoked symptoms 29

Clinical Tests for Thoracic Outlet • Rule Out Negative Tests: Highest Sensitivity (2 negative tests)

• Cervical Rotation Lateral Flexion • Roo’s Elevated Stress Test • Upper limb tension testing • Wrights • Rule In Positive Tests: Highest Specificity (5 positive tests)

• Supraclavicular pressure • Cervical Flexion Lateral Rotation • Cyriax Release Test • Roo’s Elevated Stress Test • Costoclavicular Manuever • Wright’s Test

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Posture: Scalenes Length & 1st Rib Mobility

Suspected Clinical Restriction Treatment Strategy Compression Reasoning Site Anterior & • Supraclavicular • Soft tissue • Scalenes Middle Pressure test + shortness mobilization & Scalenes • Cervical lateral • Elevated 1st stretching flexion test + rib • Neuromuscular re- • Elvey test + • Hypomobility education of 1st rib • Diaphragmatic breathing • 1st rib mobilization

Teach Diaphragmatic Breathing • Teach diaphragmatic breathing • Scalenes release • Stretch scalenes • 1st rib mobility

(Hooper, Denton, McGalliard, Brismee & Sizer, 2010) 32

Soft Tissue Mobilization Technique #1: Scalenes Soft Tissue Release • Teach diaphragmatic breathing • Scalenes release • Stretch scalenes • 1st rib mobility Client is sitting with therapist standing behind client. Therapist places index and/or long digits on anterior scalenes with moderate caudal pressure. Client moves slowly towards slight lateral flexion to uninvolved side

and rotation to involved side.(Hooper, Perform Denton, McGalliard, 5Brismee to & Sizer,10 2010) reps. 33 33

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• Teach diaphragmatic breathing st Promote 1 Rib Mobility • Scalenes release • Stretch scalenes • 1st rib mobility • Clinician places radial hand on the 1st rib while using the other hand to stabilize the shoulder. • The patient turns their head towards the treatment side. • Clinician provides a glide to the 1st rib towards the opposite hip and slightly anterior.

(Hooper, Denton, McGalliard, Brismee & Sizer, 2010)

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Promote 1st Rib Mobility Home Program

Self 1st Rib Mobility The patient is in sitting with cervical spine retracted. The client sits on a sheet/towel and places the sheet 1 inch lateral to the transverse process of T1. The patient uses their own hand to pull on the sheet in a contralateral caudal (opposite hip) direction. Adding a head rotation will stretch the scalenes (Hooper, Denton, McGalliard, Brismee & Sizer, 2010) 35

Suspected Clinical Restriction at Scapula Treatment Strategy Compres- Reasoning sion Site Costoclavicular • Poor posture • Depression: poor muscular • Diaphragmatic breathing between • Depressed recruitment to achieve Depression clavicle and 1st and/or scapular upward rotation • Stretch tight muscles rib downwardly and/or muscular tightness at (latissimus and rotated shoulder depressors pectoralis) scapula (latissimus dorsi, pectoralis • Neuromuscular observed major/minor) retraining (taping) • Scapular • Downward Rotation: same scapula upward rotators Correction as above except muscle • Strengthening scapula Test + tightness possibly at scapular upward rotators (lower downward rotators (levator trapezius and serratus scapulae and rhomboids) anterior) • Poor movement patterns • Scapula mobilization between scapula and • Disassociate scapula and humerus humerus motion 36

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Suspected Clinical Restriction Scapula or Treatment Strategy Compres- Reasoning Glenohumeral Joint sion Site Costoclavicular • Palpation • Poor scapula posture and • Diaphragmatic breathing space and/or • Observations recruitment: Anterior tilted Depression beneath of poor and/or downward rotation • Stretch tight muscles pectoralis posture due to muscular shortness or (latissimus and minor • Scapula poor muscular recruitment pectoralis) correction patterns • Neuromuscular test + • Poor glenohumeral motion: retraining (taping) • Anterior tilted posterior capsule tightness; scapula upward rotators scapula unable to dissociate scapular • Strengthening scapula • Short from glenohumeral motions upward rotators (lower pectoralis trapezius and serratus minor muscle anterior) • Joint specific • Scapula mobilization test + for • Disassociate scapula and humerus humerus motion 37

Suspected Clinical Restriction Treatment Strategy Compres- Reasoning sion Site Costo-clavicular • Cervical • Soft tissue shortness scalenes • Scalenes mobilization & space between lateral flexion • Elevated 1st rib stretching clavicle and 1st rib test + • Hypomobility of 1st rib • Neuromuscular re-education • Diaphragmatic breathing • 1st rib mobilization

Costo- • Joint • Hypo-mobility of • AC and SC clavicular specific clavicle mobilizations space test acromioclavicular between suggest (AC) and/or clavicle and poor sternoclavicular 1st rib clavicle (SC) joints mobility 38

Lab/Treatment Strategies for: Depressed Scapula Effecting Costoclavicular Space AC & SC Mobility

• Mobilize clavicle • Correct scapular restrictions • Disassociate glenohumeral from scapula motions • Correct glenohumeral capsular restrictions • Thoracic mobility • Progress to strengthening

Image from Watson, Pizzari & Baister, 2010)

(Hooper, Denton, McGalliard, Brismee & Sizer, 2010)

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Assessing Scapula by Observation Static

Downward Rotation • Inferior border of Depressed scapula Anterior Tilt scapula is closer to • Superior border is lower that T2 • Inferior border • One arm longer than the other the spine as protrudes from thorax compared to superior border

Test: Muscle length of latissimus dorsi, pectoralis clavicular and sternal fibers

P. major sternal fibers Latissimus dorsi P. major clavicular fibers

Marik, T. Marik, T. Assess pectoralis major clavicular fibers, Assess pectoralis major clavicular fibers, December, 2009. Courtesy Tambra Marik December, 2009. Courtesy Tambra Marik Marik, T. Latissimus Dorsi assessment, December 2009. Courtesy Tambra Marik • Shortness exists • Short clavicular • Short muscle fiber when the patient fibers exist when exists when is unable to reach the arm can not horizontally abduct/drop down abduction at 120° to arms overhead to to the mat at 90° abduction 140° does not drop the mat. down to the mat.

Kendall, F.(2005). MUSCLES TESTING AND FUNCTION WITH POSTURE AND PAIN. Baltimore, MD: Lippincott Williams & Wilkins. 41

Testing: Posture Observations and Muscle Length

Inferior angle protrudes R acromion higher

• Perform muscle length test for pectoralis minor. • Client lies supine with external rotation (palms up). • Check for asymmetry. Is the posterior acromion higher off the mat on one side. • Tightness at pectoralis minor will contribute to scapular anterior tilt causing the acromion to be higher on the tight side. 42 42

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Treatment: Pectoralis Muscles

Stretching pectoralis minor with Stretching pectoralis minor and client on a foam roller and major with client on a foam roller. therapist manually stretching. Therapist’s as one hand on Therapist’s hands are on the unilateral coracoid process coracoid process stretching stretching dorsal and lateral. The dorsal and lateral. other hand supports the arm.

Treatment Strategies: Scapular Restrictions

• Mobilize clavicle • Correct scapular restrictions • Lengthen short muscles • Scapula Mobilizations • Neuromuscular Re-education • Correct glenohumeral capsular restrictions • Disassociate glenohumeral capsular restrictions from scapula • Thoracic mobility • Progress to strengthening

Treatment Strategies: Stabilize scapula with pectoralis minor in a lengthened position

The client is supine. Client is instructed to flex at knees and hips. A roller or towel is placed lengthwise down spine. Humerus supported. The client stabilizes scapula while performing external rotation exercises. Perform 5 to 10 reps 45 45

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Treatment: Mobilize Clavicle AC Glide

SC Glide • One hand on the • One hand stabilizes the AC joint scapula • The thumb of the other • Thenar eminence of the hand is placed on the other hand on the posterior acromion medial clavicle • Provide a anterior glide to the posterior acromion providing a inferior and while stabilizing with the posterior glide. Marik 2018 Nerve Compressionother and Injuries hand 46 46

Treatment: Neuromuscular Re-education Scapula Downward Rotation/Depression/Anterior Tilt • Exercises to promote scapular upward rotation • Taping to promote upward rotation • Wall slides for upward rotation. Ulnar forearm on wall. Slide towards a teardrop position. 5 to 10 reps. Progress to resisted scaption exercises. (Hooper, Denton, McGalliard, Brismee & Sizer, 2010)

As symptoms improve exercises can progress. Position #1 47

• OBSERVATIONS • MOTOR • SENSORY EVALUATION • LIGHT MOVING TOUCH PERIPHERAL • VIBRATION THRESHOLDS NERVE • CUTANEOUS PRESSURE THRESHOLDS • 2 POINT DISCRMINATION COMPRESSION • PAIN EVALUATION • PALPATION, POTENTIAL COMPRESSION SITES & CLINICAL PROVOCATIVE TESTS • EVAULATING CERVICAL

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Observations (distal) Early Late Vasomotor (temp., color, edema , cold Skin rosy Skin mottled tolerance) Skin warm Skin cold Sudomotor Dry skin Dry or overly moist skin (sweat patterns)

Pilomotor (“goose flesh”) Absent Absent

Tropic (skin texture, atrophy to digit pulps, Fingernails blemish Curved nail changes, hair growth changes, slow skin healing) Longer & fine hair growth Longer & fine hair growth

Skin soft & smooth Skin smooth/non-elastic

Slight atrophy Atrophy at finger pulps

49 SOURCE: Callahan, Anne D. : SensibilityTesting: Clinical Methods Rehab of the Hand , ed2, 1984 The CV Mosby Co. 49

Evaluation: Differentiating Nerve Lesions

• Combine clinical findings of reflex, sensory and strength testing • Motor • Nerve Root: Myotome • Peripheral: Peripheral Nerve Innervation • Sensory • Nerve Root: Dermatomes • Peripheral: Peripheral Nerve Cutaneous Distribution • Deep Tendon Reflexes • Interpreted with sensory and strength findings to determine nerve root versus peripheral nerve lesion: • Hypotonia involving lower motor neurons (nerve root, neuromuscular junction or muscle) • Hypertonia involving upper motor neurons

MOTOR EVALUATION: Manaul Muscle Testing

Nerve Root Myotome Peripheral Nerve Associations Associations • • C5- shoulder abduction Muscles innervated by each nerve • C6– Elbow flexion, Wrist extension • Median • C7 – Elbow extension, Wrist flexion • Ulnar • C8 – Finger flexion • Radial • Musculocutaneous • T1 – Finger abduction • Axillary Clinical Hints: T1 intrinsics C6 supinator C5 shoulder abduction, extension and external rotation C7 & 8 almost all others 51

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SENSORY EVALUATION: Patient Subjective Symptoms

By Grant, John Charles Boileau - An atlas of anatomy, / by regions 1962, Public Domain , https://commons.wikimedia.org/w/index.php?curid=30017222 Nerve Root • Spinal segment representation of Peripheral Nerve • dermatome (sensory) and Decreased sensation and strength in the peripheral myotome (motor) patterns distribution pattern

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 812File:Gray812.png and 52 File:Gray814.png, Public Domain, https://commons.wikimedia.org/w/index.php?curid=3460423 52

Quick Scan of Motor Scan for Peripheral

Nerve Median • Resist palmar abduction for median nerve

– Resist thumb dorsal Radial retropulsion for radial nerve

Ulnar – Resist index finger abduction and palpate 1st dorsal interossei for ulnar nerve 53

SENSORY EVALUATION: Moving Light Touch

Ten Test is a screen for large A-Beta fibers (testing moving fibers Meissner and Pacini quick adapting receptors) • Moving touch contra-lateral unaffected digit identifying normal sensation at 10/10. • Touch the same area on the involved side and patient rates the normal sensation compared to the contra-lateral side. (Strauch et. al, 1997)

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Muscle Reflexes Grade Response Interpretation Clinical Reasoning 0 No response Always abnormal Lower neuron

1+ Slight, muscle contraction May or may not Lower neuron but there is no joint be normal movement 2+ Brisk response Normal Normal 3+ Very brisk response May or may not Upper motor be normal neuron 4+ Clonus Always abnormal Upper motor neuron 55

Deep Tendon Reflexes Spinal Level Reflex Peripheral Nerve C6 Biceps Musculocutaneous

C5-6 Brachioradialis Radial Nerve

C7 Triceps Radial Nerve

Hypotonic reflex: suspect lower motor neurons/cervical radiculopathy; individuals with carpal tunnel likely will not cause changes with reflexes due to a distal compression.

SENSORY EVALUATION: Vibration Thresholds

Testing sensory return: 30 cps vibration to affected area (testing Merkel & Ruffini low frequency quick adapting receptors) Testing for early neural changes: 256 cps to digit pulp of involved followed by a comparison of sensation intensity to the uninvolved (testing Pacini and Meissner high frequency quickly adapting receptors) High adapting fibers are thought to be affected first in chronic

nerve compression (Novak & Mackinnon. 2005) 256 cps best for testing in chronic injury because they are the first affected

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SENSORY EVALUATION: Cutaneous Pressure Thresholds

Testing sensory return of fine tactile & discriminative location: Semmes Weinstein testing screens for threshold (testing slow adapting Merkel receptors)

SENSORY EVALUATION: Two Point Discrimination (pd)

Static Two-Point Discrimination (Table modified from Klein, 2014) 1-5 mm Normal 6-10 mm Fair 11-15 mm Poor Only one point Protective sensation perceived only No point perceived Anesthetic Testing quantity of innervated sensory receptor

Pain Evaluation

• Pain during varying activities (work, home, sleep, etc.) • Pain scales (visual analog scale) • Pain descriptors • Body diagram chart • How is client coping with pain? Mechanisms such as medications • Would the client benefit from psychological counseling? Will pain hinder the progress in therapy?

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Visceral Referral Pain Patterns

General characteristics of pain due to visceral pathology 1. Is poorly localized with referral to somatic structures 2. Produces nonspecific regional or whole-body motor responses 3. Produces strong autonomic responses 4. Leads to sensitization of somatic tissues 5. Produces strong affective responses By OpenStax College - Autonomic Reflexes and Homeostasis http://cnx.org/content/m46579/ (Sikandar & Dickenson, 2012) 1.2/, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30017359 61 61

Palpation, Potential Compression Sites & Clinical Tests

• Creates nerve tension and compression at nerve sites • Assist with determining compression site • Helpful identifying area of compression in the early stages when there may not be symptoms of sensory changes • Tinels and provocative tests performed from proximal to distal for clinical signs of double crush syndrome. (Novak & Mackinnon, 2005)

Nerve Pathways & Palpation: Median Nerve Path Proximally C5,6,7,8,T1 • Lateral root arises from lateral cord; medial root arises from medial cord Forearm • Follows the brachial artery; Innervations medial at elbow • Passes through two heads of pronator; deep to bicep aponeurosis • Passes b/w FDS and FCR • Emerges distally b/w FPL & FDS • Enters carpal tunnel By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 816, Public Domain, https://upload.wikimedia.org/wiki https://commons.wikimedia.org/w/index.ph 63 pedia/commons/d/de/Gray812an d814.PNG p?curid=328869 63

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Median Nerve Possible Compression Sites Carpal Pronator Syndrome (PS) Anterior Tunnel Interosseus Nerve (AIN) Syndrome

Carpal tunnel Supracondylar process (spurs)? Edge of deep pronator Ligament of Struthers FDS arch Bicipital aponeurosis Accessory head FPL Gantzers B/w ulnar and humeral heads of Accessory muscle from pronator teres FDS to FDP FDS arch 64

Carpal Tunnel vs. Cervical Radiculopathy Symptoms

Carpal Tunnel Cervical Radiculopathy

Paresthesia in digits #1-2 & Sensory deficit at lateral radial side #3 arm and digits #1-3 Waking due to night pain

Hand weakness, clumsy Arm and hand weakness

Upper extremity pain Pain at neck, scapula and upper extremity

Waier et al 2000 65 65

Provocative Tests:

Carpal Tunnel Testing CLINICAL TESTS Carpal compression test Phalens Tinels Median nerve tension test

66 66

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Clinical Tests Pronator Syndrome versus Anterior Interossei Nerve Compression tests

Pronator Teres Syndrome AIN Syndrome Resisted pronation with Weak pronation tested elbow extended (pronator with elbow flexed? teres) Weakness of thumb IP and IF DIP. Weak grip/pinch Unable to make OK sign Resisted contraction to long finger FDS (FDS compression)

67 67

Clinical Tests Pronator Syndrome • Pronator Compression Tests: Pressure for 30 seconds at PT (1.5 in distal flexion crease) muscle belly recreates symptoms.(PT compression) • + Tinels at proximal forearm; pronator compression • Symptoms reproduced with resisted pronation (wrist neutral) passively extending elbow.(PT compression) • Resist elbow flexion between 120-130 degrees with supination recreates symptoms. (Bicipital aponeurosis compression) 68

Nerve Pathways & Palpation: Radial Nerve Path Proximally C6,7,8,T1

Proximal Innervations Triceps Anconeus ECRL • Exits triangular interval ECRB • Posterior between long head Brachioradialis of triceps and humerus • Through spiral groove • Lateral intermuscular septa (b/w brachialis and By Henry Vandyke Carter - Henry By Henry Vandyke Carter - Henry Gray (1918) Gray (1918) Anatomy of the Anatomy of the Human Body (See "Book" brachioradialis anterior to Human Body (See "Book" section section below)Bartleby.com: below)Bartleby.com: Gray's Gray's Anatomy, Plate 818, Public Domain, Anatomy, Plate 818, Public https://commons.wikimedia.org/w/index.ph lateral epicondyle) Domain, p?curid=541674 https://commons.wikimedia.org/ 69 w/index.php?curid=541674 69

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Compression Sites Proximal to the Elbow: TRIANGULAR INTERVAL (TI) & SPIRAL GROOVE

https://clinicalgate.com/wp-content/ uploads/2015/03/B9781455726721000210_ https://clinicalgate.com/wp-content/ f021-002-9781455726721.jpg uploads/2015/03/B9781455726721000210_f021-008-9781455726721.jpg http://upload.wikimedia.org/wikipedia/commons/1/16/Gray412-spaces.png Triangular Interval (TI) Spiral Groove • TI contains radial nerve and profunda artery • Compression • TI compressions can occur from: distal triceps • Posture humeral add/ir and scapular protraction • Hypertrophy of teres major • Adaptive shortening of internal rotators • Fibrous arch at the long head of triceps 70 70

Mechanism of Injury Triangular Interval Spiral Groove

Hypertrophy at teres major and Compression from leaning on a hard medial triceps surface “Saturday Night Palsy”

Fibrous bands at teres major and Radial shaft fractures medial triceps Shortened teres major Sports with forceful shoulder extension Symptoms reproduced with external rotation combined abduction

Triangular Interval Spiral Groove Presentation Motor Weakness in all Triceps spared. Presen- muscles innervated by Weakness at all Sites Radial tation radial nerve muscles Nerve innervated by radial nerve distal to triceps Sensory • Posterior cutaneous Superficial radial Presen- nerve of arm nerve tation • Lower lateral cutaneous nerve of arm • Posterior cutaneous nerve of forearm • Superficial radial

https://clinicalgate.com/wp-content/ nerve uploads/2015/03/B9781455726721000210_ f021-002-9781455726721.jpg 72 Adapted from Haymaker, W., Woodhall, B., 1953. Peripheral nerve injuries. WB Saunders, Philadelphia.) 72

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Compression Sites Radial Nerve Distal to Elbow Two conditions; Same compression sites

https://clinicalgate.com/wp-content/uploads/2015/03/B9781455726721000210_f021-002-9781455726721.jpg (Roles & Maudsley, 1972) Posterior Interossei Nerve Radial Tunnel (PIN) Fibrous bands at radiocapitellar joint Leash of Henry Medial edge of ECRB Proximal edge of supinator (Arcade of Frohse) Distal edge of the supinator 73 73

Clinical Presentation: Radial Nerve PIN Radial Tunnel Weakness Lateral proximal forearm pain, tenderness at and/or paralysis supinator muscle, pain with supination with to: ECRB, extended elbow, pain with resisted long finger. • No motor weakness supinator, ECU, EDC, EDM, APL,

https://clinicalgate.com/wp- content/uploads/ EPL, EPB, EI 2015/03/B9781455726721000210 _f021-002-9781455726721.jpg Awakens nocturnally due to forearm pain

Pronation, elbow ext and wrist flex ↑ symptoms Rule out tennis elbow, may have lateral elbow

https://clinicalgate.com/wp-content/uploads/2015/03/B9781455726721000210_f021-002-9781455726721.jpg tenderness 74 74

Provocative Tests Radial Nerve Posterior Interossei versus Radial Tunnel

Posterior Interossei Radial Tunnel Resisted supination recreates pain. Tenderness 3-5 cm distal lateral epicondyle Test for weakness of MP extension Resisted supination with the elbow and wrist weakness. and wrist extended reproduces Observe wrist extension for a bias pain. towards radial deviation. Positive pain with long finger extension test. Passive pronation with wrist flexion reproduces pain 75 75

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Nerve Pathways & Palpation: Ulnar Nerve Path C8, T1 • Arises from the medial cord • Descends distally and medially at the arm • 1/3 distal arm pierces intermuscular septum traveling posterior • Crosses elbow posterior in supracondylar area • Enters forearm b/w medial epicondyle and olecranon • Deep to FCU in forearm • In hand, lateral to pisiform and hook of hamate • Ulnar nerve superficial branch (cutaneous) and deep (motor) within Guyon’s canal

76 76

Compression Sites Ulnar Nerve

High Lesions Low Lesions Cubital Tunnel Distal to FCU and FDP motor branches Medial Intermuscular Guyon’s canal Septum Arcade of Struthers

Flexor carpi ulnaris (FCU) 77

Ulnar Nerve Clinical Presentation High Lesions • All extrinsics and intrinsics affected (weak wrist flexors) • Sensory loss over palmar and dorsal aspect of small digit and ulnar half of ring digit Low Lesions • Deep intrinsics affected (wrist flexors intact) • No sensory loss over proximal and middle phalanx of dorsal small and ring digits due to dorsal cutaneous nerve branch being spared

https://www.google.com/url?sa=i&rct=j&q=&esrc=s &source=images&cd=&cad=rja&uact=8&ved=2ahUK EwierPXpmavaAhVo94MKHQRmBCIQjRx6BAgAEAU &url=http%3A%2F%2Fteachmeanatomy. info%2Fupper-limb%2Fnerves%2Fthe-ulnar- nerve%2F&psig=AOvVaw16f9ivvlLRnTQg53iMtSzi&u st=1523294471613937 78 78

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Provocative Tests for Unar Nerve Guyons Canal versus Cubital Tunnel Clinical Tests Cubital Tunnel Tinels at cubital tunnel and Guyon’s canal

Modified Shoulder Internal Rotation Test

Elbow Flexion Test Scratch Collapse Clinical Test for Guyons Canal Sensory testing at dorsal ulnar digits normal

but, volar ulnar digits impaired 79 79

Clinical Tests: Cubital Tunnel Syndrome

Tinels Modified Shoulder Internal Elbow Flexion Test Sensitivity: Rotation Test Sensitivity: 46% to Sensitivity: 87% (5 second) 75% (1 to 3 min.) 54% to 70% (Hutchinson et al 2011) Specificity: 97% Ochi et al 2012 80

CERVICAL SCREENING

• Retrieved on 12/10/12 from: • http://upload.wikimedia.org/wikipedia/co mmons/thumb/5/54/Cervical_vertebrae_late ral2.png/600px- Cervical_vertebrae_lateral2.png

81 81

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Cervical Spondylosis: Non-specific term Cervical Cervical nerve roots compression and inflammation of Radiculopathy the nerve root or roots at or near the cervical foramen. Type I Symptoms are pain radiating into the arm corresponding to the dermatome of the involved https://www.coloradospineinstitute.com/files/ 3614/5121/6098/13_vert_body.jpg cervical nerve root Cervical Compression of the cervical spinal cord related to Myelopathy degeneration of discs and bone spurs. Symptoms can Type II include: weakness and numbness, loss of balance and coordination and neck pain. Rheumatoid arthritis can cause myelopathy due to synovium swelling

destructing facet joints. https://upload.wikimedia.org/wiki pedia/commons/c/cb/Doberman_ C6-C7_and_C5- Neck pain with pain radiation to one or more of the C6_traction_responsive_myelopat Axial Joint Pain hy_A.jpg Type III following: medial scapula, chest wall, shoulder area and head. Symptoms stem from the joints. Correlation between activity and pain. Pain is expected to improve with rest. 82

EXAMINATION 1. History 2. Pain Patterns & Scales 3. Inspection 4. AROM/PROM of upper limb & cervical 5. Palpation 6. Myotome scan 7. Dermatome scan 8. Vertebral Artery test 9. Provocative tests 10. Upper limb neural tension testing (median, ulnar, and radial nerves) 83 Adapted from McClure 2004 83

History

• Current condition and past condition • Age • Past medical information/surgeries • Onset/history of current condition • Medications • Social history (past & present) • Occupations and functional status • Past location • Pain Characteristics: patterns (dermatomal, mechanical, segmental distribution pattern, trigger point), aggravating activity, intensity, duration, location

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Pain: Classification

Central Denervation Peripheral Nerve Musculoskeletal Sensitization Significant axonal Sensitization Pain Central nervous compromise but system no central nervous Inflammation Pain is referred centralization. system changes. arising from Dominance of Loss of nerve nerve trunk or from non-neural allodynia and supply. Can be peripheral nerve structures. hyperalgesia from injury, disorders or without clinical surgery. evidence of Administer Laniss significant Pain scale denervation. http://www.bayare Injury to the area apainmedical.com/ produces a flare. chrnanm.html

Posture

• Patient attempts to shorten • Patient may attempt to anatomical distance over the increase the available space course of the sensitized nerve surrounding the nerve roots when experiencing central when experiencing sensitization neuropathic pain related to • Elevated scapula, ipsilateral denervation from side cervical flexion and elbow compressed, stenotic nerve flexed root

Inspection/Posture

Forward head posture, rounded shoulders, kyphosis • Scapula protracted & internally rotated (IR) and glenohumeral IR or flat cervical spine • Associated with headaches and interscapular

pain(Griegel-Morris, Larson, Mueller-Klaus & Oatis, 1992)

• Interscapular pain (Griegel-Morris, Larson, Mueller-Klaus & Oatis, 1992) • Overly extended cervical spine can cause Figure from: Donatelli, overstretching and friction on nerve roots R. A., & Wooden, M. J. (2009). • Asymmetry? Alignment of scapula? Scoliosis?

• Guarding

87 87

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Inspection: (cont.) Forward Head Posture

Forward Head Posture Joint Mechanical Changes • Excessive forces at mid cervical spine • Increased forces on intervertebral disc & neural arches • Degeneration of disc • Osteophytic spurs a posterior facet joints • Friction at cervical vertebrae due to repetitive extension & rotation causing friction on the nerve roots at the transverse processes

Vertebral Artery Testing

Patient can be supine or sitting. • Extend, rotate and flex the cervical spine to the right when testing the left side (vice versa for testing the right side). Hold the position for approximately 30 seconds and ask the patient to count back from 20. • Signs of a positive test are: • Dizziness • Diplopia (double vision) • Dysarthria (poor motor speech) • Dysphagia (difficulty swallowing) • Drop attacks (short loss of consciousness • Nausea and vomiting • Sensory changes • Nystagmus

Cervical AROM Check for quality of movement, burning, sharp pain, numbness is there a correlation of adverse responses? • Client actively flexes cervical spine • Followed by active cervical extension with the mouth open to avoid tension of suprahyoid and infrahyoid muscles

Clinical Reasoning: Muscular, Ligament Strain/Sprain or Nerve Root Maneuver Pain (soft tissue) Pain (nerve root) AROM Yes Yes PROM Yes Yes Provocative of ligament or Yes Yes muscle or ligament Provocation of neural No (paresthesia) Yes (paresthesia) tissue 90 90

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Cervical ROM (cont.) Active motion first, followed by overpressure, if there was no pain actively. • Flexion

• Extension

• Side-bending

• Rotation

91 91

Provocative Tests: Testing Recreation of Symptoms • AROM, if no pain

• Over pressure at end range, if no pain

• Compression/ Distraction, if no pain

• Spurlings

• Arm squeeze test (Gumina, Carbone, Albino, Gurzi & Postacchini, 2013)

• Determine cluster signs 92

Palpation • Start with uninvolved side • Palpation should be mild (blanch the nailbed of the palpating finger) • Supra and infra-clavicular fossa associated with TOS involvement • Distal nerve palpation to rule out peripheral nerve involvement

Upper and Middle Trunks • Posterior to sternocleidomastoid (STM) • Between the anterior and middle scalenes

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Paresthesia & Sensory Loss: Myotome and Dermatome Scan Referred Pain Patterns

• MYOTOME: muscles served by a single spinal nerve

• DERMATOME: spinal segment innervates skin

• SCLEROTOMAL: area of bone innervated from a single spinal segment

94 94

Myotome Scan: Testing Strength (cont.) (Painless and weak suggestive of neurologic compromise). • C2,3,4 scapular elevation

• C5 shoulder abduction

• C6 elbow flexion, wrist extension

• C7 elbow extension, wrist flexion

• C8 digit flexion

• T1 finger abduct/adduct 95

Myotome Scan (cont.)

C2,3,4 C5 C6

C6 C7

T1 T1

Marik 2018 Nerve Compression and Injuries 96 96

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Dermatome Pain: Testing sensory (cont.)

• C4 supraclavicular area • C5 lateral arm • C6 dorsal lateral thumb • C7 long finger • C8 ulnar hand • T1 medial forearm • T2 apex axilla Retrieved on 07/05/09 from: http://en.wikipedia.org/wiki/File:Der matoms.svg

Marik 2018 Nerve Compression and Injuries 97 97

Peripheral Nerve Management

PERIPHERAL NERVE MANAGEMENT

Post-op: Non-Op Management: • Good MD Communication • Improve Tissue mobility • Protect surgical structures • • Manage edema and pain Activity Modification • Sensory Re-training techniques • Improve nerve mobility • Cortical Retraining activities can be • Orthosis as needed helpful • • Maintain Mobility of uninvolved Space, motion, and slack joints • Orthosis as indicated

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Post-Surgical management

• Good Communication with MD is key • Type of repair? • Tension? • Nerve Graft and nerve conduits? • Nerve Transfer?

100

Sensory Re-education & Cortical Re-mapping

Sensory Re-education: • Localization and Discrimination • 4 to 6 months after repair

Cortical Re-mapping : • Cortical Silent period • Application EMLA cream • Cutaneous anesthesia significantly improved distal sensation after 6 weeks Lundborg, G., Björkman, A., & Rosén, B. (2007). Enhanced sensory relearning after nerve repair by using • Protect surgical structures repeated forearm anaesthesia: aspects on time dynamics of treatment. In How to Improve the Results of Peripheral Nerve Surgery (pp. 121-126). Springer, Vienna. 101

101

Sensory Re-Education and Cortical Re-mapping

• Walbruch and Kalliainen retrospective study • Established post-op standardization protocol • Result suggest cortical reorganization improve sensory outcomes.

Procedure • 2 weeks post repair forearm rubbed with anesthesia. Denervated area rubbed with varying textures (2x wk/1 mo followed by 1xwk/4 mo). • Visual and auditory feedback • Imagery activities: client described how things feel. • Laminated cards with 15 action verbs read throughout the day and client visualized doing the activity • Mirror therapy 1 to 2x daily using varying textures

(Walbruch & Kallianinen, 2015)

102 102

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Sensory Re-Education: Patient is able to identify vibration 30cps Phase II

• Nerve is beginning to innervate • Introduce traditional sensory training • Rice bins • Textures • Shapes • Tracing items with digits

103 103

Proprioceptive Activities

Light Ball Toss

Gentle Oscillations Scarf Juggling Marik 2018 Nerve Compression and Injuries 104

104

Non-operative Peripheral Nerve Management

• Goal is to create space, slack, and glide around the nerve • Soft tissue mobilization • Neuro mobilization/Nerve Glides (mobilize/glide) • Orthosis (create slack) • Taping (create space) • Cupping? (create space)

M. Butler (2019, May). Scrape, Cup & Glide: Neuro Mobilization for the UE. Presented at Select Physical Therapy Charlotte, NC

105

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Cupping Principles

• Primary objective to provide space along the nerve bed • Compressive forces around the rim and distraction at center cup • Combine with distraction to maximize tensile and distractive forces • Static- sustained pressure/tissue distraction • Evidence? • Contraindications: • Can produce erythema and ecchymosis • Avoid DVT • Compromised skin

M. Butler (2019, May). Scrape, Cup & Glide: Neuro Mobilization for the UE. Presented at Select Physical Therapy Charlotte, NC

106

Median Nerve

107

Pronator Syndrome AIN Syndrome

Rest; orthosis to avoid Rest; orthosis with rotation elbow flexion at 90 degrees (8-12 wks) Nerve glides? Nerve glides? Taping? Taping? Soft Tissue Soft Tissue Mobilization? Mobilization? Decompression surgery is indicated if symptoms remain.

108 108

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Carpal Tunnel vs. Cervical Radiculopathy: Symptoms

Carpal Tunnel Cervical Radiculopathy

Paresthesia in digits #1-2 & Sensory deficit at lateral radial side #3 arm and digits #1-3 Waking due to night pain

Hand weakness, clumsy Arm and hand weakness

Upper extremity pain Pain at neck, scapula and upper extremity

Waier et al 2000 109 109

Carpal tunnel Interventions

Interventions

Nocturnal wrist orthosis

Carpal mobilization techniques

Nerve gliding

Tendon gliding

Marik 2018 Nerve Compression and Injuries 110

110

Carpal Tunnel Treatment

Symptoms improved with wear of nocturnal and day wrist orthosis.

Walker, Metzler, Cifu, Swartz, 2000

• 12 week follow-up supports full-time wear of orthosis for median motor distal latency deduction and improvement with median motor compound muscle action potential 111 111

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Carpal & Nerve Mobilization

• Mobilization group compared to controls • Therapy 3 days a week for 4 weeks • Carpal mobilizations performed 3x for 30 seconds • Neural mobilizations performed 15 reps/3x with oscillatory elbow flexion and extension • Mobilization group improved with function status scale and improved motor latency

(Oskouei et. al, 2015)

112 112

Carpal Tunnel Gliding: adding digit abd/add

• Traditional nerve gliding exercises resulted in minimal gliding at the carpal tunnel. • Adding digit abduction increased median nerve glide at carpal tunnel. • Positive numbers represent proximal gliding • Negative numbers represent distal gliding

(Meng et. al, 2015)

113

Median Nerve Gliding Occurs during Tendon Gliding Exercises

• Significant changes from hook to fist position • Significant changes from straight to hook position • Increased compression in controls and experimental group in fist position Echigo, Aoki, Ishiai, Yamaguchi, Nakamura & Sawada, 2008)

114 114

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Carpal Tunnel Management

• Daily Orthosis Wear • Carpal Mobilization techniques can be helpful • Neuro mobilization with Finger Abduction • Avoid Forceful Gripping

115 115

Ulnar Nerve

116

Compression Sites Ulnar Nerve

High Lesions Low Lesions Arcade of Struthers Distal to FCU and FDP motor branches Medial Intermuscular Guyon’s canal Septum Cubital Tunnel

Flexor carpi ulnaris (FCU) 117 117

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Interventions for Ulnar Nerve Interventions for Cubital Interventions for Guyon’s Tunnel Canal Rest/Orthosis: elbow flexion Wrist orthosis? block nocturnally; heelbo during waking hours Patient Education Patient Education

Activity Modification: Avoid elbow Activity Modification: Avoid palmar flexion end range, leaning on elbow or any compression and/or trial wear padded protective repetitive elbow activity. gloves Nerve Glides Nerve Glides: Is this effective distally?

118

Interventions for Ulnar Nerve Cubital Tunnel Syndrome Acute phase GOAL: Decrease pain/paresthesia • Patient education: Avoid elbow flexion and leaning on cubital tunnel. • Activity modification: Avoid repetitive elbow motion, elbow flexion • Orthosis (elbow at 45 degrees flexion, wrist neutral, forearm slight supination)4-6 wks • Modalities with caution

( 119

119

Conservative Guidelines Ulnar Cubital Tunnel Syndrome

Phase II GOAL: Decrease pain/paresthesia

• Orthosis wear as needed Butler Tech. • Nerve gliding? Use with caution Retrived on 3/31/11 from: • Progress to strengthening as symptoms J Hand Ther, 2006;19:170-9. resolve with emphasis on proximal strengthening.

Retrieved on 3/31/11 from: http://3.bp.blogspot.com/ _P0F5l7HTnDU/S4YRUUOVt4I/ AAAAAAAAAJY/6vi_43V7skA/s1600/Butler .jpg.gif 120 120

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Radial Nerve

121

Interventions Triangular Interval (rare Spiral Groove condition) Avoid combined shoulder Most common radial extension activities nerve compression Transverse soft tissue High rate of nerve

mobilization of triceps and return 60% to 92% (Grass, Kabir, Ohse, Rangger, Besch & Mathiak, 2011) teres major Radial nerve gliding Wrist & digit orthosis (outrigger) Neuromuscular re-training (NMES, taping, etc.)

122

Radial Nerve Distal to the elbow PIN Radial Tunnel Weakness Lateral proximal forearm pain, and/or paralysis tenderness at supinator muscle, pain to: ECRB, with supination with extended elbow, pain with resisted long finger supinator, ECU, EDC, EDM, APL, EPL, EPB, EI

Awakens nocturnally due to forearm pain https://clinicalgate.com/wp- content/uploads/ 2015/03/B9781455726721000210 Pronation, elbow ext and wrist flex _f021-002-9781455726721.jpg symptoms Rule out tennis elbow, may have lateral elbow tenderness 123 123

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Non-operative Management Posterior Radial Tunnel Interossei Nerve (PIN) Maintain Orthosis to unload tension PROM Orthosis for Nerve gliding positioning and function Stretching wrist extensors and supinator?

Limit activities limiting pronation and elbow extension. Limit prolonged activities with wrist ext and pronation Marik 2018 Nerve Compression and Injuries 124 124

PERIPHERAL NERVE MANAGEMENT

Post-op: Non-Op Management: • Good MD Communication • Improve Tissue mobility • Protect surgical structures • • Manage edema and pain Activity Modification • Sensory Re-training techniques • Improve nerve mobility • Cortical Retraining activities can be • Orthosis as needed helpful • • Maintain Mobility of uninvolved Find a way to create Space, joints motion, and slack • Orthosis as indicated

125

• Slider: Tension off nerve • Tensioner: Tension on nerve

Theraband demonstration: median, ulnar, radial nerves Lab: Nerve Abnormal responses to gliding and/or tension Tension Testing of a nerve can result in: and Gliding • Impaired nerve mobility • Decreased nerve conduction velocity • Nerve damage • Loss of function Goal of nerve gliding: healthy blood profusion, axonal conduction and target tissue innervations

126

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Upper Limb Tension Testing Sitting Median Nerve

• Place involved side in following position: • Abduction and external rotation with slight extension • Elbow extension with forearm supination • Wrist extension • Cervical side bending to uninvolved side

Marik 2018 Nerve Compression and Injuries 127 127

Brachial Plexus Neurodynamic Test (BPNT): Grading Scale 0-5 Median Nerve Bias 0/5 Supine, shoulders level with arm with arm resting on abdomen; shoulder IR and adducted and elbow at 90°n flexion; wrist and fingers in neutral 1/5 Externally rotate shoulder to neutral; keep elbow at 90° flexion; the wrist and fingers remain neutral 2/5 The wrist and fingers remain in neutral, elbow 90° flexion; radial abduct the thumb; abduct shoulder to 110° in coronal plane while blocking scapula elevation; maintain forearm neutral rotation 3/5 Externally rotate the shoulder to 90° with the elbow remaining at 90° flexion; follow with supination while keeping the digits and wrist in neutral with thumb radial abducted 4/5 Keep the above position, but slowly extend the elbow 5/5 Same as above with elbow extended, slowly extend the wrist and digits (Butler, Karagiannopoulos & Galantino, 2019) 128

Left side testing pictured +/- + Beyond the grade but, < half-way to the next grade - > half-way to the next level Established Reliability and Accuracy 0/5 1/5

2/5 3/5 4/5 5/5 Forearm neutral Forearm supination Wrist & digits Wrist & digits (Butler, Karagiannopoulos & Galantino, 2019) neutral extended 129

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Peripheral Nerve Glide Lab

~ 5' yellow Theratube with loop for neck and finger

• Median Nerve Glide • Neck to long finger • Ulnar Nerve Glide • Neck, cubital tunnel, small finger • Radial Nerve Glide • Neck, under axilla, spiral groove to index finger

130

Median Nerve Gliding

Median Nerve: Tension: Median Nerve: Median Nerve: • Shoulder abduction • Wrist/finger extension Slider distally at Slider proximally at the • Shoulder external rotation wrist. Side bend neck. Extend the wrist • Elbow extension • Cervical side-bending neck to other side while moving the neck Thera-tube around long finger while flexing and from side flexion to https://www.youtube.com/wa extending the neutral or ipsilateral tch?v=Fv_EJV8q2E0 wrist. side flexion.

131

Upper Limb Tension Testing Sitting Radial Nerve

• Place involved side in following position: • Abduction and internal rotation with slight extension • Elbow extension with forearm pronation • Wrist flexion • Add cervical side bending to uninvolved side clinical clues

Marik 2018 Nerve Compression and Injuries 132 132

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Upper Limb Tension Testing

RadialPatient Nerve is supine while the examiner and fixates the scapula with body weight. Position 1: Shoulder girdle depression Position 2: Shoulder internal rotation & forearm pronation Position 3: Wrist & finger Differentiate flexion • Release cervical side- Position 4: Shoulder abduction bending Position 5: Cervical side- • bending Release shoulder Positive Tests: Symptoms with depression tensioning of the nerve Marik 2018 Nerve Compression• andRelease Injuries wrist flexion 133 (Schmid et al 2009) 133

Upper Limb Tension Testing Sitting Ulnar Nerve

• Place involved side in following position: • Abduction and external rotation • Elbow flexion with forearm pronation • Wrist flexion • Add cervical side bending to uninvolved side for clinical clues Marik 2018 Nerve Compression and Injuries 134

134

Upper Limb Tension Test

UlnarPatient Nerve is supine while the examiner and fixates the scapula with body weight. Differentiate Position 1: Wrist/finger extension • Release cervical side- Position 2: Forearm pronation bending Position 3: Elbow flexion Position 4: Shoulder • Release shoulder external rotation depression Position 5: Shoulder girdle depression • Release wrist Position 6: Shoulder abduction extension Positive Tests: Symptoms (Schmid et al 2009) with tensioning of the nerve

Marik 2018 Nerve Compression and Injuries 135 135

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Ulnar Nerve Gliding

Ulnar Nerve: Tensioner tube behind medial Ulnar Nerve: Ulnar Nerve: epicondyle: • Wrist/finger extension Slider at the Slider proximally. Flex • Forearm pronation elbow. Side bend elbow and side bend • Elbow flexion neck to opposite neck to neutral or • Shoulder external rotation • Shoulder girdle depression side. Flex and opposite side. May • Shoulder abduction extend elbow. need to modify elbow • Cervical side bending Thera-tube around small finger extension. 136

Radial Nerve Gliding

Radial Nerve: Tensioner wrap the tube around Radial Nerve: Radial Nerve: the humerus. • Shoulder girdle depression Slider at the wrist. Slider proximally. • Shoulder internal rotation & Move neck to forearm pronation Side bend neck to • Wrist & finger flexion opposite side while opposite side • Shoulder abduction 40° & ext 20° and back to • Cervical side-bending flex/extend wrist to tolerance. neutral with the Thera-tube around index finger. wrist extended.

137

Novel Median Nerve Gliding Techniques

• Exercise 1: ER & Abd. at • Exercise 2: ER & Abd. at shoulder, elbow shoulder, elbow extension, supination, extension, supination, wrist and digit extension wrist and digit extension while performing digit while performing abd./add. forearm supination and https://www.youtube.com/watch?v=Hl0CIg8Q pronation wY4

138

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Novel Median Nerve Gliding Techniques

• Exercise 3: ER & Abd. at shoulder, elbow extension, supination, wrist and digit extension while performing elbow flexion and extension Modify with sliding at cervical (side bend when elbow is extended)

139

Novel Median Nerve Gliding Techniques

• Exercise 4: ER & Abd. at • Exercise 5: ER & Abd. at shoulder, elbow shoulder, elbow extension, supination, extension, supination, wrist and digit extension wrist and digit extension while performing while performing shoulder circumduction shoulder distraction with side cervical bending

140

References • Apelby-Albrecht, M., Andersson, L., Kleiva, I. W., Kvåle, K., Skillgate, E., & Josephson, A. (2013). Concordance of upper limb neurodynamic tests with medical examination and magnetic resonance imaging in patients with cervical radiculopathy: a diagnostic cohort study. Journal of manipulative and physiological therapeutics, 36(9), 626-632.

• Arslantunali, D., Dursun, T., Yucel, D., Hasirci, N., & Hasirci, V. (2014). Peripheral nerve conduits: technology update. Medical Devices (Auckland, NZ), 7, 405.

• Ballestero-Pérez, R., Plaza-Manzano, G., Urraca-Gesto, A., Romo-Romo, F., de los Ángeles Atín-Arratibel, M., Pecos-Martín, D., ... & Romero-Franco, N. (2017). Effectiveness of nerve gliding exercises on carpal tunnel syndrome: a systematic review. Journal of manipulative and physiological therapeutics, 40(1), 50-59. • Brismée, J. M., Gilbert, K., Isom, K., Hall, R., Leathers, B., Sheppard, N., ... & Sizer, P. (2004). Rate of false positive using the cyriax release test for thoracic outlet syndrome in an asymptomatic population. Journal of Manual & Manipulative Therapy, 12(2), 73-81.

• Butler, M. W., Karagiannopoulos, C., Galantino, M. L., & Mastrangelo, M. A. (2019). Reliability and accuracy of the brachial plexus neurodynamic test. Journal of Hand Therapy, 32(4), 483-488. • Butler D (2000) The sensitive nervous system. Adelaide: Noigroup Publications

• DeFrancesco, C. J., Shah, D. K., Rogers, B. H., & Shah, A. S. (2019). The epidemiology of brachial plexus birth palsy in the United States: declining incidence and evolving risk factors. Journal of Pediatric Orthopaedics, 39(2), e134-e140.

• Donatelli, R. A., & Wooden, M. J. (2009). Orthopaedic Physical Therapy-E-Book. Elsevier health sciences.

• Fejer, R., Kyvik, K. O., & Hartvigsen, J. (2006). The prevalence of neck pain in the world population: a systematic critical review of the literature. European spine journal, 15(6), 834-848.

• Grubb S, Kelly C. & Bogduk N. (2000). Cervical discography: clinical implications from 12 years of experience.Spine, 25:1382-9

• Griegel-Morris, P., Larson, K., Mueller-Klaus, K., & Oatis, C. A. (1992). Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Physical therapy, 72(6), 425-431.

• Gumina, S., Carbone, S., Albino, P., Gurzi, M., & Postacchini, F. (2013). Arm Squeeze Test: a new clinical test to distinguish neck from shoulder pain. European Spine Journal, 22(7), 1558-1563.

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Website References

• https://www.orthobullets.com/spine/2031/cervical-myelopathy

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