peripheral nerve disorders & management

PERIPHERAL NERVE

DISORDERS &

MANAGEMENT

COMMON SITES OF INJURY TO PERIPHERAL NERVES

Nerve Roots Brachial Plexus Peripheral Nerves in the

Upper Quarter Lumbosacral Plexus Peripheral Nerves in the

Lower Quarter

IMPAIRED NERVE FUNCTION

Nerve Injury Neural Tension Disorders

NERVE INJURY : MECHANISMS OF NERVE INJURY

Nerves are mobile and capable of considerable torsion and lengthening owing to their arrangement. Yet they are susceptible to various types of injury including: Compression Laceration Stretch Radiation Electricity

NERVE INJURY :2 CLASSIFICATIONS OF NERVE INJURIES

Seddon’s Classification and Characteristic of Nerve Injury: Neuropraxia Axonotmesis Neurotmesis

NERVE INJURY : 2 CLASSIFICATIONS OF NERVE INJURIES

2 Classifications of Nerve Injuries Sunderland’s classification of Nerve Injury: First degree injury – (neuropraxia) Second degree injury – (axonotmesis Third degree injury – (either axonotmesis or

neurotmesis Fourth degree injury – (neurotmesis) Fifth degree injury – (neurotmesis)

NERVE INJURY : 2 CLASSIFICATIONS OF NERVE INJURIES

NERVE INJURY : COMPARISON BETWEEN SEDDON AND SUTHERLAND

NERVE INJURY : COMPARISON BETWEEN SEDDON AND SUTHERLAND

NERVE INJURY:RECOVERY OF NERVE INJURIES

When the nerve is injured, recovery is dependent on several factors including: Nature and Level of Injury Timing and Technique of Repair Age and Motivation of the Patient

NERVE INJURY:MANAGEMENT GUIDELINES – RECOVERY FROM NERVE INJURYThere are Three phases: Acute Phase – Immediately after injury or surgeryPT intervention: Immobilization – to protect the nerve, minimized

inflammation, and minimized tension at the injured/repaired site.

Movement – this is to minimize joint and connective contractures and adhesions.

Splinting/Bracing – to prevent deformities due to strength imbalances and to prevent undue stress on the healing nerve tissue.

Patient education – The patient must learn to protect the extremity to avoid injury due to loss of sensation.

NERVE INJURY: MANAGEMENT GUIDELINES – RECOVERY FROM NERVE INJURY

Recovery Phase – There are signs of reinnervation (muscle contraction, increased sensitivity)

PT intervention: Motor retraining – Muscle “hold” in the shortened

position Desensitization – multiple textures for sensory

stimulation; vibration Discriminative sensory education – identification of

objects with, then without, visual cues

NERVE INJURY:MANAGEMENT GUIDELINES – RECOVERY FROM NERVE INJURY

Chronic Phase – Reinnervation potential peaked with minimal or no signs of neurological recovery

PT intervention: Observe signs of compensatory function –

compensatory function is minimized during the recovery phase but is emphasized when full neurological recovery does not occur

NERVE INJURY:MANAGEMENT GUIDELINES – RECOVERY FROM NERVE INJURY

Preventive care – emphasis on lifelong care to involved region. Advise the patient to: While the nerve is regenerating/ if nerve

recovery is incompleteInspect Skin regularlyProvide prompt treatment of wounds or blistersCompensate for dryness with massage creams or oils

NERVE INJURY:MANAGEMENT GUIDELINES – RECOVERY FROM NERVE INJURY

In the upper extremityAvoid handling hot, cold, sharp, or abrasive objects

Avoid sustained grasps; change use of tools frequency

Redistribute hand pressure by building up the size of the handles

Wear protective gloves

NERVE INJURY:MANAGEMENT GUIDELINES – RECOVERY FROM NERVE INJURY

In the lower extremityWear protective shoesInspect feet regularly for pressure points and modify shoes or provide protection if they occur

Do not walk barefoot, esp. in the dark or on rough surfaces

Shift weight frequently when standing for long periods

NEURAL TENSION DISORDERS:SYMPTOMS AND SIGNS OF NERVE MOBILITY IMPAIRMENT

Common Symptoms are Stretch pains and Paresthesia.

NEURAL TENSION DISORDERS:CAUSE

According to Butler, symptoms are the result of tension being placed on some component of the nervous system

NEURAL TENSION DISORDERS:PRINCIPLES OF MANAGEMENT

The Principles of treatment are similar to those of any mobilization technique: The intensity of the maneuver should be related to

irritability of the tissue, patient response, and change in symptoms. The greater the irritability, the more gentle the technique.

If the restriction is primarily tension, the stretch force is applied into the tissue resistance, held for 15 to 20 seconds, released, and then repeated several times.

NEURAL TENSION DISORDERS:PRINCIPLES OF MANAGEMENT

Neurological symptoms of tingling or increased numbness should not last when the stretch is released.

Application of the techniques requires positioning the individual at the point of tension, then either passively or having the patient actively move one joint in the pattern in such a way as to stretch and then release the tension. Moving different joints in the pattern while maintaining the elongated position on the other joints changes the forces on the nerves.

After several treatments and the tissue response is known, the patient is taught self-stretching.

NEURAL TENSION DISORDERS:NEURAL TESTING AND MOBILIZATION TECHNIQUES FOR THE UPPER QUADRANT

Neural Testing for Median Nerve – for examining and treating symptoms related to median nerve distribution, thoracic outlet syndrome, and carpal tunnel syndrome.

NEURAL TENSION DISORDERS:NEURAL TESTING AND MOBILIZATION TECHNIQUES FOR THE UPPER QUADRANT

Neural Testing for Radial Nerve – for examining and treating symptoms related to shoulder girdle depression, radial nerve distribution, tennis elbow, and deQuervain’s syndrome.

NEURAL TENSION DISORDERS:NEURAL TESTING AND MOBILIZATION TECHNIQUES FOR THE UPPER QUADRANT

Neural Testing for Ulnar Nerve – for examining symptoms related to the C8 and T1 nerve roots, lower brachial plexus, ulnar nerve, and disorders such as medial epicondylitis.

NEURAL TENSION DISORDERS:NEURAL TESTING AND MOBILIZATION TECHNIQUES FOR THE LOWER QUADRANT

Neural Testing for Sciatic Nerve: Straight-Leg Raising with Ankle Dorsiflexion

NEURAL TENSION DISORDERS:NEURAL TESTING AND MOBILIZATION TECHNIQUES FOR THE LOWER QUADRANT

Neural Testing for Sciatic Nerve: Slump-sitting

NEURAL TENSION DISORDERS:NEURAL TESTING AND MOBILIZATION TECHNIQUES FOR THE LOWER QUADRANT

Neural Testing of Femoral Nerve: Prone Knee Bend

NEURAL TENSION DISORDERS:PREVENTION

Prevention – The maneuvers mentioned earlier may be used to prevent restrictive adhesions from developing if done early during treatment after an acute injury or surgery.

NEURAL TENSION DISORDERS:PRECAUTIONS:

Precautions: Know what other tissues are affected by the positions and

maneuvers Recognize the irritability of the tissues involved and do

not aggravate the symptoms with excessive stress or repeated movements

Identify whether the condition is worsening and the rate of worsening. A rapidly worsening condition requires greater care than a slowly progressing condition

Use care if there is an active disease or pathology affecting the nervous system

Watch for signs of vascular compromise. The vascular system is in close proximity to the nervous system and to no time should show signs of compromise when mobilizing the nervous system.

NEURAL TENSION DISORDERS:CONTRAINDICATIONS:

Contraindications: Acute/Unstable neurological signs Cauda equina symptoms related to

the spine including changes in bowel or bladder and perineal sensation: spinal cord injury symptoms, neoplasm, and infection

MUSCULOSKELETAL DIAGNOSES INVOLVING IMPAIRED NERVE FUNCTION

Thoracic Outlet Syndrome Carpal Tunnel Syndrome Compression in Tunnel of Guyon Complex Regional Pain Syndrome:

Reflex Sympathetic Dystrophy and Causalgia

THORACIC OUTLET SYNDROME:RELATED DIAGNOSES

Related Diagnoses – The following are commonly accepted medical diagnoses for TOS: Neurogenic TOS (True TOS) Nonspecific “symptomatic” neurogenic

TOS Vascular syndromes (arterial) Vascular syndromes (venous)

THORACIC OUTLET SYNDROME:ETIOLOGY OF SYMPTOMS

Three causative factors for TOS that could be interrelated or exist separately: Entrapment of the neural tissue from scar tissue or

pressure Compressive neuropathy Faulty posture

Contributing Factors to TOS: Postural variations Postural stress Respiratory patterns Congenital factors Traumatic injuries Hyperthrophy or Scarring

THORACIC OUTLET SYNDROME:LOCATION OF COMPRESSION/ENTRAPMENT AND TESTS OF PROVOCATION

There are 3 primary sites for compression or entrapment of the neurovascular structures that lead to tension or compression sites:

Interscalene triangle: Test of Provocation

– Adson’s Maneuver

THORACIC OUTLET SYNDROME:LOCATION OF COMPRESSION/ENTRAPMENT AND TESTS OF PROVOCATION

Axillary interval: Test of Provocation

– Roos Test

Costoclavicular space: Test of Provocation –

Military Brace Test

THORACIC OUTLET SYNDROME:COMMON IMPAIRMENT IN TOS

Intermittent brachial plexus and vascular symptoms of pain, paresthesias, numbness, weakness, discoloration, and swelling

Muscle length-strength imbalance in the shoulder girdle with tightness in anterior and medial structures and weakness in posterior and lateral structures

Faulty postural awareness in the upper quarter Poor endurance in the postural muscles Shallow respiratory pattern characterized by upper

thoracic breathing Poor clavicular and anterior rib mobility Nerve tension symptoms when the brachial plexus is

placed on a stretch

THORACIC OUTLET SYNDROME:COMMON FUNCTIONAL LIMITATIONS/DISABILITIES

Sleep disturbances that could be from excessive pillow thickness or arm posture

Inability to carry briefcase, suitcase, purse with shoulder strap, or other weighted objects on the involved side

Inability to maintain prolonged overhead reaching position

Inability to do sustained computer or desk work, cradling a telephone receiver between head and involved shoulder, or prolonged periods driving a car

THORACIC OUTLET SYNDROME:NON-OPERATIVE MANAGEMENT OF TOS:

Educate the patient Correction of impaired posture Mobilized restricted neurological tissue Mobilized restricted joints, connective

tissue, and muscle Improve muscle performance Correct faulty breathing patterns Progress functional independence

THORACIC OUTLET SYNDROME:PRECAUTION

Shoulder girdle exercises causes worsening of symptoms in some patients; or they may be progressing favorably, then symptoms worsen.

Worsening of neurological or vascular symptoms may indicate axonal disruption or vascular compromise.

Refer the patient to his or her physician; surgical decompression may be indicated.

CARPAL TUNNEL SYNDROME:ETIOLOGY OF SYMPTOMS

Etiologic Factors include: Synovial thickness Scarring in the tendon sheaths (tendinosis) Irritation Inflammation Swelling (tendinitis)These occur as a result of repetitive or sustained wrist flexion, extension, or gripping activities or sustained pressure. Because of this, CTS is frequently classified as a cumulative trauma or overuse syndrome.

CARPAL TUNNEL SYNDROME:LOCATION OF COMPRESSION AND TESTS OF PROVOCATION

The site of compression is at the wrist.

Test of Provocation – Phalen’s Test

CARPAL TUNNEL SYNDROME:COMMON IMPAIRMENTS

Increasing pain in the hand with repetitive use Progressive weakness or atrophy in the thenar

muscles and first two lumbricales (ape hand deformity)

Tightness in the adductor pollicis and extrinsic extensors of the thumb and digits 2 and 3

Irritability or sensory loss in the median nerve distribution

Possible decreased joint mobility in the wrist and MCP joints of the thumb and digits 2 and 3

May develop sympathetic changes

CARPAL TUNNEL SYNDROME:COMMON FUNCTIONAL LIMITATIONS/DISABILITIES

Decreased prehension in tip-to-tip, tip-to-pad, and pad-to-pad activities requiring fine neuromuscular control of thumb opposition

May not use the area of the hand where there is decreased sensation

Inability to perform provoking sustained or repetitive wrist motion, such as cashier checkout scanning, assembly line work, fine tool manipulation, typing, or manipulation of a computer mouse

CARPAL TUNNEL SYNDROME:NON-OPERATIVE MANAGEMENT OF CTS

Protect the nerve Modify activity and educate the patient Mobilized restricted joints, connective

tissue, and muscle/tendon Improve muscle performance Progress functional independence

CARPAL TUNNEL SYNDROME:SURGICAL INTERVENTION AND POSTOPERATIVE MANAGEMENT

Maximum Protection Phase Educate the patient Wound management, control of edema and pain Active tendon-gliding and nerve-gliding exercises Exercises – such as active finger and thumb flexion/extensionModerate and Minimum Protection Phases Scar tissue mobilization Progressive stretching and joint mobilization of restricted

tissue Muscle performance Dexterity exercises Sensory stimulation and discriminative sensory reeducation

COMPRESSION IN TUNNEL OF GUYON:ETIOLOGY OF SYMPTOMS

Injury or irritation of the ulnar nerve in the tunnel between the hook of the hamate and pisiform results from sustained pressure, such as: Prolonged handwriting Leaning forward onto extended wrists while

biking From repetitive use of the gripping action of the

4th and 5th fingers, as with knitting, tying knots, or using pliers and staplers

From trauma, such as falling on the ulnar border of the wrist

COMPRESSION IN TUNNEL OF GUYON:TESTS OF PROVOCATION

Tests of Provocation – Positive Tinel’s sign over the tunnel of

Guyon.

COMPRESSION IN TUNNEL OF GUYON:COMMON IMPAIRMENTS

Pain and paresthesias along the ulnar side of the palm of the hand and digits in the distribution of the ulnar nerve

Progressive weakness or atrophy in the intrinsic muscles innervated by the ulnar nerve

Restricted mobility in the extrinsic finger flexor and extensor muscles

Possible restricted mobility of the pisiform

COMPRESSION IN TUNNEL OF GUYON:COMMON FUNCTIONAL LIMITATIONS/DISABILITIES

Decreased grip strength Unable to use 4th and 5th digits for

spherical or cylindrical power grips Decreased ability to perform provoking

activity

COMPRESSION IN TUNNEL OF GUYON:NON-OPERATIVE MANAGEMENT

Follow the same guidelines as for CTS. Modify the provoking activity, avoid pressure to the base of the palm of the hand, and provide rest with a cock-up splint

Ulnar nerve mobilization – Move the wrist into extension and radial deviation, then apply overpressure stretch into extension against the ring and little finger

COMPRESSION IN TUNNEL OF GUYON:SURGICAL RELEASE AND POSTOPERATIVE MANAGEMENT

After release of the ulnar tunnel, the wrist is immobilized 3 to 5 days; then treatment begins with gentle ROM.

Follow the same guidelines as with carpal tunnel surgery but with ulnar nerve mobilization techniques

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIA

Classification of CPRS: CPRS type 1 (Reflex Sympathetic

Dystrophy) CPRS type 2 (Causalgia)

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIARELATED DIAGNOSES AND SYMPTOMS

Common symptoms used in the past for RSD include: Shoulder-hand syndrome Sudeck’s atrophy Reflex neurovascular dystrophy, traumatic

angiospasm or vasospasm Sympathetically Maintained Pain (SMP) – is

frequently a component of CPRS but not a distinct diagnosis in itself

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIAETIOLOGY

They usually develop in association with a persistent, painful lesion, such as painful shoulder, after trauma (such as fracture or sprain), and etc.

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIA

Three Stages of CPRS Type 1 (RSD): Stage 1 – acute/reversible stage Stage 2 – dystrophic or

vasoconstriction (ischemic) stage Stage 3 – Atrophic stage

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIACOMMON IMPAIRMENTS

Pain or hyperesthesia at the shoulder, wrist, or hand out of proportion to the injury

Limitation of motion develops. Typically, the shoulder develops limitation in a capsular pattern with most restriction in lateral rotation and abduction. In the wrist and hand, the most common restrictions are limited wrist extension and MCP and PIP flexion

Edema of the hand and wrist secondary to circulatory impairment of the venous and lymphatic systems, which in turn precipitates stiffness in the hand

Vasomotor instability Trophic changes in the skin

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIAMANAGEMENT

Stage 1 – Early Intervention Relieve pain and control edema Increase mobility (specific to involved

tissues) Improve muscle performance Improve total body circulation Desensitize the area Educate the patient

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIAMANAGEMENT

Precaution of Stage 1: Don’t exacerbate the patient’s pain and underlying

pathology. Use caution when touching sensitive areas. Maintain continuous contact to avoid the irritation of

“make-and-break” contact over the sensitive area. When the patient presents with hypersensitivity,

painful stretching or manipulations exacerbate the symptoms, utilize gentle active exercises and light massage, for short periods, throughout the day.

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIAMANAGEMENT

Stage 2 and 3 – Intervention Pain management Desensitization Mobility Muscle performance

COMPLEX REGIONAL PAIN SYNDROME: REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIAMANAGEMENT

Precaution of Stage 2 and 3: Use caution with stretching and resistive

exercises due to osteoporosis. Pain continues to be a variable, and therefore

the initiation of any therapeutic exercise or manual therapy techniques should be carefully monitored to minimize exacerbation of symptoms

THE END