Peripheral Nerves

2/18/20

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Peripheral Nerves

South Carolina Occupational Therapy Association

February 29, 2020

Tambra Marik, OTR/L, OTD, CHTMedical University of South Carolina

Marc Bartholdi, OTR/L, OTD, CHTSelect Medical

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Peripheral Nerve Injuries

South Carolina Occupational Therapy Association Annual Conference 2020

Tambra Marik, OTD, OTR/L, CHTAssistant Professor Medical University of South Carolina

Marc Bartholdi, OTR/L, OTD, CHTSelect Medical

2/28/20

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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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Structurally

• Central Nervous System (CNS)• Brain and spinal cord

• Peripheral Nervous System (PNS)• Nerve fibers and cell bodies

Functionally• Somatic Nervous System

• Voluntary: Sensory carries sensations and position sense from skin and joints. Motor carries impulses to muscles

• Autonomic Nervous System• Involuntary/visceral: walls of

blood vessels, sweat glands, viscera (internal organs), body cavities (heart, stomach, bladder, etc)

The Nervous System

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

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Peripheral Nervous System

(PNS)

Central Nervous System (CNS)

Structure: Brain & Spinal Cord

Function: Control Center & Integrative

Structure: Cranial & Spinal Nerves

Function: Communicates between CNS and the rest of the body

Sensory

Structure: Somatic & visceral fiber

Function: Connects impulses from receptors to the CNS

Motor

Structure: Motor nerve fibers

Function: Conducts impulses from CNS to muscles & glands

AutonomicInvoluntary/Visceral

Sympathetic: Fight or flight

Parasympathetic: Conserves Energy

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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=30148131

https://upload.wikimedia.org/wikipedia/commons/f/f3/Sobo_1909_615.png

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

Dorsal HornSensory

Ventral HornMotor

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http://cnx.org/content/col11496/1.6/

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Peripheral Nerve

• Peripheral nerves connect information to the central nervous system• Consist of cell body, dendrite send

messages to cell body and axon send message out• Efferent: motor• Afferent: sensory• Interneurons: connect neurons within a

specific region (sensory or motor) to the central nervous system. Play a role in reflexes.

https://upload.wikimedia.org/wikipedia/commons/1/10/Blausen_0657_MultipolarNeuron.png

By By Ruth Lawson Otago Polytechnic - originally uploaded at en.wikibooks. original description page is/was here[1], CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=8831185

Axon away

Dendrite receives messages

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Interneuron

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Spinal Nerves Mixed FibersPart 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

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• Axons: receives information• Dendrite: relays information

• All peripheral nerve fibers have a sheath cell and a Schwann cells. Larger nerve fibers have a fatty (myelin) sheath in addition to the Schwann cell

• Presence of myelin speeds conduction• Nodes of Ranvier: constrictions separating successive

segments of myelin • Nerve impulses “leap” from node to node• Farther apart=faster conduction

dendrite

soma

Schwann cell

Node of RanvierMyelin sheath

Axon terminal

Attribution: Quasar Jarosz 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

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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

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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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http://www.bayareapainmedical.com/nerve.html

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Nerve Injury ClassificationMononeuropathy• Traumatic or non-traumatic• Compression syndromes• Can result in ischemic changes, edema injury

to myelin• Can result in demyelination, axonal

degeneration, or both• Nerve lacerations/compression• Motor & Sensory Deficits in nerve distribution• Weakness is dependent on the motor units

damaged• Sensory loss is distal to injury site

Poly Neuropathy• Metabolic• Nutritional • Hereditary• Immunologically Mediated• Infectious Disease• Neoplastic• Bilateral & Symmetrical• Affects large fibers distally first• Sensory loss precedes motor loss• 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 14

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

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Nerve Injury Seddon Classification Seddon Peripheral Nerve Injury

Classification(Sunderland not on chart)

Seddon1943

Axon Endoneural Tube

Peri-neurium

Epi-neurium

Wallarian Degeneration

Nerve conduction distal to injury/Prognosis

Neuro-praxia

+ + + + No Present/Reversable

Axono-tomesis

- +/- ? + + Yes Absent/Reversable

Neuro-tomesis

- - - +/- ? Yes Absent/Irreversible

Photo by Syedm191 - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=58517905

Axonotomesis

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Nerve Injury Classification Sunderland

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Medical Treatment

• Neurapraxia - Observation

• Axonotmesis - Surgical intervention may be required

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

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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/nrvpain2.html

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http://www.bayareapainmedical.com/nrvpain2.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 pressure.• Inflammatory mediators spread distal

likely related to poor lymphatic drainage • Nerve becomes more sensitive

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.

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Histopathology of Chronic Nerve Compression

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Double Crush SyndromeAxioplasmatic 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.)

• Movement patterns and posture can be effected with a nerve compression• Muscle imbalances can occur

↓ Muscle LengthSternocleidomastoid

Serratus anterior

Pronator teres

Scalenes

Pectoralis minor↑ Nerve Tension/Compres-

sionCarpal tunnel

Cubital tunnel

Median nerve forearm

Radial sensory

Brachial plexus

Muscle Weakness

Middle trapeziusLower trapezius

Serratus anterior

Muscle OveruseUpper trapeziusLevator scapulae

↑ Muscle Length

Middle traps.Lower traps.

Novak & Mackinnon, 2005

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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

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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). Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain and therapy, 8(1), 5-18.

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Compartment of Potential Compression

Borders Contents

Interscalene triangle

Anterior: anterior scalenePosterior: middle scaleneInferior: 1st rib

• Brachial plexus

• Subclavian artery

Costoclavicular space

Anterior: subclaviusInferoposterior: 1st rib and anterior scaleneSuperior: clavicle

• Brachial plexus

• Subclavian artery

• Subclavian vein

Sub-coracoid space

Anterior: pectoralis minorPosterior: ribs 2-4Superior: coracoid

• Brachial plexus

• Axillary artery• Axillary vein

Photo from: Jones, M. R., Prabhakar, A., Viswanath, O., Urits, I., Green, J. B., Kendrick, J. B., ... & Kaye, A. D. (2019). Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain and therapy, 8(1), 5-18.

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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)

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True

•Paresthesia am & pm

•Compressors day pain > night pain

•Confirmation with neurophysiological tests

Disputed

• Paresthesia awaken often pm

• Releasers pm pain > day pain

• No confirmation with neurophysiological test

• Estimated to be 95-99% of all neurogenic types and is bilateral (Stewman, Vitanzo & Harwood, 2014)

Neurogenic TOS Estimated 95% of Cases (Freischlag & Orion, 2014)

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ReleasorCompressor

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Test Sensitivity Specificity LR+ LR-

Supraclavicular Pressure (Nord et al

2008)

NT 85-98 NA NA

Cervical Rotation Lateral Flexion (Gilbert et al 2004)

0.42-1.0 100 NT NA

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

Upper limb tension (Bertilson, Grunnesio &

Strender, 2003)

90 38 1.5 0.3

Roos Elevated Arm Stress (Rayan &

Jensen 1995)

52-84 30-100 1.2 0.4-0.53

Costoclavicular Maneuver (Nord et

al 2008)

NT 53-100 NA NA

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

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

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.

Testing right side

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Lindgren, Leino & Manninen, 1992)

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Clinical Tests: Upper Limb Tension Test (ULLT) or Elvey Test Suspected positive test for Neurogenic TOS

• #1: Arms abduction to 90°

• #2: Extend wrists

• #3: Tilt head to side

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

Position 1

Position 2

Position 3

+ test which position provoked symptoms29

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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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Suspected Compression Site

Clinical Reasoning

Restriction Treatment Strategy

Anterior & Middle Scalenes

• Supraclavicular Pressure test +

• Cervical lateral flexion test +

• Elvey test +

• Soft tissue shortness

• Elevated 1st rib

• Hypomobility of 1st rib

• Scalenes mobilization & stretching

• Neuromuscular re-education

• Diaphragmatic breathing

• 1st rib mobilization

Posture: Scalenes Length & 1st Rib Mobility

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Teach Diaphragmatic Breathing• Teach diaphragmatic

breathing• Scalenes release• Stretch scalenes• 1st rib mobility

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

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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 movesslowly towards slight lateral flexion to uninvolved side and rotation to involved side. Perform 5 to 10 reps.

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Promote 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.

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

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Promote 1st Rib Mobility Home Program

Self 1st Rib MobilityThe 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 (H o o p e r, D e n to n , M cG alliard , B rism e e & S ize r, 2 0 1 0 )

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Suspected Compres-sion Site

Clinical Reasoning

Restriction at Scapula Treatment Strategy

Costoclavicular between clavicle and 1st

rib

• Poor posture• Depressed

and/or downwardly rotated scapula observed

• Scapular Correction Test +

• Depression: poor muscular recruitment to achieve scapular upward rotation and/or muscular tightness at shoulder depressors (latissimus dorsi, pectoralis major/minor)

• Downward Rotation: same as above except muscle tightness possibly at scapular downward rotators (levator scapulae and rhomboids)

• Poor movement patterns between scapula and humerus

• Diaphragmatic breathingDepression• Stretch tight muscles

(latissimus and pectoralis)

• Neuromuscular retraining (taping) scapula upward rotators

• Strengthening scapula upward rotators (lower trapezius and serratus anterior)

• Scapula mobilization• Disassociate scapula and

humerus motion

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Clinical Reasoning

Restriction Scapula or Glenohumeral Joint

Treatment Strategy

Costoclavicular space and/or beneath pectoralis minor

• Palpation• Observations

of poor posture

• Scapula correction test +

• Anterior tilted scapula

• Short pectoralis minor muscle

• Joint specific test + for humerus

• Poor scapula posture and recruitment: Anterior tilted and/or downward rotation due to muscular shortness or poor muscular recruitment patterns

• Poor glenohumeral motion:posterior capsule tightness; unable to dissociate scapular from glenohumeral motions

• Diaphragmatic breathingDepression• Stretch tight muscles

(latissimus and pectoralis)

• Neuromuscular retraining (taping) scapula upward rotators

• Strengthening scapula upward rotators (lower trapezius and serratus anterior)

• Scapula mobilization• Disassociate scapula and

humerus motion

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Clinical Reasoning

Restriction Treatment Strategy

Costo-clavicular space between clavicle and 1st rib

• Cervical lateral flexion test +

• Soft tissue shortness scalenes• Elevated 1st rib• Hypomobility of 1st rib

• Scalenes mobilization & stretching

• Neuromuscular re-education• Diaphragmatic breathing• 1st rib mobilization

Costo-clavicular space between clavicle and 1st rib

• Joint specific test suggest poor clavicle mobility

• Hypo-mobility of clavicle acromioclavicular (AC) and/or sternoclavicular (SC) joints

• AC and SC mobilizations

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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

(H o o p e r, D e n to n , M cG alliard , B rism e e & S ize r, 2 0 1 0 )

Image from Watson, Pizzari & Baister, 2010)

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Downward Rotation• Inferior border of

scapula is closer to the spine as compared to superior border

Anterior Tilt• Inferior border

protrudes from thorax

Depressed scapula• Superior border is lower that T2• One arm longer than the other

Assessing Scapula by Observation Static

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

• Shortness exists when the patient is unable to reach arms overhead to the mat.

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

Marik, T. Latissimus Dorsi assessment, December 2009. Courtesy Tambra Marik

• Short clavicular fibers exist when the arm can not abduct/drop down to the mat at 90°abduction

Marik, T. Assess pectoralis major clavicular fibers,December, 2009. Courtesy Tambra Marik

Marik, T. Assess pectoralis major clavicular fibers,December, 2009. Courtesy Tambra Marik

• Short muscle fiber exists when horizontally abduction at 120° to 140° does not drop down to the mat.

Latissimus dorsiP. major sternal fibers

P. major clavicular fibers

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Testing: Posture Observations and Muscle Length

• 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

Inferior angle protrudes R acromion higher

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Treatment: Pectoralis Muscles

Stretching pectoralis minor with client on a foam roller and therapist manually stretching. Therapist’s hands are on the coracoid process stretching dorsal and lateral.

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

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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

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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

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Treatment: Mobilize Clavicle

• One hand on the scapula• Thenar eminence of the

other hand on the medial clavicle providing a inferior and posterior glide.

• One hand stabilizes the AC joint• The thumb of the other

hand is placed on the posterior acromion• Provide a anterior glide to

the posterior acromion while stabilizing with the other hand

SC Glide

AC Glide

Marik 2018 Nerve Compression and Injuries 46

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Treatment: Neuromuscular Re-educationScapula Downward Rotation/Depression/Anterior Tilt

• Wall slides for upward rotation. Ulnar forearm on wall. Slide towards a teardrop position. 5 to 10 reps. Progress to resisted scaption exercises.

• Exercises to promote scapular upward rotation

• Taping to promote upward rotation


47As symptoms improve exercises can progress. Position #1

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EVALUATION PERIPHERAL

NERVE COMPRESSION

• OBSERVATIONS• MOTOR• SENSORY• LIGHT MOVING TOUCH• VIBRATION THRESHOLDS• CUTANEOUS PRESSURE THRESHOLDS• 2 POINT DISCRMINATION

• PAIN EVALUATION• PALPATION, POTENTIAL COMPRESSION

SITES & CLINICAL PROVOCATIVE TESTS• EVAULATING CERVICAL

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Observations (distal) Early LateVasomotor (temp., color, edema , cold tolerance)

Skin rosy Skin mottled

Skin warm Skin coldSudomotor(sweat patterns)

Dry skin Dry or overly moist skin

Pilomotor (“goose flesh”) Absent AbsentTropic (skin texture, atrophy to digit pulps, nail changes, hair growth changes, slow skin healing)

Fingernails blemish Curved

Longer & fine hair growth Longer & fine hair growth

Skin soft & smooth Skin smooth/non-elastic

Slight atrophy Atrophy at finger pulps

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

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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

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MOTOR EVALUATION: Manaul Muscle Testing

Nerve Root Myotome Associations• C5- shoulder abduction • C6– Elbow flexion, Wrist extension • C7 – Elbow extension, Wrist flexion• C8 – Finger flexion• T1 – Finger abduction

Peripheral Nerve Associations• Muscles innervated by each

nerve• Median• Ulnar• Radial• Musculocutaneous• Axillary

Clinical Hints: T1 intrinsicsC6 supinatorC5 shoulder abduction, extension and external rotationC7 & 8 almost all others

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SENSORY EVALUATION: Patient Subjective Symptoms

Peripheral Nerve• Decreased sensation and

strength in the peripheral distribution pattern

Nerve Root• Spinal segment representation of

dermatome (sensory) and myotome (motor) patterns

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By Grant, John Charles Boileau - An atlas of anatomy, / by regions 1962, Public Domain, https://commons.wikimedia.org/w/index.php?curid=30017222

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 andFile:Gray814.png, Public Domain, https://commons.wikimedia.org/w/index.php?curid=3460423

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Quick Scan of Motor Scan for Peripheral Nerve

• Resist palmar abduction for median nerve

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

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– Resist thumb dorsal retropulsion for radial nerve

Median

Radial

Ulnar

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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 ReflexesGrade Response Interpretation Clinical Reasoning

0 No response Always abnormal Lower neuron

1+ Slight, muscle contraction but there is no joint movement

May or may not be normal

Lower neuron

2+ Brisk response Normal Normal

3+ Very brisk response May or may not be normal

Upper motor neuron

4+ Clonus Always abnormal Upper motor neuron

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Deep Tendon ReflexesSpinal Level Reflex Peripheral

NerveC6 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.

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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)

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SENSORY EVALUATION: Two Point Discrimination (pd)

Testing quantity of innervated sensory receptor

Static Two-Point Discrimination (Table modified from Klein, 2014)

1-5 mm Normal6-10 mm Fair11-15 mm PoorOnly one point perceived

Protective sensation only

No point perceived Anesthetic

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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

By OpenStax College - Autonomic Reflexes and Homeostasis http://cnx.org/content/m46579/1.2/, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30017359

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General characteristics of pain due to visceral pathology

1. Is poorly localized with referral to somatic structures2. Produces nonspecific regional or whole-body motor responses3. Produces strong autonomic responses4. Leads to sensitization of somatic tissues5. Produces strong affective responses(Sikandar & Dickenson, 2012)

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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)

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Nerve Pathways & Palpation:Median Nerve Path Proximally C5,6,7,8,T1

• Lateral root arises from lateral cord; medial root arises from medial cord

• Follows the brachial artery; 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

https://upload.wikimedia.org/wikipedia/commons/d/de/Gray812and814.PNG

ForearmInnervations

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://commons.wikimedia.org/w/index.php?curid=328869

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Median Nerve Possible Compression SitesCarpal Tunnel

Pronator Syndrome (PS) Anterior 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 pronator teres

Accessory muscle from FDS to FDP

FDS arch

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Carpal Tunnel Cervical Radiculopathy

Paresthesia in digits #1-2 & radial side #3

Sensory deficit at lateral 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

Carpal Tunnel vs. Cervical Radiculopathy Symptoms

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CLINICAL TESTSCarpal compression testPhalensTinelsMedian nerve tension test

Provocative Tests:

Carpal Tunnel Testing

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Pronator Teres Syndrome AIN Syndrome

Resisted pronation with elbow extended (pronator teres)

Weak pronation tested with elbow flexed?Weakness of thumb IP and IF DIP.Weak grip/pinchUnable to make OK sign

Resisted contraction to long finger FDS (FDS compression)

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Clinical Tests Pronator Syndrome versus Anterior Interossei Nerve Compression tests

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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)

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

• Exits triangular interval• Posterior between long head

of triceps and humerus• Through spiral groove• Lateral intermuscular septa

(b/w brachialis and brachioradialis anterior to lateral epicondyle)

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 818, Public Domain, https://commons.wikimedia.org/w/index.php?curid=541674

Proximal InnervationsTricepsAnconeusECRLECRBBrachioradialis

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 818, Public Domain, https://commons.wikimedia.org/w/index.php?curid=541674 69

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

Triangular Interval (TI)• TI contains radial nerve and profunda artery• TI compressions can occur from:

• Posture humeral add/ir and scapular protraction• Hypertrophy of teres major • Adaptive shortening of internal rotators• Fibrous arch at the long head of triceps

http://upload.wikimedia.org/wikipedia/commons/1/16/Gray412-spaces.png

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


Spiral Groove• Compression

distal triceps

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Mechanism of InjuryTriangular Interval Spiral Groove

Hypertrophy at teres major and medial triceps

Compression from leaning on a hard surface “Saturday Night Palsy”

Fibrous bands at teres major and medial triceps

Radial shaft fractures

Shortened teres majorSports with forceful shoulder extensionSymptoms reproduced with external rotation combined abduction

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Triangular Interval Spiral Groove

MotorPresen-tation

Weakness in all muscles innervated by radial nerve

Triceps spared.Weakness at all muscles innervated by radial nerve distal to triceps

SensoryPresen-tation

• Posterior cutaneousnerve of arm

• Lower lateral cutaneous nerve of arm

• Posterior cutaneous nerve of forearm

• Superficial radial nerve

Superficial radial nerve


Adapted from Haymaker, W., Woodhall, B., 1953. Peripheral nerve injuries. WB Saunders, Philadelphia.)

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Presentation Sites Radial

Nerve

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Compression Sites Radial Nerve Distal to ElbowTwo conditions; Same compression sites

Posterior Interossei Nerve (PIN)

Radial Tunnel

Fibrous bands at radiocapitellar jointLeash of HenryMedial edge of ECRBProximal edge of supinator (Arcade of Frohse)Distal edge of the supinator

https://clinicalgate.com/wp-content/uploads/2015/03/B9781455726721000210_f021-002-9781455726721.jpg (Roles & Maudsley, 1972)

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Clinical Presentation: Radial NervePIN Radial TunnelWeakness and/or paralysis to: ECRB, supinator, ECU, EDC, EDM, APL, EPL, EPB, EI

Lateral proximal forearm pain, tenderness at supinator muscle, pain with supination with extended elbow, pain with resisted long finger. • No motor weakness

Awakens nocturnally due to forearm pain

Pronation, elbow ext and wrist flex ↑ symptoms

Rule out tennis elbow, may have lateral elbow tenderness


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

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Posterior Interossei Radial TunnelResisted supination recreates pain. Tenderness 3-5 cm distal lateral

epicondyleTest for weakness of MP extension and wrist weakness.Observe wrist extension for a bias towards radial deviation.

Resisted supination with the elbow and wrist extended reproduces pain.

Positive pain with long finger extension test.Passive pronation with wrist flexion reproduces pain 75

Provocative Tests Radial NervePosterior Interossei versus Radial Tunnel

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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 canal76

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Compression Sites Ulnar Nerve

High Lesions Low LesionsCubital Tunnel Distal to FCU and FDP

motor branchesMedial Intermuscular Septum

Guyon’s canal

Arcade of StruthersFlexor carpi ulnaris (FCU)

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Ulnar Nerve Clinical PresentationHigh Lesions• All extrinsics and intrinsics affected (weak

wrist flexors)• Sensory loss over palmar and dorsal aspect

of small digit and ulnar half of ring digitLow 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=2ahUKEwierPXpmavaAhVo94MKHQRmBCIQjRx6BAgAEAU&url=http%3A%2F%2Fteachmeanatomy.info%2Fupper-limb%2Fnerves%2Fthe-ulnar-nerve%2F&psig=AOvVaw16f9ivvlLRnTQg53iMtSzi&ust=1523294471613937 78

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Clinical Tests Cubital TunnelTinels at cubital tunnel and Guyon’s canal

Modified Shoulder Internal Rotation Test

Elbow Flexion TestScratch CollapseClinical Test for Guyons CanalSensory testing at dorsal ulnar digits normal but, volar ulnar digits impaired 79

Provocative Tests for Unar NerveGuyons Canal versus Cubital Tunnel

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Clinical Tests:Cubital Tunnel Syndrome

TinelsSensitivity:54% to 70%

Modified Shoulder Internal Rotation TestSensitivity: 87% (5 second)Specificity: 97% O c h i e t a l 2 0 1 2

Elbow Flexion TestSensitivity: 46% to 75% (1 to 3 min.)

( H u t c h i n s o n e t a l 2 0 1 1 )

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CERVICAL SCREENING

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

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Cervical Spondylosis: Non-specific termCervical RadiculopathyType I

Cervical nerve roots compression and inflammation of the nerve root or roots at or near the cervical foramen. Symptoms are pain radiating into the arm corresponding to the dermatome of the involved cervical nerve root

Cervical MyelopathyType II

Compression of the cervical spinal cord related to degeneration of discs and bone spurs. Symptoms can include: weakness and numbness, loss of balance and coordination and neck pain. Rheumatoid arthritis can cause myelopathy due to synovium swelling destructing facet joints.

Axial Joint PainType III

Neck pain with pain radiation to one or more of the 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.

https://www.coloradospineinstitute.com/files/3614/5121/6098/13_vert_body.jpg

https://upload.wikimedia.org/wikipedia/commons/c/cb/Doberman_C6-C7_and_C5-C6_traction_responsive_myelopathy_A.jpg

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EXAMINATION1. History2. Pain Patterns & Scales3. Inspection4. AROM/PROM of upper limb & cervical5. Palpation6. Myotome scan7. Dermatome scan8. Vertebral Artery test9. Provocative tests 10. Upper limb neural tension testing (median, ulnar,

and radial nerves)83

Adapted from McClure 2004

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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 SensitizationCentral nervous system centralization. Dominance of allodynia and hyperalgesia

Administer Laniss Pain scalehttp://www.bayareapainmedical.com/chrnanm.html

DenervationSignificant axonal compromise but no central nervous system changes. Loss of nerve supply. Can be from injury, disorders or surgery.

Peripheral Nerve SensitizationInflammation arising from nerve trunk or peripheral nerve without clinical evidence of significant denervation. Injury to the area produces a flare.

Musculoskeletal PainPain is referred from non-neural structures.

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Posture

• Patient attempts to shorten anatomical distance over the course of the sensitized nerve when experiencing central sensitization• Elevated scapula, ipsilateral

side cervical flexion and elbow flexed

• Patient may attempt to increase the available space surrounding the nerve roots when experiencing neuropathic pain related to denervation from compressed, stenotic nerve root

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Inspection/PostureForward 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 (G rie g e l-M o rris, Larso n , M u e lle r-K lau s & O atis, 1 9 9 2 )

• Overly extended cervical spine can cause overstretching and friction on nerve roots

• Asymmetry? Alignment of scapula? Scoliosis?

• Guarding

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Figure from: Donatelli, R. A., & Wooden, M. J. (2009).

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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

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Vertebral Artery TestingPatient 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

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Cervical AROMCheck for quality of movement, burning, sharp pain, numbnessis 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

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Clinical Reasoning: Muscular, Ligament Strain/Sprain or Nerve RootManeuver Pain (soft tissue) Pain (nerve root)AROM Yes Yes

PROM Yes Yes

Provocative of ligament or muscle or ligament

Yes Yes

Provocation of neural tissue

No (paresthesia) Yes (paresthesia)

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Cervical ROM (cont.)

Active motion first, followed by overpressure, if there was no pain actively.

• Flexion

• Extension

• Side-bending

• Rotation

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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

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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

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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/adduct95

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Myotome Scan (cont.)


C2,3,4 C5C6

C7

C6 C7

T1 T1

C8

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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:Dermatoms.svg

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Peripheral Nerve Management

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PERIPHERAL NERVE MANAGEMENT

Post-op:• Good MD Communication• Protect surgical structures• Manage edema and pain• Sensory Re-training techniques• Cortical Retraining activities can be

helpful• Maintain Mobility of uninvolved

joints• Orthosis as indicated

Non-Op Management:• Improve Tissue mobility• Activity Modification• Improve nerve mobility• Orthosis as needed• Space, motion, and slack

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Post-Surgical management

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

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Sensory Re-education & Cortical Re-mapping

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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• Protect surgical structures

Lundborg, G., Björkman, A., & Rosén, B. (2007). Enhanced sensory relearning after nerve repair by using repeated forearm anaesthesia: aspects on time dynamics of treatment. In How to Improve the Results of Peripheral Nerve Surgery (pp. 121-126). Springer, Vienna.

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• 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)

Sensory Re-Education and Cortical Re-mapping

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

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

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Proprioceptive Activities


Gentle Oscillations

Light Ball Toss

Scarf Juggling

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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

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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

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Median Nerve

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Pronator Syndrome AIN Syndrome

Rest; orthosis to avoid rotation

Rest; orthosis with elbow flexion at 90 degrees (8-12 wks)

Nerve glides? Nerve glides?Taping? Taping?Soft Tissue Mobilization?

Soft Tissue Mobilization?

Decompression surgery is indicated if symptoms remain.

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Carpal Tunnel vs. Cervical Radiculopathy: Symptoms

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Carpal Tunnel Cervical Radiculopathy

Paresthesia in digits #1-2 & radial side #3

Sensory deficit at lateral 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

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Interventions

Nocturnal wrist orthosis

Carpal mobilization techniques

Nerve gliding

Tendon gliding

Carpal tunnel Interventions


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Carpal Tunnel Treatment

Symptoms improved with wear of nocturnal and day wrist orthosis.

Walker, Metzler, Cifu, Swartz, 2000

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• 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

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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)

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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)

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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 positionEchigo, Aoki, Ishiai, Yamaguchi, Nakamura & Sawada, 2008)

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Carpal Tunnel Management

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

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Ulnar Nerve

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Compression Sites Ulnar Nerve

High Lesions Low LesionsArcade of Struthers Distal to FCU and FDP

motor branchesMedial Intermuscular Septum

Guyon’s canal

Cubital TunnelFlexor carpi ulnaris (FCU)

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Interventions for Ulnar NerveInterventions for CubitalTunnel

Interventions for Guyon’s Canal

Rest/Orthosis: elbow flexion block nocturnally; heelbo during waking hours

Wrist orthosis?

Patient Education Patient Education

Activity Modification: Avoid elbow flexion end range, leaning on elbow or any repetitive elbow activity.

Activity Modification: Avoid palmar compression and/or trial wear padded protective gloves

Nerve Glides Nerve Glides: Is this effective distally?

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Interventions for Ulnar NerveCubital 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(

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Conservative GuidelinesUlnar Cubital Tunnel Syndrome

Phase II GOAL: Decrease pain/paresthesia

• Orthosis wear as needed• Nerve gliding? Use with caution• Progress to strengthening as symptoms

resolve with emphasis on proximal strengthening.

Retrived on 3/31/11 from:J Hand Ther, 2006;19:170-9.

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

Butler Tech.

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Radial Nerve

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InterventionsTriangular Interval (rare condition)

Spiral Groove

Avoid combined shoulder extension activities

Most common radial nerve compression

Transverse soft tissue mobilization of triceps and teres major

High rate of nerve return 60% to 92% (Grass, Kabir,

Ohse, Rangger, Besch & Mathiak, 2011)

Radial nerve gliding Wrist & digit orthosis (outrigger)Neuromuscular re-training(NMES, taping, etc.)

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Radial Nerve Distal to the elbowPIN Radial TunnelWeakness and/or paralysis to: ECRB, supinator, ECU, EDC, EDM, APL, EPL, EPB, EI

Lateral proximal forearm pain, tenderness at supinator muscle, pain with supination with extended elbow, pain with resisted long finger

Awakens nocturnally due to forearm painPronation, elbow ext and wrist flex symptomsRule out tennis elbow, may have lateral elbow tenderness


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Posterior Interossei Nerve (PIN)

Radial Tunnel

Maintain PROM

Orthosis to unload tension

Orthosis for positioningand function

Nerve gliding

Stretching wrist extensors and supinator?

Limit activities limiting pronation and elbow extension. Limit prolonged activities with wrist ext and pronation

Non-operative Management


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PERIPHERAL NERVE MANAGEMENT

Post-op:• Good MD Communication• Protect surgical structures• Manage edema and pain• Sensory Re-training techniques• Cortical Retraining activities can be

helpful• Maintain Mobility of uninvolved

joints• Orthosis as indicated

Non-Op Management:• Improve Tissue mobility• Activity Modification• Improve nerve mobility• Orthosis as needed• Find a way to create Space,

motion, and slack

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Lab: Nerve Tension Testing

and Gliding

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

Theraband demonstration: median, ulnar, radial nerves

Abnormal responses to gliding and/or tension of a nerve can result in:• Impaired nerve mobility• Decreased nerve conduction velocity• Nerve damage• Loss of functionGoal of nerve gliding: healthy blood profusion, axonal conduction and target tissue innervations

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Upper Limb Tension Testing SittingMedian 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


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Brachial Plexus Neurodynamic Test (BPNT): Grading Scale 0-5Median 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)

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+/-+ Beyond the grade but,

< half-way to the next grade

- > half-way to the next level

0/5 1/5

2/5Forearm neutral

4/5Wrist & digits

neutral

3/5Forearm supination

Established Reliability and Accuracy

(Butler, Karagiannopoulos & Galantino, 2019)

Left side testing pictured

5/5Wrist & digits

extended

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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

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Median Nerve:

Tension: • Shoulder abduction• Wrist/finger extension• Shoulder external rotation• Elbow extension• Cervical side-bending

Thera-tube around long fingerhttps://www.youtube.com/watch?v=Fv_EJV8q2E0

Median Nerve:Slider distally at wrist. Side bend neck to other side while flexing and extending the wrist.

Median Nerve:Slider proximally at the neck. Extend the wrist while moving the neck from side flexion to neutral or ipsilateral side flexion.

Median Nerve Gliding

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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


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Upper Limb Tension Testing Radial Nerve

Patient is supine while the examiner and fixates the scapula with body weight.Position 1: Shoulder girdle depressionPosition 2: Shoulder internal rotation & forearm pronationPosition 3: Wrist & finger flexionPosition 4: Shoulder abductionPosition 5: Cervical side-bendingPositive Tests: Symptoms with tensioning of the nerve

(Schmid et al 2009)

Differentiate• Release cervical side-

bending• Release shoulder

depression• Release wrist flexionMarik 2018 Nerve Compression and Injuries 133

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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

cluesMarik 2018 Nerve Compression and Injuries 134

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Upper Limb Tension Test Ulnar Nerve

Patient is supine while the examiner and fixates the scapula with body weight.Position 1: Wrist/finger extensionPosition 2: Forearm pronationPosition 3: Elbow flexionPosition 4: Shoulder external rotationPosition 5: Shoulder girdle depressionPosition 6: Shoulder abductionPositive Tests: Symptoms with tensioning of the nerve

(Schmid et al 2009)

Differentiate• Release cervical side-

bending• Release shoulder

depression• Release wrist

extension


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Ulnar Nerve:Tensioner tube behind medial epicondyle:

• Wrist/finger extension• Forearm pronation• Elbow flexion• Shoulder external rotation• Shoulder girdle depression• Shoulder abduction• Cervical side bending

Thera-tube around small finger

Ulnar Nerve:Slider at the elbow. Side bend neck to opposite side. Flex and extend elbow.

Ulnar Nerve:Slider proximally. Flex elbow and side bend neck to neutral or opposite side. May need to modify elbow extension.

Ulnar Nerve Gliding

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Radial Nerve:

Tensioner wrap the tube around the humerus.

• Shoulder girdle depression• Shoulder internal rotation &

forearm pronation• Wrist & finger flexion• Shoulder abduction 40° & ext 20°• Cervical side-bending

Thera-tube around index finger.

Radial Nerve:Slider at the wrist. Side bend neck to opposite side while flex/extend wrist to tolerance.

Radial Nerve:Slider proximally. Move neck to opposite side and back to neutral with the wrist extended.

Radial Nerve Gliding

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Novel Median Nerve Gliding Techniques

• Exercise 1: ER & Abd. at shoulder, elbow extension, supination, wrist and digit extension while performing digit abd./add.

https://www.youtube.com/watch?v=Hl0CIg8QwY4

• Exercise 2: ER & Abd. at shoulder, elbow extension, supination, wrist and digit extension while performing forearm supination and pronation

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https://www.youtube.com/watch%3Fv=Hl0CIg8QwY4

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• 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)

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• Exercise 4: ER & Abd. at shoulder, elbow extension, supination, wrist and digit extension while performing shoulder circumduction

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

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Website References

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

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Documents

Peripheral Nerves