Adverse Neural Tissue Tension - PowerPoint Presentation

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Adverse Neural Tissue Tension

The Manual Therapy Institute

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Anatomy & Physiology

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Going back to Anatomy…

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Connective Tissue Covering

Endoneurium

- encompasses the axon or nerve fiber; important role in protecting against transmission of substances across the membrane (the blood-nerve barrier)

Perineurium

- surrounds each fascicle; provides a

perineural

diffusion barrier capable of controlling flow of substances bi-directionally.

Epineurium

- outermost connective tissue; highly vascular and provides no diffusion barrier function

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Nerve Nutrition

Bi-directional Nutritional Flow (

Axoplasmic

Flow):

Antegrade

Flow:

Fast 400mm day, carries substances used in the transmission of impulses (neurotransmitters and transmitter vesicles)

Slow 1-6 mm/day, carries substances needed for the maintenance of the structure of the axon

Retrograde Flow: 200 mm/day, responsible for carrying extracellular materials from the nerve terminal and

trophic

messages about the status of the nerve and the target tissues

Nutritional Requirements – 20% of O

2

consumption while only composing 2% of total body weight

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Continuity of Central & Peripheral Nerves

The system is considered continuous in three ways:

1) the connective tissues are continuous

2) the neurons are interconnected electrically

3) the system is continuous chemically.

Any stresses that are imposed on the peripheral nervous system are conveyed to the central nervous system, and the reverse holds true.

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Nerve Innervation

The connective tissues of the peripheral nerves, nerve roots and autonomic nervous system have a source of intrinsic

innervation

=

nervi

nervorum

Free nerve endings have been found in the:

Perineurium

Epineurium

Endoneurium

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MOI’s & Examination of the Peripheral Nerve

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Motor Problems

– motor neuron (body, axon, motor end plate, muscle fiber).

Signs

:

distal weakness

decreased DTR’s

myotomal

patterns

Sensory Problems

– sensory neuron (cell body in ganglion, axon, sensory receptor).

Reports

: tingling, burning,

dysesthesias

,

paresthesias

; dermatome pattern.

Mixed Nerves

– both

ANS

– sweating and/or vascular control; skin changes

Dysfunctions of Peripheral Nerves

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Entrapment/Compression

- small amount of pressure chronically endured over time (

ie

posture, repeated compression or dysfunctional movement); CTS,

Cubital

Tunnel, TOS

Trauma

– laceration, severing, blunt, crushing

Heredity

– Charcot-Marie-Tooth

Nutritional/Metabolic

- diabetics, alcohol

Infections

–

Guillain-Barre

, post-Polio, Herpes Zoster, Bell’s Palsy or Trigeminal

Exposure to Toxins

– lead, organophosphates

Motor End Plate Disorders

- Myasthenia Gravis, Botulism

Both MOI’s will lead to classic nerve s/s…

Overview of MOI’s for Peripheral Nerves

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Create an “at risk” environment for the neural tissue.

Be mindful of theses conditions, and whether they are under control…

Systemic Risk Factors

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Microvascular diseases

Diabetes

Thyroid issues

Renal Disease

Inflammatory arthritis

Gender

Pregnancy

Obesity

Age

Smoking

Occupational exposure/activities

Systemic Risk Factors

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Goals:

know the major peripheral nerves

understand the individual motor and sensory function of each peripheral nerve

be able to establish a treatment plan based upon clinical presentation…

Realize that Compression leads to:

decreased vascular flow

interrupts axonal transport and conduction

leads to myelin thinning

epineural

thickening

Nerve Compression Injuries

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Diagnostic Considerations with Peripheral Nerve Compression….

Mimics some

tendonosis

/tendonitis and can occur concurrently with such

Concurrent with many other orthopedic injuries:

Lateral ankle sprains (

sural

or

peroneal

)

Proximal Humeral fractures (radial)

Knee scope (

saphenous

)

Spine

hypermobility

Occur frequently after fractures

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Pt. Hx

, physical exam and laboratory data assist in diagnosis and locating lesion.

However, no one test is 100% specific or sensitive (so look at multiple pieces of the puzzle…)

Examination Considerations

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Nerve Compression Diagnostic Procedures

Pt. History

Motor Exam –

myotomal

as well as specific to suspected peripheral nerve

Sensory Exam –

dermatomal

as well as specific peripheral nerve

NTPT (neural

tissue

provocation testing)

Provocative Testing (

ie

Tinel’s

,

Phalen’s

,

Roo’s

)

Physical findings - atrophy, clawing, etc.Body diagramsEMG/NCV studies

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Dermatomal Key Points

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Sensory Regions

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Always consider proximal points of compression….

Be mindful that initial changes may be transient, but if situation persists or worsen, the changes can become permanent with fibrosis.

Localization and correct diagnosis allow for appropriate intervention planning.

Based on peripheral nerve anatomical organization, which is affected first - motor or sensory?

Examination Note:

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Sidenote

on EMG/NCV

Sometimes the only objective measure

Can localize lesion by “inching”

Not always positive in early stages

Operator dependent

Assists in diagnosis and allows measurement of progression/resolution

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Adverse Neural Tissue Tension

Never-ending Acronyms:

ANTT =

Adverse Neural Tissue Tension

ULTT =

Upper Limb Tension Testing

NTPT =

Neural Tissue Provocation Testing

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Important Concepts

Initially

may not suspect

ANTT with straight forward orthopedic conditions

tend to

develop gradually

as a secondary result from injury

The nerve as a

source of pain

Concept of

AIG

= abnormal impulse generating site

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AIG’s

Coined by David Butler

When a peripheral nerve is injured, it can develop the ability to repeatedly

& spontaneously

generate its own impulse

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Main Characteristics of AIG’s

Mechano-sensitivity:

stimulated by mechanical stimuli (movement, touch, etc)

Spontaneous Activity

Susceptible Sites =

area of myelin damage or regenerating axon sprouts

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When to suspect

ANTT?

When not responding as should within the expected time frame

Describes in terms consistent with ANTT - “burning”, “crawling”, “electrical”, “ants on me”, “pulling”, bizarre sounding things like “warm water”

Worsening despite objective improvement of ROM, strength, etc

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Symptoms of ANTT

Development of pain &

paresthesia

is

gradual

(neural zone)

Symptoms

radiate

(either proximally or distally)

Pain along the

nerve pathway

or spot pain (

hyperalgesic

response to palpation)

Aggravated by

positions or movements

that “stretch” the nerve

Nocturnal s/s not uncommon

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Signs of ANTT

Sensory nerve?

Motor nerve?

Positive neural tissue provocation testing (NTPT)

TTP along the nerve

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What makes a NTPT positive?

Reproduction of

s/s (know it is relevant)

Response is altered by a

distant

component (either a distal or proximal component)

Difference in response from side to side, or what is

normal

May have to differentiate of a positive test is relevant or not….

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Susceptible Sites

sites of nerve branching

unyielding interfaces

sites of nerve attachment

soft tissue and fibro-osseous tunnels

sites at which a nerve is

cutaneous

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Common MOI’s

External forces –

ie

casts, belts, walking boots, ill-fitting shoes

Internal forces –

ie

swelling, bone spur

Chronic repeated

microtrauma

–

ie

posture

Double crush –

ie

ask about old injuries proximal & distal to site

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Double Crush

Proteins and cell bodies travel distally while waste products travel proximally thru axonal transport systems.

Disruption causes decreased threshold for s/s or AIG’s elsewhere along the nerve.

Either site may be asymptomatic without the second insult.

What does this tell you must be done on evaluation?

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ANTT Differential Diagnosis

Lumbar Radiculopathies:

Pain with cough, sneeze, Valsalva?

Well delineated area of sensory change?

Partial weakness, decreased reflexes?

Electrodiagnostic testing?

What is the

key

to differential diagnosis of ANTT and lumbar root?

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The Key…



Identify a

different peripheral nerve

with the major contribution from the

same root level

as the suspected nerve

Or test a more

proximal branch

originating from the same peripheral nerve

Then compare motor and sensory function



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Common LE Entrapments

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Femoral

Nerve

MOI:

pelvic fracture, scarring after abdominal surgery, tumors, inguinal hernias

S/S:

most pronounced at the knee, knee buckling may occur

Local tenderness in the groin, pain and

paresthesiae

over the

anteromedial

surface of the thigh and the medial surface of the leg.

Decreased sensation over

anteromedial

thigh, weakness of quadriceps (compensated for by hyper extending the leg in standing and walking) and

sartorius

, decreased patellar tendon reflex.

Increased pain at

endrange

hip flexion and hip extension. Positive neural tension signs.

Radiculopathy

? What level? Will present with anterior tib

and adductor weakness.

R/O:

hip arthritis and

psoas

strain

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Femoral &

Saphenous

Nerve

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Lateral Femoral

Cutaneous

Nerve

Originates from L2 and L3, runs through the pelvis and angles downward at the ASIS.

MOI

: weight distribution changes, such as a pendulous abdomen, scarring following surgery and to direct external pressure (corset or belt)

Sites of entrapment

:

fascia

lata

inguinal ligament (naturally kinked as it passes through the ligament)

C/O

: pain, numbness and

paresthesiae

over anterior and lateral surfaces of the thigh.

Aggravating Factors

: worsened by erect posture, prolonged standing, hip extension and adduction.

There are no motor signs.

Differential diagnosis

(Differentiate from L2, L3 nerve root radiculopathy and femoral nerve neuropathy): peripheral entrapment may cause complete anesthesia with well delineated borders, while with lumbar nerve root problems the loss of sensation is usually partial due to overlap of the dermatomes)Pain over the inguinal ligament is not common with lumbar

radiculopathy

, but happens frequently with peripheral nerve entrapment of the lateral femoral

cutaneous

nerve.

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Obturator

Nerve

Originates

: L2 and particularly

L3, 4

; formed in the

psoas

, runs through the pelvis to the

obturator

canal, leaves the pelvis and enters the medial thigh.

Site of entrapment =

obturator

canal.

MOIs

: pelvic fracture, hip surgery and inflammation of the pubic bone following surgery.

Clinical findings:

Pain in the groin, radiating from the inner thigh to the knee.

Decreased sensation over the medial thigh and knee, and local pain with pressure over the inguinal ligament.

Pain on

endrange

hip flexion, hip extension and abduction. Weakness in the adductor musculature leads to gait pattern disturbances: circumduction during swing phase. Duchenne during stance phase.Differential diagnosis (Radiculopathy from L2-4 and femoral nerve neuropathy) L2, 3 dermatomes include portions of the medial thigh, which could confuse the diagnosis of peripheral entrapment, but generally cover more lateral portion of the thigh. L4 is distinctively different from the sensory distribution of the

obturator

nerve.

Direct pressure in the groin should not cause pain in a lumbar

radiculopathy

, but highly typical with

obturator

entrapment.

Rule out hip arthritis and

psoas

strain.

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Obturator

Nerve

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Saphenous

MOI:

knee arthroscopy, medial

meniscal

repair, trauma

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Saphenous

Medial Knee

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Sciatic

MOI:

sacral dysfunction with

piriformis

spasm, thick wallets, scarring from hip surgery, injections,

gluteal

or pelvic tumors

Key:

glutei help differential from

radiculopathy

Caution:

Neurodynamic

testing will give the same result as for

radiculopathy

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Sciatic Nerve and Major Branches

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LE Nerves Commonly Involved

Tibial

:

MOI:

plantar

fascitis

,

eversion

sprains, “joggers” foot

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Tarsal Tunnel Syndrome

Entrapment of posterior tibial nerve within canal:

Tibial Nerve divides into:

Medial and lateral plantar nerves

Medial calcaneal branch

Symptoms:

Pain/parathesia plantar aspect of foot

Causes:

Not clear concensus regarding causitive factors but suspect:

Excessive Pronation

Assessory FDL

Tight flexor retinaculum

Ganglion cysts

Soft tissue tumors

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Tarsal Tunnel Syndrome

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Anterior Tarsal Tunnel Syndrome

Deep Peroneal Nerve entrapment:

Beneath inferior extensor retinaculum

Over talonavicular joint

Over tarsometatarsal joints

Signs and Symptoms:

Pain/parathesia over dorsum to 1

st

web space

Weakness of EDB

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Deep Peroneal Nerve

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Plantar Nerves

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LE Nerves Commonly Involved

Peroneal:

MOI:

ankle sprains, casts, walking boots, shoe wear

S/S:

pain & paresthesia lateral leg & dorsum of foot; deep peroneal - loss of sensation first web space; loss of strength in the lateral & anterior compartments

Differential:

anterior compartment syndrome (extreme pain, pallor, loss of dorsalis pedis pulse, foot drop)

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Lateral Nerves at the Foot

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Medial Nerves of the Foot

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Adverse Neural Tissue Tensioning

Provocative Testing

Positive:

Different from uninvolved LE

Reproduction of s/s

Changes with “remote” component

Caution!

Assessment of

irritability

is key, as well as severity.

Irritability

guides the nerve glide

prescription

related to intensity…

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Principles of Management of ANTT

Intensity directly related to the level of irritability present – greater the irritability the less intense the glide (

ie

NOT into s/s)

Neurological s/s (

ie

tingling, numbness) should NOT persist after gliding technique or should be improved

Choose one component motion of the testing position to utilize as the “gliding force”

Either “floss” or “glide” – either one works

Ask regarding s/s after each treatment and document changes across the course of treatment

Any worsening at all need to be immediately reported to the PT – pt. education…

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Guidelines for Prescription

Educate pt on condition and goals of treatment

Emphasize NOT to push treatment – MUST be gentle

ALWAYS start with assisting to ensure perfect form and determine response; when pt masters, give nerve glides as HEP.

1. Intensity & Duration:

Initially: Perform 20-30 glides just out of s/s

Progress to: glides with minimum s/s at the end of the “glide” only

2. Frequency:

Initially: 1x day, determine response

Progress to: Gradually build up to 3x-5x day if appropriate response achieved.