Neurodynamic Mobility

Question 1

Types of Peripheral Nerve Conditions

Answer 1

1. Neuripraxia
2. Axontmesis
3. Neurotmesis

Question 2

Neuropraxia

Answer 2

• Transient episode which damages myelin sheath preserving the axon and connective tissue
• Numbness/tingling
• Rapid recovery of days to weeks
• “Entrapments”
• Ex: Carpal Tunnel (Occurs in transverse carpal ligament), Sciatica (Pressure due to muscle over sciatica; Piriformis), Ulnar entrapement at elbow (“Hitting funny bone”), Nerve roots existing out of spine (Radiuculopathy; lesion takes up space and leads to pressure; Most common disc buldge; Nerve root - dermatome; peripheral - peripheral nerve map)

Question 3

Axonotmesis

Answer 3

• Injury more severe and involves the axon but preservation of the Schwan sheath
• Motor and sensory changes (weakness of muscles, decrease sensation)
• Recovery of several months
• Prolonged entrapments, crush or traction injury OR sustained exposure to inflammatory condition
• Ex: Direct blow (ulnar nerve most common due to being superficial)
• Ex: Common Fibular Nerve by fibular head

Question 4

Neurotmesis

Answer 4

• Nerve and sheath are disrupted
• Motor and sensory loss
• Long term deficits
• Lacerations

Question 5

What is “Adverse Neurodynamic Mobility”

Answer 5

• Impaired nerve function: Disrupted intraneural circulation or axoplasmic flow (aka: axonal transport) occurs when nerve is compressed, stretched or sheared beyond its tolerance
• Physiological changes (ex: intraneural edema and increase of sodium channel density) leads to nerve sensitization to tension (“increased mechanosensitivity”). This may explain “spread” of symptoms along the nerve (becomes the entire nerve irritated not just the one spot it was compressed)
• This leads to greater central response to nerve tension as well. Greater activation in brain pain centers (also explaining “spread” of symptoms)
• Nerve need to move along a pathway, going on stretch and shorten
• Nerves travel to muscle and are in close proximity to joints
• Ex: Median

Question 6

Common Adverse Neurodynamic Mobility Conditions

Answer 6

• Spinal radiculopathy (inflammation or mechanical irritation of nerve root) – most common C5 or C6 and L4 or L5 nerve root
• Peripheral nerve injury (neuropraxia or Axonotmesis) – most common is ulnar N. or sciatic N.

Question 7

Axoplasmic Flow

Answer 7

• Flow between cell body and terminal branches of the nerve
• Constant interchanging of mitochondria, lipids, synaptic vesicles and proteins
• Creates a sensitivity
• Disrupting this flow results in issues. Most commonly tension
• Doesn’t glide as it should

Question 8

Classification of Pain Condition

Answer 8

Nociceptive Pain
* Reaction to afferent nerves to noxious chemical, mechanical or thermal stimuli
* Pain is proportionate to the mechanism and nature of the injury

Peripheral neuropathic
* Lesion or dysfunction in the peripheral N, dorsal root ganglia or dorsal root from trauma, compression, inflammation or ischemia.
* Proportionate or disproportionate to the mechanism or nature of injury
* Radicular or Radiating Pain

. Central (or peripheral) Sensitization
* Amplification of neural signaling within the central or peripheral nervous system that elicits pain hypersensitivity
* Pain is disproportionate to the mechanism or nature of the injury

Question 9

Radiating pain should be referred to as

Answer 9

Peripheral Neuropathic Pain

Comes from the NERVE

Question 10

Referral Pain is

Answer 10

pain coming from muscles, organs, etc.

Question 11

Peripheral Neuropathic PAIN

Answer 11

• Describe pain as shooting, burning or electric type. (lacinating pain)
• May have associated numbness and tingling
• Usually have a history of nerve pathology or compromise (Trauma or sustained posture)
• Commonly describe symptoms in a cutaneous or dermatomal distribution.

Question 12

Clinical Presentation of Neurodynamic Mobility Deficits - Subjective

Answer 12

• Chronic / persistent symptoms
• Pain is deep ache
• Pain distribution MAY BE anywhere along the peripheral nerve pathway (distal symptoms)
• Commonly unilateral
• Intermittent, aggravated with sustained postures
• Lying down (unloading of spine/nerve) relieves symptoms
• Absence of TRUE neurological symptoms (reflexes, weakness, sensory) - Neuropraxia

Question 13

Clinical Presentation of Neurodynamic Mobility Deficits - Objective

Answer 13

• AROM of lumbar or cervical: Restricted motion and/or pain esp. with flexion motions or side bending away (tensioning nerve)
• AROM of peripheral joints: Variable dependent on tension of the nerve
• PROM: Variable depending on tension on nerve. Limitation of motion during selected neurodynamic test of the UE and LE (Positioning)
• Palpation: pain and /or muscle tension along path of nerve
• Special tests: Positive on neurodynamic testing
• Neuro: Usually negative neuro screen (reflexes, myotome, sensation) USUALLY except in more acute cases.

Question 14

Neurodynamic Assessement for LE

Answer 14

• Slump Sitting Testing (More likely to be accurate)
• Straight Leg Raise
• Can compare the two tests to assess for irritability levels; No issues with SLR but symptoms with slump is less irritability)
• Put tension through the nerve and identify how sensitive the nerve is based on the tension we place.
• If the nerve is sensitive will see a decrease in ROM
• Most common: Sciatica (Cervical Flexion, Lumbar Flexion, Straight Leg and DF)

POSITIVE for Adverse Neurodynamic Mobility if:
* Reproduces symptoms
* >10° side to side difference
* Sensitized with cervical flexion or Decreased with cervical extension

Question 15

Neurodynamic Assessment for UE

Answer 15

Median: Shoulder
Radial: ?
Ulnar: Elbow

POSITIVE for Adverse Neurodynamic Mobility if:
* Reproduces symptoms
* >10° side to side difference
* Sensitized with cervical SB AWAY

Question 16

Intervention options for Neurodynamic Mobility Deficits

Answer 16

• Patient education
• Joint mobilization techniques of joints in proximity to the nerve
• Soft tissue mobilization of muscles along nerve pathway
  – Ex: Scalenes, Pec Minor, Biceps, medial or lateral forearm
  – Increases axoplasmic flow and decrease sensitivity of the nerve.
• Neurodynamic mobilization techniques
  – GLIDING/SLIDING Techniques (aka: flossing); No tension just movement
  – TENSIONING Techniques

Question 17

Patient Education on NMD

Answer 17

• Pain caused by sensitivity of nerve (no soft tissue damage)
• Be diligent of getting out of positions that irritate distal symptoms
• Nerves need MOVEMENT AND BLOOD FLOW to function. Find movement that is not irritating nerve
• Need to be patient!! Takes time for nerve to “heal”

Question 18

Gliding Techniques

Answer 18

• Slides neural tissues and adjacent non-neural tissues
• Simultaneously moving a proximal & distal joint together in unison
• Performed in a non-provocative fashion
• Goal: Improve intraneural circulation and ↓ sensitivity

Question 19

Tensioning Techniques

Answer 19

• Places tension on nerve and adjacent non-neural structures
• Taking up slack in one joint and oscillating other
• DO NOT HOLD STRETCH
• Goal: Increase nerve tolerance to tension/pressure (decrease mechanosensitivity)

Question 20

Irritability and NMD Tx

Answer 20

High Irritability: Neurodynamic GLIDING TECHNIQUES
* Sx’s easily provoked
* Noticeable limitation with neurodynamic tests and may be associated with guarding
* Sensitization with palpation to light pressure along pathway of nerve
* Long time for symptoms to resolve once irritated

Moderate Irritability: Neurodynamic GLIDING to TENSIONING TECHNIQUES
* Sx’s not as easy to provoke
* Moderate limitation with neurodynamic tests
* 1:1 ratio of time to come on and time to alleviate

Low Irritability: Neurodynamic TENSIONING TECHNIQUES
* Sx’s minimal but may have periods of increased pain
* End range limitation with neurodynamic tests
* Able to alleviate immediately with change in position

Question 21

Neurodynamic Mobilization UE

Answer 21

Question 22

Neurodynamic Mobility LE in Supine

Answer 22

Question 23

Neurodynamic Mobility LE in Sitting

Answer 23