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Nerve Gliding Exercises - Excursion and Valuable Indications for Therapy

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Nerve Gliding Exercises - Excursion and Valuable Indications for Therapy

  1. 1. NERVE GLIDING EXERCISES: EXCURSION &VALUABLE INDICATIONS FORTHERAPY SARAH ARNOLD, MS, OTR HANDTO SHOULDERTHERAPY CENTER INDIANAPOLIS, INDIANA
  2. 2. OBJECTIVES 1. Describe the benefits of nerve gliding exercises 2. Describe the clinical indications for nerve gliding:  Traumatic  Non-traumatic 3. Identify key components of a therapist’s evaluation 4. Discuss treatment approaches and apply nerve glides in your clinical practice
  3. 3. WHAT IS A NERVE GLIDE? Gliding/sliding/flossing Tensioning nerve nerve
  4. 4. PHYSIOLOGY OF NERVE GLIDES h local tissue nutrition h blood flow h nerve conduction h nerve mobility Photo from: http://voer.edu Cooper, 2014
  5. 5. EXCURSION GLIDINGOFTHE NERVE RELATIVE TOTHE SURROUNDING NERVE BED Photo from: www.minneapolishanggliding.com
  6. 6. NERVE EXCURSION Ulnar Nerve Elbow flexion/extension 14 mm excursion at the elbow Grewal et. al, 2000; Wright et al., 2001 Wrist flexion/extension 14 mm excursion at the wrist Wright et al., 2001 Median Nerve Wrist flexion/extension 19.6 mm excursion at the wrist Wright et al., 1996 Digital flexion/extension 9.7 mm excursion at the wrist Radial Nerve Elbow flexion/extension 8.8 mm excursion at the elbow Wright et al., 2005 Wrist radial/ulnar deviation 4.3 mm excursion at the wrist
  7. 7. CLINICAL INDICATIONS TRAUMATIC
  8. 8. ANATOMY… WHY IS IT IMPORTANT? Ulnar Nerve Median Nerve Radial Nerve
  9. 9. CLINICAL INDICATIONS –TRAUMATIC  Goal: prevent future nerve irritation by initiating nerve glides early on in the rehab program  Mobilize the nerve(s) early on to minimize potential for adherence in scar tissue (Tubiana & Gilbert, 2005) Injury/Fracture Possible Nerve Involvement Proximal humerus Brachial plexus, radial nerve Mid-humerus Radial nerve Distal humerus Ulnar nerve Radius/ulna shaft Median nerve Distal radius Median nerve
  10. 10. CLINICAL INDICATIONS –TRAUMATIC How do we get some amount of nerve gliding with these patients to prevent or minimize nerve irritation?  Can increase nerve gliding by 3-5 mm by performing exercises with shoulder abducted (Wright, 2001)  With ORIF… easier to begin nerve glides (starting ROM sooner)  With conservative… more challenging Prevention is KEY! Clinical Pearl Initiate nerve glides early to prevent nerve from adhering to scar tissue!
  11. 11. CLINICAL INDICATIONS NON-TRAUMATIC
  12. 12. CLINICAL INDICATIONS – NON-TRAUMATIC How long is too long?
  13. 13. ULNAR NERVE AREAS OF POTENTIAL ENTRAPMENT 1. Arcade of Struthers 2. Medial intermuscular septum 3. CubitalTunnel * 4. Arcade of Fascia (Osbourne’s) 5. Guyon’s Canal * = most common Cano, 2006
  14. 14. MEDIAN NERVE AREAS OF POTENTIAL ENTRAPMENT 1. Carpal tunnel * 2. Pronator teres 3. Ligament of Struther’s 4. Bicipital aponeurosis * = most common Cano, 2006
  15. 15. RADIAL NERVE AREAS OF POTENTIAL ENTRAPMENT 1. Lateral intermuscular septum 2. Arcade of Frohse * 3. Tendinous border of the ECRB fibrous bands 4. Radial recurrent vessels at the wrist * = most common Cano, 2006; Hazani et. al, 2008
  16. 16. THERAPIST EXAMINATION
  17. 17. RELEVANT MEDICAL HISTORY WHO  DM, hypothyroidism, autoimmune disorders, etc.  History of neck injury or MVA WHAT  Description of symptoms  Duration of symptoms  Traumatic vs. non-traumatic WHEN  Specific activity/motion that provokes symptoms WHERE  Localized to one area or travelling WHY  Why is the patient seeking treatment?  Do the symptoms interfere with function? Skirven et. al, 2011
  18. 18. THERAPIST EXAMINATION  Active/passive ROM  Key symptoms (paresthesias, pain)  Sensory testing  2-point discrimination  Semmes-Weinstein  Tinel’s sign  Painful areas along the nerve  Rule out cervical involvement Clinical Pearl Don’t get stuck on a particular diagnosis… focus on the symptoms!
  19. 19. UPPER LIMB NEURALTENSIONTESTING ULNAR NERVE Butler, 2000 Shoulder abduction Shoulder ER Elbow flexion FA pronation Wrist & digit extension Ulnar Nerve
  20. 20. UPPER LIMB NEURALTENSIONTESTING MEDIAN NERVE Butler, 2000 Shoulder abduction Wrist & digit ext. FA supination Shoulder ER Elbow extension Median Nerve
  21. 21. UPPER LIMB NEURALTENSIONTESTING RADIAL NERVE Butler, 2000 Shoulder depression Elbow extension FA pronation Shoulder IR Wrist & digit flexion Radial Nerve
  22. 22. COMMON NERVE COMPRESSION SYNDROMES &TREATMENT APPROACHES Photo from: http://www.monday-8am.com
  23. 23. BASIC PRINCIPLES OF NERVE GLIDES  Emphasize to the patient that it is important to avoid reproducing symptoms  Consider frequency and duration – must be based on the patient’s response Clinical Pearl Nerve glides should always be performed symptom-free! GOAL Maximize excursion of the nerve, while minimizing the strain.
  24. 24. BASIC PRINCIPLES OF NERVE GLIDES  “Sliding” techniques produce significantly more excursion than “tensioning” techniques Clinical Pearl “Sliding” is better than tensioning! Coppieters & Butler, 2008 Median Nerve Sliding 12.6 mm of excursion at the wrist Tensioning 6.1 mm of excursion at the wrist Ulnar Nerve Sliding 8.3 mm of excursion at the elbow Tensioning 3.8 mm of excursion at the elbow
  25. 25. CUBITALTUNNEL SYNDROME ULNAR NERVE Photo from: www.moveforwardpt.com
  26. 26. ULNAR NERVE – CUBITALTUNNEL SYNDROME Conservative Management  Nerve Glides:  Avoid neural tension at the elbow by keeping the elbow extended or slightly flexed  Move adjacent joints (neck, wrist, digits)  Flexor-pronator mass flexibility stretches  Orthoses/Protection: elbow pad, night extension orthosis, etc.  Activity modification: avoid prolonged elbow flexion or resting elbow on hard surfaces Skirven et. al, 2011
  27. 27. ULNAR NERVE – CUBITALTUNNEL SYNDROME Elbow extended, wrist & digits flexed Elbow extended, wrist & digits extended Shoulder adducted, elbow flexed, wrist & digits extended Shoulder flexion, elbow extended, wrist & digits flexed
  28. 28. ULNAR NERVE – CUBITALTUNNEL SYNDROME Post-operative Management  Nerve Glides:  Grewal et. al (2000)  Decompression does not alter excursion of the UN, but does reduce the elongation in the epicondylar groove Skirven et. al, 2011; Grewal et. al, 2000 In-situ UN decompression Subcutaneous UN transposition Submuscular UN transposition Position elbow in extension Position elbow in extension Position elbow in 60-90˚ flexion
  29. 29. CARPALTUNNEL SYNDROME MEDIAN NERVE
  30. 30. MEDIAN NERVE – CARPALTUNNEL SYNDROME Conservative Management  Activity Modification:  Avoid repetitive or tight grasping/pinching  Avoid prolonged wrist flexion  Avoid prolonged static positioning Piazzini et al., 2007 Strong Evidence Moderate Evidence Limited/Mixed Evidence Local & oral steroids (short- term relief) Splinting (wrist immobilization orthosis) NSAIDs Diuretics Yoga Laser/ultrasound
  31. 31. MEDIAN NERVE – CARPALTUNNEL SYNDROME 1. 2. 3. 4. 5. 6. Totten & Hunter, 1991
  32. 32. MEDIAN NERVE – CARPALTUNNEL SYNDROME Post-operative Management  Tendon gliding exercises  Nerve gliding exercises  Scar management & desensitization  Patient education on activity modification
  33. 33. RADIALTUNNEL SYNDROME RADIAL NERVE Photo from: www.slideshare.net
  34. 34. RADIAL NERVE – RADIALTUNNEL SYNDROME Conservative Nerve glides  RN glides (symptom-free!) Orthoses:  Wrist immobilization orthosis for highly irritable nerves Activity modification:  Avoid repetitive FA rotation or wrist flexion/extension Post-Operative Management Nerve glides:  Avoid combined elbow extension, forearm pronation and wrist/digital flexion  Desensitization  Scar management Activity modification:  Same as conservative Skirven et. al, 2011
  35. 35. RADIAL NERVE – RADIALTUNNEL SYNDROME Elbow flexed, wrist & digits extended Elbow flexed, wrist flexed, digits extended Skirven et. al, 2011
  36. 36. RADIAL NERVE – RADIALTUNNEL SYNDROME Ipsilateral neck flexion, elbow extension, wrist flexion & ulnar deviation. Then return to neutral position. Verbal cue: “Like a turtle scooping sand at the beach.” Skirven et. al, 2011
  37. 37. CONSIDERATIONS Precautions Highly irritable conditions Recent diagnosis of CRPS Severe unremitting pain “Nerve gliding is an extremely powerful treatment technique that easily can increase symptoms and irritability if not used very carefully and with good understanding of the goal.” Butler 1991 Contraindications Recently repaired peripheral nerve Active inflammatory conditions Skirven et. al, 2011, Butler 1991
  38. 38. CONCLUSION “TAKE-AWAY POINTS” Nerve glides/slides serve as a good adjunct to traditional therapy treatment approaches «-» Initiate nerve glides early with traumatic injuries or post-operatively to prevent adherence in scar tissue «-» Always perform nerve-glides symptom-free… avoid tensioning the nerve
  39. 39. REFERENCES  Butler, D. S., & Jones, M. A. (1991). Mobilisation of the nervous system. Melbourne: Churchill Livingstone.  Butler, D. S. (2000). The sensitive nervous system. Noigroup publications.  Cooper, C. (2013). Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity. Elsevier Health Sciences.  Coppieters, M.W., & Butler, D. S. (2008). Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. Manual therapy, 13(3), 213-221.  Gerritsen, A.A., deVet, H. C., Scholten, R. J., Bertelsmann, F.W., de Krom, M. C., & Bouter, L. M. (2002). Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. Jama, 288(10), 1245-1251.  Grewal, R.,Varitimidis, S. E.,Vardakas, D. G., Fu, F. H., & Sotereanos, D. G. (2000). Ulnar nerve elongation and excursion in the cubital tunnel after decompression and anterior transposition. Journal of Hand Surgery (British and EuropeanVolume), 25(5), 457-460.
  40. 40. REFERENCES  Hazani, R., Engineer, N. J., Mowlavi, A., Neumeister, M., Lee, A., &Wilhelmi, B. J. (2008). Anatomic landmarks for the radial tunnel. Eplasty, 8, e37.  Piazzini, D. B., Aprile, I., Ferrara, P. E., Bertolini, C. A. R. L. O.,Tonali, P., Maggi, L. O. R. E. D. A. N. A., ... & Padua, L. U. C. A. (2007).A systematic review of conservative treatment of carpal tunnel syndrome. Clinical rehabilitation, 21(4), 299-314.  Ross, R.G. (2007).Anatomy of the Forearm,Wrist and Hand. A Guide for HandTherapists and Allied Health Professionals. Cynthia Cano, OTR,CHT. Denver, CO: C Cano Illustrations, 2006.  Skirven,T. M., Osterman, A. L., Fedorczyk, J., & Amadio, P. C. (2011). Rehabilitation of the hand and upper extremity, 2-volume set: expert consult. Elsevier Health Sciences.  Terzis, J. K., & Smith, K. L. (1990). The peripheral nerve: structure, function and reconstruction (pp. 38-72). Norfolk,VA: Hampton Press.  Totten, P. A., & Hunter, J. M. (1991).Therapeutic techniques to enhance nerve gliding in thoracic outlet syndrome and carpal tunnel syndrome. Hand clinics, 7(3), 505-520.
  41. 41. REFERENCES  Tubiana, R., & Gilbert, A. (2005). Tendon, nerve and other disorders. Informa HealthCare.  Wright,T.W., Glowczewskie, F., Cowin, D., &Wheeler, D. L. (2005). Radial nerve excursion and strain at the elbow and wrist associated with upper-extremity motion. The Journal of hand surgery, 30(5), 990-996.  Wright,T.W., Glowczewskie, F., Cowin, D., &Wheeler, D. L. (2001). Ulnar nerve excursion and strain at the elbow and wrist associated with upper extremity motion. TheJournal of hand surgery, 26(4), 655-662.  Wright,T.W., Glowczewskie, F.,Wheeler, D., Miller, G., & Cowin, D. (1996). Excursion and strain of the median nerve. The Journal of Bone &JointSurgery, 78(12), 1897-1903.

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