Nerve Gliding Exercises - Excursion and Valuable Indications for Therapy
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Transcript of Nerve Gliding Exercises - Excursion and Valuable Indications for Therapy
NERVE GLIDING EXERCISES:EXCURSION & VALUABLE INDICATIONS FOR THERAPY
SARAH ARNOLD, MS, OTRHAND TO SHOULDER THERAPY CENTERINDIANAPOLIS, INDIANA
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
WHAT IS A NERVE GLIDE?Gliding/sliding/flossing
Tensioning
nerve
nerve
PHYSIOLOGY OF NERVE GLIDES
h local tissue nutritionh blood flow
h nerve conductionh nerve mobility
Photo from: http://voer.edu Cooper, 2014
EXCURSIONGLIDING OF THE NERVE RELATIVE TO THE SURROUNDING NERVE BED
Photo from: www.minneapolishanggliding.com
NERVE EXCURSIONUlnar 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 NerveWrist flexion/extension
19.6 mm excursion at the wrist Wright et al., 1996Digital
flexion/extension9.7 mm excursion at the wrist
Radial NerveElbow flexion/extension 8.8 mm excursion at the
elbow Wright et al., 2005Wrist radial/ulnar
deviation4.3 mm excursion at the wrist
CLINICAL INDICATIONSTRAUMATIC
ANATOMY… WHY IS IT IMPORTANT?Ulnar Nerve Median Nerve Radial Nerve
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 nerveDistal humerus Ulnar nerveRadius/ulna shaft
Median nerve
Distal radius Median nerve
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!
CLINICAL INDICATIONSNON-TRAUMATIC
CLINICAL INDICATIONS – NON-TRAUMATIC
How long is too long?
ULNAR NERVEAREAS OF POTENTIAL ENTRAPMENT
1. Arcade of Struthers2. Medial intermuscular
septum 3. Cubital Tunnel *4. Arcade of Fascia
(Osbourne’s) 5. Guyon’s Canal
* = most commonCano, 2006
MEDIAN NERVEAREAS OF POTENTIAL ENTRAPMENT
1. Carpal tunnel *2. Pronator teres3. Ligament of Struther’s4. Bicipital aponeurosis
* = most common
Cano, 2006
RADIAL NERVEAREAS OF POTENTIAL ENTRAPMENT
1. Lateral intermuscular septum
2. Arcade of Frohse *3. Tendinous border of the
ECRB fibrous bands4. Radial recurrent vessels
at the wrist
* = most commonCano, 2006; Hazani et. al,
2008
THERAPIST EXAMINATION
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
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!
UPPER LIMB NEURAL TENSION TESTINGULNAR NERVE
Butler, 2000
Shoulder abduction
Shoulder ER
Elbow flexion
FA pronation
Wrist & digit extension
Ulnar Nerve
UPPER LIMB NEURAL TENSION TESTINGMEDIAN NERVE
Butler, 2000
Shoulder abduction
Wrist & digit ext.
FA supination
Shoulder ER
Elbow extension
Median Nerve
UPPER LIMB NEURAL TENSION TESTINGRADIAL NERVE
Butler, 2000
Shoulder depression
Elbow extension
FA pronation
Shoulder IR
Wrist & digit flexion
Radial Nerve
COMMON NERVE COMPRESSION SYNDROMES & TREATMENT APPROACHES
Photo from: http://www.monday-8am.com
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 responseClinical Pearl
Nerve glides should always be performed symptom-free!
GOAL Maximize excursion of the
nerve, while minimizing the strain.
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
Sliding12.6 mm of excursion at the wrist
Tensioning6.1 mm of excursion at the wrist
Ulnar Nerve
Sliding8.3 mm of excursion at the elbow
Tensioning
3.8 mm of excursion at the elbow
CUBITAL TUNNEL SYNDROMEULNAR NERVE
Photo from: www.moveforwardpt.com
ULNAR NERVE – CUBITAL TUNNEL 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 surfacesSkirven et. al, 2011
ULNAR NERVE – CUBITAL TUNNEL 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
ULNAR NERVE – CUBITAL TUNNEL SYNDROMEPost-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
transpositionPosition elbow in
extensionPosition elbow in
extensionPosition elbow in
60-90˚ flexion
CARPAL TUNNEL SYNDROMEMEDIAN NERVE
MEDIAN NERVE – CARPAL TUNNEL 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
EvidenceLocal & oral steroids (short-term relief)
Splinting (wrist immobilization orthosis)
NSAIDsDiureticsYogaLaser/ultrasound
MEDIAN NERVE – CARPAL TUNNEL SYNDROME
1. 2. 3.
4. 5. 6.
Totten & Hunter, 1991
MEDIAN NERVE – CARPAL TUNNEL SYNDROME
Post-operative Management Tendon gliding exercises Nerve gliding
exercises Scar management &
desensitization Patient education on
activity modification
RADIAL TUNNEL SYNDROMERADIAL NERVE
Photo from: www.slideshare.net
RADIAL NERVE – RADIAL TUNNEL SYNDROME
ConservativeNerve 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 managementActivity modification: Same as conservative
Skirven et. al, 2011
RADIAL NERVE – RADIAL TUNNEL SYNDROME
Elbow flexed, wrist & digits extended
Elbow flexed, wrist flexed,digits extended
Skirven et. al, 2011
RADIAL NERVE – RADIAL TUNNEL 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
CONSIDERATIONS
PrecautionsHighly irritable
conditionsRecent diagnosis of
CRPSSevere 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
ContraindicationsRecently repaired peripheral nerve
Active inflammatory conditions
Skirven et. al, 2011, Butler 1991
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
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., de Vet, 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 European Volume), 25(5), 457-460.
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 Hand Therapists 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.
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. The Journal 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 & Joint Surgery, 78(12), 1897-1903.