Upper%Extremity%Nerve% Demographic% Mobiliza4on%Following%a% - - PDF document

Upper%Extremity%Nerve% Mobiliza4on%Following%a% Brachial%Plexus%Injury%

MaAhew%R%Duff% Clinical%Problem%Solving%II% % %

Pa4ent%Informa4on%

Demographic%

– 30%y.o.% – Police%Officer%

Injury%

– Injured%L%shoulder%4%months%prior%to%ini4al%eval%aPer%a% brawl%while%serving%a%search%warrant% – Primary%pain%in%sup/post%shoulder%with%occasional% paraesthesia%into%distal%forearm% – Pain%increases%with%sleeping%on%same%side%and%ac4vity% – Pa4ent%s4ll%working%full%duty%with%difficulty%

Pa4ent%Informa4on%(cont.)%

• Premorbid%Status%–%Pt%was%working%

Independently%prior%to%injury%

• Current%living%situa4on%–%1%story%house%with%

wife%and%2%young%children%

• Pt%unable%to%sleep%throughout%the%night.%Pt%

wakes%up%5Y6%4mes%a%night%

PT%Ini4al%Evalua4on%

Pain% Current%–%4/10% @%Worst%–%8/10%(usually%aPer%sustained%ac4vity)% Objec4ve%Measures%

– Quick%DASH%–%Ini4al%–%31.28% – Floor%to%Waist%–%Did%not%test%because%of%symptoms% – Waist%to%shoulder%bilateral%liP%–%Did%not%test% because%of%symptoms% %

Strength%

Le#$Side$ Shoulder%Abd% 4/5% Supina4on% Y4/5% Shoulder%Flex% Y4/5% Wrist%Ext% Y4/5% Shoulder%ER% Y4/5% Wrist%Flex% Y4/5% Shoulder%IR% Y4/5% Finger%Abduc4on% Y4/5% Elbow%Flex% Y4/5% Finger%Ext% Y4/5% Elbow%Ext% Y4/5% Finger%Flexion% 4/5%

• All%shoulder%mo4ons%had%pain/discomfort%
• Right%side%was%5/5%in%all%direc4ons%

Range%of%Mo4on%

• Right%Side%was%WNL%in%all%ROM%

Le#$Side$ Shoulder%Flexion% 95%(Empty%End%Feel)% Shoulder%Abd% 105%(Empty%End%Feel)% Shoulder%ER% WNL% Shoulder%IR% WNL%

Sensory%and%Special%Tests%

C%6% Diminished% C%7%% Normal% C%8%% Normal% T%1% Diminished%

Posi4ve%Tests%

• Biceps%Load%II%Test%–%Labrum%%
• Drop%Arm%–%Rotator%Cuff%
• HawkinsYKennedy%Impingement%
• Median%Nerve%Tension%
• Froment’s%Sign%

Therapy%and%Pa4ent%Goals%

Pt%goal:%To%be%able%to%work%without%pain%or% paraesthesias.% PT%Goals:%

– Pt%will%improve%shoulder%ROM%to%130%degrees%of% flexion%with%no%pain%in%3%weeks%for%improved%func4on% in%overhead%ac4vi4es% – Pt%will%reduce%pain%to%5/10%at%Its%worst%in%3%weeks%for% con4nued%improvement%in%work%environment% – Pt%will%improve%sleeping%to%having%1Y3%nightly% disturbances%and%beAer%tolerance%of%posi4ons%for% improved%recovery%in%4%weeks%

Brachial%Plexus/Possible%Injury%Sites%

% %

PT%Plan%of%Care%

Assessment%–%Pt%demonstrated%complex% combina4on%of%upper%quarter%damage%including% possible%RC%tear,%Grade%IYII%AC%joint%lesion,%and% neuropraxia%of%lower%brachial%plexus.%Overall% rehab%poten4al%is%good% Frequency%

– 2x/week%for%8%weeks%

PT%Plan%of%Care%

Plan%of%Care%%

– AAROM/AROM%% – UE%endurance%training% – LiPing%and%reaching% ac4vi4es%similar%to% work%related%tasks% – Neural%mobiliza4ons%

• Strengthening%of%

rotator%cuff%and% scapular%muscles,%%

• Modali4es%to%

decrease%pain%as% needed% %

Clinical%Ques4on%

• Do%neural%mobiliza4ons%help%decrease%pain%

and%improve%func4onal%mobility%in%a%30%year%

• ld%male%with%neuropraxia%of%the%lower%

brachial%plexus?%

Sliders%and%Tensioners%–%Coppieters,% 2008%%

• Sliders%=%Tension%at%one%joint%with%simultaneous%relaxa4on%at%

another%%

• Tensioners%=%tension%at%mul4ple%joints%then%relaxa4on%=%

increased%

Effec4veness%of%Median%Nerve%Sliders% Neurodynamics%for%Managing%Pain%and%Disability% in%Cervicobrachial%Pain%Syndrome%

Rohini%Gupta,%Shallu%Sharma.%Indian%Journal%of%Physiotherapy% and%Occupa4onal%Therapy.%JanYMar.%2012,%Vol%6.%No.1.% Study%Design:%%% Random%Controlled%trial%% % Purpose:%% Assess%effec4veness%of%sliders%neurodynamics%as%compared%to% conven4onal%treatment%for%managing%pain%and%disability%in% cervicobrachial%pain%syndrome%pa4ents.%%

%

Gupta,%2012%

• 34%subjects%between%18Y40%years%old%

Inclusion%Criteria%

• Pain%at%least%5/10%in%neck%at%rest,%parascapular,%or%

upper%limb%areas%for%2Y12%weeks%

• Pain%at%least%a%7/10%during%ac4vity%and%limb%tension%

test%

Gupta,%2012%

Exclusion%Criteria%

• Cervical%radiculopathy%
• Myelopathy%
• Disc%prolapse%
• Cervical%instability%
• Stenosis%w/%neurological%deficits%
• Vertebrobasilar%artery%insufficiency%
• Cervical%trauma/surgery%
• Neoplasm%or%fixed%deformity%

Gupta,%2012%

Method%%

• Randomly%separated%into%experimental/control%groups%
• Pa4ents%were%asked%to%not%take%any%analgesic%

medica4on%for%pain%

• All%pa4ents%filled%out:%
• 1. VAS%pain%scale%
• 2. Neck%Disability%Index%(NDI)%
• 3. Cervicobrachial%Symptom%Ques4onnaire%(CBSQ)%%
• 4. Elbow%ext%ROM%during%median%nerve%tension%test%

Experimental%Group%Y%Gupta,%2012%

• Performed%3%sets%of%10.%Treatment%performed%5%out%of%7%

days%

• Pain%and%elbow%extension%measurement%taken%
• NDI%and%CBSQ%scores%taken%aPer%the%last%session%%

Gupta,%2012%

Control%Group%

• Taught%AROM%and%isometric%exercises%for%neck%

and%shoulder%to%be%performed%for%30%minutes%

• Performed%5%out%of%7%days%%
• Also%educated%on%good%posture%while%sipng,%

working%and%standing%%

• APer%5%treatments%–%NDI,%CBSQ,%VAS,%and%

elbow%extension%all%reYassessed%

Results%–%Gupta,%2012%

Group$ Variable$ Pre2 interven6on$ (Median)$ Post$ Interven6on$ (Median)$ Change$(Pre$ –$Post)$ MDC$ Experimental% VAS% 5.15% 3.3% 1.85% 2% Elbow%Ext% ROM% 44.5% 30.5% 14% 8% NDI% 15% 10% 5% 5% CBSQ% 26% 20% 6% Conven4onal% VAS% 5.3% 5% 0.3% 2% Elbow%Ext% 42% 41.5% 0.5% 8% NDI% 14% 12% 2% 5% CBSQ% 25% 23% 2%

Gupta,%2012%

Conclusions%%

– Elbow%extension%ROM%improved%more%in%nerve%mobiliza4on% group%as%compared%to%conven4onal%group%% – Other%3%categories%showed%experimental%>%conven4onal%but%the% changes%equal%to%or%less%than%MDC%

Limita4ons%

– Short%dura4on%trial% – Small%study%size% – Conven4onal%group%exercises%focused%on%neck/shoulder% – Used%the%median%for%data,%not%mean% – Not%sure%if%pa4ents%were%honest%about%analgesics%%

The%Effec4veness%of%Neural%Mobiliza4on%for% Neuromusculoskeletal%Condi4ons:%A%systema4c%Review%and% MetaYanalysis%

Basson%A,%Oliver%B,%Ellis%R,%Coppieters%M,%Stewart%A,%Mudzi%W.%% %J%Orthop%Sport%Phys%Ther.%Sep%2017%

Study%Design:%

Systema4c%Review%with%meta%analysis%of%40%studies%with%19%being%included%in% a%metaYanalysis%for%carpal%tunnel%syndrome,%nerve%related%low%back%pain,%and% nerve%related%neck%and%arm%pain%

%

Purpose:%

To%determine%the%efficacy%of%neural%mobiliza4on%for%musculoskeletal% condi4ons%with%a%neuropathic%component.%

%

Basson,%2017%

• Number%of%those%in%the%Study%

– 40%studies%with%a%total%1759%par4cipants%

Inclusion%Criteria%

• RCTs%in%English%
• Evaluated%neurodynamics%in%

par4cipants%>%18%y.o.%with% neuromusculoskeletal% condi4ons%with%a%neural% 4ssue%dysfunc4on.%

• Ac4ve/Passive%techniques%to%

neural%4ssue%or%surrounding% structures%

• Outcomes%–%pain,%disability,%

and/or%func4on%

Exclusion%Criteria%

• Case%reports/CaseYcontrol/

cohort%studies%

• Neurodynamics%on%systemic%

diseases,%CNS%disorders,%or% polyneuropathies%

• Animal%studies%
• Healthy%par4cipant%studies%

%

Basson,%2017%

Method%%

– 2%Reviewers%used%Joanna%Briggs%Ins4tute%(JBI)% MetaYAnalysis%of%Sta4s4cs%Assessment%and% Review%Instrument%for%cri4cal%appraisal%(MAStARI)%

Outcome%Variables%

– Primary%–%Pain,%disability,%and/or%func4on% %

Results%(Cont.)%–%Basson,%2017%

• 10%Studies%total%on%nerve%related%neck%and%arm%pain%
• 5%were%low%risk%
• 4%looked%at%cervical%lateral%glides%–%included%into%Meta%analysis%

Results%(Cont.)%–%Basson,%2017%

• Effect%of%tradi4onal%nerve%mobiliza4on%could%

not%be%explored%by%metaYanalysis%

– due%to%different%outcome%measures%and% techniques%used.%

• 4%studies%used%sliding/tensioning%exercises%

– Showed%significant%improvement%in%pain% – However%all%had%a%high%risk%of%bias%

Basson,%2017%

Conclusions%

– Cervical%lateral%glides%for%nerve%related%neck%and%arm% pain%helped%decrease%pain%but%no%consistent%measures% used% – Tensioners/sliders%poten4ally%help%pain%

Limita4ons%

– Use%of%mul4ple%outcome%measures%% – Small%amount%of%studies%for%meta%analysis% – High%risk%of%bias%in%studies%for%peripheral%nerve% mobiliza4ons%of%the%UE% – Many%of%the%studies%looked%at%cervical%radiculopathy%%

Relevance%to%Pa4ent%

• Evidence%directs%us%to%use%cervical%lateral%

glides%to%reduce%pain%and%hopefully%decrease% numbness/4ngling%of%arm%+%hand%

• At%this%point,%hard%to%suggest%a%par4cular%

nerve%mobiliza4ons%of%the%UE%

Pa4ent’s%ReYevalua4on%

Assessments$ Quick$DASH$ Ini4al% 31.28% 2%Week% Reassessment% 29.55% 4%Week% Reassessment% 11.36% Date$ Pain$@$ worst$ Pain$ Currently$ Ini4al% 8% 4% 2%Week% Reassessment% 8% 5% 4%Week% Reassessment% 4% 2% Le#$Side$ Ini6al$ 2$Wk$Reassess$ 4$Wk$Reassess$ Shoulder%Flexion% 95%(Empty%End%Feel)% 118%–%Ac4ve% 135%Y%Passive% 160%–%Ac4ve%% 172%Y%Passive% Shoulder%Abd% 105%(Empty%End% Feel)% 115% 155% Shoulder%ER% WNL% Shoulder%IR% WNL%

Pa4ent’s%ReYEvalua4on%

Dermatome$ Ini6al$ 2$Wk$Reassess$ C%6% Diminished% Normal% C%7%% Normal% Normal% C%8%% Normal% Normal% T%1% Diminished% Normal%

Special$Test$

Ini6al$ 2$Week$ Reassessment$ 4$Week$ Reassessment$

Biceps%Load%II%Test%

Posi4ve% Nega4ve% Nega4ve%

Drop%Arm%–%Rotator% Cuff%

Posi4ve% Nega4ve% Nega4ve%

HawkinsYKennedy% Impingement%

Posi4ve% Posi4ve% Posi4ve%

Median%Nerve% Tension%

Posi4ve% Posi4ve% Posi4ve% Froment’s%Sign% Posi4ve% Posi4ve% Posi4ve%

What%would%I%do%differently?%

• I%would%begin%with%cervical%mo4ons%and%

mobiliza4on%techniques%%

– Lateral%glides%

• I%would%ini4ate%slider%nerve%mobiliza4on%

techniques%once%pain%had%decreased.%

Overall%Conclusion%

• With%the%current%evidence%it%is%hard%to%use%

slider/tensioner%neural%mobiliza4on% techniques%

– Possibly%effec4ve%in%reducing%pain%

• Is%it%any%beAer%than%AROM?%

– Combina4ons%are%endless%% – No%consistency%in%interven4on%techniques/

• utcome%measures%used%

– Only%certain%techniques%for%certain%pa4ent% diagnoses%

References%

1. Basson%A,%Oliver%B,%Ellis%R,%Coppieters%M,%Stewart%A,%Mudzi%W.%The% Effec4veness%of%Neural%Mobiliza4on%for%Neuromusculoskeletal% Condi4ons:%A%Systema4c%Review%and%MetaYanalysis.%J%Orthop% Sport%Phys%Ther.%2017%Sep;47(9):5893Y615.% % 2. Coppieters%MW,%Butler%DS.%Do%“sliders”%slide%and%“tensioners”% tension?%An%analysis%of%neurodynamic%techniques%and% considera4ons%regarding%their%applica4on.%Man%Ther.%2008;13(3): 213Y221.%% 3. Gupta%R,%Sharma%S.%Effec4veness%of%Median%Nerve%Slider’s% Neurodynamics%for%Managing%Pain%and%Disability%in% Cervicobrachial%Pain%Syndrome.%Indian%Journal%of%Physiotherapy% and%Occupa4onal%Therapy.%JanYMar.,%2012,%Vol.%6%No.%1% %

Ques4ons?%