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

Pa4ent%Informa4on% Upper%Extremity%Nerve% Demographic% Mobiliza4on%Following%a% – 30%y.o.% – Police%Officer% Brachial%Plexus%Injury% Injury% – Injured%L%shoulder%4%months%prior%to%ini4al%eval%aPer%a% brawl%while%serving%a%search%warrant% MaAhew%R%Duff% – Primary%pain%in%sup/post%shoulder%with%occasional% Clinical%Problem%Solving%II% paraesthesia%into%distal%forearm% – Pain%increases%with%sleeping%on%same%side%and%ac4vity% % – Pa4ent%s4ll%working%full%duty%with%difficulty% % Pa4ent%Informa4on%(cont.)% PT%Ini4al%Evalua4on% • Premorbid%Status%–%Pt%was%working% Pain% Independently%prior%to%injury% Current%–%4/10% • Current%living%situa4on%–%1%story%house%with% @%Worst%–%8/10%(usually%aPer%sustained%ac4vity)% wife%and%2%young%children% Objec4ve%Measures% • Pt%unable%to%sleep%throughout%the%night.%Pt% – Quick%DASH%–%Ini4al%–%31.28% wakes%up%5Y6%4mes%a%night% – Floor%to%Waist%–%Did%not%test%because%of%symptoms% – Waist%to%shoulder%bilateral%liP%–%Did%not%test% because%of%symptoms% % Strength% Range%of%Mo4on% Le#$Side$ Le#$Side$ Shoulder%Flexion% 95%(Empty%End%Feel)% Shoulder%Abd% 4/5% Supina4on% Y4/5% Shoulder%Flex% Y4/5% Wrist%Ext% Y4/5% Shoulder%Abd% 105%(Empty%End%Feel)% Shoulder%ER% Y4/5% Wrist%Flex% Y4/5% Shoulder%ER% WNL% Shoulder%IR% Y4/5% Finger%Abduc4on% Y4/5% Shoulder%IR% WNL% Elbow%Flex% Y4/5% Finger%Ext% Y4/5% Elbow%Ext% Y4/5% Finger%Flexion% 4/5% • Right%Side%was%WNL%in%all%ROM% • All%shoulder%mo4ons%had%pain/discomfort% • Right%side%was%5/5%in%all%direc4ons%

Sensory%and%Special%Tests% Therapy%and%Pa4ent%Goals% Pt%goal:%To%be%able%to%work%without%pain%or% C%6% Diminished% paraesthesias.% C%7%% Normal% C%8%% Normal% PT%Goals:% T%1% Diminished% – Pt%will%improve%shoulder%ROM%to%130%degrees%of% flexion%with%no%pain%in%3%weeks%for%improved%func4on% Posi4ve%Tests% in%overhead%ac4vi4es% • Biceps%Load%II%Test%–%Labrum%% – Pt%will%reduce%pain%to%5/10%at%Its%worst%in%3%weeks%for% con4nued%improvement%in%work%environment% • Drop%Arm%–%Rotator%Cuff% – Pt%will%improve%sleeping%to%having%1Y3%nightly% • HawkinsYKennedy%Impingement% disturbances%and%beAer%tolerance%of%posi4ons%for% • Median%Nerve%Tension% improved%recovery%in%4%weeks% • Froment’s%Sign% PT%Plan%of%Care% Brachial%Plexus/Possible%Injury%Sites% % 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% Clinical%Ques4on% Plan%of%Care%% • Do%neural%mobiliza4ons%help%decrease%pain% - Strengthening%of% and%improve%func4onal%mobility%in%a%30%year% – AAROM/AROM%% rotator%cuff%and% old%male%with%neuropraxia%of%the%lower% scapular%muscles,%% – UE%endurance%training% - Modali4es%to% brachial%plexus?% – LiPing%and%reaching% decrease%pain%as% ac4vi4es%similar%to% needed% work%related%tasks% % – Neural%mobiliza4ons%

Sliders%and%Tensioners%–%Coppieters,% Effec4veness%of%Median%Nerve%Sliders% Neurodynamics%for%Managing%Pain%and%Disability% 2008%% in%Cervicobrachial%Pain%Syndrome% • Sliders%=%Tension%at%one%joint%with%simultaneous%relaxa4on%at% another%% Rohini%Gupta,%Shallu%Sharma.%Indian%Journal%of%Physiotherapy% • Tensioners%=%tension%at%mul4ple%joints%then%relaxa4on%=% and%Occupa4onal%Therapy.%JanYMar.%2012,%Vol%6.%No.1.% increased% 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% Gupta,%2012% Exclusion%Criteria% • 34%subjects%between%18Y40%years%old% • Cervical%radiculopathy% • Myelopathy% Inclusion%Criteria% • Pain%at%least%5/10%in%neck%at%rest,%parascapular,%or% • Disc%prolapse% upper%limb%areas%for%2Y12%weeks% • Cervical%instability% • Pain%at%least%a%7/10%during%ac4vity%and%limb%tension% • Stenosis%w/%neurological%deficits% test% • Vertebrobasilar%artery%insufficiency% • Cervical%trauma/surgery% • Neoplasm%or%fixed%deformity% Gupta,%2012% Experimental%Group%Y%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)%% • Performed%3%sets%of%10.%Treatment%performed%5%out%of%7% 4. Elbow%ext%ROM%during%median%nerve%tension%test% days% • Pain%and%elbow%extension%measurement%taken% • NDI%and%CBSQ%scores%taken%aPer%the%last%session%%

Gupta,%2012% Results%–%Gupta,%2012% Group$ Variable$ Pre2 Post$ Change$(Pre$ MDC$ Control%Group% interven6on$ Interven6on$ –$Post)$ (Median)$ (Median)$ • Taught%AROM%and%isometric%exercises%for%neck% Experimental% VAS% 5.15% 3.3% 1.85% 2% and%shoulder%to%be%performed%for%30%minutes% Elbow%Ext% 44.5% 30.5% 14% 8% ROM% • Performed%5%out%of%7%days%% NDI% 15% 10% 5% 5% • Also%educated%on%good%posture%while%sipng,% CBSQ% 26% 20% 6% working%and%standing%% Conven4onal% VAS% 5.3% 5% 0.3% 2% • APer%5%treatments%–%NDI,%CBSQ,%VAS,%and% Elbow%Ext% 42% 41.5% 0.5% 8% NDI% 14% 12% 2% 5% elbow%extension%all%reYassessed% CBSQ% 25% 23% 2% The%Effec4veness%of%Neural%Mobiliza4on%for% Gupta,%2012% Neuromusculoskeletal%Condi4ons:%A%systema4c%Review%and% MetaYanalysis% Conclusions%% Basson%A,%Oliver%B,%Ellis%R,%Coppieters%M,%Stewart%A,%Mudzi%W.%% %J%Orthop%Sport%Phys%Ther.%Sep%2017% – Elbow%extension%ROM%improved%more%in%nerve%mobiliza4on% group%as%compared%to%conven4onal%group%% – Other%3%categories%showed%experimental%>%conven4onal%but%the% Study%Design:% changes%equal%to%or%less%than%MDC% Systema4c%Review%with%meta%analysis%of%40%studies%with%19%being%included%in% Limita4ons% a%metaYanalysis%for%carpal%tunnel%syndrome,%nerve%related%low%back%pain,%and% – Short%dura4on%trial% nerve%related%neck%and%arm%pain% – Small%study%size% % Purpose:% – Conven4onal%group%exercises%focused%on%neck/shoulder% To%determine%the%efficacy%of%neural%mobiliza4on%for%musculoskeletal% – Used%the%median%for%data,%not%mean% condi4ons%with%a%neuropathic%component.% – Not%sure%if%pa4ents%were%honest%about%analgesics%% % Basson,%2017% Basson,%2017% • Number%of%those%in%the%Study% Method%% – 40%studies%with%a%total%1759%par4cipants% – 2%Reviewers%used%Joanna%Briggs%Ins4tute%(JBI)% Inclusion%Criteria% Exclusion%Criteria% MetaYAnalysis%of%Sta4s4cs%Assessment%and% • RCTs%in%English% • Case%reports/CaseYcontrol/ Review%Instrument%for%cri4cal%appraisal%(MAStARI)% • Evaluated%neurodynamics%in% cohort%studies% par4cipants%>%18%y.o.%with% • Neurodynamics%on%systemic% neuromusculoskeletal% diseases,%CNS%disorders,%or% Outcome%Variables% condi4ons%with%a%neural% polyneuropathies% 4ssue%dysfunc4on.% • Animal%studies% – Primary%–%Pain,%disability,%and/or%func4on% • Ac4ve/Passive%techniques%to% • Healthy%par4cipant%studies% neural%4ssue%or%surrounding% % % structures% • Outcomes%–%pain,%disability,% and/or%func4on%

Results%(Cont.)%–%Basson,%2017% Results%(Cont.)%–%Basson,%2017% • 10%Studies%total%on%nerve%related%neck%and%arm%pain% • Effect%of%tradi4onal%nerve%mobiliza4on%could% • 5%were%low%risk% • 4%looked%at%cervical%lateral%glides%–%included%into%Meta%analysis% 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% Relevance%to%Pa4ent% Conclusions% • Evidence%directs%us%to%use%cervical%lateral% – Cervical%lateral%glides%for%nerve%related%neck%and%arm% glides%to%reduce%pain%and%hopefully%decrease% pain%helped%decrease%pain%but%no%consistent%measures% numbness/4ngling%of%arm%+%hand% used% – Tensioners/sliders%poten4ally%help%pain% • At%this%point,%hard%to%suggest%a%par4cular% Limita4ons% nerve%mobiliza4ons%of%the%UE% – 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%% Pa4ent’s%ReYevalua4on% Pa4ent’s%ReYEvalua4on% Date$ Pain$@$ Pain$ Assessments$ Quick$DASH$ Dermatome$ Ini6al$ 2$Wk$Reassess$ worst$ Currently$ C%6% Diminished% Normal% Ini4al% 31.28% Ini4al% 8% 4% C%7%% Normal% Normal% C%8%% Normal% Normal% 2%Week% 29.55% 2%Week% 8% 5% T%1% Diminished% Normal% Reassessment% Reassessment% 4%Week% 11.36% 4%Week% 4% 2% Special$Test$ Ini6al$ 2$Week$ 4$Week$ Reassessment% Reassessment% Reassessment$ Reassessment$ Biceps%Load%II%Test% Posi4ve% Nega4ve% Nega4ve% Le#$Side$ Ini6al$ 2$Wk$Reassess$ 4$Wk$Reassess$ Drop%Arm%–%Rotator% Posi4ve% Nega4ve% Nega4ve% Shoulder%Flexion% 95%(Empty%End%Feel)% 118%–%Ac4ve% 160%–%Ac4ve%% Cuff% 135%Y%Passive% 172%Y%Passive% HawkinsYKennedy% Posi4ve% Posi4ve% Posi4ve% Shoulder%Abd% 105%(Empty%End% 115% 155% Impingement% Feel)% Median%Nerve% Posi4ve% Posi4ve% Posi4ve% Shoulder%ER% WNL% Tension% Froment’s%Sign% Posi4ve% Posi4ve% Posi4ve% Shoulder%IR% WNL%