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UE Peripheral Neuropathies

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Robin Constantino

on 22 February 2014

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Transcript of UE Peripheral Neuropathies

Upper Extremity Peripheral Nerve Entrapment's
Anatomy Review
3.) Neurotmesis
Complete disruption of the axon
Limited ability for re-growth with likely long term deficits
Common in lacerations and often require surgery
2.) Axonotmesis
Injury is more severe involving the axon
Recovery may not be full and can take several months
Occurs after crush, traction, or significant microtrauma
1.) Neurapraxia
Focal Damage to the myelin sheath preserving the axon and connective tissue
Recovery over days to weeks
Common in entrapment's or compression type injuries
Types of Nerve Injuries
Novak et al J Hand Ther 2005
1. ) Breakdown of the blood nerve barrier
Subjective findings: Intermittent paraesthesia's and/or aching
Objective Findings: Provocative tests
2.) Connective tissue thickening
Subjective findings:Persistent paraesthesia's and or muscle weakness
Objective Findings: Abnormal sensory and motor thresholds
3.) Axonal degeneration
Subjective findings:Numbness and muscle atrophy
Objective Findings: Abnormal 2-point discrimination and measurable muscle wasting and strength loss
Histopathology of Chronic
Nerve Compression
Pronator Teres Syndrome
Median nerve
Radial nerve
Neal et al Am Fam Phys 2010; Novak et al J Hand Ther 2005; Seddon et al Brain 1943
Posterior Interosseous Nerve Syndrome
Common Areas of Entrapment
Radial Tunnel Syndrome
Handcuff Neuropathy
Differentiating Radial Nerve Entrapment's
Signs and Symptoms
Radial Nerve Provocative Tests
Locations of Entrapment
Radial Tunnel Syndrome
Superficial branch compressed in the Arcade of Frohse also called the
Radial Tunnel
proximal to branch of deep fibers
Posterior Interosseous Nerve Entrapment
Deep branch compressed in the Arcade of Frohse at the entrance to the
Supinator

muscle
Handcuff Palsy
Superficial branch compressed along volar aspect of wrist on top of flexor retinaculum.
Often due to external compression (hand cuff's)
History
Sensory Exam Findings
Manual Muscle Testing
Special Tests
Radial Tunnel Syndrome
No muscle weakness
Pain with supination and repeated flexion and or/pronation
Posterior Interosseous Nerve Entrapment
Lateral elbow and forearm pain
Repetitive Supination work
Often no loss in sensation
Reported weakness
with wrist extension
Thumb extension elicits pain
Posterior Interosseous Nerve Entrapment
No sensation loss
Radial Tunnel Syndrome
Radial Tunnel Syndrome
No muscle weakness
Posterior Interosseous Nerve Entrapment
Weakness
with wrist extension, radial deviation and/or finger extensors
Thumb extension elicits pain
Handcuff Palsy
Sensation loss along radial side back of hand
Handcuff Palsy
No muscle weakness
Radial nerve
numbness
Both
Tinel's Sign
Pressure Provocative Tests
Positional Provocative Tests
Resisted middle finger extension
Diagnosis
Tinel's Sign
Tap the distal radius between ECRL and brachioradialis
Reproduction of tingling or pain indicates a positive test
Pressure Provocative Test
Sustain pressure over the tendinous junction of ECRL and brachioradialis for 60 seconds
Reproduction of tingling or pain indicates a positive test
Move the forearm into pronation with ulnar deviation
Sustain pressure over the ECRL and brachioradialis
Hold for 60 seconds
Reproduction of tingling or pain is a positive test
Differentiating Median Nerve Entrapment's
Signs and Symptoms
Median Nerve Provocative Tests
Locations of Entrapment
Pronator Teres Syndrome
Compressed as is passes
THROUGH
the
pronator teres muscle, bicipital aponeurosis, and/or fasial arch of FDS
Anterior Interosseous Nerve Entrapment
Compressed
BELOW
the
pronator teres
muscle as it becomes independent
Carpal Tunnel Syndrome
Compression occurs within the carpal tunnel of the wrist
History
Sensory Exam Findings
Manual Muscle Testing
Special Tests
Pronator Teres Syndrome
Noted heaviness and fatigue into forearm
Numbness
into hand- primarily 2nd and 3rd digits
Loss of sensation over thenar eminence
Anterior Interosseous Nerve Entrapment
Dull ache in forearm, can be severe
Minimal night symptoms
Reported weakness with grasping items
No loss of sensation
Anterior Interosseous Nerve Entrapment
No Sensation Loss
Pronator Teres Syndrome
Pronator Teres Syndrome
Weakness of thumb, index and middle fingers
Weakness of FPL, pronator quadratus, FDP
Weakness of thenar muscles
Anterior Interosseous Nerve Entrapment
Weakness of FPL, pronator quadratus, FDP
Carpal Tunnel Syndrome
Median nerve numbness
Palmer 1-3.5 digits
Sensation INTACT over thenar eminence
Carpal Tunnel Syndrome
Weakness of thenar muscles
Median nerve numbness
Palmer 1-3.5 digits
LOSS of sensation over thenar eminence
Diagnosis
Tinel's Sign
Tap
Carpal Tunnel- Just proximal to carpal canal
Forearm- Over the Pronator Teres
Reproduction of tingling or pain indicates a positive test
Pressure Provocative Test
Sustain pressure for 60 seconds
Carpal Tunnel- Just proximal to carpal canal
Forearm- Over the Pronator Teres
Reproduction of tingling or pain indicates a positive test
Neurodynamic Tension Test
Carpal tunnel- Move wrist into flexion or extension
Forearm- Move forearm into supination with pressure over pronator teres
Hold for 60 seconds
Reproduction of tingling or pain is a positive test
Differentiating Ulnar Nerve Entrapment's
Signs and Symptoms
Ulnar Nerve Provocative Tests
Locations of Entrapment
Cubital Tunnel Syndrome
Compressed at the medial Epicondyle or just below in the cubital tunnel
Guyon's Tunnel Neuropathy (Cyclist's Palsy)
Compressed between the Hook of the Hamate, Pisiform, and transverse carpal and pisohamate ligaments.
Often due to external pressure (handlebars, jack hammer etc.)
History
Sensory Exam Findings
Manual Muscle Testing
Special Tests
Cubital Tunnel Syndrome
Weakness with gripping
Loss of fine motor skills in hand
Symptoms with
repeated flexion type activities
Reports of
snapping or popping during elbow flexion and extension activities
Guyon's Tunnel Neuropathy (Cyclist's Palsy)
Intermittent paraesthesia's into 4th and 5th digits
Minimally reported weakness

Symptoms related to activity including
prolonged pressure on wrist.
Symptoms

resolve with changing activity
Guyon's Tunnel Neuropathy (Cylist's Palsy)
Minimal to no sensation loss unless in severe late stage or complete disruption of nerve
Cubital Tunnel Syndrome
Cubital Tunnel Syndrome
Weakness into digit abduction, thumb abduction, and weak index finger pinch.
Motor loss in the hypothenar, doral and palmer interossei, 3rd and 4th lumbricals, FBP and Abductor Pollicis muscles
Loss in grip strength
Guyon's Tunnel Neuropathy (Cylist's Palsy)
ONLY IN SEVERE CASES
Motor loss in the hypothenar, doral and palmer interossei, 3rd and 4th lumbricals, FBP and Abductor Pollicis muscles
Claw Hand (Intrinsic Minus) Deformity
Loss in grip strength
Otherwise no loss in strength
Late development of ulnar nerve
numbness
in 4th and 5th digits
Both
Tinel's Sign
Pressure Provocative Tests
Positional Provocative Tests
Froment's Sign
Diagnosis
Tinel's Sign
Tap
Cubital Tunnel- Beginning proximal to the cubital tunnel moving distally
Guyon's Tunnel- Beginning proximal to Guyon's tunnel moving distally
Reproduction of tingling or pain indicates a positive test
Pressure Provocative Test
Sustain pressure over
Cubital Tunnel- Proximal to the cubital tunnel
Guyon’s Canal- Digital pressure at Guyon’s canal
Reproduction of tingling or pain indicates a positive test
Anterior Interosseous Syndrome
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome
Pain paresthesia and/or numbness into second and third digits
Spared sensation into wrist
Night pain
Hand weakness
Pronator Teres Syndrome
Anterior Interosseous Nerve Entrapment
Tinel's Sign
Pressure Provocative Tests
Positional Provocative Tests
Pronator Teres Test
Pinch Grip Test
Positional Provocative Test
Move patients UE into
Shoulder Abduction
External rotation
Forearm supination
Wrist and finger extension
Elbow extension
Any asymmetry in ROM or pain is a positive test
Positional Provocative Test
Neurodynamic Tension Test
Move patients UE into
Shoulder abduction
Internal rotation
Forearm pronation
Wrist and thumb flexion
Elbow extension
Any asymmetry in ROM or pain is a positive test
Cubital Tunnel: Elbow Flexion Test
Move elbow into flexion and hold
Hold for 60 seconds
Reproduction of tingling or pain is a positive test
Positional Provocative Test
Neurodynamic Tension Test
Move patients UE into
Shoulder abduction
External rotation
Forearm pronation or supination
Wrist and finger extension
Elbow flexion
Any asymmetry in ROM of pain is a positive test
Ulnar nerve
Common Areas of Entrapment
Common Areas of Entrapment
Cubital Tunnel Syndrome
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome
APMR 2005 Wainner et al TIC
Shaking hands relieve symptoms
Wrist-ratio index >0.67
Symptom Severity Scale >1.9
Decreased sensation into Median nerve
Age >45
Guyon's Tunnel Neuropathy
References
Neal, S., & Fields, K. B. (2010). Peripheral nerve entrapment and injury in the upper extremity. American family physician, 81(2), 147–55.
Novak, C. B., & Mackinnon, S. E. (n.d.). Evaluation of nerve injury and nerve compression in the upper quadrant. Journal of hand therapy : official journal of the American Society of Hand Therapists, 18(2), 230–40. doi:10.1197/j.jht.2005.02.002
Placzek JD., & Boyce DA. Orthopedic Physical Therapy Secrets. St Louis: Mosby Elsevier 2001
Sebelski, C. The Elbow: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopaedic Physical Therapy, 3rd Edition. APTA 2011
Wadsworth, C., Barch, EF & M Erickson. The Wrist an Hand: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopaedic Physical Therapy, 3rd Edition. APTA 2011
Developed by Matt Haberl, DPT, OCS, ATC, CSCS, FAAOMPT
TREATMENT
Patient Education
Pain Education
Activity Modification
Neurodynamic & Neurobiology Education
Continuous Nervous system


Regional Interdependence
Joint Mobilization
Muscle Weaknesses
Addressing Postural Imbalances & non-neural tissue structures
Distal Nerve Entrapment's
Soft Tissue Restrictions
Joint Restrictions
Proximal Spinal Pathways
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 pressure
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
Neurodynamic Mobility
Tensioning Techniques
Gliding Techniques
Full transcript