Nerve Gliding Exercises - Excursion and Valuable Indications for Therapy

1. Nerve Gliding Exercises: Excursion & Valuable Indications for Therapy Sarah Arnold, MS, OTR Hand to Shoulder Therapy Center Indianapolis, Indiana

2. Objectives Describe the benefits of nerve gliding exercises Describe the clinical indications for nerve gliding: Traumatic Non-traumatic Identify key components of a therapist’s evaluation Discuss treatment approaches and apply nerve glides in your clinical practice

3. What is a nerve glide? Gliding/sliding/flossing Tensioning nerve nerve

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. Excursion Gliding of the nerve relative to the surrounding nerve bed Photo from: www.minneapolishanggliding.com

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. Clinical Indications Traumatic

8. Anatomy… why is it important? Ulnar Nerve Median Nerve Radial Nerve

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. Clinical Indications – Traumatic H ow 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. Clinical Indications Non-traumatic

12. Clinical Indications – Non-traumatic How long is too long?

13. Ulnar Nerve Areas of potential entrapment Arcade of Struthers Medial intermuscular septum Cubital Tunnel * Arcade of Fascia (Osbourne’s) Guyon’s Canal * = most common Cano, 2006

14. Median Nerve Areas of potential entrapment Carpal tunnel * Pronator teres Ligament of Struther’s Bicipital aponeurosis * = most common Cano, 2006

15. Radial Nerve Areas of potential entrapment Lateral intermuscular septum Arcade of Frohse * Tendinous border of the ECRB fibrous bands Radial recurrent vessels at the wrist * = most common Cano, 2006; Hazani et. al, 2008

16. Therapist Examination

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. Therapist Examination A ctive/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. Upper Limb Neural Tension Testing Ulnar Nerve Butler, 2000 Ulnar Nerve

20. Upper Limb Neural Tension Testing Median Nerve Butler, 2000 Median Nerve

21. Upper Limb Neural Tension Testing Radial Nerve Butler, 2000 Radial Nerve

22. Common Nerve Compression Syndromes & treatment approaches Photo from: http://www.monday-8am.com

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. 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. Cubital Tunnel Syndrome Ulnar Nerve Photo from: www.moveforwardpt.com

26. 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 surfaces Skirven et. al, 2011

27. 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

28. Ulnar Nerve – Cubital Tunnel 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. Carpal Tunnel Syndrome Median Nerve

30. Median Nerve – Carpal Tunnel syndrome Conservative Management Activity Modification: A void 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. Median Nerve – Carpal Tunnel syndrome 1. 2. 3 . 4. 5. 6 . Totten & Hunter, 1991

32. Median Nerve – Carpal Tunnel syndrome Post-operative Management Tendon gliding exercises Nerve gliding exercises Scar management & desensitization Patient education on activity modification

33. Radial Tunnel Syndrome Radial nerve Photo from: www.slideshare.net

34. Radial Nerve – Radial Tunnel 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. Radial Nerve – Radial Tunnel syndrome Elbow flexed, wrist & digits extended Elbow flexed, wrist flexed, digits extended Skirven et. al, 2011

36. 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

37. Considerations Precautions Highly i rritable 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. 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. 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 .

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 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.

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. 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.