clinical

1. Dr. Maria Idrees; PT

2. Review of Peripheral
Nerve Structure
Nerve Structure
⚫ Peripheral nervescontain a mix of motor, sensory, and
sympathetic neurons.
■ Alpha motor neurons (somatic efferent fibers): cell bodies located
in anteriorcolumn of spinal cord; innervateskeletal muscles
■ Gamma motor neurons (efferent fibers): cell bodies located in
lateral columnsof spinal cord; innervate intrafusal muscle fibers
of the muscle spindle
■ Sensory neurons (somatic afferent fibers): cell bodies located in
thedorsal rootganglia; innervatesensory receptors
■ Sympathetic neurons (visceral afferent fibers): cell bodies located
in sympathetic ganglia; innervate sweat glands, blood vessels,
viscera, and glands

4. Mobility Characteristics of the
Nervous System
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5. Common Sites of Injury to Peripheral
Nerves
⚫Anywherealong the pathway from the nerve roots to
their termination in the tissues of the trunk and
extremities.
⚫Intervertebral foramen
⚫Symptoms and signs of nerve impairments are sensory
changes or loss and motor weakness in the distribution
of the involved nerve fibers

6. Nerve Roots
⚫Nerve roots emerge from the spinal canal and traverse the
foraminaof the spine, where theycan become impinged as
a result of various pathologies of the spine that reduce the
space in the foramina, such as degenerative disc disease
(DDD), degenerative joint disease (DJD), disc lesions, and
spondylolisthesis.
⚫With reduced spinal canal or foraminal space (stenosis),
extension, side bending, or rotation to the side of the
stenosis furtherdecreases the space where the nerve root
courses and maycauseor perpetuatesymptoms
⚫Nerve roots of the upperquarter include C5 through T1 and
thoseof the lowerquarter L1 through S3.

8. Brachial Plexus

9. Sites of compression

10. Upperplexus injuries (C5, 6): The mechanism involves
shoulder depression and lateral flexion of the neck to the
opposite side. There is loss of abduction and lateral
rotation of the shoulderand weakness in elbow flexion and
forearm supination (waiter’s tip position). Erb’s palsy
occurs with birth injuries when the shoulder is stretched
downward.
⚫Middle plexus injuries (C7): Rarelyseen alone.
⚫Lower plexus injuries (C8, T1): Usually due to
compression by a cervical rib or stretching the arm
overhead. Klumpke’s paralysis (paralysisof the intrinsicsof
the hand) occurs in birth injuries when the baby presents
with itsarm overhead.
⚫Completeortotal injuryof the plexus: Erb-Klumpke’s
paralysis (Horner’s syndrome)

12. Myotomes

15. Lumbosacral Plexus

18. Mechanisms of Nerve Injury
■ Compression (sustained pressure applied externally, such
as tourniquet, or internally, such as from bone, tumor, or
soft tissue impingement resulting in mechanical or
ischemic injury).
■ Laceration (knife, gunshot, surgical complication, injection
injury).
■ Stretch (excessive tension, tearing from traction forces).
■ Radiation.
■ Electricity (lightening strike, electrical malfunction).
⚫Intraneural
⚫Extraneural

20. Excellentregenerative potential: radial,
musculocutaneous, and femoral nerves
Moderate regenerative potential: median, ulnar, and
tibial nerves
Poorregenerative potential: peroneal nerve

21. Outcomesof Nerve Regeneration
⚫Five possibleoutcomesof nerve regeneration.
1. Exact reinnervationof its native targetorgan with
return
⚫of function
2. Exact reinnervationof its native targetorgan but no
return
⚫of function due todegeneration of theend organ
3. Wrong receptorreinnervated in the properterritory;
therefore,
⚫improper input
4. Receptorreinnervation in wrong territorycausing
false
⚫localizationof input
5. Noconnection with an end organ

22. Management Guidelines:
Recovery from Nerve Injury
Acute Phase
⚫Movement
⚫Splinting or bracing
⚫Patient education
Recovery Phase
⚫Motor retraining
⚫Desensitization.
⚫Patient education
Chronic Phase
⚫Compensatory function

23. Suggestions for graded modalities and procedures for
desensitizing:
■ Use multiple types of texturesorcontact forsensorystimulation,
such as cotton, rough material, sandpaperof various grades, and
Velcro. The textures can be wrapped around dowel rods for finger
manipulationor to strokealong theskin.
■ Place contact particles, such as cotton balls, beans, macaroni,
sand, or other material, with various degrees of roughness in
tubs or cans, so the patient can run the involved hand or foot
through the material. Havethe patient begin by manipulating or
placing the extremity in the least irritating texture for 10
minutes. As tolerance improves, progress to the next texture of
slightly more irritating but tolerable stimulus. Maximum
progressoccurs when the most irritating texture is tolerated.
■ Use vibration. Pattern of recovery after nerve injury is pain
(hypersensitivity), perception of slow vibration (30 cps), moving
touch, constant touch, rapid vibration (256 cps), and awareness
from proximal todistal.

24. Suggestions for retraining the brain to recognize a
stimulus
■ Begin by using a moving touch stimulus, such as theeraser
end of a pencil, and stroke over the area. The patient first
watches, then closes his or her eyes, and tries to identify
where touch occurred.
■ Progress from stroking to using constant touch.
■ When the patient is able to localize constant touch,
progress to identificationof familiarobjects of various
sizes, shapes, and textures.
■ For the hand, use familiar household and personal care
objects, such as keys, eating utensils, blocks, toothbrush,
and safetypins.
■ For the feet, have the patientwalk on various surfaces, such
as grass, sand, wood, pebbles, and uneven surfaces.

25. Neural Testing and Mobilization
Techniques for the Upper Quadrant
⚫Median Nerve
⚫Radial Nerve
⚫UlnerNerve

26. Neural Testing and Mobilization
Techniques for the Lower Quadrant
⚫Sciatica Nerve
⚫ Slumpsitting
⚫Femoral Nerve