Category Archives: Nerves

Nerve Mobilizations to Treat Anterior Knee Pain?

25 Saturday Jul 2015

Posted by in Nerves, Patellofemoral Pain

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PatellofemoralPain_SM

People suffering from anterior knee pain/patellofemoral pain usually will benefit from proper strengthening, stretching, and alignment during functional activities.  But some people tend to continue to have discomfort at their knee even when those deficits are corrected.  There has been recent research showing that people suffering from anterior knee pain can also be from mechanosensitivity/hypersensitivity.

Continued irritation and swelling tends to promote blood vessel and nerve proliferation.  Also, nerves can eventually adhere to structures at the knee such as the bone, ligament, fascia, etc. from injury.  Treatment for improving neurodynamics at the femoral nerve, and associated medial and lateral patellar branches, around the knee can prove beneficial.

Two studies by Lin et al. and Huang et al. examined the use of the Femoral Slump Test to assess neurotension at the knee and other predictors that an individual might benefit from nerve tensioning/gliding.

Individuals that may benefit from this type of treatment are people with symptoms at the anterior knee at the knee cap during stair climbing, squatting, kneeling, or sitting for a long time.  They will also be positive for more than 2 of these clinical tests:

Clarke’s sign – The individual is supine with their knee extended and pressure is applied to the knee cap as they contract their quadriceps.  The test is positive if there is a reproduction of their symptoms.

Waldron Test – The individual is supine with their knee slightly flexed and pressure is applied to the knee cap the knee is progressively flexed more.  The test is positive if there is a reproduction of their pain or crepitus.

Active Patellar Grind Test – The individual sits with their knee at 90 degrees and the examiner palpates the knee cap as the individual straightens their knee.  The test is positive if crepitus is felt during the motion.

Patellar Compression Test – The individual is supine with their knee extended.  Their knee cap is compressed and shifted superiorly.  The test is positive is there is a reproduction of their symptoms.

Assessment and completion of nerve tensioning/gliding is not appropriate if the individual’s anterior knee pain is due to other pathologies such as meniscus, ligaments, etc.

The Femoral Slump Test should be completed with measurement of hip flexion bilaterally when symptoms come on.

The test is positive if the individual’s anterior knee pain is reproduced and then reduced or eliminated with extension of the head.  If the individual has a history of lower back pain and there is a difference of hip flexion during the slump (>3 degrees on the affected side) then the prediction that nerve tensioning/gliding is greatly improved.

The authors of the article completed tensioning of the nerve by taking the hip into extension in the Femoral Slump Test position until the individual’s anterior knee pain is  first felt  then held for 2 seconds.  This was completed 10 times for 3 sets.  Improvement of knee pain was seen on the first session in 50% of subjects and in all subjects by the sixth session.

References:

  1. Lin PL, Shih YF, Chen WY, Ma HL. Neurodynamic response to the femoral slump test in patients with anterior knee pain syndrome. J Ortho Phys Ther. May 2014; 44(5):350-357.
  2. Huang BY, Shih YF, Chen WY, Ma HL. Predictors for identifying patients with patellofemoral pain syndrome responding to femoral nerve mobilization. Arch Phys Med Rehabil. 2015; 96:920-927.

A Side of the Neck Too Painful to Touch: Another Tool in the Toolbox

27 Sunday Jul 2014

Posted by in Neck, Nerves

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I went on a mission to look for an article to assist me with patients that have neck pain, radicular symptoms into the arms, and hypersensitivity to touch.  The greatest obstacle to overcome would be the nerve pain and hypersensitivity.  Patients can get flared up with certain movements of the neck or pressure at the wrong areas.  Sometimes it is tough to manage symptoms if you cannot get your hands on the affected side when the symptoms are at their most extreme.  So then what can you do to calm down the nerves while still working on the origin of the problem?

The article I came across assessed effects of using a contralateral lateral glide to the unaffected side of the problem cervical vertebrae.  This allows you to improve the mobility of the affected joint/s by working on the unaffected side while avoiding a flare up.  The researchers used Grade 2 and 3 mobilizations to the unaffected side of the problem vertebrae for an average total time of 4.5 minutes.  They also placed the arm in a progressively abducted position to tension the nerve if the subject could tolerate the position.  I would combine this treatment technique with soft tissue massage to the affected upper extremity and light compression of the radiocarpal, humeroulnar, and glenohumeral joints to implement aspects of the gate theory. (Joint compression has been shown to create a calming effect on the body.)

(Click the link below for access to the article)

The Immediate Effects of a Cervical Lateral Glide Treament Technique in Patients with Neurogenic Cervicobrachial Pain

Purpose: To analyze the immediate treatment effects of cervical mobilization and therapeutic ultrasound in patients with neurogenic cervicobrachial pain.

Methods: This was a randomized controlled trial.  Inclusion criteria consisted of individuals that had an active movement dysfunction related to noncompliance of the median nerve (active neurotensioning causing pain), a passive movement dysfunction correlating with the active dysfunction (passive neurotensioning causing pain), an adverse response to median nerve palpation, a positive Upper Limb Tension Test A, and a sign of a local musculoskeletal dysfunction that would indicate a possible cause of the neurogenic disorder.  The researchers compared subjects treated with cervical mobilizations to subjects treated with ultrasound to affected upper extremity.  The subjects received cervical segmental contralateral lateral glide at one or more cervical spine segments (C5-T1) in supine for an average of 4.5 minutes at Grade 2 initially and eventually Grade 3.  The tester placed pressure for 2-3 seconds/repetition during the mobilization.  They made sure to avoid cervical side flexion or rotation during the mobilization.  The subject was placed in a nerve tensioning position (shoulder abduction) during the mobilizations if they can tolerate it and if not the upper extremity was placed on the abdomen.

Results: They found significant improvements with elbow range of motion (average increase of ~19.4 degrees), area of symptom provocation (average reduction of ~43.3%), and pain intensity (average reduction of ~1.5 points).  Pain intensity was measured using the Visual Analog Scale 0-10 point scale.