NERVE GLIDING EXERCISES:EXCURSION & VALUABLE INDICATIONS FOR THERAPY

SARAH ARNOLD, MS, OTRHAND TO SHOULDER THERAPY CENTERINDIANAPOLIS, INDIANA

OBJECTIVES

1. Describe the benefits of nerve gliding exercises

2. Describe the clinical indications for nerve gliding: Traumatic Non-traumatic

3. Identify key components of a therapist’s evaluation

4. Discuss treatment approaches and apply nerve glides in your clinical practice

WHAT IS A NERVE GLIDE?Gliding/sliding/flossing

Tensioning

nerve

nerve

PHYSIOLOGY OF NERVE GLIDES

h local tissue nutritionh blood flow

h nerve conductionh nerve mobility

Photo from: http://voer.edu Cooper, 2014

EXCURSIONGLIDING OF THE NERVE RELATIVE TO THE SURROUNDING NERVE BED

Photo from: www.minneapolishanggliding.com

NERVE EXCURSIONUlnar 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 NerveWrist flexion/extension

19.6 mm excursion at the wrist Wright et al., 1996Digital

flexion/extension9.7 mm excursion at the wrist

Radial NerveElbow flexion/extension 8.8 mm excursion at the

elbow Wright et al., 2005Wrist radial/ulnar

deviation4.3 mm excursion at the wrist

CLINICAL INDICATIONSTRAUMATIC

ANATOMY… WHY IS IT IMPORTANT?Ulnar Nerve Median Nerve Radial Nerve

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 nerveDistal humerus Ulnar nerveRadius/ulna shaft

Median nerve

Distal radius Median nerve

CLINICAL INDICATIONS – TRAUMATIC

How 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!

CLINICAL INDICATIONSNON-TRAUMATIC

CLINICAL INDICATIONS – NON-TRAUMATIC

How long is too long?

ULNAR NERVEAREAS OF POTENTIAL ENTRAPMENT

1. Arcade of Struthers2. Medial intermuscular

septum 3. Cubital Tunnel *4. Arcade of Fascia

(Osbourne’s) 5. Guyon’s Canal

* = most commonCano, 2006

MEDIAN NERVEAREAS OF POTENTIAL ENTRAPMENT

1. Carpal tunnel *2. Pronator teres3. Ligament of Struther’s4. Bicipital aponeurosis

* = most common

Cano, 2006

RADIAL NERVEAREAS OF POTENTIAL ENTRAPMENT

1. Lateral intermuscular septum

2. Arcade of Frohse *3. Tendinous border of the

ECRB fibrous bands4. Radial recurrent vessels

at the wrist

* = most commonCano, 2006; Hazani et. al,

2008

THERAPIST EXAMINATION

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

THERAPIST EXAMINATION Active/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!

UPPER LIMB NEURAL TENSION TESTINGULNAR NERVE

Butler, 2000

Shoulder abduction

Shoulder ER

Elbow flexion

FA pronation

Wrist & digit extension

Ulnar Nerve

UPPER LIMB NEURAL TENSION TESTINGMEDIAN NERVE

Butler, 2000

Shoulder abduction

Wrist & digit ext.

FA supination

Shoulder ER

Elbow extension

Median Nerve

UPPER LIMB NEURAL TENSION TESTINGRADIAL NERVE

Butler, 2000

Shoulder depression

Elbow extension

FA pronation

Shoulder IR

Wrist & digit flexion

Radial Nerve

COMMON NERVE COMPRESSION SYNDROMES & TREATMENT APPROACHES

Photo from: http://www.monday-8am.com

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 responseClinical Pearl

Nerve glides should always be performed symptom-free!

GOAL Maximize excursion of the

nerve, while minimizing the strain.

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

Sliding12.6 mm of excursion at the wrist

Tensioning6.1 mm of excursion at the wrist

Ulnar Nerve

Sliding8.3 mm of excursion at the elbow

Tensioning

3.8 mm of excursion at the elbow

CUBITAL TUNNEL SYNDROMEULNAR NERVE

Photo from: www.moveforwardpt.com

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 surfacesSkirven et. al, 2011

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

ULNAR NERVE – CUBITAL TUNNEL SYNDROMEPost-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

transpositionPosition elbow in

extensionPosition elbow in

extensionPosition elbow in

60-90˚ flexion

CARPAL TUNNEL SYNDROMEMEDIAN NERVE

MEDIAN NERVE – CARPAL TUNNEL SYNDROME

Conservative Management

Activity Modification: Avoid repetitive or tight grasping/pinching Avoid prolonged wrist flexion Avoid prolonged static positioning

Piazzini et al., 2007

Strong Evidence

Moderate Evidence

Limited/Mixed

EvidenceLocal & oral steroids (short-term relief)

Splinting (wrist immobilization orthosis)

NSAIDsDiureticsYogaLaser/ultrasound

MEDIAN NERVE – CARPAL TUNNEL SYNDROME

1. 2. 3.

4. 5. 6.

Totten & Hunter, 1991

MEDIAN NERVE – CARPAL TUNNEL SYNDROME

Post-operative Management Tendon gliding exercises Nerve gliding

exercises Scar management &

desensitization Patient education on

activity modification

RADIAL TUNNEL SYNDROMERADIAL NERVE

Photo from: www.slideshare.net

RADIAL NERVE – RADIAL TUNNEL SYNDROME

ConservativeNerve 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 managementActivity modification: Same as conservative

Skirven et. al, 2011

RADIAL NERVE – RADIAL TUNNEL SYNDROME

Elbow flexed, wrist & digits extended

Elbow flexed, wrist flexed,digits extended

Skirven et. al, 2011

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

CONSIDERATIONS

PrecautionsHighly irritable

conditionsRecent diagnosis of

CRPSSevere 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

ContraindicationsRecently repaired peripheral nerve

Active inflammatory conditions

Skirven et. al, 2011, Butler 1991

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

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.

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.

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.