Clinical Neurodynamics - Vompti
Property of VOMPTI, LLCClinical Neurodynamicswww.vompti.com Definition: clinical application of mechanics andphysiology of the nervous system as they relate toeach other and are integrated with themusculoskeletal function Links mechanics, physiology and function of the MSsystem to the nervous system Does NOT just consider tensionCLINICAL NEURODYNAMICSKristin Kelley, PT, DPT, OCS, FAAOMPT– Sliding– Physiology Intraneural blood flow Mechanosensitivity Inflammation of neural tissueOrthopaedic Manual Physical Therapy SeriesCharlottesville 2017-2018Orthopaedic Manual Physical Therapy Series 2017-2018Orthopaedic Manual Physical Therapy Series 2017-2018Effect of clinical neurodynamics Restoration of normal mechanics of theconnective tissues thus lessening thepossibility of the nerve being entrapped intheir surrounding connective tissue Enhancing the intraneural pressure in thenervous system and dispersion ofintraneural edema Improve vascularization of nervous systemand surrounding structures Improve axoplasmic flowOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comwww.vompti.comIndications for NeurodynamicTesting Pts w/symptoms anywhere in thearm, head, LBS, and thoracic spine Subjective exam suggests ANTT(Cervical flexion produces LB orLE pain when getting in/out ofcar) Post surgical pts, chronicdysfunctions and symptoms w/ojoint signsOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com1
Property of VOMPTI, LLCIndications for NeurodynamicTesting Symptoms do not fit a normal pattern (arm orleg symptoms not responding to localtreatment) UE or LE muscle tear Post whiplash, CTS, DeQervains tenosynovitis,tennis elbow, TOS, and repetitive strain injury– Clinical example: When testing active shoulderflex/abd and the pt spontaneously performsmovement w/elbow flexion and/or cerv SB towardinvolved extremityOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comNervous System: Three Part System Nerve: peripheral nerve,nerve root, dura Interface: any tissueadjacent to the nerve– Connective tissue– Bone– Muscle Piriformis: mechanicalinterface to the sciaticnerve as it pierces orcourses just adjacent toit Innervated tissueOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without t worsening ofneurologicalsigns/symptoms Cauda equinasyndrome Pathology of thenervous system(e.g.diabetes, MS, GuillianBarre) Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comNervous system primary functions Withstand tension– 18-22% elongation beforefailure– Varies btw individuals andbtw specific nerves– Elongation produces achange in blood vesselfunction—compromisessliding Longitudinal sliding—typically preventsexcessive tension Withstand Pressurewww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com2
Property of VOMPTI, LLCElongation of thecervical spinal cordwith flexion andextensionNormalmovement of thespinal cord andnerve roots in thecervical spinewithElongation of thelumbar spinal cordwith flexion andextensionOrthopaedic Manual Physical Therapy Series 2017-2018a) Extensionb) Flexionwww.vompti.comTunnel for Nerve, Artery, Vein Normal PressureGradientOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without ConsentOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comTunnel for Nerve, Artery, Vein 8% elongation-intraneural veinsstart gettingblockedwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com3
Property of VOMPTI, LLCTunnel for Nerve, Artery, Vein–Edema occursfurther increasingintratunnelpressure–15%--all bloodflow blockedTunnel for Nerve, Artery, Vein Edemacontributes toincreasedfibroblasticactivityOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comOrthopaedic Manual Physical Therapy Series RESSIONIMPAIREDGLIDINGOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018EDEMASCARRINGwww.vompti.com4
Property of VOMPTI, LLCNerve CompressionNerve Movement Disruption of axoplasmic flow due to nervecompression IS reversible 50 mm Hg x 2 hrs, reversible in 24 hrs 200 mm Hg x 2 hrs, reversible in 3 days 400 mm Hg x 2 hrs, reversible in 1 weekOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com 3 ways to move nerves–Move the joint–Move the actual nerve–Move the adjacent soft tissue(muscle, fascia)Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comTransmission of Forces Along theSystem Neural effects during neurodynamictechnique:– Early in movement—taking up slack– Mid range– sliding effects– End Range– tension effects– Reference: Wright et all 1996Upper Extremity Nerves Directly translates to treatment progressionOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com5
Property of VOMPTI, LLCOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comUE Neurodynamic Testing Upper Limb “Tension” Testing (Provocation)– “SLR of the Upper Extremity”– Not disorder specific except for a (-) test to rule outcervical radiculopathy– Biased to the terminal branches of the brachialplexus based on their anatomy Median nerve (ULTT 1 and 2a) Radial nerve (ULTT 2b) Ulnar nerve (ULTT 3)– Sensitivity 72-97%– Specificity 22-33%Orthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com6
Property of VOMPTI, LLCMedian Neurodynamic Test11.Pistol grip isolate digits1,2,3- median nervedistribution2.Therapist hand sits on bedabove shoulder usingknuckles as a fulcrum.Lean on the hand with astraight elbow. Arm in 90deg shoulder abduction,elbow at 90 deg flexion3. wrist ext4.GH ER to approx. 90 deg.(in frontal plane, stopshoulder from elevating).Do NOT depress scapulaOrthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.comMedian Neurodynamic Test 21.Perform shoulderdepression takingup slack in nerveswith anterior thigh,NOT to the point ofstretching.2.Elbow extensionOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without ConsentMedian Neurodynamic Test1 www.vompti.com4. Elbow extension to symptomreproduction or tension5. Cervical SB toward (?symptom )6. Cervical SB away (?symptom )***Structural differentiation:– distal symptoms: use cervicalSB toward/away– proximal symptoms: use wristflexionNormal response:Symptoms: pulling anteriorelbow extending to the first 3 digits.ROM—anything btw 60 deg tofull elbow extOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comMedian Neurodynamic Test 24. External rotation/supination, wristand finger extension5. Shoulder abduction** Structural Differentiation:Proximal symptoms: usewristDistal symptoms: releaseshoulder elevationNormal response:Symptoms: pulling anteriorelbow extending to the firstthree digits. Sometimesparesthesia in the hand inMedian Nerve distributionROM: anything btw 0-45degabductionOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com7
Property of VOMPTI, LLCNeurodynamic Sequencing Evaluation of side to side differences inelbow ROM during ULTT for Median andRadial nerves for onset of resistance (R1)and onset of nerve pain (P1) No difference in mean ROM btw sides Intra-individual inter-limb differences of 15 for median nerve and 11 for radialnerve exceeds the range of normal ROMasymmetry of ULTT at R1 and P1Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comNeurodynamic Sequencing Tsai 1995 Cadaver Study on Ulnar nerve– Compared tensioning: proximal to distal Distal to proximal Elbow first– Greatest strain at ulnar nerve at the elbow withthe Elbow First sequence (increased intraneuraltension by 20%)Orthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.com Sequencing of movements influences thelocation of symptoms Greater symptoms at region moved first andmost strongly Ref:Shacklock 1989, Zorn, Shacklock andTrott 1995Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comNeurodynamic Sequencing Technique considerations:– Must be consistent with testing– If you change technique, you change thetest or change the treatment– Small technique changes may produce aBIG change in responseOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com8
Property of VOMPTI, LLCNeurodynamic SequencingProgressionsNeurodynamic SequencingPROTECTIVE REMOTE Example: Acute wrist painFocusedSequenceHIGHTensionersSlidersMEDIUM1. Cervical contralateral SB2. Shoulder abduction3. Elbow extension4. Release cervical contralateral SB---”Off Switch”should reduce wrist pain– NEVER change wrist position if it is the symptomaticarea–––– Example: Low back painProtectionNerveTensionLOWOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comNeurodynamic Sequencing– 1. Dorsiflexion– 2. SLR to onset of pain– 3. Release DF---”Off Switch” should reduce back painOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comActive Median Nerve SliderSLIDER (Median nerve bias) Nerve slides toward the sitewhere force is initiated Moves both proximal anddistal area to floss vs. creatingtension on nerve Must understand course ofnerve to choose correctpositioningOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com9
Property of VOMPTI, LLCPassive Median Nerve Slider Wrist flex/elbow ext Wrist ext/elbow flexOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comSlider dosage?For Use of Participants Only. No Use orReproduction Without Consent Allows nerve to return to rest position and neverallows reproduction of symptoms duringtreatment Can be repeated several times during a sessionprovided a beneficial response occurs withfrequent reassessments Can perform 4-5 sets of 5-30 reps w/breaks ofseconds to minutesOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comNeurodynamic Sequencing If negative response, alter technique Do not give as HEP until 24 hour response isnoted May then perform as HEP from 1x daily tohourly dependent upon pt needs If cases such as acute HS injury, CTS release,shoulder surgery, and want to inhibit affectsof scar tissue lay down, may have ptperform hourlyOrthopaedic Manual Physical Therapy Series 2017-2018Slider dosage?www.vompti.comTENSIONER (Median nerve bias) Places nerve on tension Must understand course ofnerve to choose correctpositioningOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com10
Property of VOMPTI, LLCCoppieters et al. Different Nerve Gliding Exercises InduceDifferent Magnitudes of Median Nerve Longitudinal Excursion: AStudy Using Dynamic US imaging. JOSPT 2009;39:164-171. Different exercises producedifferent amounts of longitudinalnerve excursion (A) “Sliding Technique” produceslargest excursion– Ipsilateral cervical SBcombined with elbowextension (C)“Tensioning Technique”produced smaller excursion– Contralateral cervical SBcombined with elbowextensionOrthopaedic Manual Physical Therapy Series 2017-2018– 1. Cervical contralateral SB– 2. Shoulder abduction– 3. Elbow extension– 4. Wrist extension Example 2: chronic wrist pain– 1. Wrist extension– 2. Elbow extension– 3. Shoulder abduction– 4. Cervical contralateral SBwww.vompti.com Elvey 1979, Rubernach 1985 95-97% of young, asymptomatic subjectsshow a change in symptoms of tension withcontralateral neurodynamic positioning– 62% show a DECREASE– 33% show an increase– Approx 5% show no changeFor Use of Participants Only. No Use orReproduction Without ConsentFOCUSED SEQUENCE (Median nerve bias) Example1: chronic cervical painContralateral Neurodynamic TestingOrthopaedic Manual Physical Therapy Series 2017-2018Neurodynamic Sequencingwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comContralateral Neurodynamic Tension Part A (left), the nerve roots arein their neutral position. Part B (middle), this ipsilateralnerve root is pulled andtensioned by the first(ipsilateral) neurodynamic test. Part C (right), the ipsilateralnerve root has loosened becausethe spinal cord has moveddownward by the pulling of thecontralateral nerve root with thecontralateral neurodynamic test.Orthopaedic Manual Physical Therapy Series 2017-2018Nerve roots as they interact across thespinal cord and produce movement inthe cord during contralateral NDtensionwww.vompti.com11
Property of VOMPTI, LLCContralateral Neurodynamic TensionContralateral Neurodynamic Tension permits the ipsilateralnerve root to get looser challenges past ideas thatcontralateral testingproduces an increase inneural tension in theipsilateral nerve root. clinicians often notice ptswith severe lumbar nerveroot pain can get reliefwith contralateral nervetensionOrthopaedic Manual Physical Therapy Series 2017-2018 Downward (caudal)movement of the spinal cordproducing a reduction intension in the nerve roots(from Breig 1960, Shacklock2007). Produces a dec in distancebetween exit point of thenerve root from the spinalcord and the intervertebralforamen This results in a reduction intension in the nerve root.www.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018Slump Test: Effect of Contralateral Knee Extension onResponse Sensations inAsymptomatic Subjects and Cadaver Study 2 Fold study to compare theresponse of subjects to contralateralslump test and examine cadavercontralateral LB neural tensionControl group of asymptomaticsubjects had normal thigh stretchreduced w/contralateral ST vs nochange in control or shamContralateral reduction in LB neuraltension with unilateral nerve roottension in cadaver study– Supports proposed hypothesis ofreduced contralateral n. roottension in healthy individualsOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comContralateral Neurodynamic TensionOften decreases nerve root tensionCan be used to “offload” cervical spinal rootMust be particular on body/limb positionCan decrease the power of a ND techniqueCan change its level of tension/impactCan use with normal progression of theneurodynamic test UE/cervical “offload”: use contralateral mediannerve tension or SLR tension LE/LB “offload”: use contralateral SLR nerve tension www.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com12
Property of VOMPTI, LLCContralateral neurodynamic tension R median nerve orcervical nerve rootirritability R UE held in slackposition L side tension to furtherslack R UE tension UE median nervetension position used to“off-load” opposite UEtensionOrthopaedic Manual Physical Therapy Series 2017-2018Contralateral Tension Effects - LB Spine Reduction in symptoms withcontralateral SLR is typical Observations in clinical andnormal subjects suggest that theeffects are MORE SIGNIFICANTthan in cervical spine Possibly because the intraduralnerve roots are more paralleland in a better position to assistone anotherwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comSLR to Reduce Cervical Nerve Root TensionSLR to Reduce Cervical Nerve Root Tension SLR may be used to reducetension in the cervical nerveroots by moving the corddownward in the canal. LE movements can be used toease pain and mobilize thenerve roots, includingthoracic and cervical regions LE movements can substitutecontralateral upper limbneurodynamic testing If the contralateral UEnerve tension does notrelieve a patient’s neckand or upper limb pain,the SLR can be appliedinstead It is hypothesized thatthe SLR pulls the corddownward in the canalwhich produces areduction in tension inthe cervical nerve root.Orthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comShacklock 2005Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comShacklock 200513
Property of VOMPTI, LLCDiagnosing with Neurodynamic Testing Structural Differentiation (nerve sensitizing ordesensitizing movement)– Used to make a distinction between neural and nonneural structures being the source of symptoms– When nerves in a problem area are moved w/o movingMS tissues– If symptoms change with the differentiating movementsymptoms ARE NEUROGENIC– If symptoms do NOT change with the differentiatingmovement symptoms are NOT NEUROGENICOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comDiagnosing with Neurodynamic TestingStructural Differentiation (neuralsensitizing/desensitizing movement)– EXAMPLE: Forearm symptoms with ANTTtesting Change nerve tension with cervical SB If symptoms change—most likely neurogenicin origin If symptoms do NOT change—most likelynon-neural (muscle, fascia, scar tissue.etc)Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comDiagnosing with Neurodynamic TestingDiagnosing with Neurodynamic Testing Performance of test must be: Produce response/effect– Symptoms Area/distribution Choose differentiating movement– PRECISE Hand positioning Joint ROM Movement resistance Neurodynamic sequence Slow Careful– Complete—stop when youencounter first obstacle: Each movement to firstcomfortable symptoms ResistanceOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consent– Physical ROM Muscle responses Protective movementwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com14
Property of VOMPTI, LLCClassification of Responses MS response– Does NOT change w/structural differentiationmovement– Neural tissues are not likely source of symptoms Normal Neural response– Does change w/structural differentiation movement– Symptoms are similar in location, range of movementand quality of symptoms to normal subjects– Reasonably symmetrical in site and quality ofsymptoms– Reasonably symmetrical in ROM and behavior ofresistance– Does NOT reproduce clinical symptomsOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comClassification of Responses Abnormal Neural Response Example– Pt has cc/o forearm pain with computer use– “ache” during ANTT at region of the problem butdoes not reproduce exact pain– Structural differentiation: neural w/cervicalcontralateral SB– ROM of elbow ext unaffected side– Supination unaffected side that improves withreleasing cervical SB– Signs are relevant --missing them limits effectivetreatmentOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comClassification of Responses Abnormal Neural response– Does change w/structural differentiation movement– Symptoms are different in location, range of movementand quality of symptoms to normal subjects– Reduction in ROM and increasedresistance– Location and quality of symptomscan be different from unaffected side– May be abnormal but NOTreproduce patient’s symptoms– May indicate a subtle problemworth treating– May be hidden sub-clinical abnormalityOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comRelationship of Neurodynamic TestingResults to the Cause? Abnormal ND test does NOT establish cause SOMETHING in nervous system is wrongand cause must be established throughthoroughly evaluating the pt Main thing that an abnormal neurodynamictest offers is the fact that something in thenervous system is wrong and the causeneeds to be establishedOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com15
Property of VOMPTI, LLCRelationship of Neurodynamic TestingResults to the Cause? Possible causes of abnormal NDtest: Once you have decide the test is positive (viastructural differentiation)– Are those the symptoms you have had before?Pancoast tumor or malignancyOsteophyteDisc bulgeSwollen joint or tendon sheathMyotendinous or nervous systemanomalies– Neuritis– Nerve compression– Joint movement dysfunction–––––Orthopaedic Manual Physical Therapy Series 2017-2018 Yes-abnormal response No-perform stage 2 test– Is the response similar to the known normal response? ROM, tissue resistance, location, type of symptoms normal? Yes- normal positive test No-abnormal response– Not sure?—compare to contralateral side– ** any variable used in classifying the response must bepositive to structural differentiationwww.vompti.comAnalysis of Test Responses– Is it Relevant? Relevant:–Reproduces pts current clinical pain–Is tighter than normal–The symptoms spread further thannormal–This is different from asymtomatic side–The difference is in the right location ofthe pt problemOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without ConsentAnalysis of Test Responseswww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comAnalysis of Test Responses– Is it Relevant? Irrelevant:– Relates to an old problem that is no longersymptomatic– Anomalous response that is symmetrical (ie.Bilateral tightness)– Normally tight for that person and is symmetrical– May have anatomical anomaly that is not relevantOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com16
Property of VOMPTI, LLCWainner RS, Fritz JM, Irrgang JJ et al. Reliability and diagnosticaccuracy of the clinical examination and patient self-reportmeasures for cervical radiculopathy.Planning Exam and TreatmentSpine 2003;28:52-62. 82 pts referred for electrophysiologic labs with suspectedCR or CTS Examined Pt self report, NCS/EMG, and clinical exam Test item cluster of 4 variables was identified andproduced a positive likelihood ratio of 30.3 for the pthaving CR– 4 clinical exams: ( ) Spurlings A, ( ) Distraction test,( ) ULTTA, involved cervical rotation 60 degrees– Probability of condition (CR) is 65% with 3 out of 4,90% with 4 out of 4Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comMulti-Level Exam SystemLevel 1: Limited– Indications Pain easily provoked, highly irritable Severe or latent pain Pathology is present in nervous system ormechanical interface (HNP pressing on nerveroot) Progressive worsening prior to physical examOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.com Multi-Level System of deciding the extentof Exam:– Level 0: Neurodynamic TestingContraindicated Severe Pain Psychological Influences Legal problems Highly unstable condition,worsening rapidlyOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comMulti-Level Exam SystemLevel 1: Limited (cont)– Method Some components or ROM may be omitted to applyless forces on nervous system Sequencing can be altered (ie, remote alteration vs.focal) Restricted to first onset of symptoms, once only Structural differentiation is still performed, but inmodified formOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com17
Property of VOMPTI, LLCMulti-Level Exam System Level 1: Limited (cont)– Modified Structural Differentiation: Used as an “off” switch to REDUCE symptoms Instead of additional movement which adds tension Clinical example: Irritable wrist problem– Cervical contralateral SB– Shoulder abduction– Elbow ext– Structural differentiation (off-switch)—neckback to neutral– Do NOT move irritable area (wrist)Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comMulti-Level Exam System Level 2: Standard– Method: Test movements would notproduce excessive pain, neurosymptoms or go into a greatdeal of resistance Standard neurodymic testsare used Full Range of movement maybe reached, but is notessentialOrthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without ConsentMulti-Level Exam System Level 2: Standard– Neurodyanimic tests are performed to a comfortableproduction of symptoms only– May be, but not necessarily taken to end range– Indications: Problem not particularly irritable Neuro symptoms are absent or minor part ofcondition Symptoms not easily provoked Problem is stable (not deteriorating rapidly) Pain not severe and no severe latency of symptomprovocationOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.comMulti-Level Exam SystemLevel 3: Advanced: Testing of nervous system more extensive and advanced thanprevious levels Specificity and sensitivity are the focus Indications:– Level 2 exam tests are normal and do not provide useful info– Problem is stable– Patient’s clinical pain is difficult to reproduce– No evidence of pathology that might adversely affect nervoussystem.– ** If sufficient info is gained from Level 1 or 2 exam, Level 3 isunnecessary and contraindicatedwww.vompti.comOrthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com18
Property of VOMPTI, LLCMulti-Level Exam System Level 3: Advanced: Method:– Level 2 test performed first (to be sure nervous systemcan cope w/further testing) and does NOT reproducesymptoms– Add sensitizing movements– Can alter sequencing to begin with provocative area first– Combine sensitization of neural structures with MS ones– Can use functional positions or activity to reproducesymptoms (ie, throwing)Orthopaedic Manual Physical Therapy Series 2017-2018For Use of Participants Only. No Use orReproduction Without Consentwww.vompti.comLevel 3 Test Example Assessment technique of pt The patient performs athrowing position so as toreproduce the mechanism ofsymptoms. The therapist can refine theshoulder position or resist anychosen movement whilealtering the differentiationmovements (wrist flex/ext andcervical SB) to detect a hiddenneurodynamic component.Orthopaedic Manual Physical Therapy Series 2017-2018www.vompti.com19
Coppieters et al. Different Nerve Gliding Exercises Induce Different Magnitudes of Median Nerve Longitudinal Excursion: A Study Using Dynamic US imaging. JOSPT 2009;39:164-171. Different exercises produce different amounts of longitudinal nerve excursion (A) “Sliding Technique” produces largest excursion –Ipsilateral cervical SB
Anatomy - Hand The wrist The metacarpals The Phalanges –Digit 1 –thumb –Digit 5 –digiti minimi. Property of VOMPTI, LLC For Use of Participants Only. No Use or Reproduction Without Consent 2 Orthopaedic Manual Physical Therapy Series 2016-2017 www.vompti.com Osteology Proximal Row –Scaphoid Tubercle –palpated on .
The Clinical Program is administered by the Clinical Training Committee (CTC) under the leadership of the Director of Clinical Training (DCT) and the Associate Director of Clinical Training (ADCT). The program consists of three APA defined Major Areas of Study: Clinical Psychology (CP), Clinical Child Psychology (CCP), Clinical Neuropsychology .
ii DEGREE PROJECT Computer Engineering Programme Applied Artificial Intelligence Reg number Extent 15 ECTS Name of student ANTONIO SAWAYA Submission date 31-05-2010 Supervisor Dr. Hasan Fleyeh Examiner Company/Department Supervisor at the Company/Department Title Financial time series analysis: Chaos and neurodynamics approach Keywords Chaos, fractals, neural networks, cognitive process. time .
Asymmetrical upper extremity edema Pain, cyanosis, fatigability & a feeling of stiffness or heaviness of the upper extremity Venous engorgement w/ collateralization of peripheral vessels . Self Nerve Glides. Property of VOMPTI, LLC For Use of Participants Only. No Use or
IT9358 Good Clinical Practices (GCP) 1.8 IT9387 Clinical Trials Monitoring 1.8 IT9388 Clinical Trials Design 1.8 IT9359 Clinical Data Management 1.8 IT9386 Biostatistics 1.8 IT9531 Introduction to Regulatory Affairs (US) 1.2 IT9539 Safety Monitoring 1.2 IT9351 Clinical Project Management I 1.8 IT9354 Clinical Project Management II 1.8
Clinical Experience Manual - Student (February 2019) 7 Clinical Experience Any learning opportunity taking place in a clinical setting related to nursing practice that is supervised by either a school’s clinical instructor or a preceptor. Clinical Rotation A clinical experience tha
2. Clinical appointments This category includes: clinical instructor, clinical assistant professor, clinical associate professor and clinical professor. The following guidelines and policies apply to clinical appointments. a. The individual will be engaged in one or more of the follo
APS 240 Interlude Ð Writing Scientific Reports Page 5 subspecies of an organism (e.g. Calopteryx splendens xanthostoma ) then the sub-species name (xanthostoma ) is formatted the same way as the species name. In the passage above you will notice that the name of the damselfly is followed by a name: ÔLinnaeusÕ. This is the authority, the name of the taxonomist responsible for naming the .
