#45 - Upper Extremity Neurodynamics with ChiroUp, Part 1

Factor, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents, serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, happy New Year. Welcome to the first episode of The Factor Podcast in 2023. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome. And thanks for listening. Today's episode features a new training on upper extremity neurodynamics with our friends from ChiroUp, co-founders Dr. Tim Bertelsmann and Dr. Brandon Steele. ChiroUp is a company whose mission is to help evidence-based chiropractors produce exceptional clinical outcomes, then market their brand of excellence to the people who matter most— their patients, other physicians, and of course, healthcare decision makers. They do this through empowering docs with automated tools, for clinical and business success. In today's episode, Drs. Steele and Bertelsmann will discuss various hands-on neurodynamic assessments and treatments for the most common upper extremity neuropathies. The presentation will cover nerve tension tests and nerve flossing maneuvers for carpal tunnel syndrome, pronator teres syndrome, cubital tunnel syndrome, radial tunnel syndrome, and TOS. In this 2-part training, You'll learn research-backed, real-world skills to diagnose and resolve the most common upper extremity neuropathies. Now, full disclosure, most of our listeners, you guys are very used to a very high-quality audio output from us, and some of the recorded audio in today's episode isn't the best quality. Now, all of our podcasts come from recorded webinars, and in that live virtual environment, several factors can impact the final output of the audio that we use for the show. So bear with us, guys. It may not be the best audio quality, but this is definitely content that you'll want to hear. So let's cue the intro music and get started.

Thanks everybody for joining us. This will be a crash course, just to put that correctly. This is going over a little bit more of a nuance as far as upper extremity pain as compared to the norm. And I find that the norm At least when you look at the research, is musculoskeletal. We look at musculoskeletal diagnoses in the upper extremity. We look at things like impingement syndrome. We look at rotator cuff problems. We look at lateral epicondylitis. We look at the common ones. But rarely do we get into carpal tunnel syndrome, axillary neuropathy, median nerve tension. Those are the things that unfortunately sometimes propagate pain just as much as they cause pain. So it's up to us to see, is this truly something that's involved in this patient presentation? So we put together a course on this as far as upper extremity pain, but more specifically neurogenic arm pain. Because we really need to figure out, is the nerve causing the pain? Not necessarily just transmitting the signals. Obviously, that primary neuron is going to be the one responsible for picking up those nerve signals. However, is the nerve the cause of the pain? So can we use nerve tension tests to help differentiate which nerves are involved? Can we help that patient with nerve flossing maneuvers? Simple things they can do in their office, or they can do at home also. And then what conditions have these patterns, essentially, like our TOSs, like our radial tunnel syndromes? Then when we see a patient coming in with lateral epicondylitis, it's been going on for a long period of time, and they use that counterforce brace, and now it's starting to radiate down into their forearm, maybe we need to switch diagnoses. So hopefully I cover— tidbits of each one of those, clinical pearls of each one of those to help us all treat these diagnoses more efficiently.

Trying to give you practical tips that you can use this afternoon, tomorrow, and hopefully for the rest of your practice career. More importantly, we know that there's a whole lot more knowledge on that side of the camera than there is on this side of the camera. We're always eager to hear your comments in the comment box. One of the slides that we had just skipped over, we don't need to go back to it. In fact, we can skip over a few of it. It's more crash than course, this whole endeavor. But the last one that we had talked about was how much of extremity pain actually comes from an asymptomatic spine. That Rosedale did a study, it was published in JMPT, that said that a big chunk of our patients who have extremity pain are actually coming from the neck. When it comes to the shoulder, we're seeing probably 47% of that shoulder discomfort comes from an asymptomatic cervical spine. And for manual providers out there who do manipulation and address the cervical spine regularly, you know that's probably true, that a big chunk of that is. That means a big chunk of extremity pain isn't coming from an asymptomatic spine. So that's what we'll look at today. What can we do to make a difference? There's a ton of research that's, that's come out. A study that said that when we're managing the rotator cuff, that outcomes improve dramatically when we include neurodynamic or nerve flossing maneuvers. This study as well that said that lateral epicondylopathy tends to improve considerably In addition to the neck and back pain. And we know for a long time now that our carpal tunnel syndrome patients benefit significantly from neurodynamics. In fact, this study said that it's superior to what we do now, and that's exercise and bracing when it comes to rebuilding strength and function in those patients. This study just came out a couple of weeks ago, and it's something that we knew as well, that anytime that a nerve is irritable, there's a decrease in the elasticity of that nerve, in the flexibility of the nerve, in the neurodynamics of that nerve. So this said, what happens in carpal tunnel patients? We know that when a cervical nerve root is irritated, the whole nerve becomes swollen. And when that whole nerve becomes swollen, there's increased hydrostatic pressure, which means that fluids may tend to weep out, and those fluids then become weak adhesions, or at least limit the neurodynamics of that nerve through the entire course of the nerve. And our carpal tunnel syndrome patients have diminished neuroelasticity and neuromobility at the tunnel itself.

Here's the cool thing about that study, as I dug into there. What do you think happens to those adhesions after the surgery? They're still there.

They disappear.

So that's the crazy thing about this surgery is we know the recurrence rates in carpal tunnel syndrome are high, post-surgical carpal tunnel syndrome, is because that yes, we can relieve some of the compression at the carpal tunnel in this case, but we're going to learn about different anatomical sites throughout this lecture. However, we still have to do what we do. We still have to go through nerve mobilization in office and go through nerve flossing at home. To help these patients even if they go through a structural change like a surgery. So cool things that we can do for patients really goes a long way. And even the same thing with splinting is that I use that, that cock-up splint for median or carpal tunnel syndrome, even for lateral canalitis. I'll use it every once in a while for people that can't take the compression there. And those things work well to take away the compression or irritation there. But we still have to get rid of those adhesions. Because unfortunately, if they remain, then the patient's going to come back to us after they're done with that condition and still have those problems. So one of the things that was a common theme in a lot of these articles is we're not only getting rid of pain, but we're also getting rid of weakness. We're increasing function. We're helping that person get back to their activity. Even if they have a true MSK diagnosis, we can still test them for nerve flossing or nerve tension throughout their treatment process, or when we're going to release them to make sure this didn't pop up in the meantime. Because all these things will go a long way in helping a person stay out of pain.

Yeah, this study said that performing nerve gliding and nerve flossing exercises produce similar outcomes to surgery. That 40 years ago, there's an abundance of research that said, hey, exercise may help our low back pain patients. And now that's kind of a no-brainer. Well, one subset of exercises are nerve flossing and nerve gliding exercises. And there's just as much excitement about that research saying, yes, it does make a difference. An abundance of research really in the past couple of years. So the 2 things that we'll talk about today are the assessment of neurodynamics and the treatment of the neurodynamics. The 3 nerves that we'll look at are the radial, the median, and the ulnar nerves. And the good news is once you've learned one, you've got a good grasp of all the others. So while it looks like you're going to have to learn 6 things, there are some similarities that really, if we get a couple of them down, We're going to have all of them down. Yeah, it probably should go through. When we talk about a test, the first thing that we're going to do is a nerve stretch. So the 2 things that we want to think about is when we do a neurodynamic assessment, like most assessments, we want to provoke symptoms. That means we probably want to stretch both ends of the nerve. When we think about the lower extremity, how are you going to do that? Well, you could do a slump test by extending the leg, dorsiflexing the ankle. If you really want to stretch the other end, Put the head into cervical flexion as well. There wouldn't be any lower extremity case that we'd evaluate without a straight leg raise or without a slump test. But how often do we evaluate upper extremity complaints and really don't look at the equivalent of the upper extremity straight leg raise? Well, there are 3 of them based upon the specific nerve. And the goal behind performing a nerve stretch or a nerve assessment is to stretch both ends of the nerve. So if we're talking about the median nerve, first of all, coming out of the cervical spine down through the carpal tunnel, How would we stretch the top end? Well, stretching the brachial plexus is going to be a contralateral flexion of the head. And how would we stretch the rest of the nerve? We would take the arm back and put the wrist into extension. So when I'm taking this movement here, I'm stretching both ends of the nerve. If I can see that the patient has an increase in symptoms, especially in the distribution of that median nerve, those 3.5 fingers, then we can be pretty certain there's median nerve involvement. The nice thing about this, in addition to doing that kind of Phalen maneuver down low, We can play with the neck to say, what happens when I take the stretch off of the neck and put the stretch back on the neck? And when that patient's symptoms increase, now we can be really certain that that median nerve is involved. Radial nerve, really similar.

So for all these tests, we have the videos associated with this. I mean, we'll give you access to that at the very end of this. However, make sure you do them all supine in this kind of situation. You're taking away the postural muscles, you're taking away the compression of the cervical spine. And the cool thing about when you do that, imagine him laying down, is that now I can actually depress his shoulder down at the same time. So when you depress your shoulder down, creating extra tension on the brachial plexus, you're bringing the arm up, you're, for the median nerve, going into a little bit of elbow flexion, fully supinate the hand, and now when he comes down, you're going to create that extra compression on the median nerve. The same thing's going to happen with the ulnar nerve, which is—

I think next we have the radial nerve.

So the radial nerve, exact same process. This is going to be down here. You're going to push down and now you're going to take the arm down into full pronation and bring the arm back. And when you can bring this arm back, as you can imagine, that radial nerve comes right through those wrist extensors here and they're going to feel a compression, some irritation, numbness or tingling, or even just sometimes a pulling sensation going to the top part of their forearm. It'll be the top 3.5 digits of that arm. And the last one being the ulnar nerve. I always like doing this to patients because it's always kind of funny when you try to give them the direction. Like, I don't really know how to do this. But bringing the arm down, you're going to now bring the elbow into flexion. Our ulnar nerve is the funny bone essentially. So it goes right to that medial epicondyle. So when you put extra tension into flexion and then take those 2 other fingers and bring those down. And if you really don't like the patient very much, you can go even further and actually bring the arm up and see how far you can go. So he was doing a little bit of a self-test in the middle there.

Today's training is brought to you by Southeast Professional Education Group. Are you a healthcare provider interested in teaching? Have you developed content or a curriculum but have no idea how to get started in continuing education? Maybe you sit on the board for an association or group that wants to offer a virtual summit or live conference, but the logistics, planning, and marketing are just too much for your volunteer-led group. If these statements have you shaking your head yes, then it sounds like you could use our help. For almost a decade now, Southeast Professional Education Group, also known as Southeast Sports Seminars, has helped individual instructors, membership organizations, higher ed institutions, and groups of all sizes create memorable virtual and live events in the healthcare continuing education space. We have the experience, the know-how, and the infrastructure to help you bring your event or course offering to life. For more information, visit the link in our show notes to schedule a call with a member of our team. We can't wait to speak with you.

What you're doing is looking for reproduction of symptoms. And the more that you can tell the patient, you know what's going on, and that's what orthopedic testing is going for, is finding, can I reproduce this patient's symptoms? Because what you can do is you differentiate where this problem is coming from. If I can mess with his shoulder elevation and depression and change his symptoms, I'm probably going to have adhesion of that nerve in between the neck and the shoulder, or vice versa when it happens with elbow flexion. Remember, the first joint that you bend is where you get the most tension across that nerve. So if I'm bending the elbow and I get tension and I get reproduction symptoms in the 4th and 5th digit just with elbow flexion, I probably have an issue with the elbow as compared to somewhere else. You can also have the patient do these things, and I would welcome each and every one of you to do these things for yourself because it's really telling to the patient when they can do these maneuvers by themselves and reproduce their own symptoms. So the median nerve would be really taking your fingers, separating them as far as possible, extending your wrist and bringing it behind your body. And as you do that, are you getting reproduction symptoms along that median nerve tract? Same thing with the radial nerve. In this case, the patient's doing it by themselves. If they don't feel anything, some contralateral lateral flexion of their neck will also help put a little extra tension across those nerves. And the last one that we were joking about was taking your fingers and trying to look through it like a monocle and looking for rebrachial symptoms, remembering the ulnar nerve goes to that 4th and 5th digit.

Excellent. So here's a little chart that we'll be happy to share with you at the end of the class as well. You can scan the QR code. We'll give you any access to the videos or any of the charts that you But just a quick reminder of what we do in office that we can assess in office or how we can have that patient perform a nerve tension test at home. As we go through these, I think we have— we've got a couple of them here. Basically, we've gone through this information already. And the one thing that we want to think about is, could the cervical spine be more involved? So if a patient has true frank compression or irritation, maybe from some disc swelling, Maybe true compressive neuropathy. We're going to see some sometimes potentially similar symptoms. So how do we rule in or rule out a cervical spine?

I guess usually I'm right. Sometimes I'm wrong. Patients are usually pretty good about it. No, but really you're looking for, can I reproduce a cervical radiculopathy? Or is this possibly a shoulder problem? And we can give you some tests associated with that. But if it's coming from the neck, we of course want to test the neck and see if we get peripheralization of symptoms. We can use Spurling's test. And Spurling's test, there's a lot of different ways of doing that. We're going to go through some lateral flexion and possibly a little contralateral rotation and adding compression down. You're taking that intervertebral foramen and making it smaller. If I do that maneuver and I start to get reproduction of pain going down the arm, chances are I have a nerve root problem. I can also use distraction test. And this is when the patient's having symptoms going down their arm. And you can do this supine or also seated. And you're going to take right behind the antecubital process and you're pulling up on the head, creating some decompressive force to that intervertebral foramen to see if you can relieve symptoms wherever they are going down the arm. And then the upper limb nerve tension test. The upper limb nerve tension test is essentially the median nerve. However, they're going to be seated and now going through that elbow pronation and the elbow extension. When you can do that maneuver, you're putting tension across all the nerves of the brachial plexus. Reproducing symptoms, even if it was the ulnar, median, or radial nerve. And then the last one is just turning your head. Even rotation will cause compression of the intervertebral foramen. So if you can do those things and you can reproduce symptoms, chances are you have a radiculopathy. The harder thing is necessarily what is it leading to? What are the symptoms the patient's having? And that's when we can really put on our Detective hats and say, yes, you have a radiculopathy. In this case, thoracic allelic syndrome, 10% of those people have pain, numbness, tingling going down the ulnar nerve distribution. So, I'm sorry, 90%. I, I went around the wrong way. 90% have an ulnar nerve distribution. So that's good. I can make sure I know what tissue is injured, but now you need to find out where the actual compression is coming from. And that's when we can use specific tests that we know from orthopedic examination. To determine where we need to treat.

So the 3 possibilities could be getting compression of the neurovascular bundle as it comes between the middle scalene. We can get compression between the clavicle and the first rib, or we can get compression beneath the pec minor tendon. Remember, that comes off of the second, third, fourth ribs and then comes up onto the coracoid, but the brachial artery travels underneath that. So any one of those are compressive, and the good news is We have tests that can help identify any one of those 3 sites. One thing that we know is that thoracic outlet syndrome is much more common in females, that it's a 9 to 1 incidence in females, and usually middle-aged females. The peak incidence is in the 4th decade. And certainly with any compressive neuropathy, compression is not appreciated. In fact, with any neuropathy, the 2 things nerves don't like are compression and they don't like traction. So if we do either of those 2 things, The nerves provoked, and in a female, the bra strap that's pushing down constantly on a thoracic outlet region is going to make it more likely to happen. We're looking again, remember, for that pain or paresthesia in that C8-T1 distribution. 9 out of 10 cases are coming from that distribution, and when we see that, we want to define where's the area that's getting the compression. So there's a number of things that we can do.

The first is the easiest. I always love these tests. I think it's called— I learned it as Morley test. However, If you know you have compression where at the thoracic outlet, you can just create compression there. And I'm going to create some compression, maybe 2 to 10 pounds of force. And does that extra compression reproduce my patient's symptoms? Yes or no? If it does, then I need to go into my more differentiating tests, which are first the costoclavicular maneuver. Just with the arm having symptoms, you're going to have them bring their arm back, really creating some compression across that clavicle and to see if I get some neurovascular response. Once again, you're going to be monitoring the radial pulse with these symptoms. However, that doesn't mean they have to have a diminution in pulse to be a positive test. That's just one of the possible types of thoracic outlet syndrome. 1% of people actually have an arterial TOS. 4% have a venous TOS because of that subclavian vein and artery in the same area. If you have those, those are a little bit different. You're looking for a neurovascular response. Being blood's not getting into the arm or blood's not getting back out of the arm. A little beyond the scope of this talk. The next one is going to be Wright's test. With Wright's test, now you're going to extremes of hyperabduction and external rotation of the hand. Once again, monitoring the radial pulse and looking for any kind of compression across that pectoralis and possibility of causing that person's neuropathy. Last one is Cerebral Spinal Fluid Mover. I love this test because it kicked out a past test which is called the Ruse test. And Ruse test, if you guys remember from school, was putting your arms up and squeezing your fist for 3 minutes, which none of us have with our patients to spend on just one orthopedic test. A serious release maneuver is taking into consideration they have some tension in the shoulders. They're now seated, and what you're going to do is bring them back, have them nice and relaxed. I'm going to pick up on both arms Taking that tension away from the shoulders and once again releasing the nerve tensions they're having in their arms.

Which Cereax Release Maneuver can also be a self-test that if we put a patient in a chair with arms and just have them kind of slump down and let that come up, if we see that any change of revascularization, and remember that could be somebody who went from numbness to tingling or from tingling to no symptoms. So any movement in a positive direction tells us that there may be some costoclavicular or thoracic outlet compression. And then finally, the classic maneuvers, Adson's test, where we're monitoring the pulse and having the patient move in an ipsilateral rotation, and modified Adson's, where we do the same thing, but in this case, in a contralateral rotation. We always want to try to differentiate, is this a TOS? Is the radicular complaint coming from a TOS, or is the radicular complaint potentially coming from the cervical spine? You saw the earlier article from BMC Musculoskeletal Disorders saying If you have these criteria, a nerve tension test, Spurling's traction, and limited range of motion, it's probably coming from the cervical spine. Another test that can be particularly helpful is the arm squeeze test. This one isn't a slide, I don't believe. I don't believe so.

No.

But the arm squeeze test, fairly sophisticated, you're going to want to watch twice. That was it. So the arm squeeze test is based on the premise that if we have a cervical nerve root or the periphery that's irritable, Then chances are the whole nerve is irritable. So if a patient's shoulder pain is coming from a rotator cuff, tendinopathy, biceps tendinopathy, a SLAP lesion, and I squeeze their arm, there's going to be nothing— you need to get to the gym— there's going to be nothing that's happening with that instance. But if the patient has a cervical nerve root that's irritated and then I compress their arm, now we're going to see that there's an increase in symptoms. We did nothing to the shoulder. So it has fairly high sensitivity and specificity. For a cervical complaint. The other thing that has high sensitivity and specificity for our patients with a TOS is stretch that ulnar nerve, because most of the time the ulnar fibers are the ones that are going to be most affected. And remember, the self-floss for the ulnar nerve was making the monocle. I always tell the patient, imagine that you're flicking your cheek and then flip it upside down. If you have an increased numbness or tingling along that ulnar distribution, we have a likely ulnar nerve involvement.

If these are things you do in your practice or in your clinic, make sure you don't keep that position. So when you're doing that, you're taking that nerve all the way to extremes of stretch or compression. So you want to go until you touch the pain and then come back down. And then up until you touch the pain and back down. As far as frequency, I have my patients do this about once an hour when they're symptomatic. So 10 repetitions once per hour and then avoiding the positions that would aggravate that symptom. For your runners out there who have their elbows constantly bent and running, for your sleepers who sleep like this with their elbows constantly bent, for your people working at computers, those are all things you want to stay away from. I tell my patients that if we call this 90 degrees, I want you down in this area. I don't want your elbows being bent more than that because it's only perpetuating that problem.

That's it for today's episode. Be sure to tune in for episode 46, where we finish up part 2 of this training on upper extremity neurodynamics. In our next episode, Drs. Steele and Bertelsmann will examine the current evidence regarding neurodynamic techniques. They'll also review the most useful neurodynamic assessments for common upper extremity complaints and cover practical nerve flossing and nerve tensioning maneuvers that can speed recovery. You won't wanna miss it. Episode 46 drops in 2 weeks. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a 5-star rating to help us grow the show. Every little bit helps. You can also subscribe to our Patreon channel for special discounts and member perks on Factor products, live trainings, and online course offerings. To learn more, visit the Patreon link in our show notes. You'll also always find a link to download the PDF presentation from the training featured in each episode, along with a link to view the full video webinar recording if you're a visual learner. A good rule of thumb is to always visit our show notes to access links to a ton of great resources and content. And last but certainly not least, we invite you to join us for a live hands-on Factor training in a city near you. This year we'll be in cities around the globe, so be sure to visit factoreducation.com That's faktereducation.com to view the full course schedule and take advantage of any special discounts and offers. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R hyphen store dot com to find out more information about all that we have to offer. We have a variety of online offerings, as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.