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Ellis R, Richards N, Archer L, Whittington C, Mawston G. Assessing Sciatic Nerve Excursion and Strain with Ultrasound Imaging during Forward Bending. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2560-2569. [PMID: 34218969 DOI: 10.1016/j.ultrasmedbio.2021.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 06/13/2023]
Abstract
Entrapment neuropathies affecting the sciatic nerve tract may adversely affect neural biomechanical features such as excursion and strain. There is a paucity of in vivo evidence examining the effects of forward bending upon sciatic nerve excursion and strain. The purpose of this study was to assess the reliability of ultrasound imaging in measuring sciatic nerve excursion and strain during forward bending movements. Secondary aims were to quantify sciatic nerve excursion and strain during forward bending movements and to assess the relationship between sciatic nerve excursion and movements of the hip and lumbar spine. The reliability of measuring sciatic nerve excursion was high to excellent whilst measurement of sciatic nerve strain was moderate. The amount of hip flexion, during forward bending, was a strong predictor of sciatic nerve excursion. These findings will support clinicians in the assessment and treatment of entrapment neuropathies, in addition to providing a foundation for future research.
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Affiliation(s)
- Richard Ellis
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Northcote, Auckland, New Zealand; Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Northcote, Auckland, New Zealand.
| | - Nathan Richards
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Northcote, Auckland, New Zealand
| | - Logan Archer
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Northcote, Auckland, New Zealand
| | - Chris Whittington
- BioDesign Lab, School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Grant Mawston
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Northcote, Auckland, New Zealand; Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
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2
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Jack AS, Osburn BR, Tymchak ZA, Ramey WL, Oskouian RJ, Hart RA, Chapman JR, Jacques LG, Tubbs RS. Foraminal Ligaments Tether Upper Cervical Nerve Roots: A Potential Cause of Postoperative C5 Palsy. J Brachial Plex Peripher Nerve Inj 2020; 15:e9-e15. [PMID: 32728377 PMCID: PMC7383057 DOI: 10.1055/s-0040-1712982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/23/2020] [Indexed: 01/23/2023] Open
Abstract
Background
Nerve root tethering upon dorsal spinal cord (SC) migration has been proposed as a potential mechanism for postoperative C5 palsy (C5P). To our knowledge, this is the first study to investigate this relationship by anatomically comparing C5–C6 nerve root translation before and after root untethering by cutting the cervical foraminal ligaments (FL).
Objective
The aim of this study is to determine if C5 root untethering through FL cutting results in increased root translation.
Methods
Six cadaveric dissections were performed. Nerve roots were exposed via C4–C6 corpectomies and supraclavicular brachial plexus exposure. Pins were inserted into the C5–C6 roots and adjacent foraminal tubercle. Translation was measured as the distance between pins after the SC was dorsally displaced 5 mm before and after FL cutting. Clinical feasibility of FL release was examined by comparing root translation between standard and extended (complete foraminal decompression) foraminotomies. Translation of root levels before and after FL cutting was compared by two-way repeated measures analysis of variance. Statistical significance was set at 0.05.
Results
Significantly more nerve root translation was observed if the FL was cut versus not-cut,
p
= 0.001; no difference was seen between levels,
p
= 0.33. Performing an extended cervical foraminotomy was technically feasible allowing complete FL release and root untethering, whereas a standard foraminotomy did not.
Conclusion
FL tether upper cervical nerve roots in their foramina; cutting these ligaments untethers the root and increases translation suggesting they could be harmful in the context of C5P. Further investigation is required examining the value of root untethering in the context of C5P.
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Affiliation(s)
- Andrew S Jack
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada.,Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States.,Complex Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Brooks R Osburn
- Complex Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, United States.,Department of Neurosurgery, University of South Florida, Tampa, Florida, United States
| | - Zane A Tymchak
- Complex Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Wyatt L Ramey
- Complex Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Rod J Oskouian
- Complex Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Robert A Hart
- Complex Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Jens R Chapman
- Complex Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Line G Jacques
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, United States
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Berthelot JM, Darrieutort-Laffite C, Arnolfo P, Glémarec J, Le Goff B, Maugars Y. Inadequacies of the Lasègue test, and how the Slump and Bowstring tests are useful for the diagnosis of sciatica. Joint Bone Spine 2020; 88:105030. [PMID: 32561431 DOI: 10.1016/j.jbspin.2020.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 01/19/2023]
Abstract
Diagnosis of sciatica mainly relies on pain reproduction by stretching of the lumbar roots since neurological examination and medical history are usually not sufficient to guarantee diagnosis. The Lasègue test is the most popular method, which starts with the straight leg-raising test (SLR). However it is not perfect, and is not always well performed or interpreted. Passive ankle dorsiflexion at the end of the SLR (Bragard test) is more sensitive, but can also remain normal in some cases of sciatica. Other stretching tests can help to recognise lumbar root damage in patients with poorly defined pain in a lower extremity: firstly, the Christodoulides test, i.e. reproduction of L5 sciatic pain by a femoral stretch test; secondly, the Slump test, performed on a patient in a sitting position, by slowly extending their painful leg then passively bending their neck (or the opposite); and thirdly, the Bowstring test, which requires, at the end of the Lasègue test, once the knee has been slightly flexed, pressing on the course of the peroneal and/or tibial nerves in the popliteal fossea to try and reproduce the exact pain felt by the patient. The combination of all these tests takes less than 2minutes, and could improve both the sensitivity and specificity of the physical examination for the diagnosis of sciatica. This article is a review of the limitations of the Lasègue/SLR tests and of the efficacy of these other tests for stretching the lumbar roots.
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Affiliation(s)
- Jean-Marie Berthelot
- Service de rhumatologie, Hôtel-Dieu, CHU of Nantes, 44093, Nantes cedex 01, France.
| | | | - Paul Arnolfo
- Service de rhumatologie, Hôtel-Dieu, CHU of Nantes, 44093, Nantes cedex 01, France
| | - Joëlle Glémarec
- Service de rhumatologie, Hôtel-Dieu, CHU of Nantes, 44093, Nantes cedex 01, France
| | - Benoît Le Goff
- Service de rhumatologie, Hôtel-Dieu, CHU of Nantes, 44093, Nantes cedex 01, France
| | - Yves Maugars
- Service de rhumatologie, Hôtel-Dieu, CHU of Nantes, 44093, Nantes cedex 01, France
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4
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Sierra-Silvestre E, Bosello F, Fernández-Carnero J, Hoozemans MJM, Coppieters MW. Femoral nerve excursion with knee and neck movements in supine, sitting and side-lying slump: An in vivo study using ultrasound imaging. Musculoskelet Sci Pract 2018; 37:58-63. [PMID: 29986192 DOI: 10.1016/j.msksp.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/03/2018] [Accepted: 06/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neurodynamic assessment and management are advocated for femoral nerve pathology. Contrary to neurodynamic techniques for other nerves, there is limited research that quantifies femoral nerve biomechanics. OBJECTIVES To quantify longitudinal and transverse excursion of the femoral nerve during knee and neck movements. DESIGN Single-group, experimental study, with within-participant comparisons. METHODS High-resolution ultrasound recordings of the femoral nerve were made in the proximal thigh/groin region in 30 asymptomatic participants. Scans were made during knee flexion in supine and a semi-seated position, and during neck flexion in side-lying slump (Slump FEMORAL). Healthy participants were assessed to reveal normal nerve biomechanics, not influenced by pathology. Data were analysed with one-sample and paired t-tests. Reliability was assessed with intraclass correlation coefficients (ICC). RESULTS Longitudinal and transverse excursion measurements were reliable (ICC≥0.87). With knee flexion, longitudinal femoral nerve excursion was significant and larger in supine than in sitting (supine (mean (SD)): 3.6 (2.0) mm; p < 0.001; sitting: 1.1 (1.6) mm; p = 0.001; comparison: p = 0.001). There was also excursion in a medial direction (supine: 1.4 (0.3) mm; p < 0.001; sitting: 0.7 (0.6) mm; p < 0.001) and anterior direction (supine: 0.2 (0.2) mm; p < 0.001; sitting: 0.1 (0.2) mm; p = 0.06). Neck flexion in Slump FEMORAL did not result in longitudinal (0.0 (0.3) mm; p = 0.55) or anteroposterior (0.0 (0.1) mm; p = 0.10) excursion, but resulted in medial excursion (1.1 (0.5) mm; p < 0.001). CONCLUSION Although the femoral nerve terminates proximal to the knee, femoral nerve excursion in the proximal thigh occurred with knee flexion; Neck flexion in Slump FEMORAL resulted in medial excursion.
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Affiliation(s)
- Eva Sierra-Silvestre
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, Madrid, Spain; Physiotherapy, School of Allied Health Sciences, Griffith University, Gold Coast, Australia. https://twitter.com/esiesil
| | - Francesca Bosello
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Josué Fernández-Carnero
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, Madrid, Spain. https://twitter.com/Josuefisio
| | - Marco J M Hoozemans
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Michel W Coppieters
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia; Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. https://twitter.com/michelcoppie
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Reduced Spinal Cord Movement With the Straight Leg Raise Test in Patients With Lumbar Intervertebral Disc Herniation. Spine (Phila Pa 1976) 2017; 42:1117-1124. [PMID: 28542104 DOI: 10.1097/brs.0000000000002235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Controlled radiological study. OBJECTIVE To explore whether impairment of neural excursion during the straight leg raise test occurs in patients with sciatic symptoms secondary to lumbar intervertebral disc herniation (LIDH). SUMMARY OF BACKGROUND DATA Earlier studies have shown that during the straight leg raise (SLR) test in asymptomatic volunteers tensile forces are consistently transmitted throughout the neural system and the thoracolumbar spinal cord slides distally. METHODS Fifteen patients with sciatic symptoms due to subacute LIDH were studied with a 1.5 T magnetic resonance scanner. First, a spine specialist diagnosed the LIDH using conventional scanning sequences. Following this subjects were scanned using different scanning sequences for planning and measurement purposes. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between manoeuvres. RESULTS The results showed 66.6% less excursion of conus medullaris with SLR performed on the symptomatic side compared with excursions measured with SLR performed on the asymptomatic side (p ≤ 0.001). CONCLUSION In patients with LIDH, the neural displacement on the symptomatic side is significantly reduced by the compressing IVD herniation. To our knowledge, these are the first data in intact human subjects to support the limitation of neural movements in the vertebral canal with LIDH. LEVEL OF EVIDENCE 3.
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6
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Cervical extraforaminal ligaments: an anatomical study. Surg Radiol Anat 2017; 39:1377-1383. [DOI: 10.1007/s00276-017-1896-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/12/2017] [Indexed: 11/26/2022]
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7
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Does Evidence Support the Use of Neural Tissue Management to Reduce Pain and Disability in Nerve-related Chronic Musculoskeletal Pain? Clin J Pain 2016; 32:991-1004. [DOI: 10.1097/ajp.0000000000000340] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Sierra-Silvestre E, Torres Lacomba M, de la Villa Polo P. Effect of leg dominance, gender and age on sensory responses to structural differentiation of straight leg raise test in asymptomatic subjects: a cross-sectional study. J Man Manip Ther 2016; 25:91-97. [PMID: 28559668 DOI: 10.1080/10669817.2016.1200216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVES To assess the effect of structural differentiation on sensory responses of asymptomatic individuals to standard neurodynamic tests of straight leg raise (SLR) and to evaluate the relevance of leg dominance, gender, and age. BACKGROUND SLR test is a well-known neurodynamic test among physical therapists; no studies to date have investigated the influence of gender, age, and leg dominance to the sensory responses of this neurodynamic test and its structured differentiating maneuver. METHODS Thirty (16 women) asymptomatic individuals enrolled in this study. Dominancy test was performed for each participant. Pain intensity using visual analogue scale (VAS), symptoms location in a body chart, nature of symptoms evoked, and hip range of motion (ROM) were recorded and compared at ankle neutral position (N-SLR) and dorsiflexion (DF-SLR) in both legs at the point of pain tolerance during SLR (P2). In addition, hip ROM was recorded at the onset of pain (P1). RESULTS There was a statistically significant sex main effect for P1 and P2 between N-SLR and DF-SLR (p < 0.05). Mean hip ROM during the SLR was more than 10° greater in women than men. There was no statistically significant interaction between leg dominance and age group in N-SLR, DF-SLR, and VAS. Pain intensity was moderate for each SLR test. Symptoms most often described were stretch (96.7%), followed by tightness (70%) in the posterior thigh and leg. CONCLUSIONS SLR hip ROM is influenced by sex in asymptomatic individuals, leading to a greater hip ROM in SLR in women. Age and limb dominance are not relevant to SLR hip ROM or pain intensity.
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Affiliation(s)
- Eva Sierra-Silvestre
- Grupo de investigación Fisioterapia en los Procesos de Salud de la Mujer, Departamento de Fisioterapia, Universidad de Alcalá, Alcalá de Henares, Spain.,Grupo de investigación Motion in Brains, Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
| | - María Torres Lacomba
- Grupo de investigación Fisioterapia en los Procesos de Salud de la Mujer, Departamento de Fisioterapia, Universidad de Alcalá, Alcalá de Henares, Spain
| | - Pedro de la Villa Polo
- Grupo de investigación Fisioterapia en los Procesos de Salud de la Mujer, Departamento de Fisioterapia, Universidad de Alcalá, Alcalá de Henares, Spain.,Departamento de Fisiología, Universidad de Alcalá, Alcalá de Henares, Spain
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9
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Rade M, Könönen M, Marttila J, Shacklock M, Vanninen R, Kankaanpää M, Airaksinen O. In Vivo MRI Measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects with Unilateral and Sham Straight Leg Raise Tests. PLoS One 2016; 11:e0155927. [PMID: 27253708 PMCID: PMC4890805 DOI: 10.1371/journal.pone.0155927] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/06/2016] [Indexed: 01/23/2023] Open
Abstract
Background Normal displacement of the conus medullaris with unilateral and bilateral SLR has been quantified and the "principle of linear dependence" has been described. Purpose Explore whether previously recorded movements of conus medullaris with SLRs are i) primarily due to transmission of tensile forces transmitted through the neural tissues during SLR or ii) the result of reciprocal movements between vertebrae and nerves. Study design Controlled radiologic study. Methods Ten asymptomatic volunteers were scanned with a 1.5T magnetic resonance (MR) scanner using T2 weighted spc 3D scanning sequences and a device that permits greater ranges of SLR. Displacement of the conus medullaris during the unilateral and sham SLR was quantified reliably with a randomized procedure. Conus displacement in response to unilateral and sham SLRs was quantified and the results compared. Results The conus displaced caudally in the spinal canal by 3.54±0.87 mm (mean±SD) with unilateral (p≤.001) and proximally by 0.32±1.6 mm with sham SLR (p≤.542). Pearson correlations were higher than 0.99 for both intra- and inter-observer reliability and the observed power was 1 for unilateral SLRs and 0.054 and 0.149 for left and right sham SLR respectively. Conclusions Four relevant points emerge from the presented data: i) reciprocal movements between the spinal cord and the surrounding vertebrae are likely to occur during SLR in asymptomatic subjects, ii) conus medullaris displacement in the vertebral canal with SLR is primarily due to transmission of tensile forces through the neural tissues, iii) when tensile forces are transmitted through the neural system as in the clinical SLR, the magnitude of conus medullaris displacement prevails over the amount of bone adjustment.
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Affiliation(s)
- M. Rade
- Kuopio University Hospital, Department of Physical and Rehabilitation Medicine, Kuopio, Finland
- Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Orthopaedic and Rehabilitation Hospital “Prim. dr.Martin Horvat”, Rovinj, Croatia
- * E-mail: ;
| | - M. Könönen
- Kuopio University Hospital, Department of Radiology, Kuopio, Finland
| | - J. Marttila
- Kuopio University Hospital, Department of Radiology, Kuopio, Finland
| | - M. Shacklock
- Kuopio University Hospital, Department of Physical and Rehabilitation Medicine, Kuopio, Finland
- Neurodynamic Solutions, Adelaide, Australia
| | - R. Vanninen
- Kuopio University Hospital, Department of Radiology, Kuopio, Finland
| | - M. Kankaanpää
- Tampere University Hospital, Department of Physical and Rehabilitation Medicine, Tampere, Finland
| | - O. Airaksinen
- Kuopio University Hospital, Department of Physical and Rehabilitation Medicine, Kuopio, Finland
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Ellis R, Osborne S, Whitfield J, Parmar P, Hing W. The effect of spinal position on sciatic nerve excursion during seated neural mobilisation exercises: an in vivo study using ultrasound imaging. J Man Manip Ther 2016; 25:98-105. [PMID: 28559669 PMCID: PMC5430455 DOI: 10.1179/2042618615y.0000000020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 08/30/2015] [Indexed: 12/05/2022] Open
Abstract
Objectives Research has established that the amount of inherent tension a peripheral nerve tract is exposed to influences nerve excursion and joint range of movement (ROM). The effect that spinal posture has on sciatic nerve excursion during neural mobilisation exercises has yet to be determined. The purpose of this research was to examine the influence of different sitting positions (slump-sitting versus upright-sitting) on the amount of longitudinal sciatic nerve movement during different neural mobilisation exercises commonly used in clinical practice. Methods High-resolution ultrasound imaging followed by frame-by-frame cross-correlation analysis was used to assess sciatic nerve excursion. Thirty-four healthy participants each performed three different neural mobilisation exercises in slump-sitting and upright-sitting. Means comparisons were used to examine the influence of sitting position on sciatic nerve excursion for the three mobilisation exercises. Linear regression analysis was used to determine whether any of the demographic data represented predictive variables for longitudinal sciatic nerve excursion. Results There was no significant difference in sciatic nerve excursion (across all neural mobilisation exercises) observed between upright-sitting and slump-sitting positions (P = 0.26). Although greater body mass index, greater knee ROM and younger age were associated with higher levels of sciatic nerve excursion, this model of variables offered weak predictability (R2 = 0.22). Discussion Following this study, there is no evidence that, in healthy people, longitudinal sciatic nerve excursion differs significantly with regards to the spinal posture (slump-sitting and upright-sitting). Furthermore, although some demographic variables are weak predictors, the high variance suggests that there are other unknown variables that may predict sciatic nerve excursion. It can be inferred from this research that clinicians can individualise the design of seated neural mobilisation exercises, using different seated positions, based upon patient comfort and minimisation of neural mechanosensitivity with the knowledge that sciatic nerve excursion will not be significantly influenced.
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Affiliation(s)
- Richard Ellis
- Health and Rehabilitation Research Institute, School of Clinical Studies, AUT University, Auckland, New Zealand
| | | | | | - Priya Parmar
- Biostatistics Unit, Faculty of Health and Environmental Sciences, AUT University, Auckland, New Zealand
| | - Wayne Hing
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
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11
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Gilbert KK, Smith MP, Sobczak S, James CR, Sizer PS, Brismée JM. Effects of lower limb neurodynamic mobilization on intraneural fluid dispersion of the fourth lumbar nerve root: an unembalmed cadaveric investigation. J Man Manip Ther 2016; 23:239-45. [PMID: 26955255 DOI: 10.1179/2042618615y.0000000009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Manual and physical therapists incorporate neurodynamic mobilisation (NDM) to improve function and decrease pain. Little is known about the mechanisms by which these interventions affect neural tissue. The objective of this research was to assess the effects of repetitive straight leg raise (SLR) NDM on the fluid dynamics within the fourth lumbar nerve root in unembalmed cadavers. METHODS A biomimetic solution (Toluidine Blue Stock 1% and Plasma) was injected intraneurally, deep to the epineurium, into the L4 nerve roots of seven unembalmed cadavers. The initial dye spread was allowed to stabilise and measured with a digital calliper. Once the initial longitudinal dye spread stabilised, an intervention strategy (repetitive SLR) was applied incorporating NDMs (stretch/relax cycles) at a rate of 30 repetitions per minute for 5 minutes. Post-intervention calliper measurements of the longitudinal dye spread were measured. RESULTS The mean experimental posttest longitudinal dye spread measurement (1.1 ± 0.9 mm) was significantly greater (P = 0.02) than the initial stabilised pretest longitudinal dye spread measurement. Increases ranged from 0.0 to 2.6 mm and represented an average of 7.9% and up to an 18.1% increase in longitudinal dye spread. DISCUSSION Passive NDM in the form of repetitive SLR induced a significant increase in longitudinal fluid dispersion in the L4 nerve root of human cadaveric specimen. Lower limb NDM may be beneficial in promoting nerve function by limiting or altering intraneural fluid accumulation within the nerve root, thus preventing the adverse effects of intraneural oedema.
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Affiliation(s)
- Kerry K Gilbert
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Michael P Smith
- Anatomical Simulation and Research, Patient Safety, and Competency Center, Albany Medical College, Albany, New York, USA
| | - Stéphane Sobczak
- Laboratory of Anatomy, Biomechanics and Organogenesis (LABO), Faculty of Medecine, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - C Roger James
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Phillip S Sizer
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Jean-Michel Brismée
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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12
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Gilbert KK, Roger James C, Apte G, Brown C, Sizer PS, Brismée JM, Smith MP. Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: implications for the treatment of neuropathic pain and dysfunction. J Man Manip Ther 2016; 23:219-25. [PMID: 26917940 DOI: 10.1179/2042618614y.0000000094] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Neural mobilization techniques are used clinically to treat neuropathic pain and dysfunction. While selected studies report efficacy of these techniques, the mechanisms of benefit are speculative. The purpose of this study was to evaluate the effects of in vitro simulated stretch/relax neural mobilization cycles on fluid dispersion within sections of unembalmed cadaveric peripheral nerve tissue. METHODS Bilateral sciatic nerve sections were harvested from six cadavers. Matched pairs of nerve sections were secured in a tissue tester and injected with a plasma/Toluidine Blue dye solution. Once the initial dye spread stabilized, the experimental nerve sections underwent 25 stretch/relaxation cycles (e.g. simulated neural mobilization) produced by a mechanical tissue tester. Post-test dye spread measurements were compared to pre-test measurements as well as control findings (no simulated mobilization). Data were analyzed using paired t-tests. RESULTS Individual dye spread measurements were reliable [ICC(3,1) = 0·99]. The post-test intraneural fluid movement (dye spread) in the experimental section increased significantly with simulated neural mobilization compared to pre-test measurements (3·2±2·1 mm; P = 0·015) and control measurements (3·3±2·7 mm; P = 0·013). CONCLUSION Repetitive simulated neural mobilization, incorporating stretch/relax cycles, of excised cadaveric peripheral nerve tissue produced an increase in intraneural fluid dispersion. Neural mobilization may alter nerve tissue environment, promoting improved function and nerve health, by dispersing tissue fluid and diminishing intraneural swelling and/or pressure.
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Affiliation(s)
- Kerry K Gilbert
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - C Roger James
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Gail Apte
- Atlas Physical and Hand Therapy Eugene, OR, USA
| | | | - Phillip S Sizer
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jean-Michel Brismée
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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13
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Slump Test: Effect of Contralateral Knee Extension on Response Sensations in Asymptomatic Subjects and Cadaver Study. Spine (Phila Pa 1976) 2016; 41:E205-10. [PMID: 26571159 DOI: 10.1097/brs.0000000000001218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Part 1: A randomized, single-blind study on the effect of contralateral knee extension on sensations produced by the slump test (ST) in asymptomatic subjects. Part 2: A cadaver study simulating the nerve root behavior of part 1. OBJECTIVE Part 1: Test if contralateral knee extension consistently reduces normal stretch sensations with the ST.Part 2: Ascertain in cadavers an explanation for the results. SUMMARY OF BACKGROUND DATA In asymptomatic subjects, contralateral knee extension reduces stretch sensations with the ST. In sciatica patients, contralateral SLR also can temporarily reduce sciatica. We studied this methodically in asymptomatic subjects before considering a clinical population. METHODS Part 1: Sixty-one asymptomatic subjects were tested in control (ST), sham, or intervention (contralateral ST) groups and their sensation response intensity compared.Part 2: Caudal tension was applied to the L5 nerve root of 3 cadavers and tension behavior of the contralateral neural tissue recorded visually. RESULTS Part 1: Reduction of stretch sensations occurred in the intervention group but not in control and sham groups (P ≤ 0.001).Part 2: Tension in the contralateral lumbar nerve roots and dura reduced in a manner consistent with the responses in the intervention (contralateral ST) group. CONCLUSION Part 1: In asymptomatic subjects, normal thigh stretch sensations with the ST reduced consistently with the contralateral ST, showing that this is normal and may now be compared with patients with sciatica.Part 2: Contralateral reduction in lumbar neural tension with unilateral application of tension-producing movements also occurred in cadavers, supporting the proposed explanatory hypothesis.
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Excursion of the Sciatic Nerve During Nerve Mobilization Exercises: An In Vivo Cross-sectional Study Using Dynamic Ultrasound Imaging. J Orthop Sports Phys Ther 2015; 45:731-7. [PMID: 26304637 DOI: 10.2519/jospt.2015.5743] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Controlled laboratory cross-sectional study using single-group, within-subject comparisons. OBJECTIVES To determine whether different types of neurodynamic techniques result in differences in longitudinal sciatic nerve excursion. BACKGROUND Large differences in nerve biomechanics have been demonstrated for different neurodynamic techniques for the upper limb (median nerve), but recent findings for the sciatic nerve have only revealed small differences in nerve excursion that may not be clinically meaningful. METHODS High-resolution ultrasound imaging was used to quantify longitudinal sciatic nerve movement in the thigh of 15 asymptomatic participants during 6 different mobilization techniques for the sciatic nerve involving the hip and knee. Healthy volunteers were selected to demonstrate normal nerve biomechanics and to eliminate potentially confounding variables associated with dysfunction. Repeated-measures analyses of variance were used to analyze the data. RESULTS The techniques resulted in markedly different amounts of nerve movement (P<.001). The tensioning technique was associated with the smallest excursion (mean ± SD, 3.2 ± 2.1 mm; P < or = .004). The sliding technique resulted in the largest excursion (mean ± SD, 17.0 ± 5.2 mm; P<.001), which was approximately 5 times larger than that resulting from the tensioning technique and, on average, twice as large as that resulting from individual hip or knee movements. CONCLUSION Consistent with current theories and findings for the median nerve, different neurodynamic exercises for the lower limb resulted in markedly different sciatic nerve excursions. Considering the continuity of the nervous system, the movement and position of adjacent joints have a large impact on nerve biomechanics.
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A modified straight leg raise test to differentiate between sural nerve pathology and Achilles tendinopathy. A cross-sectional cadaver study. ACTA ACUST UNITED AC 2015; 20:587-91. [DOI: 10.1016/j.math.2015.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/18/2015] [Accepted: 01/23/2015] [Indexed: 12/28/2022]
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Part 3: Developing Methods of In Vivo MRI Measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects With Unilateral and Bilateral Straight Leg Raise Tests. Spine (Phila Pa 1976) 2015; 40:935-41. [PMID: 25839389 DOI: 10.1097/brs.0000000000000914] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Controlled radiological study. OBJECTIVE Verify (1) whether conus medullaris displacement varies with the range of hip flexion and (2) whether the acquired data support the "principle of linear dependence." SUMMARY OF BACKGROUND DATA We have previously quantified normal displacement of the conus with unilateral and bilateral straight leg raise (SLR) and have described the "principle of linear dependence." However, we have since effected methodological advances that have produced data that surpass previous studies. METHODS Ten asymptomatic volunteers were scanned with a 1.5-T magnetic resonance scanner using T2-weighted spc 3-dimensional scanning sequences and a device that permits greater ranges of SLR. Displacement of the conus medullaris during the unilateral and bilateral SLRs was quantified reliably with a randomized procedure. RESULTS Pearson correlations were higher than 0.99 for both intra- and interobserver reliability and the observed power was 1 for each tested maneuver. The conus displaced caudally in the spinal canal by 3.54 ± 0.87 mm (μ ± SD) with unilateral (P ≤ 0.001) and 7.42 ± 2.09 mm with bilateral SLR (P ≤ 0.001). CONCLUSION To the authors' knowledge, these are the first data on noninvasive, in vivo, normative measurement of spinal cord displacement with the SLR test at 60° of hip flexion. Conus medullaris displacement increased with hip flexion angle, while maintaining the relationship between magnitude of conus displacement and number of nerve roots involved into the movement, supporting the "principle of linear dependence." The use of T2-weighted spc 3-dimensional sequence allows for better reliability testing, which is important for future clinical utility. LEVEL OF EVIDENCE 5.
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Correlation analysis of demographic and anthropometric factors, hip flexion angle and conus medullaris displacement with unilateral and bilateral straight leg raise. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:724-31. [DOI: 10.1007/s00586-015-3861-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/10/2015] [Accepted: 03/03/2015] [Indexed: 01/23/2023]
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Lin JH, Chiang YH, Chen CC. Lumbar radiculopathy and its neurobiological basis. World J Anesthesiol 2014; 3:162-173. [DOI: 10.5313/wja.v3.i2.162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/10/2014] [Accepted: 06/11/2014] [Indexed: 02/06/2023] Open
Abstract
Lumbar radiculopathy, a group of diseases in which the dorsal root ganglia (DRG) or dorsal roots are adversely affected by herniated discs or spinal stenosis, are clinically characterized by spontaneous and evoked types of pain. The pain is underpinned by various distinct pathophysiological mechanisms in the peripheral and central nervous systems. However, the diagnosis of lumbar radiculopathy is still unsatisfactory, because the association of the pain with the neurobiological basis of radiculopathy is largely unknown. Several animal models used to explore the underlying neurobiological basis of lumbar radiculopathy could be classified as mechanical, chemical, or both based on the component of injury. Mechanical injury elevates the intraneural pressure, reduces blood flow, and eventually establishes ischemia in the dorsal root and the DRG. Ischemia may induce ischemic pain and cause nerve damage or death, and the subsequent nerve damage or death may induce neuropathic pain. Chemical injury predominately induces inflammation surrounding the dorsal roots or DRG and consequent inflammatory mediators cause inflammatory pain. Furthermore, DRG neurons sensitized by inflammatory mediators are hypersensitive to innocuous mechanical force (stretch or compression) and responsible for mechanical allodynia in radiculopathy. As well, central sensitization in the spinal cord may play an important role in pain generation in lumbar radiculopathy. Increasing knowledge of pain-generating mechanisms and their translation into clinical symptoms and signs might allow for dissecting the mechanisms that operate in each patient. With precise clinical phenotypic characterization of lumbar radiculopathy and its connection to a specific underlying mechanism, we should be able to design optimal treatments for individuals. This review discusses the present knowledge of lumbar radiculopathy and proposes a novel mechanism-based classification.
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2014 young investigator award winner: In vivo magnetic resonance imaging measurement of spinal cord displacement in the thoracolumbar region of asymptomatic subjects: part 2: comparison between unilateral and bilateral straight leg raise tests. Spine (Phila Pa 1976) 2014; 39:1294-300. [PMID: 24503694 DOI: 10.1097/brs.0000000000000264] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Controlled radiological study. OBJECTIVE Ascertain if a difference exists in the mechanical effects on the cord between the unilateral and bilateral straight leg raise (SLR) and to verify whether the effect on the spinal cord may be cumulative between the two. SUMMARY OF BACKGROUND DATA To the authors' knowledge these are the first data on noninvasive, in vivo, normative measurement of spinal cord displacement with bilateral SLR test. METHODS Sixteen asymptomatic volunteers were scanned with 1.5-T magnetic resonance scanner (Siemens Avanto, Erlangen, Germany) using T2-weighted turbo spin-echo fat-saturation sequence. The displacement of the medullar cone relative to the vertebral endplate of the adjacent vertebra during the passive bilateral SLR was quantified and compared with the position of the conus in the neutral (anatomic) position and with unilateral SLR. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by 2 observers. Four practitioners performed the maneuvers in a random sequence to avoid series effects. RESULTS Compared with the neutral (anatomic) position, the medullar cone displaced caudally in the spinal canal by 2.33 ± 1.2 mm (μ ± SD) with unilateral (P ≤ 0.001) and 4.58 ± 1.48 mm with bilateral SLR (P ≤ 0.001). Statistical significance was also reached for bilateral versus unilateral SLR (P ≤ 0.001). Spearman correlations proved higher than 0.99 for intra and interobserver reliability, and 0.984 for results reproducibility in bilateral SLR. CONCLUSION The caudal displacement of the medullar cone was significantly greater (almost double) with the bilateral SLR than the unilateral SLR. We hypothesize that this greater movement may be because more force was transmitted to the cord through a larger number nerve roots with the bilateral than unilateral SLR. The high correlation values in this study show that these movements are consistent and reproducible. This study offers baseline measurements on which further studies in diagnosis and treatment of lumbar disc protrusion and radiculopathy may be developed.
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2014 young investigator award winner: In vivo magnetic resonance imaging measurement of spinal cord displacement in the thoracolumbar region of asymptomatic subjects: part 1: straight leg raise test. Spine (Phila Pa 1976) 2014; 39:1288-93. [PMID: 24503693 DOI: 10.1097/brs.0000000000000263] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Controlled radiological study. OBJECTIVE To investigate noninvasively in vivo spinal cord displacement in the vertebral canal during the passive straight leg raise (SLR) in asymptomatic subjects. The basic assumption is that the cord follows L5 and S1 nerve roots displacement by similar magnitude and direction (principle of linear dependence). SUMMARY OF BACKGROUND DATA It is generally accepted that the SLR produces some caudal movement mainly of L5 and S1 nerve roots, but the magnitude of this displacement is still a matter of debate. METHODS Sixteen asymptomatic volunteers were scanned with 1.5-T magnetic resonance scanner (Siemens Avanto, Erlangen, Germany) using T2-weighted turbo spin-echo fat-saturation sequence. The displacement of the medullar cone relative to the vertebral endplate of the adjacent vertebra during the passive SLR was quantified and compared with the position of the conus in the neutral (anatomic) position. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by 2 observers. Four practitioners performed the maneuvers in a random sequence to avoid series effects. RESULTS Compared with the neutral (anatomic) position, the medullar cone displaced caudally in the spinal canal by 2.31 ± 1.2 mm with right (P ≤ 0.001) and 2.35 ± 1.2 mm with left SLR (P ≤ 0.001). Spearman correlations proved higher than 0.99 for intra and interobserver reliability, as well as results reproducibility testing for each maneuver. CONCLUSION The data show that the spinal cord in the thoracolumbar region slides distally in response to the clinically applied SLR test. The high correlation values in this study show that these movements are consistent and reproducible. Because of the neural continuum, the authors speculate that this movement might be directly proportional to the sliding of the L5 and S1 neural roots. This study offers baseline measurements on which further studies in diagnosis of lumbar disc protrusion and radiculopathy may be developed.
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Marshall PWM, Siegler JC. Lower hamstring extensibility in men compared to women is explained by differences in stretch tolerance. BMC Musculoskelet Disord 2014; 15:223. [PMID: 25000977 PMCID: PMC4105123 DOI: 10.1186/1471-2474-15-223] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 07/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study examined whether passive hamstring tissue stiffness and/or stretch tolerance explain the relationship between sex and hamstring extensibility. METHODS Ninety healthy participants, 45 men and 45 women (mean ± SD; age 24.6 ± 5.9 years, height 1.72 ± 0.09 m, weight 74.6 ± 14.1 kg) volunteered for this study. The instrumented straight leg raise was used to determine hamstring extensibility and allow measurement of stiffness and stretch tolerance (visual analog pain score, VAS). RESULTS Hamstring extensibility was 9.9° greater in women compared to men (p = 0.003). VAS scores were 16 mm lower in women (p = 0.001). Maximal stiffness (maximal applied torque) was not different between men and women (p = 0.42). Passive stiffness (slope from 20-50° hip flexion) was 0.09 Nm.°(-1) lower in women (p = 0.025). For women, linear and stepwise regression showed that no predictor variables were associated with hamstring extensibility (adjusted r(2) = -0.03, p = 0.61). For men, 44% of the variance in hamstring extensibility was explained by VAS and maximal applied torque (adjusted r(2) = 0.44, p < 0.001), with 41% of the model accounted for by the relationship between higher VAS scores and lower extensibility (standardized β coefficient = -0.64, p < 0.001). CONCLUSIONS The results of this study suggest that stretch tolerance and not passive stiffness explains hamstring extensibility, but this relationship is only manifest in men.
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Affiliation(s)
- Paul W M Marshall
- School of Science and Health, University of Western Sydney, Locked Bag 1797, Penrith South, NSW 2751, Australia.
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Normative sciatic nerve excursion during a modified straight leg raise test. ACTA ACUST UNITED AC 2014; 19:59-64. [DOI: 10.1016/j.math.2013.07.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 06/25/2013] [Accepted: 07/12/2013] [Indexed: 11/20/2022]
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McCormack JR. The management of bilateral high hamstring tendinopathy with ASTYM® treatment and eccentric exercise: a case report. J Man Manip Ther 2013; 20:142-6. [PMID: 23904753 DOI: 10.1179/2042618612y.0000000003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
High hamstring tendinopathy (HHT) is an overuse injury that occurs most commonly in runners. The management of HHT is often challenging and the research supporting many interventions is limited. Eccentric exercise has been proven effective in the treatment of various tendinopathies but has not been thoroughly studied with HHT. Soft tissue mobilization, including ASTYM, is often utilized in the treatment of tendinopathies, though there is limited evidence supporting this approach. The purpose of this paper is to present the case of a patient referred to physical therapy with bilateral HHT. The patient was a 41-year-old recreational runner that had an insidious onset of right buttock pain 12 months prior to initiating therapy and left buttock pain 9 months prior. Her primary complaints included an inability to run, pain with prolonged or brisk walking, and pain with sitting on hard surfaces. The patient was treated in physical therapy two times per week for 16 visits with treatment focused on eccentric hamstring strengthening and ASTYM. By her eighth visit, the patient was able to walk 2·5 miles without pain and by her 12 visit, she was able to jog 1 mile before the onset of pain. After 16 visits, the patient reported that she was approximately 95% improved, was able to run 2·5 miles without pain, and had no pain with sitting on hard surfaces. This case suggests that eccentric exercise combined with ASTYM may be an effective treatment for HHT.
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Affiliation(s)
- Joshua R McCormack
- Indiana University Health Ball Memorial Rehabilitation Services, Muncie, IN, USA ; Rocky Mountain University of Health Professions, Provo, UT, USA
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Farshad M, Min K. Abduction extension cervical nerve root stress test: anatomical basis and clinical relevance. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:1522-1525. [PMID: 23412084 PMCID: PMC3698357 DOI: 10.1007/s00586-013-2689-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Revised: 11/28/2012] [Accepted: 01/25/2013] [Indexed: 06/01/2023]
Abstract
PURPOSE While the Lasègue straight leg raising test is an established test for lumbar nerve root compression, an established equivalent for cervical nerve root compression is missing. The aim of this bi-modal study was to find the most effective way to stretch the cervical nerve roots anatomically in cadavers and to assess its value in the clinical setting. METHODS Three positional maneuvers of the upper limb were tested on three cadavers to determine the displacement by stretch of the nerve roots C5, C6 and C7. The maneuver which was most efficient in nerve root displacement was applied in 24 patients with confirmed symptomatic cervical nerve root compression (cases) and 65 controls to assess the clinical value of the test. RESULTS The most efficient way to displace the cervical nerve roots by stretch was to apply dorsal pressure on the humeral head with the shoulder in 80° of abduction and 30° of extension, with slight elbow flexion while the head is facing the contralateral side. This maneuver produced 4-5 mm of nerve root displacement in cadavers. This test aggravated radicular symptoms in 79% of the patients with cervical nerve root compression and was negative in 98% of the controls. CONCLUSION The described abduction extension test with posterior push on the humeral head creates a fulcrum over which the brachial plexus can be displaced to create stress on cervical nerve roots. This simple test is easy to perform clinically and aggravates radicular symptoms in most of the patients with cervical nerve root compression while it is negative in nearly all of the controls.
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Affiliation(s)
- M Farshad
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008 Zürich, Switzerland.
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Impact of movement sequencing on sciatic and tibial nerve strain and excursion during the straight leg raise test in embalmed cadavers. J Orthop Sports Phys Ther 2013; 43:398-403. [PMID: 23633619 DOI: 10.2519/jospt.2013.4413] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Laboratory study, repeated-measures design. OBJECTIVES To quantify differences in sciatic and tibial nerve biomechanics (strain and excursion) during common variations of the straight leg raise (SLR) test. BACKGROUND Hip flexion and ankle dorsiflexion are the primary movement components of the SLR. It has been suggested that the nervous system is loaded differently when ankle dorsiflexion is added before or after hip flexion. There are, however, no data to either support or refute this suggestion. METHODS Strain and excursion in the sciatic and tibial nerve were measured in the hip, knee, and ankle regions during 2 movement sequences for the SLR test in 10 embalmed cadavers. The proximal-to-distal sequence consisted of hip flexion followed by ankle dorsiflexion; the distal-to-proximal sequence consisted of ankle dorsiflexion followed by hip flexion. RESULTS In the SLR end position, strain and excursion were comparable for both sequences for the sciatic and tibial nerve at the knee (P>.24). Strain in the tibial nerve at the ankle was greater with the proximal-to-distal sequence (P = .008), but the actual difference was small (0.8%). The pattern of strain increase and nerve excursion varied between sequences (P≤.009), with nerve strain increasing earlier and being maintained longer in regions closest to the joint that was moved first in the movement sequence. CONCLUSION Varying the movement sequence does not substantially impact excursion and strain in the end position of the SLR. Therefore, if neurodynamic test sequencing is useful in the differential diagnosis of neuropathies, it is not likely due to differences in strain in the end position of testing.
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Specificity of the Femoral Slump Test for the Assessment of Experimentally Induced Anterior Knee Pain. Arch Phys Med Rehabil 2012; 93:2347-51. [DOI: 10.1016/j.apmr.2012.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 05/29/2012] [Accepted: 06/05/2012] [Indexed: 11/22/2022]
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Brown CL, Gilbert KK, Brismee JM, Sizer PS, Roger James C, Smith MP. The effects of neurodynamic mobilization on fluid dispersion within the tibial nerve at the ankle: an unembalmed cadaveric study. J Man Manip Ther 2012; 19:26-34. [PMID: 22294851 DOI: 10.1179/2042618610y.0000000003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To evaluate the effects of neurodynamic mobilization on the fluid dynamics of the tibial nerve in cadavers. BACKGROUND Evidence showing patients benefit from neural mobilization is limited. Mechanisms responsible for changes in patient symptoms are unclear. METHODS Bilateral lower limbs of six unembalmed cadavers (n = 12) were randomized into matched pairs and dissected to expose the tibial nerve proximal to the ankle. Dye composed of Toulidine blue and plasma was injected into the nerve. The longitudinal dye spread was measured pre- and post-mobilization. The experimental group received the intervention consisting of 30 repetitions of passive ankle range of motion over the course of 1 minute. The matched control limb received no mobilization. Data were analysed using a 2×2 repeated measures ANOVA with subsequent t-tests for pairwise comparisons. RESULTS Mean dye spread was 23.8±10.2 mm, a change of 5.4±4.7% in the experimental limb as compared to 20.7±6.0 mm, a change of -1.5±3.9% in the control limb. The ANOVA was significant (P⩽0.02) for interaction between group (experimental/control) and time (pre-mobilization/post-mobilization). t-test results were significant between pre- and post-mobilization of the experimental leg (P = 0.01), and between control and experimental limbs post-mobilization (P⩽0.02). CONCLUSION Passive neural mobilization induces dispersion of intraneural fluid. This may be clinically significant in the presence of intraneural edema found in pathological nerves such as those found in compression syndromes.
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Affiliation(s)
- Cynthia L Brown
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Normal neurodynamic responses of the femoral slump test. ACTA ACUST UNITED AC 2012; 17:126-32. [DOI: 10.1016/j.math.2011.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 09/08/2011] [Accepted: 10/17/2011] [Indexed: 11/30/2022]
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Marshall PW, Cashman A, Cheema BS. A randomized controlled trial for the effect of passive stretching on measures of hamstring extensibility, passive stiffness, strength, and stretch tolerance. J Sci Med Sport 2011; 14:535-40. [DOI: 10.1016/j.jsams.2011.05.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 05/05/2011] [Accepted: 05/06/2011] [Indexed: 02/09/2023]
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Kobayashi S, Takeno K, Yayama T, Awara K, Miyazaki T, Guerrero A, Baba H. Pathomechanisms of sciatica in lumbar disc herniation: effect of periradicular adhesive tissue on electrophysiological values by an intraoperative straight leg raising test. Spine (Phila Pa 1976) 2010; 35:2004-14. [PMID: 20959779 DOI: 10.1097/brs.0b013e3181d4164d] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN This study is aimed to investigate the changes of nerve root functions during the straight leg raising (SLR) test in vivo. OBJECTIVE To investigate the relationship between nerve root movement and the electrophysiological values during an intraoperative SLR test. SUMMARY OF BACKGROUND DATA The SLR test is one of the most significant signs for making a clinical diagnosis of lumbar disc herniation. A recent study showed that intraradicular blood flow apparently decreased during the SLR test in patients with disc herniation. METHODS The study included 32 patients who underwent microdiscectomy. During the surgery, the nerve root motion affected by the hernia was observed during the SLR test. The patients' legs were allowed to hang down to the angle at which sciatica had occurred and the change of nerve root action potentials was measured. After removal of the hernia, a similar procedure was repeated. The periradicular specimens collected during surgery were examined by light and electron microscope. RESULTS In all patients intraoperative microscopy revealed that the hernia was adherent to the dura mater of the nerve roots. During the SLR test, the limitation of nerve root movement occurred by periradicular adhesive tissue and amplitude of action potential showed a sharp decrease at the angle that produced sciatica. After removal of the hernia, all the patients showed smooth gliding of the nerve roots during the test, and there was no marked decrease of amplitude. Our data suggest that temporary ischemic changes in the nerve root cause transient conduction disturbances. Pathologic examination showed that the periradicular tissue consisted of the granulation with vascularization and many inflammatory cell infiltrations. CONCLUSION The presence of periradicular fibrosis will compound the nerve root pain by fixing the nerve in one position, thereby increasing the susceptibility of the nerve root to tension or compression.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, The University of Fukui, Fukui, Japan.
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Walsh J, Hall T. Agreement and correlation between the straight leg raise and slump tests in subjects with leg pain. J Manipulative Physiol Ther 2009; 32:184-92. [PMID: 19362228 DOI: 10.1016/j.jmpt.2009.02.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 11/25/2008] [Accepted: 01/05/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The straight leg raise (SLR) and slump tests have traditionally been used to identify nerve root compression arising from disk herniation. However, they may be more appropriate as tests of lumbosacral neural tissue mechanosensitivity. The aim of this study was to determine agreement and correlation between the SLR and slump tests in a population presenting with back and leg pain. METHODS This was an observational, cross-sectional study design. Forty-five subjects with unilateral leg pain were recruited from an outpatient Back Pain Screening Clinic at a large teaching hospital in Ireland. The SLR and slump tests were performed on each side. In the event of symptom reproduction, the ankle was dorsiflexed. Reproduction of presenting symptoms, which were intensified by ankle dorsiflexion, was interpreted as a positive test. An inclinometer was used to measure range of motion (ROM). RESULTS There was substantial agreement between SLR and slump test interpretation (kappa = 0.69) with good correlation in ROM between the 2 tests (r = 0.64) on the symptomatic side. In subjects who had positive results, ROM for both tests was significantly reduced compared to ROM on the contralateral side and ROM in subjects who had negative results. CONCLUSIONS When the SLR and slump tests are interpreted as positive in the event of reproduction of presenting leg pain that are intensified by ankle dorsiflexion, these tests show substantial agreement and good correlation in the leg pain population. When interpreted in this way, these tests may be appropriate tests of neural tissue mechanosensitivity, but further criteria must be met before a definitive conclusion in relation to neural tissue mechanosensitivity may be drawn.
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Affiliation(s)
- Jeremy Walsh
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Kitab SA, Miele VJ, Lavelle WF, Benzel EC. PATHOANATOMIC BASIS FOR STRETCH-INDUCED LUMBAR NERVE ROOT INJURY WITH A REVIEW OF THE LITERATURE. Neurosurgery 2009; 65:161-7; discussion 167-8. [DOI: 10.1227/01.neu.0000347002.67982.8f] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE
Persistent pain originating from a dysfunctional lumbar motion segment poses significant challenges in the clinical arena. Although the predominance of the existing spine literature has addressed nerve root compression as the principal cause of pain, it is equally likely that a stretch mechanism may be responsible for all or part of the pathology.
METHODS
The literature supporting the role of stretch damage as a primary cause of nerve root injury and pain was systematically reviewed. Pathoanatomic considerations between nerve roots and juxtaposed environment are described and correlated with the available literature. Potential anatomic relationships that may lead to stretch-induced injury are delineated.
RESULTS
A dynamic lumbar functional spinal unit that encloses a tethered nerve root can create significant stretch and/or compression. This phenomenon may be present in a variety of pathological conditions. These include anterior, posterior, and rotatory olisthesis as well as degenerative conditions such as the loss of disc interspace height and frank multisegment spinal deformity. Although numerous studies have demonstrated that stretch can result in nerve damage, the pathophysiology that may associate nerve stretch with chronic pain has yet to be determined.
CONCLUSION
The current literature concerning stretch-related injury to nerve roots is reviewed, and a conceptual framework for its diagnosis and treatment is proposed and graphically illustrated using cadaveric specimens. The dynamic biomechanical and functional interrelationships between neural structures and adjacent connective tissue elements are particularly important in the face of spinal deformity.
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Affiliation(s)
| | - Vincent J. Miele
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - William F. Lavelle
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward C. Benzel
- Department of Neurosurgery, Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Bueno FR, Shah SB. Implications of Tensile Loading for the Tissue Engineering of Nerves. TISSUE ENGINEERING PART B-REVIEWS 2008; 14:219-33. [DOI: 10.1089/ten.teb.2008.0020] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Franklin Rivera Bueno
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland
| | - Sameer B. Shah
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland
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