Therapy Considerations for the Median Nerve

Innervations of the Median Nerve
Sieg & Adams, Illustrated Essentials of Musculoskeletal Anatomy; 1996
Majority of injuries are at the wrist level
*Carpal Tunnel Syndrome
Charcot-Marie-Tooth disease
Gunshot Wound
(e.g. Rheumatoid Arthritis)
CTS most common
Charcot-Marie-Tooth disease:
neuronal or demyelinating disorder that leads to peripheral neuropathy
rarely occurring, benign neoplasm consisting of fibroadipose tissue that
affects peripheral nerves
Kozin, S 2005; pg 213
Muscle Loss of the Thumb
 Opponens Pollicis (OP)
 Abductor Pollicis Brevis (APB)
 Superficial head of the Flexor Pollicis Brevis (FPB)
Sensory Loss
 Thumb, Index, Middle, and radial ½ of Ring finger
Functional Loss
 Thumb opposition and manipulation
Pre-Operative Therapy
• Prepare patient, physically and psychologically, for surgery
• Enable patient to be as functional as possible prior to surgery
Splinting for Function
 Objective: Position MP in palmer abduction to stabilize
for opposition to digits
 Hand based:
 Ribbon splint
 Hand based thumb spica
Splinting for Function
 Forearm based: high median nerve lesion need to
stabilize the wrist
 Forearm based thumb spica
 Oval 8 to stabilize IP joints if Flexor
Pollicis Longus (FPL) is not working
Splinting to Prevent or Correct
 Objective: Maintain 1st web space, reduce pain, and maintain
length of extrinsics
 C-bar splint in palmer abduction for night wear
 Forearm based thumb spica to support wrist
 Resting splint for night
 Increase ability to complete tasks with weak pinch
 Built up foam for handles/utensils
 Use of adaptive equipment
large pens
Use of jump rings for zipper pulls
 Compensation with gross grasp
Angled knives
Travel mug with a handle
 Maintain full PROM for involved joints
 Electrical Stimulation
 Manual Muscle Testing
 Persistent pain management/education
 Patient Education regarding realistic expectations related
to function, timing, and rehab needs
Specific Transfers and Indications
Goal to
Opposition and
From: Donor
Tendon (working)
To: Recipient Tendon (deficient)
Low Median Nerve Palsy
Bunnell opponensplasty: base proximal
FDS of ring
phalanx or APB tendon (use FCU as pulley)
APB (pulley around ulnar side of wrist)
High Median Nerve Palsy
Thumb IP flexion Brachioradialis
Flexor Pollicis Longus
Index and long
finger flexion
FDP of index and middle (side-to-side
FDP of ring and small
finger (ulnar nerve)
Muscle Training for Transfer
 Flexor Digitorum Sublimis (FDS) of Ring Finger is primary
choice to thumb MCP (at APB and/or EPB tendon)
 Use of differential tendon gliding of RF to isolate
Post-Operative Therapy
Tendon Transfer
 First 2-3 wks post-op
 Post-op brace with 30 degrees wrist flexion to relax transfer
and thumb in full opposition
 Immediate AROM of fingers- especially RF if FDS used
 May need night finger extension gutter if RF positions in
 s/p 3 wks post-op
 Splint in forearm based dorsal blocking splint with wrist in
10-20 degrees wrist flexion
 PROM to maintain joint mobility
 4-6x/day AROM for tendon gliding and retraining
Kozin, S, JHT (2005)
Post-Operative Therapy
Tendon Transfer
 Concomitant RF flexion with thumb opposition
 MP blocking of RF to isolate PIP flexion
 Use of opposite hand
 MP flexion blocking splint
 Use of Chopstick/pen to block MP flexion
 Visualization with place and hold exercises
 Use of Graded Motor Imagery
 Discharge splint at 6 weeks post-op
 Strengthening at 8 weeks post-op
Kozin, S, JHT (2005)
Cortical Re-Mapping
 Cortical Re-mapping
 Graded motor imaging
 Left/Right discrimination
 Explicit Motor Imagery
 Mirror Therapy
 Patient Education
Joint blocking with a chopstick
Joint Blocking with ICAM
Median Nerve Transfer
 Critical for forearm pronation, wrist and finger flexion, and thumb
 Options:
 Restoring pronation
Branch to FCU to pronator teres branch
Branch to FDS to pronator teres branch
*Branch to ECRB to pronator teres branch
 Preferred due to synergistic movements of wrist extension and
 Restoring thumb opposition
Isolated low median nerve injury-use of a short interpositional graft:
proximal branch of the median nerve, specifically the terminal AIN
supplying the pronator quadratus muscle
Moore et al, JHT (2014)
Median Nerve Transfer
Restoring finger and thumb flexion
 Anterior Interosseous Nerve (AIN)- motor nerve that supplies the
FPL and FDP to to the index and middle fingers, and pronator quadratus
 Branches from musculocutaneous, radial, or ulnar nerves to
reinnervate the AIN
Brachialis branch of musculocutaneous to AIN
Supinator branch of the radial nerve to AIN
Brachioradialis branch to AIN
Radial nerve branch of ECRB and supinator to AIN
Moore et al, JHT (2014);
Post-Operative Therapy
Nerve Transfer
 Elbow/Forearm: 7-10 days
 Post-op dressing
 May change to splint as early as s/p 2-3 days
 No further protection after 10 days due to no tension on nerve
 If tendon transfer at same time, protocol paradigm shift related
to tendon
 Shoulder: up to 4 wks
 Allow intermittent ROM for elbow and hand
 Shoulder A/PROM resumes at s/p 4 wks
Moore et al, JHT, (2014)
Precautions Post Operative
 Tendon Transfer
 Same as for Tendon repair
 Nerve Transfer
 Risk of increased tension on nerve repair site
Post Operative Therapy
Tendon and/or Nerve Transfer
 Edema control
 Scar management
 Pain management
 Range of Motion
 Sensory Re-Education
 Strengthening
 Restore Function
Motor Re-education
 Objective: To correct recruitment and restoration of muscle balance and
decrease compensatory patterns
 Motor Re-education
 Challenges:
Alterations in motor cortex mapping (i.e. neuro tag smudging)
 Muscle imbalances due to weakness associated with dennervation
 May persist due to compensatory movement patterns and persistent
weakness of reinnervated muscles
 Method:
 Contract muscle from donor nerve/muscle with new muscle until motor
pattern established
 The more synergistic the action and based on original motor pattern, the
more recruitment and establishment of muscle balance
Moore et al, JHT (2014)
Sensory Re-education
Vibration: Tapping fingers
Stereognosis: Carry 3-4 small items in pocket - throughout the day try to
reach in and identify
Sensory Re-Education
Light to deep Touch
 Place and Hold with visualization and use of RF flexion initially
 AROM through full range
 Opposition exercises
 Light object pick-up
 Marble cup
 3 poker chips
 Strengthening
 Graded putty exercises
Button find
Pushing golf tees in putty
 Tearing paper
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the Brain. Neuroscientist. 2011; 17 (4).
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Kozin SH. Tendon transfers for radial and median nerve palsies.
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Moore AM, Novak CB. Advances in nerve transfer surgery. Journal
of Hand Therapy. April-June 2014; 27: 96-105.
Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded Motor
Imagery Handbook. Adelaide, Australia. Noigroup Publications.
 Murphy RKJ, Wilson ZR, Mackinnon SE. Repair of median nerve
transection injury using multiple nerve transfers, with long-term
functional recovery. Journal of Neurosurgery. Nov 2012; 117: 886889.
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Edition. Gainesville, Megabooks, Inc. 1996.
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Thank you to my family for their never ending support
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