Radial Nerve - EventBuilder

Report
Therapy Considerations
for the Radial Nerve
Sybil Hedrick, OTR/L, CHT, CSCS
August 23, 2014
[email protected]
S
Radial Nerve Innervation
Etiology
Trauma
Internal Forces
External Forces
Other
Laceration
Radial Tunnel
Tourniquet
Syndrome
*b/t head of radius
and supinator
Wartenberg Syndrome
Ischemia
Gunshot Wound
Synovitis
“Crutch Palsy”
Traction
Fracture/Disloc
ation
*mid/distal 1/3
of humerus
Tumor
Callus
Saturday Night
Palsy
X-radiation
Electrical Injury
Injection
The regional anatomy of the nerve and its adjacent structures, as well as the nerve’s
proximity to underlying bone and unyielding fascial bands, must be considered.
Muscle Loss:
Axilla or Proximal Humerus
S Weakness/paralysis of:
S Tricep
S Aconeous
S Brachioradialis
S All the muscles distal to brachioradialis
Muscle Loss:
Distal Humerus
S “Wrist Drop”
S Rests in a position of:
S Forearm pronation
S Wrist flexion
S Thumb flexion & abduction
S Slight MCP flexion
S IP extension (some flexion if
flexors are tight)
S Unable to:
S Extend wrist/fingers
S Abduct/extend thumb
Muscle Loss:
Forearm: Posterior Interosseous
Nerve
 Isolated involvement of the
deep motor branch of the
radial nerve
 Present with strong radial
deviation with extension of the
wrist
 Lack MP extension
 Splinting is similar as for radial
nerve palsy
Sensory Loss
Sensory loss in Radial Nerve Palsy is not as much of a
concern as compared to median/ulnar, address as
applicable
Functional Loss
S Cannot reach out with open hand to
obtain objects
S No stability at wrist for stable
prehension
S Difficult to write, type
Pre-Operative Therapy
And/Or Conservative
Management
Objectives
S Prevent deformity
S Maintain tissue pliability
S Promote neural regeneration and reorganization
S Maintain function
Radial Nerve Palsy often recovers spontaneously and
will often not be rushed into tendon/nerve transfers so
conservative management is key
Pre-Operative Therapy
And/Or Conservative Management
Evaluation
S History
S Sympathetic Function
S Sensibility (tho not of a huge concern with radial nerve)
S Motor Function
S ROM: active and passive
S Manual Muscle Testing
S Be aware of substitution patterns
S Dexterity
Splinting for Function
S Goal to maximize current functional use of the hand/UE
S Goal to harness wrist motion while allowing full finger
flexion/extension
S Try to recreate natural tenodesis motion to allow normal
grasp/release of the hand
* Note: a static wrist immobilization orthosis does not allow for
functional grasp/release, covers palmar sensation and in the end,
is not functional for the patient.
Splinting for Function
Splinting for Function
VanLede Radial Nerve Palsy
Splint
S
Improved functional
dexterity
S
Lower profile
S
Easier to get on/off for
patient
S
Can use Delta Cast or
Thermoplastic
S
Instructions for
thermoplastic version
can be found @
pattersonmedical.com
search for Extension
Assist Splint
Splinting to Prevent or
Correct Deformity
S Keep deneravated
muscles from resting
in an overstretched
position
S Enhance returning
muscle function instead
of allowing substitution
patterns
S Prevent joint
contractures
Adaptations/Modifications
S Cold intolerance frequently accompanies peripheral
nerve injuries (PNI): neoprene mittens, gloves
Interventions:
After Splinting
S Modalities:
S Repeated assessment to assist
S Heat
tracking of nerve recovery
S NMES
S Nerve glides
S Manual work
S Home program
S Strengthening
S Gravity eliminated
S Aquatic therapy
S Progressive resistance
(PRE)
Preparation for Tendon Transfer
S Ideal, full if possible, PROM at joints which will be involved
S Idea, full if possible, AROM as well
S Proximal muscle strength should be at least 4/5 or better
S The muscle to be transferred should have strength at least
4/5 or better
Motor Learning &
Cortical Re-Mapping
Motor Learning
S Motor Leaning aptitude should
be assessed on the non-involved
limb
S Acquisition
S Retention (consistency)
S Transfer (flexibility)
S Efficiency
Cortical Re-Mapping
Post-Operative Therapy
Radial Nerve Tendon Transfer
S Psychosocial Issues: client roles, motivation and compliance,
cognition, past and current abilities/interests
S Diminished success from transfer surgery can result with:
S Denial
S Frustration
S Lack of trust in therapy program
S Finances
S Time
S Must work closely with patient and Physician to eliminate and/or
minimize or ease these factors
Post-Operative Therapy
Radial Nerve Tendon Transfers
S Pronator Teres to the ECRB
for wrist extension
S Palmaris Longus to rerouted
EPL for thumb extension (if
no PL, FDS (IV))
S FCR to EDC for finger
extension (sometimes FCU is
used)
emedicine.medscape.com
Tendon Transfer Precautions
S Common complications from
tendon transfer include:
S Excessive radial deviation at the
wrist
S Bowstringing of transferred
tendons (EPL in particular)
S Incomplete extension of 1 or
more fingers
S Incomplete finger flexion with
simultaneous wrist flexion
S Complete Rupture
S Tendon adhesion
S Therapist can play a key role in
preventing some of these issues:
S Careful monitoring of active
motion, retrain movement
patterns
S Gradual progression out of
splint
S Ensure tendon gliding
S Education, education, education
every visit on stage of healing,
phase of rehab
Post-Operative Therapy
Radial Nerve Tendon Transfers
Phase
Goal
1 (weeks 0-3)
Protect repair site
Immobilization
Method
Good fitting orthosis positioned per
physician/therapist to minimize tension at
wrist, fingers, thumb
Ensure freedom of motion of joints
allowed to move
Manage Edema &
incision/scar care
Elevation (overhead hook fisting)
Compression (coban, Game ready)
Wound care, silicone gel
Active motion of noninvolved joints
Shoulder
PIP and DIP of fingers
Legs/core
Post-Operative Therapy
Radial Nerve Tendon Transfers
S Splint out of surgery: ultimately
S
depends on your surgeon! Sources
vary between surgical and therapy
resources. Usually 2-3 weeks
Splint picture
S Elbow included, held in a position
of pronation
S wrist 30-50 deg of extension and 10-
15 deg of UD
S MCP’s at 0deg or 0-15 deg of
flexion, finger IP’s free
S
Thumb fully abducted with IP in
full extension
Post-Operative Therapy
Radial Nerve Tendon Transfers
Phase
Goal
Method
2
Weeks
3-6
Regain AROM &
maintain PROM
Elbow extension and flexion
Protected: supination, wrist flexion, finger flexion,
thumb adduction/flexion
Pronation, wrist extension, finger extension, thumb
abduction/extension
PROM, myofascial release, scar massage
Activation of tendon
transfer
Muscle retraining:
Pronation for wrist extension
Wrist flexion for finger extension
Palm contraction for thumb abd/ext
Enhance
sensorimotor control
Grasping lightweight objects of various shapes, sizes,
manipulation
Enhance function
while maintaining
good biomechanics
Ensure normal movement patterns as much as
possible using verbal/nonverbal feedback
In clinic and with basic ADL tasks at home
Activation
Of the
transfer
Motor Re-Education
S Start with both the original motion
S Tips for specifics:
S Start in gravity eliminated position
S Wrist extension
S Resist pronation to help facilitate
combined with new motion
and/or place and hold
S Some resources say to use the
opposite limb, however the wiring is
now different??
S Slow, short session at a non-extreme
force
wrist ext
S Finger extension
S Resist wrist flexion to help
facilitate finger ext
S Caution to NOT flex forcefully
past neutral as this can stress the
repair site
S Thumb abduction/extension
Post-Operative Therapy
Radial Nerve Tendon Transfers
Phase
Goal
Method
3
Weeks
6-12
Improve strength
Usual suspects: weights, theraband
Hammer, Dynaflex*
Strengthening
& return to
prior
function
Enhance aerobic
capacity
UBE, aquatic, general conditioning
Return to prior level of
function
Work hardening, sport specific training,
don’t forget leisure!
Ongoing assessment
Capacity for continuing improvement
Needs for further surgical consult/issues
Long-term adaptive equipment/techniques
Ther Ex Pearls
Hammer
Dynaflex
The Cube
Post-Operative Therapy
Nerve Transfer for Radial Nerve
Paralysis
S Pre-operatively: Therapist should work on motor retraining using
contralateral arm and normal movement patterns
S Radial Nerve specific? Typing, reaching and grasping, playing
instrument, etc. Tasks for wrist/finger extension, thumb abd/ex
Post-Operative Therapy
Nerve Transfer for Radial Nerve
Paralysis
S Post-operative pain management
S Edema control
S Immobilization
S 7-10 days
S Early ROM
S Shoulder, trunk
S 3-4 weeks: elbow, forearm, wrist and hand
Motor Re-Education
S
Must learn to coordinate new
pathways for target muscle
activation
S
Cortical command is now different
and new
S
Motor reeducation with tasks that
are normal for elbow flexion are
instituted to relearn:
S normal movement patterns
S muscle recruitment
S reestablish muscle balance
S
1st: wrist/finger extension and
thumb abduction muscle
“contraction” combined with
contraction from donor nerve:
S FDS, FCR, PL
S
Want most synergistic action
based on original motor pattern
S
Bimanual tasks
Strengthening
S Utilize reinnervated muscle physiology and biomechanics
S 1) short duration exercise sessions (<5-10min)
S Slow onset contractions
S begin in mid-range (place and hold) or gravity eliminated
S 2) Multi-angle isometrics
S 3) Concentric strengthening
S 4) Eccentric strengthening

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