1 / 35

Therapy Considerations for the Median Nerve

Therapy Considerations for the Median Nerve. Innervations of the Median Nerve. Etiology. Majority of injuries are at the wrist level * Prolonged CTS most common Charcot-Marie-Tooth disease : neuronal or demyelinating disorder that leads to peripheral neuropathy Lipofibrohamartoma :

marcel
Download Presentation

Therapy Considerations for the Median Nerve

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Therapy Considerations for the Median Nerve

  2. Innervations of the Median Nerve

  3. Sieg & Adams, Illustrated Essentials of Musculoskeletal Anatomy; 1996

  4. Etiology Majority of injuries are at the wrist level *Prolonged CTS most common Charcot-Marie-Tooth disease: neuronal or demyelinating disorder that leads to peripheral neuropathy Lipofibrohamartoma: rarely occurring, benign neoplasm consisting of fibroadipose tissue that affects peripheral nerves Kozin, S 2005; pg 213

  5. Muscle Loss of the Thumb • OpponensPollicis (OP) • Abductor PollicisBrevis (APB) • Superficial head of the Flexor PollicisBrevis (FPB) www.meded.ucsd.edu

  6. Sensory Loss • Thumb, Index, Middle, and radial ½ of Ring finger www.rch.org.au

  7. Functional Loss • Thumb opposition and manipulation

  8. Pre-Operative Therapy Objectives • Prepare patient, physically and psychologically, for surgery • Enable patient to be as functional as possible prior to surgery

  9. Splinting for Function • Objective: Position MP in palmer abduction to stabilize for opposition to digits • Hand based: • Ribbon splint • Hand based thumb spica

  10. 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 PollicisLongus (FPL) is not working

  11. Splinting to Prevent or Correct Deformity • 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 ncmedical.com

  12. Adaptations/Modifications • 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

  13. Interventions • 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

  14. Specific Transfers and Indications www.orthobullets.com

  15. Muscle Training for Transfer • Flexor DigitorumSublimis (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

  16. Post-Operative TherapyTendon 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 flexion • 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)

  17. Post-Operative TherapyTendon 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)

  18. Cortical Re-Mapping • Cortical Re-mapping • Graded motor imaging • Left/Right discrimination • Explicit Motor Imagery • Mirror Therapy • Patient Education noigroup.com

  19. Joint blocking with a chopstick

  20. Joint Blocking with ICAM

  21. Median Nerve Transfer • Critical for forearm pronation, wrist and finger flexion, and thumb opposition • 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 pronation • 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 pronatorquadratus muscle Moore et al, JHT (2014)

  22. 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 pronatorquadratus • 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); www.neurosurgery.med.nyu.edu

  23. Post-Operative TherapyNerve Transfer Immobilization • 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 transfer • 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)

  24. Precautions Post Operative • Tendon Transfer • Same as for Tendon repair • Nerve Transfer • Risk of increased tension on nerve repair site

  25. Post Operative TherapyTendon and/or Nerve Transfer • Edema control • Scar management • Pain management • Range of Motion • Sensory Re-Education • Strengthening • Restore Function

  26. 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)

  27. Sensory Re-education Vibration: Tapping fingers Stereognosis: Carry 3-4 small items in pocket - throughout the day try to reach in and identify

  28. Sensory Re-Education Light to deep Touch danmicglobal.com

  29. Exercise • ROM • PROM • 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

  30. Dexterity/Opposition

  31. Strengthening

  32. Bibliography • Davis KD, Taylor KS, Anastakis DJ. Nerve Injury Triggers Changes in the Brain. Neuroscientist. 2011; 17 (4). • Hoard AS, Bell-Krotoskie JA, Mathews R. Application of Biomechanics to Tendon Transfers. Journal of Hand Therapy. April-June 1995; 115-123. • Kozin SH. Tendon transfers for radial and median nerve palsies. Journal of Hand Therapy. April-June 2005; 2: 208-215. • 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. 2012.

  33. Bibliography • 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: 886-889. • Sieg & Adams. Illustrated Essentials of Musculoskeletal Anatomy, 3rd Edition. Gainesville, Megabooks, Inc. 1996. • Sultana SS, MacDermid JC, Grewal R, Rath S. The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand Therapy. October 2013; 26: 1-21. • Wang JHC, Guo Q. Tendon Biomechanics and Mechanobiology-A minireview of basic concepts and recent advancements. Journal of Hand Therapy. April-June 2012; 7: 133-140.

  34. Thank you to my family for their never ending support and encouragement

More Related