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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 :

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Therapy Considerations for the Median Nerve

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  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

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