Therapy considerations for the median nerve
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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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Therapy Considerations for the Median Nerve


Innervations of the Median Nerve


Sieg & Adams, Illustrated Essentials of Musculoskeletal Anatomy; 1996


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


Muscle Loss of the Thumb

  • OpponensPollicis (OP)

  • Abductor PollicisBrevis (APB)

  • Superficial head of the Flexor PollicisBrevis (FPB)

www.meded.ucsd.edu


Sensory Loss

  • Thumb, Index, Middle, and radial ½ of Ring finger

www.rch.org.au


Functional Loss

  • Thumb opposition and manipulation


Pre-Operative Therapy

Objectives

  • 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

      PollicisLongus (FPL) is not working


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


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


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


Specific Transfers and Indications

www.orthobullets.com


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


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)


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)


Cortical Re-Mapping

  • Cortical Re-mapping

    • Graded motor imaging

      • Left/Right discrimination

      • Explicit Motor Imagery

      • Mirror Therapy

    • Patient Education

noigroup.com


Joint blocking with a chopstick


Joint Blocking with ICAM


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)


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


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)


Precautions Post Operative

  • Tendon Transfer

    • Same as for Tendon repair

  • Nerve Transfer

    • Risk of increased tension on nerve repair site


Post Operative TherapyTendon 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

    danmicglobal.com


    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


    Dexterity/Opposition


    Strengthening


    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.


    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.


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


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