Peripheral Nerve Injuries Peripheral nerve - A nerve belonging to the Peripheral Nervous System (PNS), a network of 43 pairs of motor and sensory nerves that connect the central nervous system (CNS, composed of the brain & spinal cord) to the entire human body

● Peripheral nerves control the functions of sensation, movement and motor coordination ● Fragile and can be damaged easily

Peripheral Nerve Injury

● Occurs when there is serious injury or trauma to one of the peripheral nerves. ● Can result in a minor injury or a fully severed nerve ● Based on the type and amount of damage, nerve regeneration may or may not be

possible. Causes: Peripheral nerves can sustain injury from a number of causes, including accidents or trauma.

● Laceration (a cut or tear in the nerve tissue) ● Severe bruising (contusion) ● Gunshot wounds ● Stretching (traction) ● Drug injection injury ● Electrical injury

Symptoms

● Any of the following in the the affected area ○ Severe, unrelenting pain ○ Burning sensation ○ Tingling sensation ○ Numbness sensation ○ Total loss of sensation

Treatment:

● Treatment depends on: ○ Type of injury ○ Symptoms ○ The amount/severity of nerve injury sustained.

● For mild nerve injuries, the following non-surgical treatments may be part of the plan: ○ Acupuncture ○ Massage therapy ○ Medication ○ Orthotics ○ Physical/occupational therapy and rehabilitation (exercises, stretches, physical

agent modalities)

Classification ● 3 Basic Types of PNI:

1. Stretch related - Most common. The peripheral nerves are elastic, but when a traction force is too strong, injury occurs. If the traction force is strong enough, a complete tear may occur, but most commonly the continuity is retained, resulting in injuries such as Erb's Palsy.

2. Lacerations - Type of injury in which the peripheral nerve is severed by a blade → Might be completely severed but usually some continuity remains.

3. Compressions - Type of injury caused by excessive pressure on a nerve via nerve compression or entrapment

a. Does not involve tearing of the neural elements. b. Certain nerves are more susceptible to this type of injury because of

where they are located in the body c. Common entrapment neuropathies include:

i. Median nerve entrapment (“Carpal tunnel syndrome”) ii. Radial nerve compression (“Saturday night palsy”) iii. Anterior interosseous neuropathy iv. Ulnar nerve entrapment v. Femoral nerve entrapment vi. Peroneal nerve entrapment

d. Some medical conditions may increase the likelihood of this injury, such as diabetes, hypothyroidism, acromegaly, amyloidosis, carcinomatosis, polymyalgia rheumatica, rheumatoid arthritis or gout.

● Sunderland classification system defines five different degrees of PNI: 1. First degree: A reversible local conduction block at the site of the injury. This

injury does not require surgical intervention and usually will recover within a matter of hours to a few weeks.

2. Second degree: There is a loss of continuity of the axons (the “electrical wires”) within the nerve. If this kind of injury can be confirmed through pre-operative nerve testing, surgical intervention is usually not required.

3. Third degree: There is damage to the axons and their supporting structures within the nerve. In this case, recovery is difficult to predict. Nerve conduction studies performed during surgery are often able to help indicate outcome and need for simple cleaning of the nerve (neurolysis) or a more extensive repair with grafting.

4. Fourth degree: In this case, there is damage to the axons and the surrounding tissues sufficient to create scarring that prevents nerve regeneration. Electrical testing performed during surgery confirms that no electrical energy can be passed along the neural pathways in this injured nerve. Surgical intervention with nerve grafting is necessary to repair the injury.

5. Fifth degree: These injuries are usually found in laceration or severe stretch injuries. The nerve is divided into two. The only way to repair a fifth-degree injury is through surgery.

Medical Diagnosis ● In order to fully determine the extent of the damage to the nerve, the doctor may order

one of the following diagnostic tests: ○ An electrical conduction test to determine the passage of electrical currents

through the nerves. ■ Electromyography ■ Nerve conduction velocity

○ An imaging test such as: ■ CT scan ■ MRI ■ MRI neurograph

Review of Upper Quadrant Neuroanatomy Brachial Plexus - A network of nerves in the anterior shoulder that carries movement and sensory signals from the spinal cord at vertebral levels C5 - T1 to the arms and hands.

● From the vertebrae, the cords travel through the scalene triangle, under the clavicle, under the pectoralis minor, and into the arm

● Brachial plexus injuries typically stem from trauma to the neck and can cause pain, weakness and numbness in the arm and hand.Important to how we work through our clinical reasoning

●

● Ulnar Nerve

● Innervates Flexor Carpi Ulnaris muscle, Flexor Digitorum Profundus (ulnar head) Median Nerve

● Arises from vertebral levels C6-T1 via the brachial plexus ● Courses along the brachial artery, travels down anterior department of arm ● At level of elbow: Lies between humeral, superficial, and ulnar deep heads of pronator

teres (big area of entrapment of median nerve) ● Enters anterior department of forearm into Flexor Digitorum Superficialis muscle ● At elbow and proximal aspect of forearm, innervates several muscles that are important

for hand function/typing/occupational reasons (Pronator Teres, Flexor Carpi Radialis, Palmaris Longus, and Flexor Digitrum Superficialis)

● At the level of the humeral head of Pronator Teres, the anterior interosseous nerve splits off from the median nerve. Named as such as it travels along the anterior interosseous. Innervates deep muscles of the anterior forearm except ulnar half of FDP.

● Innervation: ○ Abductor Pollicis Brevis ○ Flexor carpi radialis ○ Flexor digitorum superficialis ○ Flexor pollicis brevis & longus ○ Lumbricals 1 & 2 ○ Opponens pollicis ○ Palmaris Longus ○ Pronator quadratus ○ Pronator teres ○ Flexor digitorum profundus (radial half)

■ If you are trying to differentiate whether the issue is more myotomal (relating to spinal root) vs distal nerve, assess finger flexion strength:

● Digits 2 and 3 flexion is caused by FDP innervated by MEDIAN N. ● Digits 4 and 5 flexion is caused by FDP innervated by ULNAR N.

THEREFORE ● Finger flexion weakness in Digits 2 & 3 = median n. dysfunction ● Finger flexion weakness in Digits 4 & 5 = ulnar n. dysfunction ● Finger flexion weakness in Digits 2-5 = dysfunction more

proximally, prior to split of median and ulnar nerves ● Popular areas of entrapment:

○ Pronator teres (elbow level) ○ Carpal tunnel (wrist level)

The “Carpal Tunnel”

● The median nerve can be entrapped in a lot of different places, but it is most commonly entrapped in the “carpal tunnel” (wrist level)

● The carpal tunnel is formed where the flexor retinaculum spans from the scaphoid and trapezium to the hamate and pisiform, deep and slightly distal to the palmar carpal ligament. This creates a canal that covers the flexor digitorum superficialis tendons, the flexor digitorum profundus tendons, the tendon of flexor pollicis longus, and the median nerve. These tendons in the carpal tunnel are covered by the ulnar and radial bursae (complex synovial coverings that protect the flexor tendons). The flexor digitorum superficialis and flexor digitorum profundus tendons are covered by the ulnar bursa, and the tendon of flexor pollicis longus is covered by the radial bursa.

● Deep to the FR is the FDS, FDP, FPL, FCR ● Superficial to the FR is the Ulnar nerve & artery, Palmaris longus, and anterior palmar

branch of median nerve Radial Nerve

● Supplies the posterior portion of the upper limb ● Innervates the triceps brachii, brachialis, brachioradialis, and extensor carpi radialis

longus ● Dysfunction DIMINISHES ability to supinate, but since biceps brachii is the PRIMARY

muscle that supinates, person will still be able to supinate as long as biceps are intact Arcade of Frohse

● The most superior part of the superficial layer of the supinator muscle ● A fibrous arch over the posterior interosseous nerve ● Sometimes called the supinator arch

SPECIFIC DIAGNOSES

1. Median nerve entrapment a. 4 possible sites of median nerve entrapment:

i. (1) Distal humerus by ligament of Struthers

ii. (2) Proximal elbow by bicipital aponeurosis iii. (3) Elbow between superficial and deep head of pronator teres muscle

(**most common site of entrapment of median nerve at elbow**) 1. Pronator teres syndrome - Syndrome that occurs when median

nerve is entrapped between superficial and deep heads of pronator teres muscle in forearm

a. Symptoms i. Mimics symptoms of carpal tunnel ii. Paraesthesia (altered sensation such as tingling or

“pins and needles”) iii. Pain in: polar axis of elbow, forearm, Digits 1,2,3 &

radial half of 4th b. Assessment:

i. If patient presents with traditional Carpal Tunnel Syndrome symptoms, it is extremely important to perform differential diagnosis to determine the site of the nerve entrapment.

ii. You can do this by performing a Tinel Sign over the wrist AND over the elbow and compare which elicits more severe symptoms. A positive Tinel sign over the elbow indicates Pronator Teres Syndrome as opposed to Carpal Tunnel Syndrome.

iii. Tinel Sign - Assessment for carpal tunnel syndrome in which clinician taps on the palm side of the wrist. If it elicits (causes) increased tingling/numbness over the median nerve distribution area (palm side of digits 1, 2, 3, and half of 4), that is a positive sign.

2. Anterior interosseous syndrome - indicated by more motor weakness versus altered sensation

iv. (4) Proximal forearm at edge of flexor digitorum superficialis b. If you suspect carpal tunnel syndrome, you must differentiate whether or not

median nerve entrapment is occurring cervically (at level of cervical spine), at pronator teres (elbow), or carpal tunnel (wrist). Can differentiate by using EMG studies and compare results to normal nerve times.

2. Lateral epicondylitis or “Tennis elbow”

a. b. Characterized by:

i. Inflammation in the common extensor tendon (tendon origin of the extensor carpi radialis brevis muscle)

ii. The focal point of pain most likely near the lateral epicondyle of humerus c. Causes

i. Repetitive movement d. Treatment

i. Rest. Avoid activities that aggravate your elbow pain. ii. Pain relievers. Try over-the-counter pain relievers, such as ibuprofen

(Advil, Motrin IB) or naproxen (Aleve). iii. Ice. Apply ice or a cold pack for 15 minutes three to four times a day. iv. Technique. Make sure that you are using proper technique for your

activities and avoiding repetitive wrist motions.

3. Medial epicondylitis of “Golfer’s elbow” a. Symptoms

i. Pain and tenderness usually felt on the inner side of the elbow. The pain sometimes extends along the inner side of your forearm and is typically exacerbated by certain movements.

ii. Stiffness - The elbow may feel stiff, and making a fist might hurt. iii. Weakness - You may have weakness in your hands and wrists. iv. Numbness or tingling - These sensations might radiate into one or more

fingers — usually the ring and little fingers. b. Causes

i. Damage to the muscles and tendons that control the wrist and fingers, typically related to excess or repeated stress — especially forceful wrist and finger motions

ii. Improper lifting, throwing or hitting, as well as too little warmup or poor conditioning during racket sports, throwing sports, or weight training

iii. Forceful, repetitive occupational movements. These occur in fields such as construction, plumbing and carpentry

c. Prevention strategies: i. Strengthen your forearm muscles. Use light weights or squeeze a tennis

ball. Even simple exercises can help your muscles absorb the energy of sudden physical stress.

ii. Stretch before your activity. Walk or jog for a few minutes to warm up your muscles. Then do gentle stretches before you begin your game.

iii. Fix your form. Whatever your sport, ask an instructor to check your form to avoid overload on muscles.

iv. Use the right equipment. If you're using older golfing irons, consider upgrading to lighter graphite clubs. If you play tennis, make sure your racket fits you. A racket with a small grip or a heavy head may increase the risk of elbow problems.

v. Lift properly. When lifting anything — including free weights — keep your wrist rigid and stable to reduce the force to your elbow.

vi. Know when to rest. Try not to overuse your elbow. At the first sign of elbow pain, take a break.

d. Therapy Interventions: i. Rest. Put your golf game or other repetitive activities on hold until the pain

is gone. If you return to activity too soon, you can worsen your condition. ii. Ice the affected area. Apply ice packs to your elbow for 15 to 20 minutes

at a time, three to four times a day for several days. To protect your skin, wrap the ice packs in a thin towel. It might help to massage your inner elbow with ice for five minutes at a time, two to three times a day.

iii. Use a brace. Your doctor might recommend that you wear a counterforce brace to reduce tendon and muscle strain.

iv. Stretch and strengthen the affected area. Progressive loading of the tendon with specific strength training exercises has been shown to be especially effective.

v. Gradually return to your usual activities. When your pain is gone, practice the arm motions of your sport or activity. Review your golf or tennis swing with an instructor to ensure that your technique is correct, and make adjustments if needed.

4. DeQuervain’s tenosynovitis

a. A painful condition affecting the tendons on the thumb side of your wrist. b. Symptoms:

i. Pain when you turn your wrist, grasp anything or make a fist. ii. Pain near the base of your thumb iii. Swelling near the base of your thumb iv. Difficulty moving your thumb and wrist when you're doing something that

involves grasping or pinching v. A "sticking" or "stop-and-go" sensation in your thumb when moving it vi. If the condition goes too long without treatment, the pain may spread

further into your thumb, back into your forearm or both. Pinching, grasping and other movements of your thumb and wrist aggravate the pain.

c. Causes: i. The exact cause is unknown ii. Exacerbated by repetitive hand or wrist movement — such as working in

the garden, playing golf or racket sports, or lifting your baby. (Repeating

a particular motion day after day may irritate the carpal tunnel, causing thickening and swelling that restricts their movement.)

iii. Direct injury to your wrist or tendon; scar tissue can restrict movement of the tendons

iv. Inflammatory arthritis, such as rheumatoid arthritis d. Diagnosis

i. Examine the hand - Does the patient report pain when pressure is applied to the thumb side of the wrist?

ii. Finkelstein test - Test in which you bend your thumb across the palm of your hand and bend your fingers down over your thumb. Then you bend your wrist toward your little finger. If this causes pain on the thumb side of your wrist, you likely have de Quervain's tenosynovitis.

iii. Imaging tests, such as X-rays, generally aren't needed to diagnose de Quervain's tenosynovitis.

e. Treatment i. Medical doctor may:

1. Recommend using over-the-counter pain relievers, such as ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve) to reduce pain & swelling

2. Recommend injections of corticosteroid medications into the tendon sheath to reduce swelling

ii. PT/OT treatment may include: 1. Use of a splint or brace such as a thumb spica splint to immobilize

the thumb and wrist and to help rest the irritated tendons

2. Avoiding repetitive thumb movements as much as possible 3. Avoiding pinching with your thumb when moving your wrist from

side to side 4. Applying ice to the affected area 5. Compensatory strategies such as modifying utensils & tools to

reduce strain on wrist 6. Recommendation of ergonomic work setup to reduce strain on

wrist 7. Suggestions on how to make adjustments to relieve stress on your

wrists 8. Gentle exercises for the wrist, hand and arm to strengthen your

muscles, reduce pain and limit tendon irritation. 9. Tendon gliding exercises

5. Saturday night palsy

6. Carpal tunnel syndrome

a. Entrapment or compression of the median nerve in the carpal tunnel b. Can cause numbness, tingling, pain, and weakness in the wrist & hand c. Often occurs as a result of repetitive motions like typing or writing d. The recurrent branch of the median nerve innervates the thenar compartment of

the hand, including flexor pollicis brevis, abductor pollicis brevis, and opponens pollicis. So, if the median nerve was compressed, all of these muscles might be affected.

e. The dorsal interossei, palmar interossei, and opponens digiti minimi are all muscles of the hand which are innervated by the deep branch of the ulnar nerve.

f. Flexor pollicis longus is innervated by the median nerve, but it is a forearm muscle which is proximal to the carpal tunnel. Therefore, it would not be affected by compressing the median nerve in the carpal tunnel.

g. h. Treated with outpatient surgery to decompress the median nerve by cutting the

ligament at the bottom of the wrist to release pressure. Your hand and wrist may be bandaged for seven to 10 days. Often the bandage stays in place until you visit the clinic for removal of the stiches. You may or may not experience immediate relief, as the area will be sore following surgery. That will improve over time. Pain medication will be provided before you go home. It is recommended that you rest and elevate your hand and wrist, as well as limiting their use.

i. PT/OT Assessments

● Must assess where sensory symptoms are reported → Location of sensory symptoms will match dermatomes of specific nerve

● If you are trying to differentiate whether the issue is more myotomal (relating to spinal root) versus distal nerve, we can assess finger flexion strength

● Tinel Sign & Phalen Sign YouTube video ● Assess which digits display weakness:

○ Weakness in Digits 2 & 3 finger flexion = stemming from MEDIAN NERVE ○ Weakness in Digits 4 & 5 finger flexion = stemming from ULNAR NERVE ○ Weakness in ALL digits or digits 2-4 = stemming from NERVE ROOT

● Upper Limb Tension Tests (ULTT)

(https://www.physio-pedia.com/Neurodynamic_Assessment) ○ Also known as Brachial Plexus Tension or Elvey Test ○ Designed to put stress on neurological structures of upper limb

○ The shoulder, elbow, forearm, wrist and fingers are kept in specific position to put stress on particular nerve (nerve bias) and further modification in position of each joint is done as "sensitiser". The ULTT's are equivalent to the straight leg raise designed for the lumbar spine.

○ Purpose: ■ These tension tests are performed to check the peripheral nerve

compression or as a part of neurodynamic assessment. ■ The main reason for using a ULTT is to check cervical radiculopathy. ■ These tests are both diagnostic and therapeutic. ■ Once the diagnosis of cervical radiculopathy is made the tests are done to

mobilise the entrapped nerve. ○ Method

■ Each test is done on the normal/asymptomatic side first. Traditionally for the upper limb, the order of joint positioning is shoulder followed by forearm, wrist, fingers, and lastly elbow. Each joint positioning component is added until the pain is provoked or symptoms are reproduced. To further sensitive the upper limb tests, side flexion of cervical spine can be added[4]. If pain is provoked in the very initial position, then there is no need to add further sensitisers.

■ If pain or sensations of tingling or numbness are experienced at any stage during movement into the test position or during addition of sensitisation manoeuvres, particularly reproduction of neck, shoulder or arm symptoms, the test is positive; this confirms a degree of mechanical interference affecting neural structures.

■ Upper Limb Tension Test 1 (ULTT1, Median nerve bias) 1. Shoulder girdle depression 2. Shoulder abduction 3. Shoulder external rotation 4. Forearm Supination 5. Wrist and Finger extension 6. Elbow extension 7. Cervical side flexion

■ Upper Limb Tension Test 2A (ULTT2A, Median nerve bias) 1. Shoulder girdle depression 2. Elbow extension 3. Lateral rotation of the whole arm 4. Wrist, finger and thumb extension

■ Upper Limb Tension Test 2B (ULTT2B, Radial nerve bias) 1. Shoulder girdle depression 2. Elbow extension 3. Medial rotation of the whole arm 4. Wrist, finger and thumb flexion

■ Upper Limb Tension Test 3 (ULTT3, Ulnar nerve bias) 1. Shoulder girdle depression

2. Shoulder abduction 3. Shoulder external rotation 4. Wrist and Finger extension 5. Elbow flexion 6. Shoulder abduction

■ Musculocutaneous Nerve Tension Test (ULTT musculocutaneous) 1. Shoulder girdle depression 2. Elbow extension 3. Shoulder extension 4. Ulnar deviation of the wrist with thumb flexion 5. Either medial or lateral rotation of the arm could further sensitize

this nerve ■

● Fine Motor Coordination Tests ● DASH / QuickDASH

○ The Disabilities of the Arm, Shoulder and Hand (DASH) is a 30-item self-report questionnaire that looks at the ability of a patient to perform certain upper extremity activities. Patients can rate difficulty and interference with daily life on a 5 point Likert scale.

○ The QuickDASH is an abbreviated version of the original DASH outcome measure (11 items compared to 30) that measures an individual’s ability to complete tasks, absorb forces, and severity of symptoms using a 5-point Likert scale from which the patient can select an appropriate number corresponding to his/her severity/function level

● Modified Ashworth Scale of Spasticity (Bohannon & Smith, 1987) ○ 0: “Slight increase in muscle tone with a “catch” when the limb is moved ○ 1: Slight increase in muscle tone, manifested by minimal resistance at the end of

the ROM when the affected part is moved in flexion or extension ○ 1+: Light increase in muscle tone, manifested by catch, followed by minimal

resistance throughout the remainder (less than half) of the ROM ○ 2: More marked increase in muscle tone,but the limb is easily flexed ○ 3: Considerable increase in muscle tone ○ 4: Rigid in flexion or extension

Interventions

● Most treatment of peripheral nerve problems are geared to reduce or eliminate symptoms.

● Nonsurgical treatments include medications, immobilization and physical therapy ● Surgical treatment may be needed if the individual has persistent neurologic symptoms

or if conservative therapies have been unsuccessful. Physical Agent Modalities (PAMs): If the underlying reasons for the decreased ROM are scar tissue or pain, PAMs such as US or heat (hot pack, parrafin bath) may be indicated

● Should be used as an ADJUNCT to therapy → NOT the sole intervention

● Examples (W&S) P.664 ○ Superficial heat (hot packs, heating pads, paraffin wax, fluidotherapy, whirlpool)

■ Indiciations: ● Prior to active exercise, passive stretching, and joint mobilization ● Before traction and soft tissue mobilization ● Reduce joint pain and muscle spasms ● AFTER acute inflammation to promote tissue healing via cellular

activity ■ Contraindications

● Decreased circulation ● Decreased sensibility ● Open wounds or recently healed burns ● Signfiicant areas of edema ● Over tissue during acute inflammation

○ Deep heat US ■ Indiciations:

● Soft tissue tightness ● Subacute and chronic inflammation (i.e. tendinitis) ● Bone fracture ● Wound healing

■ Contraindications ● Do not use over or near eyes or ears ● Do not use near heart ● Do not use near pregnant uterus ● Do not use near testes, ● Do not use near known or expected malignant tumor ● Do not use near pacemaker ● Do not use near joint replacements, metal implants, insensate

areas ○ Therapeutic Cold (cold packs, cold baths, & ice massage)

■ Indiciations: ● Minimize acute inflammation ● Reduce edem & bleeding ● Reduce spasticity

■ Contraindications ● Temperature sensation deficits ● Circulation deficits ● Altered cardiorespiratory status ● Cold hypersensitivity such as Raynaud’s phenomenon

■ Evidence for Effectiveness ○ Contrast baths

■ Indiciations: ● Promotes tissue healing

■ Contraindications:

● PVD ● Loss of sensation ● Pregnancy ● Cold hypersensitivity such as Raynaud’s phenomenon

■ Precautions: ● Cardiovascular problems such as fluctuations in BP may occur

■ Evidence for Effectiveness ○ Electrotherapy iontophoresis

■ Indiciations: ● Modulate pain ● Decrease inflammation (i.e. bursitis, tendinitis) ● Reduce edema

■ Contraindications ● Do not use over eyes or ears ● Do not use over chest of person with cardiovascular disease ● Do not use over pregnant uterus ● Do not use over wounds or skin breaks ● Do not use over known or expected malignant tumor ● Do not use over pacemaker ● Do not use over blood vessels susceptible to hemorrhage,

thrombus, or embolus ● Do not use over insensate areas

■ Evidence for Effectiveness Splints - “Splints and orthotics are external devices that are applies to the body to immobilize, restrain, or support injured tissues; align or correct deformities; and improve function (Anderson, Anderson, & Ganze, 1998; O’Toole, 1997). W&S p.663

● May be used to: ○ Support healing ○ Reduce stress on joints such as wrist support splints for CTS and arthritis pain.

Thumb splints may be indicated for CMC arthritis or deQuervain’s tendinitis ○ Align or correct deformities, for example ulnar deviation splints can be used for

clients with RA ● Examples

○ Wrist Cock-up ■ Carpal tunnel syndrome ■ Radial nerve palsy ■ Tenosynovitis/tendinitis ■ Wrist fractures ■ RA ■ OA ■ Reflex sympathetic dystrophy (RSD)

○ Resting splint ■ RA

■ Traumatic injuries: crush, contusion ■ Burns ■ Tendon injuries ■ Stroke ■ SCI ■ CNS disease & injury ■ Post-op dupuytrens ■ Infections

○ Thumb spica splint ■ DeQuervain’s syndrome ■ Degenerative arthritis / basilar joint arthritis ■ RA ■ Thumb sprains ■ Median nerve injuries

Basic Anatomical and Biomechanical Considerations when Making a Splint:

● Preserve palmar arches ● Use hand creases and landmarks for splint design and molding ● Maintain antideformity position ● Properly position and tighten straps to allow blood flow or venous return ● Properly contour splints ● Avoid or minimize pressure over bony prominences ● Allow motion out of the splint when possible

(Reprinted from Emerson, S., & Shafer A. (2003). Splinting and orthotics. In E.B. Crepeau, E.S. Cohn, & B.A.B. Schell (Eds). Willard & Spackman’s Occupational Therapy (10th ed. pp677). Baltimore: Lippincott Williams & Wilkins) HEPs

● Must consider COMPLIANCE --. Therapists should make sure clients and families understand the exercises and should provide them with written or picture instructions.

● ROM ○ Full ROM is typically not achieved during everyday tasks; therefore, individuals

who have ROM deficits may need passive, active assistive, or active ROM exercises.

○ For a person who has undergone surgery or has been in a cast because of a fracture, the decrease in joint motion is due to temporary immobilization and is probably amenable to change. For this person, a more aggressive therapy using a PAM (i.e. hot pack) along with activities or exercise would be indicated to improve motion

Compensatory Strategies ● “Other compensatory approaches to treat strength and endurance impairments might

consist of using lighter-weight tools, using electric appliances, and client education regarding joint protection, energy conservation, and work simplification

● Posture a. Rounded shoulders / stooped posture causes shortening of anterior muscles.

Tight pectoralis and scalenes muscles can cause pressure on brachial plexus. ● Joint Protection principles (W&S p.668)

a. Respect pain - If pain persists for >2 hr after performing an activity, modify it by spending less time on it, using adaptive equipment, or resting during an activity

b. Use proper body mechanics and use joints in good alignment ■ Lean forward to put weight over feet and use armrests on chairs to come

to standing position ■ Use the palms of your hands on the armrests to push up to standing ■ Push or pull on objects rather than lifting ■ Avoid bending, reaching, and twisting.

c. Avoid holding one position for a long time and prolonged repetitive motions ■ Alternate sitting & standing during an activity, or shift around ■ Relax & stretch the hands every 5 minutes when doing an activity that

requires holding objects or tools such as holding cards, pencils, telephone, knitting or crochet needles, garden, kitchen, or hand tools

■ Avoid kneeling to scrub the floor or to garden; instead, sit on a stool and use longer-handled tools

d. Avoid positions and stress that cause deformity ■ Avoid pressures along the lateral (thumb) side of the fingers that

encourage ulnar deviation such as turning keys, doorknobs, or screwdrivers

■ Avoid pressure against the back of the fingers and wrist, such as propping the chin on the back of the hand

■ Avoid excessive and constant pressure against the pad of the thumb ■ Avoid positions of ulnar deviation of the wrist, such as cutting with

scissors or cutting with knives e. Use the larger and strongest muscles & joints

■ Carry a briefcase or purse over one or both shoulders instead of holding it with the fingers

■ Use the palm of the hands to lift pots and pans, or slide them along the counter/table

■ Lift objects using your legs instead of your back muscles f. Balance rest & activity

■ Exercise & activity are important for joint mobility & strength, but leisure and work should be balanced with periods of rest

g. Never begin an activity that cannot be stopped immediately if needed. ■ Preplan and pace activities ■ Try to slide, push, or pull objects rather than lifting

● Energy Conservation strategies

a. Plan ahead ■ Gather all items needed before an activity ■ Spread heavy/strenuous and light tasks throughout the day/week rather

than scheduling heavy tasks back to back ■ Schedule more energy-demanding tasks earlier in the day ■ Schedule small rest breaks into your day

b. Pace yourself ■ Build in frequent small rest breaks before, during, and after each task ■ Break activities into smaller units that can be done over a number of days ■ Pace yourself while doing activities - do not rush

c. Prioritize ■ Decide which activities are important to be completed and ones that can

be completed later or eliminated ■ Delegate tasks to other family members of friends

d. Use efficient positioning ■ Sit when possible (use a seat in the shower instead of standing, sit on the

bed or a chair to get dressed, consider a high stool to sit on while doing dishes)

■ Maintain good posture ● Avoid a prolonged stooped posture ● Avoid excessive reaching and bending by pre-arranging work

centers to be an appropriate height and keeping frequently-used items at comfortable heights

e. Use work simplification techniques ■ Eliminate unnecessary tasks (i.e. buy permanent-press clothes, precut

vegetables) ■ Work in a well-lit, ventilated environment