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Therapy Considerations for the Radial Nerve

Sybil Hedrick, OTR/L, CHT, CSCSAugust 23, 2014

sybil.hedrick@providence.org

Radial Nerve Innervation

EtiologyTrauma Internal Forces External Forces Other

Laceration Radial Tunnel Syndrome*b/t head of radius and supinatorWartenberg Syndrome

Tourniquet Ischemia

Gunshot Wound

Synovitis “Crutch Palsy” Traction

Fracture/Dislocation*mid/distal 1/3 of humerus

TumorCallus

Saturday Night Palsy

X-radiation

Electrical Injury

InjectionThe 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

Weakness/paralysis of: Tricep Aconeous Brachioradialis All the muscles distal to

brachioradialis

“Wrist Drop” Rests in a position of: Forearm pronation Wrist flexion Thumb flexion &

abduction Slight MCP flexion IP extension (some flexion

if flexors are tight)

Unable to: Extend wrist/fingers Abduct/extend thumb

Muscle Loss: Distal Humerus

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

Cannot reach out with open hand to obtain objects

No stability at wrist for stable prehension

Difficult to write, type

Pre-Operative TherapyAnd/Or Conservative

Management

Prevent deformity

Maintain tissue pliability

Promote neural regeneration and reorganization

Maintain function

Objectives

Radial Nerve Palsy often recovers spontaneously and will often not be rushed into tendon/nerve transfers so conservative management is key

Pre-Operative TherapyAnd/Or Conservative

Management

Evaluation History

Sympathetic Function

Sensibility (tho not of a huge concern with radial nerve)

Motor Function ROM: active and passive Manual Muscle Testing

Be aware of substitution patterns

Dexterity

Splinting for Function

Goal to maximize current functional use of the hand/UE

Goal to harness wrist motion while allowing full finger flexion/extension

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

Improved functional dexterity

Lower profile

Easier to get on/off for patient

Can use Delta Cast or Thermoplastic

Instructions for thermoplastic version can be found @ pattersonmedical.com search for Extension Assist Splint

Splinting to Prevent or Correct Deformity

Keep deneravated muscles from resting in an overstretched position

Prevent joint contractures

Enhance returning muscle function instead of allowing substitution patterns

Adaptations/Modifications

Cold intolerance frequently accompanies peripheral nerve injuries (PNI): neoprene mittens, gloves

Interventions: After Splinting

Modalities: Heat NMES

Nerve glides

Manual work

Home program

Repeated assessment to assist tracking of nerve recovery

Strengthening Gravity eliminated Aquatic therapy Progressive resistance

(PRE)

Preparation for Tendon Transfer

Ideal, full if possible, PROM at joints which will be involved

Idea, full if possible, AROM as well

Proximal muscle strength should be at least 4/5 or better

The muscle to be transferred should have strength at least 4/5 or better

Motor Learning & Cortical Re-Mapping

Motor Learning

Motor Leaning aptitude should be assessed on the non-involved limb

Acquisition

Retention (consistency)

Transfer (flexibility)

Efficiency

Cortical Re-Mapping

Post-Operative TherapyRadial Nerve Tendon Transfer

Psychosocial Issues: client roles, motivation and compliance, cognition, past and current abilities/interests

Diminished success from transfer surgery can result with: Denial Frustration Lack of trust in therapy program Finances Time

Must work closely with patient and Physician to eliminate and/or minimize or ease these factors

Post-Operative TherapyRadial Nerve Tendon Transfers

Pronator Teres to the ECRB for wrist extension

Palmaris Longus to rerouted EPL for thumb extension (if no PL, FDS (IV))

FCR to EDC for finger extension (sometimes FCU is used)

emedicine.medscape.com

Tendon Transfer Precautions

Common complications from tendon transfer include: Excessive radial deviation

at the wrist Bowstringing of transferred

tendons (EPL in particular) Incomplete extension of 1

or more fingers Incomplete finger flexion

with simultaneous wrist flexion

Complete Rupture Tendon adhesion

Therapist can play a key role in preventing some of these issues: Careful monitoring of

active motion, retrain movement patterns

Gradual progression out of splint

Ensure tendon gliding Education, education,

education every visit on stage of healing, phase of rehab

Post-Operative TherapyRadial Nerve Tendon Transfers

Phase Goal Method

1 (weeks 0-3)Immobilization

Protect repair site Good fitting orthosis positioned per physician/therapist to minimize tension at wrist, fingers, thumbEnsure 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 non-involved joints

ShoulderPIP and DIP of fingersLegs/core

Post-Operative TherapyRadial Nerve Tendon Transfers

Splint picture

Splint out of surgery: ultimately depends on your surgeon! Sources vary between surgical and therapy resources. Usually 2-3 weeks

Elbow included, held in a position of pronation

wrist 30-50 deg of extension and 10-15 deg of UD

MCP’s at 0deg or 0-15 deg of flexion, finger IP’s free

Thumb fully abducted with IP in full extension

Post-Operative TherapyRadial Nerve Tendon Transfers

Phase Goal Method

2Weeks3-6

ActivationOf the transfer

Regain AROM & maintain PROM

Elbow extension and flexionProtected: supination, wrist flexion, finger flexion, thumb adduction/flexionPronation, wrist extension, finger extension, thumb abduction/extensionPROM, myofascial release, scar massage

Activation of tendon transfer

Muscle retraining:Pronation for wrist extensionWrist flexion for finger extensionPalm 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 feedbackIn clinic and with basic ADL tasks at home

Motor Re-Education

Start with both the original motion combined with new motion

Start in gravity eliminated position and/or place and hold

Some resources say to use the opposite limb, however the wiring is now different??

Slow, short session at a non-extreme force

Tips for specifics:

Wrist extension Resist pronation to help

facilitate wrist ext

Finger extension Resist wrist flexion to help

facilitate finger ext Caution to NOT flex forcefully

past neutral as this can stress the repair site

Thumb abduction/extension

Post-Operative TherapyRadial Nerve Tendon Transfers

Phase Goal Method

3Weeks6-12

Improve strength Usual suspects: weights, therabandHammer, Dynaflex*

Strengthening& return to priorfunction

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 improvementNeeds for further surgical consult/issuesLong-term adaptive equipment/techniques

Ther Ex Pearls

Hammer Dynaflex

The Cube

Post-Operative Therapy Nerve Transfer for Radial Nerve

Paralysis Pre-operatively: Therapist should work on motor retraining

using contralateral arm and normal movement patterns

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

Post-operative pain management

Edema control

Immobilization 7-10 days

Early ROM Shoulder, trunk 3-4 weeks: elbow, forearm, wrist and hand

Motor Re-Education

Must learn to coordinate new pathways for target muscle activation

Cortical command is now different and new

Motor reeducation with tasks that are normal for elbow flexion are instituted to relearn: normal movement

patterns muscle recruitment reestablish muscle

balance

1st: wrist/finger extension and thumb abduction muscle “contraction” combined with contraction from donor nerve: FDS, FCR, PL

Want most synergistic action based on original motor pattern

Bimanual tasks

Strengthening

Utilize reinnervated muscle physiology and biomechanics 1) short duration exercise sessions (<5-10min)

Slow onset contractions begin in mid-range (place and hold) or gravity

eliminated 2) Multi-angle isometrics 3) Concentric strengthening 4) Eccentric strengthening