HANDS/UE: treatments Flashcards
carpal tunnel syndrome
CONSERVATIVE: tendon/median nerve glides, digit ROM, stretching, activity modifications, ergonomics (workstation)
SPLINT: INITIAL: splint wrist neutral in -15 degrees extension, volar wrist splint w/wrist neutral (less pressure on carpal tunnel)- worn at night & during day
NIGHT: thermoplastic wrist cock up splint to hold wrist firmly in position
MODALITIES: TENS, fluidotherapy, iontophoresis (pain management)
POSTOP (carpal tunnel release): edema control (volumeter), AROM, nerve/tendon glides, sensory re-education, work/activity modification, ultrasound, scar sensitivity (expose to texture)
STRENGTHENING: 6 weeks post op
CONTRAINDICATIONS: avoid repetitive motion (extreme wrist flexion, wrist flexion with repetitive finger flexion, wrist flexion with static grip), vibration to volar wrist
cubital tunnel syndrome
CONSERVATIVE: activity/work modifications
SPLINT: elbow splint 30 deg flexion to decrease compression of the nerve (especially at night), elbow pad while leaning on elbows, long arm splint (don’t sleep on stomach, wear at night)
POSTOP (decompression or transposition): AROM/ulnar nerve glides 2 weeks post op, edema control, tendon glides
SPLINT: MCP flexion anti claw/blocking splint if there is clawing
STRENGTHENING: 4 weeks postop
CONTRAINDICATIONS: avoid movements/postures that aggravate symptoms
double crush injury
treat according to the nerve involved (EX: if the two syndromes involved are carpal tunnel syndrome & brachial plexus injury, treat each syndrome); follow MD orders
Guyan’s canal
CONSERVATIVE: work activity modifications
SPLINT: wrist splint with wrist neutral
POST OP (decompression): AROM, edema control, nerve glides, sensory re-education
STRENGTHENING: 2-4 weeks, focus on power grip
pronator teres syndrome
CONSERVATIVE: activity modifications, adaptations, pain control techniques
SPLINT: elbow splint 90 degrees w/FA NEUTRAL
POST OP (decompression): AROM, work/activity modifications, nerve glides, sensory re-education, work adaptations
STRENGTHENING: @ 2 weeks post op
CONTRAINDICATIONS: avoid repetitive FA pronation & supination
radial nerve palsy
CONSERVATIVE: nerve glides, ROM, strengthening wrist/finger extensors when motor function returns, work/activity modifications
SPLINTS: dynamic extension splint, thumb extension splint, Duran dorsal protection splint, volar splint with wrist NEUTRAL (could do wrist cock up but last option)
POSTOP (decompression): activity modifications, AROM/PROM, edema control, scar management, sensory & motor re-education
STRENGTHENING: 6-8 weeks postop or per protocol
CONTRAINDICATIONS: compression caused by fractures is usually treated surgically due to the risk of bony fragments lacerating the nerve. AVOID combined FA pronation, elbow extension, wrist flexion (can place tension on the nerve)
radial tunnel syndrome
CONSERVATIVE: activity modification, pain free ROM, nerve glides
SPLINT: long arm splint with wrist EXTENDED, elbow FLEXED, FA NEUTRAL ROTATION, could be wrist extension
MODALITIES: TENS or massage
POSTOP: active & passive FA pronation & supination, scar sensitivity, edema management
SPLINTS: long arm splint w/wrist EXTENDED, elbow FLEXED, FA NEUTRAL ROTATION for 2 weeks THEN wrist cock up for 2 more weeks
STRENGTHENING: hand @ 3 weeks
RESISTIVE EXERCISE: @ 6 weeks
CONTRAINDICATIONS: avoid forceful wrist extension & supination
thoracic outlet syndrome
CONSERVATIVE: muscle strengthening around cervical spine & scapula
SPLINT: wrist splints for postural retraining
MODALITIES: ultrasound & NMES to reduce inflammation
POSTOP: activity modification, AROM/PROM, edema control, muscular reeducation to compensate for removed muscles (if any), postural retraining, scar management
CONTRAINDICATIONS: avoid heavy lifting, working with arms overhead, direct WB on the shoulder
ape hand deformity
CONSERVATIVE: PROM, prolonged stretch to counteract deformity, Strengthening exercises to build atrophied muscles of the thenar eminence, hand and forearm
SPLINT: C-bar splint with thumb opposed & fingers in “C” position, thumb spica/short opponens splint
POSTOP: gentle AROM, tendon gliding, scar management techniques and soft tissue mobilization,
SPLINT: splinting per tendon transfer protocols
STRENGTHENING + PROM: 2 months post surgery
CONTRAINDICATIONS: No PROM or strengthening post surgery until authorized by MD (usually 2 months post surgery) per tendon transfer protocols. Strengthening too early can cause damage to the transferred tissues
brachial plexus injury
CONSERVATIVE: PROM/AROM, sensation retraining including techniques to reduce tactile sensitivity, neuromuscular re-education as motor function returns
SPLINT: flail arm splint (provides stability at shoulder/elbow for functional hand positioning)
POSTOP: edema control, PROM/AROM, neuromuscular re-education to help the patient learn to recruit muscles in a different way, may use biofeedback training, (Brachial plexus injuries may require several surgeries)
STRENGTHENING: @ 4-6 weeks
CONTRAINDICATIONS: ROM is important to keep affected limb mobile as recovery may take years
Erb’s palsy
CONSERVATIVE: PROM, contracture management
SPLINT: Elbow lock splint (stabilizes the elbow to enable the individual to position the hand closer to or away from his/her body for functional use)
POSTOP: edema control, scar management at surgical site, positioning
CONTRAINDICATIONS: monitor for subluxation of the shoulder, frozen shoulder, contractures
long thoracic nerve palsy
CONSERVATIVE: Pain management techniques, scapular mobilization
POSTOP: SLING, post-surgical management if surgical grafting is completed. If the long thoracic nerve is permanently damaged, scapulothoracic fusion surgery may be completed, in which the scapula is fused to the thorax for stability
median nerve injury
CONSERVATIVE:
SPLINT: static thenar web space splint
POSTOP: AROM and PROM in splint for digits and thumb, tendon gliding exercises, scar massage
SPLINT: Dorsal wrist blocking splint with wrist in 30 degrees flexion worn for 4-6 weeks, discontinue at 6 weeks
STRENGTHENING: @ 6 weeks
median nerve laceration
CONSERVATIVE: AROM/PROM, scar management, strengthening, sensory re-education
SPLINT: Dorsal protection splint (30° wrist flexion if low lesion, 90° elbow flexion at elbow if high), C-Bar splint to prevent thumb adduction contracture
POSTOP: AROM/PROM to digits, wrist flexed at 2 weeks post op, wrist AROM at 4 weeks (elbow included if high lesion), edema control, scar management, nerve gliding exercises, AROM, sensory re-education including treatment for tactile sensitivity (begins when client demonstrates level of diminished protective sensation), strengthening per post-op protocol
CONTRAINDICATIONS: Hypertrophic scarring may lead to compression of the median nerve and additional damage
median & ulnar nerve injury
CONSERVATIVE: AROM/PROM, scar management, strengthening, sensory re-educatioN
SPLINT: Figure of eight splint to prevent MP hyperextension or dynamic MCP flexion splint
POSTOP: edema control, scar management, nerve gliding exercises, AROM, sensory re-education including treatment for tactile sensitivity, strengthening per post-op protocol
radial nerve laceration
CONSERVATIVE: ROM, sensory re-education, home program, activity modification
SPLINT: dynamic extensor splint
POSTOP: edema control, AROM, scar management, nerve gliding exercises, sensory re-education including treatment for tactile sensitivity, strengthening per post-op protocol
SPLINT: Dynamic extension splint,
CONTRAINDICATIONS: Hypertrophic scarring may lead to compression of the radial nerve and additional damage
ulnar nerve injury (claw hand)
CONSERVATIVE: SLING for type 1 fractures or comfort if the client has pain and is nervous in public places
SPLINT: Ulnar nerve injury splint, dynamic/static splint to position MP’s in flexion, MCP dorsal blocking splint. If it is a low-level ulnar nerve injury, then a splint that prevents hyperextension of the MCP joints and allows MCP flexion
POSTOP: ROM is begun early, within 1 week if medically cleared, Edema control, scar management, sensory re-education, nerve gliding exercises, strengthening per post op protocol
SPLINT: for immobilization as needed, Dorsal protection splint with wrist in 30 degrees of flexion,
deQuervain’s tenosynovitis
CONSERVATIVE: activity/work/ergonomic adaptations to work station, patient education, strengthening exercises, ice over radial styloid, cross friction massage, gentle AROM of wrist/thumb to prevent stiffness
SPLINT: forearm based thumb spica/thumb spica splint with wrist in neutral and thumb radially abducted for 3 weeks (IP free). After 3 weeks, the client can progress to a soft splint and isometric exercises
POSTOP: gentle AROM @ 0-2 weeks, tendon gliding exercises, isometric strengthening exercises @ 2-6 weeks, scar management and desensitization techniques
SPLINT: thumb spica splint or splint with wrist in 20 degrees extension
STRENGTHENING: grip and pinch strengthening after 2 weeks (when cleared)
CONTRAINDICATIONS: for conservative treatment, avoid pinch during activities, avoid circumferential movement of the thumb
lateral epicondylitis
CONSERVATIVE: stretching, activity/work modification, strengthening (isometrics —> isotonics —> eccentrics), cross friction massage
SPLINT: Lateral epicondylitis brace (tennis elbow brace) which rests the muscle and tendon and protects against pain with activity, elbow strap, wrist splint
MODALITIES: ultrasound, ice/deep friction massage
POSTOP: edema control, modalities for circulation, AROM/PROM, activity modification, gentle strengthening per post op protocol
CONTRAINDICATIONS: control of edema and gradual increases in movement post surgery needed to prevent re-injury to affected area
medial epicondylitis
CONSERVATIVE: stretching, activity modification, strengthening (isometrics —> isotonics —> eccentrics (hand supinated on wedge, bring wrist up & put weight in hand then bring wrist down), cross friction massage
SPLINT: Medial epicondylitis brace (golfer’s elbow brace) which rests the muscle and tendon and protects against pain with activity, elbow strap, wrist splint
MODALITIES: ice/deep friction massage, ultrasound
POSTOP: edema control, modalities for circulation, gentle ROM once immobilizer is removed
SPLINT: elbow immobilizer 1-3 weeks post surgery
STRENGTHENING: of flexor and pronator muscles @ 6 weeks
CONTRAINDICATIONS: activity modification necessary to avoid re-injury while doing same types of activity
rotator cuff tendonitis
CONSERVATIVE: activity modification, educate in sleeping posture (avoid arm overhead), pain management (positioning, modalities, rest), Codman exercises/pendulum exercises, strengthening below shoulder level, role/occupational training
SPLINT: shoulder support sling or neoprene shoulder support cuff
POSTOP (arthroscopic surgery): Codman’s exercises (pendulum exercises) for 2 weeks post op, PROM (0-6 weeks) —> AAROM/AROM (6-8 weeks), decrease pain (ice —> heat), activity modifications, leisure/work activities (8-12 weeks postop)
SPLINT: shoulder immobilizer, sling/abduction orthotics to be worn between exercises
STRENGTHENING: @ 8-10 weeks: isometrics —> isotonics below shoulder
CONTRAINDICATIONS: no AROM for 6 weeks post surgery due to risk of injuring the affected areas, avoid above shoulder level activities until pain subsides (conservative), avoid sleeping with arm overhead or combined adduction/IR (conservative)