Physiotherapy Management in Peripheral nerve & Plexus injuries

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Dr Sreeraj S R, Ph.D.

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Sreeraj S R
Peripheral Nerve
• The dorsal and the ventral nerve roots arising from the spinal cord come
together and join at the level of intervertebral foramina to form the spinal
nerves.
• There are 31 pairs of spinal nerves – 8 cervical, 12 thoracic, 5 lumbar, 5 sacral
and 1 coccygeal each representing a segment of a spinal cord.
• The 19 spinal nerves (8 cervical, 5 lumbar, 5 sacral and 1 coccygeal) are
instrumental in forming four plexuses.
• Each spinal nerve has three components – sympathetic, motor and sensory.
• The sympathetic components of all the 31 spinal nerves leave along 14 motor
roots (12 thoracic and 2 lumbar).

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Sreeraj S R
Plexuses
• The cervical plexus is formed by the anterior rami of the upper
four cervical nerves.
• The brachial plexus is formed by the anterior rami of the lower
four cervical nerves and the upper thoracic nerves.
• The lumbar plexus is formed by the anterior rami of the lumbar
nerve.
• The sacral plexus is formed by the fifth lumbar and part of the
fourth sacral nerve.

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Sreeraj S R
Transverse section of a PN
https://tinyurl.com/y7dy4b5p

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Sreeraj S R
Classification of PN injuries
Sunderland
Classification
Seddon
Classification
Process Recovery
First-degree Neurapraxia Myelin injury or ischemia Excellent
recovery in
weeks to
months
Second-degree Axonotmesis Axon severed, Endoneurium, Perineurium and
Epineurium intact
Good to poor
Third-degree --- Axon severed, endoneurium not intact,
perineurium fascial arrangement preserved
Good to poor
Fourth-degree --- Axon, endoneurium, perineurium-fascicle
discontinuity, epineurium intact
Poor
Fifth-degree Neurotmesis Discontinuity of entire nerve No
spontaneous
recovery

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Mechanisms of Nerve Injury
• Nerve injury can occur acutely or chronically owing to the
following.
• Compression (pressure)
• Ischemia (hypoxia)
• Traction (stretch, angulation)
• Friction

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Nerve Degeneration
• Within 72 hours following
injury, the part of the nerve
distal to the site of injury
undergoes secondary or
Wallerian degeneration and is
destroyed by phagocytosis.
• Whereas the proximal end of
the injured nerve undergoes
primary or retrograde
degeneration for a single node
of Ranvier
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Nerve Regeneration
• Regeneration begins within 24 h of injury at the proximal end of the injured
nerve only if the endoneurial tube filled with Schwann cells is intact; the
axonal sprouts readily pass across the site of injury (termed as motor march).
• The rate of nerve regeneration is 1 mm per day.
• When the endoneurial tube is not intact, the many growing sprouts from the
axonal stump migrate aimlessly into the epineurium, perineurium and into the
adjacent area to form end neuroma – or neuroma in continuity.
• When the proximal end of the nerve is widely separated from the distal end, it
may result in the formation of an end neuroma.
• When the nerve has suffered only a partial cut, it results in the formation of a
side neuroma

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Assessment of PN Injury
• Collect the demographic information, chief complain, HOPI
• Observation
• Attitude of the part (presence of wrist drop, claw hand etc)
• Wasting,
• Trophic changes in the skin (indicates either prolonged
inactivity or involvement of fiber in the peripheral nerve
regulating autonomic function),
• Pilomotor response
• Oedema.

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Assessment of PN Injury
• Examination
• Sensory evaluation along the cutaneous distribution of that
peripheral nerve not dermatomically.
• Reflexes: The deep and superficial reflexes should be checked
only if the nerve or its muscular supply are involved in the reflex
arc.
• Tone: In PNI the patient has hypotonicity or atonicity.
• MMT: Individual MMT is to be done and trick movements to be
noticed in patient with weakness or paralysis.

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Assessment of PN Injury
• Sweat Function Test for involvement of autonomous function in PNI. There are four
types of sweat function test that may be used commonly.
• The Q-Sweat (Quantitative Sweat Measurement System) quantifies human skin sweat
output via a closed chamber that is affixed to the skin and displays the data in real time
in an easy-to read, Windows based graphical user interface.
• Ninhydrin Test: Ninhydrin powder changes its color when sprayed over the skin. If the
color does not change then it means the area does not have sweat function.
• Chinizarin Start Test: Dust over the skin mixture of quinizarin sodium, sodium
carbonate and rice starch. The powder will change its color when comes in contact
with sweat.
• Galvanic Skin Resistance Test: if the resistance offered by skin surface is more than
the other areas in the body then it can be interpreted that there is sweat dysfunction.
• (To stimulate sweating the patient may be given an atmosphere that will stimulate
sweat reaction).

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Assessment of PN Injury
• Investigations
• SDC should be done periodically. It may show a normal
response till Wallerian degeneration is complete but later will
show signs of denervation.
• EMG should be done and will show a typical neurogenic
presentation.
• NCV will show decreased conduction velocity across the
lesion, but proper interpretation is necessary to differentiate
between neurapraxia, axonotmesis and neurotmesis.

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Assessment of PN Injury
• Tinel’s sign: Elicited from below upward.
Advancing along the anatomical distribution of
the nerve, particularly at the expected rate of
nerve regeneration – e/o ongoing regeneration

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Axillary nerve (C5,6) injury
• Causes :
• Dislocation of shoulder
• # of surgical neck of humerus
• IM injection high in the post. aspect of the shoulder
• After sleeping in a prone position with the arm raised above the
head
• S/S:
• Loss of sensation over the “regimental badge” area
• Flattening of the shoulder
• Deltoid muscle weakness

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Axillary nerve injury
• Muscles examined:
• Extension Lag Sign: Elevate the patient's arm to near full
extension. Ask the patient to actively maintain that position. A
positive sign is the drop of patient's arm.
• The drop sign is a lag sign beginning from 900 abduction in the
scapular plane, with elbow flexion of 900, and external rotation
of the shoulder to 900. From this position, the patient is asked
to maintain the position against gravity. Failure to resist gravity
and internal rotation of the arm is considered a positive drop
sign for teres minor weakness.

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Musculocutaneous nerve (C5,6,7) injury
• Causes:
• Usually along with Brachial Plexus Injury
• Proximal humerus #
• Shoulder dislocations
• Carpet carrier's palsy
• S/S:
• Weakness of elbow flexion
• Weakness of supination
• Loss of sensation at lateral border of forearm

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Radial nerve (C5,6,7,8,T1) Injury
• Cause:
• Most common site of injury
is Spiral Groove
• IM injection in Triceps
• Saturday night palsy
• Crutch paralysis
• # Shaft of humerus
• S/S:
• Paresis or paralysis of
extension of the elbow
• Paresis of supination of
forearm
• Wrist drop
• Sensory loss over a narrow
strip on back of forearm and
on the lateral side of dorsum
of hand
• Hypo or areflexia of triceps
and brachioradialis jerk

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Radial nerve Injury
• Muscles examined:
• Triceps: Extend the elbow against resistance applied by the examiner, whose other hand
feels for triceps contraction.
• Brachioradialis: Flex the elbow against resistance from 900 onwards, keeping the forearm
midprone, the brachioradialis stands out, and can be felt.
• Wrist extensors: The patient with paralysed wrist extensors has ‘wrist drop'. In paresis, the
contraction of the ECR and ECU muscle can be felt, though actual movement may not
occur.
• ED: Extension at the metacarpo-phalangeal joints (finger drop). Trick movement is 'extend
the fingers' at the inter-phalangeal joints (function performed by the lumbricals).
• EPL: Extension at the inter-phalangeal joint of the thumb. Stabilize the MCP joint of the
thumb, while the patient is asked to extend the IP joint.
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Ulnar Nerve (C7,8,T1) injury
• Causes:
• Ulnar nerve entrapment at the cubital tunnel behind the elbow
and Guyon’s canal in the wrist.
• # of medial condyle
• Associated with anaesthesia
• S/S:
• Radial deviation of wrist on flexion
• Claw-hand deformity
• Paresthesia and sensory loss of skin overlying the Hypothenar
eminence and medial 1½ finger up to the nail beds
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Ulnar Nerve injury
• Muscles examined:
• FCU: Palmar flex the wrist against gravity, the hand deviates towards the radial
side. On performing the same test against resistance, the tendon cannot be felt.
• Abd. DM: Abduct the little finger against resistance while keeping the hand flat on
the table.
• Interossei: These can be tested as follows:
• Egawa's Test for dorsal interossei (abductors) of the middle finger. With the
hand kept flat on a table palmar surface down, the patient is asked to move his
middle finger sideways.
• Card Test: This is for palmar interossei (adductors) of the fingers. The examiner
inserts a card between two extended fingers and the patient is asked to hold it
as tightly as possible while the examiner tries to pull the card out.

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Ulnar Nerve injury
• Muscles examined:
• Adductor pollicis:
• Froment's sign or the 'book test: The patient is asked to grasp a
book between the thumb and index finger.
• Normal response: a person will grasp the book firmly with thumb
extended.
• If the adductor pollicis is paralysed, the patient will hold the book
with flexion at the inter-phalangeal joint of the thumb by using the
flexor pollicis longus (supplied by median nerve) in place of the
adductor pollicis.

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Median nerve (C5,6,7,8,T1) injury
• Causes
• Crutch compression
• Sleep paralysis
• Penetrating trauma
• Shoulder dislocation
• Supracondylar fracture of the humerus.
• Entrapment at the elbow between the two heads of pronator teres
(pronator teres syndrome) and under the flexor retinaculum (carpal tunnel
syndrome)
• chemotherapy-induced neuropathy
• S/S:
• Atrophy of the thenar
eminence
• Simian or ape hand
• Benediction hand
Benediction hand

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Median nerve injury
• Muscles examined:
• FPL: The patient is asked to flex the terminal phalanx of the thumb
against resistance while the proximal phalanx is kept steady by the
examiner.
• FDS & lateral half of FDP: If the patient is asked to clasp his hand, the
index finger will remain straight, called 'pointing index’.
Because the available medial-half of the
FDP (supplied by the ulnar nerve) makes
flexion of the other fingers possible.

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Median nerve injury
• Muscles examined:
• FCR: The wrist deviates to the ulnar side while palmar flexion occurs and
cannot feel the tendon of the FCR getting taut.
• Muscles of the thenar eminence: Two muscles can be tested.
I. Abd. PB: With hand flat on the table with palm facing the ceiling, a pen
is held above the thumb and the patient is asked to touch the pen with
tip of his thumb. This is called the ‘pen test’;
II. Opponens pollicis: The function of this muscle is to appose the tip of
the thumb to other fingers. Apposition is a swinging movement of the
thumb across the palm and not a simple adduction. The latter
movement is by the adductor pollicis muscle supplied by the ulnar
nerve.

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Sciatic nerve (L4,5,S1,2,3) injury
• Complete lesion is rare
• Causes:
• Fracture dislocation of the
hip
• Apophyseal avulsion
fracture
• Hip joint surgery
• IM injection
• Gunshot wounds
• Femur fracture
• S/S:
• Flail foot
• Wasting of the hamstrings
and all muscles below the
knee
• Decrease or absence of the
Achilles reflex
• High step gait
• Peroneal division > tibial
division (75% of cases)

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Common peroneal nerve (L4,5,S1,2) injury
• Common site of injury is at the level of the fibular head
• Causes:
• Trauma
• During anaesthesia or coma
• Prolonged cross legs positions
• Over tight or ill-fitting plaster casts applied for leg fractures
• Anterior tarsal tunnel syndrome causing compression or entrapment of the
deep peroneal nerve.
• S/S:
• Foot drop
• Sensory disturbance over the entire dorsum of the foot and toes and the
lateral distal portion of the lower leg
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Tibial nerve (L4,5,S1,2,3) injury
• Causes:
• Trauma - Dislocation of the
knee
• Tarsal tunnel syndrome
• Space occupying lesion
• Laceration injury
• Posterior dislocation of the
knee
• Nerve entrapment in soleus
arch
• Fractures of the tibia
and fibula.
• S/S:
• Variable paralysis of plantar
flexion of the foot and toes
• Numbness of the heel and part
of the sole
• Lateral side of the foot and
posterior aspect of the leg
• weakness of the intrinsic
muscles of the foot

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Femoral nerve (L2,3,4) injury
• Causes:
• Injured by a stab, gunshot wounds
• A pelvic fracture.
• Hip operations, particularly the
anterior approach where the nerve
can be stretched and damaged.
• A catheter placed into the femoral
artery in the groin
• Diabetes
• Internal bleeding in the pelvis or
abdomen area
• Prolonged lithotomy position
during surgery or diagnostic
procedures
• S/S:
• Inability to extend the leg
• Patellar reflex depressed or absent
• Decreased sensation, numbness,
tingling, burning, or pain in the
thigh, knee, or leg,
• Weakness of the knee or leg,
• Difficulty using stairs, especially
down, with a feeling of the knee
giving way or buckling

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Typical deformities PNI
• Wrist drop: Radial nerve injury.
• Claw hand: ulnar nerve injury.
• Ape thumb: Median nerve injury.
• Winging of scapula: Thoracodorsal nerve injury.
• Pointing index: Median nerve injury.
• Foot drop: Peroneal, Sciatic nerve injury

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Physiotherapy Management in PNI
• Stage of Paralysis
• This phase usually lasts for 2-3 weeks.
• Measures to reduce pain: TENS, splinting
• Measures to control inflammation and edema
• Keep the affected limb elevated.
• Active and passive exercises to the affected and unaffected joints.
• Measures to prevent contractures:
• The affected extremities are splinted in their respective functional positions.
• When applied on an anesthetic area, repeated checks are needed to ensure pressure
sores do not develop.
• Exercises regimen :
• For the unaffected extremity, active and active-assistive ROM exercises.
• For the affected joints, full range passive movements are prescribed.
• Measures to prevent joint stiffness:
• passive stretching of the affected joints

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Physiotherapy Management in PNI
• To maintain the properties of the muscle using interrupted galvanic current. This will
ensure a proper blood supply as well as help in maintenance of excitation, contraction
and coupling.
• To maintain joint range of motion PROM for flexibility of the joints and muscles. Can
also be maintained by gentle sustained stretch.
• To prevent any abnormal attitude of the affected part Splinting in functional position.
• To maintain the skin texture in patients with trophic skin changes. The affected area
should be kept supple by applying some moisturizer or oil so that skin breakdown can
be prevented.
• Care of Anesthetic Hand or Foot by inspecting regularly for some wounds, or skin color
changes. In case of any wound immediate antiseptic precaution should be taken. Ask
patient to avoid extreme temperatures. Protective gloves may be used for hand to
prevent injury by sharp objects. Soft shoes, preferably with toe windows may be worn
to protect the foot.

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Physiotherapy Management in PNI
• Post paralytic Stage innervation has started, and the muscle begins to show
active contraction.
• Continue Stage of Paralysis protocol.
• Measures to re-educate the motor functions:
• Once the MMT grade improves or if the SDC is showing signs of
innervations then faradic reeducation can be given to the muscle.
• The patient is asked to put in voluntary effort along with the current.
• Periodic electro diagnostic tests is of importance. If no response is seen
after 18 months to 2 years, surgery is indicated.
• The PNF techniques are found to be effective in promoting early recovery.
• As the affected muscle regains its voluntary contractions, synergistic
action returns earlier than the antagonistic actions.

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Physiotherapy Management in PNI
• Biofeedback helps the patient to understand the outcome of his
effort and thus can motivate the patient to contribute more. This can
be combined with Faradic Re-education
• Strengthening: Once the muscle power has reached MMT grade 2
then strengthening exercises can be started in gravity eliminated
plane or inclined plane till the power reaches 3. Once the muscle
power reaches grade 3 then resisted exercises can be given manually
or with springs, pulleys, hydrotherapy etc.
• Functional Retraining is essential to incorporate functional activity
such as various gripping activities and for lower limbs activities like
level walking, staircase climbing etc.

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Physiotherapy Management in PNI
• Delayed Stage
• After a period of 18 months, the chances of improvement
are drastically reduced.
• Such a situation warrants surgery either in the form of
nerve repairs or tendon transfers.

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Physiotherapy after nerve repair
• During the first 3 weeks, measures to control pain, inflammation and limb edema by
TENS, icing, elevation, etc. are followed. The unaffected joints could be put through
vigorous active movements. Electrical stimulation aids in faster healing and recovery.
• After 3 weeks, gentle active exercises, relaxed passive and accessory passive
movements to its full range, exercising due care and caution to prevent excessive
stretch on the sutured nerve, is carried out.
• After 8 weeks, the functional activities and the progressive resistive exercises are
made more vigorous. The latter needs suitable alterations of the splint. Scar adhesions
due to surgery could be prevented by deep frictional massage. A satisfactory return to
function can be expected after 10-12 weeks.

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Physiotherapy after tendon transfer
• Emphasis is on retraining or re-education of the transferred tendon in assuming its new
role.
• Train the patient to practice the expected movements in the normal contra lateral
hand. After the transfer, the patient is put on the following physiotherapy protocol.
• Full range passive exercises.
• Active assisted and active movements.
• Progressive resistive exercises.
• Electrical stimulation by low faradic currents, and EMG biofeedback.
• Passive stretching of the part.
• Proper dynamic splints to assist the tendon in its new role.
• Additional measures like hydrotherapy, thermotherapy and deep ultrasound
massage to prevent tendon adhesions and improve its stretch ability.

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Brachial Plexus Injuries
• Brachial plexus injuries can be due to :
• Birth injury due to faulty forceps application.
• Bike injury by fall on the shoulder
• Traction injuries
• Tumour removal
• Abnormal pressures due to faculty postures
• Post irradiation scenario
• Surgical excision of cervical ribs
• Shoulder dislocations.
[Common traumatic mechanism of injury is a combination of depression of the
shoulder and forced lateral flexion of the neck due to traction among the nerves]
Bad prognosis most of the times.

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Brachial Plexus Injuries
• Rules of Seven 70’s
• Narakas AO (1987), a pioneer in brachial plexus surgery, outlined
the Rules of Seven 70's:
• 70% of brachial plexus injuries are due to road traffic accidents
• 70% of these involved motorbikes
• 70% have multiple injuries
• 70% are supraclavicular injuries
• 70% of these have at least 1 root avulsion
• 70% of root avulsion involve the lower plexus
• 70% of root avulsions will leave the patient with chronic pain

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Brachial Plexus Injuries
• Types
• Closed: the injury could be due to birth trauma or bike
trauma as mentioned above.
• Open: Rare, could be due to penetrating or gunshot
injuries

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Brachial Plexus Injuries
• Chuang’s Brachial plexus levels of
injury:
1. Level 1 Preganglionic root injury
2. Level 2 Postganglionic spinal
nerve injury
3. Level 3 Pre-and retro clavicular
injury (trunks and divisions
injury)
4. Level 4 Infraclavicular injury
(cords and terminal branches
injury)
https://peripheralnerve.org/meeting/abstracts/2017/31.cgi

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Types of Brachial Plexus Injuries
Types of brachial plexus injuries
Supraclavicular Infraclavicular
Preganglionic Postganglionic
Homer’s syndrome
Complete Partial
Nerve roots from C5 - T1 torn
C5, C6 root C8 -T roots
Erb's palsy Klumpke’s palsy

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Assessment of Brachial Plexus Injury
• In preganglionic lesions
• Horner’s syndrome is present.
• Patient is unable to elevate the scapula (due to disruption in the
nerve supply to the Rhomboids and Lev. scapulae)
• In postganglionic lesions
• No Horner’s syndrome.
• Patient can elevate the scapula.
• Tinel’s sign is present in the later stages. (Tapping above the
clavicle, produces tingling sensation in the anesthetic limb).

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Horner’s syndrome
• What constitutes a Horner’s syndrome? (All P’s)
• Ptosis of the eyelid.
• Pupils which are small and constricted.
• Protrusion of the eyeball which is slight.
• Pain even at rest.
• Positive sensory action potentials.
• Poor prognosis.

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Treatment for BPI
• During the initial stages
• Splinting
• For complete paralysis A flail arm splint (FAS) designed by
Framton is advised.
• For incomplete lesions here splints with necessary modifications
as per the situations can be used.
• For pain control, TENS is best suited.
• To prevent contractures and deformities, a careful passive ROM
exercises under suitable guidance is recommended.

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Treatment for BPI
• During the later stages
• Measures to strengthen the muscles: If there are movements, efforts are made to
strengthen the muscles by repeated self-resistive exercises, PNF techniques, etc.
• Re-education of the muscles: This is done by encouraging movements of th
shoulder, percutaneous electrical stimulation, stimulating techniques like icing,
etc.
• Modifying the splints and dynamising it helps.
• TENS to control pain
• After 2 years, reconstructive surgeries are planned for the residual paralysis and
deformities.

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Treatment for BPI
• Surgical Measures
• Acute phases: Suture or nerve grafting can be considered in postganglionic lesions. But not
helpful in preganglionic lesions.
• Late stages (> 2 years): Reconstructive surgeries are planned after 2 years when the
recovery can no longer take place.
• Surgeries are planned according to the residual paralysis.
• For shoulder function Trapezius transfer to the neck of the humerus to improve abduction is
advised.
• Arthrodesis of the shoulder is done in functional position.
• For elbow function Steindler’s flexorplasty (transfer of Latissmus dorsi or pectoralis major to
biceps.
• For wrist and finger extension After the surgery, patient is put on a detailed regime for
reeducating the transplanted muscle.

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https://nerveclinic.co.uk/nerve-conditions/upper-limb/brachial-plexus-injuries