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Physical Therapy

• Physical and occupational therapy is critical to treating patients with peripheral nerve injuries.
• Ideally both pre-operative consultation with the therapist and post-surgical therapy take place.
• Conservative management options are available for appropriate patients with some types of nerve injuries.
Physical/occupational therapy helps with the following:
• Maintaining passive and active range of motion.
• Pain management.
• Motor reeducation with reinnervation, nerve or tendon transfers.
• Sensory reeducation with reinnervation or sensory nerve transfers.
• Wound, edema and scar management assistance.
• Prevent/treat pain syndromes related to musculoskeletal imbalances associated with lost/impaired muscle strength.  For example:
• Preventing upper trapezius overuse and strengthening lower trapezius function for improved scapular control with long thoracic nerve dysfunction or palsy (and resulting serratus anterior muscle dysfunction).
• Maintain retained function without allowing bad habits to develop.  For example:
• In a long thoracic nerve injury (resulting in loss of serratus anterior function), preventing overuse of upper trapezius muscle and the development of painful compensatory maneuvers.
• Optimize strength and function of both donor and indirectly involved muscles (in the case of nerve or tendon transfers).
• Instruct in adaptable strategies (teaching) for handedness retraining and ADL training with one-handed or assist extremity strategies.
• Provide devices to protect surgical repairs and tendon transfers, and to maximize function.  For example:
• Supportive braces for brachial plexus injury patient with painful humeral subluxation at the glenohumeral joint due to loss of deltoid function.
• Splints such as wrist cockup splint for better hand function in a patient with a radial nerve injury.
• Supportive splinting to keep muscles at the optimal length so they do not stretch out is important.  Maintaining optimal length allows maximal force to be generated once muscles are reinnervated.  For example, splinting the interphalangeal joint of the thumb in a bit of flexion in patients with anterior interosseous nerve palsy helps maximize flexor pollicis longus function once reinnervation occurs.
Specific description of the therapy for individual procedures is discussed in the corresponding Surgical Options section.

Overview for motor nerve transfer patients:
• If possible, pre-operatively, educate patients to some degree on the anticipated nerve transfers.
• Initially post-transfer, strengthen the “donor muscle” and encourage frequent contractions of the donor muscle(s)
• Repetitive motor co-contraction of donor and recipient muscles.  Early on this will require passive assist for the recipient muscle (with assisted, simultaneous passive movement of donor muscle early on).
• Work the recipient muscle in the gravity eliminated position initially.
• Also do ‘place and hold’ exercises early on.  This is where the therapist places the joint in the position of reinnervated function and ask the patient to try and hold the joint in that position as long as possible.  For example, with reinnervation of flexor pollicis longus, place the thumb interphalangeal joint in flexion and have the patient attempt to hold it in that position.
• Add resisted exercise to the contralateral (uninjured side) to encourage co-contraction of the donor and recipient muscles and increase muscle effort.
• Add resisted exercises late, after good movement against gravity is obtained, to avoid over-fatiguing the transfer and discouraging the patient.