PERIPHERAL NERVE

BRACHIAL PLEXUS LESION

Brachial plexus is a complex structure originating from C5-T1 nerve roots. Trauma : most common cause of brachial plexopathy. Closed injuries typically produce injury due to traction on the plexus, such as after a fall.

ERB PALSY

In injuries that cause head & shoulder to be stretch apart such as in newborn deliveries or falls on shoulder, result in upper trunk plexopathies with involvement of C5-C6-C7

erb palsy.

Waiters tip deformity : Shoulder : adduction, internal rotation Elbow : extention, supination Wrist : flexion

KLUMPKE PALSY

Injury in which there is forceful upward traction on arm, result in lower trunk plexopathies affect C8-T1 fibers klumpke palsy.
Clinical presentation : hand weakness

DIAGNOSE

Anamnesa : Trauma ?
Physical Exam. : MMT Sensory Reflexes Supporting Exam. : NCV / EMG MRI (tumor ?)

TREATMENT

Positioning ROM exercise Strengthening exercise Orthoses : shoulder sling, splint Electro Stimulation : MMT < 3

CARPAL TUNNEL SYNDROME

Contents of carpal tunnel include : -Median nerve. -Flexor pollicis longus -Four tendons each from flexor digitorum superficialis & profundus muscles.
Swelling or increased pressure inside carpal tunnel lead to compression of median nerve, producing symptoms of CTS

Clinical presentation

Paresthesias (numbness, tingling, and burning) involving median nerve distribution (first 3

digits).

Deep aching pain in hand & wrist. Pain will radiate info forearm, even rarely to shoulder. Patient might report subjective swelling of hand but on inspection, no swelling is usually apparent. Nocturnal worsening of symptoms is common

Clinical presentation

Flick sign : patient often report awakening with hand paresthesias, which are then relieved by shaking involved hand.
Advance CTS : sensory symptoms last longer or become persistent, & thenar weakness develops.

CTS is often associated with repetitive hand & wrist movements or the use of vibrating machine. The great majority of cases are idiopathic in origin. Predispose / risk factor : -DM -RA -Amyloidosis -Obesity -Hypothyroidism -Pregnancy

PHYSICAL EXAMINATION

Abnormality in median sensory testing. MMT is more advance cases show weakness and atrophy of Abductor Pollicis Brevis & Opponens Pollicis Muscles. Provocative test : Tinels sign, Phalens sign, Prayer sign Flick sign Supporting examination : NCV / EMG

TREATMENT

ROM exercise Strengthening exercise Nocturnal wrist splint : hold the wrist in 030 of extension. USD / Phonoporeses / Laser Medication : NSAID, Corticosteroid injection

POLIOMYELITIS

is a viral infection involving the anterior horn cells (LMN), producing weakness in affected bulbar and/or spinal myotomes.
Clinical presentation : -Initial symptoms : fever, malaise, headache, gastrointestinal or upper respiratory track symptoms. -Weakness was typically asymmetric, more common in the lower extremities

Patient with history of polio infection may develop fatigue and worsening muscle weakness severe years or even decades after initial infection.

POST POLIO SYNDROME

Criteria for establishing a diagnosis : Confirmed history of paralitic polio Partial to fairly complete neurologic & functional recovery Periode of neurologic & functional stability for at least 15 years. No other medical explanation for the newhealth problems

Onset of 2 or more of following symptoms since achieving stability : -Unaccustomed fatique. -New weakness in muscle previously affected

and/or unaffected

-Muscle and/or joint pain -Functional loss -Cold intolerance -New atrophy

TREATMENT

ROM exercise Strengthening exercise Endurance exercise

Orthoses : HKAFO

BELLS PALSY

idiophatic peripheral fascial nerve paralysis. Risk factor : -DM -Hyperacusis -HT -Lack of lacrimalis -Pregnancy -Schizophrenia

TREATMENT

Acute (day of 0-4) : HEP : warm compress, fascial massage.

HE : sunglasses, Y-plester

Day of > 4 : -SWD / Laser -ES

HERNIATED NUCLEUS PULSOSUS

A disk injury in which the nuclear pulposus migrates through the annular fibers. A higher prevalence occurs for the lumbar region at the L4-L5 or L5-S1 followed by the C5-C6 disc.

CLASSIFICATION

Buldging disc Prolapsed disc Extruded disc Sequestered disc

ETIOLOGY

Spontaneous Lifting activities Coughting / sneezing Bending / twisting activity

CLINICAL PRESENTATION

Acute neck or back discomfort radiating down the upper or lower limb
Weakness, numbness, paresthesias or pain secondary to chemical or mechanical stimuli to the disc or nerve root. Exacerbation occurs with lumbar motion (forward flexion, extention), sitting, sneezing, coughing, valsava manuver

DIAGNOSTIC STUDY

X rays MRI Myelography

TREATMENT

Acute : relative rest Diathermi : MWD, SWD, USD Laser TENS Traction : cervical, lumbal Orthoses : Lumbar corset

HEP : William Flexion Exercise

LEPROSY (HANSENS DISEASES)

Etiology : Mycobacterium Leprae Onset : Immune status dependent Clinical presentation : -Most common world-wide neuropathy -Sensory abnormality -Drop hand, drop foot -Fascial palsy

SIGN OF LEPROSY

A slowly growing patch on the skin that does not itch or hurt

Tingling numbness, or some loss of feeling in the hand & feet. Or definite loss of feeling in

skin patches. Slight weakness or deformity in hand & feet Enlargement of certain nerves, with or without pain or tenderness.

DIAGNOSE

Definite loss or change of feeling in skin patches. Definite enlargement of nerves. Presence of leprosy bacilli in a skin smear

TREATMENT

Long term medical treatment : to control the leprosy infection as early as possible Dapsone, Rifampisin, Clofazimine. Emergency treatment (when necessary to control) & prevent further damage (from leprosy reaction). Safety measures, aids, exercise, & education to prevent deformities (sores, burns, injuries, contractures). Social Rehabilitation. Work with individual, parent, schools, & community to create a better understanding of leprosy, to lessen peoples fear, & to increase acceptance, so child & adult with leprosy can lead a full, happy, meaningful life

REHABILITATION OF LEPROSY

ROM exercise Stretching exercise Strengthening exercise ES Orthesa : Knuckle bender, dorsal spring HEP : Soaking-Oiling-Scrapping HE : sunglasses, glove, shoes/sandal

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