Rehabilitation Following Brachial Plexopathy “Stingers”

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DON’T JUST RECOVER. CONQUER. Rehabilitation Following Brachial Plexopathy “Stingers” Scott Kaylor, PT, DPT, SCS Proaxis Therapy

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Rehabilitation Following Brachial Plexopathy “Stingers” . Scott Kaylor, PT, DPT, SCS Proaxis Therapy. Acknowledgements. Timothy McHenry III, MD Whitney Wiles, ATC Matthew Baird, MD Tom Denninger, PT, DPT, OCS, FAAOMPT Chuck Thigpen, PhD, PT, ATC. Objectives. - PowerPoint PPT Presentation

Transcript of Rehabilitation Following Brachial Plexopathy “Stingers”

Page 1: Rehabilitation Following Brachial Plexopathy “Stingers”

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Rehabilitation Following Brachial Plexopathy“Stingers”

Scott Kaylor, PT, DPT, SCSProaxis Therapy

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Acknowledgements

➔ Timothy McHenry III, MD➔ Whitney Wiles, ATC➔ Matthew Baird, MD➔ Tom Denninger, PT, DPT, OCS, FAAOMPT➔ Chuck Thigpen, PhD, PT, ATC

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Objectives

➔ To identify the prevalence of brachial plexopathy.

➔ To identify the anatomy involved with brachial plexopathy injury.

➔ To describe an evidence-based return-to-play progression that is criteria driven.

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Prevalence and Incidence

➔ Common in contact and collision sports.➔ Reported annual incidence of a stinger is

between 49-65% in collegiate-level football players over a 4-year career

➔ Recurrence rate 57%➔ 5-10% of players have more serious injuries

with prolonged neurological deficits

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Common➔ Unilateral UE involvement ➔ A traumatic event ➔ Painful sensation that

radiates from their neck to their finger tips

➔ Lancinating, burning pain, and dysesthesia usually in a dermatomal pattern.

➔ Weakness/”dead arm”

Red Flags➔ Bilateral symptoms or symptoms

into more than one limb. o Suspect spinal cord

involvement➔ If the player remains on the “field

of play” the possibility of a spinal cord injury must be considered and ruled out before he is allowed to walk.

Signs and Symptoms

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➔ Pain typically seconds to hours.o Rarely beyond 24-hours

➔ May experience weakness in deltoid and supra/infraspinatus that typically resolves in 24-hours to 6 weeks.

Symptom Duration

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➔ Grade Io neurapraxia

➔ Grade IIo axonotmesis

➔ Grade IIIo neurotmesis

Injury Grading

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ManagementPhase I Phase 2 Phase 3 Phase 4

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Phase I Rehabilitation

➔ Pain control➔ Restore cervical ROM➔ Initial muscle facilitation

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➔ Manual Therapyo Tractiono Joint mobilizationo Soft tissue mobilization

➔ Modalitieso Tractiono E-stim

Phase I Rehabilitation

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➔ 1st Rib Mobilizationo Elevated 1st rib due to scalene spasmo Assess with cervical rotation lateral flexion test

Phase I Rehabilitation

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➔ Supported chin tuckso With biofeedback

Phase I Exercise Examples

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➔ Neural Dynamicso Sliders vs. tensioners to increase excursiono Do NOT want to increase strain during healing

Phase I Rehabilitation

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➔ Cervical ROM o Adjust and progress positioning

Phase I Rehabilitation

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➔ Full cervical ROM➔ Resolution of upper extremity symptoms

o Not necessarily full resolution of strength➔ Be able to maintain a supine chin tuck for 30

seconds

Criteria to Begin Phase II

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Phase II Rehabilitation

➔ Improve shoulder mobility as needed➔ Improve muscular endurance➔ Incorporate extremity movements with

stabilization.

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➔ Shoulder mobility

Phase II Rehabilitation

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➔ Quadruped and prone chin tucks➔ Cervical stabilization with extremity movements

o “No Money” o Dying bug

➔ Half kneel chop and lift➔ Upper extremity exercises

o Bandso PNFo Isotonics

Phase II Exercise Examples

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➔ Shoulder Strengthening

Phase II Exercise Examples

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➔ Half Kneel Chop and Lift

Phase II Exercise Examples

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➔ Be able to hold chin tuck with head lift (without helmet) for 30 seconds

➔ > 4/5 upper extremity strength to be able to perform light-to-moderate upper extremity strengthening without symptoms

Criteria to Begin Phase III

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Phase III Rehabilitation

➔ Improve muscular strength➔ Implement sport specific activities without

contact

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➔ Cervical Strengthening➔ Participation in weight lifting with team

Phase III Exercise Examples

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➔ Criteria to begin phase IVo Be able to maintain a chin tuck with head lift

wearing a helmet > 30 secondso No symptoms o Full upper extremity strength

Phase IV Rehabilitation

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➔ Phase IVo Initiate contact drills• Percussion to Erb’s Point• Spurling’s Test

o Return-to-play

Phase IV Rehabilitation

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Return to Play Criteria

➔ General RTP Criteria:o Adequate time to heal from primary injuryo Absence of underlying conditions that pose undue risk of

further injuryo Resolution of all symptomso Full, pain-free ROMo Appropriate cardiovascular fitnesso Normal strengtho Ability to perform sport-specific skills without symptoms

➔ Same game if complete resolution of symptoms, return-to-baseline ROM and strength profile.

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Slow-to-No Symptom Resolution

➔ Communication with and referral to team physician

➔ Further imagingo Radiographso MRIo CT scan or SPECT scan

➔ EMG study

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➔ Identifying those at risko Post-season questionnaire

➔ Proper tackling techniqueso Avoid dropping shouldero Continued eye contact with opposing player should

allow for more upright position➔ High riding shoulder pads to absorb impact➔ Protective neck rolls

o Prevent excessive lateral flexion & extension of necko NEVER connect straps from helmet to shoulder pads

Prevention

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➔ Brachial Neuropraxia Postseason Questionnaireo Clin J Sport Med. 2012; (22)6

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Key Points

➔ Stingers are common and history of stinger increases likelihood of sustaining subsequent stinger.

➔ Use criteria to drive rehabilitation progressions.➔ Do not return to play if have not returned to

baseline. ➔ Communication with sports medicine team is

important, particularly in the presence of slowly resolving symptoms.

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Thank you!

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References

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stingers. Curr Sports Med Rep. 2012 Jan-Feb;11(1):28-34.4. Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and

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