PT 602 - Lecture 4 -Treating Patients with Elbow, Wrist and Hand Pain

Lateral Glides of the Cervical Spine in the Management of Lateral Elbow Pain​

"neurodynamic technique"​ ​​ They have the painful arm bent (taking tension of radial and medial nerve- bc they would be taught if they were straight)​ -2 point reduction on the VAS which is clinically meaningful! (needs to be atleast a 2 point change in order for this to be significant)​ -they did radial nerve test, grip test, and PPT (pain pressure threshold)​ ​ Nb. Spontaneous pain = nerve related!​ Do techniques to create more space and blood for the nerve. This movement might help with flow of blood. We can start this group off in the unloaded position and then progress to a more loaded position and then maybe even a tensioner type position

DeQuervain's Teno DDx:

-Hypotheses to guide examination? •Intercarpal Instabilities •Scaphoid Fracture (direct trauma) •C6 Cervical Radiculopathy •Osteoarthritis of the 1st CMC (older individuals) -Examination? •What tests will rule in or rule out the hypotheses? Nb. Helps to differntiate b/w tendons/mms, nerves, and joint. Nb. If this came out of the blue/insidiously, you don't have to be worried about a scaphoid fracture. Nb. If they said they fell and landed on that regions + swelling you may want to send for imaging and be concerned with fractures

Managing Elbow Pain with RM: 57-year-old nurse with lateral elbow pain​

-Intermittent left elbow pain commenced for no apparent reason; present for 6 months and worsening​ -Most limited and painful with gripping movements that involved pronation and supination​ -Self referred, PMH unremarkable​ -UEFS = 68/80 (upper extrmeitiy functional scale-the higher the score the better they are doing)​ -Average NPRS = 6/10​ nb. These individulas often have intermittent sysmtpoms (come and go- and they also have a loss of ROM/obstruction to movement)​ >need to feel where R1 occurs compared to the other side​ ​ Elbow extension in unloaded position ->elbow extension in loaded position-> neural glides ​ ​ ​

Ligamentous Sprains of the Elbow​: -Name the different ligament sprain and their likelihoods -discuss the grades briefly.

-Ligament sprain and Instability​ >Medial (Ulnar) collateral ligament sprain​ >Radial (lateral) collateral ligament sprain​ ​ -Sprains often result from overuse injuries or from direct trauma​ >Grade 1 sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament.​ >Grade 2 sprain: Partial tearing of the ligament, may result in abnormal looseness (laxity).​ >Grade 3 sprain: Complete tear of the ligament​ nb. You don't see the radial side being sprained that often unless it was a relly severe injury. MORE typical to see an ulnar ligament sprain. ​

Managing Patients Following Ligamentous Sprains and Elbow Dislocations​ -outcomes? -c/o -non operative strategies to address instabilities include...? -what might not come back fully?

-Most elbow sprains and dislocations have a favorable outcome with most people returning to normal or near normal function​ -One of the most common complications following severe sprains and elbow dislocations is stiffness​ >Patients often don't regain full range of motion​ -Another complication is ligamentous instability (e.g. Posterolateral rotary instability (PLRI))​ >Non-operative strategies to address instability include​ >>Bracing​ >>Strengthening of the dynamic stabilizers at the elbow​ >>Analyze motion and strength at shoulder​ >>Analyze motions in the trunk and lower quarter​ nb. Full extension as well as supination tend to be the ROMs that don't necessarily always come back fully. ​

Complex Regional Pain Syndrome (RSD) -how does it relate to motor dysfunction (5)?

-Motor dysfunction •Motor weakness •Severe impairment of complex movements •Impairment of range of motion, initially by concomitant edema, later by contractures and fibroses •Neglect like symptoms have been found in some patients, described as the body part in question feeling foreign. Enhanced physiological tremor inaround 50%

Common Elbow Pathologies Presenting to PT​

-Non-specific Elbow Pain​ >Lateral epicondylitis, epicondylalgia​ >>"tennis elbow)​ >Medial elbow pain​ >>"Golfers elbow"​ -Specific injuries​ >Little league elbow​ >Ligament sprain​ >Strains/ruptures​ >Post-op: Fracture/dislocations​ >Nerve entrapments ​ nb. 90% Of people coming into the clinic for elbow pain will have lateral elbow pain. ​​​

The Effectiveness of Neural Mobilization for NMSK Conditions

-Not a lot of evidence to say that nerve mobilizations of the cubital tunnel was working. THAT DOESN'T MEAN WE SHOUDLNT DO IT, it just means that it lacks evidence. "2017 Systematic Review in JOSPT: Insufficient evidence for the use of NM in cubital tunnel syndrome at this time; evidence for lateral elbow pain is biased"

Little League Elbow​: - what is it? - how does it occur/what does it result in?

-Overuse injury in young thrower that includes​ >osteochondritis dissecans of the capitulum​ >>Osteochondritis dissecans is ischemic necrosis and partial detachment of a fragment of cartilage and underlying bone from the articular surface.​ >premature closure of the proximal radial epiphysis, overgrowth of the radial head​ >>medially stressed valgus overuse.​

CRPS: Phase 2 -name this phase - how long does it last? - what occurs here-be specific? - other

-Phase 2 •A phase of vasomotor instability that can last for several months. -This is the dystrophic stage, which lasts another 3-6 months. -Constricted blood vessels can cool limb temperature by nearly 10 degrees. -The area will be pale, mottled, edematous, and sweaty. Pain remains continuous, burning, or throbbing but is more severe. -Nails may crack or become brittle and heavily grooved. Limb movement is limited by muscle wasting and joint stiffness. Osteoporosis and contractures can develop.

57-year-old nurse with lateral elbow pain​: -what were the results?

-Re-evaluation 3 days later​ >Patient reported 65% better​ -Second re-evaluation in one week​ >All symptomatic and mechanical baselines improved​ >NPRS = 0/10​ >UEFS = 80/80​ >HEP = Continue with loading strategy twice daily for 2 months​ -Three-month follow-up (via phone)​ >One reoccurrence which the patient successfully managed on her own​ -One-year follow-up (via phone) ​ >Reoccurrence once every two to three months​ >Able to self-manage with exercise (2 to 3 sets of 10 reps) ​ ​

Complex Regional Pain Syndrome (RSD) -How does it relate to sensory disturbances (5)? - what increases pain (5)?

-Sensory disturbances (90%) typically in a glove or stocking-like distribution •Spontaneous pain occurs in 75%, usually burning or stinging •68% felt in deep structures •32% felt in skin •Sensory gain (Mechanical hyperalgesia, allodynia, ...) or sensory loss (hypaesthesia, hypalgesia, ...) may be present. Sharp dull tests help determine if youre making changes In their progress •Pain can be increased by orthostasis, anxiety, exercise or temperature changes. •In many cases, pain is more pronounced at night nb. Its not a peripheral nerve distribution, it is the WHOLE limb. At night, they don't like this because (nerves like blood, and during the night time we lay down flat, blood goes to the important structires as opposed to the periphery)

What phase is the most stress while pitching for little league elbow? How do we approach treatments?

-The most stress is in the late cocking and acceleration phases of pitching.​​ -Depending on severity of condition and acuteness, rest from throwing is necessary (potentially up to a year)​ -Treatment to focus on appropriate loading of tissues at the elbow​ -Address Mechanics ​ Prevention by following baseball guidelines for # of pitches​ >Preventative guidelines: no more than 50 pitches per game; no more than 6 innings per week; throw change-ups rather than curve balls, take 3 months off from throwing pitches during the year while growing; maintain overall arm conditioning.​ ​

General Considerations for Examining the Elbow, Wrist and Hand​ + extra info on them (5)

-Trauma (post surgical or immobilization)​ -Repetitive Stress Injuries​ -Neuropathies​ -OA​ -Systemic Disease​ nb. -OA is NOT seen in the elbow!!!! We see a ton of it in the hand (especially the thumb)​ ​ -Systemic Diseases:​ >Rheumatoid arhritis​ >Clubbing on the fingers d/t chronic low o2 saturation​ ​

Progression of Forces for Nerves

1.) You wouldn't wanna load that nerve, we have to find ways of offloading the n. to stop stimulating that response. Offloading the radial and median n it to bend the elbow, and even eleavte the shoulder a little bit. You could even put your hand on your head (limited tension on the upper trap and brachial plexus). General exercise would be like biking or walking or hiking, getting them walking while holding their arm in a specific position. Low intensity/long duration is good for the Active Rest group. This is bc the nerves need blood flow and we need to move the patients regardless in order to heal them in a timely fashion. If you do this well enough you can get a patient through this stage in just a week or 2, before you move into the second stage Note, if the patient has a radial n. issue and you do abduction in that radial test it will make it worse/ worsen the nerve symtpoms.

Manual therapy vs surgery for the treatment if CTS

3 visits of manual therapy produced a years worth of surgery treatment. Basically, both the surgery group and simple manual therapy were shown to be no statistically different by one year, but the MT group was better initially.

CRPS: Phase 3 -name this phase - how long does it last? - pain? - skin?

A cold end phase. -The atrophic stage is characterized by irreversible damage to muscles and joints. -Over the next 2-3 months the bones atrophy and the joints become weak, stiff, or even ankylosed. -The pain lessens and may become spasmodic or breakthrough but is no longer mediated by the sympathetic nervous system. -The skin is cool and looks glossy and pale or cyanotic.

Eccentric vs Concentric Exercise for Lateral Elbow Pain​: -what were the results?

Both groups improved function and quality of life; however, eccentric group saw quicker decreases in pain and increases in pain free grip strength​ 3 sets of 10 reps eccentric exercise Combined with static stretching better than TFM plus manipulation and Light Therapy​ nb. No loss of mobility at the elbow, neck has no influence on the sytmpoms, neurodynamic stuff doesn't produce elbow pain.... Means that your only option left is a motor production issue/strength/ tendon. ​ ​ Using eccentrics, loading slowly.​ Eccentric group got better quicker as opposed to just doing concentric. ​ >Dr. Brown would argue that It doesn't really matter ecc vs conc, as long as you do it slow (up 10 sec, down 10 secs)​

Spectrum of lateral elbow pain includes what 4 categories? -give info on them

Cervical Spine: ​ -No c/o neck pain, main c/o is elbow pain, however they don't describe any sort of activity that would explain their lateral elbow pain (they havent done anything repetitive to overload the elbow). You should start with a neuroscreen THEN look at the elbow (bc that's what the pt is complaining about-and we also NEED to get a basline of their elbow first) THEN look at the neck. ​ -Numbness tingling, burning, sharp, they do a little bit and have a large reaction after. And when a nerve is irritated it lingered/stayed for a while. ​ ​ Nerve: ​ -​Radial nerve can be sensitive ​ Mobility: ​ -Repetitive use. ​ -Could be d/t a fall​ -more problems with the humeroulnar joint and lateral elbow pain (anecdotally from Dr. Brown)​

Manipulation of the Cervical Spine in the Management of Lateral Elbow Pain​: Phase 1 vs Phase 2

Combine manual therapy with exercise together we do fairly well. MAKE SURE your examination demonstrates that the neck influences the elbow!!! You don't have to do manips to the neck, for some of these individuals it helps enough to just have them do retractions or other movements of the neck!.​ ​

Management Considerations for Nerve Entrapments: - what do we need to consider? - what are some nerve related facts??

Consider the following: •Did the patient respond to treatments aimed at the musculoskeletal interface (improve rom/ joint stuff/ mm stuff/ connective tissues around the nerve? -Yes à nerve is not the problem -No à focus more on the nerve (mobilize the nerves, use the neurodynamic tests to bias them) •Nerve tissue takes a long time to heal •Nerves like blood (20-25% of our blood volume) •Similar to tendinopathies the next day can tell you a lot about your treatment plan (we want to see how what we did effected their symptoms the next day. 24-48 hrs later). nb. Since the nerves are made of of collagen type of connective tissue (same as tendons), that's why they have a much slower healing capacity. Even though they have a lot of BF, they are made up of collagen type connective tissues and those just don't heal fast at all (especially compared to the bone and mm)

Super random flashcard: Discuss cubital tunnel syndromes prevalence? CTS prevalence? Discuss radial tunnel vs posterior interosseous syndrome

Cubital Tunnel syndrome second most common (Carpal tunnel syndrome is the #1) -If it is medial, your DDx typically starts with cubital tunnel. Radial tunnel is more sensory in nature, as opposed to posterior interosseous syndrome which was mostly motor related and not sensory related.

List the distal radioulnar joint fractures, and the carpal and metacarpal fractures associated w the wrist and hand

Distal Radioulnar joint fractures •Smith fracture •Colles fracture Carpal and Metacarpal fractures •Scaphoid fracture •Boxer's fracture •Bennet's fracture

DeQuervain's Tenosynovitis: Examination portion - History? - pain location?

Examination •History -Overuse injury vs. acute trauma, -Prior hx of signs and symptoms, -Repetitive movements of the UE with work or ADLs, -Pain localized over the base of thumb and dorsolateral aspect of the wrist near radial styloid process

Grades of Ligamentous Sprains Matched to Tx ​(CHART)

Grade 1 -people we wanna get them moving, they don't spend that long in therapy​ ​ Grade 2 - a good chunk of the ligament is loss bc of the injury. They DON'T have an instability, bc they still have a firm endfeel upon testing. Fair amt of loss of ROM. Working on getting extension back > flexion. They may have some weakness bc of the immobolization. ​ ​ Grade 3 - may see a dislocation and DEFINITLEY will see instabilities. They have a long course of care and will take a while to get better. They may not ever get all of the mobility back at the elbow following that injury. ​

Complex Regional Pain Syndrome (RSD) Interventions:

Intervention: Must be a team approach for the best outcomes. -Physical therapy is the first line of intervention •The earlier the intervention is instituted, the better the prognosis. Immobilization and overprotecting the affected limb may produce or exacerbate demineralization, vasomotor changes, edema, and trophic changes >Pain reduction >Recovery from muscle dysfunction, swelling, and joint stiffness requires appropriate physical activity and exercise, and pressure and motion are necessary to maintain joint movement and prevent stiffening. nb. You can get past this and gain a reasonable amt of function back if we do a multidisciplinary approach? This can really turn a person's life upside down/ quite debilitating. Early treatment is focused on desensitization, using lower reps and less exposure to pain.

What can we do to help patients with mild CTS? What can we do to help patients with moderate CTS? What can we do to help patients with severe CTS?

Lateral glides, mobiliziaiton, sliders... These are all things you can do to help with people who have mild CTS. If they are moderate, we may need to offload a little bit before we do the mobs, you may even be able to start on the opposite limb (depending on their level of irritabilitiy). If severe -> Surgery.

How can u treat DeQ Teno for a joint related problem (1)?

Manual Therapy •Patient self mobilized using distraction of the thumb combined with UD 10- 20 times every three hours •Symptoms abolished in three visit •Follow up in one year with similar wrist pain abolished with similar movement Nb. Distractions coupled with ulnar deviation changed the pts symtpoms, then they taught the patient how to do this on their own. This is a treatment for DeQ if pain in this region is due to the joint!! Not the tendons, and Not the nerves. -You would go this route if they had limited ROM of the wrist/ movements at the wrist changed their symtpoms. >if it was mm/tendon issue then ROM wouldn't have been limited.

How can u treat DeQ Teno for a joint related problem (2)?

Mob w movement We hold them below their ulnar styloid process/wrist, and we hold them at their carpal bones and we push into radial deviation as the ptient does Active flexion and extension. We do this technique in order to see that during the treatment they have a dec in their symtpom during the treatment, ROM improves, localization occurs >5-10 reps of this -these guys are the groups of people who tend to respond quickly.

Manipulation of the Wrist for UE Pain​: What was this study testing/ what were the results?

Mobilization of the distal radius and they just extend the wrist. It causes the radial head to move indirectly. They did this so that they wouldn't have to push on the tender spot in the elbow, while still producing the same effect. They are mobilizing at the base of the radius. ​ ​ ​ ​

Mobilization with Movement for Lateral Elbow Pain​ (Lateral glide while performing grip strength test​): What were the results of this study?

Mulligan technique​ ​ -Compared PT with corticosteroid injection (as well as a control wait and see group). They did a lateral glide while the pt squeezes.​ -8 sessions over 6 weeks then followed up w them over the course of a year. ​ -wait and see group AND PT group did better than the steroid injection group (in all stages of this study)​ >in other words, the injection only lasts for several weeks but never full address the issue which is why is lacks​ ​ ​

Complex Regional Pain Syndrome (RSD) -What is the diagnostic standardized tool for CRPS? >what is the name of this criteria? >elaborate on the specific aspects of the diagnostic standard?

No golden diagnostic standard has been developed yet, but included here are the Budapest criteria: •The following must be met -Continuing pain, which is disproportionate to any inciting event •Must report at least one symptom in three of the four following categories: 1.)Sensory: » reports of hypoesthesia and/or deep pain 2.)Vasomotor: » reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry 3.)Sudomotor/edema: » reports of edema and/or sweating changes and/or sweating asymmetry 4.)Motor/trophic: » reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

CRPS: Phase 1 -name the phase -how many days does it last? -what happens to the affected limb? -reversible or irreversible? -what does the pain look like? -what happens by the end of this stage?

Phase 1 •An acute inflammatory phase that can last from 10 days to 2-3 months. -The acute stage of CRPS lasts from 1 to 3 months. -This stage is reversible if the patient is treated. -The affected limb becomes flushed, warm, and dry because regional blood vessels are relaxed, and stimulation of the sweat glands is reduced. -The pain is diffuse, severe, and constant with a burning, throbbing, or aching quality. -Edema and increased hair and nail growth can also occur. -By the end of this stage, the limb turns cold, sweaty, and cyanotic from vasoconstriction caused by paradoxical sympathetic stimulation. nb. These phases go through progression over time. Key for CRPS is to get on this as early as you can

57-year-old nurse with lateral elbow pain​: -what did they do for a physical exam?

Physical Exam​ -Gripping reproduced lateral elbow pain​ -TTP over proximal wrist extensor tendon​ -Stretching of wrist extensors produces pain​ -Minimal loss of elbow flexion end-range pain; minimal loss of elbow extension no pain​ -Repeated movement with loaded elbow extension abolished patients resting pain and end-range pain during elbow flexion; Range of motion restored; pain with gripping decreased​ -HEP: 10 reps every 1 to 2 hours​ nb. If you have full ROM at the joint, then you likely will be dealing w a nerve or a mm. ​

What is the graded motor imagery approach and what is it used for?

Push to look at the central problems of this. Graded motor imagery= Using more top down interventions to interact w the NS to get under the radar so that we don't cause further aggravation to the NS. Using graded activity to encourage these people to become more active. >start off by just imagining movements/ not moving, then you can preserve their function until you can start introducing the mirror to help start reintegrating sensory input into the system and then motor input. You can use the opposite arm to do movements and your brain can pick it up and incorperate it for your other limb. This really can make a significant impact on their NS functions.

Michelle from Virtual Hand Care on youtube info

Sometimes having the pt just do different grips can help (pincer grip, chuck grip, pinch grip, etc). Sometimes just doing small flexions of the tips of the fingers, doing basic opposition, or doing basic lumbrical stuff. We could use putty and roll it out, or we could place the puddy b/w our thumb and index and pinch down. You could even use the putty like a band and do band resisteence into thumb extension.

List the Sprains, Nerve Entrapments, Tendon Injuries, and Other Conditions associated w the wrist and hand

Sprains •TFCC •One of the many ligaments in the hand Nerve Entrapments •Median nerve •Ulnar nerve Tendon Injuries •DeQuervain's Other Conditions •CRPS

Intervention strategies for elbow pain

Symtpom modulation = modalities group/ acute pain issues. They tend to be your rapid responders as well. ​ ​ The majority of lateral elbow pain is joint issues?? He said most people think its tendon, but he thinks its joint. ​ ​ ​

What does the research show regarding CTS and PT Interventions?

We don't do well w CTS. The only thing that has value is carpal tunnel release (They snip the retinaculum in the tunnel). The research in PT said that we don't really make a big dent in patients dealing w CTS. Anything beyond mild cases its almost as if patients should just get Sx as opposed to rehab. ****>>>>>> CTS is the one area where we don't really do that great outcome wise and we might j be adding to the cost of care despite the fact that we cant really help. In mild cases, PT can/may be effective, it gets to be a little bit questionable when we get to moderate or severe cases (in those cases they'll basically only benefit from Sx)>>>>>>>***** ----in a mild case you might be able to push off Sx for a while.

Yes/No With DeQ Teno, do we need to consider the Neck at all?

Yes You would still need to consider looking at the neck (moving the neck around) to see if it effects the peripheral pain at the wrist. Even if we this its DeQ (which is an overuse injury), we dont want to bottleneck our care yet so we still need to clear the fact that it might be a central issue instead.

What is the DASH important for

You can use the DASH from the shoulder all the way to the hand to test for functionality of those areas, and ALSO to test for cervical radiculopathies :(​ ​

DeQuervain's Tenosynovitis: - what kind of injury is it? - to what aspects of the hand/wrist? - primary c/o? - what is the pain described as? - what aggravates pain? - DDx?

•A Repetitive Stress Injury •Stenosing tenosynovitis, first dorsal compartment (APL, EPB) •The primary complaint is radial sided wrist pain that radiates up the forearm with grasping or extension of the thumb. •The pain has been described as a "constant aching, burning, pulling sensation." •Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand. Swelling in the anatomical snuff box, tenderness at the radial styloid process, decreased CMC abduction ROM of the 1st digit, palpable thickening of the extensor sheaths of the 1st dorsal compartment •DDx: Radial tunnel syndrome

Complex Regional Pain Syndrome (RSD) -what kind of disorder is it? - what are some of the SxS of it (5)?

•Autonomic and trophic disorders: -Distal Edema in 80% of the patients -Skin temperature changes at the affected body part in 80% of the patients, initially warmer and in 40% of patients gradually cools down until colder in comparison to the rest of the body as the disease progresses (may b 10 deg cooler than unnafected side) -In 40% of the patients skin at the affected body part starts showing redness, but becomes pale in later stages -In 55% altered sweating takes place, with hyperhydrosis (excess sweating) being more common than hypohydrosis. -Hair and nail growth possibly increase in early stages -Atrophy of skin and muscles in later stages, as well as contractures may severely restrict movement

Complex Regional Pain Syndrome (Aka Reflex Sympathetic Dystrophy/ RSD) - when does it occur MOST of the time? - what are 6 other reasons?

•CRPS is found to result: -After traumatic injury (65%) -1-2% of all fractures result in CRPS -Largest risk of CRPS for fractures of the wrist (7-35%) -After surgical intervention (19%) -Infection (4%) -Peripheral nerve injury (2-5%) -Prior inflammation (2%) -No clear cause (10-26%) nb. ANS disorder, brought on by trauma of some sort. This is an extremely challenging problem to deal with. This would be neurogenic inflammation here. This is the far end of the spectrum, peripheral neuropathic issue, but it leads to so many central problems. Highly excitable.

Lots of Choices for Patients with Limited Mobility and Force Production/Tolerance Following Fx Exercise therapy vs Manual therapy

•Exercise Therapy: -AAROM -AROM with OP in limited Direction >Play around with hold times (e.g. static versus intermittent loading) -Activation exercises >Following increase in range of motion >Isometric holds, PNF etc. (to fatigue) >RTC, Scapular mm, forearm, wrist hand •Manual Therapy: -PROM -Non-thrust Joint manipulations -Soft-tissue Mobilization •

Key points of the wrist/hand portion of the lecture?

•Injury to the wrist and hand complex is common •Causes of injury include trauma, repetitive overuse and systemic disease/infection •Most common conditions seen in PT include CTS (pre and post surgery) and OA of the thumb/hand, and post immobilization from wrist fracture •With traumatic injuries need to consider multiple tissues (e.g. TFCC)

Take Home Messages for the Elbow:

•Non-specific lateral elbow pain is most common complaint -Consider referred pain from C-Spine in the absence of MOI •Consider location of symptoms and MOI -Sprains/Fracture and dislocation occur most often following trauma -Elbow stiffness is one of the most common impairments following these injuries •Nerve entrapments can occur through repetitive overuse or trauma -Common entrapments involve the median and ulnar nerve (less radial nerve) •Regardless of the pathology, consider classification when developing a plan of care •

General Considerations for Post-Op/Immobilization Following Wrist/Hand Fracture:

•Patient education •Range of motion will be lacking (locally and proximally in some cases) -AAROM/PROM progress to AROM as tolerated -Joint mobilization -Soft tissue mobilization •Strength will be lacking Extrinsic mm -Intrinsic mm -Consider sub-max isometric if painful progress as tolerated •Consider Neural mobilization for persistent deficits in pain, ROM, strength •Gradual return to function incorporating ADL skill training prn nb. Just like before... What you do in the forearm, this will have no impact on the hand. We NEED to focus on intrinsic mms in the case of the hand.

Nerve Entrapments at the Elbow: -how are peripheral nerves typically injured? - what would they have difficulties performing? - what provokes their symptoms? -Nb!!!!!!!

•Peripheral nerves can be injured due to repetitive stress or acute trauma -Prolonged pressure or stretch -Sudden pressure or stretch •Difficulty performing tasks involving specific muscles that are weak or have decreased sensation. Pain with tasks that stretch nerves that are constricted. Repetitive activities may provoke symptoms Nb. Nerves are made up of more than just axons and sheaths. They have fasciles and bundles and vasculature and tissues that surround/ support the axons. Lots of connective tissue in there. So nerve pain can be d/t the nerve itself or d/t the connective tissue supporting the nerve. Nb. We don't always have to mobilize the NS in order to fix a nerve problem. We could work on the tissues or stiff joints etc.

Managing Patients Post-Op/Immobilization Following Elbow Fracture: - how does this effect ROM? - how does this effect strength? -in terms of healing, how does bone relate to mms relate to nerves?

•Range of motion will be lacking (locally and proximally in some cases) -Loss of ROM above and below that can affect how they move. •Strength will be lacking -Extrinsic -Intrinsic •Consider Neural Dysfunctions for persistent deficits in pain, ROM, strength (patient will likely report concurrent injury) •Gradual return to function over many months Nb.Work in the arthokinematic range of motion AND osteokinemetic gross range of motion. Nb. Balll squeezes work on muscles in the forearm and SHOULDN'T be used at all to increase strength of intrinsic hand mms. It wont help the intrinisc hand mms. Nb. Mm and bone heal a lot faster than the nerve.

Complex Regional Pain Syndrome (RSD) -Diagnosis info >A number of other conditions need to be ruled out before establishing a diagnosis of CRPS, and these include, but are not limited to the following (6):

•Rheumatoid and septic arthritis •Gout •Disk herniation •Peripheral neuropathy •Peripheral nerve entrapment •Peripheral vascular disease

Management of Elbow Fractures: - Supracondylar humeral fractures require? - Radial head fractures require? > > > >

•Supracondylar humeral fractures often require ORIF in adults and may involve percutaneous pins in children (to make sure that the fx is stable). •Radial head resection may be necessary following radial head fractures or chronic synovitis as in RA. -The head of the radius may or may not be replaced with a prosthetic implant. -Post surgery immobilization follows in a splint that can be removed for passive and AA exercise. -Patient can regain full pronation and supination. Radius remains stable because of the interosseous membrane and distal RU joint. This will take a long amount of time. -In children radial head resection is associated with a high incidence of overgrowth and poor outcome