505 brachial plexus and Rhumatoid diseases

how are Rheumatoid Diseases classified?

‒Systemic

‒Chronic

‒Wide-ranging symptoms

‒More than arthritis

what is the etiology of Rheumatoid Diseases?

Auto-immune (body attacks own tissues)

• Typified by inflammation

‒ Joint lining, or connective tissue

‒ Organ impact may also be seen

• Skin, eyes, kidney

Not well know what triggers this response

what is the most common autoimmune form of arthritis?

Rheumatiod arthritis

causes pain, swelling, and joint stiffness

what are some examples of Rheumatic diseases?

Gout

Fibromyalgia

Lupus

Scleroderma

what occupations are affected first with Rheumatic diseases?

“heavy” occupations

• complicated actvites

• lifting heavy objects

• requires alot of ROM

what does a typical evaluation look like for Rheumatic diseases?

‒ Occupatonal profle

‒ Analysis of occupatonal performance

‒ Performance skills & Client factor

what are the Performance skills & Client factors observed in the evaluation of Rheumatic diseases?

• Endurance & Fatgue

• AROM, PROM, & presence of deformites

• Strength

• Pain

• Mood

• Balance

types of interventions used for Rheumatic diseases?

• Occupatons

• Activities

• Physical Agent Modalities (manages symptoms)

• Orthotics (hand splints)

• Assistive Technology (voice machine so they dont use hands)

• Education

• Self-Advocacy

what are the 4 intervention approaches?

• establish

• maintain

• modify

• prevent

what is the purpose of Energy Conservaton Work Simplifcaton?

Educatonal interventon

• Restoring or maintaining functon in occupatons & actvites

• Decreasing demand of actvites

• Pacing of energy

what are the most common symptoms for Rheumatic diseases?

Pain, endurance, fatgue, & movement disrupton are the most common

what is the Brachial Plexus Injury Epidemiology?

Traumatc in nature

• caused by forceful pulling or stretching of arm

what is the most common Brachial Plexus Injury?

Obstetric injury

• MVA

• Winter Sports

• Motorcycle accident

what is the most severe Brachial Plexus Injury?

Avulsion

• torn from nerve root

may NOT be surgically repairable

Stretch (Brachial Plexus Injury)

Mild injuries

• may heal without interventon

Rupture(Brachial Plexus Injury)

More forceful stretch

• partial or full tear

Sometimes able to be repaired

Laceration (Brachial Plexus Injury)

Usually more distal (further away from the core of BP)

• Sometimes able to be repaired primarily or with nerve transfers

Upper Trunk Palsy (Brachial Plexus Injury)

what happens: angle between shoulder & neck forcibly widens

Causes:

• you fall onto your shoulder

• your head is forced to opposite side

Lower-Trunk Palsy (Brachial Plexus Injury)

what happens: angle between arm & chest is forcibly widened

Causes:

• arm & shoulder are forced upward

• ex: falls from ladder/ tree (catch yourself and then you hang with arm extended)

Pan-Plexus Palsy Injuries (Brachial Plexus Injury)

Most severe

• all levels of nerves & trunks are injured

• Complete limb paralysis

What is the typical course of recovery for the Brachial Plexus?

Typically a long recovery

• Nerves regenerate at 1mm/day, 1 inch/month

  May not regain full functon

what are some typical medical interventions for Brachial Plexus injuries?

Evaluation by MD

• Electromyography (EMG)

• Nerve Repair

• Nerve Graft

• Nerve Transfer

what are some OT intervention strategies for Brachial Plexus injuries?

• Custom orthosis (Proper positoning)

• Passive ROM to maintain mobility & prevent joint contractures (they aren’t able to move, but therapy increases mobilty)

• Scar mobilization (move scar so that scar tissue is not present to impair mobility)

• Adaptive equipment

• ADL retraining

Erb’s Palsy (Erb-Duchenne syndrome)

Obstetric Brachial Plexus injury

Causes:

• the head being moved away from the shoulder in both

  vaginal & cesarean deliveries

Risk factors:

• Large baby

• Small mother

• Low or mid forceps delivery

• 2nd stage of delivery more than 60 minutes

Erb’s Treatment

OT & PT in the first 9 months with a watchful wait

• Surgery before a year old

80 to 90% will experience recovery

Thoracic Outlet Syndrome

Compressing or pinching of the brachial plexus OR

Blood vessels at the level of the thoracic outlet (neck)

Symptoms:

• ‒ Neck pain

  ‒ Shoulder pain

  ‒ Arm pain

  ‒ Numbness/tingling

  ‒ Decreased circulaton to the extremites

Thoracic Outlet Syndrome onset (signs of disease)

Traumatic: ex: MVA (motor vehicle accident)—-if you have a history of traumatic events

• if you have an extra rib

• if you have muscle or soft tissue bulk (body building or obesity)

Elevated Arm Stress Test (EAST) or Roos Test

test for Thoracic Outlet Syndrome(TOS)

‒ Touch down positon – 3 minutes: Failure to maintain positon = TOS

Interventons for Thoracic Outlet Syndrome

Full recovery is rare

• Operative treatment (last resort, not very successful)]

• Non-operative treatment

  ‒ Diaphragm breathing

  ‒ Strengthening the scapular musculature

  ‒ Nerve gliding exercises

  ‒ Stretching within tolerance

  ‒ Learn to manage sympt3ms

Four rotator cuff muscles

‒ Supraspinatus

‒ Infraspinatus

‒ Teres minor

‒ Subscapularis

Adhesive Capsulits

Other name: Frozen Shoulder

shoulder joint slowly becomes immobilized

Common with:

• axial webbing (post mastectomy)

• post trauma

• insidious onset (you dont relize it is happening)

what are the 2 types of Adhesive Capsulitis?

Primary – Idiopathic onset (happens naturally)

Secondary – Post-traumatic onset (ex: post-mastectomy- surgery)

what happens in the Freezing phase of Adhesive Capsulitis?

(2-9 months)

• WFL ROM with pain, causing guarding

painful for you soooooo you try not to use it

what happens in the Frozen phase of Adhesive Capsulitis?

up to 1 year

Substitution of ST motion for loss of GH motion

substitue how you are moving bc your losing motion in you glenal humeral joint (shoulder)

what happens in the Thawing phase of Adhesive Capsulitis?

up to 26 months

• gradual return of motion

Adhesive Capsulits Interventons

Non-operatve treatment

• Modalites

• A/PROM

Operative treatment

‒ Arthroscopic release of the GH capsule

‒ Manipulation under anesthesia

Workstation modification—— long recovery, so you want to make sure the intervention matches their occupations

• ex: if they work at computer, focus on that

Interventons for RTC injuries

Can be age-related degeneration

• Most are partial-thickness tears

• progressing to full full-thickness tear

What are the treatments for RTC(rotator cuff) injuries?

Non-operatve treatments:

‒ Rest

‒ Anti-infammatory medication

‒ Early AAROM exercises

‒ Pendulums (rocking your body)

‒ Wand

‒ Strengthening the healthy portion (usually shoulder IR, adducton, extension)

Operative treatment protocol:

‒ Often immobilized with only PROM during therapy

Most common cause of shoulder disability

Rotator Cuff Tears

Etiology(causes) for Rotator Cuff Tears

Degeneratve or Acute

‒ Impingement (pinching)

‒ Tensile overload

‒ Repetitive stress

‒ Poor vascularity

‒ Trauma

Typical Course of Recovery

Typically a long recovery if surgical intervention is required

• May not regain full function

Typical Medical Interventon

Evaluation by MD

• Special tests

• MRI

• OT/PT

• Surgical repair