19 Brachial Plexus Injury Assessment and Interventions
Gabe Byars, OTR/L; Casandra Empy, OTAS; and Cassidy Limby, OTAS
Background
The following videos demonstrate how the occupational therapy (OT) practitioner can assess and treat common brachial plexus disorders. The disorders that are discussed include carpal tunnel, cubital tunnel, and thoracic outlet syndrome. The assessments performed include Tinel’s sign, Phalen’s test, Durkan’s test, and Roos’ test. These videos also provide great information on how the OT practitioner can perform compensatory and remedial treatment, including splinting, nerve glides, nerve flossing, and much more.
Previously, you learned a lot about compensatory strategies and adaptive equipment. These videos showcase some excellent remedial strategies that are specific to brachial plexus dysfunction, but they also point out how important it is to use a splint if needed or to change the way that you perform an activity to avoid damaging your client’s limb. This section also cements information that you previously learned about nerve and spinal cord involvement, in that all of your assessments work upstream to determine the correct treatment plan for each client.
Carpal Tunnel Assessment
This video demonstrates how the OT practitioner can assess for carpal tunnel syndrome.
Carpal Tunnel Assessment Video Transcript
Carpal Tunnel Assessment Tips
- Ask your client what activities make the pain worse and what activities make it better.
- Check your client’s hand sensation with the Semmes-Weinstein monofilament test.
- Refer your client to a doctor if they have atrophy in the thenar eminence—this indicates severe carpal tunnel.
- Specific Tests:
- Tinel’s Sign: The OT practitioner taps over the nerve compression site to reproduce numbness, pain, or tingling signs and symptoms.
- Phalen’s Test: The OT practitioner has the client’s hands held in forced flexion—reverse prayer—for sixty seconds to reproduce numbness, pain, or tingling signs and symptoms.
- Durkan’s Test: The OT practitioner pushes two thumbs into their client’s carpal tunnel for thirty seconds to produce numbness, pain, or tingling signs and symptoms.
Carpal Tunnel Treatment
This video discusses the OT practitioner’s treatment options for their clients with carpal tunnel syndrome.
Carpal Tunnel Treatment Video Transcript
Carpal Tunnel Treatment Tips
- Don’t zing a nerve—rule of thumb, if you zing a nerve, you make it worse.
- Splint to remind—Keep your client’s wrist neutral to ten degrees of extension. Splint the wrist for a reminder during activities that cause symptoms if necessary.
- Perform an ergonomic assessment—ask what’s their workspace? What is their home set up? What tools might they benefit from?
- Know other modalities—know about ultrasound over transverse carpal ligament and low-level laser therapy options.
- Know tendon and nerve movements:
- Tendon Glides: Have your client open their hand to tiger claw, to table top, to flat fist, to full fist.
- Nerve Glides: Have your client begin with their fist with the thumb facing up, then extend the fingers, next move into wrist extension, move to thumb abduction and extension, to supinate, and extend elbows. You pull on their affected thumb.
- Median Nerve Tensioner: Have your client look at a ring, show it to a child behind them, then look away.
- Standing Nerve Glide: Have your client answer the phone, extend the arm, then extend their hand.
- Median Nerve Flossing: Have your client hold a tray, push it away, dump it out.
- Median Nerve Mobilization: Have your client grab their affected hand palm up, then stretch and extend it back.
Cubital Tunnel Assessment and Treatment
This video demonstrates how the OT practitioner can assess their client for cubital tunnel syndrome and discuss treatment options.
Cubital Tunnel Assessment and Treatment Video Transcript
Cubital Tunnel Assessment and Treatment Tips
- Check Presentation: Your client will present with pain in the pinky finger and one-half of the ring finger, which is the ulnar nerve. Your client will feel pain at night with prolonged elbow flexion.
- Assess Upstream: Check your client’s posture and ulnar nerve sensation.
- Know Severe Ulnar Nerve Involvement: It is severe if your client has atrophy in the center of the palm.
- Conduct Specific Tests:
- Perform Tinel’s sign test at the cubital tunnel: Tap the posterior medial elbow to recreate symptoms.
- Perform the elbow flexion test: Have your client be in elbow flexion and abduction. Hold for one minute.
- Perform Treatments:
- Have your client adapt their tasks to avoid pain.
- Have your client wear a soft neoprene splint during the day, which serves as a reminder. Have your client place a pillow in the crook of their arm and tape it in place at night.
- Perform ulnar nerve glides: Have your client comb the hair back and bring their arm forward.
- Perform ulnar nerve flossing: Have your client do the I Dream of Genie, Walk Like an Egyptian, and racoon-mask stretch exercises.
Thoracic Outlet Assessment and Treatment
This video demonstrates how the OT practitioner can assess for thoracic outlet syndrome and give their clients treatment options.
Thoracic Outlet Assessment and Treatment Video Transcript
Thoracic Outlet Assessment and Treatment Tips
- Check Presentation:
- Check your client for numbness, pain, tingling down the arm that does not follow peripheral nerve distributions.
- Check your client’s static postures, overhead tasks, tasks that depress the scapula—these all tend to be problematic.
- Check if your client’s pain doesn’t follow typical distribution because it is coming out through the thoracic outlet.
- Check your client’s posture, sensation, strength, and activities that bother them.
- Perform Specific Tests:
- Perform Roos’ test: Have your client hold their arms up, ninety degrees, abducted. Have them open and close their fists for thirty seconds.
- Perform upper-limb tension tests: These tell you which nerve is being compressed.
- Perform Treatments: Work on your client’s posture, remobilization, stretching, and nerve mobilization.
- See resources for tests below.
