NAME- MAHIMA BHATIA

CLASS – BPT FOURTH YEAR (19TH BATCH)

ROLL NUMBER – 15
SUBJECT –PT IN MEDICINE – PTM
TOPIC – Peripheral Nerve Injuries
FACULTY – Dr. SAMPADA
QUESTION - Management of Radial Nerve Injury

 COURSE - The radial nerve is one of the terminal branches of the posterior cord. In the axilla,
it lies behind the axillary and upper brachial arteries and passes anterior to the tendons of teres
minor, latissimus dorsi and subscapularis. It enters the posterior compartment of the arm
passing through a triangular space, formed by the lateral humerus, long head of triceps and teres
minor. Through this space, the nerve enters the spiral groove of the humerus and descends
obliquely between lateral and medial heads of triceps where it reaches the lateral border of the
humerus in the distal third of the arm.

 The nerve enters the anterior compartment by piercing through the lateral intermuscular septum
where it continues between brachialis and brachioradialis. Anterior to the lateral epicondyle the
nerve splits into its terminal superficial and deep branches.

 The posterior cutaneous nerve of the arm arises in the axilla, piercing the deep fascia near the
posterior axillary fold. The lower lateral cutaneous nerve of the arm arises before the radial
nerve, pierces the intermuscular septum and becomes cuntaneous below the deltoid.

 The superior branch of the radial nerve continues on from the radial nerve anterior to the lateral
epicondyle. It travels along the anterolateral side of the forearm. It is the only function is
sensory. In the distal third of the forearm, the nerve rises posteriorly from below the tendon of
brachioradialis and pierces the deep fascia to become superior. It further divides into the digital
nerves.

 The deep branch of the radial nerve or posterior interosseous nerve, is entirely motor. It begins
anterior to the lateral epicondyle of the humerus and enters the posterior compartment of the
forearm through the two heads of supinator where it curves around the lateral and posterior
surfaces of the radius. It descends between the deep and superficial extensor muscles and lies on
the interosseous membrane and ends in a flattened expansion.

 It originates from the brachial plexus, carrying fibers from the ventral roots of spinal nerves C5, C6,
C7, C8 & T1.
 Radial nerve injuries are associated with the path it travels close to the humerus. Mechanisms of
injury can be humerus fracture, a direct blow or sustained pressure (i.e. from incorrect use of
a crutch). Motor function of the triceps are usually preserved as they are innervated superiorly
whereas wrist and digit extensors are often paralysed leading to the dropped wrist deformity.

 A loss of synergic action between wrist flexors and extensors causes excessive and unwanted
wrist flexion. This can be observed in a simple gripping task or asking the individual to make a
fist. Both tasks will be difficult to complete as movement will be ineffective. Interphalangeal
joints can be extended by the lumbricals and interossei due to their attachments at the dorsal
digital expansion. Due to overlapping cutaneous nerves, there is only a small patch exclusive to
the radial nerve on the dorsum of the thumb web.

MARKED IN YELLOW – RADIAL

NERVE COURSE
 Mechanism of Injury
1. Humeral Shaft Fracture-
Humeral shaft fractures are the leading cause of radial neuropathy in the arm. These are commonly spiral
fractures between the middle and distal thirds of the humeral shaft. A spiral fracture in the distal third
followed by proximal and radial displacement of the distal bone fragment is also known as a Holstein-Lewis
fracture.It can be compressed between the overlapping bone fragments leading to entrapment neuropathy.

2. Secondary to Lateral Intermuscular Septum Compression

The lateral intermuscular septum is also a common site of radial nerve compression. A known site of limited
mobility for the radial nerve, the lateral intermuscular septum can cause chronic compression after an insult
to the humerus. In one reported case, delayed radial neuropathy occurred three months after a humeral shaft
fracture and was the result of the radial nerve’s entrapment within the lateral intermuscular septum.

3. Secondary to Callus Formation

The radial nerve can become encased within a healing callus of the fractured humeral shaft. In such cases,
symptoms manifest gradually as the callus forms, requiring surgical removal of the callus to restore nerve
function. Hence, patients suffering from humeral fractures with no neurological deficits at the time of
presentation can still develop delayed radial nerve palsy over a period of months to years.

4. Secondary to Fracture Manipulation

A “secondary radial palsy” during fracture manipulation or reduction can occur as a result of intraoperative
nerve exploration or the surgical approach used. The radial nerve is extremely sensitive to even slight
tension exerted during surgical exploration of the fracture.For the most part, radial nerve entrapment is seen
after fracture manipulation when the nerve is unknowingly entrapped between bone and an installed plate,
compressed by a bone fragment or if excessive nailing of the bone occurs.
 5. Compression by Lateral Head of Triceps Brachii
Compression of the radial nerve can also be caused by the fibrous arch of the lateral head of the triceps
muscle in the arm. Following strenuous muscular effort at the elbow, some individuals were reported to have
suffered from radial nerve paralysis. The fibrous arch consists of muscle fibers that originate from the
tendon of the lateral head of the triceps muscle and insert just below the lateral part of the spiral groove.

6. Tumors
Radial nerve compression in the arm can also occur from a tumor growth. It can be either a malignant soft
tissue mass causing compression of the nerve through infiltration or a benign growth in a closed anatomical
space (such as the posterior or anterior compartments of the arm).

7. Blood Pressure Cuff

Perioperative radial nerve compression can result from prolonged inflation of an automatic blood pressure
cuff around the arm, especially in a lean patient. One of the main reasons this type of compression occurs is
because the blood pressure cuff is placed over the distal third of the arm.

8. Anomalous Brachioradialis Muscle

A rare variation of the brachioradialis muscle, which originates from the acromion instead of the lateral
supracondylar ridge of the humerus and blends with the normal brachioradialis muscle, has been known to
cause compression of the radial nerve in the arm. This occurs when the variant muscle crosses over the
radial nerve in the anterior compartment of the arm creating a narrow tunnel between its fibers or with those
of the biceps brachii muscle.

9. Saturday Night Palsy

The term “Saturday Night Palsy” is used for a radial nerve injury caused by prolonged compression of the
nerve at the spiral groove. The origin of the term is due to the association of the condition with a night spent
in alcoholic stupor with the arm draped over a chair or bench. Mechanical compression of the radial nerve in
the spiral groove can also occur as a result of the continuous use of crutches or prolonged kneeling in a
“shooting” position.
 MANAGEMENT

RADIAL NERVE AND TENDON TRANSFERS

 Tendon transfers involve using of a functional muscle tendon unit to replace a lost function. The
more closely the tendon to be transferred resembles the non-functioning muscle tendon unit, the
more likely it will be successful.

BASIC PRINCIPLES OF NERVE AND TENDON TRANSFER : - -

1. Correction of Contracture: All joints should be supple with full passive motion prior to tendon
transfer, as postoperative active motion will not be greater than preoperative passive motion. If the
joint does not have full passive motion, this is corrected prior to tendon transfer by contracture
release.
2. Tissue Equilibrium: The optimal time should not be before until the scars are mature, the joints are
supple, and the edema has resolved. Every effort should be made to place the transfers in healthy
tissue, even if this means performing a different transfer. When a bed of healthy tissue is not present,
consideration should be given to resurfacing with vascularized fascio-cutaneous flaps prior to tendon
transfer.
3. Straight Line of Pull: The most efficient tendon transfer is one that passes in a straight-line from its
origin to the site of insertion.
4. One Tendon—One Function: It is obvious that a tendon cannot be used for two different functions
(digital flexion and extension), but the effectiveness of the transfer is reduced when trying to provide
two similar functions (digital extension and thumb extension), as the transfer will only effectively
move the joint to which it is most tightly attached.
5. Strength: The tendon chosen for transfer must have adequate strength to perform its new function. A
muscle loses roughly one grade of strength following the transfer, ie, a muscle graded at 5/5 might
decrease to 4+/5 following the transfer.
6. Synergy: A transfer will be more effective and easier for the patient to use if the action of the
transferred muscle is synergistic to the one it is replacing. Because wrist extension is synergistic with
digital flexion and wrist flexion with digital extension, these reciprocal actions are to be kept in mind
when performing a transfer.
7. Arthrodesis: It is generally best to avoid arthrodesis to stabilize a joint as patients can use a mobile
joint to their advantage, even if there is limited voluntary control of the joint. For example, a patient
with a supple wrist may have minimal wrist control, but can supinate the forearm, allowing for wrist
extension through gravity and attendant digital flexion via tenodesis to help with grasp.

OPERATIVE TECHNIQUE
When performing a tendon transfer, the functional tendon is repaired to the non-functional tendon using a
strong weave to connect the tendons and decrease the chance for separation of the two tendons. This is
commonly completed with three Pulvertaft weaves, in which one tendon is passed through the substance of
the second tendon, interlocking the tendons and securing them to each other, creating a strong repair.

Radial Nerve Palsy- Type of tendon Used :-

1. Radial nerve palsy can be divided into high and low injuries. A high radial nerve palsy involves the
radial nerve proper, whereas the low palsy involves the posterior interosseous nerve (both of these are
near the level of the elbow).
2. The importance in the difference in high and low radial nerve palsies is in the presence or absence of
active wrist extension.
3. The radial nerve proper will innervate the brachioradialis (BR), extensor carpi radialis longus (ECRL),
and extensor carpi radialis brevis (ECRB) prior to dividing into the posterior interosseous nerve and the
radial sensory nerve and thus, a patient with the high radial nerve palsy will lack wrist extension,
thumb extension, and digital extension.
4. With radial nerve injuries, three functions are lost and must be replaced:
 Thumb extension
 Finger extension
 In high nerve palsies, wrist extension.
5. Low radial nerve transfers
 Thumb extension
Digital extension

PL—Extensor pollicis longus (EPL)

TYPES OF TENDON USED – Brand—Flexor carpi radialis (FCR)–EDC
FOR THE VARIOUS MUSCLES Jones—Flexor carpi ulnaris (FCU)–EDC
Modified Boyes—FDS ring–EDC

 Each of these transfers for digital extension can be used successfully. The disadvantage of the FCU
transfer lies in sacrificing the strongest wrist flexor and its importance in hammering or the “dart
throwing” motion. The disadvantage in the FDS ring transfer is the lack of synergism and although
EDC excursion is best replicated by the FDS transfer, it is more difficult for the patient to retrain a
muscle traditionally used for digital flexion to provide digital extension.

6. High radial nerve transfers

 Wrist extension—Pronator teres - ECRB
 Pronator teres is almost always used to restore wrist extension and is transferred to the most
central radial wrist extensor—ECRB.
 PHYSIOTHERAPY MANAGEMENT

1. SENSORY EDUCATION AND RE-LEARNING -

 Sensory re-training (also referred to as sensory re-education) is a cognitive therapy technique that
helps the patient with a nerve injury to meaningfully interpret the altered profile or neural impulses
reaching his conscious level after the altered sensation area has been stimulated. Moreover, the
repetitive neural input from sensory re-training exercises can produce plastic changes in the
somatosensory cortex via the same mechanisms underlying those evoked by altered input from the
nerve damage. This reorganization through re-training can compensate, in part, for some of the
impairments associated with nerve injury.
 It will work on the principle of neural plasticity.
 Neuroplasticity, also known as brain plasticity, is the ability of neural networks in the brain to
change through growth and reorganization. These changes range from individual neuron pathways
making new connections, to systematic adjustments like cortical remapping.
 The process of sensory re-training can be likened to the brain learning a new language in
progressive phases of difficulty. Initially, use of the words is slow, challenging and error prone.
With time and practice, verbal fluency may be acquired.

 The following things can be used – Pinching , Tapping , Brushing , Icing

 We try and stimulate the sensory pathway by Rubbing different textures on the upper limb by
this we are trying to establish the normal experiences of skin and also trying to keep the
receptors active by given natural stimuli to the area.
 The following products can be used :- Jute , sieve, rough paper, texture, pumice stone.

 Sensory re-training as a rehabilitative approach has been used extensively over the past several
decades for patients who had nerve injuries affecting the hand. The emphasis of the sensory re-
training exercises for hand injury patients has been to teach the patient to interpret the perception of
objects manipulated by the fingers in a meaningful and functional way. Hand injury patients learn to
recognize and to discriminate the shapes of small objects (various buttons, coins and keys
 Although improvement has been reported when re-training isn’t initiated soon after the injury,
reorganization of the cortex after changes in peripheral input happens quite quickly. Persistent
chronic altered sensation may result in irreversible cortical changes. One of the goals of re-training is
to avoid, minimize or modulate the central functional re-organization.
 2. PAIN MANAGEMENT –

 Pain is one of the most common and annoying consequences of nerve damage.
Neuropathic pain affects the quality of life and is a common consequence of nerve damage. Pain
control is of paramount importance. Complete relief is rarely obtained. A multidisiplinary approach is
taken, with most input from PHYSIOTHERAPISTS. The following modalities can be used by a
PHYSIOTHERAPIST :--

 TENS -- Application of Transcutaneous electrical nerve stimulation has been found to be of

benefit in pain reduction in neuropathic pain. It was found to be of benefit if used at 100hz
in constant mode.
Frequency – 80-120 HZ.
Pulse duration – short 50 microseconds
Amplitude – strong tingling but below motor threshold.
Time duration – 10-15min/day.

 Low Level Laser Therapy (LLLT) - Studies have found this to be of benefit in pain relief
and acceleration of healing in treatment of neuropathic pain and neurological deficits as
adjuvant therapy.

 Massage - Aromatherapy massage, in studies, has shown to help manage neuropathic pain
and increase QOL. Many differing massage techniques like kneading, wringing and
efflurage have been employed showing benefits for pain management and QOL.

SOME OTHER PAIN RELIEF TECHNIQUES INCLUDE :--

 Relaxation techniques
 Acupuncture
 Meditation
 Acupuncture - Acupuncture is a technique used to treat pain and relieve discomfort. The needles
used in acupuncture are inserted into your body’s pressure points to stimulate the nervous
system. This releases endorphins, your body’s natural painkillers, in the muscles, spine,
and brain. This technique changes your body’s response to pain. Many people with neuropathy
turn to acupuncture to relieve their chronic pain. Acupuncture also stimulates blood flow to
restore nerve damage.
3. ELECTRICAL STIMULATION –
 This can be done for all the muscles that are supplied by the radial nerve to prevent it from going into
atrophy.
 This will also prevent any deformity.
 In this method, an electric current is introduced through the nerve which causes an excess ion
flux through the axon membrane, thereby triggering an action potential. This method avoids
prolonged currents and only rectangular pulses are given. Nerve stimulation is also impacted
with the help of refractory periods
 Therapeutic Interrupted Galvanic current is used to stimulate the muscles of the forearm and the
hands as it possess Less chances of burns – Indirect current
 As due to the injury of the radial nerve the sensation might be affected so we need to be careful of
the burns – So there this type of current will be the best.

4. CARE OF DENNERVATED SKIN

The following measures can be taught to the patient to avoid these burns and wounds :-
 Don’t switch on the geyser and take bath with normal water – To prevent burning.
 Always wear gloves in kitchen and use wooden sticks to avoid unnecessary burning.
 Oil and moisture your hands to prevent any wounds.
 Do not let your hands dry up.
 Wrap a cloth while holding a cup of hot tea or coffee
 Continuous inspection of the skin is needed – Take help of family members.
 Try and avoid any sharp objects as it may cause injury that wont even be felt.
 Proper hot and sharp objects handling
 Taking care of nails
 Avoiding long term cold weather exposure
 Well-padded splints
 Protect your skin from Sun
 Shave carefully
 Skin also should be cleaned with mild soap and warm water and gently patted dry.
 If the area is vulnerable to excess moisture -can be protected with talcum powder and too dry area
should have lotion applied.
 Direct or using a mirror for daily skin inspection is important to identify vulnerable areas for sores
such as high pressure points under splints.
5. PASSSIVE ROM
 PROM at all the joints of the UE can be performed through patient’s full available range. They also
form an important component of the home exercise program (HEP). The movements should be slow
and within the child’s tolerance. These can be administered either in anatomical planes of motion or
in diagonal patterns of motion (PNF patterns), with the latter being more efficient.

 Full passive range of motion in all joints of the wrist and hand and prevention of contractures,
including that of the thumb-index web

6. ASSISTIVE ACTIVE MOVEMENTS-

In active assisted exercises, the patient performs the desired movements or activity to the best of
their ability only requiring the assistance of a helper to:
• complete a full range-of-motion
• reduce resistance to the limb, by support or
• help move the limb when the patient fatigues and can no longer safely control the limb. Active-
assisted exercises are usually initiated early in the home rehabilitation process when strength loss is
usually greatest.
 7. MUSCLE WEAKNESS – STRENGTHENING –
Strength training exercises help to make the muscles stronger and more injury resistant. It can help
you regain lost strength in your muscles through constant training routines. Here are some strength
training exercises you can do.
Muscle strengthening exercises are employed as appropriate eg- isometric, graded weight
progression, open-close chain.

8. STRETCHING –
Wrist Extension Stretch – Straighten your arm and bend your wrist back as if signaling someone to “stop.”

• Use your opposite hand to apply gentle pressure across the palm and pull it toward you until you feel a stretch on
the inside of your forearm.

• Hold the stretch for 15 seconds.

• Repeat 5 times, then perform this stretch on the other arm.

Wrist Flexion Stretch- Straighten your arm with your palm facing down and bend your wrist so that your fingers
point down.

• Gently pull your hand toward your body until you feel a stretch on the outside of your forearm.

• Hold the stretch for 15 seconds.

• Repeat 5 times, then perform this stretch on the other arm.

9. STRESS MANAGEMENT –
Meditation techniques
 Meditation 20-30 minutes in morning or evening produce body relaxation.

Progressive muscle relaxation

 The whole body muscle progressively contract which ultimately produce full body relaxation.

Yoga
 It is a combination of general exercise with breathing exercise.

Social support
 All family members, friends, neighbours and pets developing social support which help in healthy
life.

10. PROPIROCEPTION-
 Proprioception is basically a continuous loop of feedback between sensory receptors throughout your
body and your nervous system.
 The central nervous system integrates proprioception and other sensory systems, such as vision and
the vestibular system, to create an overall representation of body position, movement, and
acceleration.
 Proprioception is critical for meaningful interactions with our surrounding environment.
Proprioception helps with the planing of movements, sport performance, playing a musical
instrument and ultimately helping us avoid an injury.
 The neurological basis of proprioception comes primarily from sensory receptors
(mechanoreceptors and proprioceptors) located in your skin, joints, and muscles (muscle
spindles with a smaller component from tendon organ afferents, cutaneous receptors and
minimal input from joint receptors). These muscle afferents receptors allow for the
identification of limb position and movement via neural signalling of a change in muscle, skin
or joint stretch. Hence, proprioception is basically a continuous loop of feed forward and
feedback inputs between sensory receptors throughout your body and your nervous system.

11. JOINT STIFFNESS MANAGEMENT -

 The soft tissues of the region and adjacent regions supplied by the damaged nerve are at risk of
contractures if left in shortened positions. Regular daily massage, PROM exercises are needed
on a daily basis. Protective removable static splints are also useful in contracture prevention.
For joints that have become stiff ultrasound and laser are of useful therapies.
 The insensitive joints and ligaments and other surrounding tissues which are affected by the injury to
all or some supplying nerves are at the risk of stiffness, shortening and finally contracture.
 Regular daily massage, passive motion in full range at least one time per day.
 12. ORTHOTIC MANAGEMENT / SPLINTING TECHNIQUES -
 Proper splinting techniques, from the postoperative splint and cast to splints that prevent
deformities, to overcome established contractures and improve function, aids in the patient's
recovery.
 Use of support slings may be employed to assist the movement and take the weight of the
limb. As may static and dynamic splints- helping to rest paralysed muscles in optimum
positioning to avoid overstretching and or contractures. They also assist in allowing
unaffected muscles to operate from correct positions

Dorsal cock-up splint

OBJECTIVE - Immobilization of the wrist in a functional or antalgic position.

INDICATIONS

 All flaccid palsies of the wrist (radial nerve injuries, neuropathy, etc.);
 Post traumatic flexion contracture;
 Carpal tunnel syndrome.

Material guidelines

The volar wrist cock-up orthosis is ideally fabricated with a thermoplastic material that has a high degree of
conformability to ensure a close fit.

If you prefer working with a more elastic material for this orthosis to accommodate remodelling when
needed in case of decreasing oedema in the patient’s arm or hand, we recommend one of the following
materials.

 Orfit NS
 Orfit Colors NS
 Aquafit NS
 Orfit Classic

 Orthoses for the wrist are typically fabricated from 3.2mm (1/8”) thick materials. This thickness
offers enough rigidity and support for most adult patients. However, for small children and smaller
adults, a material of 2.0mm, or 2.4mm (1/12” or 3/32”) thickness may also provide adequate support.

Benefits

 Protection of the palmar surface.

 Easy to fabricate.
 Allows for functional activities using the fingers and thumb.
 Firm support of the wrist.

The splint will assist with wrist, finger and thumb extension and release will allow the patient
to conduct a natural grasp reflex.
It will prevent adaptive shortening of the digital and wrist flexors while protecting the
extensor mechanism from elongation.
 Dorsal cock-up splint

SPIDER SPLINT
 It is useful for finger release I precision movements and for large grasp. This splint consists of four
plastic coated wires , fixed by a cuff round the base of the proximal phalanx of the thumb, spread out
and looped under the middle finger. This allows full flexion of the fingers to take place and holds the
metacarpophalangeal joints in slight flexion when the hand is relaxed.

Burkhalter splint
13. EMOTIONAL STRESS-
 Severe pain and paralysis accompanying nerve injury usually lead to cognitive problem; sleep
disorder and anxiety reduce quality of life and hamper efficient medical treatment.
 Alteration of extracellular glycine concentration in related spinal cord and brain cortex develop
mechanical hypersensitivity after peripheral nerve injury may exhibit impaired recognition ability
and may be the main mechanism of long lasting pain and a source of emotional stress.
 If it is not addressed properly and as soon as possible it may lead to chronic hippocampal plasticity
and develop chronic pain
 Chronic neuropathic pain has a life-debilitating effect causing emotional stress and reduced
QOL. To properly treat a client with neuropathic pain this must be respected. The ultimate goal
is not simply to reduce pain but to achieve better QOL. This can only be achieved if the
depression, anxiety, and sleep disorders are also addressed.
 Cognitive rehabilitation programs address mood disturbance, enhance functional outcome and also
prevent or decline chronic pain following nerve injury and repair.

14. ADVANCE THERAPY –

 Pool therapy can be helpful to improve joint contractures and eliminate the effects of gravity during
initial motor recovery, thereby enhancing muscular performance.
 Biofeedback may provide sensory input to facilitate motor re-education.
 Early-phase sensory re-education decreases mis-localization and hypersensitivity and reorganizes
tactile sub-modalities, such as pressure and vibration.
 Later goals include recovery of tactile gnosis.

15. LOSS OF FUNCTION –

 Rehabilitation must focus on manipulation of central nervous processes rather than peripheral
factors.
 Using the brain capacity for Visio-tactile and audio-tactile interaction and fine motor relearning
is the main concept for maintaining sensory cortex and periphery relationship in the initial phase
following nerve injury and repair.
 Rehabilitation protocols that focus on relearning programs of fine tasks increase the chance of
functional outcome improvement after nerve repair.

16. EXERCISES FOR RADIAL NERVE INJURY –

- Pouring water: Start by holding an empty cup and turn it upside-down as if pouring out water.
- Figure of eight: Stand leaning forwards with your unaffected hand on a worktop/ back of a chair for
support. Swing your affected arm in a figure of eight, with your palm facing outwards when across
your body and inwards when away from your body.
- Pump water: Hold your hands together as shown in the picture. Bring hands up and down in a
‘pumping action’.
- Tip please: Look towards the affected side. Take your hand behind your back as if to accept a
backhanded tip.
- Table stretch: Keep the back of your hand flat on the table and rotate your whole body away.
- Back massage: Massage your back in a circular motion. Depending on the side affected, the right
hand should circle anti-clockwise, with the left hand circling clockwise.
17. PREVENTION OF ATROPHY –
 The term muscle atrophy refers to the loss of muscle tissue. Atrophied muscles appear
smaller than normal. Lack of physical activity due to an injury or illness, Injury to the radial
nerve can lead to atrophy of the hand and the forearm.
 Muscle atrophy can occur after long periods of inactivity. If a muscle does not get any use,
the body will eventually break it down to conserve energy. This inactivity of the muscles can
be due to the lack of nerve supply to the area.
 Muscle atrophy that develops due to inactivity can occur if a person remains immobile while
they recover from an illness or injury. Getting regular exercise and trying physical
therapy may reverse this form of muscle atrophy.
 Functional electric stimulation Functional electrical stimulation (FES) is
another effective treatment for muscle atrophy. It involves the use of electrical impulses to
stimulate muscle contraction in affected muscles. During FES, a trained technician attaches
electrodes to an atrophied limb. The electrodes transmit an electrical current, which triggers
movement in the limb. This will be useful. When the muscle twitch happens along with that
the personal can perform the movement himself.
 Focused ultrasound therapy- This technique delivers beams of ultrasound energy to
specific areas in the body. The beams stimulate contractions in atrophied muscle tissue.This
novel technology is in the development phase and has not yet entered the clinical trial phase.
18. PREVENTION OF DEFORMITY :-
 We have to prevent formation of any hand deformity so the following exercises can be
done-

19. HAND EXERCISES FOR GRIPPING -

 There are several types of grip exercises that all train different muscle groups.

1. Crush Grip: crushing is the action of closing your hand around something and squeezing. This
would be what you do every time you hold onto a dumbbell.

2. Pinch Grip: pinching is the action of holding onto an object and squeezing with just your fingertips
and not letting it drop. It can also be the act of pinching something together with just your fingertips
(eg pinching a clothes pin….do people still use those?).

3. Supporting Crush Grip: this is the act of supporting an object with a crush grip where you support
most of the load with your fingers. Common examples are carrying a dumbbell, deadlifting or even
carrying your grocery bags by the handle.

4. Open Crush Grip: this is when you are using a crush grip but your fingers don’t quite touch or
overlap. Fat bar or awkward object holds are great to train open crush grip. The real life carry over
here would be an easier time opening jars (among other things) when your fingers are spread open.
Having a strong open crush grip really comes in handy!
5. Hand Extension: this technically isn’t a grip exercise in every sense of the word but it trains from
the synergistic muscles to the ones you use for grip. This keeps a healthy muscle balance in your
hands and wrists, which aids in preventing injury and overuse of those muscle groups.

PECK BOARDS CAN ALSO BE USED FOR THE

PATIENT. THIS CAN BE TIME REGULATED SO THAT
THE IMPROVEMENT IN THE DEXTRITY CAN BE
JUDGED.