Upper Limb peripheral nerve injury Assessment

SOAP   ASSESSMENT IDENTIFICATION

S (SUBJECTIVE)

This component is in a detailed, narrative format and describes the patient’s self-report of their current status in terms of their current condition/complaint, function, activity level, disability, symptoms, social history, family history, employment status, and environmental history. It may also include information from the family or caregivers and if exact phrasing is used, should be enclosed in quotation marks. The patient’s goals and prior response to treatment intervention are also included. Medical information obtained from the patient’s chart can also be included the therapist has not directly observed these findings.

It allows the therapist to document the patient’s perception of their condition as it relates to their progress in rehabilitation, functional performance, or quality of life.

Common errors:

• Passing judgment on a patient e.g. “Patient is over-reacting again”.
• Documenting irrelevant information e.g. patient complaining about previous therapist.

O (OBJECTIVE)

This section outlines what the therapist observes, tests, and measures. Objective information must be stated in measurable terms. Using measurable terms helps in reassessment after treatment to analyze the progression of the patient and hindering as well as helping factors. 

The objective results of the re-assessment help to determine the progress towards functional goals, and the effect of treatment. The therapist should indicate changes in the patient’s status, as well as communication with colleagues, family, or carers.

Common errors:

• Scant detail is provided.
• Global summary of an intervention e.g. “ROM exercises given”.

A (ASSESSMENT)

This is potentially the most important legal note because this is the therapist’s professional opinion in light of the subjective and objective findings. It should explain the reasoning behind the decisions taken and clarify and support the analytical thinking behind the problem-solving process. A prioritized problems list is generated with impairments linked to functional limitations. International Classification of Functioning, Disability, and Health (ICF) is very useful to determine and prioritized problem lists and thus helps to make functional physiotherapy diagnoses.

Progress towards the stated goals is indicated, as well as any factors affecting it that may require modification of the frequency, duration or intervention itself. Adverse, as well as positive response, should be documented in re-assessment.

Common errors:

• The assessment is too vague e.g. “Patient is improving”.
• Little insight is provided.

The Goals of treatment should be SMART

• Specific (simple, sensible, significant).
• Measurable (meaningful, motivating).
• Achievable (agreed, attainable).
• Relevant (reasonable, realistic and resourced, results-based).
• Time bound (time-based, time limited, time/cost limited, timely, time-sensitive).

P (PLAN OF TREATMENT)

The final component of the note includes anticipated goals and expected outcomes and outlines the planned interventions to be used. Information should be provided concerning the frequency, specific interventions, treatment progression, equipment required and how it will be used, and education strategies. The plan also documents referrals to other professionals and recommendation s for future interventions or follow-up care. The therapist should report on what the patient’s home exercise programme (HEP) will consist of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.

Common errors:

• The upcoming plan is not indicated.
• Vague description of the plan e.g. “Continue treatment”.

After a diagnosis of a peripheral nerve injury, a full subjective and objective examination is required to get a clear picture of the way the lesion is affecting the client.  

SUBJECTIVE ASSESSMENT ( WHAT THE PATIENT SAYS ABOUT THE PROBLEM / INTERVENTION)

• Collect demographic information.
•  chief complaint.
• Past history

  OBJECTIVE ASSESSMENT

OBSERVATION

• Presence of deformity (drop wrist, claw hand ,Ape hand, square shoulder ).
• Edema
• Trophic changes in the skin (indicates either prolonged inactivity or involvement of fiber in the peripheral nerve regulating autonomic function ).
• Muscle Wasting

EXAMINATION

SENSORY EVALUATION: ALONG THE CUTANEOUS DISTRIBUTION OF THAT PERIPHERAL NERVE, NOT DERMATOLOGICALLY

• The evaluation of sensation is highly dependent on the ability and desire of the patient to cooperate.
• Sensation belongs to the patient (i.e., is subjective) and the examiner must therefore depend almost entirely on their.
• One of the principle goals of the sensory exam is to identify meaningful patterns of sensory loss.
• Basic testing should sample the major functional subdivisions of the sensory systems.
• The patient’s eyes should be closed throughout the sensory examination.
• Exam in this order:
• Superficial (Exteroceptive) sensation
• Proprioceptive(deep) sensation
• Combined cortical sensations.
• If the superficial sensation is impaired then some impairment is also seen in deep and combined sensations.
• Sensory tests are done from the distal to the proximal direction.

Superficial Sensation	Deep Sensation	Combined Cortical Sensation
Pain Perception. Temperature Awareness. Touch Awareness. Pressure Perception.	Kinesthesia Awareness. Vibration Perception.	Stereognosis Perception. Tactile Localization. Two-Point Discrimination. Double Simultaneous Stimulation. Graphesthesia. Recognition of TextureBarognosis.

Sensory evaluation

REFLEXES: THERE ARE THREE PRIMARY DEEP TENDON REFLEXES IN THE UPPER LIMB: BICEP, BRACHIORADIALIS AND TRICEPS

Each reflex corresponds to a particular root and muscle and will evaluate the integrity of the root and associated nerve.

• Biceps: root C5-C6, biceps muscle (Musculocutaneous nerve).
• Brachioradialis: root C6, brachioradialis muscle (Radial nerve).
• Tricep: roots C7, C8, triceps muscle (Radial nerve).

 Technique for testing reflexes:

1. The muscle group to be tested must be in a neutral position (i.e. neither stretched nor contracted).
2. The tendon attached to the muscle(s) which is/are to be tested must be clearly identified. Place the extremity in a positioned that allows the tendon to be easily struck with the reflex hammer.
3. To easily locate the tendon, ask the patient to contract the muscle to which it is attached. When the muscle shortens, you should be able to both see and feel the cord like tendon, confirming its precise location.
4. Strike the tendon with a single, brisk, stroke. You should not elicit pain.

This grading system is rather subjective.

• 0 No evidence of contraction.
• 1+ Decreased, but still present (hypo-reflexic). Hyporeflexia is generally associated with a lower motor neuron deficit (at the alpha motor neurons from spinal cord to muscle).
• 2+ Normal.
• 3+ Super-normal (hyper-reflexic) Hyperreflexia is often attributed to upper motor neuron lesions.
• 4+ Clonus: Repetitive shortening of the muscle after a single stimulation.

TONE

In PNI the patient has hypotonicity or atonicity.

MMT

individual MMT is to be done and trick movement is to be noticed in patients with weakness or paralysis.

Manual muscle test (MMT) is a procedure for the evaluation of strength of individual muscle or muscles group, based upon the effective performance of a movement in relation to the forces of gravity or Manual Resistance through the available Range of motion (ROM)

0	0		No visible or palpable contraction
Trace	I	1	Visible or palpable contraction (No ROM)
Poor–		2–	Partial ROM, gravity eliminated
Poor	II	2	Full ROM, gravity eliminated
Poor+		2+	Gravity eliminated/slight resistance or < 1/2 range against gravity
Fair–		3–	> 1/2 but < Full ROM, against gravity
Fair	III	3	Full ROM against gravity
Fair+		3+	Full ROM against gravity, slight resistance
Good–		4–	Full ROM against gravity, mild resistance
Good	IV	4	Full ROM against gravity, moderate resistance
Good+		4+	Full ROM against gravity, almost full resistance
Normal	V		Normal, maximal resistance

Manual Muscle Testing Grading System

GONIOMETRY

is the measuring of angles created by the bones of the body at the joints.

SPECIAL TESTS.

UPPER LIMB NERVE TENSION TESTS.

MUSCULOCUTANEOUS NERVE TENSION TEST  

1. Shoulder girdle depression
2. Elbow extension
3. Shoulder extension
4. Ulnar deviation of the wrist with thumb flexion.
5. Either medial or lateral rotation of the arm could further sensitize th

   RADIAL NERVE TENSION TEST

1. Shoulder girdle depression
2. Elbow extension
3. Medial rotation of the whole arm
4. Wrist, finger and thumb flexion

 MEDIAN NERVE TENSION TEST  

1. Shoulder girdle depression
2. Elbow extension
3. Lateral rotation of the whole arm
4. Wrist, finger and thumb extension

 ULNAR NERVE TENSION TEST  

1. Shoulder girdle depression
2. Shoulder abduction
3. Shoulder external rotation
4. Wrist and Finger extension
5. Elbow flexion
6. Shoulder abduction

TINEL SIGN TEST  

A positive Tinel sign means that tapping your nerve causes a tingling sensation to radiate through that area of your body. It’s sometimes described as a pins and needles feeling. 

ULNAR NI TESTS :

• Wartenberg sign.
• Froment sign.

MEDIAN NI TESTS

• Hand of benediction .
•  pinch sign (OK sign).
• median claw(when extending the fingers)

INVESTIGATION

1. EMG should be done and will show a typical neurogenic presentation.
2. A nerve conduction velocity (NCV) will show decreased conduction velocity across the lesion, but the proper interpretation is necessary to differentiate between neuropraxia, axonotmesis, neurotmesis.

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References

1. Duralde X. Neurologic injuries in the athlete’s shoulder. Journal of Athletic Training. 2000;35(3):316-328.

2.Manske R, Sumler A, Runge J. Quadrilateral space syndrome. Humen Kinetics- ATTI.2009;14(2):45-47.

3. Neal S, Fields K. Peripheral nerve entrapment and injury in the upper extremity. American Family Physician. 2010; 81(2): 147-155.

4.Peripheral Nerve Injury. (2021). Family Practice Book. https://fpnotebook.com/ortho/neuro/PrphrlNrvInjry.htm

5.Peripheral nerve injuries. (2020). AMBOSS. https://www.amboss.com/us/knowledge/Peripheral_nerve_injuries/

6.Peripheral nerve injuries. (2021). Mayoclinic. https://www.mayoclinic.org/diseases- conditions/peripheral-nerve-injuries/diagnosis-treatment/drc-20355632

7.Peripheral Nerve Injury. (2021). John Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/peripheral-nerve-injury

8.Perlmutter G, Apruzzese W. Axillary nerve injuries in contact sports: recommendations for treatment and rehabilitation. Sports Med. 1998;26(5): 351-360.

 9. Safran M. Nerve injury about the shoulder in athletes, Part 1: Suprascapular nerve and axillary nerve. Am J Sports Med . 2004;32(3):803-819.

10.Tezcan, A. (2017). Peripheral Nerve Injury and Current Treatment Strategies. Intechopen. https://www.intechopen.com/chapters/55127