PNS: Neuralgia, bells palsy, brachial plexus/traction injuries
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Questions and Answers

A client presents with Bell's palsy and reports difficulty closing their left eye. Which muscle is most likely affected, contributing to this specific symptom?

  • Orbicularis oculi (correct)
  • Zygomaticus major
  • Frontalis
  • Levator palpebrae superioris

A patient with Bell's palsy reports increased sensitivity to low-frequency sounds. Which of the following best explains this phenomenon?

  • Inflammation of the inner ear.
  • Damage to the vestibulocochlear nerve (CN VIII).
  • Compensatory hearing in the unaffected ear.
  • Paralysis of the stapedius muscle due to facial nerve involvement. (correct)

During an assessment of a client with suspected Bell's palsy, which of the following findings would be least likely to be present if the condition is isolated to the facial nerve (CN VII)?

  • Impaired function of the trapezius muscle. (correct)
  • Loss of taste on the anterior two-thirds of the tongue.
  • Unilateral facial drooping.
  • Difficulty wrinkling the forehead on the affected side.

A patient's history reveals a gradual onset of Bell's palsy symptoms over a two-week period. Which of the following questions is most important to ask regarding the progression and sensory changes?

<p>Are you experiencing any pain, and if so, where is it located? (B)</p> Signup and view all the answers

A patient with Bell's palsy is experiencing excessive tearing in their affected eye. Which of the following is the most likely underlying cause?

<p>Inability to effectively drain tears due to impaired muscle function. (B)</p> Signup and view all the answers

A patient reports experiencing sudden, intense, electric shock-like pain along their cheek and jaw. Palpation of a specific area on their cheek reliably triggers the pain. Which condition is MOST likely?

<p>Trigeminal neuralgia (C)</p> Signup and view all the answers

Which of the following characteristics BEST describes the pain associated with neuralgia?

<p>Sharp, stabbing pain that follows the distribution of a specific nerve. (B)</p> Signup and view all the answers

A patient with suspected neuralgia reports that their pain is often clustered, with multiple attacks occurring over a short period, followed by periods of relief. What does this pattern suggest?

<p>The pain is paroxysmal in nature, consistent with neuralgia. (A)</p> Signup and view all the answers

What is the primary goal of decreasing Sympathetic Nervous System (SNS) activity in the context of provided treatments?

<p>To reduce overall tension and promote relaxation. (D)</p> Signup and view all the answers

A patient presents with intercostal neuralgia following a bout of shingles. Which of the following is the MOST likely underlying mechanism of their nerve pain?

<p>Demyelination of the intercostal nerves due to viral infection. (C)</p> Signup and view all the answers

Why are fascial techniques generally avoided according to the given treatment guidelines?

<p>They may be too intense for fragile or compromised tissues. (D)</p> Signup and view all the answers

Which condition involving nerve dysfunction is characterized by pain along the distribution of a nerve in the absence of objective signs or structural damage to the nerve itself?

<p>Neuralgia (D)</p> Signup and view all the answers

What is the purpose of using hydrotherapy on compensatory areas?

<p>To balance muscle tone and reduce tension in overused muscles. (C)</p> Signup and view all the answers

Why is diaphragmatic breathing emphasized in the treatment approach?

<p>To promote efficient oxygen exchange. (A)</p> Signup and view all the answers

What is the rationale behind using inhibitory techniques in this context?

<p>To reduce hypertonicity and spasm in specific muscles. (D)</p> Signup and view all the answers

Why is a towel placed between the therapist and the affected side during the treatment?

<p>To protect fragile tissue from excessive pressure. (C)</p> Signup and view all the answers

What is the primary purpose of applying cool washes to the affected tissues?

<p>To stimulate tissue and reduce edema. (D)</p> Signup and view all the answers

In addition to the affected side of the face, where else should compensatory muscles be treated?

<p>The contralateral neck and shoulder. (A)</p> Signup and view all the answers

During the acute phase of trigeminal neuralgia, what is the MOST appropriate approach to treatment?

<p>Focus treatment on areas of the body away from the trigger zone. (B)</p> Signup and view all the answers

Which of the following is the MOST important question to ask a client with suspected trigeminal neuralgia before considering any treatment near a potential trigger zone?

<p>Do you know what triggers the pain? (C)</p> Signup and view all the answers

A client with trigeminal neuralgia reports pain in the V2 maxillary nerve distribution. Which area is MOST likely affected?

<p>Mucosa of the nose, palate, and upper teeth. (D)</p> Signup and view all the answers

In the context of trigeminal neuralgia, what is the MOST crucial precaution to observe during assessment and treatment?

<p>Avoiding any stimulation of the identified trigger zone. (D)</p> Signup and view all the answers

What is the PRIMARY focus of home care advice for a client recovering from a trigeminal neuralgia attack?

<p>Diaphragmatic breathing exercises. (B)</p> Signup and view all the answers

A patient presents with symptoms mimicking trigeminal neuralgia. What differentiating factor would suggest the pain is MOST likely myofascial in origin?

<p>A gradual onset with a constant, dull ache in the affected area. (B)</p> Signup and view all the answers

Following a recent acute attack of trigeminal neuralgia, what treatment approach is MOST appropriate during the acute phase?

<p>Focusing treatment on areas distant from the affected region. (B)</p> Signup and view all the answers

A client presents with a sharp, recurring pain along their cheek and jawline. They also report experiencing muscle spasms in their face. Which condition is MOST likely indicated by these symptoms?

<p>Trigeminal neuralgia. (B)</p> Signup and view all the answers

Which of the following cranial nerves is affected in trigeminal neuralgia?

<p>Trigeminal nerve (CN V). (B)</p> Signup and view all the answers

What homecare recommendation would be MOST beneficial for a patient with trigeminal neuralgia to help prevent pain?

<p>Performing regular facial exercises. (D)</p> Signup and view all the answers

Which branch of the facial nerve (CN VII) primarily innervates the forehead and orbital area?

<p>Temporal branch. (C)</p> Signup and view all the answers

Besides mastication, what other function is associated with the motor branch of the trigeminal nerve?

<p>Tension of the tensor tympani muscle for audition. (C)</p> Signup and view all the answers

If a lesion of the facial nerve occurs after the stylomastoid foramen, what function would be exclusively affected?

<p>Motor function. (A)</p> Signup and view all the answers

A client with trigeminal neuralgia experiences locked jaw. Which of the following is the MOST likely cause of this symptom?

<p>Paralysis of the muscles of mastication. (A)</p> Signup and view all the answers

What is the MOST appropriate initial treatment strategy when working with a client who has a history of trigeminal neuralgia, but is not currently experiencing an acute attack?

<p>Start with techniques that avoid the known trigger zones, focusing on areas like the diaphragm and ribs. (D)</p> Signup and view all the answers

Damage to the stapedius muscle, innervated by the facial nerve, may result in what auditory symptom?

<p>Hyperacusis (increased sensitivity to sound). (D)</p> Signup and view all the answers

Which sensory function is NOT associated with the mandibular branch (V3) of the trigeminal nerve?

<p>Sensation of taste on the anterior two-thirds of the tongue. (D)</p> Signup and view all the answers

A patient presents with rapid onset unilateral facial paralysis, but reports no facial pain. Which condition is MOST likely?

<p>Bell's Palsy. (C)</p> Signup and view all the answers

Which etiological factor is LEAST likely to be associated with Bell's Palsy?

<p>Cervical strain. (B)</p> Signup and view all the answers

Which population has an increased risk for developing Bell's Palsy?

<p>Pregnant women in their 3rd trimester. (A)</p> Signup and view all the answers

A client with Bell's Palsy is receiving facial massage. On the affected side, which massage technique is MOST appropriate?

<p>Light brushing/stroking moving toward the lesion. (A)</p> Signup and view all the answers

Which of the following instructions is MOST suitable for a Bell's Palsy client to perform at home to improve function?

<p>Perform gentle facial exercises in front of a mirror, 2-5 minutes at a time, 2-3 times per day. (D)</p> Signup and view all the answers

Why is diaphragmatic breathing encouraged in the treatment of Bell's Palsy?

<p>To reduce overall stress and promote relaxation, which can indirectly benefit facial nerve function. (C)</p> Signup and view all the answers

What is the MOST common resting deformity observed in infants with Erb's Palsy?

<p>Waiter's Tip Deformity (C)</p> Signup and view all the answers

A patient presents with Erb's palsy following a traumatic injury. Which group of muscles is MOST likely to exhibit motor deficits?

<p>Shoulder abductors, elbow flexors, and forearm supinators. (B)</p> Signup and view all the answers

In the acute stage of Erb's Palsy, which intervention is MOST appropriate to maintain joint health and prevent contractures?

<p>Passive range of motion (PROM) within pain-free limits. (C)</p> Signup and view all the answers

A client presents with Klumpke's paralysis. Which deformity is MOST likely to be observed?

<p>Claw hand deformity (C)</p> Signup and view all the answers

Which of the following muscles would be MOST affected in Klumpke's palsy?

<p>Lumbricals (C)</p> Signup and view all the answers

A patient with Klumpke's paralysis exhibits vasomotor dysregulation. What clinical sign would MOST likely be observed?

<p>Severe edema (C)</p> Signup and view all the answers

Following a brachial plexus injury, what precaution should be taken when applying massage to the affected area?

<p>Avoid tractioning a regenerating nerve and treat edema proximally. (B)</p> Signup and view all the answers

To avoid placing drag on healing tissue during treatment of a brachial plexus injury, what technique is MOST appropriate?

<p>Blocking with the ulnar border of the hand just proximal to the lesion. (A)</p> Signup and view all the answers

A football player experiences a burner (stinger) after a collision. Which symptom is LEAST likely to be associated with this injury?

<p>Gradual loss of motor function in the affected limb over several weeks (B)</p> Signup and view all the answers

In Horner's Syndrome associated with Klumpke's paralysis, which combination of symptoms would be expected on the affected side?

<p>Pupil constriction, drooping eyelid, recession of the eyeball, and absence of facial sweating (A)</p> Signup and view all the answers

Which of the following factors is MOST important to consider when treating a client with a brachial plexus injury?

<p>Ensuring any massage techniques do not place tractional forces on regenerating nerves. (B)</p> Signup and view all the answers

Which of the following is the MOST likely cause of Horner's syndrome in a patient with Klumpke's paralysis?

<p>Injury to the superior cervical ganglion / autonomic fibers innervating the eyes and face. (B)</p> Signup and view all the answers

Flashcards

Neuralgia

Nerve pain resulting from nerve dysfunction, often without structural damage.

Neuralgia Pain

Sudden, intense pain that feels like electric shocks or throbbing along a nerve.

Common Neuralgia Nerves

Trigeminal nerve (CN V) and Intercostal nerves

Trigger Zone

A specific area that, when stimulated, triggers a neuralgia attack.

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Causes of Neuralgia

Local compression from neuroma or demyelinating conditions.

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Trigeminal Neuralgia Treatment (Acute)

Avoid direct treatment during an acute phase; focus on relaxation and mobility elsewhere.

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Relaxation Techniques for Trigeminal Neuralgia

Gentle techniques like diaphragmatic breathing and abdominal massage to promote relaxation.

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Rib Springing for Thoracic Mobility

Restoring movement of the ribs to aid thoracic mobility.

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When to Treat the Trigger Zone

Only when you understand triggers and your touch won't provoke pain.

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Trigeminal Nerve Function

Motor: Mastication, tensor tympani (audition), tensor veli palitini (deglutition). Sensory: Facial skin.

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V1 Supraorbital Branch Innervation

Upper eyelid, cornea, forehead, and anterior scalp.

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V2 Maxillary Branch Innervation

Mucosa of nose, palate, upper teeth, upper lip, and lower eyelid.

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V3 Mandibular Branch Innervation

Anterior 2/3 tongue (not taste), cheeks, lower teeth, mandible skin, floor of mouth.

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Trigeminal Neuralgia Trigger Zones

Areas like the lips, face, or tongue that provoke intense pain when stimulated.

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Key Sign of Trigeminal Neuralgia

Horrible, lightning-like, terrible pain that occurs in fits, often for no apparent reason.

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Facial Nerve Branches

Branches of the facial nerve (CN VII): Temporal, Zygomatic, Buccal, Mandibular, and Cervical.

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Bell's Palsy Key Sign

Difficulty or inability to close the eye due to orbicularis oculi muscle dysfunction.

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Bell's Palsy Manifestations

Unilateral loss of forehead wrinkles, droopy face, difficulty blinking, nasal issues, and altered taste/salivation.

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Bell’s Palsy Systemic Disorder Risk Factors

Diabetes, pregnancy and cardiovascular conditions.

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Key History Questions for Bell's Palsy

Onset, rate of change, sensory changes, impacts on normal function; pain.

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Trigeminal Neuralgia

Sudden, intense facial pain caused by nerve irritation, often with a trigger zone.

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Trigeminal Neuralgia vs. Myofascial Pain

Sharp, stabbing facial pain, potentially mistaken for myofascial pain.

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Trigeminal Neuralgia Precaution

Avoid stimulating the trigger zone during assessment and treatment.

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Trigeminal Neuralgia - Acute Treatment

Avoid direct treatment during the acute phase or after a recent attack.

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Trigeminal Neuralgia Treatment

Warm cloths, relaxation, and gentle massage can decrease facial pain.

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Trigeminal Neuralgia Homecare

Facial exercises to help prevent pain.

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Facial Nerve (CN VII) - Motor Function

Facial expression is a key function controlled by 5 branches.

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Facial Nerve (CN VII) - Sensory Function

Taste sensation on the anterior 2/3 of the tongue.

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Facial Nerve (CN VII) - Autonomic Function

Lacrimation (tears) and sweating.

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Bell's Palsy

Rapid onset of unilateral facial paralysis/weakness, often idiopathic.

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Decrease SNS

To reduce activity of the Sympathetic Nervous System.

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Swedish Massage

Gentle massage techniques to promote relaxation; avoid deep work on fragile tissue itself.

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Treat Compensatory Muscles

Focus on other side of face, contralateral muscles, neck and shoulder.

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Hydrotherapy for Affected Area

Warmth can soothe; cool washes can stimulate or reduce edema.

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Diaphragmatic Breathing

Promotes relaxation and reduces tension.

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Inhibitory Techniques

Techniques that reduce muscle tone and tension.

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Towel Placement

To protect fragile tissue.

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Avoid Fascial Techniques on affected tissue

Gentle techniques used for relaxation, not structural change.

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Erb's Palsy Cause

Forcibly moving the head/neck & shoulders apart, injuring C5-C6 nerve roots (upper plexus).

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Waiter's Tip Deformity

Arm hangs limp in adduction/internal rotation, elbow extended, forearm pronated, wrist/fingers flexed.

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Erb's Palsy Nerves

C5-C6 nerve roots

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Erb's Palsy Myotome Deficits

Shoulder abduction (C5) and elbow flexion/wrist extension (C6).

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Erb's Palsy Sensory Deficits

C5 and C6 dermatomes

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Klumpke's Palsy Cause

Traction on the c-spine with shoulder extension affecting C8-T1.

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Claw Hand Deformity

MCP extension, PIP/DIP flexion due to lumbrical loss.

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Klumpke's Palsy Nerves

C8-T1. Affects ulnar and median nerve fibers.

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Klumpke's Palsy Myotome Deficits

C8 (thumb extension, ulnar deviation) and T1 (finger abduction).

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Klumpke's Palsy Sensory Deficits

C8 and T1 dermatomes

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Horner's Syndrome Signs

Miosis (pupil constriction), ptosis (drooping eyelid), enophthalmos (recessed eyeball), anhidrosis (lack of sweating).

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Horner's Syndrome Etiology

Injury to superior cervical ganglion / autonomic fibers.

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Burners/Stingers Cause

Over-stretch or compression injury to brachial plexus.

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Brachial Plexus Injury Treatment

Segmental techniques proximal to lesion site.

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Burners/Stingers Symptoms

Immediate lancinating pain, paresthesia, weakness.

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Study Notes

  • Neuralgia is nerve pain that comes from nerve dysfunction.
  • Nerve pain presents as pain in a nerve’s distribution, with or without objective signs.
  • Trigeminal neuralgia and intercostal neuralgia are the most common types.

Trigeminal Neuralgia (CNV)

  • Causes excruciating "lightning-like" or throbbing pain.
  • Is often due to damage or injury to affected nerve
  • Has a trigger zone that causes attacks when stimulated.
  • Causes paroxysmal, intense, unilateral pain along the nerve's distribution that lasts seconds to minutes.
  • Originate from a neuroma, previous injury, demyelinating conditions like MS, or bony callus.
  • Can be triggered by light touch, temperature extremes, intense light, or movement.
  • Avoid stimulating the trigger zone during assessment or treatment.
  • The trigeminal nere has three branches: V1 is the supraorbital branch, V2 is the maxillary branch, and V3 is the mandibular branch.
  • V1 innervates the eyelid, lacrimal gland, and upper nasal cavity.
  • V2 innervates a part of the pharynx, teeth, upper lip, and lower eyelid.
  • V3 innervates the anterior 2/3 of the tongue (not taste).
  • V2 is the most common area affected.
  • Symptoms include painful tics, fascial tics, loss of hearing due to paralysis of tensor tympani.
  • Can cause a locked jaw due to paralysis of muscles of mastication.
  • Differential diagnosis includes acute migraines and cluster headaches.
  • Myofascial pain can make it difficult to differentiate the cases

Intercostal Neuralgia

  • Causes unilateral pain in a segment at the intercostal laterally.
  • Is not a condition of nerve degeneration but is terrible, lightning-like pain that is often comes on in fits for no reason.
  • Post-herpes zoster (shingles) can lead to intercostal neuralgia.
  • Address what triggers the pain, what diagnosis or treatment is the patient receiving, and the rate of change.
  • Avoid treating the trigger zone during the acute phase but treat the rest of the body.
  • Diaphragmatic breathing works around the trigger.

Facial Nerve

  • The areas affected by a facial nerve lesion include mastication, audition, deglutition, and the skin of the face.
  • Temporal, zygomatic, and mandibular paralysis
  • Damage may result in fast transition from tone to flaccidity.
  • Bell’s Palsy is Idiopathic
  • Increased risk for people with diabetes mellitus and pregnant women in their 3rd trimester
  • Can result in flaccid paralysis with autonomic (lacrimation, sweating) and sensory (taste) dysfunctions and impact hearing (hyperacusis).
  • Common symptoms: eye closure difficulty, overall drooping, difficulty speaking/eating/drinking, brow droop, disappearing of wrinkles on affected side, and excess lacrimation.
  • Unable to close the eye and wrinkle forehead
  • Palsy is a condition of nerve degeneration.
  • Protect fragile tissue on the affected side, encouragement is helpful

Treatments for facial lesions

  • Techniques should feed and stimulate the area from mid-line toward the lesion
  • Treatments include diaphragmatic breathing and treating the chest, posterior shoulder, scalp, face.
  • Use light brushing/stroking toward lesion and PNF stretching.
  • Can do cue and assist with fascial expressions (therapeutic movement)
  • Avoid fascial techniques and ensure pressure and stroking on unaffected side is toward lesion site.

Brachial Plexus Traction Injuries

  • Typically from birthing process/difficult delivery.
  • Can occur from traumatic injury in adults.
  • Over-stretch injury or compression injury.
  • Erb's Palsy typically affects the upper plexus.
  • Erb's Palsy is Typically caused by Deltoid CS-.
  • Erb's Palsy leads to extension of the shoulder with traction of c-spine
  • Can be caused falling from a height and grabbing catch
  • or Manipulation during delivery of breech birth
  • Klumpke's Paralysis affects the lower plexus.
  • Results in clawed hand, ape hand, path hand resulting in loss of nerve fibres
  • Klumpke's Paralysis will result in finger adduction/finger abd and add/MCP flexion, PIP & DIP flexion
  • Horner's syndrome is associated with Klumpke's paralysis.
  • Horner's Syndrome is probably injury to the superior cervical ganglion/autonomic fibres innervating the eyes and face which leads to Miosis
  • Anhidrosis relates to dysregulation/inhibition

Common Symptoms

  • Report lancinating pain or pain occurring hours after incident.
  • Causes progressive weakness right after injury, or may only take a few minutes or hours.
  • Treat proximally to the edge of the edema if present.
  • "Blocking " proximal to the lesion prevents placing drag on the healing tissue.
  • After regeneration has passed that site (approx 2 weeks post trauma or 3 weeks if slower to heal), treat tissues closer to lesion with light strokes and gentle compression.

Continued Care and Questions to Ask

  • Has healing progressed/plateaued and prevented chronic situation?
  • Positioning, splinting/immobilizing or range of motion.
  • How often does patient perform exercise/movement/stretches?
  • Address positioning when changing position on the table.
  • Is the affected side shortened or contracted?
  • What does myotome, dermatome, and sensory testing indicate? How are they going?
  • Splinting, retraining, and re-education.
  • Focus on regaining lost function and preventing deformity.
  • Help manage edema using unidirectional stroking, manual lymphatic drainage.
  • Decrease contractures.
  • Promote relaxation with diaphragmatic breathing and gentle contrast hydro therapy.
  • Facilitate any regained function through strengthening exercises and sensory re-education.
  • Educate on being aware of the desensitized tissues, using different fabrics, etc.

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