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DON’T JUST RECOVER. CONQUER. Rehabilitation Following Brachial Plexopathy “Stingers” Scott Kaylor, PT, DPT, SCS Proaxis Therapy.

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Presentation on theme: "DON’T JUST RECOVER. CONQUER. Rehabilitation Following Brachial Plexopathy “Stingers” Scott Kaylor, PT, DPT, SCS Proaxis Therapy."— Presentation transcript:

1 DON’T JUST RECOVER. CONQUER. Rehabilitation Following Brachial Plexopathy “Stingers” Scott Kaylor, PT, DPT, SCS Proaxis Therapy

2 DON’T JUST RECOVER. CONQUER. Acknowledgements ➔ Timothy McHenry III, MD ➔ Whitney Wiles, ATC ➔ Matthew Baird, MD ➔ Tom Denninger, PT, DPT, OCS, FAAOMPT ➔ Chuck Thigpen, PhD, PT, ATC

3 DON’T JUST RECOVER. CONQUER. Objectives ➔ To identify the prevalence of brachial plexopathy. ➔ To identify the anatomy involved with brachial plexopathy injury. ➔ To describe an evidence-based return-to-play progression that is criteria driven.

4 DON’T JUST RECOVER. CONQUER. Prevalence and Incidence ➔ Common in contact and collision sports. ➔ Reported annual incidence of a stinger is between 49-65% in collegiate-level football players over a 4-year career ➔ Recurrence rate 57% ➔ 5-10% of players have more serious injuries with prolonged neurological deficits

5 DON’T JUST RECOVER. CONQUER. Common ➔ Unilateral UE involvement ➔ A traumatic event ➔ Painful sensation that radiates from their neck to their finger tips ➔ Lancinating, burning pain, and dysesthesia usually in a dermatomal pattern. ➔ Weakness/”dead arm” Red Flags ➔ Bilateral symptoms or symptoms into more than one limb. o Suspect spinal cord involvement ➔ If the player remains on the “field of play” the possibility of a spinal cord injury must be considered and ruled out before he is allowed to walk. Signs and Symptoms

6 DON’T JUST RECOVER. CONQUER. ➔ Pain typically seconds to hours. o Rarely beyond 24-hours ➔ May experience weakness in deltoid and supra/infraspinatus that typically resolves in 24-hours to 6 weeks. Symptom Duration

7 DON’T JUST RECOVER. CONQUER. ➔ Grade I o neurapraxia ➔ Grade II o axonotmesis ➔ Grade III o neurotmesis Injury Grading

8 DON’T JUST RECOVER. CONQUER. Pain control Restore ROM Muscle facilitation Improve muscular endurance Improve shoulder mobility as needed Incorporate extremity movements with stabilization Improve muscle strength Implement sport specific activities without contact Initiate contact drills Return to play Management Phase I Phase 2 Phase 3 Phase 4

9 DON’T JUST RECOVER. CONQUER. Phase I Rehabilitation ➔ Pain control ➔ Restore cervical ROM ➔ Initial muscle facilitation

10 DON’T JUST RECOVER. CONQUER. ➔ Manual Therapy o Traction o Joint mobilization o Soft tissue mobilization ➔ Modalities o Traction o E-stim Phase I Rehabilitation

11 DON’T JUST RECOVER. CONQUER. ➔ 1 st Rib Mobilization o Elevated 1 st rib due to scalene spasm o Assess with cervical rotation lateral flexion test Phase I Rehabilitation

12 DON’T JUST RECOVER. CONQUER. ➔ Supported chin tucks o With biofeedback Phase I Exercise Examples

13 DON’T JUST RECOVER. CONQUER. ➔ Neural Dynamics o Sliders vs. tensioners to increase excursion o Do NOT want to increase strain during healing Phase I Rehabilitation

14 DON’T JUST RECOVER. CONQUER. ➔ Cervical ROM o Adjust and progress positioning Phase I Rehabilitation

15 DON’T JUST RECOVER. CONQUER. ➔ Full cervical ROM ➔ Resolution of upper extremity symptoms o Not necessarily full resolution of strength ➔ Be able to maintain a supine chin tuck for 30 seconds Criteria to Begin Phase II

16 DON’T JUST RECOVER. CONQUER. Phase II Rehabilitation ➔ Improve shoulder mobility as needed ➔ Improve muscular endurance ➔ Incorporate extremity movements with stabilization.

17 DON’T JUST RECOVER. CONQUER. ➔ Shoulder mobility Phase II Rehabilitation

18 DON’T JUST RECOVER. CONQUER. ➔ Quadruped and prone chin tucks ➔ Cervical stabilization with extremity movements o “No Money” o Dying bug ➔ Half kneel chop and lift ➔ Upper extremity exercises o Bands o PNF o Isotonics Phase II Exercise Examples

19 DON’T JUST RECOVER. CONQUER. ➔ Shoulder Strengthening Phase II Exercise Examples

20 DON’T JUST RECOVER. CONQUER. ➔ Half Kneel Chop and Lift Phase II Exercise Examples

21 DON’T JUST RECOVER. CONQUER. ➔ Be able to hold chin tuck with head lift (without helmet) for 30 seconds ➔ > 4/5 upper extremity strength to be able to perform light-to-moderate upper extremity strengthening without symptoms Criteria to Begin Phase III

22 DON’T JUST RECOVER. CONQUER. Phase III Rehabilitation ➔ Improve muscular strength ➔ Implement sport specific activities without contact

23 DON’T JUST RECOVER. CONQUER. ➔ Cervical Strengthening ➔ Participation in weight lifting with team Phase III Exercise Examples

24 DON’T JUST RECOVER. CONQUER. ➔ Criteria to begin phase IV o Be able to maintain a chin tuck with head lift wearing a helmet > 30 seconds o No symptoms o Full upper extremity strength Phase IV Rehabilitation

25 DON’T JUST RECOVER. CONQUER. ➔ Phase IV o Initiate contact drills Percussion to Erb’s Point Spurling’s Test o Return-to-play Phase IV Rehabilitation

26 DON’T JUST RECOVER. CONQUER. Return to Play Criteria ➔ General RTP Criteria: o Adequate time to heal from primary injury o Absence of underlying conditions that pose undue risk of further injury o Resolution of all symptoms o Full, pain-free ROM o Appropriate cardiovascular fitness o Normal strength o Ability to perform sport-specific skills without symptoms ➔ Same game if complete resolution of symptoms, return-to-baseline ROM and strength profile.

27 DON’T JUST RECOVER. CONQUER. Slow-to-No Symptom Resolution ➔ Communication with and referral to team physician ➔ Further imaging o Radiographs o MRI o CT scan or SPECT scan ➔ EMG study

28 DON’T JUST RECOVER. CONQUER. ➔ Identifying those at risk o Post-season questionnaire ➔ Proper tackling techniques o Avoid dropping shoulder o Continued eye contact with opposing player should allow for more upright position ➔ High riding shoulder pads to absorb impact ➔ Protective neck rolls o Prevent excessive lateral flexion & extension of neck o NEVER connect straps from helmet to shoulder pads Prevention

29 DON’T JUST RECOVER. CONQUER. ➔ Brachial Neuropraxia Postseason Questionnaire o Clin J Sport Med. 2012; (22)6

30 DON’T JUST RECOVER. CONQUER. Key Points ➔ Stingers are common and history of stinger increases likelihood of sustaining subsequent stinger. ➔ Use criteria to drive rehabilitation progressions. ➔ Do not return to play if have not returned to baseline. ➔ Communication with sports medicine team is important, particularly in the presence of slowly resolving symptoms.


32 DON’T JUST RECOVER. CONQUER. References 1. Vaccaro et al. Return to play criteria for the athlete with cervical spine injuries resulting in stinger and transient quadriplegia/paresis. Spine Journal. 2002 Sep-Oct;2(5):351-6. 2. Castro, F. Stingers, cervical cord neurapraxia, and stenosis. Clin Sports Med22 (2003) 483-492. 3. Concannon LG, et al. Radiating upper limb pain in the contact sport athlete: an update on transient quadriparesis and stingers. Curr Sports Med Rep. 2012 Jan-Feb;11(1):28-34. 4. Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. 5. Coppieters MW, et al. The immediate effects of cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. J Orthop Sports Phys Ther. 2003 July;33(7):369-378. 6. Coppieters MW, et al. Different nerve-gliding exercises induce different magnitudes of median nerve longitudinal excursion: an in vivo study using dynamic ultrasound imaging. J Orthop Sports Phys Ther. 2009 March;39(3):164-171. 7. Safran MR. Nerve injury about the shoulder in athletes, part 2. AJSM. 2004;32(4):1063-1076. 8. Editorial. Improving application of neurodynamic (neural tension) testing and treatments: A message to researchers and clinicians. Manual Therapy. 2005;10:175-179. 9. Weinstein, SM. Assessment and rehabilitation of the athlete with a stinger. Clinics in Sports Medicine. 1998;(17)1:127-135. 10. Jellad, A, et al. The value of intermittent cervical traction in recent cervical radiculopathy. Annals of Physical and Rehabilitative Medicine. 2009;(52)638-652. 11. Schenk, R, et al. Inclusion of mechanical diagnosis and therapy (MDT) in the management of cervical radiculopathy: a case report. The Journal of Manual & Manipulative Therapy. 2008;16(1):E2-E8.

33 DON’T JUST RECOVER. CONQUER. 12. Rihn, JA, et al. Cervical spine injuries in American football. Sports Med. 2009;39(9):697-708. 13. Cantu RV and Canut RC. Current thinking: return to play and transient quadriplegia. Current Sports Medicine Reports. 2005, 4:27-32. 14. Abdulwahab, SS and Sabbahi, M. Neck retractions, cervical root decompression, and radicular pain. JOSPT. 2000;30(1):4-12. 15. Gross, AR, et al. Knowledge to action: A challenge for neck pain treatment. JOSPT. 2009;39(5):351-363. 16. O’Leary, S, et al. Muscle dysfunction in cervical spine pain: implications for assessment and management. JOSPT. 2009;39(5):324-333. 17. Ghiselli, G, et al. On-the-field evaluation of an athlete with a head or neck injury. Clin Sports Med. 2003;22:445- 465. 18. Olson, DE, et al. Unilateral cervical nerve injuries: brachial plexopathies. Current Sports Medicine Reports. 2007,6:43-49. 19. Charbonneau, RM, et al. Brachial neuropraxia in Canadian Atlantic University Sport Football Players: What is the incidence of “stingers”? Clin J Sport Med. 2012; 22(6):472-477. 20. Weinberg, J, et al. Etiology, treatment, and prevention of athletic “stingers”. Clin Sports Med. 2003,21:493-500. 21. Standaert CJ and Herring SA. Expert opinion and controversies in musculoskeletal and sports medinice: stingers. Arch Phys Med Rehabil. 2009,90:402-406. 22. Stracciolini A. Cervical burners in the athlete. Pediatr Case Rev. 2003,3:181-188. 23. Sterling M. (2003) Development of motor dysfunction following whiplash injury. Pain, 103, 65–73. 24. Jull, G. (2002) A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27(17), 1835–43.

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