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Rehabilitation Following Brachial Plexopathy “Stingers” . Scott Kaylor, PT, DPT, SCS Proaxis Therapy. Acknowledgements. Timothy McHenry III, MD Whitney Wiles, ATC Matthew Baird, MD Tom Denninger, PT, DPT, OCS, FAAOMPT Chuck Thigpen, PhD, PT, ATC. Objectives. - PowerPoint PPT Presentation
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DON’T JUST RECOVER. CONQUER.
Rehabilitation Following Brachial Plexopathy“Stingers”
Scott Kaylor, PT, DPT, SCSProaxis Therapy
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
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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.
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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
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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
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➔ 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
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➔ Grade Io neurapraxia
➔ Grade IIo axonotmesis
➔ Grade IIIo neurotmesis
Injury Grading
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ManagementPhase I Phase 2 Phase 3 Phase 4
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Phase I Rehabilitation
➔ Pain control➔ Restore cervical ROM➔ Initial muscle facilitation
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➔ Manual Therapyo Tractiono Joint mobilizationo Soft tissue mobilization
➔ Modalitieso Tractiono E-stim
Phase I Rehabilitation
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➔ 1st Rib Mobilizationo Elevated 1st rib due to scalene spasmo Assess with cervical rotation lateral flexion test
Phase I Rehabilitation
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➔ Supported chin tuckso With biofeedback
Phase I Exercise Examples
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➔ Neural Dynamicso Sliders vs. tensioners to increase excursiono Do NOT want to increase strain during healing
Phase I Rehabilitation
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➔ Cervical ROM o Adjust and progress positioning
Phase I Rehabilitation
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➔ 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
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Phase II Rehabilitation
➔ Improve shoulder mobility as needed➔ Improve muscular endurance➔ Incorporate extremity movements with
stabilization.
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➔ Shoulder mobility
Phase II Rehabilitation
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➔ 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 Bandso PNFo Isotonics
Phase II Exercise Examples
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➔ Shoulder Strengthening
Phase II Exercise Examples
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➔ Half Kneel Chop and Lift
Phase II Exercise Examples
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➔ 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
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Phase III Rehabilitation
➔ Improve muscular strength➔ Implement sport specific activities without
contact
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➔ Cervical Strengthening➔ Participation in weight lifting with team
Phase III Exercise Examples
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➔ Criteria to begin phase IVo Be able to maintain a chin tuck with head lift
wearing a helmet > 30 secondso No symptoms o Full upper extremity strength
Phase IV Rehabilitation
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➔ Phase IVo Initiate contact drills• Percussion to Erb’s Point• Spurling’s Test
o Return-to-play
Phase IV Rehabilitation
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Return to Play Criteria
➔ General RTP Criteria:o Adequate time to heal from primary injuryo Absence of underlying conditions that pose undue risk of
further injuryo Resolution of all symptomso Full, pain-free ROMo Appropriate cardiovascular fitnesso Normal strengtho Ability to perform sport-specific skills without symptoms
➔ Same game if complete resolution of symptoms, return-to-baseline ROM and strength profile.
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Slow-to-No Symptom Resolution
➔ Communication with and referral to team physician
➔ Further imagingo Radiographso MRIo CT scan or SPECT scan
➔ EMG study
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➔ Identifying those at risko Post-season questionnaire
➔ Proper tackling techniqueso Avoid dropping shouldero 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 necko NEVER connect straps from helmet to shoulder pads
Prevention
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➔ Brachial Neuropraxia Postseason Questionnaireo Clin J Sport Med. 2012; (22)6
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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.
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Thank you!
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References
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