Appendix 1
Facial assessment
Hand assessment
Foot assessment
Appendix 2
Name of the device |
Indication |
Brief description |
Adapted spoon |
Those with no grasp due to absorbed digits or complete paralysis of hand muscles |
Device is made of a spoon attached to an aluminum cuff to facilitate the retention of the spoon in the hand while eating. This device can be adopted for a toothbrush and a comb. |
Built-up spoon |
Those with some grasp but inability to hold thin items such as a spoon or toothbrush during function movement |
Soft material is padded around the spoon handle to facilitate grip for those with poor hand grasp. The same modifications can be done for a toothbrush, pen, shaving razors, and comb. |
Nail cutting device |
Those with deformities; clawed fingers and thumb paralysis |
Nail cutter is attached to stable base and cutter handle is broadened to facilitate easy cutting of nail. |
Soap holder |
Those with paralyzed fingers and thumb or absorbed digits with difficulty in grasp |
Soap is fixed into an aluminum holder, which is attached to a stable cuff around the palm to facilitate the retention of the soap in the hand. This device is rarely used. |
Button hook |
Those with difficulty in fine motor activity due to paralysis and/or loss of sensation |
A hook is fixed to a soft handle to facilitate buttoning, which is very challenging for those with thumb paralysis. |
Writing aid |
Those with poor prehension (tripod) function with some pinch power |
A soft rubber grip slips onto a pen or pencil to facilitate grip while writing. |
Grip aids |
Those with absorbed digits with some grasp/prehension function |
Made of a special material that takes the shape of the contact surface of the fingers to facilitate easy grasp. |
Universal cuff |
Those with poor or no grasp due to absorbed digits or paralysis of muscles of the hand Those without fingers or loss of grasp |
This device consists of a nylon or leather cuff around the palm with a pocket to insert a spoon, toothbrush, comb, etc. |
Zipper puller |
Those with poor prehension function |
This device consists of a hook with a ring at one end to facilitate pulling a zipper. |
Appendix 3
Nerve |
Major Muscle(s) affected |
Active Exercise |
Active Assisted Exercise |
Passive Exercise |
Facial |
Orbicularis Occuli |
Patient should try to tightly close eye, hold it for 10–20 counts, and then open it. Repeat 5 to 10 times hourly. |
Patient should place index finger at lateral side of eye and gently pull eyelid laterally so that it closes. |
|
Ulnar |
Abductor digiti Minimi Interossei Lumbricals 4th & 5th Flexor Digitorum Profundus 4th & 5th Flexor Carpi Ulnaris |
Patient is asked to adduct and abduct fingers as much as possible with palm placed on flat surface (thigh / table). IP joints are flexed and extended while MCP joints are kept in flexion, wrist in neutral, and elbow in extension on soft padded surface. |
MCP joints of affected hand are supported at 90 degrees by other hand, which is held in lumbrical position. From this position (MCP at 90 degrees flexion and wrist in neutral), interphalangeal joints of medial four fingers of affected hand need to be flexed and extended completely. |
Hand is placed on thigh or soft flat surface, with palm facing up. Palm or hypothenar area of unaffected hand is used to gently straighten fingers. Once one cycle of exercise is over, other hand is lifted up and then exercise is done again. Repeat exercise at least 10 times every 2–3 hours. Oil or Vaseline can be used to soften hand. |
Median |
Abductor Pollicis Brevis Extensor Digitorum Profundus 2 & 3rd Oppones Pollicis Longus Lumbricals 2nd & 3rd |
Extended thumb of affected hand is moved into abducted position; position needs to be maintained for some time. |
Support MCP joint of affected thumb with thumb and fingers of other hand: With thumb fixed in above position, interphalangeal joint of thumb should be flexed and extended. Exercise will prevent contracture of IP joints of thumb. |
Hand is placed on soft flat surface with palm facing up. Extended thumb of affected hand is moved into opposition with other four fingers. Thumb is also actively moved into abduction position and this position is maintained for about 5 seconds. Repeat exercise at least 10 times every 2–3 hours. |
Radial |
Extensor Carpi Ulnaris Extensor Carpi Radialis longus & Brevis Extensor Digitorum Communis & Indicis |
Keep wrist on edge of table, palm facing down. Ask patient to extend wrist and hold it for 30 seconds. Repeat exercise at least 10 times every 2–3 hours. |
Two palms are placed in approximation with each other. From this position, wrist of normal hand is flexed to make affected wrist move into extension. Extension of paralyzed wrist should make it move to end ranges. Other method of exercising wrist is to place it flat on surface and lift elbow perpendicular to wrist joint. |
|
Lateral Popliteal |
Tibialis Anterior Extensor Digitorum Longus Extensor Hallusis Longus |
Patient sits high with legs not supported by ground. Foot is dorsiflexed and position is maintained for about 15 to 20 seconds. Repeat exercise at least 10 times every 2–3 hours. |
Leg with paralyzed foot is placed over other leg and patient actively tries to dorsiflex foot on this gravity-eliminated plane. |
Patient is positioned in long sitting (leg in extended position). Towel is placed over plantar surface over forefoot and patient holds edges of towel. When towel is pulled towards patient, foot is dorsiflexed and held in this position for about 10 seconds and then released. Another exercise can be performed by standing about a foot in front of a wall, facing wall. Patient can lean forward with hands placed on wall for support. Position causes foot to dorsiflex. Repeat exercise at least 10 times every 2–3 hours. |
Posterior Tibial |
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Patient is positioned with affected leg resting on other thigh. Patient can use hand to stretch toes passively and hold for 20 seconds. |
* IP = Interphalangeal; MCP = Metacarpophalangeal
Appendix 4
|
Pre-Operative Assessment |
Post-Operative Assessment |
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Ulnar Nerve |
Median Nerve |
Radial Nerve |
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Muscle Assessment |
Abductors of little and index fingers Intrinsic muscles Flexor Digitorum Profundus – Ring and Little finger Flexor carpi Ulnaris |
Abductors and the opposers of thumb Flexor Carpi Radialis Intrinsic muscles Flexor Digitorum Profundus – Index and middle finger Pronator Teres Palmaris Longus Flexor Pollicis longus |
Extensor carpi Radialis longus and brevis Extensor carpi ulnaris Extensor digitorum communis Extensor pollicis longus Extensor digiti minimi |
Infection Stitch abscess Swelling Adhesion Loose tension Tendon slipping Pain Sublimus Minus Check Rein |
Sensation |
Sensory areas supplied by ulnar nerve |
Sensory areas supplied by median nerve |
Sensory areas supplied by radial nerve |
|
Angle Measurements |
Finger PIP angles in MCP flexion Thumb MP and IP angles |
Thumb web measurement Thumb MP and IP angles |
Wrist angles |
|
Secondary Impairments |
Assess for
|
Assess for
|
|
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Functional Assessment |
Grasp contact Grasp strength Pinch Contact Pinch strength 9-hole peg boards Other functional activities concerning the patients occupation:
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* PIP = Proximal Interphalangeal; MCP = Metacarpophalangeal; IP = Interphalangeal; DDE = Dorsal Digital Expansion
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Lateral Popliteal Nerve |
|
|
Pre-Operative Assessment |
Post-Operative Assessment |
Muscle Assessment |
Tibialis anterior Tibialis posterior Extensor Hallucis longus Extensor digitorum longus |
Infection Stitch abscess Swelling Adhesion Loose tension Tendon slipping Pain |
Sensation |
Sensory areas of the lateral popliteal and posterior tibial nerve |
|
Angle Measurements |
Ankle at rest With Knee Extended
With Knee Flexed (90º)
Inversion and eversion at dorsiflexion Inversion and eversion at plantar flexion |
|
Functional Assessment |
Navicular Height Gait (123 pattern) Whether able to walk short / long distances, run, climb stairs, and squat SALSA Scale score |
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Eye |
|
Pre-Operative Assessment |
Post-Operative Assessment |
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Muscle Assessment |
Functioning of orbiculari occuli |
Functioning of the transferred tendon “temporalis muscle” |
Sensory assessment |
Corneal Sensation – Blink Lid gap in light closure (in millimeters) Lid gap in tight closure (in millimeters) Vision (Snellen’s E-Chart) |
Lid gap in light closure (in millimeters) Lid gap in tight closure (in millimeters) Vision (Snellen’s E-Chart) |
Other assessments |
Ectropion Entropion Watering of the eye Corneal Ulcer |
Ectropion Entropion Watering of the eye Corneal Ulcer |
Appendix 5
Surgical |
Pre-Operative |
Post-Operative Rehabilitation |
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1st Week |
2nd Week |
3rd Week |
4th Week |
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Extensor to Flexor 4 Tail Transfer (EF4T) |
To gain isolation and full strength of ECRL, support hand in pronation and practice wrist extension without allowing finger or thumb movement. To strengthen ECRL, do same action against resistance. |
Isolate and do wrist extension with radial deviation, looking for MCP joint flexion and PIP extension in all fingers. Use cylindrical splints for finger extension and lumbrical slab to reduce swelling. Assess at end of 1st week. |
MCP extension Assess at end of 2nd week. |
Start MCP and PIP joint flexion. Assess at end of 3rd week. |
Perform functional activities:
Assess at end of 4th week. |
Extensor to Extensor 4 Tail transfer |
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Post-operative exercises are same as EF4T, except too much full wrist flexion should be avoided in post-operative period. |
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Palmaris Longus 4 Tail Transfer |
Isolate PL by wrist flexion and hand cupping. |
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Sublimus Transfer |
Ask patient to flex PIP joint of only long finger; all other fingers should be relaxed. MCP of long finger should be flat and DIP joint must be relaxed. |
Post-operative exercises are same as above surgeries except care must be taken for “check-rein” and “sublimus-minus” deformities. |
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Lasso Procedure |
Ask patient to flex PIP joint of only long finger; all other fingers should be relaxed. MCP of long finger should be flat and DIP joint must be relaxed. |
Perform isolation exercises of transfer (FDS of long finger). Flex and extend PIP and DIP joints while maintaining MCP joint in 55°. Use POP slab when not exercising. Assess at end of 1st week. |
Flex and extend PIP and DIP joints while maintaining MCP joint in 55°. Assess at end of 2nd week. |
Perform coordination exercises. Perform more extensions of MCP joints. Change slab to one with MCP joints in 30° extension. Assess at end of 3rd week.
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Perform functional activities:
Assess at end of 4th week. |
Sublimus Transfer |
Ask patient to flex PIP joint of only long finger; all other fingers should be relaxed. MCP of long finger should be flat and DIP joint must be relaxed. |
Perform isolation exercises of transfer (FDS of long finger). Look for MCP joint flexion and PIP extension in all fingers. Immobilize IP joints using POP cylindrical splints. Assess at end of 1st week. |
Perform MCP extension. Assess at end of 2nd week. |
Start MCP and PIP joint flexion. Assess at end of 3rd week. |
Perform functional activities:
Assess at end of 4th week. |
Opponens |
To gain isolation and full strength of ring finger FDS, support hand in supination and practice PIP flexion of that finger. DIP joint and all other fingers must remain relaxed. Thumb web angle should be 40°. |
Try old action of PIP flexion of ring finger and watch for new action of thumb abduction / rotation. Make sure while doing exercises that:
Apply thumb spica POP or cylinder POP to thumb along with anterior slab to hold it in abduction / opposition between treatments. |
To strengthen transferred muscle:
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To improve coordination of transferred muscle:
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To train functional use of transferred muscle, activities may include
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Triple Nerve Palsy Correction – Restoration of wrist and finger extension
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Perform isolated contraction of Pronator Teres (i.e., Pronation of forearm with all other muscles relaxed). Perform isolated contraction of FCR (i.e., Flexion of wrist joint into radial deviation, with other muscles relaxed). |
Patient does gentle exercises as taught pre-operatively. Watch for wrist extension by graft when doing pronation and extension of fingers and thumb and when doing wrist flexion. Apply post-operative anterior slab when not exercising. |
Perform same exercises, but more strongly, change positions, hold for longer time. |
If good control of graft, start gentle flexion of wrist, fingers, and thumb and supination and extension of elbow. |
Continue exercises Start functional activities as possible to prepare for lumbrical and opponens operation. |
Temporalis Muscle Transfer (TMT) |
Assess:
Perform isolated contraction of temporalis muscles, i.e., biting. Perform biting exercises on a hard substance, e.g., a piece of rubber or chewing gum, to strengthen temporalis muscle. |
Liquid diet |
Semi-solid diet |
Normal diet Start biting exercises and measure inter lid width when exercising. |
Longer exercise sessions Hold contraction for longer time Bite on a hard substance |
Tibialis Posterior Transfer (TPT) |
Gain isolation of Tibialis Posterior. Strengthen Tibialis Posterior by sitting with affected foot supported on opposite knee and practicing inversion. Resistance may be given to medial side of foot. |
To isolate transferred muscle:
To prevent damage or misuse of transferred tendon, provide back slab. |
To strengthen transferred muscle:
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To improve coordination of transferred muscle with associated leg muscles:
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Gain full weight bearing by decreasing, then removing, support of parallel bars, crutches, etc. Encourage walking in all situations, progressing to:
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* ECRL = Extensor Carpi Radialis Longus; MCP = Metacarpo Phalangeal; PIP = Proximal Interphalangeal; DIP = Distal Interphalangeal; ROM = Range of motion; POP = Plaster of Paris; FDS = Flexor Digitorum Sublimus; IP = Interphalangeal; FCR = Flexor Carpi Radialus; EDC = Extensor Digitorum Communis; EPL = Extensor Pollicis Longus