Phase 4: Strengthening and functional movements (12 - 24 months postop)


Key points:
1. Developing the patient’s ability to perform functional tasks with the new movement is the ultimate goal.  
2. Strengthening starts with gravity eliminated tasks and then progresses to against gravity as the recipient muscle strengthens.  
3. Focus is on the quality of the movement while building strength in the recipient muscle.  
4. Recipient muscle contraction becomes more automatic and eventually will not require conscious thought to activate the donor nerve.  

Information for Patients:

In this phase of rehabilitation you start practicing functional tasks using the new movement in your operated arm/hand.  
High volumes of practice is very important at improving your ability to use the operated arm and hand well.    
Practice these movements for 30-60 mins, 2x per day (at minimum).

  1. Shoulder external rotation: Initially, you will practice sliding your arm away from your body across a table or other flat surface. When you get stronger, tie an elastic band to a door handle or steady it with your other arm. Practice slow rotating your hand away from your body with your elbow bent at 90 degrees. 
  2. Shoulder abduction: Initially, you can li on your back and with a straight elbow, move your arm away from your body. When you get stronger,  with your arm straight, lift it away from the side of your body, until your arm is parallel with the floor (forming a “T”). As you  get stronger, you can do this with a small weight (e.g., 2-5 pounds). The fina progression is performing this movement (with or without a weight), with your elbow bent. This exercise is similar to performing “shoulder flies”/lateral arm raises at the gym.
  3. Elbow flexion: Initially, practice bringing your hand to your mouth, first while lying on your side, with your arm stablized on a flat surface, progressing to performing this movement in the sitting position. You may already have experience performing this exercise. It is a basic biceps curl, with your palm facing away from you. Slowly increase the weight as you get stronger.

Information for Clinicians:

This stage rehabilitation focuses on strengthening the new movements (initially with gravity eliminated and progressing to assisted antigravity movements).  

Goals of rehabilitation during this phase are:

  1. Focus with this transfer is the opening of the hand to then grasp things.
  1. Do gravity eliminated exercises first.  Continue to activate donor nerve by providing resistance to elicit a stronger activation/contraction in the recipient muscle.
  1. Once antigravity strength has been achieved in the recipient muscle, then progress exercises to include antigravity movements.  This may require active assisted movements at the beginning.  
  1. Progressing to new functional movements with resistance (either antigravity or weighted tasks, i.e. grasping a cup and bringing it up in a drinking motion).
  1. Eventually patients will learn to uncouple/individualize the movements so they don’t have to contract the donor muscle to activate the new movement.  Meaning they will be able to open fingers without going palm up and supinating.
  1. Use active assisted orthosis if needed to assist weak muscles.  

Deltoid-to-Triceps nerve transfer (elbow extending)

  1. Muscle Strengthening:  
    - Without gravity
    - Antigravity  F
    - Functional activities: Lifting/elbow extension and also eccentric contraction (assistance with full elbow extension against gravity, hold, and then slowly control your forearm as it flexes downwards).
  2. Functional Activities: reaching for items between shoulder and overhead level, seat lifts, manual or sliding board transfers)

Supinator to PIN nerve transfer (hand opening):

  1. Once you observe flickers in finger extensors then promote movement through active assisted exercises, biofeedback, and functional electrical stimulation.   Muscle Strengthening:  
    - Without gravity
    - Antigravity  
    - Functional activities. Extending the index finger to a mouse or to use chopsticks, keyboard use, catheterizing, buttons. Picking up and releasing objects of different sizes: glasses, mugs.
  2. Finger extension is not as strong a movement as flexion and you want to ensure it does not dominate over the finger flexion.
  3. Ensure the client’s fingers bend at the knuckles (MCP joints) when extending the wrist.  
  4. Isolate the wrist and MCPs to initiate finger extension at IP joints first.

Brachialis to AIN nerve transfer (hand closing):

  1. Muscle Strengthening:
    - Without gravity
    - Antigravity  
    - Functional activities: Grasp different objects of different sizes, picking up different items  

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