SOAP ASSESSMENT IDENTIFICATION
This component is in a detailed, narrative format and describes the patient’s self-report of their current status in terms of their current condition/complaint, function, activity level, disability, symptoms, social history, family history, employment status, and environmental history. It may also include information from the family or caregivers and if exact phrasing is used, should be enclosed in quotation marks. The patient’s goals and prior response to treatment intervention are also included. Medical information obtained from the patient’s chart can also be included the therapist has not directly observed these findings.
It allows the therapist to document the patient’s perception of their condition as it relates to their progress in rehabilitation, functional performance, or quality of life.
- Passing judgment on a patient e.g. “Patient is over-reacting again”.
- Documenting irrelevant information e.g. patient complaining about previous therapist.
This section outlines what the therapist observes, tests, and measures. Objective information must be stated in measurable terms. Using measurable terms helps in reassessment after treatment to analyze the progression of the patient and hindering as well as helping factors.
The objective results of the re-assessment help to determine the progress towards functional goals, and the effect of treatment. The therapist should indicate changes in the patient’s status, as well as communication with colleagues, family, or carers.
- Scant detail is provided.
- Global summary of an intervention e.g. “ROM exercises given”.
This is potentially the most important legal note because this is the therapist’s professional opinion in light of the subjective and objective findings. It should explain the reasoning behind the decisions taken and clarify and support the analytical thinking behind the problem-solving process. A prioritized problems list is generated with impairments linked to functional limitations. International Classification of Functioning, Disability, and Health (ICF) is very useful to determine and prioritized problem lists and thus helps to make functional physiotherapy diagnoses.
Progress towards the stated goals is indicated, as well as any factors affecting it that may require modification of the frequency, duration or intervention itself. Adverse, as well as positive response, should be documented in re-assessment.
- The assessment is too vague e.g. “Patient is improving”.
- Little insight is provided.
The Goals of treatment should be SMART
- Specific (simple, sensible, significant).
- Measurable (meaningful, motivating).
- Achievable (agreed, attainable).
- Relevant (reasonable, realistic and resourced, results-based).
- Time bound (time-based, time limited, time/cost limited, timely, time-sensitive).
P (PLAN OF TREATMENT)
The final component of the note includes anticipated goals and expected outcomes and outlines the planned interventions to be used. Information should be provided concerning the frequency, specific interventions, treatment progression, equipment required and how it will be used, and education strategies. The plan also documents referrals to other professionals and recommendation s for future interventions or follow-up care. The therapist should report on what the patient’s home exercise programme (HEP) will consist of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.
- The upcoming plan is not indicated.
- Vague description of the plan e.g. “Continue treatment”.
After a diagnosis of a peripheral nerve injury, a full subjective and objective examination is required to get a clear picture of the way the lesion is affecting the client.
SUBJECTIVE ASSESSMENT ( WHAT THE PATIENT SAYS ABOUT THE PROBLEM / INTERVENTION)
- Collect demographic information.
- chief complaint.
- Past history
- Presence of deformity (drop wrist, claw hand ,Ape hand, square shoulder ).
- Trophic changes in the skin (indicates either prolonged inactivity or involvement of fiber in the peripheral nerve regulating autonomic function ).
- Muscle Wasting
SENSORY EVALUATION: ALONG THE CUTANEOUS DISTRIBUTION OF THAT PERIPHERAL NERVE, NOT DERMATOLOGICALLY
- The evaluation of sensation is highly dependent on the ability and desire of the patient to cooperate.
- Sensation belongs to the patient (i.e., is subjective) and the examiner must therefore depend almost entirely on their.
- One of the principle goals of the sensory exam is to identify meaningful patterns of sensory loss.
- Basic testing should sample the major functional subdivisions of the sensory systems.
- The patient’s eyes should be closed throughout the sensory examination.
- Exam in this order:
- Superficial (Exteroceptive) sensation
- Proprioceptive(deep) sensation
- Combined cortical sensations.
- If the superficial sensation is impaired then some impairment is also seen in deep and combined sensations.
- Sensory tests are done from the distal to the proximal direction.
|Superficial Sensation||Deep Sensation||Combined Cortical Sensation|
Double Simultaneous Stimulation.
Recognition of TextureBarognosis.
REFLEXES: THERE ARE THREE PRIMARY DEEP TENDON REFLEXES IN THE UPPER LIMB: BICEP, BRACHIORADIALIS AND TRICEPS
Each reflex corresponds to a particular root and muscle and will evaluate the integrity of the root and associated nerve.
- Biceps: root C5-C6, biceps muscle (Musculocutaneous nerve).
- Brachioradialis: root C6, brachioradialis muscle (Radial nerve).
- Tricep: roots C7, C8, triceps muscle (Radial nerve).
Technique for testing reflexes:
- The muscle group to be tested must be in a neutral position (i.e. neither stretched nor contracted).
- The tendon attached to the muscle(s) which is/are to be tested must be clearly identified. Place the extremity in a positioned that allows the tendon to be easily struck with the reflex hammer.
- To easily locate the tendon, ask the patient to contract the muscle to which it is attached. When the muscle shortens, you should be able to both see and feel the cord like tendon, confirming its precise location.
- Strike the tendon with a single, brisk, stroke. You should not elicit pain.
This grading system is rather subjective.
- 0 No evidence of contraction.
- 1+ Decreased, but still present (hypo-reflexic). Hyporeflexia is generally associated with a lower motor neuron deficit (at the alpha motor neurons from spinal cord to muscle).
- 2+ Normal.
- 3+ Super-normal (hyper-reflexic) Hyperreflexia is often attributed to upper motor neuron lesions.
- 4+ Clonus: Repetitive shortening of the muscle after a single stimulation.
In PNI the patient has hypotonicity or atonicity.
individual MMT is to be done and trick movement is to be noticed in patients with weakness or paralysis.
Manual muscle test (MMT) is a procedure for the evaluation of strength of individual muscle or muscles group, based upon the effective performance of a movement in relation to the forces of gravity or Manual Resistance through the available Range of motion (ROM)
|0||0||No visible or palpable contraction|
|Trace||I||1||Visible or palpable contraction (No ROM)|
|Poor–||2–||Partial ROM, gravity eliminated|
|Poor||II||2||Full ROM, gravity eliminated|
|Poor+||2+||Gravity eliminated/slight resistance or < 1/2 range against gravity|
|Fair–||3–||> 1/2 but < Full ROM, against gravity|
|Fair||III||3||Full ROM against gravity|
|Fair+||3+||Full ROM against gravity, slight resistance|
|Good–||4–||Full ROM against gravity, mild resistance|
|Good||IV||4||Full ROM against gravity, moderate resistance|
|Good+||4+||Full ROM against gravity, almost full resistance|
|Normal||V||Normal, maximal resistance|
Manual Muscle Testing Grading System
is the measuring of angles created by the bones of the body at the joints.
UPPER LIMB NERVE TENSION TESTS.
MUSCULOCUTANEOUS NERVE TENSION TEST
- Shoulder girdle depression
- Elbow extension
- Shoulder extension
- Ulnar deviation of the wrist with thumb flexion.
- Either medial or lateral rotation of the arm could further sensitize th
RADIAL NERVE TENSION TEST
- Shoulder girdle depression
- Elbow extension
- Medial rotation of the whole arm
- Wrist, finger and thumb flexion
MEDIAN NERVE TENSION TEST
- Shoulder girdle depression
- Elbow extension
- Lateral rotation of the whole arm
- Wrist, finger and thumb extension
ULNAR NERVE TENSION TEST
- Shoulder girdle depression
- Shoulder abduction
- Shoulder external rotation
- Wrist and Finger extension
- Elbow flexion
- Shoulder abduction
TINEL SIGN TEST
A positive Tinel sign means that tapping your nerve causes a tingling sensation to radiate through that area of your body. It’s sometimes described as a pins and needles feeling.
ULNAR NI TESTS :
- Wartenberg sign.
- Froment sign.
MEDIAN NI TESTS
- Hand of benediction .
- pinch sign (OK sign).
- median claw(when extending the fingers)
- EMG should be done and will show a typical neurogenic presentation.
- A nerve conduction velocity (NCV) will show decreased conduction velocity across the lesion, but the proper interpretation is necessary to differentiate between neuropraxia, axonotmesis, neurotmesis.
MEDICAL MANAGMENT AFTER PNI
The management of a peripheral nerve injury varies depending on the cause, type, and degree of the nerve injury. If a nerve is not healing properly surgery may be required to repair the damaged section. Physiotherapy is very important to promote the recovery of peripheral nerve injuries regardless of whether surgery is required.
The application of physical or chemical agents to a nerve in order to cause a temporary degeneration of targeted nerve fibers. When the nerve fibers degenerate, it causes an interruption in the transmission o
The surgical suturing of a divided nerve.
The sural nerve is commonly used during nerve grafting, not only of the axillary nerve, but in other peripheral nerves injuries as well. Prognosis for the axillary nerve with graft repair is better than other peripheral nerve repairs secondary to its short length.
Also known as nerve transfer. A healthy, but less valuable nerve, or its proximal stump is transferred in order to reinnervate a more important sensory or motor territory that has lost its innervation through irreparable damage to the nerve.
PHYSIOTHERAPY INTERVENTIONS AFTER PNI
As a reminder, nerve regeneration takes place at a rate of an estimated ~1 millimetre (mm) per day. Therefore the recovery can be long and discouraging for the patient at times. Help manage expectations as a clinician with this type of injury.
STAGE OF PARALYSIS (2-3 WEEKS)
- Care of anasthetic Hand (patient education):
- Cut nails.
- By inspecting rgularly for wounds or skin color changes.
- Ask patient to avoid extreme temprature.
- Using protective gloves for hand to prevent injury by sharp objectives.
- Reduce Pain :
- Control edema :
keep the affected limb elevated ,pumbing exercises.
- Prevent Contractres:
The affected extremities are splinted in their respective functional position.
When applied on an anesthetic area , repeated checks are needed to ensure presure sores do not develop.
- Prevent joint stiffness and maintain ROM:
Full PROM exercise and stretching exercise for the muscles around the affected joints.
- Maintain the properties of the muscle:
Using Monophasic Pulsed current. This will ensure a proper blood supply as well as help in maintainance of excitation contraction and coupling.
- Stimulation start after 2 weeks of injury.
- Monophasic pulsed current (Rectangular wave form used).
- Parameter: 1. Long pulse duration (grater than 10ms)
2. frequency less than 10Hz.
3.current amplitude should increased until reach visible contraction.
4.pause period between stimulation should be 1:4 (longer than stimulation period to minimize fatigue).
- Treatment time 15-20 min.
- Electrode Position For treating denervated muscles as follows
- Prevent deformities:
Using splinting in Functional position
- Maintain skin Texture in patients with tropic skin changes. The affected area should be kept supple by applying some moisturizer or oil that skin breakedown can be prevented.
- Reduce paresthesia and numbness:
It progresses gradually from stimuli that produce the least painful response to stimuli that produce the most painful response. Once the affected area begins to acclimate to the initial stimulus, the next stimulus is incorporated. For example a desensitization program may progress from a very soft material stimulus (i.e., silk) to a rougher material (i.e. wool) or textured fabric (i.e. Velcro). The course of this progression may take several days to several weeks, depending on the level of hypersensitivity.
Note: Desensitization is a treatment technique used to modify how sensitive an area is to particular stimuli. This technique is utilized to decrease, or normalize, the body’s response to particular sensations
POST PARALYTIC STAGE:
Innervation has started and the muscle begins to show active contraction.
- Continue stage of paralysis protocol.
- Biphasic pulsed rectangular current is used
- Frequency adjust to 35-55 to minimize muscle fatigue.
- Ramp up and ramp down is set to 2-3 sec.
- On/off time is set to 1:4 or 1:5.
- The intensity of the current set until see muscle contraction.
- Total treatment time 15 min.
- Electrode placement should be over muscle belly.
- When MMT reached grade 2 strengthening exercise can be started until reach grade 3. Once the muscle power reached grade 3 then resisted exercises can be given manual or mechanical.
Tools can be used to strength small hand muscles:
- Theraband can be used after making small holes for the fingers, as in the following pictures.
- Canadian Board can be used as shown in the picture
- Functional Re-training is essential to incorporate functional activity such as various gripping activities.
- when the prevention of joint stiffness failed , peripheral joint mobilization grade 3 , 4 can be applied then Boxing positioning for 30 min .
Note: periphera Joint mobilization is a skilled manual therapy technique aimed at improving joint range of motion and reducing pain.
Grades of Mobilization(Mitland):
Grade I – small amplitude movement at the beginning of the available range of movement
Grade II – large amplitude movement at within the available range of movement
Grade III – large amplitude movement that moves into stiffness or muscle spasm
Grade IV – small amplitude movement stretching into stiffness or muscle spasm
Grade V – 5th grade is possible but further training will be required to perform safely.
PHYSIOTHERAPY AFTER NERVE REPAIR
- Phase I: 0-45 days
- Splinting (restricted splint) to prevent over stretch.
- Edema control.
- Restricted range of motion. Exc.:
some degree to prevent joint stiffness but without stretching to improve healing.
- Phase II: 45 days- 8 month
- Enhance the tissue glide by:
- active exercise.
- Passive exercise.
- gentle Stretching exercise
After a period of 18 months, the chances of improvement are drastically reduced.
- Monophasic pulsed current until re- innervation done then start using Biphasic pulsed current.
- Reinforcement muscle training.
- Sensory reeducation.
Such a situation warrants surgery either in the form of nerve repairs or tendon transfers.
1. Duralde X. Neurologic injuries in the athlete’s shoulder. Journal of Athletic Training. 2000;35(3):316-328.
2. Handoll HHG, Hanchard NCA, Goodchild LM, Feary J. Conservative management following closed reduction of traumatic ; anterior dislocation of the shoulder (review). Cochrane Database of Systematic Review. 2006;1:1-26.
3.Manske R, Sumler A, Runge J. Quadrilateral space syndrome. Humen Kinetics- ATTI.2009;14(2):45-47.
4.Miller T. Axillary neuropathy following traumatic dislocation of the shoulder: a case study. The Journal of Manual & Manipulative Therapy. 1998;6(4):184-185.
5.Physiotherapy Management in Peripheral nerve & Plexus injuries. (2021). Slide share. https://www.slideshare.net/sreerajsr/physiotherapy-management-in-peripheral-nerve- plexus-injuries
6. Neal S, Fields K. Peripheral nerve entrapment and injury in the upper extremity. American Family Physician. 2010; 81(2): 147-155.
7.Nerve Injury Rehabilitation. (2021). Physiopedia. https://www.physio pedia.com/Nerve_Injury_Rehabilitation
8.Payne M, Doherty T, Sequeira K, Miller T. Peripheral nerve injury associated with shoulder trauma: a retrospective study and review of literature. Journal of Clinical Neuromuscular Disease. 2002;
9.Peripheral Nerve Injury. (2021). Family Practice Book. https://fpnotebook.com/ortho/neuro/PrphrlNrvInjry.htm
10.Peripheral nerve injuries. (2020). AMBOSS. https://www.amboss.com/us/knowledge/Peripheral_nerve_injuries/
11.Peripheral nerve injuries. (2021). Mayoclinic. https://www.mayoclinic.org/diseases- conditions/peripheral-nerve-injuries/diagnosis-treatment/drc-20355632
12.Peripheral Nerve Injury. (2021). John Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/peripheral-nerve-injury
13.Perlmutter G, Apruzzese W. Axillary nerve injuries in contact sports: recommendations for treatment and rehabilitation. Sports Med. 1998;26(5): 351-360.
14.Qaradaya, A. (2019). Electro-stimulation MSF protocols.
15.Qaradaya, A. (2015). Nerve post surgical repair MSF protocol.
16. Safran M. Nerve injury about the shoulder in athletes, Part 1: Suprascapular nerve and axillary nerve. Am J Sports Med . 2004;32(3):803-819.
17.Tezcan, A. (2017). Peripheral Nerve Injury and Current Treatment Strategies. Intechopen. https://www.intechopen.com/chapters/55127