Ulnar nerve stimulation

ulnar nerve stimulation #electrotheraphy # electrode placement # positioning # physiotherapy # practical procedure

1. ULNAR NERVE STIMULATION

2. CONTENTS Introduction ULNAR nerve : A) Root value B) O rigin, course, termination C) Muscle involved D) M otor point E) Types of ulnar nerve injury F ) Signs of ulnar nerve injury G) Applied aspect H) Practical Procedure 2

3. ULNAR N ERVE Ulnar nerve is also called as musicians nerve It is continuation of medial cord of brachial plexus which arise from the anterior division of lower trunk It runs along the medial side /ulnar side of limb Root value: ventral rami of C8 and T1. 3

4. Origin , Course ,Termination It lies behind the medial epicondyle of humerus AXILLA: lies in between axillary vein and axillary artery Arm : Medial to brachial artery at middle of arm it pierces medial intramuscular septum Descends on back of medial epicondyle of humerus 4

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7. Flexor pollicis brevis lumbricals Dorsal Interossei Flexor Digitorum Profundus Adductor P ollicis Flexor and opponens digiti minimi Abductor digiti minimi Flexor Carpi Ulnaris 7

8. Type of ulnar nerve injury High ulnar nerve palsy Low ulnar nerve palsy All extrinsic and intrinsic muscles affected Sensory loss over palmar and dorsal aspect of medial third of hand Sensory loss over palmar and dorsal aspect of whole of little finger and ular half of ring finger Only intrinsic muscles affected No sensory loss over proximal and middle phalanx of little and ring finger due to sparing of dorsal cutaneous branch 8

9. Causes: Sleeping with the arm folded behind neck, elbows bent. Pressing the elbows upon the arms of a chair while typing. Resting or bracing the elbow on the arm rest of a vehicle. Bench pressing. Intense exercising and strain involving the elbow Clinical features: Numbness in the 4 th & 5 th fingers which may progress to complete weakness if left untreated Ulnar claw hand deformity Atrophy in advanced cases Sensory,trophic,vasomotor changes Loss of adduction & abduction of all fingers Loss of adduction of thumb 9

10. Signs of ulnar nerve injury Egawa test : Froment’s sign (Book test): 10

11. Duchenne sign : Bouvier sign: 11

12. Wartenberg’s sign Tinel sign: 12

13. Jeanne’s sign: Masse sign: 13

14. APPLIED ASPECTS ULNAR PARADOX CUBITTAL TUNNEL SYNDROME GUYONS CANNAL SYNDROME PSEDUO ULNAR NERVE PALSY TARDY ULNAR NERVE PALSY ULNAR CLAW HAND 14

15. ULNAR PARADOX If the ulnar nerve lesion occurs more proximally the flexor digitorum profundus muscle is denervated . As a result, flexion of the IP joints is weakened Instead , the fourth and fifth fingers are paralyzed This is called the "ulnar paradox " 15

16. Cubittal Tunnel Syndrome Cubittal tunnel Syndrome Tunnel Syndrome is a condition that involves pressure or stretching of the ulnar nerve which can cause numbness or tingling in the ring 16

17. Guyon’s Canal Syndrome: Ulnar nerve impingement along an anatomical space in the wrist called Guyon's canal is known as  Guyon's canal syndrome called "hypothenar hammer syndrome," seen in workers who repetitively use a hammer, and "occupational neuritis" due to hard, repetitive compression against a desk surface. 17

18. Pseduo ulnar nerve palsy It refers to weakness in the hand in an ulnar distribution due to contralateral cerebral infarction in the white matter of the angular gyrus of the inferior parietal lobe Tardy ulnar nerve palsy It occurs of non-union of pediatric lateral epicondyle fractures which leads to a cubitus valgus deformity. When the child grows,the deformity worsens and the ulnar nerve is gradually stretched 18

19. Ulnar claw hand( deformity) It also known as claw hand , or ' spinster's claw ' or an abnormal attitude of the hand that develops due to ulnar nerve damage causing paralysis of the lumbricals . A claw hand presents with a hyper-extension at the MCP Joint and flexion at the PIP and DIP Joint of the 4th and 5th fingers. 19

20. Practical procedur e Receiving the patient : Good morning sir /mam . I am a student Physiotherapist going to treat you today. Please wait until I go through your case sheet 20

21. Case sheet reading Check the following details during case sheet reading :- Name Age Gender Occupation IP number Address Chief complaints History –present ,past ,family & medical Examination : Check the site and side of injury where the treatment has to be given ..so that the contraindications are ruled out 21

22. Check for contraindications General Fever Hypertension Hypersensitive skin Metal implant in the tissue Renal/ cardiac disease Infections Pregnant women Malignancy Cardiac pacemakers Local Open wounds Hairy skin Scars Local skin infection Cuts Abrasion Eczema Haemorrhagic spots Recent fracture 22

23. Preparation of tray skin resistance lowering tray : water ,bowl, soap ,cotton ,towel T reatment tray :- water bowl Salt Lint cloth Pen electrode Plate electrode Main Cable Wires Strap Soft pad Mackinstosh sheet Pillow 23

24. Instructions to patient Ask the patient not to sleep during the treatment session Ask them not to touch the apparatus Inform the patient the feel of current : mild prickling sensation If there is any discomfort or burning sensation, patient should inform the therapist Enquire about the feel of current Checking the apparatus Check the connection of the apparatus with the cable and also the main cable and also the main connection with the plug point . Before treatment self test should be done to check the flow of current Check whether the knobs are at zero,before switching the apparatus Check for any damage to the apparatus, cable and plug point Check the insulation of wire 24 Self test

25. Position of patient Place patient in well supported, comfortable relaxed position. Expose the body part to be treated Remove all jewellery from the part to be treated Use adequate P illow, towel,& bed sheet Patient is made to sit in a wooden /plastic chair with back support Place his hand on the couch with arm abducted ,forearm supinated and elbow semi extended 25

26. Position of therapist : W alk stance by the side of the patient. Therapist should be close to the machine & near to the affected side of the patient. The therapist should position self as to observe face of the patient in a triangular manner . Spacing of the electrode : Inactive electrode - over medial epicondyle Active electrode - over motor point 26

27. Treatment procedure : C lean the treatment area with soap and water and wipe it softly using cotton 27

28. Selection of current :- Faradic current is given in case of ulnar nerve injuries . Treatment :- After the placement of electrode ,the duration ,intensity, rest time is adjusted according to the type and day of nerve injury. Nerve stimulation : Faradic Current C hecking the treatment area :- After the treatment ,check whether if there is any erythema formation over the skin 28

29. Do’s & Dont’s Avoid overhead activities Do not apply hot pack over skin because vessels are dilated Avoid weight bearing on affected side Limit activities that can make it worse, such as tennis or golf. Do not lean on your elbow while driving or sitting. Keep your arm straight while at rest. Wear a splint while you sleep to prevent the elbow from bending. Try to prevent falls or direct impact to the inside of the elbow 29

30. Home exercise : 30

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36. Fixing up the next appointment: - Next treatment time should be scheduled according to patient & therapist convenience. Winding up :- Replace the material and tray back to its place Check the apparatus again whether all the knobs are at zero 36

37. Follow up:- It has to be filled up by the patient as well as the therapist as it may be useful for future reference The feedback of the patient is much important as it helps in progression of future treatment . 37

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