POLIOMYELITIS + POSTPOLIO SYNDROME

DEFINITION
● Viral infection causing nerve injury which leads SIGNS & SYMPTOMS
to partial or full paralysis Asymptomatic / Abortive
● Often called polio or infantile paralysis, is an ● 4%-8% of all cases
infectious disease caused by the poliovirus ● Over abut 72hours
● A viral infection which involves the anterior horn ● Patient experiences slight fever, malaise,
cells (lower motor neuron), that produces headache, sore throat and vomiting
weakness in affected bulbar and/or spinal Nonparalytic
myotomes ● Moderate fever
● Disabling and life-threatening disease caused by ● Headache
poliovirus ● Vomiting
● The name of the disease refers to the affinity of ● Lethargy
viruses for the gray matter of the spinal cord ● Irritability
(polios=gray). ● Pains in neck, back, arms, legs and abdomen
Paralytic
EPIDEMIOLOGY ● 5-7 days after onset of fever
● 2009: 1,500 confirmed cases ● Patient complains of symptoms similar to those of
● most common: through fecal oral route nonparalytic and then develops weakness and
● occurs in sporadic, endemic, epidemic form at any paralysis
time of year ● Paresthesia
● mostly in children and young adults ● Urine retention
● ages between 1-5 years old are most often ● Constipation
attacked ● abdominal distension
● Peak in summer months ● Dysphasia
● most infectious period: 7-10 days ● Hoyne’s sign= head falls back when supine and
● present in stool: 3-6 weeks shoulders elevated, unable to raise his legs a full
90 degrees.
ETIOLOGY MC: PICORNAVIRUS Both non paralytic and paralytic polio:
● The cause of poliomyelitis is a virus called ● Observe resistance to neck flexion
picornavirus which are small, nonenveloped ● Patient extends his arms behind him for support
● RNA viruses that multiply in the cytoplasm of (tripod) when he sits up
cells. It is divided into 3 subgroups:
○ enteroviruses = gastrointestinal tract SIX CRITERIA FOR POST POLIO SYNDROME
○ rhinoviruses = nasopharynx
Criteria Description
○ hepatits A virus
● Three types of polio virus: Prior paralytic Documentary history of acute polio
○ Brunhilde = most frequent cause of poliomyelitis diagnosis, motor neuron loss, residual
paralytic polio weakness, muscle atrophy, and EMG
○ Lansing = 2nd most frequent cause showing denervation of muscles
○ Leon= least frequent
Period of partial or Evidence of acute paralytic polio with
■ Also triggered by surgery
complete recovery recovery and stable neurological functions
(tonsillectomy, tooth for an interval of about 15 years or more
extraction are predisposing
factors) Gradual or sudden Decreased erndurance, muscle and joint
onset of progressive pain; onset possibly occurring after
PATHOPHYSIOLOGY and persistent new surgery, trauma, or periods of inactivity
muscle weakness or
● The virus enters via the oral route and multiplies abnormal muscle
in the intestinal mucosa lymphoid tissues in the fatigability
pharynx. It is usually present in the throat and
stool before clinical onset little virus exists in the New difficulties with Unlikely but possible development of
throat, but it continues to be excreted in the stool breathing and problems with breathing and swallowing
swallowing
for several weeks.
● The virus invades the local lymphoid tissue,
Symptoms as listed Length of time that client reports having
enters the bloodstream and then infects the CNS. here that may persist symptoms sometimes relevant in the
Viral replication in the anterior horn cells of the for at least a year diagnosis of postpolio syndrome
spinal cord and the brainstem motor neuron cells
results in cell destruction and paralysis Other causes of these Exclusion of other neurologic, medical and
symptoms ruled out orthopedic problems
 SPECIAL TESTS SURGICAL MANAGEMENT
Kiss the Knee Test ● Tendon Transference
● Method: knees kept down, child ask to kiss his ○ Best performed at 3 to 8 years old and
knees arthrodesing operations after eight or
● Observation: cannot do the maneuver due to nine years of age. Muscle evalua in
stiffness spine may draw up the knees sharply poliomyelitis is necessary to determine
Head Drop Sign muscle function and muscle
● Method: hand placed under patient’s shoulder contracture.
and trunk is raised ○ The objective of surgery is to correct
● Observation: head lags behind limply deformity, improve function and
Neck Rigidity stability and to eliminate braces,
● Method: in uncooperative child - place child’s corsets or other appliances by
head beyond the edges of table osteotomy, arthrodesis,
● Observation: true involuntary neck rigidity epiphyseodeosis, tendon transfers and
persists, voluntary stiffening of muscles myofascial releases.
disappears ○ Surgery of the LE will include hip
joint, the knee joint, the ankle and foot
COURSE AND PROGNOSIS
● The outlook depends on the form of the disease DIFFERENTIAL DIAGNOSIS
(subclinical, or paralytic) and the body area ● Carcinomatous meningitis
affected. Most of the time, complete recovery is ○ A subacute and fairly symmetric but
likely if the spinal cord and brain are not mainly distal weakness
involved. ○ Has an irregular distribution of
● Brain or spinal cord involvement is a medical weakness between proximal and distal
emergency that may result in paralysis or death parts, absence of facial weakness,
(usually from respiratory problems). appearance of symptoms in one limb
● Disability is more common than death. Infection after another
that is located high in the spinal cord or in the ● Myasthenia Gravis
brain increases the risk of breathing problems. ○ Ptosis and oculomotor weakness
● The prognosis is poor when the paralysis is ○ No sensory symptoms and tendon
extensive or when there is slow progress of reflexes are unimpaired
paralysis with exacerbations and involvement of ● Botulism
new muscles over period of days ○ Pupillary reflexes are lost in early the
early stage
LAB TESTS ○ Bradycardia
● Virus Culture - the laboratory diagnosis of polio is ● Tick Paralysis
confirmed by isolation of virus by cultures, from ○ Rare condition which is the result of a
the stool or throat swab or cerebrospinal fluid toxin secreted by the gravid tick
(rare). In an infected person, the virus is most ○ The neurotoxin caused a generalized
likely to be cultured in stool cultures. flaccid, areflexic paralysis, appearing
● Serologic Test - Acute and convalescent serum over 1 or 2 days
sample may be tested for rise in antibody titer ● Sometimes cause ataxia and may paralyze eye
(antibodies to the poliovirus), but the repost can movements but sensory loss is not usual and CSF
be difficult to interpret as in many cases, the rise protein remains normal
in titer may occur prior to paralysis
● Cerebrospinal fluid test - Infection with polio
virus may cause an increased number of white
blood cells and a mildly elevated protein level in
cerebrospinal fluid

PHARMACOLOGICAL MANAGEMENT
● Analgesics to ease headache, pain and leg spasms
● Morphine contraindicated because of danger of
additional respiratory depression
● Catheterization for convection-enhanced delivery
of the PVS-RIPO (vaccine) and bladder
involvement.
● Mechanical ventilation for respiratory
involvement
● Surgery for correction of deformities and increase
stability of joints
FOR ○ Know the different motions to
Rehabilitation FOR assess
● Patients with PM/PPS can restore ○ If naay problems sa joints,
independence with compensation swelling or contractures, assess
strategies/techniques ROM
○ Helpful in compensation/
remediation (kaya pa ni px
muimprove sa iya
strength/abilities)
○ Goal: functional or independent
despite the pain
Proprioceptive Neuromuscular Function
● These mass movement patterns that are
spiral and diagonal in nature and
resemble the movement seen in
functional activities which can help pts
with PM/PPS participate more
effectively in daily occupations
○ Help px to know how to move
normally
○ Techniques help with paralysis
○ PNF is made tungod sa polio
Biomechanical FOR
● Pts with PM/PPS can regain
occupational performance through
addressing underlying impairments
that limit performance of activities
○ Bottom up
○ Addresses the underlying Fatigue and Pain
impairments Fatigue Severity Scale (FFS)
MOHO, Cog-Beh FOR, CMOP-E
● To truly understand the client's
perspective with his/her condition and
occupations to provide proper
interventions
PEOP/PEO/EHP (Ecological FORs)
● To understand the demand of the
environment surrounding the patient to ● A total score of less than 36 suggests
assess if it has a good or poor fit and that the patient may not be suffering
draw proper interventions from fatigue.
● A total score of 36 or more suggests that
EVALUATION the patient may need further evaluation
Range of Motion and Manual Muscle Testing by a physician.
● Assess client's AROM, PROM and muscle
strength Checklist for Individual Strength (CIS)
○ Make sure you know how to ● 4 dimensions
administer, and the landmarks ○ Fatigue severity
like where to put the axis, ○ concentration problems
positioning, etc. ○ Motivation
○ Better to know the approx ○ physical activity
degrees of ROM ● 20 Items
● 7-point likert scale
 ● Higher scores indicate a higher degree ○ To know if it’s still manageable
of fatigue, more concentration with medication
problems, lower motivation, and less ● Relieving factors
activity ○ Used by OTs to know what to do
if the cx experiences pain
○ If mawala ra nag pain if
magprone, extend ang elbow
● Pattern
○ What kind of dermatome
pattern mo follow after sa pain?
○ Unsay innervation ang naay
problem, muscles affected due to
pain
○ Dermatome

Functional Assessments/ QOL Assessments

● Functional Independence Measure
○ Observe how the patients do it
normally
● Canadian Occupational Performance
Visual Analogue Scale or Numerical Pain Rating Measure
Scale ○ Good tool to know what
** Post-polio pain occupations ang problems sa px
● Intensity ● Occupation-based Evaluation
● Location
○ Maam, tell me where it hurts Dysphagia Evaluation
○ Asa dapit ang sakit ● Oral Assessment: Outer Oral Status and
● Exacerbating Factors Intraoral Status
○ Factors na makapa samot sa ○ Observe the client while eating
pain. Ex. mo samot ang pain if Assessment for fitting of splints/ devices
init, etc. ● KAFO (Knee, Ankle, Foot Orthosis)
○ Mucarry ug heavy objects or ○ Shoe, foundation, ankle control,
magbarog kay musakit samot knee control
● Quality ● Can also be reacher and other assistive
○ Cramping, twitching, electric, devices: shoehorn, sockaid
hapdos, etc.
● Onset and Duration
○ Chronic or acute
○ Bag o raba nagsugod, mawala
raba sha dayon
○ Pila na ka months
nakaexperience sa pain
Psychological Evaluation
● Beck's Depression Inventory
○ Don’t set a tone. Dapat neutral
ra when you read it
○ 21 items
■ 0-13 minimal
■ 14-19 mild
■ 20-28 moderate ● Rosenberg Self-Esteem Scale
■ 29-63 severe ○ 10 items
● Sorensen Self-Esteem Questionnaire ○ Higher the score, higher the
● Rosenberg Self-Esteem Scale self-esteem

● Sorensen Self-Esteem Questionnaire

○ 50 items

Gait Evaluation
- For fxnal mobility
● Tinetti Test
○ Balance and Gait Evaluation
○ Aka Performance Oriented
Mobility Assessment
 improvement of strength, ROM,
coordination, or movement patterns, as
applicable.
5. Some sensory feedback must be
available, sensation must be at least
partially intact so that the client can
perceive motion and the position of the
exercised part and sense superficial and
deep pain.
6. Muscles and tendons must be intact,
stable, and free to move.
7. Joints are able to move through an
INTERVENTION effective ROM for those types of exercise
Focus on: that use joint motion.
● ECTs, join protection techniques, work 8. Client is relatively free of pain during
simplification techniques motion and should be able to perform
Therapeutic Exercise and Activity isolated, coordinated movement.
The general purposes: 9. If the client has any dyskinetic
1. To develop awareness of normal movement, he or she should be able to
movement patterns and improve control it so that the procedure can be
voluntary, automatic movement performed as prescribed.
responses NOTE:
2. To develop strength and endurance in Exercise must be carefully supervised because it
patterns of movement that are may aggravate pain and overwork of muscles
acceptable and necessary and do not innervated by a limited number of motor units
produce deformity Signs of excessive activity:
3. To improve coordination, regardless of ● further weakness
strength ● discomfort
4. To increase the power of specific ● pain
isolated muscles or muscle groups ● muscle spasm
5. To aid in overcoming ROM deficits ● chronic fatigue
6. To increase the strength of muscles that
will power hand splints, mobile arm Pain Management
supports, and other devices. ● Pain medications - prescribed by
7. To increase work tolerance and physical doctors
endurance through increased strength ● As therapists
8. To prevent or eliminate contractures ○ Post-polio pain
developing as a result of imbalanced ■ Begin a stretching routine -
muscle power by strengthening the guided by the tx
antagonistic muscles. ● Some muscles should
- Px with polio will show improvement not be overstretched
with 2 times in a week therapeutic ■ Energy conservation
exercise techniques
- Goal of the exercise is for them not to feel ○ Overuse pain
tired ■ Rest
Criteria: ■ Ice/Heat
1. Medically stable ■ PT - Muscle release and
2. Able to understand the directions and stretching
purposes ○ Biomechanical Pain
3. Interested and motivated to perform. ■ Improve posture and address
4. Must have available motor pathways mechanical abnormalities,
and the potential for recovery or
 assistive devices, braces, ○ Nature and course of Polio and
supports and shoes Post Polio
Mobile Arm Support ○ Preventive Measures
● MAS's have increased upper extremity ■ Through vaccination;
function for persons with severe arm education on the importance of
paralysis. vaccine, asa makaget ug
● It is used for pain relief in the upper vaccine
arm during occupational performance. ● Work Simplification
● MASs compensate for proximal ● Energy Conservation
weakness in the upper extremities in ● Adaptive Equipment as needed
three ways: ● Environmental Modifications
○ (1) they provide arm motion, ● Joint Protection Techniques
which allows for active ROM in ** Functional and leisure activities: Yoga and Tai
the shoulder and elbow; Chi activities - while incorporating the
○ (2) they allow weak muscles techniques
that cannot perform movement
to allow for occupational Energy Conservation
performance; and ● Decrease in the amount of energy
○ (3) they enable hand placement during daily activities leads to an
in a variety of positions for increase in overall function of ADL
occupational performance. ● 8 main principles
1. Limit the amount of work you set
for yourself
2. Plan ahead
3. Organize your storage and
workspace
4. Sit to work
5. Use correct equipment
6. Use efficient methods
7. Plan and include rest breaks in
your day
8. Use correct body mechanics
● Be aware of how much energy certain
tasks are using
● Plan most tiring tasks later in the day
● Avoid "Boom and Bust" energy levels
● Schedule rest breaks

Dressing
● Preparation -layout your clothes and
toiletries
● Use proper body mechanics
Psychological Intervention
● avoid bending or leaning over
● A supportive and realistic approach by
● fasten bra in front then turn to back
the healthcare team, along with client
● Sit down
and family education, is the key to
● Use long handled show horns
lifestyle modification
● Clothes
● Introduce Lifestyle changes gradually
○ Front opening, loose fitting
● Education
clothes
○ Effects of Polio
○ Wear comfortable shoes, low
○ Information about the current
heeled, slip on shoes
symptoms
 ○ Consider elastic shoe laces ● Plan a route
○ Wrinkle resistant fabrics ○ make a list
● Donning: Affected side first ○ Park near/ in a convenient
● Doffing: Unaffected side first location
● Bathing/Showering ● Use a shopping cart
○ Grab bars/ elevated toilet seat/ ● Lighten load when bringing groceries
shower chair into the house
○ Use shelves - not to high or low ○ More trips with lighter load vs
○ Use extension handles on sponges/ use of wheeled cart with less
brushes to wash back and legs trips
○ Use tepid water
○ Wear a terry cloth robe instead of Work Simplification
drying off An act of performing a task in the easiest way to
conserve time and energy
● Cooking
○ Arrange your prep environment for
easy access to the items you use the
most
■ at waist level or above and less used
items below waist level
■ Use wheeled cart for carrying food
from the kitchen to the table and
cleaning up after
○ Use convenient and easy-to-prepare
foods ● Don't multitask
○ Sit down ● Cooking
■ Use high tools ○ Buy pre-chopped vegetables/
○ Slide heavy containers along shredded cheese
countertops rather than lifting ○ Freeze commonly used
○ Prepare double portions and freeze ingredients to thaw and use at a
half (meal preparation) later time
○ Use dispodable paper good and ● Dressing
utensils to minimize clean-up ○ Lay-out clothes and work in
○ Soak dishes instead of scrubbing and rest breaks
let dishes air dry ● Shopping
Household chores ○ Ask for a Map of your local
● Schedule tasks throughout the week store
● Use long-handled dusters and dust ● Cleaning
mops to avoid having to reach high and ○ Put misplaced items into
low organized bins and put them
● Use a wheeled cart ot carpenter's apron away at a later time
to carry supplies ○ Separate laundry as soon as
● Drag or slide objects rather than lifting you take them off
● Do housework sitting down when
possible Joint Protection Techniques
● Stop working before becoming overly ● Respect pain
tired ● Maintain muscle strength and joint ROM
● Delegate heavy housework, shopping, ● Use each joint in its most stable
laundry and child care when possible anatomical and functional plane
● Avoid positions of deformity
Shopping ● Use strongest joints available
 ● Ensure correct patterns of movement median and ulnar nerve, but is
● Avoid staying in one position for long MC injured in fractures
periods ■ If mafracture, mostly ang
● Avoid starting an activity that cannot be radial nerve ang affected
stopped immediately since close sila sa bones
● Balance rest and activity ○ Brachial plexus is a frequent
● Reduce force and effort site of traumatic injury
○ Traumatic neuropathies - MC in
CBT young males after vehicular
● For chronic pain accidents in UEs.
● Teaches clients about the dynamics of
pain and coping strategies Etiology
○ Stress management Non-traumatic
○ Relaxation and visualization ● Hereditary Peripheral Neuropathy
○ Appropriate use of play (Hereditary Motor Sensory Neuropathy
○ Humor or Charcot-Marie-Tooth)
○ Recognition of fatigue ○ Genetic
○ Activity pacing ○ Affects both children and adults
○ Monitoring self-tasl ■ Manifest 1-2nd decade of life
○ Family training ○ Types:
Acute pain- can be medicated ■ CMT 1- hypertrophic
Chronic pain- does not reac to med demyelinating neuropathy
(onion bulbs) and reduced
nerve conduction velocities
● Onion-bulb appearance sa
Peripheral Nerve Injuries microscope
Definition: ● Hinay muconduct ang
● Any injury/damage in the nerve or information such as
axons (axonopathy) and myelin sheaths saltatory condition =
(demyelinization) problems with
○ Hinay muconduct ang impulses sensory/weakness
if no myelin sheath - slow ■ CMT 2- axonal neuropathy and
movement/weakness normal or slightly reduced
● It can be a motor, sensory or autonomic nerve conduction velocities
problem. ● Occurs later age
● Less involvement of the
Epidemiology small muscles of the hands
● Can occur at any age and no palpable enlarged
○ Mostly traumatic ang causes sa nerves
PNI ● Usually, naa niy muscle
● UE PNI > LE PNI wasting sa gastrocs/calf
○ The median nerve is commonly ● Appearance: inverted na
entrapped at the wrist (CTS), champagne bottle/stork leg
more common in women, ■ CMT 3- (Dejerine-Sottas
occurs bilaterally (50% of disease) demyelinating
cases) peripheral neuropathy with a
○ Ulnar nerve - 2nd MC more severe phenotype
entrapped presenting in infancy.
○ Radial nerve - less frequently ● Usually has severe
involved in entrapment hypertrophic demyelinating
syndromes compared to polyneuropathy
 ● During early life: infancy ● 70% of the cases
and early childhood ● MC MOI due to blunt or penetrating
● They may learn how to injury, constriction of fascial bands,
ambulate, but later on, they lacerations, compression and crush
need to use wheelchair injury & stretching of nerves
■ CMT 4- (Refsum's Disease) ● Fracture and fracture/disclocation -
Altered mitochondrial activity carry a high risk of nerve damage
in Schwann cell ○ Usually if naay fracture = nerve
● Important for myelin sheath damage
production
● If naay problem here, Basic Medical Sciences
nagkaproblema ang nerve Peripheral Nervous System
conduction velocity ● 12 Cranial Nerves
■ CMT 5- Associaciated with ● 31 Spinal Nerves - innervates specific
spinocerebellar degeneration ○ Myotome and dermatome
and presents with spastic ● sensory distributions and muscle
paraplegia groups
● I take note lang ang ● Plexuses - cervical and lumbosacral
spinocerebellar regions
degeneration and spastic Neuron
paraplegia ● Basic neural structure
■ CMT 6- Associated with optic
atrophy
■ CMT 7- Associated with
retinitis pigmentosa
● Dark spots sa atong eyes
● Immune Mediated Peripheral
Neuropathy
○ Immune system attacks myelin
sheaths/nerves leading to
avascularization or ischemia
○ GBS (Acute inflammatory
demyelination Polyneuropathy)
● Toxic
○ Lead neuropathy - involves Gap - mas paspas ang conduction
radial nerve Endoneurium - covers axons
■ Once naay lead toxicity, If magtapok/bundled endoneurium= fascicles =
maaffected ang RN covered by Perineurium
● Metabolic Bundled perineurium = Epineurium
○ Diabetes Mellitus Endoneurium - contains axons
■ Sensory> Motor, Perineurium - important for intrafascicular
Distal>Proximal, pressure
Symmetrical>Asym If ang perineurium kay maguba, magka signal
■ CN 3 and 6, Median conduction problems
nerve, LFCN (lateral Epineurium - supports the fascicles of peripheral
femoral cutaneous nerves
nerve) affectation
● Infection
○ Leprosy - CN 7 and CN 5, Ulnar
nerve
Traumatic
 ○ APL, EPB
Motor and Sensory Innervation ○ BRANCHES:
Roots ○ Supinator
● Dorsal Scapular Nerve ○ EPL
○ Rhomboids ○ EI - most distal na giinervate
○ Levator Scapula ○ EDM
○ ECU
○ Anconeus
● LTN ● Median Nerve - MC nerve entrap = CTS
○ Serratus Anterior - protraction ○ Pronator Teres
and upward rotation of the ○ Pronator Quadratus
scapula ○ FCR
Trunks ○ FDP (Lateral 2)
● Suprascapular Nerve ○ PL
○ Supraspinatus ○ FPL
○ Infraspinatus ○ Thenar Eminence (AFO)
● Nerve to Subclavius ○ Lumbricals (Lateral 2)
○ Subclavius ms ● Ulnar Nerve
○ FCU
Cords ○ FDP (Medial 2)
● Lateral Pectoral Nerve ○ Palmaris Brevis
○ Pectoralis Major ○ Lumbricals (Medial 2)
● Middle Subscapular Nerve/ ○ ADDuctor Pollicis
Thoracodorsal ○ Hypothenar Eminence (AFO)
○ Subscapularis ○ Interossei (8)
● Lower Subscapular n
○ Subscapularis CUTANEOUS SENSATION OF UE
○ Teres Major ARM
● Medial Pectoral Nerve ● Upper lateral arm - Axillary
○ Pectoralis mj ● Lower lateral arm - radial
○ Pectoralis min ● Medial arm - MCN o Arm
● Medial Cutaneous Nerve of the Arm ● Posterior - Radial nerve
○ Sensation of medial arm Forearm
● Medial Cutaneous Nerve of the Forearm ● Lateral FA- Musculocutaneous nerve
○ Sensation of medial forearm ● Medial FA- MCN o FA
● Posterior Strip o FA- radial nerve
Branches: Hands
● Musculocutaneous Nerve (BBiCo) ● Medial half of ring finger to little finger
○ Brachialis (ant and post) - Ulnar nerve
○ Biceps Brachii ● Volar aspect of hand with thumb to ring
○ Coracobrachialis finger - Median nerve
● Axillary ● Dorsal aspect of hand c thumb to ring
○ Deltoids finger - Radial Nerve
○ Teres minor
● Radial Nerve (Largest branch of the
Brachial Plexus)
○ Triceps - most proximal muscle
na giinervate
○ Brachioradialis
○ ECRL/B
○ EDC
 ● Test/Military Brace Test
● Halstead Test
● Addson's Test
● Roo's
● Allen's
● Wright
Conditions:
● Cervical rib syndrome
Presence of extra rib extending
from the neck
Pathophysiology ● Scalenus Anticus Syndrome
Entrapment due to tightness of
anterior and middle scalenes
due to muscle hypertrophy

2. PANCOAST TUMOR
● Apical lung tumor and causes
compression to the lower trunk
of brachial plexus (C8-T1)
● Ss and Sx:
○ Pain and paresthesias
SPECIFIC LEVELS OF ENTRAPMENT (C8-T1)
Root Level ○ Nocturnal Pain
MOI: Secondary to ○ Muscle wasting of
● Herniated nucleus pulposus intinstic muscle of the
● Compression fracture hand
● Spinal Stenosis ○ (+) Horner's Syndrome
● Spondylolisthesis ■ Miosis
Manifestation ■ Anhydrosis
● Radiculopathy ■ Ptosis
■ Enophthalmos
Trunk Level
1. THORACIC OUTLET SYNDROME 3. KLUMPKE’S PALSY/ DEJERINE
Compressed structures: KLUMPKE
● Subclavian Artery ● Excessive pulling or stretching
○ Provides blood supply during a vaginal birth
to UE ● Affected nerves: C8-T1 or lower
○ Origin of brachial Trunk
artery ● MOI: Obstetrical Traction
● Lower trunk of Brachial Plexus Injury
(C8, T1) ● Clinical Presentation:
Signs and Sx: ○ Claw hand deformity
● absent radial pulse due to ○ Pain and parethesias
Subclavian artery entrapment ○ Atrophy and weakness
● Pain and Paresthesia on C8-TI of intrinsic muscles
distribution ○ Sensory loss of medial
Special Test: arm
● Costoclavicular ○ (+) Horner's Syndrome
 NEUROPATHIES OF SHOULDER GIRDLE AND
4. ERB’S PALSY/ ERB’S DUCHENNE PROXIMAL ARM
● Excessive pulling or stretching 1. LONG THORACIC NERVE INJURY
during a vaginal birth ● Caused by Radical Mastectomy
● Affected nerves: C5-C6 or ● Muscle: Serratus Anterior
Upper Trunk ○ (+) Medial winging or open
● MOI: Obstetrical Traction book paralysis
Injury ○ (+) Pain upon shoulder forward
● Clinical Presentation: flexion c extended elbow
○ (+) Waiter's Tip or 2. SPINAL ACCESSORY NERVE INJURY
Porter's Tip ● Caused by Radical Neck
○ Shoulder adduction Dissection
○ Shoulder IR ● Muscle affected: Trapezius and
○ Extended elbow SCM
○ Pronated FA ○ Lateral winging/
○ Flexed wrist sliding door deformity
○ Sensory loss at Lateral ○ (+) Pain upon shoulder
Arm abduction
3. DORSAL SCAPULAR NERVE
● Caused by Direct trauma to the
posterior scapula
5. STINGER/ BURNER SYNDROME ● Affected ms: Rhomboids and
● Injury to the upper trunk of the brachial Levator scapulae
Plexus ○ (+) posterior winging of scapula
● MOI: Traction injury 4. MUSCULOCUTANEOUS NERVE INJURY
● Sudden forceful depression o shoulder ● Cause: Fracture of humerus
with lateralflexion of the neck in the ● Affected ms: Brachialis, Biceps,
opposite side ● Coracobrachialis (BBiCo)
● Due to sports injury --> Football ● Ss and Sx:
○ MOI: Compression ○ Weak elbow
○ Neck rotation and extension ○ Diminished
towards the ipsilateral sensation/loss at the
shoulder lateral or radial aspect
● Ss and Sx: of FA
○ Tingling sensation
○ Burning pain 5. AXILLAR NERVE INJURY
○ Paresthesias/numbness ● Cause: Anterior shoulder
dislocation (MC) and Humeral
6. RUCKSACK PALSY neck fx
● Injury to upper trunk of ● Affected ms: Deltoid and Teres
brachial plexus and long minor
thoracic nerve, ● Ss and Sx:
● secondary to backpack straps ○ Weak ABER muscles
● MOI: Compression due to ○ AB> ER (since other ER
backpack straps muscles can
● Ss and Sx: compensate)
○ Isolated scapular ○ Decrease of sensation
winging on upper lateral arm
○ Paresthesias
6. SUPRASCAPULAR NERVE INJURY
 ● Cause: Scapular fracture or ○ At the bicipital aponeurosis/
compression at suprascapular lacertus fibrosus
notch ● Causes:
● Affected ms: Supraspinatus and ○ Penetrating Injury (IV Cath)
infraspinatus ○ Overuse of PT
● Ss and Sx: Weak ABER of shd ○ carrying a bag flexed
○ Tight casting
MEDIAN NERVE ENTRAPMENT
● Ss and Sx:
○ Motor
■ impairment of all
muscles innervated by
median nerve except
PT
○ Sensory
■ Pain at elbow and
proximal FA
exacerbated by forceful
or resisted FA
pronation/ finger
flexion
Arm
■ Sensory loss/ impaired
A. Humeral supracondylar process syndrome
sensation @ palmar
● Entrapment of median nerve by the
aspect of hand with
ligament of Struthers
thumb and lat half of
○ Runs from an abnormal spur on
ring finger
the shaft of the humerus to the
medial epicondyle
Forearm
● Causes:
A. Anterior Interosseous Nerve Syndrome
○ Trauma and Inflammation
Aka Kiloh Nevin Syndrome
● Ss and Sx:
● Sites of Compression
○ Motor
○ Gantzer Muscle
■ Impairment of all ms
■ Accessory ms of FPL
innervate my median
■ Fibrous arch formed by
nerve
pronator teres and FDS
○ Sensory
ms
■ Pain and paresthesia @
● Causes:
elbow and FA
○ FA fracture - Monteggia Fx
■ Sensory loss @palmar
● Ss and Sx: Pure Motor Neuropathy
aspect of hand including
● Ms affected:
the thumb to half of
○ FDP (lateral half)
lateral finger
○ FPL
○ PQ
Elbow
● Weak flexion of IP joint, thumb and DIP
A. Pronator Teres Syndrome/Grocery bag
joint of index and middle fingers
neuropathy
● (-) OK sign, (+) key pinch sign
● Sites of compression:
○ Between 2 heads of PT muscle
(superior and deep)
○ Between the bridging fascial
band of FDS ms
 RADIAL NERVE

Wrist
A. Carpal Tunnel Syndrome
● MC entrapment neuropathy
● Site of compression:
○ Carpal Tunnel/ Canal

● Exact Etiology is still unknown

○ Associated with DM, Axilla
Obesity, A. Crutch Palsy
Hypothyroidism, RA, ● Cause: Improper use of crutches
Pregnancy and ● S/Sx:
keyboard and use of ○ Motor:
vibratory tools ■ Impairment of all ms
innervated by radial
● F>M nerve
● Usually has bilateral ■ (+) wrist drop
manifestations ○ Sensory
● Ss and Sx ○ Numbness/ loss of sensation on
○ Motor -Weakness of: the posterior arm and FA, and
■ APB Lower lateral arm to parts of
■ Opponens Pollicis hand innervate by radial nerve
■ Lumbricals
■ Difficulty opening jars, Spiral Groove/Radial Groove
buttoning and dropping of A. Saturday Night Palsy
objects ● Honey mooner's palsy
■ (+) atrophy of thenar eminence ● Bride's groom palsy
if severe CTS ● Tourniquet Palsy
○ Sensory ○ Entrapment of the RN
■ Numbness, paresthesia at secondary to tourniquet,
palmar aspect of thumb to arm positioned over a
lateral half of RF sharp ledge/ person's
■ SPARED thenar eminence head resting on the
(palmar cut br) humerus.
● Pain that ● Ss and Sx:
radiates up to ○ Motor:
FA and Shd ■ Imp of all ms
● Nocturnal innervate by radial
awakening nerve except:
B. Wrist Slashing Triceps and
● Affects: Anconeus
○ APL ■ (+) wrist drop
○ OPB ○ Sensory
○ Lumbricals
 ■ Numbness/ loss of
sensation ULNAR
@posterior arm &
FA and dorsal
aspect of the hand
Forearm
A. Posterior Interosseous Nerve Syndrome
● Pure motor
● AKA The Arcade of Frohse Syndrome/
● Supinator syndrome
● Spared:
○ Triceps
○ Anconeus
○ Brachialis
○ ECRL/B
○ Cutaneous Sensation
○ (-) Wrist Drop
● Causes: Elbow
○ Synovitis from RA A. Cubital Tunnel Syndrome
○ Lipoma ● Entrapment of Ulnar nerve at Cubital
○ Ganglion Cyst (MC at wrist) tunnel
● S/Sx ● Causes:
○ Radial deviation upon wrist ○ External pressure to the ulnar
extension groove
○ Supinator ms is variably ○ Repetitive elbow flexion
affected ○ Repetitive gripping
● Manifestations:
B. Radial Tunnel Syndrome ○ Complete motor and sensory
● Sensorimotor affectation loss along the distribution of
● Entrapment of deep branch of radial Ulnar nerve
nerve at the entrance to the tunnel to Wrist
radial head A. Biker’s or Cyclist’s Palsy
● Weakness of the most distally supplied ● AKA Handlebar palsy/
ms of radial nerve Jackhammer Palsy
● (+) deep aching pain at upper dorsal FA ● Entrapment of UN at Tunnel of
Guyon/ Pisohamate canal
Wrist ● Cause:
A. Cheiralgia Paresthetica ○ Wrist ganglion
● Entrapment of superficial radial nerve ○ RA
● No motor loss ○ Increase pressure to
● Causes: the medial side of
○ Swelling wrist
○ Trauma ● Spared:
○ Tight cast, wrist watch, ○ Motor: FCU and FDP
handcuff (3rd & 4th)
● S/Sx: ○ Sensory: Palmar
○ Nocturnal pain @ dorsal aspect cutaneous branch and
of wrist, thumb and webspace Dorsal cutaneous
○ Numbness/burning/tingling branch
pain @dorsal aspect of radial
hand
LOWER EXTREMITY PNI
 on the middle medial
thigh

3. FEMORAL NERVE INJURY

● Secondary to
○ Anterior hip
dislocation
○ Femoral fx
○ Childbirth
● Affected
○ Quadriceps
○ Iliopsoas
○ Pectineus
○ Sartorius
● Ss/Sx
○ Weakness of hip
flexion and knee
extension
○ (+) sensory problem
on anterior femur/
thigh, lower portion of
medial thigh and
posteromedial leg.
○ (+) forward trunk
leaning = d/t weak
1. MERALGIA PARESTHETICA
quads
● AKA: Bernhardt-Roth
4. SCIATIC NERVE INJURY
Syndrome
● Cause
● Affected: Lateral Femoral
○ Injection palsy
Cutaneous Nerve of thigh
○ Piriformis syndrome
● Cause: Tight corset, jeans/ belt
○ Fat wallet syndrome
● Ss/Sx:
○ Posterior hip
○ Numbness
dislocation
○ Tingling
● Ss/Sx:
○ Pain
○ All nerves under your
○ Paresthesia
SN is affected:
2. OBTURATOR NERVE INJURY
■ TN, CPN, SPN,
● Obstetric Palsy secondary to
DPN, LPN,
childbirth
MPN
● Ss/Sx:
5. COMMON PERONEAL NERVE
○ weakness of hip
○ Site: Level of Fibular Head
adductors
■ Crossed leg palsy
■ Add. Longus
■ sidelying
■ Add. Magnus
■ prolonged squatting
■ Add. Brevis
■ ER of leg
■ Gracilis
■ Strawberry picker's syndrome
■ Obturator
■ Guitarist's posture palsy
Externus
■ Indian Sitting
○ Sensory loss: If severe ->
○ Ss/Sx:
paresthesia,
■ Weak DF
hypoesthesia, numbness
■ Foot slap at Heel Strike
 ■ Foot drop at swing c toe drag
■ Can't walk on calcaneus
■ (-) Heel strike
■ Sensory dysfunction on
anterior leg, dorsum of the foot
and 1st dorsal webspace
6. DEEP PERONEAL NERVE INJURY
○ Anterior compartment syndrome/
anterior tarsal tunnel
○ Ski boot's deformity
○ Structures affected:
■ Extensor Hallucis Brevis
■ Extensor Digitorum Brevis
○ Ss/Sx:
■ Sensory dysfxn: 1st Dorsal
webspace
7. TIBIAL NERVE INJURY
● Site: Popliteal Fossa
○ RA: Baker's cyst
○ Wheelchair has too long seat
depth
● Tarsal tunnel Syndrome (behind medial
malleolus)
● @Popliteal Fossa
○ weakness of PF
○ No push off
○ Can't walk on toes
○ Decreased sensation on sole of
foot
○ Weakness of intrinsics

8. MEDIAL PLANTAR NERVE INJURY

● AKA Jogger's/Pronated/Runner's with
flat feet
● Ss/Sx: Weakness of:
○ Flexor Hallucis Brevis
○ Abductor hallucis
○ Flexor Digitorum Brevis
○ 1st Lumbricals