Rehabilitation Guidelines following a Free Functional Muscle Transplant Please note that this is advisory information only. Your experiences may differ from those described. All exercises must be demonstrated to a patient by a fully qualified Physiotherapist. We cannot be held liable for the outcome of you undertaking any of the exercises shown here independently of direct supervision from the RNOH. Indications Prolonged loss of muscle activity Inadequate function after primary nerve transfers Possible complications Infection Pain Neurovascular compromise Non functioning muscle transfer Pre operative management Agree on functional goals with the patient Correct any trick movements Strengthen the donor tendon/muscle used for the transfer Mobilise the joint prior to surgery with exercises to improve the range In anticipation of further surgery, scar adhesions, oedema and soft tissue tightness must be addressed and minimised Explain the post operative routine and principles of motor control retraining for adults. In young children the tendon transfer may occur spontaneously without training and/or with functional play activities. 1 Failure to progress If a patient is failing to progress, then consider the following: Possible problem Pain inhibition Poor Compliance/Quality of Home Exercise Programme (HEP) Stiff elbow Poor hand function Action Adequate analgesia Keep exercises pain-free If severe night pain/resting pain – refer to PNI Unit In order for the muscle transplant to have a good chance of working, exercises need to be done repetitively on a daily basis. Without undertaking this the muscle transplant will fail to work. Discuss exercise prescription with Physiotherapist at The RNOH ROM exercises Adequate pain management Splinting if applicable Discuss with OTs to review functional splinting if appropriate Also consider possible complications noted previously. See guidelines for further guidance. It is essential you contact us if you have any concerns. Physiotherapy/ Occupational Therapy Team - 02089095519 PNI Unit – 020 8909 5803 2 Rehabilitation guidelines for Free Muscle Transplant Initial rehabilitation phase: 0-6 weeks Goals: 1. Optimise tissue healing 2. Protect the nerves that have been transferred to the muscle transplant 3. Pain control Restrictions: 1. No use of operated upper limb Treatment Sling: Worn day and night Pain relief: resting positions Patient education: post-op restrictions; importance and nature of rehab process; importance of maintaining good posture; advice re: functional activities e.g. dressing/washing – Occupational Therapy review. Postural awareness: relaxation of shoulder girdle; cervical spine ROM. Milestones to progress to next rehabilitation phase: 1. Adequate wound healing 2. Team are happy with quality of Tendon transfer (Refer to post operative instructions) 3. Pain controlled 3 Rehabilitation guidelines for Free Muscle Transplant Early recovery rehabilitation phase: six weeks – 9 months Goals: 1. Gently increase ROM Restrictions: 1. No exercises that increase pain 2. Do not stretch the tendon transfer 3. For the first week of mobilisation following an intercostal nerve transfer movement is restricted to only 10° of abduction 4. No abduction beyond 90 degrees for the first 15 weeks Treatment Sling: When not exercising the patient should be encouraged to keep their arm in the polysling to protect the muscle transplant. Patient education: exercising caution with activities to optimise healing; postural awareness; encourage exercises discussed below to assist nerve growth into the muscle and to help muscle activation once fibres have entered the muscle itself. Pain Management: Tens/acupuncture if applicable Exercises: Gentle ROM exercises for the shoulder and elbow – if the patient had an intercostal nerve transferred to the muscle transplant it is crucial that you progress abduction slowly starting at 10° at 6 weeks. With each passing week a further 10 degrees of movement can be added, so that by 15 weeks after the operation the patient can achieve 90° of abduction. If the patient had a pectoralis nerve transfer the same holds true as above. If the patient had an accessory nerve or one of the nerves from the arm transferred then the movement at the shoulder can begin in an unrestricted manner. Depending on which nerve has been transferred:  Accessory nerve – repeated shoulder shrugs; 100 shoulder shrugs every hour  Intercostal nerves – Deep Breathing exercises; 10 deep breaths every 10 minutes (be careful the patient does not get dizzy) coupled with a daily walk of more than a mile at a pace that makes the patient just out of breath  Ulnar nerve – clenching fist and flexing wrist; 100 times per hour  Pectoralis nerve – adduction; 100 times per hour Muscle stimulation can be used to stimulate the muscle transplant – if appropriate Elbow extension AROM and stretches as tolerated (no restriction) Scar massage 4 General fitness/balance work/proprioception Stretch opposing muscle groups Milestones to progress to next rehabilitation phase: 1. 2. 3. 4. No sling support needed 3/12 post op Minimal pain Visible/palpable muscle twitch Tendon is mobile and free from adhesions and tethering Failure to meet milestones: 1. Delay progression to next phase of rehabilitation 2. Consider possible reasons for failure to progress and act accordingly 3. Refer to/discuss with PNI Team 5 Rehabilitation guidelines for Free Muscle Transplant Late recovery rehabilitation phase: 9 months + Goal: 1. Isolated tendon muscle action at low efforts progressing to strengthening 2. Increase in functional ability Restrictions: 1. No exercises/activities that increase pain Treatment Patient education: Encourage return to normal activities within comfortable limits; advise patient of ongoing improvements expected for up to three years – this varies from individual to individual and amongst the different nerves used to power the muscle transplant. Exercises: Once the muscle has started to twitch (this usually starts around 9 months after the procedure) active range of movement exercise can begin – initially with the aid of gravity which can then be progressed to against gravity and resistance. Use of biofeedback/facilitation techniques – using EMG, mirror feedback, palpation of muscle belly/tendon Water based exercises are encouraged to assist with movement. Postural awareness Proprioception/balance work Functional activities – review functional goals Milestones for discharge: 1. Achieved functional goals agreed with patient Failure to meet milestones: 1. Encourage patient to continue with home exercise programme 2. Refer to/discuss with PNI Team 6 FREE MUSCLE TRANSFER PATHWAY Physiological action of the nerve transferred e.g. for intercostal nerve transfer Cough/Breath Physiological action of the nerve transferred + assisted movement of the arm e.g. for the intercostal nerve transfer cough/breath + bend elbow to aid elbow flexion Assisted movement of the arm e.g. assisted elbow bend Unassisted movement of the arm e.g. Bending elbow with gravity eliminated Functional active movement e.g. Bending elbow against gravity Resisted Movement e.g. Against resistance 7