Abbreviation: RJMS Vol: 14 Issue: 4 eISSN: 2581-7248 pISSN 2231-1947
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Sumi Rose1 , Kaviya N2 , K A Shruti2
1: Associate Professor, 2: BPT student, Acharya College of Physiotherapy, R T Nagar, Bengaluru
Corresponding author
Dr Sumi Rose
Associate Professor
51, Acharya College of Physiotherapy
R T Nagar, Bengaluru
Email: rosempt@yahoo.com
Mob: 8880726780
Abstract
Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. The brachial artery is the most frequently injured artery in the upper extremity. The study was undertaken with an intention to rehabilitate the hand function post brachial artery revascularization surgery at elbow caused by dog bite. A single case experimental study data was collected with hand dynamometer for the grip strength, pinch grip and movement analysis was done using range of motion (ROM) and manual muscle testing (MMT) for muscle power. 3 months of physical therapy intervention was done using hand exerciser unit and galvanic stimulation. Result showed significant hand function strength improvement. Wrist extension was 47 % and radial deviation 45% and ROM of wrist showed overall 60 % improvement post treatment session. Grip strength showed minimal improvement of 7.5% whereas pinch grip had 33% improvement. There was marked improvement in ROM and strength post intervention although the hand function grip strength and pinch grip did not show marked improvement.
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INTRODUCTION
Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. 95.45% of dog bite cases were reported in tertiary care center of Bangalore Medical College and Research Institute, Bengaluru1. Similar results were recorded in a study, stating dog was the most common (95.8%) biting animal,2 The brachial artery is the most frequently injured artery in the upper extremity. Its injury accounts for approximately 28% of all vascular injuries3,6,7,12. The median nerve courses with the brachial artery throughout its length. The radial and ulnar nerves are parallel portions of the brachial artery11,13. Therefore, as in all upper extremity vascular injuries, there is a high incidence of associated nerve injuries with brachial artery injuries.
Case Report
A 56-year old house wife, right dominant, came to outpatient department (OPD) during September 2018 post right brachial revascularization surgery (May 2018). Surgery had been carried out as an emergency procedure due to a dog bite with the chief complaint of inability to move the right hand for day-to-day purposes. She reported to OPD after one month of physiotherapy intervention which was not specified. She had been given cock-up splint for 1-month post-surgery. She was diabetic and hypertensive and was on medication for past 10 years. Limb attitude at base line observation was, right shoulder slightly elevated, elbow flexed and wrist drop and ulnar deviation was prominent. Ulnar claw hand was noted and muscles of the hand were atrophied.
Investigations: NCV showed grade IV Sunderland classification of right radial nerve injury, grade II in ulnar and median nerve. Main Objective was to rehabilitate the hand function post Brachial revascularization surgery at elbow caused due to dog bite
Diagnostic Assessment
Outcome measures
1. Hand Dynamometer
2. Pinch Dynamometer
3. Manual Muscle Testing (MMT)
4. Range of Motion (ROM)
Duration of the Study: 12 weeks
Study design: Single case experimental study
Therapeutic Intervention
Written consent was obtained from the patient and patient was explained about the exercise protocol. Grip strength was measured by hand dynamometer, and pinch grip by pinch dynamometer. Range of motion of wrist joint, MMT was measured for wrist muscle strength.
Galvanic stimulation4 for 3 weeks was given followed by hand function exercise using hand exerciser unit was continued up-to 12th week of intervention.
Intervention details
1. Galvanic stimulation: 30 contraction/minute for Brachioradialis, Extensor Carpi Radialis Longus And Brevis, Extensor Digitorum, Extensor Carpi Ulnaris, Abductor Pollicis Longus Extensor Pollicis Longus and Brevis and Extensor Indicis for 5 days/week for 3 weeks. Progressed to 20 contraction/minute from 4th to 6th week. Galvanic stimulation was stopped after 6 weeks Fig.1).
2. Exercise: Passive range of motion and active assisted exercise was continued initial 3 weeks for 10 repetition/exercise for 3 session/day for 5 days /week. It was progressed to Hand exerciser unit exercise initiated with bimanual task, precision training, bimanual Velcro strap training, sorting the pebbles to various boxes 10 repetition/exercise for 3 sessions/day for 5 days /week. Variable practice was continued from 4th to 6th week beyond 6th week variable practice was continued and progressed to power gripper exercise for 15 repetition / session for 3 session /day for 5 days /week up to 12th week, the detailed description is given in the table and post assessment of outcome measures were measured(Fig.2).
Patient Perspective: Subject had regained hand function though the grip strength was not improved significantly, although the subject wanted to perform her day to day activities independently. subject was satisfied with the improvement after 12 weeks; subject did not take any medications or any health care services and her social functioning was normal.
RESULTS
Significant improvement in hand muscle strength of about 47% wrist extension, 45% radial deviation, there was improvement of ROM about 60% improvement in wrist extension. Though there was improvement in pinch grip 33.3% and grip strength 7.5% but was not marked improvement. Graph 1.1, 1.2, 1.3)
Graph 1.1: The graph represents the graded grip strength improvement which represents weekly improvement to 1.5 kg by the end of the 12th week whereas pinch grip did not improve to the second session of assessment and pinch grip could increase upto 1 kg by the end of 12th week. Pinch grip 33.3% and grip strength 7.5% but was not marked improvement. Hand muscle strength of about 47% wrist extension, 45% radial deviators
Graph 1.2: Graph 1.2 Represents that muscle power of wrist flexors, ulnar deviation improved significantly and radial deviation improved to grade 2 only but the wrist extension improvement was significant by 12th week but initially by 6th week.
Graph 1.3: wrist extension and radial deviation was least improved post intervention. there was improvement of ROM ,60% improvement wrist extension.
DISCUSSION
Hand function was the primary concern for the subject and current clinical finding showed significant improvement in hand muscle strength of about 47% wrist extension, 45% radial deviators, there was improvement of ROM ,60% improvement wrist extension. Though there was improvement in pinch grip 33.3% and grip strength 7.5% but was not marked improvement. Galvanic stimulation was continued till the 6th week of intervention main aim of giving galvanic stimulation was to induce vasomotor effect. Galvanic stimulation is used to stimulate the muscle directly following the nerve injury 4,5,. Hand exercises were given with constant feedback of performance and knowledge of result, the exercises were progressed gradually by 6th week with variable practice which was continued throughout intervention. Hand exerciser unit is low cost project which can be used effectively in community for rehabilitation. constant motivation to the patient was given throughout the intervention. Future researches should consider focus on post vascular surgeries rehabilitation. Future research should also focus on psychological status of these subjects.
Brachial artery is the main artery of upper extremity any damage to the artery can deprive the blood supply to the muscle of the hand and injuries can also lead to nerve damage 8-10. Vascular injuries are very common and rehabilitation should focus on post vascular surgeries. There is scarcity of research post brachial artery vascular surgery rehabilitation. Long term rehabilitation is required post brachial artery surgeries and constant motivation is the key for success in rehabilitation.
CONCLUSION
Hand function improved significantly followed by hand rehabilitation there was marked improvement in ROM and strength post intervention although the grip strength and pinch grip had no marked improvement.
Conflict of interest: Nil
Supporting File
References
1. Navya Sri Sreenivas, Saraswathi Sakranaik, Ranganath T, Sobagiah,Anil kumar.An epidemiology of animal bite cases attending tertiary care center of Bangalore Medical College and Research Institute, Bengaluru: a retrospective study. Int J Community Med Public Health .2017 ; 4: 2538-2542
2. Pavithra R, Viveki RG, Halappanavar AB. Socio Demographic Profile and Management Practices of Animal Bite Cases Attending Anti Rabies Clinic in a Tertiary Care Centre in North Karnataka. IJAR.2015;5:371-3.
3. Zellweger R, Hess F, Nicol A, OmoshoroJones J, Kahn D, Navsaria P .An analysis of 124 surgically managed brachial artery injuries. Am J Surg. 2004; 188:240-5.
4. Pandyan AD .Electrical stimulation for preventing and treating post-stroke shoulder pain. Cochrane Systematic Review – Intervention.2000
5. Gaurav Thakral, Javier LaFontaine, Bijan Najafi, Talal K. Talal, Paul Kim, Lawrence A. Lavery. Electrical stimulation to accelerate wound healing. Diabet Foot Ankle. 2013; 4: 10.3402
6. MDSteven G.Katz , MDRoy D.Kohl. Direct revascularization for the treatment of forearm and hand ischemia Amer J Surg .1993;165:312- 316
7. Ryun Lee.Acute Osteomyelitis in the Hand Due to Dog Bite Injury: A Report of 3 Cases. Arch Plast Surg. 2017; 44: 444–448.
8. Borkar A. Epidemiology of Animal Bite Cases Reported to Anti-Rabies Vaccination Clinic, at a Tertiary Care Hospital, in Tribal Area. IJAR. 2014; 4:426-8.
9. Pavithra R, Viveki RG, Halappanavar AB. Socio Demographic Profile and Management Practices of Animal Bite Cases Attending Anti Rabies Clinic in a Tertiary Care Centre in North Karnataka. IJAR. 2015; 5:371-3
10. Seligsohn D. Dog bite incidence and associated risk factors. Available at: http://stud.epsilon. slu.se/ 6622/7/seligsohn_d_140908.pdf. Accessed on 2nd February 2016
11. Acharya R, Sethia R, Sharma G, Meena R. An analysis of animal bite cases attending antirabies clinic attached to tertiary care centre, Bikaner, Rajasthan, India. Int J Comm Med Public Health. 2016;1945-8.
12. Ekim H, Tuncer M. Management of traumatic brachial artery injuries: a report on 49 patients. Ann Saudi Med. 2009;29:105–9.
13. LoCicero J, Talucci R, Kertein MD. Brachial artery reconstruction after traumatic disruption. South Med J. 1982; 75:1099–100