|
| |
 |
|
| REVIEW ARTICLE |
|
| Year : 2019 | Volume
: 12
| Issue : 3 | Page : 96-98 |
|
Rehabilitation of peripheral nerve injuries
Othmar Schuhfried
Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
| Date of Submission | 30-Apr-2019 |
| Date of Acceptance | 30-Apr-2019 |
| Date of Web Publication | 23-Aug-2019 |
Correspondence Address:
Othmar Schuhfried
Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna
Austria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/HMJ.HMJ_35_19
Rehabilitation after peripheral nerve lesions involves several professional groups such as medical doctors, physiotherapists, occupational therapists and orthopaedic technicians. The therapy goal is not only to treat the immediate symptoms due to the nerve lesion but also to avoid secondary damage. Peripheral nerve lesions often lead to severe functional limitations that affect the quality of life and professional and social participation and require appropriately targeted intervention in this regard.
Keywords: Conservative management, injury, peripheral nerve, rehabilitation
How to cite this article:
Schuhfried O. Rehabilitation of peripheral nerve injuries. Hamdan Med J 2019;12:96-8 |
| Introduction | |  |
The extent and effect of a peripheral nerve lesion strongly depends on the location of the lesion, the severity of the lesion and the cause of the damage. Peripheral nerve lesions have a pronounced negative effect on a patient's functional abilities, quality of life and social and emotional well-being.[1] Often, rehabilitation is very protracted with frustration and depression of the patient and requires a lot of patience from both the patient and the therapist.
| Diagnosis | | |
When preparing a treatment plan for peripheral nerve injury, an exact physical examination is essential to determine the type and extent of the lesion as accurately as possible. For this, it is necessary to test the active and passive mobility of all affected joints and the muscles that move them. From the distribution pattern, it should be determined whether it is a nerve endastomy lesion or nerve stem lesion or possibly a plexus lesion. The latter should be assessed with regard to fascicles and the possibility of a plexus tear or root lesion.
Existing muscle atrophy or passive restriction of movement must be documented. Sensitivity testing is essential and can enhance the image gained through strength and motility testing. The trophism of skin and nails should be noted, as well as temperature, sweating and blood circulation. Pain intensity and pain quality (burning, sharp, dull…) and functional disability and decreased the quality of life due to the nerve lesion must be documented. Regular physical examinations to assess the course of the disease are recommended.
Nerve conduction studies and electromyography expand the clinical findings.[2] In addition, examination with high-resolution ultrasound can provide information about the extent of the lesion and cause of the damage.[3] The history and other clinical findings will lead to a complete diagnosis. This should clarify whether a conservative treatment makes sense or whether surgical intervention is essential.
| Peripheral Nerve Lesion Classification | | |
For the prognosis and treatment strategies, the determination of the degree of the peripheral nerve lesion is very important and the following classification is applied:[4],[5]
Neurapraxia: segmental demyelination without damage of the axons. Duration of paralysis: hours to several weeks.
In neuropraxia, there is damage to the nerve sheath, often caused by pressure (through a crutch or during sleep). Normally, a surgical intervention is unnecessary. Frequently a cure, depending on the extent of the conduction block, is possible in a few weeks.
Axonotmesis: damage of the axons in preserved nerve sheaths. Duration of paralysis: depending on lesion height, months to years.
In axonotmesis, the envelope structures of the nerve are preserved, but the axon is damaged. Here is the possibility of complete restitution without surgical intervention. Occasionally, however, the cause of the injury must be surgically removed.
Neurotmesis: damage of the axons and nerve sheaths.
Duration of paralysis: surgical indication, then dependent on lesion height, months to years.
In neurotmesis, there is a complete interruption of continuity of the nerve, surgical reconstruction, such as nerve suture or nerve grafting, is essential as well as intensive rehabilitation measures.
The regeneration success is dependent from the severity and cause of the lesion, the height of lesion site and estimated recovery time and if a lead compound exists. In proximal nerve injuries, the long distance makes it difficult to reinnervate distal muscles before irreversible changes occur.[6]
| Strategies in Rehabilitation After Peripheral Nerve Injuries | | |
The rehabilitation after a peripheral nerve lesion contains the following goals:[7]
Prevention of secondary damage such as joint contractures, trophic skin damage, oedema, delaying the atrophy of the affected muscles, stimulating the regeneration of the affected nerves or at least eliminating obstacles to regeneration. Compensation of the finally perished structures by strengthening of the remaining musculature, compensation by trick movements, by splints or orthoses, possibly also by surgical interventions such as muscle transplantation or muscle displacements.
The central intervention in the rehabilitation of peripheral nerve lesions is the physiotherapeutic exercise therapy. Initially, it serves only to maintain joint mobility and muscle length. As soon as the first active movements are possible, one will try to strengthen the musculature with carefully performed resistance exercises. The stronger the regenerating musculature becomes, the more one will pay attention to continuous loading. The strengthening exercises should be adapted to the respective stage of reinnervation. Strengthening can be achieved either by isolated training of the affected musculature using only slight manual resistance, or by training synergistic muscle groups, moving the paretic muscles with the help of the intact synergistic muscle groups.[8] In case of severe or complete paresis, an attempt is made to increase the tension of the muscles on the paretic side by tightening and contraction of the same muscles contralaterally.[9]
To excite the movement of the weak muscles, various stimuli can be used: stimulation of muscle, tendons and joint receptors by pressure, tapping or stretching and setting of skin stimuli by brushing and thermal stimuli. Also important is the reduction of gravity which can be achieved by exercises in the water. If the affected musculature no longer achieves its original function due to the lack of reinnervation, strengthening the unaffected musculature is important in order to at least partially compensate for the missing function. The patients should be instructed and guided to perform independently and regularly their exercises at home.
With the exercise therapy, an electrical stimulation can be combined.[10] Electrotherapeutic methods can be not only used for pain reduction but also for preventing muscle atrophy. The electrical stimulation of the paralysed muscles should be designed so that the entire muscle is stimulated and a significant muscle contraction occurs. In lesions of the lower (second) motor neuron, the muscle is separated from the motor nerve supplying it. Electrically stimulated can now only the muscle itself. The denervated muscle fibre as the nerve fibre is also a stimulant substrate and can be electrically excited. However, this requires other stimulation parameters.[11] Compared with the nerve fibre which can be excited with pulses of short duration of <1 ms, the muscle fibre requires pulses of longer duration (often much >1 ms) that is, the denervated muscles have a longer time required (prolonged chronaxy values) to trigger a muscle contraction. The rapidly occurring muscular atrophy should be prevented or at least slowed down by regularly stimulating the denervated muscle by electrostimulation. Electrical muscle stimulation should be started early (if possible, a few days after the onset of the lesion) and must be performed regular and often long (months). However, there should be no muscle fatigue due to overstimulation.
For electrotherapy of neuropathic pain, easy-to-perform procedures such as transcutaneous electrical nerve stimulation with narrow pulses (<1 ms) can be used.[12] For this, there are easy-to-use battery devices for independent home therapy available [Figure 1]. | Figure 1: Transcutaneous electrical nerve stimulation application in a patient with neuropathic pain in the sensory distribution area of the peroneal nerve
Click here to view |
The manual massage can be applied for muscle detoning, pain reduction and contracture prophylaxis.
In the treatment of neuropathic pain, drug therapy plays an important role. This chapter will not discuss this topic in detail.
In occupational therapy functional movement sequences and the functional use of the involved arm and hand are practiced. Sensitivity training tries to improve the sense of perception. In case of painful dysaesthesia, desensitisation can reduce the stimulation threshold due to repetitive stimulation.
The provision of splints or orthoses can help to avoid deformities and contractures and to improve the function of the limb. For example, in a loss of wrist and finger extension in lesions of the radial nerve wrist splints support the hand- or toe-off orthosis support the ankle dorsiflexion in lesions of the peroneal nerve. On the lower extremity, the paresis of the foot dorsal extension is the most common indication for orthotic treatment. In this case, a drop foot is compensated by a toe-off orthosis and a symmetrical gait pattern is possible while avoiding a stepper gait.
In combination with orthotic treatment, the application of functional aids is often necessary, for example, handle thickening, special cutlery and so on. Furthermore, the private and professional environment of the patient should be ergonomically adapted. In case of non-permanent paresis often only a few, simple adaptations are necessary. In the case of permanent paresis with severe functional impairment, one should use all the possible technical assistance and adaptions of the environment to maintain independence in daily activities.
General instructions for the patient are an important part of the rehabilitation process.[7] Due to the lack of sensitive feedback, the risk of injury to the skin is increased. Wearing gloves can be a simple protection against mechanical and thermal stimuli. On the feet, a well-fitting not too hard footwear is very important. Due to the oedema, the tendency of the affected limb due to disturbance of the vasomotor function and lack of muscle activity, the extremity should be regularly put up and as far as possible decongesting exercises should be performed.
Since the affected region is used less due to the weakness, there is also an increased risk of contraction for the adjacent joints. The affected and adjacent joints must be moved passively and as far as possible actively, and the patient should be instructed to do this regularly.
| Conclusion | | |
The aim in the rehabilitation of peripheral nerve injuries is not only to treat the consequences of the damage on physical level (weakness, sensory disturbances, pain, joint contractures, muscular dysbalance, connective tissue changes…), but also to reduce impairments in function and participation (loss of independence in daily life, loss of job, loss of social integration and loss of socioeconomic autonomy).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Wojtkiewicz DM, Saunders J, Domeshek L, Novak CB, Kaskutas V, Mackinnon SE, et al. Social impact of peripheral nerve injuries. Hand ( N Y) 2015;10:161-7.  |
| 2. | Oh SJ, editor. Nerve conduction techniques. In: Clinical Electromyography. 2 nd ed. Baltimore: Williams and Wilkins; 1993. p. 39-55. |
| 3. | Peer S, Gruber H. Traumatic nerve lesions. In: Peer S, Bodner G, editors. High-Resolution Sonography of the Peripheral Nervous System. 2 nd ed. Berlin, Heidelberg: Springer; 2010. p. 123-51. |
| 4. | Seddon HJ. A classification of nerve injuries. Br Med J 1942;2:237-9. |
| 5. | Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain 1951;74:491-516. |
| 6. | Campbell WW. Evaluation and management of peripheral nerve injury. Clin Neurophysiol 2008;119:1951-65. |
| 7. | Paternostro-Sluga T. Rehabilitation peripherer Nervenläsionen. In: Crevenna R, editor. Kompendium Physikalische Medizin and Rehabilitation. 4 th ed. Wien-New York: Springer; 2017. p. 353-62. |
| 8. | Stockert BW. Peripheral neuropathies. In: Neurological Rehabilitation. Umphred DA, editor. St. Louis: Mosby; 1995. p. 360-77. |
| 9. | Kabat H, Knott M. Proprioceptive facilitation technics for treatment of paralysis. Phys Ther Rev 1953;33:53-64. |
| 10. | Asensio-Pinilla E, Udina E, Jaramillo J, Navarro X. Electrical stimulation combined with exercise increase axonal regeneration after peripheral nerve injury. Exp Neurol 2009;219:258-65. |
| 11. | Pieber K, Herceg M, Paternostro-Sluga T, Schuhfried O. Optimizing stimulation parameters in functional electrical stimulation of denervated muscles: A cross-sectional study. J Neuroeng Rehabil 2015;12:51. |
| 12. | Kılınç M, Livanelioǧlu A, Yıldırım SA, Tan E. Effects of transcutaneous electrical nerve stimulation in patients with peripheral and central neuropathic pain. J Rehabil Med 2014;46:454-60. |
[Figure 1]
|
Search Pubmed for