treatment of peripheral nerve lesions

8/6/2019 Treatment of Peripheral Nerve Lesions

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Treatment of peripheral nerve lesions

Conservative treatment:

In every case of nerve injury the limb should be splinted in a position that will completely relax

the affected muscle, e.g. a cock up splint for radial nerve palsy, abduction splint for deltoid

paralysis etc. physiotherapy is given to the limb intermittently. The approximate rate of

regeneration of the nerve is clinically detected by eliciting Tinels sign. In this, the limb is gently

percussed with a finger over the course of the nerve from distal to the proximal. The point where

the patient experiences tingling along the course of the nerve is taken as the site of regeneration

and noted as the site of positive Tinels sign. Distal progression of this site in due course of

treatment gives the approximate rate of nerve regeneration.

Operative treatment:

The basic principles of operartive treatment in a nerve lesion are as follows:

1. Neurolysis when, at operation, the nerve is found in contunity but is encircled byfibrosis, the nerve is freed of this fibrotic tissue and thereby the nerve is decompressed.

This procedure is termed as neurolysis. External neurolysis is the one in which the nerve

sheath is not opened but the nerve is freed of the surrounding fibrous tissue. Ininternal

neurolysis the nerve sheath is opened up and the fascicles are freed of the intervening

fibrous tissues.

2. Nerve suture end to end nerve suture, when done early, gives best results. With theadvent of microsurgical techniques, using an operating microscope, it has become

possible to accurately match the nerve bundles thereby improving the chances of

recovery. In fascicular nerve repair, the outer sheath of the nerve is excised and the

fascicles are separated. The fascicles of both the cut ends of the nerve are matched

together and stitched with very thin suture materials. In late cases, the cut ends of thenerve get retracted and that makes therir approximation difficult. In such cases the joints

of that particular limb are kept in flexion and the nerve is mobilized so that the ends of

the nerve can be approximated without any tension. The limb is kept in a plaster slab in

the flexed position in the post operative period for about 3 4 weeks. The joints are then

gradually extended over another 3 weeks time.


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3. Nerve grafting in late cases where the cut ends of the nerve have retracted considerably,their approximation is impossible. In such cases, the gap is bridged by nerve grafts

obtained from sural nerve or some some cutaneous nerve, e.g. lateral cutaneous nerve of

the thigh, etc.

4. Tendon transfers there is a critical period described for every nerve after which norecovery is expected. This period varies with individual nerve, but generally it is 14 18

months after injury. In cases untreated beyond this critical period or where no recovery

occurs after repair or graft, tendon transfers are indicated to improve the appearance

and/or function of the hand/foot.

Median nerve:

The common disability in a median nerve palsy is loss of opposition resulting in monkey hand.

Opposition may be restored by transfer of flexor digitorum sublimis or extensor indicis into the

abductor pollicis brevis. After operation, the thumb is maintained in the position of opposition,

with the help of a plaster or PVC splint for 4 6 weeks.

Ulnar nerve:

Ulnar nerve palsy commonly occurs in leprosy and following injury. Claw hand deformity with

the inability to flex the MP joints is the resultant disability. This can be corrected by transfer of a

sublimis tendon to the extensors.

Radial nerve:

Radial nerve palsy causes wrist drop with loss of extension of the wrist, fingers, extension and

abduction of the thumb. The commonly performed tendon transfers are: pronator teres to

extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum and Palmaris longus to

abductor pollicis longus. The wrist and hand are maintained in the corrected position, after

tendon transfers, for a period of 4 6 weeks, after which mobilization is started.


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Principles of physiotherapy management:

First 3 weeks after a thorough evaluation, the treatment programme is planned on an individual

basis.

1. In the presence of anesthesia, he basic principle in the care is the protection of the numbarea. This will prevent further damage by burns or trophic ulcers.

2. Maintainence of ROM to avoid contractures and deformities. A proper resting splint isgiven to avoid undue strenuous movements.

3. Control inflammation and swelling by gentle movements (active or relaxed passive) andelevation. Controlling edema is more important in severe lesions.

4. Improving muscle-power, endurance, and flexibility, especially of the involved muscles.5. Reduction of pain by proximal TENS, diapulse, or cold immersions.

After 3 weeks

1. Electro-diagnostic tests are conducted to assess the degree of nerve damage, by electricalreaction of degeneration test, to plan accurate regime of electrotherapy.

2. Maintainence of the soft tissue excursion by gentle stretches.3. Modifications in the splint to further improve the functional status.4. Electrical stimulation to prevent muscle fibrosis and atrophy.5. Motor re-education correct methods of exercises to re-educate muscle function are

extremely important as soon as the recovery is indicated by diagnostic tests. Bilateral

symmetrical patterns are of special significance.

6. Sensory re-education as the efficiency of the motor activity depends upon the sensorystatus, sensory re-education plays a predominant role. It should be begun as soon as

possible.

7. As the voluntary movement returns, the splint can be modified to provide resistiveexercises.

8. Electro-diagnostic tests should be repeated at regular intervals to know the response oftreatment. If no recovery is seen even after 18 20 months to 2 years, surgery should be

contemplated. After complete initial assessment, the treatment measures are planned as

per the requirements of the patients condition:


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y During early stage (first three weeks) this is the stage of paralysis and all the symptoms ofearly injury to the nerve are present. The treatment measures are : -

(a) Reduction of inflammation: first priority is to reduce and prevent oedema, by limbelevation.

(i) Active and passive movements to improve circulation.(ii)Exercises to adjacent joints and muscles.

(b) Reduction of pain: TENS can be effective in reducing pain. In sensory impaired areas

electrodes may be placed over the nearest area where intact sensation is present or over the nerve

trunk.

(c) Splint: a splint is fabricated to provide rest and optimal support to the area of involvement. Its

fitting and use need to be explained. One has to be careful while advising splints in the presence

of impaired sensations. It needs repeated checking of the anesthetic and pressure areas.

(d) Exercises:

Active and resistive exercises to the muscles, which are unaffected, should be repeated asoften as possible.

Relaxed full range passive movements should be given t the affected joints. Muscleimbalance, due to the paralysis of muscle groups, needs to be observed for the over

activity of intact antagonists. The patient should be educated on simple but correct

methods of repeated passive stretching of these contracture prone muscles and joints.

Accessory passive movements are also effective in preventing joint stiffness and shouldbe included.

y During the stage of recovery (3 weeks onwards) (a)Re-education of movement: re-assessment will give indication regarding recovery.

Electro-diagnostic tests at this stage are of primary importance to diagnose the extent of

the nerve injury. This is the most important phase to hasten the rate of recovery. As there

is recovery in the voluntary contractions of the paralysed muscle, it recovers initially in

its action as a synergist, which should be followed as an antagonist at a later stage. To

help early recovery, the movement should be assisted from outer part of the middle range.


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PNF techniques are extremely valuable at this stage. Educating the patient on accurate,

gentle and sustained self-resisted technique is valuable.

(b)Splint: a splint, which was initially static, should be modified to dynamic. Whenever possible, the splint should provide resistance to the returning muscle power, offering

passive stretching of the contracture prone muscles and joints. It provides optimal

stability and assistance in muscle re-education. Simple functional tasks should be

introduced so that movements can be repeated in a natural manner. Exercise programme

should be made intensive till good function returns.

(c)Sensory re-education: it is one of the important responsibilities of the physiotherapistduring this stage.

(i) Sensory re-education in patients with total sensory loss is difficult. It should beincorporated with electrical stimulation and simultaneous active efforts by the

patient. Initially it should be incorporated with passive educative movements.

While giving stimulation, electrodes should be placed on the nerve trunk and the

proximal area of the skin where sensations are intact.

(ii) Sensory re-education is easy in patients where partial voluntary movement is present. Active effort by the patient to produce the recovering movement is

reinforced with visual and auditory feedback.

(iii) Attempted self correction of the blind folded responses alternated with visualfeedback techniques are also used for sensory re-education. The patients

concentrated and repeated efforts are needed to practice these techniques.

(iv) The technique of bio feedback can be used to the greatest advantage.y Late stage when the chances of recovery are poor, surgery is indicated. Physiotherapy will

depend upon the type of surgical procedure.

Physiotherapy following suture:(i) During immobilization phase: - Limb elevation and measures to reduce inflammation. Diapulse can be given through immobilization for early healing. Vigorous active movements to other mon-immobilized joints to improve circulation

and to prevent contractures.

(ii) Mobilization phase: -


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Movement should be intensified and active movement to be progressed to mildresistive exercises and intrinsic self developed tension exercises.

Relaxed passive movements to be carried out to full range of motion. Accessory passive movements can be added.(iii) Restoration: - the whole programme of mobilization and strengthening should be

made intensive by:

Initiating progressive resistive exercises. Functional activities should be made vigorous and vocation oriented. Deep friction massage to the surgical scar to avoid adherence. Splint should be altered to offer resistive exercises.

By 8 10 weeks adequate return of movement and function should be achieved.

Physiotherapy following tendon transfers:

If the recovery of the nerve following nerve suture is not enough to carry out functional tasks,

tendon transfer is undertaken. The basic objective of physiotherapy is to re-educate the

transferred tendon for its altered function. It is essential that the donor muscle must be strong

enough to atleast grade 4 (MMT). After transfer its power is usually reduced by atleast 1 grade.

Therefore, if the power of the donor muscle is less than 4, surgery should not be undertaken.

treatment of peripheral nerve lesions

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