Nerve Injury Rehabilitation
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- 1 Clinically Relevant Anatomy
- 2 Pathological Process
- 3 Clinical Presentation
- 4 Assessment
- 5 Outcome Measures
- 6 Physiotherapy Management / Interventions
- 7 Related Pages
- 8 References
Clinically Relevant Anatomy
Nerve regrowth in the peripheral nervous system is dependant on type of injury. Functional disability due to nerve lesions is intertwined with severity of lesion. Before reading this article it would be advised to have a good knowledge of the type of lesion and the denervation consequences . Please read Classification of Peripheral Nerve Injury as an introduction to this page.
Peripheral nerve injuries have numerous causes including: traumatic injuries; infections; metabolic problems ( one of the most common causes is diabetes mellitus); inherited causes; exposure to toxins; tumours; iatrogenic causes.Watch the below to grasp the concepts of nerve damage and repair
Clinical presentation varies according to the nerve affected ie sensory, motor, or combined.
Signs and symptoms may include
- Gradual onset of numbness, prickling or tingling in your feet or hands, which can spread upward into your legs and arms
- Sharp, jabbing, throbbing, freezing or burning pain
- Extreme sensitivity to touch
- Lack of coordination and falling
- Muscle weakness or paralysis if motor nerves are affected
- Neuromatous or causalgia pain.
After a diagnosis of a peripheral nerve injury a full subjective and objective examination is required to get a clear picture of the way the lesion is affecting the client. The examination should focus on
- Pain assessment
- Sensation deficit and skin condition
- Muscle strength/loss
- Functional deficits
- Balance deficits
- Joint stiffness
- Emotional stress
Depends on various criteria ( eg upper or lower limb) but could include:
- Oxford scale
- Romberg or Berg balance test
- Visual analogue scale
- Short form McGill pain questionnaire
- Nine-hole peg test
Physiotherapy Management / Interventions
Management is directed towards:
Neuropathic pain affects quality of life and is a common consequence of nerve damage. Complete relief is rarely obtained and 40-60 % find means to obtain partial relief. A multidisiplinary approach is taken, with most input from the pharmocologist(s). Anticonvulsants and tri-cyclic anti depressants are the most used drugs for neuropathic pain. Physiotherapist can employ other modalities that show in various studies to be of benefit as a complementary medicine for pain relief. These include
- massage eg aromotherapy massage, in studies, has shown to help manage neuropathic pain and increase QOL. Many differing massage techniques have been employed showing benefits for pain management and QOL.
- TENS.Application of TENS has been found to be of benefit in pain reduction in neuropathic pain. It was found to be of benefit if used at 100hz in constant mode.
- Low Level Laser Therapy (LLLT). Studies has found this to be of benefit in pain relief and acceleration of healing in treatment of neuropathic pain and neurological deficits as an adjuvant therapy.
- Relaxation techniques
A consequence of denervation is muscle atrophy and functional deficits. The healthy neuromuscular junction (NMJ) is critical for nervous control of muscles. TENS has been seen in numerous studies to have a positive effect on maintaining NMJ health and in prevention of muscle atrophy.A 2018 study found the use of TENS was most beneficial if delayed to one week post trauma, the use of 100hz being most beneficial.
Muscle care is of utmost importance to prevent damage to muscle units, in particular prevent: heat or cold trauma; over stretching by gravity or incorrect lifting/transfer techniques; contractures of muscles. The below video clips give a good guide to proper handling techniques involved in passive ROM.
Techniques employed by physiotherapist to achieve the above goals are massage, US, hydrotherapy, splints, passive ROM stretches and correct transfer skill education.
When muscle strengthening exercises can commence it is important not to damage the healing nervous tissue, if pins and needles, numbness or increased pain occurs the exercise is too hard and can have a negative effect on healing.
Muscle strengthening exercises are employed as appropriate eg isometric, graded weight progression, open close chain. Use of support slings may be employed to assist the movement and take weight of the limb. As may static and dynamic splints- helping to rest paralysed muscles in optimum positioning to avoid over stretching and or contractures. They also assist in allowing unaffected muscles to operate from correct positions. See video clip below for examples
A recent study found that exercise can enhance axonal growth via a neurotrophin-dependent mechanism affecting adult dorsal root ganglion neurons. Aerobic activity should also be encouraged ( aiming for 30 minutes 4 times a week) for its’ known health benefits.
Functional deficits and sensory deficit
In the relearning of functional tasks the brain is utilised to regain visio-tactile and audio-tactile interaction. In the upper limb the focus is on fine motor skill learning. In the lower limb balance and coordination are areas of focus.
In sensory stimulation pinching and tapping, brushing and icing are regularly used.
The following video clip gives some good ways to do more advanced balance and proprioception training
The next video clips give an insight into exercises for fine motor skills
see Otago balance program as an example of a good balance program.
The soft tissues of the region and adjacent regions supplied by the damaged nerve are at risk of contractures if left in shortened positions. Regular daily massage, PROM exercises are needed on a daily basis. Protective removable static splints are also useful in contracture prevention. For joints that have become stiff ultrasound and laser are of useful therapies.
Chronic neuropathic pain has a life debilitating effect causing emotional stress and reduced QOL. To properly treat a client with neuropathic pain this must be respected. The ultimate goal is not simply to reduce pain, but to achieve better QOL. This can only be achieved if the depression, anxiety and sleep disorders are also addressed.
- Reza Salman Roghani and Seyed Mansoor Rayegani (2012). Basics of Peripheral Nerve Injury Rehabilitation, Basic Principles of Peripheral Nerve Disorders, Dr. Seyed Mansoor Rayegani (Ed.), ISBN: 978-953-51-0407-0, InTech, Available from: http://www.intechopen.com/books/basic-principles-of-peripheral-nervedisorders/basics-of-peripheral-nerve-injury-rehabilitation (last accessed 24.3.2019)
- Mayo clinic. Peripheral neuropathy. Available from: https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061 (last accessed 24.3.2019)
- Dr. Simon Freilich. Nerve damage and repair. Available from: https://www.youtube.com/watch?v=OlNyp0RfiBg&feature=youtu.be (last accessed 24.3.2019)
- Medscape. Peripheral nerve injuries clinical presentation. Available from: https://emedicine.medscape.com/article/1270360-clinical (last accessed 24.3.2019)
- Gok Metin, Zehra & Arikan Dönmez, Ayşe & Izgu, Nur & Ozdemir, Leyla & Emre Arslan, Ismail. (2017). Aromatherapy Massage for Neuropathic Pain and Quality of Life in Diabetic Patients. Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing. 49. 10.1111/jnu.12300. (last accessed 25.3.2019)
- The foundation for peripheral neuropathy. Massage for neuropathy. Available from: https://www.foundationforpn.org/living-well/integrative-therapies/massage/ (last accessed 25.3.2019)
- Yameen F, Shahbaz NN, Hasan Y, Fauz R, Abdullah M. Efficacy of transcutaneous electrical nerve stimulation and its different modes in patients with trigeminal neuralgia. JPMA-Journal of the Pakistan Medical Association. 2011 May 1;61(5):437. (last accessed 25.3.2019)
- Cotler HB, Chow RT, Hamblin MR, Carroll J. The use of low level laser therapy (LLLT) for musculoskeletal pain. MOJ orthopedics & rheumatology. 2015;2(5). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743666/ (last accessed 26.3.2019)
- Su HL, Chiang CY, Lu ZH, Cheng FC, Chen CJ, Sheu ML, Sheehan J, Pan HC. Late administration of high-frequency electrical stimulation increases nerve regeneration without aggravating neuropathic pain in a nerve crush injury. BMC neuroscience. 2018 Dec;19(1):37.(last accessed 25.3.2019)
- Kellog community college. PROM upper extremity. Available from:https://www.youtube.com/watch?v=J-YE4lAVEmo&t=30s (last accessed 27.3.2019)
- Kelloge community college. PROM lower extremity. Available from: https://www.youtube.com/watch?v=CK6Uq7JGy0g&t=6s (last accessed 27.3.2019)
- HomeCEU Dynamic splinting. Available from: https://www.youtube.com/watch?v=XT68ZcEXG5A (last accessed 25.3.2019)
- Voluntary exercise increases axonal regeneration from sensory neurons Raffaella Molteni, Jun-Qi Zheng, Zhe Ying, Fernando Gómez-Pinilla, Jeffery L. Twiss Proceedings of the National Academy of Sciences Jun 2004, 101 (22) 8473- Available from: https://www.pnas.org/content/101/22/84738478; DOI:10.1073/pnas.0401443101 (last accessed 26.3.2019)
- Dr Ben Kim. Simlpe ways to improve balance and proprioception. Available from: https://www.youtube.com/watch?v=KDvJpp6-ID0 (last accessed 27.3.2019)
- MSUrehabed. Hand motor skills. Available from:https://www.youtube.com/watch?v=HYScddTCH3U (last accessed 26.3.2019)
- Torta R, Ieraci V, Zizzi F. A Review of the Emotional Aspects of Neuropathic Pain: From Comorbidity to Co-Pathogenesis. Pain and therapy. 2017 Dec 1;6(1):11-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701895/ (last accessed 27.3.2019)