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Peripheral nerve lesions Cecilia Katzke 2010 What is a peripheral nerve lesion? Superior surface of the fourth cervical vertebra: spinal cord in its vertebral foramen spinal nerve in its intervertebral foramen General structure of the spinal cord, nerve roots and meninges What causes peripheral nerve injuries? Penetrating wounds Pressure Ischemia Fractures Dislocations Traction Continuous stretching Tumour Neuritis Extent of nerve injuries differ Classification of nerve injuries Neuropraxia Axonotmesis Neurotmesis Neuropraxia Nature of injury: Prognosis: Contusion of nerveInflammatory response Nerve cell & - fibre intact Temporary loss of conduction Good Recover within 6-8 weeks Medical Tx: If no open wound, “wait & see approach” Splint + NSAIDS Neuron / Nerve cell Axonotmesis Nature of injury: Usually a traction injury More severe injury Axon injured – degenerate Neurilemma sheath intact Degree of injury vary Prognosis: Relatively good Recovery incomplete→complete Medical Tx: Usually no open wound, “wait & see” Medication(NSAIDS & pain) & splint Physiotherapy NB! Cross section through a peripheral nerve Neurotmesis Nature of injury: Prognosis: Axon & sheaths are damaged Complete degeneration distally Nerve must be sutured Not good Incomplete recovery Medical Tx: Penetrating wound →investigate Primary repair / debridement Regeneration / Degeneration / Surgery ?????? Surgery: Nerve Repair Primary / Secondary repair Epineural /Fascicular repair General regime: Post Nerve Repair General regime: Post Nerve Repair 0-3 weeks → immobilisation of adjacent joints 3-6 weeks → strengthening of antagonist muscles, gentle mobilisation of adjacent joints and repaired nerve(distal from area of surgery), dynamic splint > 6 weeks → stretching of surrounding muscles, mobilisation of neural tissue Rate of nerve recovery: Extent of lesion Distance between lesion and cell body / end organ Type of surgical suture Elapsed time between the injury and surgery Scar tissue formation Type of nerve Age of patient General health Diet Mixed spinal peripheral nerve Consequences of peripheral nerve injury How does the patient present? Motor system Sensory system Autonomic system Pain Function Motor system Decreased / loss of muscle power Decreased muscle tone Decreased / loss of reflexes Muscle atrophy → Fat & fibrous tissue Sensory system Decreased / loss of skin sensation Decreased / loss of proprioception Autonomic system Oedema Changes in the skin: ▪ scaly ▪ smooth & shiny ▪ loss of perspiration ▪ nails brittle & suppressed growth Osteoporosis Pain Trauma Immobilisation Hypersensitivity Overuse Function Functionality is influenced due to : Loss / decreased motor function Loss /decreased sensation Changes in autonomic function Pain Possible complications Deformities Adhesions Trauma Dislocations / Sublaxations Muscle strains or tears Slow wound healing CRPS Evaluation: Interview History Medical / Surgical management (precautions) Socio-economic background: ▪occupation, possibility of returning ▪finances – paid leave? ▪support at home – physical & emotional What problems does the patient experience with ADL? Participation in community? What does the patient expect of physiotherapy? Evaluation: Objective (compare with same & opposite side) Observation: Palpation Sensation ROM Muscle testing Neurodynamic tests Function Observation General: Posture Compensation Local: Skin (colour, condition, ? wounds) Oedema Atrophy Palpation Skin temperature Skin texture Oedema Sensation Temperature Sharp / blunt Deep pressure Proprioception Stereognosis Tinell’sign Range of Movement Passive – of all joints underlying affected muscles Muscle lengths Muscle testing Beware trick movements Use Oxford scale Test in groups → individual muscles Neurodynamic tests Within limits of pain Precaution surgery Test applicable nerve ▪confirmed nerve injury ▪base test ▪mechanism of injury Function With & without splint (static and / or dynamic splint) Problem list Evaluation (Re-Evaluation) Aims of Treatment + Treatment PROBLEM AIM / AIMS Support / Paralysed muscles Protect TREATMENT Provide / Arrange splint Prevent contacture Maintain muscle characteristics Passive muscle stretches Electric muscle stimulations PROBLEM AIM / AIMS TREATMENT Ice Tapping Decreased muscle strength Facilitate, reeducate and strengthen affected muscles Suspension Re-education board PNF Active functional exercises PROBLEM Loss / Decreased sensation AIM / AIMS To give advice regarding loss / decreased sensation TREATMENT Education: care for skin Proprioception exercises Retrain sensation Fine discrimenation exercises PROBLEM AIM / AIMS TREATMENT Passive joint movements Autonomic changes (↓ circulation) Increase circulation and prevent edema or Increase circulation and decrease edema Positioning (day - sling / pressure bandage night - elevation) Massage Electrotherapy PROBLEM AIM / AIMS TREATMENT Mobilising neural tissue Pain ( ? cause) Decrease pain Trigger points Massage Electrotherapy PROBLEM Decreased functionality AIM / AIMS TREATMENT Functional exercises, with / without splints Improve functionality Functional exercises using trick movements PROBLEM Possible complications Deformities Dislocations / Sublaxations Muscle strains Wounds AIM / AIMS Prevent complications from developing TREATMENT Patient education: nature of injury prognosis role of physiotherapy patient responsibility Food for thought Each patient is unique Problem list differ from patient to patient Priorities of physiotherapy problems for each patient are different Generally: patient education high priority for peripheral nerve injuries Radial Nerve Ulnar Nerve Ulnar Nerve Ulnar Nerve Ulnar Nerve Ulnar Nerve Median Nerve Median Nerve Median Nerve Group work A 40 year old man was involved in a high speed MVA, during which he sustained a posterior dislocation of his right hip. The hip dislocation was reduced and the patient was referred for physiotherapy. Upon evaluation you find that the patient’s hip extension is weak, and that there is total motor loss of knee flexion, as well as ankle and foot movements. Furthermore there is also sensory loss of almost the complete area below the knee. 1. Which structure was most probably also injured with the dislocation of the hip? 2. What will the immediate aims of physiotherapy be for this patient? 3. Explain how you will achieve these aims.