Download Peripheral nerve lesions

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.