Medical managment after PNI
The management of a peripheral nerve injury varies depending on the cause, type, and degree of the nerve injury. If a nerve is not healing properly surgery may be required to repair the damaged section. Physiotherapy is very important to promote the recovery of peripheral nerve injuries regardless of whether surgery is required.
Surgical Procedures:
Neurolysis
The application of physical or chemical agents to a nerve in order to cause a temporary degeneration of targeted nerve fibers. When the nerve fibers degenerate, it causes an interruption in the transmission o
Neurorrhaphy
The surgical suturing of a divided nerve.
Nerve grafting
The sural nerve is commonly used during nerve grafting, not only of the axillary nerve, but in other peripheral nerves injuries as well. Prognosis for the axillary nerve with graft repair is better than other peripheral nerve repairs secondary to its short length.
Neurotization
Also known as nerve transfer. A healthy, but less valuable nerve, or its proximal stump is transferred in order to reinnervate a more important sensory or motor territory that has lost its innervation through irreparable damage to the nerve.
Physiotherapy Interventions after PNI
As a reminder, nerve regeneration takes place at a rate of an estimated ~1 millimetre (mm) per day. Therefore the recovery can be long and discouraging for the patient at times. Help manage expectations as a clinician with this type of injury.
Stage of paralysis (2-3 weeks)
- Care of anasthetic Hand (patient education):
- Cut nails.
- By inspecting rgularly for wounds or skin color changes.
- Ask patient to avoid extreme temprature.
- Using protective gloves for hand to prevent injury by sharp objectives.
- Reduce Pain :
TENS, Splinting
- Control edema :
keep the affected limb elevated ,pumbing exercises.
- Prevent Contractres:
The affected extremities are splinted in their respective functional position.
When applied on an anesthetic area , repeated checks are needed to ensure presure sores do not develop.
- Prevent joint stiffness and maintain ROM:
Full PROM exercise and stretching exercise for the muscles around the affected joints.
- Maintain the properties of the muscle:
Using Monophasic Pulsed current. This will ensure a proper blood supply as well as help in maintainance of excitation contraction and coupling.
- Stimulation start after 2 weeks of injury.
- Monophasic pulsed current (Rectangular wave form used).
- Parameter: 1. Long pulse duration (grater than 10ms)
2. frequency less than 10Hz.
3.current amplitude should increased until reach visible contraction.
4.pause period between stimulation should be 1:4 (longer than stimulation period to minimize fatigue).
- Treatment time 15-20 min.
- Electrode Position For treating denervated muscles as follows
- Prevent deformities:
Using splinting in Functional position
- Maintain skin Texture in patients with tropic skin changes. The affected area should be kept supple by applying some moisturizer or oil that skin breakedown can be prevented.
- Reduce paresthesia and numbness:
It progresses gradually from stimuli that produce the least painful response to stimuli that produce the most painful response. Once the affected area begins to acclimate to the initial stimulus, the next stimulus is incorporated. For example a desensitization program may progress from a very soft material stimulus (i.e., silk) to a rougher material (i.e. wool) or textured fabric (i.e. Velcro). The course of this progression may take several days to several weeks, depending on the level of hypersensitivity.
Note: Desensitization is a treatment technique used to modify how sensitive an area is to particular stimuli. This technique is utilized to decrease, or normalize, the body’s response to particular sensations
Post Paralytic Stage:
Innervation has started and the muscle begins to show active contraction.
- Continue stage of paralysis protocol.
- Biphasic pulsed rectangular current is used
- Frequency adjust to 35-55 to minimize muscle fatigue.
- Ramp up and ramp down is set to 2-3 sec.
- On/off time is set to 1:4 or 1:5.
- The intensity of the current set until see muscle contraction.
- Total treatment time 15 min.
- Electrode placement should be over muscle belly.
- When MMT reached grade 2 strengthening exercise can be started until reach grade 3. Once the muscle power reached grade 3 then resisted exercises can be given manual or mechanical.
Tools can be used to strength small hand muscles:
- Theraband can be used after making small holes for the fingers, as in the following pictures.
- Canadian Board can be used as shown in the picture
- Functional Re-training is essential to incorporate functional activity such as various gripping activities.
- when the prevention of joint stiffness failed , peripheral joint mobilization grade 3 , 4 can be applied then Boxing positioning for 30 min .
Note: periphera Joint mobilization is a skilled manual therapy technique aimed at improving joint range of motion and reducing pain.
Grades of Mobilization(Mitland):
Grade I – small amplitude movement at the beginning of the available range of movement
Grade II – large amplitude movement at within the available range of movement
Grade III – large amplitude movement that moves into stiffness or muscle spasm
Grade IV – small amplitude movement stretching into stiffness or muscle spasm
Grade V – 5th grade is possible but further training will be required to perform safely.
Physiotherapy after nerve repair
- Phase I: 0-45 days
- Splinting (restricted splint) to prevent over stretch.
- Edema control.
- Restricted range of motion. Exc.:
some degree to prevent joint stiffness but without stretching to improve healing. - Phase II: 45 days- 8 month
- Enhance the tissue glide by:
- active exercise.
- Passive exercise.
- gentle Stretching exercise
After a period of 18 months, the chances of improvement are drastically reduced.
- Monophasic pulsed current until re- innervation done then start using Biphasic pulsed current.
- Reinforcement muscle training.
- Sensory reeducation.
Delayed Stage
Such a situation warrants surgery either in the form of nerve repairs or tendon transfers.
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