MANAGEMENT FOR PERIPHERAL NERVE INJURY, Physiotherapy Management.

 MANAGEMENT FOR PERIPHERAL NERVE INJURY

Acute Stage

This is a stage of total paralysis. Hence, the main aim of the management will be as under:

To Maintain the Properties of the Muscle 

• This can be achieved by stimulating paralyzed muscles using interrupted galvanic current. 

• Galvanic current can stimulate denervated muscle as they are of longer pulse duration. 

• Artificially contracting muscles will ensure a proper blood supply as well as help in maintenance of excitation, contraction and coupling. 

• Faradic current cannot be used for these purposes as it is of shorter pulse duration and hence does not stimulate denervated muscles.

To Maintain Joint Range of Motion 

• Passive range of motion is given to the paralyzed area so that the joint range of motion can be maintained. 

• The flexibility of the muscles can also be maintained by gentle sustained stretch.

To Prevent any Abnormal Attitude of the Affected Part

• Splinting is necessary for the purpose of giving a functional position and also to prevent overstretching of the affected muscles.

To Maintain the Skin Texture

• This management is very essential while treating patients with trophic skin changes.

• The affected area should be kept supple by applying some moisturizer or oil so that skin breakdown can be prevented.

Care of Anesthetic Hand or Foot

• The involved part should be inspected regularly for some wounds, or skin color changes.

• In case of any wound immediate antiseptic precaution should be taken. 

• The patient should be asked to avoid extreme temperatures. 

• Protective gloves should be used for hand to prevent injury by sharp objects. 

• Soft shoes, preferably with toe windows may be worn to protect the foot. 

• The skin should be kept moist but not wet. 

• Proper hygienic measures should be taken to prevent any infection to the affected area.

Prevention of Edema

• This is possible in cases of gross paralysis of the upper or lower limb like a brachial plexus or sciatic nerve injury respectively. 

• Odema occurs due to gravity dependent position of limb coupled with lack of muscular tone hence elastocrepe bandage and elevation is given to prevent edema

Consistent Monitoring

• The patient should be monitored by the therapist quite regularly for checking any deterioration or improvement in the condition. 

• SDC is done every week to note the signs of innervations.

Recovery Stage

• In this stage innervation has started and the muscle begins to show active contraction. 

Thus the aim of treatment will be as under:

Muscle Reeducation

• Once the MMT grade is I or if the SDC is showing signs of innervation then faradic reeducation should be given to the muscle. 

• In this treatment Faradic current is used to produce the action of a muscle and the patient is asked to put in voluntary effort along with the current. 

• The intensity of the current is slowly decreased during the subsequent session so that the patient will be able to perform the action without any assistance.

Combination of Faradic Re-education and Biofeedback

• This method is very effective to bring about muscle reeducation as the biofeedback helps the patient to understand the outcome of his effort and thus can motivate the patient to contribute more. 

Strengthening 

• Once the muscle power has reached MMT grade 2 then strengthening exercises can be started in the gravity eliminated plane or inclined plane till the power reaches 3. 

• Reeducation board or table is helpful in gradually changing the muscle work from a gravity eliminated plane to against gravity. 

• Once the muscle power reaches grade 3 then resisted exercises can be given manually or with springs, pulleys, hydrotherapy etc.

Functional Retraining

• Although the muscle may appear to be strengthened to the maximum grade, it is essential to incorporate functional activity into the rehabilitation program. 

• This is necessary because an increase in strength of a muscle for one activity does not necessarily guarantee efficient performance for other activity. 

• Thus for hand various gripping activities and for lower limbs activities like level walking, staircase climbing etc needs to be given. 

• It should be noted that the therapist should wait for adequate time for recovery to take place that can be calculated considering the rate of regeneration (1mm per day on an average) and the site of lesion. 

• However once the patient does not recover in the predicted time then based on various investigation and evaluation he may be sent for plastic surgery intervention. 

• This is essential to give some functional independence to the patient. 

• These treatment principles can be applied for all the nerves.