1. Peripheral nerve lesions Cecilia Katzke 2010

2. What is a peripheral nerve lesion?

3. Superior surface of the fourth cervical vertebra: spinal cord in its vertebral foramen spinal nerve in its intervertebral foramen

4. General structure of the spinal cord, nerve roots and meninges

6. What causes peripheral nerve injuries? Penetrating wounds Pressure Ischemia Fractures Dislocations Traction Continuous stretching Tumour Neuritis

7. Extent of nerve injuries differ Classification of nerve injuries Neuropraxia Axonotmesis Neurotmesis

8. Neuropraxia Nature of injury: Contusion of nerve- Inflammatory response Nerve cell & - fibre intact Temporary loss of conduction Prognosis: Good Recover within 6-8 weeks Medical Tx: If no open wound, “wait & see approach” Splint + NSAIDS

9. Neuron / Nerve cell

10. 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!

11. Cross section through a peripheral nerve

12. Neurotmesis Nature of injury: Axon & sheaths are damaged Complete degeneration distally Nerve must be sutured Prognosis: Not good Incomplete recovery Medical Tx: Penetrating wound →investigate Primary repair / debridement

13. Regeneration / Degeneration / Surgery ? ? ? ? ? ?

14. Surgery: Nerve Repair Primary / Secondary repair Epineural /Fascicular repair General regime: Post Nerve Repair

15. 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

16. 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

17. Mixed spinal peripheral nerve

18. Consequences of peripheral nerve injury How does the patient present? Motor system Sensory system Autonomic system Pain Function

19. Motor system Decreased / loss of muscle power Decreased muscle tone Decreased / loss of reflexes Muscle atrophy → Fat & fibrous tissue

20. Sensory system Decreased / loss of skin sensation Decreased / loss of proprioception

21. Autonomic system Oedema Changes in the skin: ▪ scaly ▪ smooth & shiny ▪ loss of perspiration ▪ nails brittle & suppressed growth Osteoporosis

22. Pain Trauma Immobilisation Hypersensitivity Overuse

23. Function Functionality is influenced due to : Loss / decreased motor function Loss /decreased sensation Changes in autonomic function Pain

24. Possible complications Deformities Adhesions Trauma Dislocations / Sublaxations Muscle strains or tears Slow wound healing CRPS

25. 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?

26. Evaluation: Objective (compare with same & opposite side) Observation: Palpation Sensation ROM Muscle testing Neurodynamic tests Function

27. Observation General: Posture Compensation Local: Skin (colour, condition, ? wounds) Oedema Atrophy

28. Palpation Skin temperature Skin texture Oedema

29. Sensation Temperature Sharp / blunt Deep pressure Proprioception Stereognosis Tinell’sign

30. Range of Movement Passive – of all joints underlying affected muscles Muscle lengths

31. Muscle testing Beware trick movements Use Oxford scale Test in groups → individual muscles

32. Neurodynamic tests Within limits of pain Precaution surgery Test applicable nerve ▪confirmed nerve injury ▪base test ▪mechanism of injury

33. Function With & without splint (static and / or dynamic splint)

34. Problem list Aims of Treatment + Treatment Evaluation (Re- Evaluation)

35. PROBLEM Paralysed muscles AIM / AIMS Support / Protect Prevent contacture Maintain muscle characteristics TREATMENT Provide / Arrange splint Passive muscle stretches Electric muscle stimulations

36. PROBLEM Decreased muscle strength AIM / AIMS Facilitate, re- educate and strengthen affected muscles TREATMENT Ice Tapping Suspension Re-education board PNF Active functional exercises

37. PROBLEM Loss / Decreased sensation AIM / AIMS To give advice regarding loss / decreased sensation Retrain sensation TREATMENT Education: care for skin Proprioception exercises Fine discrimenation exercises

38. PROBLEM Autonomic changes (↓ circulation) AIM / AIMS Increase circulation and prevent edema or Increase circulation and decrease edema TREATMENT Passive joint movements Positioning (day - sling / pressure bandage night - elevation) Massage Electrotherapy

39. PROBLEM Pain ( ? cause) AIM / AIMS Decrease pain TREATMENT Mobilising neural tissue Trigger points Massage Electrotherapy

40. PROBLEM Decreased functionality AIM / AIMS Improve functionality TREATMENT Functional exercises, with / without splints Functional exercises using trick movements

41. 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

42. 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

43. Radial Nerve

44. Ulnar Nerve

49. Median Nerve

52. 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.