Rehabilitation Following Peripheral Nerve Injury

To be evaluated

Evaluation tools

Objective measure

Subjective measure

Test

Prognostic tool

Rating scales

Questionnaires

Pain and cold sensitivity

Rosén Score – a tool to assess functioning and pain of patients suffering from median and/or ulnar nerve laceration at wrist or distal forearm level

Visual analog scale (VAS)

McGill Pain Questionnaire

Numeric rating scale (NRS)

Cold Sensitivity Severity (CSS)

Cold Intolerance Symptom Severity (CISS)

Motor function

Reflexes

Manual muscle testing

Grip and pinch strength testing with dynamometer and pinch gauge

Sensory function

Two-point discrimination (2PD)

Semmes-Weinstein monofilament testing (SWM)

Modified Moberg pickup test

Shape/texture identification(STI) test

Grating domes

Localization of touch (as locognosia test)

Ten test

Functional use of hand requires motor and sensory function

Activities of daily living (ADL) checklist

9-Hole Peg Test

Functional Dexterity Test (FDT)

Purdue Pegboard Test

Jebsen Taylor Test of Hand Function

Sollerman hand function test

Disabilities of arm, hand, and shoulder (DASH) or QuickDASH

Canadian Occupational Performance Measure (COPM)

Michigan Hand Questionnaire (MHQ)

Quality of life

Short Form 36 (SF-36)

Sense of coherence

Antonovsky’s short 13-item scale

For example, evaluation of range of motion, strength, and sensory function certainly help to determine levels of biomechanical function and impairments, but this does not translate into an assessment of overall functional status in multiple life domains of the patient. It is important to consider the psychosocial factors such as coping, depression, and anxiety as well. The rehabilitation process should also focus on improvements in quality of life (QoL) and function in daily living. There is a “need for increased screening and assessment of factors that reach beyond the biomedical model” [28]. Figure 9.1 illustrates the multiple factors that can impact the outcome for a patient with a PNI. While many of the factors are a given such as age and cognitive capacity, some of them can be influenced during the rehabilitation process.

Fig. 9.1

Influences on outcome after PNI

A multicentered prospective study in the Netherlands [11] found that sensibility of the hand, grip strength, and the disabilities of arm, hand, and shoulder (DASH) questionnaire score were the best prognostic factors for functional recovery after peripheral nerve injury (median and/or ulnar nerve) at the level of the forearm. The Rosén Score, developed for median and ulnar nerve injuries at the level of the forearm, is a helpful prognostic tool for surgeons, therapists, and patients [20, 21, 25, 27].

The therapist’s evaluation is ongoing and essential for her clinical reasoning processes and planning therapy. Once the initial evaluation has been completed, treatment is implemented. The treatment plan is customized to the needs of the patient, and the therapist will make use of many tools, methods, and approaches in an effort to treat the patient at a very individual level.

9.2.2 Rehabilitation: Considerations and Methods

The therapeutic approach is multimodal and may include treatment to decrease pain and edema, the use of custom-made or prefabricated splints, instruction in adaptive methods to improve function in day-to-day life, and facilitation of motor relearning and sensory reeducation. Nerves recover slowly after laceration and repair, notably at the rate of 1–3 mm per day after a 2–3-week latency period [6], and a prolonged course of therapy is usually required. The frequency of therapy may vary considerably depending on the nerve that is injured and the subsequent impact on the patients’ function and the phase of recovery. The focus of therapy in the initial phase, defined as the early postoperative phase, is on protecting the injured structures, reduction of postoperative swelling, pain management, maintaining function in adjacent noninjured structures, preserving cortical representation, and improving the level of function in daily activities.

As the patient progresses to the innervation phase, therapy focuses on regaining motor and sensory function and reintegrating this function into the overall function of daily living. Pain management or addressing sensory gain of function as hyperesthesia may still be a treatment aim. The patient may require splints that balance or support muscle function in the hand. At each step of the recovery process, it is important that patients are given tools and instructions that allow them to participate fully in the process and facilitate their recovery. A well-designed home program is essential at every step of the rehabilitation process. The program should be reevaluated and adjusted at regular intervals. Effective rehabilitation makes use of the patients’ resources and abilities during each of the recovery phases. It is beneficial for a patient to attend therapy at regular intervals to monitor progress and adapt the home program. For some patients, once the home program is established, it may be sufficient for therapy visits to take place on a weekly or even monthly basis. Recovery may be prolonged, and periods of intensive therapy are required when treatment is initiated and periodically in response to changes or additional surgery. In this section, we will describe some of the tools and methods used in therapy to achieve these aims.

9.2.2.1 Postoperative Swelling and Protection of the Sutured Nerve

Postoperative swelling is to be expected and is treated much the same as for any other injury, that is, with positioning, elevation, manual edema mobilization, and compression. An initial period of protection following the operative repair of the nerve is recommended [6, 22]. In the initial phase of therapy, therapists protect the repaired nerve with splinting or bandaging. The surgeon in charge defines the period of protection; it depends on the location of the injury and how much tension there is on the repair site. While it is important to protect the repair, to limit the expected side effects on non-involved tissue and joints, it is advisable to immobilize the fewest joints and soft tissues possible without compromising the repair [14].

9.2.2.2 Pain Management

“Pain has been defined as a multidimensional experience consisting of sensory-discriminative, affective–motivational, and cognitive–evaluative components” [24]. After peripheral nerve injury, pain is to be expected, and it is a priority to address all aspects of pain as early as possible in the course of treatment. Strategies for pain management are manifold, as shown in Table 9.2.

Table 9.2

Overview of pain management methods used in hand therapy following peripheral nerve injury

Management used	Aim
Positioning the affected body part	Prevention of secondary harm through mal positioning
Sensory input	Providing positive, comfortable sensations
Thermal modalities	Decrease of muscle tone proximal to the injured side and/or positive comfortable sensations
Transcutaneous electrical nerve stimulation (TENS)	Triggers the gate and opiate systems for pain modulation
Graded motor imagery (which includes mirror therapy)	Maintain and/or reawaken cortical representation
Providing information about injury, pain mechanism, coping strategies	Improve patient’s ability to cope with and self-manage pain

Some patients develop neuropathic pain after peripheral nerve injury. Pain management for these patients is of utmost importance and includes the previously mentioned strategies; additional psychological support must be considered. It is recognized that neuropathic pain is associated with a poor outcome and high levels of disability [16]. Patient outcomes, such as level of pain, disability, and patient satisfaction, are influenced by psychosocial factors, such as depression, coping, and anxiety [28]. It is therefore paramount that the therapists assess and address these psychosocial factors as part of the rehabilitation process.

9.2.2.3 Scar Optimization

As with any other type of injury, it is important that the scar be as mobile, flexible, and esthetically appealing as possible. To this end, the therapist may employ scar massage, taping, electrophysical modalities, and in some cases the use of silicone with compression dressings [2]. Patients can be instructed to perform daily scar massage as part of their home program. The use of silicone dressings for scar treatment is to be avoided if there is a problem with gain of function: hyperesthesia, hyperalgesia, or allodynia. In our experience, the silicone dressing is often so comfortable for the patient that as sensation returns, which is often quite uncomfortable, the patient may refuse to discontinue the use of the dressing and the hypersensitive area thus becomes even more uncomfortable.

9.2.2.4 Improving Function and Activities of Daily Living

Gaining functional use of the extremity and overall function in day-to-day life is ongoing. It is important that the extremity be integrated into any activity as much as possible. This may mean the injured extremity can only be used initially to stabilize objects, while the uninjured hand performs the majority of the task. Maintaining cortical representation for the injured extremity is essential, the brain is plastic and remodels rapidly, and nonuse of the extremity will result in a cortical reorganization [15], which may be challenging to remodel as recovery of the nerve and function progresses. Not only cortical representation is very important, therapist must also consider the mobility of torso and shoulder; if the upper extremity is not incorporated into daily tasks, the flexibility of the thoracic spine diminishes rapidly, resulting in unwanted side effects.

During therapy, the patient will be instructed in adaptive methods, and adaptive equipment will be provided as needed to accomplish activities of daily living. As patients’ needs vary depending on their living, work, and family situations as well as their coping mechanisms, this process is highly individualized. The use of ADL checklists and questionnaires such as the DASH can be very helpful in identifying areas of function that can be improved upon with therapy.

9.2.2.5 Sensory Function and Reeducation

Initially, a nerve laceration results in an absence of sensation. When there is no sensation present, it is easy to burn or cut the hand in the area that lacks sensation. Patients must be taught to inspect the body area that lacks sensation on a daily basis and to care for any injuries to this area carefully. It is important to use the hand to maintain integration in body schema. The use of a body part that has no sensation is quite challenging, it requires close visual control on the part of the patient, and this is a skill that must be learned.

As the nerve recovers and sensory function resumes, in some cases, the patient may experience an excess of sensation, so-called hyperesthesia, in the area where sensation is recovering. This can be quite uncomfortable and result in protective behavior and nonuse of the hand. In this situation, the therapist will instruct the patient in a desensitization program. Desensitization uses materials, contact particles, and vibration to reduce the hyperesthesia of the affected body part [4, 29]. Frequent and regular application of stimulus, beginning with material that is just tolerable to touch and progressing toward materials that are perceived to be more noxious, is required to achieve the desired effect. Significant improvement in the level of discomfort resulting from the hyperesthesia has been observed with a 6-week course of desensitization treatment [4, 10, 29]. Patients are instructed in a home program that is monitored closely and adjusted regularly. Most patients see an improvement within 1–2 weeks, although it may take several weeks of treatment with the home program until feelings of hyperesthesia are sufficiently resolved to allow the hand to be used freely.

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