“Peripheral nerve” is a term often used synonymously with peripheral nervous system (PNS). PNS is a network of nerves that connect brain and spinal cord to rest of the body. The peripheral nerves control the function of movement, sensation and motor coordination. They are fragile and can be easily damaged.
Any injury to peripheral nerves can affect the brain’s ability to communicate with the connected organ or muscle. Some of the common Peripheral nerve injuries are carpal tunnel syndrome, cervical and lumbar radicuopathy, neurogenic thoracic outlet syndrome, tardy ulnar palsy, peroneal nerve palsy, brachial plexus injuries, suprascapular nerve palsy, tarsal tunnel syndrome etc.
Peripheral Nerve Injury Physical Therapy
Peripheral nerve injuries can be caused due to a variety of trauma. Some of the common causes may include:
- Focal contusion
- Stretch/traction injury
- Electrical injury
- Drug injection injury
Various systems have been developed which correlate microscopic changes of peripheral nerve injuries with patient’s clinical symptoms so as to help clinicians grade the degree of injury to a peripheral nerve. A system called Sunderland Classification system divides Peripheral Nerve Injury into five parts. These include:
- First – degree injury/ Neurapraxia – A local conduction block at the site of injury in which nerve fibers respond to electrical stimuli proximal and distal to the lesion but not at the site of the lesion. The first degree injury is reversible in nature with preservation of axonal continuity and without wallerian degeneration. It does not require surgical intervention and the injury usually recovers within hours or a few weeks.
- Second – degree injury/ Axonotmesis – A loss of continuity of axons or electrical wires within the nerve. There is disruption of axon into proximal and distal portions with interrupted axoplasmic flow. Wallerian degeneration occurs in distal portion of axon with slight affection in proximal portion also. The connective tissue element remains intact with axon regenerating at the rate of 1 mm/day to the original end organ. Surgical intervention is not required if this injury is confirmed through pre-operative nerve testing.
- Third – degree injury/ Endoneurotmesis – It is marked by damage to axon and endoneurium with perineurium remaining intact. In this case, wallerian degeneration occurs and axons may regenerate but may be blocked by scar tissue. The recovery in this case is variable. To predict outcome of the injury, intra-operative nerve conduction studies are often done. In such injuries simple cleaning of the nerve (neurolysis) or an extensive repair with grafting may be done.
- Fourth – degree injury / Perineurotmesis – In a fourth – degree nerve injury, there is damage to axons, endoneurium and perineurium in such a way that a scar is created that prevents nerve to regenerate. Wallerian degeneration occurs with increased chances of aberrant regeneration, synkinesis and incomplete recovery. Intra-operative electrical testing shows that the injured nerve does not allow electrical energy to pass along the neural pathways. Surgical intervention with nerve grafting is required to repair the nerve damage.
- Fifth – degree injury/ Neurotmesis – In this case, there is complete disruption of neural continuity. Such injuries are found in laceration or severe stretch injuries where the nerve is divided into two. Surgery is the only way to repair a fifth – degree injury.
Here, there is a complete disruption of neural continuity. Except in cases of complete transection, nerve injury is usually a combination of degrees of injury.
Peripheral nerve injuries can be classified into two:
- Complete lesions – Complete nerve injuries are marked when all the nerve fibres in the injured section of nerve are damaged. The clinical picture is such that there is total loss of muscle power and sensation below the level of lesion.
- Incomplete lesions – When some part of the nerve remains intact and there are chances of nerve to recover, then such an injury is said to have an incomplete lesion. In incomplete lesion, there will be some muscle power and sensation below the level of lesion.
The symptoms of peripheral nerve injury start gradually and then worsen. Some of the symptoms may include:
- Sensitivity to touch
- Burning and tingling
- Muscle weakness
- Loss of function
In order to determine the extent of nerve damage, a detailed neurologic examination is done to assess motor, sensory and autonomic loss. The diagnostic tests include:
- Electromyography (EMG)
- Nerve Conduction Velocity (NCV)
- CT scan
- MRI neurography
The treatment for Peripheral nerve damage depends upon the extent of nerve injury.
- Non – Surgical treatment – If the nerve is not divided into two, the team of neurologists and neuro/orthosurgeons would assess whether the nerve is healing. If the nerve heals properly, no surgical repair is required. The line of treatment in such a case would be medications, regular check-up to make sure recovery continues and physical therapy.
- Surgery – There are cases where a section of nerve is damaged beyond repair or is cut completely. In such cases nerve repair (removing the damaged nerve and reconnecting healthy nerve ends) or a nerve graft (implanting a nerve piece from another part of the body) may be required. In cases where a nerve is borrowed from another working nerve to make the injured nerve work, the procedure is known as nerve transfer.
- Restoring function – The treatment for restoring function may include use of braces or splints, physical therapy, electrical stimulation and exercises.
For nerve injuries, rehabilitation medicine is a non-surgical management of pain, preventing long-term deformities such as contractures, use of modalities and proper techniques to enhance nerve repair and recovery.
At OVERSEAS REHABILITATION CARE (ORC), We associate with the most experienced physical therapists and rehabilitation experts who are specialized in diagnosing and treating various types of peripheral nerve injuries. Our team approach and giving a personalized care makes us stand apart from rest of the rehabilitation centers in India.
At OVERSEAS REHABILITATION CARE (ORC) associated clinics, treatment for peripheral nerve injury is delivered at all stages i.e – at the time of injury or later for evaluation and treatment or at the time when there is no adequate functional recovery after previous treatment (for secondary treatment). It is however important that medical care be given to the patient soon after a peripheral nerve injury (within 9-12 months) beyond which nerves may not regenerate themselves. As nerves have a remarkable ability to regenerate, getting timely recovery done is beneficial for the patient.
The management of peripheral nerve injuries depends upon the type, extent and cause of the injury to the nerve. Regardless of the need of surgery, physiotherapy is vital for the treatment of PNI. Our specialized approach of using bracing, splinting and electrical stimulation makes our program highly efficient for the treatment of nerve injuries.
Our specialized physiotherapy program aims to:
- Maintain joint range of motion
- Enhance muscle strength
- Manage neuropathic pain
- Increase sensation
- Maintain nerve integrity
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