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electromyograph
is a device that amplifies and converts the minute voltages recorded by a needle
electrodetypically a fi ne wire inserted within a 24-gauge hollow needleinserted
into muscle and expresses these currents by speaker or visually by a cathode ray
oscilloscope.
EMG is often performed when patients have unexplained motor weakness. EMG
helps to distinguish between muscle conditions in which the problem begins in the
muscle and muscle weakness resulting from nerve disorders. EMG can be used to
detect true weakness as opposed to weakness from reduced use because of pain or
lack of motivation. EMG can also be used to isolate the level of nerve irritation or
injury. EMG can detect disease involving the lower motor neuron from the anterior
horn cell to the neuromuscular junction, defects in transmission at the
neuromuscular junction, and primary muscle disease.
Ultrasound
Is specific and sensitive for compression of the median nerve at the wrist.
The test also can identify other structures that can complicate surgical procedures if not
appreciated early, such as persistent median artery within the carpal tunnel
Can help determine whether a cancer, another mass, or injury causing the plexus disorder.
Offer a larger field of view and opportunity to utilize intravenous contrast, but their value
is counter balanced by high cost and the extensive scan time needed to image a nerve
along its entire course.
CT Scan
MRI
Cardiac Enzymes
Th e CK-MB is a particular CK enzyme found primarily in the heart. Th e CK-MB and
CK are measured in suspected cardiac injury, and if the CK-MB exceeds 5.0% of the
CK, there is a strong likelihood that cardiac injury has occurred.
PHARMACOLOGICAL MANAGEMENT
Medications Used to Treat Pain That Is Due to Peripheral
Neuropathy-delisa
Tricyclic antidepressants
Amitryptiline, imipramine, nortriptyline, desipramine
Anticonvulsants
Gabapentin, lamotrigine, phenytoin, carbamazepine, valproic
acid, topiramate
Antiarrhythmics
Topical agents
Capsaicin cream, lidocaine gel
Nonsteroidal antiinflammatory drugs
Antispasticity agents
Selective serotonin reuptake inhibtors
Tramadol
Clonidine
Stimulatory peptides
Neurotrophic factors
N-methyl-D-aspartate antagonists
Vitamin B
Biotin
Choline
Inositol
Thiamine
Gamma linolenic acid
Alpha-lipoic Acid
Mexilitine
Insulinlike growth factor1
Memantine
Dextromethorphan
Pain Management
1. Long-Acting Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
For patients with very mild pain
2. Anticonvulsants (Phenytoin, Gabapentin, Lamotrigine, Valproic acid, Topiramate)
Postulated to work by stabilizing the peripheral nerve membrane, suppressing ectopic or
ephaptic discharges, and modulating sodium channels.
3. Tricyclicanti Depressant
Nortriptyline or antiepileptic drugs such as gabapentin (Neurontin) and lamotrigine
(Lamictal).
4. Patients with severe neuropathic pain may require narcotic analgesia. Usually begins with
tramadol (Ultram). If becomes ineffective, oxycodone (OxyContin) is used with increasing doses.
The author uses fentanyl patches for patients who are allergic to codeine, morphine sulfate (MS
Contin) and methadone for patients with severe pain.
Others
1. Adjuvant Drugs
Medications that achieved initial Food and Drug Administration approval for indications
other than pain.
2. Gabapentin Monotherapy
For diabetic peripheral neuropathy can effectively reduce pain and improve sleep, and
has positive effects on mood and quality of life.
3. Stimulatory Peptides
Composed of short chains of amino acids and are derived from cytokine proteins or
growth factors.
These may work through membrane receptors to encourage remyelination, decrease and
reverse sensorimotor deficits, alleviate neuropathic pain, and prevent neuronal death.
4. Vitamin B, Biotin, Choline, Inositol, and Thiamine
Have been studied as possible treatments for diabetic and HIV-associated peripheral
neuropathies, with encouraging initial data.
5. Alpha-lipoic Acid
An antioxidant and may also prevent damage and inflammation of the peripheral nerve in
patients with diabetes.
6. Gabapentin
Used in treating neuropathic pain.
7. Carbamazepine
Work best for the prickling and tingling sensation, and also to some degree for the
burning discomfort.
8. Opiods (Oral Morphine, Methadone)
For patients who experience extremely severe pain.
SURGICAL MANAGEMENTS
1.
2.
b.
Epineural Repair
a.
b.
c.
It is critical to properly align nerve ends during repair to maximize potential of recovery.
3.
Fascicular Repair
Indications:
a. Median nerve in distal third of forearm
b. Ulnar nerve in distal third of forearm
c. Sciatic nerve in thigh
Technique:
Similar to epineural repair, but in addition repair the perineural sheaths
(individual fascicles are approximated under a microscope).
Outcomes:
No improved results have been demonstrated over epineural repair.
4.
Nerve Grafting
a.
Autologous Graft
Remains the gold standard of repair for segmental defects > 5cm is autologous
nerve grafting.
b. Allograft
The only synthetic graft which shows equal results to autologous nerve grafting
is a collagen conduit.
Rehabilitation
Intervention for Peripheral
Nerve Injury STEPHEN J. CARP, PT, PHD, GCSPG 177-179
Principle 1: Control Inflammation and the Downstream Components: Pain,
Scarring, Edema, Angiogenesis
High repetitionlow force and low repetitionhigh force injuries to soft tissue result in
an immediate migration of macrophages and monocytes to the site of injury. These
cells express proinflammatory cytokines that activate the inflammatory cascade.
Pain, edema (secondary to increased vascular permeability), angiogenesis, scarring,
and other healing activities develop at the injured site. Eventually,
antiinflammatory cytokines are expressed that turn off the inflammatory cascade.
If pathological activity and irritation continue at the injured site and the
inflammatory cascade is left unchecked, chronic pain and disability may result. The
rehabilitation therapist has many modalities available that control the downstream
effects of the proinflammatory cytokines. These are easily remembered with the
Early motion:
Early motion is helpful with reducing the muscle atrophy associated with rest,
assists with maintaining joint function, and assists with preventing ligamentous
creeping.
Medications:
Although not within the realm of physical therapy practices in most locations,
the judicious use of steroid and nonsteroidal medications assists with controlling
and limiting the inflammatory cascade.
Principle 2: Increase Flexibility
With the scarring that is a consequence of the inflammatory cascade, loss of
flexibilityarticular, single muscle, two joint muscle, and nerveis an expected
complication of injury. Posture and strength are dependent on proper joint
mechanics and range of motion. With a primary peripheral nerve injury, nerve glides
and slides within the symptom-free range are of tantamount importance in the
rehabilitation plan. Care must be taken when performing articular or muscle
stretching to avoid tension to injured neural tissue.
Principle 3: Correct Posture
With injury, the adaptive shortening and lengthening of tissues coupled with
protective and painful positioning leads to learning of abnormal, and, if untreated,
obligatory, posturing. Th e restoration of proper posture in standing, sitting, and
lying down assists with alleviating abnormal torque and joint positioning on the axial
and appendicular systems. Retraining correct posture can often be aided by
popular therapeutic techniques such as Alexander technique, yoga, Feldenkris,
Pilates, and Tai Chi Chuan.
Principle 4: Improve Movement Quality
Byl and Coq et al. showed that peripheral injury may result in alteration of the
central maintenance components of motor control leading to a loss of coordination
and function. As part of a coordinated plan of intervention, movement quality
cannot be ignored. Classic principles of motor acquisition, training, and learning
should be employed when there is identified loss of motor control.
Principle 5: Analyze and Integrate the Entire Kinetic Chain
The movement at one joint often depends on the quality of motion and the afferent
feedback of the large myelinated afferent sensory fibers from the distal and
proximal joints. A comprehensive rehabilitation plan encompassing all links along
the kinetic chain improves outcomes. Emerging research indicates improper
treatment goals and time frames, risk factor modification, and precautions. A
trusting therapeutic relationship promotes program adherence.
Principle 10: Incorporate Patient Self-Management
Many of the patients therapists treat have chronic or relapsing conditions. As part
of the therapeutic intervention, illness self-management skills are taught to the
patient. Self-management skills include disease specific knowledge of medication,
prevention, acute response to exacerbation, healthy lifestyle choices, and
intervention.
Principle 11: Ensure a Safe Return to a Maximum Level of Independent
Function
A focus of patient teaching is safety. The Joint Commission has taken the lead via
the National Patient Safety Goals encouraging the development of safety as a goal
for every patient in the United States. From hand washing to fall prevention to
documentation standards mandating the identification of at-risk suicidal patients,
the National Patient Safety Goals encourage therapists to promote a risk-free
assessment and intervention environment.
Principle 12: Coordination of Care
This is a general principle for all persons providing health care. All care, regardless
of the provider, must be communicated to the health care stakeholders of the
patient. These stakeholders vary by patient and episode of care. In most cases, the
primary care physician, as the gatekeeper of the patients care, should be informed
of all therapeutic interventions. In other instances, therapists may need to
communicate cogent fi ndings to nurses, specialists, social workers, case managers,
insurance companies, and other rehabilitation professionalsall within the scope of
patient privacy legislation.
Electrical Stimulation
ES following PNI has long been considered to
promote nerve regeneration, decrease pain
associated with injury, and maintain denervated
skeletal muscle.
Regeneration of Nerve
low-frequency alternating current (AC) after
crush injury was reported to accelerate the
return of reflex foot withdrawal and contractile
force in reinnervated muscles.
ES has been associated with several fi ndings
indicative of nerve regeneration.
Modulation of Pain
Transcutaneous electrical nerve stimulation
(TENS) has been used in the management of
pain associated with peripheral neuropathy.
Prior studies of TENS on neuropathic pain are largely from populations with diabetic
peripheral neuropathy, with TENS reported to reduce pain in 50% to 75% of
patients.
Preservation of Denervated Muscle
Use of ES for increasing strength, volitional recruitment, re-education, and function
in normally innervated but weak skeletal muscle is well known and supported.
Ultrasound
Use of therapeutic US for PNI has been studied for two distinct eff ects: (1) reduction
of pain and improved function and (2) facilitation of nerve regeneration. Therapeutic
US is classifi ed as thermal or nonthermal. Th e physiological eff ects realized from
thermal or continuous US generally refl ect the thermal eff ects observed with other
thermal agents with two exceptions: (1) Th e depth of eff ect is greater with US than
other thermal agents except short wave diathermy, and (2) the eff ect is more
pronounced in tissues with higher collagen content because these tissues retain
more sound energy.
Laser
use of LLLT for tissue healing, based on the purported ability of LLLT to augment or
enhance the bodys natural processes of healing.
use of laser for PNI stems from observed responses in the metabolic activity of
tissues and cells, such as fi broblasts, endothelial cells, osteoclasts, and neurons,
exposed to laser energy in primarily animal models and in a few human studies.
Acute LLLT has shown decreased production of bradykinin, reduced levels of
prostaglandin E 2 , increased secretion of endogenous opioids, increased production
of serotonin and nitric oxide, and increased axonal sprouting and nerve cell
regeneration.
Laser energy, or photoenergy, emits packets of light energy, called photons,
that are absorbed by receptor chromophores within the mitochondria and cell
membrane of tissues irradiated with laser energy. Absorption of photoenergy
increases cellular metabolism and increases the oxidative production of adenosine
triphosphate (ATP)a process known as photobiomodulation. In the presence of
injury, ATP is used to synthesize DNA, RNA, proteins, and enzymes; facilitate cellular
mitosis; and increase synthesis of growth factors to repair compromised tissue.
LLLT for repair of incomplete PNI is proposed to (1) increase the rate of axonal
growth and myelination, (2) prevent or limit degeneration in the corresponding
motor neurons of the spinal cord, (3) off er immediate protective effects to increase
functional activity of the injured nerve, (4) maintain functional activity of injured
nerve over time, and (5) minimize scar formation.
Use of MIRE for the restoration of impaired sensation in patients with peripheral
neuropathy
Impaired
control
Autonomic
dysfunction
motor
Loss of endurance
Loss of
proprioception,
imbalance, impaired
fine motor control
As above
Abnormal sweating,
cold intolerance
Decreased activity
GCEs Education in
energy
conservation
Fine motor
exercises
Assistive device
(e.g., cane)
Pain
Educate regarding
gloves, clothing,
antiperspirant
Analgesics, TNS,
surgery
Deformity
Foot orthotics,
bracing, surgery