Professional Documents
Culture Documents
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
CT Scan
MRI
Cardiac Enzymes
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 HIVassociated 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. Direct muscular neurotization
a. Insert proximal nerve stump into affected muscle belly.
b. Results in less than normal function but is indicated in certain cases.
2. Epineural Repair
a. Primary repair of the epineurium in a tension free fashion.
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
b. Allograft
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.
consumer of health care, and the patient assists with educating the therapist about
the patients perceptions of illness and disability. The patient is taught to selfmanage his or her condition and how to prevent reoccurrences. The home program,
an extension of the clinical relationship, consists of the exercise prescription,
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.
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 E2 , 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
Muscle Weakness
Electrical stimulation has a great beneficial regarding effect in nerve growth.
Muscle care following nerve injury is essential and includes protection against
cold and heat exposures, minor trauma and overstretching by gravity.
Low level laser therapy or phototherapy which has promising effect in nerve
re growth
Modalities which have significant role to achieve above goals are:
a. Warmth
b. Massage
c. Passive movements
d. Bandaging
e. Ultrasound therapy
f. Hydrotherapy
g. Splints static and detachable is useful mechanical devices to give
rest to the paralyzed muscles and joints, preventing overstretching and
shortening and to allow exercises and other therapeutic methods to
prevent complications of immobilization.
Loss of Function
Using the brain capacity for Visio-tactile and audio-tactile interaction and fine
motor learning is the main concept for maintaining sensory cortex and
periphery relationship in the initial phase following nerve injury and repair
After initiation of nerve re-growth, anesthesia of intact peripheral skin with
topical agents especially during sensory relearning sessions is a new method
to prevent early changes until sensory recovery completes and relearning
process made possible. Another issue in proper functional recovery is
neuromuscular junction instability immediately after denervation which is
hard to stabilize properly even after repair and complete regeneration.
Joint Stiffness
Regular daily massage, passive motion in full range at least one time per day
and protective detachable static splints could prevent these complications.
In case of joint stiffness dynamic splints and physical modalities such as
ultrasound and laser will help to regain the softening and range of motion.
Care of Denervated Skin
Proper hot and sharp objects handling, take care of nails, avoiding long term
cold weather exposure, and well padded splints use are the corner stone of
denervated skin care.
Skin also should be cleaned with mild soap and warm water and gently
patted dry.
Locations is vulnerable to excess moisture can be protected with talcum
powder and too dry area should have lotion applied.
Direct or using a mirror for daily skin inspection is important to identify
vulnerable areas for sores such as high pressure points under splints.
Emotional Stress
Cognitive rehabilitation programs would address mood disturbance, enhance
functional outcome and also prevent or decline chronic pain following nerve
injury and repair.