Medical Management and Rehabilitation
The diagnosis of a peripheral nerve disorder should be confirmed by a specialist – and differentiated from a spinal root disorder. Peripheral nerve disorders present as traumatic injuries, entrapment syndromes (e.g. carpal tunnel syndrome), or tumors. In the early days after onset of injury, any associated skeletal injuries or fractures should be confirmed by clinical and radiographic evaluation since these injuries may preclude early occupational/physical therapy. No substantial evidence exists to support further injury to the peripheral nerves with gentle handling of the affected arm, and immobilization of the arm is not recommended except in the context of skeletal injuries. Other neurologic disorders occurring concurrently with the peripheral nerve disorder can be suspected with the presence of a lack of spontaneous movements and normal reflexes that suggest more global neurological deficits. The passive and active range of motion of the affected arm should be assessed. Entrapment syndromes usually develop slowly, but when a neurological deficit develops, more aggressive management may be appropriate. Regarding nerve sheath tumors, most are benign without significant neurological deficit and are appropriately managed conservatively; however, patients with neurocutaneous syndromes (e.g. neurofibromatosis) may require more frequent surveillance. Supplementing the physical examination with electrodiagnostic (EDX) and radiographic (magnetic resonance imaging, MRI, ultrasound, CT) findings are helpful to decide whether surgery will be beneficial or whether the disorder should be managed conservatively.
Early referral (as soon after injury as possible) of patients with peripheral nerve disorders to interdisciplinary specialty clinics can improve overall functional outcomes. Regardless of the need for surgical intervention, rehabilitation management is critical. Occupational/physical therapy to maintain the normal passive range of motion in all upper extremity joints (especially shoulder external rotation and forearm pronation and supination) increases the possibility for the successful global recovery of function. Patients and families should consider themselves to be the patient’s primary therapist by performing range of motion exercises regularly, with multimedia assistance, if available, several times during the day. Reinforced use of the affected arm while constraining the normal arm (constraint therapy) can aid the functional recovery and strengthen the arm or leg through increased use during appropriate activities. Splinting may be used during sleep to avoid the formation of contractures or to protect floppy joints. Specific therapeutic modalities such as ultrasound, fluidotherapy, electrical stimulation or robotic-assisted movement or gait training may be used to help patients recover function. Recreational activities like swimming, dance, sports, and more recently, experimental therapist-designed video game platforms can help to sustain the goals of formal occupational/physical therapy. Our program currently has registered occupational therapists who can evaluate and treat the peripheral nerve patients. They directly contribute to the provision of Interdisciplinary Clinic Evaluations, Recommendations, and Therapy Services - and indirectly, by communicating with distant health providers about continued care for patients with peripheral nerve disorders who live far away.
For peripheral nerve patients with extensive and/or severe traumatic injury, significant entrapment neuropathies with functional deficit, or enlarging tumors associated with motor weakness who have failed medical management, surgery may be an option. The goal of nerve surgery is not to regain a normal limb, but to optimize and prevent further loss of function. Instead, nerve surgery is a step towards a functional limb with adequate movement for activities of daily living. Nerve graft repair and/or nerve transfer are the primary options for reconstructing traumatic peripheral nerve disorders that do not recover spontaneously. Nerve regeneration is very slow, so the ultimate functional outcome from nerve reconstruction surgery may not be apparent for 1-3 years. For associated musculoskeletal abnormalities, clinical function and radiographic imaging can guide the decision to pursue further orthopedic or plastic/hand surgery intervention. Surgical options include muscle lengthening with or without tendon transfers, corrective osteotomies, and/or open or arthroscopic reduction of the shoulder joint. For patients with residual elbow, forearm, and hand problems, secondary procedures by a hand surgeon may help function: these procedures include soft tissue releases, joint fusions, muscle transfers, and corrective osteotomies. Secondary reconstruction of shoulder or elbow/forearm function can occur years after injury or when needed. Decompression surgery to release entrapped nerves can preserve function and preclude further loss of function, and nerve sheath tumors can be resected when appropriate. For all surgical interventions, the most important factor in producing the optimal result is a cooperative patient with intense support from assertive families.