Cold intolerance and neuropathic pain after peripheral nerve injury in upper extremity.
Magistroni Ernesta,Parodi Giulia,Fop Fabrizio,Battiston Bruno,Dahlin Lars B
Journal of the peripheral nervous system : JPNS
Cold intolerance and pain can be a substantial problem in patients with peripheral nerve injury. We aimed at investigating the relationships among sensory recovery, cold intolerance, and neuropathic pain in patients affected by upper limb peripheral nerve injury (Sunderland type V) treated with microsurgical repair, followed by early sensory re-education. In a cross-sectional clinical study, 100 patients (male/female 81/19; age 40.5 ± 14.8 years and follow-up 17 ± 5 months, mean ± SD), with microsurgical nerve repair and reconstruction in the upper extremity and subsequent early sensory re-education, were evaluated, using Cold Intolerance Symptoms Severity questionnaire-Italian version (CISS-it, cut-off pathology >30/100 points), CISS questionnaire-12 item version (CISS-12, 0-46 points-grouping: healthy that means no cold intolerance [0-14], mild [15-24], moderate [25-34], severe [35-42], very severe [43-46] cold intolerance), probability of neuropathic pain (DouleurNeuropathique-4; [DN4] 4/10), deep and superficial sensibility, tactile threshold (monofilaments), and two-point discrimination (cutoff S2; Medical Research Council scale for sensory function; [MRC-scale]). A high CISS score is associated with possible neuropathic pain (DN4 ≥ 4). Both a low CISS-it score (ie, < 30) and DN4 < 4 is associated with good sensory recovery (MRC ≥ 2). In conclusion patients affected by upper limb peripheral nerve injuries with higher CISS scores more often suffer from cold intolerance and neuropathic pain, and the better their sensory recovery is, the less likely they are to suffer from cold intolerance and neuropathic pain.
Early compensatory sensory re-education.
Daniele Hugo R,Aguado Leda
Journal of reconstructive microsurgery
After a neurorrhaphy, there will be a distal disconnection between the cortex and skin receptors, along with interruption of sensibility information. This report demonstrates the efficacy of a new sensory re-education program for achieving optimal sensation in a relatively short time. Between 1999 and 2001, in the authors' Hand Rehabilitation Department, 11 patients with previous neurorrhaphy were subjected to a program of early "compensatory sensory re-education." Lesions were caused by clean cut. There were 13 primary digital nerve procedures, 12 at the distal palmar MP level, and one at the radial dorsal branch of the index (just after emerging from the common digital nerve). The technique of compensatory sensory re-education was based on a previous, but modified, sensory re-education method. In order to evaluate the results in the compensatory sensory re-education series described, additional tests for evaluation of achieved functional sensibility were used. The authors' best results were achieved in a maximum of 8 weeks (4-8 weeks), much less time than with the original method (1-2 years). Using the British classification, it was possible to compare the achieved levels of sensibility and the time required for optimal results. The different methods of sensibility re-education may be similar, but with the authors' compensatory sensory re-education method, substantial time is saved.
Effect of sensory re-education after low median nerve complete transection and repair.
Mavrogenis Andreas F,Spyridonos Sarantis G,Antonopoulos Dimitris,Soucacos Panayotis N,Papagelopoulos Panayiotis J
The Journal of hand surgery
PURPOSE:To compare the sensory results of patients with low median nerve complete transection and repair, with and without sensory re-education. METHODS:We studied 40 patients, aged 20 to 32 years, with low median nerve complete transection. Primary epineural repair using 8-0 single-strand sutures was done in all patients. Hands were immobilized in a splint for 4 weeks, followed by physical therapy for 1 month. At a mean of 3.5 months (range, 3-4 months) after surgery, when vibration sense (pallesthesia), using the 256-cycles-per-second tuning fork, was perceived at the fingertips of the 3.5 radial fingers innervated by the median nerve, the patients were randomly assigned to 2 equal groups: group A patients were rehabilitated with a sensory re-education program, and group B patients had no further treatment. Clinical evaluation at 18 months after surgery (range, 17.5-18.5 months) included locognosia (the ability to localize touch), the static and moving 2-point discrimination tests, and the Moberg pick-up test. RESULTS:All patients were included in the postoperative evaluation. Static and moving 2-point discrimination were not statistically significant between groups. Locognosia was significantly improved in group A, and a statistical trend was identified regarding the Moberg pick-up test in group A compared to group B. CONCLUSIONS:Sensory re-education appeared to have significant value only in re-education of locognosia at 18 months after low median nerve complete transection and repair. TYPE OF STUDY/LEVEL OF EVIDENCE:Therapeutic II.
Effects of a new sensory re-education training tool on hand sensibility and manual dexterity in people with multiple sclerosis.
Kalron Alon,Greenberg-Abrahami Michal,Gelav Simona,Achiron Anat
OBJECTIVE:To describe and evaluate the effects of a new home-based sensory re-education training tool on hand sensibility and manual dexterity in people with MS experiencing upper limb sensory deficits. METHODS:Twenty-five people with relapsing-remitting MS (18 women), mean age 50.6 years (SD = 11.4), volunteered to participate. Participants were initially assigned to a 7-week control phase followed by a 3-week home-based sensory re-education phase. Measurements used were the nine-hole peg test, the two point discrimination test, the monofilaments test and the functional dexterity test. Measurements were collected at baseline, following the control phase and at the end of the trial. RESULTS:Participants demonstrated an improvement in the nine-hole peg (26.8 (SD = 3.5) vs. 22.6 (SD = 3.2); mean difference (95% CI) 4.9 (0.9, 7.1), P = 0.03) and functional dexterity tests (38.6 (SD = 4.4) vs. 33.8 (SD = 4.9); mean difference (95% CI) 4.8 (1.8, 7.0); P = 0.02) at the end of the sensory re-education phase compared to the end of the control phase. No differences were observed as to the monofilaments and two-point discrimination tests. CONCLUSIONS:Sensory re-education training does not affect the level of sensory impairment in the hand but may lead to improvement in select measures of manual dexterity.
Early sensory re-education of the hand after peripheral nerve repair based on mirror therapy: a randomized controlled trial.
Paula Mayara H,Barbosa Rafael I,Marcolino Alexandre M,Elui Valéria M C,Rosén Birgitta,Fonseca Marisa C R
Brazilian journal of physical therapy
BACKGROUND:Mirror therapy has been used as an alternative stimulus to feed the somatosensory cortex in an attempt to preserve hand cortical representation with better functional results. OBJECTIVE:To analyze the short-term functional outcome of an early re-education program using mirror therapy compared to a late classic sensory program for hand nerve repair. METHOD:This is a randomized controlled trial. We assessed 20 patients with median and ulnar nerve and flexor tendon repair using the Rosen Score combined with the DASH questionnaire. The early phase group using mirror therapy began on the first postoperative week and lasted 5 months. The control group received classic sensory re-education when the protective sensation threshold was restored. All participants received a patient education booklet and were submitted to the modified Duran protocol for flexor tendon repair. The assessments were performed by the same investigator blinded to the allocated treatment. Mann-Whitney Test and Effect Size using Cohen's d score were used for inter-group comparisons at 3 and 6 months after intervention. RESULTS:The primary outcome (Rosen score) values for the Mirror Therapy group and classic therapy control group after 3 and 6 months were 1.68 (SD=0.5); 1.96 (SD=0.56) and 1.65 (SD=0.52); 1.51 (SD=0.62), respectively. No between-group differences were observed. CONCLUSION:Although some clinical improvement was observed, mirror therapy was not shown to be more effective than late sensory re-education in an intermediate phase of nerve repair in the hand. Replication is needed to confirm these findings.
Greater Cortical Activation and Motor Recovery Following Mirror Therapy Immediately after Peripheral Nerve Repair of the Forearm.
Chen Yueh-Hsia,Siow Tiing-Yee,Wang Ju-Yu,Lin Shang-Ying,Chao Yuan-Hung
Cortical reorganization occurs immediately after peripheral nerve injury, and early sensorimotor training is suggested during nerve regeneration. The effect of mirror therapy and classical sensory relearning on cortical activation immediately after peripheral nerve repair of the forearm is unknown. Six participants were randomly assigned to the mirror-therapy group or the sensory-relearning group. Sensorimotor training was conducted in a mirror box for 12 weeks. The mirror-therapy group used mirror reflection of the unaffected hand in order to train the affected hand, and the sensory-relearning group trained without mirror reflection. Semmes-Weinstein Monofilaments (SWM) test, static 2-point discrimination test (S-2PD), grip strength, and the Disabilities of the Arm, Shoulder and Hand (DASH) scores were measured at baseline, the end of the intervention (T1), and 3 months after the intervention (T2). Finger and manual dexterity were measured at T1 and T2, and a functional MRI (fMRI) was conducted at T1. All participants showed improvement in the SWM, S-2PD tests, upper extremity function, and grip strength after the intervention at T1, except for the participant who injured both the median and ulnar nerves in the sensory-relearning group. In addition, the mirror-therapy group had better outcomes in finger dexterity and manual dexterity, and fMRIs showed greater activation in the multimodal association cortices and ipsilateral brain areas during motor tasks. This study provides evidence-based results confirming the benefits of early sensorimotor relearning for cortical activation in peripheral nerve injury of the forearm and different neuroplasticity patterns between mirror therapy and classical sensor relearning.
Task-relevant cognitive and motor functions are prioritized during prolonged speed-accuracy motor task performance.
Solianik Rima,Satas Andrius,Mickeviciene Dalia,Cekanauskaite Agne,Valanciene Dovile,Majauskiene Daiva,Skurvydas Albertas
Experimental brain research
This study aimed to explore the effect of prolonged speed-accuracy motor task on the indicators of psychological, cognitive, psychomotor and motor function. Ten young men aged 21.1 ± 1.0 years performed a fast- and accurate-reaching movement task and a control task. Both tasks were performed for 2 h. Despite decreased motivation, and increased perception of effort as well as subjective feeling of fatigue, speed-accuracy motor task performance improved during the whole period of task execution. After the motor task, the increased working memory function and prefrontal cortex oxygenation at rest and during conflict detection, and the decreased efficiency of incorrect response inhibition and visuomotor tracking were observed. The speed-accuracy motor task increased the amplitude of motor-evoked potentials, while grip strength was not affected. These findings demonstrate that to sustain the performance of 2-h speed-accuracy task under conditions of self-reported fatigue, task-relevant functions are maintained or even improved, whereas less critical functions are impaired.
A Touch-Observation and Task-Based Mirror Therapy Protocol to Improve Sensorimotor Control and Functional Capability of Hands for Patients With Peripheral Nerve Injury.
The American journal of occupational therapy : official publication of the American Occupational Therapy Association
IMPORTANCE:To develop a practical program in the early phase after nerve repair for more rapid return of function. OBJECTIVE:To investigate the effects of touch-observation and task-based mirror therapy on the sensorimotor outcomes of patients with nerve repair. DESIGN:An assessor-blinded study with a randomized controlled design. SETTING:University hospital. PARTICIPANTS:We recruited 12 patients with median or ulnar nerve repair between the level of midpalm and elbow referred by the plastic surgeons. INTERVENTION:The patients were randomized into touch-observation and task-based mirror therapy or control groups, and both groups received training for 12 wk. OUTCOMES AND MEASURES:The Semmes-Weinstein monofilament (SWM) test, two-point discrimination test, Purdue Pegboard Test (PPT), Minnesota Manual Dexterity Test (MMDT), and pinch-holding-up activity test were assessed at pretreatment, immediately after treatment, and 12 wk after the last treatment. RESULTS:The experimental group showed greater improvements in the results of the pinch-holding-up activity test and the PPT Unilateral Pin Insertion, Bilateral Pin Insertion, and Assembly subtests. However, change on the SWM test revealed no significant difference between the two groups. CONCLUSIONS AND RELEVANCE:Touch-observation and task-based mirror therapy is an effective but low-cost treatment protocol to optimize sensorimotor control and functional capability of the upper limb in patients with peripheral nerve injury.
Results of primary nerve repair in the upper extremity.
Mailänder P,Berger A,Schaller E,Ruhe K
The results of primary repair of peripheral nerve injury in the upper extremity are reported for 143 nerves in 120 patients, with a mean follow-up of 24 months. Normal values for static and moving two-point discrimination were established and related to the person's age. Sensory reeducation was employed routinely in the postoperative rehabilitation program. Moving two-point discrimination recovered to a better level in 61%, the same level in 38%, and a worse level in 1% than static two-point discrimination after nerve repair. Results for digital, median, ulnar, and radial nerve repairs are reported.
A prospective study of early tactile stimulation after digital nerve repair.
Cheng A S,Hung L,Wong J M,Lau H,Chan J
Clinical orthopaedics and related research
Forty-nine patients with 65 digital nerve injuries were randomized into two groups after nerve repair. Group 1 received early tactile stimulation and Group 2 was a control group. The patients were assessed prospectively for 6 months for recovery of functional sensibility. Tactile stimulation in Group 1 was provided from 3 weeks after nerve repair with a specially designed rotating tactile stimulator and a pocket tactile stimulator. Constant two-point discrimination, moving two-point discrimination, and cutaneous pressure threshold were measured and sensibility was graded with the Medical Research Council (UK) sensibility grading. At 6 months, 68.8% of patients in Group 1 had a Medical Research Council grading of S3+ or S4 sensibility compared with 36 % in Group 2. With this prospective randomized study, the value of sensory reeducation in improving sensibility after digital nerve injury was confirmed. Starting tactile stimulation from the early postoperative period is recommended; however, use of the rotating tactile stimulator and pocket tactile stimulation need additional study.
Recovery of touch after median nerve lesion and subsequent repair.
Meek M F,Coert J H,Wong K H
Many techniques have been developed for the evaluation of peripheral nerve function. Consequently, physicians use different techniques in the clinic. This study describes the evaluation of touch after median nerve lesions in the forearm and repair. In order to evaluate touch, 25 patients, aged 11-51 years (mean, 29 years), were evaluated 3-10.5 years (mean, 5 years) after median nerve repair. The evaluation included the moving two-point discrimination test and Semmes-Weinstein monofilaments. We showed that 32% good-excellent results can be obtained with difficult nerve lesions. The results could have been improved if a sensory reeducation regime had been applied.
Sensory feedback in the learning of a novel motor task.
Mulder T,Hulstijn W
Journal of motor behavior
The role of different forms of feedback is examined in learning a novel motor task. Five groups of ten subjects had to learn the voluntary control of the abduction of the big toe, each under a different feedback condition (proprioceptive feedback, visual feedback, EMG feedback, tactile feedback, force feedback). The task was selected for two reasons. First, in most motor learning studies subjects have to perform simple movements which present hardly any learning problem. Second, studying the learning of a new movement an provide useful information for neuromuscular reeducation, where patients often also have to learn movements for which no control strategy exists. The results show that artificial sensory feedback (EMG feedback, force feedback) is more powerful than "natural" (proprioceptive, visual, and tactile) feedback. The implications of these results for neuromuscular reeducation are discussed.
Case study of a five-stage sensory reeducation program.
Nakada M,Uchida H
Journal of hand therapy : official journal of the American Society of Hand Therapists
The purpose of this paper is to describe a sensory reeducation program classified into five stages: (1) feature detection and recognition of objects; (2) correction of the pattern of prehension in the hand; (3) control of precise force for grasping objects; (4) maintenance of grip force during movement of the proximal joints; and (5) manipulation of objects. The program is specific to hand function in activities of daily living and is based on recent neurophysiological findings. It is illustrated by a detailed case study. The authors report that, through sensory reeducation a patient who had an insensitive hand gained the ability to recognize objects. She learned to utilize a sense of muscle resistance and a sense of vibration in the shoulder. Her body image improved along with the usefulness of her hand in activities of daily living.
Successful reeducation of functional sensibility after median nerve repair at the wrist.
Imai H,Tajima T,Natsumi Y
The Journal of hand surgery
The effect of sensory reeducation was evaluated in a group of twenty-two adult patients who had a repair of a clean-cut median nerve at the wrist. These results were compared with the sensibility in a group of twenty-four adults with repair of clean-cut median nerve at the wrist who had never received sensory reeducation. The reeducation group were evaluated between one and two years from the time of their median nerve repair. The control patients were retrospectively evaluated between one and sixteen years after their nerve repair. The effect of reeducation on improving the paresthesias that accompany neural regeneration was also evaluated. Sensibility was determined by an object recognition test and by measurement of static and moving two-point discrimination. The results demonstrated that sensory reeducation significantly (p less than 0.01) diminished the severity of postoperative paresthesias. It also gave significantly better improvement in moving two-point discrimination than in static two-point discrimination within the timeframe evaluated (p less than 0.002). Excellent recovery of sensibility, as determined by ability to recognize nine or more objects out of twelve, was significantly greater (p less than 0.005) for the sensory reeducation group than at any time interval beginning after six months after nerve repair. It is concluded that a program of sensory reeducation after median nerve repair at the wrist in adults minimizes discomfort and improves sensibility in the postoperative period.
Sensory relearning after nerve repair.
Lundborg G,Rosén B
Lancet (London, England)
One of the challenges in reconstructive surgery is to ensure hand sensibility is regained after median nerve repair. We assessed tactile gnosis in 54 patients (mean age 32 [range 4-72] years) after repair of transected median or ulnar nerves at the wrist level. We found that there is a well-defined critical period for sensory relearning after nerve repair. There is an optimum capacity below age 5-10 years followed by a rapid decline, which levels out after puberty. The curve correlates with previously published data on critical periods for language acquisition among immigrants. Recovery of functional sensibility after nerve repair is based on a learning process and in many ways is analogous to learning a second language.
Sensory relearning after surgical treatment for carpal tunnel syndrome: a pilot clinical trial.
Jerosch-Herold Christina,Shepstone Lee,Miller Leanne
Muscle & nerve
INTRODUCTION:Surgical treatment for carpal tunnel syndrome does not always alleviate sensory deficits, especially in patients with severe disease. No proven treatment is currently available for these patients. METHODS:We conducted a pilot randomized, controlled trial to evaluate the feasibility, patient acceptability, and efficacy of a sensory relearning (SR) program in patients who have ongoing sensory deficits after carpal tunnel decompression. Patients were randomized to receive either: (i) a 4-week sensory relearning home program; or (ii) no further treatment. Outcomes were assessed at baseline and 4 and 8 weeks after randomization. RESULTS:Thirty-one patients were randomized. Efficacy analysis adjusted for baseline score and age showed a potentially clinically worthwhile benefit of SR. CONCLUSIONS:Data on screening, eligibility, and patient acceptability of the intervention confirm the feasibility of undertaking a definitive randomized, controlled trial.
Does sensory relearning improve tactile function after carpal tunnel decompression? A pragmatic, assessor-blinded, randomized clinical trial.
Jerosch-Herold C,Houghton J,Miller L,Shepstone L
The Journal of hand surgery, European volume
Despite surgery for carpal tunnel syndrome being effective in 80%-90% of cases, chronic numbness and hand disability can occur. The aim of this study was to investigate whether sensory relearning improves tactile discrimination and hand function after decompression. In a multi-centre, pragmatic, randomized, controlled trial, 104 patients were randomized to a sensory relearning ( n = 52) or control ( n = 52) group. A total of 93 patients completed a 12-week follow-up. Primary outcome was the shape-texture identification test at 6 weeks. Secondary outcomes were touch threshold, touch localization, dexterity and self-reported hand function. No significant group differences were seen for the primary outcome (Shape-Texture Identification) at 6 weeks or 12 weeks. Similarly, no significant group differences were observed on secondary outcomes, with the exception of self-reported hand function. A secondary complier-averaged-causal-effects analysis showed no statistically significant treatment effect on the primary outcome. Sensory relearning for tactile sensory and functional deficits after carpal tunnel decompression is not effective. LEVEL OF EVIDENCE:II.
The effect of early relearning on sensory recovery 4 to 9 years after nerve repair: a report of a randomized controlled study.
Vikström Pernilla,Rosén Birgitta,Carlsson Ingela K,Björkman Anders
The Journal of hand surgery, European volume
Twenty patients randomized to early sensory relearning (nine patients) or traditional relearning (11 patients) were assessed regarding sensory recovery 4 to 9 years after median or ulnar nerve repair. Outcomes were assessed with the Rosen score, questionnaires, and self-reported single-item questions regarding function and activity. The patients with early sensory relearning had significantly better sensory recovery in the sensory domain of the Rosen score, specifically, discriminative touch or tactile gnosis and dexterity. They had significantly less self-reported problems in gripping, clumsiness, and fine motor skills. No differences were found in questionnaires between the two groups. We conclude that early sensory relearning improves long-term sensory recovery following nerve repair. LEVEL OF EVIDENCE:I.
Efficacy and feasibility of SENSory relearning of the UPPer limb (SENSUPP) in people with chronic stroke: A pilot randomized controlled trial.
Carlsson Håkan,Rosén Birgitta,Björkman Anders,Pessah-Rasmussen Hélène,Brogårdh Christina
PM & R : the journal of injury, function, and rehabilitation
BACKGROUND:Sensorimotor impairments of the upper limb (UL) are common after stroke, but there is a lack of evidence-based interventions to improve functioning of UL. OBJECTIVE:To evaluate (1) the efficacy of sensory relearning and task-specific training compared to task-specific training only, and (2) the feasibility of the training in chronic stroke. DESIGN:A pilot randomized controlled trial. SETTING:University hospital outpatient clinic. PARTICIPANTS:Twenty-seven participants (median age; 62 years, 20 men) were randomized to an intervention group (IG; n = 15) or to a control group (CG; n = 12). INTERVENTION:Both groups received training twice weekly in 2.5-hour sessions for 5 weeks. The training in the IG consisted of sensory relearning, task-specific training, and home training. The training in the CG consisted of task-specific training. MAIN OUTCOME MEASURES:Primary outcome was sensory function (touch thresholds, touch discrimination, light touch, and proprioception). Secondary outcomes were dexterity, ability to use the hand in daily activities, and perceived participation. A blinded assessor conducted the assessments at baseline (T1), post intervention (T2), and at 3-month follow-up (T3). Nonparametric analyses and effect-size calculations (r) were performed. Feasibility was evaluated by a questionnaire. RESULTS:After the training, only touch thresholds improved significantly from T1 to T2 (p = .007, r = 0.61) in the IG compared to the CG. Within the IG, significant improvements were found from T1 to T2 regarding use of the hand in daily activities (p = .001, r = 0.96) and movement quality (p = .004, r = 0.85) and from T1 to T3 regarding satisfaction with performance in meaningful activities (p = .004, r = 0.94). The CG significantly improved the performance of using the hand in meaningful activities from T1 to T2 (p = .017, r = 0.86). The training was well tolerated by the participants and performed without any adverse events. CONCLUSIONS:Combined sensory relearning and task-specific training may be a promising and feasible intervention to improve UL sensorimotor function after stroke.
Experiences of SENSory Relearning of the UPPer Limb (SENSUPP) after Stroke and Perceived Effects: A Qualitative Study.
International journal of environmental research and public health
Recently, it was shown that sensory relearning of the upper limb (SENSUPP) is a promising intervention to improve sensorimotor function after stroke. There is limited knowledge, however, of how participants perceive the training. Here, we explored how persons with sensory impairments in the upper limb experienced the SENSUPP protocol (combined sensory- and motor training and home exercises for 5 weeks) and its effect. Fifteen persons (mean age 59 years; 10 men; >6 months post-stroke) were individually interviewed, and data were analyzed with qualitative content analysis. An overall theme 'Sensory relearning was meaningful and led to improved ability to perform daily hand activities' and two categories with six subcategories emerged. The outpatient training was perceived as meaningful, although the exercises were demanding and required concentration. Support from the therapist was helpful and training in small groups appreciated. The home training was challenging due to lack of support, time, and motivation. Small improvements in sensory function were perceived, whereas increased movement control and ability in performing daily hand activities were reported. In conclusion, the SENSUPP protocol is meaningful and beneficial in improving the functioning of the UL in chronic stroke. Improving compliance to the home training, regular follow-ups, and an exercise diary are recommended.
Enhanced sensory relearning after nerve repair by using repeated forearm anaesthesia: aspects on time dynamics of treatment.
Lundborg G,Björkman A,Rosén B
Acta neurochirurgica. Supplement
BACKGROUND:We describe a new principle for enhancing the effects of sensory re-education following nerve injury and repair. The outcome from nerve repair in adult patients is generally poor. One reason is the functional cortical reorganisation which always occurs because of axonal misdirection at the repair site. In healthy individuals selective anaesthesia of the forearm results in improved hand sensation. Here we hypothesised that this principle would be valid also after nerve injury and repair. METHOD:In a prospective, randomised, double blind study we studied the effects of cutaneous forearm anaesthesia combined with sensory reeducation on the outcome after median or ulnar nerve repair at wrist or distal forearm level. FINDINGS:EMLA-application four times over a two week period starting with beginning reinnervation of the fingers resulted in significantly improved sensory recovery (tactile gnosis) as compared to the placebo group and also at assessment four weeks after the last EMLA-session. However, at assessment 8-11 months after the first EMLA-treatment there was no difference between the groups. CONCLUSIONS:Our findings indicate that repeated cutaneous forearm anaesthesia over a two week period can enhance the effects of sensory re-education at least over the four following weeks. However, the optimal time protocol for EMLA-treatment, aiming at a long-lasting or permanent effect on sensory recovery still has to be defined.
Similar 2-point discrimination and stereognosia but better locognosia at long term with an independent home-based sensory reeducation program vs no reeducation after low-median nerve transection and repair.
Antonopoulos Dimitrios K,Mavrogenis Andreas F,Megaloikonomos Panayiotis D,Mitsiokapa Evanthia,Georgoudis George,Vottis Christos Th,Antonopoulos George K,Papagelopoulos Panayiotis J,Pneumatikos Spyridon,Spyridonos Sarantis G
Journal of hand therapy : official journal of the American Society of Hand Therapists
STUDY DESIGN:Prospective controlled study. INTRODUCTION:Previous studies evaluated the effectiveness of sensory reeducation (SR) after peripheral nerve injury and repair. However, evidence for long-term clinical usefulness of SR is inconclusive. PURPOSE OF THE STUDY:The purpose of this study is to compare the sensory results of patients with low-median nerve complete transection and microsurgical repair, with and without SR at long term. METHODS:We prospectively studied 52 consecutive patients (mean age, 36 years; range, 20-47 years) with low-median nerve complete transection and microsurgical repair. When reinnervation was considered complete with perception of vibration with a 256-cycles per second tuning fork (mean, 3.5 months after nerve injury and repair), the patients were sequentially allocated (into 2 groups [group SR, 26 patients, SR; group R, 26 patients, reassured on recovery without SR). SR was conducted in a standardized fashion, in 2 stages, as an independent home-based program: the first stage was initiated when reinnervation was considered complete, and included instruction in home exercises to identify familiar objects and papers of different roughness, and localization of light touch (eyes open and closed); the second stage was initiated when the patients experienced normal static and moving 2-point discrimination (2PD) at the index fingertip of injured hand, and included instruction in home exercises for stereognosia, supplementary exercises for localization of light touch, and identification of small objects (eyes open and closed). Exercises were prescribed for 5-10 minutes, 4 times per day. At 1.5, 3, and 6 years after nerve injury and repair, we evaluated the static and moving 2PD, stereognosia with the Moberg's pick-up test, and locognosia with the modified Marsh test. Comparison between groups and time points was done with the nonparametric analysis of variance (Kruskal-Wallis analysis of variance). RESULTS:Static and moving 2PD and stereognosia were not significantly different between groups at any study period. Locognosia was significantly better at 1.5 and 3 years in group SR; locognosia was excellent in 17 patients of group SR vs 5 patients of group R at 1.5-year follow-up and in 14 patients of group SR vs 5 patients of group R at 3-year follow-up. Locognosia was not different between the study groups at 6-year follow-up. CONCLUSION:A 2-stage home program of SR improved locognosia at 1.5 and 3 years after low-median nerve complete transection and repair without significant differences in other modalities or the 6-year follow-up of a small subsample.
Cortical Plasticity in Rehabilitation for Upper Extremity Peripheral Nerve Injury: A Scoping Review.
The American journal of occupational therapy : official publication of the American Occupational Therapy Association
IMPORTANCE:Poor outcomes after upper extremity peripheral nerve injury (PNI) may arise, in part, from the challenges and complexities of cortical plasticity. Occupational therapy practitioners need to understand how the brain changes after peripheral injury and how principles of cortical plasticity can be applied to improve rehabilitation for clients with PNI. OBJECTIVE:To identify the mechanisms of cortical plasticity after PNI and describe how cortical plasticity can contribute to rehabilitation. DATA SOURCES:PubMed and Embase (1900-2017) were searched for articles that addressed either (1) the relationship between PNI and cortical plasticity or (2) rehabilitative interventions based on cortical plastic changes after PNI. STUDY SELECTION AND DATA COLLECTIO:: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Articles were selected if they addressed all of the following concepts: human PNI, cortical plasticity, and rehabilitation. Phantom limb pain and sensation were excluded. FINDINGS:Sixty-three articles met the study criteria. The most common evidence level was Level V (46%). We identified four commonly studied mechanisms of cortical plasticity after PNI and the functional implications for each. We found seven rehabilitative interventions based on cortical plasticity: traditional sensory reeducation, activity-based sensory reeducation, selective deafferentation, cross-modal sensory substitution, mirror therapy, mental motor imagery, and action observation with simultaneous peripheral nerve stimulation. CONCLUSION AND RELEVANCE:The seven interventions ranged from theoretically well justified (traditional and activity-based sensory reeducation) to unjustified (selective deafferentation). Overall, articles were heterogeneous and of low quality, and future research should prioritize randomized controlled trials for specific neuropathies, interventions, or cortical plasticity mechanisms. WHAT THIS ARTICLE ADDS:This article reviews current knowledge about how the brain changes after PNI and how occupational therapy practitioners can take advantage of those changes for rehabilitation.
Evaluation of the effectiveness of sensory reeducation following digital replantation and revascularization.
Shieh S J,Chiu H Y,Lee J W,Hsu H Y
Sensory recovery following digital replantation plays an important role in the restoration of hand function. Twelve patients with twenty-four replanted or revascularized digits were randomly selected to enter a program of sensory reeducation, and another 15 patients with 22 replanted or revascularized digits were selected as controls who did not receive sensory reeducation. A moving two-point discrimination and a Semmes-Weinstein pressure threshold test were evaluated for monitoring the sensory recovery. The period of sensory reeducation was 18.83 weeks on average, and the mean follow-up time was 11.94 months. The group that received sensory reeducation significantly improved to a better degree of moving two-point discrimination and Semmes-Weinstein threshold level by both univariate and multiple regression analysis. We suggest that sensory reeducation should be an integral part of the postoperative rehabilitation protocol following digital replantation and revascularization.
Long-term effects of sensory reeducation following digital replantation and revascularization.
Shieh S J,Chiu H Y,Hsu H Y
The long-term maintenance of sensory gain following sensory reeducation is still unknown for replanted digits. Ten patients with 18 replanted or revascularized digits, who had received a formal sensory reeducation program for 1.5 years postoperatively, were reevaluated with moving two-point discrimination and Semmes-Weinstein pressure threshold test after discontinuing sensory reeducation for 1 year. Another four patients with seven replanted or revascularized digits, who have never received sensory reeducation after surgery, were also followed up in the same way. After cessation of sensory reeducation, the degree of moving two-point discrimination became significantly worse in the formal sensory-reeducated group (P < 0.05) and significantly improved in the group without sensory reeducation initially (P < 0.05), whereas it showed a nonsignificant change of Semmes-Weinstein threshold both in the group with formal sensory reeducation and without sensory reeducation. Sensory retraining did influence the progressive change of moving two-point discrimination, but not in a parallel way with the Semmes-Weinstein threshold test.
The effects of sensory re-education on hand function recovery after peripheral nerve repair: A systematic review.
Xia Weili,Bai Zhongfei,Dai Rongxia,Zhang Jiaqi,Lu Jiani,Niu Wenxin
BACKGROUND:Peripheral nerve injury can result in both sensory and motor deficits, and these impairments can last for a long period after nerve repair. OBJECTIVE:To systematically review the effects of sensory re-education (SR) on facilitating hand function recovery after peripheral nerve repair. METHODS:This systematic review was limited to articles published from 1970 to 20 December 2020. Electronic searching was performed in CINAHL, Embase, PubMed, Web of Science, and Medline databases to include trials investigating the effects of SR training on hand function recovery after peripheral nerve repair and included only those studies with controlled comparisons. RESULTS:Sixteen articles were included in final data synthesis. We found that only four studies could be rated as having good quality and noted obvious methodological limitations in the remaining studies. The current evidence showed that early SR with mirror visual feedback and the combinational use of classic SR and topical temporary anesthetic seemed to have long- and short-term effects, respectively on improving the sensibility and reducing the disabilities of the hand. The evidence to support the effects of conventional classical SR on improving hand functions was not strong. CONCLUSIONS:Further well-designed trials are needed to evaluate the effects of different SR techniques on hand function after nerve repair over short- and long-term periods.
Effects of sensory reeducation programs on functional hand sensibility after median and ulnar repair: a systematic review.
Miller Leanne K,Chester Rachel,Jerosch-Herold Christina
Journal of hand therapy : official journal of the American Society of Hand Therapists
INTRODUCTION:This is the first systematic review looking at the effectiveness of sensory re-education programmes on functional sensibility which focuses purely on clinical trials of adult patients with median and ulnar nerve injuries. METHODS:A literature search of AMED, CINAHL, Embase and OVID Medline (from inception to July 2011) was undertaken. Studies were selected if they met the following inclusion criteria: controlled trials (with or without randomization) of sensory re-education, including early and late phase, in adults with median and/or ulnar nerve repair. Two independent assessors rated study quality and risk of bias using the 24 point MacDermid Evaluation Tool. RESULTS:A total of seven articles met the inclusion criteria representing five separate studies Study quality ranged from 13 to 33 out of 48 points on the Evaluation Tool. Due to heterogeneity of the interventions and outcomes assessed it was not possible to pool the results from all studies. There is limited evidence to support the use of early and late SR programmes. CONCLUSION:Further trials are needed to evaluate the effect of early and late sensory re-education which are adequately powered, include validated and relevant outcomes and which are reported according to CONSORT (Consolidated Standards of Reporting Trials) guidelines. LEVEL OF EVIDENCE:2b.