Crush & Severance Injuries to Peripheral Nerves

Question 1

Peripheral Nerves

Answer 1

Peripheral nerves have the ability to regenerate if the axon is damaged, providing that the cell body of the nerve is intact

If the lesion site is too near the cell body and the cell body is destroyed, regeneration is not possible and therefore, permanent functional losses result
When an injury occurs, the axon of the nerve will regenerate distal to the lesion site and the myelin surrounding the nerve distal to the lesion will likely degenerate-this is known as the Wallerian degeneration

In order to ensure the greatest likelihood of successful regeneration, doctors may suture the proximal and distal ends of the perineurium or the epineural ends
If the nerve stumps are too short, a graft from another nerve-often the sural nerve from the lower leg is inserted to bridge the gap

Question 2

Regeneration of a Nerve

Answer 2

Regeneration of a nerve occurs at a rate of approximately 1-2mm daily, with the more proximal nerve sections regenerating faster than those at an increased distance from the neuron’s cell body
Regeneration proceeds more slowly the more distal the axon is to the cell body

Even if regeneration occurs, there are factors that will affect successful functional return

If the reinnervated tissue is severely dystrophic, full functional return is unlikely

Question 3

Permanent Lesions

Answer 3

Permanent lesions result when the nerve does not re-generate successfully

The cell body may have been damaged or there may be a systemic toxic condition, such as alcoholism

If surgery fails, the functional, sensory and autonomic losses or dysfunctions that occurred upon injury or with only partial regeneration remain

Question 4

Combination Lesions

Answer 4

Injuries can result in a lesion to a single nerve whereas others result in combination lesions

Examples of combination lesions are:
Klumpke’s Paralysis
Erb’s Paralysis

Question 5

Klumpke’s Paralysis

Answer 5

• Definition: A traction injury of the lower brachial plexus (C8-T1)
  It results in a combination of median and ulnar nerve lesions

The traction is extreme and traumatic in nature

• Causes: In children, poor positioning at birth, breech or legs first, or being pulled from the birth canal by forceps can cause sufficient traction for injury

In adults, falling from a height and grabbing something to break the fall causes traction as the force of the person’s body weight stretches the nerve rooms

• Symptoms: are similar to those of a median and an ulnar nerve lesion which includes a claw hand presentation combined with the thumb positioned on the same plane as the palm

Atrophy and functional losses primarily affect the muscles of the hand

Severe edema and vasomotor and trophic changes are also evident in the hand

Sensory losses affect the C8 and T1 dermatomes

An additional complication may be Horner’s syndrome which manifests on the affected side with:
1. Constriction of the pupil (miosis)
2. Drooping of the eyelid (ptosis)
3. Loss of sweating to the face and neck (anhydrosis)
4. Recession of the eyeball into the orbit (enophthalmos)

HEALTH HISTORY Q’S:
* any history of systemic disorder?
* when and how did the lesion occur?
* is it a complete or partial lesion? Was surgery performed?
* is the client currently under the care of a neurologist? What prognosis was given?
* is the physician or neurologist aware the client is coming for massage therapy?
* what functions have been most affected in ADL’s?
* any sensory loss or sensory change?
* does the client experience any pain? What type?
* is client on any meds?
* is client receiving any other treatment?

CONTRAINDICATIONS:
* massage and movement of affected limb are CId for up to 3 weeks if surgical intervention occurred
* massage on site of lesion not advised until neurologist advises a trace contraction present
* do not traction or excessively move joints affected limb until muscle function has clearly returned
* hydro to limb should not begin until autonomic and vasomotor control have returned, indicated by return of muscle function and improved appearance of skin
* frictions and deep pressure on flaccid or compromised tissue
* joint play not performed until innervation occurs and joint stable
* rhythmic techniques avoided on body until some control of limb has returned

Question 6

Erb’s Paralysis

Answer 6

A traction injury but involves the upper brachial plexus (C5-C6)

In children, a birth trauma can cause this paralysis if the baby is pulled from the birth canal when the neck is extended rotated and laterally flexed
In adults, the cause is usually a trauma that violently separates the neck and shoulder. This can occur from a MVA or motorcycle accident if the person is thrown and lands on the head and shoulder. Sports accidents can result in a similar violent fall which could traction these nerves

Symptoms include a presentation of the arm and hand called waiters tip, with the shoulder adducted and internally rotated, the elbow extended, forearm pronated and the wrist and fingers flexed
Muscle wasting and motor dysfunction affect all muscles above the elbow, especially the shoulder abduction, external rotators and extensors, as well as the forearm supinators and pronators
Sensory loss involves the C5 and C6 dermatomes
Tissue edema and dystrophy are not significant

Question 7

Symptom Picture-Regenerating Lesions:

Complete Lesions
Partial Lesions
Edema-Complete Nerve Lesion
Edema-Partial Nerve Lesion

Answer 7

Complete Lesions
A nerve injury which results in damage to all the fibres within the nerve

Partial Lesions
Results in damage to some fibres within the nerve

Edema-Complete Nerve Lesion
Edema will be present initially due to the injury
If autonomic fibres are affected, the edema will remain until the fibers regenerate and vasomotor function returns
Poor tissue health occurs secondary to edema

Edema-Partial Nerve Lesion
Initially, edema will be present due to the injury
While it will remain present until full function returns to the autonomics, there will be less edema than with a complete lesion as there is still some local muscle function which assists lymphatic return

Question 8

Symptom Picture-Regenerating Lesions:

Altered Tissue Health-Complete Nerve Lesion
Altered Tissue Health-Partial Nerve Lesion

Answer 8

Altered Tissue Health-Complete Nerve Lesion
Loss of autonomic function will affect skin, hair and nails
The tissue will be fragile, dystrophic and easily injured
If a secondary injury occurs to these structures, a longer healing time is required
Loss of piloerection and loss of sweating will be apparent over the denervated tissue

Altered Tissue Health-Partial Nerve Lesion
Tissue changes will occur, though generally not as severe as with a complete lesion
An increased piloerector response may occur over the area of denervation

Question 9

Symptom Picture-Regenerating Lesions:

Motor Function-Complete Nerve Lesion
Motor Function-Partial Nerve Lesion

Answer 9

Motor Function-Complete Nerve Lesion
Flaccid paralysis results and muscle wasting can occur within 3 weeks
Fibrillation, a spontaneous contraction of muscle fibres in the denervated tissue occurs a few weeks after the injury
These contractions cannot be seen through the skin
Testing will reveal diminished or lost tendon reflexes

Motor Function-Partial Nerve Lesion
Variable symptoms will result depending on which fascicles were damaged
Weakness in some muscles and possible loss of other innervated muscles
Fibrillation is present
There will often be diminished deep tendon reflexes

Question 10

Symptom Picture-Regenerating Lesions:

Holding Patterns-Complete Nerve Lesion
Holding Patterns-Partial Nerve Lesion

Answer 10

Holding Patterns-Complete Nerve Lesion
Typical holding patterns may be present

Holding Patterns-Partial Nerve Lesion
Typical holding patterns will generally be less apparent with partial lesions since some muscles are still functional

Question 11

Symptom Picture-Regenerating Lesions:

Holding Patterns-Complete Nerve Lesion
Holding Patterns-Partial Nerve Lesion

Answer 11

Holding Patterns-Complete Nerve Lesion
Typical holding patterns may be present

Holding Patterns-Partial Nerve Lesion
Typical holding patterns will generally be less apparent with partial lesions since some muscles are still functional

Question 12

Symptom Picture-Regenerating Lesions:

Contractures-Complete Nerve Lesion
Contractures-Partial Nerve Lesion

Answer 12

Contractures-Complete Nerve Lesion
The affected flaccid muscles are unable to exert force on the joints they cross
The intact antagonists are much more powerful in their effect on the joints, even at rest
Contractures will develop in these unopposed antagonists as they draw into a shortened position
This becomes more pronounced if the nerve regeneration and subsequent return of muscle strength in the agonists occurs

Contractures-Partial Nerve Lesion
Contractures can develop in the unopposed antagonists
These contractures are less severe than with a complete lesion because some opposition to the antagonists is present from the unaffected or less affected agonists

Question 13

Symptom Picture-Regenerating Lesions:

Pain-Complete Nerve Lesion
Motor Function-Partial Nerve Lesion

Answer 13

Pain-Complete Nerve Lesion
There will be an area of anesthesia of the cutaneous division of the nerve
Pain can be variable
There may be decreased or altered sensation that may or may not be interpreted by the client as painful

Motor Function-Partial Nerve Lesion
There will likely be areas of hyperesthesia and possibly dysesthesia which are perceived by the client as painful
Causalgia and RSD may be present, especially in the client presenting with a partial lesion

Question 14

Symptom Picture-Regenerating Lesions:

Scar Tissue
Overall

Answer 14

Scar Tissue
Is present at the lesion site with a complete or partial nerve lesion
It may interfere with the regeneration of the nerve

Overall
If the complete or partial lesion regenerates much muscle, sensory and autonomic function will eventually return, though often full recovery is not possible

Question 15

Permanent Lesions

Answer 15

If regeneration does not occur, the original functional, sensory and autonomic losses of a complete lesion, or dysfunction of a partial lesion will remain

Edema will remain
Trophic changes and muscle wasting will become more marked with time
Holding patterns will remain
Scar tissue develops at the lesion site
Pain may be present
Compensatory changes are present with permanent nerve lesions

Question 16

Health History Questions

Answer 16

Is there any history of a systemic disorder?
When and how did the lesion occur?
Is the lesion complete or partial? Was surgery performed?
Are you currently under the care of a neurologist? What prognosis has been given?
Is your physician or neurologist aware you are seeking massage?
What functions have been more affected in your ADL’s?
Is there any sensory loss or sensory change?
Have hydrotherapy restrictions been imposed?
Do you experience any pain? If so, what type, where and when?
Are you on any medication?
Are you receiving any other treatment?

Question 17

Observations

Answer 17

Holding patterns typical to the lesion may be evident
Functional losses can be noted as the therapist observes the client before the treatment
Altered gait may result from nerve lesions in the lower limb
An antalgic facial expression or posture may be observed if a pain syndrome is present
A decrease in muscle bulk will be evident
Edema may be present
Trophic changes of the skin, hair and nails often occur
Inflammation or bruising is likely present in the acute and subacute stages of healing
Supportive splints or braces maybe in use to support the affected limb in a balanced position to allow safe use of the limb while regeneration occurs

Question 18

Palpation

Answer 18

Due to the fragility of the skin and concern for not interrupting the healing process of the nerve, care should be exercised during palpation in the early stages of healing
Muscle bulk is likely reduced in the affected tissue
Loss of local sweating will result in a dry texture to the skin
Edema results in boggy tissue
Contractures may be palpated while assessing the tone of the unopposed antagonists
The amount of mobility of the scar tissue at the lesion site are assessed after the axons have successfully regenerated to the distal endoneurial tube
Tenderness will be variable, depending on the individual lesion
Presence of a neuroma or a pain syndrome will usually result in pain when the lesion site is touched
Temperature of the skin could be variable due to the specific lesion and how long standing it is

Question 19

Testing

Answer 19

Actions that traction the affected nerve are to be avoided until the nerve has regenerated past the lesion site
AF ROM is performed by asking the client to show the movements that can be done easily
A partial lesion will result in difficulty in performing certain actions due to muscle weakness
A complete lesion will result in the loss of function of those muscles solely innervated by the affected nerve
PR ROM with a complete or partial regenerating nerve is initially performed on the unopposed antagonist muscles only, to assess the amount of contracture present in these muscles. PR ROM is not performed in any range that stretches the affected tissue until minimal contraction is possible in the muscles crossing the being moved
AR testing is performed to discern specific lost or weakened functions or to assess what function has returned as the nerve regenerates, with the therapist providing minimal resistance to the affected muscles

Question 20

Contraindications

Answer 20

Massage and movement of the affected limb are CI’d for up to 3 weeks if surgical intervention has occurred
Massage on the site of the lesion is not advised until the neurologist advises that a trace contraction is present
Do not traction or excessively move the joints of the affected limb in any way that might affect the regeneration process
Hydrotherapy to the limb should not begin until autonomic and vasomotor control have returned
Frictions and deep pressure on the flaccid or compromised tissue must be avoided
Joint play is not performed on the affected limb until innervation occurs and the joint is stable
Rhythmic techniques are avoided anywhere on the body until some control of the limb has returned

Question 21

Regenerating Lesions: Early Stages of healing

Answer 21

Do not disrupt the healing process of the regenerating nerve, specifically taking care not to traction the nerve before there is regeneration past the lesion site
If splints or braces are being worn and the neurologist has given permission to remove them, the client should do so just prior to treatment
The limb should be gently moved out of its holding pattern and placed in a comfortable and relatively neutral position
Hydrotherapy such as cool compresses can be used in the acute stage of the healing
Hydrotherapy is CI’d to the affected limb if there is loss of dysfunction of the autonomics

Decrease SNS firing and provide emotional support
Proximal to the lesion site, the main goal is to decrease edema and treat the overworked but functional muscles for hypertonicity and TPs
Distal to the lesion site, compromised muscles whether flaccid or weak are treated with light stroking and gently compressions.
Distal to the lesion site, unaffected muscles are treated using carefully applied Swedish techniques and modified fascial techniques
Maintain health in all joints of the affected limb, but care needs to be taken when grasping the limb so fragile tissue is not damaged through too much compression

PR ROM is performed in mid-to full ranges to the joints in the direction that shortens the affected tissue and nerve
Encourage motor re-education of the affected muscles
Maintain the strength or weak muscles by performing active assisted movements with the client who has weak but not lost actions

Question 22

Regenerating Lesions: Later Stages as Function Returns

Answer 22

Hydrotherapy applications of mild contrast washes are appropriate where the autonomics are functional
Decrease SNS firing and continues encouragement of the client
In the tissue that is reinnervated and with functional protective reflexes, tractioning the nerve is not a concern, but distal to the regeneration site of the nerve, the tissue is still not innervated and is treated as if it were in the early stages of healing
Reduce edema if present
Promote tissue health of unaffected and newly innervated tissue
Reduce scar tissue formation in the tissue surrounding the lesion site

Maintain and improve joint health and ROM
Encourage motor re-education of the affected muscles
Perform sensory awareness re-education by gradually introducing varied textures to the affected area

Question 23

Permanent Lesions

Answer 23

Hydrotherapy restrictions must be maintained if there is permanent loss of autonomic function
Modifications in weight, duration and temperature of applications is necessary on denervated and dystrophic tissue
Decrease SNS firing and provide emotional support to the client
Decrease edema if present
Maintain tissue health
Limit the contracture of the unopposed antagonist muscles with PR full ROM and segmental fascial techniques are used
Reduce scar tissue formation in the tissue surrounding the lesion site

Maintain joint health through careful application of PR movement in full, pain-free ranges
Maintain awareness of the affected limb by performing PR ROM while the client observes this and follows the actions with the unaffected side
Decrease pain if present

Question 24

Self-Care:
Regenerating lesions Early Stages of healing

Answer 24

Encourage relaxation
Educate the client about tissue health
Encourage motor re-education with passive or active assisted movement to the denervated muscles
Maintain strength and ROM, 3 weeks following surgical repair with passive movement into shortened ranges and active assisted movement performed in the same ranges for weak actions

Question 25

Self-Care:
Regenerating lesions
Later Stages as function returns

Answer 25

Educate client on maintain tissue health
Encourage motor re-education
Maintain then increase strength and ROM
Encourage re-education of sensory awareness

Question 26

Self-Care:
Permanent lesions

Answer 26

Encourage relaxation
Educate the client to maintain tissue health
Maintain strength and ROM of the affected limb