Structured Motor Rehabilitation After Selective Nerve Transfers

Abstract

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning. Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation. Video Link The video component of this article can be found at https://www.jove.com/video/59840/ 9 , movements associated with ulnar nerve activity (such as hand closing or ulnar abduction of the wrist) are used for the activation of the biceps muscle directly after re-innervation. However, exercises based on this approach can be performed in other body parts as well. If special considerations are necessary to implement this in other body parts (e.g., the lower extremity), this is pointed out within the protocol. Independent from the body part affected, therapy sessions should not exceed 30 min as muscles become easily fatigued shortly after reinnervation 8 and successful training requires a patient's full commitment and focus.

Bionic Upper Limb Reconstruction: A Valuable Alternative in Global Brachial Plexus Avulsion Injuries—A Case Series

“…This is highly cognitively demanding since faint muscle contractions do not lead to actual movements of the arm and hand and the brain has long "lost" the central representation of the denervated extremity. In some patients intense cognitive training including motor re-learning with appropriate biofeedback [28][29][30] result in the identification of separable sEMG signals. In others, new muscles need to be added (free functional muscle transfer) or relocated to establish sEMG signals available for prosthetic control.…”

Physical therapeutic treatment for traumatic brachial plexus injury in adults: A scoping review

“…The majority of the studies included were case reports/series and non‐systematic reviews published over the last 10 years (Table 1). Three articles derived from the same research group and consisted of one case series 15 and two articles that refer to the findings from this case series 16,17 . To avoid redundancy on reporting these results, our appraisal focused mainly on the two articles that offered a more in‐depth description of the protocol utilized 16,17 …”

“…The average age of patients could not be established due to some studies reporting only the minimum and maximum ages of the sample and others reporting only the average age. Thus some studies were included even though the minimum 18‐20 or maximum age 16,21‐23 of the patients was either lower or higher than the eligibility criteria of this review, since the sample was composed mainly of patients who met the criteria (the estimated pooled mean age reported in these studies was 25.2 to 50.2 years). Three studies included individuals with varied types of peripheral nerve injury and reported a sample ratio of 52 of 107 (48.6%), 24 2 of 10 (20%), 22 and 32 of 50 (64%) 25 of patients with BPI in their total sample.…”

Proprioceptive neuromuscular facilitation compared to conventional physiotherapy for adults with traumatic upper brachial plexus injury: A protocol for a randomized clinical trial

“…The loss of sensory and motor functions resulting from denervation caused by peripheral nerve injuries affects not only the peripheral nervous system, but also the central (CNS) system, which experiences sudden changes in cortical activity (Anastakis, Malessy, Chen, Davis, & Mikulis, 2008; Novak & von der Heyde, 2015; Simon, Franz, Gupta, Alden, & Kliot, 2016; Sturma, Hruby, Farina, & Aszmann, 2019). The consequences on cortical representations are evident and can be long‐lasting, such as the topographic reorganization of the somatosensory cortex, a fundamental area that is responsible for coordinating movements in space (Anastakis et al, 2008; Shumway‐cook & Woolacott, 2012; Simon et al, 2016).…”

“…Function restoration after TBPI therefore depends on the recovery of its representation in the brain, and this understanding has become even clearer with the expansion of treatment with nerve transfers (Kahn & Moore, 2016; Sturma et al, 2019). Although this surgical option has exhibited favorable results, control of the reinnervated muscle without activation of the donor muscle can only be achieved with the establishment of new motor patterns and cortical remapping, which requires time and a well‐structured rehabilitation based on concepts such as neuroplasticity, relearning, and motor control (Anastakis et al, 2008; Novak & von der Heyde, 2015; Simon et al, 2016; Sturma, Hruby, Prahm, Mayer, & Aszmann, 2018).…”